Implementation of the North Carolina HIV Bridge Counseling Program to Facilitate Linkage and Reengagement in Care for Individuals Infected with HIV/AIDS.

BACKGROUND Statewide interventions are critical to meeting the goals of the National HIV/AIDS Strategy in this country. In 2012, the North Carolina Division of Public Health developed the North Carolina State Bridge Counselor program to improve linkage to and reengagement in care for newly diagnosed persons and persons living with HIV who were out-of-care.METHODS We reviewed the planning process for the North Carolina State Bridge Counselor program, which involved a review of existing strengths-based counseling models for persons living with HIV, implementation of these models, and communication strategies with other providers. State bridge counselor responsibilities were delineated from the role of disease intervention specialists while retaining the fieldwork capability of disease intervention specialists to conduct outreach and provide services for persons living with HIV throughout the state.RESULTS Program implementation required extensive planning with stakeholders, incorporation of strengths-based counseling models, development of performance standards, and utilization of CAREWare, an HIV care software program to document referrals and data-sharing between state bridge counselors and clinics. By the end of 2014, state bridge counselor services were provided to approximately 60 of the 400 persons living with HIV (15%) who are diagnosed each quarter in North Carolina, with increasing utilization of the program.LIMITATIONS We assessed the development of this intervention specific to the North Carolina Division of Public Health, which may limit its generalizability. However, the State Bridge Counselor program was implemented in both urban and rural areas throughout the state, which increases its applicability to different public health programs throughout the country.CONCLUSION We demonstrated that a statewide State Bridge Counselor program for linkage and reengagement activities can be implemented by leveraging existing infrastructures, electronic medical records, HIV care networks, and fieldwork activities.

Prolonged measurement improves the assessment of the barrier function of the esophago-gastric junction by high-resolution manometry.

BACKGROUND: Etiology of gastro-esophageal reflux disease (GERD) is multifactorial, but incompetence of the esophago-gastric junction (EGJ) appears to be of crucial importance. Established manometric parameters for assessment of EGJ barrier function are sub-optimal, potentially because they reflect only a very brief (up to 30 seconds), not necessarily representative period. This prospective, case-control study tested the performance of novel, high-resolution manometry (HRM) parameters of EGJ function in the assessment of GERD. METHODS: Patients with reflux symptoms and healthy controls (HC) underwent standard HRM and 24-hour pH±impedance measurements. EGJ morphology, lower esophageal sphincter pressure integral (LES-PI), EGJ contractile integral (EGJ-CI) were compared with total-EGJ-CI, a novel parameter summarizing EGJ barrier function during the entire HRM protocol. Esophageal acid exposure ≥4.2%/24 h (A-Reflux-pos) or ≥73 reflux episodes in 24 hours (V-Reflux-pos) were considered pathological. KEY RESULTS: Sixty five HC and 452 patients completed HRM, 380 (84%) patients underwent ambulatory reflux-monitoring. LES-PI, EGJ-CI and total-EGJ-CI correlated with EGJ morphology subtypes (all P<.00001). Only total-EGJ-CI was consistently lower in A-Reflux-pos and V-Reflux-pos subjects compared with HC and patients without GERD. Total-EGJ-CI was also the single best parameter for prediction of pathological reflux (optimal cut-off 47 mmHg cm, AUC 0.746, P<.0001). This cut-off value, approximately 1 SD below the mean normal value, showed modest sensitivity 54% and positive predictive value 46%, but good specificity 85% and negative predictive value 89% for GERD diagnosis. CONCLUSION & INFERENCES: Total EGJ-CI, a new metric that summarizes EGJ contractility over time, allows an improved assessment of EGJ barrier function. Pathological reflux is unlikely if this metric is within the upper two-thirds of the normal range.

Platforms for energy and nutrient recovery from domestic wastewater: A review.

Alternative domestic wastewater treatment processes that recover energy and nutrients while achieving acceptable nutrient limits (<5mgNL(-1)) are a key challenge. Major drivers are value and availability of phosphorous, nitrogen, and potassium, and increasing energy costs. The two major platforms that can achieve this are (a) low energy mainline (LEM), with low strength anaerobic treatment, followed by mainline anaerobic nitrogen removal and chemical or adsorptive phosphorous removal and (b) partition-release-recover (PRR), in which carbon and nutrients are partitioned to solids through either heterotrophic or phototrophic microbes, followed by anaerobic digestion of these solids and recovery from the digestate. This paper reviews practical application of these processes, with a focus on energy costs. Compared to conventional processes which require 0.5kWhkL(-1) electricity (500mgCODL(-1) influent concentration), PRR requires only 0.05kWhkL(-1) electricity. LEM offers the possibility to recover 0.1kWhkL(-1) as electricity with net energy generation above 400mgCODL(-1)influent, while PRR becomes energy generating at >650mgCODL(-1). PRR offers the possibility for recovery of nitrogen and other nutrients (including potassium) through assimilative recovery. However, the energetic overhead of this is substantial, requiring 5kWhkgN(-1) as electricity, which compares to ammonia fixation costs. The lower energy costs, and near to market status of LEM treatment make it likely as a recovery platform in the shorter term, while ability to recover other elements such as nitrogen and potassium, as well as enhance favourability on concentrated wastewaters may enhance the desirability of partitioning in the longer term.

Impact of effluent organic matter on low-pressure membrane fouling in tertiary treatment.

This study aims at comparing low-pressure membrane fouling obtained with two different secondary effluents at bench and pilot-scale based on the determination of two fouling indices: the total fouling index (TFI) and the hydraulically irreversible fouling index (HIFI). The main objective was to investigate if simpler and less costly bench-scale experimentation can substitute for pilot-scale trials when assessing the fouling potential of secondary effluent in large scale membrane filtration plants producing recycled water. Absolute values for specific flux and total fouling index for the bench-scale system were higher than those determined from pilot-scale, nevertheless a statistically significant correlation (r(2) = 0.63, α = 0.1) was obtained for the total fouling index at both scales. On the contrary no such correlation was found for the hydraulically irreversible fouling index. Advanced water characterization tools such as excitation-emission matrix fluorescence spectroscopy (EEM) and liquid chromatography with organic carbon detection (LC-OCD) were used for the characterization of foulants. On the basis of statistical analysis, biopolymers and humic substances were found to be the major contribution to total fouling (r(2) = 0.95 and r(2) = 0.88, respectively). Adsorption of the low molecular weight neutral compounds to the membrane was attributed to hydraulically irreversible fouling (r(2) = 0.67).

Impact of a positive family history on diagnosis, management, and survival of breast cancer: different effects across socio-economic groups.

BACKGROUND: This study aims to investigate whether increased awareness of breast cancer, due to a positive family history (FH), reduces diagnostic, therapeutic, and survival differences between women of low versus high socio-economic status (SES). METHODS: All breast cancer patients registered between 1990 and 2005 at the population-based Geneva Cancer Registry were included. With multivariate logistic and Cox regression analysis, we estimated the impact of SES and FH on method of detection, treatment, and mortality from breast cancer. RESULTS: SES discrepancies in method of detection and suboptimal treatment, as seen among women without a FH, disappeared in the presence of a positive FH. SES differences in stage and survival remained regardless of the presence of a positive FH. Overall, positive FH was associated with better survival. This effect was the strongest in women of high SES (age-adjusted Hazard Ratio [HR(ageadj)] 0.54 [0.3-1.0]) but less pronounced in women of middle (0.77 [0.6-1.0]), and absent in women of low SES (0.80 [0.5-1.2]). CONCLUSION: A positive FH of breast cancer may reduce SES differences in access to screening and optimal treatment. However, even with better access to early detection and optimal treatment, women of low SES have higher risks of death from their disease than those of high SES.

Greenhouse gas production in wastewater treatment: process selection is the major factor.

Many practical design and operating decisions on wastewater treatment plants can have significant impacts on the overall environmental performance, in particular the greenhouse gas (GHG) emissions. The main factor in this regard is the use of aerobic or anaerobic treatment technology. This paper compares the GHG production of a number of case studies with aerobic or anaerobic main and sludge treatment of domestic wastewater and also looks at the energy balances and economics. This comparison demonstrates that major advantages can be gained by using primarily anaerobic processes as it is possible to largely eliminate any net energy input to the process, and therefore the production of GHG from fossil fuels. This is achieved by converting the energy of the incoming wastewater pollutants to methane which is then used to generate electricity. This is sufficient to power the aerobic processes as well as the mixing etc. of the anaerobic stages. In terms of GHG production, the total output (in CO2 equivalents) can be reduced from 2.4 kg CO2/kg COD(removed) for fully aerobic treatment to 1.0 kg CO2/kg COD(removed) for primarily anaerobic processes. All of the CO2 produced in the anaerobic processes comes from the wastewater pollutants and is therefore greenhouse gas neutral, whereas up to 1.4 kg CO2/kg COD(removed) originates from power generation for the fully aerobic process. This means that considerably more CO2 is produced in power generation than in the actual treatment process, and all of this is typically from fossil fuels, whereas the energy from the wastewater pollutants comes primarily from renewable energy sources, namely agricultural products. Even a change from anaerobic to aerobic sludge treatment processes (for the same aerobic main process) has a massive impact on the CO2 production from fossil fuels. An additional 0.8 kg CO2/kg COD(removed) is produced by changing to aerobic sludge digestion, which equates for a typical 100,000 EP plant to an additional production of over 10 t CO2 per day. Preliminary cost estimates confirm that the largely anaerobic process option is a fully competitive alternative to the mainly aerobic processes used, while achieving the same effluent quality.

Optimisation of Noosa BNR plant to improve performance and reduce operating costs.

Noosa WWTP is publicly owned and privately operated by Australian Water Services. The process includes primary sedimentation, raw sludge fermentation, biological nutrient removal (BNR), sand filtration and ultraviolet (UV) disinfection. An innovative feature of the plant is the supplementary carbon dosing facility to avoid the use of metal salts (alum or ferric) for phosphorus removal. The average flow treated during 2000 was 9.0 ML/d. The annual 50 percentile effluent quality requirements for nutrients are total N < 5 mg/L and total P < 1 mg/L. The objectives of this project were to: determine the cause of variability in phosphorus removal; develop a strategy to control the variability in phosphorus removal; and minimise the operating cost of supplementary carbon dosing while achieving the effluent quality requirements. An investigation of chemical and microbiological parameters was implemented and it was concluded that there were several factors causing variability in phosphorus removal, rather than a single cause. The following four major causes were identified, and the control strategies that were adopted resulted in the plant achieving annual 50 percentile effluent total P = 0.37 mg/L and total N = 3.0 mg/L during 2001. First, phosphorus removal was limited by the available VFA supply due to consumption of VFA by other organisms competing with phosphate accumulating organisms (PAO), and due to diurnal variations in the sewage VFA and phosphate concentrations. Therefore, supplementary carbon dosing was essential to make allowance for competing reactions. Second, increasing the fermenter VFA yield via supplementary carbon dosing with molasses was found to be an effective and economic way of ensuring reliable phosphorus removal. Third, nitrate in the RAS resulted in consumption of VFA by denitrifying bacteria, particularly with process configurations where the RAS was recycled directly into the anaerobic zone. Incorporating a RAS denitrification zone into the process rectified this problem. Finally, glycogen accumulating organisms (GAO) were observed in BNR sludge samples, and consumption of VFA by GAO appeared to cause decreased phosphorus removal. Better phosphorus removal was obtained using VFA derived from the fermenter than dosing an equivalent amount of acetic acid. It was hypothesized that GAO have a competitive advantage to use acetate and PAO have a competitive advantage to use propionate, butyrate or some other soluble COD compound in the fermenter effluent. Contrary to popular belief, acetate may not be the optimum VFA for biological phosphorus removal. The competition between PAO and GAO for different VFA species under anaerobic conditions requires further investigation in order to control the growth of GAO and thereby improve reliability of biological phosphorus removal processes.

[How extensively should irritable bowel syndrome be investigated? Expensive bowel sounds in the abdomen]. / Wie gründlich muss das Reizdarmsyndrom abgeklärt werden? Teures Rumoren im Bauch.

Its high prevalence, chronic course, sometimes very troubling symptoms and rather limited therapeutic options, make the irritable bowel syndrome (IBS) one of the most common conditions seen by the family doctor, internist and gastroenterologist. IBS is characterized by abdominal pain accompanied by altered bowel movements and a facultative association with abdominal distension. IBS runs a chronic recurrent course punctuated by relatively symptom-free phases, and an overall good prognosis for survival (quoad vitam). Visceral hypersensitivity, altered gastrointestinal motility, psychosocial factors, and neurotransmitter imbalance are under discussion as underlying pathophysiology. An orienting medical history, clinical examination and exclusion of such alarm symptoms as weight loss, general debility and rectal bleeding, must be followed by a rational choice of further diagnostic measures.

Neuropsychological assessment of battered women: a pilot study.

Mean performance of 19 battered women was significantly lower than that of 9 control women on the Halstead-Reitan Neuropsychological Battery, the Wechsler Memory Scale-Revised, and the Quick Neurological Screening Test. 58% of the battered women scored in the impaired range on the Halstead-Reitan Impairment Index; and 53% scored in the impaired range on the Quick Neurological Screening Test. More definitive research was recommended.

Depolarization and blurring of optical images by biological tissue.

We present a study of the image blurring and depolarization resulting from the transmission of a narrow beam of light through a continuous random medium. We investigate the dependence of image quality degradation and of depolarization on optical thickness, correlation length of the inhomogeneities, and incident polarization state. This is done numerically with a Monte Carlo method based on a transport equation that takes into account polarization of light. We compare our results with those for transport in media with discrete spherical scatterers. We show that depolarization effects are different in these two models of biological tissue.

Financing biotechnology projects: lender due diligence requirements and the role of independent technical consultants.

An increasing number of biotechnology projects are being brought to commercialization using conventional structured finance sources, which have traditionally only been available to proven technologies and primary industries. Attracting and securing competitive cost financing from mainstream lenders, however, will require the sponsor of a new technology or process to undergo a greater level of due diligence. The specific areas and intensity of investigation, which are typically required by lenders in order to secure long-term financing for biotechnology-based manufacturing systems, is reviewed. The processes for evaluating the adequacy of prior laboratory testing and pilot plant demonstrations is discussed. Particular emphasis is given to scale-up considerations and the ability of the proposed facility design to accommodate significant modifications, in the event that scale-up problems are encountered.

The impact of "managed care" on the practice of psychological testing: preliminary findings.

Although the impact of managed care constraints on assessment practices has received recent attention, a review of the literature found no data-based articles that address this issue. We report survey data on 137 members of the National Register of Health Service Providers in Psychology (Council for the National Register of Health Service Providers in Psychology, 1996) on current testing practices. The majority (72%) reported that their use of tests has changed in the last 5 years due to managed care directives. These clinicians are doing less testing overall and restrict their pool of assessment instruments. The Rorschach inkblot technique (Rorschach, 1942), the Thematic Apperception Test (Murray, 1943), and the Wechsler Intelligence scales (Matarazzo, 1972) were the instruments most noted for disuse. Apparently, practitioners are relying more on short, brief self-report measures that tap targeted symptoms or problem areas, and less on tests that demand considerable clinicians' time. Implications and limitations of the findings are discussed.

US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study.

OBJECTIVES: A large US sample was used to estimate the effects of race, employment status, income, education, occupation, marital status, and household size on mortality. METHODS: Approximately 530,000 persons 25 years of age or more were identified from selected Current Population Surveys between 1979 and 1985. These individuals were followed for mortality through use of the National Death Index for the years 1979 through 1989. RESULTS: Higher mortality was found in Blacks than in Whites less than 65 years of age; in persons not in the labor force, with lower incomes, with less education, and in service and other lower level occupations; and in persons not married and living alone. With occasional exceptions, in specific sex and age groups, these relationships were reduced but remained strong and statistically significant when each variable was adjusted for all of the other characteristics. The relationships were generally weaker in individuals 65 years of age or more. CONCLUSIONS: Employment status, income, education, occupation, race, and marital status have substantial net associations with mortality. This study identified segments of the population in need of public health attention and demonstrated the importance of including these variables in morbidity and mortality studies.

Business coalition initiatives related to behavioral healthcare purchasing and quality improvement.

Across America there are over 90 employer health coalitions, and their ranks are growing. Their members can be businesses located in a city, a region or a state, while a few encompass employers located in multistate regions. Coalitions may include only private-sector employers, or private- and public-sector employers; some are coalitions between employer purchasers and providers. Following a brief historical overview, this article summarizes the behavioral healthcare initiatives that are currently under way in six business coalitions.

Age differences in the breast cancer management of rural women.

This article describes the effect of age on the pattern of access to breast cancer care among rural women diagnosed in 1986-1989. Cases were identified by the Illinois State Cancer Registry and information on breast cancer management was obtained through review of hospital records and physician survey. Case follow-back was more than 99% complete. State-of-the-art breast cancer management was defined by the Physician Data Query (PDQ) and included diagnostic evaluation, prognostic evaluation, and stage-specific definitive treatment. The data did not indicate age differences in bilateral diagnostic mammography, performance of hormone receptor assays, radiation therapy, and stage-appropriate treatment. Tumor staging and axillary node dissection did differ by age with significant negative trends in the multivariate model. Also, women younger than 55 years were the most likely to receive separate diagnostic biopsy, limited surgery, and chemotherapy, whereas women 55 to 74 years were most likely to receive hormone therapy. Although rural populations may experience barriers to some aspects of state-of-the-art breast cancer management, age does not always exacerbate them.