Lessons Learned from Contact Tracing COVID-19 cases in Dental Settings in East Scotland.

INTRODUCTION: Dental settings were considered high risk settings for COVID-19. A Dental Public Health Team in East Scotland worked to risk assess each situation timeously to break chains of transmission. AIM: To present learning from routine data collected from contact tracing COVID-19 cases in the dental setting. DESIGN: Retrospective analysis of a routine data set of COVID-19 cases associated with a dental setting reported via the national contact tracing system for two health board areas in the East of Scotland. METHODS: Descriptive statistics summarise the data collected over a 13-month period (Oct 2020-Dec 2021) during which all included COVID-19 cases were confirmed by PCR. A narrative presents output from contact tracing of all cases and includes themes identified during contact tracing that led to transmission within a dental setting. A case study illustrates impact of transmission. RESULTS: 752 cases are included. No evidence of staff to patient transmission or vice versa was found in this study. Staff to staff transmission occurred in non-clinical areas contributing to 33% of total staff cases with the remainder assessed to result from community transmission. CONCLUSION: Transmission of COVID-19 in a dental setting, in the context of this study, appears to be confined to non-clinical areas with the majority of staff cases resulting from community transmission. Future pandemic plans should include tools to aid with implementation of guidance in non-clinical areas.

Lessons Learned from Contact Tracing COVID-19 cases in Dental Settings in East Scotland.

INTRODUCTION: Dental settings were considered high risk settings for COVID-19. A Dental Public Health Team in East Scotland worked to risk assess each situation timeously to break chains of transmission. AIM: To present learning from routine data collected from contact tracing COVID-19 cases in the dental setting. DESIGN: Retrospective analysis of a routine data set of COVID-19 cases associated with a dental setting reported via the national contact tracing system for two health board areas in the East of Scotland. METHODS: Descriptive statistics summarise the data collected over a 13-month period (Oct 2020-Dec 2021) during which all included COVID-19 cases were confirmed by PCR. A narrative presents output from contact tracing of all cases and includes themes identified during contact tracing that led to transmission within a dental setting. A case study illustrates impact of transmission. RESULTS: 752 cases are included. No evidence of staff to patient transmission or vice versa was found in this study. Staff to staff transmission occurred in non-clinical areas contributing to 33% of total staff cases with the remainder assessed to result from community transmission. CONCLUSION: Transmission of COVID-19 in a dental setting, in the context of this study, appears to be confined to non-clinical areas with the majority of staff cases resulting from community transmission. Future pandemic plans should include tools to aid with implementation of guidance in non-clinical areas.

A Health Inequalities Impact Assessment of the surveillance of COVID-19 in asymptomatic patients attending dental settings in Scotland.

INTRODUCTION: A key aspect of the public health response to COVID-19 in Scotland was enhanced community surveillance, including testing in dental settings. Across Scotland, dental settings offered patients over 5-years-old the opportunity to participate in community surveillance of COVID-19. METHODS: A Health Inequalities Impact Assessment (HIIA) was conducted to understand the differential impacts the programme would have on the population and to improve the accessibility of the programme. HIIA is a tool to allow the assessment, understanding, and mitigation of impacts on people of a proposed policy or practice. It fulfils an organisational duty to meet the requirements of the Equality Act and Fairer Scotland Duty. The HIIA was conducted rapidly in parallel with the programme development. An action research approach included an online workshop, consultation, review of population data and a literature search. RESULTS: Adjustments were required to improve the programme's accessibility. Stakeholders, including dental teams from across Scotland were involved in the consultation and brought their front-line experience in different settings. Common issues identified included digital literacy and access, language and cultural barriers to participation, and issues relating to the implications of a positive COVID-19 result. Literature indicated limited evidence on the acceptability, accessibility, and equity of asymptomatic COVID-19 surveillance. CONCLUSION: This HIIA was conducted during the COVID-19 pandemic. As an example of good practice in tackling inequalities in access to programmes it should represent the benchmark for other similar initiatives.

SARS-CoV-2 Positivity in Asymptomatic-Screened Dental Patients.

Enhanced community surveillance is a key pillar of the public health response to coronavirus disease 2019 (COVID-19). Asymptomatic carriage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a potentially significant source of transmission, yet remains relatively poorly understood. Disruption of dental services continues with significantly reduced capacity. Ongoing precautions include preappointment and/or at appointment COVID-19 symptom screening and use of enhanced personal protective equipment (PPE). This study aimed to investigate SARS-CoV-2 infection in dental patients to inform community surveillance and improve understanding of risks in the dental setting. Thirty-one dental care centers across Scotland invited asymptomatic-screened patients aged over 5 y to participate. Following verbal consent and completion of sociodemographic and symptom history questionnaire, trained dental teams took a combined oropharyngeal and nasal swab sample using standardized Viral Transport Medium-containing test kits. Samples were processed by the Lighthouse Lab and patients informed of their results by SMS/email with appropriate self-isolation guidance in the event of a positive test. All positive cases were successfully followed up by the national contact tracing program. Over a 13-wk period (from August 3, 2020, to October 31, 2020), 4,032 patients, largely representative of the population, were tested. Of these, 22 (0.5%; 95% CI, 0.5%-0.8%) tested positive for SARS-CoV-2. The positivity rate increased over the period, commensurate with uptick in community prevalence identified across all national testing monitoring data streams. To our knowledge, this is the first report of a COVID-19 testing survey in asymptomatic-screened patients presenting in a dental setting. The positivity rate in this patient group reflects the underlying prevalence in community at the time. These data are a salient reminder, particularly when community infection levels are rising, of the importance of appropriate ongoing infection prevention control and PPE vigilance, which is relevant as health care team fatigue increases as the pandemic continues. Dental settings are a valuable location for public health surveillance.

Clinical and echocardiographic characteristics of cardioembolic stroke.

BACKGROUND AND PURPOSE: Ischaemic stroke frequently has a cardioembolic (CE) source. Clinical and echocardiographic parameters associated with CE stroke were evaluated. METHODS: In all, 93 consecutive ischaemic stroke patients who underwent a transthoracic echocardiogram were retrospectively analysed; strokes were classified by TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Echocardiographic parameters related to CE stroke, including left atrial volumes and function, were compared to 73 healthy controls. RESULTS: Of 93 patients (mean age 66.1 years, 56% male), nine (10%) had large artery atherosclerosis, 38 (41%) CE stroke, two (2%) small vessel disease, two (2%) other and 42 (45%) undetermined aetiology. Left atrial (LA) maximum volumes (LAVImax ) and minimum volumes (LAVImin ) were larger in the CE group than the non-CE group (45 vs. 32 ml/m2 , 32 vs. 13 ml/m2 , respectively, P < 0.001), whilst LA function indices including LA emptying fraction and LA function index (LAFI) were lower in the CE group (34% vs. 55%, and 0.12 vs. 0.35, respectively, P < 0.001). Adjusting for clinical characteristics, LAFI ≤0.3 was an independent predictor of CE stroke (adjusted odds ratio 5.3, P = 0.001). Additionally, LAVImax and LAVImin were larger (61 vs. 44 and 32 vs. 24 ml/m2 respectively, P < 0.01) and LAFI significantly lower (0.34 vs. 0.52, P < 0.001) in the undetermined aetiology group versus healthy controls. CONCLUSIONS: Left atrial enlargement with reduced LA function was associated with CE stroke and LAFI was the best independent predictor. LA parameters were also altered in the undetermined aetiology group, suggesting an underlying LA myopathy in this subset.

Placebo-controlled pilot trial testing dose titration and intravenous, intramuscular and subcutaneous routes for ketamine in depression.

OBJECTIVE: This pilot study assessed the feasibility, efficacy and safety of an individual dose-titration approach, and of the intravenous (IV), intramuscular (IM) and subcutaneous (SC) routes for treating depression with ketamine. METHOD: Fifteen treatment-refractory depressed participants received ketamine or midazolam (control treatment) in a multiple crossover, double-blind study. Ketamine was administered by IV (n = 4), IM (n = 5) or SC (n = 6) injection. Dose titration commenced at 0.1 mg/kg, increasing by 0.1 mg/kg up to 0.5 mg/kg, given in separate treatment sessions separated by ≥1 week, with one placebo control treatment randomly inserted. Mood, psychotomimetic and hemodynamic effects were assessed and plasma ketamine concentrations assayed. RESULTS: Twelve participants achieved response and remission criteria, achieved at doses as low as 0.1 mg/kg. All three routes of administration resulted in comparable antidepressant effects. Fewest adverse effects were noted with the SC route. Antidepressant response, adverse effects and ketamine concentrations were dose-related. CONCLUSION: Antidepressant response occurred at a range of doses and at <0.5 mg/kg. The dose-titration approach is a practical method for optimizing the efficacy - side-effects trade-off on an individual patient basis. This pilot study provides preliminary evidence for SC injection as a practical, feasible and efficacious treatment approach.

The evolution of sexual health nursing in Australia: a literature review.

BACKGROUND: The purpose of this paper is to describe and encapsulate the elements of the sexual health nurse's role in Australia. In Australia, sexual health nursing is a fast evolving speciality operating within a climate of diverse role expectations, settings and population groups. Today's health care climate demands that nurses' roles and their impact on patient care be held up to scrutiny. METHODS: A literature review was conducted that used descriptive analysis to elicit the recurrent themes appearing in the Australian sexual health nursing literature that would describe the role. RESULTS: A model of sexual health nursing was evident with the two primary themes of professional responsibility and patient care. The professional role included a philosophy of sharing nursing experiences, collaboration, employment in multiple settings, and the development of the role into advanced practice, appropriate academic and clinical preparation and a commitment to research. The patient care role included the provision of individual and holistic patient care, ability to access specific at-risk groups, clinical effectiveness, patient education and community development roles. CONCLUSION: Australian sexual health nurses make a specific and measurable contribution to the health care system. They are likely to continue to advance their role supported by appropriate research that validates their models of practice, continues their philosophy of sharing their experiences and that documents the impact they have on the health outcomes of individuals and populations.

Clinical equivalence trial on budesonide delivered either by the Novolizer multidose dry powder inhaler or the Turbuhaler in asthmatic patients.

BACKGROUND AND OBJECTIVES: To investigate the therapeutic equivalence of the two formulations of the glucocorticosteroid budesonide delivered either by the budesonide Novolizer, i.e. a multidose dry powder inhaler, or by the Pulmicort Turbuhaler in asthmatic patients in terms of efficacy, safety and tolerability during a 12-week treatment. METHODS: A total of 315 patients were randomised in this open, multicentre study. Inclusion criteria comprised previously diagnosed bronchial asthma of mild to moderate persistent intensity (ranging from 60% to a maximum of 90% predicted FEV(1)), need for anti-inflammatory therapy, inhalation of beta(2)-sympathomimetics on an as needed to regular basis, reversibility of airway obstruction of >12% after inhalation of 2 actuations of 100 microg salbutamol. Primary variable was FEV(1), secondary were other pulmonary function test variables, PC(20)FEV(1) for histamine challenge, morning and evening PEFR, salbutamol usage, asthma symptoms, reactions after inhalation, standard safety variables. RESULTS: The comparison of the FEV(1) at study endpoint indicated that the Novolizer was at least as efficacious as the Turbuhaler (p < 0.001). All other variables of the pulmonary function tests as well as the asthma symptoms, nocturnal awakenings, PEFR measurements, or salbutamol usage indicated no relevant difference. Only 1 patient (Turbuhaler discontinued prematurely due to lack of efficacy. None of the other safety variables (adverse events, laboratory variables, vital signs, etc.) indicated any difference between the groups. CONCLUSIONS: The budesonide Novolizer is therapeutically equivalent to the Pulmicort Turbuhaler for the long-term treatment of patients with mild to moderate persistent asthma.

Tyrosine phosphorylation of human keratinocyte beta-catenin and plakoglobin reversibly regulates their binding to E-cadherin and alpha-catenin.

We show that tyrosine phosphorylation, produced by incubation of normal human keratinocytes with the tyrosine phosphatase inhibitor peroxovanadate, directly and reversibly regulates the association of beta-catenin and plakoglobin with E-cadherin and alpha-catenin. Prior studies have demonstrated a correlative, but not causal, association between increased tyrosine phosphorylation and decreased adherens junction mediated cell-cell adhesion. We observed that (i) binding of tyrosine phosphorylated beta-catenin and plakoglobin to E-cadherin and to alpha-catenin was substantially reduced, but could be restored in vitro by removal of phosphate from beta-catenin and plakoglobin with added tyrosine phosphatase, and (ii) tyrosine phosphorylation of beta-catenin and plakoglobin was associated with decreased cell-cell adhesion. These findings support a direct and causal role for tyrosine phosphorylation of beta-catenin and plakoglobin in regulating adherens junction mediated cell-cell adhesion. We propose that tyrosine phosphorylation of specific and probably different residues is responsible for regulating the binding of beta-catenin or plakoglobin to (i) E-cadherin and (ii) alpha-catenin. Additionally, because beta-catenin and plakoglobin have both structural and regulatory functions, the data raise the possibility that beta-catenin or plakoglobin released from the adherens junctions by tyrosine phosphorylation may transduce a signal to the nucleus regarding the adhesive state of the cell.

Scintigraphic comparison of budesonide deposition from two dry powder inhalers.

Chlorofluorocarbons (CFCs), used in metered dose inhalers (MDIs), have been identified as being deleterious to the environment leading to a ban on their production. Dry powder inhalers (DPIs) are a widely used alternative to MDIs. One disadvantage of DPIs is that in vivo lung deposition can be influenced by the patient's inspiratory flow rate. The ASTA Medica multi-dose dry powder inhaler (AM-MDPI) has been designed to offer low resistance on inhalation, so that asthmatic patients can achieve inhaled flow rates of approximately 90 L x min(-1). The aim of the study was to evaluate the in vivo deposition of budesonide from the AM-MDPI at different flow rates and to compare this with delivery from a Turbuhaler DPI at a high flow rate. The study was a scintigraphic, randomized, crossover study in which 13 healthy volunteers inhaled a single 200 microg dose of radiolabelled budesonide on four separate occasions with a minimum 44-h washout period between dosings. At the lowest flow rate of 54 L x min(-1), comparable to that for the Turbuhaler (58 L x min(-1)), a similar percentage of the metered dose was delivered to the lung (AM-MDPI median 19.9%; Turbuhaler median 21.4%). At high flow rate (peak inspiratory flow rate 99 L x min(-1)) the AM-MDPI delivered significantly more drug to the lung (median 32.1% of metered dose) than at 65 L x min(-1) or 54 L x min(-1) (median 25.0% and 19.9% of metered dose, respectively), thus demonstrating flow rate dependence. The pattern of regional lung deposition from the AM-MDPI was similar for all three inhalation manoeuvres. It was concluded that the ASTA Medica multi-dose dry powder inhaler achieves at least as much deposition of budesonide in the lungs as a Turbuhaler when used at similar inspiratory flow rates.

Differential effects of new-generation H1-receptor antagonists in pruritic dermatoses.

In search of an improved treatment of pruritic dermatoses, we have studied azelastine, a novel H1-receptor antagonist, during a 2-week treatment period, using a double-blind, placebo-controlled design. The potent H1-antagonist cetirizine was used for comparison. Symptoms were recorded daily by the patients on a diary card, using a 4-point scale. The same parameters and adverse events were evaluated at weekly intervals, and global improvement was evaluated at the end of treatment. In all 230 evaluable patients with moderate to severe itching, azelastine caused an overall significant improvement in comparison to placebo (P = 0.02), with significance also for pruritus (P = 0.01 after 1 week and P = 0.02 after 2 weeks). Both drugs reduced itching more effectively in urticaria than in atopic eczema. Azelastine was superior to cetirizine in reducing pruritus, whereas cetirizine caused a more marked reduction of whealing. Both drugs rarely caused fatigue and dry mouth, but taste perversion occurred only in azelastine-treated patients (9.7%) and headaches only with cetirizine (10.4%). Therefore, the two H1-blockers exert differential effects on pruritus verses whealing and a distinctive adverse events pattern. The data also underline the low efficacy of antihistamines in atopic eczema, compared to urticaria.

Human immunodeficiency virus-related abdominal pain in South Africa. Aetiology, diagnosis and survival.

BACKGROUND: Abdominal pain in acquired immunodeficiency syndrome (AIDS) patients is often a marker of an underlying opportunistic pathologic condition. There are no data on HIV-related abdominal pain in Africa. METHODS: Forty-four consecutive Cape Town patients with advanced human immunodeficiency virus (HIV) infection (CD4 < 200) and abdominal pain were studied prospectively to determine aetiology and survival. RESULTS: A probable cause of pain was identified in 37 (84%): disseminated Mycobacterium tuberculosis infection in 11, cryptosporidiosis in 6, cytomegalovirus infection in 6, and atypical mycobacterial infection in 2. Gastrointestinal lymphoma and pancreatitis were not seen. Fever, hepatomegaly, respiratory symptoms, abnormal chest radiograph, and adenopathy, ascites, or abscesses on ultrasound had predictive diagnostic value for disseminated M. tuberculosis. Fifty-one per cent of abdominal pain patients survived 6 months, compared with 73% of all AIDS patients (P < 0.001). CONCLUSIONS: The aetiology of HIV-related abdominal pain in Cape Town reflects the high local prevalence of tuberculosis. Clinical and ultrasound features facilitate diagnosis. Abdominal pain is associated with poor survival.

Independent epidemics of heterosexual and homosexual HIV infection in South Africa--survival differences.

Survival with HIV infection is shorter in sub-Saharan Africa than in developed countries. The pattern of HIV transmission in our region has changed from homosexual to heterosexual, with viral subtypes similar to those in North America/Europe and Central Africa, respectively. We compared survival for the two transmission patterns after AIDS, and after the first CD4+ lymphocyte counts < 200/microliter and < 50/microliter, for adults presenting 1988-1993. Antiretroviral therapy was excluded. There were 180 homosexuals (63% White, 56% employed) and 314 heterosexuals (67% Black, 34% employed). Extrapulmonary tuberculosis was the AIDS-defining diagnosis in 36/90 heterosexuals and 5/58 homosexuals (p < 0.0001). Survival after AIDS was longer in heterosexuals (p = 0.0015), but AIDS occurred earlier as shown by their higher CD4+ count at AIDS onset (median 98/microliter vs. 40/microliter; p = 0.036). Survival was similar in the two groups after first CD4+ count < 200/microliter and < 50/microliter. Race, socioeconomic status and morbidity are markedly different in the two transmission groups. AIDS occurs with less severe immune suppression in heterosexuals, with correspondingly longer survival. Survival after defined CD4+ counts, however, is remarkably similar.

Intergroup comparisons of oral lesions in HIV-positive South Africans.

OBJECTIVE: To determine whether there are any differences in the oral manifestations of sub-groups of persons with HIV. These data could provide information for planning of oral health promotion and prevention programmes. DESIGN: A comparative inter-group cross-sectional investigation of the oral manifestations of HIV. Ethnic, gender and sexual orientation differences were taken into consideration. SETTING: Three large general hospitals that offer comprehensive medical investigations and care to persons with HIV. SUBJECTS AND METHODS: A total of 485 HIV-positive adults participated. Clinical examination and, where necessary, swabs or smears of lesions for microbiology, biopsies for histology. MAIN OUTCOME MEASURES: Presence of lesions, associated signs, incidence and type of micro-organisms. RESULTS: A total of 485 HIV-positive persons were examined over a period of 3 years consisting of 225 Blacks, 191 Coloureds (persons of 'mixed' descent) and 69 Whites. Data were analysed using, where relevant, the chi 2 test or Fisher's exact test. Heterosexual males revealed a higher prevalence of all oral lesions combined when compared with heterosexual females. A similar finding was evident when HIV-associated periodontal diseases was compared in these two groups. Homosexual males had a higher prevalence of candidal infections than heterosexual males. Coloured heterosexuals had a higher prevalence of oral lesions combined than black heterosexuals. All these results showed statistical significance. CONCLUSIONS: The study tends to show that different patterns of prevalence emerge when inter-group comparisons are made of oral soft tissue diseases evident in HIV-infected South Africans.

Hailey-Hailey disease keratinocytes: normal assembly of cell-cell junctions in vitro.

The blisters in the inherited disorder, Hailey-Hailey disease, may be caused by defective epidermal junctional complexes. We evaluated these structural complexes in vivo and in vitro. We induced a vesicular lesion in the apparently normal skin of a patient with Hailey-Hailey disease and studied a biopsy of this lesion by transmission electron microscopy. To determine whether acantholysis was related to a defect in the number or assembly of intercellular junctions, we cultured Hailey-Hailey disease keratinocytes in medium containing 0.1 mM Ca2+ and increased the [Ca2+] to 1.1 mM in order to induce assembly of cell-cell junctions. Keratinocytes were examined by double immunofluorescence with antibodies to the desmosome protein, desmoplakin, and the adherens junction protein, vinculin, at intervals after the increase in [Ca2+]. Characteristic Hailey-Hailey disease histopathology was observed by electron microscopy of the patient's skin after trauma, but we found no splitting of desmosomes. Based on the location, intensity, and rate of change of immunofluorescent staining, Hailey-Hailey and normal keratinocytes did not differ in their ability to assemble desmosomes and adherens junctions. Furthermore, we observed no significant morphologic differences between normal and Hailey-Hailey keratinocytes cultured in low and high [Ca2+]-containing media; Hailey-Hailey cells contained abundant normal-appearing desmosomes in 1.1 mM [Ca2+]. Since Hailey-Hailey disease keratinocytes can assemble normal-appearing adherens junctions and desmosomes in vitro, the functional defect may not lie in assembly of cell-cell adhering junctions, or additional perturbation may be required to expose the defect.

The impact of human immunodeficiency virus (HIV) infection on quality of life in a multiracial South African population.

We set out to document quality of life in South African HIV subjects, using the Medical Outcomes Survey (MOS) SF-36 instrument, and to determine whether this was affected by race, gender or clinical stage of disease. A cross-sectional survey of 134 HIV outpatients (42 White, 49 Mixed race, 43 Black) and 114 healthy non-medical hospital personnel (36 White, 37 Mixed race, 42 Black) was carried out at a referral centre for HIV patients in the Western Cape region of South Africa. Scores on eight scales measuring different aspects of quality of life were calculated. Black female controls scored significantly lower on all scales (p < 0.05) except physical function. HIV-infected subjects of Mixed race (both genders) reported poorer physical function (p < 0.05) but no other scale was affected by race. HIV subjects scored significantly lower than controls on all scales (p < 0.01); the majority of the decline in function occurred early in disease by WHO stages 1 and 2. We conclude that HIV-infection impacts early on all aspects of quality of life and that this impact is largely independent of racial origin.

PIP: During April 1993 to May 1994, in Cape Town, South Africa, the Medical Outcomes Survey SF-36 was administered in English, Afrikaans, and Xhosa to 114 healthy non-medical hospital personnel aged 20-40 from the three racial groups (White, Mixed race, and Black) working at Somerset Hospital and to HIV patients attending the hospital's HIV clinic. Researchers aimed to examine the quality of life in this HIV population and to determine whether race, gender, or clinical stage of disease affects quality of life. The health concepts addressed in the survey were limitations in physical activities, limitations in social activities, general mental health (psychological distress and well-being), limitations in usual role activities, vitality, and general health perceptions. Black, female, healthy, non-HIV-infected non-medical personnel scored much lower on all scales (p 0.05) except physical function than other groups. HIV-infected persons of mixed race had poorer physical function than the other racial groups (p 0.05). Race affected no other scale. HIV-infected patients scored much lower than the healthy controls on all scales (p 0.01). Most of the decline in physical function took place early in HIV disease (i.e., by World Health Organization stages 1 and 2), when symptoms have not yet appeared. These findings indicate that HIV infection impacts early on all aspects of quality of life and that race-related differences in quality of life do not seem to be important. In conclusion, health workers must not neglect the needs of patients with early HIV disease and must support them at a primary care level.

AIDS in Africa.

HIV has infected more than 10 million people in sub-Saharan Africa with prevalence rates of up to 30% reported from some countries. Adult transmission of HIV in Africa is mainly heterosexual and over half of new infections are in women. About 40% of infants born to HIV-positive mothers are themselves infected. Diarrhoea occurs in 90% of African AIDS patients and 'slim disease' (prolonged diarrhoea and wasting usually due to coccidian parasites) is pathognomic of AIDS in Central Africa. Dual infection with HIV and tuberculosis is a major problem. African AIDS patients appear to succumb to virulent pathogens, especially Mycobacterium tuberculosis, before they become sufficiently immunosuppressed to develop the opportunistic infections typically associated with advanced HIV disease in developed countries.

Constipation in an elderly community: a study of prevalence and potential risk factors.

OBJECTIVE: The epidemiology of chronic constipation in the elderly remains poorly defined. We aimed to study the prevalence of, and potential risk factors for, constipation in a representative elderly community, using symptom-based diagnostic criteria. METHODS: An age and gender-stratified random sample of 1833 eligible residents of Olmsted County, Minnesota, aged 65 yr and over, was mailed a valid self-report questionnaire; 1375 responded (75%). RESULTS: The overall age- and gender-adjusted prevalence (per 100) of any constipation was 40.1 (95% CI 38.9, 44.4); for functional constipation and outlet difficulty or delay, the prevalence rates were 24.4 (95% CI 22.0-26.9) and 20.5 (95% CI 18.2-22.8), respectively. Self-reported constipation did not reliably identify functional constipation or outlet delay. Outlet delay, but not functional constipation, was more frequent in women; functional constipation, but not outlet delay, was associated with advancing age. Nonsteroidal anti-inflammatory drugs and other medications were significant risk factors in subjects with functional constipation and outlet delay combined. CONCLUSIONS: In independently living, elderly persons, constipation is a common complaint; among these subjects, there appear to be symptom subgroups that can be identified.

Quality of life in HIV infection.

HIV infection gives rise to incurable, debilitating disease in young persons and treatments capable of prolonging survival are often associated with toxicity. Quality of Life (QOL) assessment is therefore important in the evaluation of clinical interventions in HIV-infected patients. It also has a role in determining the needs of individuals and directing healthcare resources. A wide range of QOL instruments is available and choice of instrument should be guided by the information required. As would be expected, poorer QOL is correlated with the presence of disease-related symptoms and advancing WHO clinical stage of disease. Psychological dysfunction, however, is evident from the time of diagnosis and should not be overlooked.