Referral Process for Surgical Management of Tuberculosis in Lima: A Qualitative Study.

BACKGROUND: Lung resection surgery can be a complementary therapy for managing tuberculosis (TB) complications, but access is lacking in high-burden areas. The referral process for surgical evaluation is not well described. This study aimed to elucidate the TB surgery referral process in Peru. METHODS: A qualitative study was conducted using focus groups and interviews of health care providers from the Peruvian National TB Program. A semi-structured interview guide was developed with local partners. Focus groups and individual interviews were recorded and transcribed. Thematic analysis was used to reconstruct the referral process and identify barriers as well as areas for improvement. RESULTS: A total of 12 sessions were recorded (7 interviews and 5 focus groups; 36 participants total). The main themes identified were: (1) Surgical referral workflow, (2) Unstandardized selection criteria for surgery, (3) Limited inter-institutional communication, and (4) Material barriers to surgical management. CONCLUSION: Health care providers involved in the referral process of surgical management of tuberculosis in Lima reported a hierarchical referral workflow. Interinstitutional communication may be a critical interventional point to improve a patient's quality of care during the referral process.

Evaluation of a New Immunochromatographic Test Using Recombinant Antigen B8/1 for Diagnosis of Cystic Echinococcosis.

Diagnosis of cystic echinococcosis (CE) is based on the identification of the cyst(s) by imaging, using immunodiagnostic tests mainly as complementary tools in clinical settings. Among the antigens used for immunodiagnosis, previous studies described a good performance of the recombinant antigen B8/1 (rAgB) in an enzyme-linked immunosorbent assay (ELISA) format; however, in remote parts of areas where the disease is endemic, the implementation of an ELISA is difficult, so a more simple, rapid, and reliable method such as the immunochromatographic test (ICT) is required. In this study, using a set of 50 serum samples from patients with surgically confirmed CE, we compared the performance of an ICT and that of an ELISA using the rAgB. The overall sensitivities of ICT and ELISA were not statistically different (78% versus 72%; P = 0.36). The overall agreement between both tests was moderate (κ = 0.41; P < 0.01). Concordance between ICT and ELISA was substantial or almost perfect for patients with liver involvement (κ = 0.65; P < 0.001) and patients with more than one hydatid cyst (κ = 0.82; P < 0.001), respectively. Moreover, specificity analysis using a total of 88 serum samples from healthy individuals (n = 20) and patients (n = 68) with other parasitic infections revealed that ICT had a specificity of 89.8%. ICT and ELISA had similar performance for the detection of specific antibodies to E. granulosus, and ICT had a high specificity, opening the possibility of using ICT as a screening tool in rural settings.

Management of Pulmonary Hydatidosis and Lung Abscess in Low-Resource Settings.

In the modern era, infections of the lung are typically managed medically. However, all pulmonary hydatid cysts require surgery with rare exceptions, and bacterial abscesses require surgery if they are complicated, resistant to treatment, and/or large. Surgical treatment of these pulmonary conditions requires clinical knowledge of tests for causative organisms, perioperative antimicrobial therapies, options for surgical management, and postoperative care.

Absence of brain involvement and factors related to positive serology in a prospective series of 61 cases with pulmonary hydatid disease.

A prospective series of 65 patients with surgically confirmed lung cystic hydatid disease was evaluated in terms of their radiologic characteristics, serologic response, and presence of cysts in other organs. Cysts were mostly single and located in lower lung lobes. Liver compromise was found in 34% of the patients. Despite a systematic search, no patient showed brain cysts in this series. Twelve patients had previous hydatid disease: six in the liver and eight in the lung (two had involvement of both organs in the past). Serology using bovine cyst fluid in an immunoblot assay was 85% sensitive. Serologic response was not associated with number or cyst or compromise of other organs but was clearly associated to the presence of at least one complicated cyst. Cyst status in terms of complications should be described to allow appropriate assessment of serologic evaluations.

Surgery for patients with drug-resistant tuberculosis: report of 121 cases receiving community-based treatment in Lima, Peru.

BACKGROUND: While most patients with tuberculosis (TB) can be successfully treated using short-course medical chemotherapy, thoracic surgery is an important adjunctive strategy for many patients with drug-resistant disease. The need for physical, technical and financial resources presents a potential challenge to implementing surgery as a component of treatment for multidrug-resistant TB (MDR-TB) in resource-poor settings. However, a cohort of patients with severe MDR-TB in Lima, Peru underwent surgery as part of their treatment. METHODS: 121 patients underwent pulmonary surgery for drug-resistant tuberculosis between May 1999 and January 2004. Surgery was performed by a team of thoracic surgeons under the Ministry of Health. Patient demographic data, clinical characteristics, surgical procedures and surgical outcomes were studied. RESULTS: Most of the patients had failed multiple TB regimens and were resistant to a median of seven drugs. The median time of follow-up after surgery was 33 months. 79.3% of patients were culture-positive before surgery, and sustained culture-negative status among survivors was achieved in 74.8% of patients. 63% of those followed up for at least 6 months after surgery were either cured or probably cured. Postoperative complications, observed in 22.6% of patients, were associated with preoperative haemoptysis, vital capacity <50% and low forced expiratory volume in 1 s. CONCLUSIONS: This is one of the largest cohorts with MDR-TB to be treated with surgery, and the first from a resource-poor country. Although surgery is not often considered an option for patients in resource-poor settings, the findings of this study support the argument that adjunctive surgery should be considered an integral component of MDR-TB treatment programmes, even in poor countries such as Peru.