Improving Patient-Provider Communication in the Health Care context

The following study focuses on ways in which health care providers seem to competently breaking bad news to patients that are college age (18-25yrs old). Breaking bad news is an inevitable and daunting part of working in the health care profession. Delivering this type of news to college age students could occur more frequently than with other cohorts. Buckman (1992) presents methodology for teaching breaking bad news to health care providers in the form of the SPIKES model, which are similar to the identified “essential elements” of communication in medical encounters described by communication scholars (Makoul, 2001). Several interviews were conducted with college age participants who had bad news broken to them by a health care provider. These bad news situations ranged from STDs, death of a family member, life long illness, and sport injuries. Two over arching themes of effective and ineffective ways to break bad news were present in the data; the sub-categories of express caring and being direct were shown as effective ways to break bad news to college age students and robotic and non-responsive as ineffective. The findings presented in this study can provide health care providers with insight on how to improve communication skills when working with college age patients

An Exhibition in Student Leadership: The Academic Alternative Spring Break Experience

An Exhibition in Student Leadership: The Academic Alternative Spring Break Experience Ryan Kilpatrick and Elise Glidden Faculty Sponsor: Gail Faris, Women’s Center The Academic Alternative Spring Break program was founded at URI by Gail Faris six years ago in an effort to introduce students to the ideas of service learning, social justice, and what it means to be a concerned citizen. We were first introduced to this idea in the spring of 2009, when we took the course, Classroom without Borders: Academic Alternative Spring Break. It was about a year later that we both decided that our senior project would focus around this concept, but with an added component of student leadership. The idea of an Academic Alternative Spring Break may not be specifically related to our respective majors, but it is one that is both important in our lives and will help us in our future careers, whatever they may be. Our project is unique for two reasons. It is a joint project, and it is also the first AASB to be led by students at the University of Rhode Island. In order to prepare for this trip, we underwent leadership training, planned and coordinated the logistics of the trip, and played a key part in selecting the students who would participate in the pilot program. We also acted as teacher’s assistants in the Spring 2011 Classroom Without Borders in order to familiarize ourselves with the material covered in the class and with the six students we chose for our trip. The spring break trip itself was a culmination of our training and a test of our leadership skills. Our product, a student leadership guide, highlights the numerous steps undertaken to successfully plan and implement an AASB trip from a student leader perspective. It is our hope that this guide is informative and will be passed on and used by future student leaders at URI so that they will have the success that we did. Our presentation will portray the dedication and effort that went into our senior project before, during, and after the spring break trip. It will also include pictures and videos that further capture the spirit of our experience. It is our firm belief that the successful completion of this project has led to both the development of our leadership skills, and our passion to serve as concerned citizens of our local and national communities, and we see this project as a stepping stone to a life of servant leadership and a commitment to social justice

The value of kinetic glomerular filtration rate estimation on medication dosing in acute kidney injury.

BackgroundIn acute kidney injury (AKI), medication dosing based on Cockcroft-Gault creatinine clearance (CrCl) or Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated glomerular filtration rates (eGFR) are not valid when serum creatinine (SCr) is not in steady state. The aim of this study was to determine the impact of a kinetic estimating equation that incorporates fluctuations in SCrs on drug dosing in critically ill patients.MethodsWe used data from participants enrolled in the NIH Acute Respiratory Distress Syndrome Network Fluid and Catheters Treatment Trial to simulate drug dosing category changes with the application of the kinetic estimating equation developed by Chen. We evaluated whether kinetic estimation of renal function would change medication dosing categories (≥60, 30-59, 15-29, and <15mL/min) compared with the use of CrCl or CKD-EPI eGFR.ResultsThe use of kinetic CrCl and CKD-EPI eGFR resulted in a large enough change in estimated renal function to require medication dosing recategorization in 19.3% [95 CI 16.8%-21.9%] and 23.4% [95% CI 20.7%-26.1%] of participants, respectively. As expected, recategorization occurred more frequently in those with AKI. When we examined individual days for those with AKI, dosing discordance was observed in 8.5% of total days using the CG CrCl and 10.2% of total days using the CKD-EPI equation compared with the kinetic counterparts.ConclusionIn a critically ill population, use of kinetic estimates of renal function impacted medication dosing in a substantial proportion of AKI participants. Use of kinetic estimates in clinical practice should lower the incidence of medication toxicity as well as avoid subtherapeutic dosing during renal recovery

Helicobacter pylori test-and-treat intervention compared to usual care in primary care patients with suspected peptic ulcer disease in the United States

The Helicobacter pylori ( H. pylori ) “test-and-treat” strategy in uninvestigated dyspepsia is an effective alternative to prompt endoscopy. Our aims were to determine whether the combination of an educational session and availability of office-based H. pylori testing (test-and-treat intervention [TTI]) increases use of the test-and-treat strategy by primary care practitioners and whether it improves patient outcomes. Methods : We conducted a 1-yr prospective trial of patients with suspected peptic ulcer disease in six primary care centers, three with TTI and three designated as usual care controls (UCC). Results : H. pylori testing was performed in 81% of 54 TTI patients and in 49% of 39 UCC patients ( p = 0.004). TTI and UCC patients had similar gastroenterology referral rates (24% vs 33%, p = 0.33), endoscopy or upper GI radiography rates (30% vs 31%, p = 0.91), and primary care visits per patient (3.1 ± 2.8 vs 3.1 ± 2.6, p = 0.92). TTI patients were less likely than UCC patients to receive repeated antisecretory medication prescriptions (35% vs 66%, p = 0.003). Symptomatic status at 1 yr and satisfaction with medical care did not differ between groups. Median (and interquartile range) annualized disease-related expenditures per patient were $454 ($162–932) for TTI and $576 ($327–1435) for UCC patients ( p = 0.17). Conclusions : The combination of an educational session and availability of office-based H. pylori testing may increase acceptance of the test-and-treat strategy by primary care providers. It remains to be determined whether increased use of the test-and-treat strategy yields significant improvements in clinical and economic outcomes compared to usual care.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74830/1/j.1572-0241.2002.07118.x.pd

Evaluating the impact of policies recommending PrEP to subpopulations of men and transgender women who have sex with men based on demographic and behavioral risk factors.

IntroductionDeveloping guidelines to inform the use of antiretroviral pre-exposure prophylaxis (PrEP) for HIV prevention in resource-limited settings must necessarily be informed by considering the resources and infrastructure needed for PrEP delivery. We describe an approach that identifies subpopulations of cisgender men who have sex with men (MSM) and transgender women (TGW) to prioritize for the rollout of PrEP in resource-limited settings.MethodsWe use data from the iPrEx study, a multi-national phase III study of PrEP for HIV prevention in MSM/TGW, to build statistical models that identify subpopulations at high risk of HIV acquisition without PrEP, and with high expected PrEP benefit. We then evaluate empirically the population impact of policies recommending PrEP to these subpopulations, and contrast these with existing policies.ResultsA policy recommending PrEP to a high risk subpopulation of MSM/TGW reporting condomless receptive anal intercourse over the last 3 months (estimated 3.3% 1-year HIV incidence) yields an estimated 1.95% absolute reduction in 1-year HIV incidence at the population level, and 3.83% reduction over 2 years. Importantly, such a policy requires rolling PrEP out to just 59.7% of MSM/TGW in the iPrEx population. We find that this policy is identical to that which prioritizes MSM/TGW with high expected PrEP benefit. It is estimated to achieve nearly the same reduction in HIV incidence as the PrEP guideline put forth by the US Centers for Disease Control, which relies on the measurement of more behavioral risk factors and which would recommend PrEP to a larger subset of the MSM/TGW population (86% vs. 60%).ConclusionsThese findings may be used to focus future mathematical modelling studies of PrEP in resource-limited settings on prioritizing PrEP for high-risk subpopulations of MSM/TGW. The statistical approach we took could be employed to develop PrEP policies for other at-risk populations and resource-limited settings

PREDOMINANTLY LOW METALLICITIES MEASURED IN A STRATIFIED SAMPLE OF LYMAN LIMIT SYSTEMS AT Z = 3.7

We measured metallicities for 33 z = 3.4–4.2 absorption line systems drawn from a sample of H i-selected-Lyman limit systems (LLSs) identified in Sloan Digital Sky Survey (SDSS) quasar spectra and stratified based on metal line features. We obtained higher-resolution spectra with the Keck Echellette Spectrograph and Imager, selecting targets according to our stratification scheme in an effort to fully sample the LLS population metallicity distribution. We established a plausible range of H i column densities and measured column densities (or limits) for ions of carbon, silicon, and aluminum, finding ionization-corrected metallicities or upper limits. Interestingly, our ionization models were better constrained with enhanced α-to-aluminum abundances, with a median abundance ratio of [α/Al] = 0.3. Measured metallicities were generally low, ranging from [M/H] = −3 to −1.68, with even lower metallicities likely for some systems with upper limits. Using survival statistics to incorporate limits, we constructed the cumulative distribution function (CDF) for LLS metallicities. Recent models of galaxy evolution propose that galaxies replenish their gas from the low-metallicity intergalactic medium (IGM) via high-density H i "flows" and eject enriched interstellar gas via outflows. Thus, there has been some expectation that LLSs at the peak of cosmic star formation (z ≈ 3) might have a bimodal metallicity distribution. We modeled our CDF as a mix of two Gaussian distributions, one reflecting the metallicity of the IGM and the other representative of the interstellar medium of star-forming galaxies. This bimodal distribution yielded a poor fit. A single Gaussian distribution better represented the sample with a low mean metallicity of [M/H] ≈ −2.5.Massachusetts Institute of Technology. Undergraduate Research Opportunities ProgramNational Science Foundation (U.S.) (Award AST-1109915

A coupled terrestrial and aquatic biogeophysical model of the Upper Merrimack River watershed, New Hampshire, to inform ecosystem services evaluation and management under climate and land-cover change

Accurate quantification of ecosystem services (ES) at regional scales is increasingly important for making informed decisions in the face of environmental change. We linked terrestrial and aquatic ecosystem process models to simulate the spatial and temporal distribution of hydrological and water quality characteristics related to ecosystem services. The linked model integrates two existing models (a forest ecosystem model and a river network model) to establish consistent responses to changing drivers across climate, terrestrial, and aquatic domains. The linked model is spatially distributed, accounts for terrestrial–aquatic and upstream–downstream linkages, and operates on a daily time-step, all characteristics needed to understand regional responses. The model was applied to the diverse landscapes of the Upper Merrimack River watershed, New Hampshire, USA. Potential changes in future environmental functions were evaluated using statistically downscaled global climate model simulations (both a high and low emission scenario) coupled with scenarios of changing land cover (centralized vs. dispersed land development) for the time period of 1980–2099. Projections of climate, land cover, and water quality were translated into a suite of environmental indicators that represent conditions relevant to important ecosystem services and were designed to be readily understood by the public. Model projections show that climate will have a greater influence on future aquatic ecosystem services (flooding, drinking water, fish habitat, and nitrogen export) than plausible changes in land cover. Minimal changes in aquatic environmental indicators are predicted through 2050, after which the high emissions scenarios show intensifying impacts. The spatially distributed modeling approach indicates that heavily populated portions of the watershed will show the strongest responses. Management of land cover could attenuate some of the changes associated with climate change and should be considered in future planning for the region

Depression and Oral FTC/TDF Pre-exposure Prophylaxis (PrEP) Among Men and Transgender Women Who Have Sex With Men (MSM/TGW).

We conducted a longitudinal and cross-sectional analysis of depressive symptomology in iPrEx, a randomized, placebo-controlled trial of daily, oral FTC/TDF HIV pre-exposure prophylaxis (PrEP) in men and transgender women who have sex with men. Depression-related adverse events (AEs) were the most frequently reported severe or life-threatening AEs and were not associated with being randomized to the FTC/TDF arm (152 vs. 144 respectively OR 0.66 95 % CI 0.35-1.25). Center for Epidemiologic Studies Depression scale (CES-D) and a four questions suicidal ideation scale scores did not differ by arm. Participants reporting forced sex at anal sexual debut had higher CES-D scores (coeff: 3.23; 95 % CI 1.24-5.23) and were more likely to have suicidal ideation (OR 2.2; 95 % CI 1.09-4.26). CES-D scores were higher among people reporting non-condom receptive anal intercourse (ncRAI) (OR 1.46; 95 % CI 1.09-1.94). We recommend continuing PrEP during periods of depression in conjunction with provision of mental health services