Burden of HIV and treatment outcomes among TB patients in rural Kenya: a 9-year longitudinal study.

BACKGROUND: Although tuberculosis (TB) patients coinfected with HIV are at risk of poor treatment outcomes, there is paucity of data on changing trends of TB/HIV co-infection and their treatment outcomes. This study aims to estimate the burden of TB/HIV co-infection over time, describe the treatment available to TB/HIV patients and estimate the effect of TB/HIV co-infection on TB treatment outcomes. METHODS: This was a retrospective data analyses from TB surveillance in two counties in Kenya (Nyeri and Kilifi): 2012‒2020. All TB patients aged ≥ 18 years were included. The main exposure was HIV status categorised as infected, negative or unknown status. World Health Organization TB treatment outcomes were explored; cured, treatment complete, failed treatment, defaulted/lost-to-follow-up, died and transferred out. Time at risk was from date of starting TB treatment to six months later/date of the event and Cox proportion with shared frailties models were used to estimate effects of TB/HIV co-infection on TB treatment outcomes. RESULTS: The study includes 27,285 patients, median (IQR) 37 (29‒49) years old and 64% male. 23,986 (88%) were new TB cases and 91% were started on 2RHZE/4RH anti-TB regimen. Overall, 7879 (29%, 95% 28‒30%) were HIV infected. The proportion of HIV infected patient was 32% in 2012 and declined to 24% in 2020 (trend P-value = 0.01). Uptake of ARTs (95%) and cotrimoxazole prophylaxis (99%) was high. Overall, 84% patients completed six months TB treatment, 2084 (7.6%) died, 4.3% LTFU, 0.9% treatment failure and 2.8% transferred out. HIV status was associated with lower odds of completing TB treatment: infected Vs negative (aOR 0.56 (95%CI 0.52‒0.61) and unknown vs negative (aOR 0.57 (95%CI 0.44‒0.73). Both HIV infected and unknown status were associated with higher hazard of death: (aHR 2.40 (95%CI 2.18‒2.63) and 1.93 (95%CI 1.44‒2.56)) respectively and defaulting treatment/LTFU: aHR 1.16 (95%CI 1.01‒1.32) and 1.55 (95%CI 1.02‒2.35)) respectively. HIV status had no effect on hazard of transferring out and treatment failure. CONCLUSION: The overall burden of TB/HIV coinfection was within previous pooled estimate. Our findings support the need for systematic HIV testing as those with unknown status had similar TB treatment outcomes as the HIV infected.

Sources of funding for research articles in medical education journals from 1999 to 2019.

BACKGROUND: Prior studies report that most published medical education research is unfunded. We sought to determine the extent and sources of funding for medical education research articles published in leading journals, and how these have changed in the last two decades. METHODS: All research articles published in Academic Medicine, Advances in Health Sciences Education, Medical Education and Medical Teacher in 1999, 2004, 2009, 2014, and 2019 were reviewed for funding declarations. Funding sources were categorised as: government; university; healthcare organisation; private not-for-profit organisation; and for-profit company. Time trends were analysed using the Cochran-Armitage test. RESULTS: 1822 articles were analysed. Over the aggregate 20-year period, 44% of all articles reported funding, with the proportion increasing from 30% in 1999 to 50% in 2019 (p < .001). The proportion of articles with government (10% to 16%, p = .049), university (6% to 17% p < .001), and not-for-profit funding sources (15% to 20%, p = .04) increased. Proportions of healthcare (3% to 4%, p = .45) and for-profit funding (2% to 1%, p = .25) did not significantly change with time. CONCLUSIONS: Over the last 20 years, the proportion of funded published medical education research has significantly increased, as has funding from government, universities, and not-for-profit sources. This may assist researchers in identifying funders with a track record of supporting medical education research, and enhances transparency of where research funding in the field originates.

Breaking Borders: How Barriers to Global Mobility Hinder International Partnerships in Academic Medicine.

This article describes the authors' personal experiences of collaborating across international borders in academic research. International collaboration in academic medicine is one of the most important ways by which research and innovation develop globally. However, the intersections among colonialism, academic medicine, and global health research have created a neocolonial narrative that perpetuates inequalities in global health partnerships. The authors critically examine the visa process as an example of a racist practice to show how the challenges of blocked mobility increase inequality and thwart research endeavors. Visas are used to limit mobility across certain borders, and this limitation hinders international collaborations in academic medicine. The authors discuss the concept of social closure and how limits to global mobility for scholars from low- and middle-income countries perpetuate a cycle of dependence on scholars who have virtually barrier-free global mobility-these scholars being mainly from high-income countries. Given the current sociopolitical milieu of increasing border controls and fears of illegal immigration, the authors' experiences expose what is at stake for academic medicine when the political sphere, focused on tightening border security, and the medical realm, striving to build international research collaborations, intersect. Creating more equitable global partnerships in research requires a shift from the current paradigm that dominates most international partnerships and causes injury to African scholars.

"Turning Point": Evaluating the Impact of a Three-Month UK-Based Clinical Education Training Programme for Physicians from a Chinese Medical School.

PURPOSE: Transnational faculty development programmes are increasingly popular in medicine, although evaluation of such activities rarely consider longer-term outcomes or the impact of language training. This study attempts to fill this gap by evaluating the lasting impacts of a three-month clinical education and English language training programme at University College London Medical School, UK, for medical educators from Ningbo University, China. METHODS: In-depth, semi-structured interviews were conducted in China with 41 participants who had completed the programme between 2013 and 2018. Interview data were analysed using an inductive thematic analysis, and themes were categorised using the four primary components of the faculty development model outlined by Irby and O'Sullivan (2011) - context, facilitator, programme, and participant. RESULTS: Contextual impacts included the importance of participants learning in the familiar environment of their own clinical discipline, the cultural enrichment gained by spending time overseas, reflecting on differences in health-care systems, and attempts to implement and disseminate learning on return to China. Facilitator-related factors included new insights into the student-educator relationship and valuing the support of programme mentors. Programme-related factors included exposure to new teaching methods and technical presentation skills, the challenges of navigating observership placements, spoken English language and pronunciation issues, and establishing a peer network of medical educators. Participant-related factors included improved confidence and self-reflection, adjusting educational approaches for different student groups, and career development in medical education. CONCLUSION: Participants gained teaching confidence from their engagement in the programme and many described it as a turning point in their careers as educators. Although in the period after attending, individuals changed their own practices and influenced colleagues within their organisation, often through taking on senior roles, systematic education changes were generally not implemented. Dedicated English language classes and clinical placements were considered the most positive features of the programme.

Medication-taking experiences in attention deficit hyperactivity disorder: a systematic review.

Background: Although attention deficit hyperactivity disorder (ADHD) is a common condition for which pharmacotherapy is considered an effective treatment, guidelines on the treatment of ADHD have been challenging to implement. Considering the views of patients and caregivers involved in medication-taking could help shed light on these challenges. Objective: This review combines the findings of individual studies of medication-taking experiences in ADHD in order to guide clinicians to effectively share decisions about treatment. Methods: Five databases (MEDLINE, Embase, PsycINFO, SCOPUS and CINAHL) were systematically searched for relevant published research articles. Articles were assessed for quality using a Critical Appraisal Skills Programme checklist, and synthesis was performed using meta-ethnography. Results: Thirty-one articles were included in the final synthesis, comprising studies of caregivers, paediatric patients and adult patients across seven countries. Findings were categorized into five different constructs, including coming to terms with ADHD, anticipated concerns about medication, experiences of the effects of medication, external influences and the development of self-management. The synthesis demonstrates that decisions surrounding medication-taking for ADHD evolve as the child patient enters adulthood and moves towards autonomy and self-management. In all parts of this journey, decisions are shaped by a series of 'trade-offs', where potential benefits and harms of medication are weighed up. Conclusions: This review offers a comprehensive insight into medication-taking experiences in ADHD. By considering the shifting locus of decision-making over time and the need for individuals and families to reconcile a variety of external influences, primary care and mental health clinicians can engage in holistic conversations with their patients to share decisions effectively.

Medication taking in coronary artery disease: a systematic review and qualitative synthesis.

PURPOSE: Despite the compelling evidence supporting cardiovascular medications in the secondary prevention of coronary artery disease, many patients discontinue treatment. In this synthesis, we sought to understand from a patient perspective the factors that promote medication persistence. METHODS: We systematically searched 7 databases (MEDLINE, Embase, PsycINFO, SCOPUS, CINAHL, ASSIA, and SSCI) for published qualitative research about the medication-taking experiences of patients with coronary artery disease and their partners. Articles were assessed for quality using a modified CASP (Critical Appraisal Skills Programme) checklist. Synthesis was undertaken using well-established meta-ethnographic approaches. RESULTS: We included 17 articles in the final synthesis from the United Kingdom (6), Europe (5), United States (4), China (1), and Australia (1), with a total sample size of 391 patients. Analyses suggested that some patients hold fatalistic beliefs about their disease, whereas others believe they have been cured by interventions; both can lead to failure to take medication. Patients who adapt to being a "heart patient" are positive about medication taking. Some individuals dislike taking tablets generally and are wary of long-term effects. Relationships with prescribing clinicians are of critical importance for patients, with inaccessibility and insensitive terminology negatively affecting patients' perceptions about treatments. CONCLUSIONS: Strategies to promote higher persistence of secondary prevention medications in patients with coronary artery disease need to recognize the key role of the prescribing clinician. Providing medication-specific information at the time of initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may all help to modify patient attitudes toward drugs to prevent further cardiovascular disease.