Non-completion of latent tuberculous infection treatment among children in Rio de Janeiro State, Brazil

BACKGROUND

Children with latent tuberculous infection (LTBI) are particularly vulnerable to progression to active tuberculosis (TB), and are thus a priority target for isoniazid preventive therapy (IPT). However, adherence to IPT is poor. We hypothesised that children from poorer families, with reduced access to health care and lack of understanding about the disease are more likely to default from IPT.

METHODS

A questionnaire was administered to close child contacts or their parents at the time of prescribing IPT in three cities in Rio de Janeiro State. The children were followed prospectively. Treatment adherence was defined as taking 80% of prescribed doses.

RESULTS

Among 1078 children screened for LTBI, 97 (8.9%) did not return for tuberculin skin test (TST) reading; 332 (30.8%) were TST-positive; 115/332 (34.6%) were prescribed IPT, 6 of whom did not initiate treatment and 11 did not adhere during the first 2 months; 25 additional children did not complete IPT. Overall non-completion was four times more frequent among those with lower income. Health care access and knowledge did not improve treatment completion.

CONCLUSIONS

Substantial losses to follow-up occurred before IPT prescription; this should be further investigated. Among the children who started isoniazid, low income, but not difficult access or poor knowledge, increased the risk of treatment non-completion.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Quality of tuberculosis care in India: a systematic review

BACKGROUND

While Indian studies have assessed care providers' knowledge and practices, there is no systematic review on the quality of tuberculosis (TB) care.

METHODS

We searched multiple sources to identify studies (2000-2014) on providers' knowledge and practices. We used the International Standards for TB Care to benchmark quality of care.

RESULTS

Of the 47 studies included, 35 were questionnaire surveys and 12 used chart abstraction. None assessed actual practice using standardised patients. Heterogeneity in the findings precluded meta-analysis. Of 22 studies evaluating provider knowledge about using sputum smears for diagnosis, 10 found that less than half of providers had correct knowledge; 3 of 4 studies assessing self-reported practices by providers found that less than a quarter reported ordering smears for patients with chest symptoms. In 11 of 14 studies that assessed treatment, less than one third of providers knew the standard regimen for drug-susceptible TB. Adherence to standards in practice was generally lower than correct knowledge of those standards. Eleven studies with both public and private providers found higher levels of appropriate knowledge/practice in the public sector.

CONCLUSIONS

Available evidence suggests suboptimal quality of TB care, particularly in the private sector. Improvement of quality of care should be a priority for India.

Laparoscopic splenectomy is emerging 'gold standard' treatment even for massive spleens

INTRODUCTION

Since its first description by Delaitre and Maignien in 1991, laparoscopic splenectomy (LS) has evolved as treatment of choice for mild-to-moderately-enlarged spleens and for benign haematological disorders. LS is a challenge if massive spleens or malignant conditions necessitate treatment, but we report our method and its feasibility in this study.

METHODS

We undertook a retrospective study of prospectively collected data of all elective splenectomies carried out in our firm of upper gastrointestinal surgeons from June 2003 to June 2012. Only patients opting for elective LS were included in this study.

RESULTS

From June 2003 to June 2012, elective splenectomy was carried out in 80 patients. Sixty-seven patients underwent LS and 13 underwent open splenectomy (OS). In the LS group, there were 38 males and 29 females. Age ranged from 6 years to 82 years. Spleen size in the LS group ranged from ≤11 cm to 27.6 cm. Twelve patients had a spleen size of >20 cm. Weight ranged from 35 g to 2,400 g. Eighteen patients had a spleen weight of 600-1,600 g and eight had a spleen weight >1,600 g. Operating times were available for 56 patients. Mean operating time for massive spleens was 129.73 min. There was no conversion to OS. There were no major complications.

CONCLUSIONS

With improved laparoscopic expertise and advancing technology, LS is safe and feasible even for massive spleens and splenic malignancies. It is the emerging 'gold standard' for all elective splenectomies and has very few contraindications.

Determinants of Bacillus Calmette-Guérin (BCG) vaccination among Québec children

OBJECTIVES

To identify determinants of Bacillus Calmette-Guérin (BCG) vaccination among children born in Québec, Canada, in 1974, the last year of the systematic vaccination campaign.

METHOD

A retrospective birth cohort was assembled in 2011 through probabilistic linkage of administrative databases (n=81,496). Potential determinants were documented from administrative databases and by interviewing a subset of subjects (n=1643) in 2012. Analyses were conducted among subjects with complete data, 71,658 (88%) birth cohort subjects and 1154 (70%) interviewed subjects, then redone using multiple imputation. Determinants of BCG vaccination during the organized vaccination program (in 1974), and after the program (1975 onwards) were assessed separately. Logistic regression with backward elimination was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Overall, 46% of subjects were BCG vaccinated, 43% during the program and 4% after it ended. BCG vaccination during the program was associated with parents' birthplace and urban or rural residence. BCG vaccination after the organized program was only related to ethnocultural origin of the child's grandparents.

CONCLUSION

Different factors were related to vaccination within and after the organized program. Determinants of BCG vaccination in Québec, Canada, have never been studied and will be useful for future research and vaccination campaigns.

Molecular confirmation of nine cases of Cornelia de Lange syndrome diagnosed prenatally

OBJECTIVES

Cornelia de Lange syndrome (CdLS) is characterized by distinct facial features, growth retardation, upper limb reduction defects, hirsutism, and intellectual disability. NIPBL mutations have been identified in approximately 60% of patients with CdLS diagnosed postnatally. Prenatal ultrasound findings include upper limb reduction defects, intrauterine growth restriction, and micrognathia. CdLS has also been associated with decreased PAPP-A and increased nuchal translucency (NT). We reviewed NIPBL sequence analysis results for 12 prenatal samples in our laboratory to determine the frequency of mutations in our cohort.

METHODS

This retrospective study analyzed data from all 12 prenatal cases with suspected CdLS, which were received by The University of Chicago Genetic Services Laboratories. Diagnostic NIPBL sequencing was performed for all samples. Clinical information was collected from referring physicians.

RESULTS

NIPBL mutations were identified in 9 out of the 12 cases prenatally (75%). Amongst the NIPBL mutation-positive cases with clinical information available, the most common findings were upper limb malformations and micrognathia. Five patients had NT measurements in the first trimester, of which four were noted to be increased.

CONCLUSION

We demonstrate that prenatally-detected phenotypes of CdLS, particularly severe micrognathia and bilateral upper limb defects, are associated with an increased frequency of NIPBL mutations.

Drug resistance beyond extensively drug-resistant tuberculosis: individual patient data meta-analysis

The broadest pattern of tuberculosis (TB) drug resistance for which a consensus definition exists is extensively drug-resistant (XDR)-TB. It is not known if additional drug resistance portends worsened patient outcomes. This study compares treatment outcomes of XDR-TB patients with and without additional resistance in order to explore the need for a new definition. Individual patient data on XDR-TB outcomes were included in a meta-analysis comparing outcomes between XDR alone and three nonmutually exclusive XDR-TB patient groups: XDR plus resistance to all the second-line injectables (sli) and capreomycin and kanamycin/amikacin (XDR+2sli) XDR plus resistance to second-line injectables and to more than one group 4 drug, i.e. ethionamide/protionamide, cycloserine/terizidone or para-aminosalicylic acid (XDR+sliG4) and XDR+sliG4 plus resistance to ethambutol and/or pyrazinamide (XDR+sliG4EZ). Of 405 XDR-TB cases, 301 were XDR alone, 68 XDR+2sli, 48 XDR+sliG4 and 42 XDR+sliG4EZ. In multivariate analysis, the odds of cure were significantly lower in XDR+2sli (adjusted OR 0.4, 95% CI 0.2-0.8) compared to XDR alone, while odds of failure and death were higher in all XDR patients with additional resistance (adjusted OR 2.6-2.8). Patients with additional resistance beyond XDR-TB showed poorer outcomes. Limitations in availability, accuracy and reproducibility of current drug susceptibility testing methods preclude the adoption of a useful definition beyond the one currently used for XDR-TB.

Nebulised DNase post-therapeutic bronchoalveolar lavage in near fatal asthma exacerbation in an adult patient refractory to conventional treatment

Mucus plugging plays a vital role in the pathophysiology of fatal and near fatal asthma as demonstrated in various postmortem studies. There is a paucity of published literature on how to manage mucus plugging in adult patients with refractory asthma exacerbation not responding to conventional therapies as compared with its paediatric cohort. We describe a dramatic improvement with the use of rhDNase, following bronchoalveolar lavage in an intubated adult female patient, with status asthmaticus refractory to conventional treatment.

Interferon-Gamma Release Assays versus Tuberculin Skin Testing for the Diagnosis of Latent Tuberculosis Infection: An Overview of the Evidence

A profusion of articles have been published on the accuracy and uses of interferon-gamma releasing assays. Here we review the clinical applications, advantages, and limitations of the tuberculin skin test and interferon-gamma release assays and provide an overview of the most recent systematic reviews conducted for different indications for the use of these tests. We conclude that both tests are accurate to detect latent tuberculosis, although interferon-gamma release assays have higher specificity than tuberculin skin testing in BCG-vaccinated populations, particularly if BCG is received after infancy. However, both tests perform poorly to predict risk for progression to active tuberculosis. Interferon-gamma release assays have significant limitations in serial testing because of spontaneous variability and lack of a validated definition of conversion and reversion, making it difficult for clinicians to interpret changes in category (conversions and reversions). So far, the most important clinical evidence, that is, that isoniazid preventive therapy reduces the risk for progression to disease, has been produced only in tuberculin skin test-positive individuals.

Epidemiology of tuberculosis immunology

Immunological impairment plays a major role in the epidemiology of TB. Globally, the most common causes of immunological impairment are malnutrition, diabetes, HIV/AIDS, aging, and smoking. With the notable exception of HIV, each factor leads to relatively mild immunological impairment in individuals. However, as these conditions affect a significant proportion of the population, they contribute substantially to the incidence of TB at a global scale. Understanding immunological impairment is central to understanding the global TB pandemic, and vital to the development of effective disease control strategies.

Validation of ICD-9 diagnostic codes for bronchopulmonary dysplasia in Quebec's provincial health care databases

INTRODUCTION

Bronchopulmonary dysplasia (BPD) is a chronic respiratory disease caused by neonatal lung injury. The aim of this study was to validate the use of ICD-9 diagnostic codes for BPD in administrative databases to allow for their use in health care utilization analyses.

METHODS

The validation process used a retrospective cohort composed of preterm infants, with or without respiratory complications, admitted to the Montréal Children's Hospital, Montréal, Quebec, between 1983 and 1992. BPD subjects were identified using ICD-9 diagnostic codes in the provincial administrative databases (medical services and MED-ECHO) and then matched with subjects with confirmed BPD from the validation cohort. We examined concordance and estimated sensitivity and specificity associated with the use of these diagnostic codes for BPD.

RESULTS

True positive and false negative BPD subjects did not differ significantly according to gestational age, birth weight and Apgar scores. False positive BPD subjects were found to have significantly lower gestational age than true negative subjects. The use of the ICD-9 diagnostic codes for BPD was associated with a specificity between 97.6% and 98.0%. The sensitivity was lower at 45.0% and 52.4% for the medical services and MED-ECHO databases, respectively. Milder cases of BPD tended to be missed more frequently than more severe cases.

CONCLUSION

The specificity of the use of ICD-9 diagnostic codes for BPD in the Quebec provincial health care databases is adequate to allow its routine use. Its lower sensitivity for milder cases will likely result in an underestimation of the impacts of BPD on the long-term health care utilization of preterm infants.

Validation of ICD-9 diagnostic codes for bronchopulmonary dysplasia in Quebec's provincial health care databases

Introduction

Bronchopulmonary dysplasia (BPD) is a chronic respiratory disease caused by neonatal lung injury. The aim of this study was to validate the use of ICD-9 diagnostic codes for BPD in administrative databases to allow for their use in health care utilization analyses.

Methods

The validation process used a retrospective cohort composed of preterm infants, with or without respiratory complications, admitted to the Montréal Children's Hospital, Montréal, Quebec, between 1983 and 1992. BPD subjects were identified using ICD-9 diagnostic codes in the provincial administrative databases (medical services and MED-ECHO) and then matched with subjects with confirmed BPD from the validation cohort. We examined concordance and estimated sensitivity and specificity associated with the use of these diagnostic codes for BPD.

Results

True positive and false negative BPD subjects did not differ significantly according to gestational age, birth weight and Apgar scores. False positive BPD subjects were found to have significantly lower gestational age than true negative subjects. The use of the ICD-9 diagnostic codes for BPD was associated with a specificity between 97.6% and 98.0%. The sensitivity was lower at 45.0% and 52.4% for the medical services and MED-ECHO databases, respectively. Milder cases of BPD tended to be missed more frequently than more severe cases.

Conclusion

The specificity of the use of ICD-9 diagnostic codes for BPD in the Quebec provincial health care databases is adequate to allow its routine use. Its lower sensitivity for milder cases will likely result in an underestimation of the impacts of BPD on the long-term health care utilization of preterm infants.

Potential cost-effectiveness of rifampin vs. isoniazid for latent tuberculosis: implications for future clinical trials

SETTING

Standard treatment for latent tuberculosis infection (LTBI) is 9 months daily isoniazid (9INH). An alternative is 4 months daily rifampin (4RMP), associated with better completion and less toxicity; however, its efficacy remains uncertain.

OBJECTIVES

To assess the cost-effectiveness of these regimens for treating LTBI in human immunodeficiency virus negative persons, using results from a recent clinical trial, plus different scenarios for 4RMP efficacy, and to estimate the costs of an adequately powered noninferiority trial and resulting savings from substitution with 4RMP.

DESIGN

A decision-analysis model tracked TB contacts and lower-risk tuberculin reactors receiving 9INH, 4RMP or no treatment. For different 4RMP efficacy scenarios, we estimated the cost-effectiveness, sample size and cost of non-inferiority trials, and potential cost savings substituting 4RMP for 9INH for 10 years in Canada.

RESULTS

With an assumed 4RMP efficacy of 60%, 9INH was more effective but slightly more expensive. Above a threshold efficacy of 69%, 4RMP was cheaper and more effective than 9INH. If the true efficacy of 4RMP is ≥75%, a trial powered to detect non-inferiority with a lower limit of 60% estimated efficacy (~20 000 subjects) may lead to cost savings within 10 years, even with the extreme assumption that Canada bears the entire cost.

CONCLUSION

4RMP may be a reasonable alternative to 9INH. Costs of a large-scale non-inferiority trial may be offset by subsequent savings.

Clinical outcomes of pyrazinamide-monoresistant Mycobacterium tuberculosis in Quebec

BACKGROUND

In Quebec, 6.2% of all tuberculosis (TB) isolates from Canadian-born patients are resistant to pyrazinamide (PZA) alone. The clinical significance of PZA-monoresistant (PZA(MR)) TB is unknown.

METHODS

Canadian-born patients with PZA(MR) TB diagnosed between 1 January 1990 and 31 December 2000 and reported in a prior study were compared to randomly selected Canadian-born patients with fully susceptible isolates diagnosed within the same time period.

RESULTS

A total of 318 patients were eligible, of whom 40 (12.6%) had missing outcome information. Mean total duration of treatment was respectively 9.0 and 8.9 months for those with PZA(MR) and pan-susceptible strains. Respectively 91% and 89% of PZA(MR) and pan-susceptible patients received at least 6 months of rifampin-containing treatment. Among 67 patients with PZA(MR) TB, 51 (76%) were cured, 3 (4%) relapsed, none failed treatment, and 16 (24%) died within 6 months of diagnosis. Of 211 subjects with fully susceptible isolates, 181 (86%) were cured, 2 (1%) relapsed, 2 (1%) failed treatment, and 30 (14%) died within 6 months of diagnosis. PZA monoresistance was associated with decreased odds of successful clinical outcomes compared with pan-susceptible TB (OR 0.4, 95%CI 0.2-0.8).

CONCLUSION

Patients with PZA(MR) TB had significantly worse clinical outcomes than patients with fully susceptible strains.

Global survey of national tuberculosis drug policies

SETTING

National tuberculosis (TB) programmes (NTPs) in 100 countries.

OBJECTIVES

To evaluate the relationship between the estimated prevalence of multidrug resistance in previously untreated TB cases and policies regarding sales and distribution of TB drugs, particularly rifampicin (RMP).

DESIGN

Questionnaire survey of national TB drug control policies, completed by NTP managers. Results were correlated with recent World Health Organization estimates of prevalence of drug resistance in new cases of TB.

RESULTS

Questionnaires were received from 100 countries, including 88 low- and middle-income countries (LMICs) and 17 of the 22 high-burden countries. Current policies were considered adequate in only 40 of the 88 LMICs (45%). A higher prevalence of multidrug resistance was associated with fewer years of free availability of TB drugs from the NTP (P = 0.02) and more years of availability of RMP from providers or pharmacies outside the NTP (P = 0.02). Eleven of the 20 countries with the highest prevalence of multidrug resistance had inadequate policies governing sales and distribution of TB drugs.

CONCLUSIONS

These findings suggest that policies regarding sales and distribution of TB drugs should receive more emphasis as part of the global strategy to control drug resistance.

Microcolony culture techniques for tuberculosis diagnosis: a systematic review

BACKGROUND

There is considerable demand for quicker and more affordable yet accurate diagnostic tools for tuberculosis (TB). The microscopic observation drug susceptibility (MODS) assay and the thin-layer agar (TLA) assay are inexpensive, rapid microcolony-based culture methods.

METHODS

A systematic review and meta-analysis was performed to assess the accuracy and other test characteristics of MODS and TLA compared to a reference standard of traditional solid or liquid culture. Pooled estimates of sensitivity and specificity and their 95% confidence intervals were estimated with an exact binomial likelihood random effects meta-analysis.

RESULTS

A total of 21 eligible studies were identified, 12 that evaluated MODS, seven that evaluated TLA and two that evaluated both. The overall pooled sensitivity and specificity of MODS were respectively 92% (95%CI 87-97) and 96% (90-100), and for TLA they were respectively 87% (95%CI 79-94) and 98% (95%CI 94-100), although there was considerable heterogeneity of results. When the studies were restricted to those assessing accuracy of MODS in sputum samples only, the sensitivity was 96% (95%CI 94-98) and the specificity 96% (95%CI 89-100). The mean intervals from reception of specimens to results were 9.2 days with MODS and 11.5 days with TLA; contamination rates averaged 6.6% with MODS and 12.3% with TLA; materials and supplies costs averaged US$1.48 for MODS and US$2.42 for TLA.

CONCLUSIONS

MODS and TLA appear to be accurate and rapid yet inexpensive diagnostic tools for active TB. However, this review did not find sufficient evidence on the feasibility and costs of implementation of these tests, nor on the impact of these tests on patient outcomes.