Latent Tuberculosis Infection and Associated Factors among Health Care Workers in Kigali, Rwanda.

INTRODUCTION: Data are limited regarding tuberculosis (TB) and latent TB infection prevalence in Rwandan health facilities. METHODS: We conducted a cross-sectional survey among healthcare workers (HCWs) in Kigali during 2010. We purposively selected the public referral hospital, both district hospitals, and randomly selected 7 of 17 health centers. School workers (SWs) from the nearest willing public schools served as a local reference group. We tested for latent TB infection (LTBI) using tuberculin skin testing (TST) and asked about past TB disease. We assessed risk of LTBI and past history of TB disease associated with hospital employment. Among HCWs, we assessed risk associated with facility type (district hospital, referral hospital, health center), work setting (inpatient, outpatient), and occupation. RESULTS: Age, gender, and HIV status was similar between the enrolled 1,131 HCWs and 381 SWs. LTBI was more prevalent among HCWs (62%) than SWs (39%). Adjusted odds of a positive TST result were 2.71 (95% CI 2.01-3.67) times greater among HCWs than SWs. Among HCWs, there was no detectable difference between prevalence of LTBI according to facility type, work setting, or occupation. CONCLUSION: HCWs are at greater risk of LTBI, regardless of facility type, work setting, or occupation. The current status of TB infection control practices should be evaluated in the entire workforce in all Rwandan healthcare facilities.

Medication-related cognitive artifacts used by older adults with heart failure.

OBJECTIVE: To use a human factors perspective to examine how older adult patients with heart failure use cognitive artifacts for medication management. METHODS: We performed a secondary analysis of data collected from 30 patients and 14 informal caregivers enrolled in a larger study of heart failure self-care. Data included photographs, observation notes, interviews, video recordings, medical record data, and surveys. These data were analyzed using an iterative content analysis. RESULTS: Findings revealed that medication management was complex, inseparable from other patient activities, distributed across people, time, and place, and complicated by knowledge gaps. We identified fifteen types of cognitive artifacts including medical devices, pillboxes, medication lists, and electronic personal health records used for: 1) measurement/evaluation; 2) tracking/communication; 3) organization/administration; and 4) information/sensemaking. These artifacts were characterized by fit and misfit with the patient's sociotechnical system and demonstrated both advantages and disadvantages. We found that patients often modified or "finished the design" of existing artifacts and relied on "assemblages" of artifacts, routines, and actors to accomplish their self-care goals. CONCLUSIONS: Cognitive artifacts are useful but sometimes are poorly designed or are not used optimally. If appropriately designed for usability and acceptance, paper-based and computer-based information technologies can improve medication management for individuals living with chronic illness. These technologies can be designed for use by patients, caregivers, and clinicians; should support collaboration and communication between these individuals; can be coupled with home-based and wearable sensor technology; and must fit their users' needs, limitations, abilities, tasks, routines, and contexts of use.

Crowdsourcing participatory evaluation of medical pictograms using Amazon Mechanical Turk.

BACKGROUND: Consumer and patient participation proved to be an effective approach for medical pictogram design, but it can be costly and time-consuming. We proposed and evaluated an inexpensive approach that crowdsourced the pictogram evaluation task to Amazon Mechanical Turk (MTurk) workers, who are usually referred to as the "turkers". OBJECTIVE: To answer two research questions: (1) Is the turkers' collective effort effective for identifying design problems in medical pictograms? and (2) Do the turkers' demographic characteristics affect their performance in medical pictogram comprehension? METHODS: We designed a Web-based survey (open-ended tests) to ask 100 US turkers to type in their guesses of the meaning of 20 US pharmacopeial pictograms. Two judges independently coded the turkers' guesses into four categories: correct, partially correct, wrong, and completely wrong. The comprehensibility of a pictogram was measured by the percentage of correct guesses, with each partially correct guess counted as 0.5 correct. We then conducted a content analysis on the turkers' interpretations to identify misunderstandings and assess whether the misunderstandings were common. We also conducted a statistical analysis to examine the relationship between turkers' demographic characteristics and their pictogram comprehension performance. RESULTS: The survey was completed within 3 days of our posting the task to the MTurk, and the collected data are publicly available in the multimedia appendix for download. The comprehensibility for the 20 tested pictograms ranged from 45% to 98%, with an average of 72.5%. The comprehensibility scores of 10 pictograms were strongly correlated to the scores of the same pictograms reported in another study that used oral response-based open-ended testing with local people. The turkers' misinterpretations shared common errors that exposed design problems in the pictograms. Participant performance was positively correlated with their educational level. CONCLUSIONS: The results confirmed that crowdsourcing can be used as an effective and inexpensive approach for participatory evaluation of medical pictograms. Through Web-based open-ended testing, the crowd can effectively identify problems in pictogram designs. The results also confirmed that education has a significant effect on the comprehension of medical pictograms. Since low-literate people are underrepresented in the turker population, further investigation is needed to examine to what extent turkers' misunderstandings overlap with those elicited from low-literate people.

Precontoured superior locked plating of distal clavicle fractures: a new strategy.

BACKGROUND: The ideal management of fractures of the distal third of the clavicle remains a topic of debate. Locked plating is a new treatment method but is not yet widely studied. QUESTIONS/PURPOSES: We therefore determined union rates, function, and complications treated with locked plating. PATIENTS AND METHODS: We retrospectively reviewed 20 patients with Neer Type II distal clavicle fractures. All patients were treated with superior locked plating augmented with suture cerclage or screw fixation into the coracoid when there were concerns with screw purchase in the lateral fragment. Union was assessed radiographically and function was reported in terms of American Shoulder and Elbow Surgeons (ASES) scores and motion. Sixteen of 20 patients were followed for a minimum of 1 year; four of the patients with less than 1 year followup were included only for reporting of complications. The 16 patients were followed a minimum of 12 months (average, 30.7 months; range, 13-87 months). RESULTS: Union occurred in 15 of 16 (94%) patients. Average forward elevation and external rotation were 165.6° (range, 115°-180°) and 58.8° (range, 20°-90°), respectively. The average ASES score at the most recent followup was 79.0 (range, 33.3-100). Complications occurred in two patients. One patient developed an infected nonunion and a second patient sustained a peri-implant fracture. CONCLUSIONS: Acute unstable distal clavicle fractures can be treated with superior locking plates with union rates, ASES scores, and ROM that are comparable to similar studies in the literature. The treatment method described allows supplemental fixation such as suture augmentation or a coracoclavicular screw. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.