Depression among Tuberculosis patients and its association with treatment outcomes in district Srinagar

Drug-induced hypothyroidism in tuberculosis

INTRODUCTION

Adverse reactions to tuberculosis treatment can impact patient adherence and prognosis. Hypothyroidism is a frequent adverse reaction caused using ethionamide, prothionamide, and para-aminosalicylic acid and is often underdiagnosed.

AREAS COVERED

We searched Scielo, Scopus, and EMBASE databases, including 67 articles. Antitubercular drug-induced hypothyroidism has a prevalence of 17%. It occurs after 2 to 3 months of treatment and resolves within 4 to 6 weeks after discontinuation. It is postulated to result from the inhibition of thyroperoxidase function, blocking thyroid hormone synthesis. Symptoms are nonspecific, necessitating individualized thyroid-stimulating hormone measurement for detection. Specific guidelines for management are lacking, but initiation of treatment with levothyroxine, as is customary for primary hypothyroidism, is recommended. Discontinuation of antitubercular drugs is discouraged, as it may lead to unfavorable consequences.

EXPERT OPINION

Antitubercular drug-induced hypothyroidism is more common than previously thought, affecting one in six MDR-TB patients. Despite diagnostic and treatment recommendations, implementation is hindered in low-income countries due to the lack of certified laboratories. New drugs for tuberculosis treatment may affect thyroid function, requiring vigilant monitoring for complications, including hypothyroidism.

Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies

BACKGROUND

India accounts for about one-quarter of people contracting tuberculosis (TB) disease annually and nearly one-third of TB deaths globally. Many Indians do not navigate all care cascade stages to receive TB treatment and achieve recurrence-free survival. Guided by a population/exposure/comparison/outcomes (PECO) framework, we report findings of a systematic review to identify factors contributing to unfavorable outcomes across each care cascade gap for TB disease in India.

METHODS AND FINDINGS

We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches of PubMed, Embase, and Web of Science from January 1, 2000 to August 14, 2023 were conducted. We identified articles evaluating factors associated with unfavorable outcomes for each gap (reported as adjusted odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons for these outcomes (reported as proportions), with specific quality or risk of bias criteria for each gap. Findings were organized into person-, family-, and society-, or health system-related factors, using a social-ecological framework. Factors associated with unfavorable outcomes across multiple cascade stages included: male sex, older age, poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) health services. People previously treated for TB were more likely to seek care and engage in the diagnostic workup (Gaps 1 and 2) but more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable treatment outcomes (Gap 4), especially those who were lost to follow-up during their prior treatment. For individual care cascade gaps, multiple studies highlighted lack of TB knowledge and structural barriers (e.g., transportation challenges) as contributing to lack of care-seeking for TB symptoms (Gap 1, 14 studies); lack of access to diagnostics (e.g., X-ray), non-identification of eligible people for testing, and failure of providers to communicate concern for TB as contributing to non-completion of the diagnostic workup (Gap 2, 17 studies); stigma, poor recording of patient contact information by providers, and early death from diagnostic delays as contributing to pretreatment loss to follow-up (Gap 3, 15 studies); and lack of TB knowledge, stigma, depression, and medication adverse effects as contributing to unfavorable treatment outcomes (Gap 4, 86 studies). Medication nonadherence contributed to unfavorable treatment outcomes (Gap 4) and TB recurrence (Gap 5, 14 studies). Limitations include lack of meta-analyses due to the heterogeneity of findings and limited generalizability to some Indian regions, given the country's diverse population.

CONCLUSIONS

This systematic review illuminates common patterns of risk that shape outcomes for Indians with TB, while highlighting knowledge gaps-particularly regarding TB care for children or in the private sector-to guide future research. Findings may inform targeting of support services to people with TB who have higher risk of poor outcomes and inform multicomponent interventions to close gaps in the care cascade.

Influencing Factors of Treatment Outcomes Among Patients with Pulmonary Tuberculosis: A Structural Equation Model Approach

BACKGROUND

Pulmonary tuberculosis (PTB) is a serious infectious disease, and the factors and pathways that influence final treatment outcomes are unclear. Here, we aimed to assess the factors that influence treatment outcomes in patients with PTB using a structural equation model.

METHODS

Participants completed a questionnaire covering demographics, understanding of PTB, psychological status, and history of medical treatment. Exploratory factor analysis and reliability testing were performed, and a structural equation model was constructed using the SPSS and Amos software.

RESULTS

A total of 251 participants were enrolled. Symptoms of depression were observed in 94.4% of participants, whereas 6% showed mild or greater anxiety. Through factor rotation, four common factors were extracted with a total variation of 66.15%. The structural equation model indicated that regular tuberculosis-related follow-up behaviour had a direct and positive effect on the final treatment outcome, with a path coefficient value of 0.20; the level of PTB understanding had a direct positive effect on the testing behaviour for PTB, with a path coefficient of 0.26; patients' psychological characteristics had a direct negative impact on regular testing behaviour, with a path coefficient of -0.13. The psychological characteristics and level of disease understanding of patients exerted indirect effects on the treatment outcome by affecting the way patients approached tuberculosis detection behaviour.

CONCLUSION

Interventions aimed at improving the treatment outcomes of patients with PTB should mainly focus on financial support and improvements in psychological status in addition to a greater understanding and knowledge of PTB. Furthermore, patients should be encouraged to undergo regular PTB testing during the follow up period, as this mediates the effect of other factors on treatment outcomes and also helps in achieving favourable treatment outcomes.

Post-TB health and wellbeing

TB affects around 10.6 million people each year and there are now around 155 million TB survivors. TB and its treatments can lead to permanently impaired health and wellbeing. In 2019, representatives of TB affected communities attending the '1st International Post-Tuberculosis Symposium´ called for the development of clinical guidance on these issues. This clinical statement on post-TB health and wellbeing responds to this call and builds on the work of the symposium, which brought together TB survivors, healthcare professionals and researchers. Our document offers expert opinion and, where possible, evidence-based guidance to aid clinicians in the diagnosis and management of post-TB conditions and research in this field. It covers all aspects of post-TB, including economic, social and psychological wellbeing, post TB lung disease (PTLD), cardiovascular and pericardial disease, neurological disability, effects in adolescents and children, and future research needs.

Prevalence of depression in people with tuberculosis in East Africa: a systematic review and meta-analysis

BACKGROUND

Depression is one of the most common mental health problems comorbid with tuberculosis. However, a consolidated picture of the prevalence of depression among tuberculosis patients in East Africa remains unknown. This systematic review and meta-analysis provide new understandings by systematically examining evidence concerning the prevalence of depression among tuberculosis patients in East Africa.

METHODS

Literature was found in a database of HINARI, SCOPUS, PubMed, Science Direct, and Google Scholar. The Newcastle-Ottawa quality assessment scale was used to appraise the quality of the selected studies. Then, the DerSimonian and Laird random-effects model was applied because of the presence of heterogeneity among studies.

RESULTS

A total of 409 studies were accessed. However, only 29 qualified for a full-text review, and 9 studies with a population of 2838 were included in the qualitative description and quantitative analysis. The pooled prevalence estimate of depression amongst tuberculosis patients was 43.03 % (34.93, 51.13). The highest prevalence was observed in Kenya, with 45.71% (29.26, 62.16); a similar rate was observed in Ethiopia, with 45.11 % (34.60, 55.62). Subgroup analysis based on screening tool was used: 45.71% with BDI and 41.53% with PHQ.

Exploring migration intention among registered pharmacists in Kerala: a mixed-methods study

OBJECTIVES

This study investigated the intention to migrate among pharmacists in Kerala and explored the factors driving pharmacist migration in Kerala.

METHODS

A sequential mixed-methods study was carried out to explore the intention to migrate among pharmacists in Kerala, India. A survey of 256 registered pharmacists and in-depth interviews with 15 pharmacists having high migration intentions were undertaken. Quantitative data were analysed employing univariate approaches and binary logistic regression. Qualitative data were analysed employing thematic analysis.

KEY FINDINGS

About 44.5% (n = 114) of pharmacists expressed a high intention to migrate. Younger age of up to 30 years (AOR = 8.31, 95% CI = 2.24-30.82), more opportunities abroad (AOR = 4.28, 95% CI = 1.87-9.80), better salaries (AOR = 2.48, 95% CI = 1.04-5.95) and a general negative outlook towards a pharmacy career in Kerala (AOR = 2.83, 95% CI = 1.22-6.56) predicted a high level of intention to migrate among pharmacists. Lower incomes, working conditions, respect and recognition in the society, professional conflict and social connections were observed to be major push factors influencing pharmacists' migration intentions.

CONCLUSIONS

Just under half of the registered pharmacists in Kerala has a high intention to migrate abroad. Economic factors, workplace factors, lack of opportunities, social status and so on, were influencers of the intention to migrate among pharmacists. Ensuring implementation of equitable wage policies, preventing unlicensed pharmacy practice, improving societal awareness and providing clear job roles for pharmacists with PharmD and MPharm degrees are needed.

Catastrophic Costs among Tuberculosis-Affected Households in Egypt: Magnitude, Cost Drivers, and Coping Strategies

Despite national programs covering the cost of treatment for tuberculosis (TB) in many countries, TB patients still face substantial costs. The end TB strategy, set by the World Health Organization (WHO), calls for "zero" TB households to be affected by catastrophic payments by 2025. This study aimed to measure the catastrophic healthcare payments among TB patients in Egypt, to determine its cost drivers and determinants and to describe the coping strategies. The study utilized an Arabic-validated version of the TB cost tool developed by the WHO for estimating catastrophic healthcare expenditure using the cluster-based sample survey with stratification in seven administrative regions in Alexandria. TB payments were considered catastrophic if the total cost exceeded 20% of the household's annual income. A total of 276 patients were interviewed: 76.4% were males, 50.0% were in the age group 18-35, and 8.3% had multidrug-resistant TB. Using the human capital approach, 17.0% of households encountered catastrophic costs compared to 59.1% when using the output approach. The cost calculation was carried out using the Egyptian pound converted to the United States dollars based on 2021 currency values. Total TB cost was United States dollars (USD) 280.28 ± 29.9 with a total direct cost of USD 103 ± 10.9 and a total indirect cost of USD 194.15 ± 25.5. The direct medical cost was the main cost driver in the pre-diagnosis period (USD 150.23 ± 26.89 pre diagnosis compared to USD 77.25 ± 9.91 post diagnosis, p = 0.013). The indirect costs (costs due to lost productivity) were the main cost driver in the post-diagnosis period (USD 4.68 ± 1.18 pre diagnosis compared to USD 192.84 ± 25.32 post diagnosis, p < 0.001). The households drew on multiple financial strategies to cope with TB costs where 66.7% borrowed and 25.4% sold household property. About two-thirds lost their jobs and another two-thirds lowered their food intake. Being female, delay in diagnosis and being in the intensive phase were significant predictors of catastrophic payment. Catastrophic costs were high among TB households in Alexandria and showed wide variation according to the method used for indirect cost estimation. The main cost driver before diagnosis was the direct medical costs, while it was the indirect costs, post diagnosis.

Sleep quality and influencing factors and correlation with T-lymphocyte subpopulation counts in patients with pulmonary tuberculosis: a cross-sectional study

BACKGROUND

Patients diagnosed with pulmonary tuberculosis (TB) have poor sleep quality due to multiple factors. We aimed to assess the sleep status and related factors of TB patients in Shenzhen, China.

METHODS

A questionnaire survey was conducted on 461 TB patients hospitalized at Shenzhen Third People's Hospital from March 2021 to January 2022, and sleep quality was assessed using the Pittsburgh sleep quality index (PSQI).

RESULTS

A total of 459 valid questionnaires were collected, and 238 of the 459 TB patients had general or poor sleep quality (PSQI > 5). Patients' gender, marriage, nutritional screening score, family atmosphere, fear of discrimination, fear of interactions, and the impact of the disease on their work life had significant effects on sleep quality (P < 0.05); PSQI scores of TB patients were negatively correlated with lymphocyte counts (r =  - 0.296, P < 0.01), T-lymphocyte counts (r =  - 0.293, P < 0.01), helper T lymphocyte counts (r =  - 0.283, P < 0.01), killer T lymphocyte counts (r =  - 0.182, P < 0.05), and were positively correlated with depression scores (r = 0.424, P < 0.01). Multivariable logistic regression analysis showed that male (OR = 1.64,95% CI 1.11-2.42, P < 0.05), unmarried (OR = 1.57, 95% CI 1.02-2.42, P < 0.05), NRS score grade 3(OR = 5.35, 95% CI 2.08-15.73, P < 0.01), general family atmosphere (OR = 2.23, 95% CI 1.07-4.93, P < 0.05), and the disease affecting work (OR = 1.66, 95% CI 1.11-2.50, P < 0.05) were factors influencing poor sleep quality.

CONCLUSION

Most TB patients had varying degrees of sleep disturbance, which may be affected by their gender, marriage, family atmosphere, nutritional status, the effect of the disease on work life, and, depression, as well as lower absolute T-lymphocyte subpopulation counts. Appropriate interventions should be implemented to improve their sleep quality, when treating or caring for such patients.

Association between depression or anxiety symptoms and immune-inflammatory characteristics in in-patients with tuberculosis: A cross-sectional study

BACKGROUND

Depression and anxiety are major psychological issues among patients with tuberculosis (TB) owing to chronic and complex treatments, have been reported to be closely correlated with immune and inflammation. However, the association of peripheral immune-inflammatory characteristics with depression/anxiety symptoms in in-patients with TB has rarely been reported.

METHODS

A cross-sectional study of 338 in-patients with TB from 3 hospitals in China were enrolled to investigate their depression and anxiety status by using the nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalized Anxiety Disorder Scale (GAD-7). Participants were divided into groups based on their PHQ-9 and GAD-7 scores, and differences in demography and immune-inflammatory characteristics were studied. Logistic analysis was performed to explore factors related to depression and anxiety symptoms.

RESULTS

Depression and anxiety prevalence among patients with TB was 47.9 and 42.6%, respectively. Furthermore, 38.5% of patients reported a comorbidity of depression and anxiety symptoms. The counts of CD3, CD4, CD8, and lymphocytes decreased, whereas those of neutrophils, platelets, and peripheral blood cells and their derived indices increased among TB patients with depression or anxiety in comparison with those without symptoms (p < 0.05). In addition, increasing age, lower income (monthly income ≤ 3,000 yuan), divorced or widowed, drug resistance, and higher systemic immune inflammation index (SII) were significantly associated with depression or anxiety symptoms (p < 0.05).

CONCLUSION

Approximately half of the patients with TB suffered from depression or/and anxiety symptoms. Patients with depression or anxiety present worse cell immune status and stronger inflammatory responses compared to those without symptoms. We emphasized the importance of paying attention to the dysfunction of immune-inflammation process of TB patients with depression or anxiety symptoms. Especially, SII has a potential application value in guiding the evaluation of TB-related depression or anxiety owing to its easily accessibility and being economical.