Compliance of patients and physicians: experience and lessons from tuberculosis-II

Prevalence and determinants of anti-tuberculosis treatment non-adherence in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Tuberculosis is a global public health problem. One of the overarching dilemmas and challenges facing most tuberculosis program is non-adherence to treatment. However, in Ethiopia there are few studies with variable and inconsistent findings regarding non-adherence to treatment for tuberculosis.

METHODS

This systematic review and meta-analysis was conducted to determine the prevalence of non-adherence to tuberculosis treatment and its determinants in Ethiopia. Biomedical databases including PubMed, Google Scholar, Science Direct, HINARI, EMBASE and Cochrane Library were systematically and comprehensively searched. To estimate the pooled prevalence, studies reporting the prevalence of adherence or non-adherence to tuberculosis treatment and its determinants were included. Data were extracted using a standardized data extraction tool prepared in Microsoft Excel and transferred to STATA/se version-14 statistical software for further analyses. To assess heterogeneity, the Cochrane Q test statistics and I2 test were performed. Since the included studies exhibited high heterogeneity, a random effects model meta- analysis was used to estimate the pooled prevalence of non-adherence to tuberculosis treatment. Finally, the association between determinant factors and non-adherence to tuberculosis treatment was assessed.

RESULTS

The result of 13 studies revealed that the pooled prevalence of non-adherence to tuberculosis treatment in Ethiopia was found to be 21.29% (95% CI: 15.75, 26.68). In the subgroup analysis, the highest prevalence was observed in Southern Nations and Nationalities of Ethiopia, 23.61% (95% CI: 21.05, 26.17) whereas the lowest prevalence was observed in Amhara region, 10.0% (95% CI: 6.48, 13.17.0;). Forgetfulness (OR = 3.22, 95% CI = 2.28, 4.53), fear side effect of the drugs (OR = 1.93, 95% CI = 1.37, 2.74), waiting time ≥ 1 hour during service (OR = 4.88, 95% CI = 3.44, 6.91) and feeling distance to health institution is long (OR = 5.35, 95% CI = 4.00, 7.16) were found to be determinants of non-adherence to tuberculosis treatment.

CONCLUSION

In this meta-analysis, the pooled prevalence of non-adherence to tuberculosis treatment in Ethiopia was high. Forgetfulness, fear of side effect of the drugs, long waiting time (≥1 hour) during service and feeling distance to health institution is long were the main risk factors for non-adherence to tuberculosis treatment in Ethiopia. Early monitoring of the side effects and other reasons which account for missing medication may increase medication adherence in patients with tuberculosis in Ethiopia.

Factors contributing to non-adherence with treatment among TB patients in Sodo Woreda, Gurage Zone, Southern Ethiopia: A qualitative study

Poor adherence by tuberculosis (TB) patients to their medication contributes not only to the worsening of their TB situation but also paves a way for incidence of drug resistance. This study, hence, aims to explore factors contributing for non-adherence of TB treatment among TB patients in Sodo Woreda, Gurage Zone, Southern Ethiopia. A qualitative study, which included 22 in-depth interviews from four health centers and seven health posts, was conducted from February 25 to April 27, 2014. Although the drugs were given free of charge, many patients were unable to adhere to their treatment because of one or a combination of the following factors; lack of adequate food, poor communication between healthcare providers and patients, beliefs in traditional healing system, unavailability of the service in nearby health facilities, side-effect and pill burden of the drugs, stigma and discrimination. The patients take their anti-TB medications under difficult circumstances and experienced a wide range of interacting factors. This, in turn, has resulted for non-adhered treatment taking behavior by many patients. Health professionals and policy makers should be aware of such factors and initiate sustained educational campaigns directed towards all parties in the study area to obtain a good success with TB treatment.

Non-adherence of new pulmonary tuberculosis patients to anti-tuberculosis treatment

BACKGROUND

Non-adherence to anti-tuberculosis (TB) treatment adversely affects treatment success rate. It increases disease morbidity and mortality. Also, it contributes significantly to the development of drug resistance.

AIM

To identify risk factors for non-adherence to anti-TB treatment by new pulmonary TB patients.

SUBJECTS AND METHODS

It is a prospective cohort study at 21 TB treatment centres in E ward of Mumbai Municipal Corporation. All sputum smear positive new pulmonary TB patients initiated on treatment regimen of short course chemotherapy fro 1(st) January to 30(th) June of a calendar year were enrolled and followed up till any final outcome as per revised national TB control program. Non-adherence was defined as interruption of anti-TB treatment for ≥ 1 month. The factors were identified by univariate and logistic regression analysis.

RESULTS

We studied 156 newly diagnosed pulmonary TB patients. Out of these 78 (50%) were non-adherent to anti-tuberculosis treatment (ATT). Independent risk factors for non-adherence were identified as male gender (P = 0.035) and lack of knowledge of importance of regular treatment (P = 0.001). Being female sex worker (FSW) was also an absolute risk factor for non-adherence.

CONCLUSIONS

There is immense need for continuous, effective and reinforcing health education to the patient and his family. Special groups like males in the age group of 15-49 years, patients who do not have any family support like migrants, FSW need special attention to ensure adherence to ATT.

The value of effective public tuberculosis treatment: an analysis of opportunity costs associated with multidrug resistant tuberculosis in Latvia

BACKGROUND

A challenge to effective protection against tuberculosis is to sustain expensive and complex treatment public programs. Potential consequences of program failure include acquired drug resistance, poor patient outcomes, and potentially much higher system costs, however. In contrast, effective efforts have value illustrated by impacts they prevent. We compared the healthcare costs and treatment outcomes among multidrug-resistant tuberculosis (MDR-TB) and non MDR-TB patients in Latvia to identify benefits or costs associated with both.

METHODS

We measured and compared costs, healthcare utilization, and outcomes for patients who began treatment through Latvia's TB control program in 2002 using multivariate regression analysis and negative binomial regression.

RESULTS

We analyzed data for 92 MDR-TB and 54 non MDR-TB patients. Most (67%) MDR-TB patients had history of prior tuberculosis treatment. MDR-TB was associated with lower cure rates (71% vs. 91%) and greater resource utilization. MDR-TB treatment cost almost $20,000 more than non MDR-TB.

CONCLUSION

Up to 2/3 of MDR-TB treated in our sample was preventable at a potential savings of over $1.3 million in healthcare resources as well as substantial individual health.

Pathophysiology of the antiphospholipid antibody syndrome

Antiphospholipid antibodies (aPL) are associated with the recurrent pregnancy loss and thrombosis that characterizes the antiphospholipid antibody syndrome (APS). Although the ontogeny of these pathogenic antibodies has not been fully elucidated, there is evidence that indicates the involvement of both genetic and environmental factors. The ability of aPL to induce a procoagulant phenotype in APS patients plays a central role in the development of arterial and venous thrombotic manifestations typical of the disease. Inflammation serves as a necessary link between this procoagulant phenotype and actual thrombus development and is an important mediator of the placental injury seen in APS patients with obstetric complications. Recent evidence has indicated a role for abnormal cellular proliferation and differentiation in the pathophysiology of APS, especially in those patients with pregnancy morbidity and other more atypical manifestations that have no identifiable thrombotic cause. The interplay of genetic and environmental factors responsible for aPL development and the mechanisms by which these antibodies produce disease in APS patients is the focus of this review.

Does directly observed therapy (DOT) reduce drug resistant tuberculosis?

Background

Directly observed therapy (DOT) is a widely recommended and promoted strategy to manage tuberculosis (TB), however, there is still disagreement about the role of DOT in TB control and the impact it has on reducing the acquisition and transmission of drug resistant TB. This study compares the portion of drug resistant genotype clusters, representing recent transmission, within and between communities implementing programs differing only in their directly observed therapy (DOT) practices.

Methods

Genotype clusters were defined as 2 or more patient members with matching IS6110 restriction fragment length polymorphism (RFLP) and spoligotype patterns from all culture-positive tuberculosis cases diagnosed between January 1, 1995 and December 31, 2001. Logistic regression was used to compute maximum-likelihood estimates of odds ratios (ORs) and 95% confidence intervals (CIs) comparing cluster members with and without drug resistant isolates. In the universal DOT county, all patients received doses under direct observation of health department staff; whereas in selective DOT county, the majority of received patients doses under direct observation of health department staff, while some were able to self-administer doses.

Results

Isolates from 1,706 persons collected during 1,721 episodes of tuberculosis were genotyped. Cluster members from the selective DOT county were more than twice as likely than cluster members from the universal DOT county to have at least one isolate resistant to isoniazid, rifampin, and/or ethambutol (OR = 2.3, 95% CI: 1.7, 3.1). Selective DOT county isolates were nearly 5 times more likely than universal DOT county isolates to belong to clusters with at least 2 resistant isolates having identical resistance patterns (OR = 4.7, 95% CI: 2.9, 7.6).

Conclusions

Universal DOT for tuberculosis is associated with a decrease in the acquisition and transmission of resistant tuberculosis.

Osmotically regulated asymmetric capsular systems for simultaneous sustained delivery of anti-tubercular drugs

Sustained release asymmetric membrane capsular systems were developed for simultaneous oral delivery of rifampicin and isoniazid sodium in order to reduce the problems associated with the multi drug therapy of tuberculosis. Dense semipermeable membrane coating capsules were also prepared for the delivery of these drugs by adopting two different filling approaches. In vitro release studies were carried out for both types of systems and the results were compared. Asymmetric membrane capsules provided sustained release of rifampicin associated with initial burst release, where isoniazid release rates were comparatively high due to higher aqueous solubility. Dense semipermeable membrane systems provided controlled release of both drugs but were devoid of initial burst release of isoniazid. To overcome these drawbacks, a modified asymmetric system was developed by adding appropriate amount of hydrophilic polymer mixture with isoniazid. The system provided satisfactory sustained release of rifampicin and isoniazid with initial burst release may be sufficient to achieve minimum effective concentration in blood. In vitro dissolution kinetics of the systems followed first order kinetics and statistical analysis of release rate data proved that modified asymmetric system was better amongst the developed systems.

The role of DOTS in tuberculosis treatment and control

Directly Observed Therapy Shortcourse (DOTS) is composed of five distinct elements: political commitment; microscopy services; drug supplies; surveillance and monitoring systems and use of highly efficacious regimens; and direct observation of treatment. The difference in the way the term 'DOTS' as defined by WHO and interpreted by many observers has led to some misunderstanding. WHO generally uses the term to mean the five components of DOTS. But the word 'DOTS' is an acronym for Directly Observed Therapy Shortcourse. Many workers therefore interpret DOTS purely as direct supervision of therapy. DOTS is not an end in itself but a means to an end. In fact it has two purposes, to ensure that the patient with tuberculosis (TB) completes therapy to cure and to prevent drug resistance from developing in the community. The main criticism of DOTS rightly derives from the fact that some properly conducted randomized, controlled trials of directly observed therapy with or without the other components have shown no benefit from it. The problem is that it is impossible to design a study of modern directly observed therapy against the previous self-administered, poorly-resourced programs. As soon as a study is implemented, the attention to patients in the control (non-directly observed therapy) arm inevitably improves from the previous non-trial service situation. What is of concern is that in some trials less than 70% cure rates were achieved even in the direct observation arm. With no new drugs or adjuvant treatment available to bring the length of treatment down to substantially less than 6 months, DOTS offers the best means we have at our disposal for TB control.

Adherence to HAART regimens

The problem of inadequate adherence to prescribed highly active antiretroviral therapy (HAART) drug regimens to treat HIV infection and AIDS is ubiquitous. Adherence can be inadequate despite both provider and patient understanding of the consequences of nonadherence. Successful long-term treatment of HIV/AIDS requires at least 95% adherence to HAART in order to prevent emergence of drug-resistant HIV variants that lead to regimen failure and limit options for future therapy. Despite the prevalence of inadequate adherence, many patients succeed, and HAART has transformed HIV infection into a chronic illness increasingly managed in primary care. The barriers to adherence observed in HIV treatment resemble barriers to the successful treatment of other chronic diseases: regimen complexity, side effects resulting in poor tolerability, patient lifestyle factors, and patient-provider relationships. Treatment of HIV infection has shown that patient-provider collaboration can result in the selection of a lifestyle-tailored regimen characterized by convenient dosing, low pill burden, and tolerable side effects that enhances adherence, effectiveness, and the patient's willingness to remain on anti-HIV therapy long term. This review focuses on the current understanding of adherence reporting, improvement of adherence, and, hence, improvement of treatment outcomes in HIV infection and AIDS.

Chemotherapeutic activity against murine tuberculosis of once weekly administered drugs (isoniazid and rifampicin) encapsulated in liposomes

Co-administration of isoniazid (INH) and rifampicin (RIF) encapsulated in lung specific stealth liposomes at one third of their recommended doses of 12 and 10 mg/kg b.wt., respectively, exhibited a sustained release of these drugs in plasma (5 days) and lungs, liver and spleen (7 days). At these concentrations, T(max) and area under curve (AUC) values of liposomal drugs were more than that observed with free drugs. The elimination constant (Kel) was higher for liposomal INH (-0.034+/-0.008) and RIF (-0.017+/-0.009) compared with free INH (-0.392) and RIF (-0.243). Chemotherapeutic efficacy of once weekly-administered liposomal drugs for 6 weeks reduced the mycobacterial load significantly in lungs, liver and spleen of infected mice compared with untreated animals.

Patient characteristics associated with failure of tuberculosis prevention

OBJECTIVES

The cost-effectiveness of tuberculin screening may be substantially reduced by non-compliance of patients and physicians. We have examined the association of these problems with the socio-demographic characteristics of tuberculin reactors.

METHODS

Community-based tuberculin screening was conducted among students in grades 6 and 10, and in post-secondary health training, as well as young adult workers. A follow-up survey was conducted to determine if tuberculin reactors referred for further evaluation actually reported, if they were prescribed therapy when indicated, and if they took therapy when it was prescribed. Association of reactors' socio-demographic characteristics with these outcomes was analyzed.

RESULTS

Canadian-born subjects were less likely to report if they were: older (adjusted and standardized odds ratio: 0.7, 95% confidence interval: [0.5, 0.9]), resident in more affluent neighbourhoods (0.7 [0.6, 0.99]), and from single parent households (0.1 [0, 0.9]). Even when indicated, physicians were less likely to prescribe treatment for Canadian-born subjects who reported bacille Calmette-Guérin vaccination, but had not actually received this (0.3 [0.1, 0.7]), or who were from single-parent households (0.1 [0, 0.9]). Physicians were less likely to prescribe treatment for foreign-born who gave a history of BCG vaccination (0.1 [0.1, 0.3]), and were more likely to prescribe treatment for reactors from countries such as Haiti or Vietnam. The only factor significantly associated with compliance was that older Canadian-born subjects were less compliant (0.6 [0.4, 0.97]).

CONCLUSIONS

Failure to report for further medical evaluation and physician non-compliance were associated with a number of socio-demographic characteristics, and substantially reduced the benefit of a tuberculosis screening program.

Short-course therapy of pulmonary tuberculosis: doctor's compliance

OBJECTIVE

The present study, conducted from 1986 to 1991, investigated the accuracy of treatment monitoring performed by practitioners in the out-patient treatment of pulmonary tuberculosis.

DESIGN

All patients with smear or culture positive pulmonary tuberculosis, receiving 6-month short-course chemotherapy with Isoniazid (H), Rifampicin (R) and Pyrazinamide (Z), were included. Treatment had been initiated either in our unit, or shortly before, with discharge after an average time of 8 weeks. Practitioners were sent a flow sheet advising how to perform standardized ambulatory controls.

RESULTS

Forty-three patients were included in the study, four of whom did not visit their practitioner after discharge. It must be assumed that they did not complete treatment. The average follow-up time of the remaining 39 patients was 159 weeks. In 13 cases the treatment was prolonged without obvious reason. For four patients who had not converted to a negative sputum culture at discharge, negativity was never been proven thereafter. Objective means of assessing patient compliance by H-urine strip testing were undertaken only in three cases. X-ray controls were performed adequately in 44.4% of the cases. By contrast monthly checks of liver enzymes had been done only in 23.1% of the patients.

CONCLUSION

We conclude that even a highly standardized protocol of short-course tuberculosis treatment requires a certain level of experience and compliance on the part of the practitioner. We accordingly recommend that every case of pulmonary tuberculosis should be reviewed at least twice by a chest physician.

Paradoxical response to antitubercular drugs

Seven patients with paradoxical response to antitubercular drugs are reported. In three cases of intracranial tuberculomas, newer lesions appeared and in two cases preexisting tuberculomas enlarged. In two cases of tubercular meningitis, multiple tuberculomas appeared. All these cases exhibited newer symptoms and CT/MBI revealed the paradoxical response to antitubercular drugs. All responded to continued conservative therapy, with addition of pyrazinamide.

Maintenance of therapeutically active levels of isoniazid for prolonged periods in rabbits after a single implant of biodegradable polymer

SETTING

Poor patient compliance is the serious limiting factor in the chemotherapy of tuberculosis.

OBJECTIVE

To solve this problem we have been developing depot-drug delivery of antimycobacterial drugs. Earlier studies with mice using isoniazid in polylactic-co-glycolic acid (PLGA) co-polymer have shown that a single implant of the polymer could ensure sustained levels of free isoniazid for up to 8 weeks. Similar studies were not undertaken in rabbits.

DESIGN

The biodegradable PLGA polymer rods containing isoniazid were implanted on the back of the rabbits under anaesthesia in an isoniazid dose of 90 mg/kg. Concentrations of isoniazid and acetylisoniazid in serum and urine were determined by the high-performance liquid chromatography (HPLC) method at close intervals up to 96 h to study the burst-size, and later at weekly intervals up to 9 weeks to study the sustained levels.

RESULTS AND CONCLUSIONS

There was no abnormal release of isoniazid in the earlier periods. Concentrations of isoniazid > or = 0.2 microgram/ml were found both in serum and urine up to 63 days after implant. Urine specimen obtained at 6 weeks after giving the implant inhibited the growth of Mycobacterium tuberculosis in vitro as measured by the radiometric (Bactec) method. These findings in non-rodent animal species confirm the usefulness of the depot-drug delivery method of drug administration and warrant hopes for the successful treatment of tuberculosis avoiding the problem of non-compliance.

Determinants of compliance with iron supplementation: supplies, side effects, or psychology?

Iron deficiency anemia affects over 2 billion people. Particularly at risk are pregnant women and young children. Although distribution of iron supplements is practised in many antenatal care programs in developing countries, it has often been alleged that pregnant women do not take them. Poor compliance arises not only because of patient behavior but also from factors out of the patient's control. This paper presents the results of a review of the literature on medical compliance to determine whether iron supplementation is different from other medications, to assess the known levels of compliance, and to synthesize recommendations for improving compliance relevant to iron supplementation. The review showed that compliance with iron therapy is a specific case of medical compliance. Reasons for non-compliance with iron deficiency treatment include: inadequate program support (lack of political commitment and financial support); insufficient service delivery (poor provider-user dynamics; lack of supplies, access, training, and motivation of health care professionals); and patient factors (misunderstanding instructions, side effects, frustration about the frequency and number of pills taken, migration, fear of having big babies, personal problems, nausea that accompanies pregnancy, and the subtlety of anemia which makes demand for treatment low). Much has been made about the side effects (nausea, constipation, etc.) that women might experience during iron therapy as the cause of poor compliance with iron supplementation without justification according to this review. Instead, unavailability of iron supplements was the most common reason why women did not take iron supplements. Women bear a disproportionate burden from iron deficiency anemia even though the technology exists to address the problem at low cost. Governments and health care professionals must renew their commitment to iron therapy by monitoring and improving compliance. We can significantly improve compliance by: making sure that iron supplements are available at all times; providing advanced warning about the possibility of side effects; involving the patient in the therapeutic strategy; and providing reminders, such as posters and calendars, about taking supplements.

The effect of directly observed therapy on the rates of drug resistance and relapse in tuberculosis

BACKGROUND

Tuberculosis has reemerged as an important public health problem, and the frequency of drug resistance is increasing. A major reason for the development of resistant infections and relapse is poor compliance with medical regimens. In Tarrant County, Texas, we initiated a program of universal directly observed treatment for tuberculosis. We report the effect of the program on the rates of primary and acquired drug resistance and relapse among patients with tuberculosis.

METHODS

We collected information on all patients with positive cultures for Mycobacterium tuberculosis in Tarrant County from January 1, 1980, through December 31, 1992. Through October 1986, patients received a traditional, unsupervised drug regimen. Beginning in November 1986, nearly all patients received therapy under direct observation by health care personnel.

RESULTS

A total of 407 episodes in which patients received traditional treatment for tuberculosis (January 1980 through October 1986) were compared with 581 episodes in which therapy was directly observed (November 1986 through December 1992). Despite higher rates of intravenous drug use and homelessness and an increasing rate of tuberculosis during this 13-year period, the frequency of primary drug resistance decreased from 13.0 percent to 6.7 percent (P < 0.001) after the institution of direct observation of therapy, and the frequency of acquired resistance declined from 14.0 percent to 2.1 percent (P < 0.001). The relapse rate decreased from 20.9 percent to 5.5 percent (P < 0.001), and the number of relapses with multidrug-resistant organisms decreased from 25 to 5 (P < 0.001).

CONCLUSIONS

The administration of therapy for M. tuberculosis infection under direct observation leads to significant reductions in the frequency of primary drug resistance, acquired drug resistance, and relapse.

Compliance with tuberculosis therapy

The treatment experience in TB control can be a very rewarding time for both the patient and the provider. If the patient is made to feel that the provider cares for him as a person, a meaningful relationship can develop and can have a positive influence on the patient's behavior in taking medications and perhaps even in the direction of his life. Noncompliance with medications unfortunately has been a "given" in the TB control program. The successful program must be patient centered and include the following components: (1) fair and equal treatment of all patients, (2) patient involvement in the plan of care, (3) the most current patient treatment and services, including the availability of DOT for patients with TB infection and disease, and (4) rewards for patients and staff for positive behavior in the completion of treatment. Given current levels of staffing and other resources, some noncompliance will continue even in the best TB programs. Caring and knowledgeable staff members who support the patient-centered approach can make TB treatment a positive experience for both the patient and themselves.

Tuberculosis: commentary on a reemergent killer

Tuberculosis remains the leading cause of death in the world from a single infectious disease, although there is little knowledge of the mechanisms of its pathogenesis and protection from it. After a century of decline in the United States, tuberculosis is increasing, and strains resistant to multiple antibiotics have emerged. This excess of cases is attributable to changes in the social structure in cities, the human immunodeficiency virus epidemic, and a failure in certain major cities to improve public treatment programs. The economic costs of not adequately addressing the problem of tuberculosis in this country are estimated from an epidemiological model.

Treatment of tuberculosis by private general practitioners in India

Early detection and optimal treatment constitute the most important measures in the control of tuberculosis. This study of prescriptions for tuberculosis recommended by 102 private doctors, practising in the slums of Bombay, shows a lack of awareness among doctors who treat tuberculosis patients in their own clinics about the standard drug regimens for treatment of tuberculosis recommended by national and international agencies. While there are a few standard, efficient, recommended regimens, 100 private doctors prescribed 80 different regimens, most of which were both inappropriate and expensive. The study highlights the need for effective communication between those implementing national tuberculosis programmes and the practising private doctors, continuing education of these doctors for updating their knowledge and their active participation in at least those national disease programme for which their curative functions could contribute significantly to control of a disease.

Sustained release of isoniazid in vivo from a single implant of a biodegradable polymer

In order to solve the problem of poor patient compliance, attempts were made to prolong the bioavailability of antimycobacterial drugs after a single administration. A single implant of polylactic-co-glycolic acid (PLGA) co-polymer containing isoniazid ensured its sustained release up to 6 weeks. The levels are comparable with those obtained from daily doses. Homogenates of liver and lungs from animals killed at 6 weeks after a single implant showed high antimycobacterial activity against Mycobacterium tuberculosis. Sera from the implant and daily dose group animals showed no significant difference in renal, hepatic and haematological parameters. The implant caused no local or systemic toxicity.

Inter-relations between relapses, drug regimens and compliance with treatment in tuberculosis

The inter-relationships between relapse, treatment regimen and compliance in 1009 patients treated for tuberculosis between 1978 and 1987 are reported. Multiple linear logistic regression using relapse as the dependent variable was used because of the complex relationships between treatment, compliance, age and calendar year of treatment. Compliance (P less than 0.0001) was the major determinant of relapse, but age (P = 0.047) was also significantly associated. Relapse was not related to sex, site of disease, ethnic group or the presence of multiple disease sites. Although the regimen given, the total duration of treatment and treatment with or without pyrazinamide were not statistically associated with relapse, pyrazinamide containing regimens were associated with better compliance. Compliance was best in those aged 60 years and over and worst in those aged 15-29 years. Some of the non-compliance leading to relapse was only uncovered by close Health Visitor surveillance and not by the physician supervising treatment, emphasizing the important role of field staff in patient follow-up.

Orocaecal transit time in Duchenne muscular dystrophy

Smooth muscle degeneration may occur in Duchenne muscular dystrophy. We measured fasting orocaecal transit time in patients with advanced Duchenne muscular dystrophy and other muscular dystrophies and in healthy controls. No significant differences were found. In contrast to reports of gastric hypomotility in Duchenne muscular dystrophy, we found no evidence of impaired small intestinal motility.

Patient compliance with tuberculosis treatment in Ghana: factors influencing adherence to therapy in a rural service programme

In Agogo Hospital in the hills of Ashanti, Ghana, default and cure rates among 569 consecutive sputum-smear positive pulmonary tuberculosis (PTB) patients registered between 1984 and 1987 in a rural ambulatory non-supervised service program were analysed. Female gender, shorter home-to-clinic distances and younger age were significantly associated with higher cure and lower default rates. Within the district where liaison health workers paid home visits to PTB patients, the home-to-clinic distance effect on default was overruled by the effect of follow-up. Data from two surveys held in 1985 and 1987, among 68 and 49 PTB patients respectively, revealed that many patients visited healing churches but few admitted to having consulted traditional healers; that financial expenses for transport outweighed hospital charges; that lower educational levels were not associated with poorer compliance to therapy and that health education had improved significantly over the 2-year-period. It is concluded that intervention with liaison health workers and simple health education results in improved outcome in rural service tuberculosis programme.

Small intestinal bacterial overgrowth in patients with chronic lymphocytic leukaemia

As part of a study to assess the possible contribution of lymphoid infiltration of the gastrointestinal mucosa to occult blood loss or malabsorption 20 patients with chronic lymphocytic leukaemia (CLL) had a lactulose hydrogen breath test. In 10 cases (50%) a small intestinal peak was detected, suggesting small bowel bacterial overgrowth, and this was confirmed in seven patients by the positive culture of jejunal aspirate. Of the patients with a positive hydrogen breath test, radiological examination showed a duodenal diverticulum in two but no anatomical abnormalities in the other cases. There was no evidence of achlorhydria and transit times were normal. There was no difference in the incidence of hypogammaglobulinaemia among those patients with evidence of small intestinal bacterial overgrowth and those without. Seven patients with a positive hydrogen breath test, however, had undetectable secretory piece in their jejunal aspirates whereas this was present in all patients with a normal breath test who had local immunoglobulin concentrations measured (p less than 0.05), indicating that the small intestinal bacterial overgrowth may be due to impaired local immunity.

Metabolic disposition of pyrazinamide in the rat: identification of a novel in vivo metabolite common to both rat and human

Only limited studies have been reported on the disposition and pharmacokinetics of pyrazinamide (PZA) in both animals and humans. The metabolism of PZA has never been completely elucidated, consequently the metabolites of PZA, pyrazinoic acid (PA), 5-hydroxypyrazinoic acid (5-HOPA), and 5-hydroxypyrazinamide (5-HOPZA) were characterized and the disposition of PZA was examined following administration of 150 mg kg-1 of 14C-PZA to male Wistar rats. Comparable t1/2 for total radiolabel 14C (1.45 +/- 0.06 h) and PZA (1.39 +/- 0.04 h) in the blood compartment were observed. Cumulative 48 h excretion in urine and faeces accounted for 82.6 +/- 3.2 per cent and 11.0 +/- 1.3 per cent, respectively, of the dose administered. In the 0-6 h urine collections PA, 5-HOPA, 5-HOPZA, and PZA, respectively, accounted for 25.4 +/- 1.7, 17.7 +/- 1.2, 11.6 +/- 0.8, and 2.7 +/- 0.2 per cent of the administered dose. In the 6-12 h urine samples the proportions of PA and 5-HOPA increased statistically over the 0-6 h excretion whereas 5-HOPZA decreased. Administration of PZA to humans indicated 5-HOPZA was a major urinary metabolite in human. These data suggested that direct hydroxylation of PZA was an alternative pathway in the oxidation of PZA of importance to both human and rat.