Adoption of the chronic care model to improve HIV care: In a marginalized,largely aboriginal population

Objective

To measure the effectiveness of implementing the chronic care model (CCM) in improving HIV clinical outcomes.

Design

Multisite, prospective, interventional cohort study.

Setting

Two urban community health centres in Vancouver and Prince George, BC.

Participants

Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites.

Intervention

Systematic implementation of the CCM during an 18-month period.

Main outcome measures

Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period.

Results

Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P < .001 for all) increases in pneumococcal immunization (54% vs 84%), syphilis screening (56% vs 91%), tuberculosis screening (23% vs 38%), and antiretroviral uptake (47% vs 77%), as well as increased viral load suppression rates among those receiving ART (72% vs 90%). Stable housing at baseline was associated with a 4-fold increased probability of survival. Aboriginal ethnicity was not associated with better or worse outcomes at baseline or at follow-up.

Conclusion

Application of the CCM approach to HIV care in a marginalized, largely aboriginal patient population led to improved disease screening, immunization, ART uptake, and virologic suppression rates. In addition to addressing underlying social determinants of health, a paradigm shift away from an “infectious disease” approach to a “chronic disease management” approach to HIV care for marginalized populations is strongly recommended.     

Staphylococcus aureus and influenza A virus stimulate human bronchoalveolar cells to release histamine and leukotrienes

Mediator release was examined from superficially lying cells in the airway epithelium obtained by bronchoalveolar lavage (BAL) in 13 non-atopic individuals. The BAL-cells were incubated (20 min, 37 degrees C) with Staphylococcus (Staph.) aureus or with human influenza A virus Staph. aureus was found to release histamine from cells from 7 of the 13 individuals and influenza A virus in 3 of 5 persons. Furthermore, Staph, aureus stimulated the BAL-cells to release leukotriene B4 in 7 of 11 subjects, whereas no release was found by influenza A virus in 7 examined persons. When cells from 4 persons were stimulated with Staph. aureus no release of leukotriene C4 was found. The mediator release caused by bacteria and virus might be of importance for the exacerbation of bronchial asthma in upper respiratory tract infections, since histamine is assumed to increase the epithelial permeability with entrance of allergens and other insulting particles, and leukotriene B4 facilitates airway inflammation.     

Role modelling and cigarette smoking: vulnerable working class girls? A longitudinal study.

Risk factors for the onset of cigarette smoking were examined by means of a prospective longitudinal study in 1230 Norwegian adolescents aged 12-18. In particular the importance of role modelling was focused. The findings revealed that the age period between 12 and 15 is most important when it comes to the initiation of smoking. Among those who initiate smoking, the incidence rates of quitting is low, indicating that most of the initiators quickly seem to develop a relatively stable smoking habit. Smoking initiation can be divided into two stages. The first, experimental one, is predicted by peer modelling and low socioeconomic status (SES). The second, establishing a regular pattern of use, is predicted by modelling of parental smoking and the interaction between female sex and low SES. Studying the characteristics of the regular smokers cross-sectionally, peer modeling showed the strongest correlates. Studying the predictors of the transitions longitudinally, the more complex picture described above was uncovered. This indicates that the complexity of the role modelling process can only be simulated adequately by means of prospective research methods and by paying attention to such parameters as gender, age, SES and stage in the smoking acquisition process.     

Immune parameters in male atheletes after a lacto-ovo vegetarian diet and a mixed Western diet

The influence of a lacto-ovo vegetarian diet versus a meat-rich Western diet on in vitro measures of immune function was studied in eight male endurance athletes. Subjects consumed two different diets for 2 x 6 wk, separated by 4 wk on an ad libitum diet, in a cross-over design. Both diets consisted of 57 energy % (E%) carbohydrates, 14 E% protein and 29 E% fat. One diet was a mixed meat-rich diet (M) prepared with 69% animal protein sources, whereas the other diet (V) was a lacto-ovo vegetarian diet prepared with 82% vegetable protein sources. Blood for determination of leukocyte subpopulations and in vitro function was collected at the end of each diet period 36 h after the last training bout. Fiber content and P/S ratio of fatty acids were twice as high on the V diet as on the M diet. Training volume was similar on the two diets, and maximal aerobic capacity did not change during diet periods. The number of CD3+ (pan T-cells), CD8+ (mainly T suppressor cells), CD4+ (mainly T helper cells), CD16+ (natural killer cells), and CD14+ (monocytes) was similar after the two different diets. Similarly, proliferations of mononuclear cells after stimulation with interleukin-2 (IL-2), phytohemagglutinin, and purified derivative of tuberculin (PPD), as well as activity of natural killer cells in the unstimulated state and after stimulation with IL-2, indomethacin, and interferon-alpha (IFN-alpha), were identical after the two diet periods.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of tactile and mechanomyo-graphical assessment of response to double burst and train-of-four stimulation during moderate and profound neuromuscular blockade

It is common clinical practice to estimate the degree of neuromuscular blockade by tactile evaluation of twitch responses. The aim of the present study was to evaluate the use of tactile responses of adductor pollicis to double-burst stimulation (DBS) and train-of-four (TOF) peripheral nerve stimulation for monitoring moderate and profound levels of neuromuscular blockade. The study comprised 44 women scheduled for gynaecological laparotomy and anaesthetised with midazolam, fentanyl, thiopentone, halothane, nitrous oxide and atracurium. The tactile responses of the adductor pollicis were compared with mechanomyographical measurements in the contra lateral arm during recovery from neuromuscular blockade. The observers (anaesthetic nurses) of the tactile responses were blinded with regard to the stimulation pattern and the mechanomyo-graphical measurements. The time from injection of the initial dose of atracurium until tactile reappearance of the first twitch in DBS (D₁), was 24.6 (0–39.8) min, median (range). This was more rapid than the time until tactile reappearance of the first twitch in TOF (T₁) 32.8 (18.–243.4) min (P< 0.05). The median time from tactile reappearance of D₁ until T₁ recovered to 15% of the control twitch height was longer than the median time from tactile reappearance of T₁ (14.6 versus 10.5 min) (P < 0.05). One or two responses to DBS or TOF were often felt before any responses had been detected mechanomyographically in the contralateral arm. When three or four responses to TOF were felt, responses were always detected mechanomyographically. It is concluded that tactile evaluation of responses to DBS stimulation can estimate deeper levels of blockade than tactile evaluation of responses to TOF.     

Risk factors for hip fracture in a high incidence area: A case-control study from Oslo,Norway

The aim of this population-based matched case-control study was to evaluate the effect of risk factors for hip fracture in Oslo, Norway, which has some of the highest incidence rates ever reported. The study population comprised all non-institutionalized persons 50 years or older living in the catchment area of two Oslo hospitals, and cases were 246 patients admitted for hip fracture during a 1-year period. The controls were randomly selected from the study population, matched 1:1 for age and sex. Hip fracture was associated with lean body stature, smoking, low grip strength and decreased levels of physical activity, and inversely with length of education. In addition, hip fracture was inversely related to indicators of total food intake (number of meals per day, frequency of dinners, and slices of bread per day). A relation between hip fracture and low vitamin D intake was also suggested, whereas no association with dietary calcium intake was found. Finally, increased risk of fracture was seen in persons reporting two or more hospital admissions in the previous 2 years, and in those reporting weight reduction due to poor appetite during the previous year. In conclusion, the risk factor pattern for hip fracture was much the same in the elderly population of Oslo as previously described in other populations with a lower incidence of fracture. This study also indicates a relation between hip fracture and low food intake.     

HIV-related non-Hodgkin's lymphoma among European AIDS patients

Abstract: The epidemiology of HIV associated non-Hodgkin's lymphoma (NHL) was investigated in 6550 European patients with AIDS. NHL was diagnosed in 3.5% of all patients at the time of the AIDS diagnosis. Although the probability of being diagnosed with NHL at AIDS diagnosis was significantly higher among intravenous drug users than among homosexual men, and was associated with increasing age, the observed incidences of NHL were more strikingly similar than any differences. The rate of developing NHL after a previous AIDS diagnosis was 2.4 per 100 patient years of follow-up, and remained constant during a 5-year follow-up period. While primary brain lymphomas comprised only 9% of NHL diagnosed at the time of AIDS, they comprised 38% of NHL diagnosed after AIDS (p<0.001). The prognosis for patients with NHL at AIDS diagnosis was poor with a median survival of 5 months. A diagnosis of primary brain lymphoma was uniformly associated with a poor outcome. It is concluded that the probability of developing NHL in late stage HIV infection is lower than previously anticipated from the results of small studies on patients receiving long-term anti-retroviral therapy.     

Comparison of four Mycoplasma pneumoniae IgM-, IgG- and IgA-specific enzyme immunoassays in blood donors and patients

Mycoplasma pneumoniae antibodies were studied in 504 blood donors and 102 patients with infections not caused by M. pneumoniae with the use of enzyme immunoassay kits from ThermoLabsystems (L), Savyon (S), Bio-Rad (B) and Novitec (N). Detection frequencies of M. pneumoniae IgM in blood donors were 14.9% (L), 16.0% (S), 2.8% (B) and 3.8% (N), and in patients were 40.2% (L), 42.2% (S), 9.8% (B) and 16.7% (N). Detection frequencies of M. pneumoniae IgA were 68.5% (L) and 22.8% (S), and in 65 respiratory disease patients were 100% (L) and 53.8% (S). Thus, use of some kits may lead to overdiagnosis of M. pneumoniae infections.