Consortium for Research in Elder Self‐Neglect of Texas Research: Advancing the Field for Practitioners

An external advisory board consisting of members from the fields of geriatric internal medicine, family practice geriatrics, criminal prosecution, civil law, police force, adult protective services, and victims advocacy was created to advise and guide the research conducted by the Consortium for Research in Elder Self‐neglect of Texas (CREST). This panel of experts performed site visits and facilitated the research through responses to every‐other‐week fact sheets and quarterly conference calls. This paper provides the perspective of five of the board members regarding the research findings that were presented at the CREST National Conference in 2006. The discussions outline the successes of the CREST research, describe obstacles and the necessary next steps for continuance of the scientific exploration of this syndrome, and highlight the practice implications of the current and proposed research.     

Cost-sharing strategies combining targeted public subsidies with private-sector delivery achieve high bednet coverage and reduced malaria transmission in Kilombero Valley, southern Tanzania

Background

Cost-sharing schemes incorporating modest targeted subsidies have promoted insecticide-treated nets (ITNs) for malaria prevention in the Kilombero Valley, southern Tanzania, since 1996. Here we evaluate resulting changes in bednet coverage and malaria transmission.

Methods

Bednets were sold through local agents at fixed prices representing a 34% subsidy relative to full delivery cost. A further targeted subsidy of 15% was provided to vulnerable groups through discount vouchers delivered through antenatal clinics and regular immunizations. Continuous entomological surveys (2,376 trap nights) were conducted from October 2001 to September 2003 in 25 randomly-selected population clusters of a demographic surveillance system which monitored net coverage.

Results

Mean net usage of 75% (11,982/16,086) across all age groups was achieved but now-obsolete technologies available at the time resulted in low insecticide treatment rates. Malaria transmission remained intense but was substantially reduced: Compared with an exceptionally high historical mean EIR of 1481, even non-users of nets were protected (EIR [fold reduction] = 349 infectious bites per person per year [×4]), while the average resident (244 [×6]), users of typical nets (210 [×7]) and users of insecticidal nets (105 [×14]) enjoyed increasing benefits.

Conclusion

Despite low net treatment levels, community-level protection was equivalent to the personal protection of an ITN. Greater gains for net users and non-users are predicted if more expensive long-lasting ITN technologies can be similarly promoted with correspondingly augmented subsidies. Cost sharing strategies represent an important option for national programmes lacking adequate financing to fully subsidize comprehensive ITN coverage.     

Medical-legal issues of mild traumatic brain injury

Numerous concussions/mild traumatic brain injuries occur each year during athletic participation by a variety of athletes not only in the United States but around the globe. A variety of standards-type statements have been developed by various athletic and sports medicine groups that can be used to improve and standardize the diagnosis and treatment of these injuries. These standards can also be used to assist practitioners in sports medicine clearance for participation and return-to-play decisions. In a medical-legal arena these statements can be used to support the care that is provided to athletes and thus serve as a “shield” to medical-legal claims and suits. However, these standards can also be used to attack the service that is provided and then be used as a “sword.” Legal issues surrounding standards statements regarding these injuries and the diagnosis and management of them should be recognized and appreciated by sports medicine providers and used to balance the applicable medical and legal risks associated with their practices.     

Future of the TNM classification and staging system in head and neck cancer

Staging systems for cancer, including the most universally used TNM classification system, have been based almost exclusively on anatomic information. However, the question arises whether staging systems should be based on this information alone. Other parameters have been identified that should be considered for inclusion in classification systems like the TNM. This is all the more important, as a shift toward nonsurgical treatments for head and neck cancer has been made over the years. For these treatment modalities tumor/biologic characteristics next to anatomic information may be particularly important for treatment choice and outcome. The shortcomings of the current TNM classification system will be discussed, along with suggestions for improvement and expansion of the TNM system based on tumor, patient, and environment‐related factors. Further improvement of the TNM classification is expected to result in better treatment choices, outcome and prognostication of patients with head and neck cancer. © 2010 Wiley Periodicals, Inc. Head Neck, 2010     

History of viral suppression on combination antiretroviral therapy as a predictor of virological failure after a treatment change*

Objectives

HIV‐infected persons experience different patterns of viral suppression after initiating combination antiretroviral therapy (cART). The relationship between such differences and risk of virological failure after starting a new antiretroviral could help with patient monitoring strategies.

Methods

A total of 1827 patients on cART starting at least one new antiretroviral from 1 January 2000 while maintaining a suppressed viral load were included in the analysis. Poisson regression analysis identified factors predictive of virological failure after baseline in addition to traditional demographic variables. Baseline was defined as the date of starting new antiretrovirals.

Results

Four hundred and fifty‐one patients (24.7%) experienced virological failure, with an incidence rate (IR) of 7.3 per 100 person‐years of follow‐up (PYFU) [95% confidence interval (CI) 6.7–8.0]. After adjustment, patients who had rebounded in the year prior to baseline had a 2.4‐times higher rate of virological failure after baseline (95% CI 1.77–3.26; P<.0001), while there was no increased incidence in patients whose last viral rebound was >3 years prior to baseline [Incidence rate ratio (IRR) 1.06; 95% CI 0.75–1.50; P=0.73] compared with patients who had never virally rebounded. Patients had an 86% (95% CI 1.36–2.55; P<.0001), 53% (95% CI 1.06–2.04; P=0.02) and 5% (95% CI 0.80–1.38; P=0.72) higher virological failure rate after baseline if they were virally suppressed <50%, 50–70% and 70–90% of the time they were on cART prior to baseline, respectively, compared with those virally suppressed >90% of the time.

Discussion

Intensive monitoring after a treatment switch is required in patients who have rebounded recently or have a low percentage of time suppressed while on cART. Consideration should be given to increasing the provision of adherence counselling.     

Massive astrocyte destruction in neuromyelitis optica despite natalizumab therapy

Auto-antibody mediated astrocyte injury is implicated as a primary event in neuromyelitis optica (NMO) by biomarker, post-mortem and experimental studies that differentiate the condition from multiple sclerosis. We describe the clinical, radiological and neuropathological features of a severe cerebral attack in a natalizumab-treated patient with relapsing myelitis and serum aquaporin-4 antibodies. Our findings support autopsy evidence that abrupt astrocyte destruction precedes demyelination in NMO, and emphasize the importance of serological testing in patients with limited disease. Adherence to current NMO diagnostic criteria may delay treatment, or lead to inappropriate therapy with beta-interferon or natalizumab.