Attitudes of mothers toward their daughters' use of contraceptives in Israel

The objective of the study was to examine mothers' knowledge about contraception, their attitudes to their daughters' use of contraception, and their communication with their daughters on the subject. A 20-item questionnaire was distributed in gynecological clinics throughout Israel for completion by women who had daughters over the age of 14 years. The questionnaire covered the mothers' demographic data, use of contraception, knowledge of contraception, attitude to their daughters' contraceptive use and sexual relationships, and communication with their daughters about contraception. Only 36% of the women received contraceptive information from physicians. Almost half felt their daughter should begin sexual relations when she felt she was ready; over two-thirds felt she should begin using contraception before or at the time of beginning sexual relations. Over three-quarters spoke with their daughters about contraception. Higher educational level of the mother was associated with high rate use of contraception by the mother, her support of earlier use of contraception by her daughter, a greater likelihood of her discussing contraception with her daughter, and a lesser likelihood to view contraceptives as dangerous to one's health. It is concluded that mothers of teenage daughters in Israel are involved in their daughters' decisions to begin sexual relations and the use of contraceptives. Their knowledge of contraception is adequate, although some gaps are still apparent. Clear correlation is found between higher educational level of the mothers and a more liberal attitude toward their daughters' sex life.

Perceptions of HAART among gay men who declined a treatment offer: preliminary results from an interview-based study

As part of a prospective study of treatment decision making among people with HIV infection, we explored perceptions of HAART in a cohort who declined a treatment offer. This was a qualitative study in which 26 gay men were interviewed in relation to their views about HAART soon after treatment was recommended by their HIV physician. Fifteen themes were associated with the decision to decline HAART. These were grouped under three broad categories: doubts about personal necessity for HAART, concerns about potential adverse effects of taking HAART and satisfaction with the amount of personal control over the decision. These findings provide new insights into the type of beliefs that might inform people's evaluation of their perceived need for HAART and their concerns about HAART. Initiatives to support informed decisions should take account of these perceptions.

Diagnosis of MDR-TB: a developing world problem on a developed world budget

The resurgence of tuberculosis worldwide has been accompanied by an increase in the incidence of multidrug-resistant tuberculosis on all continents. While significant advances have been made in the rapid and accurate diagnosis of Mycobacterium tuberculosis, the molecular biology methods used in the research laboratory to elucidate the mechanisms of drug resistance cannot be transferred to the centers delivering patient care. These methods require skilled operators, cumbersome protocols and extravagant expense. A number of companies that already have a large investment in M. tuberculosis diagnostics are adapting their high-throughput technology to drug susceptibility testing. These methodologies are not applicable to the developing world not only because of the costs involved but through a lack of infrastructure that is required to operate these machines and deliver specimens to the point of testing. Alternative technologies for drug susceptibility testing that do not rely on an investment in expensive hardware are presented and their potential use in the field is discussed. Though still relatively expensive to perform, these newer innovations may lead to the development of less intricate technologies that have universal application and begin to move away from our obsession with molecular-based diagnostics to produce on all encompassing gold standard.

Response to Antiretroviral Therapy among Patients Exposed to Three Classes of Antiretrovirals: Results from the Eurosida Study

There is an increasing proportion of HIV-positive patients exposed to all licensed classes of antiretrovirals, and the response to salvage regimens may be poor. Among over 8500 patients in EuroSIDA, the proportion of treated patients exposed to nucleosides, protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitor (NNRTI) increased from 0% in 1996 to 47% in 2001. Four-hundred-and-thirteen patients, who had failed virologically two highly active antiretroviral therapy (HAART) regimens and experienced all three main drug classes, started a salvage regimen of at least three drugs, in which at least one new PI or NNRTI was included. Median viral load was 4.7 log copies/ml [Interquartile range (IQR) 4.2–5.2], CD4 lymphocyte count 150/mm3 (IQR 60–274/mm3) and follow-up 14 months. Of these patients, 283 (69%) subsequently experienced at least a 1 log decline in viral load and 202 (49%) achieved a viral load <500 copies/ml. Conversely, the CD4 count halved from the baseline value in 88 (21%), and 45 (11%) experienced a new AIDS-defining disease. In multivariable analyses, a 1 log viral load reduction was related to baseline viral load [relative hazard (RH) 1.27 per 1 log higher; P=0.008], a previous viral load of less than 500 copies/ml (RH 1.69; P=0.002), more recent initiation of the regimen (RH 1.36 per year more recent; P=0.02), number of new drugs in the regimen (RH 1.20 per drug; P=0.02), time since start of antiretroviral therapy (RH 0.94 per extra year; P=0.035) and time spent on HAART with viral load >1000 copies/ml (RH 0.96 per extra month; P=0.0001). Analysis of factors associated with CD4 count decline and new AIDS disease also indicated improved outcomes in more recent times and a tendency for a better response in those starting more new drugs, but no relationship with the total number of drugs. Outcomes in people starting salvage regimens appear to depend on the number of new drugs started but not on the total number of drugs being used.

Thymic activity in late-stage HIV-1 infected individuals receiving highly active antiretroviral therapy: potential effect of steroid therapy

OBJECTIVE

Our objective was to monitor the effect of steroid therapy on the thymic output and function of late-stage HIV-1-infected patients undergoing highly active antiretroviral therapy (HAART).

DESIGN

The indirect measurement of T cells that have recently emigrated from the thymus as a means of quantifying thymic output, and therefore thymic function, was achieved through use of the polymerase chain reaction-based signal joint T cell receptor rearrangement excision circles (sjTREC) assay. Proliferative capacity and interleukin (IL)-2 and IL-4 production by T cells after antigenic, mitogenic and IL-2 stimulation were also analysed.

METHOD

Measurements were made of sjTREC levels in peripheral blood mononuclear cell DNA samples from five HIV-1 infected patients (one on steroid therapy prior to and at the time of sample extraction) receiving HAART. IL-2 and IL-4 production and proliferative capacity were also measured in three patients, including the patient receiving steroids.

RESULT

The sjTREC assay gave an extremely weak result for the patient on steroids but, under the same assay conditions, provided clear, positive readings for the four patients not on steroids. Comparison of the patients' cytokine profiles revealed that IL-2 production was generally low or absent in all three patients tested but that IL-4 production was significantly higher in the patient given steroids. Functional potential as revealed by proliferation assays showed very low or absent cellular proliferation.

CONCLUSION

The thymic contribution to the restoration of T lymphocyte numbers, particularly during the treatment of HIV-1 infection, may become compromised if thymic inhibitory factors such as steroids are used. Furthermore, the use of steroids may also favour the development of a T helper 2 response, which could prove particularly undesirable during HIV-1 infection.

Cardiopulmonary resuscitation directives on admission to intensive-care unit: an international observational study

BACKGROUND

Resuscitation directives should be a sign of patient's preference. Our objective was to ascertain prevalence, predictors, and procurement pattern of cardiopulmonary resuscitation directives within 24 h of admission to the intensive-care unit (ICU).

METHODS

We enrolled 2916 patients aged 18 years and older from 15 ICUs in four countries, and recorded whether, when, and by whom their cardiopulmonary resuscitation directives were established. By polychotomous logistic regression we identified factors associated with a resuscitate or do-not-resuscitate directive.

FINDINGS

Of 2916 patients, 318 (11%; 95% CI 9.8-12.1) had an explicit resuscitation directive. In 159 (50%; 44.4-55.6) patients, the directive was do-not-resuscitate. Directives were established by residents for 145 (46%; 40.0-51.3) patients. Age strongly predicted do-not-resuscitate directives: for 50-64, 65-74, and 75 years and older, odds ratios were 3.4 (95% CI 1.6-7.3), 4.4 (2.2-9.2), and 8.8 (4.4-17.8), respectively. APACHE II scores greater than 20 predicted resuscitate and do-not-resuscitate directives in a similar way. An explicit directive was likely for patients admitted at night (odds ratio 1.4 [1.0-1.9] and 1.6 [1.2-2.3] for resuscitate and do-not-resuscitate, respectively) and during weekends (1.9 [1.3-2.7] and 2.2 [1.5-3.2], respectively). Inability to make a decision raised the likelihood of a do-not-resuscitate (3.7 [2.6-5.4]) than a resuscitate (1.7 [1.2-2.3]) directive (p=0.0005). Within Canada and the USA, cities differed strikingly, as did centres within cities.

INTERPRETATION

Cardiopulmonary resuscitation directives established within 24 h of admission to ICU are uncommon. As well as clinical factors, timing and location of admission might determine rate and nature of resuscitation directives.

Titration of subcutaneously administered eprinomectin against mature and immature nematodes in cattle

Eprinomectin has been approved for use as a topically applied endectocide for beef and dairy cattle. To determine if eprinomectin has utility as an injectable anthelmintic, it was titrated at 0.05, 0.1, and 0.2 mg/kg s.c. against adult (Trial 1) and at 0.05, 0.1, 0.14, and 0.2 mg/kg s.c. against immature (Trial 2) stages of lung and gastrointestinal nematodes in cattle. In Trial 1, every dose of subcutaneously delivered eprinomectin showed maximal or near-maximal (> or = 99%) efficacy against Haemonchus placei, Ostertagia ostertagi, Trichostrongylus axei, T colubriformis, Cooperia punctata, Nematodirus helvetianus, Oesophagostomum radiatum, and Dictyocaulus viviparus. Adult C. oncophora was the only exception. However, even against this species, the lowest dose of 0.05 mg/kg showed 93% efficacy, and the efficacious dose necessary to kill 95% (ED95) of adults was 0.056 mg/kg. In Trial 2, every dose of subcutaneously delivered eprinomectin showed maximal or near-maximal (> or = 99%) efficacy against the immature stages of all of the above species of endoparasites. As a result, ED95 values could not be calculated. Consequently, the exquisite potency against endoparasites through parenteral administration suggests that eprinomectin may also have potential utility as an injectable product for cattle.

Crystallization and preliminary X-ray analysis of glucose dehydrogenase from Haloferax mediterranei

Glucose dehydrogenase (E.C. 1.1.1.47; GlcDH) from Haloferax mediterranei has been overexpressed in Escherichia coli, solubilized by the addition of 8 M urea and refolded by rapid dilution. The protein has been purified by conventional techniques and crystallized by the hanging-drop vapour-diffusion method using sodium citrate as the precipitant. Two crystal forms representing the free enzyme and the binary complex with NADP(+) grow under these conditions. Crystals of form I diffract to beyond 3.5 A resolution and belong to the hexagonal space group P622, with unit-cell parameters a = b = 89.1, c = 214.6 A, alpha = beta = 90, gamma = 120 degrees. Crystals of form II diffract to greater than 2.0 A and belong to the orthorhombic space group I222 or I2(1)2(1)2(1), with unit-cell parameters a = 61.8, b = 110.9, c = 151.7 A, alpha = beta = gamma = 90 degrees. Calculated values for V(M) and consideration of the packing for both crystal forms suggests that the asymmetric units in both crystal forms contain a monomer.

Health-related quality of life in individuals infected with HIV in the era of HAART

PURPOSE

To compare health-related quality of life (HR-QOL) in individuals infected with HIV to general population levels and to assess the relationship between HR-QOL and markers of disease progression in the era of highly active antiretroviral therapy (HAART).

METHOD

This was a cross-sectional questionnaire-based study. This study included 154 individuals at least 18 years old with HIV who either were attending a London hospital or were visited by a community team in Brighton. Study participants were asked to complete two HR-QOL questionnaires. This study used HR-QOL, as measured using the Medical Outcome Study HIV Health Survey (MOS-HIV) and EuroQoL self-report (EQ-5D) questionnaires, as the main outcome measure. Responses on the EQ-5D were compared with a published general population data set. The relationships between scores on the MOS-HIV and EQ-5D questionnaires and a number of independent variables including CD4 count and viral load were also assessed.

RESULTS

Each analysis was based on the results of at least 128 questionnaires. The mean MOS-HIV mental and physical component scores were 43.2 (SD = 12.2) and 41.8 (SD = 13.2), respectively. After adjusting for differences in age and gender, it was shown that individuals with HIV reported significantly lower EQ-5D(utility) ( p =.0001) and EQ-5D(VAS) ( p =.0001) compared with the general population. However, further analysis revealed few significant associations between markers of disease progression and HR-QOL.

CONCLUSION

Individuals with HIV generally recorded significantly lower HR-QOL compared with the general population. Thus, prevention of further transmissions of the virus is still likely to prevent significant morbidity losses in addition to mortality losses, despite the availability of HAART. However, disease progression as measured is not clearly related to further reductions in HR-QOL.

Monoclonal antibody to polycyclic aromatic hydrocarbons based on a new benzo[a]pyrene immunogen

Benzo[a]pyrenebutyric acid (B[a]PBA) has been synthesized and covalently coupled to bovine serum albumin to generate monoclonal antibodies (Mab). A competitive indirect enzyme-linked immunosorbent assay (ELISA) for polycyclic aromatic hydrocarbons (PAH) has been developed with Mab B[a]P-13. It was shown by testing with 21 parent PAH and 10 compounds carrying methyl, hydroxy, or butyric acid functions that the antibody had broad specificity. Highest affinity was found for four- to six-ring PAH. Different organic co-solvents were tested. No loss in sensitivity, compared with controls in PBS, were found with methanol, dimethyl sulfoxide, and glycerol at final concentrations of 5 to 10%. Further, an observation was made that a modification (fine-tuning) of the affinity and specificity of the antibodies was possible by changing the type of the added organic co-solvent. The high susceptibility of the ELISA with regard to inorganic ions might be an indication of a more hydrophilic binding pocket e.g. involving a pi-cation interaction. Investigation of the effect of pH revealed that for pH between 6 to 9 there was no noticeable impairment. With an LOD as low as 30 pg per well for B[a]P the sensitivity of the ELISA is sufficient for analyses of solvent extracts of many environmental samples. As an example, the determination of a PAH sum parameter, given as B[a]P-equivalents, in crude aerosol extracts by both ELISA and HPLC revealed good correlation (r2=0.717) but approximately five-fold overestimation by the immunochemical method, obviously as a result of cross-reacting analytes.

The AKT kinase is activated in multiple myeloma tumor cells

Immunohistochemistry (IHC) was performed on archived bone marrow (BM) with a phosphospecific anti-AKT antibody. IHC on 26 BM biopsies from patients with multiple myeloma (MM) demonstrated phospho-AKT staining of malignant plasma cells in a cell membrane-specific pattern, whereas nonmalignant hematopoietic cells did not stain. Preabsorption of the antibody with phosphorylated AKT peptide, but not nonphosphorylated peptide, abrogated staining. Frequency of plasma cell staining in BMs of patients with stage I or smoldering MM was significantly less than that of stage III MM marrows. Plasma cells in 10 patients with monoclonal gammopathy of undetermined significance were not stained by the antibody. To investigate the significance of AKT activation, 2 cell lines initiated from cultures of primary MM cells were also studied. Both demonstrated constitutive AKT activation. Interruption of AKT activation and activity, achieved by either exposure to wortmannin or by ectopic expression of a dominant negative AKT mutant, resulted in inhibition of MM cell growth in vitro. These results indicate that activation of the AKT kinase is a characteristic of MM cells and suggest that AKT activity is important for MM cell expansion.

Monitoring a clinical trial conducted under the Food and Drug Administration regulations allowing a waiver of prospective informed consent: the diaspirin cross-linked hemoglobin traumatic hemorrhagic shock efficacy trial

In 1996, the US Food and Drug Administration (FDA) enacted Rule 21 CFR section 50.24, which allows a narrow exception to the requirement for prospective informed consent from human research subjects in clinical trials investigating potentially beneficial therapies for acute, life-threatening conditions. The first clinical trial to be conducted under this rule was sponsored by Baxter Healthcare Corporation and approved by the FDA on November 21, 1996. This large, multicenter, randomized clinical trial was designed to compare the addition of diaspirin cross-linked hemoglobin (DCLHb) with standard care in the initial resuscitation of adults experiencing severe, uncompensated, traumatic hemorrhagic shock. Before the first planned interim analysis of the data, review of fatal adverse events revealed an imbalance in mortality between the 2 treatment groups. The Data Monitoring Committee (DMC) recommended suspension of patient enrollment 24 days later. Additional data collection and analyses confirmed the excess number of deaths in patients treated with DCLHb but failed to reveal the cause of these deaths. The trial was formally terminated after only 112 of the planned 850 patients had been enrolled. We review the events leading up to and the rationale behind the DMC recommendations for suspension of patient enrollment and trial termination. Although the DCLHb trial was unsuccessful in achieving its goals, the monitoring process worked well. Emergency research was facilitated by DMC oversight, and the interests of research subjects were protected by the actions of the DMC.

Development of a self-directed learning readiness scale for nursing education

Self-directed learning is a method of instruction used increasingly in adult education. A scale was developed in response to a need for a valid and reliable instrument to measure self-directed learning readiness. Such a scale will allow nurse educators to diagnose students' attitudes, abilities and personality characteristics, necessary for self-directed learning. This study was undertaken in two stages. In the first, the Delphi technique utilizing a panel of 11 nurse educator experts was used to assess the content and construct validity of a number of items perceived to reflect self-directed learning readiness. Each panel member was asked to independently rate the relevance of each item on a Likert scale. The second stage involved the administration of the questionnaire to a convenience sample of 201 undergraduate nursing students. The questionnaire was analysed using principal components factor analysis with varimax rotation, Chronbach's coefficient alpha, and item-to-total correlations to measure the scale's construct validity, internal consistency (reliability), and unidimensionality, respectively.The resulting self-directed learning readiness scale appears homogeneous and valid. The scale will assist nurse educators in the diagnosis of student learning needs, in order for the educator to implement teaching strategies that will best suit the students. Furthermore the development of this scale will provide valuable data for curriculum development.

Surfing with spirochaetes: an ongoing syphilis outbreak in Brighton

BACKGROUND/OBJECTIVES

There has been a recent shift in the epidemiology of early syphilis in the developed world with sporadic outbreaks on a historic low level of background disease. Here we describe an ongoing outbreak of syphilis in Brighton.

METHODS

Data collected on all patients with a diagnosis of early infectious syphilis at Brighton GUM clinic.

RESULTS

30 cases of early syphilis were diagnosed over a 25 month period beginning in July 1999. 28 were homosexual or bisexual men, giving a rate of 134 cases per 100 000 homosexual men. The cases reported a median of three sexual contacts (range 1-50) in the preceding 6 months and 77% had concurrent regular and casual partners. 83% of contacts were casual and untraceable. Over one third (11) of these cases reported oral sex as their only risk factor for syphilis acquisition and were unaware of this transmission route. 70% were diagnosed with primary or secondary infection, the remaining 30% being asymptomatic with early latent infection. Eight of the cases were HIV positive and a further eight remain untested for HIV. At least one concurrent STI was found in 40% of cases. Regular outbreak control meetings, involving relevant healthcare professionals, were held to plan appropriate interventions.

CONCLUSION

The high rate of casual and untraceable contacts in this outbreak suggest that alternative control measures are necessary, including on-site testing and further health education regarding the oral transmission of syphilis. Continued vigilance for syphilis is essential, especially in those patients who are HIV positive.