Is there a race-based disparity in the survival of veterans with HIV?

BACKGROUND: Disparities in survival for black patients with HIV in the United States have been reported. The VA is an equal access health care system. OBJECTIVE: To determine whether such disparities are present in the VA health care system. DESIGN: Retrospective cohort study using national VA administrative databases. PATIENTS: Two thousand three hundred and four white and 3,641 black HIV-infected patients first hospitalized for HIV between October 1, 1996 and September 30, 2000. MEASUREMENTS: Thirty-day mortality after first hospitalization with HIV, and subsequent long-term survival. Follow-up ended at death or September 30, 2002. Data were adjusted for age, sex, HIV disease severity, non-HIV-related comorbidities, primary discharge diagnosis, hepatitis C status, and facility effects. RESULTS: The mean follow-up was 3.2 years. Overall survival was similar for black patients compared with white patients (adjusted hazard ratio 1.09, P=.09). Hospital mortality was 7.0% for black and 6.4% for white patients (P=.35). Adjusted hospital mortality for black patients was similar to that of white patients (odds ratio 1.20, P=.10). Long-term survival after hospitalization did not significantly differ by race (adjusted hazard ratio 1.07, P=.21, for black patients compared with white patients). CONCLUSIONS: Survival during and after first hospitalization with HIV in the VA did not significantly differ for white and black patients, possibly indicating similar effectiveness of care for HIV. Further research is needed to understand the reasons for the lack of disparities for VA patients with HIV and whether the VA's results could be replicated.     

Male partners’ involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: A systematic review

Abstract

In sub-Saharan Africa (SSA), male partners are rarely present during prevention of mother-to-child transmission (PMTCT) services. This systematic review aims to synthesize, from a male perspective, male partners’ perceived roles, barriers and enablers of their involvement in PMTCT, and highlights persisting gaps. We carried out a systematic search of papers published between 2002 and 2013 in English on Google Scholar and PubMed using the following terms: men, male partners, husbands, couples, involvement, participation, Antenatal Care (ANC), PMTCT, SSA countries, HIV Voluntary Counseling and Testing and disclosure. A total of 28 qualitative and quantitative original studies from 10 SSA countries were included. Men's perceived role was addressed in 28% (8/28) of the studies. Their role to provide money for ANC/PMTCT fees was stated in 62.5% (5/8) of the studies. For other men, the financial responsibilities seemed to be used as an excuse for not participating. Barriers were cited in 85.7% (24/28) of the studies and included socioeconomic factors, gender role, cultural beliefs, male unfriendly ANC/PMTCT services and providers’ abusive attitudes toward men. About 64% (18/28) of the studies reported enablers such as: older age, higher education, being employed, trustful monogamous marriages and providers’ politeness. In conclusion, comprehensive PMTCT policies that are socially and culturally sensitive to both women and men need to be developed.     

Does selected ecological evidence give a true picture of HIV transmission in Africa?

Current reconsideration of the contributions of various modes of transmission to HIV epidemics in sub-Saharan Africa has important implications for HIV prevention. In recent reviews, we argue that accumulated evidence supports the hypothesis that unsafe health care fuels Africa's HIV epidemics. In response, critics have presented selected ecological evidence - age and sex distribution of HIV infections and geographic distribution of hepatitis C virus infections - to support the conventional hypothesis that sexual contact accounts for most HIV infections. In this communication, we examine critics' evidence and arguments. Critics ignore or reject important evidence including, for example, large numbers of unexplained HIV infections in children, strong associations between incident HIV and injections, and genetically-linked infections in persons with no known sexual contact. We urge that research projects in Africa disclose unpublished relevant evidence on risks for incident HIV. In any case, because each iatrogenic infection causes subsequent linked infections, the impact of HIV transmission through health care has been underestimated. We commend the emerging consensus to improve the safety of health care delivery. In countries with generalized HIV epidemics, we urge public education about the risks for HIV acquisition from unsterile health care.     

Is there a gender difference in the associations of birthweight and adult hypothalamic-pituitary-adrenal axis activity?

OBJECTIVE: Increased hypothalamic-pituitary-adrenal (HPA) axis activity in men of low birthweight may be an important link between early life and the adult metabolic syndrome. In animal models females are more sensitive than males to HPA axis programming, but whether gender influences susceptibility in humans is unknown. DESIGN: Birth cohort study. METHODS: We studied 106 women aged 67-78 years, from Hertfordshire, UK, in whom birthweight was recorded. Negative feedback sensitivity was assessed by an overnight low-dose (0.25 mg) dexa-methasone suppression test, and adrenal sensitivity by a low-dose (1 microg) ACTH(1 - 24) stimulation test. Cortisol and its metabolites were analysed in a 24 h urine collection. Data were compared with previously published identical measurements in 205 men aged 66-77 years from the same cohort. RESULTS: In women, plasma cortisol levels after dexamethasone were lower (P < 0.0001) and peak cortisol following ACTH(1 - 24) were higher (P < 0.0001) than in men, suggesting a more responsive HPA axis. As in men, women with lower birthweight had enhanced plasma cortisol responses to ACTH(1 - 24) (P = 0.05 for trend) but no difference in plasma cortisol after dexamethasone or in urinary cortisol metabolite excretion. The strength of the association in women was not different from that in men; a 1 lb decrease in birthweight was associated with an incremental rise in cortisol of 12.6 nmol/l (95% confidence interval (CI) 1.4, 23.8) in men, P = 0.03, and 14.8 nmol/l (95% CI -0.4, 29.9) in women, P = 0.05 (P = 0.82 for birthweight x gender interaction). In a combined analysis of men and women adjusted for gender (n = 302), a 1 lb decrease in birthweight was associated with a 13.4 nmol/l (95% CI 4.5, 22.4) greater incremental rise in plasma cortisol, P = 0.003. CONCLUSIONS: Associations between lower birthweight and increased HPA axis activity are similar in men and women, supporting the hypothesis that HPA axis activation is an important mechanism underlying programming of adult disease.     

Is there a role for glycosuria testing in sub-Saharan Africa?

BACKGROUND: With increasing urbanization and westernization, rates of diabetes in sub-Saharan Africa (sSA) are likely to rise. Early detection and intervention plays an important role in delaying development of complications. In sSA in particular there is need for an affordable, reliable, safe, feasible test to avert human suffering and exhausting already stressed health facilities. METHODS: Data from two large community-based studies were used to assess the value of glycosuria testing in the detection of diabetes in adults in a sub-Saharan country. A first study (A) tested participants for glycosuria by dipstick; if positive, fasting capillary glucose was measured. A later study (B) measured glucose concentration in venous blood 2 h after a 75-g glucose load; if glycaemia was > or = 10 mmol/l, urine was tested for glycosuria. RESULTS: The positive predictive value of glycosuria for a diagnosis of diabetes (fasting glucose > or = 6.7 mmol/l) was 48%. Sensitivity was 64% (57% if a 2-h-value > or = 10 mmol/l was used as gold standard). Sensitivity was higher among overweight and/or hypertensive subjects, among elderly people in the urban area, and among subjects with higher blood glucose levels. Extrapolated specificity was 99.7%, and the likelihood ratio 190. CONCLUSIONS: Glycosuria testing can identify a considerable number of undiagnosed diabetic patients when specially targeted at high-risk groups (obese, hypertensive, or elderly people). Dipstick glycosuria testing is an appropriate, safe, feasible test for sSA, where the prevalence of diabetes is expected to increase considerably in the near future.     

Is there a difference in the perception of symptoms between african americans and whites with osteoarthritis?

OBJECTIVE: To determine if there is a difference in the perception of pain and functional disability between African Americans and Whites at any given radiographic severity of osteoarthritis (OA). Ethnic differences in utilization of joint replacement may reflect differences in the perception of symptoms of OA. METHODS: A cross-sectional survey included 596 male veterans (44% African Americans and 56% Whites) with chronic moderate to severe knee and/or hip pain at the General Medicine Clinics. The average age of the total cohort was 65.63 +/- 9.5 years. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for pain and function were the primary outcome measures of interest. All knee and or hip radiographs were graded using the Kellgren-Lawrence (K/L) grading system. RESULTS: African Americans and Whites were comparable with respect to age (65 +/- 9.5 vs 66 +/- 9, respectively); body mass index > or = 30 kg/m2 (53.9% vs 58.8%); Lequesne severity score (11 +/- 4 vs 11 +/- 4); geriatric depression score (4.5 +/- 3.3 vs 5.0 +/- 3.8) and Charlson Comorbidity Index (2.3 +/- 2 vs 2.5 +/- 2). African Americans had lower socioeconomic status with fewer high school graduates (57% vs 71%, p = 0.001), lower employment rate (8.4% vs 14.7%, p = 0.017), and lower total household incomes (41.4% vs 20.4% reported income < $10,000, p = 0.000). African Americans and Whites were not different in mean scores for WOMAC pain and WOMAC function when stratified by joint space narrowing, osteophyte and Kellgren Lawrence grades. After controlling for important covariates, ethnicity was not a significant predictor of WOMAC pain and function. CONCLUSION: In this sample of male veterans, African Americans and Whites perceived the same degree of pain and functional difficulties at any given radiographic severity of OA. Differences in the perception of symptoms cannot explain the observed ethnic disparity in utilization of joint replacement.     

What's in a trough? Therapeutic drug monitoring and antiretroviral regimens

The benefits and toxicity of any drug are a function of the drug's concentration in the patient. Therapeutic drug monitoring (TDM), or drug concentration analysis, implies that a patient's drug concentration must fall within a certain range in order for the drug to be therapeutic. TDM requirements are described in a table. Researchers are looking at the relationship between antiretroviral drug concentrations and clinical outcome. There is no consensus regarding TDM use for antiretroviral drugs. An appendix includes text from the AIDS Clinical Trials Group Pharmacology Committee Position Paper on Therapeutic Drug Monitoring for Antiretroviral Drugs. The committee does not recommend using drug concentrations to change antiretroviral therapy in individual patients.     

Is there a difference between a chief of cardiology and a chief of medicine?

The job of Chief of Medicine demands considerably more administrative effort than the Chief of Cardiology. However, one can still maintain a significant presence in cardiology as a Chief of Medicine. Each job has its own merits, joys, and irritations.     

Is there a rural/urban gap in the quality of HIV care for treatment-naïve HIV-positive individuals initiating antiretroviral therapy in British Columbia?

Rurally located people living with HIV (PLWH) face unique challenges associated with remoteness that may negatively affect their HIV care outcomes. The Programmatic Compliance Score (PCS) has been used previously as a quality of care metric, and is predictive of mortality for treatment-naïve individuals initiating combination antiretroviral therapy (cART). This study looked at whether the rurality of PLWH impacted their PCS. PCS was calculated for PLWH (≥19 years old) initiating cART in British Columbia between 2000 and 2013. Rurality was determined at the time of cART initiation using two methodologies: (1) a categorical postal code method; and (2) the General Practice Rurality Index (GPRI), a score representing an individual’s degree of rurality. Ordinal logistic regression modeling was used to assess the relationship between rurality and PCS. Among 4616 PLWH with an evaluable PCS, 176 were classified as rural and 3512 as urban (928 had an unknown postal code). After adjusting for age, sex, hepatitis C status, Indigenous ancestry, and year of cART initiation, categorical rurality was not associated with a worse PCS (adjusted odds ratio (AOR) 1.04; 95% CI: 0.77–1.39). However, an increasing degree of rurality was associated with a worse PCS (AOR (per 10 increase in GPRI) 1.13; 95% CI: 1.06–1.20). Given that a poor PCS has been shown to be predictive of all-cause mortality for individuals initiating cART, strategies to improve access to HIV care for rural individuals should be evaluated.     

Is there a role for microorganisms in the pathogenesis of sarcoidosis?

Sarcoidosis is a granulomatous disease that has the immunopathological features of being antigen-driven. It is a complex disease that appears to arise from the interaction of one or more triggers with an immunologically predisposed host. Previous reports of familial clustering and varying prevalence of sarcoidosis in different populations could reflect differences in ethnic predisposition or differences in local environmental exposures. This review focuses specifically on these areas that have been the subjects of intensive investigation recently. Specific focus is provided on the issue of an infective trigger and highlights popular candidates. It is concluded that microbes are a likely trigger (but not as an infection) in a genetically predisposed individual and that this initial event culminates in the sarcoidosis granulomatous response.     

Is there a referral bias in the diagnoses of patients of a memory clinic?

In a recent study addressing the contribution of neuropsychology and neuroradiology to the improvement of the dementia diagnoses of a memory clinic more than 45% of the patients (45 out of 101) did not meet the criteria for dementia. This finding was unexpected because all patients had been referred for the diagnosis and differential diagnosis of dementia. The aim of the present study was to examine whether the proportion of nondemented patients varies with the "modus of referral". This was not found to be true. The frequency of the diagnosis "no dementia" was not significantly different for the two patient groups "general practitioner" vs. "neuropsychiatrist" referred patients (p=0.859). In conclusion, there is no difference between the two groups of physicians in the reliability judging whether a "cognitive complainer" needs to be referred to a specialized memory clinic.