A meta-analysis of the effect of HIV prevention interventions on the sex behaviors of drug users in the United States

We examined the effectiveness of 33 U.S.-based HIV intervention studies in reducing the sexual risk behaviors of drug users by reducing unprotected sex or increasing the use of male condoms. The studies, identified as of June 1998, through the HIV/AIDS Prevention Research Synthesis project, were published in 1988 or later, measured behavioral or biologic outcomes, used experimental designs or certain quasi-experimental designs, and reported sufficient data for calculating an effect size for sexual risk reduction. Of the 33 studies, 94% recruited injection drug users; 21% recruited crack users. The mean age of participants was 36 years. Almost all studies were randomized (94%), provided another HIV intervention to the comparison groups (91%), and evaluated behavioral interventions (91%). On average, interventions were conducted in 5 sessions (total, 10 hours) during 4.5 months. Interventions compared with no interventions were strong and significant (k = 3; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.43-0.85). Interventions compared with other HIV interventions showed a modest additional benefit (k = 30; OR, 0.91; 95% CI, 0.81-1.03). When we extrapolated our result (an OR of 0.60) to a population with a 72% prevalence of risk behavior, the proportion of drug users who reduced their risk behaviors was 12.6% greater in the intervention groups than in the comparison groups. Our meta-analysis shows that interventions can lead to sexual risk reduction among drug users and justifies providing interventions to drug users. Developing interventions with stronger effects to further reduce sexual risk behaviors among drug users must remain a high priority.

Continuous self-improvement: systems thinking in a personal context

BACKGROUND

Continuous quality improvement (CQI) thinking and tools have broad applicability to improving people's lives--in continuous self-improvement (CSI). Examples include weight loss, weight gain, increasing exercise time, and improving relationship with spouse. In addition, change agents, who support and facilitate organizational efforts, can use CSI to help employees understand steps in CQI. A STEP-BY-STEP APPROACH: Team members should be involved in both the definition of the problem and the search for the solution. How do everyday processes and routines affect the habit that needs to change? What are the precursors of the event? Clients list possible solutions, prioritize them, and pilot test the items selected. One needs to change the daily routines until the desired behavior is accomplished habitually and with little external decision.

DISCUSSION

CSI is successful because of its emphasis on habits embedded in personal processes. CSI organizes support from process owners, buddies, and coaches, and encourages regular measurement, multiple small improvement cycles, and public reporting.

Collaborating for improvement in health professions education

Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.

The role of the family system in HIV risk reduction: youths with hemophilia and HIV infection and their parents. Adolescent Hemophilia Behavioral Intervention Evaluation Project (HBIEP) Study Group

OBJECTIVE

To examine the relationship between family communication and HIV risk reduction behaviors among a multisite sample of 125 male youths (ages 12-25) with hemophilia and HIV- infection, as well as their parents.

METHODS

Participants completed self-report surveys assessing communication and attitudes regarding HIV risk reduction interventions; adolescents also provided data about their sexual behaviors.

RESULTS

Adolescents with parents who discuss sexual issues were more likely to report HIV status disclosure to sexual partners. Most parents were supportive of HIV risk reduction interventions for their adolescents, but the youths themselves tended to endorse only interventions that offered opportunities for recreational activities and socialization with peers.

CONCLUSIONS

Findings are discussed in terms of intervention implications and the need for family systems-based programs.

Formulating the mess: lessons from "Building Knowledge of Health Care as a System"

This article describes the experiences of a group of health administration educators, a group of medical educators, and a group of nursing educators in applying the lessons of the exercise "Building Knowledge of Health Care as a System" to the organization of health professions education.

Taking aim at interdisciplinary education for continuous improvement in health care

Over the last 30 years, nursing faculty have achieved varying levels of success in their efforts to engage in interdisciplinary education. To sharpen the focus, the Institute for Healthcare Improvement sponsored a national demonstration project in which nursing faculty from four universities participated.

The NCLEX-RN examination is changing: are you ready?

The NCLEX-RN Test Plan has been revised. The test plan retains "Client Needs" as the major content dimension and integrates "Phases of the Nursing Process" into all areas. Client Needs are divided into four categories. The four categories are divided further into a total of 10 subcategories that will be used to determine the percentage of questions on each candidate's examination. The authors describe the changes to the NCLEX-RN Test Plan and implications for nursing educators.

Rosai-Dorfman disease presenting as a parotid mass

Sinus histiocytosis with massive lymphadenopathy (SHML) is a rare, benign disease of unknown aetiology. This disease typically presents with massive, painless cervical lymphadenopathy but may occur in a wide variety of extranodal sites. Our report describes a 71-year-old man who presented with a discrete, unilateral parotid mass which was clinically suggestive of a primary salivary gland tumour. Initial cytological examination of a fine needle aspirate specimen taken from the mass demonstrated a discohesive cell population with nuclear atypia, raising the possibility of malignancy. However, excision of the mass and histological examination enabled a definitive diagnosis to be made.

Health care reform and managed care: challenges for nursing education

The future of nursing education is inextricably linked to structural changes in the health care delivery system, changes brought about by health care reform, integrated health care delivery systems, and the use of "managed care." Multiple entry points to nursing education cause overlap in skills of graduates and result in rework. This article discusses this problem, the impact of the changing job market and case management on nursing education, and two new emerging advanced practice roles: the primary care nurse practitioner and the acute care nurse practitioner.

Working from upstream to improve health care: the IHI interdisciplinary professional education collaborative

BACKGROUND

Recognizing the need to find new models for educating health professionals, the Institute for Healthcare Improvement (IHI) initiated the Interdisciplinary Professional Education Collaborative in April 1994. The goal of the Collaborative is to improve health care by working from upstream, to address the health professions workforce changes demanded by the need to deliver better care at a lower cost. With support and advice from IHI and others, faculty leaders in health professions education from the disciplines of medicine, nursing, and health administration framed a vision of the future in which "health professions education has evolved into an integrated teaching/learning environment in which health professionals are working together across discipline boundaries, using the best knowledge for improvement to continuously improve health care". This article describes the first year of the three-year project.

SUMMARY

The 1994-1995 pilot year of the Collaborative involved more than 60 learners and 50 faculty members, across multiple disciplines. At each of the four sites, education was integrated with efforts to improve health care delivery. Education-oriented outcomes include assessment of student learning (applied knowledge and skills) and program evaluation (student and faculty feedback on the effect of the project on community-based experiential learning sites). Even at this early stage, there is evidence of change in participating institutions. The Collaborative in now planning how to increase the number of students and faculty involved in such a way that a deeper understanding of how to prepare new health professionals to improve health care may be determined.

Lack of effect of relaxin on oxytocin output from the porcine neural lobe in vitro or in lactating sows in vivo

Oxytocin was measured in incubates and perifusates of neurosecretosomes prepared from sow neural lobes (n = 50) and in incubates of isolated neural lobes (n = 5). In none of these preparations was oxytocin output affected by exposure to purified porcine relaxin (at concentrations up to 10(-7) mol l-1). Moreover, in lactating sows (n = 9), 6-10 days post partum, the administration of porcine relaxin (1.5 or 3.0 mg) intravenously, immediately before a suckling episode, did not affect the plasma oxytocin profile compared with saline treatments (within sow) nor did it alter suckling behaviour or the weight gain of the litter. In all sows, a spike (25-75 pg ml-1) of oxytocin was measured during milk ejection coincident with suckling. These results suggest that porcine relaxin does not affect oxytocin release in suckling sows in contrast to reported findings in rats. The data also support the view that porcine relaxin could be used at farrowing without adverse effects on suckling.

The serologic response of hamsters to experimental liver inoculations with Entamoeba histolytica as measured by indirect hemagglutination test and enzyme linked immunosorbent assay

Results of testing 298 sera from hamsters inoculated in the liver with Entamoeba histolytica and from 25 uninoculated controls by indirect hemagglutination (IHA) and enzyme linked immunosorbent assay (ELISA) showed that measurable amounts of antibody appeared as early as 5 days after inoculation, generally increased to a high level within 20 days, and persisted for the duration of the experiments (58 days). There was fair correlation between size of liver lesion and titers. Strain differences in amebae used for antigen and for inoculation could not be detected by either test. The IHA test appeared to be very sensitive, and titers of 1:16 and above were specific. With the ELISA technique, it was tentatively concluded that titers of 1:32 were specific for anti-amebic antibodies but only those of 1:128 and above were indicative of liver infections in the experimentally infected hamsters.

The laboratory diagnosis of Pneumocystis carinii pneumonia

In the diagnosis of Pneumocystis carinii infection in man, rather exacting methods of staining must be used for the organism to be visualized in lung tissue. Techniques for sample collection, which range from open lung biopsy to endobronchial brush methods or collection of sputum, are discussed. Recent advances in the serologic diagnosis and in the culture of the organism are also covered.

Failure of pentamidine isethionate to provide chemoprophylaxis against Pneumocytis carinii infection in rats

Latent Pneumocystis carinii infections were exacerbated in 54 adult male Sprague-Dawley rats by administration of alternating subcutaneous doses of hydrocortisone-21-phosphate and of cortisone acetate three times a week, plus 0.5% chlortetracycline in their drinking water, until death or the termination of the experiment at 120 days. Twenty-eight of the rats were also given pentamidine isethionate (4mg/kg) intramuscularly daily for 14 days. Pentamidine-treated animals that died within the 120 days of the experiment survived longer than control animals. At necropsy, however, every animal in both groups had P. carinii in the lungs. The intensity of the infection was the same in the pentamidine-treated and control groups. Pentamidine isethionate administered in this standard regimen does not exert a significant chemoprophylactic effect against proliferation of P. carinii in rats. The study provides little encouragement for use of pentamidine as a prophylactic agent against P. carinii in high-risk patients.

Some observations on the serology of Pneumocystis carinii infections in the United States

An indirect immunofluorescent (IF) test with antigen of partially cleaned Pneumocystis carinii cysts was evaluated for sensitivity and specificity. The test was reactive at the 1:8 and above level for 44% of the persons who had suspected and confirmed infections, for 7.3% of the healthy contacts, and for 1.4% of the general population. Results of tests with sera from people with measurable antibodies to other diseases and those on immunosuppressant therapy suggest that only titers of 1:20 and above are specific. At this level, tests with sera of 32% of the cases, 4% of the contacts, 0% of the healthy controls, and from 0% to 37% (average 5%) of individuals on long-term immunosuppressive therapy or with antibodies to other diseases were positive. The high percentage of positive reactions in cytomegalovirus and in fungal infections could represent double infections. The complement fixation test was less sensitive than the IF test. Antibodies measured by the IF test were immunoglobulin G. No differences in antigenicity were demonstrated by the IF test among the cysts from eight human infections or from induced rat infections.