Prevalence of psychological distress and associated factors among adult tuberculosis patients attending public health institutions in Dire Dawa and Harar cities, Eastern Ethiopia.

BACKGROUND: In developing countries, the prevalence of psychological distress was higher among tuberculosis patients. Patients with tuberculosis infection were more prone to psychological distress than peoples without tuberculosis. However, little studies were conducted on psychological distress among tuberculosis patients in Ethiopia, particularly in the Eastern Ethiopian health institutions. METHODS: Institution-based cross-sectional study design was conducted. Based on the TB burden, four hospitals and six health centers were selected from Dire Dawa and Harar cities. Socio-demographic factors, psychological distress, TB related stigma experience, and alcohol use data were collected by face to face interview while TB and HIV related variables collected from TB registration book. All TB patients from the first month of TB treatment initiation through 6 were consecutively interviewed by trained data collectors from January to February 2018. The collected data were entered into Epi Data Version 3.1 software and exported into SPSS window version 20 for analysis. Bivariate and multivariate binary logistic regression was carried out. All variables with P-value ≤0.25 were taken into the multivariate model. Crude and adjusted odds ratios with a 95% confidence interval were estimated, and variables with P-value less than 0.05 in the final model were taken as significant predictors of psychological distress. RESULTS: The prevalence of psychological distress among tuberculosis in this study population was 63.3% (95% CI: 58.1, 68.1). Being from rural residence (AOR: 1. 98; 95% CI: 1.01,3.86), co-infection TB- HIV (AOR: 2.15; 95% CI:1.02, 4.56), presence of at least one chronic disease (AOR:3.04; 95% CI:1.59,5.79), experience of stigma (AOR: 1.71; 95% CI:1.01, 2.90), Pulmonary and MDR-TB (AOR:2.53; 95% CI:1.50,4.28) and smoking cigarette (AOR:2.53; 95% CI:1.06,6.03) were associated with psychological distress. CONCLUSIONS: In this study, almost two-thirds of the tuberculosis patients had psychological distress. Chronic disease morbidity, HIV-TB co-infection and experienced TB related stigma were associated with psychological distress. Attention should be given to chronic diseases including HIV/AIDS diagnosis and referring to chronic disease units to prevent the impact on mental health. Consideration should be given for psychological distress and linking moderate to severe form of the disease to the Psychiatric clinics to hinder its effects.

[Local public health services: a descriptive study of the municipalities of Catalonia in 2016]. / Los servicios locales de salud pública: estudio descriptivo de los municipios de Catalunya en 2016.

OBJECTIVE: The health system in Spain rests mostly in the Autonomous Communities (similar to the states in the US). The public health activities of many local governments are little studied. The objective of this work was to bring knowledge about the public health activities of the municipalities, providing information obtained from a recent survey in Catalonia. METHODS: Descriptive study based on a survey to public health officers in the 119 municipalities above 10,000 population in Catalonia, excluding the city of Barcelona. The survey was conducted between May and October 2016, with 103 municipalities (86.6%) reporting on their services in 2015, prior to the survey. Data were collected and descriptive analyses performed. RESULTS: A consolidation of both political and professional public health structures of the municipalities was observed. Most frequent activities in health protection were related to legionella control, the control of urban pests and the management of complaints and requests by citizens. Most frequent activities in the field of health promotion were related to physical activity and health, prevention in tobacco and alcohol, food and nutrition. There were relatively few changes reported in public health structures and their officers, as well as in human resources. CONCLUSIONS: In Catalonia, municipalities above 10,000 population have a remarkable level of activity in public health. Both the areas of health protection (with mandatory minimum services for local governments) and of health promotion show high levels of activity. The system seems stable regarding political changes and budget constraints. There are opportunities for improvement in the training of professionals and service accreditation. It would be desirable to find ways to improve coordination among these services.

OBJETIVO: El sistema sanitario en España pivota sobre las Comunidades Autónomas. La salud pública gestionada por muchos gobiernos locales está poco estudiada. El objetivo de este trabajo fue contribuir al conocimiento de las actividades de salud pública de los municipios con una encuesta reciente. METODOS: Estudio descriptivo basado en cuestionario a los responsables de salud pública de los 119 municipios mayores de 10,000 habitantes de Catalunya, excluyendo la ciudad de Barcelona. Se realizó entre mayo y octubre de 2016, respondiendo 103 municipios (86,6 %) sobre la situación en 2015, anterior a la encuesta. Los datos se tabularon y sometieron a análisis descriptivos. RESULTADOS: Se apreció una consolidación de las estructuras políticas y técnicas de los municipios en salud pública. Las actuaciones más frecuentes en protección de la salud eran las referidas a la legionelosis, el control de plagas urbanas y la gestión de quejas y denuncias de la ciudadanía; en el ámbito de la promoción de la salud fueron actividad física y salud, prevención en tabaco y alcohol, alimentación y nutrición. Se refirieron relativamente pocos cambios recientes en las estructuras de salud pública, de sus responsables, y de los recursos humanos. CONCLUSIONES: Los municipios catalanes de más de 10.000 habitantes tienen un notable nivel de actividad en salud pública. Tanto los ámbitos de protección de la salud (con servicios mínimos obligatorios para los gobiernos locales) como los de promoción de la salud muestran niveles altos de actividad. El sistema parece estable respecto a cambios políticos y restricciones presupuestarias. Hay oportunidades de mejora en formación de profesionales y acreditación de servicios. Sería deseable mejorar la coordinación entre estos servicios.

State-Level Point-of-Sale Tobacco News Coverage and Policy Progression Over a 2-Year Period.

BACKGROUND: Mass media content may play an important role in policy change. However, the empirical relationship between media advocacy efforts and tobacco control policy success has rarely been studied. We examined the extent to which newspaper content characteristics (volume, slant, frame, source, use of evidence, and degree of localization) that have been identified as important in past descriptive studies were associated with policy progression over a 2-year period in the context of point-of-sale (POS) tobacco control. METHOD: We used regression analyses to test the relationships between newspaper content and policy progression from 2012 to 2014. The dependent variable was the level of implementation of state-level POS tobacco control policies at Time 2. Independent variables were newspaper article characteristics (volume, slant, frame, source, use of evidence, and degree of localization) and were collected via content analysis of the articles. State-level policy environment contextual variables were examined as confounders. RESULTS: Positive, significant bivariate relationships exist between characteristics of news content (e.g., high overall volume, public health source present, local quote and local angle present, and pro-tobacco control slant present) and Time 2 POS score. However, in a multivariate model controlling for other factors, significant relationships did not hold. DISCUSSION: Newspaper coverage can be a marker of POS policy progression. Whether media can influence policy implementation remains an important question. Future work should continue to tease out and confirm the unique characteristics of media content that are most associated with subsequent policy progression, in order to inform media advocacy efforts.

Health policy programs realised in Poland in 2016-2017

Background: Health Policy Program (Program Polityki Zdrowotnej ­ PPZ) is a state policy tool for engaging local government units into the mechanism of granting provision of health services. Authors show areas in which self-governments most often took preventive health care actions and describe legislative changes in the Act on provision of health services. Objective: The aim of the article is to quantitative and qualitative statement of PPZ prepared in Poland in 2016 and 2017, as well as presenting changing legal situation in the scope of evaluation of these projects. Materials and methods: Authors use descriptive method, presenting changes of legal status. The article includes data available in the Bulletin of Public Information by The Agency for Health Technology Assessment. 590 programs were analyzed (239 from 2016 and 351 from 2017). Results: In 2016 ­ 67% of submitted programs were given a positive opinion and in 2017 ­ 71%. The most of positively evaluated PPZ submitted by local government units (53% in 2016; 47% in 2017) referred to prevention of infectious diseases by vaccines. On the basis of analyses conducted, significant differences were observed in the implementation of the PPZ in various regions of Poland. Conclusions: In the recent years a big improvement in the quality of planned self-government health programs is observed. It is suggested that due to the regulation defining the model of the health policy program and the model of the final report, this trend will continue.

[Shortage of physicians in rural areas and in the public health service : A critical analysis of the evidence on the role of medical education and training]. / Ärztemangel in der hausärztlichen Versorgung auf dem Lande und im Öffentlichen Gesundheitsdienst : Eine kritische Analyse der Evidenz bezüglich der Rolle von Aus- und Weiterbildung.

BACKGROUND: A shortage of medical personnel has been seen for several decades in at least two sectors of the healthcare system: primary care in remote areas as well as medical care in the state public health departments (Öffentliches Gesundheitswesen). Strategies to reduce these problems are being sought. OBJECTIVE: This review examines the proposals, practical initiatives and empirical studies in under- and postgraduate medical education in order to estimate their potential impact on the solution of these problems. The analysis covers both Germany and Anglo-Saxon countries. MATERIALS AND METHODS: The study is based on a literature search in PubMed and Medline covering the last 20 years. With regard to Germany, programmatic documents and studies published in the German Journal of General Practice (Zeitschrift für Allgemeinmedizin) were also included. RESULTS AND DISCUSSION: Foreign empirical studies identify almost equal two factors with regard to primary care in remote areas: the recruitment of students from rural areas combined with special educational programs with a rural primary care orientation both in under- and postgraduate medical education. These programs should include several and longer practical working periods in primary care units and be well coordinated between the medical school and the local teaching physicians. As for the state public health sector, comparable initiatives are still lacking.

When public health intervention is not successful: Cost sharing, crowd-out, and selection in Korea's National Cancer Screening Program.

This study investigates the impact of and behavioral responses to cost sharing in Korea's National Cancer Screening Program, which provides free stomach and breast cancer screenings to those with an income below a certain cutoff. Free cancer screening substantially increases the screening take up rate, yielding more cancer detections. However, the increase in cancer detection is quickly crowded out by cancer detection through other channels such as diagnostic testing and private cancer screening. Further, compliers are much less likely to have cancer than never takers. Crowd-out and selection help explain why the program has been unable to reduce cancer mortality.

Public health services and their relationship with rapid HIV test utilization and access for key populations in Morelos, Mexico.

OBJECTIVE: In 2009, 4 749 rapid HIV tests were run in Morelos, Mexico, despite lacking evidence on their results. This article seeks to analyze how public health organization relates to utility of rapid HIV test among healthcare users. MATERIALS AND METHODS: Joint study: comparison of differences in applied test and positive results for each group with the Bonferroni statistical tool, observational study in 34 health subsystems, and 11 interviews with public healthcare users. RESULTS: Each subsystem processes influenced the use and usefulness of screening; for instance, primary care centers test only pregnant women and exclude men who have sex with men (MSM). That group shows significant differences (p<0.007) in the HIV-positive test with respect to other groups. CONCLUSIONS: Despite the availability of rapid detection tests and epidemiological evidence, the way public health services are organized impedes an efficient diagnosis in the group with higher risk, namely MSM. The distribution of rapid HIV tests was guided by stigmatization.

Public health services and their relationship with rapid HIV test utilization and access for key populations in Morelos, Mexico / La organización de los servicios de salud y su relación con la utilización y acceso a las pruebas rápidas para la detección del VIH en las poblaciones clave en Morelos, México

Objective. In 2009, 4 749 rapid HIV tests were run in Morelos, Mexico, despite lacking evidence on their results. This article seeks to analyze how public health organization relates to utility of rapid HIV test among healthcare users. Materials and methods. Joint study: comparison of differences in applied test and positive results for each group with the Bonferroni statistical tool, observational study in 34 health subsystems, and 11 interviews with public healthcare users. Results. Each subsystem processes influenced the use and usefulness of screening; for instance, primary care centers test only pregnant women and exclude men who have sex with men (MSM). That group shows significant differences (p<0.007) in the HIV-positive test with respect to other groups. Conclusions. Despite the availability of rapid detection tests and epidemiological evidence, the way public health services are organized impedes an efficient diagnosis in the group with higher risk, namely MSM. The distribution of rapid HIV tests was guided by stigmatization.

Objetivo. En 2009, 4 749 pruebas rápidas de detección de VIH fueron aplicadas en Morelos, México, sin evidencias de resultados. Se hace necesario analizar la distribución de estas pruebas y las consecuencias que la organización de los servicios de salud tuvo para el diagnóstico del VIH en las poblaciones clave. Material y métodos. Estudio mixto: comparación de diferencias en pruebas aplicadas y casos diagnosticados en grupos mediante la técnica de Bonferroni, observaciones en 34 subsistemas de salud y 11 entrevistas a usuarios. Resultados. Los procesos de cada subsistema incidieron en la utilización y utilidad del tamizaje: se focalizó en mujeres embarazadas y se excluyó a grupos en mayor riesgo (p<0.007) en hombres que tienen sexo con otros hombres (HSH). Conclusiones. A pesar de la disponibilidad de las pruebas y de información epidemiológica, la organización de los servicios impidió una mayor captación de HSH. La estigmatización influyó en las formas de distribuirlas.

Assessment of compliance with U.S. Public Health Service clinical practice guideline for tobacco by primary care physicians.

BACKGROUND: The US Public Health Service clinical practice guideline treating tobacco use and dependence: 2008 update established an expanded standard of care, calling on physicians to consistently identify their patients who use tobacco and treat them using counseling and medication. FINDINGS: To assess compliance, we examined the extent to which physicians self-report following four of the five components of the 5A model: Ask about tobacco use, Advise patients who use tobacco to quit, Assist the patient in making a quit attempt, and Arrange for follow-up care. We used data from a Web-based panel survey administered to a convenience sample of 1,253 primary care providers (family/general practitioners, internists, and obstetrician/gynecologists). We found that 97.1% of the providers reported that they consistently Asked and documented tobacco use, while 98.6% reported that they consistently Advised their patients to quit using tobacco. Among the family/general practitioners and internists, 98.3% recommended "any" (medication, counseling, counseling and medication, telephone quitline) smoking cessation strategies (Assist). Among all providers, 48.0% reported that they consistently scheduled a follow-up visit (Arrange). CONCLUSIONS: This study revealed that most primary care physicians reported that they Ask their patients about tobacco use, Advise them to quit, and Assist them in making a quit attempt, but only half reported that they Arrange a follow-up visit. Tobacco use screening and intervention are among the most effective clinical preventive services; thus, efforts to educate, encourage, and support primary care physicians to provide evidence-based treatments to their patients should be continued.

Rural populations and early periodic screening, diagnosis, and treatment services: challenges and opportunities for local public health departments.

OBJECTIVES: We examined geographic differences in Early Periodic Screening, Diagnosis, and Treatment (EPSDT) visits as the South Carolina Department of Health and Environmental Control (SCDHEC) transitioned from direct service provision (DSP) to assuring delivery within the larger health care system. METHODS: We examined infant cohorts with continuous Medicaid coverage and normal birth weights from 1995 to 2010. Outcome variables included any EPSDT visit and the ratio of observed to expected visits. Change in SCDHEC market share over time by residence was the primary variable of interest. We used growth curve models to examine changes in EPSDT visits by rural areas and levels of DSP over time. RESULTS: A small proportion of the study population (10%) resided in rural counties that were more dependent on SCDHEC for DSP. The trajectory of not having visits among counties with high DSPs was steeper in rural areas (0.208; P = .001) compared with urban areas (0.145; P = .002). In counties with high DSPs, the slope of the predicted ratio in rural areas (-0.033; P < .001) was steeper than that of urban areas (-0.013; P < .001). CONCLUSIONS: Health departments operations continue to transition from DSP, which might decrease access to well-child care in rural communities. Health care reform provides opportunities for health departments to work with community partners to facilitate DSP from public to private sectors.

Building the evidence for decision-making: the relationship between local public health capacity and community mortality.

OBJECTIVES: We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina. METHODS: We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality. RESULTS: Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05). CONCLUSIONS: Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

Using a public health approach to improve end-of-life care: results and discussion of a health needs assessment undertaken in a large city in northern England.

A detailed health needs assessment (HNA) for end-of-life care (EoLC) services was led by public health in Leeds to inform a commissioning strategy. To answer the question: are we delivering the best possible EoLC services within the resources available? Mixed methods were used with three approaches: epidemiological, corporate and comparative. More people from deprived communities die in hospital. 18% of people who die each year are on a palliative care register, reflecting a lack of recognition and planning for EoLC given that 75% of people who die need EoLC. Over 100 staff, patients and carers were interviewed and over 200 staff returned questionnaires. Staff highlighted concerns about capacity of services; pressure on out-of-hospital care; problems at physical and electronic interfaces between services; suboptimal hospital discharge; need for earlier recognition of the EoL stage for patients. Patients and carers stressed the importance of communication, coordination and continuity of care; full involvement in care planning; honesty and support for the bereaved; an advocate for patients and families; accessible information; improved urgent care; integrated team working; pain relief, dignity and respect. Issues from comparator sites included the need for sustainable leadership for change, lack of interoperability between IT systems; building advance care planning into working culture; gaps in psychological services, bereavement and pastoral support; integration within all clinical areas; lack of district nurses; few investment opportunities; getting home care support right; concerns about 111; incentives for general practitioners to deliver EoLC; variability in service and the Liverpool Care Pathway controversy. Ethical approval was not sought as the HNA was undertaken as a service evaluation. Local policy is that ethical approval is not required for service evaluation.

Changes in health promotion practice in hospitals across England: the National Health Promotion in Hospital Audit 2009 and 2011.

BACKGROUND: There is increasing focus on hospitals to provide health promotion (HP) to patients who smoke, misuse alcohol, are obese or physically inactive, yet there is little published literature on assessment and HP in English hospitals. METHODS: Thirty hospitals participated in national audits, both in 2009 and 2011, to assess HP in hospitalized patients. Random samples of 100 patients were selected per hospital per year. RESULTS: Between the 2009 and 2011 audit, assessment rates increased for smoking (82 versus 86%; P < 0.001) and obesity (38 versus 53%; P < 0.001), alcohol assessments remained similar (71 versus 73%; P = 0.123) and physical activity assessments decreased (34 versus 28%; P < 0.001). Provision of HP was similar in both audits for smoking (22 versus 26%; P = 0.17), alcohol misuse (47 versus 44%; P = 0.12) and physical inactivity (43 versus 44%; P = 0.865), but fell for obesity (26 versus 14%; P < 0.001). Few hospitals met the standards for assessment and HP for each risk factor. CONCLUSIONS: Whilst patients are being assessed for most lifestyle risk factors, and despite an increased policy focus, there remains little evidence of HP practice in English hospitals. There is potential for health gain across England that could be exploited through wider provision of HP for hospitalized patients.

Management of children exposed to Mycobacterium tuberculosis: a public health evaluation in West Java, Indonesia.

OBJECTIVE: To investigate qualitatively and quantitatively the performance of a programme for managing the child contacts of adult tuberculosis patients in Indonesia. METHODS: A public health evaluation framework was used to assess gaps in a child contact management programme at a lung clinic. Targets for programme performance indicators were derived from established programme indicator targets, the scientific literature and expert opinion. Compliance with tuberculosis screening, the initiation of isoniazid preventive therapy in children younger than 5 years, the accuracy of tuberculosis diagnosis and adherence to preventive therapy were assessed in 755 child contacts in two cohorts. In addition, 22 primary caregivers and 34 clinic staff were interviewed to evaluate knowledge and acceptance of child contact management. The cost to caregivers was recorded. Gaps between observed and target indicator values were quantified. FINDINGS: THE GAPS BETWEEN OBSERVED AND TARGET PERFORMANCE INDICATORS WERE: 82% for screening compliance; 64 to 100% for diagnostic accuracy, 50% for the initiation of preventive therapy, 54% for adherence to therapy and 50% for costs. Many staff did not have adequate knowledge of, or an appropriate attitude towards, child contact management, especially regarding isoniazid preventive therapy. Caregivers had good knowledge of screening but not of preventive therapy and had difficulty travelling to the clinic and paying costs. CONCLUSION: The study identified widespread gaps in the performance of a child contact management system in Indonesia, all of which appear amenable to intervention. The public health evaluation framework used could be applied in other settings where child contact management is failing.

Cervical and female breast cancers in the Americas: current situation and opportunities for action.

OBJECTIVE: To understand better the current regional situation and public health response to cervical cancer and female breast cancer in the Americas. METHODS: Data on cervical cancer and female breast cancers in 33 countries, for the period from 2000 to the last year with available data, were extracted from the Pan American Health Organization (PAHO) Regional Mortality Database and analysed. Changes in mortality rates over the study period - in all countries except those with small populations and large fluctuations in time-series mortality data - were calculated using Poisson regression models. Information from the PAHO Country Capacity Survey on noncommunicable diseases was also analysed. FINDINGS: The Bahamas, Trinidad and Tobago and Uruguay showed relatively high rates of death from breast cancer, whereas the three highest rates of death from cervical cancer were observed in El Salvador, Nicaragua and Paraguay. Several countries - particularly Paraguay and Venezuela - have high rates of death from both types of cancer. Although mortality from cervical cancer has generally been decreasing in the Americas, decreases in mortality from breast cancer have only been observed in a few countries in the Region of the Americas. All but one of the 25 countries in the Americas included in the PAHO Country Capacity Survey reported having public health services for the screening and treatment of breast and cervical cancers. CONCLUSION: Most countries in the Americas have the public health capacity needed to screen for - and treat - breast and cervical cancers and, therefore, the potential to reduce the burden posed by these cancers.

Pediatric and adolescent tuberculosis in the United States, 2008-2010.

OBJECTIVE: We examined heterogeneity among children and adolescents diagnosed with tuberculosis (TB) in the United States, and we investigated potential international TB exposure risk. METHODS: We analyzed demographic and clinical characteristics by origin of birth for persons <18 years with verified case of incident TB disease reported to National TB Surveillance System from 2008 to 2010. We describe newly available data on parent or guardian countries of origin and history of having lived internationally for pediatric patients with TB (<15 years of age). RESULTS: Of 2660 children and adolescents diagnosed with TB during 2008-2010, 822 (31%) were foreign-born; Mexico was the most frequently reported country of foreign birth. Over half (52%) of foreign-born patients diagnosed with TB were adolescents aged 13 to 17 years who had lived in the United States on average >3 years before TB diagnosis. Foreign-born pediatric patients with foreign-born parents were older (mean, 7.8 years) than foreign-born patients with US-born parents (4.2 years) or US-born patients (3.6 years). Among US-born pediatric patients, 66% had at least 1 foreign-born parent, which is >3 times the proportion in the general population. Only 25% of pediatric patients with TB diagnosed in the United States had no known international connection through family or residence history. CONCLUSIONS: Three-quarters of pediatric patients with TB in the United States have potential TB exposures through foreign-born parents or residence outside the United States. Missed opportunities to prevent TB disease may occur if clinicians fail to assess all potential TB exposures during routine clinic visits.

[A study on the long-term non-small cell lung cancer survivors in the Expand Access Program of gefitinib in China].

BACKGROUND AND OBJECTIVE: The Expand Access Program (EAP) of Iressa(gefitinib, ZD1839) in China was initiated in 2001 with the aim of providing gefitinib to non-small cell lung cancer (NSCLC) patients who failed to respond to standard treatment or who could not tolerate chemotherapy. The primary objective was to describe the quality of life (QoL), tumor control status, drug safety, and clinical/genomic features of active long-term survivors enrolled in the EAP. The secondary objective was to determine the clinical characteristics of long-term survivors in the EAP program. METHODS: In this descriptive observational study, data were collected based on epidemiological research methods. The data of patients who were actively participating in the EAP and still undergoing gefitinib treatment were collected in a cross-sectional manner to reflect the current status of each patient. Meanwhile, the data of patients who had been on gefitinib treatment for more than three years and had already been terminated from the EAP or those who were fast progressors were collected retrospectively. RESULTS: A total of 934 patients were screened in the EAP database. Among these patients, 25 were active long-term survivors still enrolled in the EAP and 34 were long-term survivors who had been terminated from the program. These 59 patients were enrolled in 15 different centers in China, and the remaining 875 patients were fast progressors. The median scores for the Functional Assessment of Cancer Therapy-Lung (FACT-L), Trial Outcome Index (TOI), and Lung Cancer Subscale (LCS) of the 25 long-term survivors were 64.5, 37 and 12.5, respectively. The performance status 0-1 accounted for 91.6% of the data observed during the cross-sectional survey. For active long-term survivors, the objective response rate was 37.5%, the disease control rate was 87.5%, and the median duration of response time was almost 68 months. In the long-term survivor group, no serious and new adverse events were reported. Patients who were aged under 65 years (68.5%), affected with adenocarcinoma (81.4%), female (55.9%), or had never smoked (71%) accounted for majority of the long-term survivors. The percentage of females was significantly higher in the long-term survivor group than in the fast progressor group (P=0.02). Three tissue samples were collected from each of the 24 active long-term survivors, and one patient was found to be positive of EGFR mutation. Twenty-two blood samples were also collected, and one patient tested positive for EGFR mutation. The Ki67 protein expression was also tested in three tissue samples, and two of these were found positive for Ki67 protein expression, with a response duration time of over 73 months. CONCLUSIONS: A 250 mg dose of gefitinib offers good QoL and is safe for advanced NSCLC long-term survivors even after more than three years of treatment. According to the evaluation of the current tumor control statuses of patients, gefitinib demonstrates good efficacy in these active long-term survivors.

Public health services, an essential determinant of health during crisis. Lessons from Cuba, 1989-2000.

During the 1990s, Cuba was able to overcome a severe crisis, almost without negative health impacts. This national retrospective study covering the years 1989-2000 analyses the country's strategy through essential social, demographic, health process and health outcome indicators. Gross domestic product (GDP) diminished by 34.76% between 1989 and 1993. In 1994 slow recuperation started. During the crisis, public health expenses increased. The number of family doctors rose from 9.22 to 27.03 per 104 inhabitants between 1989 and 2000. Infant mortality rate and life expectancy exemplify a series of health indicators that continued to improve during the crisis years, whereas low birth weight and tuberculosis incidence are among the few indicators that suffered deterioration. GDP is inversely related to tuberculosis incidence, whereas the average salary is inversely related to low birth weight. Infant mortality rate has a strong negative correlation with the health expenses per inhabitant, the number of maternal homes, the number of family doctors and the proportion of pregnant women receiving care in maternal homes. Life expectancy has a strong positive correlation with health expenses, the number of nursing personnel and the number of medical contacts per inhabitant. The Cuban strategy effectively resolved health risks during the crisis. In times of serious socio-economic constraints, a well conceptualized public health policy can play an important role in maintaining the overall well-being of a population.

The ethics of sin taxes.

ABSTRACT The current global economic crisis is forcing governments to consider a variety of methods to generate funds for infrastructure. In the United States, smoking-related illness and an obesity epidemic are forcing public health institutions to consider a variety of methods to influence health behaviors of entire target groups. In this paper, the author uses a public health nursing model, the Public Health Code of Ethics (Public Health Leadership Society, 2002), the American Nurses' Association (ANA) Code of Ethics (2001), and other relevant ethical theory to weigh and balance the arguments for and against the use of sin taxes. A position advocating the limited use of sin taxes is supported as a reasonable stance for the public health professional.