Treatment Outcomes for Adolescents With Multidrug-Resistant Tuberculosis in Lima, Peru

Treatment outcomes for adolescents with multidrug-resistant tuberculosis are rarely reported and, to date, have been poor. Among 90 adolescents from Lima, Peru, 68 (75.6%) achieved cure or completion of treatment. Unsuccessful treatment was less common in the Peru cohort than previously described in the literature

Updating the Leapfrog Group Intensive Care Unit Physician Staffing Standard

Abstract The Leapfrog Group, a consortium of large health care purchasers representing 35 million employees, supports the adoption of 3 proven standards to prevent medical mistakes in hospitals. In this paper, the authors describe the process used to revise Leapfrog's ICU physician staffing standard, including a review of evidence supporting the standard. Primary or secondary authors who published studies that evaluated the effect of increased ICU physician staffing by intensivists on hospital mortality were surveyed. The 8-item telephone survey instrument evaluated hours of intensivist care on weekend and weekdays and pager response times. To revise the standard, comments were compiled, salient issues were identified, revisions were proposed, and evidence review was performed. National advisory panel votes were collected and compiled. Of 19 hospital studies, 100% reported responding to 95% of pages within 5 minutes. Hours of weekend coverage ranged from 1.5 to 24, with a mean of 8 hours. 84% of intensivists were present in the ICU 4 hours per day or more on the weekends, and 42% of intensivists were present 8 hours or more. Hours of weekday coverage ranged from 3 to 24, with a mean of 11 hours. 95% of intensivists were present in the ICU 4 hours or more on the weekday, and 74% of intensivists were present 8 hours or more. Evidence was found in the literature to support the components of the Leapfrog ICU staffing standard and proposed revisions to the standard

Multidrug-resistant tuberculosis treatment failure detection depends on monitoring interval and microbiological method

Debate persists about monitoring method (culture or smear) and interval (monthly or less frequently) during treatment for multidrug-resistant tuberculosis (MDR-TB). We analysed existing data and estimated the effect of monitoring strategies on timing of failure detection. We identified studies reporting microbiological response to MDR-TB treatment and solicited individual patient data from authors. Frailty survival models were used to estimate pooled relative risk of failure detection in the last 12 months of treatment; hazard of failure using monthly culture was the reference. Data were obtained for 5410 patients across 12 observational studies. During the last 12 months of treatment, failure detection occurred in a median of 3 months by monthly culture; failure detection was delayed by 2, 7, and 9 months relying on bimonthly culture, monthly smear and bimonthly smear, respectively. Risk (95% CI) of failure detection delay resulting from monthly smear relative to culture is 0.38 (0.34–0.42) for all patients and 0.33 (0.25–0.42) for HIV-co-infected patients. Failure detection is delayed by reducing the sensitivity and frequency of the monitoring method. Monthly monitoring of sputum cultures from patients receiving MDR-TB treatment is recommended. Expanded laboratory capacity is needed for high-quality culture, and for smear microscopy and rapid molecular tests

Multidrug-Resistant Tuberculosis Treatment Failure Detection Depends on Monitoring Interval and Microbiological Method Multidrug-resistant tuberculosis treatment failure detection depends on monitoring interval and microbiological method behalf of the Col

Citation Multidrug-resistant tuberculosis treatment failure detection depends on monitoring interval and microbiological method. ABSTRACT Debate persists about monitoring method (culture or smear) and interval (monthly or less frequently) during treatment for multidrug-resistant tuberculosis (MDR-TB). We analysed existing data and estimated the effect of monitoring strategies on timing of failure detection. We identified studies reporting microbiological response to MDR-TB treatment and solicited individual patient data from authors. Frailty survival models were used to estimate pooled relative risk of failure detection in the last 12 months of treatment; hazard of failure using monthly culture was the reference. Data were obtained for 5410 patients across 12 observational studies. During the last 12 months of treatment, failure detection occurred in a median of 3 months by monthly culture; failure detection was delayed by 2, 7, and 9 months relying on bimonthly culture, monthly smear and bimonthly smear, respectively. Risk (95% CI) of failure detection delay resulting from monthly smear relative to culture is 0.38 (0.34-0.42) for all patients and 0.33 (0.25-0.42) for HIV-co-infected patients. Failure detection is delayed by reducing the sensitivity and frequency of the monitoring method. Monthly monitoring of sputum cultures from patients receiving MDR-TB treatment is recommended. Expanded laboratory capacity is needed for high-quality culture, and for smear microscopy and rapid molecular tests. @ERSpublications Monthly culture monitoring is crucial to earlier detection of treatment failure in MDR-TB patient

Clinical Information Systems – Seen through the Ethics Lens

Objective: The more people there are who use clinical information systems (CIS) beyond their traditional intramural confines, the more promising the benefits are, and the more daunting the risks will be. This review thus explores the areas of ethical debates prompted by CIS conceptualized as smart systems reaching out to patients and citizens. Furthermore, it investigates the ethical competencies and education needed to use these systems appropriately. Methods: A literature review covering ethics topics in combination with clinical and health information systems, clinical decision support, health information exchange, and various mobile devices and media was performed searching the MEDLINE database for articles from 2016 to 2019 with a focus on 2018 and 2019. A second search combined these keywords with education. Results: By far, most of the discourses were dominated by privacy, confidentiality, and informed consent issues. Intertwined with confidentiality and clear boundaries, the provider-patient relationship has gained much attention. The opacity of algorithms and the lack of explicability of the results pose a further challenge. The necessity of sociotechnical ethics education was underpinned in many studies including advocating education for providers and patients alike. However, only a few publications expanded on ethical competencies. In the publications found, empirical research designs were employed to capture the stakeholders’ attitudes, but not to evaluate specific implementations. Conclusion: Despite the broad discourses, ethical values have not yet found their firm place in empirically rigorous health technology evaluation studies. Similarly, sociotechnical ethics competencies obviously need detailed specifications. These two gaps set the stage for further research at the junction of clinical information systems and ethics

Tumor imaging with monoclonal antibodies

Immunoscintigraphy offers the possibility of specifically targeting human tumors, but the complexity of the human immune system, as well as tumor-related phenomena, prevent monoclonal antibodies from reaching a large number of tumor cells in which they can interact with the antigen. Possible ways to overcome these problems are the use of small fragments, in particular those of genetically engineered humanized antibodies including single immunoglobulin-variable domains, as well as techniques to label the antibody in vivo after a sufficient amount has been taken up by the tumor and the remainder has been eliminated. Despite the low absolute tumor uptake, results of European studies, presently available radiolabeled monoclonal antibodies in gastrointestinal and ovarian cancers yield an average sensitivity of more than 70% with an average specificity of more than 80%, even in otherwise occult tumors. Because of possible tracer uptake in normal liver, the detection rate of liver metastases varies from less than 10% to more than 90%. For the detection of local recurrence in the pelvis, immunoscintigraphy has been found to be more accurate than methods that are based on the imaging of structural changes. Fusion of morphological and functional images might improve the early detection of recurrent and metastatic disease. In melanoma, another tumor that has been extensively studied in Europe, similar results have been obtained, whereas only few data are presently available for other tumors (especially lung and breast cancer)