Longer duration of homelessness is associated with a lower likelihood of non-detectable plasma HIV-1 RNA viral load among people who use illicit drugs in a Canadian setting

Homelessness is common among people who use drugs (PWUD) and, for those living with HIV/AIDS, an important contributor to sub-optimal HIV treatment outcomes. This study aims to investigate the relationship between the duration of homelessness and the likelihood of plasma HIV-1 RNA viral load (VL) non-detectability among a cohort of HIV-positive PWUD. We used data from the ACCESS study, a long-running prospective cohort study of HIV-positive PWUD linked to comprehensive HIV clinical records including systematic plasma HIV-1 RNA VL monitoring. We estimated the longitudinal relationship between the duration of homelessness and the likelihood of exhibiting a non-detectable VL (i.e., <500?copies/mL plasma) using generalized linear mixed-effects modelling. Between May 1996 and June 2014, 922 highly active antiretroviral therapy-exposed participants were recruited and contributed 8188 observations. Of these, 4800 (59%) were characterized by non-detectable VL. Participants reported they were homeless in 910 (11%) interviews (median: six months, interquartile range: 6–12 months). A longer duration of homelessness was associated with lower odds of VL non-detectability (adjusted odds ratio?=?0.71 per six-month period of homelessness, 95% confidence interval: 0.60–0.83) after adjustment for age, ancestry, drug use patterns, engagement in addiction treatment, and other potential confounders. Longer durations of episodes of homelessness in this cohort of HIV-positive illicit drug users were associated with a lower likelihood of plasma VL non-detectability. Our findings suggest that interventions that seek to promptly house homeless individuals, such as Housing First approaches, might assist in maximizing the clinical and public health benefits of antiretroviral therapy among people living with HIV/AIDS.     

The Role of the Medical Expert in the Retrospective Assessment of Testamentary Capacity

Objectives:Physicians and other mental health experts are increasingly called on to assist the courts with the determination of testamentary capacity. We aim to improve the understanding of the retrospective assessment of testamentary capacity for medical experts in order to provide more useful reports for the court’s determinations and to provide a methodology for the retrospective assessment of testamentary capacity.Method:Medical experts with experience in the retrospective assessment of testamentary capacity collaborated with lawyers who practice estate litigation. The medical literature on the assessment of testamentary capacity was reviewed and integrated. The medical experts provided a clinical perspective, while the lawyers ensured that the case law and legal perspective were integrated into this review.Results:The focus and limitations of the medical expert are outlined including the need to be objective, nonpartisan, and fair. For the benefit of the court, the medical expert should describe the nature and severity of relevant medical, psychiatric, and cognitive disorders, and how they may impact on the specific criteria for testamentary capacity as defined by the leading case of Banks v Goodfellow. Medical experts should opine only on the issue of vulnerability to influence and defer to the court to determine the facts of the case regarding any influence that may have been exerted.Conclusions:Although the ultimate determination of testamentary capacity is a legal one, medical experts can help the court achieve the most informed legal decision by providing relevant information on clinical issues that may impact the criteria for testamentary capacity.     

Evaluating the Benefit of Elevated Acoustic Output in Harmonic Motion Estimation in Ultrasonic Shear Wave Elasticity Imaging

Harmonic imaging techniques have been applied in ultrasonic elasticity imaging to obtain higher-quality tissue motion tracking data. However, harmonic tracking can be signal-to-noise ratio and penetration depth limited during clinical imaging, resulting in decreased yield of successful shear wave speed measurements. A logical approach is to increase the source pressure, but the in situ pressures used in diagnostic ultrasound have been subject to a de facto upper limit based on the Food and Drug Administration guideline for the mechanical index (MI <1.9). A recent American Institute of Ultrasound in Medicine report concluded that an in situ MI up to 4.0 could be warranted without concern for increased risk of cavitation in non-fetal tissues without gas bodies if there were a concurrent clinical benefit. This work evaluates the impact of using an elevated MI in harmonic motion tracking for hepatic shear wave elasticity imaging. The studies indicate that high-MI harmonic tracking increased shear wave speed estimation yield by 27% at a focal depth of 5?cm, with larger yield increase in more difficult-to-image patients. High-MI tracking improved harmonic tracking data quality by increasing the signal-to-noise ratio and decreasing jitter in the tissue motion data. We conclude that there is clinical benefit to use of elevated acoustic output in shear wave tracking, particularly in difficult-to-image patients.     

Anti-inflammatory effect of low-intensity laser on the healing of third-degree burn wounds in rats

Third-degree burn wounds are considered severe injuries because they destroy all the skin layers and may affect subcutaneous tissues, fasciae, muscles, and bones. To favor the healing process of the injured tissues, it is very useful to diminish the occurrence of the inflammatory process. The present study was aimed at comparing the effect of different energetic densities of AlGaInP laser on the inflammatory process and in the healing of third-degree burn wounds in Wistar rats. This study was approved by the Ethics Committee, in which 36 adult male rats were selected and suffered the induction of third-degree burn injury. These rats were divided as follows: group 1—control (treated with silver sulfadiazine), group 2—received energy density of 3 J/cm², and group 3—received energy density of 6 J/cm². All animals daily received an occlusive bandage with silver sulfadiazine and 8 % papain. The laser therapy was performed alternatively three times a week. The animals were evaluated on the 3rd, 7th, 14th, and 21st days after the initial lesion and euthanized for the macroscopic, histologic, and morphometric analysis. A higher production of collagen was observed at 7 days and a greater re-epithelialization at 21 days in group 3 (6 J/cm²). Furthermore, the latter when compared to the other groups presented macroscopically a better aspect of the scar at 21 days with more granulation tissue and fibrosis. We conclude that the AlGaInP laser used in dosages of 3 and 6 J/cm² favors the healing of third-degree burn wounds induced in rats.