BACKGROUND Hepatic manifestations in chronic lymphocytic leukemia(CLL)are common:Elevation of liver enzymes frequently occurs,and differential diagnosis is often challenging.Liver infiltration by leukemic cells,primar...BACKGROUND Hepatic manifestations in chronic lymphocytic leukemia(CLL)are common:Elevation of liver enzymes frequently occurs,and differential diagnosis is often challenging.Liver infiltration by leukemic cells,primary and secondary hepatic malignancies,drug-induced hepatotoxicity,immunological disorders,and infections have been reported.Nevertheless,syncytial giant cell hepatitis(GCH)as a manifestation of autoimmune hepatitis in patients with CLL is an extremely rare condition,currently reported only in anecdotal cases.CASE SUMMARY Here,we report the case of a 62-year-old Caucasian woman affected by CLL,who developed GCH with peculiar histopathological features.The patient was evaluated for abnormal liver test results.Liver histology revealed significant inflammatory lymphomononuclear infiltrates with a plasma cell component,widespread syncytial changes in the hepatocytes with gigantocellular features,hepatocyte rosettes,and the typical feature of emperipolesis,consistent with a diagnosis of GCH.The patient was treated with corticosteroids and mycophenolate mofetil,resulting in a complete biochemical response.CONCLUSION Early histological diagnosis of GCH is crucial in patients with CLL,with mycophenolate mofetil representing a promising treatment option.展开更多
<b><span style="font-family:Verdana;">Background:</span></b><span style="font-family:""><span style="font-family:Verdana;"> Until recently, the ex...<b><span style="font-family:Verdana;">Background:</span></b><span style="font-family:""><span style="font-family:Verdana;"> Until recently, the experience on implementing community based management of acute malnutrition (CMAM) among children has been largely based in African settings. While the government in Bangladesh is yet to scale up CMAM approach, there is still paucity of knowledge on the experience of CMAM within the complex milieu of an urban slum context. In Kamrangirchar slum, Dhaka, Bangladesh, this paper describes a CMAM programme performance and outcomes run by Médecins Sans Frontières (MSF)/Doctors without Borders, in light to performance indicators set by MSF and the Sphere minimum standards. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> This was a descriptive retrospective study using routinely collected programme data of children admitted with severe acute malnutrition between May 2010 and November 2011. Kamrangirchar is an urban slum of a large migrant population in Dhaka, Bangladesh. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> There was a total of 640 new admissions, of whom 333 (52%) were males. The median age was 18 months (Inter-quartile range (IQR) 12 - 41). 599 children had a reported nutritional outcome at discharge from ambulatory therapeutic feeding centre (ATFC), this included: cure rate of 69% with an average length of stay of 68.8 (SD ± 46.0) days and average weight gain of 3.8 g/kg/day (SD ± 2.7). The lost-to-follow-up rate was 18% and 5% reported to the programme that they will leave the slum and go back to their villages. These performance indicators did not meet the threshold level indicators set by MSF and Sphere standards. </span><b><span style="font-family:Verdana;">Conclusions:</span></b><span style="font-family:Verdana;"> Our experience highlights the need for developing more adapted and contextualised indicators for assessing the performance of CMAM programmes in settings such as urban slums. Community engagement in the process of developing relevant standards is crucial. Nutrition humanitarian actors have a vital role to collaborate with local authorities to contextualize and refine these standards.展开更多
Clinical practice with respect to metastatic colorectal cancer differs from the other two most common cancers,breast and lung,in that routine surveillance is recommended with the specific intent of detecting liver and...Clinical practice with respect to metastatic colorectal cancer differs from the other two most common cancers,breast and lung,in that routine surveillance is recommended with the specific intent of detecting liver and lung metastases and undertaking liver and lung resections for their removal.We trace the history of this approach to colorectal cancer by reviewing evidence for effectiveness from the 1950s to the present day.Our sources included published citation network analyses,the documented proposal for randomised trials,large systematic reviews,and meta-analysis of observational studies.The present consensus position has been adopted on the basis of a large number of observational studies but the randomised trials proposed in the 1980s and 1990s were either not done,or having been done,were not reported.Clinical opinion is the mainstay of current practice but in the absence of randomised trials there remains a possibility of selection bias.Randomised controlled trials(RCTs)are now routine before adoption of a new practice but RCTs are harder to run in evaluation of already established practice.One such trial is recruiting and shows that controlled trial are possible.展开更多
Background:National tuberculosis(TB)programs increasingly engage with international non-governmental organizations(INGOs),especially to provide TB care in complex settings where community involvement might be required...Background:National tuberculosis(TB)programs increasingly engage with international non-governmental organizations(INGOs),especially to provide TB care in complex settings where community involvement might be required.In Myanmar,however,there is limited data on how such INGO community-based programs are organized and how effective they are.In this study,we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar,and assess their contribution to TB case detection.Methods:We conducted a descriptive study using program data from four INGOs and the National TB Program(NTP)in 2013-2014.For each INGO,we extracted information on its approach and key activities,the number of presumptive TB cases referred and undergoing TB testing,and the number of patients diagnosed with TB and their treatment outcomes.The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships.Results:All four INGOs implemented community-based TB care in challenging contexts,targeting migrants,post-conflict areas,the urban poor,and other vulnerable populations.Two recruited community volunteers via existing community health volunteers or health structures,one via existing community leaderships,and one directly involved TB infected/affected individuals.Two INGOs compensated volunteers via performance-based financing,and two provided financial and in-kind initiatives.All relied on NTP laboratories for diagnosis and TB drugs,but provided direct observation treatment support and treatment follow-up.A total of 21995 presumptive TB cases were referred for TB diagnosis,with 7383(34%)new TB cases diagnosed and almost all(98%)successfully treated.The four INGOs contributed to the detection of,on average,36%(7383/20663)of the total new TB cases in their respective townships(range:15-52%).Conclusion:Community-based TB care supported by INGOs successfully achieved TB case detection in hard-toreach and vulnerable populations.This is vital to achieving the World Health Organization End TB Strategy targets.Strategies to ensure sustainability of the programs should be explored,including the need for longer-term commitment of INGOs.展开更多
Background:It is estimated that the standard,passive case finding(PCF)strategy for detecting cases of tuberculosis(TB)in Myanmar has not been successful:26%of cases are missing.Therefore,alternative strategies,such as...Background:It is estimated that the standard,passive case finding(PCF)strategy for detecting cases of tuberculosis(TB)in Myanmar has not been successful:26%of cases are missing.Therefore,alternative strategies,such as active case finding(ACF)by community volunteers,have been initiated since 2011.This study aimed to assess the contribution of a Community Based TB Care Programme(CBTC)by local non-government organizations(NGOs)to TB case finding in Myanmar over 4 years.Methods:This was a descriptive study using routine,monitoring data.Original data from the NGOs were sent to a central registry within the National TB Programme and data for this study were extracted from that database.Data from all 84 project townships in five regions and three states in Myanmar were used.The project was launched in 2011.Results:Over time,the number of presumptive TB cases that were referred decreased,except in the Yangon Region,although in some areas,the numbers fluctuated.At the same time,there was a trend for the proportion of cases treated,compared to those referred,that decreased over time(P=0.051).Overall,among 84 townships,the contribution of CBTC to total case detection deceased from 6%to 4%over time(P<0.001).Conclusions:Contrary to expectations and evidence from previous studies in other countries,a concerning reduction in TB case finding by local NGO volunteer networks in several areas in Myanmar was recorded over 4 years.This suggests that measures to support the volunteer network and improve its performance are needed.They may include discussion with local NGOs human resources personnel,incentives for the volunteers,closer supervision of volunteers and improved monitoring and evaluation tools.展开更多
Background:International non-governmental organizations(INGOs)have been implementing community-based tuberculosis(TB)care(CBTBC)in Myanmar since 2011.Although the National TB Programme(NTP)ultimately plans to take ove...Background:International non-governmental organizations(INGOs)have been implementing community-based tuberculosis(TB)care(CBTBC)in Myanmar since 2011.Although the National TB Programme(NTP)ultimately plans to take over CBTBC,there have been no evaluations of the models of care or of the costs of providing CBTBC in Myanmar by INGOs.Methods:This was a descriptive study using routinely-collected programmatic and financial data from four INGOs during 2013 and 2014,adjusted for inflation.Data analysis was performed from the provider perspective.Costs for sputum examination were not included as it was provided free of charge by NTP.We calculated the average cost per year of each programme and cost per patient completing treatment.Results:Four INGOs assisted the NTP by providing CBTBC in areas where access to TB services was challenging.Each INGO faced different issues in their contexts and responded with a diversity of strategies.The total costs ranged from US$140754 to US$550221 during the study period.The cost per patient completing treatment ranged from US$215 to US$1076 for new cases and US$354 to US$1215 for retreatment cases,depending on the targeted area and the package of services offered.One INGO appeared less costly,more sustainable and patient oriented than others.Conclusions:This study revealed a wide variety of models of care and associated costs for implementing CBTBC in diverse and challenging populations and contexts in Myanmar.Consequently,we recommend a more comprehensive evaluation,including development of a cost model,to estimate the costs of scaling up CBTBC country-wide,and cost-effectiveness studies,to best inform the NTP as it prepares to takeover CBTBC activities from INGOs.While awaiting evidence from these studies,model of CBTBC that have higher sustainability potential and allocate more resources to patient-centered care should be given priority support.展开更多
Sarcopenia is a well-known complication of chronic liver disease(CLD),and it is almost always observed in patients with cirrhosis,at least in those with decompensated disease.Since nonalcoholic fatty liver disease(NAF...Sarcopenia is a well-known complication of chronic liver disease(CLD),and it is almost always observed in patients with cirrhosis,at least in those with decompensated disease.Since nonalcoholic fatty liver disease(NAFLD),recently renamed metabolic dysfunction-associated steatotic liver disease(MASLD),is becoming the leading cause of end-stage liver disease,a new scenario characterized by the frequent coexistence of NAFLD,obesity,and sarcopenia is emerging.Although it is not yet resolved whether the bidirectional relationship between sarcopenia and NAFLD subtends causal determinants,it is clear that the interaction of these two conditions is associated with an increased risk of poor outcomes.Notably,during the course of CLD,deregulation of the liver-muscle-adipose tissue axis has been described.Unfortunately,owing to the lack of properly designed studies,specific therapeutic guidelines for patients with sarcopenia in the context of NAFLD-related CLD have not yet been defined.Strategies aimed to induce the loss of fat mass together with the maintenance of lean body mass seem most appropriate.This can be achieved by properly designed diets integrated with specific nutritional supplementations and accompanied by adequate physical exercise.Future studies aiming to add to the knowledge of the correct assessment and approach to sarcopenia in the context of NAFLD-related CLD are eagerly awaited.展开更多
Recently generalized exponential distribution has received considerable attentions. In this paper, we deal with the Bayesian inference of the unknown parameters of the progressively censored generalized exponential di...Recently generalized exponential distribution has received considerable attentions. In this paper, we deal with the Bayesian inference of the unknown parameters of the progressively censored generalized exponential distribution. It is assumed that the scale and the shape parameters have independent gamma priors. The Bayes estimates of the unknown parameters cannot be obtained in the closed form. Lindley’s approximation and importance sampling technique have been suggested to compute the approximate Bayes estimates. Markov Chain Monte Carlo method has been used to compute the approximate Bayes estimates and also to construct the highest posterior density credible intervals. We also provide different criteria to compare two different sampling schemes and hence to find the optimal sampling schemes. It is observed that finding the optimum censoring procedure is a computationally expensive process. And we have recommended to use the sub-optimal censoring procedure, which can be obtained very easily. Monte Carlo simulations are performed to compare the performances of the different methods and one data analysis has been performed for illustrative purposes.展开更多
Background:This study examined evolving malaria profiles from January,2010 to December,2014 to evaluate achievements and challenges of implementing measures to prevent and control spread of artemisinin resistance in M...Background:This study examined evolving malaria profiles from January,2010 to December,2014 to evaluate achievements and challenges of implementing measures to prevent and control spread of artemisinin resistance in Myanmar.Methods:Using National Malaria Control Programme(NMCP)data,a cross-sectional descriptive study of 52 townships in artemisinin-resistant containment areas in Myanmar was conducted.Annual program data were analysed,and trends over time are graphically presented.Results:In the 52 study townships populated by 8.7 million inhabitants,malaria incidence showed a decreasing trend from 10.54 per 1000 population in 2010 to 2.53 in 2014,and malaria mortalities also decreased from 1.83 per 100000 population in 2010 to 0.17 in 2014.The proportion of confirmed to total tested malaria cases also decreased from 6 to 1%,while identification of cases improved.All cases from all parasites species,including Plasmodium falciparum,decreased.Coverage of LLIN(long-lasting insecticidal net)/ITN(insecticide-treated mosquito nets)and indoor residual spraying(IRS)was high in targeted areas with at-risk persons,even though the total population was not covered.In addition to passive case detection(PCD),active case detection(ACD)was conducted in hard-to-reach areas and worksites where mobile migrant populations were present.ACD improved in most areas from 2012 to 2014,but continues to need to be strengthened.Conclusions:The findings provide useful data on the malaria situation in artemisinin-resistant initiative areas,which may be useful for the NMCP to meet its elimination goal.These profiles could contribute to better planning,implementation,and evaluation of intervention activities.展开更多
Background:Since 2005,the Myanmar National Tuberculosis Programme(NTP)has been implementing active case finding(ACF)activities involving mobile teams in hard-to-reach areas.This study revealed the contribution of mobi...Background:Since 2005,the Myanmar National Tuberculosis Programme(NTP)has been implementing active case finding(ACF)activities involving mobile teams in hard-to-reach areas.This study revealed the contribution of mobile team activities to total tuberculosis(TB)case detection,characteristics of TB patients detected by mobile teams and their treatment outcomes.Methods:This was a descriptive study using routine programme data between October 2014 and December 2014.Mobile team activities were a one-stop service and included portable digital chest radiography(CXR)and microscopy of two sputum samples.The algorithm of the case detection included screening patients by symptoms,then by CXR followed by sputum microscopy for confirmation.Diagnosed patients were started on treatment and followed until a final outcome was ascertained.Results:A total of 9349 people with symptoms suggestive of TB were screened by CXR,with an uptake of 96.6%.Of those who were meant to undergo sputum smear microscopy,51.4%had sputum examinations.Finally,504 TB patients were identified by the mobile teams and the overall contribution to total TB case detection in the respective townships was 25.3%.Among total cases examined by microscopy,6.4%were sputum smear positive TB.Treatment success rate was high as 91.8%in study townships compared to national rate 85%(2014 cohort).Conclusions:This study confirmed the feasibility and acceptability of ACF by mobile teams in hard-to-reach contexts,especially when equipped with portable,digital CXR machines that provided immediate results.However,the follow-up process of sputum examination created a significant barrier to confirmation of the diagnosis.In order to optimize the ACF through mobile team activity,future ACF activities were needed to be strengthened one stop service including molecular diagnostics or provision of sputum cups to all presumptive TB cases prior to CXR and testing if CXR suggestive of TB.展开更多
Background:Myanmar lies in the Greater Mekong sub-region of South-East Asia faced with the challenge of emerging resistance to artemisinin combination therapies(ACT).Migrant populations are more likely than others to ...Background:Myanmar lies in the Greater Mekong sub-region of South-East Asia faced with the challenge of emerging resistance to artemisinin combination therapies(ACT).Migrant populations are more likely than others to spread ACT resistance.A vital intervention to reduce malaria transmission,resistance spread and eliminate malaria is the use of bed nets.Among seasonal and stable migrants in an artemisinin resistance containment region of Myanmar,we compared a)their household characteristics,b)contact with health workers and information material,and c)household knowledge,access and utilization of bed nets.Methods:Secondary data from community-based surveys on 2484 migrant workers(2013 and 2014,Bago Region)were analyzed of which 37%were seasonal migrants.Bed net access and utilization were assessed using a)availability of at least one bed net per household,and b)one bed net per two persons,and c)proportion of household members who slept under abed net during the previous night(Indicator targets=100%).Results:Over 70%of all migrants were from unstable work settings with short transitory stays.Average household size was five(range 1-25)and almost half of all households had children under-five years.Roughly 10%of migrants were night-time workers.Less than 40%of households had contact with health workers and less than 30%had exposure to information education and communication(IEC)materials,the latter being significantly lower among seasonal migrants.About 70%of households were aware of the importance of insecticide-treated bed-nets/long-lasting insecticidal nets(ITNs/LLINs),but knowledge on insecticide impregnation and retreatment of ITNs was poor(<10%).Although over 95%of households had access to at least one bed net,the number with one bed net per two persons was grossly inadequate(13%for stable migrants and 9%for seasonal migrants,P=0.001).About half of all household members slept under a bed net during the previous night.Conclusions:This study reveals important short-falls in knowledge,access and utilization of bed nets among migrants in Myanmar.Possible ways forward include frequent distribution campaigns to compensate for short transitory stays,matching household distributions to household size,enhanced information campaigns and introducing legislation to make mosquito repellents available for night-time workers at plantations and farms.Better understanding through qualitative research is also merited.展开更多
Background:As part of the WHO End TB strategy,national tuberculosis(TB)programs increasingly aim to engage all private and public TB care providers.Engagement of communities,civil society organizations and public and ...Background:As part of the WHO End TB strategy,national tuberculosis(TB)programs increasingly aim to engage all private and public TB care providers.Engagement of communities,civil society organizations and public and private care provider is the second pillar of the End TB strategy.In Myanmar,this entails the public-public and public-private mix(PPM)approach.The public-public mix refers to public hospital TB services,with reporting to the national TB program(NTP).The public-private mix refers to private general practitioners providing TB services including TB diagnosis,treatment and reporting to NTP.The aim of this study was to assess whether PPM activities can be scaled-up nationally and can be sustained over time.Methods:Using 2007-2014 aggregated program data,we collected information from NTP and non-NTP actors on 1)the number of TB cases detected and their relative contribution to the national case load;2)the type of TB cases detected;3)their treatment outcomes.Results:The total number of TB cases detected per year nationally increased from 133,547 in 2007 to 142,587 in 2014.The contribution of private practitioners increased from 11%in 2007 to 18%in 2014,and from 1.8%to 4.6%for public hospitals.The NTP contribution decreased from 87%in 2007 to 77%in 2014.A similar pattern was seen in the number of new smear(+)TB cases(31%of all TB cases)and retreatment cases,which represented 7.8%of all TB cases.For new smear(+)TB cases,adverse outcomes were more common in public hospitals,with more patients dying,lost to follow up or not having their treatment outcome evaluated.Patients treated by private practitioners were more frequently lost to follow up(8%).Adverse treatment outcomes in retreatment cases were particularly common(59%)in public hospitals for various reasons,predominantly due to patients dying(26%)or not being evaluated(10%).In private clinics,treatment failure tended to be more common(8%).Conclusions:The contribution of non-NTP actors to TB detection at the national level increased over time,with the largest contribution by private practitioners involved in PPM.Treatment outcomes were fair.Our findings confirm the role of PPM in national TB programs.To achieve the End TB targets,further expansion of PPM to engage all public and private medical facilities should be targeted.展开更多
文摘BACKGROUND Hepatic manifestations in chronic lymphocytic leukemia(CLL)are common:Elevation of liver enzymes frequently occurs,and differential diagnosis is often challenging.Liver infiltration by leukemic cells,primary and secondary hepatic malignancies,drug-induced hepatotoxicity,immunological disorders,and infections have been reported.Nevertheless,syncytial giant cell hepatitis(GCH)as a manifestation of autoimmune hepatitis in patients with CLL is an extremely rare condition,currently reported only in anecdotal cases.CASE SUMMARY Here,we report the case of a 62-year-old Caucasian woman affected by CLL,who developed GCH with peculiar histopathological features.The patient was evaluated for abnormal liver test results.Liver histology revealed significant inflammatory lymphomononuclear infiltrates with a plasma cell component,widespread syncytial changes in the hepatocytes with gigantocellular features,hepatocyte rosettes,and the typical feature of emperipolesis,consistent with a diagnosis of GCH.The patient was treated with corticosteroids and mycophenolate mofetil,resulting in a complete biochemical response.CONCLUSION Early histological diagnosis of GCH is crucial in patients with CLL,with mycophenolate mofetil representing a promising treatment option.
文摘<b><span style="font-family:Verdana;">Background:</span></b><span style="font-family:""><span style="font-family:Verdana;"> Until recently, the experience on implementing community based management of acute malnutrition (CMAM) among children has been largely based in African settings. While the government in Bangladesh is yet to scale up CMAM approach, there is still paucity of knowledge on the experience of CMAM within the complex milieu of an urban slum context. In Kamrangirchar slum, Dhaka, Bangladesh, this paper describes a CMAM programme performance and outcomes run by Médecins Sans Frontières (MSF)/Doctors without Borders, in light to performance indicators set by MSF and the Sphere minimum standards. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> This was a descriptive retrospective study using routinely collected programme data of children admitted with severe acute malnutrition between May 2010 and November 2011. Kamrangirchar is an urban slum of a large migrant population in Dhaka, Bangladesh. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> There was a total of 640 new admissions, of whom 333 (52%) were males. The median age was 18 months (Inter-quartile range (IQR) 12 - 41). 599 children had a reported nutritional outcome at discharge from ambulatory therapeutic feeding centre (ATFC), this included: cure rate of 69% with an average length of stay of 68.8 (SD ± 46.0) days and average weight gain of 3.8 g/kg/day (SD ± 2.7). The lost-to-follow-up rate was 18% and 5% reported to the programme that they will leave the slum and go back to their villages. These performance indicators did not meet the threshold level indicators set by MSF and Sphere standards. </span><b><span style="font-family:Verdana;">Conclusions:</span></b><span style="font-family:Verdana;"> Our experience highlights the need for developing more adapted and contextualised indicators for assessing the performance of CMAM programmes in settings such as urban slums. Community engagement in the process of developing relevant standards is crucial. Nutrition humanitarian actors have a vital role to collaborate with local authorities to contextualize and refine these standards.
基金Supported by The British Heart Foundation(to Fiorentino F)
文摘Clinical practice with respect to metastatic colorectal cancer differs from the other two most common cancers,breast and lung,in that routine surveillance is recommended with the specific intent of detecting liver and lung metastases and undertaking liver and lung resections for their removal.We trace the history of this approach to colorectal cancer by reviewing evidence for effectiveness from the 1950s to the present day.Our sources included published citation network analyses,the documented proposal for randomised trials,large systematic reviews,and meta-analysis of observational studies.The present consensus position has been adopted on the basis of a large number of observational studies but the randomised trials proposed in the 1980s and 1990s were either not done,or having been done,were not reported.Clinical opinion is the mainstay of current practice but in the absence of randomised trials there remains a possibility of selection bias.Randomised controlled trials(RCTs)are now routine before adoption of a new practice but RCTs are harder to run in evaluation of already established practice.One such trial is recruiting and shows that controlled trial are possible.
基金This study was funded by the Special Program for Research and Training in Tropical Diseases at the World Health Organization(WHO/TDR)Impact Grant given to two TDR alumni from the DMRThe funders had no role in the study design,data collection and analysis,decision to publish,or preparation of the paper.
文摘Background:National tuberculosis(TB)programs increasingly engage with international non-governmental organizations(INGOs),especially to provide TB care in complex settings where community involvement might be required.In Myanmar,however,there is limited data on how such INGO community-based programs are organized and how effective they are.In this study,we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar,and assess their contribution to TB case detection.Methods:We conducted a descriptive study using program data from four INGOs and the National TB Program(NTP)in 2013-2014.For each INGO,we extracted information on its approach and key activities,the number of presumptive TB cases referred and undergoing TB testing,and the number of patients diagnosed with TB and their treatment outcomes.The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships.Results:All four INGOs implemented community-based TB care in challenging contexts,targeting migrants,post-conflict areas,the urban poor,and other vulnerable populations.Two recruited community volunteers via existing community health volunteers or health structures,one via existing community leaderships,and one directly involved TB infected/affected individuals.Two INGOs compensated volunteers via performance-based financing,and two provided financial and in-kind initiatives.All relied on NTP laboratories for diagnosis and TB drugs,but provided direct observation treatment support and treatment follow-up.A total of 21995 presumptive TB cases were referred for TB diagnosis,with 7383(34%)new TB cases diagnosed and almost all(98%)successfully treated.The four INGOs contributed to the detection of,on average,36%(7383/20663)of the total new TB cases in their respective townships(range:15-52%).Conclusion:Community-based TB care supported by INGOs successfully achieved TB case detection in hard-toreach and vulnerable populations.This is vital to achieving the World Health Organization End TB Strategy targets.Strategies to ensure sustainability of the programs should be explored,including the need for longer-term commitment of INGOs.
基金The program was funded by WHO/TDR Impact grant to two TDR alumni from DMR.The funders had no role in study design,data collection and analysis,decision to publish,or preparation of the manuscript。
文摘Background:It is estimated that the standard,passive case finding(PCF)strategy for detecting cases of tuberculosis(TB)in Myanmar has not been successful:26%of cases are missing.Therefore,alternative strategies,such as active case finding(ACF)by community volunteers,have been initiated since 2011.This study aimed to assess the contribution of a Community Based TB Care Programme(CBTC)by local non-government organizations(NGOs)to TB case finding in Myanmar over 4 years.Methods:This was a descriptive study using routine,monitoring data.Original data from the NGOs were sent to a central registry within the National TB Programme and data for this study were extracted from that database.Data from all 84 project townships in five regions and three states in Myanmar were used.The project was launched in 2011.Results:Over time,the number of presumptive TB cases that were referred decreased,except in the Yangon Region,although in some areas,the numbers fluctuated.At the same time,there was a trend for the proportion of cases treated,compared to those referred,that decreased over time(P=0.051).Overall,among 84 townships,the contribution of CBTC to total case detection deceased from 6%to 4%over time(P<0.001).Conclusions:Contrary to expectations and evidence from previous studies in other countries,a concerning reduction in TB case finding by local NGO volunteer networks in several areas in Myanmar was recorded over 4 years.This suggests that measures to support the volunteer network and improve its performance are needed.They may include discussion with local NGOs human resources personnel,incentives for the volunteers,closer supervision of volunteers and improved monitoring and evaluation tools.
基金The program was funded by a WHO/TDR Impact grant to two TDR alumni from DMR.The funders had no role in study design,data collection and analysis,decision to publish,or preparation of the manuscript。
文摘Background:International non-governmental organizations(INGOs)have been implementing community-based tuberculosis(TB)care(CBTBC)in Myanmar since 2011.Although the National TB Programme(NTP)ultimately plans to take over CBTBC,there have been no evaluations of the models of care or of the costs of providing CBTBC in Myanmar by INGOs.Methods:This was a descriptive study using routinely-collected programmatic and financial data from four INGOs during 2013 and 2014,adjusted for inflation.Data analysis was performed from the provider perspective.Costs for sputum examination were not included as it was provided free of charge by NTP.We calculated the average cost per year of each programme and cost per patient completing treatment.Results:Four INGOs assisted the NTP by providing CBTBC in areas where access to TB services was challenging.Each INGO faced different issues in their contexts and responded with a diversity of strategies.The total costs ranged from US$140754 to US$550221 during the study period.The cost per patient completing treatment ranged from US$215 to US$1076 for new cases and US$354 to US$1215 for retreatment cases,depending on the targeted area and the package of services offered.One INGO appeared less costly,more sustainable and patient oriented than others.Conclusions:This study revealed a wide variety of models of care and associated costs for implementing CBTBC in diverse and challenging populations and contexts in Myanmar.Consequently,we recommend a more comprehensive evaluation,including development of a cost model,to estimate the costs of scaling up CBTBC country-wide,and cost-effectiveness studies,to best inform the NTP as it prepares to takeover CBTBC activities from INGOs.While awaiting evidence from these studies,model of CBTBC that have higher sustainability potential and allocate more resources to patient-centered care should be given priority support.
文摘Sarcopenia is a well-known complication of chronic liver disease(CLD),and it is almost always observed in patients with cirrhosis,at least in those with decompensated disease.Since nonalcoholic fatty liver disease(NAFLD),recently renamed metabolic dysfunction-associated steatotic liver disease(MASLD),is becoming the leading cause of end-stage liver disease,a new scenario characterized by the frequent coexistence of NAFLD,obesity,and sarcopenia is emerging.Although it is not yet resolved whether the bidirectional relationship between sarcopenia and NAFLD subtends causal determinants,it is clear that the interaction of these two conditions is associated with an increased risk of poor outcomes.Notably,during the course of CLD,deregulation of the liver-muscle-adipose tissue axis has been described.Unfortunately,owing to the lack of properly designed studies,specific therapeutic guidelines for patients with sarcopenia in the context of NAFLD-related CLD have not yet been defined.Strategies aimed to induce the loss of fat mass together with the maintenance of lean body mass seem most appropriate.This can be achieved by properly designed diets integrated with specific nutritional supplementations and accompanied by adequate physical exercise.Future studies aiming to add to the knowledge of the correct assessment and approach to sarcopenia in the context of NAFLD-related CLD are eagerly awaited.
基金supported by a grant from the Department of Science and Technology, Government of India
文摘Recently generalized exponential distribution has received considerable attentions. In this paper, we deal with the Bayesian inference of the unknown parameters of the progressively censored generalized exponential distribution. It is assumed that the scale and the shape parameters have independent gamma priors. The Bayes estimates of the unknown parameters cannot be obtained in the closed form. Lindley’s approximation and importance sampling technique have been suggested to compute the approximate Bayes estimates. Markov Chain Monte Carlo method has been used to compute the approximate Bayes estimates and also to construct the highest posterior density credible intervals. We also provide different criteria to compare two different sampling schemes and hence to find the optimal sampling schemes. It is observed that finding the optimum censoring procedure is a computationally expensive process. And we have recommended to use the sub-optimal censoring procedure, which can be obtained very easily. Monte Carlo simulations are performed to compare the performances of the different methods and one data analysis has been performed for illustrative purposes.
基金The program was funded by the WHO/TDR Impact grant to two TDR alumni from DMRThe funders had no role in study design,data collection and analysis,decision to publish,or preparation of the manuscript.
文摘Background:This study examined evolving malaria profiles from January,2010 to December,2014 to evaluate achievements and challenges of implementing measures to prevent and control spread of artemisinin resistance in Myanmar.Methods:Using National Malaria Control Programme(NMCP)data,a cross-sectional descriptive study of 52 townships in artemisinin-resistant containment areas in Myanmar was conducted.Annual program data were analysed,and trends over time are graphically presented.Results:In the 52 study townships populated by 8.7 million inhabitants,malaria incidence showed a decreasing trend from 10.54 per 1000 population in 2010 to 2.53 in 2014,and malaria mortalities also decreased from 1.83 per 100000 population in 2010 to 0.17 in 2014.The proportion of confirmed to total tested malaria cases also decreased from 6 to 1%,while identification of cases improved.All cases from all parasites species,including Plasmodium falciparum,decreased.Coverage of LLIN(long-lasting insecticidal net)/ITN(insecticide-treated mosquito nets)and indoor residual spraying(IRS)was high in targeted areas with at-risk persons,even though the total population was not covered.In addition to passive case detection(PCD),active case detection(ACD)was conducted in hard-to-reach areas and worksites where mobile migrant populations were present.ACD improved in most areas from 2012 to 2014,but continues to need to be strengthened.Conclusions:The findings provide useful data on the malaria situation in artemisinin-resistant initiative areas,which may be useful for the NMCP to meet its elimination goal.These profiles could contribute to better planning,implementation,and evaluation of intervention activities.
基金The program was funded by WHO/TDR Impact grant to two TDR alumni from DMRThe funders had no role in study design,data collection and analysis,decision to publish,or preparation of the manuscript。
文摘Background:Since 2005,the Myanmar National Tuberculosis Programme(NTP)has been implementing active case finding(ACF)activities involving mobile teams in hard-to-reach areas.This study revealed the contribution of mobile team activities to total tuberculosis(TB)case detection,characteristics of TB patients detected by mobile teams and their treatment outcomes.Methods:This was a descriptive study using routine programme data between October 2014 and December 2014.Mobile team activities were a one-stop service and included portable digital chest radiography(CXR)and microscopy of two sputum samples.The algorithm of the case detection included screening patients by symptoms,then by CXR followed by sputum microscopy for confirmation.Diagnosed patients were started on treatment and followed until a final outcome was ascertained.Results:A total of 9349 people with symptoms suggestive of TB were screened by CXR,with an uptake of 96.6%.Of those who were meant to undergo sputum smear microscopy,51.4%had sputum examinations.Finally,504 TB patients were identified by the mobile teams and the overall contribution to total TB case detection in the respective townships was 25.3%.Among total cases examined by microscopy,6.4%were sputum smear positive TB.Treatment success rate was high as 91.8%in study townships compared to national rate 85%(2014 cohort).Conclusions:This study confirmed the feasibility and acceptability of ACF by mobile teams in hard-to-reach contexts,especially when equipped with portable,digital CXR machines that provided immediate results.However,the follow-up process of sputum examination created a significant barrier to confirmation of the diagnosis.In order to optimize the ACF through mobile team activity,future ACF activities were needed to be strengthened one stop service including molecular diagnostics or provision of sputum cups to all presumptive TB cases prior to CXR and testing if CXR suggestive of TB.
基金The program was funded by WHO/TDR Impact grant to two TDR alumni from DMR.The funders had no role in study design,data collection and analysis,decision to publish,or preparation of the manuscript.
文摘Background:Myanmar lies in the Greater Mekong sub-region of South-East Asia faced with the challenge of emerging resistance to artemisinin combination therapies(ACT).Migrant populations are more likely than others to spread ACT resistance.A vital intervention to reduce malaria transmission,resistance spread and eliminate malaria is the use of bed nets.Among seasonal and stable migrants in an artemisinin resistance containment region of Myanmar,we compared a)their household characteristics,b)contact with health workers and information material,and c)household knowledge,access and utilization of bed nets.Methods:Secondary data from community-based surveys on 2484 migrant workers(2013 and 2014,Bago Region)were analyzed of which 37%were seasonal migrants.Bed net access and utilization were assessed using a)availability of at least one bed net per household,and b)one bed net per two persons,and c)proportion of household members who slept under abed net during the previous night(Indicator targets=100%).Results:Over 70%of all migrants were from unstable work settings with short transitory stays.Average household size was five(range 1-25)and almost half of all households had children under-five years.Roughly 10%of migrants were night-time workers.Less than 40%of households had contact with health workers and less than 30%had exposure to information education and communication(IEC)materials,the latter being significantly lower among seasonal migrants.About 70%of households were aware of the importance of insecticide-treated bed-nets/long-lasting insecticidal nets(ITNs/LLINs),but knowledge on insecticide impregnation and retreatment of ITNs was poor(<10%).Although over 95%of households had access to at least one bed net,the number with one bed net per two persons was grossly inadequate(13%for stable migrants and 9%for seasonal migrants,P=0.001).About half of all household members slept under a bed net during the previous night.Conclusions:This study reveals important short-falls in knowledge,access and utilization of bed nets among migrants in Myanmar.Possible ways forward include frequent distribution campaigns to compensate for short transitory stays,matching household distributions to household size,enhanced information campaigns and introducing legislation to make mosquito repellents available for night-time workers at plantations and farms.Better understanding through qualitative research is also merited.
基金The program was funded by WHO/TDR Impact grant to two TDR alumni from DMR.The funders had no role in study design,data collection and analysis,decision to publish,or preparation of the manuscript.
文摘Background:As part of the WHO End TB strategy,national tuberculosis(TB)programs increasingly aim to engage all private and public TB care providers.Engagement of communities,civil society organizations and public and private care provider is the second pillar of the End TB strategy.In Myanmar,this entails the public-public and public-private mix(PPM)approach.The public-public mix refers to public hospital TB services,with reporting to the national TB program(NTP).The public-private mix refers to private general practitioners providing TB services including TB diagnosis,treatment and reporting to NTP.The aim of this study was to assess whether PPM activities can be scaled-up nationally and can be sustained over time.Methods:Using 2007-2014 aggregated program data,we collected information from NTP and non-NTP actors on 1)the number of TB cases detected and their relative contribution to the national case load;2)the type of TB cases detected;3)their treatment outcomes.Results:The total number of TB cases detected per year nationally increased from 133,547 in 2007 to 142,587 in 2014.The contribution of private practitioners increased from 11%in 2007 to 18%in 2014,and from 1.8%to 4.6%for public hospitals.The NTP contribution decreased from 87%in 2007 to 77%in 2014.A similar pattern was seen in the number of new smear(+)TB cases(31%of all TB cases)and retreatment cases,which represented 7.8%of all TB cases.For new smear(+)TB cases,adverse outcomes were more common in public hospitals,with more patients dying,lost to follow up or not having their treatment outcome evaluated.Patients treated by private practitioners were more frequently lost to follow up(8%).Adverse treatment outcomes in retreatment cases were particularly common(59%)in public hospitals for various reasons,predominantly due to patients dying(26%)or not being evaluated(10%).In private clinics,treatment failure tended to be more common(8%).Conclusions:The contribution of non-NTP actors to TB detection at the national level increased over time,with the largest contribution by private practitioners involved in PPM.Treatment outcomes were fair.Our findings confirm the role of PPM in national TB programs.To achieve the End TB targets,further expansion of PPM to engage all public and private medical facilities should be targeted.
