Resources and infrastructure for the delivery of antiretroviral therapy at primary health care facilities in the Free State Province,South Africa

There are concerns as to whether South Africa's public health system has sufficient resources, human and otherwise, to ensure universal access to antiretroviral treatment (ART). We report on public sector implementation of the Comprehensive Care Management and Treatment (CCMT) programme in the Free State Province, South Africa, in particular whether the primary health care (PHC) infrastructure was able to mobilise the necessary inputs to effectively provide ART, without undermining other services within facilities.

A longitudinal study was conducted of the first 16 PHC facilities accredited to provide ART in the province. The facilities were visited on three occasions over 2 years, involving both structured and open-ended interviews with professional and lay staff, and observations of available resources. The resources assessed were staffing, space, essential equipment, drug supplies and laboratory systems.

Approximately one-fifth (20%) of professional nurses were allocated to the CCMT programme in the facilities, although the overall number of professional nurses increased by only 14%. This process resulted in some displacement of professional nurses towards the CCMT Programme away from other services in the facilities. However, this could have been partially compensated for by task shifting towards community health workers and the appointment of additional support staff. Staff were largely positive about the programme. Drug supplies, availability of equipment and laboratory systems, although good at the baseline, improved further over the period of observation. The lack of adequate space to accommodate the new programme was a frequently reported problem.

Overall, our assessment is that the PHC infrastructure in the Free State's public health system is capable of implementing and benefiting from the CCMT programme. Nevertheless, constraints in the availability of professional staff threaten future implementation of both the CCMT and other PHC programmes.     

Clinical outcomes and costs for patients with type 2 diabetes mellitus initiating insulin therapy in Greece: Two-year experience from the INSTIGATE study

AimsTo evaluate the quality of metabolic control, clinical outcomes, resource costs, and quality of life among patients with type 2 diabetes mellitus (T2DM), who initiated insulin for the first time as part of routine clinical practice.MethodsThe INSTIGATE study is a prospective, multicentric, observational study of patients initiating insulin treatment. This sub-cohort analysis focuses on Hellenic outcomes.ResultsAt baseline, 263 Greek patients were enrolled just before initiating insulin for the first time. At the 6-month visit, 237 patients (90.1%) remained and consented to an additional 18-month observation period. In these 237 extension patients, over the 24-month post-initiation period, HbA1c (mean(SD)) decreased from 9.7%(1.6%) to 7.1%(0.9%) and body weight and BMI increased (+3(6) kg and +1.1(2.2) kg/m², respectively). At each post-baseline visit approximately one in five patients reported ≥1 episodes of hypoglycaemia in the preceding 3–6 months. Median total costs fluctuated from 438€ at baseline to 538€ up to 6 months and 451€ at 24 months; mean costs were 496(383)€, 573(276)€ and 485(247)€, respectively.ConclusionsIn this cohort, insulin treatment seems to be effective with little long-term impact on cost. Findings should be interpreted in the context of an observational study.     

Cardiovascular Disease and Homelessness

Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.     

Transcatheter Closure of Atrial Septal Defects in a Center With Limited Resources: Outcomes and Short Term Follow-Up

Background:

Transcatheter closure of atrial septal defects (ASD) has been accepted world-wide as an alternative to surgical closure with excellent results. This interventional, non-surgical technique plays an important role in the treatment of ASD mostly in the developing world where resources are limited.

Objectives:

To report the outcomes and short term follow-up of transcatheter closure of ASD over a 12-year period at our institution with limited resources.

Patients and Methods:

This retrospective study included all patients with the diagnosis of secundum ASD and significant shunting (Qp/Qs > 1.5:1) as well as dilated right atrium and right ventricle who had transcatheter closure at Integrated Cardiovascular Center (PJT), Dr. Cipto Mangunkusumo Hospital between October 2002 and October 2014. One hundred fifty-two patients enrolled in this study were candidates for device closure. Right and left heart cardiac catheterization was performed before the procedure. All patients underwent physical examination, ECG, chest X-ray and transthoracal echocardiography (TTE) prior to device implantation.

Results:

A total of 152 patients with significant ASD underwent device implantation. Subjects’ age ranged from 0.63 to 69.6 years, with median 9.36 years and mean 16.30 years. They consisted of 33 (21.7%) males and 119 (78.3%) females, with mean body weight of 29.9 kg (range 8 to 75; SD 18.2). The device was successfully implanted in 150 patients where the majority of cases received the Amplatzer septal occluder (147/150; 98%) and the others received the Heart Lifetech ASD occluder (3/150, 2%), whereas two other cases were not suitable for device closure and we decided for surgical closure. The mean ASD size was 19.75 (range 14 - 25) mm. During the procedure, 5 (4.9%) patients had bradycardia and 3 (2.9%) patients had supraventricular tachycardia (SVT), all of which resolved.

Conclusions:

In our center with limited facilities and manpower, transcatheter closure of atrial septal defect was effective and safe as an alternative treatment to surgery. The outcome and short-term follow-up revealed excellent results, but long-term follow-up is needed.     

The closing survival gap after liver transplantation for hepatocellular carcinoma in the United States

BackgroundSocio-economic inequalities among different racial/ethnic groups have increased in many high-income countries. It is unclear, however, whether increasing socio-economic inequalities are associated with increasing differences in survival in liver transplant (LT) recipients.MethodsAdults undergoing first time LT for hepatocellular carcinoma (HCC) between 2002 and 2017 recorded in the Scientific Registry of Transplant Recipients (SRTR) were included and grouped into three cohorts. Patient survival and graft survival stratified by race/ethnicity were compared among the cohorts using unadjusted and adjusted analyses.ResultsWhite/Caucasians comprised the largest group (n=9,006, 64.9%), followed by Hispanic/Latinos (n=2,018, 14.5%), Black/African Americans (n=1,379, 9.9%), Asians (n=1,265, 9.1%) and other ethnic/racial groups (n=188, 1.3%). Compared to Cohort I (2002-2007), the 5-year survival of Cohort III (2012-2017) increased by 18% for Black/African Americans, by 13% for Whites/Caucasians, by 10% for Hispanic/Latinos, by 9% for patients of other racial/ethnic groups and by 8% for Asians (All P values<0.05). Despite Black/African Americans experienced the highest survival improvement, their overall outcomes remained significantly lower than other ethnic∕racial groups (adjusted HR for death=1.20; 95%CI 1.05-1.36; P=0.005; adjusted HR for graft loss=1.21; 95%CI 1.08-1.37; P=0.002).ConclusionThe survival gap between Black/African Americans and other ethnic/racial groups undergoing LT for HCC has significantly decreased over time. However, Black/African Americans continue to have the lowest survival among all racial/ethnic groups.     

基于开源内容管理系统Drupal的医院护理学学科平台建设

针对医院护理人员知识层次较低、工作强度大、碎片时间多和信息素养低的特征,结合医院图书馆的服务现状,建立了借助开源软件Drupal的护理学学科信息服务平台。通过整合医院图书馆现有馆藏资源,包括纸质、电子文献资源及网络资源等,为护理人员提供文献资源推送、标签云揭示、个性化定制等Web2.0信息服务;充分利用护理人员的碎片时间,提高护理人员信息素养及科研能力,进而最大化利用图书馆资源;探索了Web2.0环境下医院图书馆的新型服务模式。