Does the quality of safetalk motivational interviewing counseling predict sexual behavior outcomes among people living with HIV?

ObjectiveAlthough past research has demonstrated a link between the quality of motivational interviewing (MI) counseling and client behavior change, this relationship has not been examined in the context of sexual risk behavior among people living with HIV/AIDS. We studied MI quality and unprotected anal/vaginal intercourse (UAVI) in the context of SafeTalk, an evidence-based secondary HIV prevention intervention.MethodsWe used a structured instrument (the MISC 2.0 coding system) as well as a client-reported instrument to rate intervention sessions on aspects of MI quality. Then we correlated client-reported UAVI with specific counseling behaviors and the proportion of interactions that achieved MI quality benchmarks.Results/ConclusionHigher MISC-2.0 global ratings and a higher ratio of reflections to questions both significantly predicted fewer UAVI acts at 8-month follow-up. Analysis of client ratings, which was more exploratory, showed that clients who rated their sessions higher in counselor acceptance, client disclosure, and relevance reported higher numbers of UAVIs, whereas clients who selected higher ratings for perceived benefit were more likely to have fewer UAVI episodes.Practice implicationsFurther research is needed to determine the best methods of translating information about MI quality into dissemination of effective MI interventions with people living with HIV.     

Are feelings of responsibility to limit the sexual transmission of HIV associated with safer sex among HIV-positive injection drug users?

We developed a scale among HIV-positive injection drug users (IDUs) to measure self-perceived responsibility to limit HIV transmission during sex. We describe the characteristics of HIV-positive IDUs (n=1114, 62% male, HIV-positive for 9 years on average) who felt responsible for protecting their sexual partners from HIV and evaluated whether such feelings were associated with safer sexual practices. Using this scale (Cronbach alpha=0.83) and audio computer-assisted self-interviewing technology, 75% of this sample felt responsible for protecting their sexual partners from HIV. In cross-sectional multivariate analysis, HIV-positive IDUs who felt responsible were those with greater HIV knowledge (adjusted odds ratio [95% confidence interval]: 1.74 [1.26 to 2.40]), perceived social support (1.77 [1.28 to 2.44]), self-efficacy for safely injecting (1.41 [1.02 to 1.94]), and self-efficacy for using condoms (1.92 [1.38 to 2.68]). Feeling responsible was associated with having relatively fewer sex partners (<10 vs. >or=10, 0.57 [0.34 to 0.96]) and a lower odds of unprotected sex (0.63 [0.45 to 0.89]) but was not associated with safer injection practices. Feelings of responsibility did not vary by demographic characteristics, suggesting that prevention messages that encourage HIV-positive people to play a role in curbing HIV transmission may be acceptable to many HIV-positive IDUs. Working with HIV-positive IDUs to increase or reinforce feelings of responsibility may reduce the sexual transmission of HIV.     

With whom did you have sex? Evaluation of a partner notification training for STI professionals using motivational interviewing

ObjectiveTo enhance partner notification (PN) practices in Dutch STI clinics, a PN training using motivational interviewing as core strategy was offered to STI professionals and evaluated.MethodsThe effectiveness of PN training on professionals’ attitude, self-efficacy, skills and behavior toward PN, was examined using within-subject and between-subject comparison. Before the training and at three months follow-up, a questionnaire was completed by the intervention group (n = 54) and a non-random control group (n = 37).ResultsIn the within-subject comparison, positive changes were observed in self-efficacy, skills, and PN behaviors (all p < .05), but not in attitudes toward PN. When we examined differences in change-scores between the intervention and control group, self-efficacy was no longer significant.ConclusionThe PN training significantly improved PN skills and -behavior, but had no effect on professionals’ attitudes or self-efficacy toward PN. The selection of a convenience control sample seems to offer a more rigorous test of hypotheses than pre–post evaluation only.Practice implicationsThe beneficial effect of PN training of STI professionals seems to support a wider roll-out of the training to all STI clinics in the Netherlands, although effects on the number of partners notified and transmissions prevented need to be examined in future research.     

Does apolipoprotein E polymorphism influence susceptibility to malaria?

Outcome of infection varies greatly among people, and in the case of three very different viruses, it is determined by apolipoprotein E (APOE) genotype. APOE might affect outcome of malaria infection also, since apoE protein and the protozoon (like the viruses) share cell entry mediators (heparan sulphate proteoglycans and/or specific apoE receptors). APOE polymorphisms give rise to protein variants that differ in binding strength to these mediators; thus, the extent of competition between apoE and protozoon for cell entry, and hence magnitude of protozoan damage, might depend on apoE isoform. Genotypes of infants infected with malaria were examined. It was found that APOE epsilon 2 homozygotes became infected at an earlier age than those carrying the other genotypes, the difference being statistically significant. Parasite densities, all of which were low, did not differ significantly. This effect, although based on small numbers, suggests that APOE epsilon 2 may be a risk factor for early infection.     

Does time spent in child care influence risk for unintentional injury?

OBJECTIVE: To investigate the effect of quantity and quality of early child care on children's risk for unintentional injury. METHODS: A diverse cohort of 1,225 children was recruited from several sites in the United States and followed from birth until first grade. Quantity and quality of child care from birth until entry into kindergarten were used to predict unintentional injuries from age 6 months until first grade. Measures from an evaluation at 6 months of age were tested as covariates. RESULTS: Children who spent more time in nonparental childcare environments were at slightly reduced risk for unintentional injury after controlling for child (gender, temperament), family [socioeconomic status (SES)], parent (positive parenting), and child care (quality of care) characteristics. CONCLUSIONS:We discuss possible explanations for the results, including the possibilities that childcare center environments are safer than the homes of most preschoolers or that attendance in child care is nonrandom.     

Is the transtheoretical model and motivational interviewing approach applicable to the treatment of eating disorders? A review

Research in eating disorders is reviewed examining the (1) utility of the Transtheoretical Model in predicting outcome, and (2) efficacy of Motivational Interviewing (MI). There were promising results showing significant relationships between initial stage of change and treatment outcome related to eating pathology (not including purging), body mass index, and some aspects of psychopathology. Of those treatment studies utilising a control group, there was little indication that using MI conferred significant treatment benefit, with the exception of improving motivation and binge eating for people with binge eating disorder and bulimia nervosa. Overall the content of the studies varied greatly with relation to: stage of change and outcome measures, format of MI, diagnostic groupings, age of participants, utilisation of other adjunctive treatments, sample size, presence of follow-up assessments, and study design. Few of the 9 studies examining the efficacy of MI could be considered to have robust methodology. It is recommended that future research using the Transtheoretical Model to predict outcome adopt more uniform methodology so that we can more specifically determine its applicability, and that well-designed treatment studies in eating disorder populations be conducted so that we develop a stronger evidence base from which to decide whether MI confers benefit.     

Re-examining phone counseling for smoking cessation: Does the evidence apply to low-SES smokers?

IntroductionA 2019 Cochrane review concluded telephone counseling is an effective intervention for smoking cessation. However, the review did not assess the role of socioeconomic status (SES) indicators on the effectiveness of telephone counseling.MethodsWe reviewed 65 U.S. studies from the Cochrane review. We abstracted data on education, income, employment status and insurance status, and examined associations with targeted recruitment, intervention uptake, attrition, and cessation outcomes.ResultsExcept for education, SES indicators were seldom reported or used in analysis: 61 studies reported education, 24 reported insurance status, 23 reported employment status, and 17 reported income. Nine studies exclusively recruited low-SES samples. Thirteen studies examined associations between SES and smoking cessation. Among these, two reported lower education predicted greater cessation and two reported higher education predicted greater cessation. Other studies found higher income (n = 2) or employment type (n = 1) predicted cessation.ConclusionsEvidence supporting telephone counseling for cessation is less clear when applied to low-SES smokers. Future research should directly assess intervention effectiveness in this priority population.Practice implicationsGiven the evidence, it may be hard to justify future studies not focusing on low-SES populations. Innovative counseling solutions from providers helping low-income smokers quit should be evaluated to inform best practice.     

Does body mass index influence responsiveness to inhaled corticosteroids in persistent asthma?

BackgroundAlthough the relationship between asthma and obesity has been extensively explored, the effect of body mass index (BMI) on the dose–response relationship to inhaled corticosteroids (ICS) has received little attention.ObjectiveTo assess the dose–response of inhaled budesonide on outcome measures of asthma between overweight and normal weight patients with persistent asthma.MethodsSeventy-two patients with mild to moderate persistent asthma from a post hoc analysis of previously reported trial data were divided into 2 groups: overweight, BMI 25 kg/m² or higher; normal weight, BMI less than 25 kg/m². Each group received 4 weeks' treatment with inhaled (hydrofluoroalkane) budesonide 200 μg/day then 800 μg/day with ICS washout pretreatment. Outcome measures forced expiratory volume in 1 second (FEV₁), fractional exhaled nitric oxide (FeNO), methacholine PC20, total daily asthma symptom score, and overnight urinary cortisol/creatinine ratio were performed at baseline and after each dose.ResultsSignificantly greater improvements were seen in the normal weight group for both FeNO and symptom responses at 0 to 200 μg and 0 to 800 μg ICS doses (as change from baseline), compared with the overweight group: FeNO 0 to 200 μg, P = .002; 0 to 800 μg, P = .045; symptoms 0 to 200 μg, P = .002; 0 to 800 μg, P = .013. A trend also was seen toward attenuated cortisol suppression in overweight subjects at 0 to 800 μg (P = .06), but no significant difference was seen at either dose in FEV₁ and methacholine PC20 between weight groups.ConclusionOverweight patients with persistent asthma may have attenuated symptom and FeNO dose responses to inhaled budesonide compared with normal weight patients with asthma, with no differences in FEV₁ or methacholine PC20 between groups. Attenuated cortisol suppression in the overweight group may be the clue to this difference, alluding to reduced peripheral lung deposition or absorption in overweight patients with asthma.     

Are 6‐month‐old foals sensitive to dam's influence?

A recent study has shown that gently handling dams in front of their few days old foals may strongly influence the development of human-foal relationships. In the present study, we test whether 6-month-old foals remain sensitive to their dams' influence. The study was performed on 16 foal-mare dyads, with half of the mares receiving positive contacts from the experimenter in presence of their 6-month-old foals (n = 8) whereas the other mares were not handled (n = 8). All foals were tested 15 and 30-35 days later under various conditions (reaction to a motionless human, approach test, saddle-pad tolerance test). We observe a positive effect of mare' handling on foals' reactions to humans but with a high interindividual variability, suggesting a higher effect of the foals' own behavioral characteristics at this age than at earlier stages.     

Does the contribution of stimulus-hand correspondence to the auditory Simon effect increase with practice?

In two-choice reaction tasks for which stimulus location is irrelevant, crossing the hands typically does not alter the benefit for corresponding stimulus and response locations (the Simon effect), which implies location coding of responses. However, for auditory tasks in which a consistent mapping between responding hand and tone pitch is maintained, the Simon effect may become smaller for crossed than uncrossed hands with practice, suggesting increased reliance on anatomical coding. Two experiments tested this possibility. In Exp. 1, the Simon effect tended to be smaller with crossed than uncrossed hands in the second half of 1,600 trials but not in the first half. Experiment 2 showed that this result was not due to reinstructing subjects mid-experiment about the consistent mapping of stimuli to hands. Although the Simon effect was apparent with crossed hands throughout both experiments, it tended to be slightly smaller than the effect obtained with uncrossed hands.     

‘Maybe it would be better if you spoke to my mother?’—Genetic counseling and personal experience

This is the narratives of a family physician and a teacher of Medical Ethics, who herself suffers from Gaucher's disease. She was asked by a colleague to give an advice to a couple trying to decide whether to terminate a pregnancy of a fetus “like her”.     

Does general practice deliver safe primary care to people living with HIV? A case-notes review

Background

Safe care in general practice for people living with HIV requires early diagnosis of undetected infection and safe co-prescribing with antiretroviral therapy (ART).

Aim

To evaluate safe co-prescribing in general practice patients who are taking ART, and to describe missed diagnostic opportunities for undiagnosed HIV infection in primary care.

Design and setting

Retrospective case-notes review in general practices within NHS City and Hackney Primary Care Trust (PCT), London, UK.

Method

All general practices in NHS City and Hackney PCT were invited to participate. Patients known to be HIV positive were identified using Read Codes. Each practice undertook retrospective case-notes reviews on specialist correspondence, coding of ART, prescribing of common contraindicated drug pairings, and missed opportunities for HIV diagnosis.

Results

In total, 31/44 (70.5%) practices participated, and 1022 people living with HIV were identified. Practices had received HIV clinic letters for 698 of those 1022 (68.3%) patients in the previous 12 months. Of the 787 patients known to be prescribed ART, only 413 (52.5%) had correct drug codes recorded; 32/787 (4.1%) were receiving specified contraindicated drug pairings. In total, 89 patients were eligible for their case-notes to undergo a retrospective review of occurrences that took place pre-diagnosis. In the 2 years preceding diagnosis, these 89 had attended 716 face-to-face GP consultations, of which 123 (17.2%) were for indicator conditions. Fifty-one of these patients (57.3%) presented at least once with an indicator condition (interquartile range 1–3; median 2).

Conclusion

In a large-scale evaluation of GP records of people living with HIV, gaps in ART recording and co-prescribing were identified, and evidence demonstrated missed opportunities for diagnosis within general practice. Specialists and generalists must communicate better to enhance safe prescribing and reduce delayed diagnosis.     

Teaching cardiac auscultation to trainees in internal medicine and family practice: Does it work?

Background  

The general proficiency in physical diagnostic skills seems to be declining in relation to the development of new technologies. The few studies that have examined this question have invariably used recordings of cardiac events obtained from patients. However, this type of evaluation may not correlate particularly well with bedside skills. Our objectives were 1) To compare the cardiac auscultatory skills of physicians in training with those of experienced cardiologists by using real patients to test bedside diagnostic skills. 2) To evaluate the impact of a five-month bedside cardiac auscultation training program.     

Does adoption of an evidence-based practice lead to job turnover? Results from a randomized trial

It is important to understand the impact of implementation of evidence-based practices (EBPs) on the workforce. EBP implementation can increase job demands, stress, and burnout, and may thereby exacerbate turnover. This study examined the effects of implementation of an EBP on turnover among staff at nine child welfare agencies. A total of 102 providers were randomized to either adopt an EBP, SafeCare^©, or continue providing services as usual. Participants completed a baseline survey assessing demographics, attitudes toward EBPs, and organizational functioning, and provider turnover was recorded for up to 18 months following implementation. The overall turnover rate was 35%, but did not differ by EBP assignment (odds ratio [OR] = 1.27; 95% confidence interval [0.66, 2.45]). Variables associated with turnover included age (OR = 0.92), years since degree completion (OR = 0.94), prior exposure to EBP (OR = 3.91), believing that adopting an EBP was burdensome (OR = 0.52), and motivation for change (OR = 0.89). EBP assignment moderated two aspects of negative attitudes toward EBP (divergence and monitoring) to predict turnover; those attitudes were only positively related to turnover for individuals assigned to the EBP (OR = 1.46, 1.16). Implications of the findings for implementation are discussed.     

Pre‐ and probiotics for allergy prevention: time to revisit recommendations?

Reduced intensity and diversity of microbial exposure is considered a major factor driving abnormal postnatal immune maturation and increasing allergy prevalence, particularly in more affluent regions. Quantitatively, the largest important source of early immune‐microbial interaction, the gut microbiota, is of particular interest in this context, with variations in composition and diversity in the first months of life associated with subsequent allergy development. Attempting to restore the health consequences of the ‘dysbiotic drift’ in modern society, interventions modulating gut microbiota for allergy prevention have been evaluated in several randomized placebo‐controlled trials. In this review, we provide an overview of these trials and discuss recommendations from international expert bodies regarding prebiotic, probiotic and synbiotic interventions. Recent guidelines from the World Allergy Organization recommend the use of probiotics for the primary prevention of eczema in pregnant and breastfeeding mothers of infants at high risk for developing allergy and in high‐risk infants. It is however stressed that these recommendations are conditional, based on very low‐quality evidence and great heterogeneity between studies, which also impedes specific and practical advice to consumers on the most effective regimens. We discuss how the choice of probiotic strains, timing and duration of administration can critically influence the outcome due to different effects on immune modulation and gut microbiota composition. Furthermore, we propose strategies to potentially improve allergy‐preventive effects and enable future evidence‐based implementation.     

Patients’ medical knowledge and health counseling: What kind of information helps to make communication patient-centered?

Objective

To examine how physicians use information about a patient's background knowledge when both anticipating what a patient knows and producing actual answers in an email counseling setting.

Methods

A fictitious patient used a (high vs. low) level of technical jargon in an email inquiry about diabetes and provided explicit information on prior knowledge (high vs. low) through self-report. Final-year medical students (semi-experts) were asked to gauge the patient's knowledge level (Experiment 1) and to produce an answer to the inquiry (Experiment 2). A total of N = 150 participated in one of the two experiments.

Results

Information from word usage and self-reports was used differently in the two experiments. A patient self-reporting low knowledge was assumed to have less background knowledge than one reporting some knowledge about the domain. The technicality of the patient's word use influenced the answers: these were more technical when the inquiry used technical jargon instead of everyday language.

Conclusion

Knowledge anticipation and communication behavior in email health care seem to be guided by different hints regarding the patient, suggesting the existence of two separate mechanisms.

Practice implications

Beyond merely teaching physicians or health care providers to be aware of the patient's knowledge level when formulating a patient-centered response, on-task methods should support health care providers during the actual communication phase by providing, for instance, metacognitive prompts.