Alendronate Reduces Bone Resorption in HIV-Associated Osteopenia/Osteoporosis

PURPOSE

To evaluate the effects of alendronate, vitamin D, and calcium supplementation on bone metabolism and bone mineral density (BMD) in both HIV-infected men and women treated with highly active antiretroviral therapy (HAART).

METHOD

We performed a 52-week prospective, multicenter, randomized, open-label clinical trial. Eligible participants were on stable HAART and had BMD values at the femoral neck or lumbar spine that corresponded to a t score less than -1. Patients were randomized to receive alendronate 70 mg weekly or no alendronate; calcium 1000 mg daily and vitamin D 500 IU daily were provided to all study recipients. Primary endpoint of the study was the change in bone metabolism evaluated by N-telopeptide of type 1 collagen and bone-specific alkaline phosphatase; the secondary endpoint was BMD variation.

RESULTS

18 patients were randomized to the alendronate and 23 to the no-alendronate group (controls). The alendronate-treatment group compared to controls had a significant decrease in serum N-telopeptides, 1914 +/- 1433.4 vs. 3967 +/- 1650.5 pM/L (p = .005) after 1 year. Lumbar spine BMD increased by 4% in the alendronate group (p = .004) vs. 3.7% (p = .062) in controls, compared to baseline values. Femoral neck BMD decreased by 0.5% in the alendronate group (p = .05) and by 3.5% in the control group (p = .04). No between-groups differences for BMD were found (Delta lumbar-BMD 0.0351 +/- 0.0406 in cases and 0.0356 +/- 0.073 in controls [p = .977], Delta femoral-BMD -0.085 +/- 0.160 in cases and -0.100 +/- 0.165 in controls [p = .795]).

CONCLUSION

Alendronate plus vitamin D and calcium was effective in reducing bone resorption. Alendronate improved lumbar BMD and minimized femoral BMD decrease after 52 weeks compared to treatment with vitamin D and calcium alone in patients on HAART with osteopenia/osteoporosis.

Subgroup-specific effects of questionnaire wording on population-based estimates of mammography prevalence

OBJECTIVES

This study investigated whether an apparent downturn in prevalence rates of mammography use reported in the 1992 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire resulted from a change in questionnaire wording.

METHODS

In a pretest-posttest design (1990-1991 vs 1992), piecewise linear regression analyses were based on monthly prevalence estimates of mammography use among female BRFSS respondents 40 years or older.

RESULTS

Self-reported mammography use was lower by 3.5 percentage points (95% confidence interval [CI] = 1.5, 5.5) overall--and lower by 13.6 percentage points (95% CI = 2.6, 24.6) among Black women with less than a high school education--when predicted from 1992 data than when predicted from 1990-1991 data.

CONCLUSIONS

A change in questionnaire wording in the BRFSS caused demographic-specific effects in population-based estimates of mammography use.

Sexual behavior and exposure to HIV infection: estimates from a general-population risk index

OBJECTIVES

The spread of the human immunodeficiency virus (HIV) in the general population has been a much debated topic in the mass media. The aim of this study was to create an approach to estimating the risk of exposure to HIV resulting from sexual behaviors.

METHODS

A theoretical estimate was applied to data obtained from a large-scale risk factor survey carried out in Britain. An HIV infection-exposure risk index was constructed by ranking different sex-related categorizations derived from variables in the survey.

RESULTS

The risk index involved a Delphi-based assessment of self-reported behavioral factors associated with HIV exposure and subsequent transmission. Roughly 85% of the adult population aged 18 to 50 were estimated to be at some risk for behavioral exposure to HIV virus with regard to reported sexual behavior. Over time, those who could be considered at no risk have declined as a proportion of the population.

CONCLUSIONS

The estimates appear to refute commonplace assertions that exposure to HIV through sexual behavior is not a problem for general populations.

Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon

BACKGROUND

Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health.

METHODS

Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought.

RESULTS

Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation.

CONCLUSION

Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

The influence of socioeconomic status on health service utilisation by patients with AIDS in north Italy. The North-East Italian Group for Planning of AIDS Health Care

Evidence for an association between socioeconomic status (SES) and health service utilisation (HSU) by patients with AIDS is examined using data for an Italian AIDS study population. A composite measure of SES which takes into account several key variables was developed using Multiple Correspondence Analysis. A classification of SES categories (high, medium-high, medium-low, low) was constructed and resource utilisation across the categories compared. The study population were patients with AIDS referred to 10 AIDS clinics in the study area in North-East Italy. A questionnaire survey was undertaken over the period January to June 1994, and was completed by 555 patients. Statistical analysis was conducted, using log-linear modelling, of health service utilisation (covering inpatient and day care) by SES categories, illness severity and HIV transmission route group. The analysis demonstrated that SES has a statistically significant association with variation in HSU, secondary in importance to severity of illness. This finding has important implications for future care planning for HIV/ AIDS in Italy, and potentially to other countries. Further research is needed to examine the relationship between SES and health service utilisation and costs in Italy and in other European countries.

Efficiency and rationality in the planning of health care for people with AIDS: an application of the balance of care approach. North-East Italian Group for Planning of AIDS Health Care

OBJECTIVE

To demonstrate the application of an approach for assessing efficiency and rationality in the use of resources for the care of patients with AIDS (PWA), using data for north-east Italy.

DESIGN

An economic methodology, the balance of care (BoC) approach, enabled identification of scenarios for the current, planned and recommended provision of care in the study region.

METHODS

Data on the supply and utilization of care by PWA across four locations (inpatient care, day care, home care and sheltered accommodation) was collected for a 6-month period during 1994. The current BoC measured in care contacts across the locations was compared with a planned BoC scenario, derived from the Italian AIDS Health Plan, and a recommended BoC scenario based on a delphi expert panel judgement of the appropriate care location according to sets of hypothetical clinical and social characteristics of PWA. The cost consequences of reallocating patient contacts between the current BoC to the recommended BoC was assessed for inpatient and day care contacts.

RESULTS

There is an overprovision of home care in the planned BoC scenario if applied to the study region. The cost consequences of a shift of care contacts according to the recommended scenario results in a potential cost reduction of 9.2% compared with the current scenario, and hence an expected efficiency improvement.

CONCLUSION

The BoC approach can be applied to improve the efficiency and rationality of resource use in planning care provision for PWA.

Influence of posture on blink reflex prepulse inhibition induced by somatosensory inputs from upper and lower limbs

BACKGROUND

Prepulse inhibition (PPI) is a neurophysiological phenomenon whereby a weak stimulus modulates the reflex response to a subsequent strong stimulus. Its physiological purpose is to avoid interruption of sensory processing by subsequent disturbing stimuli at the subcortical level, thereby preventing undesired motor reactions. An important hub in the PPI circuit is the pedunculopontine nucleus, which is also involved in the control of posture and sleep/wakefulness.

OBJECTIVE

To study the effect of posture (supine versus standing) on PPI, induced by somatosensory prepulses to either upper or lower limb. PPI was measured as the percentage inhibition of the blink reflex response to electrical supraorbital nerve (SON) stimulation.

METHODS

Sixteen healthy volunteers underwent bilateral blink reflex recordings following SON stimulation either alone (baseline) or preceded by an electrical prepulse to the median nerve (MN) or sural nerve (SN), both in supine and standing. Stimulus intensity was 8 times sensory threshold for SON, and 2 times sensory threshold for MN and SN, respectively. Eight stimuli were applied in each condition.

RESULTS

Baseline blink reflex parameters did not differ significantly between the two postures. Prepulse stimulation to MN and SN caused significant inhibition of R2. In supine but not in standing, R2 was significantly more inhibited by MN than by SN prepulses. In standing, SN stimulation caused significantly more inhibition of R2 than in supine, while the inhibition caused by MN prepulses did not differ significantly between postures.

SIGNIFICANCE

PPI induced by lower limb afferent input may contribute to postural control while standing.

Socio-economic differences in healthcare access from a welfare system perspective, Italy: 2007-2010

Inequalities between poorer and wealthier people in accessing healthcare services have been widely studied, but the mechanisms generating them are still to be fully understood. Among these, there is still a lack of evidence of relationships between health prevention/health promotion policies, welfare systems and social differences. We analysed 68 201 females from the PASSI Italian surveillance system for the years 2007-2010. The prevalence of women undergoing Pap testing was used as an example of access to preventive services. An odds ratio gradient was found with regard to different welfare system clusters: the probability of undergoing a screening test is higher for more advanced welfare systems. A strong association was found between having received a letter from the local health unit and having undergone the screening test. Significant differences still exist between high- and low-income women and their access to Italian preventive public services. As we expected, social determinants play an important role in health disparities, as these are also strongly influenced by typologies of welfare systems and by health policies.

[An index of HIV infection risk in the population]

The paper presents a risk index constructed on the basis of some sexual behaviour-related variables. It is intended for measuring the risk of exposure to HIV infection for the general population. Variables are from a study on Lifestyle and Health conducted on a sample of the population living in the London, Edinburgh, and Glasgow metropolitan area by the Research Unit in Health and Behavioural Change at the Edinburgh University. The construction of the index has been realized through a delphi study which has collected information from a panel of AIDS national experts. Methodological problems in summarising information coming from several variables are discussed. The main task of the study is not to provide a total prediction of HIV infection in the population of Britain, but to assess the component which may stem from sexual behaviours when estimated from self-reports. Major findings are the consistency of the population in the "medium risk" group, that, if a spread of AIDS among the heterosexual population can be hypothesized, gives a rather pessimist scenario. Moreover, a trend analysis (possible because of the continuity in the data collection) shows an increase in this "medium risk" group, although the "high risk" group appears much less consistent (less than two percent) and slowly declining over time.

[Indirect morbidity indicators and social differences in the ISTAT quarterly workforce survey]

Information on the health condition job related of the population are often collected in specific studies, usually limited over time and concerned with a small part of the general population. Looking at official statistics, sources such as national health surveys (in Europe and in North America) are rich on health data, but often offer little information on job-conditions, and job history. On the other hand, one also can find official sources, mainly concerned with labour and job related topics, in which information related to the health status of the people interviewed are routinely collected. These are the Labour Force Surveys, carried out in the most of developed countries. In the Italian Labour Force Survey (RTFL) the Italian Statistical Institute (ISTAT) quarterly collects information on health-related sick absence, part-time job and unemployment. Data from RTFL of two Italian regions (Lombardy: 1985, '86, '89 and Veneto: 1985, '86) show differentials by age and job-position that are consistent with expectation, encouraging an extensive use of this source for surveillance purposes at the national and regional level.

Assessment of adequacy of ICU admission

BACKGROUND

Direct costs of critical care are increasing more than in other health care sectors. Tools are needed to evaluate adequacy of ICU admission in order to have a proper allocation of ICU resources.

OBJECTIVE

evaluation of different ways used to assess adequacy of ICU admission.

METHODS

STUDY TYPE

12 months prospective descriptive study.

SETTING

24 Intensive Care beds of a 1000 beds tertiary hospital in Italy.

PATIENTS

2314 patients admitted to Cardiac Surgery, General and Postoperative Intensive Care Units.

INTERVENTIONS

all patients admitted to the ICUs were studied. Information was collected for the patients' age, source of admission, diagnoses, surgical status, reason for admission, SAPS II score, NEMS daily score, LOS, ICU outcome. The number of available beds (ventilated or not) and nurse working hours were obtained.

RESULTS

2373 patients were admitted to the ICs, with an overall readmission rate of 2.5%, and a total amount of 8084 NEMS record. The mean Work Utilization Ratio was significantly different between the three IC and between working and weekend days in PACU and CSU. The 49.7% of the NEMS points is scored by the SAPS II 43-78 patients, corresponding to the 29.2% of >24 h admissions. The level of care provided and the trend of each admission was derived from NEMS score according to Iapichino. The proportion of HT records in each IC was 88.3% in ICU, 73.1% in PACU and 91.2% in CSU; the outcome (dead/discharged) was significantly different between LT and HT.

CONCLUSIONS

Despite the difficulties imposed by he rigid nurses' work organization in Italy, a daily data collection about level of care, severity of illness, workload utilization could provide, together with standard administrative indexes, the necessary framework to assess and to improve adequacy of ICU admission.