Integrating tuberculosis and mental health services: global receptivity of national tuberculosis program directors.

A global survey of National Tuberculosis Program (NTP) directors. To assess the perceived mental health needs of persons with tuberculosis (TB), current practices, and receptivity to integrating evidence-based mental and substance use treatment into national TB guidelines. Semi-structured survey of NTP directors from 26 countries of all income levels using a standardized questionnaire. Of the 26 countries, 21 were classified as high incidence and/or burden countries for TB, TB and human immunodeficiency virus coinfection, and/or drug-resistant TB. Two NTPs included routine screening for any mental disorder, four assessed alcohol or drug use, and five had standard protocols for the co-management of disorders. If effective and low-cost integrated care models were available, 17 NTP directors felt that it was highly likely, and five somewhat likely, that their NTPs would integrate mental health treatment into national TB guidelines and services. The main perceived barriers to service integration were limited capacity, not recognizing mental health as a problem, insufficient resources, and TB-related social stigma. NTPs currently do not address mental disorders as part of routine practice. Nevertheless, receptivity is high, which creates a ripe opportunity to integrate the management of TB and mental disorders into the policies and guidelines of NTPs worldwide. .

Building the capacity of public health programmes to become data rich, information rich and action rich.

Good quality, timely data are the cornerstone of health systems, but in many countries these data are not used for evidence-informed decision making and/or for improving public health. The SORT IT (Structured Operational Research and Training Initiative) model has, over 8 years, trained health workers in low- and middle-income countries to use data to answer important public health questions by taking research projects through to completion and publication in national or international journals. The D2P (data to policy) training initiative is relatively new, and it teaches health workers how to apply 'decision analysis' and develop policy briefs for policy makers: this includes description of a problem and the available evidence, quantitative comparisons of policy options that take into account predicted health and economic impacts, and political and feasibility assessments. Policies adopted from evidence-based information generated through the SORT IT and D2P approaches can be evaluated to assess their impact, and the cycle repeated to identify and resolve new public health problems. Ministries of Health could benefit from this twin-training approach to make themselves 'data rich, information rich and action rich', and thereby use routinely collected data in a synergistic manner to improve public health policy making and health care delivery.

Des données de bonne qualité et disponibles rapidement sont la pierre angulaire des systèmes de santé, mais dans de nombreux pays ces données ne sont pas utilisées pour les prises de décision fondées sur des preuves et/ou pour améliorer la santé publique. Le modèle SORT IT (Structured Operational Research and Training Initiative) a, en 8 années, formé le personnel de santé des pays à revenu faible et moyen à l'utilisation des données pour répondre à d'importantes questions de santé publique en amenant les projets de recherche jusqu'à leur achèvement et à la publication dans des revues nationales ou internationales. L'initiative de formation D2P (données pour la politique) est relativement nouvelle et forme le personnel de santé à la manière d'appliquer l'analyse de décision et à l'élaboration d'énoncés de politiques à l'intention des décideurs politiques : ceci inclut la description d'un problème et les preuves disponibles, une comparaison quantitative des options de politique qui tiennent compte des impacts prédits en matière de santé et d'économie, et une évaluation de politique et de faisabilité. Les politiques adoptées à partir d'informations basées sur des preuves générées grâce aux approches SORT IT et de D2P peuvent être évaluées en termes d'impact, et le cycle répété afin d'identifier et de résoudre de nouveaux problèmes de santé publique. Les ministres de la santé pourraient bénéficier de cette approche de formation double afin qu'ils soient « riches de données, riches d'information et riches d'action ¼, et donc utiliser les données recueillies en routine d'une manière synergique afin d'améliorer les choix en matière de politique de santé publique et de prestation des soins de santé.

La buena calidad de los datos y su puntualidad constituyen los pilares de los sistemas de salud, pero en muchos países esta información no se utiliza con el fin de orientar la toma de decisiones basadas en la evidencia o mejorar la salud pública. El modelo de Investigación Operativa Estructurada e Iniciativa para la Formación (SORT IT) se ha aplicado durante más de 8 años en la capacitación de los profesionales de salud de países de ingresos bajos y medianos, en materia de aplicación de los datos para resolver importantes preguntas de salud pública, al acompañar los proyectos de investigación hasta su finalización y publicación en revistas de ámbito nacional o internacional. La iniciativa de formación D2P (de los datos a las políticas) es relativamente nueva e instruye a los trabajadores de salud sobre la forma de aplicar el 'análisis decisional' y formular documentos normativos destinados a las instancias decisorias; la iniciativa comprende la descripción de un problema y la evidencia disponible, una comparación cuantitativa de las opciones normativas que tiene en cuenta las repercusiones de salud y económicas previstas y una evaluación política y de factibilidad. Es posible evaluar las políticas adoptadas a partir de información basada en la evidencia científica generada por conducto de las estrategias SORT IT y D2P con el propósito de analizar su repercusión y se puede repetir el ciclo a fin de detectar y resolver nuevos problemas de salud pública. Los ministerios de salud pueden aprovechar este enfoque doble de capacitación con el objeto de alcanzar una situación de 'riqueza de datos, de información y de acción' y aplicar sinérgicamente los datos recogidos de manera sistemática con miras a optimizar la toma de decisiones de salud pública y la prestación de los servicios de salud.

Addressing the tuberculosis-depression syndemic to end the tuberculosis epidemic.

Tuberculosis (TB) and depression act synergistically via social, behavioral, and biological mechanisms to magnify the burden of disease. Clinical depression is a common, under-recognized, yet treatable condition that, if comorbid with TB, is associated with increased morbidity, mortality, community TB transmission, and drug resistance. Depression may increase risk of TB reactivation, contribute to disease progression, and/or inhibit the physiological response to anti-tuberculosis treatment because of poverty, undernutrition, immunosuppression, and/or negative coping behaviors, including substance abuse. Tuberculous infection and/or disease reactivation may precipitate depression as a result of the inflammatory response and/or dysregulation of the hypothalamic-pituitary-adrenal axis. Clinical depression may also be triggered by TB-related stigma, exacerbating other underlying social vulnerabilities, and/or may be attributed to the side effects of anti-tuberculosis treatment. Depression may negatively impact health behaviors such as diet, health care seeking, medication adherence, and/or treatment completion, posing a significant challenge for global TB elimination. As several of the core symptoms of TB and depression overlap, depression often goes unrecognized in individuals with active TB, or is dismissed as a normative reaction to situational stress. We used evidence to reframe TB and depression comorbidity as the 'TB-depression syndemic', and identified critical research gaps to further elucidate the underlying mechanisms. The World Health Organization's Global End TB Strategy calls for integrated patient-centered care and prevention linked to social protection and innovative research. It will require multidisciplinary approaches that consider conditions such as TB and depression together, rather than as separate problems and diseases, to end the global TB epidemic.

Whole effluent risk estimation for a small recipient watercourse.

Whole effluent toxicity is most often considered as a static parameter. However, toxicity might change as degradation processes, especially biodegradation goes by and intermediate products appear. These intermediates can even be more toxic than the original effluent was, posing higher risk to the ecosystem of the recipient water body. In our test series it was assessed how toxicity of a municipal wastewater sample changes during biodegradation taking into consideration different temperature regimes (10, 20 and 30 degrees C). Results proved our null hypothesis: after the high initial toxicity of the fresh effluent sample toxicity did show a further increase. Biodegradation resulted in toxicity reduction only after an approx. 2 week-period.

Engineering mixed states in a degenerate four-state system.

A method is proposed for preparing any pure and wide class of mixed quantum states in the decoherence-free ground-state subspace of a degenerate multilevel lambda system. The scheme is a combination of optical pumping and a series of coherent excitation processes, and for a given pulse sequence the same final state is obtained regardless of the initial state of the system. The method is robust with respect to the fluctuation of the pulse areas, as in adiabatic methods; however, the field amplitude can be adjusted in a larger range.

Subcutaneous phaeohyphomycotic abscess caused by Pleurophomopsis lignicola.

A 41-year-old man with a past medical history of diabetes mellitus type II, AIDS (diagnosed 2 years earlier; CD4 count < 10), peripheral neuropathy, and pulmonary tuberculosis of 2 years duration was admitted to the hospital with abnormal liver function tests. There was a chronic hepatitis/cholestasis that had worsened while the patient was undergoing directly observed tuberculosis therapy. On admission, the patient complained of a painful swelling on his right arm. In the posterior aspect of the arm, there was a 3-4-cm subcutaneous mass that was fluctuant, mobile and tender. Incision of the mass released yellowish pus mixed with blood. Direct examination of the pus in KOH mounts and Gram-stained smears revealed subhyaline, septate, branched hyphae. When the pus was cultured on Sabouraud dextrose agar containing chloramphenicol, several velvety, olivaceous grey colonies grew after 7 days at 25 degrees C. When grown on oatmeal agar, the fungus produced subglobose, rostrate pycnidia with phialidic conidiogenous cells, and 1-celled cylindrical conidia. It was identified as Pleurophomopsis lignicola Petrak. This report describes the third known case of subcutaneous infection caused by P. lignicola in an immunocompromized patient.

New York City syndromic surveillance systems.

New York City's first syndromic surveillance systems were established in 1995 to detect outbreaks of waterborne illness. In 1998, daily monitoring of ambulance dispatch calls for influenza-like illness began. After the 2001 World Trade Center attacks, concern about biologic terrorism led to the development of surveillance systems to track chief complaints of patients reporting to emergency departments, over-the-counter and prescription pharmacy sales, and worker absenteeism. These systems have proved useful for detecting substantial citywide increases in common viral illnesses (e.g., influenza, norovirus, and rotavirus). However, the systems have not detected more contained outbreaks earlier than traditional surveillance. Future plans include monitoring school health and outpatient clinic visits, augmenting laboratory testing to confirm syndromic signals, and conducting evaluation studies to identify which of these systems will be continued for the long term.

Needs assessment of the displaced population following the August 1999 earthquake in Turkey.

In August 1999 a major earthquake struck north-western Turkey. An assessment followed to identify the immediate needs of the displaced population. A random cluster sample of displaced families living in temporary shelter outside of organised relief camps was designed. Representatives of 230 households from the four communities worse affected by the earthquake were interviewed. Most families lived in makeshift shelters (84 per cent), used bottled water (91 per cent), obtained food from relief organisations (61 per cent), had access to latrines (90 per cent), had a member on routine medication (53 per cent) and obtained information by word of mouth (81 per cent). Many respondents reported having family members who were over the age of 65 (32 per cent) or under age three (20 per cent), who were pregnant (6 per cent), or who had been ill since the earthquake (64 per cent). The greatest immediate need reported by most families was shelter requirements (37 per cent), followed by food (23 per cent) and hygiene requirements (19 per cent). Ten days after the earthquake, basic environmental health needs of food, shelter and hygiene still predominated in this displaced population. Significant portions may have special needs due to age or illness.

Clinical manifestations of psychiatric patients who are carriers of tay-sachs disease. Possible role of psychotropic drugs.

Patients with late-onset Tay-Sachs disease (TSD) may manifest with neuropsychiatric features. We hypothesized that the prevalence of TSD carriers in psychiatric patients is higher than in the general population and their clinical profile is different from that of their noncarrier counterparts. Among 500 Ashkenazi-Jewish psychiatric patients, 19 were found to be TSD carriers. Their prevalence in the study population is proportional to that in the general Ashkenazi population. However, abnormal neurological findings, especially cognitive impairment, were commoner among TSD carriers (47.4 vs. 26.2%, p = 0.04). It is possible that chronic use of some psychotropic drugs plays a role in this phenomenon.

Traveler's diarrhea at sea: three outbreaks of waterborne enterotoxigenic Escherichia coli on cruise ships.

Enterotoxigenic Escherichia coli (ETEC) has become the leading bacterial cause of gastroenteritis outbreaks on cruise ships. Investigation of recent outbreaks of ETEC gastroenteritis on 3 cruise ships indicated that all were associated with consuming beverages with ice cubes on board the ship (relative risk [RR], 1.4, 95% confidence interval [CI], 1.0-1.9, P=.02; RR, 1.9, 95% CI, 1.3-2. 9, P<.001; and RR, 1.3, 95% CI, 1.0-1.6, P<.01), and 2 were associated with drinking unbottled water (RR, 2.7, 95% CI, 1.8-4.1, P<.001; RR, 1.7, 95% CI, 1.3-2.3, P<.001). Multiple ETEC serotypes were detected in patients' stool specimens in each of the 3 outbreaks, and 12 (38%) of 32 isolates were resistant to > or =3 antimicrobial agents. ETEC appears to be emerging as a waterborne pathogen on cruise ships. Water bunkered in overseas ports was the likely source of ETEC infection in these outbreaks. To ensure passenger safety, cruise ships that take on water in foreign ports must ensure that water treatment and monitoring systems function properly.

Interaction of Dithane M-45 (mancozeb) and lead acetate during a teratogenicity test in rats.

The teratogenic effects of lead acetate (Trial 1) and the possible teratogenic effect of this compound administered in combination with a fungicide containing 80% mancozeb (Trial 2) were studied in rats. The test substances were administered by gavage on Days 6-15 of gestation. In Trial 1, five groups were treated with lead acetate administered at doses of 0.1, 0.5, 1.0, 10.0 and 1000.0 mg/kg body weight (bwkg), respectively. In Trial 2, lead acetate was applied at doses of 0.1, 10.0 and 1000.0 mg/bwkg, respectively. In the latter case the dose of the pesticide was 750 mg/bwkg in all treated groups. Lead acetate was not teratogenic after a single administration. Combined administration of lead acetate and mancozeb gave rise to the following toxic effects: average maternal weight decreased during pregnancy, the ratio of live fetuses decreased after the two lowest doses, and fetal mortality increased in the lowest and in the highest dose groups. The ratio of fetal resorption was higher in all the treated groups than in the control group. A significant decrease occurred in average fetal and placental weight in each treated group as compared to the control. Maternal toxicity was expressed in paralysis of the hindlimbs in the two lowest dose groups. Maternal mortality was between 16.7 and 23.3% at the three dose levels. Phocomelia and hernia cerebri occurred as characteristic fetal developmental anomalies in all the treated groups. It is concluded that the joint administration of lead acetate and a mancozeb-containing fungicide can cause maternal toxicity, embryotoxicity and characteristic teratogenic effects.

Mechanism and dynamics of macroautophagy in murine exocrine pancreatic cells. A review of vinblastine-induced changes.

Autophagy is a major pathway of lysosomal degradation of cellular macromolecules. The paper summarizes the results obtained in the studies on macroautophagy using the exocrine pancreatic acinar cell as model system and vinblastine as inducer. Current knowledge about the origin and properties of the limiting membranes of autophagic vacuoles, and the results of quantitative morphological studies into the dynamics and kinetics of vinblastine-induced autophagocytosis, as well as recent achievements in isolation and characterization of subclasses of autophagic vacuoles (autophagosomes and autolysosomes) are reviewed.

Regression of autophagic vacuoles in mouse pancreatic cells: a morphometric study of the effect of methylamine and chloroquine followed by cycloheximide treatment.

Treatment of mice with methylamine and chloroquine for two hours markedly increased the volume fraction of autophagic vacuoles in the pancreatic acinar cells of the mouse. The autophagic vacuoles disappeared from the cells within 20 min after the administration of a suppressor of autophagic sequestration cycloheximide to animals pretreated with 0.25 mg b.w. dose of methylamine. In contrast, no regression or very slow decay was seen in cells of mice pretreated with higher doses of methylamine (0.50-0.70 mg/g b.w.) and chloroquine (0.08 mg/g b.w.). Our data show that the two drugs retard the disintegration of autophagic vacuole content. It is concluded, that accumulation of autophagic vacuoles due to their slow turnover is an important mechanism of the expansion of autophagic vacuole compartment under the effect of methylamine and chloroquine.

Morphometric evaluation of the turnover of autophagic vacuoles after treatment with Triton X-100 and vinblastine in murine pancreatic acinar and seminal vesicle epithelial cells.

Large numbers of autophagic vacuoles were found in murine pancreatic acinar and seminal vesicle epithelial cells following the administration of Triton X-100 or vinblastine for 4 h. The autophagic vacuoles disappeared rapidly from the cells after the administration of cycloheximide to animals pretreated with Triton X-100. The decay in seminal vesicle cells appeared to follow first-order kinetics with an estimated t1/2 of 8.7 min. The regression in pancreatic cells was equally rapid and less than half the initial volume of autophagic vacuoles was found at the 12th min after cycloheximide injection. This time, the decay curve appeared to be linear rather than exponential. Our data, together with the work of others, support the view that the average half-life of autophagic vacuoles is a fairly constant parameter kept within the range of 6-9 min in various types of mouse and rat cell when the late steps of autophagocytosis (i.e. the fusion of autophagosomes and lysosomes and the degradation within lysosomes) are not affected. The regression of autophagic vacuoles was slow in mice pretreated with vinblastine (t1/2 of about 27-30 min) suggesting that this drug slows down the turnover of autophagic vacuoles. Morphometric evaluation of the regression of the autophagic vacuole compartment after cycloheximide treatment can be used as a tool to distinguish between treatments which elevate the amount of autophagic vacuoles within the cells by increasing the rate of sequestration from those which expand the autophagic vacuole compartment by causing accumulation of autophagic vacuoles as a result of blockade of the late steps of the autophagic process.