How tuberculosis programs can navigate the world of social health insurance.

Many countries with a high tuberculosis (TB) burden are adopting social health insurance (SHI) schemes. However, the national TB programs (NTPs) of these countries are only just starting to grapple with the effects of SHI on their operations. Here, we review the rationale for analyzing TB programs in light of the changes brought by SHI. We consider the influence of certain purchasing decisions on TB care and prevention, and the opportunities that SHI may present for NTPs to broaden private sector engagement, extract TB data across the health sector, and facilitate quality improvement efforts. We also explore which functions are likely to be performed by SHI systems, which require special attention with the advent of SHI, and the metrics that indicate how much of TB care seeking and treatment can be reached and influenced by SHI. SHI presents certain risks for TB programs, but also opportunities to adapt to a more modern health system and to bring quality TB care and treatment to more people.

Reproductive tract disorders among Afghan refugee women attending health clinics in Haripur, Pakistan.

Afghans comprise one of the largest groups of refugees in the world, with the majority living in Pakistan. The objective of this study was to identify commonly-occurring reproductive tract infections (RTIs), describe knowledge of women about RTIs, and assess physical and behavioural factors contributing to the development of RTIs. Afghan women presenting at Basic Health Units in refugee camps in Haripur, Pakistan, with reproductive health-related complaints, were included in the study (n=634). Data collection included implementation of an interviewer-administered questionnaire, along with a physical examination and laboratory tests. A descriptive analysis was conducted first. Qualitative data were coded and analyzed using predetermined themes. Chi-square test was used for determining the possible relationships between a binary outcome and categorical risk factors. Over three-fourths (76.7%) of those who reported to the health clinics with reproductive complaints had an RTI. Nearly half (49.5%) of these women were diagnosed with some form of vaginitis, and 14.7% were diagnosed with clinical suspicion of pelvic inflammatory disease (PID). Women with cervical prolapse (p = 0.033) or who cleansed after intercourse (p = 0.002) were more likely to have vaginitis. There was a significant difference (p = 0.017) in the prevalence of suspected PID among women who used mud only (11.1%), any water (18.8%), and an old cloth or toilet paper (9.8%) for cleansing after defaecation. Specific physical and behavioural contributors to the high prevalence of RTIs in this population were identified, and recommendations to ameliorate these factors are offered.

Impact of clean delivery kit use on clean delivery practices in Beni Suef Governorate, Egypt.

OBJECTIVE: A major factor contributing to neonatal and maternal infections is unhygienic delivery practices. This study explores the impact of clean delivery kit (CDK) use on clean delivery practices during home and facility deliveries. DESIGN: Kits were distributed from primary care facilities and mothers and birth attendants received training on kit importance and use. The study was designed as a cross-sectional cohort study. Raedat (community health workers) visited 349 women during the postpartum period to administer a structured questionnaire. SETTING: The study was conducted from mid-March through mid-July 2001 in two rural areas of Ihnasia district in Beni Suef Governorate (Upper Egypt). RESULT: In bivariate analysis, CDK users in the home were more likely to report that the birth attendant had clean hands (P<0.001), washed/wiped the mother's perineum (P<0.001), used a sterile cord tie (P=0.001), applied antiseptic to the cord after cutting (P<0.001), and used a sterile cord cover (P<0.001) as compared with non-CDK users. CDK users at the facility were more likely to report that the birth attendant washed/wiped the mothers perineum (P=0.049) and used a sterile cord cover (P=0.030) as compared with non-CDK users. CONCLUSION: In settings in which unhygienic practices during home as well as facility deliveries are prevalent, use of inexpensive CDKs can promote clean delivery practices.

Genetic analysis of susceptibility to Chlamydia trachomatis in mouse.

Chlamydia trachomatis is a bacterial pathogen that is a major cause of blindness and infertility in diverse populations across the world. In an effort to model genetic complexities that are observed in human populations and to identify novel genes involved in susceptibility to C. trachomatis, we have adapted a murine model of systemic infection for use in genetic analysis. In this model, chlamydial colonization and replication is measured in the spleens of mice shortly after intravenous delivery of C. trachomatis L2. Here, we show that C57BL/6J and C3H/HeJ inbred mice are differentially susceptible to this systemic infection. Additionally, fibroblasts cultured from C57BL/6J and C3H/HeJ embryos are differentially permissive for chlamydial replication. We have taken advantage of this natural variation to map quantitative trait loci on Chromosomes 2, 3, and 11 that segregate with the bacterial load in F2 cross progeny during the acute phase of C. trachomatis infection in vivo. To validate our mapping results, we also generated mice that are congenic for a portion of Chromosome 11 from the susceptible parent. This congenic interval confers increased susceptibility to C. trachomatis, both in vivo and in vitro, suggesting that our screen identified at least one gene that is involved in cellular resistance to C. trachomatis replication.

Perflubron as an oral contrast agent for MR imaging: results of a phase III clinical trial.

PURPOSE: To assess perflubron for magnetic resonance (MR) imaging in the abdomen and pelvis in a multicenter trial. MATERIALS AND METHODS: MR images were obtained in 127 subjects before and after ingestion of perflubron with T1-, proton-density-, and T2-weighted sequences at 0.38, 1.0, or 1.5 T. Postcontrast images were compared with baseline images, and percentage of additional bowel darkened, distinction of bowel from adjacent tissue, and change in image artifact were graded. RESULTS: Perflubron increased the bowel darkening in over 92% of subjects with all sequences and field strengths. It improved definition of the left lobe of the liver and body and tail of the pancreas in 67%, 29%, and 42% of subjects, respectively, and of the uterus and bladder in 80% and 76%. Abnormal tissue was more conspicuous in 69% of subjects. Highest scores were achieved when the upper abdomen was imaged 5-30 minutes and the pelvis 10-40 minutes after ingestion. No image artifacts or side effects were attributed to perflubron. CONCLUSION: Perflubron is safe, and its efficacy was unaffected by pulse sequences, magnetic field strength, or time delay.

Sonographic appearance of left spermatic vein thrombosis simulating incarcerated inguinal hernia.

We report a case of exercise-induced spontaneous thrombosis of the left spermatic vein. The sonographic appearance mimicked an incarcerated left inguinal hernia by demonstrating a tubular, hypoechoic, noncompressible, cystic appearing inguinal mass with no flow evident on color Doppler imaging.

Accuracy of ultrasound in the diagnosis of acute appendicitis compared with the surgeon's clinical impression.

OBJECTIVE: To compare the accuracy of the surgeon's clinical diagnosis of acute appendicitis with that of an ultrasonographic examination of the abdomen. DESIGN: Prospective trial. SETTING: US Navel Hospital, San Diego, Calif. PATIENTS: One hundred ten patients admitted to the hospital with suspected appendicitis from May 1990 to June 1992. INTERVENTION: Symptoms and signs for each patient were recorded, along with the surgeon's clinical impression of immediate surgery or observation. The patient then underwent an ultrasound examination performed by a staff radiologist. On the basis of the ultrasound findings the patient was placed into one of three categories: appendicitis, normal examination results, or other conditions. Patients with an ultrasound-based diagnosis of appendicitis proceeded to the operation, regardless of the surgeon's clinical impression. Those with other conditions diagnosed with ultrasonography were treated as was appropriate for the condition. RESULTS: The ultrasound-derived diagnosis of appendicitis had a sensitivity of 85.5%, a specificity of 84.4%, a positive predictive value of 88.3%, a negative predictive value of 80.1%, and an overall accuracy of 85.0%. The surgeon's clinical impression at the time of admission had a sensitivity of 62.9%, a specificity of 82.2%, a positive predictive value of 82.9%, a negative predictive value of 61.7%, and an overall accuracy of 71.2%. CONCLUSION: The overall accuracy of ultrasonography in the diagnosis of appendicitis was statistically superior to that of the surgeon's clinical impression (P < .0001). However, 24% of the patients with normal ultrasound findings were ultimately found to have appendicitis at operation, emphasizing the point that ultrasonography cannot be relied on to the exclusion of the surgeon's careful and repeated evaluation.

Self-localization in US of appendicitis: an addition to graded compression.

Graded-compression ultrasound (US) of the right lower quadrant (RLQ) has been a valuable addition to the diagnostic evaluation of acute appendicitis. In an effort to expedite the sonographic evaluation and improve diagnostic accuracy, a method of self-localization was added to the standard graded-compression examination. A total of 236 patients with signs of appendicitis were studied. Eighty-five percent (121 of 142) of the patients with proved appendicitis were able to decisively self-localize their pain. Of the patients without appendicitis who still had significant disease in the RLQ, 88% (29 of 33) were able to self-localize their pain, with an accuracy rate of 86% for significant disease. Among patients without significant disease, only 15% (nine of 61) self-localized their pain. This "sonographic self-localization sign" reduced the time of the examination and was a valuable addition to standard graded-compression US of the appendix.

Tubular ectasia of the testicle: sonographic and MR imaging appearance.

OBJECTIVE: Ectasia of the seminiferous tubules at the level of the mediastinum is a recently recognized benign condition of the testicles. Although it may have typical sonographic features, the condition can at times be difficult to distinguish from tumors on the basis of sonography. We describe the sonographic and MR appearance of this condition in seven men in whom we were able to distinguish tubular ectasia from tumors of the testicles on the basis of the imaging findings. MATERIALS AND METHODS: Ectasia of the seminiferous tubules was histologically proved in a man who had an intratesticular mass seen on sonograms and MR images. We analyzed the sonographic and MR imaging features in this man and in six others who had similar imaging findings but did not have biopsy proof of tubular ectasia. RESULTS: The first patient was a man with bilateral findings who had a unilateral orchiectomy that revealed ectasia of the seminiferous tubules. Spermatocelectomy was performed in another man whose testis was normal on surgical inspection and on subsequent follow-up. Imaging findings have remained unchanged in one man with 3-year imaging follow-up and in three men with clinical follow-up of 8-22 months. One patient was lost to follow-up. At presentation, most of the men were more than 55 years old. All had a scrotal mass typical of a spermatocele on physical examination, with normal testes when the testes could be palpated. The spermatocele was larger than 4 cm in six of 11 involved epididymides. On imaging, in five of the seven patients, the intratesticular process was bilateral, involved the mediastinum testis, began at the periphery adjacent to the spermatocele, and extended for a variable distance within the testis. On sonograms, the lesion was hypoechoic with coarse internal echoes. MR imaging of six of the seven patients showed characteristic findings and allowed the identification of two additional testicles with tubular ectasia that were missed sonographically. Lesions had a homogeneous signal similar to that of the coexisting spermatocele with all pulse sequences. They were hypointense relative to the testis on T1- and proton density-weighted images and, unlike tumors, were not visible on T2-weighted images. CONCLUSION: Our experience suggests that ectasia of the seminiferous tubules can be distinguished from testicular tumor on the basis of characteristic clinical, sonographic, and MR imaging findings. Thus, orchiectomy is unnecessary to establish the diagnosis and to rule out tumor.

Hill-Sachs lesion: comparison of detection with MR imaging, radiography, and arthroscopy.

Magnetic resonance (MR) imaging has proved to be a valuable method for documenting Hill-Sachs lesions. The authors retrospectively analyzed the diagnostic interpretations at plain film radiography, arthroscopy, and MR imaging in 76 patients. The analysis revealed that neither radiography nor arthroscopy displayed the lesion with sufficient accuracy to represent a true standard of reference for the evaluation of MR imaging in the diagnosis of the Hill-Sachs lesion. The data from the diagnostic interpretations were analyzed in three ways, each of which revealed that findings at MR imaging were more helpful than findings at radiography and/or arthroscopy in the diagnosis of the Hill-Sachs lesion. When the agreement of findings in two or three methods was used to assign a final diagnosis, MR imaging resulted in sensitivity of 97%, specificity of 91%, and accuracy of 94% in the detection of Hill-Sachs lesions.

The use of Doppler ultrasound to assist with sciatic nerve blocks.

Twenty consecutive patients requiring surgical procedures on a lower extremity received leg blocks using a modification of Labat's classic approach. A Doppler ultrasound pencil probe was used to identify the dominant arterial structure exiting the sciatic notch with the sciatic nerve. A block needle was inserted in the same orientation as the probe until paraesthesias were elicited; then 25 ml of local anesthetic was injected. Successful block was achieved in one or two attempts in 70% of the patients.

Uterine inner myometrial echogenic foci. Relationship to prior dilatation and curettage and endocervical biopsy.

The frequent presence of small echogenic foci within the inner myometrium in women who have had prior uterine instrumentation is reported. Bright foci were observed in 35 of 80 patients who had had prior dilatation and curettage or endocervical biopsy and in only 2 of 174 patients who gave no history of either procedure (P less than 0.005). These foci tend to be small (3 to 6 mm), linear, usually nonshadowing, single or multiple, and located immediately adjacent to the endometrium anywhere along the length of the endometrial cavity; they can be seen many years after the procedure was performed. The histopathologic features of these foci are unconfirmed, but we suspect they represent calcification or fibrosis at sites of mechanical injury to myometrium. The presence of these foci serves as a marker of prior instrumentation and probably has no clinical significance. However, sonographers who are aware of their possible occurrence, can avoid mistaking them for leiomyoma calcifications or for air in the endometrium or myometrium in patients with suspected endometritis.

CT of the normal appendix.

We conducted a prospective evaluation of the normal vermiform appendix in 203 patients. Conventional CT techniques were utilized with an 8 mm slice thickness and 10 mm slice interval. The normal appendix was definitely identified in 51% of the patients studied. Computed tomographic appearance of the normal appendix is demonstrated, and potential pitfalls are described.

Tears of the glenoid labrum: MR imaging of 88 arthroscopically confirmed cases.

Two hundred eighty-one patients underwent magnetic resonance (MR) imaging of the shoulder over a 2-year period. Eighty-eight patients underwent arthroscopic surgery, and their surgical results were correlated with the findings at MR imaging. MR imaging enabled accurate prediction of anterior labral tears, with a sensitivity of 95%, a specificity of 86%, and an accuracy of 92%. MR imaging was less effective in the prediction of tears of the superior labrum, with a sensitivity of 75%, a specificity of 99%, and an accuracy of 95%. These two categories accounted for the majority of the surgically correctable disease. MR imaging was found to be unreliable in the prediction of posterior (sensitivity, 7.7%) or inferior (sensitivity, 40%) labral tears, isolated cases of which occurred in only two (2%) of those undergoing surgery. MR imaging proved to be a highly accurate, noninvasive technique for the clinical evaluation of shoulder instability.

Prenatal ultrasound detection of intra-abdominal pulmonary sequestration with postnatal MRI correlation.

Extralobar pulmonary sequestration is part of the spectrum of bronchopulmonary-foregut malformations. Intra-abdominal pulmonary sequestration has been described as a cause of a fetal abdominal mass [1-3]. We report a case of intra-abdominal pulmonary sequestration with associated elements of cystic adenomatoid malformation and a gastric duplication cyst detected on prenatal ultrasound with postnatal magnetic resonance imaging correlation.

Suspected testicular torsion and ischemia: evaluation with color Doppler sonography.

Color Doppler sonography was performed in 32 patients with a painful scrotum in whom testicular ischemia from torsion or postherniorrhaphy was clinically suspected. Surgical correlation was available in 15 patients, and scintigraphic correlation was available in 17 patients. Seven of the 32 patients were diagnosed as having testicular ischemia from torsion. Color Doppler flow imaging demonstrated a lack of intratesticular flow in six of the seven testes with torsion and relatively normal intratesticular flow in one of the patients with acute torsion. Normal or increased intratesticular flow was demonstrated by color Doppler in all 57 of the nonischemic testes. Using the single criterion of presence or absence of identifiable intratesticular flow, the authors found that color Doppler was 86% sensitive, 100% specific, and 97% accurate in the diagnosis of torsion and ischemia in the painful scrotum. Color Doppler sonography is an accurate, noninvasive means of rapidly assessing perfusion of the testis in the painful scrotum.

MR image of localized giant cell tumor of the tendon sheath involving the knee.

A case of giant cell tumor of the tendon sheath is presented. The CT and magnetic resonance appearances are described, correlated with pathologic findings, and compared with those of villonodular synovitis.