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Kuczmarska A.,The Commonwealth Medical College | Ngo L.H.,Beth Israel Deaconess Medical Center | Ngo L.H.,Harvard University | Guess J.,Beth Israel Deaconess Medical Center | And 7 more authors.
Journal of General Internal Medicine | Year: 2016

Background: Delirium is common in older hospitalized patients and is associated with poor outcomes, yet most cases go undetected. The best approach for systematic delirium identification outside the intensive care unit remains unknown. Objective: To conduct a comparative effectiveness study of the Confusion Assessment Method for the ICU (CAM-ICU) and the newly developed 3-minute diagnostic assessment for delirium using the Confusion Assessment Method (3D-CAM) in general medicine inpatients. Design: Cross-sectional comparative effectiveness study. Setting: Two non-intensive care general medicine units at a single academic medical center. Participants: Hospitalized general medicine patients aged ≥75 years. Measurements: Clinicians performed a reference standard assessment for delirium that included patient interviews, family interviews, and review of the medical record. An expert panel determined the presence or absence of delirium using DSM-IV criteria. Two blinded research assistants administered the CAM-ICU and the 3D-CAM in random order, and we determined their diagnostic test characteristics compared to the reference standard. Results: Among the 101 participants (mean age 84 ± 5.5 years, 61 % women, 25 % with dementia), 19 % were classified as delirious based on the reference standard. Evaluation times for the 3D-CAM and CAM-ICU were similar. The sensitivity [95 % confidence interval (CI)] of delirium detection for the 3D-CAM was 95 % [74 %, 100 %] and for the CAM-ICU was 53 % [29 %, 76 %], while specificity was >90 % for both instruments. Subgroup analyses showed that the CAM-ICU had sensitivity of 30 % in patients with mild delirium vs. 100 % for the 3D-CAM. Conclusions: In this comparative effectiveness study, we found that the 3D-CAM had substantially higher sensitivity than the CAM-ICU in hospitalized older general medicine patients, and similar administration time. Therefore, the 3D-CAM may be a superior screening tool for delirium in this patient population. © 2015, Society of General Internal Medicine. Source


Cioe P.A.,Brown University | Gamarel K.E.,Brown University | Pantalone D.W.,University of Massachusetts Boston | Monti P.M.,Brown University | And 3 more authors.
AIDS and Behavior | Year: 2016

Cigarette smoking and heavy alcohol use is prevalent among HIV-infected men who sex with men (MSM) and have been linked to imperfect antiretroviral therapy (ART) adherence. Our study examined the correlates of smoking and whether smoking was independently associated with imperfect adherence in heavy-drinking HIV-infected MSM. Of the 185 participants, approximately half (n = 91, 49.2 %) reported having smoked cigarettes in the past 30 days. Current smokers were more likely to have reported imperfect adherence compared to non-smokers (37.4.2 vs. 22.3 %, p < 0.05). In multivariable regression analyses, only lower education was significantly associated with imperfect adherence. This study demonstrated that the greatest risk factor for smoking and imperfect ART adherence was low socioeconomic status, in which MSM of color were over-represented. As the first study to examine smoking and ART adherence in this population, our study has the potential to inform the clinical care provided to heavy-drinking MSM. © 2016 Springer Science+Business Media New York Source


Yanik E.L.,University of North Carolina at Chapel Hill | Napravnik S.,University of North Carolina at Chapel Hill | Cole S.R.,University of North Carolina at Chapel Hill | Achenbach C.J.,Northwestern University | And 12 more authors.
Clinical Infectious Diseases | Year: 2013

BackgroundCancer is an important cause of morbidity and mortality in individuals infected with human immunodeficiency virus (HIV), but patterns of cancer incidence after combination antiretroviral therapy (ART) initiation remain poorly characterized.MethodsWe evaluated the incidence and timing of cancer diagnoses among patients initiating ART between 1996 and 2011 in a collaboration of 8 US clinical HIV cohorts. Poisson regression was used to estimate incidence rates. Cox regression was used to identify demographic and clinical characteristics associated with cancer incidence after ART initiation.ResultsAt initiation of first combination ART among 11 485 patients, median year was 2004 (interquartile range [IQR], 2000-2007) and median CD4 count was 202 cells/mm3 (IQR, 61-338). Incidence rates for Kaposi sarcoma (KS) and lymphomas were highest in the first 6 months after ART initiation (P <. 001) and plateaued thereafter, while incidence rates for all other cancers combined increased from 416 to 615 cases per 100 000 person-years from 1 to 10 years after ART initiation (average 7% increase per year; 95% confidence interval, 2%-13%). Lower CD4 count at ART initiation was associated with greater risk of KS, lymphoma, and human papillomavirus-related cancer. Calendar year of ART initiation was not associated with cancer incidence.ConclusionsKS and lymphoma rates were highest immediately following ART initiation, particularly among patients with low CD4 cell counts, whereas other cancers increased with time on ART, likely reflecting increased cancer risk with aging. Our results underscore recommendations for earlier HIV diagnosis followed by prompt ART initiation along with ongoing aggressive cancer screening and prevention efforts throughout the course of HIV care. © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. Source


Barresi P.,University of California at San Francisco | Husnik M.,Statistical Center for Research and Prevention | Camacho M.,New York Blood Center | Powell B.,Howard Brown Health Center | And 4 more authors.
AIDS Education and Prevention | Year: 2010

Testing HIV prevention strategies requires that researchers recruit participants at high risk of HIV infection. Data from the EXPLORE Study, a behavioral intervention trial involving men who have sex with men (MSM), were used to examine the relationship between recruitment strategies and participant characteristics, sexual risk behaviors and HIV incidence. The EXPLORE Study used a wide variety of recruitment strategies; no one strategy accounted for more than 20% of enrolled men. Younger men and men of color were more likely to be recruited through club and bar outreach, friend referral, and street outreach. Men reporting 10 or more sexual partners were more likely to be recruited through advertising and street outreach. Men reporting unprotected sex were more likely to be recruited through clinic referrals. HIV incidence did not significantly differ by recruitment strategy. Our findings support the need for a wide range of recruitment strategies in attracting MSM at high risk for HIV into clinical studies. © 2010 The Guilford Press. Source


Yanik E.L.,University of North Carolina at Chapel Hill | Napravnik S.,University of North Carolina at Chapel Hill | Ryscavage P.,University of Maryland, Baltimore | Eron J.J.,University of North Carolina at Chapel Hill | And 10 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2013

We assessed laboratory monitoring after combination antiretroviral therapy initiation among 3678 patients in a large US multisite clinical cohort, censoring participants at last clinic visit, combination antiretroviral therapy change, or 3 years. Median days (interquartile range) to first hematologic, hepatic, renal, and lipid tests were 30 (18-53), 31 (19-56), 33 (20-59), and 350 (96-1106), respectively. At 1 year, approximately 80% received more than 2 hematologic, hepatic, and renal tests consistent with guidelines. However, only 40% received 1 or more lipid tests. Monitoring was more frequent in specific subgroups, likely reflecting better clinic attendance or clinician perception of higher susceptibility to toxicities. Copyright © 2013 by Lippincott Williams & Wilkins. Source

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