Is endemic political corruption hampering provision of ART and PMTCT in developing countries?

Introduction

Leadership is a key factor in the success of HIV prevention and treatment. Positive HIV-related outcomes are also affected by funding levels for HIV, health sector resources, disease burden and the socio-economic environment. Leadership on HIV as well as these other factors are affected by the quality of political governance of the country, which may be an overarching factor that influences the making of effective responses to the HIV epidemic.

Aim

The aim of the study was to investigate the association between quality of political governance, on one hand, and coverage of antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT), on the other, in low- to middle-income countries.

Methods

This investigation was carried out through a global review, online data sourcing and statistical analyses. We collected data on health burden and resources, the socio-economic environment, HIV prevalence, ART and PMTCT coverage and indicators of political governance. Outcome variables were coverage of ART (from 2004) and PMTCT (from 2007) to 2009 as a percentage of persons needing it. Potential predictors of treatment coverage were fitted with a baseline multilevel model for univariable and multivariable analyses.

Results

Countries with higher levels of political voice and accountability, more political stability and better control of corruption have higher levels of ART coverage but not PMTCT coverage. Control of corruption (in standard deviation units) had a strong association with ART (AOR=1.82, p=0.002) and PMTCT (AOR=1.97, p=0.01) coverage. Indicators of economic development were not significant when control of corruption was included in the multivariable regression model. Many countries in all income groups had high ART but not PMTCT coverage (e.g. Mexico, Brazil and Romania in the upper-middle-income group; Papua New Guinea and Philippines in the lower-middle-income group; and Cambodia, Laos and Comoros in the low-income group). Very few low-income countries (notably, Haiti and Kenya) had high PMTCT coverage.

Conclusions

Our research found a significant relationship between quality of political governance and treatment coverage. Measures and policies for improving the quality of political governance should be considered as a part of HIV programme implementation to more effectively improve the welfare of people living with HIV, particularly mothers living with HIV and their babies.     

Melatonin regulation of biliary functions

The intrahepatic biliary epithelium is a three-dimensional tubular system lined by cholangiocytes, epithelial cells that in addition to modify ductal bile are also the targets of vanishing bile duct syndromes (i.e., cholangiopathies) such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) that are characterized by the damage/proliferation of cholangiocytes. Cholangiocyte proliferation is critical for the maintenance of the biliary mass and secretory function during the pathogenesis of cholangiopathies. Proliferating cholangiocytes serve as a neuroendocrine compartment during the progression of cholangiopathies, and as such secrete and respond to hormones, neurotransmitters and neuropeptides contributing to the autocrine and paracrine pathways that regulate biliary homeostasis. The focus of this review is to summarize the recent findings related to the role of melatonin in the modulation of biliary functions and liver damage in response to a number of insults. We first provide a general background on the general function of cholangiocytes including their anatomic characteristics, their innervation and vascularization as well the role of these cells on secretory and proliferation events. After a background on the synthesis and regulation of melatonin and its role on the maintenance of circadian rhythm, we will describe the specific effects of melatonin on biliary functions and liver damage. After a summary of the topics discussed, we provide a paragraph on the future perspectives related to melatonin and liver functions.     

A Randomized,Controlled Pragmatic Trial of Telephonic Medication Therapy Management to Reduce Hospitalization in Home Health Patients

Objective

To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing hospitalizations among home health patients.

Setting

Forty randomly selected, geographically diverse home health care centers in the United States.

Design

Two-stage, randomized, controlled trial with 60-day follow-up. All Medicare- insured home health care patients were eligible to participate. Twenty-eight consecutive patients within each care center were recruited and randomized to usual care or MTM intervention. The MTM intervention consisted of the following: (1) initial phone call by a pharmacy technician to verify active medications; (2) pharmacist-provided medication regimen review by telephone; and (3) follow-up pharmacist phone calls at day seven and as needed for 30 days. The primary outcome was 60-day all-cause hospitalization.

Data Collection

Data were collected from in-home nursing assessments using the OASIS-C. Multivariate logistic regression modeled the effect of the MTM intervention on the probability of hospitalization while adjusting for patients’ baseline risk of hospitalization, number of medications taken daily, and other OASIS-C data elements.

Principal Findings

A total of 895 patients (intervention n = 415, control n = 480) were block-randomized to the intervention or usual care. There was no significant difference in the 60-day probability of hospitalization between the MTM intervention and control groups (Adjusted OR: 1.26, 95 percent CI: 0.89–1.77, p = .19). For patients within the lowest baseline risk quartile (n = 232), the intervention group was three times more likely to remain out of the hospital at 60 days (Adjusted OR: 3.79, 95 percent CI: 1.35–10.57, p = .01) compared to the usual care group.

Conclusions

This MTM intervention may not be effective for all home health patients; however, for those patients with the lowest-risk profile, the MTM intervention prevented patients from being hospitalized at 60 days.     

Influence of Hormonal Contraceptive Use and Health Beliefs on Sexual Orientation Disparities in Papanicolaou Test Use

Objectives. Reproductive health screenings are a necessary part of quality health care. However, sexual minorities underutilize Papanicolaou (Pap) tests more than heterosexuals do, and the reasons are not known. Our objective was to examine if less hormonal contraceptive use or less positive health beliefs about Pap tests explain sexual orientation disparities in Pap test intention and utilization.Methods. We used multivariable regression with prospective data gathered from 3821 females aged 18 to 25 years in the Growing Up Today Study (GUTS).Results. Among lesbians, less hormonal contraceptive use explained 8.6% of the disparities in Pap test intention and 36.1% of the disparities in Pap test utilization. Less positive health beliefs associated with Pap testing explained 19.1% of the disparities in Pap test intention. Together, less hormonal contraceptive use and less positive health beliefs explained 29.3% of the disparities in Pap test intention and 42.2% of the disparities in Pap test utilization.Conclusions. Hormonal contraceptive use and health beliefs, to a lesser extent, help to explain sexual orientation disparities in intention and receipt of a Pap test, especially among lesbians.Reproductive health screenings, such as Papanicolaou (Pap) tests, are a necessary part of quality health care.1 These screenings can detect precancerous conditions that may lead to cervical cancer if not treated. Despite the health benefits, sexual minority (e.g., lesbian, bisexual) female adolescents and young adults underutilize Pap tests.2–7 In a previous study with the cohort employed in this study, sexual minorities, compared to heterosexuals, were less likely to have had a Pap test within the last year or in their lifetime.8 We now extend this finding by exploring how hypothesized determinants of Pap testing intentions and behaviors help to explain sexual orientation disparities. A more thorough understanding of factors that explain underutilization may enable targeted clinical care and public health messages.It has been proposed that lesbians are less likely than heterosexuals to regularly visit a gynecologist because of their lower likelihood of hormonal contraceptive use.6,7 Other factors that may explain screening disparities include lower risk perception3 of cervical cancer and negative attitudes and beliefs toward Pap tests.9 Previous studies report that lesbians, in contrast to heterosexuals, perceive themselves to be at lower risk for contracting the human papillomavirus (HPV) and subsequently developing cervical cancer. Common reasons include the belief that sex between women is intrinsically safe because of limited fluid transmission, feeling invisible in gay male-focused sexual health promotions and therefore feeling “safe” because of a lack of messaging, and the emphasis in the “safer sex” discourse that one needs to only worry about penile penetrative sex.10 Physician recommendations have proved to be the strongest factor associated with Pap test utilization among all women.11 However, 10% of bisexuals and lesbians report being discouraged by physicians from getting a Pap test.12 Sexual minority adolescents may be particularly at risk because negative perceptions and attitudes about HPV are associated with lower screening rates among adolescents.13The Health Belief Model (HBM) is a psychological model that aims to explain and predict health behaviors. To our knowledge, it has yet to be applied to Pap test use within various sexual orientation groups but has effectively explained health disparities in other populations.14 The model includes 4 constructs focused on an individual’s attitudes and beliefs: susceptibility, severity, benefits, and barriers.15 An additional concept, cues to action, is thought to further motivate behavior,16 as are normative beliefs.The Institute of Medicine states that more data on Pap test use among sexual minority women are needed to better inform medical, governmental, and educational policies.17 Therefore, we examined sexual orientation group disparities in hormonal contraceptive use and HBM constructs (i.e., risk perception, attitudes and beliefs, cues to action) as they relate to Pap testing among adolescents and young adults. We hypothesized that unlike completely heterosexuals, sexual minorities

1. use hormonal contraceptives less frequently (and therefore may not see a health care provider as frequently who could provide a Pap test);
2. perceive themselves to be at lower risk for cervical cancer;
3. perceive themselves to be at lower severity of cervical cancer, if a diagnosis did occur;
4. believe there are fewer benefits to Pap test use;
5. believe there are more barriers to Pap test use;
6. hold fewer normative beliefs about Pap test use;
7. receive fewer cues to action for Pap test use; and
8. perceive fewer other individuals utilizing Pap tests.

Additionally, we hypothesized that these factors would partially explain (i.e., mediate) sexual orientation group disparities in Pap test intention and utilization.     

Estimating the measles effective reproduction number in Australia from routine notification data

Objective

To estimate the measles effective reproduction number (R) in Australia by modelling routinely collected notification data.

Methods

R was estimated for 2009–2011 by means of three methods, using data from Australia’s National Notifiable Disease Surveillance System. Method 1 estimated R as 1 − P, where P equals the proportion of cases that were imported, as determined from data on place of acquisition. The other methods estimated R by fitting a subcritical branching process that modelled the spread of an infection with a given R to the observed distributions of outbreak sizes (method 2) and generations of spread (method 3). Stata version 12 was used for method 2 and Matlab version R2012 was used for method 3. For all methods, calculation of 95% confidence intervals (CIs) was performed using a normal approximation based on estimated standard errors.

Findings

During 2009–2011, 367 notifiable measles cases occurred in Australia (mean annual rate: 5.5 cases per million population). Data were 100% complete for importation status but 77% complete for outbreak reference number. R was estimated as < 1 for all years and data types, with values of 0.65 (95% CI: 0.60–0.70) obtained by method 1, 0.64 (95% CI: 0.56–0.72) by method 2 and 0.47 (95% CI: 0.38–0.57) by method 3.

Conclusion

The fact that consistent estimates of R were obtained from all three methods enhances confidence in the validity of these methods for determining R.     

Rethinking Patient Engagement in Cancer Research

The Patient - Patient-Centered Outcomes Research -     

Attrition from Therapy Effectiveness Research Among Youth in a Clinical Service Setting

This study examined research attrition in clinical service settings by comparing psychotherapy research completers and dropouts in a private therapy practice. Seventy-seven children 7–12 years old enrolled in the Resilience Builder Program^® (RBP), a manualized group therapy created and administered in a private practice. Children had social impairments, and most were diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and/or anxiety disorders. Results found that compared to completers, research dropouts had significantly greater social deficits, disruptive behavior problems, affective problems, medication use, and were more likely to be ethnic minorities. We discuss implications for research recruitment and retention in clinical service settings.     

The use of the Rey 15-Item Test and recognition trial to evaluate noncredible effort after pediatric mild traumatic brain injury

The Rey 15-Item Test (FIT) is a performance validity test commonly used in adult neuropsychological assessment. FIT classification statistics across studies have been variable, so a recognition trial was created to enhance the measure (Boone, K. B., Salazar, X., Lu, P., Warner-Chacon, K., & Razani, J. (2002). The Rey 15-Item recognition trial: A technique to enhance sensitivity of the Rey 15-Item Memorization Test. Journal of Clinical and Experimental Neuropsychology, 24(5), 561–573.). The current study assessed the utility of the FIT and recognition trial in a pediatric mild traumatic brain injury sample (N = 319, M = 14.57 years). All participants were administered the FIT and recognition trial as part of an abbreviated clinical neuropsychological evaluation. Failure on the Medical Symptom Validity Test was used as the criterion for noncredible effort. Fifteen percent of the sample met the criterion. The traditional adult cutoff score of <9 on the FIT recall trial yielded excellent specificity (98%), but very poor sensitivity (12%). When the recognition trial was utilized, a total score of <26 resulted in the best combined cutoff score (sensitivity = 55%, specificity = 91%). Results indicate that the FIT with recognition trial may be useful in the assessment of noncredible effort with children and adolescents, at least among relatively high-functioning populations.     

Assessment of rat sciatic nerve function following acute implantation of high density utah slanted electrode array (25 electrodes/mm2) based on neural recordings and evoked muscle activity

Introduction: High density Utah slanted electrode arrays (HD‐USEAs) have been developed recently for intrafascicular access to submillimeter neural structures. Insertion of such high electrode density devices may cause nerve crush injury, counteracting the intended improved selective nerve fiber access. Methods: HD‐USEAs were implanted into sciatic nerves of anesthetized rats. Nerve function was assessed before and after HD‐USEA implantation by measuring changes in evoked muscle and nerve compound action potentials and single unit neuronal recordings. Results: Neural activity was recorded with over half of all implanted electrodes. Average decreases of 38%, 36%, and 13% in nerve, medial gastrocnemius, and tibialis anterior compound action potential amplitudes, respectively, were observed following array implantation. Only 1 of 8 implantations resulted in loss of all signals. Conclusions: These studies demonstrate that HD‐USEAs provide a useful neural interface without causing a nerve crush injury that would otherwise negate their use in acute preparations (<12 h). Muscle Nerve 50 : 417–424, 2014