Publications

In this paper, we discuss how life history drawings can serve as a valuable method for global health research. The introduction discusses qualitative approaches to concepts such as reliability, validity and triangulation, and situates the use of participatory visual methods within the broader field of participatory research. The paper reports on an experience using life history drawings as part of extended ethnographic research in rural Mexico and among Mexican migrants living in Atlanta. The primary method for that parent project was comparative ethnographic research, which included life histories collected from 13 pairs of women over 15 months of participant observation. Early in the research, the drawings contributed to a major reorientation in the direction of the research project. The insights generated through analysis of the life history drawings exemplify how this participatory research technique can direct attention to social processes that feel salient to community members. In this case, they called attention to the enormity of social change in this community over one generation, reorienting the study from one focused on change causes by migration to one that focused on two trajectories of change: generational and migration-related.

OBJECTIVE

Among HIV-infected persons, tenofovir disoproxil fumarate (TDF) use is associated with higher risk of developing chronic kidney disease (CKD). Because lower serum bicarbonate concentrations may precede CKD onset, this study investigated the associations between TDF use and bicarbonate concentrations, and between bicarbonate with CKD risk among TDF users and nonusers.

METHODS

Retrospective cohort study of 16,070 HIV-infected US veterans who initiated antiretroviral therapy between 1997-2011. The association between TDF use with longitudinal bicarbonate concentrations and associations between bicarbonate with incident CKD stratified by TDF use (never, initial, and later user) were evaluated.

RESULTS

Compared with TDF users, never users had faster declines in bicarbonate concentrations: change in bicarbonate -0.11 mmol/l per year (95% confidence interval -0.16, -0.05), compared with -0.04 mmol/l per year (-0.06, 0.05) in initial users and -0.02 mmol/l per year (-0.05, 0.01) in later users. Low baseline bicarbonate (<22 mmol/l) was significantly associated with CKD risk among TDF never users (1.80; 1.21, 2.68), but not among TDF users (0.98; 0.69, 1.38). Similarly, declining bicarbonate concentrations were associated with higher CKD risk among never users (hazard ratio 1.67 per mmol/l; 1.34, 2.08), but not among TDF users (1.09; 0.98, 1.22). Interactions were highly significant for both analyses (P value = 0.001).

CONCLUSION

Despite associations with nephrotoxicity, TDF use was associated with higher serum bicarbonate concentrations longitudinally. Additionally, TDF use obscured the strong associations of bicarbonate with CKD risk in HIV-infected persons. Therefore, the role of bicarbonate concentrations as a tool to monitor kidney health in HIV-infected persons may be limited in the setting of TDF use.

BACKGROUND

As the population ages, an increasing number of older patients are undergoing major surgery. We examined the impact of advanced age on outcomes following major gastrointestinal cancer surgery in an era of improved surgical outcomes.

MATERIALS AND METHODS

This was a population-based, retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We evaluated patients undergoing major abdominal gastrointestinal cancer surgery from 2005-2012. Multivariable logistic regression was performed to determine the independent effect of advanced age on outcomes. Our primary outcome was 30-d mortality, and our secondary outcomes were 30-d major postoperative adverse events, discharge disposition, length of stay, reoperation, and readmission.

RESULTS

Elderly (≥65 y) patients were twice as likely to have multiple comorbidities as those <65 y but prevalence of comorbidities was similar across all older age groups. Mortality increased with age across all procedures (P < 0.05). The risk of advanced age on mortality was highest in hepatectomy (odds ratio = 5.17, 95% confidence interval = 2.19-12.20) and that for major postoperative adverse events was highest in proctectomy (odds ratio = 2.32, 95% confidence interval = 1.53-3.52). Patients were more likely to be discharged to an institutional care facility as age increased across all procedures (P < 0.01).

CONCLUSIONS

Despite being highly selected for surgery, elderly patients undergoing major gastrointestinal cancer surgery have substantially worse postoperative outcomes than younger patients (<65 y). The risk of age on postoperative outcomes was present across all operations but had its highest association with liver and rectal cancer resections.