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1.  An initiative to improve adherence to evidence-based guidelines in the treatment of URIs, sinusitis, and pharyngitis 
Upper respiratory infections, acute sinus infections, and sore throats are common symptoms that cause patients to seek medical care. Despite well-established treatment guidelines, studies indicate that antibiotics are prescribed far more frequently than appropriate, raising a multitude of clinical issues.
The primary goal of this study was to increase guideline adherence rates for acute sinusitis, pharyngitis, and upper respiratory tract infections (URIs). This study was the first Plan-Do-Study-Act (PDSA) cycle in a quality improvement program at an internal medicine resident faculty practice at a university-affiliated community hospital internal medicine residency program. To improve guideline adherence for respiratory infections, a package of small-scale interventions was implemented aimed at improving patient and provider education regarding viral and bacterial infections and the necessity for antibiotics. The data from this study was compared with a previously published study in this practice, which evaluated the adherence rates for the treatment guidelines before the changes, to determine effectiveness of the modifications. After the first PDSA cycle, providers were surveyed to determine barriers to adherence to antibiotic prescribing guidelines.
After the interventions, antibiotic guideline adherence for URI improved from a rate of 79.28 to 88.58% with a p-value of 0.004. The increase of adherence rates for sinusitis and pharyngitis were 41.7–57.58% (p=0.086) and 24.0–25.0% (p=0.918), respectively. The overall change in guideline adherence for the three conditions increased from 57.2 to 78.6% with the implementations (p<0.001). In planning for future PDSA cycles, a fishbone diagram was constructed in order to identify all perceived facets of the problem of non-adherence to the treatment guidelines for URIs, sinusitis, and pharyngitis. From the fishbone diagram and the provider survey, several potential directions for future work are discussed.
Passive interventions can result in small changes in antibiotic guideline adherence, but further PDSA cycles using more active methodologies are needed.
PMCID: PMC3937558  PMID: 24596644
antibiotic; guideline; adherence
2.  Improvement in Asthma Quality of Life in Patients Enrolled in a Prospective Study to Increase Lifestyle Physical Activity 
Asthma patients know the benefits of exercise but often avoid physical activity because they are concerned it will exacerbate asthma. The objective of this analysis was to assess longitudinal asthma status in 256 primary care patients in New York City enrolled in a trial to increase lifestyle physical activity.
Patients were randomized to two protocols to increase physical activity during 12 months. At enrollment patients completed the Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire (ACQ), and received asthma self-management instruction through an evaluative test and workbook. Exercise and self-management were reinforced every 2 months. The AQLQ was repeated every 4 months and the ACQ was repeated at 12 months.
The mean age was 43 years and 75% were women. At 12 months there were clinically important increases in physical activity with no differences between groups; thus data were pooled for asthma analyses. The enrollment AQLQ score was 5.0±1.3 and increased to 5.9±1.1; corresponding to a clinically important difference. Correlations between AQLQ and physical activity were approximately 0.35 (p<.0001) at each time point. In a mixed effects model, variables associated with improvement in AQLQ scores over time were male sex, less severe asthma, not taking maintenance asthma medications, fewer depressive symptoms, and increased physical activity (all variables p<0.03). According to the ACQ, asthma was well controlled in 38% at enrollment and in 60% at 12 months (p<.0001).
In conclusion, with attention to self management, increased physical activity did not compromise asthma control and was associated with improved asthma.
PMCID: PMC3567614  PMID: 23173979
exercise; energy expenditure; kcal/week; asthma control; asthma self-management
3.  Ambulatory Morning Report 
We assessed the ability of a novel ambulatory morning report format to expose internal medicine residents to the breadth of topics covered by the American Board of Internal Medicine (ABIM) exam. Cases were selected by the Ambulatory Assistant Chief Residents and recorded in a logbook to limit duplication. We conducted a retrospective review of 406 cases discussed from July 1998 to July 2000 and cataloged each according to the primary content area. The percentage of cases in each area accurately reflected that covered by the ABIM exam, with little redundancy or over-selection of esoteric diseases. Our data suggest that a general medicine clinic is capable of exposing house staff to the wide breadth of internal medicine topics previously thought to be unique to subspecialty clinics.
PMCID: PMC1495020  PMID: 11929507
postgraduate education; ambulatory care; internal medicine residency; morning report
4.  Identification, Genomic Organization, and Analysis of the Group III Capsular Polysaccharide Genes kpsD, kpsM, kpsT, and kpsE from an Extraintestinal Isolate of Escherichia coli (CP9, O4/K54/H5) 
Journal of Bacteriology  1998;180(2):338-349.
Group III capsular polysaccharides (e.g., K54) of extraintestinal isolates of Escherichia coli, similar to group II capsules (e.g., K1), are important virulence traits that confer resistance to selected host defense components in vitro and potentiate systemic infection in vivo. The genomic organization of group II capsule gene clusters has been established as a serotype-specific region 2 flanked by regions 1 and 3, which contain transport genes that are highly homologous between serotypes. In contrast, the organization of group III capsule gene clusters is not well understood. However, they are defined in part by an absence of genes with significant nucleotide homology to group II capsule transport genes in regions 1 and 3. Evaluation of isogenic, TnphoA-generated, group III capsule-minus derivatives of a clinical blood isolate (CP9, O4/K54/H5) has led to the identification of homologs of the group II capsule transport genes kpsDMTE. These genes and their surrounding regions were sequenced and analyzed. The genomic organization of these genes is distinctly different from that of their group II counterparts. Although kpsK54DMTE are significantly divergent from their group II homologs at both the DNA and protein levels phoA fusions and computer-assisted analyses suggest that their structures and functions are similar. The putative proteins KpsK54M and KpsK54T appear to be the integral membrane component and the peripheral ATP-binding component of the ABC-2 transporter family, respectively. The putative KpsK54E possesses features similar to those of the membrane fusion protein family that facilitates the passage of large molecules across the periplasm. At one boundary of the capsule gene cluster, a truncated kpsM (kpsMtruncated) and its 5′ noncoding regulatory sequence were identified. In contrast to the complete kpsK54M, this region was highly homologous to the group II kpsM. Fifty-three base pairs 3′ from the end of kpsMtruncated was a sequence 75% homologous to the 39-bp inverted repeat in the IS110 insertion element from Streptomyces coelicolor. Southern analysis established that two copies of this element are present in CP9. These findings are consistent with the hypothesis that CP9 previously possessed group II capsule genes and acquired group III capsule genes via IS110-mediated horizontal transfer.
PMCID: PMC106889  PMID: 9440523

Results 1-4 (4)