Safety and efficacy of sofosbuvir-based direct-acting antiviral regimens for hepatitis C virus genotypes 1-4 and 6 in Myanmar: Real-world experience.

This open-label, clinical experience investigated the safety and efficacy of direct-acting antiviral (DAA) hepatitis C virus (HCV) therapy in Myanmar; 344 patients completed treatment between June 2015 and May 2016. Patients with HCV genotypes 1-4 and 6 received one of four treatments: (i) Peg-interferon (PEG-IFN)+sofosbuvir (SOF)+ribavirin (RBV) for 12 weeks, (ii) SOF+RBV for 24 weeks, (iii) ledipasvir (LDV)+SOF for 12 weeks or (iv) daclatasvir (DCV)+SOF+RBV for 12 or 24 weeks. Genotype 3 was most common (n=133, 38.7%), followed by genotype 6 (n=122, 35.5%) and genotype 1 (n=86, 25%). Overall, 91% of patients achieved sustained virologic response (SVR); 99% in group 1, (n=148/149), 90% in group 2 (n=95/106), 78% in group 3 (n=65/83) and 100% in group 4 (n=6/6). In group 3, SVR rates were 96.8% in genotype 1 (n=30/31) and 64.1% in genotype 6 (n=25/39). Multivariable regression analysis identified advanced fibrosis (F3-4) (OR=.16 CI: 0.05-0.57, P=.005), genotype 6 (OR=.35, CI: 0.16-0.79, P=.012) and diabetes (OR=.29, CI: 0.12-0.71, P=.007) as negative independent predictors of response. Adverse events were mild with all-oral therapy. CONCLUSION: DAA therapy ±PEG-IFN achieved high SVR rates. Genotype 6 patients had a low SVR to 12 weeks of LDV and SOF raising the need for other regimens, RBV or longer treatment duration in this population.

Left atrial strain in heart failure with preserved ejection fraction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a syndrome in which patients have symptoms and signs of heart failure but preserved ejection fraction. Left atrial (LA) volume and function are known to be impaired in these patients. Two-dimensional speckle-tracking echocardiography (2D-STE) has recently enabled the quantification of LA deformation dynamics. In this study, we evaluated the use of 2D-STE for the diagnosis of HFpEF. PATIENTS AND METHODS: The study included 83 patients with suspected HFpEF. Patients were divided into two groups after HFpEF had been diagnosed according to current guidelines. Parameters of diastolic dysfunction were evaluated, including left ventricular mass index (LVMI), LA volume index (LAVI), E/A ratio, deceleration time (DT), E/E', and STE parameters such as global longitudinal LA strain during ventricular systole (GLAs-res) and strain during late diastole (GLAs-pump). RESULTS: The values of BNP, LVMI, DT, LAVI, and GLAs-res were significantly different between the two groups. In univariate analysis, a strong negative correlation was seen between GLAs-res and BNP (r = -0.567, p < 0.001) as well as between GLAs-res and DT (r = -0.665, p < 0.001), while a moderate negative correlation was found between GLAs-res and LVMI (r = -0.458, p < 0.001) and GLAs-res and LAVI (r = -0.316, p = 0.004). In logistic regression analysis, GLAs-res (p = 0.049, OR = 0.71, 95 % CI = 0.451-0.99), BNP (p = 0.025, OR = 1.08, 95 % CI = 1.01-1.14), and LAVI (p = 0.042, OR = 1.59, 95 % CI = 1.02-2.48) were found to be independent predictors of HFpEF. CONCLUSION: LA function as assessed by 2D-STE is impaired in patients with HFpEF. A GLAs-res value of < 17.5 % can be useful for the diagnosis of HFpEF.

Little Polymorphism at the K13 Propeller Locus in Worldwide Plasmodium falciparum Populations Prior to the Introduction of Artemisinin Combination Therapies.

The emergence and spread of artemisinin-resistant Plasmodium falciparum is of huge concern for the global effort toward malaria control and elimination. Artemisinin resistance, defined as a delayed time to parasite clearance following administration of artemisinin, is associated with mutations in the Pfkelch13 gene of resistant parasites. To date, as many as 60 nonsynonymous mutations have been identified in this gene, but whether these mutations have been selected by artemisinin usage or merely reflect natural polymorphism independent of selection is currently unknown. To clarify this, we sequenced the Pfkelch13 propeller domain in 581 isolates collected before (420 isolates) and after (161 isolates) the implementation of artemisinin combination therapies (ACTs), from various regions of endemicity worldwide. Nonsynonymous mutations were observed in 1% of parasites isolated prior to the introduction of ACTs. Frequencies of mutant isolates, nucleotide diversity, and haplotype diversity were significantly higher in the parasites isolated from populations exposed to artemisinin than in those from populations that had not been exposed to the drug. In the artemisinin-exposed population, a significant excess of dN compared to dS was observed, suggesting the presence of positive selection. In contrast, pairwise comparison of dN and dS and the McDonald and Kreitman test indicate that purifying selection acts on the Pfkelch13 propeller domain in populations not exposed to ACTs. These population genetic analyses reveal a low baseline of Pfkelch13 polymorphism, probably due to purifying selection in the absence of artemisinin selection. In contrast, various Pfkelch13 mutations have been selected under artemisinin pressure.

Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey.

BACKGROUND: Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34% of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women. METHODS: From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres. RESULTS: Overall, only 514 (30%) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21% to 37%, p = 0.0172), month of diagnosis (37% in February 2015 and 23% in March 2015 p = 0.0004) and age group (26% in 25-64 years and 49% in 18-25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36% from 30%. CONCLUSIONS: Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

Case series of a rare complication of CABG. Fistula between the internal mammary artery and pulmonary vasculature.

BACKGROUND: There are few reports in the literature on the development of a fistulous connection between the left internal mammary artery (LIMA) and the pulmonary vasculature (PV) after coronary artery bypass grafting (CABG). This type of fistula may cause angina after CABG. Various mechanisms in the pathophysiology of this rare condition have been proposed. METHODS: We evaluated 537 consecutive patients with CABG surgery who underwent coronary angiography at our institution between January 2011 and March 2012. The post-CABG angiograms were evaluated for LIMA-PV fistula formation. Presence of a LIMA-PV fistula was defined as opacification of the PV or parenchyma after injection of radiopaque contrast medium into the LIMA. RESULTS: We found that 5 of 537 patients (0.93 %) had a LIMA-PV fistula on post-CABG coronary angiograms. The mean age of patients with a LIMA-PV fistula was 61.4 years (range, 51-72 years) and all patients were male. Coronary angiography was performed in the setting of myocardial infarction for 2 patients with a LIMA-PV fistula, and stable angina pectoris was the indication for coronary angiography in the remaining 3 patients. The mean diagnosis time of LIMA-PV fistula after CABG was 3.4 years (range, 1-9 years). None of the patients had a history of redo-CABG, perioperative mediastinitis, or pneumonia. CONCLUSION: LIMA-PV fistulas may occur more frequently than reported on post-CABG angiogram findings. Angina in post-CABG patients may be associated with a LIMA-PV fistula, and selective cannulation of the LIMA with careful evaluation of the angiographic images may provide proper diagnosis and treatment of this entity.

Left atrial deformation and nonischemic dilated cardiomyopathy. A 2D speckle-tracking imaging study.

BACKGROUND: Left ventricular filling pressure (LVFP) is raised by the compromised contraction and impaired ventricular compliance in dilated hearts with systolic dysfunction. Timely recognition and staging of this condition are important for planning of the treatment strategy and making the prognosis. Two-dimensional speckle- tracking echocardiography (2D-STE) has recently enabled the quantification of left atrial (LA) myocardial deformation dynamics. In this study, echocardiographic indicators of increased LVFP and NT-pro-BNP were compared with LA strain measured by 2D-STE. METHODS: A total of 49 nonischemic dilated cardiomyopathy (DCMP) patients were included in the study. All patients underwent standard 2D echocardiography. In the 2D-STE analysis of the LA, global longitudinal LA strain during ventricular systole (GLAs-res) and strain during late diastole (GLAs-pump) were obtained. NT-pro-BNP levels were measured. The patients were divided into two groups--normal (group 1) and increased (group 2) LVFP--according to E/A ratio, E velocity, and E/E' ratio. RESULTS: LAVi-max, LAVi-min, and NT-pro-BNP were higher in group 2, whereas LAtotalEF, LAactiveEF, GLAs-res, and GLAs-pump were lower. In univariate analysis, a good negative correlation was seen between GLAs-res vs. NT-pro-BNP, GLAs-res vs. LAVi-max, and GLAs-res vs. E/E' ratio; a good negative correlation was present between GLAs-pump vs. NT-pro-BNP, GLAs-pump vs. LAVi-max, and GLAs-pump vs. E/E' ratio. LAVi-max, LAactiveEF, NT-pro-BNP, GLas-res, and GLAs-pump were studied by logistic regression analysis. GLAs-res (p = 0.009, OR = 0.593, 95 % CI 0.4-0.877), NT-pro-BNP (p = 0.028, OR = 1.027, 95 % CI 1.003-1.052), and LAactiveEF (p = 0.022, OR = 0.001, 95 % CI 0.001-0.024) were found to be independent predictors of increased LVFP. CONCLUSION: 2D-STE-based LA function is impaired in patients with nonischemic DCMP. LA reservoir and pump function parameters together with NT-pro-BNP levels might be useful in estimating LVFP in this patient group.

Noncompaction cardiomyopathy. Is it more than noncompaction?

Noncompaction cardiomyopathy, a rare congenital cardiomyopathy, is characterized by increased trabeculation in one or more segments of the ventricle. The coexistence of other cardiac anomalies such as coronary-cameral fistula, bicuspid aortic valve, ventricular septal defect, patent ductus arteriosus and bradyarrhythmias make noncompaction cardiomyopathy resemble the reptile heart. The defect in myocardial compaction and the frequently seen accompanying anomalies may share a common causative factor during embryogenesis.

A successful septal ablation of the first septal perforator artery arising from the circumflex artery.

Congenital coronary anomalies are usually incidental, uncommon and asymptomatic. We present a case of a successful septal ablation of the first septal perforator artery arising from the circumflex artery in a patient with symptomatic hypertrophic cardiomyopathy.

Accordion effect in a thin-strut coronary stent.

Longitudinal compression (accordion effect) of modern thinner-strut stents has been recently recognised. We report a typical case of longitudinal stent compression caused by a post-dilatation balloon.

A successful percutaneous closure of ventricular septal defect following septal myectomy in patients with hypertrophic obstructive cardiomyopathy.

Postoperative ventricular septal defect (post-op VSD) after septal myectomy in patients with hypertrophic obstructive cardiomyopathy is a rare and unexpected complication. We report a case of successful percutaneous closure of VSD following septal myectomy and mitral valve replacement in a patient with intrinsic mitral valve disease and severe mitral valve regurgitation together with hypertrophic obstructive cardiomyopathy.

Contributions of GeneXpert® to TB diagnosis in Myanmar.

BACKGROUND: Xpert® MTB/RIF, a rapid, molecular TB diagnostic assay, can detect Mycobacterium tuberculosis and rifampin resistance directly from clinical sputum samples in <2 h with high sensitivity and specificity. The added diagnostic value of Xpert over smear microscopy at a national level in Myanmar has not been previously reported.METHODS: We evaluated 339,358 Xpert and demographic records captured from January 2015 to December 2018 as part of the Myanmar National TB Program Data Utilization and Connectivity Project to examine the additional diagnostic yield of Xpert relative to smear for the detection of M. tuberculosis for TB diagnosis in Myanmar, with a focus on people living with HIV (PLHIV) and sample type.RESULTS: Use of Xpert increased TB case detection by 40% compared to smear microscopy results. Among PLHIV, use of Xpert increased TB case detection by almost 100% compared to smear microscopy results.CONCLUSION: Xpert testing identified more patients with TB than smear microscopy alone, particularly in cohorts with significant proportions of PLHIV. The use of Xpert as a screening tool in countries with a high burden of TB could lead to significantly increased diagnosis of TB at a regional and national level.

Is 5-fluorouracil-induced vasospasm a Kounis syndrome? A diagnostic challenge.

Cardiovascular hypersensitivity is a rare and well-documented side-effect of 5-FU (5-fluorouracil). Besides the common complications such as angina pectoris and myocardial infarction, it can also cause cardiogenic shock, and supraventricular and ventricular arrhythmias. Studies have reported that FU-induced angina most commonly occurred due to vasospasm. In our case, 9 hours after stopping the infusion of 5-FU, the patients developed symptoms and electrocardiographic (ECG) findings consistent with acute myocardial infarction. We intend to share this rare case and discuss whether this late complication after 5-FU infusion is an FU-induced vasospasm or rather an allergic reaction leading to Kounis syndrome.

Phenotypic and functional analysis of CD8(+) T cells undergoing peripheral deletion in response to cross-presentation of self-antigen.

Not all T cells specific for autoantigens are eliminated in the thymus, and therefore alternate mechanisms are required to prevent potentially autoreactive T cells from developing into effectors. Adoptive transfer of CD8(+) T cells from influenza hemagglutinin-specific Clone 4 TCR transgenic mice into mice that express hemagluttinin in the pancreatic islets results in tolerance. This is preceded by activation of Clone 4 T cells that encounter antigen cross-presented in the draining lymph nodes of the pancreas. In this report we compare the phenotype, function, and costimulatory requirements of Clone 4 T cells activated by endogenous self-antigen, with Clone 4 T cells stimulated by influenza virus. The cells undergoing tolerance upregulate both CD69 and CD44, yet only partially downregulate CD62L, and do not express CD49d or CD25. Most importantly, they lack the ability to produce interferon-gamma in response to antigen and show no cytolytic activity. Clone 4 T cells disappear after several cycles of division, apparently without leaving the site of initial activation. Surprisingly, despite the fact that such stimulation occurs through recognition of antigen that is cross-presented by a professional antigen-presenting cell, we find this activation is not dependent on costimulation through CD28. These data demonstrate that the recognition by naive CD8(+) T cells of cross-presented self-antigen results in localized proliferation and deletion, without the production of effector cells.

Promoting evidence-based practices for breast cancer care through web-based collaborative learning.

The Knowledge Summaries for Comprehensive Breast Cancer Control (KSBCs) are a series of 14 publications aligned with World Health Organization guidance on evidence-based breast cancer control and accepted frameworks for action. To study utilization of the KSBCs in the development of locally relevant breast cancer control policies and programs in limited resource settings, the National Cancer Institute Center for Global Health, the University of Washington and the Fred Hutchinson Cancer Research Center developed the Project ECHO® for KSBCs (KSBC ECHO). Project ECHO is an online model which employs case-based learning, while promoting multi-directional learning and network-building. The program was evaluated using a pre-post study design to assess if this online collaborative learning platform can be an effective model for dissemination and utilization of the KSBCs to inform breast cancer control programs and policy advocacy in limited resource settings. A total of 28 KSBC ECHO participants (57%) responded to the baseline and endpoint program evaluation surveys. Across all 28 respondents, analysis of the data indicates that knowledge increase was statistically significant overall: average knowledge gain was 0.77, 95% CI [0.44 - 1.08] and p value < 0.0001. A majority of responding team leads reported that the core ECHO components (case/didactic presentations, discussion) contributed to a great extent to strengthening their project proposal/goals. Program evaluation survey responses indicate that utilization of this online platform provided an opportunity for individual knowledge gain, multi-directional information exchange, network-building, and strengthening of the proposed breast cancer control projects based in limited resource settings.

Fully vs. partially integrated services for TB-HIV in Myanmar: a health services review and a cohort study.

In Myanmar, integrated services for tuberculosis (TB) and human immunodeficiency virus (HIV) are operated either fully (as one single unit) or partially (each vertical programme provides both services). To review the fully and partially integrated services for TB-HIV and to assess their TB treatment outcomes. We analysed the compiled service database and conducted a cohort study on newly registered TB-HIV patients in 12 townships in Myanmar. No significant association between region/state and types of integration was detected. Townships with partially integrated services had a significantly larger population size, higher proportion of urban population as well as higher TB and TB-HIV case notification rates; however, the cartridge-based Xpert® MTB/RIF assay was used less frequently than in townships with fully integrated services. Treatment completion rate and unfavourable outcomes were not significantly different between the two models, although fully integrated services reported a higher cure rate. These mixed results suggest that during expansion of fully integrated services, the progress of treatment outcomes should be monitored carefully. .

Childhood TB in Myanmar: trends in notification, profile and treatment outcomes in the private sector.

SETTING: Myanmar National Tuberculosis (TB) programme (NTP). OBJECTIVE: To describe 1) the trends in childhood TB (aged ⩾ 14 years) notification from 2014 to 2017 and quantify the private sector contribution to this notification; and 2) the profile and treatment outcomes of childhood TB managed in the private sector in 2016. STUDY DESIGN: This was an observational study involving the review of routine records and reports of the NTP public-private mix (PPM) projects managed by the Myanmar Medical Association and Population Service International. RESULTS: The total number of childhood TB notified has declined from 36 314 in 2014 to 28 723 in 2017 (average annual decline = 2607 cases per year). The private sector contribution to the notification remained between 17% and 19%. Of the 5616 childhood TB cases diagnosed and treated under the two PPM projects in 2016, 99% were clinically diagnosed and 5459 (97.7%) had successful treatment outcomes. Children aged ⩾10 years, males, those with bacteriologically confirmed TB, those treated in the regions or states of Mandalay, Chin and Shan had a higher risk of an unfavourable outcome (lost to follow-up, death, move to second-line treatment and not evaluated). CONCLUSION: Childhood TB notification is showing a declining trend. One of five notified childhood TB cases was diagnosed and treated in the private sector, where the successful treatment rate was high.

High prevalence and incidence of tuberculosis in people living with the HIV in Mandalay, Myanmar, 2011-2017.

SETTING: Two human immunodeficiency virus (HIV) clinics providing antiretroviral therapy (ART), Mandalay, Myanmar. OBJECTIVE: To assess prevalent TB at enrolment, incident TB during follow-up and associated risk factors in adult people living with HIV (PLHIV) between 2011 and 2017. DESIGN: Cohort study using secondary data. RESULTS: Of 11 777 PLHIV, 2911 (25%) had prevalent TB at or within 6 weeks of enrolment. Independent risk factors for prevalent TB were being male or single/widowed, daily alcohol consumption, CD4 count 200 cells/µl and anaemia. During 6 years follow-up in 8866 PLHIV with no prevalent TB, the rate of new TB was 2.9 per 100 person-years (95%CI 2.6-3.1). Cumulative TB incidence was 9.6%, with 370 (72%) of 517 new TB cases occurring in the first year. Independent risk factors for incident TB were being male and anaemia. Incident TB was highest in the first year of ART, in PLHIV with CD4 counts 200 cells/µl and those not receiving isoniazid preventive therapy (IPT). Incident TB declined with time on ART and rising CD4 counts. CONCLUSION: Prevalent and incident TB were high in PLHIV in the Mandalay clinics. Consideration should be given to earlier TB diagnosis using more sensitive diagnostic tools, effective ART and scaling up IPT.

IPT in people living with HIV in Myanmar: a five-fold decrease in incidence of TB disease and all-cause mortality.

SETTING: Myanmar, a country with a high human immunodeficiency virus-tuberculosis (HIV-TB) burden, where the tuberculin skin test or interferon-gamma release assays are not routinely available for the diagnosis of latent tuberculous infection. OBJECTIVE: To assess the effect of isoniazid (INH) preventive therapy (IPT) on the risk of TB disease and mortality among people living with HIV (PLHIV). DESIGN: A retrospective cohort study of routinely collected data on PLHIV enrolled into care between 2009 and 2014. RESULTS: Of 7177 patients (median age 36 years, interquartile range 31-42; 53% male) included in the study, 1278 (18%) patients received IPT. Among patients receiving IPT, 855 (67%) completed 6 or 9 months of INH. Patients who completed IPT had a significantly lower risk of incident TB than those who never received IPT (adjusted hazard ratio [aHR] 0.21, 95%CI 0.12-0.34) after controlling for potential confounders. PLHIV who received IPT had a significantly lower risk of death than those who never received IPT (PLHIV who completed IPT, aHR 0.25, 95%CI 0.16-0.37; those who received but did not complete IPT, aHR 0.55, 95%CI 0.37-0.82). CONCLUSION: Among PLHIV in Myanmar, completing a course of IPT significantly reduced the risk of TB disease, and receiving IPT significantly reduced the risk of death.

Sputum smear-positive, Xpert® MTB/RIF-negative results: magnitude and treatment outcomes of patients in Myanmar.

Setting: Myanmar's National Tuberculosis Programme (NTP) uses the Xpert® MTB/RIF assay to diagnose rifampicin (RMP) resistance in sputum smear-positive (Sm+) pulmonary tuberculosis (TB) patients. The Xpert test may occasionally yield negative results (Xpert-) for Mycobacterium tuberculosis complex, indicating a false-positive sputum smear result, false-negative Xpert result or infection with non-tuberculous mycobacteria (NTM). Patients with NTM may respond poorly to first-line anti-tuberculosis treatment. Objective: To assess the burden of Sm+, Xpert- results at the national level and treatment outcomes of Sm+, Xpert- patients in Yangon Region. Design: A cohort study involving a retrospective record review of routinely collected NTP data. Result: In 2015 and 2016, 4% of the 25 359 Sm+ patients who underwent Xpert testing nationally were Sm+, Xpert-. Similarly, in the Yangon Region, 5% of the 5301 Sm+ patients were also Xpert- and were treated with first-line anti-tuberculosis regimens. Smear grade (scanty/1+) and age ⩾65 years were associated with Sm+, Xpert- results. The 88% treatment success rate for this group was similar to that of Sm+, Xpert+ patients without RMP resistance. Conclusion: Approximately 4-5% of Sm+ TB patients were Xpert-. There is an urgent need to formulate guidelines on how to reassess and manage these patients.

Contexte : Le programme national tuberculose du Myanmar (PNT) recourt au test Xpert® MTB/RIF pour diagnostiquer la résistance à la rifampicine (RMP) chez les patients atteints de tuberculose (TB) pulmonaire à frottis de crachats positif (Sm+). Les résultats du test Xpert peuvent parfois être négatifs (Xpert­) pour le complexe Mycobacterium tuberculosis indiquant soit un résultat de frottis de crachats faussement positif, soit un résultat de test Xpert faussement négatif ou une infection à mycobactéries non-tuberculeuse (NTM). Les patients atteints de NTM peuvent répondre de façon médiocre au traitement anti-tuberculose de première ligne.Objectif : Evaluer la proportion de patients Sm+/Xpert­ au niveau national et les résultats du traitement dans la région de Yangon.Schéma : Etude de cohorte impliquant une revue rétrospective des dossiers de données recueillies en routine par le PNT.Résultats: Au niveau national, en 2015 et 2016, 4% des 25 359 patients Sm+ qui ont eu un test Xpert ont été Xpert­. De même, dans la région de Yangon, 5% des 5301 patients Sm+ ont été Xpert­ et ils ont été traités avec des protocoles anti-tuberculose de première ligne. Le grade du frottis (rare/1+) et l'âge ⩾ 65 ans ont été associés aux résultats Sm+/Xpert­. Le taux de succès du traitement a été de 88% ce qui a été similaire aux résultats des patients Sm+/Xpert+ sans résistance à la RMP.Conclusion : La proportion de patients TB Sm+/Xpert­ a été d'environ 4­5%. Il y a un besoin urgent de formuler des directives sur la manière de réévaluer et de prendre en charge de façon optimale ces patients.

Marco de referencia: En el Programa Nacional contra la Tuberculosis (PNT) de Birmania se utiliza la prueba Xpert® MTB/RIF con el fin de diagnosticar la resistencia a rifampicina (RMP) en los pacientes con diagnóstico de tuberculosis (TB) pulmonar y baciloscopia positiva (Sm+). El resultado de la prueba Xpert en ocasiones puede ser negativa para el complejo Mycobacterium tuberculosis, lo cual puede corresponder ya sea a un resultado positivo falso de la baciloscopia del esputo, un resultado negativo falso de la prueba Xpert o a la infección por una micobacteria atípica. Los pacientes infectados por micobacterias atípicas pueden tener una respuesta deficiente al tratamiento antituberculoso de primera línea.Objetivo: Evaluar la proporción de casos SM+, Xpert­ a escala nacional y los desenlaces terapéuticos de estos pacientes en la región de Yangon.Método: Se realizó un estudio de cohortes retrospectivo a partir del análisis de los datos corrientes recogidos en las historias clínicas en el PNT.Resultados: A escala nacional, en el 2015 y el 2016, el 4% de los 25 359 pacientes Sm+ que realizaron la prueba Xpert obtuvo un resultado negativo. Asimismo, en la región de Yangon, el 5% de los 5301 pacientes con Sm+ tuvo un resultado negativo de la prueba Xpert y recibió tratamiento con esquemas antituberculosos de primera línea. Los factores que se asociaron con Sm+ y una prueba Xpert­ fueron el grado de la baciloscopia (bacilos escasos o 1+) y la edad a ⩾ 65 años. La tasa de éxito terapéutico en estos casos fue 88%, una proporción equivalente a los desenlaces de los pacientes Sm+ y Xpert+, sin resistencia a RMP.Conclusión: La proporción de pacientes con Sm+ y Xpert­ fue del 4% al 5%. Existe una necesidad urgente de formular directrices sobre la forma reevaluar estos pacientes y tratarlos de manera óptima.

Rifampicin-resistant tuberculosis patients in Myanmar in 2016: how many are lost on the path to treatment?

SETTING: Regional tuberculosis (TB) centres of the Yangon and Mandalay Regions of Myanmar, which account for 65% of all notified rifampicin-resistant tuberculosis (RR-TB) cases countrywide. OBJECTIVE: To determine 1) initial loss to follow-up (LTFU), 2) treatment delay, and 3) factors associated with initial LTFU and treatment delay among RR-TB patients residing in the Yangon and Mandalay regions diagnosed using Xpert® during January-August 2016. DESIGN: This was a retrospective cohort study. Each diagnosed patient was tracked in the drug-resistant TB treatment registers of the Yangon and Mandalay regional treatment centres for January-December 2016 using patient name, age, sex, township and date of diagnosis. If the diagnosed patient was not found in the treatment register by 31 December 2016, he/she was considered 'initial LTFU'. RESULTS: Of the 1037 RR-TB patients diagnosed, 310 (30%) experienced initial LTFU, which was significantly higher among patients aged 55 years and among those diagnosed in the Mandalay Region. A treatment delay of >1 month was observed in 440 (70%) patients (median delay 41 days). Delay was uniformly high across patient subgroups, and was not associated with any factor. CONCLUSION: Initial LTFU and treatment delays among RR-TB patients were high. Future studies using qualitative research methods are needed to ascertain the reasons for this observation.