Maintenance of Certification-The Value to Patients and Physicians.

This Viewpoint discusses the ABIM's continuing efforts to innovate and streamline maintenance of certification, including the recently launched Longitudinal Knowledge Assessment (LKA), to better accommodate physicians' schedules and desires for flexibility.

Barriers and Facilitators to HIV Service Access among Hispanic/Latino Gay, Bisexual, and Other Men Who Have Sex with Men in Metropolitan Atlanta-a Qualitative Analysis.

Hispanic/Latino persons are disproportionately impacted by HIV in the US, and HIV diagnoses among Hispanic/Latino men in Georgia have increased over the past decade, particularly in metropolitan Atlanta. In 2022, the Georgia Department of Public Health detected five clusters of rapid HIV transmission centered among Hispanic/Latino gay, bisexual, and other men who have sex with men (HLMSM) in metropolitan Atlanta. We conducted in-depth interviews with 65 service providers and 29 HLMSM to identify barriers and facilitators to HIV service access for HLMSM. Interviews were audio recorded, transcribed, and translated, if needed. Initial data analyses were conducted rapidly in the field to inform public health actions. We then conducted additional analyses including line-by-line coding of the interview transcripts using a thematic analytic approach. We identified four main themes. First, inequity in language access was a predominant barrier. Second, multiple social and structural barriers existed. Third, HLMSM encountered intersectional stigma. Finally, the HLMSM community is characterized by its diversity, and there is not a one-size-fits-all approach to providing appropriate care to this population. The collection of qualitative data during an HIV cluster investigation allowed us to quickly identity barriers experienced by HLMSM when accessing HIV and other medical care, to optimize public health response and action. Well-designed program evaluation and implementation research may help elucidate specific strategies and tools to reduce health disparities, ensure equitable service access for HLMSM, and reduce HIV transmission in this population.

Public Health Response to Clusters of Rapid HIV Transmission Among Hispanic or Latino Gay, Bisexual, and Other Men Who Have Sex with Men - Metropolitan Atlanta, Georgia, 2021-2022.

During February 2021-June 2022, the Georgia Department of Public Health (GDPH) detected five clusters of rapid HIV transmission concentrated among Hispanic or Latino (Hispanic) gay, bisexual, and other men who have sex with men (MSM) in metropolitan Atlanta. The clusters were detected through routine analysis of HIV-1 nucleotide sequence data obtained through public health surveillance (1,2). Beginning in spring 2021, GDPH partnered with health districts with jurisdiction in four metropolitan Atlanta counties (Cobb, DeKalb, Fulton, and Gwinnett) and CDC to investigate factors contributing to HIV spread, epidemiologic characteristics, and transmission patterns. Activities included review of surveillance and partner services interview data,† medical chart reviews, and qualitative interviews with service providers and Hispanic MSM community members. By June 2022, these clusters included 75 persons, including 56% who identified as Hispanic, 96% who reported male sex at birth, 81% who reported male-to-male sexual contact, and 84% of whom resided in the four metropolitan Atlanta counties. Qualitative interviews identified barriers to accessing HIV prevention and care services, including language barriers, immigration- and deportation-related concerns, and cultural norms regarding sexuality-related stigma. GDPH and the health districts expanded coordination, initiated culturally concordant HIV prevention marketing and educational activities, developed partnerships with organizations serving Hispanic communities to enhance outreach and services, and obtained funding for a bilingual patient navigation program with academic partners to provide staff members to help persons overcome barriers and understand the health care system. HIV molecular cluster detection can identify rapid HIV transmission among sexual networks involving ethnic and sexual minority groups, draw attention to the needs of affected populations, and advance health equity through tailored responses that address those needs.

The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study.

The genealogy of graduate medical education in America begins at the bedside. However, today's graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association's (AMA) "Reimagining Residency" initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.

The Clinical Examination and Socially At-Risk Populations: The Examination Matters for Health Disparities.

Data from the United States show that persons from low socioeconomic backgrounds, those who are socially isolated, belong to racial or ethnic minority groups, or identify as lesbian, gay, bisexual, or transgender experience health disparities at a higher rate. Clinicians must transition from a biomedical to a biopsychosocial framework within the clinical examination to better address social determinants of health that contribute to health disparities. We review the characteristics of successful patient-clinician interactions. We describe strategies for relationship-centered care within routine encounters. Our goal is to train clinicians to mitigate differences and reduce disparities in health care delivery.

Race/ethnicity and HAART initiation in a military HIV infected cohort.

BACKGROUND: Prior studies have suggested that HAART initiation may vary by race/ethnicity. Utilizing the U.S. military healthcare system, which minimizes confounding from healthcare access, we analyzed whether timing of HAART initiation and the appropriate initiation of primary prophylaxis among those at high risk for pneumocystis pneumonia (PCP) varies by race/ethnicity. METHODS: Participants in the U.S. Military HIV Natural History Study from 1998-2009 who had not initiated HAART before 1998 and who, based on DHHS guidelines, had a definite indication for HAART (CD4 <200, AIDS event or severe symptoms; Group A), an indication to consider HAART (including CD4 <350; Group B) or electively started HAART (CD4 >350; Group C) were analyzed for factors associated with HAART initiation. In a secondary analysis, participants were also evaluated for factors associated with starting primary PCP prophylaxis within four months of a CD4 count <200 cells/mm3. Multiple logistic regression was used to compare those who started vs. delayed therapy; comparisons were expressed as odds ratios (OR). RESULTS: 1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62 participants were evaluated in both Groups A and B]; 94% male, 46% African American, 40% Caucasian). Race/ethnicity was not associated with HAART initiation in Groups A or B. In Group C, African American race/ethnicity was associated with lower odds of initiating HAART (OR 0.49, p = 0.04). Race and ethnicity were also not associated with the initiation of primary PCP prophylaxis among the 408 participants who were at risk. CONCLUSIONS: No disparities in the initiation of HAART or primary PCP prophylaxis according to race/ethnicity were seen among those with an indication for therapy. Among those electively initiating HAART at the highest CD4 cell counts, African American race/ethnicity was associated with decreased odds of starting. This suggests that free healthcare can potentially overcome some of the observed disparities in HIV care, but that unmeasured factors may contribute to differences in elective care decisions.

Effect of hamstring flexibility on hip and lumbar spine joint excursions during forward-reaching tasks in participants with and without low back pain.

OBJECTIVE: To examine the correlation between hamstring flexibility and hip and lumbar spine joint excursions during standardized reaching and forward-bending tasks. DESIGN: Retrospective analysis of data obtained during 2 previous prospective studies that examined kinematics and kinetics during forward-reaching tasks in participants with and without low back pain (LBP). SETTING: The 2 previous studies were conducted in the Motor Control Lab at Ohio University and the Orthopaedic Ergonomics Laboratory at The Ohio State University. PARTICIPANTS: Data from a total of 122 subjects from 2 previous studies: study 1: 86 subjects recovered from an episode of acute LBP (recovered) and study 2 (A.I. McCallum, unpublished data): 18 chronic LBP subjects and 18 healthy-matched controls (healthy). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Correlation values between hamstring flexibility as measured by straight leg raise (SLR) and amount of hip and lumbar spine joint excursions used during standardized reaching and forward-bending tasks. RESULTS: No significant correlation was found between hamstring flexibility and hip and lumbar joint excursions during forward-bending tasks in the LBP or recovered groups. The SLR had a significant negative correlation with lumbar spine excursions during reaching tasks to a low target in the healthy group (right SLR: P=.011, left SLR: P=.004). CONCLUSIONS: Hamstring flexibility is not strongly related to the amount of lumbar flexion used to perform forward-reaching tasks in participants who have chronic LBP or who have recovered from LBP. More research needs to be conducted to examine the influence of hamstring flexibility on observed movement patterns to further evaluate the efficacy of flexibility training in the rehabilitation of patients with LBP.

Virologic response differences between African Americans and European Americans initiating highly active antiretroviral therapy with equal access to care.

OBJECTIVE: Studies comparing virologic response to highly active antiretroviral therapy (HAART) between African Americans (AA) and European Americans (EA) have been confounded by differences in duration of HIV infection and access to health care. We evaluated virologic response to HAART between ethnicities in a large cohort with fewer confounders. METHODS: The odds of attaining viral suppression at 6- and 12-months post-HAART were determined by multivariate logistic regression for HIV-infected AA and EA prospectively followed in a large US military cohort. Time-to-event methods were used to compare maintenance of suppression. RESULTS: A total of 1363 subjects (51% AA, 92% men) with viral load results available 6 months after HAART initiation were included. There was no difference between ethnicities in time from seroconversion to HIV diagnosis or HAART initiation or in HAART regimens. Adjusted for multiple demographic and HIV-related factors, AA had significantly lower odds of obtaining undetectable viral loads after 6 (odds ratio 0.6, 95% confidence interval 0.4-0.8, P < 0.001) and 12 months (odds ratio 0.6, 95% confidence interval 0.4-0.8, P = 0.002) of HAART. Once undetectable, there was no difference in time to virologic failure between AA and EA. CONCLUSIONS: Despite similar durations of HIV infection and equal access to health care, AAs were significantly less likely to achieve viral suppression compared with EA.

Hospital-acquired device-associated infections at a deployed military hospital in Iraq.

BACKGROUND: To date, there have been no published studies describing rates of device-associated infections over extended periods at deployed military hospitals. We describe the rates of utilization and device-associated infections at the Air Force Theater Hospital (AFTH) in Iraq. METHODS: This is a retrospective review of infection control (IC) records at the AFTH intensive care unit (ICU) from November 2006 through December 2007. Monthly device utilization and infection rates (per 1000 device days) were analyzed for trend and compared with pooled means for US trauma ICUs. RESULTS: Central line utilization rates were constant (mean, 64%) with central line- associated bloodstream infection (CLAB) rates of 0 to 7.7 (US rate 4.6) except from September to December 2007, when the rate ranged from 7.4 to 29.3. An IC program reduced ventilator-associated pneumonia (VAP) rates to a baseline of 9.7 to 11.6. However, VAP rates rose to 13.3 to 56.3 in the 4-month period of January through April 2007 and 14.3 to 28.2 during September through December 2007. Neither CLAB nor VAP rates correlated with ICU admissions. The urinary catheter-associated urinary tract infection rate was 0 to 6.7 (US rate 5.5). Overall, Staphylococcus aureus was the predominant organism during May through October 2007 and Acinetobacter in November and December 2007. CONCLUSIONS: Substantial variability exists in the rates of CLAB and VAP in the AFTH. Potential explanations are staff turnover and prolonged stays among non-US personnel who may serve as a reservoir for ongoing infections. Identification of barriers to IC may help inform the process of creating and implementing effective IC strategies in deployed military hospitals.

Occupational exposure to blood and other bodily fluids at a military hospital in Iraq.

BACKGROUND: Exposure to bloodborne pathogens, namely HIV, hepatitis B, and hepatitis C, remains a risk for healthcare workers. Given the austere and challenging environments in a combat zone, it is unclear to what extent blood and other bodily fluid occupational exposures pose a risk of infection for military healthcare workers deployed to a level III military treatment facility in support of Operation Iraqi Freedom. METHODS: This is a retrospective review of electronic infection control records at the Air Force Theater Hospital in Iraq in which blood and other bodily fluid occupational exposure data were available: October 1, 2005 through May 31, 2006 and January 15, 2007 through April 30, 2007. RESULTS: During the first study period, there were 46 exposures for an average monthly exposure of 5.8 (range, 2-16 per month). The majority of exposures were percutaneous fingersticks (74%), whereas the remainder were splashes (17%) or not documented (9%). During the second study period, there were 19 exposures with percutaneous device and splash exposure encompassing 68% and 32% of cases, respectively. The majority of occurrences were in the intensive care unit (53%) and primarily among nurses (37%). Overall, there were 65 exposures per 1,000 persons during the year review. CONCLUSIONS: During the time periods evaluated, a substantial number of blood and other bodily fluid exposures occurred in a combat zone military healthcare facility. This finding is comparable to US civilian institutions. Maintaining programs for preventing, tracking, and implementing postexposure prophylaxis remain a worthy and achievable goal at every military treatment facility, regardless of the austerity of the environment.

Infectious complications of open type III tibial fractures among combat casualties.

BACKGROUND: Combat is associated with high-energy explosive injuries, often resulting in open tibial fractures complicated by nonunion and infection. We characterize the infections seen in conjunction with combat-associated type III tibial fractures. METHODS: We performed a retrospective medical records review to identify US military service members wounded in Iraq or Afghanistan with open diaphyseal tibial fractures who were admitted to our facility (Brooke Army Medical Center, Fort Sam Houston, Texas) between March 2003 and September 2006. RESULTS: Of the 62 patients with open tibial fractures who were identified in our initial search, 40 had fractures that met our inclusion criteria as type III diaphyseal tibial fractures. Three patients were excluded because their fractures were managed with early limb amputation, and 2 were excluded because of incomplete follow-up records. Twenty-seven of these 35 patients had at least 1 organism present in initial deep-wound cultures that were performed at admission to the hospital. The pathogens that were identified most frequently were Acinetobacter, Enterobacter species, and Pseudomonas aeruginosa. Thirteen of the 35 patients had union times of >9 months that appeared to be associated with infection. None of the gram-negative bacteria identified in the initial wound cultures were recovered again at the time of a second operation; however, all patients had at least 1 staphylococcal organism. One patient had an organism present during initial culture and in the nonunion wound; this organism was a methicillin-resistant Staphylococcus aureus strain that was inadvertently not treated. Five of 35 patients ultimately required limb amputation, with infectious complications cited as the reason for amputation in 4 of these cases. CONCLUSIONS: Combat-associated type III tibial fractures are predominantly associated with infections due to gram-negative organisms, and these infections are generally successfully treated. Recurrent infections are predominantly due to staphylococci.

Efficacy of fluoroquinolones against Leptospira interrogans in a hamster model.

Ciprofloxacin, gatifloxacin, and levofloxacin were evaluated for their abilities to prevent mortality in hamsters infected with a lethal inoculum of Leptospira interrogans serovar Portlandvere. Each agent produced a statistically significant survival advantage compared to no treatment and demonstrated survival similar to that seen with doxycycline therapy.