Hypertension and treatment outcomes in Palestine refugees in United Nations Relief and Works Agency primary health care clinics in Jordan.

OBJECTIVE: In six United Nations Relief and Works Agency (UNRWA) primary health care clinics in Jordan serving Palestine refugees diagnosed with hypertension, to determine the number, characteristics, programme outcomes and measures of disease control for those registered up to 30 June, 2013, and in those who attended clinic in the second quarter of 2013, the prevalence of disease-related complications between those with hypertension only and hypertension combined with diabetes mellitus. METHOD: Retrospective cohort study with programme and outcome data collected and analysed using E-Health. RESULTS: There were 18 881 patients registered with hypertension with females (64%) and persons aged ≥ 40 years (87%) predominating. At baseline, cigarette smoking was recorded in 17%, physical inactivity in 48% and obesity in 71% of patients. 77% of all registered patients attended clinic in the second quarter of 2013; of these, 50% had hypertension and diabetes and 50% had hypertension alone; 9% did not attend the clinics and 10% were lost to follow-up. Amongst those attending clinic, 92% had their blood pressure measured, of whom 83% had blood pressure <140/90 mm Hg. There were significantly more patients with hypertension and diabetes (N = 966, 13%) who had disease-related complications than patients who had hypertension alone (N = 472, 6%) [OR 2.2, 95% CI 2.0-2.5], and these differences were found for both males [18% vs. 10%, OR 1.9, 95% CI 1.6-2.2] and females [11% vs. 5%, OR 2.4, 95% CI 2.1-2.9]. CONCLUSION: Large numbers of Palestine refugees are being registered and treated for hypertension in UNRWA primary health care clinics in Jordan. Cohort analysis and E-Health can be used to regularly assess caseload, programme outcomes, clinic performance, blood pressure control and cumulative prevalence of disease-related complications. Current challenges include the need to increase clinic attendance and attain better control of blood pressure.

Tuberculosis: distribution, risk factors, mortality.

About a century after Koch's discovery of the TB bacilli the tuberculosis epidemic which had appeared to be under control was again recognized as a major global health threat. The decline in the epidemic in this century had been largely through the improved living standards and, eventually, the availability and use of effective antibiotics. While tuberculosis gradually disappeared from the health agenda in the western world it remained a big killer throughout the century and in 1992 an estimated 2.7 million TB deaths occurred; 30 million will die from TB during the 1990s if current trends are not reversed. The annual number of new cases will increase from 7.5 million estimated in 1990 to more than 10 million in the year 2000. The main factors for this increase are demographic forces, population movements, the HIV epidemic and increasing drug resistance. The impact of the HIV epidemic is already felt in many sub-Saharan African countries and now threatens Asia where almost two-thirds of the world's TB infected population live and where HIV is spreading. Tuberculosis has also reemerged as a major public health problem in industrialized countries due to international migration, the breakdown of health services, including TB services etc. The control of the epidemic can only be through a concerted action to reinstate TB as priority among health concerns, reflected in national and international resources. A coalition of public and private supporters must be mobilized to support the effort to fight the disease. Governments, non-governmental organizations, the business community, refugee organizations, medical institutions, and other UN agencies are invited to join with WHO in this effort.

PIP: Robert Koch discovered the tuberculosis (TB) bacilli about a century before the epidemic that had appeared to be under control was again recognized as a major global health threat. The decline in the epidemic in this century had been largely through improved living standards and, eventually, the use of antibiotics. While TB gradually disappeared from the health agenda in the Western world, at the end of the 20th century TB is the most important cause of death among infectious diseases. In 1992 an estimated 2.7 million TB deaths occurred, and the global TB death rate was about 50/100,000, with more than 95% of deaths in developing countries. 30 million will die from TB during the 1990s if current trends are not reversed. The annual number of new cases will increase from 7.5 million estimated in 1990 to more than 10 million in the year 2000. The main factors for this increase are demographic forces, population movements, the HIV epidemic, and increasing drug resistance. The impact of the HIV epidemic is already felt in many Sub-Saharan African countries and now threatens Asia, where almost 2/3 of the world's TB infected population live and where HIV is spreading. One third of the world's population had been infected by TB in mid-1993 and more than 5 million of these were dually infected with HIV and TB. TB has also reemerged as a major public health problem in industrialized countries owing to international migration and the breakdown of health services including TB services. In the US between 1985 and 1991 the number of reported cases increased by 20%, causing 39,000 more cases than expected. Similarly, in eastern Europe and the former Soviet Union the TB situation is deteriorating. In western Europe the low rates of TB have been offset by increasing incidence among foreign born residents. The epidemic can only be controlled through concerted national and international action.

[Clinical study of eradicated and resistant patients to treatment with ivermectin for strongyloidiasis].

We treated 70 patients with strongyloidiasis (41 males and 29 females) with ivermectin (IVM), and obtained the following results: 1. The eradication rates at 1-2 months, 3-4 months and 5-6 months after treatment were 90.7% (49 of 54 patients), 100.0% (47 of 47 patients) and 95.7% (45 of 47 patients), responsively. Twelve patients were resistant (non-responsive) to treatment. 2. When compared to patients whose parasites were completely eradicated, the resistant patients showed the following results: 1) Incidence of symptoms observed before treatment was significantly lower (50.0% vs. 84.5%). 2) Positive rate of anti-HTLV-I antibody was significantly higher (66.7% vs. 20.7%). 3) Blood eosinophil counts before treatment were significantly lower (266.6 +/- 117.2/mm3 vs. 533.2 +/- 429.7/mm3). 4) Serum IgE levels before treatment were significantly lower (217.2 +/- 442.9 IU/ml vs. 1,076.8 +/- 2,108.0 IU/ml). 5) There were no significant differences in age, sex and dosage of ivermectin. 3. Comparing anti-HTLV-I antibody positive and negative patients, the following results were obtained: 1) Eradicated patients; a) Eosinophils and IgE levels before and after the first administration of medicine in anti-HTLV-I antibody positive patients were significantly lower than those of negative patients. b) Gammaglobulin levels before treatment and after both administrations of the drug, IgG before therapy and OKT4/OKT8 after therapy were significantly higher than in anti-HTLV-I antibody positive patients. 2) Resistant patients; Eosinophils after treatment were significantly lower in anti-HTLV-I antibody negative patients than in positive patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arterial oxygenation during one lung ventilation in obese patients].

To test the hypothesis that arterial oxygenation during one lung ventilation (OLV) is impaired more in obese patients than in non-obese control patients, we performed consecutive measurements of arterial oxygen tension (PaO2) during OLV in 48 patients scheduled for pulmonary lobectomy. Minimum value of PaO2 during OLV was significantly less in 16 obese patients [body mass index (BMI) > 25] compared to 32 control patients (BMI < 25). Moreover, PaO2 value of left lung ventilation was significantly less than the value of right lung ventilation in obese patients while the difference was not statistically significant in the control group.

[High tissue concentration of 5-FU reduced local recurrence after administration of tegafur suppositories].

Forty-two patients with head and neck cancer were treated with tegafur suppository for 7 days preoperatively and clinical value of this treatment was assessed. In a group which indicated tumor tissue concentrations of 5-FU were more than 0.5 micrograms/g, local recurrence decreased in the period of postoperative observation for 42 months. A survival rate of this group was better than others. From these results, preoperative tegafur suppository treatment seemed to have a role in expectation of improvement of local control in head and neck cancer therapy.

Diabetes mellitus and treatment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan.

SETTING: Six primary health care clinics in Jordan, serving Palestine refugees diagnosed with diabetes mellitus (DM). OBJECTIVES: To report on the number and characteristics of new DM patients registered in the second quarter of 2013 and of all DM patients ever registered by 30 June 2013, with treatment outcomes and cumulative burden of late-stage complications. DESIGN: A descriptive cohort study using routine data collected through e-Health. RESULTS: Of the 288 new patients in Q2 2013 and 12 548 patients ever registered with DM by 30 June 2013, smoking, physical inactivity and obesity were recorded in 19%, 50% and 47%, respectively. In Q2 2013, 9740 (78%) patients attended a clinic, with >99% having undergone disease control measures: of these, 72% had postprandial blood glucose ⩽ 180 mg/dl, 71% had blood cholesterol < 200 mg/dl, 82% had blood pressure < 140/90 and 40% had body mass index < 30 kg/m(2). Late-stage complications were present in 1130 (11.6%) patients who attended a clinic, with cardiovascular disease and stroke being the most common. Several differences in outcomes were found between males and females. CONCLUSION: There is a high burden of disease due to DM at primary health care clinics in Jordan. Cohort analysis using e-Health is a vital way to assess management and follow-up.

Government intervention programs in HIV/tuberculous infection. Outline of guidelines for national tuberculosis control programs in view of the HIV epidemic.

Tuberculosis is one of the most widespread infections known in the world. WHO estimates that in 1990, 1.7 billion people, or one third of the world population, are or have been infected with the tubercle bacillus. Fortunately, few of those infected develop active forms of the disease but it is estimated that in 1990, there will be 8 million new cases and 2.9 million deaths from tuberculosis in the world. This already alarming situation of the tuberculosis problem is getting worse, mainly due to the AIDS epidemic. A basic understanding of tuberculosis/HIV epidemiology is necessary and priority actions are to be strongly recommended for application in government intervention programs. They are specified in the present article.

Tuberculosis control--is DOTS the health breakthrough of the 1990s?

The resurgence of tuberculosis in recent years has made an effective control strategy indispensable. The strategy exists and is called DOTS--Directly Observed Treatment, Short-course. It has proved its effectiveness and now needs to be used worldwide on a much larger scale.

Suppression by methylprednisolone of augmented plasma endotoxin-like activity and interleukin-6 during cardiopulmonary bypass.

It has been reported that plasma endotoxin, measured by Limulus amoebocyte lysate assays, markedly increased during extracorporeal circulation (ECC). Therefore, this study was undertaken to see if pretreatment with methylprednisolone 30 mg kg-1 modifies the endotoxaemia and associated increases in plasma cytokines in 17 patients undergoing cardiac surgery requiring ECC. We found that methylprednisolone suppressed significantly the ECC-induced increases in plasma endotoxin, measured by a conventional Limulus amoebocyte lysate assay (Toxicolor), and interleukin-6. Plasma concentrations of endotoxin, measured by a highly specific chromogenic Limulus test (Endospecy test), tumour necrosis factor-alpha and interleukin-1 beta did not increase significantly in either the control or methylprednisolone groups.

Effects of portal vein occlusion on myocardial contractility.

We studied canine left ventricular contractile performance following 15 min of portal vein occlusion by analyzing the end-systolic pressure diameter relationship (ESPDR) which many investigators have reported as being independent of changes in preload and afterload but sensitive to changes in ventricular contractility. Portal vein occlusion for 15 min decreased the mean arterial pressure, left ventricular peak systolic pressure, and cardiac index, while the release of the occlusion gradually increased these values, although it did not restore them to the control values. The systemic vascular resistance index increased during portal vein occlusion and returned to the control values after release. Left ventricular end diastolic diameter decreased during portal clamping and returned to the control values after release. ESPDR and percent shortening were not significantly changed during or after portal clamping. These results indicate that the decrease in blood pressure during portal vein occlusion was not due to a reduction in myocardial contractility but rather was due to a reduction in preload.

HIV-associated tuberculosis in developing countries: epidemiology and strategies for prevention.

The association between tuberculosis and HIV presents an immediate and grave public health and socioeconomic threat, particularly in the developing world. In early 1992 WHO estimated that approximately 4 million people had been infected with both Mycobacterium tuberculosis and HIV since the beginning of the pandemic; 95% of them were in developing countries. The association between tuberculosis and HIV is evident from the high incidence of tuberculosis, estimated at 5-8% per year, among HIV-infected persons, the high HIV seroprevalence among patients with tuberculosis, the high occurrence of tuberculosis among AIDS patients, and the coincidence of increased tuberculosis notifications with the spreading of the HIV epidemic in several African countries. The impact of the two epidemics on resource-poor countries has ominous social and medical implications, and the already overstretched health services now have to face a tremendously increasing tuberculosis problem. HIV infection worsens the tuberculosis situation by increasing reactivation of latent tuberculosis infection in dually infected persons as well as by favouring rapid progression of new infections in the HIV-infected. This also results in an increase of the risk of infection and a subsequent increase of cases in the general population. In order to respond to this urgent problem, the highest priority must be given to strengthening tuberculosis control programmes in the countries where they are poorly developed and where the prevalence of HIV and tuberculosis infections is high. Besides improving the cure rate by early diagnosis and prompt treatment of patients with tuberculosis, two major strategies that need consideration include BCG vaccination and preventive chemotherapy among HIV-infected individuals. The latter strategy is considered as the most critical intervention that would help to limit the expected increase in clinical tuberculosis from the pool of HIV and tuberculosis coinfected individuals. However, a number of issues need to be addressed urgently and before such an intervention can be implemented in the developing countries.

Global tuberculosis incidence and mortality during 1990-2000.

Forecasts of tuberculosis morbidity and mortality are presented for the decade 1990-99. An estimated 88 million new cases of tuberculosis, of which 8 million will be attributable to HIV infection, will occur in the world during the decade; 30 million people are predicted to die of tuberculosis in the same period, including 2.9 million attributable to HIV infection. The number of new tuberculosis cases occurring each year is predicted to increase from 7.5 million (143 cases per 100,000) in 1990 to 8.8 million (152 per 100,000) in 1995 and 10.2 million (163 per 100,000) in the year 2000. In 1990, 2.5 million persons were estimated to have died of tuberculosis; at the same level of availability of treatment, it is predicted that 3.0 million tuberculosis deaths will occur in 1995 and 3.5 million in 2000. Demographic factors, such as population growth and changes in the age structure of populations, will account for 79.5% of the predicted increases in new cases. Age-specific incidence rates in sub-Saharan Africa are increasing due to the HIV epidemic and will account for the remaining 20.5% of the forecast increase in new cases. In WHO's South-East Asian Region and in Central and South America the age-specific incidence rates are expected to fall during 1990-2000, but at a slower rate than in previous years because of the expected increase in HIV seroprevalence.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Over the period 1990-99, an estimated 88 million new cases of tuberculosis (TB) will occur worldwide, of which 8 million will be attributable to HIV infection. 30 million people are predicted to die of TB over the period, including 2.9 million attributable to HIV infection. Given a constant level of treatment availability, the numbers of new cases and deaths will both increase each year over the period. Demographic factors such as population growth and changes in the age structure of populations will account for 79.5% of the predicted increases in new cases. Age-specific incidence rates in sub-Saharan Africa, however, are increasing due to the HIV epidemic and will account for the remaining 20.5% of the forecast increase in new cases. In the World Health Organization's Southeast Asia region and in Central and South America, age-specific incidence rates are expected to fall during 1990-2000, but at a slower rate than in previous years because of the expected increase in HIV seroprevalence. Finally, in the Western Pacific and Eastern Mediterranean regions, intervention strategies should reduce the age-specific incidence rates during the period, but population growth will fuel an increase in the total number of new cases until the year 2000.

Tuberculosis: a global overview of the situation today.

The overall tuberculosis situation in the world in 1990 and its recent trends are reviewed by an analysis of the case notifications to WHO and tuberculosis mortality reports. Estimates of the prevalence of tuberculosis infection and the incidence of tuberculosis disease and deaths predicted in 1990 were carried out with simple epidemiological models. Approximately one third of the world's population is infected with Mycobacterium tuberculosis. In the past decade, an average of 2.5 to 3.2 million cases were notified every year globally, the small decrease in notification rates in recent years being offset by population growth. In 1990, an estimated 8 million people developed tuberculosis worldwide and 2.6 to 2.9 million died. The majority of these cases and deaths occurred in Asia, with an increasing number among HIV-infected individuals, especially in Africa where an upward trend is clearly detectable. Data on tuberculosis cases notified by WHO Member States demonstrate the magnitude of the problem but must be interpreted with caution. Being less than the expected incidence, they reflect the inadequacies of tuberculosis control programmes. This review confirms the very high global magnitude of the tuberculosis problem and calls for an urgent revitalization of tuberculosis control programmes throughout the world.

HIV-associated tuberculosis in developing countries: clinical features, diagnosis, and treatment.

This article reviews the clinical aspects and diagnosis of HIV-associated tuberculosis in developing countries, and summarizes WHO's recommendations for treatment. According to WHO estimates (early 1992) over 4 million persons worldwide have been infected with HIV and tuberculosis; 95% of them are in the developing countries. Clinical features of HIV-associated pulmonary tuberculosis in adults are frequently atypical, particularly in the late stage of HIV infection, with non-cavitary disease, lower lobe infiltrates, hilar lymphadenopathy and pleural effusion. More typical post-primary tuberculosis with upper lobe infiltrates and cavitations is seen in the earlier stages of HIV infection. Extrapulmonary tuberculosis is reported more frequently, despite the difficulties in diagnosing it. WHO's recent guidelines recommend 6-month short-course chemotherapy with isoniazid, rifampicin, pyrazinamide and ethambutol for patients with HIV-associated tuberculosis. The older 12-month regimen without rifampicin is much less effective. Streptomycin should not be used, because of the risk of transmitting blood-borne pathogens through contaminated needles. Thioacetazone should be abandoned, because of severe adverse reactions observed among HIV-infected patients. The roles of preventive chemotherapy and BCG vaccination for prevention of tuberculosis are also briefly discussed.

PIP: This article reviews the clinical aspects and diagnosis of HIV-associated tuberculosis in developing countries, and summaries WHO's recommendations for treatment. According to WHO estimates (early 1992) over 4 million persons worldwide have been infected with HIV and tuberculosis; 95% of them are in the developing countries. Clinical features of HIV-associated pulmonary tuberculosis in adults are frequently atypical, particularly in the late stage of HIV infection, with non-cavitary disease, lower lobe infiltrates, hilar lymphadenopathy, and pleural effusion. More typical post-primary tuberculosis with upper lobe infiltrates and cavitations is seen in the earlier stages of HIV infection. Extrapulmonary tuberculosis is reported more frequently, despite the difficulties in diagnosing it. WHO's recent guidelines recommend 6-month short-course chemotherapy with isoniazid, rifampicin, pyrazinamide, and ethambutol for patients with HIV-associated tuberculosis. The older 12-month regimen without rifampicin is much less effective. Streptomycin should not be used, because of the risk of transmitting blood-borne pathogens through contaminated needles. Thioacetazone should be abandoned, because of severe averse reactions observed among HIV-infected patients. The roles of preventive chemotherapy and BCG vaccination for prevention of tuberculosis are also briefly discussed. (author's)

Assessment of worldwide tuberculosis control. WHO Global Surveillance and Monitoring Project.

BACKGROUND: Because worldwide tuberculosis (TB) control had never been assessed, WHO set up a surveillance and monitoring project in 1995. The objectives were to assess the performance of national TB programmes; to assess the extent of implementation of the WHO strategy of TB control; and to attempt a comparison between regions that had adopted the WHO strategy and those that had not. METHODS: In June, 1996, we sent data-collection forms requesting information on national TB programmes' control policies, 1995 case notifications, and 1994 treatment results to 216 countries, areas, and territories. We assessed the performance of national TB programmes by comparing case notifications with estimated incidence and by outcome of treatment in cohorts of patients. We also investigated worldwide treatment success and case detection among sputum-smear-positive patients. FINDINGS: 180 (83%) of the 216 countries, areas, and territories surveyed replied to WHO (98% of the worldwide population). In 1995, the WHO control strategy had been implemented in 75 countries, and in 39 of these implementation was countrywide. UP to 23% of the worldwide population lived in regions where the strategy was available. In 1995, 3 297 688 cases of TB (all types) were reported, of which 1161411 (35%) were sputum-smear positive. 54% of all reported cases in countries that used the WHO strategy were sputum-smear positive, compared with 30% in other countries. The worldwide case-detection rate of new sputum-smear-positive cases was 35%. 92% of cases registered for treatment in 1994 in regions that used WHO strategy were assessed for outcome and 76% were treated successfully, compared with 54% and 42%, respectively, in regions that had not implemented the WHO strategy. Among cases reported worldwide in 1994, the documented treatment-success rate was 43%. INTERPRETATION: National TB programmes that have adopted the WHO TB control strategy achieve higher cure rates, but their impact on TB is modest on a worldwide scale. Wider continuous coverage with the WHO strategy is needed for effective worldwide TB control.