First archaeological evidence for ginger consumption as a potential medicinal ingredient in a late medieval leprosarium at St Leonard, Peterborough, England.

Leprosy was one of the most outwardly visible diseases in the European Middle Ages, a period during which leprosaria were founded to provide space for the sick. The extant documentary evidence for leprosy hospitals, especially in relation to diet, therapeutic, and medical care, is limited. However, human dental calculus stands to be an important source of information as it provides insight into the substances people were exposed to and accumulated in their bodies during their lives. In the present study, microremains and DNA were analysed from the calculus of individuals buried in the late medieval cemetery of St Leonard, a leprosarium located in Peterborough, England. The results show the presence of ginger (Zingiber officinale), a culinary and medicinal ingredient, as well as evidence of consumption of cereals and legumes. This research suggests that affected individuals consumed ingredients mentioned in medieval medical textbooks that were used to treat regions of the body typically impacted by leprosy. To the authors' knowledge, this is the first study which has identified Zingiber officinale in human dental calculus in England or on the wider European continent.

Do índio Passos ao doutor Chernoviz: experiências de cura da lepra no Pará do século XIX / From Passos the Indian to Doctor Chernoviz: experiments to cure leprosy in nineteenth-century Pará

Resumo O artigo analisa uma experiência de cura da lepra com assacu (Hura crepitans L.), realizada em Santarém, Pará, em 1847, por um indígena chamado Antonio Vieira dos Passos. A experiência passou a ser realizada nas demais províncias do Brasil e também no exterior. Por essa razão, o artigo estabelece relações com práticas médicas realizadas em outras partes do país, tendo como foco o diálogo entre a medicina oficial e a medicina indígena. A análise de matérias de jornais e documentos oficiais revelou que os saberes indígenas sobre o uso de plantas medicinais eram amplamente reconhecidos e utilizados pelos médicos com a intenção de incorporá-los em seu repertório terapêutico.

Abstract This article analyzes an experiment to cure leprosy using the assacu plant (Hura crepitans L.) conducted in Santarém, Pará, in 1847, by an Indigenous man named Antonio Vieira dos Passos. The experiment was later repeated in other Brazilian provinces and abroad. This article establishes relationships between medical practices in other parts of the country while focusing on the dialog between official and Indigenous medicine. Newspaper articles and official documents of the time show that Indigenous knowledge of medicinal plants was widely recognized and utilized by physicians wishing to incorporate it into the official therapeutic repertoire.

Reduced vitamin D receptor (VDR) and cathelicidin antimicrobial peptide (CAMP) gene expression contribute to the maintenance of inflammatory immune response in leprosy patients.

Leprosy is an infectious disease influenced by genetic, immunological, and environmental factors. Reduced gene expressions may be associated with the immunological response pattern and leprosy susceptibility. We investigated the direct and indirect effects of Vitamin D Receptor (VDR) and Cathelicidin Antimicrobial Peptide (CAMP) gene expressions on the serum levels of vitamin D, Cathelicidin, and cytokines in newly-diagnosed leprosy patients and post-six-months of multidrug therapy (MDT). Thirty-four leprosy patients were assessed, paucibacillary (PB; n = 14) and multibacillary (MB; n = 20) cases, untreated or having received six months of MDT, 18 healthy controls, and 25 household contacts. VDR and CAMP gene expression levels were strongly correlated to some important cytokines in both, untreated leprosy patients (PB, r = 0.9319; MB, r = 0.9569) and patients who had undergone MDT (PB, r = 0.9667; MB, r = 0.9569). We observed that both gene expressions directly influenced IL-2, IFN-γ, and IL-17F serum levels in leprosy patients compared to the household contacts and healthy individuals. VDR and CAMP gene expressions induced a persistent inflammatory response in PB and MB leprosy patients, even after six months of MDT, to fight the Mycobacterium leprae infection. Due to the persistent inflammatory profile, multidrug therapy is suggested to be maintained for more than six months, especially for MB patients. Vitamin D supplementation is recommended from the onset as a transcription factor to improve VDR and CAMP gene expression in leprosy patients.

Disease Burden and Current Therapeutical Status of Leprosy with Special Emphasis on Phytochemicals.

BACKGROUND: Leprosy (Hansen's disease) is a neglected tropical disease affecting millions of people globally. The combined formulations of dapsone, rifampicin and clofazimine (multidrug therapy, MDT) is only supportive in the early stage of detection, while "reemergence" is a significant problem. Thus, there is still a need to develop newer antileprosy molecules either of natural or semi-synthetic origin. OBJECTIVES: The review intends to present the latest developments in the disease prevalence, available therapeutic interventions and the possibility of identifying new molecules from phytoextracts. METHODS: Literature on the use of plant extracts and their active components to treat leprosy was searched. Selected phytoconstituents were subjected to molecular docking study on both wild and mutant types of the Mycobacterium leprae. Since the M. leprae dihydropteroate synthase (DHPS) is not available in the protein data bank (PDB), it was modelled by the homology model method and validated with the Ramachandran plot along with other bioinformatics approaches. Two mutations were introduced at codons 53 (Thr to Ile) and 55 (Pro to Leu) for docking against twenty-five selected phytoconstituents reported from eight plants that recorded effective anti-leprosy activity. The chemical structure of phytochemicals and the standard dapsone structure were retrieved from the PubChem database and prepared accordingly for docking study with the virtual-screening platform of PyRx-AutoDock 4.1. RESULTS: Based on the docking score (kcal/mol), most of the phytochemicals exhibited a higher docking score than dapsone. Asiaticoside, an active saponin (-11.3, -11.2 and -11.2 kcal/mol), was proved to be the lead phytochemical against both wild and mutant types DHPS. Some other useful phytoconstituents include echinocystic acid (-9.6, -9.5 and -9.5 kcal/mol), neobavaisoflavone (-9.2, -9.0 and -9.0 kcal/mol), boswellic acid (-8.90, -8.90 and -8.90 kcal/mol), asiatic acid (-8.9, -8.8 and -8.9 kcal/mol), corylifol A (-8.8, 8.0, and -8.0), etc. Overall, the computational predictions support the previously reported active phytoextracts of Centella asiatica (L.) Urban, Albizia amara (Roxb.) Boivin, Boswellia serrata Roxb. and Psoralea corylifolia L. to be effective against leprosy. CONCLUSION: A very small percentage of well-known plants have been evaluated scientifically for antileprosy activity. Further in vivo experiments are essential to confirm anti-leprosy properties of such useful phytochemicals.

Antimicrobial resistance among leprosy patients in Brazil: real-world data based on the National Surveillance plan

Brazil ranks second among countries for new cases and first for relapse cases of leprosy worldwide. The Mycobacterium leprae Resistance Surveillance Plan was established. We aimed to present the results of a 2-year follow-up of the National Surveillance Plan in Brazil. A cross-sectional study of leprosy cases was performed to investigate antimicrobial resistance (AMR) in Brazil from October 2018 to September 2020. Molecular screening targeting genes related to dapsone (folP1), rifampin (rpoB), and ofloxacin resistance (gyrA) was performed. During the referral period, 63,520 active leprosy patients were registered in Brazil, and 1,183 fulfilled the inclusion criteria for molecular AMR investigation. In total, only 16 (1.4%) patients had genetic polymorphisms associated with AMR. Of these, 8 (50%) had cases of leprosy relapse, 7 (43.8%) had cases of suspected therapeutic failure with standard treatment, and 1 (6.2%) was a case of new leprosy presentation. M. leprae strains with AMR-associated mutations were found for all three genes screened. Isolates from two patients showed simultaneous resistance to dapsone and rifampin, indicating multidrug resistance (MDR). No significant relation ship between clinical variables and the presence of AMR was identified. Our study revealed a low frequency of AMR in Brazil. Isolates were resistant mainly to dapsone, and a very low number of isolates were resistant to rifampin, the main bactericidal agent for leprosy, or presented MDR, reinforcing the importance of the standard World Health Organization multidrug therapy. The greater frequency of AMR among relapsed patients supports the need to constantly monitor this group

Late follow-up of peripheral neural decompression in leprosy: functional and clinical outcomes.

BACKGROUND: Peripheral neural surgical decompression (PNSD) is used as a complementary therapy to the clinical treatment of neuritis to preserve neural function. OBJECTIVE: To evaluate the long-term (≥ 1 year) clinical and functional results for PNSD in leprosy neuritis. METHODS: This cross-sectional study included leprosy patients who were in late postoperative period (LPO) of surgical decompression of ulnar, median, tibial, and fibular nerves. Socioeconomic, epidemiological, and clinical data were collected. The following instruments were used in this evaluation: visual analogue pain scale (VAS), Douleur Neuropathique en 4 Questions (DN4), SALSA scale, and simplified neurological assessment protocol. The preoperative (PrO) and 180-day postoperative (PO180) results were compared. RESULTS: We evaluated 246 nerves from 90 patients: 56.6% were on multidrug therapy (MDT) and 43.3% discharged from MDT. Motor scores and pain intensity showed statistically significant improvement (p<0.01). There was an increase in sensory scores only for bilateral ulnar nerves (p<0.05). Of the operated cases, 26.0% of patients were referred for surgery of ulnar neuritis and 23.6% of tibial neuritis. Neuropathic pain was reported in 41% of cases. Daily dose of prednisone reduced from 39.6 mg (±3.0) in PrO, 16.3 mg (±5.2) in PO180, to 1.7 mg (±0.8) in LPO. The SALSA scale results showed mild activity limitation in 51% and moderate in 34% of patients. Eighty percent of individuals reported that the results reached their expectations. CONCLUSIONS: PNSD in leprosy was effective in the long term to decrease the prevalence and intensity of pain, improve motor function, and reduce the dose of corticosteroids, which is reflected in the patients' satisfaction.

Late follow-up of peripheral neural decompression in leprosy: functional and clinical outcomes / Seguimento tardio da descompressão neural periférica na hanseníase: resultados funcionais e clínicos

ABSTRACT Background: Peripheral neural surgical decompression (PNSD) is used as a complementary therapy to the clinical treatment of neuritis to preserve neural function. Objective: To evaluate the long-term (≥ 1 year) clinical and functional results for PNSD in leprosy neuritis. Methods: This cross-sectional study included leprosy patients who were in late postoperative period (LPO) of surgical decompression of ulnar, median, tibial, and fibular nerves. Socioeconomic, epidemiological, and clinical data were collected. The following instruments were used in this evaluation: visual analogue pain scale (VAS), Douleur Neuropathique en 4 Questions (DN4), SALSA scale, and simplified neurological assessment protocol. The preoperative (PrO) and 180-day postoperative (PO180) results were compared. Results: We evaluated 246 nerves from 90 patients: 56.6% were on multidrug therapy (MDT) and 43.3% discharged from MDT. Motor scores and pain intensity showed statistically significant improvement (p<0.01). There was an increase in sensory scores only for bilateral ulnar nerves (p<0.05). Of the operated cases, 26.0% of patients were referred for surgery of ulnar neuritis and 23.6% of tibial neuritis. Neuropathic pain was reported in 41% of cases. Daily dose of prednisone reduced from 39.6 mg (±3.0) in PrO, 16.3 mg (±5.2) in PO180, to 1.7 mg (±0.8) in LPO. The SALSA scale results showed mild activity limitation in 51% and moderate in 34% of patients. Eighty percent of individuals reported that the results reached their expectations. Conclusions: PNSD in leprosy was effective in the long term to decrease the prevalence and intensity of pain, improve motor function, and reduce the dose of corticosteroids, which is reflected in the patients' satisfaction.

RESUMO Antecedentes: A descompressão cirúrgica neural periférica (DCNP) é usada como uma terapia complementar ao tratamento clínico da neurite hansênica para preservar a função neural. Objetivo: Avaliar a longo prazo (≥ 1 ano) os resultados clínicos e funcionais da DCNP na neurite hansênica. Métodos: Este estudo transversal incluiu pacientes que estavam no pós-operatório tardio (POT) de cirurgia de descompressão dos nervos ulnares, medianos, tibiais e fibulares. Foram coletados dados socioeconômicos, epidemiológicos e clínicos. Os instrumentos utilizados foram: escala visual analógica de dor (EVA), questionário de dor neuropática 4 (DN4), escala SALSA e protocolo de avaliação neurológica simplificada. Os resultados obtidos foram comparados com os do pré-operatório (PrO) e pós-operatório de 180 dias (PO180). Resultados: Foram avaliados 246 nervos de 90 pacientes: 56,6% estavam em poliquimioterapia (PQT) e 43,3% em alta da PQT. Escores motores e intensidade da dor apresentaram melhora significante (p<0,01). Houve aumento nos escores sensitivos nos nervos ulnares bilaterais (p<0,05). Neurite ulnar foi indicação cirúrgica em 26,0% dos casos operados, seguida pela neurite tibial (23,6%). Dor neuropática foi relatada em 41% dos casos. Dose diária de prednisona reduziu de 39,6 mg (±3,0) na PrO, 16,3 mg (±5,2) na PO180, para 1,7 mg (±0,8) na POT. Escala SALSA mostrou limitação leve da atividade em 51% e moderada em 34% dos pacientes. 80% dos indivíduos relataram que os resultados atingiram suas expectativas. Conclusão: DCNP na hanseníase foi eficaz a longo prazo na redução da prevalência e intensidade da dor, na melhora da função motora e redução da dose de corticosteroides, refletindo na satisfação do paciente.

[The history and influence of Losheng Sanatorium in Taiwan area].

Losheng Sanatorium, as a prophylactic-therapeutic institution for isolation, treatment, rehabilitation and social control of leprosy patients, was established by the Japanese colonial government in Taiwan in 1930. Losheng Sanatorium effectively carried out the compulsory isolation of leprosy patients, under the assistance of the public medical system with the help of police and the Bao-Jia management in the Japanese colonial period in Taiwan. Losheng sanatorium imported DDS, a therapeutic drug for leprosy, popularised an outpatient treatment model of leprosy, and developed mobile medical services after the Second World War. Losheng detected and treated leprosy patients successfully through the support of special skin clinics in public hospitals and missionary hospitals after Multi-drug Therapy was introduced in Taiwan in 1984. The Department of Health, Executive Yuan of the Taiwan area in commenced administration of Losheng Sanatorium in 1999 transformed it into a community-based general hospital. Losheng sanatorium adopted different control strategies in different historical periods based on the requirements of health, epidemic prevention systems and leprology developments to achieve its goals of leprosy control. The Sanatorium provides an example to understand and further study epidemical control and public health practice in the Taiwan area.

Post-exposure prophylaxis (PEP) efficacy of rifampin, rifapentine, moxifloxacin, minocycline, and clarithromycin in a susceptible-subclinical model of leprosy.

BACKGROUND: Subclinical infection with Mycobacterium leprae is one potential source of leprosy transmission, and post-exposure prophylaxis (PEP) regimens have been proposed to control this source. Because PEP trials require considerable investment, we applied a sensitive variation of the kinetic mouse footpad (MFP) screening assay to aid in the choice of drugs and regimens for clinical trials. METHODOLOGY/PRINCIPAL FINDINGS: Athymic nude mice were inoculated in the footpad (FP) with 6 x 103 viable M. leprae and treated by gastric gavage with a single dose of Rifampin (SDR), Rifampin + Ofloxacin + Minocycline (SD-ROM), or Rifapentine + Minocycline + Moxifloxacin (SD-PMM) or with the proposed PEP++ regimen of three once-monthly doses of Rifampin + Moxifloxacin (RM), Rifampin + Clarithromycin (RC), Rifapentine + Moxifloxacin (PM), or Rifapentine + Clarithromycin (PC). At various times post-treatment, DNA was purified from the FP, and M. leprae were enumerated by RLEP quantitative PCR. A regression analysis was calculated to determine the expected RLEP value if 99.9% of the bacilli were killed after the administration of each regimen. SDR and SD-ROM induced little growth delay in this highly susceptible murine model of subclinical infection. In contrast, SD-PMM delayed measurable M. leprae growth above the inoculum by 8 months. The four multi-dose regimens delayed bacterial growth for >9months post-treatment cessation. CONCLUSIONS/SIGNIFICANCE: The delay in discernable M. leprae growth post-treatment was an excellent indicator of drug efficacy for both early (3-4 months) and late (8-9 months) drug efficacy. Our data indicates that multi-dose PEP may be required to control infection in highly susceptible individuals with subclinical leprosy to prevent disease and decrease transmission.

Hypovitaminosis D and reduced cathelicidin are strongly correlated during the multidrug therapy against leprosy.

Mycobacterium leprae infection depends on the competence of the host immune defense to induce effective protection against this intracellular pathogen. The present study investigated the serum levels of vitamin D and the antimicrobial peptide cathelicidin, to determine the statistical correlation between them in leprosy patients before and post-six months of multidrug therapy (MDT), household contacts, and healthy individuals. Previous studies associated these molecules with high risks to develop mycobacterial diseases, such as tuberculosis and leprosy. A total of 34 leprosy patients [paucibacillary (n = 14), multibacillary (n = 20)], and 25 household contacts were recruited. Eighteen healthy adults were selected as a control group. Serum concentrations of vitamin D (25(OH)VD3) and cathelicidin were measured using high-performance liquid chromatography (HPLC), and an enzyme-linked immunosorbent assay (ELISA) kit, respectively. There were no significant differences in serum levels of 25(OH)VD3 between all groups, and the overall prevalence rate of vitamin D deficiency was 67.1%. Cathelicidin levels were significantly lower in both untreated and treated patients when compared to controls and household contacts (p < 0.05). Strong correlations between hypovitaminosis D and reduced cathelicidin in untreated (r = 0.86) and post-six months of MDT (r = 0.79) leprosy patients were observed. These results suggest that vitamin D status and cathelicidin levels are strongly correlated during multidrug therapy for leprosy and nutritional supplementation from the beginning of treatment could strengthen the immune response against leprosy.

Evidence for Mycobacterium leprae Drug Resistance in a Large Cohort of Leprous Neuropathy Patients from India.

Resistance to anti-leprosy drugs is on the rise. Several studies have documented resistance to rifampicin, dapsone, and ofloxacin in patients with leprosy. We looked for point mutations within the folP1, rpoB, and gyrA gene regions of the Mycobacterium leprae genome predominantly in the neural form of leprosy. DNA samples from 77 nerve tissue samples were polymerase chain reaction (PCR)-amplified for M leprae DNA and sequenced for drug resistance-determining regions of genes rpoB, folP1, and gyrA. The mean age at presentation and onset was 38.2 ± 13.4 (range 14-71) years and 34.9 ± 12.6 years (range 10-63) years, respectively. The majority had borderline tuberculoid leprosy (53 [68.8%]). Mutations associated with resistance were identified in 6/77 (7.8%) specimens. Mutations seen were those associated with resistance to rifampicin, ofloxacin, and dapsone. All the six patients were drug-naive. The clinical and pathological manifestations in this group did not differ from the drug-sensitive group. This study highlights the occurrence of resistance to the standard multidrug therapy and ofloxacin in leprosy. Among the entire cohort, 1/77 (1.3%) showed resistance to rifampicin, 2/77 (2.6%) to dapsone, and 5/77 (6.4%) to ofloxacin. Six new patients showing infection by mutant strains indicated the emergence of primary resistance. Resistance to ofloxacin could be due to frequent use of quinolones for many bacterial infections. The results of the study indicate the need for development of a robust and strict surveillance system for detecting drug resistance in leprosy in India.

Patients help other patients: Qualitative study on a longstanding community cooperative to tackle leprosy in India.

BACKGROUND: Although leprosy is portrayed as a disappearing disease, leprosy affected persons in India are still suffering massively. Even further, nearly 60% of the world's newly detected cases are appearing from India alone. The problem has exacerbated due to the drastic decrease of global funding after India's official declaration of 'elimination', which did not foster the actual pain of patients beyond prevalence. Leprosy patients have hardships in their lives due to disabilities, stigma and poverty; thus, they require sustained, continuous care even after release from treatment. Yet, current interventions mostly have a vertical, short-term approach, not showing much progress in lightening the burden of leprosy. In contrast, Little Flower Hospital Community (LFHC) in India has been remarkably providing holistic care for thousands of leprosy patients for 35 years. However, there has not been any research conducted to uncover the underlying factors of this longstanding leprosy control model. Therefore, this research explores the in-depth contextual attributes of this hospital community that has been able to successfully provide sustainable care for a long time even without excessive external funds. METHODS AND FINDINGS: This qualitative research used a grounded theory approach, involving 28 in-depth interviews of 11 patients, 13 workers, and 4 board members from the hospital. The interview data were inductively analyzed to examine the contextual factors of the hospital's sustainability. Open coding, axial coding and selective coding were conducted, and Glaser's Six C's model was used to create a theoretical model of the sustainability of LFHC. The fundamental cause of the sustainability was the leprosy patients' strong craving for life with dignity, despite the isolation from the society. The desire resulted in a bottom-up formation of a 'consumer-provider cooperative', where patients mutually support each other with basic treatment learned from experience. The profits earned from the patients' occupational efforts such as dairy farming, cover the costs needed to manage the hospital community, which contributes to economical sustainability. Social sustainability was established through the holistic care including psychosocial, educational, medical, and residential support. The wholesome care socially rehabilitated the patients to be included in the society with satisfaction, social justice and social cohesion. The main limitation of this study is that this study cannot be generalized due to the nature of Grounded Theory based study. CONCLUSIONS: This study investigated the determinants that made LFHC sustainable, and the findings suggested the importance of forming a cooperative community and implementing social rehabilitation for sustainable leprosy control. More exploration on transferring this model to other leprosy colonies will have great impact in maintaining sustainable care for leprosy patients. Furthermore, this research may highlight the importance of sustainable development in policies targeting neglected tropical diseases beyond leprosy as well.

[From relief to life, the last memory of leprosy sanatorium: investigation and patient interview in Wukang sanatorium].

Zhejiang Wukang sanatorium evolved from Hangchow C. M.S. Hospital, which was founded in 1887. It is the leprosy prevention and treatment center of Zhejiang Province after the founding of the People's Republic of China. Most of the leprosy patients (convalescents)in sanatoriums entered the hospital successively in 1960s. Due to the limitation of dapsone monotherapy and the poor living conditions, the convalescents need to receive long-term isolation treatment and engage in collective production. After the implementation of Reform and Opening-up policy, the leprosy patients' health care has been greatly improved. The leprosy prevention and treatment course has been gradually reduced; the widespread knowledge of leprosy gradually freed leprosy patients from the dilemma of being stigmatized. In the post-leprosy era, Wukang sanatorium changed from the original focus on disease treatment to strengthening the psychological construction of patients. Its function changed from isolation and prevention to rest and pension, and the status of leprosy patients changed from "patients" to "convalescents" . These changes reflect the humanistic care and guidance of destigmatization in the process of leprosy isolation and epidemic prevention from prevention to treatment to the aged.

Neutrophil extracellular traps contribute to the pathogenesis of leprosy type 2 reactions.

Up to 50% of patients with the multibacillary form of leprosy are expected to develop acute systemic inflammatory episodes known as type 2 reactions (T2R), thus aggravating their clinical status. Thalidomide rapidly improves T2R symptoms. But, due to its restricted use worldwide, novel alternative therapies are urgently needed. The T2R triggering mechanisms and immune-inflammatory pathways involved in its pathology remain ill defined. In a recent report, we defined the recognition of nucleic acids by TLR9 as a major innate immunity pathway that is activated during T2R. DNA recognition has been described as a major inflammatory pathway in several autoimmune diseases, and neutrophil DNA extracellular traps (NETs) have been shown to be a prime source of endogenous DNA. Considering that neutrophil abundance is a marked characteristic of T2R lesions, the objective of this study was to investigate NETs production in T2R patients based on the hypothesis that the excessive NETs formation would play a major role in T2R pathogenesis. Abundant NETs were found in T2R skin lesions, and increased spontaneous NETs formation was observed in T2R peripheral neutrophils. Both the M. leprae whole-cell sonicate and the CpG-Hlp complex, mimicking a mycobacterial TLR9 ligand, were able to induce NETs production in vitro. Moreover, TLR9 expression was shown to be higher in T2R neutrophils, suggesting that DNA recognition via TLR9 may be one of the pathways triggering this process during T2R. Finally, treatment of T2R patients with thalidomide for 7 consecutive days resulted in a decrease in all of the evaluated in vivo and ex vivo NETosis parameters. Altogether, our findings shed light on the pathogenesis of T2R, which, it is hoped, will contribute to the emergence of novel alternative therapies and the identification of prognostic reactional markers in the near future.

Diet and nutrition: An important risk factor in leprosy.

Leprosy, once considered as poor man's disease may cause severe neurological complications and physical disabilities. Classification of leprosy depends upon the cell mediated and humoral immune responses of the host, from tuberculoid to lepromatous stage. Current therapy to prevent the disease is not only very lengthy but also consists of expensive multiple antibiotics in combination. Treatment and the duration depend on the bacillary loads, from six months in paucibacillary to a year in multibacillary leprosy. Although as per WHO recommendations, these antibiotics are freely available but still out of reach to patients of many rural areas of the world. In this review, we have focused on the nutritional aspect during the multi-drug therapy of leprosy along with the role of nutrition, particularly malnutrition, on susceptibility of Mycobacterium leprae and development of clinical symptoms. We further discussed the diet plan for the patients and how diet plans can affect the immune responses during the disease.

Contextual analysis of health care at discharge in leprosy: an integrative review. / Análise contextual da atenção à saúde na alta em hanseníase: uma revisão integrativa.

OBJECTIVE: To analyze contextual relations of health care in the discharge of leprosy. METHOD: An analytical, reflexive study based on the theoretical framework of context analysis, elaborated through an integrative review of literature in the databases SCOPUS, PUBMED, LILACS, SCIELO and BDENF, with uncontrolled descriptors Leprosy and Patient Discharge, obtaining 14 publications. RESULTS: The immediate context addresses health care at discharge in leprosy; the specific context treats leprosy as a public health problem; the symbolic conceptions and marks involving leprosy are encompassed by the general context; and in the metacontext are described the health programs and policies that subsidize the care of leprosy patients. CONCLUSION: The contextual elements emphasize the need to guarantee universal coverage of cases of leprosy, from diagnosis to the post-discharge, reinforcing leprosy as a public health problem. Despite the limitations of the bibliographic studies, these have relevance for the health area.

Análise contextual da atenção à saúde na alta em hanseníase: uma revisão integrativa / Análisis contextual de la atención a la salud en el alta en lepra: una revisión integradora / Contextual analysis of health care at discharge in leprosy: an integrative review

Resumo OBJETIVO Analisar as relações contextuais da atenção à saúde na alta em hanseníase. MÉTODO Estudo analítico pautado no referencial teórico de análise do contexto, elaborado mediante revisão integrativa de literatura nas bases de dados SCOPUS, PUBMED, LILACS, SCIELO e BDENF, com descritores Hanseníase e Alta do Paciente, obtendo-se 14 publicações. RESULTADOS O contexto imediato aborda a atenção em saúde na alta em hanseníase; o contexto específico trata da hanseníase como problema de saúde pública; as concepções simbólicas que envolvem a hanseníase são abarcadas pelo contexto geral; e no metacontexto estão descritos programas e políticas de saúde que subsidiam o atendimento à pessoa com hanseníase. CONCLUSÃO Os elementos contextuais ressaltam a necessidade de garantir a atenção em saúde para os casos de hanseníase, do diagnóstico até o pós-alta, reconhecendo a hanseníase como problema de saúde pública. Apesar das limitações dos estudos bibliográficos, estes possuem relevância para a área da saúde.

Resumen OBJETIVO Analizar las relaciones contextuales de la atención a la salud en el alta en lepra. MÉTODO Estudio analítico, pautado en el referencial teórico de análisis del contexto, elaborado mediante revisión integrativa de literatura en las bases de datos SCOPUS, PUBMED, LILACS, SCIELO y BDENF, con descriptores Lepra y Alta del Paciente, obteniendo 14 publicaciones. RESULTADOS El contexto inmediato aborda la atención en salud en el alto en lepra; el contexto específico trata de la lepra como problema de salud pública; las concepciones simbólicas que envuelven la lepra son abarcadas por el contexto general; y en el metacontexto se describen los programas y políticas de salud. CONCLUSIÓN Los elementos contextuales resaltan la necesidad de garantizar cobertura universal casos de lepra, del diagnóstico hasta el post-alta, reforzando la hanseniasis como problema de salud. A pesar de las limitaciones de los estudios bibliográficos, éstos tienen relevancia para el área de la salud.

Abstract OBJECTIVE To analyze contextual relations of health care in the discharge of leprosy. METHOD An analytical, reflexive study based on the theoretical framework of context analysis, elaborated through an integrative review of literature in the databases SCOPUS, PUBMED, LILACS, SCIELO and BDENF, with uncontrolled descriptors Leprosy and Patient Discharge, obtaining 14 publications. RESULTS The immediate context addresses health care at discharge in leprosy; the specific context treats leprosy as a public health problem; the symbolic conceptions and marks involving leprosy are encompassed by the general context; and in the metacontext are described the health programs and policies that subsidize the care of leprosy patients. CONCLUSION The contextual elements emphasize the need to guarantee universal coverage of cases of leprosy, from diagnosis to the post-discharge, reinforcing leprosy as a public health problem. Despite the limitations of the bibliographic studies, these have relevance for the health area.

An enhanced regimen as post-exposure chemoprophylaxis for leprosy: PEP+.

The ongoing transmission of Mycobacterium (M.) leprae reflected in a very slow decline in leprosy incidence, forces us to be innovative and conduct cutting-edge research. Single dose rifampicin (SDR) as post-exposure prophylaxis (PEP) for contacts of leprosy patients, reduces their risk to develop leprosy by 60%. This is a promising new preventive measure that can be integrated into routine leprosy control programmes, as is being demonstrated in the Leprosy Post-Exposure Programme that is currently ongoing in eight countries.The limited (60%) effectiveness of SDR is likely due to the fact that some contacts have a preclinical infection beyond the early stages for which SDR is not sufficient to prevent the development of clinical signs and symptoms of leprosy. An enhanced regimen, more potent against a higher load of leprosy bacteria, would increase the effectiveness of this preventive measure significantly.The Netherlands Leprosy Relief (NLR) is developing a multi-country study aiming to show that breaking the chain of transmission of M. leprae is possible, evidenced by a dramatic reduction in incidence. In this study the assessment of the effectiveness of an enhanced prophylactic regimen for leprosy is an important component. To define the so called PEP++ regimen for this intervention study, NLR convened an Expert Meeting that was attended by clinical leprologists, public health experts, pharmacologists, dermatologists and microbiologists.The Expert Meeting advised on combinations of available drugs, with known efficacy against leprosy, as well as on the duration of the intake, aiming at a risk reduction of 80-90%. To come to a conclusion the Expert Meeting considered the bactericidal, sterilising and bacteriostatic activity of the potential drugs. The criteria used to determine an optimal enhanced regimen were: effectiveness, safety, acceptability, availability, affordability, feasibility and not inducing drug resistance.The Expert Meeting concluded that the enhanced regimen for the PEP++ study should comprise three standard doses of rifampicin 600 mg (weight adjusted when given to children) plus moxifloxacin 400 mg given at four-weekly intervals. For children and for adults with contraindications for moxifloxacin, moxifloxacin should be replaced by clarithromycin 300 mg (weight adjusted).

Efectos colaterales de antibacilares en pacientes con enfermedad de Hansen / No disponible

Introducción: La Organización Mundial de la Salud (OMS) recomendó el uso de la poliquimioterapia (PQT) desde 1981, y desde 1998 esta pauta de tratamiento fue introducida en Paraguay. Desde ese entonces y hasta la actualidad el esquema Multibacilar (MB) comprende tres drogas: rifampicina, clofazimina y dapsona, y, el esquema Paucibacilar (PB), dos drogas: rifampicina y dapsona. Todas ellas relacionadas en mayor o menor medida a efectos colaterales. A pesar de ello, hay pocos estudios a nivel mundial, y ningún estudio en el Paraguay. Métodos: Estudio retrospectivo, observacional, de corte transversal con componente analítico, llevado a cabo en la Cátedra de Dermatología del Hospital de Clínicas - Universidad Nacional de Asunción, en San Lorenzo, Paraguay. En el periodo de enero de 2013 a octubre de 2017. Resultados: Fueron incluidos en el estudio 58 pacientes con enfermedad de Hansen, de los cuales 45 (78%) presentaron al menos un efecto colateral a la PQT, 3 pacientes presentaron más de un efecto colateral. De los 45, 25 (56%) fueron del sexo masculino y 20 (44%) del sexo femenino. En cuanto a la distribución por rango de edad: Dos (4%) en menores de 18 años, 8 (18%) de 19 a 30 años, 27 (18%) de 31 a 59 años y 8 (18%) 60 y más años. Seis (3%) pacientes de procedencia rural y 39 (87%) de procedencia urbana. Cuarenta y siete (98%) casos de efectos colaterales hematológicos (Anemia: 45; leucopenia: 1 y trombocitopenia: 1) y 1 (2%) caso de efecto colateral gastrointestinal (hepatitis). La conducta en casos de anemia: suplementación con hierro y ácido fólico: 40, suspensión de dapsona: 10 y ninguna conducta: 6 suspensión de la dapsona en 1 caso de leucopenia, suspensión de la dapsona en 1 caso de trombocitopenia y suspensión de la rifampicina en 1 caso de hepatitis. En 26 (58%) pacientes los efectos colaterales se presentaron al mes del inicio de la PQT, en 15 (33%) pacientes entre 2 y 5 meses del inicio y en 4 (9%) pacientes a los 6 y más meses del inicio. En 14 (31%) de los pacientes con efectos colaterales existía comorbilidad y en 31 (69%) casos, eran pacientes sanos. De los 45 pacientes, 41 (91%) estaban en tratamiento MB, 4 (9%) en tratamiento PB. Conclusión: La mayoría de los pacientes incluidos en el estudio presentaron efectos colaterales. Los hombres fueron los más afectados, el rango etario en el cual se presentaron con mayor frecuencia fue entre los 31 y 59 años. La mayoría procedían del medio urbano. Los efectos colaterales más frecuentes fueron los hematológicos y, de entre ellos, la anemia. Ante tal situación la medida más frecuentemente adoptada fue la suplementación con hierro y ácido fólico. En la mayoría de los casos los efectos colaterales aparecieron en el primer mes de recibir la medicación. Aquellos pacientes que recibieron PQT MB presentaron la mayor frecuencia de efectos colaterales

Introduction: The World Health Organization (WHO) recommends the implementation of multidrug (MDT) since 1981, and this régimen was introduced in Paraguay in 1998. The MDT administrate three drugs: rifampicin, clofazimine and dapsone to multibacillary patients (MB) and only two: rifampicina and dapsone to paucibacillary patients (PB). All the drugs have some adverse effects. But very few statistics have been carried out in the world on this matter and none at all in Paraguay. Methods: The work is a retrospective, observational, cross-sectional and analytical study carried out at Catedra de Dermatología del Hospital de Clínicas-Universidad Nacional de Asunción, San Lorenzo, Paraguay between January 2013 and October 2017. Results: Fifty eight leprosy patients were registered in the study and 45 (78%) presented at least one adverse effect to the MDT and 3 patients presented more tan one. 25/45 were men and 20 (44%) women. The age distributions were: Two (4%) less than 18 years old, 8 (18%) between 19-30 years old, 27(18%) 31-59 years old and 8 (18%) 60 and older. Six (3%) lived in rural setting and 39 (87%) urban. Forty seven (98%) presented adverse hematological effects (anemia: 45, leucopenia: 1 and thrombocytopenia:1) and 1 (2%) presented a gastrointestinal effect. Forty patients with anemia received iron and folic acid supplements and 6 cases with no modifications. There was 1 case leucopenia, 1 thrombocytopenia, and 1 hepatitis due to rifampicine. In 26 patients (58%) adverse effects were detected during first month of MDT, in 15 (33%) between 2-5 of treatment and in 4 (9%) patients after 6 or more months of treatment. Fourteen (31%) patients had comorbility and 31 (69%) were healthy patients. Forty one (91%) patients were receiving MB MDT and 4 (9%) PB MDT. Conclusions: The mayority of the patients in the study presented adverse effects. Men were the most affected and the mayority were in the 31-59 years age group and from urban settings. Most of the effects were hematological and among them, anemia the most frequent. These cases were supplemented with iron and folic acid. Most adverse effects appeared during the first month of treatment and MB MDT group was the most affected