Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya.

BACKGROUND: Substantial efforts have been made to ensure people living with HIV (PLHIV) are linked to and retained in care but many challenges deter care utilization. We report perceived benefits of seeking HIV care and barriers to HIV care that were identified through a formative assessment conducted to advise the development of an alternative care model to deliver antiretroviral treatment therapy (ART) in Trans Nzoia County, Kenya. METHODS: Data were collected in 2015 through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs). The study involved 55 participants of whom 53% were female. Ten KIIs provided community contextual information and viewpoints on the HIV epidemic in Trans Nzoia County while 20 PLHIV (10 male and 10 female) participated in IDIs. Twenty-five individuals living with HIV participated in four FGDs - two groups for men and two for women. Key informants were purposively selected, while every third patient above 18 years at the Kitale HIV Clinic was invited to share their HIV care experience through IDIs or FGDs. Trained research assistants moderated all sessions and audio recordings were transcribed and analyzed thematically. RESULTS: Findings showed that PLHIV in Trans Nzoia County used both conventional and complementary alternative care for HIV; however, public health facilities were preferred. Popular perceived benefits of adopting care were relief from symptoms and the chance to live longer. Benefits of care uptake included weight gain, renewed energy, and positive behavior change. Individual-level barriers to HIV care included lack of money and food, use of alternative care, negative side effects of ART, denial, and disclosure difficulties. At the community level, stigma, limited social support for conventional HIV treatment, and poor means of transport were reported. The health system barriers were limited supplies and staff, long distance to conventional HIV care, and unprofessional providers. CONCLUSIONS: Diverse individual, community and health system barriers continue to affect HIV care-seeking efforts in Kenya. Appreciation of context and lived experiences allows for development of realistic care models.

The relationship between complaints of night-time heartburn and sleep-related gastroesophageal reflux.

This study investigated whether the complaint of night-time heartburn (NHB) as opposed to daytime heartburn (DHB) is a reliable reflection of actual sleep-related reflux events. Three groups of individuals were studied: individuals with complaints of NHB at least twice per week (n = 24), individuals with complaints of DHB (n = 23), and normal participants without any complaints of regular heartburn during the day or night (n = 25). All three groups were studied on one occasion with combined pH monitoring and polysomnography, and subjective questionnaires about sleep disturbance and sleep quality were given to all participants. The NHB group had significantly more sleep-related reflux events compared with both DHB and control groups (P < 0.01). DHB subjects had significantly (P < 0.05) more sleep-related reflux events than normal controls. Total acid contact time (ACT) was significantly (P < 0.05) elevated in the NHB group compared with both the DHB and control group. Sleep-related ACT was also significantly (P < 0.05) elevated in the NHB group compared with the other two groups, while upright (daytime) ACT was not significantly different. The NHB group was significantly (P < 0.05) worse regarding measures of both objective and subjective sleep quality. Subjects with exclusively DHB do have sleep-related reflux that is greater than normal controls. Subjects with NHB have significantly more sleep-related reflux, and both objective and subjective sleep abnormalities compared with normal controls. Complaints of NHB reflect sleep-related reflux events and may be indicative of a more clinically significant condition.

Environmental conditions during early life determine the consequences of inbreeding in Agrostemma githago (Caryophyllaceae).

In an inbred population, selection may reduce the frequency of deleterious recessive alleles through a process known as purging. Empirical studies suggest, however, that the efficacy of purging in natural populations is highly variable. This variation may be due, in part, to variation in the expression of inbreeding depression available for selection to act on. This experiment investigates the roles of life stage and early-life environment in determining the expression of inbreeding depression in Agrostemma githago. Four population-level crosses ('self', 'within', 'near' and 'far') were conducted on 20 maternal plants from a focal population. Siblings were planted into one of three early environmental treatments with varying stress levels. Within the focal population, evidence for purging of deleterious recessive alleles, as well as for variation in the expression of inbreeding depression across the life cycle was examined. In addition, the effect of early environment on the expression of inbreeding depression and the interaction with cross-type was measured. We find that deleterious recessive alleles have not been effectively purged from our focal population, the expression of inbreeding depression decreases over the course of the life cycle, and a stressful early environment reduces the variance in inbreeding depression expressed later in life, but does not consistently influence the relative fitness of inbred versus outcrossed individuals.

The effect of baclofen on nocturnal gastroesophageal reflux and measures of sleep quality: a randomized, cross-over trial.

BACKGROUND: Baclofen, a GABA(b) agonist, has been shown to reduce episodes of gastroesophageal reflux (GER). To determine if baclofen would significantly reduce reflux during sleep, and also improve objective and subjective measures of sleep. METHODS: Twenty-one individuals with complaints of nighttime heartburn at least twice a week and a Carlsson GERD score of at least 5 were studied. Patients underwent polysomnography (PSG) and simultaneous esophageal pH monitoring on two occasions separated by approximately 1 week in a cross-over design. The night of each polysomnographic study, patients consumed a refluxogenic meal. Baclofen (40 mg) or placebo was given in random order 90 min prior to the start of the PSG. KEY RESULTS: Baclofen significantly reduced the number of reflux events compared with placebo. Upright and recumbent acid contact times were both reduced by baclofen vs placebo, but the differences were not significant. Regarding sleep outcomes, several variables were significantly improved by baclofen. Total sleep time and sleep efficiency increased, and wake after sleep onset decreased in the baclofen condition compared with placebo. Proportion of Stage 1 sleep was also significantly decreased on baclofen. CONCLUSIONS & INFERENCES: In addition to reducing the number of reflux events during sleep, baclofen significantly improved several measures of sleep in patients with documented GER and sleep disturbances. Baclofen could therefore be considered as a useful adjunct therapy to proton pump inhibitors (PPIs) in patients with nighttime heartburn and sleep disturbance who continue to have heartburn and/or sleep complaints despite PPI therapy.

The effect of acid suppression on sleep patterns and sleep-related gastro-oesophageal reflux.

BACKGROUND: Several studies have demonstrated that night-time gastro-oesophageal reflux affects sleep quality, and thereby impairs daytime functioning. AIM: To determine whether treatment with a proton-pump inhibitor (rabeprazole) would improve both objective and subjective measures of sleep. METHODS: Individuals with complaints of significant gastro-oesophageal reflux disease were studied by polysomnography and 24-h pH monitoring on two separate nights. On one occasion, participants received 20 mg rabeprazole b.d., and on another they received placebo. Both study conditions were preceded by a week of treatment with either rabeprazole or placebo. The order of treatments was randomized. RESULTS: Rabeprazole significantly reduced overall acid reflux, but it did not significantly reduce night-time acid contact. Rabeprazole treatment significantly improved subjective indices of sleep quality. There were no significant differences on objective measures of sleep between placebo and rabeprazole treatment. CONCLUSIONS: Consistent with other studies of pharmacological treatments for gastro-oesophageal reflux, subjective measures of sleep improved with heartburn medication but objective measures were not affected.

Cyclic ADP-ribose production by CD38 regulates intracellular calcium release, extracellular calcium influx and chemotaxis in neutrophils and is required for bacterial clearance in vivo.

Cyclic ADP-ribose is believed to be an important calcium-mobilizing second messenger in invertebrate, mammalian and plant cells. CD38, the best-characterized mammalian ADP-ribosyl cyclase, is postulated to be an important source of cyclic ADP-ribose in vivo. Using CD38-deficient mice, we demonstrate that the loss of CD38 renders mice susceptible to bacterial infections due to an inability of CD38-deficient neutrophils to directionally migrate to the site of infection. Furthermore, we show that cyclic ADP-ribose can directly induce intracellular Ca++ release in neutrophils and is required for sustained extracellular Ca++ influx in neutrophils that have been stimulated by the bacterial chemoattractant, formyl-methionyl-leucyl-phenylalanine (fMLP). Finally, we demonstrate that neutrophil chemotaxis to fMLP is dependent on Ca++ mobilization mediated by cyclic ADP-ribose. Thus, CD38 controls neutrophil chemotaxis to bacterial chemoattractants through its production of cyclic ADP-ribose, and acts as a critical regulator of inflammation and innate immune responses.

A patient acuity and staffing tool for stroke rehabilitation inpatients based on the FIM instrument.

We undertook to develop a tool based on the FIM instrument to predict the number of nursing hours required to care for stroke patients in an acute inpatient rehabilitation program. The initial study to evaluate the feasibility of using the FIM instrument revealed that the total FIM score had a strong inverse relation to the level of care indicated by the Patient Care Index (PCI) at days 1, 5, 7, 10, 15, and 20 of rehabilitation (rs = -.76 to -.87). The results warranted continued investigation of the FIM instrument as a guide for nurse staffing decisions. Based on data from the initial study, five categories of FIM score ranges were designated that demonstrated the most accuracy of placing patients at the correct level of care. Special care considerations unique to institutional settings were identified and incorporated into the tool's final format, as were the calculations to determine the amount of assistance needed. The study reported here was undertaken to evaluate the level of care indicated by the adapted tool, compared with that of the PCI, in a sample of 67 stroke admissions. Spearman correlations revealed a moderate relationship (rs = .49 to .54) between the amount of care determined by the Patient Acuity and Staffing tool and through the PCI at the first, second, and third team meetings. We conclude that the system is an effective, efficient guide for scheduling nurse staffing on the stroke rehabilitation unit.

Determining stroke rehabilitation inpatients' level of nursing care.

The purpose of this study was to evaluate the feasibility of using the Functional Independence Measure (FIM) to predict staffing needs of stroke patients in an acute inpatient rehabilitation program. The Patient Care Index (PCI) was concurrently administered with the FIM on all stroke admissions to a stroke rehabilitation unit over a 3-month period. One hundred fourteen patients 18 years of age or older admitted to the unit with a medical diagnosis of stroke were included in the sample. Total FIM score had a strong inverse relationship to the level of care indicated by the PCI at Days 1, 5, 7, 10, 15, and 20 of rehabilitation (r(s) = -. 76 to -.87). Total FIM score and the need for staff supervision for safety were the two factors predictive of the level of nursing care. The FIM has potential to guide nurse-staffing decisions.

Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.

CONTEXT: Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome. OBJECTIVE: To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI. DESIGN: Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997. SETTING: Two large, urban, rapid-transport emergency medical services (EMS) systems. PARTICIPANTS: A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up. INTERVENTIONS: Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420). MAIN OUTCOME MEASURES: Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group. RESULTS: There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22). CONCLUSION: These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.

Scopolamine and Pavlovian fear conditioning in rats: dose-effect analysis.

Muscarinic-cholinergic antagonism produces learning and memory deficits in a wide variety of hippocampal-dependent tasks. Hippocampal lesions produce both acquisition deficits and retrograde amnesia of contextual fear (fear of the place of conditioning), but do not impact fear conditioning to discrete cues (such as a tone). In order to examine the effects of muscarinic antagonism in this paradigm, rats were given 0.01 to 100 mg/kg of scopolamine (or methylscopolamine) either before or after a fear conditioning session in which tones were paired with aversive footshocks. Fear to the context and the tone were assessed by measuring freezing in separate tests. It was found that pretraining, but not post-training, scopolamine severely impaired fear conditioning; methylscopolamine was ineffective in disrupting conditioning. Although contextual fear conditioning was more sensitive to cholinergic disruption, high doses of scopolamine also disrupted tone conditioning. Scopolamine did not affect footshock reactivity, but did produce high levels of activity. However, hyperactivity was not directly responsible for deficits in conditioning. It was concluded that scopolamine disrupts CS-US association formation or CS processing, perhaps through an attenuation of hippocampal theta rhythm.

Differences in depressive symptoms between traditional workers and shiftworkers.

Shiftwork causes a number of physical and psychological problems. As a result, we predicted depression to be worse for shiftworkers than for workers with more traditional schedules. In addition, we predicted that women would report more depressive symptoms than men as is the case in the general population. Questionnaire packets which included the Beck Depression Inventory were mailed to 153 workers in a small community. Analysis showed that, contrary to expectation, shiftworkers as a group suffered no more depressive symptoms than traditional workers. However, while both sexes had similar mean scores on depression among the shiftworkers, women were significantly more depressed than men among traditional workers.

Walking trajectory and hand movements in unilateral left neglect: a vestibular hypothesis.

This is the first systematic study of walking trajectories in unilateral neglect. Six patients with unilateral left neglect approached and walked through a doorway, and all six deviated to the right of centre when doing so. Four out of six significantly centred their walking trajectories by making left hand movements while approaching the doorway. The group effect of walking with no hand movements vs walking with hand movements was statistically significant. Age-matched control patients showed a similar but significant smaller rightward deviation. The results are interpreted in terms of recent research in limb activation effects on neglect (Robertson and North, Neuropsychologia 30, 553-563, 1992), and also in the light of research showing close anatomical correspondence between the cortical projections of the vestibular nerve on the one hand, and the hand/arm representational fields of the central sulcus on the other.

Axis-based neglect of visual shapes.

A new test of "object-centered" visual neglect uses equilateral triangles, with ambiguous principal axes that can be manipulated by context. Three left neglect patients detected gaps in such triangles. The location of the gap relative to the biased principal axis was varied, while maintaining the same egocentric locus. More gaps were missed on the left of the axis. This supports Driver and Halligan's (Cognit. Neuropsychol. 8, 475-496, 1991) claim that neglect can apply to the contralesional side of a shape's principal axis, while avoiding serious flaws in their method. The relation between axis-based neglect and other cases of object-centred neglect is discussed.

Biochemical indices and neuromuscular function tests in rural Gambian schoolchildren given a riboflavin, or multivitamin plus iron, supplement.

Ninety preselected children, aged between 8 and 14 years, living in two rural West African (Gambian) villages, were randomly divided into three groups, matched for age and sex. One group received a placebo (lactose) tablet, one received riboflavin (5 mg) on 5 d every week, which was sufficient to correct an endemic riboflavin deficiency, and one received a multivitamin supplement (Protovit; Hoffmann La Roche), on 5 d every week, together with FeSO4 (200 mg) once weekly, and the supplements were given for 1 year. Neuromuscular tests, including arm tremor and manipulative skills, were performed on three occasions: once just before the introduction of the supplements; again 6 weeks after commencing the supplements; and again 1 year later. Venous blood samples were collected at the same time as the first two sets of neuromuscular tests. These samples were used for haematology and nutrient status indices: plasma ferritin, ascorbic acid, cyanocobalamin and pyridoxal phosphate, and erythrocyte tests for folate status, for riboflavin status (erythrocyte glutathione reductase activation coefficient) and thiamine status (erythrocyte transketolase activation coefficient). The riboflavin in both supplements achieved a clear-cut response in biochemical status, which was dose-dependent. The pyridoxine, ascorbic acid and Fe components of the multivitamin also affected the associated biochemical indices. Although overall the arm tremor and related neuromuscular function tests did not respond significantly to the supplements, significant improvement was seen in the boys for the arm-tremor test in both the supplemented groups.

Simple reaction time and predictive tracking in Parkinson's disease: do they converge on a single, fixed impairment of preparation?

Patients with Parkinson's disease exhibit a number. of abnormalities that seem more marked in circumstances in which stimulus and response are predictable in advance. In this article, we consider the prolonged movement onset latencies exhibited by Parkinsonian subjects in the tracking of predictable targets and in the simple reaction time (RT) task. It has been suggested that the performance impairments on both these tasks stem from a common planning deficit. We argue that the Parkinsonian tendency to refrain from predictive tracking cannot be ascribed to an inability to anticipate due to a planning deficit. The data are better accommodated by our alternative thesis that when Parkinsonians' response initiation lags behind that of normal subjects, this is a result of a strategic adaptation to an impairment of the accuracy of movements guided by an internal representation of the target. Our conclusion, that the primary impairment of predictive tracking is one of inaccurate movement execution rather than delayed response initiation, precludes postulation of the same deficit as a source of the selective prolongation of simple RT sometimes found in Parkinson's disease. Moreover, an analysis of the processing demands of the two tasks shows that the predictability that characterizes each of them is quite different in nature. Hence, the impairments in predictive tracking and simple RT tasks are unlikely to stem from a single mechanism that is defective in Parkinson's disease.

Impaired epidermal growth factor production in genetically obese ob/ob mice.

Epidermal growth factor (EGF) is a potent inhibitor of adipose differentiation in vitro and delays adipose tissue development in vivo. Here we show that in the homozygous male obese mice the level of EGF in the submaxillary gland and plasma is significantly lower than in the glands and plasma of age-matched control littermates. This EGF deficiency in ob/ob mice was observed as early as 5 wk of age when obesity had just become apparent and was also found in adult mice. The level of prepro-EGF mRNA expression in the submaxillary gland was also lower in obese mice than in control littermates. However, the level of kidney prepro-EGF mRNA was the same in mice with both phenotypes, suggesting that the regulation of prepro-EGF mRNA expression is different in both tissues. These results indicate that genetic obesity in mice is accompanied by a decrease in the production of EGF.

Balance evaluation in hemiparetic stroke patients using lateral forces applied to the hip.

A technique for assessing balance that involves applying predictable controlled forces to the hips is described. Impairments in hemiparetic stroke patients' balance were documented by comparing their hip movements during and after a push with those of control subjects of similar age. Stroke patients swayed further and took longer to stabilize hip position than did the control subjects. The disturbance to stroke patients' balance caused by the termination of lateral force caused them more difficulty than did the onset of the force. Differences between stroke patients' involved and noninvolved sides were more pronounced on release from a push than at its onset. The implications of the findings for the assessment and treatment of balance after stroke are discussed.