HIV and tuberculosis coinfection: a qualitative study of treatment challenges faced by care providers.

SETTING: Infectious Diseases Department, Karolinska University Hospital, Stockholm, Sweden. OBJECTIVE: To understand the challenges faced by nurses and physicians in the treatment of patients co-infected with the human immunodeficiency virus (HIV) and tuberculosis (TB), with special focus on opportunities for information and communication technology. DESIGN: Using a qualitative study design, on-site observations and informal discussions were carried out to become acquainted with the clinical context. Seven nurses and six physicians were purposefully selected to participate in one-to-one in-depth interviews inspired by cognitive task analysis. Interviews were audio recorded and transcribed verbatim, and analysed using inductive thematic analysis. RESULTS: Care providers faced challenges related to 1) the complexities inherent to TB-HIV co-treatment, 2) clinical knowledge and task standardisation, 3) care coordination and collaboration, 4) information management, and 5) engaging patients in their treatment. CONCLUSION: Support is needed on several levels to address the emerging burden of TB-HIV coinfection in Sweden. Educational material and tools need to be further developed to support care providers in making decisions about adequate care, and to support collaborative activities and communication among patients and care providers. Information and communication technology based solutions may provide an opportunity to address some of these challenges.

Cross-cultural evaluation of two drinking assessment instruments: alcohol timeline followback and inventory of drinking situations.

This article describes the psychometric characteristics of two major assessment instruments used in a World Health Organization (WHO) clinical trial: (a) Alcohol Timeline Followback (TLFB, which assesses daily drinking patterns), and (b) Inventory of Drinking Situations (IDS, which assesses antecedents to "heavy" drinking). Clients (N = 308) were outpatient alcohol abusers from four countries (Australia, Canada, Mexico, and Sweden). Generally, the Alcohol TLFB and IDS were shown to be reliable and valid with outpatient alcohol abusers in four countries, and in three languages. These results suggest that the Alcohol TLFB and the IDS can be used in clinical and research settings with Swedish-, Spanish-, and English-speaking alcohol abusers.

[Ten questions about alcohol as identifier of addiction problems. Psychometric tests at an emergency psychiatric department]. / Tio frågor om alkohol identifierar beroendeproblem. Psykometrisk prövning på psykiatrisk akutmottagning.

It is important to develop and evaluate methods of identifying alcohol dependent patients and patients at risk of alcohol problems. The World Health Organisation recommends a 10-item questionnaire, AUDIT (Alcohol Use Disorders Identification Test), which assesses hazardous alcohol use, dependence symptoms, and harmful alcohol use. The article describes a Swedish version of AUDIT that has been psychometrically tested on a sample of patients admitted to a psychiatric emergency ward. Both internal consistency, reliability and validity were found to be satisfactory in terms of sensitivity and specificity in predicting DSM alcoholism diagnoses.

Drinking-related assessment instruments: cross-cultural studies.

In recent years a number of drinking-related assessment instruments have undergone extensive developmental work and are in widespread use. These include measures that are designed to assess: 1) patterns of alcohol consumption. Timeline Followback Method (TLFB); and 2) antecedents to alcohol use, Inventory of Drinking Situations (IDS)-two constructs that would be expected to be sensitive to cross-cultural variability in drinking practices. These assessment tools present opportunities for the study of cross-cultural differences in drinking patterns and the circumstances under which drinking occurs. A World Health Organization project utilizing these assessment tools is currently underway in five countries (Australia, Canada, Mexico, Poland, and Sweden). This project focuses on the identification of profile differ.

Autonomic cardiovascular control in normal and pre-eclamptic pregnancy.

BACKGROUND: Pre-eclampsia is regarded as a primary placental disorder, in which defect placentation causes endothelial and cardiovascular disturbances. Evidence of disturbed neural cardiovascular control in this condition has been suggested, as well as in other hypertensive diseases. The purpose of the present study was to non-invasively evaluate the sympathovagal balance during normal and pre-eclamptic pregnancy. METHODS: In twelve healthy pregnant women, thirteen pre-eclamptic women and ten nonpregnant controls, heart rate, blood pressure and breathing movements were registered and recorded on a tape recorder for off-line analysis. Variability in heart rate, blood pressure and breathing movements were computed by an autoregressive spectral analysis algorithm. Heart rate variability was quantitated as the area under the spectral curve, and Student's t-test was performed on logarithmic values. RESULTS: Heart rate variability contained two major components in power, a low frequency peak predominantly attributed to sympathetic tone, and a high frequency peak reflecting vagal tone. Women with pre-eclampsia were characterized by a significantly reduced high frequency peak compared to healthy pregnant (p = 0.03) and non-pregnant (p = 0.02) women. In the low frequency band there were no significant differences in power between the groups. Blood pressure variability did not differ between the groups. CONCLUSIONS: The present results indicate that pre-eclampsia is associated with decreased vagal control of the heart. Furthermore, the results indicate that pregnancy per se does not change sympatho-vagal balance.

Noninvasive test of microvascular endothelial function in normal and hypertensive pregnancies.

OBJECTIVE: To examine microvascular endothelial cell function in vivo in pre-eclampsia. DESIGN: Iontophoresis of acetylcholine (Ach), which gives rise to endothelial cell dependent vasodilatation, and of sodium nitroprusside (SNP), which elicits vasodilatation independently of functioning vascular endothelium. SETTING: Södersjukhuset, Stockholm, Sweden. SUBJECTS: Ten pre-eclamptic patients, ten healthy pregnant women and ten healthy nonpregnant women were examined. MAIN OUTCOME MEASURES: The degree of vasodilatation following iontophoretic administration of Ach compared with SNP was recorded with a laser Doppler technique, the data being analysed on a personal computer. RESULTS: Both Ach and SNP administration resulted in marked vasodilatation; the magnitude of the vasodilatation was similar in the three groups of women. CONCLUSION: Following iontophoretic administration of endothelial cell dependent or independent vasodilatators, laser Doppler measurement of blood flow demonstrated no microvascular endothelial cell dysfunction in pre-eclamptic women.

Brief group psychotherapy in relapse prevention for alcohol dependent patients.

The effects of brief group psychotherapy in relapse prevention were tested. The groups focused on the clients' capacity to formulate their own treatment goals, including controlled drinking, programmed relapse, and total abstinence. Twelve months after completion of the eight-week outpatient group treatment, thirty-five clients were followed up. There appeared to be no harmful effects as a result of the treatment. Nobody in the follow-up group had a deteriorated drinking pattern as compared to pretreatment data. The follow-up results were significantly better than before treatment and also than in a comparison group of alcohol dependent patients. It seemed as if those patients who could benefit from the treatment had a shorter duration of abuse and had a later onset of uncontrolled drinking compared to those who continued with a negative drinking pattern and the dropouts. The clients assigned the positive treatment effects to course leaders' encouragement of personal decision making, increased awareness of risk situations, and improved coping skills. The group situation in itself seemed to be of special importance for this result. The degree of structure implemented by course leaders allowed a free and respectful openness to develop between group members.

Efficacy expectations among alcohol-dependent patients--a Swedish version of the Situational Confidence Questionnaire.

The Situational Confidence Questionnaire (SCQ) developed by Annis (1986 A relapse prevention model for treatment of alcoholics. In Treating Addictive Behaviors. Processes of Change, Miller W. R. and Heather, N. eds, pp. 407-435. Plenum Press, New York) is an important assessment instrument for use in the treatment of alcoholism and particularly in relapse prevention. The SCQ was translated into Swedish and tested on 91 alcohol-dependent patients. A principal component analysis of the item responses resulted in a shortened 35-item version of the SCQ with satisfactory test-retest reliability, internal consistency and scale specificity. Instead of eight relapse situation categories the analysis resulted in four categories with lower intercorrelations than in the original SCQ. The components were: (1) unpleasant emotions; (2) social pressure; (3) testing personal control; and (4) positive emotional states. In a one-way ANOVA only the Social Pressure scale had a significant relationship with severity of alcohol problems.

Mental alertness in response to hypoglycaemia in normal man: the effect of 12 hours and 72 hours of fasting.

To study the influence of hypoglycaemia and starvation on mental functions eight healthy male students age 25-34 years with an ideal body mass of 99.9% +/- 2.5% (mean +/- SEM) were recruited. Hypoglycaemia was induced in random order by an insulin-glucose clamp technique (insulin: 2.4 mU/kg/min + glucose at variable rate) keeping the venous blood glucose at 2.2 mmol/l both after an overnight fast and after 72 h fasting. Mental alertness was assessed by measuring the recognition time, moving time and total reaction time to a visual signal and by a verbal mental clearness test and a synonym learning test during normo- as well as hypoglycaemia. Hypoglycaemia prolonged the total reaction time (p less than 0.05) and the time required for the mental clearness test (p less than 0.05). Compared with a control study performed at normoglycaemia the learning effect of the synonym test was reduced by hypoglycaemia. Fasting, which resulted in a body weight reduction of 2.6 +/- 0.3 kg and ketonuria prolonged the total reaction time (p less than 0.005) by increasing the moving time but did not affect the mental clearness test. When hypoglycaemia was preceded by 72 h fasting it did not increase the total reaction time, nor did it modify the mental clearness test. Moreover, the learning effect of the synonym test was less impaired. In conclusion, mental alertness was reduced by moderate hypoglycaemia after an overnight fast while similar hypoglycaemia did not reduce mental alertness after prolonged fasting. This may illustrate a decrease of the glucose dependency of the central nervous system during prolonged fasting.

The relation between drinking habits and neuroticism and weak ego among male and female alcoholic patients.

The relationship between drinking habits and personality functioning was studied in a consecutive series of 300 alcoholic inpatients during treatment and 2 1/2 years later. The alcoholic sample showed more signs of neuroticism and lack of ego strength than the general population. Among the alcoholics there was a relationship between advanced drinking habits and more pathological personality functioning. However at the follow-up improved drinking habits were connected only with improved self-esteem, particularly among female patients.

Severity of alcohol problems at follow-up--an outcome measure.

An ordinal scale to measure severity of alcohol problems in a follow-up study was constructed. The measure refers to the preceding 6 months and is based on reports of amount of alcohol consumed, drinking pattern, signs of alcohol dependence and time sober. The measure was tested on 300 patients reinvestigated about 2 1/2 years after discharge for inpatient treatment for alcoholism. Thirteen percent of the patients had no alcohol problems and 22% had severe alcohol problems. Rather more than one quarter of the group (27%) were classified as positive intermediates and 38% as negative intermediates. These results were compared with other data and information obtained from official records. It was concluded that the measure had satisfactory validity.

Detecting early signs of alcohol problems: a clinical application of an interview method.

In this study a simple interview method to identify patients with potential alcohol problems was tested in a clinical setting. Nurses interviewed an unbiased sample of 393 patients attending practices within occupational health care. The technique used was a day by day follow back procedure covering the preceding two weeks. The time needed to accomplish the interviews varied between 2 and 15 minutes, depending on how much alcohol consumption was reported. Nurses and doctors reported that the interview was easily integrated in daily working routines. When defining the limit of high consumption as more than 200 g absolute alcohol for the two week period, 11% of the group studied (17% among men and 2% among women) were regarded as high consumers. Strategies for confronting and motivating patients for further analysis of their alcohol habits and for treatment are discussed.

Determinants of relapse among alcoholics: a cross-cultural replication study.

This study reports on a replication of Marlatt and Gordon's (1980) findings concerning relapse determinants among alcoholics. It was undertaken in a somewhat different drinking culture (Sweden) and with a group of alcoholics also containing patients relapsing after a longer period of abstinence than those in the Marlatt and Gordon study. The difference in drinking culture is reflected in the finding that most subjects in this study took their first drink at home. The group studied by Marlatt and Gordon in Seattle most frequently started to drink in a bar or restaurant. In spite of the differences between the groups, we arrive at a similar picture when it comes to the distribution of relapse determinants according to the model proposed by Marlatt and Gordon. The categories not only have face validity but also construct validity, reflected in meaningful correlations with results on an intelligence test and a personality inventory. A descriptive analysis shows that subjects with poorer results on the intelligence test and having a high tendency to muscle tension and somatized anxiety tended to relapse in intrapersonal situations. Patients who do not readily adjust to other persons' opinions relapsed in interpersonal conflicts, and patients who are more impulsive could not resist social pressure to drink.

Interference effects in optical fiber connections.

Optical interference may occur in fiber connections, and this can have an important effect on transmission loss. A theoretical analysis shows that the effect occurs in both single-mode and multimode fibers and depends on fiber end face separation, the source spectrum, and the modal power distribution in the fiber. Experimental observations of interference in dry multimode fiber connections confirm the analysis for both laser diode and LED sources.