Evaluating a two-step approach to sexual risk reduction in a publicly-funded STI clinic: rationale, design, and baseline data from the Health Improvement Project-Rochester (HIP-R)

BackgroundSexually transmitted infection (STI) clinics provide an opportune setting for HIV prevention efforts. This randomized controlled trial evaluated a unique, two-step approach to sexual risk reduction at a publicly-funded STI clinic.MethodsDuring an initial visit, patients completed an audio-computer assisted self-interview (ACASI), were randomized to and received one of two brief interventions, obtained medical care, and completed a post-assessment. Next, two-thirds of the patients were assigned to attend an intensive sexual risk reduction workshop. At 3, 6, and 12 months, patients completed additional ACASIs and provided urine specimens to assess behavior change and incident STIs.ResultsDuring a 28-month interval, 5613 patients were screened, 2691 were eligible, and 1483 consented to participate and were randomized; the modal reason for declining was lack of time (82%). Consenting patients included 688 women and 795 men; 64% of participants were African-American. The sample was low-income, with 57% reporting an annual income of less than $15,000; most participants (62%) had a high school education or less, and 51% were unemployed. Sexual risk behavior was common, as indicated by multiple sexual partners (mean = 32.8, lifetime; mean = 2.8, past 3 months), unprotected sex (mean = 17.3 episodes, past 3 months), and prior STIs (mean = 3.3, lifetime; 23% at baseline). Bivariate analyses confirmed our prediction that HIV-related motivation and behavioral skills would be related to current sexual risk behavior. All patients received a brief intervention; patient satisfaction ratings were uniformly high for both interventions (all means ≥ 3.7 on 4-point scales). Fifty-six percent of invited patients attended the intensive workshop, and attendance did not differ as a function of brief intervention. Patient satisfaction ratings were also uniformly positive for the workshop interventions (all means ≥ 3.6). Return to follow-up assessments exceeded 70%.ConclusionsResults demonstrate that implementing an HIV preventive program in a busy, public clinic is feasible and well-accepted by patients. Ongoing evaluation will determine if the interventions reduce sexual risk behavior and lower incident STIs.     

Emergence of rifampin-resistant Rhodococcus equi with several types of mutations in the rpoB gene among AIDS patients in northern Thailand

The antimicrobial susceptibilities of 30 Rhodococcus equi isolates obtained from 30 patients between 1993 and 2001 in northern Thailand were investigated. The MICs showed a tendency toward resistance to various antibiotics but sensitivity to imipenem, minocycline, vancomycin, and teicoplanin (MICs, /=64 micro g/ml) to rifampin. PCR amplification and DNA sequencing of the rpoB gene and molecular typing by pulsed-field gel electrophoresis (PFGE) were performed for eight R. equi isolates from eight AIDS patients with pneumonia or lung abscess caused by R. equi between 1998 and 2001, including one low- and three high-level rifampin-resistant isolates. As a result, two high-level rifampin-resistant strains with PFGE pattern A had a Ser531Trp (Escherichia coli numbering) mutation, and one high-level rifampin-resistant strain with PFGE pattern B had a His526Tyr mutation, whereas one low-level rifampin-resistant strain with PFGE pattern C had a Ser509Pro mutation. Four rifampin-susceptible strains with PFGE patterns D and E showed an absence of mutation in the rpoB region. Our results indicate the presence of several types of rifampin-resistant R. equi strains among AIDS patients in northern Thailand.     

Participatory action research,mixed methods,and research teams: learning from philosophically juxtaposed methodologies for optimal research outcomes

Background

Workplace health interventions incorporating qualitative and quantitative components (mixed methods) within a Participatory Action Research approach can increase understanding of contextual issues ensuring realistic interventions which influence health behaviour. Mixed methods research teams, however, face a variety of challenges at the methodological and expertise levels when designing actions and interventions. Addressing these challenges can improve the team’s functionality and lead to higher quality health outcomes. In this paper we reflect on the data collection, implementation and data analysis phases of a mixed methods workplace health promotion project and discuss the challenges which arose within our multidisciplinary team.

Methods

This project used mixed methods within a Participatory Action Research approach to address workers’ sun safety behaviours in 14 outdoor workplaces in Queensland, Australia, and elucidate why certain measures succeeded (or failed) at the worker and management level. The project integrated qualitative methods such as policy analysis and interviews, with a range of quantitative methods – including worker surveys, ultraviolet radiation (UVR) exposure measurement, and implementation cost analyses.

Results

The research team found the integration of qualitative and quantitative analyses within the Participatory Action Research process to be challenging and a cause of tensions. This had a negative impact on the data analysis process and reporting of results, and the complexity of qualitative analysis was not truly understood by the quantitative team. Once all researchers recognised qualitative and quantitative data would be equally beneficial to the Participatory Action Research process, methodological bias was overcome to a degree to which the team could work cooperatively.

Conclusions

Mixed methods within a Participatory Action Research approach may allow a research team to discuss, reflect and learn from each other, resulting in broadened perspectives beyond the scope of any single research methodology. However, cohesive and supportive teams take constant work and adjustment under this approach, as knowledge and understanding is gained and shared. It is important researchers are cognisant of, and learn from, potential tensions within research teams due to juxtaposed philosophies, methodologies and experiences, if the team is to function efficiently and positive outcomes are to be achieved.

     

Significance of abnormal sonographic findings in postmenopausal women with and without bleeding

ObjectiveWe sought to determine the incidence of cancer and to compare pathologic outcomes in bleeding and non-bleeding postmenopausal patients who underwent hysteroscopy.MethodsWe conducted a retrospective chart review of 294 postmenopausal women with abnormal uterine bleeding and 142 postmenopausal women without symptoms who underwent hysteroscopy. An 11 mm cut-off for asymptomatic women was applied to determine whether this endometrial thickness threshold would differentiate women with and without endometrial cancer in the asymptomatic group.ResultsIn symptomatic patients, 14 were found to have endometrial cancer and 10 were found to have endometrial hyperplasia. In the asymptomatic group, two women (1. 4%) were found to have endometrial cancer with average thickness 17 . 5 mm, and one (0 . 71%) was found to have endometrial hyperplasia . Logistic regression models showed the risk of a bleeding patient developing endometrial cancer at an endometrial thickness of 4 mm was the same as the risk in a non-bleeding patient at a thickness of 15 mm.ConclusionAsymptomatic postmenopausal women have a low risk of having significant endometrial pathology . Cancer was approximately four times more prevalent in women with bleeding than in women with no bleeding     

“I just answer ‘yes’ to everything they say”: Access to health care for deaf people in Worcester,South Africa and the politics of exclusion

Objective

To explore whether there are other factors besides communication difficulties that hamper access to health care services for deaf patients.

Methods

Qualitative methodology using semi-structured interviews with 16 deaf participants from the National Institute for the Deaf in Worcester and 3 Key informants from the Worcester area, South Africa.

Results

Communication difficulties were found to be a prominent barrier in accessing health care services. In addition to this interpersonal factors including lack of independent thought, overprotectedness, non-questioning attitude, and lack of familial communication interact with communication difficulties in a way that further hampers access to health care services.

Conclusion

These interpersonal factors play a unique role in how open and accepting health services feel to deaf patients.

Practice implications

Health care services need to take cognizance of the fact that providing sign language interpreters in the health care setting will not necessarily make access more equitable for deaf patients, as they have additional barriers besides communication to overcome before successfully accessing health care services.     

Analysis of expressed V(H) genes in persistent polyclonal B cell lymphocytosis reveals absence of selection in CD27+IgM+IgD+ memory B cells

Persistent polyclonal B cell lymphocytosis (PPBL) is a hematological disorder diagnosed predominantly in women, characterized by a polyclonal increase in the number of peripheral blood B lymphocytes. Abnormality of the B cell population was evidenced by the finding of multiple bcl-2/Ig gene rearrangements and an additional long-arm chromosome within a significant proportion of B cells. To gain further insight about the developmental status of B lymphocytes in PPBL, analysis of cell surface Ig receptors was undertaken. An important expansion of the CD27+IgM+IgD+ B cell population was noted in PPBL patients (n=4). When investigated by PCR, pattern of heavy chain variable region (VH) genes usage in patients (n=6) was shown tobe similar to that observed in healthy individuals (n=3). In-depth investigation was then conducted through cloning and sequencing of individual VH genes in three of those patients. They were mostly found to be mutated (21/29), correlating with the observed increase in CD27 expression, a marker of memory B cells. Altogether, these data clearly point out to the exact nature of the expanding B cell subset in patients. Finally, analysis of the repartition of recombinant versus silent mutations in framework regions (FR) of Ig genes showed no evidence of positive antigenic selection following somatic hypermutation. Thus, we suggest that a lack of response to physiological signals responsible for the elimination of low affinity memory IgM+IgD+ B cells in germinal centers could play an important role in the development of PPBL.     

Six-month multicenter study on invasive infections due to Streptococcus pyogenes and Streptococcus dysgalactiae subsp. equisimilis in Argentina

During a 6-month period, 95 invasive infections due to Streptococcus pyogenes and group C or group G Streptococcus dysgalactiae subsp. equisimilis were recorded from 40 centers of 16 cities in Argentina. We describe here epidemiologic data available for 55 and 19 patients, respectively, associated with invasive infections due to S. pyogenes and S. dysgalactiae subsp. equisimilis. The associated isolates and 58 additional pharyngeal isolates were genotyped and subjected to serologic and/or antibiotic susceptibility testing. Group A streptococcal emm type distribution and strain association with toxic shock appeared to differ somewhat from results found within the United States; however, serologic characterization and sof sequence typing suggested that emm types found in both countries are reflective of shared clonal types.     

Structural organization of the neutrophil NADPH oxidase: phosphorylation and translocation during priming and activation

The reduced nicotinamide adenine dinucleotide phosphate (NADPH) oxidase is part of the microbicidal arsenal used by human polymorphonuclear neutrophils (PMNs) to eradicate invading pathogens. The production of a superoxide anion (O2-) into the phagolysosome is the precursor for the generation of more potent products, such as hydrogen peroxide and hypochlorite. However, this production of O2- is dependent on translocation of the oxidase subunits, including gp91phox, p22phox, p47phox, p67phox, p40phox, and Rac2 from the cytosol or specific granules to the plasma membrane. In response to an external stimuli, PMNs change from a resting, nonadhesive state to a primed, adherent phenotype, which allows for margination from the vasculature into the tissue and chemotaxis to the site of infection upon activation. Depending on the stimuli, primed PMNs display altered structural organization of the NADPH oxidase, in that there is phosphorylation of the oxidase subunits and/or translocation from the cytosol to the plasma or granular membrane, but there is not the complete assembly required for O2- generation. Activation of PMNs is the complete assembly of the membrane-linked and cytosolic NADPH oxidase components on a PMN membrane, the plasma or granular membrane. This review will discuss the individual components associated with the NADPH oxidase complex and the function of each of these units in each physiologic stage of the PMN: rested, primed, and activated.     

International quality assurance study for characterization of Streptococcus pyogenes

Surveillance of group A streptococcal (GAS) infections was undertaken as a major component of the European Commission-funded project on severe GAS disease in Europe (strep-EURO). One aim of strep-EURO was to improve the quality of GAS characterization by standardization of methods. An external quality assurance study (EQA) was therefore carried out to evaluate current global performance. Eleven strep-EURO and seven other streptococcal reference centers received a panel of 20 coded GAS isolates for typing. Conventional phenotypic typing (based on cell surface T and M protein antigens and opacity factor [OF] production) and molecular methods (emm gene typing) were used either as single or combined approaches to GAS typing. T typing was performed by 16 centers; 12 centers found one or more of the 20 strains nontypeable (typeability, 89%), and 11 centers reported at least one incorrect result (concordance, 93%). The 10 centers that tested for OF production achieved 96% concordance. Limited availability of antisera resulted in poor typeability values from the four centers that performed phenotypic M typing (41%), three of which also performed anti-OF typing (typeability, 63%); however, concordance was high for both M (100%) and anti-OF (94%) typing. In contrast, the 15 centers that performed emm gene sequencing achieved excellent typeability (97%) and concordance (98%), although comparison of the performance between centers yielded typeability rates from 65 to 100% and concordance values from 83 to 100%. With the rapid expansion and use of molecular genotypic methods to characterize GAS, continuation of EQA is essential in order to achieve international standardization and comparison of type distributions.