Publications

PURPOSE OF REVIEW

This study aims to describe bone marrow fat changes in diabetes and to discuss the potential role of marrow fat in skeletal fragility.

RECENT FINDINGS

Advances in non-invasive imaging have facilitated marrow fat research in humans. In contrast to animal studies which clearly demonstrate higher levels of marrow fat in diabetes, human studies have shown smaller and less certain differences. Marrow fat has been reported to correlate with A1c, and there may be a distinct marrow lipid saturation profile in diabetes. Greater marrow fat is associated with impaired skeletal health. Marrow fat may be a mediator of skeletal fragility in diabetes. Circulating lipids, growth hormone alterations, visceral adiposity, and hypoleptinemia have been associated with greater marrow fat and may represent potential mechanisms for the putative effects of diabetes on marrow fat, although other factors likely contribute. Additional research is needed to further define the role of marrow fat in diabetic skeletal fragility and to determine whether marrow fat is a therapeutic target.

A growing body of literature has demonstrated relationships between the composition of the airway microbiota (mixed-species communities of microbes that exist in the respiratory tract) and critical features of immune response and pulmonary function. These studies provide evidence that airway inflammatory status and capacity for repair are coassociated with specific taxonomic features of the airway microbiome. Although directionality has yet to be established, the fact that microbes are known drivers of inflammation and tissue damage suggests that in the context of chronic inflammatory airway disease, the composition and, more importantly, the function, of the pulmonary microbiome represent critical factors in defining airway disease outcomes.

HIV and poverty are inextricably intertwined in sub-Saharan Africa. Economic and livelihood intervention strategies have been suggested to help mitigate the adverse economic effects of HIV, but few intervention studies have focused specifically on HIV-positive persons. We conducted three pilot studies to assess a livelihood intervention consisting of an initial orientation and loan package of chickens and associated implements to create poultry microenterprises. We enrolled 15 HIV-positive and 22 HIV-negative participants and followed them for up to 18 months. Over the course of follow-up, participants achieved high chicken survival and loan repayment rates. Median monthly income increased, and severe food insecurity declined, although these changes were not statistically significant (P-values ranged from 0.11 to 0.68). In-depth interviews with a purposive sample of three HIV-positive participants identified a constellation of economic and psychosocial benefits, including improved social integration and reduced stigma.

BACKGROUND

Depression affects 20%-30% of people with HIV. Randomized controlled trials (RCTs) have demonstrated the effectiveness of interventions to improve depression among HIV-infected adults, but typically have highly selected populations which may limit generalizability. Inverse probability of sampling weights (IPSW) is a recently proposed method to transport (or standardize) findings from RCTs to a specific external target population.

METHODS

We used IPSW to transport the 6-month effect of the Measurement-Based Care (MBC) intervention on depression from the SLAM DUNC trial to a population of HIV-infected, depressed adults in routine care in the United States between 2010 and 2014.

RESULTS

In the RCT, MBC was associated with an improvement in depression at 6 months of 3.6 points on the Hamilton Depression Rating scale [95% confidence interval (CI): -5.9 to -1.3]. When IPSW were used to standardize results from the trial to the target population, the intervention effect was attenuated by 1.2 points (mean improvement 2.4 points; 95% CI: -6.1 to 1.3).

CONCLUSIONS

If implemented among HIV-infected, depressed adults in routine care, MBC may be less effective than in the RCT but can still be expected to reduce depression. Attenuation of the intervention effect among adults in routine care reflects the fact that the trial enrolled a larger proportion of individuals for whom the intervention was more effective. Given the burden of depression among HIV-infected adults, more effective interventions to improve depression are urgently needed. However, examining the transportability of trial findings is essential to understand whether similar effects can be expected if interventions are scaled-up.

BACKGROUND

Poor retention in HIV care is associated with worse clinical outcomes and increased HIV transmission. We examined the relationship between self-reported alcohol use, a potentially modifiable behavior, and retention.

METHODS

A total of 9694 people living with HIV from 7 participating US HIV clinical sites (the Centers for AIDS Research Network of Integrated Clinical Systems) contributed 23,225 observations from January 2011 to June 2014. The retention outcomes were (1) Institute of Medicine (IOM) retention: 2 visits within 1 year at least 90 days apart and (2) visit adherence [proportion of kept visits/(scheduled + kept visits)]. Alcohol use was measured with Alcohol Use Disorders Identification Test-C, generating drinking (never, moderate, and heavy) and binge frequency (never, monthly/less than monthly, weekly/daily) categories. Adjusted multivariable logistic models, accounting for repeat measures, were generated.

RESULTS

Of our sample, 82% was men, 46% white, 35% black, and 14% Hispanic. At first assessment, 37% of participants reported never drinking, 38% moderate, and 25% heavy, and 89% of the patients were retained (IOM retention measure). Participants' mean (SD) visit adherence was 84% (25%). Heavy alcohol use was associated with inferior IOM-defined retention (adjusted odds ratio 0.78, 95% confidence interval: 0.69 to 0.88), and daily/weekly binge drinking was associated with lower visit adherence (adjusted odds ratio = 0.90, 95% confidence interval: 0.82 to 0.98).

CONCLUSIONS

Both heavy drinking and frequent binge drinking were associated with worse retention in HIV care. Increased identification and treatment of heavy and binge drinking in HIV clinical care settings may improve retention in HIV care, with downstream effects of improved clinical outcomes and decreased HIV transmission.

OBJECTIVE

The Rheumatology Informatics System for Effectiveness (RISE) is a national electronic health record (EHR)-enabled registry. RISE passively collects data from EHRs of participating practices, provides advanced quality measurement and data analytic capacities, and fulfills national quality reporting requirements. Here we report the registry's architecture and initial data, and we demonstrate how RISE is being used to improve the quality of care.

METHODS

RISE is a certified Centers for Medicare and Medicaid Services Qualified Clinical Data Registry, allowing collection of data without individual patient informed consent. We analyzed data between October 1, 2014 and September 30, 2015 to characterize initial practices and patients captured in RISE. We also analyzed medication use among rheumatoid arthritis (RA) patients and performance on several quality measures.

RESULTS

Across 55 sites, 312 clinicians contributed data to RISE; 72% were in group practice, 21% in solo practice, and 7% were part of a larger health system. Sites contributed data on 239,302 individuals. Among the subset with RA, 34.4% of patients were taking a biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD) at their last encounter, and 66.7% were receiving a nonbiologic DMARD. Examples of quality measures include that 55.2% had a disease activity score recorded, 53.6% a functional status score, and 91.0% were taking a DMARD in the last year.

CONCLUSION

RISE provides critical infrastructure for improving the quality of care in rheumatology and is a unique data source to generate new knowledge. Data validation and mapping are ongoing and RISE is available to the research and clinical communities to advance rheumatology.