Kenya's emergency-hire nursing programme: a pilot evaluation of health service delivery in two districts.

OBJECTIVE: To assess the feasibility of utilizing a small-scale, low-cost, pilot evaluation in assessing the short-term impact of Kenya's emergency-hire nursing programme (EHP) on the delivery of health services (outpatient visits and maternal-child health indicators) in two underserved health districts with high HIV/AIDS prevalence. METHODS: Six primary outcomes were assessed through the collection of data from facility-level health management forms-total general outpatient visits, vaginal deliveries, caesarean sections, antenatal care (ANC) attendance, ANC clients tested for HIV, and deliveries to HIV-positive women. Data on outcome measures were assessed both pre-and post-emergency-hire nurse placement. Informal discussions were also conducted to obtain supporting qualitative data. FINDINGS: The majority of EHP nurses were placed in Suba (15.5%) and Siaya (13%) districts. At the time of the intervention, we describe an increase in total general outpatient visits, vaginal deliveries and caesarean sections within both districts. Similar significant increases were seen with ANC attendance and deliveries to HIV-positive women. Despite increases in the quantity of health services immediately following nurse placement, these levels were often not sustained. We identify several factors that challenge the long-term sustainability of these staffing enhancements. CONCLUSIONS: There are multiple factors beyond increasing the supply of nurses that affect the delivery of health services. We believe this pilot evaluation sets the foundation for future, larger and more comprehensive studies further elaborating on the interface between interventions to alleviate nursing shortages and promote enhanced health service delivery. We also stress the importance of strong national and local relationships in conducting future studies.

Vaccination and risk of lone atrial fibrillation in the active component United States military.

PURPOSE: To evaluate the hypothesis that receipt of anthrax vaccine adsorbed (AVA) increases the risk of atrial fibrillation in the absence of identifiable underlying risk factors or structural heart disease (lone atrial fibrillation). METHODS: We conducted a retrospective population-based cohort study among U.S. military personnel who were on active duty during the period from January 1, 1998 through December 31, 2006. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify individuals diagnosed with atrial fibrillation in the Defense Medical Surveillance System, and electronic records were screened to include only individuals without evidence of predisposing medical conditions. We used multivariable Poisson regression to estimate the risk of lone atrial fibrillation after exposure to AVA. We also evaluated possible associations with influenza and smallpox vaccines. RESULTS: Our study population consisted of 2,957,091individuals followed for 11,329,746 person-years of service. Of these, 2,435 met our case definition for lone atrial fibrillation, contributing approximately 8,383 person-years of service. 1,062,176 (36%) individuals received at least one dose of AVA; the median person time observed post-exposure was 3.6 years. We found no elevated risk of diagnosed lone atrial fibrillation associated with AVA (adjusted risk ratio = 0.99; 95% confidence interval = 0.90, 1.09; p = 0.84). No elevated risk was observed for lone atrial fibrillation associated with influenza or smallpox vaccines given during military service. CONCLUSIONS: We did not find an increased risk of lone atrial fibrillation after AVA, influenza or smallpox vaccine. These findings may be helpful in planning future vaccine safety research.

Recovery of HIV service provision post-earthquake.

OBJECTIVE: To describe the level of functionality of President's Emergency Plan for AIDS Relief (PEPFAR)-supported HIV clinical services following the devastating earthquake that struck Haiti in January 2010. DESIGN: Available program-monitoring data from sites providing voluntary counseling and testing for HIV (VCT), antenatal care (ANC) and prevention of mother-to-child transmission (PMTCT) services, and antiretroviral treatment (ART) were described, comparing pre-earthquake and post-earthquake periods during October 2008 to May 2010. METHODS: Pre-earthquake HIV service baselines for VCT, PMTCT, and ART enrollment were defined as monthly mean total number of patients served over 15 months pre-earthquake. ART baseline was defined as total current patients by December 2009. Sites were categorized as high-earthquake or low-earthquake intensity based on location and instrumental shake intensity data. RESULTS: Pre-earthquake mean monthly baselines were 41 087 (VCT), 11 909 (HIV testing at ANC sites), 648 (ART enrollment), and 296 (PMTCT enrollment); baseline total current patients on ART was 24 863. Service provision in January and May 2010, reported as percentage of baseline, was 43 and 78.7% (VCT), 50.8 and 88.7% (HIV testing at ANC), 46 and 81% (PMTCT), and 41 and 82.7% (ART enrollment), respectively. Current patients on ART decreased to 97% of baseline in April, rising to 103.9% by May; the initial decline was restricted to high-earthquake intensity areas. CONCLUSION: Following the Haiti earthquake, there was a transient, marked decline in VCT and new ART patient enrollment, whereas follow-up of established ART patients remained impressively high. HIV treatment continuity should be reinforced in disaster preparedness and response strategies in HIV epidemic settings.

Comparison of HIV-1 resistance profiles in plasma RNA versus PBMC DNA in heavily treated patients in Honduras, a resource-limited country.

The World Health Organization currently does not recommend the use of dried blood spot specimens for drug resistance testing in patients undergoing antiretroviral therapy (ART). Therefore, HIV-1 resistance testing using peripheral blood mononuclear cells (PBMCs) may be of value in resource-limited settings. We compared genotypic resistance profiles in plasma and PBMCs from patients failing ART in two cities of Honduras (Tegucigalpa and San Pedro Sula), a resource-limited country. One hundred patients failing ART were randomly selected from a longitudinal patient monitoring cohort. Plasma and PBMC samples without patient identifier were used for genotypic resistance testing. Sequence data were analyzed, resistance profiles were determined and compared using Stanford HIV Drug Resistance Database algorithm. Specimens with concordant resistance profiles between the two compartments were 88% (95% CI: 80.3% - 94.5 %). Nine specimens (12%, 95% CI: 6.5% - 21.3%) had discordant resistance profiles of clinical significance. Logistic regression analyses indicated that patients on triple therapy were 17.24 times more likely to have concordant drug resistance profile than those on non-triple therapies (OR=17.24, 95% CI: 3.48, 83.33), while patients with increasing number of regimens and years on ART have a decreased rate of concordance (OR = 0.59, 95% CI: 0.32, 1.09 and OR = 0.62, 95% CI: 0.43, 0.88), respectively, than those with less number of regimens and years on ART. Our results show high level of concordance between plasma and PBMC resistance profiles, indicating the possibility of using PBMCs for drug resistance testing in resources-limited settings.

Vaccination and risk of type 1 diabetes mellitus in active component U.S. Military, 2002-2008.

AIMS/HYPOTHESIS: To evaluate whether vaccination increases the risk of type 1 diabetes mellitus in active component U.S. military personnel. METHODS: We conducted a retrospective cohort study among active component U.S. military personnel age 17-35 years. Individuals with first time diagnoses of type 1 diabetes between January 1, 2002 and December 31, 2008 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We used Poisson regression to estimate risk ratios between individual vaccine exposures and type 1 diabetes. Secondary analyses were performed controlling for receipt of multiple vaccines and available demographic variables. RESULTS: Our study population consisted of 2,385,102 individuals followed for approximately 7,644,098 person-years of service. This included 1074 incident type 1 diabetes cases. We observed no significant increased risk of type 1 diabetes after vaccination with anthrax vaccine adsorbed (AVA) [RR=1.00; 95% CI (0.85, 1.17)], smallpox vaccine [RR=0.84; 95% (CI 0.70, 1.01)], typhoid vaccine [RR=1.03; 95% CI (0.87, 1.22)], hepatitis B vaccine [RR=0.83; 95% CI (0.72, 0.95)], measles mumps rubella vaccine (MMR) [RR=0.71, 95% CI (0.61, 0.83)], or yellow fever vaccine [RR=0.70; 95% CI (0.59, 0.82)]. CONCLUSIONS: We did not find an increased risk of diagnosed type 1 diabetes and any of the study vaccines. We recommend that follow-up studies using medical record review to confirm case status should be considered to corroborate these findings.

Impaired power output and cardiac index with hypoplastic left heart syndrome: a magnetic resonance imaging study.

BACKGROUND: Unfavorable cardiac mechanics in children with hypoplastic left heart syndrome (HLHS) when compared with other single-ventricle defects may affect long-term morbidity and outcome. Using noninvasive phase contrast magnetic resonance imaging (PC MRI), we examined cardiac mechanics in children with HLHS and compared the results to other single-ventricle defects. METHODS: Eighteen children with HLHS and 18 children with other single-ventricle defects were studied after the Fontan operation. Phase contrast MRI scans were obtained perpendicular to the ascending aorta, and flow was quantified using an in-house segmentation and reconstruction scheme. The total power output was determined using the modified Bernoulli equation along with cardiac output and systemic vascular resistance index. RESULTS: Compared with non-HLHS congenital heart defects, children with HLHS had significantly lower power output (1.40 +/- 0.39 versus 1.78 +/- 0.38 W/m2, p < 0.004) and cardiac index (3.15 +/- 0.97 versus 4.09 +/- 1.23 L x Min(-1) x m(-2), p < 0.009) with a concomitant higher systemic vascular resistance index (28.94 +/- 11.5 versus 22.7 +/- 8.53 WU, p < 0.03) despite generating similar systolic blood pressures (112.9 +/- 22.4 versus 115.2 +/- 23 mm Hg, p > 0.05). CONCLUSIONS: Minimally invasive measurements with PC MRI in children with HLHS showed significantly lower power output and cardiac index when compared with other single-ventricle physiologies. Abnormal aortic flow patterns may contribute to power loss and may have long-term survival and morbidity implications associated with the Fontan procedure. Elevated systemic vascular resistance index despite similar blood pressure opens avenues for therapeutic intervention for afterload reduction.