Substantial resources and patient commitment are required to successfully scale-up antiretroviral therapy (ART) and provide appropriate HIV management in resource-limited settings. We used pharmacy refill records to evaluate risk factors for loss to follow-up (LTFU) and non-adherence to ART in a large treatment cohort in Nigeria.We reviewed clinic records of adult patients initiating ART between March 2005 and July 2006 at five health facilities. Patients were classified as LTFU if they did not return >60 days from their expected visit. Pharmacy refill rates were calculated and used to assess non-adherence. We identified risk factors associated with LTFU and non-adherence using Cox and Generalized Estimating Equation (GEE) regressions, respectively. Of 5,760 patients initiating ART, 26% were LTFU. Female gender (p < 0.001), post-secondary education (p = 0.03), and initiating treatment with zidovudine-containing (p = 0.004) or tenofovir-containing (p = 0.05) regimens were associated with decreased risk of LTFU, while patients with only primary education (p = 0.02) and those with baseline CD4 counts (cell/ml(3)) >350 and <100 were at a higher risk of LTFU compared to patients with baseline CD4 counts of 100-200. The adjusted GEE analysis showed that patients aged <35 years (p = 0.005), who traveled for >2 hours to the clinic (p = 0.03), had total ART duration of >6 months (p<0.001), and CD4 counts >200 at ART initiation were at a higher risk of non-adherence. Patients who disclosed their HIV status to spouse/family (p = 0.01) and were treated with tenofovir-containing regimens (p < or = 0.001) were more likely to be adherent.These findings formed the basis for implementing multiple pre-treatment visit preparation that promote disclosure and active community outreaching to support retention and adherence. Expansion of treatment access points of care to communities to diminish travel time may have a positive impact on adherence.
Although medical factors such as hypertension and coagulopathy have been identified that are associated with hemorrhage after renal biopsy, little is known about the role of technical factors. The purpose of our study was to examine the effects of biopsy needle direction on renal biopsy specimen adequacy and bleeding complications.Two hundred and forty-two patients who had undergone ultrasound-guided renal biopsies were included. A printout of the ultrasound picture taken at the time of the biopsy was used to measure the biopsy angle ("angle of attack" [AOA]) and to determine if the biopsy needle was aimed at the upper or lower pole and if the medulla was targeted or avoided.Of the 3 groups of biopsy angle, an AOA of between 50°-70° yielded the most glomeruli per core (P = .001) and the fewest inadequate specimens (4% vs 15% for > 70°, and 9% for < 50°, P = .038). Biopsy directed at a pole vs an interpolar region resulted in fewer inadequate specimens (8% vs 23%, P = .005), while biopsies that were medulla-avoiding resulted in fewer inadequate specimens (5% vs 16%, P = .004) and markedly reduced bleeding complications (12% vs 46%, P < .001) compared to biopsies where the medulla was entered.An AOA of approximately 60°, aiming at the poles, and avoiding the medulla were each associated with fewer inadequate biopsies and bleeding complications. While biopsy of the medulla is necessary for some diagnoses, the increased bleeding risk emphasizes the need for communication between nephrologist, pathologist, and radiologist.
Introduction: The incidence of heart failure (HF), particularly in women, is increasing rapidly. While earlier reports indicated that HF mortality was higher in men compared to women, recent studies have suggested higher HF mortality in women. The cause of this changing pattern is not well described. The purpose of this study was to explore different clinical factors and management patterns that could contribute to this. Methods: We conducted a retrospective chart review study of all the patients admitted to a tertiary academic hospital (Royal University Hospital, University of Saskatchewan, Canada) with a diagnosis of HF in 2015, with follow up analysis up to February 20, 2018. Results: In total, 379 patients were admitted with HF, of which 166 (43.8%) were women. Overall, the most important predictors of mortality on multivariate analysis include admission to non-cardiology services (NCS, p < 0.0001), age on admission (p<0.001), readmission (p=0.001), and haemoglobin on admission (P=0.004). Review of baseline characteristics showed that women with HF were older (p<0.001), and more likely to have HFpEF (26.3% vs. 46.4%, p<0.001) than men. However, women were less likely to have comorbidities including COPD, CKD, PVD, HTN, diabetes and dyslipidemia (p<0.001). In spite of this, there was a trend towards higher mortality among women over the follow up period (57.8% vs. 47.9%, p=0.055). Women were significantly less likely to be admitted to cardiology (62% vs. 71.4%, p=0.0084), and less likely to have follow up scheduled on discharge with either an internist or cardiologist (70.4% vs. 53.6%, p<0.001). Similar gender discrepancy in admission to cardiology was also observed among the subgroup of patients with HFrEF. Conclusions: In our study, women admitted with heart failure had worse overall prognosis than men, in spite of less associated comorbidities. Admission to cardiology service was the most significant positive prognostic factor overall. However, surprisingly, women were significantly less likely to be admitted to cardiology, possibly contributing to their observed poor outcome. Further studies to elucidate factors underlying this observed difference in admission pattern may help improve the management of women with HF.
Abstract Background Multiple sclerosis (MS) is a degenerative disease of the central nervous system (CNS) that disrupts walking function and results in other debilitating symptoms. This study compares the effects of ‘task-oriented exercise’ against ‘generalized resistance and aerobic exercise’ and a ‘stretching control’ on walking and CNS function in people with MS (PwMS). We hypothesize that task-oriented exercise will enhance walking speed and related neural changes to a greater extent than other exercise approaches. Methods This study is a single-blinded, three-arm randomized controlled trial conducted in Saskatchewan, Canada. Eligible participants are those older than 18 years of age with a diagnosis of MS and an expanded Patient-Determined Disease Steps (PDDS) score between 3 (‘gait disability’) and 6 (‘bilateral support’). Exercise interventions are delivered for 12 weeks (3×60-min per week) in-person under the supervision of a qualified exercise professional. Interventions differ in exercise approach, such that task-oriented exercise involves weight-bearing, walking-specific activities, while generalized resistance and aerobic exercise uses seated machine-based resistance training of major upper and lower body muscle groups and recumbent cycling, and the stretching control exercise involves seated flexibility and relaxation activities. Participants are allocated to interventions using blocked randomization that stratifies by PDDS (mild: 3–4; moderate: 5–6) Assessments are conducted at baseline, post-intervention, and at a six-week retention time point. The primary and secondary outcome measures are the Timed 25-Foot Walk Test and corticospinal excitability for the tibialis anterior muscles determined using transcranial magnetic stimulation (TMS), respectively. Tertiary outcomes include assessments of balance, additional TMS measures, blood biomarkers of neural health and inflammation, and measures of cardiorespiratory and musculoskeletal fitness. Discussion A paradigm shift in MS healthcare towards the use of “exercise as medicine” was recently proposed to improve outcomes and alleviate the economic burden of MS. Findings will support this shift by informing the development of specialized exercise programming that targets walking and changes in corticospinal excitability in PwMS. Trial registration ClinicalTrials.gov, NCT05496881, Registered August 11, 2022
Geniuses are born. But the flowering of the multifaceted personality of Rabindranath Tagore was the result of interaction of a variety of favorable environmental factors in producing the genius. The contribution of Rabindranath Tagore in this respect as well as in other fields, especially in education, has been paramount. Rabindranath Tagore, one of the epoch-making figures of the twentieth century, is one of the most widely acclaimed wordsmiths of India. Often hailed as Gurudev or the poet of poets, Tagore, through the sheer brilliance of his narratives and incommensurable poetic flair, laid an ineffaceable impression on the minds of his readers. He was not just a mere poet or writer; he was the harbinger of an era of literature which elevated him to the stature of the cultural ambassador of India. Even today, decades after his death, this saint-like man, lives through his works in the hearts of the people of Bengal who are forever indebted to him for enriching their heritage. He was the most admired Indian writer who introduced India’s rich cultural heritage to the West and was the first non-European to be bestowed the prestigious Nobel Prize. Rabindranath Tagore’s educational model has a unique sensitivity and aptness for education within multi-racial, multi-lingual and multi-cultural situations, amidst conditions of acknowledged economic discrepancy and political imbalance.
For humans and other mammals to eat effectively, teeth must develop properly inside the jaw. Deciphering craniodental integration is central to explaining the timely formation of permanent molars, including third molars which are often impacted in humans, and to clarifying how teeth and jaws fit, function and evolve together. A factor long-posited to influence molar onset time is the jaw space available for each molar organ to form within. Here, we tested whether each successive molar initiates only after a minimum threshold of space is created via jaw growth. We used synchrotron-based micro-CT scanning to assess developing molars in situ within jaws of C57BL/6J mice aged E10 to P32, encompassing molar onset to emergence. We compared total jaw, retromolar and molar lengths, and molar onset times, between upper and lower jaws. Initiation time and developmental duration were comparable between molar upper and lower counterparts despite shorter, slower-growing retromolar space in the upper jaw, and despite size differences between upper and lower molars. Timing of molar formation appears unmoved by jaw length including space. Conditions within the dental lamina likely influence molar onset much more than surrounding jaw tissues. We theorize that molar initiation is contingent on sufficient surface area for the physical reorganization of dental epithelium and its invagination of underlying mesenchyme.
The HIV epidemic is increasing among Men who have Sex with Men (MSM) and the risk for AIDS defining cancer (ADC) is higher among them.To examine the effect of MSM and CD4+ count on time to cancer AIDS (ADC) and noncancer AIDS in competing risks setting in the HAART era.Using Ontario HIV Treatment Network Cohort Study data, HIV-positive adults diagnosed between January 1997 and October 2012 having baseline CD4+ counts ≤ 500 cells/mm3 were evaluated. Two survival outcomes, cancer AIDS and non-cancer AIDS, were treated as competing risks. Kaplan-Meier analysis, Cox cause-specific hazards (CSH) model and joint modeling of longitudinal and survival outcomes were used.Among the 822 participants, 657 (79.9%) were males; 686 (83.5%) received anti-retroviral (ARV) ever. Regarding risk category, the majority (58.5%) were men who have Sex with men (MSM). Mean age was 37.4 years (SD = 10.3). In the multivariate Cox CSH models, MSM were not associated with cancer AIDS but with non-cancer AIDS [HR = 2.92; P = 0.055, HR = 0.54; P = 0.0009, respectively]. However, in joint models of longitudinal and survival outcomes, MSM were associated with cancer AIDS but not with non-cancer AIDS [HR = 3.86; P = 0.013, HR = 0.73; P = 0.10]. CD4+ count, age, ARV ever were associated with both events in the joint models.This study demonstrates the importance of considering competing risks, and timedependent biomarker in the survival model. MSM have higher hazard for cancer AIDS. CD4+ count is associated with both survival outcomes.
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