Search

Red dot basal cell carcinoma is a distinctive clinical subtype of basal cell carcinoma. It has been reported in eight individuals with a male to female ratio of 1:1; and the patients’ ages ranged from 50 to 74 years. All patients had prior history of actinic keratoses and basal cell carcinoma. In addition, some patients also had prior squamous cell carcinoma, malignant melanoma, and/or dysplastic nevus. The tumor was usually of recent onset, asymptomatic, and on sun-exposed skin. It was most commonly located on the nose (five patients); other sites were the upper lip, the mid back, or thigh—each in one patient. The red dot basal cell carcinoma was solitary and small—usually 4 mm or less in diameter. It typically presented as a red macule or papule; however, it sometimes appeared as a flesh-colored or pink to light-red papule with a bright-red central area. Microscopic features showed basaloid tumor cells (arranged as either nodular aggregates or superficial buds or both). In the central portion of the lesion, there was a proliferation of erythrocyte-containing vascular spaces between the epidermis and the neoplasm. The basal cell carcinoma pathology subtype was either nodular and superficial (three patients), nodular (two patients), or superficial (one patient). The clinical differential diagnosis of red dot basal cell carcinoma included not only benign vascular lesions (such as hemangioma and telangiectasia) but also inflammatory conditions and adnexal tumors. Other basaloid cell neoplasms were in the pathologic differential diagnosis. The pathogenesis of red dot basal cell carcinoma is similar to that of other basal cell carcinoma clinical subtypes. Mohs surgery is the treatment of choice for red dot basal cell carcinomas. Red dot basal cell carcinoma has two categories of biologic behavior based on the ratio of the postoperative wound size as compared with the size of the preoperative tumor: nonaggressive (for which the ratio was 5:1 or less for three patients) and aggressive (for which the ratio was greater than 12:1 for three patients). There was no recurrence of the red dot basal cell carcinoma after treatment. In conclusion, the incidence of red dot basal cell carcinoma—a unique morphologic variant of basal cell carcinoma—may be higher than suggested by the number of reported patients with this basal cell carcinoma subtype.

Introduction: Updated international guidelines recommend the use of a two-step algorithm (glutamate dehydrogenase [GDH] or nucleic-acid amplification test [NAAT] plus toxin) rather than NAAT alone for the diagnosis of Clostridioides difficile (formerly Clostridium difficile) infections. The goal of our project was to evaluate the impact of a new bundle on the rate of hospital-acquired C. difficile infections (CDIs), hospital-acquired CDI standardized infection ratio (SIR), antibiotic days of therapy (DOT), and financial cost. Materials and Methods: The new bundle was implemented in April 2018. This bundle was implemented across five hospitals in Catholic Health Initiatives (CHI) Texas Division. The bundle included a switch from NAAT to a two-step process (GDH and toxin). We placed the new test in an order panel which included enteric isolation and required indications for C. difficile testing. We used quarterly data pre- and post-intervention to calculate SIR and DOT. Results: In the pre-intervention period, 15.5% of the total 3513 C. difficile NAAT was positive. In the post-intervention period, 5.7% of a total of 2845 GDH and toxin assays was positive for both GDH and toxin (P < 0.0001). SIR, which adjusts for denominator and change in testing methodology, also dropped from 1.02 to 0.43. The estimated cost associated with positive C. difficile cases dropped from 1,932,150 USD to 1,113,800 USD with an estimated yearly cost saving of 794,150 USD. Compliance with enteric isolation improved from 73.1% to 92.5% (P = 0.008). Conclusion: The new testing bundle led to a marked reduction in hospital-acquired CDI and unnecessary treatment, reduction in C. difficile testing, an increase in compliance with enteric isolation, and significant cost savings.

Background According to the Centers for Disease Control and Prevention, patients admitted to the hospital are commonly discharged on antibiotic therapy with prolonged courses of therapy, which contributes to excessive antibiotic exposure and adverse events. The purpose of this study was to evaluate total antibiotic duration of therapy at hospital discharge at Indiana University Health Arnett, White Memorial, and Frankfort hospitals. Methods A multicenter, retrospective electronic health record review was conducted from 1 January to 30 June 2019. Patients were included if they were at least 18 years of age, began antibiotic therapy while admitted, and continued antibiotic therapy at hospital discharge for 1 of the following indications: skin/soft tissue infection (SSTI), urinary tract infection (UTI), community-acquired pneumonia (CAP), or acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The number of days of therapy (DOT) of each inpatient and outpatient antibiotic prescribed was collected to calculate the total DOT, which was utilized to determine the appropriateness of the duration of therapy. Results Of the 547 patients included, 233 patients (42.6%) had CAP, 120 (21.9%) had UTI, 101 (18.5%) had SSTI, and 93 (17%) had AECOPD. The median duration of antibiotic therapy across all indications was 9 days (interquartile range [IQR], 7–11). Median duration for CAP was 9 days (IQR, 7–10), AECOPD was 7 days (IQR, 5–9), UTI was 8 days (IQR, 6–10), and SSTI was 12 days (IQR, 10–14). Conclusions Excess antimicrobial duration at hospital discharge represents an unmet need of antimicrobial stewardship programs., We reviewed the total duration of antibiotic therapy in 547 patients at the time of hospital discharge. When combining inpatient and outpatient days of therapy, antibiotic duration for common types of infection is excessive compared with recommendations from clinical practice guidelines.

Background Drug resistant tuberculosis (DR-TB) infringes substantial burden in terms of longer treatment duration, morbidity and mortality. Timely identification of patients at risks of DR-TB will aid individualized treatment. Current study was aimed to ascertain several factors associated with DR-TB among patients attending a tertiary care hospital. Methods This retrospective study was conducted among patients with confirmed diagnosis of DR-TB and drug susceptible TB (DS-TB) seeking medical care from a tertiary care hospital during 2014–2019. The types of DR-TB included were rifampicin resistant tuberculosis (RR-TB), Multidrug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB). Appropriate statistical methods were implied to evaluate the factors associated with DR-TB. Results Out of 580 patients, DS-TB was diagnosed in 198 (34.1%) patients while DR-TB was present in 382 patients. Of resistance cases, RR-TB, MDR-TB and XDR-TB were diagnosed in 176 (30.3%), 195 (33.6%) and 11 (1.9%) patients, respectively. Significant differences (P < 0.05) in demographics and clinico-laboratory characteristics were observed between patients with DS-TB and DR-TB. Logistic regression analysis revealed age ≤38 years (OR: 2.5), single marital status (OR: 11.1), tobacco use (OR: 2.9), previous treatment (OR: 19.2), treatment failure (OR: 9.2) and cavity on chest X-ray (OR: 30.1) as independent risk factors for MDR-TB. However, XDR-TB was independently associated with age group of ≤38 years (OR: 13.6), students (OR: 13.0), previous treatment (OR: 12.5), cavity on chest X-ray (OR: 59.6). The independent risk factors associated with RR-TB are age ≤38 years (OR: 2.8), females (OR: 5.7), unemployed (OR: 41.5), treatment failure (OR: 4.9), previous treatment (OR: 38.2) and cavity on chest X-ray (OR: 4.3). ROC curve analysis accentuate the excellent predictive accuracy of all logistic regression models as shown by AUC (0.968, P < 0.001) for MDR-TB, AUC (0.941, P < 0.001) for XDR-TB and AUC (0.962, P < 0.001) for RR-TB. Conclusions Current study demonstrates a sizeable extent of resistant cases among pulmonary TB patients. This study presaged significant risk of DR-TB among females, young adults, unemployed, smokers, patients with previous treatment failure and cavitation on chest X-ray. Timely identification of high risk patients will give pronounced advantages regarding appropriate choices of prevention, treatment and disease control.

Thyroid cancer is usually diagnosed by ultrasound imaging and fine-needle aspiration biopsy. However, diagnosis of follicular thyroid carcinomas (FTC) is difficult because FTC lacks nuclear atypia and a consensus on histological interpretation. Diffuse optical tomography (DOT) offers the potential to diagnose FTC because it can measure tumor hypoxia, while image reconstruction of the thyroid is still challenging mainly due to the complex anatomical features of the neck. In this study, we attempted to solve this issue by creating a finite element model of the human neck excluding the trachea (a void region). By reconstruction of the absorption coefficients at three wavelengths, 3D tissue oxygen saturation maps of the human thyroid are obtained for the first time by DOT.

In magnetic resonance imaging, the application of a strong diffusion weighting suppresses the signal contributions from the less diffusion-restricted constituents of the brain's white matter, thus enabling the estimation of the transverse relaxation time T2 that arises from the more diffusion-restricted constituents such as the axons. However, the presence of cell nuclei and vacuoles can confound the estimation of the axonal T2, as diffusion within those structures is also restricted, causing the corresponding signal to survive the strong diffusion weighting. We devise an estimator of the axonal T2 based on the directional spherical variance of the strongly diffusion-weighted signal. The spherical variance T2 estimates are insensitive to the presence of isotropic contributions to the signal like those provided by cell nuclei and vacuoles. We show that with a strong diffusion weighting these estimates differ from those obtained using the directional spherical mean of the signal which contains both axonal and isotropically-restricted contributions. Our findings hint at the presence of an MRI-visible isotropically-restricted contribution to the signal in the white matter ex vivo fixed tissue (monkey) at 7T, and do not allow us to discard such a possibility also for in vivo human data collected with a clinical 3T system.

Antimicrobial stewardship program aims to reduce antibiotic use. Periodic measurement and monitoring of antibiotic use and comparison within the institution as well as with other organizations are important indicators. We analyzed antibiotic usage in a general hospital in Saudi Arabia. Antibiotic data were collected retrospectively for 2011 and from 2013 to 2015, and only adult patients (>15 year of age) were included in the study. Data were presented as days of therapy (DOT) and defined daily dose (DDD). DDD was adjusted per 100 bed-days and according to the case mix index (CMI). The total DDD was 37,557 in 2013, 36,550 in 2014 and 38,738 in 2015. The DDD per 100 patient-days was 90.7–94.5. There was a discordant findings of antibiotic measurements based on the DDD compared to DOT, and DDD/100 bed-days compared to DOT/100 bed-days. There was a negative correlation between CMI and DDD per 100 bed days (r −0.696), but a positive correlation of CMI with DOT (r +0.93). Adjusted DDD/100 bed-days showed decrease in the usage of antibiotics, reflecting activities of the antibiotic stewardship program. The increase in DOT/100 bed-days may indicate the favorable utilization of combination therapy. Antibiotic usage needs to be adjusted per 100 bed-days and correlated with CMI for better reflection of optimal antibiotic utilization, activities of the antibiotic stewardship program, and to allow benchmarking. Keywords: DDD, Antibiotic stewardship, Benchmarking, Days of therapy, DOT

Program Pengendalian Resistensi Antibiotik (PPRA) merupakan program wajib rumah sakit Indonesia sesuai Permenkes No. 8 tahun 2015. Rumkital dr. Ramelan Surabaya termasuk salah satu rumah sakit yang telah menerapkan PPRA. Tujuan penelitian ini adalah untuk mengetahui deskripsi kuantitatif-kualitatif pemakaian antibiotik, serta luaran klinis dan mikrobiologis yang teramati pascapencanangan penerapan PPRA di ICU Rumkital dr. Ramelan Surabaya. Desain penelitian adalah studi observasi cross-sectional yang dilakukan selama 3 bulan (Februari–Mei 2016) di ICU Rumkital dr. Ramelan. Deskripsi kuantitatif diamati menggunakan Days of Therapy (DOT/100 hari-pasien), deskripsi kualitatif menggunakan alur Gyssens. Pengamatan luaran klinis dilakukan terhadap infeksi nosokomial, mortalitas terkait infeksi, dan lama tinggal di ICU ( Length of Stay /LOS). Pengamatan luaran mikrobiologis dilakukan terhadap pola penyebaran bakteri multiresisten. Hasil perhitungan jumlah konsumsi antibiotik didapatkan 151,63 DOT/100 hari-pasien. Penilaian kualitas antibiotik menunjukkan hasil 52,73% terapi tepat; 8,18% tidak tepat; 7,27% tanpa indikasi; 31,82% tidak tercapai kesepakatan antar penilai (κ=0,59; p

Background Mobile health (mHealth) interventions have the potential to improve health through patient education and provider engagement while increasing efficiency and lowering costs. This raises the question of whether disparities in access to mobile technology could accentuate disparities in mHealth mediated care. This study addresses whether programs planning to implement mHealth interventions risk creating or perpetuating health disparities based on inequalities in smartphone ownership. Methods Video Directly Observed Therapy (VDOT) is an mHealth intervention for monitoring tuberculosis (TB) treatment adherence through videos sent by patients to their healthcare provider using smartphones. We conducted secondary analyses of data from a single-arm trial of VDOT for TB treatment monitoring by San Diego, San Francisco, and New York City health departments. Baseline and follow-up treatment interviews were used to assess participant smartphone ownership, sociodemographics and TB treatment perceptions. Univariate and multivariable logistic regression analyses were used to identify correlates of smartphone ownership. Results Of the 151 participants enrolled, mean age was 41 years (range: 18–87 years) and 41.1% were female. Participants mostly identified as Asian (45.0%) or Hispanic/Latino (29.8%); 57.8% had at most a high school education. At baseline, 30.4% did not own a smartphone, which was similar across sites. Older participants (adjusted odds ratio [AOR] = 1.09 per year, 95% confidence interval [CI]: 1.05–1.12), males (AOR = 2.86, 95% CI: 1.04–7.86), participants having at most a high school education (AOR = 4.48, 95% CI: 1.57–12.80), and those with an annual income below $10,000 (AOR = 3.06, 95% CI: 1.19, 7.89) had higher odds of not owning a smartphone. Conclusions Approximately one-third of TB patients in three large United States of America (USA) cities lacked smartphones prior to the study. Patients who were older, male, less educated, or had lower annual income were less likely to own smartphones and could be denied access to mHealth interventions if personal smartphone ownership is required.

Critical glycemic events, such as hypo- or hyperglycemia, are extremely common during the first week post-partum in very preterm neonates. Both hypo- and hyperglycemic changes have been associated with poor neurological outcome. Continuous glucose monitoring (CGM) is a promising tool to reduce glycemic variability in the preterm population and whole-head Diffuse Optical Tomography (DOT) is a promising tool for continuous monitoring of brain hemodynamics in newborns. In this study, we performed a combined CGM-DOT acquisition in a very preterm newborn (28 weeks gestational age). The newborn was monitored for 7 days continuously. Twelve events were detected during this period: 8 mild hypoglycemic events, one severe hypoglycemic event, two mild hyperglycemic events and one event with a mild hypo- followed by a mild-hyperglycemia. DOT data were available for all the events but two. DOT data were reconstructed with a neonatal head model for the severe hypoglycemic event before the start of the hypoglycemic event and during the maximum peak of hypoglycemia. These preliminary results showed a regional specificity of the hemodynamic changes during hypoglycemia, with a predominant recruitment of the motor and parietal areas. This study highlights the importance of using whole-head DOT in this research field and the feasibility to perform combined CGM-DOT monitoring in very preterm neonates. Future clinical trials are required to investigate this clinical problem more thoroughly and shed light on the impact of tight glycemic control on the newborn brain.

BackgroundSmartphone apps that provide women with information about their daily fertility status during their menstrual cycles can contribute to the contraceptive method mix. However, if these apps claim to help a user prevent pregnancy, they must undergo similar rigorous research required for other contraceptive methods. Georgetown University’s Institute for Reproductive Health is conducting a prospective longitudinal efficacy trial on Dot (Dynamic Optimal Timing), an algorithm-based fertility app designed to help women prevent pregnancy. ObjectiveThe aim of this paper was to highlight decision points during the recruitment-enrollment process and the effect of modifications on enrollment numbers and demographics. Recruiting eligible research participants for a contraceptive efficacy study and enrolling an adequate number to statistically assess the effectiveness of Dot is critical. Recruiting and enrolling participants for the Dot study involved making decisions based on research and analytic data, constant process modification, and close monitoring and evaluation of the effect of these modifications. MethodsOriginally, the only option for women to enroll in the study was to do so over the phone with a study representative. On noticing low enrollment numbers, we examined the 7 steps from the time a woman received the recruitment message until she completed enrollment and made modifications accordingly. In modification 1, we added call-back and voicemail procedures to increase the number of completed calls. Modification 2 involved using a chat and instant message (IM) features to facilitate study enrollment. In modification 3, the process was fully automated to allow participants to enroll in the study without the aid of study representatives. ResultsAfter these modifications were implemented, 719 women were enrolled in the study over a 6-month period. The majority of participants (494/719, 68.7%) were enrolled during modification 3, in which they had the option to enroll via phone, chat, or the fully automated process. Overall, 29.2% (210/719) of the participants were enrolled via a phone call, 19.9% (143/719) via chat/IM, and 50.9% (366/719) directly through the fully automated process. With respect to the demographic profile of our study sample, we found a significant statistical difference in education level across all modifications (P.05). ConclusionsOur findings show that agile and consistent modifications to the recruitment and enrollment process were necessary to yield an appropriate sample size. An automated process resulted in significantly higher enrollment rates than one that required phone interaction with study representatives. Although there were some differences in demographic characteristics of enrollees as the process was modified, in general, our study population is diverse and reflects the overall United States population in terms of race/ethnicity, age, and education. Additional research is proposed to identify how differences in mode of enrollment and demographic characteristics may affect participants’ performance in the study. Trial RegistrationClinicalTrials.gov NCT02833922; http://clinicaltrials.gov/ct2/show/NCT02833922 (Archived by WebCite at http://www.webcitation.org/6yj5FHrBh)

To show PR damage as the location of visually significant pathological changes in MEWDS with the use of multimodal imaging., Purpose: To elucidate the location of pathological changes in multiple evanescent white dot syndrome (MEWDS) with the use of multimodal adaptive optics (AO) imaging. Methods: A 5-year observational case study of a 24-year-old female with recurrent MEWDS. Full examination included history, Snellen chart visual acuity, pupil assessment, intraocular pressures, slit lamp evaluation, dilated fundoscopic exam, imaging with Fourier-domain optical coherence tomography (FD-OCT), blue-light fundus autofluorescence (FAF), fundus photography, fluorescein angiography, and adaptive-optics optical coherence tomography. Results: Three distinct acute episodes of MEWDS occurred during the period of follow-up. Fourier-domain optical coherence tomography and adaptive-optics imaging showed disturbance in the photoreceptor outer segments (PR OS) in the posterior pole with each flare. The degree of disturbance at the photoreceptor level corresponded to size and extent of the visual field changes. All findings were transient with delineation of the photoreceptor recovery from the outer edges of the lesion inward. Hyperautofluorescence was seen during acute flares. Increase in choroidal thickness did occur with each active flare but resolved. Conclusion: Although changes in the choroid and RPE can be observed in MEWDS, Fourier-domain optical coherence tomography, and multimodal adaptive optics imaging localized the visually significant changes seen in this disease at the level of the photoreceptors. These transient retinal changes specifically occur at the level of the inner segment ellipsoid and OS/RPE line. En face optical coherence tomography imaging provides a detailed, yet noninvasive method for following the convalescence of MEWDS and provides insight into the structural and functional relationship of this transient inflammatory retinal disease.

Red dot basal cell carcinoma is a unique variant of basal cell carcinoma. Including the three patients described in this report, red dot basal cell carcinoma has only been described in seven individuals. This paper describes the features of two males and one female with red dot basal cell carcinoma and reviews the characteristics of other patients with this clinical subtype of basal cell carcinoma. A 70-year-old male developed a pearly-colored papule with a red dot in the center on his nasal tip. A 71-year-old male developed a red dot surrounded by a flesh-colored papule on his left nostril. Lastly, a 74-year-old female developed a red dot within an area of erythema on her left mid back. Biopsy of the lesions all showed nodular and/or superficial basal cell carcinoma. Correlation of the clinical presentation and pathology established the diagnosis of red dot basal cell carcinoma. The tumors were treated by excision using the Mohs surgical technique. Pubmed was searched with the keyword: basal, cell, cancer, carcinoma, dot, red, and skin. The papers generated by the search and their references were reviewed. Red dot basal cell carcinoma has been described in three females and two males; the gender was not reported in two patients. The tumor was located on the nose (five patients), back (one patient) and thigh (one patient). Cancer presented as a solitary small red macule or papule; often, the carcinoma was surrounded by erythema or a flesh-colored papule. Although basal cell carcinomas usually do not blanch after a glass microscope slide is pressed against them, the red dot basal cell carcinoma blanched after diascopy in two of the patients, resulting in a delay of diagnosis in one of these individuals. Dermoscopy may be a useful non-invasive modality for evaluating skin lesions when the diagnosis of red dot basal cell carcinoma is considered. Mohs surgery is the treatment of choice; in some of the patients, the ratio of the area of the postoperative wound to that of the preoperative cancer was greater than 12:1, demonstrating a significant lateral spread of the tumor beyond the observed clinical margins of the neoplasm. In conclusion, in a patient with a personal history of actinic keratosis or nonmelanoma skin cancer, the appearance of a new red dot in a sun-exposed site should prompt additional evaluation of the skin lesion to exclude or establish the diagnosis of red dot basal cell carcinoma.

BackgroundWith the availability of low-cost mobile devices and the ease of internet access, mobile health (mHealth) is digitally revolutionizing the health sector even in resource-constrained settings. It is however necessary to assess end-user perceptions before deploying potential interventions. ObjectiveThis study aimed to assess the mobile phone usage patterns and the acceptability of mobile phone support during care and treatment in patients with tuberculosis (TB) in South India. MethodsThis exploratory study was conducted at an urban private tertiary care teaching hospital and nearby public primary-level health care facilities in Bangalore, South India. We recruited 185 patients with TB through consecutive sampling. Subsequent to written informed consent, participants responded to an interviewer-administered pretested questionnaire. The questionnaire included questions on demographics, phone usage patterns, and the benefits of using of mobile phone technology to improve health outcomes and treatment adherence. Frequency, mean, median, and SD or interquartile range were used to describe the data. Bivariate associations were assessed between demographics, clinical details, phone usage, and mHealth communication preferences using the chi-square test and odds ratios. Associations with a P value ≤.20 were included in a logistic regression model. A P value of

© 2016, Centers for Disease Control and Prevention (CDC). All rights reserved. A recent innovation to help patients adhere to daily tuberculosis (TB) treatment over many months is video (or virtually) observed therapy (VOT). VOT is becoming increasingly feasible as mobile telephone applications and tablet computers become more widely available. Studies of the effectiveness of VOT in improving TB patient outcomes are being conducted.

An open-label, 60-day trial was conducted in 75 newly diagnosed tuberculosis (TB) patients to assess the adjunctive effect of the oral immunomodulator Dzherelo with standard anti-TB chemotherapy (ATT) consisting of izoniazid, rifampicin, pyrazinamide and streptomycin (HRZS) administered as directly observed therapy (DOT). Group 1 (n = 28) with cavitary TB and group 2 (n = 17) with infiltrating pulmonary TB received 50 drops of Dzherelo twice daily in addition to HRZS. Group 3 (n = 30), which served as a control, received ATT only. Liver damage indicators, bilirubin, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) decreased to normal levels in groups 1 and 2, but increased significantly in group 3. Kidney failure markers, urea and creatinine, normalized in Dzherelo recipients, but were unchanged or worsened in the ATT-only group. The changes in serum lactate dehydrogenase, catalase, malondialdehyde and diene conjugates suggested that Dzherelo downregulates TB-associated inflammation. The anti-inflammatory property of Dzherelo was further supported by a favourable haematology profile, reduced erythrocyte sedimentation rate and faster defervescence. Radiological recovery was significant in both Dzherelo groups, but not in the control group (p = 0.0085, p = 0.025 and p = 0.23, respectively). These findings correlated positively with sputum smear conversion and clinical findings (r = 0.94; p < 0.05). Mycobacterial clearance at day 30 was observed in 77%, 72% and 40% of patients in groups 1, 2 and 3, respectively. After 2 months sputum conversion rates in groups 1, 2 and 3 were 93%, 89% and 70%, respectively. Sixty-day treatment outcomes in groups 1, 2 and 3 as assessed by improvement in clinical features and respiratory function attained respective p-values of 0.008, 0.25 and 0.72, and 0.013, 0.48 and 0.0015. Dzherelo is thus useful as an immunotherapeutic adjunct in the management of TB.

exico SUMMARY BACKGROUND: Although directly observed therapy (DOT) is recommended worldwide for monitoring anti-tuberculosis treatment, transportation and personnel requirements limit its use. OBJECTIVE: To evaluate the feasibility and acceptability of ‘video DOT’ (VDOT), which allows patients to record and transmit medication ingestion via videos watched remotely by health care providers to document adherence. METHODS: We conducted a single-arm trial among tuberculosis (TB) patients in San Diego, California, USA, (n ¼ 43) and Tijuana, Mexico (n ¼ 9) to represent high- and low-resource settings. Pre-/post-treatment interviews assessed participant characteristics and experiences. Adherence was defined as the proportion of observed doses to expected doses. RESULTS: The mean age was 37 years (range 18–86), 50% were male, and 88% were non-Caucasian. The mean duration of VDOT use was 5.5 months (range 1– 11). Adherence was similar in San Diego (93%) and Tijuana (96%). Compared to time on in-person DOT, 92% preferred VDOT, 81% thought VDOT was more confidential, 89% never/rarely had problems recording videos, and 100% would recommend VDOT to others. Seven (13%) participants were returned to in-person DOT and six (12%) additional participants had their phones lost, broken or stolen. CONCLUSIONS: VDOT was feasible and acceptable, with high adherence in both high- and low-resource settings. Efficacy and cost-effectiveness studies are needed. KEY W ORDS: US-Mexico border; drug resistance; medication adherence; DOT; cellular phone; mHealth

Background Directly observed therapy (DOT), as recommended by the World Health Organization, is used in many countries to deliver tuberculosis (TB) treatment. The effectiveness of community-based (CB DOT) versus clinic DOT has not been adequately assessed to date. We compared TB treatment outcomes of CB DOT (delivered by community health workers or community volunteers), with those achieved through conventional clinic DOT. Methods We performed a systematic review and meta-analysis of studies before 9 July 2014 comparing treatment outcomes of CB DOT and clinic DOT. The primary outcome was treatment success; the secondary outcome was loss to follow-up. Results Eight studies were included comparing CB DOT to clinic DOT, one a randomised controlled trial. CB DOT outperformed clinic DOT treatment success (pooled odds ratio (OR) of 1.54, 95% confidence interval (CI) 1.01 – 2.36, p = 0.046, I2 heterogeneity 84%). No statistically significant difference was found between the two DOT modalities for loss to follow-up (pooled OR 0.86, 95% CI 0.48 to 1.55, p = 0.62, I2 83%). Conclusions Based on this systematic review, CB DOT has a higher treatment success compared to clinic DOT. However, as only one study was a randomised controlled trial, the findings have to be interpreted with caution. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-0945-5) contains supplementary material, which is available to authorized users.

Background: Tuberculosis rates in the world remain high, especially in low- and middle-income countries. International tuberculosis (TB) policy generally recommends the use of directly observed therapy (DOT) to ensure treatment adherence. Objective: This article examines a change in TB treatment support that occurred in 2005 in South Africa, from DOT to the enhanced TB adherence programme (ETA). Design: Seven key individuals representing academics, policy makers and service providers involved in the development of the ETA programme or knowledgeable about the issue were purposively sampled and interviewed, and participant observation was conducted at ETA programme steering group meetings. Qualitative content analysis was used to analyse the data, drawing on the Kingdon model of agenda setting. This model suggests that three independent streams problem, policy and politics come together at a certain point, often facilitated by policy entrepreneurs, to provide an opportunity for an issue to enter the policy agenda. Results: The results suggest the empowerment-oriented programme emerged through the presence of policy entrepreneurs with access to resources. Policy entrepreneurs were influenced by a number of simultaneously occurring challenges including problems within the existing programme; a perceived mismatch between patient needs and the existing TB treatment model; and the TB-HIV co-epidemic. Policy entrepreneurs saw the ART approach as a possible solution to these challenges. Conclusions: The Kingdon model contributed to describing the process of policy change. Research evidence seemed to influence this change diffusely, through the interaction of policy entrepreneurs and academics. Keywords: tuberculosis; South Africa; policy; treatment; DOT; qualitative (Published: 16 August 2012) Citation: Glob Health Action 2012, 5 : 14385 - http://dx.doi.org/10.3402/gha.v5i0.14385

Background: For the realization of “2015 UN Millennium Development Goals”, a question arises pertaining to the course of tuberculosis in Greece and its relationship to patient adherence to treatment, given the fact that the country is undergoing a financial crisis and is a gateway for economic migrants. Methods: The study concerned 1179 patients of the anti-TBdepartment, “Sotiria” General Chest Diseases Hospital, Athens, Greece collaborating with the National Reference Centre of Mycobacteria, covering a year before the financial crisis, 2007 and 2010-11, the first years of the crisis. A special recording form was used, on the basis of a specific protocol. Results: Out of 954 patients were diagnosed with tuberculosis disease, 657 of which were foreigners. Out of 791 patients residing in the same area, 632 were foreigners. Of the patients who proceeded to a first self-discontinuation of the medication, only 38.3% (n=18) completed the treatment, while 40.4% of them self-discontinued within the first month. Duration of treatment was 6.68±3.54 months for those (n=805) with no discontinuation and 7.48±3.68 months for those (n=149) with at least one discontinuation, regardless of the etiology p= 0,032. Cases increased during financial crisis, with gradual decrease in mean treatment duration for patients with first line treatment to 7.77±3.81 months in 2007, and 6.53±3.47 and 6.40±3.31 months in 2010 and 2011, respectively. Conclusions: Since the beginning of treatment measurable signs of either adherent/non-adherent behavior appeared, affecting mean treatment duration and completion. Duration of treatment decreased in the years of financial crisis. Migrants ghettoization calls for implementation of DOTS.

Purpose The purpose of this study was to validate a newly developed diffuse optical tomography (DOT) system on benign cysts in the breast. Procedures Eight patients with 20 benign cysts were included. Study procedures consisted of optical breast imaging and breast magnetic resonance imaging (MRI) for comparison. A reconstruction algorithm computed three-dimensional images for each of the four near-infrared wavelengths used by our DOT system (Philips Healthcare, Best, The Netherlands). These images were combined using a spectroscopic model to assess tissue composition and lesion size. Results Twenty cysts were analyzed in eight patients. By using the spectroscopic information, 13 of 20 cysts (65%) were visualized with DOT, confirming their high water and low total hemoglobin content. Lesion size and location showed good agreement with MRI; Pearson correlation coefficient was 0.7 (p < 0.01). Conclusions DOT can visualize benign cysts in the breast and elucidate their high water and low total hemoglobin content by spectroscopic analysis.

Objective To evaluate the cost-effectiveness of different tuberculosis control strategies in Thailand. Methods Different tuberculosis control strategies, which included health-worker, community-member, and family-member directly observed treatment (DOT) and a mobile phone "contact-reminder" system, were compared with self-administered treatment (SAT). Cost-effectiveness analysis was undertaken by using a decision tree model. Costs (2005 international dollars [I$]) were calculated on the basis of treatment periods and treatment outcomes. Health outcomes were estimated over the lifetime of smear-positive pulmonary tuberculosis patients in disability-adjusted life years (DALYs) averted on the basis of Thai evidence on the efficacy of the selected strategies. Results Cost-effectiveness results indicate no preference for any strategy. The uncertainty ranges surrounding the health benefits were wide, including a sizeable probability that SAT could lead to more health gain than DOT strategies. The health gain for family-member DOT was 9400 DALYs (95% uncertainty interval −7200 to 25,000), for community-member DOT was 13,000 DALYs (95% uncertainty interval −21,000 to 37,000), and for health-worker DOT was 7900 DALYs (95% uncertainty interval −50,000 to 43,000). There were cost savings (from less multi-drug resistant tuberculosis treatment) associated with family-member DOT (−I$9 million [95% uncertainty interval −I$12 million to −I$5 million]) because the trial treatment failure rate was significantly lower than that for SAT. The mobile phone reminder system was not cost-effective, because the mortality rate associated with it was much higher than that associated with other treatment strategies. Conclusions Because of the large uncertainty intervals around health gain for DOT strategies, it remains inconclusive whether DOT strategies are more cost-effective than SAT. It is evident, however, that family-member DOT is a cost-saving intervention.

Background Tobacco cessation medication adherence is one of the few factors shown to improve smoking cessation rates among methadone-maintained smokers, but interventions to improve adherence to smoking cessation medications have not yet been tested among methadone treatment patients. Methadone clinic-based, directly observed therapy (DOT) programs for HIV and tuberculosis improve adherence and clinical outcomes, but have not been evaluated for smoking cessation. We describe a randomized controlled trial to evaluate whether a methadone clinic-based, directly observed varenicline therapy program increases adherence and tobacco abstinence among opioid-dependent drug users receiving methadone treatment. Methods/Design We plan to enroll 100 methadone-maintained smokers and randomize them to directly observed varenicline dispensed with daily methadone doses or treatment as usual (self-administered varenicline) for 12 weeks. Our outcome measures are: 1) pill count adherence and 2) carbon monoxide-verified tobacco abstinence. We will assess differences in adherence and abstinence between the two treatment arms using repeated measures models. Discussion This trial will allow for rigorous evaluation of the efficacy of methadone clinic-based, directly observed varenicline for improving adherence and smoking cessation outcomes. This detailed description of trial methodology can serve as a template for the development of future DOT programs and can guide protocols for studies among opioid-dependent smokers receiving methadone treatment. Trial Registration clinicaltrials.gov NCT01378858