Top PDF Mortality among MDR-TB cases: comparison with drug-susceptible tuberculosis and associated factors.

Mortality among MDR-TB cases: comparison with drug-susceptible tuberculosis and associated factors.

Mortality among MDR-TB cases: comparison with drug-susceptible tuberculosis and associated factors.

This study includes over 200 cases of MDR-TB under a directly-observed treatment scheme (DOTS), which is a notable strength. In addition, sample size allowed us to control for several variables in our proposed models. Nevertheless, this study has several limitations. First, non- TB related deaths such as accidents or other chronic diseases could have been included as the death certificate stating specific cause of death was not available. Although this might propose a bias in our findings, the results are greatly compatible and comparable with literature. Sec- ond, it was not possible to obtain drug-susceptibility test data for non-MDR TB participants. Drug-susceptibility and cultures are performed only in those with high risk or suspected MDR- TB, yet are not done in patients without such risk factors. Third, the starting point of evalua- tion, especially in the situation of MDR-TB cases, can be an issue as potentially resistant forms of tuberculosis may need longer periods of diagnosis and have previously administered treat- ment. Therefore, our results might be overestimated. Nonetheless, our findings are comparable to the investigations previously mentioned—many of which consider the beginning of treat- ment as their starting point of analysis. In addition, data from the ESNPCT maintains a certain level of objectivity and uniformity as it bases its clinical records on clinical forms and notifica- tions. Fourth, there is a possibility of misclassification of MDR-TB into the drug-susceptible group as MDR-TB is widely under-diagnosed. Nevertheless, our findings show a high propor- tion of MDR-TB cases (about 20%), greater than previous studies using cultures to detect resis- tant cases [11] and even greater than the official ESNPCT surveillance report [5]. Finally, the data concerning smoking, alcohol and drug use was collected as a self-report notification. No clinical parameters, questionnaires or scales were applied to properly define the use of these substances. Due to its small amount, we believe that the risk of misclassification is non-differ- ential, thus allowing the report of a true association.
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Predictors of multidrug- and extensively drug-resistant tuberculosis in a high HIV prevalence community.

Predictors of multidrug- and extensively drug-resistant tuberculosis in a high HIV prevalence community.

While several studies have shown previous TB treatment to be a risk factor for MDR TB [15,16], little is known about the relative contribution of this and other risk factors in high HIV prevalence settings. Drug-resistant TB risk factors are likely to differ in low- resource, high HIV prevalence settings due to the increased risk of transmission in congregate settings [17], more rapid progression to active disease following infection [18], and higher mortality from TB/HIV co-infection [4,19]. Thus, patients are less likely to survive multiple prior courses of TB treatment and fit the classic profile of a ‘‘chronic’’ TB case. Conversely, HIV/AIDS has been associated with TB drug malabsorption [20], which may contribute to higher rates of amplified drug resistance in this setting. To date, there have been no studies of clinical or epidemiologic risk factors for MDR or XDR TB in a high HIV prevalence setting.
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Rates of anti-tuberculosis drug resistance in Kampala-Uganda are low and not associated with HIV infection.

Rates of anti-tuberculosis drug resistance in Kampala-Uganda are low and not associated with HIV infection.

The overall low MDR prevalence could result from community- based TB care with fewer chances of MDR-TB and HIV infected patients coming into close contact when seeking care in health facilities. In settings with high HIV prevalence, MDR outbreaks have been reported, generally resulting in increased anti-TB drug resistance prevalence among HIV infected patients [13]. Lack of association between drug resistance and HIV infection shows that opportunities for (nosocomial) transmission of drug-resistant TB may indeed be limited. In addition, supply of fixed dose combinations free of charge by the NTLP may contribute to patient adherence and prevent monotherapy during treatment. Finally the Uganda NTLP uses for adult new TB patients, who contribute about 80% of all the adult TB cases in Kampala, the eight-month standard regimen in which rifampicin is only given in the intensive phase. This regimen is likely to result in higher relapse rates than the six-month regimen where rifampicin is used Table 2. Anti-TB drug resistance among new and previously treated cases in Kampala; August-December 2008.
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Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

Incidences of tuberculosis (TB) in EE are approximately 100 new cases per 100 000 per year in countries such as Russia, Belarus, and Latvia, and the prevalence of HIV coinfection is esti- mated to be 5–19% [4]. TB in HIV-positive individuals poses a diagnostic challenge in terms of lower sensitivity for smear microscopy, atypical chest radiographic appearances, and frequent extra-pulmonary localisation. TB treatment also poses a challenge due to long term high pill- burden regimens, interactions between TB medication and cART, overlapping toxicity and adherence issues, and especially in EE, high rates of multi-drug resistant TB (MDR-TB), concurrent hepatitis C coinfection, and injecting drug use (IDU) [5 – 7]. The prevalence of MDR-TB and extensively drug-resistant TB (XDR-TB) is particularly high, and still increasing, in EE and Central Asia [4, 8, 9]. Proportions of MDR-TB have been reported ranging from 12– 35% in new TB cases to 32–77% in retreatment cases in Latvia, Russia and Belarus [6, 8, 10]. Treatment of MDR-TB and XDR-TB is both complicated and costly, and associated with high morbidity and mortality [11 – 14]. The extent of TB and HIV coinfection in EE is probably underestimated as many countries in this region have suboptimal diagnostic services and sur- veillance systems for both TB and HIV, including data on anti-TB drug resistance [8].
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Primary drug-resistant tuberculosis in Hanoi, Viet Nam: present status and risk factors.

Primary drug-resistant tuberculosis in Hanoi, Viet Nam: present status and risk factors.

The association between younger age and anti-TB drug resistance has been reported previously [9,21]. The results of univariate and multivariate analyses performed in our study indicate that primary drug resistance among the younger population may be confounded by the recent transmission of Beijing strains [9,22]. In the current study, living in an old urban area and infection with clustered strains were associated with INH, but not SM, resistance, suggesting that the transmission of INH-resistant strains is concentrated in areas with a high population density, whereas SM-resistant strains are spreading more diffusely throughout the city. Initially, SM was used for treatment of wound infections during the war in Viet Nam in the early 1950s, which may partly explain the widespread development of SM-resistant nonclustered strains, whereas INH was first circulated in 1960s, and RMP was introduced at around 1975 [23,24]. The Beijing genotype was significantly associated with resistance to any drug, INH, and SM, but it was not associated with either RMP resistance or MDR. A direct role of Beijing strains in drug resistance remains controversial [22,25-27].
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Loss-To-Follow-Up on Multidrug Resistant Tuberculosis Treatment in Gujarat, India: The WHEN and WHO of It.

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

Systematic reviews have described a plethora of characteristics associated with LFU along with other poor TB outcomes while on TB treatment, which include socio-demographic factors (age, male sex, lower socioeconomic status, low education level), clinical factors(low BMI, alco- holism, HIV-infection, drug use) and programmatic factors(treatment adverse events, prior history of anti-tuberculosis treatment, previous LFU, poor bacteriologic response and treat- ment duration prior to LFU)and certain other factors such as lack of social support, dissatisfac- tion with health care worker attitudes and lack of counseling[1,2,7,8,9]. Previous studies that examined risk factors specific to MDR-TB treatment LFU, found that it was most strongly pre- dicted by substance abuse, dissatisfaction with healthcare worker’s attitudes, low or unstable socioeconomic status and poor response to treatment[7,10]. There is however, paucity of litera- ture for programmatic factors associated with LFU in the global and Indian contexts. This study aimed to determine the proportion of LFU and the factors associated with LFU among patients put on MDR-TB treatment in a programmatic setting in Central Gujarat, India. A comprehensive understanding of these factors may assist to develop effective programmatic, patient-centered strategies to improve retention in care.
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Factors associated with underreporting of tuberculosis based on data from Sinan Aids and Sinan TB

Factors associated with underreporting of tuberculosis based on data from Sinan Aids and Sinan TB

ABSTRACT: Introduction: Tuberculosis (TB) is one of the world’s major public health problems. Epidemiological surveillance has proved to be an important tool to assist in the control and prevention of communicable diseases such as TB and AIDS. This study aimed to estimate the rate and factors associated with the underreporting of TB among cases of coinfection with human immunodeficiency virus (HIV)/AIDS in the state of Pernambuco, based on data from the TB and Aids Notifiable Diseases Information System (Sinan TB and Sinan AIDS). Methods: A cross-sectional study was carried out based on the records of the TB and AIDS Notification System to identify cases of TB underreporting in the study period. In order to identify underreporting, a probabilistic linkage was undertaken using RecLink III software. Results: The rate of TB underreporting was 29%, and the factors associated were: presenting a clinical form of TB as cavitary or unspecified pulmonary TB or having both kinds of TB at the same time; being treated outside the municipality of Recife; and being treated at health services not specialized for HIV/AIDS. Discussion: The proportion of underreporting found in our study was lower than that observed in other Brazilian studies that took into account underreporting from mortality data. Conclusion: The variables associated with underreporting of TB were mostly related to the healthcare system rather than to individual characteristics, which points to the need for training of health professionals in order to notify the information systems correctly.
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Treatment outcomes of new tuberculosis patients hospitalized in Kampala, Uganda: a prospective cohort study.

Treatment outcomes of new tuberculosis patients hospitalized in Kampala, Uganda: a prospective cohort study.

We enrolled 96 hospitalized TB patients of whom 64 (66.7%) were HIV -infected. Table 1 compares characteristics of partic- ipants at the time of enrolment by HIV status. The mean age of HIV-uninfected was 32.3 years, which was similar to that of HIV- infected (33.1 years). There was a higher proportion of females among HIV-infected than among the HIV-uninfected (61% vs. 22%). The duration of symptoms before hospitalization was shorter among HIV-infected (median 12 weeks, IQR 8-16) than among HIV-uninfected (median 16 weeks, IQR 8 – 24). The prevalence of different symptoms at the time of time of admission was similar in the 2 groups. Cavitation on chest X-ray was observed more frequently in HIV-uninfected (87%) compared to HIV-infected (20%) and a higher proportion of HIV-uninfected were judged to have severe disease on the chest X-ray (90% vs. 43%). HIV-infected patients generally presented with advanced AIDS (median CD4 cell count 58 cells/ m l). Six patients (2 HIV- uninfected and 4 HIV-infected) had mono-resistance to INH or RIF and one patient (HIV uninfected) had primary MDR-TB.
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Additional Risk factors for infection by multidrug-resistant pathogens in healthcare associated infection: a large cohort study

Additional Risk factors for infection by multidrug-resistant pathogens in healthcare associated infection: a large cohort study

All variables potentially associated with MDR pathogen infection (including MDR-GN and ESKAPE pathogens) were studied among all infected patients admitted from the community, those with CAI and HCAI, and included: age, sex, previous antibiotic therapy, hospitalization in the previous year, immunosuppression, chronic hepatic dis- ease, chronic heart failure, chronic respiratory disease, chronic hematologic disease, cancer, diabetes, atheroscler- osis and decreased functional capacity (Karnofsky index <70). Those with a clear association in the univariate ana- lysis (p < 0.1) were included in the multivariable analysis. The results of the multivariable models are expressed as odds ratio (OR) with 95% confidence interval and p- values. The calibration was tested using the Hosmer- Lemeshow goodness-of-fit test. The significance level was defined as p < 0.05. Data were analyzed using SPSS ver- sion 18 for Windows (SPSS Inc., Chicago, IL, USA).
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Emergência da tuberculose muitirresistente e extensivamente resistente : caracterização em co-infectados por VIH e em imunocompetentes

Emergência da tuberculose muitirresistente e extensivamente resistente : caracterização em co-infectados por VIH e em imunocompetentes

de M. tuberculosis multirresistente, 238,356,357 seria documentada por genotipagem e por estudo epidemiológico. 102,118,126,128,129,182,358-360 De facto, um doente co-infectado por VIH, a quem fora diagnosticada TB sensível aos antituberculosos de 1ª linha, em Setembro de 1994, e que era acompanhado no Serviço, emigrou para Londres, onde, em Abril de 1995, lhe foi diagnosticada TB MR, num hospital local. A caracterização molecular por RFLP-IS6110 foi feita em todos os isolados de M. tuberculosis deste caso índice, em oito doentes ingleses seropositivos para VIH, que entretanto contactaram o doente naquela cidade e, ainda, em 16 estirpes de M. tuberculosis multirresistente, de igual número de doentes, do Serviço, em Lisboa. A análise de DNA fingerprinting identificou duas estirpes geneticamente distintas de M. tuberculosis no caso índice, indicando que o doente adquiriu uma segunda infecção com uma estirpe multirresistente. Todas as estirpes de TB MR dos oito doentes infectados de Londres e de seis dos doentes de Lisboa eram indistinguíveis, demonstrando-se que foi em Portugal, que adquiriu a segunda estirpe. A estirpe daquele doente (identificada como estirpe B), revelava uma larga epidemia de TB MR que decorria em Lisboa, e a continuação do estudo mostraria que circulavam entre os doentes dois clusters de estirpes de TB MR diferentes, mas geneticamente relacionados (identificados como pertencendo à família Lisboa), sugerindo a existência de dois surtos epidémicos simultâneos entre nós. 126 Nesta epidemia, em que a percentagem de doentes não curados foi muito superior para os co-infectados por VIH (90,0% vs 16,7% em imunocompetentes) e que se caracterizou por grande rapidez de progressão e elevada taxa de mortalidade, demonstrou-se, a partir de um doente co-infectado por VIH, a transmissão primária quer a outros co-infectados por VIH, quer a imunocompetentes, com possível passagem para a comunidade. 102,129,182 Por estes anos o CDC de Atlanta reportava um grande número de epidemias hospitalares e institucionais nos EUA, nas quais a TB MR se espalhava entre doentes e profissionais de saúde, resultando em elevada mortalidade. 53,60-65,132,361 O mesmo era relatado no sul da Europa 59,66-
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Rev. Soc. Bras. Med. Trop.  vol.49 número4

Rev. Soc. Bras. Med. Trop. vol.49 número4

Introduction: Recent studies have shown a high incidence and prevalence of latent tuberculosis infection (LTBI) in indigenous populations around the World. We aimed to estimate the prevalence and annual risk of infection (ARI) as well as to identify factors associated with LTBI in an indigenous population from the Brazilian Amazon. Methods: We conducted a cross-sectional study in 2011. We performed tuberculin skin tests (TSTs), smears and cultures of sputum samples, and chest radiographs for individuals who reported cough for two or more weeks. Associations between LTBI (TST ≥5mm) and socio-demographic, clinical, and epidemiological characteristics were investigated using Poisson regression with robust variance. Prevalence ratio (PR) was used as the measure of association. Results: We examined 263 individuals. The prevalence of LTBI was 40.3%, and the ARI was 2.4%. Age ≥15 years [PR=5.5; 95% confi dence interval (CI): 3.5-8.6], contact with tuberculosis (TB) patients (PR=3.8; 95% CI: 1.2–11.9), previous TB history (PR=1.4; 95% CI: 1.2-1.7), and presence of Bacillus Calmette-Guérin (BCG) scar (PR=1.9, 95% CI: 1.2-2.9) were associated with LTBI. 
 Conclusions : Although some adults may have been infected years prior, the high prevalence of infection and its strong association with age ≥15 years, history of TB, and recent contact with TB patients suggest that the TB transmission risk is high in the study area.
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Factors associated with pulmonary tuberculosis among patients seeking medical attention at referral clinics for tuberculosis

Factors associated with pulmonary tuberculosis among patients seeking medical attention at referral clinics for tuberculosis

Objective: The identification of behavioral and clinical factors that are associated with pulmonary tuberculosis might improve the detection and treatment of the disease, thereby reducing its duration and transmission. Our objective was to identify sociodemographic, clinical, and behavioral factors that are associated with the diagnosis of pulmonary tuberculosis. Methods: This was a cross-sectional study conducted between April of 2008 and March of 2009 at three health care clinics in the city of Fortaleza, Brazil. We selected 233 patients older than 14 years of age who spontaneously sought medical attention and presented with cough for ≥ 2 weeks. Sociodemographic, clinical, and behavioral data were collected. Sputum smear microscopy for AFB and mycobacterial culture were also carried out, as were tuberculin skin tests and chest X-rays. The patients were divided into two groups (with and without pulmonary tuberculosis). The categorical variables were compared by the chi-square test, followed by logistic regression analysis when the variables were considered significant. Results: The prevalence of pulmonary tuberculosis was 41.2%. The unadjusted OR showed that the following variables were statistically significant risk factors for pulmonary tuberculosis: fever (OR = 2.39; 95% CI, 1.34-4.30), anorexia (OR = 3.69; 95% CI, 2.03-6.75), and weight loss (OR = 3.37; 95% CI, 1.76-6.62). In the multivariate analysis, only weight loss (OR = 3.31; 95% CI, 1.78-6.14) was significantly associated with pulmonary tuberculosis. Conclusions: In areas with a high prevalence of tuberculosis, weight loss could be used as an indicator of pulmonary tuberculosis in patients with chronic cough for ≥ 2 weeks.
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Cad. Saúde Pública  vol.31 número9

Cad. Saúde Pública vol.31 número9

These studies show that low socioeconomic sta- tus negatively influences adherence due to the direct and indirect costs of treatment, such as transport, additional medication, and even the time spent on treatment (i.e., time spent away from work) 6,7,28 . Our study suggests that other factors also affect adherence among patients with low socioeconomic status. Patients who have to use more than one means of transport to visit the health center were five times more likely to not adhere than patients who only use one means. Several studies show that high transport costs reduce the patient’s capacity to continue treatment, particularly those with a low socio- economic status 6,7,11 . In our study, household income was lower among nonadherent patients than in adherent patients. However, this vari- able was excluded from the final model due to the small sample size. Further research is needed to analyze the influence of indirect costs on pa- tients’ capacity to adhere to treatment, particu- larly in high poverty contexts.
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Treat MDR-TB and XDR-TB Reducing pill burden Lower dosing frequency Drug-drug interactions Available in low price

Treat MDR-TB and XDR-TB Reducing pill burden Lower dosing frequency Drug-drug interactions Available in low price

Tuberculosis infection is a serious human health threat and the early 21st century has seen a remarkable increase in global tuberculosis activity. The pathogen responsible for tuber- culosis is Mycobacterium tuberculosis, which adopts diverse strategies in order to survive in a variety of host lesions. These survival mechanisms make the pathogen resistant to cur- rently available drugs, a major contributing factor in the failure to control the spread of tuberculosis. Multiple drugs are available for clinical use and several potential compounds are being screened, synthesized, or evaluated in preclinical or clinical studies. Lasting and effective achievements in the development of anti-tuberculosis drugs will depend largely on the proper understanding of the complex interactions between the pathogen and its human host. Ample evidence exists to explain the characteristics of tuberculosis. In this study, we highlighted the challenges for the development of novel drugs with potent bacterio- static or bactericidal activity, which reduce the minimum time required to cure tuberculosis infection.
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Use of Lot Quality Assurance Sampling to Ascertain Levels of Drug Resistant Tuberculosis in Western Kenya.

Use of Lot Quality Assurance Sampling to Ascertain Levels of Drug Resistant Tuberculosis in Western Kenya.

As compared to countrywide surveys, targeted LQAS typically costs less than the average national survey price of $250,000-$300,000, given that fewer resources are needed to evaluate a smaller sample size [4], and typically has more rapid completion times. As a result, LQAS may offer TB control programs an alternative approach to evaluate levels of resistance in suspected localized hotspots or to investigate emerging resistance in the time between conducting larger surveys. Information about high or low levels of resistance may help inform programs as to the need to re-evaluate policies. Such policies include free provision of DST only for failing or relapsed patients rather than for all TB patients and all contacts of patients diagnosed with drug resistant TB as well as the use of alternative initial empiric treatment regimens for TB patients pending further information in areas where primary drug resistance is found to be at a high level. Although this study did not speed the survey completion time, the study provided information about a specific area with suspected high levels of resistance during a time period when the next country-wide survey was not yet being conducted and may not have included the potential hotspot as a site of sampling. Findings were shared with the national TB program, which was prepared to target greater resources to both sites if they had been classified as having high resistance.
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J. bras. pneumol.  vol.33 número5 en v33n5a14

J. bras. pneumol. vol.33 número5 en v33n5a14

Para descrever a resistência a drogas em cepas de Mycobacterium tuberculosis isoladas de amostras de escarro de 263 pacientes suspeitos de tuberculose moradores do Complexo de Manguinhos, Rio de Janeiro, Brasil, as culturas positivas entre outubro de 2000 e dezembro de 2002 foram submetidas a teste de sensibilidade para isoniazida, rifampicina, estreptomicina, etionamida e etambutol. Resistência a qualquer das drogas foi encontrada em 21,4% (16/75) dos pacientes diagnosticados com tuberculose. Destes, 50% (8/16) eram casos novos e 50% (8/16) eram casos com tratamento anterior. A tuberculose multirresistente foi encontrada em 10,6% (8/75) do total de pacientes, estando associada a tratamento anterior em 8% (6/75) deles. Nossos resultados podem ter sido subestimados, pois M. tuberculosis não pôde ser isolado em todas as amostras positivas para bacilos álcool-ácido resistentes. Contudo, eles pelo menos revelam parte do problema.
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Ciênc. saúde coletiva  vol.22 número12

Ciênc. saúde coletiva vol.22 número12

We can conclude that the probability of relapse was higher in adults with pulmonary tuberculo- sis and readmission in young male adults with low education, alcohol-dependent and with greater odds of abandoning treatment again. Thus, a systematic follow-up of post-discharge tuberculosis cases, in addition to investments in education and health, can contribute to the pre- vention and control of the cases. It is worth men- tioning that, in this context, the structuring of programs to meet this demand and the training of community workers, which serve as a bridge between health services and the community are important points that can contribute to a better control of tuberculosis.
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Identificação de ligantes da chiquimato quinase de Mycobacterium tuberculosis por docking molecular

Identificação de ligantes da chiquimato quinase de Mycobacterium tuberculosis por docking molecular

Tuberculosis (TB) is the major cause of human mortality from a curable infectious disease, attacking mainly in developing countries. Among targets identified in Mycobacterium tuberculosis genome, enzymes of the shikimate pathway deserve special attention, since they are essential to the survival of the microorganism and absent in mammals. The object of our study is shikimate kinase (SK), the fifth enzyme of this pathway. We applied virtual screening methods in order to identify new potential inhibitors for this enzyme. In this work we employed MOLDOCK program in all molecular docking simulations. Accuracy of enzyme-ligand docking was validated on a set of 12 SK-ligand complexes for which crystallographic structures were available, generating root-mean square deviations below 2.0 Å. Application of this protocol against a commercially available database allowed identification of new molecules with potential to become drugs against TB. Besides, we have identified the binding cavity residues that are essential to intermolecular interactions of this enzyme.
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Fatores associados ao abandono e ao óbito de casos de tuberculose drogarresistente (TBDR) atendidos em um centro de referência no Rio de Janeiro, Brasil Factors associated with loss to follow-up and death in cases of drug-resistant tuberculosis (DR-TB) tr

Fatores associados ao abandono e ao óbito de casos de tuberculose drogarresistente (TBDR) atendidos em um centro de referência no Rio de Janeiro, Brasil Factors associated with loss to follow-up and death in cases of drug-resistant tuberculosis (DR-TB) tr

La tuberculosis farmacorresistente (TBFR) repre- senta hoy una grave amenaza para los avances en el control de la tuberculosis (TB) en Brasil y en el mundo. En este estudio, se investigan factores aso- ciados al abandono y al óbito de casos en trata- miento para TBDR, dentro de un centro de refe- rencia de carácter terciario del municipio de Río de Janeiro, Brasil. Se trata de un estudio de cohorte retrospectiva, a partir de los casos notificados en el Sistema de Información de Tratamientos Especia- les de Tuberculosis (SITETB), durante el período del 1 de enero de 2012 al 31 de diciembre de 2013. Un total de 257 pacientes fue notificado en el SI- TETB y comenzó el tratamiento para TBDR. De ese total, 139 (un 54,1%) tuvieron éxito terapéu- tico como desenlace, 54 (un 21%) abandonaron el tratamiento y un 21 (8,2%) evolucionaron hacia óbito. Tras el análisis de regresión logística mul- tinomial múltiple, la franja de edad por encima de cincuenta años se observó como el único factor de protección al abandono, al mismo tiempo que tener menos de ocho años de escolaridad y rein- gresar en el sistema educativo tras el abandono fueron considerados como factores de riesgo. Re- ingreso tras abandono, recidiva e insolvencia indi- caron factores de riesgo. Nuestros datos refuerzan la concepción de que el abandono del tratamien- to de tuberculosis resistente es un serio problema de salud pública, siendo necesario un adecuado acompañamiento en el tratamiento de pacientes con este historial y con baja escolaridad. Además, una red de apoyo social entorno al paciente es im- prescindible para que los desenlaces desfavorables sean evitados.
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Factors associated with maternal mortality among patients meeting criteria of severe maternal morbidity and near miss

Factors associated with maternal mortality among patients meeting criteria of severe maternal morbidity and near miss

The study has strengths. First, its population is similar to that of numerous other studies, and the sample represents epidemio- logically the obstetric population in economically disadvantaged regions, thereby allowing its findings to be extrapolated to other locations in Brazil and other countries. Second, the 1-year study period should take into account all possible seasonal interferences. Third, its approach was directed toward the criteria of near miss and severe maternal morbidity in an obstetric and neonatal referral cen- ter.Thespecificassociationofeachoneofthesecriteriawaseval- uated directly, in addition to how the interference between them can contribute to maternal death, identifying those that are prin- cipallyresponsiblefortheunfavorableoutcomeinthispopulation. Accordingly,inapopulationclassifiedasseverematernalmorbidity ornearmiss,asdefinedbyWHO,themaindeterminingcriteriafor maternal death were eclampsia, low oxygen saturation, need for admission in ICU, need for intubation, mechanical ventilation, and cardiopulmonary resuscitation. The use of magnesium sulfate was foundtobeaprotectivefactor.
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