Measurement of retention in care among adults infected with HIV in an urban clinic.

Adults infected with HIV live longer when they receive regular medical care, yet many adults are not retained in care. Providers measure retention in order to evaluate interventions to improve retention and quality of HIV care. However, multiple measures for retention exist. This study compares two methods of operationalizing retention and evaluates the contribution of individual characteristics on the likelihood of retention. A chart review was performed for a random sample of 212 active clients of an urban HIV primary care clinic. Data on clinic utilization, sex, age, race, mental illness, substance use, AIDS diagnosis, language, and housing were collected for each participant. Clinic utilization data were used to classify participants for retention status and to score them by frequency of visits. Binary logistic regression analysis was compared with ordinal logistic regression analysis, using distinct retention measures as outcome variables. In the binary model, those with a history of substance use were about half as likely to be retained (OR 0.52, 95% CI 0.29-0.94) and those with an AIDS diagnosis were more than twice as likely to be retained (OR 2.18, 95% CI 1.17-4.09). These characteristics were significant predictors in the ordinal model, with the additional finding that those reporting English as a primary language were less likely to have higher retention scores (OR 0.40, 95% CI 0.19-0.84). An ordinal score for retention can identify unexpected predictors, but a dichotomous measure of retention may be easier to use and interpret for providers involved in retention-related quality improvement activities.

Acute coronary syndrome: factors affecting time to arrival in a diverse urban setting.

This study seeks to better understand how individuals of different cultural/ethnic backgrounds in an urban setting assess the signs and symptoms of Acute Coronary Syndrome (ACS) and the ensuing decision to take urgent action. Few studies exist which examine these differences and enhance understanding of how to address these differences and, ultimately, reduce morbidity and mortality from ACS. Face-to-face interviews were conducted with a convenience sample of urban patients of different cultural and socioeconomic backgrounds regarding their actions upon recognition of ACS signs and symptoms. Patients (423) with presumed or diagnosed ACS were interviewed within 12 h of arrival at the urban emergency rooms. Among the different cultural groups, Haitians delayed the longest (median) from symptom onset to hospital arrival (8.24 h), followed by Caribbeans (7.83 h), African Americans (6.62 h) and Hispanics (6.00 h). Although these delay intervals were not statistically significant across groups, each racial/ethnic group sought care well beyond the recommended time period of 3 h after initial recognition of ACS signs and symptoms. Among all the cultural groups, the two key factors motivating early arrival were being employed and taking positive actions. ACS symptom perception by different cultural groups appears to play an important role in the decision to seek emergency treatment. This is an area that has not been widely studied among or within different cultural/ethnic groups. As such, further research is needed to delineate these concepts and actions and to provide opportunities for appropriate education.

A pilot study assessing the role of 25 hydroxy vitamin D levels in patients with vitiligo vulgaris.

BACKGROUND: Very low vitamin D levels have been noted in patients with a variety of autoimmune diseases. OBJECTIVE: To determine whether low vitamin D levels are associated with autoimmunity in the setting of vitiligo vulgaris. METHODS: A prospective cohort study was conducted on 45 consecutive patients with vitiligo vulgaris. 25-Hydroxyvitamin D levels were determined from sera collected at the time of study enrollment. Logistic regression analysis of the relationship of 25-hydroxyvitamin D levels to disease state was performed, including surface area, recent-onset vitiligo, Fitzpatrick skin type and ethnicity, dairy intake, and both personal and family history of autoimmunity. Multiple univariate and multivariate logistic regression models were developed to assess the interrelationship of these parameters. RESULTS: 25-Hydroxyvitamin D levels were divided into 3 groups: 31.1% were normal (>30 ng/mL), 55.6% were insufficient (<30 ng/mL), and 13.3% were very low (<15 ng/mL). Insufficient 25-hydroxyvitamin D levels were associated with increasing Fitzpatrick phototypes (odds ratio [OR] = 1.76, 95% confidence interval [CI] = 1.12-2.77). Very low 25-hydroxyvitamin D levels were associated with comorbid autoimmune illness (OR = 10.00, 95% CI = 1.06-94.7), but not with age, gender, race/ethnicity, family history of vitiligo or autoimmune disease, new-onset disease, or body surface area affected. None of the surveyed patients reported daily vitamin D intake of greater than 200 IU. LIMITATIONS: This study consists of a small cohort that assesses point prevalence without assessing seasonal variation in vitamin D levels. CONCLUSIONS: Very low 25-hydroxyvitamin D levels (<15 ng/mL) appear to be a reasonable screening tool for the presence of comorbid autoimmunity. Furthermore, we demonstrate that Fitzpatrick phototype, rather than ethnicity, is specifically associated with 25-hydroxyvitamin D levels that are insufficient (<30 ng/mL).

A randomized controlled trial for reducing risks for sexually transmitted infections through enhanced patient-based partner notification.

OBJECTIVES: We sought to assess the effectiveness of approaches targeting improved sexually transmitted infection (STI) sexual partner notification through patient referral. METHODS: From January 2002 through December 2004, 600 patients with Neisseria gonorrhoeae or Chlamydia trachomatis were recruited from STI clinics and randomly assigned to either a standard-of-care group or a group that was counseled at the time of diagnosis and given additional follow-up contact. Participants completed an interview at baseline, 1 month, and 6 months and were checked at 6 months for gonorrhea or chlamydial infection via nucleic acid amplification testing of urine. RESULTS: Program participants were more likely to report sexual partner notification at 1 month (86% control, 92% intervention; adjusted odds ratio [AOR] = 1.8; 95% confidence interval [CI] = 1.02, 3.0) and were more likely to report no unprotected sexual intercourse at 6 months (38% control, 48% intervention; AOR = 1.5; 95% CI = 1.1, 2.1). Gonorrhea or chlamydial infection was detected in 6% of intervention and 11% of control participants at follow-up (AOR = 2.2; 95% CI = 1.1, 4.1), with greatest benefits seen among men (for gender interaction, P = .03). CONCLUSIONS: This patient-based sexual partner notification program can help reduce risks for subsequent STIs among urban, minority patients presenting for care at STI clinics.

Predictors of partner notification for C. trachomatis and N. gonorrhoeae: an examination of social cognitive and psychological factors.

Efforts to control chlamydial and gonococcal infections include notifying eligible sexual partners of possible infection, primarily by asking the diagnosed patient to notify their partners. This approach, known as patient referral, is widely used but poorly understood. The current study examined psychosocial and cognitive factors associated with patient referral among an urban, minority sample of 168 participants recently diagnosed with Chlamydia trachomatis or Neisseria gonorrhoeae. At a follow-up interview 1-month from diagnosis, participants were more likely to have notified all eligible partners if they had greater intention to notify at baseline (OR = 3.72; 95% CI = 1.34, 10.30) and if they had only one partner at baseline (OR = 4.08; 95% CI = 1.61, 10.31). There were also gender differences as well as differences based on type of partner (i.e., regular, casual, one-time). The implications of these findings for the design of programs to promote patient referral for sexually transmitted infections are discussed.

Long-term results of maximally aggressive trimodality therapy in a high-risk subset of early-stage cervical cancer patients.

OBJECTIVE: To evaluate the long-term survival and treatment-related morbidity associated with treating patients who have early-stage cervical carcinoma metastatic to the paraaortic lymph nodes with radical hysterectomy, pelvic and paraaortic lymphadenectomy, and adjuvant, extended field chemoradiation with cisplatin and 5-fluorouracil (5-FU). STUDY DESIGN: From 1988 to 1997, 14 consecutive patients referred to Radiological Associates of Sacramento following radical hysterectomy and pelvic and paraaortic lymphadenectomy with findings of clinical stage IB or IIA cervical cancer and histologically confirmed lymph node metastasis to the common iliac or paraaortic distributions were treated with adjuvant, extended field chemoradiation utilizing prolonged infusion 5-FU and bolus cisplatin. Retrospective chart review was performed, and survival and morbidity information were analyzed. Recurrence was assessed among patients based on age, race, total number of nodes involved, gross vs. microscopic nodal involvement, squamous vs. nonsquamous tumor histology, time to initiation of adjuvant treatment and time required to complete that treatment. Calculated 5-year survival, mean survival, morbidity type and incidence are reported for the group as a whole. RESULTS: Calculated 5-year survival of patients in this series was 38% by life table analysis. Median survival was 4.4 years; 50% of patients had a recurrence. None of the examined parameters were significant predictors of recurrence. There was 1 treatment-related death and a second case of severe treatment-related morbidity (radiation enteritis requiring colostomy and bilateral ureteral stenosis requiring bilateral nephrostomies). There were 6 cases of minor treatment-related toxicity occurring in 5 of 14 (36%) treated patients. CONCLUSION: In general, survival in the current series of patients was akin to that in clinically similar patients treated with chemoradiation alone. Morbidity among our patients was significant. In the presence of positive paraaortic lymph nodes there were no independent predictors of recurrence among the pathologic or treatment parameters examined.

Haymaker gene expression in malignant and normal gynecologic tissues.

We previously reported that cell lines established from human carcinomas and leukemias/lymphomas expressed high levels of an intracellular membrane-bound protein, Haymaker, whereas cell lines derived from non-malignant connective tissue cells and lymphoid cells expressed low levels of this gene product. To determine whether these findings reflect neoplastic transformation or, alternatively, tissue specificity, we examined by immunohistochemical and molecular methods the expression of Haymaker in gynecologic organs with and without tumor. A highly specific, affinity-purified rabbit polyclonal antibody against a 25-mer Haymaker peptide was used for immunohistochemical staining and morphometric analysis of 85 tissue specimens. Immunohistochemical studies demonstrate, for the first time, that Haymaker protein is highly expressed in epithelial cells of the endometrium of the normal uterus and to a somewhat lesser extent in the mucosa of the normal vagina and cervix, but is poorly expressed or absent in cells of the connective tissue and smooth muscle strata of these organs (p < 0.005). Significant differences in Haymaker expression, as assessed by immunohistochemistry, between malignant and normal gynecologic tissues were not observed (p = 0.27). The expression of Haymaker protein does not appear, therefore, to be a marker of malignant transformation of the epithelium of gynecologic organs but rather distinguishes both normal and malignant epithelial cells from normal connective tissue and smooth muscle cells.

Implications of radioactive seed migration to the lungs after prostate brachytherapy.

OBJECTIVES: To review the incidence and the impact of pulmonary seed migration after prostate brachytherapy on lung function. Isolated reports of seed migration to the lungs after prostate brachytherapy have been published; however, the clinical consequences of this pulmonary migration have not been adequately evaluated. METHODS: We performed a retrospective review of patients undergoing prostate brachytherapy from 1998 to 2000. Pulmonary imaging with chest x-ray was performed 15 to 90 days (median 45) after the procedure. The chest radiographs were reviewed by a single radiologist (V.S.D.), and patients with seed migration to the lungs were evaluated by a single pulmonologist (A.M.H.) using a questionnaire, chest radiography, and pulmonary function tests. Computed tomography of the prostate after seed implantation was performed to check seed position and dosimetry. Odds ratio, confidence intervals, chi-square tests, and logistic regression analysis were performed to evaluate the relationship between the type and number of seeds used, the incidence of pulmonary migration, and the effects on pulmonary function. RESULTS: A total of 83 patients underwent prostate brachytherapy during the study period and 58 patients underwent chest radiography. Seed migration occurred in 21 (36.2%) of 58 patients (95% confidence interval 23.8% to 48.6%). Thirty-four (0.71%) of 4755 seeds used migrated to the lungs. Nine patients had single seed migration to the right lung and three to the left lung. Nine patients had multiple (maximum of 4) and bilateral seed migration. No consistent relationship was found between seed migration and the type of seeds used (P = 0.24). Borderline statistical significance suggested an increased incidence of seed migration with an increasing number of implanted seeds (P = 0.054). Repeat chest radiography in 21 patients revealed no delayed migration at a median follow-up of 16 months. Clinical and pulmonary function testing revealed no consistent abnormality attributable to seed migration. CONCLUSIONS: Radioactive seed migration occurred in 36.2% of brachytherapy patients who had chest radiographs done in our series. Pulmonary seed migration may be influenced by the number of implanted seeds and does not appear to be influenced by the seed type. Additional study of this observed phenomenon is required. A thorough pulmonary workup failed to reveal any short-term harmful side effects; however, long-term follow-up is needed. Healthcare providers should discuss the possibility of pulmonary seed migration with patients with prostate cancer considering prostate brachytherapy.