Mobile HIV testing in South Africa: maximizing yield through data-guided site selection.

BACKGROUND: Mobile community HIV testing can effectively reach undiagnosed people living with HIV in southern Africa. Variable yield in HIV test positivity has been a challenge with high- and low-yield sites often being closely situated. We sought to test whether easy-to-identify, site-level characteristics were associated with HIV positivity yield in a routine mobile HIV testing program. METHODS: We used routine testing program test data augmented with site-level characterization, either of the community or shopping site at which HIV testing was offered. Specifically, we described the local environment and interviewed key informants to gain additional information regarding the availability of HIV and other services in the locale. RESULTS: We included 122 residential and 26 shopping sites with median HIV-positive test yields of 7.6% and 6.9%, respectively. The range for community sites was from 2 to 55% with high and low yields at geographically proximal sites. Factors related to lower income and marginalization, including informal housing and the absence of name-brand stores in shopping venues, were associated with higher HIV-positive testing yield. CONCLUSIONS: Characterization of sites, particularly identifying factors related to marginalization, lack of services, and poverty, can aid in identifying sites with higher HIV-positive yield.

CONTEXTE: Le dépistage communautaire mobile du VIH est un moyen efficace pour atteindre les personnes vivant avec le VIH non diagnostiquées en Afrique australe. Les taux de positivité variables aux tests de dépistage du VIH constituent un défi puisque certains sites aux taux de positivité élevés sont souvent géographiquement proches de sites dont les taux de positivité sont faibles. Nous avons cherché à tester si certaines caractéristiques faciles à identifier et propres aux sites étaient associées aux taux de positivité des tests de dépistage du VIH dans un programme de dépistage du VIH mobile systématique. MÉTHODES: Nous avons utilisé les données des tests du programme de dépistage systématique et procédé à une caractérisation des sites, soit de la communauté soit de la zone commerciale où le dépistage du VIH était proposé. Plus précisément, nous avons décrit l'environnement local et interrogé des informateurs clés afin d'obtenir des informations supplémentaires sur la disponibilité de services anti-VIH et autres dans cette zone. RÉSULTATS: Nous avons inclus 122 résidents et 26 zones commerciales avec un taux médian de positivité aux tests de dépistage du VIH de 7,6% et 6,9%, respectivement. L'étendue allait de 2% à 55% pour les sites communautaires, avec des taux de positivité faibles ou élevés dans des sites géographiquement proches. Les facteurs liés à de faibles revenus et à une marginalisation (par ex., logement informel et absence de magasins de marque dans les zones commerciales) étaient associés à de plus forts taux de positivité aux tests de dépistage du VIH. CONCLUSIONS: La caractérisation des sites, notamment l'identification des facteurs liés à la marginalisation, au manque de services et à la pauvreté, peut aider à identifier les sites où les taux de positivité aux tests de dépistage du VIH sont plus élevés.

Arizona Ridge-nosed rattlesnake envenomation: Case report of a personal encounter with the official state reptile of Arizona, Crotalus willardi willardi.

This case report describes the effects of an envenomation from one of the most infrequently encountered species of rattlesnake in the United States, Crotalus willardi willardi (C. w. willardi), the Arizona Ridge-nosed Rattlesnake. A previously healthy 57-year-old male sustained a bite to his non-dominant hand from a C. w. willardi. The most pronounced effect from the envenomation was edema and progression of edema that extended from his hand to the mid bicep. He also experienced erythema and tenderness to palpation in the affected limb, and some diminished range of motion in the hand. He expressed only minimal pain. Other than a mildly positive D-Dimer and leukocytosis, he had no significant hematologic effects and no systemic effects. He was treated with standard doses of Crotalidae Polyvalent Immune Fab (Ovine). He reported complete recovery from the envenomation within three days of the bite. Although envenomation from rattlesnakes is somewhat common in Arizona, knowing the exact species of snake is not. Confirmed documentation is exceedingly rare as most people do not recognize the different rattlesnake species. In addition, some species of rattlesnake (such as C. w. willardi) are especially reclusive and found only in isolated mountainous regions. Being able to confirm an envenomation by C. w. willardi would require not only someone knowledgeable in herpetology, but also, preferably, photographic evidence. This case has both.

Effect of hyaluronic acid solution on healing of bowel anastomoses.

Hyaluronic acid (HA) solution has the ability to coat and lubricate serosal surfaces, and potentially prevent serosal trauma during surgery, which can result in the postoperative formation of adhesions in the abdomen. Previous animal studies utilizing HA have shown a reduction of intra-abdominal adhesion formation. Human clinical trials are currently underway. The prevention of adhesions could conceivably have deleterious effects on bowel anastomosis healing. As a result, solutions of HA were studied in rabbits to determine their effect on the healing of a bowel anastomosis. In 30 rabbits, test solutions of either HA (0.4 or 1.0%) or phosphate-buffered saline (PBS) as a control were instilled into the open peritoneal cavity just prior to the performance of small bowel anastomosis. At sacrifice 14 days later, intestinal bursting pressures were 110.5 +/- 16.0 mm Hg (SEM) in the PBS group, 108.5 +/- 15.2 mm Hg in the 0.4% HA group, and 138.7 +/- 14.1 mm Hg in the 1.0% group. Average bursting pressures among the three groups did not vary significantly (p > .05). Small sterile mucoceles formed at the anastomosis in 70% of the PBS group, in 10% of the 0.4% HA group, and in 30% of the 1.0% HA group. Histologic examination of specimens taken at the anastomosis did not reveal any differences in the level of healing between groups. HA solution, when instilled in the presence of a small bowel anastomosis in rabbits, does not appear to interfere with the healing process.

Diseases, parasites and survival of coyotes in south-central Georgia.

Serologic testing, radio-telemetry and post-mortem diagnostic evaluations were used to investigate survival and causes of mortality among 17 coyotes (Canis latrans) in south-central Georgia (USA). Prevalence of canine heartworm (Dirofilaria immitis) microfilariae was lower (P = 0.057) among fall-captured (22%) than among winter-captured (75%) coyotes. Prevalence of heartworm was higher among adults than juveniles in the fall, but no significant difference was detected between animals captured in winter. Antibodies were found against canine parvovirus (65%), canine parainfluenza virus (59%), infectious canine hepatitis virus (41%), and Toxoplasma gondii (18%). Antibodies were not found to Brucella canis, canine coronavirus, five serovars of Leptospira interrogans, or canine distemper virus. Seroprevalence of canine parvovirus was lower (P = 0.009) among fall-captured animals (33%) than winter-captured animals (100%). The Kaplan-Meier estimate of annual survival was 0.500 for all animals. Juvenile survival did not differ (P = 0.79) from adult survival, but male survival (S = 0.217) was lower (P = 0.11) than female survival (S = 0.804). Two of nine (22%) mortalities were human-caused, one was due to concurrent canine parvovirus and canine distemper virus infections, one animal died of trauma, two were considered natural mortalities of unknown cause, and no cause of death could be determined for the remaining three animals. Natural mortality may be significant for coyotes in south-central Georgia, although there was no apparent link between exposure to pathogens and the animals' subsequent fate in our small sample.

The effect of in-line microwave energy on blood: a potential modality for blood warming.

The treatment of hypothermia associated with hemorrhage, exposure, or intraoperative intervention continues to represent a challenge for trauma care teams. An innovative technique for combining microwave heating with continuous temperature monitoring into a feedback-controlled system for blood warming has been developed. The effect of microwave warming on the structure and function of blood was compared with that in nonheated controls. Erythrocyte structural integrity (hemolysis) was evaluated by comparing levels of lactate dehydrogenase (LDH), potassium (K+), and plasma hemoglobin (PHGB), and hematocrit (HCT) in heated and nonheated (control) samples of banked red blood cells. Hemoglobin function was evaluated in fresh blood by comparing the P50 and hemoglobin electrophoresis of experimental and control samples. Prewarming temperatures were 3 degrees or 23 degrees C; temperatures after warming were 35 degrees, 37 degrees, or 39 degrees C. The results reflect the percentage of changes for 84 heated and 24 unheated blood samples. There were no statistical differences in any of the biochemical variables measured. The P50 for three heated and three unheated samples was 30.7 +/- 1.2 and 30.5 +/- 0.9 mm Hg (p greater than 0.05). There were no changes in the hemoglobin electrophoretic patterns in experimental or control samples. This system is designed to deliver microwave energy in a uniform and controlled manner, overcoming the limitations of conventional microwave ovens that in the past caused local overheating and subsequent hemolysis when used for blood warming. The structural and functional integrity of erythrocytes after microwave warming indicate the safety and effectiveness of this technique.

Mechanisms of osteoporosis in adult and adolescent women with anorexia nervosa.

Osteoporosis is a known consequence of anorexia nervosa (AN) in adults, but the mechanism of bone loss is not established, and there have been no studies of bone mass in women developing AN before attaining peak bone mass. To investigate the causes of bone loss in AN and to determine the consequences of developing AN during adolescence on bone mass, we compared the effects of AN on cortical and trabecular bone in 26 women with AN (19 adults, 18-42 yr old, and 7 adolescents, 14.9-17.0 yr old) using direct radial photon absorptiometry and both single and dual energy spinal computed tomography. The adult AN patients had marked spinal osteopenia [mean bone density, 120 +/- 28 (+/- SD) mg K2HPO4/cm3] compared with age-matched normal women (mean, 176 +/- 26 mg K2HPO4/cm3; P = 0.0001), which was severe (greater than 2 SD below the normal mean) in 50% of patients. Adult AN patients with the onset of amenorrhea before age 18 yr had significantly (P = 0.04) lower spinal bone density than those developing amenorrhea later (mean, 103 +/- 25 vs. 129 +/- 25 mg K2HPO4/cm3) independent of other variables correlated with bone density (duration of amenorrhea or urinary cortisol excretion). We found a negative correlation between spinal bone density and duration of amenorrhea (P = 0.006; r = -0.53). To determine the contribution of endogenous cortisol excess to the pathogenesis of the osteoporosis, urinary cortisol was measured. Urinary cortisol/creatinine clearance was significantly (P = 0.001) higher in AN patients than in normal women (mean, 2.7 +/- 1.2 vs. 1.0 +/- 0.3 nmol/L) and was negatively correlated (P = 0.03; r = -0.43) with bone mass. We conclude that AN affects trabecular bone and that both the onset of AN before attainment of peak bone mass and prolonged duration of amenorrhea result in more severe osteopenia. In addition to the significant contribution of hypogonadism, the cortisol excess that occurs in AN patients may contribute to the development of osteoporosis in these patients.

Freeze-dried skin allografts. A human clinical and histological study.

Free gingival autografts still remain the most predictable method for creating attached gingiva. However, a need exists for sources of connective tissue other than the patient's own connective tissue. Yukna et al. have proposed freeze-dried skin (FDS) allografts as a substitute for gingival autografts. The purpose of the present study was to evaluate FDS allografts on humans, clinically and histologically. Ten FDS allografts and two free gingival (FG) autografts were performed on ten patients, two of them receiving both FDS and FG grafts. Clinical measurements were made before surgery, immediately after surgery and then 2 and 6 months after surgery. After 4 and 24 months, biopsies were performed on both FG and FDS grafts. Routine histologic staining was done. The results show a mean gain of attached gingiva of 0.32 mm with a range from 0 to 0.8 mm. Compared biopsies sections of FDS allografts and FG autografts show that the tissue obtained with the FDS allografts do not display the histomorphologic pattern of attached gingiva. The FDS allografts do not seem to represent a good substitute to free gingival autografts. However, they might be used successfully as a biological bandage.

Interdisciplinary collaboration: psychiatric medical backup in the outpatient clinic.

The provision of psychiatric medical backup to nonphysician therapists is currently an important issue in inpatient and outpatient practice. Like all team approaches, backup offers the possibility of increased efficiency, professional growth, and access to treatment. At the same time, the psychiatrist providing medical backup is confronted with practical and ethical dilemmas in meeting his or her responsibilities. The authors define the role of psychiatrist medical backup and propose a collaborative model for outpatient practice. Issues to be considered in the planning of backup arrangements are discussed. The importance of clear role definition and communication between collaborators is emphasized.

Electroconvulsive therapy in patients on anticoagulants.

Despite studies in the early literature showing that ECT may lead to CNS bleeding, it is unclear whether unmodified ECT increases the risk for hemorrhage in patients taking anticoagulants. The authors report two cases of depressed patients who required ECT while on coumarin derivatives. Both patients were switched to heparin. Heparin's short duration of action allowed temporary discontinuation 6-8 hours prior to each ECT with return of coagulation function close to normal when the stimulus was administered. No complications were observed in any of the patients. The authors believe that this technique minimizes any possible risks from ECT in patients on anticoagulants.

Clinical supervision of the initial interview: effects on patient care.

The authors raise the question of whether the directly supervised initial evaluation of outpatients by psychiatric residents influences the quality of patient care. The charts of 78 patients with direct supervision and 78 patients with traditional supervision were randomly selected for review four months after the initial interview. More than twice as many patients with direct supervision remained in active treatment or terminated after successful short-term treatment compared with traditionally supervised patients in the early intake period. Patients with direct supervision also received a less pathological diagnosis.

Mid-adult development and psychopathology.

The authors studied a group of 193 psychiatric outpatients with varying diagnoses and a comparison group of 136 nonpatients across nine measures: sense of self; feelings about marriage, sex, career, and leisure time; relationship to parents, friends, and children; and sense of time passing. They found significant differences between the groups at specific ages in the areas of sense of self, feelings about career and sex, and relationship to parents, children, and friends. They discuss these results with a view toward identifying and elucidating normal and pathological factors in the adult life cycle.

Discriminative effects of morphine in the squirrel monkey.

Squirrel monkeys were trained in a two-choice discrete trial avoidance task to discriminate between intramuscular injections of saline and 3.0 mg/kg of morphine. Morphine (0.1-10 mg/kg) produced a dose-related increase in the number of trials completed on the morphine-appropriate lever. The stimulus control produced by the discriminative effects of morphine met the following criteria for classification as a specific narcotic effect: 1) morphine-like stimulus control was produced by all other narcotic analgesics tested (fentanyl, oxymorphone, levorphanol, methadone and meperidine); 2) in so doing, these drugs spanned a 900-fold potency range relative to morphine; 3) stimulus control was blocked by the specific narcotic antagonist naloxone; and 4) stereospecificity was a requirement for stimulus control--levorphanol produced stimulus control equivalent to 3.0 mg/kg of mrophine but its optical isomer dextrorphan did not. The time course of the stimulus control produced by 3.0 mg/kg of morphine showed that the animals continued to respond on the morphine-appropriate lever up to 14 hours after morphine administration. In contrast, monkeys administered 0.01 mg/kg of fentanyl responded on the morphine lever for only as lone as 1/2 hour after fentanyl administration. Naloxone, d-amphetamine and pentobarbital all failed to substitute for morphine, Thus, this study has extended previous observations of the discriminative properties of morphine in rats by demonstrating that qualitatively similar data are produced in a second species, the squirrel monkey.