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BACKGROUND This phase III OAK trial (NCT02008227) subgroup analysis (data cutoff, January 9, 2019) evaluated the predictive value of 2 PD-L1 IHC tests (VENTANA SP142 and Dako 22C3) for benefit from atezolizumab versus docetaxel by programmed death ligand 1 (PD-L1) status in patients with previously treated metastatic non-small cell lung cancer. METHODS PD-L1 expression was assessed prospectively with SP142 on tumor cells (TC) and tumor-infiltrating immune cells (IC) and retrospectively with 22C3 using a tumor proportion score (TPS) based on TC membrane staining. Efficacy was assessed in the 22C3 biomarker-evaluable population (22C3-BEP) (n = 577; 47.1% of SP142-intention-to-treat population) and non-22C3-BEP (n = 648) in PD-L1 subgroups (high, low, and negative) and according to selection by 1 or both assays. RESULTS In the 22C3-BEP, overall survival benefits with atezolizumab versus docetaxel were observed across PD-L1 subgroups; benefits were greatest in SP142-defined PD-L1-high (TC3 or IC3: hazard ratio [HR], 0.39 [95% confidence interval (CI), 0.25-0.63]) and 22C3-defined PD-L1-high (TPS ≥ 50%: HR, 0.56 [95% CI, 0.38-0.82]) and low (TPS, 1% to < 50%: HR, 0.55 [95% CI, 0.37-0.82]) groups. Progression-free survival improved with increasing PD-L1 expression for both assays. SP142 and 22C3 assays identified overlapping and unique patient populations in PD-L1-high, positive, and negative subgroups. Overall survival and progression-free survival benefits favored atezolizumab over docetaxel in double PD-L1-positive and negative groups; patients with both SP142- and 22C3-positive tumors derived the greatest benefit. CONCLUSIONS Despite different scoring algorithms and differing sensitivity levels, the SP142 and 22C3 assays similarly predicted atezolizumab benefit at validated PD-L1 thresholds in patients with non-small cell lung cancer.

Introduction The phase 2 POPLAR and phase 3 OAK studies of the anti–programmed death-ligand 1 (PD-L1) immunotherapy atezolizumab in patients with previously treated advanced NSCLC revealed significant improvements in survival versus docetaxel (p = 0.04 and 0.0003, respectively). Longer follow-up permits evaluation of continued benefit of atezolizumab. This study reports the final overall survival (OS) and safety findings from both trials. Methods POPLAR randomized 287 patients (atezolizumab, 144; docetaxel, 143) and OAK randomized 1225 patients (atezolizumab, 613; docetaxel, 612). The patients received atezolizumab (1200 mg fixed dose) or docetaxel (75 mg/m2) every 3 weeks. Efficacy and safety outcomes were evaluated. Results A longer OS was observed in patients receiving atezolizumab versus docetaxel in POPLAR (median OS = 12.6 mo versus 9.7 mo; hazard ratio = 0.76, 95% confidence interval [CI]: 0.58–1.00) and OAK (median OS = 13.3 versus 9.8 mo; hazard ratio = 0.78, 95% CI: 0.68–0.89). The 4-year OS rates in POPLAR were 14.8% (8.7–20.8) and 8.1% (3.2–13.0) and those in OAK were 15.5% (12.4–18.7) and 8.7% (6.2–11.3) for atezolizumab and docetaxel, respectively. Atezolizumab had improved OS benefit compared with docetaxel across all PD-L1 expression and histology groups. Most 4-year survivors in the docetaxel arms received subsequent immunotherapy (POPLAR, 50%; OAK, 65%). Of the 4-year survivors, most had Eastern Cooperative Oncology Group performance status of 0 and nonsquamous histological classification and approximately half were responders (POPLAR: atezolizumab, seven of 15; docetaxel, three of four; OAK: atezolizumab, 24 of 43; docetaxel, 11 of 26). Treatment-related grade 3/4 adverse events occurred in 27% and 16% of atezolizumab 4-year survivors in POPLAR and OAK, respectively. Conclusions Long-term follow-up suggests a consistent survival benefit with atezolizumab versus docetaxel in patients with previously treated NSCLC regardless of PD-L1 expression, histology, or subsequent immunotherapy. Atezolizumab had no new safety signals, and the safety profile was similar to that in previous studies.

Background Atezolizumab (anti–programmed death-ligand 1 [PD-L1]) received approval from the US Food and Drug Administration and European Medicines Agency for previously treated advanced non–small-cell lung cancer based on OAK—a randomised, phase III trial that showed significantly improved survival with atezolizumab versus docetaxel regardless of PD-L1 expression. With longer follow-up, we summarised the characteristics of long-term survivors (LTSs). Methods In OAK (NCT02008227), patients were randomised 1:1 to receive atezolizumab or docetaxel until loss of clinical benefit or disease progression, respectively. Overall survival was evaluated after a 26-month minimum follow-up, including in patient subgroups defined by best overall response (BOR). LTSs were defined as patients who lived ≥24 months since randomisation. Non-LTSs died within 24 months, and patients censored before 24 months were excluded from the analysis. The baseline characteristics, including biomarkers, BOR, subsequent non-protocol therapy (NPT) and safety, are reported. Results Survival benefit with atezolizumab was observed across all patient subgroups defined by BOR. More atezolizumab-treated patients were LTSs versus those treated with docetaxel (28% versus 18%). Most atezolizumab responders were LTSs (77%) versus only 48% of docetaxel responders. However, 21% of atezolizumab-arm LTSs had progressive disease (PD) as BOR, and more atezolizumab-arm LTSs than non-LTSs continued treatment post-PD. Fifty-two percent of docetaxel-arm LTSs received immunotherapy as subsequent NPT. Despite extended treatment duration in atezolizumab-arm LTSs (median, 18 months), atezolizumab was well tolerated. Conclusions After >2 years of follow-up, atezolizumab continued to provide durable survival benefit versus docetaxel, with tolerable safety. Atezolizumab-arm LTSs were enriched for patients with high PD-L1 expression and included PD-L1–negative patients. Long-term survival was not limited to responders.

Introduction Cancer immunotherapy may alter tumor biology such that treatment effects can extend beyond radiographic progression. In the randomized, phase III OAK study of atezolizumab (anti–programmed death-ligand 1) versus docetaxel in advanced NSCLC, overall survival (OS) benefit with atezolizumab was observed in the overall patient population, without improvement in objective response rate (ORR) or progression-free survival (PFS). We examine the benefit-risk of atezolizumab treatment beyond progression (TBP). Methods Eight hundred fifty patients included in the OAK primary efficacy analysis were evaluated. Atezolizumab was continued until loss of clinical benefit. Docetaxel was administered until Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1) disease progression (PD)/unacceptable toxicity; no crossover to atezolizumab was allowed. ORR, PFS, post-PD OS, target lesion change, and safety were evaluated. Results In atezolizumab-arm patients, ORR was 16% versus 14% and median PFS was 4.2 versus 2.8 months per immune-modified RECIST versus RECIST v1.1. The median post-PD OS was 12.7 months (95% confidence interval [CI]: 9.3–14.9) in 168 atezolizumab-arm patients continuing TBP, 8.8 months (95% CI: 6.0–12.1) in 94 patients switching to nonprotocol therapy, and 2.2 months (95% CI: 1.9–3.4) in 70 patients receiving no further therapy. Of the atezolizumab TBP patients, 7% achieved a post-progression response in target lesions and 49% had stable target lesions. Atezolizumab TBP was not associated with increased safety risks. Conclusions Within the limitations of this retrospective analysis, the post-PD efficacy and safety data from OAK are consistent with a positive benefit-risk profile of atezolizumab TBP in patients performing well clinically at the time of PD.

Background The randomized phase III OAK (a study of atezolizumab compared with docetaxel in participants with locally advanced or metastatic non–small-cell lung cancer [NSCLC] who have failed platinum-containing therapy) trial investigated the anti–programmed cell death ligand 1 (PD-L1) antibody atezolizumab for advanced or metastatic, previously treated, NSCLC. Atezolizumab significantly improved overall survival (OS) compared with docetaxel (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.62-0.87; P = .0003; median OS, 13.8 vs. 9.6 months, respectively). Patient-reported outcomes (PROs) were collected to evaluate disease-related symptoms and health-related quality of life (HRQoL) to support the finding of a survival benefit. Patients and Methods The first 850 patients were randomized to receive atezolizumab (1200 mg every 3 weeks) or docetaxel (75 mg/m2 every 3 weeks). PROs were collected on day 1 of cycle 1, day 1 of every subsequent cycle, and at the end-of-treatment visit for patients who completed ≥ 1 baseline and 1 postbaseline PRO assessment. The European Organisation for the Research and Treatment of Cancer QoL questionnaire and lung cancer module were used to assess PROs. Results Atezolizumab delayed the time to deterioration (TTD) in physical function (HR, 0.75; 95% CI, 0.58-0.98) and role function (HR, 0.79; 95% CI, 0.62-1.00) and numerically improved patients’ HRQoL from baseline compared with docetaxel. Atezolizumab also prolonged the TTD in chest pain (HR, 0.71; 95% CI, 0.49-1.05; P = .0823), although both arms showed an objective reduction relative to baseline. Overall, the patients had no clinically significant worsening in treatment-related symptoms, although the scores favored atezolizumab. Conclusion These PRO data support the clinical benefit of atezolizumab in patients with previously treated advanced or metastatic NSCLC. Atezolizumab prolonged the TTD of patients’ limitations in role and physical functions compared with docetaxel.

Responding to suggestions that physicians are obligated to inquire fully about complementary and alternative medicine (CAM) use and its scientific evidence, to acknowledge patients' health beliefs and practices, and to accommodate diverse healing practices, our interdisciplinary CAM integration project created an advisory committee (AC) composed of CAM practitioners and institutional personnel to incorporate CAM- related information into health professions training. We report on the collaborative process and describe group members' perceptions of medicine and clinical teaching.Information collected from the first two years' quarterly meetings, the first annual retreat, and other venues was analyzed in conjunction with semi-structured in-person interviews of 10 biomedical and CAM practitioner committee members. Data were analyzed using qualitative methodology and N5 software to identify themes and patterns.Analysis confirmed expectations that allopathic and CAM AC members held different views of health and healing. Member comments reflected points of tension that clustered into three intertwined themes:Differences between CAM and allopathic providers were frequent but did not obviate common goals or collaboration. Results demonstrate the potential for collaboration between these groups and our activities may be useful to others seeking to implement interdisciplinary care, particularly between CAM and allopathic providers.

BACKGROUND We describe the rationale, methods, and important lessons learned from doing a practice content study in a new practice-based research network (PBRN). METHODS We performed a modified replication of the National Ambulatory Medical Care Survey (NAMCS) in the Kentucky Ambulatory Network (KAN). Network clinicians had input into focused modifications of the NAMCS protocol, including addition of data fields of special interest to them. Cross-sectional sampling of patient visits was done for a 1-year period, with each practice collecting data during 2 separate weeks. We used selected results to illustrate lessons learned and the value of this endeavor. RESULTS Twenty-three KAN clinicians helped recruit 33 of their colleagues, and these 56 community-based primary care clinicians collected data on 2,228 office visits. Patient demographics (except race) and the top 10 diagnoses were similar to US NAMCS data. One third of visits addressed 3 or more diagnoses, and one fourth of the visits involved 4 or more medications. The top 10 primary diagnoses represented only one third of all primary diagnoses. Seventy percent of adult patients were either overweight (30%) or obese (40%). Rates of counseling on diet or exercise rose with increases in body mass index. CONCLUSION This study helped us establish and activate our new PBRN, increasing its membership in the process. The descriptive data gained will stimulate, guide, and support our future research activities.

BACKGROUND For family physicians to be prepared to deliver the core attributes and system services of family medicine in the future, especially within the New Model of family medicine that has been proposed, changes will need to be made in how family physicians are trained. This Future of Family Medicine task force report presents a plan for implementing appropriate changes in medical school and residency programs. METHODS As a foundation for the development of specific recommendations on medical education, this task force reviewed relevant findings from research conducted for the Future of Family Medicine project and presents an historical perspective of the specialty. We addressed accreditation criteria for family medicine residency programs and examined various relevant projects and programs, including the Academic Family Medicine Organizations/Association of Family Practice Residency Directors Action Plan, the Residency Assistance Program Criteria for Excellence, the Accreditation Council for Graduate Medical Education Outcome Project, the Family Medicine Curriculum Resource Project, and the Arizona Study of Career Selection Factors. The task force relied on the Institute of Medicine report, Health Professions Education: A Bridge to Quality, as a foundation for proposing a new vision and mission for family medicine residency education. MAJOR FINDINGS The training of future family physicians must be grounded in evidence-based medicine that is relevant to the care of the whole person in a relationship and community context. It also must be technologically up to date, built on a solid foundation of clinical science, and strong in the components of interpersonal and behavioral skills. Family physicians must continue to be broadly trained and have the competencies required to practice in a variety of settings. It is important that training in maternity care and training in the care of hospitalized patients continue to be included in the family medicine residency curriculum, but programs must be allowed to tailor that curriculum to be compatible with educational resources and individual trainee needs. CONCLUSION Given the changes taking place in the specialty and within the broader health care system, it is clear that the traditional family medicine curriculum, although successful in the past, cannot meet the needs of the future. The educational process must train competent family physicians who will provide a personal medical home for their patients, a key concept that must be an integral part of whatever new systems are designed. Such competency will require family physicians who understand and practice process-oriented care, who utilize the biopsychosocial model to create superb physician-patient relationships, who actively measure outcomes, and whose practices are driven by information system access to evidence-based principles of care.

9001 Background: Cancer immunotherapy (CIT) can have a positive impact on OS that exceeds response rate or PFS effects, termed post progression prolongation of survival (PPPS). This effect can also result from unconventional CIT response due to tumor immune infiltration or delayed response, reducing reliability of RECIST v1.1 (RECIST) PD as an indicator of treatment failure. In the primary analysis (N = 850) of OAK, a study of atezo vs docetaxel (doc) in 2L/3L NSCLC, OS favored atezo (HR 0.73; 95% CI: 0.62, 0.87), despite similar PFS between arms (HR 0.95; 95% CI: 0.82, 1.10). Here we evaluate clinical benefit from TBP, defined by post PD tumor regression, OS and safety. Methods: Patients (pts) received atezo 1200 mg IV q3w until PD or loss of clinical benefit per investigator or doc 75 mg/m2 IV q3w until PD per RECIST. No crossover was allowed. Primary outcome measure: OS. Atezo TBP pts were evaluated for post PD tumor change and for safety pre and post PD. OS from time of PD per RECIST was evaluated in both arms (data cutoff, July 7, 2016; minimum follow-up, 19 mo). Results: Among 332 atezo pts with PD, 51% (n = 168) continued atezo TBP; 7% (12/168) achieved subsequent response in target lesions (≥ 30% reduction from new baseline at PD); 49% (83/168) had stable target lesions (best change between +20% and −30%). mOS was 12.7 mo (95% CI: 9.3, 14.9) post PD for pts on atezo TBP (Table). Atezo TBP was not associated with increased safety risk. Conclusions: This is the first report from a Phase III study of CIT in NSCLC to evaluate post PD OS in pts continuing treatment beyond RECIST PD. Atezo TBP was associated with high frequency of stable or decreased target lesions, mOS > 1 year and a tolerable safety profile, all supporting prolonged treatment benefit consistent with PPPS. NCT02008227 Clinical trial information: NCT02008227. [Table: see text]

Within the past decade, HIV disease has become one of the most significant epidemics the world has seen. An estimated 29.4 million people have been infected world-wide, with 604,176 cases diagnosed in the United States as of June 1997. In the United States, HIV infection primarily is acquired by male to male sexual transmission and the sharing of needles among intravenous (IV) drug users, although a significant proportion of cases have occurred as a result of heterosexual transmission. The AIDS epidemic has been increasing disproportionately in black and Hispanic populations, and rates of infected women also are rising. Although there are many different manifestations of HIV disease, neoplasms occur frequently among the more severely compromised patients. As many as one in six HIV-infected people will develop an HIV-related neoplasm. It is not uncommon for patients to be unaware of their HIV-infected status and to have developed to advanced stages of infection where neoplasms are more commonly associated. The primary physician should be aware of symptoms of both the initial and advanced stages of HIV infection, and should attempt to identify patients at-risk as early in the infectious period as possible. Two neoplasms, Kaposi's sarcoma and non-Hodgkin's lymphoma, account for the greatest number of malignancies in HIV-infected patients.

Hepatitis A is a common viral illness worldwide, although the incidence in the United States has diminished in recent years as a result of extended immunization practices. Hepatitis A virus is transmitted through fecal-oral contamination, and there are occasional outbreaks through food sources. Young children are usually asymptomatic, although the likelihood of symptoms tends to increase with age. Most patients recover within two months of infection, although 10 to 15 percent of patients will experience a relapse in the first six months. Hepatitis A virus does not usually result in chronic infection or chronic liver disease. Supportive care is the mainstay of treatment. The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend routine vaccination of all children 12 to 23 months of age, as well as certain vulnerable populations. Hepatitis A vaccine is also recommended for most cases of postexposure prophylaxis, although immunoglobulin is an acceptable alternative in some situations.

In theory, a negative Poisson’s ratio (i.e. auxetic) material has improved hardness, impact resistance, fracture toughness, and shear modulus over one with a positive Poisson’s ratio and comparable stiffness. These enhanced properties make them attractive candidates for a wide range of applications, including ones in the biomedical industry. Over the past two decades there has been increasing interest in auxetic materials leading to the discovery and development of new auxetic materials at the micro- and macro-scales. It has been reported in the literature that some human trabecular bone is auxetic; however verification of this claim and measurement of the Poisson’s ratio of biological materials remains a challenge. This research need is the motivation for the current work. The central research objective of this project is to develop an approach to gain fundamental insight into the geometric characteristics of auxetic open cell materials by studying the underpinning mechanics behind the transition from positive to negative Poisson’s ratio that takes place when open-cell foam is compressed and heat treated. The approach involves detailed image analysis and finite element modeling of the microstructure of polyurethane foam, which is commonly used as a test material to model the structure of human cancellous bone. By studying both conventional and auxetic foam, and the process by which conventional foams are transformed to auxetic, we seek to identify the critical features of auxetic open-cell structures. The results will lead to a better understanding of auxetic cellular materials in general, and will be used to develop a framework for use in determining the mechanical properties and potential auxeticity of human trabecular bone and to aid in the design of synthetic auxetic biomaterials. In this paper we report on preliminary results of our modeling efforts.Copyright © 2011 by ASME

The Southern Oman Salt Basin 3D seismic survey being acquired by Petroleum Development Oman (PDO) is the largest, most densely populated wide-azimuth (WAZ) land seismic survey yet acquired, benefiting from the use of a land seismic super-crew. PDO geoscientists Robert Sambell, Said Al-Mahrooqi, Christopher Matheny, Said Al-Abri and Said Al-Yarubi describe what was involved in this breakthrough survey.

The financial climate for academic family medicine departments is increasingly threatened by reductions in federal funding and ever more competitive health care markets.Our objective was to evaluate the financial status of US Departments of Family Medicine, comparing 1998 and 2004 data.In 1999 and 2005, family medicine department chairs were surveyed for the Association of Departments of Family Medicine. Information reported about departments' financial status for 1998 and 2004 included department size, faculty compensation, revenue sources, expenditures, residents' salary support, payer mix, and department reserves. The 2005 survey data were compared to the 1999 survey reports.Eighty-five departments responded to the 2005 survey (69% of 124 departments). For 2004, the largest source of department revenue was clinical income; the median percent of revenue from clinical work increased from 32% in 1998 to 46% in 2004. The contributions of school/government support and hospital support decreased. Median expenditures for faculty salaries and fringe benefits increased (from 49% to 54%). Although the percentage of departments with reserves had increased (from 57% to 71%), 18% of departments reported debt in 2004.Family medicine departments increasingly rely on clinical income. They continue to be vulnerable to changes in support from government and hospital sources, since these sources constitute significant portions of department budgets but have declined in the past 6 years.

The world is facing movements of peoples unparalleled in history. Even the heartland of the American continent, which has seen few new population groups since the European immigration of the 19th century, has felt the effects of this restive population shift during the late 1980s and 1990s. Physicians who themselves have had little experience outside their own cultural environment are now dealing with health and social issues of patients who approach their surroundings in profoundly different ways than they might themselves. Yet the differences have always been present.

In several respects, palliative care in late HIV disease tends to differ from that in other terminal diseases such as cancer, and special difficulties arise in alleviation of pain and suffering. The following story is illustrative: The case of Dona Dona, age 33, is the widow of Ed, who was diagnosed with HIV when incarcerated in 1991 for possession of marijuana. Almost at the same time, Dona was admitted to hospital with pneumonia which proved to be tuberculous. Not until she was discharged did she discover that she was infected with HIV, acquired from her husband, an intravenous drug user. Both Ed and Dona were started on zidovudine, the only anti-HIV drug then readily available. Ed soon developed Pneumocystis pneumonia and candida oesophagitis, complicated by anaemia due to the zidovudine. When new drugs for HIV became available, Ed and Dona were switched to these. Ed developed AIDS-related dementia, becoming paranoid and abusing Dona mentally and physically. She filed for divorce but continued to look after him until he died in 1995. Within two months of his death, Dona developed ataxia and a right-sided paralysis from what proved to be a central nervous system lymphoma—a condition that at that time was expected to cause death within 90 days. Three weeks after this diagnosis the first protease inhibitors were released, and she has been on triple therapy for over 4 years. She now has neuropathy, lipodystrophy, abnormal cervical smears and hearing loss, and has been in hospice care for 4 years. However, her brain lymphoma has regressed and recently, for the first time, she had a ‘negative viral load’.

This study measured the prevalence of service in federally designated medically underserved communities (FD-MUC) by Title VII-funded, full-time faculty development fellowship alumni.A two-stage survey of alumni of full-time, family medicine faculty development fellowships was completed. Alumni were dichotomized as serving in an FD-MUC or not.Of the 105 fellowship alumni identified, 81% (n = 85) responded; 42% (n = 36) were serving in an FD-MUC. Of alumni serving in an FD-MUC, the mean full-time equivalent service time was 73%. Of the demographic variables measured, only race was significantly associated with FD-MUC service, and minorities were more likely to practice in an FD-MUC. Respondents serving in FD-MUCs were more satisfied with their relationships with nonphysician health professionals, salary and income, and their role in making organizational and administrative decisions than those not serving in FD-MUCs.Title VII has the broad policy objective of increasing access to medical care by improving the supply and distribution of physicians and recruitment of minority health professionals. Alumni of faculty development programs have a high service rate in FD-MUCs, and minority alumni are significantly more likely to practice in these sites.

Patients with a diagnosis of acute deep venous thrombosis have traditionally been hospitalized and treated with unfractionated heparin followed by oral anticoagulation therapy. Several clinical trials have shown that low-molecular-weight heparin is at least as safe and effective as unfractionated heparin in the treatment of uncomplicated deep venous thrombosis. The use of low-molecular-weight heparin in an outpatient program for the management of deep venous thrombosis provides a treatment alternative to hospitalization in selected patients. Use of low-molecular-weight heparin on an outpatient basis requires coordination of care, laboratory monitoring, and patient education and participation in treatment. Overlapping the initiation of warfarin permits long-term anticoagulation. Advantages include a decreased incidence of heparin-induced thrombocytopenia and fewer episodes of bleeding complications. Future clinical trials evaluating the safety and efficacy of low-molecular-weight heparin in the treatment of complicated deep venous thrombosis will further define appropriate indications for use and strategies for outpatient management.

The world is facing movements of peoples unparalleled in history. Even the heartland of the American continent, which has seen few new population groups since the European immigration of the nineteenth century, has felt the effects of this restive population shift during the late 1980s and 1990s. Physicians who themselves have had little experience outside their own cultural environment are now dealing with health and social issues of patients who approach their surroundings in profoundly different ways than they might themselves. Yet the differences have always been present.

Because of the complexity of their illness, patients infected with HIV may require many services to facilitate the management of the disease. The primary care provider must understand and facilitate the services that are needed and needs to be familiar with the individuals responsible for the care of each patient. There are many stresses that have been identified in HIV caregiving, for informal caregivers and health care workers. These stresses are described, and suggestions for appropriate interventions are outlined.

Despite recent evidence of faster than average increases in HIV/AIDS cases in rural areas across the U.S., there is still a generally poor understanding of successful models of rural HIV/AIDS health-care delivery. Past research in rural Kentucky suggested several barriers to care resulting in most rural HIV-positive patients traveling from rural to urban areas for care. Patients sought urban areas for care for reasons including patient confidentiality, a perceived lack of expertise on the part of rural physicians in caring for HIV-positive patients, and outright referral from rural to urban areas. Case histories are used to illustrate a variety of models of care used by rural HIV-positive patients. These include splitting and sharing care between rural primary care physicians and urban medical specialists, as well as patients receiving all their care in urban areas. Implications of these models for quality of care are discussed.

Many media have been formulated for the growth of Trichomonas vaginalis, but the relative sensitivities of these media have not been determined. We evaluated the ability of six media, including all five media commercially available in the United States, to grow Trichomonas vaginalis from vaginal secretions. In a first experiment, we evaluated the ability of five media to grow T. vaginalis from vaginal secretions of 375 women and determined the optimal days on which to read culture tubes, by inoculating aliquots of secretions into each medium and reading the tubes 1, 2, 3, 4, and 7 days later. Sixty-five patients (17%) had a positive wet-mount examination for T. vaginalis, and all the positive results were confirmed by growth in at least one medium. Of 310 wet-mount-negative specimens, 37 (12%) grew T. vaginalis; overall, 102 women (27%) had a positive culture. Diamond and modified Diamond media (the latter being the only medium not commercially available) detected 99 (97%) and 92 (90%) isolates, respectively, compared with three formulations of Kupferberg medium, which detected 77 (75%), 50 (49%), and 43 (42%) isolates. The optimal single day to read wet-mount-negative cultures was day 7, but 4 (11%) of the 37 positive specimens were positive only before day 7. In a second study, we compared the ability of modified Diamond medium with that of a sixth medium, Lash medium, to grow T. vaginalis from 48 wet-mount-positive specimens; modified Diamond medium supported growth in all cases, whereas Lash medium supported growth in only 26 (54%) cases. We conclude that formulations of Diamond medium are superior to formulations of Kupferberg or Lash medium for growth of t. vaginalis.