Estimated cost per HIV infection diagnosed through routine HIV testing offered in acute general medical admission units and general practice settings in England.

OBJECTIVES: Following national guidelines to expand HIV testing in high-prevalence areas in England, a number of pilot studies were conducted in acute general medical admission units (ACUs) and general practices (GPs) to assess the feasibility and acceptability of testing in these settings. The aim of this study was to estimate the cost per HIV infection diagnosed through routine HIV testing in these settings. METHODS: Resource use data from four 2009/2010 Department of Health pilot studies (two ACUs; two GPs) were analysed. Data from the pilots were validated and supplemented with information from other sources. We constructed possible scenarios to estimate the cost per test carried out through expanded HIV testing in ACUs and GPs, and the cost per diagnosis. RESULTS: In the pilots, cost per test ranged from £8.55 to £13.50, and offer time and patient uptake were 2 minutes and 90% in ACUs, and 5 minutes and 60% in GPs, respectively. In scenario analyses we fixed offer time, diagnostic test cost and uptake rate at 2 minutes, £6 and 80% for ACUs, and 5 minutes, £9.60 and 40% for GPs, respectively. The cost per new HIV diagnosis at a positivity of 2/1000 tests conducted was £3230 in ACUs and £7930 in GPs for tests performed by a Band 3 staff member, and £5940 in ACUs and £18 800 in GPs for tests performed by either hospital consultants or GPs. CONCLUSIONS: Expanded HIV testing may be more cost-efficient in ACUs than in GPs as a consequence of a shorter offer time, higher patient uptake, higher HIV positivity and lower diagnostic test costs. As cost per new HIV diagnosis reduces at higher HIV positivity, expanded HIV testing should be promoted in high HIV prevalence areas.

Evaluation of innovations in nursing practice: report and discussion.

AIM: To assess whether a pilot study conducted in the UK achieved its objective to reduce admissions to hospital and bed days in patients identified as suitable recipients of case management by community matrons. BACKGROUND: The Department of Health has advocated the use of nurse-led case management to improve the coordination of care and prevent inappropriate hospital admissions. METHOD: 66 patients and another 66 controls were identified for the 'Evercare' caseload according to criteria set by United Healthcare. Admissions data for the six months after entry into the study were collected from the hospital information system. FINDINGS: admission rates in both the control and intervention group decreased over time and there was no significant difference in rates between the two groups at six months. There was no demonstrable effect on length of stay either. Users were satisfied with the service and nurses cited several clinical stories implying benefits for individual patients.

The challenges and conflictsof facilitating learning in practice: the experiences of two clinical nurse educators.

This is a descriptive paper discussing the experiences of two clinical educators in practice.It highlights some of the practice issues around accountability, advocacy and roleconflicts in clinical teaching roles. The issue of training nurses fit for pr actice giventhe recommendations of Fitness for Practice (UKCC 1999) and Making a Difference (Department of Health 1999) is discussed within the context of the reality of the clinical environment. The number of learners in the clinical area has increased in the last fewyears, and will continue to do so with the increase in nurses promised by t he NHS Planand new initiatives to attract nurses back into the profession. As a result of this the clinical environment, already stretched with service demands, requires additional support to facilitate the development of learners. Recommendations are m ade for the future of generic practice facilitative roles in the light of the current debate to get nurse educators back into practice.

Conservative management of ovarian cysts in pregnancy during third trimester and intrapartum.

We treated two patients with large ovarian cysts in pregnancy conservatively. In both cases, aspiration of the cysts under ultrasound guidance allowed successful vaginal delivery. In one case, the cyst fluid reaccumulated, and required further aspiration in labour. In both cases, benign ovarian cysts were removed laparoscopically at a later date. Various strategies for dealing with ovarian cysts in pregnancy are discussed.

Increased platelet volume and aggregation precede the onset of preeclampsia.

OBJECTIVE: To determine whether changes in platelet aggregation, numbers, or mean volume precede the onset of preeclampsia in patients given anti-platelet therapy. METHODS: Changes in platelet aggregation, numbers, and volumes were followed longitudinally in 17 women who had previously lost 44 of 56 pregnancies and were thus considered to be at risk of preeclampsia. The subjects were treated with low-dose aspirin. Mean platelet volume, platelet numbers, and platelet aggregation were monitored every 2-4 weeks during pregnancy. RESULTS: All eight subjects who developed preeclampsia delivered growth-retarded infants before term. All showed increased platelet aggregation in vitro, accompanied by increased platelet volumes (by at least 0.8 fL) and decreased platelet numbers (by at least 60 x 10(9)/L) in five subjects, increased volumes alone in one, and decreased numbers alone in one. The increases in platelet aggregation and volumes predated the development of preeclampsia by 2-5 weeks. Nine subjects had pregnancies that progressed normally to term (beyond 37 weeks), with the delivery of eight normal and one growth-retarded infant; platelet aggregation, numbers, and volumes did not change to the same extent as in the subjects who developed preeclampsia. CONCLUSION: Increased mean platelet volume and increased platelet aggregation compared to the individual patient's first-trimester data were detected 2-5 weeks before the development of all cases of preeclampsia. In contrast, normal pregnancies did not show significant changes in mean platelet volume or platelet aggregation.

Detection of antibodies to Herpesvirus simiae and Herpesvirus hominis in nonhuman primates.

Sera from nonhuman primates, predominantly Macaca species, were assayed by a serum neutralization test for antibodies to antigenically related Herpesvirus simiae (B virus) and Herpesvirus hominis type 1. The data indicate that there would have been approximately 50% error in the diagnosis of Herpesvirus simiae infection if these sera had been tested only against Herpesvirus hominis antigen. The role of active guinea pig complement in the serum neutralization test was also evaluated and found to be required by many of the sera for reproducible and enhanced virus neutralization, particularly for B virus antibody determination. A plaque reduction assay was found to be highly sensitive, especially when complement (2.5-5.0 hemolytic units) was added, but impractical for large-scale serum surveys.

Biotransformation of xenobiotics in human intestinal mucosa.

Drug-metabolizing enzymes, especially monooxygenases, play a major role in biotransformation and detoxification of many foreign compounds including environmental carcinogens. Although largely localized in the liver they are also found in the small intestine, which is the portal of entry of dietary toxins. Therefore cytochrome P-450 content as well as monooxygenase (7-ethoxycoumarin O-deethylase) and NADPH-cytochrome c reductase activities were determined in surgical specimens of the human small intestine and in jejunal biopsy material obtained from patients by use of a hydraulic biopsy instrument. Microsomes were prepared from surgical material; these ranged in P-450 content from 30 to 120 pmole/mg protein and in monooxygenase activity from 60 to 110 pmole/min-mg protein. In the 20,000g supernatant of the homogenized biopsy material, monooxygenase activity was undetectable in patients who had total villous atrophy, and low enzyme rates were found when the mucosa showed a partial villous atrophy. The mucosal monooxygenase activity of patients with normal jejunal histology and steatorrhea was significantly higher than in mucosa with villous atrophy but was only half of that observed in normal controls. These eight control patients had normal histology and no malassimilation. Our results suggest that monooxygenase activity in the human small intestine is dependent on the morphological integrity of the mucosa and that in normal mucosa the enzyme rates are reduced when malassimilation is present.

Serodiagnosis of herpesvirus infection in primates.

The presence of herpesviruses in various animal tissues used for vaccine production is of importance, inasmuch as these viruses may go unrecognized, residing in latent form. Of greatest concern is Herpesvirus simiae (B virus) present in the majority of macaca species, one of the more extensively used laboratory nonhuman primates. The close antigenic relationship of B virus to human herpes strains (H. hominis) and SA8 (a baboon herpesvirus) makes serologic differentiation extremely difficult, but necessary. Complicating the differential diagnosis is the frequent infection of simian species with human strains. The present study clearly shows that many animal sera negative to herpes simplex will be negative to B virus in the neutralization test. However, a sufficient number of sera will be negative to simplex, but positive to B virus, indicating that the assumed one-way cross is invalid. Also, if antibody to simplex is present, and this antibody is present in most adult macaques, then differentiation requires testing with B virus. At least 50% of these positive sera may appear to be negative for B virus if only tested with H. hominis. Approximately 25% of the remaining positive sera will have higher titers to B virus than to herpes simplex and 25% will have the same titers to both viruses. Further, complement is required by many of the test sera to detect the presence of antibodies to B virus.

Cell DNA replication as a function in the synthesis of human cytomegalovirus.

The rate of virus and cell DNA synthesis was studied in human embryonic lung cells pre-treated with 5-iodo-2'-deoxyuridine (IdUrd) and exposed to cytomegalovirus (CMV) or medium. Analysis of DNA in CMV-infected cells following sequential 4 h pulses with 3H-thymidine indicated that a temporal relationship existed in the pattern of virus and cell DNA synthesis. The pattern of DNA replication in infected cells resembled that of a typical cell cycle, whereas the rate of cell DNA synthesis in uninfected cells remained low throughout the study. Increased rates of cell and virus DNA synthesis began concomitantly at 16 h post-infection and reached a maximum at 36 h post-infection. The rate of DNA synthesis then declined and remained at lower levels until 48 h post-infection. This was subsequently followed by a second increase in the rate of cell and virus DNA synthesis. The rates of cell and virus DNA replication were similar throughout the study in that increased and decreased rates of synthesis occurred simultaneously. It was of interest to note that CMV induced cell DNA replication in IDUrd arrested cells; in contrast, addition of fresh serum did not induce a similar increase in the rate of DNA synthesis in IdUrd arrested, but uninfected, cells.

Doctors' career choice: previous research and its relevance for policy-making.

During the last 10 years, a good deal of interest has been shown by both researchers and policy-makers in the factors which determine doctors' choice of specialty. In this sense 'specialty' includes not only the hospital specialties but general practice and occupational and community health. This interest has arisen in part from the problems of geographical and inter-specialty maldistribution which have persisted since the inception of the Health Service. As plans for increasing the total numbers of British doctors begin to be put into effect, the attention of medical manpower planners may well be more sharply focused on ways of ensuring that this increased supply is used in the best possible way.