Methodological standards in non-inferiority AIDS trials: moving from adherence to compliance: Response

A response to Parienti JJ, Verdon R and Massari V: Methodological standards in non-inferiority AIDS trials: moving from adherence to compliance. BMC Med Res Meth 2006, 6:4

Malnutrition: More that the eye can see

Objectives: To assess the magnitude of malnutrition in a hospital setting and to relate anthropometric measures to the clinical diagnosis of malnutrition.Design: A descriptive study whereby anthropometric measures (length and weight) were taken of every child under the age of five years who was admitted to the hospital. The anthropometric data were analysed using the EPI-Info statistical package, which calculates z-scores for weight-for-age, weight-for-height and height-for-age. As reference curve, the reference growth curves of the NCHS were used. Of all the children who were classified as being malnourished, it was recorded if the clinical diagnosis of malnutrition was made at the time of admission or during the hospital stay.Setting: Misikhu Mission Hospital, western Kenya.Subjects: Every child under the age of five years who was admitted to the hospital, was eligible to enter the study. The data of 1130 children were used. The data of 40 other children who were admitted in this period were not complete and could therefore not be used.Results: An overall percentage for malnutrition of 44.3 was found. Only fourteen per cent of the malnourished children were clinically diagnosed as having malnutrition.Conclusion: Anthropometric measures are an easy, but time-consuming way of identifying children with malnutrition, it identifies more children with malnutrition than clinical diagnosis alone. Therefore it should be considered to implement standardised anthropometry in a hospital setting

Behavioral public performance: making effective use of metrics about government activity

Oliver James, Donald Moynihan, Asmus Olsen and Gregg van Ryzin discuss how insights from behavioural science show the way managers, politicians and citizens make sense of, and act on, information about government performance

Response to highly active antiretroviral therapy among severely immuno-compromised HIV-infected patients in Cambodia.

BACKGROUND: HAART efficacy was evaluated in a real-life setting in Phnom Penh (Médecins Sans Frontières programme) among severely immuno-compromised patients. METHODS: Factors associated with mortality and immune reconstitution were identified using Cox proportional hazards and logistic regression models, respectively. RESULTS: From July 2001 to April 2005, 1735 patients initiated HAART, with median CD4 cell count of 20 (inter-quartile range, 6-78) cells/microl. Mortality at 2 years increased as the CD4 cell count at HAART initiation decreased, (4.4, 4.5, 7.5 and 24.7% in patients with CD4 cell count > 100, 51-100, 21-50 and < or = 20 cells/microl, respectively; P < 10). Cotrimoxazole and fluconazole prophylaxis were protective against mortality as long as CD4 cell counts remained < or = 200 and < or = 100 cells/microl, respectively. The proportion of patients with successful immune reconstitution (CD4 cell gain > 100 cells/microl at 6 months) was 46.3%; it was lower in patients with previous ART exposure [odds ratio (OR), 0.16; 95% confidence interval (CI), 0.05-0.45] and patients developing a new opportunistic infection/immune reconstitution infection syndromes (OR, 0.71; 95% CI, 0.52-0.98). Similar efficacy was found between the stavudine-lamivudine-nevirapine fixed dose combination and the combination stavudine-lamivudine-efavirenz in terms of mortality and successful immune reconstitution. No surrogate markers for CD4 cell change could be identified among total lymphocyte count, haemoglobin, weight and body mass index. CONCLUSION: Although CD4 cell count-stratified mortality rates were similar to those observed in industrialized countries for patients with CD4 cell count > 50 cells/microl, patients with CD4 cell count < or = 20 cells/microl posed a real challenge to clinicians. Widespread voluntary HIV testing and counselling should be encouraged to allow HAART initiation before the development of severe immuno-suppression

Implementation and effect of intensified case finding on diagnosis of tuberculosis in a large urban HIV clinic in Uganda: a retrospective cohort study.

BACKGROUND: Increased detection of tuberculosis (TB) using intensified or active case finding (ICF) is one of the cornerstones of the Stop TB Strategy, and contrasts with passive case finding (PCF) which relies on self-reported symptoms. There is no clear guidance on implementation strategies. We implemented ICF in addition to ongoing PCF in our large urban HIV clinic in July 2010 using a twice-daily announcement screen method by a trained peer educator, asking waiting patients to self-refer to a trained peer supporter for screening of TB symptoms. We sought to determine the associated effect on TB case detection. METHODS: Suspects were investigated by sputum smear, chest X-ray and ultrasound, if indicated. Routinely collected clinical and laboratory data were merged with the ICF register and TB clinic data for patients attending the clinic in 2010. We compared the yield of TB cases (defined as the prevalence of newly diagnosed TB cases in the screened population), the type of TB diagnosed and the total cost per TB case identified (in United States Dollars [USD]) for the period before and after ICF implementation. RESULTS: Of the 20,456 patients who visited the clinic in 2010, 614 were identified as TB suspects, 220 pre-ICF and 394 post-ICF (229 via PCF and 165 via ICF). The proportion diagnosed with TB dropped from 66% to 48% (60% in suspects identified through PCF and 31% through ICF). During the post-ICF period, TB suspects identified through ICF compared to PCF identification were more likely to be female, older, on ART and to have been enrolled in HIV care for a longer duration. The yield of combined PCF and ICF screening was 1.4% pre-ICF and 1.7% post-ICF with a cost per TB case identified of 12.29 USD and 21.80 USD, respectively. CONCLUSIONS: Implementation of ICF in a large HIV clinic yielded more TB suspects and cases, but substantially increased costs and was unable to capture the majority of TB suspects who were referred for diagnosis by clinicians through PCF. The overall yield of TB cases in a mature HIV clinic was low, although targeted screening of those recently enrolled in care may increase the yield