Delay before drug susceptibility testing among patients with presumptive multidrug-resistant tuberculosis in Gujarat, India.

Background: Reducing delay in the diagnosis of multidrug-resistant tuberculosis (MDR-TB) by performing genotypic drug susceptibility testing (DST) among eligible patients as early as possible can improve clinical presentation and treatment outcomes and reduce transmission. We aimed to determine the delay from being eligible for DST to performing DST and factors associated with the delay. Methods: This was a retrospective cohort study involving record review among presumptive MDR-TB patients who underwent genotypic DST from five selected districts in the state of Gujarat, India (2014). Specimens were couriered from the designated microscopy centres (DMCs) to two designated genotypic DST facilities located outside the districts. Results: Of 2212 patients, the median duration from eligibility to the specimen being sent, from the specimen being sent to DST and from eligibility to DST was 3, 5 and 8 d, respectively. Patients from DMCs in teaching hospitals and with presumptive MDR-TB criteria 'follow-up smear positive' and 'TB-human immunodeficiency virus co-infection' had a significantly higher risk of delay between eligibility and testing (≥8 d). The delay in the specimen being sent after eligibility contributed to high delays in these subgroups. Conclusion: The districts were doing well in implementing timely DST among presumptive MDR-TB patients. However, there is room for improvement in reducing the delays in the sending of specimens among certain patient subgroups.

Delay and attrition before treatment initiation among MDR-TB patients in five districts of Gujarat, India.

Setting: Gujarat, a state in west India. Background: Although treatment initiation has been improving among patients diagnosed with multidrug-resistant tuberculosis (MDR-TB) in programme settings, it has still not reached 100%. Objectives: To determine pre-treatment attrition (not initiated on treatment within 6 months of diagnosis), delay in treatment initiation (>7 days from diagnosis) and associated factors among MDR-TB patients diagnosed in 2014 in five selected districts served by two genotypic drug susceptibility testing (DST) facilities and a drug-resistant TB centre in Gujarat. Design: This was a retrospective cohort study involving record review. Results: Among 257 MDR-TB patients, pre-treatment attrition was seen in 20 (8%, 95%CI 5-12). Patients with 'follow-up sputum-positive' as their DST criterion and sputum smear microscopy status 'unknown' at the time of referral for DST were less likely to be initiated on treatment. The median delay to treatment initiation was 8 days (interquartile range 6-13). Patients referred for DST from medical colleges were more likely to face delays in treatment initiation. Conclusion: The Gujarat TB programme is performing well in initiating laboratory-confirmed MDR-TB patients on treatment. However, there is further scope for reducing delay.

Contexte : Dans le Gujarat, un état de l'ouest de l'Inde, même si la mise en route du traitement a été améliorée pour les patients ayant eu un diagnostic de tuberculose multirésistante (TB-MDR) dans le contexte des programmes, elle n'a pas encore atteint 100%.Objectif : Déterminer l'attrition avant traitement (c'est-à-dire un traitement pas mis en route dans les 6 mois suivant le diagnostic), le retard à la mise en route (>7 jours du diagnostic) et les facteurs associés parmi des patients TB-MDR diagnostiqués en 2014 dans cinq districts sélectionnés servis par deux structures de test génotypique de pharmacosensibilité (DST) et un centre de TB résistante au Gujarat.Schéma : Ceci a été une étude rétrospective de cohorte basée sur une revue de dossiers.Résultats : Sur 257 patients TB-MDR, l'attrition avant traitement a été constatée chez 20 patients (8% ; IC95% 5­12). Les patients ayant un « crachat de suivi positif ¼ comme critère de DST et un statut de microscopie de frottis de crachats « inconnu ¼ lors de la référence pour DST ont été moins susceptibles d'être mis sous traitement. Le délai médian de mise en route du traitement a été de 8 jours (intervalle interquartile 6­13). Les patients référés pour DST de centres hospitalières universitaires sont plus susceptibles de rencontrer des retards à la mise en route du traitement.Conclusion : Le programme TB du Gujarat est performant en mettant en route le traitement de TB-MDR confirmé par le laboratoire. Il reste cependant une marge d'amélioration en matière de réduction des délais.

Marco de referencia: Guyarat es un estado del occidente de la India donde se han logrado avances en la iniciación del tratamiento de los pacientes con diagnóstico de tuberculosis multirresistente (TB-MDR) en el marco programático, pero aún no se ha alcanzado el 100%.Objetivos: Determinar la tasa de abandono anterior al tratamiento (no haber iniciado tratamiento en un lapso de 6 meses después del diagnóstico), el retraso en la iniciación del tratamiento (>7 días después del diagnóstico) y los factores asociados en los pacientes diagnosticados con TB-MDR de cinco distritos escogidos de Guyarat atendidos por dos centros de pruebas genotípicas de sensibilidad a los medicamentos (DST) y un centro de tuberculosis resistente en el 2014.Método: Fue este un estudio de cohortes retrospectivo con examen de las historias clínicas.Resultados: De los 257 pacientes con diagnóstico de TB-MDR, se observó un abandono anterior al tratamiento en 20 casos (8%; IC95% 5­12). La probabilidad de iniciar el tratamiento era menor en los pacientes cuyo criterio para practicar las DST era 'seguimiento a la positividad del esputo' y su situación de la baciloscopia del esputo era desconocida en el momento de la remisión para las pruebas. La mediana del retraso en la iniciación del tratamiento fue 8 días (amplitud intercuartil 6­13). Los pacientes remitidos de las facultades de medicina para realizar las DST presentaban con mayor frecuencia retrasos en la iniciación del tratamiento.Conclusión: El desempeño del programa contra la TB de Guyarat es adecuado con respecto a la iniciación del tratamiento de los pacientes con TB-MDR confirmada por el laboratorio. Sin embargo, aún son necesarios progresos en esta esfera con el fin de acortar los retrasos.

"When Treatment Is More Challenging than the Disease": A Qualitative Study of MDR-TB Patient Retention.

BACKGROUND: One-fifth of the patients on multidrug-resistant tuberculosis treatment at the Drug-Resistant-TB (DR-TB) Site in Gujarat are lost-to-follow-up(LFU). OBJECTIVE: To understand patients' and providers' perspectives on reasons for LFU and their suggestions to improve retention-in-care. DESIGN: Qualitative study conducted between December 2013-March 2014, including in-depth interviews with LFU patients and DOT-providers, and a focus group discussion with DR-TB site supervisors. A thematic-network analysis approach was utilised. RESULTS: Three sub-themes emerged: (i) Struggle with prolonged treatment; (ii) Strive against stigma and toward support; (iii) Divergent perceptions and practices. Daily injections, pill burden, DOT, migratory work, social problems, prior TB treatment, and adverse drugs effects were reported as major barriers to treatment adherence and retention-in-care by patients and providers. Some providers felt that despite their best efforts, LFU patients remain. Patient movements between private practitioners and traditional healers further influenced LFU. CONCLUSION: The study points to a need for repeated patient counselling and education, improved co-ordination between various tiers of providers engaged in DR-TB care, collaboration between the public, private and traditional practitioners, and promotion of social and economic support to help patients adhere to MDR-TB treatment and avoid LFU.

Loss-To-Follow-Up on Multidrug Resistant Tuberculosis Treatment in Gujarat, India: The WHEN and WHO of It.

BACKGROUND: Multidrug-resistant Tuberculosis (MDR-TB) is a rising global threat to public health and concerted efforts for its treatment are diluted if the outcomes are not successful, loss to follow up (LFU) being one of them. It is therefore necessary to know the proportion and the associated reasons for LFU and devise effective patient-centered strategies to improve retention in care. METHODS: A retrospective cohort study was conducted at the MDR-TB treatment site (DR-TB Site)in Central Gujarat among all patients registered from February 2010 to June 2013.LFU patients were defined as those whose treatment was interrupted for two or more consecutive months for any reason. Descriptive statistics, survival analysis and multivariate modeling were used to determine the proportion of patients LFU and to assess associations between LFU and selected demographic and clinical factors. RESULTS: A total of 796 patients were enrolled during the study period; 71.9% were male and the median age was 35 years [Interquartile range (IQR) 27-45].The overall proportion of LFU patients was 153/796 (19.2%).The majority of LFU patients (133/153 i.e.87%) were lost within the first 6 months of treatment. Ambulatory treatment initiation (adjusted Hazards ratio aHR=2.63, CI:1.01-6.86), different providers in IP and CP ( aHR=1.27, CI:1.18-1.38)and culture conversion after more than 4 months of treatment(aHR=1.34, CI: 1.21-1.49)were found to be significantly associated with LFU in multivariate models. CONCLUSIONS: A high proportion of LFU among patients on MDR-TB treatment was found in a programmatic setting in India. Clinical but equally important programmatic factors were associated with LFU, accounting for one-fifth of all the outcomes of MDR-TB treatment. Proper training for DOT providers and aggressive counseling and health system strengthening with patient friendly follow up services may help reduce LFU.

Dietary pattern of schoolgoing adolescents in urban Baroda, India.

Diet plays a very important role in growth and development of adolescents, during which the development of healthy eating habits is of supreme importance. There is a dual burden of undernutrition and overnutrition in this age-group. The study assessed the food habits, food preferences, and dietary pattern of schoolgoing urban adolescents in Baroda, India. Both quantitative and qualitative methods were used in this study. A quantitative survey was carried out using a pre-tested self-administered structured questionnaire among 1,440 students from class 6 to 12 in 7 English medium and 23 Gujarati medium schools. Focus group discussions, 5 each with adolescent boys and girls, were held, along with 5 focus group discussions with teachers of Gujarati and English medium schools. Nearly 80% of adolescents had consumed regular food, like dal, rice, chapati, and vegetables, including green leafy vegetables. Nearly 50% of them had consumed chocolates, and about one-third consumed fast foods. Nearly 60% of adolescents had their breakfast daily while the remaining missed taking breakfast daily. Nearly one-third of adolescents were missing a meal once or twice a week. A large majority had consumed regular foods. However, more than half of them had consumed chocolates, soft drinks, and over one-third had taken fast foods.

Reproductive health awareness among urban school going adolescents in Vadodara city.

AIMS: To identify the reproductive health issues associated with adolescence and the readiness to avail services like Adolescent Friendly Clinic (AFC) among urban school going children. MATERIALS AND METHODS: A quantitative survey was carried out using a self-administered structured questionnaire among 1440 (748 girls and 692 boys) students from classes 6 -12 in 7 English medium and 23 Gujarati medium schools. Focus group discussions, 5 each with adolescent boys and girls and teachers were held from Gujarati and English medium schools. RESULTS: A higher proportion of boys and girls could identify visible external changes in the opposite sex as compared to the changes not seen outwardly. The sources of information on human reproduction for most of the boys and girls were schoolbooks, television, teachers, friends and parents in the same order. Over two-thirds of the boys and girls expressed a need for more information on reproduction. Teachers also perceived that adolescents, though curious, lacked opportunities for open discussions to answer their queries related to reproductive health. One-third of the boys and one-fourth of the girls had heard about contraception. Two-thirds of boys and girls had heard of HIV/AIDS, and about half of them correctly knew various modes of transmission of HIV. Majority of the adolescents expressed their readiness to use the services of Adolescent Friendly Centre. CONCLUSIONS AND RECOMMENDATIONS: Information on the human reproductive system and related issues on reproductive health need special attention. Teachers' sensitization to adolescent health care is required.

Reproductive health awareness among rural school going adolescents of Vadodara district.

OBJECTIVES: To identify the reproductive health issues associated with adolescence and their readiness to avail services like Adolescent Friendly Clinic (AFC) among rural school going children. MATERIALS AND METHODS: A quantitative survey was carried out using a self-administered structured questionnaire among 768 (428 boys and 340 girls) students from 15 schools by systematic random sampling from schools (3 schools from 5 talukas). Focus group discussions, 5 each with adolescent boys and girls and teachers were held. RESULTS AND DISCUSSION: Only 31% of the boys and 33% of the girls mentioned that they had heard about contraception. More than half of the adolescent boys and girls knew correctly about various modes of transmission of HIV/AIDS. A large proportion of boys and girls have mentioned changes in the opposite sex such as increase in height, change in voice, breast development, and growth of facial hair, growth of hair in private parts, onset of menstruation in girls, etc. Nearly 70% of adolescents were ready to use AFC. Teachers perceived that adolescents become curious about the changes taking place in them, but they lack information and opportunities for open-discussions to get answers to their queries related to reproductive health. They are willing to take help from teachers but teachers are not equipped with knowledge nor are they comfortable discussing these issues with their students. RECOMMENDATIONS: Information on the human reproductive system and related issues on reproductive health need special attention. Teachers' sensitization to "adolescent health care" is required.

Adolescent sexuality education and sources of information.

PIP: A survey of 959 young females (ages 10-21 years) from India highlighted the importance of educational attainment to fertility-related behaviors. Respondents represented a spectrum of educational levels: school drop-outs (32%), primary and secondary school attendees (41%), and college students (27%). The mean age at menarche was 13.6 years. School drop-outs were most likely to have obtained information about sexuality from films and other mass media, while students cited friends and neighbors as primary sources. There was an positive association between educational level and both preferred age at marriage and intended interval from marriage to first birth. 42% of adolescents with a secondary or college education planned to marry after 23 years of age and 84% wanted to defer childbearing for at least two years after marriage. The desire for formal sex education was strong in all educational subgroups (about 62%), however. It has been estimated that postponement of the marriage age from 16 years to 20-21 years would result in a 20-30% decrease in the annual number of births in India. School-based sex education represents a feasible mechanism for helping to achieve this goal.^ieng

A case report of percutaneous transluminal angioplasty following failure of femoro-popliteal venous bypass graft.

This brief case report illustrates the utility of angioplasty in lower-extremity limb salvage situations that often occur following failure of femoropopliteal bypass grafting, as well as the use of angioplasty in tibial vessels. It also demonstrates that angioplasty of multiple lesions can be successfully achieved at a single sitting.

Use of tolazoline enahanced superior mesenteric arteriography to improve opacification of a cecal vascular ectasia: a case report.

The use of vasodilators to enhance venous opacification during superior mesenteric arteriography is well established. This is a report on the use of intra-arterial tolazoline hydrochloride during angiography to improve opacification of a cecal vascular ectasia which was poorly demonstrated on an arteriogram performed without tolazoline.

Arteriographic demonstration of spontaneous right coronary artery spasm in a patient with Prinzmetal's angina.

Coronary artery spasm may occur spontaneously during coronary angiography in patients with clinically documented or suspected Prinzmetal's angina. In other patients with Prinzmetal's angina, the spasm can be provoked by the administration of ergonovine. A patient with spontaneous spasm of the right coronary artery during coronary angiography is reported and some considerations for diagnosis and therapy of this entity is offered. Although intraoperative spasm has been reported in the cardiology literature, no such case has been described in the radiology literature.

A modified technique for percutaneous insertion of biliary T-tube.

Following percutaneous removal of retained biliary calculi through a t-tube tract, a tube should be reinserted over a guide wire. Reinsertion usually is easy; however, if buckling occurs, a coaxial system consisting of a t-tube over a teflon dilator will give added stiffness, and the t-tube will advance easily into the common bile duct.