Summarybackground Public-private partnerships are felt to be necessary for tuberculosis (TB) control in some developing countries.objectives To evaluate the potential of a collaboration between the National TB Programme (NTP) and private pharmacies in Bolivia, the country with the highest TB incidence in Latin America.methods We contacted the local Pharmacists' Association in the city of Cochabamba, and designed a two phase intervention. The objectives of the first phase were to decrease the availability of TB drugs in private pharmacies on a voluntary basis, and to improve referral of clients seeking TB drugs to the NTP. A survey of all pharmacies allowed for a before-after comparison with a baseline survey. The objectives of the second phase were to obtain referral of pharmacy clients with chronic cough for TB screening in the NTP. This phase was started in 70 pharmacies and evaluated after 2 months using the referral slips issued by the pharmacists.results The proportion of pharmacies selling TB drugs decreased (rifampicin: 23-11.5%; isoniazid: 16-3.1%; P < 0.001) and the proportion of pharmacies referring to the NTP clients seeking TB drugs increased (22-58%; P < 0.0001). In the second phase, 26 of 70 pharmacies (38%) referred a total of 41 clients for screening in the NTP (i.e. an average of 0.29 clients per pharmacy and per month); 11 of 41 (27%) were screened and three of 11 (27%) diagnosed with smear-positive TB.conclusion The first phase of the intervention proved effective in reducing the availability of the main TB drugs in pharmacies, and in improving referral of clients seeking TB drugs. Key factors in this success were not specific to Bolivia, and collaboration between private pharmacies and public services appears possible in that respect. However, collaboration with pharmacies does not seem an efficient way to increase the number of patients screened for TB, and to shorten delays to TB diagnosis and treatment.

Outbreaks of Clostridium difficile infections (CDI) with increased severity, high relapse rate and significant mortality have been related to the emergence of a new, hypervirulent C. difficile strain in North America and Europe. This emerging strain is referred to as PCR ribotype 027 (Type 027). Since 2005, individual countries have developed surveillance studies about the spread of type 027. C. difficile Type 027 has been reported in 16 European countries. It has been responsible for outbreaks in Belgium, Germany, Finland, France, Ireland, Luxembourg, The Netherlands, Switzerland and the United Kingdom (England, Wales, Northern Ireland and Scotland). It has also been detected in Austria, Denmark, Sweden, Norway, Hungary, Poland and Spain. Three countries experienced imported patients with CDI due to Type 027 who acquired the infection abroad. The antimicrobial resistance pattern is changing, and outbreaks due to clindamycin-resistant ermB positive Type 027 strains have occurred in three European countries. Ongoing epidemiological surveillance of cases of CDI, with periodic characterisation of the strains involved, is required to detect clustering of cases in time and space and to monitor the emergence of new, highly virulent clones.

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Short delays to treatment are important for the control of tuberculosis (TB). National Tuberculosis Programmes provide free diagnosis and treatment for smear-positive patients, so that the patients' out-of-pocket medical expenditure could be almost nil. The factors associated with delays in starting treatment, and the pre-treatment out-of-pocket medical expenditure for TB patients, have now been investigated in the Bolivian city of Cochabamba. Bolivia is the Latin American country with the highest incidence of TB. It is covered by a national TB programme that provides free diagnosis and free treatment for smear-positive patients. Structured interviews with 144 smear-positive patients enrolled in this programme revealed median patient, provider and total delays of 3.6, 6.2 and 12.9 weeks, respectively. The total delays were longer for the female patients than for the male, and for patients who consulted private doctors than for the other patients. When the first healthcare provider was a doctor, the median provider delay was 4.9 weeks in the public sector but 7.2 weeks in the private. The median out-of-pocket medical expenditure per patient, which was U.S.$13.2 overall, was much higher for those who consulted a private doctor than for those who did not (U.S.$21.9 v. U.S.$5.4, respectively; P<0.001). It appears that interventions targeting doctors (in both the private and public sectors) are likely to have a larger impact on the shortening of delays in TB treatment than interventions targeting patients. They could also reduce unnecessary out-of-pocket expenditure.

We report a case of Charcot spinal arthropathy in a diabetic patient and emphasize the clinical reasoning leading to the diagnosis, discuss the differential diagnosis, and insist on the crucial role of the radiologist and pathologist which allows the distinction between Charcot spinal arthropathy and infectious or tumoural disorders of the spine.