Focus groups: collecting aggregate-level data to understand community health phenomena

Focus-group method is an apt strategy for studying community health phenomena at the aggregate level. Not only can its use facilitate the inclusion of segments of the population who have been underserved by previous research, but it can generate a depth of understanding about public health problems, community strengths, and potential interventions that have local meaning and utility. Advantages and potential uses of focus groups are explored, as well as purposes and processes of focus-group interviewing, strategies for analysis, methodological limitations, and implications for practice and policy. The author presents investigatory examples to illustrate how focus-group method expands on the possibilities of individual interviewing to explore community interpretations and understand the health needs and experiences of an aggregate.

Mesalazine-associated interstitial nephritis

BACKGROUND

When used for oral treatment of inflammatory bowel disease, Asacol (a coated form of mesalazine = 5-aminosalicylic acid) can cause interstitial nephritis. The spectrum of severity, frequency of occurrence and the best renal function test to detect this complication are not known. The value of immunosuppression in addition to drug withdrawal is similarly undetermined.

METHODS

Four cases of interstitial nephritis which occurred in association with oral Asacol treatment are presented and a further 12 cases who received similar treatment are reviewed. Clinical trials published previously were scrutinized to assess the frequency of impaired renal function.

RESULTS

The available evidence suggests that renal impairment of any severity may occur in up to 1 in 100 patients, but that clinically significant interstitial nephritis occurs in less than 1 in 500 patients. This is most reliably detected by an elevated serum creatinine concentration. If the diagnosis of nephrotoxicity is delayed until 18 months after commencement of medication, restoration of renal function, which is seen on withdrawal of medication alone up to 10 months, does not occur and there is no evidence to date to indicate that addition of immunosuppression confers any significant advantage at this later stage.

CONCLUSIONS

It is suggested that serum creatinine concentration should be measured each month for the first 3 months of treatment, 3-monthly for the remainder of the first year and annually thereafter. The use of concurrent immunosuppressive therapy may necessitate extension to the period of intensive monitoring. Any elevation of serum creatinine which cannot be related to a relapse of inflammatory bowel disease should prompt immediate withdrawal of Asacol and related medications and substitution of alternative therapy. Neither the lack of urinary abnormalities on routine testing nor the absence of clinical or laboratory features of drug allergy can be relied upon to rule out interstitial nephritis during oral therapy with these drugs.

Antiphospholipid antibodies and venous thromboembolism

The clinical relevance of antiphospholipid antibodies (APLA) in patients without systemic lupus erythematosus who have venous thromboembolism (VTE) in unknown. Limited evidence suggests that there is an association between the presence of APLA and both initial and recurrent episodes of VTE and that patients with APLA and VTE are resistant to warfarin therapy. Unselected patients with a first episode of clinically suspected deep vein thrombosis or pulmonary embolism were evaluated with objective tests for VTE and with laboratory tests for APLA; the latter included tests for the lupus anticoagulant (LA) and anticardiolipin antibodies (ACLA). Patients with VTE were treated with anticoagulant therapy and observed during and after discontinuation of anticoagulants for symptomatic recurrence of VTE. There was a strong association between LA and VTE (odds ratio, 9.4; 95% confidence interval [CI], 2.1 to 46.2) and 9 to 65 (14%; 95% CI, 7% to 25%) patients with VTE had LA. There was no association between the presence of ACLA and VTE (odds ratio, 0.7; 95%CI, 0.3 to 1.7) because of the high frequency of positive ACLA assays in patients without VTE. None of the 16 patients with VTE and APLA developed recurrent VTE while receiving warfarin therapy. There was no difference in rates of recurrent VTE in patients with or without APLA after anticoagulant therapy was discontinued. The strong association between LA and VTE suggests that testing for LA in patients with VTE is useful. The measurement of ACLA in patients with VTE has no clinical usefulness because the results are abnormal in a high proportion of patients without VTE. Although the presence of APLA in patients with VTE was not associated with resistance to a conventional intensity of warfarin or an increased risk of recurrent VTE after discontinuation of warfarin, a larger study should address these issues in a subgroup of patients with VTE and LA.

Impact of HIV/AIDS on women in the United States: challenges of primary and secondary prevention

Women are the fastest growing group in the United States being infected with HIV. Although the majority of people with AIDS in the United States are men, AIDS is increasing almost four times as fast among women. Yet women remain understudied, underreport, and underdiagnosed. There are insufficient resources and services targeting the primary prevention needs of women, so women keep getting infected. Secondary prevention efforts for women infected with HIV have been stymied, and nearly a decade has been lost that might have been devoted to early detection of HIV infection in women, documentation of the natural history of HIV in women, exploration of their health needs, expansion of gender-specific services, and development of interventions to improve quality and length of life for HIV-positive women. In this article, I analyze the impact of HIV/AIDS on women in the United States and pose challenges for primary and secondary prevention.

The future of graduate education in nursing: scholarship, the health of communities, and health care reform

The authors critically examine the urgent needs posed by national health care reform and the forces impinging on the nursing profession to prepare nurse practitioners to meet these needs. With references to other struggles in nursing's professional history, the authors caution against exclusive investment in the nurse practitioner role as the discipline's hope for long overdue recognition of nursing's value to society. They argue that with health care reform, nurses have the chance to make graduate nursing education more responsive to the actual health needs of the populace and more relevant for practice in communities. The actions advocated include reflecting carefully on the articulation of nurse practitioner roles with others in the discipline, taking a partisan stand with vulnerable groups, developing substantive expertise in community-based practice and research, applying an understanding of the broader environmental context of health, and committing as a discipline to practice and scholarship that really makes a difference in the health of the public.

Evaluation of a soluble fibrin assay in patients with suspected deep vein thrombosis

BACKGROUND

The objective of this study was to determine the clinical utility of an enzyme immunoassay (EIA) for soluble fibrin in patients with clinically suspected deep vein thrombosis (DVT).

METHODS AND RESULTS

101 unselected patients with clinically suspected DVT underwent blood sampling for measurement of plasma levels of soluble fibrin, and objective testing for DVT. According to results of the objective tests, patients were classified as DVT-positive (n = 34) or DVT-negative (n = 67). Using different cut-points of soluble fibrin results, the sensitivities, specificities, positive and negative predictive values of the soluble fibrin assay were calculated. A soluble fibrin result of < or = 0.75 mg/ml showed a sensitivity and negative predictive value of 100%, and a specificity of 17.9% for DVT, a soluble fibrin result of < or = 1.40 mg/ml showed a sensitivity of 91.2% and a negative predictive value of 93.6%, and a specificity of 65.7% for DVT, whereas a soluble fibrin result of < or = 8.0 mg/ml showed a specificity and positive predictive value of 100% for DVT.

CONCLUSIONS

This study demonstrates that the soluble fibrin assay used in the study has potential clinical utility as a diagnostic test in patients with clinically suspected DVT and supports further evaluation of this assay.

HIV seroprevalence in emergency department patients: Portland, Oregon, 1988-1991

OBJECTIVES

In Portland, OR: 1) to determine the changes in HIV seroprevalence for ED patients from 1988 to 1991, 2) to define the characteristics of the HIV-positive ED patient, 3) to determine the hepatitis B seroprevalence of HIV-seropositive ED patients, and 4) to demonstrate the feasibility of an ED population-based surveillance investigation.

METHODS

A prospective, multiyear observational, cross-sectional, multicenter, population-based seroprevalence study was performed using seven urban hospital EDs. Serologic testing for HIV and hepatitis B was performed on excess blood obtained from ED patients. Four sampling periods were used at each hospital at 14-month intervals starting June 1988 and ending December 1991. The blood specimens were obtained concurrently at all the participating hospitals.

RESULTS

Of 1,681 patients, 17 (1.0%) were HIV-positive. The HIV seroprevalence rate was relatively stable over time: 0.5% (2/444) in 1988, 1.7% (7/396) in 1989, 1% (3/296) in 1990, and 0.9% (5/545) in 1991. Most (94%) HIV patients were men, 100% were white, 81% were > or = 30 years old. Most (59%) of the HIV-positive patients also were positive for hepatitis B core antibody. Many (76%) of the HIV-positive patients were known to be positive by the emergency health care worker.

CONCLUSION

HIV seroprevalence among the ED patients in Portland, OR, was generally stable from 1988 to 1991. Many HIV-positive patients also were hepatitis B-positive, thus representing a double occupational infectious disease risk to ED personnel. A significant minority (24%) of the HIV-positive patients were not known to be HIV-positive by the ED personnel. Universal precautions and hepatitis B immunization are paramount for reducing the risk of infectious disease due to exposure to body fluids.

Protective effects of a novel 32-amino acid C-terminal fragment of CAP18 in endotoxemic pigs

BACKGROUND

Cationic antimicrobial protein of 18 kd (CAP18) is a neutrophil-derived peptide that binds lipopolysaccharide (LPS) with high affinity. We hypothesized that CAP18(106-137), a novel synthetic 32-amino acid C-terminal fragment of CAP18, would neutralize the physiologic derangements induced by LPS in anesthetized swine.

METHODS

Pigs were randomly allocated into three groups. Those in the LPS group (n = 6) were infused with LPS (3 micrograms/kg/hr for 4 hours). Pigs in the LPS/CAP18 group (n = 6) were challenged with LPS (3 micrograms/kg/hr for 4 hours) and also treated with CAP18(106-137) (4 mg/kg/hr for 4 hours). Pigs in the RL group (n = 4) received neither LPS nor CAP18(106-137).

RESULTS

Treatment with CAP18(106-137) blocked LPS-induced increases in plasma levels of 6-keto-prostaglandin F1 alpha and tumor necrosis factor-alpha and prevented LPS-induced changes in cardiac output, arterial PO2, phagocyte activation, and peripheral leukocyte count. Changes in circulating concentrations of thromboxane B2, mean pulmonary artery pressure, and dynamic pulmonary compliance were attenuated in the LPS/CAP18 group.

CONCLUSIONS

Treatment with CAP18(106-137) neutralizes many of the deleterious effects of LPS in pigs.

Effect of granulocyte colony-stimulating factor treatment on ex vivo blood cytokine response in human volunteers

We explored the ex vivo alteration in the cytokine release of stimulated blood taken from healthy volunteers treated subcutaneously with 480 micrograms granulocyte colony-stimulating factor (G-CSF). In a double-blind, controlled, randomized study with 21 volunteers who received G-CSF once or twice 24 hours apart, we measured lipopolysaccharide (LPS)-inducible release of various cytokines and soluble receptors at different times after treatment. At day 1 after a single dose of G-CSF, mediator release was also initiated with muramyl dipeptide, Staphylococcus aureus enterotoxin A, lipoteichoic acid, streptolysin O, complement factor C5a, phytohemagglutinin, or phorbol myristate acetate. In blood from G-CSF-treated subjects, our major findings were (1) a maximal 12-fold increase in interleukin-1 receptor antagonist (IL-1ra) release and an increase of both the p55 and p75 soluble tumor necrosis factor (TNF) receptors; (2) a reduction in TNF release when using all the various stimuli described except LPS; (3) an increase in G-CSF and, to lesser extent, in IL-6, IL-8, and IL-10 release; and (4) an attenuation of interferon-gamma (IFN-gamma) and granulocyte-macrophage (GM)-CSF release. Our findings demonstrate that the major effect of G-CSF treatment is a change in the responsiveness of blood towards a variety of stimuli, which we interpret as a shift toward an antiinflammatory cytokine response.

A novel and rapid whole-blood assay for D-dimer in patients with clinically suspected deep vein thrombosis

BACKGROUND

The clinical utility of using a novel whole blood assay for D-dimer (SimpliRED), alone or in combination with impedance plethysmography (IPG), was investigated in a two-center, prospective cohort study of 214 consecutive patients with clinically suspected deep vein thrombosis (DVT).

METHODS AND RESULTS

All patients underwent the SimpliRED D-dimer assay, contrast venography, and IPG. According to the results of venography, 43 patients had proximal DVT (popliteal and/or more proximal veins), 10 had isolated calf DVT, and 161 had DVT ruled out. The D-dimer had a sensitivity of 93% for proximal DVT and of 70% for calf DVT, an overall specificity of 77%, and a negative predictive value of 98% for proximal DVT. The sensitivity and specificity of IPG for proximal DVT were 67% and 96%, respectively. When analyzed in combination with the IPG results, it was determined that (1) the combination of a negative D-dimer and a normal IPG had a negative predictive value of 97% for all DVT and of 99% for proximal DVT and occurred in 58% of patients (likelihood ratio, 0.1) and (2) the combination of a positive D-dimer and an abnormal IPG had a positive predictive value of 93% for any DVT and of 90% for proximal DVT and occurred in 14% of patients (likelihood ratio, 42.6). When the D-dimer and IPG results were discordant, it was not possible to exclude or diagnose DVT reliably; discordant results occurred in 28% of patients.

CONCLUSIONS

The SimpliRED D-dimer assay, which can be performed and interpreted at the bedside within 5 minutes, has great potential in patients with clinically suspected DVT, especially for ruling out DVT, and is complementary to IPG. The assay should be evaluated in large clinical management studies.

Dissociation of cytolysis and monokine release by bovine mononuclear phagocytes incubated with Pasteurella haemolytica partially purified leukotoxin and lipopolysaccharide

The bovine respiratory pathogen Pasteurella haemolytica secretes an exotoxin that is specific for ruminant leukocytes (leukotoxin). Previous studies have shown that subcytolytic concentrations of the leukotoxin stimulate bovine neutrophils to undergo a respiratory burst and degranulate. Relatively little is known about the stimulatory effects of the leukotoxin on bovine mononuclear phagocytes. In this study, we compared the relative cytolytic effects of partially purified leukotoxin on bovine peripheral blood monocytes and alveolar macrophages. We found monocytes to be approximately 8- to 10-fold more sensitive than alveolar macrophages to the cytolytic effect of leukotoxin. In addition, incubation of monocytes and alveolar macrophages with sublethal doses of leukotoxin stimulated release of IL-1 and TNF activities in a dose-dependent manner. Addition of an antileukotoxin MAb neutralized the cytolytic effects of leukotoxin, but potentiated TNF release. Heat inactivation also blocked the cytolytic activity of LKT, but only slightly reduced its ability to stimulate TNF release. Although the leukotoxin preparations were estimated to have only small amounts of lipopolysaccharide (LPS) contamination, as determined by a standard Limulus amebocyte lysate coagulation assay, a chromogenic Limulus assay indicated much greater amounts of LPS were present. Adding equivalent doses of P. haemolytica LPS largely duplicated the monokine release stimulated by leukotoxin. These results suggest that the stimulatory effects of the P. haemolytica leukotoxin on bovine mononuclear phagocytes may principally involve LPS, perhaps complexed with leukotoxin.

Doppler ultrasound in renal disease: not quite "the answer to a maiden's prayer"

Initial wild enthusiasm for the use of Doppler ultrasound in renal disease, particularly in renal transplants, led to claims that Doppler would enable diagnosis of various abnormalities without recourse to more invasive techniques. These claims have not been borne out by a more reasoned and scientific assessment of the role of Doppler ultrasound in the diagnosis of native and transplant kidney dysfunction. With the realization that changes in the Doppler findings merely reflect changes in renal blood flow induced by a variety of pathological processes has come a better understanding of how Doppler may be of benefit in the diagnosis and monitoring of these processes. The combination of duplex Doppler and color flow mapping with conventional B-mode ultrasound allows acquisition of both physiological and morphological information entirely non-invasively. Doppler ultrasound may not quite be "the answer to a maiden's prayer" in the evaluation of kidney disease but nevertheless represents a very useful tool in the nephrologist's investigative armamentarium, a tool which may be used repeatedly without detriment or risk to the patient.

Structural and interpersonal impact of heterosexual assumptions on lesbian health care clients

In this feminist narrative study using in-depth interviews and focus groups, a racially and economically diverse sample of 45 lesbians described their access to and experience with health care. The multistaged narrative analysis revealed structural and interpersonal conditions uniquely faced by lesbians in obtaining health care services. At the macrolevel, heterosexist structuring of health care delivery was obstructive to lesbians' health care seeking, health knowledge, and health behaviors. At the micro, or individual level, health care providers' heterosexual assumptions competed against potentially supportive interactions with lesbian clients.

Demographics of cardiac arrest: association with residence in a low-income area

OBJECTIVE

To report cardiac arrest demographics and assess whether arrest rate is associated with differences in intracity regional population densities, incomes, or race distributions.

METHODS

One-year retrospective review of out-of-hospital cardiac arrests in a city with a two-tier emergency medical service (EMS) system. Associations of population density, median income, and race data with age- and gender-adjusted cardiac arrest rates for seven city regions and groupings of high- and low-income census tracts were made.

RESULTS

Median income, but not race or population density, was associated with sex- and age-adjusted intracity regional cardiac arrest rates (p = 0.034). This association of cardiac arrest rate with income status was magnified when the 20 lowest and the 20 highest income census tracts were compared. Cardiac arrest victims in these two income groups did not differ in regard to rate of witnessed arrest, bystander-administered CPR, or previous cardiac disease. Rates of survival to hospital discharge were not significantly different between the two groups.

CONCLUSION

The association of lower income with cardiac arrest suggests that cardiac health promotion and EMS intervention measures, including CPR instruction, should be targeted to lower-income neighborhoods. These findings may help explain previous studies suggesting a racial or population density association with cardiac arrest rates.

Lesbians' health-related experiences of care and noncare

In this feminist narrative study using in-depth interviews, focus groups, and a multistaged narrative analytic approach, a racially and economically diverse sample of 45 lesbians conveyed their health care experiences. Participants recounted a total of 332 health care interactions across a wide range of health care facilities, health care providers, and health conditions; 23% of these interactions they evaluated positively and 77%, negatively. In their stories, lesbians described the pivotal dimensions of face-to-face health care from their perspective as clients. Each of these interactional dimensions is defined by a fundamental experiential contrast gleaned from their descriptions of caring and noncaring clinical situations. They are as follows: existence: reflection versus facelessness; bodily integrity: intimate care versus intrusion; emotional integrity: sheltered versus shamed; worth: sustained versus abandoned; expression: voiced versus silenced; and power: solidarity versus dominance.

HIV prevention education for lesbians and bisexual women: a cultural analysis of a community intervention

AIDS is increasing almost four times as fast among women, yet lesbians and bisexual women are among the least studied, least understood and most elusive populations affected by the AIDS epidemic. This paper reports the results of community-level HIV prevention research designed: (a) to examine the knowledge, perceptions, social contingencies and political constraints affecting the HIV risk taking of lesbians and bisexual women; and (b) to offer them context specific HIV prevention education. The study was a peer educator-based intervention project situated in San Francisco's women's bars, dance clubs, and sex clubs to reach socially and sexually active lesbians and bisexual women in natural settings. Between June 1992 and May 1993, ethnographic interviews were conducted with 626 women attending the bars and clubs; group presentations at these locales reached 1,315 women. The structure of the intervention was effective in prompting interest in HIV prevention information and intent to change behavior. The resultant cultural analysis details risk behaviors lesbians and bisexual women participate in, myriad constraints they face in trying to enact safer behaviors, gaps in knowledge, difficulties comprehending the relevance of HIV prevention, and risk reduction strategies commonly employed.