Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society-USA panel.

CONTEXT: Recent data regarding the consequences of untreated human immunodeficiency virus (HIV) infection and the expansion of treatment choices for antiretroviral-naive and antiretroviral-experienced patients warrant an update of the International AIDS Society-USA guidelines for the use of antiretroviral therapy in adults with HIV infection. OBJECTIVES: To provide updated recommendations for management of HIV-infected adults, using antiretroviral drugs and laboratory monitoring tools available in the international, developed-world setting. This report provides guidelines for when to initiate antiretroviral therapy, selection of appropriate initial regimens, patient monitoring, when to change therapy, and what regimens to use when changing. DATA SOURCES AND STUDY SELECTION: A panel with expertise in HIV research and clinical care reviewed relevant data published or presented at selected scientific conferences since the last panel report through April 2010. Data were identified through a PubMed search, review of scientific conference abstracts, and requests to antiretroviral drug manufacturers for updated clinical trials and adverse event data. DATA EXTRACTION AND SYNTHESIS: New evidence was reviewed by the panel. Recommendations were drafted by section writing committees and reviewed and edited by the entire panel. The quality and strength of the evidence were rated and recommendations were made by full panel consensus. CONCLUSIONS: Patient readiness for treatment should be confirmed before initiation of antiretroviral treatment. Therapy is recommended for asymptomatic patients with a CD4 cell count < or = 500/microL, for all symptomatic patients, and those with specific conditions and comorbidities. Therapy should be considered for asymptomatic patients with CD4 cell count > 500/microL. Components of the initial and subsequent regimens must be individualized, particularly in the context of concurrent conditions. Patients receiving antiretroviral treatment should be monitored regularly; treatment failure should be detected and managed early, with the goal of therapy, even in heavily pretreated patients, being HIV-1 RNA suppression below commercially available assay quantification limits.

Kernel-based methods for change detection in remote sensing images

Nowadays, the joint exploitation of images acquired daily by remote sensing instruments and of images available from archives allows a detailed monitoring of the transitions occurring at the surface of the Earth. These modifications of the land cover generate spectral discrepancies that can be detected via the analysis of remote sensing images. Independently from the origin of the images and of type of surface change, a correct processing of such data implies the adoption of flexible, robust and possibly nonlinear method, to correctly account for the complex statistical relationships characterizing the pixels of the images. This Thesis deals with the development and the application of advanced statistical methods for multi-temporal optical remote sensing image processing tasks. Three different families of machine learning models have been explored and fundamental solutions for change detection problems are provided. In the first part, change detection with user supervision has been considered. In a first application, a nonlinear classifier has been applied with the intent of precisely delineating flooded regions from a pair of images. In a second case study, the spatial context of each pixel has been injected into another nonlinear classifier to obtain a precise mapping of new urban structures. In both cases, the user provides the classifier with examples of what he believes has changed or not. In the second part, a completely automatic and unsupervised method for precise binary detection of changes has been proposed. The technique allows a very accurate mapping without any user intervention, resulting particularly useful when readiness and reaction times of the system are a crucial constraint. In the third, the problem of statistical distributions shifting between acquisitions is studied. Two approaches to transform the couple of bi-temporal images and reduce their differences unrelated to changes in land cover are studied. The methods align the distributions of the images, so that the pixel-wise comparison could be carried out with higher accuracy. Furthermore, the second method can deal with images from different sensors, no matter the dimensionality of the data nor the spectral information content. This opens the doors to possible solutions for a crucial problem in the field: detecting changes when the images have been acquired by two different sensors.

La planification de sortie des personnes âgées hospitalisées dans un service de médecine

Contexte: la planification infirmière de sortie des personnes âgées est une composante importante des soins pour assurer une transition optimale entre l'hôpital et la maison. Beaucoup d'événements indésirables peuvent survenir après la sortie de l'hôpital. Dans une perspective de système de santé, les facteurs qui augmentent ce risque incluent un nombre croissant de patients âgés, l'augmentation de la complexité des soins nécessitant une meilleure coordination des soins après la sortie, ainsi qu'une augmentation de la pression financière. Objectif: évaluer si les interventions infirmières liées à la planification de sortie chez les personnes âgées et leurs proches aidants sont prédictives de leur perception d'être prêts pour le départ, du niveau d'anxiété du patient le jour de la sortie de l'hôpital et du nombre de recours non programmé aux services de santé durant les trente jours après la sortie. Méthode: le devis est prédictif corrélationnel avec un échantillon de convenance de 235 patients. Les patients âgés de 65 ans de quatre unités d'hôpitaux dans le canton de Vaud en Suisse ont été recrutés entre novembre 2011 et octobre 2012. Les types et les niveaux d'interventions infirmières ont été extraits des dossiers de soins et analysés selon les composantes du modèle de Naylor. La perception d'être prêt pour la sortie et l'anxiété ont été mesurées un jour avant la sortie en utilisant l'échelle de perception d'être prêt pour la sortie et l'échelle Hospital Anxiety and Depression. Un mois après la sortie, un entretien téléphonique a été mené pour évaluer le recours non programmé aux services de santé durant cette période. Des analyses descriptives et un modèle randomisé à deux niveaux ont été utilisés pour analyser les données. Résultats: peu de patients ont reçu une planification globale de sortie. L'intervention la plus fréquente était la coordination (M = 55,0/100). et la moins fréquente était la participation du patient à la planification de sortie (M = 16,1/100). Contrairement aux hypothèses formulées, les patients ayant bénéficié d'un plus grand nombre d'interventions infirmières de préparation à la sortie ont un niveau moins élevé de perception d'être prêt pour le départ (B = -0,3, p < 0,05, IC 95% [-0,57, -0,11]); le niveau d'anxiété n'est pas associé à la planification de sortie (r = -0,21, p <0,01) et la présence de troubles cognitifs est le seul facteur prédictif d'une réhospitalisation dans les 30 jours après la sortie de l'hôpital ( OR = 1,50, p = 0,04, IC 95% [1,02, 2,22]). Discussion: en se focalisant sur chaque intervention de la planification de sortie, cette étude permet une meilleure compréhension du processus de soins infirmiers actuellement en cours dans les hôpitaux vaudois. Elle met en lumière les lacunes entre les pratiques actuelles et celles de pratiques exemplaires donnant ainsi une orientation pour des changements dans la pratique clinique et des recherches ultérieures. - Background: Nursing discharge planning in elderly patients is an important component of care to ensure optimal transition from hospital to home. Many adverse events may occur after hospital discharge. From a health care system perspective, contributing factors that increase the risk of these adverse events include a growing number of elderly patients, increased complexity of care requiring better care coordination after discharge, as well as increased financial pressure. Aim: To investigate whether older medical inpatients who receive comprehensive discharge planning interventions a) feel more ready for hospital discharge, b) have reduced anxiety at the time of discharge, c) have lower health care utilization after discharge compared to those who receive less comprehensive interventions. Methods: Using a predictive correlational design, a convenience sample of 235 patients was recruited. Patients aged 65 and older from 4 units of hospitals in the canton of Vaud in Switzerland were enrolled between November 2011 and October 2012. Types and level of interventions were extracted from the medical charts and analyzed according to the components of Naylor's model. Discharge readiness and anxiety were measured one day before discharge using the Readiness for Hospital Discharge Scale and the Hospital Anxiety and Depression scale. A telephone interview was conducted one month after hospital discharge to asses unplanned health services utilization during this follow-up period. Descriptive analyses and a two- level random model were used for statistical analyses. Results: Few patients received comprehensive discharge planning interventions. The most frequent intervention was Coordination (M = 55,0/100) and the least common was Patient participation in the discharge planning (M = 16,1/100). Contrary to our hypotheses, patients who received more nursing discharge interventions were significantly less ready to go home (B = -0,3, p < 0,05, IC 95% [-0,57, -0,11]); their anxiety level was not associated with their readiness for hospital discharge (r = -0,21, p <0,01) and cognitive impairment was the only factor that predicted rehospitalization within 30 days after discharge ( OR = 1,50, p = 0,04, IC 95% [1,02, 2,22]). Discussion: By focusing on each component of the discharge planning, this study provides a greater and more detailed insight on the usual nursing process currently performed in medical inpatients units. Results identified several gaps between current and Best practices, providing guidance to changes in clinical practice and further research.

Factor structure of the SOCRATES questionnaire in hospitalized medical patients.

The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), a 19-item instrument developed to assess readiness to change alcohol use among individuals presenting for specialized alcohol treatment, has been used in various populations and settings. Its factor structure and concurrent validity has been described for specialized alcohol treatment settings and primary care. The purpose of this study was to determine the factor structure and concurrent validity of the SOCRATES among medical inpatients with unhealthy alcohol use not seeking help for specialized alcohol treatment. The subjects were 337 medical inpatients with unhealthy alcohol use, identified during their hospital stay. Most of them had alcohol dependence (76%). We performed an Alpha Factor Analysis (AFA) and Principal Component Analysis (PCA) of the 19 SOCRATES items, and forced 3 factors and 2 components, in order to replicate findings from Miller and Tonigan (Miller, W. R., & Tonigan, J. S., (1996). Assessing drinkers' motivations for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behavior, 10, 81-89.) and Maisto et al. (Maisto, S. A., Conigliaro, J., McNeil, M., Kraemer, K., O'Connor, M., & Kelley, M. E., (1999). Factor structure of the SOCRATES in a sample of primary care patients. Addictive Behavior, 24(6), 879-892.). Our analysis supported the view that the 2 component solution proposed by Maisto et al. (Maisto, S.A., Conigliaro, J., McNeil, M., Kraemer, K., O'Connor, M., & Kelley, M.E., (1999). Factor structure of the SOCRATES in a sample of primary care patients. Addictive Behavior, 24(6), 879-892.) is more appropriate for our data than the 3 factor solution proposed by Miller and Tonigan (Miller, W. R., & Tonigan, J. S., (1996). Assessing drinkers' motivations for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behavior, 10, 81-89.). The first component measured Perception of Problems and was more strongly correlated with severity of alcohol-related consequences, presence of alcohol dependence, and alcohol consumption levels (average number of drinks per day and total number of binge drinking days over the past 30 days) compared to the second component measuring Taking Action. Our findings support the view that the SOCRATES is comprised of two important readiness constructs in general medical patients identified by screening.

Food's visually perceived fat content affects discrimination speed in an orthogonal spatial task.

Choosing what to eat is a complex activity for humans. Determining a food's pleasantness requires us to combine information about what is available at a given time with knowledge of the food's palatability, texture, fat content, and other nutritional information. It has been suggested that humans may have an implicit knowledge of a food's fat content based on its appearance; Toepel et al. (Neuroimage 44:967-974, 2009) reported visual-evoked potential modulations after participants viewed images of high-energy, high-fat food (HF), as compared to viewing low-fat food (LF). In the present study, we investigated whether there are any immediate behavioural consequences of these modulations for human performance. HF, LF, or non-food (NF) images were used to exogenously direct participants' attention to either the left or the right. Next, participants made speeded elevation discrimination responses (up vs. down) to visual targets presented either above or below the midline (and at one of three stimulus onset asynchronies: 150, 300, or 450 ms). Participants responded significantly more rapidly following the presentation of a HF image than following the presentation of either LF or NF images, despite the fact that the identity of the images was entirely task-irrelevant. Similar results were found when comparing response speeds following images of high-carbohydrate (HC) food items to low-carbohydrate (LC) food items. These results support the view that people rapidly process (i.e. within a few hundred milliseconds) the fat/carbohydrate/energy value or, perhaps more generally, the pleasantness of food. Potentially as a result of HF/HC food items being more pleasant and thus having a higher incentive value, it seems as though seeing these foods results in a response readiness, or an overall alerting effect, in the human brain.

New considerations on the management of osteoporosis in Central and Eastern Europe (CEE): summary of the "3rd Summit on Osteoporosis-CEE", November 2009, Budapest, Hungary.

INTRODUCTION: In November 2009, the "3rd Summit on Osteoporosis-Central and Eastern Europe (CEE)" was held in Budapest, Hungary. The conference aimed to tackle issues regarding osteoporosis management in CEE identified during the second CEE summit in 2008 and to agree on approaches that allow most efficient and cost-effective diagnosis and therapy of osteoporosis in CEE countries in the future. DISCUSSION: The following topics were covered: past year experience from FRAX® implementation into local diagnostic algorithms; causes of secondary osteoporosis as a FRAX® risk factor; bone turnover markers to estimate bone loss, fracture risk, or monitor therapies; role of quantitative ultrasound in osteoporosis management; compliance and economical aspects of osteoporosis; and osteoporosis and genetics. Consensus and recommendations developed on these topics are summarised in the present progress report. CONCLUSION: Lectures on up-to-date data of topical interest, the distinct regional provenances of the participants, a special focus on practical aspects, intense mutual exchange of individual experiences, strong interest in cross-border cooperations, as well as the readiness to learn from each other considerably contributed to the establishment of these recommendations. The "4th Summit on Osteoporosis-CEE" held in Prague, Czech Republic, in December 2010 will reveal whether these recommendations prove of value when implemented in the clinical routine or whether further improvements are still required.

Influence of compliance to respiratory weaning consensus conference criteria on respiratory outcome within 48h after planned extubation

INTRODUCTION. A two-step assessment (readiness to wean (RW) followed by spontaneousbreathing trial (SBT)) of predefined criteria is recommended before planned extubation(PE)1.OBJECTIVES. We aimed to evaluate if compliance to all guideline criteria was associatedwith better respiratory outcome within 48 h after PE.METHODS. The data (extracted from our clinical information system) of 458 consecutivepatients who underwent PE after C48 h of invasive ventilation in our medico-surgical ICUwere analyzed. We evaluated compliance with guidelines [1] regarding respiratory rate, tidalvolume, PaO2, FiO2, PEEP, PaCO2, pH, heart rate, systolic arterial pressure and arrhythmiaduringRWand SBT assessment (RW and SBT within 2 h). A patient was classified as RW+ ifallRWcriteria were fulfilled andRW-if at least 1 criterion was violated. The same approachwas used to define SBT+ and SBT- patients. During the 48 h following PE, we assessed theoccurrence of post-PE respiratory failure (PRF) (defined as the presence of at least 1 consensuscriterion of respiratory failure [1]), reintubation (after NIV failure or because of immediateintubation criteria) and cumulative duration of post-PE ventilation (PPEV = Post-PE invasive+ non-invasive ventilation). ICU mortality was recorded. Comparisons for variousoutcomes were performed by Chi-square and t tests.RESULTS. All consensus criteria were fulfilled in 77.3% of the patients during RW and in68.1% of the patients during SBT.[Compliance to weaning criteria and outcome]N = 458 PRF (%) Reintubation (%) PPEV (min) ICU mortality (%)All patients 53.5 10.0 542 ± 664 6.1RW+ 50.0 9.3 490 ± 626 5.4RW- 65.4* 12.5 718 ± 757** 8.7SBT+ 52.6 8.0 498 ± 594 6.7SBT- 55.5 14.4*** 637 ± 788**** 4.8Occurrence of PRF only was not associated with increased ICU mortality: 4.2 versus 7.8%,p = 0.11. By contrast, ICU mortality was significantly increased in patients requiring reintubation:21.7 versus 4.4%. p\0.001; * p = 0.006 RW+ versus RW-; ** p = 0.003RW+ versus RW-; *** p = 0.035 SBT+ versus SBT-; **** p = 0.030 SBT+ versusSBTCONCLUSIONS.In our ICU, compliance to all criteria of the two-step published approach ofrespiratory weaning was not optimal but reintubation rate was comparable to published data.Compliance with consensus conference guidelines was associated with lower reintubation rateand shorter PPEV but not with ICU mortality. As mortality was increased by reintubation,more sensitive and specific criteria to predict the risk of reintubation are probably needed.REFERENCE. Boles JM, et al. Eur Respir J 2007;29:1033-56.

Treating tobacco use and dependence in clinical practice.

Physicians are in a unique position to advise smokers to quit by the ability to integrate the various aspects of nicotine dependence. This review provides an overview of the intervention strategies for smokers presented in a primary care setting. The strategies that are used for smoking cessation counselling differ according to the patient's readiness to quit. For smokers who do not intend to give up smoking, physicians should inform about tobacco use and the benefits of cessation. For smokers who are dissonant, physicians should use motivational strategies, such as discussing the barriers to successful cessation and their solutions. For smokers who are ready to quit, the physician should show strong support, help set a date to quit, prescribe pharmaceutical therapies for nicotine dependence, such as nicotine replacement therapy (i.e., gum, transdermal patch, nasal spray, mouth inhaler, lozenges, and micro and sublingual tablets) and/or bupropion (an atypical antidepressant thought to work by blocking the neural re-uptake of dopamine and/or noradrenaline), with instructions for use, and suggest behavioural strategies to prevent relapse. The efficacy of all of these pharmacotherapies is comparable, roughly doubling the cessation rates over control conditions.

Emotion expression in body action and posture

Emotion communication research strongly focuses on the face and voice as expressive modalities, leaving the rest of the body relatively understudied. Contrary to the early assumption that body movement only indicates emotional intensity, recent studies show that body movement and posture also convey emotion specific information. However, a deeper understanding of the underlying mechanisms is hampered by a lack of production studies informed by a theoretical framework. In this research we adopted the Body Action and Posture (BAP) coding system to examine the types and patterns of body movement that are employed by 10 professional actors to portray a set of 12 emotions. We investigated to what extent these expression patterns support explicit or implicit predictions from basic emotion theory, bi-dimensional theory, and componential appraisal theory. The overall results showed partial support for the different theoretical approaches. They revealed that several patterns of body movement systematically occur in portrayals of specific emotions, allowing emotion differentiation. While a few emotions were prototypically encoded by one particular pattern, most emotions were variably expressed by multiple patterns, many of which can be explained as reflecting functional components of emotion such as modes of appraisal and action readiness. It is concluded that further work in this largely underdeveloped area should be guided by an appropriate theoretical framework to allow a more systematic design of experiments and clear hypothesis testing.

Rauchentwohnung-- die zentrale Rolle der Arztinnen und Arzte [Smoking cessation--a central role for physicians]

Physicians are in a unique position to advice smokers to quit by the ability to integrate the various aspects of nicotine dependence. This review provides an overview of intervention with smokers presenting in a primary care setting. Strategies used for smoking cessation counseling differed according to patient's readiness to quit. For smokers who do not intend to quit smoking, physicians should inform and sensitize patients about tobacco use and cessation, especially by personalizing benefits to quit and challenging smokers 'beliefs. For smokers who are dissonant, physicians should use motivational strategies, such as discussing barriers to cessation and their solutions. For smokers ready to quit, the physician should show strong support, help set a quit date, prescribe pharmaceutical therapies for nicotine dependence, such as replacement therapy and/or bupropion, with instructions for use, and suggest behavioral strategies to prevent relapse.

Mechanisms of action of brief alcohol interventions remain largely unknown - a narrative review.

A growing body of evidence has shown the efficacy of brief intervention (BI) for hazardous and harmful alcohol use in primary health care settings. Evidence for efficacy in other settings and effectiveness when implemented at larger scale are disappointing. Indeed, BI comprises varying content; exploring BI content and mechanisms of action may be a promising way to enhance efficacy and effectiveness. Medline and PsychInfo, as well as references of retrieved publications were searched for original research or review on active ingredients (components or mechanisms) of face-to-face BIs [and its subtypes, including brief advice and brief motivational interviewing (BMI)] for alcohol. Overall, BI active ingredients have been scarcely investigated, almost only within BMI, and mostly among patients in the emergency room, young adults, and US college students. This body of research has shown that personalized feedback may be an effective component; specific MI techniques showed mixed findings; decisional balance findings tended to suggest a potential detrimental effect; while change plan exercises, advice to reduce or stop drinking, presenting alternative change options, and moderation strategies are promising but need further study. Client change talk is a potential mediator of BMI effects; change in norm perceptions and enhanced discrepancy between current behavior and broader life goals and values have received preliminary support; readiness to change was only partially supported as a mediator; while enhanced awareness of drinking, perceived risks/benefits of alcohol use, alcohol treatment seeking, and self-efficacy were seldom studied and have as yet found no significant support as such. Research is obviously limited and has provided no clear and consistent evidence on the mechanisms of alcohol BI. How BI achieves the effects seen in randomized trials remains mostly unknown and should be investigated to inform the development of more effective interventions.

Nursing discharge planning for older medical inpatients in Switzerland: A cross-sectional study.

Nursing discharge planning for elderly medical inpatients is an essential element of care to ensure optimal transition to home and to reduce post-discharge adverse events. The objectives of this cross-sectional study were to investigate the association between nursing discharge planning components in older medical inpatients, patients' readiness for hospital discharge and unplanned health care utilization during the following 30 days. Results indicated that no patients benefited from comprehensive discharge planning but most benefited from less than half of the discharge planning components. The most frequent intervention recorded was coordination, and the least common was patients' participation in decisions regarding discharge. Patients who received more nursing discharge components felt significantly less ready to go home and had significantly more readmissions during the 30-day follow-up period. This study highlights large gaps in the nursing discharge planning process in older medical inpatients and identifies specific areas where improvements are most needed.

Under what conditions? Therapist and client characteristics moderate the role of change talk in brief motivational intervention.

OBJECTIVE: Client change talk has been proposed as a mechanism of change in motivational interviewing (MI) by mediating the link between therapist MI-consistent behaviors (MICO) and client behavioral outcomes. We tested under what circumstances this mechanism was supported in the context of a clinical trial of brief MI for heavy drinking among nontreatment seeking young men. METHOD: We conducted psycholinguistic coding of 174 sessions using the MI Skill Code 2.1 and derived the frequency of MICO and the strength of change talk (CTS) averaged over the session. CTS was examined as a mediator of the relationship between MICO and a drinking composite score measured at 3-month follow-up, controlling for the composite measure at baseline. Finally, we tested therapist gender and MI experience as well as client readiness to change and alcohol problem severity as moderators of this mediation model. RESULTS: CTS significantly predicted outcome (higher strength related to less drinking), but MICO did not predict CTS. However, CTS mediated the relationship between MICO and drinking outcomes when therapists had more experience in MI and when clients had more severe alcohol problems (i.e., significant conditional indirect effects). CONCLUSIONS: The mechanism hypothesized by MI theory was operative in our brief MI with heavy drinking young men, but only under particular conditions. Our results suggest that attention should be paid to therapist selection, training, and/or supervision until they reach a certain level of competence, and that MI might not be appropriate for nontreatment seeking clients drinking at a lower level of risk. (PsycINFO Database Record