Multilevel and Multifactorial Interventions to Reduce Alcohol Consumption and Improve ART Adherence and Related Factors Among HIV Positive Men in Mumbai, India.

Alcohol use has a deleterious effect on the health status of persons living with HIV, negatively affecting antiretroviral adherence and increasing the risk of transmission. Alcohol use is not an isolated behavior but intimately linked to stigma and poor psychological status among other factors. This paper utilizes a crossover design to test the efficacy of three multilevel interventions, individual counselling (IC), group intervention (GI) and collective advocacy (CA) for change, among HIV positive males who consume alcohol, treated at five ART Centers in urban Maharashtra, India. While GI shows a significant effect on the largest number of outcome variables, IC through its psychosocial emphasis demonstrated a significant impact over time on stigma and depression, and CA with its emphasis on societal change showed positive impact on stigma and advocacy for self and others. Each of the interventions had variable effects on CD4 count and viral load.Clinical Registration Number: NCT03746457; Clinical Trial.Gov.

RESUMEN: El consumo de alcohol tiene un efecto nocivo en el estado de salud de las personas que viven con VIH, afectando negativamente la adherencia a los antirretrovirales y aumentando el riesgo de transmisión del virus. El consumo de alcohol no es un comportamiento aislado, sino que está íntimamente relacionado con el estigma y el mal estado psicológico, entre otros factores. Este documento utiliza un diseño cruzado para evaluar la eficacia de tres intervenciones: asesoramiento individual, intervención grupal y defensa colectiva para el cambio, entre hombres con VIH que consumen alcohol que reciben tratamiento en cinco centros de terapia antiretroviral en la zona urbana de Maharashtra, India. Si bien la intervención grupal muestra un efecto significativo en el mayor número de variables de interés, el asesoramiento individual a través de su énfasis psicosocial demostró un impacto significativo en el estigma y la depression a largo plazo, y la defensa colectiva con su énfasis en el cambio social mostró un impacto positivo en el estigma y la defensa de sí mismo y otros.

Temporal dynamics of the relationship between change in depressive symptoms and cannabis use in adolescents receiving psychosocial treatment for cannabis use disorder.

AIMS: Cannabis use disorder (CUD) and depression frequently co-occur in youth. How depressive symptoms change over the course of CUD treatment and how they impact substance use treatment outcomes is unknown. In the current study, we examine the temporal relationships between cannabis use and depression in adolescents receiving evidence-based treatments for CUD as part of a multisite clinical trial. DESIGN: Six hundred adolescents (age 12-18) with a CUD were randomly assigned to substance use treatment from one of five evidence-based psychosocial interventions. We assessed self-reported cannabis use frequency and depressive symptoms at baseline (BL) and again at 3-, 6-, 9, and 12-months. A bivariate latent change model assessed bidirectional effects of baseline levels and time-lagged changes in depressive symptoms and cannabis use on depression and cannabis use outcomes. FINDINGS: Depressive symptoms (72%) and major depressive disorder (MDD) (18%) were common at BL. Both depression and cannabis use decreased over time and change in cannabis use was significantly associated with change in depressive symptoms (b = 1.22, p = .003). Time-lag analyses showed that within-subject change in depression (from one time point to the next) was predicted by previous depression (b = -0.71, p < .001) but not cannabis use (p = .068), and change (decrease) in cannabis use was predicted by previous (greater) depressive symptoms (b = -1.47, p < .001) but not cannabis use (p = .158), respectively. CONCLUSION: These findings indicate an enduring relationship between decreasing cannabis use and decreasing depression among adolescents lasting for 9-months after receiving psychosocial interventions for CUD. The presence of depressive symptoms did not appear to interfere with substance use treatment or attenuate improvements in cannabis use frequency. A decrease in cannabis use was not contingent upon a reduction in depressive symptoms. These findings are limited by the possibility of regression to the mean for both cannabis use and depressive symptoms, and the lack of a nonintervention control group.

Integrated Analysis of Clinical and Microbiome Risk Factors Associated with the Development of Oral Candidiasis during Cancer Chemotherapy.

Oral candidiasis is a common side effect of cancer chemotherapy. To better understand predisposing factors, we followed forty-five subjects who received 5-fluorouracil- or doxorubicin-based treatment, during one chemotherapy cycle. Subjects were evaluated at baseline, prior to the first infusion, and at three additional visits within a two-week window. We assessed the demographic, medical and oral health parameters, neutrophil surveillance, and characterized the salivary bacteriome and mycobiome communities through amplicon high throughput sequencing. Twenty percent of all subjects developed oral candidiasis. Using multivariate statistics, we identified smoking, amount of dental plaque, low bacteriome and mycobiome alpha-diversity, and the proportions of specific bacterial and fungal taxa as baseline predictors of oral candidiasis development during the treatment cycle. All subjects who developed oral candidiasis had baseline microbiome communities dominated by Candida and enriched in aciduric bacteria. Longitudinally, oral candidiasis was associated with a decrease in salivary flow prior to lesion development, and occurred simultaneously or before oral mucositis. Candidiasis was also longitudinally associated with a decrease in peripheral neutrophils but increased the neutrophil killing capacity of Candida albicans. Oral candidiasis was not found to be associated with mycobiome structure shifts during the cycle but was the result of an increase in Candida load, with C. albicans and Candida dubliniensis being the most abundant species comprising the salivary mycobiome of the affected subjects. In conclusion, we identified a set of clinical and microbiome baseline factors associated with susceptibility to oral candidiasis, which might be useful tools in identifying at risk individuals, prior to chemotherapy.

Chemotherapy-induced oral mucositis is associated with detrimental bacterial dysbiosis.

BACKGROUND: Gastrointestinal mucosal injury (mucositis), commonly affecting the oral cavity, is a clinically significant yet incompletely understood complication of cancer chemotherapy. Although antineoplastic cytotoxicity constitutes the primary injury trigger, the interaction of oral microbial commensals with mucosal tissues could modify the response. It is not clear, however, whether chemotherapy and its associated treatments affect oral microbial communities disrupting the homeostatic balance between resident microorganisms and the adjacent mucosa and if such alterations are associated with mucositis. To gain knowledge on the pathophysiology of oral mucositis, 49 subjects receiving 5-fluorouracil (5-FU) or doxorubicin-based chemotherapy were evaluated longitudinally during one cycle, assessing clinical outcomes, bacterial and fungal oral microbiome changes, and epithelial transcriptome responses. As a control for microbiome stability, 30 non-cancer subjects were longitudinally assessed. Through complementary in vitro assays, we also evaluated the antibacterial potential of 5-FU on oral microorganisms and the interaction of commensals with oral epithelial tissues. RESULTS: Oral mucositis severity was associated with 5-FU, increased salivary flow, and higher oral granulocyte counts. The oral bacteriome was disrupted during chemotherapy and while antibiotic and acid inhibitor intake contributed to these changes, bacteriome disruptions were also correlated with antineoplastics and independently and strongly associated with oral mucositis severity. Mucositis-associated bacteriome shifts included depletion of common health-associated commensals from the genera Streptococcus, Actinomyces, Gemella, Granulicatella, and Veillonella and enrichment of Gram-negative bacteria such as Fusobacterium nucleatum and Prevotella oris. Shifts could not be explained by a direct antibacterial effect of 5-FU, but rather resembled the inflammation-associated dysbiotic shifts seen in other oral conditions. Epithelial transcriptional responses during chemotherapy included upregulation of genes involved in innate immunity and apoptosis. Using a multilayer epithelial construct, we show mucositis-associated dysbiotic shifts may contribute to aggravate mucosal damage since the mucositis-depleted Streptococcus salivarius was tolerated as a commensal, while the mucositis-enriched F. nucleatum displayed pro-inflammatory and pro-apoptotic capacity. CONCLUSIONS: Altogether, our work reveals that chemotherapy-induced oral mucositis is associated with bacterial dysbiosis and demonstrates the potential for dysbiotic shifts to aggravate antineoplastic-induced epithelial injury. These findings suggest that control of oral bacterial dysbiosis could represent a novel preventive approach to ameliorate oral mucositis.

Novel PAradigm to improve Inflammatory burden in end stage Renal disease (rePAIR): study protocol for a randomized controlled trial.

BACKGROUND: Given the importance of inflammation as a predictor of poor outcomes in End Stage Renal Disease (ESRD), reductions in inflammatory biomarkers have been proposed as a critical target in this population. This study targets chronic periodontitis, an oral inflammatory disease of microbial etiology causing persistent inflammation in ESRD. Unlike the previously reported episodic periodontal interventions, we propose to control periodontal inflammation with a continuous maintenance and oral health behavior modifications. We hypothesize that this strategy will improve systemic inflammation and oxidative stress, oral health and quality of life within the 6-month observation period. METHODS: The rePAIR (novel PAradigm to improve Inflammatory burden in ESRD) study is a pilot and feasibility, parallel-arm, and randomized controlled clinical trial that will recruit 72 ESRD subjects with periodontitis in a model of computerized block randomization. This trial aims to compare the effect of standard-of-care vs. repeated non-surgical periodontal therapy on systemic and oral inflammatory burden. This trial will recruit ESRD adult patients with periodontitis older than 21 years old with a minimum of 12 teeth and no history of periodontal treatment within a year. The trial will examine serum C-reactive protein (CRP) (primary outcome) as a biomarker of inflammation as well as interleukin-6 (IL-6), F2 isofurans and F2 isoprostanes (secondary outcomes) and compare their difference between groups from baseline to 6 months. The trial will also compare the difference between groups in patient-centered and clinical oral outcomes from baseline to 6 months. DISCUSSION: The trial follows a rigorous and transparent study design capturing elements such as pre-specified eligibility criteria, pre-specified primary and secondary outcomes, detailed intervention description to allow replication, intervention random allocation and concealment, blinding in outcome assessment, appropriate sample size calculations, explanation of interim analysis, as per CONSORT Guidelines. Further, gender diversity is secured not only at recruitment but also throughout the trial and during the analysis. Therefore, treatment response outcomes will be examined per gender category. In order to manage anticipated problems, the protocol has included alternative approaches. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03241511 . Registered on 7 August 2017.

The Role of Alcohol on Antiretroviral Therapy Adherence Among Persons Living With HIV in Urban India.

OBJECTIVE: The purpose of this study was to estimate the prevalence of alcohol use among men living with HIV on antiretroviral therapy (ART) and examine the association of alcohol use and psychosocial variables on ART adherence. The study was a cross-sectional survey supplemented by medical records and qualitative narratives as a part of the initial formative stage of a multilevel, multicentric intervention and evaluation project. METHOD: A screening instrument was administered to men living with HIV (n = 3,088) at four ART Centers using the Alcohol Use Disorders Identification Test-consumption questions (AUDIT-C) to determine alcohol use for study eligibility. Alcohol screening data were triangulated with medical records of men living with HIV (n = 15,747) from 13 ART Centers to estimate alcohol consumption among men on ART in greater Mumbai. A survey instrument to identify associations between ART adherence and alcohol, psychosocial, and contextual factors was administered to eligible men living with HIV (n = 361), and in-depth interviews (n = 55) were conducted to elucidate the ways in which these factors are manifest in men's lives. RESULTS: Nearly one fifth of men living with HIV on ART in the Mumbai area have consumed alcohol in the last 30 days. Non-adherence was associated with a higher AUDIT score, consumption of more types of alcohol, and poorer self-ratings on quality of life, depression, and external stigma. The qualitative data demonstrate that non-adherence results from avoiding the mixing of alcohol with medication, forgetfulness when drinking, and skipping medication for fear of disclosure of HIV status when drinking with friends. CONCLUSIONS: As the demand for ART expands, Indian government programs will need to more effectively address alcohol to reduce risk and maintain effective adherence.

Community Gender Norms Change as a Part of a Multilevel Approach to Sexual Health Among Married Women in Mumbai, India.

Inequitable gender norms in societies and communities negatively contribute to women's sexual and reproductive health. While the need for change in gender norms is well recognized, the task is highly challenging in terms of intervention design, implementation and assessment of impact. This paper describes a methodology for identification of gender norms, the design of community level intervention, community participation and the assessment of intervention impact in a low income, predominately Muslim community of 600,000 people in Mumbai, India. Formative research focused on in-depth interviews with women, men and couples yielding gender normative statements and assessment of community resources to facilitate change. A Gender Equity Scale (GES) based on this formative research was developed and administered annually for a three-year period to random, cross-sectional samples in the intervention and control communities, and to community based, non-governmental organizations (NGO) staff and Imams (religious leaders) in the intervention community. NGO staff disseminated gender oriented messages to their female constituency through their regular outreach activities and through special events and festivals in the community. Imams disseminated gender messages through lectures on social issues for men attending Friday prayers. The results showed that the NGO staff and Imams, assumed more gender equitable attitudes across time. The intervention was associated with a significant improvement in attitudes towards gender equity in the intervention relative to the control community. Men showed a dramatic change in more positive gender attitudes, while women lagged behind in their GES scores. The meaning of these results are explored and the implications assessed for the generalizability of the methodology for other countries, cultures and communities.

End stage renal disease as a modifier of the periodontal microbiome.

BACKGROUND: Evidence supports high prevalence of periodontitis in patients with chronic kidney disease. Several renal factors have been proposed as possible modifiers of periodontitis pathogenesis in this population. In this cross sectional study, we investigated whether distinct microbial profiles in renal patients could explain high periodontitis prevalence. METHODS: We characterized the subgingival microbiome in 14 End Stage Renal Disease (ESRD) and 13 control individuals with chronic periodontitis with similar demographic and clinical parameters. Medical, demographic and periodontal parameters were recorded. Subgingival biofilm samples were collected from the deepest pocket in two different quadrants and characterized via 454-pyrosequencing of the 16S rRNA gene. RESULTS: We found 874 species-level operational taxonomic units (OTU) across samples. Renal and control groups did not differ in the individual proportions of periodontitis-associated taxa. However, in principal coordinate plots of distance among samples based on OTU prevalence, some renal patients clustered apart from controls, with the microbial communities of these outlier subjects showing less diversity. Univariate correlation analysis showed a significant negative correlation between dialysis vintage and community diversity. CONCLUSIONS: Within the study limitations, dialysis vintage was associated with a less diverse periodontal microbial community in ESRD suggesting the need for further research.

An approach to mental health in low and middle income countries: a case example from urban India.

Women in low and middle income countries (LMICs) facing poverty, challenging living conditions and gender inequality often express their emotional difficulties through physical health concerns and seek care at primary health facilities. However, primary care providers in LMICs only treat the physical health symptoms and lack appropriate services to address women's mental health problems. This paper, presents data from the counseling component of a multilevel, research and intervention project in a low income community in Mumbai, India whose objective was to improve sexual health and reduce HIV/STI risk among married women. Qualitative data from counselor notes shows that poor mental health, associated with negative and challenging life situations, is most often expressed by women as gynecological concerns through the culturally-based syndrome of tenshun. A path analysis was conducted on baseline quantitative data that confirmed the relationships between sources of tenshum, emotional status and symptoms of common mental disorders (CMDs). Based on these findings, the authors propose a need for culturally appropriate primary care services for LMICs that would integrate mental and physical health. This approach would reduce mental health morbidity among women through early intervention and prevention of the development of CMDs.

Microgravity alters the expression of salivary proteins.

Spaceflight provides a unique opportunity to study how physiologic responses are influenced by the external environment. Microgravity has been shown to alter the function of a number of tissues and organ systems. Very little, however, is known about how microgravity affects the oral cavity. The rodent model is useful for study in that their salivary gland morphology and physiology is similar to that of humans. Useful also is the fact that saliva, a product of the salivary glands with a major role in maintaining oral health, can be easily collected in humans whereas the glands can be studied in experimental animals. Our working hypothesis is that expression of secretory proteins in saliva will respond to microgravity and will be indicative of the nature of physiologic reactions to travel in space. This study was designed to determine which components of the salivary proteome are altered in mice flown on the US space shuttle missions and to determine if a subset with predictive value can be identified using microscopy and biochemistry methods. The results showed that the expression of secretory proteins associated with beta-adrenergic hormone regulated responses and mediated via the cyclic AMP pathway was significantly altered, whereas that of a number of unrelated proteins was not. The findings are potentially applicable to designing a biochemical test system whereby specific salivary proteins can be biomarkers for stress associated with travel in space and eventually for monitoring responses to conditions on earth.

The efficacy of contingency management for adolescent cannabis use disorder: a controlled study.

BACKGROUND: This study was performed to investigate the efficacy of a voucher-based reinforcement therapy (VBRT) rewarding drug-free urine for adolescents with cannabis use disorder. METHODS: A controlled 10-week study where 59 adolescents aged 14-18 years were assigned by cohorts into groups of either an integrated cognitive-behavioral therapy (CBT) and VBRT or CBT with attendance-based reward program. Substance use was monitored by twice-weekly urinalysis. Other measures were collected at pre- and posttreatment and at 3-month follow-up. RESULTS: There was no significant difference in the linear change between conditions for cannabis use either from Sessions 1 to 10 or between end-of-treatment to 3-month follow-up. Also, self-efficacy and coping response did not show improvement during treatment. CONCLUSIONS: In this study, the addition of contingency management (CM) to CBT in youth was not found to be more efficacious than similar compensation rewarding attendance only. Continued examination of the efficacy of CM and its interaction with the associated mechanisms of behavior change of CBT in youth is necessary. Examination of the effect of the magnitude of the reward as well as considering the emotional and cognitive developmental differences from adults is warranted.

Effects of a health care provider intervention in reduction of sexual risk and related outcomes in economically marginal communities in Mumbai, India.

BACKGROUND: The present study assessed the effectiveness of a brief narrative intervention implemented by trained biomedical and Ayurveda, Yoga, Unani, Siddha, Homeopathy (AYUSH) providers from three low-income communities in Mumbai, India. METHODS: A quasi-experimental research design compared attitudinal and behavioural changes among a cohort of 554 patients presenting gupt rog ('secret sexual illnesses') to biomedical and AYUSH providers who were trained in the narrative intervention model (NIM; referred to as 'narrative prevention counseling' in the intervention manual) with those providing standard care (untrained in NIM). Data were analysed using multivariate and longitudinal statistical models. RESULTS: Patients who received treatment for gupt rog from trained providers reported receiving a significantly higher number of services than those receiving services from untrained providers (mean 8.9 vs 7.6 services, respectively; P<0.001). In addition, a higher number of patients seeing the trained providers no longer had gupt rog problems than those seeing untrained providers (42% vs 25%, respectively; P<0.001). Patient-reported sex with a partner who was not the wife decreased significantly from baseline to follow-up for the entire sample but was significantly greater among patients receiving treatment from trained AYUSH providers (from 27% at baseline to 2% at follow up) compared with untrained providers (from 18% at baseline to 5% at follow up; P<0.001). CONCLUSIONS: The results support the effectiveness of brief narrative intervention in primary care settings for reducing sexual risk and associated vulnerabilities among married men.

Quality and efficiency in small practices transitioning to patient centered medical homes: a randomized trial.

BACKGROUND: There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition. OBJECTIVE: Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices. DESIGN: Randomized Controlled Trial. PARTICIPANTS: Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices. INTERVENTIONS: Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments. MAIN MEASURES: Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures. KEY RESULTS: Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures. CONCLUSIONS: In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

The subgingival microbiome in health and periodontitis and its relationship with community biomass and inflammation.

The goals of this study were to better understand the ecology of oral subgingival communities in health and periodontitis and elucidate the relationship between inflammation and the subgingival microbiome. Accordingly, we used 454-pyrosequencing of 16S rRNA gene libraries and quantitative PCR to characterize the subgingival microbiome of 22 subjects with chronic periodontitis. Each subject was sampled at two sites with similar periodontal destruction but differing in the presence of bleeding, a clinical indicator of increased inflammation. Communities in periodontitis were also compared with those from 10 healthy individuals. In periodontitis, presence of bleeding was not associated with different α-diversity or with a distinct microbiome, however, bleeding sites showed higher total bacterial load. In contrast, communities in health and periodontitis largely differed, with higher diversity and biomass in periodontitis. Shifts in community structure from health to periodontitis resembled ecological succession, with emergence of newly dominant taxa in periodontitis without replacement of primary health-associated species. That is, periodontitis communities had higher proportions of Spirochetes, Synergistetes, Firmicutes and Chloroflexi, among other taxa, while the proportions of Actinobacteria, particularly Actinomyces, were higher in health. Total Actinomyces load, however, remained constant from health to periodontitis. Moreover, an association existed between biomass and community structure in periodontitis, with the proportion of specific taxa correlating with bacterial load. Our study provides a global-scale framework for the ecological events in subgingival communities that underline the development of periodontitis. The association, in periodontitis, between inflammation, community biomass and community structure and their role in disease progression warrant further investigation.

A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices.

BACKGROUND: Transition to a Patient-Centered Medical Home (PCMH) is challenging in primary care, especially for smaller practices. OBJECTIVE: To test the effectiveness of providing external supports, including practice redesign, care management and revised payment, compared to no support in transition to PCMH among solo and small (<2-10 providers) primary care practices over 2 years. DESIGN: Randomized Controlled Trial. PARTICIPANTS: Eighteen supported practices (intervention) and 14 control practices (controls). INTERVENTIONS: Intervention practices received 6 months of intensive, and 12 months of less intensive, practice redesign support; 2 years of revised payment, including cost of National Council for Quality Assurance's (NCQA) Physician Practice Connections(®)-Patient-Centered Medical Home™ (PPC(®)-PCMH™) submissions; and 18 months of care management support. Controls received yearly participation payments plus cost of PPC(®)-PCMH™. MAIN MEASURES: PPC(®)-PCMH™ at baseline and 18 months, plus intervention at 7 months. KEY RESULTS: At 18 months, 5 % of intervention practices and 79% of control practices were not recognized by NCQA; 10% of intervention practices and 7% of controls achieved PPC(®)-PCMH™ Level 1; 5% of intervention practices and 0% of controls achieved PPC(®)-PCMH™ Level 2; and 80% of intervention practices and 14% of controls achieved PPC(®)-PCMH™ Level 3. Intervention practices were 27 times more likely to improve PPC(®)-PCMH™ by one level, irrespective of practice size (p < 0.001) 95% CI (5-157). Among intervention practices, a multilevel ordinal piecewise model of change showed a significant and rapid 7-month effect (p(time7) = 0.01), which was twice as large as the sustained effect over subsequent 12 months (p(time18) = 0.02). Doubly multivariate analysis of variance showed significant differential change by condition across PPC(®)-PCMH™ standards over time (p(time x group)=0.03). Intervention practices improved eight of nine standards, controls improved three of nine (p(PPC1) = 0.009; p(PPC2) = 0.005; p(PPC3) = 0.007). CONCLUSIONS: Irrespective of size, practices can make rapid and sustained transition to a PCMH when provided external supports, including practice redesign, care management and payment reform. Without such supports, change is slow and limited in scope.

Inflammation associated with neoplastic colonic polyps.

Little is known about the significance of inflammation in neoplastic colon polyps: tubular, tubulovillous, and villous polyps/adenomas (TVPs) and hyperplastic/serrated polyps (HSPs). We undertake this study to ascertain the significance of acute and chronic inflammation in neoplastic polyps. Eighty-one consecutive, randomized TVPs and fifty-four randomized HSPs accessioned in the UCHC surgical pathology laboratory were selected for final analysis. The TVPs display increased acute and chronic inflammation compared to normal and adjacent non-dysplastic colonic mucosa. Adenoma size correlates with degree of acute and chronic inflammation. TVPs show increased overall acute and chronic inflammation compared to HSPs of the same size. This difference was statistically highly significant (p<.001). The number of adenomas exhibiting high grade dysplasia was insufficient to evaluate the relationship between polyp inflammation, polyp size, and degree of dysplasia. The HSPs showed significantly lower incidence and severity of acute and chronic inflammation compared to the TVPs. No correlation was seen in the HSP group between polyp size and acute or chronic inflammation. The prevalence of IBD was higher in patients with HSP showing acute inflammation than in the general population, but this statistic may be skewed by the low overall incidence of acute inflammation in the HSP group.

Twelve-month follow-up of aftercare for adolescents with alcohol use disorders.

Adolescents with alcohol use disorders (AUDs) previously completed a randomized controlled outpatient aftercare study (Y. Kaminer, J. A. Burleson, & R. H. Burke, 2008) in which they were randomly assigned to in-person, brief telephone, or no-active aftercare. Youth were assessed at end of aftercare and at 3-, 6-, and 12-month follow-up on frequency and quantity of alcohol use. It was predicted that active aftercare (in-person and brief telephone) would be superior to no-active aftercare in reducing alcohol use, as shown in the original study. No subject or therapy group attributes were significant moderators of outcome. Active aftercare in general maintained short-term favorable effects by reducing relapse in youth with AUD and should be considered as part of standard procedures in therapeutic interventions for all alcohol and other substance use. In-person and the brief telephone procedures did not differ in their effectiveness. Structured communications with AUD youth during and after treatment by use of electronic technology rather than in-person contact might therefore be more fully investigated.

Dehydroepiandrosterone combined with exercise improves muscle strength and physical function in frail older women.

OBJECTIVES: To investigate the effects of dehydroepiandrosterone (DHEA) combined with exercise on bone mass, strength, and physical function in older, frail women. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: A major medical institution. PARTICIPANTS: Ninety-nine women (mean age 76.6 ± 6.0) with low sulfated DHEA (DHEAS) levels, low bone mass, and frailty. INTERVENTION: Participants received 50 mg/d DHEA or placebo for 6 months; all received calcium and cholecalciferol. Women participated in 90-minute twice-weekly exercise regimens. MEASUREMENTS: Hormone levels, bone mineral density (BMD), bone turnover markers, body composition, upper and lower extremity strength, physical performance. RESULTS: Eighty-seven women (88%) completed 6 months. There were no significant changes in BMD or bone turnover markers. DHEA supplementation resulted in gains in lower extremity strength (from 459 ± 121 N to 484 ± 147 N; P=.01). There was also improvement in Short Physical Performance Battery score, a composite score that focuses on lower extremity function, in those taking DHEA (from 10.1 ± 1.8 to 10.7 ± 1.9; P=.02). There were significant changes in all hormone levels, including DHEAS, estradiol, estrone, and testosterone, and a decline in sex hormone-binding globulin levels in those taking DHEA. CONCLUSION: DHEA supplementation improved lower extremity strength and function in older, frail women involved in a gentle exercise program of chair aerobics or yoga. No changes were found in BMD either due to small sample size, short duration of study or no effect. The physical function findings are promising and require further evaluation as frail women are at high risk for falls and fracture.

Improving pediatric asthma control among minority children participating in medicaid: providing practice redesign support to deliver a chronic care model.

BACKGROUND: Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have over-reliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach. OBJECTIVE: The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC). METHODS: In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt. RESULTS: Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315-4.204). In Phase II (the post-enrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients' asthma control. CONCLUSIONS: The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.

Sexual health, marital sex, and sexual risk in urban poor communities in India.

Marital sex has been an unaddressed component of sexual risk. This article explores marital sex and its link to men's extramarital sexual behavior in 3 economically marginal communities in Mumbai, India. Using in-depth interviews with women, men, and couples, qualitative results are presented on first night experiences, ability of women to refuse their husbands' demands for sex, sexual communication, and sexual pleasure associated with marital sex. Using regression analysis of survey data for 260 couples, the quantitative results indicate that greater sexual satisfaction for both men and women is significantly related to men's lesser involvement in extramarital sex. These results provide a basis for a couples' intervention effort that can yield greater marital and sexual communication and reduction in sexual risk.