1
|
Oliveira VDA, Almeida RAMDB, Cavalcante RDS, de Andrade LGM, Ribeiro SM. Radiological presentation of active pulmonary tuberculosis in kidney transplant recipients: a retrospective study of four cases and a review of the literature. Radiol Bras 2024; 57:e20230124. [PMID: 38993963 PMCID: PMC11235070 DOI: 10.1590/0100-3984.2023.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/06/2023] [Accepted: 01/24/2024] [Indexed: 07/13/2024] Open
Abstract
Although kidney transplantation is the best therapeutic option for patients with chronic kidney disease, the immunosuppression required greatly increases susceptibility to infections that are responsible for high post-transplant mortality. Pulmonary tuberculosis (TB) represents a major cause of such infections, and its early diagnosis is therefore quite important. In view of that, we researched the manifestations of active pulmonary TB in kidney transplant recipients, through chest X-ray and computed tomography (CT), as well as determining the number of cases of active pulmonary TB occurring over a 3.5-year period at our institution. We identified four cases of active pulmonary TB in kidney transplant recipients. The CT scans provided information complementary to the chest X-ray findings in all four of those cases. We compared our CT findings with those reported in the literature. We analyzed our experience in conjunction with an extensive review of the literature that was nevertheless limited because few studies have been carried out in lowand middle-income countries, where the incidence of TB is higher.
Collapse
Affiliation(s)
- Virgilio de Araujo Oliveira
- Faculdade de Medicina de Botucatu, Universidade Estadual Paulista
“Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil
| | | | - Ricardo de Souza Cavalcante
- Faculdade de Medicina de Botucatu, Universidade Estadual Paulista
“Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil
| | | | - Sergio Marrone Ribeiro
- Faculdade de Medicina de Botucatu, Universidade Estadual Paulista
“Júlio de Mesquita Filho” (UNESP). Botucatu, SP, Brazil
| |
Collapse
|
2
|
Qiu Q, Li S, Chen Y, Yan X, Yang S, Qiu S, Peng A, Chen Y. Development, assessment and validation of a novel prediction nomogram model for risk identification of tracheobronchial tuberculosis in patients with pulmonary tuberculosis. BMJ Open Respir Res 2023; 10:e001781. [PMID: 37931979 PMCID: PMC10632898 DOI: 10.1136/bmjresp-2023-001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVE Tracheobronchial tuberculosis (TBTB), a specific subtype of pulmonary tuberculosis (PTB), can lead to bronchial stenosis or bronchial occlusion if not identified early. However, there is currently no available means for predicting the risk of associated TBTB in PTB patients. The objective of this study was to establish a risk prediction nomogram model for estimating the associated TBTB risk in every PTB patient. METHODS A retrospective cohort study was conducted with 2153 PTB patients. Optimised characteristics were selected using least absolute shrinkage and selection operator regression. Multivariate logistic regression was applied to build a predictive nomogram model. Discrimination, calibration and clinical usefulness of the prediction model were assessed using C-statistics, receiver operator characteristic curves, calibration plots and decision analysis. The developed model was validated both internally and externally. RESULTS Among all PTB patients who underwent bronchoscopies (n=2153), 40.36% (n=869) were diagnosed with TBTB. A nomogram model incorporating 11 predictors was developed and displayed good discrimination with a C-statistics of 0.782, a sensitivity of 0.661 and a specificity of 0.762 and good calibration with a calibration-in-the-large of 0.052 and a calibration slope of 0.957. Model's discrimination was favourable in both internal (C-statistics, 0.782) and external (C-statistics, 0.806) validation. External validation showed satisfactory accuracy (sensitivity, 0.690; specificity, 0.804) in independent cohort. Decision curve analysis showed that the model was clinically useful when intervention was decided on at the exacerbation possibility threshold of 2.3%-99.2%. A clinical impact curve demonstrated that our model predicted high-risk estimates and true positives. CONCLUSION We developed a novel and convenient risk prediction nomogram model that enhances the risk assessment of associated TBTB in PTB patients. This nomogram can help identify high-risk PTB patients who may benefit from early bronchoscopy and aggressive treatment to prevent disease progression.
Collapse
Affiliation(s)
- Qian Qiu
- Post-Doctoral Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Siju Li
- Emergency Department, Chongqing Public Health Medical Center, Chongqing, China
| | - Yong Chen
- Department of Endocrinology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaofeng Yan
- Division of Tuberculosis, Chongqing Public Health Medical Center, Chongqing, China
| | - Song Yang
- Division of Tuberculosis, Chongqing Public Health Medical Center, Chongqing, China
| | - Shi Qiu
- Department of Nutrition, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Anzhou Peng
- Division of Tuberculosis, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| |
Collapse
|
3
|
Muacevic A, Adler JR, Kumar S, Shayowitz DJ. Hospital Practices for Respiratory Isolation for Patients With Suspected Tuberculosis and Potential Application of Prediction Models. Cureus 2022; 14:e32294. [PMID: 36627984 PMCID: PMC9822524 DOI: 10.7759/cureus.32294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
Hospitalized persons with suspected pulmonary tuberculosis (PTB) are placed in airborne isolation to prevent nosocomial infection, as recommended by the Centers for Disease Control and Prevention (CDC). There is significant evidence that clinicians overuse this resource due to an abundance of caution when confronted with a patient with possible PTB. Many researchers have developed predictive tools based on clinical and radiographic data to assist clinicians in deciding which patients to place in respiratory isolation. We assessed the isolation practices for an urban hospital serving a large immigrant population and then retrospectively applied seven previously derived prediction models of isolation of PTB to our population. Our current clinical practice results in 76% of patients with PTB being placed in isolation on admission. However, 208 patients without PTB were placed in isolation unnecessarily for a total of 584 days. Four models had sensitivities greater than 90%, and two models had sensitivities of 100%. The use of these models would have potentially saved more than 150 days of patient isolation per year.
Collapse
|
4
|
George M, Dinant GJ, Kentiba E, Teshome T, Teshome A, Tsegaye B, Spigt M. Evaluation of the performance of clinical predictors in estimating the probability of pulmonary tuberculosis among smear-negative cases in Northern Ethiopia: a cross-sectional study. BMJ Open 2020; 10:e037913. [PMID: 33148731 PMCID: PMC7640509 DOI: 10.1136/bmjopen-2020-037913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the performance of the predictors in estimating the probability of pulmonary tuberculosis (PTB) when all versus only significant variables are combined into a decision model (1) among all clinical suspects and (2) among smear-negative cases based on the results of culture tests. DESIGN A cross-sectional study. SETTING Two public referral hospitals in Tigray, Ethiopia. PARTICIPANTS A total of 426 consecutive adult patients admitted to the hospitals with clinical suspicion of PTB were screened by sputum smear microscopy and chest radiograph (chest X-ray (CXR)) in accordance with the Ethiopian guidelines of the National Tuberculosis and Leprosy Program. Discontinuation of antituberculosis therapy in the past 3 months, unproductive cough, HIV positivity and unwillingness to give written informed consent were the basis of exclusion from the study. PRIMARY AND SECONDARY OUTCOME MEASURES A total of 354 patients were included in the final analysis, while 72 patients were excluded because culture tests were not done. RESULTS The strongest predictive variables of culture-positive PTB among patients with clinical suspicion were a positive smear test (OR 172; 95% CI 23.23 to 1273.54) and having CXR lesions compatible with PTB (OR 10.401; 95% CI 5.862 to 18.454). The regression model had a good predictive performance for identifying culture-positive PTB among patients with clinical suspicion (area under the curve (AUC) 0.84), but it was rather poor in patients with a negative smear result (AUC 0.64). Combining all the predictors in the model compared with only the independent significant variables did not really improve its performance to identify culture-positive (AUC 0.84-0.87) and culture-negative (AUC 0.64-0.69) PTB. CONCLUSIONS Our finding suggests that predictive models based on clinical variables will not be useful to discriminate patients with culture-negative PTB from patients with culture-positive PTB among patients with smear-negative cases.
Collapse
Affiliation(s)
- Mala George
- Department of Biomedical Sciences, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Geert-Jan Dinant
- Department of Family Medicine, CAPHRI School of Public Health and Primary Care/Maastricht University, Maastricht, The Netherlands
| | - Efrem Kentiba
- Department of Sports Science, Arba Minch College of Teachers Education, Arba Minch, Ethiopia
| | - Teklu Teshome
- Department of Biomedical Sciences, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Abinet Teshome
- Department of Biomedical Sciences, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Behailu Tsegaye
- Department of Biomedical Sciences, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Mark Spigt
- Department of Family Medicine, CAPHRI School of Public Health and Primary Care/Maastricht University, Maastricht, The Netherlands
- General Practice Research Unit, Department of Community Medicine, Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
5
|
Wang S, Tu J. Nomogram to predict multidrug-resistant tuberculosis. Ann Clin Microbiol Antimicrob 2020; 19:27. [PMID: 32505203 PMCID: PMC7276074 DOI: 10.1186/s12941-020-00369-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background Multidrug-resistant tuberculosis (MDR-TB) is burgeoning globally, and has been a serious challenge in TB management. Clinically, the ability to identify MDR-TB is still limited, especially in smear-negative TB. The aim of this study was to develop a nomogram for predicting MDR-TB. Methods Demographics and clinical characteristics of both MDR-TB and drug-susceptible TB patients were utilized to develop a nomogram for predicting MDR-TB. The LASSO regression method was applied to filter variables and select predictors, and multivariate logistic regression was used to construct a nomogram. The discriminatory ability of the model was determined by calculating the area under the curve (AUC). Moreover, calibration analysis and decision curve analysis (DCA) of the model were performed. This study involved a second analysis of a completed prospective cohort study conducted in a country with a high TB burden. Results Five variables of TB patients were selected through the LASSO regression method, and a nomogram was built based on these variables. The predictive model yielded an AUC of 0.759 (95% CI, 0.719–0.799), and in the internal validation, the AUC was 0.757 (95% CI, 0.715–0.793). The predictive model was well-calibrated, and DCA showed that if the threshold probability of MDR-TB was between 70 and 90%, using the proposed nomogram to predict MDR-TB would obtain a net benefit. Conclusions In this study, a nomogram was constructed that incorporated five demographic and clinical characteristics of TB patients. The nomogram may be of great value for the prediction of MDR-TB in patients with sputum-free or smear-negative TB.
Collapse
Affiliation(s)
- Saibin Wang
- Department of Respiratory Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, No. 365, East Renmin Road, Jinhua, 321000, Zhejiang Province, China.
| | - Junwei Tu
- Department of Respiratory Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, No. 365, East Renmin Road, Jinhua, 321000, Zhejiang Province, China
| |
Collapse
|
6
|
Behan S, Belton S, Peers C, O'Connor NE, Issartel J. Moving Well-Being Well: Investigating the maturation of fundamental movement skill proficiency across sex in Irish children aged five to twelve. J Sports Sci 2019; 37:2604-2612. [PMID: 31379260 DOI: 10.1080/02640414.2019.1651144] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Fundamental movement skills (FMS) are the basic building blocks of more advanced, complex movements required to participate in physical activity. This study examined FMS proficiency across the full range of Irish primary school children (n = 2098, 47% girls, age range 5-12 years). Participants were assessed using the Test of Gross Motor Development, 3rd edition (TGMD-3), Victorian Fundamental Movement skills manual, and the balance subtest from the Bruininks-Oseretsky Test of Motor Proficiency 2 (BOT-2). Independent sample t-tests and a one way between groups ANOVA with planned comparisons were used analyse sex and age differences. Mastery or near mastery of skills ranged from 16% for overhand throw, to 75.3% for run. Girls scored significantly higher than boys in the locomotor and balance subtests with the boys outperforming the girls in object control skills. Improvements in ability can be seen over time (F(8,1968) = 70.18, p < 0.001), with significant increases in FMS proficiency seen up to the age of 10, after which proficiency begins to decline. The findings demonstrate the low levels of FMS proficiency amongst Irish primary school children, the differences between sex that exist, and highlights the need for more programmes that focus on developing these FMS at an early age.
Collapse
Affiliation(s)
- Stephen Behan
- School of Health and Human Performance, Dublin City University , Dublin , Ireland.,Insight Centre for Data Analytics, Dublin City University , Dublin , Ireland
| | - Sarahjane Belton
- School of Health and Human Performance, Dublin City University , Dublin , Ireland
| | - Cameron Peers
- School of Health and Human Performance, Dublin City University , Dublin , Ireland.,Insight Centre for Data Analytics, Dublin City University , Dublin , Ireland
| | - Noel E O'Connor
- Insight Centre for Data Analytics, Dublin City University , Dublin , Ireland
| | - Johann Issartel
- School of Health and Human Performance, Dublin City University , Dublin , Ireland
| |
Collapse
|
7
|
Development of a Predictive Model of Tuberculosis Transmission among Household Contacts. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2019; 2019:5214124. [PMID: 31467622 PMCID: PMC6701319 DOI: 10.1155/2019/5214124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/11/2019] [Indexed: 12/29/2022]
Abstract
Background Household contacts of patients with tuberculosis (TB) are at great risk of TB infection. The aim of this study was to develop a predictive model of TB transmission among household contacts. Method This was a secondary analysis of data from a prospective cohort study, in which a total of 700 TB patients and 3417 household contacts were enrolled between 2010 and 2013 at two study sites in Peru. The incidence of secondary TB cases among household contacts of index cases was recorded. The LASSO regression method was used to reduce the data dimension and to filter variables. Multivariate logistic regression analysis was applied to develop the predictive model, and internal validation was performed. A nomogram was constructed to display the model, and the AUC was calculated. The calibration curve and decision curve analysis (DCA) were also evaluated. Results The incidence of TB disease among the contacts of index cases was 4.4% (149/3417). Ten variables (gender, age, TB history, diabetes, HIV, index patient's drug resistance, socioeconomic status, spoligotypes, and the index-contact share sleeping room status) filtered through the LASSO regression technique were finally included in the predictive model. The model showed good discriminatory ability, with an AUC value of 0.761 (95% CI, 0.723–0.800) for the derivation and 0.759 (95% CI, 0.717–0.796) for the internal validation. The predictive model showed good calibration, and the DCA demonstrated that the model was clinically useful. Conclusion A predictive model was developed that incorporates characteristics of both the index patients and the contacts, which may be of great value for the individualized prediction of TB transmission among household contacts.
Collapse
|
8
|
Clinical-Laboratory Prediction Rule Derivation for Pulmonary Tuberculosis Diagnosis in General Hospitals in a High-Burden Country. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Systematic review with meta-analyses and critical appraisal of clinical prediction rules for pulmonary tuberculosis in hospitals. Infect Control Hosp Epidemiol 2015; 36:204-13. [PMID: 25633004 DOI: 10.1017/ice.2014.29] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To systematically review studies evaluating clinical prediction rules (CPRs) for adult inpatients suspected to have pulmonary tuberculosis. DESIGN Systematic review with meta-analyses. SETTING Hospitals. Patients Inpatients at least 15 years of age admitted to acute care. METHODS A search was conducted in 5 indexed electronic databases with no language or year of publication restrictions. We performed a meta-analysis for those CPRs with at least 2 validation studies. Results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS Of the 461 abstracts selected, 36 articles were fully analyzed and 11 articles were included, yielding 8 CPRs derived in 4 countries. Broad validation studies were identified for 2 CPRs. The most frequent clinical predictors were fever and weight loss. All CPRs included chest imaging signs. Most CPRs were derived in countries with a low prevalence of pulmonary tuberculosis and included homeless, immigrants, and those who reacted to the purified protein derivative test. Both of the CPRs derived in countries with a high prevalence of pulmonary tuberculosis strongly relied on chest radiograph predictors. Accuracy of the different CPRs was high (area under receiver operating characteristic curve, 0.79-0.91). Meta-analysis of 4 validation studies for Wisnivesky's CPR indicates optimistic pooled results: sensitivity, 94.1% (95% CI, 89.7%-96.7%); negative likelihood ratio, 0.22 (95% CI, 0.12-0.40). CONCLUSION On the basis of a critical appraisal of the 2 best validated CPRs, the presence of weight loss and/or fever in inpatients warrants obtaining a chest radiograph, regardless of the presence of productive cough. If the chest radiograph is abnormal, the patient should be placed in isolation until more specific test results are available. Validation in different settings is required to maximize external generalization of existing CPRs.
Collapse
|
10
|
Review of nucleic acid amplification tests and clinical prediction rules for diagnosis of tuberculosis in acute care facilities. Infect Control Hosp Epidemiol 2015; 36:1215-25. [PMID: 26166303 DOI: 10.1017/ice.2015.145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Tuberculosis (TB) remains an important cause of hospitalization and mortality in the United States. Prevention of TB transmission in acute care facilities relies on prompt identification and implementation of airborne isolation, rapid diagnosis, and treatment of presumptive pulmonary TB patients. In areas with low TB burden, this strategy may result in inefficient utilization of airborne infection isolation rooms (AIIRs). We reviewed TB epidemiology and diagnostic approaches to inform optimal TB detection in low-burden settings. Published clinical prediction rules for individual studies have a sensitivity ranging from 81% to 100% and specificity ranging from 14% to 63% for detection of culture-positive pulmonary TB patients admitted to acute care facilities. Nucleic acid amplification tests (NAATs) have a specificity of >98%, and the sensitivity of NAATs varies by acid-fast bacilli sputum smear status (positive smear, ≥95%; negative smear, 50%-70%). We propose an infection prevention strategy using a clinical prediction rule to identify patients who warrant diagnostic evaluation for TB in an AIIR with an NAAT. Future studies are needed to evaluate whether use of clinical prediction rules and NAATs results in optimized utilization of AIIRs and improved detection and treatment of presumptive pulmonary TB patients.
Collapse
|
11
|
Rudolf F. The Bandim TBscore--reliability, further development, and evaluation of potential uses. Glob Health Action 2014; 7:24303. [PMID: 24857613 PMCID: PMC4032506 DOI: 10.3402/gha.v7.24303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 04/20/2014] [Accepted: 04/28/2014] [Indexed: 12/12/2022] Open
Abstract
Background The tuberculosis (TB) case detection rate has stagnated at 60% due to disorganized case finding and insensitivity of sputum smear microscopy. Of the identified TB cases, 4% die while being treated, monitored with tools that insufficiently predict failure/mortality. Objective To explore the TBscore, a recently proposed clinical severity measure for pulmonary TB (PTB) patients, and to refine, validate, and investigate its place in case finding. Design The TBscore’s inter-observer agreement was assessed and compared to the Karnofsky Performance Score (KPS) (paper I). The TBscore’s variables underlying constructs were assessed, sorting out unrelated items, proposing a more easily assessable TBscoreII, which was validated internally and externally (paper II). Finally, TBscore and TBscoreII’s place in PTB-screening was examined in paper III. Results The inter-observer variability when grading PTB patients into severity classes was moderate for both TBscore (κW=0.52, 95% CI 0.46–0.56) and KPS (κW=0.49, 95% CI 0.33–0.65). KPS was influenced by HIV status, whereas TBscore was unaffected by it. In paper II, proposed TBscoreII was validated internally, in Guinea-Bissau, and externally, in Ethiopia. In both settings, a failure to bring down the score by ≥25% from baseline to 2 months of treatment predicted subsequent failure (p=0.007). Finally, in paper III, TBscore and TBscoreII were assessed in health-care-seeking adults and found to be higher in PTB-diagnosed patients, 4.9 (95% CI 4.6–5.2) and 3.9 (95% CI 3.8–4.0), respectively, versus patients not diagnosed with PTB, 3.0 (95% CI 2.7–3.2) and 2.4 (95% CI 2.3–2.5), respectively. Had we referred only patients with cough >2 weeks to sputum smear, we would have missed 32.1% of the smear confirmed cases in our cohort. A TBscoreII>=2 missed 8.6%. Conclusions TBscore and TBscoreII are useful monitoring tools for PTB patients on treatment, as they could fill the void which currently exists in risk grading of patients. They may also have a role in PTB screening; however, this requires our findings to be repeated elsewhere.
Collapse
Affiliation(s)
- Frauke Rudolf
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark;
| |
Collapse
|
12
|
Pinto LM, Dheda K, Theron G, Allwood B, Calligaro G, van Zyl-Smit R, Peter J, Schwartzman K, Menzies D, Bateman E, Pai M, Dawson R. Development of a simple reliable radiographic scoring system to aid the diagnosis of pulmonary tuberculosis. PLoS One 2013; 8:e54235. [PMID: 23349835 PMCID: PMC3548832 DOI: 10.1371/journal.pone.0054235] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 12/10/2012] [Indexed: 02/02/2023] Open
Abstract
Rationale Chest radiography is sometimes the only method available for investigating patients with possible pulmonary tuberculosis (PTB) with negative sputum smears. However, interpretation of chest radiographs in this context lacks specificity for PTB, is subjective and is neither standardized nor reproducible. Efforts to improve the interpretation of chest radiography are warranted. Objectives To develop a scoring system to aid the diagnosis of PTB, using features recorded with the Chest Radiograph Reading and Recording System (CRRS). Methods Chest radiographs of outpatients with possible PTB, recruited over 3 years at clinics in South Africa were read by two independent readers using the CRRS method. Multivariate analysis was used to identify features significantly associated with culture-positive PTB. These were weighted and used to generate a score. Results 473 patients were included in the analysis. Large upper lobe opacities, cavities, unilateral pleural effusion and adenopathy were significantly associated with PTB, had high inter-reader reliability, and received 2, 2, 1 and 2 points, respectively in the final score. Using a cut-off of 2, scores below this threshold had a high negative predictive value (91.5%, 95%CI 87.1,94.7), but low positive predictive value (49.4%, 95%CI 42.9,55.9). Among the 382 TB suspects with negative sputum smears, 229 patients had scores <2; the score correctly ruled out active PTB in 214 of these patients (NPV 93.4%; 95%CI 89.4,96.3). The score had a suboptimal negative predictive value in HIV-infected patients (NPV 86.4, 95% CI 75,94). Conclusions The proposed scoring system is simple, and reliably ruled out active PTB in smear-negative HIV-uninfected patients, thus potentially reducing the need for further tests in high burden settings. Validation studies are now required.
Collapse
Affiliation(s)
- Lancelot M. Pinto
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Québec, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Québec, Canada
| | - Keertan Dheda
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Grant Theron
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Brian Allwood
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Gregory Calligaro
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Richard van Zyl-Smit
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - Jonathan Peter
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Kevin Schwartzman
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Québec, Canada
- Respiratory Division, Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Québec, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Québec, Canada
- Respiratory Division, Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Eric Bateman
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
- University of Cape Town Lung Institute, Cape Town, South Africa
| | - Madhukar Pai
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Québec, Canada
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Québec, Canada
| | - Rodney Dawson
- Division of Pulmonology, Department of Medicine, University of Cape Town Lung Institute, Cape Town, South Africa
- University of Cape Town Lung Institute, Cape Town, South Africa
- * E-mail:
| |
Collapse
|
13
|
Symptom screen for identification of highly infectious tuberculosis in people living with HIV in Southeast Asia. J Acquir Immune Defic Syndr 2012; 60:519-24. [PMID: 22487587 DOI: 10.1097/qai.0b013e318256b3db] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tuberculosis (TB) is the leading cause of death among people living with HIV and frequently transmitted among this susceptible group. Transmission can be reduced by infection control practices. Simple evidence-based methods to identify patients who should be isolated are not well described in the literature. We sought to identify a simple, sensitive symptom or symptom combination that healthcare providers in resource-limited settings can use to identify and isolate persons living with HIV with highly infectious TB. METHODS Participants from 8 outpatient facilities in Cambodia, Thailand, and Vietnam underwent an extensive evaluation for TB. Patients with ≥1 positive sputum smear and Mycobacterium tuberculosis culture growth from a pulmonary site were defined as having highly infectious TB. We calculated sensitivity and prevalence of individual symptoms and >1000 symptom combinations. RESULTS Of 1980 participants, 272 (14%) had TB. Forty percent (n = 109) were highly infectious. Sensitivity for detecting highly infectious TB was highest for having the following symptoms in the past month as follows: weight loss (84%), cough (83%), fever (81%), and fatigue (78%); however, these symptoms were found in 46%-54% of all participants. Having 2 or 3 of 4 symptoms (prevalence, 26%-47%)-weight loss, fever, current cough, and night sweats-was 72%-90% sensitive for highly infectious TB. CONCLUSIONS The 2 or 3 of 4 symptom combinations of weight loss, fever, current cough, and night sweats, which are the same symptoms comprising the current World Health Organization-recommended TB diagnostic screen, are sensitive for detecting highly infectious TB in people living with HIV.
Collapse
|
14
|
Rodrigo T, Caylà JA, Casals M, García-García JM, Caminero JA, Ruiz-Manzano J, Blanquer R, Vidal R, Altet N, Calpe JL, Penas A. A predictive scoring instrument for tuberculosis lost to follow-up outcome. Respir Res 2012; 13:75. [PMID: 22938040 PMCID: PMC3490987 DOI: 10.1186/1465-9921-13-75] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/22/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adherence to tuberculosis (TB) treatment is troublesome, due to long therapy duration, quick therapeutic response which allows the patient to disregard about the rest of their treatment and the lack of motivation on behalf of the patient for improved. The objective of this study was to develop and validate a scoring system to predict the probability of lost to follow-up outcome in TB patients as a way to identify patients suitable for directly observed treatments (DOT) and other interventions to improve adherence. METHODS Two prospective cohorts, were used to develop and validate a logistic regression model. A scoring system was constructed, based on the coefficients of factors associated with a lost to follow-up outcome. The probability of lost to follow-up outcome associated with each score was calculated. Predictions in both cohorts were tested using receiver operating characteristic curves (ROC). RESULTS The best model to predict lost to follow-up outcome included the following characteristics: immigration (1 point value), living alone (1 point) or in an institution (2 points), previous anti-TB treatment (2 points), poor patient understanding (2 points), intravenous drugs use (IDU) (4 points) or unknown IDU status (1 point). Scores of 0, 1, 2, 3, 4 and 5 points were associated with a lost to follow-up probability of 2,2% 5,4% 9,9%, 16,4%, 15%, and 28%, respectively. The ROC curve for the validation group demonstrated a good fit (AUC: 0,67 [95% CI; 0,65-0,70]). CONCLUSION This model has a good capacity to predict a lost to follow-up outcome. Its use could help TB Programs to determine which patients are good candidates for DOT and other strategies to improve TB treatment adherence.
Collapse
Affiliation(s)
- Teresa Rodrigo
- Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Lagrange-Xélot M, Porcher R, Gallien S, Wargnier A, Pavie J, de Castro N, Molina JM. Prevalence and clinical predictors of pulmonary tuberculosis among isolated inpatients: a prospective study. Clin Microbiol Infect 2011; 17:610-4. [PMID: 20459437 DOI: 10.1111/j.1469-0691.2010.03259.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Guidelines help to prevent the transmission of Mycobacterium tuberculosis in healthcare settings, but may also result in the unnecessary isolation of many patients. We performed a prospective study to assess the prevalence and identify clinical predictors of culture-proven tuberculosis among inpatients isolated for suspected pulmonary tuberculosis (PTB) at our hospital. We also wished to validate a pre-existing clinical decision rule to improve our isolation policy. From August 2005 to January 2007, 134 patients isolated on admission to the ward for suspicion of PTB were prospectively enrolled. The admitting team made the decision to isolate patients on the basis of clinical and radiological findings, without the use of the clinical decision rule, and graded the overall suspicion of PTB. Twenty-six of the 134 isolated patients had PTB (prevalence: 19.4%), as well as one patient not isolated at admission. Univariate analysis revealed that PTB was significantly associated with young age, lack of human immunodeficiency virus (HIV) infection, weight loss, night sweats, fever, upper lobe disease and, especially, cavitary lesions on chest X-ray (adjusted OR 25.4, p <0.0001). Low suspicion of PTB by the admitting team and low clinical decision rule score had negative predictive values of 98.5% and 95.8% for PTB, respectively. Use of the clinical decision rule in addition to the team assessment would have led to the isolation of the patient with PTB not isolated on admission, and avoided 16 (14.8%) unnecessary isolations. In conclusion, the prevalence of PTB among isolated inpatients was high, and the use of a clinical decision rule in addition to clinical impression might improve isolation decisions.
Collapse
Affiliation(s)
- M Lagrange-Xélot
- Department of Infectious Diseases, Laboratory of Microbiology, Saint Louis Hospital, AP-HP and University of Paris Diderot Paris, Paris, France.
| | | | | | | | | | | | | |
Collapse
|
16
|
Solari L, Acuna-Villaorduna C, Soto A, van der Stuyft P. Evaluation of clinical prediction rules for respiratory isolation of inpatients with suspected pulmonary tuberculosis. Clin Infect Dis 2011; 52:595-603. [PMID: 21292665 DOI: 10.1093/cid/ciq186] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the framework of hospital infection control, various clinical prediction rules (CPRs) for respiratory isolation of patients with suspected pulmonary tuberculosis (PTB) have been developed. Our aim was to evaluate their performance in an emergency department setting with a high prevalence of PTB. METHODS We searched the MEDLINE and OVID databases to identify CPRs to predict PTB. We used a previously collected database containing clinical, radiographical, and microbiological information on patients attending an emergency department with respiratory complaints, and we applied each CPR to every patient and compared the result with culture for Mycobacterium tuberculosis as the reference standard. We also simulated the proportion of isolated suspects and missed cases for PTB prevalences of 5% and 30%. RESULTS We withheld 13 CPRs for evaluation. We had complete data on 345 patients. Most CPRs achieved a high sensitivity but very low specificity and very low positive predictive value. Mylotte's score, which includes results of sputum smear as a predictive finding, was the best-performing CPR. It attained a sensitivity of 88.9% and a specificity of 63.9%. However, at a 30% PTB prevalence, 498 of 1000 individuals with suspected PTB would have to be isolated; 267 of these cases would be true PTB cases, and 33 cases would be missed. Two consecutive sputum smears had a sensitivity of 75.6% and a specificity of 99.7%. CONCLUSIONS In a setting with a high prevalence of PTB, only 1 of the 13 assessed CPRs demonstrated high sensitivity combined with satisfactory specificity. Our results highlight the need for local validation of CPRs before their application.
Collapse
Affiliation(s)
- Lely Solari
- Epidemiology and Disease Control Unit, Institute of Tropical Medicine, Antwerp, Belgium.
| | | | | | | |
Collapse
|
17
|
Martínez D, Heudebert G, Seas C, Henostroza G, Rodriguez M, Zamudio C, Centor RM, Herrera C, Gotuzzo E, Estrada C. Clinical prediction rule for stratifying risk of pulmonary multidrug-resistant tuberculosis. PLoS One 2010; 5:e12082. [PMID: 20711459 PMCID: PMC2920322 DOI: 10.1371/journal.pone.0012082] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 07/19/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Multidrug-resistant tuberculosis (MDR-TB), resistance to at least isoniazid and rifampin, is a worldwide problem. OBJECTIVE To develop a clinical prediction rule to stratify risk for MDR-TB among patients with pulmonary tuberculosis. METHODS Derivation and internal validation of the rule among adult patients prospectively recruited from 37 health centers (Perú), either a) presenting with a positive acid-fast bacillus smear, or b) had failed therapy or had a relapse within the first 12 months. RESULTS Among 964 patients, 82 had MDR-TB (prevalence, 8.5%). Variables included were MDR-TB contact within the family, previous tuberculosis, cavitary radiologic pattern, and abnormal lung exam. The area under the receiver-operating curve (AUROC) was 0.76. Selecting a cut-off score of one or greater resulted in a sensitivity of 72.6%, specificity of 62.8%, likelihood ratio (LR) positive of 1.95, and LR negative of 0.44. Similarly, selecting a cut-off score of two or greater resulted in a sensitivity of 60.8%, specificity of 87.5%, LR positive of 4.85, and LR negative of 0.45. Finally, selecting a cut-off score of three or greater resulted in a sensitivity of 45.1%, specificity of 95.3%, LR positive of 9.56, and LR negative of 0.58. CONCLUSION A simple clinical prediction rule at presentation can stratify risk for MDR-TB. If further validated, the rule could be used for management decisions in resource-limited areas.
Collapse
Affiliation(s)
- Dalila Martínez
- Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Gustavo Heudebert
- Division of General Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, United States of America
| | - Carlos Seas
- Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - German Henostroza
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Martin Rodriguez
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Carlos Zamudio
- Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Robert M. Centor
- Division of General Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, United States of America
| | - Cesar Herrera
- Peruvian Tuberculosis Program, Ministry of Health, Lima, Perú
| | - Eduardo Gotuzzo
- Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Carlos Estrada
- Division of General Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, United States of America
| |
Collapse
|
18
|
Development of a simple model for predicting need for surgery in patients who initially undergo conservative management for adhesive small bowel obstruction. Am J Surg 2010; 200:215-23. [PMID: 20591400 DOI: 10.1016/j.amjsurg.2009.07.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 06/05/2009] [Accepted: 07/09/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Among patients with adhesive small bowel obstruction (ASBO) initially managed with a conservative strategy, predicting risk of operation is difficult. METHODS We investigated ASBO patients at 2 different periods to derive and validate a clinical prediction model for risk of operation. RESULTS One hundred fifty-four patients were enrolled into the derivation cohort and 96 into the validation cohort. Based on the derived scoring, including age > or =65 years, presence of ascites, and gastrointestinal drainage volume >500 mL on day 3, each patient was classified into 1 of 4 risk classes from low risk to high risk. When applied to the validation cohort, the positive predictive value (PPV) for operation in the high-risk class was 72%, while the negative predictive value (NPV) in the low-risk class was 100% with high sensitivity (100%) and specificity (96%). CONCLUSIONS The prediction model performs well for risk stratification of need for surgical intervention following conservative strategy among ASBO patients.
Collapse
|