An ED-focused clinical redesign project was associated with a 17% improvement in NEAT performance with no evidence of an increase in clinical deterioration on inpatient wards and evidence for an improvement in hospital mortality.

BackgroundThe comparative impact of chronic viral monoinfection versus coinfection on inpatient outcomes and health care utilization is relatively unknown. This study examined trends, inpatient utilization, and hospital outcomes for patients with HIV, HCV, or HIV/HCV coinfection.MethodsData were from the 1996–2010 National Hospital Discharge Surveys. Hospitalizations with primary ICD-9-CM codes for HIV or HCV were included for HIV and HCV monoinfection, respectfully. Coinfection included both HIV and HCV codes. Demographic characteristics, select comorbidities, procedural interventions, average hospital length of stay (LOS), and discharge status were compared by infection status (HIV, HCV, HIV/HCV). Annual disease estimates and survey weights were used to generate hospitalization rates.Results~6.6 million hospitalizations occurred in patients with HIV (39%), HCV (56%), or HIV/HCV (5%). The hospitalization rate (hospitalizations per 100 persons with infection) decreased in the HIV group (29.8 in 1996; 5.3 in 2010), decreased in the HIV/HCV group (2.0 in 1996; 1.5 in 2010), yet increased in the HCV group (0.2 in 1996; 0.9 in 2010). Median LOS from 1996 to 2010 (days, interquartile range) decreased in all groups: HIV, 6 (3–10) to 4 (3–8); HCV, 5 (3–9) to 4 (2–6); HIV/HCV, 6 (4–11) to 4 (2–7). Age-adjusted mortality rates decreased for all three groups. The rate of decline was least pronounced for those with HCV monoinfection.ConclusionHospitalizations have declined more rapidly for patients with HIV infection (including HIV/HCV coinfection) than for patients with HCV infection. This growing disparity between HIV and HCV underscores the need to allocate more resources to HCV care in hopes that similar large-scale improvements can also be accomplished for patients with HCV.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-536) contains supplementary material, which is available to authorized users.

Purpose The objectives of the study were to examine: (a) the types of questions that African American patients have about glaucoma for their providers and (b) how patients’ socio-demographic characteristics are associated with where and from whom they would like to learn about glaucoma and glaucoma medications. Methods Forty-nine Adult African American patients with glaucoma were recruited at a private ophthalmology clinic where they completed a questionnaire for this cross-sectional study. Results African American patients had a mean of 3.9 questions for their ophthalmologists; the questions that patients checked as having most often were “What is my prognosis with glaucoma?” (49%) and “What is my intraocular pressure?” (45%). Seventy-six percent of patients preferred that an educational program about glaucoma be offered at the doctor's office and 39% preferred it be offered at a community or senior citizen center. Ninety percent said that the education program should be offered by doctors. Patients under the age of seventy were significantly more likely to want a program on the Internet than patients age seventy and over (Pearson chi-square=4.7, p=0.03). If an educational program was developed patients reported being most interested in the following topics, glaucoma medications (84%), what is glaucoma and what does it mean to have it (83%). Conclusions African American patients have many questions about glaucoma for their eye care providers. African American patients would prefer glaucoma educational programs be offered at their provider's office. Our findings could be used to develop educational programs for African American patients with glaucoma.

We report hypersexuality in three people with schizophrenia after starting risperidone, with evidence suggesting a possible link between risperidone and the hypersexuality. Mrs X, 71 years old, married once and widowed for 20 years, with no known history of hypersexuality, was started on risperidone 25 mg intramuscular (IM) injection three times weekly. Two months later, she complained of 'having to' masturbate two to three times daily without being able to orgasm, lactating and losing 'too much fluids' vaginally. She became fixated on an imagined romantic relationship, took off her old wedding ring and attempted to hire a tourist boat for a wedding reception she planned for herself. Risperidone was stopped after 6 months and switched to pipotiazine 25 mg IM injection, three times weekly, after a washout period of 5 days. Features of hypersexuality waned and resolved 10 days later, with no recurrence. A 53-year-old man, Mr Y, took clozapine for 14 years before it was stopped due to neutropenia. He was started on oral risperidone 2 mg twice daily and developed thoughts fixated on masturbation, erections and needing a sexual partner. Risperidone was stopped and olanzapine initiated, with no disclosed sexual content in his thoughts from the next day. Hypersexual thoughts recurred on overnight leave. During the second overnight leave, he behaved indecently towards two young women in a park and was charged with indecent assault. A 23-year-old man, Mr Z, was re-titrated on risperidone after a period of non-adherence. From the day after oral risperidone was titrated up to 5 mg daily, when risperidone 50 mg IM injection was also administered, ten episodes of hypersexual behaviour were documented in a period of 10 days, including sexually disinhibited speech, propositioning and exhibitionism. Risperidone was tapered and stopped, and Mr Z was started on flupentixol 20 mg IM injection. There were no further episodes of hypersexual behaviour other than one episode of disinhibited speech when the risperidone was 3 mg daily. Mr Z was later readmitted and maintained on flupentixol 20 mg IM injection. No hypersexual behaviour occurred during this admission. None of these people were hypomanic. Bipolar disorder was excluded. Prolactin levels on risperidone were 2737 IU/l for Mrs X, and 468 IU/l for Mr Y. A review of the literature showed similar case reports. 1,2 Antagonism of 5-HT 2A receptors by risperidone, which increases dopamine release in the prefrontal cortex, and antagonism of alpha-2 adrenergic receptors, which disinhibits noradrenergic neurons and plays a role in genital stimulation, 3,4 could explain this effect. A similar mechanism of alpha-2 adrenergic blockade has been postulated for yohimbine. The expression of these receptors in individuals may affect vulnerability. Conventional

Ongoing injection drug use contributes to the HIV and HCV epidemics in people who inject drugs. In many places, pharmacies are the primary source of sterile syringes for people who inject drugs; thus, pharmacies provide a viable public health service that reduces blood-borne disease transmission. Replacing the supply of high dead space syringes with low dead space syringes could have far-reaching benefits that include further prevention of disease transmission in people who inject drugs and reductions in dosing inaccuracies, medication errors, and medication waste in patients who use syringes. We explored using pharmacies in a structural intervention to increase the uptake of low dead space syringes as part of a comprehensive strategy to reverse these epidemics.

BackgroundFew studies have explored how utilization of outpatient services differ for HIV/HCV coinfected patients compared to HIV or HCV monoinfected patients. The objectives of this study were to (1) compare annual outpatient clinic visit rates between coinfected and monoinfected patients, (2) to compare utilization of HIV and HCV therapies between coinfected and monoinfected patients, and (3) to identify factors associated with therapy utilization.MethodsData were from the 2005–2010 U.S. National Hospital Ambulatory Medical Care Surveys. Clinic visits with a primary or secondary ICD-9-CM codes for HIV or HCV were included. Coinfection included visits with codes for both HIV and HCV. Monoinfection only included codes for HIV or HCV, exclusively. Patients <15 years of age at time of visit were excluded. Predictors of HIV and HCV therapy were determined by logistic regressions. Visits were computed using survey weights.Results3,021 visits (11,352,000 weighted visits) met study criteria for patients with HIV/HCV (8%), HIV (70%), or HCV (22%). The HCV subgroup was older in age and had the highest proportion of females and whites as compared to the HIV/HCV and HIV subgroups. Comorbidities varied significantly across the three subgroups (HIV/HCV, HIV, HCV): current tobacco use (40%, 27%, 30%), depression (32%, 23%, 24%), diabetes (9%, 10%, 17%), and chronic renal failure (<1%, 3%, 5%), (p < 0.001 for all variables). Annual visit rates were highest in those with HIV, followed by HIV/HCV, but consistently lower in those with HCV. HIV therapy utilization increased for both HIV/HCV and HIV subgroups. HCV therapy utilization remained low for both HIV/HCV and HCV subgroups for all years. Coinfection was an independent predictor of HIV therapy, but not of HCV therapy.ConclusionThere is a critical need for system-level interventions that reduce barriers to outpatient care and improve uptake of HCV therapy for patients with HIV/HCV coinfection.

Prior studies that have assessed engagement within the various stages of care for persons living with HIV (PLWH) studied patients receiving care in HIV medical care facilities. These data are not representative of care received throughout the United States, as not all PLWH receive care in HIV clinics. This study evaluated engagement in outpatient care and healthcare utilization for PLWH, beyond facilities that specialize in HIV. Cross-sectional data were from the 2009-2010 National Hospital Ambulatory Medical Care Survey. Levels of care included receiving any care, receiving HIV-related care, established in care, engaged in care, and prescribed antiretroviral therapy (ARV). Factors associated with ARV prescription were determined by logistic regression. We analyzed data for *2.6 million outpatient clinic visits for PLWH. Of these, 90% were receiving HIV-related care, 86% were established in care, 75% were engaged in care, and 65% were prescribed ARV. In stratified analysis, the proportion of PWLH who were engaged in care varied by race/ethnicity ( p < 0.001) and ARV prescription varied significantly across the three age groups ( p = 0.004). Clinic visits within the past year did not differ for those prescribed ARV vs. not prescribed ARV [median, IQR = 3.3 visits (1.8-5.6) vs. 3.6 visits (1.3-5.9); p = 0.7]. Seeing a physician was associated with ARV prescription (OR = 0.27, 95% CI = 0.15-0.51), whereas routine engagement in care was not associated with ARV prescription (OR = 0.99, 95% CI = 0.96-1.03). Given that non-ARV-treated PLWH utilized outpatient care services at rates similar to ARV-treated PLWH, these routine clinic visits are missed opportunities for increasing ARV prescription in untreated patients.

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