Retreatment Of Patients Research Articles

Mycobacterium tuberculosis Beijing Strains Favor Transmission but Not Drug Resistance in China

The Mycobacterium tuberculosis Beijing strains are widespread globally. We aimed to determine whether Beijing strains in China are more likely than other strains to spread, and whether they are more likely to become drug resistant. We also sought to determine whether different Beijing sublineages have distinct phenotypic characteristics. We conducted a population-based molecular epidemiologic study in 6 provinces in China from 2009 to 2010. We analyzed data and specimens from culture-confirmed pulmonary tuberculosis patients. Each patient's isolate was genotyped using 16-loci variable number of tandem repeats and 6 single-nucleotide polymorphisms. By genotyping, 75.0% (1031/1375) of the strains of M. tuberculosis were Beijing strains. Beijing strains were more likely than non-Beijing strains to be in a genotypic cluster (odds ratio, 2.40, P < .001), and were significantly associated with younger age (P(trend) < .05). There was no significant difference in the proportion of Beijing strains and non-Beijing strains that were drug resistant, even when stratified by new vs retreatment patients. We identified 6 sublineages of Beijing strains in the study population. The modern sublineage of Beijing strains were more likely than the ancient sublineages to be clustered (odds ratio, 2.27, P < .001). Beijing strains of M. tuberculosis were significantly associated with genotypic clustering, reflecting recent transmission, and younger age, but were not associated with drug resistance. Future studies of Beijing family strains should avoid assuming and attributing characteristics to the entire family and should assess strains of specific sublineages and/or settings.

Diagnostic performance of multiplex cytokine and chemokine assay for tuberculosis

Simultaneous detection of multiple biomarkers might lead to improved diagnostic performance for Mycobacterium tuberculosis infection. In this study, we screened soluble biomarkers that had significant differences in patients with active tuberculosis and healthy controls and evaluated the diagnostic performance of the multiplex cytokine/chemokine assay. Overall, 178 patients with active pulmonary tuberculosis, 156 healthy individuals and 35 patients with bacterial pneumonia or lung cancer were evaluated. Among the 16 soluble biomarkers screened by the microbead-based multiplex assay, five cytokines/chemokines including IFN-γ, IP-10, MIG, TNF-α and IL-2 that showed most significant differences between active pulmonary tuberculosis patients and healthy controls were selected for further analysis. When analyzed individually, both IP-10 and MIG had sensitivity and specificity comparable to IFN-γ in detection of active TB. Combined detection of IFN-γ, IP-10 and MIG had significantly improved sensitivity and specificity as compared with individual cytokine and chemokine detection. The responsive levels of IFN-γ, IP-10, MIG, TNF-α and IL-2 were significantly lower in re-treatment pulmonary tuberculosis patients than in new tuberculosis patients. It is concluded that combined IFN-γ, IP-10, MIG multiplex detection had better diagnostic performance for tuberculosis than the individual cytokine/chemokine assays. The re-treatment pulmonary tuberculosis patients had poor responses to ESAT-6/CFP-10 peptides stimulation.

Multidrug-Resistant Tuberculosis in Admitted Patients at a Tertiary Referral Hospital of Bangladesh

BackgroundThis study was set out to investigate the magnitude, patterns and molecular characterization of drug-resistant Mycobacterium tuberculosis strains at a tertiary referral hospital in Bangladesh.MethodsPulmonary tuberculosis (TB) patients admitted at National Institute of Diseases of the Chest and Hospital from February 2002 to September 2005 with or without previous history of TB and/or other complications were randomly interviewed. Among 265 participants enrolled, M. tuberculosis isolates from 189 patients were finally tested for susceptibility to rifampicin (RMP), isoniazid (INH), ethambutol (ETM) and streptomycin (STM). Genotyping of M. tuberculosis was done using deletion analysis and spoligotyping.ResultsEighty-eight percent (n = 167) of the patients had history of previous anti-TB treatment while the remaining 12% were new TB cases. Of the 189 isolates, 9% were fully susceptible to the first line anti-TB drugs and 73.5% were multi-drug resistant TB. Other susceptibility results showed 79.4%, 77.2%, 76.7% and 78.8% resistance to INH, RMP, ETM and STM respectively. Multi-drug resistance was significantly higher among the 130 (78%) patients with previous history of anti-tuberculosis treatment (95% confidence interval, p = 0.001). Among the 189 analyzed isolates, 69% were classified as “modern” M. tuberculosis strains (i.e. TbD1- strains, lacking the M. tuberculosis-deletion region TbD1), whereas the remaining 31% were found to belong to the “ancestal” TbD1+ M. tuberculosis lineages. One hundred and five different spoligotype patterns were identified in which 16 clusters contained 100 strains and 89 strains had unique pattern. Strains with a spoligotype characteristic for the “Beijing” cluster were predominant (19%) and most of these strains (75%) were multi-drug resistant (MDR).ConclusionsA high level of drug resistance observed among the re-treatment patients poses a threat of transmission of resistant strains to susceptible persons in the community. Proper counseling of patients and attention towards the completion of the anti-TB treatment is needed.

Quality of life among tuberculosis (TB), TB retreatment and/or TB-HIV co-infected primary public health care patients in three districts in South Africa

IntroductionTB and HIV co-morbidity amount to a massive burden on healthcare systems in many countries. This study investigates health related quality of life among tuberculosis (TB), TB retreatment and TB-HIV co-infected public primary health care patients in three districts in South Africa.MethodsA cross sectional study was conducted among 4900 TB patients who were in the first month of anti-TB treatment in primary public health care clinics in three districts in South Africa. Quality of life was assessed using the social functioning (SF)-12 Health Survey through face to face interviews. Associations of physical health (Physical health Component Summary = PCS) and mental health (Mental health Component Summary = MCS) were identified using logistic regression analyses.ResultsThe overall physical and mental health scores were 42.5 and 40.7, respectively. Emotional role, general health and bodily pain had the lowest sub-scale scores, while energy and fatigue and mental health had the highest domain scores. Independent Kruskal–Wallis tests found significant positive effects of being TB-HIV co-infected on the domains of mental health functioning, emotional role, energy and fatigue, social function and physical role, while significant negative effects were observed on general health, bodily pain and physical function. In multivariable analysis higher educational, lower psychological distress, having fewer chronic conditions and being HIV negative were significantly positively associated with PCS, and low poverty, low psychological distress and being HIV positive were positively significantly associated with MCS.ConclusionTB and HIV weaken patients’ physical functioning and impair their quality of life. It is imperative that TB control programmes at public health clinics design strategies to improve the quality of health of TB and HIV co-infected patients.

Early results of systematic drug susceptibility testing in pulmonary tuberculosis retreatment cases in Cameroon

BackgroundThe number of pulmonary tuberculosis (PTB) patients reported with resistance to first-line anti-tuberculosis drugs after a standardized retreatment regimen in Cameroon is increasing. Hence, the National Tuberculosis Control Program (NTP) implemented, in one of the ten Regions of the country, a pilot programme aimed at performing routine drug susceptibility testing (DST) for previously treated PTB cases. The objectives of the programme were to evaluate the feasibility of monitoring drug resistance among retreatment cases under programme conditions and to measure the presence and magnitude of anti-TB drug resistance in order to inform NTP policies.FindingsThis retrospective cohort study was conducted in the Littoral Region of Cameroon in 2009. It included all sputum smear positive (SM+) PTB cases registered for retreatment. TB cases were identified and classified according to World Health Organization (WHO) recommendations for national TB programs. Bacterial susceptibility testing to first-line anti-TB drugs was performed using standard culture methods. In 2009, 5,668 TB cases were reported in the Littoral Region, of which 438 (7.7%) were SM + PTB retreatment cases. DST results were available for 216 (49.4%) patients. Twenty six patients (12%) harbored multi-drug resistant (MDR) strains. Positive treatment outcome rates were particularly low in retreatment patients with MDR-TB (46.2%; 95% CI: 27.1-66.3). Thirteen MDR-TB patients were treated using a standardized MDR treatment regimen. Delivery of laboratory results took on average 17 (12-26) weeks.ConclusionsWHO-recommended routine DST in retreatment patients seems feasible in Cameroon. However, coverage needs to be improved through better management. Moreover, diagnostic delay should be shortened by introducing more rapid diagnostic tools. The high risk of MDR in standard regimen failure cases virtually rules out the standard retreatment regimen for such patients without prior DST.

Factors contributing to the high prevalence of multidrug-resistant tuberculosis: a study from China

BackgroundThe rapid spread of multidrug-resistant tuberculosis (MDR-TB) has attracted global concerns. This study aimed to identify factors contributing to the high prevalence of MDR-TB in China's Heilongjiang province.MethodsA cross-sectional survey...

Patient- and provider-level risk factors associated with default from tuberculosis treatment, South Africa, 2002: a case-control study.

BackgroundPersons who default from tuberculosis treatment are at risk for clinical deterioration and complications including worsening drug resistance and death. Our objective was to identify risk factors associated with tuberculosis (TB) treatment default in South Africa.MethodsWe conducted a national retrospective case control study to identify factors associated with treatment default using program data from 2002 and a standardized patient questionnaire. We defined default as interrupting TB treatment for two or more consecutive months during treatment. Cases were a sample of registered TB patients receiving treatment under DOTS that defaulted from treatment. Controls were those who began therapy and were cured, completed or failed treatment. Two respective multivariable models were constructed, stratified by history of TB treatment (new and re-treatment patients), to identify independent risk factors associated with default.ResultsThe sample included 3165 TB patients from 8 provinces; 1164 were traceable and interviewed (232 cases and 932 controls). Significant risk factors associated with default among both groups included poor health care worker attitude (new: AOR 2.1, 95% CI 1.1-4.4; re-treatment: AOR 12, 95% CI 2.2-66.0) and changing residence during TB treatment (new: AOR 2.0, 95% CI 1.1-3.7; re-treatment: AOR 3.4, 95% CI 1.1-9.9). Among new patients, cases were more likely than controls to report having no formal education (AOR 2.3, 95% CI 1.2-4.2), feeling ashamed to have TB (AOR 2.0, 95% CI 1.3-3.0), not receiving adequate counseling about their treatment (AOR 1.9, 95% CI 1.2-2.8), drinking any alcohol during TB treatment (AOR 1.9, 95% CI 1.2-3.0), and seeing a traditional healer during TB treatment (AOR 1.9, 95% CI 1.1-3.4). Among re-treatment patients, risk factors included stopping TB treatment because they felt better (AOR 21, 95% CI 5.2-84), having a previous history of TB treatment default (AOR 6.4, 95% CI 2.9-14), and feeling that food provisions might have helped them finish treatment (AOR 5.0, 95% CI 1.3-19).ConclusionsRisk factors for default differ between new and re-treatment TB patients in South Africa. Addressing default in both populations with targeted interventions is critical to overall program success.

Occurrence and prevalence of pulmonary tuberculosis in rural communities in Narsingdi, Bangladesh

Tuberculosis is a chronic communicable disease. Infections are initially asymptomatic and latent but eventually progresses to active disease, which, if left untreated, may have ≥50% mortality. In 2011, an anti- tuberculosis drug resistance survey in Narsingdi, Bangladesh enrolled both new and retreatment patients. In the study, a number of villages were randomly selected and 264 pulmonary tuberculosis (PTB) patients were identified. All the patients received treatment with standardized first-line drug (FLD) regimens and were investigated to document treatment efficiency. Among the patients, 130 were reported in lower income, 117 in medium income and only 17 in higher income group. Farmers (95%) in low income group, and female housewives (68%) in medium income group were mostly infected. Silicosis and malnutrition were assumed responsible for high PTB cases in farmers and housewives respectively. Males were more prone to PTB and the ratios of male to female patients were found to increase with increasing age. The working youth group (25-34) and older people (above 64) were found most vulnerable. PTB patients in Bangladesh had high recurrence and death rates even after treatment with standardized FLD regimens, reinforcing the need for early survey, diagnosis and treatment, including assessment of treatment outcomes. Keywords - Age, Bangladesh, Pulmonary tuberculosis, Socio-economic condition, Treatment efficiency

Endodontic Retreatment Patients with Clinical Symptoms Have Strong Biofilm Formation Ability and High Expression of Virulence Factors of E. faecalis

Endodontic Retreatment Patients with Clinical Symptoms Have Strong Biofilm Formation Ability and High Expression of Virulence Factors of E. faecalis

DOTS for TB relapse in India: A systematic review

In India, under the Revised National Tuberculosis Control Program (RNTCP), the percentage of smear-positive re-treatment cases is high. The causes of re-treatment include relapse of the disease after successful completion of treatment, treatment failure, and default in treatment. RNTCP does not follow up the patients for any period of time after successful completion of treatment to determine whether they relapse. Given the high cost of treatment for each patient under RNTCP and the potential for spread of disease from these patients, it is crucial for the success of the program and control of the disease in the country to find out more about the reasons behind this. T0 o conduct a systematic review of literature and determine evidence regarding recurrence of TB after its successful treatment with standard short course chemotherapy under DOTS guidelines. T0 en databases were searched including Medline, Cochrane database, Embase and others and reference lists of articles. 255 papers resulted from these searches. Seven studies were finally included in the review after applying the inclusion, exclusion and quality assessment criteria. R0 elapse rate is high (almost 10%) in India which is higher than international studies. Majority of relapse cases present soon after completion of treatment (first six months). Risk factors for relapse included drug irregularity, initial drug resistance, smoking and alcoholism Sex and weight were not risk factors in India. The outcome of relapse cases put on treatment is positive but less effective than new cases. There are sound arguments and sketchy evidence that DOTS Category 2 treatment may not be adequate for retreatment patients.

Re-Treatment Tuberculosis Cases Categorised as “Other”: Are They Properly Managed?

BackgroundAlthough the World Health Organization (WHO) provides information on the number of TB patients categorised as “other”, there is limited information on treatment regimens or treatment outcomes for “other”. Such information is important, as inappropriate treatment can lead to patients remaining infectious and becoming a potential source of drug resistance. Therefore, using a cohort of TB patients from a large registration centre in Lilongwe, Malawi, our study determined the proportion of all TB re-treatment patients who were registered as “other”, and described their characteristics and treatment outcomes.MethodsThis retrospective observational study used routine program data to determine the proportion of all TB re-treatment patients who were registered as “other” and describe their characteristics and treatment outcomes between January 2006 and December 2008.Results1,384 (12%) of 11,663 TB cases were registered as re-treatment cases. Of these, 898 (65%) were categorised as “other”: 707 (79%) had sputum smear-negative pulmonary TB and 191 (21%) had extra pulmonary TB. Compared to the smear-positive relapse, re-treatment after default (RAD) and failure cases, smear-negative “other” cases were older than 34 years and less likely to have their HIV status ascertained. Among those with known HIV status, “other” TB cases were more likely to be HIV positive. Of TB patients categorised as “other”, 462 (51%) were managed on the first-line regimen with a treatment success rate of 63%.ConclusionA large proportion of re-treatment patients were categorised as “other”. Many of these patients were HIV-infected and over half were treated with a first-line regimen, contrary to national guidelines. Treatment success was low. More attention to recording, diagnosis and management of these patients is warranted as incorrect treatment regimen and poor outcomes could lead to the development of drug resistant forms of TB.

How far do we still need to go to provide health solutions for the poor?

In this issue of Public Health Action, we revisit the matter of knowing how to provide health solutions for the poor. To our previous list of publications1 we add three more countries, India, Kenya and Zimbabwe, and evaluate issues related to tuberculosis and HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome). And, once again, we discover what is actually going on in health services rather than what is meant to be going on. Sadly, a resume of the findings of this first series of manuscripts does not make happy reading—all of them demonstrate serious challenges in the most basic aspects of health services delivery. A study on the management of a series of 141 patients admitted to hospital with chest symptoms reported that less than half of them had sputum smears examined, and only half of those with negative smears had chest radiographs.2 And yet, 42% of those having full investigations had tuberculosis. It makes little sense to spend resources on active case finding when we don’t even examine those admitted to hospital with symptoms consistent with tuberculosis. A paper on 2463 tuberculosis patients living with HIV reported that only one in six were commenced at an early stage on antiretroviral treatment but that, more importantly, one-third of all these patients had an unfavourable treatment outcome.3 A third study of 2922 deaths among patients on antiretroviral treatment for HIV reported that more than one out of eight were omitted when being transcribed from one register to another, calling into serious question the quality of even the most basic health statistics we use to monitor our activities.4 A study from Pakistan of 1698 consecutive sputum smear-positive tuberculosis patients reported that one in every sixteen was never registered on treatment, most of them having been diagnosed in tertiary care hospitals.5 If we fail to provide comprehensive care for our patients in the very locations where we are training the next generation of physicians, it does not bode well for our ability to stop tuberculosis. A study of 19 200 malnourished children in Ethiopia found 179 with malaria, most of them without a record of fever, even though the presence of fever is the indication for undertaking tests for malaria.6 A study of 267 children with tuberculosis diagnosed in a large teaching hospital reported that 38% were not registered in the health statistics, including 73% of those with an unfavourable treatment outcome, indicating the unreliability of the routine statistics that we depend upon.7 A study from Zimbabwe of 1800 tuberculosis patients reported that 39% of them were never tested for HIV, even though most of those tested were found to be positive.8 Moreover, less than one in ten were started on antiretroviral treatment. A study from India on 3000 pulmonary tuberculosis patients who completed treatment reported that one in three new patients and more than one half of retreatment patients did not have complete follow-up examinations.9 Comprehensive follow-up is one of the means by which we identify those most likely to have drug-resistant disease, which requires more complex and prolonged treatment. Finally, a study from Kenya on 187 pregnant women living with HIV reported that seven of the ten tuberculosis cases detected had no symptoms and were identified by chest radiograph, indicating that current advice on screening for tuberculosis in this setting is not relevant.10 What is our conclusion? Should this journal be re-labelled the ‘Journal of Bad News’? These overall depressing results do not stem from the fact that we selected only those reports with bad news for publication —and certainly we have much bad news to face and to come to terms with. These two first issues of PHA also indicate the important role played by operational research in finding health solutions for the poor. However, these solutions will only be found when we address the issues raised and when we determine that the actions resulting from this research actually change policy, practice and health outcomes.

Stereotactic Ablative Radiotherapy for Previously Irradiated Lung Tumors

Stereotactic Ablative Radiotherapy for Previously Irradiated Lung Tumors

Analysis of resistance to anti-TB drugs of mycobacterium tuberculosis among inpatients with pulmonary tuberculosis in Shantou

Objective To analyze resistant situation to anti-TB drugs of mycobacterium tuberculosis among inpatients with pulmonary tuberculosis in the Third People's Hospital of Shantou.Methods The retrospective sampling analysis was conducted on drug resistant tests to IN H,RFP,SM and EMB of mycobacterium tuberculosis among 100 inpatients from Jan 1,2008 to Dec 31,2010.The drug resistance rate of new treatment group and re-treatment group were observed.Results The drug resistance rate of INH,RFP and EMB of re-treatment group were significantly higher than those of new treatment group ( 59.5％ vs 25.4％,40.5％ vs 7.9％ and 43.2％ vs 11.1％,all P ＜ 0.01 ); The drug resistance rate of SM were 18.9％ in the re-treatment group and 20.6％ in the new treatment group,the difference between the two groups were not statistically significant ( P ＞ 0.05 ).Conclusions The drug resistant tests of anti-TB drugs were necessary to the patients with pulmonary tuberculosis especially in re-treatment patients,and the use of SM should be caused to attention. Key words: Pulmonary Tuberculosis; Mycobacterium tuberculosis; Drug resistance

Favorable factors for re‐treatment with pegylated interferon α2a plus ribavirin in patients with high viral loads of genotype 1 hepatitis C virus

Effect of re-treatment for pegylated interferon (PEG-IFN) plus ribavirin was not fully evaluated. We examined the effects of re-treatment with PEG-IFN plus ribavirin in patients with high viral loads of genotype 1 hepatitis C virus who failed to achieve a sustained virological response (SVR) with combination therapy. We examined 38 patients who were re-treated with PEG-IFN α2a plus ribavirin for more than 60 weeks, among whom 14 were non-responders and 24 were relapsers after previous treatment with PEG-IFN α2b plus ribavirin. IL28B genotyping was done in 21 patients. The overall SVR rate was 34%. Analysis of baseline characteristics showed that the relapsers had a significantly higher SVR rate than the non-responders (50.0%, 12/24 vs. 7.1%, 1/14, respectively, P = 0.012) The SVR rates of re-treated patients who had turned hepatitis C virus (HCV) RNA-negative at weeks 8, 12, 24, and 48 of the previous therapy were 67% (4/6), 67% (4/6), 29% (2/7), and 25% (1/4), respectively. Re-treatment achieved an SVR in five of 12 patients with IL28B major alleles and three of nine patients with IL28B minor alleles. During the re-treatment, patients with complete viral suppression at week-12 achieved a significantly higher SVR rate (P = 0.001). Re-treatment with PEG-IFN α2a plus ribavirin therapy is effective in patients who relapse after a course of PEG-IFN α2b plus ribavirin therapy. Re-treatment is a particularly useful option for patients who achieve early viral clearance during previous therapy.

Complete Early Virological Response Was Highly Achieved by Double Filtration Plasmapheresis Plus IFN‐Beta Induction Therapy for HCV‐1b Patients With Relapse or No Response After Previous IFN Therapy

The efficacy of double filtration plasmapheresis (DFPP) plus interferon (IFN)-β induction therapy was preliminarily investigated in re-treated patients with chronic genotype 1b hepatitis C and high viral load (patients with relapse or non-response to previous IFN therapies). In eight patients with chronic hepatitis C, DFPP was performed five times over 2 weeks during IFN-β therapy, and 3 MU of IFN-β was administered twice a day for 2 weeks. Combination therapies with ribavirin and pegylated IFN-α2b (PEG-IFN-α2b) or pegylated IFN-α2a (PEG-IFN-α2a) were subsequently used. After 4 weeks, hepatitis C virus (HCV)-RNA tended to be more greatly decreased with DFPP combination therapy than with previous IFN therapy (4.5 ± 2.0 log(10) IU/mL vs. 2.9 ± 1.2 log(10) IU/mL). Rates of both rapid virological response and complete early virological response were significantly higher with DFPP and IFN-β induction therapy than with previous IFN therapy. DFPP plus IFN-β induction therapy produced a great reduction of viral load during the early stage of treatment and achieved a high early virological response, suggesting that this combination therapy may be useful as a new treatment modality for chronic hepatitis C patients in difficult-to-treat states. This combination may contribute to sustained virological response (SVR). The effects of DFPP on SVR and its significance remain to be clarified.

Research on the association of TIRAP coding region polymorphism with susceptibility to tuberculosis in Chinese Han population

Objective To detect specific polymorphisms in Toll-interleukin 1 receptor domain containing adaptor protein(TIRAP) coding region for Chinese Han population, and verify whether they are associated with susceptibility to tuberculosis. Methods Search TIRAP polymorphisms by sequencing in small sample; detect single nucleotide polymorphism(SNP) by ligase detection reaction technique in large sample; analyze whether polymorphisms are related to tuberculosis by statistic methods. Results Four polymorphisms were present in the TIRAP coding region. 394A had higher frequencies in the tuberculosis(TB)group than the control. But allelic and genotypic analysis showed that there were no significant difference in statistic between TB patients and controls(P>0.05). The SNP G164A mutation related with TB patient's condition. Comparing to controls, retreatment patients' allelic frequencies had significant difference in statistic(P<0.05), sputum positive patients and lung cavitation patients had lower 164A frequencies. Conclusion TIRAP coding region polymorphisms may be risk factors for TB occurrence and development in Chinese Han population. Key words: Tuberculosis; Toll-interleukin 1 receptor domain containing adaptor protein; Susceptibility; Single nucleotide polymorphisms

Treatment outcomes among new smear positive and retreatment cases of tuberculosis in Mangalore, South India – a descriptive study.

India has the highest tuberculosis burden in the world. For successful implementation of the Revised National Tuberculosis Control Programme (RNTCP), treatment outcomes and factors which influence them need to be assessed on a regular basis. This study was thus done to find out the sputum conversion rates, treatment outcomes and sociodemographic factors of new smear positive cases (NSP) and retreatment cases of pulmonary tuberculosis of the Mangalore Tuberculosis Unit (TU) registered at the District Tuberculosis Centre (DTC), Mangalore. This record-based cross-sectional study was undertaken in June 2009. Information pertaining to NSP or Category I patients and retreatment patients or Category II patients between June 2008 to May 2009 (one year period) were recorded. Of 286 tuberculosis patients, 74.1% were on Category I treatment. The sputum conversion rate among Category I and II patients was 91.5% and 73% respectively. Category I patients showed a cure rate of 77.4%, a default rate of 7.5% and a failure rate of 15.1%. Category II patients showed a cure rate of 47.3%, default rate of 20.3% and failure rate of 32.4%. The differences in treatment outcomes between the two categories of treatment were found to be statistically significant (X(2) = 23.737, P <0.001). A favourable treatment outcome in Category I was significantly more in patients aged 30 years or less when compared to the rest (X(2) = 15.7, P = 0.004). However, gender and place of residence did not have a significant influence on treatment outcomes among NSP patients. Among retreatment patients, age, gender and place of residence did not have a significant influence on treatment outcomes. Sputum conversion rates were satisfactory but the treatment outcome rates were poorer in our study area compared to Indian national figures. Among the sociodemographic factors, age was found to significantly influence treatment outcomes in Category I patients.

Impact of the use of autologous stem cell transplantation at first relapse both in naive and previously rituximab exposed follicular lymphoma patients treated in the GELA/GOELAMS FL2000 study

We analyzed detailed characteristics and salvage treatment in 175 follicular lymphoma patients from the FL2000 study who were in progression after first-line therapy with or without addition of rituximab to chemotherapy and interferon. The impact of using autologous stem cell transplantation and/or rituximab administration at first progression was investigated, taking into account initial therapy. With a median follow up of 31 months, 3-year event free and overall survival rates after progression were 50% (95%CI 42-58%) and 72% (95%CI 64-78%), respectively. The 3-year event free rate of rituximab re-treated patients (n=112) was 52% (95%CI 41-62%) versus 40% (95%CI 24-55%) for those not receiving rituximab second line (n=53) (P=0.075). There was a significant difference in 3-year overall survival between patients receiving autologous stem cell transplantation and those not: 92% (95%CI 78-97%) versus 63% (95%CI 51-72%) (P=0.0003), respectively. In multivariate analysis, both autologous stem cell transplantation and period of progression/relapse affected event free and overall survival. Regardless of front-line rituximab exposure, this study supports incorporating autologous stem cell transplantation in the therapeutic approach at first relapse for follicular lymphoma patients.

Risk factors for tuberculosis treatment failure, default, or relapse and outcomes of retreatment in Morocco

BackgroundPatients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high.MethodsPatients with smear- or culture-positive pulmonary tuberculosis presenting for retreatment were identified using clinic registries in nine urban public clinics in Morocco. Demographic and outcomes data were collected from clinical charts and reference laboratories. To identify factors that had put these individuals at risk for failure, default, or early relapse in the first place, initial treatment records were also abstracted (if retreatment began within two years of initial treatment), and patient characteristics were compared with controls who successfully completed initial treatment without early relapse.Results291 patients presenting for retreatment were included; 93% received a standard Category II regimen. Retreatment was successful in 74% of relapse patients, 48% of failure patients, and 41% of default patients. 25% of retreatment patients defaulted, higher than previous estimates. Retreatment failure was most common among patients who had failed initial treatment (24%), and default from retreatment was most frequent among patients with initial treatment default (57%). Drug susceptibility testing was performed in only 10% of retreatment patients. Independent risk factors for failure, default, or early relapse after initial treatment included male gender (aOR = 2.29, 95% CI 1.10-4.77), positive sputum smear after 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), and hospitalization (OR 2.09, 95% CI 1.01-4.34). Higher weight at treatment initiation was protective. Male sex, substance use, missed doses, and hospitalization appeared to be risk factors for default, but subgroup analyses were limited by small numbers.ConclusionsOutcomes of retreatment with a Category II regimen are suboptimal and vary by subgroup. Default among patients receiving tuberculosis retreatment is unacceptably high in urban areas in Morocco, and patients who fail initial tuberculosis treatment are at especially high risk of retreatment failure. Strategies to address risk factors for initial treatment default and to identify patients at risk for failure (including expanded use of drug susceptibility testing) are important given suboptimal retreatment outcomes in these groups.