Colonization and decolonization of global health: which way forward?

Despite taking on several forms throughout history such as colonial medicine, tropical medicine, and international health, the field of global health continues to uphold colonialist structures. History demonstrates that acts of colonialism inevitably lead to negative health outcomes. Colonial powers promoted medical advancements when diseases affected their own people, and only did so for locals when in the colonies' best interests. Numerous medical advancements in the United States also relied on the exploitation of vulnerable populations. This history is critical in evaluating the actions of the United States as a proclaimed leader in global health. A significant barrier to progress in the field of global health is that most leaders and leading institutions are located in high-income countries, thereby defining the global standard. This standard fails to meet the needs of most of the world. In times of crisis, such as the COVID-19 pandemic, colonial mentalities may be more evident. In fact, global health partnerships themselves are often ingrained in colonialism and may be counterproductive. Strategies for change have been called into question by the recent Black Lives Matter movement, particularly in evaluating the role that less privileged communities should have in their own fate. Globally, we can commit to evaluating our own biases and learning from one another.

Transforming medical education in Liberia through an international community of inquiry

A critical component of building capacity in Liberia's physician workforce involves strengthening the country's only medical school, A.M. Dogliotti School of Medicine. Beginning in 2015, senior health sector stakeholders in Liberia invited faculty and staff from U.S. academic institutions and non-governmental organizations to partner with them on improving undergraduate medical education in Liberia. Over the subsequent six years, the members of this partnership came together through an iterative, mutual-learning process and created what William Torbert et al describe as a "community of inquiry," in which practitioners and researchers pair action and inquiry toward evidence-informed practice and organizational transformation. Incorporating faculty, practitioners, and students from Liberia and the U.S., the community of inquiry consistently focused on following the vision, goals, and priorities of leadership in Liberia, irrespective of funding source or institutional affiliation. The work of the community of inquiry has incorporated multiple mixed methods assessments, stakeholder discussions, strategic planning, and collaborative self-reflection, resulting in transformation of medical education in Liberia. We suggest that the community of inquiry approach reported here can serve as a model for others seeking to form sustainable global health partnerships focused on organizational transformation.

How Sanctions Have Impacted Iranian Healthcare Sector: A Brief Review

Many studies have shown the crippling effects of sanctions on the healthcare sector of different countries, including Iran. Long-standing sanctions against Iran escalated recently and severely limited commercial activities with Iran. The devastating consequences of these embargoes have affected all aspects of health care delivery in Iran, limiting the availability of critical medicines and medical devices, and negatively impacting primary health care, treatment of complex diseases including cancer, medical tourism, and medical education and research. The present novel coronavirus disease 2019 (COVID-19) pandemic has uncovered this long-standing crisis in the Iranian health care sector. In this communication, we briefly discuss selected aspects of these sanctions and their impact on the health care system and people of Iran during this critical time.

Pregnancy and Calving Rates of Cloned Dromedary Camels Produced by Conventional and Handmade Cloning Techniques and In Vitro and In Vivo Matured Oocytes

Despite practical implication of cloning in camelids, its broad application has been hampered by technical and biological problems. Method of somatic cell nuclear transfer (SCNT) and oocyte competence are the principal technical and biological factors, respectively, that determine the cloning efficiency. This study, therefore, investigated differential contributions of two SCNT methods [modified handmade cloning (mHMC) vs. conventional (cNT)] and two recipient oocyte sources [abattoir-derived (Vitro) vs. FSH-stimulated (Vivo)] on the efficiency of dromedary camel cloning. The mHMC method supported similar rates of fusion, cleavage, and total blastocyst development, compared to conventional NT (cNT) (94, 89.1, and 68.5% vs. 78.9, 92, and 73.5%, respectively) when Vivo oocytes are used. However, using Vitro oocytes, mHMC supported significantly higher rates for these criteria, except for the cleavage, compared to cNT (95.5, 76.2, 25.2% vs. 75.3, 76.7, and 13.9%, respectively). A total of seven clones were born from mHMC/Vitro (four calves), mHMC/Vivo (one calf), cNT/Vitro (one calf), and mHMC/Vivo&Vivo (one calf)-derived embryos with overall efficiencies of 31.9, 26.6, 20, and 30% for initial pregnancy, 10.6, 6.6, 7.5, and 5% for development to term, and 8.5, 6.6, 2.5, 5% for development to weaving, respectively. To conclude, the quality of recipient oocyte greatly impacts cloning efficiency in vitro with no apparent carrying over effect on cloning efficiency in vivo, but the efficiency of SCNT method may compensate for the initial poor oocyte competence during in vitro and in vivo development of cloned embryos. The introduced mHMC could be a superior alternative to conventional method for simple, fast, and efficient production of cloned offspring in camelids.

Challenges in the Recognition and Management of Acute Kidney Injury by Hospitals in Resource-Limited Settings

Introduction

Acute kidney injury (AKI) is prevalent in low- and middle-income countries (LMIC) and is associated with significant morbidity and mortality, particularly among hospitalized patients. Successful strategies for the prevention and management of AKI in these countries are dependent on the capacity of primary care centers to provide optimal initial management of patients at risk for this disorder.

Methods

From December 2018 to February 2019, using mixed methods, we assessed hospital capacity and the knowledge of clinicians relevant to the prevention, diagnosis, and management of AKI in Rwanda. A checklist based on Kidney Disease: Improving Global Outcomes (KDIGO) guidelines and clinical vignette-based assessment tool were used to assess hospital capacity and provider knowledge base, respectively. Data were analyzed using stata 13 with findings reported as simple frequencies or means with standard deviation. Multivariate analysis was used to assess factors associated with a higher knowledge score among clinicians.

Results

Ten hospitals and 193 health care providers from sites throughout Rwanda participated in the survey. Surveyed hospitals were equipped with basic general medical equipment but were deficient in diagnostic tools and medical supplies that would allow the diagnosis and nondialytic management of AKI. Although 20% of the hospitals could offer hemodialysis services, peritoneal dialysis services were nonexistent. With regard to knowledge base, the health care providers demonstrated significant deficiencies in the diagnosis and management of AKI. The mean knowledge score for all health providers was 6.3 (±1.5) of a maximum of 11, with a mean (±SD) score for doctors, nurses, and midwives of 6.3 ± 2.05, 6.4 ± 1.3, and 6.08 ± 1.2, respectively. On multivariate analysis, the length of clinical experience and age of the respondents were significantly associated with participants’ knowledge score.

Conclusion

This study documents significant barriers to providing optimal management of AKI in primary health care settings in Rwanda, a resource-limited setting. These include lack of specialized medical personnel, significant knowledge gaps among primary health care providers, suboptimal diagnostic capacity, and limited treatment options for detection and management of AKI.

Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study

BACKGROUND

Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda.

METHODS AND RESULTS

The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13-122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections.

CONCLUSION

Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

BACKGROUND

The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda.

METHODS

The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors.

RESULTS

In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions.

CONCLUSION

The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

Developing medical education capacity in Russia: twenty years of experience

BACKGROUND

The partnership between Yale University (USA) and Kazan State Medical University (KSMU, Russia) was established in 1996 and transitioned to Western Connecticut Health Network (WCHN)/University of Vermont Robert Larner, M.D. College of Medicine (USA) in 2012 with the goal of modernizing medical education at KSMU primarily through introduction of the American medical education structure, role modeling, and educational capacity building. It was centered on the formation of a select group of Russian junior faculty members familiar with American medical education who would then initiate a gradual change in medical education at KSMU. Here we describe the 20 year partnership, rooted in local capacity building, through which a sustainable, mutually rewarding international collaboration was established. In addition, we evaluate the program's outcomes and impact on medical education at Kazan State Medical University, and assess its influence on Russian program participants.

METHODS

Senior residents and faculty were sent to KSMU to conduct teaching sessions with local faculty and trainees. Their responsibilities included familiarizing Russian colleagues with specific topics in clinical medicine, importing knowledge about the basics of teaching, clinical epidemiology and evidence based medicine, and creating, in consistency with the American model, a "Clinical Teaching Team Structure" that integrates patient care with clinical education. Furthermore, 44 of selected KSMU members, including 13 junior faculty (29.5%), 14 clinical PhD students (31.8%), 12 interns/residents (27.3%), and five medical students (11.4%), were trained at Yale/WCHN or one of their major affiliated community hospitals for a period of 1 to 12 months for a total of 844 participant-weeks of training.

RESULTS

Thirty (68.2%) individuals who were trained in the U.S. are currently working in Kazan primarily as faculty at KSMU. Among them, three trainees (10%) have become heads of their department, eight (26.7%) hold senior faculty positions, and two (6.7%) have clinical and educational administrative leadership positions. Two major clinical departments have adopted the "Clinical Teaching Team Structure." As a result of the collaboration, three teaching courses - Evidence-Based Medicine, Tropical Medicine, and HIV/AIDS Medicine - have been designed and incorporated into the curriculum.

CONCLUSION

This partnership has been instrumental in introducing the American medical education model and expanding the medical knowledge of faculty, residents, and students of KSMU on infectious diseases, HIV/AIDS, tropical medicine, renal diseases, and global health topics. Capacity building through the Yale/WCHN-KSMU exchange program has greatly contributed to the quality of medical education at Kazan State Medical University.

Implementation of Patient-Centered Education for Chronic-Disease Management in Uganda: An Effectiveness Study

BACKGROUND

The majority of non-communicable disease related deaths occur in low- and middle-income countries. Patient-centered care is an essential component of chronic disease management in high income settings.

OBJECTIVE

To examine feasibility of implementation of a validated patient-centered education tool among patients with heart failure in Uganda.

DESIGN

Mixed-methods, prospective cohort.

SETTINGS

A private and public cardiology clinic in Mulago National Referral and Teaching Hospital, Kampala, Uganda.

PARTICIPANTS

Adults with a primary diagnosis of heart failure.

INTERVENTIONS

PocketDoktor Educational Booklets with patient-centered health education.

MAIN MEASURES

The primary outcomes were the change in Patient Activation Measure (PAM-13), as well as the acceptability of the PocketDoktor intervention, and feasibility of implementing patient-centered education in outpatient clinical settings. Secondary outcomes included the change in satisfaction with overall clinical care and doctor-patient communication.

KEY RESULTS

A total of 105 participants were enrolled at two different clinics: the Mulago Outpatient Department (public) and the Uganda Heart Institute (private). 93 participants completed follow up at 3 months and were included in analysis. The primary analysis showed improved patient activation measure scores regarding disease-specific knowledge, treatment options and prevention of exacerbations among both groups (mean change 0.94 [SD = 1.01], 1.02 [SD = 1.15], and 0.92 [SD = 0.89] among private paying patients and 1.98 [SD = 0.98], 1.93 [SD = 1.02], and 1.45 [SD = 1.02] among public paying patients, p<0.001 for all values) after exposure to the intervention; this effect was significantly larger among indigent patients. Participants reported that materials were easy to read, that they had improved knowledge of disease, and stated improved communication with physicians.

CONCLUSIONS

Patient-centered medical education can improve confidence in self-management as well as satisfaction with doctor-patient communication and overall care in Uganda. Our results show that printed booklets are locally appropriate, highly acceptable and feasible to implement in an LMIC outpatient setting across socioeconomic groups.

Medical Education Capacity-Building Partnerships for Health Care Systems Development

Health care workforce development is a key pillar of global health systems strengthening that requires investment in health care worker training institutions. This can be achieved by developing partnerships between training institutions in resource-limited and resource-rich areas and leveraging the unique expertise and opportunities both have to offer. To realize their full potential, however, these relationships must be equitable. In this article, we use a previously described global health ethics framework and our ten-year experience with the Makerere University-Yale University (MUYU) Collaboration to provide an example of an equity-focused global health education partnership.

Heterogeneity in resistant fecal Bacteroides fragilis group collected from healthy people

Normal nonpathogenic flora would represent a constant lake of resistance genes potentially transferable to human pathogens. To assess the prevalence of resistance genes and genetic variability of Bacteroides fragilis group (BFG) from normal flora, 177 Bacteroides isolates obtained from the fecal samples of healthy individuals. These isolates were subjected to antibiotic susceptibility testing and pulsed field gel electrophoresis (PFGE). The isolates were further tested for the presence of ermF, tetQ and bft genes by PCR. Our results indicated the presence of different clonal strains (1 common type and 57 single types) among the resistant isolates. The resistance rate for the six antibiotics in this study was between 1% and 95%. Most of the isolates (99%) were susceptible to metronidazole. ermF and tetQ were detected in all erythromycin and tetracycline resistant isolates. None of the isolates were carried bft gene. These data suggest dissemination of heterogenic clonal groups in healthy persons and resistance to 5 high commonly used antibiotics.

Rational fluid therapy for sepsis and septic shock; what do recent studies tell us?

Sepsis and septic shock persist as major healthcare challenge, with high morbidity and mortality. Fluid management is a large part of the treatment in patients with these disorders. Fluid therapy has been an important component of the care of patients for the past century. However, recently well-designed studies have been published focusing on the impact of the type and amount of fluids on important clinical outcomes. This review summarizes all the relevant recent studies and attempts to develop a rational approach to the initial fluid management of patients with suspected sepsis.

Adipsic hypernatremic myopathy

Chronic hypernatremia due to adipsia is very rare and occasionally presents with muscle weakness and rhabdomyolysis. We report a patient with chronic hypernatremia without thirst sensation who presented with muscle weakness and was treated successfully with prescribed water intake.

Use of anion gap in the evaluation of a patient with metabolic acidosis

High anion gap (AG) metabolic acidosis, a common laboratory abnormality encountered in clinical practice, frequently is due to accumulation of organic acids such as lactic acid, keto acids, alcohol metabolites, and reduced kidney function. The cause of high AG metabolic acidosis often is established easily using historical and simple laboratory data. Despite this, several challenges in the diagnosis and management of high AG metabolic acidosis remain, including quantifying the increase in AG, understanding the relationship between changes in AG and serum bicarbonate level, and identifying the cause of high AG metabolic acidosis when common causes are ruled out. The present case was selected to highlight the importance of the correction of AG for serum albumin level, the use of actual baseline AG rather than mean normal AG, the relationship between changes in serum bicarbonate level and AG, and a systematic diagnostic approach to uncommon causes of high AG metabolic acidosis, such as 5-oxoproline acidosis (pyroglutamic acidosis).

Djenkolism: case report and literature review

Djenkolism is an uncommon but important cause of acute kidney injury. It sporadically occurs after an ingestion of the djenkol bean (Archidendron pauciflorum), which is native to Southeast Asia. The clinical features defining djenkolism include: spasmodic suprapubic and/or flank pain; urinary obstruction; and acute kidney injury. The precise pathogenesis of acute kidney injury following djenkol ingestion remains unknown. However, it is proposed that an interaction between the characteristics of the ingested beans and the host factors causes hypersaturation of djenkolic acid crystals within the urinary system, resulting in subsequent obstructive nephropathy with sludge, stones, or possible spasms. We report a case of djenkolism from our rural clinic in Borneo, Indonesia. Our systematic literature review identified 96 reported cases of djenkolism. The majority of patients recovered with hydration, bicarbonate therapy, and pain medication. Three patients required surgical intervention; one patient required ureteral stenting for the obstructing djenkolic acid stones. Four of the 96 reported patients died from acute kidney failure. We stress the importance of awareness of djenkolism to guide medical practitioners in the treatment of this rare disease in resource-poor areas in Southeast Asia.

Short-term global health research projects by US medical students: ethical challenges for partnerships

Recent interest in global health among medical students has grown drastically, and many students now spend time abroad conducting short-term research projects in low-resource settings. These short-term stints in developing countries present important ethical challenges to US-based students and their medical schools as well as the institutions that host such students abroad. This paper outlines some of these ethical issues and puts forth recommendations for ethically mindful short-term student research.

Clinical utility of Stewart's method in diagnosis and management of acid-base disorders

For the past 5 decades, a bicarbonate-based approach has been the dominant method used for the diagnosis and treatment of acid-base disorders. This approach, however, has been criticized by some as (1) qualitative and not quantitative in nature and (2) incapable of detecting important diagnoses. Stewart, using principals of electroneutrality and conservation of mass, developed a "new" approach to the diagnosis and management of these disorders. The proponents of Stewart's approach believe that it not only offers a mechanistic explanation for the disorders but also provides the tool to make a more accurate diagnosis. Although Stewart's approach has been largely ignored by nephrologists and renal physiologists, it is increasingly used by anesthesiologists and intensivists. This review discusses the clinical utility of Stewart's method compared with the traditional bicarbonate-based approach. Although Stewart's method proposes a different, however not new, approach, it does not improve our ability to diagnose more accurately or manage these disorders. Stewart's method also does not provide the tool to prognosticate any better than the traditional method.

Physician and practice characteristics influencing tumor board attendance: Results from the provider survey of the Los Angeles Women's Health Study

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Background: Coordination of care has grown in importance with the advent of new modalities of treatment requiring specialized expertise. In cancer care, multidisciplinary approaches have shown improvements in quality of care and patient satisfaction. Tumor boards provide a mechanism for improving coordination of care. We evaluated physician and practice characteristics that predict frequency of tumor board attendance. Methods: This cross-sectional study utilizes data obtained by surveying physicians of a population-based sample of women with incident breast cancer. Physicians were queried regarding tumor board attendance, specialty (medical oncologist [MO], radiation oncologist [RO], surgeon indicating that the hospital at which most breast cancer surgeries are performed has an American College of Surgeons accredited program [ACOSSg] and surgeon without such affiliation [non-ACOSSg]), physician characteristics (gender, race, teaching involvement, patient volume, number of offices, ownership interest), and practice setting (practice type, size, reimbursement). Univariate, bivariate, and multivariate analyses were performed for the dependent variable characterizing provider report of frequency of tumor board meeting attendance. Results: Most surveyed physicians (83%) report attending tumor board weekly (58%) or monthly (25%). Weekly participation was reported by 63%, 92%, 47%, and 32% of MOs, ROs, ACOSSgs, and non-ACOSSgs (p < 0.01). Specialty and higher patient volumes are significant predictors of more frequent attendance, after adjustment for practice size and type. In comparison to the most prevalent specialty category (low volume ACOSSgs), high volume MOs attend more (p = 0.01), and low volume non-ACOSSgs attend less frequently (p = 0.00). Conclusions: Tumor board attendance implies increased participation in multidisciplinary care, but specific subsets of providers are less frequent users. This not only has implications for choosing providers, but also for efforts to increase attendance. Tumor board agendas and formalized institution wide policies could be designed to further engage low frequency attendees as a means to promote multidisciplinary care and improve health outcomes.

[Table: see text]

New concepts in pathogenesis of renal hypophosphatemic syndromes

During the past decades, our knowledge of renal phosphate handling has advanced dramatically. This advance is primarily due to the discovery of sodium-phosphate transport channels and their regulation in health and disease. The discovery of phosphatonins, initially in patients with tumor-induced osteomalacia, has not only allowed us to develop a better understanding of several rare diseases including vitamin D-resistant rickets, but also it has expanded our knowledge of the dynamic interaction between the bone and the kidney critical to bone mineralization. In this review, the author focuses on these new developments and their importance to our understanding of phosphate homeostasis in health and disease.

Use of the ΔAG/ΔHCO3− Ratio in the Diagnosis of Mixed Acid-Base Disorders: Figure 1

When a strong acid is added to plasma, one expects a quantitative relationship between excess anion gap (DeltaAG) and bicarbonate deficit (DeltaHCO(3)(-)) with the DeltaAG/DeltaHCO(3)(-) ratio close to unity. If true, then this ratio could be used to diagnose mixed acid-base disorders in patients with metabolic acidosis. Although the mean ratio in selected patients is close to unity, this ratio also has a wide range, making its use in individual patients problematic. The ratio should therefore be used cautiously in making a diagnosis of mixed acid-base disorders.

The craft of writing: a physician-writer's workshop for resident physicians

INTRODUCTION

How can residency programs help trainees address conflicting emotions about their professional roles and cultivate a curiosity about their patients' lives beyond their diseases? We drew on the medical humanities to address these challenges by creating an intensive writing workshop for internal medicine residents.

AIM

To help participants become better physicians by reflecting on their experiences and on what gives meaning to work and life. This paper describes the workshop and how residents were affected by the focus on the craft of writing.

SETTING

A group of 15 residents from 3 training programs affiliated with 1 institution.

PROGRAM DESCRIPTION

We engaged the expertise of physician-writer Abraham Verghese in planning and facilitating the 2 and one-half day workshop. Residents' submissions were discussed with a focus on the effectiveness of the writing. We also conducted a focus group with participants to evaluate the workshop.

PROGRAM EVALUATION

Themes in the writing included dysphoria, impotence of the physician, and the healing power of compassion. Our focus group data suggested that this workshop served as a creative outlet from the rigors of medicine, created a sense of community among participants, enhanced both self-awareness and awareness of their patients' lives, and increased intra-institutional and extra-institutional interest in writing and the residency program.

DISCUSSION

Teaching creative writing to residents in an intensive workshop may deepen interactions with peers and patients, improve writing skills, and increase interest in writing and the residency program.

How do women make decisions about hormone replacement therapy?

Although clinicians are often expected to include patients in medical decision making, there is little data to assist clinicians in this process. The objective of this study was to investigate how patients make decisions and the role clinicians can play in this process in the context of how women decide about hormone replacement therapy.Twenty-three women who were deciding whether to take hormone replacement therapy, but who had not begun treatment, were interviewed individually using a semistructured protocol with open-ended questions. The interviews were audiotaped, transcribed, and converted into a database. The transcripts were labeled according to their content, and the database was used to identify common themes. The content of the women's statements were organized into nine descriptive categories. A common set of processes involved in patient decision making was identified and organized into a model of patient decision making. Four areas where clinicians might influence or assist patients in making decisions include the provision of information, the process by which patients selectively pay attention to some information, the patients' perception of their own health, and the patients' development of an explanatory narrative. This new model describes some of the complexity of the patient decision-making process and contributes to our understanding of the clinician's role. To examine its generalizability, the model should be tested on other types of patients making other medical decisions.

The care of HIV-infected adults in rural areas of the United States

OBJECTIVE

This study describes the population of HIV-infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas.

METHODS

Interviews were conducted with a nationally representative sample of 367 HIV-infected adults receiving health care in rural areas and 2806 HIV-infected adults receiving health care in urban areas of the contiguous United States.

RESULTS

We estimate that 4800 HIV-infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV-infected patients (38% vs. 3%; p <.001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p <.001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p =.006).

CONCLUSIONS

Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high-quality HIV care.

Hypokalaemia and hyperkalaemia

Disturbances in potassium homoeostasis presenting as low or high serum potassium are common, especially among hospitalised patients. Given the fact that untreated hypokalaemia or hyperkalaemia is associated with high morbidity and mortality, it is critical to recognise and treat these disorders promptly. In this article, normal potassium homoeostasis is reviewed initially and then a pathophysiological approach to work-up and management of hypokalaemia and hyperkalaemia is presented. Recent advances with respect to the role of kidney in handling of the potassium, the regulation of renal ion transporters in hypokalaemia, and treatment of hypokalaemia and hyperkalaemia will be discussed.

Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States

BACKGROUND

Little is known about the rates of Mycobacterium avium complex (MAC) and Pneumocystis carinii (PCP) prophylaxis adherence to guidelines and how they have changed after introduction of effective antiretroviral therapy.

OBJECTIVE

To determine rates of primary prophylaxis for MAC and PCP and to evaluate the influence of sociodemographic characteristics, region, and provider experience.

DESIGN

National probability sample cohort of HIV patients in care.

SETTING

One hundred sixty HIV health care providers.

PATIENTS

A total of 2864 patients interviewed in 1996 to 1997 (68% response) and 2267 follow-up interviews, representing 65% of surviving sampled patients (median follow-up, 15.1 months).

MEASUREMENTS

Use of prophylactic drugs, most recent CD4 count, sociodemographics, and regional and total HIV patients/providers.

RESULTS

Of patients eligible for primary MAC prophylaxis (most recent CD4 count <50/mm(3) ), 41% at baseline and 40% at follow-up patients were treated. Of patients eligible for primary PCP prophylaxis (i.e., those with CD4 counts <200/mm(3) ), 64% and 72% were treated, respectively. MAC prophylaxis at baseline was less likely in African American (adjusted odds ratio [OR], 35; 95% confidence interval [CI], 0.20-0.59), Hispanic (OR, 27; 95% CI, 0.08-0.94) and less-educated (OR, 0.61; 95% CI, 0.36-1.0) patients and more likely in U. S. geographic regions in the Pacific West (OR, 4.9; 95% CI, 1.0-23) and Midwest (OR, 6.4; 95% CI, 1.2-33) and in practices with more HIV patients.

CONCLUSIONS

Most eligible patients did not receive MAC prophylaxis; PCP prophylaxis rates were better but still suboptimal. Our results support outreach efforts to African Americans, Hispanics, the less educated, and those in the northeastern United States and in practices with fewer HIV patients.

Expenditures for the care of HIV-infected patients in the era of highly active antiretroviral therapy

BACKGROUND

The introduction of expensive but very effective antiviral medications has led to questions about the effects on the total use of resources for the care of patients with human immunodeficiency virus (HIV) infection. We examined expenditures for the care of HIV-infected patients since the introduction of highly active antiretroviral therapy.

METHODS

We interviewed a random sample of 2864 patients who were representative of all American adults receiving care for HIV infection in early 1996, and followed them for up to 36 months. We estimated the average expenditure per patient per month on the basis of self-reported information about care received.

RESULTS

The mean expenditure was $1,792 per patient per month at base line, but it declined to $1,359 for survivors in 1997, since the increases in pharmaceutical expenditures were smaller than the reductions in hospital costs. Use of highly active antiretroviral therapy was independently associated with a reduction in expenditures. After adjustments for the interview date, clinical status, and deaths, the estimated annual expenditure declined from $20,300 per patient in 1996 to $18,300 in 1998. Expenditures among subgroups of patients varied by a factor of as much as three. Pharmaceutical costs were lowest and hospital costs highest among underserved groups, including blacks, women, and patients without private insurance.

CONCLUSIONS

The total cost of care for adults with HIV infection has declined since the introduction of highly active antiretroviral therapy. Expenditures have increased for medications but have declined for other services. However, there are large variations in expenditures across subgroups of patients.

Chronic renal failure in Iranian children

We investigated chronic renal failure (CRF) in 166 Iranian children (95 boys and 71 girls) from July 1991 to June 1999. The mean age at onset of CRF was 7.9+/-4.5 years. The most common cause of CRF was congenital urological malformations (78 cases). The second most common cause of CRF was hereditary nephropathy (21%). Glomerular diseases accounted for only 10% of children who later went on to develop renal failure. High rates of cystinosis and primary hyperoxaluria were seen, and these elevated rates could be due to a high prevalence of parental consanguinity. Eighty-six patients required renal replacement therapy, of whom the majority underwent hemodialysis. The prevalence of primary reflux as a cause of CRF was high compared with reports from western countries. Earlier diagnosis and management of urinary tract infections in this group could reduce the prevalence of reflux as a cause of CRF in this population.

Lactic acidosis in the setting of antiretroviral therapy for the acquired immunodeficiency syndrome. A case report and review of the literature

Type B lactic acidosis, a rare but often fatal disorder, has been reported in 21 AIDS patients on antiretroviral therapy (ART). We present an AIDS patient with severe and prolonged lactic acidosis on stavudine and lamivudine. The lactic acidosis occurred in the absence of mitochondrial myopathy, hepatomegaly, or liver failure. This is the second report of lactic acidosis in a patient on stavudine and lamivudine. This patient recovered after aggressive supportive therapy including intravenous alkali and fluid administration as well as continuous venovenous hemodiafiltration. A single dose of dichloroacetate (DCA) was associated with a decrease in the serum lactate level by 20%, which persisted for more than 24 h. Seventeen months after recovery, the patient was rechallenged with ART without recurrence of lactic acidosis. We review and summarize all reported cases of patients with ART-associated lactic acidosis reported in the English literature.

Alignment of liquid crystals on a photosensitive substrate studied by surface optical second-harmonic generation

The adsorption kinetics and orientational ordering of 4(')-n-octyl-4-cyanobiphenyl (8CB) liquid crystal films evaporated onto photosensitive poly(vinyl-cinnamate) (PVCN) substrates were investigated by surface optical second-harmonic generation. The adsorption rate of the first monolayer decreases with increasing degree of photochemical modification of the polymer. The in-plane orientational anisotropy of the 8CB films grown on unidirectionally photopolymerized PVCN substrates is considerably lower than the intrinsic surface orientational anisotropy of these substrates, which can explain the generally found weak surface anchoring of liquid crystals on PVCN alignment layers.

Lifshitz point in the phase diagram of a ferroelectric liquid crystal in an external magnetic field

The Lifshitz point in the (H,T) phase diagram of a ferroelectric liquid crystal in a transverse magnetic field has been determined using photon correlation spectroscopy and linear electrooptic response measurements. The extrapolated Lifshitz magnetic field is 25(1+/-0.1) T for a smectic-C* material with an unperturbed helical period of approximately 6 &mgr;m, and the Lifshitz point is located approximately 100 mK above the zero-field transition temperature. We have observed the reentrant helical modulated smectic-C* phase just below the lambda line. The width of this phase is 100 mK at the low temperature critical field H(c) and decreases continuously to zero as we approach the Lifshitz point. The phase boundary between the reentrant phase and the smectic-A phase is of second order, whereas the phase boundary with the unwound smectic-&Cmacr;(*) phase is of first order far away from the Lifshitz point and becomes of second order close to the Lifshitz point. The order parameter dynamics is discussed within the Landau theory.

Slow mode of the smectic-A-smectic-C(*)(alpha) phase transition

Unusual slow fluctuations as revealed recently by dynamic light scattering close to the Sm-A-Sm-C(alpha)(*) phase transition in the antiferroelectric liquid crystal 4-(1-methylheptyloxy-carbonyl)phenyl 4(')-octyloxy biphenyl-4-carboxylate can be explained by the electrostatic coupling between impurity ions and director fluctuations. Within the vicinity of Sm-A-Sm-C(alpha)(*) transition, the relaxation rate of the slow mode depends linearly on temperature, but with a different slope in each phase. The square root of its intensity shows a clear Curie-Weiss divergence at the phase transition, which is a direct confirmation of the electrostatic coupling mechanism.

Characterization of unidirectional photopolymerization in poly(vinyl cinnamate) by surface optical second-harmonic generation

Surface optical second-harmonic generation measurements were used to determine the change in the surface density and the surface orientational order parameter of the trans-cinnamoyl side groups of unidirectionally photopolymerized poly(vinyl cinnamate) (PVCN) films. The observed surface features were compared to the bulk properties of the films, which were probed by their UV absorption spectra and birefringence measurements. We found that the surface and the bulk photoreaction kinetics of the trans cinnamoyl side groups of the PVCN are very similar. The two photoreaction processes (trans-cis photoisomerization and photo-induced cross linking) appear to affect the linear and nonlinear optical properties of the polymer differently. This may explain the discrepancy between the birefringence and the azimuthal anchoring force of the unidirectionally photopolymerized PVCN.

Suggested guidelines for treatment of acute renal failure in earthquake victims

The 1990 Iran earthquake affected two states with a combined population of 2,300,000. It resulted in at least 13,888 deaths, 43,390 injured, and 33,616 hospitalized. The overall mortality among hospitalized patients was 0.17%. Acute renal failure (ARF) requiring dialysis support was diagnosed in 156 patients nationwide, with a mortality rate of 14%. Three teaching hospitals of Tehran University of Medical Sciences (UMS) admitted 495 patients, with total mortality of 7.5%. Of these, 30 patients (6%) required dialysis, with a mortality of 40%, accounting for 12 of the deaths. On admission, patients with ARF were more severely injured and had significantly higher incidence of multiple trauma; peripheral nerve injury; elevated muscle enzymes, potassium, and phosphorus; and abnormal urinalysis. In one of these hospitals, patients were treated with a specific hydration protocol coupled with a cautious approach to fasciotomy. The incidence of ARF, mortality associated with ARF, and fasciotomy were lower in this group. Based on these findings, guidelines are suggested that may be helpful in the treatment of ARF in earthquake victims.