Factors affecting outcomes of individualised treatment for drug resistant tuberculosis in an endemic region.

BACKGROUND: Individualised treatment regimens for drug resistant tuberculosis have improved outcomes. This retrospective observational study examined potential factors that affect individualised treatment in an endemic region, and highlighted predictors of a successful outcome. METHODS: We examined records of proven MDR, pre-XDR and XDR TB patients diagnosed and started on treatment between 2010 and 2014, and collected the following data for each patient: age, gender, comorbidities, past history of TB, diagnosis, site of disease, drug susceptibility testing (DST) results, treatment, adverse reactions to anti-tubercular drugs, treatment changes and outcomes, which were recorded as positive, negative or neutral. Tests of association were carried out between factors and outcomes, following which multiple logistic regression analysis was done to determine the predictors of a positive outcome such as patient cured after completion of treatment at 18 months or longer. RESULTS: Fifty-nine patients completed treatment at our centre. The median age was 26 years (range 8-65 years). There were 31 (52.5%) female patients. Forty-four (74.6%) were successfully treated over a median treatment period of 23 months (range 18-30 months). Successful outcomes were associated with age less than 45 years (P=0.01, OR=6.67, 95% CI=1.73-23.47), resistance to fewer than five drugs (P=0.001, OR=9.51, 95% CI=2.50-38.18) and susceptibility to Group 4 drugs (P=0.04, OR=4.71, 95% CI=1.03-16.83). CONCLUSIONS: Age and drug susceptibility were important predictors of treatment outcome.

Inconsistency in the reporting of antitubercular drug susceptibility tests in an endemic region.

BACKGROUND: Individualized treatment for multidrug-resistant tuberculosis (MDR TB) is associated with improved outcomes. Therapy needs to be tailored to drug susceptibility testing (DST) results. We present our observations on the inconsistency in DST reporting in an endemic region with a high prevalence of MDR TB. METHODS: We retrospectively analyzed 118 DST reports from 10 different laboratories. OBSERVATIONS: Of 118 patients, only 79 (67%) had DST reports with results to all first-line drugs, a fluoroquinolone (excluding ciprofloxacin), all aminoglycosides, and a polypeptide. Twenty-one (18%) isolates did not have DST reports for all first-line drugs; 4 (3%) did not have DST reports for any second-line drugs; 9 (8%) did not have DST reports for a fluoroquinolone; and 31 (26%) did not have DST reports for all second-line aminoglycosides and polypeptide. CONCLUSION: Inconsistencies were observed in several of the 118 DST reports. A case is made for sensitization toward standardization and completeness in TB DST reporting in India.

Utility of Transcutaneous Capnography for Optimization of Non-Invasive Ventilation Pressures.

INTRODUCTION: Nocturnal Non-invasive Positive Pressure Ventilation (NPPV) is the treatment of choice in patients with chronic hypercapnic respiratory failure due to hypoventilation. Continuous oxygen saturation measured with a pulse oximeter provides a surrogate measure of arterial oxygen saturation but does not completely reflect ventilation. Currently, Partial Pressure of Arterial (PaCO2) measured by arterial blood analysis is used for estimating the adequacy of ventilatory support and serves as the gold standard. AIM: To examine the safety, feasibility and utility of cutaneous capnography to re-titrate the non-invasive positive pressure ventilation settings in patients with chronic hypercapnic respiratory failure due to hypoventilation. MATERIALS AND METHODS: Twelve patients with chronic hypercapnic respiratory failure prospectively underwent complete polysomnography and cutaneous capnography measurement on the ear lobe. Non-invasive ventilation pressures were adjusted with the aim of normalizing cutaneous carbon dioxide or at least reducing it by 10 to 15 mmHg. Sensor drift for cutaneous carbon dioxide of 0.7 mmHg per hour was integrated in the analysis. RESULTS: Mean baseline cutaneous carbon dioxide was 45.4 ± 6.5 mmHg and drift corrected awake value was 45.1 ± 8.3 mmHg. The correlation of baseline cutaneous carbon dioxide and the corrected awake cutaneous carbon dioxide with arterial blood gas values were 0.91 and 0.85 respectively. Inspiratory positive airway pressures were changed in nine patients (75%) and expiratory positive airway pressures in eight patients (66%). Epworth sleepiness score before and after the study showed no change in five patients, improvement in six patients and deterioration in one patient. CONCLUSION: Cutaneous capnography is feasible and permits the optimization of non-invasive ventilation pressure settings in patients with chronic hypercapnic respiratory failure due to hypoventilation. Continuous cutaneous capnography might serve as an important additional tool to complement diurnal arterial carbon dioxide tension values.

Who will teach the teachers: An analysis of the inhaler technique of Indian patients and health care providers in a tertiary health care centre.

INTRODUCTION: The proper use of inhalers is essential for ensuring proper control of the disease. Various studies have shown high levels of improper use and lack of knowledge of the correct technique among patients with asthma. However, less data are available on how health care workers (HCW's) use inhalers. MATERIALS AND METHODS: The study was conducted at a Tertiary Care Hospital in Mumbai. We evaluated the pMDI technique in 141 consecutive adult asthmatics and 100 HCW's. All patients and HCW's were graded out of 10 points for following 10 steps. These were derived from Melani et al.'s study on inhaler mishandling. RESULTS: Techniques of 141 patients and 100 HCW's (55 nurses and 45 doctors) were analyzed. The average technique score among patients ranged from 0 to 10 with a mean of 4.65 ± 2.00. The combined score for health workers ranged from 3 to 9 with a mean of 5.45 ± 1.47. Doctors had a higher score of 6.35 ± 1.33 as opposed to the nurses' score of 4.70 ± 1.13 (P < 0.05). There was no significant difference between scores of nurses and patients (P > 0.05). CONCLUSIONS: Our study highlights the need for better education of not only patients but also health care providers regarding the appropriate use of inhaler devices in order to achieve optimal control of obstructive airway diseases.