The impact of user fees on health services utilization and infectious disease diagnoses in Neno District, Malawi: a longitudinal, quasi-experimental study.

BACKGROUND: User fees have generally fallen out of favor across Africa, and they have been associated with reductions in access to healthcare. We examined the effects of the introduction and removal of user fees on outpatient attendances and new diagnoses of HIV, malaria, and tuberculosis in Neno District, Malawi where user fees were re-instated at three of 13 health centres in 2013 and subsequently removed at one of these in 2015. METHODS: We conducted two analyses. Firstly, an unadjusted comparison of outpatient visits and new diagnoses over three periods between July 2012 and October 2015: during the period with no user fees, at the re-introduction of user fees at four centres, and after the removal of user fees at one centre. Secondly, we estimated a linear model of the effect of user fees on the outcome of interest that controlled for unobserved health centre effects, monthly effects, and a linear time trend. RESULTS: The introduction of user fees was associated with a change in total attendances of -68 % [95 % CI: -89 %, -12 %], similar reductions were observed for new malaria and HIV diagnoses. The removal of user fees was associated with an increase in total attendances of 352 % [213 %, 554 %] with similar increases for malaria diagnoses. The results were not sensitive to control group or model specification. CONCLUSIONS: User fees for outpatient healthcare services present a barrier to patients accessing healthcare and reduce detection of serious infectious diseases.

Phase 1 trial of dichloroacetate (DCA) in adults with recurrent malignant brain tumors.

BACKGROUND: Recurrent malignant brain tumors (RMBTs) carry a poor prognosis. Dichloroacetate (DCA) activates mitochondrial oxidative metabolism and has shown activity against several human cancers. DESIGN: We conducted an open-label study of oral DCA in 15 adults with recurrent WHO grade III - IV gliomas or metastases from a primary cancer outside the central nervous system. The primary objective was detection of a dose limiting toxicity for RMBTs at 4 weeks of treatment, defined as any grade 4 or 5 toxicity, or grade 3 toxicity directly attributable to DCA, based on the National Cancer Institute's Common Toxicity Criteria for Adverse Events, version 4.0. Secondary objectives involved safety, tolerability and hypothesis-generating data on disease status. Dosing was based on haplotype variation in glutathione transferase zeta 1/maleylacetoacetate isomerase (GSTZ1/MAAI), which participates in DCA and tyrosine catabolism. RESULTS: Eight patients completed at least 1 four week cycle. During this time, no dose-limiting toxicities occurred. No patient withdrew because of lack of tolerance to DCA, although 2 subjects experienced grade 0-1 distal parasthesias that led to elective withdrawal and/or dose-adjustment. All subjects completing at least 1 four week cycle remained clinically stable during this time and remained on DCA for an average of 75.5 days (range 26-312). CONCLUSIONS: Chronic, oral DCA is feasible and well-tolerated in patients with recurrent malignant gliomas and other tumors metastatic to the brain using the dose range established for metabolic diseases. The importance of genetic-based dosing is confirmed and should be incorporated into future trials of chronic DCA administration.

The development of cytomegalovirus-induced adrenal failure in a patient with AIDS while receiving corticosteroid therapy.

We report a case of Addisonian crisis due to cytomegalovirus (CMV) adrenalitis occurring in a patient with AIDS while receiving supraphysiological doses of steroids for the treatment of Pneumocystis carinii pneumonia. The case highlights the importance of considering the diagnosis of adrenal failure in AIDS, even in patients receiving supraphysiological doses of steroids.

Influenza-like episodes in HIV-positive patients: the role of viral and 'atypical' infections.

OBJECTIVES: To document viral and 'atypical' infections in HIV-positive patients and association with influenza-like symptoms. PATIENTS AND METHODS: Monthly culture of urine, faeces and throat swabs in 63 HIV-positive patients (30 asymptomatic and 33 with AIDS-related complex/AIDS) over 5-27 months (with 1125 patient-months of follow-up), with further sample collections during influenza-like episodes. Standard viral detection methods were used. Throat swabs were assessed for Chlamydia sp. by culture and immunoblotting, and for Mycoplasma pneumoniae by polymerase chain reaction. RESULTS: Viruses were detected in 15 (50%) and M. pneumoniae in nine (30%) out of 30 HIV-positive patients during an influenza-like illness. A close temporal relationship with symptoms was observed in 12 (40%) patients: cytomegalovirus in six (20%), M. pneumoniae in three (10%), herpes simplex virus in three (10%), and enterovirus in one (4%). Influenza-like symptoms were more frequent in asymptomatic HIV infection than in AIDS-related complex/AIDS patients (actuarial risk at 1 year, 63 versus 26%; P=0.002), particularly in those with CD4 cell counts >300 x 10(6)/l at enrolment (P=0.002). At least 44% (four out of nine) M. pneumoniae infections were asymptomatic and 78% (seven out of nine) were associated with prolonged excretion (2-17 months). Chlamydia sp. were not detected. CONCLUSIONS: Influenza-like symptoms were more likely to be reported by HIV-positive patients at early stages of disease, possibly as a result of differences in immune responses to viral infection. There was a close association in 40% of cases between the development of symptoms and detection of cytomegalovirus, herpes simplex virus, enterovirus and M. pneumoniae (a previously unrecognized association).

The relationship of DSM diagnostic criteria and Gough's Prejudice Scale: exploring the clinical manifestations of the prejudiced personality.

The relationship of psychopathology, symptoms of personality disorder, and outgroup prejudice was examined with 193 outpatient psychotherapy clients. Primary DSM-IV diagnosis, General Adaptive Functioning (GAF) scores, personality disorder criteria, and Minnesota Multiphasic Personality Inventory (MMPI) scale scores were examined in relationship to Pr (Prejudice) Scale scores and client outgroup attributions. Results of a 3 x 10 Multivariate analysis of variance (MANOVA) indicated that clinician ratings of outgroup bias were significantly related with the Axis II criteria for Paranoid, Borderline, and Antisocial disorders. MANOVA results for ratings of outgroup bias and MMPI scores did not yield a significant multivariate effect; however, significant univariate ANOVA results were found with the MMPI F, HS, PD, and MA scales. Computed univariate ANOVA results indicated that Pr Scale scores did not significantly vary between primary Axis I and Axis II DSM-IV diagnosis, but did yield a significant difference for (categorical) diagnosis by Axis II Cluster groups. Both Pr Scale scores and clinician ratings of client outgroup bias were significantly related to greater psychopathology, as reflected by lower GAF scores assigned at the initiation of treatment. Findings provide preliminary evidence of the relationship of traits of personality disorder, as characterized by impulsivity, relational disturbance, and affective lability, to outgroup prejudice with a clinical population.

The prejudiced personality, racism, and anti-Semitism: the PR scale forty years later.

The relationship of prejudiced personality traits with racism and anti-Semitism was examined with 150 Asian American and White university students. The Prejudice (PR) scale, composed of 32 items from the Minnesota Multiphasic Personality Inventory, was administered along with the McConahay racism scale and the Selznick and Steinberg Anti-Semitism scale. Results indicated that for Whites, the PR scale was significantly correlated with old-fashioned and modern racism and anti-Semitism, replicating Gough's 1951 study (Gough, 1951b) with the PR scale. However, no such relationship was observed for the Asian American group. This suggests that personality traits of prejudicial attitudes may be relatively stable for Whites but may not be related to outgroup bias for other racial or ethnic groups.

Epidemiology and molecular characterisation of toxigenic Corynebacterium diphtheriae var mitis from a case of cutaneous diphtheria in Manchester.

Diphtheria is now an uncommon disease in Britain. We describe an imported case of cutaneous diphtheria in a previously immunised adult cause by C. diphtheriae var mitis. The control measures adopted to deal with the index case and two secondary cases so as to limit further spread among household and school contacts are outlined. Molecular typing was used to study the mode of spread of the organism among contacts.

Recurrent meningococcal septicaemia and properdin deficiency.

A 32-year-old male presented with two episodes of meningococcal septicaemia, each of which was caused by a different serogroup of Neisseria meningitidis. Examination of the alternative pathway of complement revealed the rare X-linked disorder properdin deficiency (PD). Meningococcal Infection in complement deficiency states is discussed and the unusual features of this case are highlighted.

Coping with culture-based conflict: implications for counseling research and practice.

Interpersonal conflict related to sociocultural group membership was examined with a multicultural university sample. The Social Group Conflict Scale (SGCS), collective self-esteem (CSE), and Bradburn affect scale were administered to 248 university students. The current study attempted to replicate and extend the findings on social group-based conflict recently proposed by Dunbar, Sue, and Liu. Results indicated that 51% of the subjects reported encountering interpersonal conflict attributable to their social group memberships, with ethnicity being the most frequently attributed group category. Significant gender and ethnic differences were noted in coping approach employed in responding to the conflict event. The current findings are considered in regard to effectively assessing and responding to intercultural conflict for mental health practice.

Outcome of an exercise to notify patients treated by an obstetrician/gynaecologist infected with HIV-1.

Experience with hepatitis B suggests that the risk of HIV transmission from a health care worker infected with HIV to a patient will be greatest during major surgical procedures. The number of patients worldwide who are known to have undergone such procedures, been notified, and subsequently tested is still too small to be confident that the risk of HIV transmission in these circumstances is negligible. We describe a patient notification exercise, undertaken in the United Kingdom in 1991. Attempts were made to contact 1217 patients, in three health districts (A, B, and C), who had undergone surgical procedures performed by an obstetrician/gynaecologist who was infected with HIV. The exercise aimed to offer the patients reassurance, counselling and--if they wished--HIV testing. One thousand one hundred and forty-two patients (94%) were contacted, and all 520 who elected to be tested were negative for anti-HIV. The proportion of identified patients tested was 63% in district A, 35% in district B, and 61% in district C. Surgical procedures were classified retrospectively according to the likely risk (none, possible, or high) of exposure to the doctor's blood and, therefore, risk of HIV transmission. One hundred and ninety-five of those tested had undergone a procedure that carried a high risk of exposure; 179 had undergone a procedure thought to carry no risk. Patients in districts A and C who had undergone a procedure that carried a high risk of exposure were more likely to be tested than those who had not; 206 patients overall had undergone procedures that carried a high risk of exposure but were not subsequently tested.(ABSTRACT TRUNCATED AT 250 WORDS)

Ty1-copia group retrotransposons are ubiquitous and heterogeneous in higher plants.

We have used the polymerase chain reaction to isolate fragments of Ty1-copia group retrotransposons from a wide variety of members of the higher plant kingdom. 56 out of 57 species tested generate an amplified fragment of the size expected for reverse transcriptase fragments of Ty1-copia group retrotransposons. Sequence analysis of subclones shows that the PCR fragments display varying degrees of sequence heterogeneity. Sequence heterogeneity therefore seems a general property of Ty1-copia group retrotransposons of higher plants, in contrast to the limited diversity seen in retrotransposons of Saccharomyces cerevisiae and Drosophila melanogaster. Phylogenetic analysis of all these sequences shows, with some significant exceptions, that the degree of sequence divergence in the retrotransposon populations between any pair of species is proportional to the evolutionary distance between those species. This implies that sequence divergence during vertical transmission of Ty1-copia group retrotransposons within plant lineages has been a major factor in the evolution of Ty1-copia group retrotransposons in higher plants. Additionally, we suggest that horizontal transmission of this transposon group between different species has also played a role in this process.

Efficacy and effects on pulmonary function tests of weekly 600 mg aerosol pentamidine as prophylaxis against Pneumocystis carinii pneumonia.

A prospective study was designed to evaluate the efficacy and effects on pulmonary function tests of weekly 600 mg aerosolised pentamidine as prophylaxis against Pneumocystis carinii pneumonia (PCP) amongst two groups of patients infected with the human immunodeficiency virus. Group 1 (primary prophylaxis) consisted of patients with either diseases indicative of AIDS other than PCP or whose absolute CD4 positive lymphocyte count was below 200/mm3, and Group 2 (secondary prophylaxis) comprised patients with previous proven episodes of PCP. Fifty-five patients (30-Group 1, 25-Group 2) were studied over a period of 36 months, and no patients reached a study end point of either relapse or death due to PCP after a mean duration of treatment of 14.9 months (range 9-36 months). There were no significant differences between the pulmonary function tests (forced expiratory volume in the first second, forced vital capacity and carbon monoxide diffusion capacity) performed at the start and end of the study on both groups of surviving patients. Ten patients (18%) reported coughing and eight patients (15%) were documented to have bronchoconstriction, which was found to be preventable by prior administration of disodiumcromoglycate. The results showed that weekly 600 mg aerosolised pentamidine is effective and well tolerated for primary and secondary prophylaxis against PCP without additional adverse effects. Further prospective randomized trials are needed to determine whether doses higher than the current recommended 300 mg monthly dosage of aerosolised pentamidine provide more efficacy before such an alternative prophylactic treatment is generally adopted for patients who cannot tolerate other systemic agents.