Facilitators and barriers to TB care during the COVID-19 pandemic.

BACKGROUND: Knowledge about factors influencing access and adherence to TB care, and on the impact of the COVID-19 pandemic on TB care in resource-restricted settings is scarce. We conducted this study in Atsimo-Andrefana, a rural region in southern Madagascar where TB prevalence, poverty and food insecurity rates are high. We aimed to determine facilitators and barriers to access to and provision of TB care in rural Madagascar during the COVID-19 pandemic. METHODS: We conducted qualitative focus group discussions (FGDs) and in-depth interviews (IDIs) with patients with TB, community health workers, facility-based health workers, public health officials and non-governmental organisation staff. We analysed interviews using thematic analysis. RESULTS: We conducted 11 FGDs and 23 IDIs. We identified three main barriers to access and adherence to TB care: 1) stigma, 2) indirect treatment costs, and 3) food insecurity. The facilitator perceived as most influential was high health worker motivation. The effects of the COVID-19 pandemic on TB care varied between stake-holders; some health workers described delays in TB diagnosis and increased workload. CONCLUSIONS: To improve access and adherence to TB care, both indirect treatment costs and stigma need to be reduced; undernourished patients with TB should receive food support.

CONTEXTE: Les connaissances sur les facteurs influençant l'accès et l'adhésion aux soins antituberculeux, ainsi que sur l'impact de la pandémie de COVID-19 sur les soins antituberculeux dans les milieux à ressources limitées sont rares. Nous avons mené cette étude à Atsimo-Andrefana, une région rurale du sud de Madagascar où la prévalence de la TB et les taux de pauvreté et d'insécurité alimentaire sont élevés. Nous avons cherché à déterminer les facilitateurs et les obstacles à l'accès et à la fourniture de soins antituberculeux dans les zones rurales de Madagascar pendant la pandémie de COVID-19. MÉTHODES: Nous avons mené des discussions qualitatives en groupe (FGD) et des entretiens approfondis (IDI) avec des patients atteints de tuberculose, des agents de santé communautaires, des agents de santé en établissement, des responsables de la santé publique et des membres d'organisations non gouvernementales. Nous avons analysé les entretiens en utilisant l'analyse thématique. RÉSULTATS: Nous avons mené 11 FGD et 23 IDI. Nous avons identifié trois principaux obstacles à l'accès et à l'observance des soins antituberculeux : 1) la stigmatisation, 2) les coûts indirects du traitement et 3) l'insécurité alimentaire. Le facilitateur perçu comme le plus influent était la forte motivation des agents de santé. Les effets de la pandémie de COVID-19 sur les soins antituberculeux varient selon les parties prenantes ; certains agents de santé ont décrit des retards dans le diagnostic de la TB et une augmentation de la charge de travail. CONCLUSIONS: Pour améliorer l'accès et l'adhésion aux soins antituberculeux, il faut réduire à la fois les coûts indirects du traitement et la stigmatisation ; les patients tuberculeux sousalimentés devraient recevoir une aide alimentaire.

Maternal uniparental disomy for chromosome 14 in a boy with a normal karyotype.

We report on a boy with a maternal uniparental disomy for chromosome 14 (UPD(14)). At 7 years of age he was referred to us by the paediatrician because of symptoms of Prader-Willi syndrome (PWS). He showed short stature, obesity, mild developmental delay, cryptorchidism, and some mild dysmorphic features. The history further indicated intrauterine growth retardation at the end of the pregnancy. His mother was 44 years of age at the time of his birth. After birth he showed hypotonia with poor sucking, for which gavage feeding was needed. Motor development was delayed. After 1 year he became obese despite a normal appetite. Recurrent middle ear infections, a high pain threshold, and a great skill with jigsaw puzzles were reported. There were no behavioural problems or sleep disturbance. Chromosomal analysis was normal (46,XY). DNA analysis for Prader-Willi syndrome showed no abnormalities. Two years later he was re-examined because we thought his features fitted the PWS-like phenotype associated with maternal UPD(14). At that time precocious puberty was evident. DNA analysis showed maternal heterodisomy for chromosome 14. In all the previously described 11 cases with maternal UPD(14), a Robertsonian translocation involving chromosome 14 was detected cytogenetically before DNA analysis. This is the first report of diagnosis of maternal UPD(14) based on clinical features. This finding underlines the importance of DNA analysis for maternal UPD(14) in patients with a similar PWS-like phenotype even without previous identification of a Robertsonian translocation involving chromosome 14.

Influence of physical stress on the plasma concentration of serum amyloid-A (SAA) and haptoglobin (Hp) in calves.

The influence of physical stress on the plasma concentration of the acute-phase proteins serum amyloid-A (SAA) and haptoglobin (Hp) was studied in 10 calves. Two different stress levels were created by housing two groups of five calves, each on different types of floor. The stress level was assessed by studying videotapes of the animals, and, subsequently, by quantifying the problems related with moving across the pens and the time the calves spent lying down and standing. Plasma concentrations of Hp, SAA, aldolase, and cortisol were measured in blood samples obtained by jugular venepuncture. Plasma SAA concentrations were significantly (p < 0.001) elevated in animals housed on the floor type associated with the highest level of physical stress, although the concentrations were within the normal range for healthy adult cattle. Hp concentrations were not elevated. The floor type did not alter the stress related biochemical variables aldolase and cortisol. It is concluded that plasma SAA concentrations rise upon physical stress, whereas Hp concentrations do not change. The absence of a significant difference in aldolase or cortisol concentrations indicates that the difference in the level of neuro-endocrine stress between the animals housed on the two floor types is only minimal. Consequently, SAA is suggested to be a sensitive variable to assess physical welfare in calves.

[Sudden and unexpected death in a young child. 'Crib death' in an older child]. / Een plotseling en onverwacht overleden peuter. 'Wiegedood' bij een ouder kind.

The history of a toddler who died suddenly and unexpectedly is given. The day before the child suffered from gastro-enteritis. Postmortem examination revealed hypoglycemia. Urine-analysis was highly suspective of a medium chain acyl-CoA dehydrogenase deficiency. This diagnosis was confirmed by further family-investigation, including identification of the common point mutation in this disorder. The consequence of such a deficiency is discussed.

Prenatal risk factors for cot death in very preterm and small for gestational age infants.

In a nationwide prospective survey on very preterm and very-low-birthweight infants in The Netherlands, the incidence of cot death in infants discharged alive was 15%. The postnatal age at death in these infants did not differ significantly from age at death in other cot death infants. Using a case-control design, possible risk factors associated with cot death were identified: lower maternal age at first pregnancy; maternal smoking during pregnancy; hypothermia of the infant immediately after birth; decreased number of white blood cells and thrombocytes in the infant on the first day of life. Intrauterine hypoxia is hypothesized as the entity common to these factors.

Fatal aplastic anaemia complicating infectious mononucleosis.

A 7-year-old boy developed fatal aplastic anaemia, 2 weeks after the first signs of infectious mononucleosis. Although some drugs were administered, infection with the Epstein-Barr virus, leading to infectious mononucleosis, is assumed to be the cause of this aplastic anaemia. Some mechanisms possibly leading to the aplasia are discussed.