Evaluation of the impact of PEPFAR transition on retention in care in South Africa's Western Cape Province

BACKGROUND

Research on the impact of the US President's Emergency Plan for AIDS Relief (PEPFAR) transition in South Africa (SA) in 2012 found varying results in retention in care (RIC) of people living with HIV (PLWH).

OBJECTIVES

To investigate the factors that impacted RIC during the PEPFAR transition in Western Cape Province, SA, in 2012.

METHODS

We used aggregate data from 61 facilities supported by four non-governmental organisations from 2007 to 2015. The main outcome was RIC 12 months after antiretroviral therapy initiation for two periods - during PEPFAR and post PEPFAR. We used adjusted quantile regression to estimate the effect of the PEPFAR pull-out on RIC.

RESULTS

Regression models (50th quantile) for 12-month RIC showed a 4.0% (95% CI -7.7 - -0.4%) decline in RIC post-direct service. Facilities supported by Anova/Kheth'impilo fared worst post PEFPAR, with a decline in RIC of -4.9% (95% CI -8.8 - -1.0%), while TB, HIV/AIDS, Treatment Support, and Integrated Therapy (that'sit) fared best (3.6% increase in RIC; 95% CI: -0.2 - 7.3%). There was a decrease in RIC when comparing urban with rural areas (-7.8%; 95% CI -12.8 - -2.9%). City of Cape Town combined with Western Cape Government health facilities showed a substantial decrease (-6.1%; 95% CI -10.6 - -1.7%), while community health clinic (v. central day clinics) declined (-6.4; 95% CI -10.6 - -2.1%) in RIC. We observed no RIC difference by facility size and a slight increase when two or more human resources transitioned from PEPFAR to the government.

CONCLUSION

When PEPFAR funding decreased in 2012, there was a decrease in RIC. To ensure the continuity of HIV care when a major funder withdraws sufficient and stable transition resources, investment in organisations that understand the local context, joint planning and co-ordination are required.

Changing environmental conditions have altered the feeding ecology of two keystone Arctic marine predators

Environmental change in the Arctic has impacted the composition and structure of marine food webs. Tracking feeding ecology changes of culturally-valued Arctic char (Salvelinus alpinus) and ringed seals (Pusa hispida) can provide an indication of the ecological significance of climate change in a vulnerable region. We characterized how changes in sea ice conditions, sea surface temperature (SST), and primary productivity affected the feeding ecology of these two keystone species over a 13- and 18-year period, respectively, in northern Labrador, Canada. Arctic char fed consistently on pelagic resources (δ13C) but shifted over time to feeding at a higher trophic level (δ15N) and on more marine/offshore resources (δ34S), which correlated with decreases in chlorophyll a concentration. A reduction in Arctic char condition factor and lipid content was associated with higher trophic position. Ringed seals also shifted to feeding at a higher trophic level, but on more pelagic resources, which was associated with lower SST and higher chlorophyll a concentrations. Years with abnormally high SSTs and reduced sea ice concentrations resulted in large isotopic niche sizes for both species, suggesting abrupt change can result in more variable feeding. Changes in abundance and distribution of species long valued by the Inuit of Labrador could diminish food security.

The effect of end-ischaemic normothermic machine perfusion on donor hepatic artery endothelial integrity

BACKGROUND

Ex vivo normothermic machine liver perfusion (NMLP) involves artificial cannulation of vessels and generation of flow pressures. This could lead to shear stress-induced endothelial damage, predisposing to vascular complications, or improved preservation of donor artery quality. This study aims to assess the spatial donor hepatic artery (HA) endothelial quality downstream of the cannulation site after end-ischaemic NMLP.

METHODS

Remnant HA segments from the coeliac trunk up to the gastroduodenal artery branching were obtained after NMLP (n = 15) and after static cold storage (SCS) preservation (n = 15). Specimens were fixed in 10% neutral buffered formalin and sectioned at pre-determined anatomical sites downstream of the coeliac trunk. CD31 immunohistostaining was used to assess endothelial integrity by a 5-point ordinal scale (grade 0: intact endothelial lining, grade 5: complete denudation). Endothelial integrity after SCS was used as a control for the state of the endothelium at commencement of NMP.

RESULTS

In the SCS specimens, regardless of the anatomical site, near complete endothelial denudation was present throughout the HA (median scores 4.5-5). After NMLP, significantly less endothelial loss in the distal HA was present compared to SCS grafts (NMLP vs. SCS: median grade 3 vs. 4.5; p = 0.042). In NMLP specimens, near complete endothelial denudation was present at the cannulation site in all cases (median grade: 5), with significantly less loss of the endothelial lining the further from the cannulation site (proximal vs. distal, median grade 5 vs. 3; p = 0.005).

CONCLUSION

Loss of endothelial lining throughout the HA after SCS and at the cannulation site after NMLP suggests extensive damage related to surgical handling and preservation injury. Gradual improved endothelial lining along more distal sites of the HA after NMLP indicates potential for re-endothelialisation. The regenerative effect of NMLP on artery quality seems to occur to a greater extent further from the cannulation site. Therefore, arterial cannulation for machine perfusion of liver grafts should ideally be as proximal as possible on the coeliac trunk or aortic patch, while the site of anastomosis should preferentially be attempted distal on the common HA.

226 Management of Liver Trauma: Outcomes at One of Europe's Most Active HPB and Liver Transplant Centres

Introduction

The management of liver trauma (LT) has gradually moved away from surgery and more towards conservative or interventional radiological management. Positive outcomes depend upon careful selection for non-operative management, and to avoid surgical intervention in all grade I-III injuries unless haemodynamically unstable following resuscitation. This study investigated the management of all LT patients over a 12-month period at our institution.

Method

We undertook a retrospective study of all patients admitted with LT in 2019 (n = 60). We assessed records to determine the grade of LT (I-VI), concurrent injuries, their management, length of stay and outcomes.

Results

Of the 60 patients admitted with LT, 43 were male (72%) and 41 patients (68%) sustained injuries to multiple organs. 53/60 patients (88%) sustained injuries classified as grade 3 or below. In patients with multiple organ injuries, 7/41 (17%) underwent intervention compared to 7/12 (58%) in those with isolated LT. No deaths were recorded in patients with LT, and 6 people died in the multiple injury group (mortality 10%). Any form of intervention was associated with a doubling in average length of stay.

Conclusions

Non-operative management underpins most isolated LT care; if this fails or is associated with multiple organ traumas, morbidity and mortality rise dramatically.

A comparative analysis of asthma treatment guidelines and Essential Medicine Lists in sub-Saharan Africa

INTRODUCTION: Asthma is a chronic condition affecting between 300 and 400 million people worldwide. Studies have shown that asthma symptoms can be controlled by the daily use of inhaled corticosteroids (ICS). The management of asthma varies in different settings.METHODS: Asthma management in 13 sub-Saharan African countries was compared to the 2018 Global Initiative for Asthma (GINA) guidelines and the 20^th WHO model list of essential medicines (2019). A table with predefined criteria extracted from the international guidelines was used to analyse the content and compare the different treatment guidelines using an Excel spreadsheet.RESULTS: There are variations in the way asthma is diagnosed and treated in different countries. Countries with older treatment guidelines do not have a stepwise approach to assessing severity as stipulated by GINA. Of the 13 countries, only 46% have inhaled ICS at the primary level, 38% have ICS at the secondary level and 16% do not specify.CONCLUSION: The management of asthma varies widely between different countries in sub-Saharan Africa. The noticed variations in approach to care can be explored as an opportunity to harness resources to produce similar and updated guidelines, resulting in uniformity of care across different countries.

Out of hours magnetic resonance imaging for suspected cauda equina syndrome: lessons from a comparative study across two centres

BACKGROUND

Cauda equina syndrome, a rare but disabling spinal surgical emergency, requires prompt investigation, ideally using magnetic resonance imaging as patients may require decompressive surgery. Out of hours access to magnetic resonance imaging is only routinely available in major trauma centres and neurosurgical units. Patients in regional hospitals with suspected cauda equina syndrome may require transfer for diagnostic imaging. We retrospectively studied the proportion of patients referred with suspected cauda equina syndrome who required out of hours transfer for magnetic resonance imaging and decompressive surgery.

MATERIALS ANDS METHODS

Retrospective cohort study of patients referred using online referral platforms with suspected acute cauda equina syndrome and transferred out of hours between 6pm to 8am on weekdays and all day on weekends to two of the largest neurosurgical units in the UK in Birmingham and Cambridge.

RESULTS

A total of 441 patients were referred across both sites with a suspicion of acute cauda equina syndrome; 339 patients were transferred for diagnostic scans and only 16 of them (4.7%) were positive for cauda equina compression, necessitating prompt decompressive surgery. Of the patients with negative magnetic resonance scans, 50% had their discharge or transfer back to referring hospitals delayed by more than 24 hours.

CONCLUSIONS

Over 95% of patients who were transferred for imaging did not undergo emergency decompression. The authors propose a greater role for the provision of out of hours magnetic resonance imaging in all hospitals admitting emergency patients to streamline management.

Prices and availability of locally produced and imported medicines in Ethiopia and Tanzania

Background

To assess the effect of policies supporting local medicine production to improve access to medicines.

Methods

We adapted the WHO/HAI instruments measuring medicines availability and prices to differentiate local from imported products, then pilot tested in Ethiopia and Tanzania. In each outlet, prices were recorded for all products in stock for medicines on a country-specific list. Government procurement prices were also collected. Prices were compared to an international reference and expressed as median price ratios (MPR).

Results

The Ethiopian government paid more for local products (median MPR = 1.20) than for imports (median MPR = 0.84). Eight of nine medicines procured as both local and imported products were cheaper when imported. Availability was better for local products compared to imports, in the public (48% vs. 19%, respectively) and private (54% vs. 35%, respectively) sectors. Patient prices were lower for imports in the public sector (median MPR = 1.18[imported] vs. 1.44[local]) and higher in the private sector (median MPR = 5.42[imported] vs. 1.85[local]). In the public sector, patients paid 17% and 53% more than the government procurement price for local and imported products, respectively.

The Tanzanian government paid less for local products (median MPR = 0.69) than imports (median MPR = 1.34). In the public sector, availability of local and imported products was 21% and 32% respectively, with patients paying slightly more for local products (median MPR = 1.35[imported] vs. 1.44[local]). In the private sector, local products were less available (21%) than imports (70%) but prices were similar (median MPR = 2.29[imported] vs. 2.27[local]). In the public sector, patients paid 135% and 65% more than the government procurement price for local and imported products, respectively.

Conclusions

Our results show how local production can affect availability and prices, and how it can be influenced by preferential purchasing and mark-ups in the public sector. Governments need to evaluate the impact of local production policies, and adjust policies to protect patients from paying more for local products.

The diagnostic utility and cost-effectiveness of selective nerve root blocks in patients considered for lumbar decompression surgery: a systematic review and economic model

BACKGROUND

Diagnostic selective nerve root block (SNRB) involves injection of local anaesthetic, sometimes in conjunction with corticosteroids, around spinal nerves. It is used to identify symptomatic nerve roots in patients with probable radicular pain that is not fully concordant with imaging findings.

OBJECTIVES

(1) Determine the diagnostic accuracy of SNRB in patients with low back and radiating pain in a lower limb; (2) evaluate whether or not accuracy varies by patient subgroups; (3) review injection-related adverse events; and (4) evaluate the cost-effectiveness of SNRB.

DATA SOURCES

MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service (BIOSIS), Latin American and Caribbean Health Sciences Literature (LILACS) and grey literature databases were searched from inception to August 2011. Reference lists of included studies were screened.

METHODS

A systematic review (SR) of studies that assessed the accuracy of SNRB or adverse events in patients with low back pain and symptoms in a lower limb for the diagnosis of lumbar radiculopathy. Study quality was assessed using the quality assessment of diagnostic accuracy studies (QUADAS)-2 checklist. We used random-effects meta-analysis to pool diagnostic accuracy data. Decision tree and Markov models were developed, combining SR results with information on the costs and outcomes of surgical and non-surgical care. Uncertainty was assessed using probabilistic and deterministic sensitivity analyses.

RESULTS

Five studies assessed diagnostic accuracy: three diagnostic cohort and two within-patient case-control studies. All were judged to be at high risk of bias and had high concerns regarding applicability. In individual studies, sensitivity ranged from 57% [95% confidence interval (CI) 43% to 70%] to 100% (95% CI 76% to 100%) and specificity from 9.5% (95% CI 1% to 30%) to 86% (95% CI 76% to 93%). The most reliable estimate was judged to come from two cohort studies that used post-surgery outcome as the reference standard; summary sensitivity and specificity were 93% (95% CI 86% to 97%) and 26% (95% CI 5% to 68%), respectively. No study provided sufficient detail to judge whether or not accuracy varied by patient subgroup. Seven studies assessed adverse events. There were no major or permanent complications; minor complications were reported in 0-6% of patients. The addition of SNRB to the diagnostic work-up was not cost-effective with an incremental cost per quality-adjusted life-year of £1,576,007. Sensitivity analyses confirmed that SNRB was unlikely to be a cost-effective method for diagnosis and planning surgical therapy.

LIMITATIONS

We identified very few studies; all were at high risk of bias. The conduct and interpretation of SNRBs varied and there was no gold standard for diagnosis. Limited information about the impact of SNRB on subsequent care and the long-term costs and benefits of surgery increased uncertainty about cost-effectiveness.

CONCLUSIONS

There were few studies that estimated the diagnostic accuracy of SNRB in patients with radiculopathy and all were limited by the difficulty of making a reference standard diagnosis. Summary estimates suggest that specificity is low, but results are based on a small number of studies at a high risk of bias. Based on current weak evidence, it is unlikely that SNRB is a cost-effective method for identifying the symptomatic nerve root prior to lumbar spine surgery. Future research should focus on randomised controlled trials to evaluate whether or not SNRB improves patient outcomes at acceptable cost.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Practical measurement of affordability: an application to medicines

OBJECTIVE

To develop two practical methods for measuring the affordability of medicines in developing countries.

METHODS

The proposed methods--catastrophic and impoverishment methods--rely on easily accessible aggregated expenditure data and take into account a country's income distribution and absolute level of income. The catastrophic method quantifies the proportion of the population whose resources would be catastrophically reduced by spending on a given medicine; the impoverishment method estimates the proportion of the population that would be pushed below the poverty line by procuring a given medicine. These methods are illustrated by calculating the affordability of glibenclamide, an antidiabetic drug, in India and Indonesia. The results were validated by comparing them with the results obtained by using household micro data for India and Indonesia.

FINDINGS

When accurate aggregate data are available, the proposed methods offer a practical way to obtain informative and accurate estimates of affordability. Their results are very similar to those obtained with household micro data analysis and are easily compared across countries.

CONCLUSION

The catastrophic and impoverishment methods, based on macro data, can provide a suitable estimate of medicine affordability when the household level micro data needed to carry out more sophisticated studies are not available. Their usefulness depends on the availability of accurate aggregated data.

A randomised comparative trial of infusional ECisF versus conventional FEC as adjuvant chemotherapy in early breast cancer: the TRAFIC trial

BACKGROUND

The epirubicin with cisplatin and infusional 5-fluorouracil (5-FU) (ECisF) regimen was found to be highly active in the treatment of metastatic breast cancer and as neoadjuvant therapy. The UK TRAFIC (trial of adjuvant 5-FU infusional chemotherapy) trial (CRUK/95/007) compared this schedule with 5-FU, epirubicin and cyclophosphamide (FEC60) as adjuvant therapy in patients with early breast cancer.

METHODS

In this multicentre, open-label, phase III randomised controlled trial, 349 women were randomly assigned to receive i.v. ECisF [epirubicin 60 mg/m(2), day 1, cisplatin 60 mg/m(2), day 1 and 5-FU 200 mg/m(2) by daily 24-h infusion (n = 172)] or FEC [5-FU 600 mg/m(2), day 1, epirubicin 60 mg/m(2), day 1 and cyclophosphamide 600 mg/m(2), day 1 (n = 177)]. Both treatments were delivered every 3 weeks for six cycles. The primary end point was relapse-free interval (RFI). TRAFIC is registered as an International Standard Randomised Controlled Trial (ISRCTN 83324925).

RESULTS

All randomised patients were included in the intent-to-treat population. With a median follow-up of 112 months, there was no significant difference in RFI between the treatment groups [hazard ratio 0.84 (95% confidence interval 0.60-1.19); P = 0.33]. Toxic effects were more frequent in patients allocated to ECisF.

CONCLUSIONS

While limited by size, TRAFIC has long follow-up. No evidence of a clinically worthwhile benefit for the infusional treatment compared with standard treatment was observed which would justify further investigation or widespread use.

Medicine prices, availability, and affordability in 36 developing and middle-income countries: a secondary analysis

BACKGROUND

WHO and Health Action International (HAI) have developed a standardised method for surveying medicine prices, availability, affordability, and price components in low-income and middle-income countries. Here, we present a secondary analysis of medicine availability in 45 national and subnational surveys done using the WHO/HAI methodology.

METHODS

Data from 45 WHO/HAI surveys in 36 countries were adjusted for inflation or deflation and purchasing power parity. International reference prices from open international procurements for generic products were used as comparators. Results are presented for 15 medicines included in at least 80% of surveys and four individual medicines.

FINDINGS

Average public sector availability of generic medicines ranged from 29.4% to 54.4% across WHO regions. Median government procurement prices for 15 generic medicines were 1.11 times corresponding international reference prices, although purchasing efficiency ranged from 0.09 to 5.37 times international reference prices. Low procurement prices did not always translate into low patient prices. Private sector patients paid 9-25 times international reference prices for lowest-priced generic products and over 20 times international reference prices for originator products across WHO regions. Treatments for acute and chronic illness were largely unaffordable in many countries. In the private sector, wholesale mark-ups ranged from 2% to 380%, whereas retail mark-ups ranged from 10% to 552%. In countries where value added tax was applied to medicines, the amount charged varied from 4% to 15%.

INTERPRETATION

Overall, public and private sector prices for originator and generic medicines were substantially higher than would be expected if purchasing and distribution were efficient and mark-ups were reasonable. Policy options such as promoting generic medicines and alternative financing mechanisms are needed to increase availability, reduce prices, and improve affordability.

Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa

Adherence levels in Africa have been found to be better than those in the US. However around one out of four ART users fail to achieve optimal adherence, risking drug resistance and negative treatment outcomes. A high demand for 2nd line treatments (currently ten times more expensive than 1st line ART) undermines the sustainability of African ART programs. There is an urgent need to identify context-specific constraints to adherence and implement interventions to address them. We used rapid appraisals (involving mainly qualitative methods) to find out why and when people do not adhere to ART in Uganda, Tanzania and Botswana. Multidisciplinary teams of researchers and local health professionals conducted the studies, involving a total of 54 semi-structured interviews with health workers, 73 semi-structured interviews with ARTusers and other key informants, 34 focus group discussions, and 218 exit interviews with ART users. All the facilities studied in Botswana, Tanzania and Uganda provide ARVs free of charge, but ART users report other related costs (e.g. transport expenditures, registration and user fees at the private health facilities, and lost wages due to long waiting times) as main obstacles to optimal adherence. Side effects and hunger in the initial treatment phase are an added concern. We further found that ART users find it hard to take their drugs when they are among people to whom they have not disclosed their HIV status, such as co-workers and friends. The research teams recommend that (i) health care workers inform patients better about adverse effects; (ii) ART programmes provide transport and food support to patients who are too poor to pay; (iii) recurrent costs to users be reduced by providing three-months, rather than the one-month refills once optimal adherence levels have been achieved; and (iv) pharmacists play an important role in this follow-up care.

HER2 testing in the UK: consensus from a national consultation

OBJECTIVE

To gain an understanding of current attitudes among oncologists and pathologists to prospective HER2 testing in breast cancer and to gauge whether a national consensus exists regarding extent and quality of testing.

DESIGN

Qualitative study, with semi-quantitative components, using emailed questionnaires and open-ended discussion documents.

PARTICIPANTS

186 relevant specialists, including 76 breast oncologists and 99 pathologists, representing all but three of the UK cancer networks.

RESULTS

A strong consensus was seen in favour of universal, non-selective testing for HER2 at the point of breast cancer diagnosis. Similarly, an overwhelming majority of participants agreed that, to optimise the quality of test results, all laboratories undertaking HER2 testing should be CPA-accredited, participate in the recognised national external quality assessment scheme (UK NEQAS), and carry out a formal annual audit of its testing service. A further recommendation that testing be restricted to laboratories undertaking a minimum 250 tests per annum for immunohistochemistry and 100 tests per annum for in situ hybridisation techniques met with majority support. However, this was not a clear consensus; a significant minority of participants favoured continued use of local services falling short of these criteria.

CONCLUSION

This study was successful in gauging national specialist opinion regarding the extent and quality assurance of HER2 testing in the UK.

A blinded, randomized controlled trial of neo-adjuvant celecoxib in patients with early prostate cancer

4563

Background: Celecoxib inhibits tumorigenesis in many in vitro and in vivo models by anti-angiogenesis, induction of apoptosis, and inhibition of tumour cell proliferation and hypoxia. Methods: 45 cT1–2 prostate cancer patients were block randomized 2:1 to four weeks celecoxib 400mg b.d. or no drug prior to radical prostatectomy (RP). Tumour immunohistochemistry was performed for cell proliferation (Ki-67), angiogenesis (CD-31, VEGF, VEGF-R2), hypoxia (HIF-1), apoptosis (TUNEL), and COX-2. All scoring was performed blind by PS and a random 20% were validated blindly by an immunopathologist (SBF). In 19 patients (12 celecoxib-treated, 7 control), peri-operative peripheral zone biopsies were subjected to cDNA microarray analysis to identify differences in gene expression profiling (GEP) between the groups. Results: There was ‘substantial’ (kappa >0.6) or ‘almost perfect’ (kappa >0.8) inter-observer agreement in immunoscoring for all stains. Baseline scores were not significantly different between the celecoxib and control groups. In the celecoxib group, RP scores were significantly lower for Ki-67 (p = 0.036), and non-significantly lower for hypoxia (p = 0.15), KDR (p = 0.16), COX-2 (p = 0.19), microvessel density (p = 0.53), and VEGF (p = 0.83); tumour apoptosis was non-significantly higher (p = 0.26). MANOVA of the full model of stains showed that the difference between the two groups approached statistical significance (p = 0.058), and this was visualized with principal component analysis. GEP revealed that 76 genes were significantly differentially expressed between the celecoxib and control groups using uncorrected t-tests. In the celecoxib group, the tumour suppressor gene p73 and genes associated with protection against oxidative stress were significantly up-regulated; genes associated with cell adhesion were significantly down-regulated, consistent with a reduction in metastatic potential. Conclusions: Celecoxib appears to have marked anti-cancer effects on prostate tumours, most notably affecting cell cycle regulation, oxidative stress, and cell signalling. It may therefore be a promising agent in the management of prostate cancer and warrants further investigation.

No significant financial relationships to disclose.

Tension pneumothorax complicating autologous "blood patch" pleurodesis

Autologous "blood patching" has been used successfully for the treatment of persistent air leak in patients with spontaneous secondary pneumothorax. The case history is presented of a 19 year old woman with cystic fibrosis who developed tension pneumothorax following this procedure, with rapid clinical deterioration until the obstruction was cleared. To avoid this potentially fatal complication we recommend that "blood patch" pleurodesis be performed only through large bore intercostal catheters, that blood is rapidly transferred into the catheter tubing, a sterile saline flush and full resuscitation equipment is available, and the operator is skilled in the management of tension pneumothorax.

Accompaniment needs of nursing students related to the dying patient

Nurse educators are responsible for accompanying students towards becoming capable, competent professional nurses who are a credit to themselves, their patients, colleagues and profession. Student nurses need, therefore, to be taught to render comprehensive nursing care to patients in all stages of their lives, including when they are dying. Being confronted with human suffering and death is challenging and traumatic. Those exposed to such events on a daily basis need to have a solid foundation of self preservation to see past the pain of suffering and to bring light and hope to those in need. A young student nurse will only experience positive growth and development in these circumstances if she is also cared for and guided with understanding. The researcher utilized a qualitative, explorative, descriptive and contextual design based on the phenomenological approach to enquiry. The following question was asked at the beginning of each unstructured phenomenological interview: “How was if for you to care for a dying or deceased patient?” The central theme identified that student nurses experience turmoil in their different relationships in their accompaniment of the dying patient. Guidelines based on the central theme and sub-themes that emerged from raw data, as well as literature, are offered as strategies to promote/enhance optimal accompaniment of student nurses caring for the dying patient.

Capacity building for international tuberculosis control through operations research training

SETTING

In resource-poor countries, few tuberculosis (TB) program staff at the national, provincial, and even district levels have the basic analytical and epidemiological skills necessary for collecting and analyzing quality data pertaining to national TB control program (NTP) improvements. This includes setting program priorities, operations planning, and implementing and evaluating program activities.

OBJECTIVES

To present a model course for building capacity in basic epidemiology and operations research (OR).

DESIGN

A combination of didactic lectures and applied field exercises were used to achieve the main objectives of the 6-day OR course. These were to increase the understanding of quantitative and qualitative research concepts, study design, and analytic methods, and to increase awareness of how these methods apply to the epidemiology and control of TB; and to demonstrate the potential uses of OR in answering practical questions on NTP effectiveness. As a final outcome, course participants develop OR proposals that are funded and later implemented.

RESULTS

Since 1997, this OR course has been conducted nine times in five countries; 149 key NTP and laboratory staff have been trained in OR methods, and 44 OR protocols have been completed or are underway.

CONCLUSION

This low-cost model course can be adapted to a wide range of public health issues.

European Collaborative Group on Prostate Brachytherapy: Preliminary Report in 1175 Patients

OBJECTIVE

To establish a multi-centre database of a large number of patients treated with brachytherapy across Europe.

METHODS

A total of 1175 patient files were registered in the database and the completeness of the data on these patients resulted in the majority being included in the analysis.

RESULTS

The database of patients treated with brachytherapy across Europe indicates that optimal patient selection for this procedure has been made, both in terms of outcome and side-effects, which will be subject of future analyses. This should enable refinement of the treatment choice and administration as well as provide useful guidance to other centres that want to establish this procedure for their patients. It will also set the ground for prospective studies.

CONCLUSIONS

The established database indicates that brachytherapy as a treatment option for prostate cancer is well established in many centres.

Community-acquired pneumonia: influence of management practices on length of hospital stay

AIMS

To identify variation in the management of -community-acquired pneumonia between two New Zealand hospitals and the factors that may account for any differences.

METHODS

A 12-month, prospective two-centre study was conducted. Between July 1999 and July 2000, 474 adult patients with community-acquired pneumonia were enrolled: 304 in Christchurch Hospital and 170 in Waikato Hospital. The patients were similar in age, sex, prior antibiotic use and comorbidity. There was no significant difference in the clinical outcomes for the patients at the two centres.

RESULTS

The mean duration of i.v. antibiotic therapy was 1.7 versus 3.0 days (P < 0.001) and length of stay (LOS) was 3.0 versus 5.9 days (P < 0.001) for Waikato and Christchurch Hospitals, respectively. Using multivariate analysis, we could account for 61% of the observed variation in LOS. Duration of i.v. antibiotic therapy independently accounted for 16% of variation in LOS compared with age (2%), chronic obstructive pulmonary disease, duration of fever, intensive care unit admission and centre of admission (all <1%). For the duration of i.v. antibiotics, centre of admission, largely reflecting clinician practice at each centre, independently accounted for 13% of variation, compared with duration of fever (5%), admission to the Intensive Care Unit (4%), Pneumonia Severity Index score (3%) and bacteraemia (3%).

CONCLUSION

Of the identifiable factors, variations in clinician behaviour outweighed the influence of patient factors on the duration of i.v. antibiotic therapy, which in turn was the major determinant of LOS for patients hospitalised with community-acquired pneumonia. An early switch from i.v. to oral antibiotic therapy in conjunction with early discharge planning may significantly reduce LOS without compromising patient outcomes.

Fixed dose combinations for tuberculosis: Lessons learned from clinical, formulation and regulatory perspective

Worldwide, tuberculosis (TB) remains one of the most important communicable diseases in terms of morbidity and mortality. Its control requires multi-drug therapy for at least six months, which could lead to patient non-compliance, failure of therapy and ultimately resulting in the emergence of drug resistance. Fixed dose combinations (FDCs) in TB therapy reduce the number of tablets to be consumed and thereby increase patient compliance with recommended treatment regimens. Thus, FDCs play a significant role in preventing the emergence of drug resistance and successful treatment. However, the quality of FDCs with respect to variable bioavailability and their registration requirements are major hurdles to their implementation in national TB control programs. It is anticipated that a large global market for FDCs will encourage large-scale production and increased competition, which in turn will result in FDCs at affordable prices. The Global Drug Facility (GDF), established by the World Health Organization (WHO), aims to ensure universal uninterrupted access to quality TB drugs for implementation of directly observed treatment short-course (DOTS) in resource-poor countries. In this program, four FDCs were accepted as the drugs of first choice because of their obvious advantages in controlling TB. This demands the necessity of addressing quality and registration requirements of FDCs systematically. In light of this current knowledge on anti-TB FDCs, their dosage, combinations, available clinical studies and the experiences with TB therapy has been discussed in this article, which should serve as lessons for selection of appropriate FDCs for other diseases such as malaria and AIDS.

Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study

BACKGROUND

In the assessment of severity in community acquired pneumonia (CAP), the modified British Thoracic Society (mBTS) rule identifies patients with severe pneumonia but not patients who might be suitable for home management. A multicentre study was conducted to derive and validate a practical severity assessment model for stratifying adults hospitalised with CAP into different management groups.

METHODS

Data from three prospective studies of CAP conducted in the UK, New Zealand, and the Netherlands were combined. A derivation cohort comprising 80% of the data was used to develop the model. Prognostic variables were identified using multiple logistic regression with 30 day mortality as the outcome measure. The final model was tested against the validation cohort.

RESULTS

1068 patients were studied (mean age 64 years, 51.5% male, 30 day mortality 9%). Age >/=65 years (OR 3.5, 95% CI 1.6 to 8.0) and albumin <30 g/dl (OR 4.7, 95% CI 2.5 to 8.7) were independently associated with mortality over and above the mBTS rule (OR 5.2, 95% CI 2.7 to 10). A six point score, one point for each of Confusion, Urea >7 mmol/l, Respiratory rate >/=30/min, low systolic(<90 mm Hg) or diastolic (</=60 mm Hg) Blood pressure), age >/=65 years (CURB-65 score) based on information available at initial hospital assessment, enabled patients to be stratified according to increasing risk of mortality: score 0, 0.7%; score 1, 3.2%; score 2, 3%; score 3, 17%; score 4, 41.5% and score 5, 57%. The validation cohort confirmed a similar pattern.

CONCLUSIONS

A simple six point score based on confusion, urea, respiratory rate, blood pressure, and age can be used to stratify patients with CAP into different management groups.

Optimizing antibiotic therapy-the Aberdeen experience

OBJECTIVE

To study the quality and continuity of treatment in the Acute Medicines Assessment Unit (AMAU) with regard to empirical prescription of antibiotics, mode of administration, adherence to ward antibiotic policy, as well as collection, awareness and utilization of microbiological investigations.

METHODS

A prospective study over a 3-month period at the AMAU, Aberdeen Royal Infirmary (ARI), a teaching hospital in north-eastern Scotland, was performed. The study included all patients started on empirical antibiotics on admission to the AMAU and followed up until their discharge.

RESULTS

Of 1303 patients admitted, 221 (17%) were started on empirical antibiotics. This was in accordance with hospital antibiotic policy in 52% of cases. Appropriate specimens were taken from 77% of patients. Culture results showed that 29% (n = 65) of the patients had clinically significant growth of organisms. Of the 65 patients with clinically significant culture results, 49% (n = 32) were on an inappropriate empirical regimen. In 55%, the medication was not changed to a more appropriate antibiotic. In 72% of the patients with a negative culture, the culture report had no obvious effect on the duration or type of antibiotic being administered. Intravenous antibiotics were used in 60% of patients.

CONCLUSION

This study demonstrates a significant overuse of antibiotics, especially intravenous forms, despite a paucity of positive sepsis parameters and chest X-ray findings in these patients The duration of treatment could be shortened and an early switch policy introduced if culture results and sepsis profiles were taken into consideration, as there was a large number of unproven infections. Suggestions are made about how these improvements in prescribing could be made within the current administrative set-up of AMAUs.

The use of glyceryl trinitrate ointment with EMLA cream for i.v. cannulation in children undergoing routine surgery

This prospective randomized controlled double-blind trial was performed to investigate whether glyceryl trinitrate (GTN) ointment, applied ten minutes after the removal of a eutectic mixture of local anaesthetic cream, lignocaine/ prilocaine (EMLA), influences site selection for intravenous cannulation in children. Eighty children aged between five and 15 years, having general surgery as day patients, received EMLA cream on both hands for 90 minutes prior to transfer to the theatre suite. Acting as their own controls, the children received GTN on one hand, and placebo on the other, after removal of the EMLA cream and ten minutes prior to the insertion of an intravenous cannula. The application of GTN or placebo to left or right hand was blinded and randomized. At induction, the hand with the visually best quality veins was selected and cannulated. The primary outcome was selection between the EMLA/GTN hand and EMLA/placebo hand. The selection having been made, the number of attempts at cannulation, ease of insertion and pain scores (VAS) for cannulation were also recorded. The choice of hand was positively influenced by the use of GTN, with the GTN hand chosen in 51 of 72 (70%) children who completed the protocol (P = 0.001). The findings of this study suggest that the application of GTN after EMLA removal may be clinically useful in aiding cannulation in children.

Community-acquired pneumonia in Christchurch and Waikato 1999-2000: microbiology and epidemiology

AIMS

To prospectively record current epidemiology and microbiology of community-acquired pneumonia in two New Zealand centres.

METHODS

Between July 1999 and 2000 all adults admitted to Christchurch and Waikato Hospitals with community-acquired pneumonia were screened for study inclusion. All those enrolled had their medical history, clinical variables, inpatient management and clinical outcomes recorded and standardised microbial diagnostic testing carried out.

RESULTS

474 participants were enrolled with a mean age of 64 years and a microbial diagnosis was made in 197 cases (42%). Streptococcus pneumoniae (14%), Haemophilus influenzae (10%) and Influenza A virus (7%), Legionella spp (4%) and Mycoplasma pneumoniae (3%) were the most commonly isolated organisms. An 'atypical' organism was diagnosed in 8% of cases compared to 30% and 23% in previous Christchurch and Waikato studies respectively. Fourteen of the 67 S pneumoniae isolates (21%) had reduced susceptibility to penicillin, all with a MIC < or = 2 microg/mL, a level of reduced susceptibility not associated with worse patient outcomes. Clinical outcome included a mean hospital stay of 6.7 days and a 6 week mortality of 6%.

CONCLUSION

Although S pneumoniae was the most commonly isolated organism in this study there have been significant changes in the prevalence of atypical organisms since previous surveys. Ongoing surveillance of antibiotic resistance and variations in the prevalence of organisms causing community-acquired pneumonia is required to guide clinicians' empiric antibiotic use.

The use of the Hospital Anxiety and Depression Scale (HADS) in patients with chronic obstructive pulmonary disease: a pilot study

AIMS

To investigate the use of the Hospital Anxiety and Depression Scale (HADS) with recuperating chronic obstructive pulmonary disease (COPD) patients. To study prevalence rates and changes in clinically relevant anxiety and depression during rehabilitation.

METHODS

Consecutive patients admitted to a non acute respiratory ward over a twelve week period were asked to complete a HADS questionnaire on three occasions. Nurses recorded basic demographic information on admission. Additional demographic, medical and psychiatric data were obtained by retrospective review of medical records.

RESULTS

Of 93 consecutive inpatients, 79 (85%) completed the admission HADS. 72 patients were eligible to complete the day three HADS and 60 the discharge HADS. Clinically relevant anxiety (HADS score of > or =8) was indicated in 39 patients (50%) and depression in 22 (28%). HADS anxiety (p=0.05) and total scores (anxiety+depression) (p=0.03) decreased between admission and discharge. A larger proportion of patients scored within the normal or mild psychopathology range by discharge. More severe COPD (FEV1% predicted) correlated with higher HADS anxiety scores (r=-0.39, p<0.001) and HADS depression scores (r=-0.34, p<0.005). Patients with a recorded history of anxiety (p<0.0001) and depression (p<0.02) had higher WADS scores. Females (n=37) when compared to males (n=42), recorded significantly higher HADS anxiety scores throughout (p<0.005).

CONCLUSIONS

Clinically relevant anxiety, indicated by higher HADS scores, was more common in patients with severe COPD, a past history of anxiety or depression and females. Anxiety and total mood improved during inpatient rehabilitation. The use of this instrument with New Zealand COPD patients may improve identification and treatment of anxious and depressed patients.

The impact of supervision on stock management and adherence to treatment guidelines: a randomized controlled trial

Ensuring the availability of essential drugs and using them appropriately are crucial if limited resources for health care are to be used optimally. While training of health workers throughout Zimbabwe in drug management (including stock management and rational drug use) resulted in significant improvements in a variety of drug use indicators, these achievements could not be sustained, and a new strategy was introduced based on the supervision of primary health care providers. This was launched in 1995 with a training course in supervisory skills for district pharmacy staff. In order to evaluate the impact of the supervision and the effectiveness of the training programme, adherence to standard treatment guidelines (STG) and stock management protocols was evaluated in a randomized controlled trial. The study compared three different groups of health facilities: those that received supervision for either use of STG (n = 23) or stock management (n = 21) - each facility acting as control for the other area of supervision - and a comparison group of facilities which received no supervision (n = 18). On-the-spot supervision by a specially trained pharmacy staff, based around identified deficiencies, took place at the start of the study and 3 months later. The evaluation compared performance on a variety of drug management indicators at baseline and 6-8 months after the second supervisory visit. The results of the study showed that, following supervision, overall stock management improved significantly when compared with the control and comparison groups. Similar improvements were demonstrated for adherence to STG, although the effect was confounded by other interventions. The study also showed that supervision has a positive effect on improving performance in areas other than those supervised, and demonstrated that pharmacy technicians with limited clinical skills can be trained to influence primary health care workers to positively improve prescribing practices. Allocating resources to supervision is likely to result in improved performance of health workers with regard to the rational use of essential drugs, resulting in improved efficiency and effectiveness.