The power of vivid experience in hand hygiene compliance.

In recent years, explicit behavioural theories have been used in some research into hand hygiene behaviour. One of the most prominent of these has been the theory of planned behaviour (TPB). In this qualitative study aimed at increasing understanding of infection prevention practice in the acute care setting, TPB was identified as a suitable framework for the emergence of new insights that have the potential to improve the power of existing education and training. The theory emerging from the research was based on a finding that individual experience is of greater import than formal education in explaining hand hygiene behaviour. This indicated that exposure to vivid vicarious experience is a potential means to improving the power of existing training methods and increasing the propensity for instilling sustainable adequate hand hygiene habits.

Heterogeneity in the spatial distribution of bacterial sexually transmitted infections.

OBJECTIVES: Detailed knowledge of the spatial distribution of disease is required to inform service delivery and plan effective interventions. In order to elucidate the spatial epidemiology of three common sexually transmitted infections (STI) further, any significant spatiotemporal clustering of gonorrhoea, chlamydia or syphilis cases in New South Wales (NSW) was detected and described. METHODS: Eleven years of notified STI case data were analysed. Calculation of age and sex-stratified incidence rates was followed by spatiotemporal cluster analyses to investigate differences in the epidemiology of gonorrhoea, chlamydia and syphilis. RESULTS: More than one-third of all gonorrhoea, chlamydia and syphilis cases in NSW were detected within cluster areas. Gonorrhoea cases were the most highly clustered, followed by syphilis, then chlamydia. Clusters were highly significant and relative risk estimates ranged from 1.6 to 22.9. CONCLUSION: The findings establish the high degree of geographical heterogeneity in STI incidence in NSW and indicate that the postal area of residence is an important predictor of STI incidence. Geographical surveillance could be incorporated into routine STI surveillance to identify populations in need of intervention. The evidence presented in this report indicates a need to implement geography-specific and phase-appropriate STI prevention and control strategies.

Joining the DOTS in Bali: private practitioners' perceptions of tuberculosis control.

SETTING: The Indonesian island of Bali has both a national public tuberculosis (TB) programme and a significant private sector that provides treatment for patients with TB. OBJECTIVE: To explore private practitioners' perceptions of barriers to the treatment of patients with TB in Bali to inform strategies for future programme development. DESIGN: Semi-structured interviews were conducted with private practitioners who treated TB patients in their private practice. RESULTS: The main barriers to improved TB control in Bali identified by private practitioners reflect difficulties encountered within the following four areas: patient nonadherence to treatment, limitations of public services, public-private integration and limitations of private services. Private practitioners identified the need for improvements in the level of community education regarding TB, the degree of public-private interaction, the quality of diagnostic services and practitioner access to training. CONCLUSION: This study identified both strengths and weaknesses for TB control in the private sector, as well as considerable variations in perceptions and practice among private practitioners. The development of strategies to address these difficulties and utilise the inherent strengths of both public and private practitioners will be essential for improved service provision and TB control in Bali.

Does smoking explain sex differences in the global tuberculosis epidemic?

To date there has been no satisfactory explanation of the worldwide excess of tuberculosis (TB) notifications among adult males. We investigated the epidemiological basis for sex differences in TB notifications in high-burden countries using available group-level data. Multiple linear regression analysis was used to explore the ecological relationship between smoking and sex differences in TB notifications among high-burden countries. Cigarette consumption was a significant predictor of the sex ratio of TB notifications, and explained 33% of the variance in the sex ratio of TB notifications. Our findings suggest that smoking is an important modifiable factor which has a significant impact on the global epidemiology of TB, and emphasize the importance of tobacco control in countries with a high incidence of TB. This analysis provides support for the interpretation of sex differences in worldwide TB notification rates as indicative of true differences in the epidemiology of TB between males and females.

The association between subjective and clinical indicators of health in prospective Vietnamese migrants.

We conducted a cross-sectional survey of 1669 prospective Vietnamese migrants who had applied to migrate to Australia to describe the association between self-reported health status and several commonly used clinical indicators of health among prospective Vietnamese migrants. Participants were recruited from the International Organization for Migration's standardised medical screening program.' We found that clinical indicators of health are related to self-reported health status among prospective Vietnamese migrants. Self-reported health status, which was assessed using a modified version of the Short Form-36 health survey, was significantly associated with clinical indicators of health, including the number of body system abnormalities identified during medical screening, evidence of tuberculosis on chest radiograph, and self-reported weight loss over the previous six months. These findings support the validity of self-reported health status assessment among prospective migrants, although the assessment of subjective indicators of health during compulsory medical screening may be limited by reporting bias.

Results of tuberculosis screening in applicants for migration in Vietnam and Cambodia.

SETTING: Pre-migration medical screening programmes in Ho Chi Minh City, Vietnam and Phnom Penh, Cambodia. OBJECTIVE: To compare the rates of newly diagnosed bacteriologically confirmed tuberculosis (TB) in a cohort of migration applicants in Vietnam and Cambodia with current estimates of the TB burden in these countries. DESIGN: Interviews and medical screening of 5108 Vietnamese and 910 Cambodian migration applicants who applied for an Australian visa. RESULTS: On initial testing, the rate of bacteriologically confirmed TB among the Vietnamese cohort was 157 per 100,000 population compared to 989/100,000 among the Cambodian cohort. When cases detected during follow-up testing were included, the rate in the Vietnamese cohort was 489/100,000 compared to 1209/100,000 in the Cambodian cohort. CONCLUSIONS: Although it has been suggested that the rate of newly diagnosed bacteriologically confirmed TB among migration applicants would underestimate the prevalence of TB in the Vietnamese and Cambodian populations, the rates found were substantially higher than current point estimates of the prevalence of TB, particularly for Vietnam. Our findings suggest that current published estimates of the tuberculosis burden in Vietnam and Cambodia may be conservative.

Clinic staff perceptions of tuberculosis treatment delivery in Bali.

A number of studies have investigated patient perceptions of tuberculosis (TB) treatment delivery, but few have systematically investigated the perceptions of clinic staff. We therefore conducted individual interviews using Q-methodology with 25 staff directly involved in the delivery of TB treatment services in 18 different public sector health centres in Bali. Factor analysis was used to identify shared perceptions of TB treatment delivery in Bali among the sample studied. Three distinct perspectives emerged, indicating that all staff do not have shared understandings of difficulties and priorities in TB treatment. The main areas of difference in staff perceptions concerned the existence of barriers to treatment and the focus on the community context of TB treatment. The demonstrated variation in the perceptions of TB treatment delivery in Bali has important implications for the design of strategies to improve treatment delivery and the control of TB.

Tuberculosis treatment delivery in Bali: a qualitative study of clinic staff perceptions.

SETTING: Little is known about the challenges of delivering tuberculosis (TB) treatment in Indonesia's southern province of Bali. OBJECTIVE: We aimed to explore staff perceptions of TB treatment delivery and barriers to improved TB control in Bali to inform strategies for programme development. DESIGN: Semi-structured interviews were conducted with staff who were involved in the delivery of TB treatment services in the public sector. RESULTS: The main issues perceived by staff to influence TB treatment delivery include: the low level of community awareness of TB; delays to treatment seeking and the frequent use of private treatment providers; diagnostic difficulties; non-adherence to treatment; and a low level of staff education specific to TB. CONCLUSION: Staff perceived a number of significant barriers to the early diagnosis and successful treatment of TB in Bali. The development of strategies to address these identified difficulties in TB control is essential to support improved programme effectiveness and enhanced TB control in Bali.

Tuberculosis rates among migrants in Australia and Canada.

Multiple linear regression analysis was used to compare the regression coefficients for Australia and Canada on the association between tuberculosis (TB) rates among migrants and the estimated incidence in the country of birth. Regression coefficients predicting the rate of TB among migrants based on the incidence of TB in the country of birth are not significantly different between populations of migrants in Australia and Canada. Our findings support the ability of the incidence of TB in the country of birth to predict variation in the incidence of TB in migrants groups in two migration receiving countries. This information can be used to focus TB treatment and prevention efforts towards high-risk groups.

Predictors of tuberculin reactivity among prospective Vietnamese migrants: the effect of smoking.

We investigated the prevalence and predictors of positive tuberculin skin test (TST) results among prospective Vietnamese migrants. We interviewed and medically screened 1395 Vietnamese people aged over 15 years who had applied to migrate to Australia. Approximately 44% of applicants had an induration of 10 mm or more, and 18.6% had an induration of 15 mm or more. A positive tuberculin skin test at 5 mm, 10 mm and 15 mm of induration cut-points was significantly associated with age (OR 1.01-1.02 per year) and duration of smoking (OR 1.03-1.12 per year). Smoking appears to be an important factor associated with increased susceptibility to mycobacterial infection. It is not yet clear whether the increased tuberculin reactivity associated with smoking reflects an increased risk of tuberculosis among these migrants.

Predicting tuberculosis among migrant groups.

In industrialized countries migrants remain a high-risk group for tuberculosis (TB). Multiple linear regression analysis was used to determine the ability of indicators of TB incidence in the country of birth to predict the incidence of TB among migrants in Australia during 1997. World Health Organization total case notifications, new smear-positive case notifications and the estimated incidence of TB by country of birth explained 55, 69 and 87% of the variance in TB incidence in Australia, respectively. Gross national income of the country of birth and unemployment level in Australia were also significant predictors of TB in migrant groups. Indicators of the incidence of TB in the country of birth are the most important group-level predictors of the rate of TB among migrants in Australia.

The human nuclear xenobiotic receptor PXR: structural determinants of directed promiscuity.

The human nuclear pregnane X receptor (hPXR) activates cytochrome P450-3A expression in response to a wide variety of xenobiotics and plays a critical role in mediating dangerous drug-drug interactions. We present the crystal structures of the ligand-binding domain of hPXR both alone and in complex with the cholesterol-lowering drug SR12813 at resolutions of 2.5 and 2.75 angstroms, respectively. The hydrophobic ligand-binding cavity of hPXR contains a small number of polar residues, permitting SR12813 to bind in three distinct orientations. The position and nature of these polar residues were found to be critical for establishing the precise pharmacologic activation profile of PXR. Our findings provide important insights into how hPXR detects xenobiotics and may prove useful in predicting and avoiding drug-drug interactions.

Tuberculin reactivity and the risk of tuberculosis: a review.

SETTING: Although various studies have examined the association between tuberculin reactivity and the risk of tuberculosis (TB), this evidence has not been collated and examined to determine the strength and consistency of the association across multiple studies. OBJECTIVE: To review the evidence supporting the association between tuberculin reactivity and the risk of TB. DESIGN: Prospective studies which included raw data on the incidence of TB according to three or more tuberculin reactor categories were located using electronic search methods. The findings of these studies were recalibrated if necessary and compared. RESULTS: All 11 studies identified demonstrated that increased tuberculin skin test (TST) reactivity was associated with an increased risk of TB, and several found that low tuberculin reactivity was associated with a protective effect. The magnitude of the association between TST reactivity and the risk of TB varied substantially. The association between tuberculin reactivity and the risk of TB was greater among studies that reported a lower incidence of TB among the smallest tuberculin reactor category. CONCLUSION: All studies reviewed support a positive association between tuberculin reactivity and the risk of TB. However, this review found a substantial degree of variation in the extent of increased risk associated with larger tuberculin reactions.

Development of a Vietnamese version of the Short form-36 Health Survey.

We aimed to test the psychometric properties of a culturally relevant translation of the medical outcomes study short form-36 health survey (SF-36) with prospective Vietnamese migrants. The translated survey was interviewer-administered to 1610 Vietnamese aged over 15 years who had applied to migrate to Australia. All but two SF-36 items had good discriminant validity, and all eight scales of the Vietnamese version of the SFS-36 had good discriminant validity, which supports the use of SF-36 constructs to assess self-reported health status among Vietnamese migrants. However, the mental health, vitality and bodily pain scales demonstrated low internal consistency. This finding is likely to be a product of the increased diversity among scale items following modifications to improve cultural relevance. Further modifications to improve the internal consistency of these scales are required.

Measurement of aging anxiety in an elderly Australian population.

The purpose of this investigation was to modify an existing aging anxiety scale to produce an instrument specifically designed to assess aging anxiety in an elderly population. Existing instruments fail to consistently orientate aging associated threats into the future, and this poses a significant problem for the measurement of aging anxiety in the elderly population. It is proposed that this factor has confounded reports of the relationship between aging anxiety and advancing age. An existing valid and reliable instrument, the Anxiety about Aging Scale was modified for use with elderly respondents and tested on 123 independent community dwelling elderly individuals. The results indicated the modified scale provides a valid assessment of aging anxiety in the elderly.

Nitroglycerin injection manufactured by a hospital pharmacy.

A method used by a hospital pharmacy department for manufacturing and testing a ready-to-administer i.v. nitroglycerin injection is described, and costs for this extemporaneously prepared injection are compared with costs for commercially available nitroglycerin products for i.v. use. A powder adsorbate containing one part nitroglycerin and nine parts lactose was used to prepare nitroglycerin injection in two strengths: 0.04 mg/mL (250-mL quantities) in 0.9% sodium chloride injection and 0.4 mg/mL (400-mL quantities) in 5% dextrose injection. Each batch was tested for sterility, for presence of pyrogens (endotoxin testing), and for nitroglycerin concentration (spectrophotometric assay). In one year, a total of 1217 bottles of nitroglycerin injection were prepared. This required 75 hours; preparation from commercial i.v. nitroglycerin products would have required approximately 200 hours (including admixture preparation). First-year costs for extemporaneous preparation (excluding costs of i.v. solutions and containers) were approximately $2200, far less than drug costs alone for the commercial i.v. nitroglycerin products. Nitroglycerin injection of high quality and confirmed potency was prepared extemporaneously in a hospital pharmacy department. Costs for this method were substantially less than those for use of commercial i.v. nitroglycerin products.