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PubMed1990

Dealing with the stress of an HIV-positive diagnosis at an Army medical center.

Following mandatory military-wide testing for the human immunodeficiency virus (HIV), Army medical facilities have gained extensive experience with HIV-positive persons who undergo special stresses as a result of their affiliation with the military. The consequences of evacuation to medical centers for evaluation of HIV status are presented and the impact of this process on the medical center staff are considered. This paper is a description of one system designed to evaluate, treat, and support HIV-positive soldiers and their families.

HIV Infections↗
PubMed1988

Thyroglobulin and 131I uptake of remaining tissue in patients with differentiated carcinoma after thyroidectomy.

In 158 thyroidectomized patients with well-differentiated non-metastatic thyroid cancer the results of serum thyroglobulin (Tg) determination and 131I uptake values established immediately before radioiodine treatment (19 days after surgery) were compared. In 113 patients (72%) Tg was above 6 ng ml-1 (lower limit of detection) and 131I uptake exceeded 2%. In 11 patients (7%) Tg was undetectable and 131I uptake less than 2%. In these cases a radioiodine treatment was not performed; the thyroid ablation was achieved by surgery only. In 34 patients (21%) with undetectable Tg, 131I uptake values, however, varied between 3 and 46% (mean value: 9.6%). Only in 4 of these 34 patients was TSH not maximally (50 microU ml-1) stimulated because of a shorter (9, 10, 11, 13 days) period from thyroidectomy. In conclusion, remaining thyroid tissue, highly stimulated by TSH, can trap a remarkable amount of radioiodine, but may be unable to produce detectable amounts of Tg. Therefore, in contrast to 131I, measuring Tg is insufficient to document the success of thyroid ablation. For the first follow-up study after ablative therapy, the uptake test with radioiodine is mandatory.

Adenocarcinoma↗
PubMed1986

[Oligoclonal immunoglobulin M in the cerebrospinal fluid of patients with Garin-Bujadoux-Bannwarth meningopolyneuritis].

Paired cerebrospinal fluid (CSF) and serum samples from 15 patients with meningopolyneuritis Garin-Bujadoux-Bannwarth (MPN-GBB) were investigated by agarosegel electrophoresis (AE) and consecutive immunofixation (IF). Oligoclonal immunoglobulin (Ig) was detected in the CSF in 13 cases, 8 of which showed oligoclonal IgM; oligoclonal Ig was not found in the respective serum samples. Local CSF synthesis of IgM is a characteristic feature in patients with MPN-GBB. Further serological testing for borreliosis is mandatory in such cases.

Borrelia Infections↗
PubMed1986

Quality assurance in home laboratory testing.

In review, one is compelled to the notion that a variety of the aforementioned thoughts become pre-eminent in assuring quality. The selection of the tests available for home testing is crucial. They should be divided into categories of single encounter tests and multiple use tests. The single encounter implies a test that has an extremely high degree of reliability and is likely to achieve an answer to the question asked. This should relate to a disease or process for which potential favorable treatment can be achieved or which may have a major favorable impact on public health. In this category one thinks in terms of the worldwide prevalence of hepatitis B and other infectious diseases that are particularly common in third world countries. Yet, these are not "markets" likely to be able to afford this testing. Similarly, these societies are not currently sophisticated in terms of application of preventive measures. On the other hand, major benefits could be projected from the other category of testing, namely, therapeutic monitoring in the hands of individuals who will repetitively test for the same substance in the same manner. This includes not only diabetes but other conditions that are monitored for drug therapy, including seizure disorders and bronchospasm. Inherent in this aspect is the requirement for meaningful and ongoing instruction in proper testing methodology and recording of results. The incorporation of some type of memory device to enforce this aspect of testing appears extremely desirable, if not mandatory. Finally, we must consider the potential for misuse of the single test type of device. One suspects that it would be highly desirable that any test made available for self-testing should also be mandated as accessible through certified laboratories at the request of an individual, which would at least provide reliable performance of the test with a quality result. The development of the concept of quality assurance in home testing is in its infancy and will require continuing evolution.

Aged↗
PubMed1983

Response of age forty and over military personnel to an unsupervised, self-administered aerobic training program.

The Army recently extended mandatory physical training and testing to include personnel 40 yrs of age and older. The purpose of this study was to describe the profile of aerobic fitness in a representative group from this age population and to evaluate the response of such a group to a self-administered, unsupervised training program. Maximal oxygen uptake (Vo2 max) and percent body fat (%BF) were assessed in 260 military personnel (40-53 yrs of age) before and after 6 mo of physical training consisting of a progressive walk/run mode of exercise. Before training the mean +/- S.D. for Vo2 max and %BF for all subjects was 38.1 +/- 6.2 ml/kg . min and 26.1 +/- 4.7%, respectively. Subjects were divided into three groups based upon their initial level of physical activity determined by interview as follows: inactive, moderately active and active. Upon retesting after 6 mo, 40% of the inactive group had not participated to any appreciable degree in the program and subjects of this group who did participate showed only a slight and insignificant increase (4.4%) in Vo2 max. The pretraining level of Vo2 max for the total population studied was similar to that reported in other studies on comparably aged subjects. However, changes with training were well below those seen with supervised group programs of 6 mo duration.

Adult↗
PubMed1982

Empyema thoracis.

Seventy-five adult and 25 pediatric patients with empyema thoracis are reported upon herein. A high incidence of postpneumonectomy and postlobectomy empyema were found in the adult population, 15.5 and 3.7 per cent, respectively. The causal factors of such a high incidence are unknown. Faulty surgical techniques and poor clinical judgment in the management of patients undergoing thoracic operations will invariably lead to a significant mortality and morbidity. Morbidity was indirectly evaluated by the length of hospitalization, the mean being 56.8 days for the adult population and 22.6 days for the pediatric group. These figures barely expose the degree of frustration and suffering that patients with empyema thoracis go through. To decrease the incidence of iatrogenic empyema with its associated mortality and morbidity, good clinical judgment and impeccable surgical techniques must be used in the management of patients having thoracic operations. An aggressive approach to drain the empyemic space to allow pulmonary expansion of sterilization of the postpneumonectomy space must be taken once faced with this complication. Children require no more than repeat thoracentesis or placement of an intercostal chest tube to obtain sufficient drainage and recovery. Antibiotic therapy must be selected according to the bacteria encountered and the results of the sensitivity test. Close supervision is mandatory to detect overgrowth, frequently encountered with the use of broad spectrum antibiotics. Anaerobic bacteria as well as fungus and acid-fast bacilli must be searched for during the routine bacteriologic workout.

Adult↗
PubMedDate not supplied

Clinical implications of advances in the molecular genetics of colorectal cancer.

AIMS AND BACKGROUND: Hereditary nonpolyposis colorectal cancer (HNPCC) is the most common occurring hereditary form of colorectal cancer (CRC) where it accounts for as much as 10 percent of the total CRC burden. HNPCC is characterized by an autosomal dominant inherited predisposition to early age of onset (= 44 years) of CRC with proximal predominance (= 70% proximal to the splenic flecture) with an excess of synchronous and metachronous CRC (45% 10 years after initial hemicolectomy or segmental resection as opposed to subtotal colectomy), features which characterize the Lynch syndrome I variant, while the Lynch syndrome II variant of HNPCC shows all of these features, but in addition, there is a marked excess of carcinoma of the endometrium, ovary, small bowel, stomach, pancreas, and transitional cell carcinoma of the ureter and renal pelvis, lesions which are integral to this syndrome. Because of the early onset, we recommend colonoscopy to be initiated at age 25 and repeated every other year through age 35 and then annually thereafter. Women need to undergo endometrial aspiration biopsy at the time of initial colonoscopy. METHODS AND RESULTS: Major advances in the molecular genetics of HNPCC have occurred during the past two years with identification of the hMSH2 gene at chromosome 2p and the hMLH1 gene at chromosome 3p, both of which have been cloned. PMS1 at chromosome 2p and PMS2 2 at chromosome 7q have also been implicated in HNPCC's etiology. CONCLUSIONS: Genetic counseling is mandatory for presymptomatic DNA testing and for delivering information about the patient's germline status. Patients with germline mutations are offered prophylactic subtotal colectomy as an option to continued colonoscopy. It is now important for physicians to take careful cancer family histories so that this disorder can be readily identified, thereby enabling the initiation of highly targeted surveillance and management programs.

Adult↗
PubMed1996

HIV infection in women: an escalating health concern.

The proportion of women infected with the human immunodeficiency virus (HIV) continues to increase. Over one-half of women acquire the virus through heterosexual contact. The diagnoses that define the acquired immunodeficiency syndrome and the use of antiretroviral therapy are similar in men and women, except in pregnancy. However, management decisions differ significantly regarding contraceptive and gynecologic care. Besides abstinence, use of the latex condom continues to be the most effective way of preventing transmission of HIV. The management of human papillomavirus-associated disease, pelvic inflammatory disease and vaginal candidiasis is especially challenging in women with HIV infection. A positive status for the virus does not appear to affect pregnancy outcome. Each year, up to 2,000 infants are born infected with HIV. Transmission can occur by transplacental or intrapartum spread or through breast milk. Since 1994, prophylaxis with zidovudine has been shown to be an effective method of limiting transmission to infants. It is important to offer all pregnant women a test for HIV, with counseling provided both before and after the test, even if testing does not become mandatory under the law.

AIDS Serodiagnosis↗
PubMedDate not supplied

Liquid chromatographic determination of beta-lactam antibiotics in milk: a multiresidue approach.

In the United States, testing of all milk for residues of beta-lactam antibiotics is now mandatory. Although a number of screening tests for determination of beta-lactam antibiotic residues have been proposed, few reference methods of the required sensitivity (< 10 ppb) are available. Methods for determination of several beta-lactam antibiotics using an automated liquid chromatography (LC) cleanup have been described recently. This paper describes the integration of these methods into a single extraction and cleanup procedure. Milk was deproteinized with 0.2M Et4NCI and acetonitrile. The resulting filtrate was evaporated to about 1 mL, made to 4 mL, and filtered through a disposable filter cartridge. For cleanup, 2 mL filtrate was loaded onto a bonded C18 LC column in 0.01M KH2PO4 (A) and eluted with an acetonitrile (B) gradient using a program of 100 A:0 B(0-3 min) to 60 A:40 B (30 min). The beta-lactams were concentrated into narrow bands and separated from each other. A fraction corresponding to each compound of interest was collected and rechromatographed for analysis. The procedure has been applied successfully to determination of ampicillin, amoxicillin, cephapirin, penicillin G, penicillin V, ceftiofur, and cloxacillin. In principle it can be applied to the determination of any beta-lactam antibiotic or metabolite thereof by collecting the appropriate fractions.

Animals↗
PubMed2001

EAU Guidelines on benign prostatic hyperplasia (BPH).

OBJECTIVE: To establish guidelines for the diagnosis, treatment, and follow-up of BPH. METHODS: A search of published work was conducted using Medline. In combination with expert opinions recommendations were made on the usefulness of tests for assessment and follow-up: mandatory, recommended, or optional. In addition, indications and outcomes for the different therapeutic options were reviewed. RESULTS: A digital rectal examination is mandatory in the assessment for the diagnosis of BPH. Recommended tests are the International Prostate Symptom Score, creatinine measurement (or renal ultrasound), uroflowmetry, and postvoid residual urine volume. All other tests are optional. The aim of treatment is to improve patients' quality of life, and it depends on the severity of the symptoms of BPH. The watchful waiting policy is recommended for patients with mild symptoms, medical treatment for patients with mild-moderate symptoms, and surgery for patients who failed medication or conservative management and who have moderate-severe symptoms, and/or complications of BPH which require surgery. Regarding non-surgical treatments, transurethral microwave thermotherapy is the most attractive option. These treatments should be reserved for patients who prefer to avoid surgery or who no longer respond favourably to medication. Finally, recommendations for follow-up tests and a recommended follow-up time schedule after BPH treatment are provided. CONCLUSIONS: Recommendations for assessment, possible therapeutic options, and follow-up of patients with BPH are made.

Follow-Up Studies↗
PubMed2005

Hemochromatosis: genetic testing and clinical practice.

The availability of a facile treatment for hemochromatosis renders early diagnosis of iron overload syndromes mandatory, and in many instances genetic testing allows identification of individuals at risk of developing clinical disease before pathologic iron storage occurs. Numerous proteins implicated in iron homeostasis have recently come to light, and defects in the cognate genes are associated with iron storage. Although most adult patients with hereditary iron overload are homozygous for the C282Y mutation of the HFE gene, an increasing number with hereditary iron storage have an HFE genotype not characteristic of the disease. Heterozygosity for mutations in the gene encoding ferroportin 1 (FPN1) is probably the second most common genetic cause of hereditary iron storage in adults; here the primarily affected cell is the macrophage. Rare defects, including mutations in the transferrin receptor 2 (TFR2) gene, have also been identified in pedigrees affected with "non-HFE hemochromatosis." Homozygous mutations in the newly identified genes encoding hemojuvelin (HFE2) and hepcidin (HAMP) cause juvenile hemochromatosis. At the same time, heterozygosity for mutations in these genes can modify the clinical expression of iron storage in patients predisposed to iron storage in adult life. Hemochromatosis might thus be considered as a polygenic disease with strong environmental influences on its clinical expression. As our mechanistic understanding of iron pathophysiology improves, our desire to integrate clinical decision making with the results of laboratory tests and molecular analysis of human genes poses increasing challenges.

Adult↗
PubMed1990

Consent, compulsion and confidentiality in relation to testing for HIV infection: the views of WA doctors.

A survey was undertaken of all of the consultant staff members of Perth's major teaching hospitals together with all the fellows of The Royal Australian College of General Practitioners in Western Australia in order to define their views on the issues of informed consent, compulsion in relation to surgery, and confidentiality in a particular circumstance, when testing for infection with the human immunodeficiency virus (HIV). Of the 701 individuals surveyed, 548 (78.2%) responded. Of these, 74.3% considered that it was not always necessary to gain informed consent, 22.0% believed that it was always necessary to do so, while 2.3% were undecided. General practitioners (38.4%) were more likely to think it necessary to obtain consent than were hospital consultants (19.0%), but otherwise the field of specialty had little effect on opinion. Of the respondents, 39.0% believed that testing before elective surgery is mandatory for all patients, while 53.0% considered that it should be compulsory in high-risk groups. Similar views were held about compulsory HIV antibody testing after emergency surgery. Similar responses were obtained from all specialty groups. When asked about whether they would tell a sexual partner of a patient's HIV status when the patient refused, 10.5% of doctors stated they would never advise the partner, 24.7% of doctors would on some occasions, 41.0% of doctors would tell a partner, and 23.8% always were undecided. Many individuals commented that they failed to see why HIV infection was being treated differently from other serious diseases. We have found that the majority opinion of the most senior members of the medical profession is that specific, informed consent should not always be required, that there is great support for compulsory testing, and that confidentiality may be broken under certain circumstances. These views must be recognized by administrators and legislators when framing measures to control this infection.

Acquired Immunodeficiency Syndrome↗
PubMed1995

[Hearing screening within the scope of pediatric U5 preventive examination: can diagnosis be improved by use of a parent questionnaire?].

OBJECTIVE: Assessment of a) the efficacy of hearing loss screening in baby check-ups at the age of 6 to 8 months b) the efficiency and efficacy using parent questionnaires about hearing loss risk factors and parents' concern about the child's hearing as part of baby check-up. METHODS: The analyses are based on 7282 baby check-ups carried out in 47 pediatricians' offices in the Düsseldorf area from July 1991 to March 1993: 3385 of these check-ups were performed in the traditional manner (period A; July 1, 1991, to January 1, 1992; 3897 check-ups involved parent questionnaires (period B June 1, 1992, to March 31, 1993). All children who failed the tests and a random sample of those who had passed the test when tested in the traditional manner, were offered extensive hearing assessment. RESULTS: In period A, 4.3% of the children failed the test as compared to 21.7% with the first version of the questionnaire and 14.3% with a revised questionnaire in period B. Compliance to the offer of extensive hearing assessment was unsatisfactory (53% in period A and 63% in period B). The first extensive hearing examination failed to distinguish healthy children from children with probable sensorineural hearing loss in about 30% of the patients, mainly because of glue ear. One child with sensorineural hearing loss was identified by the screening in period A as compared to six children in period B. CONCLUSIONS: 1) The systematic use of parent questionnaires in baby check-ups at ages 6 to 8 months is likely to increase the efficacy of the screening. 2) The efficiency of the questionnaires currently in use, however, needs to be improved and can be improved with the data from the study. 3) The compliance with extensive hearing testing in children who have failed the screening test must be improved. 4) Due to the high prevalence of conductive hearing loss in this age group, treatment of potential glue ear problems is mandatory before referral for extensive testing for sensorineural hearing loss.

Deafness↗
PubMed1989

[The AIDS epidemic and its importance in obstetrics and gynecology].

There is hardly any other disease where differences of opinion are so dramatic as they are in AIDS. Safely established epidemiologic data are interpreted most controversially and heatedly discussed. Gynaecology and obstetrics are no exception; here, too, scientific discussion is marred by emotional overtones. The article attempts to survey update information and to sum up epidemiologic knowledge while trying to strike a balance. Since even the nomenclature is not always clear or uniform, the most important definitions and abbreviations are listed. Special attention is focussed on the problems of the incubation time (3 months to more than 19 years), where in contrast to other diseases it is not the time of manifestation but the final stage of the disease that counts. That an infection may even be transmitted via intact mucosa is a newly established fact. Routes of infection can also be--besides those already known--saliva, gynaecological (vaginal and rectal) specula and possibly a direct iatrogenic infection. At the time of writing (1 January 1989) 82,500 manifest AIDS patients have been recorded in the U.S.A., 46,000 of whom died. There are about 500,000 patients with prestage signs and about 1 to 1.5 million carriers of the virus. Statistics for the Federal Republic of Germany on 31 January 1989 are: 2885 AIDS patients; about 30,000 serum-positive cases; estimated number of virus carriers: ca. 100,000 including about 10,000 women who are capable of bearing children. Switzerland: 702 AIDS patients, about 30,000 virus carriers. Austria: 243 AIDS cases. Figures for other European countries are also stated. The sequence of risk groups is graded. The article also describes the paths of transmittance in their correlation to the individual risk groups. No effective antiviral treatment is at present in sight. Medium-term prognosis for the FRG leads us to expect about 10,000 AIDS cases by the beginning of 1992 (cumulative figure; about half of these patients will have died by that time). The problem of the incidence of mother-to-child transmittance during pregnancy has not yet been clarified. According to latest results the probable quota of infected children is about 40%. Pregnancy care must include the offer of HIV testing; this is in fact mandatory, especially in women with enhanced risk of infection. If the doctor omits this information, he is liable to be sued for damages. Even in late pregnancy stages, testing is still meaningful (vaccination recommendations, newborn and infant care). Special precautionary measures are recommended for parturition. There is as yet no proof of the effectiveness of primary Caesarean section.(ABSTRACT TRUNCATED AT 400 WORDS)

Acquired Immunodeficiency Syndrome↗
PubMed1998

[A micromanipulator for intraoperative vibratory hearing assessment with an implantable hearing aid transducer].

First concepts of implantable hearing aids to be coupled to the ossicular chain are available for patients with combined or sensorineural hearing loss (SNHL). To ensure that hearing can be improved intraoperative coupling of a test transducer to the ossicular chain is mandatory for allowing surgical anatomy to be checked and vibratory hearing tests to be performed. To achieve this, the test transducer has to be held and positioned securely in situ for some minutes, avoiding risks for middle or inner ear structures. This is not possible using conventional surgical instruments. Thus, a micromanipulator to hold the test transducer during intraoperative hearing tests was developed. This surgical device allows the surgeon safe, risk-free, and controlled coupling of the test transducer to the ossicular chain with one axial and three rotational degrees of freedom. With the aid of a conventional ear retractor (2x2 prongs), the manipulator is fixed at the patient's ear. In conjunction with a piezoelectric test transducer, the manipulator was used in nine patients during local anesthesia. The test transducer is part of an electronic hearing implant (Tübingen implant) specifically designed for SNHL that may be coupled to a middle ear ossicle or the perilymph of the cochlea. The micromanipulator was easy to handle. It allowed accurate positioning of the test transducer in the ear and the desired coupling of the transducer's probe tip to the ossicular chain during auditory tests. According to the principles of integrated safety, the intraoperative risk of ossicular or inner ear injuries caused, for instance, by the patient's head movement is minimized. The design of the manipulator system is universal, also allowing its use for other electronic hearing implants or minimal invasive surgery after minor modifications.

Ear Ossicles↗
PubMedDate not supplied

p24 antigen screening to reduce the risk of HIV transmission by seronegative bone allograft donors.

BACKGROUND: During the last decade, more than 2000 bone allografts harvested from 888 donors and processed by the Queensland Bone Bank have been transplanted in over 1500 patients in Australia and New Zealand. A strict protocol to eliminate HIV transmission by fresh frozen allografts is followed; and not a single case of HIV transmission has been reported. METHODS: All donors were screened and strict donor exclusion criteria were used. All donor blood samples were subjected to double testing including antibody to HIV-1, HIV-2 and HTLV-1 and p24 antigen. The allografts negative for these tests were subjected to processing, including removal of extraneous tissue, pulsatile lavage to remove marrow elements, and immersion in 97% alcohol for 20 minutes. Allografts were subjected to 25 cGy irradiation before transplantation. RESULTS: Allografts were retrieved from a total of 950 donors and 51 were discarded after screening for contamination by organisms other than HIV-1. Eleven donors negative for HIV-1 antibodies tested positive for p24 antigen and were discarded. Allografts from donors testing negative for both the tests (n = 888) were irradiated and used for transplantation. CONCLUSIONS: Routine p24 antigen testing and irradiation of allograft should be mandatory for bone banks, especially those freezing fresh allografts. p24 antigen testing is inexpensive, rapid and easy. Certain guidelines must be followed to avoid misleading results of p24 testing.

Bone Transplantation↗
PubMed1996

Correlates of acceptance of HIV testing and post-test counseling in the obstetrical setting.

Recent results of AZT testing among pregnant women by NIH indicate that early diagnosis and medical intervention can reduce vertical transmission of HIV. Debates have been rekindled concerning whether testing should remain voluntary or be made mandatory. This article analyzes predictors of women's decisions to accept testing voluntarily and return for their test results. Although derived from the postpartum setting, this information is also likely to be useful in understanding voluntary acceptance of prenatal HIV testing, as well as acceptance among those who are hard to reach during pregnancy. Results indicate that the time spent counseling each client and the individual HIV counselor were the best predictors of which women were most likely to test. Minority, self-paid, or uninsured clients, and women with little prenatal care were least likely to return for post-test counseling. The findings of this study point to the central importance of the counselor and the counseling process and to the relatively lesser impact of patient characteristics. Further study of counseling content and counselor performance is recommended.

AIDS Serodiagnosis↗
PubMed2004

Universal prenatal HIV screening: patient attitudes and perceptions.

In 1995, Center for Disease Control guidelines were modified to replace targeted HIV screening of pregnant women with universal screening. Public health scholars have argued that one rationale for universal screening is to reduce the potential stigmatization of women of color and lower socioeconomic status who are typically targeted under selective screening. Here, we examine whether experiences and impressions of prenatal screening differ across socioeconomic and racial lines. Data are drawn from an NIH-funded pilot study of 353 pregnant women across several sites in Connecticut, a state with unusually strong prenatal HIV screening laws. We find no significant differences on testing protocols and attitudes toward mandatory HIV screening. However, minority and lower socioeconomic status women are more likely (1) to understand the screening law, (2) to report that their doctor stresses the importance of the test, and (3) to express much higher levels of concern about the confidentiality of the test.

Adolescent↗