A retrospective review comparing treatment outcomes of adjuvant lung resection for drug-resistant tuberculosis in patients with and without human immunodeficiency virus co-infection

Global treatment outcomes of extensively drug-resistant tuberculosis in adults: A systematic review and meta-analysis

INTRODUCTION

Historically, extensively drug-resistant tuberculosis has been notoriously difficult to treat with devasting outcomes. As we are coming to the end of an era where the 2006 extensively drug-resistant tuberculosis definitions and old treatment regimens are being replaced, we aimed to estimate the proportion of extensively drug-resistant tuberculosis patients globally who achieved successful treatment outcomes.

METHODS

We conducted a systematic review of PubMed/MEDLINE, Scopus, Web of Science, and Embase from January 1, 2005, through April 3, 2023. Included studies reported WHO treatment outcomes, or adaptions hereof, for pre-extensively and/or extensively drug-resistant tuberculosis patients according to the 2006 WHO definition. Eligible studies included cohorts of at least 10 adults (aged>18 years) that were not pregnant. Using a random-effects model, we calculated pooled proportions of treatment outcomes and performed sensitivity and subgroup analyses. PROSPERO registration number: CRD42022340961.

RESULTS

Among 5056 studies reviewed, we identified 94 studies from 26 countries, involving 10,223 extensively drug-resistant tuberculosis patients. The pooled proportion of successful treatment outcomes was 44.2% (95%CI: 38.3-50.3). Sensitivity analyses consistently produced similar estimates. A slight improvement in treatment outcomes was observed after 2013. Furthermore, 25 studies reported outcomes for 3564 individuals with pre-extensively drug-resistant tuberculosis, of which 63.3% achieved successful treatment (95%CI: 43.1-72.5).

CONCLUSION

Globally, the success rate of extensively drug-resistant tuberculosis treatment is 44.2%, far below the WHO's target rate of 75%. These results may serve as a reference for future studies assessing extensively drug-resistant tuberculosis treatment outcomes under the 2021 definition treated with better treatment regimens available. Comprehensive surveillance data of extensively drug-resistant tuberculosis outcomes from the whole world are desirable to monitor treatment progress.

Galangin Inhibits Cholangiocarcinoma Cell Growth and Metastasis through Downregulation of MicroRNA-21 Expression

Galangin, a natural flavonoid product derived from the root of galangal, is emerging as a promising anticancer agent against multiple cancers. Yet, whether it also has antitumor effects on cholangiocarcinoma (CCA) and the underlying mechanism is still unknown. Herein, we demonstrate that galangin exhibits multiple antitumor effects on CCA cells including decreases cell viability; inhibits proliferation, migration, and invasion; and induces apoptosis. Moreover, those phenotypic changes are associated with downregulated microRNA-21 (miR-21) expression. To support, overexpression of miR-21 blocks galangin-mediated antisurvival and metastasis effects on CCA cells. Mechanically, galangin increases the expression of phosphatase and tensin homolog (PTEN), a direct target of miR-21, resulting in decreased phosphorylation of AKT, a protein kinase which plays a critical role in controlling survival and apoptosis. In contrast, overexpression of miR-21 abrogates galangin-regulated PTEN expression and AKT phosphorylation. Taken together, these findings indicate that galangin inhibits CCA cell proliferation and metastasis and induces cell apoptosis through a miR-21-dependent manner, and galangin may provide a novel potential therapeutic adjuvant to treat CCA.

Treatment of Drug-Resistant Tuberculosis. An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline

Background: The American Thoracic Society, U.S. Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America jointly sponsored this new practice guideline on the treatment of drug-resistant tuberculosis (DR-TB). The document includes recommendations on the treatment of multidrug-resistant TB (MDR-TB) as well as isoniazid-resistant but rifampin-susceptible TB.Methods: Published systematic reviews, meta-analyses, and a new individual patient data meta-analysis from 12,030 patients, in 50 studies, across 25 countries with confirmed pulmonary rifampin-resistant TB were used for this guideline. Meta-analytic approaches included propensity score matching to reduce confounding. Each recommendation was discussed by an expert committee, screened for conflicts of interest, according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.Results: Twenty-one Population, Intervention, Comparator, and Outcomes questions were addressed, generating 25 GRADE-based recommendations. Certainty in the evidence was judged to be very low, because the data came from observational studies with significant loss to follow-up and imbalance in background regimens between comparator groups. Good practices in the management of MDR-TB are described. On the basis of the evidence review, a clinical strategy tool for building a treatment regimen for MDR-TB is also provided.Conclusions: New recommendations are made for the choice and number of drugs in a regimen, the duration of intensive and continuation phases, and the role of injectable drugs for MDR-TB. On the basis of these recommendations, an effective all-oral regimen for MDR-TB can be assembled. Recommendations are also provided on the role of surgery in treatment of MDR-TB and for treatment of contacts exposed to MDR-TB and treatment of isoniazid-resistant TB.

Validating the surgical indication value of the LTB-S classification system for drug resistant tuberculosis

BACKGROUND

Currently there is no guideline based on preoperative clinical parameters for assessing the prognosis of the adjunctive surgery for drug-resistant tuberculosis.

METHODS

We retrospectively analyzed 138 patients who had undergone surgical resection as a treatment for drug- resistant tuberculosis after 24 months. Four clinical parameters on lesion type, treatment history, body physiological status, and surgery approach were evaluated. Categorical preoperative clinical parameters were analyzed by ordinal logistic regression model when considering postoperative complications as outcomes ordered in terms of severity. Statistically significant parameters were then combined in a single classification system for predicting the outcomes of the adjunctive surgery.

FINDINGS

Diffused, progressive bilateral lesions, or active/progressive extra pulmonary tuberculosis (L3), and history of less than 2 months treatment before surgery (T3) were the strongest predicative parameters for postoperative complications and for surgery failure. Classification systems based on the four parameters were found to have a statistically significant effect on postoperative complications and postoperative efficacy. 24- month follow up indicated a high cure rate (above 95.5%) among patients without T3, L3, or severe physiological complications (B3).

INTERPRETATION

A classification system based on objective clinical parameters showed predicative value for the prognosis of the adjunctive surgery and could guide management of drug-resistant Tuberculosis.

Treatment of pulmonary tuberculosis: past and present

OBJECTIVES

Surgical interventional has been key in the treatment of tuberculosis (TB) for a long time. Its importance diminished after the emergence of chemotherapy. However, the spread of rapid multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB has led us to return to surgery to treat TB. Today, every second patient in Russia with destructive TB has either MDR or XDR TB, which is the reason for the low efficacy of conservative treatment. In 2015, treatment with drugs resulted in clinical recovery in only 29.8% of new cases of destructive TB acid-fast bacilli (AFB)+.

METHODS

The author's data from 1999 to 2016 have been analysed. The author performed 5599 surgeries on patients with pulmonary TB aged from 1 to 87 years (mean age 34.6 years). The most common reasons for surgical treatment were fibrotic cavitary and cavitary pulmonary TB, tuberculoma with destruction, tuberculous pleural empyema, caseous pneumonia and intrathoracic lymph nodes. The strategy of early collapse therapy and the use of surgery to treat TB was proposed in the Penza region of Russia; the results were analysed to estimate the long-term outcomes of treatment.

RESULTS

In 5599 surgeries, the full clinical effect was achieved in 93% of operated patients with MDR TB, in 92.1% of those with XDR TB and in 98% of patients without MDR or XDR resistance. According to the data from the Penza region, 3 years after surgery, 93.9% (149 of 159 cases) of the operated patients exhibited clinical recovery.

CONCLUSIONS

Taking into account the data from the World Health Organization on the insufficient level of therapeutic success in the treatment of MDR and XDR pulmonary TB, surgical treatment is necessary in regions with a high frequency of drug-resistant cases.

Do specialist pulmonologists appropriately utilise thoracic surgery for drug-resistant pulmonary tuberculosis? A survey

Background

Adjuvant lung resection in patients with drug-resistant tuberculosis (DR-TB) not only is cheaper than a 2-month course of drug therapy for multidrug-resistant tuberculosis (MDR-TB) but also, more importantly, has a higher cure rate than medical therapy alone. The cure rate for some MDR-TB patients treated with adjuvant lung resection is about 90%. With the more severe forms of DR-TB, surgical cure rates in selected patients remain high, whereas cure rates decrease when only medical therapy is used. In addition, adjuvant lung resection for DR-TB in selected patients with HIV co-infection does not appear to have a higher complication rate.

Objectives

To determine whether specialist pulmonologists in South Africa utilise thoracic surgical intervention for DR-TB appropriately.

Methods

A cross-sectional survey was conducted among pulmonologists of the South African Thoracic Society. The study tool was a predesigned, anonymous questionnaire that included 17 closed-ended questions about the role of cardiothoracic surgery in the management of DR-TB.

Results

A 50% response rate was achieved. The majority of respondents did not know the indications for adjuvant lung surgery in the setting of DR-TB, but would have altered their referral behaviour had they been aware of these indications.

Conclusion

Participating pulmonologists’ uncertainty regarding optimal use of adjuvant lung resection for DR-TB suggests the need for local guidelines and education initiatives relevant to the management of these patients. These strategies should include the participation of both the pulmonologist and the cardiothoracic surgeon.

Surgical aspects of pulmonary tuberculosis: an update

Tuberculosis remains a major global medical challenge and concern. In the world's population of over 7.4 billion people, 8.6 million are estimated to be infected with Mycobacterium tuberculosis; another 2.2 billion have latent tuberculosis. There is an annual incidence of 16,000 new cases in the USA and 7-8 million new cases worldwide, of which 440,000 are multidrug-resistant or extensively multidrug-resistant, mainly in developing countries or emerging economies. According to the World Health Organization, the incidence of tuberculosis is 133 cases per 100,000 of the population; 3.3% new cases are drug resistant and 20% are already treated cases. Of the drug-resistant cases, 9.7% are extensively drug-resistant. The annual global mortality attributable to tuberculosis is over 1.3 million people. The association with HIV/AIDS in 430,000 people has compounded the global concern and challenge. This review presents the historical indications for surgical treatment of tuberculosis, reviews the current literature and clinical experience, and collates this into increased awareness and contemporary understanding of the indications and need for surgery in primary active tuberculosis, adjuvant surgical therapy for multidrug-resistant tuberculosis, and the complications of chronic tuberculosis sequelae or previous tuberculosis surgery.