Timing of default from tuberculosis treatment: a systematic
review
Margaret E. Kruk
1
, Nina R. Schwalbe
2
and Christine A. Aguiar
1
1 Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
2 Global Alliance for TB Drug Development, TB Alliance, New York, NY, USA
Summary objectives To provide a systematic assessment of the timing of default from tuberculosis (TB)
treatment which could help to quantify the potential contribution of new shorter duration TB drugs to
global TB control.
methods We performed a systematic review following QUOROM guidelines. MEDLINE was searched
from 1998 to the present using the terms TB and default or drop-out or compliance or adherence
and therapy. A total of 840 articles were returned. A further detailed manual review selected 15
randomized trials and observational studies that reported timing of drop-out and focused on developing
countries.
results The selected studies comprised randomized controlled trials, retrospective record reviews, and
qualitative assessments and spanned 10 countries. Both directly observed treatment (DOT) and
non-DOT programs were represented. Thus results were highly heterogeneous and not statistically
aggregated. Data suggest, but do not conclude, that the majority of defaulters across the studies
completed the 2-month intensive phase of treatment.
conclusions There is insufficient high-quality comparable information on the timing of default
from TB treatment to permit any firm conclusions on trends in default. However, a substantial pro-
portion of defaulters appear to leave treatment in the later stages of the current 6-month regimen,
suggesting that new TB chemotherapeutic agents which can reduce the length of treatment have the
potential to improve global TB treatment success rates.
keywords tuberculosis therapy, directly observed treatment, default, time of default, temporal trends
Introduction
Tuberculosis (TB) is a global health emergency, killing
nearly 1.6 million people each year, mostly in low- and
middle-income countries (Stop-TB Partnership 2006). TB
cases in Africa have more than quadrupled since 1990, as a
result of co-infection with HIV (WHO 2005). The World
Health Organization (WHO) – recommended treatment
strategy, directly observed treatment or direct observation
(DOT), which forms the basis of the Stop TB Strategy, is a
6- to 8-month regimen with a combination of anti-TB
agents (Lienhardt & Ogden 2004). This regimen is also
known as short-course chemotherapy (SCC). The first
2 months of SCC, known as the intensive phase, generally
involve a combination of four drugs and the 4- to 6-month
follow-up period, known as the continuation phase,
involves two drugs. Both the drugs used in treatment and
the duration of the intensive phase may vary within SCC
programs.
While cure rates with this combination under optimal
conditions approach 95%, actual global treatment success
in 2005 was 84% (Borgdorff et al. 2002; WHO 2007).
This figure is much lower in some regions: In Africa, the
overall cure rate for smear-positive TB was 74% and as
low as 54% in some areas (WHO 2007.) Further,
Mycobacterium tuberculosis resistant to both isoniazid and
rifampicin, or multi-drug resistant TB, is now diagnosed in
an estimated 4.3% of all new and previously treated TB
patients (Zignol et al. 2006).
A major contributor to both treatment failure and the
rise of multidrug-resistant TB is inadequate and incomplete
treatment (Borgdorff et al. 2002; Sharma & Mohan 2006).
While structural factors such as interruptions in drug
supply play a role, patient default ESPGHAN Committee on 08/09/2011 GIỚI THIỆU CÁC LOẠ LOẠI BÓNG, MẶT NẠ NẠ GIÚP THỞ THỞ KHOA HỒ HỒI SỨ SỨC Bóng, mặt nạ dụng cụ thiếu HSCC, bóp bóng qua mặt nạ (hay gọi thông khí áp lực dương qua mask) cách hiệu bước quan trọng trình cấp cứu BN ngưng tim, ngưng thở BÓNG GIÚP THỞ CÁC LOẠI BÓNG, MẶT NẠ Có hai loại : 1.Bóng tự phồng : Sẽ tự phồng sau bị bóp xẹp, kéo khí (oxy hay khí trời) vào bóng Bóng phồng theo lưu lượng (còn gọi bóng gây mê): Chỉ phồng có khí từ nguồn khí nén ñi vào bóng MẶT NẠ (MASK) Mặt nạ có ñệm ñệm hơi, có hình tròn hình dáng giải phẫu Mặt nạ có ñệm hơi: Vành mặt nạ ñược làm từ chất liệu ñàn hồi, mềm mút cao su hay vòng ñể bơm khí vào, cần áp nhẹ lên mặt trẻ ñể tạo màng kín, nguy làm tổn thương mặt trẻ Mặt nạ ñệm : Thường có bờ cạnh cứng → khó tạo ñược màng kín, làm tổn thương mặt trẻ úp mặt nạ chặt 08/09/2011 BÓNG TỰ PHỒNG CẤU TẠO VÀ CÁCH SỬ DỤNG CÁC LOẠI BÓNG Có thành phần bóng tự phồng : Đường khí vào nơi gắn phận dự trữ oxy Túi dự trữ oxy Đường khí oxy vào bóng Đường khí BN (là nơi gắn mask) Nơi gắn van PEEP Van xả áp lực THỰC HÀNH BÓP BÓNG Thường dùng có cỡ : Cho trẻ sơ sinh, trẻ em người lớn Cách chọn bóng : Bóng Ambu (ml) Túi dự trữ(ml) Sơ sinh Trẻ em N Lớn Sơ sinh Trẻ em N Lớn < kg 250 7- 30kg 450 650 >30kg 1000 1600 < 7kg 600 7-30kg 20002600 >30kg 2600 ☻ Kiểm tra trước sử dụng : Gắn oxy túi dự trữ oxy vào, chỉnh lưu lượng – 10 l/ph ( trung bình - 8l/ph ) Bịt kín mặt nạ ñường khí BN lòng bàn tay bóp bóng → Sẽ cảm nhận áp lực chống lại lòng bàn tay có khí thoát van xả áp lực Tư BN bóp bóng qua mặt nạ : Lót vai trẻ cuộn khăn nhỏ ñể cổ trẻ ngửa (không nên ưỡn) ñể giúp mở ñường thở Tư ĐD bóp bóng : Nên ñứng bên hông phía ñầu BN, ñể dể quan sát ngực bụng BN bóp bóng Tay thuận bóp bóng, tay giữ mặt nạ (lực giữ ngón ngón trỏ), ngón lại nâng cằm phía trước ñể giúp khai thông ñường thở trẻ sơ sinh nhũ nhi 08/09/2011 Tần số bóp bóng: - Số lần bóp tùy theo lứa tuổi Vd: 40 lần/phút = bóp-2-3-bóp -2-3-bóp-2-3…( # 1,5 giây bóp cái) - Thời gian nhát bóp ½ - ¾ giây Sử dụng van PEEP : Một số bóng có nơi gắn van PEEP,trên van PEEP có mức áp lực từ 5-10-15-20cmH2O, ta vặn lên or xuống ñể ñiều chỉnh , bình thường PEEP sinh lý dao ñộng từ – cmH2O,nhưng lưu ý không ñể PEEP cao(> 10cmH2O )vì gây vỡ phế nang Áp lực bóp bóng : - Sơ sinh : 15 – 20 cmH2O - Trẻ nhỏ : 20 – 40 cmH2O - Trẻ lớn : 40 – 60 cmH2O → Bình thường van xả an toàn vị trí 40 cmH2O → Bóp bóng ñều ñặn phù hợp với nhịp thở BN (nếu có), không bóp mạnh hay bóp chậm rãi → Bóp bóng cho ñến lồng ngực hay bụng nhô lên -2cm ñủ Các dấu hiệu nhận biết bóp bóng hiệu quả: - Lồng ngực BN di ñộng tốt theo nhịp bóp bóng - Nghe phế âm ñều hai bên - Cải thiện màu sắc da, niêm, nhịp tim • NHỮNG ĐIỂM CẦN LƯU Ý KHI BÓP BÓNG QUA MẶT NẠ Trường hợp trẻ không cải thiện: Kiểm tra lại tư BN Kiểm tra oxy, bóng, mối nối, áp lực Đã cung cấp oxy 100% chưa ? BS xem xét ñặt NKQ Trong trường hợp bóp bóng kéo dài ñặt thông dày ñể giảm chướng bụng → ñề phòng trào ngược hít sặc Chọn mặt nạ cỡ bóng phù hợp Mặt nạ phải che kín ñỉnh cằm, miệng mũi BN, không ñược che mắt Mặt nạ phải ñược áp sát vào mặt BN không áp chặt Áp mặt nạ từ ñỉnh cằm lên, sau ñó che phủ lên mũi Đối với mặt nạ dạng giải phẫu phải hướng phần nhọn phía mũi 08/09/2011 Đối với bóng tự phồng: ñể cung cấp nồng ñộ oxy cao bóng phải có túi dự trữ oxy Không ñược khóa van xả áp lực (trừ trường hợp bệnh lý ñặc biệt) Phải kiểm tra bóng trước bóp bóng ñể chắn van xả áp lực không bị khóa KHỬ KHUẨN Bóng, mặt nạ sau sử dụng cho BN→ tháo rời → ngâm vào dung dịch Hexanios (UniDecon ) 0.5 % 15 phút→ rửa vòi nước → ñể khô xịt air → bỏ vào bao rác lây nhiễm, ghi tên khoa → gửi khoa chống nhiễm khuẩn xử lý → sử dụng cho BN sau Cám ơn quí vị ñã lắng nghe! ORIGINAL RESEARCH Open AccessEmergency intraosseous access in a helicopteremergency medical service: a retrospective studyGeir A Sunde1,2*, Bård E Heradstveit1,2, Bjarne H Vikenes1,2, Jon K Heltne1,2,3AbstractBackground: Intraosseous access (IO) is a method for providing vascular access in out-of-hospital resuscitation ofcritically ill and injured patients when traditional intravenous access is difficult or impossible. Different intraosseoustechniques have been used by our Helicopter Emergency Medical Services (HEMS) since 2003. Few articlesdocument IO use by HEMS physicians. The aim of this study was to evaluate the use of intraosseous access in pre-hospital emergency situations handled by our HEMS.Methods: We reviewed all medical records from the period May 2003 to April 2010, and compared three differenttechniques: Bone Injection Gun (B.I.G® - Waismed), manual bone marrow aspiration needle (Inter V - Medical DeviceTechnologies) and EZ-IO® (Vidacare), used on both adults and paediatric patients.Results: During this seven-year period, 78 insertion attempts were made on 70 patients. Overall success rates were50% using the manual needle, 55% using the Bone Injection Gun, and 96% using the EZ-IO®. Rates of success onfirst attempt were significantly higher using the EZ-IO® compared to the manual needle/Bone Injection Gun (p <0.01/p < 0.001). Fifteen failures were due to insertion-related problems (19.2%), with four technical problems (5.1%)and three extravasations (3.8%) being the most frequent causes. Intraosseous access was primarily used inconnection with 53 patients in cardiac arrest (75.7%), including traumatic arrest, drowning and SIDS. Otherdiagnoses were seven patients with multi-trauma (10.0%), five with seizures/epilepsy (7.1%), three with respiratoryfailure (4.3%) and two others (2.9%). Nearly one third of all insertions (n = 22) were made in patients younger thantwo years. No cases of osteomyelitis or other serious complications were documented on the follow-up.Conclusions: Newer intraosseous techniques may enable faster and more reliable vascular access, and this canlower the threshold for intraosseous access on both adult and paediatric patients in critical situations. We believethat all emergency services that handle critically ill or injured paediatric and adult patients should be familiar withintraosseous techniques.BackgroundVascular access is important in the resuscitation of criti-cally ill or injured adult and paediatric patients [1,2]. Itcan be challenging to obtain vascular access, especiallyin the resuscitation of small children in emergencysituations [3-5]. The European Resuscitation Council2005 guidelines [6] and International Liaison Committeeon Resuscitation guidelines [4] recommend intraosseousaccess during resuscitation if intravenous access provesto be difficult or impossible. Despite these recommenda-tions, intraosseous techniques appear to be rarely used[7]. While numerous reports have been published aboutthe use of different intraosseous devices in emergencypatients, they are primarily from paramedic-basedambulance services [2,8]. Few comparisons have beenpublished of different IO techniques used by physiciansin emergency departments [7] or in HEMS servicesmanned by physicians/nurses [9,10].Typical HEMS operating conditions make specialdemands on medical equipment such as IO devices.Rain, cold, darkness and non-sterile conditions meanthat such equipment must be durable and simple to usein all conditions. User friendliness is important for res-cuers, both on-scene and in-flight [10].Intravenous access is traditionally regarded as theoptimal route for medication and fluids, and the* Oral Ondansetron for Gastroenteritis in a Pediatric Emergency Department Background BỘ GIÁO DỤC VÀ ĐÀO TẠO TRƯỜNG ĐẠI HỌC DÂN LẬP HẢI PHÒNG ------------------------------- ISO 9001 : 2008 KHÓA LUẬN TỐT NGHIỆP NGÀNH: NGOẠI NGỮ HẢI PHÒNG - 2010 2 HAIPHONG PRIVATE UNIVESITY FOREIGN LANGUAGES DEPARTMENT ----------------------------------- GRADUATION PAPER A STUDY ON TRANSLATION OF ENGLISH - RELATED TERMS IN FINANCE AND BANKING INTO VIETNAMESE By: BUI THI THOM Class: NA 1004 Supervisor: DAO THI LAN HUONG, M.A HAI PHONG - 2010 3 BỘ GIÁO DỤC VÀ ĐÀO TẠO TRƯỜNG ĐẠI HỌC DÂN LẬP HẢI PHÒNG -------------------------------------- Nhiệm vụ đề tài tốt nghiệp Sinh viên: .Mã Số: Lớp: Ngành: Tên đề tài: . . 4 Nhiệm vụ đề tài 1. Nội dung và các yêu cầu cần giải quyết trong nhiệm vụ đề tài tốt nghiệp ( về lý luận, thực tiễn, các số liệu cần tính toán và các bản vẽ). …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… 2. Các số liệu cần thiết để thiết kế, tính toán. …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… …………………………………………………………………………… Update on mangement of patent ductus arteriosus in preterm infants Dr Trinh Thi Thu Ha Outline Overview of PDA Timing of screening PDA? When to treat PDA? Timing of ductal closure Prenatal MgSO4, tocolytic Postnatal surfactant Early, severe pulmonary hemorrhage is associated with ductal patency at 12 to 18 hours of age, but later pulmonary hemorrhage (after the first week) is not related to persistent ductal patency (Workbook in Practical Neonatology 5th Edition 2015) Diagnosis: In most cases, the clinically silent PDA during the first few days goes undetected unless an echocardiogram is performed Signs of bounding pulses, active precordium, and systolic murmur were of reasonable specificity but very low sensitivity in the first to days of birth for diagnosis of an echocardiographically defined significant PDA Relying on clinical signs alone led to a mean diagnostic delay of days (A blinded comparison of clinical and echocardiographic evaluation of the preterm infant for patent ductus arteriosus.Skelton R1, Evans N, Smythe J JPaediatr Child Health 1994 Oct;30(5):406-11) Ibuprofen Prophylaxis No significant differences in mortality, IVH, or BPD No reduction in IVH, PAL in the treated group Increased risk of gastrointestinal bleeding Prophylactic ibuprofen exposes many infants to renal and gastrointestinal side effects without any important short-term benefits and is not recommended Pre-symptomatic Pharmacologic Treatment No effect on the rate of mortality, BPD, IVH, ROP, or length of ventilation, death, IVH, NEC,… More renal side effect Presymptomatic indomethacin or ibuprofen therapy for PDA in preterm infants is not recommended Conservative Management Fluid restriction Diuretics, avoidance of loop diuretics Maintaining a hematocrit of 35 to 40 percent Increased positive airway pressure Correction of alkalosis Avoidance of pulmonary vasodilators: oxygen or NO Asymptomatic infants with PDAs generally not require medical management or surgical ligation These infants should be monitored for evidence of CHF, failure or renal PEDIATRIC OBSTRUCTIVE SLEEP APNEA (OSA) DEFINITION OSA • Inspiratory airflow is either partly (hypopnea) or completely (apnea) occluded during sleep The combination of sleep-disordered breathing with daytime sleepiness is referred to as the OSA syndrome • Obstructive apnea occurs when there is complete cessation of airflow for ≥ 10 s PATHOPHYSIOLOGY major predisposing factors for upper airway obstruction: • Anatomic narrowing • Abnormal mechanical linkage between airway dilating muscles and airway walls • Muscle weakness • Abnormal neural regulation PATHOPHYSIOLOGY • • • • Sleep fragmentation Increased work of breathing Alveolar hypoventilation Intermittent hypoxemia COMPLICATIONS • • • • • Neurobehavioral disturbances, ADHD Diminished learning capabilities Failure to thrive Pulmonary hypertension Cor pulmonale CONDITION ASSOCIATED-CAUSES • • • • • • • • Tonsillar and adenoid hypertrophy Neuromuscular disorders Myelomeningocele Obesity Pierre Robin sequence Cerebral palsy Down syndrome Hypothyroidism EPIDEMIOLOGY • United States: Affecting 2–3% of all children (snoring: 8-27%) • 2-8 years (adenotonsillar lymphatic tissue growth) • Sex: prepubertal children: male = female, older adolescents: male > female • Races: black children > white children, high frequency of OSA / adult Asia: craniofacial structures HISTORY • Nonspecific • Interview: speciality, sensity # 50-60% • Family: snoring, allergies, exposure to tobacco smoke • History of loud snoring >=3 nights/week: increase suspicion of OSA • Breathing difficulties during sleep, unusual sleeping positions, morning headaches, daytime fatigue, irritability, poor growth, behavioral problems PHYSICAL • • • • • • • • Growth chart, height, weight, obesity Nasal passenge Palate Tonsillar hypertrophy, uvula Malformation: cleft, chin, maxilla Compression Cardiac examination Conditions in cause POLYSOMNOGRAPHY • • • • Sleep state (>2 EEG leads) Electrooculogram (right and left) Electromyelogram (EMG) Airflow at nose and mouth (thermistor, capnography, or mask and pneumotachygraph) • Chest and abdominal wall motion • Electrocardiogram (preferably with R-R interval derivation technology) POLYSOMNOGRAPHY • Pulse oximetry (including a pulse waveform channel) • End-tidal carbon dioxide (sidestream or mainstream infrared sensor) • Video camera monitor with sound montage • Transcutaneous oxygen and carbon dioxide tensions (in infants and children 10 minutes • Total sleep time (TST) > 5.5 hours • Rapid eye movement (REM) sleep >15% of TST • Percentage of stage 3-4 non-REM sleep > 25% of TST • Respiratory arousal index (number per hour of TST) < • Periodic leg movements (number per hour of TST) < • Apnea index (number per hour of TST) 95% • Desaturation index (>4% for s; number / hour of TST) < • Highest CO2 52 mm Hg • CO2 > 45 mm Hg < 20% of TST TREATMENT Medical therapy: limited value • Antihistamine or antimuscarinic: nasal congestion, benefit is uncertain • Leukotriene modifier: eliminate residual OSA following surgery, improve clinical outcomes without surgery • Budesonide for weeks: sustained improvement in mild OSA TREATMENT Positive-pressure ventilation: safe, efficient, alternative to further surgery or tracheotomy in children and infants with unresolved OSA after tonsillectomy and adenoidectomy • CPAP • BiPAP TREATMENT Surgery: • Tonsillectomy and adenoidectomy • Tracheotomy • Uvulopharyngopalatoplasty, epiglottoplasty • Bariatric surgery Pediatric obstructive sleep apnea (OSA): A potential late consequence of respiratory syncitial virus (RSV) bronchiolitis Ayelet Snow, MD,1 Ehab Dayyat, MD,1 Hawley E MANAGEMENT OF SUSPECTED VIRAL ENCEPHALITIS IN CHILDREN OVERVIEW • 1980s: dramatically improved by aciclovir HSV encephalitis in adults • Delays treatment(> 48h after hospital admission): associated with a worse prognosis OVERVIEW • Syndrome of neurological dysfunction: inflammation of the brain parenchyma • Many causes: Infectious: viruses, bacteria, parasites and fungi Non- infectious: antibody-mediated RECOMMENDATION • Which clinical features should lead to a suspicion of encephalitis in children? RECOMMENDATION • Current or recent febrile illness: altered behaviour, personality, cognition or consciousness, seizures or new focal neurological signs (A, II) • The differential diagnosis: metabolic, toxic, autoimmune causes or sepsis outside the CNS (B, III), past history is very important • Sub-acute (weeks to months) encephalitis: autoimmune, paraneoplastic, metabolic aetiologies (C, III) • Priority of the investigations: determined by clinical history and clinical presentation (C, III) RECOMMENDATION • Diagnostic features for specific aetiologies? Age Immunocompetence Geography Exposure HSV encephalitis RECOMMENDATION • Symptom: non – specific • Children: labial – herpes is diagnostic specific (develop encephalitis with primary HSV infection) • Acute opercular syndrome (disturbance of voluntary control of the facio-linguo-glossopharyngeal muscles leading to oro-facial palsy, dysarthria and dysphagia) • Sexual abuse RECOMMENDATION • MRI: as soon as possible on all patients with suspected encephalitis/ diagnosis is uncertain, 24 hrs – 48 hrs after hospital admission (B, II) • MRI: chosen appropriately should be interpreted by an experienced paediatric neuroradiologist • SPECT and PET are not indicated in the assessment of suspected acute viral encephalitis (B, II) • For which patients should aciclovir treatment be started empirically? RECOMMENDATIO • Initial CSF and/or imaging suspected encephalitis: start acyclovir within hours of admission if these results are awaited (A, II) • First CSF/imaging: normal, clinical suspicion of HSV or VZV encephalitis: start acyclovir within hours of admission whilst further diagnostic investigations are awaited (A, II) RECOMMENDATION • Dose? 3 months-12 years 500mg/m2 hourly >12 years 10mg/kg hourly reduced in patients with pre-existing renal impairment (A, II) If meningitis is also suspected, should also be treated (A, II) • How long should acyclovir be continued in proven HSV encephalitis, and is there a role for oral treatment? RECOMMENDATION • Proven: continued for 14-21 days (A, II), repeat LP • CSF PCR is still positive for HSV: aciclovir should continue, with weekly CSF PCR until it is negative (B, II) • months-12 years a minimum of 21 days of aciclovir should be given before repeating the LP (B, III) • When can presumptive treatment with aciclovir be safely stopped, in patients that are HSV PCR negative? RECOMMENDATION • An alternative diagnosis has been made, or • HSV PCR in the CSF is negative on two occasions 24-48 hours apart, and MRI imaging (performed >72 hours after symptom onset), is not characteristic for HSV encephalitis, or • HSV PCR in the CSF is negative once >72 hours after neurological symptom onset, with normal level of consciousness, normal MRI, CSF white cell count of less than 106/L (B, III) • What is the role of corticosteroids in HSVB encephalitis? RECOMMENDATION • Corticosteroids should not be used routinely in patients with HSV encephalitis (B, III) • Corticosteroids may have a role in patients with HSV encephalitis under specialist supervision (study results are awaited (C, III)) • What should be the specific management of VZV encephalitis? RECOMMENDATION • No specific treatment for VZV cerebellitis (B, II) • ... lần/phút = bóp -2 - 3-bóp -2 - 3-bóp -2 - 3 ( # 1,5 giây bóp cái) - Thời gian nhát bóp ½ - ¾ giây Sử dụng van PEEP : Một số bóng có nơi gắn van PEEP,trên van PEEP có mức áp lực từ 5-1 0-1 5 -2 0 cmH2O, ta vặn... dao ñộng từ – cmH2O,nhưng lưu ý không ñể PEEP cao(> 10cmH2O )vì gây vỡ phế nang Áp lực bóp bóng : - Sơ sinh : 15 – 20 cmH2O - Trẻ nhỏ : 20 – 40 cmH2O - Trẻ lớn : 40 – 60 cmH2O → Bình thường van...08/09 /20 11 BÓNG TỰ PHỒNG CẤU TẠO VÀ CÁCH SỬ DỤNG CÁC LOẠI BÓNG Có thành phần bóng tự phồng : Đường khí vào nơi gắn phận dự trữ oxy Túi dự trữ oxy Đường khí oxy vào bóng Đường khí BN (là nơi gắn mask)