Bacterial resistance development is one of the most urgent problems in healthcare worldwide. In Europe, dentistry accounts for a comparatively high amount of antibiotic prescriptions. In light of increasing levels of bacterial resistance, this development is alarming. So far, very few interventional studies have been performed, and further research is urgently needed. By means of a complex educational intervention, the DREAM trial aims at optimising antibiotic prescribing behaviour of general dentists in Germany.This is a cluster-randomised controlled trial, where each cluster consists of one dental practice and all of its patients in a defined period. Participants are general dentists practicing in the German region of Mecklenburg-Western Pomerania. Randomisation takes place after baseline data collection (6 months) and will be stratified by the antibiotic prescribing rates of the participating dental practices. Dentists randomised into the intervention group will participate in a complex small group educational seminar that aims at: increasing knowledge on bacterial resistance, pharmacology, and prophylaxis of infectious endocarditis; increasing awareness of dentist-patient communication using video-taped vignettes of dentist-patient communication on antibiotic treatment; improving collaboration between general dentists, general practitioners, and practice-based cardiologists on the necessity of antibiotic prophylaxis; enhancing awareness of the dentists’ own prescribing habits by providing antibiotic prescribing feedback; and increasing patient knowledge on antibiotic treatment by providing patient-centred information material on antibiotic prophylaxis of endocarditis. The dentists randomised into the control group will not receive any educational programme and provide care as usual. Primary outcome is the overall antibiotic prescribing rate measured at T1 (period of six months after intervention). In a subgroup of adult patients affected by odontogenic infections, microbiological analyses for antibiotic resistance of oral streptococci are performed.Major aim of the study is to improve the process of decision making with regard to antibiotic prescribing. The approach is simple to implement and might be used rapidly in graduate and post-graduate medical education. We expect the results of this trial to have a major impact on antibiotic prescription strategies and practices in Germany.ISRCTN09576376Current Controlled Trials  Rising levels of bacterial resistance are one of the most urgent problems in healthcare worldwide. The overuse and the misuse of antibiotics are the basic reasons for this development. Studies consistently confirm the association between antimicrobial consumption and bacterial resistance . As a coApart from this severe global development, at the individual level, treatment with antibiotics correlates with drug-related adverse reactions, such as diarrhea or allergic reactions. Especially, if antibiotics are not indicated, these reactions outweigh any benefit of the treatment .Prescribing non-indicated antibiotics also has an impact on healthcare expenditures. Both unnecessary consumption of antibiotics and treatment of preventable drug-related adverse reactions, including hospital stays, put a huge financial burden on national healthcare systems. Optimising the use of antibiotics will decrease this burden .Data on outpatient antibiotic use show that since 1997 daily defined doses per 1,000 inhabitants per day (DID) have increased in Europe. At the same time, prescriptions of broad spectrum antibiotics have become more common, while narrow spectrum antibiotics have been used less ,5. This As to general dentistry in Germany, little data exists. However, comparing absolute numbers of antibiotic prescriptions in primary care, dentists are fourth, following general practitioners, internal specialists, and pediatricians . Data ofOptimising antibiotic prescribing in general dentistry might contribute to decreasing levels of antibiotic resistance development and thereby increase the quality of healthcare provision in general. In the past, several interventional randomised controlled trials (RCTs) from other medical fields were successful in optimising antibiotic prescribing. Most of these studies focused on respiratory tract infections, the disease that causes most antibiotic misuse and overuse in primary care. Results show that complex interventions that aim at changing behaviour rather than just providing information are most efficient ,12-14.et al., for example, collected data of antibiotic prescribing among general dentists six weeks before and after an audit that included educational components and the provision of guidelines. Antibiotic prescriptions decreased by 42.5%. Above that, guideline conformity could be improved [et al., the efficiency of educational outreach visits was compared to the provision of information material by mail in an intervention group and to no intervention in a control group. The educational outreach visits were successful in reducing prescribing rates significantly and also improved prescribing appropriateness [Concerning dentistry, very few interventional studies have been performed so far. Palmer improved . Despiteiateness . In the To investigate the underlying reasons for inadequate antibiotic treatment in German general dentistry, within the DREAM trial we performed extensive qualitative research. Narrative in-depth interviews with dentists revealed areas and situations of non-indicated antibiotic prescribing. These include treatment of patients during emergency services or shortly before weekends or holidays when, due to a lack of time and/or follow-up, dentists were inclined to prescribe antibiotics. Moreover, the treatment of patients suffering from multimorbidity was perceived as a challenge. Both the lack of medical knowledge on cardiac impairments and the fear of judicial consequences induced dentists to prescribe antibiotics for safety reasons. Based on these results, approaches to solve these challenging situations were developed. Especially with regard to their acceptability and practicability, these approaches were discussed extensively among dentists by means of focus group discussions. The results contributed significantly to the development of the complex intervention.By means of a complex educational intervention, the cluster-randomised controlled DREAM trial aims at optimising antibiotic-prescribing behaviour of general dentists in Germany. The complex educational intervention is based on narrative in-depth interviews and focus group discussions with dentists and includes transfer of relevant knowledge, dentist-patient communication, improved collaboration with physicians from other fields, antibiotic prescribing feedback, and patient education. The trial will test the efficiency of the intervention. In addition, the study contains a subset of microbiological analyses on antibiotic resistance among a subgroup of patients affected by odontogenic infections.A cluster-randomised controlled trial (cRCT) will be performed. Clusters are employed to avoid contamination between the intervention and the control group. Each cluster will consist of one general dentist practice and all of its patients during a defined period. Prior to randomisation, baseline data will be collected over a period of six months (T0) to adjust for inter-cluster imbalances of antibiotic prescribing. After randomisation, the intervention takes place which is followed by two more six-month periods of collecting antibiotic prescribing data (T1 and T2).General dentists with their practices in the German region of Mecklenburg-Western Pomerania are eligible for participation in the trial. Given their highly selective group of patients, dentists with sub-specializations will not be included. Among the participating dentists, antibiotic prescribing data of all patients will be collected.All general dentists with a practice in and around 150 kilometers of Rostock (n = 665), the largest city of Mecklenburg-Western Pomerania, will receive postal invitations to take part in the study. These invitations will be sent out in waves and will be based on a random sample of eligible dentists. Participating dentists will receive case payments to compensate for time and effort. The payments are identical in the intervention and the control group. Trained study assistants take care of the enrolment process. Participating dentists provide informed consent before baseline data collection and randomization.Cluster-randomisation takes place after baseline data collection. Concealment of allocation is preserved. Randomisation will be stratified by the antibiotic prescribing rates of the participating dental practices and will be performed by a statistician; this will avoid imbalances between the intervention and the control group.Within the DREAM trial, it will not be possible to blind dentists, study personnel, and statisticians.After randomisation, dentists of the intervention group will participate in a four-hour, small-group intervention seminar. The complex educational seminar is based on a review of the literature and on own extensive qualitative research. The seminar addresses the most challenging situations in the decision-making relating to antibiotic prescribing in general dentistry. It includes condensed transfer of relevant knowledge on bacterial resistance, pharmacology, and prophylaxis of infectious endocarditis; in-depth discussion on dentist-patient communication using three video-taped examples of poor, good, and elaborated dentist-patient communication on antibiotic treatment—the discussion particularly aims at elaborating strategies to satisfy dentists’ and patients’ needs for safety without prescribing non-indicated antibiotics; improved collaboration between dentists, general practitioners, and practice-based cardiologists by means of a standard fax form to agree upon the need for an antibiotic prophylaxis of endocarditis; antibiotic prescribing feedback that will be provided every six months, and will enhance dentists’ awareness of their own prescribing habits compared to those of their colleagues; and patient-centred information material to be used in the dentists’ practices. The information on the necessity to use or not use an antibiotic prophylaxis of endocarditis shall increase patients’ knowledge on antibiotic treatment.During the trial, the dentists of the control group receive neither the seminar nor the information material. They will provide care as usual. After the trial, the dentists of the control group will be invited to take part in the seminar.Primary outcome is the overall antibiotic prescribing rate of the intervention group and the control group measured at T1, thus measured in the interval between months one to six after intervention. A number of secondary outcomes will be analyzed for the subgroup of patients suffering from odontogenic infections (see below).Data from Northern Germany shows that about 6% of all patients cared for in general dentistry receive antibiotics . A relatIn a subgroup of adult patients suffering from odontogenic infections, microbiological analyses on antibiotic resistance of oral streptococci are conducted. Intraoral swabs from the buccal mucosa will be collected of these study patients at three points in time: at the first consultation due to an odontogenic infection (T0), after two weeks (T1), and after six months (T2). The swabs will be transported at room temperature to the accredited diagnostic laboratory within two hours. There, the swabs will be streaked onto sheep blood agar plates. After 48 hours of incubation under a CO2-enriched atmosphere, samples from every morphologic type of alpha-hemolytic colonies will be gained for species identification and for determination of the antibiotic resistance profile. For each patient, the temporal changes in present oral streptococcal species and antibiotic resistance profiles will be recorded.In the context of the overall cRCT, objective information about antibiotic resistance development will be correlated to antibiotic prescribing behaviour of dental care practices. This information will be communicated to dentists (via feedback) to enhance positive competition. For this subgroup, we intend to include a total number of 500 patients suffering from odontogenic infections. Among these patients, several secondary outcomes will be assessed. These include severity of the infection (judged by the dentist), pain severity, duration of therapy, re-consultation rate, adverse drug events (with reference to antibiotics), complications, and antibiotic resistance developments.Data collection will be based on practice software. In Germany, dentists make use of a large variety of software packages. Trained study assistants will visit the participating practices regularly to collect data and to verify data quality by comparing antibiotic prescriptions and number of patient visits with software entries. After data collection, a second study assistant will check the data file for completeness and correctness.A ‘full analysis set’ (FAS) following the principle of intent-to-treat (ITT) will include every patient as randomised. First, confirmatory analyses on efficacy variables will be performed on the FAS patients. Because imbalances are more likely among cluster-randomised trials than among trials randomised at the patient level, variables related to dentists’ characteristics will already be included in the primary data analysis. Initially, baseline characteristics will be compared between groups. If significant differences are found for variables that could potentially bias the results, data analysis will be based on a comparison of the baseline-adjusted rates of antibiotic prescribing between the intervention and the control group at T1 (primary outcome) and T2. The direct maximum likelihood approach is used as estimation procedure and will provide unbiased estimated values. Analyses for secondary endpoints will be performed in a strictly exploratory way using analogue models.e.g., standard fax form for dentist-physician communication or patient information material) and the way dentists made use of it. Recommendations for improvement will also be collected. The interviews will be recorded, transcribed, and analysed.After T1 a short standardised questionnaire and some qualitative in-depth interviews with dentists of the intervention group will be performed. The interviews will focus on the usefulness and usability of the material offered during the intervention seminar .The study has been registered with Current Controlled Trials Ltd. with the reference ISRCTN09576376.Currently (the end of 2013), the baseline data have been collected, the participating dentists have been randomised, and the dentists of the intervention group have been trained. The T1 data collection period has started. The data on T1 will be collected by the end of the T1 six-month period in spring 2014.In light of rising levels of antibiotic resistance worldwide, reducing the number of non-indicated prescriptions of antibiotics is highly relevant. A substantial part of antibiotic resistance is caused in primary care ,18. ThisThe modeling of the intervention is based on concepts, such as communication training or prescribing feedback, that have already proven their efficiency in reducing non-indicated antibiotic prescribing in general practice ,14. By pet al. found that, in a healthy population, treatment with amoxicillin—which is commonly used in dentistry—increases antibiotic resistance [As to bacterial resistance development of oral streptococci, very little research exists. A study by Chardin sistance . The stuIn case of positive evaluation, the intervention seminar developed for the DREAM trial might serve as a theoretically grounded and efficient concept tested for feasibility and acceptability. Consequently, it might be integrated into graduate and post-graduate education. Because the intervention seminar is easy to implement and demands relatively little time from the dentists, it might be transferred to other healthcare systems. This way, the approach might contribute to a sustainable reduction of antibiotic prescribing in general dentistry.DID: Daily defined doses per 1000 inhabitants per day; FAS: Full analysis set; ICC: Intra-class correlation coefficient; ITT: Intention-to-treat ; RCT: Randomised controlled trials.The authors declare that they have no competing interests.AA, HL, AP and CL initiated and designed the study; all authors performed further development. The paper was drafted by CL and FB and all authors read and approved the final manuscript.


The mechanical properties of high-strength ductile concrete (HSDC) have been investigated using Metakaolin (MK) as the cement replacing material and PVA fibers. Total twenty-seven (27) mixes of concrete have been examined with varying content of MK and PVA fibers. It has been found that the coarser type PVA fibers provide strengths competitive to control or higher than control. Concrete with coarser type PVA fibers has also refined microstructure, but the microstructure has been undergone with the increase in aspect ratio of fibers. The microstructure of concrete with MK has also more refined and packing of material is much better with MK. PVA fibers not only give higher stiffness but also showed the deflection hardening response. Toughness Index of HSDC reflects the improvement in flexural toughness over the plain concrete and the maximum toughness indices have been observed with 10% MK and 2% volume fraction of PVA fibers. Each year about 14% and 20% of global industrial energy are consumed by cement and steel manufacturing industries [Since the industrial revolution, large economic and industrial growth caused a massive increase in cement and steel usage which are main building construction materials. The requirement of cement and steel has been amplified about 84% and 64% during the last decade , 2; espemissions , 4 and tmissions . Indeed,Metakaolin (MK) during the last two decades gets recognition as mineral admixture. The general chemical and physical properties of MK with other mineral admixtures and ordinary Portland cement (OPC) are shown in Low tensile strength of concrete is due to the propagation of single internal crack. If the crack restrained locally by extending into another matrix adjacent to it, the initiation of crack is retarded and higher tensile strength of concrete is achieved . This rePolyvinyl alcohol (PVA), an organic fiber, was explored 50 years ago by Japanese and has been used in cement applications since the 1980s due to suitable characteristics as reinforcing materials for cementitious composites. PVA fibers have tensile strength and young's modulus higher than other organic fibers. Because of higher modulus of elasticity, PVA fibers perform better for cracking control. Finer type PVA fiber has been used for fiber cement roofing replacing asbestos. Coarse PVA has been used in tunnel lining, industrial floor, and roadbed overlays . The mosUsing mineral admixtures, along with superplasticizer with low water content, very dense high-strength concrete (HSC) has been obtained , but dueThe use of steel fibers in fiber reinforced concrete (FRC) and in UHPFRC has been widely studied; however limited research has been carried out on the effect of other reinforcing fibers in concrete. Moreover, High-performance fiber reinforced concrete has been studied with silica fume and metakaolin with the steel fiber, and it has been found that metakaolin has better performance with steel fibers . CementiThe basic focus of the current study is to use MK and PVA fibers together in order to lessen the use of cement and steel without compromising the performance. The performance criteria are the mechanical properties of concrete with MK and PVA fibers. Cube compressive strength, splitting tensile strength, and flexural strength of concrete have been observed to check the effect of MK and PVA fibers. Also, the microstructure of HSDC has been examined through field emission scanning electron microscope and results of microstructure and compressive strength has been compared.Twenty-seven (27) mixes of concrete have been prepared; three (03) out of twenty-seven (27) are control mixes without PVA fibers. Nomenclature and detail of mix proportion of concrete have been mentioned in ”) opening sieve and retained on sieve no. 200 has been used as fine aggregates in all concrete mix. 20 mm (3/4”) opening sieve passing and 10 mm (3/8”) opening sieve passing have been used as coarse aggregates. Polyvinyl alcohol (PVA) fibers have been selected due to their reinforcing properties. Length-diameter ratio is one of the parameters of the current study, which has been varied from 45 to 120, and fiber volume fraction has been varied from 1% to 2% by volume of concrete. PVA fiber of aspect ratio 45 is coarser (Diameter 0.667 mm) while PVA fibers of aspect ratio higher than 45 are finer (Diameter 0.2 mm). Locally available kaolin has been calcined to form MK and it has been used as mineral admixture. The physical and chemical properties of MK have been mentioned in Ordinary Portland cement (OPC) has been used. Sand passing through 3.125 mm  of HSDC have been tested based on BS standards. Prior to testing, all concrete mixes have been tested for slump test to set a slump of 50 ± 10 mm. Size of all specimens has been set up as per BS standard to determine mechanical properties. Specimens have been cast using steel moulds to avoid any attack of cement. Slump test has been performed according to BS 1881 to set up the optimum content of superplasticizer for the workability of concrete. Apparatus, operation, and standards have been adapted to comply with BS 1881: Part 102 standards.All concrete mixes have been prepared to determine the mechanical properties of concrete. Specimens for determining compressive strength of concrete have been cast according to BS 1881: Part 108. Specimen of 100 × 100 × 100 mm cube has been used for testing of compressive strength.Specimens for determining the splitting tensile strength of concrete have been cast as per BS 1881: Part 110. Cylinder of 150 mm diameter and 150 mm height has been used for testing of splitting tensile strength.Specimens for determining the flexural strength of concrete have been cast as per BS 1881: Part 109. Beam of 100 × 100 × 500 mm has been used for testing of flexural strength.From In In HSDC, the target is to reduce the cement content and induce ductility without compromising the performance. To provide better packing without increasing the cement content and with the coarse aggregate, mineral admixture metakaolin has been utilized to increase the paste in the concrete. As shown in Figures The behavior of MK and PVA fibers may also be understood by images of microstructure of concrete through field emission scanning electron microscope (FESEM) as shown in From Figures Inclusion of 5 and 10% MK (00-5 and 00-10) caused 16.5% and 24% increase in splitting tensile strength at age of 28 days as compared to control (00-0) as shown in From Figures With 5 and 10% MK (00-5 and 00-10), the seven-day flexural strength has been increased about 33% and 22% in relation to concrete without MK as shown in The performance of PVA fibers has also been illustrated through load-deflection diagram under bending as shown in Figures I30 is 15.81 in HSDC which is slightly lesser than the toughness index reported with steel fiber reinforced high strength concrete [The postpeak-load behavior may further be described by comparing the flexural toughness of concrete. The area under a load-deflection curve is the flexural toughness for the beam tested in third-point bending. Toughness indices have been calculated as per ASTM C-1018 and ACI 544 as shown in concrete .All the mixes of HSDC considered in this study have common trend, that is, all strengths have been increased with the age and with increase in volume fraction of fibers from 1 to 2%.The highest cube compressive strength has been observed with 2% volume fraction of fibers having aspect ratio 45 and 5–10% MK .PVA fibers of aspect ratio up to 90 are better in terms of compressive strength. The coarser type PVA fibers provide good workability and results in least problems of workability in the concrete in the presence of coarse aggregates and hence provides compressive strength comparable to concrete without fibers.The compressive strength of concrete with 5% and 10% MK has been increased about 5% and 16.5% at age of 28 days as compared to control (00-0), respectively.The microstructure of concrete with MK has been refined and packing of material is much better with MK which is also reported by Poon et al. . There iConcrete with PVA fibers of aspect 45 has also refined microstructure; however, the microstructure has suffered with the increase in aspect ratio of fibers.In comparison with control (00-0) splitting tensile strength of concrete is increasing with the increase in the aspect ratio up to 90 with fiber volume fraction 1 to 2%. Based on this trend, it may infer that increase in aspect ratio and volume fraction of fibers gives higher splitting tensile strength.Inclusion of 5 and 10% MK (00-5 and 00-10) caused 16.5% and 24% increase in splitting tensile strength at age of 28 days as compared to control (00-0).5% MK together with PVA fibers has higher splitting tensile strength with PVA fiber having aspect ratio 45, 60, and 90 with 2% volume fraction. Even though the fiber showed slightly lesser or comparable strength as compared to 5% MK without fibers (00-5), the splitting tensile strengths are quite higher than control (00-0).10% MK gives peak splitting tensile strength with PVA fibers having aspect ratio 45 and 2% volume. All mixes with fiber showed higher strength with 10% MK as compared to control (00-0). Also, splitting tensile strength is more consistent and higher in early age with 10% MK and PVA fibers as compared to 5% MK and PVA fibers. With the increase in volume fraction and aspect ratio of fibers, 10% MK concrete demonstrated an increase in splitting tensile strength.In comparison with control (00-0), flexural strength of concrete with PVA fibers alone has been increased about 3% with fiber volume fraction of 2% having aspect ratio 45 (A2-0). With PVA fibers of other aspect ratio, the flexural strength has been found to be either competitive to control or lesser than control.With 5 and 10% MK (00-5 and 00-10), the seven-day flexural strength has been increased about 33% and 22% in relation to concrete without MK. This is very important for construction schedule view point as formwork and temporary supports would be required for lesser days in HSDC.10% MK together with fibers having aspect ratio 45, 60 and 90 with 2% volume fraction have higher flexural strength among all concrete mix. About 7.5% and 4.3% increase in flexural strength have been observed with fibers having aspect ratio 45, 2% volume fraction, and 10% MK (A2-10) as compared to control 00-0 and 00-10, respectively.PVA fibers not only give higher stiffness but also showed the postpeak-load trend that is absent in case of control (00-0) and concrete with only MK .Most of postpeak-load deflections of concrete with only PVA fibers prolong to 4 mm but the load carrying capacity is lesser than control; however, 5% MK together with PVA fibers not only increased the postpeak-load deflection but also increased the load carrying capacity.10% MK together with PVA fibers continues to improve the response under bending and gives the maximum load carrying capacity. Stiffness has been improved further on these concrete mixes and most postpeak-load deflection reached to 6 mm. Deflection hardening is further pronounced in almost all the mix with 10% MK.HSDC with 2% volume fraction and 10% MK is sustainable concrete having deflection hardening response. Toughness Index I for fiber-reinforced concrete reflects the improvement in flexural toughness over the plain concrete.I30 is 15.81 in HSDC which is slightly lesser than the toughness index reported with steel fiber reinforced high strength concrete [Among all the mix, the maximum toughness indices have been observed with 10% MK and 2% volume fraction. The maximum value of toughness index concrete .


Endemic Chagas disease has emerged as an important health disparity in the Americas. As a result, we face a situation in both Latin America and the US that bears a resemblance to the early years of the HIV/AIDS pandemic.Neglected tropical diseases (NTDs) are among the most common conditions afflicting the estimated 99 million people who live on less than US$2 per day in the Latin American and Caribbean (LAC) region Trypanosoma cruzi infection also live in the US and Europe While most of the world's cases of Chagas disease occur in the LAC region, there is increasing recognition that many people with T. cruzi living in the US, immigration status presents an additional challenge to seeking care and prevention services. Just as stigma due to sexual orientation has been a barrier to HIV care and prevention, especially in the beginning of the epidemic, immigration status may function as a deterrent to Chagas disease care and prevention.There are a number of striking similarities between people living with Chagas disease and people living with HIV/AIDS, particularly for those with HIV/AIDS who contracted the disease in the first two decades of the HIV/AIDS epidemic. Both diseases are health disparities, disproportionately affecting people living in poverty Based on the assertions outlined above—the chronic morbidities and high mortalities, the prolonged and expensive treatment courses, the lack of therapeutic options, and barriers to access to essential medicines—a patient living with Chagas disease faces formidable challenges that resemble those faced by someone living with HIV/AIDS, especially the challenges that occurred in the early years of the HIV/AIDS epidemic. Shown in T. cruzi infection is approximately 5% , whereas it is 15%–40% for untreated HIV/AIDS There are additional parallels. Chagas disease has emerged as an important blood transfusion–related risk throughout the Americas just as HIV/AIDS did in the early 1980s, prior to the implementation of widespread blood screening and testing It is only appropriate to point out that there are important differences between Chagas disease and HIV/AIDS. Whereas HIV/AIDS is almost always a fatal condition in the absence of antiviral therapy, up to 70%–80% of people with Chagas disease do not progress to cardiomyopathy. Moreover, Chagas disease is a true NTD and there is a paucity of anti-protozoan drugs available for this condition, whereas HIV/AIDS can no longer be considered neglected in this sense as there is an armamentarium of antiretroviral drugs currently available . As another contrast between the two diseases, there is also evidence for oral transmission of Chagas through food contamination in the Amazon basin Over the last three decades of the global HIV/AIDS pandemic, an aggressive and committed activist community has achieved success in promoting widespread access to antiretroviral drugs in developed and developing countries. As a result, at present millions of people living with HIV/AIDS receive antiretroviral therapy, and pediatric HIV/AIDS has been nearly eliminated as a public health problem in the US In parallel with global advocacy efforts, expansion of operational research activities is crucial to optimize the efficacy of existing control and elimination efforts, including the testing of more field-adapted tools Stark similarities exist between today's global Chagas disease epidemic and the first two decades of the HIV/AIDS epidemic. This translates into a humanitarian catastrophe for the poorest people in the Americas and elsewhere. This perceptible health disparity demands urgent attention by global health policy makers to prioritize Chagas disease and develop a comprehensive strategy for control and elimination efforts, blood screening and point-of-care testing, maternal and child interventions, health education, and parallel research and development. Successfully addressing the vast burden of Chagas disease will require overcoming the current lack of available drugs, together with expanding vector control strategies and developing new and innovative control tools. To this end, eliminating Chagas disease will require a commitment from international health agencies, governments of the disease-endemic countries, PDPs, and patient advocacy groups.


Internalized stigma among people living with HIV/AIDS (PLHA) is prevalent in Bangladesh. A better understanding of the effects of stigma on PLHA is required to reduce this and to minimize its harmful effects. This study employed a quantitative approach by conducting a survey with an aim to know the prevalence of internalized stigma and to identify the factors associated with internalized stigma among a sample of 238 PLHA  in Bangladesh. The findings suggest that there is a significant difference between groups with the low and the high-internalized HIV/AIDS stigma in terms of both age and gender. The prevalence of internalized stigma varied according to the poverty status of PLHA. An exploratory factor analysis (EFA) found 10 of 15 items loaded highly on the three factors labelled self-acceptance, self-exclusion, and social withdrawal. About 68% of the PLHA felt ashamed, and 54% felt guilty because of their HIV status. More than half  of the PLHA blamed themselves for their HIV status while many of them  felt that they should be punished. The male PLHA more frequently chose to withdraw themselves from family and social gatherings compared to the female PLHA. They also experienced a higher level of internalized stigma compared to the female PLHA. The results suggest that the prevalence of internalized stigma is high in Bangladesh, and much needs to be done by different organizations working for and with the PLHA to reduce internalized stigma among this vulnerable group. From the beginning, since its first diagnosis, HIV/AIDS has been recognized as a disease associated with fear and stigma . Stigma,HIV/AIDS-related stigma is a complex multidimensional issue that varies from individual to individual because of the different perspectives about the disease. People living with HIV/AIDS (PLHA) are not different in this aspect.et al., ‘felt’ or ‘perceived’ or ‘internal’ stigma refers to real or imagined fear of societal attitudes and potential discrimination arising from a particular undesirable attribute, disease (such as HIV), or association with a particular group or behaviour   . ‘Enacteiscuity) ,8. The tiscuity) . Of the iscuity) .Since HIV/AIDS-related internalized stigma has an impact on the well-being of PLHA and can hinder his/her participation in most community and social activities, this study focused on measuring internalized stigma among a group of diverse PLHA in Bangladesh. In our study, internalized stigma was defined as the product of internalization of shame, blame, hopelessness, guilt, and fear of discrimination associated with being HIV-positive .Results of studies showed that internalized stigma may discourage PLHA from seeking care  and may Historically, Bangladesh is a patriarchal society where men exercise control over women's sexua-lity and their access to services. Men tend to be the main decision-makers within the family, and the social norms and responsibilities allow men to control women's behaviour. As a result of gender inequality and social structure, women living with HIV/AIDS are more at risk of experiencing stigma.et al. found that 41% of 293 staff members surveyed believed that PLHA should not be allowed to work  country report, 1,745 HIV cases were detected in Bangladesh, and 250 new cases were detected in 2009 . While t to work . ResultsThis study highlighted the present picture of the prevalence of HIV/AIDS-related internalized stigma among PLHA in Bangladesh. It also identified the domains that might be helpful to discriminate against different manifestations of internalized HIV/AIDS-related stigma.We conducted a quantitative survey of 238 adult PLHA (aged not less than 15 years) following the stigma index questionnaire developed by the International Planned Parenthood Federation (IPPF) in partnership with the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Global Network of People Living with HIV (GNP+), and the International Community of Women Living with HIV (ICW). Data were collected during October 2008–November 2008 in four divisions: Dhaka, Chittagong, Sylhet, and Khulna, using the face-to-face interview technique. The participants (n=238) were recruited from four organizations, such as Ashar Alo Society, Mukto Akash Bangladesh, GEON Health Foundation, and CAAP, working for and with the PLHA and giving care, treatment, and support to them. First, these four organizations were requested to provide the names and details of 405 members living in the four divisions. The list of members well-represented the PLHA of the four divisions as it included most adult PLHA aged 15 years and above, living in these areas. From this list of 405 members, a systematic random sample of 278 PLHA was taken. However, we were able to conduct 238 interviews from the list of 278 participants because many participants were unavailable at the time of interview, and some of them did not agree to participate.To find the prevalence of internalized HIV/AIDS-related stigma among men and women, an internalized stigma scale was developed. The internalized HIV/AIDS-related stigma scale included 15 questions from the section “Internal stigma (the way you think about yourself) and your fear” of the stigma index questionnaire. These 15 items cover three domains of internalized stigma  and were adapted from the set of internal stigma indicators reported by Brouard and Wills . Every iet al.  National poverty-line generally set up by the national government and (b) An international poverty-line, such as a ‘US$ 1-a-day’ poverty-line. The percentage of people who are living under the ‘US$ 1-a-day’ poverty-line were said to be hardcore poor .An international poverty-line (US$ 1-a–day poverty-line) was used for assessing the current poverty situation among the PLHA. The purchasing power parity (PPP) exchange rate method  was usedData were analyzed using the SPSS software (version 11.5) . We assessed the prevalence of internalized stigma among the PLHA according to gender and poverty status.To examine whether the prevalence of internalized stigma varies across the sample, we first used the frequencies of responses of the internalized stigma items. We then obtained the cumulative internalized stigma score for each of the PLHA and cate-gorized these into groups. Finally, we conducted several chi-square tests to examine the possible differences in the two groups  according to a number of characteristics .In search of finding the possible domains of internalized stigma linked to HIV/AIDS, the original 15 items of the internalized stigma scale were assessed by conducting exploratory factor analysis using the principal components extraction method and oblique factor rotation with Scree plot.At the beginning of each interview, written informed consent was obtained from each participant. The ethical review committee of the James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh, approved the study.As described in the methodology section, we classified a subset of the participants into two groups  according to their scores. We found that 82 (34.4%) PLHA fell in the low-internalized stigma group and 84 (35.3%) PLHA fell in the high-internalized stigma group. The data-screening process of factor analysis was done by, first, finding the correlation matrix. The results of the correlation matrix ensured that none of the correlation coefficients is zero, and no extreme multi-collinearity exists. The initial factor analysis solution (oblique rotation using direct oblimin procedure) yielded five factors with eigenvalues greater than 1. However, the results suggested dropping of five items having low factor loadings (standard regression coefficient <0.30) from the 15 items. Finally, 10 items were used for the analysis. Both Scree plot and Kaiser's eigenvalue greater than 1 method  confirmeThe three factors that emerged from the exploratory factor analysis were ‘self–acceptance’, ‘self-exclusion’, and ‘social withdrawal’. Five items  loaded on the first factor ‘self-acceptance’ and included the questions relating to feeling ashamed, feeling guilty, blaming self, have low self-esteem, and desiring punishment. The second set of factor loadings  were included on the second factor ‘self-exclusion’ and was related to the decision the PLHA made because of their HIV status. This factor included the questions on decision of not to work, decision of not to apply for a job, and decision of not to participate in any educational programme. Two items (9 and 10) loaded on the third factor ‘social withdrawal’ and included the questions relating to their decision of not to get married and not to have sex.et al. that men are more likely to report experiencing HIV/AIDS-related internalized stigma than women  of HIV between the two groups. This finding is different from the finding of a study by Lee recently . In anotmination .et al., who viewed HIV/AIDS-related internalized stigma as multidimensional  that might be helpful to discriminate against different manifestations of internalized HIV/AIDS stigma. The factor self-acceptance relates to feelings of PLHA. This factor might be useful in identifying the needs of PLHA. For example, PLHA who have a low level of self-acceptance require more counselling and psychosocial support. The factor ‘self-exclusion’ relates to the situation when a person living with HIV/AIDS excludes himself/herself from receiving services and availing of the opportunities of society . The resensional . AlthougThe present study had several limitations. We were only able to recruit our participants  through the existing PLHA peer group network. Thus, the sample is not completely representative of the national population living with HIV/AIDS in the country. Another limitation was that individual income of the PLHA was not reported in the data. To examine the poverty status of PLHA, we used the average income of each member of the house . We also acknowledge that the study measured only a few domains of internalized stigma, and other domains reported in the literature include over-compensation, fear of disclosure, and subterfuge . The stuEven with its limitations, the study is pioneering as it attempts to know the prevalence of internalized stigma and the factors linked to internalized stigma among a sample of 238 PLHA in Bangladesh for the first time. Based on the findings, we conclude that internal stigma is very common among all PLHA, and most of them feel some form of stigma in their life. The silence surrounding this virus and disease, along with the misconceptions and widely-perceived negative risk factors associated with HIV/AIDS  among both PLHA and general population, might be the potential cause of internalized stigma. It is clear from the findings that internalized stigma affects the psychological well-being of PLHA. Although it is the key issue that prohibits PLHA from participating in different social activities, national-level intervention to reduce stigma among the PLHA is yet to be taken. To combat stigma among the PLHA, comprehensive programmes, including education to understand complexities and factors which surround HIV/AIDS, can work towards reducing its stigmatization. Support groups/network, including PLHA and other stakeholders, might also help reduce stigma at the individual level. More mass-media campaign on HIV/AIDS, its causes, knowledge, and prevention and moving away from just a negative focus on risks/blaming of individuals, may work towards encouraging compassion, understanding, and reducing stigma which is deeply embedded in the society.The study received financial support from the Joint United Nations Programme on HIV/AIDS. The authors gratefully acknowledge the continuous support and assistance of members and staff of the four organizations working for and with the PLHA: Ashar Alo Society, Confidential Approach to AIDS Prevention, GEON Health Foundation, and Mukto Akash Bangladesh. They also acknowledge the support from the International Planned Parenthood Federation. The authors thank Mr. Dan Odallo, Country Coordinator, UNAIDS, Bangladesh, and Dr. Tahmina Mirza, Director, AIDS, Family Planning Association of Bangladesh, for their continuous support during the study. They also thank Mr. Al-Mahmud, System Administrator, James P. Grant School of Public Health, for helping them in formatting the tables and text.


To summarize the diagnosis and treatment of cystic renal cell carcinoma (CRCC).A retrospective study was conducted on 13 patients with CRCC at our center from August 2004 to April 2012. The pathologic features, clinical manifestation, imaging characteristics, treatment, and prognosis of CRCC were summarized according to available literature.Of the 13 patients, 11 were diagnosed with CRCC by preoperative B ultrasonography and computed tomography (CT) scan. The remaining two cases were initially misdiagnosed with simple renal cysts. Open radical nephrectomy was performed on two of the 13 cases, laparoscopic radical nephrectomy on seven cases, and open partial nephrectomy on four cases. All diagnoses of CRCC were confirmed by pathological examination. After the operation, all patients had an uneventful recovery. During the follow-up , the serum creatinine concentrations and GFR of the partially removed kidneys remained stable within the normal range. No tumor recurrence or metastasis occurred.By combining imaging examinations (B ultrasonography and CT scan) with intraoperative pathological examination, most cases of CRCC can be diagnosed and treated promptly and accurately. Nephrectomy is the first-line therapy. Nephron-sparing surgery should be preferred for CRCC. After a successful operation, the prognosis of CRCC is good. Cystic renal cell carcinoma (CRCC) is a special type of renal cell carcinoma. It is relatively rare and involves fluid-filled masses. The classification of cystic renal disease is based on the Bosniak classification system Table  1,2]. H,2. H1,2]Approval for this study was granted by the ethics committee of Nanjing Medical University (China). Written informed consent was obtained from the patient for publication of this report and any accompanying images.Data were acquired from13 patients with CRCC (10 men and threewomen) at our center from August 2004 and April 2012. The mean age was 62 years . Four patients were symptomatic. They showed flank pain or discomfort (three cases) and indolent hematuria (one case). Nine patients were asymptomatic. Their cystic renal masses were accidentally found during health examinations. All patients received B ultrasonography, computed tomography (CT) scan, and preoperative serum creatinine determination. Glomerular filtration rate (GFR) was measured on cases preparing for partial nephrectomy. The diagnoses were made according to the Bosniak classification system.Patients with CRCC underwent open or laparoscopic nephrectomy. Intraoperative frozen section analysis was performed on every case. Cases with simple renal cysts received laparoscopic renal cyst decortications.1-2N0M0 stage.The preoperative serum creatinine concentration and GFR were in normal range. Left renal cystic masses were observed in eight patients. The remaining five showed right renal cystic masses. Of the 13 patients, ninemultilocularCRCC, one unilocular CRCC, and three simple renal cysts were diagnosed using B ultrasonography Figure , one ‘siThe 11 patients diagnosed with CRCC underwent nephrectomy, with one case of open radical nephrectomy, six of laparoscopic radical nephrectomy, and four of open partial nephrectomy. Intraoperative frozen section analysis certified to preoperative diagnosis of CRCC. The two patients diagnosed with simple renal cysts received laparoscopic cyst decortication. During the operation, dark red hydatid fluid and abnormal capsule walls were observed in one case. Intraoperative frozen section analysis of excised capsule walls suggested renal clear cell carcinoma. The procedure was then changed to laparoscopic radical nephrectomy. Postoperative pathology confirmed the diagnosis of CRCC (clear cell carcinoma). The final pathological result confirmed the diagnosis of clear cell carcinoma, although no abnormalities were observed in another patient during operation. The patient was readmitted for open radical nephrectomy 1 month later.After operation, all patients had an uneventful recovery. During the follow-up , the serum creatinine concentrations and GFR of the partially removed kidneys remained stable within the normal range. No tumor recurrence or metastasis occurred.Cystic degeneration of the kidney is very common in renal lesions. About 50% of individuals aged >50 years have cystic renal disease. However, CRCC is relatively rare . AccuratThe pathogenesis of CRCC remains unclear. Some possible reasons are as follows. First, the tumor originates from the epithelium of the proximal convoluted tubule and grows in a cystic pattern. Then the cystic neoplasm gradually forms mutually unintelligible cysts with different sizes, containing hemorrhages and pseudo-capsules. This kind of tumor is usually multilocularCRCC. Second, insufficient blood supply, hemorrhage, and necrosis of renal cell carcinoma can lead to the formation of pseudocysts. This kind of tumor is usually unilocularCRCC and shows thick and irregular capsule walls. Third, the tumor originates from the epithelial cells of the cyst wall. The mass is usually located in the base of the cyst. Lastly, the tumor may obstruct the kidney tubules and renal arterioles, which can cause cysts to form. This kind of CRCC is relatively rare. In the present study, nine cases were found to be multilocular and four were unilocular.Pathologically, the mass of CRCC usually has clear boundaries and is composed of capsular cavities of different sizes . At the The triad of hematuria, flank pain, and abdominal mass is the classic symptoms of renal cell carcinoma, including CRCC. However, only 10% of patients with renal cell carcinoma have all three signs. This often means that tumor is in the advanced stage. The majority of patients with CRCC are identified despite the absence of clinical symptoms. In our study, nine asymptomatic patients with CRCC were identified through routine physical examinations. Only four patients showed typical symptoms.B ultrasonography and CT scan are the main methods of diagnosing CRCC ,7. Typicet al. compared several surgical approaches of CRCC, including radical nephrectomy, simple nephrectomy, partial nephrectomy, and tumor enucleation [et al. reported zero-ischemia combination therapy of superselective arterial embolization with partial nephrectomy to T1 renal carcinomas without hilar clamping [et al. reported a novel approach to facilitate zero-ischemia partial nephrectomy without hilar clamping, in which tumor-specific or higher-order renal arterial branches were microdissected and blocked using neurosurgical aneurysm micro-bulldog clamps [1 stage. Open nephrectomy was the gold standard treatment for CRCC. Recently, laparoscopic nephrectomy and even robot-assisted nephrectomy have become more widely used [Nephrectomy is the most effective treatment for CRCC . Coricaecleation . Their rclamping ,11. In aclamping . Gill etg clamps ,14. Intrg clamps . These dely used ,14. WithAccording to our experience, active surveillance or aspiration biopsy should be performed on suspected cystic renal masses <3 cm in diameter. CRCC should be considered if the capsule walls thicken rapidly or if the contents of the cyst change. If the size of the cystic renal lesions is >3 cm or if the imaging characteristics do not meet the performance of renal cysts, surgical exploration is needed. Intraoperative pathological examination may facilitate accurate diagnosis and help clinicians develop further surgical approaches. However, a few cases with CRCC do not show any malignant signs. In our study, one ‘simple renal cyst’ case was diagnosed as CRCC and the patient underwent open radical nephrectomy 1 month later. For patients unsuitable for surgery, renal artery embolism, radiofrequency ablation, immunotherapy, molecular target therapy, and radiotherapy can be considered. However, the exact effect remains controversial.CRCC has better prognosis due to low nuclear grade and TNM stage, regardless of tumor size . The 10-In the present study, we retrospectively analyzed a series of patients with CRCC and summarize the pathologic features, clinical manifestation, imaging characteristics, surgical treatment, and prognosis of CRCC. Our study showed that most cases of CRCC can be diagnosed and treated promptly and accurately through the combination of imaging examinations (B ultrasonography and CT scan) and intraoperative pathological examination. Nephrectomy is the first-line therapy. Nephron-sparing surgery should be preferred for CRCC. The prognosis of CRCC is good after a successful operation.CRCC is a special type of renal cell carcinoma. The diagnosis and treatment of CRCC are sometimes difficult because its clinical manifestations and imaging characteristics can be similar to those of benign renal cystic disease. By combining imaging examinations (B ultrasonography and CT scan) with intraoperative pathological examination, most cases of CRCC can be diagnosed and treated promptly and accurately. Nephrectomy is the first-line therapy. Nephron-sparing surgery should be preferred for CRCC. The prognosis of CRCC is good after a successful operation.The authors declare that they have no competing interests.JZ and BL participated in the operation and wrote the paper. NS and MG designed the study and did the operation. LH and ZW participated in the operation. CY helped to do draft the manuscript. All authors read and approved the final manuscript.


The main objective of the current study is to monitor the auditory status in a group of adults with AIDS, receiving Highly Active Antiretroviral Therapy (HAART)  in a hospital outpatient clinic in Gauteng. A total sample of 54 adults (between the ages of 18 and 50 years) in the experimental group and 16 in the control group were assessed prospectively following a repeated measures design. All participants were assessed at baseline at three months, and at six months into the treatment.The participants underwent case history interviews and medical record reviews, otoscopy, and tympanometry, as well as conventional pure tone audiometry and distortion product otoacoustic emission testing. Both descriptive and inferential statistics were used to analyze the data.P<0.05) were established, only in the experimental group, for pure tone audiometry — with clinically significant changes found at high frequencies. Statistically significant changes with clinically significant changes were obtained for distortion product otoacoustic emissions (DPOAEs) in the experimental group, particularly at high frequencies — implying subclinical hearing function changes; while lack of statistically significant changes with no clinically significant changes were found in the control group. The subclinical hearing changes in the experimental group were also evident in the findings of the subclinical hearing loss group, who, although they had normal pure tone function after six months of follow up, presented with clinical changes on DPOAEs at 6 and 8 kHz.On audiological monitoring, statistically significant changes  on hearing, through the use of more sensitive tools of assessment when conducting drug trials. During the early stages of the human immunodeficiency virus / acquired immune deficiency syndrome (HIV / AIDS) pandemic, treatment strategies did not seem to have a positive influence on patients’ lives, and therefore, hearing loss did not seem to be an important manifestation of HIV / AIDS that required characterization. However, hearing loss has become one of a number of sensory disabilities associated with HIV / AIDS that must now compete for attention by the research and medical community. Friedman and Noffsinger were amoUnderstanding the effects of HIV / AIDS and the treatment of HIV / AIDS on the auditory system is becoming more important, because patients with HIV / AIDS are living longer due to the positive effects of highly active antiretroviral therapy (HAART). The discovery of antiretroviral drugs for the treatment of HIV / AIDS has changed the face of the HIV / AIDS pandemic internationally, and has also led to changes in the medical field, with people who have HIV / AIDS living for longer periods of time experiencing toxic-related morbidity that influences the quality of life indicators. There iset al..For the experimental group, however, the ototoxicity monitoring phase yielded different results to those of the comparison group, in that, some results indicated the presence of both statistically and clinically significant changes . For purP value (P<.001) for all frequencies assessed - implying that the cochlear function changed after ARV initiation.However, results of the DPOAE analysis revealed the cochlea function to be normal at sessions 1 and 2, at all frequencies evaluated, with changes at repeated measures, indicating declining DPOAE values . These cThe presence of significant changes on DPOAEs in the three different sessions, over a period of six months, in the experimental group, indicated possible microcochlear pathology that was not necessarily indicated on pure tone audiometry. Hence, it would seem to be a possibility that based on the objective nature of the DPOAE measures, subclinical auditory changes occurred after a six-month period. This finding also highlights the crucial need for the use of such sensitive measures (DPOAE) in monitoring the possible effects of toxins on the ear, as DPOAEs have been shown to be superior to pure tone audiometry in this regard.subclinical hearing loss group further illustrate that subtle subclinical changes can only be identified by DPOAEs and not pure tone audiometry. For the statistically significant results for DPOAEs in the ‘within group’ analysis, the Tukey-Kramer test indicated that generally, significant changes occurred between baseline measures and session 2 (at three months) for the lower frequencies, with the higher frequencies being significantly affected all through the three sessions of testing. This early onset of symptoms  again highlights the need for early involvement of the audiologist in the assessment and management of patients with AIDS. Findings from the The presence of DPOAE changes indicating subclinical changes in hearing status suggested hearing loss that could have possibly been due to medications used by the participants in the experimental group . These results were consistent with the reports that have associated iatrogenic hearing loss with many of the drugs used to treat HIV / AIDS.14Although the current study may not be able to draw a definitive conclusion that ARVs used in the sample had a direct effect on hearing - because of the difficulty in controlling the other interacting factors - an index of suspicion is raised by the fact that the results of the participants in the experimental group seem more consistent with ototoxic hearing loss than those in the comparison group, and the fact is that the only identifiable difference between the two groups is that of ARV use. However, the current researcher is of the opinion that isolating all the possible contributing confounding variables may provide a more accurate answer, but may not necessarily provide a practical, relevant, and context-sensitive finding. Within the South African AIDS population, it may be impossible to find participants who are only exposed to just one strict ARV regimen without any other medications coming into play. The results of this study are felt to be valuable and applicable to the South African context, and may provide more realistic and context-specific implications; those that are needed for establishment and implementation of ototoxicity monitoring protocols as part of the routine clinical management of adults with HIV / AIDS.This study displays and highlights an expanded role of the audiologist in Food and Drug Administration processes of drug development, drug approval, and drug monitoring. The sub-clinical hearing changes (cochlea function changes detected before the hearing loss is seen on an audiogram) highlight the importance of DPOAEs in ototoxicity monitoring studies.This research also demonstrates the important role that the audiologist may have in both the assessment and treatment of patients with HIV / AIDS. Finally, implications raised by the current study can be translated into recommendations for the clinical assessment and management of patients with HIV / AIDS who are taking ARVs; education of team members; policy formulation; as well as further research.Medical awareness of ARV doses, forms of administration, populationsat risk, and possible synergism with other factors is necessary to developappropriate care in the prescription of drugs with possible or established ototoxicside effects. Furthermore, issues such as risk-benefitanalysis, patient-informed consent, and quality-of-life considerations, are also crucial factors to beconsidered in the management of patients with HIV / AIDS. Regardless of whether the effects of the drug are negligible or not, these effects still need to be determined so that proper patient adherence counseling can take place. It is fundamental that audiologists establish and become aware of the ototoxic effects of medications used to manage chronic conditions such as HIV / AIDS, as also medications prescribed to significant numbers of people - such as 11% of the population afflicted by HIV / AIDS in South Africa. This awaClinically used drugs and chemical agents may potentially causeadverse effects to the human auditory and vestibular systems. Many of When life-threatening illness necessitates treatment with ototoxic drugs, preserving the quality of the patients’ remaining life is customarily a treatment goal. Early detection of ototoxic hearing loss provides physicians with critical information and the opportunity necessary to minimize further impairment, and in some cases, prevent hearing loss from progressing to the point where permanent damage occurs. Although hearing loss is not regarded as a life-threatening condition, it does become a severe threat to the essential quality of life indicators unless intervention occurs early during treatment. The adverse effects of hearing loss on cognitive-linguistic skills and psychosocial behavior are well documented, as also the serious vocational, social, and interpersonal consequences for the patient.ubhejane,’ which has been reported to be in widespread use.[sound toxic?Findings of the current study, although important, should be interpreted after taking the identified methodological limitations into account. The main limitations of the current study included, first, the nature of the HIV / AIDS disease and the population being studied precluded complete control over the confounding variables, which could have had an influence on the results such as interactions of ARVs with other therapies; especially traditional medicine in the form of ‘read use. Second, The known effects of HIV / AIDS on the auditory system that have been reported in the literature are mainly based on cross-sectional studies and case reports conducted internationally in industrialized countries, with very limited information coming from third world countries where the presentation of the virus and its treatments may be different. Furthermore, because this evidence may not be viewed to be contextually relevant to the developing world, its incorporation into routine clinical assessment and management lags behind significantly. Hence, the need for categorizing the ototoxic effects of HIV / AIDS treatment, in an effort to ensure that ototoxicity monitoring protocols are established and implemented as part of the routine clinical management among infected patients. Research in ototoxicity in HIV / AIDS needs to be locally relevant, should include large sample sizes and longitudinal follow-up of cases, and should also utilize sensitive audiological test measures to improve the validity and reliability of the findings.


Cyclodextrin vesicles are versatile models for biological cell membranes since they provide a bilayer membrane that can easily be modified by host–guest interactions with functional guest molecules. In this article, we investigate the multivalent interaction of the lectin concanavalin A (ConA) with cyclodextrin vesicles decorated with mannose–adamantane conjugates with one, two or three adamantane units as well as one or two mannose units. The carbohydrate–lectin interaction in this artificial, self-assembled glycocalyx was monitored in an agglutination assay by the increase of optical density at 400 nm. It was found that there is a close relation between the carbohydrate density at the cyclodextrin vesicle surface and the multivalent interaction with ConA, and the most efficient interaction  was observed for mannose–adamantane conjugates, in which both the cyclodextrin–adamantane and the lectin–mannose interaction is inherently multivalent. The surface modification of materials with carbohydrates has attracted much attention due to the fact that such materials can be compared to and compatible with the cell surface . The “glKa = (2–3) × 104 M−1). We were able to recently demonstrate the interaction of monovalent bifunctional guest molecules, containing a maltose or lactose unit and an adamantane unit, with cyclodextrin vesicles, and their ability to agglutinate with lectins  = decreases with an increasing number of adamantane functions present in the guest molecule. In other words, agglutination is less efficient for 3 compared to 2 in spite of the higher surface affinity of trivalent guest 3 compared to divalent guest 2. This observation can be explained by the density of mannose on the surface of the vesicles. The average distance between two cyclodextrins at the vesicle surface is approximately 2.2 nm [dCH is expected to be the same when using a 100% surface coverage of cyclodextrin vesicles with monovalent guest 1. A decrease in the surface density of mannose due to replacement of guest 1 by “inert” guest 6 decreases the agglutination by ConA (see dCH) exceeds the binding-site separation of ConA (dBS) [Perhaps counter intuitively, the extent of agglutination y 2.2 nm . The disConA see  since evnA (dBS) . However2 (with two adamantane units and a single mannose) the maximum surface density of mannose is only half of the surface density that can be achieved with monovalent guest 1. As a consequence, the average distance dCH of the mannose residues is similar to the effective binding-site separation of ConA, and agglutination is quite efficient. However, it can be seen that although agglutination can be completely suppressed by replacement with guest 6, the concentration dependence is completely different from that observed for guest 1: rather than showing a threshold value, agglutination persists even at a rather low percentage of guest 2 compared to inert guest 6. In the case of trivalent guest 3 (with three adamantane units and a single mannose) the maximum surface density of mannose on the cyclodexrin vesicle is only one third of the maximum surface density for guest 1. As a consequence, the average distance of the mannose residues exceeds the effective binding-site separation of ConA, and very little agglutination is observed upon addition of ConA. Thus, it could be said that more adamantane units in the guest molecule in fact diminish the agglutination by ConA, since they result in a substantially lower surface coverage of mannose.In the case of divalent guest 4. Guest 4 contains two adamantane units as well as two mannose residues. A 100% surface coverage of the cyclodextrin vesicles with guest 4 is therefore expected to give an average distance of 2.2 nm between the mannose functions, similar to the average spacing obtained for guest 1. However, due to the inherent multivalency of guest 4, it should have a much higher affinity both for the cyclodextrin vesicle surface as well as for ConA. Indeed it was found that guest 4 . At higher surface coverage, the rate of agglutination is much higher for guest 4, but the extent of agglutination is similar. These observations can be rationalized as illustrated in 4 has two mannose units, it can bind in a divalent fashion to ConA irrespective of the surface coverage. Nevertheless, the agglutination should still be surface coverage dependent, since multivalent intervesicular binding is more likely to occur when more mannose is presented on the cyclodextrin vesicles. Since guest 2 has only one mannose unit, one would expect that ConA can only bind in a divalent fashion to the cyclodextrin vesicle if the surface coverage is rather high. However, as can be seen from 4) even at rather low surface coverage, albeit with a substantially lower rate of agglutination. These observations can be explained on the basis of a clustering of mannose residues in the mixed glycocalyx of guest 2 and “inert” guest 6: clusters of guest 2 could offer multivalent “adhesive patches” for ConA even if the average surface coverage of guest 2 is far below 50%. The low rate of agglutination could be a consequence of a slow rearrangement of the glycocalyx, i.e., a “receptor-induced clustering” of mannose in the presence of ConA.Finally, we investigated the agglutination behavior of cyclodextrin vesicles decorated with guest guest 4 ( = 20 μM)In this study we described a biomimetic model for the glycocalyx of a cell membrane based on multivalent adamantane–mannose conjugates that bind to cyclodextrin vesicles. In this dynamic supramolecular system the guest molecules bind with their adamantane units to the cyclodextrin cavity, which acts as a receptor, and as a consequence the vesicle surface is covered by mannose. In turn, the mannose units are ligands for the lectin ConA, which induces agglutination due to multivalent cross-linking of the vesicles. Strikingly, the multivalency of the guest molecules was found to have a detrimental effect on the glycocalyx: divalent and trivalent guest molecules can induce cross-linking of the vesicles even in the absence of ConA, and the interaction with ConA is reduced due to the lower surface coverage with mannose. The optimal binder therefore is a divalent guest molecule that carries two mannose residues: this molecule binds inherently divalent to the cyclodextrin vesicle surface as well as to ConA and, hence, is able to mediate fast agglutination at low overall concentration as well as low surface coverage. These findings should further the understanding of the complex and dynamic interactions of oligosaccharides on cell surfaces.Materials: Throughout this work, chemicals were used as received from Acros Organics  or Sigma-Aldrich Chemie  without further purification. The synthesis and analysis of guest molecule 1–4 is reported in 5 was synthesized as described in the literature [terature .Methods: Isothermal titration calorimetry (ITC) measurements were performed on a Nano-Isothermal Titration calorimeter III . All samples were measured in distilled water at 23 °C by using a stirring rate of 250 rpm. For each experiment 20 injections with 10 µL volume were carried out with a 250 µL syringe, into the measurement cell (V = 980.5 µL). Concentrations of host and guest molecules are reported in 5 in a HEPES-buffer solution with a Liposofast manual extruder through a polycarbonate membrane with a pore size of 100 nm. Unilamellar vesicles with an average diameter of 100–140 nm are obtained [2 and 1 mM MnCl2. Reagents were added in the following order: To 1 mL vesicle solution, 10 μL of guest molecule stock solution is added after 1 min, and 10 μL ConA stock solution after 2 min.obtained . OpticalFile 11–4.Synthesis, NMR and mass spectra of guest molecules


Continuous murmur is a peculiarity of cardiovascular auscultation, relatively rare, which often hides complex cardiovascular diseases. This article is a review of literature data related to the continuous murmurs accompanied by commenting and illustrating them through our own cases.Recognizing of a continuous murmur and understanding the cardiovascular pathologies that it can hide, is a challenge in current practice. This requires: a good technique and experience, as Froment R. said "auscultation (of the heart) is a music; which supposed a very long sensory education" [6].Knowing the conditions that determinate continuous murmur, can facilitate recognition of this type of murmur and then establish the diagnosis [Definition.2].The murmur that disappears completely before the next first sound, is still considered continuous, if the systolic part of it continues without interruption during the second sound [6].The continuous murmur is the murmur that begins in systole and continues without interruption, encompassing the second sound, throughout diastole or part of thereof [7].The continuous murmurs are often intense, rough and accompanied by quivering . The presence of a systolic-diastolic murmur (systolic murmur and diastolic murmur) so called a to-and-fro murmur, is not a continuous murmur, being different, by separating the two murmurs through a small "silence". A to-and-fro murmur, involves two components: a systolic one, in which the blood flows in one direction, and a diastolic one in which the blood flows in the opposite direction, while those with true continuous murmur, the blood flows in the same direction in both systole and diastole [7].Double murmur occurs most frequently in cases in which there is a valvular stenosis and a valvular regurgitation . This is due to a major reshuffle of valve cusps, they cannot open or close, being fenestrated, shortened or immobilized . - changes in veins flows . These pathologies may be secondary to an acquired trauma, spontaneous (rupture of an aneurysm in venous system), iatrogenic  or may be simply congenital defects.− Table 1).A physiological classification of continuous murmurs as described by Myers and coworkers (Table 2).For a good presentation of the clinical context in which continuous murmurs can appear, they can be classified according to the place of auscultation  [2].Later, in 1900, George Gibson presented a more precise description. "It persists trough the second sound and dies away gradually during the long pause. The murmur is rough and trembling. It begins softly and increases in intensity so as to reach its acme just about, or immediately after, the incidence of the second sound, and from that point gradually wanes until its termination” . Sometimes, these patients can be recognized by the existence of cyanosis of the lower limbs and left upper limb instead the face, lips and upper right limb are colored as normal  [10]. Achieving a continuous murmur presupposes the draining in the right cavities, pulmonary artery or coronary sinus .Coronary arteriovenous fistulas. It represents a communication between a coronary artery (most commonly the right coronary) and a cavity of the heart or a large vein that drains at this level [Figure 3) [10]. A continuous murmur caused by coronary fistulas is different from that of the patent ductus arteriosus by the place where you can hear it best, usually second intercostals space, left or right parasternal, depending on the artery’s origin and the drain cavity, with maximum of intensity during diastole . Exercise with the stethoscope a light compression to the breast tends to increase its intensity, while an energetic compression with the finger or stethoscope leads to its abolition, also passing standing may diminish its intensity [27]. Continuous murmur of internal mammary artery can be secondary to a fistula between the internal mammary artery and vein, pathology described as rare complication, but increasingly often described in literature, following implantation of a pacemaker or secondary sternal closure after aortic valvuloplasty/valvulotomie. This pathology must be discovered as early as possible, to be interventional solved, because of the increased risk of complications  in which the developed collateral circulation is not sufficient to ensure normal flow in diastole, thus makes a continuous gradient systolic-diastolic. The murmur is best heard in the posterior chest, interscapulovertebral, with maximum of intensity in systole.Figure 5),  and  [9].In some patients with coarctation of the aorta a continuous murmur may be from the dilated intercostals collateral arteries  and pulmonary circulation. So it generates a continuous murmur with similar characteristics of the patents ductus arteriosus only that it is widely distributed on the surface of the chest [9].Pulmonary arteriovenous fistula.This can determine a continuous murmur that is superficially heard and usually is associated with cyanosis and typical X-ray changes [12]. Patients with pulmonary arterio-venous fistula associated frequently with hereditary hemorrhagic teleangiectazia [9].Truncus arteriosus. It is a rare congenital anomaly that can sometimes lead to continuous murmurs, to those with low pulmonary resistance and high pulmonary flow. The diagnosis is suggested by the absence of pulmonary artery to the heart lung radiological examination [12].Anomalies of origin of the pulmonary artery. Rarely pulmonary arteries originate from the distal aorta and communicate with pulmonary arterial trunk. It can determinate a continuous murmur by the difference of pressure, in the systemic-pulmonary circulation communication [9].A branch of pulmonary artery stenosis. This most often causes a systolic murmur, but the severe one, may extend into the first part of diastole, the murmur is perceived more strongly in the armpit, infraclavicular, interscapulovertebral and more rarely precordial.It is often associated with other pathologies like: interatrial septum defect, tetralogy of Fallot, pulmonary valve stenosis or ventricular septal defect.24].This disease may be caused by pulmonary embolism, lung carcinoma or lung granuloma [3].The venous hum. It was first described in 1867 by Pontain, it is by far the most common physiological continuous murmur, frequently found in healthy children and young. The best heard of the venous hum is just above the clavicle, either medial to the sternocleidomastoid muscle or between its insertions. A venous hum is more likely to be heard on the right side because the right jugular is larger than the left, since it must carry about two-thirds of the intracranial venous drainage .It is more intense in diastole, often harsh and noisy . Thyrotoxicosis, anemia and certain cancers, that increase cardiac output may initiate or exacerbate cervical venous hum .Continuous murmur caused by severs arterial stenosis. An arterial stenosis  greater than 80%, can cause continuous murmurs at the respective site, a continuous murmur with systolic component louder and with short diastolic component. Continuous murmurs in these cases are conditioned by lack of artery collaterals [9].Arteriovenous extrathoracic fistulas. These rare diseases can be congenital or caused by trauma, iatrogenic or may occur even spontaneously. At physical examination the continuous murmur can be detected audibly in systole, accompanied by rustling, and loudest where the fistula is located. The compression of the fistula site abolished murmur, and after stimulation of baroreceptors at this level, it produces sinus bradycardia (sign Branham) and later with it decompression it can produce reflex tachycardia.9].The determination of these fistulas is very important because they tend to expand, while achieving a high flux at this level, can lead to the phenomena of congestive heart failure [Figure 7) and . It is known that the presence of an arteriovenous fistula larger than 1 cm can lead in about one year to phenomena of cardiac failure .Cardiovascular auscultation remains one of the most important, simple and inexpensive clinical investigation, which, in those with continuous murmurs can lead to a possible diagnosis and establish a targeted strategy for evaluation and treatment.


Antibiotic usage in acute care is widely reported to be suboptimal. Inappropriate use of antibiotics is a major contributing factor to emergence of multi-drug resistance and healthcare associated infection. Addressing antibiotic prescribing behaviour (APB) is a key component of antibiotic stewardship.We carried out a novel systematic review of both qualitative and quantitative literature on APB in acute care. We assessed the extent to which behavioural sciences and social marketing were applied and whether this could be related to the effectiveness of reported outcomes. MEDLINE, EMBASE, ASSIA, Business Source Complete, The Cochrane Library, PsycINFO, Dare and HMIC were searched for studies undertaken in 1999-2009 and published in English.5 qualitative and 5 quantitative studies out of a total of 180 met the quality criteria. Qualitative studies highlight the predominant influence of social norms, attitudes, and beliefs on APB. Quantitative studies reporting interventions to optimise antibiotic prescribing do not use theoretical science or primary research to inform the design and choice of the interventions deployed.Despite qualitative evidence demonstrating the impact of behavioural determinants and social norms on prescribing, these influences are not given due consideration in the design and evaluation of interventions. To ensure a better understanding of APBs and to improve the quality of interventions and research in this area, the application of behavioural sciences supported by appropriate multidisciplinary collaboration is recommended.None declared.


School-based HIV/AIDS education is a common and well-proven intervention strategy for providing information on HIV/AIDS to young people. However, lack of skills among teachers for imparting sensitive information to students can lead to programme failure in terms of achieving goals. A cross-sectional study was conducted among teachers to identify the factors that support or hinder their role in HIV/AIDS education. A self-administered questionnaire was used for interviewing teachers from randomly-selected schools in two adjacent districts in Bangladesh. Based on exposure to teachers’ training, the districts were divided into control and intervention areas and the teachers’ ability, skill, and their participation in HIV/AIDS education were compared between the districts. Trained teachers in the intervention schools were more likely to participate, less likely to face difficulties, and more likely to use interactive teaching methods in HIV/AIDS classes compared to the controls who did not receive any training. Inadequate allocation of time for conducting the HIV/AIDS class was found to be barriers to HIV/AIDS education that suggest the need to provide teachers with more support in terms of training and logistics. Around the world, young people are at the centre of the HIV epidemic; almost half of all HIV-infected people are aged 15 −24 years ,4. Whileet al. reviewed the evaluations of multiple studies of such interventions and found that successful curriculum-based programmes have 17 characteristics  and the local education department (in the control area). Schools were then selected using the simple random-sampling procedure in the SPSS software (version 11.5). We have calculated sample-size on a 2-sample comparison of proportions considering 95% confidence and 80% power. For calculation, we have used a conservative estimate of 50% prevalence in the control group and a 15% improvement in the intervention group. Given the estimation that the calculated sample-size is 333 per group and an estimated 4 teachers per school, 90 schools were considered adequate to obtain the needed sample. However, in the final analysis, we included 81 schools from the intervention area and 71 schools from the control area.A pre-tested, self-administered questionnaire was used for collecting data during September-October 2008. The questionnaire included both open- and closed-ended questions. It addressed the level of knowledge on HIV/AIDS, attitudes , and views on the value and appropriateness of teaching HIV/AIDS to school students and levels of comfort and confidence in teaching about HIVAIDS. Problems faced by the teachers and support offered to them by others were also assessed. Finally, questions about practical implementation in the classroom were asked, which included topics, such as the amount of available time for teaching about HIV/AIDS, adequacy of the time available, level of engagement by students during discussions on HIV/AIDS, type of students taught, and teaching methods followed. If new teaching methods introduced by the training were used, comfort in using those methods was also explored.Trained field research assistants (FRAs) visited each school and sought permission from the headmaster, and written consent was obtained from the subject teachers to conduct the survey. The field team arranged questionnaire-administration session at each school. They briefed each teacher about the study objectives and procedure and obtained individual consent before copies of the questionnaire were distributed. All eligible teachers in a school, who were present on the day of the interview, were invited to participate. All the participating teachers of a school completed the questionnaire during the same session. The field team made the sitting arrangement in such a way that there was a reasonable distance between the participants to ensure confidentiality and to stop discussion among them. The FRAs observed the completion of the questionnaire, responded to the participant's questions regarding the questionnaire, and maintained field notes on the data-collection process.We reviewed short-answer responses and developed code lists. We edited, compiled, and coded all data before entering these into the computer, using the Epi Info 6 software. Data were analyzed using the SPSS software (version 11.5) and R software (version 2.15.0). We ensured the quality of data through monitoring, supervision, and checking for the consistency of data. For performing cluster analysis, we have considered each school as a unit (containing a group or cluster of teachers). These schools were selected randomly, and we have drawn inference on these rather than individual teachers. Different results are obtained on schools both in the intervention and the control areas by accumulating results on individual teachers in the respective schools. The test statistical values and the p values of these tests are also given here. Due to not meeting the assumption of the number of successes and failures, some tests were not conducted.The participants included 353 teachers from 81 schools in the intervention area and 352 teachers from 71 schools in the control area. Once the desired sample-size was reached, no additional schools were enrolled. On average, 3-5 subject teachers were interviewed from each school. Overall, 96/801 (12%) teachers were not available at school on the day when the questionnaire was administered. This rate was higher in the intervention area compared to the control area because schools in the intervention area were reached during the Ramadan holidays.Most (85%) teachers were from rural areas, with little variation between the intervention and the control district. The large majority of the teachers (77%) were enrolled in the study from co-education schools, reflecting the structure of the school system in Bangladesh. The mean age of the participants was 40 years. Nearly half of them in both the areas had at least either a bachelor's degree or a bachelor's degree with BEd (Bachelor of Education). The majority of the teachers (66%) in both the areas had been working in their current schools for 10 years or more .The subject teachers who received training (85%) were almost twice as likely to have taught about HIV in the classroom compared to those who did not receive the training (43%). The teachers were less likely to teach about HIV/AIDS to students in the lower grades. For example, although a teacher may have taught classes from Grade 6 to Grade 10 s/he may have taught about HIV/AIDS only to students of Grade 9. HIV was taught by more teachers per school in the intervention area than in the control area. In 51% of schools in the control area, none of the teachers taught about HIV; this was true in only 19% of the schools in the intervention area . Most  cited traditional teaching methods, such as lectures and question-and-answer sessions. In all schools of both the study areas, at least one teacher used traditional teaching methods. In the intervention district, at least one teacher in 97% (95% CI 93.85–100) schools used interactive teaching methods whereas, in the control district, at least one teacher used such methods in only 41% (95% CI 28.21-53.99) schools, and the use of interactive teaching methods has a significant difference (p<0.001) between the schools in two districts .The use of interactive training methods was positively associated with asking questions by students during lessons, particularly among the teachers who used group discussions and case study methods. In a separate analysis, about 91% of the teachers who used group discussion mentioned that their students asked questions compared to 77% of the teachers who did not use this method (p<0.001). The findings were similar in the case of the use of case study method.Of the teachers in the intervention area, who taught about HIV/AIDS in the classroom, 13% did not complete the HIV/AIDS chapter. However, slight variations were observed between the teachers in general secondary schools and madrasas; 16% of madrasa teachers (n=91) did not complete the chapter compared to 12% of general secondary school teachers (n=359). Of those who did not complete the chapter, the most commonly-avoided content was sexual relationships, which 82% of the teachers in general secondary schools and 92% of the teachers in madrasas avoided. The main reason for avoiding such a chapter in the class was that students (70%) and teachers (26%) felt shy. The reason did not differ between the intervention and the control area.When asked specifically whether it was easy or difficult to talk about HIV transmission and prevention, at the school-level analysis, there were about 57% (95% CI 46.05-68.15) schools in which at least one teacher faced difficulty while talking about HIV transmission in the intervention district, which is slightly larger  in the control district. In about 49% (95% CI 38.23-60.57) schools in the intervention district, at least one teacher faced difficulty while talking about HIV prevention; the figure was much larger  in the control district; facing such difficulties was significantly different (p=0.031) between the two groups of schools. In more schools, teachers reported that they faced difficulty while talking about HIV issues in the control district compared to the intervention district .The subject teachers reported that the supplementary materials were effective in supporting teaching about HIV/AIDS in a classroom setting. Although it was assumed that all teachers in the intervention area received a teaching guide, only 61% had actually received it. Even among teachers who acted as core trainers and taught in an HIV class, 17% did not receive the guide. However, the teachers in the intervention area, who received the guide, found it easier to talk about HIV prevention than the teachers who did not receive it ; they were more likely to report that they could create a comfortable environment for talking about sexual relationships in the classes .To create an enabling environment for teaching about HIV/AIDS in the classroom setting, the teachers who received training were more likely to arrange meetings with the community members, other teachers, and parents than the teachers in the control area. In the intervention area, such meetings were held at almost two-thirds of the schools. Where the meetings were conducted, not all teachers were involved. In 20% of the schools, less than half of the teachers participated in the meetings.At school-level analysis, receiving community supports from the members of school managing committee, parents, and other teachers are significantly higher (p<0.001) in the intervention schools compared to the control area. In the intervention district, teachers in almost 95% (95% CI 89.84-99.76) schools reported that they got support from the members of school managing committees about HIV/AIDS-related classes, which is true for only 25% (95% CI 13.66-36.34) schools in the control district. Similarly, in the intervention area, teachers in 73% (95% CI 62.75-82.65) schools got support from parents; and teachers in 95% (95% CI 89.84-99.76) schools got support from other teachers; in the control district, these percentages were only 18% (95% CI 7.86-27.94) schools for parents, and 41% (95% CI 28.21-53.99) schools for other teachers .The teachers felt that the time allocated for each of the HIV/AIDS classes was insufficient. Although the teachers had 40 minutes officially allocated for each class, in over half of the schools  in the intervention area, at least one teacher reported having 40 minutes or more to conduct each HIV/AIDS class, which was almost similar  in proportion of schools in the control area. In terms of mean allocated time for HIV/AIDS class, there was no statistical significance between the schools in these two districts . When thThe results of the study suggest that simply introducing HIV/AIDS topics into the curriculum is not sufficient to ensure that it is implemented. In the control district where teachers did not receive training, less than half of them had taught HIV to their students. The teachers in the district where training was provided were more likely to have taught about HIV at all grade levels, particularly to the students of Grade 6 and 7. Exposure to training was also associated with lower levels of difficulties in teaching about HIV/AIDS at the classroom setting. No community members, including parents, actively opposed the teaching about HIV/AIDS in the classroom. The barriers to HIV/AIDS education in the classroom were quite practical; for example, the time for teaching was not adequate, and the teaching guide was not received by all the teachers.Training of teachers on the new HIV/AIDS curriculum was positively associated with the development of their individual skills and building of confidence, and this finding directly correlated with the findings of other studies . TraininIn more schools in the control district, higher number of teachers reported that they face difficulty while talking about HIV issues compared to the intervention district. This also demonstrated the lack of skills of the teachers and indicated the training need among them. Similar findings were observed in several studies of teachers feeling uncomfortable in discussing sexuality-related matters -18 and sOne anticipated obstacle—opposition from the community—was not found to be a problem, except for a few teachers in some schools. No community members actively opposed the teaching about HIV/AIDS in the classroom. This finding contrasts with the findings of other studies in low- and middle-income countries where the community plays a strong role in advocating against sexual health education ,21. In mThis assessment also identified factors from the school level that held additional challenges to implementing the curriculum, and these challenges are consistent with findings in other settings , 21,23. Another barrier identified at the programme implementation level was inadequate distribution of teaching materials. About 40% of the teachers did not receive the materials, although the findings highlight the importance of the teaching guide provided to the teachers in the intervention area. Those teachers who received it were more able to discuss HIV prevention with their students and to create a comfortable atmosphere for discussing sexual relationships. Both factors are generally related to the success of school-based HIV-prevention programmes , Government of the People's Republic of Bangladesh and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Grant No. BAN-39724). The authors acknowledge the commitment of Save the Children–USA, the management agency of the project to this research effort. The authors also thank all the subject teachers who participated in the study. The authors are grateful to Robin Morrison Martz for reviewing the earlier draft of the manuscript and Rashedul Haque for his support during data analysis. The authors also thank the Field Research Supervisors and Field Research Assistants who helped during data collection.