Elysia Larson

Clinical Utility of 4D FDG-PET/CT Scans in Radiation Treatment Planning

PURPOSE The potential role of four-dimensional (4D) positron emission tomography (PET)/computed tomography (CT) in radiation treatment planning, relative to standard three-dimensional (3D) PET/CT, was examined. METHODS AND MATERIALS Ten patients with non-small-cell lung cancer had sequential 3D and 4D [(18)F]fluorodeoxyglucose PET/CT scans in the treatment position prior to radiation therapy. The gross tumor volume and involved lymph nodes were contoured on the PET scan by use of three different techniques: manual contouring by an experienced radiation oncologist using a predetermined protocol; a technique with a constant threshold of standardized uptake value (SUV) greater than 2.5; and an automatic segmentation technique. For each technique, the tumor volume was defined on the 3D scan (VOL3D) and on the 4D scan (VOL4D) by combining the volume defined on each of the five breathing phases individually. The range of tumor motion and the location of each lesion were also recorded, and their influence on the differences observed between VOL3D and VOL4D was investigated. RESULTS We identified and analyzed 22 distinct lesions, including 9 primary tumors and 13 mediastinal lymph nodes. Mean VOL4D was larger than mean VOL3D with all three techniques, and the difference was statistically significant (p < 0.01). The range of tumor motion and the location of the tumor affected the magnitude of the difference. For one case, all three tumor definition techniques identified volume of moderate uptake of approximately 1 mL in the hilar region on the 4D scan (SUV maximum, 3.3) but not on the 3D scan (SUV maximum, 2.3). CONCLUSIONS In comparison to 3D PET, 4D PET may better define the full physiologic extent of moving tumors and improve radiation treatment planning for lung tumors. In addition, reduction of blurring from free-breathing images may reveal additional information regarding regional disease.

Bypassing primary care clinics for childbirth: a cross-sectional study in the Pwani region, United Republic of Tanzania

OBJECTIVE To measure the extent, determinants and results of bypassing local primary care clinics for childbirth among women in rural parts of the United Republic of Tanzania. METHODS Women were selected in 2012 to complete a structured interview from a full census of all 30076 households in clinic catchment areas in Pwani region. Eligibility was limited to those who had delivered between 6 weeks and 1 year before the interview, were at least 15 years old and lived within the catchment areas. Demographic and delivery care information and opinions on the quality of obstetric care were collected through interviews. Clinic characteristics were collected from staff via questionnaires. Determinants of bypassing (i.e. delivery of the youngest child at a health centre or hospital without provider referral) were analysed using multivariate logistic regression. Bypasser and non-bypasser birth experiences were compared in bivariate analyses. FINDINGS Of 3019 eligible women interviewed (93% response rate), 71.0% (2144) delivered in a health facility; 41.8% (794) were bypassers. Bypassing likelihood increased with primiparity (odds ratio, OR: 2.5; 95% confidence interval, CI: 1.9-3.3) and perceived poor quality at clinics (OR: 1.3; 95% CI: 1.0-1.7) and decreased if clinics recently underwent renovations (OR: 0.39; 95% CI: 0.18-0.84) and/or performed ≥ 4 obstetric signal functions (OR: 0.19; 95% CI: 0.08-0.41). Bypassers reported better quality of care on six of seven quality of care measures. CONCLUSION Many pregnant women, especially first-time mothers, choose to bypass local primary care clinics for childbirth. Perceived poor quality of care at clinics was an important reason for bypassing. Primary care is failing to meet the obstetric needs of many women in this rural, low-income setting.

Long-term clinical outcomes following treatment of childhood craniopharyngioma†

To review our institutions experience with treatment of craniopharyngioma in children, and to report long‐term treatment outcomes stratified by treatment era to assess whether modern treatment techniques result in improvements in local control and survival.

Moving Toward Patient-Centered Care in Africa: A Discrete Choice Experiment of Preferences for Delivery Care among 3,003 Tanzanian Women

Objective In order to develop patient-centered care we need to know what patients want and how changing socio-demographic factors shape their preferences. Methods We fielded a structured questionnaire that included a discrete choice experiment to investigate women’s preferences for place of delivery care in four rural districts of Pwani Region, Tanzania. The discrete choice experiment consisted of six attributes: kind treatment by the health worker, health worker medical knowledge, modern equipment and medicines, facility privacy, facility cleanliness, and cost of visit. Each woman received eight choice questions. The influence of potential supply- and demand- side factors on patient preferences was evaluated using mixed logit models. Results 3,003 women participated in the discrete choice experiment (93% response rate) completing 23,947 choice tasks. The greatest predictor of health facility preference was kind treatment by doctor (β = 1.13, p<0.001), followed by having a doctor with excellent medical knowledge (β = 0.89 p<0.001) and modern medical equipment and drugs (β = 0.66 p<0.001). Preferences for all attributes except kindness and cost were changed with changes to education, primiparity, media exposure and distance to nearest hospital. Conclusions Care quality, both technical and interpersonal, was more important than clinic inputs such as equipment and cleanliness. These results suggest that while basic clinic infrastructure is necessary, it is not sufficient for provision of high quality, patient-centered care. There is an urgent need to build an adequate, competent, and kind health workforce to raise facility delivery and promote patient-centered care.

Supporting the massive scale-up of antiretroviral therapy: the evolution of PEPFAR-supported treatment facilities in South Africa, 2005-2009

BackgroundSouth Africa has an estimated 1.5 million persons in need of antiretroviral therapy (ART). In 2004, the South African government began collaborating with the United States Presidents Emergency Plan for AIDS Relief (PEPFAR) to increase access to ART. We determined how PEPFAR treatment support changed from 2005-2009.MethodsIn order to describe the change in number and type of PEPFAR-supported ART facilities, we analyzed routinely collected program-monitoring data from 2005-2009. The collected data included the number, type and province of facilities as well as the number of patients receiving ART at each facility.ResultsThe number of PEPFAR-supported facilities providing ART increased from 184 facilities in 2005 to 1,469 facilities in 2009. From 2005-2009 the number of PEPFAR-supported government facilities increased 10.1 fold from 54 to 546 while the number of PEPFAR-supported NGO facilities (including general practitioner and NGO facilities) increased 6.2 fold from 114 to 708. In 2009 the total number of persons treated at PEPFAR-supported NGO facilities was 43,577 versus 501,089 persons at PEPFAR-supported government facilities. Overall, the median number of patients receiving ART per site increased from 81 in 2005 to 136 in 2009.ConclusionsTo mitigate the gap between those needing and those receiving ART, more facilities were supported. The proportion of government facilities supported and the median number of persons treated at these facilities increased. This shift could potentially be sustainable as government sites reach more individuals and receive government funding. These results demonstrate that PEPFAR was able to support a massive scale-up of ART services in a short period of time.

Who is left behind on the road to universal facility delivery? A cross-sectional multilevel analysis in rural Tanzania.

To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage.

What elements of the work environment are most responsible for health worker dissatisfaction in rural primary care clinics in Tanzania

BackgroundIn countries with high maternal and newborn morbidity and mortality, reliable access to quality healthcare in rural areas is essential to save lives. Health workers who are satisfied with their jobs are more likely to remain in rural posts. Understanding what factors influence health workers’ satisfaction can help determine where resources should be focused. Although there is a growing body of research assessing health worker satisfaction in hospitals, less is known about health worker satisfaction in rural, primary health clinics. This study explores the workplace satisfaction of health workers in primary health clinics in rural Tanzania.MethodsOverall, 70 health workers in rural Tanzania participated in a self-administered job satisfaction survey. We calculated mean ratings for 17 aspects of the work environment. We used principal components analysis (PCA) to identify groupings of these variables. We then examined the bivariate associations between health workers demographics and clinic characteristics and each of the satisfaction scales.ResultsResults showed that 73.9% of health workers strongly agreed that they were satisfied with their job; however, only 11.6% strongly agreed that they were satisfied with their level of pay and 2.9% with the availability of equipment and supplies. Two categories of factors emerged from the PCA: the tools and infrastructure to provide care, and supportive interpersonal environment. Nurses and medical attendants (compared to clinical officers) and older health workers had higher satisfaction scale ratings.ConclusionsTwo dimensions of health workers’ work environment, namely infrastructure and supportive interpersonal work environment, explained much of the variation in satisfaction among rural Tanzanian health workers in primary health clinics. Health workers were generally more satisfied with supportive interpersonal relationships than with the infrastructure. Human resource policies should consider how to improve these two aspects of work as a means for improving health worker morale and potentially rural attrition.Trial registration(ISRCTN 17107760)

Scale-up of isoniazid preventive therapy in PEPFAR-assisted clinical sites in South Africa.

We reviewed the implementation of isoniazid preventive therapy (IPT) in South Africa from January 2010 to March 2011. The South African National Department of Health distributed revised IPT guidelines in May 2010 to increase IPT use in eligible human immunodeficiency virus (HIV) infected patients. We found a dramatic increase in the absolute numbers of patients reported to have been initiated on IPT (from 3309 in January-March 2010 to 49 130 in January-March 2011), representing an increase in the proportion (1.0-10.5%) of potentially eligible HIV-infected patients started on IPT.We reviewed the implementation of isoniazid preventive therapy (IPT) in South Africa from January 2010 to March 2011. The South African National Department of Health distributed revised IPT guidelines in May 2010 to increase IPT use in eligible human immunodeficiency virus (HIV) infected patients. We found a dramatic increase in the absolute numbers of patients reported to have been initiated on IPT (from 3309 in January-March 2010 to 49 130 in January-March 2011), representing an increase in the proportion (1.0-10.5%) of potentially eligible HIV-infected patients started on IPT.

Dual skin tests with Mycobacterium avium sensitin and PPD to detect misdiagnosis of latent tuberculosis infection.

BACKGROUND A positive tuberculin skin test (TST) may indicate cross-reacting immunity to non-tuberculous mycobacteria (NTM) and not latent tuberculosis infection (LTBI). OBJECTIVES To assess misclassification of LTBI, as assessed by skin testing with Mycobacterium avium sensitin (MaS), and to determine how this misclassification affects the analysis of risk factors for LTBI. METHODS In a population-based survey, participants underwent skin testing with M. tuberculosis purified protein derivative (PPD) and MaS. A PPD-dominant skin test was a reaction that was ≥ 3 mm larger than the MaS reaction; a MaS-dominant skin test was a reaction that was ≥ 3 mm larger than the PPD reaction. RESULTS Of 447 randomly selected persons, 135 (30%) had a positive PPD test. Of these, 21 (16%) were MaS- dominant, and were therefore attributable to NTM and misclassified as LTBI. PPD reactions of 5-14 mm were more likely to be misclassified than those ≥ 15 mm (OR = 5.0, 95%CI 1.9-13.2). Adjusting for misclassification had only a small impact on the analysis of risk factors for LTBI. CONCLUSIONS A substantial number of individuals who are diagnosed with LTBI are actually sensitized to NTM. Using dual skin testing would reduce misdiagnosis and prevent unnecessary treatment.

Cost-effectiveness of HIV and syphilis antenatal screening: a modelling study

Objectives The WHO called for the elimination of maternal-to-child transmission (MTCT) of HIV and syphilis, a harmonised approach for the improvement of health outcomes for mothers and children. Testing early in pregnancy, treating seropositive pregnant women and preventing syphilis reinfection can prevent MTCT of HIV and syphilis. We assessed the health and economic outcomes of a dual testing strategy in a simulated cohort of 100 000 antenatal care patients in Malawi. Methods We compared four screening algorithms: (1) HIV rapid test only, (2) dual HIV and syphilis rapid tests, (3) single rapid tests for HIV and syphilis and (4) HIV rapid and syphilis laboratory tests. We calculated the expected number of adverse pregnancy outcomes, the expected costs and the expected newborn disability-adjusted life years (DALYs) for each screening algorithm. The estimated costs and DALYs for each screening algorithm were assessed from a societal perspective using Markov progression models. Additionally, we conducted a Monte Carlo multiway sensitivity analysis, allowing for ranges of inputs. Results Our cohort decision model predicted the lowest number of adverse pregnancy outcomes in the dual HIV and syphilis rapid test strategy. Additionally, from the societal perspective, the costs of prevention and care using a dual HIV and syphilis rapid testing strategy was both the least costly (