Nurse led, primary care based antiretroviral treatment versus hospital care: a controlled prospective study in Swaziland.

BACKGROUND: Antiretroviral treatment services delivered in hospital settings in Africa increasingly lack capacity to meet demand and are difficult to access by patients. We evaluate the effectiveness of nurse led primary care based antiretroviral treatment by comparison with usual hospital care in a typical rural sub Saharan African setting. METHODS: We undertook a prospective, controlled evaluation of planned service change in Lubombo, Swaziland. Clinically stable adults with a CD4 count > 100 and on antiretroviral treatment for at least four weeks at the district hospital were assigned to either nurse led primary care based antiretroviral treatment care or usual hospital care. Assignment depended on the location of the nearest primary care clinic. The main outcome measures were clinic attendance and patient experience. RESULTS: Those receiving primary care based treatment were less likely to miss an appointment compared with those continuing to receive hospital care (RR 0.37, p < 0.0001). Average travel cost was half that of those receiving hospital care (p = 0.001). Those receiving primary care based, nurse led care were more likely to be satisfied in the ability of staff to manage their condition (RR 1.23, p = 0.003). There was no significant difference in loss to follow-up or other health related outcomes in modified intention to treat analysis. Multilevel, multivariable regression identified little inter-cluster variation. CONCLUSIONS: Clinic attendance and patient experience are better with nurse led primary care based antiretroviral treatment care than with hospital care; health related outcomes appear equally good. This evidence supports efforts of the WHO to scale-up universal access to antiretroviral treatment in sub Saharan Africa.

Cytokine production by cryopreserved human peripheral blood mononuclear cells in response to periodontal pathogens.

Freezing techniques provide a way of repeating and extending immunological assays by using frozen portions of an individual's peripheral blood mononuclear cell fraction. Earlier work shows that the lymphocytes that are stored frozen retain their ability to respond to polyclonal B-cell activators, mitogens, superantigens and bacterial extracts of oral interest. These studies extend previous findings by determining cytokine production by lymphocytes following frozen storage for up to 24 weeks. Production of interleukin (IL)-1beta, IL-2, IL-6, and tumour necrosis factor (TNF)-beta by stimulated lymphocytes after cyropreservation was not significantly different from those responses before storage, with one exception: IL-6 production was negligible after 24 weeks' frozen storage when thawed cells were cocultured with pokeweed mitogen. After stimulation with extracts from Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans, the proliferative capacity of the frozen cells was maintained as well as the production of IL-1beta, IL-2, and IL-6. TNF-beta was not produced in response to bacterial antigen stimulation. The ability of peripheral blood mononuclear cells to retain functional activity after frozen storage should permit more effective monitoring during longitudinal clinical studies and a better evaluation of changes in cytokine production in patients with advanced periodontitis both during and after treatment.

Pharmacology of the pulmonary diseases.

The management of patients with pulmonary diseases may pose a challenge to the dentist. A thorough understanding of the major respiratory diseases is paramount to the successful treatment of these individuals. Morbidity and mortality for COPD patients have increased over time. There has been a decline in the number of smokers in the United States, but it may take two or three decades before health care systems notice a decrease in associated health care visits. Smoking tobacco is the major cause of COPD. Health care providers need to inform patients about smoking cessation programs and motivate them toward that end. The most important factor in preventing COPD is helping patients stop smoking. Mainstays in the treatment of COPD include inhaled anticholinergics and supplemental oxygen, when indicated. For certain patients, beta2-agonists, mucolytics, anti-inflammatory agents, and antibiotics are indicated. Asthma morbidity and mortality continue to rise significantly despite scientific advances and improved understanding of the disease and ability to render effective treatment. The reasons for this are not entirely clear. Asthma treatment has been revolutionized over the past decade. If proper preventive environmental measures and medications are prescribed, and the patients are carefully educated and complaint, their prognosis is good, and their condition should rarely require emergency treatment or hospitalization. The management of TB in the dental office involves several aspects of the disease. The dentist should be able to refer properly a patient with signs and symptoms of disease or to follow up on inadequate treatment. The medications taken for TB do not usually modify the dental management of the patient. The complications of the medications may, however, affect some drugs the dentist could prescribe. The resurgence of TB in the United States mandates that every dentist understand this disease and its importance.