Enhancing tuberculosis case finding in Tanzania: implementation of a quality improvement initiative.

Tuberculosis (TB) is one of the major causes of morbidity and mortality in Tanzania. A quality improvement (QI) initiative was implemented by the National Tuberculosis Programme with support from The Global Fund to enhance TB case finding. The initiative involved identifying gaps in the quality of services, introducing tools, building capacity of health workers, and strengthening laboratory and referral services. The initiative was piloted at sub-national level and subsequently scaled-up nationally. Overall, 1280 health workers were trained, leading to an 81% cumulative increase in notified TB cases in the pilot region and 4000 additional TB cases notified nationally. The QI initiative could serve as a model for the improvement of TB case notification in other settings.

La tuberculose (TB) est une des causes majeures de morbidité et de mortalité en Tanzanie. Une initiative d'amélioration de la qualité (QI) en trois points a été mise en œuvre par le Programme National Tuberculose avec un soutien du Fonds Mondial pour améliorer la détection des cas de TB. L'initiative a impliqué l'identification des failles de qualité des services de TB, l'introduction d'outils, le renforcement des capacités du personnel de santé, le renforcement du laboratoire TB et des services de référence. L'initiative a été pilotée au niveau sous national et ensuite étendue au niveau national : 1280 personnels de santé ont été formés, la coordination de la QI a été renforcée et ceci a contribué à 81% de l'augmentation cumulée des cas de TB notifiés dans la région pilote et à la notification de 4000 cas de TB supplémentaires au niveau national. L'initiative QI pourrait servir de modèle pour améliorer la notification des cas de TB dans d'autres contextes.

La tuberculosis (TB) es una de las principales causas de morbilidad y mortalidad en Tanzanía. El Programa Nacional contra la Tuberculosis introdujo, con el apoyo del Fondo Mundial, una iniciativa triple de mejoramiento de la calidad (QI) encaminada a reforzar la búsqueda de casos de TB. La iniciativa comportaba el reconocimiento de las deficiencias en la calidad de los servicios de TB, la introducción de instrumentos, el fortalecimiento de la capacidad de los trabajadores de salud y el refuerzo de los laboratorios de TB y los servicios de remisiones. Después de un ensayo piloto a escala subnacional, se amplió la iniciativa a todo el país. Se capacitaron 1280 trabajadores de salud y se reforzó la coordinación de la QI, con lo cual se propició un aumento acumulado de 81% de los casos de TB notificados en la región piloto y la notificación de 4000 casos de TB adicionales a escala nacional. La iniciativa de QI podría servir como modelo para mejorar la notificación de casos de TB en otros entornos.

Performance-based technical support for drug-resistant TB responses: lessons from the Green Light Committee.

Drug-resistant tuberculosis (DR-TB) constitutes a global threat and a major contributor to deaths related to antimicrobial resistance. Despite progress in DR-TB detection and treatment over the last decade, huge gaps remain in treatment coverage, access to quality care and treatment outcome. Global Fund investments have been critical to scaling up the existing and new diagnostic tools, treatment coverage and people-centred service delivery. The United Nations General Assembly (UNGA) high-level meeting represents unprecedented opportunities to accelerate towards addressing DR-TB. Established in 2000 and funded by the Global Fund since 2009, the Green Light Committee (GLC) mechanism has evolved from project approval to providing demand-based technical assistance to countries to scale up response to DR-TB based on their need and priorities. Lessons learnt from the GLC mechanism over 10 years demonstrate that a result-based, systematic and accountable technical assistance model to support scale-up of DR-TB response is critically important. Meeting the UNGA declaration targets requires major scale-up of current efforts and new tools, and hence the need for predictable, consistent and sustained technical support to countries, including through the regional GLC mechanism. The application of the principles and processes of this model could be adapted and replicated to design a similar performance-based and quality-assured technical support mechanism.

Aneurysm of the pulmonary artery. Rare long term complication of central aorto-pulmonary shunts for congenital heart disease. Report of two cases with review of the literature.

Aneurysm of the left pulmonary artery developed in two patients with tetralogy of Fallot at the site of a Potts' shunt. Although such a complication is known we could not find any previously reported case of successful surgical treatment in the literature. Cardiac catheterization and angiography provided the definitive diagnosis. One patient refused surgical intervention but later presented with fatal rupture and massive hemoptysis. Closure of the Potts' shunt, angioplastic repair of the pulmonary artery aneurysm and total correction of tetralogy of Fallot were successfully accomplished using cardiopulmonary bypass and cardioplegic arrest. Aneurysm should be suspected whenever a mediastinal mass appears in patients with a previous systemic-pulmonary artery shunt.

Induction of cardioplegia with blood and crystalloid potassium solutions during prolonged aortic cross-clamping.

Recent controversy concerns the proper vehicle for delivery of potassium cardioplegia. In the present study, adult dogs supported by cardiopulmonary bypass were subjected to 2 hours of multidose, hypothermic potassium cardioplegic arrest with 30 minutes of reperfusion with either autologous blood or crystalloid solution as the cardioplegic vehicle. Preservation of myocardial high-energy nucleotide stores was assessed by serial left ventricular biopsies assayed for adenosine triphosphate (ATP) and creatine phosphate. Preischemic and postischemic ventricular function was assessed by the use of an isovolumic intraventricular balloon. ATP stores were equally maintained at preischemic levels after ischemia and reperfusion by both autologous blood and crystalloid solution. Although creatine phosphate stores significantly declined (P less than 0.01, both groups) after 2 hours of arrest, reperfusion allowed equal restoration of preischemic levels. Maximum first derivative of left ventricular pressure and measured velocity were not depressed by either mode of protection. Similarly, myocardial compliance, as assessed by length-tension curves, showed no change following either autologous blood or crystalloid solution. The data show equal and significant myocardial protection by multidose, hypothermic potassium cardioplegia when both delivery vehicles were used.

Sarcoidosis: a comparative study of diagnostic procedures.

The diagnosis of sarcoidosis, as with other intrathoracic lesions, remains a challenge to the clinician. An adequate history, a thorough physical examination, and the employment of various laboratory tests often establish the diagnosis. When a definitive diagnosis is not made, biopsy of suspected lesions is indicated. Various diagnostic procedures are presented and compared.