"You don't put it down to arthritis": A qualitative study of the first symptoms recalled by individuals with knee osteoarthritis

Objective

As part of the first phase of the OARSI Early-stage Symptomatic Knee Osteoarthritis (EsSKOA) initiative, we explored the first symptoms and experiences recalled by individuals with knee osteoarthritis (OA).

Design

This qualitative study, informed by qualitative description, was a secondary analysis of focus groups (n ​= ​17 groups) and one-on-one interviews (n ​= ​3) conducted in 91 individuals living with knee OA as part of an international study to better understand the OA pain experience. In each focus group or interview, participants were asked to describe their first symptoms of knee OA. We inductively coded these transcripts and conducted thematic analysis.

Results

Mean age of participants was 70 years (range 47-92) and 68 ​% were female. We developed four overarching themes: Insidious and Episodic Onset, Diverse Early Symptoms, Must be Something Else, and Adjustments. Participants described the gradual and intermittent way in which symptoms of knee OA developed over many years; many could not identify a specific starting point. Participants described diverse initial knee symptoms, including activity-exacerbated joint pain, stiffness and crepitus. Most participants dismissed early symptoms or rationalized their presence, employing various strategies to enable continued participation in recreational and daily activities. Few sought medical attention until physical functioning was demonstrably impacted.

Conclusions

The earliest symptoms of knee OA are frequently insidious in onset, episodic and present long before individuals present to health professionals. These results highlight challenges to identifying people with knee OA early and support the development of specific classification criteria for EsSKOA to capture individuals at an early stage.

On the estimation of the effect of weight change on a health outcome using observational data, by utilising the target trial emulation framework

BACKGROUND/OBJECTIVES

When studying the effect of weight change between two time points on a health outcome using observational data, two main problems arise initially (i) 'when is time zero?' and (ii) 'which confounders should we account for?' From the baseline date or the 1st follow-up (when the weight change can be measured)? Different methods have been previously used in the literature that carry different sources of bias and hence produce different results.

METHODS

We utilised the target trial emulation framework and considered weight change as a hypothetical intervention. First, we used a simplified example from a hypothetical randomised trial where no modelling is required. Then we simulated data from an observational study where modelling is needed. We demonstrate the problems of each of these methods and suggest a strategy.

INTERVENTIONS

weight loss/gain vs maintenance.

RESULTS

The recommended method defines time-zero at enrolment, but adjustment for confounders (or exclusion of individuals based on levels of confounders) should be performed both at enrolment and the 1st follow-up.

CONCLUSIONS

The implementation of our suggested method [adjusting for (or excluding based on) confounders measured both at baseline and the 1st follow-up] can help researchers attenuate bias by avoiding some common pitfalls. Other methods that have been widely used in the past to estimate the effect of weight change on a health outcome are more biased. However, two issues remain (i) the exposure is not well-defined as there are different ways of changing weight (however we tried to reduce this problem by excluding individuals who develop a chronic disease); and (ii) immortal time bias, which may be small if the time to first follow up is short.

The impact of having a carer on adult health and social care utilisation across five settings of care: A matched cohort study

INTRODUCTION

An estimated 6.8 million people are (informal) carers in the UK. The economic value of annual carer contributions is an estimated .·132bn. Reliance on carers appears to be increasing. There is mixed evidence on whether carers are substitutes for formal care. This study investigated the association between having a carer and service use patterns across five care settings when compared to a matched cohort without a carer.

MATERIALS AND METHODS

A matched case-control group analysis using person-level data in Barking and Dagenham (B&D), a London borough in the U.K., to assess the impact of having a carer in terms of the differences in cost-weighted utilisation relative to a matched control group.

RESULTS

In 2016/17, for adult residents of B&D, having a carer (n = 1,295) was associated with 27% increased cost-weighted utilisation (mean difference of £2,662, CI £1,595, £3,729, p<0.001) compared to a matched cohort without a carer. 39% of the cost difference was social care.

CONCLUSIONS

Findings suggest additional service use induced by carers may dominate any substitution effect. Having a carer may be a key element in enabling access to services. As such, there may be wider inequalities in service access for people without a carer. For an ageing society with projections suggesting there will be more people without carers in the future, these inequalities need to be addressed.

Pregnancy outcomes after first-trimester treatment with artemisinin derivatives versus non-artemisinin antimalarials: a systematic review and individual patient data meta-analysis

BACKGROUND

Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisinin-based combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisinin-based treatment (ABT) versus non-ABTs in the first trimester of pregnancy.

METHODS

For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371.

FINDINGS

We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5·7%) of 736 ABT-exposed pregnancies compared with 96 (8·9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0·71, 95% CI 0·49-1·03). Similar results were seen for the individual components of miscarriage (aHR=0·74, 0·47-1·17), stillbirth (aHR=0·71, 0·32-1·57), and major congenital anomalies (aHR=0·60, 0·13-2·87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4·8%] of 524 vs 84 [9·2%] of 915; aHR 0·58, 0·36-0·92).

INTERPRETATION

We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted.

FUNDING

Medicines for Malaria Venture, WHO, and the Worldwide Antimalarial Resistance Network funded by the Bill & Melinda Gates Foundation.

Daily Life and Challenges Faced By Households With Permanent Childhood Developmental Disability in Rural Tanzania - A Qualitative Study

Severe developmental disability in children affects the life of the child and entire household. We conducted a qualitative study to understand how caregivers manage severe developmental disabilities in children in rural Africa. Families and six children (out of 15 children) who had serious permanent sequelae from a cerebral infection in Handeni, Tanzania, were contacted and invited to a workshop to recount their experience living with severe developmental disabilities. After consent, individual interviews were conducted first through recording of individual digital stories and then through individual semi-structured interviews. Pre-determined key categories were used to analyse the data. Our results showed that developmental disabilities required constant care and reduced the autonomy of the children. Schooling had not been attempted or was halted because of learning problems or inability to meet specialized school costs. Parents were under constant physical, emotional and financial stress. Their occupational earnings decreased. Some families sold their assets to survive. Others began to rely on relatives. Understanding the consequences of developmental disability helps to identify where social support should be focused and improved.

Pharmacokinetic Study of Rectal Artesunate in Children with Severe Malaria in Africa

When severe malaria is suspected in children, the WHO recommends pretreatment with a single rectal dose of artesunate before referral to an appropriate facility. This was an individually randomized, open-label, 2-arm, crossover clinical trial in 82 Congolese children with severe falciparum malaria to characterize the pharmacokinetics of rectal artesunate. At admission, children received a single dose of rectal artesunate (10 mg/kg of body weight) followed 12 h later by intravenous artesunate (2.4 mg/kg) or the reverse order. All children also received standard doses of intravenous quinine. Artesunate and dihydroartemisinin were measured at 11 fixed intervals, following 0- and 12-h drug administrations. Clinical, laboratory, and parasitological parameters were measured. After rectal artesunate, artesunate and dihydroartemisinin showed large interindividual variability (peak concentrations of dihydroartemisinin ranged from 5.63 to 8,090 nM). The majority of patients, however, reached previously suggested in vivo IC50 and IC90 values (98.7% and 92.5%, respectively) of combined concentrations of artesunate and dihydroartemisinin between 15 and 30 min after drug administration. The median (interquartile range [IQR]) time above IC50 and IC90 was 5.68 h (2.90 to 6.08) and 2.74 h (1.52 to 3.75), respectively. The absolute rectal bioavailability (IQR) was 25.6% (11.7 to 54.5) for artesunate and 19.8% (10.3 to 35.3) for dihydroartemisinin. The initial 12-h parasite reduction ratio was comparable between rectal and intravenous artesunate: median (IQR), 84.3% (50.0 to 95.4) versus 69.2% (45.7 to 93.6), respectively (P = 0.49). Despite large interindividual variability, rectal artesunate can initiate and sustain rapid parasiticidal activity in most children with severe falciparum malaria while they are transferred to a facility where parenteral artesunate is available. (This study has been registered at ClinicalTrials.gov under identifier NCT02492178.).

Consensus recommendations for optimizing biomarker testing to identify and treat advanced EGFR-mutated non-small-cell lung cancer

The advent of personalized therapy for non-small-cell lung carcinoma (nsclc) has improved patient outcomes. Selection of appropriate targeted therapy for patients with nsclc now involves testing for multiple biomarkers, including EGFR. EGFR mutation status is required to optimally treat patients with nsclc, and thus timely and accurate biomarker testing is necessary. However, in Canada, there are currently no standardized processes or methods in place to ensure consistent testing implementation. That lack creates challenges in ensuring that all appropriate biomarkers are tested for each patient and that the medical oncologist receives the results for making informed treatment decisions in a timely way. An expert multidisciplinary working group was convened to create consensus recommendations about biomarker testing in advanced nsclc in Canada, with a primary focus on EGFR testing. Recognizing that there are biomarkers beyond EGFR that require timely identification, the expert multidisciplinary working group considered EGFR testing in the broader context of integration into complex lung biomarker testing. Primarily, the panel of experts recommends that all patients with nonsquamous nsclc, regardless of stage, should undergo comprehensive reflex biomarker testing at diagnosis with targeted next-generation sequencing. The panel also considered the EGFR testing algorithm and the challenges associated with the pre-analytic, analytic, and post-analytic elements of testing. Strategies for funding testing by reducing silos of single biomarker testing for EGFR and for optimally implementing the recommendations presented here and educating oncology professionals about them are also discussed.

Relationship between country income, socioeconomic factors and control of cardiovascular disease risk factors in patients with type 2 Diabetes: insights from the global DISCOVER registry

Background

In patients with type 2 diabetes (T2D), optimal management of cardiovascular (CV) risk factors is critical for primary prevention of CV disease.

Purpose

To describe the association of country income and patient socioeconomic factors with risk factor control in patients with T2D.

Methods

DISCOVER is a 37-country, prospective, observational study of 15,983 patients with T2D enrolled between January 2016 and December 2018 at initiation of 2nd-line glucose-lowering therapy and followed for 3 years. In patients without known CV disease with sub-optimally controlled risk factors at baseline, we examined achievement of risk factor control (HbA1c &lt;7%, BP &lt;140/90 mmHg, appropriate statin) at the 3 year follow-up. Countries were stratified by gross national income (GNI)/capita, per World Bank report. We explored variability across countries in risk factor control achievement using hierarchical logistic regression models and examined the association of country- and patient-level economic factors with risk factor control.

Results

Among 9,613 patients with T2D but without CV disease (mean age 57.2 years, 47.9% women), 83.1%, 37.5%, and 66.3% did not have optimal control of glucose, BP, and statins, respectively, at baseline. Of these, 40.8%, 55.5%, and 28.6% achieved optimal control at 3 years of follow-up. There was substantial variability in achievement of risk factor control across countries (Figure) but no association of country GNI/capita on achievement of risk factor control (Table). Insurance status, which differed substantially by GNI group, was strongly associated with glycemic control, with no insurance and public insurance associated with lower odds of patients achieving HbA1c &lt;7%.

Conclusions

In a global cohort of patients with T2D, a substantial proportion do not achieve risk factor control even after 3 years of follow-up. The variability across countries in risk factor control is not explained by the GNI/capita of the country.

Proportion of patients at goal

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): The DISCOVER study is funded by AstraZeneca

The use of geospatial tools to study the evolution of TB incidence in North Portugal between 2008-18

Background

Tuberculosis continues to be a significant global health problem. Portugal isn't an exception to this health problem, being considered by the ECDC a high incidence country. According to the SDG target 3.3, the world must end the epidemics of tuberculosis by 2030. However, several parishes in Portugal continue to observe extremely high values of TB, taking into account the WHO goal for pre-elimination of 10 TB cases per million people.

Methods

A cross-sectional study was conducted with data from the Surveillance System of the National Program against Tuberculosis. Descriptive and regression analyses were carried out using R 3.6.1 and Rstudio 1.2.5033. The geospatial analysis was carried out with ArcMap 10.7.1 using a five-year average of TB incidence. Animations and videos were made with Microsoft Office365 PowerPoint v2002.

Results

In the period 2008-2012, 55,7% of parishes had registered cases of tuberculosis. That value decreased to 50,6% parishes in the period 2014-2018. For the period of 2014-18, 30,3% of parishes had a five-year average incidence above 20/100.000 people (value defined as high-incidence by the ECDC) and 45,0% parishes an incidence above 10/100.000 people. With ArcMap HotSpot analysis was possible to observe the existence of a significant cluster of TB in the southwest of North Portugal. With animation analysis, it was also possible to see the global spatial reduction of TB cases between 2008 and 2018, and the ongoing problem of a high incidence of TB in specific regions of North Portugal.

Conclusions

TB continues to be a significant health problem in North Portugal. The spatial analysis pointed to a specific area of North Portugal that needs priority action. Videos produced by the Department of Public Health may guide health professionals and policymakers for future strategies to be implemented to reach SDG3.

Key messages

The importance of desegregated spatial data for TB elimination. The elimination efforts must be scaled up in specific areas to achieve SDG3.

0804 Sleep Bruxism, Awake Bruxism and Sleep Related Breathing Disorders in Adults With Down Syndrome

Introduction

To our knowledge, no studies have accessed theawake bruxism (AB) and stage by stage sleep bruxism (SB) in adults with Down syndrome. Recent works have shown that portable PSG systems are accurate for SB assessment even in the absence of audio-video recording. We aimed to evaluate the prevalence of awake bruxism, stage-by-stage sleep bruxism and Sleep Related Breathing Disorders (SRBD) in adults with Down syndrome.

Methods

Twenty-three adults with Down Syndrome (DS) were enrolled in this study. General health, dental status, parafunctional habits and temporomandibular symptoms were assessed. The history of SB/AB was taken from a questionnaire to the caregivers. A portable PSG type II system (Embla Embletta MPR+PG ST+Proxy, Natus, California-USA) was used to perform a full-sleep study at patients’ home. RMMA activity was defined as low (&gt;1 and &lt;2 episodes/h of sleep), moderate (&gt;2 and &lt;4 episodes/h of sleep), or high (&gt;4 episodes/h of sleep). PSG diagnose of SB was assumed if RMMA index was &gt;2 episodes/h of sleep.

Results

According to caregiver’s report, AB was present in all patients whereas only 13.1% had SB. PSG records showed a SB prevalence of 91.3%, with a mean RMMA index 40.0±30.0/h. Only 2 (8,7%) showed RMMA index of 0.0/h. SB episodes were predominant in N3 and REM sleep stage in 14 and 9 patients, respectively. All but one (95,7%) patient (isolated snoring) presented with OSA (AHI=32.8±28.6). A unique TMD symptom (pain on palpation) was present in 8,7% of the global sample.

Conclusion

The high prevalence of “definitive SB” together with the high prevalence of OSA and snoring point in favor to the recommendation of routine PSG in adults with DS. Furthermore, the low sensitivity of parent-oriented questionnaires reinforces the need of more accurate assessment tools in order to get a better standard of care in this particular group of patients.

Support

State of Sao Paulo Research Support Foundation - FAPESP grant number: 2017/06835-8

0657 Impact of Treatment With Mandibular Advancement Oral Appliance on Respiratory Parameters, Sleep and Cardiometabolic Risk Factors of CPAP Non-Adherent Patients With Severe Obstructive Sleep Apnea

Introduction

Obstructive sleep apnea (OSA) may trigger systemic changes linked to important cardiometabolic risk factors such as hypertension, stroke and diabetes II. As a life-threatening, multifactorial disorder, OSA demands a multiprofessional approach. The most common worldwide treatments are Continuous Positive Airway Pressure (CPAP) and Mandibular Advancement Oral Appliance (OAm). The aim of this study was to evaluate the impact of OAm treatment on CPAP non-adherent patients with severe OSA, comparing objective and subjective data between baseline and follow up.

Methods

A prospective study was carried out including non-adherent severe OSA patients, which were referred to OAm therapy evaluation. Patients presenting with snoring, gasping/choking during sleep, fatigue and daily sleepiness were evaluated by a sleep medicine specialist and the diagnosis of severe OSA with a basal polysomnography (PSG). All the patients were treated with a standard OAm (PMPositioner®). Baseline and Follow up (6 months) sleep parameters (PSG and Epworth Sleepiness Scale - ESS) were compared to assess treatment efficacy.

Results

Seventeen patients (9 with hypertension and 8 with hypertension + diabetes) met the inclusion criteria and 13 finished the protocol. After treatment with OAm the following parameters improved significantly: OSA severity (44.5±13.5 to 9.0±4.3, p≤0.001), ODI (46.8±11.6 to 12.1±9.1(p&lt;0.05)), REM (18.4± 4.8 to 21.5± 2.9 (p&lt;0.05)) and SaO2nadir (75.7± 9.4 to 87.0±3.6, p&lt;0.001), ESS (p&lt;0.005). Ten patients (58%) reported a reduction either in systolic and diastolic blood pressure with 3 of them (30%) reduced the hypertensive drug dose.

Conclusion

Our findings show that OAm is a safe and effective treatment option to CPAP non-adherent severe OSA patients. Furthermore OAm therapy had also a positive impact on cardiometabolic risk factors which are particularly relevant outcomes in OSA patients.

Support

State of Sao Paulo Research Support Foundation (FAPESP).

Preliminary Data from Famidem Survey: Can we assume who is at Risk Regarding Informal Caregiving in Dementia?

Background and aims:

In meridional European countries such as Portugal, informal caregivers are almost always close relatives, either key-relatives (those more involved) or not. There are few systematic comparisons between the experience of key-relatives/primary caregivers (PC) and other/secondary caregivers (SC) in psychogeriatrics. We present some preliminary data from the FAMIDEM (Families of People with Dementia) survey.

Methods:

Non-randomised cross-sectional study comparing two related samples of caregivers (PC versus SC) of 41 patients with DSM-IV dementia from outpatient practices in Lisbon (Portugal). Caregivers’ assessments included: Zarit Burden Interview, Caregiver Activity Survey (CAS), Positive Aspects of Caregiving, GHQ-12, Social Network Questionnaire and Dementia Knowledge Questionnaire.

Results:

Patients’ mean age was 78,7 years (SD 7,9). 24 (58,5%) were women and 58,5% had Alzheimer disease.PC were older than SC (p=0,000) and tended to live with the patient (p=0,000). They reported less emocional support (p=0,021) but higher objective burden-CAS (p=0,002). Regarding all other outcome variables, significant differences between groups were not found. Within the global sample, comparing spousals (n=23) and adult children/other relatives (n=59) yielded interestingly different preliminary results, eg higher GHQ-12 levels (p=0,010).

Conclusions:

The experience of caregiving is possibly different regarding PC and SC, but further research is warranted in order to define who really is at risk. Being a spouse may be much more determinant, although most spouses are PC as well. for the moment, it seems prudent not to exclude SC from risk assessments. the final FAMIDEM results, even lacking generalizability, will probably provide interesting clues.

The fidelity of implementation of recommended care for children with malaria by community health workers in Nigeria

BACKGROUND

In the context of task shifting, a promoted approach to healthcare delivery in resource-poor settings, trained community health workers (CHWs) have been shown to be effective in delivering quality care of malaria for febrile under-5 children. While their effectiveness has been documented, the fidelity of implementation (FOI) has not been adequately studied. By understanding and measuring whether an intervention has been performed with fidelity, researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. The objective of this study was to assess the FOI of a recommended protocol for malaria care by CHWs in a resource-poor setting in Nigeria.

METHODS

Thirty-five female CHWs who participated in a 3-day training on home management of malaria among under-5 children were studied. They managed 1,646 children over the implementation period and then underwent evaluation via a one-time hospital-based observation by the trainers. During the evaluation, a pre-tested standard checklist was used to compute performance scores for CHWs; doctors and nurses were selected to serve as the gold standard for comparison. Performance scores (PS) recorded during the evaluation were used to assess adherence and compliance with the recommended treatment protocol.

RESULTS

Of the 4 skill domains assessed, adherence was greatest for compliance with malaria treatment recommendations (94%) and lowest for post-treatment initiation counseling of home-based caregivers (69%). The average overall adherence of 83% was comparable to adherence by gold standard comparators. Mean PS was not found to be significantly associated with CHW demographics. Scores for clinical evaluation among those whose occupation was not healthcare-related were significantly lowered by 0.52 [95% CI (1.05-0.01), p = 0.05]. Compliance with the treatment protocol increased by 23% for every unit increase in total PS (p = 0.07) and doubled for every unit increase in scores for post-treatment initiation counseling of caregivers (p = 0.002).

CONCLUSIONS

Studying intervention fidelity stands to identify the shortcomings of implementation and specific areas to target for improvement in future adoption or implementation. This study concludes that future trainings should emphasize clinical evaluation and post-treatment counseling of caregivers by CHWs to ensure the best outcome for children.

P3816Cost-effectiveness of ventricular tachycardia catheter ablation: limitations in the current trial evidence base

Introduction

Randomised clinical trials (RCTs) have suffered from criticisms including a lack of generalisability as well as a lack of cost-effectiveness analysis of the different interventions being studied. Such analyses are used by organisations including the UK's National institute for Health and Care Excellence (NICE) to inform system-level decisions regarding which treatments are funded. There is the potential for a growing chasm to exist between what is the latest innovation in cardiology and what can be afforded.

Purpose

To evaluate the cost-effectiveness of ventricular tachycardia (VT) catheter ablation versus anti-arrhythmic drug (AAD) therapy in ischemic heart disease.

Methods

A decision-analytic Markov model was used to calculate the costs and health outcomes of catheter ablation or AAD treatment of VT for a hypothetical cohort of patients with ischaemic cardiomyopathy andan implantable cardioverter defibrillator (ICD). Model inputs where informed using RCT-level evidence [Table 1] wherever possible. Costs were calculated from a UK perspective.

Results

Catheter ablation vs. AAD therapy had an incremental cost-effectiveness ratio (ICER) of £144,150 (€161,448) per quality adjusted life year (QALY) gained, over a five-year time horizon. The ICER for a ten-year time horizon was £75,074 (€84,083) and £69,986 (€78,384) over the cohort's lifetime. Using probabilistic sensitivity analyses to account for model parameter uncertainty, the likelihood of catheter ablation being cost-effective was only 11%, assuming a willingness to pay threshold of £30,000 used by the NICE [Figure 1].

Table 1. Summary of RCT level source data used to inform Markov model inputs Name of trial SMASH VT VTACH SMS CALYPSO VANISH VISTA Sample size 128 110 111 27 259 118 Mean age 67 66 67 64 68 66 Control AAD AAD AAD AAD AAD Clinical ablation Intervention Ablation Ablation Ablation Ablation Ablation Substrate ablation Length of follow up 22 months 24 months 28 months 6 months 28 months 12 months Mortality (%) 11% [AAD] 7% [AAD] 19% [AAD] 14% [AAD] 28% [AAD] 15% [C-ablation] vs. vs. vs. vs. vs. vs. 9% [Ablation] 10% [Ablation] 17% [Ablation] 15% [Ablation] 27% [Ablation] 9% [S-Ablation] Readmission (%) 19% [AAD] 55% [AAD] 44% [AAD] 50% [AAD] 31% [AAD] 32% [C-ablation] vs. vs. vs. vs. vs. vs. 12% [S-ablation] 6% [Ablation] 33% [Ablation] 39% [Ablation] 38% [Ablation] 25% [Ablation]

Cost-effectiveness acceptability curve

Conclusion

Catheter ablation of VT is unlikely to be cost-effective compared with AAD therapy alone in patients with ischaemic cardiomyopathy implanted with an ICD based on pooled trial evidence. However, better designed studies incorporating detailed and more frequent quality of life assessment are needed to advise health policy in this field and to provide more informed cost-effectiveness analyses.

Acknowledgement/Funding

NIHR Academic Clinical Fellowship

HIV screening of tuberculosis patients in Portugal: what are we missing?

BACKGROUND

Knowledge of human immunodeficiency virus (HIV) status is essential to effectively manage both tuberculosis (TB) and HIV infection. This is why the World Health Organization (WHO) recommends routine HIV testing in all TB patients.

OBJECTIVE

To determine the number of TB patients with unknown HIV status in Portugal and to identify the factors associated with unknown HIV status.

METHODS

A retrospective study of all TB notifications from 2008 to 2014 in Portugal was conducted. A multiple logistic regression model was used to evaluate the association of sociodemographic and clinical factors with unknown HIV status.

RESULTS

We examined the records of 18 445 patients with TB notification, 2402 of whom (13%) had unknown HIV status. Unknown HIV status was positively associated with age 65 years (adjusted odds ratio [aOR] 1.208, 95%CI 1.037-1.408) and extra-pulmonary TB (aOR 1.381, 95%CI 1.252-1.523), but negatively associated with unemployment (aOR 0.755, 95%CI 0.637-0.895), alcohol dependence (aOR 0.809, 95%CI 0.682-0.959) and drug dependence (aOR 0.566, 95%CI 0.449-0.713).

CONCLUSION

Risk perception is the most important barrier to complete knowledge of HIV status in TB patients in Portugal. Given the importance of HIV screening in TB patients, every effort should be made to ensure that all TB patients undergo HIV screening.

Analyse thématique de l’expérience des soins socioesthétiques des patients hospitalisés à domicile en oncologie

Objectif : Décrire l’expérience des soins socioesthétiques (SE) des patients hospitalisés à domicile dans le cadre d’une pathologie cancéreuse.

Matériel et méthodes : Sept participantes décrivent leurs expériences grâce à un entretien semi-directif, enregistré par un dictaphone.

Résultats : Les participantes expriment que les soins SE ont un effet sur « la dimension sociale et relationnelle », « la restauration de l’image de soi », « le remaniement du mode de vie » et « la transformation du vécu de la maladie ».

Conclusion : Ce soin de support est perçu par les participantes comme un privilège utile et bénéfique pour elles.

Electron scattering from 1-butanol at intermediate impact energies: Total cross sections

We report experimental measurements of the absolute total cross sections (TCSs) for electron scattering from 1-butanol at impact energies in the range 80-400 eV. Those measurements were conducted by considering the attenuation of a collimated electron beam, at a given energy, through a gas cell containing 1-butanol, at a given pressure, and through application of the Beer-Lambert law to derive the required TCS. We also report theoretical results using the Independent-Atom Model with Screening Corrected Additivity Rule and Interference approach. Those results include the TCS, the elastic integral cross section (ICS), the ionization total ICS, and the sum over all excitation process ICSs with agreement at the TCS level between our measured and calculated results being encouraging.

Development of Rectodispersible Tablets and Granulate Capsules for the Treatment of Serious Neonatal Sepsis in Developing Countries

Current pediatric antibiotic therapies often use oral and parenteral routes of administration. Neither are suitable for treating very sick neonates who cannot take oral medication and may be several hours away from hospital in developing countries. Here, we report on the development of rectal forms of ceftriaxone, a third-generation cephalosporin. Rectodispersible tablets and capsules were developed and successfully passed 6-month accelerated stability tests. Rabbit bioavailability showed plasma concentrations above the minimal inhibitory concentrations for 3 formulations of rectodispersible tablets and 2 formulations of hard capsules. Clinical batches are currently being prepared for human evaluation with the prospect of offering therapeutic alternatives for treating critically ill neonates. This proof of concept for efficient rectal delivery of antibiotics could help the development of other rectal antibiotic treatments and increase options for noninvasive drug development for pediatric patients.

Abstract P5-09-21: Not presented

This abstract was not presented at the conference.

Citation Format: Servais L, Gardner A, Gomes M, Zimmer AD, Silvestrini A, Siqueira de Abreu e Lima R. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-21.

Household costs and time to treatment for children with severe febrile illness in rural Burkina Faso: the role of rectal artesunate

Background

Community health workers (CHWs) were trained to identify children with malaria who could not take oral medication, treat them with rectal artesunate (RA) and refer them to the closest healthcare facility to complete management. However, many children with such symptoms did not seek CHWs’ care. The hypothesis was that the cost of referral to a health facility was a deterrent. The goal of this study was to compare the out-of-pocket costs and time to seek treatment for children who sought CHW care (and received RA) versus those who did not.

Methods

Children with symptoms of severe malaria receiving RA at CHWs and children with comparable disease symptoms who did not go to a CHW were identified and their parents were interviewed. Household out-of-pocket costs per illness episode and speed of treatment were evaluated and compared between RA-treated children vs. non-RA treated children and by central nervous symptoms (CNS: repeated convulsions, altered consciousness or coma).

Results

Among children with CNS symptoms, costs of RA-treated children were similar to those of non-RA treated children ($5.83 vs. $4.65; p = 0.52), despite higher transport costs ($2.74 vs. $0.91; p < 0.0001). However, among children without CNS symptoms, costs of RA-treated children were higher than the costs of non-RA treated children with similar symptoms ($5.62 vs. $2.59; p = 0.0001), and the main driver of the cost difference was transport. After illness onset, CNS children reached CHWs for RA an average of 9.0 h vs. 16.1 h for non-RA treated children reaching first treatment [difference 7.1 h (95% CI − 1.8 to 16.1), p = 0.11]. For non-CNS patients the average time to CHW-delivered RA treatment was 12.2 h vs. 20.1 h for those reaching first treatment [difference 7.9 h (95% CI 0.2–15.6), p = 0.04]. More non-RA treated children developed CNS symptoms before arrival at the health centre but the difference was not statistically significant (6% vs. 4%; p = 0.58).

Conclusions

Community health worker-delivered RA does not affect the total out-of-pocket costs when used in children with CNS symptoms, but is associated with higher total out-of-pocket costs when used in children with less severe symptoms. RA-treated children sought treatment more quickly.

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2526-8) contains supplementary material, which is available to authorized users.

Fistula Size and Hemodynamics: An Experimental Model in Canine Femoral Arteriovenous Fistulas

Purpose

The objective was to evaluate the impact of anastomosis diameter on blood flow in an arteriovenous fistula (AVF), comparing two different anastomosis sizes with a modified side-to-side technique in canine femoral arteries.

Methods

Ten mongrel dogs were subjected to two AVFs each, both using a modified side-to-side technique. On one side, the anastomosis diameter was 1.5 times the arterial diameter and on the other side 3.0 times the arterial diameter. Mean proximal and caudal blood flow and mean venous flow were measured using an electronic flowmeter 15, 20 and 25 min after surgery. The Mann-Whitney, Friedman and Wilcoxon non-parametric tests were used for data analysis (α ≤ 0.05).

Results

Femoral artery flow cranial to the fistula became 5.6 times greater in the 1.5 arterial diameter group, and 8.4 times greater in the 3.0 arterial diameter group, when compared to initial arterial flow. The mean flow in the cranial vein was greater in the 3.0 group (10.09 times greater vs. 6.46 times greater in the 1.5 group). Both in the proximal artery and in the vein there was a significantly greater flow in the group with the larger anastomosis diameter (Wilcoxon test). In the femoral artery caudal to the fistula, the flow in most of the animals was reversed: 3.5 times greater in the 1.5 group and 1.2 times greater in the 3.0 group, without statistical difference.

Conclusions

These results suggest that 3.0 times the arterial diameter for the AVF size in dogs leads to greater venous flow than with 1.5 times the arterial diameter, without increasing the reversed flow.

Mycobacterium avium infection in Portugal

BACKGROUND

Although the incidence rates of non-tuberculous mycobacteria (NTM) have been increasing in many countries, the basic epidemiology of NTM remains to be fully understood.

OBJECTIVE

To assess the incidence, clinical relevance and geographical distribution of NTM disease in Portugal and to identify demographic and clinical characteristics associated with Mycobacterium avium complex (MAC) disease.

METHODS

Information stored in an electronic database of all NTM cases reported over an 11-year period was retrospectively reviewed. Significant demographic and clinical characteristics of MAC disease (vs. having any other NTM disease) were determined using multiple logistic regression models.

RESULTS

We identified 632 patients, mostly male, native Portuguese, with pulmonary disease, predominantly from Lisbon and Porto. The annual incidence of NTM disease was 0.54 per 100 000 population. The annual number of NTM cases increased throughout the study period. MAC was most frequently isolated. MAC disease was positively (and significantly) associated with being female, age >45 years and human immunodeficiency virus infection.

CONCLUSIONS

The increasing incidence of NTM over the study period emphasises the importance of NTM as a public health issue. This study provides important information for health care professionals and a basis for further study of NTM in Portugal.

Tuberculosis among the homeless: should we change the strategy?

BACKGROUND

Tuberculosis (TB) is a major concern among high-risk populations such as the homeless.

OBJECTIVES

To evaluate TB incidence and treatment outcomes among homeless patients in Portugal and to identify predictors of unsuccessful TB treatment outcomes among the homeless.

DESIGN

This was a retrospective cohort study of all TB patients notified in Portugal from 2008 to 2014. Characteristics of homeless TB patients were assessed and predictors of unsuccessful TB treatment were determined using logistic regression.

RESULTS

TB incidence among the homeless was 122/100,000 homeless persons and was positively correlated with TB incidence among non-homeless persons. Homeless TB patients had a higher prevalence of alcohol and/or drug use, human immunodeficiency virus (HIV) co-infection, cavitary TB and smear positivity. The rate of unsuccessful treatment outcomes among the homeless was 28.6%, and was significantly associated with increased age, injection drug use (IDU) and HIV co-infection.

CONCLUSION

TB incidence among homeless persons was five times that among the non-homeless, and higher in regions with greater TB incidence among non-homeless persons. The successful treatment outcome rate was lower. Predictors of unsuccessful treatment were age, IDU and HIV co-infection. Integrated TB programmes targeting homeless and non-homeless patients, with measures targeting specific characteristics, may contribute to TB elimination in Portugal.

Longitudinal clustering of tuberculosis incidence and predictors for the time profiles: the impact of HIV

BACKGROUND

Portugal remains the country with the highest tuberculosis (TB) incidence in Western Europe.

OBJECTIVES

To identify longitudinal trends in TB incidence in Portugal from 2002 to 2012 and investigate the longitudinal effect of sociodemographic and health-related predictors among the resident population on the TB incidence rate.

METHODS

We used data from the National Tuberculosis Surveillance System and other national institutions. K-means longitudinal clustering algorithm was performed on TB incidence time profiles from districts of Portugal.

RESULTS

Three longitudinal profiles for the TB incidence rate of Portugal were identified. In all of them, TB incidence decreased over time. Among all studied sociodemographic and health-related predictors, human immunodeficiency virus (HIV) notification rate and unemployment were shown to have (positive) significant effects on TB incidence. In particular, the greatest effects were found for the HIV notification rate.

CONCLUSIONS

Our study supports the view that combined TB-HIV strategies and the improvement of social determinants can contribute to decreases in TB incidence.

Compliance With Referral Advice After Treatment With Prereferral Rectal Artesunate: A Study in 3 Sub-Saharan African Countries

Background. Children aged <5 years were enrolled in a large study in 3 countries of sub-Saharan Africa because they had danger signs preventing them from being able to take oral medications. We examined compliance and factors associated with compliance with referral advice for those who were treated with rectal artesunate.

Methods. Patient demographic data, speed of accessing treatment after danger signs were recognized, clinical symptoms, malaria microscopy, treatment-seeking behavior, and compliance with referral advice were obtained from case record forms of 179 children treated with prereferral rectal artesunate in a multicountry study. We held focus group discussions and key informant interviews with parents, community health workers (CHWs), and facility staff to understand the factors that deterred or facilitated compliance with referral advice.

Results. There was a very high level of compliance (90%) among patients treated with prereferral rectal artesunate. Age, symptoms at baseline (prostration, impaired consciousness, convulsions, coma), and malaria status were not related to referral compliance in the analysis.

Conclusions. Teaching CHWs to diagnose and treat young children with prereferral rectal artesunate is feasible in remote communities of Africa, and high compliance with referral advice can be achieved.

Feasibility of Malaria Diagnosis and Management in Burkina Faso, Nigeria, and Uganda: A Community-Based Observational Study

Background. Malaria-endemic countries are encouraged to increase, expedite, and standardize care based on parasite diagnosis and treat confirmed malaria using oral artemisinin-based combination therapy (ACT) or rectal artesunate plus referral when patients are unable to take oral medication.

Methods. In 172 villages in 3 African countries, trained community health workers (CHWs) assessed and diagnosed children aged between 6 months and 6 years using rapid histidine-rich protein 2 (HRP2)–based diagnostic tests (RDTs). Patients coming for care who could take oral medication were treated with ACTs, and those who could not were treated with rectal artesunate and referred to hospital. The full combined intervention package lasted 12 months. Changes in access and speed of care and clinical course were determined through 1746 random household interviews before and 3199 during the intervention.

Results. A total of 15 932 children were assessed: 6394 in Burkina Faso, 2148 in Nigeria, and 7390 in Uganda. Most children assessed (97.3% [15 495/15 932]) were febrile and most febrile cases (82.1% [12 725/15 495]) tested were RDT positive. Almost half of afebrile episodes (47.6% [204/429]) were RDT positive. Children eligible for rectal artesunate contributed 1.1% of episodes. The odds of using CHWs as the first point of care doubled (odds ratio [OR], 2.15; 95% confidence interval [CI], 1.9–2.4; P < .0001). RDT use changed from 3.2% to 72.9% (OR, 80.8; 95% CI, 51.2–127.3; P < .0001). The mean duration of uncomplicated episodes reduced from 3.69 ± 2.06 days to 3.47 ± 1.61 days, Degrees of freedom (df) = 2960, Student's t (t) = 3.2 (P = .0014), and mean duration of severe episodes reduced from 4.24 ± 2.26 days to 3.7 ± 1.57 days, df = 749, t = 3.8, P = .0001. There was a reduction in children with danger signs from 24.7% before to 18.1% during the intervention (OR, 0.68; 95% CI, .59–.78; P < .0001).

Conclusions. Provision of diagnosis and treatment via trained CHWs increases access to diagnosis and treatment, shortens clinical episode duration, and reduces the number of severe cases. This approach, recommended by the World Health Organization, improves malaria case management.

Clinical Trials Registration. ISRCTN13858170.

Pre-referral Rectal Artesunate Treatment by Community-Based Treatment Providers in Ghana, Guinea-Bissau, Tanzania, and Uganda (Study 18): A Cluster-Randomized Trial

Background. If malaria patients who cannot be treated orally are several hours from facilities for injections, rectal artesunate prior to hospital referral can prevent death and disability. The goal is to reduce death from malaria by having rectal artesunate treatment available and used. How best to do this remains unknown.

Methods. Villages remote from a health facility were randomized to different community-based treatment providers trained to provide rectal artesunate in Ghana, Guinea-Bissau, Tanzania, and Uganda. Prereferral rectal artesunate treatment was provided in 272 villages: 109 through community-based health workers (CHWs), 112 via trained mothers (MUMs), 25 via trained traditional healers (THs), and 26 through trained community-chosen personnel (COMs); episodes eligible for rectal artesunate were established through regular household surveys of febrile illnesses recording symptoms eligible for prereferral treatment. Differences in treatment coverage with rectal artesunate in children aged <5 years in MUM vs CHW (standard-of-care) villages were assessed using the odds ratio (OR); the predictive probability of treatment was derived from a logistic regression analysis, adjusting for heterogeneity between clusters (villages) using random effects.

Results. Over 19 months, 54 013 children had 102 504 febrile episodes, of which 32% (31 817 episodes) had symptoms eligible for prereferral therapy; 14% (4460) children received treatment. Episodes with altered consciousness, coma, or convulsions constituted 36.6% of all episodes in treated children. The overall OR of treatment between MUM vs CHW villages, adjusting for country, was 1.84 (95% confidence interval [CI], 1.20–2.83; P = .005). Adjusting for heterogeneity, this translated into a 1.67 higher average probability of a child being treated in MUM vs CHW villages. Referral compliance was 81% and significantly higher with CHWs vs MUMs: 87% vs 82% (risk ratio [RR], 1.1 [95% CI, 1.0–1.1]; P < .0001). There were more deaths in the TH cluster than elsewhere (RR, 2.7 [95% CI, 1.4–5.6]; P = .0040).

Conclusions. Prereferral episodes were almost one-third of all febrile episodes. More than one-third of patients treated had convulsions, altered consciousness, or coma. Mothers were effective in treating patients, and achieved higher coverage than other providers. Treatment access was low.

Clinical Trials Registration. ISRCTN58046240.

Training Community Health Workers to Manage Uncomplicated and Severe Malaria: Experience From 3 Rural Malaria-Endemic Areas in Sub-Saharan Africa

Background. Use of community health workers (CHWs) to increase access to diagnosis and treatment of malaria is recommended by the World Health Organization. The present article reports on training and performance of CHWs in applying these recommendations.

Methods. Two hundred seventy-nine CHWs were trained for 3–5 days in Burkina Faso, Nigeria, and Uganda, and 19 were certified to diagnose and treat only uncomplicated malaria and 235 to diagnose and treat both uncomplicated and severe malaria. Almost 1 year after training, 220 CHWs were assessed using standard checklists using facility staff responses as the reference standard.

Results. Training models were slightly different in the 3 countries, but the same topics were covered. The main challenges noticed were the low level of education in rural areas and the involvement of health staff in the supervision process. Overall performance was 98% (with 99% in taking history, 95% in measuring temperature, 85% for measuring respiratory rates, 98% for diagnosis, 98% for classification, and 99% for prescribing treatment). Young, single, new CHWs performed better than their older, married, more experienced counterparts.

Conclusions. Training CHWs for community-based diagnosis and treatment of uncomplicated and severe malaria is possible with basic and refresher training and close supervision of CHWs’ performance.

Clinical Trials Registration. ISRCTRS13858170.

Quantifying and Valuing Community Health Worker Time in Improving Access to Malaria Diagnosis and Treatment

Background. Community health workers (CHWs) are members of a community who are chosen by their communities as first-line, volunteer health workers. The time they spend providing healthcare and the value of this time are often not evaluated. Our aim was to quantify the time CHWs spent on providing healthcare before and during the implementation of an integrated program of diagnosis and treatment of febrile illness in 3 African countries.

Methods. In Burkina Faso, Nigeria, and Uganda, CHWs were trained to assess and manage febrile patients in keeping with Integrated Management of Childhood Illness recommendations to use rapid diagnostic tests, artemisinin-based combination therapy, and rectal artesunate for malaria treatment. All CHWs provided healthcare only to young children usually <5 years of age, and hence daily time allocation of their time to child healthcare was documented for 1 day (in the high malaria season) before the intervention and at several time points following the implementation of the intervention. Time spent in providing child healthcare was valued in earnings of persons with similar experience.

Results. During the high malaria season of the intervention, CHWs spent nearly 50 minutes more in daily healthcare provision (average daily time, 30.2 minutes before the intervention vs 79.5 minutes during the intervention; test for difference in means P < .01). On average, the daily time spent providing healthcare during the intervention was 55.8 minutes (Burkina Faso), 77.4 minutes (Nigeria), and 72.2 minutes (Uganda). Using the country minimum monthly salary, CHWs’ time allocated to child healthcare for 1 year was valued at US Dollars (USD) $52 in Burkina Faso, USD $295 in Nigeria, and USD $141 in Uganda.

Conclusions. CHWs spend up to an hour and a half daily on child healthcare in their communities. These data are informative in designing reward systems to motivate CHWs to continue providing good-quality services.

Clinical Trials Registration. ISRCTN13858170.

Malaria Rapid Diagnostic Tests and Malaria Microscopy for Guiding Malaria Treatment of Uncomplicated Fevers in Nigeria and Prereferral Cases in 3 African Countries

Background. The World Health Organization recommends that malaria treatment be based on demonstration of the infecting Plasmodium parasite specie. Malaria rapid diagnostic tests (RDTs) are recommended at community points of care because they are accurate and rapid. We report on parasitological results in a malaria study in selected rural communities in 3 African countries.

Methods. In Nigeria, community health workers (CHWs) performed RDTs (SD-Bioline) and thick blood smears on all children suspected to have malaria. Malaria RDT-positive children able to swallow received artemisinin-based combination therapy (Coartem). In all countries, children unable to take oral drugs received prereferral rectal artesunate irrespective of RDT result and were referred to the nearest health facility. Thick blood smears and RDTs were usually taken at hospital admission. In Nigeria and Burkina Faso, RDT cassettes and blood smears were re-read by an experienced investigator at study end.

Results. Trained CHWs enrolled 2148 children in Nigeria. Complete parasitological data of 1860 (86.6%) enrollees were analyzed. The mean age of enrollees was 30.4 ± 15.7 months. The prevalence of malaria parasitemia in the study population was 77.8% (1447/1860), 77.6% (1439/1855), and 54.1% (862/1593) by RDT performed by CHWs vs an expert clinical research assistant vs microscopy (gold standard), respectively. Geometric mean parasite density was 6946/µL (range, 40–436 450/µL). There were 49 cases of RDT false-negative results with a parasite density range of 40–54 059/µL. False-negative RDT results with high parasitemia could be due to non-falciparum infection or result from a prozone effect. Sensitivity and specificity of SD-Bioline RDT results as read by CHWs were 94.3% and 41.6%, respectively, while the negative and positive predictive values were 86.1% and 65.6%, respectively. The level of agreement in RDT reading by the CHWs and experienced research staff was 86.04% and κ statistic of 0.60. The malaria parasite positivity rate by RDT and microscopy among children with danger signs in the 3 countries was 67.9% and 41.8%, respectively.

Conclusions. RDTs are useful in guiding malaria management and were successfully used for diagnosis by trained CHWs. However, false-negative RDT results were identified and can undermine confidence in results and control efforts.

Motivation of Community Health Workers in Diagnosing, Treating, and Referring Sick Young Children in a Multicountry Study

Background. Community health workers (CHWs) are an important element of care provision for a wide range of conditions, but their turnover rate is high. Many studies have been conducted on health workers’ motivation, focusing on formal sector staff but not CHWs. Although CHWs are easy to recruit, motivating and retaining them for service delivery is difficult. This article investigates factors influencing CHW motivation and retention in health service delivery.

Methods. Quantitative and qualitative data were collected to identify the key factors favoring motivation and retention of CHWs as well as those deterring them. We interviewed 47, 25, and 134 CHWs in Burkina Faso, Nigeria, and Uganda, respectively, using a structured questionnaire. Focus group discussions (FGDs) were also conducted with CHWs, community participants, and facility health workers.

Results. Except for Burkina Faso, most CHWs were female. Average age was between 38 and 41 years, and most came from agricultural communities. The majority (52%–80%) judged they had a high to very high level of satisfaction, but most CHWs (approximately 75%) in Burkina Faso and Uganda indicated that they would be prepared to leave the job, citing income as a major reason. Community recognition and opportunities for training and supervision were major incentives in all countries, but the volume of unremunerated work, at a time when both malaria-positive cases and farming needs were at their peak, was challenging.

Conclusions. Most CHWs understood the volunteer nature of their position but desired community recognition and modest financial remuneration.

Clinical Trials Registration. ISRCTN13858170.

Impact of Improving Community-Based Access to Malaria Diagnosis and Treatment on Household Costs

Background. Community health workers (CHWs) were trained in Burkina Faso, Nigeria, and Uganda to diagnose febrile children using malaria rapid diagnostic tests, and treat positive malaria cases with artemisinin-based combination therapy (ACT) and those who could not take oral medicines with rectal artesunate. We quantified the impact of this intervention on private household costs for childhood febrile illness.

Methods. Households with recent febrile illness in a young child in previous 2 weeks were selected randomly before and during the intervention and data obtained on household costs for the illness episode. Household costs included consultation fees, registration costs, user fees, diagnosis, bed, drugs, food, and transport costs. Private household costs per episode before and during the intervention were compared. The intervention's impact on household costs per episode was calculated and projected to districtwide impacts on household costs.

Results. Use of CHWs increased from 35% of illness episodes before the intervention to 50% during the intervention (P < .0001), and total household costs per episode decreased significantly in each country: from US Dollars (USD) $4.36 to USD $1.54 in Burkina Faso, from USD $3.90 to USD $2.04 in Nigeria, and from USD $4.46 to USD $1.42 in Uganda (all P < .0001). There was no difference in the time used by the child's caregiver to care for a sick child (59% before intervention vs 51% during intervention spent ≤2 days). Using the most recent population figures for each study district, we estimate that the intervention could save households a total of USD $29 965, USD $254 268, and USD $303 467, respectively, in the study districts in Burkina Faso, Nigeria, and Uganda.

Conclusions. Improving access to malaria diagnostics and treatments in malaria-endemic areas substantially reduces private household costs. The key challenge is to develop and strengthen community human resources to deliver the intervention, and ensure adequate supplies of commodities and supervision. We demonstrate feasibility and benefit to populations living in difficult circumstances.

Clinical Trials Registration. ISRCTN13858170.

Compliance With Malaria Rapid Diagnostic Testing by Community Health Workers in 3 Malaria-Endemic Countries of Sub-Saharan Africa: An Observational Study

Background. The World Health Organization recommends that all malaria management be based on parasitological identification. We monitored performance of trained community health workers (CHWs) in adhering to this recommendation to restrict artemisinin-based combination therapies (ACTs) to positive rapid diagnostic test (RDT)–confirmed cases in children in 3 malaria-endemic sub-Saharan African countries.

Methods. In 33 villages in Burkina Faso, 45 villages in Nigeria, and 84 villages in Uganda, 265 CHWs were trained over a minimum of 3 days to diagnose malaria using RDTs (prepare, read, record results, and inform the patient about results) and treat RDT-confirmed uncomplicated malaria cases with ACTs. In Nigeria, CHWs were also taught to obtain a thick blood smear. Spent RDT kits and prepared blood slides were collected and interpreted independently in Burkina Faso and Nigeria to confirm CHWs' diagnoses. Interviews were held with 12 of 17 CHWs who prescribed ACTs for patients with RDT-negative test results, and with 16 of 29 caregivers to determine factors related to noncompliance.

Results. Of 12 656 patients treated with ACTs in the participating countries (5365 in Burkina Faso, 1648 in Nigeria, and 5643 in Uganda), 29 patients (8 from Burkina Faso, 17 from Nigeria, 4 from Uganda) were RDT negative. The small number of RDT-negative ACT-treated cases limits statistical analysis. Only a few CHWs were involved, and they were more likely to be traders rather than farmers (odds ratio [OR], 6.15; 95% confidence interval [CI], 2.09–18.07; P = .0004). RDT-negative children who were treated with ACTs had a significantly higher probability of residing in a village other than that of the CHW (OR, 3.85; 95% CI, 1.59–9.30; P = .0018). Parental pressure was identified in interviews with parents.

Conclusions. Noncompliance with results of RDT tests is relatively rare when CHWs are trained and well supervised.

Clinical Trials Registration. ISRCTN13858170.

Total cross sections for electron scattering by 1-propanol at impact energies in the range 40-500 eV

Absolute total cross section (TCS) measurements for electron scattering from 1-propanol molecules are reported for impact energies from 40 to 500 eV. These measurements were obtained using a new apparatus developed at Juiz de Fora Federal University-Brazil, which is based on the measurement of the attenuation of a collimated electron beam through a gas cell containing the molecules to be studied at a given pressure. Besides these experimental measurements, we have also calculated TCS using the Independent-Atom Model with Screening Corrected Additivity Rule and Interference (IAM-SCAR+I) approach with the level of agreement between them being typically found to be very good.

Nosocomial tuberculosis prevention in Portuguese hospitals: a cross-sectional evaluation

SETTING

Measures to control tuberculous infection are crucial to prevent nosocomial transmission and protect health care workers (HCWs). In Portugal, the extent of implementation of tuberculosis (TB) control measures in hospitals is not known.

OBJECTIVE

To determine the current implementation of preventive measures for tuberculous infection at administrative, environmental and personal levels in Portuguese hospitals.

DESIGN

A cross-sectional evaluation was performed using two anonymous questionnaires: one sent to all the hospital infection control (IC) committees and the other sent to all pulmonologists and physicians specialising in infectious disease.

RESULTS

Fourteen IC committees and 72 physicians responded. According to the IC committees, 92% of hospitals had a written TB control plan, but only 37% of the physicians said there was always/almost always a fast track for diagnosing suspected pulmonary TB cases. The majority of the hospitals had an isolation policy (85%) and these patients were always/almost always admitted in separate rooms, according to 70% of physicians. Both HCWs and TB patients used respiratory protection equipment (92%).

CONCLUSION

These findings indicate that the most basic TB IC measures had been undertaken, but some TB IC measures were not fully implemented at all hospitals. An institutional effort should be made to solve this problem and strengthen TB prevention activities.