Clinical assessment of medication adherence among HIV-infected children: examination of the Treatment Interview Protocol (TIP)

This paper presents findings of a multi-site study designed to document: (1) caregivers' regimen knowledge; (2) barriers to adherence; and (3) the relationships between adherence, regimen knowledge and barriers. Fifty-one predominantly female, African American parents and caregivers of HIV-infected children completed the Treatment Interview Protocol (TIP), a brief, structured interview designed to assess regimen knowledge and barriers to adherence. TIP data were compared to information obtained from medical records and pharmacy refill histories. Forty-nine per cent of children were considered adherent, defined as > or = 90% refill rate, which was significantly associated with virologic response. Significant regimen knowledge deficits were observed among caregivers, and inaccurate identification of prescribed medications was significantly associated with adherence. Caregivers identified 21 barriers to adherence, and poor adherence was significantly related to the number of barriers reported. Results indicate that the TIP is a successful tool for identifying regimen knowledge, potential adherence barriers and adherence problems. Results suggest that the TIP could be integrated into clinical practice as a quick, effective tool to identify poor adherers and guide interventions and treatment decision making.     

Psychological distress across the course of care: a case study from implantable cardioverter defibrillator to cardiac transplantation evaluation

The psychological distress of cardiac patients can complicate treatment or the recovery process. This case study presents a 47-year-old male recipient of an implantable cardioverter defibrillator who experienced multiple, consecutive shocks and subsequently developed anxiety and depressive difficulties. Psychological treatment to diminish these symptoms was employed. Despite declining cardiac function, the patient made significant progress in managing this negative affect. Subsequently, he was evaluated for cardiac transplant, and this treatment progress became critical evidence of his psychosocial suitability for transplant.     

Homology modeling using multiple molecular dynamics simulations and docking studies of the human androgen receptor ligand binding domain bound to testosterone and nonsteroidal ligands

To facilitate the rational design of novel and more potent androgen receptor ligands, three-dimensional models for the human androgen receptor ligand binding domain bound to testosterone have been developed. These models of the androgen receptor were based on the crystal structure of the highly homologous human progesterone receptor ligand binding domain. The homology modeled androgen receptor was refined using unrestrained multiple molecular dynamics simulations in explicit solvent. Key H-bonding partners with the 17-hydroxy group and 3-keto group of testosterone are Asn705 and Thr877, and Gln711 and Arg752, respectively. These models show the presence of a unique unoccupied cavity within the androgen receptor binding pocket which may be valuable in the development of novel selective androgen receptor ligands. A qualitative analysis of amino acid mutations within the hAR binding pocket that affect ligand binding are consistent with these androgen receptor models. In addition to testosterone, the binding modes of several hydroxyflutamide-like nonsteroidal ligands for the androgen receptor are investigated using flexible docking with FlexX followed by refinement of the initial complexes with molecular dynamics simulations. These docking studies indicate that Asn705 is an important determinant in binding hydroxyflutamide and its derivatives by participating in H-bond interactions with the alpha-hydroxy moiety of these ligands. In addition, the nitro functionality mimics the 3-keto group of the natural ligand testosterone and is involved in H-bonding interactions with Gln711 and Arg752. From these docking studies, we suggest a mechanism for the enantioselective binding of chiral hydroxyflutamide derivatives and expand upon the previously reported structure-activity relationship for hydroxyflutamide and its derivatives.     

Micro-Flow Visualization of Red Blood Cell-Enhanced Platelet Concentration at Sudden Expansion

Microscopic steps and crevices are inevitable features within prosthetic blood-contacting devices. This study aimed to elucidate the thrombogenicity of the associated microscopic flow features by studying the transport of fluorescent platelet-sized particles in a suspension of red blood cells (RBCs) flowing through a 100 μm:200 μm sudden expansion. Micro-flow visualization revealed a strong influence of hematocrit upon the path of RBCs and spatial concentration of particles. At all flow rates studied (Re = 8.3–41.7) and hematocrit 20% and lower, RBC streamlines were found to detach from the microchannel wall creating an RBC-depleted zone inside the step that was much larger than the cells themselves. However, the observed distribution of particles was relatively homogeneous. By contrast, the RBC streamlines of samples with hematocrit equal to or greater than 30% more closely followed the contour of the microchannel, yet exhibited enhanced concentration of particles within the corner. The corresponding size of the cell depletion layer was comparable with the size of the cells. This study implies that local platelet concentration in blood within the physiological range of hematocrit can be elevated within the flow separation region of a sudden expansion and implicates the role of RBCs in causing this effect.     

Ethnic and racial differences in HPV knowledge and vaccine intentions among men receiving HPV test results

We examined factors associated with HPV vaccine intentions by racial/ethnic group among men participating in a HPV natural history study. HPV knowledge, vaccine intentions and perceived barriers were assessed among non-Hispanic White, non-Hispanic Black and Hispanic men. Men were tested for HPV every 6 months. After receiving test results from their previous visit, participants (N = 477) reported their intentions for HPV vaccination in a computer-assisted survey instrument (CASI). Vaccine intentions were high among all respondents, although differences were found between racial and ethnic groups in awareness and knowledge of HPV and, vaccine intentions and perceived access and barriers to receiving the HPV vaccine. In order to effectively disseminate the vaccine among men, factors that may promote or inhibit vaccine acceptability need to be identified. Identifying these factors related to vaccine intentions among minority and majority men offers an opportunity for addressing barriers to health equity and, in turn, reductions in HPV-related disparities.     

Rethinking Preconception Care: A Critical,Women’s Health Perspective

Objectives Preconception care aims to provide care to reproductive aged individuals in order to improve pregnancy and birth outcomes. Given that preconception care is a public health priority, it is important to evaluate the evolution of this health paradigm and the promotion of preconception messages that are obtained by the public. We identified online preconception health messages, which were critically assessed through a women’s health perspective. Methods We searched for “preconception care” on three major search engines. Websites were included if they were U.S.-based, provided content in English, and mentioned preconception care. Blogs and journal articles were excluded. The final sample included 52 websites. Using a content analysis approach, we assessed the presence of gender bias and identified other emergent themes. Results The majority of websites focused on preconception care for women only (67%). The recommendations centered on: (1) health behaviors for women (e.g., folic acid, drinking, smoking); (2) visiting healthcare providers; and (3) evaluating medical risks. Moreover, most content implied that women desired, or should desire, pregnancy. Overall, the messages used biomedical language and rarely mentioned other important health topics, such as social support and violence. Conclusions The primary messages presented on preconception care websites emphasized biomedical aspects of women’s health. The current context of preconception care medicalizes this pre-pregnancy period by defining it as a biomedical condition requiring lifestyle changes and interventions. Additionally, the biases presented in these messages assumed women want and are capable of pregnancies and excluded an integral factor for heteronormative reproduction—men.

     

Rethinking cocaine-associated chest pain and acute coronary syndromes

Every year more than 500,000 patients present to the emergency department with cocaine-associated complications, most commonly chest pain. Many of these patients undergo extensive work-up and treatment. Much of the evidence regarding cocaine's cardiovascular effects, as well as the current management of cocaine-associated chest pain and acute coronary syndromes, is anecdotally derived and based on studies written more than 2 decades ago that involved only a few patients. Newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and treatment of this common clinical scenario. However, there continues to be a paucity of prospective, randomized trials addressing this topic as it relates to clinical outcomes. We searched PubMed for English-language articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, cardiac biomarkers, electrocardiogram, coronary computed tomography, observation unit, β-blockers, benzodiazepines, nitroglycerin, calcium channel blockers, phentolamine, and cardiomyopathy; including various combinations of these terms. We reviewed the abstracts to confirm relevance, and then full articles were extracted. References from extracted articles were also reviewed for relevant articles. In this review, we critically evaluate the limited historical evidence underlying the current teachings on cocaine's cardiovascular effects and management of cocaine-associated chest pain. We aim to update the reader on more recent, albeit small, studies on the emergency department evaluation and clinical and pharmacologic management of cocaine-associated chest pain. Finally, we summarize recent guidelines and review an algorithm based on the current best evidence.