A Nationwide Enumeration of the Surgical Workforce, its Production and Disparities in Operative Productivity in Liberia.

BACKGROUND: Any health care system that strives to deliver good health and well-being to its population relies on a trained workforce. The aim of this study was to enumerate surgical provider density, describe operative productivity and assess the association between key surgical system characteristics and surgical provider productivity in Liberia. METHODS: A nationwide survey of operation theatre logbooks, available human resources and facility infrastructure was conducted in 2018. Surgical providers were counted, and their productivity was calculated based on operative numbers and full-time equivalent positions. RESULTS: A total of 286 surgical providers were counted, of whom 67 were accredited specialists. This translated into a national density of 1.6 specialist providers per 100,000 population. Non-specialist physicians performed 58.3 percent (3607 of 6188) of all operations. Overall, surgical providers performed a median of 1.0 (IQR 0.5-2.7) operation per week, and there were large disparities in operative productivity within the workforce. Most operations (5483 of 6188) were categorized as essential, and each surgical provider performed a median of 2.0 (IQR 1.0-5.0) different types of essential procedures. Surgical providers who performed 7-14 different types of essential procedures were more than eight times as productive as providers who performed 0-1 essential procedure (operative productivity ratio = 8.66, 95% CI 6.27-11.97, P < 0.001). CONCLUSION: The Liberian health care system struggles with an alarming combination of few surgical providers and low provider productivity. Disaggregated data can provide a high-resolution picture of local challenges that can lead to local solutions.

Impact of surgical infrastructure and personnel on volume and availability of essential surgical procedures in Liberia.

BACKGROUND: Essential surgical procedures rank among the most cost-effective of all healthcare interventions. The aim of this study was to enumerate surgical volumes in Liberia, quantify surgical infrastructure, personnel and availability of essential surgical procedures, describe surgical facilities, and assess the influence of human resources and infrastructure on surgical volumes. METHODS: An observational countrywide survey was done in Liberia between 20 September and 8 November 2018. All healthcare facilities performing surgical procedures requiring general, regional or local anaesthesia in an operating theatre between September 2017 and August 2018 were eligible for inclusion. Information on facility infrastructure and human resources was collected by interviewing key personnel. Data on surgical volumes were extracted from operating theatre log books. RESULTS: Of 70 healthcare facilities initially identified as possible surgical facilities, 52 confirmed operative capacity and were eligible for inclusion; all but one shared surgical data. A national surgical volume of 462 operations per 100 000 population was estimated. The median hospital offered nine of 26 essential surgical procedures. Unequal distributions of surgical infrastructure, personnel, and essential surgical procedures were identified between facilities. In multivariable regression analysis, surgical human resources (ß = 0·60, 95 per cent c.i. 0·34 to 0·87; P < 0·001) and infrastructure (ß = 0·03, 0·02 to 0·04; P < 0·001) were found to be strongly associated with operative volumes. CONCLUSION: The availability of essential surgical procedures in Liberia is extremely low. Descriptive tools can quantify inequalities, guide resource allocation, and highlight rational investment areas.

ANTECEDENTES: Los procedimientos quirúrgicos esenciales se encuentran entre los más coste-efectivos de todas las intervenciones de salud. El objetivo de este estudio fue enumerar los volúmenes quirúrgicos en Liberia, cuantificar la infraestructura quirúrgica, personal y disponibilidad de procedimientos quirúrgicos esenciales, describir las instalaciones quirúrgicas y evaluar la influencia de los recursos humanos e infraestructura en los volúmenes quirúrgicos. MÉTODOS: Se realizó una encuesta observacional a nivel nacional en Liberia entre el 20 de septiembre y 8 de noviembre de 2028. Todos los centros médicos que realizaban procedimientos quirúrgicos que precisasen anestesia general, regional o local en un quirófano entre septiembre 2017 y agosto 2018 fueron elegibles para su inclusión. La información sobre la infraestructura de las instalaciones y los recursos humanos fue recogida entrevistando a personal clave. Los datos sobre los volúmenes quirúrgicos se extrajeron de los libros de registro de quirófano. RESULTADOS: De 70 centros médicos inicialmente identificados como posibles instalaciones quirúrgicas, 52 confirmaron disponer de capacidad quirúrgica y fueron elegibles para la inclusión; todos menos uno, compartieron los datos quirúrgicos. Se estimó un volumen quirúrgico nacional de 462 operaciones por 100.000 habitantes. El hospital promedio ofrecía nueve de 26 procedimientos quirúrgicos esenciales. Se identificaron distribuciones desiguales de infraestructura quirúrgica, personal y procedimientos quirúrgicos esenciales entre los centros. Se encontró que los recursos humanos quirúrgicos (ß = 0,60, P < 0,001, i.c. del 95% 0,34-0,87) y la infraestructura (ß = 0,029, P < 0,001, i.c. del 95% 0,019-0,039) estaban fuertemente asociadas con los volúmenes quirúrgicos. CONCLUSIÓN: La disponibilidad de procedimientos quirúrgicos esenciales en Liberia es extremadamente bajo. Instrumentos descriptivos pueden cuantificar desigualdades, orientar las decisiones de asignación de recursos y destacar las áreas para una inversión racional.

A multicentred study to validate a consensus bleeding assessment tool developed by the biomedical excellence for safer transfusion collaborative for use in patients with haematological malignancy.

BACKGROUND: There continues to be uncertainty about the optimal approach to documenting bleeding data in platelet transfusion trials, with a desire to apply a common assessment tool across all trials. With this in mind, a consensus bleeding assessment tool (BAT) has been developed by the Biomedical Excellence for Safer Transfusion (BEST) collaborative, based on review of data collection forms used in published randomized trials and following content validation with a range of healthcare professionals at seven haematology centres through BEST members. This study aimed to evaluate reliability and reproducibility of the consensus BAT. METHODS: Replicated clinical assessments of bleeding were undertaken by participants with haematological malignancies recruited at four haematology centres in an international, multicentred, observational study. Concordance of repeat assessments was calculated for agreement in site and grade of bleeding observed. RESULTS: Forty patients consented to participate, and 13 trained bleeding assessors collected these data. Bleeding assessments were carried out on 113 separate days. Of all 225 bleeding assessments, 204 were compared for grade concordance, and 160 were compared for site concordance. There was very good grade concordance (83%, 95% confidence interval 74-93%) and good bleeding site concordance (69%, 95% confidence interval 57-79%) in observations of bleeding. Discordance was primarily in relation to assessing skin bleeding. CONCLUSIONS: Alongside a structured training programme, levels of concordance for a consensus BAT were high. Researchers using assessment tools for bleeding need to balance comprehensive data collection against potential loss of accuracy for some types of bleeding, such as skin findings.

Knockdown and recovery of malaria diagnosis and treatment in Liberia during and after the 2014 Ebola outbreak.

Setting: The malaria-endemic country of Liberia, before, during and after the 2014 Ebola outbreak. Objective: To describe the consequences of the Ebola outbreak on Liberia's National Malaria Programme and its post-Ebola recovery. Design: A retrospective cross-sectional study using routine countrywide programme data. Results: Malaria caseloads decreased by 47% during the Ebola outbreak and by 11% after, compared to the pre-Ebola period. In those counties most affected by Ebola, a caseload reduction of >20% was sustained for 12 consecutive months, while this lasted for only 4 consecutive months in the counties least affected by Ebola. Linear regression of monthly proportions of confirmed malaria cases-as a proxy indicator of programme performance-over the pre- and post-Ebola periods indicated that the malaria programme could require 26 months after the end of the acute phase of the Ebola outbreak to recover to pre-Ebola levels. Conclusions: The differential persistence of reduced caseloads in the least- and most-affected counties, all of which experienced similar emergency measures, suggest that factors other than Ebola-related security measures played a key role in the programme's reduced performance. Clear guidance on when to abandon the emergency measures after an outbreak may be needed to ensure faster recovery of malaria programme performance.

Contexte : Le Liberia, pays d'endémie palustre, avant, pendant et après l'épidémie d'Ebola de 2014.Objectif : Décrire les conséquences de l'épidémie d'Ebola sur le programme national de lutte contre le paludisme et sa récupération après Ebola.Schéma : Étude rétrospective transversale utilisant des données de routine du programme dans tout le pays.Résultats : Le nombre de cas de paludisme déclarés a baissé de 47% pendant et de 11% après l'épidémie d'Ebola, comparé à la période pré-Ebola. Dans les comtés les plus affectés par Ebola, une réduction de plus de 20% a été maintenue pendant plus de 12 mois consécutifs, tandis que celle-ci n'a duré que pendant 4 mois consécutifs dans les comtés les moins affectés par Ebola. Une régression linéaire des proportions mensuelles de cas de paludisme confirmés­comme indicateur indirect de la performance du programme­sur les périodes pré- et post-Ebola a montré que le programme paludisme pourrait avoir besoin de 26 mois après la fin de la phase aiguë de l'épidémie d'Ebola pour revenir aux niveaux d'avant Ebola.Conclusion: La persistance différentielle de réduction des cas déclarés dans les comtés les moins et les plus affectés, qui ont tous expérimenté des mesures d'urgence similaires, suggère que des facteurs autres que les mesures de sécurité liées à Ebola ont joué des rôles clés dans la réduction de la performance du programme. Des recommandations claires sur le moment auquel il faut abandonner les mesures d'urgence après une flambée pourraient être nécessaires pour assurer une récupération plus rapide de la performance du programme.

Marco de referencia: El país de Liberia, con una situación endémica de paludismo, antes de la epidemia de fiebre hemorrágica del Ébola, durante el brote y después del mismo en el 2014.Objetivos: Describir las consecuencias del brote epidémico del Ébola sobre el programa nacional contra el paludismo y su recuperación después de la epidemia.Método: Fue este un estudio transversal retrospectivo a partir de los datos corrientes del programa en todo el país.Resultados: La carga de morbilidad por paludismo disminuyó un 47% durante la epidemia y un 11% después de la misma, en comparación con el período anterior. En las provincias más afectadas por el brote se observó una disminución constante de más del 20% durante 12 meses consecutivos, comparada con 4 meses en las provincias menos afectadas. La regresión lineal de la proporción mensual de casos confirmados de paludismo, utilizada como indicador indirecto del desempeño del programa durante los períodos anterior y posterior a la epidemia del Ébola, puso de manifiesto que el programa precisó 26 meses después del final de la fase aguda de la epidemia hasta recuperar su nivel de desempeño anterior al brote.Conclusiones: La recuperación diferencial de la notificación en las provincias menos afectadas y las más afectadas por la epidemia, pese a que en todas las regiones se ejecutaron intervenciones de emergencia equivalentes, indica que factores diferentes a las medidas de seguridad desencadenadas por la epidemia influyeron de manera importante en la disminución del desempeño del programa. Se precisan orientaciones claras con respecto al momento más oportuno para interrumpir las intervenciones de emergencia después de los brotes epidémicos, con el propósito de facilitar una recuperación más rápida del funcionamiento del programa contra el paludismo.

Charge-Induced Force Noise on Free-Falling Test Masses: Results from LISA Pathfinder.

We report on electrostatic measurements made on board the European Space Agency mission LISA Pathfinder. Detailed measurements of the charge-induced electrostatic forces exerted on free-falling test masses (TMs) inside the capacitive gravitational reference sensor are the first made in a relevant environment for a space-based gravitational wave detector. Employing a combination of charge control and electric-field compensation, we show that the level of charge-induced acceleration noise on a single TM can be maintained at a level close to 1.0 fm s^{-2} Hz^{-1/2} across the 0.1-100 mHz frequency band that is crucial to an observatory such as the Laser Interferometer Space Antenna (LISA). Using dedicated measurements that detect these effects in the differential acceleration between the two test masses, we resolve the stochastic nature of the TM charge buildup due to interplanetary cosmic rays and the TM charge-to-force coupling through stray electric fields in the sensor. All our measurements are in good agreement with predictions based on a relatively simple electrostatic model of the LISA Pathfinder instrument.

Turmoil at Turrialba Volcano (Costa Rica): Degassing and eruptive processes inferred from high-frequency gas monitoring.

Eruptive activity at Turrialba Volcano (Costa Rica) has escalated significantly since 2014, causing airport and school closures in the capital city of San José. Whether or not new magma is involved in the current unrest seems probable but remains a matter of debate as ash deposits are dominated by hydrothermal material. Here we use high-frequency gas monitoring to track the behavior of the volcano between 2014 and 2015 and to decipher magmatic versus hydrothermal contributions to the eruptions. Pulses of deeply derived CO2-rich gas (CO2/Stotal > 4.5) precede explosive activity, providing a clear precursor to eruptive periods that occurs up to 2 weeks before eruptions, which are accompanied by shallowly derived sulfur-rich magmatic gas emissions. Degassing modeling suggests that the deep magmatic reservoir is ~8-10 km deep, whereas the shallow magmatic gas source is at ~3-5 km. Two cycles of degassing and eruption are observed, each attributed to pulses of magma ascending through the deep reservoir to shallow crustal levels. The magmatic degassing signals were overprinted by a fluid contribution from the shallow hydrothermal system, modifying the gas compositions, contributing volatiles to the emissions, and reflecting complex processes of scrubbing, displacement, and volatilization. H2S/SO2 varies over 2 orders of magnitude through the monitoring period and demonstrates that the first eruptive episode involved hydrothermal gases, whereas the second did not. Massive degassing (>3000 T/d SO2 and H2S/SO2 > 1) followed, suggesting boiling off of the hydrothermal system. The gas emissions show a remarkable shift to purely magmatic composition (H2S/SO2 < 0.05) during the second eruptive period, reflecting the depletion of the hydrothermal system or the establishment of high-temperature conduits bypassing remnant hydrothermal reservoirs, and the transition from phreatic to phreatomagmatic eruptive activity.

Sub-Femto-g Free Fall for Space-Based Gravitational Wave Observatories: LISA Pathfinder Results.

We report the first results of the LISA Pathfinder in-flight experiment. The results demonstrate that two free-falling reference test masses, such as those needed for a space-based gravitational wave observatory like LISA, can be put in free fall with a relative acceleration noise with a square root of the power spectral density of 5.2±0.1 fm s^{-2}/sqrt[Hz], or (0.54±0.01)×10^{-15} g/sqrt[Hz], with g the standard gravity, for frequencies between 0.7 and 20 mHz. This value is lower than the LISA Pathfinder requirement by more than a factor 5 and within a factor 1.25 of the requirement for the LISA mission, and is compatible with Brownian noise from viscous damping due to the residual gas surrounding the test masses. Above 60 mHz the acceleration noise is dominated by interferometer displacement readout noise at a level of (34.8±0.3) fm/sqrt[Hz], about 2 orders of magnitude better than requirements. At f≤0.5 mHz we observe a low-frequency tail that stays below 12 fm s^{-2}/sqrt[Hz] down to 0.1 mHz. This performance would allow for a space-based gravitational wave observatory with a sensitivity close to what was originally foreseen for LISA.

Norovirus genotype diversity associated with gastroenteritis outbreaks in aged-care facilities.

Noroviruses are a major cause of gastroenteritis. Vaccine strategies against norovirus are currently under consideration but depend on a detailed knowledge of the capsid genotypes. This study examined the incidence of norovirus outbreaks in residential aged-care facilities in Victoria, Australia over one year (2013) and documented the (capsid) norovirus genotypes associated with these outbreaks. It was found that 65·0% of 206 outbreaks tested were associated with norovirus infection, thereby showing norovirus to be the major cause of viral gastroenteritis in residential aged-care facilities. Fifteen capsid (open reading frame 2) genotypes were identified as follows: GI.2 (0·9%), GI.3 (1·8%), GI.4 (3·7%), GI.6 (0·9%), GI.7 (0·9%), GI.8 (0·9%), GII.1 (0·9%), GII.2 (0·9%), GII.3 (1·8%), GII.4 (2009-like) (0·9%), GII.4 (2012) (48·6%), GII.4 (2012-like) (16·5%), GII.4 (unknown) (9·2%), GII.5 (2·8%), GII.6 (0·9%), GII.7 (0·9%), GII.13 (6·4%) and an as yet unclassified GII genotype (0·9%). Although GII.4 was the most common norovirus capsid genotype detected, the great diversity of norovirus genotypes in the elderly indicates vaccination strategies for this demographic are not straightforward.

Evaluation of the RIDAGENE real-time PCR assay for the detection of GI and GII norovirus.

The current study examined the efficacy of the RIDAGENE norovirus (NoV) real-time polymerase chain reaction assay (R-Biopharm, Darmstadt, Germany) for use in a routine diagnostic laboratory. The RIDAGENE assay had an overall sensitivity of 98% but was more sensitive for GII than GI NoV. The assay had a specificity of 98%. The RIDAGENE assay could detect a variety of GI and GII open reading frame 2 genotypes including GI.1, GI.3, GI.8, GI.13, GII.2, GII.3, GII.4 (including the following variants: 2006b, 2009, 2012, and 3 others that have not been assigned), GII.6, GII.12, and GII.13. The assay did not cross react with a number of gastroenteritis viruses including adenovirus, astrovirus, rotavirus, and sapovirus. The assay was straightforward to perform, and for a run of 50 specimens, a result was obtainable in roughly 4 hours. The RIDAGENE assay can be recommended as a valuable detection method for NoV.

Safety of platelet transfusion: past, present and future.

Platelet components became routinely available to many institutions in the late 1960s and since then utilization has steadily increased. Platelets are produced by three principal methods and their manufacturing process is regulated by multiple agencies. As the field of platelet transfusion has evolved, a broad array of strategies to improve platelet safety has developed. This review will explore the evolution of modern platelet component therapy, highlight the various risks associated with platelet transfusion and describe risk reduction strategies that have been implemented to improve platelet transfusion safety. In closing, the reader will be briefly introduced to select investigational platelet and platelet-mimetic products that have the potential to enhance platelet transfusion safety in the near future.

Emergence of GII.e as a major ORF 1 norovirus genotype and its associated ORF 2 GII.4 variant forms.

The noroviruses are a major cause of outbreaks of gastroenteritis. The norovirus genotype "GII.e", identified by ORF (Open Reading Frame) 1 nucleotide sequencing, appears to be an obligatory recombinant, in that no unique GII.e ORF 2 genotype has been identified. In 2012 GII.e norovirus became the predominant ORF 1 genotype in norovirus outbreaks in Victoria, Australia, and the current study documents changes in the ORF 1 region of GII.e norovirus since it first emerged in 2008, as well as in the ORF 2 genotypes associated with GII.e norovirus. GII.e norovirus underwent significant genetic change in ORF 1 between 2010 and 2012 and this genetic change corresponded to a significant increase in the prevalence of the virus. Nucleotide sequencing of the ORF 2 region of GII.e specimens showed that in 2008-2009, all the ORF 2 sequences corresponded to the GII.4 (2007) variant, in 2010 all the ORF 2 sequences corresponded to the GII.4 (2012-like) variant and in 2012 all the ORF 2 sequences corresponded to the GII.4 (2012) variant, the GII.4 (2012-like) variant, or the GII.4 (2009-like) variant. The evidence indicated that the development of the 2012 GII.e epidemic strains was due to evolutionary change rather than a novel recombination event. The results also support the notion that ORF 1 is critical in determining the virulence of a norovirus strain.

Four centuries of change in northeastern United States forests.

The northeastern United States is a predominately-forested region that, like most of the eastern U.S., has undergone a 400-year history of intense logging, land clearance for agriculture, and natural reforestation. This setting affords the opportunity to address a major ecological question: How similar are today's forests to those existing prior to European colonization? Working throughout a nine-state region spanning Maine to Pennsylvania, we assembled a comprehensive database of archival land-survey records describing the forests at the time of European colonization. We compared these records to modern forest inventory data and described: (1) the magnitude and attributes of forest compositional change, (2) the geography of change, and (3) the relationships between change and environmental factors and historical land use. We found that with few exceptions, notably the American chestnut, the same taxa that made up the pre-colonial forest still comprise the forest today, despite ample opportunities for species invasion and loss. Nonetheless, there have been dramatic shifts in the relative abundance of forest taxa. The magnitude of change is spatially clustered at local scales (<125 km) but exhibits little evidence of regional-scale gradients. Compositional change is most strongly associated with the historical extent of agricultural clearing. Throughout the region, there has been a broad ecological shift away from late successional taxa, such as beech and hemlock, in favor of early- and mid-successional taxa, such as red maple and poplar. Additionally, the modern forest composition is more homogeneous and less coupled to local climatic controls.

Novel NaPi-IIc mutations causing HHRH and idiopathic hypercalciuria in several unrelated families: long-term follow-up in one kindred.

Homozygous and compound heterozygous mutations in SLC34A3, the gene encoding the sodium-dependent co-transporter NaPi-IIc, cause hereditary hypophosphatemic rickets with hypercalciuria (HHRH), a disorder characterized by renal phosphate-wasting resulting in hypophosphatemia, elevated 1,25(OH)(2) vitamin D levels, hypercalciuria, rickets/osteomalacia, and frequently kidney stones or nephrocalcinosis. Similar albeit less severe biochemical changes are also observed in heterozygous carriers, which are furthermore indistinguishable from those encountered in idiopathic hypercalciuria (IH). We now searched for SLC34A3 mutations (exons and introns) in two previously not reported HHRH kindreds, which resulted in the identification of three novel mutations. The affected members of kindred A were compound heterozygous for two different mutations, c.1046_47del and the intronic mutation c.560+23_561-42del, while the index case in kindred B was homozygous for the nonsense SLC34A3 mutation c.1764C>G (p.Y588X). The patient in kindred C was diagnosed with IH because of bilateral medullary nephrocalcinosis, suppressed PTH levels, and hypercalciuria; she was found to have a novel heterozygous c.1571_1880del mutation. The HHRH patients in kindred A were treated for up to 7years with oral phosphate, which led to reversal of hypophosphatemia, hypercalciuria, and prevention or healing of the mild bone abnormalities. PTH levels were normal throughout the observation period, while 1,25(OH)(2) vitamin D levels remained elevated and may thus be helpful for assessing treatment efficacy and patient compliance in HHRH.

Obliquity-paced Pliocene West Antarctic ice sheet oscillations.

Thirty years after oxygen isotope records from microfossils deposited in ocean sediments confirmed the hypothesis that variations in the Earth's orbital geometry control the ice ages, fundamental questions remain over the response of the Antarctic ice sheets to orbital cycles. Furthermore, an understanding of the behaviour of the marine-based West Antarctic ice sheet (WAIS) during the 'warmer-than-present' early-Pliocene epoch ( approximately 5-3 Myr ago) is needed to better constrain the possible range of ice-sheet behaviour in the context of future global warming. Here we present a marine glacial record from the upper 600 m of the AND-1B sediment core recovered from beneath the northwest part of the Ross ice shelf by the ANDRILL programme and demonstrate well-dated, approximately 40-kyr cyclic variations in ice-sheet extent linked to cycles in insolation influenced by changes in the Earth's axial tilt (obliquity) during the Pliocene. Our data provide direct evidence for orbitally induced oscillations in the WAIS, which periodically collapsed, resulting in a switch from grounded ice, or ice shelves, to open waters in the Ross embayment when planetary temperatures were up to approximately 3 degrees C warmer than today and atmospheric CO(2) concentration was as high as approximately 400 p.p.m.v. (refs 5, 6). The evidence is consistent with a new ice-sheet/ice-shelf model that simulates fluctuations in Antarctic ice volume of up to +7 m in equivalent sea level associated with the loss of the WAIS and up to +3 m in equivalent sea level from the East Antarctic ice sheet, in response to ocean-induced melting paced by obliquity. During interglacial times, diatomaceous sediments indicate high surface-water productivity, minimal summer sea ice and air temperatures above freezing, suggesting an additional influence of surface melt under conditions of elevated CO(2).

Histological evaluation of hyperpigmentation on female Filipino axillary skin.

Females in South East Asia (Thailand, Indonesia and the Philippines) show concern about dark areas of skin which develop in their underarms, but little is known about the features differentiating pale and hyperpigmented axillary skin in the general population. To investigate this, a histology study was undertaken in the Philippines to define the aetiology of underarm darkening, which is postulated to be a mild form of postinflammatory hyperpigmentation (PIHP). Punch biopsies were taken from dark and light axillary skin sites of 20 female subjects, of whom seven had hyperpigmented underarms, based on an instrumental (Mexameter MX-18, Courage and Khazaka Electronic GmbH, Cologne, Germany) measure, and 13 had not. Histological and immunohistochemical analyses were undertaken using a range of stains and antibodies, including haematoxylin-eosin for general histopathology, Masson-Fontana for melanin, anti-CD68 for monocytes and macrophages, Van Gieson's technique for fibrosis, anti-proliferating cell nuclear antigen for cell mitosis, and the melanocyte-specific immunostains, anti-tyrosinase and anti-tyrosinase-related protein 1. In most cases, dark skin sites from hyperpigmented panelists had increased intensity of Masson-Fontana, anti-tyrosinase and/or anti-TRP1 staining, indicative of melanocyte stimulation and increased melanin production. Furthermore, hair plucking emerged as a key stimulus to increased pigmentation. The trauma of hair plucking slightly increased the number of infiltrating mononuclear cells and macrophages that ingested melanosomes leaking from the damaged epidermis, more so in the skin of hyperpigmented panelists; this, in turn, potentially increases pigmentation. However, cell infiltration was focal, mainly near the plucked follicles, and not indicative of diffuse inflammation. The results from this study support the hypothesis that axillary darkening is mild PIHP, characterized by increased epidermal melanin, following stimulation or mild irritation of skin, with hair plucking as a key factor in this process.

The effects of knowledge, attitudes, and significant others on decisions to enroll in a clinical trial on osteoporosis: implications for recruitment of older African-American women.

This preliminary study explored the roles of knowledge, attitudes, and significant others on decisions of older African-American women to enroll in a clinical trial involving estrogen and osteoporosis. Sixteen older African-American women (average age 75 years) participated in three focus groups. Twelve of the women had enrolled in the clinical trial and four, although eligible, refused to enroll. Discussions revealed that knowledge of osteoporosis and estrogen and expectations of personal rewards and group benefits from medical research appear to differentiate the women who participated in the clinical trial from those who refused. The women who participated also perceived the research institution as accessible. In addition, assuring full disclosure of testing procedures and test results eased their apprehensions about participation. However, the women who refused to enroll saw no personal benefit and were unwilling to expose themselves, in part because of their age, to the risks of taking estrogen and the uncertain outcomes of the clinical trial. The study illustrates how focus groups can be used to develop multiple strategies to enable recruitment of older African-American women with different demographic characteristics, levels of knowledge, and attitudes toward a disease and medical research.

The health of a group of young Australians in a New South Wales juvenile justice detention centre: a pilot study.

OBJECTIVE: To consider the health profile of a sample of young, largely male Australians as assessed on their admission to a New South Wales Juvenile Justice Detention Centre. METHOD: A retrospective analysis of primary care nurse health records for 100 sequential admissions. RESULTS: Of the 97 males and three females (mean age = 15.9 years), 30 were Aboriginal and 39 did not live with either parent at the time of admission. Respiratory illness, such as bronchitis and asthma were common. These diagnoses were overshadowed by histories of significant physical injury. The sample was at high risk of sexually transmitted disease. Forty-six per cent had prior contact with a mental health professional, 26% reported they had thought of suicide and 9% reported having attempted suicide. There was a high prevalence of substance abuse. CONCLUSION: The health of these young Australians is at risk from every perspective. Improving the quality of their health assessments is an important issue for the clinicians who attend them as individuals and for policy makers who aim to reduce the considerable social and economic cost of juvenile crime. The discussion of these results from one centre has revealed opportunities to make such improvements. There is a need for a gathering of expertise to address the issue, preferably on a national basis.

Neuropsychological Dysfunction in HIV Infection:A Review.

FIfty-six studies which used neuropsychological tests to investigate areas of function affected by central nervous system dysfunction in HIV were reviewed. Only studies which compared the performance of HIV + subjects to HIV - controls using analysis of variance techniques were included. The results are examined in terms of broad neuropsychological function domains, and are examined separately for asymptomatic and symptomatic subjects. Studies which did and did not find significant differences between HIV + and HIV - subjects were compared in terms of various confounding factors such as risk groups, number of tests, sample size and subject characteristics. There was evidence for some dysfunction among subjects who are otherwise asymptomatic in the areas of verbal memory (27% of studies), executive function (43%), motor performance (20%) and information processing (44%). Studies of subjects with more advanced HIV infection showed consistent evidence of abnormal functioning in the areas of verbal (48% of studies) and visual memory (43%), executive functioning (71%), complex attention (62%), motor performance (37%) and information processing (69%). These deficits occurred prior to the onset of clinically apparent dementia. There were no consistent significant differences between studies which did and did not find significant differences between HIV + and HIV - subjects in terms of most of the confounding variables investigated, although studies of ASX subjects were more likely to find differences between HIV + subjects and controls with larger neuropsychological test battereies. However, much of the variation in results due to the neuropsychological tests used. In many cases, tests which relied on functions with a frontal lobe component were more likely to find significant results.