From Brochures to Videos to Counseling: Exposure to HIV-Prevention Programs

This research tested the prediction that reading a preventive brochure leads people to watch a preventive video, and that watching this video in turn leads to an increase in the likelihood of participating in a preventive counseling session. A sample of men and women from a southeastern community in the United States was recruited for a general health survey with the objective of examining participation in HIV-prevention interventions. Unobtrusive measures of exposure to HIV-prevention brochures, an HIV-prevention video, and an HIV-prevention counseling session were obtained. Findings indicated that reading the brochures increased watching the video and that watching the video increased participation in the counseling session. The association between exposure to the video and exposure to the counseling was mediated by expectations that the counseling would be useful. Findings are discussed in terms of the need to ensure exposure to interventions to achieve intervention effectiveness.     

A tool to assess barriers to adherence to hand hygiene guideline

This Brief Report presents results of preliminary testing of a tool, "Attitudes Regarding Practice Guidelines," adapted from previous work by Cabana et al to examine barriers to adherence to practice guidelines. In a small sample of 21 clinicians (10 infectious disease physicians and 11 clinical nurses), the test-retest reliability was.86 and Chronbach alpha was.80, indicating acceptable levels of stability. It is recommended that the instrument undergo further testing and adaptation as a measure of potential barriers to adherence to practice guidelines in general, and to the new Hand Hygiene Guideline for Healthcare Settings specifically.     

Innovations to improve access to musculoskeletal care

Innovation is a form of realising a new way of doing something, often ignoring traditional wisdom, in order to meet new challenges. Globally, particularly in emerging economies, the high burden of musculoskeletal conditions and their contribution to multimorbidity continue to rise, as does the gap for services to deliver essential care. There is a growing need to find solutions to this challenge and deliver person-centred and integrated care, wherein empowering patients with the capacity for self-management is critical. Whilst there is an abundance of information available online to support consumer education, the number of sources for credible medical information is diluted by uninformed anecdotal social media solutions. Even with the provision of high-quality information, behavioural change does not necessarily follow, and more robust educational approaches are required.In this chapter, we examine innovation, its management and the strategic directions required to improve musculoskeletal healthcare at macro (policy), meso (service delivery) and micro (clinical practice) levels. We discuss the critical role of consumer agency (patients and their families/carers) in driving innovation and the need to leverage this through empowerment by education.We provide a snapshot of real-world examples of innovative practices including capacity building in consumer and interprofessional musculoskeletal education and practice; recommendations to transform the access and delivery of integrated, person-centred care; and initiatives in musculoskeletal care and implementation of models of care, enabled by digital health solutions including telehealth, remote monitoring, artificial intelligence, blockchain technology and big data. We provide emerging evidence for how innovation can support systems' strengthening and build capacity to support improved access to ‘right’ musculoskeletal care, and explore some of the ways to best manage innovations.We conclude with recommended systematic steps to establish required leadership, collaboration, research, networking, dissemination, implementation and evaluation of future innovations in musculoskeletal health and care.     

New approaches to overcome tolerance to nitrates

In isolated cells (vascular smooth muscle, endothelium, platelets), perfused hearts, in vivo experiments, conscious instrumented animals, and in human subjects the induction of tachyphylaxis and tolerance to various exogenous NO-donors was analyzed. Various ways to circumvent tolerance were successfully tested.Different nitrovasodilators were associated with different rates and magnitudes of generation of tolerance and reactive oxygen radicals (ROS) in all models tested, beginning with PETN (pentaerithrityltetranitrate) (lowest rate) and concluding with GTN (highest rate). This pattern was found in all models tested (isolated cells, perfused organs, and in vivo experiments). The observed changes in ROS production in isolated cells were identical to changes in ROS production in vascular smooth muscle, endothelial cells, and platelets. Thus, blood cells such as washed platelets could be used as marker cells to identify induction of tolerance and rise in platelet activity, closely reflecting changes in the rate of tolerance generation to nitrates associated with enhanced oxidant stress (ROS generation).Generation of tachyphylaxis could be suppressed or even avoided by supplementation of appropriate antioxidants (SOD, vitamin C, DMSO, ß-blockers with antioxidant capacity, modulators of prostanoid metabolism such as ASS) in all models tested, including human subjects. Even fully developed tolerance (during non-intermittent GTN-administration) could be reversed by starting an appropriate antioxidant supplementation. This indicates that other potential factors involved in the generation of nitrovasodilator-associated tolerance (reducing the intended vasodilation and the concovactent decreases in blood pressure, namely augmented sympathetic and RAS-activity, changes in the activity of soluble guanylyl cyclase, protein kinase C, phosphodiesterase, etc.) are of minor importance. Thus, the treatment of tolerance under clinical conditions should closely target changes in redox potential and antioxidant capacity.     

Reply to Letter to the Editor

We appreciate the interest of Dr. Koutroulis in our article.¹The Lagrangian strain definition =(L–     

Updates to Adherence to Hypertension Medications

Purpose of Review

The purpose of this review is to discuss recent studies that have described approaches or interventions to improve hypertension medication adherence and to suggest how providers can integrate evidenced-based approaches into routine clinical care to improve medication adherence and blood pressure control.

Recent Findings

Factors that can impact medication include patient-related factors, social- and economic-related factors, health system/health care team-related factors, and therapy-related factors. Overall, a multifaceted approach is needed to improve medication adherence. Important components include (1) patient education on hypertension, its treatment modalities and its long-term complications; and (2) patient engagement building on the foundation of education. The various interventions tested have engaged patients through interactive educational sessions, health coaching, motivational interviewing, stage of change behavioral counseling, and pharmacist hypertension management.

Summary

Strategies utilizing patient education and engagement are needed to improve medication adherence and blood pressure control.

     

When to refer to a pain clinic

This chapter addresses the questions of which patients might profitably be referred to pain clinics, as well as when this should happen for the optimum results. Since there are many different types of pain clinic, the question of to which pain clinic should a patient be referred is also examined. The development of multidisciplinary pain clinics and the types of services (assessment and treatments) they offer are reviewed as well as evidence for the effectiveness and cost-benefits of pain clinics. In order to make constructive use of pain clinics the potential misuse of pain clinics, by, for example, seeing them as 'last resorts' for hopeless cases or through inadequate preparation, is explored. Common criticisms of pain clinics, such as long-waiting lists and poor linkages to referrers and primary practitioners, and ways in which these are being addressed are also considered. A number of issues to be considered by the doctor when making a referral to a pain clinic are also identified.     

Response to the letter to the editor

We thank Dr. Saura for the interest in our work. Dr. Saura raisedan important issue regarding the preferred venous route of contrastadministration during bubble studies for assessment of a patentforamen ovale (PFO). In the vast majority of published literatureand more relevant in clinical practice an antecubital venous     

The right to be allowed to die

Commenting on the California case of Elizabeth Bouvia, a quadreplegic who requested hospital assistance to alleviate suffering while she starved herself to death, Brahams expresses the hope that no patient in the United Kingdom will ever be forcibly fed against his or her wishes. Since passage of Britain's Suicide Act of 1961, taking one's own life is not a crime, although aiding a suicide is illegal. In a court case involving a book published by the Voluntary Euthanasia Society, Mr. Justice Woolf ruled that giving the booklet to another person could amount to encouraging suicide. Brahams contends that provision of medical comfort does not constitute encouragement. She cites the British government's decision not to force feed IRA hunger strikers, the possibility that force feeding constitutes battery under British law, and a Florida court ruling that a patient had the right to decline life prolonging treatment.     

Hypersensitivity to inhaled TOBI following reaction to gentamicin

Cystic fibrosis (CF) is the most common autosomal-recessive disease in Caucasians. Colonization with Pseudomonas aeruginosa (P. aeruginosa) of the CF airways causes deterioration of pulmonary status. TOBI (Tobramycin solution for inhalation) is an inhaled antibiotic that can improve the pulmonary disease. We report on a 9-year old boy with CF who developed a rash following a course of IV gentamicin. The rash resolved after its discontinuation. However, the rash returned all over his body, with the start of inhalation of TOBI therapy. We desensitized the patient using escalating doses of inhaled TOBI. He tolerated the procedure well, and continues to be on TOBI 9 months after desensitization on a once-a-day regimen.     

Reply to the letter to the editor

Dr Callejas Rubio contends that the prevalence of mild pulmonaryarterial hypertension (PAH) in patients with autoimmune disease(PAH) is excessively high based on the parameters used in ourassessment. Assessment of pulmonary artery pressure (PAP) remains an emergingutility     

Return to clinical in contrast to serologically-based diagnoses

The future of rheumatology is predicated upon a return to basics. The advent and facile availability of laboratory testing led to reduction of emphasis on clinical skills. Recognition that immunologic abnormalities are not limited to individuals who clearly have related pathology provides new motivation for reorientation of training programs to assure that graduates have appropriate information gathering, diagnostic and procedural skills. Inadequate accessibility to rheumatologic care requires innovative approaches and especially training and educating those individuals who provide primary care. While the rheumatologist can elicit the patient’s history remotely, telerheumatology will be feasible only when the individual interacting physically with the patient has confidence in their examination skills and when those skills have been validated. Named syndromes or diseases will be modified to avoid impugning the individual or compromising their future access to health, disability and life insurance. Interventions will be pursued in a more cost-effective, evidence-based manner. The future of rheumatology is dependent upon the rheumatologist’s ability to amortize the inadequate reimbursement for direct patient interaction, depending on skills of interpretation of standard X-rays, ultrasound performance and results.     

Mechanisms of damage to corals exposed to sedimentation

We investigated the mechanisms leading to rapid death of corals when exposed to runoff and resuspended sediments, postulating that the killing was microbially mediated. Microsensor measurements were conducted in mesocosm experiments and in naturally accumulated sediment on corals. In organic-rich, but not in organic-poor sediment, pH and oxygen started to decrease as soon as the sediment accumulated on the coral. Organic-rich sediments caused tissue degradation within 1 d, whereas organic-poor sediments had no effect after 6 d. In the harmful organic-rich sediment, hydrogen sulfide concentrations were low initially but increased progressively because of the degradation of coral mucus and dead tissue. Dark incubations of corals showed that separate exposures to darkness, anoxia, and low pH did not cause mortality within 4 d. However, the combination of anoxia and low pH led to colony death within 24 h. When hydrogen sulfide was added after 12 h of anoxia and low pH, colonies died after an additional 3 h. We suggest that sedimentation kills corals through microbial processes triggered by the organic matter in the sediments, namely respiration and presumably fermentation and desulfurylation of products from tissue degradation. First, increased microbial respiration results in reduced O(2) and pH, initiating tissue degradation. Subsequently, the hydrogen sulfide formed by bacterial decomposition of coral tissue and mucus diffuses to the neighboring tissues, accelerating the spread of colony mortality. Our data suggest that the organic enrichment of coastal sediments is a key process in the degradation of coral reefs exposed to terrestrial runoff.