Client and Provider Experiences in Uganda Suggest Demand for and Highlight the Importance of Addressing HIV Stigma and Gender Norms Within Safer Conception Care.

Safer conception counseling supports HIV-serodifferent couples to meet reproductive goals while minimizing HIV transmission risk, but has not been integrated into routine HIV care. We piloted a novel safer conception program in an established public-sector HIV clinic in Uganda to inform future implementation. In-depth interviews and counseling observations explored experiences of program clients and healthcare providers to assess program acceptability, appropriateness, and feasibility. Fifteen index clients (8 women, 7 men), 10 pregnancy partners, and 10 providers completed interviews; 15 participants were living with HIV. Ten observations were conducted. We identified four emergent themes: (1) High demand for safer conception services integrated within routine HIV care, (2) Evolving messages of antiretroviral treatment as prevention contribute to confusion about HIV prevention options, (3) Gender and sexual relationship power inequities shape safer conception care, and (4) HIV-related stigma impacts safer conception care uptake. These findings confirm the need for safer conception care and suggest important implementation considerations.

Using Concept Unique Identifiers to Filter Electronic Health Records for Delirium Cases.

Delirium, an acute mental status change associated with inattention, confusion, hypervigilance, or somnolence due to a medical cause, is considered a medical emergency. Unfortunately, screening and diagnosis of delirium in acute care are often inadequate. It is estimated that 60% of delirium cases are not identified, and in claims data, they are underreported. Using information technology, we investigated whether concept unique identifiers from the Unified Language Medical System Metathesaurus could be used as a method to filter electronic health records for possible delirium cases. This article provides the reader with an overview of delirium, the Unified Language Medical System Metathesaurus, and our method for retrospectively filtering electronic health records for delirium cases from our clinical research database. Using a retrospective observational approach, we randomly selected 150 electronic health records with narrative notes containing a delirium concept unique identifier. One hundred records were used for training and 50 were used for validation and interrater reliability. Our results validate electronic health record-selected concept unique identifiers and provide insights into their use. Refinement and application of this method on a larger scale can provide an initial filter for identifying patients with delirium from the electronic health record.

Vocational Rehabilitation in the Veterans Health Administration Polytrauma System of Care: Current Practices, Unique Challenges, and Future Directions.

OBJECTIVE/PURPOSE: Veterans and service members (V/SMs) with traumatic brain injury (TBI) and comorbid conditions are treated in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC). These V/SMs comprise a unique population with distinct needs for restoring community reintegration, including participation in meaningful employment. Low employment rates after TBI vary and are influenced by many factors. Employment is a central aspect of the VHA priority of facilitating adjustment, and addressing vocational needs alongside healthcare is critical to community reintegration. The purpose of this article is to outline current practices of addressing vocational rehabilitation in the PSC, discuss the unique challenges in serving Veterans with polytrauma, and outline future directions to improve vocational services and outcomes. METHODS: Briefly review literature on V/SM with TBI and employment, describe the PSC and VHA vocational programs for V/SM with polytrauma, and synthesize proceedings on vocational rehabilitation from the 2017 VHA "Community Reintegration in the Polytrauma System of Care" meeting. CONCLUSIONS: To advance and expand vocational services the following guidelines were recommended: (1) designing flexible services based on individualized needs, (2) increasing access to vocational services through communication and collaboration, (3) promoting cross-disciplinary education and engagement in vocational care, and (4) systematically tracking employment outcomes.

Implementation of a safer conception programme for HIV-affected men and women in rural Uganda.

We integrated safer conception care into a Ugandan HIV clinic. People with HIV (PWH), or partnered with a PWH, and desiring children were eligible for the Healthy Families Clinic Program. Clients completed quarterly safer conception counselling visits and questionnaires to provide information around method preferences and outcomes (partner pregnancy, partner seroconversion). We used clinic level data to evaluate longitudinal viral suppression among PWH. Between November 2016 and January 2020, 361 clients (53% men) accessed services. 75% were PWH (51% women, 96% men): 99% were on antiretroviral therapy (ART) and most reported HIV-sero-different partnerships (97%). Frequently selected safer conception methods included ART (86%), timed condomless sex (74%), and PrEP (40%) with important differences by HIV-serostatus and gender. 22.5% reported pregnancy. Most (97%) PWH were virally suppressed at enrolment and 81% of non-virally suppressed PWH were virally suppressed at 15 months. Two HIV-negative clients (2%) had HIV seroconversion. There is demand for safer conception care in a public sector HIV-clinic in Uganda. Men and women have unique safer conception care preferences. The majority of clients engaged in safer conception care had viral suppression at follow up.

PrEP for people who use opioids: A NIDA clinical trials network survey study in Southern U.S. cities where HIV incidence is high.

BACKGROUND: People who use opioids (PWUO) are at increased risk for HIV. Pre-exposure prophylaxis (PrEP) is effective but underutilized as HIV prevention among PWUO. This study examined predictors of willingness to take daily oral PrEP and long-acting injectable (LAI) PrEP among PWUO across eight Southern urban cities with high HIV incidence. METHODS: HIV-negative PWUO (N = 308) seeking services in community-based programs participated in this cross-sectional survey study. Measures included demographics, sexual risk behavior, substance use frequency, and awareness of and willingness to take oral and injectable PrEP. Data were analyzed using mixed-effects models. RESULTS: Willingness to take daily oral and LAI PrEP was moderately high (69.16% and 62.02%, respectively). Half had heard of PrEP, but only 4% had ever taken it. Only education and condomless vaginal sex predicted willingness to take oral PrEP. Only education predicted willingness to take LAI PrEP. Polysubstance use was prevalent, with substantial proportions of PWUO reporting frequent use of injection drugs (opioids or stimulants, 79.5%), non-injection opioids (73.3%), non-injection stimulants (71.1%), cannabis (62.6%), and hazardous drinking (29.6%). About 20% reported past-year condomless anal sex, and one-third reported past-year condomless vaginal sex. CONCLUSIONS: PWUO in this study were amenable to PrEP, particularly in light of education and condomless vaginal sex. Careful consideration for matching PrEP messaging to the PWUO audience is needed. PrEP promotion should expand beyond men who have sex with men to include groups such as these predominantly heterosexual, polysubstance-using PWUO with HIV risk who were open to both formulations of PrEP.

Laboratory-based versus non-laboratory-based method for assessment of cardiovascular disease risk: the NHANES I Follow-up Study cohort.

BACKGROUND: Around 80% of all cardiovascular deaths occur in developing countries. Assessment of those patients at high risk is an important strategy for prevention. Since developing countries have limited resources for prevention strategies that require laboratory testing, we assessed if a risk prediction method that did not require any laboratory tests could be as accurate as one requiring laboratory information. METHODS: The National Health and Nutrition Examination Survey (NHANES) was a prospective cohort study of 14 407 US participants aged between 25-74 years at the time they were first examined (between 1971 and 1975). Our follow-up study population included participants with complete information on these surveys who did not report a history of cardiovascular disease (myocardial infarction, heart failure, stroke, angina) or cancer, yielding an analysis dataset N=6186. We compared how well either method could predict first-time fatal and non-fatal cardiovascular disease events in this cohort. For the laboratory-based model, which required blood testing, we used standard risk factors to assess risk of cardiovascular disease: age, systolic blood pressure, smoking status, total cholesterol, reported diabetes status, and current treatment for hypertension. For the non-laboratory-based model, we substituted body-mass index for cholesterol. FINDINGS: In the cohort of 6186, there were 1529 first-time cardiovascular events and 578 (38%) deaths due to cardiovascular disease over 21 years. In women, the laboratory-based model was useful for predicting events, with a c statistic of 0.829. The c statistic of the non-laboratory-based model was 0.831. In men, the results were similar (0.784 for the laboratory-based model and 0.783 for the non-laboratory-based model). Results were similar between the laboratory-based and non-laboratory-based models in both men and women when restricted to fatal events only. INTERPRETATION: A method that uses non-laboratory-based risk factors predicted cardiovascular events as accurately as one that relied on laboratory-based values. This approach could simplify risk assessment in situations where laboratory testing is inconvenient or unavailable.

It takes a village to raise the world.

My experience in Tanzania has not only made me a better person, but also a better nurse. Creating this organization has been an awesome challenge. It is through Duluti Initiative, Inc. that I can give of myself and create opportunities for others who share in this mission. The mission of Duluti Initiative, Inc. is to decrease mortality and morbidity of the people of Tanzania, Africa by providing funds and access to healthcare. Here is how you can get involved. Donate. $15, for example, will supply a woman in our Expectant Mothers program with nutritious fruits and vegetables for one month. Spread the word! Contact us! http://duluti.org/. We would love to know your thoughts. Send us an e-mail about fundraising or other ways to contribute. Use the search engine www.goodsearch.com. Simply click the box that indicates which charity the search is for, enter duluti and click verify. For every search you conduct, Duluti Initiative, Inc. receives one penny. If 100 people use this search engine and conduct 10 searches per day for one year, at the end of the year Duluti Initiative, Inc. will receive a check for $3,650! Imagine what a contribution you can make! The best part is, all it costs is a little of your time. My experience in Tanzania has reinforced the importance of having strong nursing assessment skills, being able to think critically, and having a willingness to listen. Nursing is a "portable career" that we can take to any location on the planet and make a difference in someone's life. As nurses, we often take what we do for granted--but those that we help, do not.

A scoping review of interventions to address intimate partner violence in sub-Saharan African healthcare.

Intimate partner violence (IPV) is a widespread global health problem, with negative effects on women's health and HIV transmission and treatment. There is little evidence on how to address IPV effectively in lower-resourced healthcare settings, particularly those that are impacted by significant HIV epidemics. We conducted a scoping review to provide an overview of the literature on IPV screening and intervention programmes in sub-Saharan African healthcare. The included studies used mainly qualitative methods. We identified five main themes: the acceptability to female clients, the importance of confidentiality, provider concerns, barriers due to gender norms, and need for referrals and comprehensive services. Research in this field is limited, and a robust research agenda is needed to provide effective IPV interventions for women seeking healthcare in sub-Saharan Africa.

Reintegrating Veterans with Polytrauma into the Community and Workplace.

This article addresses employment as a critical part of community reintegration for polytrauma patients. Interdisciplinary polytrauma teams can work to effectively identify and eliminate known barriers to employment for veterans and offer continued support and guidance. This article discusses key themes pertinent to vocational reentry for service members/veterans, identifies evidenced-based employment models, highlights the essential role of everyday technology in meeting support needs, and describes 2 exemplar polytrauma models: the Louis Stokes Cleveland Veteran Affairs Medical Center in Cleveland, Ohio, and the Service member Transitional Advanced Rehabilitation (STAR) program at the Hunter Holmes McGuire Veterans Affairs Medical Center in Richmond, Virginia.

Prevalence and correlates of physical and sexual intimate partner violence among women living with HIV in Uganda.

BACKGROUND: Intimate partner violence (IPV) is a significant global health problem. Women who experience IPV have increased HIV incidence, reduced antiretroviral adherence, and a lower likelihood of viral load suppression. There is a lack of evidence regarding how to effectively identify and support women living with HIV (WLWH) experiencing IPV, including uncertainty whether universal or targeted screening is most appropriate for lower-resourced settings. We examined physical and sexual IPV prevalence and correlates among WLWH in Uganda to understand the burden of IPV and factors that could help identify women at risk. METHODS: We utilized data from women receiving ART and enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) cohort study between 2011 and 2015. Bloodwork and interviewer-administered questionnaires were completed every 4 months. IPV was assessed annually or with any new pregnancy. Multivariate models assessed independent socio-demographic and clinical factors correlated with IPV, at baseline and follow-up visits. RESULTS: 455 WLWH were included. Median age was 36 years, 43% were married, and median follow-up was 2.8 years. At baseline 131 women (29%) reported any experience of past or current IPV. In the adjusted models, being married was associated with a higher risk of baseline IPV (ARR 2.33, 95% CI 1.13-4.81) and follow-up IPV (ARR 2.43, 95% CI 1.33-4.45). Older age (ARR 0.96, 95% CI 0.94-0.99) and higher household asset index score (ARR 0.81, 95% CI 0.68-0.96) were associated with lower risk of IPV during follow-up. CONCLUSION: There was a high prevalence of physical and sexual IPV amongst WLWH, and many women experienced both types of violence. These findings suggest the need for clinic-based screening for IPV. If universal screening is not feasible, correlates of having experienced IPV can inform targeted approaches.

Evaluation of Fluorophotometry to Assess the Vitreal Pharmacokinetics of Protein Therapeutics.

PURPOSE: In this work, we assessed the ability of fluorophotometry to measure the vitreal pharmacokinetics (PK) of fluorescently-labeled ranibizumab in the rabbit after intravitreal injection. We compared these values to those obtained using enzyme-linked immunosorbent assays (ELISA). Data obtained in this study were also compared to historical ranibizumab ocular PK data, either measured in-house or previously published. METHODS: Three individual in vivo studies were performed in New Zealand White rabbits to assess the feasibility of using fluorophotometry to measure rabbit ocular PK of ranibizumab; explore the dynamic range of dosing fluorescently-labeled ranibizumab; and directly compare ranibizumab concentrations and calculated PK parameters measured by vitreal fluorophotometry to those measured using ELISA. RESULTS: In direct comparisons between fluorophotometry and ELISA, the calculated clearance (CL) values were 0.26 and 0.21 mL/day, the volumes of distribution at steady state (Vss) were 0.80 and 0.94 mL, the half-lives (t1/2) were 3.1 and 2.9 days and the dose normalized areas under the curve (AUC/D) were 4.7 and 3.9 µg·day/mL/µg, respectively. These values fell within the ranges of 0.13 to 0.44 mL/day for CL, 0.5 to 1.8 mL for Vss, 2.8 to 3.5 days for t1/2, and 2.3 to 7.9 µg·day/mL/µg for AUC/D that have been either measured previously in-house or published elsewhere. CONCLUSIONS: Although not suitable for measuring retinal concentrations, fluorophotometry is a valuable, noninvasive method to measure vitreous concentrations of protein therapeutics after intravitreal injection.

Return to work for persons with spinal cord injury: designing work supports.

Recent advances in medical practices have led to increased survival rates among persons with spinal cord injuries. Many of these individuals find themselves unemployed post injury and face a myriad of challenges, such as lack of transportation, limited accessibility, and health problems. This paper describes how a Supported Employment approach can be used to assist persons with SCI with return to work. A number of issues that may impede employment and how to circumvent each are offered, along with a case study that describes one individual's return to work.

An integrated approach to identify normal tissue expression of targets for antibody-drug conjugates: case study of TENB2.

BACKGROUND AND PURPOSE: The success of antibody-drug conjugates (ADCs) depends on the therapeutic window rendered by the differential expression between normal and pathological tissues. The ability to identify and visualize target expression in normal tissues could reveal causes for target-mediated clearance observed in pharmacokinetic characterization. TENB2 is a prostate cancer target associated with the progression of poorly differentiated and androgen-independent tumour types, and ADCs specific for TENB2 are candidate therapeutics. The objective of this study was to locate antigen expression of TENB2 in normal tissues, thereby elucidating the underlying causes of target-mediated clearance. EXPERIMENTAL APPROACH: A series of pharmacokinetics, tissue distribution and mass balance studies were conducted in mice using a radiolabelled anti-TENB2 ADC. These data were complemented by non-invasive single photon emission computed tomography - X-ray computed tomography imaging and immunohistochemistry. KEY RESULTS: The intestines were identified as a saturable and specific antigen sink that contributes, at least in part, to the rapid target-mediated clearance of the anti-TENB2 antibody and its drug conjugate in rodents. As a proof of concept, we also demonstrated the selective disposition of the ADC in a tumoural environment in vivo using the LuCaP 77 transplant mouse model. High tumour uptake was observed despite the presence of the antigen sink, and antigen specificity was confirmed by antigen blockade. CONCLUSIONS AND IMPLICATIONS: Our findings provide the anatomical location and biological interpretation of target-mediated clearance of anti-TENB2 antibodies and corresponding drug conjugates. Further investigations may be beneficial in addressing the relative contributions to ADC disposition from antigen expression in both normal and pathological tissues.

Fade statistics and aperture averaging for Gaussian beam waves in moderate-to-strong turbulence.

The performance of lasercom systems operating in the atmosphere is reduced by optical turbulence, which causes irradiance fluctuations in the received signal. The result is a randomly fading signal. Fade statistics obtained from experimental data were compared to theoretical predictions based on the lognormal and gamma-gamma distributions. The probability of fade, the expected number of fades per second, and the mean fade time were calculated from the irradiance fluctuations of a Gaussian beam wave propagating through the atmosphere along a horizontal path, near ground, in the moderate-to-strong optical turbulence regime. Irradiance data were collected simultaneously at three receiving apertures, each with a different size. Atmospheric propagation parameters were inferred from the measurements and were used in calculations for the theoretical distributions. It was found that fade predictions made by the gamma-gamma and lognormal distributions provide an upper and lower bound, respectively, for the probability of fade and the number of fades per second for the irradiance data collected in the moderate-to-strong fluctuation regime. What is believed to be a new integral expression for the expected number of fades based on the gamma-gamma distribution was developed. This new expression tracked the gamma-gamma distributed data more closely than the existing approximation and resulted in a higher number of fades.

Theoretical wave structure function when the effect of the outer scale is significant.

The wave structure function (WSF) for a plane wave, calculated from the basic Rytov theory, is usually expressed as 6.88(r/r(0))(5/3), but this does not include the effect of a finite outer scale (or of a nonzero inner scale) of turbulence. When separation distance r is only 5% of the outer scale, this expression overpredicts the WSF by a factor of approximately 2. Accurate evaluations of the Rytov formulas are given for the WSFs of plane and spherical waves in Kolmogorov and von Karman turbulence and for the structure function of the atmosphere's index of refraction. Simple formulas make the results easy to use.

Aperture averaging effects on the probability density of irradiance fluctuations in moderate-to-strong turbulence.

The lognormal (LN) and gamma-gamma (GG) distributions are compared to simulated and experimental data of the irradiance fluctuations of a Gaussian beam wave propagating through the atmosphere along a horizontal path, near the ground, in the moderate-to-strong turbulence regime. Irradiance data were collected simultaneously at three receiving apertures of different sizes. Atmospheric parameters were inferred from the measurements and scintillation theory and were used to develop the parameters for the theoretical probability density functions. Numerical simulations were produced with the same C(n)(2) value as the experimental data. Aperture-averaging effects were investigated by comparing the irradiance distributions for the three apertures at two different values of the structure parameter C(n)(2), and, hence, different values of the coherence radius rho(0). For the moderate-to-strong fluctuation regime, the GG distribution provides a good fit to the irradiance fluctuations collected by finite-sized apertures that are significantly smaller than rho(0). For apertures larger than or equal to rho(0), the irradiance fluctuations appear to be LN distributed.

Inferring path average Cn2 values in the marine environment.

Current mathematical scintillation theory describing laser propagation through the atmosphere has been developed for terrestrial environments. Scintillation expressions valid in all regimes of optical turbulence for propagation in the maritime environment, based on what we believe to be a newly developed marine atmospheric spectrum, have been developed for spherical waves. Path average values of the structure parameter, C(n)(2), were inferred from optical scintillation measurements of a diverged laser beam propagating in a marine environment, using scintillation expressions based on both terrestrial and marine refractive index spectra. In the moderate-to-strong fluctuation regime, the inferred marine C(n)(2) values were about 20% smaller than inferred terrestrial C(n)(2) values, but a minimal difference was observed in the weak fluctuation regime. Measurements of angle-of-arrival fluctuations were used to infer C(n)(2) values in the moderate-to-strong fluctuation regime, resulting in values of the structure parameter that were at least an order of magnitude larger than the two scintillation-inferred C(n)(2) values.

Characterizing the propagation path in moderate to strong optical turbulence.

In February 2005 a joint atmospheric propagation experiment was conducted between the Australian Defence Science and Technology Organisation and the University of Central Florida. A Gaussian beam was propagated along a horizontal 1500 m path near the ground. Scintillation was measured simultaneously at three receivers of diameters 1, 5, and 13 mm. Scintillation theory combined with a numerical scheme was used to infer the structure constant C2n, the inner scale l0, and the outer scale L0 from the optical measurements. At the same time, C2n measurements were taken by a commercial scintillometer, set up parallel to the optical path. The C2n values from the inferred scheme and the commercial scintillometer predict the same behavior, but the inferred scheme consistently gives slightly smaller C2n values.

The importance of abdominal pressure during colonoscopy: techniques to assist the physician and to minimize injury to the patient and assistant.

This article outlines techniques that can be used to assist the physician's ability during colonoscopy to achieve cecal intubation in both standard situations and in specific conditions such as the obese patient. When applied properly, abdominal pressure can help shorten the length of the procedure, minimize the angle of turns in the colon, and minimize discomfort to the patient. A Mayo physician survey unanimously concluded that abdominal pressure is beneficial during colonoscopy. This article addresses the ergonomics of applying pressure and suggests techniques that minimize risk of injury to both the patient and the assistant. In addition, questions that new assistants may ask are addressed.