Facilitators and barriers to TB care during the COVID-19 pandemic.

BACKGROUND: Knowledge about factors influencing access and adherence to TB care, and on the impact of the COVID-19 pandemic on TB care in resource-restricted settings is scarce. We conducted this study in Atsimo-Andrefana, a rural region in southern Madagascar where TB prevalence, poverty and food insecurity rates are high. We aimed to determine facilitators and barriers to access to and provision of TB care in rural Madagascar during the COVID-19 pandemic. METHODS: We conducted qualitative focus group discussions (FGDs) and in-depth interviews (IDIs) with patients with TB, community health workers, facility-based health workers, public health officials and non-governmental organisation staff. We analysed interviews using thematic analysis. RESULTS: We conducted 11 FGDs and 23 IDIs. We identified three main barriers to access and adherence to TB care: 1) stigma, 2) indirect treatment costs, and 3) food insecurity. The facilitator perceived as most influential was high health worker motivation. The effects of the COVID-19 pandemic on TB care varied between stake-holders; some health workers described delays in TB diagnosis and increased workload. CONCLUSIONS: To improve access and adherence to TB care, both indirect treatment costs and stigma need to be reduced; undernourished patients with TB should receive food support.

CONTEXTE: Les connaissances sur les facteurs influençant l'accès et l'adhésion aux soins antituberculeux, ainsi que sur l'impact de la pandémie de COVID-19 sur les soins antituberculeux dans les milieux à ressources limitées sont rares. Nous avons mené cette étude à Atsimo-Andrefana, une région rurale du sud de Madagascar où la prévalence de la TB et les taux de pauvreté et d'insécurité alimentaire sont élevés. Nous avons cherché à déterminer les facilitateurs et les obstacles à l'accès et à la fourniture de soins antituberculeux dans les zones rurales de Madagascar pendant la pandémie de COVID-19. MÉTHODES: Nous avons mené des discussions qualitatives en groupe (FGD) et des entretiens approfondis (IDI) avec des patients atteints de tuberculose, des agents de santé communautaires, des agents de santé en établissement, des responsables de la santé publique et des membres d'organisations non gouvernementales. Nous avons analysé les entretiens en utilisant l'analyse thématique. RÉSULTATS: Nous avons mené 11 FGD et 23 IDI. Nous avons identifié trois principaux obstacles à l'accès et à l'observance des soins antituberculeux : 1) la stigmatisation, 2) les coûts indirects du traitement et 3) l'insécurité alimentaire. Le facilitateur perçu comme le plus influent était la forte motivation des agents de santé. Les effets de la pandémie de COVID-19 sur les soins antituberculeux varient selon les parties prenantes ; certains agents de santé ont décrit des retards dans le diagnostic de la TB et une augmentation de la charge de travail. CONCLUSIONS: Pour améliorer l'accès et l'adhésion aux soins antituberculeux, il faut réduire à la fois les coûts indirects du traitement et la stigmatisation ; les patients tuberculeux sousalimentés devraient recevoir une aide alimentaire.

[Neurological side effects of checkpoint inhibitors]. / Neurologische Nebenwirkungen von Checkpoint-Inhibitoren.

BACKGROUND: In recent years the treatment of many tumor entities has been revolutionized by the use of modern immunotherapies with checkpoint inhibitors; however, good response rates are contrasted by many immune-mediated side effects. Neurological immune-mediated side effects are rare but often severe complications of checkpoint inhibitor treatment. METHOD: A systematic search in the PubMed and Web of Sciences databases was carried out for case reports and studies on neurological side effects during checkpoint inhibitor treatment. RESULTS: A total of 42 articles on neurological side effects of checkpoint inhibitors with a total of 85 reported cases could be identified. The most frequently reported neurological side effects were myopathies, neuropathies, diseases of the neuromuscular endplates and encephalitides. Among those, encephalitides and myopathies with accompanying myocarditis were associated with the highest morbidity and mortality. CONCLUSION: Against the background of a rapidly increasing use of checkpoint inhibitors, this article provides an overview of currently available reports on the clinical courses of neurological side effects. Controlled studies on the treatment of neurological side effects are lacking. From case studies it can be assumed that early steroid treatment increases the probability of a complete remission of neurological symptoms. Typical symptom constellations must therefore be rapidly recognized and an immunosuppressive treatment must be initiated.

[Nationwide survey of postgraduate medical training in clinical neurology]. / Deutschlandweite Evaluation der ärztlichen Weiterbildung in der klinischen Neurologie.

BACKGROUND: Currently, no data are available, which reflect the situation of medical doctors specializing in neurology in German hospitals. In order to secure the high standard of neurological patient care it is essential to evaluate the working conditions and the specialty training in neurology. OBJECTIVE: This nationwide survey was conducted throughout Germany with the aim to address problems and to give suggestions for improvements in neurological training curricula. MATERIAL AND METHODS: The survey was online from February to May 2017 and 953 neurologists undergoing further training participated. RESULTS: More than half of the young neurologists were satisfied with their medical training. One of the main problems that complicates clinical training is the workload. In addition, organizational obstacles within the clinic, such as poor structure of education or a lack of mentors, lead to dissatisfaction among participants. The size or type of the department, as well as the prevailing service system, exert only a minor influence on the quality of specialist training, although there were differences especially in the self-assessment of the participants in connection with the type of department (university hospital versus public or private hospital). CONCLUSION: Specialist training in neurology can be improved by simple arrangements, e. g., the introduction of a binding rotation scheme, internal mentoring and structured feedback. In addition, it will be necessary to relieve medical staff of administrative duties in order to create time for training and the learning of competencies.

Risk factors for higher cost in congenital heart operations.

BACKGROUND: For many congenital heart defects, hospital mortality is no longer a sensitive parameter by which to measure outcome. Although hospital survival rates are now excellent for a wide variety of lesions, many patients require expensive and extensive hospital-based services during the perioperative period to enable their convalescence. These services can substantially increase the cost of care delivery. In today's managed care environment, it would be useful if risk factors for higher cost could be identified preoperatively so that appropriate resources could be made available for the care of these patients. The focus of this retrospective investigation is to determine if risk factors for high cost for repair of congenital heart defects can be identified. METHODS: We assessed financial risk by tracking actual hospital costs (not charges) for 144 patients undergoing repair of atrial septal defect (58 patients), ventricular septal defect (48 patients), atrioventricular canals (14 patients), or tetralogy of Fallot (24 patients) at Duke University Medical Center between July 1, 1992, and September 15, 1995. Furthermore, we were able to identify where the costs occurred within the hospital. Financial risk was defined as a large (> 60% of mean costs) standard deviation, which indicated unpredictability and variability in the treatment for a group of patients. RESULTS: Cost for atrial septal defect repair was predictably consistent (low standard deviation) and was related to hospital length of stay. There were factors, however, for ventricular septal defect, atrioventricular canal, and tetralogy of Fallot repair that are identifiable preoperatively that predict low- and high-risk groups using cost as an outcome parameter. Patients undergoing ventricular septal defect repair who were younger than 6 months of age at the time of repair, who required preoperative hospital stays of longer than 7 days before surgical repair, or who had Down's syndrome had a less predictable cost picture than patients undergoing ventricular septal defect repair who were older than 2 years, who had short (< 4 days) preoperative hospitalization, or who did not have Down's syndrome ($48,252 +/- $42,539 versus $15,819 +/- $7,219; p = 0.008). Patients with atrioventricular canals who had long preoperative hospitalization (> 7 days), usually due to pneumonia (respiratory syncytial virus) with preoperative mechanical ventilation had significantly higher cost than patients with atrioventricular canals who underwent elective repair with short preoperative hospitalization ($83,324 +/- $60,138 versus $26,904 +/- $5,384; p = 0.05). Patients with tetralogy of Fallot had higher costs if they had multiple congenital anomalies, previous palliation (combining costs of both surgical procedures and hospital stays), or severe "tet" spells at the time of presentation for operation compared with patients without these risk factors ($114,202 +/- $88,524 versus $22,241 +/- $7,071; p = 0.0005). One patient (with tetralogy of Fallot) with multiple congenital anomalies died 42 days after tetralogy of Fallot repair of sepsis after a gastrointestinal operation. Otherwise, hospital mortality was 0% for all groups. CONCLUSIONS: Low mortality and good long-term outcome for surgical correction of congenital heart defects is now commonplace, but can be expensive as some patients with complex problems receive the care necessary to survive. This study demonstrates that it is possible to identify factors preoperatively that predict financial risk. This knowledge may facilitate implementation of risk adjustments for managed care contracting and for strategic resource allocation.