Publications

Communicating bad news to patients and their families is a difficult but routine responsibility for hospitalists. Most practitioners have little or no formal training for this task. Preparation for, delivery of, and follow-up to these conversations should be deliberately planned in order to meet patients' needs. In this article, we review the literature that guides this process and, with a case example, describe steps practitioners can take to effectively deliver bad news and pitfalls that should be avoided. As competency in this skill set is necessary for effective patient care, hands-on training should be part of the core curriculum for all health care practitioners. Hospitalists should be proficient in this area and may serve as role models and instructors for colleagues and trainees.

BACKGROUND

Few research studies have examined the HIV transmission risk behaviors of HIV-positive injection drug users (IDUs) who are men who have sex with men and women (MSMW).

METHODS

We compared unprotected vaginal or anal sex with an HIV-negative or unknown (UNK) status sexual partner of MSMW (n=118) with men who have sex exclusively with women (MSW; n=469) and men who have sex exclusively with men (MSM; n=90) using baseline information from the Intervention for Seropositive Injectors-Research and Evaluation (INSPIRE) study, a 4-city randomized controlled trial.

RESULTS

MSMW were twice as likely to report unprotected vaginal sex (P<0.001) and 3 times as likely to report unprotected anal sex with an HIV-negative/UNK status female partner (P<0.001) as MSW. MSMW did not differ in their report of unprotected insertive anal sex and were half as likely to report unprotected receptive anal sex with HIV-negative/UNK status men (P=0.02) as MSM. MSMW were 2 times as likely to report engaging in transactional sex (buying or selling sex in exchange for money, drugs, or housing) than MSM or MSW (81%, 43%, and 36%, respectively; P<0.001).

CONCLUSIONS

Further research is needed to understand the contexts of unprotected sex among HIV-positive injection drug-using MSMW. Prevention programs should target the unique prevention needs of this population, particularly their risk with female partners.

OBJECTIVE

To identify modifiable factors associated with health care utilization by HIV-negative seropositive injection drug users (IDUs).

METHODS

We analyzed longitudinal data from 966 participants in a randomized controlled trial of a behavioral intervention designed to address medical care, adherence, and risk reduction. The outcomes of this study were usual place for care (clinic vs. emergency room) and frequency of primary care visits.

RESULTS

Results of multiple logistic regression analysis showed that increase in "importance of HIV care scale" score (odds ratio [OR]=2.99; P<0.001), empowerment (OR=3.53; P<0.001), utilization of case management (OR=3.07; P=0.007), and having a stable residence (OR=2.63; P=0.008) were significantly associated with participants being "clinic users." Increase in importance of HIV care scale score (OR=5.65; P=0.01) increased empowerment (OR=2.42; P=0.005), taking greater control of one's health (OR=2.17; P=0.001), having health insurance (OR=2.58; P=0.003), utilization of case management (OR=3.14; P=0.027), and CD4 count>or=200 cells/mm (OR=2.09; P=0.007) were significantly associated with reporting 2 or more primary HIV care visits in the past 6 months.

CONCLUSIONS

Future interventions for this population may be strengthened by addressing the importance of HIV primary care; empowering participants with respect to the health care system; and promoting linkages to case management, health insurance, and local housing programs.

OBJECTIVE

The study goals were (1) to assess the feasibility of using an existing telephone health information and referral service for low-income, ethnically diverse women to recruit women for research participation; (2) to assess the feasibility of recruiting low-income, African American and Latino men into health research through the women callers to the telephone service; and (3) to describe the challenges women face and the strategies they use when talking to men about the men's health and research participation.

DESIGN

We recruited women for individual semi-structured qualitative interviews via the Every Woman Counts (EWC) telephone information and referral service, a California Department of Health Services Cancer Detection Program. This paper describes our eligibility and recruitment assessment, and our qualitative data from 23 interviews with low-income African American and Latino women who called EWC.

RESULTS

We found that it was feasible to recruit women, but not to recruit men through women who call this telephone service. Almost 50% (113) of women demographically eligible for recruitment, completed our screening questionnaire, despite calling EWC for a different purpose. Some 48% (54) of those women were eligible for an interview. Of interview-eligible women, 58% (10) of African Americans and 35% (13) of Latinos completed an interview. Only 17% (4) of women referred a man for participation in an interview for our study. Several themes emerged from our analysis of interview data: (1) women's role in men's health can be significant but is often uneasy; (2) challenges when talking to men about their health include health access, gender dynamics, and men's fear of health care; (3) women's understanding of research may be limited; (4) women use a range of strategies to address and overcome men's resistance to taking care of their health and participating in research.

CONCLUSIONS

The challenges women face when talking with men about their health affect their ability to effectively speak to men about research participation. However, EWC and similar telephone health services may be an effective means for recruiting low-income women to chemoprevention and other studies requiring healthy participants.

OBJECTIVE

This study assessed whether smoking in the movies was associated with smoking in young adults.

METHODS

A national web-enabled cross-sectional survey of 1528 young adults, aged 18-25, was performed between September and November 2005. Logistic regression and path analysis using probit regression were used to assess relationships between exposure to smoking in the movies and smoking behavior. Analysis was completed in December 2006.

RESULTS

Exposure to smoking in the movies predicted current smoking. The adjusted odds of current smoking increased by a factor of 1.21 for each quartile increase in exposure to smoking (p<0.01) in the movies, reaching 1.77 for the top exposure quartile. The unadjusted odds of established smoking (100+ cigarettes with current smoking) increased by 1.23 per quartile (p<0.001) of exposure, reaching 1.86 for the top quartile. This effect on established smoking was mediated by two factors related to smoking in the movies: positive expectations about smoking and exposure to friends and relatives who smoked, with positive expectations accounting for about two thirds of the effect.

CONCLUSIONS

The association between smoking in the movies and young adult smoking behavior exhibited a dose-response relationship; the more a young adult was exposed to smoking in the movies, the more likely he or she would have smoked in the past 30 days or have become an established smoker.

Cardiovascular disease (CVD) is the primary cause of death among women worldwide. In the United States, more women than men die of CVD every year. Research has shown that there are important sex differences in terms of prevention, diagnosis, treatment, and outcomes in patients with CVD. Although women are being included in clinical trials in increasing numbers, lack of knowledge about sex differences persists because sex-specific analysis and reporting of sex-specific results remains limited. This knowledge gap limits the ability of health care professionals to provide optimal care for both women and men. Ongoing support and encouragement is needed for both the inclusion of sufficient numbers of women in clinical trials and for the reporting of sex-specific results of CVD trials. This increased knowledge and awareness can then be used to optimize high quality care for men and women.

UNLABELLED

Acute biliary obstruction leads to periductal myofibroblasts and fibrosis, the origin of which is uncertain. Our study provides new information on this question in mice and humans. We show that bile duct obstruction induces a striking increase in cholangiocyte alphavbeta6 integrin and that expression of this integrin is directly linked to fibrogenesis through activation of transforming growth factor beta (TGF-beta). Administration of blocking antibody to alphavbeta6 significantly reduces the extent of acute fibrosis after bile duct ligation. Moreover, in beta6-null mice subjected to the injury, fibrosis is reduced by 50% relative to that seen in wild-type mice, whereas inflammation occurs to the same extent. The data indicate that alphavbeta6, rather than inflammation, is linked to fibrogenesis. It is known that alphavbeta6 binds latent TGF-beta and that binding results in release of active TGFbeta. Consistent with this, intracellular signaling from the TGFbeta receptor is increased after bile duct ligation in wild-type mice but not in beta6(-/-) mice, and a competitive inhibitor of the TGFbeta receptor type II blocks fibrosis to the same extent as antibody to alphavbeta6. In a survey of human liver disease, expression of alphavbeta6 is increased in acute, but not chronic, biliary injury and is localized to cholangiocyte-like cells.

CONCLUSION

Cholangiocytes respond to acute bile duct obstruction with markedly increased expression of alphavbeta6 integrin, which is closely linked to periductal fibrogenesis. The findings provide a rationale for the use of inhibitors of alphavbeta6 integrin or TGFbeta for down-regulating fibrosis in the setting of acute or ongoing biliary injury.