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Division of Infectious Diseases

Policies, Principles and Pragmatism: Are We Following Evidence or Emotion Regarding Infection Control in the OR

In this recent invited article in Clinical Infectious Diseases, our surgical colleagues highlight the ongoing debate regarding what surgical attire should be worn in the operating room.  Highlighted issues are what type of hats should be donned, including those noted in the picture of skullcap versus bouffant, whether or not scrubs are safer or more likely to spread bacteria (hence the title catch phrase of ‘Naked Surgeons?’), the value of protective eye wear and the discordant recommendations of the different organizations regarding whether arms should be bare or covered. Many of our current practices are be based on written guidelines and regulations, which may not have a robust evidence base.

The thought provoking, non-systematic review of the literature, does raise the question of whether we are truly making recommendations and hospital policies that are actually evidence-based and yet practical, or if we are responding more so to the emotional attachment to tradition, our perceptions of risk that may be unproven, our believed principles of how infection is likely spread in the OR and the ease of not shifting patient expectations.

Perhaps it is time to reconsider the how and why of what we implement in Infection Control – and how we can truly improve to practical, evidence-based, regulations, guidelines and effective, infection control programs.

ID Administrator completes MBA degree as Distinguished Graduate

The University of Nebraska Medical Center Division of Infectious Diseases would like to congratulate our Division Administrator Jonathan Nguyen who recently successfully completed his MBA program at University of Nebraska.

In recognition of his hard work,  Jon was singled out for honors by being selected as the Distinguished Graduate of his class by the business school faculty.

Congratulations on a terrific achievement Jon! Also, congratulations to Jon’s family who have had to sacrifice while Jon completed coursework and various projects.

We look forward to the application of Jon’s newly acquired skills and knowledge in the management of the ID Division.

Content courtesy Dr. Mark Rupp MD, Infectious Diseases Division Chief

Nebraska AIDS Projects’ Night of A Thousand Stars – Under the City Lights: A Gala with a Mission

As December, and our HIV awareness posts come to an end, we want to celebrate one of Nebraska Medicine’s partners that works closely with our Specialty Care Center to provide HIV care, and creates inclusive and safe spaces for diverse communities across Nebraska.

The Nebraska AIDS Project (NAP) is a non-profit organization established in 1984 in response to the early AIDS crisis when less was known about HIV and AIDS and there were fewer treatment options. NAP serves the entire state of Nebraska with offices in Omaha, Lincoln, Norfolk, Kearney, and Scottsbluff, reaching approximately 350-400 people living with HIV at any given time in Case Management and Supportive Services (social support, financial assistance, linkage to care and treatment). NAP also provides free and confidential testing across the state of Nebraska, performing approximately 2,000 tests annually and provides free access to condoms and safe sex counseling.

On Saturday December 2, 2017, the Nebraska AIDS Project put on a gala with a mission: The Night of a Thousand Stars.  This is an annual event targeted to raise around $100k to support the programs of the Nebraska AIDS Project. The Stars gala has raised over two million dollars since the fundraiser began in 1998, and on December 2, in 2017, they raised $86,000 for their programs.

Every year NAP recognizes individuals in the community who have publicly demonstrated dedication to serving the community. This year’s Shining Star Award Winners at Stars were Brenda Council and Dr. Jay Irwin and the honorary chair was State Senator Adam Morfeld.

  • Brenda Council was on the original NAP board, and has served on the Omaha Public School Board, on the Omaha City Council, in the Nebraska Legislature, and nearly became the mayor of Omaha TWICE in 1994 and then again in 1997, losing by a narrow margin both times. More recently, she drives the Adolescent Health Project (AHP) effort for Douglas County and she continues to perform public service in a number of different ways, most passionately linked to reducing unplanned and/or unwanted teen pregnancies. Her role as the AHP Program Director enables her to work on teen pregnancy AND reduction of STI’s among young adults as well.
  • Jay Irwin is a well-respected community member who represents inclusion of all types of identities within his primary role as a professor at UNO, but also as an elected member to Ralston’s Public School board. Jay has a unique tie to an audience of young folx in our community (“folx” is a term that refers to a generic group but with intentional inclusion of non-binary people, similar to “Latinx”).  Young folx are a demographic targeted by NAP for education/testing services and NAP embraces the active voices in the community that speak to this audience. Jay was the first openly-trans man to be elected to a publicly held office in the state of Nebraska (elected to RPS school board in 2016) and is also a part of the Midlands Sexual Health Research Collaborative.
  • State Senator Adam Morfeld was this year’s Night of a Thousand Stars honorary chair– similarly selected by overall values and initiatives that are in line with the NAP mission, Adam is continually pushing social justice issues in the unicam and is the acting Executive Director of Nebraskans for Civic Reform (NCR).

Nebraska AIDS project would like to thank Nebraska Medicine, one of the Night Under The Stars’ Gold sponsors, and all sponsors who contributed to making this event a success.

Content provided by London Woolman, Interim Executive Director, Nebraska AIDS Project

 

Faculty and Staff of the UNMC/Nebraska Medicine Specialty Care Center at the Night of A Thousand Stars Gala Event on December 2, 2017

Photo courtesy Justin Barnes and Nebraska AIDS Project

Research in HIV Medicine…charting a path to longer lives and ending HIV transmission

Research has long been an important part of the mission of the HIV Team at UNMC’s Specialty Care Center For many years, clinic patients clinic have had the opportunity to take part in a variety of projects including interventional treatment for HIV, the study of comorbid conditions and opportunistic infections, and trials targeted towards HIV prevention.

Currently, our team has patients enrolled in eleven active studies:

  • Five trials currently involve providing innovative treatment for HIV through long-acting injectable medications given either every four or every eight weeks.
  • The addition of pharmacists to our staff has enabled us to initiate pharmacist-led studies, including prevention of HIV through pre-exposure prophylaxis (PrEP), increasing medication adherence by using telehealth services in rural areas, and the study of pharmacokinetics in transgender women receiving both PrEP and feminizing hormone therapy.
  • Teaming with the UNMC Department of Pharmacology and Experimental Neuroscience, we are examining the brain basis of HIV-associated neurocognitive disorder using MEG and MRI technology coupled with neuropsychological evaluation. An extension of this study involves looking at marijuana consumption and its effects on the brain in those living with HIV infection.
  • Working with the AIDS Clinical Trial Group of the NIH, the REPRIEVE study looks at using pitavastatin as a medication to prevent cardiovascular events in people living with HIV who are otherwise not at high risk for cardiac disease.

We feel fortunate to be a part of an institution that supports research and gives our patients the chance to be a part of the most up-to-date science in HIV care.

 

For more information about ongoing research studies at the HIV Clinic, contact Maureen Kubat, RN, BSN at mo.kubat@unmc.edu or Jen O’Neill, RN, BSN at jloneill@unmc.edu

Content courtesy Mo Kubat and Jen O’Neill

Caring for persons living with HIV is not just about keeping viral loads undetectable

Preparing for my 4-week advanced pharmacy practice experience at the Nebraska Medicine Specialty Care Clinic was slightly nerve-wracking if I am honest. In the days leading up to my start, trepidation creeped in as I considered the unknown of the experience. “What if I say something wrong?” “Will it sound false if I am trying to relate?” “I want to ensure they receive the best care- even from a student.” These were just some of the thoughts I had running through my head. Thanks to my didactic education I felt confident my clinical knowledge would be up to the challenge of the rotation, but could I say that my patient care skills were equally ready? If I had to say at the time, maybe they were not as ready, but those questions of concern should not have been any different for this rotation than any other. Yes, this was a new patient population for me, and yes, I was new to them, but beyond that, my rotation at SCC still required the same care and approach as each one before it. In the end, my trepidation was minimized with some of my first patient interactions.

As a pharmacy student, my usual focus is on the safety and appropriateness of each medication prescribed. However, at SCC, each patient encounter goes beyond that. Each opportunity to interview, counsel, or make recommendations for a patient is an opportunity to learn about their experience, management of their diagnosis, and even trepidations about their diagnosis or regimen. Because for an HIV-infected patient, their diagnosis is only one portion of their life and as unique as the person themselves. They can be an individual who has managed their HIV for decades and seen the changes in treatment firsthand or another who is newly diagnosed, undertaking the beginning of their treatment, and still unsure of what to ask. It is because of their individuality as patients that I developed more as a care provider with each clinic day. I was continually amazed by each patient’s willingness to keep an open dialogue and provide me, the student, with their perspective at the visit. It required patience and practice to adapt each care plan for the patient. I am confident I did not always hit every point, and once or twice, quote, “stepped in it” with my approach, but those were the days when I learned the most. In fact, so many of my experiences at the clinic ended up with my learning more from the patient than I had set out to share with them when I walked in the room.

And at the Nebraska Medicine Specialty Care Clinic, the staff is truly focused on complete care for each patient. It is not simply about keeping viral loads undetectable and CD4 counts high, but ensuring the continued health of their patients – both their physical and mental well-being is maintained and working as a team to do so. Every patient’s care is managed from multiple angles thanks to the providers, nurses, pharmacists, clinic coordinators, social workers, and ancillary staff. No patient is the same and the staff’s continued effort to maintain this perspective is exceptional. Even on days when the patient load is high and the hours are long, no one is forgotten or minimized. Care is provided until the last patient walks out the door. It is inspiring for students who are just beginning their careers to see such dedication and commitment to this patient population.

On my last day at SCC, I saw one of my patients from the first week of my rotation. A seasoned patient who had years of experience managing his diagnosis, but still some struggles along the way. I felt so honored to have been another contributor to maintaining his care at SCC. I had only a small role in his care, but the opportunity to hear his story, join in his management, and make a difference in his health was a satisfying culmination to four weeks of learning.

 

Content courtesy Lauren E Pohren, UNMC PharmD Candidate 2018

Textbook on Immunocompromised Patients Goes Global

 

Dr. Alison Freifeld co-edited a clinical textbook on infections in immunocompromised hosts with Dr. Pranatharthi Chandrasekar, Dr. Ajit Limaye and Dr. Emily Blumberg. The textbook is gaining a global audience and is now available in Japanese. 

Dr. Freifeld was the section editor for infections in Oncology patients. 

Per Dr. Freifeld:  “Immunosuppressed patients — particularly those being treated for malignancies — are found globally and accordingly, it is essential for physicians (and especially ID physicians who are often the consultants for the tougher cases) to be able to diagnose and treat the infectious risks as a consequence of cancer and it’s therapies.” 

 Congratulations on expanding education efforts to an increasingly global audience!

Learn more about the Infectious Diseases Division and Dr. Freifeld here.

 


 

Pharmacists’ care of persons living with HIV – more than just medications

Josh Havens, PharmD, BCPS, Kim Scarsi, PharmD, BCPS, Anthony Podany, PharmD, and Valentina Orduna make up the pharmacy team at the Specialty Care Clinic (SCC).  Pharmacy staff are fully integrated within the HIV care team at SCC.  We help manage SCC patients for a variety of issues including antiretroviral therapy (ART) initiation or switching, management of ART related drug-drug interactions, medication adherence, medication access, Hepatitis C treatment, pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP/nPEP). All pharmacy staff are involved with National Institutes of Health and industry supported investigator-initiated research. SCC also supports the education mission of UNMC, as an advanced pharmacy practice experiential site for fourth year pharmacy students.

SCC provides a unique experience for a pharmacist. We autonomously see patients and collaborate with other SCC team members to provide the best comprehensive care for our patients. The amount of trust put into the pharmacy staff by other SCC team members is a rarity and we are truly grateful to be a part of the SCC team.

Providing care for patients living with HIV can be very rewarding yet challenging at times.  The smallest change in our patients care can result in drastic improvements in their health and well-being.  Seeing the impact of the interdisciplinary care provided at the SCC never ceases to amaze.  At the end of the day, it is an awesome experience to be an  important part of our patients’ care.

Content courtesy Joshua Havens, PharmD (Clinical Pharmacist, Specialty Care Clinic),  Kim Scarsi, PharmD MS (Associate Professor, Department of Pharmacy), and  Valentina Orduna (Pharmacy Support Assistant, Specialty Care Clinic)


 

Welcoming Ada Florescu as our ID blog assistant!

We are SO thrilled to have Ada joining our blog team! She will be helping with creating and scheduling posts, so we want to introduce her to you all!

“My name is Ada Florescu and I am a junior at the University of Nebraska at Lincoln.  I am a Biology major and a Spanish minor. I recently studied abroad in Seville, Spain so the number of classes I need to take for my minor are quickly dwindling. On the other side of things, it is time to take on several semesters of a full course load of science courses. I am projected to graduate in the Spring of 2019 and after my graduation I am hoping to take a gap year in order to work in a professional medical environment and to get myself prepared for what is to come in medical school. There is still so much time for me to decide, but as of right now, my career goal is to become an OB/GYN or fertility doctor.* I believe UNMC will be such a positive resource to me in achieving these goals so I am so excited to be a part of the UNMC ID blog. I believe it will allow me to acquaint myself with more medical terminology and cases in order to better prepare me for the things I will face in my future.”

*Don’t worry, we are planning on trying to convince her that Internal Medicine and Infectious Diseases are definitely the way to go!!


 

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Testimony: A Patient with HIV Speaks Up to Share her Status and Try to Change Minds

I don’t know how to sum up the last 24 years into just a few paragraphs, but I will try.

Words can be quite powerful. The most unforgettable were the ones I read when my adult life was just beginning. At the age of 17, I received a certified letter stating that I had a “potentially serious condition of a personal nature”.   I had just finished my High School Government night class, with plans to continue to the Air Force boot camp. But then I had to go back to the Military Entrance Processing Station I had spent an entire day at a few weeks before.

I knew whatever it was must have been pretty serious because there were at least four other people in the room this time.  The doctor sat in his leather chair behind a large fancy desk. He was dressed in a white coat and he opened up my file and read from it.  Positive results for the HIV antibody.

I knew what HIV was because I had watched the Ricki Lake Show and MTV’s The Real World with Pedro who was openly HIV positive. Tom Hanks made a movie (Philadelphia) and won many awards so you know it was serious. HIV was making headlines (when people actually dared to talk about it). But they were all on the Coasts – New York, Philadelphia, Hollywood; this had to be something that happens other places, right?  Surely not here in the Midwest in the middle of the 1990s.

But it did happen in the Midwest; and now I was proof. Proof that HIV is not a “gay disease” or a “black disease”. I had never used drugs.  I had never had a blood transfusion. I had more fingers I could count than sexual partners. I thought, “What do I do now?” I knew I had to tell my parents. I lived with my mother at the time and paying for my funeral would be one more thing I had to hear them fight about.

I had been referred to Dr. Susan Swindells at UNMC.  I had more tests done, and she told me in her British accent that if I was not going to take the medicine then there would be nothing else they could do to help me. I needed to take the meds, for the rest of my life; and we did not know how long that would really be. I qualified for the Ryan White Program so that I could have these pills… AZT (the first antiretroviral) was a tiny, shiny white capsule with a blue stripe.

I was very lucky though even if I did not believe it at the time. Every 3 months I would have blood tests at the Med Center, and I felt fine. Was I really even sick? Four years later in 1998 I wed my first husband. He had also tested positive shortly after I disclosed my results to him. We began discussing having children and in 1999 we decided to take the chance because we were both being treated. We did decide together that it was worth the risk and my first daughter was born by C-section after 3 or 4 hours of having an IV fill me up with meds before her delivery. I also gave her liquid AZT for the first 6 weeks and she officially tested negative at about the 2 year mark.

By 2003 I became anxious; I was worried that I had been so blessed and it was only a matter of time before I began developing symptoms and becoming sick.  I made very significant changes in 2006 and took control of my life over somethings I did not even know if I was strong enough to do. I became a working single mother with HIV.

I became empowered to openly share my status after I briefly dated someone who lied about being married. When I discovered he was married, I ended the relationship. Later, I vented to a co-worker about the entire situation. He almost left me speechless when his response was “Girl he “forgot” to tell you he was married then I woulda forgot to tell him I had AIDS!”    My stomach flipped and in that moment I said, “I don’t have AIDS but I do have HIV.”

It was very empowering to share my status and see the shock that it gave him. I married one of his best friends 3 years later. My husband is HIV-negative and when we began having condomless sex in 2007 I made him come to a doctor’s appointment to meet my Specialty Care team. At that point, “Undetectable=Untransmittable” campaign was still years away, and I was not fully convinced that I could not transmit HIV. Honestly, it was more of a visit to document that I had fully disclosed my status and he was completely aware of the risk. I did not want to go to jail if or when he tested positive.

The next few years were filled with change. I had to “change” jobs because someone was disclosing my status without my permission.  That change led to a career that I did not even think I could do and I just celebrated 10 years there. I changed my last name when I remarried. Then I changed diapers again…when I gave birth to my 2nd daughter. Last year I changed a bad habit and quit smoking (over 15 months now).  Now I speak up to share my status to try and change minds. 

I choose to continue my care at the Specialty Care Center. It has changed locations over the last 24 years a few times but the care remains the same. My health team has become like extended family and I get to visit them twice a year. I have watched some providers retire or be promoted to other positions. They have watched me grow and change. The team has been with me through the hardest moments in my life. I know that each of them have my best interest in mind and in their heart and that will never change.

Content courtesy Erin Fulton

Editorial note: Erin Fulton is a patient-activist living with HIV who boldly stands up and publicly shares her story on many forums including social media. She regularly participates in patient panels organized by the SCC and UNMC College of Medicine, in the hopes that by engaging in discussion she can increase awareness and help eliminate the stigma associated with a diagnosis of HIV. Thank you Erin for allowing us to be a platform to share your story today.


 

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