A comparative study of rifapentine treatment and three years follow-up on initial pulmonary tuberculous

A clinical study about the efficacy of rifapentine in the treatment and 3 years' follow up on initial pulmonary tuberculous patient. Altogether 267 patients of initial pulmonary tuberculosis with positive smears were randomly divided into 3 groups; Group I with DL473 twice-weekly (2HE+L2/7H2L2), Group IIARFp twice-weekly (2HE+R2/7H2R2) and Group IIBRFP daily (2HRE/7HR) for controls. Results are: the conversion rate to smear negative are 96.0%, 96.4% and 97.1% respectively (P > 0.05); the sputum conversion rate by cultures are 98.0%, 95.7% and 96.4% respectively (P > 0.05). From X-Ray pictures, the treatment effect of Group I are similar to that of Group IIB. But in Group I with less side action were observed. The relapse rate of the three groups are 2.6%, 3.8% and 3.1% respectively (P > 0.05). From this investigation, we can draw a conclusion that the twice-weekly of rifapentine has at least an effect similar to rifampicin given daily. Further investigation of DL473 once weekly will soon be followed.     

Russian family practice training program: a single step on a long journey

SETTING: The outcome of tuberculosis treatment is often not assessed in low-incidence countries such as Switzerland. In economically developed countries, private practitioners do not have the final responsibility for ensuring the completion of adequate tuberculosis treatment, and public health officers have little or no legal means of intervening if they are not specifically requested to do so. Furthermore, the reluctance of private practitioners to follow official guidelines may be an obstacle to the implementation of a regular surveillance policy. OBJECTIVE: To assess the results of treatment in patients with culture-positive pulmonary tuberculosis and to identify the risk factors for non-adherence to treatment. DESIGN: Retrospective study of all cases notified between 1988 and 1992 in Vaud County, and mainly treated by independent practitioners. RESULTS: Among 133 patients notified with culture-positive pulmonary tuberculosis, complete information about treatment outcome was available for 120. Treatment success (cure or completed adequate treatment) was observed in 84 patients (70%), 17 died (14%) and 19 (16%) were considered as defaulters. The default rate was higher among immigrants, alcoholics, intravenous drug users and male patients. Among non-adherent patients, 4/19 (21%) relapsed within 3 years, compared with 3/84 (4%) among adherent patients. CONCLUSION: The outcome of treatment in this group of patients does not correspond to the expected standards: the treatment completion rate was too low, and the default rate was too high. Better education of medical staff and health-care workers, use of directly-observed treatment, and regular surveillance of treatment outcome will be necessary to improve the results.     

Drug resistant tuberculosis in prisons in Azerbaijan: case study

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.     

Tuberculosis control in Bangladesh: success of the DOTS strategy

SETTING: Tuberculosis (TB) has been a major public-health problem in Bangladesh for many decades. National control efforts in the past have not been successful, with less than half of detected cases being cured. In 1993, a project based on the DOTS (directly observed treatment, short-course) strategy was initiated for a population of approximately one million in a rural setting. Following a 78% cure rate in the initial cohort of new smear-positive patients, the project was expanded in phases to cover a rural population of 67 million in 1996. OBJECTIVES: Routine programme data on all new sputum smear-positive patients registered in the TB project since its inception until 1996 were analysed. Case finding results are presented until 1996, as are results of sputum smear conversion after 2 months of treatment in new smear-positive patients for the same cohort of patients. Final treatment outcome results were analysed for new smear-positive patients registered up to 1995. RESULTS: A total of 41,525 patients were registered in the project during the 3-year period. Two-thirds of these were new smear-positive cases and 27% were new smear-negative patients. Sputum smear conversion in 26,151 new smear-positive patients at 2 months was 85%; 5% remained smear-positive, 3% had died and the rest had no sputum examination. Final treatment outcome results in 10,142 new smear-positive patients registered during 1993-1995 showed that 75% were cured, 4% completed treatment but did not have a sputum smear result, 2% remained smear-positive, 6% died, 10% defaulted and 3% were transferred out. CONCLUSION: The DOTS strategy can be successfully implemented in phases in large countries with a high tuberculosis burden. This success is due to decentralizing sputum smear microscopy and treatment delivery services to peripheral health facilities, utilizing the existing primary health care network. High cure rates can be maintained despite rapid expansion of coverage, with proper implementation of the strategy and regular monitoring of reports on case finding, sputum smear conversion and treatment outcome. Case detection needs to be further increased by informing and involving the community in TB control efforts through social mobilization.     

Resistance of Mycobacterium tuberculosis to antituberculosis drugs in the Central Region of Thailand, 1996

OBJECTIVE: To determine the proportion and profile of antituberculosis drug resistance among Mycobacterium tuberculosis isolates in Thailand. SETTING: A 500-bed cardiothoracic centre. DESIGN: From January to December 1996, isolates of M. tuberculosis from consecutive patients with pulmonary tuberculosis underwent susceptibility testing to isoniazid (H), rifampicin (R), ethambutol (E), streptomycin (S), kanamycin (K), and ofloxacin (O). RESULTS: In all, 1861 strains were tested, 1738 from new cases and 123 from previously treated cases. Overall initial and acquired resistance were 20.9% and 53.6%, respectively. The percentages of initial resistance to R, H, S, O, K and E were 12.6, 8.3, 6.6, 1.8, 1.1 and 0.8, respectively, whereas those of acquired resistance were 43.0, 29.2, 21.1, 9.7, 8.1 and 4.8, respectively. Multidrug resistance was observed in 4.2% of new patients and 25.2% of previously treated patients. CONCLUSION: The overall drug resistance of M. tuberculosis in the central region of Thailand is high, and acquired multidrug resistance has reached an ominous level. The results have serious implications for tuberculosis control in Thailand. Urgent measures are needed to control the spread of drug resistance, and supervised treatment of standard protocol should be adhered to more strictly.     

Rifapentine

Rifapentine is a rifamycin antibiotic with antimycobacterial activity. Rifapentine is generally more active against Mycobacterium tuberculosis than rifampicin (rifampin), although strains resistant to rifampicin are usually cross-resistant to rifapentine. Sputum culture conversion rates were slightly higher after 6 months of rifapentine- versus rifampicin-based therapy in patients with pulmonary tuberculosis in a Western study; however, relapse rates were higher in rifapentine recipients during follow-up. The excess relapses in the rifapentine group appeared to be related to poor compliance with nonrifamycin antituberculosis drugs during the intensive phase (first 2 months) of therapy. Rifapentine- and rifampicin-containing regimens produced similar sputum culture conversion rates with low rates of relapse in 2 randomised clinical trials in patients with smear-positive tuberculosis in China. In one trial, there was no difference in sputum culture conversion rates in patients treated with rifapentine once weekly or rifampicin twice weekly in combination with isoniazid and ethambutol during the continuation phase of treatment. Hyperuricaemia, which was reported only during the intensive phase, elevated ALT and AST levels and neutropenia were the most common treatment-related adverse events reported in patients receiving rifapentine- or rifampicin-containing regimens for tuberculosis in 1 Western study.     

Histamine phase shifts the hamster circadian pacemaker via an NMDA dependent mechanism

SETTING: The Netherlands, 1993 and 1994. OBJECTIVE: To determine 1) rates of drug resistance in relation to nationality and country of birth, 2) risk factors for drug resistance, 3) treatment outcome of drug-resistant cases, and 4) rates of primary and acquired drug resistance. DESIGN: Retrospective study of all cases notified with bacillary tuberculosis in The Netherlands in 1993 and 1994. RESULTS: Drug resistance to one or more drugs was reported in 268 (14.6%) of all 1836 cases, of whom 203 (76%) were foreign born. In Dutch patients rates of isoniazid (H) (2.9%) and streptomycin resistance (3.6%) were lower than in foreign patients (8.6% and 10.6% respectively, P < 0.001). Multidrug (H and rifampicin [R]) resistance was reported in 0.5% of Dutch-born and 1.4% of foreign cases (P = 0.055). Rates of acquired resistance to H (11.4%) and HR (5.7%) were higher than rates of primary resistance to these drugs (5.2% and 0.7% respectively, P < 0.05), but the number of retreatment cases was low (6.8% of all cases). Drug resistance was associated with immigration but not with drug use, homelessness or human immunodeficiency virus (HIV) co-infection. One fifth (20%) of drug-resistant cases was diagnosed by active case finding. Treatment outcome in sensitive and resistant cases was compared. CONCLUSION: These findings suggest that drug resistance is imported, but it is unclear to what extent drug resistance among foreigners has been transmitted or created in The Netherlands. Drug resistance data should be monitored in Dutch and foreign patients separately.     

Better efficacy of a 12-month interferon alfa-2b retreatment in patients with chronic hepatitis C relapsing after a 6-month treatment: a multicenter, controlled, randomized trial. Le Groupe D'étude et De Traitement du Virus De L'hépatite C (Get.Vhc)

We studied the efficacy of three interferon alfa-2b (IFN-2b) regimens for the retreatment of patients with chronic hepatitis C (CHC) with prior complete response followed by relapse. Consecutive patients with CHC who had a complete biochemical response but relapse after a first course of 6 months of IFN with 3 million units (MU) given subcutaneously three times per week were enrolled in the study. Six to 24 months after the end of the first treatment, the patients were randomly assigned to receive IFN with either the same regimen (group 1), a regimen of 12 months with 3 MU (group 2), or a regimen of 6 months with 10 MU (group 3). Sustained biochemical response was defined as normal serum alanine transaminase (ALT) values during the follow-up and sustained virological response as a clearance of hepatitis C virus (HCV) RNA from the serum at the end of follow-up (6 months' posttreatment). Histological improvement was defined as a decrease of 1 point in Metavir score between the first liver biopsy and a biopsy performed at 6 months' postretreatment. Two hundred forty-seven patients were randomized: 75 to group 1, 91 to group 2, and 81 to group 3. In an intent-to-treat analysis, 12%, 36.3%, and 18.5% of patients had a sustained biochemical response after retreatment in groups 1, 2, and 3, respectively (P <.001); 13. 8%, 32.4%, and 17.2% of patients had a sustained virological response after retreatment in groups 1, 2, and 3, respectively (P <. 05). A low viral load and patients in group 2 were independently associated with a sustained biochemical response. A low Knodell score index before treatment, patients with a high level of ALT before retreatment, genotype 3, low viral load, and patients in group 2 were independently associated with sustained virological response. Younger age, a high level of ALT, a low level of gamma-glutamyl transferase before retreatment, low viral load, and patients in group 2 were independently associated with sustained biochemical and virological response. Among the 80 patients with repeated liver biopsies, 47.6% had improved histological activity scores; this improvement was associated with a sustained biochemical and virological response. In patients with CHC initially treated with 3 MU of IFN given subcutaneously three times per week over a 6-month period, and who subsequently developed a relapse after a biochemical response, retreatment with a regimen of 3 MU of IFN given three times per week for 12 months produced better biochemical and virological sustained response rates than regimens involving a higher dose or a shorter duration of retreatment. The biochemical and virological sustained response was associated with histological improvement.     

Modification of natural immunity in mice by imipenem/cilastatin

SETTING: A tuberculosis programme in hill and mountain districts of Nepal supported by an international non-governmental organisation (NGO). OBJECTIVE: To evaluate under programme conditions the effectiveness of unsupervised monthly-monitored treatment using an oral short-course regimen. DESIGN: In this prospective cohort study, outcomes for new cases of smear-positive tuberculosis starting treatment over a two-year period in four districts in which a 6-month rifampicin-containing regimen was introduced as first-line treatment (subjects) were compared to outcomes for similarly defined cases in four districts where a 12-month regimen with daily streptomycin injections in the intensive phase continued to be used (controls). RESULTS: Of 359 subjects started on the 6-month regimen, 85.2% completed an initial course of treatment compared to 62.8% of 304 controls started on the 12-month regimen (P < 0.001); 78.8% of subjects and 51.0% of controls were confirmed smear-negative at the end of treatment (P < 0.001). The case-fatality rate during treatment was 5.0% among subjects and 11.2% among controls (P = 0.003). Among those whose status was known at two years, 76.9% of subjects were smear-negative without retreatment, compared to 60.9% of controls (P < 0.001). CONCLUSION: In an NGO-supported tuberculosis control programme in remote districts of Nepal, patient-responsible short-course therapy supported by rapid tracing of defaulters achieved acceptable outcomes. Where access and health care infrastructure are poor, district-level tuberculosis teams responsible for treatment planning, drug delivery and programme monitoring can be an appropriate service model.     

Women in dentistry

By analyzing the present-day tuberculosis epidemiological situation in the country and sociomedical characteristics of new cases, the authors present methods for detecting and treating patients, which are of paramount importance for today. Of the most significance is the need to promptly identify patients with strains on their referral to the general somatic hospitals for complaints by using 3-multiple sputum bacterioscopy for Mycobacterium tuberculosis by the Ziehl-Neelsen method. The vital problem is also to change chemotherapeutical regimens as more severe progressive types of the disease require more active treatment in the first months after detection especially in the cohort of socially disadapted persons.     

Discrimination of productive and non-productive cough by sound analysis

SETTING: Sixteen districts of Budapest, Hungary. OBJECTIVE: To determine the frequency of primary and secondary drug resistance, and to recommend treatment regimens. DESIGN: A retrospective survey. METHODS: Mycobacterium tuberculosis isolates were collected from 264 newly diagnosed and 147 previously treated patients. All strains were tested against isoniazid (INH), rifampicin (RIF), streptomycin (SM) and ethambutol (EMB) using the proportion method. Bacteriologic examinations were performed in the Diagnostic Laboratory of the Koranyi National Institute for Tuberculosis and Pulmonology in Budapest. RESULTS: Primary resistance to INH alone was 4%, to SM alone 2%, to RIF alone 0.4%, to INH and SM 1%, and to INH, RIF, SM and EMB 0.4%. Of the isolates of 78 relapse cases, six (8%) were resistant to INH alone, one (1%) to INH and RIF, two (3%) to INH, RIF, SM and EMB. Of the isolates of 69 patients notified with active tuberculosis for over a year, 51 (74%) were susceptible to the drugs tested. CONCLUSION: Based on the level of primary drug resistance as well as on the resistance pattern of relapse cases, it is recommended to start the treatment of newly detected and relapse cases with four drugs. The high rate of chronic cases with susceptible strains can be explained by poor compliance. To prevent development of resistant cases and to achieve good compliance, it is necessary to apply direct observation of treatment in all types of patients.     

Syndecan proteoglycans and cell adhesion

Recent Mongolian political, social and economic changes have had a great impact on its health care system and tuberculosis control program. The objective of this study is to assess time trend in incidence and mortality of tuberculosis and characteristics of notified tuberculosis cases in Mongolia. 1) Data on statistics of tuberculosis are obtained from reports of the National Tuberculosis Center in Mongolia. The mortality of tuberculosis in Mongolia shows a downward trend during 1985-1995. The number of notified tuberculosis cases had gradually decreased during 1985-1989. It suddenly dropped in 1990 and was the lowest in 1993. After that, about two fold increase in the notified cases was observed in recent three years from 1993 to 1995. Such a large fluctuation in the number of notified cases after 1990 is unlikely to be associated with the epidemiologic situation of tuberculosis, but rather due to a reporting bias. The shortage of drugs and economic hardship prevented patients from consulting medical facilities. The shortage of drugs also prevented doctors from notifying patients to the tuberculosis registry, because the notification did not lead to treating the disease. The improvement of health care system and the supply of essential drugs since 1994 seems to contribute to the increase in the number of notified cases. 2) The study subjects include 618 patients who were diagnosed as active tuberculosis at ten tuberculosis specialized facilities in Ulaanbaatar, Mongolia from May 1995 to March 1996. Patients were interviewed about their demographic factors and their medical records were reviewed. Fifty one percent of the cases were female. The mean age was 26.9 years old. Ninety percent of the cases underwent chest X-ray examination, while 72% of the cases underwent bacteriological examination and only 21% were confirmed bacteriologically. It is necessary to improve the quality control of sputum smear examination and the validity of diagnosis of tuberculosis in Mongolia. As for treatment regimens, only 29% of the cases were being treated with at least four drugs (isoniazid, rifampicin, pyrazinamide, ethambutol and/or streptomycin). It is needed to provide directly observed treatment using the WHO recommended standard regimen to at least smear positive tuberculosis cases.     

The use of sputum induction for establishing a diagnosis in patients with suspected pulmonary tuberculosis in Malawi

SETTING: There has been a marked increase in notified cases of smear-negative pulmonary tuberculosis in Malawi since 1986. One reason for this may be related to the difficulties of getting adequate samples of expectorated sputum from patients. Sputum induction with nebulized hypertonic saline may be a simple way of obtaining a better specimen. OBJECTIVE: To examine the value of sputum induction for detecting cases of smear-positive tuberculosis. DESIGN: Sputum induction was performed on 82 adults presenting to the Queen Elizabeth Central Hospital, Blantyre, Malawi with clinically suspected pulmonary tuberculosis who were expectorated sputum smear-negative or unproductive of sputum. The induced sputum smear was examined for acid-fast bacilli and cultured for mycobacteria. RESULTS: Sputum was successfully induced from 73 of the 82 patients (26 previously smear-negative and 47 previously unproductive). The induced sputum was smear-positive in 18 patients (5 previously smear-negative and 13 unproductive). Cultures were positive for Mycobacterium tuberculosis in the 18 smear-positive patients and a further 12 that had been smear-negative. 94 cases of smear-positive pulmonary tuberculosis were notified during the study period. 18 (19%) were as a result of sputum induction. CONCLUSION: Sputum induction is a useful technique for improving the case detection rate of smear-positive tuberculosis in Malawi.     

Pulmonary resection as an adjunct in the treatment of multiple drug-resistant tuberculosis

BACKGROUND: Over the past decade the incidence of pulmonary disease due to drug-resistant strains of Mycobacterium tuberculosis has increased worldwide. We reviewed our local experience to clarify the benefits and risks of pulmonary resection in the management of drug-resistant strains of Mycobacterium tuberculosis. METHODS: A retrospective review was performed of 62 patients undergoing pulmonary resection for drug-resistant strains of Mycobacterium tuberculosis between January 1990 and November 1995. RESULTS: Fifty-three percent were men and 47% women with an average age of 34 years (range, 16 to 72 years). There was one postoperative death, for a perioperative (30-day) mortality of 1.6%. Sixteen complications occurred in 14 patients for an overall morbidity of 23%. Eighteen of 24 patients (75%) who were persistently sputum positive at the time of operation immediately converted to a negative sputum smear and culture. For all patients who were sputum negative after operation 80% remain relapse-free by actuarial analysis. CONCLUSIONS: We believe that operation plays an important ancillary role in the treatment of drug-resistant strains of Mycobacterium tuberculosis. The operation can be performed with acceptable morbidity and mortality and must be combined with appropriate and well-monitored pre- and postoperative antituberculous drug therapy.     

Treatment of new and chronic tuberculous patients with ethambutol and Rifampicin (author''s transl)

In patients with chronic pulmonary tuberculosis the results of chemotherapy between drug regimens containing ethambutol or rifampicin were compared. Patients in both groups were randomized selected. After 4 months of chemotherapy negativization was reached to 100% in the RMP-group compared to 80% of the patients in the EMB-group. In 98 chronics EMB was added to the chemotherapy regimen and resulted in 90% of negativization. In a small subgroup RMP was added to the regimen and 100% negativization could be obtained. Among 220 patients with chronic pulmonary tuberculosis, treated with RMP in 9 hospitals according to our protocoll, in 205 patients (93.2%) the excretion of bacilli was cessated. In 54 new cases treated with EMB and another combination and in 20 new cases treated additionally with RMP the sputum converted to negative in 100% of the patients. But the the negativization was reached 24 days earlier on the average in the group treated with RMP. Antituberculotic drugs are administered in our clinic according to the body weight.     

The choice of surgical methodology in gunshot injury of the colon

To enhance the efficiency of treatment in new cases of infiltrative and disseminated destructive pulmonary tuberculosis, an intermittent (twice daily) regimen of intravenous dropwise administration of three drugs (isoniazid, rifampicin, PASK) was proposed. The immediate results of clinical observations suggest that intermittent 3-drug intravenous chemotherapy supplemented by collapse therapy in some indicated cases, provides a high control over the therapy, sparing drug load, good tolerance, and rather high efficiency: elimination of destructions in 81.4% (mean 4.2 months), cessation of bacterial isolation in 88.9% in the early (2.2 months) period.     

Chondrodysplasia in Australian Dexter cattle

To evaluate the current prevalence of initial and acquired resistance to the main antituberculosis drugs in Yaounde, isolates of M. tuberculosis complex obtained from sputum cultures of 602 adult patients with pulmonary tuberculosis (516 new cases and 86 old cases) consecutively admitted into the tuberculosis centre of H?pital JAMOT from July 1994 to December 1995 were studied. The susceptibility of isolates to the major antituberculosis drugs was tested by the indirect proportion method. The overall resistance rate (1 or more drugs) was 35.2%, with initial resistance 31.8% (164 of 516) and acquired resistance 55.8% (48 of 86). Initial resistance to streptomycin was the most frequent (20.5%), followed by isoniazid 12.4%), thiacetazone (5.6%), rifampicine (0.8%) and ethambutol (0.4%). Initial resistance was noted as 25% to 1 drug, 5.8% to 2 drugs, 0.8% to 3 drugs and 0.2% to 4 drugs. Acquired resistance to isoniazid was the most frequent (45.3%), followed by streptomycin (40.7%), rifampicine (30.2%), thiacetazone (10.5%) and ethambutol (9.3%). Acquired resistance was found as 13.9% to one drug, 19.8% to 2 drugs, 12.8% to 3 drugs and 9.3% to 4 drugs. A combined resistance to rifampicine and isoniazid in the same patient was noted in 0.8% of the new cases and in 26.7% of the old cases. These high rates af antituberculosis drug resistance in Yaounde underline the urgent need to reestablish a tuberculosis control programme in Cameroon.     

A study on the relapse and its potential causes in pulmonary tuberculosis

A retrospective cohort study was conducted to acquire the general picture of relapse in pulmonary tuberculosis in China and to clarify the relationship between potential causes and relapse rate. All data were collected from 4,797 initial sputum-positive cases. Results showed: (1) Bacteriological relapse rate within two years after chemotherapy was 4.6%. (2) Cumulative relapse rates within half a year and a year only accounted for respectively 28% and 43% of that within two years after chemotherapy. (3) Patients over 60 years old, with drug-resistant bacilli, with long excretion of bacilli, or with residual cavity(ies) or bacterial-negative conversion of less than 3 months at the end of treatment, were the high risk population of relapse.     

Quantitative bacillary response to treatment in HIV-associated pulmonary tuberculosis

A group of 122 patients with culture-proven pulmonary tuberculosis were recruited to examine the concentrations of Mycobacterium tuberculosis in sputum and the relationship to HIV-1 antibody status. They were followed for up to 28 days from the start of antituberculous chemotherapy to assess the early bacillary response to two chemotherapeutic regimens. Of 67 treated with streptomycin, thiacetazone, and isoniazid 17 were HIV positive, and subsequently 55, of whom 20 were HIV positive, were treated with streptomycin, rifampin, isoniazid, and pyrazinamide. The mean initial concentration of M. tuberculosis in the sputum of the HIV-negative patients was significantly higher than in HIV-positive patients (6.95 and 6.34 log colony-forming units respectively; p = 0.019). The HIV-positive patients had less radiologic evidence of disease and significantly fewer zones of lung affected with cavities. The response to treatment was similar, but with HIV-positive patients more likely to become culture negative by 28 days. The differences that exist between HIV-positive and HIV-negative patients are minor, and standard regimens are at least as effective in HIV-positive patients in the first month of treatment.     

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?

SETTING: A study conducted by the Uganda-Case Western Reserve University Research Collaboration in Kampala, Uganda, a country with high incidence rates of tuberculosis (TB) and human immunodeficiency virus type 1 (HIV-1) infection. OBJECTIVE: To assess clinical, microbiologic and radiographic factors associated with risk for relapse in HIV-infected adults treated for initial episodes of pulmonary TB. DESIGN: Nested case-control study within a randomized prospective clinical trial comparing the safety and efficacy of thiacetazone- and rifampicin-containing regimens for TB treatment in HIV-infected adults. RESULTS: The analysis was based on 119 patients who completed therapy. Median follow-up for all subjects was 22.3 months. Ten patients relapsed a median of 12.7 months after the end of therapy; seven of these were initially treated with the thiacetazone (T)-containing regimen. Each relapse case was matched to four controls by length of follow-up after initial TB treatment. In a univariate analysis risk for relapse was associated with treatment with the T-containing regimen (OR = 4.2, P = 0.08), age > or = 30 yrs (OR = 2.9, P = 0.16), and irregular compliance (OR = 3.6, P = 0.1). Baseline anergy on Mantoux tuberculin skin testing, cavitary disease, radiographic extent of disease and sputum bacillary burden, two month culture negativity, and residual cavitary disease at the end of treatment did not differ between relapses and controls. CONCLUSION: Older HIV-1 infected patients, those with poor treatment compliance, and those being treated with T-containing regimens, may be at increased risk for relapse after TB treatment and require closer post-treatment surveillance. Risk for relapse in HIV-infected adults with pulmonary TB after treatment with a nine month rifampicin-containing regimen was low (3.1 per 100 person-years observation) compared with those treated with a thiacetazone-containing regimen (10.1 per 100 person-years observation).