Subcellular Epithelial HMGB1 Expression Is Associated with Colorectal Neoplastic Progression, Male Sex, Mismatch Repair Protein Expression, Lymph Node Positivity, and an 'Immune Cold' Phenotype Associated with Poor Survival

New treatment targets are needed for colorectal cancer (CRC). We define expression of High Mobility Group Box 1 (HMGB1) protein throughout colorectal neoplastic progression and examine the biological consequences of aberrant expression. HMGB1 is a ubiquitously expressed nuclear protein that shuttles to the cytoplasm under cellular stress. HMGB1 impacts cellular responses, acting as a cytokine when secreted. A total of 846 human tissue samples were retrieved; 6242 immunohistochemically stained sections were reviewed. Subcellular epithelial HMGB1 expression was assessed in a CRC Tissue Microarray (n = 650), normal colonic epithelium (n = 75), adenomatous polyps (n = 52), and CRC polyps (CaP, n = 69). Stromal lymphocyte phenotype was assessed in the CRC microarray and a subgroup of CaP. Normal colonic epithelium has strong nuclear and absent cytoplasmic HMGB1. With progression to CRC, there is an emergence of strong cytoplasmic HMGB1 (p < 0.001), pronounced at the leading cancer edge within CaP (p < 0.001), and reduction in nuclear HMGB1 (p < 0.001). In CRC, absent nuclear HMGB1 is associated with mismatch repair proteins (p = 0.001). Stronger cytoplasmic HMGB1 is associated with lymph node positivity (p < 0.001) and male sex (p = 0.009). Stronger nuclear (p = 0.011) and cytoplasmic (p = 0.002) HMGB1 is associated with greater CD4⁺ T-cell density, stronger nuclear HMGB1 is associated with greater FOXP3⁺ (p < 0.001) and ICOS⁺ (p = 0.018) lymphocyte density, and stronger nuclear HMGB1 is associated with reduced CD8⁺ T-cell density (p = 0.022). HMGB1 does not directly impact survival but is associated with an 'immune cold' tumour microenvironment which is associated with poor survival (p < 0.001). HMGB1 may represent a new treatment target for CRC.

Low Intensity Shockwave Treatment Modulates Macrophage Functions Beneficial to Healing Chronic Wounds

Extracorporeal Shock Wave Therapy (ESWT) is used clinically in various disorders including chronic wounds for its pro-angiogenic, proliferative, and anti-inflammatory effects. However, the underlying cellular and molecular mechanisms driving therapeutic effects are not well characterized. Macrophages play a key role in all aspects of healing and their dysfunction results in failure to resolve chronic wounds. We investigated the role of ESWT on macrophage activity in chronic wound punch biopsies from patients with non-healing venous ulcers prior to, and two weeks post-ESWT, and in macrophage cultures treated with clinical shockwave intensities (150–500 impulses, 5 Hz, 0.1 mJ/mm²). Using wound area measurements and histological/immunohistochemical analysis of wound biopsies, we show ESWT enhanced healing of chronic ulcers associated with improved wound angiogenesis (CD31 staining), significantly decreased CD68-positive macrophages per biopsy area and generally increased macrophage activation. Shockwave treatment of macrophages in culture significantly boosted uptake of apoptotic cells, healing-associated cytokine and growth factor gene expressions and modulated macrophage morphology suggestive of macrophage activation, all of which contribute to wound resolution. Macrophage ERK activity was enhanced, suggesting one mechanotransduction pathway driving events. Collectively, these in vitro and in vivo findings reveal shockwaves as important regulators of macrophage functions linked with wound healing. This immunomodulation represents an underappreciated role of clinically applied shockwaves, which could be exploited for other macrophage-mediated disorders.

The Impact of NOD2 Variants on Fecal Microbiota in Crohn's Disease and Controls Without Gastrointestinal Disease

BACKGROUND/AIMS

Current models of Crohn's disease (CD) describe an inappropriate immune response to gut microbiota in genetically susceptible individuals. NOD2 variants are strongly associated with development of CD, and NOD2 is part of the innate immune response to bacteria. This study aimed to identify differences in fecal microbiota in CD patients and non-IBD controls stratified by NOD2 genotype.

METHODS

Patients with CD and non-IBD controls of known NOD2 genotype were identified from patients in previous UK IBD genetics studies and the Cambridge bioresource (genotyped/phenotyped volunteers). Individuals with known CD-associated NOD2 mutations were matched to those with wild-type genotype. We obtained fecal samples from patients in clinical remission with low fecal calprotectin (<250 µg/g) and controls without gastrointestinal disease. After extracting DNA, the V1-2 region of 16S rRNA genes were polymerase chain reaction (PCR)-amplified and sequenced. Analysis was undertaken using the mothur package. Volatile organic compounds (VOC) were also measured.

RESULTS

Ninety-one individuals were in the primary analysis (37 CD, 30 bioresource controls, and 24 household controls). Comparing CD with nonIBD controls, there were reductions in bacterial diversity, Ruminococcaceae, Rikenellaceae, and Christensenellaceae and an increase in Enterobacteriaceae. No significant differences could be identified in microbiota by NOD2 genotype, but fecal butanoic acid was higher in Crohn's patients carrying NOD2 mutations.

CONCLUSIONS

In this well-controlled study of NOD2 genotype and fecal microbiota, we identified no significant genotype-microbiota associations. This suggests that the changes associated with NOD2 genotype might only be seen at the mucosal level, or that environmental factors and prior inflammation are the predominant determinant of the observed dysbiosis in gut microbiota.

Molecular Analysis of the Microbiome in Colorectal Cancer

The human gut microbiota plays a major role in the development of colorectal cancer (CRC). Many studies have attempted to define links between microbiota residents, their function and disease development. We now have incredible molecular tools to allow us to study the gut microbiome however in order to make best use of these sophisticated approaches we need to ensure that samples are collected and processed using standardized and reproducible protocols. Here we provide an overview of molecular analysis methods and describe protocols for collecting and processing clinical samples for subsequent microbiome analysis.

First-Pass Meconium Samples from Healthy Term Vaginally-Delivered Neonates: An Analysis of the Microbiota

Background

Considerable effort has been made to categorise the bacterial composition of the human gut and correlate findings with gastrointestinal disease. The infant gut has long been considered sterile at birth followed by rapid colonisation; however, this view has recently been challenged. We examined first-pass meconium from healthy term infants to confirm or refute sterility.

Methods

Healthy mothers were approached following vaginal delivery. First-pass meconium stools within 24 hours of delivery were obtained from healthy, breastfed infants with tight inclusion/exclusion criteria including rejecting any known antibiotic exposure - mother within 7 days preceding delivery or infant after birth. Stools were processed in triplicate for fluorescent in-situ hybridisation (FISH) with 16S rRNA-targeted probes including Bifidobacterium; Bacteroides-Prevotella; Lactobacillaceae/Enterococcaceae; Enterobacteriaceae; Streptococcaceae; Staphylococcaceae and Enterococcaceae. Absolute counts of all bacteria and proportional identification of each bacterial group were calculated. Confirmation of bacterial presence by PCR was undertaken on FISH-positive samples.

Results

The mothers of 31 newborn infants were recruited, 15 met inclusion/exclusion criteria and provided a sample within 24 hours of birth, processed in the lab within 4 hours. All babies were 37–40 weeks gestation. 8/15 were male, mean birth weight was 3.4kg and mean maternal age was 32 years. Meconium samples from 10/15 (66%) infants had evidence of bacteria based on FISH analysis. Of these, PCR was positive in only 1. Positive FISH counts ranged from 2.2 - 41.8 x 10⁴ cells/g with a mean of 15.4 x 10⁴ cells/g. (The limit of detection for automated counting is 10⁶ cells/g). Cell counts were too low to allow formal diversity analysis. Amplification by PCR was not possible despite positive spiked samples demonstrating the feasibility of reaction. One baby was dominated by Enterobacteriaceae. The others contained 2-5 genera, with Bifidobacterium, Enterobacteriaceae, Enterococcaceae and Bacteroides-Prevotella the most prevalent. There was no association between bacterial counts and rupture of membrane duration, time to passage of meconium or time to lab.

Conclusion

This study provides evidence that low numbers of bacteria are present in first-pass meconium samples from healthy, vaginally-delivered, breastfed term infants. Only two-thirds of meconium samples had detectable bacteria, though at levels too low for automated counting or for reliable confirmation by PCR. This study suggests that gut bacterial colonisation is extremely limited at birth and occurs rapidly thereafter.

Mucosal microbiome in patients with recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common disease affecting oral mucosae. Etiology is unknown, but several factors have been implicated, all of which influence the composition of microbiota residing on oral mucosae, which in turn modulates immunity and thereby affects disease progression. Although no individual pathogens have been conclusively shown to be causative agents of RAS, imbalanced composition of the oral microbiota may play a key role. In this study, we sought to determine composition profiles of bacterial microbiota in the oral mucosa associated with RAS. Using high-throughput 16S rRNA gene sequencing, we characterized the most abundant bacterial populations residing on healthy and ulcerated mucosae in patients with RAS (recruited using highly stringent criteria) and no associated medical conditions; we also compared these to the bacterial microbiota of healthy controls (HCs). Phylum-level diversity comparisons revealed decreased Firmicutes and increased Proteobacteria in ulcerated sites, as compared with healthy sites in RAS patients, and no differences between RAS patients with healthy sites and HCs. Genus-level analysis demonstrated higher abundance of total Bacteroidales in RAS patients with healthy sites over HCs. Porphyromonadaceae comprising species associated with periodontal disease and Veillonellaceae predominated in ulcerated sites over HCs, while no quantitative differences of these families were observed between healthy sites in RAS patients and HCs. Streptococcaceae comprising species associated with oral health predominated in HCs over ulcerated sites but not in HCs over healthy sites in RAS patients. This study demonstrates that mucosal microbiome changes in patients with idiopathic RAS--namely, increased Bacteroidales species in mucosae of RAS patients not affected by active ulceration. While these changes suggest a microbial role in initiation of RAS, this study does not provide data on causality. Within this limitation, the study contributes to the understanding of the potential role of mucosal microbiome changes in oral mucosal disease.

The fungal microbiota of de-novo paediatric inflammatory bowel disease

Inflammatory bowel disease (IBD) is characterised by an inappropriate chronic immune response against resident gut microbes. This may be on account of distinct changes in the gut microbiota termed as dysbiosis. The role of fungi in this altered luminal environment has been scarcely reported. We studied the fungal microbiome in de-novo paediatric IBD patients utilising next generation sequencing and compared with adult disease and normal controls. We report a distinct difference in fungal species with Ascomycota predominating in control subjects compared to Basidiomycota dominance in children with IBD, which could be as a result of altered tolerance in these patients.

The impact of different DNA extraction kits and laboratories upon the assessment of human gut microbiota composition by 16S rRNA gene sequencing

INTRODUCTION

Determining bacterial community structure in fecal samples through DNA sequencing is an important facet of intestinal health research. The impact of different commercially available DNA extraction kits upon bacterial community structures has received relatively little attention. The aim of this study was to analyze bacterial communities in volunteer and inflammatory bowel disease (IBD) patient fecal samples extracted using widely used DNA extraction kits in established gastrointestinal research laboratories.

METHODS

Fecal samples from two healthy volunteers (H3 and H4) and two relapsing IBD patients (I1 and I2) were investigated. DNA extraction was undertaken using MoBio Powersoil and MP Biomedicals FastDNA SPIN Kit for Soil DNA extraction kits. PCR amplification for pyrosequencing of bacterial 16S rRNA genes was performed in both laboratories on all samples. Hierarchical clustering of sequencing data was done using the Yue and Clayton similarity coefficient.

RESULTS

DNA extracted using the FastDNA kit and the MoBio kit gave median DNA concentrations of 475 (interquartile range 228-561) and 22 (IQR 9-36) ng/µL respectively (p<0.0001). Hierarchical clustering of sequence data by Yue and Clayton coefficient revealed four clusters. Samples from individuals H3 and I2 clustered by patient; however, samples from patient I1 extracted with the MoBio kit clustered with samples from patient H4 rather than the other I1 samples. Linear modelling on relative abundance of common bacterial families revealed significant differences between kits; samples extracted with MoBio Powersoil showed significantly increased Bacteroidaceae, Ruminococcaceae and Porphyromonadaceae, and lower Enterobacteriaceae, Lachnospiraceae, Clostridiaceae, and Erysipelotrichaceae (p<0.05).

CONCLUSION

This study demonstrates significant differences in DNA yield and bacterial DNA composition when comparing DNA extracted from the same fecal sample with different extraction kits. This highlights the importance of ensuring that samples in a study are prepared with the same method, and the need for caution when cross-comparing studies that use different methods.

The microaerophilic microbiota of de-novo paediatric inflammatory bowel disease: the BISCUIT study

INTRODUCTION

Children presenting for the first time with inflammatory bowel disease (IBD) offer a unique opportunity to study aetiological agents before the confounders of treatment. Microaerophilic bacteria can exploit the ecological niche of the intestinal epithelium; Helicobacter and Campylobacter are previously implicated in IBD pathogenesis. We set out to study these and other microaerophilic bacteria in de-novo paediatric IBD.

PATIENTS AND METHODS

100 children undergoing colonoscopy were recruited including 44 treatment naïve de-novo IBD patients and 42 with normal colons. Colonic biopsies were subjected to microaerophilic culture with Gram-negative isolates then identified by sequencing. Biopsies were also PCR screened for the specific microaerophilic bacterial groups: Helicobacteraceae, Campylobacteraceae and Sutterella wadsworthensis.

RESULTS

129 Gram-negative microaerophilic bacterial isolates were identified from 10 genera. The most frequently cultured was S. wadsworthensis (32 distinct isolates). Unusual Campylobacter were isolated from 8 subjects (including 3 C. concisus, 1 C. curvus, 1 C. lari, 1 C. rectus, 3 C. showae). No Helicobacter were cultured. When comparing IBD vs. normal colon control by PCR the prevalence figures were not significantly different (Helicobacter 11% vs. 12%, p = 1.00; Campylobacter 75% vs. 76%, p = 1.00; S. wadsworthensis 82% vs. 71%, p = 0.312).

CONCLUSIONS

This study offers a comprehensive overview of the microaerophilic microbiota of the paediatric colon including at IBD onset. Campylobacter appear to be surprisingly common, are not more strongly associated with IBD and can be isolated from around 8% of paediatric colonic biopsies. S. wadsworthensis appears to be a common commensal. Helicobacter species are relatively rare in the paediatric colon.

TRIAL REGISTRATION

This study is publically registered on the United Kingdom Clinical Research Network Portfolio (9633).

A comprehensive evaluation of colonic mucosal isolates of Sutterella wadsworthensis from inflammatory bowel disease

Inflammatory bowel disease (IBD) arises in genetically susceptible individuals as a result of an unidentified environmental trigger, possibly a hitherto unknown bacterial pathogen. Twenty-six clinical isolates of Sutterella wadsworthensis were obtained from 134 adults and 61 pediatric patients undergoing colonoscopy, of whom 69 and 29 respectively had IBD. S. wadsworthensis was initially more frequently isolated from IBD subjects, hence this comprehensive study was undertaken to elucidate its role in IBD. Utilizing these samples, a newly designed PCR was developed, to study the prevalence of this bacterium in adult patients with ulcerative colitis (UC). Sutterella wadsworthensis was detected in 83.8% of adult patients with UC as opposed to 86.1% of control subjects (p = 0.64). Selected strains from IBD cases and controls were studied to elicit morphological, proteomic, genotypic and pathogenic differences. This study reports Scanning Electron Microscopy (SEM) appearances and characteristic MALDI-TOF MS protein profiles of S. wadsworthensis for the very first time. SEM showed that the bacterium is pleomorphic, existing in predominantly two morphological forms, long rods and coccobacilli. No differences were noted in the MALDI-TOF mass spectrometry proteomic analysis. There was no distinct clustering of strains identified from cases and controls on sequence analysis. Cytokine response after monocyte challenge with strains from patients with IBD and controls did not yield any significant differences. Our studies indicate that S. wadsworthensis is unlikely to play a role in the pathogenesis of IBD. Strains from cases of IBD could not be distinguished from those identified from controls.

Detection of Campylobacter concisus and other Campylobacter species in colonic biopsies from adults with ulcerative colitis

INTRODUCTION

The critical role of bacteria in the pathogenesis of ulcerative colitis (UC) is well recognized, but an individual causative microorganism has not been singled out so far. Campylobacter concisus and other non-jejuni species of Campylobacter have been implicated as putative aetiological agents in inflammatory bowel disease in children, but such studies have not been addressed in adults. This study investigated the prevalence of Campylobacter species in colonic biopsy samples from adults with UC and healthy controls.

METHODS

Adult patients who were undergoing diagnostic colonoscopy were recruited for the study, which included 69 patients with histologically proven UC and 65 healthy controls. DNA was extracted from the biopsy samples and subjected to Campylobacter genus specific and Campylobacter concisus specific polymerase chain reaction and sequencing.

RESULTS

Detection of all Campylobacter DNA utilising genus specific primers was significantly higher in cases of UC, with a prevalence of 73.9% (51/69) compared to 23.1% (15/65) in controls (p = 0.0001). Nested PCR for C. concisus DNA was positive in 33.3% (23/69) of biopsy samples from subjects with UC, which was significantly higher than the prevalence rate of 10.8% (7/65) from controls (p = 0.0019). Sequencing of the remaining Campylobacter positive samples revealed that Campylobacter ureolyticus was positive in 21.7% (15/69) of samples from UC subjects as opposed to 3.1% (2/65) in controls (p = 0.0013). Mixed Campylobacter species were more common in UC patients, 20.3% (14/69) as compared to controls 4.6% (3/65) (p = 0.0084).

CONCLUSION

The higher prevalence of Campylobacter genus and more specifically C. concisus and C. ureolyticus in biopsy samples from adults with UC suggests these genera of bacteria may be involved in the chronic inflammation that is characteristically seen in UC. To the best of our knowledge this is the first report of this association of C. concisus and C. ureolyticus with UC in adults.

Biochemical characterization of Sinorhizobium meliloti mutants reveals gene products involved in the biosynthesis of the unusual lipid A very long-chain fatty acid

Sinorhizobium meliloti forms a symbiosis with the legume alfalfa, whereby it differentiates into a nitrogen-fixing bacteroid. The lipid A species of S. meliloti are modified with very long-chain fatty acids (VLCFAs), which play a central role in bacteroid development. A six-gene cluster was hypothesized to be essential for the biosynthesis of VLCFA-modified lipid A. Previously, two cluster gene products, AcpXL and LpxXL, were found to be essential for S. meliloti lipid A VLCFA biosynthesis. In this paper, we show that the remaining four cluster genes are all involved in lipid A VLCFA biosynthesis. Therefore, we have identified novel gene products involved in the biosynthesis of these unusual lipid modifications. By physiological characterization of the cluster mutant strains, we demonstrate the importance of this gene cluster in the legume symbiosis and for growth in the absence of salt. Bacterial LPS species modified with VLCFAs are substantially less immunogenic than Escherichia coli LPS species, which lack VLCFAs. However, we show that the VLCFA modifications do not suppress the immunogenicity of S. meliloti LPS or affect the ability of S. meliloti to induce fluorescent plant defense molecules within the legume. Because VLCFA-modified lipids are produced by other rhizobia and mammalian pathogens, these findings will also be important in understanding the function and biosynthesis of these unusual fatty acids in diverse bacterial species.

Enterohepatic helicobacter in ulcerative colitis: potential pathogenic entities?

BACKGROUND

Changes in bacterial populations termed "dysbiosis" are thought central to ulcerative colitis (UC) pathogenesis. In particular, the possibility that novel Helicobacter organisms play a role in human UC has been debated but not comprehensively investigated. The aim of this study was to develop a molecular approach to investigate the presence of Helicobacter organisms in adults with and without UC.

METHODOLOGY/PRINCIPAL FINDINGS

A dual molecular approach to detect Helicobacter was developed. Oligonucleotide probes against the genus Helicobacter were designed and optimised alongside a validation of published H. pylori probes. A comprehensive evaluation of Helicobacter genus and H. pylori PCR primers was also undertaken. The combined approach was then assessed in a range of gastrointestinal samples prior to assessment of a UC cohort. Archival colonic samples were available from 106 individuals for FISH analysis (57 with UC and 49 non-IBD controls). A further 118 individuals were collected prospectively for dual FISH and PCR analysis (86 UC and 32 non-IBD controls). An additional 27 non-IBD controls were available for PCR analysis. All Helicobacter PCR-positive samples were sequenced. The association between Helicobacter and each study group was statistically analysed using the Pearson Chi Squared 2 tailed test. Helicobacter genus PCR positivity was significantly higher in UC than controls (32 of 77 versus 11 of 59, p = 0.004). Sequence analysis indicated enterohepatic Helicobacter species prevalence was significantly higher in the UC group compared to the control group (30 of 77 versus 2 of 59, p<0.0001). PCR and FISH results were concordant in 74 (67.9%) of subjects. The majority of discordant results were attributable to a higher positivity rate with FISH than PCR.

CONCLUSIONS/SIGNIFICANCE

Helicobacter organisms warrant consideration as potential pathogenic entities in UC. Isolation of these organisms from colonic tissue is needed to enable interrogation of pathogenicity against established criteria.

Influence of isoflurane general anesthesia or anesthesia and surgery on thyroid function tests in dogs

BACKGROUND

Anesthesia and surgery affect thyroid function tests in humans but have not been studied in dogs.

HYPOTHESIS

Anesthesia and anesthesia with surgery will affect thyroid function tests in dogs.

ANIMALS

Fifteen euthyroid dogs.

METHODS

Prospective, controlled, interventional study. Dogs were assigned to one of 3 groups: control, general anesthesia, and general anesthesia plus abdominal exploratory surgery. Dogs in the anesthesia and surgery groups were premedicated with acepromazine and morphine, induced with propofol, and maintained on isoflurane. Samples for measurement of serum thyroxine (T4), free T4 (fT4) by equilibrium dialysis, triiodothyronine (T3), reverse T3 (rT3), and thyroid-stimulating hormone concentrations were collected from each dog immediately before premedication, at multiple times during anesthesia, surgery, 4, 8, 12, 24, 36, and 48 hours after anesthesia, once daily for an additional 5 days, and once 14 days after anesthesia. Sampling was performed at identical times in the control group.

RESULTS

Serum T4 decreased significantly from baseline in the surgery and anesthesia groups compared with the control group at 0.33 (P= 0.043) and 1 hour (P= 0.018), and 2 (P= 0.031) and 4 hours (P= 0.037), respectively, then increased significantly in the surgery group compared with the control group at 24 hours (P= 0.005). Serum T3 decreased significantly from baseline in the anesthesia group compared with the control group at 1 hour (P= 0.034). Serum rT3 increased significantly from baseline in the surgery group compared with the control and anesthesia groups at 8 (P= 0.026) and 24 hours (P= 0.0001) and anesthesia group at 8, 12, 24, and 36 hours (P= 0.004, P= 0.016, P= 0.004, and P= 0.014, respectively). Serum fT4 increased significantly from baseline in the surgery group compared to the control at 24 hours (P= 0.006) and at day 7 (P= 0.037) and anesthesia group at 48 hours (P= 0.023).

CONCLUSIONS AND CLINICAL IMPORTANCE

Surgery and anesthesia have a significant effect on thyroid function tests in dogs.

Localization and identification of thrombin and plasminogen activator activities in model human thrombi by in situ zymography

Human thrombi vary in their susceptibility to lysis and this is clinically important. Several potential contributory factors were examined in this study by using model thrombi, created under flow; these provide a robust, reproducible and easily-manipulated system. Here we identify the plasminogen activators (PA) active in model thrombi of known age and define the cellular and plasma contribution to activity in different areas. The cell-rich head of model thrombi had strong thrombin and PA activity, with coagulant activity also at the tail. Thrombin activity decreased as model thrombi were aged. PA activity in the thrombus head also decreased on ageing of thrombi but activity emerged around the thrombi, including the tail. Activity in the head of fresh model thrombi was primarily due to uPA, with some contribution from tPA. Experiments with thrombi prepared from platelet-rich plasma and added leucocytes showed that uPA activity at the head of fresh thrombi was derived from PMN. Older thrombi had tPA activity around the tail of the thrombus; this activity occurred in the absence of cells. This study highlights the importance of PMN-derived uPA activity in the lysis of fresh thrombi, with activity originating in the leucocyte-rich head. It also shows that thrombi are dynamic structures in which fibrin can be repeatedly laid down and lysed, observations that are relevant to therapeutic lysis and potential rethrombosis.

The care of HIV-infected adults in rural areas of the United States

OBJECTIVE

This study describes the population of HIV-infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas.

METHODS

Interviews were conducted with a nationally representative sample of 367 HIV-infected adults receiving health care in rural areas and 2806 HIV-infected adults receiving health care in urban areas of the contiguous United States.

RESULTS

We estimate that 4800 HIV-infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV-infected patients (38% vs. 3%; p <.001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p <.001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p =.006).

CONCLUSIONS

Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high-quality HIV care.

A national survey of stress reactions after the September 11, 2001, terrorist attacks

BACKGROUND

People who are not present at a traumatic event may also experience stress reactions. We assessed the immediate mental health effects of the terrorist attacks on September 11, 2001.

METHODS

Using random-digit dialing three to five days after September 11, we interviewed a nationally representative sample of 569 U.S. adults about their reactions to the terrorist attacks and their perceptions of their children's reactions.

RESULTS

Forty-four percent of the adults reported one or more substantial stress symptoms; 91 percent had one or more symptoms to at least some degree. Respondents throughout the country reported stress syndromes. They coped by talking with others (98 percent), turning to religion (90 percent), participating in group activities (60 percent), and making donations (36 percent). Eighty-five percent of parents reported that they or other adults in the household had talked to their children about the attacks for an hour or more; 34 percent restricted their children's television viewing. Thirty-five percent of children had one or more stress symptoms, and 47 percent were worried about their own safety or the safety of loved ones.

CONCLUSIONS

After the September 11 terrorist attacks, Americans across the country, including children, had substantial symptoms of stress. Even clinicians who practice in regions that are far from the recent attacks should be prepared to assist people with trauma-related symptoms of stress.

Expectations regarding aging among older adults and physicians who care for older adults

BACKGROUND

Understanding older adults' expectations regarding aging is important for both clinicians and policy-makers.

OBJECTIVES

1) To identify the content for a survey to measure expectations regarding aging; 2) to qualitatively compare older adults' and physicians' expectations regarding aging.

SETTING

Three senior centers and one university-based internal medicine faculty practice.

PARTICIPANTS

Forty-nine adults (mean age 78 years); 11 primary care clinicians (mean age 37 years).

MEASUREMENTS

A facilitator conducted five focus groups of older adults and two of physicians using a standardized script designed to elicit expectations regarding aging. Qualitative analysis by two independent reviewers identified domains of expectations, with a 3rd reviewer used to resolve discrepancies. A corresponding coding scheme was applied to each line of the transcripts. Content and frequency of expectations regarding aging and beliefs regarding care seeking were examined and compared.

RESULTS

Content analysis identified 26 domains of expectations regarding aging. Each of the seven most frequently mentioned domains of expectations was mentioned by at least 50% of participants. Of 760 unique statements coded, the most frequently described domains in both the older adult and physician groups were physical function, cognitive function, social function, pain, and sexual function. Older adults differed from physicians by describing five mental-health related domains: anxiety, emotional-well-being, happiness, sleep, and length of life/death.

CONCLUSIONS

Using focus groups of older adults and physicians, we identified consistent content for a closed-ended patient-centered survey to measure expectations regarding aging. Further study should determine whether physicians address mental health aspects of aging valued by older persons.

Expenditures for the care of HIV-infected patients in the era of highly active antiretroviral therapy

BACKGROUND

The introduction of expensive but very effective antiviral medications has led to questions about the effects on the total use of resources for the care of patients with human immunodeficiency virus (HIV) infection. We examined expenditures for the care of HIV-infected patients since the introduction of highly active antiretroviral therapy.

METHODS

We interviewed a random sample of 2864 patients who were representative of all American adults receiving care for HIV infection in early 1996, and followed them for up to 36 months. We estimated the average expenditure per patient per month on the basis of self-reported information about care received.

RESULTS

The mean expenditure was $1,792 per patient per month at base line, but it declined to $1,359 for survivors in 1997, since the increases in pharmaceutical expenditures were smaller than the reductions in hospital costs. Use of highly active antiretroviral therapy was independently associated with a reduction in expenditures. After adjustments for the interview date, clinical status, and deaths, the estimated annual expenditure declined from $20,300 per patient in 1996 to $18,300 in 1998. Expenditures among subgroups of patients varied by a factor of as much as three. Pharmaceutical costs were lowest and hospital costs highest among underserved groups, including blacks, women, and patients without private insurance.

CONCLUSIONS

The total cost of care for adults with HIV infection has declined since the introduction of highly active antiretroviral therapy. Expenditures have increased for medications but have declined for other services. However, there are large variations in expenditures across subgroups of patients.

Measuring the incremental cost of clinical cancer research

PURPOSE

To summarize evidence on the costs of treating patients in clinical trials and to describe the Cost of Cancer Treatment Study, an ongoing effort to produce generalizable estimates of the incremental costs of government-sponsored cancer trials.

METHODS

A retrospective study of costs will be conducted with 1,500 cancer patients recruited from a randomly selected sample of institutions in the United States. Patients accrued to either phase II or phase III National Cancer Institute-sponsored clinical trials during a 15-month period will be asked to participate in a study of their health care utilization (n = 750). Costs will be measured approximately 1 year after their trial enrollment from a combination of billing records, medical records, and an in-person survey questionnaire. Similar data will be collected for a comparable group of cancer patients not in trials (n = 750) to provide an estimate of the incremental cost.

RESULTS

Evidence suggests insurers limit access to trials because of cost concerns. Public and private efforts are underway to change these policies, but their permanent status is unclear. Previous studies found that treatment costs in clinical trials are similar to costs of standard therapy. However, it is difficult to generalize from these studies because of the unique practice settings, insufficient sample sizes, and the exclusion of potentially important costs.

CONCLUSION

Denials of coverage for treatment in a clinical trial limit patient access to trials and could impede clinical research. Preliminary estimates suggest changes to these policies would not be expensive, but these results are not generalizable. The Cost of Cancer Treatment Study is an ongoing effort to provide generalizable estimates of the incremental treatment cost of phase II and phase III cancer trials. The results should be of great interest to insurers and the research community as they consider permanent ways to finance cancer trials.

National probability samples in studies of low-prevalence diseases. Part I: Perspectives and lessons from the HIV cost and services utilization study

OBJECTIVE

To examine the trade-offs inherent in selecting a sample design for a national study of care for an uncommon disease, and the adaptations, opportunities and costs associated with the choice of national probability sampling in a study of HIV/AIDS.

SETTING

A consortium of public and private funders, research organizations, community advocates, and local providers assembled to design and execute the study.

DESIGN

Data collected by providers or collected for administrative purposes are limited by selectivity and concerns about validity. In studies based on convenience sampling, generalizability is uncertain. Multistage probability sampling through households may not produce sufficient cases of diseases that are not highly prevalent. In such cases, an attractive alternative design is multistage probability sampling through sites of care, in which all persons in the reference population have some chance of random selection through their medical providers, and in which included subjects are selected with known probability. DATA COLLECTION AND PRINCIPAL FINDINGS: Multistage national probability sampling through providers supplies uniquely valuable information, but will not represent populations not receiving medical care and may not provide sufficient cases in subpopulations of interest. Factors contributing to the substantial cost of such a design include the need to develop a sampling frame, the problems associated with recruitment of providers and subjects through medical providers, the need for buy-in from persons affected by the disease and their medical practitioners, as well as the need for a high participation rate. Broad representation from the national community of scholars with relevant expertise is desirable. Special problems are associated with organization of the research effort, with instrument development, and with data analysis and dissemination in such a consortium.

CONCLUSIONS

Multistage probability sampling through providers can provide unbiased, nationally representative data on persons receiving regular medical care for uncommon diseases and can improve our ability to accurately study care and its outcomes for diseases such as HIV/AIDS. However, substantial costs and special circumstances are associated with the implementation of such efforts.

National probability samples in studies of low-prevalence diseases. Part II: Designing and implementing the HIV cost and services utilization study sample

OBJECTIVE

The design and implementation of a nationally representative probability sample of persons with a low-prevalence disease, HIV/AIDS.

DATA SOURCES/STUDY SETTING

One of the most significant roadblocks to the generalizability of primary data collected about persons with a low-prevalence disease is the lack of a complete methodology for efficiently generating and enrolling probability samples. The methodology developed by the HCSUS consortium uses a flexible, provider-based approach to multistage sampling that minimizes the quantity of data necessary for implementation.

STUDY DESIGN

To produce a valid national probability sample, we combined a provider-based multistage design with the M.D.-colleague recruitment model often used in non-probability site-specific studies.

DATA COLLECTION

Across the contiguous United States, reported AIDS cases for metropolitan areas and rural counties. In selected areas, caseloads for known providers for HIV patients and a random sample of other providers. For selected providers, anonymous patient visit records.

PRINCIPAL FINDINGS

It was possible to obtain all data necessary to implement a multistage design for sampling individual HIV-infected persons under medical care with known probabilities. Taking account of both patient and provider nonresponse, we succeeded in obtaining in-person or proxy interviews from subjects representing over 70 percent of the eligible target population.

CONCLUSIONS

It is possible to design and implement a national probability sample of persons with a low-prevalence disease, even if it is stigmatized.

Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study

CONTEXT

Studies of selected populations suggest that not all persons infected with human immunodeficiency virus (HIV) receive adequate care.

OBJECTIVE

To examine variations in the care received by a national sample representative of the adult US population infected with HIV.

DESIGN

Cohort study that consisted of 3 interviews from January 1996 to January 1998 conducted by the HIV Cost and Services Utilization Consortium.

PATIENTS AND SETTING

Multistage probability sample of 2864 respondents (68% of those targeted for sampling), who represent the 231400 persons at least 18 years old, with known HIV infection receiving medical care in the 48 contiguous United States in early 1996 in facilities other than emergency departments, the military, or prisons. The first follow-up consisted of 2466 respondents and the second had 2267 (65% of all surviving sampled subjects).

MAIN OUTCOME MEASURES

Service utilization (<2 ambulatory visits, at least 1 emergency department visit that did not lead to hospitalization, at least 1 hospitalization) and medication utilization (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia).

RESULTS

Inadequate HIV care was commonly reported at the time of interviews conducted from early 1996 to early 1997 but declined to varying degrees by late 1997. Twenty-three percent of patients initially and 15% of patients subsequently had emergency department visits that did not lead to hospitalization, 30% initially and 26% subsequently of those who had CD4 cell counts below 0.20 x 10(9)/L did not receive P carinii pneumonia prophylaxis, and 41% initially and 15% subsequently of those who had CD4 cell counts below 0.50 x 10(9)/L did not receive antiretroviral therapy (protease inhibitor or nonnucleoside reverse transcriptase inhibitor). Inferior patterns of care were seen for many of these measures in blacks and Latinos compared with whites, the uninsured and Medicaid-insured compared with the privately insured, women compared with men, and other risk and/or exposure groups compared with men who had sex with men even after CD4 cell count adjustment. With multivariate adjustment, many differences remained statistically significant. Even by early 1998, fewer blacks, women, and uninsured and Medicaid-insured persons had started taking antiretroviral medication (CD4 cell count adjusted P values <.001 to <.005).

CONCLUSIONS

Access to care improved from 1996 to 1998 but remained suboptimal. Blacks, Latinos, women, the uninsured, and Medicaid-insured all had less desirable patterns of care. Strategies to ensure optimal care for patients with HIV requires identifying the causes of deficiency and addressing these important shortcomings in care.

The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium

BACKGROUND AND METHODS

In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas.

RESULTS

During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year.

CONCLUSIONS

In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.

Impact of a high school condom availability program on sexual attitudes and behaviors

CONTEXT

While making condoms available in high schools has provoked much debate, evidence on the actual effects of such programs on students' attitudes and behavior is sparse.

METHODS

Prior to implementation of a condom availability program in a Los Angeles County high school, 1,945 students in grades 9-12 (98% of eligible students) completed a self-administered anonymous survey on their sexual behavior and on related knowledge and attitudes; one year later, 1,110 students (59% of eligible students) completed a follow-up survey.

RESULTS

There was no significant change over time in the percentage of males or females who had ever had vaginal intercourse or who had had vaginal intercourse during the year prior to the survey. The percentage of males who reported using condoms every time they engaged in vaginal intercourse during the past year increased significantly, from 37% to 50%, and the percentage of males who reported condom use at recently initiated first vaginal intercourse increased from 65% to 80%. On the other hand, female respondents showed no significant change in their condom use. The self-reported likelihood of using a condom for vaginal intercourse during the following year did not change significantly for students who had had vaginal intercourse, but it increased dramatically for those who, had never had vaginal intercourse. The students' attitudes toward sex and condom use either remained the same between surveys or changed in a direction favoring less sexual behavior and greater risk prevention.

CONCLUSIONS

The condom availability program appears not to have produced an increase in sexual activity among high school students, and it appears to have led to improved condom use among males. The apparent strong effect on students' intention to use condoms and on males' use at first vaginal intercourse suggests that such programs may have a particular impact on the least sexually experienced adolescents.

Students' acquisition and use of school condoms in a high school condom availability program

OBJECTIVES

To determine what students know about a condom availability program in their high school, how they react to the program, whether they obtain condoms from it, and what they do with these condoms.

DESIGN

Self-administered anonymous survey conducted 1 year after the program began.

SETTING

An urban California school district.

PARTICIPANTS

A total of 1112 students, 9th through 12th grade, 59% of eligible students present on the survey day.

MAIN OUTCOME MEASURES

History of obtaining condoms from the program, use of these condoms, knowledge about the program, and attitudes toward the program.

RESULTS

Forty-eight percent of students had personally taken school condoms, and another 5% had gotten them from someone else, for a total of 53% who had obtained school condoms. Seventy percent of nonvirgins and 38% of virgins obtained condoms. Males were more likely than females to have obtained condoms (60% vs 45%). Fifty-four percent of students who had obtained school condoms had used them for sexual activity: 52% had used them for vaginal intercourse, 7% for anal intercourse, and 4% for fellatio. Students also explored school condoms without having sex, eg, removing them from the packet, putting them on fingers, or putting them on their penis or a partner's penis. Thirty-four percent of students who had used a condom for vaginal intercourse during the previous year had obtained the condom they last used from school, with more males than females reporting the school as their source (41% vs 26%). Eighty-eight percent of students knew that all students were allowed to obtain condoms, and 74% knew that parental permission was not required. Students generally supported the condom program: 88% thought the school should give out condoms, and 79% thought that if the school were to require parental permission for students to get condoms, students would get them less often than with the present system (which does not require permission). Thirteen percent agreed and 71% disagreed that "having condoms available at school makes it harder for someone who doesn't want to have sex to say no."

CONCLUSIONS

Providing high school students with direct access to condoms leads to widespread use of school condoms, both for sexual activity and for exploratory activities that familiarize students with condoms. Condoms are of interest to both students who have and students who have not engaged in sexual activities for which condoms are recommended.

Derivation and properties of a brief health status assessment instrument for use in HIV disease

Health status measures adapted from the Medical Outcomes Study (MOS) scales have been shown to be useful and highly reliable in human immunodeficiency virus-infected populations, but acceptance of these measures has been limited in part by concerns over investigator, patient, and data burden. We sought to address these concerns by reducing the number of items in the MOS scales rather than by reducing the number of domains covered. We selected items for the shorter scales based on the static and dynamic relationships to the longer scales and to indicators of clinical and functional status in 10,399 responses from 1,934 participants, as well as in relevant subpopulations. The resulting scales have a total of 21 items, as compared to 38 in the longer instrument. Correlations between the shorter and longer scales were excellent. At 0.78 to 0.85, the reliability of the subscales was lower than that of the full scales. However, compared to an index based on the longer scales, an index based on the subscales had identical reliability, yielded nearly identical values, and was as sensitive in detecting treatment differences in a clinical trial. The resulting instrument continues to cover disability, work, utilization, and health status, but is less than half the length of our previous comprehensive questionnaires.

A Perceived Health Index for use in persons with advanced HIV disease: derivation, reliability, and validity

Acceptance of health status as an outcome in clinical trials of new treatments for HIV disease has been hampered by the lack of valid and clinically relevant means of summarizing differences across multiple dimensions. We formed a summary Perceived Health Index from health status measures adapted from RAND Medical Outcomes Study scale and contained in the HIV-PARSE survey instrument, which had been administered to a large number of participants in clinical trials for advanced HIV disease. The psychometric properties of the included health status scales were assessed using multitrait scaling and test-retest stability. Weights for the index were derived from regressions of Current Health Perceptions on the domain-specific health status scales. The effect of participant characteristics on weights was tested. Finally, the reliability and known-clinical groups validity of the index was assessed. Data were obtained from 1,862 clinical trial participants who provided a total of 7,352 observations. The mean CD4 count was 131. The internal consistency reliability of the multi-item scales ranged from 0.86 to 0.90, and items demonstrated excellent discrimination across scales. The domain-specific scales explained 59% of the variation in the Current Health Perceptions scale (P < 0.00001). The resulting Perceived Health Index was equal to 0.20 Physical Functioning + 0.15 Pain + 0.41 Energy/Fatigue + 0.10 Emotional Well-being + 0.05 Social Functioning + 0.09 Role Functioning. The strong positive bivariate relationship between the Cognitive Function/Distress scale and the Current Health Perceptions scale was subsumed by the combination of the other domain-specific scales in multiple regressions, so it does not appear independently in the index. The proportional weights used in the index were insensitive to variations in demographics. The reliability of the index was conservatively estimated to be 0.94. Patients with index scores in the lowest quartile had a 2- to 11-fold higher probability than those in the highest quartile of reporting various specific clinical events, and the index correlated significantly more highly with the number of such events than did the current health perceptions scale. The modified MOS health status scales included in the HIV-PARSE are reliable and valid in patients with advanced HIV disease. The Perceived Health Index provides a reliable and valid means of summarizing self-reported current health, correlates strongly with clinical indicators, and should be useful as a outcome measure in patients enrolling into clinical trials of therapies for advanced HIV disease. Regression based weights are a useful means of summarizing multidimensional measures.

Narratives of birth and the postpartum: analysis of the focus group responses of new mothers

Focus groups were conducted to encourage and examine women's frank discussions of the events surrounding their experiences of labor, birth, and the postpartum period. Transcripts of the tape-recorded narratives of 41 new mothers were analyzed and five themes were identified: loss of autonomy and control; unexpected physical pain of childbirth; unexpected emotional reactions; financial pressures; and the effects of support during labor and birth. Participants' perceptions shed light on and supplemented previous questionnaire and interview research on these topics. The survey results suggest ways to help improve women's birth experiences.