Risk factors for early mortality in patients with pulmonary tuberculosis admitted to the emergency room.

BACKGROUND AND OBJECTIVES: Mortality of patients with pulmonary tuberculosis (TB) admitted to emergency departments is high. This study was aimed at analysing the risk factors associated with early mortality and designing a risk score based on simple parameters. METHODS: This prospective case-control study enrolled patients admitted to the emergency department of a referral TB hospital. Clinical, radiological, biochemical and microbiological risk factors associated with death were compared among patients dying within one week from admission (cases) and those surviving (controls). RESULTS: Forty-nine of 250 patients (19.6%) experienced early mortality. Multiple logistic regression analysis showed that oxygen saturation (SaO2) ≤90%, severe malnutrition, tachypnoea, tachycardia, hypotension, advanced disease at chest radiography, severe anaemia, hyponatremia, hypoproteinemia and hypercapnia were independently and significantly associated with early mortality. A clinical scoring system was further designed to stratify the risk of death by selecting five simple parameters (SpO2 ≤ 90%, tachypnoea, hypotension, advanced disease at chest radiography and tachycardia). This model predicted early mortality with a positive predictive value of 94.88% and a negative predictive value of 19.90%. CONCLUSIONS: The scoring system based on simple parameters may help to refer severely ill patients early to a higher level to reduce mortality, improve success rates, minimise the need for pulmonary rehabilitation and prevent post-treatment sequelae.

Rehabilitation, optimized nutritional care, and boosting host internal milieu to improve long-term treatment outcomes in tuberculosis patients.

BACKGROUND: The holistic management of tuberculosis (TB) patients can improve life expectancy and lost organ function. REHABILITATION: Chronic sequelae are very common among patients who survive TB, which can lead to a further decline in lung function. There is still no guidance for 'cured' patients with impaired lung function who need pulmonary rehabilitation. Additional tests for evaluation should be given after the end of treatment, as recent studies have shown the good effect of pulmonary rehabilitation for TB patients. OPTIMIZED NUTRITIONAL CARE: Malnutrition is very common among TB patients and is related to malabsorption. The latter can cause lower drug exposure, which may result in treatment failure, increasing the risk of death, and can lead to acquired drug resistance. Malnutrition should be assessed according to the Global Leadership Initiative on Malnutrition (GLIM) criteria and the diagnosis should lead to an individualized treatment plan, including sufficient proteins and preferably in combination with adequate training. PROTECTIVE IMMUNE RESPONSES: Under normal circumstances, most immune cells use a glucose-based mechanism to generate energy. Therefore the patient's nutritional status is a key factor in shaping immune responses. Disease-related malnutrition leads to proteolysis and lipolysis. In the end, the identification of individuals who will benefit from immune-modulatory strategies may lead to clinically relevant markers.

Surgical Resection in the Treatment of Pulmonary Tuberculosis.

Surgery for tuberculosis is becoming more relevant today. This article discusses the main indications, contraindications, features of operations, and perioperative period. This information is useful for practicing surgeons and specialists in the treatment of pulmonary tuberculosis.

Associação entre desfecho do tratamento, características sociodemográficas e benefícios sociais recebidos por indivíduos com tuberculose em Salvador, Bahia, 2014-2016 / Asociación entre resultado del tratamiento, características sociodemográficas y beneficios sociales recibidos por individuos con tuberculosis en Salvador, Bahía, Brasil, 2014-2016 / Association between treatment outcome, sociodemographic characteristics and social benefits received by individuals with tuberculosis in Salvador, Bahia, Brazil, 2014-2016

Objetivo: analisar associação entre desfecho do tratamento da tuberculose, características sociodemográficas e benefícios sociais recebidos. Métodos: estudo de coorte desenvolvido em Salvador, Bahia, Brasil, no período 2014-2016; analisaram-se associações bivariadas entre desfecho do tratamento, características sociodemográficas e benefícios sociais. Resultados: foram acompanhados 216 indivíduos, dos quais 79,6% foram curados; maior proporção de cura associou-se com escolaridade >9 anos (87,5%; p=0,028), união conjugal (86,3%; p=0,031) e densidade domiciliar ≤2 pessoas/dormitório (84,1%; p=0,013); foram adotados como referência indivíduos com escolaridade ≤9 anos, sem união conjugal, e densidade domiciliar >2 pessoas/dormitório; maior proporção de cura também foi verificada entre indivíduos que recebiam benefícios governamentais e não governamentais (90,5%) ou somente benefícios diretos (81,6%). Conclusão: escolaridade >9 anos, união conjugal e densidade domiciliar ≤2 pessoas/dormitório associaram-se com maior proporção de cura; este desfecho foi mais frequente entre indivíduos que acumulavam benefícios governamentais e não governamentais ou recebiam somente benefícios diretos.

Objetivo: analizar la asociación entre resultados del tratamiento de la tuberculosis, características sociodemográficas y los beneficios sociales recibidos. Métodos: estudio de cohorte en Salvador, Bahia, Brasil, en el período 2014-2016; se analizaron correlaciones bivariadas entre resultados del tratamiento, características sociodemográficas y beneficios. Resultados: participaron 216 individuos, de los cuales 79,6% fueron curados; una mayor proporción de cura se asoció con escolaridad >9 años (87,5%; p=0,028), unión conyugal (86,3%; p=0,031) y densidad domiciliaria ≤2 personas/dormitorio (84,1%; p=0,013); fueron adoptados como referencia escolaridad ≤9 años, solteros y densidad domiciliaria >2 personas/dormitorio; mayor curación también se verificó entre individuos que recibían beneficios gubernamentales y no gubernamentales (90,5%) o únicamente beneficios directos (81,6%). Conclusión: escolaridad >9 años, unión conyugal y densidad domiciliaria ≤2 personas/dormitorio se asociaron con curación; este resultado fue más frecuente entre los que acumulaban beneficios gubernamentales y no gubernamentales o recibían solamente beneficios directos.

Objective: to analyze association between tuberculosis treatment outcome, sociodemographic characteristics and receipt of social benefits. Methods: this was a cohort study conducted in Salvador, Bahia, Brazil, in the period 2014-2016; we analyzed bivariate associations between treatment outcome, sociodemographic characteristics and social benefits. Results: 216 individuals were followed, of whom 79.6% were cured; higher cure proportion was associated with schooling >9 years (87.5%; p=0.028), marital union (86.3%; p=0.031), and household density ≤2 individuals/bedroom (84.1%; p=0.013); we took as our reference individuals with schooling ≤9 years, not in marital union, and housing density >2 people/bedroom; higher cure proportion was also found among recipients of government and non-government benefits (90.5%), and among those who only received direct benefits (81.6%). Conclusion: schooling >9 years, marital union, and household density ≤2 individuals/bedroom were associated with higher cure; this outcome was more frequent among individuals receiving government and non-government benefits, and among individuals receiving only direct benefits.

A pre-post intervention study of pulmonary rehabilitation for adults with post-tuberculosis lung disease in Uganda.

Setting: The study was conducted at Mulago Hospital, Kampala, Uganda. Objective: As chronic respiratory disease (CRD) is a huge, growing burden in Africa, with few available treatments, we aimed to design and evaluate a culturally appropriate pulmonary rehabilitation (PR) program in Uganda for people with post-tuberculosis lung disorder (p-TBLD). Design: In a pre-post intervention study, a 6-week, twice-weekly PR program was designed for people with p-TBLD. Outcome measures included recruitment, retention, the Clinical COPD Questionnaire (CCQ), tests of exercise capacity, and biometrics. Given this was a developmental study, no formal statistical significance testing was undertaken. Results: In all, 34 participants started PR and 29 (85%) completed all data collection. The mean age of the 29 participants was 45 years, and 52% were female. The mean (95% confidence interval) CCQ score at baseline was 1.8 (1.5, 2.0), at the end of PR was 1.0 (0.8, 1.2), and at 6 weeks after the end of PR was 0.8 (0.7, 1.0). The Incremental Shuttle Walking Test (ISWT) was 299 m (268.5, 329.4) at baseline, 377 (339.6, 413.8) at the end of PR, and 374 (334.2, 413.5) at 6 weeks after the end of PR. Improvements were seen in measures of chest pain; 13/29 (45%) participants reported chest pain at baseline but only 7/29 (24%) at the end of PR, and in those with persistent pain, the mean pain scores decreased. Mild hemoptysis was reported in 4/29 (17%) participants at baseline and in 2/29 (7%) at the end of PR. Conclusion: PR for people with p-TBLD in Uganda was feasible and associated with clinically important improvements in quality of life, exercise capacity, and respiratory outcomes. PR uses local resources, requires little investment, and offers a new, sustainable therapy for p-TBLD in resource-limited settings. With the rising global burden of CRD, further studies are needed to assess the value of PR in p-TBLD and other prevalent forms of CRD.

[Spirometric and radiographic profile of patients with pulmonary tuberculosis treated and cured at the Department of Pulmonology of Brazzaville University Hospital]. / Profil spirométrique et radiographique des patients anciens tuberculeux pulmonaires traités et guéris au service de pneumologie du CHU de Brazzaville.

INTRODUCTION: Tuberculosis is a real public health problem in Congo. Pulmonary localization can lead to sequelae of respiratory functional repercussions. OBJECTIVE: Describe the spirometric and radiographic profile of patients treated with pulmonary tuberculosis treated and cured. PATIENTS AND METHODS: This was a cross-sectional study that included 150 patients with previous pulmonary tuberculosis with positive microscopy treated and cured in the Pulmonary Department of Brazzaville University Hospital. In which we performed a functional exploration (Spirometry) and a chest X-ray. The study took place from 1st January 2016 to 31st August 2016. RESULTS: The spirometry performed in all patients was pathological in 68.67% (103 cases/150) of the cases. Among them 74.76% (77 cases/103) had a restrictive profile (FEV1/FVC >70% and CVF <80%), 9.71% (10 cases/103) an obstructive syndrome (FEV1/FVC ≤70% and CVF >80%) and 15.53% (16 cases/103) a mixed syndrome (FVC <80% and FEV1/FVC <70%). Of the 150 chest radiographs performed, 120 or 80% were pathological; the degree of parenchymal stage III destruction represented 28.33%. There was a significant correlation between the degree of parenchymal destruction and the delay in treatment on the one hand and between the degree of parenchymal destruction and the different pulmonary volumes and volumes on the other hand. CONCLUSION: The prevention of these respiratory functional disorders is based on the prophylaxis of tuberculosis on early diagnosis of the disease.

Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis?

The role of tuberculosis as a public health care priority and the availability of diagnostic tools to evaluate functional status (spirometry, plethysmography, and DLCO determination), arterial blood gases, capacity to perform exercise, lesions (chest X-ray and CT), and quality of life justify the effort to consider what needs to be done when patients have completed their treatment. To our knowledge, no review has ever evaluated this topic in a comprehensive manner. Our objective was to review the available evidence on this topic and draw conclusions regarding the future role of the "post-tuberculosis treatment" phase, which will potentially affect several million cases every year. We carried out a non-systematic literature review based on a PubMed search using specific keywords (various combinations of the terms "tuberculosis", "rehabilitation", "multidrug-resistant tuberculosis", "pulmonary disease", "obstructive lung disease", and "lung volume measurements"). The reference lists of the most important studies were retrieved in order to improve the sensitivity of the search. Manuscripts written in English, Spanish, and Russian were selected. The main areas of interest were tuberculosis sequelae following tuberculosis diagnosis and treatment; "destroyed lung"; functional evaluation of sequelae; pulmonary rehabilitation interventions (physiotherapy, long-term oxygen therapy, and ventilation); and multidrug-resistant tuberculosis.The evidence found suggests that tuberculosis is definitively responsible for functional sequelae, primarily causing an obstructive pattern on spirometry (but also restrictive and mixed patterns), and that there is a rationale for pulmonary rehabilitation. We also provide a list of variables that should be discussed in future studies on pulmonary rehabilitation in patients with post-tuberculosis sequelae. RESUMO O papel da tuberculose como uma prioridade de saúde pública e a disponibilidade de ferramentas diagnósticas para avaliar o estado funcional (espirometria, pletismografia e DLCO), a gasometria arterial, a capacidade de realizar exercícios, as lesões (radiografia de tórax e TC) e a qualidade de vida justificam o esforço de se considerar o que deve ser feito quando os pacientes completam seu tratamento. Até onde sabemos, nenhuma revisão avaliou esse tópico de forma abrangente. Nosso objetivo foi revisar as evidências disponíveis e obter algumas conclusões sobre o futuro papel da fase de "tratamento pós-tuberculose", que irá potencialmente impactar milhões de casos todos os anos. Realizou-se uma revisão não sistemática da literatura tendo como base uma pesquisa no PubMed usando palavras-chave específicas (várias combinações dos termos "tuberculose", "reabilitação", "tuberculose multirresistente", "doença pulmonar", "doença pulmonar obstrutiva", e "medidas de volume pulmonar"). As listas de referências dos artigos principais foram recuperadas para melhorar a sensibilidade da busca. Foram selecionados manuscritos escritos em inglês, espanhol e russo. As principais áreas de interesse foram sequelas de tuberculose após diagnóstico e tratamento; "pulmão destruído"; avaliação funcional das sequelas; intervenções de reabilitação pulmonar (fisioterapia, oxigenoterapia de longo prazo e ventilação); e tuberculose multirresistente. As evidências encontradas sugerem que a tuberculose é definitivamente responsável por sequelas funcionais, principalmente causando um padrão obstrutivo na espirometria (mas também padrões restritivos e mistos) e que há razão para a reabilitação pulmonar. Fornecemos também uma lista de variáveis a serem discutidas em futuros estudos sobre reabilitação pulmonar em pacientes com sequelas pós-tuberculose.

Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis? / Existe razão para reabilitação pulmonar após o tratamento quimioterápico bem-sucedido para tuberculose?

ABSTRACT The role of tuberculosis as a public health care priority and the availability of diagnostic tools to evaluate functional status (spirometry, plethysmography, and DLCO determination), arterial blood gases, capacity to perform exercise, lesions (chest X-ray and CT), and quality of life justify the effort to consider what needs to be done when patients have completed their treatment. To our knowledge, no review has ever evaluated this topic in a comprehensive manner. Our objective was to review the available evidence on this topic and draw conclusions regarding the future role of the "post-tuberculosis treatment" phase, which will potentially affect several million cases every year. We carried out a non-systematic literature review based on a PubMed search using specific keywords (various combinations of the terms "tuberculosis", "rehabilitation", "multidrug-resistant tuberculosis", "pulmonary disease", "obstructive lung disease", and "lung volume measurements"). The reference lists of the most important studies were retrieved in order to improve the sensitivity of the search. Manuscripts written in English, Spanish, and Russian were selected. The main areas of interest were tuberculosis sequelae following tuberculosis diagnosis and treatment; "destroyed lung"; functional evaluation of sequelae; pulmonary rehabilitation interventions (physiotherapy, long-term oxygen therapy, and ventilation); and multidrug-resistant tuberculosis.The evidence found suggests that tuberculosis is definitively responsible for functional sequelae, primarily causing an obstructive pattern on spirometry (but also restrictive and mixed patterns), and that there is a rationale for pulmonary rehabilitation. We also provide a list of variables that should be discussed in future studies on pulmonary rehabilitation in patients with post-tuberculosis sequelae.

RESUMO O papel da tuberculose como uma prioridade de saúde pública e a disponibilidade de ferramentas diagnósticas para avaliar o estado funcional (espirometria, pletismografia e DLCO), a gasometria arterial, a capacidade de realizar exercícios, as lesões (radiografia de tórax e TC) e a qualidade de vida justificam o esforço de se considerar o que deve ser feito quando os pacientes completam seu tratamento. Até onde sabemos, nenhuma revisão avaliou esse tópico de forma abrangente. Nosso objetivo foi revisar as evidências disponíveis e obter algumas conclusões sobre o futuro papel da fase de "tratamento pós-tuberculose", que irá potencialmente impactar milhões de casos todos os anos. Realizou-se uma revisão não sistemática da literatura tendo como base uma pesquisa no PubMed usando palavras-chave específicas (várias combinações dos termos "tuberculose", "reabilitação", "tuberculose multirresistente", "doença pulmonar", "doença pulmonar obstrutiva", e "medidas de volume pulmonar"). As listas de referências dos artigos principais foram recuperadas para melhorar a sensibilidade da busca. Foram selecionados manuscritos escritos em inglês, espanhol e russo. As principais áreas de interesse foram sequelas de tuberculose após diagnóstico e tratamento; "pulmão destruído"; avaliação funcional das sequelas; intervenções de reabilitação pulmonar (fisioterapia, oxigenoterapia de longo prazo e ventilação); e tuberculose multirresistente. As evidências encontradas sugerem que a tuberculose é definitivamente responsável por sequelas funcionais, principalmente causando um padrão obstrutivo na espirometria (mas também padrões restritivos e mistos) e que há razão para a reabilitação pulmonar. Fornecemos também uma lista de variáveis a serem discutidas em futuros estudos sobre reabilitação pulmonar em pacientes com sequelas pós-tuberculose.

[Therapy and Rehabilitation of Patients with Pulmonary Tuberculosis and Different Treatment Adherence].

The pulmonary tuberculosis process as dependent on the disease form and the therapy efficacy with the use of Cycloferon in the treatment scheme were investigated. The study had two stages. At the first stage the data concerning 358 patients with primary pulmonary tuberculosis and infiltration (93 patients) or degradation (89 patients) and 176 patients with pulmonary fibrocavernous tuberculosis were analysed. At the second stage the efficacy of the treatment schemes applied to the patients with pulmonary fibrocavernous tuberculosis was compared. The etiotropic therapy intensive phase was applied to all the patients. Moreover, 56 patients (group 1) under the therapy and rehabilitatinon were treated with Cycloferon in a dose of 0.25 administered intramuscularly twice a week (not less than 16 injections for the course), 60 patients (group 2) were treated with Omega 3, 30 patients (group 3) were given the standard complex (vitamins and tonics), 30 patients (group 4) were under the etiotropic therapy alone. The following additional factors promoting progression and aggravation of the tuberculosis process were confirmed: degradation at the time of the disease diagnosis, high resistance of the pathogen to antituberculosis drugs, low adherence to the treatment, social desadaptation and especially psychofunctional state of the patients. The use of Cycloferon in the schemes of the intensive phase treatment of the primary fibrocavernous tuberculosis resulted in reduction of the intoxication signs, bacteria isolation, positive dynamics of the cavity healing, lower lung infiltration and consequently high frequency of the treatment positive outcomes (94.1 ± 3.33%).

[Evidences related to pulmonary rehabilitation in the respiratory pathology]. / Evidente legate de reabilitarea pulmonara în patologia respiratorie.

Pulmonary rehabilitation represents a modern therapeutic approach of respiratory diseases, with a multidisciplinary character, including: physical training, therapeutic education, psychosocial counseling, and nutritional approach. Pulmonary rehabilitation addresses to any patient suffering from pulmonary pathology whose quality of life is affected by the respiratory symptoms, regardless of the degree of functional impairment. This article is an analysis of evidences from the medical literature on outcomes of rehabilitation programs conducted in various lung diseases. The main indication of pulmonary rehabilitation is the chronic obstructive pulmonary disease - COPD (stable state and exacerbation) in which most studies were carried out. Pulmonary rehabilitation in patients with other respiratory pathology has its reason in the pathophysiological changes that they undergo (impaired lung function and gas exchange, muscle atrophy and deconditioning etc.) leading to symptoms, lower exercise tolerance and decrease daily physical activity, all of which ultimately result in impaired quality of life. The role of rehabilitation is reviewed in the following diseases: post-surgical lung volume reduction for emphysema, asthma, bronchiectasis, interstitial lung disease, cystic fibrosis, lung cancer, neuromuscular disease, intensive care, obstructive sleep apnea, pulmonary hypertension, post-tuberculous sequelae, lung transplantation.

Effectiveness of a home-based pulmonary rehabilitation programme in pulmonary function and health related quality of life for patients with pulmonary tuberculosis: a pilot study.

BACKGROUND: Patients with Pulmonary Tuberculosis (PTB) often develop impairment in pulmonary function due to anatomical changes secondary to the illness. Physiotherapy in the form of pulmonary rehabilitation has been advocated. OBJECTIVE: The aim of the study was to determine whether adherence to a six-week home-based pulmonary rehabilitation programme (PRP) improved the baseline measurements of lung function, exercise tolerance and health-related quality of life (HRQoL) in patients receiving out-patient treatment for PTB. METHOD: A single blinded randomized control study design was used to assess the effects of a six-week home- based PRP in patients receiving treatment for PTB at a local clinic in Khayelitsha, Western Cape. We evaluated lung function by spirometry (MINATO AUTOSPIRO-model no. AZ-505), exercise tolerance using the 6-min-walk test (6MWT), the Borg exercise exertion scale and HRQoL using the EQ-5 D questionnaire in an intervention group (n=34) and a control group (n=33). The trend of the effects of the PRP on lung function was towards increases, but there was no statistical difference between the intervention and control groups at the end of the sixth week in the values of FVC (p=0.2; 95% CI -0.9 to 0.51) as well as FEV1 (p=0.1; 95% CI -0.07 to 0.51). Similar trend was observed for exercise tolerance, and there was no significant difference in HRQoL (p=0.789). CONCLUSION: The outcome of the study provides motivation for further consideration and implementation of a pulmonary rehabilitation programme for patients with PTB.

Philip King Brown and Arequipa Sanatorium: early occupational therapy as medical and social experiment.

Historical inquiry enriches occupational therapy practice by identifying enduring values and inspiring future excellence. This study presents for the first time the pioneering life and work of Philip King Brown, a San Francisco physician who used occupation to treat the physical, mental, and social effects of tuberculosis (TB) at Arequipa Sanatorium, the institution he founded in 1911. Through textual analysis of the Arequipa Sanatorium Records, this article evaluates and defends Brown's assertion that his institution was medically and socially experimental. The Arequipa Sanatorium promoted occupational therapy by demonstrating its viability in the treatment of TB, the era's most critical health threat. It also put into practice the ideals of holism, humanism, and occupational justice that resonate within the profession today. Finally, Arequipa provided an example of how an occupation program can change the public perception of disability.

[PSYCHOLOGICAL FEATURES IN CHILDREN AND ADOLESCENTS WITH RESPIRATORY TUBERCULOSIS].

The development of a biopsychosocial model of disease acquires a great practical value for modern phthisiology, which presupposes an in-depth study of the psychological and social constituents of disease as important factors of therapy optimization and an increase in the efficiency of the rehabilitative measures being implemented. The problem of psychological causes and factors associated with the occurrence of a tuberculous process in children and adolescents has been inadequately developed in phthisiology. A psychodiagnostic study was conducted in 90 patients from Moscow pediatric tuberculosis facilities. The children and adolescents with respiratory tuberculosis were ascertained to have the personality characteristics distinct them from their somatically healthy coevals: tenderness, responsibility, honesty, diligence, deliberate observance of generally accepted moral rules and regulations, inclination to moralize, anxiety, irritability, infantilism, low frustration tolerance, dependence, sensitivity, and a need for support. The revealed psychological features enhance the pathogenicity of stressors, lead to the tension of adaptive mechanisms and may contribute to the development of the disease. Psychocorrective measures aimed at expanding the behavioral range and molding self-regulation skills in these patients should be developed within the complex rehabilitation system for children and adolescents with respiratory tuberculosis, which will aid in enhancing the efficiency of their psychoemotional adaptation and preventing the recurrences of the underlying disease.

La representación social de los portadores de SIDA o tuberculosis: una experiencia del cuidar en la terapia ocupacional / The social representation of the carriers of AIDS or tuberculosis: an experience of caring in occupational therapy

El presente trabajo se fundamenta en las bases teóricas de la atención en Terapia Ocupacional (TO) y en la teoría de la representación social. Desarrolladas en clientes con tuberculosis (TB) o SIDA, en un hospital universitario, evaluando visando la adherencia al tratamiento. La cuestión central de esta investigación es el carácter relacional entre el tratamiento y el portador de TB o SIDA. Así, se objetiva caracterizar como la TO puede contribuir con la adhesión al tratamiento. Algunas preguntas fueron contestadas: ¿cómo es la organización de los clientes entorno de hechos que constituyen sus medios físico y social?; ¿será que la TO puede cuidar de estas personas? ¿la TO puede facilitar la adherencia al tratamiento? La estrategia para la producción de datos fue apoyada en Talleres de Creatividad, con 12 clientes, por medio de la actividad artística. Los pacientes hablaron de los sentimientos que surgen en la relación entre el desarrollo y la convivencia con sus enfermedades. Los resultados mostraron que la TO contribuye con la disminución de comportamientos agresivos facilitando la adhesión al tratamiento. La conclusión es que la TO, favorece a que las personas, se preparen para hacer frente a las reacciones adversas, provocando la adhesión al tratamiento.

This work builds upon the theories of care in Occupational Therapy (OT) and the theory of social representation. Developed in clients with tuberculosis (TB) and AIDS in a university hospital, aiming to assess adherence to treatment. The central question of this research is the relational character between the treatment and the carrier of TB or AIDS. That objectively characterized as the OT can help with treatment adherence. Some questions were answered: How is the organization of the customers’ environment facts constituting their physical and social? Can it be that the OT can take care of these people? OT may facilitate adherence to treatment? The strategy for data production was supported in Creativity Workshops, with 12 clients, through artistic activity. Patients spoke of the feelings that arise in the relationship between development and living with their diseases. The results showed that the OT contributes with decrease of aggressive behavior by facilitating treatment compliance. The conclusion is that the OT, encourages people to prepare to cope with adverse events causing treatment adherence.

Rationale and staff evaluation of using a "therapeutic milieu" for substance users within a tuberculosis ward.

Approximately 30% of tuberculosis (TB) patients in Israel were treated, in part, in two dedicated hospital wards during the years 2003-2005. A portion of them manifested severe psychosocial conditions. An intervention based on the "Therapeutic Milieu" (TM) model was implemented in the larger ward and included a staff evaluation of this intervention. The concept of TM, based on psychosocial paradigms and behavioral medicine, is aimed at providing a supportive environment for patients. Weekly group patients' meetings and monthly group staff supervisions were performed during 15 months (2003-2005). Forty of the 196 (20%) TB patients, mainly "complex," and 13 of 20 staff members (65%) attended regularly and discussed how to deal with substance abuse, personality disorders, and immigration-related crises. Out of 40 TB cases, 30 (75%) were also substance users. Ten staff members self-analyzed the impact of this intervention in terms of (1) having given adequate tools for the staff, (2) reducing physical violence, (3) increasing adherence to TB treatment, and (4) more efficient treatment for their substance use. No direct evaluation was done among the TB patients. According to staff members, this intervention had a positive overall impact. However, using Therapeutic Milieu in TB ward hospitalization, as a "window of opportunity," remains the first step in a longer journey for rehabilitation. The study's limitations are noted.

Consequences of bed rest.

Bed rest is frequently prescribed for critically ill patients because it is assumed to be beneficial for preventing complications, for conserving scarce metabolic resources, and for providing patient comfort. Furthermore, higher levels of physical activity in critically ill patients have been assumed to be impractical or not feasible. Bed rest has been prescribed in the past for several other clinical conditions including acute flares of rheumatoid arthritis, cavitary tuberculosis, acute myocardial infarction, and acute low back pain. However, randomized, controlled, clinical trials failed to demonstrate beneficial effects of bed rest in most of these conditions. Bed rest can cause several complications that may delay or prevent recovery from critical illnesses including disuse muscle atrophy, joint contractures, thromboembolic disease, and insulin resistance. Recent studies demonstrated the feasibility and safety of physical medicine programs in critically ill patients including those with acute respiratory failure requiring mechanical ventilation. Other physical medicine tools, such as neuromuscular electrical stimulation and passive stretching of muscles, may also reduce some complications of bed rest.

[To the program on state guarantees to deliver free medical aid to Russia's citizens in tuberculosis facilities].

The program on state guarantees for free medical aid to Russia's citizens in tuberculosis facilities shows too high standards for round-the-clock adult tuberculosis inpatient beds. Tuberculosis sanatorium beds that are also round-the-clock stay beds and should be a part of the federal standard are disregarded. Hospital-replacing technologies have been inadequately developed in the antituberculosis service. There is an excess of pediatric tuberculosis sanatorium beds that serve mainly for social, rather than clinical indications.