Summary Background China scaled up a tuberculosis control programme (based on the directly observed treatment, short-course DOTS strategy) to cover half the population during the 1990s, and to the ...entire population after 2000. We assessed the effect of the programme. Methods In this longitudinal analysis, we compared data from three national tuberculosis prevalence surveys done in 1990, 2000, and 2010. The 2010 survey screened 252 940 eligible individuals aged 15 years and older at 176 investigation points, chosen by stratified random sampling from all 31 mainland provinces. All individuals had chest radiographs taken. Those with abnormal radiographs, persistent cough, or both, were classified as having suspected tuberculosis. Tuberculosis was diagnosed by chest radiograph, sputum-smear microscopy, and culture. Trained staff interviewed each patient with tuberculosis. The 1990 and 2000 surveys were reanalysed and compared with the 2010 survey. Findings From 1990 to 2010, the prevalence of smear-positive tuberculosis decreased from 170 cases (95% CI 166–174) to 59 cases (49–72) per 100 000 population. During the 1990s, smear-positive prevalence fell only in the provinces with the DOTS programme; after 2000, prevalence decreased in all provinces. The percentage reduction in smear-positive prevalence was greater for the decade after 2000 than the decade before (57% vs 19%; p<0·0001). 70% of the total reduction in smear-positive prevalence (78 of 111 cases per 100 000 population) occurred after 2000. Of these cases, 68 (87%) were in known cases—ie, cases diagnosed with tuberculosis before the survey. Of the known cases, the proportion treated by the public health system (using the DOTS strategy) increased from 59 (15%) of 370 cases in 2000 to 79 (66%) of 123 cases in 2010, contributing to reduced proportions of treatment default (from 163 43% of 370 cases to 35 22% of 123 cases) and retreatment cases (from 312 84% of 374 cases to 48 31% of 137 cases; both p<0·0001). Interpretation In 20 years, China more than halved its tuberculosis prevalence. Marked improvement in tuberculosis treatment, driven by a major shift in treatment from hospitals to the public health centres (that implemented the DOTS strategy) was largely responsible for this epidemiological effect. Funding Chinese Ministry of Health.
Summary Infectious diseases remain the major causes of morbidity and mortality in China despite substantial progress in their control. China is a major contributor to the worldwide infectious disease ...burden because of its population size. The association of China with the rest of the world through travel and trade means that events in the country can affect distant populations. The ecological interaction of people with animals in China favours the emergence of new microbial threats. The public-health system has to be prepared to deal with the challenges of newly emerging infectious diseases and at the same time try to control existing diseases. To address the microbial threats, such as severe acute respiratory syndrome, the government has committed substantial resources to the implementation of new strategies, including the development of a real-time monitoring system as part of the infectious-disease surveillance. This strategy can serve as a model for worldwide surveillance and response to threats from infectious diseases.
Summary Background China has a quarter of all patients with multidrug-resistant tuberculosis (MDRTB) worldwide, but less than 5% are in quality treatment programmes. In a before-and-after study we ...aimed to assess the effect of a comprehensive programme to provide universal access to diagnosis, treatment, and follow-up for MDRTB in four Chinese cities (population 18 million). Methods We designated city-level hospitals in each city to diagnose and treat MDRTB. All patients with smear-positive pulmonary tuberculosis diagnosed in Center for Disease Control (CDC) clinics and hospitals were tested for MDRTB with molecular and conventional drug susceptibility tests. Patients were treated with a 24 month treatment package for MDRTB based on WHO guidelines. Outpatients were referred to the CDC for directly observed therapy. We capped total treatment package cost at US$4644. Insurance reimbursement and project subsidies limited patients' expenses to 10% of charges for services within the package. We compared data from a 12 month programme period (2011) to those from a retrospective survey of all patients with MDRTB diagnosed in the same cities during a baseline period (2006–09). Findings 243 patients were diagnosed with MDRTB or rifampicin-resistant tuberculosis during the 12 month programme period compared with 92 patients (equivalent to 24 per year) during the baseline period. 172 (71%) of 243 individuals were enrolled in the programme. Time from specimen collection for resistance testing to treatment initiation decreased by 90% (from median 139 days IQR 69–207 to 14 days 10–21), the proportion of patients who started on appropriate drug regimen increased 2·7 times (from nine 35% of 26 patients treated to 166 97% of 172), and follow-up by the CDC after initial hospitalisation increased 24 times (from one 4% of 23 patients to 163 99% of 164 patients). 6 months after starting treatment, the proportion of patients remaining on treatment increased ten times (from two 8% of 26 patients to 137 80% of 172), and 116 (67%) of 172 patients in the programme period had negative cultures or clinical–radiographic improvement. Patients' expenses for hospital admission after MDRTB diagnosis decreased by 78% (from $796 to $174), reducing the ratio of patients' expenses to annual household income from 17·6% to 3·5% (p<0·0001 for all comparisons between baseline and programme periods). However, 36 (15%) patients did not start or had to discontinue treatment in the programme period because of financial difficulties. Interpretation This comprehensive programme substantially increased access to diagnosis, quality treatment, and affordable treatment for MDRTB. The programme could help China to achieve universal access to MDRTB care but greater financial risk protection for patients is needed. Funding Bill & Melinda Gates Foundation.
Objective Controversies regarding the safety, morbidity, and mortality of thoracoscopic lobectomy have prevented the widespread acceptance of the procedure. This series analyzed the safety, pain, ...analgesic use, and discharge disposition in patients who underwent thoracoscopic lobectomy and segmentectomy at a single institution. Methods We collected data from 153 consecutive patients who underwent thorascopic (video-assisted thoracic surgery) lobectomy and assessed the perioperative outcomes, postoperative pain, and chemotherapy course. A total of 111 of 127 patients with lung cancer had stage I non–small cell lung cancer. The operative technique required 2 ports and an access incision (5–8 cm), individual hilar ligation, and lymph node dissection performed without rib-spreading devices. Results There were 9 major complications (6%), including 1 perioperative death (0.7%). Conversion to thoracotomy occurred in 14 patients (9.2%). Blood transfusion was required in 11 patients (7%). The median chest tube time was 3 days, and the length of hospital stay was 4 days; 94.4% of patients went home at the time of discharge, and 5.6% of patients required a rehabilitation facility. At a median postsurgical follow-up time of 2 weeks, the mean postoperative pain score was 0.6 (0–3), 73% of patients did not use narcotics for pain control, and 47% of patients did not use any pain medication. Of patients receiving chemotherapy (N = 26), 73% completed a full course on schedule and 85% received all intended cycles. Conclusion Thoracoscopic (video-assisted thoracic surgery) lobectomy can be performed safely. Discharge independence and low pain estimates in the early postoperative period suggest that this approach may be beneficial. Furthermore, there is a trend toward improved tolerance of chemotherapy.
Background Although the procedure is generally safe, significant morbidity and even mortality have occurred after laparoscopic donor nephrectomy (LDN). The learning curves for both surgeons and ...institutions with LDN have not been well delineated, and longterm donor data are not well reported. Study Design A retrospective study of the initial 512 patients undergoing LDN performed at Mount Sinai Medical Center between October 1996 and March 2006 was performed. Intraoperative and immediate postoperative surgical outcomes were reviewed. Univariate analysis and multivariate logistic regressions were performed to identify predictors of outcomes, including the experience level of individual surgeons and of the institution. Longitudinal followup data of donor patients between 1 month and 9 years were obtained. Results Mean donor age was 39.2 years, and 54.6% of patients were women. Left kidneys were procured in 84.0%. Operative time averaged 215.2 minutes, and warm ischemia time, 166.6 seconds. The conversion rate was 1.4%, and hand-assistance was used in 49.9%. The intraoperative complication rate was 5.5%, 30-day complication rate 9.4%, and 1.4% of patients required reoperation. Immediate graft survival was 97.1%, acute tubular necrosis occurred in 8.5%, and delayed graft function in 3.7%. At a mean followup of 37.2 months, delayed donor complications were infrequent, but included chronic pain, hypertension, incisional hernia, and small bowel obstruction. Although individual surgeons and our institution gained experience, operative and warm ischemia times decreased significantly, but complication rates were unchanged. Conclusions Although a learning curve was discovered for operative time and warm ischemia time, excellent results can be achieved during the early experience of both surgeons and institutions with LDN, and maintained over time. Younger, female, and nonobese donors were associated with fewer complications. Longterm donor morbidity is uncommon, but mandates better followup.
Abstract Objective Documentation of quality measures (QMs) in rheumatoid arthritis (RA) is used as a surrogate for measure of quality of care, but the association of this documentation with ...radiographic outcomes is uncertain. We examined documentation of RA QMs, for disease activity and functional status and the association with radiographic outcomes. Methods Data were analyzed for 438 RA patients in a longitudinal cohort with complete data on van der Heijde-modified Total Sharp Score (TSS). All rheumatologist ( N = 18) notes in the electronic medical record during a 24-month period were reviewed for RA QMs. Any mention of disease activity categorized as low, moderate, or high was considered documentation of the QM for disease activity. Functional status QM documentation included any mention of the impact of RA on function. Change in TSS was quantified with progression defined as ≥1 unit per year. We compared percent of visits with an RA QM documented and mean change in TSS. Results The mean age in the cohort was 56.9 years, disease duration was 10.8 years, baseline DAS28 score was 3.8 (±1.6), 67.7% were seropositive, and 33.9% used a biologic DMARD. Radiographic progression was observed in 28.5%. Disease activity was documented for 29.0% of patient visits and functional status in 74.7%; neither had any significant relationship to mean TSS change (both P > 0.10). Conclusion The documentation of RA QMs was infrequent and not associated with radiographic outcomes over 24 months.
To compare the optical biometry measurements and intraocular lens (IOL) power estimation using the IOLMaster (Carl Zeiss Meditec, Dublin, CA) in phakic eyes and eyes with hydrophobic acrylic lenses.
...Observational cross-sectional study.
A total of 156 patients (226 eyes).
The IOLMaster measurements (IOLM-1) were performed before phacoemulsification and reexamined 3 months postoperatively (IOLM-2). One of the foldable acrylic IOLs (AcrySof SA60AT, SN60WF, or SN60D3, Alcon Laboratories Inc., Dallas, TX) was implanted.
The expected refraction and estimation error calculated from IOLM-1 using the SRK II, SRK/T, and Haigis formulae were compared with the residual refraction 3 months postoperatively. The power of the implanted IOL and IOLM-2 measurement data were used to re-estimate the postoperative expected refraction in pseudophakic eyes. The difference in expected refraction and estimation error between phakic and pseudophakic eyes was studied. Differences in the anterior chamber depth and axial length measured by IOLM-1 and IOLM-2 were analyzed and correlated with the estimation error.
The IOLMaster measured an axial length 0.10+/-0.15 mm shorter in pseudophakic eyes (P<0.001). Calculations from IOLM-2 gave a significantly more hyperopic expected refraction than IOLM-1, with an averaged 0.20+/-0.46 diopters (D), 0.18+/-0.45 D, and 0.65+/-0.59 D calculated by the SRK II, SRK/T, and Haigis formulae, respectively. There was no significant difference among the 3 IOLs. The difference in estimation error correlated with the difference in axial length and anterior chamber depth (P<0.001 for the SRK II, SRK/T, and Haigis formulae). However, the correlation was strongest when the Haigis formula was used for the calculation.
The expected refraction in pseudophakic eyes differed significantly from that in phakic eyes by the IOLMaster depending on the IOL formulae used for the calculation rather than the type of IOL. An adjustment of target refraction by 0.20 to 0.65 D toward the hyperopic side of the desired refraction could be considered when using optical biometry data in pseudophakic eyes to achieve postoperative emmetropia.
Summary China has the world's second largest tuberculosis epidemic, but progress in tuberculosis control was slow during the 1990s. Detection of tuberculosis had stagnated at around 30% of the ...estimated total of new cases, and multidrug-resistant tuberculosis was a major problem. These signs of inadequate tuberculosis control can be linked to a malfunctioning health system. The spread of severe acute respiratory syndrome (SARS) in 2003, brought to light substantial weaknesses in the country's public-health system. After the SARS epidemic was brought under control, the government increased its commitment and leadership to tackle public-health problems and, among other efforts, increased public-health funding, revised laws that concerned the control of infectious diseases, implemented the world's largest internet-based disease reporting system, and started a programme to rebuild local public-health facilities. These measures contributed to acceleration in efforts to control tuberculosis. By 2005, the detection of cases of tuberculosis had increased to 80% of the estimated total new cases, permitting China to achieve the 2005 global tuberculosis control targets. At the same time, specific efforts to improve tuberculosis control also contributed to strengthening of the public-health system. We examine how the strengthening of a disease control programme and the public-health system worked together to achieve a desired health outcome.
Immune checkpoint blockade (ICB) has revolutionized cancer treatment, yet quality of life and continuation of therapy can be constrained by immune-related adverse events (irAEs). Limited ...understanding of irAE mechanisms hampers development of approaches to mitigate their damage. To address this, we examined whether mice gained sensitivity to anti-CTLA-4 (αCTLA-4)-mediated toxicity upon disruption of gut homeostatic immunity. We found αCTLA-4 drove increased inflammation and colonic tissue damage in mice with genetic predisposition to intestinal inflammation, acute gastrointestinal infection, transplantation with a dysbiotic fecal microbiome, or dextran sodium sulfate administration. We identified an immune signature of αCTLA-4-mediated irAEs, including colonic neutrophil accumulation and systemic interleukin-6 (IL-6) release. IL-6 blockade combined with antibiotic treatment reduced intestinal damage and improved αCTLA-4 therapeutic efficacy in inflammation-prone mice. Intestinal immune signatures were validated in biopsies from patients with ICB colitis. Our work provides new preclinical models of αCTLA-4 intestinal irAEs, mechanistic insights into irAE development, and potential approaches to enhance ICB efficacy while mitigating irAEs.
(1), which demonstrated that higher trough plasma dabigatran concentrations were associated with: 1) decreasing risk of stroke/systemic embolic event (SEE); and 2) increasing major bleeding risk in ...the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial (2). Data in their Table 1 and Figure 2 show that for a 72-year-old male with atrial fibrillation, diabetes mellitus, and previous stroke, there was a 3-fold increase in risk of major bleeding events between the 10th and 90th percentiles of trough concentrations.
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