Latent TB infection and pulmonary TB disease among patients with diabetes mellitus in Bandung, Indonesia.

Background: Screening and treatment of latent TB infection (LTBI) and TB disease could reduce diabetes mellitus (DM)-associated TB. We aimed to describe the prevalence of LTBI and pulmonary TB among patients with DM in a TB-endemic setting. Methods: Patients with DM attending a hospital and community centres in Bandung, Indonesia, underwent LTBI screening using interferon gamma release assay (IGRA). TB was investigated by sputum smear, culture and x-ray. TB contacts from a parallel study were age- and sex-matched to patients with DM to compare LTBI and TB disease prevalence. Results: Of 682 patients with DM screened, 651 (95.5%) were eligible. Among 'TB disease-free' patients, LTBI prevalence was 38.9% (206/530; 95% CI 34.7-43.2). Patients with DM were less likely to be IGRA positive than TB contacts (38.6%, 54/140; 95% CI 30.5-46.6 vs 68.6%, 96/140; 95% CI 60.9-72.3: p<0.001); but had a higher disease prevalence (4.9%, 8/164; 95% CI 1.6-8.2 vs 1.2%, 2/164; 95% CI -0.5 to 2.9: p=0.054). Patients with DM in crowded households had increased risk of LTBI (AOR 1.71; 95% CI 1.19-2.45). Conclusions: LTBI prevalence in patients with DM was lower than in household contacts, but patients with DM were more likely to have TB disease. Further studies should explore possible benefits of LTBI screening and preventive therapy in patients with DM in TB-endemic settings.

Health-related quality of life and Chlamydia trachomatis infection in sexually experienced female inner-city students: a community-based cross-sectional study.

This cross-sectional study was undertaken to compare health-related quality of life (EQ-5D) in women with and without undiagnosed Chlamydia trachomatis infection. We analysed data from 2401 multi-ethnic sexually active female students aged 16-27 years who were recruited to a randomised controlled trial of chlamydia screening - the prevention of pelvic infection trial in 2004-2006. At recruitment, all participants were asked to provide self-taken vaginal swabs for chlamydia testing and to complete a sexual health questionnaire including quality of life (EQ-5D). Most women (69%) had an EQ-5D of one representing 'perfect health' in the five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. We therefore compared the proportion of women with an EQ-5D score < 1 implying 'less than perfect health' in women with and without chlamydia infection, and women with symptomatic chlamydia versus the remainder. The proportion of women with EQ-5D score < 1 was similar in women with and without undiagnosed chlamydia: 34% (47/138) versus 31% (697/2263; RR 1.11, 95% CI 0.87 to 1.41). However, more women with symptomatic chlamydia had EQ-5D score < 1 than the remainder: 45% (25/55) versus 31% (714/2319; RR 1.47, CI 1.10 to 1.98). In this community-based study, EQ-5D scores were similar in women with and without undiagnosed chlamydia. However, a higher proportion of women with symptomatic chlamydia infection had 'less than perfect health'. Undiagnosed chlamydia infection may not have a major short-term effect on health-related quality of life, but EQ-5D may not be the best tool to measure it in this group.

Which sexually active young female students are most at risk of pelvic inflammatory disease? A prospective study.

OBJECTIVE: To identify risk factors for pelvic inflammatory disease (PID) in female students. METHODS: We performed a prospective study set in 11 universities and 9 further education colleges in London. In 2004-2006, 2529 sexually experienced, multiethnic, female students, mean age 20.8 years, provided self-taken vaginal samples and completed questionnaires at recruitment to the Prevention of Pelvic Infection chlamydia screening trial. After 12 months, they were followed up by questionnaire backed by medical record search and assessed for PID by blinded genitourinary medicine physicians. RESULTS: Of 2004 (79%) participants who reported numbers of sexual partners during follow-up, 32 (1.6%, 95% CI 1.1% to 2.2%) were diagnosed with PID. The strongest predictor of PID was baseline Chlamydia trachomatis (relative risk (RR) 5.7, 95% CI 2.6 to 15.6). After adjustment for baseline C. trachomatis, significant predictors of PID were ≥2 sexual partners or a new sexual partner during follow-up (RR 4.0, 95% CI 1.8 to 8.5; RR 2.8, 95% CI 1.3 to 6.3), age <20 years (RR 3.3, 95% CI 1.5 to 7.0), recruitment from a further education college rather than a university (RR 2.6, 95% CI 1.3 to 5.3) and history at baseline of vaginal discharge (RR 2.7, 95% CI 1.2 to 5.8) or pelvic pain (RR 4.1, 95% CI 2.0 to 8.3) in the previous six months. Bacterial vaginosis and Mycoplasma genitalium infection were no longer significantly associated with PID after adjustment for baseline C. trachomatis. CONCLUSIONS: Multiple or new partners in the last 12 months, age <20 years and attending a further education college rather than a university were risk factors for PID after adjustment for baseline C. trachomatis infection. Sexual health education and screening programmes could be targeted at these high-risk groups. TRIAL REGISTRATION NUMBER: (ClinicalTrials.gov NCT00115388).

Which sexually active female students get themselves tested for Chlamydia trachomatis? A cohort study.

Using data from the Prevention of Pelvic Infection (POPI) chlamydia screening trial, we compared the characteristics of female students who did or did not get tested for chlamydia outside the trial during 12 months' follow-up. Of the 2529 women in the trial, we excluded 68 chlamydia positives in the intervention group who were referred for treatment at baseline. Of the remaining 2461 women, 1980 (80%) answered the question about testing during follow-up on their 12 months' questionnaire and were included in the cohort. Of 1980 respondents, 529 (27%) reported having an independent chlamydia test, including 30 (48%) of 63 women with undiagnosed chlamydia at baseline. Predictors of testing included having undiagnosed chlamydia at baseline (adjusted odds ratio 2.44; 95% confidence interval 1.39-4.28), ≥2 sexual partners in the year prior to baseline (OR 1.99; 95% CI 1.60-2.48), history of sexually transmitted infection (1.63: 1.20-2.22); symptoms of pelvic discomfort, dyspareunia, abnormal vaginal discharge or inter-menstrual bleeding (1.38; 1.09-1.73); and black ethnicity (1.37, 1.06-1.76). Although more women with risk factors got tested, half of women with undiagnosed chlamydia did not get tested. To optimise detection of chlamydia, testing should be offered routinely.

Frequency and risk factors for incident and redetected Chlamydia trachomatis infection in sexually active, young, multi-ethnic women: a community based cohort study.

OBJECTIVE: To investigate the frequency and risk factors for incident and redetected Chlamydia trachomatis infection in sexually active, young, multi-ethnic women in the community. DESIGN: Cohort study. SETTING: 20 London universities and Further Education colleges. PARTICIPANTS: 954 sexually experienced women, mean age 21.5 years (range 16-27), 26% from ethnic minorities, who were recruited to the Prevention of Pelvic Infection (POPI) chlamydia screening trial between 2004 and 2006, and returned repeat postal self-taken vaginal swabs 11-32 (median 16) months after recruitment. RESULTS: The estimated annual incidence of chlamydia infection among 907 women who tested negative at baseline was 3.4 per 100 person-years (95% CI 2.5 to 4.6 per 100 person-years), but 6.6 per 100 person-years (95% CI 4.5 to 9.3 per 100 person-years) in the 326 teenagers (<20 years). Predictors of incident chlamydia infection were age <20 years (relative risk (RR) 4.0, 95% CI 2.1 to 7.5), and (after adjusting for age) a new sexual partner during 12 months follow-up (RR 4.4, 95% CI 2.0 to 9.9), smoking (RR 2.2 95% CI 1.2 to 3.9), concurrent bacterial vaginosis (RR 2.0 95% CI 1.1 to 3.9) and high risk carcinogenic human papillomavirus (RR 2.2, 95% CI 1.1 to 4.3). Of 47 women positive for chlamydia at baseline, 12 (25.5%, 95% CI 13.9% to 40.3%) had redetected infection at a median of 16 months follow-up. Taking into account follow-up time (65 person-years), the annual redetection rate was 18.5 per 100 person-years (95% CI 9.9 to 30.0 per 100 person-years). CONCLUSIONS: One in four women with chlamydia infection at baseline retested positive, supporting recent recommendations to routinely retest chlamydia positives.

Evaluation of a specialist nurse-led hypertension clinic with consultant backup in two inner city general practices: randomized controlled trial.

BACKGROUND: Although practice nurses are increasingly involved in hypertension management, there is little robust evidence of effectiveness. OBJECTIVE: To evaluate the effect of a specialist nurse-led hypertension clinic with consultant backup on change in systolic blood pressure. DESIGN: Randomized trial. SETTING: Two inner city general practices. Participants. Three hundred and fifty-three patients, mean age 62 years (range 18-99), with last recorded blood pressure ≥ British Hypertension Society audit standard were randomly allocated to the nurse-led clinic or usual care. Intervention. Patients received a letter informing them that their last blood pressure was over target and inviting them to the clinic. After assessment at the clinic, the nurse discussed any changes in anti-hypertensive treatment with a visiting consultant and the patient's GP, and followed up the patient over 6 months until blood pressure targets were achieved. MAIN OUTCOME MEASURE: Reduction in systolic blood pressure, assessed using two audits of the practices' computerized records where blood pressure was measured independently by practice staff before and after the intervention period. RESULTS: Follow-up was 89% (313/353). There was greater reduction in systolic blood pressure in the clinic group (n = 144) than usual care group (n = 169, adjusted difference 4.4 mmHg; 95% CI 0.7 to 8.2). Of 167 patients randomly selected for the clinic, 91 (55%) attended, 49 had blood pressure above target when measured according to protocol and 26 had their anti-hypertensive treatment intensified by their GP. CONCLUSION: Invitation to a specialist nurse-led hypertension clinic with consultant back up was associated with reduced systolic blood pressure.

Home blood pressure monitoring in hypertensive stroke patients: a prospective cohort study following a randomized controlled trial.

BACKGROUND: We found little data on long-term home blood pressure monitoring in stroke patients. OBJECTIVES: After completing a 12-month trial of home monitoring in hypertensive stroke patients, we investigated the following: 1. The proportion of 118 control patients offered a monitor at the end of the trial without nurse support who used it at least monthly after 6 months. 2. The proportion of 119 intervention patients continuing to use their monitor monthly after 18 months. 3. Possible predictors of monitoring weekly in the first month after receiving a monitor: age, gender, ethnicity, cognition, anxiety, disability, ability to monitor blood pressure unaided and smoking. METHODS: Participants (mean age 71, 34% with disability and 21% from ethnic minorities) were surveyed 1 and/or 6 months after the trial ended by postal and/or telephone questionnaire. RESULTS: Of 237 potential participants, 53 (22%) declined, 16 (6%) were lost and 9 (4%) died during follow-up. Overall, reported monthly use of the monitor without nurse support was 47% [54/114, 95% confidence interval (CI) 38.2-56.5] at 6 months and 50% (57/114, 95% CI 40.8-59.2) at 18 months. Participants who monitored weekly after 1 month were more likely than the remainder to have no disability [Rankin score ≤ 1; relative risk (RR) 1.2; 95% CI 1.0-1.5] and low anxiety levels (FEAR score = 0; RR 1.5; 95% CI 1.1-2.0). CONCLUSION: Around half of hypertensive stroke patients offered a blood pressure monitor but no support continued to use it after 6 and 18 months. Monitoring in the first month was common in those who were not anxious or disabled.

How reliable are stroke patients' reports of their numbers of general practice consultations over 12 months?

BACKGROUND: Data on primary health care use are frequently used in economic evaluations. However, it is unclear how patient self-reports of their number of consultations with their general practitioner (GP) relate to actual consultations in the electronic records. These data are crucial if self-reports are used to conduct economic evaluations. OBJECTIVES: To report the accuracy of stroke patients' self-reports of their number of primary care consultations over a 12-month period by comparison with practice-held electronic records. We also recorded the number of contacts required to collect service use data from the practices. METHODS: We contacted 65 practices requesting electronic consultation records over 12 months for 115 stroke patients who took part in a trial of home blood pressure monitoring. Consultation rates from the electronic records were compared with patients' self-reported number of consultations from a questionnaire covering the same period. RESULTS: Fifty-one practices (78%) responded. Patients' questionnaires (n = 83) reported a mean of 5.7 consultations with their GP per year compared with 7.2 in the electronic records (difference 1.6, 95% confidence interval 0.5-2.7, P < 0.01). The mean time taken to obtain records from practices was 6 weeks. CONCLUSIONS: Patients modestly under-reported the number of consultations they had with a GP. Obtaining patient records from practices required more effort than obtaining information from patient questionnaires at the same time as assessing main trial outcomes. If patient self-reports of health care usage are used in economic evaluations in primary care, researchers should consider validating a sample against electronic records.

Where do sexually active female London students go to access healthcare? Evidence from the POPI (Prevention of Pelvic Infection) chlamydia screening trial.

BACKGROUND: Little is known about where sexually active female students access healthcare. OBJECTIVES: Using data from the Prevention of Pelvic Infection (POPI) cohort, the authors aimed to: Describe where sexually active female students aged ≤ 27 years reported accessing healthcare. Investigate the association between numbers of sexual partners during 12 months of follow-up and healthcare usage, health-related quality of life (EQ-5D) and demographic and behavioural characteristics. METHODS: Participants provided vaginal swabs and completed questionnaires on sexual health and quality of life at baseline and at a 12-month follow-up. The follow-up questionnaire also asked about healthcare attendances during the previous 12 months. Mann-Whitney tests were used to relate healthcare seeking behaviour and other characteristics to reported numbers of partners during follow-up. RESULTS: Of 1865 women included in the analysis, 79% paid at least one visit to their general practice during follow-up, 23% attended an accident and emergency/walk-in clinic, 21% a family planning clinic and 14% a genitourinary medicine clinic. As the number of sexual partners increased (0-1, 2-3, 4+), women were more likely to have visited a genitourinary medicine clinic (10%, 16%, 30%, p<0.001) or accident and emergency/walk-in clinic (21%, 26%, 29%, p<0.002). Women with more sexual partners were also more likely to smoke, use condoms, be aged <16 years at sexual debut, have bacterial vaginosis, chlamydia or gonorrhoea at baseline and to have lower EQ5-D scores. CONCLUSION: This is the first UK study of healthcare attendance in multiethnic female students recruited outside healthcare settings. The high attendance in general practice may represent a valuable opportunity for screening for sexually transmitted infections.

Demographics and diagnoses at rural health camps in Nepal: cross-sectional study.

BACKGROUND: The charity 'Health Partnership Nepal' is committed to both improving global health care and providing medical training links between Nepal and the UK. This paper analyses data gathered at rural health camps. AIM: To describe the demographics, diagnoses and treatments offered to people attending three rural health camps in Nepal during 2009. Design Cross-sectional study. Setting Three free health care camps established within the Nuwakot district of Nepal during April-May 2009. Camps were staffed by doctors including GPs, nurses and medical students from London and Kathmandu. METHODS: Attendees had treatment sheets completed which recorded their demographics, diagnoses and dispensed medications. RESULTS: The mean age of the 1903 consecutive patients attending was 42.8 years (range one month to 98 years) of whom 68.6% were female and 13.7% were children. The majority, 82.3%, were agricultural workers. For adults (n = 1574), the most frequent complaints were stomach pain 20.1%, musculoskeletal pain 19.3% and visual acuity problems 6.1%. Stomach pain was significantly more common in women than men [21.2% (236/1064) versus 14.5% (65/449) P < 0.01]. For children (n = 249), the most common diagnoses were helminthiasis 10.4%, conjunctivitis 7.6% and upper respiratory tract infection 7.2%. Overall, opthalmological, gastroenterological and rheumatological diagnoses were significantly more common in Nepalese than UK general practice patients. Of 1109 recorded prescriptions, the most common were multivitamins 23%, oral analgesics 15% and oral antibiotics 14%. CONCLUSIONS: There is a considerable unmet disease burden within rural districts of Nepal particularly for stomach pain, musculoskeletal pain and visual acuity problems. When planning similar rurally based health camps, we recommend recruiting GPs and ophthalmologists.