Ever and repeat HIV testing rates among male and female clients: Findings from a reproductive health services integration project in South Africa.

BACKGROUND: HIV testing rates have increased in recent years. Repeat testing is recommended to identify and treat new HIV infections timeously. However, there are limited data on repeat HIV testing, especially in South Africa (SA). OBJECTIVES: To provide data on repeat HIV testing rates in males and females in a district in SA. METHODS: A sexual and reproductive health (SRH) service integration model was implemented in seven healthcare facilities in eThekwini District, KwaZulu-Natal Province, SA, between 2009 and 2011. HIV testing data were collected from male and female clients attending these facilities, prior to (baseline) and after the implementation (endline) of the 3-year health services integration intervention. RESULTS: There were 230 clients at baseline (195 female, 35 male) and 200 at endline (169 female, 31 male). High ever-tested rates were reported at baseline (females 95.4%, males 74.3%) and endline (females 91.7%, males 87.1%), with large increases in male testing rates over time. In addition, high increases were seen between baseline and endline among those who had tested more than once and more than twice in their lifetime. Increases between baseline and endline testing rates were highest in HIV testing services (HTS) (37.0 - 93.3% for clients who had tested more than once, and 11.1 - 53.3% for those who had tested more than twice). CONCLUSIONS: HIV testing and repeat testing increased over time, especially in males and in HTS. Promotion and integration of SRH services are critical to facilitate improved health-seeking behaviour and HIV testing of both male and female clients. They are also important for continued access to HTS at multiple service delivery points.

Recommendations for mental health professionals in the NICU.

This article describes recommended activities of social workers, psychologists and psychiatric staff within the neonatal intensive care unit (NICU). NICU mental health professionals (NMHPs) should interact with all NICU parents in providing emotional support, screening, education, psychotherapy and teleservices for families. NMHPs should also offer educational and emotional support for the NICU health-care staff. NMHPs should function at all levels of layered care delivered to NICU parents. Methods of screening for emotional distress are described, as well as evidence for the benefits of peer-to-peer support and psychotherapy delivered in the NICU. In the ideal NICU, care for the emotional and educational needs of NICU parents are outcomes equal in importance to the health and development of their babies. Whenever possible, NMHPs should be involved with parents from the antepartum period through after discharge.

Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa.

HIV-infected men and women who choose to conceive risk infecting their partners. To inform safer conception programs we surveyed HIV risk behavior prior to recent pregnancy amongst South African, HIV-infected women (N = 209) and men (N = 82) recruited from antenatal and antiretroviral clinics, respectively, and reporting an uninfected or unknown-HIV-serostatus pregnancy partner. All participants knew their HIV-positive serostatus prior to the referent pregnancy. Only 11 % of women and 5 % of men had planned the pregnancy; 40 % of women and 27 % of men reported serostatus disclosure to their partner before conception. Knowledge of safer conception strategies was low. Around two-thirds reported consistent condom use, 41 % of women and 88 % of men reported antiretroviral therapy, and a third of women reported male partner circumcision prior to the referent pregnancy. Seven women (3 %) and two men (2 %) reported limiting sex without condoms to peak fertility. None reported sperm washing or manual insemination. Safer conception behaviors including HIV-serostatus disclosure, condom use, and ART at the time of conception were not associated with desired pregnancy. In light of low pregnancy planning and HIV-serostatus disclosure, interventions to improve understandings of serodiscordance and motivate mutual HIV-serostatus disclosure and pregnancy planning are necessary first steps before couples or individuals can implement specific safer conception strategies.

"If I don't use a condom I would be stressed in my heart that I've done something wrong": Routine Prevention Messages Preclude Safer Conception Counseling for HIV-Infected Men and Women in South Africa.

Intended conception likely contributes to a significant proportion of new HIV infections in South Africa. Safer conception strategies require healthcare provider-client communication about fertility intentions, periconception risks, and options to modify those risks. We conducted in-depth interviews with 35 HIV-infected men and women accessing care in South Africa to explore barriers and promoters to patient-provider communication around fertility desires and intentions. Few participants had discussed personal fertility goals with providers. Discussions about pregnancy focused on maternal and child health, not sexual HIV transmission; no participants had received tailored safer conception advice. Although participants welcomed safer conception counseling, barriers to client-initiated discussions included narrowly focused prevention messages and perceptions that periconception transmission risk is not modifiable. Supporting providers to assess clients' fertility intentions and offer appropriate advice, and public health campaigns that address sexual HIV transmission in the context of conception may improve awareness of and access to safer conception strategies.

"We have to try and have this child before it is too late": missed opportunities in client-provider communication on reproductive intentions of people living with HIV.

Men and women living with HIV with access to ARVs are living longer, healthier lives that can and often do include bearing children. Children occupy a key space in men and women's personal and social lives and often play a fundamental role in maintaining these relationships, irrespective of illness concerns. Couples living with HIV need to balance prevention needs and ill-health while trying to maintain healthy relationships. Health-care providers serving the reproductive needs of HIV-affected couples need to consider the social and relational factors shaping reproductive decisions associated with periconception risk behaviors. This paper based on qualitative research at three hospital sites in eThekwini District, South Africa, investigates the childbearing intentions and needs of people living with HIV (PLHIV), and the attitudes and experiences of health-care providers serving the reproductive needs of PLHIV, and client and provider views and knowledge of safer conception. This research revealed that personal, social, and relationship dynamics shape the reproductive decisions of PLHIV, and "unplanned" pregnancies are not always unintended. Additionally, conception desires are not driven by the number of living children; rather clients are motivated by whether or not they have had any children with their current partner/spouse. Providers should consider the relationship status of clients in discussions about childbearing desires and intentions. Although many providers recognize the complex social realities shaping their clients' reproductive decisions, they have outdated information on serving their reproductive needs. Appropriate training to enable providers to better understand the relationship and social realities surrounding their clients' childbearing intentions is required and should be used as a platform for couples to work together with providers toward safer conception. The adoption of a more participatory approach should be employed to equalize client-provider power dynamics and to ensure clients are more involved in decision-making about reproduction and conception.

Varix of the retromandibular vein within the parotid gland: case study.

OBJECTIVE: To report a case of varix of the retromandibular vein within the parotid gland. METHODS: Case report, and discussion of the appropriate selection and use of radiological investigation techniques. RESULTS: A 64-year-old lady who presented with unilateral tinnitus underwent a magnetic resonance imaging scan to exclude a vestibular schwannoma. The magnetic resonance scout images revealed an incidental finding of a hyperechoic mass within the parotid gland. The mass was most consistent with a pleomorphic adenoma. Ultrasound-guided fine needle aspiration cytology was arranged; the ultrasound identified the mass as a varix of the retromandibular vein and fine needle aspiration cytology was not performed. CONCLUSION: A varix of the retromandibular vein is a very rare cause of a parotid mass. Appropriate radiological investigations can prevent unnecessary invasive investigations or procedures.

A rare cause of Horner syndrome.

OBJECTIVES: To demonstrate the importance of thorough investigation of patients with Horner syndrome, and to explain the relevant anatomy. CASE REPORT: A 46-year-old man presented with right-sided Horner syndrome. No other abnormality was found. Magnetic resonance imaging showed calcification of the stylohyoid ligament, with a pseudoarthrosis in the mid-portion of the ligament. This pseudoarthrosis was displacing and compressing the internal carotid artery and the adjacent sympathetic chain, causing Horner syndrome. CONCLUSION: In this case, magnetic resonance imaging was invaluable in elucidating the cause of the Horner syndrome. This is the first described case of pseudoarthrosis of a calcified stylohyoid ligament causing Horner syndrome.

Congenital cholesteatoma of occipital bone or intradiploic epidermoid cyst? One and the same disease.

OBJECTIVE: We report an extremely rare case of congenital cholesteatoma affecting the occipital bone. METHODS: We present a case report, plus a review of the world literature on similar lesions. RESULTS: This case report describes the presentation and treatment of a congenital cholesteatoma arising in an apparently unique location within the occipital bone, with no effect on middle-ear structure or function. The different imaging characteristics of this lesion are described and illustrated. The discussion centres on the differentiation of this lesion from intradiploic epidermoid cysts, more commonly described in the neurosurgical literature. The possible methods of pathogenesis are discussed, along with treatment suggestions. CONCLUSION: Congenital cholesteatomas and intradiploic epidermoid cysts are indistinguishable both histologically and radiologically, and would appear to be the same disease.

Case report of glomus jugulare tumour associated with a posterior fossa cyst.

A subgroup of complex glomus jugulare tumours exists. This includes: multiple, giant or neuropeptide-secreting lesions; those associated with other lesions, such as dural arterio-venous malformation or an adrenal tumour; and tumours in which there has been previous treatment with adverse outcome. To our knowledge, we present the first case of a glomus jugulare tumour associated with a posterior fossa cyst. This entity should be included in the subgroup of complex glomus jugulare tumours.

What should South African HIV vaccine trials do about social harms?

Phase I and II HIV vaccine trials are currently underway in South Africa. Sites are being prepared for Phase III vaccine trials. Participants in these trials risk exposure to 'social harms' that may impact on participant enrolment and retention and threaten their welfare. Potential social harms should be prevented, minimised and/or addressed. This paper examines the literature on potential social harms in HIV vaccine trials. It outlines the type and severity and frequency of potential social harms and ways these have been monitored in settings in the developed world and Thailand. We argue that many of these social harms are likely to manifest in South African trials, however, it is also likely social harms may manifest differently in our setting, such as domestic violence. Therefore careful formative research is required to identify what constitutes a social harm in our setting. Measures should be carefully tailored to record such events and methods established to prevent or address these.

Evaluation of quality of life and psychiatric morbidity in patients with malignant tumours of the skull base.

In general, patients with malignant tumours of the skull base have a poor prognosis. Treatment may have a disfiguring physical and disabling mental effect on patients. To evaluate the effect of treatment on physical and mental quality of life in patients with skull base malignancy, we conducted a cross-sectional patient survey of 18 patients treated for such tumours, using the University of Washington (version 4) quality of life questionnaire and the hospital anxiety and depression scale. The total quality of life score (median value) was 980 (550-1125). Patients with anterior skull base malignancy scored lower than those with lateral skull base malignancy (p=0.003). In general, the worst individual domain scores were: mood (64 per cent); activity (69 per cent); and, specifically for patients with anterior skull base malignancy, taste (54 per cent, p=0.004) and anxiety (60 per cent, p=0.034). One-third of skull base cancer patients were at risk of suffering from mental distress and psychiatric morbidity (indicated as a score of more than seven on the hospital anxiety and depression scale).

Provision of HIV treatment in HIV preventive vaccine trials: a developing country perspective.

HIV treatment for participants who become infected during HIV vaccine trials has been the focus of ethical controversy. The obligations of sponsors to ensure that participants have access to antiretrovirals have been a particular focus of this debate. This paper presents three arguments that have been made in this regard, and some of their limitations, in anticipation of HIV vaccine trials in South Africa. The first argument is that HIV risk behaviour increases in such trials, and HIV infection can be viewed as a research-related injury, justifying sponsor provision of treatment on grounds of compensation for harm. We conclude that risk-behaviour studies to date do not show general increases in risk behaviour that could constitute the basis for a general obligation. Participation may well adversely impact on risk behaviour for some individuals, and conceivably this could be demonstrated. This argument may, therefore, have merit at the individual level; however, it seems a weak platform from which to argue that sponsors should treat all HIV infections acquired during trials. The second argument is that treatment should be provided based on distributive justice. We conclude that traditional concepts of "distributive justice" in research appear limited in justifying obligations of sponsors to ensure access to antiretrovirals. Further, using research initiatives to reduce global health care inequities is controversial, and even proponents may disagree about the fairest use of finite resources. The third argument is that sponsors should ensure antiretroviral access on grounds of beneficence; namely, the maxim that if one can do something beneficial without sacrificing anything of comparable significance, it ought to be done. Thus, sponsors should provide more interventions than those minimally required to conduct the research. However, beneficence may demand levels of altruism that exceeds what is reasonable. While the latter arguments may provide stronger justifications than the first, it is difficult to use these arguments to establish that sponsor provision of antiretrovirals to infected individuals is obligatory.

Treatment for swallowing difficulties (dysphagia) in chronic muscle disease.

BACKGROUND: The management of dysphagia (difficulty in swallowing), a common complication of long-term progressive muscle disease in children and adults, is currently unclear. OBJECTIVES: Our objective was to determine the most appropriate intervention for dysphagia in people with chronic, untreatable, non-inflammatory muscle disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register, Cochrane Central Register of Controlled Trials (Cochrane Library Issue 2, 2003), MEDLINE (from January 1966 to Week 2 June 2003), EMBASE (from January 1980 to Week 2 June 2003), AMED (from January 1985 to Week 2 June 2003), LILACS (from January 1982 to June 21 2003) and CINAHL (from January 1982 to Week 2 June 2003) and contacted authors of published studies and other experts. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials of adults and children with chronic untreatable non-inflammatory muscle disease. The interventions under review included dietary modification, swallowing manoeuvres, a range of surgical interventions and enteral feeding. Our primary outcome was stabilisation of previously documented progressive weight loss not attributable to any other cause or weight gain of at least 5 kg in adults or increase in weight to at least the 10th centile in children, maintained for at least six months following the intervention. Secondary outcomes were: reduction in laryngeal penetration of bolus and/or aspiration observed on videofluoroscopy (modified barium swallow), reduction in chest infections attributable to aspiration over a six-month period, improvement in quality of life using a validated rating scale, the proportion of subjects who refused the intervention, the proportion of carers who refused the intervention, and serious adverse events related to the intervention within the first twelve months after intervention. DATA COLLECTION AND ANALYSIS: We identified no randomised controlled trials. We identified seven case series reporting the results of surgical intervention for moderate to severe dysphagia, and one reporting on the outcome of feeding advice and enteral feeding in children with a congenital myopathy. MAIN RESULTS: No studies were found that fulfilled the inclusion criteria. Therefore it was not possible to determine the benefit or otherwise of surgical intervention (cricopharyngeal myotomy or upper oesophageal dilatation) for oculopharyngeal muscular dystrophy or other chronic progressive muscle diseases, and dietary advice or enteral feeding for children with congenital myopathy, compared with no intervention or an alternative intervention. REVIEWERS' CONCLUSIONS: There are no trials that have adequately evaluated treatments in the management of dysphagia for chronic muscle disease. It is therefore not possible to decide on the most appropriate treatment for a given individual based on current evidence.

Comparison of low cost measurement techniques for long-term monitoring of atmospheric ammonia.

An inter-comparison of techniques for long-term sampling of atmospheric ammonia (NH3) was conducted with a view to establishing a national network with > 50 sites. Key requirements were for: a low cost system, simplicity and durability to enable a postal exchange with local site operators, a precision of < +/- 20% for monthly sampling at expected NH3 concentrations of 1-2 micrograms m-3, a detection limit sufficient to resolve the small NH3 concentrations (< 0.2 microgram m-3) expected in remote parts of the UK, and a quantitative means to establish quality control. Five sampling methods were compared: A, a commercially available membrane diffusion tube (exposed in triplicate), with membranes removed immediately after sampling; B, the above method, with the membranes left in place until analysis; C, open-ended diffusion tubes (exposed with 4 replicates); D, a new active sampling diffusion denuder system; and E, an active sampling bubbler system. Method D consisted of two 0.1 m acid coated glass denuders in series with sampling at approximately 0.3 l min-1. These methods were deployed at 6 locations in the UK and the Netherlands and compared against reference estimates. Method D was the most precise and sensitive of the techniques compared, with a detection limit of < 0.1 microgram m-3. The bubbler provided a less precise estimate of NH3 concentration, and also suffered several practical drawbacks. The diffusion tubes were found to correlate with the reference at high concentrations (> 3 micrograms m-3), but were less precise and overestimated NH3 at smaller concentrations. Of the passive methods, A was the most precise and C the least precise. On the basis of the results, method D has been implemented in the national network, together with application of method A to explore spatial variability in regions with expected high NH3 concentrations.

Potential for ammonia recapture by farm woodlands: design and application of a new experimental facility.

There has been increasing pressure on farmers in Europe to reduce the emissions of ammonia from their land. Due to the current financial climate in which farmers have to operate, it is important to identify ammonia control measures that can be adopted with minimum cost. The planting of trees around farmland and buildings has been identified as a potentially effective and low-cost measure to enhance ammonia recapture at a farm level and reduce long-range atmospheric transport. This work assesses experimentally what fraction of ammonia farm woodlands could potentially remove from the atmosphere. We constructed an experimental facility in southern Scotland to simulate a woodland shelterbelt planted in proximity to a small poultry unit. By measuring horizontal and vertical ammonia concentration profiles within the woodland, and comparing this to the concentration of an inert tracer (SF6) we estimate the depletion of ammonia due to dry deposition to the woodland canopy. Together with measurements of mean ammonia concentrations and throughfall fluxes of nitrogen, this information is used to provide a first estimate of the fraction of emitted ammonia that is recaptured by the woodland canopy. Analysis of these data give a lower limit of recapture of emitted ammonia, at the experimental facility, of 3%. By careful design of shelterbelt woodlands this figure could be significantly higher.

Extracranial internal carotid artery aneurysm in a child: a diagnostic and surgical challenge.

This paper reports the presentation and management of an extra-cranial internal carotid artery aneurysm in a 15-year-old male. To our knowledge there is no previous report of a similar case in childhood.

Trigeminal neurinoma presenting with trismus.

We describe a patient with trigeminal neurinoma whose main presenting symptom was trismus. This has not previously been reported in the literature. We review the previously described symptoms and signs of trigeminal neurinoma.

Fibrous dysplasia and ossifying fibroma of the paranasal sinuses.

Fibro-osseous lesions involving the paranasal sinuses, the mid-face and anterior skull base are uncommon. In addition, there appears to be no clear pathological or clinical classification that embraces the variety of lesions that exhibit such diverse pathological and clinical behaviour, yet may still be referred to as a fibro-osseous lesion. The diagnosis of fibrous dysplasia and ossifying fibroma is made on a combination of clinical, radiological and pathological criteria. This paper emphasizes the clinical and pathological differences between fibrous dysplasia and ossifying fibroma. The more aggressive clinical behaviour of the latter is highlighted and a more radical surgical approach is recommended. In contradistinction, fibrous dysplasia can exhibit a more benign behaviour and radical surgery is not always justified. A clinicopathological distinction between these two conditions is important from a management perspective despite the fact that they both may be encompassed under the 'umbrella' term fibro-osseous lesion.