An exploration of the concept of directly observed treatment (DOT) for tuberculosis patients: from a uniform to a customised approach

Tuberculosis (TB) management has moved from chaotic systems and low patient adherence with treatment regimens to the directly observed therapy, short course (DOTS) strategy, which has been described as a new paradigm of TB control. Directly observed treatment (DOT) is only one component of the full DOTS strategy. DOT versus self-administered treatment (SAT) has been the subject of extensive debate, particularly about what approach improves treatment adherence. This debate has been complicated by different case-holding rates and cure outcomes in different contexts where DOT is in place. The increasing range of DOT applications in different settings, including the choice of provider, place, target population, and the extent to which DOT is part of a wider approach, has not been sufficiently taken into account. However, the concrete reality of DOT is an important determinant of the overall success or failure of the programme, and has implications in terms of equity and accessibility of care during treatment. This article aims to go beyond the frequently polarised debate of DOT versus SAT and document the diversity of ways in which DOT has been implemented internationally. We also aim to raise key issues for further discussion, including 1) viewing DOT as part of a complex and lengthy set of interventions that are context-specific, 2) incorporating an equity approach that discusses individual patients' needs and the relationship between the patient and provider, and 3) the role of incentives and enablers. It is anticipated that this exchange of opinion and experiences from different parts of the world will be useful for those involved in the policy formulation and practice of TB management.

Deficiency in parvalbumin increases fatigue resistance in fast-twitch muscle and upregulates mitochondria

The soluble Ca2+-binding protein parvalbumin (PV) is expressed at high levels in fast-twitch muscles of mice. Deficiency of PV in knockout mice (PV -/-) slows down the speed of twitch relaxation, while maximum force generated during tetanic contraction is unaltered. We observed that PV-deficient fast-twitch muscles were significantly more resistant to fatigue than were the wild type. Thus components involved in Ca2+ homeostasis during the contraction-relaxation cycle were analyzed. No upregulation of another cytosolic Ca2+-binding protein was found. Mitochondria are thought to play a physiological role during muscle relaxation and were thus analyzed. The fractional volume of mitochondria in the fast-twitch muscle extensor digitorum longus (EDL) was almost doubled in PV -/- mice, and this was reflected in an increase of cytochrome c oxidase. A faster removal of intracellular Ca2+ concentration ([Ca2+]i) 200-700 ms after fast-twitch muscle stimulation observed in PV -/- muscles supports the role for mitochondria in late [Ca2+]i removal. The present results also show a significant increase of the density of capillaries in EDL muscles of PV -/- mice. Thus alterations in the dynamics of Ca2+ transients detected in fast-twitch muscles of PV -/- mice might be linked to the increase in mitochondria volume and capillary density, which contribute to the greater fatigue resistance of these muscles.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of health care providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care are increasingly advocated by consumers and clinicians and incorporated into training for health care providers. The effects of interventions that aim to promote patient-centred care need to be evaluated.

OBJECTIVES

To assess the effects of interventions for health care providers that aim to promote patient-centred approaches in clinical consultations.

SEARCH STRATEGY

We searched Medline (1966 - Dec 1999); Health Star (1975 - Dec 1999); PsycLit (1887- Dec 1999); Cinahl (1982 - Dec 1999); Embase (1985-Dec 1999) and the bibliographies of studies assessed for inclusion.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for health care providers that promote patient-centred care in clinical consultations. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). The participants were health care providers, including those in training.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality for each study. We extracted all outcomes other than health care providers' knowledge, attitudes and intentions.

MAIN RESULTS

17 studies met the inclusion criteria. These studies display considerable heterogeneity in terms of the interventions themselves, the health problems or health concerns on which the interventions focused, the comparisons made and the outcomes assessed. All included studies used training for health care providers as an element of the intervention. Ten studies evaluated training for providers only, while the remaining studies utilised multi-faceted interventions where training for providers was one of several components. The health care providers were mainly primary care physicians (general practitioners or family doctors) practising in community or hospital outpatient settings. In two studies, the providers also included nurses. There is fairly strong evidence to suggest that some interventions to promote patient-centred care in clinical consultations may lead to significant increases in the patient centredness of consultation processes. 12 of the 14 studies that assessed consultation processes showed improvements in some of these outcomes. There is also some evidence that training health care providers in patient-centred approaches may impact positively on patient satisfaction with care. Of the eleven studies that assessed patient satisfaction, six demonstrated significant differences in favour of the intervention group on one or more measures. Few studies examined health care behaviour or health status outcomes.

REVIEWER'S CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations may significantly increase the patient centredness of care. However, there is limited and mixed evidence on the effects of such interventions on patient health care behaviours or health status; or on whether these interventions might be applicable to providers other than physicians. Further research is needed in these areas.

Ambivalence of primary health care professionals towards the South African guidelines for hypertension and diabetes

BACKGROUND

Consensus-derived guidelines for hypertension and diabetes management were introduced by the National Department of Health to improve quality of care. However, the incorporation of guidelines into clinical practice is largely dependent on the attitudes of health professionals.

OBJECTIVE

To audit the responses and examine the attitudes of health professionals in primary care towards the diabetes and hypertension care guidelines.

DESIGN

Qualitative focus group, in-depth discussions and clinic observations.

SETTING

Four community health centres (CHCs) in the Western Cape.

SUBJECTS

Fifteen doctors and 10 professional nurses.

METHODS

The responses of health professionals to the guidelines were audited. Their attitudes were evaluated at a single pilot CHC using focus group discussions and in-depth interviews. Semi-structured interviews based on these themes were conducted at 3 other CHCs. Clinic consultations were observed to validate the responses.

RESULTS

The guidelines were not systematically implemented at local CHCs and individual doctors consulted the guidelines infrequently. Several themes were identified as barriers to the application of the guidelines, including the consultation process by which the guidelines were developed, time constraints, scepticism about durability of the guidelines, conflict with local practices, health system problems, and patient beliefs.

CONCLUSION

The usefulness of passive dissemination of guidelines to health professionals in primary care should be reviewed as several attitudinal barriers to implementation may exist. Guidelines may be adopted more readily if these barriers are addressed.

Acute meningococcaemia complicated by late onset gastrointestinal vasculitis

Extra-meningeal and non-cutaneous manifestations of meningococcal infection are well recognized but rare. Herein we report a little recognized complication of meningococcaemia, namely late-onset gastrointestinal vasculitis. In the case presented, the prostacycline analogue iloprost was used in an attempt to minimize incipient digital gangrene ina patient with evidence of protracted immunological phenomena. In addition, diclofenac was used to treat severe arthralgia. Withdrawal of iloprost on day 19 was associated with abdominal pain and peritonism. Laparotomy demonstrated ischaemia and ulceration in the caecum, and histology revealed full thickness mucosal ulceration with a prominent vasculitic process. It is postulated that these findings were immunologically mediated, with possible rebound vasoconstriction following withdrawal of iloprost. It is also possible that NSAID use contributed to the findings via cyto-toxicity to mucosal cells.

A structured record to implement the national guidelines for diabetes and hypertension care

BACKGROUND

Guidelines to improve standards of care for hypertension and diabetes were disseminated by the National Department of Health in 1996 but have generally not been implemented by health professional in local primary care. A strategy for the adoption and implementation of the Guidelines was developed in collaboration with health professionals in primary care.

OBJECTIVES

The development of a structured record, with prompts for the management of diabetes and hypertension according to the Guidelines.

SETTING

Three community health centres (CHCs) in the Western Cape.

PARTICIPANTS

Doctors and nurses managing patients with diabetes and hypertension.

METHODS

A draft of the structured record was developed at a single-pilot CHC in the Western Cape. Focus group discussions established the core requirements for a structured record. Process, result and structural indicators in line with the national Guidelines were considered for inclusion in the draft record. This draft record was then piloted at two other CHCs. Comments from semi-structured interviews and pre- and post-test evaluation questionnaires were used to compile the final instrument.

RESULTS

Eleven doctors and 8 nurses participated in the development of the final instrument. Important considerations in the design were a single-page, user-friendly format, tick-boxes to reduce writing, prompts, provision for sequential recording, target setting, and compatibility with the Guidelines. The final instrument was piloted and elicited a favourable overall response.

CONCLUSION

The structured record simplifies the application of the Guidelines and the systematic recording of processes of care. The effectiveness of the Guidelines will be evaluated further in a randomised control trial using the structured record.

An outbreak of vancomycin-dependent Enterococcus faecium in a bone marrow transplant unit

Outbreaks of vancomycin-resistant enterococci (VRE) are well described. The presence of mutants of VRE, such as vancomycin-dependent enterococci (VDE), in individual patients has been documented, but their potential to spread nosocomially has not been known. We present the first cluster of patients who acquired VDE nosocomially. Five bone marrow transplantation patients were infected or colonized by a genotypically indistinguishable multiantibiotic-resistant strain of Enterococcus faecium. Vancomycin dependence in 3 of the 5 isolates was demonstrated. All cluster patients had received protracted prophylactic treatment with vancomycin (mean, 22.6 days), and specimens from >/=2 body sites were repeatedly culture-positive for the outbreak strain. The outbreak was controlled with aggressive infection control strategies, and prophylactic antibiotic policies were revised. Awareness of the potential for nosocomial spread of multiantibiotic-resistant VDE is vital for the care of immunocompromised patients, especially those receiving prophylactic antibiotics.

Perceptions of overweight African women about acceptable body size of women and children

PURPOSE

Malnutrition, presenting as obesity in women and under-nutrition in children, is a prevalent problem in the squatter communities of Cape Town. Food habits are determined by a complex matrix of economic, social and cultural factors which need to be understood by health professionals prior to the implementation of strategies to improve the nutritional status of this community. This qualitative study is designed to explore the perceptions of overweight black women in Cape Town, with underweight infants, about the culturally acceptable body size for women and children.

METHOD

Qualitative in-depth interviews were conducted with 10 overweight black women who were resident in the metropolitan area of Khayelitsha in Cape Town. A snowballing technique was utilised to select the key informants, all of whom were mothers of underweight infants. The interviews were conducted in Xhosa and recorded, with the permission of participants, onto tape. They were then transcribed and translated into English. The transcripts were coded and analysed by two researchers who worked independently to ensure content validity.

RESULTS

The informants came from disadvantaged communities in which food was highly valued as a result of the fact that food security was not assured. The concept of an individual voluntarily regulating the intake of nutrients when food did become available, appeared unacceptable to the informants. It was not clear from the interviews how the participants perceived their normal or "desired" body weight. Increased body mass was regarded as a token of well-being in that marital harmony was perceived to be reflected in increased body weight. Overweight children were regarded as reflecting health as it was associated with sufficient food supply and intake.

CONCLUSIONS

Although women expressed the desire to loose some excess weight for practical reasons, there was no negative social pressure to motivate this. The attitudes recorded from this qualitative research project suggest cultural perceptions of excess body weight that will complicate the design of effective health promotion strategies to normalise and maintain ideal body weight in this group of African women.

Prolonged contraction-relaxation cycle of fast-twitch muscles in parvalbumin knockout mice

The calcium-binding protein parvalbumin (PV) occurs at high concentrations in fast-contracting vertebrate muscle fibers. Its putative role in facilitating the rapid relaxation of mammalian fast-twitch muscle fibers by acting as a temporary buffer for Ca2+ is still controversial. We generated knockout mice for PV (PV -/-) and compared the Ca2+ transients and the dynamics of contraction of their muscles with those from heterozygous (PV +/-) and wild-type (WT) mice. In the muscles of PV-deficient mice, the decay of intracellular Ca2+ concentration ([Ca2+]i) after 20-ms stimulation was slower compared with WT mice and led to a prolongation of the time required to attain peak twitch tension and to an extension of the half-relaxation time. The integral [Ca2+]i in muscle fibers of PV -/- mice was higher and consequently the force generated during a single twitch was approximately 40% greater than in PV +/- and WT animals. Acceleration of the contraction-relaxation cycle of fast-twitch muscle fibers by PV may confer an advantage in the performance of rapid, phasic movements.

Risk factors and clinical impact of central line infections in the surgical intensive care unit

OBJECTIVE

To determine the risk factors and clinical impact of central line infections in critically ill surgical patients.

DESIGN

Retrospective study.

SETTING

The surgical intensive care unit of a large tertiary care university hospital.

PATIENTS

A total of 232 consecutive central line catheters sent for culture from patients in a surgical intensive care unit during 1996 and 1997. Catheters were sent for microbiologic analysis when the patient was clinically infected and the central line was a possible source.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Risk factors associated and clinical impact of a positive catheter culture.

RESULTS

Of 232 consecutive catheters from 93 patients sent for microbiologic analysis, 114 catheters (49%) had no growth, 40 (17%) were colonized (<15 colonies), and 78 (34%) were considered infected (> or =15 colonies). Univariate analysis showed that site (internal jugular vs subclavian, P<.001), catheter use (monitoring > dialysis > fluid > nutrition, P=.006), placement in the operating room vs the intensive care unit (P=.02), and placement of a new catheter (> guide wire, > new site, P=.003) were all significant factors. Surprisingly, neither the number of lunmens nor the duration of the catheter in situ were predictors when a catheter was suspected and not proved infected compared with a suspected and proved catheter infection. In the multiple regression model, the placement of the catheter in the internal jugular position was the single most important predictor of a catheter infection (P<.001; odds ratio, 1.83; 95% confidence interval [CI], 1.41-2.37). The presence or absence of a specific clinical sign of infection was not predictive of a proved catheter infection. Eighty-six percent of patients had gram-positive bacteria identified on the culture, while the remaining patients had gram-negative bacteria or Candida identified. Of the catheter infections, 68% were monomicrobial, whereas 32% were polymicrobial. Of the catheters sent for microbiologic analysis, 209 (90%) had concurrent peripheral blood cultures for analysis. Nineteen (32%) with no growth from the catheter, and 14 (23%) of colonized catheters had concurrent bacteremia; all had another identifiable cause of infection. Twenty-seven (45%) of infected catheters had a concurrent bacteremia, and 9 of 27 had a second site positive for the same organism. Death related to the infection occurred in 15 patients, 2 in the first 72 hours and 13 in the following 14 days.

CONCLUSIONS

Central line infections remain an important cause of morbidity and mortality. Comprehensive review of hospital practices may show a directed focus for performance improvement practices. At our institution, internal jugular catheters have the highest rate of infection. This may suggest breaks in technique during catheter insertion or during catheter maintenance and care.

CREB-2, a cellular CRE-dependent transcription repressor, functions in association with Tax as an activator of the human T-cell leukemia virus type 1 promoter

The Tax protein of the human T-cell leukemia virus type 1 (HTLV-1) has been implicated in human T-cell immortalization. The primary function of Tax is to transcriptionally activate the HTLV-1 promoter, but Tax is also known to stimulate expression of cellular genes. It has been reported to associate with several transcription factors, as well as proteins not involved in transcription. To better characterize potential cellular targets of Tax present in infected cells, a Saccharomyces cerevisiae two-hybrid screening was performed with a cDNA library constructed from the HTLV-1-infected MT2 cell line. From this study, we found 158 positive clones representing seven different cDNAs. We focused our attention on the cDNA encoding the transcription factor CREB-2. CREB-2 is an unconventional member of the ATF/CREB family in that it lacks a protein kinase A (PKA) phosphorylation site and has been reported to negatively regulate transcription from the cyclic AMP response element of the human enkephalin promoter. In this study, we demonstrate that CREB-2 cooperates with Tax to enhance viral transcription and that its basic-leucine zipper C-terminal domain is required for both in vitro and in vivo interactions with Tax. Our results confirm that the activation of the HTLV-1 promoter through Tax and factors of the ATF/CREB family is PKA independent.

'Dysphagia Severity Score' system: clinical outcomes in paediatric dysphagia

Clinical evaluation and analysis of therapeutic intervention, by means of a user-friendly outcome measure system, is essential in the management of a paediatric dysphagia caseload. The objective of this study was to design a Dysphagia Severity Score (DSS) system and to evaluate its usefulness in profiling dysphagia outcomes. Clinical outcome data, based on ten clinical parameters describing dysphagic status pre- and post-intervention, were collated for 23 concurrent cases and recorded on a data base. Results indicate that all subjects scored an improvement in DSS percentage post-intervention, with an average improvement of 21%. Dysphagia Severity Score profiles are presented for two patients and the limitations and applications are discussed.

A graphical tool for ad hoc query generation

Medical data are characterized by complex taxonomies and evolving terminology. Questions that clinicians, medical administrators, and researchers may wish to answer using medical databases are not easily formulated as SQL queries. In this paper we describe a graphical tool that facilitates formulation of ad hoc questions as SQL queries. This tool manages multiple attribute hierarchies and creates SQL query strings by navigating through the hierarchies. This interactive tool has been optimized using indexing to improve the overall speed of the query building and the data retrieval process. Indexed queries performed 5 to 100 times faster than query strings. However, query string generation time depends on the size of the taxonomies describing the hierarchies, while the index generation time depends on the size of the data warehouse.

Propofol 2% in critically ill patients: effect on lipids

OBJECTIVE

To investigate the concentrations of triglyceride, cholesterol, and high-density lipoprotein during a 50-hr infusion of 2% propofol, starting within 24 hrs of admission to the intensive care unit (ICU).

DESIGN

Prospective, clinical study.

SETTING

ICU, university hospital.

PATIENTS

Thirty adult patients, who were ventilated and expected to be sedated for >2 days, were studied for 50 hrs, beginning at 1800 hrs on the first day of ICU admission.

MEASUREMENTS AND MAIN RESULTS

Triglyceride, cholesterol, and high-density lipoprotein were measured at 2000, 0400, and 0800 hrs. Tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and C-reactive protein were measured at 2000 hrs. Median cholesterol and high-density lipoprotein concentrations were at the low end of the normal range. In seven patients, peak triglyceride concentrations were >3 mmol/L up to a maximum of 4.83 mmol/L. Although there was no statistical difference in lipid concentrations between days 1 and 2, there was an apparent pattern of increasing triglyceride concentrations. There was a correlation between peak triglyceride concentration and total propofol consumption, but there was no correlation between lipids and age, gender, or Acute Physiology and Chronic Health Evaluation II scores. There was a direct correlation between triglyceride and C-reactive protein concentrations, and an inverse correlation between cholesterol and C-reactive protein. Twenty-two patients had evidence of TNF and 11 patients had an IL-6 of >1000 pg/mL, but there was no relationship between concentrations of cytokines and triglycerides in plasma.

CONCLUSIONS

Infusion of 2% propofol to critically ill patients over a 50-hr period does not result in a significant increase in triglyceride concentrations. Mean cholesterol and high-density lipoprotein concentrations were low throughout the study period. There was a significant direct correlation between triglyceride and C-reactive protein and an inverse correlation between cholesterol and C-reactive protein, suggesting that the changes in lipids in critically ill patients may be partly attributable to the acute-phase response.

Combating tuberculosis--lessons learnt from a rural community project in the Klein Drakenstein area of the Western Cape

OBJECTIVE

To describe and evaluate a lay worker project designed to enhance the effective control of tuberculosis in a rural/farm setting.

DESIGN

A descriptive cohort study using both qualitative and quantitative research methodology.

SETTING AND PARTICIPANTS

Farming community in the Klein Drakenstein area of Paarl, Western Cape, with health services provided by the Cape Metropolitan Council. The adherence of patients receiving tuberculosis treatment from 1 January 1993 to 31 December 1995 was analysed. The acceptability of the project was assessed using indepth interviews with key stakeholders.

RESULTS

A cohort of 402 tuberculosis patients was included in the study. This cohort was divided into the patients from farms that had participated in the project (intervention group) and those that had not (non-intervention group). The adherence data for children and adults were analysed separately. The adherence rates for children in both groups were the same (RR = 1.00, 95% Cl 0.88-1.14), whereas the adherence rate for the adult intervention group was significantly better than that of the non-intervention group (RR = 1.19, 95% Cl 1.08-1.31). The qualitative component of the investigation indicated a high level of commitment to the intervention from the members of the implementation team, the farm health workers and their employers. The farm health workers described how their role had assisted their communities and had improved their own perceptions of self-efficacy. The close bond that they had developed with the formal health sector had improved the access of the labourers on the farm to primary health care. Although the project had commenced as a tuberculosis initiative, the farm health workers were dealing with a variety of health issues. Their ongoing training was designed to facilitate this development. The formal health sector found their activities facilitated by the easy access that they had with a representative from each farm. The employers were satisfied that the project had increased the cost-effectiveness of their economic endeavours.

CONCLUSION

This farm worker project appears to be a model of a well-designed and expertly managed community-based project for tuberculosis control in rural/farm areas.

Use of 2% propofol to produce diurnal sedation in critically ill patients

OBJECTIVE

The assessment of propofol to produce diurnal sedation in critically ill patients.

DESIGN

Prospective clinical study.

SETTING

Intensive Care Unit, University Hospital.

PATIENTS AND PARTICIPANTS

Thirty consecutive patients admitted to the Intensive Care Unit older than 18 years who were expected to be sedated for more than 50 h.

INTERVENTIONS

The patients were randomised into two groups. All received sedation with a constant background infusion of morphine and a variable infusion rate of propofol, which was altered hourly to maintain the intended sedation score. The first group received constant light sedation (CLS) over 50 h aiming for a Ramsay score of 2-3. The second group received CLS between 0600 h and 2200 h and additional night sedation (ANS) with propofol between 2200 h and 0600 h, aiming for a sedation score of 4-5.

MEASUREMENTS AND RESULTS

Patients were studied for 50 h from 1800 h on the first day of admission. Recordings of heart rate, blood pressure, sedation scores and propofol and morphine infusion rates were made hourly. An APACHE II score was recorded for each patient. Sedation scores were analysed by blind visual assessment and cosinor analysis, which is used in chronobiology to examine the correlation of data with a cosine curve. Patients in the ANS group had significantly better rhythmicity of sedation levels using cosinor analysis (r = 26% v 8%) p < 0.01. There was no difference between the CLS and ANS groups with respect to age, sex or APACHE II scores. Nine out of 15 patients in the ANS group achieved diurnal sedation. Three patients in the CLS group showed diurnal rhythmicity of sedation, which can be attributed to natural sleep, and had a median APACHE II score of 12. Five patients in the CLS group and three in the ANS group showed a deep constant sedation pattern. They had high APACHE II scores (median 21.5) and an obtunded conscious level on admission due to severe sepsis.

CONCLUSION

Propofol can safely provide diurnal sedation in the critically ill when titrated against the Ramsay score. Sedation levels cannot be manipulated in some severely ill patients.

Shared vision--a health education project designed to enhance adherence to anti-tuberculosis treatment

SETTING

Two adjacent Cape Town Local Authority health clinics in Cape Town, South Africa, were selected. Clinic A was designated the 'intervention clinic' and Clinic B the 'control clinic.'

OBJECTIVE

To assess whether the combined strategy of a patient-centred interview plus the issuing of a patient education booklet would have the effect of increasing the adherence of notified pulmonary tuberculosis (TB) patients to prescribed treatment.

DESIGN

A controlled intervention study was implemented using a cohort of the first 60 consecutive patients notified with pulmonary TB at both Clinic A and Clinic B; the patient cohort thus consisted of 120 patients.

RESULTS

The risk of patient non-adherence to anti-tuberculosis treatment was significantly reduced at the intervention clinic compared to the control clinic.

CONCLUSION

The results of this study indicate the need for further operational research to assist health providers in developing standardised protocols of health education to enhance adherence to treatment in patients who require protracted treatment regimens.

Communication with TB patients; a neglected dimension of effective treatment?

Previous research has shown that patients who are satisfied with their interactions with a health provider tend to adhere to treatment. This study sets out to investigate the quality of the communication in the interactions between clinic nurses at a Western Cape clinic and newly notified tuberculosis patients. Routine interviews between clinic nurses and tuberculosis patients were video-recorded, transcribed and analysed, using a qualitative instrument devised by the researchers. The interactions were evaluated as being essentially nurse-centred; there was an unequal distribution of control, poor receptivity to the patient and little confirmation of the patient. The nursing staff received a period of training in communication skills. After this training their interviews with patients revealed a significant shift towards a more patient-centred approach, resulting in mutual satisfaction of nurse and patient. Training in communication skills should be introduced at TB clinics, in order to improve patients' adherence to therapy.

Aminoglycoside levels in the rabbit vitreous cavity after intravenous administration

PURPOSE

To determine the penetration of gentamicin and amikacin into the rabbit vitreous cavity after their intravenous administration.

METHODS

Gentamicin (1.6 mg/kg every 8 hours) and amikacin (6 mg/kg every 12 hours) were administered intravenously to 25 rabbits that had previously had the lens and vitreous removed from 43 eyes. For each drug, ocular inflammation was induced in one group of eyes by injection of heat-killed Staphylococcus epidermidis, while the other group was maintained as a control. Samples from the vitreous cavity were taken at regular intervals for 72 hours after beginning the intravenous medications and were analyzed for drug concentrations.

RESULTS

The maximum intravitreal concentration +/- SD achieved for gentamicin was 1.8 +/- 0.5 microgram/ml. The maximum intravitreal concentration for amikacin was 8.5 +/- 3.2 micrograms/ml. Inflamed eyes demonstrated higher concentrations than did those without inflammation.

CONCLUSIONS

In a rabbit model with conditions optimized to enhance penetration of antimicrobials into the vitreous cavity after intravenous administration, neither gentamicin nor amikacin penetrated sufficiently to reach potentially therapeutic concentrations consistently for either Pseudomonas or S epidermidis organisms.

Tuberculosis in the community: 2. The perceptions of members of a tuberculosis health team towards a voluntary health worker programme

SETTING

A voluntary community health worker programme, in the Western Cape, South Africa, utilizing volunteers to administer directly observed therapy to tuberculosis (TB) patients.

OBJECTIVE

This study describes the perceptions of health team members regarding the voluntary community health worker project.

DESIGN

A qualitative, participatory research study utilizing focus groups.

RESULTS

TB was perceived by the health team to be a stigmatized disease causing some patients to be reluctant to be associated with the TB control programme. Despite the project's dedicated approach to case-holding, volunteers expressed the need to develop skills in providing more comprehensive care. The volunteers appear to administer a more personalized service to TB patients and can bridge the gap between TB patients and the health agency.

CONCLUSION

Sustained evaluation and support seem to be a vital tool in integrating a volunteer project into a health team approach. Its effectiveness appears to depend to a large degree on the people involved.

Tuberculosis in the community: 1. Evaluation of a volunteer health worker programme to enhance adherence to anti-tuberculosis treatment

SETTING

A voluntary health worker project (Operation Elsies River) was started in a high incidence tuberculosis (TB) area in the Western Cape of South Africa, in order to assist the local TB Control programme with case-holding.

OBJECTIVE

To evaluate the effectiveness of this group of volunteers in enhancing adherence of notified TB patients to tuberculosis treatment.

DESIGN

A cohort study was conducted with 351 TB patients (203 children and 148 adults).

RESULTS

The data from the child and the adult groups were analysed separately. The child group was more adherent to TB treatment than adults. The supervision option with staff dedicated to the treatment of TB, such as the clinic and the SANTA crèche, achieved better adherence results for pre-school children. The supervision modalities for adults did not differ in their adherence performance even following adjustment for confounders.

CONCLUSION

The supervision option provided by the volunteers did not significantly improve the adherence of adult patients to antituberculosis treatment.

Development of a health education booklet to enhance adherence to tuberculosis treatment

Effective anti-tuberculosis chemotherapy was developed during the 1950's, yet four decades later the cure rates for tuberculosis (TB) worldwide remain unacceptably low. A major reason for the failure to eliminate TB is that many patients with active disease fail to take sufficient anti-tuberculosis medication to render a cure. This paper describes a project designed to involve clinic nurses in the process of exploring how TB patients experience their disease. Information obtained from the qualitative research process was used to develop a photonovel which can be used to supplement the education given to newly diagnosed TB patients.

Induction of transmitter release at the neuromuscular junction prevents motoneuron death after axotomy in neonatal rats

Motoneurons to rat hindleg muscles die after neonatal nerve injury. Here we show that increasing transmitter release of motor nerve terminals by treatment with 4-aminopyridine, prior to nerve injury at three days, reduces the extent of motoneuron death. Retrograde labelling of soleus motoneurons was carried out in 10-week-old animals that had their sciatic nerve crushed on one side when they were three days old. Only 20% (+/- 4.2 S.E.M.) of the motoneurons survived the nerve injury. A group of animals similarly injured at three days had their calf muscles treated with 4-aminopyridine at birth, prior to nerve injury. In these animals a significantly higher percentage (51 +/- 6.6% S.E.M.) of soleus motoneurons survived. In order to assess the proportion of surviving alpha-motoneurons only, the number of motor units in both the soleus and extensor digitorum longus muscles was established by following the stepwise increments of twitch tension in response to increasing intensity of stimulation of the respective motor nerve. After nerve injury at three days only 18% (+/- 4.1% S.E.M.) of motor units to soleus and 28.5% (+/- 4.9% S.E.M.) to extensor digitorum longus survived and were able to reinnervate their respective muscles. If the nerve injury was preceded by local application of 4-aminopyridine, then the number of motor units present in the reinnervated muscles was significantly greater, so that in soleus 52.7% (+/- 5.4% S.E.M.) and in extensor digitorum longus 52.1% (+/- 2.4% S.E.M.) of motor units were present. This increase of motoneuron survival was reflected in a smaller weight loss and in a better restoration of force production by the pretreated as compared to untreated muscles on reinnervation after nerve injury. It is suggested that enhancing transmitter release from nerve endings in neonatal animals induces the motoneuron to become more resistant to nerve injury.

Blocking of NMDA receptors during a critical stage of development reduces the effects of nerve injury at birth on muscles and motoneurones

Blocking of NMDA receptors during a critical stage of development reduces the effects of nerve injury at birth on muscles and motoneurones. Injury to the sciatic nerve at birth causes many motoneurones to soleus and extensor digitorum longus (EDL) muscles of rats to die. This is reflected in a reduction of motor units in these muscles. In the soleus only 4 (12.3%) motor units remain while 10 (24.3%) remain in the EDL, showing that soleus alpha motoneurones are more sensitive to nerve injury at birth. Treatment with MK-801, an NMDA receptor blocker, rescues a proportion of motor units in both muscles, so that in the soleus 11 (36%) and in the EDL 17 (42%) of motor units survive. This loss of motor units results in muscle weakness and a reduction in force of both muscles. Treatment with MK-801 reduces the effect of nerve injury, so that muscles of treated animals are stronger and weigh more. Cross-sectional area and muscle fibre number in EDL muscles were assessed and found to be dramatically reduced after nerve injury at birth, so that the area was 20% of control, with only 13% of fibres remaining. Moreover the majority of the remaining EDL muscle fibres which are normally fast are converted into slow type I fibres, with 68% of fibres expressing slow myosin compared with 3% in control EDL muscles. In animals treated with MK-801 only 47% of muscle fibres are lost after nerve injury at birth, hence the area of the muscle is greater (51% of control). The change of muscle phenotype induced by nerve injury is prevented and the muscle fibre composition resembles that of normal EDL muscles in that 4% of muscle fibres express slow myosin compared with 3.5% in control EDL muscles. Thus, blocking NMDA receptors with MK-801 shortly after nerve injury at birth reduces the loss of motor units and this is directly reflected in an improved performance of the affected muscles.

Educating nurse administrators

There are startling changes occurring in the Canadian health care system as it restructures to new realities. The need for well-prepared nursing leaders has never been more evident. This article focuses on the importance of improved educational preparation for nurse administrators/executives. The authors reviewed 91 North American university calendars to determine existing educational programs. Administrators and educators must collaborate to develop educational programs that adequately prepare graduates to function within the changing health care system. To date, there is little evidence that this collaboration has taken place. In this article, the writers outline a proposed model and suggestions for a graduate education program in "nursing administration" that will meet the unique needs of today's nurse administrator/executive.

Vancomycin levels in the vitreous cavity after intravenous administration

PURPOSE

We studied the effects of inflammation, repeated antibiotic doses, and the surgical status of the eye on penetration of vancomycin hydrochloride into the rabbit vitreous cavity after intravenous administration.

METHODS

We studied three anatomic states (phakic, aphakic, and aphakic, vitrectomy-treated eyes) subdividing each into inflamed and noninflamed groups. Intravenous vancomycin hydrochloride (15 mg/kg of body weight) was administered every 12 hours for 48 hours. Eyes were harvested for the assay of vitreous cavity antibiotic levels at various intervals from one to 49 hours. We determined concentrations and calculated mean values and S.E.M.

RESULTS

Therapeutic levels were not established in the vitreous cavity at any time period in the two phakic groups. At 25 hours, the inflamed aphakic eyes had concentrations of 5.05 +/- 1.9 micrograms/ml and the control noninflamed aphakic eyes 4.5 +/- 1.23 micrograms/ml; slight increases were found by 49 hours. Concentrations tested in the aphakic, vitrectomy-treated eyes at two, 13, 25, and 49 hours demonstrated progressive increases both in the inflamed eyes (5.4 +/- 2.4 micrograms/ml, 9.64 +/- 4.25 micrograms/ml, 9.2 +/- 3.96 micrograms/ml, 10.34 +/- 4.49 micrograms/ml) and noninflamed eyes (3.52 +/- 2.1 micrograms/ml, 5.4 +/- 1.96 micrograms/ml, 6.8 +/- 2.53 micrograms/ml, 8.7 +/- 5.44 micrograms/ml).

CONCLUSIONS

Vitreous vancomycin concentrations in aphakic and aphakic, vitrectomy-treated eyes after intravenous administration exceed the minimal inhibitory concentrations for the usual gram-positive pathogens that create endophthalmitis, suggesting a role for intravenous vancomycin in the treatment of bacterial endophthalmitis.

Percutaneous cholecystolithotomy: risks, benefits, and long-term outcome

BACKGROUND

For symptomatic patients with gallbladder stones and a patent cystic duct who wish to retain their 'functioning' gallbladders, percutaneous cholecystolithotomy (PCCL) offers an alternative to open or laparoscopic cholecystectomy. However, there are few data on the risks and benefits of this approach or on the long-term outcome.

METHODS AND RESULTS

In 21 patients with symptomatic calcified gallstones, PCCL was successful (gallstone clearance) in 17 (81%). Four to 62 (median, 35) months after clearance 9 of the 17 remained symptom-free and stone-free, whereas 4 developed biliary sludge at 7, 30, 32, and 35 months, 2 of whom subsequently developed gallstones. In four other patients gallstones recurred without evidence of preceding biliary sludge at 9, 16, 19, and 27 months, corresponding to an actuarial gallstone recurrence rate at 36 months of 53.4 +/- SEM 15.1%, and a combined stone/sludge recurrence rate of 63.4 +/- 13.5%.

CONCLUSIONS

PCCL is moderately effective but, because of the frequency of complications and sludge/stone recurrence, is likely to have only a limited residual role in the era of laparoscopic cholecystectomy.

Vitreous cavity penetration of ceftazidime after intravenous administration

PURPOSE

Penetration of ceftazidime, a third generation cephalosporin, into the vitreous cavity after intravenous administration was investigated.

METHODS

Because antimicrobial penetration varies with surgical status of the eye and with inflammation, studies were conducted in phakic, aphakic, and aphakic, vitrectomized eyes in both normal and inflamed conditions. Ceftazidime 50 mg/kg was administered every 8 hours and vitreous cavity concentrations were tested at intervals from 2 to 72 hours after the initial dose.

RESULTS

No penetration was found into control phakic and aphakic eyes, but drug concentrations were detected in inflamed eyes at 24 hours. Vitreous concentrations of ceftazidime in aphakic, vitrectomized eyes reached levels well above the minimal inhibitory concentration (MIC) for Pseudomonas organisms within 2 hours of intravenous administration in control eyes (8.5 micrograms/ml) and inflamed eyes (35.4 micrograms/ml). Inflammation and removal of the lens and vitreous significantly enhanced ceftazidime penetration at all time periods tested.

CONCLUSION

Ceftazidime penetrates into the vitreous cavity of inflamed eyes after intravenous administration and achieves concentrations above the MIC for Pseudomonas organisms. Penetration is greatest in aphakic, vitrectomized eyes.

The design of a case register for tuberculosis. A pilot study in the south-western Cape

The development and piloting of a tuberculosis register that aims at providing a single source of information for the surveillance of tuberculosis and the measures for its control are discussed. Old-fashioned punch cards are appropriate in both isolated rural and sophisticated urban settings. The card system proved an effective and efficient clinic-based epidemiological tool but its implementation on a broad scale depends on the rationalisation of current administrative procedures.

A cluster of invasive pneumococcal disease in young children in child care

OBJECTIVE

To investigate a cluster of invasive pneumococcal disease in children 8 to 26 months of age, using standard microbiological procedures and ribosomal DNA gene-restriction patterns to characterize the outbreak strain.

DESIGN

Outbreak investigation.

SETTING

A family child-care home with six children in Baltimore, Md.

RESULTS

During an 8-day period, three of the six children in the family child-care home had febrile illnesses with pneumococcal bacteremia, and a fourth had purulent pneumococcal conjunctivitis. Type 12F Streptococcus pneumoniae was isolated from the four ill children and from the nasopharynges of the two healthy children. Ribotyping revealed all outbreak isolates had an identical ribotype pattern. Administration of rifampin to the children did not eradicate carriage of the organism.

CONCLUSIONS

Our data demonstrate that child care provides an opportunity for outbreak of invasive pneumococcal disease in young children. This observation suggests a need for increased alertness for clusters of pneumococcal disease in young children in child-care facilities and underscores the necessity for a pneumococcal vaccine that is effective in infants and young children.

Prevalence of rotavirus on high-risk fomites in day-care facilities

STUDY OBJECTIVE

The objective of this study was to determine the prevalence of rotavirus contamination on environmental surfaces in day-care environments, using the polymerase chain reaction technique.

DESIGN

High-risk fomites were identified in two day-care centers and sampled biweekly during a 6-month study period. Water samples from water-play tables in each center were also collected during the study period. During an infectious disease outbreak, fomites were sampled from the rooms in which the outbreak occurred. Reverse transcriptase/polymerase chain reaction was carried out for viral detection of rotavirus from the fomites, and standard bacteriologic measures were used to detect bacteria in samples from water-play tables.

RESULTS

A total of 96 fomite samples were tested for presence of rotavirus from the two centers, of which 18/96 (19%) tested positive for rotavirus. The timing of the positive samples differed between the two centers. In the center that housed infants, a peak of rotavirus-positive fomites coincided with two enteric outbreaks. Rotavirus contamination was found on the telephone receiver, drinking fountain, water-play table, and toilet handles in both centers. Bacteria in large quantities were also identified in water-play table samples.

CONCLUSIONS

Moist surfaces including the telephone, water fountains, and water-play tables are common sources of rotavirus contamination within the day-care environment. Until a safe and affordable drug or vaccine against rotavirus is available for general use, avoidance of rotaviral infections is the most effective method for the prevention of rotavirus gastroenteritis.

Progressive deterioration of muscles in mdx mice induced by overload

1. Extensor digitorum longus muscles of C57 BL/10 and mdx mice were overloaded by removing the synergist tibialis anterior muscle of 9-12-day-old animals. The effect of this operation on the weight, contractile properties and force of the extensor digitorum longus muscle was examined at two different ages, i.e. at 2-3 months (young group) and at 5-8 months (old group). The changes with age in both the control and overloaded muscles of normal and mdx mice are also described. The values obtained from the overloaded muscles were always compared with those for the control, unoperated extensor digitorum longus. 2. In the normal strain of mice the weight of the overloaded extensor digitorum longus muscle in the younger group was increased and it remained higher in the older animals. In the mdx mice the overloaded extensor digitorum longus muscles weighed more in the younger animals but not in the older group of mice. 3. The twitch and tetanic tensions of the overloaded muscles were slightly, but not significantly, increased in the younger group of mdx mice, whereas in the older animals there was a significant decrease in both twitch and tetanic tensions. 4. Thus the overloaded muscles from mdx mice progressively deteriorated with age. In both strains of mice the overloaded muscles become less fatigable with time.

Magnetic stimulation of the nervous system

Magnetic brain stimulation is a painless method of exciting cortical neurons and provides a measure of corticospinal tract function. Its clinical role is currently limited though advances in coil design may lead to wider clinical applications and to greater understanding of how the cerebral cortex functions in vivo.

One-stage versus two-stage anterior and posterior spinal reconstruction in adults. Comparison of outcomes including nutritional status, complications rates, hospital costs, and other factors

Twenty-four patients undergoing anterior and posterior spinal fusion were preoperatively assessed and at weekly intervals during their hospitalization for the following: serum albumin, transferrin, total lymphocyte count, skin anergy and anthropometric measurements. Eleven patients underwent staged anterior and posterior spinal reconstruction and 13 patients underwent similar procedures in a combined fashion. The groups were similar in age, sex, diagnosis, and number of levels fused. Results of these tests were kept as well as operative time, blood loss, transfusion requirements, wound healing problems, infection, length of hospital stay, patient satisfaction, and total cost. All 24 patients had normal preoperative nutritional parameters. Seven patients in the staged group and ten in the combined group became malnourished after surgery. No patient in the combined group developed infection or a wound healing problem. Wound infections developed in two of the seven patients in the staged group after their second procedure. The average number of units of blood transfused and the operating time were similar for both groups. The average length of hospital stay for the staged group was 20 days compared to 13 days for the combined group. Total hospital bills averaged 30% less in the combined group. All patients stated that they preferred to have the procedures done under the same anesthetic. The authors conclude that protein and calorie malnutrition develops to an appreciable extent in adults undergoing anterior and posterior spinal reconstructive procedures. It therefore increases the postoperative morbidity if staged surgical procedures are performed too close together as is currently done by many spine surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)