Upper gastro - intestinal haemorrhage.

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Use of chest radiography in patients suspected of pulmonary tuberculosis

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Medical kaleidoscope

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Unusual cause of coma

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The timing of death in patients with tuberculosis who die during anti-tuberculosis treatment in Andhra Pradesh, South India

Background: India has 2.0 million estimated tuberculosis (TB) cases per annum with an estimated 280,000 TBrelated deaths per year. Understanding when in the course of TB treatment patients die is important for determining the type of intervention to be offered and crucially when this intervention should be given. The objectives of the current study were to determine in a large cohort of TB patients in India:- i) treatment outcomes including the number who died while on treatment, ii) the month of death and iii) characteristics associated with “early” death, occurring in the initial 8 weeks of treatment. Methods: This was a retrospective study in 16 selected Designated Microscopy Centres (DMCs) in Hyderabad, Krishna and Adilabad districts of Andhra Pradesh, South India. A review was performed of treatment cards and medical records of all TB patients (adults and children) registered and placed on standardized anti-tuberculosis treatment from January 2005 to September 2009. Results: There were 8,240 TB patients (5183 males) of whom 492 (6%) were known to have died during treatment. Case-fatality was higher in those previously treated (12%) and lower in those with extra-pulmonary TB (2%). There was an even distribution of deaths during anti-tuberculosis treatment, with 28% of all patients dying in the first 8 weeks of treatment. Increasing age and new as compared to recurrent TB disease were significantly associated with “early death”. Conclusion: In this large cohort of TB patients, deaths occurred with an even frequency throughout anti-TB treatment. Reasons may relate to i) the treatment of the disease itself, raising concerns about drug adherence, quality of anti-tuberculosis drugs or the presence of undetected drug resistance and ii) co-morbidities, such as HIV/ AIDS and diabetes mellitus, which are known to influence mortality. More research in this area from prospective and retrospective studies is needed

Operational research in Malawi: making a difference with cotrimoxazole preventive therapy in patients with tuberculosis and HIV.

BACKGROUND: In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions. DISCUSSION: District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART. SUMMARY: Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not

Lumbar puncture in acute admissions to an adult medical ward

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The effects of placing an operational research fellow within the Viet Nam National Tuberculosis Programme.

In April 2009, an operational research fellow was placed within the Viet Nam National Tuberculosis Control Programme (NTP). Over the 6 years from 2010 to 2015, the OR fellow co-authored 21 tuberculosis research papers (as principal author in 15 [71%]). This constituted 23% of the 91 tuberculosis papers published in Viet Nam during this period. Of the 21 published papers, 16 (76%) contributed to changes in policy (n = 8) and practice (n = 8), and these in turn improved programme performance. Many papers also contributed important evidence for better programme planning. Highly motivated OR fellows embedded within NTPs can facilitate high-quality research and research uptake

Should Kiribati continue to aim for 100% voluntary non-remunerated blood donation as recommended by the WHO?

Setting: Tungaru Central Hospital Blood Bank Laboratory, Nawerewere, Tarawa, Kiribati. Objective: To determine characteristics, deferrals and reasons for deferral amongst blood donors from 2011 to 2016. Design: A cross-sectional study using routinely collected data. Results: From January 2011 to March 2016, 8531 potential blood donors were registered. For each full year, the proportion of voluntary non-remunerated blood donors (VNRBD) was below 10%, although it increased to 13% in 2015. The overall proportion of blood donors deferred increased each year over the 5-year period, from 44% to 57%, with similar increases in deferrals in VNRBD and family replacement donors (FRD). Among all blood donors, a higher proportion of females than males (59% vs. 43%) and VNRBD than FRD (56% vs. 44%) were deferred (P < 0.001). Deferrals were due to 1) failing the medical questionnaire (53%), 2) having anaemia and/or high white cell count (26%), or 3) transfusion-transmissible infections (21%). More VNRBD were deferred due to failing the medical questionnaire, while more FRD were deferred due to anaemia and/or high white-cell count; the number of deferrals was similar for transfusion-transmissible infections. Conclusion: This 5-year study showed that the proportion of VNRBD is low and deferrals are higher for this group than for FRD. There is a strong case for encouraging both types of donor in the country

HIV and tuberculosis--science and implementation to turn the tide and reduce deaths.

INTRODUCTION: Every year, HIV-associated tuberculosis (TB) deprives 350,000 mainly young people of productive and healthy lives.People die because TB is not diagnosed and treated in those with known HIV infection and HIV infection is not diagnosed in those with TB. Even in those in whom both HIV and TB are diagnosed and treated, this often happens far too late. These deficiencies can be addressed through the application of new scientific evidence and diagnostic tools. DISCUSSION: A strategy of starting antiretroviral therapy (ART) early in the course of HIV infection has the potential to considerably reduce both individual and community burden of TB and needs urgent evaluation for efficacy, feasibility and broader social and economic impact. Isoniazid preventive therapy can reduce the risk of TB and, if given strategically in addition to ART, provides synergistic benefit. Intensified TB screening as part of the "Three I's" strategy should be conducted at every clinic, home or community-based attendance using a symptoms-based algorithm, and new diagnostic tools should increasingly be used to confirm or refute TB diagnoses. Until such time when more sensitive and specific TB diagnostic assays are widely available, bolder approaches such as empirical anti-TB treatment need to be considered and evaluated. Patients with suspected or diagnosed TB must be screened for HIV and given cotrimoxazole preventive therapy and ART if HIV-positive. Three large randomized trials provide conclusive evidence that ART initiated within two to four weeks of start of anti-TB treatment saves lives, particularly in those with severe immunosuppression. The key to ensuring that these collaborative activities are delivered is the co-location and integration of TB and HIV services within the health system and the community. CONCLUSIONS: Progress towards reducing HIV-associated TB deaths can be achieved through attention to simple and deliverable actions on the ground