Post-treatment Mortality Among Patients With Tuberculosis: A Prospective Cohort Study of 10 964 Patients in Vietnam.

BACKGROUND: Tuberculosis is the leading infectious cause of death. Steep reductions in tuberculosis-related mortality are required to realize the World Health Organization's "End Tuberculosis Strategy." However, accurate mortality estimates are lacking in many countries, particularly following discharge from care. This study aimed to establish the mortality rate among patients with pulmonary tuberculosis in Vietnam and to quantify the excess mortality in this population. METHODS: We conducted a prospective cohort study among adult patients treated for smear-positive pulmonary tuberculosis in 70 clinics across Vietnam. People living in the same households were recruited as controls. Participants were re-interviewed and their survival was established at least 2 years after their treatment with an 8-month standardized regimen. The presence of relapse was established by linking identifying data on patients and controls to clinic registries. Verbal autopsies were performed. The cumulative mortality among patients was compared to that among a control population, adjusting for age and gender. RESULTS: We enrolled 10964 patients and 25707 household controls. Among enrolled tuberculosis patients, 9% of patients died within a median follow-up period of 2.9 years: 342 (3.1%) during treatment and 637 (5.8%) after discharge. The standardized mortality ratio was 4.0 (95% confidence interval 3.7-4.2) among patients with tuberculosis, compared to the control population. Tuberculosis was the likely cause of death for 44.7% of these deceased patients. CONCLUSIONS: Patients treated for tuberculosis had a markedly elevated risk of death, particularly in the post-treatment period. Interventions to reduce tuberculosis mortality must enhance the early detection of drug-resistance, improve treatment effectiveness, and address non-communicable diseases.

Tuberculin skin testing and QuantiFERON™-TB Gold Plus positivity among household contacts in Vietnam.

SETTING: TB infection (TBI) is diagnosed using the technique-dependent tuberculin skin test (TST) or costly, more accurate interferon-gamma release assays. The TST (⩾10 mm) threshold was indicated by previous research among household contacts in Vietnam, but routine implementation with a different tuberculin reagent showed unexpectedly low TST positivity. OBJECTIVE: TST (⩾5 mm and ⩾10 mm) results were compared to QuantiFERON™-TB Gold Plus (QFT) results in household contacts during community campaigns in 2020 and 2021. DESIGN: This was a cross-sectional multi-center implementation study. RESULTS: Among 1,330 household contacts in 2020, we found a TBI prevalence of 38.6% (QFT), similar to TST ⩾5 mm (37.4%) and higher than TST ⩾10 mm (13.1%). QFT+/TST+ was higher for TST ⩾5 mm (20.7%) than TST ⩾10 mm (9.4%). QFT was not discordant with TST ⩾5 mm (McNemar's test = 0.6, P = 0.5) but was discordant with TST ⩾10 mm (McNemar's test = 263.9, P < 0.01). Older age and Southern region increased odds for positive TST ⩾5 mm and QFT with weaker associations for TST ⩾10 mm. Agreement and discordance were similar in 2021 for 1,158 household contacts. CONCLUSION: Tuberculin reagents affect TST positivity rates. High TB burden countries should monitor reliability of TBI diagnosis, including tuberculin potency, cold chain, and TST technique to optimize eligibility for TB preventive treatment.

CONTEXTE: L'infection tuberculeuse (TBI) est diagnostiquée à l'aide du test cutané à la tuberculine (TST), qui dépend de la technique, ou de tests de libération de l'interféron-gamma, coûteux et plus précis. Des recherches antérieures ont indiqué que le TST (⩾10 mm) est généralement utilisé pour diagnostiquer la TB parmi les contacts familiaux au Vietnam ; la mise en œuvre de routine avec un réactif de tuberculine différent a montré une faible positivité inattendue du TST. OBJECTIF: Les résultats du TST (⩾5 mm et ⩾10 mm) ont été comparés aux résultats de QuantiFERON™-TB Gold Plus (QFT) chez les contacts familiaux au cours des campagnes communautaires de 2020 et 2021. MÉTHODE: Il s'agissait d'une étude transversale multicentrique de mise en œuvre. RÉSULTATS: Parmi 1 330 contacts familiaux en 2020, nous avons trouvé une prévalence de TBI de 38,6% (QFT), similaire au TST ⩾5 mm (37,4%) et plus élevée que le TST ⩾10 mm (13,1%). Le QFT+/TST+ était plus élevé pour le TST ⩾5 mm (20,7%) que pour le TST ⩾10 mm (9,4%). Le QFT n'était pas discordant avec le TST ≥5 mm (test de McNemar = 0,6 ; P = 0,5) mais était discordant avec le TST ⩾10 mm (test de McNemar = 263,9 ; P < 0,01). L'âge avancé et la région méridionale augmentaient les probabilités d'un TST positif ⩾5 mm et d'un QFT, avec des associations plus faibles pour un TST ⩾10 mm. La concordance et la discordance étaient similaires en 2021 pour 1 158 contacts familiaux. CONCLUSION: Les réactifs de tuberculine affectent les taux de positivité des TST. Les pays à forte charge de TB doivent surveiller la fiabilité du diagnostic de TBI, y compris la puissance de la tuberculine, la chaîne du froid et la technique du TST afin d'optimiser l'éligibilité au traitement préventif de la TB.

[Covering of Finger-Tissue Loss by Local Flaps in Hanoi, Vietnam]. / Recouvrement des pertes de substance de la pulpe des doigts par des lambeaux locaux à Hanoï, Vietnam.

The accidental loss of fingertip soft tissues, which may expose tendons and bones, is a common injury in emergency departments. If these lesions are poorly treated, they can impair fine motor skills and tactile sensitivity of the fingertips. The study was conducted on 30 patients (24 males and 6 females) with 32 soft tissue defects of the fingertip treated in emergency plastic surgery with local pedicled flap at the Plastic Surgery Department of Saint Paul Hospital Hanoi from 01/2016 to 06/2017. The most common cause of injury (21/30) was occupational accidents. At the time of the accident, 12 patients did not have personal protective equipment (PPE). Among 18 patients who had one, eight had incomplete equipment. Of 32 implanted skin flaps, 31 survived completely without necrosis or infection, only one being affected by epidermolysis. Postoperative evaluation showed excellent motor skills for 31/32 fingers and a sensitivity restoration at S4 level for 27/32. Workplace accident is the main cause of fingers soft tissue defects. Covering the fingers soft tissue defects with local pedicled flap in emergency preserves the fine motor function and the delicated tactile sensation of the fingers.

Une étude sur les pertes de substance accidentelles de la pulpe des doigts et leur recouvrement par lambeaux locaux a été réalisée dans le service de chirurgie reconstructive de l'hôpital Saint Paul de Hanoï de janvier 2016 à juin 2017. Elle a concerné 30 patients, 24 hommes et 6 femmes. La cause la plus fréquente était l'accident de travail, soit 21/30 cas. Au moment de l'accident, 12 patients ne disposaient pas d'équipement de protection individuelle (EPI). Sur les 18 patients qui en possédaient, 8 avaient un équipement incomplet. Sur 32 lambeaux mis en place, 31 ont survécu complètement sans nécrose, ni infection, et un a subi une épidermolyse. Trente et un des 32 doigts opérés ont conservé une fonction motrice de bonne qualité et 27 ont récupéré une sensibilité de niveau S4. Le traitement en urgence des pertes de substance de la pulpe des doigts par des lambeaux locaux permet de préserver la fonction motrice fine et la sensibilité des pulpes des doigts.

Tuberculosis and HIV co-infection in Vietnam.

UNLABELLED: Tuberculosis (TB) and human immunodeficiency virus (HIV) infection are leading causes of disease and death in Vietnam, but TB/HIV disease trends and the profile of co-infected patients are poorly described. METHODS: We examined national TB and HIV notification data to provide a geographic overview and describe relevant disease trends within Vietnam. We also compared the demographic and clinical profiles of TB patients with and without HIV infection. RESULTS: During the past 10 years (2005-2014) cumulative HIV case numbers and deaths increased to 298,151 and 71,332 respectively, but access to antiretroviral therapy (ART) improved and new infections and deaths declined. From 2011-2014 routine HIV testing of TB patients increased from 58.9% to 72.5% and of all TB patients diagnosed with HIV in 2014, 2,803 (72.4%) received ART. The number of multidrug resistant (MDR)-TB cases enrolled for treatment increased almost 3-fold (578 to 1,532) from 2011-2014. The rate of HIV co-infection in MDR and non-MDR TB cases (51/1,532; 3.3% vs 3,774/100,555; 3.8%; OR 0.77, 95% CI 0.7-1.2) was similar in 2014. CONCLUSIONS: The care of TB/HIV co-infected patients have shown sustained improvement in Vietnam. Rising numbers of MDR-TB cases is a concern, but this is not "driven" by HIV co-infection.

Periodontal associations in cardiovascular diseases: The latest evidence and understanding.

Periodontal and cardiovascular diseases (CVD) are inflammatory diseases. Recent epidemiological studies have associated the effect of periodontitis on CVD progression. Findings of oral pathogens in carotid atheromas provided a plausible relationship between these two diseases. One possible mechanism is the infiltration of oral/periodontal pathogens through inflamed and ulcerated gingival epithelium. This results in translocation of oral pathogens throughout the systemic circulation affecting vascular tissues, and initiating a cascade of inflammatory reactions detrimental to the cardiovascular system. In addition, leakage of pro-inflammatory cytokines/chemokines from the ulcerated periodontium into the bloodstream may cause the production of hepatic acute-phase proteins. Moreover, as chronic bacteremia occurs, the adaptive immune system is activated. Antibodies produced in response to periodontal pathogens trigger a cross-reaction between endothelial cells and modified low-density lipoprotein to enhance the movement of lipids into cells within the vessel wall. Some antibodies and inflammatory cytokines promote the Th1 response, thereby further activating macrophages within the atheroma. These plausible mechanisms are contributing factors in initiating and propagating atherogenesis. This review discusses the current understanding of CVD pathology/periodontitis, potential underlying mechanisms regarding this association, and general guidelines for treating patients with CVD risks.

Abnormal Pap smear follow-up in a high-risk population.

Low-income women are at high risk of developing cervical cancer attributable not only to the higher prevalence of risk factors in this population but also to the lack of timely follow-up of abnormal Pap smears. This study evaluates the efficacy of an aggressive follow-up strategy. Women with abnormal Pap smear results after screening in a public hospital emergency department were randomly assigned to follow-up either by a case-managed approach using computerized tracking and universal colposcopy or by traditional care. The main outcome was the proportion of women receiving follow-up in 6 months. A secondary outcome was the proportion of women receiving follow-up by 6 months and diagnostic resolution in 18 months. Of 54 women in the intervention group, 65% kept at least one follow-up appointment in 6 months compared with 41% of the 54 women in the control group (P = 0.012). Half the women in the intervention group versus 19% of women in the control group had follow-up in 6 months and diagnostic resolution in 18 months (P = 0.001). After adjusting for age, initial Pap smear result, and race/ethnicity, the odds of having follow-up in 6 months were four times greater for women in the intervention group (odds ratio = 4.0; 95% confidence interval, 1.6-9.7), and the odds of having both follow-up in 6 months and diagnostic resolution in 18 months were more than six times greater (odds ratio = 6.5; 95% confidence interval, 2.4-17.8). This study demonstrates that an aggressive follow-up strategy significantly improves the rate of both initial follow-up and diagnostic resolution of abnormal Pap smears among low-income women with atypical squamous cells of undetermined significance and atypical glandular cells of undetermined significance when compared with traditional care.

Does willingness to pay vary by race/ethnicity? An analysis using mammography among low-income women.

As part of a population-based intervention to improve periodic mammogram screening, we examined WTP for mammography in five ethnic groups. Through random digit dialing, we contacted households in low-income census tracts of Alameda County, California (San Francisco Bay area). Women who met the ethnicity, age and cancer-free eligibility criteria were invited to participate. For the baseline assessment, women were surveyed over the phone in their preferred language. Of the 1465 surveyed women, 499 identified themselves as African-American, 199 were Chinese, 167 were Filipino, 300 were Latina, and 300 were non-Hispanic white. Bivariate and multivariate analysis showed that WTP varied significantly by ethnicity (P<0.05). We also found that when Filipino and Chinese women had a female relative with breast cancer, they were willing to pay less money for a mammogram. African-American, Latino, and non-Hispanic white women, however, were willing to pay more money for a mammogram if a female relative had had breast cancer. This ethnic difference, when there is a familial link to breast cancer, needs further study as it has implication for genetic testing. Nevertheless, WTP studies that do not account for ethnic differences may be overstating net benefits to society.

CathSim: an intravascular catheterization simulator on a PC.

The development of a medical simulator that incorporates substantial training value and realism into an affordable product has been a huge challenge for the simulation community. A large hurdle to making an inexpensive simulator has been the high cost of the computers needed for adequate realism. We have met this challenge by developing CathSim, a low-cost medical simulator that integrates force feedback, multimedia, and 3D graphics simulation technology on an industry standard PC. This product is commercially available and is currently being used by numerous training institutions and hospitals. The CathSim system includes software and a force feedback interface device. The platform and device can be used to train health care providers to perform needle-stick medical procedures. Our first module teaches users the techniques of peripheral intravenous (i.v.) catheterization. Other training modules that will be added to the CathSim platform include central venous catheter (CVC) insertion and peripherally inserted central catheter (PICC) placement. This paper discusses the challenges of this project and the trade-offs and solutions that we developed to overcome them. We describe our process of analyzing and prioritizing the medical tasks necessary to correctly perform peripheral intravenous catheterization. This analysis and prioritization was used to decide which tasks would be included in the simulator and how the included tasks would be replicated. We discuss the method by which we obtained the needed realism in the 3D graphics rendering and in the tactile feedback of the input device. We illustrate how we blended together simulation and multimedia technology to ensure adequate immersion and training efficacy, while keeping the system cost to a minimum.

The teleos virtual environment toolkit for simulation-based surgical education.

In the past, surgical simulations have largely been created through the development of dedicated applications that require considerable programming and computer graphics skills. Advances in simulation-based surgical education have been limited by this dependence on computer graphics programming expertise. To lower barriers to the adoption of simulation-based training, we are developing tools based on Teleos, software technology that allows a wide variety of medical content developers to author surgical training simulations without programming.

Phylogenetic and phylogeographic analyses of porcine circovirus type 2 among pig farms in Vietnam.

This study demonstrated the prevalence of Porcine circovirus type 2 (PCV2) among pig farms in Vietnam. Analyses of the genome, capsid protein and phylogeny classified all 30 Vietnamese PCV2 strains as the PCV2b genotype, belonging to the clusters of 1A, 1B, 1C and recombinant forms. Each viral genome was 1767 nucleotides long and shared 96.0-100% nucleotide sequence identity. The amino acid substitutions in the capsid protein of the Vietnamese PCV2 strains were in immunodominant regions, and the majority of strains (24/30) contained a lysine extension at the C-terminus. Bayesian phylogeographic analysis revealed epidemic links of the PCV2 recombinant cluster within and among countries, which supports a circulating recombinant form of PCV2. Further analysis by the Jameson-Wolf antigenic index indicated antigenic alterations at important sites in the capsid protein (sites 131-133) among the recombinant cluster and the other clusters of PCV2b.

Physiologic identification of eighth nerve subdivisions: direct recordings with bipolar and monopolar electrodes.

The purpose of this study was to determine stimulation and recording parameters that maximize differences in evoked responses recorded between the cochlear nerve and the surrounding tissues. Click-evoked potentials were obtained using monopolar and bipolar recording electrodes placed directly on the exposed eighth nerve of anesthetized cats. Responses were compared as stimulus intensity, electrode location, and bipolar electrode orientation and interelectrode spacing were systematically varied. Wave amplitudes increased monotonically with intensity for both monopolar and bipolar configurations, but bipolar configurations exhibited greater selectivity in differentiating cochlear from vestibular subdivisions. The optimal stimulus intensity was 70 to 80 dB peak sound pressure level (pSPL). Monopolar recordings were often confounded by activity originating at remote sites, typically the cochlear nucleus and (for recording sites on the vestibular nerve) the cochlear nerve. Bipolar response amplitudes increased with interelectrode spacing and were largest when electrodes were oriented parallel to the long axis of the nerve. Extrapolation of empirical data indicated that amplitudes of bipolar responses would be maximal at an electrode separation of 7.5 mm. Cochlear nerve conduction velocity, calculated from wave latencies at each of the two monopolar electrodes, was 11.6 +/- 1.6 m/sec.

Epidemiology of electrical and lightning related deaths and injuries among Canadian children and youth.

Among burn injuries, electrical injuries constitute a small but devastating fraction. To describe the epidemiology of electrical injuries in Canadian children, data on deaths and emergency department visits related to electrical injuries, including lightning strikes, were obtained from provincial coroners' offices and the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) respectively, for the years 1991-96. Twenty one deaths and 606 emergency visits highlight that electrical related deaths, more frequent among school age children, are more likely the result of high voltage and lightning strike, while emergency department visits, more frequent among younger children, are more likely the result of low voltage. While the introduction of legislated standards for child safe outlets and educational programs for parents, children, and youth are recommended strategies toward reducing the frequency of these incidents, these strategies require further evaluation before their effectiveness can be estimated.

Promoting cancer prevention activities among Vietnamese physicians in California.

BACKGROUND: To promote prevention and early detection of cancer, the authors conducted a three-year intervention targeting Vietnamese physicians in solo practice in California. METHODS: Twenty subjects who had received their medical training in Vietnam were recruited into a randomized controlled trial. The intervention included computerized or manual cancer screening reminders, continuing medical education seminars, Vietnamese-language health education materials, newsletters, and oncology data-query programs. Evaluation included chart audits for eight targeted activities pre- and post-intervention. RESULTS: Before the intervention, annual physician performance rates were low for all eight activities: routine checkups (65.6%), Pap testing (13.8%), pelvic examinations (19.8%), clinical breast examinations (13.3%), mammography (6.4%), hepatitis B serologies (21.9%), hepatitis B immunizations (12.8%), and smoking cessation counseling (1.6%). After the intervention, performance rates increased significantly for smoking cessation counseling (p = 0.02), Pap testing (p = 0.004), and pelvic examinations (p = 0.01). CONCLUSIONS: The results demonstrate the efficacy of an intervention targeting Vietnamese primary care physicians in promoting smoking cessation counseling, Pap testing, and pelvic examinations, but not other cancer prevention activities.

Effect of a media-led education campaign on breast and cervical cancer screening among Vietnamese-American women.

BACKGROUND: Previous research has shown that breast and cervical cancer screening rates are low among Vietnamese women. METHODS: Over a 24-month period, we implemented a media-led community education campaign to promote recognition, intention, receipt, and currency of routine checkups, clinical breast examinations, mammograms, and Pap tests among Vietnamese-American women in Alameda and Santa Clara Counties in northern California. Women in Los Angeles and Orange Counties in southern California served as controls. To evaluate its impact, pretest telephone interviews were conducted of 451 randomly selected women in the intervention area and 482 women in the control area and posttest interviews with 454 and 422 women, respectively. RESULTS: At posttest, after controlling for demographic differences in the surveyed populations, the odds ratios for the intervention effect were statistically significant for having heard of a general checkup, Paptest, and clinical breast examination (CBE); planning to have a checkup, Pap test, CBE, and mammogram; and having had a checkup and Pap test. The intervention had no effect on being up to date for any of the tests. CONCLUSIONS: A media-led education intervention succeeded in increasing recognition of and intention to undertake screening tests more than receipt of or currency with the tests.