HIV-positive status disclosure in patients in care in rural South Africa: implications for scaling up treatment and prevention interventions.

CAPRISA, 2015Abstract available in pdf

Geospatial analysis of emergency department visits for targeting community-based responses to the opioid epidemic

The opioid epidemic in the United States carries significant morbidity and mortality and requires a coordinated response among emergency providers, outpatient providers, public health departments, and communities. Anecdotally, providers across the spectrum of care at Massachusetts General Hospital (MGH) in Boston, MA have noticed that Charlestown, a community in northeast Boston, has been particularly impacted by the opioid epidemic and needs both emergency and longer-term resources. We hypothesized that geospatial analysis of the home addresses of patients presenting to the MGH emergency department (ED) with opioid-related emergencies might identify “hot spots” of opioid-related healthcare needs within Charlestown that could then be targeted for further investigation and resource deployment. Here, we present a geospatial analysis at the United States census tract level of the home addresses of all patients who presented to the MGH ED for opioid-related emergency visits between 7/1/2012 and 6/30/2015, including 191 visits from 100 addresses in Charlestown, MA. Among the six census tracts that comprise Charlestown, we find a 9.5-fold difference in opioid-related ED visits, with 45% of all opioid-related visits from Charlestown originating in tract 040401. The signal from this census tract remains strong after adjusting for population differences between census tracts, and while this tract is one of the higher utilizing census tracts in Charlestown of the MGH ED for all cause visits, it also has a 2.9-fold higher rate of opioid-related visits than the remainder of Charlestown. Identifying this hot spot of opioid-related emergency needs within Charlestown may help re-distribute existing resources efficiently, empower community and ED-based physicians to advocate for their patients, and serve as a catalyst for partnerships between MGH and local community groups. More broadly, this analysis demonstrates that EDs can use geospatial analysis to address the emergency and longer-term health needs of the communities they are designed to serve

Percent of all visits which are opioid-related.

<p>Bar graph of the percent of all visits to the MGH ED which are opioid-related from each census tract in Charlestown, MA. The dashed line represents the median percent of visits which are opioid-related from all census tracts within Charlestown (1.4%).</p

Opioid-related ED visits and addresses compared to population levels.

<p>Bar graph of observed vs population-weighted expected opioid-related visits (Left), and addresses (Right) from each census tract in Charlestown, MA. Expected distributions were calculated by weighting the total number of opioid-related ED visits (Left) or addresses (Right) from Charlestown by the population in each census tract. Observed distributions are the actual number of opioid-related ED visits (Left) or addresses (Right) from each census tract. The horizontal dotted line represents a simple (i.e. not population-weighted) average obtained by distributing the total number of opioid-related ED visits (Left) or addresses (Right) equally across all census tracts.</p

Opioid-related ED visits from Charlestown, MA.

<p>Choropleth map of Charlestown, MA at 1:17,000 scale with census tracts colored by level of opioid-related ED visits to MGH. Grey areas show boundaries of census tracts outside of Charlestown. Compass arrow at upper left points north. Blue shaded areas represent water and show the confluence of the Massachusetts Bay and the heads of the Charles, Mystic, and Chelsea Rivers.</p

Emergency department visits per capita.

<p>Bar graph of all visits (opioid-related and otherwise) to the MGH ED per capita from each census tract in Charlestown, MA based on the census tract level population from the 2010 US Census. The dashed line represents the median per capita visits across all census tracts in Charlestown (0.55).</p

Serial Procalcitonin Levels Correlate with Microbial Etiology in Hospitalized Patients with Pneumonia

Abstract Background: Procalcitonin (PCT) is a biomarker that is finding increasing diagnostic and prognostic utility in lower respiratory infections. It remains unclear, however, whether it can be helpful in predicting the bacterial etiology of pneumonia, with a view to informing antibiotic choice and duration. This study examines the relationship between serial PCT measurements and microbial etiology in patients hospitalized for pneumonia to determine whether changes in PCT levels provide discriminatory information on microbial etiology. Methods: We performed a subgroup analysis of data from a prospective cohort study of 505 patients admitted to a tertiary care center with findings concerning for pneumonia. Microbial etiology of pneumonia was determined from high quality respiratory samples, blood cultures or other relevant diagnostic tests according to standard protocols. Procalcitonin levels were measured serially during the first four days of hospitalization. We compared procalcitonin levels between different bacterial etiologies over the first four days of admission, using the Mann–Whitney-U test to assess for statistical significance. Results: Out of 505 patients, the diagnosis of pneumonia was adjudicated in 317, and bacterial etiology determined in 62 cases. The predominant pathogens were Staphylococcus aureus (N = 18), Streptococcus pneumoniae (N = 6), Pseudomonas aeruginosa (N = 11) and Haemophilus influenza (N = 5). Admission levels of PCT were lowest in Pseudomonas infections and highest in pneumococcal infections, though not reaching statistical significance. On hospital days two and three, pneumococcal procalcitonin levels were significantly higher than all other etiologies, but on day four, there was no statistically significant difference in PCT values for different microbial etiologies. Conclusion: Serial procalcitonin levels during the early course of bacterial pneumonia reveal a difference between pneumococcal and other bacterial etiologies, and may have an adjunct role in guiding antibiotic choice and duration. Disclosures All authors: No reported disclosures