Multidisciplinary advisory teams to manage multidrug-resistant tuberculosis: the example of the French Consilium.

SETTING: The World Health Organization (WHO) recommends that multidrug-resistant tuberculosis (MDR-TB) treatment should be managed in collaboration with multidisciplinary advisory committees (consilia). A formal national Consilium has been established in France since 2005 to provide a centralised advisory service for clinicians managing MDR-TB and extensively drug-resistant (XDR-TB) cases.OBJECTIVE: Review the activity of the French TB Consilium since its establishment.DESIGN: Retrospective description and analysis of the activity of the French TB Consilium.RESULTS: Between 2005 and 2016, 786 TB cases or contacts of TB cases were presented at the French TB Consilium, including respectively 42% and 79% of all the MDR-TB and XDR-TB cases notified in France during this period. Treatment regimens including bedaquiline and/or delamanid were recommended for 42% of the cases presented at the French TB Consilium since 2009. Patients were more likely to be presented at the French TB Consilium if they were born in the WHO Europe Region, had XDR-TB, were diagnosed in the Paris region, or had resistance to additional drugs than those defining XDR-TB.CONCLUSION: The French TB Consilium helped supervise appropriate management of MDR/XDR-TB cases and facilitated implementation of new drugs for MDR/XDR-TB treatment.

[Adjuvant surgical resection for multidrug-resistant tuberculosis: A review]. / Chirurgie et tuberculose multi/ultrarésistante : une revue de la littérature réhabilite une intervention adjuvante à l'antibiothérapie chez des patients sélectionnés.

INTRODUCTION: The frequency of multi and extensively drug resistant pulmonary tuberculosis (MDR/XDR-TB) is increasing worldwide, with major issues related to treatment modalities and outcome. In this setting, the exact benefits associated with surgical resection are still unknown. METHODS: We performed a literature review to determine the indications, morbidity, mortality and bacteriological success associated with the surgical management of MDR/XDR-TB patients. RESULTS: Altogether, 177 publications dealing with surgical resection and MDR/XDR-TB have been analyzed, including 35 surgical series and 24 cohort studies summarized in one meta-analysis. The surgical series reported success rates from 47% to 100%, complication rates from 0 to 29%, and mortality rates from 0 to 8%. The published meta-analysis reported a statistically significant association between surgical resection and treatment success (OR 2.24, IC95% 1.68-2.97). However, all these studies were associated with selection bias. International consensual guidelines included a multidisciplinary assessment in a reference centre, a personalized and prolonged antibiotic treatment and a medico-surgical discussion on a case-to-case basis. PERSPECTIVES: These guidelines are now applied for the management of patients with MDR/XDR-TB in our centre. Further studies are required to avoid further increase in the burden of MDR/XDR-TB and to establish the optimal timing of medical and surgical treatments.

[Quality control of dose delivered by in vivo dosimetry: can one tolerance be used for all localizations?]. / Contrôle qualité de la dose délivrée par dosimétrie in vivo : un critère de tolérance unique peut-il satisfaire toutes les localisations ?

PURPOSE: In vivo dosimetry measurements are accepted when the difference between measured and calculated dose is under 5%. A statistical analysis has been conducted to determine whether this tolerance matched the clinical practice for the studied localizations: pelvis, thorax, head and neck, breast. MATERIALS AND METHODS: The technical characteristics of the detectors were checked before being used in clinical practice. Then an automatic statistical analysis was implemented using the 2450 in vivo dosimetry measurements obtained during 1 year. MAIN RESULTS: The global average is 1.10%, the standard deviation 2.46% and the percentage of out of level measurements 4.09%. By distinguishing the localizations, the 5% tolerance appeared to be too narrow for the breast localization. DISCUSSION/CONCLUSION: Several investigations were initiated to justify the modification of the tolerance for the breast localization. They highlighted an underestimation of the calculated dose when high beam angles are set: a new correction factor was defined to take account this error. A specific tolerance was also specified for the breast localization.