Aim To describe the epidemiology of tuberculosis in the city of Liepaja during the last 27 years and the management of patients with tuberculosis during the period 1993-2002; to identify problems in tuberculosis management relevant to increasing level of morbidity and the registered high levels of drug-resistance. Material and methods The cases were all persons reported with tuberculosis in 1975-2002. The data sources were the yearly Health Statistics books at the Latvian Office of Medical Statistics. The study used data from the available 655 individual patient records from Liepaja Tuberculosis Dispensery and TB Register of 1993 – 2002. Information was extracted selectively and extraction sheets containing the variables of interest were developed. The incidence differences according to sex and age, possible clustering of patients in high-risk living areas of the city, differences in occupation of the patients were studied. The differences of time from disease symptoms to diagnosis, as well as investigation data, treatment regimens, the proportions of treatment outcomes were analysed. Analysis was done using EPI-INFO programme for statistical analysis. Results In the 1980s tuberculosis was under control in Latvia and the incidence was at the European average level. After Latvia had regained independence in 1991, with economical and political disruption and changes in the health care system, TB incidence and mortality in the country increased rapidly as well as in Liepaja. Although not very high compared to global TB rates, there was great concern about TB control in Latvia. In addition, the emergence of drug resistance and multi-drug resistant bacteria made the TB epidemic more serious. The TB incidence increase in children suggested that there was quite a big number of undetected cases of TB. Tuberculosis control and early detection activities were not integrated into the PHC system. Treatment results of TB were quite poor and showed high proportions of interruptions, defaults, relapses. The tuberculosis control Programme in Latvia and Liepaja put much effort into the improvement of the epidemiological situation with TB, focusing on TB control activities and management during the period 1993-2002. The incidence of tuberculosis in Liepaja was higher than in Latvia, particularly in some living areas in the city, and above endemic level. Mortality rate in average was higher as in the whole country. The proportion of socially sensitive groups (children, unemployed, pensioners, disabled) comprised more than 50 % of the tuberculosis incidence. Incidence among medical staff was higher than in general population in the all professional groups. Medical delay of diagnosis decreased, but early detection of tuberculosis was not fully integrated in PHC system. There were quite big differences in numbers of MDR-TB in years 1993-2002. DOTS was introduced in Liepaja five years later than in Latvia –in year 2000 and strategy was not fully successful. The number of positive treatment outcomes increased, but the registered numbers of treatment relapses and defaults were higher than in Latvia . Conclusions The situation with regard to tuberculosis development and tuberculosis management in Liepaja during the period under study was unfavourable. Particularly : the incidence and mortality rates, much variation in the diagnostic process, results of treatment ,a high proportion of MDR-TB , unsatisfactory links between local government, family doctors and medical professionals and multi-sectoral collaboration in TB control activities , the objectives set up by WHO for DOTS treatment were not reached / <p>ISBN 91-7997-139-3</p>

Background: Historically the identification of ACL injuries upon initial presentation is low and considerable diagnostic delays have been reported. However, specific evidence on the individual elements of, and factors which influence delay, is lacking. Aims: The overarching aim was to provide a comprehensive picture of delay to diagnosis and specialist consultation, including factors which influence delay. An additional aim was to determine whether the approach to examining acute knee injuries varied as a consequence of varying patient presentation or experience of the assessing clinician. Methods: Study 1: Cross -sectional survey. Study 2: Non-participant direct observation methodology. Results: Data from 194 patients were analysed in the survey. Only 15.5% of patients were given a correct diagnosis of ACL rupture at the initial consultation. Median delay to diagnosis was 67.5 days (IQR= 15 to 178 days) and specialist consultation 108 days (IQR= 38 to 292 days). The factors most influential on delay were whether a follow-up appointment was arranged after attending A&E, whether the site of attendance operated an acute knee clinic and whether MRI was performed. The direct observation study showed wide variation in approach to injury assessment. Specialist clinicians performed the most comprehensive examination. A&E clinicians were more likely to assess for bony, neurovascular and gross tendon injuries as opposed to ligamentous or meniscal injury. Conclusions: The diagnostic rate of ACL injury at initial presentation remains low. Considerable delays to diagnosis and specialist consultation are apparent following ACL injury, the majority of which is attributable to health system delay.

Background: Historically the identification of ACL injuries upon initial presentation is low and considerable diagnostic delays have been reported. However, specific evidence on the individual elements of, and factors which influence delay, is lacking. Aims: The overarching aim was to provide a comprehensive picture of delay to diagnosis and specialist consultation, including factors which influence delay. An additional aim was to determine whether the approach to examining acute knee injuries varied as a consequence of varying patient presentation or experience of the assessing clinician. Methods: Study 1: Cross -sectional survey. Study 2: Non-participant direct observation methodology. Results: Data from 194 patients were analysed in the survey. Only 15.5% of patients were given a correct diagnosis of ACL rupture at the initial consultation. Median delay to diagnosis was 67.5 days (IQR= 15 to 178 days) and specialist consultation 108 days (IQR= 38 to 292 days). The factors most influential on delay were whether a follow-up appointment was arranged after attending A&E, whether the site of attendance operated an acute knee clinic and whether MRI was performed. The direct observation study showed wide variation in approach to injury assessment. Specialist clinicians performed the most comprehensive examination. A&E clinicians were more likely to assess for bony, neurovascular and gross tendon injuries as opposed to ligamentous or meniscal injury. Conclusions: The diagnostic rate of ACL injury at initial presentation remains low. Considerable delays to diagnosis and specialist consultation are apparent following ACL injury, the majority of which is attributable to health system delay.

Made available in DSpace on 2015-05-08T14:47:27Z (GMT). No. of bitstreams: 1 Arquivototal.pdf: 1628055 bytes, checksum: 5fbea21bd6abc49c7e677b65f48ff968 (MD5) Previous issue date: 2011-03-31 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Tuberculosis (TB) is still a great challenge for public health in Brazil and in the world, being the use of health services the center of functioning of the health systems. In this aspect, the form of organization of TB care should be a guaranteeing factor in the access to the early diagnosis of TB in the cities of Brazil. The time of TB diagnosis corresponds to the period between the beginning of the signs and symptoms and the closing of diagnosis, however the access to the diagnosis in the primary care seems to be hampered by several obstacles that need to be elucidated. The present study aimed to analyze, in the perception of the diseased, the use of health services in the Attention to TB diagnosis identifying the first health service sought by the diseased when they began to present signs and symptoms; the health services that made the diagnosis and the time elapsed between the search of the diseased for the health service and the diagnosis of TB and the association between components of accessibility and the type of service sought by the diseased. The execution of this research occurred by means of a sectional epidemiological inquiry of quantitative approach. The scenery of this investigation was the city of João Pessoa, in the state of Paraíba. The population of the study was composed by the diseased with TB (in treatment, older than 18 years, resident of the studied city), being the sample constituted of 101 patients. The data were collected by means of primary sources (interview with the diseased) and secondary sources (charts) digitalized and stored in electronic spreadsheet of Microsoft Office Excel 2003 and transferred to the Table of Data Entry of Software Statistica 9.0 of Statsoft for the application of Pearson s chi-square test. In the use of the association test, statistical significance, p<0.05, was evidenced between the first health service sought by the diseased and the localization of diagnosis, where the Family Health Strategy (FHS) was the first health service most sought by the diseased with 46.5% and the Tuberculosis Control Program (TCP) was the service that most made TB diagnosis with 54.4% of the cases. In regard to the time for the diagnosis of TB 84 (83.2%) of the diseased were diagnosed in the time interval less than or equal to 30 days. However, despite the existence of a decentralization of Health the FHS is still not efficient in what regards the guarantee of access to TB diagnosis, where the TCP continues to centralize the actions regarding TB diagnosis being characterized as main entryway of TB cases in the city of João Pessoa. Therefore efforts must be undertaken to transform this reality and make FHS the entryway for the access to TB diagnoses through more resolving health services make, articulated and structured to act in the control of TB. / A tuberculose (TB) ainda é um grande desafio para saúde pública no Brasil e no mundo, sendo a utilização dos serviços de saúde o centro do funcionamento dos sistemas de saúde. Nesse aspecto, a forma de organização da atenção a TB deveria ser um fator de garantia do acesso ao diagnóstico precoce da TB nos municípios do Brasil. O tempo do diagnóstico da TB corresponde ao período entre o início dos sinais e sintomas e o fechamento do diagnóstico, contudo o acesso ao diagnóstico na atenção básica parece estar obstaculizado por várias barreiras que precisam ser elucidadas. O presente estudo visou avaliar, na perspectiva do doente, a utilização dos serviços de saúde na Atenção ao diagnóstico da TB identificando o primeiro serviço de saúde procurado pelo doente quando começou a apresentar os sinais e sintomas; os serviços de saúde que realizaram o diagnóstico, o tempo decorrido entre a procura do doente pelo serviço de saúde e o diagnóstico da TB e a associação entre componentes da acessibilidade e o tipo de serviço procurado pelo doente. A realização dessa pesquisa ocorreu por meio de um inquérito epidemiológico seccional de abordagem quantitativa. O cenário desta investigação foi o município de João Pessoa, no estado da Paraíba. A população do estudo foi composta pelos doentes de TB (em tratamento, maiores de 18 anos, residentes no município de estudo), sendo a amostra constituída por 101 pacientes. Os dados foram coletados por meio de fontes primárias (entrevistas com doentes) e secundárias (prontuários) digitados e armazenados em planilha eletrônica do Microsoft Office Excel 2003 e transferidos para a Tabela de Entrada de Dados do Software Statistica 9.0 da Statsoft para aplicação do teste qui-quadrado de Pearson. No uso do teste de associação, evidenciou-se significância estatística p<0,05 entre o primeiro serviço de saúde procurado pelo doente e o local do diagnóstico, onde a Estratégia de Saúde da Família (ESF) foi o primeiro serviço de saúde mais procurado pelo doente com 46,5% e o Programa de Controle da Tuberculose (PCT) foi o serviço que mais realizou o diagnóstico de TB com 54,4% dos casos. Com relação ao tempo para o diagnóstico da TB 84 (83,2%) dos doentes foram diagnosticados no intervalo de tempo menor ou igual a 30 dias. No entanto, apesar da existência de uma política de descentralização da Saúde a ESF ainda não se tornou eficiente no que diz respeito à garantia do acesso ao diagnóstico da TB, onde o PCT continua centralizando as ações relacionadas ao diagnóstico da TB sendo caracterizado como principal porta de entrada dos casos de TB no município de João Pessoa. Portanto, esforços precisam ser empreendidos para transformar essa realidade e tornar a ESF a porta de entrada para o acesso ao diagnóstico da TB por meio de serviços de saúde mais resolutivos, articulados e estruturados para atuar no controle da TB.