结核病中断治疗的危险因素分析:赞比亚301例结核病患者前瞻性队列研究

背景:赞比亚一家城市结核病门诊部。目的:确认与中断治疗增加有关的患者特征,尤其是关于接受治疗的相关知识及费用因素。设计:对15岁以上、开始治疗的结核病患者进行前瞻性队列研究,采用半结构式调查表调查及对其后一周三次直接观察下治疗(DOT)就诊情况的观察。结果:301例患者中,共有76例(25.2%)中断了治疗,25例未恢复治疗。中断治疗率较高者为对治疗成功信心不足者(HR3.64;95%CI:1.42-9.31,P=0.007)及因接受治疗有明显的时间和费用限制者(HR2.67;95%CI:1.05-6.81;P=0.04)。在不同治疗阶段这些因素的影响不同,在开始治疗的90天,对治疗成功信心不足的因素影响明显,而因到门诊部接受治疗而增加交通费用的因素则多发生于治疗90天后。结论:在赞比亚,在开始治疗及治疗期间的不同阶段均可发现中断治疗的高危人群。在治疗3个月后,患者对治疗成功信心增强后,可考虑采用以家庭为基础的自我服药,这样可减少患者去门诊部接受治疗的费用。     

Certification in Medical Physics Imaging,The Workforce and Training Models

The pathway to becoming a qualified medical physicist (QMP) in the imaging physics disciplines includes several certification organizations. Imaging QMPs play an essential role in the safe practice of the diagnostic disciplines, and their qualifications are necessary for compliance with federal bodies and professional accreditation organizations. The future demand for imaging QMPs is largely unknown, but professional organizations that represent these groups agree that efforts should be made to increase the number of matriculating trainees. The number of imaging residency programs that provide the necessary professional experience to enter the certification pathway has increased substantially in recent years. Most of these programs follow a traditional academic hospital-based training model, but guidance on program construction from the accrediting body permits flexibility. Existing training models for medical physics imaging also include consortiums of affiliate partners and private consulting service groups. In this article, the authors briefly review the certification pathways for imaging QMPs, workforce estimates, and training models.     

Common problems with antiretroviral therapy among three Swedish groups of HIV infected individuals

Objective The main objective of this study was to identify and compare the common problems and difficulties associated with combination antiretroviral therapy (CART) as experienced by three major groups of HIV infected individuals (homo- or bisexuals, former injecting drug users and origins of Sub-Saharan Africa) in Sweden. Methods Based on the results from in-depth interviews with 15 representatives from the three major groups, a questionnaire was designed for use in a problem detection study (PDS). The study was conducted with 195 HIV-positive patients residing in the major cities of Sweden. Results The overall response rate was 79%. The problems identified in all three groups were negative attitudes from the public, worries about disease progression or therapy failure, medication or drug-related problems and problems in connection to pharmacy visits. A specific problem in the homo- or bisexual group was drug-related problems such as adverse effects, drug interactions and pill burden. For former injecting drug users, the specific problem was disease-related conflicts with relatives and the problem of coping with the social and psychological burden caused by the HIV infection. The African group termed the risk of exposing their medication at the pharmacy as a specific problem, as this could reveal their HIV status. Conclusions Our findings regarding problems with CART in three patient groups in Sweden may be of use to tailor pharmacy care to HIV infected individuals. General strategies to improve adherence need to be complemented with approaches that will address the specific needs for the different patient groups affected by HIV. Further studies on group-specific interventions that promote concordance and adherence to CART will be necessary to minimize therapy failure and viral resistance.     

Temporal variation in out-of-hospital cardiac arrest with validated cardiac cause

Objective. Temporal variations in the occurrence of out-of-hospital cardiac arrest (OHCA) have been shown. Most previous studies have in common that they include individuals whom have received cardiopulmonary resuscitation (CPR) and thus excluding a great number of all the actual cases of OHCA when conducting a study. Therefore the aim of this study was to describe temporal variations of OHCA, regardless of whether CPR was performed or not. Design. All individuals aged 25–74 years in northern Sweden, 1989–2009, who suffered an out-of-hospital cardiac arrest with validated myocardial infarction aetiology (OHCA-V), regardless of whether CPR was performed or not, were included in this study, which resulted in 3357 individuals. Results. Regarding the diurnal variation, a daytime excess of OHCA-V was seen, with most occurring between 12:00–17:59 (29%) closely followed by the 06:00–11:59 time block (27%). In terms of the weekly variation, most OHCA-V was seen on Saturdays (17%), while January (11%), followed by December (9%), saw the highest incidence of the months. Conclusion. A temporal variation in OHCA-V is seen even when including cases where no CPR is attempted. However, this variation differs in some aspects to what some previous studies have shown, in that no clear morning or Monday peaks were seen. In order to explore potential triggers and underlying factors that influence OHCA, more studies like these are needed, preferably following standardized inclusion criteria and definitions of OHCA to better be able to compare results, all in order to develop the best possible preventive strategies.     

Meeting oxygen needs in Africa: an options analysis from the?Gambia

Objective

To compare oxygen supply options for health facilities in the Gambia and develop a decision-making algorithm for choosing oxygen delivery systems in Africa and the rest of the developing world.

Methods

Oxygen cylinders and concentrators were compared in terms of functionality and cost. Interviews with key informants using locally developed and adapted WHO instruments, operational assessments, cost-modelling and cost measurements were undertaken to determine whether oxygen cylinders or concentrators were the better choice. An algorithm and a software tool to guide the choice of oxygen delivery system were constructed.

Findings

In the Gambia, oxygen concentrators have significant advantages compared to cylinders where power is reliable; in other settings, cylinders are preferable as long as transporting them is feasible. Cylinder costs are greatly influenced by leakage, which is common, whereas concentrator costs are affected by the cost of power far more than by capital costs. Only two of 12 facilities in the Gambia were found suitable for concentrators; at the remaining 10 facilities, cylinders were the better option.

Conclusion

Neither concentrators nor cylinders are well suited to every situation, but a simple options assessment can determine which is better in each setting. Nationally this would result in improved supply and lower costs by comparison with conventional cylinders alone, although ensuring a reliable supply would remain a challenge. The decision algorithm and software tool designed for the Gambia could be applied in other developing countries.     

Screening for tuberculosis among 2381 household contacts of sputum-smear-positive cases in The Gambia

Contact investigation is a key component of tuberculosis (TB) control in developed, but not developing, countries. We aimed to measure the prevalence of TB among household contacts of sputum-smear-positive TB cases in The Gambia and to assess the sensitivity of an enzyme-linked immunospot (ELISPOT) assay in this regard. Household contacts of adult smear-positive TB patients were assessed by questionnaire, purified protein derivative (PPD) skin test, ELISPOT assay, physical examination, chest X-ray and sputum/gastric aspirate. Thirty-three TB cases were identified from 2174 of 2381 contacts of 317 adult smear-positive pulmonary TB patients, giving a prevalence of 1518/100000. The cases identified tended to have milder disease than those passively detected. The sensitivity of ESAT-6/CFP-10 ELISPOT test as a screening test for TB disease was estimated as 71%. Fifty-six per cent of contacts with a PPD skin test result >or=10mm induration had detectable responses to ESAT-6/CFP-10 by ELISPOT; 11% with a negative PPD skin test (<10mm) had a positive ESAT-6/CFP-10 response. Active screening for TB among contacts of TB patients may have a role in TB control in The Gambia. These individuals are a high-risk group, and the disease identified is less advanced than that found through passive case detection. An ELISPOT assay was relatively insensitive as a screening test for TB.     

IFNGR1 gene promoter polymorphisms and susceptibility to cerebral malaria

Interferon (IFN)-gamma is a critical mediator of immunity to malaria. This study explored the relationship between polymorphisms in the promoter region of the gene encoding IFN-gamma receptor 1 (IFNGR1) and susceptibility to malaria in African children. Four polymorphisms were found in the region between -1400 and +100 nt of the translational start site by sequencing, and analysis of 562 nuclear families revealed 6 haplotypes. Case-control analysis of 562 Gambian children with severe malaria and 569 umbilical cord blood samples (controls) showed that in Mandinka, the major Gambian ethnic group, heterozygotes for the IFNGR1-56 polymorphism were protected against cerebral malaria (odds ratio, 0.54; P=.016) and against death resulting from cerebral malaria (odds ratio, 0.22; P=.006). Analysis of a family study by transmission disequilibrium testing revealed a similar result. Further data are needed to validate this finding, but these results are reminiscent of those for other well-established heterozygote advantages, such as that associated with hemoglobin S.     

Idiopathic Serous Detachment of the Choroid,Ciliary Body,and Retina (Uveal Effusion Syndrome)

Nine patients with bilateral idiopathic serous detachment of the peripheral choroid, ciliary body, and retina (uveal effusion syndrome)are presented. The following features are emphasized: (1) dilationof episcleral vessels, (2) vitreous cells, (3) characteristic leopardspot pigment epithelial changes, and (4) ultrasonic and angiographic findings. One patient presented with recurrent serous macular detachment and was misdiagnosed as idiopathic central serous choroidopathy. Although the pathogenesis of this syndrome is uncertain, the available clinical and histopathologic findings suggest that obstruction of the venous outflow of the uveal tract occurring predominantly in nanophthalmic or normal size eyes with abnormally thick sclera and vortex vein anomalies may be the primary cause of the uveal and retinal detachment.