A tale of two cascades: promoting a standardized tool for monitoring progress in HIV prevention

INTRODUCTION

To achieve significant progress in global HIV prevention from 2020 onward, it is essential to ensure that appropriate programmes are being delivered with high quality and sufficient intensity and scale and then taken up by the people who most need and want them in order to have both individual and public health impact. Yet, currently, there is no standard way of assessing this. Available HIV prevention indicators do not provide a logical set of measures that combine to show reduction in HIV incidence and allow for comparison of success (or failure) of HIV prevention programmes and for monitoring progress in meeting global targets. To redress this, attention increasingly has turned to the prospects of devising an HIV prevention cascade, similar to the now-standard HIV treatment cascade; but this has proven to be a controversial enterprise, chiefly due to the complexity of primary prevention.

DISCUSSION

We address a number of core issues attendant with devising prevention cascades, including: determining the population of interest and accounting for the variability and fluidity of HIV-related risk within it; the fact that there are multiple HIV prevention methods, and many people are exposed to a package of them, rather than a single method; and choosing the final step (outcome) in the cascade. We propose two unifying models of prevention cascades-one more appropriate for programme managers and monitors and the other for researchers and programme developers-and note their relationship. We also provide some considerations related to cascade data quality and improvement.

CONCLUSIONS

The HIV prevention field has been grappling for years with the idea of developing a standardised way to regularly assess progress and to monitor and improve programmes accordingly. The cascade provides the potential to do this, but it is complicated and highly nuanced. We believe the two models proposed here reflect emerging consensus among the range of stakeholders who have been engaging in this discussion and who are dedicated to achieving global HIV prevention goals by ensuring the most appropriate and effective programmes and methods are supported.

Course of post-traumatic stress disorder and health care utilisation among resettled refugees in the Netherlands

BACKGROUND

Post-traumatic stress disorder (PTSD) is a major health problem among refugees worldwide. After resettlement, the prevalence of PTSD remains high despite the fact that various PTSD treatments are known to be effective.

METHODS

We examined the course of PTSD and the role of mental health care utilisation at a 7-year interval (2003-2010) among a cohort of refugees from Iran, Afghanistan, and Somalia after resettlement in the Netherlands.

RESULTS

The unchanged high prevalence of PTSD (16.3% in 2003 and 15.2% in 2010) was attributable in part to late onset of PTSD symptoms (half of the respondents with PTSD at T2 were new cases for whom PTSD developed after 2003). The second reason concerned the low use of mental health care services at T1. Whereas the multivariate analyses showed the effectiveness of mental health care, only 21% of respondents with PTSD at T1 had had contact with a mental health care provider at that time. Use of mental health care during the first wave increased the odds of improvement in PTSD symptoms between both measurements (OR 7.58, 95% CI 1.01; 56.85).

CONCLUSIONS

The findings of this study suggest there are two possible explanations for the persistently high prevalence of PTSD among refugees. One is the late onset of PTSD and the other is the low utilisation of mental health care. Health care professionals should be aware of these issues, especially given the effectiveness of mental health care for this condition.

Health and health care utilisation among asylum seekers and refugees in the Netherlands: design of a study

Background

This article discusses the design of a study on the prevalence of health problems (both physical and mental) and the utilisation of health care services among asylum seekers and refugees in the Netherlands, including factors that may be related to their health and their utilisation of these services.

Methods/Design

The study will include random samples of adult asylum seekers and refugees from Afghanistan, Iran and Somali (total planned sample of 600), as these are among the largest groups within the reception centres and municipalities in the Netherlands.

The questionnaire that will be used will include questions on physical health (chronic and acute diseases and somatization), mental health (Hopkins Symptoms Checklist-25 and Harvard Trauma Questionnaire), utilisation of health care services, pre- and post-migratory traumatic experiences, life-style, acculturation, social support and socio-demographic background. The questionnaire has gone through a translation process (translation and back-translation, several checks and a pilot-study) and cross-cultural adaptation. Respondents will be interviewed by bilingual and bicultural interviewers who will be specifically trained for this purpose.

This article discusses the selection of the study population, the chosen outcome measures, the translation and cross-cultural adaptation of the measurement instrument, the training of the interviewers and the practical execution of the study. The information provided may be useful for other researchers in this relatively new field of epidemiological research among various groups of asylum seekers and refugees.

Splinting or surgery for carpal tunnel syndrome? Design of a randomized controlled trial [ISRCTN18853827]

BACKGROUND

Carpal tunnel syndrome is a common disorder, which can be treated with surgery or conservative options. However, there is insufficient evidence and no consensus among physicians with regard to the preferred treatment for carpal tunnel syndrome. Therefore, a randomized controlled trial is conducted to compare the short- and long-term efficacy of surgery and splinting in patients with carpal tunnel syndrome. An attempt is also made to avoid the (methodological) limitations encountered in earlier trials on the efficacy of various treatment options for carpal tunnel syndrome.

METHODS

Patients of 18 years and older, with clinically and electrophysiologically confirmed idiopathic carpal tunnel syndrome, are recruited by neurologists in 13 hospitals. Patients included in the study are randomly allocated to either open carpal tunnel release or wrist splinting during the night for at least 6 weeks. The primary outcomes are general improvement, waking up at night and severity of symptoms (main complaint, night and daytime pain, paraesthesia and hypoesthesia). Outcomes are assessed up to 18 months after randomization.

Systematic review of randomized clinical trials of surgical treatment for carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is a common disorder for which several surgical treatment options are available. However, there is no consensus on the most effective method of treatment. The object of this systematic review is to compare the efficacy of the various surgical techniques in relieving the symptoms of CTS and promoting return to work and/or activities of daily living.

METHODS

Computer-aided searches of Medline, EMBASE and the Cochrane Controlled Trials Register were conducted, together with reference checking. A rating system, based on the number of studies and their methodological quality and findings, was used to determine the strength of the available evidence for the efficacy of the treatment.

RESULTS

Fourteen studies were included in the review. None of the alternatives to standard open carpal tunnel release (OCTR) seems to offer better relief of symptoms. There is conflicting evidence about whether endoscopic carpal tunnel release results in earlier return to work and/or activities of daily living.

CONCLUSION

Standard OCTR is still the preferred method of treatment for CTS. It is just as effective as the alternatives, but is technically less demanding, so incurs a lower risk of complications and of added costs.

Conservative treatment for repetitive strain injury

Various conservative treatment options for repetitive strain injury are widely used, despite questionable evidence of their effectiveness. This systematic review evaluates the effectiveness of these treatment options for relieving symptoms of repetitive strain injury and improving activities of daily living. Searches in Medline and Embase, with additional reference checking resulted in 15 eligible trials for this review. Methodological quality was assessed, and data-extraction was performed. With the use of a "best-evidence synthesis", no strong evidence was found for the effectiveness of any of the treatment options. There is limited evidence that multidisciplinary rehabilitation, ergonomic intervention measures, exercises, and spinal manipulation combined with soft tissue therapy are effective in providing symptom relief or improving activities of daily living. There is conflicting evidence for the effectiveness of behavioral therapy. In conclusion, little is known about the effectiveness of conservative treatment options for repetitive strain injury. To establish strong evidence, more high-quality trials are needed.

Hearing deficits at school age; the predictive value of otitis media in infants

AIM

To evaluate the long-term predictive value of persistent/recurrent otitis media with effusion (OME) in infants in relation with hearing levels at (early) school age.

DESIGN

A case-cohort study among a population-based sample of school-age children screened for hearing deficits.

POPULATION AND METHODS

Schoolchildren (second grade, 5-6 years of age) in the city of Utrecht, the Netherlands, who failed the hearing screening test and a sample of children invited for this screening. History of otitis media (serosa and acute) was assessed using three sources of information: a self-completion questionnaire mailed to the parents; medical records of otolaryngology visits; data from the (Ewing) hearing screening test at 9 months of age.

RESULTS

Children who failed the primary Ewing test and children with recurrent and or persistent OME in the first 2 years of life showed an increased risk of failing school audiometry compared to children without such an OME history (OR=1.6 and 2.3, respectively). In a logistic model, the results of the primary Ewing test and the frequency of acute otitis media, proved to be moderately predictive for the screening test result at school age.

CONCLUSION

OME in infants is a prognostic factor for hearing performance in the early school years.

Mild dehydration and atrial natriuretic peptide in young and elderly subjects

The influence of mild dehydration on plasma levels of atrial natriuretic peptide (ANP) was studied in both young (aged 18 to 25 years) and elderly (aged 72 to 86 years) subjects. We expected that dehydration would lower ANP concentrations due to the ensuing volume contraction. A different response of the ANP hormonal system in the elderly might help to explain the observation that elderly subjects are more predisposed to dehydration as compared to young subjects. Dehydration was induced by restriction of fluid intake to 25% of normal for one day. During the study, urinary osmolality increased while osmolar clearance and body weight decreased. Basal ANP concentrations were higher in the elderly subjects. However, these levels did not change during the dehydration study neither in the young nor in the elderly subjects. This may be explained by the activation of counter-regulatory systems preventing a decrease in central blood volume and hence a decrease in ANP concentration.