Why ethics is indispensable for good-quality operational research.

This article outlines challenges encountered when ethics is taught and promoted in the Operational Research courses of the International Union Against Tuberculosis and Lung Disease, with a focus on ethical issues related to studies that involve health records reviews. Problems observed by the Ethics Advisory Group include engagement of all stakeholders, maintenance of confidentiality and authorship. The omission of ethics in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement and its explanatory commentary published in 2007 is highlighted and questioned.

Cet article souligne les défis rencontrés lorsque, dans les cours de Recherche Opérationnelle de L'Union, on enseigne et on promeut l'éthique en se focalisant sur les problèmes éthiques liés aux études qui comportent des revues de dossiers de santé. Les problèmes observés par l'Ethics Advisory Group comportent l'engagement de tous les responsables et le respect de la confidentialité et de la propriété des auteurs. L'omission de l'éthique dans la prise de position STROBE (Strengthening the Reporting of Observational Studies in Epidemiology, Renforcement des rapportages d'études observationnelles en épidémiologie) et son commentaire explicatif publié en 2007 est mise en évidence et remise en question.

En el presente artículo se describen las dificultadas que plantea la enseñanza y el estímulo de la ética en los cursos de investigación operativa impartidos por la Unión Internacional Contra la Tuberculosis y Enfermadades Respiratorias (La Unión), con un interés particular en los aspectos éticos de los estudios donde se examinan los expedientes clínicos. Entre los problemas observados por el grupo consultivo de La Unión en materia de ética se encuentran el compromiso de todas las partes interesadas, el respeto de la confidencialidad y la autoría. Se destaca y se objeta la omisión de la ética en la declaración de STROBE (Strengthening the Reporting of Observational Studies in Epidemiology, sobre las recomendaciones para mejorar la calidad de la comunicación de los estudios de observación en epidemiología) y en su nota explicativa, publicadas en el 2007.

Prevalence of chronic kidney disease stages 3-5 among acute medical admissions: another opportunity for screening.

BACKGROUND: Early identification of chronic kidney disease (CKD) can help delay or prevent its progression, but the opportunities for systematic screening of patients are not well defined. AIM: To define the prevalence of CKD Stages 3-5 and related anaemia among acute medical admissions. DESIGN: Retrospective analysis. METHODS: We studied all acute medical admissions to a major London teaching hospital during one year. The lowest creatinine, highest haemoglobin (Hb) and average mean corpuscular volume (MCV) were determined for 3 months before and after admission. Patients were categorized as CKD Stages 3-5 if the highest estimated GFR (eGFR) was <60 ml/min/1.73 m2. CKD-related anaemia was diagnosed if these patients had Hb <11 g/dl with normal MCV. RESULTS: A total of 6073 patients were studied: male 49.0%, age 65.4 +/- 19.6 years (mean +/- SD), creatinine 82.7 +/- 46.7 micromol/l, eGFR 89.1 +/- 32.5 ml/min/1.73 m2, Hb 13.6 +/- 1.73 g/dl, MCV 87.7 +/- 7.2 fl. There was an inverse correlation between eGFR and age (r2 = 0.5; P < 0.001). Males were younger than females (63.5 +/- 18.4 years vs. 67.3 +/- 20.5) and had higher eGFR (93.6 +/- 34.1 vs. 84.7 +/- 30.2 ml/min/1.73 m2; P < 0.001). A total of 743 patients (12.2%) had raised creatinine >110 micromol/l, however using eGFR <60 ml/min/1.73 m2, 1075 patients (17.7%) were identified. The patients were categorized as follows: Stage 3: 950 (15.6%), Stage 4: 100 (1.7%), Stage 5: 25 (0.4%). Ninety-nine (9.2%) of the 1075 patients had normocytic anaemia. CONCLUSION: We have found a high prevalence of CKD Stages 3-5 (17.7%) among acute medical admissions, of whom 9.2% had a related anaemia. Our findings highlight an important opportunity (amongst the 1.9 million acute medical admissions annually in England) for detecting patients with CKD.

TB control programmes: the challenges for Africa.

PIP: Governmental neglect of tuberculosis (TB), inadequately managed and inaccurately designed TB control programs, population growth, and the HIV epidemic account for the resurgence of TB in sub-Saharan Africa. The World Health Organization and the International Union against TB and Lung Disease have developed a TB control strategy that aims to reduce mortality, morbidity, and transmission of TB. It aims for an 85% cure rate among detected new cases of smear-positive TB and a 70% rate of detecting existing smear-positive TB cases. The strategy involves the provision of short-course chemotherapy (SCC) to all identified smear-positive TB cases through directly observed treatment (DOTS). SCC treatment regimens for smear-positive pulmonary TB recommended for sub-Saharan African countries are: initial phase = daily administration over 2 months of streptomycin, rifampicin, isoniazid, and pyrazinamide; continuation phase = 3 doses over 4 months of isoniazid and rifampicin or daily administration of thiacetazone and isoniazid or of ethambutol and isoniazid. A TB control policy must be implemented to bring about effective TB control. The essential elements of this policy include political commitment, case detection through passive case-finding, SCC, a regular supply of essential drugs, and a monitoring and evaluation system. Political commitment involves establishing a National TB Control Program to be integrated into the existing health structure. Increased awareness of TB in the community and among health workers and a reference laboratory are needed to make case finding successful. A distribution and logistics system is needed to ensure uninterrupted intake of drugs throughout treatment. These regimens have been very successful and cost-effective but pose several disadvantages (e.g., heavy workload of recommended 3 sputum smear tests). A simplified approach involves 1 initial sputum smear for 6 months; 6-months, intermittent rifampicin-based therapy, 100% DOTS throughout entire treatment course, and ascertainment of treatment completion rates and mortality rates in all patients.^ieng

Chronic hyperpigmentation from a heated mustard compress burn: a case report.

This is a case study of a woman who sustained a second-degree, partial-thickness burn of the midchest and medial breast distribution after the application of a heated mustard compress as a naturopathic remedy for a recent bout of pneumonia. This case study demonstrates the potential for hyperpigmentation and hypertrophic scarring associated with heated mustard burns. A photograph of the presenting burn with the region of hyperpigmentation 3 days after the injury is provided.

AIDS: an update.

PIP: In sub-Saharan Africa, where the acquired immunodeficiency syndrome (AIDS) epidemic threatens to undermine the social and economic structure of society, there has been insufficient attention to health care demand, supply, and quality issues. Most of those currently infected with human immunodeficiency virus (HIV) will register their demand for increased health services within the next six years. A study of medical insurance claims in Zimbabwe indicated that the claims of HIV-infected persons in the last 7-15 months of their lives were 700% higher than the average claim for the same age group. Absenteeism by HIV-infected health care workers is affecting the quality of care in hospitals, and countries that provide sickness benefits for public sector workers face the double drain of financing these benefits and paying for replacement staff. Emerging evidence suggests that HIV screening and counseling is not an effective intervention in this culture. Pregnant Kenyan women screened for HIV tended not to want the results, failed to inform their partner of a positive result, or were subjected to violence and abandonment when they did inform their husbands. Most effective, in this region, have been programs aimed at improving the diagnosis and treatment of sexually transmitted diseases. Other recommendations include decentralization of care to district health systems where costs are lower, increased support for home-based care, AIDS education for traditional healers, and informational campaigns to counter discrimination against HIV-infected community members.^ieng

Use of fish hook-shaped electrode in burn patients.

Use of a fish hook-shaped needle electrode for electrocardiographic monitoring in burn patients is described.

Limb salvage procedure for neoplasms about the knee by spherocentric total knee arthroplasty and autogenous autoclaved bone grafting.

Spherocentric total joint arthroplasty was performed for treatment of neoplasm in 15 patients. The average follow-up period was 30 months. In nine of the patients concomitant autoclaved autologous bone implants were also prepared from the resected specimens. The results were satisfactory in ten patients and unsatisfactory in five. One patient had an infection that required amputation. One patient with osteosarcoma had a recurrence at 20 months and was treated by amputation. Poor results were caused by stem failure in two patients and by component loosening in one patient. Total joint arthroplasty combined with autoclaved bone implantation is a useful limb salvage procedure for resected neoplasms about the knee.

Pyogenic vertebral osteomyelitis complicating abdominal stab wounds.

Pyogenic vertebral osteomyelitis may follow any process which initiates bacteremia and should be considered in a differential diagnosis of back pain occurring in the convalescent phase of septicemia. The two cases discussed here, following abdominal stab wounds, illustrate the principles of diagnosis and management of this problem. Diagnosis is based on gradual onset of low back pain with spinal tenderness and paravertebral muscle spasms, without neurologic symptoms. Serial X-rays are helpful, as are technetium phosphate or gallium bone scans. Appropriate antibiotic plus immobilization are recommended.