Amit C Achhra

Abstract:

Abstract: OBJECTIVE: To investigate the relative predictive value of CD4(+) metrics for serious clinical endpoints. DESIGN: Observational. METHODS: Patients (3012; 20 317 person-years) from control arms of ESPRIT and SILCAAT were followed prospectively. We used Cox regression to identify CD4(+) metrics (latest, baseline and nadir CD4(+) cell count, latest CD4(+)%, time spent with CD4(+) count below certain thresholds and CD4(+) slopes) independently predictive of all-cause mortality, non-AIDS deaths, non-AIDS (cardiovascular, hepatic, renal and non-AIDS malignancy) and AIDS events. Akaike information criteria (AIC) were calculated for each model. Significant metrics (P < 0.05) were then additionally adjusted for latest CD4(+) cell count. RESULTS: Non-AIDS deaths occurred at a higher rate than AIDS deaths [rate ratio: 6.48, 95% confidence interval (CI) 5.1-8.1], and non-AIDS events likewise (rate ratio: 1.72, 95% CI 1.65-1.79). Latest CD4(+) cell count was strongly predictive of lower risk of death (hazard ratio per log2 rise: 0.48, 95% CI 0.43-0.54), with lowest AIC of all metrics. CD4(+) slope over seven visits, after additional adjustment for latest CD4(+) cell count, was the only metric to be an independent predictor for all-cause (hazard ratio for slope <-10 cells/microl per month vs. 0 +/- 10: 3.04, 95% CI 1.98-4.67) and non-AIDS deaths (hazard ratio for slope <-10 cells/microl per month vs. 0 +/- 10: 2.62, 95% CI 1.62-4.22). Latest CD4(+) cell count (per log(2) rise) was the best predictor across all four endpoints and predicted hepatic (hazard ratio 0.46, 95% CI 0.33-0.63) and renal events (hazard ratio 0.39, 95% CI 0.21-0.70), but not cardiovascular events (hazard ratio 1.05, 95% CI 0.77-1.43) or non-AIDS cancers (hazard ratio 0.78, 95% CI 0.59-1.03). CONCLUSION: Latest CD4(+) cell count is the best predictor of serious endpoints. CD4(+) slope independently predicts all-cause and non-AIDS deaths.

Abstract: BACKGROUND: General practitioners are well placed to provide health promotion, both at the individual level and more broadly by addressing socioenvironmental determinants of health. However, important barriers exist which need to be tackled. OBJECTIVE: This article describes the current approach to health promotion by Australian GPs and identifies a gap in GP training and education as an important barrier to health promotion. DISCUSSION: Health promotion by Australian GPs is currently focused on the individual behaviour of patients. To improve the health of individuals, however, it is also vital to tackle the broader socioenvironmental determinants of health. One of the important barriers to a more holistic approach is a lack of understanding about the principles of health promotion among GPs, suggesting a significant gap in their training. Future research should focus on integrating health promotion into the medical curricula at the undergraduate, graduate and continuing medical education levels.