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  • Tuberculosis case finding and diagnostics are

    2019-06-12

    Tuberculosis case-finding and diagnostics are far from perfect. The worldwide case detection rate of tuberculosis has stagnated at around 60%, not reaching the target of 70% originally set for 2000 but postponed to 2005, and then judged to be unreachable. In sub-Saharan Africa, case detection rates are as low as 52%. Diagnosis of tuberculosis in high-endemic low-income areas has been, and still is, a challenge. Although the gold standard for tuberculosis diagnosis is sputum culture, which takes time and relies on a consistent power supply, many settings are still reliant on sputum smear microscopy, a 125-year-old method that fails to detect up to 50% of cases––even more if laboratory capacity is exceeded, as is often the case in low-resource settings. Since WHO has recommended Xpert MTB/RIF, it has been used by 108 of the 145 countries that were eligible for concessional pricing. From the initially recommended use in people at risk of multidrug-resistant tuberculosis and HIV-infected patients, current guidelines encourage use of Xpert MTB/RIF for all people with suspected tuberculosis. In , Gavin Churchyard and colleagues report the results of XTEND, a cluster-randomised trial testing the effect of Xpert MTB/RIF on patient-relevant outcomes in the context of routine implementation. The XTEND trial was embedded in the national South African rollout of Xpert MTB/RIF and compared the effect of XPERT MTB/RIF with fluorescence microscopy on outcomes such as mortality at 6 months, proportion of positive cases, and the proportion of patients investigated for tuberculosis who started treatment.
    Throughout the world, order Epoxomicin are central to children\'s development. In addition to health and nutrition, children gain cognitive, language, and personal–social skills through interactions with family members. When symptoms of maternal depression disrupt parenting interactions, children\'s health and development can be compromised. Despite the recognition that, in low-income and middle-income countries, millions of young children are not reaching their developmental potential and that the prevalence of maternal depressive symptoms might exceed 50%, most intervention strategies have been directed towards the promotion of either early child development or maternal mental health, not both. The article by Daisy Singla and colleagues in is a striking example of an integrated, manualised maternal wellbeing and child development intervention in rural Uganda with beneficial effects on young children\'s cognitive and receptive language skills and on maternal depressive symptoms. Unlike most successful interventions delivered through home visits, this 12 session integrated intervention was delivered in a group format. Participants received activity booklets and encouragement to follow recommended activities, but no direct intervention. The changes in parenting practices (dietary diversity, preventive practices, stimulation, and maternal knowledge), plus the mediating effects of the Home Observation for Measurement of the Environment inventory on the children\'s development suggest that parents altered their parenting practices in response to the intervention, with beneficial effects on their children\'s receptive language and cognition. These findings are in contrast to the adage that direct intervention and practice are necessary to alter parenting behaviour and child development, and suggest that, in some cultures, group interventions are effective. There are at least four possible explanations for the beneficial effects of the group intervention. First, the maternal wellbeing intervention emphasised “love and respect” in a parent\'s relationships with self, child, and spouse, using a process that has been effectively implemented in other low-income and middle-income countries. By halting the increase in depressive symptoms reported by the control group, the intervention provides evidence that many maternal depressive symptoms are modifiable by group interventions delivered by community volunteers. Without depressive symptoms, mothers might have been receptive to the recommendations for stimulating activities with their children.