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.

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.

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.

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.

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.