HIV in young people: characteristics and predictors for late diagnosis of HIV

Late diagnosis of human immunodeficiency virus (HIV) infection remains a challenging issue, especially in young population, which accounts for approximately half of new HIV infections. This study aimed to assess factors associated with late diagnosis of HIV infection in young people. It employed a hospital-based case-control design, conducted during January 2012 through August 2013. A total of 193 patients aged 18-25 years old from 21 hospitals across Thailand were studied. Late diagnosis was defined as presentation when the CD4 cell count was less than 350 cells/µL within 12 months of the first HIV diagnosis, or AIDS-defining event is present within 12 months of the first HIV diagnosis. Factors associated with the late diagnosis of HIV were those who: did not live with their parent (OR 3.87; 95% CI 1.40-10.66), had no children (OR 3.25; 95% CI 1.27-8.31), had their first sexual intercourse at age older than 18 years (OR 4.25; 95% CI 1.27-14.22), had same-age or older partners (OR 3.36; 95% CI 1.39-8.08), were substance users (OR 3.65; 95% CI 1.22-10.88), believed they changed their behaviors after receiving HIV education (OR 2.48; 95% CI 1.02-5.99), and sought care at regional (OR 3.19; 95% 1.31-7.79) or general hospitals (OR 3.34; 95% 1.07-10.35). Strategies for early HIV detection in young people should be reconsidered; particularly the involvement of parents and targeting the right population.

The role of craving in alcohol use, dependence, and treatment

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The organizer and chair was Barbara A. Flannery, and the co-chairs were Barbara A. Flannery and Helen Pettinati. The presentations were (1) Animal models of alcohol craving and relapse, by Amanda Roberts; (2) Real-time field assessment of alcohol craving, by Ned Cooney; (3) Medications and alcohol craving, by Robert Swift; (4) The assessment of craving: Insights from the clinic and clinical laboratory studies, by Raymond Anton; (5) A comparison of three alcohol craving questionnaires, by Barbara Flannery; (6) and Assessing posttreatment urge to drink, by Damaris Rohsenow.

Usefulness of Doppler sonography in the diagnosis of ovarian torsion

OBJECTIVE

To assess the predictive value of Doppler sonography in the diagnosis of ovarian torsion and to correlate Doppler results with surgical findings and various clinical characteristics.

DESIGN

Retrospective study of discharged inpatients.

SETTING

An academic community hospital.

PATIENT(S)

Twenty-one patients with surgically confirmed ovarian torsion over an 8-year period.

INTERVENTION(S)

Data were collected on Doppler flow results, ultrasound and surgical findings, patient characteristics, and associated morbidity.

MAIN OUTCOME MEASURE(S)

Accuracy of Doppler diagnosis as to presence of ovarian torsion.

RESULT(S)

Twenty-one patients had surgically confirmed ovarian torsion. Doppler sonography was performed in 10 of the 21 patients. Doppler sonographic findings were normal in 60% (6 of 10), and abnormal (decreased or absent) in 40% suggestive of torsion. In cases involving ovulation induction, Doppler sonography findings were normal in 25% (1 of 4). Furthermore, the time to diagnosis of ovarian torsion (mean = 5.3 hours) and the time to hospital discharge (mean = 2 days) were both decreased when compared with instances when normal flow was detected by Doppler sonography (59 hours and 2.7 days, respectively).

CONCLUSION(S)

Abnormal flow detected by Doppler sonography is highly predictive of adnexal torsion and is therefore useful in the diagnosis of ovarian torsion. However, when normal flow is detected by Doppler sonography, it does not necessarily exclude an ovarian torsion; in fact, torsion is missed in 60% of cases, and time to diagnosis in these cases is delayed. In cases of ovulation induction, sensitivity is increased to 75%.

CSF monoamine metabolite and beta endorphin levels in recently detoxified alcoholics and healthy controls: prediction of alcohol cue-induced craving?

BACKGROUND

Abnormalities in central neurotransmitter systems have been described in alcohol-dependent individuals and may contribute to alcohol craving. This study compared cerebrospinal fluid (CSF) levels of monoamine metabolites and beta endorphin levels in samples from early-onset alcohol-dependent patients (n = 20), late-onset alcohol-dependent patients (n = 14), and healthy controls (n = 23). It also evaluated whether these CSF measures levels predicted the degree of craving experienced in response to an alcohol cue.

METHODS

Individuals meeting DSM-III and -IV R-criteria for alcohol dependence, 1 to 3 months postdetoxification, and healthy controls underwent a lumbar puncture. Patients also completed a cue exposure test day between 3 and 15 days later.

RESULTS

Alcohol-dependent patients had lower CSF levels of the norepinephrine metabolite MHPG compared with the healthy subjects, but this difference disappeared when differences in age between the groups were accounted for. No other group comparisons between patients and healthy subjects reached significance. CSF levels of the dopamine metabolite HVA were significantly higher in the early-onset patients compared with the late-onset patients and controls. The CSF measures did not predict the precue levels of craving, or the increase in craving after alcohol cue exposure.

CONCLUSIONS

These results are inconclusive about the role of monoaminergic dysregulation in recovering alcoholics. They also question the utility of these CSF measures to predict alcohol cue reactivity in patients who have been sober at least 1 month.

Health outcomes for people who use palliative care services

Health outcomes are being promoted as a necessary evaluation measure in health care services. Less often discussed is the notion that health outcomes are artificially designated endpoints and that different people in the health system have different ideas of what the outcomes ought to be. Whose evidence is acceptable and relevant in constructing a framework of health outcomes in palliative care? This paper presents the findings of a research project undertaken in New South Wales, Australia, on health outcomes as evaluated by patients and caregivers. A wide range of health care professionals also participated. Patients and caregivers valued outcomes or endpoints in palliative care that were not necessarily brought about by expert clinical intervention. By adopting too narrow an interpretation of outcomes we risk sacrificing that which is uniquely valuable in palliative care services.

Evidence of acoustic startle hyperreflexia in recently detoxified early onset male alcoholics: modulation by yohimbine and m-chlorophenylpiperazine (mCPP)

Preclinical studies suggest that acoustic startle amplitude is increased during ethanol withdrawal. The current study evaluated the effects of intravenous infusion of the alpha 2-adrenergic antagonist, yohimbine (0.4 mg/kg), the serotonin partial agonist m-chlorophenylpiperazine (mCPP, 0.1 mg/kg), and placebo administered to 22 male patients meeting DSM-III-R criteria for alcohol dependence and 13 male healthy subjects. Patients and healthy subjects completed 3 test days under double-blind conditions in a randomized order. Patients were sober for 12-26 days prior to testing. On each test day, participants completed startle testing 80 min following drug infusion. Stimuli with varying intensities (90, 96, 102, 108, 114 dB) were presented in a randomized order balanced across four blocks. Stimuli consisted of 40-ms bursts of white noise administered every 45-60 s for 15-20 min through headphones. Analyses indicated that patients exhibited elevated acoustic startle magnitudes on the placebo day relative to healthy subjects. In patients, the magnitude of startle amplitudes elicited at 90 dB, but not 114 dB, correlated significantly with the number of previous alcohol detoxifications. Yohimbine increased startle magnitudes and reduced startle latencies relative to placebo and mCPP in both patients and healthy subjects. mCPP did not alter startle magnitude in either group. Yohimbine also increased the probability that a 90-dB stimulus produced a startle response in healthy subjects, but not in patients. Blunting of yohimbine effects on startle probability may reflect the baseline elevations in startle probability levels in patients, but may also be consistent with other evidence of reduced postsynaptic, but not presynaptic, noradrenergic function in these same patients. These data replicate and extend previous reports indicating that yohimbine facilitates the acoustic startle response in humans. They also further implicate the number of episodes of ethanol withdrawal as a factor influencing subsequent neurobiological responsivity in chronic alcoholic patients. Based on the current data, future research should explore whether measurement of the acoustic startle response provides an objective quantitative severity measure of ethanol withdrawal.

Specificity of ethanollike effects elicited by serotonergic and noradrenergic mechanisms

BACKGROUND

This study evaluated the specificity of the ethanollike effects of the serotonergic receptor partial agonist m-chlorophenylpiperazine hydrochloride (MCPP) relative to the alpha 2-adrenergic receptor antagonist yohimbine hydrochloride and the placebo in recently detoxified alcoholics. It also examined the relationship between ethanollike discriminative properties and the induction of craving in these patients. Both MCPP and yohimbine are anxiogenic in humans; thus, this study evaluated the role of anxiogenic and ethanollike effects in the elicitation of craving.

METHODS

Twenty-two male inpatients who met DSM-III-R criteria for alcohol dependence and who had not consumed alcohol for 12 to 26 days prior to the study completed 3 days of testing that involved the intravenous infusion of MCPP (0.1 mg/kg), (0.1 mg/kg), yohimbine hydrochloride (0.4 mg/kg), or a saline solution over 2 weeks under double-blind conditions. Ethanollike subjective effects were assessed using the Sensation Scale and visual analog scales to measure the degree of similarity to the effects of ethanol, cocaine, and marijuana. Five components of craving for alcohol were assessed using visual analog scales. The effects of the drugs on mood were assessed using visual analog scales. Plasma levels of cortisol, prolactin, and 3-methoxy-4-hydroxyphenylethyleneglycol were also measured during the test days.

RESULTS

m-Chlorophenylpiperazine and yohimbine produced significant increases compared with placebo in Sensation Scale scores and the visual analog scale score for nervousness. However, the effects of MCPP were rated as more similar to those of ethanol, cocaine, and marijuana than were those of either yohimbine or placebo. Also, MCPP but not yohimbine or placebo significantly increased craving for alcohol. Yohimbine and MCPP increased plasma prolactin and cortisol levels relative to placebo, whereas only yohimbine increased plasma 3-methoxy-4-hydroxyphenylethleneglycol levels.

CONCLUSIONS

m-Chlorophenylpiperazine produced ethanollike effects and alcohol craving in recently detoxified alcoholics. Yohimbine increased Sensation Scale scores but was not recognized as ethanollike by patients. Although both drugs produced comparable levels of nervousness, yohimbine did not increase craving for alcohol. These data further implicate serotonergic systems in the discriminative properties of ethanol and may indicate a serotonergic contribution to craving. Noradrenergic systems contributed to the discriminative properties of ethanol but not to those features of ethanol response that were salient to craving in this population.

Comparison of metal versus Vialon subcutaneous catheters in a palliative care setting

In 63 evaluable palliative care patients requiring intermittent bolus subcutaneous administration of medication, who were randomly assigned either a standard metal subcutaneous needle or a PTFE (Vialon) catheter, there was a significantly greater incidence of local reactions at the insertion site with the metal needles (9/30) compared with the PTFE catheters (2/33). Despite this, there was no significant difference between the two in functional survival. Volume of medication injected per day was the best predictor of total time that the subcutaneous lines remained in situ.

Reactivity to alcohol cues in alcoholics and non-alcoholics: implications for a stimulus control analysis of drinking

The present study is an attempt to identify responses to alcohol-related stimuli which might differentiate alcoholics from non-alcoholics. The assumption was that alcoholics would be more reactive to alcohol cues because of prior conditioning history with respect to alcohol and drinking. Eight alcoholics in treatment were compared with ten non-alcoholic controls and two recovering alcoholics, using swallowing and salivation as the principal dependent measures. (The concordance of swallowing and salivation was validated using dental rolls with an independent group of ten alcoholics.) Five-minute "sniff-trials" were provided in which subjects smelled either cedar chips or their favorite alcoholic beverage, in a labelled container. Swallowing (salivation) and craving (desire to drink alcohol) were significantly elevated in alcohol-sniffing trials for alcoholics in treatment compared with non-alcoholics; cardiac rate and galvanic skin response duration were also elevated in alcoholics in treatment, though not significantly. Recovering alcoholics resembled alcoholics in treatment more closely than they resembled non-alcoholics. The data were examined in the context of conditioned withdrawal resembled non-alcoholics. The data were examined in the context of conditioned withdrawal and homeostatic protective mechanisms. Implications for the stimulus control analysis of drinking were discussed.