Accelerated rehabilitation following thumb ulnar collateral ligament repair with suture tape augmentation: A case series of professional basketball players.

STUDY DESIGN: Case series. INTRODUCTION: Rehabilitation protocols following thumb metacarpophalangeal (MCP) ulnar collateral ligament (UCL) repair typically do not allow for return to sport until 12 weeks post-surgery. The potential for accelerated rehabilitation following thumb MCP UCL repair with suture tape augmentation has yet to be explored. PURPOSE OF THE STUDY: To describe the accelerated rehabilitation following thumb MCP UCL repair with the suture tape augmentation in professional basketball players. METHODS: Three professional basketball players underwent thumb MCP UCL repair with suture tape augmentation. The athletes followed an accelerated rehabilitation program post-surgery that began with range-of-motion exercises at 2-3 days, proximal strengthening at 7-10 days, grip/pinch strengthening at 1-2 weeks, followed by progressive sport specific intervention with a custom orthosis. RESULTS: At 5-6 weeks post-surgery, active thumb MCP range of motion returned to 83%-100%, grip strength to 81%-100%, and tripod pinch strength to 73%-78% of the contralateral side. All athletes successfully returned to sport within 5-6 weeks post-surgery. DISCUSSION/CONCLUSION: This is the first clinical application of an accelerated rehabilitation protocol in athletes following thumb MCP UCL repair. In this series, professional basketball players were able to return to sport in half the routine recovery time. Further prospective studies re-thinking current rehabilitation protocols are warranted.

Can we do it faster? accelerated rehabilitation following thumb ulnar collateral ligament repair with suture tape augmentation.

Ulnar Collateral Ligament (UCL) injuries are the most common thumb metacarpophalangeal joint ligamentinjury. Rehabilitation protocols traditionally permit return to sport at 12 weeks post-surgery. In this article, we propose anacellerated rehabilitation protocol permitting return to sport at 5-6 post-surgery in the recreational athlete.

Impact of mental disorders on active TB treatment outcomes: a systematic review and meta-analysis.

BACKGROUND: Comorbid mental disorders in patients with TB may exacerbate TB treatment outcomes. We systematically reviewed current evidence on the association between mental disorders and TB outcomes.METHODS: We searched eight databases for studies published from 1990 to 2018 that compared TB treatment outcomes among patients with and without mental disorders. We excluded studies that did not systematically assess mental disorders and studies limited to substance use. We extracted study and patient characteristics and effect measures and performed a meta-analysis using random-effects models to calculate summary odds ratios (ORs) with 95% confidence intervals (CIs).RESULTS: Of 7687 studies identified, 10 were included in the systematic review and nine in the meta-analysis. Measurement of mental disorders and TB outcomes were heterogeneous across studies. The pooled association between mental disorders and any poor outcome, loss to follow-up, and non-adherence were OR 2.13 (95%CI 0.85-5.37), 1.90 (95%CI 0.33-10.91), and 1.60 (95%CI 0.81-3.02), respectively. High statistical heterogeneity was present.CONCLUSION: Our review suggests that mental disorders in TB patients increase the risk of poor TB outcomes, but pooled estimates were imprecise due to small number of eligible studies. Integration of psychological and TB services might improve TB outcomes and progress towards TB elimination.

Integrating tuberculosis and mental health services: global receptivity of national tuberculosis program directors.

A global survey of National Tuberculosis Program (NTP) directors. To assess the perceived mental health needs of persons with tuberculosis (TB), current practices, and receptivity to integrating evidence-based mental and substance use treatment into national TB guidelines. Semi-structured survey of NTP directors from 26 countries of all income levels using a standardized questionnaire. Of the 26 countries, 21 were classified as high incidence and/or burden countries for TB, TB and human immunodeficiency virus coinfection, and/or drug-resistant TB. Two NTPs included routine screening for any mental disorder, four assessed alcohol or drug use, and five had standard protocols for the co-management of disorders. If effective and low-cost integrated care models were available, 17 NTP directors felt that it was highly likely, and five somewhat likely, that their NTPs would integrate mental health treatment into national TB guidelines and services. The main perceived barriers to service integration were limited capacity, not recognizing mental health as a problem, insufficient resources, and TB-related social stigma. NTPs currently do not address mental disorders as part of routine practice. Nevertheless, receptivity is high, which creates a ripe opportunity to integrate the management of TB and mental disorders into the policies and guidelines of NTPs worldwide. .

High rates of exposure to tuberculosis patients among HIV-infected health care workers in Botswana.

OBJECTIVE: To compare daily exposure to tuberculosis (TB) patients between HIV-infected and non-HIV-infected health care workers (HCWs), and examine the uptake of antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) among HIV-infected HCWs in Botswana. DESIGN: We conducted a cross-sectional study among HCWs in 30 hospitals and clinics. We determined self-reported exposure frequency to TB patients and HIV status through in-person interviews. HCWs with unknown or negative HIV status were offered rapid HIV testing. Multivariable Poisson regression modeling with robust variance was used to estimate the association between HIV status and daily exposure to TB patients. RESULTS: Of 1877 participants enrolled, 1388 (73.9%) with complete data were included in this study. Among 277 (20.0%) HIV-infected participants, 14.3% were newly diagnosed, 57.8% were on ART, and 34.3% reported previously receiving IPT. Daily exposure to TB patients was reported by respectively 48.4% and 52.9% of HIV-infected and non-infected participants. After adjusting for sex, age, occupation, and department, the rates of daily TB exposure remained similar between HIV-infected and non-HIV-infected participants (prevalence ratio 0.96, 95%CI 0.85-1.08). CONCLUSIONS: We found similar rates of exposure to TB patients between HIV-infected and non-HIV-infected HCWs. Improved efforts are needed to reduce nosocomial exposure to TB among HIV-infected HCWs.

Detecting selection signatures between Duroc and Duroc synthetic pig populations using high-density SNP chip.

The development of high throughput genotyping techniques has facilitated the identification of selection signatures of pigs. The detection of genomic selection signals in a population subjected to differential selection pressures may provide insights into the genes associated with economically and biologically important traits. To identify genomic regions under selection, we genotyped 488 Duroc (D) pigs and 155 D × Korean native pigs (DKNPs) using the Porcine SNP70K BeadChip. By applying the FST and extended haplotype homozygosity (EHH-Rsb) methods, we detected genes under directional selection associated with growth/stature (DOCK7, PLCB4, HS2ST1, FBP2 and TG), carcass and meat quality (TG, COL14A1, FBXO5, NR3C1, SNX7, ARHGAP26 and DPYD), number of teats (LOC100153159 and LRRC1), pigmentation (MME) and ear morphology (SOX5), which are all mostly near or at fixation. These results could be a basis for investigating the underlying mutations associated with observed phenotypic variation. Validation using genome-wide association analysis would also facilitate the inclusion of some of these markers in genetic evaluation programs.

Isoniazid therapy for Mycobacterium tuberculosis infection in HIV clinics, Los Angeles, California.

SETTING: Publicly funded human immunodeficiency virus (HIV) clinics in Los Angeles County, California, USA. BACKGROUND: HIV-infected persons are a high priority group for targeted testing and treatment for Mycobacterium tuberculosis infection in the United States. OBJECTIVE: To describe rates of isoniazid (INH) initiation and completion among HIV-1 and M. tuberculosis co-infected persons in Los Angeles County. DESIGN: We conducted a cross-sectional study using routinely collected surveillance data from publicly funded HIV clinics. We examined differences in INH treatment initiation and completion between four clinic categories: the three largest clinics (Clinics A, B, and C) and 'Other' clinics (pooled data for the remaining 10 clinics). RESULTS: During 2010-2013, 802 (5.3%) of 15 029 HIV-1-infected persons tested positive for M. tuberculosis infection. INH was initiated in 581 (72.4%) persons, of whom 457 (78.7%) completed treatment. We found significant differences between clinics in terms of treatment initiation (range 59.1-93.4%) and completion (range 58.8-82.3%). Overall, 57% (457/802) of HIV and M. tuberculosis co-infected persons completed the recommended treatment (range across clinics 34.8-76.3%). CONCLUSION: We identified significant gaps in the treatment for M. tuberculosis infection among HIV-infected persons in Los Angeles County. Interventions are needed to improve initiation and completion of treatment for M. tuberculosis infection in this population.

Dose-response association between salivary cotinine levels and Mycobacterium tuberculosis infection.

SETTING: Tijuana, Mexico. OBJECTIVE: To describe the association between salivary cotinine levels and interferon-gamma (IFN-γ) release assay results. DESIGN: We conducted a cross-sectional study among injection drug users. Salivary cotinine levels were measured using NicAlert, a semi-quantitative dipstick assay. QuantiFERON©-TB Gold In-Tube (QFT-GIT) was used to determine Mycobacterium tuberculosis infection. RESULTS: Among 234 participants, the prevalence of QFT-GIT positivity for NicAlert cotinine categories 0 (non-smoking), 1 (second-hand smoke exposure or low-level smoking) and 26 (regular smoking) were respectively 42.1%, 46.4% and 65.2% (Ptrend 0.012). We found increasing trends in QFT-GIT positivity (Ptrend 0.003) and IFN-γ concentrations (Spearman's r 0.200, P 0.002) across cotinine levels 0 to 6. In multivariable log-binomial regression models adjusted for education, cotinine levels were not associated with QFT-GIT positivity when included as smoking categories (1 and 26 vs. 0), but were independently associated with QFT-GIT positivity when included as an ordinal variable (prevalence ratio 1.09 per 1 cotinine level, 95%CI 1.021.16). CONCLUSION: Our findings suggest that a dose-response relationship exists between tobacco smoke exposure and M. tuberculosis infection. Longitudinal studies that use biochemical measures for smoking status are needed to confirm our findings.

Clinical characteristics, drug resistance, and treatment outcomes among tuberculosis patients with diabetes in Peru.

OBJECTIVES: Diabetes is a risk factor for active tuberculosis (TB). Data are limited regarding the association between diabetes and TB drug resistance and treatment outcomes. We examined characteristics of TB patients with and without diabetes in a Peruvian cohort at high risk for drug-resistant TB. Among TB patients with diabetes (TB-DM), we studied the association between diabetes clinical/management characteristics and TB drug resistance and treatment outcomes. METHODS: During 2005-2008, adults with suspected TB with respiratory symptoms in Lima, Peru, who received rapid drug susceptibility testing (DST), were prospectively enrolled and followed during treatment. Bivariate and Kaplan-Meier analyses were used to examine the relationships of diabetes characteristics with drug-resistant TB and TB outcomes. RESULTS: Of 1671 adult TB patients enrolled, 186 (11.1%) had diabetes. TB-DM patients were significantly more likely than TB patients without diabetes to be older, have had no previous TB treatment, and to have a body mass index (BMI) >18.5 kg/m(2) (p<0.05). In patients without and with previous TB treatment, the prevalence of multidrug-resistant TB was 23% and 26%, respectively, among patients without diabetes, and 12% and 28%, respectively, among TB-DM patients. Among 149 TB-DM patients with DST results, 104 (69.8%) had drug-susceptible TB and 45 (30.2%) had drug-resistant TB, of whom 29 had multidrug-resistant TB. There was no association between diabetes characteristics and drug-resistant TB. Of 136 TB-DM patients with outcome information, 107 (78.7%) had a favorable TB outcome; active diabetes management was associated with a favorable outcome. CONCLUSIONS: Diabetes was common in a cohort of TB patients at high risk for drug-resistant TB. Despite prevalent multidrug-resistant TB among TB-DM patients, the majority had a favorable TB treatment outcome.

Impact of rapid drug susceptibility testing for tuberculosis: program experience in Lima, Peru.

SETTING: Programmatic implementation of decentralized rapid drug susceptibility testing (DST) in Lima, Peru. OBJECTIVE: Pre-post analysis compared time to diagnosis, treatment outcome and survival among patients tested with direct nitrate reductase assay (NRA) vs. indirect conventional methods. DESIGN: From 2005 to 2009, we prospectively followed all patients referred for DST before (control) and after (intervention) NRA implementation. Among those referred for DST, NRA was used for smear-positive samples of patients with no prior history of multidrug resistance or treatment for multidrug-resistant tuberculosis (TB). Data were abstracted from patient charts and laboratory registers. Endpoints were favorable outcomes, time to result and time to death. RESULTS: Of those patients who met the criteria for NRA, 740 underwent NRA and 621 underwent conventional DST. NRA yielded test results for 78.4% of cases vs. 68.8% for conventional DST (P < 0.0001); the median time to result was 44 vs. 133 days, respectively (adjusted HR 0.64, 95%CI 0.56-0.73). Among individuals without previous anti-tuberculosis treatment, NRA was associated with a favorable treatment outcome (adjusted OR 1.39, 95%CI 1.01-1.90) and prolonged survival (adjusted HR 0.53, 95%CI 0.31-0.90). CONCLUSION: Direct NRA significantly shortened time to test result and improved treatment outcomes and survival in certain groups.

Factors leading to under-reporting of tuberculosis in the private sector in Korea.

OBJECTIVE: To identify factors associated with under-reporting of tuberculosis (TB) in the private sector in Korea. DESIGN: A cross-sectional study of 37,820 cases in whom treatment was initiated between January and December 2008 using data from the Nationwide Medical Records Survey of Patients with TB. Adjusted odds ratios (aOR) for under-reporting with respect to socio-demographic and clinical factors were estimated. RESULTS: Among the 37,820 identified cases, 21,611 (57.1%) were reported to the Korean TB Surveillance System. Factors associated with under-reporting on univariate analysis included young children, foreign-born persons, non-multidrug-resistant TB, persons prescribed fewer than four anti-tuberculosis drugs, non-performance of or negative result on sputum smear and extra-pulmonary TB (particularly abdominal or genitourinary TB). For pulmonary TB, cases with no sputum smear results vs. smear-positive patients (aOR 2.23, P < 0.001) and those prescribed <4 drugs vs. those who were prescribed ≥4 drugs (aOR 1.60, P < 0.001) were strongly related to under-reporting on multivariate analysis. CONCLUSION: The extent of under-reporting was greater among young children, persons who had not received sputum smear testing and those who had been prescribed fewer than four drugs. Furthermore, TB diagnostic investigations were often inadequate. Education on reporting requirements, including the importance of following guidelines on TB management, and a stricter enforcement of the existing TB Prevention Law, are needed.

Alcohol use and the management of multidrug-resistant tuberculosis in Tomsk, Russian Federation.

SETTING: Alcohol use increases the risk of multidrug-resistant tuberculosis (MDR-TB) and poses challenges for successful MDR-TB treatment, including the potential for additional adverse events. AIM: To investigate the association between alcohol consumption during MDR-TB treatment and adverse events and treatment outcomes in a cohort of patients in Tomsk, Russia. DESIGN: From 2000 to 2004, retrospective data were collected on 407 MDR-TB patients in Tomsk. Factors associated with treatment outcomes were assessed using logistic regression. RESULTS: Of the 407 patients, 253 (62.2%) consumed alcohol during treatment ('drinkers'), and 367 (90.2%) had at least one documented adverse advent. No significant differences were noted in frequency of adverse events in drinkers vs. non-drinkers. Drinkers had less favourable treatment outcomes (OR 0.28, 95%CI 0.18-0.45). Among drinkers, favourable treatment outcome was associated with adherence to at least 80% of prescribed doses (OR 2.89, 95%CI 1.30-6.43) and the occurrence of an adverse event requiring treatment interruption (OR 2.49, 95%CI 1.11-5.59). CONCLUSIONS: Alcohol use did not appear to increase the risk of adverse events during MDR-TB treatment; however, alcohol consumption was associated with poor outcome. Our findings suggest that individuals who drink alcohol should receive aggressive attention to optimise treatment adherence and manage adverse events.

Hepatotoxicity during treatment for multidrug-resistant tuberculosis: occurrence, management and outcome.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) treatment program in Tomsk, Russia. OBJECTIVE: To describe the incidence and management of hepatotoxicity during treatment of MDR-TB, and to assess risk factors associated with its development and impact on treatment outcomes. DESIGN: A retrospective case series performed among 608 patients. RESULTS: Hepatotoxicity, using American Thoracic Society (2006) definitions, was observed in 91/568 patients (16.5%). The median time to the first hepatotoxic event was 196 days post treatment commencement. Baseline factors associated with hepatotoxicity included elevated alanine aminotransferase/aspartate aminotransferase/bilirubin (OR 53.9, 95%CI 6.30-438.7), and renal insufficiency (OR 19.6, 95%CI 2.71-141.6). High treatment adherence (OR 3.25, 95%CI 2.07-5.09) and starting treatment in prison (OR 1.77, 95%CI 1.04-3.01) were associated with treatment success. Smoking (OR 0.44, 95%CI 0.21-0.92) and bilateral cavitary disease (OR 0.51, 95%CI 0.34-0.77) were associated with worse outcomes. For alcohol users, developing hepatotoxicity was associated with better outcomes (OR 4.40, 95%CI 1.79-10.81) than not (OR 0.42, 95%CI 0.25-0.68). One or more medications were permanently stopped in 10/91 patients, but in no case was treatment entirely discontinued. CONCLUSION: MDR-TB treatment in the face of hepatotoxicity during therapy did not result in a statistically significant increase in poor outcomes.

Patient and doctor perspectives on incorporating smoking cessation into tuberculosis care in Beijing, China.

SETTING: Tuberculosis (TB) hospital in Beijing, China. OBJECTIVE: To describe perspectives of patients and physicians regarding the incorporation of smoking cessation interventions as part of TB treatment. DESIGN: Seven focus groups were conducted with 39 patients and 17 physicians. RESULTS: Patients were more receptive to physicians' advice to quit smoking due to increased concerns about their health after becoming ill with TB. However, patients indicated that they might start smoking again after they recovered from TB. Patients' attempts to quit smoking may have been inhibited by exposure to smoking at the TB facility. Physicians had low levels of knowledge regarding the effect of smoking on TB. Many doctors, particularly those who smoked, did not view smoking cessation as an integral part of TB treatment. CONCLUSION: Despite the presence of a 'teachable moment', TB patients experience significant barriers to quitting smoking. Patient education in TB treatment programs should address the specific effects of smoking on TB and the general health benefits of cessation. Smoke-free policies should be strictly enforced in TB facilities. Successful integration of smoking cessation interventions within TB treatment regimens may require that providers adopt smoking cessation as an essential part of TB treatment.

Use of fluoroquinolone antibiotics leads to tuberculosis treatment delay in a South African gold mining community.

BACKGROUND: Empiric use of fluoroquinolone (FQ) antibiotics could delay tuberculosis (TB) treatment and lead to FQ-resistant TB. METHODS: We examined the impact of FQ use on TB outcomes, including smear status, treatment delay and FQ resistance, through a retrospective cohort study of 440 FQ-exposed and 511 non-exposed patients in a gold mining community in South Africa. We considered both recent (≤ 100 days before sputum collection) and distant exposure (≤ 1 year). We examined 201 and 180 isolates from FQ-exposed and non-exposed individuals for the presence of gyrA mutations. RESULTS: Patients recently exposed to ≥ 5 days of FQ were less likely to be smear-positive (OR 0.27, 95%CI 0.11-0.63), with an increased time to treatment (time ratio 2.02, 95%CI 1.19-3.44). The strength of association decreased when we considered distant exposure. Adjusting for smear status nullified the effect of FQ exposure on treatment delay. We detected a gyrA mutation in one isolate (0.5%) taken from an individual exposed to FQ for 8 days. CONCLUSION: FQ exposure is associated with treatment delay, mediated by negative smear status. Short exposures to FQ do not routinely lead to resistance encoded by gyrA mutations. We recommend prudent use of FQ in settings with a high burden of human immunodeficiency virus and TB.

Electronic laboratory system reduces errors in National Tuberculosis Program: a cluster randomized controlled trial.

OBJECTIVE: To evaluate the impact of the e-Chasqui laboratory information system in reducing reporting errors compared to the current paper system. DESIGN: Cluster randomized controlled trial in 76 health centers (HCs) between 2004 and 2008. METHODS: Baseline data were collected every 4 months for 12 months. HCs were then randomly assigned to intervention (e-Chasqui) or control (paper). Further data were collected for the same months the following year. Comparisons were made between intervention and control HCs, and before and after the intervention. RESULTS: Intervention HCs had respectively 82% and 87% fewer errors in reporting results for drug susceptibility tests (2.1% vs. 11.9%, P = 0.001, OR 0.17, 95%CI 0.09-0.31) and cultures (2.0% vs. 15.1%, P < 0.001, OR 0.13, 95%CI 0.07-0.24), than control HCs. Preventing missing results through online viewing accounted for at least 72% of all errors. e-Chasqui users sent on average three electronic error reports per week to the laboratories. CONCLUSIONS: e-Chasqui reduced the number of missing laboratory results at point-of-care health centers. Clinical users confirmed viewing electronic results not available on paper. Reporting errors to the laboratory using e-Chasqui promoted continuous quality improvement. The e-Chasqui laboratory information system is an important part of laboratory infrastructure improvements to support multidrug-resistant tuberculosis care in Peru.

Recombinant human epidermal growth factor treatment of radiation-induced severe oral mucositis in patients with head and neck malignancies.

Mucositis of the oral cavity and pharynx is a major dose-limiting factor in the application of radiotherapy (RT) to patients with head and neck cancer. Therefore, we evaluated the wound healing effect of human recombinant epidermal growth factor (rhEGF) in head and neck cancer and lymphoma patients with irradiation (with or without combined chemotherapy-induced oral mucositis). Patients at Asan Medical Center who had undergone definitive RT of the head and neck region with or without combined chemotherapy and who had developed severe oral mucositis (higher than the Radiation Therapy Oncology Group grade 3) were treated with topical rhEGF twice daily for 7 days. The evaluation of response with regard to oral mucositis was performed 1 week later. Of the 11 treated patients, three had nasopharyngeal carcinoma, three had carcinoma of the oropharynx, two had carcinoma of the oral cavity, one had carcinoma of the hypopharynx and two had lymphoma of the head and neck. Six patients received RT only, and five patients received concurrent chemoradiotherapy. All patients showed improvements in their oral mucositis after topical treatment with rhEGF in that the Radiation Therapy Oncology Group grade was significantly decreased (P = 0.0000). This finding suggests that rhEGF is effective and safe for the treatment of radiation-induced mucositis. Further studies are needed to determine the optimal dosage and fractionation schedule.

Neurolysis of the distal superficial radial nerve for dysaesthesia due to nerve tethering.

The subcutaneous course of the superficial radial nerve over the radial border of the wrist and hand renders it very susceptible to injury. Both traumatic and iatrogenic injury can produce tethering of this nerve, presenting as dysaesthesia. This study was designed to evaluate the efficacy of neurolysis of the distal superficial radial nerve for this condition. Twenty-five cases of tethered superficial radial nerves underwent neurolysis. At final follow-up (mean 3.5 years), fourteen cases reported symptomatic resolution while eleven continued to experience dysaesthesia. Intra-operatively, evidence of external abnormality, scarring, or compression was identified in only six cases, and its presence did not correlate with symptomatic outcome. Although the majority of patients were improved postoperatively, the success rate was lower than anticipated. Therefore, while neurolysis of the superficial radial nerve offers the opportunity for pain relief, it does not reliably produce success.

Expanding global HIV treatment: case studies from the field.

In the last 25 years, human immunodeficiency virus (HIV) has become the leading infectious killer of adults globally, with an estimated 44 million people infected with the virus worldwide. Most of these individuals live in poor regions of the world, particularly sub-Saharan Africa. Although a great deal of work has been done in identifying and treating individuals with the disease, there has been little action to date to address the complex socioeconomic factors that lie at the heart of this global pandemic. Understanding and responding to such factors is of paramount importance if HIV infection is to be managed in a meaningful way. This article explores the social context of people living with HIV in three different geographic and epidemiologic settings and highlights the social factors that shape and define an individual's risk of acquiring HIV. It also discusses unique programs aimed at addressing the complex realities of the world in which HIV thrives. These programs can act as models of HIV prevention and treatment.

Treating multidrug-resistant tuberculosis in Tomsk, Russia: developing programs that address the linkage between poverty and disease.

Tuberculosis (TB) and multidrug-resistant TB (MDR-TB) are diseases of poverty. Because Mycobacterium tuberculosis exists predominantly in a social space often defined by poverty and its comorbidities--overcrowded or congregate living conditions, substance dependence or abuse, and lack of access to proper health services, to name a few--the biology of this organism and of TB drug resistance is intimately linked to the social world in which patients live. This association is demonstrated in Russia, where political changes in the 1990s resulted in increased socioeconomic inequality and a breakdown in health services. The effect on TB and MDR-TB is reflected both in terms of a rise in TB and MDR-TB incidence and increased morbidity and mortality associated with the disease. We present the case example of Tomsk Oblast to delineate how poverty contributed to a growing MDR-TB epidemic and increasing socioeconomic barriers to successful care, even when available. The MDR-TB pilot project implemented in Tomsk addressed both programmatic and socioeconomic factors associated with unfavorable outcomes. The result has been a strengthening of the overall TB control program in the region and improved case-holding for the most vulnerable patients. The model of MDR-TB care in Tomsk is applicable for other resource-poor settings facing challenges to TB and MDR-TB control.