Informal caregivers and the intention to hasten AIDS-related death.

OBJECTIVES: To determine the extent to which homosexual men dying of the acquired immunodeficiency syndrome (AIDS) receive medication intended to hasten death. To assess the impact on caregivers of administering medications intended to hasten death. METHODS: In a prospective study of caregiving partners of men with AIDS (n = 140), characteristics of the ill partner, the caregiver, and the relationship were assessed at baseline and 1 month before the ill partner's death. Three months after the death, caregivers were asked if they had increased their partner's narcotic and/or sedative-hypnotic medication dose and if so, what had been the objective of the increase, and their comfort with their medication decisions. RESULTS: Of 140 ill partners who died of AIDS, 17 (12.1%) received an increase in the use of medications immediately before death intended to hasten death. Diagnoses and care needs of ill partners who received increases in the use of medications to hasten death did not differ from those of ill partners receiving medication for symptoms. Fourteen increases (10%) in use of medications were administered by caregivers. These caregivers did not differ from those administering medication for symptom control in level of distress, caregiving burden, relationship characteristics, or comfort with the medication decision, but they reported more social support and positive meaning in caregiving. CONCLUSION: The decision to hasten death is not a rare event in this group of men. There is no evidence that it is the result of caregiver distress, poor relationship quality, or intolerable caregiving burden; and it does not cause excessive discomfort in the surviving partner. This study, although small, has implications for the policy debate on assisted suicide.

Detection of Chlamydia trachomatis in first catch urine samples from symptomatic and asymptomatic males.

BACKGROUND AND OBJECTIVES: Non-invasive tests are needed to detect Chlamydia trachomatis in the genital tract. For men, urine appears to be a useful specimen for chlamydial antigen or nucleic acid detection. GOAL OF THIS STUDY: To evaluate enzyme immunoassays (EIA) for chlamydial antigens in first catch urine (FCU) from symptomatic and asymptomatic men. STUDY DESIGN: We conducted five different studies; FCUs and urethral swabs were collected from 1,341 symptomatic and 816 asymptomatic males. Four EIAs (SureCell, Chlamydiazyme, MicroTrak and IDEIA) were tested on the FCU sediments. RESULTS: Prevalence of chlamydia by tissue culture isolation was 6% for asymptomatic and 14% for symptomatic men. With symptomatic males, the EIA sensitivities and specificities were: SureCell 85% and 97%, IDEIA 82% and 98%, MicroTrak 86% and 99%, and Chlamydiazyme 91% and 95%. For asymptomatic men, Chlamydiazyme sensitivity was 35% with frozen urine vs 77% with fresh urine. Overall, tissue culture sensitivity was about 90%. CONCLUSION: EIA results on FCU sediments are comparable to that of tissue culture isolation on urethral swabs. In many settings, FCU may be the specimen of choice for diagnosing chlamydial infections in men.

Evaluation of urine-based screening strategies to detect Chlamydia trachomatis among sexually active asymptomatic young males.

OBJECTIVE: To evaluate the performances of diagnostic screening tests alone or in combination to detect asymptomatic chlamydial urethral infection in young males. DESIGN: Comparisons of the performance profiles of the following chlamydia screening strategies were done: urethral culture; identification of polymorphonucleocytes (PMNs) on spun first-void urine (FVU); urinary leukocyte esterase test (LET) on unspun FVU; chlamydial enzyme immunoassay (EIA) applied to FVU sediment; combining LET on unspun FVU followed by EIA with or without direct fluorescent antibody (DFA) confirmation on FVU sediment; and combining PMNs on spun FVU followed by EIA with or without DFA confirmation. SETTING: General clinics at a youth detention center, university-based teen clinic, college health service, and a military screening clinic. PATIENTS: A total of 618 males aged 12 to 35 years (mean, 17 years) were recruited as a convenience sample; site participation rates ranged from 50% to 80%. Eligible subjects were sexually active, denied symptoms of urethritis, and had taken no antibiotics in the prior 2 weeks. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive values of each test strategy's ability to detect Chlamydia trachomatis infection, and cost to confirm each positive case. RESULTS: With a 7% prevalence of chlamydial infection, tissue culture had a sensitivity of only 61%. However, two strategies yielded significantly better performance profiles compared with the others: EIA confirmed by DFA test with a sensitivity of 84%, a specificity of 100%, and a cost to identify each positive case of $434; and PMNs followed by EIA confirmed by DFA test with a sensitivity of 78%, a specificity of 100%, and a cost to identify each positive case of $199. The LET followed by EIA-DFA had a similar performance profile to the PMN test strategies. CONCLUSIONS: A combination of a nonspecific screening of FVU for PMNs or LET followed by specific testing with EIA with DFA confirmation has superior clinical and cost-effective performance for detecting asymptomatic C trachomatis urethritis in young males compared with other strategies. However, an evaluation of the medical, fiscal, and psychological benefits and risks associated with a specific screening strategy for sexually transmitted diseases must be made before adopting a specific strategy for a particular population.