Introducing Life-long Learning Skills in a Patient Presentation Problem-Based Curriculum: The Case for Librarian Integration.

Medical students must learn how to find, critically appraise, and apply high-quality information to support their clinical decisions. To reinforce these skills, the Hackensack Meridian School of Medicine embedded medical librarians into a longitudinal case-based, problem-based learning curriculum, where they provide individualized feedback on student's skills in this area.

Comparative effectiveness of propranolol and botulinum for the treatment of essential voice tremor.

OBJECTIVES/HYPOTHESIS: To assess the comparative effectiveness of botulinum toxin and propranolol in patients with essential vocal tremor (EVT). STUDY DESIGN: Individual prospective cohort study. METHODS: Study patients were recruited at the Emory Voice Center from patients seeking treatment for EVT. Exclusion criteria included current ß-blocker treatment, spasmodic dysphonia, or other disease that prevented the use of propranolol therapy. A 10-week washout period from prior botulinum toxin treatment occurred before enrollment. Patients were assessed via the Voice-Related Quality-Of-Life (VRQOL) questionnaire, Quality of life in Essential Tremor questionnaire, and blinded perceptual voice assessment. These assessments were made at baseline voice 2 weeks after propranolol therapy and 4 weeks after botulinum toxin injection. RESULTS: Eighteen patients were enrolled. After 2 to 4 weeks of propranolol therapy (with a maximum dosage of 60 mg to 90 mg per day), patients report an average ΔVRQOL of 9.31. Six patients report significant VRQOL improvement >10, with the rest reporting changes between -7.5 and 7.5. Fifteen patients were followed for at least 4 weeks after botulinum toxin injection, reporting an average improvement in scaled VRQOL of 22.00. Blinded perceptual voice assessment demonstrates an improvement in overall severity of tremor with botulinum toxin. CONCLUSIONS: In some patients with EVT, propranolol led to significant vocal improvement with no major side effects. Although botulinum toxin remains the gold-standard therapy for patients with EVT, propranolol represents a possible alternative or adjuvant therapy for certain patients.

Incidence of and risk factors for community acquired pneumonia in US HIV-infected children, 2000-2005.

The incidence of and risk factors for community-acquired pneumonia (CAP) are described from 2000 to 2005 in a multicenter US cohort of HIV-infected children. In 736 patients, 87 episodes of CAP (33.2 events/1000 person-years) had a mean CD4% of 23% (controls: 30%) and mean CD4 cell count of 668 cells/µl (controls: 870 cells/µl). CAP incidence decreased 44% from 2000-2001 to 2002-2005. On multivariate analysis, viral load at least 100 000 copies/ml (odds ratio 3.98; confidence interval 1.05-15.13) was associated with CAP. Herd immunity through pneumococcal immunization may have diluted the effect of individual immunization in this cohort.

Contemporary costs of HIV healthcare in the HAART era.

BACKGROUND: The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management. METHODS: We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/µl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care. RESULTS: Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/µl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/µl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/µl or less, for whom inpatient costs were highest. CONCLUSION: HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

Use of outpatient mental health services and psychotropic medications among HIV-infected patients in a multisite, multistate study.

OBJECTIVE: Although co-occurring psychiatric disorders are highly prevalent among those with HIV, little is known about the use of outpatient mental health services (MHS) and psychotropic medication in the highly active antiretroviral therapy (HAART) era. METHODS: During 2003, 951 patients were interviewed at 14 sites in the HIV Research Network. Patients were questioned about use of MHS and psychotropic medications. Logistic regression was used to identify socio-demographic and clinical factors associated with MHS and psychotropic medication utilization. RESULTS: The sample characteristics were as follows: 68% male, 52% black, 14% Hispanic, median age 46 years (range 20-85), 69% were on HAART. Approximately 34% reported at least one MHS within 6 months and 37% reported use of psychotropic medication for a mental health condition. In multivariate logistic regression, MHS was greater among disabled patients [adjusted odds ratio 2.39 (95% CI 1.53-3.72)], current [2.26 (1.53-3.35)] and former drug users [1.84 (1.24-2.73)], and those with more than seven primary care visits in the past 6 months. Blacks [0.61 (0.41-0.92)] were significantly less likely to use MHS compared to whites. Similarly, usage of psychotropic medications was greater among disabled patients [1.79 (1.14-2.82)], women [1.66 (1.13-2.43)], )] and those with more than seven primary care visits. Blacks [0.37 (0.24-0.58])] and Hispanics [0.39 (0.22-0.72)] were less likely to use a psychotropic medication. HAART utilization was not associated with MHS or psychiatric medication use. CONCLUSIONS: In the HAART era, self-reported rates of mental health service and psychotropic medication utilization are high. Blacks continue to report lower use of MHS and psychotropic medication compared to whites.

Health-related quality of life in HIV-infected patients: the role of substance use.

HIV infection and substance use disorders are chronic diseases with complex contributions to health-related quality of life (HRQOL). We conducted a cross-sectional survey of 951 HIV-infected adults receiving care at 14 HIV Research Network sites in 2003 to estimate associations between HRQOL and specific substance use among HIV-infected patients. HRQOL was assessed by multi-item measures of physical and role functioning, general health, pain, energy, positive affect, anxiety, and depression. Mental and physical summary scales were developed by factor analysis. We used linear regression to estimate adjusted associations between HRQOL and current illicit use of marijuana, analgesics, heroin, amphetamines, cocaine, sedatives, inhalants, hazardous/binge alcohol, and drug use severity. Current illicit drug use was reported by 37% of subjects. Mental HRQOL was reduced for current users [adjusted beta coefficient -9.66, 95% confidence interval [(CI]) -13.4, -5.94] but not former users compared with never users. Amphetamines and sedatives were associated with large decreases in mental (amphetamines: beta = -22.8 [95% CI -33.5, -12.0], sedatives: beta = -18.6 [95% CI -26.2, -11.0]), and physical HRQOL (amphetamines: beta = -11.5 [95% CI -22.6, -0.43], sedatives: beta = -13.2 [95% CI -21.0, -5.36]). All illicit drugs were associated with decreased mental HRQOL: marijuana (beta = -7.72 [95% CI -12.0, -3.48]), non-prescription analgesics (beta = -13.4 [95% CI -20.8, -6.07]), cocaine (beta = -10.5 [95% CI -16.4, -4.67]), and inhalants (beta = -14.0 [95% CI -24.1, -3.83]). Facilitating sobriety for patients with attention to specific illicit drugs represents an important avenue for elevating HRQOL in patients living with HIV.

Impact of patient race on patient experiences of access and communication in HIV care.

BACKGROUND: Patient-centered care--including the domains of access and communication--is an important determinant of positive clinical outcomes. OBJECTIVE: To explore associations between race and HIV-infected patients' experiences of access and communication. DESIGN: This was a cross-sectional survey. PARTICIPANTS: Nine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics. MEASUREMENTS: Dependent variables included patients' reports of travel time to their HIV care site and waiting time to see their HIV provider (access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with them (communication). We used multivariate logistic regression to estimate associations between patient race and dependent variables, and random effects models to estimate site-level contributions. RESULTS: Patients traveled a median 30 minutes (range 1-180) and waited a median 20 minutes (range 0-210) to see their provider. On average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported more positive experiences with provider communication. CONCLUSIONS: We observed racial disparities in patients' experience of access to care but not in patient-provider communication. Disparities were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient-provider interactions.

Substance abuse treatment in human immunodeficiency virus: the role of patient-provider discussions.

Substance abuse treatment is associated with decreases in human immunodeficiency virus (HIV) risk behavior and can improve HIV outcomes. The purpose of this study was to examine factors associated with substance abuse treatment utilization, including patient-provider discussions of substance use issues. We surveyed 951 HIV-infected adults receiving care at 14 HIV Research Network primary care sites regarding drug and alcohol use, substance abuse treatment, and provider discussions of substance use issues. Although 71% reported substance use, only 24% reported receiving substance abuse treatment and less than half reported discussing substance use issues with their HIV providers. In adjusted logistic regression models, receipt of substance abuse treatment was associated with patient-provider discussions. Patient-provider discussions of substance use issues were associated with current drug use, hazardous or binge drinking, and Black race or ethnicity, though substance use was comparable between Blacks and Whites. These data suggest potential opportunities for improving engagement in substance abuse treatment services.