Health-seeking pathway of drug-resistant TB patients in Vadodara, India.

BACKGROUND: Health-seeking behaviour refers to patients' choices regarding their preferred healthcare destination and the timing of seeking assistance for treatment. Patients with TB usually first approach the private sector and/or lose several months' time in inappropriate diagnosis and treatment due to lack of awareness regarding the availability of standard treatment protocols. This can lead to poor outcomes such as drug-resistant TB (DR-TB) and/or death. METHODOLOGY: A cross-sectional study was conducted to examine the health-seeking pathway and delays in diagnosis and initiation of DR-TB treatment among patients registered with the DR-TB centre in Vadodara District (India). RESULTS: A total of 93 patients were enrolled in the study; the median age was 35 years (IQR 24-45). For the first visit, 59 (63%) patients chose a public healthcare facility, mainly because the facility was near their residence (n = 20, 21.5%). The median delay in reaching the first healthcare facility was 12 days (IQR 7.5-30). Delay in reaching second- and third-level care was respectively 25 days (IQR 9-68) and 16 days (IQR 4-67). CONCLUSION: Two-thirds of patients required visits to a second healthcare centre for diagnosis, while one third needed a third visit. The overall median delay for reaching the DR-TB centre was 60 days (IQR 26-122). The median duration from symptom onset to the first healthcare contact fell within the timeframe for screening symptoms in standard diagnosis.

CONTEXTE: Le comportement de recherche de santé fait référence aux choix des patients concernant leur destination préférée en matière de soins de santé et le moment où ils recherchent de l'aide pour le traitement. Les patients atteints de TB s'adressent généralement en premier lieu au secteur privé et/ou perdent plusieurs mois en diagnostics et traitements inappropriés en raison d'un manque d'information sur la disponibilité des protocoles de traitement standard. Cela peut conduire à des résultats médiocres tels que la TB résistante aux médicaments (DR-TB, pour l'anglais « drug-resistant TB ¼) et/ou la mort. MÉTHODOLOGIE: Une étude transversale a été menée pour examiner le parcours de recherche de soins et les retards dans le diagnostic et l'initiation du traitement de la DR-TB parmi les patients enregistrés au centre de DR-TB dans le district de Vadodara (Inde). RÉSULTATS: Au total, 93 patients ont participé à l'étude ; l'âge médian était de 35 ans (IQR 24­45). Pour la première visite, 59 patients (63%) ont choisi un établissement de santé public, principalement parce que l'établissement était proche de leur résidence (n = 20 ; 21,5%). Le délai médian pour atteindre le premier établissement de santé était de 12 jours (IQR 7,5­30). Le délai pour atteindre le deuxième et le troisième niveau de soins était respectivement de 25 jours (IQR 9­68) et de 16 jours (IQR 4­67). CONCLUSION: Deux tiers des patients ont dû se rendre dans un deuxième centre de soins pour obtenir un diagnostic, tandis qu'un tiers a dû se rendre dans un troisième centre. Le délai médian global pour atteindre le centre de lutte contre la TB était de 60 jours (IQR 26­122). La durée médiane entre l'apparition des symptômes et le premier contact avec les soins de santé correspondait au délai de dépistage des symptômes dans le cadre du diagnostic standard.

Specific allergen immunotherapy for the treatment of atopic eczema: a Cochrane systematic review.

BACKGROUND: Specific allergen immunotherapy (SIT) is an effective allergy treatment, but it is unclear whether SIT is effective for atopic eczema (AE). We undertook a systematic review to assess SIT efficacy and safety for treating AE. METHODS: We searched databases, ongoing clinical trials registers, and conference proceedings up to July 2015. Randomized controlled trials (RCTs) of SIT using standardized allergen extracts, compared with placebo/control, for treating AE in patients with allergic sensitization were eligible. RESULTS: We identified 12 eligible trials with 733 participants. Interventions included subcutaneous (six trials), sublingual (four trials), oral or intradermal SIT in children/adults allergic to house dust mite (10 trials), grass pollen or other inhalants. Risk of bias was moderate, with high loss to follow-up and nonblinding as the main concerns. For our primary outcomes, three studies (208 participants) reported no significant difference - patient-reported global disease severity improvement RR 0.75 (95% CI 0.45, 1.26); and eczema symptoms mean difference -0.74 on a 20-point scale (95% CI -1.98, 0.50). Two studies (85 participants) reported a significant difference - SIT improved global disease severity RR 2.85 (95% CI 1.02, 7.96); and itch mean difference -4.20 on a 10-point scale (95% CI -3.69, -4.71). Meta-analysis was limited due to extreme statistical heterogeneity. For some secondary outcomes, meta-analyses showed benefits for SIT, for example investigator-rated improvement in eczema severity RR 1.48 (95% CI 1.16, 1.88; six trials, 262 participants). We found no evidence of adverse effects. The overall quality of evidence was low. CONCLUSION: We found no consistent evidence that SIT is effective for treating AE, but due to the low quality of evidence further research is needed to establish whether SIT has a role in AE treatment.

What drives junior doctors to use clinical practice guidelines? A national cross-sectional survey of foundation doctors in England & Wales.

BACKGROUND: Clinical practice guidelines (CPGs) aim to improve patient care, but their use remains variable. We explored attitudes that influence CPG use amongst newly qualified doctors. METHODS: A self-completed, anonymous questionnaire was sent to all Foundation Doctors in England and Wales between December 2012 and May 2013. We included questions designed to measure the 11 domains of the validated Theoretical Domains Framework (TDF). We correlated these responses to questions assessing current and future intention to use CPGs. RESULTS: A total of 13,138 doctors were invited of which 1693 [corrected] (13 %) responded. 1,035 (62.5 %) reported regular CPG use with 575 (34.4 %) applying CPGs 2-3 times per week. A significant minority of 606 (36.6 %) declared an inability to critically appraise evidence. Despite efforts to design a questionnaire that captured the domains of the TDF, the domain scales created had low internal reliability. Using previously published studies and input from an expert statistical group, an alternative model was sought using exploratory factor analysis. Five alternative domains were identified. These were judged to represent: "confidence", "familiarity", "commitment and duty", "time" and "perceived benefits". Using regression analyses, the first three were noted as consistent predictors of both current and future intentions to use CPGs in decreasing strength order. CONCLUSIONS: In this large survey of newly qualified doctors, "confidence", "familiarity" and "commitment and duty" were identified as domains that influence use of CPGs in frontline practice. Additionally, a significant minority were not confident in critically appraising evidence. Our findings suggest a number of approaches that may be taken to improve junior doctors' commitment to CPGs through processes that increase their confidence and familiarity in using CPGs. Despite limitations of a self-reported survey and potential non-response bias, these findings are from a large representative sample and a review of existing implementation strategies may be warranted based on these findings.

Transient pseudohypoaldosteronism masquerading as congenital adrenal hyperplasia.

We report a six-week-old boy with genitourinary structural abnormalities who presented with profound hyponatraemia and hyperkalaemia due to transient type 1 pseudohypoaldosteronism (PHA) precipitated by a urinary tract infection (UTI), which responded rapidly to intravenous saline and antibiotics. In infants with structural abnormalities of the urinary tract, we wish to highlight the importance of recognizing type 1 PHA and its association with a UTI since prompt and appropriate treatment rapidly corrects the associated metabolic abnormalities. Conversely, the identification of type 1 PHA in an infant should precipitate a search for a UTI and structural abnormalities of the urinary tract.