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Background: Pain in response to noxious cold has a complex molecular background probably involving several types of sensors. A recent observation has been the multimodal distribution of human cold pain thresholds. This study aimed at analysing reproducibility and stability of this observation and further exploration of data patterns supporting a complex background.Method: Pain thresholds to noxious cold stimuli (range 32-0 °C, tonic: temperature decrease -1 °C/s, phasic: temperature decrease -8 °C/s) were acquired in 148 healthy volunteers. The probability density distribution was analysed using machine-learning derived methods implemented as Gaussian mixture modeling (GMM), emergent self-organizing maps and self-organizing swarms of data agents.Results: The probability density function of pain responses was trimodal (mean thresholds at 25.9, 18.4 and 8.0 °C for tonic and 24.5, 18.1 and 7.5 °C for phasic stimuli). Subjects' association with Gaussian modes was consistent between both types of stimuli (weighted Cohen's κ = 0.91). Patterns emerging in self-organizing neuronal maps and swarms could be associated with different trends towards decreasing cold pain sensitivity in different Gaussian modes. On self-organizing maps, the third Gaussian mode emerged as particularly distinct.Conclusion: Thresholds at, roughly, 25 and 18 °C agree with known working temperatures of TRPM8 and TRPA1 ion channels, respectively, and hint at relative local dominance of either channel in respective subjects. Data patterns suggest involvement of further distinct mechanisms in cold pain perception at lower temperatures. Findings support data science approaches to identify biologically plausible hints at complex molecular mechanisms underlying human pain phenotypes.Significance: Sensitivity to pain is heterogeneous. Data-driven computational research approaches allow the identification of subgroups of subjects with a distinct pattern of sensitivity to cold stimuli. The subgroups are reproducible with different types of noxious cold stimuli. Subgroups show pattern that hints at distinct and inter-individually different types of the underlying molecular background. [ABSTRACT FROM AUTHOR]

Background: Remdesivir has demonstrated benefit in some hospitalized patients with coronavirus disease 2019 (COVID-19) on supplemental oxygen and in nonhospitalized patients breathing room air. The durability of this benefit across time periods with different circulating severe acute respiratory syndrome coronavirus 2 variants of concern (VOC) is unknown. This comparative effectiveness study in patients hospitalized for COVID-19 and not receiving supplemental oxygen at admission compared those starting remdesivir treatment in the first 2 days of admission with those receiving no remdesivir during their hospitalization across different VOC periods., Method: Using a large, multicenter US hospital database, in-hospital mortality rates were compared among patients hospitalized for COVID-19 but not requiring supplemental oxygen at admission between December 2020 and April 2022. Patients receiving remdesivir at hospital admission were matched 1:1 to those not receiving remdesivir during hospitalization, using propensity score matching. Cox proportional hazards models were used to assess 14- and 28-day in-hospital mortality rates or discharge to hospice., Results: Among the 121 336 eligible patients, 58 188 remdesivir-treated patients were matched to 17 574 unique patients not receiving remdesivir. Overall, 5.4% of remdesivir-treated and 7.3% in the non-remdesivir group died within 14 days, and 8.0% and 9.8%, respectively, died within 28 days. Remdesivir treatment was associated with a statistically significant reduction in the in-hospital mortality rate compared with non-remdesivir treatment (14-day and 28-day adjusted hazard ratios [95% confidence interval], 0.75 [0.68-0.83] and 0.83 [0.76-0.90], respectively). This significant mortality benefit endured across the different VOC periods., Conclusions: Remdesivir initiation in patients hospitalized for COVID-19 and not requiring supplemental oxygen at admission was associated with a significantly reduced in-hospital mortality rate. These findings highlight a potential survival benefit when clinicians initiated remdesivir on admission across the dominant variant eras of the evolving pandemic., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Remdesivir (RDV) improved clinical outcomes among hospitalized patients with coronavirus disease 2019 (COVID-19) in randomized trials, but data from clinical practice are limited., Methods: We examined survival outcomes for US patients hospitalized with COVID-19 between August and November 2020 and treated with RDV within 2 days of hospitalization vs those not receiving RDV during their hospitalization using the Premier Healthcare Database. Preferential within-hospital propensity score matching with replacement was used. Additionally, patients were also matched on baseline oxygenation level (no supplemental oxygen charges [NSO], low-flow oxygen [LFO], high-flow oxygen/noninvasive ventilation [HFO/NIV], and invasive mechanical ventilation/extracorporeal membrane oxygenation [IMV/ECMO]) and 2-month admission window and excluded if discharged within 3 days of admission (to exclude anticipated discharges/transfers within 72 hours, consistent with the Adaptive COVID-19 Treatment Trial [ACTT-1] study). Cox proportional hazards models were used to assess time to 14-/28-day mortality overall and for patients on NSO, LFO, HFO/NIV, and IMV/ECMO., Results: A total of 28855 RDV patients were matched to 16687 unique non-RDV patients. Overall, 10.6% and 15.4% RDV patients died within 14 and 28 days, respectively, compared with 15.4% and 19.1% non-RDV patients. Overall, RDV was associated with a reduction in mortality at 14 days (hazard ratio [95% confidence interval]: 0.76 [0.70-0.83]) and 28 days (0.89 [0.82-0.96]). This mortality benefit was also seen for NSO, LFO, and IMV/ECMO at 14 days (NSO: 0.69 [0.57-0.83], LFO: 0.68 [0.80-0.77], IMV/ECMO: 0.70 [0.58-0.84]) and 28 days (NSO: 0.80 [0.68-0.94], LFO: 0.77 [0.68-0.86], IMV/ECMO: 0.81 [0.69-0.94]). Additionally, HFO/NIV RDV group had a lower risk of mortality at 14 days (0.81 [0.70-0.93]) but no statistical significance at 28 days., Conclusions: RDV initiated upon hospital admission was associated with improved survival among patients with COVID-19. Our findings complement ACTT-1 and support RDV as a foundational treatment for hospitalized COVID-19 patients., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: The objective of this study was to characterize hospitalized coronavirus disease 2019 (COVID-19) patients and describe their real-world treatment patterns and outcomes over time., Methods: Adult patients hospitalized on May 1, 2020-December 31, 2020 with a discharge diagnosis of COVID-19 were identified from the Premier Healthcare Database. Patient and hospital characteristics, treatments, baseline severity based on oxygen support, length of stay (LOS), intensive care unit (ICU) utilization, and mortality were examined., Results: The study included 295657 patients (847 hospitals), with median age of 66 (interquartile range, 54-77) years. Among each set of demographic comparators, the majority were male, white, and over 65. Approximately 85% had no supplemental oxygen charges (NSOc) or low-flow oxygen (LFO) at baseline, whereas 75% received no more than NSOc or LFO as maximal oxygen support at any time during hospitalization. Remdesivir (RDV) and corticosteroid treatment utilization increased over time. By December, 50% were receiving RDV and 80% were receiving corticosteroids. A higher proportion initiated COVID-19 treatments within 2 days of hospitalization in December versus May (RDV, 87% vs 40%; corticosteroids, 93% vs 62%; convalescent plasma, 68% vs 26%). There was a shift toward initiating RDV in patients on NSOc or LFO (68.0% [May] vs 83.1% [December]). Median LOS decreased over time. Overall mortality was 13.5% and it was highest for severe patients (invasive mechanical ventilation/extracorporeal membrane oxygenation [IMV/ECMO], 53.7%; high-flow oxygen/noninvasive ventilation [HFO/NIV], 32.2%; LFO, 11.7%; NSOc, 7.3%). The ICU use decreased, whereas mortality decreased for NSOc and LFO., Conclusions: Clinical management of COVID-19 is rapidly evolving. This large observational study found that use of evidence-based treatments increased from May to December 2020, whereas improvement in outcomes occurred over this time-period., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Oral pre-exposure prophylaxis (PrEP) is a highly effective option for HIV prevention. To realize the full benefit of PrEP at the population level, uptake must reach those at the greatest risk of HIV acquisition. Guidance published by Centers for Disease Control and Prevention (CDC) suggests that the number of individuals with indications for PrEP is 1.1-1.2 million nationally based on survey data of key populations and local transmission patterns. We applied these estimates at state and county levels to determine the number of individuals who might benefit from PrEP locally and compared our estimates to CDC-published estimates for Colorado., Objective: This analysis aimed to produce estimates of key populations with indications for PrEP in Colorado as a whole and by county type. These estimates will be used for public health strategic planning for HIV prevention goals at the state and county jurisdictional levels., Methods: Colorado population estimates were obtained from the state demography office, which utilizes US decennial census data and input from county and local agencies to forecast the population. We limited our analysis to adults aged 18-59 years to be consistent with CDC methodology for PrEP estimates. We performed a literature review to define the best population-level percentages to determine numbers of HIV-negative men who have sex with men (MSM) and people who inject drugs (PWID) in Colorado. These percentages were applied to the state and to each county by its rural-urban designation. Finally, CDC-derived percentages of MSM and PWID with indications for PrEP were applied to these estimates to determine numbers of MSM and PWID who may benefit from PrEP use., Results: In 2017, 3,252,648 adults aged 18-59 years were living in Colorado. By applying published estimates of percentages of men who had sex with other men in the past 12 months, we determined that 41,353-49,624 adult males could be considered sexually active MSM. We estimated that 9758-13,011 adults aged 18-59 years were likely to have injected drugs in the past 12 months. By accounting for numbers of people living with HIV in those categories and applying the CDC PrEP percentages of MSM and PWID with indications for PrEP nationally, we estimated that 8792-12,528 MSM and PWID in Colorado had indications for PrEP; this number is smaller than that estimated by CDC, although within the lower CI limit., Conclusions: By employing a simple framework consisting of census data, literature review, population estimates, and national estimates for PrEP indicators, we derived estimates for potential PrEP use in our state. Statewide estimates of key populations by state and county type will enable health officials to set informed goals and track progress toward optimizing PrEP uptake. This formula may be applicable to other states with similar epidemics and resources. ., (©Jennifer A Donnelly, Thomas T Deem, Megan A Duffy, Anita K Watkins, Alia A Al-Tayyib, Daniel J Shodell, Mark Thrun, Sarah E Rowan. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 16.01.2019.)

Objective: The instructional approach used to teach skills and competencies seems to have a critical impact on retaining and performing the learned skills/competencies. However, for most of them, the effect of different instructional approaches as well as evidence for appropriate approaches is unknown. The aim of the present study was to analyze and compare the impact of different instructional approaches in the acquisition of basic skills during undergraduate surgical training., Design: Randomized controlled cohort study. For the intervention, four instructional approaches ('See one - Do one', 'Video 4-Step Approach', 'Mental Group Mapping', and 'Control') were compared in six basic skills. Students completed a six-station OSCE (one for each skill) during their skills lab training week after the intervention., Setting: This study was conducted at the medical faculty of the Goethe University, Frankfurt, Germany., Participants: Medical students in their fourth year completing their four week of obligatory surgical training., Results: A total of 151 students were included. The group 'Mental Group Mapping' scored significantly higher in comparison to 'See one - Do one' in four of the six skills and 'Control' in five skills. The group 'Video 4-Step Approach' scored significantly higher in comparison to 'See one - Do one' (three skills) in comparison to 'Control' (two skills). There were no significant differences between the approaches 'Mental Group Mapping' and 'Video 4-Step Approach' as well as between the approaches 'See one - Do one' and 'Control'., Conclusion: Activating instructional approaches such as the '4-Step Approach' and 'Mental Group Mapping' have a significant impact on performing the learned skills and competencies., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

An online consultation tool, the Sexually Transmitted Diseases Clinical Consultation Network is a new resource for sexually transmitted disease clinicians and clinic managers. An initial evaluation shows that most requests (29%) were from medical doctors, followed by nurse practitioners (22%). Syphilis queries comprised 39% of consults followed by gonorrhea (12%) and chlamydia (11%).

Lipid metabolism has been suggested to be a major pathophysiological mechanism of multiple sclerosis (MS). With the increasing knowledge about lipid signaling, acquired data become increasingly complex making bioinformatics necessary in lipid research. We used unsupervised machine-learning to analyze lipid marker serum concentrations, pursuing the hypothesis that for the most relevant markers the emerging data structures will coincide with the diagnosis of MS. Machine learning was implemented as emergent self-organizing feature maps (ESOM) combined with the U*-matrix visualization technique. The data space consisted of serum concentrations of three main classes of lipid markers comprising eicosanoids ( d = 11 markers), ceramides ( d = 10), and lyosophosphatidic acids ( d = 6). They were analyzed in cohorts of MS patients ( n = 102) and healthy subjects ( n = 301). Clear data structures in the high-dimensional data space were observed in eicosanoid and ceramides serum concentrations whereas no clear structure could be found in lysophosphatidic acid concentrations. With ceramide concentrations, the structures that had emerged from unsupervised machine-learning almost completely overlapped with the known grouping of MS patients versus healthy subjects. This was only partly provided by eicosanoid serum concentrations. Thus, unsupervised machine-learning identified distinct data structures of bioactive lipid serum concentrations. These structures could be superimposed with the known grouping of MS patients versus healthy subjects, which was almost completely possible with ceramides. Therefore, based on the present analysis, ceramides are first-line candidates for further exploration as drug-gable targets or biomarkers in MS.

Introduction: Federal health reform has the potential to impact many public health services, especially sexual health clinics. To assess the impact of such reform within the Denver Sexual Health Clinic (DSHC), we conducted a survey of patients to better understand our client population and their care-seeking behavior., Methods: Survey data were collected from patients attending the DSHC at 3 different points in time to ascertain insurance status, reasons for not having insurance, reasons for choosing care at the DSHC, and health care use over the past 12 months., Results: A total of 1603 surveys were completed. Forty-two percent of participants were enrolled in health insurance at the time of visit. The percentage of patients with Medicaid increased more than 200% across the survey cycles. Cost was the main reason cited for not having insurance. Participants identified confidentiality and convenience among the top reasons for seeking care at the DSHC regardless of sex or insurance. Although there was no difference in health care use for sexual health services, individuals with health insurance were more likely to have used nonsexual health services in the past 12 months than those without insurance., Conclusions: Patients continue to visit the DSHC despite having health insurance. Sexual health clinics must work to understand what drives people to seek care so that they can better prepare for the future.

Denver Public Health implements the National HIV Behavioral Surveillance System (NHBS), a cyclical survey of populations at increased risk for HIV. We evaluated the implementation of NHBS among Denver men who have sex with men (MSM), considering the system's simplicity, data quality, representativeness, and sensitivity to trends. We found that the time required for implementation and the complexity of data management and analysis are barriers to disseminating local findings. Data quality has improved in each cycle of the study but must be protected by continually checking for errors and training field staff to be attentive to detail. Compared with the US census and other convenience samples of Denver MSM, the overall demographic representativeness of NHBS has improved over time. However, there is concern that the underlying population included in the study may be changing. NHBS survey data show evidence of two suspected trends in the local MSM population at risk for HIV: increasing sexual risk-taking and the transition away from bars as a dominant partner-finding location. It is unclear whether the increasing reports of sexual risk-taking reflect a real trend or simply a change in the population sampled, since most NHBS participants are recruited at gay bars and other venues. To ensure that the sample continues to represent the underlying population at risk and accurately identify trends, it is necessary to closely monitor MSM sample characteristics during implementation and incorporate weighted data provided by the Centers for Disease Control and Prevention into analyses.

Whether overt attention in natural scenes is guided by object content or by low-level stimulus features has become a matter of intense debate. Experimental evidence seemed to indicate that once object locations in a scene are known, salience models provide little extra explanatory power. This approach has recently been criticized for using inadequate models of early salience; and indeed, state-of-the-art salience models outperform trivial object-based models that assume a uniform distribution of fixations on objects. Here we propose to use object-based models that take a preferred viewing location (PVL) close to the centre of objects into account. In experiment 1, we demonstrate that, when including this comparably subtle modification, object-based models again are at par with state-of-the-art salience models in predicting fixations in natural scenes. One possible interpretation of these results is that objects rather than early salience dominate attentional guidance. In this view, early-salience models predict fixations through the correlation of their features with object locations. To test this hypothesis directly, in two additional experiments we reduced low-level salience in image areas of high object content. For these modified stimuli, the object-based model predicted fixations significantly better than early salience. This finding held in an object-naming task (experiment 2) and a free-viewing task (experiment 3). These results provide further evidence for object-based fixation selection--and by inference object-based attentional guidance--in natural scenes., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Persons living with HIV (PLWH) are living longer, remaining sexually active, and may continue risky sexual behaviors. As such, it is crucial for providers to ask all HIV-positive patients about behaviors related to HIV transmission and STD acquisition. The "Ask, Screen, Intervene" (ASI) curriculum was developed to increase provider knowledge, skills, and motivation to incorporate risk assessment and prevention services into the care of PLWH. The ASI curriculum was delivered to 2558 HIV-care providers at 137 sites between September 30, 2007 and December 31, 2010. Immediately post-training, participants self-reported significant gains in perceived confidence to demonstrate ASI knowledge and skills (p < 0.001) and 89% agreed they would update practices as a result of the training. Three to six months post-training, 320 participants who served PLWH or supervised HIV-care providers self-reported more frequently performing ASI skills (p < 0.001), and 71% self-reported greater perceived confidence than before training to perform those skills (p < 0.001). Limitations include self-reported measures and a 30% response rate to the 3-6 month follow-up survey. Our findings suggest that a well-coordinated training program can reach a national audience of HIV-care providers, significantly increase self-reported capacity to incorporate HIV/STD prevention into the care of PLWH, and increase implementation of national recommendations.

Background: Partner notification of exposure to gonorrhea or chlamydia is traditionally conducted by the index case or a disease intervention specialist. However, a significant proportion of partners remain untreated and thus are at risk for continued transmission. Expedited partner therapy (EPT) obviates the requirement for a health care visit by the partner: the index case delivers medications to the partner. Although shown to be efficacious in randomized control trials, effectiveness studies of delivering EPT in real-world situations are needed. We describe the implementation, patient characteristics, and clinical impact of an EPT program at the Denver Metro Health Clinic (DMHC)., Methods: We identified 2578 patient visits eligible for EPT (heterosexual men or women diagnosed as having chlamydia or gonorrhea) from November, 2006, to April, 2011. We examined EPT acceptance rates over clinical process improvements. To measure clinical impact, we assessed the association between initial acceptance of EPT and infection status among 351 patients who returned for retesting., Results: Requiring complete documentation of EPT in the clinic electronic medical record increased EPT acceptance from 20% to 48%. Expedited partner therapy acceptance was associated with a reduced risk of chlamydial reinfection (odds ratio, 0.7; 95% confidence interval, 0.3-1.6) and a reduced risk of gonorrheal reinfection (odds ratio, 0.5; 95% confidence interval, 0.2-1.4); however, these changes were not statistically significant., Conclusions: Expedited partner therapy at the DMHC was substantially enhanced by process changes in the clinic and may be associated with a decreased risk of reinfection.

Most people living with HIV/AIDS (PLWHA) disclose their serostatus to their sexual partners and take steps to protect their partners from HIV. Prior research indicates that some PLWHA portray themselves to their sexual partners as HIV-negative or otherwise misrepresent their HIV status. The aim of this study was to document the prevalence of misleading sexual partners about HIV status and to identify factors associated with misleading. A sample of 310 PLWHA completed a self-administered questionnaire assessing demographic information, disclosure, HIV knowledge, HIV altruism, psychopathy, and sexual risk behavior. Participants were also asked "Since you were diagnosed as having HIV, have you ever misled a sexual partner about your HIV status?" Overall, 18.6% of participants indicated that they had misled a sexual partner. Those who had misled a partner at some point since their diagnosis reported more current HIV transmission risk behaviors, including unprotected anal or vaginal sex with a partner who was HIV-negative or whose HIV status was unknown. Participants who had misled a partner did not differ from those who had not in terms of demographic characteristics. Individuals who had misled a partner scored significantly lower on a measure of HIV knowledge than those who had not misled a partner. HIV altruism and psychopathy were associated with sexual risk behavior, but did not differ between those who had misled and those who had not. Disclosure of HIV status can reduce HIV transmission, but only if people are candid. Interventions aimed at increasing knowledge and accurate disclosure may reduce the spread of HIV.

Objectives: In 2006, the Centers for Disease Control and Prevention (CDC) published recommendations for HIV testing in health care settings, calling for nontargeted opt-out rapid HIV screening in most settings, including emergency departments (EDs). Although a number of ED-based testing strategies exist, it is unclear to what extent they are used. The objective of this study is to survey academic and community EDs throughout the United States to determine ED-based HIV testing practices., Methods: This was a cross-sectional survey study of all academic EDs and a weighted random sample of all community-based EDs in the United States. A standardized survey instrument was developed and administered with an Internet-based survey platform, followed by direct contact and mail. The survey included domains related to perceived HIV testing barriers, whether HIV testing was performed and methods used, and familiarity with the CDC recommendations and whether they had been adopted., Results: Of the 131 total academic sites and the 435 community sites, 99 (76%) and 150 (35%) completed the survey, respectively. A larger proportion of academic sites believed HIV testing was needed (P=.02) and a larger proportion actually provided HIV testing (65% versus 50%; P=.04). Among the academic and community EDs that provided testing, 74% and 62% performed diagnostic testing, 26% and 22% performed targeted screening, and 16% and 6% performed nontargeted screening, respectively. A larger proportion of academic EDs reported receiving external funding to support testing (23% versus 4%; P=.001), whereas a large proportion of community sites considered costs a significant barrier to testing (P=.03). A larger proportion of academic EDs reported being familiar with the 2006 CDC recommendations (64% versus 40%; P<.001), although only 26% and 37% reported having implemented any part of them, respectively., Conclusion: Academic EDs only make up approximately 3% of all EDs in the United States. Significant differences exist between academic and community EDs as they relate to performing HIV testing. Increased efforts should be made to improve the ability of community EDs to provide this service., (Copyright © 2011. Published by Mosby, Inc.)

Few studies have examined the psychosocial factors associated with sexual transmission behaviors among HIV-positive men who have sex with men (MSM), heterosexual men (MSW) and women. We enrolled 1,050 sexually active HIV-positive patients at seven HIV clinics in six US cities as part of a clinic-based behavioral intervention. We describe the sexual transmission behaviors and examine demographic, clinical, psychosocial, and clinic prevention variables associated with unprotected anal or vaginal intercourse (UAVI). Twenty-three percent of MSM, 12.3% of MSW and 27.8% of women engaged in UAVI with partners perceived to be HIV-negative or of unknown serostatus. Among MSM and MSW, having multiple partners and lower self-efficacy were associated with increased odds of UAVI. Self-rating one's health status as excellent/very good was a risk factor for UAVI among MSM. Among women, binge drinking and stressful life events were associated with UAVI. These findings identify variables that warrant attention in targeted interventions.

In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.

The Centers for Disease Control and Prevention have recommended that HIV care clinics incorporate prevention into clinical practice. This report summarizes HIV care providers' attitudes and counseling practices before and after they received training to deliver a counseling intervention to patients. Providers at seven HIV clinics received training in delivering a counseling intervention (Positive STEPs) to their patients and completed baseline and follow-up questionnaires to measure changes in prevention parameters. A cohort of patients at each clinic was independently surveyed about counseling experiences. Compared with the pretraining period, providers' self-ratings collected after they initiated the intervention showed significant (p < .05) positive changes in attitudes, comfort, self-efficacy, and frequency of delivering prevention counseling. Patients reported an increase in prevention counseling received from providers after training. The findings indicate that the training and delivery of the Positive STEPs intervention was associated with positive changes in providers' attitudes and HIV prevention counseling to patients.

We conducted a demonstration project to design, implement, and evaluate a risk-reduction intervention delivered by medical providers to patients with HIV during routine care in 2005 and 2006. Medical providers at seven HIV clinics in the United States received training to deliver an intervention in which they screened patients for behavioral risks, gave targeted counseling, and delivered prevention messages. A longitudinal cohort (n = 767) of patients completed a baseline questionnaire and two follow-up questionnaires (6-month intervals) after the intervention was initiated. Logistic regression and generalized estimating equations (GEE) methods were used in analyses. The cohort had a median age of 41, was 58% black, 28% white, and 10% Hispanic; 32% were women and 42% self-identified as men who have sex with men. The 3-month prevalence of unprotected anal or vaginal intercourse (UAVI) with any partners declined significantly (p < 0.001) from baseline (42%) to follow-up (26% at first follow-up, 23% at second follow-up). The decline was significant with partners who were HIV-negative/unknown serostatus or HIV-positive. Cohort patients' self-reported receipt of safer-sex counseling at all, some, or no clinic visits during the interval between baseline and first follow-up showed a dose-response relationship with decline in prevalence of UAVI in that interval, with relative reductions of 45%, 35%, and 19%, respectively. All findings were confirmed in multivariate models that controlled for demographic factors and HIV clinical status of participants. This project demonstrated that with only brief training, HIV medical providers successfully conducted an HIV prevention intervention with their clinic patients. Our findings indicate that clinics that serve HIV patients can incorporate such programs as standard of care.

One of the many causes of enteral feeding (EF) intolerance after traumatic brain injury (TBI) is superior mesenteric artery syndrome (SMAS). Although it is reported in pediatric brain injury, few cases are noted in adults. To increase awareness of this medically treatable condition, we present two patients who developed SMAS after sustaining severe brain injury. SMAS results from compression of the duodenum by the SMA against the aorta and risk factors include acute weight loss, prolonged recumbency, and spasticity--all frequently encountered in severe TBI. After gastric decompression, symptoms often resolve with weight gain achieved by conservative treatment; including feeding in the left lateral or prone position, hyperalimentation, or extension of a feeding tube beyond the obstruction. SMAS should be considered in the presence of EF intolerance in severe adult TBI because multiple risk factors may be present.

Organized cooperation in the field of vocational rehabilitation has been established at EC-level more than fifteen years ago, the first meeting of the community network of rehabilitation centres having taken place on the 20th of October, 1975. This cooperation has been intensified and extended by HELIOS, the second action programme on behalf of disabled persons adopted by the Council of Ministers in April 1988, to continue the efforts started by the initial action programme. In the fields of occupational qualification, languages, and new technologies, "Europe 92" will give rise to new challenges that imperatively ask for closer cooperation among rehabilitation workers in the Community. In the framework of HELIOS, this cooperation has already been started.

Developed in the 1960s, the concept for vocational rehabilitation in the vocational retraining centres has proven its worth also in the face of the great challenges of the 80s. Not all of the partly profound changes which have taken place in the environs of vocational rehabilitation over the last few years had been positive ones. Before this background, it must therefore be asked how the standard attained by the vocational retraining centres is to be viewed and which route the vocational rehabilitation field is going to take in the 90s. The process of societal and technological change over recent years is likely to further accelerate in the 90s, with numerous implications for vocational education and disability policies. Even more so than in the past, this process will require adjustments to be made, but equally give rise to innovative efforts and developments. The demands to be faced by the facilities are therefore going to increase, and major re-structuring processes will have to take place also in the vocational retraining centres.