Same Strategy Different Industry: Corporate Influence on Public Policy

In March 2013 a state judge invalidated New York City’s proposal to ban sales of sugar-sweetened beverages larger than 16 ounces; the case is under appeal. This setback was attributable in part to opposition from the beverage industry and racial/ethnic minority organizations they support. We provide lessons from similar tobacco industry efforts to block policies that reduced smoking prevalence. We offer recommendations that draw on the tobacco control movement’s success in thwarting industry influence and promoting public health policies that hold promise to improve population health.Tobacco control policies, including cigarette taxes and smoke-free air laws, are largely responsible for dramatic declines in smoking rates over the past several decades.1 Likewise, public policies that seek to influence the food and physical activity environment hold promise for reducing the prevalence of obesity.2 However, policies that aim to limit access to unhealthy foods or tobacco products are often met with opposition by industries concerned that new regulations may have a negative impact on product sales. Evidence from statewide tobacco control efforts has demonstrated that effective grassroots advocacy is an important strategy to counter this opposition and engage policymakers and legislators in efforts to implement policies to improve population health.3,4 As such, organizations that represent racial/ethnic minority groups have particularly important roles to play when one considers the disproportionately higher burden of preventable disease among these groups compared with that among Whites. For example, African Americans have obesity rates that are approximately 40% greater than rates among Whites.5Yet, during New York City’s (NYC’s) recent attempt to restrict sales of sugar-sweetened beverages (SSBs) as part of a strategy to reverse negative trends in obesity rates, it was leading minority organizations, such as the National Association for the Advancement of Colored People (NAACP), who sided with the beverage industry to strongly oppose the policy. In this article, we explore parallels between the tobacco industry’s strategies to prevent grassroots support for tobacco control policies, particularly among minority-led organizations, and recent actions taken by the beverage industry to impede the regulation of SSB sales. We offer recommendations, which draw on the success of the tobacco control movement, to minority organizations and the public health community for promoting obesity-related policy initiatives.     

Association of Global DNA Methylation and Global DNA Hydroxymethylation with Metals and Other Exposures in Human Blood DNA Samples

Background: The association between human blood DNA global methylation and global hydroxymethylation has not been evaluated in population-based studies. No studies have evaluated environmental determinants of global DNA hydroxymethylation, including exposure to metals.Objective: We evaluated the association between global DNA methylation and global DNA hydroxymethylation in 48 Strong Heart Study participants for which selected metals had been measured in urine at baseline and DNA was available from 1989–1991 (visit 1) and 1998–1999 (visit 3).Methods: We measured the percentage of 5-methylcytosine (5-mC) and 5-hydroxymethylcytosine (5-hmC) in samples using capture and detection antibodies followed by colorimetric quantification. We explored the association of participant characteristics (i.e., age, adiposity, smoking, and metal exposure) with both global DNA methylation and global DNA hydroxymethylation.Results: The Spearman’s correlation coefficient for 5-mC and 5-hmC levels was 0.32 (p = 0.03) at visit 1 and 0.54 (p < 0.001) at visit 3. Trends for both epigenetic modifications were consistent across potential determinants. In cross-sectional analyses, the odds ratios of methylated and hydroxymethylated DNA were 1.56 (95% CI: 0.95, 2.57) and 1.76 (95% CI: 1.07, 2.88), respectively, for the comparison of participants above and below the median percentage of dimethylarsinate. The corresponding odds ratios were 1.64 (95% CI: 1.02, 2.65) and 1.16 (95% CI: 0.70, 1.94), respectively, for the comparison of participants above and below the median cadmium level. Arsenic exposure and metabolism were consistently associated with both epigenetic markers in cross-sectional and prospective analyses. The positive correlation of 5-mC and 5-hmC levels was confirmed in an independent study population.Conclusions: Our findings support that both epigenetic measures are related at the population level. The consistent trends in the associations between these two epigenetic modifications and the characteristics evaluated, especially arsenic exposure and metabolism, suggest the need for understanding which of the two measures is a better biomarker for environmental epigenetic effects in future large-scale epidemiologic studies.Citation: Tellez-Plaza M, Tang WY, Shang Y, Umans JG, Francesconi KA, Goessler W, Ledesma M, Leon M, Laclaustra M, Pollak J, Guallar E, Cole SA, Fallin MD, Navas-Acien A. 2014. Association of global DNA methylation and global DNA hydroxymethylation with metals and other exposures in human blood DNA samples. Environ Health Perspect 122:946–954; http://dx.doi.org/10.1289/ehp.1306674     

The HIV-1 proviral landscape reveals that Nef contributes to HIV-1 persistence in effector memory CD4+ T cells

Despite long-term antiretroviral therapy (ART), HIV-1 persists within a reservoir of CD4⁺ T cells that contribute to viral rebound if treatment is interrupted. Identifying the cellular populations that contribute to the HIV-1 reservoir and understanding the mechanisms of viral persistence are necessary to achieve an effective cure. In this regard, through Full-Length Individual Proviral Sequencing, we observed that the HIV-1 proviral landscape was different and changed with time on ART across naive and memory CD4⁺ T cell subsets isolated from 24 participants. We found that the proportion of genetically intact HIV-1 proviruses was higher and persisted over time in effector memory CD4⁺ T cells when compared with naive, central, and transitional memory CD4⁺ T cells. Interestingly, we found that escape mutations remained stable over time within effector memory T cells during therapy. Finally, we provided evidence that Nef plays a role in the persistence of genetically intact HIV-1. These findings posit effector memory T cells as a key component of the HIV-1 reservoir and suggest Nef as an attractive therapeutic target.     

A 2017 update: Challenging the cosmetic procedural delay following oral isotretinoin therapy

For decades it has been widely accepted that elective procedures should be delayed for at least 6-months following completion of isotretinoin therapy. However, numerous 2017 publications demonstrate the need for change in best practice. The evidence has yet to be succinctly summarized in a single article or in a stand-alone quick reference algorithm for physicians. This article’s review of all 2017 publications confirms that the 6-month delay is not necessary for all procedures and provides a simple algorithmic approach to summarize the updated recommendations for procedural delay of cosmetic procedures following systemic isotretinoin therapy. This is a useful tool for clinicians and allows patients to receive the most appropriate and timely cosmetic therapy to minimize the psychosocial impact of the skin condition.     

Toward a research agenda for competency-based medical education

Competency-based medical education (CBME) is both an educational philosophy and an approach to educational design. CBME has already had a broad impact on medical schools, residency programs, and continuing professional development in health professions around the world. As the CBME movement evolves and CBME programs are implemented, a wide range of emerging research questions will warrant scholarly examination. In this paper, we describe a proposed CBME research agenda developed by the International CBME Collaborators. The resulting framework includes questions about the meaning of key concepts of CBME and their implications for learners, faculty members, and institutional structures. Other research questions relate to the learning process, the meaning of entrustment decisions, fundamental measurement issues, and the nature and definition of standards. The exploration of these questions will help to solidify the theoretical foundation of CBME, but many issues related to implementation also need to be addressed. These pertain to, among other things, nurturing independent learning, assembling and using assessment results to make decisions about competence, structuring feedback, supporting remediation, and how best to evaluate the longer-term outcomes of CBME. High-quality research on these questions will require rigorous outcome measures with strong validity evidence. The complexity of CBME necessitates theoretical and methodological diversity. It also requires multi-institutional studies that examine effects at multiple levels, from the learner to the team, the institution, and the health care system. Such a framework of research questions can guide and facilitate scholarly discourse on the theoretical and practical body of knowledge related to competency-based health professions education.     

Local narratives of sexual and other violence against children and young people in Zanzibar

Understandings of violence, and especially sexual violence against children, must be situated within the local context. The 2009 Violence against Children Survey in Zanzibar indicated that 6% of girls and 9% of boys reported having experienced sexual violence before the age of 18 years. This paper reports on an in-depth qualitative study conducted in Zanzibar to provide further insights to these findings by examining the circumstances for sexual and other violence against children in Zanzibar. Twenty-four in-depth interviews with young people and 18 focus-group discussions with young people and adults were conducted in rural and urban Zanzibar. A further 8 interviews were conducted with parents and key stakeholders in government and NGO offices that provide services for children. The findings revealed that religious and cultural practices, which form the foundation of Swahili culture in Zanzibar, provide a moral frame for childhood development, but structural factors make children vulnerable to sexual violence. Both boys and girls are vulnerable to sexual violence in the home, neighbourhood, at school and, in particular, at madrasa or Qur’anic schools. As religion and culture are strong influences on childhood, preventing sexual violence at madrasa schools would strengthen the positive aspects of religious teachings for ensuring a safe childhood.     

Review of Real-World Implementation Data on Emtricitabine-Tenofovir Disoproxil Fumarate as HIV Pre-exposure Prophylaxis in the United States

The antiretroviral combination of emtricitabine-tenofovir disoproxil fumarate (FTC/TDF) was approved by the U.S. Food and Drug Administration for use as pre-exposure prophylaxis (PrEP) in individuals at high risk for acquiring human immunodeficiency virus (HIV) in July 2012. Since then, Centers for Disease Control and Prevention guidelines for the use of PrEP have been published and implemented into clinical practice throughout the United States. A number of published open-label and PrEP demonstration projects have evaluated the real-world use of PrEP including analysis of the barriers to its use and addressing major concerns. Despite the approval of FTC/TDF for PrEP, its use for this indication relies on patient and provider acceptance, and its effectiveness requires patient adherence and retention in care during periods of high-risk behaviors. Concerns regarding the use of PrEP in healthy individuals persist and include medication adverse effects including renal dysfunction and bone mineral density loss; risk compensation leading to HIV infections, sexually transmitted infections, and unintended pregnancies; and the development of drug resistance in the event of seroconversion. The cost-effectiveness of PrEP continues to be assessed with the greatest cost-effectiveness remaining in those at highest risk of acquiring HIV. Additionally, cases of HIV acquisition in individuals who are adherent to PrEP highlight scenarios in which PrEP is not 100% effective including against the transmission of drug-resistant HIV strains. This review examines data on the implementation of PrEP outside the setting of clinical trials with the aim of providing clinicians with a summary of the current barriers and opportunities for PrEP use with a specific focus on the role of pharmacists in the optimization of PrEP implementation.