Challenges faced by health workers in implementing the prevention of mother-to-child HIV transmission (PMTCT) programme in Uganda.

BACKGROUND: To report the experience of health workers who had played key roles in the early stages of implementing the prevention of mother-to-child HIV transmission services (PMTCT) in Uganda. METHODS: Interviews were conducted with 15 key informants including counsellors, obstetricians and PMTCT coordinators at the five PMTCT test sites in Uganda to investigate the benefits, challenges and sustainability of the PMTCT programme. Audio-taped interviews were held with each informant between January and June 2003. These were transcribed verbatim and manually analysed using the framework approach. RESULTS: The perceived benefits reported by informants were improvement of general obstetric care, provision of antiretroviral prophylaxis for HIV-positive mothers, staff training and community awareness. The main challenges lay in the reluctance of women to be tested for HIV, incomplete follow-up of participants, non-disclosure of HIV status and difficulties with infant feeding for HIV-positive mothers. Key informants thought that the programme's sustainability depended on maintaining staff morale and numbers, on improving services and providing more resources, particularly antiretroviral therapy for the HIV-positive women and their families. CONCLUSION: Uganda's experience in piloting the PMTCT programme reflected the many challenges faced by health workers. Potentially resource-sparing strategies such as the 'opt-out' approach to HIV testing required further evaluation.

The impact of HIV on maternal quality of life in Uganda.

To study the effect of HIV infection on quality of life (QOL) during pregnancy and puerperium, QOL was measured in a cohort study at St. Francis Hospital Nsambya, Kampala, Uganda. Dartmouth COOP charts were administered to 132 HIV-positive and 399 HIV-negative women at 36 weeks of pregnancy and six weeks post-partum. Responses were coded from 0 = best health-status to 4 = worst health-status and scores of 3-4 defined as poor. Odds ratios (OR) (95% confidence intervals(CI)) for poor scores were calculated and independent predictors of poor QOL examined using logistic regression. In pregnancy, HIV-positive women were more likely to have poor scores in feelings: OR = 3.2(1.9-5.3), daily activities: OR = 2.8(1.4-5.5), pain: OR = 2.1(1.3-3.5), overall health: OR = 1.7(1.1-2.7) and QOL: OR = 7.2(3.6-14.7), all p= 0.2). HIV infection was independently associated with poor QOL: OR = 8.5(3.8-19). Findings in puerperium were similar to those in pregnancy except more HIV-positive women had poor scores in social activities: OR = 2.5(1.4-4.7) and change in health: OR = 5.4(2-14.5) and infant death also predicted poor QOL: OR = 6.7(2.4-18.5). The findings reflect HIV's adverse impact on maternal QOL and the need for interventions to alleviate this infection's social and emotional effects.

Audit of antibiotic policies in the South East of England, 2004.

OBJECTIVES: The antibiotic policies of hospitals and primary care trusts (PCTs) in South East England were audited in the summer of 2004, to see how they had improved since 2000. METHODS: Antibiotic policies were obtained from pharmacists in NHS hospitals and PCTs, and examined for dates, formats, evidence base for policies, the type of guidance given on dosage, length of treatment, choice of antibiotics, coverage of common infections and reasons for prophylaxis. RESULTS: Twenty-three hospital and 25 primary care policies were examined. The average age of policies was 12 months, but 13 were more than 2 years old. The commonest format was an A4-sized document available in an electronic version. Primary care policies were more uniform than hospital policies. More primary care than hospitals' policies gave evidence to support their guidance. Ten policies used plain English for dosages, and 38 (79%) policies made few or no cautionary points about the drugs recommended. Respiratory and urinary infections were covered in most policies, but guidance on gastroenteritis and antibiotic prophylaxis was less frequent. There was little advice in the policies on the management of methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Primary care policies have improved since 2000, using a national model for evidence and a consistent style. Hospitals could benefit from similar national guidance, especially in the evidence to support the contents of antibiotic policies.

A survey of hepatitis C prevalence amongst the homeless community of Oxford.

Hepatitis C (HCV) is an emerging health concern across the world, with 170 million people chronically infected and at risk of liver cancer, cirrhosis or liver failure. There is no vaccination and so it is important to learn as much as possible about how to prevent future infection. Modes of transmission include intravenous drug use (IDU), blood products, tattooing and, to a lesser extent, sexual intercourse. Homelessness is a risk factor of HCV because of the environments and behaviours associated with homeless communities such as poor hygiene, poor nutrition and high levels of IDU. The aim of this project was to determine the prevalence of HCV and its risk factors amongst the homeless community of Oxford, which is the second largest in the country. Ninety-eight individuals of the Oxford homeless community were interviewed and tested for HCV. The results gave an estimated HCV prevalence of 26.5 percent. The major risk factors in this population were IDU (past and present), age (over 20 years old) and sharing the paraphernalia used by i.v. drug users (e.g. spoons, foil and filters). With the exception of age, these risk factors could all be targeted in an attempt to reduce this prevalence and combat the major public health concern that HCV poses to the homeless community of Oxford.

Encouraging good antimicrobial prescribing practice: a review of antibiotic prescribing policies used in the South East Region of England.

BACKGROUND: Good prescribing practice has an important part to play in the fight against antimicrobial resistance. Whilst it was perceived that most hospitals and Health Authorities possessed an antibiotic policy, a review of antibiotic policies was conducted to gain an understanding of the extent, quality and usefulness of these policies. METHODS: Letters were sent to pharmacists in hospitals and health authorities in across the South East region of the National Health Service Executive (NHSE) requesting antibiotic policies. data were extracted from the policies to assess four areas; antibiotic specific, condition specific, patient specific issues and underpinning evidence. RESULTS: Of a possible 41 hospital trusts and 14 health authorities, 33 trusts and 9 health authorities (HAs) provided policies. Both trust and HA policies had a median publication date of 1998 (trust range 1993-99, HA 1994-99). Eleven policies were undated. The majority of policies had no supporting references for the statements made. All policies provided some details on specific antibiotics. Gentamicin and ciprofloxacin were the preferred aminoglycoside and quinolone respectively with cephalosporins being represented by cefuroxime or cefotaxime in trusts and cephradine or cephalexin in HAs. 26 trusts provided advice on surgical prophylaxis, 17 had meningococcal prophylaxis policies and 11 covered methicillin resistant Staphylococcus aureus (MRSA). There was little information for certain groups such as neonates or children, the pregnant or the elderly. CONCLUSION: There was considerable variation in content and quality across policies, a clear lack of an evidence base and a need to revise policies in line with current recommendations.

Invasive pneumococcal disease in England and Wales: vaccination implications.

Knowledge of the epidemiology of invasive pneumococcal disease (IPD) will aid in planning the use of pneumococcal vaccines. A United Kingdom (UK)-based surveillance in England and Wales (1995-1997) of 11,528 individuals with IPD and a local enhanced surveillance in the Oxford (UK) area (1995-1999) have been analyzed. IPD has a high attack rate in children, with 37.1-48.1 cases per 100,000 infants <1 year old per year, and in older persons, with 21.2-36.2 cases per 100,000 persons >65 years old per year, for England, Wales, and Oxford. The 7-valent conjugate vaccine includes serotypes causing < or =79% of IPD in children <5 years old, but only 66% in adults >65 years old. The data also indicate that IPD varies by serotype, age, and country, emphasizing that the epidemiology of IPD is heterogeneous and requires continued surveillance.

Obstacles to a randomised controlled trial of intensive dynamic psychotherapy: an account of the New South Wales Section of Psychotherapy outcomes project.

OBJECTIVE: This paper examines the obstacles to a randomised controlled trial (RCT) of intensive dynamic psychotherapy (IDP) by reference to the fate of the New South Wales Section of Psychotherapy outcomes project. METHOD: Planning was complete and the final research protocol was about to be implemented when funding difficulties led to suspension of the project. The opinions of the research subcommittee regarding the main obstacles to the ultimate success of the project are now analysed in the expectation that better research strategies will follow. RESULTS: With hindsight, six of the eight members of the research subcommittee reported that the project was not feasible. By choice of questionnaire items they identified the greatest threats to a successful trial as: standardisation of the procedures, termination at 24 months, the availability of funding and the choice of treatment procedures. The most frequently volunteered concerns related to the enlistment and cooperation of the trial therapists (5), standardisation of the experimental therapy (3), probable shortfall in trial subjects (3) and the availability of funding (2). CONCLUSIONS: The most powerful general obstacles to success of the project related to the standardisation of procedures and the failure to maintain sufficient cooperation of trial therapists. The protocol required IDP therapists to terminate procedures at 24 months, which contradicted their usual practices and led to some alienation from the project. Amendments to the protocol might improve the possibility of a successful trial. However, one might also conclude that it is premature to attempt a naturalistic RCT of IDP.

Altered patterns of gene expression in response to myocardial infarction.

The use of cDNA microarrays has made it possible to simultaneously analyze gene expression for thousands of genes. Microarray technology was used to evaluate the expression of >4000 genes in a rat model of myocardial infarction. More than 200 genes were identified that showed differential expression in response to myocardial infarction. Gene expression changes were monitored from 2 to 16 weeks after infarction in 2 regions of the heart, the left ventricle free wall and interventricular septum. A novel clustering program was used to identify patterns of expression within this large set of data. Unique patterns were revealed within the transcriptional responses that illuminate changes in biological processes associated with myocardial infarction.

Excitation of a Cr:forsterite laser to the (3)T(1) band.

Laser oscillation of Cr:forsterite was obtained with ruby laser pumping to the lowest-lying levels of the (3)T(1) band in Cr(4+). Pump polarization effects, temporal response, and broadband 220-nm tuning are reported. Frequency doubling in potassium titanyl phosphate generate tunable red-yellow light. This unconventional excitation scheme is of interest for potential high-energy output and for direct diode pumping.

Diagnosis of viral infections of the central nervous system: clinical interpretation of PCR results.

BACKGROUND: Standard laboratory techniques, such as viral culture and serology, provide only circumstantial or retrospective evidence of viral infections of the central nervous system (CNS). We assessed the diagnostic accuracy of PCR of cerebrospinal fluid (CSF) in the diagnosis of viral infections of the CNS. METHODS: We examined all the CSF samples that were received at our diagnostic virology laboratory between May, 1994, and May, 1996, by nested PCR for viruses associated with CNS infections in the UK. We collected clinical and laboratory data for 410 patients from Oxford city hospitals (the Oxford cohort) whose CSF was examined between May, 1994, and May, 1995. These patients were classified according to the likelihood of a viral infection of the CNS. We used stratified logistic regression analysis to identify the clinical factors independently associated with a positive PCR result. We calculated likelihood ratios to estimate the clinical usefulness of PCR amplification of CSF. FINDINGS: We tested 2233 consecutive CSF samples from 2162 patients. A positive PCR result was obtained in 143 patients, including 22 from the Oxford cohort. Logistic regression analysis of the Oxford cohort showed that fever, a virus-specific rash, and a CSF white-cell count of 5/microL or more were independent predictors of a positive PCR result. The likelihood ratio for a definite diagnosis of viral infection of the CNS in a patient with a positive PCR result, relative to a negative PCR result, was 88.2 (95% CI 20.6-378). The likelihood ratio for a possible diagnosis of viral infection of the CNS in a patient with a negative PCR result, relative to a positive PCR result, was 0.10 (0.03-0.39). INTERPRETATION: A patient with a positive PCR result was 88 times as likely to have a definite diagnosis of viral infection of the CNS as a patient with a negative PCR result. A negative PCR result can be used with moderate confidence to rule out a diagnosis of viral infection of the CNS. We believe that PCR will become the first-line diagnostic test for viral meningitis and encephalitis.

Measurement of autobiographical recall.

The finding by Huffman and Weaver (1996) of no support for the hypothesis that personal episodic recall involves visual imagery may be a consequence of their method of assessment. Further research which employs more measures than simply number of events recalled and which gives subjects longer time to respond is needed.

A study of 42 episodes of overwhelming post-splenectomy infection: is current guidance for asplenic individuals being followed?

Individuals without a spleen have an increased risk of overwhelming post-splenectomy infection (OPSI). Improved awareness in recent years has stimulated increased efforts to prevent OPSI. Published guidelines have described policies for immunization, chemoprophylaxis and other measures considered beneficial to asplenic patients, yet OPSI episodes continue to occur. In an attempt to investigate why serious infections are still being seen, we have conducted a nationally based survey of recent OPSI episodes, using mainly a network of medical microbiologists. Data including clinical background to both splenectomy and OPSI episode, immunization and chemoprophylaxis history have been collated. Forty-two cases of overwhelming infection were reported by June 1996. Patients of all ages were affected with OPSI occurring up to 59 years after splenectomy. A mortality rate of 45% was seen. Pneumococcal infection caused at least 37 of 42 episodes, but only 12 patients had received pneumococcal vaccine. Four cases were possible vaccine failures. Only 22% of individuals had taken any chemoprophylaxis since splenectomy, and only one carried a medical alert card. Much more needs to be done to ensure that asplenic patients are warned of the risks of infection, and given at least pneumococcal vaccine. The role of antibiotics for either continual prophylaxis or as a reserve supply for self-prescription at appropriate times also needs greater discussion. Further work on improving pneumococcal vaccine response together with suitable programmes for revaccination are required. Surveillance should continue until the incidence of OPSI reaches an irreducible minimum.

Meningococcal vaccines for the United Kingdom.

New meningococcal vaccines are needed in the United Kingdom with some urgency. Almost all Neisseria meningitidis disease in this country is caused by serogroups B and C. Infants have the highest attack rates, but also make the poorest immunological responses to potential vaccines. The development of vaccines that protect infants is a significant challenge. A capsule-based serogroup B vaccine is unlikely to be successful in infants because the capsule is poorly immunogenic and the polysaccharide molecule mimics a human epitope. Without completely discounting capsule as an immunogen, alternate antigens are being considered for immunisation: outer membrane proteins (OMP), iron regulating proteins, and lipopolysaccharide. Vaccines based on OMP have been used in several phase 3 trials in South Africa, Cuba, Brazil, Norway, and Chile, in which two doses of vaccine were given. The Cuban and Norwegian vaccines have been compared in phase 2 trials in Iceland and Chile. Potential limitations are epitope heterogeneity and the theoretical ability of N. meningitidis to adapt even to hosts who have received polyvalent vaccines. A phase 2 trial of a hexavalent class 1 OMP vaccine is under way in Gloucester, with 100 babies receiving injections at 2, 3, and 4 months. Serogroup C vaccines have been developed from capsular polysaccharide but, unconjugated, these vaccines do not protect those under 2 years of age. Conjugate vaccines with C and AC polysaccharides are immunogenic in infants, but antibody titres may wane quickly.(ABSTRACT TRUNCATED AT 250 WORDS)

Jumping from a general hospital.

Jumping is the most common reported means of suicide in general hospitals. There have been no published reviews of suicides of nonpsychiatric inpatients since 1980. We describe 12 subjects who, between January 1980 and January 1992, jumped from a large general teaching hospital. Eight of them succumbed, providing a rate of suicide of 1.7 per 100,000 admissions. There were three clinical subgroups: those admitted after suicide attempts, the acutely delirious, and the chronically medically ill. Factors appearing frequently in the third subgroup were pain, dyspnea, transient confusion, poor prognosis, and recent adverse news. When we compared the hospital jumpers with 30 nonfatal jumpers who attended our Emergency Department, the medical and psychiatric profiles differed in the frequency of medical illnesses, advancing age, male gender, and absence of preexisting psychiatric illness. Proximity and ease of access to balconies and windows appeared to be highly relevant to the prevention of hospital jumping.