Use it or lose it: The relationship between two image-based biomarkers in better understanding osteoarthritis progression in the wrist.

Bone tissue is influenced by its mechanical environment and adapts in response to its mechanical load. This is supported by studies analyzing bone adaptation in the knee and hip. Changes to the bone have also been found to precede cartilage degeneration in diseases such as osteoarthritis (OA). Our objective was to demonstrate the relationship between joint contact and bone density in the wrists of healthy adults. Static CT scans with a calibration phantom were taken to obtain measures of bone mineral density (vBMD) in 3 normalized depths; 0 - 2.5, 2.5 - 5, and 5 - 7.5 mm. Participants underwent a four-dimensional CT scan (4DCT) while performing maximum wrist extension to maximum wrist flexion. 3D bone models of the distal radius, scaphoid, and lunate were made, and analyzed vBMD and joint contact area (JCA) in the radiolunate (RL) and radioscaphoid (RS) joints separately. Correlation coefficients were calculated where vBMD was the dependent variable, and kinematic JCA throughout every 10 degrees of motion were the independent variables. Statistically significant independent variables associated with vBMD were assessed using a regression model and were entered in steps; (1) significant correlations, (2) sex, and (3) age.An increase in vBMD was significantly, positively associated with an increase in JCa. Notably, in the deeper regions (5 - 7.5 mm) of the radius that is primarily composed of trabecular bone. Sex contributed to the variance in vBMD, while age did not. Subchondral bone changes are influenced by wrist position, demonstrating that the wrist serves to bear load similar to the knee and hip.

A Kinematic Analysis of Wrist and Carpal Function Using Four-Dimensional Computed Tomography Technology: A Dynamic Perspective.

PURPOSE: An emerging imaging modality, four-dimensional computed tomography, can provide dynamic evaluation of carpal motion, which allows for a better understanding of how the carpals work together to achieve range of motion. The objective of this work was to examine kinematic motion of the carpus through a flexion/extension arc of motion using four-dimensional computed tomography. METHODS: A convenience sample of 20 uninjured participants underwent a four-dimensional computed tomography scanning protocol through a complete arc of flexion/extension motion. Kinematic changes in motion were quantified using helical axes motion data for each carpal. Rotation angles were compared between bones to identify differences in kinematic motion between bones. RESULTS: The bones within the proximal carpal row, the lunate, scaphoid, and triquetrum, rotate significantly to differing magnitudes at the ends of motion (40° of flexion and 40° of extension). The scaphoid rotates to the highest magnitude, followed by the triquetrum, and lastly, the lunate. The distal carpal row bones rotate to similar magnitudes throughout the entire range of motion. CONCLUSIONS: This work describes the kinematics of the carpals throughout dynamic in vivo flexion and extension. CLINICAL RELEVANCE: This study adds to an understanding of wrist mechanics and the possible clinical implications of pathological deviation from baseline kinematics.

Perceptions of the Healthcare System Among Black Men with Previously Undiagnosed Diabetes and Prediabetes.

OBJECTIVE: Given the significant disparities in diabetes burden and access to care, this study uses qualitative interviews of Black men having HbA1c levels consistent with previously undiagnosed diabetes or prediabetes to understand their perceptions of the healthcare system. RESEARCH DESIGN AND METHODS: We recruited Black men from Black-owned barbershops in Brooklyn, NY, who were screened using point-of-care HbA1c tests. Among those with HbA1c levels within prediabetes or diabetes thresholds, qualitative interviews were conducted to uncover prevalent themes related to their overall health status, health behaviors, utilization of healthcare services, and experiences with the healthcare system. We used a theoretical framework from the William and Mohammed medical mistrust model to guide our qualitative analysis. RESULTS: Fifty-two Black men without a prior history of diabetes and an HbA1c reading at or above 5.7% were interviewed. Many participants stated that their health was in good condition. Some participants expressed being surprised by their abnormal HbA1c reading because it was not previously mentioned by their healthcare providers. Furthermore, many of our participants shared recent examples of negative interactions with physicians when describing their experiences with the healthcare system. Finally, several participants cited a preference for incorporating non-pharmaceutical options in their diabetes management plans. CONCLUSION: To help alleviate the disparity in diabetes burden among Black men, healthcare providers should take a more active role in recognizing and addressing their own implicit biases, engage in understanding the specific healthcare needs and expectations of each patient, and consider emphasizing non-medication approaches to improve glycemic control.

Targeting versus Tailoring Educational Videos for Encouraging Deceased Organ Donor Registration in Black-Owned Barbershops.

In the U.S., black men are at highest risk for requiring kidney transplants but are among those least likely to register for organ donation. Prior outreach used videos culturally targeted for Black communities, yet registration rates remain insufficient to meet demand. Therefore, we assessed whether generic versus videos culturally targeted or personally tailored based on prior organ donation beliefs differentially increase organ donor registration. In a randomized controlled trial, 1,353 participants in Black-owned barbershops viewed generic, targeted, or tailored videos about organ donation. Logistic regression models assessed the relative impact of videos on: 1) immediate organ donor registration, 2) taking brochures, and 3) change in organ donation willingness stage of change from baseline. Randomization yielded approximately equal groups related to demographics and baseline willingness and beliefs. Neither targeted nor tailored videos differentially affected registration compared with the generic video, but participants in targeted and tailored groups were more likely to take brochures. Targeted (OR = 1.74) and tailored (OR = 1.57) videos were associated with incremental increases in organ donation willingness stage of change compared to the generic video. Distributing culturally targeted and individually tailored videos increased organ donor willingness stage of change among Black men in Black-owned barbershops but was insufficient for encouraging registration.Abbreviations: CI - confidence interval; DMV - Department of Motor Vehicles; BOBs - Black-owned barbershops; ODBI - organ donation belief index; ODWS - organ donation willingness stage of change; OR - odds ratio.

Including Medical Footage and Emotional Content in Organ Donation Educational Videos for Latinx Viewers.

We assessed whether videos with medical footage of organ preservation and transplantation plus sad, unresolved, or uplifting stories differentially affect deceased organ donor registration among clients in Latinx-owned barbershops and beauty salons. In a 2 × 3 randomized controlled trial, participants (N = 1,696, mean age 33 years, 67% female) viewed one of six videos. The control portrayed a mother who received a kidney (uplifting), excluding medical footage. Experimental videos included medical footage and/or showed a mother waiting (unresolved) or sisters mourning their brother's death (sad). Regression models assessed relative impact of medical footage and storylines on: (1) registry enrollment, (2) donation willingness stage of change, and (3) emotions. Randomization yielded approximately equal groups relative to age, sex, education, religion, nativity, baseline organ donation willingness, beliefs, and emotions. Overall, 14.8% of participants registered. Neither medical footage, sad, nor unresolved stories differentially affected registration and changes in organ donation willingness. Sad and unresolved stories increased sadness and decreased positive affect by ~0.1 logits compared with the uplifting story. Educational videos about organ donation which excluded or included medical footage and varying emotional valence of stories induced emotions marginally but did not affect viewers' registration decisions differently. Heterogeneity of responses within video groups might explain the attenuated impact of including medical footage and varying emotional content. In future work, we will report qualitative reasons for participants' registration decisions by analyzing the free text responses from the randomized trial and data from semistructured interviews that were conducted with a subset of participants.

Qualitative Research in Veterinary Medical Education: Part 1-Principles of Qualitative Design.

Qualitative methodologies are relative newcomers to health sciences education research. While they may look very different to their quantitative counterparts in terms of size and scope, when well-applied they offer a fresh perspective and generate valuable research findings. Although qualitative research is being increasingly conducted in veterinary medical education, there are few contextualized resources to assist those who would like to develop their expertise in this area. In this article, we address this by introducing the principles of qualitative research design in a veterinary medical education context. Drawing from a range of contemporary resources, we explore the types of research goals and questions that are amenable to qualitative inquiry and discuss the process of formulating a worthwhile research question. We explain what research paradigms are and introduce readers to some of the methodological options available to them in qualitative research. Examples from veterinary medical education are used to illustrate key points. In a second companion article, we will focus on the decisions that need to be made regarding data sampling, collection, and analysis. We will also consider how qualitative research is evaluated, and discuss how qualitative findings are applied. Taken together, the two articles build an understanding of qualitative research, illuminate its potential to contribute to the scholarship of teaching and learning in veterinary medical education, and equip readers with an improved capacity to appraise its value.

Qualitative Research in Veterinary Medical Education: Part 2-Carrying Out Research Projects.

This is the second of two articles that together comprise an orientation and introduction to qualitative research for veterinary medical educators who may be new to research, or for those whose research experience is based on the quantitative traditions of biomedicine. In the first article (Part 1-Principles of Qualitative Design), we explored the types of research interests and goals suited to qualitative inquiry and introduced the concepts of research paradigms and methodologies. In this second article, we move to the strategies and actions involved in conducting a qualitative study, including selection and sampling of research sites and participants, data collection and analysis. We introduce some guidelines for reporting qualitative research and explore the ways in which qualitative research is evaluated and the findings applied. Throughout, we provide illustrative examples from veterinary and human medical education and suggest useful resources for further reading. Taken together, the two articles build an understanding of qualitative research, outline how it may be conducted, and equip readers with an improved capacity to appraise its value.

TeamMate: A Longitudinal Study of New Zealand Working Farm Dogs. III. Factors Affecting the Risk of Dogs Being Lost from the Workforce.

Working farm dogs are essential to many livestock farmers. Little is known about factors that influence dogs' risk of being lost from work. This paper explores risk factors for farm dogs being lost through death, euthanasia and retirement. All enrolled dogs were working and a minimum of 18 months old. Five data collection rounds were performed over four years. Data about dogs were collected from owners and dogs were given physical examinations by veterinarians. Dogs that were lost from work were counted and owner-reported reasons for loss were recorded. Multivariable logistic regression modelling was used to investigate risk factors for loss. Of 589 dogs, 81 were lost from work. Of these, 59 dogs died or were euthanized and 22 were retired. Farm dogs tended to reach advanced ages, with 38% being 10 years or older when last examined. Acute injury or illness was the most commonly owner-reported reason for loss. Age group (p < 0.0001) and lameness (p = 0.04, OR = 1.8) significantly affected dogs' risk of being lost. These results expand our knowledge about factors that affect health, welfare and work in farm dogs. Further investigation into reasons for lameness may help improve health and welfare in working farm dogs.

Developing a coordinate-based strategy to support cognitive targeted prostate biopsies and correlative spatial-histopathological outcome analysis.

Lack of investment for magnetic resonance (MR) fusion systems is an obstacle to deliver targeted prostate biopsies within the prostate cancer diagnostic pathway. We developed a coordinate-based method to support cognitive targeted prostate biopsies and then performed an audit on cancer detection and the location of lesions. In each patient, the prostate is considered as two separate hemiprostates, and each hemiprostate is divided into 4 × 4 × 4 units. Each unit is therefore defined by a three-dimensional coordinate. We prospectively applied our coordinates approach to target 106 prostatic lesions in 93 men. Among 45 (of 106; 42.5%) lesions positive for cancer, 27 lesions (60.0%) harbored clinically significant disease. PSA density was significantly higher in patients with proven cancer (median: 0.264 ng ml-2) when compared to the noncancer group (median: 0.145 ng ml-2; P = 0.003, Wilcoxon rank-sum test). Lesions with Prostate Imaging-Reporting and Data System (PIRADS) score of 5 were found to have a cancer incidence of 65.2%, while PIRADS 4 and 3 lesions have a lower risk of cancer detection, as expected, at 37.3% and 31.3%, respectively. The probability of a lesion being cancerous in our series significantly decreases as we go from the "apex-to-base" dimension (odds ratio [OR]: 2.62, 95% confidence interval [CI]: 1.55-4.44, P = 0.00034). Our analysis also indicates that the probability of cancer decreases as the prostate volume increases (OR: 1.03, 95% CI: 1.01-1.05, P = 0.00327). Based on this feasibility study, the use of coordinates to guide cognitive targeted prostate biopsies warrants future validation study in additional centers.

TeamMate: A Longitudinal Study of New Zealand Working Farm Dogs. II. Occurrence of Musculoskeletal Abnormalities.

Musculoskeletal injury and disease are common in dogs, and a major cause of retirement in working dogs. Many livestock farmers rely on dogs for the effective running of their farms. However, the incidence of musculoskeletal disease has not been explored in working farm dogs. Here we explore the occurrence of musculoskeletal abnormalities in 323 working farm dogs that were enrolled in TeamMate, a longitudinal study of working farm dogs in New Zealand. All dogs were free of musculoskeletal abnormalities on enrolment to the study and were present for at least one follow-up examination. During the follow-up period, 184 dogs (57%, 95% confidence interval (CI) = 52%-62%) developed at least one musculoskeletal abnormality during 4,508 dog-months at risk, corresponding to 4.1 dogs (95% CI = 3.5-4.7) with recorded abnormalities per 100 dog-months at risk. The most common abnormalities were reduced range of motion and swelling of the carpus or stifle, while the hip was the most common site of pain. No major differences in incidence rate (IR) between sexes or types of dogs were observed, though Huntaways had a slightly lower rate of carpal abnormalities than Heading dogs (IR ratio = 0.6, 95% CI = 0.3-1.0). Eighty-one of 119 dogs (68%, 95% CI = 60%-76%) that had a first musculoskeletal abormality developed a second abnormality. The most common type of abnormality that was seen in the same dog more than once was reduced range of motion in the carpus (14 of 119 dogs, 12%, 95% CI = 6%-18%). Although we do not provide data on diagnoses, the high incidence rate of recorded musculoskeletal abnormalities and dogs' high activity mean it is likely that working farm dogs are at a high risk of conditions that could impair their welfare and reduce the lengths of their working careers. Preventing and managing musculoskeletal injury and illness should be a priority for owners and veterinarians caring for working farm dogs.

Qualitative Research in Veterinary Medical Education: Part 1-Principles of Qualitative Design.

Qualitative methodologies are relative newcomers to health sciences education research. While they may look very different to their quantitative counterparts in terms of size and scope, when well-applied they offer a fresh perspective and generate valuable research findings. Although qualitative research is being increasingly conducted in veterinary medical education, there are few contextualized resources to assist those who would like to develop their expertise in this area. In this article, we address this by introducing the principles of qualitative research design in a veterinary medical education context. Drawing from a range of contemporary resources, we explore the types of research goals and questions that are amenable to qualitative inquiry and discuss the process of formulating a worthwhile research question. We explain what research paradigms are and introduce readers to some of the methodological options available to them in qualitative research. Examples from veterinary medical education are used to illustrate key points. In a second companion article, we will focus on the decisions that need to be made regarding data sampling, collection, and analysis. We will also consider how qualitative research is evaluated, and discuss how qualitative findings are applied. Taken together, the two articles build an understanding of qualitative research, illuminate its potential to contribute to the scholarship of teaching and learning in veterinary medical education, and equip readers with an improved capacity to appraise its value.

Horses Used for Educational Purposes in New Zealand: A Descriptive Analysis of Their Use for Teaching.

Horses are used in practical teaching classes in many equine and veterinary science degree programmes to develop and refine the handling and clinical skills of students. In this study, the activities of 24 teaching horses grouped in three herds were investigated over an entire calendar year. Although also used for research and general husbandry, teaching-related activities were the predominant use of the horses. Herd B was used for a greater number of teaching sessions (median = 28, IQR = 27-29.5 per year) than herds M (median = 21, IQR = 20-21 per year) and T (median = 19.5, IQR = 13.75-25.5 per year), which translates to a relatively low workload (one or two weekly sessions during the teaching semester). Sedation was used in dentistry classes (in alignment with national best practice standards) but was rarely required for other teaching activities. Mare reproductive rectal- and medical rectal examination practical classes (specific to 5th-year veterinary teaching and characterised by more restraint (in stocks)) were significantly shorter and had fewer students per horse than the other practical classes. Although the low workload reported suggests an opportunity to increase students' exposure to horses without compromising the horses' welfare, further investigation to determine specific stressors to the horses in the teaching environment may be required.

A Descriptive Study of Training Methods for Fédération Equestre Internationale Endurance Horses in New Zealand.

Training measures, particularly those that examine the interactions between training volume, speed, and recovery, can improve understanding of training practices that contribute to success and avoid adverse horse welfare outcomes in endurance competitions. This study describes the training of Fédération Equestre Internationale (FEI) 100-160 km level horses in New Zealand. A convenience sample of 16 participants and 25 horses were surveyed before commencement of training. Participants then reported daily data for an entire nine-month season of training and competition. Participants began their season with predetermined goals and individual training plans for each horse. They intended to use competitions for training. Competitions contributed a median of 44% [IQR, 36%-49%] of total accumulated distance (in training and competition) for each horse for the season, despite being only 11% (207/1,933) of all days worked. Most starts (80%) were in domestic-level (CEN) competition ≤80 km. Speed ranged from 2-18 km/hour on home training days to 6-18.5 km/hour in CEN competitions and 10.9-16.9 km/hour in FEI competitions. Horses were worked 34% [IQR, 21-38] of days in training, ranging from 12% to 55% for individual horses. The most common horse health problem was lameness, affecting 12/25 horses, for a median of 9 (range, 1-78) days. This study highlights the potential for CEN data as a resource to improve understanding of training and competition load, speed, and recovery and therefore reduce adverse horse welfare outcomes in FEI competitions.

TeamMate: a longitudinal study of New Zealand working farm dogs. I. Methods, population characteristics and health on enrolment.

BACKGROUND: Working farm dogs are invaluable on New Zealand sheep and beef farms. To date no study describing farm dog population and health has included information about incidence of illness and injury, or risk factors affecting health and career duration. This paper describes the methodology and initial results from TeamMate, a longitudinal study that was designed to address this gap. We describe the study population, husbandry practices, and prevalence of clinical abnormalities on enrolment. METHODS: Data about the farms, owners, husbandry practices and dogs were collected on farm at approximately 6-month intervals. All dogs over 18 months old and in full work were enrolled. Dogs were given physical examinations by veterinarians. On examination all abnormalities were noted, regardless of clinical significance. RESULTS: Six hundred forty-one working farm dogs and 126 owners were enrolled from the South Island of New Zealand. Forty-nine percent of dogs were Heading dogs (314 of 641) and 48% Huntaways (308 of 641). Median age of dogs was 4 years (range 1.5-14) and median body condition score (BCS) was four on a 9-point scale (interquartile range (IQR) 3-5). Fifty-four percent of dogs were male (345 of 641), and 6% (41 of 641) were neutered. Eighty-one percent of owners (102 of 126) fed dogs commercial biscuits and meat sourced on farm. Forty-four percent of dogs (279 of 641) had bedding in their kennel, 14% (55 of 393) had insulated kennels, 69% (442 of 641) had been vaccinated and 33% (213 of 641) were insured. Clinical abnormalities were found in 74% of dogs (475 of 641). Common abnormalities involved the musculoskeletal system (43%, 273 of 641), skin (including scars and callouses; 42%, 272 of 641), and oral cavity (including worn and broken teeth; 35%, 227 of 641). CONCLUSIONS: Our results expand on those from previous surveys and indicate that musculoskeletal illness and injury, and skin trauma are the most commonly seen clinical abnormalities in working farm dogs. These results will provide a baseline for investigation of incidence and risk factors for illness, injury, retirement and death in New Zealand working farm dogs.

Benefits of Animal Exposure on Veterinary Students' Understanding of Equine Behaviour and Self-Assessed Equine Handling Skills.

Horses are one of the most dangerous animals veterinarians have to work with. For many veterinary students, their first exposure to horses occurs during practical classes. To evaluate the level of knowledge students have of equine behaviour and their equine handling competency when entering the programme, 214 veterinary students (1st and 4th year) were recruited to participate in a questionnaire. Participants were asked to choose one out of 12 terms that best represented the affective state of a horse in a picture, and to self-assess their equine handling skills. Half (n = 56/115) of the first-year students correctly interpreted the horse's behaviour. The majority had (1) a poor understanding of equine learning mechanisms and (2) poor self-rated equine handling skills. A history of pet ownership (p = 0.027) and the presence of horses on their family property (p = 0.001) were significantly associated with a correct understanding of equine behaviour. Fourth-year students were three times more likely to accurately interpret the horse's behaviour (p = 0.01) and rated their handling skills higher than first-year students (p = 0.006). These results suggest that previous animal experience confers a considerable advantage to interpret equine behaviour and highlight the critical importance of practical training in the veterinary programme.

Assessing veterinary students using in-training evaluation scores: what is being assessed?

In-training evaluations are commonly used for assessing veterinary students during clinical training, but are criticised for being unable to discriminate dimensions of performance. This study investigated scores on an in-training evaluation in use at one veterinary school to determine the dimensions being assessed and the influence of the dimensions on the overall score awarded. Common factor analysis and ordinal logistic regression were conducted on a retrospective sample of 3466 evaluations of 197 final year veterinary students. The findings suggested a higher-order dimensional structure, with one overarching factor and two to four subfactors, consistent with the complex construct of competency that thSAS Institute e assessment was intended to assess. In the four -factor model, all dimensions were significantly related to overall grade, with the effects of the professional attitude factor and the knowledge factor dependent on the placement. The professional attitude factor had the strongest effect on overall grade (ß=2.71, P=0.0004). There was a significant effect of placement on overall grade (P=0.021). Neither academic status of the supervisor nor grade point average had significant effects on the overall grade (P>0.49), and a student's overall grade did not significantly differ over time (P=1). The results suggest that the complexity of supervisor judgement is effectively represented in evaluation scores.

Secondary immune thrombocytopenia (ITP) as an initial presentation of Whipple's disease.

Immune thrombocytopenia (ITP) is a heterogeneous autoimmune disease characterized by low platelet count that has been associated with a number of chronic infections but rarely described as a manifestation of Whipple's disease (WD). We present a case of Whipple's disease in a patient initially diagnosed with ITP. A 46-year old male in the fifth decade of life presented with presumed idiopathic ITP and was treated with several therapies including corticosteroids, rituximab, and thrombopoietin receptor agonists. Several years later, he developed weight loss and worsening arthralgias. He was found to have evidence of WD in a jejunal lymph node, the duodenum, and the cerebral spinal fluid (CSF). His diagnosis of WD, as a cause of secondary ITP, came a full 8 years after he was discovered to have thrombocytopenia and over 4 years after he was diagnosed with ITP. WD is an uncommon, multiorgan system disease caused by the actinomycete Tropheryma whipplei. Whipple's disease presents a diagnostic challenge due to the wide array of possible presenting clinical manifestations, as well as a prolonged time course with separation of symptoms over many years. While T. whipplei is ubiquitous in the environment, few individuals develop clinical disease, raising the prospect that select immunodeficiencies, both singular or in combination, may play a role in infection. While rare, in the appropriate clinical setting, one should consider infection with T. whipplei in addition to other chronic infections as a cause of secondary ITP regardless of how long ago the diagnosis of ITP was made.

Lesson From the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program.

STUDY OBJECTIVE: In 2006, the Institute of Medicine emphasized substantial potential to expand organ donation opportunities through uncontrolled donation after circulatory determination of death (uDCDD). We pilot an out-of-hospital uDCDD kidney program for New York City in partnership with communities that it was intended to benefit. We evaluate protocol process and outcomes while identifying barriers to success and means for improvement. METHODS: We conducted a prospective, participatory action research study in Manhattan from December 2010 to May 2011. Daily from 4 to 12 pm, our organ preservation unit monitored emergency medical services (EMS) frequencies for cardiac arrests occurring in private locations. After EMS providers independently ordered termination of resuscitation, organ preservation unit staff determined clinical eligibility and donor status. Authorized parties, persons authorized to make organ donation decisions, were approached about in vivo preservation. The study population included organ preservation unit staff, authorized parties, passersby, and other New York City agency personnel. Organ preservation unit staff independently documented shift activities with daily operations notes and teleconference summaries that we analyzed with mixed qualitative and quantitative methods. RESULTS: The organ preservation unit entered 9 private locations; all the deceased lacked previous registration, although 4 met clinical screening eligibility. No kidneys were recovered. We collected 837 notes from 35 organ preservation unit staff. Despite frequently recounting protocol breaches, most responses from passersby including New York City agencies were favorable. No authorized parties were offended by preservation requests, yielding a Bayesian posterior median 98% (95% credible interval 76% to 100%). CONCLUSION: In summary, the New York City out-of-hospital uDCDD program was not feasible. There were frequent protocol breaches and confusion in determining clinical eligibility. In the small sample of authorized persons we encountered during the immediate grieving period, negative reactions were infrequent.

Voices of homeless alcoholics who frequent Bellevue Hospital: a qualitative study.

STUDY OBJECTIVE: We describe the evolution, environment, and psychosocial context of alcoholism from the perspective of chronically homeless, alcohol-dependent, frequent emergency department (ED) attendees. We use their words to explore how homelessness, health care, and other influences have contributed to the cause, progression, and management of their alcoholism. METHODS: We conducted detailed, semistructured, qualitative interviews, using a phenomenological approach with 20 chronically homeless, alcohol-dependent participants who had greater than 4 annual ED visits for 2 consecutive years at Bellevue Hospital in New York City. We used an administrative database and purposive sampling to obtain typical and atypical cases with diverse backgrounds. Interviews were audio recorded and transcribed verbatim. We triangulated interviews, field notes, and medical records. We used ATLAS.ti to code and determine themes, which we reviewed for agreement. We bracketed for researcher bias and maintained an audit trail. RESULTS: Interviews lasted an average of 50 minutes and yielded 800 pages of transcript. Fifty codes emerged, which were clustered into 4 broad themes: alcoholism, homelessness, health care, and the future. The participants' perspectives support a multifactorial process for the evolution of their alcoholism and its bidirectional reinforcing relationship with homelessness. Their self-efficacy and motivation for treatment is eroded by their progressive sense of hopelessness, which provides context for behaviors that reinforce stigma. CONCLUSION: Our study exposes concepts for further exploration in regard to the difficulty in engaging individuals who are incapable of envisioning a future. We hypothesize that a multidisciplinary harm reduction approach that integrates health and social services is achievable and would address their needs more effectively.