Understanding Concerns About Treatment-as-Prevention Among People with HIV who are not Using Antiretroviral Therapy.

The use of antiretroviral therapy to prevent HIV transmission is now advocated in many settings, yet little research has documented the views of people with HIV. Semi-structured interviews were conducted in Australia between 2012 and 2014 with 27 HIV-positive people not using treatment at the time of interview. Thematic analysis of views on treatment-as-prevention found that while many participants recognised potential prevention benefits, only a minority was in support of initiating treatment solely to achieve those benefits. A range of uncertain or critical views were expressed regarding who would benefit, risk reduction, and changing treatment norms. Participants resisted responsibility narratives that implied treatment should be used for the public good, in favour of making considered decisions about their preferred approach to managing HIV. Engaging communities in dialogue and debate regarding the risks and benefits of treatment will be critical if this new prevention strategy is to engender public trust.

Is there a role for primary care clinicians in providing shared care in HIV treatment? A systematic literature review.

BACKGROUND: Despite HIV being increasingly considered as a chronic illness, there is as yet no consensus about how primary care should be integrated with specialty care to provide optimal clinical management for people living with HIV. OBJECTIVE: To examine the effectiveness of shared care models of HIV between primary care and specialty care and how primary care providers can assist in improving the care of people with HIV. METHODS: Three databases, PubMed, Medline and EMBase, were searched for relevant terms from studies published in the period from 1996 to 2011. Studies that integrated primary care in HIV management and included highly active antiretroviral therapy (HAART) as part of the treatment modality were included. RESULTS: Eleven studies that met the inclusion criteria were included in this review. Primary care was found to be at least as effective in HIV counselling, testing and treatment and, to a lesser degree, prevention, when compared with specialty care alone. Screening for HIV at a primary care level was cost-effective, especially in a high HIV prevalence and high-risk community. There were no significant adverse clinical outcomes reported in a primary care approach. Effectiveness of various interventions using a primary care approach was demonstrated in the review, including HAART adherence programmes, home care, the involvement of peer health workers and perinatal use of HAART. CONCLUSIONS: Primary care has an important role in the shared care of the diagnosis and management of people with HIV. Some improvements with current guidelines on the management in primary care of people with HIV in developing countries should be considered.

Patient safety events reported in general practice: a taxonomy.

OBJECTIVE: To develop a taxonomy describing patient safety events in general practice from reports submitted by a random representative sample of general practitioners (GPs), and to determine proportions of reported event types. DESIGN: 433 reports received by the Threats to Australian Patient Safety (TAPS) study were analysed by three investigating GPs, classifying event types contained. Agreement between investigators was recorded as the taxonomy developed. SETTING AND PARTICIPANTS: 84 volunteers from a random sample of 320 GPs, previously shown to be representative of 4666 GPs in New South Wales, Australia. MAIN OUTCOME MEASURES: Taxonomy, agreement of investigators coding, proportions of error types. RESULTS: A three-level taxonomy resulted. At the first level, errors relating to the processes of healthcare (type 1; n = 365 (69.5%)) were more common than those relating to deficiencies in the knowledge and skills of health professionals (type 2; n = 160 (30.5%)). At the second level, five type 1 themes were identified: healthcare systems (n = 112 (21.3%)); investigations (n = 65 (12.4%)); medications (n = 107 (20.4%)); other treatments (n = 13 (2.5%)); and communication (n = 68 (12.9%)). Two type 2 themes were identified: diagnosis (n = 62 (11.8%)) and management (n = 98 (18.7%)). The third level comprised 35 descriptors of the themes. Good inter-coder agreement was demonstrated with an overall kappa score of 0.66. A least two out of three investigators independently agreed on event classification in 92% of cases. CONCLUSIONS: The proposed taxonomy for reported events in general practice provides a comprehensible tool for clinicians describing threats to patient safety, and could be built into reporting systems to remove difficulties arising from coder interpretation of events.

Running effective meetings: a primer for doctors.

This paper uses a series of exercises and practical examples to assist individuals and groups of doctors in training to gain skills in a critical area of management: conducting and participating in effective meetings. Through this paper, readers will be shown how to recognise and manage situations as they occur in meetings to work towards appropriate outcomes. By understanding the elements of conducting a meeting from preparation through to follow up, doctors will be able to conduct and participate more effectively in meetings that arise in their workplaces.

Conflict management: a primer for doctors in training.

Conflict in the health arena is a growing concern and is well recognised for doctors in training. Its most extreme expression, workplace violence is on the increase. There is evidence that many conflicts remain unsatisfactorily resolved or unresolved, and result in ongoing issues for staff morale. This paper describes the nature of conflict in the health care system and identifies the difference between conflict and disagreement. Using a conflict resolution model, strategies for dealing with conflict as it arises are explored and tips are provided on how to effectively manage conflict to a satisfactory resolution for all parties.

Hybridization and contemporary evolution in an introduced cichlid fish from Lake Malawi National Park.

Rapidly evolving systems offer the chance to observe genetic and phenotypic change in real time. We exploit a well-characterized introduction of cichlid fish into Lake Malawi National Park to document a short history of habitat colonization and the evolution of genes and colour pattern. In the early 1960s, a fish exporter introduced individuals of Cynotilapia afra to a single site (Mitande Point) of Thumbi West Island and, as late as 1983, the species was confined to this location. In 2001, C. afra had colonized the entire perimeter of Thumbi West. In July of that year, we sampled C. afra individuals from six sites around the island and scored variation in dorsal fin colour as well as allelic diversity at six microsatellite loci. We found that, in two decades, C. afra had diverged into genetically distinct, phenotypically different northern and southern populations. We observed a high proportion of hybrids between the introduced C. afra and the native Metriaclima zebra on the southern coast of Thumbi West, and speculate that hybridization is facilitated by low water clarity at these windward sites. The short history of C. afra at Thumbi West is a microcosm of contemporary evolutionary divergence and may provide the opportunity to study the process from start to finish in genetic detail.

Gonorrhoea screening in general practice: perceived barriers and strategies to improve screening rates.

OBJECTIVE: To investigate perceived barriers to gonorrhoea screening in general practice and suggest strategies to overcome them. DESIGN: Questionnaire-based survey. SETTING AND PARTICIPANTS: All 47 general practitioners (GPs) authorised to prescribe subsidised HIV drugs under the Pharmaceutical Benefits Scheme in inner, eastern and northern Sydney. MAIN OUTCOME MEASURES: Agreement on a five-point Likert scale with statements about attitudes and practices in relation to gonorrhoea screening of homosexually active men, and views on how testing rates could be increased. RESULTS: 32 GPs responded (68%). Perceived barriers to gonorrhoea testing included structural measures imposed by the Federal Government to limit pathology testing by GPs (the Medicare "three-test rule") (17 respondents agreed or strongly agreed), pressure from the Health Insurance Commission (HIC) to minimise pathology testing (15), concerns about confidentiality of notification procedures (8), clinical time pressure (8), and concerns about recriminations against HIV patients with gonorrhoea (6). Suggested measures to increase testing were education of gay men to request testing (25), relaxation of the three-test rule (25), easier tests (23), anonymous notification procedures, review of HIC policy on screening, and training about testing (21 each). CONCLUSIONS: Sydney GPs with high HIV caseloads perceived structural barriers to gonorrhoea testing and supported a range of achievable strategies to overcome these. As the sustained epidemic of gonorrhoea in Sydney may be directly promoting HIV transmission, these strategies should be considered urgently.

Clinical practice guidelines and the computer on your desk.

The majority of Australia's general practitioners are now believed to be using a computer to support clinical practice. This technology has the potential to deliver evidence-based clinical practice guidelines to the GP during consultations. If clinical practice guidelines are to be incorporated into electronic medical record systems, to assist clinical decision making at the point of care, guideline development will need to be significantly revised. Computerised clinical decision support at the time of consultation may become a major method for continuing medical education for Australian GPs.

Evaluation of electrochemiluminescence- and bioluminescence-based assays for quantitating specific DNA.

The clinical value of PCR technology would be increased by development of improved quantitative methodology. Two new methods, electrochemiluminescence (ECL) and bioluminescence (BL), were evaluated for analytical dynamic range, sensitivity, and reproducibility of quantitation of specific DNA. The two assays were compared using an IL-2 template DNA amplified using one biotinylated forward primer and detected with sequence identical probes labeled in two different ways. PCR products were, captured on streptavidin-coated plates for BL and by streptavidin-coated beads for ECL. Product detection was accomplished using either a ruthenium (ECL) or a digoxigenin-labeled probe (BL). The ECL measurement was performed using the Perkin Elmer QPCR System 5000, while the BL methodology used a SeaLife Science AquaLite Aequorin-antibody conjugate, which was detected with a ML3000 luminometer. Both instruments were found to be extremely sensitive with accurate quantitation of label in the attomole range, allowing detection during the exponential phase of PCR amplification. In our hands, it was possible to detect 1.5 x 10(14) copies (18 cycles) of IL-2 PCR product using ECL and 1 x 10(13) copies (14 cycles) using BL technology. Overall, we found the BL assay to be a rapid, sensitive, and inexpensive way to quantitate PCR-generated products with a broad range of potential analytical applications.

Induction of long-lasting immunity to Plasmodium yoelii malaria with whole blood-stage antigens and copolymer adjuvants.

We previously reported that protection of mice from nonlethal Plasmodium yoelii malaria by immunization with whole killed blood-stage parasites was dependent on the adjuvant and that adjuvants influenced both the specificity and isotype of Ab. Additional studies with the most effective formulations were undertaken to better define the protective responses and 100% protection from lethal P. yoelii malaria was produced by three immunizations with Ag in copolymer P1004 and detoxified RaLPS as adjuvants and 83% protection was induced by a single immunization. The protection lasted for 9 mo and was associated with an anamnestic rise in Ab titer of the IgG2a isotype during the challenge infection. Passive immunization with Ab from animals that had been immunized and challenged transferred sterile immunity. Splenectomy reduced, but did not abolish, protection. These data suggest that the effective Ab is directed against labile epitopes on the surface of blood-stage parasites. The vaccines primed animals for production of such Ab, but its synthesis was efficiently induced only by challenge with live organisms.

Educational support for overseas-trained doctors.

Overseas-trained doctors face a number of obstacles in the process of seeking to become registered to practise medicine in Australia. Educational support programs have been developed in all states to assist overseas-trained doctors to prepare for the examinations of the Australian Medical Council. We describe our experiences in providing such support and detail the educational needs we have identified of overseas-trained doctors migrating to Australia.

Role of adjuvants in the modulation of antibody isotype, specificity, and induction of protection by whole blood-stage Plasmodium yoelii vaccines.

Mice were immunized with whole killed blood stage Plasmodium yoelii parasites in 15 adjuvant formulations then boosted and challenged with parasitized blood. Five of six groups immunized with the Ag in oil-in-water emulsions or formulations without oil were protected. Formulations that induced protection contained saponin, pertussis, copolymer P1004, and detoxified RaLPS. In contrast, none of nine groups of animals immunized with Ag in water-in-oil emulsions were protected. Ineffective adjuvants included CFA and water-in-squalene emulsions with copolymer L141 plus detoxified RaLPS, dimethyldioctadecyl ammonium bromide, and mycobacterial cell wall skeletons. Antibody was measured by ELISA against disrupted parasites and by indirect fluorescent antibody (immunofluorescence) using intact parasites. Protection was associated with antibody of the IgG2a isotype detected by immunofluorescence but not with other isotypes detected by immunofluorescence or any type antibody detected by ELISA. The water-in-oil adjuvants induced high titers by ELISA but low titers by immunofluorescence. These results, together with Western blot analyses, suggested that adjuvant vehicles control the specificity of antibody and that this, in turn, is essential for induction of protective immune responses in this model.

Induction of pulmonary granulomas, macrophage procoagulant activity, and tumor necrosis factor-alpha by trehalose glycolipids.

Trehalose 6,6' dimycolate (TDM), a mycobacterial glycolipid, induces granulomas and hemorrhagic toxic reactions when administered in oil but not as a suspension in saline. It was previously demonstrated by us that TDM forms highly structured layers at oil-water interfaces and then postulated that its toxicity derives from the adhesive properties of these layers. To test this hypothesis, an evaluation was made of the ability of TDM and two analogs, trehalose 6-monomycolate (TMM) and galactose-galactose 6, 6' dimycolate (GDM), to induce pulmonary granulomas and stimulate expression of procoagulant activity (PCA) and tumor necrosis factor-alpha (TNF-alpha). Intravenous injection in mice of oil-in-water emulsions of TDM produced more and larger pulmonary granulomas than injection of TMM or GDM. Similarly, TDM on the surface of beads induced higher levels of PCA and TNF-alpha in human mononuclear cells than the analogs. The correlation of these results with the structure of surface layers of the glycolipids strengthens the hypothesis that the particular surface structure formed by TDM is necessary for its biologic activity.

What do medical students know about computers?

OBJECTIVE: To evaluate the computer knowledge and skills of medical students in the first, fourth and final years of the Monash University medical course. DESIGN: Questionnaire. SETTING: Undergraduate medical education. PARTICIPANTS: All first, fourth and final year medical students in the Monash University medical course in 1991. RESULTS: The students in first year were found to have greater computer skills than those in sixth year. There were also significant differences between the sexes, particularly in sixth year, with male students having significantly greater computer skills than female students. CONCLUSIONS: The perceived importance of computing in medicine was high among all students and there was enthusiasm for the development and inclusion of a course on medical computing in the undergraduate curriculum.