Evaluation of the POP-UP programme: a multicomponent model of care for people living with HIV with homelessness or unstable housing.

OBJECTIVE: Homelessness is the greatest risk factor for HIV viremia in San Francisco. Innovative care models for people with HIV (PWH) with homelessness or unstable housing (HUH) are needed to address this inequity. We developed a novel low-barrier clinic-based program for PWH-HUH in an urban safety-net clinic ('POP-UP') and report outcomes on care engagement and viral suppression. DESIGN: A prospective cohort study. SETTING: San Francisco General Hospital HIV Clinic (Ward 86). PARTICIPANTS: We enrolled PWH who are HUH, viraemic and for whom usual care is not working (at least one missed primary care appointment and at least two drop-in visits at Ward 86 in the last year). INTERVENTION: POP-UP provides drop-in comprehensive primary care, housing assistance and case management, financial incentives and patient navigation with frequent contact. MAIN OUTCOME MEASURES: We describe uptake of eligible patients into POP-UP, and cumulative incidence of antiretroviral therapy (ART) initiation, return to care and virologic suppression 6 months post-enrolment, estimated via Kaplan--Meier. RESULTS: Out of 192 referred patients, 152 were eligible, and 75 enrolled. All 75 were off ART and viraemic; 100% had a substance use disorder; and 77% had a mental health diagnosis. Over three-quarters restarted ART within 7 days of enrolment, and 91% returned for follow-up within 90 days. The cumulative incidence of viral suppression at 6 months was 55% (95% confidence interval 43-68). CONCLUSION: A novel care model for PWH-HUH demonstrates early success in engaging viraemic patients in care and improving viral suppression. Low-barrier, high-contact primary care programmes offering comprehensive services and incentives may improve outcomes for this vulnerable population.

A Retrospective Analysis Comparing Post-Operative Bleeding with Various Doses of Aspirin after Lower Extremity Joint Arthroplasty or Revision.

STUDY OBJECTIVE: Previous studies have shown that aspirin is noninferior to other anticoagulation therapies in preventing postoperative venous thromboembolism following lower extremity arthroplasty or revision; however, its optimal dosing for this indication is less clear. This study aims to compare the odds of bleeding between different aspirin dosages following lower extremity joint arthroplasty or revision. DESIGN: This is a 3-year retrospective multi-center cohort study across the United States and its territories. SETTING: This study included patients admitted for total hip or knee arthroplasty or revision and were treated with prophylactic aspirin. PATIENTS, INTERVENTION, MEASUREMENTS: Patients were assigned to groups based on a total daily aspirin dose of 81, 162, 325, or 650 mg. Data were analyzed for postsurgical bleeding and thromboembolism events occurring during the initial admission and up to 40 days following surgery. Other exploratory variables included type of surgery, hip or knee arthroplasty, length of stay, and patient demographic data. MAIN RESULTS: Among 53,848 patients receiving aspirin, 3922 received a total daily dose of 81 mg, 19,341 received a total daily dose of 162 mg, 5256 received a total daily dose of 325 mg, and 25,329 received a total daily dose of 650 mg. Bleeding occurred in 466 (0.87%) patients and venous thromboembolism (VTE) in 209 patients (0.39%). The odds of bleeding were compared using logistic regression, with the 650-mg dose as the reference group. None were statistically significant for bleeding between all studied aspirin doses: 81 mg (OR 1.12, 95% CI 0.83-1.51, p = 0.451), 162 mg (OR 0.83, 95% CI 0.67-1.03, p = 0.097), and 325 mg (OR 0.83, 95% CI 0.59-1.13, p = 0.245). The odds of VTE were also not statistically significant: 81 mg (OR 0.71, 95% CI 0.40-1.17, p = 0.181), 162 mg (OR 0.75 95% CI 0.54-1.03, p = 0.072), and 325 mg (OR 1.00, 95% CI 0.64-1.53, p = 0.989). CONCLUSIONS: There were no significant differences in the odds of bleeding or venous thromboembolism among all studied aspirin dosages in patients receiving aspirin for thromboprophylaxis following lower extremity joint arthroplasty or revision.

Low-level embryonic crude oil exposure disrupts ventricular ballooning and subsequent trabeculation in Pacific herring.

There is a growing awareness that transient, sublethal embryonic exposure to crude oils cause subtle but important forms of delayed toxicity in fish. While the precise mechanisms for this loss of individual fitness are not well understood, they involve the disruption of early cardiogenesis and a subsequent pathological remodeling of the heart much later in juveniles. This developmental cardiotoxicity is attributable, in turn, to the inhibitory actions of crude oil-derived mixtures of polycyclic aromatic compounds (PACs) on specific ion channels and other proteins that collectively drive the rhythmic contractions of heart muscle cells via excitation-contraction coupling. Here we exposed Pacific herring (Clupea pallasi) embryos to oiled gravel effluent yielding ΣPAC concentrations as low as ~ 1 µg/L (64 ng/g in tissues). Upon hatching in clean seawater, and following the depuration of tissue PACs (as evidenced by basal levels of cyp1a gene expression), the ventricles of larval herring hearts showed a concentration-dependent reduction in posterior growth (ballooning). This was followed weeks later in feeding larvae by abnormal trabeculation, or formation of the finger-like projections of interior spongy myocardium, and months later with hypertrophy (overgrowth) of the spongy myocardium in early juveniles. Given that heart muscle cell differentiation and migration are driven by Ca2+-dependent intracellular signaling, the observed disruption of ventricular morphogenesis was likely a secondary (downstream) consequence of reduced calcium cycling and contractility in embryonic cardiomyocytes. We propose defective trabeculation as a promising phenotypic anchor for novel morphometric indicators of latent cardiac injury in oil-exposed herring, including an abnormal persistence of cardiac jelly in the ventricle wall and cardiomyocyte hyperproliferation. At a corresponding molecular level, quantitative expression assays in the present study also support biomarker roles for genes known to be involved in muscle contractility (atp2a2, myl7, myh7), cardiomyocyte precursor fate (nkx2.5) and ventricular trabeculation (nrg2, and hbegfa). Overall, our findings reinforce both proximal and indirect roles for dysregulated intracellular calcium cycling in the canonical fish early life stage crude oil toxicity syndrome. More work on Ca2+-mediated cellular dynamics and transcription in developing cardiomyocytes is needed. Nevertheless, the highly specific actions of ΣPAC mixtures on the heart at low, parts-per-billion tissue concentrations directly contravene classical assumptions of baseline (i.e., non-specific) crude oil toxicity.

The Golden Compass Program: Overview of the Initial Implementation of a Comprehensive Program for Older Adults Living with HIV.

The population with HIV is aging and has unique health needs. We present findings from an evaluation of the geriatric-HIV program, Golden Compass, at San Francisco General Hospital. We used the implementation science framework, RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) to guide the evaluation and used quantitative and qualitative methods to assess RE-AIM dimensions. From January 2017 to June 2018, 198 adults age ≥50 years participated in the program, with an estimated reach of 17%. Providers and patients indicated high acceptability of the program and were satisfied with clinics and classes. Colocation of services, specific pharmacy and geriatric assessments, and social support from classes were valued (effectiveness). Provider adoption was high, and the program was implemented as originally designed. Areas for improvement included challenges of framing aging services to patients. Future efforts will focus on expanding the reach of the program and examining long-term outcomes.

Dietary exposure to a binary mixture of polybrominated diphenyl ethers alters innate immunity and disease susceptibility in juvenile Chinook salmon (Oncorhynchus tshawytscha).

Polybrominated diphenyl ethers (PBDEs) have been used as flame retardants in consumer products and are now found in the aquatic environment. The presence of PBDEs puts the health and survival of aquatic species at risk due to the various toxic effects associated with exposure to these compounds. The effects of a binary dietary mixture of PBDEs on innate immunity and disease susceptibility of juvenile Chinook salmon (Oncorhynchus tshawytscha) were examined in the present study. Salmon were fed roughly 1:1 mixtures of two environmentally predominant PBDE congeners, BDE-47 and BDE-99. The six resulting whole body total PBDE concentrations ranged from less than the limit of quantification to 184 ng/g, wet weight (ww). The innate immune system was assessed by using two in vitro macrophage function assays. Specifically, assays that examined the ability of head kidney macrophages to: (1) engulf sheep red blood cells (SRBCs); and (2) produce a respiratory burst, as determined by the production of a reactive oxygen species, superoxide anion. Macrophages from salmon fed the BDE-47/99 mixture diets engulfed more SRBCs and produced greater superoxide anion than salmon fed the control diet. An increase in macrophage function was observed in fish with whole body total PBDE concentrations ranging from 2.81 ng/g, ww to 184 ng/g, ww. The mechanism for this increase in macrophage function due to PBDE exposure is currently unknown, but may be due to the ability of PBDEs to act as an endocrine receptor agonist and/or antagonist. Salmon exposed to the BDE-47/99 mixture diets were also challenged with the pathogenic bacteria, Vibrio (Listonella) anguillarum to determine disease susceptibility. Kaplan-Meier survival curves of fish exposed to the BDE-47/99 mixture and control diets were significantly different. The Cox proportional hazard risk ratios of disease-induced mortality in juvenile Chinook salmon with whole body concentrations of total PBDEs of 10.9, 36.8, and 184 ng/g, ww were significantly greater than the fish fed the control diet by 1.56, 1.83 and 1.50 times, respectively. Not all concentrations of the binary mixture diets had significant hazard ratios relative to the control diet, due to a non-monotonic concentration response curve. The mixture of PBDE congeners resulted in interactive effects that were generally non-additive and dependent upon the congener concentrations and metric examined. Consequently, predicting the interactive effects in juvenile Chinook salmon exposed to mixtures of PBDE congeners on innate immunity and disease susceptibility cannot be readily determined from the adverse effects of individual PBDE congeners.

Pain, opioids, and confusion after arthroplasty in older adults.

BACKGROUND: Postoperative confusion is a common complication in older adults, particularly after total joint replacement (arthroplasty). Confusion after surgery can result in slower mobility progression, longer hospital stay, and increased patient distress. Postoperative pain has been shown to be a risk factor related to confusion; however, there is limited evidence regarding pain level, medication use, and confusion development in postoperative arthroplasty patients. PURPOSE: To evaluate development of postoperative confusion and the current practice of pain management for older adult patients with hip or knee arthroplasty. METHODS: Two-month retrospective chart review of medical records at a large, Midwestern, private hospital. Pain assessments were performed on a regular basis using self-report 11-point Numeric Rating Scale (0-10). Opioid use was scored using an equianalgesic conversion chart. RESULTS: Ninety-eight patients met inclusion criteria and 97 received treatment with opioids during the first 48 hours postoperatively. No patients received opioid agents that are contraindicated in older adults. Thirty-three patients had evidence in the medical record of confusion during the first 48 hours postoperatively. Lower equianalgesic dose was significant for increased age and increased confusion on postoperative day 1 (POD 1) and POD 2. Patients with higher equianalgesic scores were less likely to meet benchmark pain scores less than 5 on POD 0, POD 1, and POD 2. CONCLUSIONS: Patients receiving lower amounts of opioids in the first 48 hours after surgery were more likely to be confused on POD 1(p = .023) and POD 2 (p = .049).

Ethnic identity and body image among black and white college females.

OBJECTIVE: This study examines ethnic identity and body image in black and white college females. PARTICIPANTS: Researchers surveyed 118 students at 2 universities, 1 traditionally white and 1 historically black. METHODS: Correlations and multivariate analysis of variance (MANOVA) were used to investigate the relationship between race, ethnic identity, and body dissatisfaction. RESULTS: There was no relationship between a woman's ethnic identity and her body dissatisfaction. Although white women scored higher on body dissatisfaction measures, women in both groups who had higher body dissatisfaction scores also choose smaller ideal body types. Results suggest that identification with an ethnic group may not shield women from being dissatisfied with their bodies. CONCLUSION: Colleges and universities should be aware that many women could experience body dissatisfaction and develop diverse programs that target women from different ethnic groups.

Nurses' body size and public confidence in ability to provide health education.

PURPOSE: To replicate research about confidence level in receiving health teaching from either an overweight or a weight-appropriate RN. METHODS: A quasi-experimental post-test only design was used. Participants were randomly assigned to be shown images of a nurse, either overweight or weight-appropriate, then asked to rate their confidence in health teaching received from that nurse. Descriptive statistics, t test for independent samples, and covariate analyses were performed. RESULTS: A significant difference in confidence p=0.000 was noted between participants who viewed the image of a weight-appropriate nurse and participants who viewed the image of an overweight nurse. CONCLUSIONS: Weight-appropriate nurses may inspire more confidence in their teaching. Further study is indicated to explore the implications of these findings for practice. CLINICAL RELEVANCE: Nurses need to be conscious of clients' perceptions of weight when planning teaching interventions.

The utility of videoconferencing to provide innovative delivery of psychological treatment for rural cancer patients: results of a pilot study.

The unmet psychological needs of rural cancer patients are numerous. Telepsychology is a novel and feasible option that may provide cost-savings and help overcome inequalities in access to specialists. This is the first known study of psychological treatment for people with cancer delivered entirely via videoconferencing. We hypothesized that a telepsychology service would improve rural cancer patients' anxiety and depression levels and quality of life, and would be an acceptable, satisfactory, and practical mode of service delivery. Twenty-five cancer patients attended an average of three sessions with a clinical psychologist providing brief cognitive-behavioral therapy. Questionnaires were completed at pre-, post-, and 1-month follow-up. Patients benefited in terms of anxiety (P=0.01) and quality of life (P=0.04). The service was both practical and acceptable. These preliminary positive results provide a firm basis to conduct a randomized controlled trial of face-to-face interaction vs. videoconferencing.

Increased survival of tumor-bearing mice by the delta opioid SNC 80.

Opioids represent a major source of relief from pain. However, opioid abuse may cause immunosuppression and cancer. We have recently reported results on novel non-peptidic delta- and mu-selective opioids that induced immunopotentiation of T cell and macrophage functions in vitro and ex vivo. In the present study, the effects of the delta-opioid receptor agonist and potent analgesic (+)-4-((alpha R)-alpha-((2S, 5R)-4-allyl-2, 5-dimethyl-1-piperazinyl)-3-methoxybenzyl)-N, N-diethyl-benzamide (SNC80) on in vitro and in vivo tumor cell growth were investigated using the L5178Y-R murine model. SNC80 marginally, but significantly (p < 0.05), inhibited (up to 14%) the in vitro growth of L5178Y-R tumor cells. However, in vivo intratumor administration of SNC80 (2 and 4 mg/kg) reduced up to 60% L5178Y-R tumor-bearing Balb/c mice death, and significantly (p < 0.05) reduced tumor weights (up to 73% reduction) in these animals. This study may support the evaluation of SNC80 in preclinical and clinical studies.

Potentiation of rat lymphocyte proliferation by novel non-peptidic synthetic opioids.

Opioids represent a major source of relief for acute and chronic, moderate to severe nonmalignant pain. However, opioid abuse may cause immunosuppression leading to infections and cancer development. Recently we reported results on novel non-peptidic delta- and mu-selective opioids that induced immunopotentiation in vitro and ex vivo. In the present study, we investigated the effects of the delta agonist SNC 80, and mu agonists, naltrindole and naltrexone derivatives for their capacity to alter lymphoproliferation in vitro. They were observed to stimulate lymphoproliferation at concentrations ranging from 10(-10) to 10(-5) M. SNC 80 significantly (p<0.05) stimulated (43-311%) proliferation of resident and concanavalin A (Con A)-treated lymphocytes; the naltrindole derivatives 9332 and 9333 caused significant (p<0.05) 26-47% and 13-43%, respectively, stimulation of Con A-treated lymphoproliferation; whereas the naltrexone derivatives 9334 and 9336 significantly (p<0.05) stimulated 9-40% and 15-69%, respectively, proliferation of resident and Con A-treated lymphocytes. These novel opioid ligands could serve as immunotherapeutic agents by increasing the pool of lymphocytes with potential use in the treatment of infectious diseases including AIDS. This study provides evidence of the relationship structure/function of opioids on lymphoproliferation, and supports further evaluation of opioids with immunomodulatory potential in preclinical and clinical studies.

Is it ACT yet? Real-world examples of evaluating the degree of implementation for assertive community treatment.

Despite growing interest in assessment of program implementation, little is known about the best way to evaluate whether a particular program has implemented the intended service to a level that is minimally acceptable to a funding source, such as a state mental health authority. Such is the case for assertive community treatment (ACT), an evidence-based practice being widely disseminated. Using an exploratory, actuarial approach to defining program standards, this study applies different statistical criteria for determining whether or not a program meets ACT standards using the 28-item Dartmouth Assertive Community Treatment Scale. The sample consists of 51 ACT programs, 25 intensive case management programs, and 11 brokered case management programs which were compared to identify levels of fidelity that discriminated between programs, but were still attainable by the majority of ACT programs. A grading system based on mean total score for a reduced set of 21 items appeared to be most attainable, but still discriminated ACT programs from other forms of case management. Implications for setting and evaluating ACT program standards are discussed.

All in the family: a belated response to Knudson-Martin's feminist revision of Bowen theory.

The first formal attempt at revising Bowen theory within the marriage and family therapy literature is represented in the work of Knudson-Martin (1994). Claiming that several of the theory's concepts are defined at odds with female development, Knudson-Martin (1994) reconceptualizes and expands Bowen theory to rectify these perceived shortcomings. In turn, we address several fundamental concerns with Knudson-Martin's critique and revision of Bowen theory. An alternative representation of Bowen Theory, as well as its relationship to feminist thought, is put forth. Suggestions for the field's future relationship to Bowen theory are also discussed.