PubMed Health⌕ Search

Biomedical subjects

J A Caminero

Publications and source records attributed to J A Caminero.

At least 19 recordsLinked to original sources
PubMed2006

[Controversies in the treatment of extrapulmonary tuberculosis].

Tuberculosis (TB) can spread to any tissue or organ of the body by way of hematogenous or lymphatic dissemination or contiguity. However, pulmonary TB is the most common presentation and the only form of the disease of epidemiologic importance. Consequently, the literature on the various forms of extrapulmonary TB (EPTB) is scant, and most of the published authors are specialists in specific extrapulmonary forms. As a result, in most of the major areas of study of EPTB, recommendations similar to those for pulmonary TB or others based on little or no evidence have been accepted. This lack of evidence is of particular concern in the case of treatment guidelines. The present article reviews important work that has given rise to current treatment guidelines. While most of these guidelines reveal the lack of evidence available on this subject, it can, nevertheless, be concluded that a 6-month treatment regimen similar to that used in patients with pulmonary TB may be sufficient to treat all forms of EPTB, including meningeal disease. The role of steroids and surgery in the treatment of TB affecting different sites is also discussed. Other topics dealt with are the considerations that should be taken into account and the treatment modifications necessary in patients infected with the human immunodeficiency virus.

Humans↗
PubMed2006

Treatment of multidrug-resistant tuberculosis: evidence and controversies.

In the last decade, multidrug-resistant tuberculosis (MDR-TB, defined as resistance to at least isoniazid and rifampicin) has become an epidemiological issue of first priority at the global level. Case management needs to be simplified and standardised, as in many countries MDR-TB cases cannot receive individualised attention from specialist physicians. However, before any decision can be made on standardisation, a careful analysis must first be made of the evidence and controversies behind the various published recommendations. Unfortunately, the controversies outweigh the evidence. The difficulties lie not only in the absence of controlled trials to validate specific recommendations, but also in the very different and even contradictory results found in the literature. It is therefore essential to analyse these discrepancies before developing rational, uniform recommendations. The analysis should encompass the most essential and controversial issues regarding the management of MDR-TB patients: 1) confirmation of diagnosis in a suspected MDR-TB patient, and determination of the value of drug susceptibility testing; 2) the number of anti-tuberculosis drugs required to treat MDR-TB; 3) the most rational use of effective drugs against tuberculosis; 4) the advisable length of parenteral drug administration or of the initial phase of treatment; 5) the contribution of surgery to the management of MDR-TB patients; and 6) the optimal regimen for treating MDR-TB: standardised vs. individualised regimens. The evidence and controversies regarding each of the above questions are analysed with the aim of facilitating decision making in the treatment of these complex patients.

Antibiotics, Antitubercular↗
PubMed2005

Management of multidrug-resistant tuberculosis and patients in retreatment.

Retreatment of tuberculosis involves the management of entities as diverse as relapse, failure, treatment after default, and poor patient adherence to the previous treatment. The emergence of conditions for selection of resistance (failure and partial abandonment) is a matter of great concern. The development of a retreatment regimen for tuberculosis requires consideration of certain basic premises. The importance of a comprehensive and directed history of drugs taken in the past, and the limited reliability of susceptibility tests to many of these drugs, should be kept in mind. Taking this into account, and possessing a thorough knowledge of all anti-tuberculosis medications, it is possible to cure almost all patients with an appropriate retreatment regimen including a minimum of three or four drugs not previously used. Nonetheless, the treatment of these patients is so complex that it should only be carried out by experienced staff. Concern about treating tuberculosis patients with drug resistance varies greatly depending on the available resources. High-income countries should provide individual treatment regimens adapted to each patient; however, in other settings, restricted resources could justify the implementation of standardised therapeutic guidelines with second-line drugs in order to facilitate management and reduce costs.

Antibiotics, Antitubercular↗
PubMed2005

Results of a national study on anti-mycobacterial drug resistance in El Salvador.

SETTING: The DOTS strategy was introduced in El Salvador in 1997 and had become fully implemented countrywide by 2001. Previously, many deficiencies were identified in the management of patients with tuberculosis (TB). OBJECTIVE: To ascertain the prevalence of Mycobacterium tuberculosis resistant to first-line drugs. DESIGN: A national prospective survey was carried out in 2001 using the standardised World Health Organization/ International Union Against Tuberculosis and Lung Disease model. RESULTS: A total of 711 cultures were analysed (59% of total smear-positive cases); 611 were never treated and 100 were previously treated patients. The study showed resistance rates to isoniazid and rifampicin, either alone or combined (multidrug resistance, MDR), of 1.3%, 1.1% and 0.3%, respectively, in never treated patients, and 12%, 13% and 7%, respectively, in previously treated patients. CONCLUSION: The low rates of MDR-TB in El Salvador are puzzling, as out-patient DOTS was introduced only recently and fixed-dose combination tablets have not been used.

Age Distribution↗
PubMed2005

A 6-month regimen for EPTB with intermittent treatment in the continuation phase: a study of 679 cases.

BACKGROUND: No large studies have demonstrated the effectiveness of a 6-month regimen for all forms of extra-pulmonary tuberculosis (EPTB). METHODS: Retrospective, observational analysis to evaluate the effectiveness of a 6-month treatment regimen (2HRZE/4H3R3) for all patients diagnosed with EPTB in Caracas, Venezuela, from 1 January 1998 to 31 December 2000, using direct observation. RESULTS: Of 679 patients enrolled, 101 (14.9%) had AIDS. In 83.2% the diagnosis was based on microbiological, histological or genetic amplification information. Of 612 (90.1%) patients who took more than 90% of the doses, treatment had to be altered in six (1%) due to drug side effects. Of the remaining 606 patients who took more than 90% of the doses, 603 (99.5%) were cured and three failed. In the follow-up conducted 2 years after the end of treatment, only 6 relapsed (1%). Cures without relapse were achieved in 24 cases of central nervous system involvement, 27 cases of osteoarticular involvement and in the 42 who had miliary and/or disseminated TB. CONCLUSION: A 6-month treatment regimen for all forms of EPTB, with treatment three times a week during the continuation phase, was highly effective.

Adolescent↗
PubMed2004

Current status of treatment completion and fatality among tuberculosis patients in Spain.

OBJECTIVES: To determine treatment completion among patients with tuberculosis (TB), and to analyse factors associated with treatment default and fatality. METHODS: A prospective cohort study of patients who began treatment between 1 June 1999 and 31 May 2000 in areas where members of the SEPAR Tuberculosis and Respiratory Infections Group work. Factors associated with treatment default and fatality were studied using logistic regression, calculating odds ratios (OR) and their 95% confidence intervals (95%CI). RESULTS: The study involved 142 physicians from 76 different hospitals who provided information on 1515 cases. Eighty-two per cent of the patients completed treatment correctly, 14% defaulted, 5% died, 0.5% failed, and 8.7% interrupted treatment due to transfer or other reasons. The variables associated with default were intravenous drug use (IVDU) (OR 6.00, 95%CI 2.59-13.89) and immigration (OR 8.57, 95%CI 3.78-19.45); sex, age, homelessness, incarceration, directly observed treatment (DOT) or hospitalisation were not associated with default. Variables found to be predictive of fatality were alcoholism (OR 6.38, 95%CI 2.09-19.48), human immunodeficiency virus (HIV) infection (OR 7.08, 95%CI 2.08-29.15) and age >64 years (OR 10, 95%CI 2.9-34.07), whereas sex, IVDU, homelessness, DOT and hospitalisation were not. CONCLUSIONS: In industrialised countries, IVDU patients and immigrants should be targeted for DOT, while to reduce fatality rates stricter monitoring is required for patients who are alcoholic, HIV-infected, or aged >64 years.

Adolescent↗
PubMed2004

Impact of a model training course for private and public specialist physicians in El Salvador.

BACKGROUND: Private and non-private specialist practitioners are often considered an obstacle to the performance of the National Tuberculosis Control Programme (NTP). OBJECTIVE: To evaluate the impact of an intensive refresher course directed at specialist physicians in El Salvador, a questionnaire was sent to all course participants on their basic knowledge of tuberculosis (TB) control. RESULTS: Of 64 participants, 55 were assessed (86%); 33 were chest physicians and 22 belonged to other related specialities. The evaluation showed a considerable improvement in both groups in their ability to suspect the disease, in their tendency to avoid hospitalising patients and instead refer them to out-patient clinics, and in their adherence to the recommendations of the NTP manual (diagnostic procedures, treatment guidelines, case notification and cohort studies). Improvements were more noticeable, in all the parameters evaluated, among the non-chest physicians. CONCLUSION: The intervention model succeeded in improving the collaboration of private and non-private specialist practitioners with the NTP.

Education, Medical↗
PubMed2003

Epidemiology of tuberculosis on Gran Canaria: a 4 year population study using traditional and molecular approaches.

BACKGROUND: In recent years several population based studies using restriction fragment length polymorphism (RFLP) analysis have shown a higher rate of recent transmission of tuberculosis than previously thought. This study was undertaken to determine the transmission patterns of tuberculosis and the potential causes of recent transmission on the island of Gran Canaria (Spain). METHODS: The strains of all patients diagnosed with tuberculosis confirmed by culture between 1 January 1993 and 31 December 1996 were typed by RFLP using the insertion sequence IS6110. A cluster was defined as two or more isolates with an identical RFLP pattern. Epidemiological linkage through contact tracing was investigated. RESULTS: Of the total of 719 patients, 153 (21.3%) were excluded because there was inadequate bacterial DNA for genotyping (n=129) or the isolates of Mycobacterium tuberculosis had less than five copies of IS6110 (n=24). The isolates from 409 patients (72.3%) were grouped into 78 different clusters with an estimated 58.5% of the cases being due to recent transmission. Young age was the only significant predictor of clustering. Only in 147 (35.9%) of the 409 patients belonging to a cluster could an epidemiological link be found. 111 patients (19.6%) were identified as having had previous contact with a tuberculosis patient and 81 of them (72.9%) belonged to a cluster. The three largest clusters included 75, 49 and 20 patients, respectively. CONCLUSION: Recent transmission is frequent among patients with tuberculosis on Gran Canaria and could be associated with certain aspects of control measures. Some of the clusters described in the study could be due to the prevalence of particular strains of M tuberculosis on the island.

Adult↗
PubMed2003

Evaluation of tuberculosis trends in Spain, 1991-1999.

SETTING: There are no reliable official data available on tuberculosis (TB) in Spain. OBJECTIVE: To ascertain the epidemiological trends of TB in Spain from 1991-1999. METHODS: In an annual survey conducted by the Tuberculosis and Respiratory Infections (TRI) Working Group of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), data on tuberculosis disease and infection were solicited from two information sources: 1) the public health services of the 17 Autonomous Regions (AR), and 2) 60 TRI members in different parts of Spain. RESULTS: TB incidence declined from 36.4/100,000 in 1991 to 26.7 in 1999 according to the AR (average annual decline 3.3%), and from 45.6 to 26.8 according to TRI members (annual decline 5.1%). A similar observation was made for smear-positive cases (AR annual decline: 3.0%; TRI: 5.6%). Tuberculosis infection at 6 years of age also decreased according to both information sources (AR: 0.87% in 1991 to 0.5% in 1998, annual decline 6%, and TRI members: 1.00% in 1991 and 0.9% in 1997, annual decline 4.2%). CONCLUSIONS: The observed rates of TB are higher than stated in official figures. In spite of the decreasing trend, observed declines are small and the current rates continue to be among the highest among industrialised countries.

Adolescent↗
PubMed2003

Is the DOTS strategy sufficient to achieve tuberculosis control in low- and middle-income countries? 1. Need for interventions in universities and medical schools.

Now that progress is gradually being made in the implementation of the DOTS strategy in low-income countries, we must take into account the fact that nearly 30% of all tuberculosis (TB) cases worldwide occur in middle-income countries, which usually have an adequate health infrastructure and sufficient economic resources for TB control. These countries nevertheless have other limitations that make it necessary to develop other aspects in addition to the DOTS strategy. These can be summarised in three main themes: 1) adequate coordination of all health structures involved in TB management, ensuring that they follow the basic norms of the National Tuberculosis Programme (NTP), 2) direct intervention in universities and medical schools, which are ubiquitous in such countries, and 3) specific collaboration with specialists and physicians in private practice, an important obstacle to the success of NTPs in several countries. A detailed analysis is presented of strategies that need to be implemented in different countries depending on their economic resources and their TB situation. The need to carry out specific interventions in addition to training in DOTS in universities and medical schools in order to improve TB control is discussed. A specific project in this area developed by the IUATLD in Latin America is described.

Directly Observed Therapy↗
PubMed2003

Is the DOTS strategy sufficient to achieve tuberculosis control in low- and middle-income countries? 2. Need for interventions among private physicians, medical specialists and scientific societies.

In the first of these two articles it was expressed how, in practically all middle-income and many low-income countries, it is necessary to implement interventions in addition to the DOTS strategy if adequate tuberculosis control is to be achieved. We need to act in two directions: 1) in universities and medical schools, as explained in the first article, and 2) specifically among private physicians and medical specialists, an important obstacle for many National Tuberculosis Programmes (NTPs). These professionals, especially medical specialists (many of whom also work in private practice), are an influential sector that is held in high regard, but which tends not to follow guidelines considered as excessively simplistic or rigid, such as those stipulated by the NTP. Private physicians have practically no access to information or training programmes, which accounts for the surprising disparity in their clinical criteria. All this leads to important distortions that can compromise the NTP's outcome. The present article evaluates the need to intervene among private physicians and medical specialists in order to achieve better tuberculosis control. Special strategies are described to obtain concrete, specific agreements for their participation in the NTP, and for the implementation of specific training programmes for this group. At the end of the article the work performed by the IUATLD in these groups in Latin America is described.

Developing Countries↗
PubMed2001

Epidemiological evidence of the spread of a Mycobacterium tuberculosis strain of the Beijing genotype on Gran Canaria Island.

Molecular epidemiological studies suggest that particular Mycobacterium tuberculosis strains have an enhanced capacity to spread within a community. One strain, the Beijing genotype, has been associated with outbreaks in a number of communities throughout the world. IS6110 restriction fragment length polymorphism (RFLP) analysis was performed on M. tuberculosis isolates from 566 of the 721 patients (78.5%) diagnosed with tuberculosis (TB) on Gran Canaria Island from 1993 to 1996, as well as 35% of isolates from 1991-1992 (85 strains). RFLP identification of the family of strains of the Beijing genotype was confirmed by spoligotyping. Medical records of all patients were reviewed and epidemiological links were identified. Of 566 M. tuberculosis isolates from 1993 to 1996 with RFLP available, 72% belonged to clusters. The largest contained 75 cases and was caused by a strain of the Beijing genotype that was introduced to the island in 1993. It was found in 10 patients in 1993 (5.5%), 12 in 1994 (8.1%), 18 in 1995 (16.4%), and 35 in 1996 (27.1%). Epidemiological linkage was confirmed for 68% of cases. This study has demonstrated rapid dissemination of this strain of the Beijing genotype. This genotype might play an important role in the future of the worldwide tuberculosis epidemic.

Adolescent↗
PubMed2001

Exogenous reinfection with tuberculosis on a European island with a moderate incidence of disease.

The frequency and determinants of exogenous reinfection and of endogenous reactivation of tuberculosis in patients previously treated are poorly understood. In Gran Canaria Island, Spain, between 1991 and 1996, 962 tuberculosis cases were confirmed by culture. Drug susceptibility testing was performed on available bacterial isolates and IS6110-based RFLP genotyping was carried out. Twenty-three patients (2.4%) had two positive cultures separated by at least 12 mo, 18 of whom had bacterial DNA available for genotypic analysis. The initial and final isolates from eight (44%) were different genotypes, indicating exogenous reinfection. Six of them were retreated after cure and two retreated after default. Six were HIV seronegative and two were HIV seropositive. Endogenous reactivation was seen in the remaining 10 patients of whom eight were retreated after default and two after cure. Three of the eight (38%) being retreated after default developed multidrug resistance. One genotype was responsible for a second episode of tuberculosis in five cases, three exogenous reinfections and two endogenous reactivations. In the context of a moderate incidence of tuberculosis, exogenous reinfection is an important cause of TB recurrence, even in HIV-seronegative patients.

Adult↗
PubMed2000

Towards elimination of tuberculosis in a low income country: the experience of Cuba, 1962-97.

BACKGROUND: This study describes the epidemiological trends of tuberculosis in Cuba and the performance of the tuberculosis control programme. The circumstances that caused an increase in the incidence of new cases of tuberculosis between 1991 and 1994 had been analysed and were corrected in 1995-7. METHODS: A descriptive study of the incidence rates of new cases of tuberculosis notified from 1962 to 1997 was made, with special emphasis on the total change between 1965 and 1991 and the increase thereafter. RESULTS: The case notification rate of 14.7 per 100 000 in 1994 was almost three times the rate found in 1991 (4.8 per 100 000) and reversed the mean annual decrease of 5% observed since 1965. This increase was almost twofold in the rate of smear positive new cases (4.4 per 100 000 in 1991 and 8.3 in 1994). From 1971 onwards the programme had achieved a cure rate of 90% throughout the country with only 2% absconding by applying directly observed treatment. The main factors associated with the increasing trends were: (1) a probable underdetection of cases for the 1988-92 period that generated contagious sources in the community; (2) improved case finding from 1993 onwards and the introduction of an expanded case definition in 1994; (3) a considerable increase in the diagnostic delay from initial medical consultation to beginning of antituberculosis treatment (56.9 days in 1993); and (4) operational changes in the tuberculosis control programme due to the economic crisis in Cuba. In 1995, 1996 and 1997 it has been possible to reverse this trend, achieving rates of 14.1, 13.5, and 12.2 per 100 000, respectively (7. 6, 7.6, and 6.9 for smear positive cases) as a result of effective intervention correcting the problems identified. Reducing the diagnostic delay attributable to shortcomings in the health care system and the study of contacts were of particular importance for re-establishing the tuberculosis programme as a priority. CONCLUSIONS: Cuba represents a good example of how it is possible to fight against tuberculosis effectively, even in a low income country, by applying control strategies advocated by the World Health Organisation and the International Union Against Tuberculosis and Lung Disease and by giving adequate support to the programme through political commitment.

Cuba↗
PubMed1996

Evaluation of a directly observed six months fully intermittent treatment regimen for tuberculosis in patients suspected of poor compliance.

BACKGROUND: Although a priority for tuberculosis control is to achieve the maximum cure rate, compliance with chemotherapy in specific high risk groups (homeless, intravenous drug abusers, chronic alcoholics) is usually poor. METHODS: From January 1990 to December 1994 102 patients with tuberculosis (96 pulmonary, six extrapulmonary) who were poorly compliant with treatment were treated with a six month fully intermittent (twice weekly) directly observed regimen. They comprised 71 homeless subjects, 50 chronic alcoholics, 23 intravenous drug abusers, nine infected with HIV, and 11 who had previously abandoned a daily antituberculosis regimen; 53 had more than one of these risk factors. Treatment included isoniazid and rifampicin for six months and pyrazinamide during the first two months. Patients who failed to take their medication on two consecutive occasions were actively sought by telephone or by personal search. RESULTS: After two months of treatment 95 of the 102 patients had taken their medication regularly and 90 of them had negative cultures. Four of the remaining patients had negative cultures after three months. At the end of the six months 87 patients had completed treatment and were considered cured. Only 15 patients abandoned the treatment (13 of whom had more than one risk factor). Only three relapses occurred in the 102 patients at one year follow up and in the 88 patients followed for two years. Two patients required a change of treatment due to major side effects. Although intravenous drug abuse was the only predictor of non-compliance in the multivariate analysis, if the available variables in the second month of treatment were analysed, current poor compliance and abandonment of treatment in the past were found to be significantly associated with non-compliance. CONCLUSIONS: This study shows the efficacy of this intermittent regimen and the effectiveness of a directly observed treatment programme.

Adolescent↗
PubMed1995

Surgical treatment of childhood mediastinal tuberculous lymphadenitis.

Between 1985 and 1991, we treated 6 children, aged 2 months to 3 years, who required an invasive procedure for the management of complications caused by enlarged mediastinal lymph nodes secondary to tuberculosis. Radiologic and endoscopic studies revealed bronchial involvement by lymph nodes, with endobronchial granulomas and lobar or pulmonary obstruction in 4 patients and marked tracheal and esophageal stenosis produced by extrinsic compression in the remaining 2. Pathologic study of the lymph node or bronchial samples from the 6 patients disclosed granulomas with caseous necrosis and Langhans' giant cells. All the children were treated with a standard 6-month drug regimen consisting of isoniazid, rifampicin, and pyrazinamide. Five of the patients underwent thoracotomy for the purpose of nodal curettage or excision. In 1, upper right lobectomy and bronchoplasty were necessary. The sixth patient was treated by endoscopic resection of the granulomas. There was no postoperative morbidity, and radiologic and endoscopic evidence of resolution of the lesions was observed in all the patients. In our experience, surgical treatment, when performed as a coadjuvant treatment for tracheobronchial complications stemming from mediastinal tuberculous lymphadenitis, results in the resolution of the lesions and has no related morbidity.

Bronchoscopy↗
PubMed1995

The epidemiology of tuberculosis in Gran Canaria, Canary Islands, 1988-92: effectiveness of control measures.

SETTING: Since there is no national programme for tuberculosis control in Spain and the epidemiological situation in this country is unknown, a programme against tuberculosis in Gran Canaria (Canary Islands) was started in 1987. OBJECTIVE: To analyze the impact of this control programme, particularly the trend of new cases of tuberculosis by age groups and risk factors for 1988-92. DESIGN: A detailed search of all new cases of tuberculosis was carried out by examining the files of all public and private hospitals and outpatient clinics of the island, the records of the Services of Clinical Microbiology and Pathology of the public hospitals, and the registers of patients with AIDS. RESULTS: The annual rates of new cases of tuberculosis per 100,000 were 32.2 in 1988 (214 cases), 26.2 in 1990 (174 cases), and 29.4 in 1992 (196 cases), and the rates of sputum-positive cases 13.3 (89 cases), 12 (80 cases) and 15 (100 cases), respectively. The distribution of tuberculosis cases by age peaked in the age groups 40-49 and 30-39 years. Between 1988 and 1992, statistically significant differences were found in the percentage of cured patients (21% [45/214] vs 85.7% [168/196]), patients with a delay in diagnosis > 3 months (40.2% [86/214] vs 21.9% [43/196]), and contacts evaluated (45.3% [97/214] vs 90.3% [177/196]). However, an upward trend in the incidence of tuberculosis for 1990-92 was found in association with an increase of new cases among the homeless, immigrants, and HIV-infected people. When these three population groups were excluded from the analysis, the annual rate for the total population showed a progressive decline from 1988-92. CONCLUSIONS: The data studied here show that successful priority control measures (cure rate, early diagnosis, study of contacts) have been achieved in this island. It is necessary, however, to develop strategies for combating the tuberculosis problem in specific high risk populations.

Adolescent↗