Toxicology studies of aqueous-alcohol extracts of Harpagophytum procumbens subsp. procumbens (Burch.) DC.Ex Meisn. (Pedaliaceae) in female and male rats.

BACKGROUND: A variety of medicinal products prepared from secondary tubers of Harpagophytum procumbens subsp. procumbens (Burch.) DC.ex Meisn. (Devil's Claw) and H. zeyheri are marketed in Africa, Europe, the United States, South America and elsewhere, where they are used for inflammatory and musculoskeletal conditions such as arthritis, lower back pain, rheumatism and neuralgia, etc. While clinical studies conducted over the last twenty years support the general safety of such products, infrequent gastrointestinal disturbances (diarrhea, nausea, vomiting, abdominal pain), headache, vertigo and hypersensitivity (allergic) reactions (rash, hives and face swelling) have been documented. Sex-related differences occur in the health conditions for which Devil's Claw products are used, so it is likely that usage is similarly sex-related and so might be side effects and potential toxicities. However toxicologic studies of Devil's Claw products have been conducted primarily with male animals. To address this deficit, we report toxicological studies in female and male rats of several H. procumbens (HP) aqueous-alcohol extracts chemically analyzed by UPLC-MS. METHODS: Female and male Sprague Dawley rats were studied for one and three months in groups differing by consumption of diets without and with HP extracts at a 7-10-fold human equivalent dose (HED). Sera were analyzed for blood chemistry, and heart, liver, lung, kidney, stomach, and small and large intestine tissues were examined for histopathology. Treatment group differences for blood chemistry were analyzed by ANOVA with Dunnett's test and significant group differences for endpoints with marginal distributional properties were verified using the Kruskal-Wallis test. Group differences for histopathology were tested using Chi Square analysis. RESULTS: Significant group by sex-related differences in blood chemistry were detected in both studies. Additionally, several sex-related differences occurred between the studies. However, significant histopathology effects associated with the consumption of the extracts were not detected. CONCLUSION: Toxicologic analysis of Devil's Claw extracts cause significant sex-related effects in blood chemistry. However, in our judgement, none of the observed effects suggest serious toxicity at these doses and durations. Subsequent toxicologic and clinical studies of H. procumbens and other medicines with similar properties should explore in greater detail the basis and consequences of potential sex-related effects.

Extragenital Gonorrhea and Chlamydia Among Men and Women According to Type of Sexual Exposure.

BACKGROUND: Current guidelines recommend screening for extragenital gonorrhea (GC) and chlamydia (CT) only among men having sex with men (MSM). Extragenital GC and CT is associated with treatment failure and disease transmission. The prevalence of extragenital GC/CT infections in women and in men having sex with women (MSW) are less well studied. We sought to determine the prevalence of extragenital CG and CT among all persons attending a sexually transmitted diseases clinic who engaged in extragenital sexual activity. METHODS: We examined demographic and clinical data of all patients who engaged in extragenital sexual activity between January 2012 and October 2014. Nucleic acid amplification testing for GC and CT was performed at sites of exposure among all men and women at pharyngeal, rectal, and urogenital sites. Multivariable logistic regression analyses were performed to determine the extent that age, race/ethnicity, and number of sexual partners predicted a positive test result. RESULTS: Pharyngeal GC was found in 3.1% of MSW, representing 35% of the GC infections in MSW. Thirty-six percent of MSW with pharyngeal GC tested negative at their urogenital site. Pharyngeal GC in MSW prevalence was higher among those with younger age or a higher number of sex partners. Pharyngeal GC, rectal GC, and rectal CT rates were 8.5%, 15.0%, and 16.5%, respectively, among MSM and 3.8%, 4.8%, and 11.8% among women having sex with men (WSM), respectively. CONCLUSIONS: Extragenital GC and CT rates of infection was highest among MSM but was also observed in WSM and MSW, representing an unrecognized disease burden.

Relationships Between Course Capture Systems and Student Performance in Dental Hygiene Education.

Purpose: The aim of this mixed-methods longitudinal study was to assess student perceptions of technology use, and to examine the relationship between technology use and performance as reflected by self-reported student grade point averages.Methods: Students (n=351) enrolled in a dental hygiene program within a dental school located in the mid-western United States were surveyed in three courses from 2008 through 2012 to gather their perceptions regarding usage of a lecture recording system (LRS). Additionally, self-reported grade point averages were collected over the same period of time. Data were analyzed using a statistical software program (IBM SPSS; Armonk, NY).Results: The response rate was 82%. Descriptive statistics demonstrated that students believed that the LRS increased their success and satisfaction in the course and would be useful in other courses. Students also reported they would not choose to miss class sessions based on the availability of the recorded lectures. Correlation statistics found no relationship between student GPA and students' perceptions regarding the LRS.Conclusion: Students reported LRS use and availability did not impact their attendance. No relationship was found between students' self-reported GPA and evaluation of the LRS use within the limits of this study.

Bolstering diagnostic reasoning skills with adaptive learning.

PURPOSE: Adaptive learning emerges when precise assessment informs delivery of educational materials. This study will demonstrate how data from Human Dx, a case-based e-learning platform, can characterize an individual's diagnostic reasoning skills, and deliver tailored content to improve accuracy. METHODS: Pearson Chi-square analysis was used to assess variability in accuracy across three groups of participants (attendings, residents, and medical students) and three categories of cases (core medical, surgical, and other). Logistic regression analyses were conducted to explore the relationship between solve duration and accuracy. Mean accuracy and duration were calculated for 370 individuals. Repeated measures analysis of variance (ANOVA) were used to assess variability for an individual solver across the three categories. RESULTS: There were significant differences in accuracy across the three groups and the three categories (p < 0.001). Individual solvers have significant variance in accuracy across the three categories. Shorter solve duration predicted higher accuracy. Patterns of performance were identified; four profiles are highlighted to demonstrate potential adaptive learning interventions. CONCLUSIONS: Human Dx can assess diagnostic reasoning skills. When weaknesses are identified, adaptive learning strategies can push content to promote skill development. This has implications for customizing curricular elements to improve the diagnostic skills of healthcare professionals.

"Poems in the Entrance Area": Using Photo-Stories to Promote HIV Medication Adherence.

Adherence to antiretroviral medication among people living with HIV (PL-HIV) is critical to individual and public health. By some estimates only a quarter of PL-HIV are sufficiently adherent, underscoring a continued need for adherence-promoting strategies. In this analysis we explore the effect of adherence education posters developed via Photovoice. A group of PL-HIV generated images and captions to describe their adherence experiences and used their photo-stories to design 10 posters. We assessed viewers' ( N = 111) adherence knowledge, self-efficacy, and communication changes quantitatively and qualitatively before and 3 months after poster placement in the clinic. We analyzed quantitative data with an independent groups t test or a Mann-Whitney test, and qualitative interviews via theme analysis. Quantitative findings indicated no significant differences. Qualitative interviewees said that posters enhanced knowledge with nonthreatening, relatable information; self-efficacy by motivating patients to take medicine and disclose HIV to others; and communication by facilitating adherence conversations and creating a visually supportive clinic. Divergent quantitative and qualitative findings can be partially explained by inquiry methods. The posters may be more effective as part of discussions about their content, like those facilitated by qualitative interviews. Additional research regarding the application of Photovoice to health promotion is warranted.

Systematic procedures to promote U.S. HIV medication adherence via Photovoice.

Medication adherence is essential to promote the health of people living with HIV (PL-HIV) and prevent HIV transmission in the U.S. Novel medication health promotion interventions are needed that address patient-centeredness, understandability, and communication with providers. The aims of this article are to define the systematic stages we used to develop an effective health promotion intervention via the products (e.g. images and stories) of Photovoice. We designed an intervention to improve HIV adherence knowledge, attitudes, and communication with providers through Photovoice. 16 PL-HIV used Photovoice strategies to describe their experiences with medication via images and captions and create an intervention (10 adherence promotion posters) that integrated photo-stories of their adherence motivators, journeys from sickness to health, and how they manage and counter HIV stigma. We outline the systematic process we used to adapt Photovoice to create the effective intervention for replication. The process included six stages: (i) identify scope of the project; (ii) create collaborative project team; (iii) design project materials; (iv) review and revise materials with team members; (v) disseminate materials; and (vi) evaluate materials. Photovoice is used traditionally as a social action research method. In this project, it was adapted to create patient-driven images and stories for health promotion posters. Poster viewers experienced improved self-efficacy for HIV medication adherence. Describing the adaptation of the Photovoice process in a deliberate and transparent way can support fidelity to the essence of the participant-driven method, while also allowing researchers and practitioners to replicate Photovoice as a successful health promotion intervention.

Environmental Tobacco Smoke and Periodontitis in United States Non-Smokers, 2009 to 2012.

BACKGROUND: Epidemiologic studies using half-mouth designs for assessment of periodontal disease prevalence have reported that environmental tobacco smoke (ETS) exposure of non-smokers is associated with a two- to three-fold increase in the odds of developing periodontitis. In response to the possibility of under-reporting of periodontitis, the Centers for Disease Control updated periodontal examination procedures in 2009 for the National Health and Nutritional Examination Survey (NHANES), including full-mouth, six-site periodontal probing, and attachment loss assessment. Aims of this study are to estimate prevalence of periodontitis among United States non-smoking adults exposed to ETS, report the values of the improved methods for estimating disease prevalence, and evaluate the predictive contribution of ETS exposure to periodontitis. METHODS: A cross-sectional study was conducted using NHANES data from the 2009 to 2012 examination cycle. To address these aims, oral examination data were used to determine prevalence of periodontitis among United States non-smoking adults and to test the influence of ETS exposure on occurrence of periodontitis. RESULTS: There was a 28% increase in the odds of periodontitis for those with any ETS exposure compared with those with no measurable exposure (Wald χ2 test statistic [df] = 6.58 [1], P = 0.01; 95% confidence interval = 1.06 to 1.55). CONCLUSION: ETS exposure increases the risk of an individual developing periodontitis.

A Qualitative Description of HIV-Infected African American Women's Experiences of Psychological Distress and Their Coping Strategies.

HIV-infected individuals are at risk for psychological distress, including depression, sadness, and suicidality. The purpose of this qualitative descriptive study was to examine 22 HIV-infected African American women's experiences of psychological distress and use of coping strategies. Data were collected through in-person one-on-one interviews until conceptual saturation was reached. Data were analyzed using inductive content analysis. Four themes were found: (a) psychoemotional suffering, (b) contextual factors negatively influence the everydayness of living with HIV infection, (c) HIV-related stigma perpetuates isolation and loneliness, and (d) creating a safe haven. Implications for nurses and other health care providers include (a) holistic assessment to include evaluation of emotional and mental state, and (b) coping strategies. Integration of spiritual practices into plan of care is also important. Development and evaluation of individualized coping interventions that address stigma and psychological distress through holistic modalities is warranted.

Another Way to Talk: Exploring Photovoice as a Strategy to Support Safe Disclosure Among Men and Women With HIV.

HIV status disclosure can reduce stigma and facilitate medication adherence and safer sex among people living with HIV (PLH). Effective disclosure interventions are limited, however, and new strategies are necessary. We conducted a pilot Photovoice-based project with 38 PLH in four cities in the Midwest and Northeast U.S. and explored how the project affected disclosure perspectives and experiences. Participants attended three group Photovoice sessions, one individual session, and an optional photo exhibit. Qualitative strategies of theme and narrative analysis of photos and session transcripts revealed that participants discussed three categories of disclosures to others: fearful, reluctant, and open. The project supported all disclosure types, helping fearful participants manage their emotions, reluctant participants plan for more effective disclosures, and open participants share their HIV status. Pilot findings suggest that Photovoice should be further developed and studied as a safe and powerful strategy to improve disclosure and subsequent health and prevention outcomes among PLH.

Fetoplacental regional variations in the expression of angiopoietin-1, angiopoietin-2, and Tie2 in normal-term and near-term pregnancies.

BACKGROUND: Angiopoietin-1 (Ang1), angiopoietin-2 (Ang2), and the receptor tyrosine kinase with immunoglobulin-like and EGF-like domains 2 (Tie2) are known to be involved in fetoplacental angiogenesis adequacy, which is a primary determinant of fetal growth. Regional variations in Ang1, Ang2, and Tie2 remain unknown, although fetoplacental vascularity and gene expressions differ between the placental center and the periphery. OBJECTIVE: The aim of this study was to test the hypothesis that there are regional variations in the expression of these angiopoietins in human placentas from uncomplicated term and near term pregnancies. STUDY DESIGN: In this prospective study, central and peripheral samples were collected from fresh placentas from normal-term and near-term pregnancies delivered by Cesarean section (n = 7, 36-41 week gestation) prior to the onset of labor. Regional differences in Ang1, Ang2, and Tie2 protein expressions were measured by Western blot and densitometric analyses with b-actin normalization, and their fetoplacental regional localization assessed by immunohistochemistry. The Ang1 and Ang2 ratios at central and peripheral sites were determined. Statistical analysis was performed using Student's t-test. RESULTS: Ang1 protein expression was higher in the placental periphery than in the center (2.48 ± 0.42 versus 1.74 ± 0.27, p = 0.01). In contrast, Ang2 protein expression was greater in the placental center than in the periphery (10.10 ± 1.82 versus 7.15 ± 1.12, respectively, p = 0.03). The Ang1-Ang2 ratio reflected these differential expressions. Tie2 protein expression was higher in the placental periphery than in the center (0.21 ± 0.02 versus 0.16 ± 0.02, p = 0.003). The immunoreactivity of Ang1 and Tie2 was stronger in the periphery than in the center, and that of Ang2 was stronger in the center than in the periphery. CONCLUSIONS: Ang1, Ang2, and Tie2 are differentially expressed in placental center and periphery. Ang1/Ang2 ratio reflects this regional variation in the angiogenic balance that has implications for fetoplacental villous angiogenesis. The results also demonstrate the importance of considering the location of placental sampling sites for any future investigations of fetoplacental villous angiogenesis.

Down-regulation of placental neuropilin-1 in fetal growth restriction.

BACKGROUND: Fetal growth restriction (FGR) is associated with adverse outcomes extending from fetal to adult life, and thus, constitutes a major health care challenge. Fetuses with progressive growth restriction show increasing impedance in the umbilical artery flow, which may become absent during end-diastole. Absent end-diastolic flow (AEDF) is associated with adverse perinatal outcomes including stillbirths and perinatal asphyxia. Placentas from such pregnancies demonstrate deficient fetoplacental vascular branching. Current evidence, moreover, indicates an antiangiogenic state in maternal circulation in several pregnancy complications including preeclampsia, small-for-gestational-age births, fetal death, and preterm labor. The angiogenic mediators in maternal circulation are predominantly of placental origin. Information, however, on the role of specific proangiogenic and antiangiogenic mechanisms operating at the placental level remains limited. Elucidation of these placenta-specific angiogenic mechanisms will not only extend our understanding of the causal pathway for restricted fetal growth but may also lead to the development of biomarkers that may allow early recognition of FGR. OBJECTIVE: We sought to test the hypothesis that fetoplacental angiogenic gene expression is altered in pregnancies complicated with FGR and umbilical artery Doppler AEDF. STUDY DESIGN: Placental samples were collected from FGR pregnancies complicated with umbilical artery Doppler AEDF (study group, n = 7), and from uncomplicated pregnancies (control group, n = 7), all delivered by cesarean during the last trimester of pregnancy. Angiogenic oligonucleotide microarray analysis was performed and was corroborated by quantitative real-time polymerase chain reaction, Western blot analysis, and immunohistochemistry. The Student t test with Bonferroni correction was used with P < .05 considered statistically significant. Independent groups t test was used to analyze the immunostain intensity scores with a P < .05 considered statistically significant. RESULTS: Our microarray results showed that among several differentially expressed angiogenic genes in the growth-restricted group, only the down-regulation of neuropilin (NRP)-1 was most significant (P < .0007). Quantitative real-time polymerase chain reaction confirmed a significantly lower NRP-1 gene expression in the FGR group than in the control group (mean ± SD (ˆ)cycle threshold: 0.624 ± 0.55 and 1.325 ± 0.84, respectively, P = .04). Western blot validated significantly lower NRP-1 protein expression in the FGR group than in the control group (mean ± SD NRP-1/ß-actin ratio: 0.13 ± 0.04 and 0.34 ± 0.05, respectively, P < .001). Finally, immunohistochemistry of placental villi further corroborated a significantly decreased expression of NRP-1 in the FGR group (P = .006). CONCLUSION: The study demonstrated significant down-regulation of placental NRP-1 expression in FGR pregnancies complicated with AEDF in umbilical artery. As NRP-1 is known to promote sprouting angiogenesis, its down-regulation may be involved in the deficient vascular branching observed in FGR placentas suggesting the presence of an antiangiogenic state. Further studies may elucidate such a causal role and may lead to the development of novel diagnostic and therapeutic tools.

Cesarean Delivery with External Negative Pressure Dressing System: A Retrospective Cohort Study.

Objective To determine whether the use of external negative pressure dressing system (ENPDS) can reduce the incidence of wound complications after cesarean delivery (CD) compared with traditional dressings. Methods Retrospective review of all patients undergoing CD between November 2011 and March 2013. Information was collected on demographics, body mass index (BMI), duration of labor, pre- and postnatal infections, incision and dressing type, and postoperative course. Comparisons were made between traditional dressing and an external negative pressure dressing system. Results Of 970 patients included in the study, wound complications occurred in 50 patients (5.2%). Comparisons of ENPDS ( n = 103) and traditional dressing ( n = 867) groups revealed higher wound complications for ENPDS with odds ratio (OR) 3.37 and confidence interval (CI) 1.68 to 6.39. ENPDS was more commonly used in patients with BMI > 30 and preexisting diabetes. After controlling for BMI and pregestational diabetes in logistic regression analysis, ENPDS was equivalent to traditional dressing for risk of wound complications with an adjusted OR 2.76 (CI 0.97 to 7.84), with a trend toward more wound complications with ENPDS. Wound separation also tended to be more common in ENPDS group versus traditional dressing with an adjusted OR 2.66 (CI 0.87 to 8.12), although this result did not reach significance. Conclusion ENPDS is equivalent to traditional dressing for preventing wound complications after controlling for the higher-risk population selected for its use. In particular, wound separation appears to occur more frequently in women treated with ENPDS versus traditional dressing and should be regarded as a potential hazard of the system.

Consumption of Sutherlandia frutescens by HIV-Seropositive South African Adults: An Adaptive Double-Blind Randomized Placebo Controlled Trial.

BACKGROUND: Sutherlandia frutescens (L.) R. Br. is widely used as an over the counter complementary medicine and in traditional medications by HIV seropositive adults living in South Africa; however the plant's safety has not been objectively studied. An adaptive two-stage randomized double-blind placebo controlled study was used to evaluate the safety of consuming dried S. frutescens by HIV seropositive adults with CD4 T-lymphocyte count of >350 cells/µL. METHODS: In Stage 1 56 participants were randomized to S. frutescens 400, 800 or 1,200 mg twice daily or matching placebo for 24 weeks. In Stage 2 77 additional participants were randomized to either 1,200 mg S. frutescens or placebo. In the final analysis data from Stage 1 and Stage 2 were combined such that 107 participants were analysed (54 in the S. frutescens 1,200 mg arm and 53 in the placebo arm). RESULTS: S. frutescens did not change HIV viral load, and CD4 T-lymphocyte count was similar in the two arms at 24 weeks; however, mean and total burden of infection (BOI; defined as days of infection-related events in each participant) was greater in the S. frutescens arm: mean (SD) 5.0 (5.5) vs. 9.0 (12.7) days (p = 0.045), attributed to two tuberculosis cases in subjects taking isoniazid preventive therapy (IPT). CONCLUSION: A possible interaction between S. frutescens and IPT needs further evaluation, and may presage antagonistic interactions with other herbs having similar biochemical (antioxidant) properties. No other safety issues relating to consumption of S. frutescens in this cohort were identified. TRIAL REGISTRATION: ClinicalTrials.gov NCT00549523.

Butyrylcholinesterase genotype and enzyme activity in relation to Gulf War illness: preliminary evidence of gene-exposure interaction from a case-control study of 1991 Gulf War veterans.

BACKGROUND: Epidemiologic studies have implicated wartime exposures to acetylcholinesterase (AChE)-inhibiting chemicals as etiologic factors in Gulf War illness (GWI), the multisymptom condition linked to military service in the 1991 Gulf War. It is unclear, however, why some veterans developed GWI while others with similar exposures did not. Genetic variants of the enzyme butyrylcholinesterase (BChE) differ in their capacity for metabolizing AChE-inhibiting chemicals, and may confer differences in biological responses to these compounds. The current study assessed BChE enzyme activity and BChE genotype in 1991 Gulf War veterans to evaluate possible association of this enzyme with GWI. METHODS: This case-control study evaluated a population-based sample of 304 Gulf War veterans (144 GWI cases, meeting Kansas GWI criteria, and 160 controls). BChE enzyme activity levels and genotype were compared, overall, in GWI cases and controls. Potential differences in risk associated with cholinergic-related exposures in theater were explored using stratified analyses to compare associations between GWI and exposures in BChE genetic and enzyme activity subgroups. RESULTS: Overall, GWI cases and controls did not differ by mean BChE enzyme activity level or by BChE genotype. However, for the subgroup of Gulf War veterans with less common, generally less active, BChE genotypes (K/K, U/AK, U/A, A/F, AK/F), the association of wartime use of pyridostigmine bromide (PB) with GWI (OR=40.00, p=0.0005) was significantly greater than for veterans with the more common U/U and U/K genotypes (OR=2.68, p=0.0001). CONCLUSIONS: Study results provide preliminary evidence that military personnel with certain BChE genotypes who used PB during the 1991 Gulf War may have been at particularly high risk for developing GWI. Genetic differences in response to wartime exposures are potentially important factors in GWI etiology and should be further evaluated in conjunction with exposure effects.

A randomized controlled trial examining the efficacy of motivational counseling with observed therapy for antiretroviral therapy adherence.

This study determined whether motivational interviewing-based cognitive behavioral therapy (MI-CBT) adherence counseling combined with modified directly observed therapy (MI-CBT/mDOT) is more effective than MI-CBT counseling alone or standard care (SC) in increasing adherence over time. A three-armed randomized controlled 48-week trial with continuous electronic drug monitored adherence was conducted by randomly assigning 204 HIV-positive participants to either 10 sessions of MI-CBT counseling with mDOT for 24 weeks, 10 sessions of MI-CBT counseling alone, or SC. Poisson mixed effects regression models revealed significant interaction effects of intervention over time on non-adherence defined as percent of doses not-taken (IRR = 1.011, CI = 1.000-1.018) and percent of doses not-taken on time (IRR = 1.006, CI = 1.001-1.011) in the 30 days preceding each assessment. There were no significant differences between groups, but trends were observed for the MI-CBT/mDOT group to have greater 12 week on-time and worse 48 week adherence than the SC group. Findings of modest to null impact on adherence despite intensive interventions highlights the need for more effective interventions to maintain high adherence over time.

Nonengagement in HIV care: a descriptive and qualitative study in hospitalized patients and community-based analysis.

Nonengagement in HIV care is a major clinical and public health challenge. To identify the risk factors and reasons, we performed (1) a retrospective study of patients admitted to the hospital with advanced HIV disease, (2) a prospective qualitative study, and (3) a population-based area-wide telephone interview. In the retrospective study, clinic care engagement was associated with age (43.9 ± 9.1 years vs 37.9 ± 7.2 years, P = .005) and improved from 23% to 44% (P = .03) after hospitalization. Survival was higher (93% vs 73%, P = .03) among those who engaged in care. Twelve inpatients were interviewed in the qualitative study. Themes identified for nonengagement were social stigma, indifference, or lack of understanding of care needs/denial and life care issues. In the population-based study, 145 patients were interviewed. In all, 49 denied the need for HIV care and 28 denied their HIV status. Stigma, denial, and indifference or lack of understanding of need are significant barriers to care engagement.

Effect of risk adjustment method on comparisons of health care utilization between complementary and alternative medicine users and nonusers.

OBJECTIVES: Complementary and alternative medicine (CAM) providers are becoming more integrated into the United States health care system. Because patients self-select CAM use, risk adjustment is needed to make the groups more comparable when analyzing utilization. This study examined how the choice of risk adjustment method affects assessment of CAM use on overall health care utilization. DESIGN AND SUBJECTS: Insurance claims data for 2000-2003 from Washington State, which mandates coverage of CAM providers, were analyzed. Three (3) risk adjustment methods were compared in patients with musculoskeletal conditions: Adjusted Clinical Groups (ACG), Diagnostic Cost Groups (DCG), and the Charlson Index. Relative Value Units (RVUs) were used as a proxy for expenditures. Two (2) sets of median regression models were created: prospective, which used risk adjustments from the previous year to predict RVU in the subsequent year, and concurrent, which used risk adjustment measures to predict RVU in the same year. RESULTS: The sample included 92,474 claimants. Prospective models showed little difference in the effect of CAM use on RVU among the three risk adjustment methods, and all models had low predictive power (R(2) ≤0.05). In the concurrent models, coefficients were similar in direction and magnitude for all risk adjustment methods, but in some models the predicted effect of CAM use on RVU differed by as much as double between methods. Results of DCG and ACG models were similar and were stronger than Charlson models. CONCLUSIONS: Choice of risk adjustment method may have a modest effect on the outcome of interest.

The association of complementary and alternative medicine use and health care expenditures for back and neck problems.

BACKGROUND: Health care costs associated with use of complementary and alternative medicine (CAM) by patients with spine problems have not been studied in a national sample. OBJECTIVES: To estimate the total and spine-specific medical expenditures among CAM and non-CAM users with spine problems. RESEARCH DESIGN: Analysis of the 2002-2008 Medical Expenditure Panel Survey. SUBJECTS: Adults (above 17 y) with self-reported neck and back problems who did or did not use CAM services. MEASURES: Survey-weighted generalized linear regression and propensity matching to examine expenditure differences between CAM users and non-CAM users while controlling for patient, socioeconomic, and health characteristics. RESULTS: A total of 12,036 respondents with spine problems were included, including 4306 (35.8%) CAM users (40.8% in weighted sample). CAM users had significantly better self-reported health, education, and comorbidity compared with non-CAM users. Adjusted annual medical costs among CAM users was $424 lower (95% confidence interval: $240, $609; P<0.001) for spine-related costs, and $796 lower (95% confidence interval: $121, $1470; P = 0.021) for total health care cost than among non-CAM users. Average expenditure for CAM users, based on propensity matching, was $526 lower for spine-specific costs (P<0.001) and $298 lower for total health costs (P = 0.403). Expenditure differences were primarily due to lower inpatient expenditures among CAM users. CONCLUSIONS: CAM users did not add to the overall medical spending in a nationally representative sample with neck and back problems. As the causal associations remain unclear in these cross-sectional data, future research exploring these cost differences might benefit from research designs that minimize confounding.

Outcomes from a mentored research boot camp: Focused Investigator Training (FIT) Program.

STUDY OBJECTIVE: To evaluate the change in mentee self-efficacy with regard to research, number of grant submissions, and total amount of new monies awarded to graduates of a novel, mentored, investigator-training program-the Focused Investigator Training (FIT) Program. DESIGN: Retrospective observational analysis. SETTING: American College of Clinical Pharmacy Research Institute. PARTICIPANTS: Fifty-five mentees from the 2008, 2009, 2010, and 2011 FIT Programs. INTERVENTION: The FIT Program is a novel, intensive, 5-day, mentored development "boot camp" for mid-career investigators holding research-intensive positions. The program consists of proposal groups of two mentors and two-four mentees, one-on-one office hours, lectures, panel discussions, directed readings, and small group sessions. Twelve highly successful researchers and biostatisticians were recruited as mentors. Mentees submitted a detailed proposal and received faculty feedback before the program. MEASUREMENTS AND MAIN RESULTS: The main outcomes of the FIT Program were mentee self-efficacy with regard to research, number of grant submissions, and total amount of new monies awarded to 2008 and 2009 FIT Program graduates. Univariate statistical analysis was conducted to determine characteristics of those FIT attendees with subsequent successful grantsmanship. A combined measure of self-confidence in successful grantsmanship was significantly increased after completion of the FIT program. More than $2.7 million was funded to FIT graduates as principal investigators, and as coinvestigators or subcontractors, an additional $382,000 was awarded in new funds. Seven mentees from the 2008 and 2009 classes received new federal funding, mostly through various K-type award mechanisms. CONCLUSION: The FIT Program was associated with a significant increase in attendees' self-efficacy for obtaining external research funding. Program attendance was associated with numerous successfully funded grants by pharmacist investigators. Future FIT Program success hinges on attracting adequate numbers of qualified applicants.

Do coping styles mediate the relationship between substance use and educational attainment and antiretroviral adherence?

There is a substantial body of literature that demonstrates that substance use and lower educational attainment are associated with poorer antiretroviral (ART) adherence, however, the nature of these relationships are not well understood. The purpose of this study was to explore whether coping styles mediate the relationship between substance use and educational attainment and ART adherence in order to better understand how these variables relate to adherence. The sample consisted of 192 HIV-positive patients (mean age = 41 years; 75.5 % male, 46.9 % heterosexual; 52.6 % with a high school/GED education or less) who were on ART. Path analysis revealed that active and avoidant coping significantly mediated the relationship between drug use and ART adherence. No form of coping was found to mediate the relationship between either binge drinking or educational attainment and adherence. Findings suggest that a focus on coping skills should be included in any multimodal intervention to increase ART adherence among HIV-positive drug using patients.