Social factors affecting ART adherence in rural settings in Zambia

The purpose of this study was to assess the factors that influence ART adherence arising in rural settings in Zambia. A survey was conducted with face-to-face interviews using a semi-structured questionnaire and written informed consent was obtained at ART sites in Mumbwa District in rural Zambia. The questionnaire included items such as the socio-demographic characteristics of respondents, support for adherence, ways to remember when to take ARVs at scheduled times, and the current status of adherence. Valid responses were obtained from 518 research participants. The mean age of the respondents was 38.3 years and the average treatment period was 12.5 months. More than half of the respondents (51%) were farmers, about half (49%) did not own a watch, and 10% of them used the position of the sun to remember when to take ARVs. Sixteen percent of respondents experienced fear of stigma resulting from taking ARVs at work or home, and 10% felt pressured to share ARVs with someone. Eighty-eight percent of the participants reported that they had never missed ARVs in the past four days. Multivariable logistic regression analysis identified age (38 years old or less, odds ratio (OR) = 2.5, 95% confidence interval (CI): 1.3-4.8, p=0.005), "remembering when to take ARVs based on the position of the sun" (OR = 3.3, 95% CI: 1.3-8.8, p=0.016), and "feeling pressured to share ARVs with someone" (OR = 4.4, 95% CI: 1.6-12.0, p=0.004) as independent factors for low adherence. As ART services expand to rural areas, program implementers should pay more attention to more specific factors arising in rural settings since they may differ from those in urban settings.     

Expansion of antiretroviral treatment to rural health centre level by a mobile service in Mumbwa district, Zambia

Problem

Despite the Government’s effort to expand services to district level, it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages.

Approach

The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa.

Local setting

Mumbwa is a rural district with an area of 23 000 km² and a population of 167 000. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital.

Relevant changes

The mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases “lost to follow-up”. This might be due to the closer involvement of the community and the better support offered by these services to rural clients.

Lessons learnt

These mobile ART services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.     

A case of disseminated peritoneal leiomyomatosis developing after laparoscope-assisted myomectomy

A 36-year-old nulliparous woman developed multiple extra-uterine fibroids in the pelvic cavity years after laparoscopic myomectomy. Molecular genetic analysis by methylation-specific polymerase chain reaction (MSPCR) of the human X-linked androgen receptor gene and loss of heterozygosity (LOH) analysis at 5 microsatellite loci was performed on the tumors. All tumors showed an identical non-random X-chromosome inactivation pattern by MSPCR and an identical pattern of LOH was found in all the tumors by LOH analysis. This demonstrated that 3 fibroids resected 2 years later and 14 fibroids resected 6 years later were all metastatic tumors originating from the uterine leiomyoma found during the initial surgery, suggesting that morcellation before removal of the leiomyoma nodule during laparoscopic myomectomy may have been associated with the pathogenesis of this case.     

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique

ObjectiveTo describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method.MethodsA pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty‐five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo–Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5–8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley''s criteria.ResultsTwenty‐five patients were followed up for an average of 28.96 (Range, 15–48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5–9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection.ConclusionsThe combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.     

Bovine cervical mucus as a substitute of human cervical mucus

The sperm penetration test (SPT) in cervical mucus (CM) is an important test in screening for sperm-CM incompatibility. For a routine SPT, a sufficient amount of preovulatory CM is necessary, but the amount of human CM is often inadequate. We examined estrous bovine CM as a substitute for human CM in the SPT. Preovulatory human CM and estrous bovine CM were collected and stored frozen at -20 degrees C until use. After being thawed at room temperature, the two CM samples were compared as to their pH, spinnbarkeit and ferning patterns, and it was found that they are quite similar. In Kremer's method of SPT, sperm penetration distance, density and motility were similar in human and bovine CM for 12 hours, but thereafter sperm motility became much lower in bovine CM than in human CM. The results of SPT with spermatozoa from patients with oligozoospermia were quite similar in both CMs. When spermatozoa pretreated with antisperm antibody were used for SPT, sperm penetration was completely blocked in human CM, but no inhibition was seen in bovine CM. From these results, we conclude that bovine CM can be substituted for human CM for some, but not all, purposes.     

Do optimal Dipoles obtained by the Dipole Tracing Method slways suggest true source locations?

Summary Scalp potentials generated by a concentrated electric source in the brain are very similar to potentials generated by an electric dipole at the source position. In this sense a concentrated source in the brain is modelled as an electric dipole. When the source is diffuse such a dipole which best approximates the scalp potential is called an optimal dipole. Its position is calculated by the Dipole Tracing Method based on a realistic head model with homogeneous electric conductivity. There are 2 major difficulties inherent in this method: (1) The low electric conductivity of the skull causes systematic shifts of the optimal dipole positions from the true positions of concentrated sources; (2) the optimal dipoles cannot specify diffuse source positions. The first difficulty is overcome by using the numerical correction obtained by comparing the known dipole positions generated within a human head with their optimal ones. The second difficulty is removed to a certain extent by comparing the optimal dipole positions obtained with the 1-dipole and 2-dipole models together with their dipolarity. We have obtained criteria for the validity of the dipole approximation and source concentration.The authors thank Professor K.-E. Hagbarth, Professor S. Blom and Dr. R. Flink of Uppsala University Hospital; Dr. M. Seino of the National Epilepsy Center, Shizuoka; and Professor Y. Okamoto of Chiba Inst. Technology. Supported in part by Int. Scientific Research Programs (Joint Research) of the Ministry of Education, No. 01044026 and No. 02044054 and the Nissan Science Foundation.     

Dipole tracing method analysis for source of auditory brainstem response (wave V) in two normal hearing subjects]

The location and vector moment of the equivalent current dipoles of ABR (wave V) evoked by unilateral acoustic stimuli were estimated in normal adults with the Dipole Tracing (DT) Method. The ABR's were recorded through 21 electrodes arranged according to the international 10-20 standard. The DT method is based on a realistic head shape with uniform volume conductor and individual differences of the skull were corrected for afterwards. The 3-D dipole locations were plotted on the cross-sectional MRI data of the subject. As a result the dipole of the wave V of auditory brainstem responses was found near the contralateral midbrain.