Diabetes UK funded surveys of the structural provision of primary care diabetes services in the UK

AIM

To describe diabetes service provision in primary care in the UK.

METHODS

Postal questionnaires were sent to all UK primary care organizations (PCOs), and to a sample of general practices in England and all practices in Wales and Scotland. The data collection period ended on 30 April 2001.

RESULTS

Seventy-nine per cent of the PCOs and 40% of the practices provided usable information. There is evidence that respondents were not significantly biased in relation to their interest in diabetes care. Diabetes was included as a Health Improvement Programme (or equivalent) priority by 62% of PCOs and had been identified as a clinical governance priority by 27%. Sixty-five per cent had information about the ethnic composition of their general population, 57% had an estimate of the number of people with diabetes. Sixty-nine per cent had a local diabetes register but this was said to cover the entire local population in only 64% of these. At least one audit of diabetes care had been carried out (in the previous 5 years) in 75% and, in 76%, clinical guidelines on diabetes care were made available to practices. In the practices, 80% had a designated lead person for diabetes. Seventy-three per cent had at least one general practitioner with a special interest and 87% at least one nurse. Seventy-two per cent of practices ran specific diabetes clinics and 51% had a screening policy. Eighty-six per cent considered that they had adequate systems in place for the delivery of diabetes care. However, only 6% were able to offer a dedicated diabetes telephone help or advice line and only 9% an evening out of hours clinic. Regular practice meetings were held to discuss diabetes in 35%, whereas 39% had a formal shared care protocol. Fourteen per cent held regular joint meetings with the hospital-based team and in 38% there was membership of Diabetes UK for at least one partner or the practice itself. A third (34%) of responding practices were unsure whether a Local Diabetes Services Advisory Group or equivalent existed in their area. Geographical differences in service provision were identified with, for example, practices in London having fewer components in place that were specifically related to the provision of diabetes care. Single-handed practices, wherever they were situated, had in place fewer staff and facilities specifically for diabetes care.

Changes in third ventricular size with neuroendoscopic third ventriculostomy: a blinded study

The objective was to study the relation between changes in cerebral ventricular size and clinical outcome after neuroendoscopic third ventriculostomy (NTV) in both primary (no previous surgery) and secondary (previous CSF diversion for hydrocephalus) NTV. Changes in ventricular size were related to the need for further surgery for CSF diversion. A blinded retrospective study of the pre-NTV and post-NTV sizes of the ventricles in an unselected series of patients undergoing this procedure was done. A decrease in third ventricular size was seen in significantly more patients in the primary group than in the secondary group. Median change in third ventricle width for those who did not require further CSF diversion was significantly greater than those with no clinical benefit (p=0.01). Positive predictive power for successful outcome was highest for measures of the third ventricle; 73% and 68% for third ventricle width and height respectively, 88% for anterior to posterior commissure distance. In conclusion, third ventricular size reduces after NTV. The use of such a change as an arbiter of success in this procedure is questionable as clinically successful cases can have no change in ventricular size. It is considered that clinical outcome is the most important guide to success or failure as reduction in ventricular size is by no means guaranteed. Radiological outcomes alone may be misleading and reliance on them should be avoided.

Dermatitis herpetiformis and neurological dysfunction

Dermatitis herpetiformis and coeliac disease are gluten sensitive diseases, which have common immunopathological and genetic mechanisms. Neuropsychiatric complications have been reported in up to 26% of patients with coeliac disease. This is probably an overestimate, because of the chance associations with some common neurological conditions such as epilepsy. The pathogenesis is speculative but it has been postulated that gluten is neurotoxic possibly via immune mechanisms. The frequency of neurological dysfunction in patients with dermatitis herpetiformis has not been characterised. Patients with dermatitis herpetiformis might be expected to be particularly susceptible to neuronal damage as some continue to consume gluten when their dermatological symptoms are controlled by dapsone. Thirty five patients were recruited with dermatitis herpetiformis from dermatology clinics at St Mary's Hospital, London and Queen's Medical Centre, Nottingham and investigated for evidence of neurological abnormality. All patients underwent a full neurological examination and were asked about their neurological and general medical history by means of a structured questionnaire. Serum samples were taken and screened for the presence of anti-neuronal antibodies (anti-Hu and Yo) as well as anti-gliadin (IgA and G) anti-endomysial (IgA), and anti-tissue transglutaminase (IgA) antibodies. Neurophysiological tests were carried out where appropriate. Only two patients were identified with unexplained neurological abnormalities (one essential tremor, and one chorea). Two other patients had a history of migraine. The patient with chorea also had borderline/equivocally positive anti-Hu antibodies by immunofluorescence assay. All other samples were negative for anti-neuronal antibodies. Fifteen patients were positive for anti-gliadin antibodies (IgA and/or IgG), four for anti-endomysial antibodies (monkey oesophagus or umbilical cord), and six for anti-tissue transglutaminase antibodies. The presence of these antibodies did not correlate with the presence of neurological abnormalities. No cases of "gluten ataxia" were identified. In conclusion, there was no convincing evidence for immune mediated neurological damage in this pilot study of dermatitis herpetiformis.

Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States

BACKGROUND

Little is known about the rates of Mycobacterium avium complex (MAC) and Pneumocystis carinii (PCP) prophylaxis adherence to guidelines and how they have changed after introduction of effective antiretroviral therapy.

OBJECTIVE

To determine rates of primary prophylaxis for MAC and PCP and to evaluate the influence of sociodemographic characteristics, region, and provider experience.

DESIGN

National probability sample cohort of HIV patients in care.

SETTING

One hundred sixty HIV health care providers.

PATIENTS

A total of 2864 patients interviewed in 1996 to 1997 (68% response) and 2267 follow-up interviews, representing 65% of surviving sampled patients (median follow-up, 15.1 months).

MEASUREMENTS

Use of prophylactic drugs, most recent CD4 count, sociodemographics, and regional and total HIV patients/providers.

RESULTS

Of patients eligible for primary MAC prophylaxis (most recent CD4 count <50/mm(3) ), 41% at baseline and 40% at follow-up patients were treated. Of patients eligible for primary PCP prophylaxis (i.e., those with CD4 counts <200/mm(3) ), 64% and 72% were treated, respectively. MAC prophylaxis at baseline was less likely in African American (adjusted odds ratio [OR], 35; 95% confidence interval [CI], 0.20-0.59), Hispanic (OR, 27; 95% CI, 0.08-0.94) and less-educated (OR, 0.61; 95% CI, 0.36-1.0) patients and more likely in U. S. geographic regions in the Pacific West (OR, 4.9; 95% CI, 1.0-23) and Midwest (OR, 6.4; 95% CI, 1.2-33) and in practices with more HIV patients.

CONCLUSIONS

Most eligible patients did not receive MAC prophylaxis; PCP prophylaxis rates were better but still suboptimal. Our results support outreach efforts to African Americans, Hispanics, the less educated, and those in the northeastern United States and in practices with fewer HIV patients.

Long-term predictors of coronary artery disease and mortality in type 1 diabetes

We assessed clinical and biochemical predictors of death and/or cardiovascular disease in 147 type 1 diabetes mellitus (DM) patients followed-up for 14 years. At follow-up, 28 of patients (19%) had died, and 25 patients (18%) had developed or died of coronary artery disease (CAD). At baseline, those who died had significantly higher serum creatinine (p=0.001) and urine albumin/creatinine ratio (p=0.016), greater prevalence of retinopathy (p=0.006), lower serum apolipoprotein A1 (p=0.046), and lower daily insulin dose (p=0.024) than those who survived. CAD patients had a longer duration of diabetes (p<0.001), were older at the onset of diabetes and at presentation (p=0.001), and had higher prevalences of retinopathy (p=0.005) and neuropathy (p=0.016). The CAD group also had higher baseline serum creatinine (p=0.02), lower HDL cholesterol (p=0.004) and apolipoprotein A1 (p=0.007) and higher LDL cholesterol (p=0.028) and apolipoprotein B concentrations (p=0.027). Under logistic regression analysis (adjusted for age and sex), baseline urine albumin/creatinine ratio (p=0.003), presence of retinopathy (p=0.004), serum creatinine (p=0.028), and serum urea (p=0.034) were the most powerful predictors of mortality, while duration of diabetes (p<0.0001), baseline HDL cholesterol (p=0.012), serum creatinine (p=0.02), apolipoprotein B (p=0.038), LDL cholesterol (p=0.039), and systolic blood pressure (p=0.055) were the strongest predictors of CAD. These findings emphasize the role of abnormal lipoprotein metabolism in the development of CAD in type 1 DM. Indicators of renal impairment and the presence of retinopathy seem to be of greater importance in predicting overall mortality.

Complete diagnostic evaluation in colorectal cancer screening: research design and baseline findings

BACKGROUND

While indicated by guidelines, complete diagnostic evaluation, or CDE (i.e., colonoscopy or combined flexible sigmoidoscopy plus barium enema X ray), is often not recommended and performed for persons with an abnormal screening fecal occult blood test (FOBT) result. We initiated a randomized trial to assess the impact of a physician-oriented intervention on CDE rates in primary care practices.

METHODS

In 1998, we identified 1,184 primary care physicians (PCPs) in 584 practices whose patients received FOBTs that are mailed annually by a managed care organization screening program. A total of 470 PCPs in 318 practices completed a baseline survey. Practices were randomly assigned either to a Control Group (N = 198) or to an Intervention Group (N = 120). Control Group practices received the screening program. Intervention Group practices received the screening program and the intervention (i.e., CDE reminder-feedback plus educational outreach). Practice CDE recommendation and performance rates are the primary outcomes to be measured in the study.

RESULTS

Baseline CDE recommendation and performance rates were low and were comparable in Control and Intervention Group practices (54 to 57% and 39 to 40%, respectively). PCPs in the practices tended to view FOBT screening and CDE favorably, but had concerns about screening efficacy, time involved in CDE, and patient discomfort and adherence. Control Group physicians were more likely than Intervention Group physicians to believe that a mail-out FOBT screening program helps in the practice of medicine.

CONCLUSIONS

We were able to enroll a high proportion of targeted primary care practices, measure practice characteristics and CDE rates at baseline, and develop and implement the intervention. Study outcome analyses will take into account baseline differences in practice characteristics.

Enhancing the specificity of the COBAS AMPLICOR CT/NG test for Neisseria gonorrhoeae by retesting specimens with equivocal results

The COBAS AMPLICOR CT/NG test for Neisseria gonorrhoeae cross-reacts with certain strains of nonpathogenic Neisseria species. In some strains, the target sequence is identical to that of N. gonorrhoeae, whereas other strains have a small number of mismatches within the regions recognized by the primers or probe used in the COBAS AMPLICOR NG test. These cross-reactive strains are occasionally present in urogenital specimens, causing false-positive results in the COBAS AMPLICOR NG test. Analysis of the data generated in a large multicenter clinical trial showed that 2.9% of the specimens gave signals between A(660)s of 0.2 and 3.5 but that one-half of these equivocal specimens did not contain N. gonorrhoeae. Most of these equivocal specimens were correctly classified as true positive or true negative by retesting in duplicate and defining a PCR-positive result as two of three results with an A(660) of > or =2.0. If specimens had been classified as positive or negative based on a single test result using a cutoff of an A(660) of 0.2, specificity would have ranged from 96.2 to 98.9% depending on specimen type, sex, and presence of symptoms. By employing the equivocal zone-retesting algorithm, specificity increased to 98.6 to 99.9% with little effect (0.1 to 4.9% decrease) on sensitivity in most specimen types, enabling the test to achieve a positive predictive value of at least 90% in populations with a prevalence of 4% or higher. In lower-prevalence populations, the test could be used to screen for presumptive infections that would have to be confirmed by an independent test.

Ventricular enlargement in multiple sclerosis: a comparison of three-dimensional and linear MRI estimates

Atrophy of central white matter is related to irreversible clinical disability in multiple sclerosis (MS) and ventricular enlargement may be a sensitive marker of this tissue loss. Therapeutic trials in MS have provided MRI data for investigation of cerebral atrophy in MS. These studies use almost exclusively two-dimensional (2-D) images, which may be limited in the assessment of three-dimensional (3-D) structures. We used 3-D MRI data to estimate ventricular volumes in 40 patients with MS and 10 healthy controls, to look at associations with clinical disability and the stage of the disease. We then compared simple linear measures of ventricular size from conventional 2-D images, with 3-D volume estimates to establish the best available linear indices of ventricular volume. Mean ventricular volumes were increased in the patients and significantly larger in the more disabled patients. The estimated volume of the third ventricle obtained from 3-D MRI showed the strongest association with the clinical stage of the disease, duration of symptoms and levels of disability. Finally, we confirmed that in patients with MS accurate data on ventricular size can be obtained from 2-D images by two simple and convenient linear measures, the width of the third ventricle and of the anterior horn of the lateral ventricle.

Communication between members of the cardiac arrest team--a postal survey

AIMS

Effective communication enhances team building and is perceived to improve the quality of team performance. A recent publication from the Resuscitation Council (UK) has highlighted this fact and recommended that cardiac arrest team members make contact daily. We wished to identify how often members of this team communicate prior to a cardiopulmonary arrest.

METHOD

A questionnaire on cardiac arrest team composition, leadership, communication and debriefing was distributed nationally to Resuscitation Training Officers (RTOs) and their responses analysed.

RESULTS

One hundred and thirty (55%) RTOs replied. Physicians and anaesthetists were the most prominent members of the team. The Medical Senior House Officer is usually nominated as the team leader. Eighty-seven centres (67%) have no communication between team members prior to attending a cardiopulmonary arrest. In 33%, communication occurs but is either informal or fortuitous. The RTOs felt that communication is important to enhance team dynamics and optimise task allocation. Only 7% achieve a formal debrief following a cardiac arrest.

CONCLUSION

Communication between members of the cardiac arrest team before and after a cardiac arrest is poor. Training and development of these skills may improve performance and should be prioritised. Team leadership does not necessarily reflect experience or training.

Allozyme polymorphism and variability in permethrin tolerance in British populations of the parthenogenetic stored product pest Liposcelis bostrychophila (Liposcelididae, Psocoptera)

Variability in allozyme patterns is demonstrated among 111 British populations of Liposcelis bostrychophila (Badonnel), an obligatory parthenogenetic liposcelid species that is a common domestic pest in the United Kingdom. In addition four tropical strains and a laboratory culture were included in the analysis. Permethrin toxicity was measured in a subset of the populations.Using cellulose acetate paper electrophoresis, 16 of 34 enzymes tested were found in the liposcelid material and, of these, four were polymorphic. A total of 47 distinct morphs were recognised. This enzyme variation appears to be random with respect to geography throughout the country.Permethrin tolerance was highly variable among populations. A significant relationship was demonstrated between the mean LC(50) for permethrin and latitude such that there appears to be higher levels of tolerance in southern, than in northern, Britain.No link could be established between the allozyme polymorphisms, particularly in the esterases, and permethrin tolerance.

Relationship between DNA methylation, histone H4 acetylation and gene expression in the mouse imprinted Igf2-H19 domain

DNA methylation and histone H4 acetylation play a role in gene regulation by modulating the structure of the chromatin. Recently, these two epigenetic modifications have dynamically and physically been linked. Evidence suggests that both modifications are involved in regulating imprinted genes - a subset of genes whose expression depends on their parental origin. Using immunoprecipitation assays, we investigate the relationship between DNA methylation, histone H4 acetylation and gene expression in the well-characterised imprinted Igf2-H19 domain on mouse chromosome 7. A systematic regional analysis of the acetylation status of the domain shows that parental-specific differences in acetylation of the core histone H4 are present in the promoter regions of both Igf2 and H19 genes, with the expressed alleles being more acetylated than the silent alleles. A correlation between DNA methylation, histone hypoacetylation and gene repression is evident only at the promoter region of the H19 gene. Treatment with trichostatin A, a specific inhibitor of histone deacetylase, reduces the expression of the active maternal H19 allele and this can be correlated with regional changes in acetylation within the upstream regulatory domain. The data suggest that histone H4 acetylation and DNA methylation have distinct functions on the maternal and paternal Igf2-H19 domains.

CT assessment of tumour response to treatment: comparison of linear, cross-sectional and volumetric measures of tumour size

Changes in cross-sectional area are currently used to assess tumour response to treatment. The aims of this study were to validate a helical CT technique for volume determination using a series of phantoms and to compare tumour responses indicated by one-, two- and three-dimensional measures of tumour size change in patients treated for germ cell cancer or lymphoma. All studies were performed on an IGE HiSpeed Advantage helical CT scanner with an Advantage Windows workstation. Phantom volumes were calculated using volume reconstruction software and compared with reference volumes determined by water displacement. 20 lymph node masses were studied on serial CT scans in 16 patients treated with chemotherapy for germ cell cancer or lymphoma. For each lesion the maximum diameter, maximum cross-sectional area and volume were determined before and after treatment. Tumour response was assessed using the standard World Health Organisation criteria (i.e. changes in cross-sectional area) and the newly proposed unidimensional response evaluation criteria in solid tumour (RECIST). The CT volume measurement error was 1.0-5.1% for regularly shaped phantoms larger than 35 cm3. In the assessment of treatment response there was 90% agreement between one-dimensional (1D) and two-dimensional (2D) measurements and 100% agreement between 2D and three-dimensional (3D) measurements. CT volume measurements are accurate and reproducible, particularly for larger structures. Assessment of tumour response using 1D, 2D and 3D measures had limited influence on the classification of treatment response. However, the impact of CT assessment of tumour response using 1D, 2D and 3D measurements on clinical decisions and patient outcome remains to be determined.

Computed tomography 21 days after chemotherapy, three-dimensional estimates of metastatic volume and the need for surgery in patients with germ cell cancer

OBJECTIVE

To assess whether the response visible on computed tomography (CT) 21 days after the first course of chemotherapy in patients with nonseminomatous germ cell tumour predicts the need for surgery and whether three-dimensional (3D) reconstruction adds to the diagnostic accuracy.

PATIENTS AND METHODS

CT scans from 52 patients treated with cisplatin-based chemotherapy were assessed for tumour shrinkage by measuring the changes of a one-dimensional (1D) measurement of the maximum transverse diameter, and comparing CT scans before, 21 days after the first course and at the end of chemotherapy (1D method). In a subset of patients, using a special formula, the 1D-derived 2D and 3D shrinkage (2Dder and 3Dder) were compared with four other computed or calculated methods (1D, 2D, 3Dcalc, 3Dcomp).

RESULTS

At day 21, in 32 of 52 patients (62%) there was < 50% tumour shrinkage using the 1D assessment; 21 of them (66%) needed surgery, compared with none of the 20 patients with > 50% tumour shrinkage by day 21 (chi2 = 22.83, P < 0.001). The 1D method showed significantly less shrinkage than all the other methods but when this was used to derive a 3D shrinkage, assuming the mass to be spherical (3Dder), it was not statistically different from that of 3Dcomp.

CONCLUSIONS

The assessment of the response from 1D CT scan estimates 21 days after initiating chemotherapy identifies a subgroup of patients who have a high probability of needing surgery. Although expected to be more accurate, the 3Dcomp estimate of tumour shrinkage was no better than the 3Dder estimate.

Multicenter evaluation of AMPLICOR and automated COBAS AMPLICOR CT/NG tests for Neisseria gonorrhoeae

The fully automated COBAS AMPLICOR CT/NG and semiautomated AMPLICOR CT/NG tests were evaluated in a multicenter trial for their ability to detect Neisseria gonorrhoeae infections. Test performance compared to that of culturing was evaluated for 2,192 matched endocervical swab and urine specimens obtained from women and for 1, 981 matched urethral swab and urine specimens obtained from men. Culture-negative, PCR-positive specimens that tested positive in a confirmatory PCR test for an alternative target sequence within the N. gonorrhoeae 16S rRNA gene were considered to be true positives. The overall prevalences of gonorrhea were 6.6% in women and 20.1% in men. The COBAS AMPLICOR and AMPLICOR formats yielded concordant results for 98.8% of the specimens and exhibited virtually identical sensitivities and specificities. The results that follow are for the COBAS AMPLICOR format. With the infected patient as the reference standard, the resolved sensitivities of PCR were 92.4% for endocervical swab specimens and 64.8% for female urine specimens. There were no significant differences in these rates between women with and without symptoms. Among symptomatic men, COBAS AMPLICOR sensitivities were 94.1% for urine and 98.1% for urethral swabs; for asymptomatic men, the results were 42.3 and 73.1%, respectively. In comparison, the sensitivities of culturing were 84.8% for endocervical specimens, 92.7% for symptomatic male urethral specimens, and only 46.2% for urethral specimens obtained from asymptomatic men. When PCR results were analyzed as if only a single test had been performed on a single specimen type, the resolved sensitivity was always higher. The resolved specificities of PCR were 99.5% for endocervical swab specimens, 99.8% for female urine specimens, 98.9% for male urethral swab specimens, and 99.9% for male urine specimens. The internal control revealed that 2.1% of specimens were inhibitory when initially tested. Nevertheless, valid results were obtained for 99.2% of specimens because 60.0% of the inhibitory specimens were not inhibitory when a second aliquot was tested. The COBAS AMPLICOR CT/NG test for N. gonorrhoeae exhibited high sensitivity and specificity with urethral swab and urine specimens from men and endocervical swab specimens from women and thus is well suited for diagnosing and screening for N. gonorrhoeae infection.

Cerebral infarction complicating intravenous immunoglobulin therapy in a patient with Miller Fisher syndrome

Intravenous immunoglobulin (IVIg) therapy is being increasingly used in a wide range of neurological conditions. However, treatment is expensive and side effects may be severe. A patient with Miller Fisher syndrome who developed cortical blindness as a consequence of occipital infarction precipitated by IVIg is reported on.

Multicenter evaluation of the AMPLICOR and automated COBAS AMPLICOR CT/NG tests for detection of Chlamydia trachomatis

The fully automated COBAS AMPLICOR CT/NG and semiautomated AMPLICOR CT/NG tests were evaluated in a multicenter trial for the ability to detect Chlamydia trachomatis infections. Test performance compared to that of culture was evaluated for 2,236 matched endocervical swab and urine specimens obtained from women and for 1,940 matched urethral swab and urine specimens obtained from men. Culture-negative, PCR-positive specimens that tested positive in a direct fluorescent-antibody test or in a confirmatory PCR test for an alternative target sequence were resolved as true positives. The overall prevalences of chlamydia were 2.4% in women and 7.2% in men. The COBAS AMPLICOR and AMPLICOR formats yielded concordant results for 98.1% of the specimens. With the infected patient as the reference standard, the resolved sensitivities of COBAS AMPLICOR were 89.7% for endocervical swab specimens, 89.2% for female urine specimens, 88.6% for male urethral swab specimens, and 90.3% for male urine specimens. When results were analyzed as if only a single test had been performed on a single specimen type, the resolved sensitivity was always higher. The resolved specificities of PCR were 99.4% for endocervical swab specimens, 99.0% for female urine specimens, 98.7% for male urethral swab specimens, and 98.4% for male urine specimens. The internal control revealed that 2.4% of the specimens were inhibitory when initially tested. Nevertheless, valid results were obtained for 98.6% of the specimens because 59.1% of the inhibitory specimens were not inhibitory when a second aliquot was tested. The COBAS AMPLICOR and AMPLICOR CT/NG tests for C. trachomatis exhibited equally high sensitivity and specificity with both urogenital swab and urine specimens and thus are well suited for screening for C. trachomatis infection.

Immune response to orally consumed antigens and probiotic bacteria

The gut mucosal system must fulfil conflicting roles in suppressing immune responses against orally fed antigens (tolerance) while still retaining the ability to respond to potential enteric pathogens. It must also, to a large degree, not mount an immune response against commensal enteric bacteria and the administration of large numbers of probiotic bacteria formulated as dietary supplements in food products. Contrary to this dogma, it has been found that feeding ovalbumin as a marker antigen, in association with selected probiotic bacteria, appears to prime for an intestinal immune response that is further augmented by skin vaccination. Skin immunization is known to stimulate a strong innate, humoral and cellular immune response. Such dominant immunogenic signals appear to override tolerogenic signals engendered by oral feeding of antigen. High-dose antigen feeding stimulated a strong Th2-dependent antibody response to skin vaccination but completely suppressed cytotoxic T cell responses. This was true even when ovalbumin was administered in conjunction with various selected probiotic bacteria. However, while yeast appeared to be better at priming for an enhanced humoral response, Lactobacillus fermentum and Staphylococcus carnosus were more effective in enhancing the postvaccinal lymphoproliferative response against ovalbumin.

Violence victimization after HIV infection in a US probability sample of adult patients in primary care

OBJECTIVES

This study estimated the proportion of HIV-infected adults who have been assaulted by a partner or someone important to them since their HIV diagnosis and the extent to which they reported HIV-seropositive status as a cause of the violence.

METHODS

Study participants were from a nationally representative probability sample of 2864 HIV-infected adults who were receiving medical care and were enrolled in the HIV Costs and Service Utilization Study. All interviews (91% in person, 9% by telephone) were conducted with computer-assisted personal interviewing instruments. Interviews began in January 1996 and ended 15 months later.

RESULTS

Overall, 20.5% of the women, 11.5% of the men who reported having sex with men, and 7.5% of the heterosexual men reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes.

CONCLUSIONS

HIV-related care is an appropriate setting for routine assessment of violence. Programs to cross-train staff in antiviolence agencies and HIV care facilities need to be developed for men and women with HIV infection.

Dissection plane of the human vocal fold lamina propria and elastin fibre concentration

To determine whether a natural plane of dissection occurs in the normal human vocal fold, semi-blunt instruments (Bouchayer laryngeal dissectors) were used to dissect the lamina propria. The depth of the plane of dissection was correlated with the elastin fibre concentration to determine whether the plane occurred at a predictable point in the elastin concentration as it increased between the superficial and middle layers. Eight human larynges were dissected using an operative microscope. The dissection plane consistently occurred between 23-50% depth into the lamina propria. No consistent correlation was found with the elastin fibre concentration. The depth of the plane of dissection has an interesting association with age: dissection planes occurred more superficially in older specimens.