Evaluation of the effect of an educational intervention on knowledge and adherence to HIV guidelines among frontline health workers in Alex-Ekwueme Federal University Teaching Hospital Abakaliki,Nigeria

BackgroundThe aim of this study was to appraise the implementation of the National HIV guidelines and determine the effect of an educational intervention on health worker knowledge and practice of the guidelines.MethodsA before and after study design without control was carried out using a self-administered questionnaire and key informant interviews. Data was also collected from client record cards. An educational intervention was carried out using pamphlets containing summarized information on the guideline. Data analysis was carried out using IBM-SPSS version 20.ResultResults showed that 54.5% of the respondents were males and 76% were medical doctors. Baseline knowledge level of respondents was high with 97% of respondents having good knowledge with a mean score of 3.9. This increased to 4.1 out of 5 post-intervention. All respondents had good practice of the guidelines before and after intervention with a mean score of 4.5 out of 5. Client records also showed good practice. Barriers to guideline implementation include: poor knowledge, inadequate training, guideline unavailability, poor functioning of the laboratory equipment, poor funding.ConclusionHIV guidelines are being implemented in the clinic to a large extent; however, trainings, funding and provision of the guideline in the clinics are recommended.     

The definition of pneumonia, the assessment of severity, and clinical standardization in the Pneumonia Etiology Research for Child Health study

To develop a case definition for the Pneumonia Etiology Research for Child Health (PERCH) project, we sought a widely acceptable classification that was linked to existing pneumonia research and focused on very severe cases. We began with the World Health Organization's classification of severe/very severe pneumonia and refined it through literature reviews and a 2-stage process of expert consultation. PERCH will study hospitalized children, aged 1-59 months, with pneumonia who present with cough or difficulty breathing and have either severe pneumonia (lower chest wall indrawing) or very severe pneumonia (central cyanosis, difficulty breastfeeding/drinking, vomiting everything, convulsions, lethargy, unconsciousness, or head nodding). It will exclude patients with recent hospitalization and children with wheeze whose indrawing resolves after bronchodilator therapy. The PERCH investigators agreed upon standard interpretations of the symptoms and signs. These will be maintained by a clinical standardization monitor who conducts repeated instruction at each site and by recurrent local training and testing.     

Dihydropyrimidinase-related protein 2 (DRP-2) gene and association to deficit and nondeficit schizophrenia.

A previous study has shown an association between the *2236T > C allele polymorphism of the dihydropyrimidinase-related protein 2 (DRP-2) gene and schizophrenia in a Japanese sample [Nakata et al. (2003); Biological Psychiatry 53:571-576]. DRP-2 is an important molecule in guiding neuronal development and its gene is located in 8p21, a chromosomal region that was previously shown to have significant linkage to schizophrenia and to several deficit symptoms of schizophrenia. We compared the frequency of the DRP-2 *2236T > C polymorphism between subjects with (n = 117) and without (n = 72) schizophrenia, and then further evaluated whether the association was specific for the deficit (n = 24) and nondeficit (n = 93) forms of schizophrenia. In both Caucasians and African-Americans, the C allele occurred more frequently in schizophrenia cases than controls, with this difference achieving statistical significance in Caucasians (C allele frequency: 42.0% in cases vs. 25.0% in controls, P = 0.014) but not African Americans (52.6% in cases vs. 50.0% in controls, P = 0.93). In Caucasians, the frequency of the C allele was significantly higher in both the deficit (allele frequency 53.3%, P = 0.009) and nondeficit (39.2%, P =0.050) forms of schizophrenia compared to controls (allele frequency 25.0%). We conclude that the DRP-2 *2236 C allele may mark another polymorphism in DRP-2, or in a nearby gene, that may influence susceptibility to schizophrenia.     

Impaired kynurenine pathway metabolism in the prefrontal cortex of individuals with schizophrenia

The levels of kynurenic acid (KYNA), an astrocyte-derived metabolite of the branched kynurenine pathway (KP) of tryptophan degradation and antagonist of α7 nicotinic acetylcholine and N-methyl-D-aspartate receptors, are elevated in the prefrontal cortex (PFC) of individuals with schizophrenia (SZ). Because endogenous KYNA modulates extracellular glutamate and acetylcholine levels in the PFC, these increases may be pathophysiologically significant. Using brain tissue from SZ patients and matched controls, we now measured the activity of several KP enzymes (kynurenine 3-monooxygenase [KMO], kynureninase, 3-hydroxyanthranilic acid dioxygenase [3-HAO], quinolinic acid phosphoribosyltransferase [QPRT], and kynurenine aminotransferase II [KAT II]) in the PFC, ie, Brodmann areas (BA) 9 and 10. Compared with controls, the activities of KMO (in BA 9 and 10) and 3-HAO (in BA 9) were significantly reduced in SZ, though there were no significant differences between patients and controls in kynureninase, QPRT, and KAT II. In the same samples, we also confirmed the increase in the tissue levels of KYNA in SZ. As examined in rats treated chronically with the antipsychotic drug risperidone, the observed biochemical changes were not secondary to medication. A persistent reduction in KMO activity may have a particular bearing on pathology because it may signify a shift of KP metabolism toward enhanced KYNA synthesis. The present results further support the hypothesis that the normalization of cortical KP metabolism may constitute an effective new treatment strategy in SZ.     

Clozapine in Reducing Aggression and Violence in Forensic Populations

Popular media often portray people with a mental illness as being aggressive, violent, and incarcerated as a result of their behavior. Despite exaggeration in the media, risks for some aggressive behaviors are in fact higher in individuals with schizophrenia. This is often the case with influence of comorbid substance use disorders. It is essential that mental health professionals are aware of treatments that may help with attenuating and treating behaviors that contribute to violence, aggression and incarceration. This paper reviews violence and incarceration in individuals with schizophrenia as well as recommendations, guidelines and benefits for the use of clozapine in this population. Clozapine remains one of the most underutilized evidence-based medications available in the psychiatric arena in the United States. It is a viable and recommended option in the forensic population and it may be helpful on the path to recovery as well as bring substantial savings to the criminal justice system.     

Nicotine Enhances but Does Not Normalize Visual Sustained Attention and the Associated Brain Network in Schizophrenia

Sustained attention abnormality in schizophrenia is usually refractory to available treatment. Nicotine can transiently improve sustained attention in schizophrenia patients, although its neural mechanisms are unknown. Understanding the neural basis of this effect may lead to new treatment strategies for this cognitive deficit. Twenty schizophrenia patients and 24 healthy comparison smokers participated in a double-blind, placebo-controlled, crossover, randomized functional magnetic resonance imaging study comparing nicotine vs placebo patch on sustained attention, using the rapid visual information–processing task. Schizophrenia patients had impaired visual sustained attention accuracy and processing speed (all P’s <.001) and showed significantly reduced activation in the frontal-parietal-cingulate-thalamic attention network compared with healthy comparison subjects. Nicotine administration enhanced accuracy and processing speed compared with placebo (all P’s ≤.006), with no drug × diagnosis interactions. However, schizophrenia patients’ task performance remained impaired during the nicotine condition, even when compared with healthy comparison subjects in the placebo condition (all P’s ≤.01). Nicotine exerted no significant reversal of the impaired attention network associated with schizophrenia. Activations in brain regions associated with nicotine-induced behavioral improvement were not significantly different between patients and comparison subjects. Thus, nicotine transiently enhanced sustained attention similarly in schizophrenia patients and in healthy comparison smokers. The neural mechanisms for this nicotinic effect in schizophrenia appear similar to those for healthy comparison subjects. However, nicotine, at least in a single sustained dose, does not normalize impaired sustained attention and its associated brain network in schizophrenia. These findings provide guidance for developing new treatment strategies for the sustained attention deficit in schizophrenia.     

Vertical supranuclear gaze palsy in Niemann-Pick type C disease

Vertical supranuclear gaze palsy (VSGP) is a key clinical feature in patients with Niemann-Pick type C disease (NP-C), a rare, autosomal recessive, neuro-visceral disorder caused by mutations in either the NPC1 or NPC2 gene. VSGP is present in approximately 65?% of the cases and is, with gelastic cataplexy, an important risk indicator for NP-C. VSGP in NP-C is characterized by a paralysis of vertical saccades, especially downward, with the slow vertical eye movement systems (smooth pursuit and the vestibulo-ocular reflex) spared in the early phase of the disease. This dissociation is caused by a selective vulnerability of the neurons in the rostral interstitial nuclei of the medial longitudinal fasciculus (riMLF) in NP-C. Here we discuss VSGP in NP-C and how clinicians can best elicit this sign.     

Using social network analysis to examine the decision-making process on new vaccine introduction in Nigeria

The decision-making process to introduce new vaccines into national immunization programmes is often complex, involving many stakeholders who provide technical information, mobilize finance, implement programmes and garner political support. Stakeholders may have different levels of interest, knowledge and motivations to introduce new vaccines. Lack of consensus on the priority, public health value or feasibility of adding a new vaccine can delay policy decisions. Efforts to support country-level decision-making have largely focused on establishing global policies and equipping policy makers with the information to support decision-making on new vaccine introduction (NVI). Less attention has been given to understanding the interactions of policy actors and how the distribution of influence affects the policy process and decision-making. Social network analysis (SNA) is a social science technique concerned with explaining social phenomena using the structural and relational features of the network of actors involved. This approach can be used to identify how information is exchanged and who is included or excluded from the process. For this SNA of vaccine decision-making in Nigeria, we interviewed federal and state-level government officials, officers of bilateral and multilateral partner organizations, and other stakeholders such as health providers and the media. Using data culled from those interviews, we performed an SNA in order to map formal and informal relationships and the distribution of influence among vaccine decision-makers, as well as to explore linkages and pathways to stakeholders who can influence critical decisions in the policy process. Our findings indicate a relatively robust engagement of key stakeholders in Nigeria. We hypothesized that economic stakeholders and implementers would be important to ensure sustainable financing and strengthen programme implementation, but some economic and implementation stakeholders did not appear centrally on the map; this may suggest a need to strengthen the decision-making processes by engaging these stakeholders more centrally and earlier.