Implementation of HIV pre-exposure prophylaxis for women of color: Perspectives from healthcare providers and staff from three clinical settings

Women of color (WOC) account for 83% of new HIV infections among women in the United States. While pre-exposure prophylaxis (PrEP) is a safe, effective HIV prevention method for women, WOC are less likely to be prescribed PrEP than other populations. Guided by an implementation science research framework, we investigated the implementation of a PrEP initiative for WOC in a US city with high HIV incidence. Across three clinical sites, only three WOC were prescribed PrEP after one year. Analysis of qualitative interviews with clinic staff and providers identified time constraints, reluctance to prescribe PrEP, and discomfort with counseling as implementation barriers. Implementation facilitators included staff and leadership support for PrEP, alignment of PrEP services with organizational missions, and having a centralized PrEP Coordinator. By addressing these identified implementation barriers and facilitators, clinic staff and providers can ensure that WOC are provided with the full range of HIV prevention options.

Alcohol Consumption and Bone Mineral Density in People with HIV and Substance Use Disorder: A Prospective Cohort Study

BACKGROUND

People living with HIV (PLWH) commonly have low bone mineral density (BMD) (low bone mass and osteoporosis) and are at high risk for fractures. Fractures and low BMD are significant causes of morbidity and mortality, increasingly relevant as PLWH age. Alcohol use is common among PLWH and known to affect bone health. The association between alcohol use and changes in BMD among PLWH is not well understood.

METHODS

We conducted a 3.5-year prospective cohort study of 250 PLWH with substance use disorder or ever injection drug use. Annual alcohol consumption was measured as a mean of grams per day of alcohol, mean number of heavy drinking days per month, mean number of days abstinent per month, and any heavy drinking, using the 30-day Timeline Followback method twice each year. The primary outcome was annual change in BMD measured each year by dual energy X-ray absorptiometry in grams per square centimeter (g/cm2 ) at the femoral neck. Additional dependent variables included annual change in total hip and lumbar spine BMD, >6% annual decrease in BMD at any site, and incident fractures in the past year. Regression models adjusted for relevant covariates.

RESULTS

The median age of participants was 50 years. The median duration of HIV infection was 16.5 years and the mean time since antiretroviral therapy initiation was 12.3 years. At study entry, 67% of participants met criteria for low BMD (46% low bone mass, 21% osteoporosis). Median follow-up was 24 months. We found no significant associations between any measure of alcohol consumption and changes in BMD (g/cm2 ) at the femoral neck (adjusted β for g/d of alcohol = -0.0032, p = 0.7487), total hip, or lumbar spine. There was no significant association between any measure of alcohol consumption and >6% annual decrease in BMD at any site, or incident fractures.

CONCLUSIONS

In this sample of PLWH and substance use disorders or ever injection drug use, we detected no association between any of the alcohol measures used in the study and changes in BMD or incident fractures.

HIV-infected individuals who use alcohol and other drugs, and virologic suppression

People living with HIV (PLWH) on antiretroviral therapy (ART) who use substances were examined to (a) describe those with virologic control and (b) determine which substance use-factors are associated with lack of virologic control. Participants were adult PLWH taking ART with either past 12-month DSM-IV substance dependence or past 30-day alcohol or illicit drug use. Substance use factors included number of DSM-IV alcohol or drug dependence criteria and past 30-day specific substance use. Associations with HIV viral load (HVL) (<200 vs. ≥200 copies/mL) were tested using logistic regression models. Multivariable analyses adjusted for age, sex, homelessness and anxiety or depression. Participants (n = 202) were median age 50 years, 66% male, 51% African American and 75% self-reported ≥90% past 30-day ART adherence. Though HVL suppression (HVL <200 copies/mL) was achieved in 78% (158/202), past 30-day substance use was common among this group: 77% cigarette use; 51% heavy alcohol use; 50% marijuana; 27% cocaine; 16% heroin; and 15% illicit prescription opioid use. After adjusting for covariates, specific substance use was not associated with a detectable HVL, however number of past 12-month DSM-IV drug dependence criteria was (adjusted odds ratio = 1.23 for each additional criterion, 95% CI: 1.04-1.46). Three-quarters of a substance-using cohort of PLWH receiving ART had virologic control and ≥90% ART adherence. Substance dependence criteria (particularly drug dependence), not specifically substance use, were associated with lack of virologic control. Optimal HIV outcomes can be achieved by individuals who use alcohol or drugs and addressing symptoms of substance dependence may improve HIV-related outcomes.

Lifetime and recent alcohol use and bone mineral density in adults with HIV infection and substance dependence

Low bone mineral density (BMD) is common in people living with HIV infection (PLWH), increasing fracture risk. Alcohol use is also common in PLWH and is a modifiable risk factor for both HIV disease progression and low BMD. In PLWH, alcohol's effect on BMD is not well understood.We studied adult PLWH with substance dependence. We measured lifetime alcohol use (kg) and recent (i.e., past 30-day) alcohol use (categorized as: abstinent, low risk, or high risk). In adjusted multivariable regression analyses, we tested associations between lifetime and recent alcohol use and (i) mean BMD (g/cm) at the femoral neck, total hip, and lumbar spine and (ii) low BMD diagnosis (i.e., osteopenia or osteoporosis). We also examined associations between 2 measures of past alcohol use (i.e., total consumption [kg] and drinking intensity [kg/year]) and BMD outcome measures during 3 periods of the HIV care continuum: (i) period before first positive HIV test, (ii) period from first positive HIV test to antiretroviral therapy (ART) initiation, and (iii) period following ART initiation.We found no significant associations between lifetime alcohol use and mean femoral neck (β -0.000, P = .62), total hip (β -0.000, P = .83) or lumbar spine (β 0.001, P = .65) BMD (g/cm), or low BMD diagnosis (adjusted odds ratio [aOR] = 0.98, 95% Confidence Interval [CI]: 0.95-1.01). There was no significant correlation between past 30-day alcohol use and mean BMD (g/cm). Past 30-day alcohol use was associated with low BMD diagnosis (P = .04); compared to abstainers, the aOR for high risk alcohol use was 1.94 (95% CI: 0.91-4.12), the aOR for low risk alcohol use was 4.32 (95% CI: 1.30-14.33). Drinking intensity (kg/year) between first positive HIV test and ART initiation was associated with lower mean BMD (g/cm) at the femoral neck (β -0.006, P = .04) and total hip (β -0.007, P = .02) and increased odds of low BMD (aOR = 1.18, 95% CI = 1.03-1.36).In this sample of PLWH, we detected no association between lifetime alcohol use and BMD. However, recent drinking was associated with low BMD diagnosis, as was drinking intensity between first positive HIV test and ART initiation. Longitudinal studies should confirm these associations.

Comparison of the Biobullet versus traditional pharmaceutical injection techniques on injection-site tissue damage and tenderness in beef subprimals

The incidence and severity of injection-site lesions has decreased since the development of the Beef Quality Assurance program. The objective was to evaluate the route of administration and the pharmaceutical product on the impact on tenderness, collagen concentration, and lesion occurrence in muscles of chucks and rounds. A total of 144 yearling steers (initial BW = 383 +/- 29.4 kg) were selected and transported to Oklahoma State University. Steers were blocked into 2 groups of 72 based on initial BW and were randomly allocated, within block, into pens of 6 head per pen (12 pens per block). Each pen was randomly assigned an injection protocol. On May 19, 2006 (d 0), steers were administered one of the following treatment injections: a standard Biobullet containing 100 mg of ceftiofur sodium (Naxel, Pfizer Inc., New York, NY); a traditional needle and syringe dose of ceftiofur sodium; a standard Biobullet containing BallistiVac infectious bovine rhinotracheitis (IBR; Titanium 5, SolidTech Animal Health, Newcastle, OK); a traditional needle and syringe dose of IBR; a traditional needle and syringe dose of Vira Shield 5 (Grand Laboratories Inc., Freeman, SD); a standard placebo Biobullet; or a traditional needle and syringe dose of sterile water. Percentage of samples with an identifiable lesion did not differ by drug administered or injection method. Warner-Bratzler shear force values of lesion center cores in chucks tended to be different (P = 0.07) from cores from the control steaks and at 2.54 and 5.08 cm away from the lesion center. Lesion centers from the Biobullet-BallistiVac IBR had a Warner-Bratzler shear force value of 7.01 kg, which was greater (P < 0.05) than values for lesion centers from chucks injected with a Biobullet-placebo (6.27 kg) or needle-ceftiofur sodium (5.08 kg). No significant differences (P > 0.10) were observed in the total collagenous connective tissue in samples extracted from the chuck or round. The comparison of lesion site and control (nonlesion site) samples for lipid concentration showed no significant difference (P > 0.10) among treatments in the round. It was concluded the Biobullet did not create a greater occurrence of lesions in the muscles of the chuck and round. The Biobullet is not an appropriate injection method for the round of beef cattle because it caused tissue damage similar to a needle injection. However, the Biobullet can be used effectively in neck (chuck) applications without additional negative effects on tenderness.

Bacterial contamination of blenderized whole food and commercial enteral tube feedings in the Philippines

Hospital-prepared tube feedings from four Philippine acute-care hospitals were analysed for microbial contamination. Two feedings were prepared on three separate days at each hospital. The tube feedings were either blended natural whole foods or a reconstituted commercial powdered nutritional product. Samples of each feeding were collected for coliform count and standard plate count at the time of preparation and at 1, 2 and 4 h after preparation after maintenance at room temperature (26-31 degrees C). At the time of preparation, mean coliform and standard plate counts for all samples were 10.3 most probable number per gram (MPN/g) and 7.4x10(4)colony-forming units per gram (cfu/g), respectively. Nine of 24 samples (38%) had coliform counts greater than 10 MPN/g, and 22/24 (92%) samples had standard plate counts greater than 10(3) cfu/g. There were significant increases in mean coliform and standard plate counts over 4 h (P=0.0005 and P=0.008, respectively). At 4 h after preparation, the mean coliform and standard plate counts were 18.2 MPN/g and 2.1x10(5) cfu/g, respectively. At this time, 18/24 (75%) samples had coliform counts greater than 10 MPN/g and 20/24 (83%) samples had standard plate counts greater than 10(5) cfu/g. The results of this study show that the microbial quality of the majority of the hospital-prepared enteral tube feedings analysed were not within published guidelines for safety.

Effect of high ambient temperature on contamination and physical stability of one-liter ready-to-hang enteral delivery systems

The effect of high ambient temperature on the physical stability and bacterial contamination of 1-L, prefilled, closed enteral feeding systems was examined under simulated clinical conditions. One hundred Jevity Ready-to-Hang enteral feeding systems (Abbott Park, IL, USA) were placed in a 37 degrees C incubator for 24 h. The Ready-to-Hang formula containers were visually inspected at 0 and 24 h. Formula samples were collected from the containers at 24 h and plated on trypticase soy agar. Two samples had insignificant bacterial growth of one colony-forming unit per milliliter that was not demonstrated in repeat culture. No growth was observed for any other sample. Additional samples collected from the two apparently contaminated delivery sets showed no growth. No set showed signs of formula instability, such as coagulation, clumping, or curdling. These findings suggest that, even at a high ambient temperature of 37 degrees C, the risk of bacterial contamination or compromised physical integrity is very low with the use of 1-L, prefilled, closed enteral feeding systems.

Kidney transplantation: a therapy option

The growing number of patients with end stage renal disease (ESRD) choosing kidney transplantation as a therapy option has increased critical care nurses' exposure to this patient population. Critical care nurses have a crucial involvement when caring for the patient in the postoperative period or when serious complications develop. A knowledge base of immunosuppressive therapy and the body's response to it is helpful in assessing and identifying rejection, infection, and technical complications.

Diabetic microangiopathy in patients with cystic fibrosis

Individuals with cystic fibrosis have a 1% to 7% incidence of insulin-dependent diabetes mellitus. The occurrence of diabetic microangiopathy in patients with cystic fibrosis has been reported recently. From 1978 to 1987, 19 patients with cystic fibrosis and diabetes mellitus were followed up. Four patients (21%) had evidence of diabetic microangiopathy. In one, peripheral neuropathy developed 5 years after the onset of diabetes mellitus, and the other 3 patients each had complications of retinopathy, nephropathy, and neuropathy which developed 10 years after the onset of diabetes mellitus. All were poorly compliant in their medical care. Significant morbidity was seen in the 3 patients with multisystem involvement--blindness, glaucoma, hypertension, and renal failure. The combination of long-standing diabetes mellitus, poor glycemic control, plus pathophysiologic features associated with cystic fibrosis may have contributed to the development of microangiopathy. The use of steroids in 4 other patients and dextrose infusions (as part of hyperalimentation) in another 4 patients precipitated or exacerbated diabetes. The data indicate that diabetic microangiopathy can occur in the individual with cystic fibrosis. Routine screening for diabetes and its complications in the population with cystic fibrosis, as well as optimal control of hyperglycemia, is warranted.

The cytodiagnosis of well-differentiated neuroendocrine carcinoma. A distinct clinicopathologic entity

Well-differentiated neuroendocrine carcinoma (WDNE) has been recognized as a distinct variant of pulmonary neuroendocrine carcinoma, with characteristic histopathologic and clinical features that separate it from both carcinoid and small-cell carcinoma (SCC). Histologic review of tumors in long-term survivors (greater than two years) with an initial diagnosis of SCC has shown that the majority of these cases are, in fact, better classified as WDNE; the distinction of WDNE from SCC has, therefore, important prognostic and therapeutic implications. A retrospective review of 200 cytologies originally diagnosed as SCC was undertaken in an attempt to characterize the cytomorphologic features of WDNE. The cytologic criteria that distinguished cases of WDNE included polygonal-to-fusiform cells with a variable amount of lacy cytoplasm, oval nuclei with coarsely dispersed chromatin and frequent chromocenters, and mild nuclear and cytoplasmic anisomorphism. The majority of malignant cells were arranged either in acinarlike clusters or in epithelial sheets with evidence of palisading. Twenty-two cases were reclassified cytologically as WDNE and were accurately distinguished from all other neoplastic and SCC cases on repeated double-blind review. Clinical and histologic data confirmed the diagnosis of WDNE in all cases; it can be concluded that SCC and SDNE are cytologically distinct entities.

Isotypic and antigenic restriction of the blocking antibody response to ryegrass pollen: correlation of rye group I antigen-specific IgG1 with clinical response

To investigate the role of blocking antibodies in allergen immunotherapy (IT), we analyzed IgE, IgG, and IgG subclass 1 to 4 antibody responses to ryegrass group I antigen (RGGI) in a prospective double-blind, heterologous allergen, allergen-controlled trial of grass-pollen IT in 18 adults with seasonal rhinitis and asthma. Serum was assayed preseasonally before starting IT and again in midseason at time of documented highest natural exposure. Antibodies were measured by ELISA, and immunogenic specificities of ryegrass extract were examined by Western immunoblots. Nine subjects receiving grass-pollen IT and nine control subjects had similar clinical and immunologic status before IT. RGGI-specific IgE antibodies (sIgE) did not change from pretreatment levels in actively treated subjects but increased in control subjects (p less than 0.002). RGGI sIgG increased approximately thirteen-fold with active IT versus threefold during natural seasonal exposure (p less than 0.0005). The IgG-blocking response to RGGI was restricted to IgG1 and IgG4. Ten nonatopic subjects had similar RGGI sIgG1 but lower or undetectable sIgE and sIgG4 than the 18 atopic study subjects. Active IT dramatically increased RGGI sIgG4 (p less than 0.001) and to a lesser extent RGGI sIgG1 (p less than 0.01). Immunoblots demonstrated eight IgE-binding ryegrass-polypeptide allergens, with RGGI ubiquitous, and 11 IgG-binding polypeptides, including all eight allergens. A negative correlation between seasonal rhinitis symptom-medication scores and RGGI sIgG1 levels was found (r = -0.62, p less than 0.01), but no other immunologic parameters assayed were related to clinical improvement. Although RGGI sIgG4 predominates in the blocking response and is a useful marker of effective IT, early beneficial biologic effects may involve IgG1 antibodies.

Supraventricular tachycardia in patients with cystic fibrosis

Reports on arrhythmias in cystic fibrosis (CF) patients are limited. Four CF patients treated at our center had recurrent supraventricular tachycardia (SVT). Three had cor pulmonale, as evidenced by echocardiogram, and all had baseline tachycardia. Twenty-four hour Holter monitoring in three patients showed ectopic atrial pacing and premature atrial and ventricular contractions in one patient, rare PVCs in another, and SVT in all three. All patients had significant bronchospasm requiring the use of theophylline, prednisone, and frequent daily doses of beta-2 adrenergic agonists; two also used nebulized atropine. Average theophylline level for the group was 13.4 micrograms/ml during SVT. There was no correlation between pulmonary obstruction and the frequency of SVT. Factors such as cor pulmonale, ectopy, hypoxia, infection, intensive combination bronchodilator therapy, and corticosteroids probably interacted to precipitate SVT. Altered autonomic responses and a myocardial infiltrative process noted in some patients with CF may also play a role in causing arrhythmias.

Altered antibody isotype in cystic fibrosis: possible role in opsonic deficiency

Patients with cystic fibrosis (CF) whose respiratory tracts are colonized with Pseudomonas aeruginosa (PA) may develop a specific opsonic deficiency for alveolar macrophage phagocytosis of PA. We examined the possible role of altered antibody (Ab) isotype in this phenomenon by measuring serum levels and distribution of IgG and IgG subclass Ab (IgG1, IgG2, IgG3, and IgG4) to the major opsonic immunodeterminant, serotype-specific lipopolysaccharide (LPS), by means of enzyme-linked immunosorbent assays employing monoclonal secondary antibodies, and comparing these results to the serum opsonic capacity in an in vitro murine alveolar macrophage phagocytic assay. Twenty-one patients with CF who were colonized with PA had approximately a 30-fold elevation of PA LPS IgG Ab levels and higher IgG subclass 1-4 Ab compared to 10 uncolonized patients with CF and 11 healthy controls (p less than 0.05-0.0005 depending on the isotype). Colonized patients with CF had a shift in PA LPS Ab distribution toward IgG3 compared to uncolonized patients with CF (p less than 0.02). A surprising finding was that uncolonized patients with CF had lower levels (p less than 0.05) and proportion (p less than 0.002) of PA LPS IgG2 Ab than controls, with an apparent shift to higher levels and proportion of PA LPS IgG4 (p less than 0.01). Serum from colonized patients with CF showed diminished opsonic capacity for phagocytosis of PA compared to uncolonized patients and controls (p less than 0.005), with 42% showing inhibitory activity. Functional Ab was also found to be inhibitory at high (greater than 500 ng/ml) concentrations. Serum opsonic capacity appeared to include a noncomplement cofactor for optimal activity.(ABSTRACT TRUNCATED AT 250 WORDS)

CT-guided stereotactic biopsy of intracranial lesions: correlation between core biopsy and aspiration smear

Computerized tomography (CT)-guided stereotactic biopsies of intracranial lesions in 29 patients were analyzed, paying particular attention to the correlation between core biopsies and aspiration smears. Seven percent were nondiagnostic due to sampling error. Discrepancies occurred between core biopsies and aspiration smears in 10% of the cases. In two instances of such discrepancies, cytologic findings on the aspiration smear yielded the diagnosis of metastatic tumor. One patient, with herpetic encephalitis, was diagnosed by electron microscopic review of the core biopsy only. One patient died of an intraoperative hemorrhage, a complication of the fine-needle technique.

Limitations and value of aspiration cytology

The successes of aspiration cytology have enhanced its popularity over the past few years. Now the limitations of the technique are becoming apparent. This article reviews the uses and contraindications for the detection of benign and malignant lesions in various body sites.

Investigation with tritiated thymidine of the relationship between the sex chromosomes, sex chromatin, and the drumstick in the cells of the female nine-banded armadillo, Dasypus novemcinctus

The functional analogies between the sex chromosomes, sex chromatin, and the drumstick in the cells of the female nine-banded armadillo (<i>Dasypus no&#965;emcinctus</i>) were investigated utilizing tritium labelled thymidine both <i>in vitro </i>and <i>in vivo</i>. Tissue culture studies demonstrated that one of the female X chromosomes is asynchronous and synthesizes DNA later than the other X and most of the autosomal complement. In interphase nuclei a peripheral focus of heavier labelling was found overlying the Barr body, indicating that the sex chromatin is formed by a great part or all of the late replicating X chromosome. Localized labelling was also observed over several drumsticks in studies performed <i>in vivo </i>supporting the view that a relationship exists between the drumstick and the asynchronous X chromosome.