Testosterone replacement therapy and motor function in men with spinal cord injury: a retrospective analysis

OBJECTIVE: To evaluate motor function in men with spinal cord injury (SCI) given testosterone replacement therapy (TRT). DESIGN: American Spinal Injury Association (ASIA) rehabilitation discharge motor index scores were compared between men with SCI given TRT (testosterone cypionate, 200 mg, monthly; n = 50) and a comparison group (n = 480) in a retrospective study. Covariates included admission motor and FIM scores, level of injury (paraplegia/tetraplegia), days since injury, and age. RESULTS: ASIA discharge motor scores for ASIA impairment scale grades C and D were significantly different (P < 0.05) in men with incomplete SCI given TRT, relative to the comparison group. The covariate-adjusted mean discharge score for the TRT group was higher than for the comparison group. There were no significant differences in discharge FIM scores (P = 0.34) for men with incomplete injuries and no differences in the adjusted discharge ASIA motor scores (P = 0.92) or adjusted discharge FIM scores (P = 0.16) for men with complete injuries. CONCLUSION: The data support a relationship between TRT and strength gains in men with residual motor function after SCI. Prospective studies are necessary to validate these findings.     

CD4+ T cell depletion during all stages of HIV disease occurs predominantly in the gastrointestinal tract

The mechanisms underlying CD4(+) T cell depletion in human immunodeficiency virus (HIV) infection are not well understood. Comparative studies of lymphoid tissues, where the vast majority of T cells reside, and peripheral blood can potentially illuminate the pathogenesis of HIV-associated disease. Here, we studied the effect of HIV infection on the activation and depletion of defined subsets of CD4(+) and CD8(+) T cells in the blood, gastrointestinal (GI) tract, and lymph node (LN). We also measured HIV-specific T cell frequencies in LNs and blood, and LN collagen deposition to define architectural changes associated with chronic inflammation. The major findings to emerge are the following: the GI tract has the most substantial CD4(+) T cell depletion at all stages of HIV disease; this depletion occurs preferentially within CCR5(+) CD4(+) T cells; HIV-associated immune activation results in abnormal accumulation of effector-type T cells within LNs; HIV-specific T cells in LNs do not account for all effector T cells; and T cell activation in LNs is associated with abnormal collagen deposition. Taken together, these findings define the nature and extent of CD4(+) T cell depletion in lymphoid tissue and point to mechanisms of profound depletion of specific T cell subsets related to elimination of CCR5(+) CD4(+) T cell targets and disruption of T cell homeostasis that accompanies chronic immune activation.     

National Study of the Relation of Primary Care Shortages to Emergency Department Utilization

Background: Emergency department (ED) visit volumes are increasing nationwide. Objectives: To determine whether states with primary care shortages have higher rates of ED use. Methods: Populations residing in primary care shortage areas were abstracted from the Health Resources and Services Administration Geospatial Database. Annual ED visit volumes were available from the 2001 National ED Inventory. Population data and potential confounders were abstracted from federal data sets. All analyses were conducted at the state level. Results: Primary care shortage densities varied greatly across states, ranging from 3 (New Jersey) to 28 (Mississippi) medically underserved individuals per 100 people. States also varied in their annual ED visit densities, ranging from 23 visits (Hawaii) to 65 visits (Washington, DC) per 100 people. Of the 17 states in the top tertile for primary care shortage, 7 also were in the top tertile for ED visits. Primary care shortage density was positively associated with ED visit density. An increase of 10 medically underserved individuals per 100 people was associated with an annual increase of 4.2 ED visits per 100 people (p = 0.04). The association remained after controlling for six factors, with an increase of 10 medically underserved individuals per 100 people associated with an annual increase of 3.3 ED visits per 100 people (p = 0.04). Nevertheless, five states had high ED visit densities despite comparatively low primary care shortage densities (Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), whereas five others had low ED visit densities despite high primary care shortage densities (Arizona, Idaho, Montana, New Mexico, and South Dakota). Conclusions: A positive association between primary care shortage densities and ED visit densities was found. Although most states adhere to this pattern, some states do not. Further investigation of this dissociation may yield additional explanations for rising ED visit volumes.     

Symptom distress, spirituality, and quality of life in African American breast cancer survivors

This study examined the relationships among the demographic characteristics, symptom distress, spirituality, and quality of life (QOL) of African American breast cancer survivors. A convenience sample of 30 survivors with a mean age of 56 years and a mean survival of 6 years was recruited from African American breast cancer support groups and churches in the Southeastern United States. Data were collected through face-to-face interviews using a demographic questionnaire, the Quality of Life Index-Cancer Version, the Symptom Distress Scale, and the Spiritual Perspective Scale. Statistically significant relationships were found between symptoms and QOL (r = -0.62, P < .05) and between spirituality and QOL (r = 0.70, P < .05). No statistically significant relationships were found between age at diagnosis, income, or education and QOL. This research suggests that symptoms and spirituality are associated with QOL. Culturally appropriate care should be provided to these women to reduce health disparities and to improve their QOL.     

Attitudes of Homeless and Drug-Using Youth Regarding Barriers and Facilitators in Delivery of Quality and Culturally Sensitive Health Care

PROBLEM:  Major barriers to care included a lack of culturally competent, accessible care despite the proximity of numerous health service agencies serving homeless youth.
METHODS:  A qualitative approach using semistructured focus groups was used to assess the perspectives of 54 homeless and drug-using youth, aged 18–24 years, recruited from street- and shelter-based settings.
FINDINGS:  Substance use was perceived as an adaptive response to psychological pain and survival on the streets as well as a health risk and barrier to care.
CONCLUSIONS:  Facilitators to care and suggestions for improved health delivery and quality of care included utilization of health "mentors" to assist in navigating the medical system, cultural competency enhancements, improved amenities in clinic wait areas, and expanded pharmaceutical services.     

Developing and testing the health literacy universal precautions toolkit

The health literacy demands of the healthcare system often exceed the health literacy skills of Americans. This article reviews the development of the Health Literacy Universal Precautions (HLUP) Toolkit, commissioned by the Agency for Healthcare Research and Quality and designed to help primary care practices structure the delivery of care as if every patient may have limited health literacy. The development of the toolkit spanned 2 years and consisted of 3 major tasks: (1) developing individual tools (modules explaining how to use or implement a strategy to minimize the effects of low health literacy), using existing health literacy resources when possible, (2) testing individual tools in clinical practice and assembling them into a prototype toolkit, and (3) testing the prototype toolkit in clinical practice. Testing revealed that practices will use tools that are concise and actionable and are not perceived as being resource intensive. Conducting practice self-assessments and generating enthusiasm among staff were key elements for successful implementation. Implementing practice changes required more time than anticipated and some knowledge of quality improvement techniques. In sum, the HLUP Toolkit holds promise as a means of improving primary care for people with limited health literacy, but further testing is needed.