RESUMO
SETTING: Multidrug-resistant TB (MDR-TB) clinical trial in Lima, Peru and Cape Town, South Africa.OBJECTIVE: To identify baseline factors associated with screening failure and study withdrawal in an MDR-TB clinical trial.DESIGN: We screened patients for a randomized, blinded, Phase II trial which assessed culture conversion over the first 6 months of treatment with varying doses of levofloxacin plus an optimized background regimen (ClinicalTrials.gov: NCT01918397). We identified factors for screening failure and study withdrawal using Poisson regression to calculate prevalence ratios and Cox proportional hazard regression to calculate hazard ratios. We adjusted for factors with P < 0.2.RESULTS: Of the 255 patients screened, 144 (56.5%) failed screening. The most common reason for screening failure was an unsuitable resistance profile on sputum-based molecular susceptibility testing (n = 105, 72.9%). No significant baseline predictors of screening failure were identified in the multivariable model. Of the 111 who were enrolled, 33 (30%) failed to complete treatment, mostly for non-adherence and consent withdrawal. No baseline factors predicted study withdrawal in the multivariable model.CONCLUSION: No baseline factors were independently associated with either screening failure or study withdrawal in this secondary analysis of a MDR-TB clinical trial.
Assuntos
Mycobacterium tuberculosis , Tuberculose Resistente a Múltiplos Medicamentos , Antituberculosos/uso terapêutico , Humanos , Levofloxacino/uso terapêutico , África do Sul/epidemiologia , Escarro , Tuberculose Resistente a Múltiplos Medicamentos/complicações , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológicoRESUMO
In Peru, it is estimated that about 150 000-400 000 people carry the Human T-lymphotropic virus 1 (HTLV-1). Only 10% of HTLV-1 carries develop complications related to HTLV-1. HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) is a chronic disabling inflammatory disease affecting the spinal cord. HAM/TSP produces principally weakness in the lower limbs and bladder disturbances, among other complications. In a previous study, our group identified three SNPs (rs3138053, rs2233406, and rs3138045) located in the promoter region of the NFKBIA gene associated with HAM/TSP. This study aimed to analyze the association between four Tag-SNPs (rs10148482, rs17103274, rs17103282, and rs762009) located in the upstream region of the NFKBIA gene and HAM/TSP, and to delimit the linkage disequilibrium zone in the upstream region of the NFBKIA gene associated with HAM/TSP. The tetra-primers ARMS-PCR technique was used to genotype 4 Tag-SNPs on 140 HAM/TSP patients and 258 asymptomatic carriers. The SNP rs17103282 showed a deviation from Hardy-Weinberg equilibrium (pâ¯<â¯.0001). Neither of three Tag-SNPs showed an association with HAM/TSP (Pâ¯>â¯.05). No linkage disequilibrium between four Tag-SNPs evaluated in this study and previous ones was observed. Here we show the region located in the upstream region of the NFKBIA gene highly associated with HAM/TSP disease in patients infected with HTLV-1 from Lima, Peru.
Assuntos
Infecções por HTLV-I/genética , Inibidor de NF-kappaB alfa/genética , Paraparesia Espástica Tropical/virologia , Polimorfismo de Nucleotídeo Único , Adulto , Estudos de Casos e Controles , Feminino , Predisposição Genética para Doença , Humanos , Desequilíbrio de Ligação , Masculino , Pessoa de Meia-Idade , Peru , Carga ViralRESUMO
BACKGROUND: Tuberculosis (TB) diagnosis in human immunodeficiency virus (HIV) positive persons is difficult, particularly in resource-limited settings. The relationship between TB culture status and mortality in HIV-positive persons treated for TB is unclear. METHODS: We evaluated HIV-positive adults treated for TB at or after their first HIV clinic visit in Argentina, Brazil, Chile, Honduras, Mexico or Peru from 2000 to 2015. Anti-tuberculosis treatment included 2 months of isoniazid, rifampicin (RMP)/rifabutin (RBT), pyrazinamide ± ethambutol, followed by continuation phase treatment with isoniazid + RMP/RBT. RESULTS: Of 759 TB-HIV patients, 238 (31%) were culture-negative, 228 (30%) had unknown culture status or did not undergo culture and 293 (39%) were culture-positive. The median CD4 at TB diagnosis was 96 (interquartile range 40-228); 636 (84%) received concurrent antiretroviral therapy (ART) and anti-tuberculosis treatment. There were 123 (16%) deaths: 90/466 (19%) with TB culture-negative, unknown or not performed vs. 33/293 (11%) who were TB culture-positive (P = 0.005). In Kaplan-Meier analysis, mortality in TB patients without culture-confirmed disease was higher (P = 0.002). In a Cox model adjusted for age, sex, CD4, ART timing, disease site and stratified by study site, mortality in persons without culture-confirmed TB was not significantly increased compared to those with culture-positive TB (hazard ratio 1.39, 95%CI 0.89-2.16, P = 0.15). CONCLUSION: Most HIV-positive patients treated for TB did not have culture-confirmed TB, and mortality tended to be higher in patients without culture-confirmed disease, although the association was not statistically different after adjusting for other variables. Accurate TB diagnosis in HIV-positive persons is crucial.
Assuntos
Fármacos Anti-HIV/administração & dosagem , Antituberculosos/administração & dosagem , Infecções por HIV/complicações , Tuberculose/diagnóstico , Adulto , Contagem de Linfócito CD4 , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/mortalidade , Humanos , América Latina , Masculino , Tuberculose/tratamento farmacológicoRESUMO
We compared the cost-effectiveness (CE) of an active case-finding (ACF) programme for household contacts of tuberculosis (TB) cases enrolled in first-line treatment to routine passive case-finding (PCF) within an established national TB programme in Peru. Decision analysis was used to model detection of TB in household contacts through: (1) self-report of symptomatic cases for evaluation (PCF), (2) a provider-initiated ACF programme, (3) addition of an Xpert MTB/RIF diagnostic test for a single sputum sample from household contacts, and (4) all strategies combined. CE was calculated as the incremental cost-effectiveness ratio (ICER) in terms of US dollars per disability-adjusted life years (DALYs) averted. Compared to PCF alone, ACF for household contacts resulted in an ICER of $2155 per DALY averted. The addition of the Xpert MTB/RIF diagnostic test resulted in an ICER of $3275 per DALY averted within a PCF programme and $3399 per DALY averted when an ACF programme was included. Provider-initiated ACF of household contacts in an urban setting of Lima, Peru can be highly cost-effective, even including costs to seek out contacts and perform an Xpert/MTB RIF test. ACF including Xpert MTB/RIF was not cost-effective if TB cases detected had high rates of default from treatment or poor outcomes.
Assuntos
Análise Custo-Benefício , Testes Diagnósticos de Rotina/economia , Testes Diagnósticos de Rotina/métodos , Características da Família , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Tuberculose Pulmonar/diagnóstico , Doenças Endêmicas , Infecções por HIV/epidemiologia , Humanos , Peru/epidemiologia , Tuberculose Pulmonar/epidemiologiaRESUMO
OBJECTIVE: To evaluate the diagnostic performance of manual MGIT™ (MMGIT) compared to the gold standard, Löwenstein-Jensen (LJ), in the diagnosis of pulmonary tuberculosis (TB) in a high-burden setting. METHODS: Individuals with suspected TB enrolled in parallel diagnostic trials during 2007-2011 were included. Two samples were obtained from each patient and inoculated into MMGIT and LJ medium. Diagnostic tests were performed, and the incremental yield of a second test and time to detection (TTD) were calculated. Analyses were performed per patient and per sample. Gold standard was based on LJ culture. RESULTS: In the per patient and per sample analysis, we evaluated 1436 patients and 4142 samples. The sensitivity and specificity for smear and MMGIT per sample were respectively 89.9%/92.2% and 97.1%/98.9%. Contamination was observed in 1.4% of samples on MMGIT. The mean TTD (days) was 11.8 for MMGIT and 22.9 for LJ. The sensitivity and specificity for smear and MMGIT per patient were respectively 89.9% and 92.2% and 97.1% and 98.3%. A second MMGIT culture had an incremental yield of 1.6%. CONCLUSIONS: MMGIT has high sensitivity and specificity, regardless of smear result, with a 50% reduction in TTD compared to LJ. These features make MMGIT an acceptable TB diagnostic method for use in resource-limited settings.
Assuntos
Técnicas Bacteriológicas , Pulmão/microbiologia , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Pulmonar/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Técnicas Bacteriológicas/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Peru/epidemiologia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Escarro/microbiologia , Fatores de Tempo , Tuberculose Pulmonar/economia , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/microbiologia , Adulto JovemRESUMO
OBJECTIVE: To determine the time from diagnosis to start of multidrug resistant tuberculosis (MDR TB) treatment in Lima, Peru. METHODS: We studied new smear-positive TB adults that were started on MDR TB treatment or that were switched to it between June 2008 and December 2011. RESULTS: Time from the first positive smear to MDR-TB treatment was >30 days in 35% (13/37) of patients. Among the 27% (24/88) of patients that switched to MDR-TB treatment, time from the last dose of a drug-susceptible regimen was >30 days. CONCLUSION: Start of and switching to MDR TB treatment is still delayed.
Assuntos
Antituberculosos/uso terapêutico , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Pulmonar/tratamento farmacológico , Adulto , Substituição de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Incidência , Masculino , Avaliação de Resultados em Cuidados de Saúde , Peru/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Pulmonar/epidemiologiaRESUMO
SETTING: Peru reports among the highest multidrug-resistant tuberculosis (MDR-TB) rates in the Americas, with a growing proportion in previously untreated tuberculosis (TB) cases. The identification of clusters of primary MDR-TB compared with drug-susceptible TB (DS-TB) could help prioritize interventions. OBJECTIVE: To examine the clustering of primary MDR-TB case residences and their proximity to high-risk locations in San Juan de Lurigancho District, Lima, Peru. DESIGN: Enrolled primary MDR-TB and primary DS-TB cases were interviewed and their primary residence was recorded using handheld Global Positioning System devices. Kuldorff's spatial scan statistic was used for cluster detection (SaTScan(TM), v. 9.1.1). Identified clusters were visualized in Quantum Geographic Information Systems software (v1.8.0). The following cluster centers were tested: a health centre with the highest TB and MDR-TB rates (Clinic X), a hospital and two prisons. Using regression analyses, we examined predictors of primary MDR-TB cases. RESULTS: A statistically significant cluster of primary MDR-TB cases was identified within a 2.29 km radius around Clinic X. Proximity to Clinic X remained a significant predictor of primary MDR-TB in adjusted regression analyses. CONCLUSION: We identified a hotspot of primary MDR-TB cases around Clinic X in a TB-endemic area. Causes of this clustering require investigation; targeted interventions for this high-risk area should be considered.
Assuntos
Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Adolescente , Adulto , Idoso , Análise por Conglomerados , Feminino , Sistemas de Informação Geográfica , Humanos , Masculino , Pessoa de Meia-Idade , Peru/epidemiologia , Análise de Regressão , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , Adulto JovemRESUMO
SETTING: Ten peripheral laboratories performing routine acid-fast bacilli (AFB) smear microscopy in Lima, Peru. OBJECTIVES: To test whether external quality assessment (EQA) rechecking of AFB smears becomes more efficient with stratified lot sampling of treatment follow-up smears. DESIGN: In 2 consecutive years, a stratified lot sample of 36 treatment follow-up slides and 24 diagnostic slides were randomly selected and blindly rechecked. A second controller determined the final result for discordant slides. Feedback was provided to laboratory technicians during supervisory visits. RESULTS: More false-negative errors were found in the follow-up slides than in the tuberculosis suspect slides: 25 vs. 3. This represented a yield of 3.5% in 720 follow-up slides and only 0.6% in 480 diagnostic slides. Positive predictive values were high in both years. Respectively three and eight laboratories did not reach a relative sensitivity of >65% during the first and second year, and a clear improvement was seen in only one laboratory. Excessive workload seemed to preclude raising the level of routine performance. CONCLUSIONS: EQA with stratified lot sampling of treatment follow-up slides proved very efficient and effective for identifying laboratories with substandard performance in a setting with low positivity rates in routine diagnostic smears.
Assuntos
Técnicas de Laboratório Clínico/normas , Microscopia/normas , Mycobacterium tuberculosis/isolamento & purificação , Indicadores de Qualidade em Assistência à Saúde , Tuberculose/diagnóstico , Antituberculosos/uso terapêutico , Reações Falso-Negativas , Reações Falso-Positivas , Humanos , Variações Dependentes do Observador , Peru , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Resultado do Tratamento , Tuberculose/tratamento farmacológico , Tuberculose/microbiologia , Carga de TrabalhoRESUMO
OBJECTIVE: To determine the efficiency of routine tuberculosis (TB) case detection by examining sputum smear positivity for acid-fast bacilli in relation to duration of cough, characteristics of TB suspects examined and health service factors. METHOD: We combined patient interviews with routine data from laboratory registers in 6 health care facilities in San Juan de Lurigancho district, Lima, Peru. A TB case was defined as a TB suspect with at least one positive sputum smear. We calculated adjusted odds ratios with 95% confidence intervals for the association between smear positivity and health service and patient's characteristics. RESULTS: Smear positivity was 7.3% (321/4376). Of the 4376 adults submitting sputa, 55.3% (2418) reported cough for <14 days. In this group, smear microscopy yielded 3.2% (78/2418) positive results vs. 12.4% (243/1958) in patients coughing for 14 or more days. Having cough for >2 weeks, being referred by health care staff, attending a secondary-level health care facility, male sex and age between 15 and 44 years were independent determinants of smear positivity. CONCLUSIONS: Routine case detection yields a low proportion of smear-positive cases because of the inclusion of a high proportion of patients without cough or coughing for <2 weeks. Adherence to the national TB control programme guidelines on the selection of TB suspects would have a positive impact on the smear positivity rate, reduce laboratory costs and workload and possibly improve the reading quality of smear microscopy.
Assuntos
Tosse/microbiologia , Mycobacterium tuberculosis/isolamento & purificação , Escarro/microbiologia , Tuberculose Pulmonar/diagnóstico , Adolescente , Adulto , Distribuição por Idade , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Peru/epidemiologia , Distribuição por Sexo , Fatores de Tempo , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/epidemiologia , Adulto JovemRESUMO
Our objective was to correlate antibiotic resistance in gut E. coli flora of children, aged 6-72 months, with use of antibiotics, socioeconomic status (SES) and household characteristics in the urban communities of Yurimaguas and Moyobamba in the Amazonian area of Peru. Caregivers of 1598 children were interviewed using a structured questionnaire in a cross-sectional survey. Faecal samples were collected from the children and the antimicrobial susceptibility of E. coli was analysed by a rapid resistance screening method. Significantly higher odds for resistance were seen for children who had used antibiotics, both during the last 2 weeks and the last 6 months. Children from wealthier families had significantly higher odds for resistance to a number of antibiotics than children from the least wealthy families (Yurimaguas: nalidixic acid, OR = 2.13; ciprofloxacin, OR = 2.09; chloramphenicol, OR = 1.98. Moyobamba: nalidixic acid, OR = 1.59; ciprofloxacin, OR = 1.69). Thus, the children of wealthier families had a significantly increased odds ratio for resistance, also when controlling for the family's antibiotic use. Unknown factors related to socioeconomic status seem to contribute to the results seen in the study area.
Assuntos
Antibacterianos/administração & dosagem , Farmacorresistência Bacteriana Múltipla , Escherichia coli/efeitos dos fármacos , Intestinos/microbiologia , Áreas de Pobreza , Criança , Pré-Escolar , Estudos Transversais , Escherichia coli/isolamento & purificação , Humanos , Lactente , Razão de Chances , Peru/epidemiologia , Inquéritos e QuestionáriosRESUMO
SETTING: Tuberculosis control programmes of two health care centres in the central rainforest of Peru. OBJECTIVE: To evaluate if bodyweight gain (BWG) predicts treatment outcome in patients with pulmonary tuberculosis (PTB). DESIGN: Retrospective cohort study of adults with PTB diagnosed between 1995 and 2004. BWG was assessed after month 1 of treatment, after the initial phase and at the end of treatment. Patients were stratified into two BWG categories, < or = 5% and >5%. Failures and relapses were grouped together as unsuccessful treatment outcome. RESULTS: A total of 650 patients were included: 7.2% (n = 47) had an unsuccessful outcome. Unsuccessful outcome was associated with BWG < or = 5% at the end of treatment (RR 2.05, 95%CI 1.10-3.80), but not at the completion of month 1 (RR 0.99, 95%CI 0.52-1.88) or at completion of the initial phase (RR 1.46, 95%CI 0.82-2.57). Median BWG at completion of the initial phase was higher in cured patients (P = 0.007). BWG < or = 5% at end of treatment (RR 2.35, 95%CI 1.17-4.72), initial sputum smear 2+ (RR 2.48, 95%CI 1.14-5.31) and positive smear microscopy at month 2 (RR 4.0, 95%CI 1.30-12.31) were independent predictors of unsuccessful treatment outcome. CONCLUSION: BWG < or = 5% at the end of treatment, high bacterial load and lack of sputum conversion correlate with unsuccessful treatment outcome in this setting. New discriminative cut-offs for BWG are proposed.
Assuntos
Antituberculosos/uso terapêutico , Tuberculose Pulmonar/tratamento farmacológico , Aumento de Peso , Adulto , Distribuição de Qui-Quadrado , Feminino , Humanos , Masculino , Peru/epidemiologia , Valor Preditivo dos Testes , Curva ROC , Estudos Retrospectivos , Estatísticas não Paramétricas , Resultado do Tratamento , Tuberculose Pulmonar/epidemiologiaRESUMO
SETTING: University-affiliated hospital located in an area with a high incidence of pulmonary tuberculosis (PTB). OBJECTIVE: To develop a clinical prediction rule (CPR) based on information obtainable on admission, to permit rapid identification of patients with PTB. DESIGN: Information from patients with respiratory symptoms who attended the emergency department of Cayetano Heredia Hospital, Lima, Peru, was collected prospectively. Clinical symptoms, past medical history, demographic data and results of chest X-rays (CXRs), sputum smear and culture in Löwenstein-Jensen media were obtained. Based on logistic regression, we constructed a scoring system to predict PTB. RESULTS: A total of 345 patients were enrolled in the study, including 109 (31%) culture-proven PTB cases. In logistic regression analysis, we found age, previous history of PTB, weight loss, presence of cavities, upper lobe infiltrate and miliary pattern on CXR as independent predictors of PTB. We designed a scoring system with these variables, taking into account their statistical weight. The score attained 93% sensitivity and 42% specificity. CONCLUSION: The CPR that was developed performed well in our population. It merits further validation in other settings. It should not, however, replace, but should complement sputum microscopy when deciding on isolation, and it does not preclude microbiology in making a definitive diagnosis.
Assuntos
Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência , Tuberculose Pulmonar/diagnóstico , Hospitais Universitários , Humanos , Modelos Logísticos , Peru , Estudos Prospectivos , Curva ROCRESUMO
OBJECTIVE: To describe the health-seeking behaviour and use of antibiotics in the urban community of Yurimaguas in the Amazonian area of Peru. METHOD: Cross-sectional survey of caregivers of 798 children aged 6-72 months by interview using a semi-structured questionnaire. Reported symptoms were classified as illnesses where antibiotics would or would not be recommended based on principles of the integrated management of childhood illnesses algorithm. RESULTS: Forty-one per cent of consultations were with health care professionals; 71% of antibiotics were obtained through the formal public health sector and prescribed mainly by medical doctors. All prescribed antibiotics were on the Peruvian essential drugs list. When prescribing, doctors and nurses hardly discriminated between illnesses where antibiotic treatment was or was not indicated; there was no significant difference in antibiotic prescribing rates between the two (doctors, P = 0.24; nurses, P = 0.32). Not all caregivers sought help for children with severe symptoms. CONCLUSION: Although most of the antibiotics were prescribed by doctors and nurses, they were commonly prescribed for illnesses where they were not indicated. The use of antibiotics needs to be rationalized, and barriers to health care must be overcome.
Assuntos
Antibacterianos/administração & dosagem , Atitude do Pessoal de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Áreas de Pobreza , Padrões de Prática Médica , Criança , Pré-Escolar , Competência Clínica , Tosse/tratamento farmacológico , Estudos Transversais , Diarreia/tratamento farmacológico , Disenteria/tratamento farmacológico , Comportamentos Relacionados com a Saúde , Humanos , Lactente , Peru , Pneumonia/tratamento farmacológico , Saúde da População UrbanaRESUMO
OBJECTIVES: To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis; and to understand the contextual factors which impede or facilitate its success. METHODS: Twenty-six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six-month periods pre- and post-intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals' clinical behaviour after the introduction of clinical audit. RESULTS: We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients' attitudes towards illness. CONCLUSIONS: Clinical audit may drive improvements in the quality of clinical care in resource-poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.
Assuntos
Auditoria Clínica , Serviços de Diagnóstico/organização & administração , Avaliação de Processos em Cuidados de Saúde/normas , Tuberculose Pulmonar/diagnóstico , Atitude do Pessoal de Saúde , Atitude Frente a Saúde , Bolívia , Cuba , Humanos , Peru , Saúde da População Rural , Saúde da População UrbanaRESUMO
The purpose of this study was to assess the association between human T-lymphotropic virus 1 (HTLV-1) and a lifetime history of active tuberculosis (TB) among relatives of HTLV-1-infected patients. We reviewed clinical charts of all relatives of HTLV-1-infected index cases who attended our institute in Lima from 1990-2004. The data of 1233 relatives was analysed; 394 (32.0%) were HTLV-1 positive. Eighty-one subjects (6.6%) had a history of active TB, including 45/394 (11.4%) HTLV-1-positive and 36/839 (4.3%) HTLV-1-negative relatives (P<0.001). On multivariate analysis, three factors were associated with TB history: HTLV-1 infection (adjusted OR 2.5, 95% CI 1.6-3.9), age (adjusted OR 1.3, 95% CI 1.1-1.5 per 10-year age increase) and relation to the index case (adjusted OR 2.6, 95% CI 1.3-5.1, for siblings vs. spouses of index cases). In conclusion, HTLV-1 infection may increase the susceptibility to active TB. In populations where both infections are frequent, such an association could affect the dynamics of TB.
Assuntos
Infecções por HTLV-I/epidemiologia , Tuberculose Pulmonar/epidemiologia , Adolescente , Adulto , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Estudos Transversais , Saúde da Família , Feminino , Infecções por HTLV-I/complicações , Humanos , Masculino , Peru/epidemiologia , Tuberculose Pulmonar/complicaçõesRESUMO
Este es el reporte de un caso inusual de colitis pseudomembranosa con un desenlace fatal en el que se demostró la coexistencia de C. difficile y citomegalovirus en un paciente peruano con Sida y compromiso gastrointestinal por una micobacteria.
We report an unusual case of pseudomembranous colitis with fatal outcome where C. difficile and cytomegalovirus coexistense in a Peruvian patient with AIDS and gastrointestinal compromise by a mycobacterium.
Assuntos
Humanos , Masculino , Adulto , Citomegalovirus , Clostridioides difficile , Enterocolite PseudomembranosaRESUMO
SETTING: Tuberculosis (TB) and human T-lymphotropic virus 1 (HTLV-1) are frequent in Peru. The prevalence of HTLV-1 among Peruvian TB patients is unknown. OBJECTIVE: To determine the prevalence of HTLV-1, HTLV-2 and the human immunodeficiency virus (HIV) in out-patients with TB and to compare HTLV-1-infected patients with seronegative patients. DESIGN: Cross-sectional study including subjects aged 18-65 years diagnosed with smear-positive pulmonary TB at health centres in northern Lima from November 2004 to August 2005. HTLV and HIV screening was performed using enzyme-linked immunosorbent assay; HTLV-1 and HTLV-2 were confirmed using line immunoassay. RESULTS: There were 311 participants with a median age of 29 years; 173 (56%) were men. HTLV-1 prevalence was 5.8% (18/311, 95%CI 3.2-8.4) and HIV prevalence was 1.3% (4/304, 95%CI 0.4-3.3). HTLV-2 was not diagnosed. In comparison with HIV- and HTLV-seronegative patients, HTLV-1-infected subjects were older (median age 44 vs. 28, P < 0.001) and were more likely to have been born in the southern Andes (OR 4.4, 95%CI 1.6-11.9). They were also more likely to report a history of TB deaths in the family (OR 5.4, 95%CI 1.7-16.8) and had more sputum smear results graded as 3+ (OR 4.1, 95%CI 1.5-11.2). CONCLUSION: HTLV-1 screening among Peruvian TB patients is important. Because 3+ sputum smears are frequent and mortality is high among relatives, families of HTLV-1/TB-positive cases merit special attention.
Assuntos
Infecções por HTLV-I/epidemiologia , Pacientes Ambulatoriais/estatística & dados numéricos , Tuberculose Pulmonar/complicações , Adolescente , Adulto , Idoso , Feminino , HIV/imunologia , Anticorpos Anti-HIV/análise , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , Anticorpos Anti-HTLV-I/análise , Infecções por HTLV-I/complicações , Infecções por HTLV-I/virologia , Anticorpos Anti-HTLV-II/análise , Infecções por HTLV-II/complicações , Infecções por HTLV-II/epidemiologia , Infecções por HTLV-II/virologia , Vírus Linfotrópico T Tipo 1 Humano/imunologia , Vírus Linfotrópico T Tipo 2 Humano/imunologia , Humanos , Técnicas Imunoenzimáticas , Masculino , Pessoa de Meia-Idade , Peru/epidemiologia , Prevalência , Estudos Retrospectivos , Fatores de Risco , Tuberculose Pulmonar/epidemiologiaRESUMO
Three obese patients underwent sleeve gastrectomy. They developed gastric dehiscence with generalized peritonitis, sepsis and shock, being operated as total gastrectomy of the remanent stomach with Roux in Y esophago-jejunostomy reconstruction as a last chance of life saving procedure.
Assuntos
Gastrectomia/métodos , Derivação Gástrica , Sepse/cirurgia , Deiscência da Ferida Operatória/cirurgia , Adulto , Feminino , Derivação Gástrica/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Sepse/etiologiaRESUMO
SETTING: Sixteen primary care health centres in Peru and Bolivia. OBJECTIVES: To assess the utilisation of microscopy services in Peru and Bolivia and determine if clinical audit, a quality improvement tool, improves the utilisation of these services. DESIGN: We estimated the percentage of patients with suspected tuberculosis (TB) in whom sputum microscopy was effectively utilised in Peru and Bolivia over two 6-month periods before and after a clinical audit intervention that included standards setting, measuring clinical performance and feedback. RESULTS: Before the intervention, only 31% (95%CI 27-35) of TB suspects were assessed with sputum microscopy in Peru. In Bolivia, 30% (95%CI 25-35) underwent at least two sputum microscopy examinations. After clinical audit, the availability of sputum microscopy results improved by respectively 7% (95%CI 1-12, P < 0.05) and 23% (95%CI 15-30, P < 0.05) over 2 years in Peru and Bolivia. CONCLUSIONS: Despite World Health Organization recommendations that all TB suspects should undergo sputum microscopy before treatment, results are available for further assessment for only one third. This is a potentially serious obstacle to TB case detection. Clinical audit can bring some improvement. We recommend regular monitoring of effective utilisation of microscopy services and investigations to ascertain organisational and structural issues in their uptake and use.
Assuntos
Acessibilidade aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Programas de Rastreamento/métodos , Auditoria Médica , Microscopia/estatística & dados numéricos , Mycobacterium tuberculosis/isolamento & purificação , Escarro/microbiologia , Tuberculose/diagnóstico , Bolívia/epidemiologia , Fidelidade a Diretrizes , Humanos , Incidência , Microscopia/normas , Peru/epidemiologia , Guias de Prática Clínica como Assunto , Garantia da Qualidade dos Cuidados de Saúde , Tuberculose/epidemiologia , Tuberculose/microbiologiaRESUMO
We report an unusual case of pseudomembranous colitis with fatal outcome where C. difficile and cytomegalovirus coexistense in a Peruvian patient with AIDS and gastrointestinal compromise by a mycobacterium.