Costs of distributing HIV self-testing kits in Eswatini through community and workplace models

BACKGROUND

This study evaluates the implementation and running costs of an HIV self-testing (HIVST) distribution program in Eswatini. HIVST kits were delivered through community-based and workplace models using primary and secondary distribution. Primary clients could self-test onsite or offsite. This study presents total running economic costs of kit distribution per model between April 2019 and March 2020, and estimates average cost per HIVST kit distributed, per client self-tested, per client self-tested reactive, per client confirmed positive, and per client initiating antiretroviral therapy (ART).

METHODS

Distribution data and follow-up phone interviews were analysed to estimate implementation outcomes. Results were presented for each step of the care cascade using best-case and worst-case scenarios. A top-down incremental cost-analysis was conducted from the provider perspective using project expenditures. Sensitivity and scenario analyses explored effects of economic and epidemiological parameters on average costs.

RESULTS

Nineteen thousand one hundred fifty-five HIVST kits were distributed to 13,031 individuals over a 12-month period, averaging 1.5 kits per recipient. 83% and 17% of kits were distributed via the community and workplace models, respectively. Clients reached via the workplace model were less likely to opt for onsite testing than clients in the community model (8% vs 29%). 6% of onsite workplace testers tested reactive compared to 2% of onsite community testers. Best-case scenario estimated 17,458 (91%) clients self-tested, 633 (4%) received reactive-test results, 606 (96%) linked to confirmatory testing, and 505 (83%) initiated ART. Personnel and HIVST kits represented 60% and 32% of total costs, respectively. Average costs were: per kit distributed US$17.23, per client tested US$18.91, per client with a reactive test US$521.54, per client confirmed positive US$550.83, and per client initiating ART US$708.60. Lower rates for testing, reactivity, and linkage to care in the worst-case scenario resulted in higher average costs along the treatment cascade.

CONCLUSION

This study fills a significant evidence gap regarding costs of HIVST provision along the client care cascade in Eswatini. Workplace and community-based distribution of HIVST accompanied with effective linkage to care strategies can support countries to reach cascade objectives.

Enabling cross-country learning and exchange to support universal health coverage implementation

As countries transition from external assistance while pursuing ambitious plans to achieve universal health coverage (UHC), there is increasing need to facilitate knowledge sharing and learning among them. Country-led and country-owned knowledge management is foundational to sustainable, more equitable external assistance for health and is a useful complement to more conventional capacity-building modalities provided under external assistance. In the context of external assistance, few initiatives use country-to-country sharing of practitioner experiences, and link learning to receiving guidance on how to adapt, apply and sustain policy changes. Dominant knowledge exchange processes are didactic, implicitly assuming static technical needs, and that practitioners in low- and middle-income countries require problem-specific, time-bound solutions. In reality, the technical challenges of achieving UHC and the group of policymakers involved continuously evolve. This paper aims to explore factors which are supportive of experience-based knowledge exchange between practitioners from diverse settings, drawing from the experience of the Joint Learning Network (JLN) for UHC-a global network of practitioners and policymakers sharing experiences about common challenges to develop and implement knowledge products supporting reforms for UHC-as an illustration of a peer-to-peer learning approach. This paper considers: (1) an analysis of JLN monitoring and evaluation data between 2020 and 2023 and (2) a qualitative inquiry to explore policymakers' engagement with the JLN using semi-structured interviews (n = 14) with stakeholders from 10 countries. The JLN's experience provides insights to factors that contribute to successful peer-to-peer learning approaches. JLN relies on engaging a network of practitioners with diverse experiences who organically identify and pursue a common learning agenda. Meaningful peer-to-peer learning requires dynamic, structured interactions, and alignment with windows of opportunity for implementation that enable rapid response to emerging and timely issues. Peer-to-peer learning can facilitate in-country knowledge sharing, learning and catalyse action at the institutional and health system levels.

Harnessing Country Experiences for Health Benefit Package Design: Evidence-Informed Deliberative Processes and Experiences From the Joint Learning Network Comment on "Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide"

Amidst competing priorities for allocating finite health resources, using evidence-informed priority setting is a valuable tool for achieving population-level health goals. The paper by Baltussen et al comprehensively reports on the development of practical guidance for evidence-informed deliberative processes (EDPs) which will help with sustainability of programs aimed at universal health coverage (UHC). The authors' experience with the Joint Learning Network for UHC's (JLN) peer-to-peer learning platform on evidence-informed priority setting offers insights on the practical challenges faced by countries in health benefits package (HBP) design, especially to draw in actors to advocate for the priorities and values across the health system. Lessons harvested from JLN countries that have established such advisory committees can provide practical insights for countries in earlier stages of establishing a systematic process for HBP design. Peer-to-peer learning modalities among countries offer viable and effective approaches to institutionalizing EDPs and systematic priority setting.

Spatial Clustering and Risk Factors for Malaria Infections and Marker of Recent Exposure to Plasmodium falciparum from a Household Survey in Artibonite, Haiti

Targeting malaria interventions in elimination settings where transmission is heterogeneous is essential to ensure the efficient use of resources. Identifying the most important risk factors among persons experiencing a range of exposure can facilitate such targeting. A cross-sectional household survey was conducted in Artibonite, Haiti, to identify and characterize spatial clustering of malaria infections. Household members (N = 21,813) from 6,962 households were surveyed and tested for malaria. An infection was defined as testing positive for Plasmodium falciparum by either a conventional or novel highly sensitive rapid diagnostic test. Seropositivity to the early transcribed membrane protein 5 antigen 1 represented recent exposure to P. falciparum. Clusters were identified using SaTScan. Associations among individual, household, and environmental risk factors for malaria, recent exposure, and living in spatial clusters of these outcomes were evaluated. Malaria infection was detected in 161 individuals (median age: 15 years). Weighted malaria prevalence was low (0.56%; 95% CI: 0.45-0.70%). Serological evidence of recent exposure was detected in 1,134 individuals. Bed net use, household wealth, and elevation were protective, whereas being febrile, over age 5 years, and living in either households with rudimentary wall material or farther from the road increased the odds of malaria. Two predominant overlapping spatial clusters of infection and recent exposure were identified. Individual, household, and environmental risk factors are associated with the odds of individual risk and recent exposure in Artibonite; spatial clusters are primarily associated with household-level risk factors. Findings from serology testing can further strengthen the targeting of interventions.

A Systematic Review and Network Meta-analyses to Assess the Effectiveness of Human Immunodeficiency Virus (HIV) Self-testing Distribution Strategies

Background

We conducted a systematic review and network meta-analysis to identify which human immunodeficiency virus (HIV) self-testing (HIVST) distribution strategies are most effective.

Methods

We abstracted data from randomized controlled trials and observational studies published between 4 June 2006 and 4 June 2019.

Results

We included 33 studies, yielding 6 HIVST distribution strategies. All distribution strategies increased testing uptake compared to standard testing: in sub-Saharan Africa, partner HIVST distribution ranked highest (78% probability); in North America, Asia, and the Pacific regions, web-based distribution ranked highest (93% probability), and facility based distribution ranked second in all settings. Across HIVST distribution strategies HIV positivity and linkage was similar to standard testing.

Conclusions

A range of HIVST distribution strategies are effective in increasing HIV testing. HIVST distribution by sexual partners, web-based distribution, as well as health facility distribution strategies should be considered for implementation to expand the reach of HIV testing services.

Comparison of Three Methods for Determination of Crude Protein in Meat: Collaborative Study

A study was designed to compare the Kjel-Foss automated macro-Kjeldahl method and a block digestion- steam distillation method. The official AOAC Kjeldahl method was used as a reference procedure. Six products with a crude protein range of 10-30% were analyzed by 23 laboratories. Five laboratories analyzed the samples by the official AOAC method, 8 laboratories used the automated Kjel-Foss method, and 11 laboratories used the block digestion with steam distillation method. Standard deviations for each product and each method for both repeatability and reproducibility are given. The block digestion- steam distillation method has been adopted official first action.

Modeling virus- and antibody-specific factors to predict human immunodeficiency virus neutralization efficiency

Efforts to prevent human immunodeficiency virus type 1 (HIV-1) infection would benefit from understanding the factors that govern virus neutralization by antibodies. We present a mechanistic model for HIV-1 neutralization that includes both virus and antibody parameters. Variations in epitope integrity on the viral envelope glycoprotein (Env) trimer and Env reactivity to bound antibody influence neutralization susceptibility. In addition, we define an antibody-specific parameter, the perturbation factor (PF), that describes the degree of conformational change in the Env trimer required for a given antibody to bind. Minimally perturbing (low-PF) antibodies can efficiently neutralize viruses with a broad range of Env reactivities due to fast on-rates and high affinity for Env. Highly perturbing (high-PF) antibodies inhibit only viruses with reactive (perturbation-sensitive) Envs, often through irreversible mechanisms. Accounting for these quantifiable viral and antibody-associated parameters helps to predict the observed profiles of HIV-1 neutralization by antibodies with a wide range of potencies.

Contribution of intrinsic reactivity of the HIV-1 envelope glycoproteins to CD4-independent infection and global inhibitor sensitivity

Human immunodeficiency virus (HIV-1) enters cells following sequential activation of the high-potential-energy viral envelope glycoprotein trimer by target cell CD4 and coreceptor. HIV-1 variants differ in their requirements for CD4; viruses that can infect coreceptor-expressing cells that lack CD4 have been generated in the laboratory. These CD4-independent HIV-1 variants are sensitive to neutralization by multiple antibodies that recognize different envelope glycoprotein epitopes. The mechanisms underlying CD4 independence, global sensitivity to neutralization and the association between them are still unclear. By studying HIV-1 variants that differ in requirements for CD4, we investigated the contribution of CD4 binding to virus entry. CD4 engagement exposes the coreceptor-binding site and increases the "intrinsic reactivity" of the envelope glycoproteins; intrinsic reactivity describes the propensity of the envelope glycoproteins to negotiate transitions to lower-energy states upon stimulation. Coreceptor-binding site exposure and increased intrinsic reactivity promote formation/exposure of the HR1 coiled coil on the gp41 transmembrane glycoprotein and allow virus entry upon coreceptor binding. Intrinsic reactivity also dictates the global sensitivity of HIV-1 to perturbations such as exposure to cold and the binding of antibodies and small molecules. Accordingly, CD4 independence of HIV-1 was accompanied by increased susceptibility to inactivation by these factors. We investigated the role of intrinsic reactivity in determining the sensitivity of primary HIV-1 isolates to inhibition. Relative to the more common neutralization-resistant ("Tier 2-like") viruses, globally sensitive ("Tier 1") viruses exhibited increased intrinsic reactivity, i.e., were inactivated more efficiently by cold exposure or by a given level of antibody binding to the envelope glycoprotein trimer. Virus sensitivity to neutralization was dictated both by the efficiency of inhibitor/antibody binding to the envelope glycoprotein trimer and by envelope glycoprotein reactivity to the inhibitor/antibody binding event. Quantitative differences in intrinsic reactivity contribute to HIV-1 strain variability in global susceptibility to neutralization and explain the long-observed relationship between increased inhibitor sensitivity and decreased entry requirements for target cell CD4.

Glucose oscillations, more than constant high glucose, induce p53 activation and a metabolic memory in human endothelial cells

AIMS/HYPOTHESIS

Damage persists in HUVECs exposed to a constant high glucose concentration long after glucose normalisation, a phenomenon termed 'metabolic memory'. Evaluation of the effects of exposure of HUVECs to oscillating high glucose on the induction of markers of oxidative stress and DNA damage (phospho-γ-histone H2AX and PKCδ) and onset of metabolic memory, and the possible role of the tumour suppressor transcriptional factor p53 is of pivotal interest.

METHODS

HUVECs were incubated for 3 weeks in 5 or 25 mmol/l glucose or oscillating glucose (24 h in 5 mmol/l glucose followed by 24 h in 25 mmol/l glucose) or for 1 week in constant 5 mmol/l glucose after being exposed for 2 weeks to continuous 25 mmol/l high glucose or oscillating glucose. Transcriptional activity of p53 was also evaluated in the first 24 h after high glucose exposure.

RESULTS

High constant glucose upregulated phospho-γ-histone H2AX and protein kinase C (PKC)δ compared with control. Oscillating glucose was even more effective than both normal and constant high glucose. Both constant and oscillating glucose resulted in a memory effect, which was more pronounced in the oscillating condition. Transcriptional activity of p53 peaked 6 h after glucose exposure, showing a predicted oscillatory behaviour.

CONCLUSIONS/INTERPRETATION

Exposure to oscillating glucose was more deleterious than constant high glucose and induced a metabolic memory after glucose normalisation. Hyperactivation of p53 during glucose oscillation might be due to the absence of consistent feedback inhibition during each glucose spike and might account for the worse outcome of this condition.

Use of genome-wide scan in women with breast cancer to identify common germline variants that may be associated with recurrence

11049

Background: Studies of normal DNA variation have identified several common single nucleotide polymorphisms (SNPs) associated with susceptibility to breast cancer. It is not known whether common SNPs are associated with breast cancer outcomes. Methods: Subjects were Ashkenazi Jewish women with familial breast cancer and without BRCA mutations. Subjects were genotyped on an Affymetrix 500K SNP platform in the first phase of a genome-wide association study seeking susceptibility loci (Gold et. al, Proc Natl Acad Sci 2008;105:4340). Clinical variables and outcomes for these women were abstracted from medical records. Using a Cox proportional hazards model, we assessed associations between clinical outcomes and the 111 SNPs that were most significantly associated with susceptibility in the case-control study and heterozygous in the subset of affected patients. Dominant, codominant, and recessive models were explored. A secondary analysis assessed associations with recurrence of 48,562 additional SNPs that were not strongly associated with susceptibility. Results: The 173 subjects were a median of 51 years of age at diagnosis (range 27–74). Median follow-up for surviving subjects was 85.5 months. Most cancers (74.6%) were T1/T2; 62% were N0. Most were ER positive (81.5%), HER2 negative (87.5%). For the entire group, the 5- and 10-year freedom from recurrence was 84% and 72%, respectively. The 5- and 10-year overall survival was 94% and 86%, respectively. Minor alleles at rs6439927 (within CLSTN2,calsyntenin2, a post-synaptic calcium-binding membrane protein, MAF 27%) and rs7943562 ( linked to GALNTL4, an N-acetylgalactosaminyltransferase, MAF 47%) were most strongly associated with disease recurrence (log likelihood ratio chi square P=0.003 and P=0.002, respectively). No additional SNPs from the secondary analysis achieved genome-wide significance. Conclusions: Genome-wide SNP genotyping of women with breast cancer identified two novel loci that may be associated with disease recurrence. Further studies in larger cohorts will be performed to replicate these findings.

No significant financial relationships to disclose.

Titration of propofol for anesthetic induction and maintenance guided by the bispectral index: closed-loop versus manual control: a prospective, randomized, multicenter study

BACKGROUND

This report describes a closed-loop titration of propofol target control infusion based on a proportional-differential algorithm guided by the Bispectral Index (BIS) allowing induction and maintenance of general anesthesia and compares this to manual propofol target control infusion.

METHODS

One hundred sixty-four patients scheduled to undergo elective minor or major surgery were prospectively randomized in a multicenter study into the closed-loop (n = 83) or manual target control infusion group (n = 81). The goal was to reach a BIS target of 50 during induction and to maintain it between 40 and 60 during maintenance. For both groups, remifentanil target control infusion was adjusted manually, and ventilation was without nitrous oxide.

RESULTS

Closed-loop control was able to provide anesthesia induction and maintenance for all patients. During induction, propofol consumption was lower in the closed-loop group (1.4 +/- 0.5 vs. 1.8 +/- 0.6 mg/kg; P < 0.0001), but the duration was longer (320 +/- 125 vs. 271 +/- 120 s; P < 0.0002). Adequate anesthesia maintenance, defined as the BIS in the range of 40-60, was significantly higher in the closed-loop group (89 +/- 9 vs. 70 +/- 21%; P < 0.0001), with a decrease of the occurrence of BIS less than 40 (8 +/- 8 vs. 26 +/- 22%; P < 0.0001). Time from discontinuation of propofol infusion to tracheal extubation was shorter in the closed-loop group (7 +/- 4 vs. 10 +/- 7 min; P < 0.017). Unwanted somatic events and hemodynamic instability were similar.

CONCLUSION

Automatic control of consciousness using the BIS is clinically feasible and outperforms manual control.

The epidemiology of drowning worldwide

The purpose of this analysis was to quantify the magnitude of death and disability from drowning and near-drowning worldwide and to provide epidemiological data on which to base prevention efforts. All data are from the Global Burden of Disease 2000 (Version 1) estimates in which deaths and disabilities are based on the WHO International Classification of Diseases. Extrapolations were made by age, sex, and WHO region. The six WHO regions of the world were further divided into high-income, and low- and middle-income based on the 1998 World Development indicators. According to the GBD 2000 data, an estimated 449,000 people drowned worldwide (7.4 per 100,000 population) and a further 1.3 million Disability Adjusted Life Years (DALYs) were lost as a result of premature death or disability from drowning. 97% of drownings occurred in low- and middle-income countries. Although 38% of drownings occurred in the Western Pacific Region, Africa had the highest drowning mortality rate (13.1 per 100,000 population). Males had higher drowning mortality rates than females for all ages and in all regions. Children under the age of 5 years had the highest drowning mortality rate for both sexes in all of the WHO regions except for Africa, where children aged 5 to 14 years had the highest mortality rate. Worldwide, for children under the age of 15 years, drowning accounted for a higher mortality rate than any other cause of injury. Drowning is a significant problem worldwide particularly for children under the age of 15 years. Low- and middle-income countries have the highest rates of drowning and account for more than 90% of such fatalities. Primary prevention efforts should thus be focused on these countries where many children who cannot swim drown in large bodies of water.

Sudden death after neck dissection for cancer

The goal of this study was to analyze the mortality data following neck dissection and determine the risk factors of early death. The hospital mortality records were analyzed from 3,015 consecutive patients who underwent neck dissection. A case control study analyzed risk factors of death during the first 3 postoperative days. The mortality incidences were 0.50% and 1.33%, respectively, during the first 3 and the first 30 postoperative days. Eleven of the 12 unexplained deaths occurred during the first 3 postoperative days, and most of these patients died suddenly. They were more likely to be alcoholic and to have undergone nerve section. In most of the patients who died after the third postoperative day, death was related to a postoperative complication. Although the mechanisms of sudden death remain unclear, careful follow-up of these patients during the early postoperative days should be performed to reduce the mortality risk by shortening the delay of care.

A role for N-WASP in invasin-promoted internalisation

Phagocytosis of Yersinia pseudotuberculosis occurs through interaction of the bacterial protein invasin with beta1-integrins. Here we report that N-WASP plays a role in internalisation of an invasin-expressing, avirulent strain of Y. pseudotuberculosis. Ectopic expression of N-WASP mutants, which affect recruitment of the Arp2/3 complex to the phagosome, reduces uptake of Yersinia. In addition, expression of the Cdc42/Rac-binding (CRIB) region of N-WASP has an inhibitory effect on uptake. Using GFP-tagged Rho GTPase mutants, we provide evidence that Rac1, but not Cdc42, is important for internalisation. Furthermore, activated Rac1 rescues Toxin B, CRIB and Src family kinase inhibitor PP2-mediated impairment of uptake. Our observations indicate that invasin-mediated phagocytosis occurs via a Src and WASP family-dependent mechanism(s), involving the Arp2/3 complex and Rac, but does not require Cdc42.

A note on hair whorl position and cattle temperament in the auction ring

The objective of this study was to further describe the relationships between facial hair whorls and temperament in cattle. Cattle (n=1636) from six commercial cattle auctions in Colorado and Texas were observed. Whorl location was classified according to lateral position (left, right, or middle) and height (high: above the top of the eye, middle: at eye level, low: below the bottom of the eye). A 4-point temperament score was used to rate each animal while it was in the auction ring. Cattle with a score of 1 remained calm and stood still or walked around, and those with a score of 4 were highly agitated and hit the ring fence, walls, partitions, or people with its head. The cattle observed were 75% Bos taurus beef breeds, 21% Holstein dairy cattle, 3% Bos indicus beef breeds, and 1% non-Holstein dairy breeds. Ten percent of cattle surveyed had no facial hair whorl, while 86% had a single spiral hair whorl, of which 47% had middle-middle whorl placement. Animals with a high whorl position or no hair whorl had higher temperament scores (P=0.01). Cattle with low whorls were more likely to have greater lateral displacement of whorls off of the centerline than cattle with high or middle whorls (P<0.01). Abnormally shaped whorls were more common on cattle with low whorls (P<0.01) and on cattle with lateral whorls located off of the centerline (P<0.01). Cattle with hair whorls on the centerline had more variable temperament scores (P=0.04). Beef cattle had more abnormal whorls than Holsteins (P<0.01). Temperament scores showed that Holsteins were calmer than beef cattle (P<0.01). Facial hair whorls in cattle may be a useful management tool in assessing which animals may become disturbed in novel environments.

The relationship between reaction to sudden, intermittent movements and sounds and temperament

Casual observations indicated that some cattle are more sensitive to sudden movement or intermittent sound than other cattle. Six commercial livestock auctions in two states and a total of 1,636 cattle were observed to assess the relationship between breed, sex, and temperament score on the response to sudden, intermittent visual and sound stimuli, such as the ringman swinging his arm for a bid and the sound of him briefly yelling a bid. A 4-point temperament score was used to score each animal while it was in the ring. The scores used were 1) walks and(or) stands still, with slow, smooth body movements; 2) continuously walks or trots, and vigilant; 3) gait is faster than a trot (runs even a couple of steps), with fast, abrupt, jerky movements, and very vigilant; and 4) hits the ring fence, walls, partitions, or people with its head. Animals were observed for flinches, startle responses, or orientation toward sudden, intermittent sounds, motions, and tactile stimulation, such as being touched with a cane or plastic paddle. The cattle observed were mostly Bos taurus beef breeds and Holstein dairy cattle. Holsteins were more sound-sensitive (P = .02) and touch-sensitive (P < .01) than beef cattle. Sensitivity to sudden, intermittent stimuli (e.g., sound, motion, and touch) increased as temperament score (excitability) increased. Cattle with a temperament score of 1 were the least sensitive to sudden, intermittent movement and sound and those with a temperament score of 4 were the most sensitive (P < .01). This same relationship was sometimes observed for touch but was not statistically significant. Motion-sensitive cattle were more likely than nonsensitive cattle to score a temperament rating of 3 or 4 (P < .01). Steers and heifers were more motion-sensitive than the older bulls and cows (P = .03). Beef cattle urinated (P < .01, n = 1,581) and defecated (P < .01, n = 1,582) more often in the ring than did dairy cattle. Cattle that became agitated during handling in an auction ring were the individuals that were most likely to be startled by sudden, intermittent sounds and movements. Reactivity to sudden, intermittent stimuli may be an indicator of an excitable temperament.

Long-term response to topiramate in patients with West syndrome

PURPOSE

The long-term effectiveness of topiramate (TPM) was evaluated in children with West syndrome previously refractory to antiepileptic drug (AED) therapy.

METHODS

Children with infantile spasms who completed a pilot study were eligible to enter a long-term extension phase in which the dosages of TPM and other AEDs could be adjusted to optimal response (maximum, 50 mg/kg/day TPM). The mean duration of long-term therapy was 18 months in the 11 children who were followed; the mean TPM dosage was 29 mg/kg/day.

RESULTS

Eight (73%) children were continuing TPM therapy at the time data were analyzed; four (50%) children were spasm free, seven (88%) had experienced a > or =50% reduction in spasms, and three (38%) were able to achieve TPM monotherapy.

CONCLUSIONS

TPM was well tolerated in that no patients discontinued because of adverse events. The response achieved with TPM during the pilot study was maintained in most children.

YopH dephosphorylates Cas and Fyn-binding protein in macrophages

The tyrosine phosphatase YopH is an essential virulence effector of pathogenic Yersinia spp. YopH, which is translocated from extracellularly located bacteria into interacting target cells, blocks phagocytosis by professional phagocytes. We show here that immunoprecipitation of YopH from lysates of J774 cells infected with Y. pseudotuberculosis expressing an inactive form of YopH resulted in co-precipitation of certain phosphotyrosine proteins. The association between the inactive YopH and phosphotyrosine proteins in the 120 kDa range was rapid and could be detected after 2 min of infection. The proteins were identified as the docking proteins Cas and Fyn-binding protein (FYB). Upon infection of J774 cells with Y. pseudotuberculosis lacking YopH expression both of these proteins became tyrosine phosphorylated. Moreover, this infection caused recruitment of Cas to peripheral focal complexes, and FYB was relocalized to areas surrounding these structures. Both Cas and FYB became dephosphorylated upon infection with Y. pseudotuberculosis expressing active YopH, and this was associated with disruption of focal complexes. With regard to the previous identification of Cas and focal complexes as targets of YopH in HeLa cells, the present study supports an important role for these targets in a general mechanism of bacterial uptake.

Topiramate pharmacokinetics in infants

PURPOSE

This study's goal was to provide preliminary data on the pharmacokinetics of topiramate (TPM) in a cohort of infants (younger than 4 years) participating in an open-label trial of TPM in refractory infantile spasms.

METHODS

The pharmacokinetics of TPM were assessed in infants receiving a stable TPM dose for >7 days during the extension phase of this trial. Blood samples were drawn just before and 0.5. 1, 1.5, 2, 4, 6, 8, and 12 h after the morning TPM dose. TPM plasma concentrations were determined by fluorescence polarization immunoassay. The noncompartmental analysis module of WinNonlin was used to calculate individual patient pharmacokinetics profiles.

RESULTS

Five infants (ages, 23.5-29.5 months) formed the study cohort. These infants had been given TPM for a median of 9 months (range, 6-11 months) and were currently receiving between 11 and 38.5 mg/kg/day TPM. One was receiving TPM monotherapy, whereas four were taking concomitant antiepileptic medications (AEDs; n = 2, enzyme-inducing agents; n = 2, non-enzyme-inducing drugs). TPM pharmacokinetics in infants appears to be linear. In this cohort, mean TPM plasma clearance (CL/F, 66.6+/-27.4 ml/h/kg) was slightly higher than that reported for children and adolescents and therefore substantially higher than that reported for adults. TPM CL/F was higher and the calculated half-life shorter in the infants receiving concomitant enzyme-inducing AEDs.

CONCLUSIONS

Based on this small cohort of patients, it appears that infants may require significantly larger TPM doses, based on weight, than children, adolescents, or adults. Titration to effect and not absolute TPM dose should guide therapy in this age group.

Prevalence of severe welfare problems in horses that arrive at slaughter plants

OBJECTIVE

To assess the prevalence of severe welfare problems in horses that arrive at slaughter plants and to identify horses that were unfit for travel.

DESIGN

Prevalence survey.

ANIMALS

1,008 horses.

PROCEDURE

Horses arriving at 2 slaughter plants were observed. The following were rated severe welfare problems in horses: body condition scores of 1 or 2 (emaciated) of 9; recumbency (down) or the inability to walk; fractured limbs or other foot or limb problems that extremely impaired mobility; severe wounds, such as deep cuts, extensive lacerations, abrasions on the head or back, eye injuries, neglected purulent lesions, and numerous bite and kick marks over extensive areas of the body; and dead on arrival. Bruises on carcasses were tabulated to further assess injuries. Horses that had been loaded with a fractured limb, arrived nonambulatory, had severe lameness that interfered with mobility, were weak and emaciated, or were dead on arrival or died shortly after arrival were considered unfit for travel.

RESULTS

Ninety-two percent (930/1,008) of the horses arrived in good condition, and 7.7% (78) had a condition that was rated a serious welfare problem. Thirty horses (3%) had a body condition score of 1 or 2, 12 (1.0%) had foot and limb problems (other than fractures), 4 (0.4%) had fractured limbs, 18 (2.0%) had deep cuts, lacerations, or injuries from bites, 8 (0.8%) were nonambulatory or dead on arrival, 2 (0.2%) had deformities, 3 (0.3%) had extensive purulent lesions, and 1 (0.1%) had a behavior problem. Characteristic patterns of 51% of carcass bruises indicated that they were caused by bites or kicks. Fighting was the major cause of injuries that occurred during transport and marketing. Fifteen (1.5%) horses were unfit for travel. Abuse or neglect by owners was the cause of 77% of the severe welfare problems observed.

CLINICAL IMPLICATIONS

To decrease the number of injuries that result from fighting when transporting horses to slaughter plants, aggressive mares and geldings that continually attack other horses must be segregated.

Prospective double-arm study of fibrinolysis in surgical patients

BACKGROUND

During surgery, the balance between thrombosis and fibrinolysis is altered. Methods reported to increase fibrinolysis, such as compression devices, may reduce venous thrombosis. However, there are no prospective studies comparing methods and the effect on fibrinolysis.

MATERIALS AND METHODS

In a prospective study, general surgical patients were randomized to either sequential compression devices (Group 1) or subcutaneous heparin (Group 2), and fibrinolysis factors were measured in order to determine the effect on the fibrinolysis system. Blood samples were drawn at a similar time of the day with the tourniquet off. Specifically, t-PA antigen, plasminogen activator inhibitor-1 (PAI-1), and D-dimer were measured preoperatively (preop) and on Postoperative Days (POD) 1 and 7 by the ELISA method. Fibrinolysis factors were reported as the mean +/- SD and as percentage change from preoperative values. Noninvasive vascular studies were performed preop, and on POD 1, 7, and 30, by an examination of the infrainguinal venous system and external iliac veins in bilateral lower extremities. Nonambulatory patients were excluded from the study and DVT prophylaxis methods were initiated at surgery and used through POD 2.

RESULTS

For the 136 patients in the study, there were no differences in clinical characteristics such as age, surgical time (all > 60 min), anesthesia type (general or spinal), type of surgical procedure, or other risk factors for DVT. Two DVTs occurred at POD 1 and 30 (both Group 2), and one pulmonary embolism in each group (POD 7 for Group 1; POD 1 for Group 2). For subjects without thrombosis, D-dimer changes were parallel for both groups, increasing through POD 7. Similarly, t-PA antigen levels rose from baseline on POD 1 in both groups, with a return toward baseline by POD 7. The PAI-1 levels increased on POD 1 in both groups, but severalfold more in Group 1 (compression devices). The elevation in PAI-1 decreased by 50% in Group 1 by POD 7, while values returned to normal in Group 2. These changes were not significant using the Mann-Whitney test. Only three patients had thrombotic episodes so that data on changes in fibrinolysis factors are difficult to compare with the larger group.

CONCLUSIONS

This is the first report of a prospective, randomized comparison of fibrinolysis factors using sequential compression devices in comparison to low dose unfractionated heparin in general surgical patients, and comparing postoperative values to preop. Both groups showed an enhanced fibrinolysis by elevation in t-PA antigen and D-dimer on POD 1, as expected when fibrinolysis occurs. While PAI-1 and t-PA work in parallel, the marked elevation of PAI-1 on POD 1 (although only slightly above reference values) and continuing into POD 7 for subjects using compression devices requires further inquiry. The elevation of PAI-1 in the face of elevated t-PA and D-dimer has been reported, but the comparison between patients using sequential compression devices and mini-dose heparin has not been reported. The reason for the elevation requires additional study into other influences on the synthesis, secretion, and/or function of PAI-1 that do not affect t-PA.

A faculty on the move into the community

Faculty at the University of Rochester School of Nursing initiated a curricular redesign to prepare students for the evolving demands of the health care job market and the changing nature of the nursing profession. The concept of the "Learning Community" serves as the metaphor for the new vision of clinical education: a set of collaborative and dynamic relationships of students, faculty, clinicians, health care consumers and institutional and community sites with the mutual responsibility for the education of students and the health of all partners. Students experience firsthand the new capabilities required of professionals in the new context of health care as more than illness care.

Identification and characterization of additional flagellin genes from Vibrio anguillarum

Previously, the flagellar filament of Vibrio anguillarum was suggested to consist of flagellin A and three additional flagellin proteins, FlaB, -C, and -D. This study identifies the genes encoding FlaB, -C, and -D and a possible fifth flagellin gene that may encode FlaE. The flagellin genes map at two separate DNA loci and are most similar to the four polar flagellin genes of Vibrio parahaemolyticus, also located at two DNA loci. The genetic organization of these two loci is conserved between both organisms. For each gene, in-frame deletions of the entire gene, the 5' end, and the 3' end were made. Mutant analysis showed that each mutation, except those in flaE, caused a loss of flagellin from the filament. However, no obvious structural loss in the filament, as determined by electron microscopy, and only slight decreases in motility were seen. Virulence analysis indicated that all but two of the mutations gave a wild-type phenotype. The 5'-end deletions of flaD and flaE decreased virulence significantly (>10(4)-fold) of infections via both the intraperitoneal and immersion routes. These results indicate that, like FlaA, FlaD and FlaE may also be involved in virulence.

5-Fluorouracil and cisplatin therapy after palliative surgical resection of squamous cell carcinoma of the esophagus. A multicenter randomized trial. French Associations for Surgical Research

BACKGROUND

The curative rate of surgical resection of squamous cell carcinoma of the esophagus is low. Reports on the efficacy of preoperative and postoperative chemotherapy are conflicting or have included limited disease or radical surgery alone.

OBJECTIVE

The authors' objective was to study the results of chemotherapy on the duration and quality of survival in patients who have undergone palliative surgical resection for esophageal squamous cell carcinoma.

PATIENTS AND METHODS

Of 124 patients with histologically proven esophageal squamous cell carcinoma situated more than 5 cm from the upper end of the esophagus, 4 patients were withdrawn for failure to comply with the protocol. The remaining 120 patients, 116 males and 4 females (mean age, 57 +/- 9 years), were randomly assigned to either a control group who were to receive no chemotherapy (68 patients) or to a group who were to be treated with chemotherapy (52 patients). Patients were subdivided into two strata as follows: (1) stratum I, complete resection of the tumor with lymph node involvement (62 patients) and (2) stratum ii, incomplete resection leaving macroscopic tumor tissue in situ or with metastases. Noninclusion criteria were histologically proven tracheobronchial involvement, esotracheal fistula, major alteration of general health status (Karnofsky score <50), cerebral or extensive (>30% of parenchyma) hepatic metastasis, peritoneal carcinomatosis, associated or previously treated upper airway cancer, or, conversely, complete resection of tumor without lymph node involvement. Chemotherapy was given in 5-day courses, every 28 days, with a maximum of 8 courses. Cisplatin was administered either as a single dose of 100 mg/m2 at the beginning of the course or as 20 mg/m2/day for 5 days given over 3 hours. 5- Fluorouracil (5-FU) (100 mg/m2/day) was infused over 24 hours for 5 days. The duration of treatment ranged from 6 to 8 months. The main aim was to establish median survival and actuarial survival curves. The subsidiary aim was to evaluate quality of survival as judged by complications due to treatment and the duration of autonomous oral feeding, that is, without palliative endoscopic treatment. No difference in survival was noted between the two groups, overall (median, 14 months), or between the strata. Conversely, significantly more patients in the treated group had hematologic, neurologic, and renal complications compared with the control group. Four patients died of complications of chemotherapy. The duration of autonomous oral alimentation was exactly the same in both groups (median, 12 + months).

CONCLUSION

The results of this study suggest that 5-FU and cisplatin are not useful for patients with squamous cell carcinoma of the esophagus who have not undergone curative resection.

Is DVT prophylaxis overemphasized? A randomized prospective study

This study was designed to prospectively evaluate a previously published prognostic index for predicting deep venous thrombosis (DVT) in general surgical patients with conventional prophylaxis. Patients undergoing procedures of at least 1 hr duration (abdominal, thoracic, head and neck, inguinal) requiring general or spinal anesthetic were prospectively randomized into the following groups: Group 1, sequential pneumatic compression devices during surgery and 2 days postoperatively; Group 2, subcutaneous heparin (5000 U q 12 hr) starting 1 hr before surgery and for 7 days postop; Group 3, control group. All patients underwent duplex evaluation of bilateral lower extremity deep venous systems preoperatively and on postoperative Days 1, 3, and 30. In addition, a previously developed predictive DVT incidence indicator, the prognostic index (PI), was calculated for each patient. A total of 137 patients were entered into the study with 29 removed for patient/staff reasons. There were no differences in PI among the three groups at the 0.05 level (ANOVA). The distribution of risk factors for DVT including increased age, body size, hemoglobin (Hb), and colorectal procedures were distributed evenly among the groups. Additional factors such as diabetes, COPD, PVD, immobilization, and cancer were also evenly distributed among the groups. The PI predicted a 20% incidence of DVT. For Groups 1 (n = 25), 2 (n = 38), and 3 (n = 45) no DVTs were detected over the 30 days of study. During the study period, 8 DVTs were detected by duplex evaluation in general surgical patients not in the study (1.5%). In conclusion, in a prospective randomized study using sequential pneumatic compression devices, subcutaneous heparin or no prophylaxis in matched general surgical patients at moderate to high risk for thromboembolism, no DVTs occurred for up to 30 days. Furthermore, neither a PI nor other factors associated with DVT accurately predicted the incidence of DVT in this patient population.

The uncertain response in the bottlenosed dolphin (Tursiops truncatus)

Humans respond adaptively to uncertainty by escaping or seeking additional information. To foster a comparative study of uncertainty processes, we asked whether humans and a bottlenosed dolphin (Tursiops truncatus) would use similarly a psychophysical uncertain response. Human observers and the dolphin were given 2 primary discrimination responses and a way to escape chosen trials into easier ones. Humans escaped sparingly from the most difficult trials near threshold that left them demonstrably uncertain of the stimulus. The dolphin performed nearly identically. The behavior of both species is considered from the perspectives of signal detection theory and optimality theory, and its appropriate interpretation is discussed. Human and dolphin uncertain responses seem to be interesting cognitive analogs and may depend on cognitive or controlled decisional mechanisms. The capacity to monitor ongoing cognition, and use uncertainty appropriately, would be a valuable adaptation for animal minds. This recommends uncertainty processes as an important but neglected area for future comparative research.

[Monitoring of multiple trauma in an emergency hospital unit]

In the monitoring of multiple trauma patients in the emergency hospital setting the use of monitors should be graduated. However, the use and interpretation of data from these monitors is becoming increasingly complex and can lead to errors and responses which may not be adopted. Clinical nomination and observation have their limits and the anaesthetist is faced with the added difficulties of interpretation of data from monitors and is pitfalls. The management of the patient is based on this human-machine relationship, which provides the basis for the therapeutic attitude and the treatment which ensues. Basic monitoring comprises a pulse oximeter, a capnograph, an ECG and a blood pressure monitor, 52% of incidents are detected by these instruments; 27% by SpO2, 24% by capnography. The pertinence is 82% for the oximeter when used alone and 55% for the capnography alone, although when the two are used together this increases to 88%. If the blood pressure monitor is added the pertinence increases to 93%, and to 95% if the FiO2 is monitored. The use of monitors of levels of haemoglobin or haematocrit must take into account the important variations in volaemia. The displayed values have a poor predictive value. The second level of monitoring comprises the use of a pulmonary artery catheter. The errors in measurement and interpretation are reviewed and finally, we consider the possible use of FOE transoesophageal echocardiography in the multiple trauma patient.

The uncertain response in the bottlenosed dolphin (Tursiops truncatus)

Humans respond adaptively to uncertainty by escaping or seeking additional information. To foster a comparative study of uncertainty processes, we asked whether humans and a bottlenosed dolphin (Tursiops truncatus) would use similarly a psychophysical uncertain response. Human observers and the dolphin were given 2 primary discrimination responses and a way to escape chosen trials into easier ones. Humans escaped sparingly from the most difficult trials near threshold that left them demonstrably uncertain of the stimulus. The dolphin performed nearly identically. The behavior of both species is considered from the perspectives of signal detection theory and optimality theory, and its appropriate interpretation is discussed. Human and dolphin uncertain responses seem to be interesting cognitive analogs and may depend on cognitive or controlled decisional mechanisms. The capacity to monitor ongoing cognition, and use uncertainty appropriately, would be a valuable adaptation for animal minds. This recommends uncertainty processes as an important but neglected area for future comparative research.

Sevoflurane elimination kinetics in children

We compared the rates of elimination of sevoflurane and halothane in 29 children, aged between one and seven years, undergoing ambulatory anaesthesia. Analgesia was provided by fentanyl and muscle relaxation by atracurium. Anaesthesia was maintained by inhalation of one MAC of either sevoflurane or halothane, based on an equipotent concentration of each agent for the age of the child. Following simultaneous discontinuation of N2O and the inhalational agent, the equation describing N2O washout was identical in the presence of halothane and sevoflurane, showing that there was no effect of the volatile agent on the rate of N2O elimination. The elimination of sevoflurane and N2O give similar types of equations. Halothane elimination gives a logarithmic type of equation, showing a slower release, corresponding to residual tissue content.

Crystallization and preliminary X-ray diffraction studies of bacterial ribosomal protein L14

Based on amino-acid sequence homology, it is predicted that ribosomal protein L14 is a member of a recently identified family of structurally related RNA-binding proteins. To verify this, the gene for Bacillus stearothermophilus L14 has been cloned, and the protein has been purified and crystallized. The crystals are in space group C2 with cell dimensions a = 67.0, b = 32.7, c = 49.4 A, and beta = 101.8 degrees, and there is one molecule in the asymmetric unit (V(m) = 2.0 A(3) Da(-1)). They are of high quality, and a native data set has been collected to a resolution of 1.6 A, with an R(merge) of 5.3%.

Evaluation of tabletop materials for autocontouring in CT treatment planning

Computerized tomography (CT) treatment planning has been proven to be essential in precision radiotherapy. Typically CT planning requires a large number of CT scans (between 3 and 50 slices) to be entered into the treatment planning system. A significant amount of time in the planning process is devoted to outlining internal structures, organs, and the external patient contour in each CT slice. In principle, external contours could be generated easily using autocontouring routines; however, in reality it does not always provide a satisfactory contour due to the limitations of the CT tabletop having nearly the same CT number as that of the body structure. A solution to this problem is to create a large CT number gradient interface between the patient and CT tabletop by inserting a thin sheet of low CT number material. The optimum material for a tabletop was investigated from a range of low-density and low atomic number media. Various materials were studied by placing them underneath an unsliced humanoid phantom. A portion of the phantom abdomen was imaged and analyzed on a Picker Premier IQ CT scanner. Results indicate that the tabletop should be made of the material that has a CT number at least 10 times lower than the tissue in contact with the table. A simple and cost-effective method of avoiding failures in autocontouring is to place a thin sheet of low-density material such as cardboard or foam board on the tabletop. Such an insert creates a large CT gradient resulting in a significant improvement in the accuracy of the edge detection algorithm used for autocontouring. Detailed analysis is presented.

Antigenic cross-reactions among immunoglobulin of diverse vertebrates (elasmobranchs to man) detected using xenoantisera

1. Antisera raised in rabbits and goats against intact immunoglobulins or their constituent light and heavy chains from man, mouse and the galapagos shark (Carcharhinus galapagenesis) were tested for their reactivity with immunoglobulins of elasmobranchs, other lower vertebrates and eutherian and prototherian mammals. 2. Xenoantisera directed against human heavy chain isotypes allowed the serological identification of IgM and IgG immunoglobulins in the echidna (Tachyglossus aculeatus), a monotreme which is one of the most primitive species of extant mammals. 3. The antisera to heavy chains reacted to varying degrees with purified immunoglobulins of non-mammalian species, including the chicken, teleost fish and elasmobranchs in a fashion that was specific for immunoglobulins, but was not related to defined human isotypic markers. 4. The reactions of some antisera seem to skip species known to possess homologous immunoglobulins. 5. Antisera directed against isotypic markers of human kappa and lambda light chains reacted with shark light chains in a manner that was specific for light chain determinants but was not isotype-related. 6. Antisera directed against heavy chains of either sharks or mammals reacted with heavy chains, but not with light chains of diverse species. 7. A rabbit antiserum specific for shark light chain reacted with human and murine monoclonal lambda chains and with two synthetic peptides corresponding to human V lambda Fr3 and Fr4 sequences. 8. These results establish that a variety of antigenic markers including conformational and linear determinants can be shared among immunoglobulins of vertebrates species that had an ancestral divergence more than 400 million years ago.

COAD (clinical outcome assessment documentation) charting: using the quality improvement process to meet the new JCAHO nursing standards

The shortage of nurses has prompted departments across the nation to examine nursing practices in individual healthcare facilities and to initiate changes where relevant. Saint Thomas Hospital, a 571-bed tertiary-care facility, developed a number of strategies designed to allow nurses to focus on skills consistent with professional practice and to reassign technical and clerical duties to other members of the healthcare team. One of the changes implemented was the clinical outcome assessment documentation (COAD) system, which communicates the plan of care without the use of a separate form, expedites charting times, and eliminates duplication. This system also facilitates the documentation of the patient's progress toward outcome-oriented goals. Evaluation of the COAD system after implementation showed improvement in documentation of the nursing process, staff satisfaction with the system, and compliance with the Joint Commission's 1991 nursing standards.

Post-herniorrhaphy urinary retention: a randomized prospective study

Urinary retention is a known complication of inguinal herniorrhaphy. Bladder distension due to vigorous fluid administration is believed to contribute to this problem. Our hypothesis is that fluid restriction will lower the incidence of urinary retention, post-herniorrhaphy. From January 1989 through March 1991, 113 male patients entered the study. Sixty patients (Group I) received unlimited iv fluids (1294 +/- 58 ml) and 9 patients (15%) developed urinary retention. Fifty-three patients (Group II) received 500 ml or less by protocol (485 +/- 2 ml) and 5 of these patients developed retention (9%). Thus, fluid restriction lowered the incidence of urinary retention post-herniorrhaphy but the difference did not reach statistical significance. In addition age over 60 years approached significance as a risk factor for postoperative urinary retention.

Hemodynamic and catecholamine response to isoflurane versus droperidol in complement to fentanyl anaesthesia

Droperidol (0.03 mg.kg-1 to 0.25 mg.kg-1) with fentanyl has been reported to be less efficient than volatile agents in the prevention of haemodynamic responses to surgery. The aim of this study was to investigate the use of high-dose droperidol in complement to fentanyl in comparison with isoflurane and fentanyl anaesthesia. Thirty patients undergoing laryngectomy were studied. Systolic blood pressure (SBP), heart rate (HR) and plasma catecholamines were analysed both during anaesthesia and during recovery. During surgery, SBP epinephrine (E) levels did not change in either group. HR was slightly lower during droperidol fentanyl anaesthesia. Norepinephrine (NE) levels were significantly higher in the droperidol group than in the isoflurane group (P less than 0.05). During recovery, in both groups, SBP increased by 20% whereas E levels increased by 65%. NE levels increased post-operatively in both groups, but this rise was significantly higher in the droperidol group (P less than 0.01). It is concluded that the two techniques contribute to the haemodynamic stability during surgery, but do not prevent haemodynamic instability during recovery.

Carbon dioxide monitoring during high frequency jet ventilation for direct laryngoscopy

To improve ventilation monitoring during direct laryngoscopy, we have developed a high frequency jet ventilator which allows the aspiration of tracheal gas for carbon dioxide analysis (PtCO2) through the injector after stopping the ventilator. In 41 patients undergoing direct laryngoscopy, PaCO2 and PtCO2 were measured simultaneously during high frequency jet ventilation under general anaesthesia. PtCO2 and PaCO2 correlated significantly (r = 0.88), but PtCO2 underestimated PaCO2 by 0.84 (SD 0.72) kPa. The arterial to tracheal PCO2 difference was influenced by airway obstruction.

Failure to find Ca2(+)-dependent proteinase (calpain) activity in a plant species, Elodea densa

Five and nine-tenth kg of Elodea densa (Anacharis), a common aquarium plant, was extracted, and the extract was subjected to column chromatographic procedures that successfully purify the two Ca2(+)-dependent proteinases (calpains) and their protein inhibitor (calpastatin) from a variety of animal tissues. Although these procedures purified a protein having 55- and 16-kDa polypeptides, neither this protein nor any of the other chromatographic fractions contained detectable proteinase or calpastatin activity. Moreover, the purified 55- and 16-kDa polypeptides did not react on immunoblots with polyclonal antibodies that were monospecific for the calpains or calpastatin. We conclude that Elodea densa contains no calpain nor calpastatin at the level of 4 micrograms per g plant protein (1 part per 250,000), which was the sensitivity of our assay.

[Caudal anesthesia in children: two-year retrospective study]

Caudal anesthesia has been used on a daily basis for two years in the Department of Anesthesia of Saint-Vincent-de-Paul Hospital. A retrospective study on 231 children was done to specify the procedures, the indication and the dosage of local anesthetics.