Adaptation and validation of a TB stigma scale for adolescents in Lima, Peru.

BACKGROUND: TB-related stigma contributes to poor clinical outcomes and reduced wellbeing for affected individuals. Adolescents may be particularly susceptible to TB-related stigma due to their heightened sensitivity to peer acceptance, yet few studies have evaluated TB-related stigma in this group. Without a validated scale, it remains challenging to measure TB-related stigma in adolescents.METHODS: We adapted and validated the Van Rie TB Stigma Scale (VTSS) for adolescents on treatment for rifampicin-susceptible TB in Lima, Peru. The modified stigma scale was administered within a larger survey, which measured other psychosocial factors, including depression, adverse childhood experiences (ACEs), and social support. Data analysis included factor analysis, internal consistency, and convergent validity.RESULTS: From October 2020 to September 2021, 249 adolescents (individuals aged 10-19 years) completed the survey. Preliminary confirmatory factor analysis led to removal of two items. The final 10-item scale demonstrated good internal consistency (Cronbach's α = 0.82) and adequate model fit (χ²/df = 2.0; root mean square error of approximation: 0.06; comparative fit index: 0.94; Tucker-Lewis Index: 0.92: standardized root mean square residual: 0.05). Stigma was positively correlated with ACEs (γ = 0.13), depression (γ = 0.39), and suicidal ideation (γ = 0.27), and negatively correlated with social support (γ = -0.19).CONCLUSION: This adolescent TB stigma scale may serve as a practical tool to measure TB-related stigma and evaluate the impact of stigma-reduction interventions in adolescents.

Clinical standards for drug-susceptible TB in children and adolescents.

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Uncovering reasons for treatment initiation delays among children with TB in Lima, Peru.

BACKGROUND: Timely diagnosis and treatment of pediatric tuberculosis (TB) is critical to reducing mortality but remains challenging in the absence of adequate diagnostic tools. Even once a TB diagnosis is made, delays in treatment initiation are common, but for reasons that are not well understood.METHODS: To examine reasons for delay post-diagnosis, we conducted semi-structured interviews with Ministry of Health (MoH) physicians and field workers affiliated with a pediatric TB diagnostic study, and caregivers of children aged 0-14 years who were diagnosed with pulmonary TB in Lima, Peru. Interviews were analyzed using systematic comparative and descriptive content analysis.RESULTS: We interviewed five physicians, five field workers and 26 caregivers with children who initiated TB treatment < 7 days after diagnosis (n = 15) or who experienced a delay of ≥7 days (n = 11). Median time in delay from diagnosis to treatment initiation was 26 days (range 7-117). Reasons for delay included: health systems challenges (administrative hurdles, medication stock, clinic hours), burden of care on families and caregiver perceptions of disease severity.CONCLUSION: Reasons for delay in treatment initiation are complex. Interventions to streamline administrative processes and tools to identify and support families at risk for delays in treatment initiation are urgently needed.

Performance of a household tuberculosis exposure survey among children in a Latin American setting.

OBJECTIVE: To evaluate the performance of a survey that quantifies the intensity of household tuberculosis (TB) exposure among children.METHODS: Children aged 0-14 years in Lima, Peru, with ≥1 signs and/or symptoms of TB and a history of contact with an adult TB patient were included. The 10-question survey was administered to caregivers and addressed sleep proximity, frequency of exposure, and infectiousness of the contact. Infection status was determined using tuberculin skin tests (TSTs). The exposure scale was evaluated for association with TST positivity using mixed-effects regression analyses.RESULTS: The exposure score was significantly associated with TST positivity (age-adjusted odds ratio [aOR] 1.14, 95%CI 1.02-1.28). We observed a stronger association with TST positivity in children aged ≤5 years; (aOR 1.23, 95%CI 1.07-1.41) and no association in children 6-14 years of age (aOR 0.99, 95%CI 0.82-1.20).CONCLUSION: This survey was easy to use and modestly successful in predicting TST positivity in children aged ≤5 years. It may be a useful resource for clinicians for diagnosing TB in children, and for national TB programs aiming to scale up preventive therapy initiatives.

Barriers to the treatment of childhood tuberculous infection and tuberculosis disease: a qualitative study.

SETTING: In 2012, Peru's National TB Program (NTP) reported approximately 2400 incident cases of tuberculosis (TB) disease in children aged <15 years. Peru's TB burden is concentrated in the Lima metropolitan area, particularly in poor districts such as El Agustino and La Victoria, where this study was conducted. OBJECTIVE: To identify barriers to the treatment of childhood tuberculous infection and TB disease in Lima from the perspective of front-line providers and patients' families. DESIGN: We conducted 10 semi-structured focus groups with 53 purposefully sampled primary care providers, community health workers, and parents/guardians of pediatric TB patients. We also completed nine in-depth interviews with National TB Program administrators and pulmonologists specializing in TB. Two authors performed inductive thematic analysis and identified emerging themes. RESULTS: Four main treatment barriers emerged from the data: 1) dosing errors, 2) time- and labor-intensive preparation and administration of medications, 3) provider concern that isoniazid preventive therapy (IPT) generates isoniazid resistance, and 4) poor adherence to IPT. CONCLUSION: Our findings highlight the urgent need for child-friendly formulations, provider and parent/guardian education about IPT, and strategies to promote adherence to IPT, including support and supervision by health workers and/or regimens with fewer doses.

Barriers to the diagnosis of childhood tuberculosis: a qualitative study.

SETTING: In 2012, Peru's National Tuberculosis Program (NTP) reported that children aged 0-14 years accounted for 7.9% of the country's tuberculosis (TB) incidence. This figure is likely an underestimate due to suboptimal diagnosis of childhood TB. OBJECTIVE: To identify barriers to childhood TB diagnosis in Lima, Peru. DESIGN: Using semi-structured guides, moderators conducted in-depth interviews with four NTP administrators and five pulmonologists specializing in TB and 10 focus groups with 53 primary care providers, community health workers (CHWs), and parents and/or guardians of pediatric TB patients. Two authors independently performed inductive thematic analysis and identified emerging themes. RESULTS: Participants identified five barriers to childhood TB diagnosis: ignorance and stigma among the community, insufficient contact investigation, limited access to diagnostic tests, inadequately trained health center staff, and provider shortages. CONCLUSION: Recent efforts to increase childhood TB detection have centered on the development of new technologies. However, our findings demonstrate that many diagnostic barriers are rooted in socio-economic and health system problems. Potential solutions include implementing multimedia campaigns and community education to reduce ignorance and stigma, prioritizing contact investigation for high-risk households, and training primary care providers and CHWs to recognize and evaluate childhood TB.

Outcome of off-pump coronary artery bypass in renal dialysis patients.

BACKGROUND: Renal dialysis patients are a subgroup at major operative risk when undergoing coronary artery bypass grafting (CABG). Even though CABG without cardiopulmonary bypass (CPB) has decreased the surgical risk and provided good short-term results, the long-term survival seems uncertain. We report here on the long-term outcome of CABG without CPB in renal dialysis patients. METHODS: From 1998 to 2002, 44 renal dialysis patients underwent elective CABG without CPB, including 17 minimally invasive direct coronary artery bypass (MIDCAB) and 27 off-pump CABG (OPCAB) procedures. There were 5 one-vessel, 12 two-vessel and 27 multi-vessel coronary artery disease patients, who mainly had left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) grafting with an additional saphenous vein graft to non-LAD coronaries. RESULTS: All 44 patients were followed up for 44.4 +/- 31.2 months. Three (6.8 %) surgical deaths within 30 days occurred and 25 late mortalities happened over a period of 2 - 79 months. The 5-year cumulative rate of total survival is 38.2 % and the freedom from cardiac death is 70.9 %. Using hazard analysis, old age (> 60 years) and incomplete coronary revascularization was found to significantly affect the total survival. CONCLUSIONS: CABG without CPB provided an acceptable surgical mortality and morbidity. The high incidence of non-cardiac death associated with dialysis complications had an adverse impact on the overall outcome. The LITA bypass operation method combined with intensive care for dialysis complications would hopefully fulfill the goal to improve the short- and long-term results in this subgroup.

Prenatal diagnosis and genetic counseling of mucopolysaccharidosis type II (Hunter syndrome).

We present prenatal diagnosis of mucopolysaccharidosis type II (MPS II) (Hunter syndrome) and demonstrate marked mucopolysaccharide deposition in multiple vital organs in a 22-gestational-week affected fetus. Level II ultrasound showed cardiomegaly and hepatomegaly. Histological examinations of the fetal vital organs manifested marked mucopolysaccharide deposition. We suggest that any therapeutic approach and counseling for prenatally diagnosed MPS II should consider the early signs of in utero marked mucopolysaccharide storage.

Effects of cue exposure on the subjective perception of alcohol dependents with different types of cue reactivity.

Thirty male alcohol-patients were divided into 3 subgroups with increased, unchanged, or reduced craving. Despite no significant difference at baseline, after cue-exposure, the increased craving subgroup showed significantly more confusion, insecurity, and anxiety, nevertheless, stronger beliefs in the positive effects of alcohol compared to the unchanged craving subgroup.

Lanthanum carbonate (Fosrenol) efficacy and tolerability in the treatment of hyperphosphatemic patients with end-stage renal disease.

AIMS: High serum phosphorus levels are a common problem in patients receiving long-term dialysis treatment. Lanthanum carbonate (Fosrenol) is a new non-aluminum, non-calcium phosphate binder developed for the treatment of hyperphosphatemia in patients with end-stage renal disease (ESRD). We report data from a recent trial, which, for the first time, assessed the efficacy and tolerability of lanthanum carbonate treatment, compared with placebo, in Chinese patients with ESRD. PATIENTS AND METHODS: Following a one- to three-week washout phase and a four-week, open-label lanthanum carbonate dose-titration phase, male and female hemodialysis patients were randomized (1:1) to receive either lanthanum carbonate or placebo for four weeks. The primary efficacy parameter of the study was the control of serum phosphorus levels (< or =1.8 mmol/l [< or = 5.6 mg/dl]). Secondary endpoints included the profile of serum phosphorus during titration and parathyroid hormone, calcium, and calcium x phosphorus (Ca x P) product levels. The safety and tolerability of lanthanum carbonate were assessed by monitoring adverse events throughout the study. RESULTS: Mean serum phosphorus level at the end of washout was 2.5 +/- 0.5 mmol/l (7.7 +/- 1.5 mg/dl; n=73), and there was no evidence of a difference in levels between the treatment groups pre-randomization. At the end of the study, lanthanum carbonate-treated patients had significantly lower phosphorus levels (1.6 +/- 0.5 mmol/l [5.1 +/- 1.5 mg/dl]; n=30) than those receiving placebo (2.3 +/- 0.4 mmol/l [7.2 +/- 1.3 mg/dl]; n=31; p < 0.001). In addition, a significantly higher proportion of patients receiving lanthanum carbonate had controlled serum phosphorus levels (60%) compared with the placebo group (10%; p < 0.001). Ca x P product levels were also significantly lower in the lanthanum carbonate group at the end of randomized treatment (p < 0.001). Lanthanum carbonate was well tolerated; only one serious adverse event was reported, which was unrelated to treatment. CONCLUSIONS: Lanthanum carbonate was shown to be an effective and well-tolerated phosphate binder for the treatment of hyperphosphatemia in Chinese patients with ESRD. This finding supports the results of previous US and European studies, which have also shown that lanthanum carbonate treatment effectively controls serum phosphorus levels.

Reduction in erythropoietin doses by the use of chronic intravenous iron supplementation in iron-replete hemodialysis patients.

BACKGROUND: Iron deficiency is the most common cause of suboptimal response to recombinant human erythropoietin (rHuEPO) in chronic hemodialysis (HD) patients. Iron supply can correct this situation, however, optimal dosage, route of administration, and monitoring of iron status during rHuEPO therapy in maintenance HD patients remains controversial. METHODS: We conducted a 12-month intravenous iron substitution trial in 149 iron-replete chronic HD patients receiving subcutaneous rHuEPO therapy. The available iron pool was maintained with 100 mg iron every 2 weeks or 1 month depending on serum ferritin and transferrin saturation levels, the rHuEPO dosage titrated depending on hematocrit (Hct) levels. RESULTS: After 12-month protocol, the Hct increased (28.7 +/- 4.1 vs 27.7 +/- 2.6, p = 0.003), rHuEPO requirement reduced 25% (46.1 +/- 28.9 vs 61.5 +/- 67.8 U/kg/week, p = 0.006), serum ferritin increased (1,383 +/- 727 vs 930 +/- 857 ng/ml, p < 0.001), so did the transferrin saturation (36.1 +/- 12.7 vs 27.5 +/- 12.8%, p < 0.001). The serum albumin decreased slightly but reached statistical significance (4.1 +/- 0.48 vs 4.2 +/- 0.36 g/dl, p = 0.006), so did the cholesterol levels (166 +/- 41 vs 173 +/- 38 mg/dl, p = 0.044) and pre-dialysis creatinine (11.3 +/- 2.3 vs 11.5 +/- 2.4 mg/dl, p = 0.015). Besides, the iPTH levels did not interfere with the rHuEPO dosage reduction and Hct increment in our patients. CONCLUSION: We conclude that maintaining high levels of serum ferritin and transferrin saturation could further reduce the requirement of rHuEPO in chronic HD patients, but the long-term effect of iron overloading to patients' nutritional status must be further evaluated in contrast to the economic saving.

Role of aggressivity on reactivity and craving before and after cue exposure in recently detoxified alcoholics: results from an experimental study.

The role of aggressivity and cue exposure in induction of craving were investigated in a clinical setting. Thirty abstinent alcoholic patients were divided into a low and a high aggressive group based on scores on the physical aggression subscale of the Buss-Durkee Hostility Inventory and exposed to alcohol cues. Craving was measured by means of the Alcohol Craving Questionnaire (ACQ) and Visual Analogue Scales (VAS). Important findings are: (1) main effects of aggressivity on 'emotionality', 'purposefulness' and 'expectancy' of ACQ were very significant; (2) on 'drinking intention' and 'craving for alcohol' of VAS, aggressivity and cue exposure showed a significant interaction; (3) the main effect of cue exposure on heart rate also reached a significance level of 0.007. The results were discussed in the context of the Classical, Operant Conditioning Theory, the Cognitive Craving Theory of Tiffany, Gilbert's STAR Model, and the Self-Medication Hypothesis.

The impact of diabetes on economic costs in dialysis patients: experiences in Taiwan.

Diabetes mellitus carries a great burden on healthcare costs due to its growing population and high co-morbidity. This adverse effect sustains even when patients develop end-stage renal disease (ESRD). We here present data showing the effect of diabetes on economic costs in dialysis therapy in Taiwan. As of the end of 1997, we have 22,027 ESRD patients with a prevalence and incidence rate of 1013 and 253 per million populations, respectively. Diabetic nephropathy is the second most common cause of the underlying renal diseases, but accounts for 24.8% of the prevalent patients and 35.9% of the incident cases. The diabetic patients engendered 11.8% more expense for care of dialysis than the non-diabetic patients (US $26,988 vs. US $24,146 per patient-year). Higher inpatient cost mainly account for the difference. As compared to non-diabetic patients, the diabetic patients had 3.5 times more inpatients costs (US $1325 vs. US $4677 per patient-year), and higher proportion of inpatient-to-annualized cost ratio (5.5 vs. 17.3%) resulting from their more frequent hospitalization (0.59 vs. 1.13 times per patient-year) and longer hospital stay (6.7 vs. 18.9 days per patient-year). The major causes responsible for a more frequent hospitalization were cardiovascular disease, poorly controlled hyperglycemia, sepsis and failure of vascular access. The annualized costs for care of dialysis patients in Taiwan, including inpatient and outpatient costs, averaged US $25,576 per patient-year. This value is approximately half of that in most of the western countries and Japan. Thus, a more cost-effective way to achieve savings is to reduce the high incidence rate of dialysis population and to maximize the quality of dialysis treatment for avoiding hospitalization. Recent studies had shown that tight blood pressure control, intensive glycemic control, and use of angiotensin converting enzyme inhibitors in diabetic patients significantly reduced not only the rate of progressive renal failure, but also substantially reduced the cost of complications and led to higher cost effectiveness. Once diabetic patients reach stage of ESRD, an optimized pre-ESRD care and consideration of kidney transplantation are essential in terms of better patient survival and cost savings.

Fibrillary glomerulonephritis.

The occurrence of fibrillary glomerulonephritis is unusual in Taiwan, whereas it occurs in approximately 1% of renal biopsy specimens taken in the United States of American. This disease is characterized by extracellular randomly arranged non-branching Congo red-negative microfibrils within glomeruli. The microfibrils are less than 30 nm in diameter, and electron microscopy is essential for diagnosis. Differential diagnosis of the deposition of extracellular non-branching microfibrils within glomeruli is important because discrete diseases have different therapeutic and prognostic implications. The report will discuss two cases of biopsy-proved fibrillary glomerulonephritis who presented with proteinuria, hematuria, renal insufficiency, and hypertension. It is noteworthy that the renal function persistently went downhill, even though the physician treated the patients with corticosteroids, pulse treatment and immunosuppressive agents.

Rapidly progressive interstitial renal fibrosis associated with Chinese herbal medications.

BACKGROUND/AIM: Nephropathy after ingestion of Chinese herbs is known as a rapidly progressive form of interstitial renal fibrosis after a slimming regimen containing aristolochic acid that was identified first in Belgium. Intake of traditional Chinese herbal medicines is very popular in Taiwan. So we looked for similar cases in our hospital. METHODS: From 1994 to 1998, we observed 20 Taiwanese patients who underwent renal biopsy for rapidly progressive renal failure of unknown origin. The medical history of these patients gave no clue to the origin of renal impairment, except for the administration of Chinese herbs before the development of renal failure in all cases. RESULTS: Although these patients took herbal medications from various sources for different purposes, their renal biopsy specimens showed strikingly similar histological patterns: extensive paucicellular interstitial fibrosis and tubular atrophy, but the glomeruli were apparently intact. They also had similar clinical features, such as a nearly normal blood pressure, obvious anemia, insignificant edema, low-grade proteinuria, and glucosuria. The renal function declined rapidly in most cases; 15 patients underwent dialysis within 3 months of renal biopsy, and 7 patients received emergency dialysis when they first came to our hospital. On clinical and morphological grounds, the nephropathy in our patients appears similar to Chinese herb nephropathy. CONCLUSIONS: Because of the diversity of the herbal regimens used, in addition to aristolochic acid, other unidentified phytotoxins may also play a role in this particular disease entity. There is a strong relation between rapidly progressive interstitial renal fibrosis and the consumption of Chinese herbs.

Low molecular weight heparin in hemodialysis patients with a bleeding tendency.

Efficacy and safety of a low-molecular-weight heparin (LMWH) were studied in 33 stable maintenance hemodialysis patients who had a bleeding tendency on unfractionated heparin. The optimal dose of LMWH for each patient was titrated before the study; the mean total LMWH dosage was 1,152 +/- 574 IU. No major bleeding or clot formation was noted in a total of 2,470 hemodialysis sessions during 6 months of LMWH administration. The mean value of plasma anti-factor Xa (anti-Xa) activity increased from 0.05 +/- 0.03 IU/ml before dialysis to 0.34 +/- 0.28 IU/ml after 2 h of dialysis and returned to 0.15 +/- 0.09 IU/ml after 4 h of dialysis; the mean activated partial thromboplastin time was 26.1 +/- 4.4 s before dialysis, 30.7 +/- 9.5 s (an 18% increase) after 2 h of dialysis, and 26.2 +/- 4.4 s after 4 h of dialysis. No significant change in serum antithrombin levels was noted throughout the whole study period. We conclude that a low dosage of LMWH is safe and effective in hemodialysis patients who have a risk of bleeding with unfractionated heparin. Serum anti-Xa activity is better than activated partial thromboplastin time and antithrombin in assessing the optimal dose of LMWH. A plasma anti-Xa activity of 0.37 IU/ml after 2 h of hemodialysis may represent an optimal dosage of LMWH for most patients.