Implementation and Operational Research: Risk Charts to Guide Targeted HIV-1 Viral Load Monitoring of ART: Development and Validation in Patients From Resource-Limited Settings.

BACKGROUND HIV-1 RNA viral load (VL) testing is recommended to monitor antiretroviral therapy (ART) but not available in many resource-limited settings. We developed and validated CD4-based risk charts to guide targeted VL testing. METHODS We modeled the probability of virologic failure up to 5 years of ART based on current and baseline CD4 counts, developed decision rules for targeted VL testing of 10%, 20%, or 40% of patients in 7 cohorts of patients starting ART in South Africa, and plotted cutoffs for VL testing on colour-coded risk charts. We assessed the accuracy of risk chart-guided VL testing to detect virologic failure in validation cohorts from South Africa, Zambia, and the Asia-Pacific. RESULTS In total, 31,450 adult patients were included in the derivation and 25,294 patients in the validation cohorts. Positive predictive values increased with the percentage of patients tested: from 79% (10% tested) to 98% (40% tested) in the South African cohort, from 64% to 93% in the Zambian cohort, and from 73% to 96% in the Asia-Pacific cohort. Corresponding increases in sensitivity were from 35% to 68% in South Africa, from 55% to 82% in Zambia, and from 37% to 71% in Asia-Pacific. The area under the receiver operating curve increased from 0.75 to 0.91 in South Africa, from 0.76 to 0.91 in Zambia, and from 0.77 to 0.92 in Asia-Pacific. CONCLUSIONS CD4-based risk charts with optimal cutoffs for targeted VL testing maybe useful to monitor ART in settings where VL capacity is limited.

Pitfalls of practicing cancer epidemiology in resource-limited settings: the case of survival and loss to follow-up after a diagnosis of Kaposi's sarcoma in five countries across sub-Saharan Africa.

BACKGROUND Survival after diagnosis is a fundamental concern in cancer epidemiology. In resource-rich settings, ambient clinical databases, municipal data and cancer registries make survival estimation in real-world populations relatively straightforward. In resource-poor settings, given the deficiencies in a variety of health-related data systems, it is less clear how well we can determine cancer survival from ambient data. METHODS We addressed this issue in sub-Saharan Africa for Kaposi's sarcoma (KS), a cancer for which incidence has exploded with the HIV epidemic but for which survival in the region may be changing with the recent advent of antiretroviral therapy (ART). From 33 primary care HIV Clinics in Kenya, Uganda, Malawi, Nigeria and Cameroon participating in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortia in 2009-2012, we identified 1328 adults with newly diagnosed KS. Patients were evaluated from KS diagnosis until death, transfer to another facility or database closure. RESULTS Nominally, 22% of patients were estimated to be dead by 2 years, but this estimate was clouded by 45% cumulative lost to follow-up with unknown vital status by 2 years. After adjustment for site and CD4 count, age <30 years and male sex were independently associated with becoming lost. CONCLUSIONS In this community-based sample of patients diagnosed with KS in sub-Saharan Africa, almost half became lost to follow-up by 2 years. This precluded accurate estimation of survival. Until we either generally strengthen data systems or implement cancer-specific enhancements (e.g., tracking of the lost) in the region, insights from cancer epidemiology will be limited.

Physician and patient determinants of the treatment of sleep difficulties in U.S. outpatient settings

The prevalence of sleep difficulties among the patients seen in the primary care settings is about 30%. This problem increases with age and is more common among females than males. Variations are noticed in prescription choices for different patients with sleep difficulties. Many factors affect a physician's prescription decision while chosen from a wide array of available medications. Both pharmacological and behavioral therapies are available for the treatment of sleep difficulties. It is important to know the impact of use of different types of prescriptions on health outcomes related to sleep difficulties. Thus the knowledge of prescription patterns among different types of patients (e.g. age, gender, race, insurance type etc.) becomes important for determining a clinical guideline. This study is designed to assist in evidence-based policymaking on understanding the variations in physician prescriptions for sleep difficulties and reasons for such variations. ^ A modified version of the model suggested by Eisenberg was used as a theoretical framework for this study to predict the factors influencing treatment of sleep difficulties. Multivariate logistic regression methods were used to analyze the 1996–2001 National Ambulatory Medical Care Survey data. ^ This study found that increased age, female gender, white race, established patients, and mental comorbidity were associated with significantly increased likelihood for prescription of some type of therapy for sleep difficulties in US outpatient settings. Patients with private insurance were associated with lower likelihood of receipt of many therapies. Psychiatrists were more likely to prescribe some kind of treatment as well as more expensive therapies for sleep difficulty as compared to other physician specialties. HMO enrolled patient visits were more likely to be associated with receipt of behavioral therapy. This study also found that 32% of patients with sleep difficulties received no type of therapy during their visits. Only 5% of the patients received behavioral therapy only. Almost three-quarters of the patients receiving some kind of medication prescription were prescribed benzodiazepines. The study results also suggest a need for wider coverage of behavioral therapy by payers in US outpatient settings. ^

A comparison of labor and delivery management activities in two settings

Similarities and differences in management activities and patient health outcomes between a traditional physician staffed labor and delivery setting and a certified nurse-midwife staffed Birth Center within the same hospital were described. The 950 study subjects, low income, minority women, were classified as low obstetrical risk by a POPRAS score of 25 points or less at time of admission for labor and delivery. The study subjects were similar in demographic, antepartum and intrapartum characteristics; the labor course was problem free for the majority in both settings. There were no remarkable differences in health outcomes between the groups. Management activities varied between settings; these variations were policy related rather than health related. The POPRAS rating system was an accurate predictor for 93% of BC subjects and 85% of LDU subjects. Charge for service was approximately $600 less for BC women; length of stay did not contribute to the difference in charge. Overall, BC respondents to the attitude survey were more satisfied with their labor and delivery experience than L\&DU women. ^

Assessing the impact of leadership on nurse job satisfaction and the desire for unionization in health care settings

This dissertation focuses on the leadership styles of managers, the impact these leadership styles have on the job satisfaction of staff nurses, and the proclivity of nurses to consider unionization. The aims of the dissertation include conducting a literature review on topics of leadership style, job satisfaction, and unionization; identifying and elucidating pertinent constructs with respect to shared interrelationships and how they could be measured; and developing a means of assessing if and to what extent transformational and transactional leadership styles affect nurse proclivity to unionize.^ The instrumentation selected includes the Multifactor Leadership Survey, Job Satisfaction Survey, and a newly created Union Preference Survey. Each survey instrument was evaluated as to its appropriateness to administer at a non-consultant level within a health care facility. Options other than self-administering the survey instruments include online access for participants, which provides confidentiality and encourages more responses. ^ The next part of the dissertation is a plan for health care facilities to use the survey tool by administering it themselves. The plan provides a general description of the survey tool, administering the instrument, rating the instrument, and leadership development. Integration of the three surveys is presented in a non-statistical format by coordinating the results of the three survey instrument responses. Recommendations are presented on how to improve leadership development warranted for improvement.^ The conclusions reached are that nurses’ preference for unions is influenced by the leadership style of direct report managers, as rated by staff nurses, and the nurses’ job satisfaction, which is in turn in part dependent on their managers’ leadership style. Thus, changes in leadership style can have a profound impact on nurse job satisfaction and on nurses’ preference for unionization.^

Pilot study assessment of indoor air quality in two dental settings: Particulate matter and volatile organic compounds

Objective: To assess the indoor environment of two different types of dental practices regarding VOCs, PM2.5, and ultrafine particulate concentrations and examine the relationship between specific dental activities and contaminant levels. Method: The indoor environments of two selected dental settings (private practice and community health center) will were assessed in regards to VOCs, PM 2.5, and ultrafine particulate concentrations, as well as other indoor air quality parameters (CO2, CO, temperature, and relative humidity). The sampling duration was four working days for each dental practice. Continuous monitoring and integrated sampling methods were used and number of occupants, frequency, type, and duration of dental procedures or activities recorded. Measurements were compared to indoor air quality standards and guidelines. Results: The private practice had higher CO2, CO, and most VOC concentrations than the community health center, but the community health center had higher PM2.5 and ultrafine PM concentrations. Concentrations of p-dichlorobenzene and PM2.5 exceeded some guidelines. Outdoor concentrations greatly influenced the indoor concentration. There were no significant differences in contaminant levels between the operatory and general area. Indoor concentrations during the working period were not always consistently higher than during the nonworking period. Peaks in particulate matter concentration occurred during root canal and composite procedures.^

Chemical analysis and argon geochronology from dive SAR_1 on Cornacya seamount of the Sardinia Channel

Sarcya 1 dive explored a previously unknown 12 My old submerged volcano, labelled Cornacya. A well developed fracturation is characterised by the following directions: N 170 to N-S, N 20 to N 40, N 90 to N 120, N 50 to N 70, which corresponds to the fracturation pattern of the Sardinian margin. The sampled lavas exhibit features of shoshonitic suites of intermediate composition and include amphibole-and mica-bearing lamprophyric xenoliths which are geochemically similar to Ti-poor lamproites. Mica compositions reflect chemical exchanges between the lamprophyre and its shoshonitic host rock suggesting their simultaneous emplacement. Nd compositions of the Cornacya K-rich suite indicate that continental crust was largely involved in the genesis of these rocks. The spatial association of the lamprophyre with the shoshonitic rocks is geochemically similar to K-rich and TiO2-poor igneous suites, emplaced in post-collisional settings. Among shoshonitic rocks, sample SAR 1-01 has been dated at 12.6±0.3 My using the 40Ar/39Ar method with a laser microprobe on single grains. The age of the Cornacya shoshonitic suite is similar to that of the Sisco lamprophyre from Corsica, which similarly is located on the western margin of the Tyrrhenian Sea. Thus, the Cornacya shoshonitic rocks and their lamprophyric xenolith and the Sisco lamprophyre could represent post-collisional suites emplaced during the lithospheric extension of the Corsica-Sardinia block, just after its rotation and before the Tyrrhenian sea opening. Drilling on the Sardinia margin (ODP Leg 107) shows that the upper levels of the present day margin (Hole 654) suffered tectonic subsidence before the lower part (Hole 652). The structure of this lower part is interpreted as the result of an eastward migration of the extension during Late Miocene and Early Pliocene times. Data of Cornacya volcano are in good agreement with this model and provide good chronological constraints for the beginning of the phenomenon.

(Table 3) Chemical analyses from DSDP Holes 22-214, 22-215 and 22-216 in the Indian Ocean

The basalts and oceanic andesites from the aseismic Ninetyeast Ridge display trachytic, vesicular and amygdaloidal textures suggesting a subaerial volcanic environment. The normative composition of the Ninetyeast Ridge ranges from olivine picriteto nepheline-normative alkaline basalt, suggesting a wide range of differentiation. This is further supported by the fractionation-differentiation trends displayed by transition metal trace elements (Ni, Cr, V and Cu). The Ninetyeast Ridge rocks are enriched in rare earth (RE) and large ion lithophile (LIL) elements and Sr isotopes (0.7043-0.7049), similar to alkali basalts and tholeiites from seamounts and islands, but different from LIL-element-depleted tholeiitic volcanic rocks of the recent seismic mid-Indian oceanic ridge. The constancy of 87Sr/86Sr ratios for basalts and andesites is compatible with a model involving fractional crystallization of mafic magma. The variation of 87Sr/86Sr ratios between 0.97 and 2.79 may possibly be explained in terms of a primordial hot mantle and/or chemically contrasting heterogeneous mantle source layers relatively undepleted in LIL elements at different periods in the geologic past. In general, the Sr isotopic data for rocks from different tectonic environments are consistent with a "zoning-depletion model" with systematically arranged alternate alkali-poor and alkali-rich layers in the mantle beneath the Indian Ocean.

(Table 2) Chemical composition of quenched glasses from the Mohns and Knipovich Ridges

The aim of this project was a petrogeochemical study of igneous rocks in the areas of the Mohns and Knipovich Ridges, both being the northern extensions of the Mid-Atlantic Ridge (MAR), using data available for quenching glass samples collected during Cruises 36 and 38 of R/V Akademic Mstislav Keldysh and during Cruise 15 of R/V Professor Logachev. Results of igneous rock studying from the Mohns and Knipovich Ridges at the background of evolution of the total North Atlantic Province, which had been identified earlier from tectonic and geophysical data, showed that igneous rocks of the Knipovich Ridge can be ranked as shallow tholeiites, primary melts of which were relatively rich in Na and Si and poor in Fe. This type of magma is characteristic of colder regions of the oceanic lithosphere. Its occurrence in the Knipovich Ridge and its potential propagation up to the Gakkel Ridge suggest that igneous rocks of this region originated under conditions of passive spreading in contrast to the MAR region in vicinity of Iceland and Azores, where substantial contribution of hotter material of a rising plume contributed to formation of the oceanic crust. The North Atlantic Ocean is the youngest province in terms of ocean-floor opening. Geologically and geophysically it is one of well studied regions of the World Ocean. Nevertheless some basic key items of its origin still remain to be clarified. In 1975 Scatler et al. proved specifics of this region manifested in growth of the gravity field, and also in relative height of the ocean floor in the region of 33-70°N, which was associated by them with rise of the hotter mantle, as compared with common regions of the Mid-Atlantic Ridge. Later this view was confirmed by character of magmatism, which differed in depth of generation and by melting degree of the resulting primary magma. Uniqueness of the North Atlantic region was also proved by the fact that this region was marked by extensive geochemical anomalies associated with Azores, Iceland, and Jan Mayen. All of these data allow to consider the northern part of the MAR (north of 33°N) as an united global geotectonic province. The Mohns and Knipovich Ridges located north of Iceland locate at the northern end of this province. This is the least known region. Therefore, new data for ridge areas of 73-77°N are needed for more complete geologic history of the Arctic Basin. The aim of this study was to carry out a complex comparison of magmatism at the Mohns and Knipovich Ridges with magmatism at large segments of the MAR northern province and to reconstruct mechanisms of primary magma formation, as well as conditions of their fractionation. This paper was based on results of studying quenched glasses, which reflect evolution of melt in the course of its formation.