Digital screening for mental health in pregnancy and postpartum: A systematic review

PURPOSE

This systematic review aimed to determine if digital screening for mental health in pregnancy and postpartum is acceptable, feasible and more effective than standard care (paper-and pen-based screening or no screening). The second aim was to identify barriers and enablers to implementing digital screening in pregnancy and postpartum.

METHOD

OVID MEDLINE, PsycINFO, SCOPUS, CINAHL, Embase, Web of Science, Joanna Briggs Database and All EMB reviews incorporating Cochrane Database of Systematic Reviews (OVID) were systematically searched for articles that evaluated digital screening for mental health in pregnancy and postpartum between 2000 and 2021. Qualitative articles were deductively mapped to the Theoretical Domains Framework (TDF).

RESULTS

A total of 34 articles were included in the analysis, including qualitative, quantitative and mixed-methods studies. Digital screening was deemed acceptable, feasible and effective. TDF domains for common barriers included environmental context and resources, skills, social/professional role and identity and beliefs about consequences. TDF domains for common enablers included knowledge, social influences, emotion and behavioural regulation.

CONCLUSION

When planning to implement digital screening, consideration should be made to have adequate training, education and manageable workload for healthcare professionals (HCP's). Organisational resources and support are important, as well as the choice of the appropriate digital screening assessment and application setting for women. Theory-informed recommendations are provided for both healthcare professionals and women to inform future clinical practice.

Experiences of Organizational Practices That Advance Women in Health Care Leadership

IMPORTANCE

Women are underrepresented in health care leadership positions. Organizational practices and culture play a key role in mitigating this disparity.

OBJECTIVE

To explore the experiences of women in leadership roles and inform how health care organizations can support the advancement of women into leadership.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used a constructivist grounded theory approach applied over a 1-year period (May 1, 2021, to May 31, 2022) in a large private health care network in Australia. Women were eligible if they had been in leadership positions for more than 5 years. Purposive and theoretical sampling guided recruitment of 28 women, representing medical, nursing, and allied health specialties. Interviews lasted 1 hour, producing 500 pages of transcripts for analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was a model of organizational practices and conditions that advance women in health care leadership, extrapolated from the collective experiences of women in leadership. Key elements pertained to organizational patterns of interaction and group norms and behaviors that contributed toward women's experiences of career advancement.

RESULTS

Overall, 28 women (23 [82%] White; 3 [11%] Southeast Asian) participated in the study, 10 (36%) of whom were in nursing, 9 (32%) of whom were in allied health, and 9 (32%) of whom were in medical disciplines. Organizational practices that advance women in health care leadership were highly dependent on conducive organizational culture enhancing women's credibility and capability as leaders. Four interrelated elements were identified that create the necessary conditions for an organizational culture to advance women in health care leadership, including (1) identifying and actively addressing systemic barriers, (2) challenging gendered assumptions and expectations of leadership behaviors, (3) providing mentorship to shape career opportunities, and (4) determining how these conditions all contribute toward raising women's credibility to enable internalizing a leadership identity. For women, advancing to leadership involved organizations moving away from ad hoc, inconsistent applications of gender equity practices and generating supportive practices that reinforced a workforce culture of credibility, collaboration, and continuous improvement to support women.

CONCLUSIONS AND RELEVANCE

In light of persisting inequity in health care leadership, women's experiences were captured in this qualitative study to identify organizational practices that support their advancement. Insights into factors that influence efficacy of these practices, including building a supportive culture and mentoring, are discussed. This research informs a National Health and Medical Research Council initiative with international collaborators to support organizations in advancing women in health care leadership.

Using a Modified Delphi Approach and Nominal Group Technique for Organisational Priority Setting of Evidence-Based Interventions That Advance Women in Healthcare Leadership

BACKGROUND

Few studies address how to prioritise organisational interventions that advance women in leadership. We report on the relevance, feasibility and importance of evidence-based interventions for a large healthcare organisation. This study supports the first stage of implementation in a large National Health and Medical Research Council funded initiative seeking to advance women in healthcare leadership.

METHODS

An expert multi-disciplinary panel comprised of health professionals and leaders from a large healthcare network in Australia participated. The initial Delphi survey was administered online and results were presented in a Nominal Group Technique workshop. Here, the group made sense of the survey results, then evaluated findings against a framework on implementation criteria. Two further consensus surveys were conducted during the workshop.

RESULTS

Five priority areas were identified. These included: 1. A committed and supportive leadership team; 2. Improved governance structures; 3. Mentoring opportunities; 4. Leadership training and development; and 5. Flexibility in working. We describe the overall priority setting process in the context of our findings.

CONCLUSIONS

With evidence and expert input, we established priorities for advancing women in healthcare leadership with a partnering healthcare organisation. This approach can be adapted in other settings, seeking to advance women in leadership.

Factors that influence the implementation of organisational interventions for advancing women in healthcare leadership: A meta-ethnographic study

BACKGROUND

Gender inequity in healthcare leadership persists and progress is slow, with the focus firmly on problems, barriers and on requiring women themselves to adapt and compete in a system not designed for them. Women are individually burdened to advance their careers, with little effort given to addressing systemic barriers in the health sector. A recent systematic review prioritised organisational-level approaches and demonstrated effective interventions. In this meta-ethnographic study, we further this work by examining factors in implementation of organisational interventions for advancing women in leadership.

METHODS

The meta-ethnographic framework applied here follows the Noblit and Hare approach for synthesising findings and applying interpretive analysis to original research. We generated a new line-of-argument with insights for the healthcare sector. The protocol is registered (CRD42020162115) on the International Prospective Register of Systematic Reviews. Three academic databases (MEDLINE, PsycINFO, SCOPUS) were searched systematically between 2000 and 2021. Studies were analysed if they included organisational-level interventions that sought to measurably advance women in leadership. Study characteristics were extracted using a standard template for intervention details. Quality appraisal was conducted using the Critical Appraisal Skills Program tool. Data synthesis was conducted across 19 criteria of the Meta-Ethnography Reporting Guide (eMERGe).

FINDINGS

Fifteen qualitative studies were included. Analysis revealed three meta-themes that are central to successful implementation of organisational interventions that advance women in healthcare leadership: (1) leadership commitment and accountability, influenced by internal and external organisational settings, salient for long term outcomes and for developing an inclusive leadership culture; (2) intervention fit with individuals with consideration given to personal beliefs, preferences, experiences, capabilities or life circumstances, including capacity for leadership roles in their broader life context; balanced against maintaining interventional fidelity, and (3) cultural climate and organisational readiness for change, addressing traditional, conservative and constrictive perspectives on gender and leadership in health, highlighting the facilitating role of male colleagues.

INTERPRETATION

This meta-ethnographic research extends past work by integrating empirical evidence from a systematic literature review of effective organisational level interventions, with the identification of pragmatic themes to generate, implement, evaluate and embed evidence-based organisational interventions to advance women in healthcare leadership. This work can inform initiatives and policymakers to generate and implement new knowledge to advance women in healthcare leadership.

FUNDING

Epworth Health and Monash University provided scholarships for MM. HT is funded by an NHMRC / MRFF Practitioner Fellowship, JB by an NHMRC fellowship and HS by a Monash Warwick University Professorship.

Advancing women in healthcare leadership: A systematic review and meta-synthesis of multi-sector evidence on organisational interventions

BACKGROUND

Women are underrepresented in healthcare leadership, yet evidence on impactful organisational strategies, practices and policies that advance women's careers are limited. We aimed to explore these across sectors to gain insight into measurably advancing women in leadership in healthcare.

METHODS

A systematic review was performed across Medline via OVID; Medline in-process and other non-indexed citations via OVID; PsycINFO and SCOPUS from January 2000 to March 2021. Methods are outlined in a published protocol registered a priori on PROSPERO (CRD42020162115). Eligible studies reported on organisational interventions for advancing women in leadership with at least one measurable outcome. Studies were assessed independently by two reviewers. Identified interventions were organised into categories and meta-synthesis was completed following the 'ENhancing Transparency in REporting the synthesis of Qualitative research' (ENTREQ) statement.

FINDINGS

There were 91 eligible studies from 6 continents with 40 quantitative, 38 qualitative and 13 mixed methods studies. These spanned academia, health, government, sports, hospitality, finance and information technology sectors, with around half of studies in health and academia. Sample size, career stage and outcomes ranged broadly. Potentially effective interventions consistently reported that organisational leadership, commitment and accountability were key drivers of organisational change. Organisational intervention categories included i) organisational processes; ii) awareness and engagement; iii) mentoring and networking; iv) leadership development; and v) support tools. A descriptive meta-synthesis of detailed strategies, policies and practices within these categories was completed.

INTERPRETATION

This review provides an evidence base on organisational interventions for advancing women in leadership across diverse settings, with lessons for healthcare. It transcends the focus on the individual to target organisational change, capturing measurable change across intervention categories. This work directly informs a national initiative with international links, to enable women to achieve their career goals in healthcare and moves beyond the focus on barriers to solutions.

Organisational best practices for advancing women in leadership: protocol for a systematic literature review

INTRODUCTION

Evidence-based approaches for achieving gender equity for women in leadership are lacking. Current efforts are of limited effectiveness, especially in healthcare. This work occurs in the context of an Australian National Health and Medical Research Council funded partnership to advance women in healthcare leadership. Partners include government, professional colleges and healthcare organisations with national reach and international links. Here we present a protocol for a systematic review, aiming to capture evidence on effective organisational strategies across multiple sectors with comparable challenges in advancing women in leadership. The aim of the review is to learn from other sectors and analyse the evidence to inform implementation in the health sector.

METHODS AND ANALYSIS

A systematic search will be performed on Ovid MEDLINE, PsycINFO and SCOPUS databases to identify studies since 2000, reflecting a major shift in the global gender equality agenda with the development of the 2000 Millennium Development Goals. Titles and abstracts will be screened to assess eligibility; data extraction, quality assessment (using the Critical Appraisal Skill Programme checklist) and synthesis of outcomes will be performed. Outcomes will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation framework. Studies in English using quantitative or qualitative design, which investigate organisational practices in any sector, for advancing women in leadership, and report on one or more measurable outcomes (eg, capacity-building, incidence of promotion) will be included. Findings will be analysed, themes will be extracted and results will be described.

ETHICS AND DISSEMINATION

Ethics approval is not required. To our knowledge, this review will be the first to provide a comprehensive synthesis of available evidence on organisational practices for advancing women in leadership from the last two decades. Findings will be published in peer-reviewed journals and disseminated at conferences and meetings. Through a large-scale funded partnership, this work will inform practice, linking to international initiatives.

PROSPERO REGISTRATION NUMBER

CRD42020162115; International Prospective Register of Systematic Reviews.

Physicians' and pharmacists' use of My Health Record in the emergency department: results from a mixed-methods study

Purpose

This study aimed to explore pharmacists' and physicians' perceptions of use, barriers to use and the healthcare outcomes associated with use of Australia's national personally controlled electronic health record-known as My Health Record-in the emergency department.

Methods

A mixed methods approach was deployed, including surveys and individual semi-structured interviews. All physicians and pharmacists who work in the emergency department at Cabrini Health (a non-for-profit healthcare provider in Victoria, Australia) were invited to participate. Due to the timing of elective blocks, physician trainees were excluded from interviews.

Results

A total of 40 emergency medicine clinicians responded to the survey. Over 50% (n = 22) of all respondents had used My Health Record in the emergency department at least once. A total of 18 clinicians participated in the semi-structured interviews, which led to the identification of three themes with multiple sub-themes regarding My Health Record: (1) benefits; (2) effectiveness; and; (3) barriers.

Conclusion

Participants reported My Health Record use in the emergency department delivers efficiencies for clinicians and has a heightened utility for complex patients, consistent with previous research conducted outside of the Australian setting. Barriers to use were revealed: outdated content, a lack of trust, a low perception of value, no patient record and multiple medical record systems. The participants in this study highlighted that training and awareness raising is needed in order to improve My Health Record use in the emergency department, a need stressed by physician's. Further observational research is required to explores meaningful MHR use at scale.

Health Outcomes and Healthcare Efficiencies Associated with the Use of Electronic Health Records in Hospital Emergency Departments: a Systematic Review

Healthcare organisations and governments have invested heavily in electronic health records in anticipation that they will deliver improved health outcomes for consumers and efficiencies across emergency departments. Despite such investment, electronic health records designed to support emergency care have been poorly evaluated. Given the accelerated development and adoption of information technology across healthcare, it is timely that a systematic review of this evidence base is updated in order to drive improvements to design, interoperability and overall clinical utility of electronic health record systems implemented in emergency departments. To assess the impact of electronic health records on healthcare outcomes and efficiencies in the emergency department we carried out a systematic review of published studies on this topic. This is the first review to summarise the cost efficiencies associated with electronic health record use outside of just the United States of America. A systematic search was performed in three scientific databases (MEDLINE, EMcare and EMBASE), of literature published between January 2000 and September 2019. Studies were included in this review if they evaluated electronic health records or health information exchanges (and synonyms for these terms), reported patient outcome and/or healthcare efficiency benefits, were peer-reviewed and published in English. Out of 6635 articles, 23 studies met our inclusion criteria. Wide variation regarding electronic health record access in the emergency department was reported (1.46-56.6%), yet was most frequently reported as less than 20%. Seven different types of health outcomes and three different types of efficiency improvements associated with electronic health record use in the emergency department were identified. The most frequently reported findings were efficiencies, including reductions in diagnostic tests, imaging and costs. This review is the first to report moderate to significant increases in admission rates are associated with electronic health record use in the emergency department, contrasting the findings of previous reviews. Diversity in the methodology employed across the included studies emphasises the need for further research to examine the impact of electronic health record implementation and system design on the findings reported, in order to ensure return on investment for stakeholders and optimised consumer care.

Modification of Mo-Si alloy microstructure by small additions of Zr

Molybdenum and its alloys are potential materials for high-temperature applications. However, molybdenum is susceptible to embrittlement because of oxygen segregation at the grain boundaries. In order to alleviate the embrittlement small amounts of zirconium were alloyed to a solid solution of Mo-1.5Si alloy. Two Mo-based alloys, namely Mo-1.5Si and Mo-1.5Si-1Zr, were investigated by the complementary high-resolution methods transmission electron microscopy and atom probe tomography. The Mo-1.5Si alloy shows a polycrystalline structure with two silicon-rich intermetallic phases Mo(5)Si(3) and Mo(3)Si located at the grain boundaries and within the grains. In addition, small clusters with up to 10 at% Si were found within the molybdenum solid solution. Addition of a small amount of zirconium to Mo-1.5Si leads to the formation of two intermetallic phases Mo(2)Zr and MoZr(2), which are located at the grain boundaries as well as within the interior of the grain. Transmission electron microscopy shows that small spherical Mo-Zr-rich precipitates (<10nm) decorate the grain boundaries. The stoichiometry of the small precipitates was identified as Mo(2)Zr by atom probe tomography. No Si-enriched small precipitates were detected in the Mo-1.5Si-1Zr alloy. It is concluded that the presence of zirconium hinders their formation.

Spectroscopic and pH-metric studies of the complexation of 3-[2-(4-methylquinolin-2-yl)hydrazono]butan-2-one oxime compound

The electronic absorption spectra of the oximic quinolinyl hydrazone (MHQ; H(2)L) and its Co(II) and Cu(II)-complexes have been studied in Britton-Rhobinson buffer solutions of varying pH's in 75% dioxane-water. The dissociation constant of the hydrazone (pK(H)) as well as the stability constants (logK) of its chelates were determined spectrophotometrically and pH-metrically. The obtained data are in good agreement. Beer's law is valid in the ranges (0.64-6.99) and (2.36-6.48)mug/mL for Cu(II) and Co(II)-ions, respectively. On the other hand, the pK(H) and logK were determined pH-metrically in 75% solvent-water; (solvent=dioxane, ethanol, methanol and isopropanol). The variation of pK(H) or logK as a function of solvent parameters viz. 1/D, E(T), AN and pi* was used to evaluate the dissociation and stability constants in the aqueous medium. Furthermore, the reaction of the oximic hydrazone (H(2)L) with copper(II)-nitrate and chloride in addition to copper(I)-iodide afforded square planar mononuclear and binuclear complexes in which the oximic hydrazone showed three different modes of bonding. The obtained complexes reflect the strong bridging ability of the oximato group as well as its ambidentate and flexidentate characters.

Spectroscopic studies on 2-[2-(4-methylquinolin-2-yl)hydrazono]-1,2-diphenylethanone molecule and its metal complexes

The electronic absorption spectra of a hydrazone: 2-[2-(4-methylquinolin-2-yl)hydrazono]-1,2-diphenylethanone (BHQ) derived from 2-hydrazino-4-methylquinoline and 1,2-diphenylethan-1,2-dione (benzil) have been studied in various solvents of different polarities. The dependence of the band shift Deltaupsilon on the solvent parameters viz.D, Z, E(T), DN, AN, alpha, beta and pi* was discussed. Also, the effect of pH on the free hydrazone and its Co(II), Ni(II) and Cu(II) complexes was studied spectrophotometrically in 75% (v/v) dioxane-water in order to determine the dissociation and stability constants. The stoichiometry of the formed complexes was determined by three different methods: Job's, mole ratio and slope ratio which indicate the formation of 1:2, M:L complexes for Co(II) and Cu(II) and 1:1, Ni(II):L. Beer's law is valid in the range 0.32-7.04 microg/mL depending on the type of the metal ion. The use of BHQ as an indicator via a spectrophotometric titration of Cu(II) and Ni(II) with EDTA was efficient.

Stability and reproductive fitness of Schistosoma mansoni isolates with decreased sensitivity to praziquantel

These studies are focused on schistosomes derived from human infections not cured by three successive doses of praziquantel that also produced infections in mice that were significantly more difficult to cure than infections with control worms. Half (three of six) of these isolates retained their decreased response to praziquantel after multiple passages through the life-cycle in the absence of therapeutic pressure. Two of the isolates, including the one initially least sensitive to praziquantel; reverted, to a sensitivity not significantly different from controls. For example, the EE6 isolate initially required 680 mg/kg praziquantel to affect a 50% reduction in worm load in murine infections, but after only six passages through the life cycle over 5 years this was reduced to 113 mg/kg, not different from control infections. The stability of some of the isolates and the reversion of others indicates that the biological or genetic factors conferring decreased praziquantel response varies among the isolates. The three isolates that retained decreased sensitivity to praziquantel all showed compromises in reproductive fitness in the laboratory, expressed most frequently as a decreased cercarial production from snails infected with those isolates compared to controls. For example, the total cercarial production of snails infected with the EE10 isolate was only 57% that of controls. The reversion of some of the isolates to a praziquantel sensitive state and the decreased reproductive fitness of those that did not revert suggest that there is some biological cost associated with the relative praziquantel insensitivity of these worms, which could help limit the impact of such isolates in the field. Infections with the less sensitive isolates also produced significantly less circulating schistosomal antigen in mice, suggesting that a decrease in the host immune response elicited by these worms could be one of the factors contributing to the diminished praziquantel efficacy.

Automated RIBA HCV strip immunoblot assay: a novel tool for the diagnosis of hepatitis C virus infection in hemodialysis patients

Hemodialysis (HD) patients remain a high-risk group for hepatitis C virus (HCV) infection. Serological assays (enzyme-linked immunosorbent assays, ELISAs) are the only tests currently approved by the Food and Drug Administration in the United States for the diagnosis of HCV. The RIBA HCV Strip Immunoblot Assay (SIA) is an established method for supplemental testing of repeat reactive hepatitis C ELISA patients on HD. However, the current manual procedure is labor intensive, requiring subjective band scoring and result interpretation. Recently, the automated CHIRON RIBA HCV Processor System has been designed to perform RIBA supplemental testing. The CHIRON RIBA HCV Processor System consists of a bench-top instrument that provides objective evaluation of the RIBA immunoblot strips, by measuring the light differentially reflected from the developed bands and white background, creating a density of reflectance. The CHIRON RIBA HCV Processor System assesses the intensity of each of the reactive bands in relation to the intensity of the internal control bands on each RIBA HCV strip. Comparison between processor and manual protocols was performed using a large (n = 200) cohort of ELISA 3.0 HCV negative and positive patients on maintenance HD. The test characteristics of RIBA HCV 3.0 SIA were identical with manual and automated runs. The relative intensity values of antigenic bands by the CHIRON RIBA HCV 3.0 Processor System between anti-HCV positive and negative patients were significantly different; only 15 of 784 (1.9%) antigenic bands had borderline reactivities. The correlation of test results between manual and automated runs was very high (kappa value 0.989). Among positive results by RIBA HCV 3.0 SIA, there was a strong concordance between manual and automated runs with regard to the pattern of reactivity (kappa value 0.943). The discordant results between manual and automated protocols were attributable to increased variability of antigen scores close to the cutoff value for both tests. In conclusion, the CHIRON RIBA HCV 3.0 Processor System is capable of performing RIBA HCV 3.0 SIA in the HD population accurately with minimal operator involvement. The test characteristics of RIBA HCV 3.0 SIA were identical by manual and automated runs. There was a strong correlation between the results of the manual and automated runs; the few discordant results between the two procedures were mostly due to increased variability of antigen scores close to the cutoff value for both tests. The Centers for Disease Control and Prevention in the USA have recently included chronic HD patients among those persons for whom routine HCV testing is recommended; HCV-infected patients on HD often have a high rate of indeterminate results by manual RIBA technology which is operator dependent for band scoring and result interpretation. The CHIRON RIBA HCV 3.0 Processor System may be very useful for supplemental anti-HCV testing of ELISA repeat reactive specimens in clinical practice within dialysis units.

Biological dynamics of viral load in hemodialysis patients with hepatitis C virus

The biological dynamics of hepatitis C virus (HCV) viremia in uremic patients with chronic infection have not been fully characterized. We prospectively studied fluctuations of HCV-RNA in sera from 52 patients with end-stage renal disease who were undergoing maintenance hemodialysis (HD) and had chronic HCV infection. We measured HCV viremia monthly over the course of 13 months with the branched-chain DNA (bDNA) signal amplification assay and prospectively analyzed liver function, expressed by monthly serum aspartate (AST) and alanine aminotransferase (ALT) determinations. We observed three different patterns of HCV viremia: (1) patients persistently positive by bDNA assay (persistent viremia; 23 of 52 patients; 44%), (2) individuals with alternatively positive and negative results (intermittent viremia; 17 of 52 patients; 33%), and (3) patients persistently negative by bDNA assay (12 of 52 patients; 23%). The HCV viral load over the follow-up was greater among patients with persistent compared with intermittent viremia (persistent, 31.7 x 10(5) Eq/mL; range, 6.3 x 10(5) to 16.03 x 10(6) Eq/mL versus intermittent, 10.4 x 10(5) Eq/mL; range, 1.1 x 10(5) to 9.4 x 10(6) Eq/mL; P = 0.0001). In addition, patients with persistent viremia had over time greater AST and/or ALT activities than the intermittent group (AST: persistent, 26.5 IU/L; range, 9.6 to 73.7 IU/L versus intermittent, 21.3 IU/L; range, 8 to 56.8 IU/L; P = 0.001 and ALT: persistent, 14.7 IU/L; range, 3.7 to 57.9 IU/L versus intermittent, 10.9 IU/L; range, 2.3 to 52.1 IU/L; P = 0.001). In the group with persistent viremia, the mean difference between maximum and minimum values of HCV-RNA observed in each individual patient was 2.09 +/- 0.7 natural logarithm (Log(n)) and in intermittent viremic patients, 1.55 +/- 1 Log(n) (P = 0.045). The HCV load at study entry (19.4 x 10(5) Eq/mL) was rather low and did not change versus the end of follow-up in all patients (P = not significant [NS]). In the entire group, the fluctuations in HCV-RNA levels over time between and within individuals were not significant (P = NS). No difference in variability of HCV-RNA values over time between patients infected with different HCV genotypes was seen. In conclusion, three different patterns of HCV viremia in HD over time were assessed; one third of viremic patients had intermittent viremia, and those patients had less HCV-RNA, enzyme-linked immunosorbent assay, and aminotransferase activity than did patients with persistent HCV load. Larger fluctuations in HCV RNA levels occurred in patients with persistent than with intermittent HCV viremia. However, the viremic HCV load was low and relatively stable over a 13-month follow-up in our population. Studies with longer observation periods are warranted to understand fully the natural history of HCV in these immunosuppressed individuals.

Extra-pulmonary tuberculosis in patients with fever of unknown origin: clinical features and diagnosis

One hundred twenty-nine patients with extra-pulmonary tuberculosis admitted at the Abbassia Fever Hospital, NAMRU-3 during a seven year period (1991 to 1997) are described. Tuberculous peritonitis was diagnosed in 35 patients, tuberculous lymphadenitis in 32, intestinal tuberculosis in 19, genito-urinary tuberculosis in 14, skeletal tuberculosis in 13, disseminated miliary tuberculosis in 11, and splenic tuberculosis in 5 patients. The clinical picture included fever, and weight loss accompanied by anaemia and an elevated erythrocyte sedimentation rate in all patients.

Intestinal tuberculosis in patients with fever of unknown origin in Egypt

Nineteen patients with intestinal tuberculosis were admitted to the Abbassia Fever Hospital in the period 1991-1997. Fever, abdominal pain, diarrhea, and weight loss were the most common symptoms. Small bowel radiology and colonoscopy were helpful in establishing the diagnosis. The difficulties in diagnosing tuberculous enteritis and the need to consider seriously the possibility of this disease in such patients is most important and is discussed.

Quantitative assessment of HCV load in chronic hemodialysis patients: a cross-sectional survey

Recent evidence has been accumulated showing that chronic hemodialysis (HD) patients have a very high prevalence of antibodies to hepatitis C virus (HCV). In contrast, there is little information addressing the virological characteristics of HCV infection in this population.

AIM

To measure HCV viral load and to correlate this with demographic, biochemical, and clinical features of a large cohort of HCV-infected patients on chronic HD.

METHODS

394 chronic HD patients were tested by branched-DNA signal amplification assay, anti-HCV enzyme-linked immunosorbent assay 2.0, and on the basis of the aspartate aminotransferase/alanine aminotransferase (AST/ALT) activity. Multivariate analysis by ordinal logistic regression model was performed: age, gender, race, time on HD, allocation of the patients among the HD units, etiology of end-stage renal disease, HBsAg status, anti-HCV positivity, HCV genotype, and AST/ALT levels were independent factors, and viremic levels of HCV in serum were assumed as dependent variables.

RESULTS

88 (22.3%) patients showed serological and/or virological signs of HCV infection. 59 (15%) out of 394 had detectable HCV RNA in serum, the mean HCV load was 19.4 x 10(5) (95% CI, 6.06 x 10(7) to 6.2 x 10(4)) Eq/ml. According to the criteria suggested by others [J Infect Dis 1994;169:1219-1225], there were 8 (13.5%) individuals with high-titer viremia (>1 x 10(7) Eq/ml) in the subset of viremic patients. A small subset (8/394 or 2%) of individuals was seronegative, but viremic; 29 (7%) out of 394 were seropositive without detectable HCV RNA in serum. Univariate analysis showed that the frequency of anti-HCV positivity was significantly higher in viremic patients as compared with individuals with no detectable HCV viremia: 51/59 (86%) vs. 29/335 (8.6%), p = 0.0001. Serum AST and ALT levels were significantly higher in viremic patients than in individuals with no detectable HCV RNA in serum: 23.8 (95% CI 60.8-9.3) vs. 17.1 (95% CI 50.4-5.8) U/l (p = 0.009) and 14.4 (95% CI 48.9-4.3) vs. 9.8 (95% CI, 37.3- 2. 5) U/l (p = 0.008). Logistic regression analysis showed an association between HCV viremia and anti-HCV positivity (p = 0. 00001) and ALT activity (p = 0.01).

CONCLUSIONS

Hepatitis C virus infection is highly prevalent in the HD population; the viral load is relatively low, and it was associated with elevated hepatic enzyme levels and anti-HCV positivity. No other clinical characteristics were associated with HCV RNA levels. Seronegative but viremic patients were also found. Longitudinal studies with long follow-up periods are necessary to evaluate the course of HCV load over time in this population.

Acquisition of hepatitis C virus in hemodialysis patients: a prospective study by branched DNA signal amplification assay

Serological data indicate that hepatitis C virus (HCV) infection is very common among chronic hemodialysis (HD) patients. Circumstantial evidence suggests that hemodialysis per se is an important risk factor for this infection. We used a novel methodology, the branched DNA (bDNA) signal amplification assay, which is capable of detecting HCV RNA and of quantifying HCV viral load in serum, to prospectively determine the rate of acquisition of HCV infection in 274 anti-HCV-negative patients undergoing HD treatment in four hemodialysis units. Moreover, we used bDNA testing to analyze the dynamics of HCV acquisition among HD patients, a high-risk group for HCV infection with immune compromise conferred from uremia. Two patients were identified with de novo acquisition during 1 year of prospective bDNA testing. Thus, the HCV incidence was 0.73% per year. De novo acquisition of HCV infection was observed in the absence of identifiable parenteral risk factors. Both patients showed the same pattern of HCV acquisition: they underwent an initial viremic phase that was associated with an increase in alanine transaminase (ALT) activity and that preceded the anti-HCV seroconversion. This was followed by HCV RNA clearance and normalization of ALT activity. Anti-HCV positivity occurred 1 and 2 months after the ALT increase in the first and second patients, respectively. Although HCV incidence was low (0.73%), further research is warranted to set the optimal policy for eliminating the risk of nosocomial transmission of HCV in the HD setting. Our findings show the pattern of HCV acquisition in chronic HD patients and emphasize the need to screen the HD population for ALT measurement combined with anti-HCV testing for detecting hepatitis C. HCV RNA testing can identify HCV before seroconversion in individuals with deranged liver function tests. The acquisition of HCV in HD patients without identifiable risk is confirmed.

The prevalence of rheumatoid arthritis in the Qassim region of Saudi Arabia

BACKGROUND

Although rheumatoid arthritis (RA) of varying degrees of severity has been seen in our clinics, there is no statistical evidence of the magnitude of the problem in Saudi nationals. We conducted this study to determine the prevalence of RA in the Al Qassim Region of Saudi Arabia.

PATIENTS AND METHODS

Five thousand eight hundred and ninety-one Saudi adults, aged 16 years and over, were studied in a house-to-house survey in the Al Qassim Region.

RESULTS

Of the 5891 adults studied, 13 cases of RA were identified, using the criteria set for the diagnosis of RA by the American College of Rheumatology. Thirty-five percent of our patients showed positive rheumatoid factor.

CONCLUSION

The prevalence of RA in Al Qassim was estimated at 2.2 per thousand people. It was also noted that the prevalence of the disease increased with age, and that it was more common in females.

Splenic tuberculosis in patients with fever of unknown origin

Splenic tuberculosis is uncommon. We report here splenic tuberculosis in 5 patients with fever of over 3 weeks duration. In the 5 patients, abdominal ultrasonography and/or abdominal computed tomography revealed multiple hypoechoic and hypodense splenic lesions. Diagnosis required biopsy of cervical lymph nodes in four cases and splenectomy in one. Despite vigorous antituberculous therapy with isoniazid, rifampin, and ethambutol, the clinical condition of 2 of these patients worsened and splenectomy was done. Histological examination of a tissue specimen of the spleen showed multiple caseating granulomas.

Focal lesions of the spleen in patients with fever of unknown origin: sonographic patterns and diagnosis

A review of ultrasonic scans performed for 811 patients admitted at the Abbassia Fever Hospital between 1990 through 1996 for investigation of fever undiagnosed for over 3 weeks revealed 28 cases of focal splenic lesions. They included lymphoma in sixteen cases, tuberculosis in six cases, echinococcal cysts in three, abscess in two, and infarction in one. Final diagnosis was obtained by correlating the ultrasonography and clinical findings, together with pathologic, bacteriologic, serologic and angiographic data.

Non-A, non-B posttransfusion hepatitis--a decade later

We have followed up 69 patients who developed non-A, non-B posttransfusion hepatitis in 1972-1978. Chronic hepatitis, defined by biochemical criteria, was observed in 46 patients (67%), the majority of whom subsequently failed to resolve the abnormalities. Chronic hepatitis was a sequela of non-A, non-B posttransfusion hepatitis less often after the blood bank changed to a policy of all volunteer donors. (However, this association may be explained by other coexistent factors.) The alanine aminotransferase level was more likely to be abnormal than the aspartate aminotransferase level during the chronic phase of non-A, non-B posttransfusion hepatitis. By actuarial means it was calculated that the probability of developing normal enzymes after 6-10 yr was 0.47. However, in spite of this high incidence of biochemical disease, virtually all of the patients have remained asymptomatic. Histologic evidence of cirrhosis has been obtained in 4 of these patients, but in only 2 patients at most has clinical evidence of hepatic failure supervened.

The pursuit of hepatitis in dialysis units

Chronic hemodialysis patients were prospectively followed at monthly intervals with hepatitis B serologic (HBsAg, anti-HBs, and anti-HBc) and aminotransferase determinations. Over this 1 year, 53/176 (30%) had two or more abnormal aminotransferase values. In at least 34 of these 53 patients, viral liver disease appeared to be the responsible factor. Although patients with anti-HBc were more likely to have abnormal aminotransferases, it is probable that most viral hepatitis in dialysis units is due to non-A, non-B hepatitis. After a further 2 1/2 years of follow-up, no clinical evidence of hepatic failure was seen in any of the patients with hepatitis. The ultimate course of this disease, however, is not yet established.