Accessibility to and utilisation of schistosomiasis-related health services in a rural area of state of Minas Gerais, Brazil

The objective of the present paper was to compare accessibility and utilisation of schistosomiasis diagnostic and treatment services in a small village and the surrounding rural area in northern part of the state of Minas Gerais Brazil. The study included 1,228 individuals: 935 central village residents and 293 rural residents of São Pedro do Jequitinhonha. Schistosoma mansoni infection rates were significantly higher in the central village than in the rural area during a survey in 2007 (44.3% and 23.5%, respectively) and during the 2002 schistosomiasis case-finding campaign (33.1% and 26.5%, respectively) (p < 0.001). However, during the 2002-2006 period, only 23.7% of the villagers and 27% of the rural residents obtained tests on their own from health centres, hospitals and private clinics in various nearby towns. In 2007, 63% of the villagers and 70.5% of the rural residents reported never having received treatment for schistosomiasis. This paper reveals considerable variation in the accessibility and utilisation of schistosomiasis-related health services between the central village and the rural area. A combination of low utilisation rates between 2002-2006 and persistently high S. mansoni infection rates suggest that the schistosomiasis control program must be more rapidly incorporated into the primary health services.

Chlamydia control activities in Europe: cross-sectional survey.

BACKGROUND: Chlamydia is the most commonly reported bacterial sexually transmitted infection in Europe. The objective of the Screening for Chlamydia in Europe (SCREen) project was to describe current and planned chlamydia control activities in Europe. METHODS: The authors sent a questionnaire asking about different aspects of chlamydia epidemiology and control to public health and clinical experts in each country in 2007. The principles of sexually transmitted infection control were used to develop a typology comprising five categories of chlamydia control activities. Each country was assigned to a category, based on responses to the questionnaire. RESULTS: Experts in 29 of 33 (88%) invited countries responded. Thirteen of 29 countries (45%) had no current chlamydia control activities. Six countries in this group stated that there were plans to introduce chlamydia screening programmes. There were five countries (17%) with case management guidelines only. Three countries (10%) also recommended case finding amongst partners of diagnosed chlamydia cases or people with another sexually transmitted infection. Six countries (21%) further specified groups of asymptomatic people eligible for opportunistic chlamydia testing. Two countries (7%) reported a chlamydia screening programme. There was no consistent association between the per capita gross domestic product of a country and the intensity of chlamydia control activities (P = 0.816). CONCLUSION: A newly developed classification system allowed the breadth of ongoing national chlamydia control activities to be described and categorized. Chlamydia control strategies should ensure that clinical guidelines to optimize chlamydia diagnosis and case management have been implemented before considering the appropriateness of screening programmes.

The clinical use of quantitative ultrasound (QUS) in the detection and management of osteoporosis

For the detection and management of osteoporosis and osteoporosis-related fractures, quantitative ultrasound (QUS) is emerging as a relatively low-cost and readily accessible alternative to dual-energy X-ray absorptiometry (DXA) measurement of bone mineral density (BMD) in certain circumstances. The following is a brief, but thorough review of the existing literature with respect to the use of QUS in 6 settings: 1) assessing fragility fracture risk; 2) diagnosing osteoporosis; 3) initiating osteoporosis treatment; 4) monitoring osteoporosis treatment; 5) osteoporosis case finding; and 6) quality assurance and control. Many QUS devices exist that are quite different with respect to the parameters they measure and the strength of empirical evidence supporting their use. In general, heel QUS appears to be most tested and most effective. Overall, some, but not all, heel QUS devices are effective assessing fracture risk in some, but not all, populations, the evidence being strongest for Caucasian females over 55 years old. Otherwise, the evidence is fair with respect to certain devices allowing for the accurate diagnosis of likelihood of osteoporosis, and generally fair to poor in terms of QUS use when initiating or monitoring osteoporosis treatment. A reasonable protocol is proposed herein for case-finding purposes, which relies on a combined assessment of clinical risk factors (CR.F) and heel QUS. Finally, several recommendations are made for quality assurance and control.

Comparación entre los pacientes con diagnóstico clínico de EPOC vs los confirmados por Espirometría en un hospital de segundo nivel en Bogotá DC, 2011

Introducción: La enfermedad pulmonar obstructiva crónica (EPOC), está caracterizada por la limitación del flujo aéreo, de forma progresiva y casi irreversible, asociada a la reacción inflamatoria atribuida a diferentes factores, principalmente a la exposición al humo de tabaco. Es considerada un problema de salud pública en Colombia y en el mundo, con un aumento acelerado de la condición crónica en la actualidad. Objetivo: Identificar las diferencias sociodemográficas, clínicas y de tratamiento, entre los pacientes con diagnóstico clínico y espirométricos de EPOC vs los pacientes con diagnóstico clínico y descartados por espirometría en el Hospital de Suba. Material y Métodos: Estudio observacional, descriptivo, retrospectivo como un componente exploratorio para comparar los grupos con diagnóstico de EPOC clínico y confirmado o descartado por espirometría, entre Enero y Agosto del 2011. Se utilizó estadística descriptiva para calcular las medidas de tendencia central, los datos cuantitativos se expresaron como la media de la variable ± desviación estándar, y los cualitativos como porcentaje, la t de Student para analizar diferencia de las variables cuantitativas de medias entre grupos y la prueba de Pearson para analizar la relación entre los datos cualitativos para aquellos con valores esperados menores a 5 se aplicó test exacto de Fisher, tuvimos en cuenta un α de 0.05 para el análisis bivariado y medidas de asociación. Todos los análisis se realizaron con el paquete estadístico SPSS 19,0 Versión corporativa. Resultados: De los 398 pacientes, solo 287 cumplían con criterios de inclusión. El promedio de edad del total de los pacientes fue de 70,29 + 11,18 años, y 59,5% de la población fue de sexo femenino. Del total de pacientes evaluados, 171 pacientes (59.6%) se descartó el diagnóstico de EPOC (VEF1/ VEC > 0,70). Al comparar los grupos de pacientes a los que se les confirmo el diagnóstico de EPOC contras los descartados por espirometría se encontró que no hay diferencias estadísticamente significativas entre la edad; en los pacientes con EPOC predomino el sexo femenino (p 0.02); en los factores de riesgo existe clara asociación entre EPOC y la exposición a humo de leña (p <0.001), y en cuanto al tabaquismo solo se encontró asociación con ex fumador (p 0,011). Para analizar las diferencias en el tratamiento se estratifico por las posible combinaciones de inhaladores con o sin teofilina, encontrando una diferencia estadísticamente significativa para los tratamientos de tres inhaladores (p 0,015), dos inhaladores + teofilina (p 0,05), tres inhaladores + teofilina (p <0.001), y en los pacientes no tratados (p <0,001).

Búsqueda de caso y diagnóstico temprano en sujetos con sospecha de la EPOC

La enfermedad pulmonar obstructiva crónica es una patología comúnmente sub-diagnosticada. A la fecha no existe ninguna revisión sistemática publicada que evalué la búsqueda de caso (sujetos mayores de 40 años con factores de riesgo sin síntomas) y el diagnóstico temprano (factor de riesgo y síntomas) de la enfermedad. Métodos: Se condujo una revisión sistemática en tres bases de datos (Pubmed, CINAHL, EMBASE) para identificar estudios observacionales que reportaran la prevalencia de la EPOC en diferentes poblaciones expuestas a factores de riesgo (búsqueda de caso) o con factores de riesgo y síntomas (diagnóstico temprano), posteriormente con dichos estudios se calculó una prevalencia ponderada para cada grupo y esta se comparó con la prevalencia reportada en la población general en estudios locales. Así mismo se identificaron estudios para determinar la precisión de estrategias de búsqueda de caso (cuestionarios y el pico flujo espiratorio portátil PiKo 6®) usando la espirometría como patrón de oro para el diagnóstico de la EPOC. Dos autores seleccionaron de forma independiente los estudios que cumplían con los criterios de inclusión y exclusión y se evaluó la calidad metodológica por medio de la estrategia GRADE. El número necesario a tamizar (1/ prevalencia) para diagnosticar un caso de EPOC con espirometría fue calculado para los dos grupos de interés y comparado con el valor conocido de la prevalencia nacional. A los cuestionarios y estudios de Piko 6® se les evaluó las características operativas (VPP, VPN) y se calcularon las probabilidades pos test negativas y positivas teniendo en cuenta la prevalencia ponderada. Resultados Para la estrategia de búsqueda de caso, once estudios cumplieron los criterios de inclusión y la prevalencia ponderada en este grupo fue de 22% con un número necesario a tamizar (NNS) con espirometría de 5, comparado con un NNS de 11 obtenido de la prevalencia de la EPOC en Colombia 8.9% ( IC 95% 8.2-9.7). Posterior a la evaluación critica de varios cuestionarios y estudios de piko 6®, seleccionamos el cuestionario desarrollado por Mullernová y cols y el estudio de Frith y cols respectivamente. El cuestionario validado mostro una probabilidad postest positiva del 56% y postest negativa del 3% con un NNS de 2; para piko 6® los valores correspondientes fueron de 44%, 7% y 2 respectivamente. Para el diagnóstico temprano la prevalencia ponderada fue del 33.9% con un NNS de 3. Conclusiones El número necesario a tamizar para la estrategia de búsqueda de caso con cuestionarios y piko 6® es substancialmente menor que el número necesario a tamizar en la población general. El uso de cuestionarios o de piko 6® disminuye a 2 el NNS en el grupo de búsqueda de caso y a 3 para el grupo de diagnóstico temprano.

A comparison of the active surveillance of scrapie in the European Union

The abattoir and the fallen stock surveys constitute the active surveillance component aimed at improving the detection of scrapie across the European Union. Previous studies have suggested the occurrence of significant differences in the operation of the surveys across the EU. In the present study we assessed the standardisation of the surveys throughout time across the EU and identified clusters of countries with similar underlying characteristics allowing comparisons between them. In the absence of sufficient covariate information to explain the observed variability across countries, we modelled the unobserved heterogeneity by means of non-parametric distributions on the risk ratios of the fallen stock over the abattoir survey. More specifically, we used the profile likelihood method on 2003, 2004 and 2005 active surveillance data for 18 European countries on classical scrapie, and on 2004 and 2005 data for atypical scrapie separately. We extended our analyses to include the limited covariate information available, more specifically, the proportion of the adult sheep population sampled by the fallen stock survey every year. Our results show that the between-country heterogeneity dropped in 2004 and 2005 relative to that of 2003 for classical scrapie. As a consequence, the number of clusters in the last two years was also reduced indicating the gradual standardisation of the surveillance efforts across the EU. The crude analyses of the atypical data grouped all the countries in one cluster and showed non-significant gain in the detection of this type of scrapie by any of the two sources. The proportion of the population sampled by the fallen stock appeared significantly associated with our risk ratio for both types of scrapie, although in opposite directions: negative for classical and positive for atypical. The initial justification for the fallen stock, targeting a high-risk population to increase the likelihood of case finding, appears compromised for both types of scrapie in some countries.

Chlamydia control activities in Europe: cross-sectional survey

Background: Chlamydia is the most commonly reported bacterial sexually transmitted infection in Europe. The objective of the Screening for Chlamydia in Europe (SCREen) project was to describe current and planned chlamydia control activities in Europe. Methods: The authors sent a questionnaire asking about different aspects of chlamydia epidemiology and control to public health and clinical experts in each country in 2007. The principles of sexually transmitted infection control were used to develop a typology comprising five categories of chlamydia control activities. Each country was assigned to a category, based on responses to the questionnaire. Results: Experts in 29 of 33 (88%) invited countries responded. Thirteen of 29 countries (45%) had no current chlamydia control activities. Six countries in this group stated that there were plans to introduce chlamydia screening programmes. There were five countries (17%) with case management guidelines only. Three countries (10%) also recommended case finding amongst partners of diagnosed chlamydia cases or people with another sexually transmitted infection. Six countries (21%) further specified groups of asymptomatic people eligible for opportunistic chlamydia testing. Two countries (7%) reported a chlamydia screening programme. There was no consistent association between the per capita gross domestic product of a country and the intensity of chlamydia control activities (P = 0.816). Conclusion: A newly developed classification system allowed the breadth of ongoing national chlamydia control activities to be described and categorized. Chlamydia control strategies should ensure that clinical guidelines to optimize chlamydia diagnosis and case management have been implemented before considering the appropriateness of screening programmes.

Avoidant coping partially mediates the relationship between patient problem behaviors and depressive symptoms in spousal Alzheimer caregivers

OBJECTIVE: Caring for a loved one with Alzheimer disease is a highly stressful experience that is associated with significant depressive symptoms. Previous studies indicate a positive association between problem behaviors in patients with Alzheimer disease (e.g., repeating questions, restlessness, and agitation) and depressive symptoms in their caregivers. Moreover, the extant literature indicates a robust negative relationship between escape-avoidance coping (i.e., avoiding people, wishing the situation would go away) and psychiatric well-being. The purpose of this study was to test a mediational model of the associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms in Alzheimer caregivers. METHODS: Ninety-five spousal caregivers (mean age: 72 years) completed measures assessing their loved ones' frequency of problem behaviors, escape-avoidance coping, and depressive symptoms. A mediational model was tested to determine if escape-avoidant coping partially mediated the relationship between patient problem behaviors and caregiver depressive symptoms. RESULTS: Patient problem behaviors were positively associated with escape-avoidance coping (beta = 0.38, p < 0.01) and depressive symptoms (beta = 0.26, p < 0.05). Escape-avoidance coping was positively associated with depressive symptoms (beta = 0.33, p < 0.01). In a final regression analysis, the impact of problem behaviors on depressive symptoms was less after controlling for escape-avoidance coping. Sobel's test confirmed that escape-avoidance coping significantly mediated the relationship between problem behaviors and depressive symptoms (z = 2.07, p < 0.05). CONCLUSION: Escape-avoidance coping partially mediates the association between patient problem behaviors and depressive symptoms among elderly caregivers of spouses with dementia. This finding provides a specific target for psychosocial interventions for caregivers.

Human alveolar echinococcosis after fox population increase, Switzerland

We analyzed databases spanning 50 years, which included retrospective alveolar echinococcosis (AE) case finding studies and databases of the 3 major centers for treatment of AE in Switzerland. A total of 494 cases were recorded. Annual incidence of AE per 100,000 population increased from 0.12-0.15 during 1956-1992 and a mean of 0.10 during 1993-2000 to a mean of 0.26 during 2001-2005. Because the clinical stage of the disease did not change between observation periods, this increase cannot be explained by improved diagnosis. Swiss hunting statistics suggested that the fox population increased 4-fold from 1980 through 1995 and has persisted at these higher levels. Because the period between infection and development of clinical disease is long, the increase in the fox population and high Echinococcus multilocularis prevalence rates in foxes in rural and urban areas may have resulted in an emerging epidemic of AE 10-15 years later.

Health risk appraisal in older people 6: factors associated with self-reported poor vision and uptake of eye tests in older people

BACKGROUND Although free eye testing is available in the UK from a nation-wide network of optometrists, there is evidence of unrecognised, tractable vision loss amongst older people. A recent review identified this unmet need as a priority for further investigation, highlighting the need to understand public perceptions of eye services and barriers to service access and utilisation. This paper aims to identify risk factors for (1) having poor vision and (2) not having had an eyesight check among community-dwelling older people without an established ophthalmological diagnosis. METHODS Secondary analysis of self-reported data from the ProAge trial. 1792 people without a known ophthalmological diagnosis were recruited from three group practices in London. RESULTS Almost two in ten people in this population of older individuals without known ophthalmological diagnoses had self-reported vision loss, and more than a third of them had not had an eye test in the previous twelve months. In this sample, those with limited education, depressed mood, need for help with instrumental and basic activities of daily living (IADLs and BADLs), and subjective memory complaints were at increased risk of fair or poor self-reported vision. Individuals with basic education only were at increased risk for not having had an eye test in the previous 12 months (OR 1.52, 95% CI 1.17-1.98 p=0.002), as were those with no, or only one chronic condition (OR 1.850, 95% CI 1.382-2.477, p<0.001). CONCLUSIONS Self-reported poor vision in older people without ophthalmological diagnoses is associated with other functional losses, with no or only one chronic condition, and with depression. This pattern of disorders may be the basis for case finding in general practice. Low educational attainment is an independent determinant of not having had eye tests, as well as a factor associated with undiagnosed vision loss. There are other factors, not identified in this study, which determine uptake of eye testing in those with self-reported vision loss. Further exploration is needed to identify these factors and lead towards effective case finding.

Risk factors for depressed mood amongst a community dwelling older age population in England: cross-sectional survey data from the PRO-AGE study.

BACKGROUND The Quality and Outcomes Framework in the United Kingdom (UK) National Health Service previously highlighted case finding of depression amongst patients with diabetes or coronary heart disease. However, depression in older people remains under-recognized. Comprehensive data for analyses of the association of depression in older age with other health and functional measures, and demographic factors from community populations within England, are lacking. METHODS Secondary analyses of cross-sectional baseline survey data from the England arm of a randomised controlled trial of health risk appraisal for older people in Europe; PRO-AGE study. Data from 1085 community-dwelling non-disabled people aged 65 years or more from three group practices in suburban London contributed to this study. Depressed mood was ascertained from the 5-item Mental Health Inventory Screening test. Exploratory multivariable logistic regression was used to identify the strongest associations of depressed mood with a previous diagnosis of a specified physical/mental health condition, health and functional measures, and demographic factors. RESULTS Depressed mood occurred in 14% (155/1085) of participants. A previous diagnoses of depression (OR 3.39; P < 0.001) and poor vision as determined from a Visual Function Questionnaire (OR 2.37; P = 0.001) were amongst the strongest factors associated with depressed mood that were independent of functional impairment, other co-morbidities, and demographic factors. A subgroup analyses on those without a previous diagnosis of depression also indicated that within this group, poor vision (OR 2.51; P = 0.002) was amongst the strongest independent factors associated with depressed mood. CONCLUSIONS Previous case-finding strategies in primary care focussed on heart disease and diabetes but health-related conditions other than coronary heart disease and diabetes are also associated with an increased risk for depression. Complex issues of multi-morbidity occur within aging populations. 'Risk' factors that appeared stronger than those, such as, diabetes and coronary heart disease that until recently prompted for screening in the UK due to the QOF, were identified, and independent of other morbidities associated with depressed mood. From the health and functional factors investigated, amongst the strongest factors associated with depressed mood was poor vision. Consideration to case finding for depressed mood among older people with visual impairment might be justified.

Modeling the impact of global tuberculosis control strategies

An epidemiological model of tuberculosis has been developed and applied to five regions of the world. Globally, 6.7 million new cases of tuberculosis and 2.4 million deaths from tuberculosis are estimated for 1998. Based on current trends in uptake of the World Health Organization’s strategy of directly observed treatment, short-course, we expect a total of 225 million new cases and 79 million deaths from tuberculosis between 1998 and 2030. Active case-finding by using mass miniature radiography could save 23 million lives over this period. A single contact treatment for tuberculosis could avert 24 million cases and 11 million deaths; combined with active screening, it could reduce mortality by nearly 40%. A new vaccine with 50% efficacy could lower incidence by 36 million cases and mortality by 9 million deaths. Support for major extensions to global tuberculosis control strategies will occur only if the size of the problem and the potential for action are recognized more widely.

Do nations' mental health policies, programs and legislation influence their suicide rates? An ecological study of 100 countries

Objective: To test the hypothesis that the presence of national mental health policies, programs and legislation would be associated with lower national suicide rates. Method: Suicide rates from 100 countries were regressed on mental health policy, program and legislation indicators. Results: Contrary to the hypothesized relationship, the study found that after introducing mental health initiatives (with the exception of substance abuse policies), countries' suicide rates rose. Conclusion: It is of concern that most mental health initiatives are associated with an increase in suicide rates. However, there may be acceptable reasons for the observed findings, for example initiatives may have been introduced in areas of increasing need, or a case-finding effect may be operating. Data limitations must also be considered.