Disclosure of complementary health approaches among low income and racially diverse safety net patients with diabetes.

OBJECTIVE: Patient-provider communication about complementary health approaches can support diabetes self-management by minimizing risk and optimizing care. We sought to identify sociodemographic and communication factors associated with disclosure of complementary health approaches to providers by low-income patients with diabetes. METHODS: We used data from San Francisco Health Plan's SMARTSteps Program, a trial of diabetes self-management support for low-income patients (n=278) through multilingual automated telephone support. Interviews collected use and disclosure of complementary health approaches in the prior month, patient-physician language concordance, and quality of communication. RESULTS: Among racially, linguistically diverse participants, half (47.8%) reported using complementary health practices (n=133), of whom 55.3% disclosed use to providers. Age, sex, race/ethnicity, nativity, education, income, and health literacy were not associated with disclosure. In adjusted analyses, disclosure was associated with language concordance (AOR=2.21, 95% CI: 1.05, 4.67), physicians' interpersonal communication scores (AOR=1.50, 95% CI: 1.03, 2.19), shared decision making (AOR=1.74, 95% CI: 1.33, 2.29), and explanatory-type communication (AOR=1.46, 95% CI: 1.03, 2.09). CONCLUSION: Safety net patients with diabetes commonly use complementary health approaches and disclose to providers with higher patient-rated quality of communication. PRACTICE IMPLICATIONS: Patient-provider language concordance and patient-centered communication can facilitate disclosure of complementary health approaches.

Identifying multidrug resistance in previously treated tuberculosis patients: a mixed-methods study in Cambodia.

SETTING: Previously treated tuberculosis (TB) patients are a priority for drug susceptibility testing (DST) to identify cases with multidrug-resistant TB (MDR-TB). A Cambodia study found that one third of smear-positive previously treated patients had DST results. OBJECTIVE: To quantify the gaps in the detection of MDR-TB in previously treated TB patients in Cambodia, and describe health workers' perspectives on barriers, facilitators and potential interventions. DESIGN: Analysis of Cambodia's 2004-2012 case notifications and semi-structured interviews with stakeholders. RESULTS: The proportion of previously treated notifications varied significantly across provinces in 2010-2012. If there had been no attrition along the path to detecting MDR-TB among smear-positive notified cases in 2012, an estimated 75 additional MDR-TB cases could have been identified, which would double the number actually detected. Most were lost due to misclassification of previously treated patients as 'new'. Barriers include patients' reluctance to disclose and staff difficulty in eliciting treatment history, partly attributed to the availability of streptomycin (SM) only in hospitals. Facilitators include collection of sputum for DST even if previously treated patients are not receiving SM, streamlining sputum transportation and prompt reporting of results. CONCLUSION: Improved monitoring, supportive staff supervision and training, patient education, and correct classification of previously treated cases are essential for improving the detection of MDR-TB.

What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.

BACKGROUND: Little is known about adverse events (AEs) that occur between physician visits for ambulatory chronic disease patients. An automated telephone self-management support programme for a diverse population of diabetes patients was implemented to capture AEs, describe the self-management domains from which they emanate and explore contributing causes. METHODS: AEs and potential AEs (PotAEs) were identified among 111 ethnically diverse diabetes patients. An AE is an injury that results from either medical management or patient self-management; a PotAE is an unsafe state likely to lead to an event if it persists without intervention. Medical record reviews were conducted to ascertain which self-management domain was involved with the event and to explore contributing causes. RESULTS: Among the 111 patients, 86% had at least one event detected over the 9-month observation period. 111 AEs and 153 PotAEs were identified. For all events, medication management was the most common domain (166 events, 63%). Only 20% of events reflected a single contributing cause; in the remaining 80%, a combination of system, clinician and patient factors contributed to their occurrence. Patient actions were implicated in 205 (77%) events, systems issues in 183 (69%) events and inadequate physician-patient communication in 155 (59%) events. Aside from communication, primary care clinician actions contributed to the occurrence of the event in only 16 cases (6%). CONCLUSIONS: Our findings reveal a complex safety ecology, with multiple contributing causes for AEs and PotAEs among ambulatory diabetes patients. Moreover, patients themselves seem to be key drivers of safety and of AEs, suggesting that patient-level self-management support and patient-centred communication are critical to AE prevention.

Lead (II) detection and contamination routes in environmental sources, cookware and home-prepared foods from Zimatlán, Oaxaca, Mexico.

An interdisciplinary investigation, involving environmental geochemists, epidemiologists, nurses, and anthropologists, was undertaken to determine the contamination source and pathway of an on-going outbreak of lead poisoning among migrants originating from Zimatlán, Oaxaca, Mexico and living in Seaside, California, and among their US-born children. An initial investigation in Seaside identified grasshopper foodstuff ("chapulines") imported from Mexico and consumed as snacks, as containing alarmingly high lead concentrations (up to 2300 mg/kg). The focus in the present work concentrates on the Oaxacan area of origin of the problem in Mexico, and two potential sources of contamination were investigated: wind-borne dusts from existing mine residues as potential contaminants of soil, plant, and fauna; and food preparation practices using lead-glazed ceramic cookware. Over a three year period, sampling was conducted in Oaxaca using community-level sampling and also targeted sampling with families of cases with lead poisoning in California. In addition to fresh field chapulines, we analyzed for total lead: soil, water, mine residues, and plant materials, both from areas adjacent to or at an abandoned waste site containing mine tailings, and from fields where chapulines are collected; foodstuffs gathered in community markets or in a food transport business; and foodstuffs and cookware gathered from relatives of case families in California. Also, selected new and used lead-glazed clay cookware was extracted for lead, using 0.02 M citric acid and with 4% acetic acid. The results indicated significant presence of lead in mine wastes, in specific foodstuffs, and in glazed cookware, but no extensive soil contamination was identified. In-situ experiments demonstrated that lead incorporation in food is made very efficient through grinding of spices in glazed cookware, with the combination of a harsh mechanical action and the frequent presence of acidic lime juice, but without heating, resulting in high but variable levels of contamination.

Association of Vpu-binding protein with microtubules and Vpu-dependent redistribution of HIV-1 Gag protein.

The efficient exit of HIV-1 particles from cells requires the action of the viral encoded protein Vpu. Vpu-binding protein (Ubp) is a cellular protein that interacts with both Vpu and the major structural component of the viral capsid (Gag) and appears to affect the efficiency of particle exit. Elucidation of the function of Ubp and characterization of the spatial distribution of Ubp may provide information pertinent to understanding the role of Ubp in virus replication. To investigate the subcellular location of Ubp, and to see whether Vpu affects the intracellular distribution of Gag, we carried out immunofluorescence localization in conjunction with confocal microscopy. Based on this analysis Ubp is present in both the nucleus and the cytoplasm. In the cytoplasm, Ubp appeared to be associated with microtubules as evidenced by cofluorescence with tubulin in the absence and in the presence of colchicine. However, cytoskeletal isolation and detergent extraction of cells resulted in association of Ubp with the soluble fractions, indicating that Ubp is not in tight association with microtubules. Moreover, flotation gradient analysis demonstrated that Ubp is cytoplasmic and not stably associated with the plasma membrane. Interestingly, expression of Vpu in cells resulted in redistribution of both Ubp and Gag to a location near the periphery of the cell. The effect of Vpu on both Ubp and Gag protein has implications for Vpu-mediated particle exit from cells.

Functional interaction of human immunodeficiency virus type 1 Vpu and Gag with a novel member of the tetratricopeptide repeat protein family.

Viral protein U (Vpu) is a protein encoded by human immunodeficiency virus type 1 (HIV-1) that promotes the degradation of the virus receptor, CD4, and enhances the release of virus particles from cells. We isolated a cDNA that encodes a novel cellular protein that interacts with Vpu in vitro, in vivo, and in yeast cells. This Vpu-binding protein (UBP) has a molecular mass of 41 kDa and is expressed ubiquitously in human tissues at the RNA level. UBP is a novel member of the tetratricopeptide repeat (TPR) protein family containing four copies of the 34-amino-acid TPR motif. Other proteins that contain TPR motifs include members of the immunophilin superfamily, organelle-targeting proteins, and a protein phosphatase. UBP also interacts directly with HIV-1 Gag protein, the principal structural component of the viral capsid. However, when Vpu and Gag are coexpressed, stable interaction between UBP and Gag is diminished. Furthermore, overexpression of UBP in virus-producing cells resulted in a significant reduction in HIV-1 virion release. Taken together, these data indicate that UBP plays a role in Vpu-mediated enhancement of particle release.

A role for urokinase-type plasminogen activator in human immunodeficiency virus type 1 infection of macrophages.

Urokinase-type plasminogen activator (uPA), a proteinase which activates plasminogen by cleaving at -CPGR(arrow downward)V-, was shown to cleave the V3 loop in recombinant gp120 of human immunodeficiency virus type 1 (HIV-1) IIIB and MN strains, as well as a synthetic, cyclized peptide representing the clade B consensus sequence of V3. Proteolysis occurred at the homologous -GPGR(arrow downward)A-, an important neutralizing determinant of HIV-1. It required soluble CD4 and was prevented by inhibitors of uPA but not by inhibitors of likely contaminating plasma proteinases. It was accelerated by heparin, a known cofactor for plasminogen activation. In immune capture experiments, tight binding of uPA to viral particles, which did not depend on CD4, was also demonstrated. Active site-directed inhibitors or uPA diminished this binding, as did a neutralizing antibody to V3. Addition of exogenous uPA to the laboratory-adapted IIIB strain of HIV-1, the macrophage-tropic field strains JR-CSF and SF-162, or a fresh patient isolate of indeterminate tropism, followed by infection of macrophages with the various treated viruses, resulted in severalfold increases in subsequent viral replication, as judged by yields of reverse transcriptase activity and p24 antigen, as well as incorporation, as judged by PCR in situ. These responses were reversible by inhibitors or antibodies targeting the proteinase active site or the V3 loop. We propose that uPA, a transcriptionally regulated proteinase which is upregulated when macrophages are HIV infected, can be bound and utilized by the virus to aid in fusion and may be an endogenous component that is critical to the infection of macrophages by HIV-1.

HIV infection among women in prison: an assessment of risk factors using a nonnominal methodology.

The relative contributions of needle use practices and sexual behaviors to human immunodeficiency virus (HIV) antibody seropositivity among 394 women incarcerated in Quebec were determined by risk factor assessment and serology with a nonnominal methodology. HIV positivity was found in 6.9% (95% confidence interval [CI] = 4.6, 9.9) of all participants and in 13% (95% CI = 8.6, 18.6) of women with a history of injection drug use. HIV seropositivity among women with a history of injection drug use was predicted by sexual or needle contact with a seropositive person, self-reported genital herpes, and having had a regular sexual partner who injected drugs, but it was not predicted by prostitution. Nonnominal testing is an ethical alternative to mandatory and anonymous unlinked testing among correctional populations.

Cervicovaginal screening in women with HIV infection: a need for increased vigilance?

OBJECTIVE: To review the current literature on cervical disease (dysplasia, cervical intraepithelial neoplasia [CIN] or carcinoma) in women with HIV infection and to assess recommendations for cervicovaginal screening in these patients. DATA SOURCES: MEDLINE and AIDSLINE were searched for relevant articles published in English or French between January 1987 and February 1993, abstracts presented at international AIDS conferences from 1989 to 1993 were evaluated, and pertinent agencies and organizations were consulted. STUDY SELECTION: A total of 92 reports of gynecologic disease in women with HIV infection were examined; 32 studies were retained that reported pertinent findings on cervical dysplasia, CIN or cervical carcinoma. DATA EXTRACTION: The following criteria were used to extract data: study design (descriptive v. comparative), sample size, heterogeneity of the study population, presence of immunodeficiency indicators (i.e., absolute CD4+ lymphocyte count) and presence of concomitant vaginal infections. Recommendations were assessed for their specific application to women with HIV infection. DATA SYNTHESIS: Data on the associations between stage of cervical disease and response to treatment at varying levels of CD4+ lymphocyte depletion were incomplete. Recommendations by official bodies for cervicovaginal screening in women with HIV infection differed little from recommendations for standard care of all women of reproductive age. CONCLUSIONS: The consequences of a missed or delayed diagnosis of cervical disease for women with HIV infection can be severe. Pending further research, more frequent cervicovaginal screening through Papanicolaou testing and colposcopy in women with HIV infection is warranted.

Clinical practice and new technology: prostate-specific antigen (PSA).

In response to a marked increase in the use of an available test, Group Health Cooperative of Puget Sound (GHC) evaluated the use of prostatic specific antigen (PSA) as a screening test for prostate cancer. A project team reviewed the literature and determined that PSA did not meet GHC's criteria for screening. An implementation team then developed a comprehensive program to educate staff, facilitate practice change, measure outcomes and provide continuing feedback to physicians. These efforts are described and preliminary reports reported.

HIV disease and AIDS in women: current knowledge and a research agenda.

The study of the clinical manifestations, progression, and outcome of human immunodeficiency virus (HIV) infection in women has begun in earnest. AIDS-defining diseases that are more common in women than in men include wasting syndrome, esophageal candidiasis, and herpes simplex virus disease, whereas Kaposi's sarcoma is rare. Non-AIDS-defining gynecological conditions such as vaginal candida infections and cervical pathology are prevalent among women at all stages of HIV infection. Associations have been documented between the presence of human papillomavirus, lower genital tract neoplasia, and HIV-related immunosuppression. Pregnancy has not been confirmed to have an effect on the clinical progression of HIV disease in women incremental to the effect of time. Differential access and utilization of therapeutic interventions appear to account for much of the reported gender discrepancy in survival. Well designed epidemiological and clinical studies will help further scientific knowledge leading to early diagnosis, appropriate treatment, and timely prevention of the manifestations of HIV disease in women.

Successful implementation of a guideline program for the rational use of lipid-lowering drugs.

Following the National Cholesterol Educational Program's (NCEP) 1988 screening and treatment recommendations, an educational and behavior-change program at Group Health Cooperative of Puget Sound (GHC) was developed to guide the use of lipid-lowering drugs within the larger context of cardiac risk reduction. The program has been successful in advancing a rational program to enhance care and manage costs of the use of lipid-lowering agents at GHC. Cost savings have been significant over the past two years. The educational design of the program includes training and ongoing education of a core group of "lipid gurus," who educate colleagues in area medical centers in a rational approach to hyperlipidemia. Patient education and patient participation in decision-making was emphasized. Program evaluation has demonstrated that physicians and patients are satisfied with the program, and inappropriate drug expenditures have been prevented. Key elements of the program include a critical review of outcome studies in the medical literature, use of information systems, algorithms and written materials organized into a well-designed, ongoing educational program, and development of a core group of physicians and pharmacists to administer the program at the clinic level.

Epidemiological evidence indicates asbestos causes laryngeal cancer.

A variety of opinions have been expressed in the literature concerning asbestos and laryngeal cancer. This paper presents an analysis of epidemiological studies based on criteria that prioritized the most heavily exposed cohorts. Emphasis was given to the six cohorts or subcohorts with lung cancer relative risk estimates of 2 or more. The two groups of workers with the highest lung cancer relative risk estimates (4.06 and 3.28) both gave strong support for a causal association of asbestos and laryngeal cancer, with relative risk estimates of 1.91 (90% confidence limits 1.00 to 3.34) and 3.75 (90% confidence limits 1.01 to 9.68), respectively. Confounding with cigarette smoking or alcohol consumption does not explain the findings. Case-control studies gave mixed results, but generally supported the hypothesis. It was concluded that asbestos is a probable cause of laryngeal cancer in view of the reasonable consistency of the studies, the strength of the association in key studies, the evidence for dose-response relationships, and the biological plausibility for asbestos being a cause of laryngeal cancer.