Legal intervention for non-adherent patients in the treatment of tuberculosis.

BACKGROUND: The Philadelphia Department of Public Health Tuberculosis (TB) Control Program has a progressively severe, stepwise legal process for managing non-adherent TB patients, potentially culminating in incarceration. OBJECTIVE: To review the application of legal procedures and to evaluate their effectiveness in the management of non-adherent TB patients. METHODS: We evaluated this process by reviewing patients' records from 2001 to 2005 to identify all non-adherent patients and determine their treatment outcomes. RESULTS: In this period, we initiated the legal process for 39 non-adherent patients. One patient died, and nine patients were lost. Twenty-nine patients became adherent after the use of a legal intervention. Our final completion percentage was 76.3%. CONCLUSION: Our legal process improved the treatment completion rate for patients who would otherwise have been non-adherent. Increasing treatment completion rates reduce the risk of relapse and disease transmission as well as the growing rate of anti-tuberculosis drug resistance.

Somatostatin receptor expression, tumour response, and quality of life in patients with advanced hepatocellular carcinoma treated with long-acting octreotide.

Octreotide may extend survival in hepatocellular carcinoma (HCC). Forty-one per cent of HCCs have high-affinity somatostatin receptors. We aimed to determine the feasibility, safety, and activity of long-acting octreotide in advanced HCC; to identify the best method for assessing somatostatin receptor expression; to relate receptor expression to clinical outcomes; and to evaluate toxicity. Sixty-three patients with advanced HCC received intramuscular long-acting octreotide 20 mg monthly until progression or toxicity. Median age was 67 years (range 28-81 years), male 81%, Child-Pugh A 83%, and B 17%. The aetiologies of chronic liver disease were alcohol (22%), viral hepatitis (44%), and haemochromatosis (6%). Prior treatments for HCC included surgery (8%), chemotherapy (2%), local ablation (11%), and chemoembolisation (6%). One patient had an objective partial tumour response (2%, 95% CI 0-9%). Serum alpha-fetoprotein levels decreased more than 50% in four (6%). Median survival was 8 months. Thirty four of 61 patients (56%) had receptor expression detected by scintigraphy; no clear relationship with clinical outcomes was identified. There were few grade 3 or 4 toxicities: hyperglycaemia (8%), hypoglycaemia (2%), diarrhoea (5%), and anorexia (2%). Patients reported improvements in some symptoms, but no major changes in quality of life were detected. Long-acting octreotide is safe in advanced HCC. We found little evidence of anticancer activity. A definitive randomised trial would identify whether patients benefit from this treatment in other ways.

Depression in the elderly living in the community. Its presentation and features.

A prevalence of depression of 13% was found among 139 coloured persons aged 65 years and over, living in the community in Cape Town, which accords with figures elsewhere. A high rate of hypochondriasis was found, but there was a low rate of suicidal intent, which could be explained by good social support. Observed depression and a depressed mood occurred in almost all depressed patients; as defined in the Present State Examination, these items appear to be an excellent screen for depression.

Depression in schizophrenia: a study of prevalence and treatment.

In an investigation of white, coloured, and black patients admitted to a psychiatric hospital, the prevalence and treatment of depression in schizophrenia was assessed and found to be 30% in group of acute, nuclear schizophrenics. While the prevalence was similar in the three groups, depression was clinically under-detected in black patients.

The rise in readmissions to psychiatric hospitals.

The progressive increase in readmissions to psychiatric hospitals in South Africa is causing concern. Readmissions now amount to 42% of total admissions, and in some cases their number exceeds that of first admissions. The phenomenon has been identified as occurring overwhelmingly among short-stay patients. Factors associated with readmissions have been examined as the first part of an ongoing investigation. Among these are a decline in available beds, an increasing shortage of psychiatric staff, differing readmission rates for different population groups, and the tendency of certain types of psychiatric disorders to relapse more frequently (schizophrenia and affective illness). The inability of the present psychiatric outpatient and community services to lower the readmission rate has been demonstrated. Factors which may have a bearing on the situation such as socio-economic conditions, substance abuse, compliance with medication and rehabilitative services are discussed.