The feasibility,acceptance, and key features of a prevention-focused oral health education program for HIV+ adults

Poor oral health is common in HIV+ adults. We explored the feasibility, acceptance, and key features of a prevention-focused oral health education program for HIV+ adults. This was a pilot substudy of a parent study in which all subjects (n = 112) received a baseline periodontal disease (PD) examination and provider-delivered oral health messages informed by the Information-Motivation-Behavioral Skills (IMB) Model. Forty-one parent study subjects were then eligible for the substudy; of these subjects, a volunteer sample was contacted and interviewed 3–6 months after the baseline visit. At the recall visit, subjects self-reported behavior changes that they had made since the baseline. PD was reassessed using standard clinical assessment guidelines, and results were shared with each subject. At recall, individualized, hands-on oral hygiene coaching was performed and patients provided feedback on this experience. Statistics included frequency distributions, means, and chi-square testing for bivariate analyses. Twenty-two HIV+ adults completed the study. At recall, subjects had modest, but nonsignificant (p > 0.05) clinician-observed improvement in PD. Each subject reported adopting, on average, 3.8 (± 1.5) specific oral health behavior changes at recall. By self-report, subjects attributed most behavior changes (95%) to baseline health messages. Behavior changes were self-reported for increased frequency of flossing (55%) and toothbrushing (50%), enhanced toothbrushing technique (50%), and improved eating habits (32%). As compared to smokers, nonsmokers reported being more optimistic about their oral health (p = 0.024) at recall and were more likely to have reported changing their oral health behaviors (p = 0.009). All subjects self-reported increased knowledge after receiving hands-on oral hygiene coaching performed at the recall visit. In HIV+ adults, IMB-informed oral health messages promoted self-reported behavior change, subjects preferred more interactive, hands-on coaching. We describe a holistic clinical behavior change approach that may provide a helpful framework when creating more rigorously designed IMB-informed studies on this topic.     

The Changing Face of Cardiac Surgery: Practice Patterns and Outcomes 2001-2010

Background

Advances in cardiac surgical care have allowed for successful surgery in high-risk elderly patients. Advances in percutaneous coronary intervention (PCI) techniques and expanded indications for PCI have resulted in a decrease in referrals for coronary artery bypass grafting (CABG). Our objective was to document changes in practice patterns and outcomes in a single tertiary cardiac surgery centre serving a large geographic area.

Methods

For all cardiac surgery cases performed from 2001-2010 we examined its use, patient clinical characteristics, and outcomes. Frailty was assessed using a measure we have previously demonstrated to be associated with adverse outcomes.

Results

During the study period, annual case volume decreased by 13%. The number of isolated CABG cases declined, and valve surgery and other complex procedures increased. The proportion of patients aged ≥ 80 years rose from 7%-12%, and the proportion of frail patients increased from 4%-10%. Although unadjusted in-hospital mortality remained relatively unchanged, intensive care unit (ICU) stays and prolonged institutional care increased. Older age and frailty were associated with mortality, prolonged ICU stays, prolonged institutional care, and a composite of mortality and major morbidities.

Conclusions

Our findings showed a decline in CABG, an increase in more complex operations, and an increase in prolonged ICU stays and prolonged institutional care. The proportion of frail and elderly patients increased over time and these patient groups were at higher risk of adverse postoperative outcomes. Particular attention is required in the decision for surgery and perioperative management of these patients.     

Synergistic effect between nisin and polymyxin B against pandrug-resistant and extensively drug-resistant Acinetobacter baumannii

Acinetobacter baumannii is an opportunistic pathogen predominantly associated with nosocomial infections. The World Health Organization's data on antibiotic-resistant ‘priority pathogens’ reports carbapenem-resistant A. baumannii as a pathogen which is in critical need of research and development of new antimicrobials. Emerging resistance against polymyxins, last-resort drugs for carbapenem-resistant A. baumannii, increases the need for new therapeutic approaches such as synergistic combinations. Nisin, an antibacterial peptide produced by the Gram-positive bacteria L. lactis, is a US Food and Drug Administration approved food preservative with bactericidal action predominantly against other Gram-positive bacteria. A 2008 study reported that topical nisin was effective against staphylococcal mastitis in humans. Additionally, nisin has shown activity against Gram-negative bacteria in combination with antimicrobials such as polymyxin B. A recent in vitro study reported that nisin and polymyxin B exhibited synergistic activity against one isolate each of A. baumannii, Acinetobacter lwoffii and Acinetobacter calcoaceticus using time-kill assay and checkerboard technique. We evaluated the synergistic potential of nisin and polymyxin B against 15 unique clinical A. baumannii isolates using time-kill assay. Three of eight (38%) extensively drug-resistant and six of seven (86%) pandrug-resistant A. baumannii isolates showed synergy with one or more combinations of nisin and polymyxin B. The synergy seen with the use of lower concentrations of polymyxin B may help in reducing the dose-dependent side effects. Additional studies involving pharmacokinetics and pharmacodynamics of nisin are required to explore clinical possibilities.     

From the Cover: Population-based screening for breast and ovarian cancer risk due to BRCA1 and BRCA2

In the Ashkenazi Jewish (AJ) population of Israel, 11% of breast cancer and 40% of ovarian cancer are due to three inherited founder mutations in the cancer predisposition genes BRCA1 and BRCA2. For carriers of these mutations, risk-reducing salpingo-oophorectomy significantly reduces morbidity and mortality. Population screening for these mutations among AJ women may be justifiable if accurate estimates of cancer risk for mutation carriers can be obtained. We therefore undertook to determine risks of breast and ovarian cancer for BRCA1 and BRCA2 mutation carriers ascertained irrespective of personal or family history of cancer. Families harboring mutations in BRCA1 or BRCA2 were ascertained by identifying mutation carriers among healthy AJ males recruited from health screening centers and outpatient clinics. Female relatives of the carriers were then enrolled and genotyped. Among the female relatives with BRCA1 or BRCA2 mutations, cumulative risk of developing either breast or ovarian cancer by age 60 and 80, respectively, were 0.60 (± 0.07) and 0.83 (± 0.07) for BRCA1 carriers and 0.33 (± 0.09) and 0.76 (± 0.13) for BRCA2 carriers. Risks were higher in recent vs. earlier birth cohorts (P = 0.006). High cancer risks in BRCA1 or BRCA2 mutation carriers identified through healthy males provide an evidence base for initiating a general screening program in the AJ population. General screening would identify many carriers who are not evaluated by genetic testing based on family history criteria. Such a program could serve as a model to investigate implementation and outcomes of population screening for genetic predisposition to cancer in other populations.Inherited mutations in BRCA1 and BRCA2 predispose to high risks of breast and ovarian cancer. Among female mutation carriers, presymptomatic surgical measures significantly reduce morbidity and mortality (1, 2). In particular, risk-reducing salpingo-oophorectomy (i.e., the removal of ovaries and fallopian tubes from a woman without ovarian cancer) reduces risk both of breast cancer and of ovarian cancer, as well as overall mortality (1). However, for many mutation carriers identified following their first cancer diagnosis, genetic testing was not previously indicated because family history did not suggest inherited cancer predisposition (3–5, 6). From a prevention perspective, it is a missed opportunity to identify a woman as a BRCA1 or BRCA2 mutation carrier only after she develops cancer.Among Ashkenazi (European) Jews (AJ), three mutations, BRCA1 185delAG, BRCA1 5382insC, and BRCA2 6174delT, account for the great majority of inherited cancer risk due to BRCA1 and BRCA2 (7). In the AJ population, 2.5% of persons carry one of these three mutations (8), and the mutations account for 11% of breast cancer (3) and 40% of ovarian cancer (9, 10). These observations suggest that genetic testing in the AJ population for these mutations fulfills WHO criteria for population screening (11, 12): The disease is an important public health burden to the target population; prevalence and attributable risk of disease due to the mutations are known; and effective interventions exist. However, one necessary piece of information remains unknown: What is the disease risk to mutation carriers ascertained from the general population, rather than carriers identified based on family history (13)?Previous studies assessing cancer risks due to mutations in BRCA1 and BRCA2 ascertained carriers through high-incidence families (14), through a single index case with breast or ovarian cancer (3, 15) or through both affected and unaffected carriers (16). In a 1997 study of AJ volunteers, most index cases had no previous cancer diagnosis, but the percentage of index cases with a family history of breast cancer was approximately double that of unselected AJs (17). In principle, these strategies could have yielded risk estimates different from those of carriers ascertained from the local host population, if cancer risk in BRCA1 or BRCA2 carriers were influenced by familial factors other than the BRCA1 or BRCA2 mutation, such as modifier genes or shared environment (18). In addition, in almost all of these studies, risk estimates were based on imputing carrier status, rather than on direct genetic testing of BRCA1 and BRCA2. This year, the Recommendation Statement on BRCA Testing from the US Preventive Services Task Force recommended against population screening for BRCA1 and BRCA2 mutations, because cancer risk to mutation carriers in the general population was not yet known (19). To address this gap, in this study we assessed breast and ovarian cancer risks in confirmed carriers of BRCA1 and BRCA2 mutations ascertained from the general population. The study was undertaken in the AJ population, because screening for only three founder mutations is sufficient to capture nearly all inherited cancer risk in this population due to BRCA1 and BRCA2 (7).