Poverty eradication and food security through agriculture in Africa: Rethinking objectives and entry points.

Agriculture in Africa is expected to meet the dual objectives of providing food and helping people to escape poverty. African agriculture is dominated by smallholdings and donors generally target their agricultural support at the smallholder sector. The expectation is that if the gap between actual and potential yields can be closed, smallholders will grow sufficient crops to feed their families, with a surplus to sell, thus meeting food security needs and bringing in an income to move them out of poverty. In practice, this is often not possible. While technologies already exist that can raise smallholder farmers' yields 3 or 4 times, even under rainfed conditions, the small size of land available to them limits how much can be grown and the per capita income from agriculture is insufficient to allow people to move above the current World Bank-defined poverty line of US$1.90 per day. We link this finding with farmer typologies to further explain that there are large differences between individual farming households themselves in terms of their investment incentives and capability to benefit from field-level technologies that are aimed at increasing farm productivity. We argue for more differentiated policies for agricultural development in Africa and suggest that policymakers should be much more aware of the heterogeneity of farms and target interventions accordingly. It is important to understand where and for whom agriculture will have the main purpose of ensuring food and nutritional security and where and for whom there is the potential for significant increases in incomes and a contribution to wider economic growth. Let us recognize the distinctiveness of these targets and underlying target groups and work towards solutions that address the underlying needs.

Rosuvastatin vs. protease inhibitor switching for hypercholesterolaemia: a randomized trial.

OBJECTIVES: The aim of the study was to compare the efficacy and safety of rosuvastatin initiation with those of switching of ritonavir-boosted protease inhibitors (PI/rs) in HIV-1-infected adults with hypercholesterolaemia and increased cardiovascular risk scores. METHODS: In this open-label, multicentre study, HIV-1-infected adults on PI/r-based therapy with viral load < 50 HIV-1 RNA copies/mL, fasting total cholesterol ≥ 5.5 mmol/L (both for ≥ 6 months) and elevated cardiovascular risk (Framingham score ≥ 8% or diabetes or family history), and not on lipid-lowering therapy, were randomized to open-label rosuvastatin 10 mg/day or to PI/r switching, both with standardized diet/exercise advice. The primary endpoint was change in total cholesterol at week 12 (intention to treat). RESULTS: There were 43 participants (23 on rosuvastatin). Baseline characteristics were: mean [± standard deviation (SD)] age 55 (8.5) years, 42 (98%) male, 41 (95%) white race, and mean (± SD) total cholesterol 6.2 (1.2) mmol/L. At enrolment, PI/rs were lopinavir/ritonavir (n = 22; 51%), atazanavir/ritonavir (n = 12; 28%) and darunavir/ritonavir (n = 9; 21%). The commonest PI/r substitutes were raltegravir (n = 9; 45%) and rilpivirine (n = 4; 20%). All participants were adherent through to week 12. Rosuvastatin yielded greater declines than PI/r switching in total (- 21.4% vs. - 8.7%, respectively; P = 0.003) and low-density lipoprotein (- 29.9% vs. - 1.0%, respectively; P < 0.001) cholesterol, but smaller declines in very low-density lipoprotein cholesterol and triglycerides (P < 0.01). Cholesterol lowering was greater in participants on atazanavir/ritonavir or once-daily darunavir/ritonavir (vs. lopinavir/ritonavir). More study drug-related adverse events (mostly grade 1 nausea/diarrhoea; 10 vs. one, respectively; P = 0.001) occurred with PI/r switching than with rosuvastatin. CONCLUSIONS: In adults receiving a PI/r, rosuvastatin 10 mg/day for 12 weeks yielded larger decreases in total and low-density lipoprotein cholesterol than PI/r switching, and was better tolerated.

No significant effect of uridine or pravastatin treatment for HIV lipoatrophy in men who have ceased thymidine analogue nucleoside reverse transcriptase inhibitor therapy: a randomized trial.

BACKGROUND: Lipoatrophy can complicate thymidine analogue nucleoside reverse transcriptase inhibitor (tNRTI)-based antiretroviral therapy (ART). Lipoatrophy may be less likely with ART including ritonavir-boosted lopinavir (LPV/r). Small, placebo-controlled studies found that uridine (in tNRTI recipients) and pravastatin improved HIV lipoatrophy over 12 weeks. Today, most patients with lipoatrophy receive non-tNRTI-based ART; the effect of uridine in such patients is unknown. METHODS: We performed a prospective, randomized trial in lipoatrophic adults with plasma HIV RNA<50 HIV-1 RNA copies/mL on tNRTI-sparing ART including LPV/r. Patients received uridine [36 g three times a day (tid) on 10 consecutive days per month; n=10], pravastatin [40 mg every night (nocte); n=12], uridine plus pravastatin (n=11) or neither (n=12) for 24 weeks. The primary endpoint was mean change in limb fat mass as assessed by dual-energy X-ray absorptiometry (DEXA). With 20 patients per intervention, the study had 80% power to detect a mean difference between a treatment and the control of 0.5 kg, assuming a standard deviation of 0.9 and an alpha threshold equal to 5% (two-sided). RESULTS: Of 45 participants (all men, with median age 49.5 years and median limb fat 2.6 kg), two discontinued pravastatin and one participant stopped both pravastatin and uridine. The difference between the mean changes in limb fat mass for uridine vs. no uridine was 0.03 kg [95% confidence interval (CI) -0.35, +0.28; P=0.79]. The respective difference for pravastatin was -0.03 kg (95% CI -0.29, +0.34; P=0.84). Pravastatin slightly decreased total cholesterol (0.44 mmol/L; P=0.099). Visceral adipose tissue measured by computed tomography did not change significantly. CONCLUSION: In this population and at the doses used, neither uridine nor pravastatin for 24 weeks significantly increased limb fat mass.

Safety and efficacy of nandrolone decanoate for treatment of wasting in patients with HIV infection.

OBJECTIVE: To evaluate the safety and efficacy of the anabolic steroid, nandrolone decanoate (Deca Durabolin) in patients with HIV wasting who are resistant to nutritional intervention. DESIGN: A 16-week open trial with subjects who had lost 5-15% of their usual body weight. SETTING: HIV/AIDS specialist ambulatory care services, both public and private, in sydney, Australia. PARTICIPANTS: Two hundred and twenty men entered the pre-therapy phase, and of these, 24 failed to gain weight and were enrolled. Seventeen subjects (81%) completed the 16-week trial. INTERVENTIONS: Pre-therapy nutritional assessment and education was conducted by the clinical dietitian. Those who failed to gain weight (10.9%) were treated with nandrolone decanoate (100 mg/ml) by deep intramuscular injection every 2 weeks for 16 weeks. MAIN OUTCOME MEASURES: Changes in weight and body composition (lean body mass, total body water and nitrogen index) were measured by anthropometry, bioelectrical impedance, and in vivo neutron activation. Changes in quality of life were assessed by the 30-item Medical Outcomes Study short form questionnaire. Changes in biochemistry, haematology and immunology were also measured. RESULTS: There were significant increases in weight (mean, 0.14 kg per week; P < 0.05) and lean body mass (mean, 3 kg by anthropometry; P < 0.005). The change in lean body mass was of similar magnitude across all measurement modalities. Quality of life parameters, especially functionality, increased significantly during the trial. No subject experienced toxicity. CONCLUSION: Nandrolone decanoate has beneficial effects on weight, lean body mass and quality of life in selected patients who have mild to moderate HIV wasting.

B-cell stimulation and prolonged immune deficiency are risk factors for non-Hodgkin's lymphoma in people with AIDS.

OBJECTIVES: To identify risk factors for non-Hodgkin's lymphoma (NHL) in people with HIV infection. DESIGN AND SETTING: Case-control study in Sydney, Australia. PARTICIPANTS AND METHODS: Two hundred and nineteen patients with AIDS-related NHL were compared with 219 HIV-infected controls without NHL, matched for CD4 positive cell count and date of specimen collection. Data on demographic, infectious, treatment-related and immunological factors were abstracted by medical record review. The association between demographic factors, sexually transmissible diseases, HIV-related opportunistic infections, anti-viral therapy, duration of immune deficiency and indices of immune stimulation and risk of NHL were derived for these groups. RESULTS: In a multivariate model, there were two independent groups of predictors of NHL risk. The first was duration of immunodeficiency, as measured by longer time since seroconversion (P for trend 0.008), and lower CD4 positive cell count 1 year prior to the time of NHL diagnosis (P for trend 0.009). The second predictor was B-cell stimulation, as indicated by higher serum globulin (a surrogate marker for serum immunoglobulin, P for trend 0.044) and HIV p24 antigenaemia [odds ratio (OR) for p24 positivity, 1.82; 95% confidence interval (CI), 1.15-2.88]. Indices of B-cell stimulation preceded the diagnosis of NHL by several years. Factors not related to NHL risk included clinical indices of Epstein-Barr virus infection and receipt of individual nucleoside analogue antiretroviral agents. Combination therapy with these agents was associated with a non-significant reduction in NHL risk (OR, 0.68; 95% CI, 0.39-1.18). CONCLUSIONS: Markers of long-standing immune deficiency and B-cell stimulation were associated with an increased risk of developing NHL. Unless the strongest risk factor for NHL, immune deficiency, can be reversed, NHL is likely to become proportionately more important as a cause of morbidity and mortality in people with HIV infection.

Lipid in the Achilles tendon. A comparative study.

The tendo Achillis of man and its homologue from a fairly wide range of exotic animals, most of which had died in captivity from natural causes, have been examined for stainable lipid. Adiposity of the tendon was seen principally in man. Chondroid plaques, containing an abundance of intracellular triglycerides, are a normal feature in birds. Similar thickenings in the few reptiles examined were rich in phospholipids. Extracellular (perifibrous, interstitial) deposits of lipid with a high content of esterified cholesterol were found in more than 90% of human specimens, in 52% of other mammals and in 62.5% of birds included in the survey. In general, lipid insudation of tendons increased with age and was less intense in animals than man. Aetiological factors and the relationship of extracellular lipid deposits in tendons to those in the arterial wall and dura mater are considered.

Serum lipoproteins and atherosclerosis in animals.

The lipoproteins have been examined in more than 300 serum or plasma samples taken during life or at post mortem from a fairly wide range of mammals, birds and reptiles. The material, which was collected over a period of several years, was subjected to a limited range of lipid analyses, but all specimens were submitted to electrophoresis with paper or cellulose acetate membrane as supporting medium. The lipoprotein pattern in mammals appears to be basically similar to that in man, but there are wide variations in lipid concentrations; the highest levels being found in bears, seals and primates. High concentrations were also observed in many birds and a few reptiles, but the lipoprotein patterns in these vertebrates differ from those in mammals and are further greatly modified by oviparity. Semi-quantitative data on the degree of atherosclerosis were available on the animals that died. There was only a crude positive correlation between the intensity of the arterial disease and high serum beta-lipoprotein levels, and it was concluded that the latter are probably of only secondary importance in the development of spontaneous atherosclerosis in animals.

Novel deletion of HIV type 1 reverse transcriptase residue 69 conferring selective high-level resistance to nevirapine.

A novel deletion of residue 69 of the HIV-1 reverse transcriptase (RT) gene was detected in combination with mutations V75I/V and F77L/F in a patient with partial virological response to several antiretroviral drug regimens, including stavudine (D4T), didanosine (DDI), lamivudine (3TC), saquinavir (SQV), and nevirapine (NVP). Longitudinal analysis of samples revealed that this deletion emerged upon reinitiation DDI/D4T therapy following a toxicity-induced short discontinuation of all antiretrovirals. Analysis of the resistance phenotype showed a greater than 62-fold increase of the IC50 of NVP, but no significant change in sensitivity to other single nonnucleoside reverse transcriptase inhibitors (NNRTIs). The mutated virus showed only a moderately reduced sensitivity to DDI (6.7-fold) and D4T (4.8 fold). In a subsequent sample 3 months later additional RT mutations were found, including A62V, Y188L, and Q151M, conferring high-level cross-resistance to multiple nucleoside analogs. Our findings provide evidence that the deletion of RT residue 69 selectively confers high-level NVP resistance.

Prescription drug dependence in the elderly population: demographic and clinical features of 100 inpatients.

OBJECTIVE: To determine the prevalence of prescription drug dependence among elderly persons in an inpatient treatment setting, to identify apparent risk factors for drug dependence, and to ascertain what factors led to admission of these patients. DESIGN: We reviewed the medical records of 100 elderly patients dependent on prescription drugs who were admitted to the Mayo Inpatient Addiction Program between 1974 and 1993. MATERIAL AND METHODS: Demographic features, chronic medical disorders, categories of substance dependence, diagnoses of mental disorders, and Minnesota Multiphasic Personality Inventory data were compiled and analyzed. RESULTS: The mean annual admissions rates for three substance use disorder groups among all elderly persons treated during the 20-year period of study were as follows: alcohol only, 72%; prescription drugs, 16%; and both alcohol and drugs, 12%. The group as a whole was socially intact. Female gender seemed to be a risk factor for drug dependence. By several measures, these elderly patients were characterized as a psychiatric population. The most frequent drug dependence involved sedatives or hypnotics. General medical data did not suggest that these elderly persons were more physically impaired than the general population. CONCLUSION: In elderly patients, awareness of coexistent diagnoses is essential in avoiding the inappropriate administration of multiple pharmaceutical agents and the possible risk of associated drug abuse and dependence.

Pseudoepileptic seizures in children and adolescents.

Eighteen patients ranging in age from 4 to 20 years who were seen at the Mayo Clinic from 1970 through 1976 for suspected epilepsy were studied. Seventeen of these patients had previously been treated with anticonvulsant medication, and the majority had been subjected to multiple diagnostic procedures. After careful analysis of their histories, clinical examinations, and appropriate laboratory studies, their seizures appeared to be nonepileptic in nature. Various psychogenic and other nonorganic causes were identified. These cases are presented to alert the physician to the not infrequent occurrence of pseudoepileptic seizures in children and adolescents who do not have epilepsy.

Recognition and management of depression in the elderly.

Depression is probably the most common psychiatric disorder of the elderly. Societal stereotypes and atypical clinical features are contributing factors to inadequate diagnosis and treatment. Somatic complaints without an obvious mood defect and a syndrome of pseudodementia are commonly encountered. Treatment strategies rest firmly on a comprehensive evaluation that considers the biological, psychologic, and social factors involved. Psychotherapy is a valuable tool in some elderly persons. When antidepressant agents are used, it should be recognized that lower than usual dosage may be effective and that the elderly person is particularly sensitive to the autonomic side effects of these chemical agents. Electroconvulsive therapy remains a helpful and sometimes lifesaving resource when other methods have failed.

Drug abuse and dependency in patients with chronic pain.

Of 144 patients with chronic pain of nonmalignant cause, 35 (24%) were drug-dependent, 59 (41%) drug abusers, and 50 (35%) nonabusers. Codeine and oxycodone (Percodan) were most frequently abused. In regard to characteristics tested, differences between the groups were not great; but there was a significant difference in outcome between nonabuse and dependent groups. Early detection and treatment of drug abuse should minimize some of the difficulties involved in management of treatment-resistive patients with chronic pain.

Developments in the treatment of alcoholism.

The treatment of alcoholism has changed during the past 2 decades. Notable developments have occurred in pharmacotherapy, psychotherapy, and health-care delivery. A better understanding of the biologic basis for addiction has led to clinical trials of medications that target neuroreceptors. One such medication is the opiate antagonist naltrexone, which decreases the craving for alcohol. Psychosocial interventions continue to be the mainstay of alcohol treatment programs. The efficacy of three different therapies was demonstrated in a study called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). This study, however, did not prove the patient-treatment "matching" hypothesis. In addition to therapies provided by addiction specialists, interest is growing in the use of brief motivational techniques in primary-care settings. As the field of addiction responds to an unfolding health-care delivery system, a broader range of treatment options in conjunction with a greater opportunity to individualize patient care is evolving.

Alcoholism in elderly persons: medical aspects and prognosis of 216 inpatients.

We describe 216 elderly patients (65 years of age or older) who were treated for alcoholism in an inpatient treatment program. Emphasis is placed on the demographics, medical characteristics, results of laboratory tests, outcome of treatment, and various comparisons of early- and late-onset alcoholism. The frequency of serious medical disorders among these patients was higher than would be expected for the overall population of a similar age. Elderly alcoholics have more abnormal results of commonly used laboratory tests than do younger alcoholics. Our data show that the elderly alcoholic can be successfully treated in a medically oriented inpatient treatment program. The concept of less-intensive treatment for the elderly alcoholic is generally not supported. More-intensive treatment may be necessary for some of these patients because of the high frequency of accompanying major medical and psychiatric problems. Early-onset alcoholism predominated, but we found no major differences between the two groups.

Alcoholism in elderly persons: a study of the psychiatric and psychosocial features of 216 inpatients.

The medical records of 216 elderly persons, admitted to the hospital for treatment of alcoholism, were reviewed. Concern of family and friends was the most common factor motivating patients for admission. Patients with late-onset alcoholism reported an association between a life event and problem drinking more frequently than did the early-onset alcoholics. The most common associated psychiatric disorders were tobacco dependence (67%), organic brain syndrome (25%), atypical or mixed organic brain syndrome (19%), and affective disorder (12%). Fourteen percent of patients also had a drug abuse or dependence problem, all using legally prescribed drugs. Psychiatric diagnoses and results of psychologic testing did not differ between early-onset and late-onset alcoholism groups. In a 60-patient cohort studied for correlation of outcome of treatment for alcoholism with major psychiatric diagnoses, no associations were found.

Rhabdomyolysis due to acute dystonic reaction to antipsychotic drugs.

Rhabdomyolysis is a rarely reported complication of antipsychotic drug-induced dystonia. The history, signs, symptoms, and laboratory findings in such a case are reported. The pathogenetic mechanisms of the rhabdomyolysis and the treatment in this case are discussed. Physicians who prescribe these drugs are advised to be aware of this potentially serious complication.

HIV infection in sexually transmissible disease practice in Sydney: the effects of legislation, public education and changing clinical spectrum.

The experience with human immunodeficiency virus (HIV) infection of a private inner-city sexually transmissible diseases (STD) clinic in Sydney was quantified. Between February 1984 and March 1988, 2073 of the Clinic's patients were tested for antibodies to HIV on 5095 occasions. Of those tested, 538 (26%) were positive for antibodies to HIV: 532 (98.9%) of the seropositives had practised male homosexual intercourse. This is the highest reported seroprevalence of HIV for any primary care service in Australia. Those individuals seropositive because of other risk behaviours were detected by voluntary contact tracing rather than by screening. Female prostitution was not found to be a risk factor for HIV. In general, rates of first HIV antibody tests were adversely affected by threatening legislation, and temporarily stimulated (among lower-risk persons) by a national television campaign. These data suggest that much of the counselling, detection and management of HIV infection in Australia is occurring in private practice, and that STD services (private and public) are at the forefront of the HIV epidemic. This has implications for disease surveillance and control, health services planning and medical education.

Subcutaneous facial emphysema secondary to use of the Cavi-Jet.

A case of subcutaneous facial emphysema secondary to use of the Cavi-Jet air polishing system is reported. Air pressure of the Cavi-Jet may exceed that of other dental instruments such as the air/water syringe or air turbine handpiece. Inadvertent angulation of the nozzle tip into a severe periodontal pocket precipitated this condition, which resolved with no serious sequelae. No treatment other than prophylactic antibiotics was prescribed.

Bulimic symptomatology, body-image, and personality characteristics of university men.

This study examined the relationships, using regression analysis, among bulimic symptomatology, body-image characteristics, and personality factors in a nonclinical sample of 46 undergraduate university men. They completed the Bulimia Test-Revised (a measure of bulimic symptomatology), the Eysenck Personality Questionnaire-Revised (a measure of personality characteristics), and the Multidimensional Body-Self Relations Questionnaire (a multidimensional measure of body-image parameters). Statistically significant relationships were identified among Appearance Evaluation, Neuroticism, and Psychoticism, and the BULIT-R scores.