Implementation and operational research: Integrated pre-antiretroviral therapy screening and treatment for tuberculosis and cryptococcal antigenemia.

OBJECTIVE: To demonstrate the feasibility of integrated screening for cryptococcal antigenemia and tuberculosis (TB) before antiretroviral therapy (ART) initiation and to assess disease specific and all-cause mortality in the first 6 months of follow-up. METHODS: We enrolled a cohort of HIV-infected, ART-naive adults with CD4 counts ≤250 cells per microliter in rural Uganda who were followed for 6 months after ART initiation. All subjects underwent screening for TB; those with CD4 ≤100 cells per microliter also had cryptococcal antigen (CrAg) screening. For those who screened positive, standard treatment for TB or preemptive treatment for cryptococcal infection was initiated, followed by ART 2 weeks later. RESULTS: Of 540 participants enrolled, pre-ART screening detected 10.6% (57/540) with prevalent TB and 6.8% (12/177 with CD4 count ≤100 cells/µL) with positive serum CrAg. After ART initiation, 13 (2.4%) patients were diagnosed with TB and 1 patient developed cryptococcal meningitis. Overall 7.2% of participants died (incidence rate 15.6 per 100 person-years at risk). Death rates were significantly higher among subjects with TB and cryptococcal antigenemia compared with subjects without these diagnoses. In multivariate analysis, significant risk factors for mortality were male sex, baseline anemia of hemoglobin ≤10 mg/dL, wasting defined as body mass index ≤15.5 kg/m, and opportunistic infections (TB, positive serum CrAg). CONCLUSIONS: Pre-ART screening for opportunistic infections detects many prevalent cases of TB and cryptococcal infection. However, severely immunosuppressed and symptomatic HIV patients continue to experience high mortality after ART initiation.

Zinc oxide nanowire arrays for silicon core/shell solar cells.

The optics of core / shell nanowire solar cells was investigated. The optical wave propagation was studied by finite difference time domain simulations using realistic interface morphologies. The interface morphologies were determined by a 3D surface coverage algorithm, which provides a realistic film formation of amorphous silicon films on zinc oxide nanowire arrays. The influence of the nanowire dimensions on the interface morphology and light trapping was investigated and optimal dimensions of the zinc oxide nanowire were derived.

Implementation and effect of intensified case finding on diagnosis of tuberculosis in a large urban HIV clinic in Uganda: a retrospective cohort study.

BACKGROUND: Increased detection of tuberculosis (TB) using intensified or active case finding (ICF) is one of the cornerstones of the Stop TB Strategy, and contrasts with passive case finding (PCF) which relies on self-reported symptoms. There is no clear guidance on implementation strategies. We implemented ICF in addition to ongoing PCF in our large urban HIV clinic in July 2010 using a twice-daily announcement screen method by a trained peer educator, asking waiting patients to self-refer to a trained peer supporter for screening of TB symptoms. We sought to determine the associated effect on TB case detection. METHODS: Suspects were investigated by sputum smear, chest X-ray and ultrasound, if indicated. Routinely collected clinical and laboratory data were merged with the ICF register and TB clinic data for patients attending the clinic in 2010. We compared the yield of TB cases (defined as the prevalence of newly diagnosed TB cases in the screened population), the type of TB diagnosed and the total cost per TB case identified (in United States Dollars [USD]) for the period before and after ICF implementation. RESULTS: Of the 20,456 patients who visited the clinic in 2010, 614 were identified as TB suspects, 220 pre-ICF and 394 post-ICF (229 via PCF and 165 via ICF). The proportion diagnosed with TB dropped from 66% to 48% (60% in suspects identified through PCF and 31% through ICF). During the post-ICF period, TB suspects identified through ICF compared to PCF identification were more likely to be female, older, on ART and to have been enrolled in HIV care for a longer duration. The yield of combined PCF and ICF screening was 1.4% pre-ICF and 1.7% post-ICF with a cost per TB case identified of 12.29 USD and 21.80 USD, respectively. CONCLUSIONS: Implementation of ICF in a large HIV clinic yielded more TB suspects and cases, but substantially increased costs and was unable to capture the majority of TB suspects who were referred for diagnosis by clinicians through PCF. The overall yield of TB cases in a mature HIV clinic was low, although targeted screening of those recently enrolled in care may increase the yield.

National Stroke Association guidelines for the management of transient ischemic attacks.

OBJECTIVE: Transient ischemic attacks are common and important harbingers of subsequent stroke. Management varies widely, and most published guidelines have not been updated in several years. We sought to create comprehensive, unbiased, evidence-based guidelines for the management of patients with transient ischemic attacks. METHODS: Fifteen expert panelists were selected based on objective criteria, using publication metrics that predicted nomination by practitioners in the field. Prior published guidelines were identified through systematic review, and recommendations derived from them were rated independently for quality by the experts. Highest quality recommendations were selected and subsequently edited by the panelists using a modified Delphi approach with multiple iterations of questionnaires to reach consensus on new changes. Experts were provided systematic reviews of recent clinical studies and were asked to justify wording changes based on new evidence and to rate the final recommendations based on level of evidence and quality. No expert was allowed to contribute to recommendations on a topic for which there could be any perception of a conflict of interest. RESULTS: Of 257 guidelines documents identified by systematic review, 13 documents containing 137 recommendations met all entry criteria. Six iterations of questionnaires were required to reach consensus on wording of 53 final recommendations. Final recommendations covered initial management, evaluation, medical treatment, surgical treatment, and risk factor management. INTERPRETATION: The final recommendations on the care of patients with transient ischemic attacks emphasize the importance of urgent evaluation and treatment. The novel approach used to develop these guidelines is feasible, allows for rapid updating, and may reduce bias.

Creative partnerships for community health improvement: a qualitative evaluation of the Healthy Carolinians community micro-grant project.

This qualitative study evaluated a recent innovative strategy used to involve community-based organizations (CBOs) in implementing health-related projects through locally administered microgrants. The purpose of this study was to identify key elements that enabled the success of the CBO projects, barriers and challenges to project success, and ways to effectively engage CBOs as partners in local health initiatives. In addition, this study sought to identify aspects of this approach that can be replicated. Study findings revealed that microfinancing CBOs aided in building partnerships, developing local leadership and expertise, and providing resources that enabled progress toward CBO missions and goals. These positive outcomes far out-weighed barriers and challenges faced by CBOs. Furthermore, the results of this study revealed ideas and information that provide useful guidelines for establishing and administering microgrant projects through local organizations that encourage community groups to design and implement community based health initiatives.

North Carolina family medicine residency programs' diabetes learning collaborative.

BACKGROUND AND OBJECTIVES: Using a learning collaborative among multiple residency programs is a new concept and has the potential to improve diabetes care beyond the usual quality improvement techniques. METHODS: This project developed a learning collaborative with six affiliated family medicine residency sites using the Chronic Care Model (CCM) to improve diabetes care according to the National Committee for Quality Assurance and the American Diabetic Association Physician Recognition Program (PRP) key measure criteria. RESULTS: Key measures of diabetic care were met or exceeded in 67% of the residency programs. One site fulfilled all PRP criteria. Two other sites exceeded two additional targets, while one site exceeded one target. Baseline and follow-up data were compiled for five sites on the Assessment of Chronic Illness Care survey, testing the implementation of the CCM. Scores started in basic support and improved to the next level of reasonably good support for diabetes care. CONCLUSIONS: The learning collaborative structured sites to focus on evaluating diabetes care and regularly reporting activities to peers. The learning collaborative resulted in improved diabetes care in practices that had formerly used quality improvement techniques and especially in sites with a history of organizational change and involvement of residents.