Immunity to HIV-1 Is Influenced by Continued Natural Exposure to Exogenous Virus

Unprotected sexual intercourse between individuals who are both infected with HIV-1 can lead to exposure to their partner's virus, and potentially to super-infection. However, the immunological consequences of continued exposure to HIV-1 by individuals already infected, has to our knowledge never been reported. We measured T cell responses in 49 HIV-1 infected individuals who were on antiretroviral therapy with suppressed viral loads. All the individuals were in a long-term sexual partnership with another HIV-1 infected individual, who was either also on HAART and suppressing their viral loads, or viremic (>9000 copies/ml). T cell responses to HIV-1 epitopes were measured directly ex-vivo by the IFN-γ enzyme linked immuno-spot assay and by cytokine flow cytometry. Sexual exposure data was generated from questionnaires given to both individuals within each partnership. Individuals who continued to have regular sexual contact with a HIV-1 infected viremic partner had significantly higher frequencies of HIV-1-specific T cell responses, compared to individuals with aviremic partners. Strikingly, the magnitude of the HIV-1-specific T cell response correlated strongly with the level and route of exposure. Responses consisted of both CD4+ and CD8+ T cell subsets. Longitudinally, decreases in exposure were mirrored by a lower T cell response. However, no evidence for systemic super-infection was found in any of the individuals. Continued sexual exposure to exogenous HIV-1 was associated with increased HIV-1-specific T cell responses, in the absence of systemic super-infection, and correlated with the level and type of exposure

Certified Medical Interpreters’ Perspectives on Relationship-Centered Communication in Safety-Net Care

This article was migrated. The article was marked as recommended. Background: Interpreters may offer valuable perspectives on ways clinicians could improve communication skills. Relationship-centered communication (RCC) curricula are based on a framework for promoting effective communication both with patients and within health care teams. Methods: We conducted a 90-minute workshop with certified interpreters at an academically-affiliated safety-net system to solicit feedback to optimize RCC skills trainings for clinicians at a U.S. academically-affiliated safety-net system. We applied an editing analysis style to transcribed quotes to reveal opportunities to optimize RCC skills trainings to improve safety-net care for diverse populations. Results: Twenty-two Spanish-, Cantonese-, Mandarin-, Vietnamese-, and Russian-speaking interpreters participated. Overall, interpreters emphasized the importance of creating a supportive environment for safety-net patients. One Spanish-speaking interpreter added: "When they get up in the morning and go to work, they may get deported. So, that's important to create an atmosphere to help them open up. And they may tell you stuff that's directly pertinent to patient care." Thematic analysis revealed opportunities to tailor and reinforce each RCC stage. On agenda-setting and rapport-building: "We need a little background on the phone, and we don't know how many people are in the room ... Sometimes you're talking to the mom, but the doctor didn't even bother to say it.. [If] we're lost, we're bound to make mistakes." On eliciting the patient's perspective: "Start with this information so they know you're still going to give them your advice: "I'm going to let you know what I think is going on, but what do you think is going on?" On negotiating a shared plan: "[Teachback] is really important. Otherwise it puts an incredible burden on the interpreter ... I'm not sure that the patient really understood." Conclusions: Teaching RCC in partnership with medical interpreters could provide opportunities to deepen clinician RCC skills for more effective patient-interpreter-clinician interactions

Certified Medical Interpreters’ Perspectives on Relationship-Centered Communication in Safety-Net Care

This article was migrated. The article was marked as recommended. Background: Interpreters may offer valuable perspectives on ways clinicians could improve communication skills. Relationship-centered communication (RCC) curricula aim to promote effective communication between patients and clinicians and among members of health care teams. Methods: We conducted a 90-minute workshop with certified interpreters at an academically affiliated safety-net system to solicit feedback on content offered during RCC skills trainings. We applied an editing analysis style to transcribed quotes to reveal opportunities to optimize RCC skills trainings for application in interpreted interactions to improve safety-net care for diverse populations. Results: Twenty-two Spanish-, Cantonese-, Mandarin-, Vietnamese-, and Russian-speaking interpreters participated. Overall, interpreters emphasized the importance of creating a supportive environment for safety-net patients. One Spanish-speaking interpreter added: "When they get up in the morning and go to work, they may get deported. So, that's important to create an atmosphere to help them open up. And they may tell you stuff that's directly pertinent to patient care." Thematic analysis revealed opportunities to tailor and reinforce each RCC stage. On agenda-setting and rapport-building: "We need a little background on the phone, and we don't know how many people are in the room ... Sometimes you're talking to the mom, but the doctor didn't even bother to say it.. [If] we're lost, we're bound to make mistakes." On eliciting the patient's perspective: "Start with this information so they know you're still going to give them your advice: "I'm going to let you know what I think is going on, but what do you think is going on?" On negotiating a shared plan: "[Teachback] is really important. Otherwise it puts an incredible burden on the interpreter ... I'm not sure that the patient really understood." Conclusions: Teaching RCC in partnership with medical interpreters could provide opportunities to deepen clinician RCC skills for more effective patient-interpreter-clinician interactions

High perceived social support and hospital readmissions in an older multi-ethnic, limited English proficiency, safety-net population.

BACKGROUND: Early readmission amongst older safety-net hospitalized adults is costly. Interventions to prevent early readmission have had mixed success. The role of perceived social support is unclear. We examined the association of perceived social support in 30-day readmission or death in older adults admitted to a safety-net hospital. METHODS: This is an observational cohort study derived from the Support From Hospital to Home for Elders (SHHE) trial. Participants were community-dwelling English, Spanish and Chinese speaking older adults admitted to medicine wards at an urban safety-net hospital in San Francisco. We assessed perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We defined high social support as the highest quartile of MSPSS. We ascertained 30-day readmission and mortality based on a combination of participant self-report, hospital and death records. We used multiple/multivariable logistic regression to adjust for patient demographics, health status, and health behaviors. We tested for whether race/ethnicity modified the effect high social support had on 30-day readmission or death by including a race-social support interaction term. RESULTS: Participants (n = 674) had mean age of 66.2 (SD 9.0), with 18.8% White, 24.8% Black, 31.9% Asian, and 19.3% Latino. The 30-day readmission or death rate was 15.0%. Those with high social support had half the odds of readmission or death than those with low social support (OR = 0.47, 95% CI 0.26-0.88). Interaction analyses revealed race modified this association; higher social support was protective against readmission or death among minorities (AOR = 0.35, 95% CI 0.16-0.76) but increased likelihood of readmission or death among Whites (AOR = 3.7, 95% CI 1.07-12.9). CONCLUSION: In older safety-net patients nearing discharge, high perceived social support may protect against 30-day readmission or death among minorities. Assessing patients social support may aid targeting of transitional care resources and intervention design. How perceived social support functions across racial/ethnic groups in health outcomes warrants further study. TRIAL REGISTRATION: NIH trials registry number ClinicalTrials.gov: NCT01221532

High perceived social support and hospital readmissions in an older multi-ethnic, limited English proficiency, safety-net population.

BackgroundEarly readmission amongst older safety-net hospitalized adults is costly. Interventions to prevent early readmission have had mixed success. The role of perceived social support is unclear. We examined the association of perceived social support in 30-day readmission or death in older adults admitted to a safety-net hospital.MethodsThis is an observational cohort study derived from the Support From Hospital to Home for Elders (SHHE) trial. Participants were community-dwelling English, Spanish and Chinese speaking older adults admitted to medicine wards at an urban safety-net hospital in San Francisco. We assessed perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We defined high social support as the highest quartile of MSPSS. We ascertained 30-day readmission and mortality based on a combination of participant self-report, hospital and death records. We used multiple/multivariable logistic regression to adjust for patient demographics, health status, and health behaviors. We tested for whether race/ethnicity modified the effect high social support had on 30-day readmission or death by including a race-social support interaction term.ResultsParticipants (n = 674) had mean age of 66.2 (SD 9.0), with 18.8% White, 24.8% Black, 31.9% Asian, and 19.3% Latino. The 30-day readmission or death rate was 15.0%. Those with high social support had half the odds of readmission or death than those with low social support (OR = 0.47, 95% CI 0.26-0.88). Interaction analyses revealed race modified this association; higher social support was protective against readmission or death among minorities (AOR = 0.35, 95% CI 0.16-0.76) but increased likelihood of readmission or death among Whites (AOR = 3.7, 95% CI 1.07-12.9).ConclusionIn older safety-net patients nearing discharge, high perceived social support may protect against 30-day readmission or death among minorities. Assessing patients' social support may aid targeting of transitional care resources and intervention design. How perceived social support functions across racial/ethnic groups in health outcomes warrants further study.Trial registrationNIH trials registry number ClinicalTrials.gov: NCT01221532

High perceived social support and hospital readmissions in an older multi-ethnic, limited English proficiency, safety-net population.

BackgroundEarly readmission amongst older safety-net hospitalized adults is costly. Interventions to prevent early readmission have had mixed success. The role of perceived social support is unclear. We examined the association of perceived social support in 30-day readmission or death in older adults admitted to a safety-net hospital.MethodsThis is an observational cohort study derived from the Support From Hospital to Home for Elders (SHHE) trial. Participants were community-dwelling English, Spanish and Chinese speaking older adults admitted to medicine wards at an urban safety-net hospital in San Francisco. We assessed perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We defined high social support as the highest quartile of MSPSS. We ascertained 30-day readmission and mortality based on a combination of participant self-report, hospital and death records. We used multiple/multivariable logistic regression to adjust for patient demographics, health status, and health behaviors. We tested for whether race/ethnicity modified the effect high social support had on 30-day readmission or death by including a race-social support interaction term.ResultsParticipants (n = 674) had mean age of 66.2 (SD 9.0), with 18.8% White, 24.8% Black, 31.9% Asian, and 19.3% Latino. The 30-day readmission or death rate was 15.0%. Those with high social support had half the odds of readmission or death than those with low social support (OR = 0.47, 95% CI 0.26-0.88). Interaction analyses revealed race modified this association; higher social support was protective against readmission or death among minorities (AOR = 0.35, 95% CI 0.16-0.76) but increased likelihood of readmission or death among Whites (AOR = 3.7, 95% CI 1.07-12.9).ConclusionIn older safety-net patients nearing discharge, high perceived social support may protect against 30-day readmission or death among minorities. Assessing patients' social support may aid targeting of transitional care resources and intervention design. How perceived social support functions across racial/ethnic groups in health outcomes warrants further study.Trial registrationNIH trials registry number ClinicalTrials.gov: NCT01221532

The Effect of a Care Transition Intervention on the Patient Experience of Older Multi-Lingual Adults in the Safety Net: Results of a Randomized Controlled Trial.

BackgroundThe Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Care Transitions Measure (CTM-3) scores are patient experience measures used to determine hospital value-based purchasing reimbursement. Interventions to improve 30-day readmissions have met with mixed results, but less is known about their potential to improve the patient experience among older ethnically and linguistically diverse adults receiving care at safety-net hospitals. In this study, we assessed the effect of a nurse-led hospital-based care transition intervention on discharge-related patient experience in an older multilingual population of adults hospitalized at a safety-net hospital.MethodsWe randomized 700 inpatients aged 55 and older at an academic urban safety-net hospital. In addition to usual care, intervention participants received inpatient visits by a language-concordant study nurse and post-discharge phone calls from a language-concordant nurse practitioner to reinforce the care plan and to address acute complaints. We measured HCAHPS nursing, medication, and discharge communication domain scores and CTM-3 scores at 30 days after hospital discharge.ResultsOf 685 participants who survived to 30 days, 90 % (n = 616) completed follow-up interviews. The mean age was 66.2 years; over half (54.2 %) of the participants had cognitive impairment, and 33.8 % had moderate to severe depression. The majority (62.1 %) of interviews were conducted in English; 23.3 % were conducted in Chinese and 14.6 % in Spanish. Study nurses spent an average of 157 min with intervention participants. Between intervention and usual care participants, CTM-3 scores (80.5 % vs 78.5 %; p = 0.18) and HCAHPS discharge communication domain scores (74.8 % vs 68.7 %; p = 0.11) did not differ, nor did HCAHPS scores in medication (44.5 % vs 53.1 %; p = 0.13) and nursing domains (67.9 % vs 64.9 %; p = 0.43). When stratified by language, no significant differences were seen.ConclusionAn inpatient standalone transition-of-care intervention did not improve patient discharge experience. Older multi-lingual and cognitively impaired populations may require higher-intensity interventions post-hospitalization to improve discharge experience outcomes