Management of patients with multidrug-resistant tuberculosis.

The emergence of multidrug-resistant tuberculosis (MDR-TB; defined as resistance to at least rifampicin and isoniazid) represents a growing threat to public health and economic growth. Never before in the history of mankind have more patients been affected by MDR-TB than is the case today. The World Health Organization reports that MDR-TB outcomes are poor despite staggeringly high management costs. Moreover, treatment is prolonged, adverse events are common, and the majority of affected patients do not receive adequate treatment. As MDR-TB strains are often resistant to one or more second-line anti-TB drugs, in-depth genotypic and phenotypic drug susceptibility testing is needed to construct personalised treatment regimens to improve treatment outcomes. For the first time in decades, the availability of novel drugs such as bedaquiline allow us to design potent and well-tolerated personalised MDR-TB treatment regimens based solely on oral drugs. In this article, we present management guidance to optimise the diagnosis, algorithm-based treatment, drug dosing and therapeutic drug monitoring, and the management of adverse events and comorbidities, associated with MDR-TB. We also discuss the role of surgery, physiotherapy, rehabilitation, palliative care and smoking cessation in patients with MDR-TB. We hope that incorporating these recommendations into patient care will be helpful in optimising treatment outcomes, and lead to more MDR-TB patients achieving a relapse-free cure.

Surgical treatment of spondylitis and diaphragm relaxation in patient less than 1 year old.

DESIGN: Case report. INTRODUCTION: The combination of severe post-infectious kyphosis and diaphragm relaxation is extremely rare in patient early than 1 year old. Its no publications concerning their simultaneous surgical treatment. CASE DESCRIPTION: 7-Month-old girl had simultaneous spinal reconstruction with anterior and posterior instrumentation and plastic of diaphragm because of sequelae of non-granulenatous spondylitis complicated by severe kyphosis (54°) and diaphragm relaxation. Between 1.5 and 3 months of live she had several infections incl. pneumonia, enterocolitis, ENT infection. Anterior fusion was done by titanium mesh with auto-rib, posterior - by compressive rods based on low-profile hooks. The deformity was reduced till 20°. 2.5 years after initial surgery and 1 year after removal of posterior instrumentation the adequate level of diaphragm and minimal (4°) loss of kyphosis correction were identified. CONCLUSIONS: The combination of spondylitis and diaphragm relaxation in early aged patient could be explained but it could not be confirmed as a sequelae of late-onset neonatal sepsis with a multi-focal lesions. The simultaneous surgery provided on the combined approaches (trans-thoracic and posterior) looks as optimal options in such combination of pathologies. In remains controversial how will the spine develop after so early reconstructive surgery, including in situ stable anterior fusion carried out by titanium mesh with auto-rib.