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      Nutritional Status of Adult Patients with Pulmonary Tuberculosis in Rural Central India and Its Association with Mortality


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          Under-nutrition is a known risk factor for TB and can adversely affect treatment outcomes. However, data from India are sparse, despite the high burden of TB as well as malnutrition in India. We assessed the nutritional status at the time of diagnosis and completion of therapy, and its association with deaths during TB treatment, in a consecutive cohort of 1695 adult patients with pulmonary tuberculosis in rural India during 2004 - 2009.Multivariable logistic regression was used to obtain adjusted estimates of the association of nutritional status with deaths during treatment. At the time of diagnosis, median BMI and body weights were 16.0 kg/m 2and 42.1 kg in men, and 15.0 kg/m 2and 34.1 kg in women, indicating that 80% of women and 67% of men had moderate to severe under-nutrition (BMI<17.0 kg/m 2). Fifty two percent of the patients (57% of men and 48% of women) had stunting indicating chronic under-nutrition. Half of women and one third of men remained moderately to severely underweight at the end of treatment. 60 deaths occurred in 1179 patients (5%) in whom treatment was initiated. Severe under-nutrition at diagnosis was associated with a 2 fold higher risk of death. Overall, a majority of patients had evidence of chronic severe under-nutrition at diagnosis, which persisted even after successful treatment in a significant proportion of them. These findings suggest the need for nutritional support during treatment of pulmonary TB in this rural population.

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          A consistent log-linear relationship between tuberculosis incidence and body mass index.

          Low weight for height is an established risk factor for tuberculosis (TB), and recent studies suggest that overweight is a protective factor. No previous systematic review has been done to explore the consistency and establish the gradient of this apparent 'dose-response' relationship. A systematic literature review was carried out to identify cohort studies that collected data on weight and height at baseline and that used a diagnosis of active TB as the study outcome. Weight-for-height measures used in the original studies were transformed into body mass index (BMI). Exponential trend lines were fitted to each data set. Six studies were included. In all of them, there was a log-linear inverse relationship between TB incidence and BMI, within the BMI range 18.5-30 kg/m(2). The average slope gave a reduction in TB incidence of 13.8% [95% confidence interval 13.4-14.2] per unit increase in BMI. The dose-response relationship was less certain at BMI 30 kg/m(2). There is a strong and consistent log-linear relationship between TB incidence and BMI across a variety of settings with different levels of TB burden. More research is required to test the relationship at very low and very high BMI levels, to establish the biological mechanism linking BMI with risk of TB and to establish the potential impact on the global TB epidemic of changing nutritional status of populations.
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            Diabetes and tuberculosis: the impact of the diabetes epidemic on tuberculosis incidence

            Background Tuberculosis (TB) remains a major cause of mortality in developing countries, and in these countries diabetes prevalence is increasing rapidly. Diabetes increases the risk of TB. Our aim was to assess the potential impact of diabetes as a risk factor for incident pulmonary tuberculosis, using India as an example. Methods We constructed an epidemiological model using data on tuberculosis incidence, diabetes prevalence, population structure, and relative risk of tuberculosis associated with diabetes. We evaluated the contribution made by diabetes to both tuberculosis incidence, and to the difference between tuberculosis incidence in urban and rural areas. Results In India in 2000 there were an estimated 20.7 million adults with diabetes, and 900,000 incident adult cases of pulmonary tuberculosis. Our calculations suggest that diabetes accounts for 14.8% (uncertainty range 7.1% to 23.8%) of pulmonary tuberculosis and 20.2% (8.3% to 41.9%) of smear-positive (i.e. infectious) tuberculosis. We estimate that the increased diabetes prevalence in urban areas is associated with a 15.2% greater smear-positive tuberculosis incidence in urban than rural areas – over a fifth of the estimated total difference. Conclusion Diabetes makes a substantial contribution to the burden of incident tuberculosis in India, and the association is particularly strong for the infectious form of tuberculosis. The current diabetes epidemic may lead to a resurgence of tuberculosis in endemic regions, especially in urban areas. This potentially carries a risk of global spread with serious implications for tuberculosis control and the achievement of the United Nations Millennium Development Goals.
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              Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru.

              Despite the prevalence of multidrug-resistant tuberculosis in nearly all low-income countries surveyed, effective therapy has been deemed too expensive and considered not to be feasible outside referral centers. We evaluated the results of community-based therapy for multidrug-resistant tuberculosis in a poor section of Lima, Peru. We describe the first 75 patients to receive ambulatory treatment with individualized regimens for chronic multidrug-resistant tuberculosis in northern Lima. We conducted a retrospective review of the charts of all patients enrolled in the program between August 1, 1996, and February 1, 1999, and identified predictors of poor outcomes. The infecting strains of Mycobacterium tuberculosis were resistant to a median of six drugs. Among the 66 patients who completed four or more months of therapy, 83 percent (55) were probably cured at the completion of treatment. Five of these 66 patients (8 percent) died while receiving therapy. Only one patient continued to have positive cultures after six months of treatment. All patients in whom treatment failed or who died had extensive bilateral pulmonary disease. In a multiple Cox proportional-hazards regression model, the predictors of the time to treatment failure or death were a low hematocrit (hazard ratio, 4.09; 95 percent confidence interval, 1.35 to 12.36) and a low body-mass index (hazard ratio, 3.23; 95 percent confidence interval, 0.90 to 11.53). Inclusion of pyrazinamide and ethambutol in the regimen (when susceptibility was confirmed) was associated with a favorable outcome (hazard ratio for treatment failure or death, 0.30; 95 percent confidence interval, 0.11 to 0.83). Community-based outpatient treatment of multidrug-resistant tuberculosis can yield high cure rates even in resource-poor settings. Early initiation of appropriate therapy can preserve susceptibility to first-line drugs and improve treatment outcomes. Copyright 2003 Massachusetts Medical Society

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                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                24 October 2013
                : 8
                : 10
                : e77979
                [1 ]Department of Internal Medicine, Himalayan Institute of Medical Sciences, Jolly Grant, Uttarakhand, India
                [2 ]Krishak Maitri Hospital, Chengail, West Bengal, India
                [3 ]Jan Swasthya Sahyog, Village and P.O.Ganiyari, Chhattisgarh, India
                [4 ]Department of Microbiology, Himalayan Institute of Medical Sciences, Jolly Grant, Uttarakhand, India
                [5 ]Department of Community Medicine, Himalayan Institute of Medical Sciences, Jolly Grant, Uttarakhand, India
                [6 ]Centre for Public Health and Equity, Bhopal, Madhya Pradesh, India
                [7 ]Respiratory Epidemiology & Clinical Research Unit, Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada
                [8 ]Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
                University of California, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: A. Bhargava MC YJ BC AK RK MB RJ MP DM. Performed the experiments: A. Bhargava MC YJ BC AK RK RD MB RJ A. Benedetti MP DM. Analyzed the data: A. Bhargava A. Benedetti MP DM. Wrote the manuscript: A. Bhargava MC YJ BC RD MB MP DM.

                Copyright @ 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                : 24 April 2013
                : 6 September 2013
                Sir Dorabji Tata Trust Mumbai ( www.dorabjitatatrust.org) and Sir Ratan Tata Trust Mumbai ( www.srtt.org) supported the TB treatment service at Jan Swashtya Sahyog during 2004-2009. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of this manuscript.
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