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Charles Muiruri,1,2 Isabelle P Sico,1 Julie Schexnayder,3 Allison R Webel,3 Nwora Lance Okeke,4 Christopher T Longenecker,5 Juan Marcos Gonzalez,1 Kelley A Jones,1 Sarah E Gonzales,1 Hayden B Bosworth1 1Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA; 2Duke Global Health Institute, Duke University, Durham, NC, USA; 3Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA; 4Department of Medicine, Duke University Medical Center, NC, USA; 5Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USACorrespondence: Charles Muiruri Email charles.muiruri@duke.eduBackground: After achieving viral suppression, it is critical for persons living with HIV (PLWH) to focus on prevention of non-AIDS comorbidities such as cardiovascular disease (CVD) in order to enhance their quality of life and longevity of life. Despite PLWH elevated risk of developing CVD compared to individuals without HIV, PLWH do not often meet evidence-based treatment goals for CVD prevention; the reasons for PLWH not meeting guideline recommendations are poorly understood. The objective of this study was to identify the factors associated with adherence to CVD medications for PLWH who have achieved viral suppression.Methods: Qualitative data were obtained from formative research conducted to inform the adaptation of a nurse-led intervention trial to improve cardiovascular health at three large academic medical centers in the United States. Transcripts were analyzed using content analysis guided by principles drawn from grounded theory.Results: Fifty-one individuals who had achieved viral suppression (< 200 copies/mL) participated: 37 in 6 focus groups and 14 in individual semi-structured interviews. Mean age was 57 years (SD: 7.8); most were African Americans (n=31) and majority were male (n=34). Three main themes were observed. First, participants reported discordance between their healthcare providers’ recommendations and their own preferred strategies to reduce CVD risk. Second, participants intentionally modified frequency of CVD medication taking which appeared to be related to low CVD risk perception and perceived or experienced side effects with treatment. Finally, participants discussed the impact of long-term experience with HIV care on adherence to CVD medication and motivational factors that enhanced adherence to heart healthy behaviors.Conclusion: Findings suggest that future research should focus on developing interventions to enhance patient–provider communication in order to elicit beliefs, concerns and preferences for CVD prevention strategies. Future research should seek to leverage and adapt established evidence-based practices in HIV care to support CVD medication adherence.Keywords: medication adherence, persons living with HIV, viral suppression, cardiovascular disease, qualitative research

In the United States, modelling studies suggest a high prevalence of hepatitis C virus (HCV) infection in incarcerated populations. However, limited HCV testing has been conducted in prisons. Through the Louisiana Hepatitis C Elimination Plan, persons incarcerated in the eight state prisons were offered HCV testing from 20 September 2019 to 14 July 2022, and facility entry/exit HCV testing was introduced. Multivariable logistic regression was used to evaluate associations with HCV antibody (anti-HCV) positivity and viremia. Of 17,231 persons in the eight state prisons screened for anti-HCV, 95.1% were male, 66.7% were 30-57 years old, 3% were living with HIV, 68.2% were Black and 2904 (16.9%) were anti-HCV positive. HCV RNA was detected in 69.3% of anti-HCV positive individuals tested. In the multivariable model, anti-HCV positivity was associated with older age including those 30-57 (odds ratio [OR] 3.53, 95% confidence interval [CI] 2.96-4.20) and those ≥58 (OR 10.43, 95% CI 8.66-12.55) as compared to those ≤29 years of age, living with HIV (OR 1.68, 95% CI 1.36-2.07), hepatitis B (OR 1.83, 95% CI 1.25-2.69) and syphilis (OR 1.51, 95% CI 1.23-1.86). HCV viremia was associated with male sex (OR 1.89, 95% CI 1.36-2.63) and Black race (OR 1.42, 95% CI 1.20-1.68). HCV prevalence was high in the state prisons in Louisiana compared to community estimates. To the extent that Louisiana is representative, to eliminate HCV in the United States, it will be important for incarcerated persons to have access to HCV testing and treatment., (© 2024 John Wiley & Sons Ltd.)

Background: Equitable sex- and gender-based representation in clinical trials is an essential step to ensuring evidence-based care for women. While multi-institutional actions have led to significant improvements in the inclusion of women in trials, inequity persists in areas like sex-neutral cancers and cardiovascular disease. We sought to identify strategies described or evaluated to boost the inclusion of women in clinical trials., Methods: We used evidence mapping methodology to examine the breadth of relevant literature. We developed an a priori protocol and followed reporting guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis where applicable. We searched MEDLINE ® (via PubMed) and EMBASE (via Elsevier) databases from inception through April 4, 2023, and used standardized procedures incorporating duplication and data verification. We included articles that described strategies to improve the recruitment and retention of women in clinical trials., Results: We identified 122 articles describing recruitment and retention strategies for 136 trials (377,595 women). Only one article distinguished between the sex and gender identity of participants, and none defined their use of the terms such as "women" or "female". The majority of articles (95%) described recruitment for only women, and 64% were conducted in the USA. Ninety-two articles (75%) described strategies in the context of sex-specific conditions (e.g., gynecologic diagnosis). The majority of included articles evaluated a behavioral intervention (52%), with 23% evaluating pharmacologic interventions and 4% invasive interventions. The most common trial phase for reported strategies was during outreach to potential participants (116 articles), followed by intervention delivery (76), enrollment (40), outcomes assessment (21), analysis and interpretation (3), and dissemination (4). We describe specific types of strategies within each of these phases., Conclusions: Most of the existing literature describing strategies to improve the inclusion of women draws from trials for sex-specific conditions and is largely related to outreach to potential participants. There is little information about how and if studies have attempted to proportionally increase the inclusion of women in trials with both men and women or those focused on invasive and pharmacologic interventions. Future work in this area should focus on how to increase the participation of women in mixed-sex studies and on those areas with remaining inequities in trial participation., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Veterans living with HIV have up to twice the risk of atherosclerotic cardiovascular disease (ASCVD) compared to those without HIV. Objective: Our study seeks to test a non-physician led virtual self-management implementation strategy to reduce ASCVD risk among people living with HIV (PWH). We aim to conduct a randomized control trial among PWH ( n  = 300) with a diagnosis of hypertension (HTN) who are enrolled in Veterans Health Administration (VHA) clinics, on suppressive antiretroviral therapy (ART), randomized 1:1 to intervention vs. education control for a 12-month duration. Methods: Using human centered design approach, we have adapted a previous 5-component telehealth focused, non-physician led intervention to a Veteran population. The education control arm receives enhanced education in addition to usual care. The primary outcome is 6 mmHg reduction in systolic BP over 12-month in the intervention arm compared to the control arm. The secondary outcome is a 12-month difference in non-HDL cholesterol. While each component of our intervention has an evidence base, they have not been tested together in an HIV context. Conclusion: The proposed multicomponent intervention has the potential to improve cardiovascular outcomes in PWH using novel virtual care methods in a patient centered care approach.

Qualitative rapid analysis is one of many rapid research approaches that offer a solution to the problem of time constrained health services evaluations and avoids sacrificing the richness of qualitative data that is needed for intervention design. We describe modifications to an established team-based, rapid analysis approach that we used to rapidly collect and analyze semi-structured interview data for a developmental formative evaluation of a cardiovascular disease prevention intervention. Over 18 weeks, we conducted and analyzed 35 semi-structured interviews that were conducted with patients and health care providers in the Veterans Health Administration to identify targets for adapting the intervention in preparation for a clinical trial. We identified 12 key themes describing actionable targets for intervention modification. We highlight important methodological decisions that allowed us to maintain rigor when using qualitative rapid analysis for intervention adaptation and we provide practical guidance on the resources needed to execute similar qualitative studies. We additionally reflect on the benefits and challenges of the described approach when working within a remote research team environment.ClinicalTrials.gov: NCT04545489.

Clinicians typically view the intersection between hepatitis C and injection drug use in terms of simultaneity - with transmission occurring via shared needles - or sequentially - with some states requiring that people stop using drugs prior to treatment. Yet, for patients, the connection between substance use and HCV infection can follow a more complex temporal pathway. In this article, we explore the non-linear temporality of "reliving" as it shapes HCV illness experience, its complex intersection with injection drug use, and the barriers patients face as they reckon with existing healthcare system responses and treatment modalities.

Purpose of Review: There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control., Recent Findings: Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery. We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts., (© 2022. The Author(s).)

Context: African American and Hispanic adults share a disproportionate burden of HIV infections in the United States but continue to experience suboptimal uptake of HIV pre-exposure prophylaxis (PrEP). Increasing PrEP accessibility in nontraditional care settings is a potential strategy to increase PrEP uptake in these high-risk groups. PrEP implementation in local health departments (LHDs) is not well characterized., Objective: To evaluate HIV PrEP implementation for African American and Hispanic adults receiving medical care in Virginia's LHDs., Design: We conducted a retrospective, mixed-methods evaluation of PrEP services implementation at LHDs completing their first PrEP program year between June 1, 2016, and June 30, 2019. Using pharmacy records, we estimated PrEP coverage and adherence using PrEP to need ratios (PnRs) and medication possession ratios (MPRs), respectively. Thematic analysis was used to identify barriers to PrEP delivery in interviews with 6 multidisciplinary LHD workers., Results: Of the 433 PrEP clients receiving an emtricitabine/tenofovir disoproxil fumarate (Truvada) prescription in year 1, 52.0% self-identified as African American and 8.9% self-identified as Hispanic. PnRs were greater for White adults in 50.0% of clinics. The average MPR (0.79) was consistent with protective medication adherence levels; however, 25.0% of clients filled only one prescription in the program year. Qualitative findings suggest incompatibilities between health PrEP services delivery and community preferences for African American and Hispanic adults; however, LHDs in one health region were able to link communities of color to PrEP at similar rates as Whites., Conclusions: Incorporating a metric sensitive to racial/ethnic differences in the burden of HIV infection improved recognition of PrEP disparities; however, population-specific targets are needed to enhance use of the PnR for program evaluation. Tailoring of PrEP services to communities with the greatest local PrEP burden may be needed to optimize the effectiveness of PrEP programs in LHDs., Competing Interests: The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

People with HIV (PWH) experience a high frequency of symptoms that are associated with poor clinical outcomes. We conducted a secondary analysis of data from an observational study to examine whether diet, muscle strength, or physical activity were associated with symptoms among PWH and their HIV-uninfected peers. One-hundred ninety-one individuals (105 PWH and 86 HIV uninfected) with similar age and race were included. Symptoms were examined using the Patient-Reported Outcomes Measurement Information System (PROMIS-29) questionnaire, for which lower scores indicate higher function or fewer symptoms. The total healthy eating index score and carbohydrates, sugar sweet beverages, alcohol, and fiber consumption per day were obtained through 24-hour dietary recalls. A dynamometer was used to determine muscle strength. Steps per day were examined through 7 days of actigraphy. Linear regression analyses were used to determine the relationship between symptoms and diet, muscle strength, and steps per day. Participants were, on average, 54 years, 83% were African American, and 58% were male. In PWH, less healthy eating, fiber intake, and muscle strength were associated with poorer physical function; more steps per day were associated with fatigue; less daily carbohydrate consumption was associated with more pain. HIV-uninfected individuals demonstrated an association between fewer steps per day and poorer physical function and more pain, and less carbohydrate intake and more sleep disturbance. The relationships between diet, muscle strength, steps per day and PROMIS-29 health domains differed by HIV status., (© 2021 Wiley Periodicals LLC.)

Abstract: People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings., (Copyright © 2021 Association of Nurses in AIDS Care.)

Background: Mobile health (mHealth) apps can provide support to people living with a chronic disease by offering resources for communication, self-management, and social support. PositiveLinks (PL) is a clinic-deployed mHealth app designed to improve the health of people with HIV. In a pilot study, PL users experienced considerable improvements in care engagement and viral load suppression. To promote its expansion to other HIV clinics, we developed an implementation strategy consisting of training resources and on-demand program support., Objective: The objective of our study was to conduct an interim analysis of the barriers and facilitators to PL implementation at early adopting sites to guide optimization of our implementation strategy., Methods: Semistructured interviews with stakeholders at PL expansion sites were conducted. Analysis of interviews identified facilitators and barriers that were mapped to 22 constructs of the Consolidated Framework for Implementation Research (CFIR). The purpose of the analysis was to identify the facilitators and barriers to PL implementation in order to adapt the PL implementation strategy. Four Ryan White HIV clinics were included. Interviews were conducted with one health care provider, two clinic managers, and five individuals who coordinated site PL activities., Results: Ten common facilitators and eight common barriers were identified. Facilitators to PL implementation included PL's fit with patient and clinic needs, PL training resources, and sites' early engagement with their information technology personnel. Most barriers were specific to mHealth, including access to Wi-Fi networks, maintaining patient smartphone access, patient privacy concerns, and lack of clarity on how to obtain approvals for mHealth use., Conclusions: The CFIR is a useful framework for evaluating mHealth interventions. Although PL training resources were viewed favorably, we identified important barriers to PL implementation in a sample of Ryan White clinics. This enabled our team to expand guidance on identifying information technology stakeholders and procuring and managing mobile resources. Ongoing evaluation results continue to inform improvements to the PL implementation strategy, facilitating PL access for future expansion sites., (©Wendy F Cohn, Chelsea E Canan, Sarah Knight, Ava Lena Waldman, Rebecca Dillingham, Karen Ingersoll, Julie Schexnayder, Tabor E Flickinger. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 28.04.2021.)

Background: People with HIV (PWH) experience increased cardiovascular disease (CVD) risk. Many PWH in the USA receive their primary medical care from infectious disease specialists in HIV clinics. HIV care teams may not be fully prepared to provide evidence-based CVD care. We sought to describe local context for HIV clinics participating in an NIH-funded implementation trial and to identify facilitators and barriers to integrated CVD preventive care for PWH., Methods: Data were collected in semi-structured interviews and focus groups with PWH and multidisciplinary healthcare providers at three academic medical centers. We used template analysis to identify barriers and facilitators of CVD preventive care in three HIV specialty clinics using the Theoretical Domains Framework (TDF)., Results: Six focus groups were conducted with 37 PWH. Individual interviews were conducted with 34 healthcare providers and 14 PWH. Major themes were captured in seven TDF domains. Within those themes, we identified nine facilitators and 11 barriers to CVD preventive care. Knowledge gaps contributed to inaccurate CVD risk perceptions and ineffective self-management practices in PWH. Exclusive prioritization of HIV over CVD-related conditions was common in PWH and their providers. HIV care providers assumed inconsistent roles in CVD prevention, including for PWH with primary care providers. HIV providers were knowledgeable of HIV-related CVD risks and co-located health resources were consistently available to support PWH with limited resources in health behavior change. However, infrequent medical visits, perceptions of CVD prevention as a primary care service, and multiple co-location of support programs introduced local challenges to engaging in CVD preventive care., Conclusions: Barriers to screening and treatment of cardiovascular conditions are common in HIV care settings and highlight a need for greater primary care integration. Improving long-term cardiovascular outcomes of PWH will likely require multi-level interventions supporting HIV providers to expand their scope of practice, addressing patient preferences for co-located CVD preventive care, changing clinic cultures that focus only on HIV to the exclusion of non-AIDS multimorbidity, and managing constraints associated with multiple services co-location., Trial Registration: ClinicalTrials.gov , NCT03643705.

Background: People living with HIV are diagnosed with age-related chronic health conditions, including cardiovascular disease, at higher than expected rates. Medical management of these chronic health conditions frequently occur in HIV specialty clinics by providers trained in general internal medicine, family medicine, or infectious disease. In recent years, changes in the healthcare financing for people living with HIV in the U.S. has been dynamic due to changes in the Affordable Care Act. There is little evidence examining how healthcare financing characteristics shape primary and secondary cardiovascular disease prevention among people living with HIV. Our objective was to examine the perspectives of people living with HIV and their healthcare providers on how healthcare financing influences cardiovascular disease prevention., Methods: As part of the EXTRA-CVD study, we conducted in-depth, semi-structured interviews with 51 people living with HIV and 34 multidisciplinary healthcare providers and at three U.S. HIV clinics in Ohio and North Carolina from October 2018 to March 2019. Thematic analysis using Template Analysis techniques was used to examine healthcare financing barriers and enablers of cardiovascular disease prevention in people living with HIV., Results: Three themes emerged across sites and disciplines (1): healthcare payers substantially shape preventative cardiovascular care in HIV clinics (2); physician compensation tied to relative value units disincentivizes cardiovascular disease prevention efforts by HIV providers; and (3) grant-based services enable tailored cardiovascular disease prevention, but sustainability is limited by sponsor priorities., Conclusions: With HIV now a chronic disease, there is a growing need for HIV-specific cardiovascular disease prevention; however, healthcare financing complicates effective delivery of this preventative care. It is important to understand the effects of evolving payer models on patient and healthcare provider behavior. Additional systematic investigation of these models will help HIV specialty clinics implement cardiovascular disease prevention within a dynamic reimbursement landscape., Trial Registration: Clinical Trial Registration Number: NCT03643705 .

Background: Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States., Methods: We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care., Results: Over half of previously referred patients (N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one's own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care., Conclusions: Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.

Background: People living with HIV (PLHIV) are at elevated risk of developing atherosclerotic cardiovascular disease (ASCVD). PLHIV do not engage in recommended levels of ASCVD prevention behaviors, perhaps due to a reduced perception of risk for ASCVD. We examined how HIV status influences knowledge, beliefs, and perception of risk for ASCVD and ASCVD prevention behaviors., Methods and Results: We conducted a mixed-methods study of 191 PLHIV and demographically similar HIV-uninfected adults. Participants completed self-reported surveys on CVD risk perceptions, adherence to CVD medication (aspirin, antihypertensives, and lipid-lowering medication) and 3 dietary intake interviews. All wore an accelerometer to measure physical activity. A subset of PLHIV (n = 38) also completed qualitative focus groups to further examine the influence of HIV on knowledge, perception of risk for ASCVD, and behavior., Participants: They were approximately 54 (±10) years, mostly men (n = 111; 58%), and African American (n = 151, 83%) with an average 10-year risk of an ASCVD event of 10.4 (±8.2)%. PLHIV were less likely to engage in physical activity (44% vs 65%, P < 0.05), and HIV status was associated with 43 fewer minutes of physical activity per week (P = 0.004). Adherence to ASCVD medications was better among PLHIV (P < 0.001). Diet composition was similar between groups (P > 0.05). HIV status did not influence ASCVD risk perceptions (P > 0.05) and modestly influenced physical activity and smoking., Conclusions: Although perceptions of ASCVD risk modestly influence some behaviors, additional barriers and insufficient cues to action result in suboptimal physical activity, dietary intake, and smoking rates. However, PLHIV have high adherence to ASCVD medications, which can be harnessed to reduce their high burden of ASCVD.

Stakeholder-informed strategies addressing cardiovascular disease (CVD) burden among people living with HIV (PWH) are needed within healthcare settings. This study provides an assessment of how human-centered design (HCD) guided the adaptation of a nurse-led intervention to reduce CVD risk among PWH. Using a HCD approach, research staff guided two multidisciplinary "design teams" in Ohio and North Carolina, with each having five HCD meetings. We conducted acceptability and feasibility testing. Six core recommendations were produced by two design teams of key stakeholders and further developed after the acceptability and feasibility testing to produce a final list of 14 actionable areas of adaptation. Acceptability and feasibility testing revealed areas for adaptation, e.g. patient preferences for communication and the benefit of additional staff to support patient follow-up. In conclusion, along with acceptability and feasibility testing, HCD led to the production of 14 key recommendations to enhance the effectiveness and scalability of an integrated HIV/CVD intervention., Competing Interests: Declaration of competing interest The author has no conflict of interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Persons living with human immunodeficiency virus (PLHIV) are at increased risk of atherosclerotic cardiovascular disease (ASCVD). In spite of this, uptake of evidence-based clinical interventions for ASCVD risk reduction in the HIV clinic setting is sub-optimal. METHODS: EXTRA-CVD is a 12-month randomized clinical effectiveness trial that will assess the efficacy of a multi-component nurse-led intervention in reducing ASCVD risk among PLHIV. Three hundred high ASCVD risk PLHIV across three sites will be randomized 1:1 to usual care with generic prevention education or the study intervention. The study intervention will consist of four evidence-based components: (1) nurse-led care coordination, (2) nurse-managed medication protocols and adherence support (3) home BP monitoring, and (4) electronic health records support tools. The primary outcome will be change in systolic blood pressure and secondary outcome will be change in non-HDL cholesterol over the course of the intervention. Tertiary outcomes will include change in the proportion of participants in the following extended cascade categories: (1) appropriately diagnosed with hypertension and hyperlipidemia (2) appropriately managed; (3) at treatment goal (systolic blood pressure <130 mm Hg and non-HDL cholesterol < National Lipid Association targets). CONCLUSIONS: The EXTRA-CVD trial will provide evidence appraising the potential impact of nurse-led interventions in reducing ASCVD risk among PLHIV, an essential extension of the HIV care continuum beyond HIV viral suppression., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Although quality and safety competencies were developed and disseminated nearly a decade ago by the Quality and Safety Education for Nurses (QSEN) project, the uptake in schools of nursing has been slow. The use of implementation science methods may be useful to accelerate quality and safety competency integration in nursing education. The article includes a definition and description of implementation science methods and practical implementation strategies for nurse educators to consider when integrating the QSEN competencies into nursing curriculum.

Background: The regimen of raltegravir (RAL), ritonavir-boosted darunavir (DAR/r), and etravirine (ETR) for HIV treatment-experienced patients in a non-clinical trial setting in the rural/semi-urban United States had not been evaluated., Objective: A retrospective cohort analysis was performed of adult patients prescribed the regimen from 2008 to 2013 at a HIV clinic serving such a population., Results: In all, 51 patients met inclusion criteria including 15 with suppressed viral loads at regimen initiation. Of the 36 patients with detectable viral loads, 22 (61.1%) achieved a plasma HIV-1 RNA level < 50 copies/ml at 28 weeks and 17 maintained viral suppression at 56 weeks (50% of those surviving without death). Of 42 patients with long-term follow-up, mean of 216 ± 83 weeks following regimen initiation, 31 (73.8%) had viral suppression. Suppression was significantly more likely in those patients that maintained adherence., Conclusions: In a non-urban clinic population from the United States with considerable treatment experience, the combination of RAL, DAR/r, and ETR was well tolerated and resulted in viral suppression in those that maintained adherence. Future prospective studies may better define the role of such a regimen in the context of revised recommendations for first-line medications in the HIV treatment naïve., Competing Interests: Conflict of interest statement: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Most of the pancreatic exocrine epithelium consists of acinar and intralobular duct (ductular) cells, with the balance consisting of interlobular and main duct cells. Fragments of mouse acinar/ductular epithelium can be isolated by partial digestion with collagenase and purified by Ficoll density gradient centrifugation. We investigated whether previously developed culture conditions used for duct epithelium would result in the selective survival and proliferation of ductular cells from the acinar/ductular fragments. The fragments were cultured on nitrocellulose filters coated with extracellular matrix. After 2 to 4 wk the filters were covered with proliferating cells resembling parallel cultures of duct epithelium by the following criteria: protein/DNA ratio, light and electron microscopic appearance, the presence of duct markers (carbonic anhydrase [CA] activity, CA II mRNA, the cystic fibrosis transmembrane conductance regulator), the near absence of acinar cell markers (amylase and chymotrypsin), a similar polypeptide profile after sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and the presence of spontaneous and secretin-stimulated electrogenic ion transport. Both duct and ductular epithelia formed fluid-filled cysts in collagen gels and both could be subcultured. We conclude that acinar/ductular tissue gives rise to ductular cells in culture by some combination of acinar cell death and/or transdifferentiation to a ductular phenotype, accompanied by proliferation of these cells and preexisting ductular cells. These cultures may be used to investigate the properties of this part of the pancreatic duct system, from which most of the pancreatic juice water and electrolytes probably originates.

Our goal is to create a transgenic mouse model for human pancreatic duct cell adenocarcinoma using the promoter/enhancer region of the carbonic anhydrase (CA) II gene to drive the expression of SV-40 T-antigen in pancreatic duct cells. This requires that the CA II gene be expressed in mouse pancreatic duct cells and not in other pancreatic cells, as has already been shown to be the case in the human and guinea pig pancreas. We have shown with an enzyme histochemical assay that mouse pancreatic duct cells contain CA activity in both intact pancreas and cultured interlobular duct epithelium. In addition, CA activity was detected with a biochemical assay in homogenates of cultured duct epithelium. The specific activity of duct cells was 2.75-fold greater than in whole pancreas, suggesting that a substantial amount of total pancreatic CA activity is contributed by duct cells. At least some of the CA in cultured duct cells was inferred to be CA II by Northern blot analysis of RNA extracted from the cells. The concentration of CA II mRNA in the cultured duct cells was substantially greater than in whole pancreas and would appear to account for the majority, if not all, of the CA II in the mouse pancreas.

Pancreatic duct fragments were isolated from rat and hamster pancreas and were cultured in an agarose matrix for up to 8 weeks (rat) or 20 weeks (hamster). The fragments consisted predominantly of duct epithelium, lesser numbers of stromal and atrophied acinar cells, and small numbers of islet cells. Hamster ducts averaged 3 micrograms protein per duct while rat ducts averaged 1 microgram, and the protein:DNA ratio of both types of ducts was less than that of whole pancreas. Estimated average duct yields of 6% (hamster) and 1% (rat) were based on the protein content of the ducts. Duct viability was shown by the incorporation of 3H-thymidine and 3H-leucine into bulk DNA and protein and by autoradiography. gamma-Glutamyl transferase and (Na + K)-ATPase specific activities were slightly elevated while amylase was depressed in the ducts when compared with whole pancreas in both species. gamma-Glutamyl transferase was localized histochemically in both duct epithelium and in surviving acinar tissue, as seen in vivo. Amylase was shown by immunohistochemistry to be present within duct lumina and in atrophied acini and their lumina. Alkaline phosphatase and Mg-ATPase specific activities were elevated in the hamster, but reduced in the rat, when compared with whole pancreas. Hamster alkaline phosphatase and Mg-ATPase were localized by histochemistry to the duct stroma, where these enzymes are not detected in vivo. Carbonic anhydrase was found in the duct epithelium of both species, as in vivo, as well as in the duct stroma, unlike in vivo. Acid glycosaminoglycans, as revealed by alcian blue staining, were found at the apical surfaces and in the lumina of both kinds of ducts. Glutathione-S-transferase and glucose-6-phosphate dehydrogenase were elevated in rat ducts, but not in hamster ducts. The polypeptide compositions of cultured ducts, freshly isolated pancreatic islets, and whole pancreas were compared by one-dimensional sodium dodecyl sulfate polyacrylamide gradient gel electrophoresis. No duct-specific polypeptides were observed; the ducts were characterized mainly by the reduction or absence of polypeptides, including some zymogens, seen in whole pancreas.

Interlobular duct fragments from the pancreas of the rat were isolated by collagenase digestion and filtration, embedded in a matrix of rat-tail collagen, and cultured in a 1:1 mixture of Dulbecco's minimal essential and Ham's F12 media supplemented with cholera toxin (CT, 100 ng/ml) and epidermal growth factor (EGF, 10 ng/ml) in addition to supplements used previously, thereby improving the yield of ducts by a factor of two compared with previous results. The ducts were harvested by digestion of the collagen matrix with collagenase and were then dissociated by treatment with EDTA in divalent cation-free salt suspended in collagen and cultured as were the ducts. Numerous cysts appeared as a function of time and some of these enlarged dramatically. Some of the larger cysts exhibited secondary tubular processes extending into the surrounding collagen. The addition of bovine pituitary extract (BPE, 50 micrograms/ml) doubled the number of cysts, whereas omission of serum or CT + EGF reduced the number. BPE or forskolin could substitute effectively for CT. Agents that stimulate (secretin) or inhibit (e.g., ouabain or acetazolamide) fluid-electrolyte secretion in vivo had no effect on the number or average diameter of the cysts. The cysts were 83 to 88% epithelial with the balance of the cells being fibroblastic in appearance. Some cysts consisted only of epithelium. The proliferative capacity of the cystic epithelium was shown by the presence of mitotic figures and by an autoradiographic labeling index of 22 to 30% after a 24-h exposure to [3H]thymidine. The labeling index was reduced by the omission of CT + EGF. Transmission electron microscopy showed that the cysts exhibited morphologic features of duct epithelium in vivo, including apical microvilli, lateral interdigitations of the plasma membrane, and typical cytoplasmic organelles.