[Drug-resistant pulmonary tuberculosis at Maradi Regional Hospital Center, Niger (2014-2018)]

Aim of study

To describe the clinical, therapeutic and evolutionary profile of patients followed for rifampicin-resistant pulmonary tuberculosis (RR-TB) at the Regional Hospital Centre (RHC) of Maradi (Niger) from 2014 to 2018.

Methods

We conducted a retrospective and descriptive study based on the records of patients followed for Multidrug-resistant tuberculosis (MDR-TB) between January 1, 2014 and June 30, 2018 at the resistant tuberculosis management unit in Maradi (Niger). This unit is located within the RHC of Maradi and has a capacity of 20 beds in 4 wards. It receives patients with tuberculosis resistant to first-line anti-tuberculosis drugs. In this study, patients diagnosed with RR-TB by genotypic (GeneXpert MTB/RIF) or phenotypic (culture) testing were included. We excluded from this study: patients previously treated for more than 1 month with second-line anti-TB drugs; patients with resistance to second-line injectables (SLI) and/or fluoroquinolones (FQ); patients with an electrocardiogram QTc greater than 500 ms (the corrected QT (QTc) estimates the QT interval at a rate of 60 beats per second); cases of atypical mycobacteriosis detected by phenotypic testing.Patients were previously on 2RHZE/4RH prior to the discovery of resistance. The treatment protocol for resistant TB was as follows: 4KmMfxPtoCfzHZE/5MfxCfzZE (The second-line injectable was replaced by Lzd in case of initial or treatment-emergent deafness). HIV co-infected patients received, in addition to anti-tuberculosis drugs, antiretrovirals and cotrimoxazole in preventive doses.

Results

A total of 80 patients were included in the present study (70 males and 10 females, mean age 34.4 years with extremes ranging from 18 to 71 years). Patients aged 18-35 years accounted for more than half. Patients with primary treatment failure were the most frequent type (36%) followed by patients with retreatment failure (24%) and patients with retreatment relapse (17%). It should be noted that 77 patients (96%) were previously treated for TB and only 3 patients (4%) were new cases. The majority of patients (70%) had a Body mass index of less than 18 kg/m2. 7.5% of patients were HIV positive, one was diabetic, 52% of the patients had grade 2 radiological lesions. Grade 1 deafness was noted at the beginning of treatment in 3%. A third of patients (36%) were primary treatment failures. The treatment protocol was as follows: 4KmMfxPtoCfzHZE/5MfxCfzZE. Only 1 patient had a positive culture at the end of the 4th month of treatment. Most of the patients had experienced adverse events, mainly digestive, with vomiting being the most common. The therapeutic success rate was 88%. We noted 10% of deaths, 1% of therapeutic failure and 1% of lost to follow-up.Six months after treatment, 48 patients (60%) were smear negative and 43 (54%) were culture negative. In 32 patients (40%), the smear was not performed and culture was not performed in 37.

Conclusion

The short treatment regime gives satisfactory results in the absence of resistance to fluoroquinolones, with rare adverse effects. In Niger, further efforts should be made to minimize the delay in diagnosis which is responsible for most deaths during treatment. A centre could usefully be designated to organize "TB consiliums" allowing any practitioner to submit difficult cases of MDR-TB.

Immunoglobulin-resistant Kawasaki disease

BACKGROUND

Kawasaki disease is a systemic vasculitis that affects small and medium-sized vessels, primarily the coronary arteries. First-line treatment includes intravenous immunoglobulin (IVIG) and acetylsalicylic acid; however, 20% do not respond adequately despite treatment. We describe a case treated with etanercept after initial IVIG failure, showing a good response.

CASE REPORT

A 5-year-old female was diagnosed with classic Kawasaki disease. Echocardiography and angiotomography revealed giant and fusiform aneurysms in the coronary arteries. A first dose of IVIG therapy was administered without improvement; after the second dose, the fever persisted, so etanercept was administered, and the fever subsided. There were no new lesions in medium-caliber vessels and the previously identified coronary lesions did not progress.

CONCLUSIONS

The use of etanercept in Kawasaki disease has demonstrated a clinically favorable response. Controlled clinical trials of this drug are needed to establish it as a formal therapy in cases of initial IVIG failure.

Ocular toxoplasmosis in immunocompetent adults: current cost-effectiveness of four treatment regimens in Colombia

BACKGROUND

Ocular toxoplasmosis is an infection caused by Toxoplasma gondii. In South America, the clinical course of ocular toxoplasmosis is more severe than in Europe and North America because virulent strains of the parasite are present. Ocular toxoplasmosis is the leading cause of posterior uveitis and retinochoroiditis in Colombia, requiring timely and appropriate treatment. However, there is no standardized therapy protocol based on economic studies for the country.

PURPOSE

To compare the cost-effectiveness of four first-line treatment regimens for active ocular toxoplasmosis in immunocompetent adults in Colombia, using the number of averted therapeutic failures as the outcome.

METHODS

We performed an economic and cost-effectiveness analysis to compare four first-line treatment regimens for ocular toxoplasmosis from the perspective of a third-party payer (Colombian General System of Social Security in Health). A decision analysis tree was used over a 24-week time horizon, considering only direct costs. Additionally, we performed a discrete sensitivity analysis and a probabilistic sensitivity analysis with 10,000 iterations in the Monte Carlo simulation.

RESULTS

For the base case, trimethoprim/sulfamethoxazole showed 86% effectiveness at a cost of <57 United States Dollars, resulting in the most cost-effective first-line alternative. When performing the probabilistic sensitivity analysis and maintaining the willingness to pay 466.00 United States Dollars, the trimethoprim/sulfamethoxazole regimen remained the most cost-effective alternative.

CONCLUSION

Ocular toxoplasmosis is a public health issue in Latin America. Despite severe visual consequences for affected patients, there are no standardized treatment guidelines in countries such as Colombia. Our evidence supports the use of trimethoprim/sulfamethoxazole as first-line treatment in Colombia because of its availability and optimal cost-effectiveness performance; it reduces recurrences and complications, while averting therapeutic failure. Furthermore, our evidence can be generalized to other Latin American countries with similar frequencies and severities of Toxoplasma gondii ocular infection and health systems similar to the Colombian system.

Ten-year follow-up of the largest oral Chagas disease outbreak. Laboratory biomarkers of infection as indicators of therapeutic failure

Trypanosoma cruzi uses various mechanisms of infection to access humans. Since 1967, food contaminated with metacyclic trypomastigotes has triggered several outbreaks of acute infection of Chagas disease by oral transmission. Follow-up studies to assess the effectiveness of anti-parasitic treatment of oral outbreaks are rather scarce. Here, we report a 10-year laboratory follow-up using parasitological, serological, and molecular tests of 106 individuals infected in 2007 of the largest known outbreak of orally transmitted Chagas disease, which occurred in Caracas city, Venezuela. Before treatment (2007), specific IgA, IgM and IgG, were found in 71% (75/106), 90% (95/106) and 100% (106/106), respectively, in addition to 21% (9/43) parasitemia, Complement Mediated Lysis (CML) in 98% (104/106) and 79% (34/43) parasitic DNA for PCR. Blood culture detected parasitemia up to 18 months post-treatment in 6% (6/106) of the patients. In 2017, the original number of cases in the follow-up decreased by 46% and due to the country's economic situation, not all the trials could be carried out in the entire population. During follow-up, IgA and IgM disappeared promptly, with IgM persisting in 19% (20/104) of the patients three years after treatment. The anti-T. cruzi IgG remained positive 10 years later in 41% (20/49) of the individuals evaluated. CML remained positive seven years later in 79% (65/82) of the cases. PCR positive cases decreased after treatment but progressively recovered, being positive in 69% (32/46) of the individuals evaluated in 2017. The group of children (under 18 years of age) showed the highest PCR positivity with 76% (26/34) of the cases, but their parasitic load tended to diminish, while in adults the parasitic load regained their initial values. The simultaneous evaluation of serological tests and PCR of the patients allowed us to separate patients among responders and non-responders to the anti-parasitic treatment, and this information prompted us to apply a second anti-parasitic treatment in the group of non-responders. In this population not subjected to the like lihood of re-infection, adult patients were more likely to be non-responders when compared to children. These results suggest that rigorous laboratory follow-up with T. cruzi infectious biomarkers is essential to detect cases of parasite persistence.

Artemether-lumefantrine treatment failure of uncomplicated Plasmodium falciparum malaria in travellers coming from Angola and Mozambique

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Artemether-lumefantrine (AL) treatment failure of imported malaria in Portugal

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AL treatment failure in the presence of wild-type pfk13 and pfmdr1

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Is the standard 3-day course of AL sufficient to ensure parasite clearance?

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AL increasing treatment failures urges closer immediate follow up of malaria patients

The failure of artemisinin combination therapy (ACT) in malaria patients returning from endemic regions may be driven by parasite resistance to this treatment. ACT is used globally as the first-line treatment for Plasmodium falciparum malaria. However, artemisinin-resistant strains of P. falciparum have emerged and spread across Southeast Asia, with the risk of reaching high malaria burden regions in Africa and elsewhere. Here, we report on two malaria imported cases from Africa with possible parasite resistance to the ACT artemether-lumefantrine (AL).

Case presentation: Two middle-aged males returning from Angola and Mozambique developed malaria symptoms in Portugal, where they were diagnosed and received treatment with AL as hospital inpatients. After apparent cure and discharge from hospital, these individuals returned to hospital showing signs of late clinical failure. Molecular analysis was performed across a number of drug resistance associated genes. No evidence of pfk13-mediated artemisinin resistance was found. Both subjects had complete parasite clearance after treatment with non-ACT antimalarials.

Conclusion: Our case-studies highlights the need for close monitoring of signs of unsatisfactory antimalarial efficacy among AL treated patients and the possible implication of other genes or mutations in the parasite response to ACTs.

Long-term failure after endovascular aneurysm sealing in a real-life, single-center experience with the Nellix endograft

BACKGROUND

Endovascular aneurysm sealing (EVAS) is an innovative alternative to conventional endovascular aneurysm repair (EVAR). EVAS relies on sac anchoring without proximal fixation to achieve sealing and should have allowed for the treatment of a broader range of anatomic features compared with standard EVAR. Despite the encouraging early reports, the mid- and long-term follow-up data have shown increased rates of failure. To address the issue, the manufacturer introduced revised instructions for use (IFU) in 2016. The present study reports the outcomes of this system after a median follow-up of 45 months.

METHODS

Data for all patients electively treated with EVAS at our institution were retrospectively collected. The patients were retrospectively reclassified according to the 2016 revised IFU of the device. All patients in the present series had undergone EVAS for the treatment of infrarenal abdominal aortic aneurysms (AAAs). The primary end point was therapeutic failure: graft migration >5 mm, sac expansion >5 mm, type IA endoleak (Is2 and Is3 using the Van den Ham classification), type Ib endoleak, and secondary rupture. The overall mortality, aortic-related mortality, and reintervention rates were also analyzed.

RESULTS

A total of 101 patients had undergone elective treatment by EVAS from 2013 to 2018 for infrarenal AAAs. The median follow-up was 3.75 years. Therapeutic failure was observed in 31 of the 101 patients (30.7%), with no significant difference between the in-IFU and off-IFU 2016 subgroups. Failure occurred at a median interval of 34 months from the index procedure. Of the 101 patients, 6.9% had presented with secondary rupture. Freedom from aneurysm-related mortality was 96.9% at 1 and 2 years and 89.9% at 5 years. Freedom from reintervention decreased over time: 94.7% at 1 year, 77% at 4 years, and 52.1% at 6 years. Of the 101 patients, 14 (13.9%) had undergone emergent or elective graft explantation.

CONCLUSIONS

EVAS performed worse than conventional endografts for several critical end points, regardless of any preoperative anatomic parameters. The incidence of therapeutic failures tended to increase over time, especially 4 years after the index procedure.

Dissemination of SHV, TEM and CTX-M Genotypes in Pseudomonas aeruginosa: A Pre-eminent Reason for Therapeutic Failure in Pediatrics

OBJECTIVE

Dissemination of extended-spectrum beta-lactamase (ESBL) genotypes in Pseudomonas aeruginosa gained attention as superbugs, which are extremely difficult to treat with conventional antibiotics. The study aimed to delineate the empirical therapy and the occurrence of SHV, TEM, and CTX-M encoding P. aeruginosa among pediatric patients.

METHODS

A total number of 33,400 continuous and non-repetitive clinical specimens collected from the debilitated pediatric patients processed for the isolation of P. aeruginosa. The characterization of the isolated strains performed using phenotypic and molecular methods. The spectrum of antibacterial resistance observed against all the isolated strains of P. aeruginosa. RESULTS: A total of 74 (18.8%) ESBL producers isolated, out of which 58 (78.4%) were bla _CTX-M, 53 (71.6%) bla _SHV, and 38 (51.4%) were bla _TEM genes. The mortality was significantly associated (p<0.001) in patients infected with ESBL producing P. aeruginosa and neonatal age group. The mean length of stay for the patients infected with ESBL and non-ESBL producing P. aeruginosa was 7.93±7.26 and 8.26±5.40, respectively. Antibiogram showed high resistance of spectrum with cephalosporins while resistance against cefoperazone-sulbactam (32; 43.2%), carbapenems (23; 31.1%), and piperacillin-tazobactam (14; 18.9%) was comparatively low.

CONCLUSION

The dissemination and co-existence of bla _CTX-M, bla _SHV, and bla _TEM genes in P. aeruginosa clones make it difficult to treat the infected pediatric patients without the new synergistic combinational regimens.

Cellular Markers for the Identification of Chemoresistant Isolates in Leishmania

Markers to diagnose chemoresistance in infecting Leishmania parasites are urgently required. This is fundamental for patients who do not heal during or after treatment, as they are unresponsive, or patients who relapse at the end of the therapy, suffering from therapeutic failure. Glucose utilization is an indicator of cell viability that closely associates with metabolic activity. In Leishmania, glucose is a source of carbon atoms and is imported into the cell through specific transporters. In experimentally developed chemoresistant Leishmania parasites a significant decrease of the expression of glucose transporters as well as in the cellular accumulation glucose has been described. Alternatively, the electrical membrane potential is an essential parameter for the formation of the electromotive force needed for the acquisition of important nutrients and solutes (e.g., glucose) by cells, and changes in glucose concentration are suggested to constitute a physiological adaptation associated with a chemoresistant phenotype of Leishmania parasites. Here we describe easy methods to measure glucose uptake and the membrane potential in isolates from patient suffering leishmaniasis. Correlation between both parameters might be helpful to identify chemoresistant parasites. Results suggest that the measured kinetics of glucose utilization rate can be correlated with the plasma membrane potential and together used to differentiate between the performance of wild-type and reference parasites on the one hand and parasites isolated from patients with therapeutic failure on the other.

[Therapeutic failure in skin carcinomas of the face]

Therapeutic failures in the management of skin carcinomas of the face are not rare, because of the very high frequency of these lesions. They come in 3 aspects: (a) tumor recurrence at the site of resection: reminders concerning the margins of excision in first surgery and in case of recurrence are made, as well as a focus on the behavior to take in case of incomplete margins; (b) Functional drawbacks related to surgery: abnormalities are addressed by anatomical location (eyelids and lips) through some examples and decisional algorithms. The nose and the ear are treated in other chapters of the book; (c) the aesthetic sequelae are finally presented thanks to new clinical cases.

Efficacy and safety of cholecalciferol-augmented anti-tuberculosis therapy for treatment of naïve patients with pulmonary tuberculosis: A randomized, controlled, clinical study

BACKGROUND/OBJECTIVE

Vitamin D deficiency may contribute to the therapeutic failure of antituberculosis therapy (ATT). The aim of this study is to explore the role of adding cholecalciferol to the standard ATT in improving the therapeutic outcome among the naïve patients with pulmonary tuberculosis (TB).

METHODS

A randomized, controlled, clinical study, which included 496 naïve patients with pulmonary TB, was carried out. The patients were randomly allocated to two groups. Group-A included 247 patients who received ATT, while group-B included 249 patients who received ATT with cholecalciferol.

RESULTS

The rate of therapeutic failure among the study population was 29.4%; it was significantly lower among patients of group-B compared to those of group-A (22.1% (95% CI 14.7-26.2) vs 38.1% (95% CI 31.5-46.1), p 0.036). In addition, the rate of early therapeutic response was significantly higher among patients of group-B compared to those of group-A (35.3% (95% CI 29.6-42.3) vs 19.4% (95% CI 15.1-24.6), p 0.041). Incidence rate of adverse effects was 19.3%; it was higher (although not statistically significant) among patients of group-A compared to those of group-B (21.9% vs 16.9%).

CONCLUSIONS

In conclusion, cholecalciferol-augmented ATT can be more efficacious in treating naïve patients with pulmonary TB compared to the standard ATT. In addition, adding vitamin D3 to ATT provides extra protection against the hepatic and muscular adverse effects of ATT.

Association between augmented renal clearance, antibiotic exposure and clinical outcome in critically ill septic patients receiving high doses of β-lactams administered by continuous infusion: a prospective observational study

This study assessed whether augmented renal clearance (ARC) impacts negatively on antibiotic concentrations and clinical outcomes in patients treated by high-dose β-lactams administered continuously. Over a 9-month period, all critically ill patients without renal impairment treated by one of the monitored β-lactams for a documented infection were eligible. During the first 3 days of antibiotic therapy, every patient underwent 24-h CL_Cr measurements and therapeutic drug monitoring. The main outcome was the rate of β-lactam underdosing, defined as a free drug concentration <4 × MIC of the known pathogen. Secondary outcomes were rates of subexposure for β-lactams and therapeutic failure. The performance of CL_Cr in predicting underdosing was assessed by a ROC curve, and multivariable logistic regression was performed to determine risk factors for subexposure and therapeutic failure. A total of 79 patients were included and 235 samples were analysed. The rate of underdosing_<4×MIC was 12%, with a significant association with CL_Cr (P <0.0001). A threshold of CL_Cr ≥ 170 mL/min had a sensitivity and specificity of 0.93 (95% CI 0.77-0.99) and 0.65 (95% CI 0.58-0.71) for predicting β-lactam underdosing_<4×MIC. Mean CL_Cr values ≥170 mL/min were significantly associated with subexposure_<4xMIC [OR = 10.1 (2.4-41.6); P = 0.001]. Patients with subexposure_<4×MIC presented higher rates of therapeutic failure [OR = 6.3 (1.2-33.2); P = 0.03]. Mean CL_Cr values ≥170 mL/min remain a risk factor for subexposure to β-lactams despite high doses of β-lactams administered continuously. β-Lactam subexposure was associated with higher rates of therapeutic failure in septic critically ill patients.

Association between augmented renal clearance and clinical failure of antibiotic treatment in brain-injured patients with ventilator-acquired pneumonia: A preliminary study

OBJECTIVES

This preliminary study aimed to determine whether augmented renal clearance (ARC) impacts negatively on the clinical outcome in traumatic brain-injured patients (TBI) treated for a first episode of ventilator-acquired pneumonia (VAP).

METHODS

During a 5-year period, all TBI patients who had developed VAP were retrospectively reviewed to assess variables associated with clinical failure in multivariate analysis. Clinical failure was defined as an impaired clinical response with a need for escalating antibiotics during treatment and/or within 15 days after the end-of-treatment. Recurrence was considered if at least one of the initial causative bacterial strains was growing at a significant concentration from a second sample. Augmented renal clearance (ARC) was defined by an enhanced creatinine clearance exceeding 130mL/min/1.73m² calculated from a urinary sample during the first three days of antimicrobial therapy.

MAIN RESULTS

During the study period, 223 TBI patients with VAP were included and 59 (26%) presented a clinical failure. Factors statistically associated with clinical failure were GSC≤7 (OR=2.2 [1.1-4.4], P=0.03), early VAP (OR=3.9 [1.9-7.8], P=0.0001), bacteraemia (OR=11 [2.2-54], P=0.003) and antimicrobial therapy≤7 days (OR=3.7 [1.8-7.4], P=0.0003). ARC was statistically associated with recurrent infections with an OR of 4.4 [1.2-16], P=0.03.

CONCLUSION

ARC was associated with recurrent infection after a first episode of VAP in TBI patients. The optimal administration and dosing of the antimicrobial agents in this context remain to be determined.

Is Leishmania (Viannia) braziliensis parasite load associated with disease pathogenesis?

BACKGROUND

Leishmania (Viannia) braziliensis is the main etiological agent of tegumentary leishmaniasis in the Americas. Parasite molecular diversity and host immune status contribute to extensive variations in its clinical presentation within endemic areas of Brazil. Pentavalent antimonials have been used for more than 60 years as the first-line drug for all cases, despite the potential for severe side effects and refractoriness. In Rio de Janeiro, Brazil, most L. (V.) braziliensis infections are benign with a scarcity of parasites, although metastasis and refractory infections can arise. In this scenario, the use of novel molecular tools can be useful for diagnosis and to assess tissue parasitism, and is of benefit to clinical and therapeutic management.

METHODS

In this study, parasite load was assessed by real-time PCR based on the leishmanial small subunit ribosomal RNA gene.

RESULTS AND CONCLUSION

The data revealed a tendency to higher tissue parasitism in the skin compared to mucous lesion sites and a reduction with disease progression. Parasite load was lower in poor compared to good responders to antimonials, and was also reduced in recurrent lesions compared to primary ones. However, parasite load became higher with sequential relapses, pointing to an immune system inability to control the infection. Therefore the parasite burden does not seem to be a good predictor of disease progression.

Ziconotide intrathecal delivery as treatment for secondary therapeutic failure of motor cortex stimulation after 6 years

INTRODUCTION

Motor cortex stimulation is a well-known treatment modality for refractory neuropathic pain. Nevertheless, some cases of therapeutic failure have been described but alternative therapies for these cases are rarely reported.

CASE REPORT

The patient presented with neuropathic pain in his right arm due to a cervical syrinx which was surgically treated by a shunt in 2003 with no clinical improvement. As alternative therapy, after an evaluation by repetitive magnetic transcranial stimulation with significant benefit, motor cortex stimulation was successfully implanted in 2004. In 2010, a similar pain occurred in the same territory. Local mean pain visual analogical scale (VAS) increased to 82/100. A newer generation stimulation device was then implanted and, within a period of 8months, different stimulation parameter settings were tested, without any pain relief. An intrathecal drug delivery pump was then implanted in 2011, and the upper extremity catheter was located at the cervicothoracic junction. There was no postoperative complication. A bitherapy was initiated at a daily dosage of 0.2mg morphine and 1.3μg ziconotide, not modified since August 2013. At 43months follow-up, mean VAS was 21/100 with improvement of daily life and spare-time activities, anxiety and depression, quality of life (as measured by the SF-36 survey and EQ5D-3L questionnaire).

DISCUSSION

Refractory neuropathic pain treated by motor cortex stimulation may be considered in palliative situations, and secondary therapeutic failure offers only a few perspectives. Intrathecal ziconotide, indicated as a first-line drug in non-cancer pain, could be proposed in such cases.

CONCLUSION

Intrathecal drug delivery including ziconotide in refractory neuropathic pain represents a reasonable option with a good clinical tolerance.

The REFRACT-LYMA cohort study: a French observational prospective cohort study of patients with mantle cell lymphoma

BACKGROUND

Mantle Cell Lymphoma (MCL) is often associated with progression, temporary response to therapy and a high relapse rate over time resulting in a poor long-term prognosis. Because MCL is classified as an incurable disease, therapeutic resistance is of great interest. However, knowledge about the biological mechanisms underlying resistance associated with MCL therapies and about associated predictors remains poor. The REFRACT-LYMA Cohort, a multicenter prospective cohort of patients with MCL, is set up to address this limitation. We here describe the study background, design and methods used for this cohort.

METHODS/DESIGN

The REFRACT-LYMA Cohort Study aims at including all patients (>18 years old) who are diagnosed with MCL in any stage of the disease and treated in specialized oncology centers in three public hospitals in Northwestern France. Any such patient providing a signed informed consent is included. All subjects are followed up indefinitely, until refusal to participate in the study, emigration or death. The REFRACT-LYMA follow-up is continuous and collects data on socio-economic status, medical status, MCL therapies and associated events (resistance, side effects). Participants also complete standardized quality of life (QOL) questionnaires. In addition, participants are asked to donate blood samples that will support ex vivo analysis of expression and functional assays required to uncover predictive biomarkers and companion diagnostics. If diagnostic biopsies are performed during the course of the disease, extracted biological samples are kept in a dedicated biobank.

DISCUSSION

To our knowledge, the REFRACT-LYMA Cohort Study is the first prospective cohort of patients with MCL for whom "real-life" medical, epidemiological and QOL data is repeatedly collected together with biological samples during the course of the disease. The integrative cohort at mid-term will be unique at producing a large variety of data that can be used to conceive the most effective personalized therapy for MCL patients. Additionally, the REFRACT-LYMA Cohort puts the medical care of MCL patients in a health and pharmacoeconomic perspective.

Therapeutic failure of primaquine and need for new medicines in radical cure of Plasmodium vivax

Primaquine has been the drug of choice for the prevention of Plasmodium vivax relapse for more than 60 years. Primaquine tolerant strain of P. vivax was identified in 1944. Significant mortality and disease burden of P. vivax calls for the need of new drugs. Primaquine resistance is a complex issue, as the mechanism of resistance is not clear. Direct evidence of resistance to primaquine by hypnozoites has not yet been shown. There are some reports detailing risk of primaquine resistance in specific regions, but the overall distribution of primaquine resistance in P. vivax-infected people is largely unknown. Confounding factors contribute to treatment failures; such as inadequate doses, inappropriate dosing intervals, risk of reinfection, combinations with blood schizontocidals, and compliance. Therefore, primaquine resistance needs to be addressed along with additional important confounding factors. Tafenoquine is the most studied drug in replacing primaquine for the radical cure of P. vivax malaria. It has comparable efficacy with primaquine. The potential advantage of tafenoquine is better compliance with a single dose regimen. Rational use of primaquine can secure its effectiveness, but it is essential in the future to have better or similar alternatives to treat P. vivax.

Decreased antimony uptake and overexpression of genes of thiol metabolism are associated with drug resistance in a canine isolate of Leishmania infantum

Visceral leishmaniasis (VL) caused by the protozoan parasite Leishmania infantum, is one of the most important zoonotic diseases affecting dogs and humans in the Mediterranean area. The presence of infected dogs as the main reservoir host of L. infantum is regarded as the most significant risk for potential human infection. We have studied the susceptibility profile to antimony and other anti-leishmania drugs (amphotericin B, miltefosine, paromomycin) in Leishmania infantum isolates extracted from a dog before and after two therapeutic interventions with meglumine antimoniate (subcutaneous Glucantime^®, 100 mg/kg/day for 28 days). After the therapeutic intervention, these parasites were significantly less susceptible to antimony than pretreatment isolate, presenting a resistance index of 6-fold to Sb^III for promastigotes and >3-fold to Sb^III and 3-fold to Sb^V for intracellular amastigotes. The susceptibility profile of this resistant L. infantum line is related to a decreased antimony uptake due to lower aquaglyceroporin-1 expression levels. Additionally, other mechanisms including an increase in thiols and overexpression of enzymes involved in thiol metabolism, such as ornithine decarboxylase, trypanothione reductase, mitochondrial tryparedoxin and mitochondrial tryparedoxin peroxidase, could contribute to the resistance as antimony detoxification mechanisms. A major contribution of this study in a canine L. infantum isolate is to find an antimony-resistant mechanism similar to that previously described in other human clinical isolates.

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Antimony resistance in a Leishmania infantum line from a dog is reported.

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Resistance due to decrease antimony uptake by lower aquaglyceroporin-1 expression.

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An increase in thiols metabolism contribute to antimony resistance.

[Therapeutic failure in scabies: An observational study]

BACKGROUND

Several sources suggest an escalation of scabies in France.

AIM

To describe a population of patients continuing to present with scabies despite multiple treatments in order to identify factors associated with persistence of infection.

PATIENTS AND METHODS

A descriptive cross-sectional study in adults and children consulting for persistent scabies despite at least one previous treatment. A standardized questionnaire explored potential sources of treatment failure.

RESULTS

Thirty-one patients were analyzed. Initial symptoms were noted to have started between two and 52 weeks earlier (mean: 19 weeks). The mean number of prior consultations with a general practitioner was 3.1 (0-10) and 1.7 with a dermatologist (0-7). The mean number of patients per household was 3.5 (1-9). At least one dose of oral ivermectin (maximum of 6 doses per household) was prescribed for 84 % of patients (29 % of whom were not fasted at the time). Further, 74 % of patients received at least one local application of esdepallethrin and piperonyl butoxide (maximum: 5 courses), four received benzyl benzoate and two received permethrin; however, 58 % did not reapply the substance after hand washing. All households bought the prescribed treatments despite the costs. Close contacts of patients were treated in 58 % of households. Decontamination of bedding and clothing was carried out properly in 90 % of households.

DISCUSSION

Persistence of infection appears to be linked to: (1) insufficient treatment of close contacts; (2) absence of a second treatment between days 7 and 14; (3) insufficient efficacy of the available treatments, doubtless due to multiple factors (intrinsic resistance of Sarcoptes, failure to repeat treatment, poor explanation of methods for dosing and application, and oral intake of treatments). Access to non-reimbursed treatments was not identified as a problem and decontamination of bedding and clothing was correctly performed in most cases.

CONCLUSION

Though certain fundamental aspects of scabies treatment must be better known, longer consultations and provision of efficacious treatments are also a priority.

Correlation of Consecutive Serum Thyroglobulin Levels During Hormone Withdrawal and Failure of Initial Radioiodine Ablation in Thyroid Cancer Patients

OBJECTIVE

The aim of this study was to evaluate the value of thyroglobulin (Tg) kinetics during preparation of radioiodine ablation for prediction of initial radioiodine ablation failure in thyroid cancer patients.

METHODS

Thyroid cancer patients after total thyroidectomy who underwent radioiodine ablation with 3-4 weeks of hormone withdrawal between May 2011 and January 2012 were included. Consecutive serum Tg levels 5-10 days before ablation (Tg1) and on the day of ablation (Tg2) were obtained. The difference between Tg1 and Tg2 (ΔTg), daily change rate of Tg (ΔTg/day) and Tg doubling time (Tg-DT) were calculated. Success of initial ablation was determined by the results of the follow-up ultrasonography, diagnostic radioiodine scan and stimulated Tg level after 6 to 20 months.

RESULTS

A total of 143 patients were included. Failed ablation was reported in 52 patients. Tg2 higher than 5.6 ng/ml and Tg-DT shorter than 4.2 days were significantly related to a high risk of ablation failure. ΔTg and ΔTg/day did not show significant correlation with ablation failure.

CONCLUSIONS

Thyroglobulin kinetics on consecutive blood sampling during hormone withdrawal may be helpful in predicting patients with higher risk of treatment failure of initial radioiodine ablation therapy in thyroid cancer patients.

Hookworm infection among patients with pulmonary tuberculosis: Impact of co-infection on the therapeutic failure of pulmonary tuberculosis

OBJECTIVE/BACKGROUND

The aim of this study is to determine the rate of hookworm infection among patients with pulmonary tuberculosis (TB) and to find out if there is a relation between hookworm infection and the therapeutic failure of pulmonary TB.

METHODS

We carried out a prospective, hospital-based study. The study included 231 naïve patients with pulmonary TB, consecutively. Patients were evaluated at the 4th month of therapy for persistence of Mycobacterium tuberculosis infection. All patients had clinical evaluation, laboratory investigations (including sputum culture and stool microscopic examination), and imaging studies (abdominal ultrasonography and chest radiography).

RESULTS

The study population mean age was 42.7±13.9 years old with 26.8% of them 40 years old or more. Out of 231 patients, 133 (57.6%) were men. Therapeutic failure rate of pulmonary TB was 29.4%. Hookworm infection was diagnosed among 16.5% of patients and 27.7% had diabetes mellitus (DM). Using multivariate analysis, it was found that age of 40 years or more (odds ratio [OR] 8.4; 95% confidence interval [CI] 1.7-41.3; p=.009), hookworm infection (OR 7.6; 95% CI 1.2-49.9; p=.034), and DM (OR 5.9; 1.2-28; p=.027) were independently associated with therapeutic failure of pulmonary TB among the study population with pulmonary TB.

CONCLUSION

In conclusion, the rate of therapeutic failure of pulmonary TB is high. Besides older age and DM, hookworm infection can reduce the therapeutic response of pulmonary TB. Screening for and control of DM and hookworm infection among patients with pulmonary TB may improve their therapeutic response.

Confronting Therapeutic Failure: A Conversation Guide

We reflect on the impact of bad news on both clinician and patient in the setting of cancer treatment failure. We review the classic six-step SPIKES (setting, perception, invitation for information, knowledge, empathy, summarize and strategize) protocol for giving bad news that has been widely adopted since it was first published in this journal in 2005. The goal of such a conversation guide is to describe both the process and the tasks that constitute vital steps for clinicians and to comment on the emotional impact of the conversation on the clinician. Confronting therapeutic failure is the hardest task for oncologists. We offer practical tips derived from a thorough review of the evidence and our clinical experience.

Factors associated with the failure of arthroscopic surgery treatment in patients with femoroacetabular impingement: A cohort study

OBJECTIVE

The aim of this study was to evaluate the association of the anatomical and functional characteristics with therapeutic failure in patients with femoroacetabular impingement, who underwent hip arthroscopy.

MATERIALS AND METHODS

A cohort study was performed on 179 patients with femoroacetabular impingement who underwent hip arthroscopy between 2004 and 2012. The demographic, anatomical, functional, and clinical information were recorded. A logistic regression model and ANCOVA were used in order to compare the described characteristics with the treatment outcomes of the hip arthroscopy.

RESULTS

The median time of follow-up for symptoms was 13 months (8-30), and the mean time of follow-up after surgery was 23.83 ± 9.8 months. At the end of the follow-up 3.91% of the patients were considered as a therapeutic failure. The WOMAC score in pain and functional branches, as well as the total WOMAC score, showed significant differences (P<.05). The mean WOMAC score was higher (0 to 100 with 0 being a perfect score) in the group of patients who failed after surgery as compared with the group who meet the requirements for a successful treatment, 65.9 vs 48.8, respectively (mean difference 17.0; 95% CI; 1.3-32.6; P=.033).

CONCLUSION

The poor functional state prior to arthroscopic treatment of femoroacetabular impingement, mainly due to preoperative pain, assessed using the WOMAC scale, is associated with a higher therapeutic failure rate.

Stimulated Serum Thyroglobulin Level at the Time of First Dose of Radioactive Iodine Therapy Is the Most Predictive Factor for Therapeutic Failure in Patients With Papillary Thyroid Carcinoma

PURPOSE

To investigate the clinical importance of serum thyroglobulin (Tg) levels just before high-dose I-131 ablation therapy (preablation Tg) for predicting therapeutic failure in patients with papillary thyroid carcinoma (PTC).

METHODS

Patients with PTC (n = 132) undergoing total thyroidectomy followed by the first high-dose I-131 ablation therapy (HI-Rx) were included in this retrospective review. Just before HI-Rx, preablation Tg, anti-Tg antibody, and TSH were measured. The patients were followed up for a mean period of 7 months (range 6-23 months) by I-123 whole-body scans (f/u IWBS) and stimulated Tg (f/u Tg). Therapeutic failure was defined by positive f/u IWBS or f/u Tg >2 ng/ml. We classified patients into three groups according to the value of preablation Tg (group 1, <1 ng/ml; group 2, ≥1 and <10 ng/ml; group 3, ≥10 ng/ml) and compared clinical variables to therapeutic response.

RESULTS

Therapeutic failure was noted in 39 patients (29.5 %). On univariate analysis, T stage, tumor size, and preablation Tg were the statistically significant factors that could predict therapeutic failure. After multivariate analysis, preablation Tg was the only independent predictor of therapeutic failure (P < 0.001). The therapeutic failure rate was significantly increased as the preablation Tg level increased (11.3 %, 33.3 %, and 87.5 % in groups 1, 2, and 3, respectively; P < 0.001). Individuals with preablation Tg levels ≥10 ng/ml had 25.5 times greater chance of therapeutic failure than those with levels <10 ng/ml (95 % CI = 5.43-119.60; P < 0.001).

CONCLUSIONS

A high preablation Tg level is the most significant predictor of therapeutic failure at the time of first HI-Rx in patients with PTC.

SOD1 plasma level as a biomarker for therapeutic failure in cutaneous leishmaniasis

We show that increased plasma superoxide dismutase 1 (SOD1) levels are statistically significant predictors of the failure of pentavalent antimony treatment for cutaneous leishmaniasis caused by Leishmania braziliensis. In Leishmania amazonensis-infected patients, host SOD1 levels can be used to discriminate between localized and drug-resistant diffuse cutaneous leishmaniasis. Using in situ transcriptomics (nCounter), we demonstrate a significant positive correlation between host SOD1 and interferon α/β messenger RNA (mRNA) levels, as well as interkingdom correlation between host SOD1 and parasite SOD2/4 mRNA levels. In human macrophages, in vitro treatment with SOD1 increases the parasite burden and induces a diffuse cutaneous leishmaniasis-like morphology. Thus, SOD1 is a clinically relevant biomarker and a therapeutic target in both localized and diffuse cutaneous leishmaniasis.

Bacteriological and resistance profile in isolates from diabetic patients

BACKGROUND

Diabetes mellitus has become a global epidemic illness and poses a threat for development of resistant bacterial infections.

AIM

This study was aimed to know the bacteriological and resistance profile of isolates obtained from diabetic patients.

MATERIALS AND METHODS

The bacterial isolates obtained from various samples of diabetic patients admitted in medicine department in 6-month period were identified and tested for antibiotic susceptibility. The extended spectrum beta-lactamases (ESβL), AmpC, and metallo-beta-lactamases (MβL) enzymes were detected in gram-negative bacilli. Methicillin, macrolide-lincosamide-streptogramin (MLS), and linezolid resistance in Staphylococcus spp. were detected. High-level aminoglycoside resistance (HLAR) in Enterococcus spp. was also tested.

RESULTS

In all, 38 of 125 diabetic patients (30.4%) had bacterial infection, 18 patients had wound infections, 18 had urinary tract infections (UTIs), and 2 had respiratory tract infections. Escherichia coli among gram-negative bacteria and Staphylococcus aureus among gram-positive bacteria were the predominant pathogens. 32.5% gram-negative bacilli were AmpC producers, 37.5% were MβL producers, and 40% were ESβL producers. Methicillin and MLS resistance was found in 50% and 33.3% isolates of Staphylococcus spp., respectively. HLAR resistance was alarming in Enterococcus spp. Polymyxin among gram-negative bacteria and vancomycin for gram-positive bacteria were the last resort with highest susceptibility rates to treat infections among diabetic patients.

CONCLUSION

Resistant bacterial infections in diabetic patients are common. The presence of various resistance mechanisms in isolates of our study shows that therapeutic failure can occur if empirical prescription is unsubstantiated.

Evaluation of the current trend of nalidixic acid susceptibility in typhoidal Salmonellae; a marker of therapeutic failure for the fluoroquinolones

BACKGROUND AND OBJECTIVES

Typhoid is a major health problem faced by the developing countries like Pakistan. More than 20 million cases are reported annually worldwide. Currently fluoroquinolones are the drugs of choice to treat typhoid fever. In vivo resistance to fluoroquinolones leading to therapeutic failure is developing rapidly and is becoming a major concern for the clinicians. The objective of this study was to determine the sensitivity pattern of Nalidixic acid over the last four years

MATERIAL AND METHODS

A descriptive cross sectional study was carried out at the Microbiology Department of the Army Medical College, National University of Sciences and Technology, Rawalpindi from January 2006 to December 2009. All the isolates were dealt with standard microbiological procedures. The antimicrobial sensitivity of Nalidixic acid and Ciprofloxacin was determined using Kirby-Bauer disc diffusion method as per the guidelines of Clinical and Laboratory Standard Institute (CLSI).

RESULTS

Out of 240 isolates, 111 were Salmonella typhi and 129 were Salmonella paratyphi A. The resistance of the typhoidal Salmonella to Nalidixic acid has reached significant levels and it seems only a matter of time when hundred percent resistance will be encountered. All isolates were sensitive to Ciprofloxacin on disc diffusion method.

CONCLUSION

Resistance to Nalidixic acid predicting therapeutic failure with fluoroquinolones is on a steady rise.

Pain management: Establishing a role for implantable technologies

Pain due to terminal illness such as AIDS and cancer-related pain should be managed according to the guidelines set forth by the World Health Organization. These guidelines suggest a pharmacologic tailoring approach to the level and intensity of the patient's pain. These guidelines obey the KISS principal (keep it simple) suggesting the use of less potent analgesic agents before utilizing more potent agents. Likewise, the treatment of non-malignant pain should be based on the same KISS principal utilizing least costly and least invasive therapies either in series or in parallel until the patient's pain is well managed. Interventional strategies and certainly implantable technologies for pain control have a place as 'tools' for the management of cancer, AIDS, and non-malignant-related pain syndromes. Since these therapies are costly and invasive, they should be used only after the failure of more conservative, less invasive and less costly therapies. This paper outlines a rational place for the use of implantable modalities for the treatment of cancer, AIDS and non-malignant pain.