The interpretation of nucleic acid amplification tests for tuberculosis: do rapid tests change treatment decisions?

OBJECTIVES: To describe changes in treatment decisions after receipt of nucleic acid amplification (NAA) test for the diagnosis of M. tuberculosis. METHODS: Retrospective notes review of treatment decisions in patients receiving a NAA test for suspected pulmonary or non-pulmonary tuberculosis at the Royal Free Hospital in London between March 2001 and February 2002. Notes were sought on a 50% random sample of patients with both smear and NAA negative specimens and all patients with other specimen results. RESULTS: Two hundred and fifty patients were tested with NAA; clinical details were obtained on 138; 61 were ever treated. Seventeen (17/18) smear-negative patients were started on treatment after a positive NAA; none of six smear-negative patients treated prior to a negative NAA result had treatment stopped. Seventeen (17/21) smear-positive patients were treated prior to NAA result and all were NAA positive; treatment was delayed in four smear-positive patients until receipt of an NAA and one NAA-negative patient was not treated. CONCLUSIONS: In routine practice a positive test in an untreated smear-negative patient leads to decision to treat in almost all, but the proportion testing positive is low (8% or 17/219). In patients already on treatment negative tests did not lead to decisions to stop.     

Paradoxical reactions during tuberculosis treatment in patients with and without HIV co-infection

BACKGROUND: It has been suggested that deterioration of tuberculosis (TB) during appropriate treatment, termed a paradoxical reaction (PR), is more common and severe in HIV positive individuals on highly active antiretroviral therapy (HAART). METHOD: A study was undertaken to determine the frequency of PR and its associated features in a population of HIV+TB+ patients and a similar sized group of HIV-TB+ individuals. RESULTS: PR occurred in 28% of 50 HIV+TB+ patients and 10% of 50 HIV-TB+ patients. Disseminated TB was present in eight of 13 HIV+TB+ patients and four of five HIV-TB+ patients with PR. In 28 HIV+TB+ patients starting HAART, PR was significantly associated with commencing HAART within 6 weeks of starting antituberculosis treatment (p = 0.03) and was more common in those with disseminated TB (p = 0.09). No association was found between development of PR and baseline CD4 count or CD4 response to HAART. CONCLUSIONS: PR is common in HIV infected and uninfected individuals with TB. Early introduction of HAART and the presence of disseminated TB appear to be important in co-infected patients.     

A multicentre randomised controlled trial of an intervention to improve the accuracy of linear growth measurement

Aims: To evaluate linear growth assessment and the effect of an intervention on measurement accuracy in primary care practices (PCP) within eight US geographical areas. Methods: In this multicentre randomised controlled intervention study, paediatric endocrine nurses as site coordinators (SC) visited 55 randomly assigned PCP to evaluate growth assessment of staff performing linear measurements. SC observed 127 measurers assessing a total of 878 children: 307 (baseline), 282 (3 months), and 289 (6 months). Accuracy was determined by SC re-measuring each child with correct technique and equipment. State of the art equipment and a standardised growth training session were provided to the intervention group (IG) following the baseline visit. SC repeated data collection at all PCP at 3 and 6 months. Results: There were no baseline differences between IG and CG equipment, technique, or accuracy; only 30% of measurements were accurate (⩽0.5 cm from SC). Post-intervention, significantly more IG measurements were accurate: IG = 55%, CG = 37% at 3 months; IG = 70%, CG = 34% at 6 months. Odds ratio of accuracy for IG versus CG was 2.1 at 3 months and 4.5 at 6 months. At 6 months, mean difference from the SC measurements was 0.5 cm in IG and 1.1 cm in CG. Conclusions: In PCP, children are measured inaccurately. Our intervention significantly improved measurement accuracy. Improved accuracy could yield more rapid detection and diagnosis of paediatric growth disorders.     

The management of fatigue in cancer patients

Severe, debilitating fatigue is common in cancer patients. For many, it is the symptom that interferes most with normal routines. Virtually every modality used to treat cancer may cause fatigue, as can complications of the disease such as sleep disturbances, infections, malnutrition, hypothyroidism, and anemia. There is a significant overlap between depression and fatigue in many patients. Given the high prevalence of cancer-related fatigue, frequent assessment of patients is essential. The evaluation should include an attempt to identify reversible causes of fatigue, and screening for depression. However, many cancer patients suffer from fatigue even in the absence of any identifiable, reversible cause. For these patients, consideration can be given to suitable exercise programs, educational support and counseling, and energy conservation strategies. A trial of a stimulant medication is also reasonable. Given the heterogeneity of patients, individualized approaches are needed. For anemic patients undergoing chemotherapy, erythropoietic agents can increase hemoglobin levels. The impact of these drugs on fatigue and quality of life is uncertain. Recent reports of increased mortality and thrombotic events in cancer patients treated with epoetin require further investigation.     

Single mothers and the use of professionals for mental health care reasons

In the present study, we examine whether higher rates of mental health service use observed among single-parent mothers is due to greater need (psychopathology) or other factors (predisposing and enabling characteristics) using a socio-behavioural model of health care use. We use data from two large surveys in Canada (the 1994-95 National Population Health Survey and the 1990 Ontario Mental Health Supplement). The bivariate results from both surveys revealed that single-parent mothers were two to three times more likely than married mothers to have sought professional help for mental health reasons over a 12-month period. Multivariate analyses showed that differences in predisposing and enabling characteristics between single and married mothers accounted for very little of the relationship between family structure and service use. Rather, differences in the prevalence of psychiatric disorders accounted for the higher use of services among single mothers. Single mothers are more likely than married mothers to seek professional help for mental health concerns. The use of services appears equitable in that need (higher rates of psychopathology) is the major factor differentiating use between married and single mothers. Further work should examine differences in pathways into formal care between single and married mothers.     

The polarized debate over complementary and alternative medicine

Debate about the place and scientific of complementary and alternative medicine (CAM) has increased markedly in 2002 following the release of the report of the White House Commission on Alternative and Complementary Medicine Policy. Arguments for and against the integration of CAM into mainstream medicine that have been made are discussed. Positions taken by organizations opposed to CAM are described as are arguments to study the place of CAM further.