High success and low recurrence with shorter treatment regimen for multidrug-resistant TB in Nepal.

SETTING: Nine drug-resistant TB centres, some of them supported by Damien Foundation in Nepal where >80% of multidrug-resistant/rifampicin-resistant TB (MDR/RR-TB) patients are treated. OBJECTIVE: To assess the uptake, effectiveness and safety of the 9-12-month shorter treatment regimen (STR) in MDR/RR-TB patients registered from January 2018 to December 2019. DESIGN: This was a cohort study involving secondary programme data. RESULTS: Of 631 patients, 301 (48.0%) started and continued STR. Key reasons for ineligibility to start/continue STR were baseline resistance or exposure to second-line drugs (62.0%), contact with extensively drug-resistant TB (XDR-TB) or pre-XDR-TB (7.0%) patients and unavailability of STR drugs (6.0%). Treatment success was 79.6%; unsuccessful outcomes were death (12.0%), lost to follow-up (5.3%), failure (2.7%) and not evaluated (0.7%). Unsuccessful outcomes were significantly associated with HIV positivity and patient age ⩾55 years, with adjusted relative risk of respectively 2.39 (95% CI 1.52-3.77) and 3.86 (95% CI 2.30-6.46). Post-treatment recurrence at 6 and 12 months was respectively 0.5% and 2.4%. Serious adverse events (SAEs) were seen in 15.3% patients - hepatotoxicity and ototoxicity were most common. CONCLUSION: STR had a modest uptake, high treatment success and low post-treatment recurrence. For proper detection and management of SAEs, improving pharmacovigilance might be considered. Availability of rapid diagnostic test for second-line drugs is crucial for correct patient management.

CADRE: Neuf centres de traitement de la TB pharmacorésistante, dont certains sont financés par Action Damien au Népal où >80% des patients atteints de TB multirésistante/résistante à la rifampicine (MDR/RR-TB) sont traités. OBJECTIF: Évaluer l'utilisation, l'efficacité et l'innocuité d'un schéma thérapeutique plus court (STR) de 9-12 mois chez les patients atteints de MDR/RR-TB enregistrés de janvier 2018 à décembre 2019. MÉTHODE: Étude de cohorte comprenant des données programmatiques secondaires. RÉSULTATS: Sur 631 patients, 301 (48,0%) ont démarré et poursuivi un STR. Les raisons principales d'inéligibilité à l'instauration/la poursuite d'un STR étaient une résistance initiale ou une exposition aux médicaments de deuxième intention (62,0%), un contact avec des patients atteints de TB ultrarésistante (XDR-TB) ou de pré-XDR-TB (7,0%) et la non-disponibilité des médicaments pour le STR (6,0%). Le taux de réussite thérapeutique était de 79,6%. Les résultats liés à la non-réussite thérapeutique étaient décès (12,0%), perte de vue (5,3%), échec thérapeutique (2,7%) et absence d'évaluation (0,7%). Les résultats liés à la non-réussite thérapeutique étaient significativement associés à l'infection par le VIH et aux patients âgés ⩾55 ans avec un risque relatif ajusté de 2,39 (IC 95% 1,52­3,77) et de 3,86 (IC 95% 2,30­6,46), respectivement. Le taux de récidive post-traitement à 6 et 12 mois était de 0,5% et 2,4%, respectivement. Des évènements indésirables graves (SAE) ont été observés chez 15,3% des patients, le plus souvent hépatotoxicité et ototoxicité. CONCLUSION: Le STR a été associé à une utilisation modérée, à une réussite thérapeutique élevée et à un faible taux de récidive post-traitement. Pour une détection et une prise en charge adéquates des SAE, l'amélioration de la pharmacovigilance peut être envisagée. La disponibilité de tests diagnostiques rapides pour les médicaments de deuxième intention est essentielle à une prise en charge adéquate des patients.

Tuberculosis contact investigation and short-course preventive therapy among young children in Africa.

SETTING: The largest cities in Benin, Burkina Faso, Cameroon and Central African Republic.OBJECTIVE: To demonstrate the feasibility and document the effectiveness of household contact investigation and preventive therapy in resource-limited settings.DESIGN: Children under 5 years living at home with adults with bacteriologically confirmed pulmonary tuberculosis (TB) were screened using questionnaire, clinical examination, tuberculin skin test and chest X-ray. Children free of active TB were offered preventive treatment with a 3-month rifampicin-isoniazid (3RH) or 6-month isoniazid (6H) regimen in Benin. Children were followed-up monthly during treatment, then quarterly over 1 year. Costs of transportation, phone contacts and chest X-rays were covered.RESULTS: A total of 1965 children were enrolled, of whom 56 (2.8%) had prevalent TB at inclusion. Among the 1909 children free of TB, 1745 (91%) started preventive therapy, 1642 (94%) of whom completed treatment. Mild adverse reactions, mostly gastrointestinal, were reported in 2% of children. One case of incident TB, possibly due to a late TB infection, was reported after completing the 3RH regimen.CONCLUSION: Contact investigation and preventive therapy were successfully implemented in these resource-limited urban settings in programmatic conditions with few additional resources. The 3RH regimen is a valuable alternative to 6H for preventing TB.

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries.

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

[Treatment of varicocele in pediatric age with retroperitoneoscopic ''one trochar'' technique. Long term follow-up]. / Trattamento del varicocele in etá pediatrica in retroperitoneoscopia, con tecnica ''one trocar'' follow-up a lungo termine.

AIM: The incidence of varicocele varies from 6% to 16.2% in male children and adolescents. Various techniques were proposed to treat it. In the last years there was an increasing interest in the use of laparoscopy in pediatric urology. The authors reports their experience in the treatment of varicocele by retroperitoneoscopy with one trocar technique and the long-term follow-up in pediatric patients. METHODS: Fourty patients were treated for idiopathic Horner's degree III or less, but symptomatic, and type 1 according to Coolsaet varicocele. All patients underwent a clinical examination and echo-color Doppler before treatment and during the follow-up. RESULTS: The following parameters were evaluated: duration of the operation, intra and postoperative complications, duration of hospitalization and of antalgic therapy. Follow-up was at 6, 12, 24 and 36 months (mean 23.4 months). Testicles diameters, persistence/recurrence of varicocele and hydroceles were estimated. CONCLUSIONS: The retroperitoneoscopic approach in the treatment of varicocele is an effective technique because it implies a minor surgical trauma, a rapid postoperative recovery and a good cosmetic result.

Active tuberculosis case finding among pregnant women: a pilot project in Burkina Faso.

Tuberculosis (TB) is a leading cause of death among women of childbearing age, and may be responsible for severe complications during pregnancy. Between August 2014 and March 2015, we conducted a pilot project to promote active TB case finding in antenatal care (ANC) clinics in the Central Region of Burkina Faso. Our results show very limited TB diagnostic practices and possible severe underdiagnosis of TB at ANC clinics, despite adequate screening practices. Integration of training and supervision of TB diagnosis and treatment into ANC services is required.

The impact of Xpert® MTB/RIF depends on service coordination: experience in Burkina Faso.

Translating the potential of Xpert(®) MTB/RIF into more effective tuberculosis (TB) care and control in low-income settings is challenged by operational issues. We report the experience in introducing this technology in Burkina Faso through a centralised approach. Xpert was successfully integrated into the diagnostic algorithm of multidrug-resistant TB cases. However, barriers to Xpert use for the diagnosis of TB in vulnerable populations, such as persons living with human immunodeficiency virus infection and children, were observed, mainly due to lack of coordination between services. Lessons learnt can be exploited to optimise the roll-out of this technology at country level.

[Enema-induced intestinal perforation. A case report]. / Perforazione intestinale da clisma di pulizia. Descrizione di un caso clinico.

Constipation is a frequent clinical condition in pediatric age, with a low frequency of evacuation and emission of voluminous and hardened stools. In the most serious cases enemas became necessary, and are usually carried out without trouble. Nevertheless, traumatic events of great importance can take place, leading the patient to urgent surgical observation. The clinical case of a girl suffering from birth from chronic constipation is reported. The girl underwent a colostomy according to Mikulitz's technique on the descending colon, due to a rectal perforation induced during an enema. After the re-canalisation and the contemporaneous resection of 18 cm of the dolicho-sigmoid colon (which was most likely the cause of chronic constipation) the girl presented a normal defecatory rhythm.

[Traumatic gut perforation (seat-belt syndrome): a case report]. / Perforazione intestinale da trauma addominale chiuso (seat-belt syndrome): descrizione di un caso clinico.

Seat belts have dramatically reduced the severity of traumas in car accidents. On the other hand, specific lesions have appeared, related to seat belt use. These lesions are defined as "seat belt syndrome". The Authors describe an intestinal medio-ileal perforation due to seat belts in a child.