A Correction for Overestimation Bias in Estimates of Black-Tailed Prairie Dog Abundance Based on Aerial Surveys of Colony Sites in Colorado and Montana

Estimates of abundance of black-tailed prairie dogs (Cynomys ludovicianus) are obtained by estimating the area occupied by colonies. An approach for estimating this area used in Colorado and Montana was based on aerial survey transects that recorded the end points where transects intercepted and exited colony sites. Line intercept mathematical techniques were applied to these intercept data to obtain estimates of occupied area. We define a “colony site” as an aggregation of prairie dog burrows while a prairie dog “colony” is defined as the portion of a colony site that is occupied by living prairie dogs. Because of poisoning, plague and other factors, colony sites are commonly not completely occupied by colonies. In both Colorado and Montana, however, estimates obtained were estimates of the area occupied by colony sites that had some undetermined level of occupancy by colonies. We show for Colorado that the difference between estimates of area occupied by colonies was much less than the area occupied by colony sites. We provide an approach to correct estimates based on the extent of colony sites. This approach requires ground surveys of a sample of aerial intercepts of colony sites to document the proportion that is actually occupied by colonies of living black-tailed prairie dogs. Black-tailed prairie dogs were found as not-warranted for listing in 2004 in part because of inflated estimates of abundance obtained in Colorado that incorrectly equated the extent of colony-sites as equivalent to the extent of colonies in that state

A clinician-nurse model to reduce early mortality and increase clinic retention among high-risk HIV-infected patients initiating combination antiretroviral treatment

<p>Abstract</p> <p>Background</p> <p>In resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting.</p> <p>Methods</p> <p>The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm³. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm³were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods.</p> <p>Results</p> <p>Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm³. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45-0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55-0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57-0.67).</p> <p>Conclusions</p> <p>Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.</p

Short-Term Rationing of Combination Antiretroviral Therapy: Impact on Morbidity, Mortality, and Loss to Follow-Up in a Large HIV Treatment Program in Western Kenya

Background. There was a 6-month shortage of antiretrovirals (cART) in Kenya. Methods. We assessed morbidity, mortality, and loss to follow-up (LTFU) in this retrospective analysis of adults who were enrolled during the six-month period with restricted cART (cap) or the six months prior (pre-cap) and eligible for cART at enrollment by the pre-cap standard. Cox models were used to adjust for potential confounders. Results. 9009 adults were eligible for analysis: 4,714 pre-cap and 4,295 during the cap. Median number of days from enrollment to cART initiation was 42 pre-cap and 56 for the cap (P < 0.001). After adjustment, individuals in the cap were at higher risk of mortality (HR = 1.21; 95% CI : 1.06–1.39) and LTFU (HR = 1.12; 95% CI : 1.04–1.22). There was no difference between the groups in their risk of developing a new AIDS-defining illness (HR = 0.92 95% CI 0.82–1.03). Conclusions. Rationing of cART, even for a relatively short period of six months, led to clinically adverse outcomes

A model for extending antiretroviral care beyond the rural health centre

<p>Abstract</p> <p>Background</p> <p>A major obstacle facing many lower-income countries in establishing and maintaining HIV treatment programmes is the scarcity of trained health care providers. To address this shortage, the World Health Organization has recommend task shifting to HIV-infected peers.</p> <p>Methods</p> <p>We designed a model of HIV care that utilizes HIV-infected patients, community care coordinators (CCCs), to care for their clinically stable peers with the assistance of preprogrammed personal digital assistants (PDAs). Rather than presenting for the standard of care, monthly clinic visits, in this model, patients were seen every three months in clinics and monthly by their CCCs in the community during the interim two months. This study was conducted in Kosirai Division, western Kenya, where eight of the 24 sub-locations (defined geographic areas) within the division were randomly assigned to the intervention with the remainder used as controls.</p> <p>Prior to entering the field, CCCs underwent intensive didactic training and mentoring related to the assessment and support of HIV patients, as well as the use of PDAs. PDAs were programmed with specific questions and to issue alerts if responses fell outside of pre-established parameters. CCCs were regularly evaluated in six performance areas. An impressionistic analysis on the transcripts from the monthly group meetings that formed the basis of the continuous feedback and quality improvement programme was used to assess this model.</p> <p>Results</p> <p>All eight of the assigned CCCs successfully passed their training and mentoring, entered the field and remained active for the two years of the study. On evaluation of the CCCs, 89% of their summary scores were documented as superior during Year 1 and 94% as superior during Year 2. Six themes emerged from the impressionistic analysis in Year 1: confidentiality and "community" disclosure; roles and responsibilities; logistics; clinical care partnership; antiretroviral adherence; and PDA issues. At the end of the trial, of those patients not lost to follow up, 64% (56 of 87) in the intervention and 52% (58 of 103) in the control group were willing to continue in the programme (p = 0.26).</p> <p>Conclusion</p> <p>We found that an antiretroviral treatment delivery model that shifted patient monitoring and antiretroviral dispensing tasks into the community by HIV-infected patients was both acceptable and feasible.</p> <p>Trial registration</p> <p>ClinicalTrials.gov ID NCT00371540</p

Differences between self-reported and electronically monitored adherence among patients receiving antiretroviral therapy in a resource-limited setting

Measurement of adherence to antiretroviral therapy (ART) by patient self-report is common in resource-limited settings but widely believed to overstate actual adherence. The extent to which these measures overstate adherence has not been examined among a large patient population

Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers

Objective: Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers. Method: Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR. Results: Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training. Conclusions: We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow

Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders

There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya

A comprehensive analysis of rare genetic variation in amyotrophic lateral sclerosis in the UK.

Amyotrophic lateral sclerosis is a progressive neurodegenerative disease of motor neurons. About 25 genes have been verified as relevant to the disease process, with rare and common variation implicated. We used next generation sequencing and repeat sizing to comprehensively assay genetic variation in a panel of known amyotrophic lateral sclerosis genes in 1126 patient samples and 613 controls. About 10% of patients were predicted to carry a pathological expansion of the C9orf72 gene. We found an increased burden of rare variants in patients within the untranslated regions of known disease-causing genes, driven by SOD1, TARDBP, FUS, VCP, OPTN and UBQLN2. We found 11 patients (1%) carried more than one pathogenic variant (P = 0.001) consistent with an oligogenic basis of amyotrophic lateral sclerosis. These findings show that the genetic architecture of amyotrophic lateral sclerosis is complex and that variation in the regulatory regions of associated genes may be important in disease pathogenesis

Correcting Mortality for Loss to Follow-Up: A Nomogram Applied to Antiretroviral Treatment Programmes in Sub-Saharan Africa

Matthias Egger and colleagues present a nomogram and a web-based calculator to correct estimates of program-level mortality for loss to follow-up, for use in antiretroviral treatment programs

More than just trees: Assessing reforestation success in tropical developing countries

Rural communities in many parts of the tropics are dependent of forests for their livelihoods and for environmental services. Forest resources in the tropics have declined rapidly over the past century and therefore many developing countries in the tropics have reforestation programs. Although reforestation is a long-term process with long-term benefits, existing evaluations of the success of these programs tends to focus on short-term establishment success indicators. This paper presents a review of reforestation assessment that highlights the need to not only consider short-term establishment success, but also longer-term growth and maturation success, environmental success and socio-economic success. In addition, we argue that reforestation assessment should not be based on success indicators alone, but should incorporate the drivers of success, which encompasses an array of biophysical, socio-economic, institutional and project characteristics. This is needed in order to understand the reasons why reforestation projects succeed or fail and therefore to design more successful projects in future. The paper presents a conceptual model for reforestation success assessment that links key groups of success indicators and drivers. This conceptual model provides the basis for a more comprehensive evaluation of reforestation success and the basis for the development of predictive systems-based assessment models. These models will be needed to better guide reforestation project planning and policy design and therefore assist rural communities in tropical developing countries to alleviate poverty and achieve a better quality of life