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Biomedical subjects

D Wilkinson

Publications and source records attributed to D Wilkinson.

At least 145 records · Page 8Linked to original sources
PubMed1999

Tuberculosis and health sector reform: experience of integrating tuberculosis services into the district health system in rural South Africa.

SETTING: Hlabisa health district, South Africa. OBJECTIVE: To describe the integration of a 'vertical' tuberculosis control programme into an emerging 'horizontal' district health system, within the context of health sector reform. DESIGN: Descriptive account of the process of integration of the programme into the health system. RESULTS: A highly 'vertical' system of delivering tuberculosis treatment (with poor programme outcomes) was converted into a 'horizontal' team, integrated within the district health system, that used available resources such as village clinics and community health workers, with improved programme outcomes. CONCLUSIONS: In some settings at least, integration of tuberculosis 'programmes' into the district health system as tuberculosis 'teams' is feasible, and may produce highly cost-effective outcomes.

Delivery of Health Care, Integrated↗
PubMed1999

Who fails to complete tuberculosis treatment? Temporal trends and risk factors for treatment interruption in a community-based directly observed therapy programme in a rural district of South Africa.

SETTING: Hlabisa Tuberculosis Programme, Hlabisa, South Africa. OBJECTIVE: To determine trends in and risk factors for interruption of tuberculosis treatment. METHODS: Data were extracted from the control programme database starting in 1991. Temporal trends in treatment interruption are described; independent risk factors for treatment interruption were determined with a multiple logistic regression model, and Kaplan-Meier survival curves for treatment interruption were constructed for patients treated in 1994-1995. RESULTS: Overall 629 of 3,610 surviving patients (17%) failed to complete treatment; this proportion increased from 11% (n = 79) in 1991/1992 to 22% (n = 201) in 1996. Independent risk factors for treatment interruption were diagnosis between 1994-1996 compared with 1991-1993 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.6-2.4); human immunodeficiency virus (HIV) positivity compared with HIV negativity (OR 1.8, 95%CI 1.4-2.4); supervised by village clinic compared with community health worker (OR 1.9, 95%CI 1.4-2.6); and male versus female sex (OR 1.3, 95%CI 1.1-1.6). Few patients interrupted treatment during the first 2 weeks, and the treatment interruption rate thereafter was constant at 1% per 14 days. CONCLUSIONS: Frequency of treatment interruption from this programme has increased recently. The strongest risk factor was year of diagnosis, perhaps reflecting the impact of an increased caseload on programme performance. Ensuring adherence to therapy in communities with a high level of migration remains a challenge even within community-based directly observed therapy programmes.

Adolescent↗
PubMed1998

Improving quality of sexually transmitted disease case management in rural South Africa.

OBJECTIVE: To measure quality of sexually transmitted disease (STD) syndromic case management and aspects of health-seeking behaviour at baseline in an intervention trial. SETTING: Ten rural primary care clinics, Hlabisa district, South Africa. DESIGN: Simulated patients (fieldworkers trained to present with STD syndromes) made a total of 44 clinic visits; 49 STD patients were interviewed when exiting clinics; facilities were assessed for availability of necessary equipment and drugs; 10 focus group discussions were held with staff; and STD syndrome surveillance was performed in all 10 clinics. RESULTS: A total of 9% of simulated patients were correctly managed (given correct drugs, plus condoms and partner notification cards), recommended drug treatment was given in only 41% of visits, and appropriate counselling was given in 48% of visits. Among patients leaving the clinic, although 39% waited over an hour to be seen and only 37% were consulted in private, all reported staff attitudes as satisfactory or good. Only six clinics had syndromic management protocols available, three reported intermittent drug shortages, and seven lacked partner notification cards. Focus group discussions revealed good staff knowledge about STD, but showed lack of training in syndromic management and low morale. Surveillance data showed that while 75% of those presenting for care did so within 1 week of symptom onset, 27% had been treated for an STD in the preceding 3 months, and only 6% of those treated were contacts. CONCLUSIONS: Quality of STD case management was poor despite good staff knowledge and availability of most essential resources. An intervention comprising staff training and STD syndrome packets has been designed to improve quality of case management.

Case Management↗
PubMed1998

Antiretroviral drugs as a public health intervention for pregnant HIV-infected women in rural South Africa: an issue of cost-effectiveness and capacity.

OBJECTIVE: To estimate cost-effectiveness and capacity requirements for providing antiretroviral drugs to pregnant HIV-infected women in rural South Africa. SETTING: Hlabisa health district, where HIV prevalence among pregnant women was 26.0% in 1997. METHODS: Calculation of the number of paediatric HIV infections averted under three scenarios, and their cost. No intervention was compared with scenario A (zidovudine delivered within current infrastructure), scenario B (zidovudine delivered through enhanced infrastructure), and scenario C (short-course zidovudine plus lamivudine delivered through enhanced infrastructure). Cost-effectiveness was defined as cost per infection averted and cost per potential life-year gained. Capacity was determined in terms of staff and infrastructure required to effectively implement the scenarios. RESULTS: With no intervention, 657 paediatric HIV infections were projected for 1997. In scenario A this could be reduced by 15% at a cost of US$ 574 825, in scenario B by 42% at US$ 1520770, and in scenario C by 47% at US$ 764901. In scenario C, drugs accounted for 76% of costs, whereas additional staff accounted for 18%. Cost per infection averted was US$ 2492 and cost per potential life-year gained (discounted at 3%) was US$ 88. Cost of scenario C was equivalent to 14% of the 1997 district health budget. At least 12 extra counsellors and nurses and one laboratory technician, together with substantial logistical and managerial support, would be needed to deliver an effective intervention. CONCLUSION: Although antiretrovirals may be relatively cost-effective in this setting, the budget required is currently unaffordable. Developing the capacity required to deliver the intervention would pose both a major challenge, and an opportunity, to improve health services.

Adult↗
PubMed1998

Effect of preventive treatment for tuberculosis in adults infected with HIV: systematic review of randomised placebo controlled trials.

OBJECTIVE: To determine whether preventive treatment for tuberculosis in adults infected with HIV reduces the frequency of tuberculosis and overall mortality. DESIGN: Systematic review and data synthesis of randomised placebo controlled trials. MAIN OUTCOME MEASURES: Active tuberculosis, mortality, and adverse drug reaction requiring cessation of the study regimen. Outcomes stratified by status of purified protein derivative skin test. RESULTS: Four trials comprising 4055 adults from Haiti, Kenya, the United States, and Uganda were included. All compared isoniazid (6-12 months) with placebo, and one trial also compared multidrug treatment for 3 months with placebo. Mean follow up was 15-33 months. Overall, frequency of tuberculosis (relative risk 0.57, 95% confidence interval 0.41 to 0.79) was reduced in those receiving preventive treatment compared with placebo: mortality was not significantly reduced (0.93, 0.83 to 1.05). In subjects positive for purified protein derivative receiving preventive treatment, the risk of tuberculosis was reduced substantially (0.32, 0.19 to 0.51) and the risk of death was reduced moderately (0.73, 0.57 to 0.95) compared with those taking placebo. In adults negative for purified protein derivative receiving preventive treatment, the risk of tuberculosis (0.82, 0.50 to 1.36) and the risk of death (1.02, 0.89 to 1.17) were not reduced significantly. Adverse drug reactions were more frequent, but not significantly so, in patients receiving drug compared with placebo (1.45, 0.98 to 2.14). CONCLUSIONS: Preventive treatment given for 3-12 months protects against tuberculosis in adults infected with HIV, at least in the short to medium term. Protection is greatest in subjects positive for purified protein derivative, in whom death is also less frequent. Long term benefits remain to be shown.

AIDS-Related Opportunistic Infections↗
PubMed1998

The microwave background anisotropies: observations.

Most cosmologists now believe that we live in an evolving universe that has been expanding and cooling since its origin about 15 billion years ago. Strong evidence for this standard cosmological model comes from studies of the cosmic microwave background radiation (CMBR), the remnant heat from the initial fireball. The CMBR spectrum is blackbody, as predicted from the hot Big Bang model before the discovery of the remnant radiation in 1964. In 1992 the cosmic background explorer (COBE) satellite finally detected the anisotropy of the radiation-fingerprints left by tiny temperature fluctuations in the initial bang. Careful design of the COBE satellite, and a bit of luck, allowed the 30 microK fluctuations in the CMBR temperature (2.73 K) to be pulled out of instrument noise and spurious foreground emissions. Further advances in detector technology and experiment design are allowing current CMBR experiments to search for predicted features in the anisotropy power spectrum at angular scales of 1 degrees and smaller. If they exist, these features were formed at an important epoch in the evolution of the universe--the decoupling of matter and radiation at a temperature of about 4,000 K and a time about 300,000 years after the bang. CMBR anisotropy measurements probe directly some detailed physics of the early universe. Also, parameters of the cosmological model can be measured because the anisotropy power spectrum depends on constituent densities and the horizon scale at a known cosmological epoch. As sophisticated experiments on the ground and on balloons pursue these measurements, two CMBR anisotropy satellite missions are being prepared for launch early in the next century.

Journal Article↗
PubMed1998

The economic consequences of Alzheimer's disease in the context of new drug developments.

The first national symptomatic treatment for Alzheimer's disease has received a very mixed and perhaps ageist reception from purchasers of health care in the UK. This is largely because detailed information on the long-term effects of this class of drugs is scarce. However, by looking at the published evidence on the economic burden of Alzheimer's disease, some observations and assumptions can be made as to the influence of the new drug treatments. The drug therapies available and those most likely to become licensed are reviewed and the potential economic impact is discussed. Long-term outcome studies would properly address this, but as these drugs have now demonstrated efficacy, particularly in non-cognitive behaviours, it will be ethically more difficult to maintain patients on placebo for long periods. Some assumptions therefore have to be made from long-term open-label studies. Those drugs currently available, and those in development, may offer effective treatment for some of the core symptoms of Alzheimer's disease, slowing the rate of cognitive decline and preserving competence in activities of daily living for longer. If handled correctly, these treatments have the potential to offer cost savings for many patients, and cost-effectiveness improvements look probable.

Aged↗
PubMed1998

Clinical experience with Donepezil (Aricept) in the UK.

Experience of the use of Donepezil (Aricept) in the UK since licensing is discussed. The results of a 30 week double blind parallel group study in the US of Donepezil 5 or 10 mg versus placebo show statistically significant improvements in cognitive and clinical global assessments. Beneficial effects were demonstrated in the absence of significant adverse effects on physical or laboratory values. The guidelines for use adopted in the UK are discussed with the emphasis on identifying non-cognitive behaviours, as significant improvements in these have been found and often have more impact on quality of life than cognitive improvements alone.

Alzheimer Disease↗
PubMed1998

A radioimmunoassay combined with solid-phase extraction for the determination (pg ml-1) of AR-C15849XX) in human plasma.

A radioimmunoassay has been developed for the determination of AR-C15849KF, a CCK-8 analogue, in human plasma. The method incorporates solid-phase sample extraction, is suitable for the determination of the analyte at pg ml-1 concentrations and is based on a method developed and validated for dog plasma. The solid-phase extraction, using ion-exchange aminopropyl and octadecyl sorbents sequentially, was retained for this procedure to remove matrix interferences in the plasma and to enhance method sensitivity. The calibration range is 10-500 pg ml-1, using a 1 ml sample of undiluted human plasma. The method has been successfully used to generate early human pharmacokinetic data during a programme of exploratory development.

Animals↗
PubMed1998

Pediatric tuberculosis in rural South Africa--value of directly observed therapy.

Tuberculosis is a major cause of mortality and morbidity among children in resource-poor settings. A strategy of community-based, directly observed therapy employed in a rural health district in South Africa since 1991 is described. Most children (75 per cent) diagnosed with tuberculosis were treated in the community and most of them (85 per cent) completed treatment. Supervision was either by clinic-based health workers (26 per cent), community health workers (20 per cent), or volunteer lay people (46 per cent). Among children diagnosed with tuberculosis who were also HIV infected, the case-fatality rate was higher than among the HIV uninfected, and a larger proportion of the HIV infected failed to complete treatment.

Adolescent↗
PubMed1998

Sexually transmitted disease syndromes in rural South Africa. Results from health facility surveillance.

BACKGROUND AND OBJECTIVE: Surveillance for sexually transmitted diseases (STD) is important for priority setting, service development, and evaluating interventions. GOAL: To conduct health facility-based surveillance for STDs to inform design of a control program and to provide baseline measures for evaluation of interventions. STUDY DESIGN: Surveillance system for patients with STD syndromes in public and private sector health facilities in Hlabisa, South Africa. RESULTS: Over a 5-month period, 4,781 patients with an STD were reported, 3,126 (65%) by clinics and 1,655 (35%) by general practitioners; 2,582 (54%) were in men. Most were diagnosed with a single syndrome. Discharge was most common (49% of both male and female patients), followed by ulcer (36% of men and 14% of women). Mean symptom duration was 18 days for women and 10 days for men (p < 0.0001). A quarter reported having another STD in the previous 3 months. The highest age-specific incidence was estimated at 16.4% among women 20 to 24 years of age. CONCLUSIONS: The burden of STDs is high in rural South Africa. There is considerable scope for improved disease control, and the private sector has an important role to play.

Adolescent↗
PubMed1998

The 'growth monitoring teaching aid' rapidly improves mothers' understanding of growth curves.

Most growth monitoring programmes in developing countries have not been successful in reducing malnutrition. This is due, at least in part, to the exclusion of mothers from the process of growth monitoring. An essential requisite for greater participation is for mothers to understand the meaning of a growth chart. The 'Growth Monitoring Teaching Aid' (GMTA) is an educational game which attempts to expedite the process of understanding growth curves by simulating the growth curve of a child using water added to a bucket suspended below the direct recording scales. Thirty mothers were divided into an experimental group who used the GMTA for 2-4 h and a control group who did not use it. Six questions were used to test each subject's understanding of growth curves. Paired t tests revealed that the experimental group significantly increased their understanding of growth, whereas the control group did not. The mean score for the experimental group prior to playing the game was 1.43; this increased to 5.27 after playing the game (P < 0.0001). The GMTA by rapidly improving the present poor level of understanding of growth curves, may allow greater maternal participation in growth monitoring.

Adult↗