Binge drinking and unsafe sex: a study of narcology hospital patients from St. Petersburg, Russia.

The purpose of this study was to assess the association between binge alcohol use and unprotected sex in Russian substance users. Participants (N = 181) were narcology hospital patients assessed on demographics, alcohol use, risky sex, and sexually transmitted disease/human immunodeficiency virus (STD/HIV) diagnoses. Adjusted generalized estimating equations (GEEs) logistic regression analysis examined the association between binge drinking and same-day unprotected sex across each of the past 30 days, per participant (N = 5430 observations). Participants were age 18 to 55 years, 75% male, and 64% binge drinking. Sex trade was reported by 27%; history of STDs by 43%; and HIV by 15%. One fourth of daily observations included sex; 88% of these involved unprotected sex. Binge drinking was not associated with same-day unprotected sex (adjusted odds ratio [OR(adj)] = 1.0, 95% confidence interval [CI] = 0.7-1.4, chi(2)(1, N = 5219) = 0.01, ns). Findings document substantial HIV/STD risk and prevalence among Russian narcology patients, but no link between binge drinking and unprotected sex in this population, possibly due to very low rates of condom use generally.

Local instillation of Staphylococcus aureus peptidoglycan at operation prevents wound healing impairment after trauma.

BACKGROUND: Considerable experimental evidence and limited clinical evidence indicate that wound healing is impaired after trauma. Because Staphylococcus aureus peptidoglycan (SaPG) accelerates healing in normal rats and prevents wound healing impairment induced by glucocorticoids, cyclophosphamide, and streptozotocin-diabetes, we hypothesized that SaPG would prevent the impaired wound healing after trauma. METHODS: In each of two experiments, 18 Sprague-Dawley male rats were divided into two groups, nine rats each, paired by weight; one group received unilateral comminuted femoral fracture and wounding (two dorsal skin incisions and six subcutaneous polyvinyl alcohol [PVA] sponges), and the other group was only wounded. The incision and PVA sponges on one side were inoculated at operation with saline (200 microL/incision, 50 microL/sponge) and on the other side with SaPG in saline (860 microg of SaPG per centimeter of incision, 0.5 mg of SaPG per sponge). Rats ate chow and drank tap water ad libitum and were killed 7 days postoperatively. RESULTS: In both experiments, the wound breaking strength (WBS) of saline-inoculated incisions was significantly lower in rats with femoral fracture; histologically, reparative granulation tissue was looser and less prominent. WBS of SaPG-inoculated incisions in rats with and without femoral fracture was significantly higher than that of saline-inoculated incisions and, histologically, reparative tissue was more prevalent, more closely packed, and more mature. WBS of SaPG-inoculated incisions in rats with femoral fracture was similar to that of saline-inoculated incisions in rats without femoral fracture. Reparative tissue hydroxyproline and histologic findings of saline-inoculated PVA sponge reparative tissue were similar in all rats, as were the increases induced by SaPG inoculation. CONCLUSION: Wound breaking strength and histologic findings of skin incisions (impaired in rats with unilateral femoral fracture) are more sensitive to the adverse effects of trauma than accumulation of PVA sponge reparative tissue. A single inoculation of SaPG at operation increased wound incision healing in rats both without and with femoral fracture and notably prevented the impaired healing in rats with femoral fracture.

Prospective comparison of catheter-based endoscopic sonography versus standard endoscopic sonography: evaluation of gastrointestinal-wall abnormalities and staging of gastrointestinal malignancies.

PURPOSE: Endoscopic sonography (EUS) is an important imaging modality for evaluating benign and malignant luminal gastrointestinal-tract abnormalities. The objectives of this study were to evaluate the feasibility of catheter-based EUS (C-EUS) during standard upper and lower endoscopy in patients with malignancies and other abnormalities of the gastrointestinal-tract lumen, to assess the image quality obtained with the 12.5-MHz catheter-based ultrasound transducer, and to prospectively compare the interpretations of C-EUS images with those of the standard EUS (S-EUS) images. METHODS: One hundred thirty-seven consecutive patients referred for EUS were evaluated with C-EUS followed by S-EUS. The patients were assigned to 1 of 2 groups: group A, patients with intramural masses or intestinal wall thickening, with biopsies negative for malignancy; and group B, patients with esophageal, gastric, duodenal, or rectal cancer referred for staging. The results of C-EUS and S-EUS were compared for each group. RESULTS: C-EUS was completed in 134 patients: 81 patients with 83 lesions in group A and 53 patients in group B. For group A, C-EUS image interpretation concurred with that of S-EUS in 74 (89%) of 83 lesions. For group B, C-EUS concurred with S-EUS for tumor depth (T) and nodal (N) classifications in 19 cases (36%) and 26 cases (49%), respectively. The depth of invasion was underestimated by C-EUS in all 34 cases in which the T classifications by C-EUS and S-EUS were discordant. In 1 of 6 patients with stenotic cancer that was nontraversable by S-EUS, C-EUS identified lymphadenopathy (incorrectly classified as N0 by S-EUS). CONCLUSIONS: C-EUS was easily performed, and the C-EUS images were comparable to the S-EUS images in assessing mucosal and intramural lesions. The limited depth of penetration of the catheter-based transducer resulted in understaging the extent of tumor invasion and underestimating the nodal spread.

Where children sit in cars: the impact of Rhode Island's new legislation.

OBJECTIVES: This study evaluated the impact of Rhode Island's legislation requiring children younger than 6 years to sit in the rear of motor vehicles. METHODS: Roadside observations were conducted in Rhode Island and Massachusetts in 1997 and 1998. Multivariate regression was used to evaluate the proportion of vehicles carrying a child in the front seat. RESULTS: Data were collected on 3226 vehicles carrying at least 1 child. In 1998, Rhode Island vehicles were less likely to have a child in the front seat than in 1997 (odds ratio = 0.6; 95% confidence interval = 0.5, 0.7), whereas no significant changes in child passenger seating behavior occurred in Massachusetts during that period. CONCLUSIONS: Rhode Island's legislation seems to have promoted safer child passenger seating behavior.

Lethality of standard total parenteral nutrition following major liver resection in rats is prevented by high arginine and high branched chain amino acids but not by glutamine.

Standard total parenteral nutrition (TPN), with or without fat, in amounts approximating the ad libitum intake of normal rats is highly lethal for rats following 70% hepatectomy. Because of significant metabolic changes including alterations of branched chain amino acids (BCAA), arginine (ARG), and glutamine (GLN) associated with serious injury, sepsis, and liver dysfunction, we hypothesized that (1) increasing concentrations of BCAA and ARG in TPN and (2) including glutamine in the TPN may diminish the lethality. Male Sprague-Dawley rats with 70% hepatectomy and jugular vein catheterization were divided into groups. Two sets of experiments were conducted. In Experiment 1, the effects of varying concentrations of BCAA and ARG in the TPN infusate, singly and together, were assessed: Group 1, Standard TPN (19% BCAA, 4.8 g ARG/L); Group II, High BCAA TPN (35% BCAA, 4.8 g ARG/L); Group III, High ARG TPN (19% BCAA, 9.6 g ARG/L); Group IV, High ARG, High BCAA TPN (35% BCAA, 9.6 g ARG/L; Group V, chow and tap water ad libitum. In experiment 2, the effect of 2% GLN in TPN was evaluated: Group A, Standard TPN and Group B, 2% GLN TPN. All infusates were isocaloric (216 Kcal/Kg/d) and isonitrogenous (1.94 g N/Kg/d) delivered at half concentration on postoperative day 1, 3/4 concentration on postoperative day 2, and at full concentration thereafter. Experiment 1: Thirty-three to 36% of rats in Groups I (Standard TPN) (4/11), II (High BCAA TPN) (4/11) and III (High ARG TPN) (4/12) died within 6 days. In sharp contrast, none died in Groups IV (High BCAA, High ARG TPN) and V (rat chow and tap water) (P < 0.05 in each comparison). Among rats in the 4 TPN groups surviving 7 days, there were no significant differences in body weight change (minus 3-4%), spleen or lung weight, extent of liver regeneration (61-66%). Serum total protein and albumin were significantly higher in Group V (chow-fed) (similar to values in normal rats) than in Groups I-IV, P < 0.05 in each case. Serum total bilirubin was significantly higher in Group I than in normals and in Groups II, III, and V. Serum lactate dehydrogenase levels were similar in normals and all 5 groups. Serum aspartate amino transferase level was higher in Group I than in normals but not significantly different from those groups II-V; the latter were similar to normals. Experiment 2: Thirty percent of rats in Groups A (Standard TPN) (3/10) and B (GLN TPN) (3/10) died within 6 days. Among rats surviving for 7 days, body weight change (minus 3-5%), liver regeneration (67-70%), and liver tests were similar in both groups. TPN modified to contain high concentrations of both BCAA and ARG (but not of either alone) prevented the high frequency of lethality induced by standard TPN in rats with 70% hepatectomy. No such salutary effect was shown by modifying the TPN to contain 2% GLN. The striking benefit observed when TPN containing high BCAA and high ARG was infused may be due to the high BCAA leading toward normalization of serum amino acid levels, reducing proteolysis, increasing protein synthesis, and accelerating early liver regeneration, combined with the high ARG likely reducing serum ammonia and leading to increased host defense, and perhaps, thereby, preventing bacterial translocation and bacteremia.

The future of subacute care.

Subacute care is a program of care for individuals with recent or current illness or injury. Currently, the services received by patients in subacute care vary considerably among sites, partly because these sites may specialize in certain treatments and partly because providers often define subacute care according to their own areas of expertise. Certain approaches to patient care, however, are universal regardless of diagnosis, and care that is given should be based on essential geriatric principles. In setting a standard for care in the subacute care setting, certain parameters must be clarified, including (1) defining subacute care, including what it is and what it is not; (2) selecting the right patient to receive subacute care; (3) making sure that care is centered on patients rather than sites or providers; and (4) ensuring that care is reimbursed adequately and appropriately. These issues are addressed, and guidelines on how to accomplish the goal of standardizing subacute care are provided.

Wound healing: captopril, an angiogenesis inhibitor, and Staphylococcus aureus peptidoglycan.

BACKGROUND: Captopril, an angiotensin-converting enzyme inhibitor, used for treating hypertension and heart failure, inhibits angiogenesis in the corneas of rats in response to basic fibroblast growth factor, slows the growth of experimental tumors in rats, and leads to the regression of Kaposi's sarcoma. Because angiogenesis is key to wound healing, we hypothesized that captopril would impair wound healing. We hypothesized also that because local application at operation of Staphylococcus aureus peptidoglycan (SaPG) increases angiogenesis and accelerates wound healing in rats, SaPG would prevent or ameliorate the postulated captopril-impaired wound healing. MATERIALS AND METHODS: In each experiment, rats were divided randomly into two groups: one drinking tap water, and the other, tap water containing 0.5 mg captopril/ml. All ate chow and drank ad libitum, pre-operatively (4-12 days) and postoperatively (7 days). In experiments 1 and 2, bilateral paravertebral 5.5-cm skin incisions were made aseptically (intraperitoneal sodium pentobarbital), and closed with interrupted No. 35 stainless-steel sutures. On one side, the wound was immediately inoculated with 157 microliter pyrogen-free isotonic saline and on the other side the wound was inoculated with 157 microliter saline containing 4.7 mg SaPG (860 microgram SaPG/cm incision). In the third experiment, polyvinyl alcohol (PVA) sponges (16-17 mg dry wt each) containing either 50 microliter saline or 0.5 mg SaPG in 50 microliter saline were implanted subcutaneously, two on each side, via 1-cm incisions closed with a single suture. In the fourth experiment, 5.5-cm bilateral skin incisions and subcutaneous implantation of PVA sponges were done as described but all sites were instilled with saline only. All rats were euthanized (CO(2) asphyxia) 7 days postoperatively. RESULTS: Wound breaking strength (WBS) of the saline-treated incisions was significantly higher (P < 0.001) in captopril-treated rats than in controls (172 +/- 13 g vs 105 +/- 6 g) in experiment 1 and higher, but not significantly in captopril-treated rats in experiment 2 (153 +/- 8 g vs 114 +/- 6 g) (PNS). SaPG inoculation of the incisions increased WBS significantly in both control and captopril-treated rats: 187 +/- 11 g vs 105 +/- 6 g (P < 0.001) and 283 +/- 16 g vs 172 +/- 13 g (P < 0.001), respectively, in experiment 1, and 217 +/- 13 g vs 114 +/- 6 g (P < 0.0001) (controls) and 266 +/- 17 g vs 153 +/- 8 g (captopril-treated rats) (P < 0.0001) in experiment 2. In experiment 3, subcutaneous PVA saline-inoculated sponge reparative tissue hydroxyproline (OHP) content was similar in control and captopril-treated rats, and SaPG inoculation increased reparative tissue OHP significantly in both groups: 2458 +/- 218 microgram/100 mg dry sponge vs 3869 +/- 230 microgram/100 mg (P < 0.001) (controls) and 2489 +/- 166 microgram/100 mg vs 4176 +/- 418 microgram/100 mg (P < 0.001) (captopril-treated rats). Histologically, angiogenesis and reparative tissue collagen were similar in control and captopril-treated rats, in both saline-inoculated and SaPG-inoculated sponges. In experiment 4 (all incisions and subcutaneous PVA sponges were saline-inoculated), there was no significant difference in WBS between control and captopril-treated rats (107 +/- 6 g vs 96 +/- 5 g, NS). PVA sponge reparative tissue OHP was significantly higher in captopril-treated rats: 3698 +/- 170 microgram/100 mg dry sponge vs 2534 +/- 100 microgram/100 mg (P < 0.0001). CONCLUSION: Unexpectedly, in four experiments, captopril did not inhibit WBS or PVA sponge reparative tissue angiogenesis or collagen accumulation; in fact, WBS was increased significantly in one of three experiments, and PVA sponge reparative tissue OHP was increased significantly in one of two experiments. Also, captopril did not interfere with the wound healing-accelerating effect of SaPG.

H(2)O(2) is an important mediator of physiological and pathological healing responses.

BACKGROUND: TGF-beta1 is a pleiotropic cytokine that plays a key role in wound healing and organ fibrosis. We have recently demonstrated that, in part, some fibrogenic actions of TGF-beta1 are mediated via formation of H(2)O(2). We have also demonstrated that TGF-beta1 plays a key role in the accelerated healing response induced by a peptidoglycan derived from some strains of Staphylococcus aureus (SaPG). METHODS: To investigate further the role of H(2)O(2) in healing responses, we implemented and improved a method to measure this reactive oxygen species. Using this method, we quantified the production of H(2)O(2) by cultured hepatic stellate cells-the main cells involved in type I collagen production in the liver-and by saline- and SaPG-inoculated polyvinyl alcohol sponges that had been surgically subcutaneously implanted in the dorsum of rats. RESULTS: We show that cultured hepatic stellate cells produce significant amounts of H(2)O(2). We show also that H(2)O(2) formation by saline- and SAPG-inoculated sponges is more intense during the early inflammatory phase of the healing response and precedes collagen deposition. Moreover, the production of H(2)O(2) is much higher in SaPG-inoculated sponges than in those inoculated with saline solution. CONCLUSIONS: Based on these findings, and on the fact that H(2)O(2) is produced during TGF-beta-induced upregulation of the alpha1(I) procollagen gene, we conclude that H(2)O(2) is one of the mediators of healing responses.

Does being a chief resident predict leadership in pediatric careers?

OBJECTIVE: Many organizations make efforts to identify future pediatric leaders, often focusing on chief residents (CRs). Identifying future leaders is an issue of great importance not only to the ultimate success of the organization but also to the profession. Because little is known regarding whether completing a CR predicts future leadership in medicine, we sought to determine if former pediatric CRs when compared with pediatric residents who were not CRs reported more often that they were leaders in their profession. DESIGN/METHODS: Twenty-four pediatric training programs stratified by resident size (<18, 18-36, and >36) and geography (East, South, Midwest, and West) were selected randomly from the Graduate Medical Education Directory (American Medical Association, Chicago, IL). Program directors were contacted by mail and telephone and asked to provide their housestaff rosters from 1965-1985. The resulting resident sample was surveyed by questionnaire in 1995. RESULTS: Fifteen of 17 program directors (88%) who possessed the requested data provided 1965-1985 rosters yielding a sample of 963 residents. Fifty-five percent of the resident sample (533) responded. Fifty-eight of the respondents had not completed a pediatric residency, leaving a survey sample of 475. Thirty-four percent (163) were CRs. The sample had a mean age of 47, 67% were male and 87% married. Fellowships were completed by 51%. More former CRs compared with non-CRs (75% vs 64%), more former fellows than non-fellows (75% vs 60%) and more males than females (74% vs 55%) reported they were professional leaders. These associations persisted in a logistic regression that controlled for CR status, gender, marital status, and fellowship status as leadership predictors. Former CRs, former fellows, and men were, respectively, 1.8, 2.3, and 2.3 times more likely to report professional leadership. CONCLUSIONS: Pediatric residents who were former CRs and/or fellows, and males were more likely to report professional leadership. Although men were more likely to report professional leadership, with more women entering pediatrics the reported gender differences will likely disappear over time.

Antibiotic therapy of Helicobacter pylori infection reduces healthcare expenditures related to duodenal ulcer.

OBJECTIVE: To test whether eradication of Helicobacter pylori saves costs in the treatment of duodenal ulcer disease, compared with conventional antisecretory therapy. STUDY DESIGN: A prospective, double-blind clinical trial was conducted at 132 sites in the United States. PATIENTS AND METHODS: Adult patients with active duodenal ulcer and confirmed H pylori infection were randomized to receive treatment with clarithromycin plus omeprazole, omeprazole alone, or ranitidine alone. Utilization of ulcer-related healthcare resources was documented during 1 year following therapy. Costs were calculated by multiplying the number of health resources utilized by the cost of each resource. Resource costs were obtained from a database containing actual average costs spent by managed care organizations on outpatient and inpatient treatment. RESULTS: Of the 819 patients enrolled, 727 completed the study: 243 received clarithromycin plus omeprazole, 248 omeprazole alone, and 236 ranitidine alone. Ulcer-related health resource utilization and total ulcer-related healthcare costs were decreased after treatment with clarithromycin plus omeprazole, compared to treatment with omeprazole or ranitidine alone. In multivariate linear regression analyses, type of treatment was found to be a significant predictor of total costs. Specific costs associated with endoscopic examinations, clinic visits, and medications were also significantly reduced by treatment with clarithromycin plus omeprazole as compared to other treatment forms. CONCLUSIONS: In a managed care environment, therapy with clarithromycin and omeprazole to eradicate H pylori in patients with duodenal ulcer disease would result in significant cost savings secondary to a reduction in the utilization of healthcare resources.

Single local instillation of Staphylococcus aureus peptidoglycan prevents diabetes-induced impaired wound healing.

Diabetes-induced impaired wound healing is characterized by inhibition of the inflammatory response to wounding, macrophage infiltration, angiogenesis, fibroplasia, reparative collagen accumulation, and wound breaking strength. Because all of these processes are accelerated in normal rats by a single local application at operation of Staphylococcus aureus peptidoglycan, we hypothesized that S. aureus peptidoglycan would prevent diabetes-induced impaired wound healing, despite persistent, untreated hyperglycemia, polydipsia, glycosuria, and polyuria. Sprague- Dawley male rats were divided into two groups. One group received an intraperitoneal injection of streptozotocin (65 mg/kg) in citrate solution; the other group received an intraperitoneal injection of an equivalent volume of citrate solution. Seventeen days after the injections, the diabetic and control rats received aseptically two 5.5-cm paravertebral incisions and subcutaneous implantation of six polyvinyl alcohol sponges, three on each side. On one side, each sponge contained 0.5 mg S. aureus peptidoglycan in 50 microliter saline solution, and the incision was inoculated along its length with 4.7 mg S. aureus peptidoglycan in 157 microliter saline solution (860 microgram/S. aureus peptidoglycan/cm incision); on the other side, the same respective volumes of saline were used. During the preoperative and postoperative periods, diabetic rats lost a small amount of weight (2%), were hyperglycemic (363 +/- 10 mg/100 ml blood), polydipsic, glycosuric, and polyuric, whereas the controls gained weight (25%) and were normoglycemic (104 +/- 5 mg/100 ml blood); these differences were significantly different (p <.001 in each case). In controls, S. aureus peptidoglycan inoculation increased wound breaking strength (by a factor of 2.0) and hydroxyproline content (by a factor of 1.4; p <.001 in each case); in diabetics, there were significant decreases in wound breaking strength (by a factor of 1.7) and hydroxyproline content (by a factor of 1.3) of saline solution-inoculated incisions and sponges compared with the wound breaking strength and hydroxyproline content of saline solution-inoculated incisions and sponges in controls (p <.02 and p <.001, respectively). These decreases were completely prevented when the incisions and polyvinyl alcohol sponges had been inoculated at operation with S. aureus peptidoglycan; S. aureus peptidoglycan inoculation in the diabetic rats increased wound breaking strength by a factor of 2.2 and sponge reparative tissue hydroxyproline by a factor of 1.6 (p <.001 in each case). Thus, diabetes-induced impaired wound healing was prevented completely by a single local instillation at operation of S. aureus peptidoglycan, despite persistent, untreated hyperglycemia, polydipsia, polyuria, and glycosuria.

Nonviable Staphylococcus aureus and its peptidoglycan stimulate macrophage recruitment, angiogenesis, fibroplasia, and collagen accumulation in wounded rats.

We have previously shown that local application at the time of operation of Staphylococcus aureus, nonviable S. aureus, its cell wall, or S. aureus peptidoglycan accelerates wound healing. We hypothesized that this effect is due to both direct and indirect mechanisms, among which is an increase in the inflammatory response to wounding, resulting in an increase in macrophages, angiogenesis, and fibroblasts. Twenty-seven Sprague-Dawley male rats were anesthetized, and two 7-cm paravertebral skin incisions were made. Four polyvinyl alcohol sponges, two on each side, containing either 100 microliter of isotonic saline or 0.5 mg of nonviable S. aureus or S. aureus peptidoglycan in 100-microliter saline were implanted subcutaneously. Nonviable S. aureus or S. aureus peptidoglycan (860 microgram/cm incision) in 200-microliter saline were inoculated into the incisions at closure. The rats ate a commercial rat chow and drank tap water ad libitum throughout. After days 3 and 7 postwounding, rats were euthanized, and tissues were examined for immunohistochemical features of reparative tissue using ED-1, Factor VIII, and vimentin antibodies, markers for monocyte/macrophages, endothelial cells, and mesenchymal cells (including fibroblasts), respectively. Incisions treated with nonviable S. aureus or S. aureus peptidoglycan showed more macrophages along and deep in the wound tract 7 days postoperatively. Nonviable S. aureus or S. aureus peptidoglycan-treated sponges were surrounded and penetrated by much larger capsules of reparative tissue than saline-treated sponges at both 3 and 7 days. Neutrophil influx was much greater in nonviable S. aureus or S. aureus peptidoglycan-treated sponges, especially in central regions, and there were many more ED-1-stained macrophages in distinct geographic locations, specifically, the more peripheral-cortical areas. Some clustering of macrophages occurred around areas of invasion by reparative tissue into the surrounding subcutaneous fat and within the interstices of the sponges at the interface between reparative tissue and acute inflammatory cells. In contrast, saline-treated sponge reparative tissue had significantly fewer macrophages, much thinner and flimsy reparative tissue, with proportionately fewer macrophages clustering centrally. There were many more mesenchymal cells (notably fibroblasts) and new blood vessels and much more reparative collagen in the nonviable S. aureus or S. aureus peptidoglycan-treated sponges. We conclude that local application of nonviable S. aureus or S. aureus peptidoglycan at wounding induces an increased number and alteration in location of macrophages, increased influx (or proliferation) of mesenchymal cells (notably fibroblasts), and increased angiogenesis and reparative collagen accumulation, as well as increasing the overall acute inflammatory response to wounding.

Health status and practices of urban Caribbean Latinos with diabetes mellitus.

Although Caribbean Latinos are more likely than non-Hispanic whites to develop diabetes, their health status has been poorly characterized. Information on diabetes management, metabolic control, dietary habits, and diabetes knowledge was gathered from a group of urban Caribbean Latinos with diabetes in order to characterize the nutritional behaviors, diabetes attitudes, health perceptions, and metabolic control of this high risk group. Interviews and medical record reviews were conducted among seventy low-income urban Caribbean Latinos with type 2 diabetes mellitus. Patients attending outpatient clinics were interviewed by bilingual interviewers. Medical records were reviewed to ascertain prevalence of diabetes-related complications, medications, and metabolic parameters. Participants were primarily Spanish-speaking and of Puerto Rican origin. Eighty-one percent were unemployed, and only 27% had completed high school or higher educational levels. Average hemoglobin A1c was 10.6%. Among those with hypertension and hyperlipidemia, many were not receiving treatment. Participants' estimation of their own degree of metabolic control was poor, as was their understanding of desirable blood glucose and weight goals. A second evening meal was common. Diets were higher in fat and sugar content than currently recommended. More effective treatment strategies for both patients and providers are needed to improve glycemic control and cardiovascular risk factors among indigent urban Caribbean Latinos. Essential features of such strategies for patient programs include culturally appropriate dietary counseling and low literacy materials to better communicate glycemic and weight goals and dietary guidelines. Provider education is needed regarding established guidelines and cultural influences on diabetes-related practices.

Subacute settings: making the most of a new model of care.

Subacute programs care for individuals in various stages of acute illness and injury, usually after but sometimes instead of hospitalization for an acute episode. Typical reasons why older patients are hospitalized prior to subacute care include life-threatening conditions. Moreover, older patients tend to have one or more comorbidities related or unrelated to their primary acute condition. Therefore, an essential task for the physician is to assess each patient's medical stability within 24 to 48 hours of admission to subacute care. In subacute settings, interdisciplinary providers deliver a coordinated package of care. Physicians coordinate the medical treatments with the observations and input of nurses and providers in other disciplines who are managing patients' functional and psychosocial problems.

Trillion virion delay: time from testing positive for HIV to presentation for primary care.

BACKGROUND: Human immunodeficiency virus (HIV)-infected individuals' initial presentation to medical care frequently occurs at a point of advanced immunosuppression. OBJECTIVES: To investigate the time between HIV testing and presentation to primary care. Also to examine factors associated with delayed presentation. METHODS: One hundred eighty-nine consecutive outpatients without prior primary care for HIV infection were assessed at 2 urban hospitals: Boston City Hospital, Boston, Mass, and Rhode Island Hospital, Providence. Sociodemographics, alcohol and drug use, social support, sexual beliefs and practices, and HIV testing issues were examined in bivariate and multivariate analyses for association with delay in presentation to primary care after positive test results for HIV. RESULTS: Of 189 patients, 74 (39%) delayed seeking primary care for more than 1 year, 61 (32%) delayed for more than 2 years, and 35 (18%) for more than 5 years after an initial positive HIV serologic evaluation. The median CD4+ cell count of subjects was 0.28 x 10(9)/L (range, 0.001-1.71 x 10(9)/L). In multiple linear regression analysis the following characteristics were found to be associated with delayed presentation to primary care after HIV testing: history of injection drug use (P<.001); not having a living mother (P=.01); not having a spouse or partner (P=.08); not being aware of HIV risk before testing (P<.001); and being notified of HIV status by mail or telephone (P=.002). An interaction effect between sex and screening for alcohol abuse was significant (P=.03) and suggested longer delays for men with positive screening test results (CAGE [an alcoholism screening questionnaire containing 4 structured questions], 2+) compared with men without positive screening test results or women. CONCLUSIONS: Patients with positive HIV test results often delay for more than a year before establishing primary medical care. Information readily available at the time of HIV testing concerning substance abuse, social support, and awareness of personal HIV risk status is useful in identifying patients who are at high risk of not linking with primary care. Patients who were notified of their HIV status by mail or telephone delayed considerably longer than those notified in person. Efforts to ensure primary care linkage at the time of notification of positive HIV serostatus are necessary to maximize benefits for both individual and public health and should be an explicit task of posttest counseling.