Impact of traumatic perinatal events on burnout rates among midwives.

BACKGROUND: Little is known about the prevalence of burnout among Irish midwives and how traumatic perinatal events in work contributes to this. AIMS: To establish the prevalence of burnout among midwives in Ireland and whether exposure to traumatic perinatal events in work contributes to this. METHODS: A cross-sectional study utilizing a designed questionnaire was carried out in a tertiary-referral maternity hospital involving all clinical midwives (n = 248). Demographic details and frequency of perinatal events deemed traumatic were recorded. The extent of distress was documented on two visual analogues read in combination to reflect the impact of the distressing events. Burnout severity was assessed using the Copenhagen Burnout Inventory. RESULTS: The response rate was 55% (n = 137). Mean scores for personal, work-related and patient-related burnout were 56.0, 55.9 and 34.3, respectively. Over 90% of respondents experienced exposure to a traumatic event in work in the previous year, with 58% reporting a frequency of monthly or greater. No significant relationship was demonstrated between frequency of trauma and burnout; however, the extent of distress experienced was positively related to burnout in each domain (R2 = 0.18, 0.15 and 0.09, respectively, P < 0.01). A modest negative linear relationship exists between personal and work-related burnout and increasing age (ρ = -0.25 and -0.27, P < 0.01). A significant difference in work-related burnout score was evident between midwives with less experience and more experienced colleagues (P < 0.01). CONCLUSIONS: Burnout is common among midwives. Exposure to discrete traumatic perinatal events experienced by women under their care contributes to this.

Purinergic signaling mediated by P2X7 receptors controls myelination in sciatic nerves.

Adenosine-5'-triphosphate, the physiological ligand of P2X receptors, is an important factor in peripheral nerve development. P2X7 receptor is expressed in Schwann cells (SCs), but the specific effects of P2X7 purinergic signaling on peripheral nerve development, myelination, and function are largely unknown. In this study, sciatic nerves from P2X7 knockout mice were analyzed for altered expression of myelin-associated proteins and for alterations in nerve morphology. Immunohistochemical analyses revealed that, in the wild-type peripheral nerves, the P2X7 receptor was localized mainly in myelinating SCs, with only a few immunopositive nonmyelinating SCs. Complete absence of P2X7 receptor protein was confirmed in the sciatic nerves of the knockout mice by Western blot and immunohistochemistry. Western blot analysis revealed that expression levels of the myelin proteins protein zero and myelin-associated glycoprotein are reduced in P2X7 knockout nerves. In accordance with the molecular results, transmission electron microscopy analyses revealed that P2X7 knockout nerves possess significantly more unmyelinated axons, contained in a higher number of Remak bundles. The myelinating/nonmyelinating SC ratio was also decreased in knockout mice, and we found a significantly increased number of irregular fibers compared with control nerves. Nevertheless, the myelin thickness in the knockout was unaltered, suggesting a stronger role for P2X7 in determining SC maturation than in myelin formation. In conclusion, we present morphological and molecular evidence of the importance of P2X7 signaling in peripheral nerve maturation and in determining SC commitment to a myelinating phenotype.

Muscarinic receptors modulate Nerve Growth Factor production in rat Schwann-like adipose-derived stem cells and in Schwann cells.

Regenerative capability of the peripheral nervous system after injury is enhanced by Schwann cells (SCs) producing several growth factors. The clinical use of SCs in nerve regeneration strategies is hindered by the necessity of removing a healthy nerve to obtain the therapeutic cells. Adipose-derived stem cells (ASCs) can be chemically differentiated towards a SC-like phenotype (dASCs), and represent a promising alternative to SCs. Their physiology can be further modulated pharmacologically by targeting receptors for neurotransmitters such as acetylcholine (ACh). In this study, we compare the ability of rat dASCs and native SCs to produce NGF in vitro. We also evaluate the ability of muscarinic receptors, in particular the M2 subtype, to modulate NGF production and maturation from the precursor (proNGF) to the mature (mNGF) form. For the first time, we demonstrate that dASCs produce higher basal levels of proNGF and mature NGF compared to SCs. Moreover, muscarinic receptor activation, and in particular M2 subtype stimulation, modulates NGF production and maturation in both SCs and dASCs. Indeed, both cell types express both proNGF A and B isoforms, as well as mNGF. After M2 receptor stimulation, proNGF-B (25 kDa), which is involved in apoptotic processes, is strongly reduced at transcript and protein level. Thus, we demonstrate that dASCs possess a stronger neurotrophic potential compared to SCs. ACh, via M2 muscarinic receptors, contributes to the modulation and maturation of NGF, improving the regenerative properties of dASCs.

Successful decolonization of methicillin-resistant Staphylococcus aureus in paediatric patients with cystic fibrosis (CF) using a three-step protocol.

Methicillin-resistant Staphylococcus aureus (MRSA) is recognized as a bacterial pathogen in patients with cystic fibrosis (CF) although its clinical effects can be variable. The aim of this study was to evaluate the efficacy of a three-step decolonization protocol for MRSA (Belfast CF MRSA decolonization protocol). Of the 17 paediatric patients treated during the five years of the study, eight (47%) were successfully decolonized following one five-day course of oral rifampicin and fusidic acid. The success rate increased to 12 (71%) patients after a second five-day oral treatment course in the 11 patients who remained culture positive at the end of the first treatment cycle. In a further four patients, clearance was achieved with a course of intravenous teicoplanin, increasing the decolonization rate to 16 of 17 patients (94%). These results compare favourably with other published studies and show that MRSA decolonization can be successful in a high proportion of paediatric CF patients.

Novel oral anticoagulants in plastic surgery.

Novel oral anticoagulants (NOACs) have emerged as a good alternative to warfarin in the prevention of stroke for patients with atrial fibrillation. NOAC use is increasing rapidly; therefore, greater understanding of their use in the perioperative period is important for optimal care. Studies and reviews that reported on the use of NOACs were identified, with particular focus on the perioperative period. PubMed was searched for relevant articles published between January 2000 and August 2015. The inevitable rise in the use of NOACs such as rivaroxaban (Xarelto™), apixaban (Eliquis™), edoxaban (Lixiana™) and dabigatran (Pradaxa™) may present a simplified approach to perioperative anticoagulant management due to fewer drug interactions, rapidity of onset of action and relatively short half-lives. Coagulation status, however, cannot reliably be monitored and no antidotes are currently available. When planning for discontinuation of NOACs, special consideration of renal function is required. Advice regarding the management of bleeding complications is provided for consideration in emergency surgery. In extreme circumstances, haemodialysis may be considered for bleeding with the use of dabigatran. NOACs will increasingly affect operative planning in plastic surgery. In order to reduce the incidence of complications associated with anticoagulation, the management of NOACs in the perioperative period requires knowledge of the time of last dose, renal function and the bleeding risk of the planned procedure. Consideration of these factors will allow appropriate interpretation of the current guidelines.

Outcomes of antiretroviral therapy among younger versus older adolescents and adults in an urban clinic, Zimbabwe.

SETTING: A non-governmental organisation-supported clinic offering health services including antiretroviral therapy (ART). OBJECTIVE: To compare ART retention between younger (age 10-14 years) vs. older (age 15-19 years) adolescents and younger (age 20-29 years) vs. older (age ⩾30 years) adults and determine adolescent- and adult-specific attrition-associated factors among those initiated on ART between 2010 and 2011. DESIGN: Retrospective cohort study. RESULTS: Of 110 (7%) adolescents and 1484 (93%) adults included in the study, no differences in retention were observed between younger vs. older adolescents at 6, 12 and 24 months. More younger adolescents were initiated with body mass index <16 kg/m(2) compared with older adolescents (64% vs. 47%; P = 0.04). There were more females (74% vs. 52%, P < 0.001) and fewer patients initiating ART with CD4 count ⩽350 cells/mm(3) (77% vs. 81%, P = 0.007) among younger vs. older adults. Younger adults demonstrated more attrition than older adults at all time-points. No attrition risk factors were observed among adolescents. Attrition-associated factors among adults included being younger, having a lower CD4 count and advanced human immunodeficiency virus disease at initiation, and initiation on a stavudine-based regimen. CONCLUSION: Younger adults demonstrated greater attrition and may require more attention. We were unable to demonstrate differences in attrition among younger vs. older adolescents. Loss to follow-up was the main reason for attrition across all age groups. Overall, earlier presentation for ART care appears important for improved ART retention among adults.

Contexte : Un centre de santé soutenu par une organisation non gouvernementale offrant des services de santé, notamment les services de traitement antirétroviral (TAR).Objectif : Comparer la rétention du TAR entre des adolescents plus jeunes (10­14 ans) et plus âgés (15­19 ans) et des adultes plus jeunes (20­29 ans) et plus âgés (⩾30 ans) et déterminer les facteurs associés à l'attrition et spécifiques des adolescents et des adultes parmi ceux qui ont mis en route du TAR en 2010­2011.Schéma : Etude rétrospective de cohorte.Résultats : L'étude a inclus 110 (7%) adolescents et 1484 (93%) adultes. Aucune différence en termes de rétention n'a été observée entre les adolescents plus jeunes et plus âgés à 6, 12 et 24 mois. Davantage des plus jeunes adolescents ont été initiés au traitement avec un index de masse corporelle <16 kg/m2 comparé aux adolescents plus âgés (64% contre 47% ; P = 0,04). Il y avait plus de femmes (74% contre 52% ; P < 0,001) et moins de patients démarrant le TAR avec un comptage de CD4 ⩽ 350 cellules/mm3 (77% contre 81% ; P = 0,007) parmi les adultes plus jeunes comparés aux plus âgés. Les adultes plus jeunes ont eu davantage d'attrition à tout moment que les plus âgés. Aucun facteur de risque d'attrition n'a été observé parmi les adolescents. Chez les adultes, les facteurs associés à l'attrition ont inclus l'âge plus jeune, un comptage de CD4 plus faible et une infection au virus de l'immunodéficience humaine plus avancée lors de la mise en route du traitement et son initiation dans le cadre d'un protocole basé sur la stavudine.Conclusion : Les adultes plus jeunes ont eu davantage d'attrition et devraient susciter davantage d'attention. Nous n'avons pas pu démontrer de différences d'attrition entre les adolescents plus jeunes et plus âgés. La perte de vue a été la cause principale d'attrition dans tous les groupes d'âge. Dans l'ensemble, un démarrage plus précoce du TAR parait important pour améliorer la rétention du TAR chez les adultes.

Marco de referencia: Un consultorio administrado por una organización no gubernamental que presta servicios de salud, como la administración del tratamiento antirretrovírico (TAR).Objetivo: Comparar la fidelización al TAR entre los jóvenes (de 10 a 14 años) y los adolescentes mayores (de 15 a 19 años) y entre los adultos jóvenes (de 20 a 29 años) y los adultos de más edad (a partir de los 30 años) y determinar los factores específicos de los adolescentes y los adultos que se asocian con la tasa de abandono, en las personas que iniciaron el tratamiento del 2010 al 2011.Método: Fue este un estudio de cohortes retrospectivo.Resultados: Se incluyeron en el estudio 110 adolescentes (7%) y 1484 adultos (93%). No se observaron diferencias en la fidelización de los jóvenes y los adolescentes mayores a los 6, 12 y 24 meses. En el grupo de adolescentes jóvenes, recibió TAR una proporción mayor de los que presentaban un índice de masa corporal <16 kg/m2 que en el grupo de adolescentes mayores (64% contra 47%; P = 0,04). En comparación con los adultos de más edad, los adultos jóvenes que iniciaron el tratamiento fueron con mayor frecuencia de sexo femenino (74% contra 52%; P < 0,001), pero una proporción menor presentaba un recuento de linfocitos CD4 ⩽ 350 células/mm3 (77% contra 81%; P = 0,007). El abandono del tratamiento fue más frecuente en los adultos jóvenes que en los adultos mayores en todos los momentos examinados. No se observaron factores de riesgo de abandono en los adolescentes. En los adultos, los factores asociados con el abandono fueron una menor edad, el recuento más bajo de linfocitos CD4 y la enfermedad avanzada por el virus de la inmunodeficiencia humana en el momento de iniciar el tratamiento y el comienzo de un régimen basado en estavudina.Conclusión: En los adultos más jóvenes la tasa de abandono del TAR fue más alta y precisan una mayor atención. No fue posible poner en evidencia diferencias en la tasa de abandono de los adolescentes más jóvenes y los adolescentes de mayor edad. La principal causa del abandono en todos los grupos de edad fue la pérdida durante el seguimiento. En general, la búsqueda temprana de TAR es un factor importante en la fidelización al tratamiento de los pacientes adultos.

Does research through Structured Operational Research and Training (SORT IT) courses impact policy and practice?

SETTING: Structured Operational Research and Training Initiative (SORT IT) courses are well known for their output, with nearly 90% of participants completing the course and publishing in scientific journals. OBJECTIVE: We assessed the impact of research papers on policy and practice that resulted from six SORT IT courses initiated between July 2012 and March 2013. DESIGN: This was a cross-sectional study involving e-mail-based, self-administered questionnaires and telephone/skype/in-person responses from first and/or senior co-authors of course papers. A descriptive content analysis of the responses was performed and categorised into themes. RESULTS: Of 72 participants, 63 (88%) completed the course. Course output included 81 submitted papers, of which 76 (94%) were published. Of the 81 papers assessed, 45 (55%) contributed to a change in policy and/or practice: 29 contributed to government policy/practice change (20 at national, 4 at subnational and 5 at hospital level), 11 to non-government organisational policy change and 5 to reinforcing existing policy. The changes ranged from modifications of monitoring and evaluation tools, to redrafting of national guidelines, to scaling up existing policies. CONCLUSION: More than half of the SORT IT course papers contributed to a change in policy and/or practice. Future assessments should include more robust and independent verification of the reported change(s) with all stakeholders.

Contexte : Les cours de l'Initiative de Recherche et de Formation Structurées Opérationnelles (SORT IT) sont bien connus pour leurs bons résultats : près de 90% des participants terminent le cours et publient dans des revues scientifiques.Objectif : Evaluer l'impact sur la politique/les pratiques de ces articles de recherche qui ont été le résultat de six cours SORT IT initiés entre juillet 2012 et mars 2013.Schéma : Une étude transversale impliquant des questionnaires auto-administrés envoyés par courriel et des réponses par téléphone/skype/en personne des auteurs principaux et/ou des co-auteurs des articles liés au cours. Une analyse descriptive du contenu des réponses a été réalisée et catégorisée par thèmes.Résultats : Sur 72 participants, 63 (88%) ont terminé le cours. Les résultats du cours ont inclus 81 articles soumis, dont 76 (94%) ont été publiés. Sur les 81 articles publiés évalués, 45 (55%) ont contribué à une modification de la politique et/ou des pratiques : 29 articles ont contribué à une modification de la politique/des pratiques par le gouvernement (20 au niveau national, 4 au niveau sous-national et 5 au niveau hospitalier), 11 à des modifications de politique d'organisations non gouvernementales et cinq à un renforcement de la politique existante. Ces changements allaient de modifications des outils de suivi et d'évaluation à une nouvelle rédaction des directives nationales et à une accélération des politiques existantes.Conclusion : Plus de la moitié des articles du cours SORT IT ont contribué à une modification de la politique et/ou des pratiques. Les évaluations futures devraient inclure des vérifications plus solides et indépendantes des modifications rapportées avec toutes les parties concernées afin d'améliorer leur rigueur et leur richesse.

Marco de referencia: Los cursos de capacitación de la Iniciativa de Capacitación Estructurada en Investigación Operativa (SORT IT, por su sigla en inglés) se conocen ampliamente gracias a sus resultados, pues cerca de 90% de los participantes completa el curso y publica artículos en revistas científicas.Objetivo: Evaluar el impacto sobre las políticas y las prácticas de los artículos de investigación producidos en seis cursos SORT IT iniciados de julio del 2012 a marzo del 2013.Método: Se llevó a cabo un estudio transversal mediante cuestionarios autoadministrados por correo electrónico y respuestas directas mediante comunicaciones telefónicas y por Skype, que se dirigieron al primer autor y a los coautores experimentados de los artículos publicados después de los cursos; se realizó un análisis de contenido de tipo descriptivo de las respuestas con el fin de derivar los temas.Resultados: De los 72 participantes, 63 completaron el curso (88%). Se produjeron 81 artículos que se presentaron para publicación y 76 fueron aceptados (94%). De los 81 artículos evaluados, 45 contribuyeron a modificar las políticas o las prácticas (55%) de la siguiente manera: 29 contribuyeron a un cambio en las políticas o prácticas gubernamentales (20 a escala nacional, 4 a escala subnacional y 5 a nivel hospitalario), 11 favorecieron cambios de políticas en organizaciones no gubernamentales y cinco fortalecieron políticas existentes. Las modificaciones abarcaron aspectos variados desde las herramientas de supervisión y evaluación, hasta la reformulación de directrices nacionales destinadas a la ampliación de escala de las políticas existentes.Conclusión: Más de la mitad de los artículos elaborados en los cursos SORT IT contribuyó a una modificación en las políticas o las prácticas. Las evaluaciones futuras deberán comportar mecanismos de verificación de los cambios notificados que sean más sólidos e independientes, con participación de todos los interesados directos a fin de reforzar su rigor y enriquecer su contenido.

Ebola, fragile health systems and tuberculosis care: a call for pre-emptive action and operational research.

The Ebola outbreak that started in late 2013 is by far the largest and most sustained in history. It occurred in a part of the world where pre-existing health systems were already fragile, and these deteriorated further during the epidemic due to a large number of health worker deaths; temporary or permanent closure of health facilities; non-payment of health workers; intrinsic fear of contracting or being stigmatised by Ebola among the population, which negatively influenced health-seeking behaviour; enforced quarantine of Ebola-affected communities, restricting the access of vulnerable individuals to health facilities; and late response by the international community. There are also reports of drug and consumable stockouts due to deficiencies in the procurement and supply chain as a result of overriding Ebola-related priorities. Providing tuberculosis (TB) care and achieving favourable treatment outcomes require a fully functioning health system, accurate patient tracking and high patient adherence to treatment. Furthermore, as Ebola is easily transmitted through body fluids, the use of needles-essential for TB diagnosis and treatment-needs to be avoided during an outbreak. We highlight ways in which a sustained Ebola outbreak could jeopardise TB activities and suggest pre-emptive preventive measures while awaiting operational research evidence.

Research output after participants complete a Structured Operational Research and Training (SORT IT) course.

Eighteen months after successfully completing one of six Structured Operational Research and Training Initiative (SORT IT) courses, e-mail questionnaires assessing post-course research output were returned by 63 participants (100% response rate). Thirty-two (51%) participants had completed new research projects, 24 (38%) had published papers, 28 (44%) had presented abstracts at conferences, 15 (24%) had facilitated at further OR courses, and 21 (33%) had reviewed scientific papers. Seven (11%) had secured further research funding and 22 (35%) stated that their institutions were involved in implementation or capacity building in operational research. Significant research output continues beyond course completion, further endorsing the value of the SORT IT model.

Dix-huit mois après avoir terminé avec succès l'un des six cours structurés de recherche et de formation opérationnelle (SORT IT), des questionnaires par e-mail évaluant les résultats de la recherche post formation ont été renvoyés par 63 participants (taux de réponse de 100%). Trente-deux (51%) participants ont achevé de nouveaux projets de recherche, 24 (38%) ont publié des articles, 28 (44%) ont présenté des abstracts lors de conférences, 15 (24%) ont été facilitateurs dans des cours de recherche opérationnelle ultérieurs et 21 (33%) ont révisé des articles scientifiques. Sept (11%) ont assuré le financement de leur recherche à venir et 22 (35%) ont affirmé que leurs institutions étaient impliquées dans la mise en œuvre ou le renforcement des capacités en recherche opérationnelle. Des bénéfices significatifs en termes de résultats de recherche se poursuivent au-delà de la fin du cours, ce qui confirme la valeur du modèle SORT IT.

Dieciocho meses después de haber completado con éxito uno de los seis cursos Estructurados de Capacitación e Investigación Operativa (SORT IT, por su nombre en inglés 'Structured Operational Research and Training'), los 63 participantes respondieron a un cuestionario enviado por correo electrónico (tasa de respuesta del 100%), con el cual se evaluaban los resultados en materia de investigación posteriores al curso. Treinta y dos participantes habían completado nuevos proyectos de capacitación (51%), 24 publicaron artículos (38%), 28 presentaron carteles en conferencias (44%), 15 participaron como facilitadores en nuevos cursos de investigación operativa (24%) y 21 habían realizado el examen crítico de artículos científicos (33%). Siete de los participantes consiguieron nuevos financiamientos de investigación (11%) y 22 declararon que sus instituciones participaban en la introducción o el reforzamiento de la capacidad en investigación operativa (35%). Después de haber completado el curso, se observaron resultados apreciables en materia de investigación, que confirman la utilidad del modelo SORT IT.

Double trouble: tuberculosis and substance abuse in Nagaland, India.

The diagnosis and treatment of tuberculosis (TB) in people who use and/or inject illicit drugs (PWUIDs) remains a barrier to achieving universal coverage for TB in India and globally. This report describes treatment outcomes in PWUIDs who received treatment for drug-susceptible TB at the Mon District Hospital in Nagaland, India, during 2012-2013. The median age of the patients was 39 years, and most (92%) were male. Two thirds (33/49) of the patients had a successful TB treatment outcome. A previous TB episode and residence in a semi-urban area were associated with unsuccessful treatment outcomes. Separate diagnostic and treatment algorithms, including regular adherence counselling and opioid substitution therapies, should be considered for PWUIDs.

Le diagnostic et le traitement de la tuberculose (TB) chez les personnes qui consomment et/ou s'injectent des drogues (PWUID) constitue encore un obstacle à l'atteinte d'une couverture universelle de la TB en Inde et dans le monde. Ce rapport décrit les résultats du traitement de PWUID qui ont bénéficié d'un traitement de TB pharmacosensible à l'hôpital Mon District de Nagaland, Inde, en 2012­2013. L'âge médian des patients a été de 39 ans et la majorité (92%) étaient des hommes. Les deux tiers (33/49) des patients ont eu un bon résultat thérapeutique. L'existence d'un épisode préalable de TB et le fait de résider en zone semi-urbaine ont été associés à un échec thérapeutique. Des algorithmes séparés de diagnostic et de traitement, incluant des séances régulières de conseil pour l'observance et des traitements de substitution aux opiacés, devraient être envisagées pour les PWUID.

El diagnóstico y el tratamiento de la tuberculosis (TB) en las personas que consumen o se inyectan drogas (PWUID) siguen creando obstáculos al cumplimiento de la cobertura universal de la TB en la India y en el mundo. En el presente informe se describe el desenlace terapéutico en personas de este grupo que recibieron un tratamiento por TB normosensible en el hospital Mon District de Nagaland, en la India, del 2012 al 2013. La mediana de la edad de los pacientes fue 39 años y la mayoría (92%) era de sexo masculino. Dos tercios de los pacientes (33 de 49) alcanzaron un desenlace favorable del tratamiento antituberculoso. Se asociaron con los desenlaces desfavorables el antecedente de un episodio TB y la residencia en una zona periurbana. Se propone que en las personas que consumen o se inyectan drogas se consideren diferentes algoritmos de diagnóstico y tratamiento que comprendan orientación en materia de cumplimiento y un tratamiento de sustitución de opioides.

Effect of increased ART-CPT uptake on tuberculosis outcomes and associated factors, Burundi, 2009-2013.

We retrospectively examined 3579 records of human immunodeficiency virus infected tuberculosis (TB) patients diagnosed from January 2009 to June 2013 in 55 TB treatment facilities in Burundi, to demonstrate whether improvement of combined cotrimoxazole preventive therapy and antiretroviral therapy (ART) uptake was accompanied by improvement of treatment outcomes, and to describe associated factors. Treatment success rates increased from 71% to 80% (P < 0.001). While loss to follow-up and transfer-out rates declined significantly, death rates decreased modestly, and remained high, at 14%. ART uptake was worse in suburban areas and private for-profit institutions. World Health Organization targets could be achieved if peripheral health facilities were prioritised.

Une étude rétrospective conduite de janvier 2009 à juin 2013 au Burundi chez 3579 patients co-infectées par la tuberculose (TB) et le virus de l'immunodéficience humaine dans 55 centres de diagnostic et de traitement de la TB, décrit l'évolution des résultats de traitement antirétroviral (ART) et cotrimoxazole et apprécie les facteurs liés à l'ART. La proportion des succès au traitement a augmenté de 71% à 80% (P < 0,001). Tandis que les taux de perdus de vue et de transferts ont baissé significativement, celui des décès n'a baissé que modestement, tout en restant élevée, à 14%. La couverture en ART est plus faible dans les centres de santé périphériques et dans ceux relevant du privé non lucratif. Les objectifs de l'Organisation Mondiale de la Santé pourraient être atteints si les districts sanitaires ruraux étaient inclus dans la fourniture des soins.

En el presente estudio se analizaron 3579 registros de pacientes aquejados de coinfección por el virus de la inmunodeficiencia humana (VIH) y la tuberculosis (TB) en Burundi de enero del 2009 a junio del 2013, provenientes de 55 establecimientos de tratamiento de la TB, con el objeto de investigar si al aumentar la aceptación del tratamiento preventivo con cotrimoxazol en asociación con el tratamiento antirretrovírico (ART) se mejoraban los desenlaces terapéuticos y también se describieron los factores que se asociaban con esta situación. Las tasas de éxito terapéutico aumentaron de un 71% a un 80% (P < 0,001). Aunque las tasas de pérdida durante el seguimiento y de remisión a otros establecimientos disminuyeron de manera significativa, la disminución de las tasas de mortalidad fue leve y permanecieron en un nivel alto de 14%. La aceptación del ART fue más deficiente en las zonas suburbanas y en los establecimientos privados con ánimo de lucro. Sería posible cumplir con las metas de la Organización Mundial de la Salud si se da prioridad a los establecimientos sanitarios periféricos.

The diagnosis of leprosy is delayed in the United Kingdom.

Diagnostic delay in leprosy can have serious neurological consequences for the patient. We studied the presentation of leprosy patients, focusing on delays in diagnosis, in a retrospective case-note review of 28 patients referred to The Hospital for Tropical Diseases during 1995-1998. The median ages at onset of symptoms and at diagnosis were 25.1 years (range 9-77.7) and 30.1 years (range 9-78.3), respectively. The median time from symptom onset to diagnosis was 1.8 years (0.2-15.2). Prior to referral to a leprologist, patients had seen a dermatologist (20), neurologist (9), orthopaedic surgeon (5) and rheumatologist (2). Delay in diagnosis occurred in 82% of cases. Misdiagnoses as dermatological and neurological conditions were important causes of delay, and 68% of patients had nerve damage resulting in disability. Leprosy can be difficult to diagnose outside endemic areas. Increased awareness amongst general practitioners and hospital specialists would lead to more rapid diagnosis, thus minimizing damage and disability.

Churg-Strauss syndrome in a district hospital.

Published series on Churg-Strauss syndrome (CSS) come from tertiary referral centres. We retrospectively studied 23 patients with CSS (18 male) seen over 14 years (1982-1995) in a District General Hospital serving a population of 500,000. Mean age of onset of vasculitis was 57, 10-19 years older than in previous series. The commonest clinical features were asthma (22) and eosinophilia > 1.5 x 10(9)/l (21). Systemic vasculitis involving two or more extrapulmonary organs occurred in 22 patients, with specific organ involvement of nervous system (18), joints (13), muscles (13), lungs (11), skin (11), kidneys (11), heart (10), and bowel (7). Various classification systems were applied including the Lanham criteria, which were met in 19 patients; the American College of Rheumatology criteria, met in 14; Churg and Strauss criteria, met in four; and the Chapel Hill Consensus definition, met only in two. ANCA was detected in 10/17 patients where measured. Treatment included corticosteroids (21), cyclophosphamide (8), azathioprine (9), immunoglobulin (2), and methotrexate (1). During follow-up six patients died, two due to myocardial vasculitis (mean age 52 years), three due to infection (mean age 80 years), and one cause unknown. Significant long-term disability was due to asthma in five and neuropathy in six.

Cephaloridine resistance in gram-negative bacteria isolated in Scotland.

The incidence of cephaloridine resistance (minimum inhibitory concentration, MIC greater than 8 mg L-1) in isolates from urinary tract infections was 45.1% in Glasgow, 22.6% in Dundee and 25.9% in Edinburgh. The incidence of ampicillin resistance (MIC greater than 8 mg L-1) was even higher:- being 45.2% in Dundee and 48.5% in Edinburgh. In Glasgow, the incidence was 71.9% which is the highest proportion of ampicillin resistance reported in the United Kingdom. The cephaloridine resistant strains were examined for beta-lactamase production. Amongst these strains 50.8% produced only a chromosomal beta-lactamase, whereas 47.9% produced beta-lactamases which were potentially plasmid-mediated on the basis of biochemical tests. Only 1% of the resistant strains produced no detectable beta-lactamase.

Rapid plastic embedding is compatible with colorimetric detection following whole mount in situ hybridization in plant specimens.

In performing in situ hybridizations, nonisotopic nucleic acid labeling coupled with colorimetric detection offers a safer, easier and more rapid alternative to using radioactively labeled nucleic acid probes and microscopic autoradiography. Whole mount in situ hybridization is also advantageous, because many samples can be processed identically and the reduced handling of specimens greatly reduces the risk of exposing tissues to RNase(s). The thickness of whole mount specimens, however, often prevents accurate determination of sites of expression within specific tissues. Although post-hybridization embedding and sectioning is a solution to this problem, the precipitate formed following the common colorimetric detection procedure is soluble in the organic solvents used for dehydration prior to embedding. We have developed a dehydration and embedding procedure that takes advantage of the compatibility of L.R. White resin containing 10% (v/v) polyethylene glycol 400, and heat polymerized. The addition of the plasticizer allows L.R. White embedded tissues to be sectioned at 10 microm providing excellent signal contrast.

The influence of the high-risk care environment on the practice of low-risk obstetrics.

This retrospective chart review compared the intervention rates in 2,365 low-risk obstetric patients at three urban teaching hospitals, two of which were high-risk, perinatal referral centers. The third cared for mostly low-risk patients. The hypothesis was that rates of intervention in low-risk pregnancies would be higher in the high-risk care environment. Family physicians at the perinatal referral centers performed significantly more artificial rupture of membranes, epidural blocks, augmentations of labor, and episiotomies on their low-risk patients than did those at the low-risk hospital. This trend was also found for obstetricians but did not reach statistical significance. Thus, the conclusion was drawn that caring for low-risk patients in a high-risk care environment is associated with a higher intervention rate by family physicians. Factors that may contribute to this finding are discussed.

Malaria at Christmas: risks of prophylaxis versus risks of malaria.

PIP: A large increase in the number of falciparum malaria cases imported into the UK was reported to the malaria reference laboratory in the first quarter of 1998. Contributory factors were unusually heavy rains in east Africa and a reduction in the use of the most effective antimalarial drug, mefloquine. There was also an increase in the number of cases of severe malaria in the UK. During December 1997 and January 1998, the Hospital for Tropical Diseases, London, treated 5 patients for severe malaria and gave advice on 20 more patients with malaria who had been admitted to intensive care units throughout England. 4 of the severe cases treated at the hospital are reported. In 3 of those 4 cases, incorrect, misleading, or inadequate advice was given by health care professionals. Media coverage of the adverse effects of antimalarial drugs has contributed to confusion about prophylactic regimens among both health care professionals and the public. The incidence of falciparum malaria among travellers who do not take prophylactic drugs is about 0.6% in east Africa and 3.5% in west Africa over a 2-week travel period. Travellers need to take measures to avoid being bitten by mosquitoes and should be taught to promptly seek medical help if they develop a fever while abroad or after they return. Moreover, using any one of the recommended prophylactic regimens is better than not using a potent regimen or no prophylaxis at all. Mefloquine is 90% protective against malaria in sub-Saharan Africa. While the efficacy of proguanil and chloroquine in 1987 was about 70% in west Africa and 50% in east Africa, those levels are now probably lower. The side effects of antimalarial drugs are discussed.^ieng

'I'm fed up': experiences of prior anti-tuberculosis treatment in patients with drug-resistant tuberculosis and HIV.

OBJECTIVES: To understand the impact of past experiences of anti-tuberculosis treatment among patients co-infected with the human immunodeficiency virus and multidrug-resistant tuberculosis (MDR-TB) on perceptions and attitudes towards treatment. METHODS: Qualitative study using in-depth interviews with 12 HIV-MDR-TB co-infected patients in Mumbai, India. RESULTS: Patients reported unnecessarily long pathways to care and fatigue with diagnostic and treatment procedures. In particular, they expressed concerns over the lack of efficacy of their current treatment regimen based on their experiences with anti-tuberculosis treatment regimens in the past. CONCLUSION: Patients reported negative experiences with previous HIV and anti-tuberculosis treatment. Access to early diagnosis and rapid initiation of integrated care for HIV-MDR-TB co-infected patients, with a strong, patient-centered support system, could help to combat the low morale and lack of faith in treatment described in this group of patients.