Thin-Film Organic Heteroepitaxy

Incorporating crystalline organic semiconductors into electronic devices requires understanding of heteroepitaxy given the ubiquity of heterojunctions in these devices. However, while rules for commensurate epitaxy of covalent or ionic inorganic material systems are known to be dictated by lattice matching constraints, rules for heteroepitaxy of molecular systems are still being written. Here, it is found that lattice matching alone is insufficient to achieve heteroepitaxy in molecular systems, owing to weak intermolecular forces that describe molecular crystals. It is found that, in addition, the lattice matched plane also must be the lowest energy surface of the adcrystal to achieve one-to-one commensurate molecular heteroepitaxy over a large area. Ultraviolet photoelectron spectroscopy demonstrates the lattice matched interface to be of higher electronic quality than a disordered interface of the same materials.

Spatial Interactions in Hydrogenated Perovskite Nickelate Synaptic Networks

A key aspect of how the brain learns and enables decision-making processes is through synaptic interactions. Electrical transmission and communication in a network of synapses are modulated by extracellular fields generated by ionic chemical gradients. Emulating such spatial interactions in synthetic networks can be of potential use for neuromorphic learning and the hardware implementation of artificial intelligence. Here, we demonstrate that in a network of hydrogen-doped perovskite nickelate devices, electric bias across a single junction can tune the coupling strength between the neighboring cells. Electrical transport measurements and spatially resolved diffraction and nanoprobe X-ray and scanning microwave impedance spectroscopic studies suggest that graded proton distribution in the inhomogeneous medium of hydrogen-doped nickelate film enables this behavior. We further demonstrate signal integration through the coupling of various junctions.

Intrinsic (Trap-Free) Transistors Based on Epitaxial Single-Crystal Perovskites

The first experimental realization of the intrinsic (not dominated by defects) charge conduction regime in lead-halide perovskite field-effect transistors (FETs) is reported. The advance is enabled by: i) a new vapor-phase epitaxy technique that results in large-area single-crystalline cesium lead bromide (CsPbBr₃ ) films with excellent structural and surface properties, including atomically flat surface morphology, essentially free from defects and traps at the level relevant to device operation; ii) an extensive materials analysis of these films using a variety of thin-film and surface probes certifying the chemical and structural quality of the material; and iii) the fabrication of nearly ideal (trap-free) FETs with characteristics superior to any reported to date. These devices allow the investigation of the intrinsic FET and (gated) Hall-effect carrier mobilities as functions of temperature. The intrinsic mobility is found to increase on cooling from ≈30 cm² V^-1 s^-1 at room temperature to ≈250 cm² V^-1 s^-1 at 50 K, revealing a band transport limited by phonon scattering. Establishing the intrinsic (phonon-limited) mobility provides a solid test for theoretical descriptions of carrier transport in perovskites, reveals basic limits to the technology, and points to a path for future high-performance perovskite electronic devices.

Understanding the Adsorption of Rare-Earth Elements in Oligo-Grafted Mesoporous Carbon

Rare-earth elements (REEs) are 17 elements of the periodic table primarily consisting of lanthanides. In modern society, the usage of REEs is ubiquitous in almost all modern gadgets and therefore efficient recovery and separation of REEs are of high importance. Selective adsorption and chelation of REEs in solid sorbents is a unique and sustainable process for their recovery. In this work, single-stranded oligos with 100 units of thymine were grafted onto carboxylated mesoporous carbon to synthesize a sorbent with phosphorus and oxygen functionalities. The sorbent was characterized by X-ray photoelectron spectroscopy, Fourier-transform infrared spectroscopy, and scanning electron microscopy-energy-dispersive X-ray spectroscopy. Three different REEs with varying atomic radii and densities, Lu, Dy, and La, were adsorbed onto the carbon from aqueous solutions. It was observed that the adsorbed amounts increased with the increase in the atomic radius or decrease in the atomic density. Calculation of the distribution coefficients for all the equilibrium adsorption amounts suggested that adsorption is more effective in the lower concentration region. The L₃-edge X-ray absorption near-edge structure confirmed a 3+ oxidation state of REEs in the adsorbed phase. Extended X-ray absorption fine structure (EXAFS) confirmed the binding of REEs with oxygen functionalities in the adsorbed phase. The radial distribution functions calculated from the EXAFS data suggest a longer RE-O distance for La compared to those for Lu and Dy. The coordination numbers and Debye-Waller factors have typical values of about 8-9 atoms and 0.01-0.02 Ų, respectively.

Helical Peptides Design for Molecular Dipoles Functionalization of Wide Band Gap Oxides

The use of helical hexapeptides to establish a surface dipole layer on a TiO₂ substrate, with the goal of influencing the energy levels of a coadsorbed chromophore, is explored. Two helical hexapeptides, synthesized from 2-amino isobutyric acid (Aib) residues, were protected at the N-terminus with a carboxybenzyl group (Z) and at the C-terminus carried either a carboxylic acid or an isophthalic acid (Ipa) anchor group to form Z-(Aib)₆-COOH or Z-(Aib)₆-Ipa, respectively. Using a combination of vibrational and photoemission spectroscopies, bonding of the two peptides to TiO₂ surfaces (either nanostructured or single-crystal TiO₂(110)) was found to be highly dependent on the anchor group, with Ipa establishing a monolayer much more efficiently than COOH. Furthermore, a monolayer of Z-(Aib)₆-Ipa on TiO₂(110) was exposed for different binding times to a solution of a zinc tetraphenylporphyrin (ZnTPP) derivative terminated with an Ipa anchor group (ZnTPP-P-Ipa). Photoemission spectroscopy revealed that ZnTPP-P-Ipa partly displaced Z-(Aib)₆-Ipa, forming a coadsorbed monolayer on the oxide surface. The presence of the peptide molecular dipole shifted the HOMO levels of the ZnTPP group to lower energy by ∼300 meV, in accordance with a simple parallel plate capacitor model. These results suggest that a mixed-layer approach, involving coadsorption of a strong molecular dipole compound with a chromophore, is a versatile method to shift the energy levels of such chromophores with respect to the band edges of the substrate.

Unveiling universal trends for the energy level alignment in organic/oxide interfaces

Organic/oxide interfaces exhibit an energy-level-alignment universal behaviour when a bias is applied. Coulomb-blockade regime is ruled by the organic electronegativity.

Nanoscale Internal Fields in a Biased Graphene-Insulator-Semiconductor Structure

Measuring and understanding electric fields in multilayered materials at the nanoscale remains a challenging problem impeding the development of novel devices. At this scale, it is far from obvious that materials can be accurately described by their intrinsic bulk properties, and considerations of the interfaces between layered materials become unavoidable for a complete description of the system's electronic properties. Here, a general approach to the direct measurement of nanoscale internal fields is proposed. Small spot X-ray photoemission was performed on a biased graphene/SiO2/Si structure in order to experimentally determine the potential profile across the system, including discontinuities at the interfaces. Core levels provide a measure of the local potential and are used to reconstruct the potential profile as a function of the depth through the stack. It is found that each interface plays a critical role in establishing the potential across the dielectric, and the origin of the potential discontinuities at each interface is discussed.

Densely-packed ZnTPPs Monolayer on the Rutile TiO2(110)-(1×1) Surface: Adsorption Behavior and Energy Level Alignment

The adsorption of a densely packed Zinc(II) tetraphenylporphyrin monolayer on a rutile TiO₂(110)-(1×1) surface has been studied using a combination of experimental and theoretical methods, aimed at analyzing the relation between adsorption behavior and barrier height formation. The adsorption configuration of ZnTPP was determined from scanning tunnel microscopy (STM) imaging, density functional theory (DFT) calculations and STM image simulation. The corresponding energy alignment was experimentally determined from X-ray and UV-photoemission spectroscopies and inverse photoemission spectroscopy. These results were found in good agreement with an appropriately corrected DFT model, pointing to the importance of local bonding and intermolecular interactions in the establishment of barrier heights.

Chemical Interaction, Space-charge Layer and Molecule Charging Energy for a TiO2/TCNQ Interface

Three driving forces control the energy level alignment between transition-metal oxides and organic materials: the chemical interaction between the two materials, the organic electronegativity and the possible space charge layer formed in the oxide. This is illustrated in this study by analyzing experimentally and theoretically a paradigmatic case, the TiO₂(110) / TCNQ interface: due to the chemical interaction between the two materials, the organic electron affinity level is located below the Fermi energy of the n-doped TiO₂. Then, one electron is transferred from the oxide to this level and a space charge layer is developed in the oxide inducing an important increase in the interface dipole and in the oxide work-function.

Tuberculosis knowledge and awareness in tribal-dominant districts of Jharkhand, India: implications for ACSM

SETTING

Forty hard-to-reach villages in the East and West Singhbhum Districts of Jharkhand State, India.

OBJECTIVES

To document knowledge and awareness of tuberculosis (TB) among the general population, understand gender differences and inform intervention activities for the improvement of TB control programmes in tribal-dominant hard-to-reach areas in India.

DESIGN

A cross-sectional community-based survey was carried out among 825 respondents using population proportionate sampling.

RESULTS

Most of the respondents were in the 18-35 years age group, tribal and married; 44% were illiterate. The study shows poor knowledge about TB symptoms, causes, modes of transmission and moderate awareness about government TB services. Correct knowledge about the cause of TB was negligible: half of the respondents reported local liquor as the cause, 61% considered TB as transmissible and one third considered sharing of food as the mode of transmission. Awareness about the availability of free treatment services at government health facilities was high, but awareness about DOTS was low. Significant gender differences were observed in knowledge and awareness levels.

CONCLUSION

Study findings point to the importance of urgent intensification of culturally congruent and gender-sensitive advocacy, communication and social mobilisation activities.

Photoelectrochemical properties of porphyrin dyes with a molecular dipole in the linker

The electronic properties of three porphyrin–bridge–anchor photosensitizers are reported with (1a, 1e, 3a and 3e) or without (2a and 2e) an intramolecular dipole in the bridge. The presence and orientation of the bridge dipole is hypothesized to influence the photovoltaic properties due to variations in the intrinsic dipole at the semiconductor–molecule interface. Electrochemical studies of the porphyrin–bridge–anchor dyes self-assembled on mesoporous nanoparticle ZrO₂ films, show that the presence or direction of the bridge dipole does not have an observable effect on the electronic properties of the porphyrin ring. Subsequent photovoltaic measurements of nanostructured TiO₂ semiconductor films in dye sensitized solar cells show a reduced photocurrent for photosensitizers 1a and 3a containing a bridge dipole. However, cooperative increased binding of the 1a + 3a co-sensitized device demonstrates that dye packing overrides any differences due to the presence of the small internal dipole.

The solid state conversion reaction of epitaxial FeF2(110) thin films with lithium studied by angle-resolved X-ray photoelectron spectroscopy

An epitaxial FeF₂(110) thin film was exposed to Li as a high-purity analogue of a Li-ion battery discharge. The stoichiometry and morphology of the film were then characterized by ARXPS.

The efficacy and tolerability of a sunitinib 3-week administration schedule in metastatic renal cell carcinoma patients: report of three cases

Sunitinib, an orally multitargeted tyrosine kinase inhibitor and standard first-line treatment for metastatic renal cell carcinoma, is usually administered on a 6-week schedule. Toxicities reported with this drug are usually of moderate grade, which results in good treatment tolerability and patients' compliance. However, in some cases high-grade or prolonged toxicities require temporary treatment interruption or dose adjustment, possibly resulting in reduced treatment efficacy. We describe three cases of metastatic renal cell carcinoma patients (a 53-year-old male, a 70-year-old woman, and a 65-year-old woman) who received a shortened 3-week sunitinib administration schedule, 2 weeks daily administration followed by 1 week of rest (2/1) due to toxicities developed on the classic 6-week schedule, which would have required a temporary treatment interruption or a dose reduction. Treatment was generally well tolerated with manageable toxicities. A 3-week administration schedule of sunitinib may represent a valid alternative for managing toxicity while maintaining the planned dose intensity over a 6-weeks period of time. Sunitinib may thus be administered using a flexible dosing schedule to meet individual patient needs, achieving better tolerability and maintaining significant response to treatment.

Increasing photocurrents in dye sensitized solar cells with tantalum-doped titanium oxide photoanodes obtained by laser ablation

Laser ablation is employed to produce vertically aligned nanostructured films of undoped and tantalum-doped TiO(2) nanoparticles. Dye-sensitized solar cells using the two different materials are compared. Tantalum-doped TiO(2) photoanode show 65% increase in photocurrents and around 39% improvement in overall cell efficiency compared to undoped TiO(2). Electrochemical impedance spectroscopy, Mott-Schottky analysis and open circuit voltage decay is used to investigate the cause of this improved performance. The enhanced performance is attributed to a combination of increased electron concentration in the semiconductor and a reduced electron recombination rate.

Implementation of new TPD analysis techniques in the evaluation of second order desorption kinetics of cyanogen from Cu(001)

The interactions of cyanide species with a copper (001) surface were studied with temperature programmed desorption (TPD) and X-ray photoelectron spectroscopy (XPS). Adsorbed cyanide species (CN(a)) undergo recombinative desorption evolving molecular cyanogen (C(2)N(2)). As the adsorbed CN species charge upon adsorption, mutually repulsive dipolar interactions lead to a marked desorption energy reduction with increasing CN(a) coverages. Two new TPD analysis approaches were developed, which used only accurately discernible observables and which do not assume constant desorption energies, E(d), and pre-exponential values, ν. These two approaches demonstrated a linear variation of E(d) with instantaneous coverage. The first approach involved an analysis of the variations of desorption peak asymmetry with initial CN coverages. The second quantitative approach utilized only temperatures and intensities of TPD peaks, together with deduced surface coverages at the peak maxima, also as a function of initial surface coverages. Parameters derived from the latter approach were utilized as initial inputs for a comprehensive curve fit analysis technique. Excellent fits for all experimental desorption curves were produced in simulations. The curve fit analysis confirms that the activation energy of desorption of 170-180 kJ/mol at low coverage decreases by up to 14-15 kJ/mol at CN saturation.

Response and safety of sunitinib in a heavily pre-treated metastatic non-small cell lung carcinoma patient

BACKGROUND

The activity of sunitinib, a multitargeted tyrosine kinase inhibitor with antiangiogenic and antitumor activities, has been explored in several solid malignancies such as breast, lung, prostate and pancreatic cancer. Currently it is approved for the treatment of metastatic renal cell carcinoma and gastrointestinal stromal tumors. Non-small cell lung cancer usually presents at an advanced or metastatic stage at diagnosis. Treatment options are limited for this disease, therefore symptom palliation and patient's quality of life are primary objectives of therapy.

CASE REPORT

We describe the case of a patient (male, 67 years old) with heavily pre-treated metastatic non-small cell lung carcinoma who received sunitinib according to the following 3-week schedule: 50 mg daily for 2 weeks followed by a 1-week rest. The patient completed six months of therapy achieving a major disease response without high-grade toxicities.

CONCLUSION

In this case, sunitinib shows promising single-agent activity in pretreated non-small cell lung cancer, with a good toxicity profile and flexible administration schedule.

Weekly administration of docetaxel and epirubicin as first-line treatment for hormone-refractory prostate carcinoma

Androgen-independent prostate carcinoma (AICP) is one of the tumors that continue to respond poorly to chemotherapy. Recently, protocols based on the use of docetaxel have significantly improved survival for patients in this disease. In other types of neoplastic disease, combined therapy with taxanes and anthracycline derivatives has been shown to produce additive effects in terms of growth inhibition, and superior tolerability when associated with weekly administration schedules. These findings prompted us to examine the tolerability and efficacy of weekly treatment of AICP with docetaxel (DOX) plus epirubicin (EPI). We enrolled 35 chemotherapy-naive men with AICP (mean age 72 years, range 68-77) and normal hepatic, renal, and cardiac function. The chemotherapy protocol provided for the IV administration of DOX (30 mg/m2) and EPI (30 mg/m2) on days 1, 8, and 15 every 28 days. Treatment was continued for 6 months or until disease progression and/or unacceptable toxicity was observed. Serum levels of prostate-specific antigen (PSA) were monitored in all patients, and reductions from baseline values of >50% were considered indicative of positive responses to treatment. Thirty-four patients were included in the analysis of toxicity, and objective responses to treatment were assessed in the 28 patients with measurable lesions. Nineteen patients (56%) experienced PSA reductions of >50% that persisted for more than 4 weeks. The response to therapy was classified as complete in 1 of the 28 patients (4%) with measurable disease (at the lymph node level). Thirteen others (13/28, 46%) had partial responses, in nine (32%) the disease remained unchanged, and progression was observed in the remaining five (18%); overall response rate was 50% (CR + PR). Of the 27 patients with pain at the time of enrollment, 16 (59%) experienced pain reduction during treatment. The median time to disease progression was 11.7 months (95% CI: 7.7-15.7) while the median survival time was 18.7 months (95% CI: 12.3-25.1). During the study, four patients developed grade 3 anemia and leukopenia, which was reversible in all cases. Lower grades of asthenia, nausea, vomiting, diarrhea, and peripheral edema were also observed. There were no cases of cardiotoxic effects. Alopecia was frequent but reversible in all cases. The results of this preliminary study indicate that the combined administration of DOX and EPI for treatment of AIPC is effective and well tolerated. The weekly administration of the drug combination appears to be a promising approach to the treatment of these tumors.

India's Revised National Tuberculosis Control Programme: looking beyond detection and cure

SETTING

Pune District, Maharashtra State, India.

OBJECTIVES

To examine delays experienced by patients in accessing directly observed treatment.

DESIGN

Data were collected from 117 new sputum-positive patients using a semi-structured interview schedule.

RESULTS

Patient delays as well as diagnostic and treatment delays, which reflect the performance of a National TB Programme, were minimal. Provider delays, however, contributed significantly to delayed entry into India's Revised National TB Control Programme (RNTCP). Patients had to resort to multiple contacts with providers due to limitations of these providers in diagnosing or directing patients to the RNTCP. Patients who consulted a private provider participating in the public-private mix (PPM) were more likely to be suspected (OR 2.63, 90% CI 1.04-6.64) and referred (OR 6.8, 95%CI 2.08-22.21) to the RNTCP. Once the patients entered the RNTCP, the response of the system was rapid, with diagnosis offered and treatment initiated within on average 7 days.

CONCLUSION

Interventions aimed at providers to encourage early suspicion and referral to the RNTCP, such as the PPM, are more important in improving patient access to TB care than those focusing on reducing patient delays.

Once weekly thyroxine treatment as a strategy to treat non-compliance

Hypothyroidism is a common disorder, which is mainly treated in primary rather than secondary care. Once daily thyroxine replacement restores euthyroidism in most patients; some patients, however, remain hypothyroid despite adequate thyroxine replacement. Non-compliance is the most common cause of lack of response to thyroxine treatment. We describe two cases of primary hypothyroidism in which daily thyroxine treatment did not restore biochemical euthyroidism but once weekly thyroxine treatment was successful. In addition we review the evidence and discuss the differential diagnosis of lack of response to thyroxine treatment. Once weekly thyroxine treatment can be a safe, well-tolerated, and effective therapy for patients with non-compliance.

Grave's Eye Disease Developing Following Radioiodine Treatment for Toxic Nodular Goitre

The development of Grave's ophthalmopathy (GO) following radioiodine (RI) treatment for Grave's thyrotoxicosis, though controversial, is well described. The development of ophthalmopathy following RI treatment for toxic nodular goitre is much less recognised. We report a 49 year-old female patient who developed thyrotoxicosis and GO after receiving RI treatment for toxic nodular goitre and we also review the relevant literature.

Surface Reactions of 3-Butenenitrile on the Si(001)-2 × 1 Surface at Room Temperature

Using a combination of local -- scanning tunneling microscopy -- and spatially integrated, but chemically sensitive probes -- X-ray photoelectron spectroscopy and near edge X-ray absorption fine structure spectroscopy -- we have examined how 3-butenenitrile reacts with the Si(001)-2 x 1 surface at room temperature. Electron spectroscopies indicate three different nitrogen chemical bonds: a Si-C=N-Si bond, a C=C=N cumulative double bond, and a CN moiety datively bonded to a silicon atom. All molecular imprints detected by scanning tunneling microscopy (STM) involve two adjacent silicon dimers in the same row. The three geometries we propose -- a double di-sigma bonding via the CN and the C=C, a cumulative double bond formation associated with alphaC-H bond dissociation, and a di-sigma vinyl bonding plus a CN datively bonded to a silicon atom -- are all compatible with electron spectroscopies and data. Real-time Auger yield kinetic measurements show that the double di-sigma bonding geometry is unstable when exposed to a continuous flux of 3-butenenitrile molecules, as the Si-C=N-Si unit transforms into a CN moiety. A model is proposed to explain this observation.

The Mumbai experience in building field level partnerships for DOTS implementation

In February 1999, the Revised National Tuberculosis (TB) Control Programme (RNTCP) was implemented in the city of Mumbai after a pilot phase of 5 years. The city has a population of more than 12 million people and an estimated annual TB incidence of 21,000 cases, 8000 of these being infectious. This paper describes a partnership between the TB programme and a Non Governmental Organization (NGO), which began with a methodological analysis of the problems faced by the programme to help identify other key organizations, who might usefully be involved. The work focussed on "networking" to ensure the optimum use of existing resources. The problems encountered affected all levels of TB control from access to drug supply and treatment. The major issues related to an inadequate public health infrastructure resulting in poor technical and administrative support to field staff. There was confusion over roles of the health personnel in the TB programme and the public health facility, as well as poor technical performance. Partnerships were found to be useful in addressing the following areas: (1) the implementation of an external quality assurance scheme for sputum microscopy through involvement of microbiologists from large hospitals and research organizations; (2) training and capacity strengthening of programme and public health facility staff through innovative training and team building exercises organized by the programme, NGOs and the private sector; (3) development of Information, Education and Communication (IEC) material through partnerships with NGOs, and (4) the involvement of local NGOs and private doctors to increase case finding and to improve access to direct observation of treatment (DOT). The paper discusses the lessons learnt in this process and identifies some of the key issues in urban TB control, for consideration by policy makers.

Attention to gender issues in tuberculosis control

Although a seventy per cent excess of male over female TB cases are reported globally each year, the reasons for this difference are unclear. Generally, women in poor countries confront more barriers than men in accessing health care services. Yet, research is lacking to explain the impact of gender inequalities in access to care on reported sex ratios for TB. A review of the limited available literature and field visits to TB programmes offered insights and suggested a framework to study gender differentials in TB. This paper considers the role of gender at various steps in effective TB care. A research strategy to study and account for gender differences in TB control is proposed.

Comparison of three assays for cytomegalovirus detection in AIDS patients at risk for retinitis

The purpose of this study was to determine the sensitivity and specificity of three different methods of cytomegalovirus (CMV) detection for AIDS patients at risk for CMV retinitis. Patients with CD4(+) counts of <100/microl and negative baseline screening eye examinations were tested for CMV infection by (i) pp65 antigenemia expression in leukocytes, (ii) the Digene Hybrid Capture CMV DNA System, and (iii) the Roche Amplicor Qualitative PCR Test. The incidence of CMV retinitis in our study of 296 patients at the Medical Center of Louisiana-New Orleans HIV Outpatient Clinic was 7. 2 per 100 person-years (a total of 20 episodes in 18 patients from April 1997 to February 1999). Receiver operating characteristic curves were calculated for each assay to determine optimal cutoff points which maximized the sensitivity and specificity of each assay. The sensitivities of the assays compared to the eye examinations were 80% for the pp65 antigenemia assay (cutoff, >0 cell per 1.5 x 10(5) leukocytes), 85% for the Digene assay (cutoff, 1,400 genome copies/ml of whole blood), and 60% for the Amplicor assay. The specificities of the assays were 84, 84, and 87%, respectively. The Digene assay with a cutoff of >/=1,400 genome copies/ml gave optimal sensitivity and specificity and was found to have predictive values equal to those of the more technically cumbersome antigenemia assay.

Delayed deterioration of hearing following bacterial meningitis

Bacterial meningitis is an important cause of acquired sensorineural deafness in childhood. Deafness following meningitis may be progressive. Previous reports have shown deterioration in hearing up to 12 years after the illness. We present two cases of sensorineural deafness following meningitis. Severe to profound sensorineural hearing losses were detected immediately after meningitis in these patients. The hearing subsequently deteriorated in both cases. Deterioration in hearing thresholds occurred 17 years after the illness in one case. In the other patient the hearing got progressively worse three years after meningitis. She subsequently required a cochlear implant.

Shifting the paradigm in tuberculosis control: illustrations from India

Drawing on literature from India and key contributions from social science, this paper asks and attempts to answer the question 'who is to blame for treatment failures in TB'? Some key lessons emerge: effective tuberculosis control cannot be achieved so long as the disease is considered in isolation from the social processes that maintain it, create the conditions facilitating its spread and act as barriers to care. Insights into the economic and social burdens incurred with a diagnosis of TB are essential to understand why many patients, especially the most disadvantaged, are unable to comply with treatment regimens. TB and health care interventions need to be appropriate to the health service contexts in which they are applied, and sensitive to the competing demands, needs and priorities of people's lives. The paper argues for the need to reorient TB control programmes towards enabling patients to obtain care. The problem of access emerges as central to people's ability to obtain and maintain appropriate therapy. Examples and characteristics of successful non-governmental projects, from which policy makers, programmers and practitioners could learn, are outlined and contrasted with more rigid directly observed treatment approaches. We conclude that treatment failures are not patient failures, and that TB control programmes need to address the social dimensions of TB, and adhere to the principles of good TB care, with the same commitment that is devoted to ensuring patients follow treatment guidelines. We suggest a paradigm shift away from a focus on diseased patients towards enabling health in the community.

Tuberculosis patients and practitioners in private clinics in India

SETTING

Rural and urban areas of Maharashtra, a large state in Western India.

OBJECTIVE

To understand tuberculosis (TB) management practices among private medical practitioners (PPs) and the treatment behaviour of the patients they manage.

DESIGN

Prospective study of help-seeking patterns and treatment behaviour among 173 pulmonary TB patients diagnosed in private clinics, and the TB management practices of 122 PPs treating these patients.

RESULTS

The first source of help for 86% of patients was a PP. The diagnostic and treatment practices of PPs were inadequate; 15% did not consider sputum examination to be necessary, and 79 different treatment regimens were prescribed by 105 reporting PPs. Sixty-seven percent of the patients diagnosed in private clinics remained with the private sector, and the rest shifted to public health services within six months of treatment. The treatment adherence rate among the patients in private clinics was 59%. There were discrepancies between the reported management practices of the PPs and what their patients actually followed.

CONCLUSION

The study identifies and highlights the need to educate PPs and their TB patients, and indicates ways in which PPs could be meaningfully involved in efforts to revitalize the national TB control programme.

Private doctors and tuberculosis control in India

Over three quarters of the 8 million registered doctors in India are engaged in private medical practice. In urban and rural areas alike people prefer private doctors to public health services for their health care needs. A majority of patients and those with suspected tuberculosis also report first to private doctors. Nevertheless private doctors seem to be alienated from national efforts towards control of tuberculosis, there being no well-defined role for them in the National Tuberculosis Programme. This study of private doctors practising in the low income areas of a metropolis of India reports on the knowledge of private doctors about diagnosis and treatment of tuberculosis and their awareness and perceptions about the public health services available for tuberculosis control. The study reveals gaps and weaknesses in the private doctors' reported practice of managing lung tuberculosis, the most important and persistent problem of public health concern in India. The need for organized efforts towards involving private doctors in disease control programmes wherein their curative functions could contribute significantly is stressed.

Community health awareness among recent medical graduates of Bombay

BACKGROUND

Since Independence in 1947, the need for reorientation of our western-style, hospital-based, urban-oriented medical education has been well recognized and much discussed but little action has been taken to make it more community-based. Against a background of 40 years of debate, we conducted a study of 342 medical graduates commencing their internship training in one government and two municipal medical colleges to assess the effects of medical education on them.

METHODS

A questionnaire was administered to examine recent interns' awareness of some aspects of community health, their perceptions of the concept of Primary Health Care and their knowledge of rational prescriptions for minor ailments and for major illnesses of public health importance.

RESULTS

We found a lack of basic health information among recent medical graduates, an apathy towards matters of public health importance, and gaps in their knowledge of curative care and rational prescribing.

CONCLUSION

We suggest that there is a need not only to effect changes in the curriculum but also to assess whether these changes might lead to the making of doctors more suited to work in our villages.

Adult T-cell leukemia-lymphoma. Unusual features of two patients from a low-incidence area

The occurrence of adult T-cell leukemia-lymphoma in two New Orleans patients, one native-born, the other originally from Honduras, is reported. Both exhibited an unusual feature. One patient was diagnosed following an atypical episode of sinusitis and demonstrated lymphomatous infiltration of the nasopharynx. A second patient had a fulminant course complicated by severe diarrhea and was found to have both tumor involvement and cytomegalovirus inclusions in the colon. Both had high titers of antibodies to HTLV-I. A cell line with T-lymphocyte characteristics was established from the peripheral blood of the first patient. Such studies may help better establish the clinical course, detection, and epidemiologic features of this difficult disease.