Facteurs associés à la létalité chez les patients hospitalisés pour le VIH avancé.

CONTEXT: A unit supported by Médecins Sans Frontières (MSF) cares for patients with advanced HIV at Donka National Hospital, Conakry, Guinea. OBJECTIVE: To determine the factors associated with the occurrence of death in patients hospitalised in the unit between 2017 and 2021. DESIGN: This was a retrospective analysis of routine data from patients hospitalised with advanced HIV. RESULTS: A total of 3,718 patients were included, with a median age of 40 years (IQR 33-51), of whom 2,241 (60.3%) were women. The mean mortality rate was 33.6% (n = 1,240), down from 40% in 2017 to 29% in 2021, but this was not statistically significant. The period most at risk of death was the first 25 days of hospitalisation. Among these patients, TB (43.8%) and toxoplasmosis (11.4%) were the most frequent diagnoses. After multivariate analysis using Cox regression, the factors associated with death were age 25-49 years (adjusted hazard ratio [aHR] 1.60; P = 0.002) or ≥50 years (aHR 1.80; P < 0.001), the presence of respiratory (aHR 1.23; P = 0.001) or abdominal symptoms (aHR 1.26; P < 0.001) and readmission (aHR 0.54; P < 0.001). CONCLUSION: Patients aged 25-49 years or older, or those presenting with respiratory or abdominal signs require increased surveillance, as they are at the greatest risk of dying from the disease, especially during the first 25 days of hospitalisation.

Clinical standards for drug-susceptible TB in children and adolescents.

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Clinical utility of target-based next-generation sequencing for drug-resistant TB.

BACKGROUND: In high TB burden countries, access to drug susceptibility testing is a major bottleneck. Targeted next-generation sequencing (tNGS) is a promising technology for rapid resistance detection. This study assessed the role of tNGS for the diagnosis of drug-resistant TB (DR-TB).METHODS: A total of 161 samples from bacteriologically confirmed TB cases were subjected to tNGS using the Deeplex® Myc-TB kit and sequenced using the MiSeq platform. These samples were also processed for conventional phenotypic DST (pDST) using 13 drugs on Mycobacteria Growth Indicator Tube and line-probe assays (MTBDRplus and MTBDRsl).RESULTS: There were 146 DR-TB and 15 drug-susceptible TB (DS-TB) samples. About 70% of patients with DR-TB had no previous TB treatment history. Overall, 88.2% had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB), 58.5% pre-extensively drug-resistant TB (pre-XDR-TB) and 9.2% had XDR-TB as defined by the WHO (2020). Around 8% (n = 13) of samples were non-culturable; however, identified 8 were resistant to first and second-line drugs using tNGS. Resistance frequency was similar across methods, with discordance in drugs less reliable using pDST or with limited mutational representation within databases. Sensitivities were aligned with literature reports for most drugs. We observed 10% heteroresistance, while 75% of strains were of Lineages 2 and 3.CONCLUSIONS: Programme data supported tNGS in the diagnosis of DR-TB for early treatment using individualised regimens.

TB screening, prevention and treatment cascade in a Malawi prison.

BACKGROUND Incarcerated individuals, especially in high HIV and TB burden settings, are at increased risk of latent TB infection and/or TB disease. We implemented a comprehensive HIV-TB intervention in a Malawi prison and studied its feasibility.METHODS Between February and December 2019, consenting individuals underwent screening for HIV, TB infection and TB disease. HIV-positive individuals without TB disease were treated with a fixed-dose combination of isoniazid, cotrimoxazole and vitamin B6 (INH-CTX-B6). HIV-negative persons with TB infection received 12 weeks of isoniazid and rifapentine (3HP).RESULTS Of 1,546 consenting individuals, 1,498 (96.9%) were screened and 1,427 (92.3%) included in the analysis: 96.4% were male, the median age was 31 years (IQR 25-38). Twenty-nine (2.1%) participants were diagnosed with TB disease, of whom 89.7% started and 61.5% completed TB treatment. Of the 1,427 included, 341 (23.9%) were HIV-positive, of whom 98.5% on antiretroviral therapy and 95% were started on INH-CTX-B6. Among 1,086 HIV-negative participants, 1,015 (93.5%) underwent the tuberculin skin test (TST), 670 (65.9%) were TST-positive, 666 (99.4%) started 3HP and 570 (85.5%) completed 3HP treatment.CONCLUSION A comprehensive TB screening and treatment package among incarcerated individuals was acceptable and feasible, and showed high prevalence of HIV, TB disease and TB infection. Treatment uptake was excellent, but treatment completion needs to be improved. Greater investment in comprehensive HIV-TB services, including access to shorter TB regimens and follow-up upon release, is needed for incarcerated individuals.

New TB drugs for the treatment of children and adolescents with rifampicin-resistant TB in Mumbai, India.

SETTING: Médecins Sans Frontières (MSF) clinic in Mumbai, India.OBJECTIVE: To determine the final treatment outcomes, culture conversion and adverse events (AEs) during treatment among children and adolescents (0-19 years) with rifampicin-resistant tuberculosis (RR-TB) who received ambulatory injectable-free treatment, including bedaquiline (BDQ) and/or delamanid (DLM) during September 2014-January 2020.DESIGN: This was a retrospective cohort study based on review of routinely collected programme data.RESULTS: Twenty-four patients were included; the median age was 15.5 years (min-max 3-19) and 15 (63%) were females. None were HIV-coinfected. All had fluoroquinolone resistance. Twelve received treatment, including BDQ and DLM, 11 received DLM and one BDQ. The median exposure to BDQ (n = 13) and DLM (n = 23) was 82 (IQR 80-93) and 82 (IQR 77-96) weeks, respectively. Seventeen (94%) patients with positive culture at baseline (n = 18) had negative culture during treatment; median time for culture-conversion was 7 weeks (IQR 5-11). Twenty-three (96%) had successful treatment outcomes: cured (n = 16) or completed treatment (n = 7); one died. Eleven (46%) had 17 episodes of AEs. Two of 12 serious AEs were associated with new drugs (QTcF >500 ms).CONCLUSION: Based on one of the largest global cohorts of children and adolescents to receive new TB drugs, this study has shown that injectable-free regimens containing BDQ and/or DLM on ambulatory basis were effective and well-tolerated among children and adolescents and should be made routinely accessible to these vulnerable groups.

Impact of the implementation of new guidelines on the management of patients with HIV infection at an advanced HIV clinic in Kinshasa, Democratic Republic of Congo (DRC).

BACKGROUND: HIV continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV. Clinical management of advanced HIV patients is thus complex and requires strict adherence to updated, empirical and simplified guidelines. The current study investigated the impact of the implementation of a new clinical guideline on the management of advanced HIV in Kinshasa, Democratic Republic of Congo (DRC). METHODS: A retrospective analysis of routine clinical data of advanced HIV patients was conducted for the periods; February 2016 to March 2017, before implementation of new guidelines, and November 2017 to July 2018, after the implementation of new guidelines. Eligible patients were patients with CD4 < 200 cell/µl and presenting with at least 1 of 4 opportunistic infections. Patient files were reviewed by a medical doctor and a committee of 3 other doctors for congruence. Statistical significance was set at 0.05%. RESULTS: Two hundred four and Two hundred thirty-one patients were eligible for inclusion before and after the implementation of new guidelines respectively. Sex and age distributions were similar for both periods, and median CD4 were 36 & 52 cell/µl, before and after the new guidelines implementation, respectively. 40.7% of patients had at least 1 missed/incorrect diagnosis before the new guidelines compared to 30% after new guidelines, p < 0.05. Clinical diagnosis for TB and toxoplasmosis were also much improved after the implementation of new guidelines. In addition, only 63% of patients had CD4 count test results before the new guidelines compared to 99% of patients after new guidelines. Death odds after the implementation of new guidelines were significantly lower than before new guidelines in a multivariate regression model that included patients CD4 count and 10 other covariates, p < 0.05. CONCLUSIONS: Simplification and implementation of a new and improved HIV clinical guideline coupled with the installation of laboratory equipment and point of care tests potentially helped reduce incorrect diagnosis and improve clinical outcomes of patients with advanced HIV. Regulating authorities should consider developing simplified versions of guidelines followed by the provision of basic diagnostic equipment to health centers.

Adverse events among people on delamanid for rifampicin-resistant tuberculosis in a high HIV prevalence setting.

SETTING: Patients with rifampicin-resistant tuberculosis (RR-TB) in the township of Khayelitsha, South Africa, were offered delamanid (DLM) within a decentralised RR-TB treatment programme.OBJECTIVE: To describe adverse events (AEs) among HIV-positive and negative people receiving DLM for RR-TB in a programmatic setting.DESIGN: Patients were followed up monthly for blood, electrocardiography and clinical monitoring and AEs were assessed for severity grade, seriousness and relationship to DLM.RESULTS: Fifty-eight patients (55% male; median age 35 years, interquartile range [IQR] 28-42) started DLM; 46 (79%) were HIV-positive, median CD4 count 173 cells/mm³ (IQR 70-294). Fifty (86%) patients experienced ≥1 new or worsening AE after starting DLM, most commonly vomiting, QTcB >450 ms and/or myalgia. Serious and/or severe AEs were experienced by 22 (38%) patients; three HIV-positive patients died (not related to DLM). HIV status was not significantly associated with number (P = 0.089) or severity/seriousness (P = 0.11) of AEs during exposure to DLM. Two (3%) patients had DLM withdrawn due to AEs.CONCLUSION: AEs during RR-TB treatment, both before and during DLM exposure, were common, with relatively few serious/severe AEs considered related to DLM and no significant association with HIV status. Clinical and electrocardiography monitoring should be prioritised in the first two months after starting DLM.

Beyond 'cure' and 'treatment success': quality of life of patients with multidrug-resistant tuberculosis.

SETTING: Two drug-resistant tuberculosis (DR-TB) sites (MSF Clinic, Jupiter Hospital) in Mumbai, India. OBJECTIVE: To assess health-related quality of life (HRQoL) and associated factors among DR-TB patients and explore their perspectives about HRQoL. DESIGN: We used a mixed-methods design: a quantitative cross-sectional questionnaire (the World Health Organization's Quality of Life Brief Questionnaire [WHOQoL-BREF]); and qualitative in-depth interviews for purposively selected patients. Assessments were conducted between April and November 2016. RESULTS: Ninety-five patients completed WHOQoL-BREF; 12 were interviewed. The psychological and physical health domains were the most affected (mean scores 56.2 ± standard deviation [SD] 18.3, and 56.5 ± SD 15.1, respectively; maximum 100). The social relations and environmental domains mean scores were respectively 68.6 (SD ±21.1) and 60.3 (SD ±15.9). Loss of jobs due to TB adversely affected the social relations and environmental domains. Qualitative analysis showed that support was the most important theme affecting quality of life. Other themes were physical factors (e.g., treatment adverse events), psychological factors (e.g., depression), social functioning (e.g., fear of stigmatisation) and environmental factors (e.g., health systems). CONCLUSION: HRQoL was lower among study participants, but not as low as previously reported among TB patients. Support was the main factor that positively affected HRQoL, although both disease and treatment were physically and socially challenging.

Barriers and solutions to finding rifampicin-resistant tuberculosis cases in older children and adolescents.

Little is known about the barriers to post-exposure management of rifampicin-resistant tuberculosis (RR-TB) in older children and adolescents. We report on implementation lessons from a pilot programme targeting household-exposed individuals aged 6-18 years in Khayelitsha, South Africa. Barriers included misperceptions regarding risk of exposure, multiple research and implementation stakeholders, additional workload for an overburdened healthcare system, logistical issues faced by families, and insufficient human and financial resources. Solutions to these barriers are possible, but creativity and persistence are required. Our experience can guide others looking to roll-out care for children and adolescents exposed to RR-TB.

On connaît mal les entraves à la prise en charge post-exposition de la tuberculose résistante à la rifampicine (RR-TB) chez les enfants plus âgés et les adolescents. Nous rapportons les leçons de la mise en œuvre d'un programme pilote ciblant les individus exposés dans leurs foyers, âgés de 6­18 ans, à Khayelitsha, Afrique du Sud. Les obstacles ont inclus des perceptions erronées à propos du risque d'exposition, la multiplicité des partenaires de recherche et de mise en œuvre, la charge de travail supplémentaire pour un système de santé déjà surchargé, les problèmes logistiques auxquels sont confrontées les familles, et l'insuffisance des ressources humaines et financières. Il y a des solutions possibles à ces obstacles mais elles demandent de la créativité et de la détermination. Notre expérience peut guider ceux qui veulent lancer la prise en charge des enfants et des adolescents exposés à la RR-TB.

Se conoce poco sobre los factores que obstaculizan la atención después de la exposición a un caso de tuberculosis resistente a rifampicina (RR-TB) en los niños mayores y los adolescentes. En el presente artículo se describen las enseñanzas aprendidas durante la ejecución de un programa piloto dirigido a los contactos domiciliarios expuestos entre los 6 y los 18 años de edad, en Khayelitsha, Suráfrica. Entre los obstáculos observados se pueden citar las percepciones equivocadas sobre el riesgo de exposición, la multiplicidad de interesados directos en la investigación y la ejecución, la carga de trabajo adicional en un sistema de salud sobresaturado, los problemas organizativos afrontados por las familias y la insuficiencia de recursos humanos y de financiamiento. Las soluciones a estos problemas son posibles, pero exigen creatividad y persistencia. Esta experiencia puede orientar a otros equipos que intenten poner en marcha la atención de los niños y los adolescentes expuestos a la RR-TB.

Scaling up HIV viral load monitoring in Manicaland, Zimbabwe: challenges and opportunities from the field.

BACKGROUND: Demand for viral load (VL) monitoring is expected to increase; however, implementation of the multifaceted VL testing poses numerous challenges. We report experiences from Médecins Sans Frontiéres (MSF) and partners in the scale-up of HIV VL in collaboration with the Ministry of Health and Child Care (MoHCC) of Zimbabwe. METHODS: A retrospective data review of routine reports from MSF-supported health facilities in Manicaland Province (Zimbabwe) was conducted. These secondary aggregate data were triangulated, and emerging themes of lessons learnt from VL monitoring were shared. RESULTS: A VL testing coverage of 63% (5966/9456) was achieved among the 40 health facilities, together with a switch rate to second-line antiretroviral therapy (ART) of 46.4% (108/233). The key enablers to scaling-up the VL monitoring were well-equipped and supported VL laboratories, the operationalisation of the on-the-job clinical mentoring and systematic weaning off of better performing health facilities. Concerted efforts from different implementing partners and funders in the HIV programme, and close collaboration with MoHCC were pivotal. CONCLUSION: Our experience indicates that clinical mentoring is effective, and resulted in high VL testing coverage and up-skilling primary health care workers in VL monitoring. Attention must be focused on innovations for improving VL result utilisation, especially the identification and management of patients who fail ART.

'I didn't know so many people cared about me': support for patients who interrupt drug-resistant TB treatment.

SETTING: Early interventions for patients who interrupt their treatment for drug-resistant tuberculosis (DR-TB) are rarely reported and assessed. A novel, patient-centred intervention for patients at risk of loss to follow-up (LTFU) from DR-TB treatment was implemented in Khayelitsha, South Africa, in September 2013. OBJECTIVE: To explore the experiences and perceptions of patients, key support persons, health care workers (HCWs) and programme managers of a patient-centred model. DESIGN: This was a qualitative study consisting of 18 in-depth interviews with patients, key support persons, HCWs, key informants and one focus group discussion with HCWs, between July and September 2017. Data were coded and thematically analysed. RESULTS: The model was well perceived and viewed positively by patients, care providers and programme managers. 'Normalisation' and tolerance of occasional treatment interruptions, tracing, tailored management plans and peer support were perceived to be beneficial for retaining patients in care. Although the model was resource-demanding, health workers were convinced that it 'needs to be sustained,' and proposed solutions for its standardisation. CONCLUSION: An intervention based on early tracing of patients who interrupt treatment, peer-delivered counselling and individualised management plans by a multidisciplinary team was considered a beneficial and acceptable model to support patients at risk of LTFU from DR-TB treatment.

I have heard about it for the first time from you! Implementation of tobacco control law by police personnel in India.

Setting and Objetives: Police personnel, alongside other key stakeholders, are responsible for implementing the Cigarettes and Other Tobacco Products Act (COTPA) in India. This study aimed to assess knowledge and attitudes about COTPA among police personnel and explore enablers and barriers in implementing it. Design: This convergent parallel mixed-methods study used a self-administered questionnaire (quantitative) and key informant interviews (qualitative). Of 300 police personnel across all eight police stations in Daman, 155 participated. Quantitative data were analysed using descriptive statistics and the χ2 test. Qualitative data from in-depth interviews of six key informants from all coordinating departments were analysed thematically. Results: Overall, 63.2% of responders were aware of any tobacco control law in India, and only 12.9% were trained in its implementation. One person had conducted inspections for COTPA compliance in the last 12 months. The majority (78.1%) of the police personnel, and significantly more tobacco non-users than users (81.2% vs. 52.9%, P = 0.016), felt that enforcing anti-tobacco regulations is one of their most important functions. Perceived benefits of the act and formal authority to act were the two main enablers of COTPA implementation. Lack of awareness and coordination, competing priorities, concentration of authority with higher-ranking officials and evasion of the law by retailers and the public hampered effective implementation of the law. Conclusion: Knowledge about the COTPA was average and implementation poor. Sensitisation and training of implementers, systematic transparent reporting and creating awareness among public are recommended for effective implementation.

Contexte et objectifs : Le personnel de la police, en collaboration avec d'autres partenaires clés, est responsable de la mise en œuvre de la Loi cigarettes et autres produits dérivés du tabac (COTPA) en Inde. Cette étude a eu pour but d'évaluer les connaissances et l'attitude au sein du personnel de la police en ce qui concerne la COTPA et a exploré les facilitateurs et les entraves à sa mise en œuvre.Schéma : Cette étude convergente parallèle à méthodes mixtes s'est basée sur un questionnaire auto-administré (méthode quantitative) et sur des entretiens avec des informateurs clés (méthode qualitative). Sur 300 personnels de police dans les huit stations de police de Daman, 155 ont participé. Les données quantitatives ont été analysées grâce à des statistiques descriptives et au test du χ2. Les données qualitatives émanant des entretiens approfondis avec six informateurs clés de tous les services de coordination ont été analysées de manière thématique.Résultats : Au total, 63,2% des participants étaient au courant de l'existence d'une loi de lutte contre le tabac en Inde, et seulement 12,9% ont été formés à sa mise en œuvre. Un seul avait réalisé des inspections relatives au respect de la COTPA au cours des 12 derniers mois. La majorité (78,1%) du personnel de police, et significativement plus de non-utilisateurs que d' utilisateurs de tabac (81,2% contre 52,9%, P = 0,016), estimaient que mettre en œuvre la loi anti-tabac était l'une de leurs fonctions importantes. Les bénéfices perçus de cette loi et le pouvoir officiel ont été les deux principaux facilitateurs de la mise en œuvre de la COTPA. Le manque de sensibilisation et de coordination, les priorités concurrentes, la concentration de l'autorité au sein des supérieurs et l'évasion de la loi par les revendeurs et le public a entravé une véritable mise en œuvre de la loi.Conclusion : La connaissance de la loi a été moyenne et sa mise en œuvre médiocre. La sensibilisation et la formation des responsables de la mise en œuvre, des rapports systématiques transparents et la sensibilisation du public sont recommandés pour une mise en œuvre efficace.

Marco de Referencia y Objetivos: El personal policial, junto con otros interesados directos, tienen a su cargo la ejecución de la COPTA (del inglés, Cigarettes and Other Tobacco Products Act, por ley sobre el consumo de cigarrillos y otros productos del tabaco) en la India. En el presente estudio se evaluaron los conocimientos y las actitudes de los miembros de la policía con respecto a la COPTA y se exploraron los factores facilitadores y los obstáculos a su aplicación.Método: Fue este un estudio de métodos mixtos convergentes y paralelos que utilizó cuestionarios rellenados por el encuestado (cuantitativos) y entrevistas a informantes clave (cualitativos). De los 300 oficiales de policía de las ocho estaciones de Daman, 155 participaron en la encuesta. Los datos cuantitativos se analizaron mediante métodos estadísticos descriptivos y la prueba del χ2. Los datos cualitativos de las entrevistas exhaustivas de seis informantes clave de todos los departamentos coordinadores se analizaron temáticamente.Resultados: En general, el 63,2% estaba al corriente de una ley de control del tabaco en la India, y solo el 12,9% había recibido capacitación relacionada con su aplicación. Solo un funcionario había realizado inspecciones sobre la conformidad con la COTPA en los últimos 12 meses. La mayor parte del personal de policía (78,1%), y una mayor proporción de no consumidores de tabaco (81,2% contra 52,9%; P = 0,016), consideraba que la aplicación de la reglamentación antitabaco constituía una de sus funciones importantes. Los dos principales factores facilitadores de la aplicación de la COPTA fueron la percepción de los beneficios de la ley y la autoridad oficial para actuar. El desconocimiento y la falta de coordinación, las prioridades concurrentes, la concentración de la autoridad en los funcionarios superiores y la evasión de la ley por parte de los comerciantes al por menor y de la población obstaculizan la aplicación eficaz de la ley.Conclusión: Se observó un conocimiento insuficiente y una escasa aplicación de la COTPA. Con miras a lograr una aplicación eficaz, se recomienda sensibilizar y capacitar al personal encargado de aplicar la ley, practicar una notificación sistemática transparente y trabajar por la concienciación de la población.

Surgical interventions for pulmonary tuberculosis in Mumbai, India: surgical outcomes and programmatic challenges.

Setting: While surgery for pulmonary tuberculosis (PTB) is considered an important adjunct for specific cases, including drug-resistant tuberculosis, operational evidence on its feasibility and effectiveness is limited. Objective: To describe surgical outcomes and programmatic challenges of providing surgery for PTB in Mumbai, India. Design: A descriptive study of routinely collected data of surgical interventions for PTB from 2010 to 2014 in two Mumbai hospitals, one public, one private. Results: Of 85 patients, 5 (6%) died and 17 (20%) had complications, with wound infection being the most frequent. Repeat operation was required in 12 (14%) patients. Most procedures were performed on an emergency basis, and eligibility was established late in the course of treatment. Median time from admission to surgery was 51 days. Drug susceptibility test (DST) patterns and final treatment outcomes were not systematically collected. Conclusion: In a high-burden setting such as Mumbai, important data on surgery for PTB were surprisingly limited in both the private and public sectors. Eligibility for surgery was established late, culture and DST were not systematically offered, the interval between admission and surgery was long and TB outcomes were not known. Systematic data collection would allow for proper evaluation of surgery as adjunctive therapy for all forms of TB under programmatic conditions.

Contexte : La chirurgie de la tuberculose pulmonaire (TBP) est considérée comme un adjuvant important dans des cas spécifiques, notamment celui de la TB pharmacorésistante ; les preuves opérationnelles de sa faisabilité et de son efficacité sont cependant limitées.Objectif : Décrire les résultats de la chirurgie et les défis programmatiques liés à l'offre de chirurgie à Mumbai, Inde.Schéma : Une étude descriptive de données recueillies en routine relatives aux interventions chirurgicales de TBP de 2010 à 2014 dans deux hôpitaux de Mumbai (un public, un privé).Résultats : Sur 85 patients, 5 (6%) sont décédés, 17 (20%) ont eu des complications, dont la plus fréquente était une infection de la plaie. Une deuxième intervention a été nécessaire dans 12 cas (14%). La majorité des procédures a été réalisée en urgence et l'éligibilité a été établie tardivement au cours du traitement. Le délai médian de l'admission à la chirurgie a été de 51 jours. Les profils de résistance de la TB et le résultat final du traitement n'ont pas été recueillis de façon systématique.Conclusion : Dans un contexte lourdement touché comme Mumbai, des données importantes relatives à la chirurgie de la TBP ont été étonnamment limitées à la fois dans le secteur privé et public. L'éligibilité à la chirurgie a été établie tardivement, la culture et le test de pharmacosensibilité n'ont pas été systématiquement proposés, l'intervalle entre l'admission et la chirurgie a été long et les résultats en matière de TB n'ont pas été notés. Un recueil systématique des données permettrait une évaluation correcte de la chirurgie comme traitement adjuvant de toutes les formes de TB dans des conditions de programme.

Marco de referencia: El tratamiento quirúrgico se considera un complemento importante en el manejo de casos específicos de tuberculosis pulmonar (TBP), como la TB farmacorresistente; sin embargo, las pruebas operativas de su factibilidad y eficacia son escasas.Objetivo: Describir los desenlaces quirúrgicos y las dificultades programáticas de la prestación de opciones quirúrgicas a los casos de TBP en Bombay, en la India.Método: Fue este un estudio descriptivo de los datos recogidos de manera sistemática sobre las intervenciones quirúrgicas por TBP, realizadas del 2010 al 2014 en dos hospitales de Bombay (uno del sector público y otro del sector privado).Resultados: De los 85 pacientes tratados, cinco fallecieron (6%), 17 presentaron complicaciones (20%), de las cuales la infección de la herida fue la más frecuente. Fue necesaria una segunda intervención en 12 pacientes (14%). La mayoría de los procedimientos tuvieron lugar en un contexto de urgencia y los criterios de selección se analizaron tarde en el curso del tratamiento. La mediana del tiempo entre la hospitalización y la cirugía fue 51 días. El tipo de resistencia de la TB y los desenlaces terapéuticos no se registraron de manera sistemática.Conclusión: En un entorno con alta carga de morbilidad por TB como Bombay, los datos importantes sobre la cirugía por TBP son sorprendentemente escasos en el sector público y también en el sector privado de atención. Los criterios de selección para la cirugía se analizan tarde, no se ofrece de manera sistemática el cultivo y las pruebas de sensibilidad a los medicamentos, el intervalo entre la hospitalización y el procedimiento es prolongado y se desconocen los desenlaces clínicos de la tuberculosis. La recogida sistemática de datos facilitaría una evaluación adecuada de la cirugía como tratamiento complementario en todas las formas de TB en un contexto programático.

Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV.

BACKGROUND: Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care. OBJECTIVE: To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support. DISCUSSION: Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps. CONCLUSION: It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.

Screening patients with tuberculosis for diabetes mellitus in Ampara, Sri Lanka.

Given the well-known linkage between diabetes mellitus (DM) and tuberculosis (TB), the World Health Organization recommends bidirectional screening. Here we report the first screening effort of its kind from a chest clinic in the Ampara district of Sri Lanka. Of 112 TB patients registered between January 2013 and October 2014, eight had pre-existing DM. Of those remaining, 83 (80%) underwent fasting plasma glucose testing, of whom two (2%) and 17 (20%) were found to have diabetes and impaired fasting glucose, respectively. All of these were enrolled in care. Screening TB patients for DM was found to be feasible at the district level. Further studies at the provincial/country level are required before making any decision to scale up bidirectional screening.

Etant donné le lien bien connu entre diabète (DM) et tuberculose (TB), l'Organisation Mondiale de la Santé recommande un dépistage bidirectionnel. Nous rapportons ici le premier effort de dépistage de ce type au Sri Lanka dans un centre de maladies respiratoires du district d'Ampara. Sur 112 patients TB enregistrés entre janvier 2013 et octobre 2014, huit avaient un DM préexistant. Parmi les autres, 83 (80%) ont eu une glycémie à jeun et parmi eux, respectivement deux (2%) et 17 (20%) ont eu un diabète et une glycémie à jeun trop élevée; tous ont été enrôlés dans un programme de soins. Le dépistage du DM chez des patients TB s'est avéré faisable au niveau du district. D'autres études au niveau provincial/national sont nécessaires avant de décider l'extension de la stratégie.

Dado el vínculo reconocido entre la diabetes (DM) y la tuberculosis (TB), la Organización Mundial de la Salud recomienda la detección sistemática bidireccional. En el presente estudio se comunica la primera campaña de detección de este tipo emprendida en Sri Lanka, en un consultorio de neumología del distrito de Ampara. De los 112 pacientes notificados al registro de TB de enero del 2013 a octubre del 2014, en ocho prexistía el diagnóstico de DM. De los casos restantes (80%), en 83 se practicó la glucemia plasmática en ayunas y se puso en evidencia el diagnóstico de DM en dos de ellos (2%) y 17 pacientes presentaron una glucemia basal alterada (20%); todos los pacientes ingresaron a un programa de atención. Se confirmó que es factible practicar la detección sistemática de la DM en los pacientes con diagnóstico de TB a escala distrital. Será necesario realizar estudios a escala de la provincia y del país antes de adoptar decisiones de ampliación de escala de la medida.