Policies and practices on the programmatic management of LTBI: a survey in the African Region.

BACKGROUND: Although the management of latent tuberculous infection (LTBI) is a core component of the End TB Strategy, there is limited information about the status of implementation of such interventions in most African countries. METHODS: A web-based survey involving the 47 countries of the African Region was conducted between November 2016 and April 2017. RESULTS: The questionnaire was completed by 32/47 (68.1%) National TB Programme managers or their delegates. LTBI guidelines were available in four countries (12.5%), while 13 (40.6%) had an LTBI section in their national TB guidelines; there was no significant association with socio-economic conditions and funding allocation. LTBI diagnosis was mostly based on clinical evaluation to rule out active disease, rather than on systematic use of the tuberculin skin test. Respectively 23 (71.8%) and 17 countries (53.1%) reported providing treatment to child contacts aged <5 years and people living with the human immunodeficiency virus (PLHIV). Over two thirds of respondent countries had ongoing activities targeting at least one of the aforementioned high-risk groups. A recording and reporting system for LTBI-related data on child contacts and PLHIV was available in respectively 14 and 12 countries; 7 countries had an LTBI monitoring and evaluation plan. CONCLUSIONS: These data suggest that greater effort is needed to appropriately scale up LTBI policies in the African Region.

Active tuberculosis case finding among pregnant women: a pilot project in Burkina Faso.

Tuberculosis (TB) is a leading cause of death among women of childbearing age, and may be responsible for severe complications during pregnancy. Between August 2014 and March 2015, we conducted a pilot project to promote active TB case finding in antenatal care (ANC) clinics in the Central Region of Burkina Faso. Our results show very limited TB diagnostic practices and possible severe underdiagnosis of TB at ANC clinics, despite adequate screening practices. Integration of training and supervision of TB diagnosis and treatment into ANC services is required.

Comparative analysis of visual and semi-quantitative assessment of striatal [123I]FP-CIT-SPET binding in Parkinson's disease.

We used qualitative visual assessment and semiquantitative measures of striatal DAT binding using [(123)I]FP-CIT-SPET in 85 patients with Parkinson's disease (PD). We compared these two assessments and their correlation with PD clinical progression. SPET imaging was visually classified by a nuclear medicine physician as normal or abnormal pattern grade I, II and III, in relation to a different degree of radioligand reduction uptake. Nineteen patients presented abnormal grade I (group 1), 53 grade II (group 2) and 13 grade III (group 3). The UPDRS III motor score, the H-Y score, the rigidity and bradykinesia subscores were significantly different among the three groups. Post hoc analysis showed that all values of these clinical parameters were higher in group 3 than in 2 and 1. All clinical indices were also significantly higher in group 2 than in group 1. This means that groups 3 and 2 were clinically more severely affected. No significant differences among the 3 groups were observed for age or duration of disease. Values of the mean striatum uptake were also significantly different among the three groups. Post hoc analysis revealed significantly lower values of the mean striatum uptake in group 3 with respect to groups 2 and 1; values were also significantly lower in group 2 than in group 1. We conclude that our findings of good consistency between visual and semi-quantitative assessment may help simplify the evaluation of striatal DAT binding in PD in a clinical routine setting.

Gamma knife radiosurgery in skull base meningiomas: a possible relationship between somatostatin receptor decrease and early neurological improvement without tumour shrinkage at short-term imaging follow-up.

BACKGROUND: This study investigates a possible relationship between the effects of gamma knife (GK) on meningioma somatostatin receptors (SRs) and the high rate of early neurological improvement without tumour reduction at short-term imaging follow-up. METHODS: From December 1997 to December 2002, somatostatin receptor scintigraphy (SRS) using an 111Indium-labelled somatostatin analogue, Octreotide, was performed both before and 7-12 months after radiosurgery in 20 patients with intracranial meningiomas. Semiquantitative data were calculated as an SRS index. FINDINGS: The pre-GK SRS index was always > 1, averaging 4.44 +/- 3.20. There were no statistically significant differences between the pre-GK average values of primary (4.80 +/- 3.65) and residual (3.75 +/- 1.93) meningiomas. At the first clinical/MRI follow-up, the neurological examination had improved in 15/20 (75%) and had not changed in 5/20 patients. A corresponding slight tumour shrinkage on high-resolution MRI was documented in 3/20 cases only. The post-GK average SRS index was lower than pre-GK values both in primary (3.87 +/- 3.19) and in adjuvant (2.52 +/- 1.14) treatments, but the differences were not significant. However, the subgroup of patients with early neurological improvement showed a higher pre-GK average SRS index (5.21 +/- 3.33) and a more substantial post-GK average SRS index decrease (3.86 +/- 3.00) than the patients whose clinical condition remained stable (2.10 +/- 0.59 and 1.99 +/- 0.55, respectively). The difference between the two subgroups of patients proved to be statistically significant (P < 0.05). CONCLUSIONS: Our preliminary findings suggest a possible relationship between a decrease in the concentration of SRs on meningioma cells at short-term functional imaging follow-up after radiosurgery and early neurological improvement.

Comparison between low-dose dobutamine echocardiography and thallium-201 scintigraphy in the detection of myocardial viability in patients with recent myocardial infarction.

AIM: To compare the predictive value of thallium-201 single photon emission computed tomography (SPECT) scintigraphy (Sci) and low-dose dobutamine echocardiography (Dob) in predicting late recovery of dysfunctioning myocardium in patients with recent, uncomplicated myocardial infarction (MI). METHODS AND RESULTS: 19 patients (18 male, aged 58+/-8 years) with recent MI and ejection fraction <50% (35.5+/-8.3%) underwent 5-15 microg/kg per min Dob, rest-redistribution Sci and coronary angiography, respectively, 14+/-6, 16+/-7 and 17+/-5 days after MI. On an eleven-segment ventricular model devised to compare Dob and Sci segment by segment, each dysfunctioning ventricular segment was considered viable if it showed recovery of mechanical function at the echocardiographic follow-up, performed 6.3+/-1.5 months after revascularization (five PTCA, five GABG) or medical therapy. Among the 104 dysfunctioning segments, of which 26 (25%) showed recovery at follow-up, Dob and Sci gave a concordant response in 50 (48%, k = 0.13), correctly predicting the recovery (or not) of function in 42. Forty-two of 54 discordant responses were due to segments judged viable only by Sci and which had no recovery at follow-up (of these 37 were akinetic or severely hypokinetic at baseline). At the segment-by-segment analysis, the sensitivity, specificity, and accuracy in predicting recovery of function at follow-up were, respectively, 69, 88 and 84% for Dob as against 88, 36 and 49% for Sci (P<0.001 for both specificity and accuracy, P=NS for sensitivity). CONCLUSION: In patients with recent MI, the specificity of Dob in the detection of myocardium capable of late mechanical recovery is significantly higher with respect to Sci, whereas sensitivity is slightly, not significantly higher for the latter. It is conceivable that Sci detects viable myocardium even if it is transmurally limited to epicardial layers in segments with severely impaired mechanical function in which viability will not affect late recovery of function.

Simultaneous measurement of gastric emptying of a solid meal by ultrasound and by scintigraphy.

OBJECTIVE: Although ultrasonic imaging may represent a valid alternative to scintigraphy for measurement of gastric emptying, most studies comparing the two methods have been carried out with liquid meals. The aim of this study was to compare scintigraphic and ultrasonographic measurements of gastric emptying of a solid meal in healthy subjects and in patients with possible delay in emptying. METHODS: Nineteen subjects were studied: five controls, six patients with gastroesophageal reflux, and eight patients with dysmotility-like dyspepsia. Gastric emptying was measured by both scintigraphy and ultrasonography after ingestion of an 800-calorie solid, realistic meal containing 99mTc-labeled chicken liver. Scintigraphic measurements were made every 15 min for 6 h, and ultrasonic imaging of antral sections was undertaken every 15 min for the first 1 h and every 30 min thereafter. Total emptying times were calculated independently using the two methods, and the emptying patterns recorded by the two methods were compared. RESULTS: Maximal antral dilation occurred 30 min (range 0-90 min) after the end of the meal and persisted until 96 +/- 42 min, by which time gastric radioactivity had decreased from its maximum by 43% +/- 23%. From this time on, the antral cross-sectional area returned toward the basal value, declining faster than the gastric counts recorded by scintigraphy. Total emptying times measured by ultrasound and by scintigraphy were in good agreement in all subjects, with a mean difference of only 4.5 min (limits of agreement, -17.1 to 21.6 min). CONCLUSIONS: Ultrasonographic measurement of antral cross-sectional area provides a valid alternative to scintigraphy for the measurement of total gastric emptying of a solid meal. It is less reliable if other parameters of gastric emptying such as T(1/2) are required.

[Vascular pathology. A study of some blood parameters indicative of leukocyte activation and platelet dysfunction]. / Patologia vascolare. Studio di alcuni parametri ematici indicativi di attivazione leucocitaria e disfunzione piastrinica.

BACKGROUND: In vascular pathology the endothelial lesions easily reflect on blood cells, inducing a reactive state. In the present study the eventual presence of activation signals in leukocytes and platelets was tested. METHODS: Fifty-eight subjects with major vascular pathology and 14 with lower limbs venous insufficiency were studied, together with a control group of 25 normal subjects. Elastase PMN, superoxide ion, leukocytes and subpopulation count, platelet factor 3, clot retraction, heparin in neutralizing activity (HNA plasmatic and intraplatelet), platelet count and volume were tested. RESULTS: As regards leukocytes, it was observed a significative increase of elastase PMN and monocytes number for both the studied pathologies, of superoxide ion and leukocyte number only for major vascular pathology; for platelets, an inhibition of functionality, revealed by clot retraction test for arterious and venous pathologies and by HNA test only for the venous one. CONCLUSIONS: As regards the leukocyte activation, elastase PMN is particularly responsive to the endothelial lesion both in arterious and in venous districts, while superoxide ion appears to increase in presence of a marked alteration. The level of monocytes is indicative of an inflammatory condition and of leukocytes of an atherosclerotic inflammatory process. As for platelets, the test clot retraction is specifically sensible to the endothelial abnormality in both the arterious and venous pathologies with addition of an abnormal HNA test only in venous insufficiency. This platelet dysfunction is probably due to endothelial release of vasoactive and heparin amplifying substances.

Ruptured abdominal aortic aneurysms: factors affecting the early postoperative outcome.

BACKGROUND: In spite of the progress in diagnosis and treatment of ruptured abdominal aortic aneurysms (RAAA) the mortality rate still remains very high (varying from 15% to 50% according to various experiences). This study is aimed at analyzing the relative contribution of preoperative hemodynamic conditions and of operative and postoperative factors to outcome of patients operated on for ruptured abdominal aortic aneurysms. METHODS: For this purpose a retrospective case series involving 152 patients operated on in emergency for RAAA, during the period 1990-1994, has been reviewed. In this group we examined the site of rupture, the size of the aneurysms, the presence or not of a shock condition at admission, the existence of inflammatory aspects, the adopted type of prosthesis. RESULTS: The mortality rate was 24.3% (37 patients). In 10 patients (27%) the cause of death was an irreversible hemorrhagic shock. Eight patients (21.6%) died for an intestinal infarction. In 7 patients the fatal outcome was due to the development of an acute renal failure. Five patients (13.5%) underwent an acute myocardial infarction and other five a multiorgan failure. Two patients (5.5%) eventually died for respiratory insufficiency. CONCLUSIONS: The results of our study seem to confirm that the outcome of patients affected by rupture of abdominal aortic aneurysms depends not only on the preoperative hemodynamic condition but also on the expertise of the surgical team.

Percutaneous treatment of iliac aneurysms and pseudoaneurysms with Cragg Endopro System 1 stent-grafts.

PURPOSE: To evaluate the feasibility and short-term follow-up results of treating iliac aneurysms by the Cragg Endopro System 1 stent-graft. METHODS: Nine lesions (two pseudoaneurysms and seven atherosclerotic aneurysms) were treated in eight patients by percutaneous implantation of a total of 10 stent-grafts. The procedure was followed by anticoagulation with heparin for 6 days, then antiplatelet therapy. Follow-up was by color Doppler ultrasound scan at 2 days and 3 months after the procedure for all patients, and by venous digital subtraction angiography and/or angio-CT up to 12 months later for four patients. RESULTS: Initial clinical success rate was 100% and there were two minor complications. In one case the delivery system was faulty resulting in failure to deploy the stent-graft. An additional device had to be used. At 3-12 months all prostheses were patent but one patient (12.5%) had a minimal pergraft leak. CONCLUSION: Percutaneous stent-grafting with this device is a safe and efficacious treatment of iliac artery aneurysms.

[Heparan sulfate in the therapy of postphlebitic syndrome. Evaluation of the efficacy and tolerability as compared to mesoglycan]. / Eparansolfato nella terapia a medio termine della sindrome postflebitica. Valutazione dell'efficacia e della tollerabilità nei confronti del mesoglicano.

BACKGROUND: Antithrombotics and profibrinolytics are indicated in several clinical thrombophilic conditions such as postphlebitic syndrome. Heparansulphate, a glycosaminoglycan, shows an antithrombotic activity with low anticoagulant effect. The aim of the study was to evaluate the efficacy and the safety of heparansulphate (100 mg b.i.d.) versus mesoglycan (50 mg b.i.d.), both administered for three months in patients with postphlebitic syndrome. METHODS: The trial was performed in an open-label, controlled, with parallel and randomized groups, design. Thirty patients, with chronic venous insufficiency and a history of venous thrombosis were enrolled. Coagulative and fibrinolytic parameters (PT, aPTT, euglobulin lysis time, fibrinogen, D-dimer, t-PA, PAI-1) and signs and symptoms (cramps, paresthesia, itch, edema, local pain, skin trophism) were assessed at enrollment, 15 days later after the pharmacological washout period and after 1, 2, 3 months of treatment. Safety was evaluated by monitoring any adverse event during the study and performing clinical laboratory tests at the beginning and at the end of treatment. RESULTS: The two drugs showed a superimposable efficacy and very good tolerability. Coagulative and fibrinolytic parameters were positively affected by both treatments and the clinical benefit was particularly evident in the heparansulphate group with a significant decrease "between times" of local pain, edema, paresthesia and itching. CONCLUSIONS: These data support the use of heparansulphate, and in general of glycosaminoglycans, in the postflebitic syndrome.

[Association of rupture abdominal aneurysm and intestinal infarct]. / Associazione fra aneurisma addominale rotto e infarto intestinale.

The authors present one patient with ruptured abdominal aortic aneurysm (rAAA) who complicate with small bowel infarction and coproperitoneum; and two patients who suffered from rAAA and simultaneous colon infarction, successfully treated by one-stage operation. They comment upon this rare pathology and analyze hypothetical causes, considering the scanty literature about it.

[Percutaneous angioplasty (PTA) in the treatment of non-penetrating injuries to the subclavian artery. A clinical case]. / Trattamento con angioplastica percutanea (PTA) di lesione da trauma non penetrante dell'arteria succlavia. Caso clinico.

Non penetrating injuries to the subclavian vessels are uncommon. We present a case of a young patient with an isolated blunt trauma of the right subclavian artery. The patient, a 25 year-old woman, was admitted to our Institute after a motor-vehicle accident, with a physical findings of absent peripheral pulses and right clavicular fracture, confirmed by non-invasive vascular evaluation and X-ray of the chest. Diagnosis was established by an urgent selective angiography that showed a subintimal hematoma with occlusion of the vessel and peripheral ischemia of the arm. The patient clinical status (hemodynamically stable) permitted a conservative management and a transluminal percutaneous angioplasty (PTA) with a trans-femoral catheter balloon. After radiologic treatment, the patient showed good palpable peripheral pulses. Clavicular fracture was treated by esternal stabilization. We believe that in selected patients, without other serious life-threatening injures, the intimal artery injury can be treated by a conservative and now also radiologic Therapy; PTA treatment avoids morbidity and mortality associated with surgical intervention.

Pathological esophageal acidification and pneumatic dilitation in achalasic patients. Too much or not enough?

Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 +/- 4.2 to 14.6 +/- 1.1 mm Hg (mean +/- SEM); there was, however, no difference between nonrefluxers and refluxers (14.8 +/- 1.2 vs 13.8 +/- 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 +/- 20.9 min vs 209 +/- 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 +/- 4.5 vs 2.5 +/- 1.8 min, P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.

Ruptured aneurysms of the thoracoabdominal aorta: a case series.

Fifteen cases of ruptured thoracoabdominal aneurysm (-TAA) were encountered in 1987-July 1994. These patients included 13 males (86.6%), 2 females (13.4%) with a mean age of 66.3 years (range 58-78). Surgery was performed on 13 patients of whom 6 (46.1%) died within 30 days. The two other patients had died of heart failure prior to surgery. In 8 of these patients (53.4%) the condition was not diagnosed until clear symptoms had appeared. The ruptured aneurysms were thoracic in 9 cases (60%), abdominal in 6 (40%). The maximum aneurysm diameter in the most frequently ruptured group was 6.1-8 cm (in 9 patients-60%)./ For 5 cases (33.4%) the maximum diameter of ruptured aneurysms included dorsolumbar pain. In one patient a concomitant aortobronchial fistula had produced rupture. Low blood pressure was found in 9 cases (60%). In 5 cases (38.4%) curative surgery was performed within 24 hours of the onset of symptoms. In this group, the mortality rate was 40% (2 patients). In the remaining 8 cases, on whom surgery could not be performed within 24 hours (range 25 hours-4 months) the mortality rate was 50% (4 cases). All four cases of paraplegia (30.7%) were encountered among patients in the second group, 2 of whom died. Follow-up revealed a 5-year mortality rate of 71.4%.

[Natural history and course of aneurysmal disease in patients operated on for abdominal aortic aneurysms]. / Storia naturale ed evoluzione della malattia aneurismatica in pazienti operati per aneurismi dell'aorta addominale.

This study is aimed at analyzing our experience in the evolution of aneurysmatic disease after surgical treatment of the typical subrenal abdominal aortic aneurysm. In fact in some cases we reobserved these patients for the onset of a new important dilatation involving the proximal tract of the abdominal aorta or the common iliac arteries. From 1980 to December 1992, 24 patients out of a group of 1508 patients previously submitted to an aorto-aortic or aorto-iliac reconstructive procedure using dacron prosthetic grafts were reoperated for relapsing aneurysmatic disease. In six cases the dangerous ectasia was located above the proximal aortic anastomosis; in four patients the re-reconstructive procedure was performed clamping the subdiaphragmatic abdominal aorta and performing the proximal anastomosis just below the ostia of the renal arteries. In two cases the aneurysmatic process involved the origins of the visceral vessels and a left thoracophrenolaparotomic access was necessary in order to perform a thoracoabdominal reconstruction reimplanting the visceral arteries on the prosthetic graft. In 18 cases the progressive aneurysmatic process involved the common iliac axis provoking, in some cases, a kinking or a shortening of the aortic prosthetic graft. The results of these reintervention are good with no mortality at operation and a satisfactory middle term (average 3 years) follow-up. Our investigation demonstrates that in a small, but significant (1.6%) percentage of patients the aneurysmatic disease spreads upward and downward involving arterial segments formerly non affected.

Spontaneous aorto-caval fistulas from ruptured abdominal aortic aneurysms.

Thirty-six cases of abdominal aortic aneurysms rupturing into the vena cava and two iliac aneurysms rupturing into iliac veins are reported. This group represents 10% of the total number of observed ruptured abdominal aortic aneurysms (388). Such a condition is therefore quite rare but should be considered positively because the reported mortality rate is less than with ruptured aneurysms in general. Nevertheless, a spontaneous aorto-caval fistula is responsible for a critical haemodynamic deterioration and sudden worsening of the general condition of the patient and therefore prompt surgical repair is mandatory. The overall mortality rate in our series was 21% (8 cases).

[Hemostatic factors of endothelial origin in major vascular pathology]. / Fattori emostatici di origine endoteliale in patologia vascolare maggiore.

There is an altered hemostatic balance in vascular-based diseases. The aim of this study was to compare a group (no. = 38) of vascular patients (aortic aneurysm, carotid obstructions arteriopathies of lower limbs) and a control group (no. = 40) and assess variations in the following endothelial factors: tPA, PAI1, vWf, fibronectin and dimer D, in differentiated degrees according to the type of pathology. These were the indicative signs of endothelial mobilization resulting in the renewed continuity of the stratum with the formation of a hemostatic plug. vWf was found to be particularly significant as a marker of an ongoing atheromasic process and its extension to various vascular districts.

[Risk factors for arteriosclerosis and diet of surgical patients. 10 years of outpatient activity]. / Fattori di rischio per arteriosclerosi e dieta in pazienti di interesse chirurgico. Attività ambulatoriale di 10 anni.

The follow-up of arteriopathic subjects who have already been hospitalized (abdominal-peripheral vascular district 79% of patient and supra-aortic branch district 21%) has been carried out for around 10 years using an out-patient regime at the Institute of General and Cardiovascular Surgery of Milan. During outpatient visit the main risk factors for arteriosclerosis are routinely checked and treated if required; among the various therapies for metabolic control particular emphasis is placed on diet since its influence on the metabolism is well known, above all in the long term. The efficacy of this treatment has been evaluated by evaluating blood chemical changes (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, VLDL and glycemia) in a group of patients who followed the diet in comparison to a group which did not. The results obtained show that in dieting patients there was a statistically significant decrease in blood values for total cholesterol, LDL cholesterol, triglycerides and VLDL, together with a decrement, which failed to reach statistical significance, in glycemia and HDL cholesterol. In non-dieting patients it was found that all parameters increased but that this was only statistically significant for total cholesterol and HDL cholesterol. The control of risk factors for arteriosclerosis through diet therapy therefore appears to be satisfactory even for secondary prevention in surgical arteriopathic subjects. It is important to underline that these results were not obtained under conditions of clinical research but in the reality of day-to-day clinical and therapeutic activity whose efficacy is vitally important for scientific health.

Splanchnic artery aneurysms.

From 1970 to October 1991, 26 patients affected by splanchnic artery aneurysms were observed and treated at the Department of General and Cardiovascular Surgery, University of Milan, Italy. Three splanchnic artery aneurysms were operated on in emergency. Visceral artery aneurysms are often completely silent and are generally detected during diagnostic procedures performed in order to clarify some diagnostic questions. When symptomatic they present a characteristic clinical picture of the involved vascular district. Two patients affected by aneurysmal disease of the proper hepatic artery died after operation. All the other splanchnic aneurysms underwent a successful surgical procedure. This study is aimed at analyzing some characteristic clinical pictures, diagnostic methods, therapeutic procedures and postoperative results.