Objectives
Among patients with primary and relapse visceral leishmaniasis (VL) in eastern Sudan, we determined the proportion eligible for treatment with sodium stibogluconate and paromomycin ...(SSG/PM) and, of these, their demographic and clinical characteristics; initial treatment outcomes including adverse side effects requiring treatment discontinuation; treatment outcomes by 6 months; and risk factors associated with initial (slow responders) and late treatment failure (relapses and post‐kala‐azar dermal leishmaniasis, PKDL).
Methods
A retrospective cohort study in Tabarak Allah Hospital, Gedaref Province, eastern Sudan, from July 2011 to January 2014.
Results
Of 1252 individuals diagnosed with VL (1151 primary and 101 relapses), 65% were eligible for SSG/PM including 83% children, almost half of them malnourished and anaemic. About 4% of individuals discontinued treatment due to side effects; 0.7% died during treatment. Initial cure was achieved in 93% of 774 primary cases and 77% of 35 relapse cases (P < 0.001). Among the 809 patients eligible for SSG/PM, 218 (27%) were lost to follow‐up. Outcomes by six months among the 591 patients with available follow‐up data were: definitive cure (n = 506; 86%), relapse (n = 38; 6%), treatment discontinuation (n = 33; 6%), PKDL (n = 7; 1%) and death (n = 7; 1%). Among those completing a full course of SSG/PM, relapses and under‐fives were at significantly higher risk of early and late treatment failure, respectively.
Conclusion
Whether SSG/PM as a first‐line regimen is an undeniable progress compared to SSG monotherapy, it excluded a considerable proportion of VL patients due to drug safety concerns. We call for accelerated development of new drugs and treatment regimens to improve VL treatment in Sudan.
Objectifs
Parmi les patients ayant une leishmaniose viscérale (LV) primaire et de rechute dans l'est du Soudan, nous avons déterminé la proportion éligibles pour un traitement avec du stibogluconate de sodium et de la paromomycine (SGS/PM) et, de ceux‐ci, leurs caractéristiques démographiques et cliniques, les résultats des traitements initiaux, y compris les effets secondaires indésirables nécessitant l'arrêt du traitement, les résultats du traitement après six mois et les facteurs de risque associés à l’échec initial (répondeurs lents) et tardif (rechutes et leishmaniose cutanée post kala‐azar, PKDL) du traitement.
Méthodes
Etude de cohorte rétrospective à l'Hôpital Tabarak Allah, dans la Province de Gedaref, dans l'est du Soudan, de juillet 2011 à janvier 2014.
Résultats
Sur 1252 personnes diagnostiquées avec la LV (1151 primaires et 101 rechutes), 65% étaient éligibles pour SGS/PM dont 83% d'enfants; près de la moitié d'entre eux souffraient de malnutrition et d'anémie. 4% des individus ont abandonné le traitement à cause d'effets secondaires, 0,7% sont décédés au cours du traitement. La guérison initiale a été atteinte chez 93% des 774 cas primaires et 77% des 35 cas de rechute (p <0,001). Il y avait 2% des répondeurs lents parmi les cas primaires et 17% (P <0,001) parmi les cas de rechute. Parmi les 809 patients éligibles pour SGS/PM, les résultats à six mois étaient: 63% de guérisons définitives, 27% de pertes au suivi, 5% de rechutes, 4% d'abandons du traitement, 0,9% de PKDL et 0,9% de décès. Parmi ceux qui ont terminé un cycle complet d’SSG/PM, les cas de rechutes et ceux de moins de cinq ans étaient à risque significativement plus élevé d’échec précoce et tardif du traitement, respectivement.
Conclusion
SSG/PM en tant que traitement de première intention a exclu une proportion considérable de patients atteints de LV en raison de préoccupations sur la sécurité des médicaments. Nous appelons à un développement accéléré de nouveaux médicaments et régimes de traitement pour améliorer le traitement de la VL au Soudan.
Objetivos
Entre pacientes con leishmaniosis visceral (LV) primaria y recaídas en el este de Sudán, hemos determinado la proporción que cumplían criterios para ser tratados con estibugluconato de sodio y paromomicina (EGS/PM) y de estos, sus características demográficas y clínicas; los resultados iniciales del tratamiento incluyendo efectos adversos que requerían descontinuar el tratamiento; resultados de tratamiento después de seis meses; y factores de riesgo asociados con un fallo inicial (respondedores lentos) y fallo en el tratamiento tardío (recaídas y leishmaniosis dérmica post kala azar, LDPK).
Métodos
Estudio retrospectivo de cohortes en el Hospital Tabarak Allah, Provincia de Gedaref, Sudán, entre Julio 2011 y Enero 2014.
Resultados
De 1252 individuos diagnosticados con LV (1151 primarios y 101 recaídas), 65% eran elegibles para EGS/PM incluyendo 83% niños, casi la mitad de ellos desnutridos y anémicos. Un 4% de los individuos descontinuaron el tratamiento debido a sus efectos secundarios; 0.7% murieron durante el tratamiento. La curación inicial se alcanzó en un 93% de los 774 casos primarios y un 77% de 35 casos de recaída (P<0.001). Entre los casos primarios, un 2% eran respondedores lentos, y entre los casos de recaída, un 17% (P<0.001). Entre los 809 pacientes elegibles para recibir EGS/PM, los resultados a seis meses eran: curación definitiva 63%, pérdida durante el seguimiento 27%, recaída 5%, discontinuación del tratamiento 4%, PKDL 0.9% y muerte 0.9%. Entre aquellos que tomaron un tratamiento completo de EGS/PM, los pacientes con recaídas y los menores de cinco años tenían un mayor riesgo de fallo en el tratamiento temprano y tardío, respectivamente.
Conclusión
EGS/PM como régimen de primera línea excluía una proporción considerable por posibles problemas de seguridad del medicamento. Hacemos un llamado a un desarrollo acelerado de nuevos medicamentos y regímenes de tratamiento para mejorar el tratamiento de LV en Sudán.
Facility-based antiretroviral therapy (ART) provision for stable patients with HIV congests health services in resource-limited countries. We assessed outcomes and risk factors for attrition after ...decentralization to community-based ART refill centers among 2603 patients with HIV in Kinshasa, Democratic Republic of Congo, using a multilevel Poisson regression model. Death, loss to follow-up, and transfer out were 0.3%, 9.0%, and 0.7%, respectively, at 24 months. Overall attrition was 5.66/100 person-years. Patients with >3 years on ART, >500 cluster of differentiation type-4 count, body mass index >18.5, and receiving nevirapine but not stavudine showed reduced attrition. ART refill centers are a promising task-shifting model in low-prevalence urban settings with high levels of stigma and poor ART coverage.
National tuberculosis (TB) programs increasingly engage with international non-governmental organizations (INGOs), especially to provide TB care in complex settings where community involvement might ...be required. In Myanmar, however, there is limited data on how such INGO community-based programs are organized and how effective they are. In this study, we describe four INGO strategies for providing community-based TB care to hard-to-reach populations in Myanmar, and assess their contribution to TB case detection.
We conducted a descriptive study using program data from four INGOs and the National TB Program (NTP) in 2013-2014. For each INGO, we extracted information on its approach and key activities, the number of presumptive TB cases referred and undergoing TB testing, and the number of patients diagnosed with TB and their treatment outcomes. The contribution of INGOs to TB diagnosis in their selected townships was calculated as the proportion of INGO-diagnosed new TB cases out of the total NTP-diagnosed new TB cases in the same townships.
All four INGOs implemented community-based TB care in challenging contexts, targeting migrants, post-conflict areas, the urban poor, and other vulnerable populations. Two recruited community volunteers via existing community health volunteers or health structures, one via existing community leaderships, and one directly involved TB infected/affected individuals. Two INGOs compensated volunteers via performance-based financing, and two provided financial and in-kind initiatives. All relied on NTP laboratories for diagnosis and TB drugs, but provided direct observation treatment support and treatment follow-up. A total of 21 995 presumptive TB cases were referred for TB diagnosis, with 7 383 (34%) new TB cases diagnosed and almost all (98%) successfully treated. The four INGOs contributed to the detection of, on average, 36% (7 383/20 663) of the total new TB cases in their respective townships (range: 15-52%).
Community-based TB care supported by INGOs successfully achieved TB case detection in hard-to-reach and vulnerable populations. This is vital to achieving the World Health Organization End TB Strategy targets. Strategies to ensure sustainability of the programs should be explored, including the need for longer-term commitment of INGOs.
Background
In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable ...risk for mother and child during labour. Here, we describe the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan.
Methods
A retrospective cohort study using programme data, compared the outcomes of obstetric risk groups of women treated with unregulated oxytocin, with those of women with regulated treatment.
Results
Of the 6379 women included in the study, 607 (9.5%) received labour-inducing medication prior to reaching the hospital; of these, 528 (87.0%) received unregulated medication. Out of 528 labour-inducing medication administrators, 197 (37.3%) traditional birth attendants (also known as dai) and 157 (29.7%) lady health workers provided unregulated treatment most frequently. Women given unregulated medication who were diagnosed with obstructed/prolonged labour were at risk for uterine rupture (RR 4.1, 95% CI: 1.7–9.9) and severe birth asphyxia (RR 3.9, 95% CI: 2.5–6.1), and those with antepartum haemorrhage were at risk for stillbirth (RR 1.8, 95% CI: 1.0–3.1).
Conclusions
In a conflict-affected region of Pakistan, exposure to unregulated treatment with labour-inducing medication is common, and carries great risk for mother and child. Tighter regulatory control of labour-inducing drugs is needed, and enhanced training of the mid-level cadres of healthcare workers is required.
Using a positional cloning approach supported by comparative genomics, we have identified a previously unreported gene, EYS, at the RP25 locus on chromosome 6q12 commonly mutated in autosomal ...recessive retinitis pigmentosa. Spanning over 2 Mb, this is the largest eye-specific gene identified so far. EYS is independently disrupted in four other mammalian lineages, including that of rodents, but is well conserved from Drosophila to man and is likely to have a role in the modeling of retinal architecture.
PDF
