Knowledge and attitudes towards TB among healthcare workers in Yogyakarta, Indonesia.

SETTING: Healthcare workers (HCWs) are at an increased risk of TB worldwide. Individual knowledge and attitudes may influence HCW behaviour, and subsequently, TB risk. Indonesia has the second highest case-load globally. OBJECTIVE: To measure TB knowledge and attitudes among a subsection of HCWs in Yogyakarta, Indonesia, and to explore factors associated with knowledge. DESIGN: A cross-sectional study using an online survey targeting all HCW staff was conducted among HCWs from four pre-selected healthcare facilities in Yogyakarta. Descriptive analysis and a multivariable linear regression were undertaken. RESULTS: Of 792 HCWs, 290 (37%) completed the survey; 64% (n = 185) were medical staff, 33% (n = 95) reported previously being tested for active TB and 8% (n = 24) for latent TB. The mean knowledge score was 7.2/11 (SD 1.5): this was higher among medical staff and those with university education (average score increase: 0.53, 95% CI 0.15 to 0.90; and 0.38, 95% CI 0.01 to 0.74, respectively). Participants agreed that free access to TB screening (93%) and treatment (93%) should be available, and 57% of medical and 77% of non-medical staff would take preventive therapy if eligible. CONCLUSION: Participants had practical understanding of TB; however, gaps were identified in knowledge about TB disease progression and prevention. Prevention programmes were viewed positively. We suggest further TB education and engagement programmes for HCWs.

CONTEXTE: Les travailleurs de la santé (HCW) sont exposés à un risque accru de TB dans le monde entier. Les connaissances et les attitudes individuelles peuvent influencer le comportement des HCW et, par conséquent, le risque de TB. L'Indonésie a le deuxième plus grand nombre de cas dans le monde. OBJECTIF: Mesurer les connaissances et les attitudes à l'égard de la TB parmi un sous-groupe de HCW à Yogyakarta, en Indonésie, et explorer les facteurs associés aux connaissances de la TB. MÉTHODE: Une étude transversale a été menée à l'aide d'un sondage en ligne ciblant tous les HCW de quatre établissements de santé présélectionnés à Yogyakarta. Une analyse descriptive et une régression linéaire multivariable ont été effectuées. RÉSULTATS: Sur 792 HCW, 290 (37%) ont répondu à l'enquête ; 62% (n = 181) étaient des membres du personnel médical, 33% (n = 95) ont déclaré avoir déjà été testés pour la TB active et 8% (n = 24) pour la TB latente. Le score moyen de connaissances était de 7,2/11 (SD 1,5) : il était plus élevé parmi le personnel médical et les personnes ayant une formation universitaire (augmentation moyenne du score : 0,53 ; IC 95% 0,11­0,93 et 0,38 ; IC 95% 0,01­0,74, respectivement). Les participants étaient d'accord pour dire que l'accès au dépistage (93%) et au traitement (93%) de la TB devrait être gratuit, et 57% du personnel médical et 77% du personnel non médical suivraient un traitement préventif s'ils étaient éligibles. CONCLUSION: Les participants avaient une compréhension pratique de la TB ; cependant, des lacunes ont été identifiées dans les connaissances sur la progression de la maladie et la prévention de la TB. Les programmes de prévention ont été perçus positivement. Nous suggérons d'autres programmes d'éducation et d'engagement sur la TB pour les HCW.

Adapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia.

The COVID-19 pandemic and response measures, including lockdowns and the reorientation of health services, have disrupted essential health services for other diseases, including TB, HIV and malaria. For TB, reductions in case detection due to the COVID-19 pandemic are projected to result in increased TB transmission, morbidity and mortality. Active case-finding (ACF) for TB using community-based approaches is a potential strategy to offset reductions in TB detection by obviating the need for patients to seek care at a health facility. A number of approaches can be used to conduct TB ACF safely and screen designated target populations while managing the risks of SARS-CoV-2 transmission for staff, individuals and the community. We present a framework of options for and experience of adapting TB ACF services in response to the challenges of COVID-19 in our programme in Yogyakarta, Indonesia. Key changes have included revised prioritisation of target populations focusing on household contacts, reducing case-finding throughput, implementation of additional infection control measures and precautions, and integration of COVID-19 screening among those being screened for TB. Our approach could inform other programmes seeking to adapt TB ACF services to mitigate the negative impact of COVID-19 on TB case detection.

La pandémie de COVID-19 et les mesures de riposte incluant des confinements et une réorientation des services de santé ont perturbé les services de santé essentiels destinés aux autres maladies comme la TB, le VIH et le paludisme. En ce qui concerne la TB, les réductions de la détection des cas dues à la pandémie de COVID-19 devrait entraîner une augmentation de la transmission, morbidité et mortalité de la TB. La recherche active des cas (ACF) de TB grâce à des approches communautaires est une stratégie potentielle visant à compenser pour les réductions de détection de la TB en écartant le besoin pour les patients de solliciter des soins dans un structure de santé. Plusieurs approches peuvent être utilisées pour réaliser l'ACF TB de façon sûre et de dépister des populations cibles désignées tout en gérant les risques de transmission du SARS-CoV-2 pour le personnel, les individus et la communauté. Nous présentons un cadre d'options et d'expériences d'adaptation des services TB ACF en réponse aux défis du COVID-19 dans notre programme à Yogyakarta, Indonésie. Les changements majeurs ont inclus une révision des priorités des populations cibles focalisée sur les contacts domiciliaires ; une réduction de la cadence de la recherche de cas ; la mise en œuvre de mesures supplémentaires de lutte contre l'infection et de précautions ; et l'intégration du dépistage de COVID-19 parmi ceux dépistés pour la TB. Notre approche pourrait informer d'autres programmes voulant adapter les services TB ACF afin d'atténuer l'impact négatif du COVID-19 sur la détection des cas de TB.

A retrospective study of tuberculosis outcomes in Gulf Province, Papua New Guinea.

SETTING: Gulf Province, a rural area of mainland Papua New Guinea, is known to have one of the highest burdens of tuberculosis (TB) in the country. OBJECTIVES: To describe the characteristics and outcomes of TB patients registered for first-line treatment in Kerema General Hospital in Gulf Province between January and December 2016. DESIGN: This was a retrospective cohort study using routinely collected programme data. RESULTS: Of 347 cases with a recorded TB site, 54% were male and 32% were aged <15 years. No human immunodeficiency virus (HIV) status was recorded for 51% of cases. TB was bacteriologically confirmed in 23% of cases. Among the cohort, there were 145 extrapulmonary TB cases (42%); the site of disease was unknown in 56% of these cases. Of the 297 cases with treatment outcome evaluated, 56% had a favourable outcome and 26% were lost to follow-up. On multivariable analysis, extrapulmonary TB (adjusted OR [aOR] 0.51, 95%CI 0.30-0.88, P = 0.02) and bacteriologically confirmed TB (aOR 0.40, 95%CI 0.21-0.77, P < 0.01) were associated with decreased odds of an unfavourable treatment outcome. CONCLUSION: The study findings highlight the need to improve TB diagnosis, access to HIV testing, treatment adherence, patient support and the quality of TB programme data in Gulf Province.

The effects of decentralisation of tuberculosis services in the East New Britain Province, Papua New Guinea.

SETTING: The tuberculosis (TB) programmes at the Nonga General Hospital, Rabaul Urban Clinic and Kerevat District Hospital in East New Britain Province, Papua New Guinea. BACKGROUND: In East New Britain, TB care was mainly offered by the General Hospital, resulting in limited community-based care and poor treatment outcomes. In 2016, TB services were decentralised from the provincial to the district level by 1) training health workers, 2) increasing community awareness of TB, and 3) providing a weekly Clinical Outreach (TACO) service. OBJECTIVE: To describe the effect of TACO on the use of TB diagnostic and treatment services from 1 January 2014 to 31 December 2017. DESIGN: This was a retrospective study comparing 2014-2015 (pre-TACO) and 2016-2017 (TACO) cohorts. RESULTS: There was an increase in pre-TACO to TACO cohorts in screened cases (1581 to 2195), total registered TB cases (678 to 824) and registered cases at decentralised sites (209 to 615). Unfavourable treatment outcomes were common (pre-TACO, 46.0% vs. TACO, 40.1%). In multivariable analysis, treatment at a decentralised Basic Management Unit (aOR 0.55, 95%CI 0.42-0.74) was significantly associated with fewer unfavourable outcomes, but treatment outcomes between the pre-TACO and the TACO group were not significantly different. CONCLUSION: Strengthening decentralisation of TB services at the district level increased TB screening and case registration, with similar treatment outcomes.

Successful implementation of bedaquiline for multidrug-resistant TB treatment in remote Papua New Guinea.

SETTING: Bedaquiline (BDQ) was introduced in the multi-drug-resistant tuberculosis (MDR-TB) programme in Daru in remote Papua New Guinea in 2015, along with a core package of active drug-safety monitoring (aDSM). OBJECTIVE: To assess interim results and safety of BDQ for the treatment of MDR-TB from 1 July 2015 to 31 December 2017. DESIGN: A retrospective cohort analysis of routine programme data. RESULTS: Of 277 MDR-TB patients, 77 (39%) received BDQ with a total of 8 serious adverse events including 5 (6.5%) deaths, of which 1 (1.3% QTcF prolongation, grade 3) was attributable to BDQ. Of 200 (61%) patients who did not receive BDQ, there were 17 (9%) deaths. Completeness of monitoring for the BDQ group was 90% for >5 electrocardiograms and 79% for ⩾2 cultures. In the interim result indicator analysis at month 6 in the BDQ and non-BDQ groups, there were respectively 0% and 1% lost to follow-up; 6.5% and 8.5% who died; 94% and 91% in care; and 92% and 96% with negative culture among those monitored. CONCLUSION: Early experience in Daru shows BDQ is safe and feasible to implement with aDSM with good interim effectiveness supporting the rapid adoption and scale-up of the 2019 WHO MDR-TB treatment guidelines in the programme and in similar remote settings.

Precise isotope-ratio measurements of lead species by capillary gas chromatography hyphenated to hexapole Multicollector ICP-MS.

The precision and accuracy of lead isotope-ratio determination on a short transient signal has been assessed by coupling capillary gas chromatography to the Isoprobe (Micromass, UK), a single-focusing inductively coupled plasma mass spectrometer with multicollector detection. A T-piece connecting the GC transfer line to the torch enabled continuous aspiration of thallium solution for mass-bias correction. The volatile lead species PbEt4 was derivatized from NIST isotopic certified lead standard SRM 981 and different amounts of PbEt4 dissolved in iso-octane were injected into the GC. Chromatograms were recorded in multicollection mode by use of Faraday cups; seven isotopes (204Pb, 206Pb, 207Pb, 208Pb,

Isolation and tissue profiles of a large panel of phage antibodies binding to the human adipocyte cell surface.

Phage display is a powerful technique for the rapid selection and isolation of antibodies to any given target antigen. We have applied this technology to isolate over 100 different human antibodies that bind to antigens expressed in situ on the human adipocyte cell surface. This is a diverse panel of antibodies, as indicated by the V-region sequences. The binding profile of each anti-adipocyte antibody has been characterised using phage antibody immunocytochemistry against a panel of normal human tissues. Although there was some variation in the intensity of the adipocyte staining, each antibody consistently recognised adipocytes, where present, irrespective of the tissue source. In addition, all of the antibodies recognised at least one other cell type other than the adipocyte cell surface. In total, over 50 different tissue-binding profiles were recorded, with the most frequently recognised tissues identified as capillaries or smooth muscle. Extensive tissue binding profiles were generated for some antibodies using a panel of 37 different human tissues. This identified anti-adipocyte antibodies with unexpected profiles, such as FAT.13, which binds only to adipocytes and capillaries in the entire tissue panel. We believe this is the most extensive survey ever undertaken of the human adipocyte cell surface. Moreover, similar methodology could be used to derive complete tissue-binding profiles of antibodies against cell-surface antigens of any cell type. Indeed, by screening antibodies on both normal and diseased tissues, it may be possible to identify antigenic associations between different cell types and the pathologies of many diseases.

Metabolic responses to mid-pregnancy shearing that are associated with a selective increase in the birth weight of twin lambs.

Previous studies have shown that shearing pregnant ewes at mid- or late-pregnancy is associated with an increase in lamb birth weight. The present study was designed to investigate metabolic responses that may underlie this response. Single- and twin-bearing ewes were either unshorn or shorn at mid-pregnancy (Day 69 of pregnancy; P69), and insulin, glucose and epinephrine challenges were conducted on P109-111 and P132-134. Shearing increased the birth weight of twin lambs by over 1 kg (P < 0.001) without having any effect on singleton birth weight. This response was associated with a 10-20% reduction in the insulin response to a glucose challenge (P < 0.05) without a change in glucose clearance following either glucose or insulin challenges. The lipolytic response to epinephrine challenge increased as pregnancy progressed, but was not associated with the increased birth weight of twin lambs born to shorn ewes. By late pregnancy, a 25% reduction in maternal IGF-I concentration and a two- to threefold increase in maternal IGFBP-1 concentration (P < 0. 05) associated with shearing were observed. The increase in lamb birth weight associated with mid-pregnancy shearing may have been associated with an increase in the non-insulin dependent uptake of glucose by the placental-fetal unit.

Managing vancomycin-resistant enterococci. A winning team approach.

Antibiotics have been the treatment of choice for a broad range of bacterial infections for decades. In recent years, however, concern has been growing over the increasing incidence of infections that are resistant to known antibiotics. A 1995 outbreak of ampicillin- and vancomycin-resistant enterococci (VRE) at the 3Y site of the McMaster University Medical Centre brought this concern home to us and resulted in the development of outbreak-management guidelines for VRE.

Patient and staff perceptions of a psychiatric ward environment.

Perceptions of 37 psychiatric patients and 34 staff were surveyed to compare their views of ward environment, using items from the Ward Atmosphere Scale (WAS). The actor-observer (A-O) model, which focuses on the inclination of individuals to make ego-enhancing explanations for their situation, was used in interpreting patient and staff differences. Perceptions of patients and staff were significantly different (p less than or equal to .05) on six of the nine WAS subscales. In situations where staff take pride in a behavior (involvement, support, spontaneity, practical orientation, personal problem orientation, and program clarity), perceptions on the WAS were higher for staff than patients. In the area of staff control, which may be perceived as negative by staff, staff rated themselves as less potent than did patients. Discussion of the difference in perception has potential therapeutic use in clarifying roles, sharing of responsibility, and enhancing the ability of patients and staff to express or modify perceptions.

Easing transitions in care delivery with a core training group.

A collaborative approach was used by the nursing staff of a state psychiatric hospital to make a transition from traditional nursing services to a self-care model on one ward. The core training group, including representatives from all levels of nursing staff, developed and evaluated a personal hygiene protocol for 30 patients with chronic mental illness. Underwood's adaptation of Orem's self-care model of nursing was modified to provide the framework for this protocol. Evaluation of the project demonstrated both improved personal hygiene for the patients and greater job satisfaction for the nursing staff. The collaborative core training group approach was effective in facilitating the transition to the self-care nursing model.

Trisomy 10 mosaicism in a newborn boy; delineation of the syndrome.

The fifth case of trisomy 10 mosaicism is presented. Only in cultured fibroblasts this mosaicism was found, while peripheral lymphocytes revealed a normal karyotype. In comparison with the literature, trisomy 10 mosaicism syndrome is further delineated compromising of failure to thrive, high forehead, hypertelorism, mongoloid eye slant, blepharophimosis, dysplastic, large ears, retrognathia, long slender trunk, marked plantar and palmar furrows, cardiopathy and early death.

Responsiveness of the pituitary gland to androgens and of the tests to gonadotrophins following damage to spermatogenesis in rats.

To test the interaction of androgen and inhibit feedback on the pituitary gland, inhibin-type feedback from the testes was reduced when they were made aspermatogenetic by bilateral ligation of the efferent ducts or local heating (43 degrees C for 30 min). There were only minor effects on the subsequent response of the pituitary gland to the removal of androgen feedback by the administration of antiserum against testosterone or by castration. However, in the antiserum-injected animals the steroidogenic response of the testis to the increased serum concentrations of LH was less in aspermatogenic than in control rats. Furthermore, unilateral aspermatogenesis was associated with reduced testosterone output by the treated testis and with compensatory increased output by the contralateral control testis, despite the absence of significant changes in serum LH and normal peripheral levels of testosterone. This suggests that the tubules can regulate the responsiveness of the Leydig cells to LH.

Effects of passive immunization against testosterone on serum and pituitary gonadotrophins: implications for the relative importance of androgens and inhibin in the control of gonadotrophin secretion in the male rat.

The acute effects of a specific reduction in androgen feedback to the hypothalamus and pituitary gland have been investigated in male rats by passive immunization against testosterone. An ovine antiserum raised against testosterone which had been conjugated through position 3 to bovine serum albumin was employed. Negative feedback control by androgens was effectively reduced by administration of the antiserum, as shown by an increase in levels of LH in the circulation. Immunized animals had a high concentration of testosterone in the circulation of which virtually all was tightly bound to antibody. In normal animals specific increases of serum LH concentration were obtained at all ages using a low dose of antiserum. At higher doses, serum FSH concentration was also increased. The LH response was reduced by anaesthesia and sham-operation. In sham-operated rats given a high dose of antiserum for 3 days the serum concentrations of LH and FSH could not be distinguished from those which followed castration while differences were found in the pituitary contents. It was concluded that testicular androgen provides an important inhibitory feedback control of secretion of FSH as well as that of LH in the adult male rat. Some of the data can best be explained by the action of inhibin as a minor or alternative inhibitor of FSH secretion.

The effects of long-term administration of either a crude inhibin preparation or an antiserum to FSH on serum hormone levels, testicular function and fertility of adult male rats.

Adult male rats were given either daily injections of ram rete testis fluid for periods of up to 70 days or injections of an antiserum against FSH every 3 days for 90 days. Compared with the control groups, the rats injected with ram rete testis fluid had lowered serum FSH levels, but only at treatment periods of 30 days and less. The levels of LH and testosterone in serum, testicular fluid secretion, sperm counts, testis weights and fertility were not affected by rete testis fluid treatment. The rats injected with anti-FSH serum exhibited an impairment of fertility which was never complete and evident only after 49 days of treatment. After 90 days of anti-FSH treatment, testis weight and free serum FSH were reduced, but sperm counts, testicular fluid secretion and serum levels of LH and testosterone were not affected.

The evidence that inhibin must exist.

The historical development of the 'inhibin' hypothesis is restated and the recent evidence reviewed. The circumstantial evidence for inhibin now seems very strong, and it probably acts in both sexes. Active materials have been isolated from several sources but it is not clear which is the circulating form of inhibin and a reciprocal relationship between circulating inhibin and FSH levels has not yet been demonstrated. Nevertheless, it appears that we may be optimistic about the existence of inhibin though the importance of its role as a physiological feedback inhibitor is still controversial.

Feedback control by the testis of gonadotrophin secretion: an examination of the inhibin hypothesis.

Spermatogenesis in rats was interrupted by local X-irradiation, heat or ligation of the testicular efferent ducts. A significant and specific rise in the serum level of FSH occurred 5--8 days after ligation of the efferent ducts, reaching twice the value observed in sham-operated controls by 21 days after the operation. After the testes were heated to 43 degrees C for 30 min, the serum levels of both LH and FSH were raised within 3 days and remained so up to 50 days after treatment. After X-irradiation, no changes in the concentration of FSH were observed in the first 21 days after treatment, but the serum levels of both gonadotrophins were increased at 49 days. By comparing the relative increases in the concentrations of FSH and LH after germ cell damage with those occurring after castration, it was evident that testicular androgens could account for only part of the normal feedback control of FSH secretion; at least one third of the inhibition of FSH secretion appeared to be due to non-androgenic sources, presumably 'inhibin'.

Drugs and the blood-testis barrier.

The functional and morphological evidence for the blood-testis barrier is discussed, together with evidence for the various processes (simple diffusion and facilitated diffusion) by which various substances enter the seminiferous tubule. Data are presented to show that methylmethane-sulfonate (MMS) and dimethylnitrosamine (DMNA) both enter the seminiferous tubules rapidly, although from the published rates of methylation of testicular DNA, by these two compounds, it might be expected that the entry of DMNA would be slower than that of MMS. It appears, however, that DMNA in blood is gradually converted to some nonpermeant compound. The possibility, as yet unsubstantiated, is discussed that a nontoxic permeant precursor may be converted into a nonpermeant toxic substance inside the tubules, thereby effectively concentrating the toxic compound inside the tubules.