Sleep quality and sleep hygiene in preclinical medical students of tertiary care center amidst COVID-19 pandemic: a cross-sectional observational study

Objectives: Due to the long-lasting pandemic measures, such as lockdown and stay-at-home orders, the COVID-19 pandemic has had a negative impact on higher education. In this study, we aimed to determine sleep quality, excessive daytime sleepiness, and sleep hygiene, and their association with anxiety, and their correlation in preclinical medical students during the COVID-19 pandemic.Materials and Methods: We included 101 medical students, aged between 17–20 years of both sex from a tertiary care medical institute. Standard questionnaires were used to assess sleep quality, sleep hygiene, daytime sleepiness, and anxiety among medical students.Results: Fifty-one percent of the medical students had good sleep quality, but 35% had borderline poor sleep quality, and 13% had poor sleep quality during the lockdown. Six percent of medical students had alarmingly high daytime sleepiness. The total Adolescent Sleep Hygiene Scale (ASHS) score was grouped into poor sleep hygiene (ASHS score ≤ 3.8) and good sleep hygiene (ASHS score ≥ 4.9). Overall, sleep hygiene of medical students was poor due to behavioral arousal and bedtime routine factors, and the scores for anxiety and sleep hygiene were significantly negatively correlated, whereas daytime sleepiness showed a significant positive correlation.Conclusion: Our study revealed a high prevalence of poor sleep quality among medical students during the lockdown. Poor sleep hygiene is an eye-opener for the mostly ignored aspect of altered sleep patterns.     

The Effect of the COVID-19 Pandemic on the Workload of an Adult Major Trauma Centre in Northern Ireland

Introduction:Based in Belfast, the Royal Victoria Hospital is the only Major Trauma Centre in Northern Ireland. Due to the COVID-19 pandemic, on 23rd March 2020, Northern Ireland was placed into ‘lockdown'' with the majority of the population advised to “stay at home”. The objective of this paper is to identify what effect the lockdown restrictions had on the workload of the Major Trauma Service at the Royal Victoria Hospital.Method:Patients were identified at the orthopaedic trauma meetings and from direct referral to the Major Trauma Service (MTS). Patients admitted and seen by the MTS from 23/03/20, the day lockdown was announced, to 29/05/20, when restrictions were partially lifted, were included in the analysis. Admissions data from this time period was then compared to admissions data from the same period in 2019 (23/03/19 - 29/05/19).Results:When comparing pre-lockdown and lockdown groups there was an overall decrease of 26% in admissions to the MTS (n=57 vs n=42). Road Traffic Accidents were reduced by 53% (n=31 vs n=15) and falls from >2m were reduced by 29% (n=21 vs n=15).Conclusion:Overall the number of admissions to the major trauma service was reduced during the lockdown period. A significant proportion of the reduction may be a result of social restrictions that reduced volume of traffic on Northern Irelands roads. Further study of future lockdowns and including admissions data of other MTCs in the UK would allow us to draw more robust conclusions.     

Coronavirus disease 2019 in India: Post-lockdown scenarios and provisioning for health care

BackgroundWith the rise of Coronavirus disease 2019 (COVID-19) cases in India, lockdown was imposed from March 25, 2020. We studied post-lockdown scenarios and evaluated health-care constraints. Our aim was to identify the scenarios in which health-care availability would not be overwhelmed.MethodsA modified compartmental SEIR stochastic model was used to calculate peak cases at various levels of effectiveness of prevention of transmission. Health-care constraints were evaluated using a Delphi study. We developed “q-metric” to evaluate the epidemic. Key constraints were matched against scenarios generated, and a monitoring mechanism was devised.ResultsContinuing lockdown (“q-metric” of >50) until mid-August was theoretically the most effective solution to end the epidemic. Lockdown might however be lifted earlier owing to various compulsions. The key constraints were identified as trained manpower and ventilators. It was estimated that shortfall of specialists to operate ventilators for COVID-19 intensive care units was approximately 40,000. This requires re-purposing of other specialists and short-term training to meet the surge. The shortage of ventilators is around 40,000–50,000. Procuring beyond those numbers would be infructuous owing to limits of training manpower. After lifting lockdown, the aim should be to contain the epidemic within the availability of key constraints. Our model suggests that this can be achieved by community containment and other non-pharmacological interventions at a “q-metric” of 19. An algorithm using “q-metric” was developed to monitor the epidemic.ConclusionVarious post-lockdown scenarios were simulated. Trained manpower and ventilators were identified as key health-care constraints. Partial community containment measures will require to be continued after the current lockdown is lifted.     

Prevalence and predictors of depression,anxiety, and stress symptoms among pregnant women during COVID-19-related lockdown in Abakaliki,Nigeria

BackgroundSeveral studies have been published on the topic of COVID-19 and pregnancy over recent months. However, few studies have evaluated the impact of this pandemic on maternal mental health, particularly in low-resource settings.AimTo determine the prevalence and predictors of COVID-19-related depression, anxiety and stress symptoms among pregnant women.MethodsThis was a cross-sectional study that involved 456 pregnant women attending prenatal care at Abakaliki, Nigeria, during the COVID-19 lockdown. These patients were screened for psychological morbidities using the Depression Anxiety and Stress Scale-21 (DASS-21).ResultsSevere and extremely severe depression were reported in 7.2% (n=33) and 6.4% (n=29) of participants, respectively. Analysis also revealed that 3.3% (n=15) and 7.7% (n=35) of women had severe and extremely severe anxiety, respectively. In total, 23% (n=105) of the participating women had severe stress while 16.7% (n=76) reported extremely severe stress. Multiparity (2–4) and occupation, such as trading and farming, were predictors of depression whereas grand-multiparity, urban residence, and trading, were identified as predictors of anxiety and stress.ConclusionSymptoms of depression, anxiety and stress were relatively common among pregnant women during the COVID-19 lockdown in Abakaliki, Nigeria. There is a clear need to integrate screening for depression, anxiety and stress, in existing antenatal care programs so as to identify and prevent long-term adverse psychological outcomes related to the COVID-19 pandemic.     

Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS.Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy.Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0–8.5] h vs. 1.0 [0.5–2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0–5.0] days vs. 2.0 [1.0–2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0–33.0] days vs. 9.0 [5.0–15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy.Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.     

Persistent risk of tuberculosis in migrants a decade after arrival in Australia

OBJECTIVE: To examine the risk of tuberculosis (TB) in migrants a decade after their arrival in Australia. DESIGN, SETTING AND PATIENTS: Retrospective review of laboratory-confirmed cases of TB in migrants diagnosed between 1990 and 2004 by the state TB reference laboratory in Victoria, analysed by a multivariate model comparing migrants diagnosed 10 or more years after arrival with those diagnosed within 10 years of arrival. MAIN OUTCOME MEASURES: Time to diagnosis; characteristics of migrants diagnosed with TB, including age, sex, region of birth, site of infection, and drug resistance. RESULTS: A third of migrants (734/1924) were diagnosed with TB 10 or more years after arrival in Australia. This group was more likely to be European-born (adjusted odds ratio [AOR], 3.4; 95% CI, 2.4-5.0) and older than 34 years (35-49 years: AOR, 3.8; 95% CI, 2.0-7.0), reflecting the longer time European migrants have been in Australia. There were two distinct European groups: European Union (EU)/Western and Central/Eastern. The Central/Eastern group were from countries with current high TB rates and, compared with the EU/Western group, were younger (mean age, 50 v 64 years) and more likely to be diagnosed within 10 years of arrival (47% v 14%; P < 0.001). CONCLUSION: European migrants were more likely to be diagnosed a decade or more after arrival in Australia. Once migrants from the currently high TB incidence areas of Asia and Africa have been in Australia for a similar period of time, their timing of diagnosis may resemble that for migrants from Europe. The current screening policy should be complemented with more sensitive techniques to detect latent TB.     

Remotely monitored inactivity due to COVID-19 lockdowns: Potential hazard for heart failure patients

Objectives:To study the impact of curfews during the COVID-19 pandemic, on the physical activity in patients of heart failure implanted withcardiac implantable electronic devices (CIEDs).Methods:This was a retrospective single-center study of heart failure patients inserted with remote monitoring (RM)-capable CIED. We analyzed the transmitted data of physical activity and fluid volume status of all patients, before, and during the lockdown periods between February and April 2020. The clinical status of the patients was also evaluated.Results:Device data from 429 patients implanted with CIED capable of RM were initially evaluated. Patients with an implantable loop recorder, Brugada or Long QT syndromes, and patients with incomplete transmissions were excluded. Eighty-two patients with heart failure were included. The median age was 65 years (58-72), and 53 (64.6%) subjects were men. There was a 27.1% decline in physical activity, and the median physical activity of patients significantly declined from 2.4 to 1.8 hours/day (p=0.000010).Conclusion:Data obtained by remotely monitored CIED in heart failure patients suggests a significant decline in physical activity during the country lockdown due to the pandemic. Awareness of the future potential hazards in this group of patients is warranted.     

Prevalence of COVID-19 antibodies among operating room and critical care staff at a tertiary teaching hospital: A cross-sectional study

Objectives:To identify the prevalence of COVID-19 antibodies among operating room and critical care staff.Methods:In this cross-sectional study, we recruited 319 Healthcare workers employed in the operation theater and intensive care unit of King Abdulaziz University Hospital (KAUH), a tertiary teaching hospital in Jeddah, Saudi Arabia between August 9, 2020 and November 2, 2020. All participants completed a 20-item questionnaire on demographic data and COVID-19 risk factors and provided blood samples. Antibody testing was performed using an in-house enzyme immunoassay and microneutralization test.Results:Of the 319 participants, 39 had detectable COVID-19 antibodies. Five of them had never experienced any symptoms suggestive of COVID-19, and only 19 were previously diagnosed with COVID-19. The odds of developing COVID-19 or having corresponding antibodies increased if participants experienced COVID-19 symptoms (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.2-7.5) or reported contact with an infected family member (OR, 5.3; 95% CI, 2.5-11.2). Disease acquisition was not associated with employment in the ICU and involvement in the intubation of or close contact with COVID-19 patients. Of the 19 previously diagnosed participants, 6 did not possess any detectable COVID-19 antibodies.Conclusions:Healthcare workers may have undiagnosed COVID-19, and those previously infected may not have long-lasting immunity. Therefore, hospitals must continue to uphold strict infection control during the COVID-19 pandemic.     

华东地区结核病患者治疗前血清IFN-γ和IL-10水平及其影响因素

 目的  探讨华东地区结核病患者治疗前体内Th1/Th2细胞因子水平及影响因素,为结核病诊疗提供有效信息。方法  采用自行设计的调查问卷,选择华东两省4个研究现场结核病防治定点门诊连续调查1年(2013年4月—2014年3月),调查对象为新诊断登记的活动性结核病患者。ELISA法检测血清中细胞因子IFN-γ和IL-10水平。结果  共计纳入1 289名活动性结核病患者,患者中咳嗽(83.1%)、咳痰(75.5%)症状出现频率最高。调查对象治疗前体内IFN-γ和IL-10因子水平分别为(2.086±1.119)pg/mL和(2.576±1.192)pg/mL,Th1/Th2比值为0.81(CIFN-γ/CIL-10,C代表因子浓度)。咳嗽、咳痰的患者体内IFN-γ水平较低,发热、乏力、夜间盗汗的患者IFN-γ较高(P<0.05)。初治结核病患者体内IFN-γ水平高于复治患者(P<0.05)。饮茶相对不饮茶患者体内IFN-γ水平高(P<0.05)。饮酒相对于不饮酒、规律均衡营养相对于偏食患者体内IL-10水平低(P<0.05)。结论  结核病患者就诊症状值得关注,健康的饮食习惯或可帮助获得较高的免疫水平并纠正结核病患者病程中的Th1/Th2细胞因子失衡。     

Inequalities in Use of Antenatal Care and Its ServiceComponents in India

Objectives: This study was performed to evaluate the use of individual components of antenatal care (ANC) services by pregnant women across India in addition to counting of ANC visits and then analyze differences according to state, socioeconomic condition, and access to health care services.Methods: The study used a nationally representative sample of 36,850 women from the National Family Health Survey (2005–2006) of India. Outcome measurements were medication, number of ANC visits, and components of ANC, including physical examination and measurements, laboratory examination, and advice about pregnancy. Differences in these outcomes according to 29 states, socioeconomic conditions, and access to health care services were examined. Independent associations between outcome measures and social and health care factors were analyzed.Results: The percentages of women who used ANC at least once and four times or more were 81.5% (ranges by states: 38.0 –99.9%) and 46.1% (15.2–97.9%), respectively. Among those who used ANC four times or more, 86.4% (54.2–98.9%) received a blood examination, and 85.8% (70.3–96.3%) were advised to deliver in a hospital. Greater wealth (OR=3.38; 95%CI 2.58–4.42) and higher education level (OR=3.19; 95%CI 2.49–4.14) were associated with receiving a blood examination during ANC. Rural residence was negatively associated with using ANC four times or more (OR=0.64; 95%CI 0.59–0.67) and receiving a blood examination (OR=0.67; 95%CI 0.59–0.76). Those who received ANC at community health centers were less likely to receive a blood pressure examination, blood and urine examination, and advice to deliver in a hospital compared with those who received ANC at public hospitals.Conclusion: This study showed substantial inequalities in use of ANC and service components of ANC received in India across geographic areas, socioeconomic conditions, and levels of access to health care services. In addition to reducing socioeconomic inequalities, it is necessary to provide quality services to those with limited access to health care services.     

Contemporary treatment and outcomes of zygomycosis in a non-oncologic tertiary care center

BACKGROUND: Zygomycosis is an emerging mycosis of increasing relevance. Limited data exist for outcomes with contemporary therapies. METHODS: A 6-year retrospective chart review was performed in a non-oncological tertiary care center for patients with zygomycosis. RESULTS: Sixteen episodes of proven (EORTC/MSG criteria) zygomycosis were identified. The average age was 49.2 years. Sites of infection were surgical/traumatic wound [5], rhinocerebral [4], disseminated [2], pulmonary [2], peritoneal [2], and localized skin [1]. Associated conditions included diabetes [7], ketoacidosis [2], end-stage renal disease [4], surgery/trauma [4], steroids [3], solid organ transplant [2], neutropenia [1], and intravenous drug use [1]. Twelve patients had surgical debridement. Medical therapy included liposomal amphotericin B, conventional amphotericin B (CAB), and amphotericin B lipid complex. Overall mortality was 4/16 (25%), occurring in a patient each with rhinocerebral, pulmonary, surgical wound infection, and disseminated disease. Mortality with surgical treatment was 2/12 (17%) vs. 2/4 (50%) without surgery. Mortality for patients treated with CAB was 1/3 vs. 3/12 for those treated with any lipid preparation. Serious morbidity occurred in 7/12 survivors. CONCLUSIONS: In this limited study of contemporary therapies, patients with zygomycosis from a non-oncological tertiary care center have lower mortality than classically described. This disease and its treatments are still associated with severe morbidity, disfigurement, and disability.     

Determinants of adverse treatment outcomes among patients treated under Revised National Tuberculosis Control Program in Wardha,India: Case–control study

Background

Tuberculosis (TB) leads to a considerable loss of lung functions and Quality Adjusted Life Years. Several factors are associated with adverse treatment outcomes from TB which further increases this loss. We undertook the study to study the determinants of adverse treatment outcomes among tuberculosis patients treated under the Revised National Tuberculosis Control Program in a tuberculosis unit in India.

Spread of Mycobacterium tuberculosis in a community implementing recommended elements of tuberculosis control

CONTEXT: Despite improvements in tuberculosis (TB) control during the past decade, Mycobacterium tuberculosis transmission and resulting disease continue to occur in the United States. OBJECTIVE: To determine the primary reasons for disease development from a particular strain of M tuberculosis. DESIGN: Population-based, molecular epidemiological study. SETTING: Urban community in the San Francisco Bay area of California with recommended elements of TB control in place. PATIENTS: Seventy-three TB cases were reported in 1996-1997 that resulted from 1 strain of M tuberculosis as identified by TB genotyping and epidemiological linkage. MAIN OUTCOME MEASURES: Transmission patterns involving source and secondary case-patients; primary reasons for disease development. RESULTS: Seventy-three (33%) of 221 TB case-patients in this community resulted from this strain of M tuberculosis. Thirty-nine (53%) of the 73 case-patients developed TB because they were not identified as contacts of source case-patients; 20 case-patients (27%) developed TB because of delayed diagnosis of their sources; and 13 case-patients (18%) developed TB because of problems associated with the evaluation or treatment of contacts; and 1 case-patient (1%) developed TB because of delay in being elicited as a contact. Of the 51 TB cases identified with sources, 49 (96%) were infected within the 2 years prior to diagnosis. CONCLUSIONS: Our results indicate that in a community that has implemented the essential elements of TB control, TB from ongoing transmission of M tuberculosis will continue to develop unless patients are diagnosed earlier and contacts are more completely identified. JAMA. 2000.     

Childhood tuberculosis in Malawi: caseload,diagnostic practices and treatment outcomes

There were 22,982 cases of TB registered in Malawi in 1998, of which 2739 (11.9%) were children. Children accounted for 11.3% of all case notifications with smear-positive pulmonary TB (PTB), 21.3% with smear-negative PTB and 15.9% with extrapulmonary TB (EPTB). A significantly higher proportion of TB cases were diagnosed in central hospitals. Only 45% of children completed treatment. There were high rates of death (17%), default (13%) and unknown treatment outcomes (21%). Treatment outcomes were worse in younger children and in children with smear-negative PTB. In 2001, all 44 non-private hospitals in Malawi that register and treat children with tuberculosis (TB) were surveyed to determine actual diagnostic practice. This cross sectional study identified 150 children aged 14 years or below in hospital receiving anti-TB treatment, 98 with pulmonary TB (PTB) and 52 with extrapulmonary TB (EPTB). Median duration of illness was 8 weeks. Most patients had fever, no response to anti-malarial treatment and antibiotics, and 40% had a positive family history of TB. Nearly 45% had weight for age < 60%. Diagnosis was mainly based on clinical features and radiography, with less than 10% having tuberculin skin tests or HIV serology, and very few having other sophisticated investigations. Diagnostic difficulties make it difficult to accurately define the actual burden of childhood TB in Malawi. Diagnostic practices are poor and treatment outcomes unsatisfactory.     

Comparing survival outcomes for patients with colorectal cancer treated in public and private hospitals

OBJECTIVE: To determine whether treatment in a private versus public hospital was an independent predictor of survival outcomes in patients with colorectal cancer. DESIGN: Retrospective, population-based study. SETTING: Tertiary care hospitals. PARTICIPANTS: All patients diagnosed with colorectal cancer in Western Australia between 1993 and 2003. INTERVENTIONS: Management in private versus public hospitals. MAIN OUTCOME MEASURES: Overall survival and cancer-specific survival rates. RESULTS: 5809 patients were treated for colorectal cancer. Of these, 1523 (26%) were managed in private hospitals. The 5-year overall survival rates for private and public hospital patients were 59.4% (95% CI, 56.9%-61.9%) and 48.6% (95% CI, 47.0%-50.2%), respectively. Significant independent predictors of overall survival were: treatment in a private hospital (P = 0.0001; relative risk [RR], 0.764; 95% CI, 0.696-0.839); younger age (P = 0.0001; RR, 1.032; 95% CI, 1.029-1.036); male sex (P = 0.001; RR, 1.148; 95% CI, 1.068-1.234); and cancer stage (eg, Stage II: P = 0.0001; RR, 1.508; 95% CI, 1.316-1.729). CONCLUSIONS: Treatment in a private hospital was a significant independent predictor of survival outcomes. Further validation of these results would have a significant bearing on how we approach health care delivery for patients with colorectal cancer.     

Tuberculosis mortality during a civil war in Guinea-Bissau

CONTEXT: Tuberculosis (TB) is an increasing global problem, despite effective drug therapies. Access to TB therapy during conflict situations has not been studied. OBJECTIVE: To determine the effect of irregular TB treatment due to an armed conflict in Guinea-Bissau, West Africa. DESIGN, SETTING, AND PATIENTS: Ongoing retrospective cohort study conducted in the capital city of Bissau among 101 patients with TB who received irregular or no treatment during the civil war (war cohort; June 7-December 6, 1998) and 108 patients with TB who received treatment 12 months earlier (peace cohort; June 7-December 6, 1997) and comparison of an additional 42 patients who had completed treatment before June 6, 1998, and 69 patients who had completed treatment before June 6, 1997. MAIN OUTCOME MEASURE: Mortality rates, compared by irregular (war cohort) vs regular (peace cohort) access to treatment, by intensive vs continuation phase of treatment, and by those who had previously completed treatment for TB. RESULTS: Irregular treatment was associated with an increased mortality rate among patients with TB. The mortality rate ratio (MR) was 3.12 (95% confidence interval [CI], 1.20-8.12) in the war cohort, adjusting for age, sex, human immunodeficiency virus (HIV) infection, residence, and length of treatment. Each additional week of treatment before the war started increased probability of survival by 5% (95% CI, 0%-10%). In the intensive phase of treatment, the adjusted MR was 3.30 (95% CI, 1.04-10.50) and in the continuation phase it was 2.26 (95% CI, 0.33-15.34). Increased mortality among the war cohort was most marked in HIV-positive patients, who had an adjusted MR of 8.19 (95% CI, 1.62-41.25). Mortality was not increased in HIV-positive or HIV-negative patients who had completed TB treatment when the war started. CONCLUSIONS: Interruption of treatment had a profound impact on mortality among patients with TB during the war in Guinea-Bissau. Regular treatment for TB was associated with significantly improved survival for HIV-infected individuals. In emergencies, it is crucial to ensure availability of TB drugs.     

Effectiveness of a strategy to improve adherence to tuberculosis treatment in a resource-poor setting: a cluster randomized controlled trial

Context  Poor adherence to treatment remains a major obstacle to efficient tuberculosis (TB) control in developing countries. Innovative strategies to improve access and adherence to treatment are needed. Objectives  To assess the effectiveness of a contextualized intervention strategy aimed at improving patients' adherence to treatment and to evaluate its impact on TB control in a resource-poor country in Africa with prevalent TB infection. Design, Setting, and Patients  A cluster randomized controlled trial, conducted between June 2003 and January 2005, at 16 government district health centers in Senegal. Patients older than 15 years with newly diagnosed sputum smear–positive pulmonary TB were randomly assigned to the intervention or control group. Intervention  The intervention strategy included reinforced counseling through improved communication between health personnel and patients, decentralization of treatment, choice of directly observed therapy (DOT) supporter by the patient, and reinforcement of supervision activities. In the control group, the usual TB control program procedures remained unchanged. Main Outcome Measure  Proportion of patients successfully completing the 8-month course of treatment and the proportion of patients defaulting from treatment. Results  A total of 1522 patients were recruited into the study. Treatment was successful for 682 (88%) of 778 patients recruited in the intervention group, and for 563 (76%) of 744 patients recruited in the control group (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.03-1.34). The proportion of patients defaulting was reduced in the intervention group to 5.5% (n = 43) compared with 16.8% (n = 125) in the control group (adjusted RR, 0.43; 95% CI, 0.21-0.89). Conclusion  The intervention package based on improved patients counseling and communication, decentralization of treatment, patient choice of DOT supporter, and reinforcement of supervision activities led to improvement in patient outcomes compared with the usual TB control procedures. This approach may be generalized in the context of TB control programs in resource-poor countries. Trial Registration  clinicaltrials.gov Identifier: NCT00412009      

武汉市汉阳区流动人口结核病发病情况及转归分析

目的探讨武汉市汉阳区流动人口肺结核的发病情况及临床特点,为开展流动人口结核病防治工作提供依据。方法分析武汉市汉阳区2008年1月-2012年12月登记管理426例流动人口结核病患者的发现方式、年龄特点、临床表现、x线胸片病灶分布特点、痰涂片抗酸杆菌检查结果及治疗转归情况,并与1038例同年龄段本地户籍患者比较。结果426例流动人口新发肺结核中15～45岁青壮年患者385例（90．4％,385／426）;以健康体检方式发现者253例（59．4％,253／426）、肺部病变累及两个或以上肺叶者267例（62．7％,267／426）、痰涂片抗酸杆菌检查阳性者152例（35．7％,152／426）,均高于户籍患者（x2值分别为98．19,37．38,39．29,P值均〈0．001）;流动人口新发肺结核治疗成功333例,占78．2％,（333／426）,明显低于户籍人121（94．8％,984／1038）（X2=92．46,P〈0．001）。结论流动人口肺结核患者病变范围广、痰涂片抗酸杆菌阳性率高、治疗成功率低,增加了结核病控制工作的难度。     

山东省初治肺结核患者直接费用及疾病经济负担分析

目的 了解山东省初治肺结核患者全疗程直接医疗费用与直接非医疗费用及其对家庭造成的经济负担,为进一步控制结核病费用、完善结核病医疗保险政策提供依据。方法 采用分层二阶段整群抽样方法,抽取10个县在2013年4月1日—2014年3月31日期间新诊断登记的初治肺结核患者910例,患者疗程结束后使用统一设计的调查问卷进行面对面询问式调查并查询医院医疗保险结算系统,调查患者的相关费用。结果 初治肺结核患者直接费用、直接医疗费用、直接非医疗费用医保报销减免前例均分别为(6 825.6±9 002.2)元、(5 490.2±8 274.7)元、(1 335.4±1 978.5)元,M (P ₂₅,P ₇₅)分别为3 636.0(2 239.0,8 390.0)元、2 515.0(1 215.0,6 515.0)元、842.0(185.0,1 880.0)元。医保报销减免后直接费用、直接医疗费用例均分别为(4 456.1±8 545.7)元、(3 120.7±8 004.8)元,M (P ₂₅,P ₇₅)分别为2 660.0(1 490.0, 4 804.0)元、1 300.0(645.0,3 000.0)元。报销减免前后直接费用、直接医疗费用差异有统计学意义(Z =-9.233,-12.623,P <0.001)。药品费(除保肝药和免费一线抗结核药外)在直接医疗费用中占比最高为50.7%,其次是保肝药品费占24.5%。营养费占直接非医疗费用的比例达81.6%。患者医疗费用报销比例为38.5%,中位数仅为6.3%,其中报销比例最高为商业医保。疾病负担系数中位数医保报销前后分别为12.3%和8.6%,发生灾难性卫生支出的患者分别占38.4%和26.8%。医保报销前后发生灾难性卫生支出的患者数差异有统计学意义(χ ²=27.577,P <0.001)。结论 初治肺结核患者全疗程的直接费用较高,给患者家庭造成了灾难性卫生支出。应进一步提高医保报销比例,合理控制保肝药和辅助抗结核药品的使用,增加营养补助费。     

Integrating primary medical care with addiction treatment: a randomized controlled trial

CONTEXT: The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment. OBJECTIVE: To examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse-related medical conditions (SAMCs). DESIGN: Randomized controlled trial conducted between April 1997 and December 1998. SETTING AND PATIENTS: Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif. INTERVENTIONS: Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. MAIN OUTCOME MEASURES: Abstinence outcomes, treatment utilization, and costs 6 months after randomization. RESULTS: Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs independent care, 73%; P =.23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs $324.09, P =.19). However, patients with SAMCs (n = 341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P =.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1.04-4.25) SAMCs. Patients with SAMCs had a slight but nonsignificant trend of higher costs in the integrated care group ($470.81 vs $427.95, P =.14). The incremental cost-effectiveness ratio per additional abstinent patient with an SAMC in the integrated care group was $1581. CONCLUSIONS: Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective. These findings are relevant given the high prevalence and cost of medical conditions among substance abuse patients, new developments in medications for addiction, and recent legislation on parity of substance abuse with other medical benefits.