Coping with tuberculosis and directly observed treatment : a qualitative study among patients from South India

Background: In India, the Revised National TB control programme (RNTCP) offers free diagnosis and treatment for tuberculosis (TB), based on the Directly Observed Treatment Short course (DOTS) strategy. We conducted a qualitative study to explore the experience and consequences of having TB on patients enrolled in DOTS and their caretakers in Tumkur district, located in a southern state of India, Karnataka. Methods: We conducted 33 in-depth interviews on a purposive sample of TB patients from three groups: (1) patients who reached RNTCP directly on their own and took DOTS at RNTCP; (2) patients who were referred by private practitioners (PPs) to RNTCP and took DOTS at RNTCP; and (3) patients diagnosed by RNTCP and took DOTS from PPs. Data was analyzed using a thematic approach with the support of NVivo9. Results: The study revealed that TB and DOTS have a large impact on patient's lives, which is often extended to the family and caretakers. The most vulnerable patients faced the most difficulty in accessing and completing DOTS. The family was the main source of support during patient's recovery. Patients residing in rural areas and, taking DOTS from the government facilities had to overcome many barriers to adhere to the DOTS therapy, such as long travelling distance to DOTS centers, inconvenient timings and unfavorable attitude of the RNTCP staff, when compared to patients who took DOTS from PPs. Advantages of taking DOTS from PPs cited by the patients were privacy, flexibility in timings, proximity and more immediate access to care. Patients and their family had to cope with stigmatization and fear and financial hardships that surfaced from TB and DOTS. Young patients living in urban areas were more worried about stigmatisation, than elderly patients living in rural areas. Patients who were referred by PPs experienced more financial problems compared to those who reached RNTCP services directly. Conclusion: Our study provided useful information about patient's needs and expectations while taking DOTS. The development of mechanisms within RNTCP towards patient centered care is needed to enable patients and caretakers cope with disease condition and adhere to DOTS

Evidence-Based Interventions that Promote Resident Wellness from the Council of Emergency Residency Directors

Initiatives for addressing resident wellness are a recent requirement of the Accreditation Council for Graduate Medical Education in response to high rates of resident burnout nationally. We review the literature on wellness and burnout in residency education with a focus on assessment, individual-level interventions, and systemic or organizational interventions

A prospective longitudinal study of tuberculosis among household contacts of smear-positive tuberculosis cases in Lima, Peru

Background: Household contacts (HHCs) of TB cases are at increased risk for TB disease compared to the general population but the risk may be modified by individual or household factors. We conducted a study to determine incident TB among HHCs over two years after exposure and to identify individual and household level risk factors. Methods: Adults newly diagnosed with a first episode of smear-positive pulmonary TB (index cases) between March 2010 and December 2011 in eastern Lima, were interviewed to identify their HHC and household characteristics. TB registers were reviewed for up to two years after the index case diagnosis and house visits were made to ascertain TB cases among HHC. The TB incidence rate ratio among HHCs as a function of risk factors was determined using generalized linear mixed models. Results: The 1178 index cases reported 5466 HHCs. In 402/1178 (34.1 %) households, at least one HHC had experienced a TB episode ever. The TB incidence among HHCs was 1918 (95% CI 1669-2194) per 100,000 person-years overall, and was 2392 (95% CI 2005-2833) and 1435 (95% CI 1139-1787) per 100,000 person-years in the first and second year, respectively. Incident TB occurred more than six months following the index case's TB diagnosis in 121/205 (59.0 %) HHCs. In HHCs, bacillary load and time between symptoms and treatment initiation in the index case, as well as the relationship to the index case and the sex of the HHC all had a significant association with TB incidence in HHCs. Conclusions: Incidence of TB among HHCs was more than ten times higher than in the general population. Certain HHC and households were at higher risk of TB, we recommend studies to compare HHC investigation to households at highest risk versus current practice, in terms of efficiency

Patients pathways to tuberculosis diagnosis and treatment in a fragmented health system : a qualitative study from a south Indian district

Background: India's Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB diagnosis and treatment. But more than 50% of TB patients seek care from private practitioners (PPs), where TB is managed sub-optimally. In India, there is dearth of studies capturing experiences of TB patients when they navigate through health facilities to seek care. Also, there is less information available on how PPs make decisions to refer TB cases to RNTCP. We conducted this study to understand the factors influencing TB patient's therapeutic itineraries to RNTCP and PP's cross referral practices linked to RNTCP. Methods: We conducted in-depth interviews on a purposive sample of 33 TB patients and 38 PPs. Patients were categorised into three groups: those who reached RNTCP directly, those who were referred by PPs to RNTCP and patients who took DOT from PPs. We assessed patient's experiences in each category and documented their journey from initial symptoms until they reached RNTCP, where they were diagnosed and started on treatment. PPs were categorised into three groups based on their TB case referrals to RNTCP: actively-referring, minimally-referring and non-referring. Results: Patients had limited awareness about TB. Patients switched from one provider to the other, since their symptoms were not relieved. A first group of patients, self-medicated by purchasing get rid drugs from private chemists over the counter, before seeking care. A second group sought care from government facilities and had simple itineraries. A third group who sought care from PPs, switched concurrently and/or iteratively from public and private providers in search for relief of symptoms causing important diagnostic delays. Eventually all patients reached RNTCP, diagnosed and started on treatment. PP's cross-referral practices were influenced by patient's paying capacity, familiarity with RNTCP, kickbacks from private labs and chemists, and even to get rid of TB patients. These trade-offs by PPs complicated patient's itineraries to RNTCP. Conclusions: India aims to achieve universal health care for TB. Our study findings help RNTCP to develop initiatives to promote early detection of TB, by involving PPs and private chemists and establish effective referral systems from private sectors to RNTCP

A Statistical Model for Large and Very Large Hail: Development, Global Climate Applications and Use in Forecasting

We have developed additive regression convective hazard models (AR-CHaMo) for predicting the occurrence of large (≥ 2 cm), very large hail (≥ 5 cm) and lightning. The models were trained using hail reports, lightning observations and parameters calculated from the ERA5 reanalysis across three different regions: Europe, the United States and Australia. The AR-CHaMo models take convective initiation explicitly into account meaning that the probability of (very) large hail is computed as the product of the probability of a thunderstorm occurring and the conditional probability of (very) large hail given a storm. AR-CHaMo outputs the probability of (very) large hail and lightning as a function of environmental predictors from the ERA5 reanalysis. While developing AR-CHaMo, we showed that a commonly used parameter such as the Convective Available Potential Energy (CAPE) should not be used as a proxy for hail worldwide as it may not fully address the fundamental physical mechanisms behind hail formation, especially across sub-tropical regions. We found the amount of CAPE released above the -10° C isotherm to outperform CAPE and to be the only instability-related parameter that can perform well regardless of the geographical region. These findings were possible thanks to the large number of (experimental) parameters,172, that were computed from ERA5 and tested within the logistic models. The AR-CHaMo models were used for two main purposes: firstly to reconstruct the long-term climatology and the associated trends in Europe, the U.S. and globally, and secondly for medium-range forecasting. The reconstruction of the long-term climatology between 1950 and 2021 across Europe and the U.S. allowed us to map the regional hotspots of (very) large hail. In the U.S., large and very large hail are most common in the Great Plains with a maximum between north-western Kansas, north-eastern Colorado and south-western Nebraska while in Europe the hotspots are northern Italy, south-western France and eastern Spain. Between 1950 and 2021, the frequency of (very) large hail has increased across most of Europe while trends are comparatively smaller in the U.S. The strongest increase is found in northern Italy where hail ≥ 5 cm is now (2012–2021) modelled to be three times more frequent than it was in the 1950s. The extension of the analysis to global scale for the period 1992–2022 showed that the positive trends detected in southern Europe are not only stronger than those in the U.S. but the strongest on a global scale. Such positive trends are driven by a local increase in low-level moisture, and consequently higher buoyancy, rather than by changes in tropospheric flow patterns. On a global scale, very large hail is most frequent across the Great Plains of the U.S., the tri-border region between Argentina, Paraguay and Brazil, and to lesser extent in South Africa. Local hotspots exist in Australia and parts of Asia but, overall, hail ≥ 5 cm is much less frequent there. During the past 30 years, very large hail is modelled to have decreased across most of the southern hemisphere especially across South America and equatorial Africa while areas of positive trends are limited to Europe and parts of the U.S. The trends of AR-CHaMo were compared to those in hail loss events across Central Europe, the U.S. and Australia. Although the number of hail loss events has increased in each of these regions, the drivers of these trends might differ. In Europe, trends in hail loss events show similarities to increases in the modelled frequency of very large hail. In the U.S., the number of hail loss events increases stronger than the modelled frequency of hail ≥ 5 cm, and in Australia the trends even show opposite signs. Increases in hail loss events are mainly driven by non-meteorological factors, namely socio-economic factors as well as more exposure with higher vulnerabilities. However, the similarities of the trend curves in Europe indicate that, here, meteorological factors might play a more important role than across the U.S. and Australia. A second application of the AR-CHaMo models involved forecasting. When applied to the ECMWF reforecasts for the period 2008–2019, AR-CHaMo proved to be skillful in predicting large hail up to 108 hours in advance. In addition, the comparison with existing composite metrics for hail forecasting showed that AR-CHaMo outperforms the product of CAPE and Deep Layer Shear (CAPESHEAR, at all lead times) and the Significant Hail Parameter (SHP, at short to medium lead times). In conclusion, the AR-CHaMo models were applied to the deterministic runs from the ECMWF IFS, GFS and ICON-EU models to yield daily probabilistic forecasts of lightning, hail ≥ 2 cm and hail ≥ 5 cm on a pan European scale. Forecasts are publicly available on the website stormforecast.eu and provide the first open- access probabilistic tool for (very) large hail forecasting. It is aimed that this tool will help forecasters in the prediction of these hazards across the whole of Europe

Psychiatric Disorders and lncRNAs: A Synaptic Match

Psychiatric disorders represent a heterogeneous class of multifactorial mental diseases whose origin entails a pathogenic integration of genetic and environmental influences. Incidence of these pathologies is dangerously high, as more than 20% of the Western population is affected. Despite the diverse origins of specific molecular dysfunctions, these pathologies entail disruption of fine synaptic regulation, which is fundamental to behavioral adaptation to the environment. The synapses, as functional units of cognition, represent major evolutionary targets. Consistently, fine synaptic tuning occurs at several levels, involving a novel class of molecular regulators known as long non-coding RNAs (lncRNAs). Non-coding RNAs operate mainly in mammals as epigenetic modifiers and enhancers of proteome diversity. The prominent evolutionary expansion of the gene number of lncRNAs in mammals, particularly in primates and humans, and their preferential neuronal expression does represent a driving force that enhanced the layering of synaptic control mechanisms. In the last few years, remarkable alterations of the expression of lncRNAs have been reported in psychiatric conditions such as schizophrenia, autism, and depression, suggesting unprecedented mechanistic insights into disruption of fine synaptic tuning underlying severe behavioral manifestations of psychosis. In this review, we integrate literature data from rodent pathological models and human evidence that proposes the biology of lncRNAs as a promising field of neuropsychiatric investigation

Demographics, Activities, and Environmental Factors Impact Burnout in a National Survey of Emergency Medicine Residents

Introduction: Burnout in emergency medicine and in residency training has been well-described. The impact of demographic, individual, and programmatic factors on burnout have not previously been determined in a national survey of emergency medicine residents. This study aimed to identify personal and environmental factors impacting resident burnout in a national sample of emergency medicine residents. Methods: A prospective Emergency Medicine Resident Wellness Survey was administered in 2017. We surveyed respondents on demographic, personal, and environmental factors; each respondent also completed the Maslach Burnout Inventory - Human Services Survey. Linear regressions were used to identify variables associated with the Maslach Burnout Inventory’s subscales of burnout (depersonalization, emotional exhaustion, and personal achievement). Results: The survey was completed by 1,522 of 7,186 (21.2%) eligible EM residents. Respondents represented 193 of 247 (78.1%) Emergency Medicine residency programs. Increased levels of depersonalization were associated with graduation from a US medical school, female gender, and increase in respondent age. Trainees who were parents and who graduated from an osteopathic (vs. allopathic) medical school were found to have decreased levels of depersonalization. Emotional exhaustion was decreased in respondents who took breaks while on shift and who engaged in regular studying. Conclusion: While some individual characteristics impact burnout, environmental factors also play a significant role, and should be a target of system-level interventions to improve trainee well-being