HIV人群中结核菌隐性感染的诊断与进展

多个世纪以来，结核病（Tuberculosis，TB）持续成为全球，特别是发展中国家的一个重要公共卫生问题。20世纪中期抗结核药物的发现使人们认为结核病已经得到了控制。随着全球结核病监测的放松、社会状况与经济状况的停滞与恶化，最终导致了20世纪80年代结核病的复燃。与此同时．HIV的流行及其与结核病的密切关系也向全球卫生系统和结核病控制部门提出了更为严峻的挑战。因此，在HIV／TB双重感染高流行的地区，结核病的预防性治疗已被纳入国家结核病控制规划的议事日程，而HIV人群中结核感染的诊断是结核病控制的关键。Williams的数学模型显示，如果没有国家结核病控制修订规划（RevisedNationalTB Control—Program，RNTCP）的实施，在1990-2015年间，HIV将使印度的TB患病率上升1％．发病率上升12％，死亡率上升33％；而在RNTCP的控制之下，有望将TB患病率下降68％，发病率下降41％，死亡率下降39％。。     

Incidence, risk factors and outcome of infection in a 1-year hysterectomy cohort: a prospective follow-up study

A prospective study was performed following 687 patients who underwent abdominal, vaginal and laparoscopic hysterectomy for benign conditions in Turku University Hospital. This study evaluates and compares infection after hysterectomy and determines risk factors associated with postoperative infection. Infective episodes were recorded during hospital stay, convalescence for 4 to 6 weeks at home and for 1 year of follow-up. Factors found to be statistically significant for hospital-acquired infection on univariate analysis were subsequently assessed by means of multivariate analysis. During the hospital stay 23.7% of the study population became infected, 38.1% after vaginal hysterectomy, 23.4% after abdominal hysterectomy and 3.0% after laparoscopic hysterectomy. Over half of all hospital-acquired infections were lower urinary tract infections. Infection during convalescence occurred in 19.2% of patients: 29.5% in the vaginal hysterectomy group, 17.4% in the abdominal hysterectomy group and 16.7% in the laparoscopic hysterectomy group. One year of follow-up did not find any infection directly attributable to surgery. Five factors were found to be related to in-hospital infection on multivariate analysis. These were lack of antibiotic prophylaxis, blood loss during operation, intermittent catheterization, anaemia and medication for urinary or bowel dysfunction after operation.     

Treatment for latent TB in correctional facilities: a challenge for TB elimination

BACKGROUND: To eliminate tuberculosis (TB) in the United States, more information is needed on how to gain access to difficult-to-reach, high-risk populations to evaluate people who would benefit from treatment for latent TB infection (LTBI). METHODS: A field study was conducted of people at risk for co-infection with TB and the human immunodeficiency virus (HIV) and to demonstrate that treating LTBI in inmates is feasible. Inmates were tested for LTBI using the Mantoux tuberculin skin test (TST). Outcomes measured were skin test results and the start and completion of treatment for LTBI. RESULTS: In 49 correctional facilities in 12 states, 198102 inmates had a skin test read. The mean skin test positivity rate among inmates was 17.0%. Of those who had a known HIV test result, 14.5% tested HIV positive. Inmates with a positive TST were 4.2 times more likely than those with a negative TST to be HIV infected (95% confidence interval [CI]=3.9-4.4). Therapy for LTBI was completed in 55.9% of patients started on treatment. Patients who were HIV positive and started on a 12-month treatment regimen were less likely than HIV-negative patients (40.0% vs 68.1%, respectively) to complete treatment (odds ratio [OR]=0.24, 95% CI=0.20-0.28). Patients treated in jails were less likely than those treated in prisons (33.6% vs 57.7%, respectively) to complete treatment (OR=0.29, 95% CI=0.26-0.32). CONCLUSIONS: Correctional facilities offer a venue for identifying and treating high-risk individuals for LTBI. However, completing treatment is more problematic in jails than in prisons.     

5-year follow-up study of children with low-to-moderate lead absorption: electrophysiological evaluation

Forty-nine children aged 6 to 12 years were evaluated for residual effects of lead exposure using psychometric, electrophysiological, and medical tests 5 years after initial assessment. The original range of blood lead (PbB) levels was 6-59 (mean = 28) micrograms/dl; the current range was 6-30 (mean = 14) micrograms/dl. A linear relationship between PbB and slow brain wave voltage during sensory conditioning was observed at initial evaluation and at 2-year follow-up. No significant relationship between PbB and slow wave voltage during passive conditioning was found at the 5-year follow-up, although a linear increase in slow wave negativity relative to the current PbB level during active conditioning was suggested by exploratory analyses. Another exploratory analysis revealed a significant linear relationship between the original PbB levels and the latency of waves III and V of the brainstem auditory evoked potential. The latency of both waves increased as a function of original PbB. Increased latency of these waves is suggestive of subclinical pathology of the auditory pathway rostral to the cochlear nucleus, although end-organ impairment cannot be ruled out. No threshold for the effect of Pb on auditory function was apparent.     

High-risk behaviors associated with early smoking: results from a 5-year follow-up

Purpose: To compare grade 7 nonsmokers, experimenters, and smokers on the basis of prevalence of other problem behaviors at both grade 7 and grade 12.

Methods: Based on longitudinal self-report data from 4327 California and Oregon students, we used logistic regression to develop weighted estimates of the prevalence of academic difficulties, substance use, and delinquent behavior within the three smoking status groups at grades 7 and 12. Huber variance estimates, which adjust for weighting and clustering of observations, were used to assess the statistical significance of differences across groups.

Results: Compared with nonsmokers, early smokers were at least 3 times more likely by grade 12 to regularly use tobacco and marijuana, use hard drugs, sell drugs, have multiple drug problems, drop out of school, and experience early pregnancy and parenthood. These adolescents were also at higher risk for low academic achievement and behavioral problems at school, stealing and other delinquent behaviors, and use of predatory and relational violence. Early experimenters were at significantly greater risk for these problems as well, although to a lesser extent than smokers. Importantly, the higher risk among experimenters and smokers of experiencing many of these problems was evident as early as grade 7.

Conclusions: Early experimenters and smokers are more likely than nonsmokers to experience various problem behaviors by grade 12, with many of these problems evident as early as grade 7. Results suggest that substance use programs that target multiple problems in addition to smoking may be most effective for these high-risk adolescents.     

Hospital care utilization in a 17,000 population sample: 5-year follow-up

The growing utilization of hospital care, especially of the services of Emergency Departments (ED), has been of great concern for many Western countries. The purpose of this study was to relate the amount of hospital care utilization to the frequency of ED visits. The study, based on a computerized medical information system, was carried out at Huddinge hospital which serves a suburban area of Stockholm, Sweden. ED visits were found to predict hospital care utilization in a 5-year follow-up of a 10% population sample. Persons who had made 2 or more ED visits during a period of 15 months before follow-up (less than 1/8 of the population sample) contributed 24% of all hospital outpatient visits, 29% of all hospital admissions and 31% of all hospital days during the 5-year follow-up period. The number of hospital outpatient visits per 100 personyears was more than 3 times higher among those who had 4 or more ED visits as compared to those who were non-visitors at the ED. Hospital admissions and days were 5 times higher. The utilization of medical specialties differed most in psychiatry, where those with 4 or more ED visits had nearly 17 times more admissions per 100 personyears than non-visitors. The difference increased gradually with increasing number of ED visits and was also evident in each age group. The mortality was also significantly increased for those with several ED visits. Higher migration in the latter group may besides indicate social instability.(ABSTRACT TRUNCATED AT 250 WORDS)     

Obstetric care in family practice residencies: a 5-year follow-up survey

BACKGROUND: The percentage of family physicians delivering babies decreased from 46% in 1978 to 32% in 1992. Some family practice leaders predicted that, by the turn of the century, training for family practice obstetrics would focus primarily on those planning to work in remote or rural settings. A 1993 study found three primary factors associated with an increased incidence of future maternity care. In 1997 the Residency Review Commission (RRC) stipulated that all family practice residencies have at least 1 family physician serve as an intrapartum attending physician for family practice resident deliveries. METHODS: Using an instrument similar to that used in 1993, we surveyed the directors of 462 family practice residencies in the United States. Sixty-four percent (295) of the program directors responded to one of two mailings. RESULTS: Compared with the survey published in 1993, program directors estimated a 16% increase in the number of residents who included obstetrics in their first practice after residency. Factors associated with increased obstetric participation included having only family physician faculty supervise uncomplicated deliveries and having family physician faculty who could perform other perinatal procedures. Programs that had 4 or more family physician faculty doing obstetrics and those that had more than 10 deliveries per month also produced more physicians who provided maternity care. Fifty-three percent of residencies that did not have family physician faculty attending deliveries before 1997 now meet this RRC requirement. CONCLUSIONS: This study shows that, according to their program directors' estimates, more family practice residents are including obstetrics in their first practice after residency compared with 5 years ago. The new RRC regulation was associated with more than 50% of previously noncompliant programs adding or retraining faculty who could attend resident deliveries within 12 months of the inception of the new policy.     

Incidence of hepatitis C virus infection and associated risk factors among Scottish prison inmates: a cohort study

To gauge the incidence of hepatitis C virus (HCV) infection and associated risk factors among inmates during their imprisonment, the authors recruited adult males in a long-stay Scottish prison into a cohort study between April 1999 and October 2000. On two occasions (at 0 and 6 months), saliva was collected for anonymous HCV antibody testing and risk behavior data were obtained through a self-administered questionnaire. The participation rate was 85% at both initial recruitment (612/719) and follow-up (375/441; 171 men were ineligible for follow-up). For inmates who reported never having injected drugs, ever having injected drugs, having injected drugs during follow-up, and having shared needles/syringes during follow-up, HCV incidences per 100 person-years of incarceration risk were 1, 12, 19, and 27, respectively. Ever having injected drugs (relative risk = 13.0, 95% confidence interval: 1.5, 114.3) and having shared needles/syringes during follow-up (relative risk = 9.0, 95% confidence interval: 1.1, 71.7) were significantly associated with HCV seroconversion. The effectiveness of existing interventions, including the provision of bleach tablets for sterilizing injection equipment, was suboptimal. The development of methadone maintenance programs in prisons and the creation of drug courts to keep offending drug injectors out of prison might help to reduce transmission in this setting.     

Sustainability of change with quality general practitioner education in adolescent health: a 5-year follow-up

OBJECTIVE: To determine whether improvements gained in general practitioners' (GPs') self-perceived competency, attitudes and knowledge after an intervention in adolescent health care designed with evidence-based strategies in continuing medical education, are maintained longterm, 5 years post intervention. The intervention was designed with evidence-based strategies in continuing medical education. DESIGN: We carried out a follow-up postal survey of the cohort of metropolitan Australian GPs trained in the intervention 5 years previously. Measures Subsets of the original measures, used in the randomised controlled trial of the intervention, were selected to re-assess the GPs by postal survey. Self-perceived competency, attitude and knowledge were measured. Doctors were also asked about further training in adolescent health over the 5 years since the intervention and about self-reported practice. RESULTS: A total of 46 of 54 (85%) of the original intervention group returned a questionnaire. Scores at 5 years were all higher than at baseline (P < 0.01) and improvements were sustained in all measures from 12 months to 5 years after the intervention. In all, 25/46 (54%) doctors had received further training in related areas over the 5 years, but this did not improve sustainability. A total of 45/46 (98%) reported maintaining their clinical approach to youth and 22/46 (46%) reported maintaining practices to address systemic barriers to adolescent health care access. CONCLUSIONS: Quality education designed according to evidence-based strategies of effectiveness has advantages for longterm sustainability.     

孕前优生健康检查人群中不孕不育发生情况的5年随访研究

目的了解江苏地区孕前检查人群5年生育和不孕不育发生情况。方法采取分层整群抽样方法对江苏苏南、苏中、苏北的3个县7个乡镇在2013年前参加免费孕前优生健康检查的5086对夫妇进行5年跟踪随访。结果①5年内共完成3次随访,随访应答率为100%。孕前检查人群1年累积受孕率为88.68%,1年累积不孕率为11.32%;2年累积受孕率为90.47%,2年累积不孕率为11.97%;5年累积受孕率为96.88%,5年累积不孕率为11.98%。②孕前检查一般风险人群不孕率为11.16%,低风险人群不孕率为11.78%,高风险人群不孕率为14.50%,差异有统计学意义(Z=2.45,P<0.05)。③不孕症患者的5年就诊率为31.42%。孕前检查后第1年就诊的患者5年累积受孕率为53.93%,第2年就诊的患者5年累积受孕率为44.29%,第3~5年就诊的患者5年累积受孕率为18.18%,差异有统计学意义(Z=2.87,P<0.05)。④122对已知不孕原因的对象中,女方原因占58.20%,男方原因占11.48%,双方原因占4.92%,不明原因占25.41%,包括2例性染色体异常对象。结论应加强孕前检查人群中不孕症患者的早期管理,结合孕前检查风险评估结果加以指导,做到早诊断、早治疗。     

Persistence of symptoms in veterans of the First Gulf War: 5-year follow-up

BACKGROUND: During the 1990-1991 Gulf War, approximately 700,000 U.S. troops were deployed to the Persian Gulf theater of operations. Of that number, approximately 100,000 have presented medical complaints through various registry and examination programs. OBJECTIVES: Widespread symptomatic illness without defining physical features has been reported among veterans of the 1991 Gulf War. We ascertained changes in symptom status between an initial 1995 symptom evaluation and a follow-up in 2000. METHODS: We assessed mailed symptom survey questionnaires for 390 previously surveyed members of the U.S. Department of Veterans Affairs Gulf War Registry for changes over the 5-year interval in terms of number and severity of symptoms. RESULTS: For the cohort as a whole, we found no significant changes in symptom number or severity. Those initially more symptomatic in 1995 showed some improvement over time, but remained much more highly symptomatic than those who had lesser initial symptomatology. CONCLUSIONS: The symptom outbreak following the 1991 Gulf War has not abated over time in registry veterans, suggesting substantial need for better understanding and care for these veterans.     

A 5-year follow-up study of 117 battered women.

This paper reports register data concerning somatic and psychiatric hospital care on 117 battered women who were identified in a surgical emergency department and offered a treatment program. Data were collected during a period of 10 years before to 5 years after the battering in question. It was concluded that the battered woman seeks hospital care much more than the average woman of the same age. It is, however, not only traumatic injuries that bring her to the hospital, but also medical, gynecological, psychiatric, and unspecified disorders and suicide attempts. In this study it was hypothesized that this overuse of hospital care reflects the situation at home characterized by ongoing battering and other psychosocial problems. During the 5 years following the battering, the women did not show any signs of reducing their use of hospital care. It is alarming that this high use of medical care continues over years, and doctors should consider battering as one possible explanation for this phenomenon.     

舟山群岛幽门螺杆菌感染5年跟踪分析

目的分析舟山群岛2006年1月-2010年9月幽门螺杆菌(Hp)的感染及耐药性,为Hp的根治提供临床依据。方法回顾性分析2006年1月-2010年9月舟山群岛地区8512例上消化道疾病患者Hp的感染率和耐药率。结果从2006-2010年,舟山群岛地区Hp感染率逐渐升高;2008-2010年Hp的平均感染率为33.41%,明显高于2006-2007年的27.91%,差异有统计学意义(P<0.05);2006-2007年胃炎的Hp感染率略有升高,消化性溃疡、胃癌和其他上消化道疾病Hp感染率比较,差异无统计学意义;2008-2010年Hp对甲硝唑、克林霉素、庆大霉素、呋喃唑酮、左氧氟沙星的耐药率均明显高于2006-2007年的耐药率,对甲硝唑的耐药率达99.74%,对克拉霉素和呋喃唑酮的耐药率均>20.00%,而2008-2010年Hp对阿莫西林的耐药率与2006-2007年比较,差异无统计学意义。结论舟山群岛地区Hp感染率呈逐年上升趋势,并且对甲硝唑和克林霉素有高耐药率,临床上应严格掌握Hp根除的适应证,避免使用Hp耐药的抗菌药物,根据药敏报告调整用药方案。     

以T-SPOT.TB检测为依据的结核病人密接者感染状况及影响因素研究

目的了解上海市松江区肺结核病人密接者潜伏结核感染的情况及影响因素分析。方法以松江区户籍人口菌阳肺结核病人及其密接者为研究对象,调查问卷的形式收集研究对象的基本信息和结核感染相关信息,结核感染T细胞斑点试验(T-SPOT.TB)技术了解结核感染情况,单因素及多因素分析影响感染状况的因素。结果研究纳入密接者144名,平均年龄44岁,男性占42.36%,T-SPOT.TB检测阳性32人,阳性率22.22%,单因素及多因素分析显示随着年龄增加及接触时间的增加,结核潜隐感染的危险性增加。结论松江区结核病人密接者结核潜隐率为22.22%,针对结核感染危险因素采取有效干预措施具有十分重要的意义。