Tuberculosis in children treated with second-line drugs under programmatic conditions in Lima, Peru.

OBJECTIVE: To characterise childhood tuberculosis (TB) treated with second-line drugs (SLDs) in Lima, Peru. DESIGN: Results for the age groups <5 and 5-14 years were compared and treatment outcomes were assessed in cases reported between 2011 and 2015 from six districts of Lima. RESULTS: Of 96 reported cases, 82 were evaluated. Among these, 59% were boys; the median age was 8 years and 32% were aged <5 years. Contact with a TB case was reported in 82% of cases; 90% were treatment-naïve, 98% had pulmonary localisation and 50% underwent the tuberculin skin test (purified protein derivative), with induration 10 mm in 88%. A positive smear was found in 40%, all in the 5-14 years age group, and 46% were culture-positive. Only 26% had confirmed multidrug-resistant TB, 90% of whom were in the 5-14 years age group. SLDs for confirmed or probable drug-resistant TB (DR-TB) were administered to all cases, with a high proportion of success (over 83%), no failures or deaths and a high proportion of loss to follow-up. CONCLUSION: The main indication for SLDs in childhood TB was the empirical treatment of DR-TB due to contact with one or more identified DR-TB patients. Bacteriological confirmation was limited; however, treatment success was adequate.

Rapid drug susceptibility testing and treatment outcomes for multidrug-resistant tuberculosis in Peru.

SETTING: The detection of multidrug-resistant tuberculosis (MDR-TB) using rapid drug susceptibility testing (DST) has increased steadily in recent years in Peru, from 9216 tests in 2010 to 27 021 tests in 2015. Research examining the impact of rapid DST on treatment outcomes is required. OBJECTIVE: To evaluate the association between rapid DST use (nitrate reductase assay, microscopic observation drug susceptibility assay [MODS] and GenoType® MTBDRplus) and treatment outcomes and mortality in MDR-TB patients in Peru. DESIGN: Retrospective cohort study of patients diagnosed with pulmonary MDR-TB between 2010 and 2013 (with treatment outcomes up to December 2015) using the electronic registry of the Peruvian National TB Programme. RESULTS: A total of 2671 MDR-TB patients were included; the median age was 27 years, 2.8% were co-infected with the human immunodeficiency virus. Use of rapid DST was associated with a 40% increase in the adjusted odds of treatment success (aOR 1.40, 95%CI 1.19-1.64) and a 54% reduction in mortality (aOR 0.46, 95%CI 0.33-0.64). Higher treatment success rates were driven by MODS and GenoType® MTBDRplus testing (aORs for unsuccessful outcomes respectively 0.68 and 0.66). CONCLUSION: The use of rapid DST (MODS and MTBDRplus) to diagnose MDR-TB was associated with a reduction in the odds of death and a substantial increase in the odds of treatment success.

Programmatic management of patients with pre-extensively drug-resistant tuberculosis in Peru, 2011-2014.

BACKGROUND: In Peru, a treatment approach for extensively drug-resistant tuberculosis (XDR-TB) incorporating World Health Organization Group 5 drugs and patient-centred care has achieved 65% success. To extend this approach to pre-XDR-TB patients, we evaluated this population separately. OBJECTIVE: To assess programmatic management of pre-XDR-TB. METHOD: Retrospective study using the official national registry from 2011 to 2014. Cases were separately evaluated according to resistance to fluoroquinolones (FQs) (pre-XDR-F) or to second-line injectables (SLIs) (pre-XDR-I). RESULTS: Of 610 pre-XDR-TB patients, 120 (20%) had pre-XDR-F and 490 (80%) had pre-XDR-I. Pre-XDR-F cases were older (34 years vs. 28 years, P < 0.001) and a higher proportion had previously received two or more regimens (70% vs. 38%, P < 0.001). Among the 452 patients who started treatment in 2011-2013, treatment success was 43.3%, 26.5% were lost to follow-up, 12.1% died and 13.7% failed treatment. Success was higher in pre-XDR-I (48.5%) than pre-XDR-F (21.4%) patients. History of previous treatment (OR 2.23, 95%CI 1.52-3.38) and pre-XDR-F (OR 2.39, CI 1.18-4.83) were associated with unsuccessful outcomes. CONCLUSION: Programmatic management of pre-XDR-TB has not been successful, particularly in pre-XDR-F patients, with lower rates of success than those achieved in the same setting for XDR-TB. The strategy used for XDR-TB should be extended to pre-XDR-TB patients in Peru.

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.

Fertility of the male alpaca: effect of daily consecutive breeding.

The fertility of the male alpaca under different frequencies of daily consecutive matings was evaluated. Fifteen adult male Huacaya alpacas were divided randomly into three groups of five each to breed lactating female alpacas. The schedule of daily matings was two, four and six consecutive breeding per group and for nine consecutive days. Ovulation was determined by progesterone at seven days after breeding. Pregnancy was determined by ultrasonography at 15 and 30 days after breeding. Two hundred and eighty females were bred with some males not fulfilling their schedule of breeding. There were differences (P < 0.05) in the fertility rate of males breeding two and four times daily (76%) in contrast to 59% for males breeding six times. There were also differences (P < 0.05) in the fertility of individual males. Length of copulation was affected (P < 0.05) by schedule of matings, day of breeding and male. Ovulation was independent of length of copulation. Overall, it seems the fertility of the male alpaca is affected significantly when consecutive matings are over four times a day and for nine consecutive days.

Semen preservation and artificial insemination in domesticated South American camelids.

Semen preservation and artificial insemination in South American camelids are reviewed giving emphasis to work done in Peru and by the authors. Reports on semen evaluation and the preservation process indicate that semen of alpacas and llamas can be manipulated by making it liquid first. Collagenase appears to be the best enzyme to eliminate viscosity. Tris buffer solution maintains a higher motility than egg-yolk citrate, phosphate buffered saline (PBS), Triladyl, and Merck-I extenders. Cooling of semen took 1h after collected, and equilibrated with 7% glycerol presented a better motility and spermatozoa survival at 1, 7, 15 and 30days after being slowly frozen in 0.25mL plastic straws. Trials of artificial insemination with freshly diluted semen and frozen-thawed semen are encouraging and needs to be tested extensively under field conditions. Recently, fertility rates varied from 3 to 67%. Semen preservation and most important, artificial insemination appear to be a reality, and could be used to improve the genetic quality of alpacas and llamas.

Effect of universal MODS access on pulmonary tuberculosis treatment outcomes in new patients in Peru.

SETTING: Primary health care centres in Callao, Peru. OBJECTIVES: To evaluate the effect of universal access to the microscopic-observation drug susceptibility (MODS) assay on treatment outcomes in new and primary multidrug-resistant tuberculosis (MDR-TB) patients and on the process of drug susceptibility testing (DST). DESIGN: Retrospective review of tuberculosis (TB) registers and clinical records before (2007) and after (2009) the introduction of MODS in 2008. RESULTS: There were 281 patients in each cohort. Favourable treatment outcomes for 2007 (81%) and 2009 (77%) cohorts were similar. There was an increase in loss to follow-up (from 6% to 10%, P = 0.04) and a reduction in failure rates (from 4% to 0.4%, P = 0.01) in the 2009 compared with the 2007 cohort. In new MDR-TB cases (n = 22), a favourable treatment outcome was improved (from 46% to 82%, P = 0.183) in the 2009 cohort. DST coverage improved (from 24% to 74%, P < 0.001), and a significant reduction in time to diagnosis of drug-susceptible (from 118 to 33 days, P < 0.001) and MDR-TB (from 158 to 52 days, P =30.003) was observed in the 2009 cohort. CONCLUSION: Universal access to MODS increased DST coverage, reduced the time required to obtain DST results and was associated with reduced failure rates. MODS can make an important contribution to TB management and control in Peru.

Missed opportunities for tuberculosis diagnosis.

BACKGROUND: In high tuberculosis (TB) burden, resource-poor countries, sputum smear microscopy remains the mainstay of diagnosis. The low sensitivity of this test means that patients with smear-negative but culture-positive TB pass undetected through the health care system. Such clinical episodes are missed opportunities for diagnosis and interruption of transmission, which might be averted through the application of more sensitive diagnostic tests. OBJECTIVES: To estimate the proportion of incident TB cases that might have been detected earlier than the actual date of diagnosis if a test more sensitive than smear microscopy had been used at an earlier presentation episode. METHOD: Retrospective cohort study in urban Peru, investigating health care facility interactions for symptoms suggestive of TB prior to TB diagnosis through patient interviews and a review of clinical records. RESULTS: Of 212 participants enrolled, 58% had one or more clinical interactions prior to their diagnostic episode. Of those with a prior episode, the median number of episodes was three. The median delay to diagnosis from first presentation was 26 days. CONCLUSION: There are clear missed opportunities for earlier TB diagnosis, delaying treatment initiation and continued spread of Mycobacterium tuberculosis to the community. The implementation of sensitive diagnostic tests appropriate to resource-poor settings should be given high priority.

Efecto de 8 semanas de corriente TENS modificada y la corriente rusa, sobre la fuerza muscular y la composición corporal / Efeito de 8 semanas de corrente TENS modificada e corrente russa sobre a força e composição corporal / Effects of 8 weeks of modified TENS current and russian current, on muscle strength and body composition

Objetivo. Comparar el efecto de 2 métodos de electroestimulación en las siguientes variables: fuerza y antropometría. Método. Se realizó una investigación experimental, aleatoria y simple ciego. Se evaluó a 18 sujetos, distribuidos en: Grupo Corriente TENS Modificada (CTM: n = 6), Grupo Corriente Rusa (CR: n = 6) y Grupo Control (TC: n = 6, sometido a corriente TENS Convencional, considerada en la presente investigación como placebo). Resultados. Al cabo de 8 semanas, solo CTM incrementó la fuerza máxima (p < 0.035) y redujo el grosor del pliegue subcutáneo de la pierna derecha (p < 0.03). Conclusiones. La técnica de electroestimulación con corriente TENS Modificada es efectiva para el entrenamiento muscular (AU)

Objetivo. Comparar o efeito de 2 métodos de eletroestimulação nas seguintes variáveis: força e antropometria. Método. Um estudo experimental, randomizado, cego simples. Foram avaliados 18 indivíduos, distribuídos em: grupo de corrente TENS modificada (CTM: n = 6), grupo corrente russa (CR: n = 6) e grupo controle (TC: n = 6, submetido a corrente TENS convencional, considerada nesta investigação como placebo). Resultados. Após 8 semanas, CTM aumentou a força máxima (p < 0,035) e reduziu a espessura de pregas subcutâneas da coxa direita (p < 0,03). Conclusões. A técnica de eletroestimulação com corrente TENS modificada é eficaz para treinamento muscular (AU)

Objective. To compare the effect of two methods of electrostimulation on the following variables: strength and anthropometry. Method. An experimental, randomized, and simple blind investigation was performed. Eighteen subjects were evaluated distributed into a Modified TENS Current Group (CTM: n = 6), Russian Current Group (CR: n = 6), and a Control Group (TC: n = 6, submitted to traditional TENS current, considered as placebo in this research). Results. After 8 weeks, only CTM obtained an increase in maximal strength (p < 0.035), and a reduction in the subcutaneous fat thickness of the right thigh (p < 0.03). Conclusions. A Modified TENS Current is effective for muscular training (AU)

Embarazo ectópico ovárico, reporte de un caso y revisión bibliográfica / Ovarian pregnancy: a case report and literature review

Ovarian pregnancy is a rare event. Its prevalence varies from one in 2100 to one in 60000 pregnancies, corresponding to 1-3 percent of ectopic pregnancies. The diagnosis is a challenge for the clinician, and without adequate resources can be a surgical finding. This article reports the case of a 30 years old woman attended in our hospital with pregnancy as diagnosis, who consulted because of three days of vaginal bleeding and abdominal pain. Ultrasonography showed a tubaric ring with a gestational sac inside, and an embryo with detectable heartbeats. A laparotomy was performed and an embryo around 6 weeks old located in the right ovary was extracted. The patient was discharged from the hospital 2 days after the surgery with a satisfactory evolution...

Curvas antropométricas de recien nacidos chilenos / Curves Chilean newborn anthropometric

Se evaluó el efecto de la fortificación dela harina de trigo con ácido fólico (iniciada en 2003) sobre la ingesta de folatos en la población de mujeres en edad reproductiva y en embarazadas y los niveles séricos de folatoy vitamina B12 en los mismos grupos. Asimismo, se analizaron los cambios ocurridos en las tasas de defectosdel tubo neural antes de la fortificación y después de ella.