Prevalence and correlates of substance use and associations with HIV-related outcomes among trans women in the San Francisco Bay Area.

BACKGROUND: Trans women face tremendous social inequities as well as disproportionate rates of HIV and substance use, yet disaggregated substance use data specific to trans women remain limited. METHODS: We conducted a secondary analysis of baseline data from the Trans*National Study (2016-2017) surveying trans women in the San Francisco Bay Area (n = 629). Multivariable logistic regression was used to analyze socio-demographic and environmental correlates of substance use, and bivariate associations between substance use and HIV-associated outcomes are presented alongside prevalence data. RESULTS: Over half (52.9%) reported using substances in the prior year, most frequently marijuana, methamphetamine, and crack/cocaine. Those with unmet gender-affirming health care needs, lack of insurance, or a history of experiencing racial violence, transphobic violence, adult housing instability, or extreme poverty had higher odds of substance use. Sex work and condomless anal sex were also independently associated with substance use. CONCLUSIONS: Among this sample of trans women, substance use and substance use concurrent with sex were highly prevalent, and associated with a number of socioeconomic and health care needs. These findings corroborate the need for holistic and intersectional efforts to reduce substance use and HIV risk.

Unmet Health and Social Welfare Needs of Women Who Inject Drugs in San Francisco.

We characterize social welfare and health care needs of women who inject drugs in a community-based survey in San Francisco. A total of 139 women were enrolled; 74.8% were homeless, and 67.6% earned below poverty level. Indicators of health care and prevention program access included: 95.7% with health insurance, 90.6% used a needle exchange program, and 58.2% tested for HIV two or more times. However, only 8.6% received HPV vaccination and there was unmet contraception need for 79.0% of women. Only 28.7% of those testing positive for HCV infection had received treatment. Physical and sexual violence in the last year were common (41.0% and 18.0%, respectively). Women who inject drugs would benefit from integrated health and social services including addressing interpersonal violence, sexual and reproductive health, and HIV and HCV prevention needs. Women-only needle exchange programs and safe injection sites may be effective delivery points for these services.

Missed opportunities to prevent HIV infections among pre-exposure prophylaxis users: a population-based mixed methods study, San Francisco, United States.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in-depth interviews with people who HIV seroconverted after using PrEP. METHODS: We identified individuals who initiated PrEP in an integrated safety-net public health system and performed in-depth chart review to determine person-time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention's Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in-depth interviews with those who seroconverted. RESULTS: Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person-years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5-fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on-demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP's benefit versus self-perceived risk; and entering a primary partnership. The individual who developed HIV using on-demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing. CONCLUSIONS: HIV incidence during gaps in PrEP use was nearly eight-fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non-daily PrEP may require additional education and support in the United States.

Quarterly screening optimizes detection of sexually transmitted infections when prescribing HIV preexposure prophylaxis.

OBJECTIVE: The optimal screening frequency of sexually transmitted infections (STIs) for MSM and transgender women (TGW) on HIV pre-exposure prophylaxis (PrEP) is unclear, with present guidelines recommending screening every 3-6 months. We aimed to determine the number of STIs for which treatment would have been delayed without quarterly screening. DESIGN: The US PrEP Demonstration Project was a prospective, open-label cohort study that evaluated PrEP delivery in STI clinics in San Francisco and Miami, and a community health center in Washington, DC. In all, 557 HIV-uninfected MSM and TGW were offered up to 48 weeks of PrEP and screened quarterly for STIs. METHODS: The proportion of gonorrhea, chlamydia, and syphilis infections for which treatment would have been delayed had screening been conducted every 6 versus every 3 months was determined by taking the number of asymptomatic STIs at weeks 12 and 36 divided by the total number of infections during the study follow-up period for each STI. RESULTS: Among the participants, 50.9% had an STI during follow-up. If screening had been conducted only semiannually or based on symptoms, identification of 34.3% of gonorrhea, 40.0% of chlamydia, and 20.4% of syphilis infections would have been delayed by up to 3 months. The vast majority of participants (89.2%) with asymptomatic STIs reported condomless anal sex and had a mean of 8.1 partners between quarterly visits. CONCLUSIONS: Quarterly STI screening among MSM on PrEP could prevent a substantial number of partners from being exposed to asymptomatic STIs, and decrease transmission.

"Chasing the pain relief, not the high": Experiences managing pain after opioid reductions among patients with HIV and a history of substance use.

BACKGROUND: Opioid overdose mortality continues to increase in the United States despite significant investments to reverse the epidemic. The national response to-date has focused primarily on reducing opioid prescribing, yet reductions in prescribing have been associated with patients reporting uncontrolled pain, psychological distress, and transition to illicit substances. The aim of this study is to qualitatively explore chronic pain management experiences among PLWH with a history of illicit substance use after long-term opioid therapy reductions or discontinuations. METHODS: We analyzed 18 interviews, stopping upon reaching thematic saturation, with HIV-positive participants with a history of substance use who were enrolled in a longitudinal cohort study to assess the impact of prescribing changes among patients with chronic pain. Participants in this nested qualitative study had been reduced/discontinued from opioid pain relievers (OPRs) within the 12 months prior to interview. Interviews were audio-recorded and transcribed verbatim. Two analysts coded all interviews, interrater reliability was measured, and coding discrepancies discussed. The study took place in San Francisco, California in 2018. RESULTS: Eleven participants were male with a mean age of 55; 8 were African American and 8 were White. All participants were HIV-positive, actively engaged in primary care, and had a lifetime history of illicit substance use. Twelve reported using illicit substances within the past year, including non-prescription opioids/heroin (10), and stimulant use (10). After being reduced/discontinued from their long-term opioid therapy, patients reported developing complex multimodal pain management systems that often included both nonpharmacological approaches and illicit substance use. Participants encountered a range of barriers to nonpharmacological therapies including issues related to accessibility and availability. Participants often reported attempts to replicate their prior OPR prescription by seeking out the same medication and dose from illicit sources and reported transitioning to heroin after exhausting other options. CONCLUSION: After being reduced/discontinued from OPRs, HIV-positive patients with a history of substance use reported experimenting with a range of pain management modalities including nonpharmacological therapies and illicit substance use to manage symptoms of opioid withdrawal and pain. Providers should consider that any change to a patients' long-term opioid therapy may result in experimentation with pain management outside of the medical setting and may want to employ patient-centered, holistic approaches when managing patients' opioid prescriptions and chronic pain.

Use of technology for delivery of mental health and substance use services to youth living with HIV: a mixed-methods perspective.

Disparities in HIV treatment outcomes among youth living with HIV (YLWH) present a challenge for ending the HIV epidemic. Antiretroviral therapy (ART) adherence can be impacted by comorbidities such as mental health and substance use. Technology use has shown promise in increasing access to mental health and substance use services. Using a mixed-methods approach, we conducted formative research to describe the relationship between mental health, substance use, and medication adherence in 18-29 year-old YLWH, and explored technology use as an approach to supporting these services. Among 101 YLWH, ART adherence was significantly negatively associated with mental health measures such as depression, trauma, and adverse childhood experiences and marijuana and stimulants use. Depression had the highest level of relative importance in its association with ART adherence. During in-depth interviews with 29 participants, barriers to and facilitators of accessing and maintaining mental health services were identified. Most participants favored technology use for mental health and substance use service delivery, including videoconferencing with a counselor. Provision of ongoing mental health and substance use treatment is an important mechanism to achieving HIV treatment engagement. Technology, particularly videoconferencing, may have the capacity to overcome many barriers to care by increasing accessibility of these services.

Adapting and Evaluating a Health System Intervention From Kaiser Permanente to Improve Hypertension Management and Control in a Large Network of Safety-Net Clinics.

BACKGROUND: Nearly half of Americans with diagnosed hypertension have uncontrolled blood pressure (BP) while some integrated healthcare systems, such as Kaiser Permanente Northern California, have achieved control rates upwards 90%. METHODS AND RESULTS: We adapted Kaiser Permanente's evidence-based treatment protocols in a racially and ethnically diverse population at 12 safety-net clinics in the San Francisco Health Network. The intervention consisted of 4 elements: a hypertension registry, a simplified treatment intensification protocol that included fixed-dose combination medications containing diuretics, standardized BP measurement protocol, and BP check visits led by registered nurse and pharmacist staff. The study population comprised patients with hypertension who made ≥1 primary care visits within the past 24 months (n=15 917) and had a recorded BP measurement within the past 12 months. We conducted a postintervention time series analysis from August 2014 to August 2016 to assess the effect of the intervention on BP control for 24 months for the pilot site and for 15 months for 11 other San Francisco Health Network clinics combined. Secondary outcomes were changes in use of guideline-recommended medication prescribing. Rates of BP control increased at the pilot site (68%-74%; P<0.01) and the 11 other San Francisco Health Network clinic sites (69%-74%; P<0.01). Statistically significant improvements in BP control rates (P<0.01) at the 11 San Francisco Health Network clinic sites occurred in all racial and ethnic groups (blacks, 60%-66%; whites, 69%-75%; Latinos, 67%-72%; Asians, 78%-82%). Use of fixed-dose combination medications increased from 10% to 13% (P<0.01), and the percentage of angiotensin-converting enzyme inhibitor prescriptions dispensed in combination with a thiazide diuretic increased from 36% to 40% (P<0.01). CONCLUSIONS: Evidence-based system approaches to improving BP control can be implemented in safety-net settings and could play a pivotal role in achieving improved population BP control and reducing hypertension disparities.

Intake of bean fiber, beans, and grains and reduced risk of hormone receptor-negative breast cancer: the San Francisco Bay Area Breast Cancer Study.

High dietary fiber intake has been associated with reduced breast cancer risk, but few studies considered tumor subtypes defined by estrogen receptor (ER) and progesterone receptor (PR) status or included racial/ethnic minority populations who vary in their fiber intake. We analyzed food frequency data from a population-based case-control study, including 2135 breast cancer cases (1070 Hispanics, 493 African Americans, and 572 non-Hispanic Whites (NHWs)) and 2571 controls (1391 Hispanics, 557 African Americans, and 623 NHWs). Odds ratios (OR) and 95% confidence intervals (CI) for breast cancer associated with fiber intake were calculated using unconditional logistic regression. Breast cancer risk associated with high intake (high vs. low quartile) of bean fiber (p-trend = 0.01), total beans (p-trend = 0.03), or total grains (p-trend = 0.05) was reduced by 20%. Inverse associations were strongest for ER-PR- breast cancer, with risk reductions associated with high intake ranging from 28 to 36%. For bean fiber, risk was reduced among foreign-born Hispanics only, who had the highest fiber intake, whereas for grain intake, inverse associations were found among NHWs only. There was no evidence of association with fiber intake from vegetables and fruits or total intake of vegetables and fruits. A high dietary intake of bean fiber and fiber-rich foods such as beans and grains may lower the risk of ER-PR- breast cancer, an aggressive breast cancer subtype for which few risk factors have been identified.

Cost-effectiveness of hepatitis C screening and treatment linkage intervention in US methadone maintenance treatment programs.

BACKGROUND: We evaluated the cost-effectiveness of a hepatitis C (HCV) screening and active linkage to care intervention in US methadone maintenance treatment (MMT) patients using data from a randomized trial conducted in New York City and San Francisco. METHODS: We used a decision analytic model to compare 1) no intervention; 2) HCV screening and education (control); and 3) HCV screening, education, and care coordination (active linkage intervention). We also explored an alternative strategy wherein HCV/HIV co-infected participants linked elsewhere. Trial data include population characteristics (67% male, mean age 48, 58% HCV infected) and linkage rates. Data from published sources include treatment efficacy and HCV re-infection risk. We projected quality-adjusted life years (QALYs) and lifetime medical costs using an established model of HCV (HEP-CE). Incremental cost-effectiveness ratios (ICERs) are in 2015 US$/QALY discounted 3% annually. RESULTS: The control strategy resulted in a projected 35% linking to care within 6 months and 31% achieving sustained virologic response (SVR). The intervention resulted in 60% linking and 54% achieving SVR with an ICER of $24,600/QALY compared to no intervention from the healthcare sector perspective and was a more efficient use of resources than the control strategy. The intervention had an ICER of $76,500/QALY compared to the alternative strategy. From a societal perspective, the intervention had a net monetary benefit of $511,000-$975,600. CONCLUSIONS: HCV care coordination interventions that include screening, education and active linkage to care in MMT settings are likely cost-effective at a conventional $100,000/QALY threshold for both HCV mono-infected and HIV co-infected patients.

Loneliness in Older Adults Living with HIV.

We conducted a cross-sectional study among HIV-positive adults age ≥ 50 in San Francisco to evaluate the frequency of loneliness, characteristics of those who reported loneliness, and the association of loneliness with functional impairment and health-related quality of life (HRQoL). Participants (N = 356) were predominately male (85%); 57% were white; median age was 56. 58% reported any loneliness symptoms with 24% reporting mild, 22% moderate and 12% severe loneliness. Lonely participants were more likely to report depression, alcohol and tobacco use, and have fewer relationships. In unadjusted models, loneliness was associated with functional impairment and poor HRQoL. In adjusted models, low income and depression remained associated with poor HRQoL, while low income, higher VACS index and depression were associated with functional impairment. A comprehensive care approach, incorporating mental health and psychosocial assessments with more traditional clinical assessments, will be needed to improve health outcomes for the aging HIV-positive population.

RESUMEN: Realizamos un estudio transversal en adultos mayores de 50 años con VIH en San Francisco para evaluar la frecuencia de la soledad, características de aquellos que reportan soledad, y la asociación de la soledad con el deterioro funcional y la calidad de vida relacionada con la salud (HRQoL). Los participantes (N = 356) fueron principalmente hombres (85%); 57% de raza blanca, la mediana de edad fue 56 años. El 58% reportó cualquier síntoma de soledad con un 24% reportando soledad leve, 22% soledad moderada, y 12% soledad severa. En los participantes que refirieron soledad era más probable que reportaran depresión, consumo de tabaco o alcohol, y menos relaciones sociales. En modelos sin ajustar, la soledad estaba asociada con deterioro funcional y baja calidad de vida relacionada con la salud. En modelos ajustados, tener bajos ingresos y depresión continuaron teniendo asociación con una baja calidad de vida relacionada con la salud, mientras que tener bajos ingresos, un índice más alto de VACS y depresión estaban asociados con deterioro funcional. Un sistema de cuidado integral, incorporando la salud mental y valoraciones psicológicas y sociales con evaluaciones médicas tradicionales, serán necesarios para poder mejorar los índices de salud de las personas VIH positivas que envejecen.

A Survey of Licensed Acupuncturists in the San Francisco Bay Area: Prevalence of Treating Oncology Patients.

BACKGROUND: Many cancer patients seek traditional Chinese medicine (TCM), the prevalence varying with diagnosis, comorbidities, and demographics. Interventions sought include acupuncture, massage, herbs, diet, and exercise, usually combined with conventional therapies. It is not known what proportion of TCM practitioners care for cancer patients, their cancer specific training or caseload, what interventions they employ, their outcomes, and their communication patterns with conventional oncologists. METHODS: A survey was mailed to all 2213 licensed acupuncturists in the 9-county San Francisco Bay Area gathering descriptive statistics. RESULTS: A total of 472 (21%) responded by mail or web-based Research Electronic Data Capture (REDCap) tool. Most respondents (77%) reported caring for patients with cancer, with 29% reporting having 6 to 10 years of practice experience, and 44.2% having 0 to 20 hours of training specific to the needs of patients with cancer. Improving quality of life was reported by 94% as what their treatment offered cancer patients as well as the area where treatment was felt to have the greatest impact. The most useful TCM modalities were acupuncture (98%), herbs (79%), diet (72%), moxibustion (46%), and meditation instruction (44%). Absence of adverse reactions was noted by 95%. Ninety-one percent reported "never" or "hardly ever" having been contacted by patients' oncologists to discuss treatment. CONCLUSIONS: Many acupuncturists seeing cancer patients have significant clinical experience and have sought specialized training. Improved communication is needed between TCM practitioners and oncologists sharing care of cancer patients.

The Effect of Yoga on Arm Volume, Strength, and Range of Motion in Women at Risk for Breast Cancer-Related Lymphedema.

OBJECTIVES: To assess the feasibility, safety, and initial estimates of efficacy of a yoga program in postoperative care for women at high risk for breast cancer-related lymphedema (BCRL). DESIGN: Single-group pretest-post-test design. SETTINGS/LOCATION: Patients were recruited from the University of California, San Francisco Carol Franc Buck Breast Care Center. SUBJECTS: Twenty-one women were enrolled in the study. Women were >18 years of age, had undergone surgical treatment for breast cancer, and were at high risk for BCRL. INTERVENTION: The women participated in an Ashtanga yoga intervention for 8 weeks. Sessions consisted of once/week instructor-led practice and once/week home practice. Particular attention was given to poses that emphasized upper body strength and flexibility, while avoiding significant time with the upper extremity (UE) in a dependent position. OUTCOME MEASURES: UE volume was assessed through circumferential forearm measurement, which was converted to volume using the formula for a truncated cone. Range of motion (ROM) was assessed for the shoulders, elbows, and wrists, using a standard goniometer. UE strength was assessed for shoulder abduction, elbow flexion, wrist flexion, and grip using a dynamometer. RESULTS: Twenty women completed the yoga intervention, with 17 returning for final assessment. Mean age was 52 (±9.1) years and body mass index was 24.8 (±5.1) kg/m2. Postintervention, mean volume in the at-risk UE was slightly reduced (p = 0.397). ROM for shoulder flexion (p < 0.01) and external rotation (p < 0.05) significantly increased bilaterally. Shoulder abduction ROM significantly improved for the unaffected limb (p = 0.001). Following intervention, strength improved on the affected side for shoulder abduction and grip strength, and bilaterally for elbow flexion (p < 0.05 for all). CONCLUSIONS: These preliminary findings suggest that yoga is feasible and safe for women who are at risk for BCRL and may result in small improvements in shoulder ROM and UE strength.

The Population Burden of Cancer: Research Driven by the Catchment Area of a Cancer Center.

Cancer centers, particularly those supported by the National Cancer Institute, are charged with reducing the cancer burden in their catchment area. However, methods to define both the catchment area and the cancer burden are diverse and range in complexity often based on data availability, staff resources, or confusion about what is required. This article presents a review of the current literature identifying 4 studies that have defined various aspects of the cancer burden in a defined geographical area and highlights examples of how some cancer centers and other health institutions have defined their catchment area and characterized the cancer burden within it. We then present a detailed case study of an approach applied by the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center to define its catchment area and its population cancer burden. We cite examples of how the Cancer Center research portfolio addresses the defined cancer burden. Our case study outlines a systematic approach to using publicly available data, such as cancer registry data, that are accessible by all cancer centers. By identifying gaps and formulating future research directions based on the needs of the population within the catchment area, epidemiologic studies and other types of cancer research can be directed to the population served. This review can help guide cancer centers in developing an approach to defining their own catchment area as mandated and applying research findings to this defined population.

Cannabis use patterns and motives: A comparison of younger, middle-aged, and older medical cannabis dispensary patients.

INTRODUCTION: Medical cannabis is increasingly being used for a variety of health conditions as more states implement legislation permitting medical use of cannabis. Little is known about medical cannabis use patterns and motives among adults across the lifespan. METHODS: The present study examined data collected at a medical cannabis dispensary in San Francisco, California. Participants included 217 medical cannabis patients who were grouped into age-defined cohorts (younger: 18-30, middle-aged: 31-50, and older: 51-72). The age groups were compared on several measures of cannabis use, motives and medical conditions using one-way ANOVAs, chi-square tests and linear regression analyses. RESULTS: All three age groups had similar frequency of cannabis use over the past month; however, the quantity of cannabis used and rates of problematic cannabis use were higher among younger users relative to middle-aged and older adults. The association between age and problematic cannabis use was moderated by age of regular use initiation such that earlier age of regular cannabis use onset was associated with more problematic use in the younger users, but not among older users. Middle-aged adults were more likely to report using medical cannabis for insomnia, while older adults were more likely to use medical cannabis for chronic medical problems such as cancer, glaucoma and HIV/AIDS. Younger participants reported cannabis use when bored at a greater rate than middle-aged and older adults. CONCLUSIONS: Findings suggest that there is an age-related risk for problematic cannabis use among medical cannabis users, such that younger users should be monitored for cannabis use patterns that may lead to deleterious consequences.

Identifying social and economic barriers to regular care and treatment for Black men who have sex with men and women (BMSMW) and who are living with HIV: a qualitative study from the Bruthas cohort.

BACKGROUND: There is little research regarding the ability of Black men who have sex with men and women (BMSMW) to access and maintain HIV-related health care and treatment adherence. This population, who often insist on secrecy about their same-sex desire, may experience unique barriers to seeking regular care and treatment. METHODS: From March 2011-April 2014, we recruited 396 BMSMW in the San Francisco Bay Area to be enrolled in our randomized controlled trial. At baseline we administered a behavioral survey assessing: demographics, homelessness, employment, history of incarceration, HIV status and disclosure practices, care and treatment adherence. 64 men reported living with HIV at intake. To learn more about their experiences, we recruited N = 25 to participate in qualitative interviews, which were conducted April-December 2014. Topics included: current living situation, diagnosis story, disclosure practices, experiences of accessing and maintaining care and treatment, and HIV-related stigma. Recordings were transcribed and coded for major themes. RESULTS: Despite being located in an area where treatment is plentiful, men faced social and economic barriers to maintaining regular care and treatment adherence. Several findings emerged to shed light on this quandary: (1) Competing needs particularly around attaining stable housing, food security, and money created barriers to treatment and care; (2) Side effects of HIV medications discouraged men from adhering to treatment; (3) Provider and Institutional level characteristics influenced care engagement; (4) Disclosure and social support made a difference in care and treatment behaviors; and (5) Participants expressed a desire for group-based intervention activities to support treatment and care among HIV+ BMSMW. Inadequate engagement in the continuum of care for HIV was born out in the quantitative data where 28% of participants did not know their Viral Load. CONCLUSIONS: A holistic approach to HIV health for BMSMW would appear to translate to better outcomes for men living with HIV, where a goal of viral suppression must also include attending to their basic social and economic support needs.

Chinese Herb Use by Patients at a San Francisco Chinatown Public Health Center.

OBJECTIVES: Chinese herbal medicine (CHM) use has not been well characterized in persons living in the United States who receive care by Western-trained healthcare providers. The primary objective of this study was to characterize use of CHM taken in the last 12 months by patients seen at a Chinatown public health center. DESIGN: Convenience sample survey. SETTING: Data collection occurred over 3 months at a San Francisco Chinatown public health center. PARTICIPANTS: Adult patients visiting their primary care provider. INTERVENTIONS: Completion of a voluntary 24-question survey on CHM use. OUTCOME MEASURES: Prevalence, type, and indications for use. RESULTS: Survey response rate was 29% (50/170). Seventy percent (35/50) of respondents had used CHM in the last 12 months and 94% (33/35) were also taking prescription medicines. The three most commonly used CHM were goji berry (37%), Dioscorea (31%), and ginseng (23%). The most common indications for herbs used in the last 12 months were general wellness (34%), cold/flu (25%), and headache (6%). Sixty-four percent of respondents had used Western medicine in combination with CHM within the last 12 months. Sixty-nine percent of respondents who used CHM did not tell their Western provider about this use. No patient had CHM use documented in the electronic medical record. CONCLUSIONS: Patients seen at a Chinatown public health center frequently used CHM products in conjunction with Western prescription medicines. Providers should routinely enquire about CHM use for health as a soup, tea, food, or pill and document this use in the medical record.

The Effect of Direct Current Stimulation versus T-Wave Shock on Defibrillation Threshold Testing.

INTRODUCTION: There are several methods to induce ventricular fibrillation (VF) during defibrillation threshold (DFT) testing. Delivering a shock at a critical time during the T wave (T-shock) is the conventional approach, while delivering a constant direct current voltage (DC stim) from the implantable cardioverter defibrillator is an alternative method. Only a few reports compare VF induction methods. The purpose of this study was to evaluate the effects and safety of DC stim versus T-shock. METHODS: We retrospectively investigated 414 consecutive patients undergoing DFT testing. We compared the two groups (DC stim and T-shock) with respect to clinical characteristics, electrocardiogram (ECG) changes, and complications. RESULTS: Ventricular arrhythmia, including ventricular tachycardia (VT) and VF, was induced by DC stim in 93 patients or T-shock in 321 patients. No more than three attempts were performed during one procedure. There was no significant difference in the baseline ECG, induced tachycardia cycle length (TCL), or complications between the two groups. However, the induced TCL was significantly shorter than the clinical TCL regardless of induction method (P = 0.001). Five patients suffered major complications (i.e., electromechanical dissociation or incessant VT). A history of atrial fibrillation was significantly greater in patients with major complications than the others (80% vs 24%, P = 0.004), and was an independent predictor on multivariate analysis. CONCLUSIONS: There is no significant difference in induced TCL or complications between the DC stim and T-shock. The induced TCL is significantly shorter than clinical TCL regardless of induction method.

Comparative effectiveness of fish oil versus fenofibrate, gemfibrozil, and atorvastatin on lowering triglyceride levels among HIV-infected patients in routine clinical care.

OBJECTIVE: The goal of this study was to compare the effectiveness of fish oil, fenofibrate, gemfibrozil, and atorvastatin on reducing triglyceride (TG) levels among a large cohort of HIV-infected patients in clinical care. DESIGN: Retrospective observational cohort study. METHODS: The primary endpoint was absolute change in TG levels measured using the last TG value pretreatment and the first TG value posttreatment. A pre-post quasi-experimental design was used to estimate the change in TG because of initiating fish oil. Linear regression models examined the comparative effectiveness of treatment with fish oil versus gemfibrozil, fenofibrate, or atorvastatin for TG reduction. Models were adjusted for baseline differences in age, sex, race, CD4⁺ cell count, diabetes, body mass index, protease inhibitor use, and time between TG measures. RESULTS: A total of 493 patients (mean age, 46 years; 95% male) were included (46 patients receiving gemfibrozil; 80, fenofibrate; 291, atorvastatin; and 76, fish oil) with a mean baseline TG of 347 mg/dL. New use of fish oil decreased TG [ΔTG, -45 mg/dL; 95% confidence interval (CI): -80 to -11] in the pre-post study. Compared with fish oil (reference), fibrates were more effective (ΔTG, -66; 95% CI: -120 to -12) in reducing TG levels, whereas atorvastatin was not (ΔTG, -39; 95% CI: -86 to 9). CONCLUSIONS: In HIV-infected patients in routine clinical care, fish oil is less effective than fibrates (but not atorvastatin) at lowering TG values. Fish oil may still represent an attractive alternative for patients with moderately elevated TGs, particularly among patients who may not want or tolerate fibrates.

24-hour urine phosphorus excretion and mortality and cardiovascular events.

BACKGROUND AND OBJECTIVES: Higher morning serum phosphorus has been associated with cardiovascular disease (CVD) in patients with or without CKD. In patients with CKD and a phosphorous level >4.6 mg/dl, the Kidney Disease Improving Global Outcomes guidelines recommend dietary phosphorus restriction. However, whether phosphorus restriction influences serum phosphorus concentrations and whether dietary phosphorus is itself associated with CVD or death are uncertain. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Among 880 patients with stable CVD and normal kidney function to moderate CKD, 24-hour urine phosphorus excretion (UPE) and serum phosphorus were measured at baseline. Participants were followed for a median of 7.4 years for CVD events and all-cause mortality. RESULTS: Mean ± SD age was 67±11 years, estimated GFR (eGFR) was 71±22 ml/min per 1.73 m(2), and serum phosphorus was 3.7±0.6 mg/dl. Median UPE was 632 (interquartile range, 439, 853) mg/d. In models adjusted for demographic characteristics and eGFR, UPE was weakly and nonsignificantly associated with serum phosphorus (0.03 mg/dl higher phosphorus per 300 mg higher UPE; P=0.07). When adjusted for demographics, eGFR, and CVD risk factors, each 300-mg higher UPE was associated with 17% lower risk of CVD events. The association of UPE with all-cause mortality was not statistically significant (hazard ratio, 0.93; 95% confidence interval, 0.82 to 1.05). Results were similar irrespective of CKD status (P interactions > 0.87). CONCLUSIONS: Among outpatients with stable CVD, the magnitude of the association of UPE with morning serum phosphorus is modest. Greater UPE is associated with lower risk for CVD events. The association was similar for all-cause mortality but was not statistically significant.

Exploring sexual health among female sexually transmitted disease clinic patients, San Francisco 2010.

BACKGROUND: Current data on sexual health in the United States is limited, in part, because of a lack of measurement tools. It is difficult for programs to develop a holistic approach to improving sexual health that is data-driven and evaluable without a tool that encompasses sexual health beyond the absence of disease. The objective of this study was to understand possible factors associated with sexual health and reported differences in sexual health among women. METHODS: We conducted a survey measuring sexual health among women seeking care at the municipal sexually transmitted disease (STD) clinic in San Francisco between January 25, 2010, and June 15, 2010. Records were matched on variables including basic demographics, reason for visit, symptoms at visit, history of an STD, and STD diagnosis at the visit. RESULTS: A total of 822 women completed the questionnaire during the study period. Women reporting no recent sexual activity reported feeling more insecure, angry, isolated, and limited because of health compared with women with recent sexual activity. However, few differences were seen among women based on symptoms and diagnosis at visit. DISCUSSION: Given the minimal differences based on symptoms and disease, this suggests that there are other factors that impact the quality of life and sexual health. Creating tools that can be used to measure sexual health is a necessary first step for programs to understand the sexual health of a community. More broad-based assessments of sexual health in a variety of populations will be critical to identifying points of intervention and progress toward success.