Reminder systems to improve patient adherence to tuberculosis clinic appointments for diagnosis and treatment

Background People with active tuberculosis (TB) require six months of treatment. Some people find it difficult to complete treatment, and there are several approaches to help ensure completion. One such system relies on reminders, where the health system prompts patients to attend for appointments on time, or re-engages people who have missed or defaulted on a scheduled appointment. Objectives To assess the effects of reminder systems on improving attendance at TB diagnosis, prophylaxis, and treatment clinic appointments, and their effects on TB treatment outcomes. Search methods We searched the Cochrane Infectious Diseases Group Specialized Register, Cochrane Effective Practice and Organization of Care Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, SCI-EXPANDED, SSCI, mRCT, and the Indian Journal of Tuberculosis without language restriction up to 29 August 2014. We also checked reference lists and contacted researchers working in the field. Selection criteria Randomized controlled trials (RCTs), including cluster RCTs and quasi-RCTs, and controlled before-and-after studies comparing reminder systems with no reminders or an alternative reminder system for people with scheduled appointments for TB diagnosis, prophylaxis, or treatment. Data collection and analysis Two review authors independently extracted data and assessed the risk of bias in the included trials. We compared the effects of interventions by using risk ratios (RR) and presented RRs with 95% confidence intervals (CIs). Also we assessed the quality of evidence using the GRADE approach. Main results Nine trials, including 4654 participants, met our inclusion criteria. Five trials evaluated appointment reminders for people on treatment for active TB, two for people on prophylaxis for latent TB, and four for people undergoing TB screening using skin tests. We classified the interventions into 'pre-appointment' reminders (telephone calls or letters prior to a scheduled appointment) or 'default' reminders (telephone calls, letters, or home visits to people who had missed an appointment). For people being treated for active TB, clinic attendance and TB treatment completion were higher in people receiving pre-appointment reminder phone-calls (clinic attendance: 66% versus 50%; RR 1.32, 95% CI 1.10 to 1.59, one trial (USA), 615 participants, low quality evidence; TB treatment completion: 100% versus 88%; RR 1.14, 95% CI 1.02 to 1.27, one trial (Thailand), 92 participants, low quality evidence). Clinic attendance and TB treatment completion were also higher with default reminders (letters or home visits) (clinic attendance: 52% versus 10%; RR 5.04, 95% CI 1.61 to 15.78, one trial (India), 52 participants, low quality evidence; treatment completion: RR 1.17, 95% CI 1.11 to 1.24, two trials (Iraq and India), 680 participants, moderate quality evidence). For people on TB prophylaxis, clinic attendance was higher with a policy of pre-appointment phone-calls (63% versus 48%; RR 1.30, 95% CI 1.07 to 1.59, one trial (USA), 536 participants); and attendance at the final clinic was higher with regular three-monthly phone-calls or nurse visits (93% versus 65%, one trial (Spain), 318 participants). For people undergoing screening for TB, three trials of pre-appointment phone-calls found little or no effect on the proportion of people returning to clinic for the result of their skin test (three trials, 1189 participants, low quality evidence), and two trials found little or no effect with take home reminder cards (two trials, 711 participants). All four trials were conducted among healthy volunteers in the USA. Authors' conclusions Policies of sending reminders to people pre-appointment, and contacting people who miss appointments, seem sensible additions to any TB programme, and the limited evidence available suggests they have small but potentially important benefits. Future studies of modern technologies such as short message service (SMS) reminders would be useful, particularly in low-resource settings

ACE and non-ACE pathways in the renal vascular response to RAS interruption in type 1 diabetes mellitus

ACE and non-ACE pathways in the renal vascular response to RAS interruption in type 1 diabetes mellitus.BackgroundThe enormous contribution of renin-angiotensin system (RAS) interruption with ACE (angiotensin-converting enzyme) inhibitors and angiotensin II receptor blockers (ARB) in the treatment of diabetic nephropathy has led to interest in the factors involved in angiotensin II (Ang II) generation. In normal subjects, RAS interruption using an ARB produced a 50% greater renal plasma flow (RPF) rise than with an ACE inhibitor, suggesting a substantial contribution of non-ACE pathways. Moreover, immunohistochemistry studies in kidneys of overtly proteinuric diabetic subjects showed up-regulation of chymase, an alternative Ang II-generating enzyme. Our aim was to determine the degree to which the non-ACE pathways contribute to RAS activation in type 1 diabetes mellitus (DM).MethodsType 1DM patients (N = 37, 14 M/23 F; age 31 ± 2 years; DM duration 16 ± 1.7 years; HbA1c 7.7.0 ± 0.3%) were studied on a high-salt diet. They received captopril 25mg po one day and candesartan 16mg po the next day. RPF and glomerular filtration rate (GFR) were measured before and up to 4 hours after drug administration.ResultsBoth captopril and candesartan induced a significant rise in RPF (baseline vs. peak <0.0001 for both), and the rise was concordant for the 2 drugs (r = 0.77,P < 0.001). However, the RPF responses were not significantly different between the 2 drugs (captopril 72 ± 11mL/min/1.73m2, candesartan 75 ± 12,P = 0.841).ConclusionIn predominantly normoalbuminuric, normotensive type 1 DM, activation of the intrarenal RAS reflects a mechanism involving primarily the classic ACE pathway

Is traumatic stress research global? A bibliometric analysis.

BACKGROUND: The representation of low- and middle-income countries (LMIC) in traumatic stress research is important to establish a global evidence base, build research capacity, and reduce the burden of unmet mental health needs around the world. Reviews of the traumatic stress literature up to 2002 showed trends toward globalization although LMIC were only marginally represented compared to high-income countries (HIC). OBJECTIVE: To examine the global nature of current traumatic stress research. In particular, we were interested in the extent to which traumatic stress research is: (1) conducted in LMIC, (2) conducted by LMIC researchers, and (3) accessible to them. METHOD: Using the databases PubMed, PsychInfo, and PILOTS, we systematically searched for peer-reviewed articles on traumatic stress published in any language in the year 2012. Out of the 3,123 unique papers identified, we coded a random sample (N=1,000) for study, author, article, and journal characteristics. RESULTS: Although our sample involved research in 56 different countries, most papers (87%) involved research in HIC, with 51% of all papers describing studies in the United States. In 88% of the papers, the author team was affiliated with HIC only. Less than 5% of all author teams involved collaborations between HIC and LMIC researchers. Moreover, 45% of the articles on LMIC studies published by a HIC corresponding author did not involve any LMIC co-authors. LMIC researchers appeared to publish empirical studies in lower impact journals. Of the 1,000 articles in our sample, 32% were open access and 10% were made available via different means; over half of the papers were not accessible without subscription. CONCLUSIONS: Traumatic stress research is increasingly global but still strongly dominated by HIC. Important opportunities to build capacity in LMIC appear to be missed. Implications toward more international traumatic stress research are discussed

Nonprescribed Antimicrobial Drugs in Latino Community, South Carolina

We investigated in a sample of Latinos the practices of antimicrobial drug importation and use of nonprescribed antimicrobial drugs. In interviews conducted with 219 adults, we assessed health beliefs and past and present behaviors consistent with acquiring antimicrobial drugs without a prescription in the United States. Many (30.6%) believed that antimicrobial drugs should be available in the United States without a prescription. Furthermore, 16.4% had transported nonprescribed antimicrobial drugs into the United States, and 19.2% had acquired antimicrobial agents in the United States without a prescription. A stepwise logistic regression analysis showed that the best predictors of having acquired nonprescribed antimicrobial drugs in the United States were beliefs and behavior consistent with limited regulations on such drugs. Many persons within the Latino community self-medicate with antimicrobial drugs obtained without a prescription both inside and outside the United States, which adds to the reservoir of antimicrobial drugs in the United States

Context-led capacity building in time of crisis: fostering non-communicable diseases (NCD) research skills in the Mediterranean Middle East and North Africa.

BACKGROUND: This paper examines one EC-funded multinational project (RESCAP-MED), with a focus on research capacity building (RCB) concerning non-communicable diseases (NCDs) in the Mediterranean Middle East and North Africa. By the project's end (2015), the entire region was engulfed in crisis. OBJECTIVE: Designed before this crisis developed in 2011, the primary purpose of RESCAP-MED was to foster methodological skills needed to conduct multi-disciplinary research on NCDs and their social determinants. RESCAP-MED also sought to consolidate regional networks for future collaboration, and to boost existing regional policy engagement in the region on the NCD challenge. This analysis examines the scope and sustainability of RCB conducted in a context of intensifying political turmoil. METHODS: RESCAP-MED linked two sets of activities. The first was a framework for training early- and mid-career researchers through discipline-based and writing workshops, plus short fellowships for sustained mentoring. The second integrated public-facing activities designed to raise the profile of the NCD burden in the region, and its implications for policymakers at national level. Key to this were two conferences to showcase regional research on NCDs, and the development of an e-learning resource (NETPH). RESULTS: Seven discipline-based workshops (with 113 participants) and 6 workshops to develop writing skills (84 participants) were held, with 18 fellowship visits. The 2 symposia in Istanbul and Beirut attracted 280 participants. Yet the developing political crisis tagged each activity with a series of logistical challenges, none of which was initially envisaged. The immediacy of the crisis inevitably deflected from policy attention to the challenges of NCDs. CONCLUSIONS: This programme to strengthen research capacity for one priority area of global public health took place as a narrow window of political opportunity was closing. The key lessons concern issues of sustainability and the paramount importance of responsively shaping a context-driven RCB

European and Developing Countries Clinical Trials Partnership (EDCTP): the path towards a true partnership

European and Developing Countries Clinical Trials Partnership (EDCTP) was founded in 2003 by the European Parliament and Council. It is a partnership of 14 European Union (EU) member states, Norway, Switzerland, and Developing Countries, formed to fund acceleration of new clinical trial interventions to fight the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS), malaria and tuberculosis (TB) in the sub-Saharan African region. EDCTP seeks to be synergistic with other funding bodies supporting research on these diseases. EDCTP promotes collaborative research supported by multiple funding agencies and harnesses networking expertise across different African and European countries. EDCTP is different from other similar initiatives. The organisation of EDCTP blends important aspects of partnership that includes ownership, sustainability and responds to demand-driven research. The Developing Countries Coordinating Committee (DCCC); a team of independent scientists and representatives of regional health bodies from sub-Saharan Africa provides advice to the partnership. Thus EDCTP reflects a true partnership and the active involvement and contribution of these African scientists ensures joint ownership of the EDCTP programme with European counterparts. The following have been the major achievements of the EDCTP initiative since its formation in 2003; i) increase in the number of participating African countries from two to 26 in 2008 ii) the cumulative amount of funds spent on EDCTP projects has reached 150 m euros, iii) the cumulative number of clinical trials approved has reached 40 and iv) there has been a significant increase number and diversity in capacity building activities. While we recognise that EDCTP faced enormous challenges in its first few years of existence, the strong involvement of African scientists and its new initiatives such as unconditional funding to regional networks of excellence in sub-Saharan Africa is envisaged to lead to a sustainable programme. Current data shows that the number of projects supported by EDCTP is increasing. DCCC proposes that this success story of true partnership should be used as model by partners involved in the fight against other infectious diseases of public health importance in the region

Developing capacity in health informatics in a resource poor setting: lessons from Peru

The public sectors of developing countries require strengthened capacity in health informatics. In Peru, where formal university graduate degrees in biomedical and health informatics were lacking until recently, the AMAUTA Global Informatics Research and Training Program has provided research and training for health professionals in the region since 1999. The Fogarty International Center supports the program as a collaborative partnership between Universidad Peruana Cayetano Heredia in Peru and the University of Washington in the United States of America. The program aims to train core professionals in health informatics and to strengthen the health information resource capabilities and accessibility in Peru. The program has achieved considerable success in the development and institutionalization of informatics research and training programs in Peru. Projects supported by this program are leading to the development of sustainable training opportunities for informatics and eight of ten Peruvian fellows trained at the University of Washington are now developing informatics programs and an information infrastructure in Peru. In 2007, Universidad Peruana Cayetano Heredia started offering the first graduate diploma program in biomedical informatics in Peru

Institutional capacity for health systems research in East and Central African Schools of Public Health: strengthening human and financial resources

BACKGROUND: Despite its importance in providing evidence for health-related policy and decision-making, an insufficient amount of health systems research (HSR) is conducted in low-income countries (LICs). Schools of public health (SPHs) are key stakeholders in HSR. This paper, one in a series of four, examines human and financial resources capacities, policies and organizational support for HSR in seven Africa Hub SPHs in East and Central Africa. METHODS: Capacity assessment done included document analysis to establish staff numbers, qualifications and publications; self-assessment using a tool developed to capture individual perceptions on the capacity for HSR and institutional dialogues. Key informant interviews (KIIs) were held with Deans from each SPH and Ministry of Health and non-governmental officials, focusing on perceptions on capacity of SPHs to engage in HSR, access to funding, and organizational support for HSR. RESULTS: A total of 123 people participated in the self-assessment and 73 KIIs were conducted. Except for the National University of Rwanda and the University of Nairobi SPH, most respondents expressed confidence in the adequacy of staffing levels and HSR-related skills at their SPH. However, most of the researchers operate at individual level with low outputs. The average number of HSR-related publications was only <1 to 3 per staff member over a 6-year period with most of the publications in international journals. There is dependency on external funding for HSR, except for Rwanda, where there was little government funding. We also found that officials from the Ministries of Health often formulate policy based on data generated through ad hoc technical reviews and consultancies, despite their questionable quality. CONCLUSIONS: There exists adequate skilled staff for HSR in the SPHs. However, HSR conducted by individuals, fuelled by Ministries’ of Health tendency to engage individual researchers, undermines institutional capacity. This study underscores the need to form effective multidisciplinary teams to enhance research of immediate and local relevance. Capacity strengthening in the SPH needs to focus on knowledge translation and communication of findings to relevant audiences. Advocacy is needed to influence respective governments to allocate adequate funding for HSR to avoid donor dependency that distorts local research agenda.DFI