A cluster randomized-controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings

OBJECTIVE

To describe the study design, methods and baseline findings of a behavioural intervention trial aimed at reducing HIV incidence.

METHOD

A cluster randomized-controlled trial (RCT) conducted in 70 villages in rural South Africa. A behavioural intervention, Stepping Stones, was implemented in 35 communities in two workshops of 20 men and 20 women in each community who met for 17 sessions (50 h) over a period of 3-12 weeks. Individuals in the control arm communities attended a single session of about 3 h on HIV and safer sex. Impact assessment was conducted through two questionnaire and serological surveys at 12-month intervals. The primary outcome was HIV incidence and secondary measures included changes in knowledge, attitude and sexual behaviours. Qualitative research was also undertaken with 10 men and 10 women from two sites receiving the intervention (one rural and one urban) and five men and five women from one village in the control arm. They were interviewed individually three times prior to the workshops and then 9-12 months later.

RESULTS

A total of 2776 participants (1409 intervention and 1367 control) were enrolled at baseline and had an interview, and HIV sero-status was established. HIV baseline prevalence rates in women were 9.8% in the intervention arm and 12.8% in the control arm. In men the prevalence was 1.7% in the intervention arm and 2.1% in the control arm. Demographic and behavioural characteristics were similar in the two arms. In the intervention groups 59.9% of participants attended more than 75% of the sessions. In the control group 66.3% attended the control session.

CONCLUSION

This is the third RCT to be conducted in sub-Saharan Africa evaluating a behavioural intervention using HIV incidence as a primary outcome. It is of particular interest as the intervention in question is used in many developing countries. There is good baseline comparability between the study arms and the process data on the workshops suggested that the interventions were feasible and adequately implemented.

Phosphorus removal using novel crystallisation technology

A soy protein manufacturing facility was faced with the challenge of reducing its effluent phosphorus (P) content from 20-50 mg L(-1) down to <2 mg L(-1) total P without increasing soluble salt levels to comply with discharge and receiving water requirements. A number of biological and chemical P removal technologies previously evaluated either failed to achieve the new standards or would have produced prohibitive amounts of residual sludge and unacceptably high effluent salt concentrations. Lime precipitation, utilising a novel crystallisation technology, was demonstrated through on-site pilot testing to meet the process objectives. It is capable of achieving the required P removal at pH 10 while not increasing soluble salts and producing rapid settling and filterable particles. Also, minimal carbonate removal was observed with residual solids generation being only 40% of a complete lime softening reaction. This paper describes the technical evaluation that led to the full-scale treatment system that was put into operation in late 2005.

The feasibility of nitric oxide delivery with high frequency jet ventilation

A 27-year-old female with acute monocytic leukaemia (M5) developed acute respiratory distress syndrome (ARDS). Because of refractory hypoxaemia and severe barotrauma during conventional mechanical ventilation, the patient was switched to high frequency jet ventilation (HFJV) as a salvage therapy. Her refractory hypoxaemia improved temporarily but worsened again. Approval of the Institutional Review Board and the Food and Drug Administration was obtained to use nitric oxide (NO) with HFJV on a compassionate basis considering the grave situation. The NO delivery system was connected to the secondary flow circuit of the HFJV immediately after the humidifier. We measured the concentration of NO at least every hour by inserting a 7-Fr catheter connected to a McNeill analyzer into the endotracheal tube. Despite improvement of oxygenation, the patient's respiratory status deteriorated further and she died. In this case we were able to achieve reliable and constant levels of NO. The purpose of this report is to discuss the technical aspects and pitfalls of this method.

Audit of nutritional guidelines for head and neck cancer patients undergoing radiotherapy

BACKGROUND

Head and neck cancer patients being treated with radiotherapy are at an increased risk of malnutrition due to the severe side-effects, e.g. mucositis, odynophagia and xerostomia, impacting on the ability to eat and drink. Effective dietetic management involves identifying those patients malnourished or at risk of becoming so and incorporating nutritional intervention into their treatment plan. The use of gastrostomy tubes in this patient group has been shown to be acceptable. By placing them prophylactically, the aim is to prevent a disruption to treatment and avoid an unnecessary admission for feeding. This audit was carried out to determine whether the implementation of locally produced nutritional guidelines improved the dietetic management of this patient group.

METHOD

A prospective audit tool was used to collect data on 32 head and neck cancer patients undergoing radiotherapy. Data was collected weekly during the course of treatment and compared with data from previous audits. Weight change was the nutritional outcome measured.

RESULTS

More patients underwent combined treatment (radiotherapy postoperatively or with concurrent weekly chemotherapy) when compared with previous audits. However, implementation of the guidelines appeared to contribute to an improvement in dietetic management, as fewer patients lost weight over the course of radiotherapy and there were no admissions for feeding. The presence of a dietitian at the multidisciplinary head and neck clinic improved access and communication and this is also likely to have contributed to the improved management.

CONCLUSIONS

Implementation of the guidelines led to an improvement in the nutritional management of this patient group. Implementation may be more likely if a dietitian is present at the combined head and neck clinic.

The impact of speed of processing training on cognitive and everyday performance

The purpose of the present investigation was to examine the impact of speed of processing training on the cognitive and everyday abilities of older adults with initial processing speed or processing difficulty. Participants were randomized to either a speed of processing intervention or a social- and computer-contact control group. Results indicate that speed of processing training not only improves processing speed, as indicated by performance on the Useful Field of View test (UFOV), but also transfers to certain everyday functions, as indicated by improved performance on Timed Instrumental Activities of Daily Living (Timed IADL). Transfer of speed of processing training to other cognitive domains was not evident. This study provides additional evidence that speed of processing training has the potential to enhance everyday functions that maintain independence and quality of life, particularly when the training is targeted toward individuals who most need it. Further study is needed to learn about the long-term effects of such training in relation to everyday abilities.

Enzyme-linked immunospot assay responses to early secretory antigenic target 6, culture filtrate protein 10, and purified protein derivative among children with tuberculosis: implications for diagnosis and monitoring of therapy

BACKGROUND

The ability to detect tuberculosis-specific lymphocytes by enzyme-linked immunospot (ELISPOT) assay may have important implications for the diagnosis and monitoring of tuberculosis in children, for which routine methods lack sensitivity. We conducted a study to determine the presence and time course of ELISPOT responses in children with tuberculosis.

METHODS

Blood samples were obtained from children with a clinical diagnosis of tuberculosis, and interferon-gamma ELISPOT assays were performed using purified protein derivative (PPD), early secretory antigenic target 6 (ESAT-6), and culture filtrate protein 10 (CFP10) as stimulants. A subset of children were retested after 1, 3, and 6 months of therapy.

RESULTS

Detectable responses to ESAT-6 or CFP10 were found in 49 of 70 children with clinical tuberculosis but were more frequently found in those with culture-proven disease (P = .05). The number of subjects with responses to PPD increased after 1 month of therapy (P = .0004) and decreased at 3 and 6 months.

CONCLUSION

Tuberculosis-specific ELISPOT testing is a promising tool that should be evaluated as a potential diagnostic test for childhood tuberculosis. We caution against the use of an early decrease in response as a marker of successful antituberculous chemotherapy.

Perceived quality of care and outcomes following spinal cord injury: minority status in the context of multiple predictors

OBJECTIVE

To determine whether patients with spinal cord injury (SCI) who are members of minority groups experience a disadvantage with regard to quality of care, and investigate predictors of perceived quality of care and indicators of outcome.

DESIGN

Correlational analysis of longitudinal data.

SAMPLE

One hundred and forty-three individuals with SCI in the first year following injury (43.3% tetraplegia, 56.7% paraplegia; 53.6% of total had complete injuries).

SETTING

Hospital and postdischarge (usually outpatient) care at 3 SCI model systems.

MAIN OUTCOME MEASURES

Perceived quality of acute, rehabilitative, and continuing care rated by patients according to standard format. Objective indicators of amount of care (eg, length of stay [LOS], charges) and outcomes (eg, medical complications, Functional Independence Measure [FIM] scores, a life satisfaction measure [the Diener Scale], and the Craig Handicap and Reporting Technique [CHART; a community participation scale]).

RESULTS

Minorities did not report statistically significant differences in perceived quality of care or other indicators (eg, amount of care, medical complications, FIM gain, life satisfaction, and CHART scores) compared with other groups. Severity of injury affected LOS and activity outcomes. Satisfaction with medical care before the injury significantly predicted perceived quality of acute hospital care, inpatient rehabilitation, and continuing care (P < 0.03, 0.02, and 0.02, respectively).

CONCLUSION

A number of factors may affect variations in perceived quality of care and outcomes, but ethnicity is not always the most important predictor. Asking patients about their satisfaction with previous care can assist in distinguishing satisfaction with current care from pre-existing biases.

Metastases to the thyroid gland: the Royal Marsden experience

AIM

A review of patients seen at the Royal Marsden Hospital with metastases to the thyroid gland.

METHOD

Experience reported on 15 patients that were seen at our institution between 1985 and 2002.

RESULTS

The most common site of origin was the kidney (4/15). Ages ranged between 26 and 76 years. Twelve presented with a neck mass. Most had metastatic disease elsewhere at the time of presentation (9/15). Diagnosis was made by fine needle aspiration cytology (5), tru-cut biopsy (1), or surgery (9); surgery comprised total thyroidectomy (3), subtotal thyroidectomy (3) or lobectomy (3). Radiotherapy resulted in disease stabilisation in three patients. Chemotherapy was used to treat local recurrence in two patients post-operatively. The interval from diagnosis of the primary tumour to thyroid metastasis varied from 0 months to 15 years. Thyroid gland metastasis was the initial manifestation of metastatic disease in five patients. Five patients are alive, with one disease free 7 years following resection of the thyroid metastasis.

CONCLUSIONS

Thyroid metastases are clinically rare, with the kidney the most common primary site of origin. They usually occur when there are metastases elsewhere, sometimes many years after diagnosis of the original primary tumour. Surgical resection of an isolated metastasis may result in prolonged disease-free survival. Radiotherapy and chemotherapy may be of value in specific situations.

Activity, safety, and immunological effects of hydroxyurea added to didanosine in antiretroviral-naive and experienced HIV type 1-infected subjects: a randomized, placebo-controlled trial, ACTG 307

We performed a 24-week, placebo-controlled, comparative trial of hydroxyurea (HU) monotherapy, didanosine(ddI) monotherapy, and the combination of ddI plus HU administered as 1000 mg qd or 1500 mg qd in antiretroviral-naive and experienced subjects with CD4+ lymphocyte counts of 200-700 cells/mm3. Enrollment included 134 subjects. HU enhanced the antiviral activity of ddI by 1.0 log10 copies/ml after 8 weeks of therapy, with sustained responses over 24 weeks. HU alone over 4 weeks had no effect. Lamivudine resistance had little impact on antiretroviral activity when examined across treatment arms. Increases in absolute CD4+ T cell counts, but not CD4+ T cell percentages, were less in subjects who received HU compared to ddI monotherapy, and lymphoproliferative responses to antigenic and mitogenic stimuli were not altered. Subjects who received HU 1500 mg were more likely to experience dose-limiting hematological toxicities compared to those who received 1000 mg, without any additional antiviral benefit. HU may continue to have a role as a component of HIV therapy.

Aboriginal perspective on middle ear disease in the arid zone of Western Australia

OBJECTIVES

To explore perceptions, knowledge and experience of otitis media (OM) and barriers to compliance with treatment among Aboriginal people of the Kalgoorlie-Boulder area, Western Australia.

METHODS

This qualitative applied research study is based on a holistic design. We conducted structured interviews with three community focus groups, 56 key informants, and 22 mothers of babies known to have suffered from OM. Written records of interviews were checked with participants. The three sources of data enabled comparison and verification of results.

RESULTS

People were concerned about serious consequences of OM, especially deafness and learning difficulties. Since early disease may have no localizing symptoms, not surprisingly, people had limited understanding of the aetiology of OM and were often only aware of disease once ear discharge was visible. Nevertheless, they usually sought treatment for non-specific symptoms. Competing demands in people's daily lives and the unpleasant, intensive nature of treatment result in families becoming resigned to a child's chronic ear discharge. Someone other than the biological mother within the extended family may be responsible for administering treatments. Half the carers thought passive smoking may predispose children to OM and 70% suggested clearing the nasal passages to prevent OM. Results of surgery were viewed positively but specialist services were not always readily accessible.

CONCLUSIONS

Since responsibility for treatment may not lie with the biological mother, awareness campaigns must target the entire community. As early OM may be asymptomatic, health personnel should be encouraged to do otoscopy on all children with non-specific symptoms.

Strategic approach to the management of Hodgkin's disease incorporating salvage therapy with high-dose ifosfamide, etoposide and epirubicin: a Northern Region Lymphoma Group study (UK)

The Northern Region Lymphoma Group is a population-based group covering 3.1 million people in Northern England. From 1991 total data collection for all Hodgkin's disease patients for this population has been in place and it has been possible to demonstrate that the overall survival for Hodgkin's disease for younger patients within this population has moved from 80% pre- 1988 to 87% post- 1988. This improvement has been brought about by the introduction of clinical trials for advanced stage disease and effective salvage regimens. This report describes the outcome of 51 patients treated with the ifosfamide, etoposide and epirubicin (IVE)schedule and includes 28 males and 23 females with a median age of 34 years. Overall 43 of 51 patients responded to treatment (84%) with 31 achieving a complete response, four a good partial response and eight a partial response. Thirty-one proceeded to autologous stem-cell transplantation. In total, with a median follow-up of 24 months (range 6-51), 26 patients remain alive and in continuous remission. Haematological toxicity,in particular neutropenia WHO grade 4, was observed in all cases but improved over the three courses of treatment. Non-haematological toxicity was not a major problem, with no significant cardiac, hepatic, renal or neurotoxicity. We conclude that the high-dose ifosfamide-containing regimens should be prospectively evaluated in the various types of non-responsive and relapsing Hodgkin's disease.

Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study

BACKGROUND

To our knowledge, a prospective, randomized study comparing operative and nonoperative treatment of a thoracolumbar burst fracture in patients without a neurological deficit has never been performed. Our hypothesis was that operative treatment would lead to superior long-term clinical outcomes.

METHODS

From 1994 to 1998, forty-seven consecutive patients (thirty-two men and fifteen women) with a stable thoracolumbar burst fracture and no neurological deficit were randomized to one of two treatment groups: operative (posterior or anterior arthrodesis and instrumentation) or nonoperative treatment (application of a body cast or orthosis). Radiographs and computed tomography scans were analyzed for sagittal alignment and canal compromise. All patients completed a questionnaire to assess any disability they may have had before the injury, and they indicated the degree of pain at the time of presentation with use of a visual analog scale. The average duration of follow-up was forty-four months (minimum, twenty-four months). After treatment, patients indicated the degree of pain with use of the visual analog scale and they completed the Roland and Morris disability questionnaire, the Oswestry back-pain questionnaire, and the Short Form-36 (SF-36) health survey.

RESULTS

In the operative group (twenty-four patients), the average fracture kyphosis was 10.1 degrees at the time of admission and 13 degrees at the final follow-up evaluation. The average canal compromise was 39% on admission, and it improved to 22% at the final follow-up examination. In the nonoperative group (twenty-three patients), the average kyphosis was 11.3 degrees at the time of admission and 13.8 degrees at the final follow-up examination after treatment. The average canal compromise was 34% at the time of admission and improved to 19% at the final follow-up examination. On the basis of the numbers available, no significant difference was found between the two groups with respect to return to work. The average pain scores at the time of the latest follow-up were similar for both groups. The preinjury scores were similar for both groups; however, at the time of the final follow-up, those who were treated nonoperatively reported less disability. Final scores on the SF-36 and Oswestry questionnaires were similar for the two groups, although certain trends favored those treated without surgery. Complications were more frequent in the operative group.

CONCLUSION

We found that operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with nonoperative treatment.

Objective and subjective handicap following spinal cord injury: interrelationships and predictors

OBJECTIVE

To investigate the relationship between objective and subjective indicators of handicap or community participation among people with spinal cord injury (SCI) 1 year postinjury.

DESIGN

Longitudinal correlational study of quality of life indicators linked to Northern New Jersey SCI System database.

SETTING AND PARTICIPANTS

A total of 126 (80% male) participants was assessed at 1 year post-SCI. Age ranged from 14-83 years (median age = 34 years); 47% had tetraplegia, and 53% had paraplegia.

PRIMARY MEASURES

Objective (or normative) handicap was measured using the Craig Handicap Assessment and Reporting Technique and the Community Integration Questionnaire. Subjective feelings about each area of handicap or community participation were assessed using the Andrews Delighted-Terrible scale.

RESULTS

Significant correlations were found between objective and subjective indicators of handicap in work life, social life, mobility, and economic status. Subjective handicap also correlated modestly with severity of impairment and length of hospitalization. These correlations were, however, weak or inconsistent across individuals. Subjective quality of life was not related to preinjury economic or social handicap. Some participants spontaneously reported dissatisfaction with items outside of the standard outcomes scales used (eg, sexuality and personal relationships).

CONCLUSIONS

The weakness and inconsistency of relationships between objective and subjective appraisals of areas of community participation is a challenge to outcomes measurement and has implications for the targeting of interventions. More research is needed to understand relationships between objective indicators of community participation and subjective appraisals of these areas.

External validation of a modified model of Acute Physiology and Chronic Health Evaluation (APACHE) II for orthotopic liver transplant patients

INTRODUCTION

The purpose of the study was to validate the newly derived postoperative orthotopic liver transplantation (OLTX)-specific diagnostic weight for the Acute Physiology and Chronic Health Evaluation (APACHE) II mortality prediction system in independent databases.

METHODS

Medical records of 174 liver transplantation patients admitted postoperatively to the adult intensive care units at King Fahad National Guard Hospital and the University of Wisconsin were reviewed, and data on age, sex, the underlying liver disease, APACHE II scores and the hospital outcome were collected. Predicted mortality was calculated using: 1) the original APACHE II diagnostic weight of postoperative other gastrointestinal surgery and 2) the newly derived OLTX-specific diagnostic category weight. Standardized mortality ratio and 95% confidence intervals were calculated. Calibration was evaluated with the Hosmer-Lemeshow goodness-of-fit C-statistic. Discrimination was tested by 2 x 2 classification matrices and by computing the areas under the receiver operating characteristic curves. Patient characteristics and outcome data were compared between the two hospitals.

RESULTS

APACHE II significantly overestimated mortality when the original diagnostic weight was used, but provided a closer estimate of mortality with the OTLX-specific diagnostic weight. The C-statistic analysis showed better calibration for the new approach; discrimination was also improved. The performances of the prediction systems were similar in the two hospitals. The new model provided more accurate estimates of hospital mortality in each hospital.

DISCUSSION

APACHE II provided an accurate estimate of mortality in liver transplant patients when the OLTX-specific diagnostic weight was used. With the new model, APACHE II can be used as a valid mortality prediction system in this group of patients.

The FOXP1 winged helix transcription factor is a novel candidate tumor suppressor gene on chromosome 3p

The JC12 monoclonal antibody recognizes a previously unknown nuclear protein that showed a restricted distribution in normal tonsil and was also overexpressed in a subset of diffuse large B-cell lymphomas. Using this reagent, we expression cloned cDNAs encoding its antigenic target and identified this protein as a novel putative transcription factor, FOXP1. The FOXP1 protein sequence contains predicted domains characteristic of transcription factors, including a winged helix DNA-binding motif, a second potential DNA-binding motif, a C(2)H(2) zinc finger, nuclear localization signals, coiled-coil regions, PEST sequences, and potential transactivation domains. The FOXP1 gene has been mapped to chromosome 3p14.1, a region that commonly shows loss of heterozygosity in a wide range of tumors and which is reported to contain a tumor suppressor gene(s). Using tissue arrays and immunohistochemistry, we demonstrate that both the FOXP1 mRNA and protein are widely expressed in normal tissues. The levels of FOXP1 mRNA were compared in paired normal and tumor tissues (from the same patient) using a tissue array containing cDNAs extracted from 68 samples taken from kidney, breast, prostate, uterus, ovary, cervix, colon, lung, stomach, rectum, small intestine, and from nine cancer cell lines. Differences in FOXP1 mRNA expression between normal and tumor samples were observed in 51% of cases. Most striking was the comparative loss of expression in 73% of colon tumors and comparative overexpression of FOXP1 mRNA in 75% of stomach tumors. Analysis of the FOXP1 mRNA expression in normal tissues (not taken from cancer patients) indicated that loss of FOXP1 expression may occur in some histologically normal tissues adjacent to tumors. Immunohistochemical analysis of FOXP1 protein expression was performed on 128 solid tumors, including 16 renal, 9 breast, 12 lung, 20 colon, 21 stomach, 10 head and neck, 35 prostate, and 5 pancreatic cases. Complete loss of expression, increased expression, and cytoplasmic mislocalization of the predominantly nuclear FOXP1 protein were frequently observed in neoplastic cells. Our study identifies FOXP1 as a new candidate tumor suppressor gene localized to the chromosome 3p14.1 region.

Childhood outcome after early high-frequency oscillatory ventilation for neonatal respiratory distress syndrome

OBJECTIVE

In a previous multicenter controlled clinical trial, we randomly assigned surfactant-treated premature newborns with moderate to severe respiratory distress syndrome to early treatment with high-frequency oscillatory ventilation (HFOV) or to conventional ventilation (CV). Compared with control infants who were treated with CV, neonates who were treated with HFOV using a strategy designed to recruit and maintain lung volume and minimize oxygen exposure had clinical evidence of improved pulmonary outcome and less lung injury. We report a follow-up study designed to determine whether clinical differences persisted between these study groups.

METHODS

Patients were recruited from 81 survivors at 1 center (Provo, Utah) and evaluated for sociodemographic and health history, growth, mental development, motor proficiency, and pulmonary function.

RESULTS

Eighty-seven percent of the cohort who originally were assigned to treatment with HFOV (n = 36) or CV (n = 33) were seen in follow-up at a mean age of 77 months (6.4 years). There were no differences in the frequency of hospitalization, pulmonary illness, asthma, or disabilities. Growth, verbal IQ, and motor development were appropriate for age and not different between groups. Patients who initially were randomized to treatment with CV showed pulmonary function evidence of decreased peak expiratory flow, increased residual lung volume, and maldistribution of ventilation.

CONCLUSION

Neurodevelopmental childhood outcome after early intervention HFOV was normal and not different compared with patients who were treated with CV. Surfactant replacement combined with early HFOV using a lung recruitment strategy ameliorates the acute lung injury in respiratory distress syndrome that predisposes some preterm infants to develop chronic lung disease.

High-dose ifosfamide in combination with etoposide and epirubicin (IVE) in the treatment of relapsed/refractory Hodgkin's disease and non-Hodgkin's lymphoma: a report on toxicity and efficacy

One hundred and seven patients (61 with diffuse large B-cell non-Hodgkin's lymphomas and 46 with Hodgkin's disease) in relapse or following of primary therapy received ifosfamide 3 g/m2 i.v. daily for 3 days in combination with epirubicin 50 mg/m2 i.v. day 1 and etoposide 200 mg/m2 i.v. days 1-3. Of the 46 patients with Hodgkin's disease (28 male, 18 female, and a median age of 28 years) 85% of patients had a response to treatment, with 17 achieving complete remission and 11 good partial remission. Twenty-eight proceeded to autologous bone marrow or peripheral blood stem cell transplantation. Twenty-three patients remain alive in continuous remission with a follow-up of 12-61 months. The median overall survival time for all patients in this group is 36 months. Haematological toxicity, particularly WHO Grade IV neutropenia, occurred in all patients but improved over the three courses of treatment. There was no major non-haematological toxicity. Further trials of this regimen in this clinical situation are indicated. The patients with non-Hodgkin's lymphomas in this study had diffuse large B-cell lymphomas and had only received first-line treatment. Twenty had primarily refractory disease, 15 had only achieved partial remissions (PR), and 26 had developed relapse following primary treatment. The overall response rate was 43%; it was 60% for those who had achieved initial PR, 58% for those in relapse after an initial CR or very good PR following initial therapy, but only 10% for those with primarily refractory disease. Tolerance to the regimen was similar to that observed in treatment of the patients with Hodgkin's disease and many were able to undergo stem cell collection, following mobilization with this regimen. The 2-year overall survival result was 22% for patients with some response to first-line treatment but 0% for primary refractory patients.

Paper alert. Immunology

A selection of interesting papers that were published in the two months before our press date in major journals most likely to report significant results in immunology.