大学生肺结核病人患病体验的现象学研究

目的深入了解和探索大学生肺结核病人患病体验。方法采用质性研究中的现象学研究法,深入访谈15位不同院校的大学生肺结核患者。结果大学生肺结核病人患病体验的5个主题:情绪复杂、对结核病认识偏颇、日常生活受影响、社会支持不足以及患病的积极影响。结论大学生患者结核病知识缺乏,患病和治疗过程中精神和心理压力大,治疗和恢复期间治疗与学习的冲突严重。大学生患者需要接受系统的健康教育;重视患者心理支持。     

Scaling up antiretroviral therapy in Africa: learning from tuberculosis control programmes--the case of Malawi.

The rapid and massive scale-up of antiretroviral drug therapy (ART) so needed in sub-Saharan Africa will not be possible using a 'medicalised' model. A more simple approach is required. DOTS has been used now for many years to provide successful anti-tuberculosis treatment to millions of patients in poor countries of the world, and many of the established concepts can be used for the delivery of ART. Malawi, a small and impoverished country in sub-Saharan Africa, is embarking on a national scale-up of ART. In this review we describe how we have adopted several of the principles of DOTS for delivering ART in Malawi: case finding and registration, treatment, monitoring, drug procurement, staffing and the issue of free drugs. We also discuss ART for HIV-infected TB patients. We hope that by using the DOTS approach we will be able to deliver ART to large numbers of HIV-infected patients under controlled conditions, and minimise the risk of developing drug resistance.     

Public-private partnership in tuberculosis control: experience in Hyderabad, India.

SETTING: Hyderabad, India. OBJECTIVE: To determine whether private practitioners and the government can collaborate with a nongovernmental intermediary to implement DOTS effectively. DESIGN: A non-profit hospital provided DOTS services to a population of 100000 for 3 years, then expanded coverage to 500000 in October 1998. A hospital physician visited all private practitioners, encouraged them to refer patients, and gave feedback on each patient referred. After diagnosis, patients received directly observed treatment free of charge at the trust hospital or at 30 conveniently located small hospitals operated by local private practitioners. No financial incentives were used to encourage physicians to refer patients or to provide treatment observation. Diagnosis, treatment, and case and outcome definitions were performed as per DOTS policies; medicines and laboratory reagents were provided by the government. RESULTS: All 244 allopathic and 114 non-allopathic physicians practising in the area agreed to participate; 59% referred at least one patient. Of 2244 persons referred, 969 (43%) had tuberculosis. Physicians had obtained chest radiographs on 80% of patients before referral for sputum microscopy. The detection rate increased from 50 to 200/100000 over the first 2-3 years of the project, and has increased gradually since expansion; 90% of new smear-positive patients and 77% of re-treatment patients were successfully treated. Compared with those treated at a neighbouring government DOTS centre, patients in this project paid less for diagnosis ($5 vs. $20) and treatment ($1 vs. $11), largely due to lower transport costs. CONCLUSIONS: Collaborative efforts between private practitioners and the government can achieve moderate-high rates of case detection and high rates of treatment success. Public-private services appeared to be more convenient to patients, who paid less for care and were less likely to miss work in order to participate in DOTS. Clearly defined roles and expectations and frequent communication are essential to success. An institution such as a non-profit hospital can serve as an effective intermediary between the government DOTS programme and private practitioners.     

Childhood tuberculosis in Malawi: nationwide case-finding and treatment outcomes.

SETTING: All 43 non-private hospitals (three central, 22 [corrected] district and 18 [corrected] mission) in Malawi that register and treat adult and paediatric TB cases. OBJECTIVE: To assess the rate, pattern and treatment outcome of childhood TB case notifications in Malawi in 1998. DESIGN: Retrospective data collection using TB registers, treatment cards and information from health centre registers. Information was collected on number of cases, types of TB and treatment outcomes using standardised definitions. RESULTS: There were 22,982 cases of TB registered in Malawi in 1998, of whom 2,739 (11.9%) were children. Children accounted for 1.3% of all case notifications with smear-positive pulmonary TB (PTB), 21.3% with smear-negative PTB and 15.9% with extra-pulmonary TB (EPTB). Estimated rates of TB in children were 78/ 100,000 in those aged less than one year, 83/100,000 in those aged 1-4 years and 33/100,000 in those aged 5-14 years. A significantly higher proportion of TB cases was diagnosed in central hospitals. Only 45% of children completed treatment. There were high rates of death (17%), default (13%) and unknown treatment outcomes (21%). Treatment outcomes were worse in younger children and in children with smear-negative PTB. Treatment completion was best (76%) and death rates lowest (11%) for the 127 children with smear-positive PTB. CONCLUSION: Childhood TB is common in Malawi and treatment outcomes are poor. Research should be directed towards improved diagnosis and follow-up of children with TB, and the National TB Programme should support appropriate management of childhood contacts of smear positive PTB cases.     

Disseminated tuberculosis: a 10-year experience in a medical center

Disseminated tuberculosis remains a diagnostic challenge because the presentations are nonspecific. In the current retrospective study we describe the clinical characteristics and outcome of disseminated tuberculosis. From January 1995 to December 2004, patients with culture-confirmed tuberculosis who fulfilled the criteria for disseminated tuberculosis were selected and their medical records reviewed. Their clinical isolates were genotyped. Of the 3058 patients with culture-confirmed tuberculosis, 164 (5.4%) had disseminated disease; 14.0% of patients had acquired immunodeficiency syndrome. The most common radiographic finding was miliary lung lesions (47.0%); 31.1% of patients died at the end of the study. Poor prognostic factors included hypoalbuminemia, hyperbilirubinemia, renal insufficiency, and delayed antituberculosis treatment. Clinical findings suggestive of disseminated tuberculosis were miliary lung lesions, serum ferritin >1000 microg/L, infiltrative liver disease, and adjusted calcium >2.6 mmol/L. Simultaneously performing mycobacterial culture and histopathologic examination of bone marrow biopsy was more sensitive and faster than just performing mycobacterial blood culture in diagnosing disseminated tuberculosis. Of the 64 preserved Mycobacterium tuberculosis isolates, 47 (73.4%) were clustered and 27 (42.2%) were Beijing family. Since prognosis was worse in patients with delayed treatment, a high index of suspicion is required, especially in those with clinical findings suggestive of disseminated tuberculosis.     

Integrated tuberculosis and HIV care in a resource-limited setting: experience from the Martin Preuss centre, Malawi

Objectives To describe the development and operation of integrated tuberculosis (TB) and HIV care at the Martin Preuss Centre, a multipartner organization bringing together governmental and non‐governmental providers of HIV and TB services in Lilongwe, Malawi. Methods We used a case study approach to describe the integrated TB/HIV service and to illustrate successes and challenges faced by service providers. We quantified effective TB and HIV integration using indicators defined by the World Health Organization. Results The custom‐designed building facilitates patient flow and infection control, and other important elements include coordinated leadership; joint staff training and meetings; and data systems prompting coordinated care. Some integrated services have worked well from the outset, such as promoting HIV testing among patients with TB (96% of patients with TB had documented HIV status in 2009). Other aspects of integrated care have been more challenging, for example achieving high uptake of antiretroviral therapy among HIV‐positive TB patients and combining data from paper and electronic systems. Good TB treatment outcomes (>85% cure or completion) have been achieved among both HIV‐positive and HIV‐negative individuals. Conclusions High‐quality integrated services for TB and HIV care can be provided in a resource‐limited setting. Lessons learned may be valuable for service providers in other settings of high HIV and TB prevalence.     

新型冠状病毒肺炎疫情防控经验对结核病防治工作的启示

我国新型冠状病毒肺炎(COVID-19)疫情防控的成功经验和科学实践,为传染病防控树立了典范。笔者通过分析、学习和借鉴我国在COVID-19疫情防控中取得的经验,结合当前我国结核病防治现状,浅析当前我国结核病防治在服务体系、政策保障和科学研究等方面需要着重考虑和解决的问题。     

High early death rate in tuberculosis patients in Malawi.

SETTING: Thirty-eight district and mission hospitals in Malawi. OBJECTIVES: In patients registered with all types of tuberculosis (TB) in 1997 to determine 1) treatment outcomes, and 2) when in the course of anti-tuberculosis treatment TB deaths occurred. DESIGN: A retrospective study using information from TB registers, health centre registers, TB treatment cards and TB ward admission books. RESULTS: A total of 16,004 patients were registered with all types of TB, 6471 with smear-positive pulmonary tuberculosis (PTB), 5305 with smear-negative PTB and 4228 with extra-pulmonary tuberculosis (EPTB). Of patients with all types of TB, 3720 (23%) died: death rates were 22% in smear-positive PTB, 26% in smear-negative PTB and 22% in EPTB. Month of death was known in 3371 patients (91% of those who died) and day of death in 3326 patients (89% of those who died). In patients who died, 19% of deaths occurred by day 7 and 41% by the end of the first month of treatment. A higher proportion of early deaths occurred in patients with smear-negative PTB and EPTB and in relation to increasing age. CONCLUSIONS: There was a high overall death rate in TB patients registered in 1997, with 40% of deaths occurring in the first month of treatment. Strategies to combat this problem are needed.     

Drug susceptibility testing of Mycobacterium tuberculosis to fluoroquinolones: first experience with a quality control panel in the Nordic-Baltic collaboration.

In the first attempt to establish a quality assurance programme for susceptibility testing of Mycobacterium tuberculosis to fluoroquinolones, 20 strains with different fluoroquinolone susceptibility patterns were distributed by the Supranational Reference Laboratory in Stockholm to the other mycobacterial reference laboratories of the Nordic and Baltic countries. Susceptibility testing to fluoroquinolones was performed according to routine procedures in each laboratory. Results were compared to sequence analysis of the gyrA gene and minimal inhibitory concentration determination. Most laboratories found identical susceptibility patterns. The two resistant strains were correctly identified by all laboratories, but three laboratories each falsely reported one susceptible strain as resistant. These results indicate that the participating laboratories yield reliable results in detection of fluoroquinolone-resistant strains, although the need for a standardised quality assurance programme for drug susceptibility testing for fluoroquinolones is stressed by the strains falsely reported as resistant.     

Diagnosis of childhood tuberculosis in Malawi: an audit of hospital practice.

SETTING: All 44 non-private hospitals in Malawi that register and treat children with tuberculosis (TB). OBJECTIVE: To determine 1) clinical features and diagnostic practices in children registered with TB, and 2) the use of the WHO score chart in diagnosis. DESIGN: A cross-sectional study of all children aged 14 years or below in hospital receiving anti-tuberculosis treatment, using reviews of treatment cards, case files and chest X-rays and performing a clinical assessment. RESULTS: There were 150 children, 98 with pulmonary TB (PTB) and 52 with extra-pulmonary TB (EPTB). The median duration of illness was 8 weeks. Most patients had fever, no response to anti-malarial treatment and antibiotics, and 40% had a family history of TB. Nearly 45% had weight for age <60%. Diagnosis was mainly based on clinical features and radiography, with less than 10% having tuberculin skin tests or HIV serology, and very few having other sophisticated investigations. A WHO diagnostic score chart was used in 13 (9%) patients by hospital staff. An independent assessment by the study team found that 61% of patients had a score of 7 or more; this was higher in EPTB than PTB patients. CONCLUSION: Diagnostic practices in children with TB in Malawi are poor, and improvements should be made.