Frequency of HIV screening in the Veterans Health Administration: implications for early diagnosis of HIV infection

We evaluated the frequency of HIV testing across the Department of Veterans Affairs (VA), the largest provider of HIV care in the United States. An electronic survey was used to determine the volume and location of HIV screening, confirmatory testing, rapid testing and laboratory consent policies in VA medical centers between October 1, 2005, and September 30, 2006. One hundred thirty-five VA laboratories reported that 112,033 HIV screening tests were performed (81% outpatients vs. 19% inpatients, p<.0001). Overall HIV prevalence was 1.49% (1.62% in inpatients vs. 1.46% in outpatients, p=N.S., range=0.2-3.8%). Rapid testing was available in 67% of facilities, 60% of which took place in the clinical laboratory. Sixty-four percent of labs required a copy of the informed consent in order to perform testing. We estimate that fewer than 10% of VA inpatients and fewer than 5% of VA outpatients were tested for HIV during the survey period. Substantial opportunities for increasing routine HIV testing exist in this population.

Phenotypic differences between esophageal and gastric intestinal metaplasia

Intestinal metaplasia is a cancer precursor in the esophagus and the stomach. Marked differences exist between the carcinogenic processes in the two locations in terms of natural history and clinical significance. We investigated biopsies from 52 patients with Barrett's esophagus and from 50 patients with gastric intestinal metaplasia in an attempt to throw light on their pathogenic processes. Morphologic characteristics, presence of Helicobacter pylori (H. pylori), and markers of differentiation, inflammation, and proliferation were evaluated by histochemical and immunohistochemical techniques. The area covered by incomplete type of intestinal metaplasia and the proportion of sulfomucins were significantly higher in the esophagus than in the stomach. Immunoreactivity with MUC1, MUC2, MUC5AC, Das-1, cytokeratins 7 and 20, inducible nitric oxide synthase and cyclooxygenase-2 antibodies was also significantly greater in Barrett's esophagus than in gastric intestinal metaplasia. In gastric intestinal metaplasia, the presence of MUC1, MUC5AC, Das-1 and cytokeratin 7 was restricted to areas with the incomplete type of metaplasia. Cell proliferation (Ki-67) was significantly higher in Barrett's esophagus than in gastric intestinal metaplasia. H. pylori was absent in all of the patients with Barrett's esophagus, while it was present in 70% of the patients with gastric intestinal metaplasia. Our observations made clear that Barrett's esophagus shares some phenotypic characteristics with gastric intestinal metaplasia, leading us to suggest that both could arise in response to injuries with eventual carcinogenic potential. However, the progression to more advanced lesions could be modulated by the nature of the carcinogenic insult.

Stigma and social barriers to medication adherence with urban youth living with HIV

Youth adherence to highly active anti-retroviral therapy (HAART) is poor, and little research exists that identifies the reasons youth have difficulty adhering to medications. Given that complete adherence is necessary for favourable health outcomes, it is essential to examine the obstacles youth face in adhering to HAART. The present investigation sought to identify these barriers and to systematically examine the experiences and attitudes youth have towards medications. Twenty-five adolescents and young adults presenting to a public primary care facility for treatment of HIV infection were asked to participate in focus groups which explored their attitudes and experiences around medication adherence. Participants provided richly detailed descriptions of the challenges of managing HIV stigma and their efforts to hide their status from friends, family, doctors, and even themselves. Fifty percent of respondents indicated that they skipped doses because they feared family or friends would discover their status. These results suggest that HIV stigma impacts treatment for youth on several levels, from the accuracy of communication with medical providers to medication adherence, subsequent health outcomes, and the emergence of treatment resistant strains.

Immune and protective abilities of ubiquitinated and non-ubiquitinated pseudorabies virus glycoproteins

Plasmids encoding ubiquitinated (ubi-) or non-ubiquitinated (non-ubi-) glycoproteins of Pseudorabies virus (PRV) were used for vaccination of pigs. We found that the fusion of ubiquitin to viral glycoproteins increased their degradation in proteasomes in vitro, in which ubiquitin plays a key role. In the animals immunized with the plasmids encoding PRV ubi-glycoproteins and then challenged with PRV, we detected a slightly decreased cellular immune response on days 13 and 19 after immunization and a reduced nasal excretion of infectious virus on day 2 after the challenge. Afterwards, no effect of the ubiquitination of the glycoproteins on humoral or cellular immunity and on excretion of infectious virus was observed. Similarly, no effect of the ubiquitination on protective abilities of PRV glycoproteins was found.

Effects of chitosan addition to self-setting bone cement

The Cementek is a self-setting bone cement composed of a solid phase and a liquid phase. After mixing these two phases, it sets in situ to form an hydroxyapatite (HAp) as the only end product. It is difficult to introduce a new component into this cement without modifying the final product and its mechanical properties. In order to improve the mechanical properties of the Cementek, a natural polymer (chitosan) was added in the initial formulation. Two types of chitosan were added into the Cementek, at various concentration, in either the liquid or the solid phase. The effects of chitosan addition on the properties of the self-setting bone cement are examined. The different composites were characterized by the determination of the setting time, the chemical transformation by X-ray diffraction and mechanical tests. The chemical transformations were not affected by the addition of chitosan neither in the liquid nor in the solid phase. The maturation towards HAp appeared to be complete for all the composites. The setting time was decreased by the addition of chitosan in the solid phase. However the setting time value of each composite remained compatible with a practical use in situ. This study shows that the maturation mode of the samples directly affects the mechanical properties of the obtained composites. The sterilization of the cement with chitosan has been studied.

Phosphorus balance and mineral metabolism with 3 h daily hemodialysis

Poor control of mineral metabolism is independently associated with mortality in patients receiving hemodialysis. We analyzed data from a 12-month, prospective, non-randomized, controlled study of daily hemodialysis (DHD) (six sessions/week 3 h each) (n=26) vs conventional hemodialysis (CHD) (three sessions/week 4 h each) (n=51) for achievement of mineral metabolism goals and we performed a substudy of weekly dialytic phosphorus removal in DHD vs CHD. Phosphorus control was superior in the DHD group (% change from baseline to end-of-study -27+/-30% vs +7%+/-35% in the CHD group, P=0.0001). Percentage of patients using phosphate binders decreased from 77 to 40% among subjects on DHD, whereas these parameters did not change (76 vs 77%) in the CHD group (P=0.03 by Breslow-Day test for homogeneity of the odds ratios). Weekly mean phosphorus removal was higher in the DHD group (2452+/-720 mg/week vs 1572+/-366 mg/week, P=0.04). Mean normalized protein catabolic rate increased (0.90+/-0.43-1.22+/-0.26 g/kg/day, P=0.0013). DHD was also associated with an increase in the percent of subjects achieving three or more mineral metabolism goals (for phosphorus, calcium x phosphorus and parathyroid hormone) (15 vs 46%, P=0.046). In conclusion, DHD improves phosphorus control by increasing dialytic phosphorus removal while maintaining nutritional status and reducing the use of phosphate binders. The net effect allows for improved achievement of mineral metabolism goals.

Once daily sublingual immunotherapy without updosing--A new treatment schedule

BACKGROUND

Treatment regimens with specific immunotherapy include updosing. Due to excellent tolerance of sublingual immunotherapy (SLIT), it was hypothesized that administration of once-daily SLIT could be initiated safely without updosing. The objective was to evaluate tolerability of SLIT administered once daily without updosing.

METHODS

135 patients suffering from allergic rhinitis with/without asthma were included in a double-blind, placebo-controlled, parallel-group study. Patients were randomized into two groups. Group 1 (n = 69) received active treatment throughout the study, including 10 days updosing (T1), 20 days maintenance treatment (T2), and 2 consecutive months on maintenance treatment (T3 and T4). Group 2 (n = 66) obtained placebo updosing (T1), placebo maintenance (T2), initiated active treatment (maintenance) at T3, and continued active treatment until the end of the study (T4). Adverse events (AEs) were assessed at T1-T4. 66 grass- and 69 mite-allergic patients were evenly distributed between groups.

RESULTS

229 AEs were reported, 157 AEs were related to treatment. The most frequently reported AEs (>5% of patients in any group) related to treatment were oral itching, ocular itching, rhinitis, and sublingual edema. For group 1 at T2, the rate of all AEs related to treatment per dose administered was 1.79%, and for group 2 at T3 the rate was 1.33% (p = 0.37). For the most frequently reported AE, oral itching, the rate per dose administered was 1.01% for group 1 at T2, and 0.74% for group 2 at T3 (p = 0.53).

CONCLUSIONS

Once daily SLIT was well tolerated and can be safely initiated without updosing.

Nephron-sparing surgery for renal tumor: a choice of treatment in an allograft kidney

The incidence of de novo malignancies is an accepted complication of organ transplantation. Renal cell carcinoma (RCC) was 4.6% of cancers occurring de novo in organ allograft recipients compared with 3% in the general population. Less than 10% of these renal cancers affected the renal allograft. Among patients developing a renal tumor in the kidney allograft, transplant nephrectomy reduced the quality of life. For these patients for whom preservation of renal function is a relevant clinical consideration, partial nephrectomy may be considered the choice for treatment. Fifteen cases have been reported regarding conservative surgery on kidney transplant tumors. Herein we have reported three cases of renal masses in well-functioning kidney transplants that were successfully treated with nephon-sparing surgery. Our experience demonstrated that in selected patients, nephron-sparing surgery on a renal allograft represents a feasible approach for tumor removal with preservation of graft function.

Hands-on robotic unicompartmental knee replacement: a prospective, randomised controlled study of the acrobot system

We performed a prospective, randomised controlled trial of unicompartmental knee arthroplasty comparing the performance of the Acrobot system with conventional surgery. A total of 27 patients (28 knees) awaiting unicompartmental knee arthroplasty were randomly allocated to have the operation performed conventionally or with the assistance of the Acrobot. The primary outcome measurement was the angle of tibiofemoral alignment in the coronal plane, measured by CT. Other secondary parameters were evaluated and are reported. All of the Acrobot group had tibiofemoral alignment in the coronal plane within 2 degrees of the planned position, while only 40% of the conventional group achieved this level of accuracy. While the operations took longer, no adverse effects were noted, and there was a trend towards improvement in performance with increasing accuracy based on the Western Ontario and McMaster Universities Osteoarthritis Index and American Knee Society scores at six weeks and three months. The Acrobot device allows the surgeon to reproduce a pre-operative plan more reliably than is possible using conventional techniques which may have clinical advantages.

Employing infrared wireless communications

Infrared wireless communication offers medical equipment designers features such as data-transfer security and noninterference with clinical equipment. This article explores the advantages of the technology over other wireless communication systems.

A simple model implementation to measure breath by breath the VO2 and VCO2 by the indirect calorimetry technique

This paper proposes a discrete random time series modeling for the VO2 and VCO2 measurement in the indirect calorimetry technique (ICT). Mathematical equations are developed in order to establish clear differences between the breath-by-breath and mixing chamber measurement based calorimeters. This simple model offers not only a physiological ICT definition approach but also defines the idea of VO2 and VCO2 short-term variability information for research. The preliminary results show a new physiological information when a computer oriented algorithm model implementation was applied to a data acquisition system in order to obtain the power spectrum analysis from a typical observation subject submitted to the clino-ortho maneuver.

Robotic clinical trials of uni-condylar arthroplasty

A randomised clinical trial has been completed for uni-condylar arthroplasty. The trial, under the auspices of the UK MHRA, comprised 15 knees of patients undergoing conventional surgery, and 13 knees of patients who had robotic surgery using the Acrobot hands-on robotic system. The results of the trial were checked by comparing post-op CT scans with pre-op CT-based plans, and show a significant improvement in accuracy using the robot. The technical concept of the Acrobot approach is also described. Details of the complete system are outlined, including the pre-operative planner. The plan incorporates 3D CT models of the leg, together with CAD models of prostheses that can be used to plan the leg alignment, position the prostheses, plan the shape of the cuts required and generate the regions within which cuts must be constrained. The robotic system is also described, together with the methods for locating, clamping, cutting and monitoring the patient. An outline is given of the means by which the preoperative model is registered or aligned to the intra-operative position of the patient and of the robot, without the need for fiducial markers. Results of the randomised clinical trial are also discussed.

Physicochemical characterization and in vitro release of salicylic acid from O/W emulsions prepared with Montanov 68: effect of formulation parameters

Montanovs are surfactants consisting of a combination of alkylpolyglucosides and long chain saturated alcohols. They are used to formulated oil in water (O/W) emulsions where they generate liquid crystals. Emulsions containing 5% Montanov 68 with 40% Lanol 1688 were prepared and salicylic acid (SA) was incorporated at different stages of the O/W emulsion preparation. This study highlights the effects of formulation parameters on the microscopic characteristics, particle size and rheologic properties of Montanov 68 O/W emulsions. Diffusion studies with these emulsions showed the influence of SA incorporation at different steps on the release kinetics. Montanov enabled the release of SA to be controlled when it was solubilized in the internal phase. The presence of a physical barrier formed by the Montanov at the interface between the oil and water appeared to modulate the SA passage to the external phase.

Development of a distributed hydrological model based on urban databanks--production processes of URBS

The objective of this study is to present a distributed hydrological model especially dedicated to urban catchments, and able to represent hydrological processes usually neglected in urban modelling, such as evapotranspiration, infiltration in roads, or direct infiltration of soil water in sewers. This model, called URBS (as Urban Runoff Branching Structure) is distributed considering the spatial variability of land use which is well known thanks to urban databanks managed by GIS. The production function is detailed at each cadastral parcel scale, and the runoff produced is routed by a simple transfer function. The estimation of the input parameters of the model is mostly based on physical considerations, and the model is applied on a suburban catchment in Nantes (France) in order to evaluate the interest of the distribution of the hydrological variables.

Behaviour of an injectable calcium phosphate cement with added tetracycline

A calcium phosphate cement containing an antibiotic can be used for filling bone defects and to ensure local antibiotherapy. A calcium phosphate cement (already marketed under the name of Cementek can become injectable thanks to the addition of silicone. For dental applications, the behaviour of this injectable cement with added tetracycline was investigated. The tetracycline hydrochloride does not allow maturation of the cement: the tetracycline has to be treated with a calcium sulphate solution. The treated tetracycline (TTC) allowed maturation of the cement towards hydroxyapatite. But the setting time was longer and the mechanical properties decreased. Study in a continuous flow cell showed that the tetracycline is released in a continuous manner: thus, after 6 days, 60% of the antibiotic was released into the surrounding medium.

[Difficult diagnosis of fever of unknown origin related to an infraclinic liposarcoma: "small tumor and fever of unknown origin"]

INTRODUCTION

Palpation of soft tissues constitutes part of the physical examination when faced with a patient with fever of unknown origin. Our case highlights the difficulty of diagnosis when the tumor still remains impalpable ten months after onset of fever and severe biological inflammatory process.

EXEGESIS

A 49-year-old woman was admitted for fever of unknown origin associated with important biological inflammatory process. In view of her past medical history of breast carcinoma, a search for a relapse was performed and remained negative. Despite multiple investigations and repeated physical examinations, no diagnosis was obtained. Finally, [18F] fluorodoexyglucose positron emission tomography led to a diagnosis showing a high fixation located in the right thigh, related to a myxoid liposarcoma after surgical resection.

CONCLUSION

Dramatic regression of fever and biological inflammatory process after surgical treatment illustrates the concept of "small tumor and fever of unknown origin", an exceptional entity but which physicians should be aware of. The role of new technical imaging with [18F] fluorodoexyglucose positron emission tomography has however to be clarified in the evaluation of fever of unknown origin.

Phenotypic differences between esophageal and gastric intestinal metaplasia

Intestinal metaplasia is a cancer precursor in the esophagus and the stomach. Marked differences exist between the carcinogenic processes in the two locations in terms of natural history and clinical significance. We investigated biopsies from 52 patients with Barrett's esophagus and from 50 patients with gastric intestinal metaplasia in an attempt to throw light on their pathogenic processes. Morphologic characteristics, presence of Helicobacter pylori (H. pylori), and markers of differentiation, inflammation, and proliferation were evaluated by histochemical and immunohistochemical techniques. The area covered by incomplete type of intestinal metaplasia and the proportion of sulfomucins were significantly higher in the esophagus than in the stomach. Immunoreactivity with MUC1, MUC2, MUC5AC, Das-1, cytokeratins 7 and 20, inducible nitric oxide synthase and cyclooxygenase-2 antibodies was also significantly greater in Barrett's esophagus than in gastric intestinal metaplasia. In gastric intestinal metaplasia, the presence of MUC1, MUC5AC, Das-1 and cytokeratin 7 was restricted to areas with the incomplete type of metaplasia. Cell proliferation (Ki-67) was significantly higher in Barrett's esophagus than in gastric intestinal metaplasia. H. pylori was absent in all of the patients with Barrett's esophagus, while it was present in 70% of the patients with gastric intestinal metaplasia. Our observations made clear that Barrett's esophagus shares some phenotypic characteristics with gastric intestinal metaplasia, leading us to suggest that both could arise in response to injuries with eventual carcinogenic potential. However, the progression to more advanced lesions could be modulated by the nature of the carcinogenic insult.

Talc Functionality as Lubricant: Texture, Mean Diameter, and Specific Surface Area Influence

Talc is widely used as a glidant (flow regulator) for powders. This study highlights the characteristics that confer to talcs new end use properties in improving the lubrication function during compression. We studied the contribution of texture, mean diameter (D50), and specific surface area on the residual die pressure, the ejection pressure, the lubrication index, and the tablet hardness. Different textures were studied: microcrystalline, macrocrystalline, and moderately macrocrystalline talc grade. The compression parameters were improved according to the texture. D50 varies from 0.62 to 15 microm. As D50 decreases, the lubrication performance is improved. Finally, the specific surface area of talcs was studied. This last characteristic of talcs was shown as the most relevant parameter in determining lubrication ability.