Carla Alexander

Controversy and confusion surround the terminology for patients who have persistent symptoms after treatment for Lyme disease (LD) or may have been misdiagnosed with Lyme disease. While Infectious Diseases (ID) use the term Post treatment Lyme disease syndrome (PTLDS), patients tend to use the term Chronic Lyme disease (CLD) to describe the syndrome associated with persistent symptoms post treatment of LD. Many ID physicians are reluctant to see patients who identify themselves as having “Chronic Lyme” disease in some part due to reluctance to prescribe repeated courses of antibiotics. The purpose of this inquiry was to assess belief regarding Lyme disease and treatment. Patients at the Integrated Lyme Program at the University of Maryland completed clinical intake forms which included questions on their familiarity and beliefs surrounding Lyme disease. We evaluated 146 patient records from our Lyme Program Registry which began in December 2018. There were 57 (34.5%) males and 108 (65.5%)females with mean age of 51 years. Forty seven percentage of patients were referred by a physician and 53 % were self-referred. Approximately 50% (71/146) were treated with less 30 days of antibiotics, 37% (54/146) were treated with 1-6 months of antibiotics and 11.6% (17/146) were treated with >6months of antibiotics prior to their initial evaluation in our Lyme program. Sixty eight percentage of patients were familiar with the term CLD but only 44% percentage were familiar with term PTLDS. Approximately half of the patients ( 52%) believed that they currently had Lyme disease and 63% believed that their current symptoms were due to Lyme disease. Despite this only 18% believed that they needed antibiotics for Lyme disease at the time completing the form. Patient referred to our Lyme center were more familiar with term CLD vs PTLDS. Many of them believed that they currently had LD and their symptoms were due to Lyme disease. Despite this, the majority did not feel that they needed antibiotics for Lyme Disease at the time of their clinical visit. More research is needed to better understand patient beliefs and understanding regarding Lyme disease. All Authors: No reported disclosures

Confusion and controversy surround various aspects of Lyme Disease (LD) including diagnosis. Typically, the diagnosis of LD is based on tick exposure, clinical history, exam, and laboratory testing. Laboratory testing and interpretation can be confusing, difficult, and a source of misdiagnosis. One hundred and fifteen records of patients referred to the Integrated Lyme Program at University of Maryland for evaluation of LD were analyzed. All patients underwent initial evaluation by Infectious Disease (ID) physician who made a determination regarding Lyme diagnosis based on history, exam, epidemiologic risk factors and laboratory test results. Pt were determined to have one of the following diagnoses: 1) Acute LD 2) Past LD 3) Post Treatment Lyme Disease Syndrome (PTLDS) 4) Misdiagnosed LD. Data was also collected on reasons for misdiagnosis based on record review, referral information and patient reported information. We evaluated 115 patient records from our Lyme Program Registry. There were 78 female (68%) and 37 males (32%). The mean age was 46 years (range 19 to 83). Of the 115 records analyzed, there were 8 (7%) patients with acute Lyme disease; 38 (33%) patients with past Lyme disease , 3 (2.6%) patients with PTLDS and 93 (81%) of patients who were misdiagnosed with LD. Patients were misdiagnosed for multiple reasons and by different people. Twenty three percent (21/93) were misdiagnosed based on false positive IGM Western Blot; 16% (15/93) were misdiagnosed based on misread IGG Western Blot and 14% (13/93) were misdiagnosed based on unconventional Lyme test. The remainder were misdiagnosed based on symptoms. Forty two percent (39/93) were misdiagnosed by PCP; 4.3%(3/93) were misdiagnosed by Urgent/Emergent care physician and 31% (29/93) were misdiagnosed by physicians’ self-referred as Lyme Literate Medical Doctor. The remainder were incorrectly self-diagnosed by patients based on symptoms. Misdiagnosis of patients referred to Lyme Center is common and due to various reasons including misinterpretation of laboratory Lyme testing by healthcare providers and misinterpretation of symptoms by patients. All Authors: No reported disclosures

Background: To provide optimal end-of-life (EOL) care in the Chinese American population, we need to have a better understanding of what matters most at EOL from their perspective. Experiencing a “good death” at the EOL is the optimal goal of palliative care. Studies show that the meaning and description of good death varies across cultures in different populations. In the United States, Chinese Americans comprise the largest Asian demographic. Aim: To describe EOL wishes, which define a good death for Chinese Americans. Method: Qualitative study using focus groups. A convenience sample of 60 Chinese Americans was recruited from a community organization in Maryland. Ten focus group discussion sessions were conducted. Results: Wishes at the EOL that defined a good death for the participants in this study included being pain-free, not being a burden to family, being with family, having a trusted physician, maintaining dignity, and prayer. Conclusion: A good death is a complex concept. What matters most to patients at the EOL differs depending on their cultural background. When caring for Chinese Americans, a comprehensive EOL care plan should include cultural considerations in addition to physical, psychosocial, and spiritual needs.

The aim of this study was to characterize the mortality at two hardmetal production factories in the United Kingdom as part of an international study. Standardized mortality ratios (SMRs) were calculated on the basis of mortality rates for England and Wales, and local rates. A nested case–control study of lung cancer was undertaken. The cohort comprised 1538 workers, with tracing complete for 94.4%. All-cause mortality was statistically significantly low for all cancers and nonmalignant respiratory disease, and for lung cancer was nonsignificantly low. The SMR for lung cancer for maintenance workers was elevated, based on only six deaths. The odds ratio for lung cancer per year of exposure to hardmetal was 0.93 (0.76 to 1.13). In this small study, there is no evidence to support that working in the UK hardmetal manufacturing industry increased mortality from any cause including lung cancer.

Advance care planning (ACP) is a critical component of quality end-of-life care. Little is known regarding the cultural influences on health professionals' attitudes toward the discussion of ACP in China. To better understand attitudes toward ACP among Chinese healthcare professionals in China and the influence of cultural factors such as filial piety, or xiào. A mixed methods study was used. This study reports the results of a descriptive cross-sectional survey of physicians, nurses and social workers with experience in palliative and end-of-life care. Some 102 completed surveys were obtained. Most Chinese health professionals had an overall positive attitude toward ACP, acknowledging that these discussions should occur. However, there was a general lack of confidence and sense of reluctance among participants to engage in ACP discussions. The lack of statistical difference between the various health professionals suggests that they all faced challenges in participating in ACP discussions. Future research should focus on the influences of cultural factors such as xiào on ACP discussion, and develop culturally sensitive strategies to facilitate these discussions in the Chinese community.

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population. It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population. It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient’s individual circumstances.