Making the choice: the translation of global HIV and infant feeding policy to local practice among mothers in Pune, India

In 2003, India had over 5.1 million infected individuals living with HIV/AIDS. The percentage of all HIV cases attributed to perinatal transmission has been increasing steadily from 0.33% of total cases in 1999 to 2.80% in 2004. Recent statistics indicate that over 130,000 infants have been infected through this route. Despite recent advances in reducing in utero and interpartum transmission with the use of antiretrovirals, there is a critical need to make infant feeding safer. Current UNAIDS/WHO/UNICEF recommendations stress avoidance of all breast-feeding if replacement feeding fulfills the key requirements of being affordable, feasible, acceptable, sustainable, and safe. In this paper, we examine how the UNAIDS/WHO/UNICEF recommendations have been actualized within the context of an urban government hospital in India. The documented patterns of infant feeding by HIV-positive mothers in Pune, India, from 2000 to 2004, highlight the complexities of making an informed and healthy choice under suboptimal conditions. The data indicate that interpersonal variations in the key requirements greatly influence the optimal practice to minimize mortality risks. Moreover, local information on health outcomes is crucial to tailoring policy recommendations to save lives. We propose the development of a decision-making algorithm that includes factors affecting mother-to-infant transmission, including site-specific data on health risks to the mother and the child. Such an algorithm would allow identification of the healthiest feeding choice and would minimize the pitfalls of promoting homogeneous practices lacking site-specific evidence-based evaluation.     

An innovative technique to cut and extract loose bent Kuntscher nail

Removal of a grossly deformed nail can be a serious and perplexing problem. We report an innovative technique to cut and extract a loose bent Kuntscher nail. The technique is simple and effective; can be used in peripheral hospitals where advanced gadgetries may not be present.     

The net transfer of transplant organs across race, sex, age, and income

PURPOSE: To determine how sociodemographic characteristics influence both access to transplantation and organ donation. METHODS: For all transplants in the United States from 1996 to 2001, donor-recipient pairs were categorized as white-white, white-black, black-white, or black-black. The difference in the percentage of white-black versus black-white pairs was calculated as a measure of the net transfer of organs from one racial group to another. A similar approach was used to examine the net transfer of organs across other sociodemographic categories. RESULTS: Among cadaveric renal transplants, 66% of donor-recipient pairs were white-white, 23% were white-black, 5% were black-white, and 6% were black-black. Thus, there was an 18% net transfer of organs from white donors to black recipients (23% minus 5%). Among living donor transplants involving spouses, there was a 36% net transfer from wives to husbands. Among all cadaveric transplants, there was a 36% to 68% net transfer from younger donors to older recipients. Among cadaveric nonrenal transplants, there was a 7% to 18% net transfer from lower-income donors to higher-income recipients. CONCLUSION: The sociodemographic characteristics of persons who donate organs and those who benefit from organ transplantation differ markedly. Efforts to improve access and increase donation should address these differences.     

Serum albumin concentration and clinical assessments of nutritional status in hospitalized older people: different sides of different coins?

OBJECTIVES: Malnutrition is common in hospitalized older people, and some have advocated routine nutritional screening. Serum albumin and clinically based measures such as the Subjective Global Assessment (SGA) are two potential methods of assessing nutritional status in hospitalized older people. Although both measures are strongly associated with prognosis, it is not clear whether they measure similar or different clinical constructs. Our goal was to assess the degree of clinical concordance between these measures. DESIGN: Cross-sectional study. SETTING: The inpatient medical service of a university teaching hospital. PARTICIPANTS: Three hundred eleven older (aged > or =70) patients. MEASUREMENTS: We independently measured serum albumin and performed the SGA on 311 older medical patients (aged > or =70) shortly after hospital admission. The SGA classified patients as well nourished, moderately malnourished (generally 5% weight loss with mild examination findings), or severely malnourished (generally >10% weight loss with marked findings) based on findings from a directed history and examination. We compared the distribution of clinical rating in patients with differing albumin levels and examined diagnostic test characteristics of albumin as a predictor of malnutrition as diagnosed on clinical examination. RESULTS: The mean age of subjects was 79.9; 64% were women, 42% were African American. Discordance between albumin and the SGA was common. For example, 38% of patients with albumin levels of 4.0 g/dL or higher were at least moderately malnourished on the SGA, whereas 28% of patients with albumin levels lower than 3.0 g/dL were rated as well nourished. No choice of albumin level was associated with simultaneously acceptable sensitivity and specificity as a predictor of SGA ratings. The area under the receiver operating characteristic curve for albumin level as a predictor of SGA rating was 0.58, suggesting that the ability of either measure to predict the other measure is only marginally better than chance. CONCLUSIONS: Albumin levels and clinical assessments, two possible measures of nutritional status in hospitalized older people, are often discordant. To some extent, this reflects limitations in both measures as markers of nutritional status. However, it also demonstrates that, in this population, albumin and clinical assessments of nutritional status reflect fundamentally different clinical processes.     

Is high-sensitivity C-reactive protein an effective screening test for cardiovascular risk?

We evaluate the suggestion that high-sensitivity C-reactive protein testing be used for risk assessment in the primary prevention of cardiovascular disease, using the criteria proposed by the Guide to Clinical Preventive Services developed by the US Preventive Services Task Force. We conclude that at present, none of the 3 major criteria--accuracy, reliability, and likelihood of beneficial intervention--are satisfied.     

In vivo hepatocyte MR imaging using lactose functionalized magnetoliposomes

The aim of this study was to assess a novel lactose functionalized magnetoliposomes (MLs) as an MR contrast agent to target hepatocytes as well as to evaluate the targeting ability of MLs for in vivo applications. In the present work, 17 nm sized iron oxide cores functionalized with anionic MLs bearing lactose moieties were used for targeting the asialoglycoprotein receptor (ASGP-r), which is highly expressed in hepatocytes. Non-functionalized anionic MLs were tested as negative controls. The size distribution of lactose and anionic MLs was determined by transmission electron microscopy (TEM) and dynamic light scattering (DLS). After intravenous administration of both MLs, contrast enhancement in the liver was observed by magnetic resonance imaging (MRI). Label retention was monitored non-invasively by MRI and validated with Prussian blue staining and TEM for up to eight days post MLs administration. Although the MRI signal intensity did not show significant differences between functionalized and non-functionalized particles, iron-specific Prussian blue staining and TEM analysis confirmed the uptake of lactose MLs mainly in hepatocytes. In contrast, non-functionalized anionic MLs were mainly taken up by Kupffer and sinusoidal cells. Target specificity was further confirmed by high-resolution MR imaging of phantoms containing isolated hepatocytes, Kupffer cell (KCs) and hepatic stellate cells (HSCs) fractions. Hypointense signal was observed for hepatocytes isolated from animals which received lactose MLs but not from animals which received anionic MLs. These data demonstrate that galactose-functionalized MLs can be used as a hepatocyte targeting MR contrast agent to potentially aid in the diagnosis of hepatic diseases if the non-specific uptake by KCs is taken into account.