Tuberculosis latente: diagnóstico y tratamiento actual / Latent tuberculosis: current diagnosis and treatment

Resumen La infección tuberculosa latente (TL) afecta al 23% de la población y constituye un reservorio de tuberculosis (TBC) ya que 10% progresa hacia una TBC. La TL se reconoce por pruebas como la tuberculina (PPD o TST) y los ensayos de liberación de Interferón gama (IGRAs). La sensibilidad de IGRAs (versión Quantiferon TB Gold plus) es 94% y del PPD 77%. La especificidad del Quantiferon TB Gold Plus es 97% y del PPD 68%. El valor predictivo de progresión a TBC activa de estas pruebas es bajo (PPD: 1,5%, IGRAs: 2,7%) pero mejora en personas de alto riesgo de contraer TBC (PPD: 2,4%, IGRAs: 6,8%). Las personas con pruebas negativas que posteriormente presentan viraje (prueba positiva) tienen mayor riesgo de progresión a TBC activa. Estas pruebas son útiles en el seguimiento de contactos intradomiciliarios, extranjeros de países con altas tasas de TBC, inmunosuprimidos, enfermedad renal crónica, diabetes, silicosis y secuelas pulmonares de TBC no tratada. En la terapia de TL se utiliza isoniazida (H) auto-administrada por plazos de 6 a 12 meses con eficacia protectora de 60% y riesgo de toxicidad hepática de 2% pero con baja adherencia (50-70%). La asociación de H con rifapentina en dosis única semanal durante 12 semanas tiene eficacia de 81%, adherencia de 82% y baja toxicidad hepática (0,4%). Nuevos biomarcadores de TL y vacunas que mejoren la inmunidad en TL se encuentran en estudio. El tratamiento de la TL puede reducir la incidencia de TBC a largo plazo.

Latent tuberculosis infection (LT) affects 23% of the population and constitutes a reservoir of tuberculosis (TB) as 10% progresses to TB. LT is recognized by tests such as tuberculin (PPD or TST) and Interferon gamma release assays (IGRAs). The sensitivity of IGRAs (Quantiferon TB Gold plus version) is 94% and PPD 77%. The specificity of Quantiferon TB Gold Plus is 97% and PPD 68%. The predictive value of progression to active TB of these tests is low (PPD: 1.5%, IGRAs: 2.7%) but improves in people at high risk of contracting TB (PPD: 2.4%, IGRAs: 6.8%). People with negative tests who subsequently turn around (positive) have a higher risk of progression to active TB. These tests are useful in the follow-up of intra-household contacts, foreigners from countries with high rates of TB, immunosuppressed, chronic kidney disease, diabetes, silicosis and pulmonary sequelae of untreated TB. In LT therapy, self-administered isoniazid (H) is used for periods from 6 to 12 months with protective efficacy of 60% and risk of liver toxicity of 2%, but with low adherence (50-70%). The association of H with rifapentine in a single weekly dose for 12 weeks has efficacy of 81%, adherence of 82% and low liver toxicity (0.4%). New LT biomarkers and vaccines that improve immunity in LT are under study. Treatment of LT may reduce the incidence of TB in the long term.

A new mixed surgical treatment for grades iii and iv hemorrhoids: modified selective hemorrhoidectomy combined with complete anal epithelial retention / Um novo tratamento cirúrgico para hemorroidas mistas graus iii e iv: hemorroidectomia seletiva modificada combinada com retenção epitelial anal completa

ABSTRACT Background: Varicose veins appear above and below the dentate line in mixed hemorrhoids, which seriously affects anal function and quality of life. Aim: To propose an improvement in tissue-selecting therapy repair of anal pad combined with complete anal canal epithelial retention comparing with Milligan-Morgan surgery. Methods: A prospective randomized controlled study was designed enrolling 200 patients with grade III and IV hemorrhoids. They were divided into control and observation groups. The control received Milligan-Morgan surgery, and the observation the modified tissue-selecting therapy stapler combined with complete anal canal preservation surgery. All patients were followed for six months to evaluate the treatment differences. Results: In final, control group included 82 and observation 87. The average operation time of the control group was significantly lower than that of the observation, while the bleeding volume was significantly lower in control group. The control group VAS score was 3 (1, 4), and observation 4 (2, 5). There was no significant difference in the incidence of urinary retention, bleeding and wound margin edema after surgery at one month postoperatively. Digital incidence of anal stenosis in the observation group was significantly lower than in control; the same occurred with residual anal margins. The postoperative anal canal diameter was significantly larger than the control group. Wexner anal incontinence score showed that no anal incontinence occurred in both groups, and the control group scored was significantly higher than observation. In final six months follow-up, the observation group did not experience any relapse and four cases were found among controls. The treatment satisfaction of the observation group was better. Conclusions: In grades III and IV hemorrhoids, modified tissue-selecting therapy combined with complete anal canal preservation had better prognosis and treatment satisfaction than Milligan-Morgan procedure, and it is a new surgical method for patients with advanced mixed hemorrhoids.

RESUMO Racional: Veias varicosas aparecem acima e abaixo da linha dentada nas hemorroidas mistas, afetando seriamente a função anal e a qualidade de vida. Objetivo: Propor melhoria na terapia de seleção de tecido de reparo do coxim anal combinado com retenção completa epitelial do canal anal em comparação com a operação de Milligan-Morgan. Métodos: Estudo prospectivo randomizado controlado foi desenhado envolvendo 200 pacientes com hemorroidas graus III e IV. Eles foram divididos em grupos de controle e observação. O controle recebeu operação de Milligan-Morgan, e o de observação procedimento de seleção de tecido modificado combinado com operação completa de preservação do canal anal. Todos os pacientes foram acompanhados por seis meses para avaliar as diferenças de tratamento. Resultados: No final, o grupo controle incluiu 82 e o de observação 87. O tempo médio de operação do grupo controle foi significativamente menor do que o de observação, enquanto o volume de sangramento foi significativamente menor no grupo controle. O escore VAS do grupo controle foi 3 (1, 4) e no de observação 4 (2, 5). Não houve diferença significativa na incidência de retenção urinária, sangramento e edema da margem da ferida no pós-operatório de um mês. A incidência de estenose anal digital no grupo observação foi significativamente menor do que no controle; o mesmo ocorreu com as margens anais residuais. O diâmetro do canal anal pós-operatório foi significativamente maior nele do que o grupo controle. A pontuação de incontinência anal de Wexner mostrou que nenhuma incontinência ocorreu em ambos os grupos, e a pontuação do grupo de controle foi significativamente maior do que no de observação. Nos últimos seis meses de acompanhamento, o grupo observação não teve nenhuma recaída e quatro casos foram encontrados entre os controles. A satisfação com o tratamento do grupo observação foi maior. Conclusões: Nas hemorroidas graus III e IV, o tratamento de seleção de tecido modificado combinado com a preservação completa do canal anal teve melhor prognóstico e satisfação do que com o procedimento de Milligan-Morgan, e é um novo método cirúrgico para pacientes com hemorroidas mistas avançadas.

Clinical profile of childhood Tuberculosis in a Tertiary Care Rural Hospital and comparision of efficacy of daily vs intermittent chemotherapy

Introduction: Tuberculosis (TB) remains a major public health problem, despite noteworthy socioeconomic development and advances in medical science. It is a curable disease but still millions of people suffer every year and a number of them die from this infectious disease, resulting in devastating social and economic impact. We report the disease course, clinical profile and factors associated with treatment outcome in a tertiary facility of Waghodia. Materials and methods: The study was carried out in the Department of Pediatrics at Dhiraj Hospital, Piparia. Recruitment took place from February 2014 to February 2015. The clinical profile of 71 patients was studied and patients were followed up to 6 months to evaluate the treatment outcome. Results: There was preponderance of males (60.56%, n=43) in study population as compared to females (39.44%, n=28). Most of the patients were belonging to age group of <6 years (32.4%, n=23) and >10 years (38.0%, n=27). Among 6 to 10 years, 21 (29.6%) patients were included in study. Most common form of TB was extra-pulmonary TB (60.56%, n=43) followed by pulmonary TB (39.43%, n=28). Non-specific symptoms like fever (82.5%, n=66) was the commonest presenting symptoms. Other symptoms included cough (33.8%, n=24), altered sensorium (19.71%, n=14), swelling (15.5%, n=11). From all the patient with follow up (n=50), 44 (88.0%) were cured. Conclusion: Diagnosis of paediatric tuberculosis still continues to be a challenge. In the study TB was more common in extra-pulmonary than pulmonary forms in our setting. Diagnosis was based on a combination of epidemiological and clinical suspicion supported by results of various investigations. Aashish Sethi, Prasad Muley. Clinical profile of childhood Tuberculosis in a Tertiary Care Rural Hospital and comparison of efficacy of daily vs. intermittent chemotherapy. IAIM, 2018; 5(5): 69-78. Page 70 Presence of paediatric TB is an indication of prevalence of TB in that community. Extra pulmonary tuberculosis is more common in pediatric population and comparison of daily vs. intermittent treatment shows similar efficacy

Clinical Profile of Childhood Tuberculosis in a Tertiary Care Rural Hospital

Introduction: Tuberculosis (TB) remains a major public health problem, despite noteworthy socioeconomic development and advances in medical science. It is a curable disease but still millions of people suffer every year and a number of them die from this infectious disease, resulting in devastating social and economic impact. TB treatment requires several months of swallowing a combination of 3 to 4 drugs every day. Patients often forget to take their medicines or stop taking them when they start to feel better. The Revised National TB Control Programme (RNTCP), based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy was launched. Studies of paediatric TB are scantily available both in global and national context. Reliable data on the treatment of paediatric TB and its follow up are not available. Hence, a study of paediatric TB is designed to evaluate the clinical profile of childhood tuberculosis and following up the treatment outcome upto 6 months Materials and methods: The study was carried out in the Department of Pediatrics at Dhiraj Hospital, Piparia. Recruitment took place from February 2014 to February 2015. The clinical profile of 71 patients was studied. Results: There was preponderance of males (60.56%, n=43) in study population as compared to females (39.44%, n=28). Most of the patients were belonging to age group of <6 years (32.4%, n=23) and >10 years (38.0%, n=27). Among 6 to 10 years, 21 (29.6%) patients were included in study. Most common form of TB was extra-pulmonary TB (60.56%, n=43) followed by pulmonary TB (39.43%, n=28). Non-specific symptoms like fever (82.5%, n=66) was the commonest presenting symptoms. Other symptoms included cough (33.8%, n=24), altered sensorium (19.71%, n=14), swelling (15.5%, Muley P, Odedara T, Memon R, Sethi A, Gandhi D. Clinical Profile of Childhood Tuberculosis in a Tertiary Care Rural Hospital. IAIM, 2017; 4(6): 109-124. Page 110 n=11). From all, the patient with follow up (n=50), 44 (88.0%) were cured, 3 (6.0%) patients expired during the course of treatment, 3(6.0%) patient showed no improvement. Conclusion: Diagnosis of paediatric tuberculosis still continues to be a challenge. In the study TB was more common in extra-pulmonary than pulmonary forms in our setting. Diagnosis was based on a combination of epidemiological and clinical suspicion supported by results of various investigations. Presence of paediatric TB is an indication of prevalence of TB in that community. As the source of transmission of TB to children is usually an adult, control of tuberculosis in adult is necessary to decrease the prevalence of TB in children. DOTS is an effective strategy for treatment of TB.

Prevalence and molecular proifle of theStaphylococcus aureus strains harboring tstand/or pvl genes / 中国感染与化疗杂志

Objective To investigate the prevalence, accessory gene regulator (agr) and staphylococcal cassette chromosome mec (SCCmec, only for methicillin resistantS. aureus, MRSA) types of theS. aureus strains carrying toxic shock syndrome toxin-1 (tst) and/or panton-valentine leukocidin (pvl) genes.Methods Nine hundred and sixteen isolates ofS. aureus were collected from seven hospitals in Shanghai and Zhejiang Province and subjected to detection oftst,pvl,mecA andmecC genes by polymerase chain reaction (PCR). Theagr and SCCmec (only for MRSA) types were determined in thetst orpvl gene positive isolates.Results Of the 916 isolates, 208 carriedtst gene (22.7%), 35 harboredpvl gene (3.8%), and 665 weremecA positive (MRSA). No isolate was mecC positive. Out of the 665 MRSA isolates, 198 hosted thetst gene (29.8%). The most commonagr and SCCmec types were agr 2 (97.0%) and SCCmec II (94.4%), respectively. For thepvl gene, only 14 isolates were positive (2.1%). Theagr 1 (85.7%), SCCmecIII (42.9%) and SCCmec IVa (28.6%) were the most commonagr type and SCCmec type. In the 251 methicillin-sensitiveS. aureus (MSSA) isolates, 10 carriedtst gene (4.0%) and 21 carriedpvl gene (8.4%). The prevalence oftst gene in MRSA was higher than that in MSSA, while the prevalence ofpvlgene was just the opposite. However, the prevalence ofpvlgene in MRSA isolates from Zhejiang Province was higher than that in the MRSA isolates from Shanghai (P severeS. aureus infections.

Tuberculin skin testing: Spectrum of adverse reactions.

Tuberculin skin testing (TST) is one of the primary diagnostic modalities recommended by the World Health Organization (WHO) and the National Institute for Health and Care Excellence (NICE) study conducted in the United Kingdom (UK) for diagnosing tuberculosis (TB). Even after acceptance as a diagnostic modality and stern standardization, TST has its own flaws that include a spectrum of adverse reactions. We report a series of cases with a spectrum of adverse reactions occurring with a higher frequency than present in the available evidence. The study has some demerits such as being a retrospective one with interobserver variation and lack of histopathological confirmation. The observation is presented to accentuate the fact that adverse reactions are not a rarity and that further studies are required to establish the cause and exact incidence of the same.

Ocorrência do gene da toxina da síndrome do choque tóxico em Staphylococcus spp. isolados de leite de vacas com mastite e de leite cru refrigerado / Occurrence of the toxic shock syndrome toxin gene in Staphylococcus spp.isolated from bovine mastitis milk and refrigerated raw milk

Avaliou-se a presença do gene (tst-1) para Toxina da Síndrome do Choque Tóxico-1 (TSST-1), utilizando-se a técnica de Reaçãoem Cadeia da Polimerase (PCR) em um total de 264 Staphylococcus spp. isolados de leite. Desses, 221 eram Staphylococcusaureus, 33 Staphylococcus coagulase negativo (SCN) e 10 Staphylococcus coagulase positivo (SCP). As amostras eram oriundasde vacas com mastite (n=96) e de leite cru refrigerado (n=168), coletadas de 46 e 22 propriedades, respectivamente. As amostrasforam coletadas de rebanhos localizados em diferentes regiões dos Estados de Minas Gerais e Rio de Janeiro. Observou-seproduto de amplificação (250 pares de base-pb) na reação de PCR para tst-1 em sete amostras (2,6%), sendo todas as estirpesidentificadas como Staphylococcus aureus isoladas de leite cru refrigerado. Embora a detecção do gene não indique a produçãoda toxina, o monitoramento de estirpes bacterianas potencialmente produtoras torna-se importante como forma de realizar umlevantamento epidemiológico e controle dos rebanhos leiteiros brasileiros, uma vez que esse gene está associado aos elementosgenéticos móveis, representando um risco à possível transferência horizontal de genes para outras bactérias. Além disso, a presençadesses genes tem sido associada à presença de genes para enterotoxinas estafilocócicas, o que pode implicar o aumento dapatogenicidade dos isolados bacterianos e um potencial risco à saúde pública.

Was evaluated the presence of the gene (tst -1) for toxic shock syndrome toxin - 1 (TSST -1), using the technique of PolymeraseChain Reaction (PCR) on a total of 264 Staphylococcus spp. isolated from milk. Of these, 221 were Staphylococcus aureus, 33Staphylococcus coagulase negative (SCN) and 10 Staphylococcus coagulase positive (SCP). The samples were from cows withmastitis (n=96) and refrigerated raw milk (n=168), collected from 46 and 22 dairy herds, respectively. Samples were collectedfrom herds located in different regions of Minas Gerais and Rio de Janeiro States. Was observed PCR amplification of the tst-1gene (250 base pairs-bp) in seven (2.6 %) samples, and all strains of Staphylococcus aureus isolated from refrigerated raw milk.Although its detection in isolated does not mean that it will be expressed, monitoring of bacterial strains producing potentiallybecomes important as performing an epidemiological survey and control of Brazilian dairy herds, since this gene is associatedwith mobile genetic elements, representing a risk to possible horizontal gene transfer to other bacteria. Furthermore, the presenceof these genes have been associated with the presence of genes for enterotoxins, which may result in increased pathogenicity ofthe isolates and a potential risk to public health.

Evaluation of QuantiFERON-TB Gold in- Tube and Immunological Tests for TB Diagnosis in Iraqi Patients.

Aims: Tuberculosis is an infectious disease caused by the bacillus Mycobacterium tuberculosis and other related species. It typically affects the lungs (pulmonary TB) but can affect other sites (extra-pulmonary TB). A profusion of articles have been published on the accuracy and uses of interferon-gamma releasing assays for detection of this disease. Experimental Design: A prospective study. Place and Duration of Study: This study was done in Kirkuk city between November 2012 to February 2013. Methodology: The present study included 50 individuals (40 suspected tuberculosis patients and 10 healthy controls). The patient were examined for the presence of TB by using QuantiFERON-TB Gold In-Tube(QFT-GIT) assay, polymerase chain reaction (PCR) and compared them with certain new and routine tests like AFB smear, OnSite TB rapid test, erythrocyte sedimentation rate and chest X-ray. Result: The present study showed a relation between QFT-GIT and OnSite TB rapid test, and they were positive in 25(86%) at the same time; QFT-GIT positive and OnSite TB rapid test were negative in 4(14%) of patients; QFT-GIT negative and OnSite TB rapid test positive were seen in 5(45%); while QFT-GIT and OnSite TB rapid test were negative in 6(55%) of patients. In the control group only one QFT-GIT positive but it was OnSite TB test negative. 9(100%) of individuals for both tests were negative, 29 were males and 21 were females. Conclusion: The study highlighted the sensitivity of IGRAs for diagnosis of active TB in combination with the rapid IgM/lgG tests for TB.The QFT assay appeared to be a more specific indicator of latent TB infection than TST. The association with blood groups and vaccination is also significant.

Tuberculin skin testing in inflammatory bowel disease patients from an endemic area of Brazil

Objective: Inflammatory bowel disease (IBD) is a chronic disorder involving the gastrointestinal tract. Immunosuppressive drugs are usually prescribed to treat IBD patients, and this treatment can lead to tuberculosis reactivation. This paper aimed to analyze tuberculin skin test (TST) results in IBD patients at a reference center in Brazil. Methods: We evaluated TST results in IBD patients using a cross-sectional study. We also analyzed the medical records of patients treated at a reference IBD outpatient unit where TST is routinely performed. Results: We reviewed 119 medical records of 57 (47.9%) Crohn's disease (CD), 57 (47.9%) ulcerative colitis (UC) and 5 (4.2%) indeterminate colitis (IC) patients. The mean (SD) age was 43.5 (13.7) years old. TST was positive in 24 (20.2%) of the patients. TST was positive in 16/57 (28.1%) UC and 6/57 (10.5%) CD patients (prevalence ratio [PR] 2.7). Forty-one patients (34.5%) were taking immunosuppressive drugs (azathioprine or prednisone) at the time of the TST, and six of these patients (14.6%) had positive test results. Two patients using infliximab had negative TST results. Thirty-five of the 41 patients (85.4%) on immunosuppressive treatment were anergic compared with 73.1% (57/78) of the untreated patients (PR 1.2). Conclusions: Patients with IBD have TST results similar to the general Brazilian population. Within the IBD population, CD patients have a lower frequency of TST positivity than UC patients. .

Comparative efficacy of behavioral despair models in depicting antidepressant-like effect of tramadol.

Background: Experimental evaluation of antidepressants (ADs) in diverse animal models is the need of time. There is a constant search for newer models with ease and rapid screening of AD activity. As earlier studies highlight AD effect of tramadol in animal models, the study was undertaken to compare antidepressant-like effect of tramadol in two models of behavioural despair in mice. Methods: Tramadol was administered intraperitoneally (i.p.) at two different doses of 20 and 40 mg/kg, once daily for 7 days to Swiss albino mice. The immobility period of control and drug-treated mice was recorded in tail suspension test (TST) and forced swim test (FST). The antidepressant (AD) effect of tramadol was compared with control (NS) and reference drug imipramine (10 mg/kg, p.o.), administered orally (p.o.) for seven successive days. Results: Tramadol in tail suspension test (TST) produced significant antidepressant effect at 20 and 40 mg/kg doses, as depicted by reduction in immobility period of drug-treated mice compared to control group. The efficacy of tramadol at dose of 40 mg/kg was comparable to that of imipramine treated group (p<0.001). Tramadol in forced swim test (FST) produced significant antidepressant effect only at the dose of 40 mg/kg as compared to control, while the results were insignificant as compared to imipramine treated group (p>0.05). Conclusion: The results of the present study depict antidepressant-like activity of tramadol in both the models of depression TST and FST. But TST in mice seems to be more efficacious in appraising the antidepressant like effect of tramadol.