TB preventive therapy preferences among children and adolescents

BACKGROUND: TB preventive therapy (TPT) is critical for ending TB, yet implementation remains poor. With new global guidelines expanding TPT eligibility and regimens, we aimed to understand TPT preferences among children, adolescents and caregivers.METHODS: We undertook a discrete choice experiment among 131 children, 170 adolescents and 173 caregivers, and conducted 17 in-depth interviews in 25 clinics in Cape Town, South Africa. The design included attributes for location, waiting time, treatment duration, dosing frequency, formulation/size, side effects, packaging and taste. Mixed-effects logistic regression models were used for analysis.RESULTS: Among children and caregivers, the number and size of pills, taste and side effects were important drivers of preferences. Among adolescents and caregivers, clinic waiting times and side effects were significant drivers of preferences. Adolescents expressed concerns about being stigmatised, and preferred services from local clinics to services delivered in the community. Dosing frequency and treatment duration were only significant drivers of choice among adolescents, and only if linked to fewer clinic visits.CONCLUSIONS: Introducing shorter TPT regimens in isolation without consideration of preferences and health services may not have the desired effect on uptake and completion. Developing TPT delivery models and formulations that align with preferences must be prioritised.

Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the Telehealth Eye and Associated Medical Services Network [TEAMSnet] project

AIM

There is a wealth of data concerning the health behaviours of Indigenous Australians, but the health behaviours of Indigenous Australians with diabetes are not systematically documented. At the clinical level, understanding a person's health behaviours can help identify and address barriers to diabetes care and promote good clinical outcomes.

METHODS

We used a novel survey tool to systematically collect health behaviour data on Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional well-being (SNAPE) from Indigenous Australians with Type 2 diabetes in a remote primary care setting in Alice Springs.

RESULTS

At least one of the five surveys in the SNAPE tool was completed by 210 participants: 30% male, mean age 52.6 years (range 22.9 - 87.4). Fifty per cent of men and 23% of women were current smokers (P < 0.001). None of the participants reported an adequate intake of vegetables. Only 9.6% reported an adequate fruit intake. Some 49% of men and 32% of women consumed alcohol in the past year (P = 0.022), and 46% of drinkers were considered high-risk or likely-dependent drinkers. On average, participants walked 10 min or more at a time 6.0 days a week and spent 4.8 h sitting on a weekday. Mean adapted Patient Health Questionnaire 9 score was 4.61, with 34% of participants having mild depressive symptoms and 11% having moderate-severe depressive symptoms.

CONCLUSIONS

Our SNAPE survey tool results present a high-risk, disadvantaged Indigenous population with Type 2 diabetes. More resources will be needed to sustainably implement interventions with the goal of improving health behaviours and subsequent long-term health.

When prevention is dangerous: perceptions of isoniazid preventive therapy in KwaZulu-Natal, South Africa

Setting

In 2011, the South African government began to offer isoniazid preventive therapy (IPT) through the public health system to presumptively treat latent tuberculous infection (LTBI) among people living with human immunodeficiency virus.

Objective

To describe IPT perceptions and experiences in three Zulu communities in KwaZulu-Natal Province, South Africa.

Design

Using a combination of community-based research and ethnographic methods, we undertook 17 individual and group interviews between October 2014 and May 2015. Interviews transcripts were analysed using qualitative content analysis and validated with grass-roots community advisors.

Results

Participants reported multiple ways in which IPT was perceived as dangerous: when costs related to pill collection or consumption were unsustainable, or when daily pill consumption resulted in stigma or was seen to introduce excess dirt or toxins, 'ukungcola', in the body. Theories on dirt are evoked to describe how IPT was perceived as 'matter out of place' when given to people who believed themselves to be healthy, suggesting that under the current TB aetiological model in Zulu culture, 'prevention as tablet' may not fit.

Conclusion

Implementing IPT without understanding the realities of community stakeholders can unintentionally undermine TB control efforts by worsening the situation for people who already encounter numerous daily problems.

Diabetic retinopathy in a remote Indigenous primary healthcare population: a Central Australian diabetic retinopathy screening study in the Telehealth Eye and Associated Medical Services Network project

AIM

To determine diabetic retinopathy prevalence and severity among remote Indigenous Australians.

METHODS

A cross-sectional diabetic retinopathy screening study of Indigenous adults with Type 2 diabetes was conducted by locally trained non-ophthalmic retinal imagers in a remote Aboriginal community-controlled primary healthcare clinic in Central Australia and certified non-ophthalmic graders in a retinal grading centre in Melbourne, Australia. The main outcome measure was prevalence of any diabetic retinopathy and sight-threatening diabetic retinopathy.

RESULTS

Among 301 participants (33% male), gradable image rates were 78.7% (n = 237) for diabetic retinopathy and 83.1% (n = 250) for diabetic macular oedema, and 77.7% (n = 234) were gradable for both diabetic retinopathy and diabetic macular oedema. For the gradable subset, the median (range) age was 48 (19-86) years and known diabetes duration 9.0 (0-24) years. The prevalence of diabetic retinopathy was 47% (n = 110) and for diabetic macular oedema it was 14.4% (n = 36). In the fully gradable imaging studies, sight-threatening diabetic retinopathy prevalence was 16.2% (n = 38): 14.1% (n = 33) for clinically significant macular oedema, 1.3% (n = 3) for proliferative diabetic retinopathy and 0.9% (n = 2) for both. Sight-threatening diabetic retinopathy had been treated in 78% of detected cases.

CONCLUSIONS

A novel telemedicine diabetic retinopathy screening service detected a higher prevalence of 'any' diabetic retinopathy and sight-threatening diabetic retinopathy in a remote primary care setting than reported in earlier surveys among Indigenous and non-Indigenous populations. Whether the observed high prevalence of diabetic retinopathy was attributable to greater detection, increasing diabetic retinopathy prevalence, local factors, or a combination of these requires further investigation and, potentially, specific primary care guidelines for diabetic retinopathy management in remote Australia. Clinical Trials registration number: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN 12616000370404.

Incorporating Individual Patient Preferences in Scheduling Bitewing Radiographs

Concern about the potential risks of low dose radiation has focussed increased attention on the question of how often to perform bitewing radiographs. To consider this question, a mathematical model was developed that describes the initiation and progression of dental caries on the approximal surfaces of permanent teeth. This model enables calculation of benefit as a function of the frequency of bitewing radiographs. The model does not, however, capture patients’ (and dentists’) subjective attitudes towards various outcomes such as dollar costs, radiation exposure, inconvenience of treatment, anxiety and pain. This paper presents a multiattribute utility approach to quantifying patient preferences for possible outcomes of decisions on radiographic frequencies. Five relevant attributes are considered and reduced to two, over which a quasi-additive utility function is found plausible. The paper demonstrates the assessment method and presents aggregate data from a group of individuals.

Diagnostic accuracy of the Xpert® MTB/RIF assay for extra-pulmonary tuberculosis: a meta-analysis

BACKGROUND

Xpert(®) MTB/RIF is a commercially available nucleic acid amplification test developed for the diagnosis of pulmonary tuberculosis (PTB).

OBJECTIVE

To determine the diagnostic accuracy of Xpert for the detection of extra-pulmonary tuberculosis (EPTB).

METHODS

We searched MEDLINE, EMBASE and Global Health databases from January 2010 to 15 August 2014 for studies of diagnostic performance in which Xpert was examined against culture for patients with clinically suspected EPTB. Bivariate random effects models were used to provide pooled estimates of diagnostic accuracy.

RESULTS

Thirty-six studies were identified, with a pooled sensitivity and specificity of respectively 77% (95%CI 66-85) and 97% (95%CI 94-98). Substantial variations existed between study estimates of sensitivity (I(2) = 99%) and specificity (I(2) = 96%). Among site-specific estimates for lymph, pleural fluid, cerebrospinal fluid, gastro-intestinal and urinary samples, the pooled sensitivity was lower in pleural fluid (37%, 95%CI 26-50, meta-regression P < 0.001) and higher in lymph node samples (87%, 95%CI 75-95, meta-regression P = 0.03).

CONCLUSION

Xpert has high specificity but limited sensitivity for the detection of EPTB. Although positive Xpert test results may be useful in rapidly identifying EPTB cases, negative test results provide less certainty for ruling out disease.

A population-based study of tuberculosis epidemiology and innovative service delivery in Canada

OBJECTIVE

To compare and interpret tuberculosis (TB) incidence rates in a Canadian population across two decennials (1989-1998 and 1999-2008) as a benchmark for World Health Organization targets and the long-term goal of TB elimination. The population under study was served by two urban clinics in the first decennial and two urban and one provincial clinic in the second.

METHODS

TB rates among Status Indians, Canadian-born 'others' and the foreign-born were estimated using provincial and national databases. Program performance was measured in on-reserve Status Indians in each decennial.

RESULTS

In each decennial, the incidence rate in Status Indians and the foreign-born was greater than that in the Canadian-born 'others'; respectively 27.7 and 33.0 times in Status Indians, and 8.0 and 20.9 times in the foreign-born. Between decennials, the rate fell by 56% in Status Indians, 58% in Canadian-born 'others', and 18% in the foreign-born. On-reserve Status Indians had higher rates than off-reserve Status Indians, and the three-clinic model out-performed the two-clinic model among those on-reserve. Rates in the foreign-born varied by World Bank region, and were highest among those from Africa and Asia.

CONCLUSION

Status Indians and the foreign-born are at increased risk of TB in Canada. Significant progress towards TB elimination has been made in Status Indians but not in the foreign-born.

[An exceptional etiology of left ventricular aneurysm: type AA amyloidosis]

Left ventricular aneurysms most often occur in the course of myocardial infarction. In rare cases they can be detected when the coronary network is devoid of any lesions. The aetiology is therefore multiple and dependent on the context. One aetiology seems less exceptional and concerns idiopathic aneurysms encountered in the African population, where the role of a "debilitating condition" such as tuberculosis has been evoked. We report the case history of a young patient from Zaire with a left ventricular aneurysm discovered in association with ganglionic tuberculosis complicated by AA amyloidosis. Histological analysis allowed the aetiological diagnosis to be established. Aneurysmal dilatation of the left ventricle was reported in the presence of amyloid deposits at the intra-myocardial arteriole level, whereas the context suggested a tubercular role. In spite of the difficulty of establishing a precise aetiological diagnosis, there seems to exist a consensus for surgical management.

Beta-2 microglobulin as a marker for HIV infection

Beta-2 microglobulin is a sensitive surrogate test for HIV infection for use in jurisdictions where HIV antibody tests are not allowed to be performed on life insurance applicants by law/regulation. The advantage of beta-2 microglobulin over T cell testing, which is a surrogate test also used by the life insurance industry for detecting HIV infection, is the stability of B 2M in serum over long periods of time.

Statistical analysis of HIV seropositive results from 1988-1993 performed on life insurance applicants

This review of statistical data, derived from HIV antibody testing performed on life insurance applicants over a period of five and one-half years, reflects the evolving nature of the HIV epidemic in the United States and demonstrates how the findings in the life insurance low risk population mirror the trends and changes that are occurring in the general population.

Sex, alcohol and violence: a community collaborative action against striptease shows

Between September 1988 and February 1989, Anyinginyi Congress, an Aboriginal community-controlled health organisation, facilitated a collaborative community action against striptease shows in public bars in Tennant Creek. This action resulted in changes to the guidelines of the Northern Territory Liquor Act to regulate striptease shows in public bars and began other processes of addressing alcohol related problems in the community. The composition and strategies of both the pro- and anti-striptease lobbies are analysed within the context of changing power relationships between Aboriginal and non-Aboriginal people, as epitomised in the growth and consolidation of Aboriginal community-controlled organisations in Tennant Creek. The role of the media in shaping the course and direction of the debates as well as the response of the Northern Territory government as the final arbiter in the striptease conflict are scrutinised. The use of sex to sell alcohol is a legitimate public health concern and community action for healthier public policy is an important strategy in creating supporting environments for health.

Longitudinal evaluation of condylar position in extraction and nonextraction treatment

In 111 patients pretreatment and posttreatment condylar position was evaluated with corrected tomograms taken with the mandible in centric occlusion. Seventy-nine of the patients were treated by nonextraction procedures and 32 were treated by extraction procedures, 27 of the patients with the extraction of one or more premolars and 5 with the extraction of one or more anterior teeth. When the condylar positions before and after treatment were compared in the entire sample of 111 patients, in the nonextraction patients, in the extraction patients, and in extraction patients relative to nonextraction patients, no statistically significant differences were found. Thus condylar position was stable during treatment and did not behave differently under extraction and nonextraction conditions. On an individual basis, condylar retropositioning, as defined in this study, occurred in only nine of the 222 joints examined and was noted in patients treated both with and without extraction.

Condylar position and maxillary first premolar extraction

Condylar position in 17 patients whose Class II treatment (14 with edgewise appliances and 3 with Begg appliances) included extraction of the maxillary first premolars and in 17 control patients was compared by means of corrected tomography. The condyles in both groups were in an anterior position, and there were no statistical differences between the groups. In addition, no statistical correlation was found when the posttreatment bite depth, interincisal angle, and maxillary incisor inclination were correlated with condylar position. Thus, as determined in this study, condylar position was unrelated to treatment, bite depth, interincisal angle, and maxillary incisor inclination.

Condylar position and Class II deep-bite, no-overjet malocclusions

By means of corrected tomography, the positions of the condyles in 19 click-free persons with Class II malocclusions characterized by a bite depth greater than 50%, no overjet, and an interincisal angle of greater than 140 degrees were compared with a positions of the condyles in 21 control subjects. Average condylar position in both groups was concentric and no significant differences between groups were found. In addition, no significant correlation was noted when condylar position was related to bite depth.

The frequency of bitewing radiographs

A model for use in analyzing the implications of different rates of caries incidence and progression for the timing of bitewing radiographs was developed. Estimates of progression rates and incidence patterns were derived from an analysis of serial bitewing radiographs. A time schedule for taking the next radiographs was determined so that carious lesions would be detected before radiolucencies reach the inner half of the dentin. For asymptomatic persons with extensive exposure to fluorides and no unrestored enamel lesions on the last radiographs, bitewing films could be scheduled every 2.5 to 3 years. For persons with little exposure to fluorides or with many early enamel lesions or at least one deep enamel lesion that has not been restored, radiographs should be performed every 6 months to 1 year.

The expected benefits from alternative frequencies of bitewing radiograms

From an analysis of serial bitewing radiograms, we have developed a mathematical model of the initiation and progression of approximal carious lesions in the permanent teeth. The model is used to estimate the expected number of lesions, per individual, not detected until they reach the inner half of the dentin, as a function of the frequency with which radiograms are taken between the ages of 8 and 20 years. If radiograms are performed every 6 months and lesions not restored until radiolucencies appear in the dentin, under 5% of all lesions developing over the 12-year period will reach the inner half of the dentin before detection. If radiograms are taken every 2 years, about 18% of all lesions will have reached the inner half of the dentin before detection. The sensitivity of these conclusions to different assumptions is examined.

A deep model of the incidence of dental caries on proximal surfaces

As a component of an analysis of the benefits of alternative frequencies of bitewing radiographs to detect dental caries, the authors developed and validated a model to generate an individual's probability distribution for new carious lesions in a year. The model postulates two sources of variability in caries incidence--differences in individuals' underlying caries susceptibilities and a random component. The model is used to examine the nature of caries risk over time. The large random fluctuations in an individual's caries susceptibility from year to year, combined with the random nature of caries attack, makes it difficult to predict future caries experience from the individual's caries experience in the recent past. By modeling the process giving rise to observed incidence data rather than focusing directly on the observed data, i.e., by developing a deep rather than a surface model, the authors have elucidated underlying disease dynamics and provided a basis for generalizing from the particular data used to develop the model.

Reliability of coding depth of approximal carious lesions from non-independent interpretation of serial bitewing radiographs

In order to help understand the effectiveness of preventive care and the source of variation in treatment decisions, it is important to determine intra- and interexaminer agreement on the presence and depth of radiolucencies on bitewing radiographs when serial radiographs on individuals are available for interpretation. Serial radiographs on 24 subjects were read in succession, and one of four depth codes was assigned to approximal lesions. The radiographs were then read a second time, both by the person who had initially read the radiographs and by a second reader. Intraexaminer agreement on presence of a lesion ranged from 60% to 90%; four of the five readers had an agreement of over 78%. Interexaminer agreement on presence of a lesion ranged from 71% to 84%. Intraexaminer agreement on depth of lesion ranged from 64% to 80%; four readers had an agreement of over 73%. Interexaminer agreement on depth of lesion ranged from 59% to 76%.

Study design to reduce biases in estimating the percentage of carious lesions that do not progress within a time period

Much of the available information on the rate of caries progression comes from studies in which two examinations have been done and the percentage of lesions that do not progress from a carious state between the examinations recorded. Extrapolation from this type of study is subject to two offsetting biases. On the one hand, slow progressing lesions that have been in a state for a long time before the first examination may progress between examinations. When these are counted as lesions that progress within the time period between the two examinations, there will be an underestimation of non-progressing lesions. On the other hand, slow progressing lesions will be over-represented in the sample of lesions detected at the first examination. This will result in an overestimation of non-progressing lesions. We suggest a three examination protocol to minimize these biases.

Use of the Kaplan-Meier estimate to reduce biases in estimating the rate of caries progression

An important determinant of how often to perform dental radiography is how rapidly dental caries progress. Estimates of the rate of progression of dental caries have been biased by the elimination of filled lesions and non-progressing lesions (i.e. censored data) from the analysis. We illustrate the use of the Kaplan-Meier estimate to incorporate information from these cases and demonstrate the effect of using this information on estimates of the rate of progression of approximal caries.

A longitudinal analysis from bite-wing radiographs of the rate of progression of approximal carious lesions through human dental enamel

Four to ten years of serial bite-wing radiographs from over 700 children from five groups, three in Sweden and two in the U.S., were interpreted. By analysing changes in the depth of unfilled lesions over time, the mean time and probability distribution for the time a lesion remains in both the outer half and inner half of the enamel were estimated. The procedure incorporated information on filled lesions and non-progressing lesions and thus minimized bias that results in overestimation of the progression rate. In primary teeth, in both the U.S. and Swedish groups, it took on average 12 months for a lesion to progress through the outer half of the enamel and on average 10-12 months for a lesion to progress through the inner half. In newly-erupted first permanent molars, it took 21-23 months for a lesion to progress through the outer half of the enamel and between 19 (U.S. data) and 28 months (Swedish data) for progression through the inner half. In older adolescents in the two Swedish groups, progression was slower: 38-41 months through the outer-half and 47-56 months through the inner-half. In older U.S. adolescents, progression appeared to be more rapid: 16 months through the outer half of the enamel and 27 months through the inner half. The duration of time a lesion remains in different halves of the enamel could be approximated by a piecewise exponential or exponential probability distribution, which exhibits extreme variability. Assuming duration in each half of the enamel follows an exponential distribution with a mean of 2 yr, about 10 per cent of new lesions will progress through the enamel in one year and 25 per cent in two years. However, over 40 per cent of the lesions will not have progressed in 4 yr. There were no consistent differences in the rate of progression by sex, between upper and lower dentitions, for premolars versus molars, or between high and low-risk individuals.

The combined reversible hydrocolloid/irreversible hydrocolloid impression system

1. Dentloid, a reversible hydrocolloid which had been altered to bond to irreversible hydrocolloid, demonstrated a bond with three irreversible hydrocolloids tested in combination with it. 2. Two conventional reversible hydrocolloids exhibited such weak bonding with irreversible hydrocolloid that it was impossible to make impressions with them. 3. The three irreversible hydrocolloids exhibited different bond strengths with Dentloid. 4. The Dentloid/irreversible hydrocolloid combination with the lowest bond strength exhibited the lowest dimensional stability. 5. Combined impressions of Dentloid with two of the three irreversible hydrocolloids exhibited dimensional stability that is a clinically acceptable. 6. Combinations of Dentloid with irreversible hydrocolloids not covered in this report should be verified for acceptable dimensional stability before clinical use. 7. The combination technique, in itself, proved to be easy and practical and overcomes many of the shortcomings inherent to conventional reversible hydrocolloid impression techniques. 8. Strict adherence to laboratory procedures for pouring a cast is as critical as for the conventional technique.

Hearing loss and the high speed dental handpiece

A pure tone air conduction audiometric evaluation was administered to 137 dentists and 80 physicians. The physicians were found to have better hearing threshold levels, notably in the 4000HZ center frequency range. The left ear of right handed dentists showed a greater loss of hearing ostensibly related to proximity to the noise source. Dental specialists showed a loss pattern similar to those of the general dentists. The findings suggest that there may be a cause and effect relationship between hearing loss and use of the highspeed dental handpiece.

A longitudinal study of multiple approaches to dental health education

An evaluation was made of the separate effects on oral hygiene of token reward treatments, discovery (project) learning, and plaque staining feedback demonstrations with children in the first through fifth grades. Both short- and long-term effects were assessed in an open classroom setting. Twenty classrooms were non-randomly assigned to treatment and control groups. Plaque scores were recorded according to the Podshadley Patient Hygiene Performance Index (PHP) at time T0, before initiation of any of the educational interventions; and again at times T1, T2, and T3; 7 days, 74 days and 255 days, respectively, following cessation of the educational interventions. The combination of dental health interventions at this school had short-range effects at every grade level, and those effects persisted for 9 months among the third and fourth graders. It was not possible to identify which of the various treatments produced the observed differences, although the project learning method was generally less effective. A linear regression analysis was used to evaluate the shifts in oral hygiene behavior, a method not previously used in studies of this type.

A study of "broken appointment" patients in a children's hospital dental clinic

Part I of this study investigated possible variables determining "High Risk No Show" behavior on the part of patients in a dental clinic. Only "source of payment" seemed important; namely, that Medicaid patients were statistically more likely to be "High Risk No Show" patients (P less than .001). Race was associated but was found to be confounded with Medicaid. In an attempt to investigate the reasons for the Medicaid group being "High Risk No Show" patients, Part II of the study compared three distinct groups of patients at the Children's Hospital Medical Center Clinic. These included the self-paying group and the Medicaid group of the original sample of 90 in addition to the Union plan group (patients receiving free third-party payment care as an employee benefit). It was shown that both groups with third-party coverage were associated with "High Risk No Show" behavior. The type of "No Show" behavior, however, was different for the two groups. Union plan patients tended to cancel appointments or at least notify in advance of inability to keep an appointment. Medicaid patients, conversely, were just as likely to fail appointments and not file advance notice of inability to keep an appointment.