Harm reduction measures and injecting inside prison versus mandatory drugs testing: results of a cross sectional anonymous questionnaire survey. The European Commission Network on HIV Infection and Hepatitis in Prison

OBJECTIVES

(a) To determine both the frequency of injecting inside prison and use of sterilising tablets to clean needles in the previous four weeks; (b) to assess the efficiency of random mandatory drugs testing at detecting prisoners who inject heroin inside prison; (c) to determine the percentage of prisoners who had been offered vaccination against hepatitis B.

DESIGN

Cross sectional willing anonymous salivary HIV surveillance linked to a self completion risk factor questionnaire.

SETTING

Lowmoss prison, Glasgow, and Aberdeen prison on 11 and 30 October 1996.

SUBJECTS

293 (94%) of all 312 inmates at Lowmoss and 146 (93%) of all 157 at Aberdeen, resulting in 286 and 143 valid questionnaires.

MAIN OUTCOME MEASURES

Frequency of injecting inside prison in the previous four weeks by injector inmates who had been in prison for at least four weeks.

RESULTS

116 (41%) Lowmoss and 53 (37%) Aberdeen prisoners had a history of injecting drug use but only 4% of inmates (17/395; 95% confidence interval 2% to 6%) had ever been offered vaccination against hepatitis B. 42 Lowmoss prisoners (estimated 207 injections and 258 uses of sterilising tablets) and 31 Aberdeen prisoners (229 injections, 221 uses) had injected inside prison in the previous four weeks. The prisons together held 112 injector inmates who had been in prison for more than four weeks, of whom 57 (51%; 42% to 60%) had injected in prison in the past four weeks; their estimated mean number of injections was 6.0 (SD 5.7). Prisoners injecting heroin six times in four weeks will test positive in random mandatory drugs testing on at most 18 days out of 28.

CONCLUSIONS

Sterilising tablets and hepatitis B vaccination should be offered to all prisoners. Random mandatory drugs testing seriously underestimates injector inmates' harm reduction needs.

A mouse model of recrudescence of Toxoplasma gondii infection

Dexamethasone was given to mice infected with Toxoplasma gondii to provide a model of recrudescence of infection in immunocompromised patients and to permit investigation of the interaction between parasite and host.

Anonymous HIV surveillance with risk-factor elicitation: at Perth (for men) and Cornton Vale (for women) prisons in Scotland

434 male and 145 female prisoners were available to participate in cross-sectional, voluntary anonymous HIV surveillance (using saliva samples) with linked self-completion questionnaire at HMP (Her Majesty's Prison) Perth on 17 May and at HMP Cornton Vale on 18 May 1995. Three hundred and four men (70%) and 136 women (94%) completed a risk-factor questionnaire and 304 and 135 samples were received for HIV antibody testing. Two hundred and eighty-two and 132 questionnaires passed logical checks. Six saliva samples from Perth (all injectors) out of 304 and none from Cornton Vale out of 134 tested were HIV antibody positive. Four were presumptively from known HIV-infected male inmates; the other 2 were local men, under 26 years, who began injecting in 1989-91, and both reported having had a recent HIV test. Overall HIV prevalence was estimated at 2% compared to a known prevalence of 1.4% (6/434), giving a 1.5 ratio of overall: disclosed HIV prevalence at HMP Perth. HIV prevalence was estimated at 7% (6/82) for injector-participants and 14% (5/35) for local injector participants. At Cornton Vale, where both known HIV-infected inmates abstained, overall and disclosed HIV prevalence, were equal at 1.4%. At Perth Prison, 29% of prisoners had injected drugs (82/278); 85% of injector-inmates reported having injected inside (some prison and 31% (25/80) had started to inject while inside, 7 during their present sentence. Of all 21 injector-inmates who first injected after 1991, 10 had started to inject inside, including one of 69 male inmates who had never been inside before. The corresponding figures for Cornton Vale, where 46% of inmates were injectors (58/132), were that 57% of injector-inmates had injected inside (32/56) but only one woman, for whom this was not her first sentence, had started to inject inside. Twenty-eight per cent of male prisoners (78/277) and 57% of male injector-inmates (47/82) had had a personal HIV test since January 1993, as had 35% of female prisoners (43/124) and 57% of female injector-inmates (30/53). A much higher proportion of Glasgow's female prisoners (64%: 38/60) were injectors than of women prisoners from the Edinburgh, Dundee and Fife area (21%: 5/26) or from elsewhere (34%: 15/45). Rape was reported by 23% of women (30/130). Women who had been raped had a more polarized distribution of male sexual partners (none to 2 plus) in the year before sentencing than other women and were more likely to report anal sex (11/30 vs 11/100, P < 0.001). Prostitution had been engaged in by 19% of female injector-inmates (11/57) and was acknowledged by one other woman. However, only 5% of women (6/130) reported ever having been treated for an STD.

Walking aches and running pains. Injuries of the foot and ankle

Running is enjoyed by approximately 30 million people in the United States, 10 million on a regular basis. It is common to encounter a patient who runs and expects his or her primary physician to have a degree of expertise in injuries caused by running. The primary care clinician also may experience the frustration of motivating a patient to exercise, only to have him or her return with complaints of foot or ankle pain. Running injuries occur from an overload on the muscles, tendons, bones, or joints. The knee, foot, and ankle are the most common sites of injury.

Common foot problems

The foot is a complex region of the body that includes the vascular, neurologic, dermatologic, and musculoskeletal organ systems. This article addresses each of these systems and the common maladies that affect them, with a view toward common presentations, evaluation, differential diagnoses, treatment alternatives, and guidelines for proper referral. Finally, a section of the article is devoted to the prevention and treatment of lower extremity problems unique to patients with diabetes.

In vivo effects of angiotensin II on vascular smooth muscle contraction and blood pressure are mediated through a protein tyrosine-kinase-dependent mechanism

The effects of in vivo angiotensin II (AII) treatment on protein tyrosine kinase (PTK) levels were examined. It was found that administration of AII to normotensive Wistar-Kyoto rats induced tyrosine phosphorylation in aorta in a time-dependent manner. There was a rapid increase in phosphotyrosine content as early as 1 min, with peak phosphorylation occurring between 5 and 10 min. The response was also dose dependent, with increases in phosphorylation levels from 1 to 1000 micrograms/kg AII. Tyrosine phosphorylation was blocked using the angiotensin type 1 receptor antagonist losartan (10 mg/kg), suggesting that the effects are receptor mediated. Tyrphostin-25 (100 microM), a selective inhibitor of PTKs, when given in vivo was also able to attenuate phosphorylation by AII, further suggesting a PTK-mediated event. To couple these biochemical changes with physiological events, we also examined the ability of AII to induce vasoconstriction and raise systolic blood pressure through a PTK-mediated mechanism. In addition to increasing phosphorylation levels, AII caused a rise in systolic pressure in vivo and induced contraction in vitro. Both of these responses could be attenuated by pretreatment with losartan or tyrphostin-25. This is the first demonstration of the effects of AII on tyrosine phosphorylation in vivo. The data suggest that AII may induce a pressor response at least in part through activation of PTKs and subsequent phosphorylation of smooth muscle contractile proteins or activation of other protein kinases.

Anesthesia blocks of the lower extremity. Comparing the Biojector with needle and syringe

Podiatric surgical procedures frequently involve administration of preoperative local anesthesia, and because of the nature of these blocks, it is believed that needle-free injection could greatly enhance this aspect of clinical practice. The object of the study was to determine if needle-free injections with the Biojector were equivalent to needle and syringe injections for ankle, Mayo, neuroma, hallux, and digital anesthetic blocks. The results indicate that needle-free injection with the Biojector is equal to needle and syringe for some anesthesia blocks. More research in this area is needed to determine if technique with the Biojector has an impact on time of anesthesia onset or on level of discomfort and ecchymosis.

Progression of HIV: follow-up of Edinburgh injecting drug users with narrow seroconversion intervals in 1983-1985

OBJECTIVE

To describe progression and survival of individuals infected with HIV by injecting drug use in Edinburgh.

DESIGN AND METHODS

From 313 HIV-infected patients with retrospectively estimated narrow seroconversion intervals, 260 infected via injecting drug use in the years 1983-1985 were selected for the study group.

MAIN OUTCOME MEASURES

The effects of gender, age, human leukocyte antigen (HLA) type and zidovudine (ZDV) treatment on progression and survival from seroconversion; Weibull estimates of the AIDS incubation distribution and the overall survival distribution; slopes of absolute CD4 lymphocyte loss (on the square root scale) and loss of CD4 percentage.

RESULTS

The cumulative progression rates at 10 years were 68% to CDC stage IV and 31% to AIDS with a mortality rate of 25%. Three-year survival rates for AIDS and CDC stage IV cases were 25 and 72%, respectively. Gender and age effects on progression or overall survival were not found, although those aged over 30 years experienced poorer survival from AIDS. A strong HLA (A1, B8, DR3) association with faster progression and poorer survival was found. Median survival was estimated by Weibull distribution to be 12.6 years; median AIDS-free time was estimated to be 11.6 years. CD4 cell loss was approximately linear when transformed to the square root scale as was the decline in CD4 percentage. Only HLA effects on slopes were found: A1,B8, DR3 was significantly associated with faster loss of both absolute CD4 cells and CD4 percentage (P < 0.001) and B27 was significantly associated with slower loss of CD4 percentage (P = 0.01).

CONCLUSIONS

Edinburgh IDU do not seem to progress more rapidly than other cohorts with predominantly different risk activities. Older age was associated with poorer survival from AIDS but no gender effect was found for progression or overall survival. The clearest significant association with AIDS progression, mortality and loss of CD4 cells was the phenotype HLA A1,B8,DR3. In contrast HLA B27 was associated with slower loss of CD4 cells.

Immunomagnetic CD4+ and CD8+ cell depletion for patients at high risk for severe acute GVHD

Acute GVHD remains a major problem in allogeneic BMT, in particular when donors other than HLA-identical siblings are used. To determine the efficacy of an immunomagnetic method for depletion of CD4+ and CD8+ lymphocytes from the marrow graft, a series of 15 patients was studied. Thirteen patients had matched unrelated donors, and two patients had related donors. Cyclosporine was used as GVHD prophylaxis in combination with CD4+ and CD8+ depletion, which removed 94.1 +/- 3.2%, 97.0 +/- 5.1%, and 96.7 +/- 3.1% of CD3+, CD4+ and CD8+ cells, respectively. All patients engrafted promptly with AGC > 500/mm3 after a median of 16 days post-BMT. Acute GVHD grade II-IV developed in 0/2 related transplants and 4/13 MUD transplants; only one patient had grade III-IV acute GVHD. No late graft failure was observed. Three patients relapsed; two had advanced disease at the time of BMT. Seven patients are alive and in CCR after a median of 497 days; actuarial survival is 39% at 24 months. The fever syndrome observed with selective CD8+ cell depletion was not seen with the combined CD4+ and CD8+ cell depletion. Immunomagnetic CD4+ and CD8+ cell depletion of marrow grafts, in combination with in vivo cyclosporine, is a simple, reproducible and effective method to decrease the incidence and severity of acute GVHD in patients at high risk for this complication after allogeneic BMT.

Scottish national survey of tuberculosis notifications 1993 with special reference to the prevalence of HIV seropositivity

BACKGROUND

The study sought to determine the contribution of HIV seropositivity to the arrest of decline in tuberculosis notifications in Scotland.

METHODS

Survey forms relating to each tuberculosis notification in 1993 were completed by the notifying consultant. Voluntary anonymous HIV testing of tuberculosis cases aged under 65 was requested. Age, sex, ethnic status, country of birth, employment status, occupation, previous tuberculosis, contact status, risk factors for HIV infection, HIV serostatus of cases aged under 65, site, radiological extent, and bacteriological status of tuberculous disease were determined.

RESULTS

Five hundred and seventy four cases of tuberculosis were originally notified, of which 77 (14%) subsequently proved to be non-tuberculous and were therefore denotified. Of the 497 cases 423 (85%) were white and 58 (12%) were from the Indian subcontinent. Eighty five per cent of patients from the Indian subcontinent were aged < 55 years whereas 64% of white patients were aged > 55 years. Pulmonary disease was found in 74%, non-pulmonary in 22%, and combined disease in 4% of patients. Of 242 HIV tests performed, three were positive and five other HIV positive patients were known, giving an HIV positivity rate of 1.6% of all tuberculosis notifications in 1993. Annual notification rates for Scotland were 9.7 per 10(5) before and 8.7 per 10(5) after exclusion of previously treated cases; rates were 8.4 per 10(5) for the white population and 179 per 10(5) for those from the Indian subcontinent.

CONCLUSIONS

The study documents the distribution of tuberculous disease in Scotland by age, sex, site, and ethnic group for the first time. Notification practices, with respect to denotification, need to be improved. Infection with HIV is presently uncommon in cases of tuberculosis in Scotland but continued vigilance is essential.

Relationships of personality traits and stress to gingival status or soft-tissue oral pathology: an exploratory study

OBJECTIVES

The purpose of this study was to examine the relationships of personality traits and stress with gingival inflammation and with soft-tissue oral pathology.

METHODS

Personality traits of psychoticism (P), extroversion and introversion (E), and neuroticism (N) were measured with Eysenck's personality questionnaire (EPQ). Stress was measured with a modified organizational and individual assessment survey (OIAS) developed by Hendrix. Military recruits from Ft. Leonard Wood, Missouri, were examined for soft-tissue oral pathology and gingival status at weeks one (n = 241) and six (n = 61) of basic combat training (BCT). The EPQ and OIAS were administered to 217 recruits during week six of BCT. A discriminant analysis was used to determine correlations among study variables.

RESULTS

Significant correlations (P < .05) were found between personality traits and various measures of tolerance of stress. Little variance was found between groups originally presenting with or without disease. Only physical stress (P < .005) was shown to affect soft-tissue pathology, while gingival inflammation correlated significantly to E scores (P < .02), tolerance to change (P < .02), and anxiety (P < .05).

CONCLUSIONS

Data support a possible relationship among certain personality traits, stress variables, and gingival inflammation or soft-tissue pathology in recruits with extreme personality characteristics or perception of high physical stress levels in basic combat training.

Weaning from mechanical ventilation: concept development

This article, the first in a series, is written to clarify the process of weaning from mechanical ventilation and to promote the development of a common language for understanding the complex weaning process. The Third National Study Group on Weaning From Mechanical Ventilation proposes a conceptual model and definitions that will provide a framework for future research on this important topic. This conceptual framework describes the preweaning phase, the weaning process, and the outcome phase of mechanical ventilation. Potential outcomes are completion of weaning, lack of completion, and terminal weaning. The weaning decision continuum incorporates: (1) when and how to begin the weaning process, (2) how to select therapies to assist with difficult weaning and chart progress during weaning, and (3) when to stop weaning if progress is no longer being made. An inherent assumption of this model is that each patient will display unique responses to the weaning process. The proposed conceptual framework and definitions provide a foundation for developing clinical practice guidelines and for guiding future ventilator weaning research.

Weaning from mechanical ventilation: concept development

This article, the first in a series, is written to clarify the process of weaning from mechanical ventilation and to promote the development of a common language for understanding the complex weaning process. The Third National Study Group on Weaning From Mechanical Ventilation proposes a conceptual model and definitions that will provide a framework for future research on this important topic. This conceptual framework describes the preweaning phase, the weaning process, and the outcome phase of mechanical ventilation. Potential outcomes are completion of weaning, lack of completion, and terminal weaning. The weaning decision continuum incorporates: (1) when and how to begin the weaning process, (2) how to select therapies to assist with difficult weaning and chart progress during weaning, and (3) when to stop weaning if progress is no longer being made. An inherent assumption of this model is that each patient will display unique responses to the weaning process. The proposed conceptual framework and definitions provide a foundation for developing clinical practice guidelines and for guiding future ventilator weaning research.

Evaluation of maternal serum immunoreactive inhibin as a first trimester marker of Down's syndrome

BACKGROUND AND OBJECTIVE

Maternal serum immunoreactive inhibin has been shown to be significantly elevated in Down's affected pregnancies in the second trimester, suggesting that it may be useful in prenatal diagnosis. We have investigated whether it is similarly elevated in the first trimester.

DESIGN

Stored maternal sera from women with Down's affected pregnancies and chromosomally normal control pregnancies were retrieved for analysis. These sera had been collected prospectively at either 11 or 12 weeks gestation as a routine antenatal booking procedure.

SUBJECTS

From records, 11 women were identified as having had a Down's pregnancy. For each of these, 4 controls matched for gestation and duration-of-storage were also identified.

MEASUREMENTS

Two different inhibin immunoassays were evaluated, one using an antibody raised against 31 kDa bovine inhibin and the other, a commercial two-site assay, using two antibodies directed against two distinct alpha-subunit epitopes.

RESULTS

Neither assay detected a significant effect of gestation on serum inhibin levels. After combining the data from both gestations, no significant difference between the Down's samples and controls for either assay was detected. However, analysis of the data for each gestation separately revealed that one assay detected a significant difference in inhibin levels between Down's affected and unaffected pregnancies at 11 weeks gestation (mean +/- SEM 3186 +/- 195 vs 2020 +/- 172 ng/l, P < 0.01) but not at 12 weeks. The other, commercial, assay did not detect a significant difference at either gestation. In addition, there was poor association between the results of the two assays.

CONCLUSIONS

These data suggest that immunoreactive inhibin, as detected by these assays, will not be useful as a late first trimester marker for Down's syndrome and also that these two assays detect different inhibin species in pregnancy serum.

Brain injury: personality, psychopathology and neuropsychology

This study investigated the relationship between brain injury and personality, using the Luria-Nebraska Neuropsychological Battery and the Clinical Analysis Questionnaire as measurement tools. Psychopathological factors, as opposed to normal personality traits, were highly correlated with measures of brain injury. Depression, in particular, was found to be substantially involved in the sequelae of brain injury for this sample. A trend in the data revealed that suicidal depression and anxious depression were differentially related to deficits on two scales of the LNNB. Patients with evidence of suicidal depression were also more sensitive to emotional dysfunction in other areas. Few differences were found between patients with traumatic brain injury and those with other types of brain injuries. Results suggest that measures of psychopathology can provide important supplementary information to neuropsychological assessment, above that obtained from measures of brain functioning alone. Controlled studies should investigate the relationship between psychopathology and neuropsychology more thoroughly to provide clearer determinations of its involvement in the rehabilitation of the brain-injured person.

Acyclovir resistant varicella zoster and HIV infection

A child infected with HIV who developed chronic varicella zoster virus infection resistant to acyclovir is presented. The clinical course of the infection, treatment, virological investigations, and relationship of the infection to the child's immunodeficient state are discussed.

Diagnosis of Pneumocystis carinii pneumonia in a population of HIV-positive drug users, with particular reference to sputum induction and fluorescent antibody techniques

Between June 1990 and May 1991, 200 sputum inductions were examined by a fluorescent antibody test (FAT) for Pneumocystis carinii (PC). A total of 164 specimens were negative, 36 were positive and a further 20 inductions were unsuccessful. All patients with a positive result, seven of whom had normal chest X-rays and blood gas analyses, were treated for Pneumocystis carinii pneumonia (PCP) with symptomatic response. Two additional patients were diagnosed as PCP during the study period. No patient with a negative or unsuccessful result developed clinical PCP during that admission, although six did develop 10 episodes of PCP (FAT positive for PC on induced sputum samples) within 3 months of a negative result. Sputum induction was well tolerated by patients and not associated with adverse events. Sensitivity of FAT for PC was 95% and specificity was 100%. These results may in part be because most of the patients were injection drug users (IDUs) who often suffer from chronic productive cough, and also because sputum induction in all cases was supervised by an experienced physiotherapist.

Noninvasive assessment of the visual system and ophthalmic and visual optics: an introduction to the joint vision features

This is an introduction to the joint feature on noninvasive assessment of the visual system and ophthalmic and visual optics.