Defining the research agenda to measure and reduce tuberculosis stigmas.

Crucial to finding and treating the 4 million tuberculosis (TB) patients currently missed by national TB programmes, TB stigma is receiving well-deserved and long-delayed attention at the global level. However, the ability to measure and evaluate the success of TB stigma-reduction efforts is limited by the need for additional tools. At a 2016 TB stigma-measurement meeting held in The Hague, The Netherlands, stigma experts discussed and proposed a research agenda around four themes: 1) drivers: what are the main drivers and domains of TB stigma(s)?; 2) consequences: how consequential are TB stigmas and how are negative impacts most felt?; 3) burden: what is the global prevalence and distribution of TB stigma(s) and what explains any variation? 4): intervention: what can be done to reduce the extent and impact of TB stigma(s)? Each theme was further subdivided into research topics to be addressed to move the agenda forward. These include greater clarity on what causes TB stigmas to emerge and thrive, the difficulty of measuring the complexity of stigma, and the improbability of a universal stigma 'cure'. Nevertheless, these challenges should not hinder investments in the measurement and reduction of TB stigma. We believe it is time to focus on how, and not whether, the global community should measure and reduce TB stigma.

Tuberculosis stigma as a social determinant of health: a systematic mapping review of research in low incidence countries.

Tuberculosis (TB)-related stigma is an important social determinant of health. Research generally highlights how stigma can have a considerable impact on individuals and communities, including delays in seeking health care and adherence to treatment. There is scant research into the assessment of TB-related stigma in low incidence countries. This study aimed to systematically map out the research into stigma. A particular emphasis was placed on the methods employed to measure stigma, the conceptual frameworks used to understand stigma, and whether structural factors were theorized. Twenty-two studies were identified; the majority adopted a qualitative approach and aimed to assess knowledge, attitudes, and beliefs about TB. Few studies included stigma as a substantive topic. Only one study aimed to reduce stigma. A number of studies suggested that TB control measures and representations of migrants in the media reporting of TB were implicated in the production of stigma. The paucity of conceptual models and theories about how the social and structural determinants intersect with stigma was apparent. Future interventions to reduce stigma, and measurements of effectiveness, would benefit from a stronger theoretical underpinning in relation to TB stigma and the intersection between the social and structural determinants of health.

Psychosocial aspects of feeding children with neurodisability.

The psychosocial support needs of parents considering a gastrostomy feeding tube for their disabled child are often overlooked, yet there is a growing body of evidence that attests to the decisional conflicts parents, often mothers, experience. This may be in addition to the stress associated with feeding a disabled child. The support needs of families and caregivers should be assessed, including the values parents attach to oral and tube feeding. Structured support should be embedded within the care pathway and both professionals, and service users, with appropriate training should be identified to ensure parental information needs, and any emotional, practical and financial issues are addressed.

What are the benefits and barriers of communicating parental HIV status to seronegative children and the implications for Jamaica? A narrative review of the literature in low/middle income countries.

OBJECTIVE: To examine the benefits/barriers for HIV positive parents of communicating their status to seronegative children in low/middle income countries in order to inform policy and practice in Jamaica. METHODS: The authors carried out a systematic search of published literature on parental disclosure in low/middle income countries written in the English language between January 1991 and September 2012, identified from databases: Academic Search Complete, CINAHL, EBSCOhostEJS, Gender Studies Database, Health Policy Reference Centre, MEDLINE (includes the West Indian Medical Journal), PsycARTICLES , PsycINFO , SocINDEX, AMED, Global Health, Embase, Social Policy and Practice, Maternity and Infant Care. The authors also refer to articles on parental disclosure in high income countries which appeared in peer-reviewed journals and conducted a local search in Jamaica for articles on HIV disclosure in the Caribbean region. RESULTS: Global estimates of parental disclosure rates were 20-97% in high income countries and 11-44% in resource constrained countries. Mean age of children at disclosure was age 10-18 years. Mothers were more likely to disclose to older children, female children, and when they had strong support networks. Barriers included fear of stigma/discrimination, not knowing how to tell the child, fear of the child disclosing to others and believing a child was too young to cope. Of the 16 articles identified which met the search criteria, 10 studies and three reviews noted positive benefits of disclosure on parental health and the parent-child relationship. CONCLUSION: Significant differences in attitudes and rates of maternal disclosure in low/middle income countries compared to high income countries reflect the impact of cultural, structural, economic and social factors and highlight the need for culturally-specific research. Implications for policy and practice in Jamaica are discussed.

The impact of social factors on tuberculosis management.

AIM: This paper is a report of a study to examine the impact of social factors on the management of tuberculosis including engagement with services, hospitalization and extended treatment. BACKGROUND: Rates of tuberculosis in major European cities have increased greatly in the last 10 years. The changing epidemiology of the disease, concentrated in marginalized groups, presents new challenges to the control of tuberculosis. METHODS: A prospective cohort study of 250 newly diagnosed tuberculosis patients was conducted in London between January 2003 and January 2005. Data were collected by means of a risk assessment tool and from medical records. Outcome measures included missed appointments, frequency and duration of hospitalization and length of treatment. RESULTS: The median age of the study sample was 33.82 (range 16.4-92.5) and 56.8% were male. Thirty-two per cent were hostel/street homeless or temporarily sharing accommodation with friends or relatives. Thirty-nine per cent were in receipt of welfare benefits and 13.2% had no income. Over a third anticipated difficulties taking their medicines and 30.3% had noone to remind them of this. Increased hospitalization was associated with hostel/street homelessness, drug or alcohol use and having noone to remind them to take their medicines (all P

Medical, surgical, and health outcomes of gastrostomy feeding.

A prospective controlled study with repeated measures before and after surgery examined the medical, surgical, and health outcomes of gastrostomy for children with disabilities at a tertiary paediatric referral centre in the North Thames area, UK. Anthropometric measures included weight, mid-upper-arm and head circumference. Five-day prospective food diaries were completed and data on physical health and surgical outcomes recorded. Seventy-six children participated and underwent gastrostomy (44 males, 32 females; median age 3 y 4 mo, range 4 mo-17 y 5 mo), and 35/76 required an anti-reflux procedure. Categories of disability were: cerebral palsy (32/76), syndrome of chromosomal or other genetic origin (25/76), slowly progressive degenerative disease (11/76), and unconfirmed diagnosis (8/76). Most children had gross motor difficulties (99%) and were non-ambulant (83%). Oromotor problems were identified in 78% of children, 69% aspirated, and 65% were fed nasogastrically before surgery. The mean weight before surgery was -2.84 standard deviation score (SDS; SD 2.21, range -9.8 to 3.4). Two-thirds of children achieved catch-up growth postoperatively: weight-for-age (mean difference 0.51 SDS, 95% CI 0.23-0.79, p=0.001) and mid-upper arm circumference (mean difference 1.12 cm, 95% confidence interval 0.50-1.75, p=0.001). Health gains included a reduction in drooling, secretions, vomiting, and constipation. Major surgical complications were found in 13/74 children. The study provides evidence that catch-up growth and health gains are possible following gastrostomy.

On withholding artificial hydration and nutrition from terminally ill sedated patients. The debate continues.

The author reviews and continues the debate initiated by her recent paper in this journal. The paper was critical of certain aspects of palliative medicine, and caused Ashby and Stoffell to modify the framework they proposed in 1991. It now takes account of the need for artificial hydration to satisfy thirst, or other symptoms due to lack of fluid intake in the terminally ill. There is also a more positive attitude to the emotional needs and ethical views of the patient's family and care-givers. However, clinical concerns about the general reluctance to use artificial hydration in terminal care remain, and doubts persist about the ethical and legal arguments used by some palliative medicine specialists and others, to justify their approach. Published contributions to the debate to date, in professional journals, are reviewed. Key statements relating to the care of sedated terminally ill patients are discussed, and where necessary criticised.

Clinical presentation of orthostatic hypotension in the elderly.

Fifty cases of orthostatic hypotension in the elderly are analysed. Three main modes of presentation were identified: (1) falls or mobility problems; (2) mental confusion or dementia; or (3) predominantly cardiac symptoms. Selected case histories are given to illustrate diagnostic difficulties. Medication was responsible for orthostatic hypotension in 66% of patients and striking examples of polypharmacy were encountered. However, 34% of cases were not iatrogenic. Only 14% of patients had overtly postural symptoms. A high index of suspicion is needed to diagnose orthostatic hypotension in the elderly and the condition is often overlooked. The paper provides useful diagnostic clues for clinicians.

On withholding nutrition and hydration in the terminally ill: has palliative medicine gone too far?

This paper explores ethical issues relating to the management of patients who are terminally ill and unable to maintain their own nutrition and hydration. A policy of sedation without hydration or nutrition is used in palliative medicine under certain circumstances. The author argues that this policy is dangerous, medically, ethically and legally, and can be disturbing for relatives. The role of the family in management is discussed. This issue requires wide debate by the public and the profession.

An inverse relationship between serum zinc and C-reactive protein levels in acutely ill elderly hospital patients.

Serum zinc and C-reactive protein (CRP) levels were measured in two groups of acutely ill geriatric hospital in-patients. Serum CRP levels were greater than 10 mg/l in 62% of the first group and 47% of the second. There was a significant negative correlation between zinc and CRP in both groups (r = -0.33, P less than 0.001, n = 103) and (r = -0.29, P less than 0.001, n = 135 respectively). The serum CRP was raised in 30% of long stay patients (n = 50) and 23% of a control group of elderly hospital patients with a normal serum albumin (n = 71), but there was no correlation between zinc and CRP in these patient groups. The results indicate that an acute phase response influences serum zinc levels in acutely ill geriatric patients. There is reason to believe that a distinction should be made between true zinc deficiency and a low serum zinc secondary to acute zinc redistribution during an inflammatory response. Measurement of CRP may help to distinguish between these two situations. We advise that if the serum zinc is low and CRP is significantly raised, zinc supplements should be avoided and a source of infection should be sought. Following recovery from severe infection low serum zinc levels return to normal while elevated CRP levels fall.

A study of serum zinc, albumin, alpha-2-macroglobulin and transferrin levels in acute and long stay elderly hospital patients.

Serum zinc levels measured by atomic absorption spectrophotometry were found to be low (less than 10.5 mumols/l) in 38% of acute geriatric admissions, 69% of long stay geriatric patients and 19% of a control group of elderly hospital patients with a normal serum albumin. There was a significant positive correlation between serum zinc and serum albumin in all groups. In acutely ill geriatric patients only, there was a weak but statistically significant positive correlation between serum zinc and alpha-2-macroglobulin (A2M) (r = 0.20), P less than 0.05). Serum transferrin was low in 46% of acute geriatric patients and 22% of long stay geriatric patients but there was no correlation between serum zinc and serum transferrin levels in any patient group. There were significant differences in serum zinc, A2M and transferrin levels between the acute and long stay geriatric patients. The differences in serum zinc levels between these patients groups could not be explained by changes in serum A2M, transferrin or albumin. Changes mediated by an acute phase response may have influenced results in the acute geriatric group of patients.

Evidence for involvement of prostaglandins in central alpha adrenergic activity and LH release in sheep.

Circhoral pulsatile release of immunoreactive luteinising hormone (LH) and prostaglandin F2 alpha (PGF2 alpha) occur synchronously into the jugular vein in ovariectomised sheep. Following a 4-hour control period, intra-carotid injections of phentolamine or intramuscular injections of phenoxybenzamine were given to ovariectomised sheep and the pulsatile release of LH and PGF2 alpha was monitored for a further 6 to 8 hours. Phenoxybenzamine caused a fall in LH and PGF2 alpha in jugular venous plasma. Phentolamine also reduced LH significantly but in this case a marked rise in PGF2 alpha as measured by radioimmunoassay (RIA) occurred after very high doses of phentolamine. Interpretation of the latter results was complicated by the fact that phentolamine at high dose levels interfered with the RIA of PGF2 alpha in plasma. Experiments were repeated in ovariectomised sheep with cannulae placed in the lateral ventricles of the brain for sampling cerebrospinal fluid (CSF). In contrast to the previously observed rise in jugular venous PGF2 alpha following high doses of phentolamine, a fall in CSF levels of immunoreactive PGF2 alpha occurred following intracarotid phentolamine or phenoxybenzamine in 3 out of 7 experiments, while no change was observed in the remaining 4 animals. Phentolamine did not reduce LH significantly in animals with intraventricular cannulae. The work provides support for the view that circhoral pulses of immunoreactive PGF2 alpha in sheep are neural in origin and may be related to sympathetic neurotransmission.

Sudden death from perforation of a benign oesophageal ulcer into a major blood vessel.

Two cases of sudden death due to perforation of a benign oesophageal ulcer into a major blood vessel are reported. In one man, anaemia and aspiration pneumonitis dominated the clinical picture. He had an oesophageal stricture and a chronic peptic ulcer associated with an incarcerated hiatus hernia. Death was due to haemorrhage caused by perforation of the ulcer into the thoracic aorta. The second patient presented with confusion and falls, backache and indigestion. She had a hiatus hernia and a large benign chronic oesophageal ulcer. Death was due to perforation of the ulcer into the left pulmonary vein. The cases are presented for their rarity, to illustrate the complex and late presentation of problems in geriatric medicine, and as a reminder that reflux oesophagitis can be dangerous.

Masked vitamin B12 and folate deficiency in the elderly.

1. A high incidence of vitamin B12 or folate deficiency, or both, may be found in the elderly, particularly those in hospital. This report concerns fifty cases detected in an inner-city-area geriatric unit during the course of routine clinical investigation. The majority had none of the classical haematological signs of vitamin B12 or folate deficiency, and all the patients reported had a mean corpuscular volume (MCV) of less than 100 fl. 2. There was a significant negative correlation between the MCV and the erythrocyte folate (P less than 0.01), supporting earlier published work using a low serum folate as an index of folate deficiency. 3. There was no correlation between the MCV and the serum vitamin B12. Published work differs on this point. 4. Serum iron, total Fe-binding capacity and percentage Fe saturation results were available in forty patients in this series. There was a significant positive correlation between the serum Fe and the MCV (P less than 0.01) and 34% of patients had haematological evidence of Fe deficiency. In the majority, however, there was no evidence that associated Fe deficiency had masked the haematological signs of vitamin B12 or folate deficiency. 5. More attention should be paid to the problem of 'masked' vitamin B12 and folate deficiency in the elderly. There is a case for routine screening of the elderly for vitamin B12 and folate deficiency irrespective of the MCV.

The use of intrauterine contraceptive devices in diabetics.

PIP: Recently, much publicity has been given to the view that IUDs are relatively ineffective in diabetes and should not be recommended. The recent questions about the effectiveness of IUDs in persons with diabetes stem from data reported from the diabetic and dietetic department of the Edinburgh Royal Infirmary and the Simpson Memorial Maternity Pavilion, Edinburgh. Steel, Parboosingh, and Duncan (1978) reported discouraging results in 21 patients with diabetes using an IUD. 7 patients conceived with an IUD in situ within 1 year. The authors expressed concern that there might be an increased risk of salpingitis in diabetics, but they did not actually observe this complication. Steel and Duncan continued to collect data and in 1980 reported that 11 out of 30 diabetic patients had become pregnant within a year of insertion of an IUD with the IUD in situ. Of the group who became pregnant, 5 had a Copper 7, 5 a Saf-T-Coil, and 1 a Dalkon Shield. 1 patient developed salpingitis and 6 had the IUD removed because of menorrhagia. The results from Edinburgh have received much publicity and were quoted in a chain reaction of articles on contraception and IUDs in diabetics during 1981. The Medical Advisory Panel of the Family Planning Association studied all available data and concluded that the evidence available was insufficient for condemning in general the use of IUDs in diabetics. The results from Edinburgh indicate a need for caution and more research to resolve the questions raised. They concluded that on present evidence diabetes should not be regarded as a contraindication to the use of an IUD. The International Medical Advisory Panel of the International Planned Parenthood Foundation (IPPF) arrived at a similar conclusion. It needs to be emphasized that the Edinburgh case against the use of Copper 7s and Saf-T-Coils in diabetics is based on a very small number of patients. There is some published work that indicates that the response of a diabetic to a Copper 7 IUD is different from that of a woman without diabetes. It is unknown why endometrial fibroinolytic activity fails to increase in diabetics after insertion of a Copper 7, but it is known that fibroinolytic activity is increased in patients with menorrhagia and that prostaglandin systhesis inhibitors are effective in the treatment of menorrhagia, including that associated with contraceptive devices.^ieng