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2.
Clin Infect Dis ; 67(11): 1643-1652, 2018 11 13.
Artigo em Inglês | MEDLINE | ID: mdl-29889240

RESUMO

Background: Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs. Methods: This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART. Results: Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/µL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but had stopped cART, 14.8% (95% CI, 14.0%-15.6%) had transferred to another clinic, 9.2% (95% CI, 8.5%-9.8%) were retained on cART, and 31.6% (95% CI, 30.6%-32.7%) could not been found. Mortality was associated with male sex, more advanced disease, and shorter cART duration; stopping cART with less advanced disease andlonger cART duration; and silent transfer with female sex and less advanced disease. Conclusions: Mortality in patients LTFU must be considered for unbiased assessments of program outcomes and UNAIDS targets in sub-Saharan Africa. Immediate start of cART and early tracing of patients LTFU should be priorities.


Assuntos
Terapia Antirretroviral de Alta Atividade , Infecções por HIV/tratamento farmacológico , Infecções por HIV/mortalidade , Perda de Seguimento , África ao Sul do Saara/epidemiologia , Antirretrovirais/uso terapêutico , Feminino , Infecções por HIV/epidemiologia , Humanos , Incidência , Masculino , Fatores Sexuais , Resultado do Tratamento , Nações Unidas
3.
Lancet ; 391(10121): 657-658, 2018 02 17.
Artigo em Inglês | MEDLINE | ID: mdl-29617265
4.
Clin Infect Dis ; 66(1): 131-133, 2018 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-29020205

RESUMO

Ebola survivors (21/27 [77.8%]) suffered more disability than their close contacts (6/54 [11.1%]) (adjusted odds ratio, 23.5 [95% confidence interval, 6.5-85.7]; P < .001) when measured by the Washington Group Disability Extended Questionnaire. Major limitations in vision, mobility, cognition, and affect were observed in survivors 1 year following the 2014-2016 Ebola outbreak, highlighting the need for long-term rehabilitation.


Assuntos
Pessoas com Deficiência/estatística & dados numéricos , Doença pelo Vírus Ebola/complicações , Doença pelo Vírus Ebola/epidemiologia , Deficiência Intelectual/epidemiologia , Limitação da Mobilidade , Sobreviventes/estatística & dados numéricos , Transtornos da Visão/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Serra Leoa/epidemiologia , Inquéritos e Questionários , Adulto Jovem
6.
BMC Infect Dis ; 17(1): 50, 2017 01 10.
Artigo em Inglês | MEDLINE | ID: mdl-28068907

RESUMO

BACKGROUND: In Nigeria multidrug-resistant tuberculosis (MDR-TB) is prevalent in 2.9% of new TB cases and 14% of retreatment cases, and the country is one of 27 with high disease burden globally. Patients are admitted and confined to one of ten MDR-TB treatment facilities throughout the initial 8 months of treatment. The perspectives of MDR-TB patients shared on social media and in academic research and those of providers are limited to experiences of home-based care. In this study we explored the views of hospitalised MDR-TB patients and providers in one treatment facility in Nigeria, and describe how their experiences are linked to accessibility of care and support services, in line with international goals. We aimed to explore the physical, social and psychological needs of hospitalized MDR TB patients, examine providers' perceptions about the hospital based model and discuss the model's advantages and disadvantages from the patient and the provider perspective. METHODS: We conducted two gender distinct focus group discussions and 11 in-depth interviews with recently discharged MDR-TB patients from one MDR-TB treatment facility in Nigeria. We triangulated this with the views of four providers who played key roles in the management of MDR-TB patients via key informant interviews. Transcribed data was thematically analysed, using an iterative process to constantly compare and contrast emerging themes across the data set for deeper understanding of the full range of participants' views. RESULTS: The study findings demonstrate the psycho-social impacts of prolonged isolation and the coping mechanisms of patients in the facility. The dislocation of patients from their normal social networks and the detachment between providers and patients created the need for interdependence of patients for emotional and physical support. Providers' fears of infection contributed to stigma and hindered accessibility of care and support services. CONCLUSION: The current trend towards discharging patients after culture conversion would reduce the psycho-social impacts of prolonged isolation and potentially reduce the risk of occupational TB from prolonged contact with MDR-TB patients. Building on shared experiences and interdependence of MDR-TB patients in our study, innovative patient-centred support systems would likely help to reduce stigma, promote access to care and support services, and potentially impact on the outcome of treatment.


Assuntos
Atitude do Pessoal de Saúde , Atitude Frente a Saúde , Hospitalização , Pacientes Internados/psicologia , Isolamento Social/psicologia , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Emoções , Feminino , Grupos Focais , Acesso aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Nigéria , Percepção , Pesquisa Qualitativa , Apoio Social , Tuberculose Resistente a Múltiplos Medicamentos/psicologia
7.
Eur Spine J ; 25(11): 3403-3410, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27554352

RESUMO

PURPOSE: Surgical treatment of Tarlov cysts is still a matter of debate. Published literature thus far includes mainly small case series with retrospective evaluation and short-term follow-up. We present a novel microsurgical technique that combines the decompression of the nerve fibers with the prevention of recurrence. The long-term follow-up is provided. METHODS: The indication for surgery was incapacitating pain refractory to medical therapy for at least 6 months. The surgical technique consisted in microsurgical opening of the cyst, relief of CSF followed by secured inverted plication of the cyst wall, packing of remnant space with fat graft, and sacroplasty. Pain and neurological deficits were evaluated according to a modified Barrow National Institute score (BNI score, 0-5) and the Departmental Neuro Score (DNS score, 0-20). RESULTS: A total of 13 patients (9 women, 4 men) were operated and followed up to 14 years (mean FU 5.3 years). Mean age at surgery was 51.8 (±14) years. Pain and neurological deficits improved significantly in 11/13 patients (BNI score pre-OP 5 vs 3.1 ± 1.2 at 1-year-FU, and 2.8 ± 1.2 at last follow-up visit; DNS score pre-OP 5.5 ± 1.5 vs 2.8 ± 2.1 at 1-year follow-up, and 2.6 ± 2.2 at last follow-up visit. Two patients needed revision surgery due to reoccurrence of the cyst. One patient suffered deterioration of preexisting neurological deficit. CONCLUSIONS: The inverted plication technique combined with sacroplasty is a promising technique. It improves pain and neurological deficits on the long term in the majority of patients with symptomatic Tarlov cysts.


Assuntos
Microcirurgia , Cistos de Tarlov , Adulto , Idoso , Descompressão Cirúrgica , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Dor , Cistos de Tarlov/fisiopatologia , Cistos de Tarlov/cirurgia
8.
J Trop Pediatr ; 62(3): 220-6, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26884443

RESUMO

BACKGROUND: Little is known about viral co-infections in African human immunodeficiency virus (HIV)-infected children. We examined the prevalence of seromarkers for cytomegalovirus (CMV), herpes simplex virus type 2 (HSV-2) and hepatitis B virus (HBV) infections among HIV-infected, antiretroviral treatment (ART)-naïve children in Lilongwe, Malawi. METHODS: Ninety-one serum samples were tested for IgG and IgM antibodies to CMV, and IgG antibodies to HSV-2 and hepatitis B surface antigen (HBsAg). Baseline demographic, clinical and laboratory data were abstracted from electronic records. RESULTS: CMV IgG was the most common positive result in all age groups (in 73% of children <1 year, and 100% in all other groups). Three patients were CMV IgM positive (3.3%), suggesting acute infection. HSV-2 IgG was positive in four patients (4.4%), and HBsAg in two (2.2%). CONCLUSIONS: CMV infection occurred early in life, and few children had specific signs of CMV infection at the time of ART initiation. Unrecognized HBV infection represents opportunities for testing and treatment of HIV/HBV co-infected children.


Assuntos
Infecções por Citomegalovirus/epidemiologia , Citomegalovirus/isolamento & purificação , Infecções por HIV/complicações , Vírus da Hepatite B/isolamento & purificação , Hepatite B/epidemiologia , Herpes Simples/epidemiologia , Herpesvirus Humano 2/isolamento & purificação , Adolescente , Anticorpos Antivirais/sangue , Biomarcadores/sangue , Criança , Pré-Escolar , Coinfecção/epidemiologia , Estudos Transversais , Citomegalovirus/imunologia , Infecções por Citomegalovirus/sangue , Infecções por Citomegalovirus/virologia , DNA Viral/sangue , Feminino , Infecções por HIV/sangue , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , Hepatite B/sangue , Hepatite B/virologia , Anticorpos Anti-Hepatite B/sangue , Antígenos de Superfície da Hepatite B/sangue , Antígenos de Superfície da Hepatite B/imunologia , Vírus da Hepatite B/imunologia , Herpes Simples/sangue , Herpes Simples/virologia , Herpesvirus Humano 2/imunologia , Humanos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Malaui/epidemiologia , Masculino , Prevalência , Estudos Soroepidemiológicos
9.
J Acquir Immune Defic Syndr ; 70(5): e160-7, 2015 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-26218409

RESUMO

BACKGROUND: Loss to follow-up (LTFU) challenges the success of antiretroviral therapy (ART) scale-up among pediatric patients. Little is known about children who drop out of care. We aim to analyze risk factors for LTFU among children on ART, find their true outcomes through tracing, and investigate their final outcomes after resuming ART. METHODS: This is a descriptive, retrospective, cohort study of children on ART between April 2006 and December 2010 in 2 clinics in urban Malawi. Routine data from an electronic data system were used and matched with information obtained through routine tracing procedures. RESULTS: Of 985 children (1999 child-years) on ART, 251 were LTFU: 12.6/100 child-years. At ART initiation, wasting [adjusted hazard ratio (AHR) 1.58 and 95% confidence interval (CI): 1.02 to 2.44] was independently associated with higher risk of LTFU. Of 201 LTFU children traced, 79% were found: 11% died, 25% stopped, 26% transferred-out, and 37% were still on ART. Median time between last visit and first tracing was 84 days (interquartile range: 64-101 days). Tracing reduced risk of LTFU by 38% (AHR 0.62 and 95% CI: 0.42 to 0.91) and decreased LTFU from 23.2% to 8.5%. Additional outcomes of stop, death, and transfer-out increased 4.4-fold, 1.8-fold, and 1.3-fold, respectively. Traced children with gaps in ART intake who resumed ART had higher risk of stopping (AHR 4.92 and 95% CI: 1.67 to 14.5) and transfer out (AHR 2.70 and 95% CI: 1.75 to 4.17) as final outcome. CONCLUSIONS: Early tracing substantially reduces LTFU; approximately one-third presumed LTFU was found to be still on ART. Children with wasting at initiation and those traced and found to have irregular ART intake require targeted interventions.


Assuntos
Antirretrovirais/administração & dosagem , Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Perda de Seguimento , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco
10.
Br J Neurosurg ; 29(4): 538-43, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25825327

RESUMO

INTRODUCTION: Surgical treatment for chronic subdural haematoma (CSH) has been analysed by applying evidence-based medicine (EBM) criteria earlier. Whether implementation of EBM-derived key factors into an optimised treatment algorithm would improve outcome, however, needs to be clarified. MATERIAL AND METHODS: Symptomatic patients with CSH who fulfilled the inclusion criteria were either assigned to an optimised treatment algorithm (OA-EBM group) or to a control group treated by the standard departmental surgical technique (SDST group) in a prospective design. For the OA-EBM algorithm only one burr hole, extensive intraoperative irrigation and a closed system drainage with meticulous avoidance of entry of air was mandatory. A two-catheter technique was used to reduce intracavital air. Final endpoints were neurological outcome (Markwalder Score), recurrence and the amount of intracranial air. RESULTS: A total of 93 out of 117 patients were evaluated accounting for 113 cases because 20 patients had bilateral haematomas. Demographic data of 68 cases in the SDST group did not differ from 45 cases in the OA-EBM group. The Markwalder Score showed greater improvement in the OA-EBM group (0.5 ± 0.6 vs. 1.0 ± 1.0, p = 0.003). The recurrence rate was 18% (12 patients) in the SDST group versus 2% (1 patient) in the OA-EBM group (p < 0.05). The amount of intracranial air was significantly lower in the OA-EBM group (3.3 ± 5.0 cm(3) vs. 5.2 ± 7.7 cm(3)) with p = 0.04. In the standard group computerised tomography scanning was performed slightly earlier (3 ± 1.7 days vs. 3.6 ± 1.4 days). When comparing only non-recurrent cases in both groups no significant difference was apparent. CONCLUSIONS: Implementation of EBM key factors into a treatment algorithm for CSH can improve neurological outcome in a typical neurosurgical department, reduce recurrence and minimise the amount of postoperative air within the haematoma cavity.


Assuntos
Hematoma Subdural Crônico/cirurgia , Procedimentos Neurocirúrgicos/métodos , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Estudos Prospectivos , Recidiva
11.
Pain Physician ; 18(2): 185-94, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25794205

RESUMO

BACKGROUND: Several mechanisms were suggested in the past to explain the beneficial effect of spinal cord stimulation (SCS) in patients suffering from neuropathic pain. Little is known about potential supraspinal mechanisms. OBJECTIVE: In this study cortical signaling of patients with neuropathic pain and successful long-term treatment with SCS was analyzed. STUDY DESIGN: Observational study. SETTING: University hospital, neurosurgical department, outpatient clinic for movement disorders and pain, institute for cognitive and clinical neuroscience. METHODS: Nine patients with neuropathic pain of a lower extremity with a lasting response to chronic SCS were included. Cortical activity was analyzed using event-related potentials of the electroencephalogram after non-painful and painful stimulation. Each patient was tested under the effect of long-term SCS and 24 hours after cessation of SCS. Cortical areas involved in the peaks of evoked potentials were localized using a source localization method based on a fixed dipole model. RESULTS: Detection threshold and intensity of non-painful stimulation did not differ significantly on both sides. Pain threshold was significantly lower on the neuropathic side under the effect of SCS (P = 0.03). Bilateral pain thresholds were significantly lower (P = 0.03 healthy side, P = 0.003 neuropathic side) in 5 patients with increased pain after cessation of SCS. Under the effect of SCS cortical negativities (N1, N2, N3) and positivities (P1) demonstrated bilaterally comparable amplitudes. After cessation of SCS, decreased threshold for peripheral stimulation resulted in lowered negativities on both sides. The positivity P1 was differentially regulated and was reduced more contralateral to the unaffected side. N2 was localized at the sensory representation of the leg within the homunculus. The main vector of P1 was localized within the cingular cortex (CC) and moved more anteriorly under the effect of SCS. LIMITATIONS: The exact time span that SCS continues to have an effect is not known. However, due to patient discomfort discontinuation of SCS therapy was not prolonged over a 24 hour period. Further limitations were the low number of patients who agreed to discontinue SCS therapy for research purposes. CONCLUSIONS: Long-term SCS for treatment of neuropathic pain influenced both pain thresholds and cortical signalling. Source localization of P1 suggests involvement of regions involved in cognitive/associative processing of pain.


Assuntos
Córtex Cerebral/fisiologia , Potenciais Evocados/fisiologia , Neuralgia/diagnóstico , Neuralgia/terapia , Medição da Dor/métodos , Estimulação da Medula Espinal/métodos , Adulto , Idoso , Eletroencefalografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neuralgia/fisiopatologia , Limiar da Dor/fisiologia , Medula Espinal/fisiologia , Estimulação da Medula Espinal/tendências , Fatores de Tempo
12.
J Neurotrauma ; 31(7): 670-3, 2014 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-24245657

RESUMO

Chronic subdural hematoma (CSH) is characterized by a net increase of volume over time. Major underlying mechanisms appear to be hemorrhagic episodes and a continuous exudation, which may be studied using labeled proteins to yield an exudation rate in a given patient. We tested the hypothesis that the concentration of vascular endothelial growth factor (VEGF) in hematoma fluid correlates with the rate of exudation. Concentration of VEGF was determined in 51 consecutive patients with CSH by the sandwich immune enzyme-linked immunosorbent assay technique. Mean values were correlated with exudation rates taken from the literature according to the appearance of CSH on computed tomography (CT) images. The CT appearance of each CSH was classified as hypodense, isodense, hyperdense, or mixed density. Mean VEGF concentration was highest in mixed-density hematomas (22,403±4173 pg/mL; mean±standard error of the mean; n=27), followed by isodense (9715±1287 pg/mL; n=9) and hypodense (5955±610 pg/mL; n=18) hematomas. Only 1 patient with hyperdense hematoma fulfilled the inclusion criteria, and the concentration of VEGF found in this patient was 24,200 pg/mL. There was a statistically significant correlation between VEGF concentrations and exudation rates in the four classes of CT appearance (r=0.98). The current report is the first to suggest a pathophysiological link between the VEGF concentration and the exudation rate underlying the steady increase of hematoma volume and CT appearance.With this finding, the current report adds another piece of evidence in favor of the pathophysiological role of VEGF in the development of CSH, including mechanisms contributing to hematoma growth and CT appearance.


Assuntos
Hematoma Subdural Crônico/diagnóstico por imagem , Hematoma Subdural Crônico/metabolismo , Fator A de Crescimento do Endotélio Vascular/análise , Fator A de Crescimento do Endotélio Vascular/metabolismo , Idoso , Ensaio de Imunoadsorção Enzimática , Exsudatos e Transudatos/metabolismo , Feminino , Humanos , Masculino , Tomografia Computadorizada por Raios X
13.
PLoS One ; 8(2): e56248, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23457534

RESUMO

BACKGROUND: Smear-positive pulmonary TB is the most infectious form of TB. Previous studies on the effect of HIV and antiretroviral therapy on TB treatment outcomes among these highly infectious patients demonstrated conflicting results, reducing understanding of important issues. METHODS: All adult smear-positive pulmonary TB patients diagnosed between 2008 and 2010 in Malawi's largest public, integrated TB/HIV clinic were included in the study to assess treatment outcomes by HIV and antiretroviral therapy status using logistic regression. RESULTS: Of 2,361 new smear-positive pulmonary TB patients, 86% had successful treatment outcome (were cured or completed treatment), 5% died, 6% were lost to follow-up, 1% failed treatment, and 2% transferred-out. Overall HIV prevalence was 56%. After adjusting for gender, age and TB registration year, treatment success was higher among HIV-negative than HIV-positive patients (adjusted odds ratio 1.49; 95% CI: 1.14-1.94). Of 1,275 HIV-infected pulmonary TB patients, 492 (38%) received antiretroviral therapy during the study. Pulmonary TB patients on antiretroviral therapy were more likely to have successful treatment outcomes than those not on ART (adjusted odds ratio : 1.83; 95% CI: 1.29-2.60). CONCLUSION: HIV co-infection was associated with poor TB treatment outcomes. Despite high HIV prevalence and the integrated TB/HIV setting, only a minority of patients started antiretroviral therapy. Intensified patient education and provider training on the benefits of antiretroviral therapy could increase antiretroviral therapy uptake and improve TB treatment success among these most infectious patients.


Assuntos
Antirretrovirais/uso terapêutico , Antituberculosos/uso terapêutico , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/tratamento farmacológico , Adolescente , Adulto , Coinfecção/complicações , Coinfecção/tratamento farmacológico , Feminino , HIV/efeitos dos fármacos , HIV/isolamento & purificação , Infecções por HIV/epidemiologia , Humanos , Pulmão/microbiologia , Pulmão/virologia , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/isolamento & purificação , Resultado do Tratamento , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/epidemiologia , Adulto Jovem
14.
Pediatrics ; 130(4): e966-77, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22987878

RESUMO

BACKGROUND: Poor growth is an indication for antiretroviral therapy (ART) and a criterion for treatment failure. We examined variability in growth response to ART in 12 programs in Malawi, Zambia, Zimbabwe, Mozambique, and South Africa. METHODS: Treatment naïve children aged <10 years were included. We calculated weight for age z scores (WAZs), height for age z scores (HAZs), and weight for height z scores (WHZs) up to 3 years after starting ART, by using the World Health Organization standards. Multilevel regression models were used. RESULTS: A total of 17990 children (range, 238-8975) were followed for 36181 person-years. At ART initiation, most children were underweight (50%) and stunted (66%). Lower baseline WAZ, HAZ, and WHZ were the most important determinants of faster catch-up growth on ART. WAZ and WHZ increased rapidly in the first year and stagnated or reversed thereafter, whereas HAZ increased continuously over time. Three years after starting ART, WAZ ranged from -2.80 (95% confidence interval [CI]: -3.66 to -2.02) to -1.98 (95% CI: -2.41 to -1.48) in children with a baseline z score < -3 and from -0.79 (95% CI: -1.62 to 0.02) to 0.05 (95% CI: -0.42 to 0.51) in children with a baseline WAZ ≥ -1. For HAZ, the corresponding range was -2.33 (95% CI: -2.62 to -2.02) to -1.27 (95% CI: -1.58 to -1.00) for baseline HAZ < -3 and -0.24 (95% CI: -0.56 to 0.15) to 0.84 (95% CI: 0.53 to 1.16) for HAZ ≥ -1. CONCLUSIONS: Despite a sustained growth response and catch-up growth in children with advanced HIV disease treated with ART, normal weights and heights are not achieved over 3 years of ART.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Transtornos do Crescimento/etiologia , Crescimento/efeitos dos fármacos , Infecções por HIV/tratamento farmacológico , Magreza/etiologia , África Austral , Fármacos Anti-HIV/farmacologia , Criança , Pré-Escolar , Feminino , Seguimentos , Infecções por HIV/complicações , Humanos , Masculino , Modelos Estatísticos , Análise de Regressão , Resultado do Tratamento
15.
J Int AIDS Soc ; 15(2): 17432, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22905359

RESUMO

BACKGROUND: In Malawi, as in other sub-Saharan African countries, nurses manage patients of all ages on antiretroviral treatment(ART). Nurse management of children is rarely studied.We compare ART prescribing between nurses and clinical officers during routine clinic visits at an urban, public clinic to inform policy in paediatric ART management. METHODS: Caregivers of children on first-line ART provided information about visit dates, pill counts, ART dosage and formulation to a nurse and, subsequently, to a clinical officer. Nurses and clinical officers independently calculated adherence, dosage based on body weight, and set next appointment date. Clinical officers, but not nurses, accessed an electronic data system that made the calculations for them based on information from prior visits, actual and expected pill consumption, and standard drug supplies. Nurses calculated with pen and paper. For numerical variables, Bland-Altman graphs plot differences of each nurse clinical officer pair against the mean, show the 95% limits of agreement (LoA), and also show the mean difference across all reviews. Kappa statistics assess agreement for categorical variables. RESULTS: A total of 704 matched nurse clinical officer reviews of 367 children attending the ART clinics between March and July 2010 were analyzed. Eight nurses and 18 clinical officers were involved; two nurses and five clinical officers managed 100 visits or more. Overall, there was a good agreement between the two cadres. Differences between nurses and clinical officers were within narrow LoA and mean differences showed little deviation from zero, indicating little skewing towards one cadre. LoA of adherence and morning and evening ART dosages varied from -24% to 24%, -0.4 to 0.4 and -0.41 to 0.40 tablets,respectively, with mean differences (95% CI) of 0.003 (-0.9, 0.91), -0.005 (-0.02, 0.01) and -0.009 (-0.02, 0.01). Next appointment calculations differed more between cadres with LoA from -40 to 42 days [mean difference: 0.96 days (95%CI:-0.6 to 2.5)], but agreement in the ART formulation prescribed was very good (kappa 0.93). CONCLUSIONS: Nurses' ART prescribing practices and calculations of adherence and next appointments are similar to clinical officers, although clinical officers used an electronic system. Our findings support the decision of Malawi's health officials to utilize nurses to manage paediatric ART patients.


Assuntos
Antirretrovirais/administração & dosagem , Terapia Antirretroviral de Alta Atividade/métodos , Assistência à Saúde/métodos , Infecções por HIV/tratamento farmacológico , Pesquisa sobre Serviços de Saúde , Adesão à Medicação/estatística & dados numéricos , Agendamento de Consultas , Criança , Pré-Escolar , Assistência à Saúde/organização & administração , Feminino , Pessoal de Saúde , Humanos , Malaui , Masculino , População Urbana
16.
Clin Infect Dis ; 54 Suppl 4: S355-61, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22544203

RESUMO

In 2004, Malawi began scaling up its national antiretroviral therapy (ART) program. Because of limited treatment options, population-level surveillance of acquired human immunodeficiency virus drug resistance (HIVDR) is critical to ensuring long-term treatment success. The World Health Organization target for clinic-level HIVDR prevention at 12 months after ART initiation is ≥ 70%. In 2007, viral load and HIVDR genotyping was performed in a retrospective cohort of 596 patients at 4 ART clinics. Overall, HIVDR prevention (using viral load ≤ 400 copies/mL) was 72% (95% confidence interval [CI], 67%-77%; range by site, 60%-83%) and detected HIVDR was 3.4% (95% CI, 1.8%-5.8%; range by site, 2.5%-4.7%). Results demonstrate virological suppression and HIVDR consistent with previous reports from sub-Saharan Africa. High rates of attrition because of loss to follow-up were noted and merit attention.


Assuntos
Antirretrovirais/farmacologia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Adulto , Antirretrovirais/uso terapêutico , Farmacorresistência Viral , Feminino , HIV/efeitos dos fármacos , HIV/genética , Infecções por HIV/virologia , Humanos , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Vigilância da População , Estudos Retrospectivos , Resultado do Tratamento , Carga Viral , Organização Mundial da Saúde
17.
Trop Med Int Health ; 17(6): 751-9, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22487553

RESUMO

OBJECTIVES: HIV-infected women identified through antenatal care (ANC) often fail to access antiretroviral treatment (ART), leaving them and their infants at risk for declining health or HIV transmission. We describe results of measures to improve uptake of ART among eligible pregnant women. METHODS: Between October 2006 and December 2009, interventions implemented at ANC and ART facilities in urban Lilongwe aimed to better link services for women with CD4 counts <250/µl. A monitoring system followed women referred for ART to examine trends and improve practices in referral completion, on-time ART initiation and ART retention. RESULTS: Six hundred and twelve women were ART eligible: 604 (99%) received their CD4 result, 344 (56%) reached the clinic, 286 (47%) started ART while pregnant and 261 (43%) were either alive on ART or transferred out after 6 months. Between 2006 and 2009, the median (IQR) time between CD4 blood draw and ART initiation fell from 41 days (17, 349) to 15 days (7,42) (P = 0.183); the proportion of eligible individuals starting ART while pregnant and retained for 6 months improved from 17% to 65% (P < 0.001). Delays generally shortened within the continuum of care from 2006 to 2009; however, time from CD4 blood draw to ART referral increased from 7 to 14 days. CONCLUSIONS: Referrals between facilities and delays through CD4 count measurements create bottlenecks in patient care. Retention improved over time, but delays within the linkage process remained. ART initiation at ANC plus use of point-of-care CD4 tests may further enhance ART uptake.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade/métodos , Infecções por HIV/tratamento farmacológico , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Complicações Infecciosas na Gravidez/tratamento farmacológico , Cuidado Pré-Natal/métodos , Encaminhamento e Consulta/organização & administração , Adolescente , Adulto , Contagem de Linfócito CD4 , Estudos de Coortes , Continuidade da Assistência ao Paciente/organização & administração , Feminino , Seguimentos , Infecções por HIV/imunologia , Infecções por HIV/transmissão , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Malaui , Sistemas Automatizados de Assistência Junto ao Leito , Gravidez , Complicações Infecciosas na Gravidez/imunologia , População Urbana/estatística & dados numéricos , Adulto Jovem
18.
J Synchrotron Radiat ; 19(Pt 2): 216-22, 2012 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22338682

RESUMO

A new sputtering system for in situ X-ray experiments during DC and RF magnetron sputtering is described. The outstanding features of the system are the modular design of the vacuum chamber, the adjustable deposition angle, the option for plasma diagnostics, and the UHV sample transfer in order to access complementary surface analysis methods. First in situ diffraction and reflectivity measurements during RF and DC deposition of vanadium carbide demonstrate the performance of the set-up.

19.
AIDS ; 26(3): 365-73, 2012 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-22095194

RESUMO

OBJECTIVES: To analyse mortality, loss to follow-up (LTFU) and retention on antiretroviral treatment (ART) in the first year of ART across all age groups in the Malawi national ART programme. DESIGN: Cohort study including all patients who started ART in Malawi's public sector clinics between 2004 and 2007. METHODS: ART registers were photographed, information entered into a database and merged with data from clinics with electronic records. Rates per 100 patient-years and cumulative incidence of retention were calculated. Subhazard ratios (sHRs) of outcomes adjusted for patient and clinic-level characteristics were calculated in multivariable analysis, applying competing risk models. RESULTS: A total of 117,945 patients contributed 85,246 person-years: 1.0% were infants below 2 years, 7.4% children 2-14, 7.5% young people 15-24, and 84.2% adults 25 years and above. Sixty percent of patients were female: women outnumbered men from age 14 to 35 years. Mortality and LTFU were higher in men from age 20 years. Infants and young people had the highest rates per 100 person-years for mortality (23.0 and 19.4) and LTFU (24.7 and 19.3), and the highest adjusted relative risks compared to age group 25-34 years: sHRs were 1.37 [95% confidence interval (CI) 1.17-1.60] and 1.17 (95% CI 1.10-1.25) for death and 1.37 (95% CI 1.18-1.59) and 1.27 (95% CI 1.19-1.35) for LTFU, respectively. CONCLUSION: In this country-wide study patients aged 0-1 and 15-24 years had the highest risk of death and LTFU, and from age 20 men were at higher risk than women. Interventions to improve outcomes in these patient groups are required.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/mortalidade , Acesso aos Serviços de Saúde/estatística & dados numéricos , Perda de Seguimento , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Contagem de Linfócito CD4 , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Seguimentos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Acesso aos Serviços de Saúde/economia , Humanos , Incidência , Lactente , Recém-Nascido , Malaui/epidemiologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Distribuição por Sexo , Adulto Jovem
20.
Trop Med Int Health ; 17(2): 169-76, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22039960

RESUMO

OBJECTIVES: Evaluating treatment failure is critical when deciding to modify antiretroviral therapy (ART). Virologic Assessment Forms (VAFs) were implemented in July 2008 as a prerequisite for ordering viral load. The form requires assessment of clinical and immunologic status. METHODS: Using the Electronic Medical Record (EMR), we retrospectively evaluated patients who met 2006 WHO guidelines for immunologic failure (≥15 years old; on ART ≥6 months; CD4 count 50% drop from peak OR CD4 persistently <100 cells) at the Lighthouse Trust clinic from December 2007 to December 2009. We compared virologic screening, VAF implementation and ART modification during the same period using Fisher's exact tests and unpaired t-tests as appropriate. RESULTS: Of 7000 enrolled ART patients ≥15 years old with at least two CD4 counts, 10% had immunologic failure with a median follow-up time on ART of 1.4 years (IQR: 0.8-2.3). Forty (6%) viral loads were ordered: 14 (35%) were detectable (>400 HIV RNA copies/mL) and one (7%) patient was switched to second-line therapy. Overall, 259 VAFs were completed: 67% for immunologic failure and 33% for WHO Stage 4 condition. Before VAF implementation, 1% of patients had viral loads drawn during routine care, whereas afterwards, 8% did (P<0.0001; 95% CI: 0.03-0.08). CONCLUSIONS: Clinicians did not identify a large proportion of immunologic failure patients for screening. Implementation of VAFs produced little improvement in virologic screening during routine care. Better training and monitoring systems are needed.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Contagem de Linfócito CD4 , Infecções por HIV/tratamento farmacológico , Carga Viral , Adolescente , Instituições de Assistência Ambulatorial , Registros Eletrônicos de Saúde , Feminino , Guias como Assunto , Infecções por HIV/imunologia , Infecções por HIV/virologia , Humanos , Malaui , Masculino , Estudos Retrospectivos , Falha de Tratamento , Organização Mundial da Saúde , Adulto Jovem
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