ABSTRACT
BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.
Subject(s)
Antitubercular Agents , Tuberculosis, Multidrug-Resistant , Adult , Antitubercular Agents/therapeutic use , Hospitalization , Hospitals , Humans , Pakistan , Tuberculosis, Multidrug-Resistant/drug therapyABSTRACT
The Forensic Algorithm Project (FAP) was born of the need for a holistic approach in the treatment of the inmate with schizophrenia. Schizophrenia was chosen as the first entity to be addressed by the algorithm because of its refractory nature and high rate of recidivism in the correctional setting. Schizophrenia is regarded as a spectrum disorder, with symptom clusters and behaviors ranging from positive to negative symptoms to neurocognitive dysfunction and affective instability. Furthermore, the clinical picture is clouded by Axis II symptomatology (particularly prominent in the inmate population), comorbid Axis I disorders, and organicity. Four subgroups of schizophrenia were created to coincide with common clinical presentations in the forensic inpatient facility and also to parallel 4 tracks of intervention, consisting of pharmacologic management and programming recommendations. The algorithm begins with any antipsychotic medication and proceeds to atypical neuroleptic usage, augmentation with other psychotropic agents, and, finally, the use of clozapine as the common pathway for refractory schizophrenia. Outcome measurement of pharmacologic intervention is assessed every 6 weeks through the use of a 4-item subscale, specific for each forensic subgroup. A "floating threshold" of 40% symptom severity reduction on Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale items over a 6-week period is considered an indication for neuroleptic continuation. The forensic algorithm differs from other clinical practice guidelines in that specific programming in certain prison environments is stipulated. Finally, a social commentary on the importance of state-of-the-art psychiatric treatment for all members of society is woven into the clinical tapestry of this article.
Subject(s)
Algorithms , Forensic Psychiatry/methods , Prisons/methods , Psychotropic Drugs/therapeutic use , Schizophrenia/drug therapy , Ambulatory Care , Clozapine/administration & dosage , Clozapine/therapeutic use , Crisis Intervention , Decision Trees , Hospitalization , Humans , Mental Disorders/drug therapy , Outcome Assessment, Health Care , Patient Care Planning , Patient Compliance , Prisoners/psychology , Psychiatric Status Rating Scales/statistics & numerical data , Psychotropic Drugs/administration & dosage , Schizophrenia/diagnosis , Schizophrenic PsychologyABSTRACT
We collected daily urine volumes (DUV) from 24 nonpolydipsic psychiatric patients and eight polydipsic schizophrenic patients. At 7 AM and 4 PM, we collected spot urine samples and measured urine creatinine concentration (UCr). Using morning weight and the UCr measurements, we compared actual DUV with estimated DUV using 3 methods to estimate DUV currently available in the literature. Each method of estimating DUV was superior among the polydipsic patients compared with the nonpolydipsic patients. We discuss the strengths and weaknesses of trying to estimate DUV in psychiatric patients. One method was simple but less accurate. The two remaining methods gave similar results but one method was substantially easier to use than the other.
Subject(s)
Behavioral Symptoms/diagnosis , Drinking Behavior , Polyuria/diagnosis , Schizophrenia/complications , Water Intoxication/prevention & control , Antimanic Agents/adverse effects , Body Weight , Case-Control Studies , Circadian Rhythm , Creatinine/urine , Drinking/physiology , Drinking Behavior/classification , Humans , Lithium/adverse effects , Longitudinal Studies , Male , Middle Aged , Monitoring, Physiologic/methods , Monitoring, Physiologic/standards , Polyuria/etiology , Reproducibility of Results , UrineABSTRACT
The Wellcolex Colour Salmonella and Shigella tests are rapid latex agglutination procedures for grouping Salmonella and Shigella using an antibody attached to multicolored latex particles. The tests correctly grouped 46 (100%) of 46 Salmonella clinical isolates in groups A through E and G, 42 (100%) of 42 Shigella clinical isolates, and seven (88%) of eight Shigella stock cultures. The stock culture missed had been passed through many transfers and may have lost some of its antigenicity. The Wellcolex Colour Salmonella test was also found useful in detecting and grouping Salmonella spp. directly from blood culture bottles.
