What Influences Linkage to Care After Home-Based HIV Counseling and Testing?

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients’ desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients’ emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.

Prospective evaluation of urinary incontinence in severely obese adolescents presenting for weight loss surgery

BACKGROUND

Obesity has been associated with daytime urinary incontinence (UI), likely due to increased intra-abdominal pressure.

OBJECTIVES

To assess incontinence symptoms in severely obese adolescents before and 3 years after bariatric surgery.

SETTING

Tertiary care pediatric hospitals in the United States.

METHODS

The Teen-Longitudinal Assessment of Bariatric Surgery is a prospective, multicenter study designed to evaluate efficacy and safety of bariatric surgery in adolescents. Patients<19 years of age undergoing bariatric surgery at 5 centers between 2007 and 2012 were enrolled. Trained study staff collected baseline and postoperative anthropometric and clinical data. Presence and severity of UI were determined by standardized interview.

RESULTS

A total of 242 patients (76% female) were evaluated at baseline. The mean age was 17.1 years at baseline, and 72% were of white race. The preoperative median body mass index was 50.5 kg/m2. At baseline, 18% of females and 7% of males reported UI. Prediction analysis at baseline indicated that females, white race, and increasing body mass index had greater odds for UI. UI prevalence in females and males decreased to 7% and 0%, respectively, at 6 months after surgery (P<.01) and remained stable out to 36 months postoperatively. Furthermore, older patients were less likely to achieve 3-year UI remission or improvement.

CONCLUSIONS

In adolescents undergoing bariatric surgery, UI was more common in females than in males. Incontinence status significantly improved by 6 months and was durable to 3 years after surgery, suggesting that bariatric surgery favorably affects anatomic or physiologic mechanisms of bladder control in both males and females.

Research capacity building integrated into PHIT projects: leveraging research and research funding to build national capacity

Background

Inadequate research capacity impedes the development of evidence-based health programming in sub-Saharan Africa. However, funding for research capacity building (RCB) is often insufficient and restricted, limiting institutions’ ability to address current RCB needs. The Doris Duke Charitable Foundation’s African Health Initiative (AHI) funded Population Health Implementation and Training (PHIT) partnership projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia) to implement health systems strengthening initiatives inclusive of RCB.

Methods

Using Cooke’s framework for RCB, RCB activity leaders from each country reported on RCB priorities, activities, program metrics, ongoing challenges and solutions. These were synthesized by the authorship team, identifying common challenges and lessons learned.

Results

For most countries, each of the RCB domains from Cooke’s framework was a high priority. In about half of the countries, domain specific activities happened prior to PHIT. During PHIT, specific RCB activities varied across countries. However, all five countries used AHI funding to improve research administrative support and infrastructure, implement research trainings and support mentorship activities and research dissemination. While outcomes data were not systematically collected, countries reported holding 54 research trainings, forming 56 mentor-mentee relationships, training 201 individuals and awarding 22 PhD and Masters-level scholarships. Over the 5 years, 116 manuscripts were developed. Of the 59 manuscripts published in peer-reviewed journals, 29 had national first authors and 18 had national senior authors. Trainees participated in 99 conferences and projects held 37 forums with policy makers to facilitate research translation into policy.

Conclusion

All five PHIT projects strongly reported an increase in RCB activities and commended the Doris Duke Charitable Foundation for prioritizing RCB, funding RCB at adequate levels and time frames and for allowing flexibility in funding so that each project could implement activities according to their trainees’ needs. As a result, many common challenges for RCB, such as adequate resources and local and international institutional support, were not identified as major challenges for these projects. Overall recommendations are for funders to provide adequate and flexible funding for RCB activities and for institutions to offer a spectrum of RCB activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor RCB activities.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2657-6) contains supplementary material, which is available to authorized users.

How Much do Doctors know about Consent and Capacity?

To assess knowledge of capacity issues across different medical specialties we conducted a cross-sectional survey with a structured questionnaire at academic meetings, lectures and conferences.

Of 190 individuals who received the questionnaire 129 (68%) responded-35 general practitioners, 31 psychiatrists, 29 old-age psychiatrists and 34 final year medical students. Correct answers on capacity to consent to or refuse medical treatment were given by 58% of the psychiatrists, 34% of the geriatricians, 20% of the general practitioners and 15% of the students. 15% of all respondents wrongly believed that a competent adult could lawfully be treated against his or her will, with no obvious differences by specialty.

As judged by this survey, issues of capacity and consent deserve more attention in both undergraduate and postgraduate medical education.

Perceptions, circumstances and motivators affecting the implementation of contagious bovine pleuropneumonia control programmes in Nigerian Fulani pastoral herds

Contagious bovine pleuropneumonia (CBPP) is an infectious disease of cattle which substantially contributes to poor productivity of the sub-Saharan pastoral livestock sector. In Nigeria and most of the West African countries, limited public funding for CBPP control have necessitated farmers to bear a bigger burden of managing the disease. Understanding the factors influencing decision of farmers to implement disease control programmes is therefore a key element in informing future policies aimed at improving CBPP management. This study explored perceptions of Nigerian Fulani pastoral herdsmen on the responsibility for cattle healthcare, and identified their circumstances and motivations in implementing CBPP management programmes. Field data were collected from 191 pastoral farmers using a semi-structured, interviewer-administered questionnaire. The results indicated that younger farmers were more likely than their older counterpart to accept the responsibility for CBPP management (p<0.01). This may signal future prospects for improved CBPP management where upcoming farmers could be encouraged to implement CBPP control programmes and uphold the costs. 13.6% of the farmers had no intention of implementing any CBPP control programme on farm, while 81.2% either had a positive intention or implemented at least one programme aimed at controlling CBPP. Intention to implement CBPP control programmes was significantly associated with educational attainment of farmers (p<0.01) and their access to CBPP control services offered by trained veterinarians (p<0.01). Farmers with negative attitudes towards implementing CBPP control programmes could be motivated to change their perspectives by advice from trusted sources and improved access to veterinary services. Conversely, farmers with positive attitudes towards implementing CBPP control programmes were more likely to be motivated by affordable veterinary services and advocacy on specific CBPP control programmes. As such, the former group of farmers will be more likely to benefit from programmes which focus on providing credible information from trusted sources, such as extension agents, veterinarians or successful peers. On the contrary, interventions targeting the latter group of farmers should prioritize cost-effective delivery of improved CBPP control technologies.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Improving Student Engagement in Veterinary Business Studies

Improving Student Engagement in Veterinary Business StudiesIn a densely packed veterinary curriculum, students may find it particularly challenging to engage in the less overtly clinical subjects, yet pressure from industry and an increasingly competitive employment market necessitate improved veterinary student education in business and management skills. We describe a curriculum intervention (formative reflective assignment) that optimizes workplace learning opportunities and aims to provide better student scaffolding for their in-context business learning. Students were asked to analyze a business practice they experienced during a period of extra-mural studies (external work placement). Following return to the college, they were then instructed to discuss their findings in their study group, and produce a group reflection on their learning. To better understand student engagement in this area, we analyzed individual and group components of the assignment. Thematic analysis revealed evidence of various depths of student engagement, and provided indications of the behaviors they used when engaging at different levels. Interactive and social practices (discussing business strategies with veterinary employees and student peers) appeared to facilitate student engagement, assist the perception of relevance of these skills, and encourage integration with other curriculum elements such as communication skills and clinical problem solving.

Results of a prospective randomized control trial comparing hydrophilic to uncoated catheters in children with neurogenic bladder

INTRODUCTION

Children with neurogenic bladder (NGB) often require a lifetime of clean intermittent catheterization (CIC), typically using uncoated catheters (UCs). Hydrophilic catheters (HCs) have lower friction than UCs with reported less damage to the urethra. The purpose of this study is to compare outcomes between these catheters.

METHODS

An investigator-initiated, prospective, randomized clinical trial was conducted to compare HCs versus UCs. Children aged 2-17 years with NGB on CIC were enrolled for 1 year. Block randomization was used. Dexterity scores were obtained in those who perform self-catheterization. Outcomes were UTI, difficulty passing the catheter, urethral injury, and patient satisfaction.

RESULTS

Demographic data is presented in the Table. Seventy-eight patients were enrolled. Age and gender were similar between the groups. Fifteen patients in each group performed CIC via an abdominal wall stoma. Eight and 15 patients withdrew from the UC and HC groups, respectively. The HC group overall had more problems with the catheter, mainly difficulty with handling. There were no differences for passing the catheter, pain, hematuria, or urethral injuries. There were two urinary tract infections (UTIs) in two HC patients and 17 UTIs in seven UC patients (p = 0.003). Patients with UTIs in the HC group went from 16% in the previous year to 5% during the study. Three children in the HC group had three or more UTIs in the year before enrollment and none during the study. The patients that completed the study with HC were overall satisfied and many requested to continue with the HC.

CONCLUSIONS

HCs may decrease the risk of UTI in children with NGB. Urethral complications were low in both groups. Most HC patients were pleased but some found the slippery coating difficult to handle.

An Exploratory Study Investigating the Non-Clinical Benefits of Evidence-Based Veterinary Medicine

<p><strong>Objective: </strong>As little prior research exists about the non-clinical benefits of evidence-based veterinary medicine (EBVM), this exploratory study was conducted to identify non-clinical benefits of EBVM to veterinary practices, as well as highlighting the barriers to further implementation, and ways to overcome them.</p><p><strong>Background:</strong> A PICO-based literature review (Hauser and Jackson, 2016) was conducted to establish current knowledge about the non-clinical benefits of EBVM. It found that while there are some papers suggesting a link between the practice of EBVM and better non-clinical benefits such as client satisfaction and client retention, a single study, focusing on the non-clinical benefits of EBVM, had yet to be conducted.</p><p><strong>Evidentiary value:</strong> This exploratory study provides a solid basis for the further development of a confirmatory study of the themes identified in the interviews. The impact on practice from our findings is significant as it details the key areas where the use of EBVM can yield commercial benefits from the perspective of a group of EBVM experts via interview. It is entirely possible that international veterinary environments which mirror that of the UK will find this research beneficial.</p><p><strong>Methods: </strong>Due to the paucity of data about the non-clinical benefits of EBVM, an exploratory, qualitative approach was taken to this research in order to build a platform for further confirmatory, quantitative investigation (Zikmund, 2003). In February and March 2016 interviews with 16 RCVS Knowledge Group chairs<a name="_ftnref1" href="#_ftn1"></a>[1] were conducted. The interview guide contained broad, open-ended questions to explore existing tacit knowledge about the non-commercial benefits of EBVM. The interviews were audio recorded and transcribed <em>verbatim</em> and subsequently analysed using NVivo 11 software.</p><p><strong>Results:</strong> This qualitative enquiry showed that the key areas where the use of EBVM can yield non-clinical benefits are through increased client satisfaction and retention, improved reputation and confidence of the veterinarian,  as well as employee engagement. In order to yield these benefits the two main barriers, time and resources, need to be overcome.</p><p><strong>Conclusion: </strong>The themes highlighted in this paper provide a solid, real world base for further, quantitative study of the non-clinical benefits of practising EBVM.  </p><p><strong>Application:</strong> The results of this research are applicable to practicing veterinarians, nurses and other practice staff. It is clear that practising EBVM not only leads to better clinical outcomes, but can also result in commercial benefits, such as better client retention and employee engagement</p><br /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/oa-icon.jpg" alt="Open Access" /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/pr-icon.jpg" alt="Peer Reviewed" />

A research agenda for moving early medical pregnancy termination over the counter

Given the overall safety profile and increasing availability of medical pregnancy termination drugs, we asked: would the mifepristone-misoprostol regimen for medical termination at ≤10 weeks of gestation meet US Food and Drug Administration regulatory criteria for over-the-counter (OTC) approval, and if not, what are the present research gaps? We conducted a literature review of consumer behaviours necessary for a successful OTC application for medical termination at ≤10 weeks of gestation and identified crucial research gaps. If we were to embark on a development programme for OTC or more generally, self-use of medical termination, the critical elements missing are the label comprehension, self-selection and actual use studies.

TWEETABLE ABSTRACT

Considering medical pregnancy termination through the over-the-counter regulatory lens clarifies critical evidence gaps.

Factors influencing pregnancy intentions and contraceptive use: an exploration of the 'unmet need for family planning' in Tanzania

Estimation of unmet need for contraception is pursued as a means of defining the climate of demand for services and the rationale for family planning programmes. The stagnation of levels of unmet need, as assessed by Demographic and Health Surveys, particularly in sub-Saharan Africa, has called into question the practical utility of this measure and its relevance to policies and programmes in settings where evidence-based guidance is needed the most. This paper presents evidence from qualitative research conducted in rural Tanzania that assesses the diverse context in which pregnancy intentions and contraceptive behaviours are formed. The multi-level sets of influences on intentions and behaviours - that is, the dichotomous components used to calculate unmet need for family planning - are reviewed and discussed. While results lend support to the concept that unmet need exists and that services should address it, they also attest to the synergistic influences of individual, spousal, organisational and societal factors that influence the implementation of childbearing preferences. Altogether, the analysis suggests that ways for assessing and addressing unmet need in Tanzania, and similar settings, be revised to reflect contextual influences that not only shape individual preferences, but constrain how individuals implement them.

MMPI Findings on Astrological and other Folklore Concepts of Personality

The 2600 community adult subjects tested in the 1989 MMPI restandardization project by Butcher, Dahlstrom Graham, Tellegen, and Kaemmer were grouped on the basis of their astrological sign the year of their birth in the oriental yearly cycle, and the day of the week on which they were born. Analyses of variance were carried out on the T scores of the basic MMPI profile scales for both males and females on each of these categories. No effect size ( R2) larger than 2% was obtained on any scale in these analyses. No evidence was found in support of these folklore concepts. Discussion focused on the continuing paucity of empirical research on and support for these notions.

Building a Business Case for EBVM

<p>The clinical benefits of EBVM are clear however the business case for EBVM requires development. We aim to expand the adoption of EBVM amongst UK veterinary practices by identifying its improvement to practice performance...</p><p>This is a podcast of Elizabeth Jackson and Sarah Hauser’s talk at the Veterinary Evidence Today conference, Edinburgh November 2, 2016.</p><p> </p><p><a title="Jackson and Hauser's podcast" href="/index.php/ve/article/view/70/92" target="_self"><img src="/public/site/images/bridget/Elizabeth-Jackson--Sarah-Hauser-audioplayer.png" alt="" /></a></p><br /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/oa-icon.jpg" alt="Open Access" />

The effects of benzylsulfonyl-D-Ser-homoPhe-(4-amidino-benzylamide), a dual plasmin and urokinase inhibitor, on facial skin barrier function in subjects with sensitive skin

OBJECTIVE

The aim of this study was to optimize the synthesis of the plasmin and urokinase (uPA) inhibitor benzylsulfonyl-D-Ser-homoPhe-(4-amidino-benzylamide) (BSFAB), to characterize its activity and mechanism of action and to assess its use to improve stratum corneum (SC) barrier function.

METHODS

Peptide coupling methods were used to synthesize BSFAB, and high-performance liquid chromatography-mass spectrometry (HPLC-MS) together with ¹ H- and ¹³ C-nuclear magnetic resonance spectroscopy (NMR) were applied to clarify its structure and determine its purity. Its binding mode was determined by docking studies to the catalytic domains of plasmin and uPA. Inhibition constants (K_i ) were determined by enzyme kinetic studies, and the effect of BSFAB on plasmin, uPA and transglutaminase 1 expression was evaluated in non-cytokine and cytokine-stimulated keratinocytes. A vehicle-controlled clinical study on SC barrier function was conducted on facial skin of subjects with self-perceived sensitive skin.

RESULTS

BSFAB was synthesized with high purity (97.3%). In silico studies indicated that the amidine moiety of BSFAB was anchored in the S1 pocket of both enzymes by binding to Asp189, Ser190 and Gly219, whereas the backbone of the D-Ser residue makes an anti-parallel β-sheet interaction with Gly216. BSFAB was shown to be an effective inhibitor of plasmin and uPA with K_i values of 29 and 25 nM, respectively. BSFAB also inhibited keratinocyte-secreted protease activities in basal (plasmin inhibition 37.7%, P < 0.05 and uPA inhibition 96.6%, P < 0.01) and cytokine-induced conditions (plasmin inhibition 41.1%, P < 0.05 and uPA inhibition 97.0%, P < 0.001) and stimulated the gene expression of transglutaminase 1 in cytokine-stimulated keratinocytes (approximately 4.5 times increased expression, P < 0.01). Clinically, BSFAB was shown to improve SC barrier integrity (P < 0.02 on day 29) and subjective improvements in the perception of healthy skin (P < 0.05 on day 28).

CONCLUSION

BSFAB binds as a reversible competitive inhibitor to the active sites of plasmin and uPA. Additionally, BSFAB positively improved keratinocyte differentiation gene expression (transglutaminase 1). These effects were translated into improvements in SC barrier integrity clinically in subjects with dry and sensitive skin and improved their perception of having a healthy skin condition.

The Evidence Base for Developing a Veterinary Business Management Curriculum

Objective: This paper sets out to highlight the ongoing need for integrated teaching of business skills in the veterinary curriculum.Background: In response to the changing environment of the veterinary profession, it is important to understand the future needs of veterinary practitioners. While changes to the veterinary curriculum have been made in recent years, they have been highly varied across schools and little evidence is available on how these have improved students’ non-technical skills, knowledge, aptitudes, and attitudes. Evidentiary value: This literature review of 23 papers provides a solid basis for the further development of knowledge on business management issues in veterinary curricula. The impact on practice from our findings is substantial. The role of clinicians in academia is recognised as a primary source of engaging students with business management through their day-to-day teaching. Furthermore, the role of first-opinion vets who take on placement students (known as extra mural studies or ‘EMS’ in the UK) cannot be underestimated as they play an essential role in ensuring that students perceive business skills with the same importance as clinical skills.Methods: This research draws on the findings of 23 papers that emerged as relevant from the structured literature search.  The search yielded 124 papers but many were excluded because they focused on issues beyond the search strategy, did not report empirical findings so were based largely on discussion and conjecture, were not about the undergraduate veterinary curriculum, were not written in English or were not related to business teaching.Results:  Employers of recent graduates highly value business skills, and often base their hiring decision on non-technical skills, rather than clinical skills. While changes to the veterinary curriculum have been made to include more non-technical training by individual veterinary schools, it is unclear how effective these programmes have been.Conclusion:  Veterinarians have identified a need for greater inclusion of business skills in the veterinary curriculum, however successfully integrating business skills into the curriculum will mean that students learn business principles in non-traditional, non-lecture-style environments with materials inter-twining with clinical teaching. This will mean a significant shift from traditional classroom based delivery of business lectures to an integrated approach. This can only be achieved if business and clinical teaching staff work together in delivering business education to the next generation of veterinarians. That said, the evidence regarding the importance of business within the veterinary medical curriculum, coupled with increasing competition in the market for first-opinion veterinary services, means that changes in the approach to teaching business may be easier to achieve than ever before.Application: The results of this research are applicable to practicing veterinarians in both academic and private practice. It is clear that business management needs to be integrated throughout the veterinary curriculum and thus ‘owned’ by academics with both clinical and non-clinical roles. Veterinarians in private practice also have a critical role to play as these people are the gatekeepers to the real-world experience that placement students encounter.