Barriers and Facilitators to Ophthalmology Visit Adherence in an Urban Hospital Setting.

Purpose: To explore barriers and facilitators to completing scheduled outpatient appointments at an urban academic hospital-based ophthalmology department. Methods: Potential participants were stratified by neighborhood Social Vulnerability Index (SVI) (range, 0-1.0, higher scores indicate greater vulnerability), and semistructured interviews were conducted with individuals 18 years and older with an SVI of greater than 0.61 (n = 17) and providers delivering care in the General Eye Clinic of the University of Illinois Chicago (n = 8). Qualitative analysis informed by human-centered design methods was conducted to classify barriers and facilitators into three domains of the Consolidated Framework for Implementation Research: outer setting, inner setting, and characteristics of individuals. Results: There were four main themes-transportation, time burden, social support, and economic situation-all of which were within the outer setting of the Consolidated Framework for Implementation Research; transportation was most salient. Although providers perceived health literacy as a barrier affecting motivation, patients expressed a high motivation to attend visits and felt well-educated about their condition. Conclusions: A lack of resources outside of the health system presents significant barriers for patients from neighborhoods with high SVI. Future efforts to improve adherence should focus on resource-related interventions in the outer setting. Improving access to eye care will require community-level interventions, particularly transportation. Translational Relevance: Understanding the barriers and facilitators within the Consolidated Framework for Implementation Research provides useful guidance for future interventions, specifically to focus future efforts to improve adherence on resource-related interventions.

Federated Learning for Multicenter Collaboration in Ophthalmology: Implications for Clinical Diagnosis and Disease Epidemiology.

OBJECTIVE: To utilize a deep learning (DL) model trained via federated learning (FL), a method of collaborative training without sharing patient data, to delineate institutional differences in clinician diagnostic paradigms and disease epidemiology in retinopathy of prematurity (ROP). DESIGN: Evaluation of a diagnostic test or technology. SUBJECTS AND CONTROLS: We included 5245 patients with wide-angle retinal imaging from the neonatal intensive care units of 7 institutions as part of the Imaging and Informatics in ROP study. Images were labeled with the clinical diagnoses of plus disease (plus, preplus, no plus), which were documented in the chart, and a reference standard diagnosis was determined by 3 image-based ROP graders and the clinical diagnosis. METHODS: Demographics (birth weight, gestational age) and clinical diagnoses for all eye examinations were recorded from each institution. Using an FL approach, a DL model for plus disease classification was trained using only the clinical labels. The 3 class probabilities were then converted into a vascular severity score (VSS) for each eye examination, as well as an "institutional VSS," in which the average of the VSS values assigned to patients' higher severity ("worse") eyes at each examination was calculated for each institution. MAIN OUTCOME MEASURES: We compared demographics, clinical diagnoses of plus disease, and institutional VSSs between institutions using the McNemar-Bowker test, 2-proportion Z test, and 1-way analysis of variance with post hoc analysis by the Tukey-Kramer test. Single regression analysis was performed to explore the relationship between demographics and VSSs. RESULTS: We found that the proportion of patients diagnosed with preplus disease varied significantly between institutions (P < 0.001). Using the DL-derived VSS trained on the data from all institutions using FL, we observed differences in the institutional VSS and the level of vascular severity diagnosed as no plus (P < 0.001) across institutions. A significant, inverse relationship between the institutional VSS and mean gestational age was found (P = 0.049, adjusted R2 = 0.49). CONCLUSIONS: A DL-derived ROP VSS developed without sharing data between institutions using FL identified differences in the clinical diagnoses of plus disease and overall levels of ROP severity between institutions. Federated learning may represent a method to standardize clinical diagnoses and provide objective measurements of disease for image-based diseases.

Federated Learning for Multicenter Collaboration in Ophthalmology: Improving Classification Performance in Retinopathy of Prematurity.

OBJECTIVE: To compare the performance of deep learning classifiers for the diagnosis of plus disease in retinopathy of prematurity (ROP) trained using 2 methods for developing models on multi-institutional data sets: centralizing data versus federated learning (FL) in which no data leave each institution. DESIGN: Evaluation of a diagnostic test or technology. SUBJECTS: Deep learning models were trained, validated, and tested on 5255 wide-angle retinal images in the neonatal intensive care units of 7 institutions as part of the Imaging and Informatics in ROP study. All images were labeled for the presence of plus, preplus, or no plus disease with a clinical label and a reference standard diagnosis (RSD) determined by 3 image-based ROP graders and the clinical diagnosis. METHODS: We compared the area under the receiver operating characteristic curve (AUROC) for models developed on multi-institutional data, using a central approach initially, followed by FL, and compared locally trained models with both approaches. We compared the model performance (κ) with the label agreement (between clinical and RSD), data set size, and number of plus disease cases in each training cohort using the Spearman correlation coefficient (CC). MAIN OUTCOME MEASURES: Model performance using AUROC and linearly weighted κ. RESULTS: Four settings of experiment were used: FL trained on RSD against central trained on RSD, FL trained on clinical labels against central trained on clinical labels, FL trained on RSD against central trained on clinical labels, and FL trained on clinical labels against central trained on RSD (P = 0.046, P = 0.126, P = 0.224, and P = 0.0173, respectively). Four of the 7 (57%) models trained on local institutional data performed inferiorly to the FL models. The model performance for local models was positively correlated with the label agreement (between clinical and RSD labels, CC = 0.389, P = 0.387), total number of plus cases (CC = 0.759, P = 0.047), and overall training set size (CC = 0.924, P = 0.002). CONCLUSIONS: We found that a trained FL model performs comparably to a centralized model, confirming that FL may provide an effective, more feasible solution for interinstitutional learning. Smaller institutions benefit more from collaboration than larger institutions, showing the potential of FL for addressing disparities in resource access.

Ocular Outcomes after Treatment of Cytomegalovirus Retinitis Using Adoptive Immunotherapy with Cytomegalovirus-Specific Cytotoxic T Lymphocytes.

PURPOSE: To describe ocular outcomes in eyes with cytomegalovirus (CMV) retinitis treated with adoptive immunotherapy using systemic administration of CMV-specific cytotoxic Tlymphocytes (CMV-specific CTLs). DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with active CMV retinitis evaluated at a tertiary care academic center. METHODS: Treatment of CMV retinitis with standard-of-care therapy (systemic or intravitreal antivirals) or CMV-specific CTLs (with or without concurrent standard-of-care therapies). MAIN OUTCOME MEASURES: The electronic medical record was reviewed to determine baseline characteristics, treatment course, and ocular outcomes, including best-corrected visual acuity (BCVA), treatments administered (CMV-specific CTLs, systemic antivirals, intravitreal antivirals), resolution of CMV retinitis, any occurrence of immune recovery uveitis, cystoid macular edema, retinal detachment, or a combination thereof. RESULTS: Seven patients (3 of whom had bilateral disease [n = 10 eyes]) were treated with CMV-specific CTLs, whereas 20 patients (6 of whom had bilateral disease [n = 26 eyes]) received standard-of-care treatment. Indications for CMV-specific CTL therapy included persistent or progressive CMV retinitis (71.4% of patients); CMV UL54 or UL97 antiviral resistance mutations (42.9%); side effects or toxicity from antiviral agents (57.1%); patient intolerance to longstanding, frequent antiviral therapy for persistent retinitis (28.6%); or a combination thereof. Two patients (28.6%; 4 eyes [40%]) received CMV-specific CTL therapy without concurrent systemic or intravitreal antiviral therapy for active CMV retinitis, whereas 5 patients (71.4%; 6 eyes [60%]) continued to receive concurrent antiviral therapies. Resolution of CMV retinitis was achieved in 9 eyes (90%) treated with CMV-specific CTLs, with BCVA stabilizing (4 eyes [40%]) or improving (4 eyes [40%]) in 80% of eyes over an average follow-up of 33.4 months. Rates of immune recovery uveitis, new-onset cystoid macular edema, and retinal detachment were 0%, 10% (1 eye), and 20% (2 eyes), respectively. These outcomes compared favorably with a nonrandomized cohort of eyes treated with standard-of-care therapy alone, despite potentially worse baseline characteristics. CONCLUSIONS: CMV-specific CTL therapy may represent a novel monotherapy or adjunctive therapy, or both, for CMV retinitis, especially in eyes that are resistant, refractory, or intolerant of standard-of-care antiviral therapies. More generally, adoptive cell transfer and adoptive immunotherapy may have a role in refractory CMV retinitis. Larger prospective, randomized trials are necessary.

Associations between Household Water Fluoridation Status and Plain Tap or Bottled Water Consumption.

INTRODUCTION: The benefits of community water fluoridation for preventing dental caries are attenuated if people do not consume tap water. OBJECTIVES: We examined associations between household water fluoride content and consuming plain tap or bottled water among US youth. METHODS: We used National Health and Nutrition Examination Survey data for 2013 to 2016 for 5,193 youth aged 2 to 19 y. Fluoride content in youth's household tap water samples was measured electrometrically with ion-specific electrodes and designated low (<0.6 mg/L) or about optimal (0.6 to 1.2 mg/L). Plain tap and bottled water consumption was obtained from one 24-h dietary recall. We used binomial regression models to estimate adjusted prevalence ratios (APRs) and 95% CIs for consuming plain tap water (including tap only or both tap and bottled) and consuming only bottled water as related to household water fluoride content (low or about optimal) and sociodemographic characteristics. RESULTS: On a given day, 52.6% of youth consumed plain tap water (43.8% exclusively and 8.8% both tap and bottled) and 28%, only bottled water. Neither tap water (APR, 0.96; 95% CI, 0.84 to 1.10) nor only bottled water (APR, 1.03; 95% CI, 0.86 to 1.22) consumption was associated with household water fluoride content. Non-Hispanic Black youth and Hispanic youth were about 30% relatively less likely to consume tap water and 60% to 80% relatively more likely to consume only bottled water than non-Hispanic Whites. Low income, low parental education, and no past-year dental visit were associated with not consuming tap water. CONCLUSION: Half of youth consumed plain tap water on a given day. Consuming plain tap water was not associated with community water fluoridation status. This study is the first to find that up to 50% of the population served by fluoridated water may not receive its full caries-preventive benefits due to not consuming plain tap water. KNOWLEDGE TRANSFER STATEMENT: Half of US youth consumed plain tap water on a given day. Consuming plain tap water was not associated with community water fluoridation status. This finding suggests that up to 50% of the population served by fluoridated water systems may not receive its full caries-preventive benefits due to not consuming plain tap water. Our findings add support for the need to identify and address barriers to tap water consumption and promote health benefits of fluoridation.

Transfer Learning for Automated OCTA Detection of Diabetic Retinopathy.

Purpose: To test the feasibility of using deep learning for optical coherence tomography angiography (OCTA) detection of diabetic retinopathy. Methods: A deep-learning convolutional neural network (CNN) architecture, VGG16, was employed for this study. A transfer learning process was implemented to retrain the CNN for robust OCTA classification. One dataset, consisting of images of 32 healthy eyes, 75 eyes with diabetic retinopathy (DR), and 24 eyes with diabetes but no DR (NoDR), was used for training and cross-validation. A second dataset consisting of 20 NoDR and 26 DR eyes was used for external validation. To demonstrate the feasibility of using artificial intelligence (AI) screening of DR in clinical environments, the CNN was incorporated into a graphical user interface (GUI) platform. Results: With the last nine layers retrained, the CNN architecture achieved the best performance for automated OCTA classification. The cross-validation accuracy of the retrained classifier for differentiating among healthy, NoDR, and DR eyes was 87.27%, with 83.76% sensitivity and 90.82% specificity. The AUC metrics for binary classification of healthy, NoDR, and DR eyes were 0.97, 0.98, and 0.97, respectively. The GUI platform enabled easy validation of the method for AI screening of DR in a clinical environment. Conclusions: With a transfer learning process for retraining, a CNN can be used for robust OCTA classification of healthy, NoDR, and DR eyes. The AI-based OCTA classification platform may provide a practical solution to reducing the burden of experienced ophthalmologists with regard to mass screening of DR patients. Translational Relevance: Deep-learning-based OCTA classification can alleviate the need for manual graders and improve DR screening efficiency.

QUANTITATIVE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES FOR OBJECTIVE CLASSIFICATION AND STAGING OF DIABETIC RETINOPATHY.

PURPOSE: This study aims to characterize quantitative optical coherence tomography angiography (OCTA) features of nonproliferative diabetic retinopathy (NPDR) and to validate them for computer-aided NPDR staging. METHODS: One hundred and twenty OCTA images from 60 NPDR (mild, moderate, and severe stages) patients and 40 images from 20 control subjects were used for this study conducted in a tertiary, subspecialty, academic practice. Both eyes were photographed and all the OCTAs were 6 mm × 6 mm macular scans. Six quantitative features, that is, blood vessel tortuosity, blood vascular caliber, vessel perimeter index, blood vessel density, foveal avascular zone area, and foveal avascular zone contour irregularity (FAZ-CI) were derived from each OCTA image. A support vector machine classification model was trained and tested for computer-aided classification of NPDR stages. Sensitivity, specificity, and accuracy were used as performance metrics of computer-aided classification, and receiver operation characteristics curve was plotted to measure the sensitivity-specificity tradeoff of the classification algorithm. RESULTS: Among 6 individual OCTA features, blood vessel density shows the best classification accuracies, 93.89% and 90.89% for control versus disease and control versus mild NPDR, respectively. Combined feature classification achieved improved accuracies, 94.41% and 92.96%, respectively. Moreover, the temporal-perifoveal region was the most sensitive region for early detection of DR. For multiclass classification, support vector machine algorithm achieved 84% accuracy. CONCLUSION: Blood vessel density was observed as the most sensitive feature, and temporal-perifoveal region was the most sensitive region for early detection of DR. Quantitative OCTA analysis enabled computer-aided identification and staging of NPDR.

Comorbid hepatitis C does not modulate prevalence or severity of diabetic retinopathy.

PURPOSE: There are limited and conflicting data regarding the impact of comorbid hepatitis C virus (HCV) infection on diabetic retinopathy (DR). This study sought to compare the prevalence and severity of DR among patients with diabetes mellitus (DM) with and without HCV. PATIENTS AND METHODS: This was a retrospective, case-control study of patients with DM comparing 120 patients with comorbid HCV and 120 age-matched controls. DR prevalence and several measures of severity were compared between groups. Subgroup analyses were performed among HCV patients with cirrhosis, comorbid HIV, or history of treatment with interferon. Statistical analysis for between-group comparisons utilized both univariate and multivariate analyses. RESULTS: Cases and controls exhibited similar baseline characteristics: average hemoglobin A1c, DM duration, and age (p>0.05). Among cases and controls, there was no difference in DR prevalence (35.8% versus 42.5%, respectively, p=0.29) or severity (p>0.05). Within the HCV subgroup, DR severity was reduced in patients with HIV or cirrhosis. However, multivariate analysis identified reduced DM duration in these subgroups as the primary contributor to lesser DR severity, rather than HIV or cirrhosis. CONCLUSION: In this study, comorbid HCV did not modulate the prevalence or severity of DR among patients with DM. These findings may inform clinical monitoring among HCV-positive diabetics undergoing ophthalmic evaluation.

Global health training in ophthalmology residency programs.

PURPOSE: To assess current global health education and international electives in ophthalmology residency programs and barriers to global health implementation in ophthalmology resident education. METHODS: A web-based survey regarding participation in global health and international electives was emailed to residency program directors at 116 accredited ophthalmology residency programs via an Association of University Professors in Ophthalmology (AUPO) residency program director listserv. RESULTS: Fifty-nine (51%) ophthalmology residency program directors responded. Thirty-seven program directors (63%) said global health was important to medical students when evaluating residency programs. Thirty-two program directors (55%) reported developing international electives. Reported barriers to resident participation in international electives were: 1) insufficient financial support, 2) inadequate resident coverage at home, and 3) lack of ACGME approval for international electives. Program directors requested more information about resident international electives, funding, and global ophthalmology educational resources. They requested ACGME recognition of international electives to facilitate resident participation. More than half (54%) of program directors supported international electives for residents. CONCLUSIONS: This survey demonstrates that program directors believe global health is an important consideration when medical students evaluate training programs. Despite perceived barriers to incorporating global health opportunities into residency training, program directors are interested in development of global health resources and plan to further develop global health opportunities.

A comparison of same setting versus delayed vitrectomy in the management of retained lens fragments after cataract surgery.

PURPOSE: Intravitreal retained lens fragments are a rare but potentially serious complication of phacoemulsification. The purpose of this study was to compare same setting ("no wait") vitrectomy with delayed surgery in the management of retained lens fragments in a single academic setting. METHODS: This study is a retrospective nonrandomized study of all patients undergoing pars plana vitrectomy for retained lens fragments after cataract surgery from 2007 to 2012. Outcomes included visual acuity and the development of various complications such as retinal detachment, elevated intraocular pressure >30 mmHg, and cystoid macular edema. Multivariate analysis was performed to adjust for potentially confounding variables such as age and preoperative visual acuity. RESULTS: Twenty-eight consecutive eyes (13 same setting, 15 delayed setting) were included in the analysis. Patients in the same setting group were older than in the delayed group (81.00 vs. 72.87 years, P = 0.053). No other preoperative differences existed between the groups (axial length, preoperative vision, and intraocular pressure). The mean time to pars plana vitrectomy in the delayed group was 26.6 days (range, 1-91 days). The mean follow-up time was 363 days (same setting) and 643 days (delayed). At the most recent follow-up, no significant difference existed in mean vision between the same setting (logMAR, 0.42) and the delayed group (logMAR, 0.57) (P = 0.132). Multivariate analysis showed no difference in final vision when adjusting for age and preoperative vision. Although there was a trend for eyes in the same setting group to obtain good vision (≥ 20/40) faster, a higher percentage of eyes in the delayed group obtained good vision at the most recent follow-up (66.7 vs. 23.1%, P = 0.02). More eyes in the delayed group had an intraocular pressure >30 at any point (P = 0.055). There was no significant difference between the groups in any other complications such as retinal detachment, choroidal detachment, and cystoid macular edema during the follow-up. CONCLUSION: In this cohort, same setting pars plana vitrectomy offers no significant visual acuity advantage over delayed pars plana vitrectomy in patients with retained lens fragments. Fewer eyes in the same setting group "ever" had an intraocular pressure ≥ 30 during follow-up, whereas no other complication differences were seen between the groups.

Training fellows for retinopathy of prematurity care: a Web-based survey.

PURPOSE: To characterize the training received by pediatric ophthalmology and retina fellows in retinopathy of prematurity (ROP) management. METHODS: Pediatric ophthalmology and retina fellowship programs were emailed a Web-based survey to assess fellowship training in ROP management. RESULTS: Of 140 programs contacted, 42 (30%) participated, resulting in 87 surveys for analysis. Of the 87 respondents, 25 (29%) reported that two-thirds or less of ROP examinations performed by fellows were also seen by an attending. When stratified by specialty, this trend was statistically different between pediatric ophthalmology and retina fellows (P = 0.03). Additionally, pediatric ophthalmology fellows performed fewer laser photocoagulation procedures than retina fellows (P < 0.001). Regarding fellows' perceived competency in ROP management, 3 of 51 (6%) felt competent at the start of their fellowship and 43 of 51 (84%) felt competent at the time of the survey. Only 7% of respondents reported the use of formal evaluations at their programs to assess fellow competence in ROP examination. CONCLUSIONS: Training programs for fellows in pediatric ophthalmology and retina vary greatly with respect to ROP training and the quality of clinical care. Many clinical ROP examinations are being performed by pediatric ophthalmology and retina fellows without involvement and/or direct supervision by attending ophthalmologists. Our findings have important implications for the development of a future workforce for ROP management.

Evaluation of tissue interactions with mechanical elements of a transscleral drug delivery device.

The goal of this work was to evaluate tissue-device interactions due to implantation of a mechanically operated drug delivery system onto the posterior sclera. Two test devices were designed and fabricated to model elements of the drug delivery device-one containing a free-spinning ball bearing and the other encasing two articulating gears. Openings in the base of test devices modeled ports for drug passage from device to sclera. Porous poly(tetrafluoroethylene) (PTFE) membranes were attached to half of the gear devices to minimize tissue ingrowth through these ports. Test devices were sutured onto rabbit eyes for 10 weeks. Tissue-device interactions were evaluated histologically and mechanically after removal to determine effects on device function and changes in surrounding tissue. Test devices were generally well-tolerated during residence in the animal. All devices encouraged fibrous tissue formation between the sclera and the device, fibrous tissue encapsulation and invasion around the device, and inflammation of the conjunctiva. Gear devices encouraged significantly greater inflammation in all cases and a larger rate of tissue ingrowth. PTFE membranes prevented tissue invasion through the covered drug ports, though tissue migrated in through other smaller openings. The torque required to turn the mechanical elements increased over 1000 times for gear devices, but only on the order of 100 times for membrane-covered gear devices and less than 100 times for ball bearing devices. Maintaining a lower device profile, minimizing microscale motion on the eye surface and covering drug ports with a porous membrane may minimize inflammation, decreasing the risk of damage to surrounding tissues and minimizing disruption of device operation.

Patients diagnosed with tuberculosis at death or who died during therapy: association with the human immunodeficiency virus.

OBJECTIVES: To describe trends and risk factors for tuberculosis (TB) mortality. DESIGN: We calculated trends, identified patient characteristics associated with TB diagnosis at death or death during TB treatment, and described diagnostic procedures using the United States National TB Surveillance System for 1997-2005. RESULTS: Human immunodeficiency virus (HIV) infected TB patients had an adjusted odds ratio (aOR) of 4-11 for TB diagnosis at death (foreign-born non-Whites, aOR = 11) and of 3-19 for death during TB treatment vs. non-HIV-infected patients. Odds increased by age. Hispanic males had an aOR of 2 for TB diagnosis at death compared with female non-Hispanics. Multidrug-resistant TB (MDR-TB) patients had a three times greater aOR of death during treatment than non-MDR patients. American Indians, Black females, residents in long-term care facilities, US-born patients, and non-HIV-infected homeless persons aged 25-44 years each had an aOR of 2 for mortality during treatment; 86% of pulmonary patients diagnosed at death had a chest radiograph, but 34% had no sputum smear or culture reported. CONCLUSION: During 1997-2005, controlling for age, HIV remained the characteristic with the greatest aOR for TB diagnosis at death or death during TB therapy. Race/ethnicity, country of birth and homelessness further increased the adjusted odds of death. Results show possible missed opportunities for TB diagnosis prior to death.

Disparities in tuberculosis between Asian/Pacific Islanders and non-Hispanic Whites, United States, 1993-2006.

SETTING: The United States (US) National Tuberculosis Surveillance System (NTSS), including 50 states, District of Columbia, and New York City. OBJECTIVE: To examine disparities in characteristics and rates of Asian/Pacific Islander (API) and non-Hispanic White tuberculosis (TB) patients. DESIGN: Descriptive analysis and logistic regression of selected 1993-2006 NTSS data. US Census Bureau Zip Code Tabulation Areas and geographic information system were used to compare API and non-Hispanic White TB patients by population density. RESULT: Of 253,299 TB cases, 19.8% were APIs and 23.2% were Whites; 94.2% APIs and 11.9% Whites were foreign-born. Factors that were most often associated with APIs were being female, age 15-24 years, extra-pulmonary TB, and drug resistance. APIs were less likely than Whites to be human immunodeficiency virus (HIV) positive, homeless, substance abusers, or on directly observed therapy. From 1993 to 2006, the API TB case rate declined by 42.9% vs. 66.6% in Whites (P < 0.01). Being foreign-born was the strongest risk factor for TB, regardless of population densities, but APIs were more likely to have TB than foreign-born Whites at lower population densities. CONCLUSION: Disparities in TB exist among US APIs and non-Hispanic Whites. TB program officials should allocate programs appropriately for foreign-born APIs in lower population density areas.

HIV-1 subtype E progression among northern Thai couples: traditional and non-traditional predictors of survival.

BACKGROUND: In the continuing effort to introduce antiretroviral therapy in resource-limited settings, there is a need to understand differences between natural history of HIV in different populations and to identify feasible clinical measures predictive of survival. METHODS: We examined predictors of survival among 836 heterosexuals who were infected with HIV subtype CRF01_AE in Thailand. RESULTS: From 1993 to 1999, 269 (49.4%) men and 65 (25.7%) women died. The median time from the estimated seroconversion to death was 7.8 years (95% confidence interval 7.0-9.1). Men and women with enrolment CD4 counts <200 cells/microl had about 2 and 11 times greater risk of death than those with CD4 counts of 200-500 and >500, respectively. Measurements available in resource-limited settings, including total lymphocyte count (TLC), anaemia, and low body mass index (BMI), also predicted survival. Men with two or more of these predictors had a median survival of 0.8 (0.5-1.8) years, compared with 2.7 (1.9-3.3) years for one predictor and 4.9 (4.1-5.2) years for no predictors. CONCLUSIONS: The time from HIV infection to death appears shorter among this Thai population than among antiretroviral naive Western populations. CD4 count and viral load (VL) were strong, independent predictors of survival. When CD4 count and VL are unavailable, individuals at high risk for shortened HIV survival may be identified by a combination of low TLC, anaemia, and low BMI. This combination of accessible clinical measures of the disease stage may be useful for medical management in resource-limited settings.

Oral manifestations of HIV infection in relation to clinical and CD4 immunological status in northern and southern Thai patients.

OBJECTIVES: To assess prevalence and variations in the oral manifestations of HIV in HIV-infected subjects in southern Thailand (a new HIV epidemic) and northern Thailand (a mature epidemic), and the association with age, sex, risk behaviours, CD4 count and medication used. SUBJECTS AND METHODS: A total of 102 and 135 HIV-infected individuals were enrolled in northern and southern hospitals, respectively. Oral and haematological examination was performed after sociodemographic interview of the patients. Clinical history was retrieved from patients' medical records. RESULTS: Oral candidiasis (OC, 55%), oral hairy leucoplakia (OHL, 21%) and HIV-associated-periodontal disease (14%) were among the most common oral lesions in southern Thailand. OHL (38%), OC (25%), HIV-associated-periodontal disease (15%) were the three most common lesions in the north. A significant association was found between any oral lesion, OC, particularly the pseudomembranous type (PC), and CD4 < 200 cells mm(-3) at both sites. A negative relationship was found between systemic antifungal treatment and OC including PC and erythematous candidiasis (EC) in the southern data. OHL showed a positive relationship with male sex and a negative relationship with antiretroviral treatment in the northern site. Younger age and being a current smoker were positively associated with oral lesions in the southern group. CONCLUSION: OC, particularly PC, could be useful as a marker for immunosuppression, particularly where CD4 count cannot be determined routinely. Antifungal treatment is of benefit in the subjects who cannot afford highly active antiretroviral therapy (HAART).

A randomized efficacy and safety trial of oxandrolone in the treatment of Duchenne dystrophy.

BACKGROUND: A pilot study suggested that oxandrolone, an anabolic steroid, improved strength in boys with Duchenne dystrophy (DD) and indicated the need for a more definitive study. METHODS: A 6-month, randomized, double-blind, placebo-controlled study of oxandrolone in boys with an established diagnosis of DD, using the change from baseline to 6 months in the average muscle strength score (MMT) as the primary efficacy measure. RESULTS: The mean change from baseline for the oxandrolone group was +0.035 and that for the placebo group was -0.140. Although the oxandrolone group did not get worse and the placebo patients showed some deterioration in strength, the difference was not significant (p = 0.13). The average of the four quantitative muscle tests (QMT) showed a significant improvement in the oxandrolone-treated boys as compared with placebo. No adverse reactions attributable to oxandrolone were recorded. CONCLUSIONS: Although oxandrolone did not produce a significant change in the average manual muscle strength score as compared with placebo, the mean change in QMT was significant. Because oxandrolone is safe, accelerates linear growth, and may have some beneficial effect in slowing the progress of weakness, it may be useful before initiating corticosteroid therapy.

Changing knowledge, attitudes, and practices of Thai oral health personnel with regard to AIDS: an evaluation of an educational intervention.

OBJECTIVE: This study evaluated the effect of an educational intervention in improving Thai oral health personnel's (OHP) knowledge, attitudes and practices (KAP) regarding HIV/AIDS. RESEARCH DESIGN: The study used a pre-test/post-test design with study and control groups. RESULTS: of the pre-test questionnaire were used to design the intervention. Three months after the study group received the intervention, the same questionnaire was given to both groups. INTERVENTION: A three-day workshop was conducted using a variety of teaching methods: lectures, videos, role-plays, interviews with HIV infected persons, and demonstrations. SETTING: The study was conducted in rural government dental clinics in three provinces in southern Thailand. One hundred and three OHP in 23 dental clinics were in the study group while 46 OHP in II dental clinics were in the control group. OUTCOME MEASURES: The outcomes were knowledge and attitudes regarding HIV/AIDS, perception of occupational risk, willingness to treat HIV infected persons and adherence to recommended infection control procedures. RESULTS AND CONCLUSIONS: The educational intervention resulted in significant improvement in many domains of KAP in the study group, while there was little change in the control group. The post-test questionnaire showed that further improvements are needed in attitudes towards HIV/AIDS and practices regarding accidental needle stick injury. The intervention was both effective and appropriate and should be considered for national use.

High rates of transmission of subtype E human immunodeficiency virus type 1 among heterosexual couples in Northern Thailand: role of sexually transmitted diseases and immune compromise.

The heterosexual transmission of subtype E human immunodeficiency virus type 1 (HIV-1) infection was evaluated in 467 couples in Thailand in whom the man was HIV-1 positive and the woman had no risk factors for HIV other than sex with her infected partner. At baseline, 216 (46.3%) of the 467 women were positive for HIV-1; prevalence of HIV among women was 52.2% when their male partners had CD4+ lymphocyte counts of <200 cells/microL, 45.9% in women whose partners had counts of 200-499 micro/L, and 39.2% in women whose partners had counts of >/=500/microL. Women were twice as likely to be HIV positive if their partners had a history of a sexually transmitted disease (STD); however, their HIV prevalence was 29% among couples who had no STD history. It appears that female partners of men infected with subtype E HIV-1 are at high risk of infection even when the man's CD4+ cell count is relatively high. A high rate of STDs may contribute significantly to this risk [corrected].