ABSTRACT
A randomized controlled trial was carried out in Pakistan in 1999 to establish the effectiveness of the direct observation component of DOTS programmes. It found no significant differences in cure rates for patients directly observed by health facility workers, community health workers or by family members, as compared with the control group who had self-administered treatment. This paper reports on the social studies which were carried out during and after this trial, to explain these results. They consisted of a survey of all patients (64% response rate); in-depth interviews with a smaller sample of different types of patients; and focus group discussions with patients and providers. One finding was that of the 32 in-depth interview patients, 13 (mainly from the health facility observation group) failed to comply with their allocated DOT approach during the trial, citing the inconvenience of the method of observation. Another finding was that while patients found the overall TB care approach efficient and economical in general, they faced numerous barriers to regular attendance for the direct observation of drug-taking (most especially, time, travel costs, ill health and need to pursue their occupation). This may be one of the reasons why there was no overall benefit from direct observation in the trial. Provider attitudes were also poor: health facility workers expressed cynical and uncaring views; community health workers were more positive, but still arranged direct observation to suit their, rather than patients', schedules. The article concludes that direct observation, if used, should be flexible and convenient, whether at a health facility close to the patient's home or in the community. The emphasis should shift in practice from tablet watching towards treatment support, together with education and other adherence measures.
Subject(s)
Observation , Patient Compliance , Social Sciences , Tuberculosis/drug therapy , Data Collection , Female , Humans , Male , Pakistan , Randomized Controlled Trials as TopicABSTRACT
BACKGROUND: In this study we extended previous work by examining whether disturbances in the circadian rhythms of cortisol during the menstrual cycle distinguish patients with premenstrual dysphoric disorder (PMDD) from normal control (NC) subjects. In addition, we tested the differential response to the effects of early and late partial sleep deprivation on cortisol rhythms. METHODS: In 15 PMDD and 15 NC subjects we measured cortisol levels every 30 min from 6:00 PM to 9:00 AM during midfollicular (MF) and late luteal (LL) menstrual cycle phases and also during a randomized crossover trial of early (sleep 3:00 AM-7:00 AM) versus late (sleep 9:00 PM-1:00 AM) partial sleep deprivation administered in two subsequent and separate luteal phases. RESULTS: In follicular versus luteal menstrual cycle phases we observed altered timing but not quantitative measures of cortisol secretion in PMDD subjects, compared with NC subjects: in the LL versus MF phase the cortisol acrophase was a mean of 1 hour earlier in NC subjects, but not in PMDD subjects. The effect of sleep deprivation on cortisol timing measures also differed for PMDD versus NC subjects: during late partial sleep deprivation (when subjects' sleep was earlier), the cortisol acrophase was almost 2 hours earlier in PMDD subjects. CONCLUSIONS: Timing rather than quantitative measures of cortisol secretion differentiated PMDD subjects from NC subjects both during the menstrual cycle and in response to early versus late sleep deprivation interventions.
Subject(s)
Circadian Rhythm/physiology , Hydrocortisone/blood , Menstrual Cycle/blood , Premenstrual Syndrome/blood , Sleep Deprivation , Adult , Affect , Cross-Over Studies , Female , Follicular Phase/blood , Follicular Phase/psychology , Gonadal Steroid Hormones/blood , Humans , Luteal Phase/blood , Luteal Phase/psychology , Menstrual Cycle/psychology , Premenstrual Syndrome/psychology , Psychiatric Status Rating ScalesSubject(s)
Angina Pectoris/etiology , Coronary Vessel Anomalies/diagnostic imaging , Fistula/diagnostic imaging , Coronary Angiography , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/physiopathology , Female , Fistula/complications , Fistula/physiopathology , Hemodynamics , Humans , Middle Aged , RecurrenceSubject(s)
Malaria, Falciparum/epidemiology , Malaria, Vivax/epidemiology , Adolescent , Adult , Aged , Child , Child, Preschool , Emigration and Immigration , Female , Humans , Infant , Malaria, Falciparum/diagnosis , Malaria, Vivax/diagnosis , Male , Middle Aged , New Jersey/epidemiology , Retrospective Studies , TravelABSTRACT
Weakness of the thumb, index, middle fingers developed over several days in a 48-year-old man with end-stage renal disease and an arteriovenous fistula in that arm. A large thrombosed aneurism was found and was shown to be compressing the anterior interosseous nerve (a branch of the median nerve). Surgical resection was followed by marked neurologic improvement. This syndrome is compared with two other median nerve compression syndromes (the pronator and carpal tunnel syndromes).
ABSTRACT
Allergic reactions, including anaphylactoid shock due to contrast material, are not uncommon. However, persistent anaphylactoid shock refractory to conventional therapy is rare. We present a case of refractory anaphylactoid shock during coronary angiography unresponsive to aggressive standard therapy in a patient on beta-blockers. Significant clinical improvement was noted upon administration of glucagon. Since beta-blockers are commonly used in patients with coronary artery disease, this potentially life-threatening complication has to be kept in mind with any procedure involving contrast media in patients on beta-blockers. Immediate access to glucagon by keeping it in the procedure room may be lifesaving in these situations.
