A Comparison of Precision and Safety using Three Recognized Ultrasound-Guided Approaches to Cervical Medial Branch Blocks: A Cadaver Study.

BACKGROUND: Ultrasound (US) guidance is widely used for needle positioning for cervical medial branch blocks (CMBB) and radiofrequency ablation, however, limited research is available comparing different approaches. OBJECTIVE: We aimed to assess the accuracy and safety of 3 different US-guided approaches for CMBB. STUDY DESIGN: A cadaveric study divided into ultrasound-guided needle placement and fluoroscopy evaluation stages. SETTING: Department of Pathology, Forensic, and Insurance Medicine, Semmelweis University. METHODS: Sonographically guided third occipital nerve (TON), C3, C4, C5 and C6 medial branch injections and radiology evaluations were performed.The 3 approaches compared were:1. ES (published by Eichenberger-Siegenthaler): US probe in the coronal plane to visualize the cervical articular pillars, needle approach out of the plane, from anterior to posterior.2. Fi (published by Finlayson): US probe in the transverse plane to visualize a cervical articular pillar and its lamina, needle approach in the plane, from posterior to anterior.3. FiM (Modified Finlayson approach): Needles are placed as in Fi, but then adjusted with a coronal view of the cervical articular pillars.Fluoroscopy images were taken and later evaluated, for "crude", "high precision" and "dangerous" placement. RESULTS: One hundred and fifty-five needle placements were assessed (10 were excluded, as no anterior-posterior fluoroscopy images were saved). Interobserver agreement on position of needle placement between the 5 observers was very high; the Fleiss' Kappa was 0.921. For crude placement, no significant differences were identified between various approaches; (77.6%, 79.5%, and 75.6% for the ES, Fi, and FiM respectively). However, for placement in predefined high-precision zones, ES resulted in significantly more success (ES: 42.9%, Fi: 22.7%, and FiM: 24.4%, P = 0.032). Fi and FiM resulted in no dangerous placements, while ES led to the potential compromise of the exiting nerve root and vertebral artery on three occasions. In 10% of the placements, the levels were identified wrongly, with no difference between the various approaches. LIMITATIONS: Feedback from a live patient, may prevent some existing nerve root injections, unlike in a cadaver. Though a higher number of needles were placed in this study than in most available publications, the number is still low at each individual medial branch level. CONCLUSION: Fi proved safer than ES. Fi was equally successful in targeting the articular pillar, however, ES proved the most successful in placing the needle in the center of the articular pillar. Adding another, (coronal) US view to check needle position in FiM did not improve safety or precision. Identifying CMB levels with the US is challenging with all approaches, therefore we still recommend using fluoroscopy for level identification. While there were pros and cons with either procedure, the efficacy findings of previous papers were not replicated on elderly cadavers with arthritic necks.

HIV prevalence among men and women admitted to a South African public psychiatric hospital.

In settings with low seroprevalence, people with severe mental illness have a higher prevalence of HIV infection compared to the general population. In the high-prevalence countries of southern Africa, where the pandemic taxes resources for HIV prevention, care, and treatment, the needs of people with mental illness can be easily overlooked if they are not identified as vulnerable to infection. Yet, few African studies have investigated HIV seroprevalence in psychiatric settings. We systematically examined the HIV seroprevalence among psychiatric patients admitted to a public psychiatric institution in KwaZulu Natal province, South Africa, between 27 July and 14 November 2003. We conducted anonymous testing among 151 patients who were psychiatrically stable and able to give informed consent. Forty patients (26.5%) were HIV-positive; women were more likely to be infected than men (OR 2.74; 95% CI=1.25-6.04; P=0.012). Our findings demonstrate that in the midst of a generalized AIDS epidemic, people with mental illness are also vulnerable and must be included in prevention and treatment efforts. These results underscore the importance of integrated mental health and HIV care in institutional and outpatient mental health settings and affirm the need for detailed HIV risk assessment as a routine part of psychiatric care. Correspondingly, HIV care and treatment programs should be made available to people with psychiatric symptoms.

The relationship between genotypic sensitivity score and treatment outcomes in late stage HIV disease after supervised HAART.

This study investigated the effect of resistance testing quantified through a genotypic sensitivity score (GSS) on virologic, immunologic, and clinical responses among patients with late stage HIV-1 disease receiving supervised highly active antiretroviral therapy (HAART). Newly admitted patients received drug resistance testing (n = 198) and then HAART supervised by residential health-care facilities nurses. After initiating a resistance testing-informed HAART regimen, patients were followed for HIV-1 RNA suppression (<50 copies/ml), mean change in CD4(+) T-cells, new AIDS defining category C opportunistic conditions and death. GSS was constructed using the HAART regimen prescribed after resistance testing and data derived from IAS-USA consensus mutations table with modification. Regressions with generalized estimating equations for robust estimation of standard errors and Cox proportional hazards regression estimated independent associations between GSS and treatment responses. After adjusting for adherence, initial log(10) HIV-1 RNA levels, and other covariates, patients with a GSS > or =3 had significantly greater HIV-1 RNA suppression (adjusted odds ratio (AOR) 2.32; 95% CI 1.14, 4.75). HIV-1 RNA levels were lower among patients with > or =95% adherence, but the effect of GSS on viral suppression was not modified by adherence. Self-rated health status, and baseline CD4(+) T-cell counts independently predicted HIV-1 RNA suppression. GSS did not predict mean change in CD4(+) cells/mm(3) (236 vs. 233, P = 0.92), occurrence of new AIDS defining category C conditions or death. These data support resistance testing-guided therapy as an independent predictive factor to improve virologic responses in treatment-experienced patients.

Seroprevalence and HIV-associated factors among adults with severe mental illness - a vulnerable population.

BACKGROUND: Adults with severe mental illness (SMI) display an increased prevalence of HIV compared with the general population. Recommendations for provider-initiated testing in South Africa lack robust evidence because the studies - mainly from low-prevalence regions - overestimate the risk of HIV among adults with SMI. OBJECTIVE: We aimed to assess whether the mentally ill are a vulnerable population in South Africa. METHODS: All new admissions to an acute psychiatric ward from July to December 2000 were tested for HIV anonymously and the results linked with socio-demographic and clinical data. We did a restricted analysis of black females from a population-based survey of black females with SMI. RESULTS: There were 216 admissions, of whom 206 were included in the analysis. The seroprevalence of HIV-1 was 29.1% (confidence interval 27.8 - 32.4); seroprevalence of HIV among the women was 40%. The following predicted HIV positivity: female (odds ratio (OR) 3.5 (1.7 - 6.9)), infections of the chest or central nervous system (OR 3.2 (1.4 - 7.5)), age group 30 - 39 years (OR 2.3 (1.1 - 4.8)) and aggression on admission. The age and sex ratios among the SMI group were similar to the general population. Adults with SMI have an almost three times greater prevalence of HIV than the general population, after controlling for age and gender. CONCLUSIONS: Adults with SMI are a vulnerable population; therefore, provider-initiated HIV testing and other prevention and treatment programmes must be tailored to their needs.

Integrating HIV care and HIV prevention: legal, policy and programmatic recommendations.

Since the start of the HIV epidemic we have witnessed significant advances in our understanding of the impact of HIV disease worldwide. Furthermore, breakthroughs in treatment and the rapid expansion of HIV care and treatment programmes in heavily impacted countries over the past 5 years are potentially critical assets in a comprehensive approach to controlling the continued spread of HIV globally. A strategic approach to controlling the epidemic requires continued and comparable expansion and integration of care, treatment and prevention programmes. As every new infection involves transmission, whether vertically or horizontally, from a person living with HIV/AIDS (PLWHA), the integration of HIV prevention into HIV care settings has the potential to prevent thousands of new infections, as well as to improve the lives of PLWHA. In this paper, we highlight how to better utilize opportunities created by the antiretroviral roll-out to achieve more effective prevention, particularly in sub-Saharan Africa. We offer specific recommendations for action in the domains of healthcare policy and practice in order better to utilize the advances in HIV treatment to advance HIV prevention.

A randomized trial of a brief HIV risk reduction intervention for men with severe mental illness.

OBJECTIVE: A six-session version of a longer, 15-session social skills intervention for reducing high-risk sexual behaviors among men with severe mental illness was assessed. METHODS: Ninety-two men were randomly assigned to the intervention or to a two-hour standard HIV educational session, and their sexual risk behaviors were assessed every six weeks for six months. RESULTS: Among the sexually active men (33 in the intervention group and 23 in the control group), a twofold reduction in sexual risk behaviors was found for the intervention group. This reduction was less than the threefold reduction seen for the original 15-session intervention and was not statically significant. CONCLUSIONS: Further study is required to determine the optimal balance between efficacy and feasibility of this intervention.

A critical analysis of the Brazilian response to HIV/AIDS: lessons learned for controlling and mitigating the epidemic in developing countries.

The Brazilian National AIDS Program is widely recognized as the leading example of an integrated HIV/AIDS prevention, care, and treatment program in a developing country. We critically analyze the Brazilian experience, distinguishing those elements that are unique to Brazil from the programmatic and policy decisions that can aid the development of similar programs in other low- and middle-income and developing countries.Among the critical issues that are discussed are human rights and solidarity, the interface of politics and public health, sexuality and culture, the integration of prevention and treatment, the transition from an epidemic rooted among men who have sex with men to one that increasingly affects women, and special prevention and treatment programs for injection drug users.