HIV Prevention and Attrition: Challenges and Opportunities

A sizable number of individuals at risk of becoming HIV infected or infecting others either do not access or drop out of AIDS prevention programs. Attrition is a relevant concern for HIV prevention research and practice alike as nonparticipation (enrolling in but never attending an intervention) and dropout (beginning but not completing an intervention) can affect internal and external validity, detrimentally impact the service provider's morale and standing with funders, and potentially lead to poor outcomes for target populations. Understanding how individual factors including demographic and developmental characteristics and programmatic factors such as intervention dosage and venue are related to attrition and how to attract and retain individuals in proven interventions is crucial to prevention efficacy in the third decade of HIV prevention. In this paper, we provide an overview of factors associated with attrition from HIV counseling interventions, offer remedies for practitioners and researchers, and provide a case analysis of a brief motivational enhancement counseling intervention that was designed, in part, to avoid some of the traditional reasons individuals do not enroll in or drop out of HIV prevention programs.     

Non-inducibility post-pulmonary vein isolation achieving exit block predicts freedom from atrial fibrillation.

AIMS: This study evaluates whether non-inducibility of atrial fibrillation (AF) after achieving bi-directional electrical pulmonary vein (PV) isolation is a useful predictor of freedom from AF recurrence. METHODS AND RESULTS: This study included 102 consecutive patients who underwent PV isolation for symptomatic paroxysmal (59%), persistent (32%), or permanent (9%) AF. Patients were followed for 16+/-10 months. Complete isolation of all four PVs was confirmed by demonstration of bi-directional block, defined by both loss of PV potentials and failure to capture the LA by pacing (at 10 mA) 10-14 bipolar pairs of electrodes on a circumferential catheter positioned at the entrance of the PV. Induction of AF by burst pacing on/off isoproterenol was attempted after PV isolation. Freedom from recurrent symptomatic or asymptomatic AF was present in 70% of patients at 6 months and 62% of patients at 12 months. In multi-variable analysis, non-inducibility post-PV isolation (OR=3.84, P=0.047) and paroxysmal AF (OR=4.80, P=0.012) predicted freedom from AF at 12 months. CONCLUSION: Non-inducibility of AF after bi-directional PV isolation predicts maintenance of sinus rhythm. This finding suggests that routine extensive left atrial ablation may be unnecessary.     

A mouse model of dilated-type cardiomyopathy due to coxsackievirus B3

Myocardial scarring was induced in 111 mice (group 3) inoculated at 14 days of age with coxsackievirus B3 and forced to swim for 30 min daily during the initial nine days of infection. The animals were observed until age 15 months. Control animals included mice infected but not forced to swim (group 2), neither infected nor forced to swim (group 1), and not infected but forced to swim (group 4). The cumulative mortality was 45% among mice in group 3 but was significantly lower in the control animals. At 15 months, mice in group 3 showed heavy deposits of calcium in the injured myocardium, atrial hypertrophy with thrombi, and myocardial fiber disintegration with replacement by fibrous scar. Mononuclear infiltration was no longer present. Pathologic changes were concentrated in the left ventricle, interventricular septum, and atrioventricular junction. Titers of type-specific neutralizing antibodies had declined to one-fifth the level present at one month. These findings represent a model of dilated-type cardiomyopathy.     

Predictors of outcome in massive upper gastrointestinal hemorrhage

We reviewed 100 consecutive cases of massive upper gastrointestinal hemorrhage (UGIH). The criteria for inclusion were a decrease in hematocrit greater than or equal to 6%, unstable vital signs, and greater than or equal to units of blood transfused (16 +/- 18 units, mean +/- SD). A multiple regression analysis of 96 variables was employed to determine the most accurate predictors of outcome. The overall mortality was 35%. Hospital status (whether the patient was an inpatient or outpatient when the UGIH began) showed a striking association with mortality (70% for inpatients vs. 22% for outpatients, p less than 0.001). Nonsurvivors also had a greater number of life-threatening diseases than survivors (1.4 +/- 1.1 vs. 0.3 +/- 0.5, p less than 0.001) and greater transfusion requirements (27 +/- 20 units vs. 10 +/- 13 units, p less than 0.001). Age, the presence of cirrhosis, and recent excessive alcohol intake were not important risk factors. At presentation, the most reliable predictor of a fatal outcome was the brevity of the interval between the onset of bleeding and the initiation of a medical work-up. The primary predictor when considering the entire hospitalization was the number of life-threatening diagnoses. Our data indicate that stratification for hospital status and for other potentially predictive risk factors should be incorporated in future trials of therapy for UGIH.     

Small bowel diverticulosis: An overlooked entity

Opinion statement Small bowel diverticulosis (SBD) is a rare entity. Most cases of diverticulosis are asymptomatic. SBD is often discovered incidentally during contrast studies and endoscopy. When patients report chronic gastrointestinal symptoms such as abdominal pain, bloating, flatulence, and anemia, SBD is often an overlooked diagnosis. Patients requiring treatment for SBD are those with complications such as malabsorption, hemorrhage, obstruction, and acute inflammation with abscess or rarely perforation. Malabsorption can be managed with broad-spectrum antibiotics and vitamin supplementation. Hemorrhage is treated conservatively with resuscitation efforts, but recurrent bleeding requires surgery. Enteroliths causing obstruction in the duodenum can be relieved by endoscopy, that is, by manipulation, but jejunoileal obstruction requires a resection. Pseudoobstruction may be managed with prokinetics such as metoclopramide, erythromycin, and the 5-hydroxytryptamine 4 agonist tegaserod. Uncomplicated cases of SBD are treated with bowel rest and antibiotics. However, perforation or abscess formation not amenable to percutaneous drainage mandates surgical resection. Any patient with a triad of anemia, abdominal pain, and an abdominal radiograph with dilated loops of small bowel merits SBD in the differential diagnosis.     

Characterization of the TPR-MET oncogene p65 and the MET protooncogene p140 protein-tyrosine kinases.

The proteins encoded by the human TPR-MET oncogene (p 65tpr-met) and the human MET protooncogene (p140met) have been identified. The p65tpr-met and p140met, as well as a truncated TPR-MET product expressed in Escherichia coli, p50met, are autophosphorylated in vitro on tyrosine residues. Using the immunocomplex kinase assay, p140met activity was detected in various human tumor epithelial cell lines. In vivo, p65tpr-met is phosphorylated on both serine and tyrosine residues, while p140met is phosphorylated on serine and threonine. p140met is labeled by cell-surface iodination procedures, suggesting that it is a receptor-like transmembrane protein-tyrosine kinase.     

Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs

The objective of this study was to evaluate human immunodeficiency virus (HIV) counseling, testing, and referral practices of emergency department health care professionals (i.e., medical doctors [MD], physician assistants [PA], nurse practitioners [NP], and registered nurses [RN]) for patients presenting with other sexually transmitted diseases (STD). All health care professionals from 10 emergency departments in a northeastern county were asked to complete an anonymous survey. The surveys were returned by 154 (41%) health care professionals (RN = 99, NP = 5, PA = 7, MD = 39, other = 4). The average years in practice were 11. Only 7% of respondents were certified to provide state mandated HIV pretest counseling (certification not required for MD). Respondents reported caring for an average of 13 patients per week with suspected STD. Fifty-five percent of respondents reported that they always or usually warn STD patients of their HIV risk, yet only 10% always or usually encouraged these patients to consent to HIV testing in their emergency department (RN = 7%, NP = 25%, PA = 0%, MD = 16%). Reasons for not offering HIV testing in their emergency department were follow-up concerns (51%), not certified to provide pretest/posttest counseling (45%), and too time consuming (19%). Twenty-seven percent of respondents indicated HIV testing was not available in their emergency department despite all hospital laboratories reporting HIV testing capability. Ninety-three percent of respondents were aware that confidential testing sites were available, but only 35% always or usually referred patients not tested in the emergency department elsewhere for testing. Emergency department health care professionals frequently fail to provide HIV counseling, testing, and/or referral for patients with suspected STD.