BACKGROUND: Enhancing patient-centered care and shared decision making (SDM) has become a national priority as a means of engaging patients in their care, improving treatment adherence, and enhancing health outcomes. Relatively little is known about the healthcare experiences or shared decision making among racial/ethnic minorities who also identify as being LGBT. The purpose of this paper is to understand how race, sexual orientation and gender identity can simultaneously influence SDM among AfricanAmerican LGBT persons, and to propose a model of SDM between such patients and their healthcare providers. METHODS: We reviewed key constructs necessary for understanding SDM among African-American LGBT persons, which guided our systematic literature review. Eligible studies for the review included English-language studies of adults (≥ 19 y/o) in North America, with a focus on LGBT persons who were African-American/black (i.e., > 50 % of the study population) or included sub-analyses by sexual orientation/gender identity and race. We searched PubMed, CINAHL, ProQuest Dissertations & Theses, PsycINFO, and Scopus databases using MESH terms and keywords related to shared decision making, communication quality (e.g., trust, bias), African-Americans, and LGBT persons. Additional references were identified by manual reviews of peer-reviewed journals' tables of contents and key papers' references. RESULTS: We identified 2298 abstracts, three of which met the inclusion criteria. Of the included studies, one was cross-sectional and two were qualitative; one study involved transgender women (91 % minorities, 65 % of whom were African-Americans), and two involved African-American men who have sex with men (MSM). All of the studies focused on HIV infection. Sexual orientation and gender identity were patient-reported factors that negatively impacted patient/provider relationships and SDM. Engaging in SDM helped some patients overcome normative beliefs about clinical encounters. In this paper, we present a conceptual model for understanding SDM in African-American LGBT persons, wherein multiple systems of social stratification (e.g., race, gender, sexual orientation) influence patient and provider perceptions, behaviors, and shared decision making. DISCUSSION: Few studies exist that explore SDM among African-American LGBT persons, and no interventions were identified in our systematic review. Thus, we are unable to draw conclusions about the effect size of SDM among this population on health outcomes. Qualitative work suggests that race, sexual orientation and gender work collectively to enhance perceptions of discrimination and decrease SDM among African-American LGBT persons. More research is needed to obtain a comprehensive understanding of shared decision making and subsequent health outcomes among African-Americans along the entire spectrum of gender and sexual orientation.

Background The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). Methods We performed a cross-over randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or non-purulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, C. difficile infection, acquisition of multidrug resistant Gram-negative organism (MDRO), and antibiotics costs. Results 6,849 participants enrolled in the study. There were no overall differences in outcomes among the intervention vs. control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [-0.97, -0.09], p=0.0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (aOR= 0.58, 95% CI [0.396, 0.854], p=0.02). Conclusion Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.

To the Editor-Understanding the prevalence of coinfections with coronavirus disease 2019 (COVID-19) is crucial to delineating its true clinical impact. Numerous studies have evaluated coinfections in adults with COVID-19, 1-3 but data on pediatric COVID-19 coinfections are limited. Here, we evaluate the burden of coinfections in pediatric COVID-19 patients at 2 large Chicagoland medical centers. Methods We retrospectively reviewed electronic health records of all pediatric patients tested for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) from March 9, 2020, through April 30, 2020, in 2 Chicagoland medical centers. At the University of Chicago Medicine, SARS-CoV-2 was diagnosed using one of the following real-time reverse transcriptase polymerase chain reaction (RT-PCR) assays on respiratory specimens: Cobas SARS-CoV-2 RT-PCR assay (Roche Basel, Switzerland) or Xpert Xpress SARS-CoV-2 test (Cepheid, Sunnyvale, CA). Respiratory coinfections were primarily identified using a multiplex RT-PCR respiratory viral panel (RVP) with the following targets: adenovirus, coronavirus 229E/HKU1/NL63/OC43, human metapneumovirus, influenza-A/-B, parainfluenzas 1-4, respiratory syncytial virus, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella pertussis, and rhinovirus/enterovirus (FilmArray Respiratory Panel, BioFire Diagnostics, Salt Lake City, UT). Coinfections were also identified using the influenza/respiratory syncytial virus (RSV) RT-PCR assay (Cepheid Xpert Xpress Flu/RSV) known as the influenza/RSV panel (IRP). At NorthShore University HealthSystem, SARS-CoV-2 was identified similarly using RT-PCR: Xpert Xpress or BD Max (Becton Dickinson, Franklin Lakes, NJ). Coinfections were detected using a multiplex RT-PCR panel that contained only the viral targets of the RVP (GenMark Dx, GenMark Diagnostics, Carlsbad, CA), as well as an IRP (Roche Cobas Liat Influenza A/B and RSV). We included all RVPs and IRPs that were obtained within 7 days of a SARS-CoV-2 test.

Remarkable advances have been made in the treatment of HIV. Despite progress in reducing perinatal HIV transmission, there is a growing number of adolescents and emerging adults with HIV who will require transfer of care from pediatric to adult providers. Adolescents with HIV have poorer retention in care and viral suppression compared to other age groups with HIV. Barriers to successful care of youth with HIV include mental health disorders, poor medication adherence, socioeconomic instability, and HIV-related stigma. Transfer of care to adult providers is often met with reluctance on the part of the adolescent. Recommendations for effective transfer of care include clear communication between adult and pediatric providers, early initiation of a transition planning discussion, a multidisciplinary team approach, and meeting the adult provider prior to the transfer of care. Adult HIV care may be more fragmented than adolescents are familiar with, but thoughtful transition approaches can foster development of health and life skills among youth with HIV. [Pediatr Ann. 2017;46(5):e198-e202.].

Shared decision making is a strategy to achieve health equity by strengthening patient-provider relationships and improve health outcomes. There is a paucity of research examining these factors among patients who identify as sexual or gender minorities and racial/ethnic minorities. Through intrapersonal, interpersonal and societal lenses, this project evaluates the relationship between intersectionality and shared decision making around anal cancer screening in Black gay and bisexual men, given their disproportionate rates of anal cancer. Thirty semi-structured, one-on-one interviews and two focus groups were conducted from 2016-2017. Participants were asked openended questions regarding intersectionality, relationships with healthcare providers and making shared decisions about anal cancer screening. 45 individuals participated; 30 in individual interviews and 15 in focus groups. All participants identified as black and male. 13 identified as bisexual and 32 as gay. Analysis revealed that the interaction of internalized racism, biphobia/ homophobia, provider bias and medical apartheid lead to reduced healthcare engagement and discomfort with discussing sexual practices, potentially hindering patients from engaging in shared decision making. Non-judgmental healthcare settings and provider relationships in which patients communicate openly about each aspect of their identity will promote effective shared decision making about anal cancer screening, and thus potentially impact downstream anal cancer rates.