Caring for patients wanting a home death.
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Attitude to Death↗
Biomedical subjects
J Todd
Publications and source records attributed to J Todd.
Graves' disease following successful treatment of severe aplastic anaemia with antilymphocyte globulin.
This case report is only the third report of thyroid dysfunction following the administration of anti-lymphocyte globulin for severe aplastic anaemia. It is the first report of the development of Grave's disease. We discuss a possible mechanism by which this may occur and highlight instances of other immune-mediated diseases occurring in ALG treated patients.
Adult↗
KCS1 encodes a fatty acid elongase 3-ketoacyl-CoA synthase affecting wax biosynthesis in Arabidopsis thaliana.
An Arabidopsis fatty acid elongase gene, KCS1, with a high degree of sequence identity to FAE1, encodes a 3-ketoacyl-CoA synthase which is involved in very long chain fatty acid synthesis in vegetative tissues, and which also plays a role in wax biosynthesis. Sequence analysis of KCS1 predicted that this synthase was anchored to a membrane by two adjacent N-terminal, membrane-spanning domains. Analysis of a T-DNA tagged kcs1-1 mutant demonstrated the involvement of the KCS1 in wax biosynthesis. Phenotypic changes in the kcs1-1 mutant included thinner stems and less resistance to low humidity stress at a young age. Complete loss of KCS1 expression resulted in decreases of up to 80% in the levels of C26 to C30 wax alcohols and aldehydes, but much smaller effects were observed on the major wax components, i.e. the C29 alkanes and C29 ketones on leaves, stems and siliques. In no case did the loss of KCS1 expression result in complete loss of any individual wax component or significantly decrease the total wax load. This indicated that there was redundancy in the elongase KCS activities involved in wax synthesis. Furthermore, since alcohol, aldehyde, alkane and ketone levels were affected to varying degrees, involvement of the KCS1 synthase in both the decarbonylation and acyl-reduction wax synthesis pathways was demonstrated.
3-Oxoacyl-(Acyl-Carrier-Protein) Synthase↗
Antibody to herpes simplex virus type 2 as a marker of sexual risk behavior in rural Tanzania.
A serosurvey was conducted in a random sample of 259 women and 231 men in 12 rural communities in Mwanza Region, Tanzania, using a type-specific ELISA for Herpes simplex virus type 2 (HSV-2) infection. Seroprevalence rose steeply with age to approximately 75% in women >=25 years old and 60% in men >=30. After adjusting for age and residence, HSV-2 prevalence was higher in women who were married, in a polygamous marriage, Treponema pallidum hemagglutination assay (TPHA)-positive, had more lifetime sex partners, or who had not traveled. Prevalence was higher in men who were married, had lived elsewhere, had more lifetime partners, had used condoms, or were TPHA-positive. HSV-2 infection was significantly associated with recent history of genital ulcer. The association between HSV-2 infection and lifetime sex partners was strongest in those <25 years old in both sexes. This association supports the use of HSV-2 serology as a marker of risk behavior in this population, particularly among young people.
Adolescent↗
Changes in HIV/AIDS education, knowledge and attitudes among Scottish 15-16 year olds, 1990-1994: findings from the WHO: Health Behaviour in School-aged Children Study (HBSC).
There is concern about the high prevalence of adolescent sexual health problems, such as sexually transmitted diseases (STDs) and unwanted pregnancies, that currently exist in the UK. If young people are to reduce their risk from HIV/AIDS and other STDs it is imperative, in the first instance, they know what the risks are and how they can avoid them. However, effective school-based sex education can only be delivered if there are accurate data on young people's current levels of knowledge and existing sex education needs. This paper details findings from the WHO: Health Behaviours of School-aged Children Study on the changes that have occurred between 1990 and 1994 in Scottish school-children's knowledge, attitudes and perceived educational needs in relation to HIV/AIDS. There have been significant changes in knowledge and attitudes that may affect their sexual behaviour, e.g. in their attitudes to condom use, risk of HIV/AIDS and other STDs, and also other sexual health problems, such as the risk of unwanted pregnancies and abortions. Finally, areas that require future research and recommendations for future sexual health education interventions are highlighted.
Adolescent↗
Venous thromboembolic disease and combined oral contraceptives: A re-analysis of the MediPlus database.
In October 1995 the Committee on Safety of Medicines advised UK doctors and pharmacists that oral contraceptives containing desogestrel and gestodene were associated with double the risk of venous thromboembolic events (VTE) compared to pills containing other progestogens. In 1997 data was analysed from the MediPlus database of UK general practitioner records, which reported odds ratios for desogestrel and gestodene lower than that for levonorgestrel. Here the results of a more stringent nested case control analysis on the MediPlus database are reported. The study was larger and cases were verified. A crude incidence of idiopathic VTE was found amongst users of combined oral contraceptives of 4.6 per 10 000 exposed women years. Using levonorgestrel 150 microg + ethinyloestradiol 30 microg as reference, non-significant odds ratios of 1.1 (0.5-2.6) for desogestrel 150 microg + ethinyloestradiol 30 microg and 1.1 (0.5-2.4) for gestodene 75 microg + ethinyloestradiol 30 microg were found. The results of this study show no significant difference in risk between different formulations of combined oral contraceptive.
Adolescent↗
An overview: health centers at the crossroads.
Health centers' flexibility in meeting changing political and economic demands throughout their history has allowed them to evolve and expand. In 1997, they served 8.3 million patients--40% uninsured and 35% Medicaid recipients. Thus far, most centers have been able to balance their mission of serving the underserved with economic survival. However, their future viability is threatened, by downward pressure on revenues, coinciding more frequently with growing numbers of uninsured patients. The centers' value as essential safety net providers, their adaptation to marketplace realities and their performance in terms of cost and quality outcomes appears to justify the increased subsidy that may be needed for continued operation.
Community Health Centers↗
Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection.
CONTEXT: Animal model studies have demonstrated the failure of penicillin to cure Streptococcus pyogenes myositis and have suggested that clindamycin is a more effective treatment. OBJECTIVE: To determine the most effective antibiotic treatment for invasive S. pyogenes infection in humans. DESIGN AND SETTING: We conducted a retrospective review of the outcomes of all inpatients from 1983 to 1997 treated for invasive S. pyogenes infection at Children's Hospital. PATIENTS: Fifty-six children were included, 37 with initially superficial disease and 19 with deep or multiple tissue infections. MAIN OUTCOME MEASURE: Lack of progression of disease (or improvement) after at least 24 h of treatment. RESULTS: The median number of antibiotic exposures was 3 per patient (range 1 to 6) with clindamycin predominating in 39 of 45 courses of protein synthesis-inhibiting antibiotics and beta-lactams predominating amongst the cell wall-inhibiting antibiotics in 123 of 126 of the remainder. Clindamycin was often used in combination with a beta-lactam antibiotic. Overall there was a 68% failure rate of cell wall-inhibiting antibiotics when used alone. Patients with deep infection were more likely to have a favorable outcome if initial treatment included a protein synthesis-inhibiting antibiotic as compared with exclusive treatment with cell wall-inhibiting antibiotics (83% vs. 14%, P = 0.006) with a similar trend in those with superficial disease (83% vs. 48%, P = 0.07). For those children initially treated with cell wall-inhibiting antibiotics alone, surgical drainage or debridement increased the probability of favorable outcome in patients with superficial disease (100% vs. 41%, P = 0.04) with a similar trend in a smaller number of deep infections (100% vs. 0%, P = 0.14). CONCLUSIONS: This retrospective study suggests that clindamycin in combination with a beta-lactam antibiotic (with surgery if indicated) might be the most effective treatment for invasive S. pyogenes infection.
Adolescent↗
Use of unlicensed medication in palliative medicine.
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Drug Approval↗
Active immunization of patients with HIV infection: a study of the effect of VaxSyn, a recombinant HIV envelope subunit vaccine, on progression of immunodeficiency.
Infection with the human immunodeficiency virus (HIV) leads to a progressive immunodeficiency characterized by decreasing levels of CD4+ T lymphocytes. VaxSyn, a vaccine based on the recombinant envelope glycoprotein subunit (rgp160) of HIV-1IIIB, was used to immunize HIV-infected patients to determine whether its administration was beneficial with respect to slowing disease progression. A 3-year multicenter, randomized, placebo-controlled, double-blinded, efficacy and safety trial of repeated immunization with VaxSyn was used to evaluate the long-term impact on the progression of immunodeficiency. VaxSyn in alum, or alum alone, was given to 278 HIV-infected asymptomatic individuals with initial CD4 counts of > or =500 cells/mm3. Clinical findings, the CD4 count, and both virological and immunological parameters were followed. No significant differences were observed between the treatment and placebo control groups in rate of CD4 T cell decline, time to initiation of antiretroviral therapy, incidence of opportunistic infections, HIV RNA plasma viremia, HIV viral infectivity as measured by quantitative HIV coculture assay, and death. This study revealed no effect on either clinical or laboratory virological parameters from the administration of VaxSyn.
AIDS Vaccines↗
Sexual and reproductive health among primary and secondary school pupils in Mwanza, Tanzania: need for intervention.
A cross-sectional questionnaire survey was conducted among 892 randomly selected pupils, aged 12 and above, attending 18 primary schools (PS) and five secondary schools (SS) in four communities of Mwanza Region in Tanzania. The goals were to assess the level of knowledge adolescents have about sexual and reproductive health (SRH), to assess the magnitude of SRH problems and to help design appropriate interventions. Median age of respondents was 15 years (range 12-20 years) and 14 years (range 12-19 years) for PS boys and girls, respectively, and 19 years (range 16-24 years) and 17 years (range 14-19 years) for SS boys and girls. Eighty per cent of PS boys and 68% of PS girls were already sexually active; the corresponding figures were 89% for SS boys and 48% for SS girls. Vaginal sex was the most common first sexual act reported by SS pupils, but 40% of PS pupils reported orogenital sex and 9% of PS pupils reported anal sex as their first sexual act. Almost half of PS girls have had sex with adults, including teachers and relatives. 'Forced sex' was reported by nearly half of PS and SS girls. Fourteen per cent of PS girls had already been pregnant, and over half of these pregnancies ended in illegally induced abortions. Despite a rather high (30%) lifetime rate of condom use, 33% and 25% of PS boys and girls, respectively, reported past experience of sexually transmitted diseases (STDs). STD rates were lower among SS pupils who had a better knowledge of STDs/HIV and fertility issues and reported higher condom use. The survey demonstrated the great vulnerability of school-going adolescents of Mwanza Region to consequences of sexual intercourse. The response should urgently come in the from of comprehensive adolescent SRH programmes.
Adolescent↗
Absolute copy number and relative change in determinations of human immunodeficiency virus type 1 RNA in plasma: effect of an external standard on kit comparisons.
Use of a common set of human immunodeficiency virus type 1 (HIV-1) RNA standards eliminated differences among absolute HIV-1 RNA copy number estimates made with three commercially available assays. The relative changes in the viral RNA levels determined by the commercial assays were similar and were unaffected by the use of a common set of standards.
Female↗
Methicillin-resistant Staphylococcus aureus infection in palliative care.
Our objective was to assess the impact of methicillin-resistant Staphylococcus aureus (MRSA) infection in palliative care. The study was conducted at three hospices in south London, totalling 118 beds, and the following two methods were used. Firstly, a retrospective review of the notes of patients who were known to be MRSA positive at admission or were subsequently found to be MRSA positive was taken. Secondly, a prospective study of factors influencing bed occupancy in one hospice was conducted. The proportion of admissions who were MRSA positive ranged from 4% to 8% in the three hospices. Seven of the 43 patients who had MRSA suffered clinically significant infections. Risk factors for colonization and bacteraemia were similar to the general population. Sites of infection were variable and multiple and treatment regimes for eradication were variable, with varying outcomes. MRSA infection appeared to delay admission because of the need for single rooms, of which there are few Time spent cleaning rooms after discharge or death also reduced the number of available beds. It was concluded that MRSA infection is associated with significant morbidity in a small number of palliative care patients. Beds unavailable because of MRSA should be considered in bed occupancy figures, otherwise bed occupancy may appear artificially low. The psychological and financial impact of the infection in palliative care patients needs further evaluation.
Adult↗
Validation of a WHO algorithm with risk assessment for the clinical management of vaginal discharge in Mwanza, Tanzania.
OBJECTIVES: (i) To determine the microbial aetiologies of vaginal discharge in STD clinic and antenatal clinic (ANC) attenders; (ii) to evaluate the performance and costs of a new WHO algorithm for the detection of gonococcal and chlamydial infections in women complaining of vaginal discharge and/or genital itching, using a risk assessment. METHODS: Two groups were enrolled: (i) 395 consecutive female patients attending a hospital outpatient clinic complaining of genital discharge or itching; and (ii) 628 consecutive pregnant women reporting at an urban ANC these symptoms. Patients were interviewed by a nurse, who applied the WHO risk score. They were then referred to the study room for interview concerning the same and other risk factors, examined, and sampled for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), and Candida albicans (CA). Sensitivity, specificity, positive predictive value, overtreatment and correct treatment rates, and cost of drugs per true case treated were estimated. RESULTS: The prevalence of NG and/or CT infections was 11.4% and 8% at the STD clinic and the ANC respectively. The most prevalent pathogens were CA (38% at both clinics) and TV (25% at the STD clinic and 34% at the ANC). The sensitivity of the WHO algorithm for NG and/or CT was 62% at the STD clinic and 46% at the ANC, and the specificities were 64% and 84% respectively. The operational feasibility of the method was good. The cost of drugs per true case treated in applying the risk assessment approach was $3.5 among nonpregnant women and $5.0 among pregnant women. This compared favourably with respective costs of $8.8 and $25.0 in applying the syndromic management alone. CONCLUSIONS: The WHO risk assessment algorithm for the diagnosis of NG and/or CT infections among women complaining of genital discharge can considerably reduce overtreatment of NG and/or CT in both pregnant and non-pregnant women, but in this study it failed to identify 38% of non-pregnant and 54% of pregnant women with these infections. The elements of the risk score may need adjustment in different settings.
Adult↗
Risk scores to detect cervical infections in urban antenatal clinic attenders in Mwanza, Tanzania.
BACKGROUND: Detection and management of gonococcal and/or chlamydial infections in women is a challenge, particularly in developing countries where laboratory tests are not always available. The World Health Organisation (WHO) has developed a risk assessment approach to identify cervical infections among women complaining of vaginal discharge. We have evaluated this approach as a screening strategy among women attending an urban antenatal clinic (ANC) in Tanzania. OBJECTIVES: (i) To measure the prevalence of pathogens associated with sexually transmitted diseases (STD) and reproductive tract infections (RTI) in an urban population of ANC attenders in Tanzania; (ii) to examine characteristics of pregnant women associated with cervical infections; and (iii) to evaluate the performance of a WHO risk assessment algorithm and alternative risk scores for the detection of cervical infections in pregnant women. METHODS: A systematic sample of 660 pregnant women reporting for routine antenatal care at an urban clinic was enrolled. Women were interviewed by a nurse, who applied the WHO risk score. They were referred to a study room for interview about sociodemographic and behavioural factors, examination, and sampling for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Candida albicans, and bacterial vaginosis. Sensitivity, specificity, positive predictive value (PPV), and theoretical cost per true case treated were estimated for the diagnosis of cervical infection with N gonorrhoeae and/or C trachomatis for the WHO and other risk scores. RESULTS: The prevalence of any vaginal or cervical infection was 68%. Prevalence rates of various pathogens were: C albicans 39%, T vaginalis 16%, bacterial vaginosis 24%, N gonorrhoeae 2.3%, C trachomatis 5.9%, any cervical infection (N gonorrhoeae and/or C trachomatis) 7.4%. The WHO score identified only five of 49 women with N gonorrhoeae and/or C trachomatis (sensitivity 10.2%). The specificity and the PPV were 92% and 9.8% respectively. The theoretical cost per true case treated on the basis of the WHO score was over $18. Several risk factors were associated with cervical infection on univariate analysis, but only six remained significant at the 10% level after multivariate analysis. These were: never use of contraceptives (OR 3.09), more than one partner in the past 3 months (OR 3.32), partner with symptoms of genital discharge syndrome (GDS) (OR 7.55), frothy vaginal discharge (OR 1.88), 5-19 polymorphonucleocytes per high power field on cervical smear (OR 3.28), or more than 20 polymorphonucleocytes per high power field (OR 16.08), and wet preparation showing evidence of T vaginalis infection (OR 1.96). Scores based on these variables failed to attain high sensitivities or PPVs (all below 40%) although the costs per true case treated were cheaper than for the WHO score. CONCLUSION: Risk assessment for the screening and management of N gonorrhoeae and/or C trachomatis among women presenting at routine antenatal services appears feasible and acceptable, but of limited value in this population because of its low sensitivity. The optimal risk score may vary considerably from one place to another. The quest for simple, cheap, and reliable tests to diagnose N gonorrhoeae and C trachomatis infections still remains a high priority on the international STD technology research agenda.
Adult↗
Peripherally inserted central catheters.
Peripherally inserted central catheters (PICCs) can meet the needs of patients requiring short- to intermediate-term intravenous therapy in a variety of settings. PICCs minimise insertion and catheter-related complications when compared to other central venous access devices (CVADs). PICCs have been introduced in the UK mainly through innovative advanced nursing practice.
Catheterization, Central Venous↗
Family cell lines available for research--an endangered resource?
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Biological Specimen Banks↗
Patterns of sexual behaviour in a rural population in north-western Tanzania.
The HIV epidemic in sub-Saharan Africa has been characterised by the predominance of heterosexual transmission. Patterns of sexual behaviour have been implicated in the spread of the epidemic, but few quantitative data are available on sexual behaviour in rural populations in Africa. This paper reports data from a survey of 1117 adults aged 15-54 years selected randomly from twelve rural communities in Mwanza Region, Tanzania. Sexual debut occurred early, 50% of women and 46% of men reporting first sex before age 16. On average, women married 1.8 years and men 6.1 years after their sexual debut. In women, age at sexual debut appears to have increased over time, in parallel with an increase in age at first marriage. Men were generally married later, to women around five to ten years younger than themselves. Marital dissolution and remarriage were common in both sexes. Reported numbers of sexual partners were compared with those recorded in a population survey in Britain. More men reported 10 or more lifetime partners, or three or more partners in the past year, in rural Mwanza (48% and 29%) than in Britain (24% and 6%). Women reported fewer partners, and results were broadly similar to British data. Casual sex during the past year was reported by 53% of the men and 15% of the women, but only 2% of men reported sexual contact with bar girls or commercial sex workers. Only 20% of men and 3% of women had ever used a condom. Interventions are needed to reduce the high levels of sexual partner change and casual sex, and low levels of condom use, recorded in this rural population. Targeting of interventions to traditional "core groups" may be of limited value in rural areas, and additional strategies are needed, focusing particularly on teenagers who are at high risk of HIV and other sexually transmitted diseases.
Adolescent↗