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Experimental Treatment with Favipiravir for Ebola Virus Disease (the…

September 01, 2016

Ebola virus disease (EVD) is a highly lethal condition for which no specific treatment has proven efficacy. In September 2014, while the Ebola outbreak was at its peak, the World Health Organization released a short list of drugs suitable for EVD research. Favipiravir, an antiviral developed for the treatment of severe influenza, was one of these. In late 2014, the conditions for starting a randomised Ebola trial were not fulfilled for two reasons. One was the perception that, given the high number of patients presenting simultaneously and the very high mortality rate of the disease, it was ethically unacceptable to allocate patients from within the same family or village to receive or not receive an experimental drug, using a randomization process impossible to understand by very sick patients. The other was that, in the context of rumours and distrust of Ebola treatment centres, using a randomised design at the outset might lead even more patients to refuse to seek care. Therefore, the researchers chose to conduct a multicenter non-randomized trial, in which all patients would receive favipiravir along with standardised care. The objectives of the trial were to test the feasibility and acceptability of an emergency trial in the context of a large Ebola outbreak, and to collect data on the safety and effectiveness of favipiravir in reducing mortality and viral load in patients with EVD. The trial was aimed at quickly gathering standardised preliminary data to optimise the design of future studies.

Safety, feasibility, and acceptability of the PrePex device for…

August 01, 2016

Nonsurgical adult male circumcision devices present an alternative to surgery where health resources are limited. This study aimed to assess the safety, feasibility, and acceptability of the PrePex device for adult male circumcision in Malawi. A prospective single-arm cohort study was conducted at 3 sites (1 urban static, 1 rural static, 1 rural tent) in Malawi. Adverse event (AE) outcomes were stratified to include/exclude pain, and confidence intervals (CIs) were corrected for clinic-level clustering.

Severe AEs were rare and similar to other programs. Immediate provision of surgical services after displacement or early removal proved a challenge. Cases of insufficient skin removal were linked to poor technique, suggesting provider training requires reinforcement and supervision.

Diabetes mellitus and tuberculosis: programmatic management issues

In August 2011, the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (The Union) launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. 

Key programmatic challenges include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB. 


Compassionate use of new drugs in children and adolescents…

Globally, there are very few children who have access to delamanid compared with the likely number who could benefit from it. Healthcare providers have described a number of challenges to the access of delamanid. The compassionate use mechanism, despite efforts to facilitate quick access, is a long, multistep and time-demanding process (request, permission for importation/use, informed consent, health staff training on the compassionate use protocol, reporting requirements and importation). This can result in substantial delays in treatment initiation, which could adversely affect treatment outcome. In this letter to the editor, the authors stress upon the need for a case to case evaluation from independent bodies to contribute to an increase in the appropriate use of new drugs among children and adolescents.

Treating all multidrug-resistant tuberculosis patients, not just bacteriologically confirmed…

The Médecins Sans Frontières (MSF) programme in Mumbai, India, has been providing treatment and care for HIV-infected MDR-TB patients since 2006. Of 174 patients enrolled in the clinic over the 10 years from 2006 to 2015, 36 (20%) did not have bacteriological confirmation of MDR-TB. These patients received presumptive treatment based on a clinical diagnosis of MDR-TB and their TB treatment history, including history of exposure to second-line anti-tuberculosis drug  and history of contact with a confirmed MDR-TB case. Of the 36 patients, 19 (53%) had a successful treatment outcome. These 36 patients would not have met the criteria for MDR-TB treatment in the RNTCP. In this correspondence, the authors propose a set of recommendations to promote presumptive treatment that would assist in reducing the global burden of MDR-TB. 


HIV viral load messages should go viral in India

Activism for the right to health is strong in India, and Indian civil society has traditionally been dynamic and occasionally successful in pushing for better HIV care. However, the same health and HIV activists who are experienced in battle and accustomed to victory are surprisingly quiet when it comes to access to routine HIV viral load monitoring for patients receiving ART. Although the Department of AIDS Control recognises the need of routine viral load testing, there are serious barriers to scale-up: high costs, weak sample transport services, lack of trained staff and limited laboratory infrastructure. Over 800, 000 tests are needed annually instead of the estimated 7000 being done. This comment lists numerous recommendations to scale up HIV viral load testing in India. 


Surgery in low-income countries during crisis: experience at Medecins…

July 01, 2016

The global burden of trauma and surgical conditions fall disproportionately on low- and middle-income countries (LMICs) [1, 2]. Inopportunely, developing countries are least equipped to provide essential surgical care [3]. As a result, LMICs have a significant burden of unmet surgical needs [4]. When these fragile health systems are disrupted by conflict, a natural disaster or an epidemic the capacity for and quality of surgical care decreases even further [5]. In response, Medecins Sans Frontieres (MSF) provides surgical humanitarian assistance in countries affected by crisis through one of the five operation centres; one of these is Operations Centre Brussels (OCB).


Unregulated usage of labour-inducing medication in a region of…

In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable risk for mother and child during labour. The research describes the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan. A retrospective cohort study using programme data, compared the outcomes of obstetric risk groups of women treated with unregulated oxytocin, with those of women with regulated treatment. It was concluded that in a conflict-affected region of Pakistan, exposure to unregulated treatment with labour-inducing medication is common, and carries great risk for mother and child. Tighter regulatory control of labour-inducing drugs is needed, and enhanced training of the mid-level cadres of healthcare workers is required.


Personal Protective Equipment for Filovirus Epidemics: A Call for…

This research aims to establish an improved evidence base for selecting PPE for use in filovirus epidemics that would provide sufficient protection from the virus while minimizing the risk of heat illness in the wearer. Given the unprecedented scope of the current Ebola epidemic, and the need for the most effective PPE, the proposed research must be a very high priority.The filovirus is the archetypal biohazard. A small infectious dose causes highly lethal disease for which there is currently no specifically effective treatment. A high death toll among healthcare workers who care for patients with Ebola and Marburg virus diseases is a fearful hallmark of filovirus outbreaks. Healthcare worker protection is one of the principal objectives of the international response to filovirus outbreaks. 


Continuity of Care for Migrant Populations in Southern Africa

Providing assistance to mobile populations has long been a challenge for healthcare providers and humanitarian organisations. The challenge is even greater when these populations need long-term chronic care for diseases such as tuberculosis or HIV, which require adherence to treatment and regular follow-up. This article examines the implications of medical care in contexts of displacement, when human movement is a major obstacle to ensuring compliance with treatment regimes. It argues that patients’ mobility can be integrated into health service provision through cross-border and regional referral systems, and examines how aid agencies can successfully work with other stakeholders, considering the impact of immigration policies, discrimination in health facilities, and xenophobia on the health of migrants in need of chronic care. It asks what the correct balance is to take in dealing with a medical crisis in a highly politicised environment. The experiences of MSF res in Southern Africa are explained as an illustration of this dilemma.


The role of antiretroviral therapy in reducing TB incidence…

With the adoption of the new Sustainable Development Goals in 2016, all countries have committed to end the tuberculosis (TB) epidemic by 2030, defined as dramatic reductions in TB incidence and mortality combined with zero TB-induced catastrophic costs for families. This paper explores how antiretroviral therapy (ART) in high HIV-TB burden countries may help in reducing TB incidence and mortality and thus contribute to the ambitious goal of ending TB. ART in people living with HIV has a potent TB preventive effect, with this being most apparent in those with the most advanced immunodeficiency. Early ART also significantly reduces the risk of TB, and with new World Health Organization guidance released in 2015 about initiating ART in all persons living with HIV irrespective of CD4 count, there is the potential for enormous benefit at the population level. Already, several countries with high HIV-TB burdens have seen dramatic declines in TB case notification rates since ART scale up started in 2004. In patients already diagnosed with HIV-associated TB, mortality can be significantly decreased by ART, especially if started within 2–8 weeks of anti-TB treatment. The benefits of ART on TB incidence and TB mortality can be further augmented respectively by the addition of isoniazid preventive therapy and cotrimoxazole preventive therapy. These interventions must be effectively implemented and scaled up in order to end the TB epidemic by 2030. 


Medication Adherence Clubs: a potential solution to managing large…

June 01, 2016

This study demonstrates the feasibility and early efficacy of Medication Adherence Clubs (MACs) for mixed chronic disease in a resource-limited setting. It supports burden reduction and flexibility of regular clinical review for stable patients. Further assessment regarding long-term outcomes of this model should be completed to increase confidence for deployment in similar contexts.


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