HIV Pre-exposure Prophylaxis Education for Clinicians Caring for Spanish-Speaking Men Who Have Sex With Men (MSM)

INTRODUCTION

A growing number of Liaison Committee on Medical Education-accredited allopathic medical schools offer formal bilingual (English and Spanish) medical education, and numerous other schools offer medical Spanish through elective workshops as part of their curricula. One significant health disparity in the Hispanic community is the incidence of HIV among Spanish-speaking men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) has emerged as an effective strategy to reduce the risk of HIV transmission.

METHODS

We developed an education module to train clinicians to discuss PrEP with Spanish-speaking MSM. Our module is adapted from an English module on PrEP education. It includes a Spanish-language PowerPoint slide deck with information about PrEP as well as a Spanish-language videotaped scripted clinical encounter.

RESULTS

The module was implemented on three occasions with 18 participants, and learners reported increased comfort in discussing and confidence in prescribing PrEP with Spanish-speaking patients.

DISCUSSION

This workshop can be incorporated within medical Spanish curriculums offered at health professional schools and community-based organizations dedicated to reducing the HIV burden in the Spanish-speaking Hispanic community.

Effect of Heat Exposure on Cognition in Persons with Tetraplegia

Individuals with cervical spinal cord injury (SCI) have impaired thermoregulatory mechanisms attributed to interruption of motor, sensory, and autonomic neuropathways. To determine the effects of heat exposure on core body temperature (Tcore) and cognitive performance in persons with tetraplegia, 8 individuals with chronic tetraplegia (C3-C7, American Spinal Cord Injury Association Impairment Scale A-B) and 9 able-bodied controls were acclimated to 27°C at baseline (BL) before being exposed to 35°C for up to 120 min (Heat Challenge). Rectal temperature (Tcore), distal skin temperatures (Tsk_avg), sweat rate (QS_avg), microvascular skin perfusion (LDF_avg), and plasma norepinephrine (NE) were measured. Cognitive performance was assessed using Stroop Color and Word and Wechsler Adult Intelligence Scale-Fourth Edition Digit Span tests at BL and at the end of Heat Challenge. After Heat Challenge, Tcore increased 0.78 ± 0.18°C (p < 0.001) in tetraplegics after an average of 118 ± 5 min. Tcore did not change in controls after 120 min. The increase in QS_avg was larger in controls than in tetraplegics (946 ± 672% vs. 51 ± 12%; p = 0.007, respectively). LDF_avg increased only in controls (109 ± 93%; p = 0.008). Tsk_avg appeared to increase less in tetraplegics than in controls. Plasma NE levels remained lower in tetraplegics compared to controls after Heat Challenge (86 ± 64 vs. 297 ± 84 pg/mL, respectively; p < 0.001). Stroop Color, Interference, and WAIS-IV Sequence scores increased only in tetraplegics (19.4 ± 17.2%; p < 0.05, 8.3 ± 5.9%; p < 0.05, 29.1 ± 27.4%; p < 0.05, respectively). Dysfunctional thermoregulatory mechanisms in the tetraplegic group allowed Tcore to rise from subnormal levels to normothermia during heat exposure. Normothermia was associated with improvements in attention, working memory, and executive function.

Self-reported effects of cold temperature exposure in persons with tetraplegia

OBJECTIVE

Cervical spinal cord injury (tetraplegia) is known to interrupt sympathetic vasculature control, thereby preventing shunting of blood from the periphery to central organs when exposed to cold temperatures. As a result, persons with tetraplegia are at risk to develop hypothermia. However, information regarding the discomfort experienced during the cooler months (late fall, winter, early spring) is overwhelmingly anecdotal. It is not known, with any certainty, how those with tetraplegia perceive cold and if discomfort in colder environments restricts them from performing activities that they routinely would perform.

DESIGN

Prospective, two-group, self-report surveys.

SETTING

VA Medical Center and Kessler Institute for Rehabilitation.

PARTICIPANTS

Forty-four subjects with tetraplegia; 41 matched non-SCI controls.

OUTCOME MEASURES

Tetraplegic and control groups responded "yes" or "no" when asked whether cold seasonal temperatures allowed comfort or negatively affected participation in routine activities.

RESULTS

Percentage of responses of tetraplegia compared to controls was different as to whether they felt cold when others in the same room were comfortable (82 vs. 24%; χ² = 28.2, P < 0.0001), felt comfortable outdoors (17 vs. 43%; χ² = 6.8, P = 0.009), or whether cold negatively affected bathing routines (55 vs. 15%; χ² = 14.8, P = 0.0001), keeping physician appointments (46 vs. 12%; χ² = 11.3, P = 0.0008), thinking clearly (41 vs. 7%; χ² = 12.9, P = 0.0003), and completing usual work duties (46 vs. 10%; χ² = 13.3, P = 0.0003).

CONCLUSION

Cold seasonal temperatures have a reported greater negative impact on personal comfort and ability to perform vital activities in persons with tetraplegia than that of non-SCI controls. These findings highlight the need to address thermoregulatory impairment in persons with tetraplegia.

Comparison of 24-hour cardiovascular and autonomic function in paraplegia, tetraplegia, and control groups: implications for cardiovascular risk

BACKGROUND

Fluctuations in 24-hour cardiovascular hemodynamics, specifically heart rate (HR) and blood pressure (BP), are thought to reflect autonomic nervous system (ANS) activity. Persons with spinal cord injury (SCI) represent a model of ANS dysfunction, which may affect 24-hour hemodynamics and predispose these individuals to increased cardiovascular disease risk.

OBJECTIVE

To determine 24-hour cardiovascular and ANS function among individuals with tetraplegia (n=20; TETRA: C4-C8), high paraplegia (n=10; HP: T2-T5), low paraplegia (n=9; LP: T7-T12), and non-SCI controls (n=10). Twenty-four-hour ANS function was assessed by time domain parameters of heart rate variability (HRV); the standard deviation of the 5-minute average R-R intervals (SDANN; milliseconds/ms), and the root-mean square of the standard deviation of the R-R intervals (rMSSD; ms). Subjects wore 24-hour ambulatory monitors to record HR, HRV, and BP. Mixed analysis of variance (ANOVA) revealed significantly lower 24-hour BP in the tetraplegic group; however, BP did not differ between the HP, LP, and control groups. Mixed ANOVA suggested significantly elevated 24-hour HR in the HP and LP groups compared to the TETRA and control groups (P<0.05); daytime HR was higher in both paraplegic groups compared to the TETRA and control groups (P<0.01) and nighttime HR was significantly elevated in the LP group compared to the TETRA and control groups (P<0.01). Twenty-four-hour SDANN was significantly increased in the HP group compared to the LP and TETRA groups (P<0.05) and rMSSD was significantly lower in the LP compared to the other three groups (P<0.05). Elevated 24-hour HR in persons with paraplegia, in concert with altered HRV dynamics, may impart significant adverse cardiovascular consequences, which are currently unappreciated.

Systemic and cerebral hemodynamics during cognitive testing

OBJECTIVE

Cognitive deficits are reported in 10-60% of individuals with SCI, the primary etiology of these deficits is believed to be concomitant traumatic brain injury (TBI). We recently documented diminished memory and marginally deficient attention and processing speed in individuals with SCI discordant for hypotension but matched for TBI.

METHODS

Twenty-nine individuals participated: 16 non-SCI controls, 6 paraplegic (T2-T10) and 7 tetraplegic (C4-C8). The Stroop test was used to measure cognitive function and transcranial Doppler ultrasound was used to measure cerebral blood flow (CBF) while resting (5 min) and continuously during cognitive testing. Mean arterial pressure (MAP) was calculated from three brachial blood pressures and cerebral vascular resistance index was calculated as: CVRi = MAP/CBF.

RESULTS

The paraplegia group (54 ± 6) was marginally older than the non-SCI (42 ± 15; p = 0.06) and tetraplegic (42 ± 11; p = 0.09) groups. Compared to non-SCI group, normalized t-score on the Stroop Color (SC) task was significantly lower in the paraplegic group (p < 0.05). In the tetraplegic group, MAP was significantly lower (p < 0.05) than the non-SCI and paraplegic groups, and related to SC t-score (r (2) = 0.873; p < 0.01). In the paraplegic group, CBF was reduced (p < 0.05) and CVRi increased (p < 0.05) compared to the non-SCI group, and CVRi was increased compared to the tetraplegic group (p < 0.05). A significant inverse relationship was noted between change in CVRi and SC t-score in the non-SCI group.

CONCLUSION

Asymptomatic hypotension relates to cognitive performance in persons with tetraplegia; therefore, BP normalization should be considered. The inappropriate cerebral vascular response to cognitive testing and poor test performance should be investigated in persons with paraplegia.

The QT variability index and cardiac autonomic modulation: perspectives from apparently healthy men with spinal cord injury

OBJECTIVE

To describe the effect of spinal cord injury (SCI) on the QT variability index (QTVI).

METHODS

Digital electrocardiograms from 113 age-matched men (40 with tetraplegia, 26 with high paraplegia, 17 low paraplegia and 31 controls) were analyzed. RR interval, heart rate (HR) variability [total power (TP(RR)), low frequency (LF(RR)) and high frequency (HF(RR))], QT interval duration, Bazett HR-corrected QT (QTc), QT interval variance (QTVN) and QTVI were compared.

RESULTS

Significant group main effects were present for RR, QTc, TP(RR) and LF(RR), but not QT duration, QTVN or HF(RR). Post hoc comparisons revealed the following: (1) longer RR in controls versus subjects with high paraplegia and low paraplegia, and in subjects with tetraplegia versus high paraplegia and low paraplegia; (2) QTc was longer in subjects with low paraplegia versus controls and shorter in subjects with tetraplegia versus high paraplegia, and (3) TP(RR) and LF(RR) were different in controls and subjects with high paraplegia compared to those with low paraplegia. QTVI was significantly elevated in all SCI groups compared to controls. Significant negative correlations between QTVI and HF(RR) were observed in all SCI groups, and TP(RR) and LF(RR) in subjects with tetraplegia and high paraplegia only. Age was negatively correlated in controls.

CONCLUSIONS

QTVI is negatively affected in otherwise healthy SCI men compared to age-matched controls. This observation appears to reflect the attenuation of vagal modulation, sympathetic impairment above the sixth thoracic vertebra and/or a heightened degree of cardiovascular disease risk.

Exhaled nitric oxide levels are elevated in persons with tetraplegia and comparable to that in mild asthmatics

The role of airway inflammation in mediating airflow obstruction in persons with chronic traumatic tetraplegia is unknown. Measurement of the fraction of exhaled nitric oxide (FeNO) affords a validated noninvasive technique for gauging the airway inflammatory response in asthma, although it has never been assessed in persons with tetraplegia. This study was designed to determine the FeNO in individuals with chronic tetraplegia compared with that in patients with mild asthma and healthy able-bodied individuals. Nine subjects with chronic tetraplegia, seven subjects with mild asthma, and seven matched healthy able-bodied controls were included in this prospective, observational, pilot study. All subjects were nonsmokers and clinically stable at the time of study. Spirometry was performed on all participants at baseline. FENO was determined online by a commercially available closed circuit, chemiluminescence method, using a single-breath technique. Subjects with tetraplegia had significantly higher values of FeNO than controls (17.72 +/- 3.9 ppb vs. 10.37 +/- 4.9 ppb; P < or = 0.01), as did subjects with asthma (20.23 +/- 4.64 ppb vs. 10.37 +/- 4.9 ppb, P < or = 0.001). There was no significant difference in FeNO between subjects with tetraplegia and those with asthma (17.72 +/- 3.9 ppb vs. 20.23 +/- 4.64 ppb, P < or = 0.27). Individuals with chronic tetraplegia have FeNO levels that are comparable to that seen in mild asthmatics and higher than that in healthy able-bodied controls. The clinical relevance of this observation has yet to be determined.

Effect of hypotensive challenge on systemic hemodynamics and cerebral blood flow in persons with tetraplegia

INTRODUCTION

Individuals with tetraplegia have impaired central control of sympathetic vascular modulation and blood pressure (BP); how this impairment affects cerebral blood flow (CBF) is unclear.

OBJECTIVES

To determine if persons with tetraplegia maintain CBF similarly to able-bodied controls after a hypotensive challenge.

METHODS

Seven individuals with chronic tetraplegia and seven age-matched, non-SCI control subjects underwent a hypotensive challenge consisting of angiotensin-converting enzyme (ACE) inhibition (1.25 mg enalaprilat) and 45 degrees head-up tilt (HUT). Heart rate (HR), low frequency systolic BP variability (LFsbp), brachial mean arterial pressure (MAP) and middle cerebral artery CBF were measured before and after the challenge. Group differences for the baseline (BL) to post-challenge response were determined by repeated measures ANOVA.

RESULTS

HR did not differ between the groups in response to the hypotensive challenge. LFsbp response was significantly reduced in the tetra compared to the control group (-38 +/- 51 vs. 72 +/- 93%, respectively). MAP did not differ between the groups at BL but was significantly lower in the tetra compared to the control group post-challenge (55 +/- 13 vs. 71 +/- 9 mmHg, respectively); the percent change in MAP was significantly greater in the tetra than in the control group (-29 +/- 14.1 vs. -13 +/- 9%, respectively). However, CBF did not differ between the groups at baseline or post-challenge; the percent change in CBF post-challenge was not different between the tetra and control groups (-29 +/- 13.2 vs. -23 +/- 10.3%, respectively).

INTERPRETATION

Despite impaired sympathetic vasomotor and BP control, CBF in persons with tetraplegia was comparable to that of control subjects during a hypotensive challenge.