Psicoterapia psicodramática focal: análise qualitativa e quantitativa no transtorno depressivo maior / Focal psychodrama psychotherapy: a quantitative and qualitative analysis on major depressive disorder

A importância de algumas abordagens psicoterápicas associadas à farmacoterapia no tratamento do Transtorno Depressivo Maior tem sido bastante destacada, no entanto, existem poucos dados sobre a Psicoterapia Psicodramática. O presente estudo comparou 20 pacientes com diagnóstico de TDM em uso de medicamentos antidepressivos e avaliados pela Escala de Depressão de HAM-D17 (escores entre 7 e 20), divididos em dois grupos: dez pacientes do Grupo Psicoterápico (GP) participaram de 4 sessões individuais de psicoterapia psicodramática e 24 de grupo. Dez pacientes do Grupo Controle (GC) não participaram de sessões psicoterápicas. Os dois grupos foram avaliados pela Escala de HAM-D17 e pela Escala de Adequação Social (EAS) no início e final do processo psicoterápico e o GP também foi avaliado pela Análise Sociométrica, fundamentada no método psicodramático. Em comparação ao GC, o GP apresentou uma melhora significativa quanto aos sintomas depressivos e ao funcionamento social, bem como uma expressiva mudança nos aspectos sociométricos investigados.(AU)

The importance of several psychotherapic approaches associated to pharmacotherapy on the treatment of Major Depressive Disorder has been quite highlighted, although, there is little information as far as Psychodramatic Psychotherapy is concerned. The present study compared 20 patients diagnosed with MDD in use of antidepressant drugs and evaluated with the Hamilton Depression Scale (scores between 7 and 20), divided into two groups as follows: ten of the patients from the Psychotherapic Group (PG) took part in 4 individual psychodramatic psychotherapy sessions and 24 psychodramatic psychotherapy group sessions. Ten of the patients from the Control Group (CG) did not participate in the psychodramatic psychotherapy sessions. Both groups were evaluated with the HAM-D17 Scale and the Social Adjustment Scale - Self Report (SASSR) at the beginning and at the end of the psychotherapic process, and the PG was also evaluated through Sociometric Analysis, based on the psychodramatic method. In comparison to the CG, the PG presented a significant improvement regarding the symptoms of depression and social functioning, as well as an expressive change on the investigated sociometric aspects.(AU)

Clinical Observation on Fuming and Steaming with Herbal Medicine and Acupoint Massage for Postpartum Arthralgia / 广州中医药大学学报

0.05),and was superior in group C than that in groups A and B(P0.05),and was superior in group C than that in groups A and B(P

Impact of malaria on the brain and its prevention.

PIP: This article focuses on the impact of malaria on the brain and its prevention. The two studies conducted in Africa observing the gross neurological sequelae of cerebral malaria have identified features of the original illness that are predictive of later cerebral impairment. Among these factors, depth of coma and repeated or prolonged seizures have emerged in almost all studies as being prognostically important. In view of these findings, a study was conducted on the effective measure for the prevention of seizures in children with cerebral malaria. The study recorded that the children given 20 mg/kg of phenobarbital had significantly fewer seizures and neurological sequelae than the children given a placebo. However, such a measure was noted to have potentially disastrous consequences; a significantly higher mortality rate in the phenobarbital group was recorded compared to the rate in the placebo group. Hence, further studies are still needed to guide the use of anticonvulsants in cerebral malaria.^ieng

Effect of phenobarbital on seizure frequency and mortality in childhood cerebral malaria: a randomised, controlled intervention study.

BACKGROUND: Seizures commonly complicate cerebral malaria and are associated with an increased risk of death and neurological sequelae. We undertook a randomised study to assess the efficacy of intramuscular phenobarbital in preventing seizures in childhood cerebral malaria. METHODS: Children with cerebral malaria admitted to one hospital in Kilifi, Kenya, were randomly assigned a single intramuscular dose of phenobarbital (20 mg/kg) or identical placebo. Clinical tolerance was assessed at the start of the trial, with particular reference to respiratory depression and hypotension. Seizures were timed and recorded, and treated in a standard way. Plasma phenobarbital concentrations were measured. Analyses were by intention to treat. FINDINGS: 440 children with cerebral malaria were admitted to the hospital; 100 were not recruited to the study. Of the remaining 340, 170 received phenobarbital and 170 placebo. The drug was adequately absorbed and well tolerated. Seizure frequency was significantly lower in the phenobarbital group than in the placebo group (18 [11%] vs 46 [27%] children had three or more seizures of any duration; odds ratio 0.32 [95% CI 0.18-0.58]) but mortality was doubled (30 [18%] vs 14 [8%] deaths; 2.39 [1.28-4.64]). The frequency of respiratory arrest was higher in the phenobarbital group than in the placebo group, and mortality was greatly increased in children who received phenobarbital plus three or more doses of diazepam (odds ratio 31.7 [1.2-814]). INTERPRETATION: In children with cerebral malaria, phenobarbital 20 mg/kg provides highly effective seizure prophylaxis but is associated with an unacceptable increase in mortality. Use of this dose cannot, therefore, be recommended.

PIP: This randomized, placebo-controlled study assesses whether a single intramuscular dose of phenobarbital (20 mg/kg) given on admission to Kenyan children with cerebral malaria could lower the frequency of seizures, which complicate cerebral malaria by increasing the risk of death and neurological sequelae. A total of 340 children with cerebral malaria were admitted to the hospital; 170 received phenobarbital and 170 received placebo. The drug was adequately absorbed and well tolerated. Findings revealed a significantly lower frequency of seizures in the phenobarbital group than in the placebo group (18 [11%] vs. 46 [27%] children had 3 or more seizures of any duration; odds ratio (OR), 0.32; 95% confidence interval (CI), 0.18-0.58). However, mortality was doubled (30 [18%] vs. 14 [8%] deaths; OR, 2.39; 95% CI, 1.28-4.64) in the phenobarbital group. In addition, the frequency of respiratory arrest was higher in the phenobarbital group than in the placebo group, and mortality was greatly increased in children who received phenobarbital plus 3 or more doses of diazepam. In conclusion, although the phenobarbital dose of 20 mg/kg given to children with cerebral malaria provides highly effective seizure prophylaxis, an unacceptable increase in mortality is noted; hence, use of this dosage is not recommended.

STDs: flushing out the "hidden epidemic".

PIP: The rapid explosion of HIV infection ranks as the most significant event in the arena of sexually transmitted diseases (STDs). In making efforts against HIV/AIDS, public health officials are now preparing to confront what is called "the hidden epidemic" of STDs. Important progress has been made in research in diagnosing and treating STDs including urine-based screening for gonorrhea, single-dose treatments for curable STDs, as well as improved chlamydia screening and treatment. While herpes simplex virus-2 (HSV-2) remains incurable, the arrival of antiviral drugs such as acyclovir, famciclovir, and valacyclovir offer suppressive treatment to keep HSV-2 outbreak to a minimum level. Efforts to eliminate syphilis have been undertaken. As progress was made on bacterial STDs, viral STDs have become more important. Health providers will need to be ready to face such STDs in the coming years. It is hoped that vaccines and microbicides will be developed to combat the epidemic.^ieng

Application of Xuemeian Capsule for Acute Leukemia During Intermission of Chemotherapy / 广州中医药大学学报

Objective To observe the therapeutic effect of Xuemeian Capsule for intermission of acute leukemia with bone marrow arrest after chemotherapy.Methods A prospective trial was carried out in 136 cases of acute leukemia after chemotherapy. The cases were randomly allocated to two groups.Group A(n=86)was treated with Xuemeian Capsule and routine western medicine and Group B(n=50)with routine western medicine.The changes of hemoglobin,platelet and leukocyte and the hyperplasia of bone marrow were observed.Results The totally effective rate was 93% and 54% in Group A and Group B respectively,the difference being significant(P

Effect of Artificial Menstrual Cycle Induction by Chinese Medicine Combined with Assisted Reproductive Techniques on Embryo Implantation Rate in In-vitro Fertilization / 广州中医药大学学报

【Objective】To observe the effect of therapy of artificial menstrual cycle induction by Chinese medicine combined with assisted reproductive techniques(ART)on embryo implantation rate in in-vitro fertilization.【Methods】Sixtynine infertility patients were randomized into groups A(n=30)and B(n=39).Group B was treated with simple ART and group A received ART treatment after artificial menstrual cycle induction by Chinese medicine for 2～3 treatment courses.The therapy of artificial menstrual cycle induced by Chinese medicine respectivdy was carried out by applying Chinese medicine respectively with the actions of tonifying kidney,activating blood and removing stasis,tonifying kidney,and activating blood and regulating menstruation according to the ovarian cyclic changes of maturation of follicle,ovulation,formation of corpus luteum and atrophy of corpus luteum.After treatment,the medication time and dosage of gonadotropin,the number of retrieved oocytes,fertilization rate,cleavage rate,the number of fine quality embryo,embryo implantation rate and pregnancy rate were compared between the two groups.【Results】In group A,the embryo implantation rate was 27.0%,higher than 15.0% in group B(P0.05).【Conclusion】Therapy of artificial menstrual cycle induction by Chinese medicine combined with ART is helpful for the improvement and coordination of organic function,and thus increase embryo implantation rate in infertility patients.

Assessment of drug resistance to the malaria parasite in residents of Kampala, Uganda.

OBJECTIVE: To assess drug-resistance of the malaria parasite in elite residents of Kampala city, Uganda. DESIGN: Recruited into the study were patients with complaints of fever, backache and headache or general malaise and body joint pains, could recall their previous treatment for the current complaints and could show laboratory reports indicating presence of malaria parasites. Blood was taken from those patients and examined for malaria parasites. SETTING: Kampala Diagnostic and Imaging Consultants Clinic, Kampala, Uganda from 1994 to 1997. RESULTS: Out of 268 patients, 27%, 26%, 12%, 11%, 6%, 6% and 5% strains of malaria parasites were respectively resistant to chloroquine, quinine, metakelfin, fansidar, halfan, artenam and camoquine. Double drug resistance was also observed in the patients who had taken chloroquine and quinine (21%), chloroquine and fansidar (16%) and quinine and fansidar (10%) out of 86. Some strains exhibited resistance to chloroquine, quinine and fansidar (12.6%) out of 71. R III was observed in 17 strains of malaria parasites, eight of them were for chloroquine, four for fansidar and three for quinine. Twenty-six patients had frequent recurrence of malaria lasting for over one year. CONCLUSION: One third of Plasmodium falciparum strains by 1997 had acquired resistance to chloroquine and quinine and some were gradually acquiring multi-drug resistance, leading to frequent recurrence of malaria and use of many different types of antimalarials.

PIP: This study assessed the resistance of malaria parasites to single and multiple drugs among elite residents of Kampala City, Uganda. The study was conducted at Kampala Diagnostic and Imaging Consultants Clinic from 1994 to 1997. It enrolled patients with complaints of fever, backache and headache or general body malaise and joint pains, who could recall their previous treatment for the current complaints and could show laboratory reports indicating the presence of malaria parasites. Blood samples of the patients were collected and examined. Out of 268 patients, 27%, 26%, 12%, 11%, 6%, 6%, and 5% strains of malaria parasites were respectively resistant to chloroquine, quinine, metakelfin, fansidar, halfan, artenam, and camoquine. Among patients who had taken two drugs, double drug resistance was observed in those who had taken chloroquine and quinine (21%), chloroquine and fansidar (16%), and quinine and fansidar (10%). Moreover, 26 patients had frequent recurrence of malaria lasting for over 1 year. In conclusion, one-third of Plasmodium falciparum strains by 1997 had acquired resistance to chloroquine and quinine and some were slowly acquiring multidrug resistance resulting in frequent recurrence of malaria and use of many different types of antimalarials.

Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.

BACKGROUND: The AIDS Clinical Trials Group protocol 076 zidovudine prophylaxis regimen for HIV-1-infected pregnant women and their babies has been associated with a significant decrease in vertical HIV-1 transmission in non-breastfeeding women in developed countries. We compared the safety and efficacy of short-course nevirapine or zidovudine during labour and the first week of life. METHODS: From November, 1997, to April, 1999, we enrolled 626 HIV-1-infected pregnant women at Mulago Hospital in Kampala, Uganda. We randomly assigned mothers nevirapine 200 mg orally at onset of labour and 2 mg/kg to babies within 72 h of birth, or zidovudine 600 mg orally to the mother at onset of labour and 300 mg every 3 h until delivery, and 4 mg/kg orally twice daily to babies for 7 days after birth. We tested babies for HIV-1 infection at birth, 6-8 weeks, and 14-16 weeks by HIV-1 RNA PCR. We assessed HIV-1 transmission and HIV-1-free survival with Kaplan-Meier analysis. FINDINGS: Nearly all babies (98.8%) were breastfed, and 95.6% were still breastfeeding at age 14-16 weeks. The estimated risks of HIV-1 transmission in the zidovudine and nevirapine groups were: 10.4% and 8.2% at birth (p=0.354); 21.3% and 11.9% by age 6-8 weeks (p=0.0027); and 25.1% and 13.1% by age 14-16 weeks (p=0.0006). The efficacy of nevirapine compared with zidovudine was 47% (95% CI 20-64) up to age 14-16 weeks. The two regimens were well tolerated and adverse events were similar in the two groups. INTERPRETATION: Nevirapine lowered the risk of HIV-1 transmission during the first 14-16 weeks of life by nearly 50% in a breastfeeding population. This simple and inexpensive regimen could decrease mother-to-child HIV-1 transmission in less-developed countries.

PIP: A study was conducted to assess the safety and efficacy of short-course nevirapine compared with zidovudine given to women during labor and to neonates during the first week of life. 626 HIV-1 infected pregnant women attending the antenatal clinic from November 1997 to April 1999 at Mulago Hospital in Kampala, Uganda, were randomly given nevirapine or zidovudine. Infants were tested for HIV-1 infection at birth, at 6-8 weeks, and at 14-16 weeks. Findings revealed that the estimated risk of HIV-1 transmission in the zidovudine and nevirapine groups was 10.4% and 8.2%, respectively, at birth; 21.3% and 11.9%, by 6-8 weeks; and 25.1% and 13.1%, by 14-16 weeks. There was a 47% relative efficacy rate of the nevirapine regimen at 14-16 weeks compared to zidovudine. Based on the findings, nevirapine lowers the risk of HIV-1 transmission by nearly 50% during the first 14-16 weeks of life in breast-fed infants.

Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa.

BACKGROUND: Identification of economical interventions to decrease HIV-1 transmission to children is an urgent public-health priority in sub-Saharan Africa. We assessed the cost effectiveness of the HIVNET 012 nevirapine regimen. METHODS: We assessed cost effectiveness in a hypothetical cohort of 20,000 pregnant women in sub-Saharan Africa. Our main outcome measures were programme cost, paediatric HIV-1 cases averted, cost per case averted, and cost per disability-adjusted life-year (DALY). We compared HIVNET 012 with other short-course antiretroviral regimens. We also compared two implementation strategies: counselling and HIV-1 testing before treatment (targeted treatment), or nevirapine for all pregnant women (universal treatment, no counselling and testing). We did univariate and multivariate sensitivity analyses. FINDINGS: For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83,333, and generate 15,862 DALYs. The associated cost-effectiveness ratios were $138 per case averted or $5.25 per DALY. At 15% seroprevalence, the universal treatment option would cost $83,333 and avert 302 cases at $276 per case averted or $10.51 per DALY. For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141,922 and avert 476 cases at $298 per case averted or $11.29 per DALY. With seroprevalence higher than 3.0% for universal and 4.5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions. The cost effectiveness of HIVNET 012 was robust under a wide range of parameters in the sensitivity analysis. INTERPRETATION: The HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. In lower seroprevalence areas, when multidose regimens are not cost effective, nevirapine therapy could have a major public-health impact at a reasonable cost.

PIP: The cost effectiveness of HIVNET 012 nevirapine regimen for treatment of HIV-1-positive mothers was assessed in a hypothetical cohort of 20,000 pregnant women in sub-Saharan Africa. The program cost, pediatric HIV-1 cases averted, and cost per disability-adjusted life-year (DALY) were the main outcome measures. Univariate and multivariate analyses were used. Results showed that the nevirapine program would avert from 603 pediatric HIV-1 cases (universal treatment at 30% seroprevalence) to 246 cases (targeted treatment at 15% seroprevalence). At 30% seroprevalence, the universal treatment would cost $83,333 with 15,862 DALY. At 15% seroprevalence, it would cost $83,333 and avert 302 cases at $276 per case averted. The HIVNET 012 regimen was more effective and less costly than other regimens. The HIVNET 012 regimen would retain cost effectiveness at seroprevalence as low as 10.7% under the universal treatment option and 22% under the targeted treatment option. Furthermore, the HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. On the other hand, in areas with low seroprevalence, nevirapine therapy could have an important public health impact at a reasonable cost.

Antiretrovirals for vertical HIV transmission.

PIP: This is a report on the presentation at the Sixth Conference on Retroviruses of a study of the efficacy of an antiretroviral therapy in reducing vertical transmission risk. The study investigated a short-course antiretroviral regimen (comprising AZT and 3TC) that was administered for 1 week beginning at the time of delivery. Transmission rates were determined 6 weeks later and 18 months later for babies and mothers. Preliminary results showed that the chance of babies becoming infected was reduced by 37%. Although this was not as high as the reduction achieved by other more elaborate regimens, in terms of cost-effectiveness the results were very impressive. This regimen has subsequently been used in Africa.^ieng

Public / private partnership: developing an oral treatment for visceral leishmaniasis.

PIP: The phase III clinical trials of a new oral treatment, miltefosine, for visceral leishmaniasis are being conducted in Bihar, India, by the Training in Tropical Diseases and ASTA Medica. Other drugs used to combat this disease were administered through injection or infusion. Pentostam causes serious side effects, such as mortality in 2-5% and toxicity in 10-15% of the patients, while pentamidine, the second-line treatment, causes mortality in 7-9% and toxicity in 60%, including diabetes. Amphotericin B, considered to be the most effective and expensive treatment, causes severe rigor, fever and sometimes anaphylaxis. Miltefosine, on the other hand, will be cheaper than the rest of the treatments. Moreover, compliance has been good and earlier trials showed an overall cure rate of 90%. The only major disadvantage is its effect on the fetus; thus it cannot be used as mass outpatient treatment and will need to be monitored all the time.^ieng

Comparative efficacy and safety of chloroquine and alternative antimalarial drugs: a meta-analysis from six African countries.

OBJECTIVE: To evaluate the safety and efficacy of the currently used antimalarial drugs in six African countries. DESIGN: A meta-analysis. MAIN OUTCOME MEASURES: The role of efficacy, safety and cost on the selection of antimalarial drugs. RESULTS: The comparative efficacy study showed that amodiaquine (with > 90% cure rate) was superior to chloroquine and sulphadoxine-pyrimethamine at seven days schedule. The efficacy of amodiaquine was also observed to be comparable to that of mefloquine and halofantrine. The parasite clearance time (PCT) of these drugs ranged between two days and a week and the fever clearance time (FCT) was within 48 hours. The recrudescence rate at D14-D21 was found to be 12-17% in chloroquine and amodiaquine, while sulphadoxine-pyrimethamine showed a trend similar to halofantrine and mefloquine (0-12% recrudescence rate). Similarly, a big difference was also noted in the cost of the different antimalarial drugs. The pharmacokinetic data, however, showed that they are of similar profile, except in adverse features and contraindications, and values like their half-life (t1/2) where the long (t1/2) in drugs like sulphadoxine-pyrimethamine endows them with suppressive-cure feature, especially against recrudescent strains. Nevertheless, as these data are obtained from resident population in Africa, who however naive are exposed to few malaria challenges in their life, the results should not be directly extrapolated to total non immunes such as visitors from Europe. CONCLUSION: The choice of alternative antimalarial drugs should be mainly based on their relative efficacy, safety and cost.

PIP: A meta-analysis study evaluating the efficacy and safety of chloroquine and alternative antimalarial drugs used in six African countries including Ethiopia, Kenya, Uganda, Cote D'Ivoire, Gambia and Nigeria is presented. Findings from the six countries showed a higher efficacy of amodiaquine and quinine (over 90%) in malaria treatment compared to chloroquine, which was found to be 70% or more effective. The efficacy of amodiaquine can also be compared to other antimalarial drugs such as mefloquine and halofantrine. Data showed that fever clearance time of these drugs was less than 2 days, but parasite clearance time ranged from 2.5 days to 1 week. Recrudescence rate also varied among the different drugs. This is a very important indicator in determining which drug can be used for prophylactic or suppressive treatment of malaria. Pharmacokinetic profile demonstrates that all these drugs have similar therapeutic effects, but differ in their adverse reactions, contraindications, and half-life. A significant difference was also noted in the cost of these antimalarial drugs; chloroquine was the cheapest, while halofantrine was the most expensive among the drugs. Based on these results, the study recommends that different aspects of antimalarial drugs have to be considered before deciding which drug is the best alternative treatment.

Combined antiviral treatment in HIV infection. Is it value for money?

There is compelling evidence that combinations of antiretroviral drugs are significantly more effective than monotherapy and appear, at least in the short run, to offset problems caused by the rapid emergence of drug resistance which is characteristic of human immunodeficiency virus (HIV) infection.1,2 The routine prescribing of combination antiretroviral therapy appears to have contributed to a fall in HIV-related in-patient admissions, mortality and morbidity, with a concomitant increase in pharmacy costs. In this paper we have attempted to determine to what extent the reduction in direct hospital costs (reduced in-patient admissions, diagnostic tests and management of complications) will offset the considerably increased pharmacy costs; by using Markhov modelling procedures together with locally gathered costs data.

PIP: The routine prescribing of combination antiretroviral therapy appears to have contributed to the fall in HIV-related in-patient admissions, mortality and morbidity, with a concomitant increase in pharmacy costs. This study estimates the cost effectiveness of combination therapies for HIV disease using local secondary care data and Markov modeling techniques. Cost effectiveness analyses of combination therapies are complicated by the fact that it is necessary to model drug effects years into the future and well ahead of actual clinical experience with many of the drugs, particularly protease inhibitors. Assumptions need to be made which are unlikely to hold true, such as the survival benefits of combination therapies remaining constant over time. Furthermore, it is not known whether long-term effects will reduce the usefulness of the therapies or cause costly side effects.

Romania to stop medication for 10,000 HIV patients.

PIP: Romania accounted for more than half of European juvenile AIDS cases. Latest data show that 3564 children are infected with HIV and another 5179 developed full-blown AIDS. This is partly because of poor sanitation and unscreened blood. Lack of funds will force Romanian health authorities to infringe free medication for 10,000 people infected with the deadly HIV virus, as disclosed by Dr. Vladimir Strainu, manager of Bucharest¿s hospital for infectious diseases. He added that the interruption of HIV/AIDS treatment for a couple of days would endanger the life of the patients, most of who are children who were infected in the late 1980s through improper medical care.^ieng

Introducing antiretroviral therapy.

PIP: This paper discusses the introduction of antiretroviral (ARV) therapy to HIV-infected patients. ARV therapy is treatment with drugs that fight the HIV virus and keep the HIV-infected patient healthy. Treatment may involve only one ARV (monotherapy) or a combination of two or more ARVs (combination therapy). The increasing availability of ARVs in many countries has caused dangerous side effects to develop quickly in patients due to the improper use of drug combinations. Some life-threatening side effects of ARV misuse include vomiting, diarrhea, fever, diabetes, and pancreatitis. People who experience these symptoms need to change their drug combination; a drug must be taken with strict instructions to prevent unpleasant side effects and its reaction with other drugs (protease inhibitors, for example, react with the tuberculosis drug rifampicin). An ARV should also be closely monitored to ensure its continuous effectiveness using CD4 and viral load counts at least every 3-6 months. A change in drug combination is required when CD4 count is dropping or the viral load is not reduced or maintained.^ieng

Drug resistant tuberculosis in prisons in Azerbaijan: case study.

OBJECTIVES: To document the existence of drug resistance in a tuberculosis treatment programme that adheres strictly to the DOTS principles (directly observed treatment, short course) and to determine the extent of drug resistance in a prison setting in one of the republics of the former Soviet Union. DESIGN: Case study. SETTING: Central Penitentiary Hospital in Baku, the referral centre for tuberculosis patients from all prisons in Azerbaijan. SUBJECTS: Prisoners with tuberculosis: 28 selected patients not responding clinically or bacteriologically to the standard treatment (group 1) and 38 consecutive patients at admission to the programme (group 2). MAIN OUTCOME MEASURES: Drug resistance of Mycobacterium tuberculosis strains grown from sputum. RESULTS: All the non-responding patients (group 1) had strains resistant to at least one drug. 25 (89%) of the non-responding patients and nine (24%) of the consecutive patients had M tuberculosis strains resistant to both rifampicin and isoniazid. A further 17 patients in group 2 had strains resistant to one or more first line drugs. CONCLUSIONS: Drug resistant M tuberculosis strains are common in prisons in Azerbaijan. Tuberculosis problems tend to be worse in prisons, but prisoners and former prisoners may have an important role in the transmission of tuberculosis, particularly of drug resistant forms, in the community. National programmes to control tuberculosis will have to take into account and address the problems in prisons to ensure their success.

PIP: Tuberculosis is a significant health problem in Azerbaijan. In prisons, this problem is compounded by overcrowding, poor general health, a high representation of risk groups, late case finding, and incomplete treatments. The present study investigated the extent of drug resistance at the Central Penitentiary Hospital in Baku--the country's only treatment center for prisoners with tuberculosis. This International Committee of the Red Cross program, established in 1995, uses the directly observed treatment, short course (DOTS) strategy. Sputum samples were collected from two groups of prisoners: 1) 28 patients who failed to respond, clinically or bacteriologically, after a minimum of 8 weeks to the treatment regimen recommended by the World Health Organization and 2) 38 patients consecutively enrolled over a 4-week period from whom sputum was taken before the start of treatment. Mycobacterium tuberculosis was isolated from all 66 sputum specimens. In the first group, 25 strains (98%) were multidrug resistant (to rifampicin and isoniazid). Such resistance occurred in all new cases and 14 (82%) of the 17 failure or relapse cases. In the second group, 9 strains (24%) were multidrug resistant and only 12 (32%) were fully susceptible. This resistance was found in 3 strains (15%) among the 20 new cases and in 6 strains (33%) among the 18 cases of treatment failure or relapse. These findings suggest that prisoners may have an important future role in the transmission of tuberculosis, especially multidrug resistant forms, in the former Soviet Union.

Progress and problems in the fight against AIDS.

PIP: The provision of double-nucleoside therapy against HIV/AIDS in Europe and North America is most likely responsible for the observed marked declines in AIDS-related morbidity and mortality in 1995 and 1996, while the addition of protease inhibitors resulted in further benefit in late 1996 and 1997. The number of inpatients with AIDS has decreased while the number of outpatients has increased, reflecting major improvements in the treatment of HIV infection. However, simpler treatments are needed and much remains to be learned about how to safely apply these new biomedical tools against HIV/AIDS, including the nature of therapy-related long-term complications. Furthermore, funds are still needed for ongoing research and prevention. For the average AIDS patient in developing countries, highly active antiretroviral therapy is an inaccessible dream, and merely a diversion for developing country health ministries from more pressing concerns which threatens more cost-effective programs against HIV, such as the targeted distribution of condoms or the treatment of sexually transmitted diseases which facilitate the spread of HIV. Since nothing will likely bridge this gap between poor and rich countries, only prevention and a vaccine will likely make a real difference for the poor in the battle against HIV/AIDS.^ieng

Short course of AZT halves HIV-1 perinatal transmission.

PIP: The ACTG 076 trial assessed the ability of zidovudine (AZT) to prevent the transmission of HIV from mother to child. In that trial, women received 100 mg of AZT 5 times daily beginning from 14-34 gestational weeks, then intravenous AZT during labor. This approach, followed by the administration of AZT to infants for 6 weeks, led to an 8% mother-to-child HIV transmission rate compared to 23% with placebo. Drug therapy proven in the ACTG 076 trial has now become the basis for current practice in developed countries. Placebo-controlled clinical trials were later launched in selected developing countries to assess the effect upon vertical transmission of providing only a short course of AZT therapy to HIV-infected mothers. In Thailand, 397 HIV-infected pregnant women were randomized to take orally either placebo or 300 mg of AZT twice daily from 36 weeks of gestation, then 300 mg every 3 hours during labor. Infants did not receive AZT and the women did not breast-feed. Kaplan-Meier analysis found a perinatal HIV-1 transmission rate of 18.6% in the placebo group and 9.2% in the treatment group. Based upon these preliminary data, the US Centers for Disease Control and Prevention (CDC), who collaborated with the Thai Ministry of Public Health in the study, announced on February 18 that all women in the CDC's Cote d'Ivoire collaboration will now receive active AZT treatment. Use of a placebo group in the Cote d'Ivoire study helped to identify the effect of the country's limited obstetric services upon neonatal mortality. UNAIDS is hosting an international meeting in March to find ways of rapidly and effectively implementing these and other data. In future perinatal trials, placebo arms should either be dropped or replaced with the CDC short-course regimen.^ieng