HIV status and viral loads among men testing positive for rectal gonorrhoea and chlamydia, Maricopa County, Arizona, USA, 2011-2013.

OBJECTIVES: Men diagnosed with rectal gonorrhoea (GC) and chlamydia (CT) have engaged in unprotected receptive anal intercourse. We reviewed the HIV positivity and HIV viral loads (VLs) of men who had rectal GC and CT testing to evaluate potential HIV acquisition and transmission risk. METHODS: Rectal GC and CT testing data for men attending the Maricopa County STD clinic during the period from 1 October 2011 to 30 September 2013 were cross-matched with HIV surveillance data to identify men with HIV coinfection. We examined HIV status, HIV diagnosis date, and the values of VL collected nearest to the date of reported rectal infection. RESULTS: During the 2-year time period, 1591 men were tested for rectal GC and CT. Of the men tested, 506 (31.8%) were positive for GC (13.2%), CT (12.2%) or both (6.4%); 119 (23.5%) of those with rectal GC or CT were coinfected with HIV. Among the 275 men with HIV at the time of rectal testing, 54 (19.6%) had no reported VL; 63 (22.9%) had an undetectable VL (< 20 HIV-1 RNA copies/mL) and 158 (57.4%) had a detectable VL collected within 1 year of rectal diagnosis. Mean VL was higher among HIV and rectal GC/CT coinfected cases compared with men with HIV alone (174 316 vs. 57 717 copies/mL, respectively; P = 0.04). CONCLUSIONS: Approximately one-third of men undergoing rectal testing were positive for GC or CT and one-quarter of men with rectal GC or CT also had HIV infection. Of the HIV-infected men tested for rectal GC or CT, more than half had a detectable VL collected near the time of rectal testing, demonstrating a risk for transmitting HIV.

Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies.

BACKGROUND: Exercise stress testing offers a non-invasive, less expensive way of risk stratification prior to coronary angiography, and a negative stress test may actually avoid angiography. However, previous meta-analyses have not included all exercise test modalities, or patients without known Coronary artery disease (CAD). METHODS AND RESULTS: We systematically reviewed the literature to determine the diagnostic accuracy of exercise stress testing for CAD on angiography. MEDLINE (January 1966 to November 2009), MEDION (1966 to July 2009), CENTRAL (1966 to July 2009) and EMBASE (1980-2009) databases were searched for English language articles on diagnostic accuracy of exercise stress testing. We included prospective studies comparing exercise stress testing with a reference standard of coronary angiography in patients without known CAD. From 6,055 records, we included 34 studies with 3,352 participants. Overall, we found published studies regarding five different exercise testing modalities: treadmill ECG, treadmill echo, bicycle ECG, bicycle echo and myocardial perfusion imaging. The prevalence of CAD ranged from 12% to 83%. Positive and negative likelihood ratios of stress testing increased in low prevalence settings. Treadmill echo testing (LR+ = 7.94) performed better than treadmill ECG testing (LR+ = 3.57) for ruling in CAD and ruling out CAD (echo LR- = 0.19 vs. ECG LR- = 0.38). Bicycle echo testing (LR+ = 11.34) performed better than treadmill echo testing (LR+ = 7.94), which outperformed both treadmill ECG and bicycle ECG. A positive exercise test is more helpful in younger patients (LR+ = 4.74) than in older patients (LR+ = 2.8). CONCLUSIONS: The diagnostic accuracy of exercise testing varies, depending upon the age, gender and clinical characteristics of the patient, prevalence of CAD and modality of test used. Exercise testing, whether by echocardiography or ECG, is more useful at excluding CAD than confirming it. Clinicians have concentrated on individualising the treatment of CAD, but there is great scope for individualising the diagnosis of CAD using exercise testing.

Does measured behavior reflect STD risk? An analysis of data from a randomized controlled behavioral intervention study. Project RESPECT Study Group.

BACKGROUND: Many studies measure sex behavior to determine the efficacy of sexually transmitted disease (STD)/HIV prevention interventions. GOAL: To determine how well measured behavior reflects STD incidence. STUDY DESIGN: Data from a trial (Project RESPECT) were analyzed to compare behavior and incidence of STD (gonorrhea, chlamydia, syphilis, HIV) during two 6-month intervals. RESULTS: A total of 2879 persons had 5062 six-monthly STD exams and interviews; 8.9% had a new STD in 6 months. Incidence was associated with demographic factors but only slightly associated with number of partners and number of unprotected sex acts with occasional partners. Many behaviors had paradoxical associations with STD incidence. After combining behavior variables to compare persons with highest and lowest risk behaviors, the STD incidence ratio was only 1.7. CONCLUSION: Behavioral interventions have prevented STD. We found people tend to have safe sex with risky partners and risky sex with safe partners. Therefore, it is difficult to extrapolate the disease prevention efficacy of an intervention from a measured effect on behavior alone.

Box C/D snoRNA-associated proteins: two pairs of evolutionarily ancient proteins and possible links to replication and transcription.

The eukaryotic nucleolus contains a diverse population of small nucleolar RNAs (snoRNAs) essential for ribosome biogenesis. The box C/D snoRNA family possesses conserved nucleotide boxes C and D that are multifunctional elements required for snoRNA processing, snoRNA transport to the nucleolus, and 2'-O-methylation of ribosomal RNA. We have previously demonstrated that the assembly of an snoRNP complex is essential for processing the intronic box C/D snoRNAs and that specific nuclear proteins associate with the box C/D core motif in vitro. Using a box C/D motif derived from mouse U14 snoRNA, we have now affinity purified and defined four mouse proteins that associate with this minimal RNA substrate. These four proteins consist of two protein pairs: members of each pair are highly related in sequence. One protein pair corresponds to the essential yeast nucleolar proteins Nop56p and Nop58p. Affinity purification of mouse Nop58 confirms observations made in yeast that Nop58 is a core protein of the box C/D snoRNP complex. Isolation of Nop56 using this RNA motif defines an additional snoRNP core protein. The second pair of mouse proteins, designated p50 and p55, are also highly conserved among eukaryotes. Antibody probing of nuclear fractions revealed a predominance of p55 and p50 in the nucleoplasm, suggesting a possible role for the p50/p55 pair in snoRNA production and/or nucleolar transport. The reported interaction of p55 with TATA-binding protein (TBP) and replication A protein as well as the DNA helicase activity of p55 and p50 may suggest the coordination of snoRNA processing and snoRNP assembly with replication and/or transcriptional events in the nucleus. Homologs for both snoRNA-associated protein pairs occur in Archaea, strengthening the hypothesis that the box C/D RNA elements and their interacting proteins are of ancient evolutionary origin.

In vitro assembly of the mouse U14 snoRNP core complex and identification of a 65-kDa box C/D-binding protein.

The eukaryotic nucleolus contains a diverse population of small nucleolar RNAs (snoRNAs) that have been categorized into two major families based on evolutionarily conserved sequence elements. U14 snoRNA is a member of the larger, box C/D snoRNA family and possesses nucleotide box C and D consensus sequences. In previous studies, we have defined a U14 box C/D core motif that is essential for intronic U14 snoRNA processing. These studies also revealed that nuclear proteins that recognize boxes C/D are required. We have now established an in vitro U14 snoRNP assembly system to characterize protein binding. Electrophoretic mobility-shift analysis demonstrated that all the sequences and structures of the box C/D core motif required for U14 processing are also necessary for protein binding and snoRNP assembly. These required elements include a base paired 5',3' terminal stem and the phylogenetically conserved nucleotides of boxes C and D. The ability of other box C/D snoRNAs to compete for protein binding demonstrated that the box C/D core motif-binding proteins are common to this family of snoRNAs. UV crosslinking of nuclear proteins bound to the U14 core motif identified a 65-kDa mouse snoRNP protein that requires boxes C and D for binding. Two additional core motif proteins of 55 and 50 kDa were also identified by biochemical fractionation of the in vitro-assembled U14 snoRNP complex. Thus, the U14 snoRNP core complex is a multiprotein particle whose assembly requires nucleotide boxes C and D.

Reducing and managing restraints in long-term-care facilities.

OBJECTIVE: To evaluate a management system designed to improve staff adherence to a federal regulation that stated restrained residents should be released, exercised, and repositioned every 2 hours. DESIGN: A delayed intervention, controlled, cross-over design with three phases. During phase one, baseline, the length of intervals that residents remained in restraints was monitored. The intervention was implemented at site A in Phase two while site B remained in baseline. During Phase three, the intervention was replicated at site B. SETTING: Two long-term care proprietary nursing facilities. PATIENTS: Sixty-three physically restrained residents in the two facilities. INTERVENTION: The intervention was a system of restraint release using colored pads corresponding to specific hours. The management rule was that the resident should be on a different colored pad every 2 hours. Staff had to lift residents to place the pad, and the colors made the system easy for supervisors to check. MAIN OUTCOME MEASURES: Checks by research personnel by black light and invisible ink, to detect movement of the knot tying the restraints. RESULTS: During the baseline phase, the majority of residents at both sites were inappropriately restrained longer than 2 hours (site A: 54.1%; site B: 60.1%). The percentage of residents restrained over 2 hours was significantly reduced during the intervention phase to 13.9% (site A) and 19.4% (site B). Three weeks after the end of the intervention, inappropriate use of restraints remained low, 14.2%, but rose to 47.7% after another 3 weeks. CONCLUSION: The management system is an effective way to increase the consistency with which nursing-home staff release and reposition restrained residents.

Allocation of study time and recall by learning disabled and nondisabled children of different ages.

Study time and recall by learning-disabled and nondisabled children of five different ages were examined in a task requiring recall of digits that were presented at the child's own rate. Recall increased with age and was significantly higher by nondisabled than disabled children, particularly at older ages. As additional digits of each sequence were presented, study time by 8-year-old disabled and nondisabled groups were relatively constant, increased in older disabled and nondisabled children, but increased more in older nondisabled children than older learning disabled children. Instructions in hierarchical grouping of digits increased recall by all groups to a similar degree, but the increase by younger children and learning disabled children was associated with longer study times. The results suggest that allocation of study time and recall are developmentally delayed in learning disabled children.

Assessment and quality control of incontinence care in long-term nursing facilities.

A statistical quality-control process was used to assess how well incontinence management procedures were being implemented by indigenous nursing staff in four nursing homes. Eighty-one incontinent patients were treated with the prompted-voiding toileting procedure. Thirty-six of these patients proved responsive to the toileting procedures, and nursing home staff was instructed to maintain the toileting program for these responsive patients. The first part of the quality-control model involved setting job standards specifying how dry the patients should be if toileted on a 2-hour schedule. Second, a job-monitoring control chart was used to continuously assess how well the job standards were being met. The remaining forty-five patients, who were unresponsive to the toileting protocol, were managed with a 2-hour changing schedule. Job standards specifying how wet (volume) the patient would be if changed on a two-hour basis were set. Control-chart monitoring of these patients urine output assessed how well the changing procedures were being implemented. Incontinence care in nursing homes is difficult to supervise because of problems in measuring how consistently nursing aides change or toilet patients. This paper describes a management system for effective incontinence care.

Statistical quality control in nursing homes: assessment and management of chronic urinary incontinence.

This article describes a statistical quality control system that allows nurse managers to monitor staff performance of a critical patient care function. Descriptive data concerning patients' incontinence frequencies were collected during a two-day assessment period for 87 patients under conditions that guaranteed that the patients' protective garments were changed on a one- or two-hour basis. The average and expected norms of patient wetness were calculated for a sample of patients in four different nursing homes. Periodic monitoring of patient wetness in each sample and the use of statistical quality control charts permitted nurse managers to determine if nursing aides were changing patients on either a one- or a two-hour schedule. The implications of the research for meeting federal incontinence care standards and for assuring high-quality patient care are discussed.

Management of patient continence in long-term care nursing facilities.

Ninety-one urinary incontinent nursing home patients who responded to a 1-hour prompted voiding toileting program were gradually moved to a 2-hour program without a significant change in either continence or appropriate toileting levels. The nursing staffs were given experiential training and written recommendations describing the patients' required toileting schedules. Follow-up data from 2 and 6 weeks after initial patient treatment documents that nursing staffs did not maintain the 2-hour program.

Prompted voiding treatment of urinary incontinence in nursing home patients. A behavior management approach for nursing home staff.

This study evaluated a treatment procedure in which 126 incontinent nursing home patients were checked on an hourly basis, asked if they needed toileting assistance (prompted), and socially reinforced for appropriate toileting. Urodynamic analysis (including cystometrogram), provocative stress test, and behavioral assessment revealed that the nursing home patients were severely debilitated, with 65% demonstrating bladder abnormalities, 87% incapable of independent toileting, and 25% failing to score on the Mini-Mental Status Exam (average score, 8.0). The treatment procedures were evaluated with a multiple baseline design in which subjects were randomly divided into immediate or delayed treatment groups after a baseline observation period. During treatment, the frequency of incontinence per 12 hours changed from a baseline average of 3.85 to a treatment average of 1.91. Three behavioral measures that can be easily collected by nursing staff significantly predicted continence levels during treatment (multiple R, 0.79) and change in incontinence during treatment (multiple R, 0.64). These prognostic criteria offer nursing staff a cost-effective method for selecting the most responsive patients for prompted-voiding treatment.

Statistical quality control in nursing homes: a key indicator to evaluate patient incontinence care.

The authors provide descriptive data regarding incontinence care within the framework of statistical quality control technology. Descriptive data of patient wetness frequencies were collected for 126 incontinent patients from six nursing homes in Middle Tennessee under conditions guaranteeing that they were checked and changed on a two-hour basis. One hundred inspection subsamples were randomly selected for five incontinent-patient sample sizes: 10, 15, 20, 25, and 30 patients. The average and expected variability of patient wetness frequency was calculated for each of these subsamples. These measures help nursing homes determine if they are in compliance with state and federal regulations regarding the timeliness of incontinence care. The authors suggest how nursing home management and regulatory agencies can use statistical quality control techniques.

Plasma-cell dyscrasia with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes: the POEMS syndrome. Distinctive radiographic abnormalities.

Three patients with an unusual multisystemic syndrome characterized by polyneuropathy, organomegaly *especially hepatosplenomegaly), endocrine dysfunction, M-protein, and skin abnormalities (POEMS syndrome) are discussed. Characteristic radiographic features include single or multiple osteosclerotic lesions and peculiar variety of bony proliferation. The relationship of the disorder to multiple myeloma and plasmacytoma and the pathogenesis of the skeletal abnormalities remain obscure.