Interdisciplinary HIV care in a changing healthcare environment in the USA.

HIV remains a complex disease that requires comprehensive, coordinated care to ensure optimal outcomes. In the USA, interdisciplinary models of care have developed over time to optimize treatment outcomes. These models may be increasingly important in an era of healthcare reform in the USA. A qualitative study of nine clinical sites funded by the Ryan White HIV/AIDS Program (RWHAP), the federally funded "safety net" program for uninsured and underinsured people living with HIV, was undertaken to identify components of successful models of interdisciplinary HIV care. Findings suggest that these include: (1) patient-centered, one-stop-shop approaches with integrated or co-located services; (2) diverse teams of clinical and nonclinical providers; (3) a site culture that promotes a stigma reducing environment for clients; (4) the availability of a comprehensive array of medical, behavioral health, and psychosocial services; (5) effective communication strategies, including electronic health records (EHRs); and (6) a focus on quality. The importance of RWHAP funding in sustaining these programs is highlighted.

Spectrum of cancer risk among US solid organ transplant recipients.

CONTEXT: Solid organ transplant recipients have elevated cancer risk due to immunosuppression and oncogenic viral infections. Because most prior research has concerned kidney recipients, large studies that include recipients of differing organs can inform cancer etiology. OBJECTIVE: To describe the overall pattern of cancer following solid organ transplantation. DESIGN, SETTING, AND PARTICIPANTS: Cohort study using linked data on solid organ transplant recipients from the US Scientific Registry of Transplant Recipients (1987-2008) and 13 state and regional cancer registries. MAIN OUTCOME MEASURES: Standardized incidence ratios (SIRs) and excess absolute risks (EARs) assessing relative and absolute cancer risk in transplant recipients compared with the general population. RESULTS: The registry linkages yielded data on 175,732 solid organ transplants (58.4% for kidney, 21.6% for liver, 10.0% for heart, and 4.0% for lung). The overall cancer risk was elevated with 10,656 cases and an incidence of 1375 per 100,000 person-years (SIR, 2.10 [95% CI, 2.06-2.14]; EAR, 719.3 [95% CI, 693.3-745.6] per 100,000 person-years). Risk was increased for 32 different malignancies, some related to known infections (eg, anal cancer, Kaposi sarcoma) and others unrelated (eg, melanoma, thyroid and lip cancers). The most common malignancies with elevated risk were non-Hodgkin lymphoma (n = 1504; incidence: 194.0 per 100,000 person-years; SIR, 7.54 [95% CI, 7.17-7.93]; EAR, 168.3 [95% CI, 158.6-178.4] per 100,000 person-years) and cancers of the lung (n = 1344; incidence: 173.4 per 100,000 person-years; SIR, 1.97 [95% CI, 1.86-2.08]; EAR, 85.3 [95% CI, 76.2-94.8] per 100,000 person-years), liver (n = 930; incidence: 120.0 per 100,000 person-years; SIR, 11.56 [95% CI, 10.83-12.33]; EAR, 109.6 [95% CI, 102.0-117.6] per 100,000 person-years), and kidney (n = 752; incidence: 97.0 per 100,000 person-years; SIR, 4.65 [95% CI, 4.32-4.99]; EAR, 76.1 [95% CI, 69.3-83.3] per 100,000 person-years). Lung cancer risk was most elevated in lung recipients (SIR, 6.13 [95% CI, 5.18-7.21]) but also increased among other recipients (kidney: SIR, 1.46 [95% CI, 1.34-1.59]; liver: SIR, 1.95 [95% CI, 1.74-2.19]; and heart: SIR, 2.67 [95% CI, 2.40-2.95]). Liver cancer risk was elevated only among liver recipients (SIR, 43.83 [95% CI, 40.90-46.91]), who manifested exceptional risk in the first 6 months (SIR, 508.97 [95% CI, 474.16-545.66]) and a 2-fold excess risk for 10 to 15 years thereafter (SIR, 2.22 [95% CI, 1.57-3.04]). Among kidney recipients, kidney cancer risk was elevated (SIR, 6.66 [95% CI, 6.12-7.23]) and bimodal in onset time. Kidney cancer risk also was increased in liver recipients (SIR, 1.80 [95% CI, 1.40-2.29]) and heart recipients (SIR, 2.90 [95% CI, 2.32-3.59]). CONCLUSION: Compared with the general population, recipients of a kidney, liver, heart, or lung transplant have an increased risk for diverse infection-related and unrelated cancers.

Monitoring VHA Optometric Eye Exam Services, Nation-Wide, 2014-2016.

INTRODUCTION: It is important to monitor the use of optometric services by Veterans and consider the implications for other optometric and vision rehabilitation services. We did not find public health reports documenting the recent utilization of Veterans Health Administration (VHA) optometric eye exam services. METHODS: A cross-sectional study design was used in this secondary data analysis report. We were interested in reporting on the number of Veterans using the VHA system with at least one VHA optometric eye exam service in 2014, 2015, or 2016 within a VHA optometry clinic. The data from Veterans were derived from the VHA Corporate Data Warehouse. RESULTS: The number of unique Veteran patients who had at least one indication of VHA optometric eye exam service, nation-wide, increased from 1.4 million Veteran patients in 2014 to 1.6 million patients in 2016. The percentage of Veterans using VHA optometric eye exam services out of all unique VHA patients receiving care in the VHA system in 2014, 2015, and 2016 was 25.4%, 25.8%, and 26.8%, respectively. During each year of this time period, about 94% of the Veteran patients were male using optometric eye exam services. Florida, California, Texas, Ohio, and New York had the largest number of Veterans using optometric eye exam services, at least once, in 2014, 2015, or 2016. CONCLUSION: Veteran patients who made at least one VHA optometric eye exam service visit, nation-wide, increased from 2014 to 2016. Data showed that Veteran patients in the older age groups (age 55 and greater) used optometric eye exam services differently when compared with Veterans in the younger age groups. This difference may invite consideration of the differing optometric needs of these two, broad groups of eligible Veterans in order to expand access to VHA optometric clinical services.

Does needle insertion site affect diskography results? A retrospective analysis.

STUDY DESIGN: A retrospective clinical data analysis was performed. OBJECTIVES: To determine the effect of needle insertion site on provocative diskography results, and to ascertain whether performing diskography ipsilaterally to a patient's reported pain leads to a higher rate of false-positives. SUMMARY OF BACKGROUND DATA: In certain groups of patients, provocative diskography is associated with a significant false-positive rate, which can lead to misdiagnosis and inappropriate treatment. Although purported by some to be a cause of false-positive diskogram results, the effect of needle insertion site on diskography results has yet to be determined. METHODS: The charts of 127 patients who underwent diskography were evaluated to determine the relationship between the location of pain, needle insertion site, and diskography results. RESULTS: Performing diskography on the side ipsilateral to a patient's pain did not result in a higher incidence of positive diskogram results. CONCLUSION: False-positive diskography results are unlikely to result from performing the procedure on the same side as a patient's reported pain.

Increasing the number of core samples taken at prostate needle biopsy enhances the detection of clinically significant prostate cancer.

OBJECTIVES: The number of cores obtained during transrectal ultrasound-guided prostate biopsy to detect cancer has increased from the previous standard of 6. Increasing the number of biopsy cores taken results in a higher prostate cancer detection rate. Because criteria for defining the clinical significance of localized prostate cancer has been proposed, the question may be asked whether the increased number of tumors found is clinically significant. METHODS: The Urology Service's surgical log database revealed 369 patients who underwent radical prostatectomy as primary therapy between January 1997 and March 2001. Only men who had had more than six core biopsies that included the standard sextant and lateral horns of the peripheral zone biopsies were considered. The hospital's clinical information system was then used to extract all additional data for age, clinical stage, pretreatment prostate-specific antigen level, and transrectal ultrasound-guided biopsy and subsequent whole mount pathology results, including pathologic stage, number of tumors, largest single and aggregate tumor volumes, highest tumor Gleason score, and tumor locations. A total of 127 men comprised our final group. RESULTS: Subgrouping based on the location of positive biopsy results yielded 40 (31.5%) in the standard sextant biopsy only, 31 (24.4%) in the lateral horns of the peripheral zone only, and 56 (44.1%) of 127 tumors in both zones. The Gleason score was similar throughout. The margin-positive rate was 12.5% for the sextant-only positive biopsies, 12.9% for the lateral horn-only positive biopsies, and 42.9% for the both positive biopsies. The insignificant tumor rate for the group as a whole was 5.5% (7 of 127). The insignificant tumor rate for the lateral horn-only positive biopsies was 3.2% (1 of 31). CONCLUSIONS: The addition of laterally directed biopsies increases the rate of prostate cancer detection, and the vast majority of these tumors are clinically significant.