UPDOs Protective Styles, a Multilevel Intervention to Improve Pre-exposure Prophylaxis Uptake Among Black Cisgender Women: Pretest-Posttest Evaluation

ABSTRACT

In the United States, Black cisgender women account for one in five new HIV infections with Black Americans, accounting for 57% of new diagnoses in the South. Pre-exposure prophylaxis (PrEP) is 99% effective at preventing HIV. Still, Black women's uptake remains at 2% due to multiple documented barriers, including lack of awareness and knowledge, mistrust, stigma, and low perceived risk. Culturally relevant interventions leveraging trusted venues, such as beauty salons, can overcome these barriers. This article reports preliminary results of an intervention to improve PrEP knowledge and awareness, PrEP stigma, PrEP trust, and uptake among Black cisgender women. This multilevel, mixed-methods study used a community-engagement approach to develop and pilot a salon-based intervention, Using PrEP and Doing it for Ourselves (UPDOs) Protective Styles. The intervention improved knowledge, awareness, and trust around PrEP among Black cisgender women. PrEP use stigma within interpersonal relationships decreased, but low perceived risk and social stigma remained constant. Culturally and socially acceptable interventions like UPDOs Protective Styles can model health care delivery to improve trust, thus improving uptake over time for this population.

An exploration of language: How nurses describe social factors that contribute to health

BACKGROUND

Over the last two centuries nurses have been practicing, teaching, and conducting research on social factors that contribute to health and the language has evolved over this time.

PURPOSE

To explore how social factors that contribute to health are described by nurse authors and how that use has changed over time.

METHODS

A scoping review using the JBI Manual for Evidence Synthesis, Cochrane Handbook, and PRISMA guidelines was completed.

FINDINGS

From 1967 to 2021, nurses used the term "social factors" most commonly and there was a shift from demographic to social factors.

DISCUSSION

As the language that nurses use has shifted from demographic descriptions to the social factors that may be associated with those descriptions, nurses have an opportunity to promote the use of non-deterministic language for health promotion and research.

Examining Stigma and Disclosure Among Women With HIV in the Southern United States: Qualitative Study Guided by the Adaptive Leadership Framework for Chronic Illness

ABSTRACT

Stigma is a fundamental cause of health inequities. Guided by the Adaptive Leadership Framework for Chronic Illness (ALFCI), this descriptive qualitative study explored the challenges of stigma and disclosure experienced by women with HIV (WWH) in the Southern United States. A convenience sample of 22 WWH aged 36 to 62 years were interviewed for this study. Analysis of participant interviews revealed that WWH face a multitude of stigma-related technical and adaptive challenges, which are consistent with the ALFCI. Once identified, technical challenges, such as recognizing the need for support, lack of trust, and fear of rejection, can be overcome by technical work, including providing assistance with HIV disclosure and building a trusted network. By identifying specific adaptive and technical challenges faced by WWH and engaging in technical and adaptive work, the WWH and the provider can reduce the fear of disclosure and the effect of stigma.

Combating Stigma in the Era of Monkeypox-Is History Repeating Itself?

ABSTRACT

Men who have sex with men (MSM) and people with HIV (PWH) perceive, internalize, and experience significant stigma from family members, health care providers, and community members because of their sexual behaviors. The current monkeypox (MPX) outbreak is affecting both communities. The pandemic has spread to 89 countries with more than 31,000 confirmed cases, and global agencies are concerned about how the disease is portrayed in the media. This article will introduce MPX and its associated stigmas, providing a brief theoretical perspective on adaptive behaviors and nursing interventions to mitigate stigma. This is followed by a case-based description of the current experiences of an MSM with MPX. We will discuss stigma prevention strategies from an adaptation and mitigation perspective. We conclude with how nurses can contribute to stigma prevention for individuals with MPX.

Monkeypox Virus Outbreak 2022: Key Epidemiologic, Clinical, Diagnostic, and Prevention Considerations

ABSTRACT

Monkeypox is a zoonotic infection that manifests as dermatologic lesions that may be painful or pruritic and can appear on the face, trunk, extremities, genitals, and mucosal surfaces. In 2022, cases of monkeypox increased exponentially and it was declared a public health emergency by the World Health Organization and the U.S. Department of Health and Human Services. Unlike previous monkeypox outbreaks, the current situation has disproportionately affected men who have sex with men and seems to be associated with lower mortality. Options for treatment and prevention are limited. The distribution and availability of vaccines and antivirals has posed challenges for patients, clinicians, and public health systems. Early recognition and management of persons with monkeypox is critical in controlling the spread of this infection. This article reviews key features of monkeypox and highlights current recommendations for clinical management, prevention, and considerations for persons with HIV. Implications for public health and nursing are discussed.

Adaptive leadership in clinical encounters with women living with HIV

BACKGROUND

Women living with HIV (WLWH) report low engagement in health care, missed office visits, and less engagement in the clinical encounter. Strengthening the clinical encounter for WLWH may improve health outcomes and quality of life. The Adaptive Leadership Framework for Chronic Illness offers specific adaptive leadership strategies for providers to improve patient-provider interactions. The purpose of this study was to examine adaptive leadership behaviors that contribute to the development of effective patient-provider communication from the perspectives of WLWH.

METHODS

The descriptive, cross-sectional and qualitative study conducted interviews with 22 WLWH to assess perceptions of the clinical encounter related to HIV-related stigma, engagement in care, medical distrust, and experiences with discrimination and quality of life. Members of the study team using a set of a priori codes analyzed data using NVivo 12.0.

RESULTS

Participants described two primary themes and subthemes of each for adaptive leadership behaviors. The primary theme for adaptive leadership of providers was "my provider cares about me"; subthemes were communication, trust building takes time, and supportive providers are trusted. The primary theme for adaptive leadership of WLWH themselves was "I care about me; subthemes were self-advocacy and self-empowerment.

CONCLUSIONS

Providers can use adaptive leadership behaviors during clinical encounters to support WLWH, improve patient-provider communication, enhance trust, and improve patient outcomes.

Adaptive Challenges, Adaptive Work, and Adaptive Leadership Among Women Living With HIV in the Southern United States: Findings From a Qualitative Study

ABSTRACT

Women living with HIV have a higher burden of non-AIDS comorbidities and prevalence of chronic conditions. The Adaptive Leadership Framework for Chronic Illness clarifies living with complex health challenges by delineating the technical work of health care providers as well as the adaptive work and leadership behaviors of patients and their providers. We conducted a descriptive, qualitative study of women residing in the Southern United States who were participating in the Women's Interagency HIV Study in North Carolina. Twenty-two participants (mean age = 52.2 years; 90.9% self-identifying as Black or African American) completed semi-structured qualitative interviews. We identified adaptive challenges (e.g., affective and disclosure challenges) and adaptive work and leadership behaviors. Women learned skills to care for their health and support their families and to work with their providers to manage their care. Findings support the importance of identifying leadership behaviors for the purpose of developing person-centered interventions.

Exploring Resilience Among Black Women Living With HIV in the Southern United States: Findings From a Qualitative Study

ABSTRACT

Black women living with HIV (WLWH) face individual and sociostructural challenges. Despite these challenges, many exemplify remarkable levels of resilience and coping. Yet, research on resilience and coping in this population is limited. Twenty Black WLWH in the Southern United States completed semi-structured interviews that explored challenges facing WLWH. We identified six themes related to resilience and coping: self-acceptance, disclosure, self-compassion, social support, will to live, and service. Of these, social support was a driving protective element and an essential component to building and sustaining resilience and coping. Women who experienced positive support often expressed a will to live as well as a desire to support other WLWH. Resilience and social support were characterized by patterns of reciprocity, in that they were mutually sustaining, stabilizing, and strengthening.

Preexposure Prophylaxis Outcomes in an Urban Community in North Carolina: Discontinuation of Care and Sexually Transmitted Infections

BACKGROUND

Few studies have examined long-term outcomes among persons who initiate preexposure prophylaxis (PrEP) in the South, including PrEP discontinuation and sexually transmitted infection (STI) rates.

METHODS

Care discontinuation (>6 months without a PrEP appointment) and incident STIs were evaluated for patients at 2 PrEP clinics in Durham, NC. We tested for predictors of discontinuation as a binary variable using logistic regression. Model covariates included age, race/ethnicity, sex, known HIV-positive partner, commercial sex work, men who have sex with men (MSM) versus not MSM, type of insurance, and clinic site. A similar analysis was completed for STI incidence, controlling for days in the study.

RESULTS

Among 271 patients, mean age was 33.2 years, 46.9% were Black and 11.1% were Latino, 81.2% were MSM, and 32% were uninsured. Preexposure prophylaxis was discontinued in 47%, and another 11% had intermittent care. Sexually transmitted infection incidence was 45.4/100 person-years, and 5 patients were diagnosed with HIV at baseline or in follow-up. Men who have sex with men were less likely to discontinue PrEP relative to non-MSM (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.10-0.64). Baseline STI was associated with a higher likelihood of incident STI (OR, 8.19; 95% CI, 3.69-19.21), whereas care discontinuation was associated with a lower likelihood of STI (OR, 0.28; 95% CI, 0.11-0.65).

CONCLUSIONS

Preexposure prophylaxis programs in the Southern United States are reaching uninsured and predominantly Black and Latino MSM, but discontinuation rates are high despite elevated rates of incident STI and HIV. Further work is required to elucidate causes of PrEP discontinuation and encourage persistence in care.

Comparison of Three Methods for Determination of Crude Protein in Meat: Collaborative Study

A study was designed to compare the Kjel-Foss automated macro-Kjeldahl method and a block digestion- steam distillation method. The official AOAC Kjeldahl method was used as a reference procedure. Six products with a crude protein range of 10-30% were analyzed by 23 laboratories. Five laboratories analyzed the samples by the official AOAC method, 8 laboratories used the automated Kjel-Foss method, and 11 laboratories used the block digestion with steam distillation method. Standard deviations for each product and each method for both repeatability and reproducibility are given. The block digestion- steam distillation method has been adopted official first action.

Partnerships between a University-Affiliated Clinic and Community Based Organizations to Reach Black Men who have Sex with Men for PrEP Care

Background

While pre-exposure prophylaxis (PrEP) is a promising strategy for reducing HIV transmission, persons at highest risk for infection are not being adequately reached, particularly Black Men who have Sex with Men (MSM).

Methods

In December 2015, a dedicated PrEP clinic was established at Duke University Medical Center in Durham, North Carolina (NC). We performed a retrospective review of patients evaluated at the PrEP clinic, abstracting the following routinely collected variables: age, race, ethnicity, sex at birth, self-identified gender, HIV risk factors and source of referral. Descriptive statistics are presented as medians and frequencies.

Results

Over 18 months, 91 patients were evaluated. Most were male (90%, n = 82), approximately half were non-Hispanic Black (46%, n = 42), and median age was 31 years (range 19–66). Most patients identified as MSM (78%, n = 71) and 3 (3%) were transgender women who have sex with men (TGW). Specifically, 30% (n = 27) were Black MSM or TGW. Risk factors for all patients included multiple sexual partners (65%), known HIV+ partner (19%), or a recent sexually transmitted infection (16%). One-quarter of patients (n = 23) were uninsured. Among all Black patients, the most common source of referral was a community-based organization (CBO) (40%, n = 17), and specifically, Black MSM and TGW were most commonly referred by a CBO (44%, n = 12). Among White patients, most were self-referrals (47%, n = 18). Demographic characteristics of our patient population relative to those newly diagnosed with HIV in NC in 2015 are shown in Table 1.

Conclusion

Although further efforts are needed to improve PrEP uptake in underserved populations in NC, the racial breakdown of our PrEP clinic is more representative of the national HIV epidemic as compared with all PrEP users in the US. Our study demonstrates that community partnerships can be a valuable avenue for patient recruitment and achieve success in reaching Black MSM with messages about PrEP.

Disclosures

All authors: No reported disclosures.

An educational initiative in response to identified PrEP prescribing needs among PCPs in the Southern U.S

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, but many primary care physicians (PCPs) have not incorporated PrEP into practice. While PrEP may be a key strategy to reducing high HIV transmission rates in the southern US, knowledge about PrEP prescribing patterns among PCPs in this region is lacking. An online survey was sent to a large network of PCPs at an academic medical center in North Carolina in October 2015. The survey was repeated in September 2016, after an educational intervention that included on-site trainings at 14 PCP offices. Chi-square tests were used to compare PrEP prescribing patterns among providers. The initial survey was sent to 389 PCPs, with 115 (30%) responding. Of these, 78% reported seeing men who have sex with men (MSM). Only 17% had prescribed PrEP. The most frequently identified barrier was lack of knowledge (60%). When the survey was repeated after the educational initiative, 79 PCPs (20%) responded. Of these, 90% reported seeing MSM, and 35% had prescribed PrEP. PCPs who had attended a training were more likely to have prescribed PrEP (OR 4.84, CI 1.77-13.21). In conclusion, PrEP prescribing among PCPs in the southern US is low. A survey among PCPs identified lack of knowledge as a barrier to prescribing, motivating an institutional-wide educational campaign in response. Further efforts are needed to continue to raise awareness and educate PCPs in the South about PrEP.

Creating simple solutions for safe naloxone use

e18185

Background: Naloxone is sometimes required to reverse acute intoxication from opioid pain medications. Although clinical guidelines exist, naloxone dosing is variable in practice. Higher doses can cause pain crisis, acute withdrawal, and possibly increased patient risk. We developed a multi-faceted intervention to increase guideline-concordant naloxone dosing. Methods: We surveyed medical staff and retrospectively collected 6 months of naloxone prescribing data to assess knowledge and frequency of guideline-concordant dosing. We reviewed the electronic order for naloxone and interviewed experienced nurses to facilitate mapping of the process of naloxone administration. We then designed 4 interventions aimed at adult inpatients on medical oncology, general medical and ICU services: 1. Simplify wording of naloxone guidelines; 2. Create naloxone kit containing all necessary equipment and instructions; 3. Auto-populate dose into electronic naloxone order; 4. Administer 5-minute educational inservice to staff (RN, NP, PA, MD). To assess rate of guideline concordance, naloxone prescribing data was collected for the pre-intervention (12 months), intervention (6 weeks), and post-intervention (8.5 months) groups. The survey was repeated after the intervention. For analysis, a generalized linear regression with logit link function and a generalized estimating equation method were used. Results: Over the 22-month study period, 137 patients received 148 naloxone doses. Patients were mean age 63.1 y/o, 54.7% female, and 75.9% white. Of the 90 naloxone doses given pre-intervention, only 24.4% were guideline-concordant. The 10 doses of naloxone given during the intervention period were guideline-concordant in 40% of the cases. Of the 48 naloxone doses given post-intervention, 62.5% were guideline-concordant, a significant increase compared to the pre-intervention group (p < 0.001). The improvement was most dramatic in the non-ICU services (26.4% to 73.5%, p < 0.001). Increases were maintained at 8 months (median concordant rate 53.5%/month (range: 33%-100%). Conclusions: A simple, inexpensive intervention can be used to increase guideline-concordant naloxone dosing and potentially avoid adverse effects of naloxone.

Effects of different treatment regimens on T cell function in acute HIV infection

In HIV-infected individuals, anti-retroviral therapy (ART) is effective in maintaining low viral loads, restoring CD4+ T cell counts, and prolonging life. However, chronic inflammation and immune dysfunction persist even after years of successful ART. Previous studies have suggested that early initiation of ART may result in improved immune reconstitution, but whether more rapid suppression of viral load during early treatment also improves immunological outcomes is unknown. In this study we compare the effects of two regimens initiated during acute infection on T cell phenotype and function. Regimen 1 (n=30) is a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen and Regimen 2 (n=30) combines an integrase strand transfer inhibitor (INSTI) with nucleoside reverse transcriptase inhibitors (NRTIs). NRTIs and NNRTIs inhibit reverse transcription of viral RNA to DNA in the infected cell, while INSTIs block integration of viral DNA into the host genome. Since Regimen 2 targets multiple stages of the viral life cycle, we hypothesize that more rapid viral suppression may be achieved with this treatment schedule. In a cross-sectional study performed 96 weeks after treatment initiation, we are comparing the effects of the two regimens on T cell activation (CD25, CD69, CD38, HLA-DR), exhaustion (PD-1, Tim-3, CD160, T-bet, Eomes), and proliferation using standardized flow cytometry panels. This study will provide valuable insights into the relationship between viral decay kinetics and immune preservation during acute infection, informing the design of future ART regimens.

Massive CD8 T cell response to primary HIV infection in the setting of severe clinical presentation

Acute HIV-1 infection causes a rapid total body depletion of CD4(+) T cells in most individuals and HIV-1-specific CD8(+) T cell expansion in response to viral replication. A numerically high CD8 T cell response may indicate limited T cell repertoire against HIV and rapid progression. We present a detailed evaluation of an acutely infected individual with a strong HIV-1-specific CD8 T cell response targeting multiple epitopes demonstrating that the upper limit of CD8 expansion in this setting may be much higher than previously reported and was likely driven by the narrow HIV-specific response.

Glucose oscillations, more than constant high glucose, induce p53 activation and a metabolic memory in human endothelial cells

AIMS/HYPOTHESIS

Damage persists in HUVECs exposed to a constant high glucose concentration long after glucose normalisation, a phenomenon termed 'metabolic memory'. Evaluation of the effects of exposure of HUVECs to oscillating high glucose on the induction of markers of oxidative stress and DNA damage (phospho-γ-histone H2AX and PKCδ) and onset of metabolic memory, and the possible role of the tumour suppressor transcriptional factor p53 is of pivotal interest.

METHODS

HUVECs were incubated for 3 weeks in 5 or 25 mmol/l glucose or oscillating glucose (24 h in 5 mmol/l glucose followed by 24 h in 25 mmol/l glucose) or for 1 week in constant 5 mmol/l glucose after being exposed for 2 weeks to continuous 25 mmol/l high glucose or oscillating glucose. Transcriptional activity of p53 was also evaluated in the first 24 h after high glucose exposure.

RESULTS

High constant glucose upregulated phospho-γ-histone H2AX and protein kinase C (PKC)δ compared with control. Oscillating glucose was even more effective than both normal and constant high glucose. Both constant and oscillating glucose resulted in a memory effect, which was more pronounced in the oscillating condition. Transcriptional activity of p53 peaked 6 h after glucose exposure, showing a predicted oscillatory behaviour.

CONCLUSIONS/INTERPRETATION

Exposure to oscillating glucose was more deleterious than constant high glucose and induced a metabolic memory after glucose normalisation. Hyperactivation of p53 during glucose oscillation might be due to the absence of consistent feedback inhibition during each glucose spike and might account for the worse outcome of this condition.

Transmitted antiretroviral drug resistance among acute and recent HIV infections in North Carolina from 1998 to 2007

Background

Transmitted drug resistance (TDR) limits antiretroviral options and thus complicates the management of HIV-positive patients. HIV disproportionately affects the southern US, but available national estimates of TDR prevalence principally reflect large metropolitan centres outside this region.

Methods

The Duke/UNC Acute HIV Program has collected data on acute or recent HIV infections (ARHI) in North Carolina since 1998. Acute infections represent antibody-negative, RNA-positive patients. Recent infection was determined by history of HIV testing or concordance between detuned ELISA and antibody avidity assays. Genotypic sequence data from the earliest collected pretreatment plasma samples were analysed with the Stanford HIV Database and screened for surveillance drug resistance mutations (SDRMs).

Results

A total of 253 individuals with ARHI between May 1998 and May 2007 had complete genotypic sequence data for analysis; 39.5% were acute infections, 78.7% were male, 64.8% were non-White and 53.8% were men who have sex with men. The overall prevalence of TDR was 17.8%, with SDRMs for non-nucleoside/ nucleotide reverse transcriptase inhibitors (NNRTIs) in 9.5% of the cohort. Mutations for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) were detected in 7.5% and for protease inhibitors (PIs) in 3.2%. K103N was the most common mutation (7.5%). Thymidine analogue mutations were found in 4.7% of samples; the most common PI SDRM was L90M (2.4%). Dual- or triple-class antiretroviral resistance was rare, encountered in only six (2.4%) samples.

Conclusions

The prevalence of TDR in North Carolina is similar to estimates from the US metropolitan areas. These findings have implications for initial regimen selection and secondary prevention efforts outside of large, metropolitan HIV epicentres.

Use of genome-wide scan in women with breast cancer to identify common germline variants that may be associated with recurrence

11049

Background: Studies of normal DNA variation have identified several common single nucleotide polymorphisms (SNPs) associated with susceptibility to breast cancer. It is not known whether common SNPs are associated with breast cancer outcomes. Methods: Subjects were Ashkenazi Jewish women with familial breast cancer and without BRCA mutations. Subjects were genotyped on an Affymetrix 500K SNP platform in the first phase of a genome-wide association study seeking susceptibility loci (Gold et. al, Proc Natl Acad Sci 2008;105:4340). Clinical variables and outcomes for these women were abstracted from medical records. Using a Cox proportional hazards model, we assessed associations between clinical outcomes and the 111 SNPs that were most significantly associated with susceptibility in the case-control study and heterozygous in the subset of affected patients. Dominant, codominant, and recessive models were explored. A secondary analysis assessed associations with recurrence of 48,562 additional SNPs that were not strongly associated with susceptibility. Results: The 173 subjects were a median of 51 years of age at diagnosis (range 27–74). Median follow-up for surviving subjects was 85.5 months. Most cancers (74.6%) were T1/T2; 62% were N0. Most were ER positive (81.5%), HER2 negative (87.5%). For the entire group, the 5- and 10-year freedom from recurrence was 84% and 72%, respectively. The 5- and 10-year overall survival was 94% and 86%, respectively. Minor alleles at rs6439927 (within CLSTN2,calsyntenin2, a post-synaptic calcium-binding membrane protein, MAF 27%) and rs7943562 ( linked to GALNTL4, an N-acetylgalactosaminyltransferase, MAF 47%) were most strongly associated with disease recurrence (log likelihood ratio chi square P=0.003 and P=0.002, respectively). No additional SNPs from the secondary analysis achieved genome-wide significance. Conclusions: Genome-wide SNP genotyping of women with breast cancer identified two novel loci that may be associated with disease recurrence. Further studies in larger cohorts will be performed to replicate these findings.

No significant financial relationships to disclose.

Transmitted antiretroviral drug resistance among acute and recent HIV infections in North Carolina from 1998 to 2007

BACKGROUND

Transmitted drug resistance (TDR) limits antiretroviral options and thus complicates the management of HIV-positive patients. HIV disproportionately affects the southern US, but available national estimates of TDR prevalence principally reflect large metropolitan centres outside this region.

METHODS

The Duke/UNC Acute HIV Program has collected data on acute or recent HIV infections (ARHI) in North Carolina since 1998. Acute infections represent antibody-negative, RNA-positive patients. Recent infection was determined by history of HIV testing or concordance between detuned ELISA and antibody avidity assays. Genotypic sequence data from the earliest collected pretreatment plasma samples were analysed with the Stanford HIV Database and screened for surveillance drug resistance mutations (SDRMs).

RESULTS

A total of 253 individuals with ARHI between May 1998 and May 2007 had complete genotypic sequence data for analysis; 39.5% were acute infections, 78.7% were male, 64.8% were non-White and 53.8% were men who have sex with men. The overall prevalence of TDR was 17.8%, with SDRMs for non-nucleoside/nucleotide reverse transcriptase inhibitors (NNRTIs) in 9.5% of the cohort. Mutations for nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) were detected in 7.5% and for protease inhibitors (PIs) in 3.2%. K103N was the most common mutation (7.5%). Thymidine analogue mutations were found in 4.7% of samples; the most common PI SDRM was L90M (2.4%). Dual- or triple-class antiretroviral resistance was rare, encountered in only six (2.4%) samples.

CONCLUSIONS

The prevalence of TDR in North Carolina is similar to estimates from the US metropolitan areas. These findings have implications for initial regimen selection and secondary prevention efforts outside of large, metropolitan HIV epicentres.

The epidemiology of drowning worldwide

The purpose of this analysis was to quantify the magnitude of death and disability from drowning and near-drowning worldwide and to provide epidemiological data on which to base prevention efforts. All data are from the Global Burden of Disease 2000 (Version 1) estimates in which deaths and disabilities are based on the WHO International Classification of Diseases. Extrapolations were made by age, sex, and WHO region. The six WHO regions of the world were further divided into high-income, and low- and middle-income based on the 1998 World Development indicators. According to the GBD 2000 data, an estimated 449,000 people drowned worldwide (7.4 per 100,000 population) and a further 1.3 million Disability Adjusted Life Years (DALYs) were lost as a result of premature death or disability from drowning. 97% of drownings occurred in low- and middle-income countries. Although 38% of drownings occurred in the Western Pacific Region, Africa had the highest drowning mortality rate (13.1 per 100,000 population). Males had higher drowning mortality rates than females for all ages and in all regions. Children under the age of 5 years had the highest drowning mortality rate for both sexes in all of the WHO regions except for Africa, where children aged 5 to 14 years had the highest mortality rate. Worldwide, for children under the age of 15 years, drowning accounted for a higher mortality rate than any other cause of injury. Drowning is a significant problem worldwide particularly for children under the age of 15 years. Low- and middle-income countries have the highest rates of drowning and account for more than 90% of such fatalities. Primary prevention efforts should thus be focused on these countries where many children who cannot swim drown in large bodies of water.

A role for N-WASP in invasin-promoted internalisation

Phagocytosis of Yersinia pseudotuberculosis occurs through interaction of the bacterial protein invasin with beta1-integrins. Here we report that N-WASP plays a role in internalisation of an invasin-expressing, avirulent strain of Y. pseudotuberculosis. Ectopic expression of N-WASP mutants, which affect recruitment of the Arp2/3 complex to the phagosome, reduces uptake of Yersinia. In addition, expression of the Cdc42/Rac-binding (CRIB) region of N-WASP has an inhibitory effect on uptake. Using GFP-tagged Rho GTPase mutants, we provide evidence that Rac1, but not Cdc42, is important for internalisation. Furthermore, activated Rac1 rescues Toxin B, CRIB and Src family kinase inhibitor PP2-mediated impairment of uptake. Our observations indicate that invasin-mediated phagocytosis occurs via a Src and WASP family-dependent mechanism(s), involving the Arp2/3 complex and Rac, but does not require Cdc42.

A note on hair whorl position and cattle temperament in the auction ring

The objective of this study was to further describe the relationships between facial hair whorls and temperament in cattle. Cattle (n=1636) from six commercial cattle auctions in Colorado and Texas were observed. Whorl location was classified according to lateral position (left, right, or middle) and height (high: above the top of the eye, middle: at eye level, low: below the bottom of the eye). A 4-point temperament score was used to rate each animal while it was in the auction ring. Cattle with a score of 1 remained calm and stood still or walked around, and those with a score of 4 were highly agitated and hit the ring fence, walls, partitions, or people with its head. The cattle observed were 75% Bos taurus beef breeds, 21% Holstein dairy cattle, 3% Bos indicus beef breeds, and 1% non-Holstein dairy breeds. Ten percent of cattle surveyed had no facial hair whorl, while 86% had a single spiral hair whorl, of which 47% had middle-middle whorl placement. Animals with a high whorl position or no hair whorl had higher temperament scores (P=0.01). Cattle with low whorls were more likely to have greater lateral displacement of whorls off of the centerline than cattle with high or middle whorls (P<0.01). Abnormally shaped whorls were more common on cattle with low whorls (P<0.01) and on cattle with lateral whorls located off of the centerline (P<0.01). Cattle with hair whorls on the centerline had more variable temperament scores (P=0.04). Beef cattle had more abnormal whorls than Holsteins (P<0.01). Temperament scores showed that Holsteins were calmer than beef cattle (P<0.01). Facial hair whorls in cattle may be a useful management tool in assessing which animals may become disturbed in novel environments.

The relationship between reaction to sudden, intermittent movements and sounds and temperament

Casual observations indicated that some cattle are more sensitive to sudden movement or intermittent sound than other cattle. Six commercial livestock auctions in two states and a total of 1,636 cattle were observed to assess the relationship between breed, sex, and temperament score on the response to sudden, intermittent visual and sound stimuli, such as the ringman swinging his arm for a bid and the sound of him briefly yelling a bid. A 4-point temperament score was used to score each animal while it was in the ring. The scores used were 1) walks and(or) stands still, with slow, smooth body movements; 2) continuously walks or trots, and vigilant; 3) gait is faster than a trot (runs even a couple of steps), with fast, abrupt, jerky movements, and very vigilant; and 4) hits the ring fence, walls, partitions, or people with its head. Animals were observed for flinches, startle responses, or orientation toward sudden, intermittent sounds, motions, and tactile stimulation, such as being touched with a cane or plastic paddle. The cattle observed were mostly Bos taurus beef breeds and Holstein dairy cattle. Holsteins were more sound-sensitive (P = .02) and touch-sensitive (P < .01) than beef cattle. Sensitivity to sudden, intermittent stimuli (e.g., sound, motion, and touch) increased as temperament score (excitability) increased. Cattle with a temperament score of 1 were the least sensitive to sudden, intermittent movement and sound and those with a temperament score of 4 were the most sensitive (P < .01). This same relationship was sometimes observed for touch but was not statistically significant. Motion-sensitive cattle were more likely than nonsensitive cattle to score a temperament rating of 3 or 4 (P < .01). Steers and heifers were more motion-sensitive than the older bulls and cows (P = .03). Beef cattle urinated (P < .01, n = 1,581) and defecated (P < .01, n = 1,582) more often in the ring than did dairy cattle. Cattle that became agitated during handling in an auction ring were the individuals that were most likely to be startled by sudden, intermittent sounds and movements. Reactivity to sudden, intermittent stimuli may be an indicator of an excitable temperament.

Long-term response to topiramate in patients with West syndrome

PURPOSE

The long-term effectiveness of topiramate (TPM) was evaluated in children with West syndrome previously refractory to antiepileptic drug (AED) therapy.

METHODS

Children with infantile spasms who completed a pilot study were eligible to enter a long-term extension phase in which the dosages of TPM and other AEDs could be adjusted to optimal response (maximum, 50 mg/kg/day TPM). The mean duration of long-term therapy was 18 months in the 11 children who were followed; the mean TPM dosage was 29 mg/kg/day.

RESULTS

Eight (73%) children were continuing TPM therapy at the time data were analyzed; four (50%) children were spasm free, seven (88%) had experienced a > or =50% reduction in spasms, and three (38%) were able to achieve TPM monotherapy.

CONCLUSIONS

TPM was well tolerated in that no patients discontinued because of adverse events. The response achieved with TPM during the pilot study was maintained in most children.

YopH dephosphorylates Cas and Fyn-binding protein in macrophages

The tyrosine phosphatase YopH is an essential virulence effector of pathogenic Yersinia spp. YopH, which is translocated from extracellularly located bacteria into interacting target cells, blocks phagocytosis by professional phagocytes. We show here that immunoprecipitation of YopH from lysates of J774 cells infected with Y. pseudotuberculosis expressing an inactive form of YopH resulted in co-precipitation of certain phosphotyrosine proteins. The association between the inactive YopH and phosphotyrosine proteins in the 120 kDa range was rapid and could be detected after 2 min of infection. The proteins were identified as the docking proteins Cas and Fyn-binding protein (FYB). Upon infection of J774 cells with Y. pseudotuberculosis lacking YopH expression both of these proteins became tyrosine phosphorylated. Moreover, this infection caused recruitment of Cas to peripheral focal complexes, and FYB was relocalized to areas surrounding these structures. Both Cas and FYB became dephosphorylated upon infection with Y. pseudotuberculosis expressing active YopH, and this was associated with disruption of focal complexes. With regard to the previous identification of Cas and focal complexes as targets of YopH in HeLa cells, the present study supports an important role for these targets in a general mechanism of bacterial uptake.

Topiramate pharmacokinetics in infants

PURPOSE

This study's goal was to provide preliminary data on the pharmacokinetics of topiramate (TPM) in a cohort of infants (younger than 4 years) participating in an open-label trial of TPM in refractory infantile spasms.

METHODS

The pharmacokinetics of TPM were assessed in infants receiving a stable TPM dose for >7 days during the extension phase of this trial. Blood samples were drawn just before and 0.5. 1, 1.5, 2, 4, 6, 8, and 12 h after the morning TPM dose. TPM plasma concentrations were determined by fluorescence polarization immunoassay. The noncompartmental analysis module of WinNonlin was used to calculate individual patient pharmacokinetics profiles.

RESULTS

Five infants (ages, 23.5-29.5 months) formed the study cohort. These infants had been given TPM for a median of 9 months (range, 6-11 months) and were currently receiving between 11 and 38.5 mg/kg/day TPM. One was receiving TPM monotherapy, whereas four were taking concomitant antiepileptic medications (AEDs; n = 2, enzyme-inducing agents; n = 2, non-enzyme-inducing drugs). TPM pharmacokinetics in infants appears to be linear. In this cohort, mean TPM plasma clearance (CL/F, 66.6+/-27.4 ml/h/kg) was slightly higher than that reported for children and adolescents and therefore substantially higher than that reported for adults. TPM CL/F was higher and the calculated half-life shorter in the infants receiving concomitant enzyme-inducing AEDs.

CONCLUSIONS

Based on this small cohort of patients, it appears that infants may require significantly larger TPM doses, based on weight, than children, adolescents, or adults. Titration to effect and not absolute TPM dose should guide therapy in this age group.

Prevalence of severe welfare problems in horses that arrive at slaughter plants

OBJECTIVE

To assess the prevalence of severe welfare problems in horses that arrive at slaughter plants and to identify horses that were unfit for travel.

DESIGN

Prevalence survey.

ANIMALS

1,008 horses.

PROCEDURE

Horses arriving at 2 slaughter plants were observed. The following were rated severe welfare problems in horses: body condition scores of 1 or 2 (emaciated) of 9; recumbency (down) or the inability to walk; fractured limbs or other foot or limb problems that extremely impaired mobility; severe wounds, such as deep cuts, extensive lacerations, abrasions on the head or back, eye injuries, neglected purulent lesions, and numerous bite and kick marks over extensive areas of the body; and dead on arrival. Bruises on carcasses were tabulated to further assess injuries. Horses that had been loaded with a fractured limb, arrived nonambulatory, had severe lameness that interfered with mobility, were weak and emaciated, or were dead on arrival or died shortly after arrival were considered unfit for travel.

RESULTS

Ninety-two percent (930/1,008) of the horses arrived in good condition, and 7.7% (78) had a condition that was rated a serious welfare problem. Thirty horses (3%) had a body condition score of 1 or 2, 12 (1.0%) had foot and limb problems (other than fractures), 4 (0.4%) had fractured limbs, 18 (2.0%) had deep cuts, lacerations, or injuries from bites, 8 (0.8%) were nonambulatory or dead on arrival, 2 (0.2%) had deformities, 3 (0.3%) had extensive purulent lesions, and 1 (0.1%) had a behavior problem. Characteristic patterns of 51% of carcass bruises indicated that they were caused by bites or kicks. Fighting was the major cause of injuries that occurred during transport and marketing. Fifteen (1.5%) horses were unfit for travel. Abuse or neglect by owners was the cause of 77% of the severe welfare problems observed.

CLINICAL IMPLICATIONS

To decrease the number of injuries that result from fighting when transporting horses to slaughter plants, aggressive mares and geldings that continually attack other horses must be segregated.

Prospective double-arm study of fibrinolysis in surgical patients

BACKGROUND

During surgery, the balance between thrombosis and fibrinolysis is altered. Methods reported to increase fibrinolysis, such as compression devices, may reduce venous thrombosis. However, there are no prospective studies comparing methods and the effect on fibrinolysis.

MATERIALS AND METHODS

In a prospective study, general surgical patients were randomized to either sequential compression devices (Group 1) or subcutaneous heparin (Group 2), and fibrinolysis factors were measured in order to determine the effect on the fibrinolysis system. Blood samples were drawn at a similar time of the day with the tourniquet off. Specifically, t-PA antigen, plasminogen activator inhibitor-1 (PAI-1), and D-dimer were measured preoperatively (preop) and on Postoperative Days (POD) 1 and 7 by the ELISA method. Fibrinolysis factors were reported as the mean +/- SD and as percentage change from preoperative values. Noninvasive vascular studies were performed preop, and on POD 1, 7, and 30, by an examination of the infrainguinal venous system and external iliac veins in bilateral lower extremities. Nonambulatory patients were excluded from the study and DVT prophylaxis methods were initiated at surgery and used through POD 2.

RESULTS

For the 136 patients in the study, there were no differences in clinical characteristics such as age, surgical time (all > 60 min), anesthesia type (general or spinal), type of surgical procedure, or other risk factors for DVT. Two DVTs occurred at POD 1 and 30 (both Group 2), and one pulmonary embolism in each group (POD 7 for Group 1; POD 1 for Group 2). For subjects without thrombosis, D-dimer changes were parallel for both groups, increasing through POD 7. Similarly, t-PA antigen levels rose from baseline on POD 1 in both groups, with a return toward baseline by POD 7. The PAI-1 levels increased on POD 1 in both groups, but severalfold more in Group 1 (compression devices). The elevation in PAI-1 decreased by 50% in Group 1 by POD 7, while values returned to normal in Group 2. These changes were not significant using the Mann-Whitney test. Only three patients had thrombotic episodes so that data on changes in fibrinolysis factors are difficult to compare with the larger group.

CONCLUSIONS

This is the first report of a prospective, randomized comparison of fibrinolysis factors using sequential compression devices in comparison to low dose unfractionated heparin in general surgical patients, and comparing postoperative values to preop. Both groups showed an enhanced fibrinolysis by elevation in t-PA antigen and D-dimer on POD 1, as expected when fibrinolysis occurs. While PAI-1 and t-PA work in parallel, the marked elevation of PAI-1 on POD 1 (although only slightly above reference values) and continuing into POD 7 for subjects using compression devices requires further inquiry. The elevation of PAI-1 in the face of elevated t-PA and D-dimer has been reported, but the comparison between patients using sequential compression devices and mini-dose heparin has not been reported. The reason for the elevation requires additional study into other influences on the synthesis, secretion, and/or function of PAI-1 that do not affect t-PA.

A faculty on the move into the community

Faculty at the University of Rochester School of Nursing initiated a curricular redesign to prepare students for the evolving demands of the health care job market and the changing nature of the nursing profession. The concept of the "Learning Community" serves as the metaphor for the new vision of clinical education: a set of collaborative and dynamic relationships of students, faculty, clinicians, health care consumers and institutional and community sites with the mutual responsibility for the education of students and the health of all partners. Students experience firsthand the new capabilities required of professionals in the new context of health care as more than illness care.

Identification and characterization of additional flagellin genes from Vibrio anguillarum

Previously, the flagellar filament of Vibrio anguillarum was suggested to consist of flagellin A and three additional flagellin proteins, FlaB, -C, and -D. This study identifies the genes encoding FlaB, -C, and -D and a possible fifth flagellin gene that may encode FlaE. The flagellin genes map at two separate DNA loci and are most similar to the four polar flagellin genes of Vibrio parahaemolyticus, also located at two DNA loci. The genetic organization of these two loci is conserved between both organisms. For each gene, in-frame deletions of the entire gene, the 5' end, and the 3' end were made. Mutant analysis showed that each mutation, except those in flaE, caused a loss of flagellin from the filament. However, no obvious structural loss in the filament, as determined by electron microscopy, and only slight decreases in motility were seen. Virulence analysis indicated that all but two of the mutations gave a wild-type phenotype. The 5'-end deletions of flaD and flaE decreased virulence significantly (>10(4)-fold) of infections via both the intraperitoneal and immersion routes. These results indicate that, like FlaA, FlaD and FlaE may also be involved in virulence.

5-Fluorouracil and cisplatin therapy after palliative surgical resection of squamous cell carcinoma of the esophagus. A multicenter randomized trial. French Associations for Surgical Research

BACKGROUND

The curative rate of surgical resection of squamous cell carcinoma of the esophagus is low. Reports on the efficacy of preoperative and postoperative chemotherapy are conflicting or have included limited disease or radical surgery alone.

OBJECTIVE

The authors' objective was to study the results of chemotherapy on the duration and quality of survival in patients who have undergone palliative surgical resection for esophageal squamous cell carcinoma.

PATIENTS AND METHODS

Of 124 patients with histologically proven esophageal squamous cell carcinoma situated more than 5 cm from the upper end of the esophagus, 4 patients were withdrawn for failure to comply with the protocol. The remaining 120 patients, 116 males and 4 females (mean age, 57 +/- 9 years), were randomly assigned to either a control group who were to receive no chemotherapy (68 patients) or to a group who were to be treated with chemotherapy (52 patients). Patients were subdivided into two strata as follows: (1) stratum I, complete resection of the tumor with lymph node involvement (62 patients) and (2) stratum ii, incomplete resection leaving macroscopic tumor tissue in situ or with metastases. Noninclusion criteria were histologically proven tracheobronchial involvement, esotracheal fistula, major alteration of general health status (Karnofsky score <50), cerebral or extensive (>30% of parenchyma) hepatic metastasis, peritoneal carcinomatosis, associated or previously treated upper airway cancer, or, conversely, complete resection of tumor without lymph node involvement. Chemotherapy was given in 5-day courses, every 28 days, with a maximum of 8 courses. Cisplatin was administered either as a single dose of 100 mg/m2 at the beginning of the course or as 20 mg/m2/day for 5 days given over 3 hours. 5- Fluorouracil (5-FU) (100 mg/m2/day) was infused over 24 hours for 5 days. The duration of treatment ranged from 6 to 8 months. The main aim was to establish median survival and actuarial survival curves. The subsidiary aim was to evaluate quality of survival as judged by complications due to treatment and the duration of autonomous oral feeding, that is, without palliative endoscopic treatment. No difference in survival was noted between the two groups, overall (median, 14 months), or between the strata. Conversely, significantly more patients in the treated group had hematologic, neurologic, and renal complications compared with the control group. Four patients died of complications of chemotherapy. The duration of autonomous oral alimentation was exactly the same in both groups (median, 12 + months).

CONCLUSION

The results of this study suggest that 5-FU and cisplatin are not useful for patients with squamous cell carcinoma of the esophagus who have not undergone curative resection.

Is DVT prophylaxis overemphasized? A randomized prospective study

This study was designed to prospectively evaluate a previously published prognostic index for predicting deep venous thrombosis (DVT) in general surgical patients with conventional prophylaxis. Patients undergoing procedures of at least 1 hr duration (abdominal, thoracic, head and neck, inguinal) requiring general or spinal anesthetic were prospectively randomized into the following groups: Group 1, sequential pneumatic compression devices during surgery and 2 days postoperatively; Group 2, subcutaneous heparin (5000 U q 12 hr) starting 1 hr before surgery and for 7 days postop; Group 3, control group. All patients underwent duplex evaluation of bilateral lower extremity deep venous systems preoperatively and on postoperative Days 1, 3, and 30. In addition, a previously developed predictive DVT incidence indicator, the prognostic index (PI), was calculated for each patient. A total of 137 patients were entered into the study with 29 removed for patient/staff reasons. There were no differences in PI among the three groups at the 0.05 level (ANOVA). The distribution of risk factors for DVT including increased age, body size, hemoglobin (Hb), and colorectal procedures were distributed evenly among the groups. Additional factors such as diabetes, COPD, PVD, immobilization, and cancer were also evenly distributed among the groups. The PI predicted a 20% incidence of DVT. For Groups 1 (n = 25), 2 (n = 38), and 3 (n = 45) no DVTs were detected over the 30 days of study. During the study period, 8 DVTs were detected by duplex evaluation in general surgical patients not in the study (1.5%). In conclusion, in a prospective randomized study using sequential pneumatic compression devices, subcutaneous heparin or no prophylaxis in matched general surgical patients at moderate to high risk for thromboembolism, no DVTs occurred for up to 30 days. Furthermore, neither a PI nor other factors associated with DVT accurately predicted the incidence of DVT in this patient population.

The uncertain response in the bottlenosed dolphin (Tursiops truncatus)

Humans respond adaptively to uncertainty by escaping or seeking additional information. To foster a comparative study of uncertainty processes, we asked whether humans and a bottlenosed dolphin (Tursiops truncatus) would use similarly a psychophysical uncertain response. Human observers and the dolphin were given 2 primary discrimination responses and a way to escape chosen trials into easier ones. Humans escaped sparingly from the most difficult trials near threshold that left them demonstrably uncertain of the stimulus. The dolphin performed nearly identically. The behavior of both species is considered from the perspectives of signal detection theory and optimality theory, and its appropriate interpretation is discussed. Human and dolphin uncertain responses seem to be interesting cognitive analogs and may depend on cognitive or controlled decisional mechanisms. The capacity to monitor ongoing cognition, and use uncertainty appropriately, would be a valuable adaptation for animal minds. This recommends uncertainty processes as an important but neglected area for future comparative research.

[Monitoring of multiple trauma in an emergency hospital unit]

In the monitoring of multiple trauma patients in the emergency hospital setting the use of monitors should be graduated. However, the use and interpretation of data from these monitors is becoming increasingly complex and can lead to errors and responses which may not be adopted. Clinical nomination and observation have their limits and the anaesthetist is faced with the added difficulties of interpretation of data from monitors and is pitfalls. The management of the patient is based on this human-machine relationship, which provides the basis for the therapeutic attitude and the treatment which ensues. Basic monitoring comprises a pulse oximeter, a capnograph, an ECG and a blood pressure monitor, 52% of incidents are detected by these instruments; 27% by SpO2, 24% by capnography. The pertinence is 82% for the oximeter when used alone and 55% for the capnography alone, although when the two are used together this increases to 88%. If the blood pressure monitor is added the pertinence increases to 93%, and to 95% if the FiO2 is monitored. The use of monitors of levels of haemoglobin or haematocrit must take into account the important variations in volaemia. The displayed values have a poor predictive value. The second level of monitoring comprises the use of a pulmonary artery catheter. The errors in measurement and interpretation are reviewed and finally, we consider the possible use of FOE transoesophageal echocardiography in the multiple trauma patient.

The uncertain response in the bottlenosed dolphin (Tursiops truncatus)

Humans respond adaptively to uncertainty by escaping or seeking additional information. To foster a comparative study of uncertainty processes, we asked whether humans and a bottlenosed dolphin (Tursiops truncatus) would use similarly a psychophysical uncertain response. Human observers and the dolphin were given 2 primary discrimination responses and a way to escape chosen trials into easier ones. Humans escaped sparingly from the most difficult trials near threshold that left them demonstrably uncertain of the stimulus. The dolphin performed nearly identically. The behavior of both species is considered from the perspectives of signal detection theory and optimality theory, and its appropriate interpretation is discussed. Human and dolphin uncertain responses seem to be interesting cognitive analogs and may depend on cognitive or controlled decisional mechanisms. The capacity to monitor ongoing cognition, and use uncertainty appropriately, would be a valuable adaptation for animal minds. This recommends uncertainty processes as an important but neglected area for future comparative research.

Sevoflurane elimination kinetics in children

We compared the rates of elimination of sevoflurane and halothane in 29 children, aged between one and seven years, undergoing ambulatory anaesthesia. Analgesia was provided by fentanyl and muscle relaxation by atracurium. Anaesthesia was maintained by inhalation of one MAC of either sevoflurane or halothane, based on an equipotent concentration of each agent for the age of the child. Following simultaneous discontinuation of N2O and the inhalational agent, the equation describing N2O washout was identical in the presence of halothane and sevoflurane, showing that there was no effect of the volatile agent on the rate of N2O elimination. The elimination of sevoflurane and N2O give similar types of equations. Halothane elimination gives a logarithmic type of equation, showing a slower release, corresponding to residual tissue content.

Crystallization and preliminary X-ray diffraction studies of bacterial ribosomal protein L14

Based on amino-acid sequence homology, it is predicted that ribosomal protein L14 is a member of a recently identified family of structurally related RNA-binding proteins. To verify this, the gene for Bacillus stearothermophilus L14 has been cloned, and the protein has been purified and crystallized. The crystals are in space group C2 with cell dimensions a = 67.0, b = 32.7, c = 49.4 A, and beta = 101.8 degrees, and there is one molecule in the asymmetric unit (V(m) = 2.0 A(3) Da(-1)). They are of high quality, and a native data set has been collected to a resolution of 1.6 A, with an R(merge) of 5.3%.