BCG vaccine: WHO position paper, February 2018 - Recommendations.

This article presented the World Health Organization's (WHO) recommendations on the use of on Bacille Calmette-Guérin (BCG) vaccine excerpted from the BCG vaccines: WHO position paper - February 2018 published in the Weekly Epidemiological Record [1]. This position paper replaces the 2004 WHO position paper on Bacille Calmette-Guérin (BCG) vaccine [2] and the 2007 WHO revised BCG vaccination guidelines for infants at risk for human immunodeficiency virus (HIV) infection [3]. It incorporates recent developments in the tuberculosis (TB) field, provides revised guidance on the immunization of children infected with HIV, and re-emphasizes the importance of the birth dose. This position paper also includes recommendations for the prevention of leprosy. Footnotes to this paper provide a number of core references including references to grading tables that assess the quality of the scientific evidence, and to the evidence-to-recommendation tables. In accordance with its mandate to provide guidance to Member States on health policy matters, WHO issues a series of regularly updated position papers on vaccines and combinations of vaccines against diseases that have an international public health impact. These papers are concerned primarily with the use of vaccines in large-scale immunization programmes; they summarize essential background information on diseases and vaccines, and conclude with WHO's current position on the use of vaccines in the global context. Recommendations on the use of cholera vaccines were discussed by the Strategic Advisory Group of Experts (SAGE) in October 2017; evidence presented at these meetings can be accessed at: http://www.who.int/immunization/sage/meetings/2017/october/presentations_background_docs/en/.

Failure of a Best Practice Alert to Reduce Antibiotic Prescribing Rates for Acute Sinusitis Across an Integrated Health System in the Midwest.

BACKGROUND: Antimicrobial resistance is a growing concern, and in recent years, there has been increased interest in ambulatory antimicrobial stewardship. Acute rhinosinusitis (ARS) is one of the most common outpatient diagnoses that results in an antibiotic prescription. OBJECTIVE: To determine if a best practice alert (BPA) will affect the percentage of oral antibiotic prescriptions for adults with ARS. METHODS: A prospective, pre/post study was initiated to evaluate the percentage of oral antibiotic prescriptions for ARS in 117 primary care clinics in the Midwest. Included in the study results were 16,570 adults who had an office visit for ARS: 8,106 patients from December 1, 2015, to February 28, 2016, were in the pre-intervention group without an active BPA, and 8,464 patients from December 1, 2016, to February 28, 2017, were in the post-intervention group when the BPA was active. The primary outcome was the number of oral antibiotic prescriptions for ARS compared with the number of office visits for ARS in the pre- and postintervention groups. RESULTS: The percentage of oral antibiotics prescribed for the pre- and postintervention groups were 94.8% and 94.3%, respectively (P = 0.152). The BPA displayed for 7,780 visits, prompting discontinuation of an antibiotic for 10 (0.1%) visits in the postintervention group. CONCLUSIONS: This study suggests that, although an electronic alert may be attractive to facilitate antimicrobial stewardship, it may be ineffective. These results warrant alternative measures to facilitate ambulatory antimicrobial stewardship. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest to declare. Study concept and design were contributed by Hansen, D. Leedahl, and N. Leedahl. Hansen and N. Leedahl took the lead in data collection, with assistance from Carson and D. Leedahl. Data interpretation was performed by all the authors. The manuscript was written by Hansen, along with the other authors, and revised by all the authors.

Guidelines for management of rheumatic diseases in developing countries from basics to real-world situation: relevance, need, and processes for development.

Guidelines or recommendations help to provide uniform standards in medical practice. The development of guidelines requires adherence to pre-defined norms prescribed by different international organizations such as the European League against Rheumatism (EULAR). We searched Pubmed and LILACS to identify published papers in five major rheumatic diseases (rheumatoid arthritis, systemic lupus erythematosus, spondyloarthropathies, osteoarthritis, and scleroderma) from different countries based on their economic prosperity and could find a lack of published literature from most economically weaker regions. Similarly, published guidelines in these rheumatic diseases were sparse from Asia and Africa, which are economically developed to a lesser extent than other regions of the world. Considering differing economic realities driving patient care in different regions of the world, unique challenges in certain geographic areas such as musculoskeletal manifestations of infectious diseases like leprosy and tuberculosis, as well as distinct risk of malignancies and other comorbid conditions, National Rheumatology societies should work towards developing more guidelines for rheumatic diseases from regions such as Asia and Africa, while following strictly the prescribed norms for the same. With a paucity of guidelines for such regions currently, an alternative (although less preferable) suggestion would be that major international societies, whose guidelines are widely read and followed the world over, should consider inputs from experts from diverse regions of the world while developing these guidelines.

Guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis: An Indian perspective.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are severe, life-threatening mucocutaneous adverse drug reactions with a high morbidity and mortality that require immediate medical care. The various immunomodulatory treatments include systemic corticosteroids, cyclosporine, intravenous immunoglobulin, cyclophosphamide, plasmapheresis and tumor necrosis factor-α inhibitors. AIM: The ideal therapy of Stevens-Johnson syndrome/toxic epidermal necrolysis still remains a matter of debate as there are only a limited number of studies of good quality comparing the usefulness of different specific treatments. The aim of this article is to comprehensively review the published medical literature and frame management guidelines suitable in the Indian perspective. METHODS: The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) assigned the task of preparing these guidelines to its special interest group on cutaneous adverse drug reactions. The group performed a comprehensive English language literature search for management options in Stevens-Johnson syndrome/toxic epidermal necrolysis across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for keywords (alone and in combination) and MeSH items such as "guidelines," "Stevens-Johnson syndrome," "toxic epidermal necrolysis," "corticosteroids," "intravenous immunoglobulin," "cyclosporine" and "management." The available evidence was evaluated using the strength of recommendation taxonomy and graded using a three-point scale. A draft of clinical recommendations was developed on the best available evidence which was also scrutinized and critically evaluated by the IADVL Academy of Dermatology. Based on the inputs received, this final consensus statement was prepared. RESULTS: A total of 104 articles (meta-analyses, prospective and retrospective studies, reviews [including chapters in books], previous guidelines [including Indian guidelines of 2006] and case series) were critically evaluated and the evidence thus gathered was used in the preparation of these guidelines. RECOMMENDATIONS: This expert group recommends prompt withdrawal of the culprit drug, meticulous supportive care, and judicious and early (preferably within 72 h) initiation of moderate to high doses of oral or parenteral corticosteroids (prednisolone 1-2 mg/kg/day or equivalent), tapered rapidly within 7-10 days. Cyclosporine (3-5 mg/kg/day) for 10-14 days may also be used either alone, or in combination with corticosteroids. Owing to the systemic nature of the disease, a multidisciplinary approach in the management of these patients is helpful.

Clinical and histopathological features of paucibacillary leprosy before and after multidrug therapy: a prospective study.

BACKGROUND: Leprosy often heals with residual skin lesions after completion of treatment. WHO recommends fixed duration multidrug therapy (MDT) irrespective of whether lesions clear or persist after treatment. Patients with residual lesions are often unsatisfied and may undergo repeat biopsy and re-treatment. This study was conducted to compare the clinicohistopathological features in paucibacillary leprosy before and after MDT from September 2012 to February 2014. METHODS: Sixty-one untreated cases of paucibacillary leprosy were investigated and given standard WHO paucibacillary-MDT for 6 months. Scoring of clinical activity was done; histopathological activity was graded according to granuloma fraction. Forty-four patients who completed the treatment were subjected to post-treatment biopsy. Clinical response to therapy was graded as active, resolving and inactive and histopathological changes were compared in all patients. RESULTS: Among the 44 patients, the lesions were inactive, resolving and active in 39% (17/44), 39% (17/44) and 23% (10/44) of patients respectively. Histologically, disease was inactive, resolving and active in 30% (13/44), 9% (4/44) and 61% (27/44). But histomorphological features suggesting regression: loose granulomas (59%, 26/44); lymphocyte predominance (66%, 29/44); vacuolar change in epithelioid cell cytoplasm (59%, 26/44), were statistically significant in post-treatment compared to pre-treatment. CONCLUSIONS: Although histological resolution is slower than clinical resolution, qualitative histomorphological changes in correlation with clinical inactivity can offer a fair suggestion to the clinician to terminate therapy.

Recommendations of the German Central Committee against Tuberculosis (DZK) and the German Respiratory Society (DGP) for the Diagnosis and Treatment of Non-tuberculous Mycobacterioses.

Non-tuberculous mycobacterioses comprise a group of diseases caused by mycobacteria which do not belong to the Mycobacterium (M.) tuberculosis-complex and are not ascribed to M. leprae. These mycobacteria are characterized by a broad variety as to environmental distribution and adaptation. Some of the species may cause specific diseases, especially in patients with underlying immunosuppressive diseases, chronic pulmonary diseases or genetic predisposition, respectively. Worldwide, a rising prevalence and significance of non-tuberculous mycobacterioses is recognized. The present recommendations summarise current aspects of epidemiology, pathogenesis, clinical aspects, diagnostics - especially microbiological methods including susceptibility testing -, and specific treatment for the most relevant species. Diagnosis and treatment of non-tuberculous mycobacterioses during childhood and in HIV-infected individuals are described in separate chapters.

Guidelines on the use of finasteride in androgenetic alopecia.

BACKGROUND: Finasteride is a widely used drug in dermatology for the treatment of androgenetic alopecia. There are many reports of associated sexual side effects. This article reviews the use of once-daily 1 mg finasteride in androgenetic alopecia and its associated sexual adverse effects. METHODS: A literature search was performed to collect data on the use of finasteride in male pattern baldness. Relevant literature published till March 2014 was obtained from MEDLINE, EMBASE, CINAHL, Cochrane registers and LILACS. The keywords "finasteride", "male pattern baldness" and "androgenetic alopecia" were used for literature search. Similarly, a search was done for finasteride in female pattern hair loss with keywords "female pattern baldness", "finasteride" and "female pattern alopecia". All systematic reviews, meta-analyses, national guidelines, randomized controlled trials, prospective open label studies and retrospective case series in the English literature were reviewed. RESULTS: Two hundred sixty two studies were evaluated, twelve of which fulfilled the inclusion criteria. CONCLUSIONS AND RECOMMENDATIONS: Current evidence on the safety of finasteride indicates that it is safe but there is growing concern about its sexual side effects. In view of this, proper information should be provided to patients prior to starting treatment (Level of recommendation 1+, Grade of recommendation B). The reported sexual side effects are few and reverse with stoppage of the drug (Grade of recommendation B) but further studies are required.

Targeted phototherapy.

BACKGROUND: Targeted phototherapy is a new form of phototherapy which has many advantages and disadvantages over conventional phototherapy. This article reviews the different technologies and outlines recommendations based on current evidence. METHODS: A literature search was performed on targeted phototherapy to collect data. Relevant literature published till March 2014 was obtained from PubMed, EMBASE, and the Cochrane Library. Keywords like "targeted phototherapy", "excimer laser", "excimer lamp", "Nonchromatic ultraviolet light", "vitiligo", and "psoriasis", were used for literature search. All systematic reviews, meta-analysis, national guidelines, randomized controlled trials (RCT), prospective open label studies and retrospective case series in English were reviewed. RESULTS: Three hundred and forty studies were evaluated, 24 of which fulfilled the criteria for inclusion in the guidelines. CONCLUSIONS AND RECOMMENDATIONS: All forms of targeted phototherapy are useful in vitiligo. Good responses were seen in localized involvement, resistant lesions and in children in whom their use is more accepted and convenient (Level of evidence 2+, Grade of recommendation B). Similarly it is useful in psoriasis, either alone or in combination with drugs, even in resistant forms such as palmoplantar psoriasis. In view of expense and practical application, their use is limited to resistant lesions and localized disease. (Level of evidence 2+, Grade of recommendation B). But in other conditions there is no convincing evidence for its use. (Level of evidence 3+, Grade of recommendation C).

Guidelines for bath PUVA, bathing suit PUVA and soak PUVA.

BACKGROUND: The aim of these guidelines is to encourage dermatologists to use bath psoralen plus ultraviolet A (PUVA), bathing suit PUVA and soak PUVA in the treatment of psoriasis vulgaris and other conditions. METHODS: Evidence was collected using searches of the PubMed, MEDLINE and COCHRANE databases using the keywords "bath PUVA," "soak PUVA," "bathing suit PUVA" and "turban PUVA." Only publications in English were reviewed. RESULTS: One hundred and thirty-eight studies were evaluated, 57 of which fulfilled the criteria for inclusion. CONCLUSIONS: Both bath PUVA and bathing suit PUVA are very effective and safe treatments for generalized stable plaque psoriasis (strength of recommendation, A). Soak PUVA is very effective in the treatment of both palmoplantar psoriasis and chronic palmoplantar eczema (strength of recommendation, A).

Tuberculosis retreatment 'others' in comparison with classical retreatment cases; a retrospective cohort review.

BACKGROUND: Many of the countries in sub-Saharan Africa are still largely dependent on microscopy as the mainstay for diagnosis of tuberculosis (TB) including patients with previous history of TB treatment. The available guidance in management of TB retreatment cases is focused on bacteriologically confirmed TB retreatment cases leaving out those classified as retreatment 'others'. Retreatment 'others' refer to all TB cases who were previously treated but with unknown outcome of that previous treatment or who have returned to treatment with bacteriologically negative pulmonary or extra-pulmonary TB. This study was conducted in 11 regional referral hospitals (RRHs) serving high burden TB districts in Uganda to determine the profile and treatment success of TB retreatment 'others' in comparison with the classical retreatment cases. METHODS: A retrospective cohort review of routinely collected National TB and Leprosy Program (NTLP) facility data from 1 January to 31 December 2010. This study uses the term classical retreatment cases to refer to a combined group of bacteriologically confirmed relapse, return after failure and return after loss to follow-up cases as a distinct group from retreatment 'others'. Distribution of categorical characteristics were compared using Chi-squared test for difference between proportions. The log likelihood ratio test was used to assess the independent contribution of type of retreatment, human immunodeficiency virus (HIV) status, age group and sex to the models. RESULTS: Of the 6244 TB cases registered at the study sites, 733 (11.7%) were retreatment cases. Retreatment 'others' constituted 45.5% of retreatment cases. Co-infection with HIV was higher among retreatment 'others' (70.9%) than classical retreatment cases (53.5%). Treatment was successful in 410 (56.2%) retreatment cases. Retreatment 'others' were associated with reduced odds of success (AOR = 0.44, 95% CI 0.22,0.88) compared to classical cases. Lost to follow up was the commonest adverse outcome (38% of adverse outcomes) in all retreatment cases. Type of retreatment case, HIV status, and age were independently associated with treatment success. CONCLUSION: TB retreatment 'others' constitute a significant proportion of retreatment cases, with higher HIV prevalence and worse treatment success. There is need to review the diagnosis and management of retreatment 'others'.

[Quality control in the follow-up of pulmonary tuberculosis contacts in Camagüey, Cuba (2008-2011)]. / Control de la calidad del seguimiento de contactos de tuberculosis pulmonar en Camagüey, Cuba (2008-2011).

INTRODUCTION: Tuberculosis is currently a health problem in the municipality of Camagüey. PURPOSE: To assess compliance of guidelines issued by the National Program for the Control of Tuberculosis for the follow-up of contacts of positive cases of pulmonary tuberculosis in the municipality of Camagüey, Cuba. DESIGN: Descriptive cross-sectional design. METHODS: 1,242 contacts resulting from 39 reported cases of tuberculosis during the study period were included in the municipality of Camagüey between 2008 and 2011. Epidemiological surveys and records of reported cases were reviewed. The results were processed and analyzed in SPSS 17.0 statistical software and subsequently presented in tables and graphs. The results were summarized by percentages. The “follow-up form for contacts of pulmonary tuberculosis” was used as main guideline, which was created by experts of the Investigation and Monitoring of Tuberculosis, Acute Respiratory Infections, and Leprosy Workshop of Tropical Medicine Institute Pedro Kourí. RESULTS: Contacts that had an initial examination and four checkups had 96.2% of acceptability. Contacts that had fewer than four checkups showed less than 10% acceptability (3.3%). All contacts were assessed from the outset and were treated, in accordance with program guidelines. CONCLUSION: We found adequate compliance of National Program for the Control of the Tuberculosis guidelines for follow-up of contacts of positive cases of pulmonary tuberculosis. Compliance is greater in younger age groups and in the actively employed (25 to 54 years). This evaluation contributed to identify existing weaknesses in follow-up, such as low interest of this population to undergo appropriate testing in the National Program of Control of Tuberculosis.

INTRODUCCIÓN: La tuberculosis constituye en la actualidad un problema de salud en el municipio de Camagüey. OBJETIVO: Evaluar el cumplimiento de los lineamientos del Programa Nacional para el Control de la Tuberculosis para el seguimiento de los contactos de casos positivos de tuberculosis pulmonar en el municipio de Camagüey, Cuba. DISEÑO: Estudio descriptivo de corte transversal en el municipio de Camagüey entre los años 2008 y 2011. MÉTODOS: Se incluyeron 1.242 contactos resultantes de 39 casos de tuberculosis reportados en el período en estudio. Se revisaron las encuestas epidemiológicas y registros epidemiológicos de los casos reportados. Los resultados se procesaron y analizaron en el software estadístico SPSS 17.0, luego se representaron en tablas y gráficos. Se utilizó el porcentaje como medida de resumen. Se empleó como herramienta guía el “Formulario de seguimiento de los contactos de tuberculosis pulmonar” creado por expertos del grupo de investigación y vigilancia de tuberculosis, infecciones respiratorias agudas y lepra del Instituto de Medicina Tropical Pedro Kourí. RESULTADOS: Los contactos con examen inicial y cuatro controles completados presentaron 96,2% de aceptabilidad; en tanto, los contactos que tuvieron menos de cuatro controles reportaron resultados inferiores a 10% (3,3%). Todos los contactos fueron investigados desde el inicio y se les administró tratamiento de acuerdo a los lineamientos del programa. CONCLUSIÓN: Se observó que hay cumplimiento en los lineamientos del Programa Nacional de Control de la Tuberculosis para el seguimiento de los contactos de casos positivos de tuberculosis pulmonar. Éste es más riguroso en las edades tempranas y laboralmente activas (entre 25 y 54 años). La evaluación contribuyó a la identificación de las debilidades existentes como la poca sensibilidad de la población para someterse a los exámenes correspondientes en el Programa Nacional de Control de la Tuberculosis.

The pits and falls of graphical presentation.

Graphics are powerful tools to communicate research results and to gain information from data. However, researchers should be careful when deciding which data to plot and the type of graphic to use, as well as other details. The consequence of bad decisions in these features varies from making research results unclear to distortions of these results, through the creation of "chartjunk" with useless information. This paper is not another tutorial about "good graphics" and "bad graphics". Instead, it presents guidelines for graphic presentation of research results and some uncommon, but useful examples to communicate basic and complex data types, especially multivariate model results, which are commonly presented only by tables. By the end, there are no answers here, just ideas meant to inspire others on how to create their own graphics.

What is new in polycystic ovary syndrome? Best articles from the past year.

This month, we focus on current research in polycystic ovary syndrome. Dr. Hansen discusses six recent publications, and each is concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in on this page, along with direct links to the abstracts.

A Delphi exercise to refine the WHO three-point disability grading system for leprosy, and to develop guidelines to promote greater accuracy and reliability of WHO disability recording.

A Delphi Exercise was undertaken with two objectives: (1) To ascertain whether operational definitions for WHO Disability Grading could be formulated by consensus. (2) To develop a set of simple guidelines based on those definitions for the guidance of health workers. Fifteen people with general expertise in prevention of disability due to leprosy were invited to participate as Delphi panel members, twelve responded positively. Eight issues that commonly cause confusion provided foci for the exercise. Operational definitions aimed at resolving those issues were developed by consensus. Simple guidelines for health workers, based on those definitions were also created and supported by consensus. This paper presents the process followed and the outcomes gained from the endeavour.

Safety and availability of clofazimine in the treatment of multidrug and extensively drug-resistant tuberculosis: analysis of published guidance and meta-analysis of cohort studies.

OBJECTIVES: Given the spread of multidrug-resistant tuberculosis (MDR-TB), new therapies are urgently needed, including the repurposing of existing drugs. We aimed to assess key considerations for the clinical and programmatic use of clofazimine (Cfz), a riminophenazine with antimycobacterial activity currently used to treat leprosy. DESIGN: Fixed and random effects meta-analysis of cohort studies and systematic review. SETTING: Electronic and manual searches were combined. INCLUSION CRITERIA: Observational studies on treatment of multidrug-resistant and extremely drug-resistant tuberculosis with Cfz or a Cfz-containing regimen, and published guidance and documents relating to cost and availability were eligible. RESULTS: 5 observational studies enrolled 861 patients, of which 602 received Cfz. The pooled proportion of adverse drug reactions requiring discontinuation of Cfz treatment was 0.1% (95% CI (0.0 to 0.6%)), and the median frequency of all adverse events was 5.1%. Cfz showed in vitro efficacy against Mycobacterium tuberculosis, and Cfz-containing regimens may have had a useful role in the treatment of patients with drug-resistant strains and who had limited alternative treatment options. However, Cfz uptake remains insufficient to meet global needs; there is only one internationally quality-assured manufacturer, which produces a limited quantity of the drug prioritised for treatment of leprosy, the only indication for which the drug is registered. CONCLUSIONS: While the data were limited, Cfz was associated with a risk for adverse drug reactions comparable to that of first-line TB treatment, which could be reasonably managed under programmatic conditions. However, low market availability and high cost are important barriers to access to Cfz for patients with MDR-TB.

[Recommendations for diagnosis and treatment of nontuberculous mycobacterioses of the German Central Committee against tuberculosis and the German Respiratory Society]. / Empfehlungen zur Diagnostik und Therapie nichttuberkulöser Mykobakteriosen des Deutschen Zentralkomitees zur Bekämpfung der Tuberkulose (DZK) und der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin (DGP).

Nontuberculous mycobacterioses comprise a group of diseases caused by mycobacteria which do not belong to the Mycobacterium (M.) tuberculosis complex and are not ascribed to M. leprae. These mycobacteria are characterized by a broad variety as to environmental distribution and adaptation. Some of the species may cause specific diseases, especially in patients with underlying immunosuppressive diseases, chronic pulmonary diseases or genetic predisposition, respectively. Worldwide a rising prevalence and significance of nontuberculous mycobacterioses can be recognized. The present recommendations summarise actual aspects of epidemiology, pathogenesis, clinical aspects, diagnostics - especially microbiological methods including susceptibility testing -, and specific treatment for the most relevant species. Diagnosis and treatment of nontuberculous mycobacterioses during childhood and in HIV-infected individuals are described in separate chapters.