Enhancing routine HIV and STI testing among young men who have sex with men: primary outcomes of the get connected clinical randomized trial (ATN 139).

BACKGROUND: Regular HIV and STI testing remain a cornerstone of comprehensive sexual health care. In this study, we examine the efficacy of Get Connected, a WebApp that combines test locators with personalized educational resources, in motivating young men who have sex with men (YMSM) to undergo regular HIV and STI testing. METHODS: Participants were randomly placed in one of two conditions. The first condition included the full version of GC (GC-PLUS), which included content tailored to users' psychosocial characteristics (e.g., age, race/ethnicity, relationship status, HIV/STI testing history). The second condition served as our attention-control and only included the testing locator (GC-TLO) for HIV/STI testing services. Participants were recruited from three cities (Houston, Philadelphia, and Atlanta) characterized by high HIV incidence. Assessments were collected at 1, 3-, 6-, 9- and 12-month follow-ups. RESULTS: Both versions of GC were acceptable and efficacious in increasing routine HIV and STI testing over a 12-month period. 40% of the sample reported testing at least twice, with no main effects observed across the two intervention arms (OR = 1.11; 95% CI: 0.69, 1.80), p =.66). Greater intervention effects were observed among YMSM who engaged more frequently with the intervention, with regional differences observed. CONCLUSIONS: Our findings underscore the need to cater to the diverse needs of YMSM through multilevel approaches. Broadly, mHealth HIV/STI testing interventions, such as Get Connected, would benefit from matching technologies to the local context to have the greatest impact. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov (NCT03132415).

Missed Prevention Opportunities: Why Young, Black MSM with Recent HIV Diagnosis did not Access HIV Pre-exposure Prophylaxis Services.

In the United States, HIV infection rate inequities persist, with new infections highest among young, Black men who have sex with men (YBMSM) in the South. We conducted 23 in-depth interviews with YBMSM newly diagnosed with HIV to explore awareness of and barriers to uptake of HIV pre-exposure prophylaxis (PrEP). Participants were recruited from two university-based HIV Clinics in Alabama and were: (1) 16-29 years of age, (2) diagnosed with HIV within the prior 365 days, (3) Black race, (4) self-identified as a cis-gender male reporting sex with men AND (5) did not report prior PrEP use. Interview guides were grounded in Anderson's Behavioral Healthcare Utilization Model (ABM), with embedded constructs from the situated Information, Motivation and Behavioral Skills theoretical framework. Coding was conducted by three independent coders using thematic analysis methods. Participants (N = 23) median age was 24, more than two-thirds reported annual incomes less than $15,000 and the majority (84%) identified as gay. Major themes that emerged as barriers to accessing PrEP included low prioritization and interests in using PrEP; low perceived HIV risk due to feelings of invincibility and trust in sex partners; lack of information about accessing PrEP; negative beliefs around PrEP; and the suggestion to change PrEP messaging from only targeting YBMSM. These findings indicate that there are important missed opportunities for HIV prevention with PrEP among YBMSM in the South. In these high-risk young men, tailored interventions are needed to better inform and frame perceptions around risk, knowledge, access and prioritization of PrEP.

En Estados Unidos, desigualdades en la tasa de infección por VIH persisten, y en el sur del pais, la tasa de nuevas infecciones hombres jóvenes Afro-americanos que tienen sexo con hombres son más altas. Realizamos veintitrés entrevistas en profundidad con YBMSM recién diagnosticado con VIH para explorar la conciencia y las barreras para la adopción de la profilaxis previa a la exposición al VIH (PrEP). Los participantes fueron reclutados de dos clínicas de VIH en centros medicos academicos en el estado de Alabama con los siguientes criterios: 1) 16-29 años de edad, 2) diagnostico VIH dentro de los 365 días, 3) raza afro-americana, 4) autoidentificados como un género cis-hombres que tienen sexo con hombres, y 5) no informaron el uso previo de PrEP. Las guías de la entrevista se basaron en el Modelo conductual de utilización de la salud (ABM) de Anderson, con construcciones integradas del marco teórico de Información, motivación y habilidades conductuales. Tres codificadores independientes codificaron utilizando métodos de análisis temáticos. La edad mediana de los participantes (N = 23) era de 24 años, más de dos tercios informaron ingresos anuales de menos de $15,000 (USD) y la mayoría (84%) se identificó como gay. Los temas principales que surgieron como barreras para acceder a PrEP incluyeron una baja priorización e interes en su; bajo riesgo percibido de VIH debido a sentimientos de invencibilidad y confianza en las parejas sexuales; falta de información sobre el acceso a PrEP; creencias negativas sobre PrEP; y la sugerencia de enfocar los mensajes sobre PreP no solo ha jovenes afro-americanos que tienen sexo con hombres. Estos hallazgos indican que hay importantes oportunidades perdidas para la prevención del VIH con PrEP entre esto jovenes en el Sur de EEUU. En estos hombres jóvenes de alto riesgo, se necesitan intervenciones personalizadas para mejor informar y enmarcar las percepciones sobre el riesgo, el conocimiento, el acceso y la priorización de PrEP.

A critical analysis of undergraduate students' cultural immersion experiences.

PURPOSE: This paper is concerned with the impact of an international health promotion experience on the understanding of culture among university students. Such immersion experiences are often cited as a strategy to prepare nurses for culturally appropriate practice. We describe students' epistemic movements over time with respect to cultural perspectives prior to, during and after a field study in Malawi. DESIGN: Data were collected at three time points from students in undergraduate nursing (n = 14) and non-nursing (n = 8) programs at a Canadian university. Two essays narrating participants' understanding of culture were submitted by consenting class members. A subgroup of nine participants (four nursing students, five from other disciplines) completed a third narrative following a subsequent field study course in Malawi. METHOD: Using narrative analysis, themes and structures in the participants' writing were identified and located within a constructivist or essentialist paradigm of cultural understanding. FINDINGS: Overwhelmingly, students' narratives were initially portrayed and informed by an essentialist understanding of culture. Later narratives demonstrated varying degrees of epistemic movement towards more constructivist viewpoints. Narratives that initially exhibited constructivist characteristics tended to display strengthened convictions in that paradigm. CONCLUSION: We challenge the claim that an international immersion experience immediately transforms participants into cultural experts; our evidence suggests that students experienced existential growth, but their understanding of culture did not change as a result of their brief stay in a different cultural context. Cultural immersion is a phenomenon that requires more critical analysis and systematic investigation to determine how such experiences contribute to learning about culture among nursing students.

Concordance in the reporting of intimate partner violence among male-male couples.

Intimate partner violence (IPV) among male couples is increasingly recognized as a public health concern. Research on IPV in opposite sex couples indicates frequent underreporting of IPV and high levels of discordance in reporting among dyads. Concordance studies inform refinement methods to measure the experience of IPV among dyads; however the lack of dyadic studies of male couples impedes our understanding of the extent to which IPV is differentially reported in male-male dyads. This study utilized baseline data from a randomized controlled trial of a behavioral intervention to optimize antiretroviral therapy (ART) adherence among 160 sero-discordant male couples in three US cities and provides the first analysis of concordance in reporting IPV among male couples. Low degrees of concordance in the reporting of IPV were identified among male dyads, with a greater proportion of men reporting violence perpetration than experiencing violence. The greater reporting of IPV perpetration may be linked to adherence to concepts of masculinity. The results underscore the unique experiences of IPV among male couples and the need to reexamine current IPV measurement and intervention strategies.

The rectal mucosa and condomless receptive anal intercourse in HIV-negative MSM: implications for HIV transmission and prevention.

Most HIV transmissions among men who have sex with men (MSM), the group that accounted for 67% of new US infections in 2014, occur via exposure to the rectal mucosa. However, it is unclear how the act of condomless receptive anal intercourse (CRAI) may alter the mucosal immune environment in HIV-negative MSM. Here, we performed a comprehensive characterization of the rectal mucosal immune environment for the phenotype and production of pro-inflammatory cytokines by CD4 and CD8 T cells, global transcriptomic analyses, and the composition of microbiota in HIV-negative MSM. Our results show that compared with men who had never engaged in anal intercourse, the rectal mucosa of MSM engaging in CRAI has a distinct phenotype characterized by higher levels of Th17 cells, greater CD8+ T cell proliferation and production of pro-inflammatory cytokines, molecular signatures associated with mucosal injury and repair likely mediated by innate immune cells, and a microbiota enriched for the Prevotellaceae family. These data provide a high-resolution model of the immunological, molecular, and microbiological perturbations induced by CRAI, will have direct utility in understanding rectal HIV transmission among MSM, and will enhance the design of future biomedical prevention interventions, including candidate HIV vaccines.

Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia.

BACKGROUND: In making decisions about life-sustaining medical interventions, respect for patient autonomy has been widely advocated, yet little is known about what variables may compete with a physician's ability to honor patient requests in clinical situations. We investigated physician attitudes and behaviors about end-of-life decisions by means of a questionnaire that posed five hypothetical scenarios in which an elderly, competent, terminally ill patient made a request that, if agreed to by the physician, could result in the patient's death. METHODS: We surveyed 392 physicians in Rhode Island and asked them to decide (1) whether or not they would comply with a specific patient request, (2) the justifications they used in making their decision, and (3) whether they had been approached with such a request in their clinical practices. RESULTS: Two hundred fifty-six physicians (65%) responded. Of the respondents, 98% agreed not to intubate the patient in the face of worsening respiratory failure. Eighty-six percent agreed to give the patient a dose of narcotics that could cause respiratory compromise and death to treat his pain adequately. Fifty-nine percent agreed, once the patient was intubated without hope of coming off the respirator, to turn the respirator off. Nine percent agreed to give the patient a prescription for an amount of sleeping pills that would be lethal if taken all at once. Only 1% agreed to give the patient a lethal injection. When they complied with patient requests, physicians cited patient autonomy as the principle most important to their decision making. Physicians who would not comply with patient requests also, paradoxically, often cited this principle but agreed with it less strongly; others cited concerns about the ethical nature of the request, legal questions, and the perception that they were "killing the patient." Sixty-five percent of respondents had been asked by patients to turn off a respirator, and 12% had been asked to administer lethal injections. Twenty-eight percent of respondents indicated that they would comply with requests for lethal injection more frequently if such an action were legal. CONCLUSIONS: Difficult clinical decisions regarding potentially life-prolonging measures are commonly heard in clinical practice. Physicians value the concept of patient autonomy but place it in the context of other ethical and legal concerns and do not always accept specific actions derived from this principle.

Megakaryocytic and erythrocytic cell lines share a common precursor cell.

Several recent studies show that production of platelets and red blood cells (RBC) are inversely related. For example, it is well established that hypoxia, a stimulator of erythropoiesis, causes thrombocytopenia in laboratory animals. The thrombocytopenia is most likely the result of a reduction in the production of platelets caused by a decrease in the number of colony-forming units-megakaryocyte (CFU-Meg), early precursor megakaryocytes (small acetylcholinesterase-positive cells, SAChE+), and recognizable megakaryocytes in the bone marrow. In all cases, active erythropoiesis was required for the thrombocytopenia. The hypoxia-induced thrombocytopenia was not caused by sequestration of platelets in an enlarged spleen or by expanding blood volumes. We speculate that this thrombocytopenia is caused by competition of a precursor cell of the erythrocytic and megakaryocytic cell lines; that is, marked stimulation of the erythroid cells by erythropoietin (Epo) causes a decrease in the number of immature megakaryocytes, leading to decreased thrombocytopoiesis. In support of this hypothesis, other recent work shows that thyroxine (a stimulator of erythropoiesis) and Epo (when given in large, chronic doses) elevate erythropoiesis and cause thrombocytopenia. Conversely, both endogenous and exogenous sources of thrombopoietin lead to elevated thrombocytopoiesis and anemia in mice. It should also be mentioned that megakaryocytes and erythrocytes have several biochemical similarities, and several clinical conditions point to an inverse relationship between RBC and platelet production. These in vivo, biochemical, and clinical data support the hypothesis that megakaryocytes and erythrocytes share a common precursor cell.

Effect of influenza vaccination on disease progression among HIV-infected persons.

OBJECTIVE: To describe the effect of influenza vaccination on long-term change in CD4 count and HIV RNA level, and on progression to AIDS or death. DESIGN AND SETTING: A longitudinal medical record review set in 113 medical clinics in 10 United States cities. PATIENTS: A total of 36,050 HIV-infected persons aged > or = 13 years in care for HIV infection. MAIN OUTCOME MEASURES: Change in CD4 count and HIV RNA level at follow-up (3-12 months after vaccination); hazard ratios (HR) for association of influenza vaccine with progression from baseline CD4 or HIV RNA level to AIDS and to death. RESULTS: The median CD4 count among all persons decreased 28 cells/year during follow-up, with no difference in change in CD4 count between the 8007 (40%) vaccinated (median = 6 months, vaccine to follow-up CD4 count) and the 11,794 unvaccinated persons. In a viral load subanalysis, median HIV RNA level decreased 90 copies/ml per year among all persons during follow-up; decreases were not different between vaccinated and unvaccinated persons (median = 7 months, vaccine to follow-up HIV RNA level determination). Influenza vaccination was weakly associated with decreased risk of progression to clinical AIDS [HR 0.93; 95% confidence interval (CI), 0.87-0.99], but not associated with time to death (HR, 0.97; CI, 0.93-1.01). CONCLUSIONS: No negative long-term effect of influenza vaccination on CD4 counts, HIV RNA levels, or progression to AIDS or death was found in this HIV-infected population. These data suggest that physicians should not withhold influenza vaccine because of concerns about long-term detrimental effects of increased viral replication.

Epidemiology of thrombosis in HIV-infected individuals. The Adult/Adolescent Spectrum of HIV Disease Project.

OBJECTIVE: To describe the incidence of clinically recognized thrombosis and associated factors among individuals infected with HIV. DESIGN: A longitudinal medical record review. SETTING: Over 100 medical clinics in nine US cities. PATIENTS: A total of 42 935 individuals aged 13 years or older with HIV infection, observed for an average of 2.4 years. MAIN OUTCOME MEASURES: The incidence of thrombosis among HIV-infected individuals; adjusted odds ratios for factors associated with thrombosis. RESULTS: The incidence of thrombosis among HIV-infected individuals was 2.6/1000 person-years (PY). Factors significantly associated with thrombosis included: age of 45 or more years (adjusted odds ratio [AOR], 1.9; 95% confidence interval [CI], 1.4-2.7); a diagnosis of cytomegalovirus disease or retinitis (AOR, 1.9; CI, 1.2-2.9), or other AIDS-defining opportunistic illness (AOR, 1.5; CI, 1.1-2.2); hospitalization (AOR, 3.3; CI, 2.5-4.4); and the prescription of megestrol acetate (AOR, 2.0; CI 1.3-2.9) or indinavir (AOR, 2.4; CI 1.4-4.3). The prescription of other protease inhibitors, sex, race, and mode of HIV exposure were not associated with thrombosis. CONCLUSION: Among HIV-infected individuals, clinically detected thrombosis is more common in those who have opportunistic illnesses, for whom megestrol acetate or indinavir have been prescribed, who have been hospitalized, and who are aged 45 years or older. Physicians should be aware of the risks of thrombosis in order to promote the early identification and appropriate treatment or prophylaxis. Further study is needed to characterize the association between indinavir and thrombosis.

Changes in AIDS incidence for men who have sex with men, United States 1990-1995.

OBJECTIVES: To describe changes in AIDS incidence for men who have sex with men (MSM) from 1990 to 1995, by demographic and geographic groups. METHODS: We examined national AIDS surveillance data reported up to 30 September 1996, for men who received AIDS diagnoses in the years 1990-1995 and whose only reported risk behavior was sex with men. We evaluated trends in AIDS rates by estimating the incidence of clinical AIDS (AIDS defined by opportunistic illnesses), and report clinical AIDS incidence rates for MSM (AIDS rates) and proportional change in rates from 1990 to 1995. RESULTS: Clinical AIDS rates (MSM per 100,000 men per year) increased by 12% from 25.5% in 1990 to 28.5% in 1995. Significant variations in AIDS rates and 5-year changes in AIDS rates were observed in various subgroups of MSM. Five-year increases in AIDS rates were highest for American-Indian/Alaskan native (53%), black (45%), and Hispanic (23%) MSM; the only decrease occurred for white MSM (-2%). Incidence for black MSM increased from twofold (in 1990) to threefold (in 1995) the rate for white MSM. Large increases in AIDS rates were observed for MSM in rural areas (34%) and areas with 50,000 to 249,999 residents (34%) and for MSM aged over 60 years (32%). CONCLUSIONS: The high national AIDS rate for MSM continued to rise, but more slowly than earlier in the epidemic. Racial/ethnic minority MSM had consistently large increases in AIDS rates; AIDS rates decreased only slightly for white MSM. The AIDS epidemic among MSM is not homogenous, and AIDS rates continue to increase for minority MSM, and MSM living in rural areas. HIV prevention remains a high priority for all MSM, especially black and Hispanic MSM.

Persistently negative HIV-1 antibody enzyme immunoassay screening results for patients with HIV-1 infection and AIDS: serologic, clinical, and virologic results. Seronegative AIDS Clinical Study Group.

OBJECTIVE: To describe persons with HIV infection and AIDS but with persistently negative HIV antibody enzyme immunoassay (EIA) results. DESIGN: Surveillance for persons meeting a case definition for HIV-1-seronegative AIDS. SETTING: United States and Canada. PATIENTS: A total of eight patients with seronegative AIDS identified from July 1995 through September 1997. MAIN OUTCOME MEASURES: Clinical history of HIV disease, history of HIV test results, and CD4 cell counts from medical record review; results of testing with a panel of EIA for antibodies to HIV-1, and HIV-1 p24 antigen; and viral subtype. RESULTS: Negative HIV EIA results occurred at CD4 cell counts of 0-230 x 10(6)/l, and at HIV RNA concentrations of 105,000-7,943,000 copies/ml. Using a panel of HIV EIA on sera from three patients, none of the HIV EIA detected infection with HIV-1, and signal-to-cut-off ratios were < or = 0.8 or all test kits evaluated. Sera from five patients showed weak reactivity in some HIV EIA, but were non-reactive in other HIV EIA. All patients were infected with HIV-1 subtype B. CONCLUSIONS: Rarely, results of EIA tests for antibodies to HIV-1 may be persistently negative in some HIV-1 subtype B-infected persons with AIDS. Physicians treating patients with illnesses or CD4 cell counts suggestive of HIV infection, but for whom results of HIV EIA are negative, should consider p24 antigen, nucleic acid amplification, or viral culture testing to document the presence of HIV.

Evaluation of murine leukemia virus infection as a model for thrombocytopenia of HIV/AIDS: mechanism of thrombocytopenia and modulation of thrombocytopenia by thrombopoietin.

Infection of mice with the murine leukemia virus (LP-BM5) was evaluated as a model for the thrombocytopenia of HIV/AIDS. Percent 35S incorporation into platelets, platelet size, platelet count, platelet-associated immunoglobulins (PAIgG), and megakaryocyte size and number were evaluated over a period of 3-9 weeks postinfection (PI). Thrombopoietin from human embryonic kidney cells was administered to mice 9 weeks PI, and similar indices of platelet production were measured 2, 3, and 4 days after treatment with a biological preparation of thrombopoietin (thrombocytopoiesis-stimulating factor, or TSF). Platelet counts decreased in a time-dependent fashion (p = 0.0006) following infection, reaching a nadir at 8 weeks PI (82% of control values). Percent 35S incorporation into platelets also decreased over the 9-week period (p = 0.0001), falling to 63% of control values by week 9. Additionally, platelet volume increased in a linear fashion (p = 0.01), rising to 105% of control values by week 9. No changes in PAIgG were noted over the 9-week period. Megakaryocyte numbers in the femoral marrow were decreased at 8 weeks PI (p = 0.02, 78% of control values), while increased mean megakaryocyte size (p = 0.007, 116% of controls) was noted in the same animals. Increased numbers of naked megakaryocyte nuclei were observed at 3 weeks PI (p < 0.05, 208% of control values). Administration of 2 U/mouse of a highly purified preparation of TSF to virus-infected, thrombocytopenic mice resulted in increased thrombocytopoiesis, as compared to human serum albumin-treated, virus-infected controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Identifying patterns of disruptive behavior in long-term care residents.

OBJECTIVES: To determine the frequency, timing, and pattern of 45 operationalized disruptive behaviors (DB) in older people in long-term care units. DESIGN: Nursing staff collected prospective descriptive data over 21 consecutive shifts for each patient to document prevalence, frequency, and co-occurrences of DBs. SETTING: All of the eight long-term care units and one acute/admission unit of a large Veterans Administration Medical Center (VAMC). Each 40-bed unit had patients with varying levels of cognitive impairment and skilled nursing needs. PARTICIPANTS: The sample consisted of 240 hospitalized VA patients with a mean age of 72.8 (SD = 8.6) years and mean length of stay of 4.02 (SD = 8.6) years. Residents had dementia, a psychiatric diagnosis, or mixed dementia and psychiatric diagnoses. MEASUREMENTS: The Disruptive Behavior Scale (DBS), an instrument designed for collecting patient-level data on 45 separate DBs. RESULTS: In a 24-hour period, the average frequency was 3.6 DBs per subject. We found that 41.2% of DB occurred during the day shift, 39.2% during the evening shift, and 19.6% during the night shift. In 32% of observed occurrences, only one DB occurred within the hour. In the remaining 68% of observations, two or more DBs occurred within the same hour. We found two behaviors, Does Not Follow Directions and Excessive Motor Activity, to occur with multiple behaviors in multiple categories. Several characteristic patterns were noted; e.g., physically aggressive behaviors rarely co-occurred with verbal DBs. Physically nonaggressive behaviors seemed to occur most frequently with other physically nonaggressive behaviors and, to a lesser extent, with verbal DBs. CONCLUSIONS: These findings lend support to the existence of patterns of DBs in long-term care patients, a useful step toward targeting interventions early in the behavioral sequence.

Comparison of a functional obstacle course with an index of clinical gait and balance and postural sway.

BACKGROUND: Older adults commonly experience falls because of balance and mobility problems. Better assessment methods are needed to understand and correct balance and mobility disorders. METHODS: We used a low technology, functional obstacle course (FOC) to measure balance and mobility in 352 community-dwelling elderly participants. To establish concurrent validity of the FOC, we compared performance on the FOC with two established measures of balance and mobility: performance on the Tinetti Index (TI) and postural sway area measured on a force platform. RESULTS: Bivariate correlation analyses revealed significant inverse correlations between FOC completion time, the TI balance and gait subscores, and the TI total score (r = -.73 to -.78). The FOC quality scores and TI balance and subscores gait and TI total scores (r = .76 to .82) were significantly positively correlated. FOC time had significant, but small, positive correlations with sway area with eyes open (r = .18) and closed (r = .17) and nonsignificant correlation with sway area with visual feedback. FOC quality also had significant, but smaller, inverse correlations with sway area with eyes open (r = -.024) and closed (r = -.015), and nonsignificant correlation with sway area with visual feedback. Regression analysis showed that TI gait and balance measures accounted for most of the variance found in FOC performance. CONCLUSIONS: Our findings support the position that the FOC and the TI measure dynamic balance, whereas postural sway measures a different aspect of balance. Advantages of the FOC include the evaluation of environmentally influenced falls and balance problems.

The case for a national center for health professions education research.

Overall concerns with the health care system have raised important questions concerning educating health professionals. The need to study and perhaps alter the assumptions of this education has been raised, but data on which to base programmatic change have not been generated, since neither the assumptions nor proposed educational innovations have been adequately tested. A national center for health professions education research is proposed to facilitate well-funded, peer-reviewed, and academically credible research in health professions education. The goals of the center would allow for the testing of models to provide physicians and other health professionals with education grounded in sound methodology and content.

Evaluating medical residents' literature-appraisal skills.

BACKGROUND: Measuring critical-appraisal skills is a key step in assessing physicians' abilities to engage in self-directed learning. The authors developed an instrument to evaluate the abilities of residents to critically appraise a journal article. METHOD: In 1991, 62 residents in the categorical internal medicine program at the New England Medical Center were asked to respond to a questionnaire, evaluate a sample article, and complete a self-assessment of competence in evaluation of research. Critical-appraisal skill was determined by calculating the resident's deviations from a "gold standard" critique developed through a modified Delphi technique, using a panel of five physicians. Spearman correlation coefficients were used to compare the residents' actual and self-perceived abilities. RESULTS: Twenty-eight residents returned the questionnaire, for a response rate of 45%. The composite score for the residents' objective assessments was 63% of the gold standard, and was not significantly correlated with post-graduate year, prior journal club experience, or self-assessed critical-appraisal skill. CONCLUSION: After further validation in other settings, the assessment instrument in this study may be used to objectively assess critical-reading skills. It may also provide feedback and measure outcomes for interventions designed to improve critical reading.

Students' educational activities during clerkship.

PURPOSE: To quantify the educational activities and types of teachers that medical students had in third-year clerkships at community-based teaching hospitals. METHOD: In October-November 1992, 201 students in third-year medical clerkships at nine community-based hospitals completed a log that recorded the primary activity, site, and educator and method of education (for teaching or supervised activities) for each 15-minute interval of a 24-hour day. Each hospital offered at least three of the clerkships studied: medicine, obstetrics-gynecology (ob-gyn), pediatrics, psychiatry, and surgery. Statistical comparisons of the clerkships were done with chi-square analysis and one-way analysis of variance. RESULTS: The students received 6.5 hours a day of teaching with an instructor and committed an additional 4.9 hours to clerkship-related learning. Nearly 75% of the teaching fell to full-time faculty members and residents. In just over half of their educational activities the students participated with other learners, such as residents. The clerkships did not differ significantly in the amounts of formal teaching given; however, medicine did significantly more informal teaching, and surgery and ob-gyn did significantly more supervised practice. CONCLUSION: This preliminary study quantified medical students' educational activities in 1992 during third-year clerkships and provides baseline data describing these activities and the educators involved. Some findings may not be replicable, however, with the increasing demands of full-time faculty members in inpatient and outpatient settings and the shifting emphases in how and where residents provide instruction. Another study such as this one would help assess the effects on medical education of changes in the health care environment.

"Inappropriate" emergency department use: a comparison of three methodologies for identification.

OBJECTIVE: To determine the level of agreement between the rates of "inappropriate" ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness. METHODS: Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90-question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 non-emergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use of ten explicit criteria (e.g., need for parenteral medication) from prior publications (EXPLICIT), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (PHYS). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores. RESULTS: Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of "inappropriate" visits using the three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. Of those deemed "inappropriate" by the EXPLICIT criteria, 81% also were judged as "inappropriate" by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed "inappropriate" by the TRIAGE criteria, 59% also were judged as "inappropriate" by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.42. CONCLUSION: There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts "inappropriate" ED visits.

Low prevalence of antiretroviral resistance among persons recently infected with human immunodeficiency virus in two US cities.

Resistance testing for treatment-naïve, recently HIV-infected persons is not currently recommended; its clinical value will depend on the prevalence of resistance-associated mutations among recently infected persons. To estimate this prevalence, specimens were collected during 1997-1999 in Seattle and Los Angeles from drug-naïve, recently HIV-infected persons. HIV-1 protease and reverse transcriptase (RT) RNA sequences were amplified from plasma by RT-polymerase chain reaction (RT-PCR), sequenced, and analysed. Of 69 patients, five (7%) had resistance-associated mutations: three (4%) had primary mutations associated with resistance to nucleoside reverse transcriptase inhibitors (NRTI) or non-nucleoside-RTIs, and three patients (4%) had secondary NRTI mutations. No primary mutation associated with resistance to protease inhibitors was observed. Mean age of the five persons with resistance-associated mutations (38 years) was higher than that of the 64 persons without resistance-associated mutations (31 years, P=0.04). The findings suggest that the prevalence of resistance-associated mutations among persons recently infected with HIV in these cities is low.

The effects of n-3 fatty acid supplementation on bleeding time, plasma fatty acid composition, and in vitro platelet aggregation in cats.

Dietary supplementation with fish and fish oils rich in the n-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) has been shown to alter eicosanoid metabolism and impair platelet function in several species. As an initial step in evaluating the antithrombotic effect of these n-3 fatty acids in cats, purified EPA and DHA were administered daily to 8 clinically normal cats for 2 months. Platelet function was evaluated biweekly by determining mucosal bleeding time and in vitro platelet aggregation parameters. Plasma fatty acid profiles were obtained before fish oil supplementation and at the termination of the study. In spite of significant increases (P < .0001) in the plasma concentrations of EPA and DHA after n-3 fatty acid supplementation, there were no significant changes in platelet aggregation or bleeding times. Although it is tempting, based on extrapolation of data from other species, to recommend dietary supplementation with fish oil for cats prone to arterial thromboembolism, these results indicate that administration of large doses of purified EPA and DHA once daily does not inhibit platelet function in normal cats and is unlikely to prevent thrombosis in cats with cardiovascular disease. Additional studies are recommended to ascertain whether more frequent administration of these purified n-3 fatty acids or continual feeding of diets high in n-3 fatty acid content will impair platelet function.