Dermatite alérgica à picada de Culicoides em muar: relato de caso / Allergic dermatitis due to bite of Culicoides in muar: case report

A dermatite alérgica à picada de ectoparasitos é uma enfermidade alergoparasitária bastante comum entre animais domésticos, sendo relatada principalmente em pequenos ruminantes e em animais de companhia. Contudo, a doença é pouco diagnosticada na clínica de equídeos devido a similaridades nosológicas com outras dermatopatias. Objetivou-se, com este relato de caso, descrever a síndrome clínica, o plano diagnóstico e a conduta terapêutica de um muar acometido por essa enfermidade. Atendeu-se, no Hospital Veterinário da Universidade Federal Rural do Pernambuco, uma mula de oito anos de idade, que apresentava lesões cutâneas pápulo-crostosas e pruriginosas com evolução clínica de dois anos. Em três situações anteriores, a doença havia sido tratada como dermatite fúngica por outros médicos veterinários. Para o diagnóstico, foram solicitados exame citopatológico e parasitológico de pele, cultivo bacteriológico e fúngico, análise histopatológica e hemograma. Os exames demonstraram uma dermatite superficial perivascular eosinofílica crônica, sendo indicada a terapia tópica com dimetilsufóxido, sulfadiazina, ureia e vitamina A. O protocolo terapêutico mostrou-se satisfatório, permitindo completa remissão do quadro clínico. Este trabalho relatou achados clínicos e patológicos da dermatite alérgica à picada de Culicoides spp. em muar, além de alertar sobre a importância de exames complementares para a realização do diagnóstico diferencial e para o direcionamento terapêutico adequado.(AU)

Allergic dermatitis to ectoparasite bites is a common parasitic disease among domestic animals, being reported mainly in small ruminants and companion animals. However, the disease is poorly diagnosed in equine clinics due to nosological similarities with other skin diseases. The aim of this case report was to describe the clinical syndrome, the diagnostic plan and the therapeutic management of a mule affected by this disease. An 8-year-old mule was observed at Universidade Federal Rural de Pernambuco, presenting papular-crusted and pruritic cutaneous lesions with clinical evolution of two years. In three previous situations, the disease had been treated as fungal dermatitis by other veterinarians. For the diagnosis, cytopathological and parasitological examination of the skin, bacteriological and fungal culture, histopathological analysis and blood count were performed. The exams showed a chronic eosinophilic perivascular superficial dermatitis. A topical therapy with dimethyl sulfoxide, sulfadiazine, urea, and vitamin A was indicated. The therapeutic protocol was satisfactory, allowing complete remission of the clinical condition. This work reported clinical and pathological findings of allergic dermatitis to the bites of Culicoides spp. in muar, in addition to alerting about the importance of complementary examinations for the accomplishment of the differential diagnosis and adequate therapeutic orientation.(AU)

Evaluation of the impact and acceptance of a nutrition program in an HIV community clinic.

The present paper describes the evaluation of a nutrition service and research model for human immunodeficiency virus (HIV)-positive clients within a community based HIV acquired immune deficiency syndrome (AIDS) medical clinic. This program was designed to develop an effective, practical, replicable model for the delivery of nutrition services in the ambulatory HIV care setting. The objectives of evaluating the model were to define the ways that nutrition services in HIV/AIDS impacted clients, the clinic, and referral sources, and to continually refine the model by determining what services provide greatest benefit to clients, especially in view of the changing landscape of HIV therapy. Four evaluation activities completed during the study period of 5 years are described. These included a focus group and semistructured interview with clients, a semistructured interview with workers from the local network of service referral agencies and a client satisfaction survey at study "close-out." These evaluation processes confirmed or prompted programmatic modifications that improved access, confidentiality, and the relevance of specific components for clients. Providers/stakeholder's concerns were addressed through more frequent communication about clients' specific nutrition issues, clearer and easier referral and cooperation in recruiting patients. Also, the evaluation activities provided a platform for the communication of general and specific information about the program and for outreach. Although clients' and workers' priorities differed in some details of program implementation, there was strong agreement on the value of addressing nutrition concerns in HIV. Favorable feedback about the program gave impetus to continue nutrition services in the clinic after the project period ended and supports its application in other sites and settings.

Satisfaction with services in innovative managed care programs for groups of traditionally underserved individuals with HIV/AIDS: empirical models.

As the number of people with HIV/AIDS receiving services in managed care models increases, concerns over quality of care and satisfaction with services have grown. This article examined data from three national demonstration projects that were funded to enroll traditionally underserved individuals and provide innovative medical services in programs developing models appropriate for managed care funding. Assessments of patient satisfaction were related to indicators of traditionally underserved status including demographic characteristics, behaviors, and other risk factors using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Overall patient satisfaction levels with these programs were very high. Through the modeling methods, the groups most likely to experience the greatest program satisfaction are identified. In general, all groups were highly satisfied with the programs.

Perceived barriers to receiving HIV services in groups of traditionally underserved individuals: empirical models.

Persons living with HIV/AIDS face many issues that make them highly vulnerable to a number of health and social problems. As the demographics of the epidemic have shifted in recent years, many members of traditionally underserved groups have encountered barriers to entering the services system. This article uses data from seven national demonstration projects funded to enroll persons with HIV/AIDS who tend to "fall through the cracks" and help them access needed services. Data on the initial perceptions of the participants about barriers to accessing services were related to 17 indicators of traditionally underserved status including demographic characteristics and behavioral variables using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through the modeling methods, the groups most likely to experience a large number of barriers to service participation are identified. Having children needing care is particularly predictive of the level of barriers to care.

Unmet needs in groups of traditionally underserved individuals with HIV/AIDS: empirical models.

Over the course of the HIV epidemic, the demographics of the populations of affected individuals have changed. Groups that traditionally have been underserved in systems of care have a number of unmet service needs. This article presents results based on data from 478 patients in five national demonstration projects which were funded to enroll individuals from traditionally underserved groups and to help them access services using different strategies. The participants in these programs had a high level of unmet need prior to enrolling in care. Data on client service needs were related to 17 indicators of traditionally underserved status including demographic characteristics and risk behaviors, using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Crack cocaine users with HIV/AIDS were more likely than other patient groups to have unmet service needs. Patients who were homeless or in precarious housing also were vulnerable. Results are discussed in terms of designing and evaluating innovative service models to close these service gaps.

Finding the underserved: directions for HIV care in the future.

The demographic, behavior, and background characteristics of 4,804 participants in 17 national demonstration projects for HIV medical and/or psychosocial support services were coded for an index of "service need" or possible under-representation in the traditional healthcare system. Fifteen items were coded including status as a person of color, lack of private insurance, unemployment/disability, problem drinking, crack cocaine use, heroin use, other illicit drug use, less than 12 years of education, criminal justice system involvement, children requiring care while the patient receives services, sex work, being the sex partner of an injection drug user, unstable housing, primary language not English, and age less than 21 or over 55 years. Most (87.7%) of the program participants had four or more of these factors present. Through CHAID modeling, those groups with the highest levels of service need and vulnerability were identified. These data suggest that these projects, designed to attract and serve individuals potentially underrepresented in the health services system, had in fact achieved that goal. Implications of the changing demographics of the HIV epidemic for the health service delivery system are discussed.

Satisfaction with innovative community and university health clinic programs for groups of traditionally underserved individuals with HIV/AIDS: empirical models.

As the demographics of the populations of affected individuals have changed, systems of care have needed to adapt to be responsive to client needs. This article examines client satisfaction data from seven national demonstration projects funded to enroll individuals from traditionally underserved groups and help them access services using different strategies. Data on client satisfaction ratings were related to indicators of traditionally underserved status, including demographic characteristics, behaviors, and other risk factors using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Client groups that were most likely to experience relatively higher and lower levels of satisfaction with services are identified. Overall, all client groups were highly satisfied with the innovative HIV/AIDS services received. The findings illustrate the success of these innovative HIV care models in being responsive and sensitive to the needs of their target populations.

Key elements for implementing comprehensive health care models for persons with HIV: a stakeholder analysis.

A semistructured interview was conducted with 69 stakeholders in three university-based health care projects that were funded to provide an integrated continuum of care for persons living with HIV/AIDS. Data from the key informant interviews yielded composite indicators of familiarity with the service model, the importance of the elements in the service model, and the perceived quality of services provided by these innovative HIV service demonstration projects. Ratings of service quality were related to ratings of the respondent's knowledge of the service demonstration project, the importance of the various elements in the service continuum, and several indicators of stakeholder characteristics using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). The groups of stakeholders most likely to give the highest quality or success ratings for these projects are identified. The implications of these findings for developing collaborative and comprehensive service models for persons with HIV/AIDS are discussed.

Do characteristics of HIV/AIDS education and training affect perceived training quality? Lessons from the evaluation of seven projects.

Initial and continuing HIV/AIDS education and training has been a critical way to bring the nation's health providers up to date on emerging developments and approaches. This study reports cross-cutting findings from seven HIV/AIDS education and training projects. Trainers described over 600 training sessions from these projects in terms of their structural characteristics and design elements, while trainees described these sessions on several dimensions related to training quality. Training characteristics were compared to trainee assessments of training quality. Using a decision-tree analytic approach for major training attributes, considerable support emerged for links between training characteristics and perceived quality of the HIV/AIDS training experience. More favorable quality ratings were associated with certain projects, the training setting, the types of trainees served by the training, the intended training impact, discussion of special populations, and training methods involving interactive learning. With increased knowledge regarding how these educational experiences relate to the ways they are perceived and processed, more targeted approaches to training design on HIV/AIDS can be developed.

Service use patterns of youth with, and at high risk for, HIV: a care typology.

This paper uses confirmatory structural equation models to develop and test a theoretical model for understanding the service utilization history of 4679 youth who received services from 10 national HIV/AIDS demonstration models of youth-appropriate and youth-attractive services funded by the Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration. Although the projects differ from one another in the areas of emphasis in their service models, each is targeted to youth at high risk for HIV, or those youth who have already contracted HIV. Collectively, the projects represent a comprehensive adolescent HIV service model. This paper examines the characteristics of the services provided to young people ranging from outreach to intensive participation in medical treatment. Major typologies of service utilization are derived empirically through exploratory factor and cluster analysis methods. Confirmatory structural equation modeling methods are used to refine the exploratory results using a derivation and replication strategy and methods of statistical estimation appropriate for non-normally distributed service utilization indicators. The model hypothesizes that youth enter the service system through a general construct of connectedness to a comprehensive service model and through service-specific methods, primarily of outreach or emergency services. Estimates are made of the degree to which a comprehensive service model drives the services as opposed to specific service entry points.

Change in perceived barriers and facilitators to treatment among women with HIV/AIDS as a function of psychosocial service utilization.

Using a repeated assessment of 185 women with HIV in three national service demonstration projects that focus on reducing barriers to care, self-reported barriers to obtaining services decreased significantly over time. At the earliest time asked, participants scored an average of 5.23 on a measure of barriers to obtaining care. At the most recent time asked, they scored an average of 4.05 on the barrier measure. In a subsample of 122 women with HIV, it was found that self-reported facilitators to obtaining services increased significantly over time. At the first time asked, participants scored an average of 8.40 on a measure of facilitators to receiving services. At the most recent time asked, they scored an average of 8.98 on the facilitator measure. Results are discussed in terms of implications for designing services to minimize barriers and maximize facilitators to care for people living with HIV/AIDS.

Trainee characteristics and perceptions of HIV/AIDS training quality.

HIV/AIDS education and training have played a vital role in keeping health providers up to date on emerging developments and approaches. This study reports findings from seven HIV/AIDS education and training projects. Participants in more than 600 training sessions described themselves, their professional background, and their general reasons for taking the training. Immediately following the training, they also rated the quality of their educational experience along several dimensions. Trainee characteristics were related to assessments of training quality, using a regression decision-tree analytic approach. Although effect sizes were generally small, quality ratings of the HIV/AIDS training experiences were associated with certain projects, basic trainee demographic characteristics, professional background, and experience in the HIV field. Greater understanding about participant characteristics can provide clues about how these training experiences are perceived and processed and may inform decision making about instructional HIV/AIDS curricula.

Effects of HIV/AIDS education and training on patient care and provider practices: a cross-cutting evaluation.

Initial and continuing training in HIV/AIDS service provision is a critical way to enable the nation's health providers to use state-of-the-art developments and perspectives. Typically, the efficacy of HIV/AIDS training programs is evaluated using assessments administered to trainees immediately following the training. This study reports cross-cutting findings from telephone interviews conducted with 218 trainees an average of 8 months after training. Long-term training effects are examined in three domains: (a) general perspectives on HIV/AIDS; (b) health care provider service provision; and (c) changes in procedures and operations at the health care system level. The findings show the different ways that the training experience had long-term positive and observable effects in these three domains. In some cases, background characteristics and job positions predicted the specific type of reported training effects. The pattern of results suggests ways in which training methods can be targeted to specific audiences.

Predicting substance abuse among youth with, or at high risk for, HIV.

This article describes data from 4,111 males and 4,085 females participating in 10 HIV/AIDS service demonstration projects. The sample was diverse in age, gender, ethnicity, HIV status, and risk for HIV transmission. Logistic regression was used to determine the attributes that best predict substance abuse. Males who were younger; HIV positive; homeless; involved in the criminal justice system; had a sexually transmitted disease (STD); engaged in survival sex; and participated in risky sex with men, women, and drug injectors were most likely to have a substance abuse history. For females, the same predictors were significant, with the exception of having an STD. Odds ratios as high as 6 to 1 were associated with the predictors. Information about sexual and other risk factors also was highly predictive of substance abuse issues among youth.

Women's steps of change and entry into drug abuse treatment. A multidimensional stages of change model.

The Transtheoretical, or Stages of Change Model, has been applied to the investigation of help-seeking related to a number of addictive behaviors. Overall, the model has shown to be very important in understanding the process of help-seeking. However, substance abuse rarely exists in isolation from other health, mental health, and social problems. The present work extends the original Stages of Change Model by proposing "Steps of Change" as they relate to entry into substance abuse treatment programs for women. Readiness to make life changes in four domains-domestic violence, HIV sexual risk behavior, substance abuse, and mental health-is examined in relation to entry into four substance abuse treatment modalities (12-step, detoxification, outpatient, and residential). The Steps of Change Model hypothesizes that help-seeking behavior of substance-abusing women may reflect a hierarchy of readiness based on the immediacy, or time urgency, of their treatment issues. For example, women in battering relationships may be ready to make changes to reduce their exposure to violence before admitting readiness to seek substance abuse treatment. The Steps of Change Model was examined in a sample of 451 women contacted through a substance abuse treatment-readiness program in Los Angeles, California. A series of logistic regression analyses predict entry into four separate treatment modalities that vary. Results suggest a multidimensional Stages of Change Model that may extend to other populations and to other types of help-seeking behaviors.

Healthcare provider characteristics and perceived confidence from HIV/AIDS education.

This study reports findings from six training projects designed to keep health providers up-to-date on emerging developments and approaches in HIV/AIDS care. Participants were 3,779 individuals who described themselves, their professional background, and their specific experience in the HIV/AIDS field. These characteristics were compared with their self-reported confidence in managing clients, counseling clients, providing services, and the training topics. A repeated-measures design examining level and change of confidence showed little support for links between provider characteristics and confidence due to HIV/AIDS training experience. Thus, knowing a provider's background does not necessarily provide diagnostic information about who might most benefit in improved confidence from HIV/AIDS educational training. These results suggest that HIV/AIDS training programs may be targeted broadly-to a wide range of healthcare providers of diverse backgrounds-with little or no impact on overall levels and changes in provider confidence.