Does appreciative inquiry decrease false positive diagnosis during leprosy case detection campaigns in Bihar, India? An operational research study.

BACKGROUND: India contributes ~60% to the global leprosy burden. The country implements 14-day community-based leprosy case detection campaigns (LCDC) periodically in all high endemic states. Paramedical staff screen the population and medical officers of primary health centres (PHCs) diagnose and treat leprosy cases. Several new cases were detected during the two LCDCs held in September-2016 and February-2018. Following these LCDCs, a validation exercise was conducted in 8 Primary health centres (PHCs) of 4 districts in Bihar State by an independent expert group, to assess the correctness of case diagnosis. Just before the February 2018 LCDC campaign, we conducted an "appreciative inquiry" (AI) involving the health care staff of these 8 PHCs using the 4-D framework (Discovery-Dream-Design-Destiny). OBJECTIVES: To assess whether the incorrect case diagnosis (false positive diagnosis) reduced as a result of AI in the 8 PHCs between the two LCDC conducted in September-2016 and February-2018. METHODOLOGY/PRINCIPAL FINDINGS: A three-phase quantitative-qualitative-quantitative mixed methods research (embedded design) with the two validation exercises conducted following September-2016 and February-2018 LCDCs as quantitative phases and AI as qualitative phase. In September-2016 LCDC, 303 new leprosy cases were detected, of which 196 cases were validated and 58 (29.6%) were false positive diagnosis. In February-2018 LCDC, 118 new leprosy cases were detected of which 96 cases were validated and 22 cases (23.4%) were false positive diagnosis. After adjusting for the age, gender, type of cases and individual PHCs fixed effects, the proportion of false positive diagnosis reduced by -9% [95% confidence intervals (95%CI): -20.2% to 1.7%, p = 0.068]. CONCLUSION: False positive diagnosis is a major issue during LCDCs. Though the decline in false positive diagnosis is not statistically significant, the findings are encouraging and indicates that appreciative inquiry can be used to address this deficiency in programme implementation.

Validação de instrumento para avaliação do conhecimento de adolescentes sobre hanseníase / Validación del instrumento para la evaluación del conocimiento de los adolescentes sobre la hanseniasis / Validation of an instrument for the evaluation of adolescents' knowledge about Hansen's disease

Resumo Objetivo: Construir e validar instrumentos para avaliação do conhecimento de adolescentes sobre hanseníase e caracterização dos sujeitos. Métodos: Pesquisa metodológica, desenvolvida em três etapas, a saber: construção dos instrumentos; validação de face e conteúdo com sete juízes; e validação semântica com 20 adolescentes, de 10 a 14 anos. Resultados: Houve concordância superior a 80% entre os juízes quanto a todos os domínios, itens e componentes avaliados. A concordância geral entre os juízes para o instrumento de avaliação do conhecimento de adolescentes sobre hanseníase, com 14 itens, foi de 89% e do instrumento para caracterização dos participantes, com 17 itens, foi de 93%. Na validação semântica, os instrumentos foram considerados com boa compreensão, e não houve dificuldades para seu preenchimento. Entre os adolescentes, 10% afirmaram ter ou ter tido casos de hanseníase na família. A maioria dos adolescentes (55%) nunca tinha ouvido falar ou tinha recebido informações sobre hanseníase, assim como a maioria (60%) afirmou não saber o que era a hanseníase. Conclusão: Os instrumentos construídos para avaliar o conhecimento de adolescentes sobre hanseníase e caracterizar a população estudada foram considerados válidos quanto à face, ao conteúdo e à semântica. Ambos os instrumentos apresentaram aparência, compreensão e relevância consideradas muito boas ou excelentes, podendo ser aplicados ao público de estudo.

Resumen Objetivo: Construir y validar instrumentos para evaluar el conocimiento de adolescentes sobre hanseniasis y caracterización de los sujetos. Métodos: Investigación metodológica desarrollada en tres etapas, a saber: construcción de los instrumentos, validación de cara y contenido con siete jueces y validación semántica con 20 adolescentes de 10 a 14 años. Resultados: Hubo correspondencia superior al 80% entre los jueces en cuanto a todos los elementos, ítems y componentes evaluados. La correspondencia general entre los jueces para el instrumento de evaluación del conocimiento de adolescentes sobre hanseniasis, con 14 ítems, fue del 89%, y del instrumento para caracterización de los participantes, con 17 ítems, fue del 93%. En la validación semántica los instrumentos fueron considerados con buena comprensión y no hubo dificultades para su diligenciamiento. Entre los adolescentes, el 10% afirmó tener o haber tenido casos de hanseniasis en la familia. La mayoría de los adolescentes (55%) nunca había oído hablar o había recibido información sobre la hanseniasis, así como la mayoría (60%) afirmó no saber lo que era la hanseniasis. Conclusión: Los instrumentos construidos para evaluar el conocimiento de adolescentes sobre hanseniasis y caracterizar a la población estudiada fueron considerados válidos en cuanto a la cara, el contenido y la semántica. Ambos instrumentos presentaron apariencia, comprensión y relevancia consideradas muy buenas o excelentes, por lo que se pudieron aplicar al público estudiado.

Abstract Objective: To construct and validate instruments for the evaluation of adolescents' knowledge about Hansen's disease and characterization of these subjects. Methods: Methodological study developed in three steps, namely: construction of instruments; face and content validation with seven judges; and semantic validation with 20 adolescents aged from 10 to 14 years. Results: There was more than 80% agreement among judges in all domains, items and components evaluated. The general agreement among judges for the instrument for evaluation of adolescents' knowledge on Hansen's disease with 14 items was 89%, and for the instrument for characterization of participants with 17 items, agreement was 93%. In the semantic validation, the instruments were considered of good understanding, and there were no difficulties for completing them. Among adolescents, 10% reported having or having had cases of Hansen's disease in the family. Most adolescents (55%) had never heard of or received information about Hansen's disease, and most (60%) also said they did not know what Hansen's disease was. Conclusion: The instruments constructed to evaluate adolescents' knowledge about Hansen's disease and to characterize the studied population were considered valid regarding face, content and semantics. The appearance, comprehension and relevance were considered as very good or excellent in both instruments, and they can be applied to the target population.

Experiências de cuidado dos enfermeiros às pessoas com hanseníase: contribuições da hermenêutica / Nursing care experiences with Hansen's disease patients: contributions from hermeneutics

Resumo Objetivo Estudo qualitativo fundamentado na hermenêutica filosófica que teve como objetivo analisar a experiência de cuidar de pessoas com hanseníase na pratica de enfermeiros do Município do Rio de Janeiro. Métodos Estudo qualitativo desenvolvido nas áreas programáticas de saúde do município do Rio de Janeiro, que apresentaram alto ou médio coeficiente de detecção de hanseníase em 2014. Foram selecionados serviços com os seguintes perfis: exclusivamente ESF, serviços com clínicas especializadas e unidades mistas que se caracterizam pela coexistência da ESF e do modelo tradicional de atendimento. Participaram da pesquisa dezenove enfermeiros que atuavam nos serviços de Atenção Primária e Secundária destas áreas. Os critérios de inclusão definidos foram possuir experiência de pelo menos cinco anos no acompanhamento de pessoas que receberam diagnóstico de hanseníase e, qualificação técnica por treinamento específico. Como critério de exclusão, estar em afastamento laboral durante toda a etapa de coleta de dados que ocorreu no período de fevereiro de 2015 a março de 2016. As entrevistas foram agendadas em comum acordo com os participantes e gravadas com autorização dos mesmos. Resultados Elaboraram-se duas categorias: Para os enfermeiros, o atendimento da pessoa com hanseníase perdeu em qualidade e os enfermeiros reconhecem o estigma como um problema que compromete o tratamento e a cura da hanseníase. Conclusão O atendimento às pessoas com hanseníase ficou reduzido à uma ação eventual, onde a relação profissional-usuário tem vínculo fragilizado. O estigma e a discriminação que comprometem o tratamento ainda estão presentes nas atitudes e no comportamento dos profissionais de saúde, e se constituem em obstáculo no restabelecimento da saúde.

Abstract Objective To analyze the experience of caring for Hansen's disease patients in the practice of nurses in the city of Rio de Janeiro. Methods Qualitative study based on philosophical hermeneutics conducted in the programmatic areas of health in the city of Rio de Janeiro, which presented high or medium rates of Hansen's disease detection in 2014. Services with the following profiles were selected: exclusively Family Health Strategy (FHS), services with specialized clinics, and hybrid units in which the FHS and the traditional care model coexist. Nineteen nurses working in the primary and secondary health services of these areas participated in the research. The inclusion criteria were having at least five years of experience in following up Hansen's disease patients, and technical ability acquired from specific training. Exclusion criterion was being absent from work during the whole data collection stage, which happened between February 2015 and March 2016. Interviews were scheduled in agreement with participants and recorded with their authorization. Results Two categories were established: For nurses, care for Hansen's disease patients lost its quality, and nurses recognize stigma as a problem that compromises Hansen's disease treatment and cure. Conclusion Treatment of Hansen's disease patients was limited to eventual actions, where the professional-user relationship has a fragile link. The stigma and discrimination that harm treatment are still present in attitudes and behaviors of health professionals, and represent an obstacle for reestablishing health.

"I Wasted 3 Years, Thinking It's Not a Problem": Patient and Health System Delays in Diagnosis of Leprosy in India: A Mixed-Methods Study.

BACKGROUND: Worldwide, leprosy is one of the major causes of preventable disability. India contributes to 60% of global leprosy burden. With increasing numbers of leprosy with grade 2 disability (visible disability) at diagnosis, we aimed to determine risk factors associated with grade 2 disability among new cases and explore patients and providers' perspectives into reasons for late presentation. METHODOLOGY/PRINCIPAL FINDINGS: This was an explanatory mixed-methods study where the quantitative component, a matched case-control design, was followed by a qualitative component. A total of 70 cases (grade 2 disability) and 140 controls (grade 0) matched for age and sex were randomly sampled from new patients registered between January 2013-January 2015 in three districts of Maharashtra (Mumbai, Thane and Amaravati) and interviewed using a structured close ended questionnaire. Eight public health care providers involved in leprosy care and 7 leprosy patients were purposively selected (maximum variation sampling) and interviewed using a structured open-ended interview schedule. Among cases, overall median (IQR) diagnosis delay in months was 17.9(7-30); patient and health system delay was 7(4-16.5) and 5.5(0.9-12.5) respectively; this was significantly higher than the delay in controls. Reasons for delayed presentation identified by the quantitative and qualitative data were: poor awareness of leprosy symptoms, first health care provider visited being private practitioners who were not aware about provision of free leprosy treatment at public health care facilities, reduced engagement and capacity of the general health care system in leprosy control. CONCLUSIONS: Raising awareness in communities and health care providers regarding early leprosy symptoms, engagement of private health care provider in early leprosy diagnosis and increasing capacity of general health system staff, especially targeting high endemic areas that are hotspots for leprosy transmission may help in reducing diagnosis delays.

Expedições científicas, fotografia e intenção documentária: as viagens do Instituto Oswaldo Cruz (1911-1913) / Scientific expeditions, photography, and documental intent: the Oswaldo Cruz Institute expeditions (1911-1913)

Analisa as séries fotográficas produzidas pelo Instituto Oswaldo Cruz em expedições científicas ao interior do Brasil, realizadas entre 1911 e 1913. Detém-se na expedição liderada por Arthur Neiva e Belisário Penna e na elaboração do seu discurso documentário. Explicita escolhas e ênfases adotadas na elaboração de cada texto visual, expresso tanto no material produzido durante o percurso quanto na seleção das imagens para publicação. As análises quantitativa e qualitativa das imagens da expedição de Neiva e Penna revelam um percurso narrativo que articula o meio natural, a vida social e as evidências de adoecimento das populações interioranas, para a constituição de um discurso que difunde o movimento pelo saneamento dos sertões.

The article analyzes the photographic series produced by the Oswaldo Cruz Institute in reference to scientific expeditions into the interior of Brazil between 1911 and 1913, with a special focus on the one headed by Arthur Neiva and Belisário Penna and on the development of their documentary discourse. It draws out the choices and emphases used in preparing each visual text, expressed both in the material produced during the journeys and in the process of selecting images for publication. The study's quantitative and qualitative analyses of images from the Neiva-Penna expedition uncover a narrative journey that articulates the natural environment, social life, and evidence of the sickly status of residents of the interior to shape a discourse that disseminates the nascent movement to sanitize the sertão regions.

Gender and leprosy: case studies in Indonesia, Nigeria, Nepal and Brazil.

There appear to be regional differences in gender ratios of leprosy patients being diagnosed and treated. In Asian countries, more men than women are registered whilst in Africa female patients outnumber males. The Netherlands Leprosy Relief (NLR) therefore initiated research into factors underlying these regional gender differences. Between 1997 and 1999, leprosy control teams in Indonesia, Nigeria, Nepal and Brazil supported by social/public health scientists, conducted comparative exploratory research. They looked at three groups of potential explanatory factors: biological, socio-cultural/economic and service-related. The studies were partially quantitative (analysis of the records of patients who according to prescription could have completed treatment) and partially qualitative (interviews/focus group discussions with patients, their relatives, community members and health staff on perceptions of leprosy, its socio-economic consequences, treatment and cure). Biological factors appeared similar in the four countries: irrespective of the M/F ratio, more men than women were registered with multibacillary (MB) leprosy. Strong traditions, the low status of women, their limited mobility, illiteracy and poor knowledge of leprosy appeared to be important sociocultural factors explaining why women were under reporting. Yet, accessible, well reputed services augmented female participation and helped to diminish stigma, which in three out of the four societies seemed greater for women than for men. These positive effects could still be higher if the services would enhance community and patient education with active participation of patients and ex-patients themselves.

An evaluation of the Sinan health information system as used by the Hansen's disease control programme, Pernambuco State, Brazil.

BACKGROUND: Since the introduction of the national notifiable diseases information system (SINAN) in Pernambuco State, Brazil, in 1994, many problems have been encountered. The aim of this study was to evaluate the SINAN software, quality of data input, the transfer of the computerised data from the municipality to state levels, human resources and other factors associated with the health information system infrastructure (HIS). METHODS: A cross-sectional study was carried out in Pernambuco state, North-eastern Brazil, in 2005. A sample of health regions and municipalities was chosen. SINAN forms from those municipalities were analysed and the flow of notifications followed from municipal level to the regional and finally to the state. Professionals from health units, district, municipal and regional Hansen's Disease Control Programme (HDCP) and Epidemiological Surveillance System (ESS) coordinators, health secretaries and managers of the municipalities and health regions selected were interviewed. RESULTS: SINAN software is functioning up to expectation. However, at all levels of the health system, serious weaknesses not related to the SINAN software were found, varying from lack of human resources (limited number of staff and staff development), lack of infrastructure (office space, computers, supplies, etc.) to an absence of effective coordination, management and supervision of the HIS. CONCLUSIONS: Lack of reliable, complete and timely information, and especially the lack of widespread analysis and use of available information in planning and management of health services were the main weaknesses found. Many areas need urgent attention: the quality of patient examination, recording and reporting, the timely processing of quality data, the coordination and management of disease control programmes, and the use of HIS reports by the health services and health managers. Regular feedback, supportive supervision visits and annual reviews are essential to monitor the system and make sure that essential information is decentralised and used by the primary health services and HDCP coordination. Assessing the quality of services from a client perspective would give additional information for the identification of strengths and weaknesses of the Hansen's disease (leprosy) services.

A public health approach for leprosy detection based on a very short term-training of primary health care workers in basic dermatology.

INTRODUCTION: In countries where leprosy control is integrated to general heath services, health workers, at primary health care level, often manage a large number of patients with skin diseases including leprosy. The distinction of leprosy from others skin diseases requires more skill and attention. Basic dermatological knowledge will help these staff to provide a better quality of care. A few years ago, a short term training programme focussed on leprosy and some common skin diseases was set up in Mali through a pilot project. This study will evaluate the impact of this training on the detection of leprosy at primary health care level. METHODS: health care workers from two health districts were invited to participate in the training. Trainee was submitted to an anonymous written test before training, immediately after and 12-18 months post-training using a standardized scoring system. The suspected or referred leprosy cases before and after training were compared. Data were recorded and analysed with the software Epi info version 6.04. RESULTS: Overall, 495 HCW attended the three anonymous written tests (before training, just after and 12-18 months later). The proportion of participants who gave correct answers before training, just after were respectively: 33 and 57% for correct diagnosis, 5 and 39% for test of sensation and 28 and 47% for referral. Eight patients suspected of leprosy were referred for further examination; in these, five cases of leprosy were detected. DISCUSSION: The training showed a huge improvement in the skill of the participants in managing leprosy patients. This study addresses how leprosy control can be improved by involving primary health care staff and by the implementation of only a single day's training on basic dermatology. CONCLUSION: The role of the dermatologist in this post-elimination era of leprosy needs to be reconsidered and adapted to the increasing need to take multiple programmes, inclusive of dermatology and leprosy, into primary health care services and those interested in leprosy control should fund these programmes.

Consensus methods: a bridge between clinical reasoning and clinical research?

Evidence-Based Practice does head the "hierarchy of evidence" upon which developments in clinical practice should be based. There are, however, situations where evidence is either unavailable, unclear, or results between studies are at variance. Consensus is a reliable contingency, and approaches to reaching consensus have acceptable construct validity (Nominal Group Technique, Delphi, and Consensus Development Conference). Consensus is reached when: (i) the method of investigation tightly controls communication to reduce the obscuring "noise" of divergent discussion; (ii) statistical measures of agreement or dissent screen out the bias that would otherwise be produced by the dictate of vociferous minorities or coalitions that may represent vested interests; (iii) all participants contribute equally to the product of the investigation.

Social representation of Hansens disease thirty years after the term leprosy was replaced in Brazil

Baseando-se nas teorias de representação social (RS) e do Núcleo Central (NC), procedeu-se ao estudo estrutural do neologismo hanseníase, introduzido no Brasil, pelo Ministério da Saúde, nos anos 1970. A pesquisa foi conduzida em 2001, em oitocentas donas de casa dos municípios do Rio de Janeiro e Duque de Caxias. Concluiu-se que a hanseníase é parte da modernização do senso comum, mais ainda ancorada na representação tradicional da lepra. Esse achado é compreensível sabendo-se que a estrutura central de uma RS tem determinação histórica, não devendo ser esperadas mudanças de curto e médio prazos. Além disso, não se observou investimento em comunicação social para a divulgação ampla da nova terminologia. Os autores discutem a interface da RS com o conceito de história das mentalidades

Evaluation of the modified leprosy elimination campaign in a high leprosy endemic district of Jharkhand.

An evaluation of the third Modified Leprosy Eradication Campaign (MLEC) was carried out in Potka block in the high endemic district of East Singhbhum, Jharkhand State, India, by our external evaluation team, from 29 October to 8 November 2001. The searchers in this block detected 389 suspects during the MLEC; of these, 181 (46%) were examined, and 69 (38%) of them were confirmed as cases by the Programme staff. The evaluators examined 189 (48.5%) of the total 389 suspects detected by the searchers, including 31 of the 69 cases confirmed by the Programme staff. Concordance of diagnosis of leprosy cases by the Programme staff and the evaluators was found to be high (90%). However, concordance of the type of leprosy was found to be variable (PB 38%, MB 72%, SSL 100%). Specificity and sensitivity of diagnosis by the Programme staff (as against those by the evaluators) were found to be 85.7% and 79.2% respectively. There was no case of re-registration. The evaluators examined 108 of the suspects detected by the Search Team, but not screened by the Programme staff, and diagnosed 47 cases (44%; PB 20, MB 9, SSL 18) from among them. The evaluators also diagnosed additional 30 new cases (PB 18, MB 5, SSL 7), during their visit. An assessment of knowledge about the disease and treatment among confirmed cases revealed that most of the patients did not know correctly about their disease. All the cases were referred by the searchers. About 45% of cases were aware of the duration for which they needed to take the treatment, 97% of cases showed the blister calendar packs and had taken the supervised dose. Availability of MDT to the patients and drug compliance were found to be adequate. Assessment of the impact of IEC activities on the awareness of leprosy among the community showed that about 50% of those interviewed were aware of the campaign. Most of them had information about the availability of leprosy drugs and knew that treatment was free. A majority of those aware of the disease said that they would refer suspects, if they come across any, to PHC centres for treatment.

Evaluation of enzyme-linked immunosorbent assay for diagnosis of post-kala-azar dermal leishmaniasis with crude or recombinant k39 antigen.

The diagnosis of post-kala-azar dermal leishmaniasis (PKDL), a dermatosis that provides the only known reservoir for the parasite Leishmania donovani in India, remains a problem. Timely recognition and treatment of PKDL would contribute significantly to the control of kala-azar. We evaluated here the potential of the enzyme-linked immunosorbent assay (ELISA) as a diagnostic tool for PKDL. Antigen prepared from promastigotes and axenic amastigotes with parasite isolates that were derived from skin lesions of a PKDL patient gave sensitivities of 86.36 and 92%, respectively, in the 88 PKDL cases examined. The specificity of the ELISA test was examined by testing groups of patients with other skin disorders (leprosy and vitiligo) or coendemic infections (malaria and tuberculosis), as well as healthy controls from areas where this disease is endemic or is not endemic. A false-positive reaction was obtained in 14 of 144 (9.8%) of the controls with the promastigote antigen and in 14 of 145 (9.7%) of the controls with the amastigote antigen. Evaluation of the serodiagnostic potential of recombinant k39 by ELISA revealed a higher sensitivity (94.5%) and specificity (93.7%) compared to the other two antigens used. The data demonstrate that ELISA with crude or recombinant antigen k39 provides a relatively simple and less-invasive test for the reliable diagnosis of PKDL.

Analysis of quantitative relationship between viability determination in leprosy by MFP, ATP bioluminescence and gene amplification assay

Two hundred twenty-one untreated, borderline lepromatous/lepromatous (BL/LL) leprosy patients have been investigated for viability by the mouse foot pad method (MFP), adenosine triphosphate (ATP) and polymerase chain reaction (PCR). The biopsies were collected at the beginning of and 12/24 months after treatment. The patient group was treated with a) immunotherapy (BCG/Mw) + MDT; b) MDT + pyrazinamide; c) control MDT; d) MDT + minocycline 100 mg once a month supervised + ofloxacin 400 mg once a month supervised. Biopsies were divided in three parts for use in the mouse foot pad, molecular and ATP investigations. In untreated and treated patients (at 12 and 24 months), there was a general agreement among all three techniques, and PCR and ATP showed higher positivity as compared to MFP. Further, there was good correlation among the viable biomass estimated by bacillary ATP levels, PCR assay and growth in mouse foot pads. The positivity was observed by MFP as well as PCR assay (18-kDa and 36-kDa) from all of the specimens when the ATP content was more than 3.6 pg/million. When the ATP content was below 3.5 pg/million, the positive takes in MFP decreased but the PCR positivity correlated with ATP bioluminescence up to 0.04 pg/million. When the ATP content was even lower, the uptake in the MFP was possibly a matter of chance, while PCR positivity was observed in 96% of the cases. For specimens with undetectable ATP, positivity was seen in 1% of the cases, showing the inability of ATP bioluminescence method to detect low background due to host ATP. PCR signals in some cases could be due to the higher sensitivity of the method or persistence of DNA after bacterial death in some cases. On the whole, the PCR methods even though targeting DNA have shown good correlations with biomass which confirm their usefulness in monitoring therapeutic responses in leprosy.

What would make your life better? A needs analysis of leprosy settlements in the middle belt region of Nigeria.

A needs analysis using rural appraisal and matrix ranking techniques was done in six leprosy communities in the middle belt region of Nigeria. Asked 'what would make their life better?' whole village groups were made to list, prioritize and rank their expressed needs by voting in a matrix table drawn on the ground. Out of a total of 504 votes, 31% was for health care or drugs for their general ailments, 23.6% for money and less than 10% for other needs that ranged from water, trade and housing to love and, least, mobility aids. Health care was prioritized in all communities but got the highest votes in three communities, money got the highest in the only two communities where it was prioritized and water in one. The need ranked the highest in each settlement seemed to be a reflection of its peculiar socio-economic situation. Apart from the similar priorities of health care and money, men's differing priorities were water, housing, clothes and assistance with farming, and women's, school fees for children, family, trade and food. These reflect their different traditional roles. Considering the variety of needs we think that there is no one solution to rehabilitation in the Nigerian context, but the situation and context of individual settlements should be considered, looking at general health care, income generation or loans schemes, schooling and water supply.

Detection of viable organisms in leprosy patients treated with multidrug therapy.

Cutaneous biopsies were collected from multibacillary leprosy patients who attended the out-patient department of Jalma Institute for treatment at different time intervals, i.e. 6 months, 12 months, 18 months, 24 months, 30 months, 36 months and 42 months after starting multidrug therapy (MDT) when they were still skin smear positive. Biopsies were processed for inoculation into mouse foot pad (MFP) and estimation of bacillary ATP levels by bioluminescent assay (ATP assay) by earlier established procedures. Viable bacilli were detectable after 1 year (25% cases by MFP and 31% cases by ATP assay), 2 years (8% cases by MFP and 12% cases by ATP assay) and 3 years (4% cases by both MFP and ATP assays). Overall, the percentage of the persisters was 10% by MFP and 13% by ATP assay. It would be important to carry out surveillance studies in larger number of BL/LL cases to know the trends and also the resultant relapses.

Reanimation of the lagophthalmos using stainless steel weight implantation; a new approach and prospective evaluation.

Weight implants have been used for over 30 years in surgical rehabilitation following lagophthalmos. However, there has been a renewed interest among ophthalmologists in recent years. The weight implant technique combined with lateral canthus resuspension was performed on 22 eyes in Thai patients. It is a reliable method for correcting lagophthalmos and ectropion. In previous studies almost pure gold was used in 99.99% of eyelid implants. However, we wanted to use other materials which are not expensive and are readily available. A stainless steel plate was selected. The majority of our surgeries were done with a stainless steel weight implant of 1.368 g. Patients were followed for 7 to 55 months, and no rejections of the implants were observed. This study achieved a > or = 90% success rate, and showed that a stainless steel plate is an alternative to gold for the weight implant technique.

[Leprosy, an "exemplary" humanitarian disease?]. / La lèpre, maladie humanitairement "exemplaire"?

Leprosy still remains a dreaded disease despite the possibilities of permanent cure, the efficacy of surgical corrections, and its forthcoming disappearance. The authors conducted several surgical missions in Benin-Africa--over 4 years and report an interesting rate of control in the survey of patients as the results of their procedures were reviewed in 84% of them. Leprosy represents the perfect example of the difficulties of any humanitarian involvement with apparent contradictions between the aims of the medical wishes and the presence of a dreaded symbol that--fortunately or not--allow the existence of the many associations involved in the fight against leprosy.

Autoapheresis and intraoperative blood salvage in oncologic surgery.

Transfusion of predeposit or salvaged autologous blood has continued to grow since the 1980s. Issues such as the indications for use and cost effectiveness as well as the safety of autologous blood salvaged during cancer surgery have emerged and should be addressed. The concern for possible contamination of autologous RBC with cancer cells responsible for metastasis has limited the use of autologous salvaged blood in cancer patients. Nevertheless, clinical experience has been gained on the use of salvaged blood in patients with colorectal, gastric, renal, hepatic, breast, bladder and lung cancer. No evidence has been reported showing an increase in metastasis or a decrease in patient survival, in spite of the obvious demonstration that salvaged blood is contaminated with viable tumor cells which are not washed out of the RBC layer during intraoperative blood salvage (IOBS). However, a number of limitations have hampered the widespread use of IOBS in these patients and the technique is not well established. Increasing knowledge of the deleterious effects of allogeneic blood transfusion both in terms of the increased number of viral or bacterial infections and the down-regulation of the patient's immune system have recalled attention to IOBS and to the techniques such as filtration, which might reduce the risk of reinfusion of cancer cells, or totally eliminate the risks such as irradiation has been proposed by Hansen's group. This paper reviews the topic with some emphasis on our personal experience with gamma and X-ray irradiation of salvaged blood in a large reference hospital, where IOBS and filtration of salvaged blood were established for use in cancer patients in 1993 and 1996.

Evaluation of direct agglutination test (DAT) as an immunodiagnostic tool for diagnosis of visceral leishmaniasis in Nepal.

Before field application of the direct agglutination test (DAT) for leishmaniasis, it was assessed as a diagnostic tool. Fifteen confirmed visceral leishmaniasis cases (bone marrow aspiration positive), 120 tuberculosis, 58 leprosy, 15 malaria, 26 intestinal parasitic infection cases, 24 endemic healthy controls from adjacent to the study area, and 18 controls from Kathmandu (who had never visited the VL endemic areas) were tested for anti-leishmanial antibody agglutination titers. Two of the tuberculosis cases were positive for anti-leishmanial agglutinating antibodies at 1:800. All the visceral leishmaniasis confirmed cases were reactive to anti-leishmanial antibody at > or = 1:3,200. Other specimens were negative for serology. The sensitivity of the direct agglutination test was 100% and the specificity was 99.2%. The direct agglutination test had positive and negative predictive values of 100% and 99.2% respectively. The direct agglutination test has been found to be simple, rapid, reliable, economic, safe and adaptable to micro-techniques using microtiter plates. It is specific and sensitive. The direct agglutination test is simple enough for it to be performed in a field laboratory.