Mandatory screening of pregnant women for human immunodeficiency virus.
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Centers for Disease Control and Prevention, U.S.↗
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Medically assisted reproduction in the presence of chronic viral diseases.
Teams practising medically assisted reproduction techniques try to avoid viruses as much as possible. Attitudes towards chronic carriers of viruses are rapidly changing, especially for human immunodeficiency virus (HIV) patients. We focus our attention on the legitimacy of systematic screening before assisted reproductive techniques and the need for specialized approaches including an adapted laboratory for viral hazards as well as the need for a multidisciplinary team. Specificities of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV) carriers and the hypothesis of a reduced fertility potential are discussed. Are male HIV carriers a new indication for assisted reproductive techniques in order to prevent virus transmission? It is largely proven that sperm gradient preparation techniques efficiently decrease viral loads and therefore have a protective effect on contamination risk during assisted reproductive techniques. Although a few thousand assisted reproductive technique cycles were performed in the world for this indication without contamination, it is still too early to demonstrate that this technology is fully safe. Two examples of contaminations during insemination are examined. Many questions remain unresolved, such as the lack of standardized techniques for semen preparation or virus detection or the relative merits of intrauterine insemination or ICSI to prevent HIV contamination during assisted reproductive techniques. The authors plead for well-structured, separate programmes of care linked to research objectives.
Acquired Immunodeficiency Syndrome↗
Human immunodeficiency virus infection in the US Air Force: seroconversions, clinical staging, and assessment of a T helper cell functional assay to predict change in CD4+ T cell counts.
As of January 1990, 933 persons with human immunodeficiency virus type 1 (HIV-1) infection were clinically evaluated at Wilford Hall US Air Force (USAF) Medical Center. The Walter Reed HIV staging system was used in these evaluations to describe disease status and progression. Most persons were diagnosed through mandatory HIV testing in the USAF and were asymptomatic at the time of diagnosis. As of May 1990, 161 HIV-positive seroconverters (estimated overall seroconversion rate of 0.156/1000 person-years between 30 June 1988 and 1 July 1990) had been identified among active-duty USAF personnel, as they had previously tested negative for antibody to HIV. Men constitute 95% of the USAF HIV-positive population. An in vitro T helper cell functional assay was assessed to predict rate of CD4+ T cell decline over the subsequent year (mean, 15 months) in patients with greater than 200 CD4+ T cells/mm3. This assay may prove useful for prognostication and comparisons of patients in clinical trials of anti-HIV interventions.
Adult↗
An estimate of the number of human immunodeficiency virus (HIV)-positive blood donations by HIV-seronegative donors in a northern Thailand HIV epicenter.
Despite mandatory antibody testing, human immunodeficiency virus (HIV) can be transmitted from HIV-infected blood that is seronegative. The objective of this study was to estimate the probability of HIV-infected blood donations during the seronegative "window period" in a northern Thailand HIV epicenter. Thus, a retrospective cohort of repeat blood donors was created. With the assumptions that the probability of HIV seroconversion is distributed uniformly between the last HIV-negative and the first HIV-positive donation and that the seronegative window is 45 days, the rate of window-period donations was calculated by multiplying the incidence by the window duration. Of 11,232 repeat donors, 273 seroconverted during 9,518,863 person-days of observation (i.e., a window-period donation rate of 1/775). There were more window-period donations among 21- to 30-year-old men and in donors replacing blood of friends or relatives. Additional measures are needed to reduce the high number of HIV-infected window-period donations.
Adolescent↗
Screening method for seventy psychoactive drugs or drug metabolites in serum based on high-performance liquid chromatography--electrospray ionization mass spectrometry.
A screening method for 70 psychoactive drugs or drug metabolites in human serum by solid-phase extraction with subsequent high-performance liquid chromatography and electrospray ionization mass spectrometry was developed. Enhanced selectivity of detection was obtained by collision-induced dissociation using two different skimmer voltages for the individual scan. The mass spectra and the retention times of the compounds were incorporated into a self-generated spectra library for identification in screening experiments. The detection limits were found to be between 0.1 and 5 ng/mL serum for the majority of the compounds when measured in the selected ion mode. Because of the very small serum concentrations and the rather low extraction yield, lysergide could not be detected in this way. It was demonstrated with 140 serum samples from alcohol-related traffic cases that this method is suitable for a routine screening in a forensic laboratory.
Accidents, Traffic↗
Influence of Helix pomatia enzyme preparations on the oxidative conversion of some clostebol acetate metabolites in urine.
Clostebol acetate (4-chloro-testosterone acetate) is an anabolic steroid used for fattening purposes in cattle breeding. To safeguard public health, its use has been prohibited by the European Commission since 1986. Screening for its urinary metabolites is therefore an important tool for the control of possible violations. Because those metabolites appear conjugated to glucuronic acid or sulfate, deconjugation prior to analysis is necessary. This work describes the variability in results seen with the use of various commercial preparations of Helix pomatia (SHP) for enzymatic hydrolysis of the conjugates. A simultaneous oxidative side reaction was observed, converting metabolites with a 3-OH-4-ene structure into a 3-oxo-4-ene structure. This was not observed when samples were incubated without enzyme or in the presence of heat-inactivated SHP. GC-MS analysis revealed oxidation of some metabolites of clostebol acetate, 4-chloro-4-androsten-3alpha-ol-17-one and 4-chloro-4-androsten-3alpha,17beta-diol, changing them into other metabolites, 4-chloro-4-androsten-3,1 7-dione and clostebol (4-chloro-testosterone), respectively. Based on the difference in cross-reactivities of the antibodies for these metabolites, comparative analysis in enzyme immunoassay, following enzymatic hydrolysis, confirmed this transformation. This oxidative conversion phenomenon could be of great importance when considering the choice or target analytes for screening bovine urine.
Animals↗
Cisplatin ototoxicity: the importance of baseline audiometry.
The role and optimal use of audiometry in monitoring for cisplatin ototoxicity are incompletely defined. Audiograms were obtained from 217 patients before treatment with cisplatin-based chemotherapy for cancers of the esophagus, lung, or head and neck. Posttreatment audiometry then was conducted in 53 of these patients. Chemotherapy consisted of two (87%) or three (13%) courses of cisplatin at a dose of 20 mg/m2/day given as a continuous intravenous infusion over 4 days. Simultaneous 5-fluorouracil or paclitaxel also was given, and 38% received concurrent radiation therapy to the head and neck. Air-conduction thresholds for each ear were obtained at 250, 500, 1000, 2000, 4000, 6000, and 8000 Hz. Three three-frequency pure-tone averages (PTA) also were calculated. Framingham gender-specific, age-adjusted norms were used, beginning at age 60 to correct for presbycusis, and the upper limit of normal was calculated as the greater of the Framingham mean plus twice the standard error, or 25 dB. Hearing abnormality was defined as a threshold >10 dB above the norm for any PTA, or >20 dB above the norm for any individual frequency. Hearing loss was defined as an elevation over baseline threshold of >10 dB for any PTA or >20 dB for any individual frequency. Of the 217 patients who underwent baseline testing, 57 (26%) were found to have hearing abnormality in excess of the expected presbycusis. Post-cisplatin audiograms demonstrated hearing loss in 19 of the 53 retested patients (36%) when compared with their own baseline. As determined by tympanometry, none of these subjects had a conductive component to their hearing loss. These observations were independent of the duration of follow-up after treatment and of the total dose of cisplatin administered. The authors conclude that significant preexisting hearing abnormality is common in this patient population and that, even after low-dose cisplatin administration, additional hearing loss occurs frequently. Baseline testing is mandatory if follow-up studies are to be adequately interpreted.
Adult↗
Ethical and legal issues in perinatal HIV.
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Confidentiality↗
Human immunodeficiency virus and the orthopaedic surgeon.
Human immunodeficiency virus is a devastating disease that ends in death. The fear that it engenders in healthworkers and patients may be out of proportion to the risks involved but an emotional response to the dangers is understandable. However, a careful study of the risks, the adoption of high standards of practice, and control of the clinical environment probably can eliminate most of the risk. There is a clear conflict of interest between the maintenance of confidentiality for the infected person and the right to information of those with whom they come into contact. Mandatory clinical testing for human immunodeficiency virus is likely to become the most contentious medicolegal issue of the next decade.
Ethics, Medical↗
Disclosure of health care workers with HIV or AIDS.
Every health care organization should have clear policies about how employees with HIV/AIDS are to be accommodated under employment laws. Managers should be knowledgeable about discrimination laws in order to handle reactions of co-workers. Administrators must ensure that educational sessions are provided for all levels of staff. Informational brochures on HIV/AIDS should be available to families and to businesses and other community organizations.
HIV Infections↗
The Omega-Project--a comparison of two diagnostic strategies for risk- and cost-oriented management of dyspepsia.
OBJECTIVES: In dyspepsia few data are available from the primary care setting on how selective, risk-factor-oriented endoscopy compares with mandatory endoscopy in the diagnostic outcome and in direct and secondary costs. We studied this in a two-armed multicentre trial (omega-project) with primary care physicians. MATERIAL AND METHODS: Patients were enrolled and treated by primary care physicians and referred to a gastroenterologist for upper gastrointestinal endoscopy (UGE). Patients were enrolled in the study if they had had epigastric complaints for more than 1 month and no obvious signs or history of organic disease. In the first arm of the study endoscopy was mandatory, in the second selective, i.e. according to a predefined risk profile. Patients enrolled were treated with prokinetic drugs for 2 months. A further indication for endoscopy was non-response to treatment (reduction of the initial symptoms score by less than two-thirds) in the study with selective endoscopy and relapse within the 2-month follow-up period in both studies. The direct costs from number of consultations with the primary care physician, UGEs, number of prescriptions per patient and also absenteeism in days per week were carefully registered in both groups. RESULTS: All 172 patients of the mandatory endoscopy study and 203/656 patients enrolled in the selective endoscopy study had an UGE (125 at admission, 78 in the follow-up period). Patients were treated for 4 weeks (cisapride or domperidone) and thereafter followed for 8 weeks, at the end of the observation period the response rates were 80% and 79%, respectively. The prevalence of gastric cancers was similar in both groups (> 1%) but extrapolation from the data collected with compulsory endoscopy suggests that two-fifths of the anticipated peptic lesions remained undetected by following the selective strategy. The cost analysis revealed a 31% cost reduction with the selective strategy--in the Swiss cost system--through a reduction in the number of endoscopies by 67%. CONCLUSION: Selective UGE is cheaper and appears not to compromise the response to prokinetics; however, its diagnostic power is less than with mandatory UGE.
Adult↗
Forcing the task.
Although not generally included in public health curricula, public health policy formulation is essential to local agency public health operations. When public health measures are mandated by referendum of the electorate, such as the HIV exposure notification laws passed in California in 1988, health agencies must act prudently and quickly to formulate effective policies. We found it prudent to convene a task force that brought together the critical, albeit diverse, legal/judicial/health players. This action not only served to bring about consensus, but provided us with an opportunity to educate participants about the policy, and the implementation of appropriate communicable disease measures. Through consensus and education, we were able to implement the disclosure laws in a timely manner, create an atmosphere of trust, and enable a skilled and confident workforce.
California↗
Prevalence and incidence of HIV among incarcerated and reincarcerated women in Rhode Island.
This study explores recent temporal trends in HIV prevalence among women entering prison and the incidence and associated risk factors among women reincarcerated in Rhode Island. Results from mandatory HIV testing from 1992 to 1996 for all incarcerated women were examined. In addition, a case control study was conducted on all seroconverters from 1989 to 1997. In all, 5836 HIV tests were performed on incarceration in 3146 women, 105 of whom tested positive (prevalence, 3.3%). Between 1992 and 1996, the annual prevalence of HIV among all women known to be HIV-positive was stable (p = .12). Age >25 years, nonwhite race, and prior incarceration were associated with seropositivity. Of 1081 initially seronegative women who were retested on reincarceration, 12 seroconverted during 1885 person-years (PY) of follow-up (incidence, 0.6/100 PY). Self-reported injection drug use (IDU; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.3-10.1) was significantly associated with seroconversion, but sexual risk was not (OR, 1.1; 95% CI, 0.4-3.5). Incarceration serves as an opportunity for initiation of treatment and linkage to community services for a population that is at high risk for HIV infection.
Case-Control Studies↗
Fatalities due to intoxicated arrestees jumping out of moving police vehicles.
Fatalities resulting from emergency vehicle crashes are relatively rare. Mortality, particularly in the case of unbelted occupants, is relatively high. Data on drunken (handcuffed) arrestees jumping out of a moving police vehicle or the circumstances of such events have not been published. Two cases of such fatalities are described in this paper. Since these cases should be considered as "death in custody," may give rise to significant covering and speculation in the media, and may raise liability questions, they require an in-depth medicolegal investigation, including investigation of the crime scene, complete medicolegal autopsy/toxicology, and reconstruction of the event in the presence of an experienced forensic pathologist. From the 2 cases described in this paper, it appears that mechanical malfunctioning of the locking device of the door of the police vehicle and lack of controlling the actual lock-tied closing of the vehicle door (instead just assuming that it happened) may precipitate such cases. Auditory control by the police officers of the arrestee tampering with or manipulating the car door may be hampered by the background noise of the police vehicle, the on-board radio, and the use of a siren. Regular visual control and adequate control of the actual locking of the vehicle door are of paramount importance to prevent such mishaps. Reconstruction of the event in the presence of the forensic experts is mandatory to test the different hypotheses of the fatal event.
Accidents, Traffic↗
The validity of serologic tests for Trypanosoma cruzi and the effectiveness of transfusional screening strategies in a hyperendemic region.
BACKGROUND: This study aims at obtaining unbiased estimates of the sensitivity and specificity of existing screening tests for Trypanosoma cruzi and at simulating the effectiveness of alternative screening strategies at different prevalence rates. STUDY DESIGN AND METHODS: A systematic random sample of 400 was taken from 1200 banked serum samples of donors screened between August 1998 and January 1999 in Santa Cruz, Bolivia. Samples were tested with indirect hemagglutination test (IHA), indirect immunofluorescence assay (IFA), and four enzyme-linked immunosorbent assays (ELISAs). Sensitivity and specificity of tests were estimated through latent class analysis. RESULTS: The sensitivity of individual tests ranged from 96.5 to 100 percent, and their specificity from 87.0 to 98.9 percent. Combinations of two tests used in parallel would, even at 40 percent prevalence, only miss approximately 1 infected unit per 10,000 screened. At 5 percent prevalence, however, they would yield 75 to 120 false-positive units per 1000 units screened. Parallel testing with IHA plus ELISA or with IHA plus IFA is marginally more cost-effective, compared to single IHA testing, than single ELISA or single IFA testing, regardless of the T. cruzi prevalence. CONCLUSIONS: Routine blood donor screening for T. cruzi with a single test results in unacceptable numbers of false-negative samples in highly endemic areas or in at risk population groups. Adding a second test seems mandatory, but which one to choose depends on local cost components and feasibility.
Animals↗
Unconditional hospitality: HIV, ethics and the refugee 'problem'.
Refugees, as forced migrants, have suffered displacement under conditions not of their own choosing. In 2000 there were thought to be 22 million refugees of whom 6 million were HIV positive. While the New Zealand government has accepted a number of HIV positive refugees from sub-Saharan Africa, this hospitality is under threat due to negative public and political opinion. Epidemic conditions raise the social stakes attached to sexual exchanges, contagion becomes a major figure in social relationships and social production, and the fears of the contagious nature of those 'just off the plane' connect refugees to an equally deep-seated fear of racial miscegenation. Jacques Derrida's notion of unconditional hospitality is a dream of a democracy which would have a cosmopolitan form. This means that one cannot decide in advance which refugees one might choose to resettle. This paper will use Derrida's notion of unconditional hospitality to emphasise the fragility of HIV positive refugees' position, caught between becoming newly made New Zealand subjects while at the same time having that subjecthood threatened. For Derrida, both ethics and politics demand both an action and a need for a thoughtful response (a questioning without limit).
Africa South of the Sahara↗
Widespread skin necrosis associated with unfractionated heparin therapy in a patient under chronic coumarin anticoagulation.
Coumarins and heparins are commonly used for temporary or long-term anticoagulation. These molecules have potentially devastating side-effects, including widespread skin necrosis. We report the case of an elderly patient under oral anticoagulation with coumarins, who developed widespread necrotic cutaneous lesions upon introduction of intravenous and subcutaneous unfractionated heparin administration for a surgical procedure. Laboratory investigations revealed the presence of circulating antibodies directed against heparin-platelet factor 4. The lesions slowly resolved after withdrawal of heparin, whereas oral coumarin was re-introduced without complications. This case illustrates the rare occurrence of skin necrosis as a result of unfractionated heparin in a patient under chronic coumarin medication. Recognition of this rare complication and appropriate laboratory testing is mandatory for prompt institution of alternative anticoagulant therapies.
Aged↗
AIDS: ethics, justice and social policy.
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AIDS Serodiagnosis↗