Healthcare seeking behaviour as a link between tuberculosis and socioeconomic factors

Socioeconomic barriers to tuberculosis care-seeking and costs due to care-seeking lead to unfavourable treatment, epidemiological and economic outcomes. Especially in the post-2015 era, socioeconomic interventions for tuberculosis control are receiving increasing attention. In Taiwan, the National Health Insurance programme minimises out-of-pocket expenses for patients, but important delays to tuberculosis treatment still exist. Based on the population and tuberculosis epidemiology in Taiwan, I develop an analysis for profiling the efficacy of tuberculosis care provision and patients' care-seeking pathways. The results highlight that the interrupted tuberculosis evaluation processes and low diagnostic capacity in small local hospitals stands as key causes of extended delays to treatment, unfavourable outcomes, and costs. I analyse socioeconomic status (SES) of employment, vulnerability, and residential contexts, to identify risk factors for different aspects of care-seeking. To link the care-seeking pathways to the nationwide tuberculosis epidemiology, I develop a data-driven hybrid simulation model. The model integrates the advantages of agent-based approaches in representing detail, and equation-based approaches in simplicity and low computational cost. This approach makes feasible Monte-Carlo experiments for robust inferences without over-simplifying the care-seeking details of interest. By comparing the hybrid model simulations with a corresponding equation-based comparator, I confirm its validity. I considered interventions to improve universal health coverage by decentralising tuberculosis diagnostic capacity. I modelled specific interventions increasing the coverage of tuberculosis diagnostic capacity using various SES-targeted scale-up strategies. These show potential benefits in terms of reducing dropouts and reducing the tuberculosis burden, without significant increases in the inequality of care-seeking costs. I suggest considering additional SES variables such as education, health illiteracy, and social segregation to find other care-seeking barriers. Further investigations of SES-related interventions against tuberculosis, including formal impact and health economic evaluation, should be pursued in collaboration with policymakers able to advise on feasibility and patients able to advise on acceptability

Adult mortality of diseases and injuries attributable to selected metabolic, lifestyle, environmental, and infectious risk factors in Taiwan: A comparative risk assessment

Background: To facilitate priority-setting in health policymaking, we compiled the best available information to estimate the adult mortality (>30 years) burden attributable to 13 metabolic, lifestyle, infectious, and environmental risk factors in Taiwan. Methods: We obtained data on risk factor exposure from nationally representative health surveys, cause-specific mortality from the National Death Registry, and relative risks from epidemiological studies and meta-analyses. We applied the comparative risk assessment framework to estimate mortality burden attributable to individual risk factors or risk factor clusters. Results: In 2009, high blood glucose accounted for 14,900 deaths (95% UI: 11,850-17,960), or 10.4% of all deaths in that year. It was followed by tobacco smoking (13,340 deaths, 95% UI: 10,330-16,450), high blood pressure (11,190 deaths, 95% UI: 8,190-14,190), ambient particulate matter pollution (8,600 deaths, 95% UI: 7,370-9,840), and dietary risks (high sodium intake and low intake of fruits and vegetables, 7,890 deaths, 95% UI: 5,970-9,810). Overweight-obesity and physical inactivity accounted for 7,620 deaths (95% UI: 6,040-9,190), and 7,400 deaths (95% UI: 6,670-8,130), respectively. The cardiometabolic risk factors of high blood pressure, high blood glucose, high cholesterol, and overweight-obesity jointly accounted for 12,120 deaths (95% UI: 11,220-13,020) from cardiovascular diseases. For domestic risk factors, infections from hepatitis B virus (HBV) and hepatitis C virus (HCV) were responsible for 6,300 deaths (95% UI: 5,610-6,980) and 3,170 deaths (95% UI: 1,860-4,490), respectively, and betel nut use was associated with 1,780 deaths from oral, laryngeal, and esophageal cancer (95% UI: 1,190-2,360). The leading risk factors for years of life lost were similar, but the impact of tobacco smoking and alcohol use became larger because the attributable deaths from these risk factors occurred among young adults aged less than 60 years. Conclusions: High blood glucose, tobacco smoking, and high blood pressure are the major risk factors for deaths from diseases and injuries among Taiwanese adults. A large number of years of life would be gained if the 13 modifiable risk factors could be removed or reduced to the optimal level

Relationships of leisure-time and non-leisure-time physical activity with depressive symptoms: a population-based study of Taiwanese older adults.

Background: Limited research has explored the relationship between non-leisure-time physical activity (NLTPA), including domestic and work-related physical activities, with depressive symptoms. This study was designed to elucidate independent associations between leisure-time physical activity (LTPA), NLTPA, and specific parameters of physical activity (frequency, duration and intensity) with depressive symptoms in older adults. Methods: A total of 2,727 persons aged ≥ 65 years participating in the 2005 Taiwan National Health Interview Survey were studied. Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale. Information regarding energy parameters for each type of LTPA and NLTPA during the past 2-week period was analyzed. After adjusting for socio-demographic variables, lifestyle behaviors and health status, multivariate logistic regression models were used to compute adjusted odds ratios (AOR) for LTPA and NLTPA for predicting depressive symptoms. Results: LTPA but not NLTPA was significantly associated with depressive symptoms. Compared with participants expending 2000+ kcal/week through LTPA, the risk of experiencing depressive symptoms was significantly higher for those expending 1-999 kcal/week (AOR = 2.06, 95% CI: 1.25-3.39), and those who expending 0 kcal/week (AOR= 3.72, 95%CI: 2.28-6.06). Among the three parameters of LTPA (intensity, duration and frequency) examined, only intensity was independently associated with depressive symptoms. Conclusions: These findings imply that exercise recommendations for older adults should emphasize the importance of higher intensity activity, rather than frequency or duration, for improved mental well-being. However, well-designed prospective cohort studies or intervention trials are needed to confirm these findings

The Sizes and Composition of HDL-Cholesterol Are Significantly Associated with Inflammation in Rheumatoid Arthritis Patients.

Rheumatoid arthritis (RA), a chronic inflammatory disease, carries a significant burden of atherosclerotic cardiovascular diseases (ASCVD). With their heterogeneous composition, high-density lipoprotein (HDL) particles have varied athero-protective properties, and some may even increase ASCVD risk. In this prospective and cross-sectional study, we aimed to examine the relationship between HDL sizes/metabolites and inflammation in RA. Using 1H-NMR-based lipid/metabolomics, differential HDL-related metabolites were identified between RA patients and healthy control (HC) subjects and between RA patients with and without anti-citrullinated peptide antibodies (ACPA). The correlation between the discriminative HDL-related metabolites and C-reactive protein (CRP) was evaluated in RA patients. RA patients demonstrated higher particle number, lipids, cholesterol, cholesterol ester, free cholesterol, and phospholipids in large/very large-sized HDLs. ACPA-positive patients had higher L-HDL-C and L-HDL-CE but lower small-/medium-sized HDL-TG levels than ACPA-negative patients. An inverse correlation was found between CRP levels and small-sized HDLs. Janus kinase inhibitor treatment was associated with increased serum small-sized HDL-related metabolites and decreased CRP levels. We are the first to reveal the significant associations between RA inflammation and HDL sizes/metabolites. A potential link between ACPA positivity and changes in serum levels of HDL-related metabolites was also observed in RA patients

Durations of asymptomatic, symptomatic, and care-seeking phases of tuberculosis disease with a Bayesian analysis of prevalence survey and notification data

This work was supported by the Wellcome Trust (206575/Z/17/Z to PM, 200901/Z/16/Z to ELC) and the UK MRC (MR/P022081/1 to PJD). This UK funded award (PJD) is part of the EDCTP2 programme supported by the European Union. KCH is supported by the European Research Council (757699) and UK FCDO (“Leaving no-one behind: transforming gendered pathways to health for TB”). This research has been partially funded by UK aid from the UK government (to KCH).Background Ratios of bacteriologically positive tuberculosis (TB) prevalence to notification rates are used to characterise typical durations of TB disease. However, this ignores the clinical spectrum of tuberculosis disease and potentially long infectious periods with minimal or no symptoms prior to care-seeking. Methods We developed novel statistical models to estimate progression from initial bacteriological positivity including smear conversion, symptom onset and initial care-seeking. Case-detection ratios, TB incidence, durations, and other parameters were estimated by fitting the model to tuberculosis prevalence survey and notification data (one subnational and 11 national datasets) within a Bayesian framework using Markov chain Monte Carlo methods. Results Analysis across 11 national datasets found asymptomatic tuberculosis durations in the range 4–8 months for African countries; three countries in Asia (Cambodia, Lao PDR, and Philippines) showed longer durations of > 1 year. For the six countries with relevant data, care-seeking typically began half-way between symptom onset and notification. For Kenya and Blantyre, Malawi, individual-level data were available. The sex-specific durations of asymptomatic bacteriologically-positive tuberculosis were 9.0 months (95% credible interval [CrI]: 7.2–11.2) for men and 8.1 months (95% CrI: 6.2–10.3) for women in Kenya, and 4.9 months (95% CrI: 2.6–7.9) for men and 3.5 months (95% CrI: 1.3–6.2) for women in Blantyre. Age-stratified analysis of data for Kenya showed no strong age-dependence in durations. For Blantyre, HIV-stratified analysis estimated an asymptomatic duration of 1.3 months (95% CrI: 0.3–3.0) for HIV-positive people, shorter than the 8.5 months (95% CrI: 5.0–12.7) for HIV-negative people. Additionally, case-detection ratios were higher for people living with HIV than HIV-negative people (93% vs 71%). Conclusion Asymptomatic TB disease typically lasts around 6 months. We found no evidence of age-dependence, but much shorter durations among people living with HIV, and longer durations in some Asian settings. To eradicate TB transmission, greater gains may be achieved by proactively screening people without symptoms through active case finding interventions.Peer reviewe

The impact of SARS on hospital performance

© 2008 Chu et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Jun Dimerization Protein 2 Controls Senescence and Differentiation via Regulating Histone Modification

Transcription factor, Jun dimerization protein 2 (JDP2), binds directly to histones and DNAs and then inhibits the p300-mediated acetylation both of core histones and of reconstituted nucleosomes that contain JDP2 recognition DNA sequences. JDP2 plays a key role as a repressor of adipocyte differentiation by regulation of the expression of the gene C/EBPδ via inhibition of histone acetylation. Moreover, JDP2-deficient mouse embryonic fibroblasts (JDP2−/− MEFs) are resistant to replicative senescence. JDP2 inhibits the recruitment of polycomb repressive complexes (PRC1 and PRC2) to the promoter of the gene encoding p16Ink4a, resulting from the inhibition of methylation of lysine 27 of histone H3 (H3K27). Therefore, it seems that chromatin-remodeling factors, including the PRC complex controlled by JDP2, may be important players in the senescence program. The novel mechanisms that underline the action of JDP2 in inducing cellular senescence and suppressing adipocyte differentiation are reviewed

Effects of coronavirus disease pandemic on tuberculosis notifications, Malawi

The coronavirus disease (COVID-19) pandemic might affect tuberculosis (TB) diagnosis and patient care. We analyzed a citywide electronic TB register in Blantyre, Malawi and interviewed TB officers. Malawi did not have an official COVID-19 lockdown but closed schools and borders on March 23, 2020. In an interrupted time series analysis, we noted an immediate 35.9% reduction in TB notifications in April 2020; notifications recovered to near prepandemic numbers by December 2020. However, 333 fewer cumulative TB notifications were received than anticipated. Women and girls were affected more (30.7% fewer cases) than men and boys (20.9% fewer cases). Fear of COVID-19 infection, temporary facility closures, inadequate personal protective equipment, and COVID-19 stigma because of similar symptoms to TB were mentioned as reasons for fewer people being diagnosed with TB. Public health measures could benefit control of both TB and COVID-19, but only if TB diagnostic services remain accessible and are considered safe to attend.Peer reviewe

Pain Assessment in the Emergency Department: A Prospective Videotaped Study

Introduction: Research suggests that pain assessment involves a complex interaction between patients and clinicians. We sought to assess the agreement between pain scores reported by the patients themselves and the clinician’s perception of a patient’s pain in the emergency department (ED). In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment. Methods: We conducted a prospective observational study in the ED of a tertiary academic medical center. Using a standard protocol, trained research personnel prospectively enrolled adult patients who presented to the ED. The entire triage process was recorded, and triage data were collected. Pain scores were obtained from patients on a numeric rating scale of 0 to 10. Five physician raters provided their perception of pain ratings after reviewing videos.  Results: A total of 279 patients were enrolled. The mean age was 53 years. There were 141 (50.5%) female patients. The median self-reported pain score was 4 (interquartile range 0-6). There was a moderately positive correlation between self-reported pain scores and physician ratings of pain (correlation coefficient, 0.46; P <0.001), with a weighted kappa coefficient of 0.39. Some discrepancies were noted: 102 (37%) patients were rated at a much lower pain score, whereas 52 (19%) patients were given a much higher pain score from physician review. The distributions of chief complaints were different between the two groups. Physician raters tended to provide lower pain scores to younger (P = 0.02) and less ill patients (P = 0.008). Additionally, attending-level physician raters were more likely to provide a higher pain score than resident-level raters (P <0.001). Conclusion: Patients’ self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement between the two. Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should consider both patient and physician factors