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A 31-year-old diamond miners with chronic and relapsing skin ulcers. What is the diagnosis?
No full textThe difficulty of questioning clinical practice: experience of facility-based case reviews in Ouagadougou, Burkina Faso
No full textOBJECTIVE: To describe the implementation of facility-based case reviews (medical audits) in a maternity unit and their effect on the staff involved. DESIGN: Cross-sectional descriptive study. SETTING: A 26-bed obstetric unit in a district hospital in Ouagadougou, Burkina Faso. SAMPLE: Sixteen audit sessions conducted between February 2004 and June 2005. Thirty-five staff members were interviewed. METHODS: An analysis of all the tools used in the management of the audit was performed: attendance lists, case summary cards and register of recommendations. The perceptions of the staff about the audits were collected through a questionnaire administrated by an external investigator from 10 June 2005 to 16 June 2005. MAIN OUTCOME MEASURES: Session participation, types of problems identified, recommendations proposed and implemented and staff reaction to the audits. RESULTS: Only 7 midwives from a total of 15 regularly attended the sessions. Eighty-two percent of the recommendations made during the audits have been implemented, but sometimes after a delay of several months. Interviewed personnel had a good understanding of the audit goals and viewed audit as a factor in changing their practice. However, midwives highlighted problems of bad interpersonal communication and lack of anonymity during the audit sessions, and pointed out the difficulty of practising self-criticism. CONCLUSIONS: A lack of staff commitment and the resistance of maternity personnel to being evaluated by their peers or service users are reducing acceptance of routine audits. The World Health Organization must take all these factors into account when promoting the institutionalisation of medical audits in obstetrics
Determinants of survival in AIDS patients on antiretroviral therapy in a rural centre in the Far-North Province, Cameroon
No full textThe definitive version is available at www3.interscience.wiley.comObjective
To analyse the outcomes of antiretroviral therapy (ART) in routine conditions in a rural hospital in the Far-North province of Cameroon. Method
Retrospective cohort study of 1187 patients >15 years who started ART between July 2001 and December 2006. The survival time was estimated by Kaplan-Meier analysis and Cox proportional hazard models were fitted to explain survival. Results
Upon enrolment, 90.4% patients were in WHO stage III or IV and 56.1% had a BMI <18.5. Median CD4 count was 105 cells/mm³ (IQR 40-173). At the end of the study period, 338/1187 had died and 59/1187 were lost to follow-up. The survival probability was 77% at 1 year [95% CI: 75-80] and 47% at 5 years [95% CI: 40-55]. The median survival time was 58 months. CD4 count, haemoglobin, BMI, sex and clinical stage at enrolment were independent predictors of mortality. Conclusion
This study confirms the clinical benefit of ART programs in a remote and resource-constrained setting operating in routine conditions. The challenge ahead is to secure earlier access to ART and to maintain its longer-term benefit
Multilocus microsatellite typing (MLMT) reveals genetic homogeneity of Leishmania donovani strains in the Indian subcontinent
No full textIn this population genetic study of Leishmania donovani parasites in the Indian subcontinent, 132 isolates obtained from patients in Bangladesh, India, Nepal and Sri Lanka suffering from Kala-azar (100), post-Kala-azar dermal leishmaniasis (PKDL) (25) and cutaneous leishmaniasis (CL) (2), and from 5 patients whose clinical patterns were not defined, were analysed by using 15 hyper-variable microsatellite loci. Multilocus microsatellite typing (MLMT) data were analysed by using a Bayesian model-based clustering algorithm and constructing phylogenic tree based on genetic distances. In total, 125 strains from Bangladesh, Bihar (India) and Nepal formed a very homogeneous population regardless of geographical origin, clinical manifestation, and whether they presented in vitro or in vivo susceptibility to antimonial drugs. Identical multilocus microsatellite profiles were found for 108 strains, other strains differed in only one marker. Considerably different microsatellite profiles were identified for three Indian strains most closely related to L. donovani from Kenya, and for four strains from Indian and Sri Lankan CL cases. The circulation of a single homogeneous population of L. donovani in Bihar (India), Bangladesh and Nepal is, most probably, related to the epidemic spread of visceral leishmaniasis in this area
Structure, dynamics and function of Leishmania genome: resolving the puzzle of infection, genetics and evolution? [discussion]
No full textWe review and discuss here the specificity and contribution of genome (re-)arrangement studies for the exploration of genetic diversity among Leishmania. We show how the early molecular karyotyping studies generated an original perception of the genetics and evolution of these Protozoa, while providing some possible explanations on the parasite diverse phenotypes (drug resistance, pathogenicity...). We compare the results with the enormous amount of data provided by the recent genome sequencing projects, so far focused on one strain per genus/species. We highlight the relevance of parallel sequencing of different strains of a same species, now made possible by the new sequencing technologies. We recommend paying a particular attention to variation in gene copy number, a feature showed by the karyotyping studies to be extremely informative
Rapid decrease of malaria morbidity following the introduction of community-based monitoring in a rural area of central Vietnam
No full textBACKGROUND: Despite a successful control programme, malaria has not completely disappeared in Vietnam; it remains endemic in remote areas of central Vietnam, where standard control activities seem to be less effective. The evolution of malaria prevalence and incidence over two and half years in a rural area of central Vietnam, after the introduction of community-based monitoring of malaria cases, is presented. METHODS: After a complete census, six cross-sectional surveys and passive detection of malaria cases (by village and commune health workers using rapid diagnostic tests) were carried out between March 2004 and December 2006 in Ninh-Thuan province, in a population of about 10,000 individuals. The prevalence of malaria infection and the incidence of clinical cases were estimated. RESULTS: Malaria prevalence significantly decreased from 13.6% (281/2,068) in December 2004 to 4.0% (80/2,019) in December 2006. Plasmodium falciparum and Plasmodium vivax were the most common infections with few Plasmodium malariae mono-infections and some mixed infections. During the study period, malaria incidence decreased by more than 50%, from 25.7/1,000 population at risk in the second half of 2004 to 12.3/1,000 in the second half of 2006. The incidence showed seasonal variations, with a yearly peak between June and December, except in 2006 when the peak observed in the previous years did not occur. CONCLUSION: Over a 2.5-year follow-up period, malaria prevalence and incidence decreased by more than 70% and 50%, respectively. Possibly, this could be attributed to the setting up of a passive case detection system based on village health workers, indicating that a major impact on the malaria burden can be obtained whenever prompt diagnosis and adequate treatment are available
African 1, an epidemiologically important clonal complex of Mycobacterium bovis dominant in Mali, Nigeria, Cameroon, and Chad
No full textWe have identified a clonal complex of Mycobacterium bovis present at high frequency in cattle in population samples from several sub-Saharan west-central African countries. This closely related group of bacteria is defined by a specific chromosomal deletion (RDAf1) and can be identified by the absence of spacer 30 in the standard spoligotype typing scheme. We have named this group of strains the African 1 (Af1) clonal complex and have defined the spoligotype signature of this clonal complex as being the same as the M. bovis BCG vaccine strain but with the deletion of spacer 30. Strains of the Af1 clonal complex were found at high frequency in population samples of M. bovis from cattle in Mali, Cameroon, Nigeria, and Chad, and using a combination of variable-number tandem repeat typing and spoligotyping, we show that the population of M. bovis in each of these countries is distinct, suggesting that the recent mixing of strains between countries is not common in this area of Africa. Strains with the Af1-specific deletion (RDAf1) were not identified in M. bovis isolates from Algeria, Burundi, Ethiopia, Madagascar, Mozambique, South Africa, Tanzania, and Uganda. Furthermore, the spoligotype signature of the Af1 clonal complex has not been identified in population samples of bovine tuberculosis from Europe, Iran, and South America. These observations suggest that the Af1 clonal complex is geographically localized, albeit to several African countries, and we suggest that the dominance of the clonal complex in this region is the result of an original introduction into cows naïve to bovine tuberculosis
Weighing harm in therapeutic decisions of smear-negative pulmonary tuberculosis
No full textPURPOSE: To relate the intuitive weight of harm by commission and harm by omission in therapeutic decisions for pulmonary tuberculosis, and to compare it with a weight based on probabilities. METHODS: Clinicians were asked for an estimation of probabilities related with the outcome of treated and nontreated pulmonary tuberculosis and for the toll of wrong decisions. Three ratios of the weight of forgoing a treatment in false-negative patients against the weight of treating false-positives were calculated. The first was based on intuitive estimations, whereas the second and third were based on calculated, either through intuitive estimations of probabilities or through literature data. The association between experience and the difference between the intuitive and the calculated ratios was assessed. RESULTS: Eighty-one participants from Ecuador, Laos, Nepal, and Rwanda responded. The ratio of intuitive weights was 2.0 (interquartile range [IQR], 1.0-4.0) and the ratio of calculated weights based on intuitive probabilities was 64 (IQR, 25.0-169.6; P < 0.001). The ratio of calculated weight based on literature probabilities was 30 (IQR, 17.9-59.2). No association (R(2) = 0.03) was found between experience and accuracy in estimating the weight of errors. CONCLUSION: The weight of a false negative is more important than the weight of a false positive for therapeutic decisions in pulmonary tuberculosis. The ratio of the intuitively estimated weights was much lower than the calculation based on intuitively estimated influencing factors. Clinicians were accurate in estimating probabilities but failed to incorporate them into therapeutic decisions