Antiretroviral therapy drug adherence in Rwanda: Perspectives from patients and healthcare workers using a mixed-methods approach

Rwanda has achieved high enrollment into antiretroviral therapy (ART) programs but data on adherence after enrollment are not routinely collected. We used a mixed-methods approach (standardized questionnaires, pill counts, focus group discussions, and in-depth interviews) to determine levels of and barriers to ART adherence from the perspective of both patients and healthcare workers (HCW). Data were available from 213 patients throughout the first year on ART; 58 of them and 23 HCW participated in a qualitative sub-study. Self-reported adherence was high (96% of patients reporting more than 95% adherence), but adherence by pill count was significantly lower, especially in the first 3 months. In the standardized interviews, patients mostly reported that they “simply forgot” or “were away from home” as reasons for nonadherence. The qualitative research identified three interrelated constructs that appeared to negatively influence adherence: stigma, difficulty coming to terms with illness, and concealment of illness. Both standardized questionnaires and the qualitative research identified poverty, disruption to daily routines, factors related to regimen complexity and side effects, and service-related factors as barriers to adherence. We conclude that regular triangulation of different sources of adherence data is desirable to arrive at more realistic estimates. We propose that program monitoring and evaluation cycles incorporate more in-depth research to better understand concerns underlying reasons for nonadherence reported in routine monitoring.     

Gender differences in eating disorder symptoms in young adults

OBJECTIVE: The major goal of this study was to identify problematic eating behaviors and attitudes in young men and compare them with those of young women. METHOD: A community sample of young adults (n = 1,056) completed a questionnaire that contained the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder Inventory, as well as probes for inappropriate compensatory behaviors, excessive exercise, and episodes of binge eating. RESULTS: A five-factor structure fit both male and female samples. Women had substantially elevated scores on all of the factors except excessive exercise, for which men had significantly higher scores. The absolute proportion of men and women wanting or having sought treatment was very low. However, at comparable levels of problematic eating behaviors, women were more likely to have sought treatment than men. DISCUSSION: The questionnaire used in this study encompasses symptoms outlined in the Diagnostic and Statistical Manual of Mental Disorders symptoms, which should prove useful in future research.     

Bacterial aortitis resulting in rapid development of infective "mycotic" aneurysm

Aortitis and aneurysms with an infective etiology, though uncommon, must be recognized at imaging so that early medical and surgical intervention can improve survival. We report a case in which serial CT scans illustrate the short-interval development of an infective "mycotic" aneurysm resulting from bacterial aortitis. Electronic Publication     

Views of breastfeeding difficulties among drop-in-clinic attendees

Breast-milk is the optimum form of nutrition for the first 6 months of life. However, breastfeeding rates in the UK are low and static compared to other European countries and those in the North-west of England in the UK are even lower. Of the women who initiate breastfeeding, many cease in the first month following the birth for reasons that might be avoided. To try and prevent this, UNICEF Baby Friendly Hospital Initiative (BFHI) 'Ten Steps to Successful Breastfeeding' state that maternity facilities should foster the development of support groups for breastfeeding women. The aim of the present study was to describe breastfeeding difficulties reported by women who attended the infant feeding clinic at a Women's Hospital in the North-west of England. During the study period, the clinic was attended mainly by primiparous mothers who were educated beyond 18 years of age and of higher socio-economic status. They presented with a variety of problems including baby not latching on, concerns about baby's weight gain/loss, sore nipples and advice about expressing milk in preparation for return to work. The women highlighted the importance of meeting other mothers and having someone to talk to who understood what they were going through. Inconsistent information/lack of detailed knowledge from health professionals was cited as contributing to breastfeeding difficulties. A number of women reported that expert hands-on, one-to-one support, was invaluable and many felt they were able to continue breastfeeding but without the support, they may have given up.     

Taking charge of epilepsy: the development of a structured psychoeducational group intervention for adolescents with epilepsy and their parents

Children and adolescents with epilepsy frequently experience poor psychosocial outcomes due to numerous factors such as perceived stigma, behavior problems, academic difficulties, and depression. Health psychology research has documented the effectiveness of psychoeducational interventions aimed at improving psychosocial outcomes for individuals with a variety of health conditions. With increasing numbers of adolescents living with epilepsy, interest in improving the quality of life for this particular population has grown. There remains, however, a paucity of research concerning psychosocial interventions for adolescents with epilepsy. The present study outlines the development and initial implementation of a 6-week structured psychoeducational group intervention for adolescents with epilepsy and their parents. Preintervention, the QOLIE-AD-48, Childhood Depression Inventory, and Revised Children's Manifest Anxiety Scale were administered. Educational topics included medical aspects of epilepsy, healthy lifestyle behaviors, family and peer relationships, understanding self-image and self-esteem, and stress management techniques. Participants were introduced to a variety of cognitive-behavioral strategies, and were encouraged to share their own experiences with epilepsy. Feedback from adolescent and parent participants indicated that the intervention was relevant to their needs, helped them better understand their epilepsy, and allowed an opportunity for positive peer support. Also, postintervention outcome measurement indicated an overall positive trend for quality of life improvement in the adolescents.     

Mastitis nonpuerperalis after nipple piercing: time to act

OBJECTIVE: To review the literature and discuss problems related to post-piercing breast abscesses. MATERIALS AND METHODS: Retrospective analysis of 10 case reports after Medline and internet search regarding breast abscess after nipple piercing. RESULTS: Nine case reports are published in Medline so far, the first in 1982, but eight within the last 3 years. One abstract of a case report presented at a meeting was found on the internet. Average patient age was 31.2 (15-60) years; 7 female and 3 male. Side of breast infection was 5 right, 4 left, and one both. The interval between piercing and treatment was on the average 20.8 (2-52) weeks, duration of symptoms 1 week to several months. Therapy in 9 patients was antibiotics and in 7 operation. The following major complications were seen: endocarditis, heart valve operation, prosthesis infection, metal foreign body in breast tissue, one reoperation because of recurrent infection, psychological stress because of primary diagnosis of breast cancer in 2 cases. CONCLUSION: The risks in nipple piercing are obviously under-documented and may be as high as 10-20% in the months after the procedure. Healing of the wound channel can take 6-12 months.     

Anesthetic technique influences brain temperature,independently of core temperature,during craniotomy in cats

Because anesthetic technique has the potential to dramatically affect cerebral blood flow and metabolism (two determinants of brain thermoregulation), we tested the hypothesis that, after craniotomy, anesthetic technique would influence brain temperature independent of core temperature. Twenty-one cats (2.7 +/- 0.4 kg; mean +/- SD) undergoing a uniform right parasagittal craniotomy received 1) halothane 1.5% end-expired and normocapnia (HN), 2) halothane 1.5% and hypocapnia (HH), or 3) large-dose pentobarbital and normocapnia (PN) (n = 7 per group). Heating devices initially maintained core and right subdural normothermia (38.0 degrees C). Thereafter, cranial heating was discontinued. Brain-to-core temperature gradients during the 3 h study were greatest in the right subdural area, averaging -2.5 degrees C +/- 0.9 degrees C in HN, -2.5 degrees C +/- 0.8 degrees C in HH, and -4.1 degrees C +/- 1.1 degrees C in PN. Gradients within the unexposed left subdural area and in the right cortex 0.5 and 1.0 cm below the brain surface were -0.8 degrees C +/- 0.5 degrees C to -1.1 degrees C +/- 0.6 degrees C for both HN and HH but were twice this amount in PN (-1.9 degrees C +/- 0.5 degrees C to -2.1 degrees C +/- 0.7 degrees C) (P < 0.05 for PN versus HN and HH). Deep barbiturate anesthesia can reduce brain temperature independently of core temperature, presumably by reducing the metabolic rate and associated brain heat production. The magnitude is sufficient to augment any direct cerebroprotective properties of the barbiturates. IMPLICATIONS: Deep barbiturate anesthesia reduced brain temperature independently of body temperature in cats and significantly more than the reduction seen with halothane anesthesia. The magnitude of temperature reduction was sufficient to account for cerebral protection by barbiturates independently of any other properties of the drug.     

Molecular profiling of hepatocellular carcinomas developing spontaneously in acyl-CoA oxidase deficient mice: comparison with liver tumors induced in wild-type mice by a peroxisome proliferator and a genotoxic carcinogen

By using cDNA microarrays, we studied the expression profiles of 26 hepatocellular carcinomas (HCC) developing spontaneously in peroxisomal fatty acyl-CoA oxidase null (AOX-/-) mice. The development of liver tumors in AOX-/- mice is due to sustained activation of peroxisome proliferator-activated receptor alpha (PPARalpha) by the unmetabolized substrates of AOX, which serve as natural PPARalpha ligands. We then compared the AOX-/- liver tumor expression profiles with those induced by ciprofibrate, a non-genotoxic peroxisome proliferator, or by the genotoxic carcinogen diethylnitrosamine (DENA) to discern differences in gene expression patterns that may predict or distinguish PPARalpha-mediated liver tumors from genotoxically derived tumors. Our results show that HCCs developing in AOX-/- mice share a number of deregulated (up- or down-regulated) genes with ciprofibrate-induced liver tumors. The overall commonality of expression between AOX-/- and ciprofibrate-induced liver tumors but not with DENA-induced tumors strongly implicates the activation of PPARalpha and PPARalpha-regulated genes in liver, including those participating in lipid catabolism, as key factors in the development of HCC in AOX-/- and in ciprofibrate-treated mice. Northern blot analysis confirmed the differential expression of some of the genes identified in the present study, and also some genes identified previously as PPARalpha regulated, such as CD36, lymphocyte antigen 6 complex locus (Ly-6D), and C3f. We found a panel of 12 genes upregulated in all three classes of liver tumors, namely AOX-/-, ciprofibrate-induced and DENA-induced. These include an uncharacterized RIKEN cDNA, lipocalin 2, insulin-like growth factor-binding protein 1, Ly-6D and CD63 among others. In conclusion, these results identify distinguishing features between non-genotoxic and genotoxic carcinogen derived liver tumors as well as genes that are upregulated in both types and suggest that RIKEN cDNA, Ly-6D and lipocalin 2 in particular appear to be desirable molecular markers for further study in liver carcinogenesis and progression.