A public health approach to increase treatment of latent TB among household contacts in Brazil.

SETTING: Two consecutive trials were conducted to evaluate the effectiveness of a public health approach to identify and correct problems in the care cascade for household contacts (HHCs) of TB patients in three Brazilian high TB incidence cities.METHODS: In the first trial, 12 clinics underwent standardised evaluation using questionnaires administered to TB patients, HHCs and healthcare workers, and analysis of the cascade of latent TB care among HHCs. Six clinics were then randomised to receive interventions to strengthen management of latent TB infection (LTBI), including in-service training provided by nurses, work process organisation and additional clinic-specific solutions. In the second trial, a similar but streamlined evaluation was conducted in two clinics, who then received initial and subsequent intensive in-service training provided by a physician.RESULTS: In the evaluation phase of both trials, many HHCs were identified, but few started LTBI treatment. After the intervention, the number of HHCs initiating treatment per 100 active TB patients increased by 10 (95%CI - 11 to 30) in the first trial, and by 44 (95%CI 26 to 61) in the second trial.DISCUSSION: A public health approach with standardised evaluation, local decisions for improvements, followed by intensive initial and in-service training appears promising for improved LTBI management.

Resource implications of the latent tuberculosis cascade of care: a time and motion study in five countries.

BACKGROUND: The End TB Strategy calls for global scale-up of preventive treatment for latent tuberculosis infection (LTBI), but little information is available about the associated human resource requirements. Our study aimed to quantify the healthcare worker (HCW) time needed to perform the tasks associated with each step along the LTBI cascade of care for household contacts of TB patients. METHODS: We conducted a time and motion (TAM) study between January 2018 and March 2019, in which consenting HCWs were observed throughout a typical workday. The precise time spent was recorded in pre-specified categories of work activities for each step along the cascade. A linear mixed model was fit to estimate the time at each step. RESULTS: A total of 173 HCWs in Benin, Canada, Ghana, Indonesia, and Vietnam participated. The greatest amount of time was spent for the medical evaluation (median: 11 min; IQR: 6-16), while the least time was spent on reading a tuberculin skin test (TST) (median: 4 min; IQR: 2-9). The greatest variability was seen in the time spent for each medical evaluation, while TST placement and reading showed the least variability. The total time required to complete all steps along the LTBI cascade, from identification of household contacts (HHC) through to treatment initiation ranged from 1.8 h per index TB patient in Vietnam to 5.2 h in Ghana. CONCLUSIONS: Our findings suggest that the time requirements are very modest to perform each step in the latent TB cascade of care, but to achieve full identification and management of all household contacts will require additional human resources in many settings.

The flexible contour backrest: a new design concept for wheelchairs.

Studies have shown that the use of a conventional sling backrest in a wheelchair may have a negative impact on the posture and health of users. To avoid such problems, this backrest is often replaced by a back cushion on a rigid surface. However, the use of the latter deprives many wheelchair users of the advantages provided by the sling backrest (easy folding, lightweight, low cost, unobtrusive, simplicity of design). In an effort to maintain these features while providing adequate posture, a new backrest was designed according to specific criteria. The "flexible contour backrest" has been developed so that it can be adapted to a person's back contour with stays, adjustable straps, and curved back posts. Preliminary comparisons done by some experts with commercially available backrests showed that design criteria were reached at 62.9% by the back cushion on a rigid surface, at 64% by the sling backrest, and at 67.7% by the adjustable-tension backrest. On the other hand, design criteria were reached at 80% by the new flexible contour backrest because its design brings together most of the positive features provided by these other backrests (easy to fold, light weight, unobtrusive, airy) as well as providing adequate posture and better fit to the user's morphology.

Assessment of independent living skills for psychotic patients. Further validity and reliability.

It is well known that psychotic patients have severe social and life-skill deficits. Psychiatric rehabilitation programs are designed to teach these skills to patients. Before implementing such a program, patient deficits should be evaluated with reliable measures. The present study assessed the psychometric properties of the French version of the "Independent Living Skills Survey" (ILSS) developed by Wallace, Kochanowicz and Wallace (Wallace C J, Kochanowicz N, Wallace J [1985] Independent living skills survey. Unpublished manuscript, Mental Health Clinical Research Center for the Study of Schizophrenia, West Los Angeles Veterans Administration Medical Center, Rehabilitation Medicine Service [Brentwood Division], Los Angeles, CA). Although widely used, the patient version of this scale has unknown psychometric properties. The ILSS was composed of 75 items, rated as present or absent and distributed in 10 scales. The French version was administered to 145 patients with a psychotic diagnosis who were living in the community. All scales had very good psychometric qualities with the exception of the job-maintenance scale. The test-retest reliability varied from .48 to .85, and alpha coefficients were good for seven of the nine scales. Various aspects of construct validity were explored. The scales discriminated between patients as a function of their subgroups, sex, and diagnosis. Concurrent validity confirmed the specificity of the ILSS dimensions. Factor analysis revealed two factors, one for basic skills and one representing higher order skills. Recommendations for future development of the ILSS are proposed.

[Training of interviewers in the utilization of standardized questionnaires in psychiatry: studies realized with the Present State Examination (PSE)]. / La formation d'interviewers à l'utilisation de questionnaires standardisés en psychiatrie: travaux réalisés avec l'Examen Psychiatrique Standardisé (EPS).

Interview questionnaires offer more validity than self-administered format in exploring psychopathological or psychosocial phenomena of interest in psychiatric research. If used, special care needs to be paid to interviewers' training and ensuring that they maintain their reliability. No widespread training standards exist and each schedule may carry its own procedure. Our aims are to indicate how we trained interviewers with the French version of the Present State Examination (Wing, Cooper and Sartorius, 1974) and how we checked and kept acceptable interraters reliability during one study. We will provide data on the interraters reliability during the training and the study, as well as the test-retest reliability. These results will be used to support some guidelines when using this sort of psychiatric research questionnaires in order to ensure comparability both within the study and between studies.

Mastication in the rabbit: a description of movement and muscle activity.

1. Mastication was studied in awake rabbits that had previously been prepared for chronic recording of jaw movement and jaw muscle electromyography (EMG) under general anesthesia. Data were stored on tape and replayed for computer-assisted analysis. Most data was taken from the mastication of rabbit chow, but the basic features described in the paper also apply to eating of other foods. The series of movements was divided into cycles, and the phases that compose them, using peaks in the vertical movement, velocity, and acceleration. 2. The whole series of movements from ingestion to swallowing was termed the masticatory sequence. We found, as have others, that the sequence can be divided into three consecutive periods, based on the form of the movements. These were named the preparatory, reduction, and preswallowing series of cycles. 3. The results of earlier studies suggest that the food is transported back to the molar teeth during the preparatory series, ground up during the reduction series, and that the bolus is formed for swallowing during the preswallowing series. 4. The typical cycle of the preparatory series was called type I; it had two phases: opening (O) and fast closing (FC). The jaw-opening muscles were very active during O, but EMG bursts from the closer muscles were small or undefinable during FC. There was not much movement away from the midline in either phase, and the cycles were the shortest in the sequence. 5. The reduction series was predominantly composed of type II cycles. These were of intermediate duration and had three phases [O, a short FC, and a slow closing phase (SC)], during which the pellets were crushed between the molar teeth. The jaw moved toward the working side during FC. At or soon after the start of SC, the closer muscles became very active and continued to contract as the teeth were drawn toward the midline and slightly backwards. 6. The preswallowing series was made up of five-phase cycles that we called type III. These were the longest of the sequence. Jaw opening now occurred in three stages: O1 was the fall from tooth contact to approximately the postural position, O2 was a pause, and O3 was defined as the final movement to maximum opening. The digastric burst occurred during O3. There were again two closing phases, FC and SC, but closer bursts were smaller than in type II, and SC was shorter.(ABSTRACT TRUNCATED AT 400 WORDS)

Computer-aided design in wheelchair seating.

This paper describes the integration of computer-aided design (CAD) with the design and fabrication of wheelchair seats. The use of CAD during the design phase permits personal seating for adult and pediatric clientele through a series of standard manufactured seating components. The advent of CAD has permitted the creation of databases of detailed 3-D wheelchair structures that are commercially available, in addition to most standard modular seating components. Direct on-screen manipulation of these components on any selected wheelchair structure is through user-friendly software. When using CAD, structural and physical limitations can be foreseen and taken into consideration during the routine initial fitting on an adjustable simulation fitting chair. The end product is a dimensioned drawing of the seating arrangement as it is positioned in the wheelchair structure. The seating components are manufactured from this drawing. The CAD system permits seating specialists to simulate a client's seating arrangement on the wheelchair in order to determine a functional position before the fabrication phase. Essentially, the CAD software is used as a simulation tool for creating functional seating units. It is also a design tool that allows access through a database to dimensional information about commercial seating products and seating products developed through the use of the CAD system.

Activity during mastication of periodontal mechanosensitive neurons of the trigeminal subnucleus oralis of the rabbit.

1. The activity of mechanosensitive neurons was examined before and during mastication. One hundred and seventy-eight neurons were recorded in the rostral parts of the trigeminal sensory nuclei of 20 rabbits anesthetized with urethan. Twenty-eight neurons received inputs from the periodontal mechanoreceptors, all on the ipsilateral side. Nineteen had receptive fields that were restricted to one tooth; 2 could be activated from more than 1 tooth, and 6 included parts of the mucosa. Only the latter were spontaneously active. 2. All periodontal neurons with a mandibular input responded to graded electrical stimulation of the inferior alveolar nerve at minimum latencies of less than or equal to 3.4 ms, and approximately half had inputs from the sensorimotor cortex. 3. Almost all periodontal units recorded were found to lie in, or just outside, the dorsal part of the most rostral subdivision of the spinal trigeminal nucleus (subnucleus oralis, pars gamma). None projected to the ipsi- or contralateral thalamus. 4. All periodontal neurons fired during mastication. Those without mucosal receptive fields fired during jaw closure, with almost all activity confined to the slow-closing phase when pressure is applied to the teeth. Injections of local anesthetic showed that input from mucosal fields was responsible for activating neurons in other phases of the cycle. 5. Possible roles in the control of mastication for these periodontal interneurons were discussed.

The role of biotransformation-detoxication in acetone-, 2-butanone-, and 2-hexanone-potentiated chloroform-induced hepatotoxicity.

The hepatotoxicity of chloroform (CHCl3) is thought to require biotransformation, by the polysubstrate monooxygenase system (P-450), to a reactive intermediate(s). Therefore, the potentiation of CHCl3-induced hepatotoxicity, which occurs following exposure to certain ketones, may hypothetically be explained by a reduced capacity of the cell to form glutathione conjugates (detoxicate the intermediate) and (or) by an increased rate of reactive intermediate(s) generation secondary to a modification of the P-450 system. To test these hypotheses, liver damage, as indicated by elevation in plasma alanine aminotransferase and ornithine carbamyl transferase activities, was modulated in male Sprague-Dawley rats by varying the time interval (10, 18, 24, 48, 72, 96 h) between acetone, 2-butanone, or 2-hexanone (15 mmol/kg, p.o.) pretreatment and CHCl3 (0.5 mL/kg, p.o.) administration. These data were compared with hepatic glutathione and with various parameters of the polysubstrate monooxygenase system: cytochrome P-450, cytochrome c reductase, cytochrome b5, and microsomal binding of 14CHCl3-derived radiolabel. Reduced detoxication capacity does not appear to be involved as hepatic glutathione levels were not reduced. Globally, a relationship between modifications to the polysubstrate monooxygenase system and potentiation of CHCl3-induced hepatotoxicity appears to exist. The rank order of each ketone's ability to modify P-450 parameters was the same in most instances as that based on peak ability to potentiate CHCl3-induced hepatotoxicity: 2-hexanone greater than 2-butanone greater than or equal to acetone. Therefore, these results suggest that a general relationship exists between the ketone-induced potentiation of CHCl3-induced hepatotoxicity and increased CHCl3 reactive metabolite generation. However, other factors may also contribute to the phenomenon.

Evidence that periodontal pressoreceptors provide positive feedback to jaw closing muscles during mastication.

1. Mastication was produced by stimulation of the right motor-sensory cortex of urethan-anesthetized rabbits with 15-s trains of shocks (1-ms duration) at 50 Hz. Movements of the lower jaw and jaw muscle electromyograms (EMGs) were recorded on magnetic tape for later computer analysis. 2. The stimulus site was chosen, and stimulus intensity adjusted, so that stereotyped movements were produced that included a wide swing of the mandible to the left side during jaw closure. 3. Control trials were alternated with trials in which a steel ball (2 mm diam) was thrust between the anterior molar teeth on the left side and left in place for several seconds. 4. When the obstruction was first introduced, a jaw opening reflex was sometimes evoked if the ball struck the buccal surface of the advancing mandibular molar teeth. Thereafter, when the ball was crushed between the occlusal surfaces of the teeth, no jaw opening reflex was seen. 5. Instead, the amplitude and duration of all the jaw closing EMGs increased, beginning at least 12 ms after contact with the ball. This caused a prolongation of the slow closing (SC) phase of the cycle that, coupled with a delay in the start of activity in the digastric muscle (jaw opener), prolonged the cycle by more than 60 ms. 6. During the SC phase of the obstructed trials, the medially directed grinding stroke was exaggerated because of an increase in the contraction of the contralateral zygomaticomandibular and anterior temporal muscles. 7. After collecting data, the sensory nerves to the maxillary and mandibular anterior molar teeth were cut to eliminate feedback from the periodontal pressoreceptors. Control and obstructed trials were repeated. 8. Following denervation, the obstructed cycles were of shorter duration. The mandible still moved to the right during SC in some animals, but the increase in closer muscle EMG activity was much reduced. 9. We conclude that periodontal receptors provide positive feedback to the jaw closing muscles during mastication. This is supplemented by input from other receptors, probably muscle spindles. In addition, an increase in periodontal feedback prolongs the SC phase and the early phases of the opening stroke.