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Introduction Rifampicin and isoniazid are key drugs in treatment regimens for drug-susceptible tuberculosis. Rifampicin-resistant tuberculosis and multidrug-resistant tuberculosis (tuberculosis which is resistant to both isoniazid and rifampicin) are managed similarly, [...], Most phase III trials in drug-resistant tuberculosis have either been underpowered to quantify differences in microbiological endpoints or have taken up to a decade to complete. Composite primary endpoints, dominated by differences in treatment discontinuation and regimen changes, may mask important differences in treatment failure and relapse. Although new regimens for drug-resistant tuberculosis appear very effective, resistance to new drugs is emerging rapidly. There is a need for shorter, safer and more tolerable regimens, including those active against bedaquiline-resistant tuberculosis. Transitioning from multiple regimen A versus regimen B trials to a single large phase III platform trial would accelerate the acquisition of robust estimates of relative efficacy and safety. Further efficiencies could be achieved by adopting modern adaptive platform designs. Collaboration among trialists, affected community representatives, funders and regulators is essential for developing such a phase III platform trial for drug-resistant tuberculosis treatment regimens. La majorite des essais de phase III relatifs a la tuberculose pharmacoreslstante soit n'etaient pas assez puissants pour quantifier les fluctuations au niveau des criteres microbiologiques, soit etaient trop longs, se poursuivant parfois pendant dix ans. Les criteres primaires composites, domines par des differences dans l'interruption du traitement et les changements de schema, pourraient dissimuler d'importantes variations en termes d'echec therapeutique et de rechute. Bien que les nouveaux traitements contre la tuberculose pharmacoresistante semblent tres efficaces, la resistance aux nouveaux medicaments evolue rapidement. Il est donc necessaire d'opter pour des traitements plus courts, plus surs et mieux toleres, y compris ceux actifs contre la tuberculose resistant a la bedaquiline. Delaisser la multitude d'essais opposant un schema de traitement A a un schema de traitement B pour se diriger vers un unique essai plateforme de phase III de grande envergure permettrait d'obtenir plus vite des estimations solides concernant l'innocuite et l'efficacite relative. En outre, adopter des modeles de plateforme modernes et adaptatifs contribuerait a de meilleures performances. Enfin, la collaboration entre investigateurs, representants des communautes concernees, bailleurs de fonds et organismes de reglementation est essentielle a l'elaboration de ce type d'essai plateforme de phase III sur les traitements contre la tuberculose pharmacoresistante. La mayoria de los ensayos en fase III sobre tuberculosis resistente a los farmacos no ha tenido la potencia suficiente para cuantificar diferencias en los criterios de valoracion microbiologicos o ha tardado hasta una decada en completarse. Los criterios de valoracion principales compuestos, dominados por las diferencias en la interrupcion del tratamiento y los cambios de regimen, pueden ocultar diferencias importantes en el fracaso del tratamiento y la recaida. Aunque los nuevos regimenes de tratamiento para la tuberculosis resistente a los farmacos parecen muy eficaces, la resistencia a los nuevos farmacos esta apareciendo rapidamente. Se necesitan regimenes de tratamiento mas cortos, seguros y tolerables, incluidos los activos contra la tuberculosis resistente a la bedaquilina. La transicion de multiples ensayos de regimen A frente a regimen B a un unico gran ensayo de plataforma en fase III aceleraria la obtencion de estimaciones solidas de la eficacia y seguridad relativas. Podrian lograrse mayores eficiencias si se adoptaran disenos de plataforma adaptativos modernos. La colaboracion entre los autores de los ensayos, los representantes de las comunidades afectadas, los financiadores y los reguladores es esencial para desarrollar un ensayo de plataforma en fase III de este tipo para los regimenes de tratamiento de la tuberculosis resistente a los farmacos.

Deborah Gue,1,2 Sandra Squire,1 Kam McIntosh,1 Claude Bartholomew,1 Nicole Summers,1 Haowei Sun,1 Ming Yang,1 Shannon Jackson1,3 1British Columbia Provincial Bleeding Disorders Program – Adult Division, St Paul’s Hospital, 2School of Nursing, 3Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada Background: The relationship between hemophilia team interventions and achievement of optimal clinical outcomes remains to be elucidated. The British Columbia Hemophilia Adult Team has previously reported results of a comprehensive approach to individualize prophylaxis that has resulted in substantially reduced bleeding rates. In order to facilitate knowledge exchange and potential replication, it was important to gain a thorough understanding of the team’s approach.Methods: A focus group of the British Columbia Hemophilia Adult Team was conducted to identify specific roles and processes that might be contributing to the prophylaxis regimen outcomes in this clinic. The focus group consisted of two workshops; one to describe the individual and collective roles of the clinic team in providing clinical care and guiding patients toward individualized prophylaxis; and the other to describe the patient journey from initial contact through reaching a successful engagement with the clinic.Results: Analysis of the results revealed team roles and processes that underpinned a shared decision-making relationship with the patient with a particular focus on supporting the patient’s autonomy. Within this relationship, team focus shifts away from “adherence” toward the process whereby patients design and implement prophylaxis regimens resulting in reduction or elimination of bleeding episodes.Limitations: Using the current methodology, it is not possible to demonstrate a causal link between specific team processes and improved bleeding rates in patients.Conclusion: Through the active support of patient autonomy in all aspects of decisions related to hemophilia management, the British Columbia Hemophilia Adult Team approach de-emphasizes “adherence” as the primary goal, and focuses on a prophylaxis plan that is customized by the patient and aligned with his priorities. Adoption of this comprehensive team approach facilitates shared goals between the patient and the team that may optimize treatment adherence, but more importantly, reduce bleeding rates. Keywords: individiualized prophylaxis, shared decision-making, autonomy support, comprehensive care team

Abstract Introduction The STOP TB Partnership aims to improve global tuberculosis (TB) control through expanding access to the directly observed treatment short course (DOTS) strategy. One approach to this is 'Engaging all Care Providers', which evolved from 'Public-Private Mix (PPM) DOTS'. The overall aim of this study was to systematically assess whether and to what degree the STOP TB Partnership's four global objectives of engaging all care providers are met through existing PPM interventions. These four objectives are; 1) Increase TB case detection; 2) Improve TB treatment outcomes; 3) Enhance access and equity; 4) Reduce financial burden on patients. The specific objectives of this assessment were to 1) Understand what PPM means to the STOP TB Partnership's PPM Subgroup and to National Tuberculosis Programme managers; 2) Scope the nature of existing country-level PPM interventions and 3) Review PPM practice against the global PPM objectives. Methods We undertook a systematic, multi-facetted assessment. The methods included interviews with National Tuberculosis Programme managers from high burden countries, clarification of key issues with the STOP TB Partnership PPM secretariat and a review of publicly accessible reports and published articles on PPM projects. Both the literature review and interviews with the National Tuberculosis Programme managers yielded data on project characteristics; PPM models at country level; National Tuberculosis Programme partners; and mechanisms for engagement. Matrices were developed from the literature review and the interviews to show the relationship between services and service providers for different PPM projects. Data from the literature were assessed against each of the four global PPM objectives. Results Twelve National Tuberculosis Programme managers from high burden countries were interviewed about the scope of PPM partnerships. Understanding of PPM and types of engaged providers varied considerably; 'private-for-profit qualified clinical providers' were the dominant category. The literature review yielded information on 22 projects in which 'private-for-profit qualified clinical providers' were again the dominant category. The contributions made by 'private-for-profit qualified clinical providers' and 'Non Governmental Organisation qualified clinical providers', were assessed against the four global PPM objectives. Reporting on tuberculosis case detection and treatment outcomes was generally good and demonstrated important PPM contributions in these areas. Reporting on equity, access and reduced patient costs was often lacking or inconclusive. Conclusions PPM has improved case detection and treatment outcomes among patients seeking care with private providers. Evidence on reducing patient costs is inconclusive, and there is scope for increasing equity in access to care by systematically engaging those providers who are the primary agents for poor people seeking health care. Guidelines outlining which types of providers best contribute to achieving the four global objectives, along with the resources required by National Tuberculosis Programs for such engagement is needed.

Abstract Background Despite substantial investment in health capacity building in developing countries, evaluations of capacity building effectiveness are scarce. By analysing projects in Africa that had successfully built sustainable capacity, we aimed to identify evidence that could indicate that capacity building was likely to be sustainable. Methods Four projects were selected as case studies using pre-determined criteria, including the achievement of sustainable capacity. By mapping the capacity building activities in each case study onto a framework previously used for evaluating health research capacity in Ghana, we were able to identify activities that were common to all projects. We used these activities to derive indicators which could be used in other projects to monitor progress towards building sustainable research capacity. Results Indicators of sustainable capacity building increased in complexity as projects matured and included - early engagement of stakeholders; explicit plans for scale up; strategies for influencing policies; quality assessments (awareness and experiential stages) - improved resources; institutionalisation of activities; innovation (expansion stage) - funding for core activities secured; management and decision-making led by southern partners (consolidation stage). Projects became sustainable after a median of 66 months. The main challenges to achieving sustainability were high turnover of staff and stakeholders, and difficulties in embedding new activities into existing systems, securing funding and influencing policy development. Conclusions Our indicators of sustainable capacity building need to be tested prospectively in a variety of projects to assess their usefulness. For each project the evidence required to show that indicators have been achieved should evolve with the project and they should be determined prospectively in collaboration with stakeholders.

Abstract Background China is facing a significant tuberculosis epidemic among rural-to-urban migrants, which poses a threat to TB control. This study aimed to understand the health seeking behaviour of and health systems responses to migrants and permanent urban residents suffering from chronic cough, in order to identify the factors influencing delays for both groups in receiving a TB diagnosis in urban China. Methods Combining a prospective cohort study of adult suspect TB patients and a qualitative study, the Piot model was used to analyze the health seeking behaviour of TB suspects among migrants and permanent urban residents, the factors influencing their decision and the responses by general health providers. Methods included a patient survey, focus group discussions with migrants in the general population, qualitative interviews with migrant and permanent resident TB suspects and TB patients as well as key stakeholders related to TB control and the management of migrants. Results Sixty eight percent of migrants delayed for more than two weeks before seeking care for symptoms suggestive of TB, compared to 54% of residents (p < 0.01). When they first decided to seek professional care, migrants were 1.5 times more likely than residents to use less expensive, community-level health services. Only 5% were ultimately referred to a TB dispensary. Major reasons for both patient and provider delay included lack of knowledge and mistrust of the TB control programme, lack of knowledge about TB (patients), and profit-seeking behaviour (providers). In the follow up survey, 61% of the migrants and 41% of the residents who still had symptoms gave up continuing to seek professional care, with a statistically significant difference between the two groups (p < 0.05). Conclusion Rural-to-urban migrants are more likely than permanent residents to delay in seeking care for symptoms suggestive of TB in urban Chongqing. 'Patient-' and 'provider-' related factors interact to pose barriers to TB diagnosis for migrants, including: low awareness, and poor knowledge among both the general public and TB suspects about TB as a disease and about the TB control programme; low financial capacity to pay for care and diagnostic tests; and inadequate use of diagnostic tests and referral to TB dispensaries by general health providers.

ObjectiveTo investigate cost changes for health systems and participants, resulting from switching to short treatment regimens for multidrug-resistant (MDR) tuberculosis.MethodsWe compared the costs to health systems and participants of long (20 to 22 months) and short (9 to 11 months) MDR tuberculosis regimens in Ethiopia and South Africa. Cost data were collected from participants in the STREAM phase-III randomized controlled trial and we estimated health-system costs using bottom-up and top-down approaches. A cost-effectiveness analysis was performed by calculating the incremental cost per unfavourable outcome avoided.FindingsHealth-care costs per participant in South Africa were 8340.7 United States dollars (US$) with the long and US$ 6618.0 with the short regimen; in Ethiopia, they were US$ 6096.6 and US$ 4552.3, respectively. The largest component of the saving was medication costs in South Africa (67%; US$ 1157.0 of total US$ 1722.8) and social support costs in Ethiopia (35%, US$ 545.2 of total US$ 1544.3). In Ethiopia, trial participants on the short regimen reported lower expenditure for supplementary food (mean reduction per participant: US$ 225.5) and increased working hours (i.e. 667 additional hours over 132 weeks). The probability that the short regimen was cost-effective was greater than 95% when the value placed on avoiding an unfavourable outcome was less than US$ 19 000 in Ethiopia and less than US$ 14 500 in South Africa.ConclusionThe short MDR tuberculosis treatment regimen was associated with a substantial reduction in health-system costs and a lower financial burden for participants.

Background: In Nigeria, men constitute over half of the people notified with tuberculosis (TB), experience longer delays before reaching care, and are estimated to account for two thirds of people who miss out on care. The higher TB risk and burden in men has implications for the whole population and reaching them earlier with TB services will reduce onward transmission in households, communities, and workplaces. The absence of a comprehensive guidance and the lack of substantial empirical evidence on TB care approaches that are responsive to the needs of men in Nigeria exacerbates this problem. Therefore, this research aimed to co-create a gender-responsive intervention for men in peri-urban communities in Nigeria. Methods: Our study utilised a researcher-led collaborative approach to engage local TB stakeholders including communities adversely affected by the disease to co-create a gender-responsive TB intervention. Between March and November 2022, we engaged 13 local TB stakeholders in a three-phase participatory intervention design process. This engagement involved two iterative cycles of Delphi research online, and an in-person workshop. In the first and second phases, participants described the potential impact of 15 listed interventions and prioritised combinations of nine interventions deemed to be effective in overcoming identified gendered barriers. Responses were analysed using a combination of qualitative framework approach, content analysis, and summary descriptive statistics assisted by NVivo software. Stakeholder consensus on a preferred intervention package was reached during the participatory workshop. Results: Overall, participants prioritised approaches that sought to actively find and systematically screen men for TB including awareness creation as a crucial component. The stakeholders placed significant considerations on the synergy between interventions and their programmatic sustainability when making their final choices. Consequently, a complex intervention package comprising three components was developed. These included targeted awareness creation among men in communities; TB screening in male-dominated socio-cultural congregate settings; and the use of digital chest X-ray screening. Anticipated early outputs of this intervention included improved TB knowledge, increased care-seeking, reduced TB-related costs and TB stigma, and accelerated early diagnosis among men in Nigeria. Conclusion: Leveraging the insights and experiences of local stakeholders through iterative engagements yielded consensus on a viable gender-responsive TB intervention. [ABSTRACT FROM AUTHOR]

STREAM stage 2 showed that two bedaquiline-containing regimens (a 9-month all-oral regimen and a 6-month regimen with 8 weeks of aminoglycoside) had superior efficacy to a 9-month injectable-containing regimen for rifampicin-resistant tuberculosis up to 76 weeks after randomisation. Our objective in this follow-up analysis was to assess the durability of efficacy and safety, including mortality, at 132 weeks. We report the long-term outcomes from STREAM stage 2, a randomised, phase 3 non-inferiority (10% margin) trial in participants (aged ≥15 years) with rifampicin-resistant tuberculosis without fluoroquinolone or aminoglycoside resistance at 13 clinical sites in seven countries (Ethiopia, Georgia, India, Moldova, Mongolia, South Africa, and Uganda). Participants were randomly assigned 1:2:2:2 (via permuted blocks and stratified by site and HIV status plus CD4 cell count) to the 2011 WHO long regimen (terminated early), a 9-month control regimen, a 9-month oral regimen with bedaquiline (primary comparison), or a 6-month regimen with bedaquiline and 8 weeks of an injectable antituberculous drug. Participants and clinicians were aware of treatment-group assignments, but laboratory staff were masked. The primary outcome, reported previously, was favourable status (negative cultures for Mycobacterium tuberculosis without a preceding unfavourable outcome; any death, bacteriological failure or recurrence, and major treatment change were considered unfavourable) at week 76. Here we report efficacy outcomes at week 132, analysed in the modified intention-to-treat (mITT) population. Safety assessments continued to 132 weeks and were in all participants who received at least one dose of the study regimen. All comparisons used concurrently randomised participants. This trial is registered on ISRCTN (ISRCTN18148631) and is now completed. Between March 28, 2016, and Jan 28, 2020, 588 participants were randomly assigned to the long (n=32), control (n=202), oral (n=211), or 6-month (n=143) treatment regimens; 352 (60%) were male and 236 (40%) were female. Of the 556 participants on the three shorter regimens, 517 were included in the mITT population (187 in control group, 196 in oral group, and 134 in 6-month group) and 465 in the per-protocol analyses. Six additional participants had an unfavourable outcome that occurred between week 76 and the end of efficacy follow-up (one in control group, four in oral group, one in 6-month group). In the mITT population, the proportion of patients with an unfavourable outcome at the end of follow-up was 19·6% (95% CI 14·3 to 24·9) in the oral group and 29·3% (23·3 to 36·5) in the control group (–9·7 percentage points difference [95% CI –18·7 to –1·8]; p superiority =0·024). An estimated 9·8% (95% CI 4·6 to 14·9) of participants on the 6-month regimen had an unfavourable outcome, which was significantly lower than for those concurrently on the control regimen (32·5% [23·7 to 40·2]; p superiority <0·0001) or the oral regimen (23·8% [16·9 to 31·1]; p superiority =0·013). Few serious or severe adverse events were reported after week 76, with no indication of a difference between the regimens. At week 132, treatment-emergent hearing loss was recorded in significantly fewer participants on the oral regimen (7/205; 3%) than the control regimen (16/198; 8%; p=0.041); there was no significant difference in severe hearing loss between the oral regimen (6/139; 4%) and the 6-month regimen (5/143; 4%; p=0·72). Death rates were low: 1·01 (95% CI 0·48 to 2·12) per 100 person-years in participants allocated to bedaquiline (ie, oral and 6-month regimen, n=287) compared with 1·52 (0·63 to 3·66) in participants on the control regimen (n=140; p=0·49). Both of the bedaquiline-containing regimens maintained superiority to the control regimen, without evidence of increased mortality, providing two additional evidence-based treatment options for patients; previous mortality concerns for bedaquiline were not substantiated. US Agency for International Development and Janssen Research & Development. [ABSTRACT FROM AUTHOR]

Background Delusional infestation (DI) is a well-recognized delusional disorder presenting as the persisting belief of being infested. Combined clinics have been run by dermatology and psychiatry in a small number of centres. In this article we focus on our Liverpool University Hospitals NHS Foundation Trust clinic hosted at the Liverpool School of Tropical Medicine, UK, where we run a specialist clinic for DI. Methods We describe the specific set-up and approach of our clinic as a guide for clinicians working in specialties likely to see patients with DI (including tropical medicine, infectious diseases and dermatology) who may either want to set up similar clinics or be better equipped to manage DI patients promptly within existing practice. Results We describe the details of the clinic's approach. Between 2018 and 2023, the service saw 208 patients, of which 82.7% could be assessed and 55.7% had DI. The female:male ratio was 2:1. Conclusion Interdisciplinary combined clinics with medical and psychiatry consultants working together offer an approach to managing this rare, challenging and high-consequence condition. [ABSTRACT FROM AUTHOR]

Xpert MTB/RIF (Cepheid, https://www.cepheid. com) is a cartridge-based nucleic amplification assay for use with Cepheid's GeneXpert diagnostic instrument systems that detects both Mycobacterium tuberculosis complex (MTB) and resistance to rifampin [...]

BackgroundIn contrast to drug-sensitive tuberculosis, the guidelines for the treatment of multi-drug-resistant tuberculosis (MDR-TB) have a very poor evidence base; current recommendations, based on expert opinion, are that patients should be treated for a minimum of 20 months. A series of cohort studies conducted in Bangladesh identified a nine-month regimen with very promising results. There is a need to evaluate this regimen in comparison with the currently recommended regimen in a randomized controlled trial in a variety of settings, including patients with HIV-coinfection.Methods/designSTREAM is a multi-centre randomized trial of non-inferiority design comparing a nine-month regimen to the treatment currently recommended by the World Health Organization in patients with MDR pulmonary TB with no evidence on line probe assay of fluoroquinolone or kanamycin resistance. The nine-month regimen includes clofazimine and high-dose moxifloxacin and can be extended to 11 months in the event of delay in smear conversion. The primary outcome is based on the bacteriological status of the patients at 27 months post-randomization. Based on the assumption that the nine-month regimen will be slightly more effective than the control regimen and, given a 10% margin of non-inferiority, a total of 400 patients are required to be enrolled. Health economics data are being collected on all patients in selected sites.DiscussionThe results from the study in Bangladesh and cohorts in progress elsewhere are encouraging, but for this regimen to be recommended more widely than in a research setting, robust evidence is needed from a randomized clinical trial. Results from the STREAM trial together with data from ongoing cohorts should provide the evidence necessary to revise current recommendations for the treatment for MDR-TB.Trial registrationThis trial was registered with clincaltrials.gov (registration number: ISRCTN78372190) on 14 October 2010.

Author(s): Peter MacPherson 1,2,3,*, Emily L. Webb 4, Wala Kamchedzera 2, Elizabeth Joekes 1, Gugu Mjoli 5, David G. Lalloo 1, Titus H. Divala 2,3,6, Augustine T. Choko 1,2, Rachael [...], Background Suboptimal tuberculosis (TB) diagnostics and HIV contribute to the high global burden of TB. We investigated costs and yield from systematic HIV-TB screening, including computer-aided digital chest X-ray (DCXR-CAD). Methods and findings In this open, three-arm randomised trial, adults ([greater than or equal to]18 years) with cough attending acute primary services in Malawi were randomised (1:1:1) to standard of care (SOC); oral HIV testing (HIV screening) and linkage to care; or HIV testing and linkage to care plus DCXR-CAD with sputum Xpert for high CAD4TBv5 scores (HIV-TB screening). Participants and study staff were not blinded to intervention allocation, but investigator blinding was maintained until final analysis. The primary outcome was time to TB treatment. Secondary outcomes included proportion with same-day TB treatment; prevalence of undiagnosed/untreated bacteriologically confirmed TB on day 56; and undiagnosed/untreated HIV. Analysis was done on an intention-to-treat basis. Cost-effectiveness analysis used a health-provider perspective. Between 15 November 2018 and 27 November 2019, 8,236 were screened for eligibility, with 473, 492, and 497 randomly allocated to SOC, HIV, and HIV-TB screening arms; 53 (11%), 52 (9%), and 47 (9%) were lost to follow-up, respectively. At 56 days, TB treatment had been started in 5 (1.1%) SOC, 8 (1.6%) HIV screening, and 15 (3.0%) HIV-TB screening participants. Median (IQR) time to TB treatment was 11 (6.5 to 38), 6 (1 to 22), and 1 (0 to 3) days (hazard ratio for HIV-TB versus SOC: 2.86, 1.04 to 7.87), with same-day treatment of 0/5 (0%) SOC, 1/8 (12.5%) HIV, and 6/15 (40.0%) HIV-TB screening arm TB patients (p = 0.03). At day 56, 2 SOC (0.5%), 4 HIV (1.0%), and 2 HIV-TB (0.5%) participants had undiagnosed microbiologically confirmed TB. HIV screening reduced the proportion with undiagnosed or untreated HIV from 10 (2.7%) in the SOC arm to 2 (0.5%) in the HIV screening arm (risk ratio [RR]: 0.18, 0.04 to 0.83), and 1 (0.2%) in the HIV-TB screening arm (RR: 0.09, 0.01 to 0.71). Incremental costs were US$3.58 and US$19.92 per participant screened for HIV and HIV-TB; the probability of cost-effectiveness at a US$1,200/quality-adjusted life year (QALY) threshold was 83.9% and 0%. Main limitations were the lower than anticipated prevalence of TB and short participant follow-up period; cost and quality of life benefits of this screening approach may accrue over a longer time horizon. Conclusions DCXR-CAD with universal HIV screening significantly increased the timeliness and completeness of HIV and TB diagnosis. If implemented at scale, this has potential to rapidly and efficiently improve TB and HIV diagnosis and treatment. Trial registration clinicaltrials.gov NCT03519425.

Eduardo N Naranjo,1 Indershini Pillay,1 Sandra J Squire,2 Agnes T Black,1 Manu Gill3 1Providence Health Care, University of British Columbia, Vancouver, British Columbia, Canada; 2Vancouver General Hospital and UBC Hospital, Vancouver, British Columbia, Canada; 3Providence Health Care, Vancouver, British Columbia, CanadaCorrespondence: Eduardo N Naranjo, Providence Health Care, Room 432, Comox Building 4th Floor, St. Paul’s Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada, Email enaranjo@providencehealth.bc.caPurpose: The Independence Model (TIM) is a new rehabilitative model of care implemented in an acute care hospital to address patients’ functional decline and a high vacancy rate for rehabilitation therapists.Methods: TIM was developed by a team with expertise in evidence, scope of practice and roles, population care needs, and current state related to rehabilitation. TIM utilizes rehabilitation assistants, supervised by physical therapists, occupational therapists or speech-language pathologists, to assist patients in functional areas such as ambulation, activities of daily living (ADLs), cognition and communication. The planning team ensured patient engagement, utilized change management principles, and evaluated the effectiveness of care.Results: Preliminary evaluation of TIM was positive, with staff reporting improved caseload quality and patients feeling more prepared for discharge.Conclusion: This study suggests innovative models of care, such as TIM, can help address the functional needs of patients while navigating the global health human resource crisis.Keywords: multidisciplinary, optimization, health human resource crisis, model of care, function, hospital

Introduction Although the World Health Organization (WHO) has monitored the emergence of drug resistance of Mycobacterium tuberculosis since 1994, (1) there have been few national surveys of such resistance in [...], Objective To document the prevalence of multidrug resistance among people newly diagnosed with - and those retreated for-tuberculosis in Malawi. Methods We conducted a nationally representative survey of people with sputum-smear-positive tuberculosis between 2010 and 2011. For all consenting participants, we collected demographic and clinical data, two sputum samples and tested for human Immunodeficiency virus (HIV).The samples underwent resistance testing at the Central Reference Laboratory in Lilongwe, Malawi. All Mycobacterium tuberculosis isolates found to be multidrug-resistant were retested for resistance to first-line drugs--and tested for resistance to second-line drugs--at a Supranational Tuberculosis Reference Laboratory in South Africa. Findings Overall, M. tuberculosis was Isolated from 1777 (83.8%) of the 2120 smear-positive tuberculosis patients. Multidrug resistance was identified in five (0.4%) of 1196 isolates from new cases and 28 (4.8%) of 581 Isolates from people undergoing retreatment. Of the 31 Isolates from retreatment cases who had previously failed treatment, nine (29.0%) showed multidrug resistance. Although resistance to second-line drugs was found, no cases of extensive drug-resistant tuberculosis were detected. HIV testing of people from whom M. tuberculosis Isolates were obtained showed that 577 (48.2%) of people newly diagnosed and 386 (66.4%) of people undergoing retreatment were positive. Conclusion The prevalence of multidrug resistance among people with smear-positive tuberculosis was low for sub-Saharan Africa probably reflecting the strength of Malawi's tuberculosis control programme. The relatively high prevalence of such resistance observed among those with previous treatment failure may highlight a need for a change in the national policy for retreating this subgroup of people with tuberculosis. Objectif Documenter la prevalence de la resistance polymedicamenteuse de latuberculose parmiles personnes nouvellement diagnostiquees et les personnes traitees a nouveau au Malawi. Methodes Nous avons mene une enquete nationale representative des personnes atteintes de tuberculose a frottis d'expectoration posltlf entre 201 Oet 2011. Pour tous les participants consentants, nous avons recueilli les donnees demographlques et cliniques, deux echantillons d'expectoration et effectue le deplstage du virus de l'immunodeficience humaine (VIH). Les echantillons ont subi des tests de resistance au Laboratoire central de reference de Lilongwe, au Malawi. Tous les isolats de Mycobacterium tuberculosis qui ont presente une resistance polymedicamenteuse ont ete retestes pour la resistance aux medicaments de premiere Intention--et testes pour la resistance aux medlcaments de deuxleme Intention--dans un laboratoire de reference supranational pour la tuberculose en Afrique du Sud. Resultats Dans l'ensemble, M. tuberculosisM. tuberculosis a ete isole chez 1777 (83,8%) des 2120 patients atteints de tuberculose a frottis positlf. La resistance polymedicamenteuse a ete identifiee dans 5 (0,4%) des 1196 Isolats obtenus a partir des nouveaux cas et dans 28 (4,8%) des 581 isolats obtenus a partir des personnes qui recevaient a nouveau un traitement. Parmi les 31 Isolats issus des cas retraites qui ont connu un echec de traitement, 9 (29%) isolats ont presente une resistance polymedicamenteuse. Bien que la resistance aux medicaments donnes en deuxieme Intention alt ete identifiee, aucun cas de tuberculose ultrareslstante aux medlcaments n'a ete detecte. Les depistages du VIH des personnes a partir desquelles les Isolats de M. tuberculosisM. tuberculosis ont ete obtenus ont montre que 577 (48,2%) des personnes nouvellement dlagnostiquees et 386 (66,4%) des personnes recevant a nouveau le traitement etalent seropositives. Conclusion La prevalence de la resistance polymedlcamenteuse chez les personnes atteintes de tuberculose a frottis positif etalt falble en Afrlque subsaharlenne-refletantprobablement la force du programme de controle de la tuberculose du Malawi. La prevalence relativement elevee de cette resistance observee chez les personnes pour lesquelles le traitement precedent a echoue peut mettre en evldence un besoin de changement dans la politique nationale en matiere de retraitement de ce sous-groupe de personnes atteintes de tuberculose. Objetivo Documentar la prevalencia de la resistencia a medicamentos multiples entre pacientes a quienes se ha diagnosticado recientemente o han vuelto a recibir tratamiento para la tuberculosis en Malawi. Metodos Llevamos a cabo una encuesta representativa a nivel nacional de pacientes con tuberculosis que dieron positivo en el analisis de esputo entre 2010 y 2011. Para todos los participantes adultos, se recogieron datos demograficos y clinicos, dos muestras de esputo y realizamos pruebas del virus de immunodeficiencia humana (VIH). Las muestras se sometieron a pruebas de resistencia en el Laboratorio Central de Referencia en Lilongwe (Malawi). Se volvieron a examinar todas las cepas de Mycobacterium tuberculosis muitirresistentes para propar la resistencia a los medicamentos de primera linea y se probo su resistencia a los medicamentos de segunda linea en un laboratorio de referencia supranaclonal para la tuberculosis en Sudafrica. Resultados En general, la M. tuberculosisM. tuberculosis se aislo en 1777 (83,8%) de los 2120 pacientes de tuberculosis con baclloscopla positiva. Se detecto multlrreslstencla a medicamentos en cinco (0,4%) de las 1196 cepas de casos nuevos y en 28 (4,8%) de las 581 cepas de pacientes que se volvieron a someter al tratamiento. De las 31 cepas de casos de repeticion del tratamiento que no habian respondido previamente al tratamiento, nueve (29,0%) mostraron multirresistencia a medicamentos. Pese a que se hallo resistencia a los medicamentos de segunda linea, no se detectaron casos de tuberculosis con resistencia extendida ajnedicamentos. Las pruebas del VIH de quienes se obtuvieron cepas de M. tuberculosisM. tuberculosis mostraron que 577 (48,2%) de los pacientes con diagnostico reciente y 386 (66,4%) de los pacientes que se volvieron a someter al tratamiento dieron positivo. Conclusion La prevalencia de la multirresistencia a medicamentos entre los pacientes con tuberculosis que dieron positivo en la baciloscopia positiva fue baja en el Africa subsahariana, lo cual probablemente refleja la eficacia del programa de control de la tuberculosis de Malawi. La prevalencia relativamente alta de dicha resistencia observada entre los pacientes que no respondieron al tratamiento anterior puede poner de manifiesto la necesidad de un cambio en la politica nacional para volver a tratar a este subgrupo de pacientes con tuberculosis.