Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India.

SETTING: Ujjain district, Madhya Pradesh, India. OBJECTIVE: To describe and compare health care seeking among men and women with cough of >3 weeks, with special focus on the utilisation of private and public health care. DESIGN: A population-based cross-sectional survey including 45 719 individuals aged > or = 15 years. RESULTS: The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69% vs. 71%), but only 23% visited a public provider at some point during their illness. A similar health care seeking pattern was found for patients diagnosed with tuberculosis (TB) in our survey. No significant differences in health care seeking were found between men and women. Only 13% of those seeking care reported having had a sputum smear examination since the onset of cough. Factors associated with sputum examination were history of TB, haemoptysis and visiting a public provider. CONCLUSION: The low utilisation of public health care services and the few sputum examinations reported in this rural Indian setting illustrate the need for improved diagnostic practices as well as involvement of private providers in TB control activities.     

Health-seeking behaviour among adults with prolonged cough in Vietnam

Objective To assess health‐seeking behaviour among adults with prolonged cough in a population‐based, nationally representative sample in Vietnam. Methods Cross‐sectional survey conducted from September 2006 to July 2007. All inhabitants aged ≥15 years were invited for screening for cough, history of tuberculosis (TB) treatment and chest X‐ray (CXR) examination. TB suspects, defined as any survey participant with CXR abnormalities consistent with TB, or productive cough for more than 2 weeks or TB treatment either currently or in the preceding 2 years submitted sputum specimens for smear examination and culture and provided information on health‐seeking behaviour in an in‐depth interview. Results Of 94 179 persons participating in the survey, 4.6% had prolonged productive cough. Forty‐four percentage of those had sought health care and reported pharmacies (35%), commune health posts (29%), public hospitals (24%) and private physicians (10%) as first point of contact. Only 7% had undergone sputum smear examination. Of TB suspects with prolonged productive cough, 2.9% were diagnosed with TB; 10.2% of these reported smear and 21.9% reported X‐ray examination when visiting a health care facility. The average patient delay was 4.1 weeks (95% CI: 3.9–4.4) among cough suspects and 4.0 weeks (95% CI: 3.1–4.9) among TB cases. Conclusions In this Vietnamese survey, nearly half of persons with cough for more than 2 weeks had visited a health care provider. The commonest first health facility contacted was the pharmacy. Sputum smears were rarely examined, except in the provincial TB hospital. Our findings highlight the need to improve diagnostic practices by retraining health staff on the performance of sputum examination for TB suspects.     

An economic analysis of persons with prolonged cough in rural northern Vietnam.

SETTING: Epidemiological surveillance in the Bavi district, northern Vietnam. OBJECTIVE: To compare the prevalences of prolonged cough across socio-economic groups defined by income, expenditure and official classification. To investigate inequalities using the Illness Concentration Index. DESIGN: Interviews in 11,547 randomly selected households with 35,832 persons aged 15 years or more. Prolonged cough was identified in 559 persons (1.5%). RESULTS: Differences between cough prevalences were found for all socio-economic indicators, but were less clear for expenditure. Lower economic groups reported higher prevalences than higher groups, and prevalences were higher among the elderly. Male was similar to female prevalence. The illness gap between the poor and rich was wider for men. The Illness Concentration Index confirmed these findings. CONCLUSION: Inequalities were found when using both different socio-economic indicators and different analysis approaches.     

Excess mortality and risk factors for mortality among a cohort of TB patients from rural south India.

OBJECTIVES: To estimate the excess general mortality among tuberculosis (TB) patients in a rural area (Tiruvallur) and identify risk factors for TB-related mortality. SETTING: The study population consisted of all TB patients aged >or=15 years who were registered under the Revised National Tuberculosis Control Programme (RNTCP) during the years 2000 to 2003 at Velliyur TB unit (TU) in south India. DESIGN: This is a retrospective cohort study of 3405 patients treated under the DOTS strategy, followed up from the date of start of treatment till the date of interview (for the survivors) or the date of death (for those who died). RESULTS: There were 2710 (79.6%) survivors and 695 (20.4%) deaths. The excess general mortalities for the cohort, expressed as standardised mortality ratio (SMR), was 4.2 (95%CI 3.9-4.5). High SMR values were obtained for patients belonging to the 15-44 years age group (12.1), patients on Category II regimen (9.3), treatment failures (9.1) and defaulters (7.8). The adjusted hazards ratios (aHR) were high for patients aged 45-59 years (1.9), >or=60 years (3.1) and with incomplete treatment due to default or failure (6.4). CONCLUSION: TB is one of the main causes of mortality in the younger age group. Among TB patients, the major risk factors for mortality are old age (>or=45 years) and incomplete treatment.     

Socioeconomic and behavioural risk factors for mortality of individuals with IDDM in Japan: population-based case-control study

Summary The aim of this population-based, one-to-one matched-pair case-control study was to evaluate the factors concerning the markedly increased risk for dying among Japanese subjects with insulin-dependent diabetes mellitus (IDDM) from a social and behavioural perspective. The study was based on the population-based cohort of IDDM subjects in the Diabetes Epidemiology Research International Mortality Study. We studied 90 cases who died and 90 living control subjects, selected from the rest of the cohort, who were matched for sex, birth year, year of diagnosis and duration of diabetes. Socioeconomic and behavioural status were surveyed through a questionnaire. Conditional logistic regression analyses based on 55 respondent pairs revealed that the better educated patients (year of completing education: odds ratio =0.66) who kept the same physician (number of times a patient changed physician: odds ratio =2.77) and who attended a clinic specializing in diabetes (attendance at university hospital clinic: odds ratio =0.18) injecting insulin several times a day (number of injections, odds ratio =0.31) and more frequently attending the clinic ( 12 times per year, odds ratio =0.23) were at substantially lower risk of death. The results begin to profile the patients with the highest risk of dying who could be identified earlier and undergo intervention treatment.Abbreviations DERI study Diabetes Epidemiology Research International study - C.I. confidence interval - S.D. standard deviation     

Ambulatory blood pressure and mortality: a population-based study

The relationship between ambulatory blood pressure and mortality in a general Western population is unknown. Therefore, we conducted this prospective study of a random sample of 1700 Danish men and women, aged 41 to 72 years, without major cardiovascular diseases. At baseline, ambulatory blood pressure, office blood pressure, and other risk factors were recorded. After a mean period of 9.5 years, 174 had died: 63 were cardiovascular deaths. In multivariate proportional hazards models, adjusted for other risk factors of significance, the relative risk of cardiovascular mortality (95% confidence interval) associated with 10 mm Hg increments in systolic and 5 mm Hg increments in diastolic ambulatory blood pressure were 1.51 (1.28 to 1.77) and 1.43 (1.26 to 1.61). The corresponding figures for all cause mortality were 1.18 (1.06 to 1.31) and 1.18 (1.09 to 1.28). The relative risks of cardiovascular mortality were lower for office blood pressure, and office blood pressure did not predict all cause mortality. When ambulatory and office blood pressures were entered in the same multivariate models, only the ambulatory blood pressures were significant predictors of all cause mortality and cardiovascular mortality. The relationship between ambulatory blood pressures and risk of mortality was log-linear, with no indication of a threshold. The absolute risk of mortality was also dependent on age and smoking status, and an upper "acceptable" ambulatory blood pressure based on risk of mortality could only be defined when other risk factors were taken into account. In conclusion, ambulatory blood pressure provided prognostic information on mortality above and beyond that of office blood pressure.     

Recurrent tuberculosis in Houston, Texas: a population-based study.

OBJECTIVE: To determine the predictors of recurrence of tuberculosis (TB), the drug resistance pattern of Mycobacterium tuberculosis strains recovered from recurrent TB patients, and the frequency of re-infection with a new M. tuberculosis strain among patients with recurrent disease. DESIGN: A population-based, retrospective case-control study using the Houston Tuberculosis Initiative database. RESULTS: We found that, among 100 patients with recurrent TB who completed adequate therapy for a first episode of TB, not receiving directly observed therapy, pulmonary disease, HIV/AIDS diagnosis, not having a family physician, being unemployed and using public transportation were predictors of recurrent disease. There was a significant increase in drug-resistant M. tuberculosis strains in the second episode of disease compared to the first episode (21.3% vs. 8.2%, P = 0.04). Exogenous re-infection with a new strain of M. tuberculosis was found to cause 24-31% of recurrent TB. CONCLUSION: Recurrent TB in Houston is associated with a significant increase in drug-resistant M. tuberculosis strains. Re-infection with a new M. tuberculosis strain causes a significant proportion of recurrent TB in an area of low TB incidence. Patients with HIV/AIDS constitute a population at increased risk of disease recurrence.     

Premature mortality in patients with Addison's disease: a population-based study

BACKGROUND: The survival rate of patients with primary adrenal insufficiency (Addison's disease) undergoing currently accepted replacement therapy is not known, although well-informed patients are considered to have a normal survival rate. In this study, we evaluated the mortality of patients with Addison's disease in Sweden. METHODS: A population-based, retrospective, observational study was performed, using the National Swedish Hospital and Cause of Death Registers, covering the period from 1987-2001. After a diagnosis of Addison's disease, each patient was followed until the end of follow-up or death. Mortality was compared with that of the Swedish background population. FINDINGS: We identified 1675 patients (995 women and 680 men) diagnosed with primary adrenal insufficiency. The average follow-up from initial diagnosis was 6.5 yr. Five hundred seven patients died during the study period compared with an expected 199. The risk ratio for all-cause mortality was 2.19 (confidence interval 1.91-2.51) for men and 2.86 (confidence interval 2.54-3.20) for women. The excess mortality in both men and women was attributed to cardiovascular, malignant, and infectious diseases. Concomitant diabetes mellitus was observed in 12% of the patients, but only contributed to the increased mortality to a minor extent. INTERPRETATION: Compared with the background population, we observed that the risk ratio for death was more than 2-fold higher in patients with Addison's disease. Cardiovascular, malignant, and infectious diseases were responsible for the higher mortality rate.     

A population-based study of mortality among patients with atrial fibrillation or flutter

PURPOSE: To determine the mortality associated with atrial flutter and atrial fibrillation in the general population. SUBJECTS AND METHODS: Using the Marshfield Epidemiologic Study Area, a database that captures nearly all medical care and deaths among its 58,820 residents, we identified patients diagnosed with atrial flutter or atrial fibrillation from July 1, 1991, through June 30, 1995. Patients were followed prospectively and compared with a group of controls without these arrhythmias. RESULTS: A total of 4775 person-years of follow-up were completed in 577 patients and 577 controls. Compared with controls, mortality among patients with atrial fibrillation or flutter was nearly 7.8-fold higher at 6 months (95% confidence interval [CI]: 4.1 to 15) and 2.5-fold higher (95% CI: 2.0 to 3.1; P < 0.0001) at the last follow-up (mean [+/- SD] of 3.6 +/- 2.3 years; range, 1 day to 7.3 years). At 6 months, mortality among patients with atrial flutter alone was somewhat greater than in controls and less than one third that of those with atrial fibrillation (with or without atrial flutter) (P = 0.02). At the last follow-up, however, mortality was greater among patients with atrial flutter (hazard ratio [HR] = 1.7; 95% CI: 1.2 to 2.6; P = 0.007), atrial fibrillation (HR = 2.4; 95% CI: 1.9 to 3.1; P < 0.0001), or both atrial arrhythmias (HR = 2.5; 95% CI: 1.9 to 3.3; P < 0.0001) when compared with controls in models that adjusted for cardiovascular risk factors. CONCLUSION: In the general population, both atrial flutter and atrial fibrillation are independent predictors of increased late mortality. The relatively benign course during the 6-month period after the initial diagnosis of atrial flutter suggests that early diagnosis and treatment of these patients may improve their long-term survival.     

HIV testing among tuberculosis patients in the era of antiretroviral therapy: a population-based study in Brazil.

SETTING: Rio de Janeiro, Brazil, a city with 29862 cases of tuberculosis (TB) reported between January 1995 and June 1998. OBJECTIVES: To evaluate the counseling and testing practices for human immunodeficiency virus (HIV) infection among TB patients, and to identify the patient characteristics associated with HIV screening as antiretroviral therapy was introduced. DESIGN: Cross-sectional study of patients with TB who were reported to the health department and who initiated anti-TB treatment. The main outcome measure was screened versus not screened for HIV. RESULTS: The proportion of TB patients who received HIV screening increased from January 1995 through June 1998 (P < 0.001). Among young adults aged 20-49 years with TB, the independent predictors of HIV screening were a diagnosis of both pulmonary and extrapulmonary TB (odds ratio [OR] = 2.4, 95% confidence interval [CI] 2.1-2.8); TB meningitis (OR = 13.5, 95%CI 6.5-31.5); disseminated TB (OR = 8.2, 95%CI 5.3-12.9); lymphatic TB (OR = 5.6, 95%CI 4.7-6.6); and male sex (OR = 1.4, 95%CI 1.3-1.6). Patients with newly diagnosed TB who were women, lived in a low income neighborhood (OR = 0.7, 95%CI, 0.6-0.7), and sought TB treatment in their own residential neighborhood (OR = 0.3, 95%CI 0.3-0.4) were less likely to receive HIV counseling and testing. CONCLUSION: Health care providers in Rio de Janeiro selectively offered HIV counseling and testing to persons they perceived to be at risk for HIV and those with advanced stages of TB. HIV counseling and testing should be expanded and offered to all TB patients.     

Self-reported physical functioning and mortality among individuals with type 2 diabetes: insights from TRIAD

AimsTo examine the association between physical functioning and mortality in people with type 2 diabetes, and determine if this association differs by race/ethnicity in managed care.MethodsWe studied 7894 type 2 diabetic patients in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Physical functioning was assessed with the Short Form Health Survey. The National Death Index was searched for deaths over 10 years of follow-up (2000–2009).ResultsAt baseline, mean age was 61.7 years, 50% were non-Hispanic White, 22% were Black, and 16% of participants reported good physical functioning. Over 10 years, 28% of participants died; 39% due to cardiovascular disease. Relative to those reporting good functioning, those reporting poor physical functioning had a 39% higher all-cause death rate after adjusting for age, sex, race/ethnicity, education, income, body mass index, smoking, and comorbidities (Hazard Ratio = 1.39; 95% Confidence Interval: 1.16, 1.67). Although Blacks were less likely than Whites to report good functioning (p < 0.01), the association between functioning and mortality did not differ by race/ethnicity.ConclusionsIn this managed care population, self-reported physical functioning was a robust independent predictor of mortality and may be a useful benchmark for tailoring clinical care.     

Attitudes to compliance with tuberculosis treatment among women and men in Vietnam.

SETTING: A study carried out in 1996 in four districts representing south and north as well as urban and rural areas of Vietnam. OBJECTIVE: To explore gender differences in knowledge, beliefs and attitudes towards tuberculosis and its treatment, and how these factors influence patients' compliance with treatment. DESIGN: Sixteen focus group discussions were performed by a multi-disciplinary research team from Vietnam and Sweden. Analysis was performed using modified Grounded Theory technique, specifically evaluating gender differences. RESULTS: Women were believed to be more compliant than men. Insufficient knowledge and individual cost during treatment were reported as main obstacles to compliance among men (poor patient compliance), while sensitivity to interaction with health staff and stigma in society (poor health staff and system compliance) were reported as the main obstacles among women. CONCLUSIONS: It is time to adopt a more comprehensive and gender-sensitive approach to compliance, which incorporates patient compliance, doctor compliance and system compliance, in order to fully support individual patients in their efforts to comply with treatment.     

Assessing the performance of overseas tuberculosis screening programs: a study among US-bound immigrants in Vietnam

BACKGROUND: Tuberculosis cases in foreign-born persons account for more than 50% of all tuberculosis cases in the United States. The Institute of Medicine has recommended enhancing overseas screening as one measure to support tuberculosis elimination efforts. We assessed the ability of overseas tuberculosis screening (chest radiograph followed by 3 acid-fast bacilli sputum smears for persons with abnormal chest radiographs [suggestive of active tuberculosis]) to detect pulmonary tuberculosis disease among US-bound immigrants with abnormal chest radiographs. METHODS: During October 1998 to October 1999, 14 098 US immigrant visa applicants were screened overseas in Vietnam. Adult applicants with abnormal chest radiographs were enrolled to assess screening test characteristics among this group using mycobacterial culture as the gold standard for pulmonary tuberculosis disease diagnosis. Risk factors for pulmonary tuberculosis disease were also evaluated. RESULTS: Among 1179 adult applicants with abnormal chest radiographs, 82 (7.0%) had positive acid-fast bacilli smear results, and 183 (15.5%) had positive Mycobacterium tuberculosis culture results (pulmonary tuberculosis disease). The sensitivity, specificity, and positive and negative predictive values of serial acid-fast bacilli screening among this group were 34.4% (63/183), 98.1% (977/996), 76.8% (63/82), and 89.1% (977/1097), respectively. Risk factors for pulmonary tuberculosis disease included younger age (18-34 years), no history of tuberculosis or treatment, reported symptoms, and cavitation or consolidation on chest radiograph. CONCLUSIONS: The ability of current overseas screening to detect tuberculosis among immigrants with abnormal chest radiographs is low. Improved diagnostic methods, enhanced screening measures, and postmigration follow-up are essential to control tuberculosis among immigrants and support US and global tuberculosis elimination.     

Excess risk of adverse pregnancy outcomes in women with porphyria: a population-based cohort study

The porphyrias comprise a heterogeneous group of rare, primarily hereditary, metabolic diseases caused by a partial deficiency in one of the eight enzymes involved in the heme biosynthesis. Our aim was to assess whether acute or cutaneous porphyria has been associated with excess risks of adverse pregnancy outcomes. A population-based cohort study was designed by record linkage between the Norwegian Porphyria Register, covering 70% of all known porphyria patients in Norway, and the Medical Birth Registry of Norway, based on all births in Norway during 1967–2006. The risks of the adverse pregnancy outcomes preeclampsia, delivery by caesarean section, low birth weight, premature delivery, small for gestational age (SGA), perinatal death, and congenital malformations were compared between porphyric mothers and the rest of the population. The 200 mothers with porphyria had 398 singletons during the study period, whereas the 1,100,391 mothers without porphyria had 2,275,317 singletons. First-time mothers with active acute porphyria had an excess risk of perinatal death [adjusted odds ratio (OR) 4.9, 95% confidence interval (CI) 1.5–16.0], as did mothers with the hereditable form of porphyria cutanea tarda (PCT) (3.0, 1.2–7.7). Sporadic PCT was associated with an excess risk of SGA [adjusted relative risk (RR) 2.0, 1.2–3.4], and for first-time mothers, low birth weight (adjusted OR 3.4, 1.2–10.0) and premature delivery (3.5, 1.2–10.5) in addition. The findings suggest women with porphyria should be monitored closely during pregnancy.