Faculty Bibliography
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department:Medicine. General Internal Medicine
recentyears:2
school:SOM
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14493
Demystifying and destigmatizing emergency department-initiated buprenorphine: A standardized experiential faculty development [Meeting Abstract]
Intro/Background: Opioid-related emergency department (ED) visits continue to rise at an alarming rate with 5% annual mortality observed among overdose survivors. Mortality was 60% lower among those receiving pharmacotherapy for opioid use disorder (OUD) in the subsequent year; however, only 1/3 did. Despite D'Onofrio's landmark study demonstrating that initiating buprenorphine and referral in the ED for treatment for OUD is feasible, highly effective, and cost-effective, this life-saving medication is rarely initiated in EDs. Purpose/Objective: Barriers to treatment exist at the patient, provider, and systems levels and include longstanding practice norms, limited experience using medications whose properties are often misunderstood, and the impact stigma has on patients seeking and providers offering treatment. We developed and piloted an experiential education session to mitigate these barriers and increase the likelihood that emergency providers will initiate buprenorphine for patients with OUD in the ED.
Method(s): We created a three case Group Objective Structured Clinical Examination (GOSCE) using standardized patients (SPs) trained to portray three commonly encountered patients with OUD. One participant interacts with one SP (8-10 minutes) while two other participants observe with a faculty member, followed by a 20 minute debrief. Participants are tasked to: a) Assess for ED-initiated buprenorphine and b) Discuss the patients' substance use; provide counseling and education where appropriate. Participants completed pre/post-GOSCE surveys. Outcomes (if available): Thirty-nine emergency medicine providers completed the GOSCE. Prior to the session, 50% had never administered buprenorphine to any patient, 35% in 1-2 patients, and 14% in 3 or more patients. Participants reported an increase in comfort administering buprenorphine comparing pre- and post OSCE surveys; 3.81 to 8.03 respectively (1 = not comfortable, 10 = very comfortable), p<0.001. Reported comfort discussing substance use disorders trended positively from 6.94 to 8.29 without achieving statistical significance.
Summary: It is paramount that emergency medicine providers use all available tools and skills to address the current opioid epidemic. Despite evidence of the benefit of buprenorphine, it remains severely underutilized in the ED. Nationally only 0.9% of emergency physicians are X-waivered to prescribe buprenorphine. In our cohort, 50% had never administered buprenorphine to any ED patient. The primary goal of this experiential education session was to increase the likelihood that emergency providers will administer and initiate BUP treatment for patients with OUD in the ED. The three unique cases provided an intense simulated experience each with challenges often faced in the ED. Case 1: 28 year old man who is anxious to leave the ED after emerging from an opioid overdose after treatment with intranasal naloxone by EMS; Case 2: 35 year old man requesting detox admission from "Oxy"; Case 3: 24 year old woman who is requesting/demanding opioid pain medication after drainage of an abscess resulting from injection drug use. The structured debrief focused on enhancing emergency providers' ability to properly screen and treat patients with buprenorphine as well as improving communication skills discussing OUD. Our results demonstrated that the GOSCE effectively increased providers' reported comfort administering buprenorphine. Qualitative data suggests the session helped facilitate the use of non-stigmatizing language when discussing OUD, acquire strategies on how to discuss buprenorphine and OUD, and positively changed perceptions of buprenorphine & OUD. Participants also found it useful to have difficult patient conversations in the simulation followed by immediate constructive feedback in the debrief. Future study includes examining performance of participants rated by SPs, assessing self-reported comfort and rates of buprenorphine initiation among trainees at six months following the GOSCE. Also, we will track global and individual provider rates of buprenorphine administration and prescribing in our EDs through electronic health record abstraction
Method(s): We created a three case Group Objective Structured Clinical Examination (GOSCE) using standardized patients (SPs) trained to portray three commonly encountered patients with OUD. One participant interacts with one SP (8-10 minutes) while two other participants observe with a faculty member, followed by a 20 minute debrief. Participants are tasked to: a) Assess for ED-initiated buprenorphine and b) Discuss the patients' substance use; provide counseling and education where appropriate. Participants completed pre/post-GOSCE surveys. Outcomes (if available): Thirty-nine emergency medicine providers completed the GOSCE. Prior to the session, 50% had never administered buprenorphine to any patient, 35% in 1-2 patients, and 14% in 3 or more patients. Participants reported an increase in comfort administering buprenorphine comparing pre- and post OSCE surveys; 3.81 to 8.03 respectively (1 = not comfortable, 10 = very comfortable), p<0.001. Reported comfort discussing substance use disorders trended positively from 6.94 to 8.29 without achieving statistical significance.
Summary: It is paramount that emergency medicine providers use all available tools and skills to address the current opioid epidemic. Despite evidence of the benefit of buprenorphine, it remains severely underutilized in the ED. Nationally only 0.9% of emergency physicians are X-waivered to prescribe buprenorphine. In our cohort, 50% had never administered buprenorphine to any ED patient. The primary goal of this experiential education session was to increase the likelihood that emergency providers will administer and initiate BUP treatment for patients with OUD in the ED. The three unique cases provided an intense simulated experience each with challenges often faced in the ED. Case 1: 28 year old man who is anxious to leave the ED after emerging from an opioid overdose after treatment with intranasal naloxone by EMS; Case 2: 35 year old man requesting detox admission from "Oxy"; Case 3: 24 year old woman who is requesting/demanding opioid pain medication after drainage of an abscess resulting from injection drug use. The structured debrief focused on enhancing emergency providers' ability to properly screen and treat patients with buprenorphine as well as improving communication skills discussing OUD. Our results demonstrated that the GOSCE effectively increased providers' reported comfort administering buprenorphine. Qualitative data suggests the session helped facilitate the use of non-stigmatizing language when discussing OUD, acquire strategies on how to discuss buprenorphine and OUD, and positively changed perceptions of buprenorphine & OUD. Participants also found it useful to have difficult patient conversations in the simulation followed by immediate constructive feedback in the debrief. Future study includes examining performance of participants rated by SPs, assessing self-reported comfort and rates of buprenorphine initiation among trainees at six months following the GOSCE. Also, we will track global and individual provider rates of buprenorphine administration and prescribing in our EDs through electronic health record abstraction
EMBASE:632417983
ISSN: 1553-2712
CID: 4547952
Chest Pain Induced by Intravenous Nitroglycerin
PMID: 31855580
ISSN: 1536-3686
CID: 4242932
Development, Implementation, and Evaluation of a Personalized Machine Learning Algorithm for Clinical Decision Support: Case Study With Shingles Vaccination
BACKGROUND:Although clinical decision support (CDS) alerts are effective reminders of best practices, their effectiveness is blunted by clinicians who fail to respond to an overabundance of inappropriate alerts. An electronic health record (EHR)-integrated machine learning (ML) algorithm is a potentially powerful tool to increase the signal-to-noise ratio of CDS alerts and positively impact the clinician's interaction with these alerts in general. OBJECTIVE:This study aimed to describe the development and implementation of an ML-based signal-to-noise optimization system (SmartCDS) to increase the signal of alerts by decreasing the volume of low-value herpes zoster (shingles) vaccination alerts. METHODS:We built and deployed SmartCDS, which builds personalized user activity profiles to suppress shingles vaccination alerts unlikely to yield a clinician's interaction. We extracted all records of shingles alerts from January 2017 to March 2019 from our EHR system, including 327,737 encounters, 780 providers, and 144,438 patients. RESULTS:During the 6 weeks of pilot deployment, the SmartCDS system suppressed an average of 43.67% (15,425/35,315) potential shingles alerts (appointments) and maintained stable counts of weekly shingles vaccination orders (326.3 with system active vs 331.3 in the control group; P=.38) and weekly user-alert interactions (1118.3 with system active vs 1166.3 in the control group; P=.20). CONCLUSIONS:All key statistics remained stable while the system was turned on. Although the results are promising, the characteristics of the system can be subject to future data shifts, which require automated logging and monitoring. We demonstrated that an automated, ML-based method and data architecture to suppress alerts are feasible without detriment to overall order rates. This work is the first alert suppression ML-based model deployed in practice and serves as foundational work in encounter-level customization of alert display to maximize effectiveness.
PMID: 32347813
ISSN: 1438-8871
CID: 4412352
Local Anesthetic Injection Resolves Movement Pain, Motor Dysfunction, and Pain Catastrophizing in Individuals With Chronic Achilles Tendinopathy, a Non-Randomized Clinical Trial
OBJECTIVES/OBJECTIVE:Peripherally-directed treatments (targeted exercise, surgery) can reduce, but not fully eliminate, pain for up to 40% of patients with Achilles tendinopathy. The objectives were to: 1) Identify indicators of altered central processing in participants with Achilles tendinopathy compared to controls; and 2) determine which indicators of altered central processing persisted after a local anesthetic injection in patients with Achilles tendinopathy. DESIGN/METHODS:Mechanistic clinical trial. METHODS:46 adults participated (23 with chronic Achilles tendinopathy, 23 matched-controls; NCT03316378). All participants repeated: 1) movement-evoked pain rating, 2) motor performance, 3) pain psychology questionnaires; 4) quantitative sensory testing. Participants with Achilles tendinopathy received a local anesthetic injection before repeat testing and controls did not. Mixed-effects ANOVAs examined group, time, and group*time effects. RESULTS:>0.05). CONCLUSION/CONCLUSIONS:.
PMID: 32349638
ISSN: 1938-1344
CID: 4436972
Management of Coronary Disease in Patients with Advanced Kidney Disease
BACKGROUND:Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS:We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS:At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS:Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
PMID: 32227756
ISSN: 1533-4406
CID: 5451232
ARGONAUT II - In vitro activity of plazomicin against carbapenemase-producing Klebsiella pneumoniae
Plazomicin was tested against 697 recently acquired carbapenem resistant Klebsiella pneumoniae isolates from the Great Lakes Region of the United States. Plazomicin MIC50 and MIC90 values were 0.25 and 1 mg/L, respectively; 680 isolates were susceptible (97.6%, MIC ≤ 2 mg/L), 9 intermediate (1.3%, MIC 4mg/L), and 8 resistant (1.1%, MIC > 32 mg/L). Resistance was associated with rmtF-, rmtB- or armA-encoded 16S ribosomal RNA methyltransferases, in all but one isolate.
PMID: 32152078
ISSN: 1098-6596
CID: 4348762
Molecular and clinical characterization of multidrug resistant and hypervirulent Klebsiella pneumoniae strains from liver abscess in Taiwan
Hypervirulent Klebsiella pneumoniae strains are the major causes of liver abscesses throughout East Asia, and these strains are usually antibiotic susceptible. Recently, multidrug resistant and hypervirulent (MDR-HV) K. pneumoniae strain emerged, arisen by hypervirulent strains acquiring antimicrobial resistance determinants or the transfer of a virulence plasmid into a classic MDR strain. In this study, we characterized the clinical and microbiological properties of K. pneumoniae liver abscess (KPLA) caused by MDR-HV strains in Taiwan. Patients with community-onset KPLA were retrospectively identified at Taipei Veterans General Hospital during January 2013 and May 2018. Antimicrobial resistance mechanisms, capsular types, and sequence types were determined. MDR-HV strains and their parental antimicrobial-susceptible strains further underwent whole genome sequencing (WGS) and in vivo mice lethality test. Thirteen MDR-HV strains were identified from a total of 218 KPLA episodes. MDR-HV strains resulted in similar outcomes to antimicrobial-susceptible strains. All MDR-HV strains were traditional hypervirulent clones carrying virulence capsular types. The major resistance mechanisms were the overexpression of efflux pumps and/or the acquisition of ESBL or AmpC β-lactamase genes. WGS showed two hypervirulent strains evolved to MDR phenotype after having a mutation in ramR and acquiring a SHV-12-bearing plasmid, respectively. Both the MDR-HV strains retained high virulence in comparison to their parental strains. The spread of MDR-HV K. pneumoniae strains in the community raises significant public concerns, and measures should be taken to prevent the further acquisition of carbapenemase and other resistance genes among these strains in order to avoid the occurrence of untreatable KPLA.
PMID: 32152079
ISSN: 1098-6596
CID: 4348772
Co-occurrence of plasmid-mediated tigecycline and carbapenem resistance in Acinetobacter spp. from waterfowls and their neighboring environment
Tigecycline serves as one of the last-resort antibiotics to treat multidrug-resistant (including carbapenem-resistant) pathogens. However, the recently emerged plasmid-mediated tigecycline resistance mechanisms, Tet(X), challenge the clinical efficacy of this class of antibiotics. In this study, we detected one hundred and eighty tet(X)-harboring Acinetobacter isolates (8.9%, n=180) from 2018 samples collected from the avian farms and adjacent environment in China. Eighteen tet(X)-harboring isolates (10.0%) were found to co-carry the carbapenemase gene blaNDM-1, mostly from waterfowls samples (94.4%, 17/18). Interestingly, among six Acinetobacter strains, the tet(X) and blaNDM-1 were found to co-localize on the same plasmids. Moreover, WGS revealed a novel orthologue of tet(X) in the six tet(X)- and blaNDM-1-co-harboring isolates. Inverse PCR suggested that the two tet(X) genes form a single transposable unit and may be co-transferred. Sequence comparison between six tet(X) and blaNDM-1-co-harboring plasmids showed they shared a highly homologous plasmid backbone, even though they were isolated from different Acinetobacter species (3 A. indicus, 2 A. schindleri, and 1 A. lwoffii) in various sources and from different geological regions, suggesting the horizontal genetic transfer of a common tet(X) and blaNDM-1-co-harboring plasmid among Acinetobacter species in China. Emergence and spread of such plasmids and strains are of great clinical concern, and measures must be implemented to avoid their dissemination.
PMID: 32122894
ISSN: 1098-6596
CID: 4339632
Coronary Artery Calcium as a Synergistic Tool for the Age- and Sex-Specific Risk of Cardiovascular and Cancer Mortality: The Coronary Artery Calcium Consortium
Background Coronary artery calcium (CAC) is a predictor for the development of cardiovascular disease (CVD) and to a lesser extent cancer. The age- and sex-specific relationship of CAC with CVD and cancer mortality is unknown. Methods and Results Asymptomatic patients aged 40 to 75 years old without known CVD were included from the CAC Consortium. We calculated sex-specific mortality rates per 1000 person-years' follow-up. Using parametric survival regression modeling, we determined the age- and sex-specific CAC score at which the risk of death from CVD and cancer were equal. Among the 59 502 patients included in this analysis, the mean age was 54.9 (±8.5) years, 34% were women, and 89% were white. There were 671 deaths attributable to CVD and 954 deaths attributable to cancer over a mean follow-up of 12±3 years. Among patients with CAC=0, cancer was the leading cause of death, the total mortality rate was low (women, 1.8; men, 1.5), and the CVD mortality rate was exceedingly low for women (0.3) and men (0.3). The age-specific CAC score at which the risk of CVD and cancer mortality were equal had a U-shaped relationship for women, while the relationship was exponential for men. Conclusions The age- and sex-specific relationship of CAC with CVD and cancer mortality differed significantly for women and men. Our age- and sex-specific CAC score provides a more precise estimate and further facilitates the use of CAC as a synergistic tool in strategies for the prediction and prevention of CVD and cancer mortality.
PMCID:7428523
PMID: 32310025
ISSN: 2047-9980
CID: 4961682
