Cost-effectiveness of active case-finding of household contacts of pulmonary tuberculosis patients in a low HIV, tuberculosis-endemic urban area of Lima, Peru.

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.

Xpert MTB/RIF Assay Shows Faster Clearance of Mycobacterium tuberculosis DNA with Higher Levels of Rifapentine Exposure.

The Xpert MTB/RIF assay is both sensitive and specific as a diagnostic test. Xpert also reports quantitative output in cycle threshold (CT) values, which may provide a dynamic measure of sputum bacillary burden when used longitudinally. We evaluated the relationship between Xpert CT trajectory and drug exposure during tuberculosis (TB) treatment to assess the potential utility of Xpert CT for treatment monitoring. We obtained serial sputum samples from patients with smear-positive pulmonary TB who were consecutively enrolled at 10 international clinical trial sites participating in study 29X, a CDC-sponsored Tuberculosis Trials Consortium study evaluating the tolerability, safety, and antimicrobial activity of rifapentine at daily doses of up to 20 mg/kg of body weight. Xpert was performed at weeks 0, 2, 4, 6, 8, and 12. Longitudinal CT data were modeled using a nonlinear mixed effects model in relation to rifapentine exposure (area under the concentration-time curve [AUC]). The rate of change of CT was higher in subjects receiving rifapentine than in subjects receiving standard-dose rifampin. Moreover, rifapentine exposure, but not assigned dose, was significantly associated with rate of change in CT (P = 0.02). The estimated increase in CT slope for every additional 100 µg · h/ml of rifapentine drug exposure (as measured by AUC) was 0.11 CT/week (95% confidence interval [CI], 0.05 to 0.17). Increasing rifapentine exposure is associated with a higher rate of change of Xpert CT, indicating faster clearance of Mycobacterium tuberculosis DNA. These data suggest that the quantitative outputs of the Xpert MTB/RIF assay may be useful as a dynamic measure of TB treatment response.

Manual MGIT™ system for the detection of Mycobacterium tuberculosis: insights from a high TB burden setting.

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.

Geographic predictors of primary multidrug-resistant tuberculosis cases in an endemic area of Lima, Peru.

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.

[Whole body PET/CT imaging for detection of metastatic choroidal melanoma]. / PET/TC de cuerpo completo para la detección de metástasis de melanoma coroideo.

Choroidal melanoma is the most common primary intraocular cancer in adults. Metastases are most commonly found in the liver and are rapidly fatal despite aggressive therapy. These metastases have been reported in the follow-up to 50 % of uveal melanoma. However, recent reports have shown that liver ultrasonography and liver function tests have low sensitivity in the diagnosis of metastatic uveal melanoma. The study reports on a patient with a history of choroidal melanoma. Preoperative medical evaluation, including CT imaging of the abdomen, complete blood count and liver enzymes proved negative. A PET/CT was requested and showed lesions in the liver and lungs. Whole-body PET/CT revealed melanoma metastases. The PET/CT is a sensitive tool for the detection and localization of hepatic and extrahepatic metastatic choroidal melanoma.

PET/TC de cuerpo completo para la detección de metástasis de melanoma coroideo / Whole body PET/CT imaging for detection of metastatic choroidal melanoma

El melanoma coroideo es el tumor maligno ocular primario más frecuente en los adultos y las metástasis más frecuentes son a nivel hepático con un mal pronóstico a pesar de los tratamientos. Estas metástasis se han descrito hasta en el 50 % de los melanomas coroideos. Estudios recientes muestran que la ecografía hepática y las analíticas hepáticas tienen baja sensibilidad en el diagnóstico de las metástasis hepáticas de los melanomas de úvea. Exponemos el caso de un paciente con historia de melanoma coroideo. La exploración preoperatoria, incluyendo TC de abdomen, analítica sanguínea y enzimas hepáticos resultó normal. En un PET/TC realizado mostró lesiones en el hígado y pulmones. El PET/TC de cuerpo entero mostró metástasis de un melanoma uveal. El PET/TC es una herramienta útil para la detección de las metástasis hepáticas y extrahepáticas (AU)

Choroidal melanoma is the most common primary intraocular cancer in adults. Metastases are most commonly found in the liver and are rapidly fatal despite aggressive therapy. These metastases have been reported in the follow-up to 50 % of uveal melanoma. However, recent reports have shown that liver ultrasonography and liver function tests have low sensitivity in the diagnosis of metastatic uveal melanoma. The study reports on a patient with a history of choroidal melanoma. Preoperative medical evaluation, including CT imaging of the abdomen, complete blood count and liver enzymes proved negative. A PET/CT was requested and showed lesions in the liver and lungs. Whole-body PET/CT revealed melanoma metastases. The PET/CT is a sensitive tool for the detection and localization of hepatic and extrahepatic metastatic choroidal melanoma (AU)

Experiencia en el entrenamiento de marcha con terapia robotizada Lokomat® en pacientes con patologías neurológicas del Instituto Teletón Santiago-Chile: 2008-2009 / Experience in gait training with Lokomat® robotic therapy in patients with neurological disorders of the Instituto Teletón Santiago, Chile: 2008-2009

Introduction: The Lokomat® robotic therapy is proposed as a new alternative for the rehabilitation of gait in patients with neurological disorders of central origin. Objective: To describe the effect of the Lokomat® in speed, gait pattern, postural stability, third party assistance, and the need of technical aids for gait in a group of patients with neurological disorders in the Institute Teletón Santiago between April 2008 and June 2009. Patients and Methods: 77 medical records of patients in the Lokomat® program were selected. These included patients with cerebral palsy (CP), stroke (CVA), traumatic brain injury (TBI) and ataxic syndrome. The patients had an average age of 16.2 years (range 4.65 to 25.98 years). Results are evaluated pre and post training measuring gait speed(10 meters test), gait pattern (visual scale of Edinburgh), postural stability and transfers (timed up and go test), third party assistance (functional ambulation categories - FAC) and gait functionality (functional mobility scale- FMS). The Wilcoxon test was applied to measure changes before and after with p < 0.05. Results: Significant changes were observed in all tests in the group of subjects with CP (p < 0.001) after orthopedic surgery and in speed and gait pattern in CP patients after onabotulinum toxin A infiltration. In patients with TBI and stroke changes in gait pattern and functional tests were evident (p < 0.05). In ataxic subjects improvement in postural stability and transfers were recorded (p < 0.01).Conclusions: The Lokomat® robotic orthosis is a useful tool in improving gait related parameters in the neurological diseases analyzed, especially in CP patients after orthopedic surgery.

Introducción: La terapia robotizada con Lokomat® se plantea como una nueva alternativa para la rehabilitación de la marcha en pacientes con patologías neurológicas de origen central. Objetivo: Describir el efecto del Lokomat® en velocidad, patrón de marcha, estabilidad postural, asistencia por terceros, necesidad de ayudas técnicas en la marcha en un grupo de pacientes portadores de patologías neurológicas del Instituto Teletón de Santiago, entre abril-2008 y junio-2009. Pacientes y Métodos: Se seleccionan 77 fichas médicas de pacientes del programa Lokomat®, portadores de parálisis cerebral (PC), accidente vascular encefálico (AVE), traumatismo encéfalo craneano (TEC) y síndrome atáxico, con edad media de 16,2 años (rango 4,65-25,98 años). Se evalúan resultados pre y post entrenamiento en velocidad de marcha (test de 10 metros), patrón de marcha (escala visual de Edimburgo), estabilidad postural y transferencias (test timed up and go), asistencia de terceros (categoría funcional de la marcha) y funcionalidad en la marcha (escala de marcha o movilidad funcional). Se aplica test de Wilcoxon para medir los cambios antes-después con p < 0,05. Resultados: Se observaron cambios significativos en todas las pruebas en el grupo de sujetos con PC postcirugía ortopédica (p < 0,001) y en velocidad y patrón de marcha en el grupo post infiltración con onabotulinumtoxinA. En pacientes con TEC y AVE se evidenciaron cambios en el patrón de marcha y en los test funcionales (p < 0,05). En sujetos atáxicos se registró mejoría en estabilidad postural y transferencias (p < 0,01). Conclusiones: La órtesis robótica Lokomat® es una herramienta útil en la mejoría de parámetros vinculados a la marcha en las patologías neurológicas analizadas, especialmente en el grupo de PC post cirugía ortopédica, donde todos los test registraron mejoras significativas.

[Fructose intolerance in patients with irritable bowel syndrome: a case-control study]. / Intolerancia a la fructosa en pacientes con síndrome de intestino irritable; un estudio de casos y controles.

INTRODUCTION: Recently it has been reported that prevalence of fructose intolerance (FI) in patients with functional gastrointestinal disorders range between 38% -75%. OBJECTIVE: To determine the prevalence of FI in subjects diagnosed with irritable bowel syndrome (IBS). METHODS: We studied 25 subjects (17 women, average age 36 years) with IBS (Rome II) and 25 healthy controls (14 women, mean age 37 years) who underwent a breath test after oral loading with fructose (Gastrolyzer ®, Bedfont Scientific Ltd., UK). The load consisted of 25 grams of fructose dissolved in 250 ml of water (10% solution). Breath test analysis of the particles per million (ppm) of hydrogen exhaled were performed every 15 minutes for 3 hours. The fructose breath test was considered positive when concentrations of hydrogen were higher than at 20 ppm or a raising greater than 5 ppm in 3 consecutive samples was detected. RESULTS: According to the Rome II criteria, 10 patients (40%) had IBS-C, 9 (36%) had IBS-D and 6 (24%) had IBS-M. Thirteen (52%) of IBS patients had IF, while only 4 (16%) of control subjects (p = 0.01). Patients with IBS and fructose intolerante tend to suffering from diarrhea predominant IBS (p = 0.053). CONCLUSIONS: Fructose intolerance may be responsible for gastrointestinal symptoms in at least half of IBS patients, especially in the group of patients with IBS-D.

Oxacillin-resistant and multidrug-resistant Staphylococcus aureus in Lima, Peru.

In a hospital in Lima, Peru, a review of 103 Staphylococcus aureus infections was conducted during 2002. The prevalence of oxacillin-resistant S. aureus strains was 68%; 25% of strains were resistant to multiple drugs. Previous use of antibiotics and undergoing a surgical procedure during the current hospital stay were associated with the presence of an oxacillin-resistant S. aureus strain.

Scintimammography in the diagnosis of breast cancer.

BACKGROUND: Mammography has a positive predictive value in the detection of breast cancer of 15% to 25%. Ten percent of patients with breast cancer present with normal mammograms; however, the false negative rate is increased in younger patients. The purpose of this study was to evaluate the effectiveness of Tc-99m Sestamibi imaging in the diagnosis of breast disease. METHODS: Images were collected on 147 women. Patients were evaluated with a combination of physical examination, sonography, and mammography. Each patient received 20 millicuries of Tc-99m Sestamibi intravenously. Anterior and lateral images were obtained, the latter with the patient prone and the breast in the dependent position. RESULTS: One hundred seven patients showed no enhancement (negative scan). Seven of these patients were found at biopsy to have carcinoma. Five had ductal carcinoma in-situ (DCIS) with no associated mass, 1 had an incidental 3 mm focus of invasive ductal carcinoma (IDC), and 1 had a 5-cm cystic lesion with IDC. Forty-one patients showed focal enhancement on their scans (positive scan). Thirty-six were found to have either invasive or in-situ cancer. Four of the 5 patients with benign findings had sclerosing adenosis. The positive and negative predictive values for scintimammography in this group of patients were 88% and 93%, respectively. The sensitivity and specificity were 84% and 95%, respectively. CONCLUSIONS: We conclude that scintimammography is a highly specific test that deserves study as a modality to further refine the indications for breast surgery.