Use of community-based participatory research in primary care to improve healthcare outcomes and disparities in care

Community-based participatory research (CBPR) has emerged to bridge the gap between research and primary-care practice through community engagement and social action to increase health equity. It is widely acknowledged that access to high-quality primary care services is important to the overall health of a community. Here, CBPR studies in a primary care setting are reviewed to assess the use of CBPR associated with common health problems seen in primary care such as access to care and disparities in chronic disease management across vulnerable populations. CBPR involves building relationships with local communities, determining areas of need and establishing priorities for health concerns. Studies showing improved access to care for a Hispanic population, reduced asthma symptoms and weight loss are highlighted.

Post-ovulatory aging of mouse oocytes leads to decreased MAD2 transcripts and increased frequencies of premature centromere separation and anaphase

Numerous cytological and biochemical alterations occur as mammalian oocytes age post-ovulation. Some of these changes can predispose cells to aneuploidy. The objective of this study was to test the hypothesis that the level of MAD2 spindle assembly checkpoint (SAC) transcripts decrease as mouse oocytes age post-ovulation and that this decrease was associated with chromosome missegregation. Female Institute of Cancer Research (ICR) mice were superovulated and oocytes collected at 14 h, 19 h and 24 h post-HCG for cytogenetic and quantitative real-time rapid cycle fluorescent RT-PCR analyses. Premature centromere separation (PCS) is now generally recognized as a predisposition to aneuploidy. The data showed that the frequencies of PCS-incomplete (PCS-I) did not significantly (P > 0.05) increase with time post-ovulation; whereas the proportions of oocytes displaying PCS-complete (PCS-C) and premature anaphase (PA) were significantly (P < 0.01) greater at 19 h and 24 h post-HCG, respectively. The higher frequencies of PCS-C and PA found at 19 h and 24 h coincided with decreased levels of MAD2 transcripts at these same times. Although the decline in MAD 2 transcripts with oocyte aging represents only one of many potential mechanisms responsible for aneuploidy, a compromised SAC appears to have a role in the unfavourable reproductive outcome associated with post-ovulatory aged oocytes.

A prospective study of endoscopy in HIV-associated diarrhea

OBJECTIVE

Diarrhea commonly occurs in persons with human immunodeficiency virus (HIV) infection. The optimal use of endoscopic procedures remains poorly studied for patients with HIV-related diarrhea. The purpose of this study is to compare the diagnostic yield of a complete endoscopic work-up including an esophagogastroduodenoscopy and colonoscopy to a more limited approach of biopsies obtainable by flexible sigmoidoscopy.

METHODS

A prospective study of 79 patients with HIV-related diarrhea. Upper endoscopy and colonoscopy were performed with tissue biopsies labelled according to location within the colon or small intestine.

RESULTS

A new infection was diagnosed in 22 of 79 patients (28%). Biopsy of the left colon yielded an enteric pathogen in 17 of 22 patients (sensitivity: 77%) and in 15 of 15 patients with cytomegalovirus colitis (sensitivity: 100%). Combined left and right colonic biopsies had a sensitivity of 82%. Combined colonic and terminal ileum biopsies missed no pathogens. Duodenal biopsies yielded no additional pathogens beyond those identified by colonoscopy and terminal ileal biopsy. Patients with a new pathogen diagnosed had significantly lower CD4 lymphocyte counts as compared to patients without a new pathogen (p = 0.001).

CONCLUSIONS

For patients with CD4 counts < 100/mm3 and unexplained AIDS-related diarrhea, flexible sigmoidoscopy with biopsy is a sufficiently thorough endoscopic evaluation.

Patients' and providers' perceptions of asthma and asthma care: a qualitative study

BACKGROUND

Differences in patients' and providers' perceptions of asthma and asthma care can create barriers to successful treatment. The primary goal of this qualitative study was to further explore patient and provider perceptions of asthma and asthma care as part of a larger Asthma Comparative Effectiveness Study.

METHODS

Focus groups held every 6 months for 3 years were designed to have a mix of both patients and providers allowing for unique understanding around asthma care.

RESULTS

The discussion centered on goal setting, asthma action plans and prevention strategies for asthma exacerbations. Three overarching themes, with a variety of subthemes, emerged as the main findings of this study. The three main themes were Cost/Economic Barriers/Process, Self-Governance/Adherence and Education.

CONCLUSIONS

These themes indicated a strong need for patient educational interventions around asthma as well as education for providers around cost, insurance coverage and patient-centered communication. Specifically, education on learning to use inhalers properly, avoiding triggers and understanding the importance of a controller medication will benefit patients in the long-term management of asthma.

Adapting community based participatory research (CBPR) methods to the implementation of an asthma shared decision making intervention in ambulatory practices

OBJECTIVE

Translating research findings into clinical practice is a major challenge to improve the quality of healthcare delivery. Shared decision making (SDM) has been shown to be effective and has not yet been widely adopted by health providers. This paper describes the participatory approach used to adapt and implement an evidence-based asthma SDM intervention into primary care practices.

METHODS

A participatory research approach was initiated through partnership development between practice staff and researchers. The collaborative team worked together to adapt and implement a SDM toolkit. Using the RE-AIM framework and qualitative analysis, we evaluated both the implementation of the intervention into clinical practice, and the level of partnership that was established. Analysis included the number of adopting clinics and providers, the patients' perception of the SDM approach, and the number of clinics willing to sustain the intervention delivery after 1 year.

RESULTS

All six clinics and physician champions implemented the intervention using half-day dedicated asthma clinics while 16% of all providers within the practices have participated in the intervention. Themes from the focus groups included the importance of being part the development process, belief that the intervention would benefit patients, and concerns around sustainability and productivity. One year after initiation, 100% of clinics have sustained the intervention, and 90% of participating patients reported a shared decision experience.

CONCLUSIONS

Use of a participatory research process was central to the successful implementation of a SDM intervention in multiple practices with diverse patient populations.

Cryptosporidiosis in a patient on PEG-interferon and ribavirin for recurrent hepatitis C after living donor liver transplantation

We report a case of a 48-year-old male who developed cryptosporidial enterocolitis while on pegylated-interferon alpha-2a and ribavirin for recurrent hepatitis C 2 years after living donor liver transplantation. He recovered after discontinuation of interferon and ribavirin and intermittent lowering of the immunosuppressant. We postulate that the myelodepressant effect of interferon and ribavirin in addition to an established immunosuppressive regimen permitted this opportunistic infection. To the best of our knowledge, this is the first case of cryptosporidiosis in a patient treated with interferon and ribavirin for recurrent hepatitis C after liver transplantation in the literature.

Use of community-based participatory research in primary care to improve healthcare outcomes and disparities in care

Community-based participatory research (CBPR) has emerged to bridge the gap between research and primary-care practice through community engagement and social action to increase health equity. It is widely acknowledged that access to high-quality primary care services is important to the overall health of a community. Here, CBPR studies in a primary care setting are reviewed to assess the use of CBPR associated with common health problems seen in primary care such as access to care and disparities in chronic disease management across vulnerable populations. CBPR involves building relationships with local communities, determining areas of need and establishing priorities for health concerns. Studies showing improved access to care for a Hispanic population, reduced asthma symptoms and weight loss are highlighted.

[Fever, malaise and new onset mitral valve insufficiency. Subacute Streptococcus bovis mitral valve endocarditis ]

A 62-year-old patient with low grade fever, fatigue, arthralgia and newly discovered mitral regurgitation was diagnosed with subacute endocarditis. Streptococcus bovis grew from all six blood culture bottles. Streptococcus bovis is known to be associated with gastrointestinal neoplasias. Therefore a colonoscopy was performed and two polyps were removed. Histological analysis revealed a tubulovillous adenoma and a serrated adenoma. Colonoscopy is mandatory for all patients with Streptococcus bovis endocarditis even without any symptoms for colorectal neoplasia. The significance of Streptococcus bovis for the carcinogenesis of colorectal neoplasias and the possible alternative pathway for colorectal carcinomas through serrated adenomas will be discussed.

Case report: 65-year-old man with metachronous left sided adrenal metastasis of hepatocellular carcinoma

INTRODUCTION AND IMPORTANCE

Due to therapeutic advances and improvements in follow-up care, the diagnosis and treatment of extrahepatic metastases of hepatocellular carcinoma [HCC] have gained clinical significance. However, adrenal gland metastases of HCC remain a rare clinical encounter. Several systemic and local treatment options are discussed in current literature. Adrenalectomy in cases of isolated adrenal metastases with well-controlled intrahepatic lesions has been shown to benefit patients in case series.

PRESENTATION OF THE CASE

This 65-year-old patient presented with suspected metachronous left sided adrenal metastasis seven years after bisegmentectomy for HCC and after undergoing trans-arterial chemoembolization [TACE] for multifocal intrahepatic recurrences while being listed for liver transplantation "beyond Milan criteria". Adrenalectomy was suggested for histopathological confirmation of the suspected metastasis and re-consideration for liver transplant. The resection was performed laparoscopically and metastasis of HCC was confirmed in histopathological analysis. Postoperatively, the patient recovered quickly. However, the patient decided against re-listing for liver transplantation.

CLINICAL DISCUSSION

Current literature suggests, that minimally-invasive adrenalectomy should be considered in patients with no more than two extrahepatic lesions, a Child-Pugh-Score of less than A5, low alpha-fetoprotein [AFP] levels <100 ng/ml and size <3 cm. The oncological goal should be to achieve a tumor free extrahepatic situation with a potential oncological benefit.

CONCLUSION

Our patient presented as an ideal candidate for resection of the adrenal gland metastasis and could have been re-assessed postoperatively for liver transplantation. Still, more research is needed to improve patient-selection for metastasectomy in HCC.

HIV-enteropathy and bile acid malabsorption: response to cholestyramine

Chronic diarrhea and weight loss are common in patients with AIDS. We report on an AIDS patient with chronic diarrhea, steatorrhea, and marked weight loss. A 75SeHCAT test demonstrated that the diarrhea was mainly due to bile acid malabsorption. Therapy with cholestyramine dramatically reduced bowel movements and led to significant reversal of weight loss.

[Cystic space-occupying lesion of the liver as an incidental finding. Symptomatic Echinococcus granulosus cyst of the right hepatic lobe]

Echinokokkus-Zysten enstehen durch eine Infektion mit Eiern des Hundebandwurms. Solche Zysten bleiben oft asymptomatisch. Unbehandelt können sie zu Hepatomegalie, Penetration in Nachbarorgane oder einer Aussaat in die Bauchhöhle führen. Entsprechend ihrer sonographischen Morphologie, klassifiziert nach Gharbi werden sie entweder durch perkutane Aspiration oder chirurgisch behandelt. Die medikamentöse Therapie hat einen untergeordneten Stellenwert.

[Esophageal intramural pseudodiverticulosis]

We report two cases of esophageal intramural pseudodiverticulosis (EIPD). EIPD is a rare condition characterized by multiple flask-shaped outpouchings in the esophageal wall representing dilated excretory ducts of submucosal glands. Dysphagia is the leading symptom. On endoscopy, minute openings in the esophageal wall, and sometimes a segmental candida esophagitis or a benign stenosis not originating from an erosive reflux esophagitis are found.

The Fas receptor in HIV infection: expression on peripheral blood lymphocytes and role in the depletion of T cells

OBJECTIVE

To analyse the role of the apoptosis-inducing Fas receptor in the depletion of CD4+ and CD8+ T cells in HIV-infected individuals.

METHODS

Peripheral blood lymphocytes (PBL) obtained from HIV-infected subjects of all 1993 Centers for Disease Control and Prevention (CDC) stages and from non-infected controls were examined. A two-colour cytofluorometry was employed using monoclonal antibodies against Fas receptor (CD95) in combination with the surface markers CD4, CD8, CD28, CD26 and CD45RO. CD4+ and CD8+ T-cell-enriched PBL were used as target cells to assess their susceptibility to lysis by CD4+ cytotoxic T lymphocytes (CTL) which kill via the Fas pathway.

RESULTS

Fas+PBL are more elevated in HIV-infected individuals than in HIV-negative controls and increase significantly from CDC stages A to C. Whereas Fas+CD4+ and Fas-CD4+ T-cell populations decline in parallel with the progression of HIV infection, the Fas+CD8+, but not of the Fas-CD8+ fraction, significantly increases. The Fas+CD8+ lymphocytes are susceptible to Fas-mediated lysis as they are efficiently killed by Fas-ligand+CD4+CTL.

CONCLUSION

The Fas receptor may contribute, but not as a unique cause, to the decline of CD4+ T cells in HIV-infected individuals. This and the significant increase of the number of Fas+ CD8+ T cells indicates that Fas-mediated immune regulation is disturbed.