Returning to education after childhood acquired brain injury: Learning from lived parental experience.

BACKGROUND: Returning to education (RtE) after an acquired brain injury (ABI) can be stressful for children/young people (CYP) and families. While much can be done to support RtE, there has been limited exploration of the lived experience of parents/carers about what can both help and hinder the process. OBJECTIVE: The aim was to understand more about RtE from parents' perspectives to inform best practice and facilitate improvements in service delivery. METHODS: A service evaluation explored parent/carer views about the RtE process and the support received from healthcare professionals at a regional centre in the UK. Questionnaires (n = 59) were sent to parents of patients treated for an ABI in the last two years. RESULTS: 31 parents (response rate = 51%) completed the survey. Results highlight the many challenges of RtE. Thematic analysis of responses revealed six key themes: Parental mindset and growth; What do they need now?; Specialist support and information; Talk and share; Challenges of new and hidden needs; and Don't forget them! CONCLUSION: Parents offer crucial insight into the challenges of the RtE process. Their feedback highlights important factors for service development and reminds professionals of the key components of an effective return.

Failure of standard tracheostomy decannulation criteria to detect suprastomal pathology.

Meeting established criteria for tracheostomy decannulation should improve success, although there will be a small proportion of patients with a tracheostomy who fail decannulation. Failure rates depend on patient characteristics and disparity between institutional practices and expert opinion. However, there are no widely accepted published failure rates, or agreement on the time-point at which failure is assessed. We present a patient who had evidence of readiness for decannulation, but had immediate failure due to extrinsic tracheal compression, which proved difficult to diagnose and required surgery to resolve. Capping the tracheostomy before decannulation may or may not have given rise to suspicion of potential failure and this practice requires further evaluation as it is not without risk. For subglottic, but suprastomal lesions, nasendoscopy is not of value. It is important to decannulate patients in a safe environment, preferably early in the day to allow post decannulation observations and interventions should they become necessary, and with the close involvement of the multi-professional team. This report illustrates the failure of our standard Tracheostomy decannulation criteria, and direct upper airway view to identify suprastomal tracheal pathology, and we discuss the potential for additional criteria which may have identified the issue before decannulation attempts.

The social implications of participant choice on adherence to Isonaizid Preventive Therapy (IPT): A follow-up study to high completion rates in Eswatini.

BACKGROUND: Eswatini (formerly Swaziland) has one of the highest rates of TB and HIV co-disease in the world. Despite national efforts to improve service delivery and prevent TB and HIV transmission, rates remain high. A recent prospective, observational study of integrated, patient-selected IPT delivery showed extraordinary improvements in IPT adherence, running counter to previous assumptions. This prompted the need to understand contextual and unseen study factors that contributed to high rates of adherence. OBJECTIVE: To investigate high rates of IPT adherence rates among people living with HIV who participated in an observational study comparing modes of IPT delivery. METHODS: Community-based participatory research guided the development of in-person administration of semi-structured questionnaires. Observational and field note data were analyzed. Qualitative data were analyzed using content analysis. RESULTS: We interviewed 150 participants and analyzed responses from the 136 who remembered being given a choice of their IPT delivery method. Fifty-seven percent were female and the median age was 42. Nearly 67% of participants chose to receive facility-based IPT. High rates of self-reported IPT treatment adherence were linked to four key concepts: 1) adherence was positively impacted by community education; 2) disclosure of status served to empower participant completion; 3) mode of delivery perceptions positively impacted adherence; and 4) choice of treatment delivery seen as helpful but not essential for treatment completion. DISCUSSION: Achieving higher rates of IPT adherence in Eswatini and similar rural areas requires community-engaged education and outreach in coordination with care delivery systems.

Tackling drug-resistant tuberculosis: we need a critical synergy of product and process innovations.

The End TB Strategy diagnostic pillar calls for access to high-sensitivity diagnostic testing and universal rapid drug susceptibility testing (DST). The recommended diagnostic technologies available in low and middle-income, high-burden countries for multidrug-resistant tuberculosis (MDR-TB) are essentially limited to Xpert® MTB/RIF and MTB/RIF Ultra assays, culture DST and the line-probe assays. The primary reasons for slow scale-up are insufficient political will, and therefore, insufficient funding for qualified human resources, and safe laboratory and health system infrastructure. Innovative approaches to enable the private health sector to provide high-quality diagnosis are also needed. The Essential Diagnostics List provides impetus and a standard benchmark for the rational implementation of MDR-TB diagnostics, but the epidemic will ultimately only be favorably impacted by complete end-to-end solutions to patients that address the complete cascade of care, including patient-centered diagnosis and treatment of TB and MDR-TB, management of comorbidities and social protection. By scaling up access to the currently available diagnostics, we lay the groundwork for future innovations for rapid accurate diagnosis of MDR-TB, which in turn will bring us closer to meeting the targets in the End TB Strategy.

Integrated and patient-selected care facilitates completion of isoniazid preventive therapy in Eswatini.

SETTING: Five human immunodeficiency virus (HIV) care facilities in Eswatini. OBJECTIVE: To identify critical factors that enabled persons living with HIV to successfully complete a 6-month course of isoniazid preventive therapy (IPT) provided through a choice of facility-based or community-based delivery, coordinated with antiretroviral therapy (ART) refills. DESIGN: This was a mixed methods, retrospective cross-sectional study. RESULTS: Between June and October 2017, we interviewed 150 participants who had completed IPT in the previous year. Fourteen participants did not recall being offered a choice, and were excluded from the analysis. Of the remaining 136, 56.6% were female and 64.7% chose facility-based care; the median age was 42.5 years. Most participants reported that having a choice was important to their treatment completion (87.7%) and that linking IPT and ART refills facilitated undergoing IPT (98.5%). Participants were knowledgeable about the benefits of IPT and valued the education received from their providers. Participants also reported a high rate of IPT disclosure (95%) to friends and family members. CONCLUSION: Offering patients a choice of IPT delivery, linking IPT with ART refills, emphasizing patient education and engagement with healthcare workers, and supporting disclosure of IPT are critical factors to enabling IPT completion. These interventions should be incorporated throughout Eswatini and in similar high tuberculosis and HIV burden settings.

Oxidative ß-C-H sulfonylation of cyclic amines.

A transition metal-free strategy for the dehydrogenative ß-sulfonylation of tertiary cyclic amines is described. N-Iodosuccinimide facilitates regioselective oxidative sulfonylation at C-H bonds positioned ß to the nitrogen atom of tertiary amines, installing enaminyl sulfone functionality in cyclic systems. Mild reaction conditions, broad functional group tolerance and a wide substrate scope are demonstrated. The nucleophilic character of the enaminyl sulfone is harnessed, demonstrating potential application for scaffold diversification.

High completion rates of isoniazid preventive therapy among persons living with HIV in Swaziland.

SETTING: Five human immunodeficiency virus (HIV) care facilities in Swaziland. OBJECTIVE: To assess adherence and treatment completion of a 6-month course of isoniazid preventive therapy (IPT) provided to HIV-infected patients through a self-selected model of facility-based, community-based or peer-supported IPT delivery coordinated with antiretroviral refills. DESIGN: Prospective cohort study. RESULTS: Between February and August 2015, we enrolled 908 patients, with follow-up until February 2016. Most were female (66.2%), with a median age of 38 years (interquartile range 31-45). Most (n = 797, 87.8%) chose facility-based delivery, 111 (12.2%) selected community-based delivery, and none selected peer-supported delivery. Adherence was high in both cohorts; among those with available data, 794 (94.8%) reported taking at least 80% of their IPT (P > 0.05). Twenty-two patients screened positive for tuberculosis (TB) at any visit; all had TB excluded and most continued IPT. In total, 812 (89.4%) patients completed treatment: 711 (89.2%) were on facility-based and 111 (91.0%) on community-based IPT (P > 0.05). No confirmed treatment failures occurred. Few patients discontinued IPT (6.3%) or were lost to follow-up (4.1%). CONCLUSION: Self-selected IPT delivery aligned with HIV care achieved high rates of adherence and treatment completion. This model may improve outcomes by simplifying clinic visits and conferring agency to the patient, and may be readily implemented in similar high TB-HIV burden settings.

Individual placement and support (IPS) for patients with offending histories: the IPSOH feasibility cluster randomised trial protocol.

INTRODUCTION: People with involvement in forensic psychiatric services face many obstacles to employment, arising from their offending, as well as their mental health problems. This study aims to assess the feasibility of conducting a randomised controlled trial (RCT) to evaluate the effectiveness of individual placement and support (IPS), in improving employment rates and associated psychosocial outcomes in forensic psychiatric populations. IPS has been found consistently to achieve employment rates above 50% in psychiatric patients without a history of involvement in criminal justice services. METHODS/DESIGN: This is a single-centre feasibility cluster RCT. Clusters will be defined according to clinical services in the community forensic services of Nottinghamshire Healthcare NHS Foundation Trust (NHCT). IPS will be implemented into 2 of the randomly assigned intervention clusters in the community forensic services of NHCT. A feasibility cluster RCT will estimate the parameters required to design a full RCT. The primary outcome is the proportion of people in open employment at 12-month follow-up. Secondary outcome measures will include employment, educational activities, psychosocial and economic outcomes, as well as reoffending rates. Outcome measures will be recorded at baseline, 6 months and 12 months. In accordance with the UK Medical Research Council guidelines on the evaluation of complex interventions, a process evaluation will be carried out; qualitative interviews with patients and staff will explore general views of IPS as well as barriers and facilitators to implementation. Fidelity reviews will assess the extent to which the services follow the principles of IPS prior, during and at the end of the trial. ETHICS AND DISSEMINATION: Ethical approval was obtained from the East Midlands Research Ethics Committee-Nottingham 1 (REC reference number 15/EM/0253). Final and interim reports will be prepared for project funders, the study sponsor and clinical research network. Findings will be disseminated through peer-reviewed journals, conferences and event presentations. TRIAL REGISTRATION NUMBER: NCT02442193; Pre-results.

Cerebellar mutism: the rehabilitation challenge in pediatric neuro-oncology: case studies.

Cerebellar Mutism Syndrome (CMS), also known as posterior fossa syndrome (CMS/PFS), refers to a transient loss of speech followed by dysarthria and is a common complication in the pediatric population following resection of a cerebellar tumor. Recognition and rehabilitation of CMS is critical in the post-operative phases of recovery. Two case studies, including neuropsychological assessments, along with the family and patient's perspectives are reviewed.

Ending neglect: providing effective childhood tuberculosis training for health care workers in Tanzania.

SETTING: Health care facilities in Dar es Salaam, Pwani, and Arusha, Tanzania. OBJECTIVE: To assess health care worker (HCW) knowledge and practices 1 year after specialized training in childhood tuberculosis (TB). DESIGN: Using a standardized survey, we interviewed a convenience sample of HCWs providing both general and specialized care to children. RESULTS: We interviewed 117 HCWs in TB clinics, maternal and child health clinics, human immunodeficiency virus (HIV) clinics, out-patient departments, and pediatric in-patient wards at 12 facilities. A total of 81 HCWs (62% of nurses, 74% of clinicians) reported having attended the national childhood TB training course. Most HCWs responded correctly to questions on childhood TB diagnosis, treatment, and TB-HIV co-management, regardless of training history. Most HCWs reported that they routinely obtain chest radiographs, HIV testing, and a TB contact history when evaluating children for TB. Less than half of HCWs reported routinely obtaining sputum for mycobacterial culture or performing a tuberculin skin test. Three times as many trained as untrained HCWs reported having ever prescribed isoniazid preventive therapy (IPT) to a child (P < 0.05). CONCLUSION: In general, levels of childhood TB knowledge were high and practices were in accordance with national guidance. Specific gaps in diagnosis, treatment and use of IPT were identified for future focused training.

Contexte : Structures de soins de santé à Dar es Salam, Pwani et Arusha, Tanzanie.Objectif : Evaluer les connaissances et pratiques du personnel de santé (HCW) un an après une formation spécifique à la tuberculose de l'enfant (TB).Schéma : Grâce à une enquête standardisée, nous avons interviewé un échantillon de complaisance de HCW offrant des soins à la fois généraux et spécialisés à des enfants.Résultats : Nous avons interviewé 117 HCW dans des dispensaires de TB, des centres de santé maternelle et infantile, des dispensaires pour le virus de l'immunodéficience humaine (VIH), des consultations externes et des services de pédiatrie dans 12 établissements. Un total de 81 HCW (62% d'infirmières, 74% de cliniciens) a affirmé avoir bénéficié de la formation nationale relative à la TB de l'enfant. La majorité a répondu correctement aux questions relatives au diagnostic de la TB de l'enfant, à son traitement et à la prise en charge conjointe de la TB et du VIH, quels que soient les antécédents de formation. La plupart ont dit demander en routine des radiographies pulmonaires, un test VIH et une recherche de contacts tuberculeux lors de l'évaluation des enfants. Moins de la moitié des HCW a affirmé recueillir des crachats en routine pour une culture mycobactérienne ou réaliser un test cutané à la tuberculine. La prescription de thérapie préventive par isoniazide (IPT) a été faite trois fois plus souvent par des HCW formés que par ceux qui ne l'avaient pas été (P < 0,05).Conclusion : En général, les connaissances en matière de TB de l'enfant étaient élevées et les pratiques conformes aux directives nationales. L'étude a identifié des lacunes spécifiques en matière de diagnostic, de traitement et d'utilisation de l'IPT afin de mieux cibler les futures formations.

Marco de referencia: Los establecimientos de atención de salud de Dar es-Salaam, Pwani y Arusha en Tanzania.Objetivo: Evaluar los conocimientos y las prácticas de los profesionales de salud (HCW) un año después de haber recibido una capacitación especializada sobre la tuberculosis (TB) de la infancia.Método: Se administró una encuesta normalizada a una muestra de conveniencia de los HCW que prestan atención general y especializada a los niños.Resultados: Se entrevistaron 117 HCW de los consultorios de TB, salud maternoinfantil, atención de la infección por el virus de la inmunodeficiencia humana (VIH) y de los servicios de atención ambulatoria y hospitalización pediátrica en 12 establecimientos. Ochenta y un HCW refirieron haber asistido al programa nacional de capacitación sobre la TB en la infancia (62% del personal de enfermería y 74% del personal médico). La mayoría de los HCW respondió de manera correcta a las preguntas sobre el diagnóstico y el tratamiento de la TB y la atención integrada de la TB-VIH, independientemente de las capacitaciones recibidas. La mayoría de los interrogados refirió la solicitud sistemática de radiografías de tórax, pruebas diagnósticas del VIH y el interrogatorio sobre los antecedentes de contacto con casos de TB cuando examinaba niños con presunción clínica de TB. Menos de la mitad de los HCW declaró la obtención corriente de muestras de esputo para cultivo de micobacterias o la práctica de la prueba cutánea de la tuberculina. Fue tres veces más frecuente que los HCW que habían recibido una capacitación, hubiesen recetado en alguna ocasión el tratamiento preventivo con isoniazida (IPT) a un niño en comparación con HCW sin antecedentes de capacitación (P < 0,05).Conclusión: En general, se observó un buen conocimiento de la TB de la infancia y las prácticas fueron conformes con las directrices nacionales. Se pusieron en evidencia algunas deficiencias en materia de diagnóstico, tratamiento y aplicación del IPT, sobre las cuales se centrará la atención en los futuros programas de capacitación.

Phase transformation in SiOx/SiO2 multilayers for optoelectronics and microelectronics applications.

Due to the quantum confinement, silicon nanoclusters (Si-ncs) embedded in a dielectric matrix are of prime interest for new optoelectronics and microelectronics applications. In this context, SiO(x)/SiO2 multilayers have been prepared by magnetron sputtering and subsequently annealed to induce phase separation and Si clusters growth. The aim of this paper is to study phase separation processes and formation of nanoclusters in SiO(x)/SiO2 multilayers by atom probe tomography. Influences of the silicon supersaturation, annealing temperature and SiO(x) and SiO2 layer thicknesses on the final microstructure have been investigated. It is shown that supersaturation directly determines phase separation regime between nucleation/classical growth and spinodal decomposition. Annealing temperature controls size of the particles and interface with the surrounding matrix. Layer thicknesses directly control Si-nc shapes from spherical to spinodal-like structures.

Evaporation of picoliter droplets on surfaces with a range of wettabilities and thermal conductivities.

The evaporation of picoliter water and ethanol droplets generated by drop-on-demand inkjet printing was investigated on substrates with apparent contact angles between 10^{∘} and 135^{∘} and thermal conductivities between 0.25 and 149 Wm^{-1}K^{-1}. Drying times were calculated from a diffusion-limited model for droplets with both pinned and moving contact lines as a function of droplet diameter and apparent contact angle. Droplets with a moving contact line take longer to dry on hydrophilic substrates than pinned droplets. The difference in drying times between evaporative modes vanishes at large apparent contact angles. Hence similar drying times are obtained for both modes on hydrophobic substrates. The predicted drying times for glass and silicon substrates were in good quantitative agreement with experimental data, suggesting that thermal effects are negligible for substrates of these base materials. However, on a PTFE substrate which has a lower thermal conductivity more relevant to inkjet printing, evaporative cooling reduces the evaporation rate causing drying times to be underpredicted by isothermal models.

Superhydrophobic hierarchical honeycomb surfaces.

Two-dimensional hexagonally ordered honeycomb surfaces have been created by solvent casting polybutadiene films under controlled humidity. Subsequent CF(4) plasmachemical fluorination introduces cross-linking and surface texturing, leading to hierarchical surfaces with roughness on both the 10 µm (honeycomb) and micrometer (texturing) length scales. For microliter droplets, these display high water contact angle values (>170°) in combination with low contact angle hysteresis (i.e., superhydrophobicity) while displaying bouncing of picoliter water droplets. In the case of picoliter droplets, it is found that surfaces which exhibit similar static contact angles can give rise to different droplet impact dynamics, governed by the underlying surface topography. These studies are of relevance to technological processes such as rapid cooling, delayed freezing, crop spraying, and inkjet printing.

Impact of picoliter droplets on superhydrophobic surfaces with ultralow spreading ratios.

The impact of picoliter-sized water droplets on superhydrophobic CF(4) plasma fluorinated polybutadiene surfaces is investigated with high-speed imaging. Variation of the surface topography by plasmachemical modification enables the dynamics of wetting to be precisely controlled. Final spreading ratios as low as 0.63 can be achieved. A comparison of the maximum spreading ratio and droplet oscillation frequencies to models described in the literature shows that both are found to be much lower than theoretically predicted.

Diagnosing tuberculosis with urine lipoarabinomannan: systematic review and meta-analysis.

Lipoarabinomannan (LAM) is a potential marker of active tuberculosis (TB). We performed a systematic review and meta-analysis regarding use of urinary LAM assays for diagnosing active TB. We systematically searched for published and unpublished studies that evaluated urinary LAM for active TB diagnosis. Extracted data were pooled using bivariate random effects models and hierarchical summary receiver operating characteristic curves. Heterogeneity was explored through subgroup analysis and meta-regression. Quality was assessed according to standardised QUADAS (Quality Assessment of Diagnostic Accuracy Studies) criteria. In seven studies that assessed test accuracy in microbiologically confirmed cases only, estimates of sensitivity ranged from 13% to 93%, while specificity ranged from 87% to 99%. In five studies that assessed accuracy in clinical and confirmed TB cases, sensitivity ranged from 8% to 80%, while specificity ranged from 88% to 99%. In five studies with results stratified by HIV status, sensitivity was 3-53% higher in HIV-positive than HIV-negative subgroups; sensitivity was highest with advanced immunosuppression. The LAM urinary assay has several characteristics that make it attractive for diagnosing active TB, but has suboptimal sensitivity for routine clinical use. Further studies are needed to evaluate the potential value of the LAM assay in individuals with advanced HIV or for diagnosis of paediatric TB.

Highly active antiretroviral therapy and employment status in accra, ghana.

OBJECTIVES: This study investigated the immunologic responses and employment history of highly-active antiretroviral therapy (HAART) patients. DESIGN: We interviewed patients and reviewed medical records to collect demographic, clinical, and employment history while on HAART. Demographic characteristics were tested as predictors of immunological response while on HAART using hierarchical linear models. SETTING: Fevers Unit, Korle-Bu Teaching Hospital, Accra, Ghana PARTICIPANTS: Subjects comprised a convenience sample of adult HAART patients receiving therapy for at least 9 months. 270 patients were interviewed. 38 were excluded due to inadequate time on HAART or inability to locate all necessary patient information. INTERVENTION: This was an observational study. MAIN OUTCOME MEASURES: We investigated the change in CD4 cell count and weight since the initiation of therapy, and their ability to maintain or regain employment as well as the reasons for this. RESULTS: The estimated mean ± standard error increase in CD4 cell count from baseline at 6, 12, and 18 months were 102 ± 5, 204 ± 11, and 236 ± 10 cells/µL, respectively. Overall, 147 patients (63.4%) reported remaining employed or obtaining new employment while on HAART. Patients who were asymptomatic at initial presentation were more likely to remain employed or returned to work while on HAART than those who were symptomatic (66.4% vs. 48.8%, P = 0.009). Most patients were employed in the informal sector, which made their economic situation particularly vulnerable to HIV-associated illness. CONCLUSION: The findings suggest that patients receiving HAART experience good clinical and immunological responses as well as improvement in employment status.

Completion of isoniazid preventive therapy among HIV-infected patients in Tanzania.

SETTING: Isoniazid preventive therapy (IPT) has not been widely implemented due to questions about acceptance, adherence and side effects. OBJECTIVE: To examine factors related to completion of IPT among human immunodeficiency virus (HIV) infected subjects in Tanzania. DESIGN: HIV-infected subjects in the DarDar TB vaccine trial with CD4 cell counts >or=200 cells/mm(3) and a positive tuberculin skin test (TST) were counseled, offered IPT for 6 months and seen monthly. RESULTS: Among 1932 subjects, TST results were positive in 631 (33%): 568 (90%) were offered IPT, 565 (99%) accepted and three (<1%) refused. Of the 565 subjects who accepted IPT, 493 (87%) completed treatment and 72 (13%) did not. Non-completion was physician-initiated in 24 (33%, due to active TB or side effects), patient-initiated in 42 (58%, due to self-cessation or loss to follow-up) and due to death in 6 (8%, unrelated to IPT). Interviews were conducted among 109 completers and 20 non-completers (12 physician- and 8 patient-initiated). Completers were motivated by fear of TB (44%), understanding the importance of IPT (32%) and counseling (22%). Patient-initiated non-completers were dissuaded by stigma (58%), side effects (14%) and travel distance (1%). CONCLUSIONS: HIV-infected subjects provided with counseling, monthly follow-up and travel reimbursement have high rates of IPT completion with minimal side effects.

Recurrent multistate outbreak of Salmonella Newport associated with tomatoes from contaminated fields, 2005.

Salmonella Newport causes more than an estimated 100,000 infections annually in the United States. In 2002, tomatoes grown and packed on the eastern shore of Virginia contaminated with a pan-susceptible S. Newport strain caused illness in 510 patients in 26 states. In July-November 2005, the same strain caused illness in at least 72 patients in 16 states. We conducted a case-control study during the 2005 outbreak, enrolling 29 cases and 140 matched neighbourhood controls. Infection was associated with eating tomatoes (matched odds ratio 9.7, 95% confidence interval 3.3-34.9). Tomatoes were traced back to the eastern shore of Virginia, where the outbreak strain was isolated from pond water used to irrigate tomato fields. Two multistate outbreaks caused by one rare strain, and identification of that strain in irrigation ponds 2 years apart, suggest persistent contamination of tomato fields. Further efforts are needed to prevent produce contamination on farms and throughout the food supply chain.

Antituberculosis drug resistance and anonymous HIV surveillance in tuberculosis patients in Botswana, 2002.

Two surveys undertaken in Botswana in the 1990s have recorded low rates of antituberculosis drug resistance, despite a three-fold rise in tuberculosis since 1989. We undertook a third survey to determine both trends since 1995 and HIV prevalence in tuberculosis patients in Botswana. Sputum specimens were obtained from patients nationwide in 2002 who also underwent anonymous, rapid HIV testing by use of Oraquick. Of 2200 sputum smear-positive patients and 219 previously treated patients with suspected recurrent tuberculosis, 1457 (60%) were infected with HIV. Resistance to at least one drug in new patients rose from 16 (3.7%) isolates in 1995 to 123 (10.4%; p<0.0001) in 2002. Interventions for tuberculosis control are urgently needed in Botswana to prevent further emergence of drug resistance.