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Schwalb A, Cachay R, Wright A, Phillips PPJ, Kaur P, Diacon AH, Ugarte-Gil C, Mitnick CD, Sterling TR, Gotuzzo E, Horsburgh CR. Factors associated with screening failure and study withdrawal in multidrug-resistant TB. Int J Tuberc Lung Dis 2022; 26:820-825. [PMID: 35996282 DOI: 10.5588/ijtld.21.0729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Multidrug-resistant TB (MDR-TB) clinical trial in Lima, Peru and Cape Town, South Africa.OBJECTIVE: To identify baseline factors associated with screening failure and study withdrawal in an MDR-TB clinical trial.DESIGN: We screened patients for a randomized, blinded, Phase II trial which assessed culture conversion over the first 6 months of treatment with varying doses of levofloxacin plus an optimized background regimen (ClinicalTrials.gov: NCT01918397). We identified factors for screening failure and study withdrawal using Poisson regression to calculate prevalence ratios and Cox proportional hazard regression to calculate hazard ratios. We adjusted for factors with P < 0.2.RESULTS: Of the 255 patients screened, 144 (56.5%) failed screening. The most common reason for screening failure was an unsuitable resistance profile on sputum-based molecular susceptibility testing (n = 105, 72.9%). No significant baseline predictors of screening failure were identified in the multivariable model. Of the 111 who were enrolled, 33 (30%) failed to complete treatment, mostly for non-adherence and consent withdrawal. No baseline factors predicted study withdrawal in the multivariable model.CONCLUSION: No baseline factors were independently associated with either screening failure or study withdrawal in this secondary analysis of a MDR-TB clinical trial.
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Affiliation(s)
- A Schwalb
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - R Cachay
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - A Wright
- Vanderbilt University Medical Center, Vanderbilt Tuberculosis Center, Nashville, TN, USA
| | - P P J Phillips
- University of California San Francisco Center for Tuberculosis, San Francisco, CA, USA
| | - P Kaur
- Boston University, Departments of Epidemiology, Biostatistics, Global Health and Medicine, Boston, MA, USA
| | - A H Diacon
- TASK Applied Science and Stellenbosch University, Cape Town, South Africa
| | - C Ugarte-Gil
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - C D Mitnick
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - T R Sterling
- Vanderbilt University Medical Center, Vanderbilt Tuberculosis Center, Nashville, TN, USA
| | - E Gotuzzo
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - C R Horsburgh
- Boston University, Departments of Epidemiology, Biostatistics, Global Health and Medicine, Boston, MA, USA
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Oelofse S, Esmail A, Diacon AH, Conradie F, Olayanju O, Ngubane N, Howell P, Everitt D, Crook AM, Mendel CM, Wills GH, Olugbosi M, del Parigi A, Sun E, Calatroni A, Spigelman M, Dheda K. Pretomanid with bedaquiline and linezolid for drug-resistant TB: a comparison of prospective cohorts. Int J Tuberc Lung Dis 2021; 25:453-460. [PMID: 34049607 PMCID: PMC8171246 DOI: 10.5588/ijtld.21.0035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND: There are no data comparing the 6-9 month oral three-drug Nix regimen (bedaquiline, pretomanid and linezolid [BPaL]) to conventional regimens containing bedaquiline (B, BDQ) and linezolid (L, LZD).METHODS: Six-month post end-of-treatment outcomes were compared between Nix-TB (n = 109) and 102 prospectively recruited extensively drug-resistant TB patients who received an ˜18-month BDQ-based regimen (median of 8 drugs). A subset of patients received BDQ and LZD (n = 86), and a subgroup of these (n = 75) served as individually matched controls in a pairwise comparison to determine differences in regimen efficacy.RESULTS: Favourable outcomes (%) were significantly better with BPaL than with the B-L-based combination regimen (98/109, 89.9% vs. 56/86, 65.1%; adjusted relative risk ratio [aRRR] 1.35; P < 0.001) and in the matched pairwise analysis (67/75, 89.3% vs. 48/75, 64.0%; aRRR 1.39; P = 0.001), despite significantly higher baseline bacterial load and prior second-line drug exposure in the BPaL cohort. Time to culture conversion (P < 0.001), time to unfavourable outcome (P < 0.01) and time to death (P < 0.03) were significantly better or lower with BPaL than the B-L-based combinations.CONCLUSION: The BPaL regimen (and hence substitution of multiple other drugs by pretomanid and/or higher starting-dose LZD) may improve outcomes in drug-resistant TB patients with poor prognostic features. However, prospective controlled studies are required to definitively answer this question.
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Affiliation(s)
- S. Oelofse
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - A. Esmail
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - A. H. Diacon
- Task Applied Science and Stellenbosch University, Cape Town, South Africa
| | - F. Conradie
- Clinical HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
,Sizwe Tropical Disease Hospital, Sandringham, South Africa
| | - O. Olayanju
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town (UCT), Cape Town, South Africa
| | - N. Ngubane
- Task Applied Science and Stellenbosch University, Cape Town, South Africa
,King DinuZulu Hospital Complex, Durban, South Africa
| | - P. Howell
- Clinical HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
,Sizwe Tropical Disease Hospital, Sandringham, South Africa
| | | | - A. M. Crook
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - G. H. Wills
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | | | - E. Sun
- TB Alliance, New York, NY, USA
| | - A. Calatroni
- Rho Federal Systems Division, Inc., Durham, NC, USA
| | | | - K. Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town (UCT), Cape Town, South Africa
,Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
,Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
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3
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Braissant O, Theron G, Friedrich SO, Diacon AH, Bonkat G. Comparison of isothermal microcalorimetry and BACTEC MGIT960 for the detection of the metabolic activity of Mycobacterium tuberculosis in sputum samples. J Appl Microbiol 2019; 128:1497-1502. [PMID: 31834654 DOI: 10.1111/jam.14549] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 11/19/2019] [Accepted: 12/08/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study explores the uses of microcalorimetry to detect Mycobacterium tuberculosis (TB) in sputum. Microcalorimetry measures metabolic heat evolution during cellular proliferation of tuberculosis (TB) and is considered as a possible alternative to conventional diagnostic tools. OBJECTIVES To compare the time to detection (TTD) from the BACTEC™ MGIT™ 960 and the calScreener™ calorimetric system. METHODS Sixty-four sputa samples were selected from patients with confirmed pulmonary tuberculosis. Those sample were then decontaminated and analysed using calorimetry and BACTEC MGIT 960 system. RESULTS The incubation period until detection of M. tuberculosis in the sample was 8·5 ± 3·7 days for the MGIT system and 10·1 ± 4·1 days (mean ± SD) for calorimetry. CONCLUSIONS The microincubations in the 48-well format calScreener offers potential for rapid and accurate diagnostic of TB in different samples. Although TTD from calorimetry is still longer than with the MGIT, our findings suggest that several improvements are possible. Still, the instrument is ideal for continuous, real-time analysis of net metabolic heat release of limited sample numbers. SIGNIFICANCE AND IMPACT OF THE STUDY Our result emphasizes that with further optimization, calorimetry can become an alternative detection method for tuberculosis.
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Affiliation(s)
- O Braissant
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland
| | - G Theron
- TASK Applied Science, Bellville, Cape Town, South Africa
| | - S O Friedrich
- TASK Applied Science, Bellville, Cape Town, South Africa.,Division of Medical Physiology, Faculty of Medicine and Health Sciences, MRC Centre for Tuberculosis Research, Stellenbosch University, Tygerberg, South Africa
| | - A H Diacon
- TASK Applied Science, Bellville, Cape Town, South Africa.,Division of Medical Physiology, Faculty of Medicine and Health Sciences, MRC Centre for Tuberculosis Research, Stellenbosch University, Tygerberg, South Africa
| | - G Bonkat
- Department of Biomedical Engineering, University of Basel, Allschwil, Switzerland.,Alta-Uro AG, Basel, Switzerland
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Donald PR, Diacon AH, Lange C, Demers AM, von Groote-Bidlingmaier F, Nardell E. Droplets, dust and guinea pigs: an historical review of tuberculosis transmission research, 1878-1940. Int J Tuberc Lung Dis 2019; 22:972-982. [PMID: 30092861 DOI: 10.5588/ijtld.18.0173] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The transmission of tuberculosis (TB) occurs mainly via inhalation of airborne droplet nuclei; however, the precise details of this process remain uncertain. We reviewed the literature from 1870 to 1940, when Mycobacterium tuberculosis was discovered and the concept of transmission emerged as a hallmark of the infectious disease. By 1940, laboratory experiments, animal studies and clinical observation had demonstrated that cough was central to TB transmission, and that guinea pigs close to patients with cough could be infected, mainly by patients coughing small droplets likely containing only 1-2 bacilli. A minority of pulmonary TB patients, usually during the early stages of the disease, with thin watery sputum, more successfully coughed small infectious droplets than patients with heavily smear-positive tenacious sputum who were often too ill and too weak to cough vigorously. There was ongoing debate regarding the possible importance of desiccated sputum particles found in surface dust. Investigation of TB transmission has a history of more than 130 years.
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Affiliation(s)
- P R Donald
- Desmond Tutu TB Centre, Paediatrics and Child Health, Stellenbosch University
| | - A H Diacon
- TASK Applied Science, Bellville, Cape Town, Division of Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - C Lange
- Clinical Infectious Diseases, German Centre for Infection Research (DZIF), Research Centre Borstel, Borstel, International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - A-M Demers
- Desmond Tutu TB Centre, Paediatrics and Child Health, Stellenbosch University
| | | | - E Nardell
- Division of Pulmonary and Critical Care Medicine, and Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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5
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Lange C, Alghamdi WA, Al-Shaer MH, Brighenti S, Diacon AH, DiNardo AR, Grobbel HP, Gröschel MI, von Groote-Bidlingmaier F, Hauptmann M, Heyckendorf J, Köhler N, Kohl TA, Merker M, Niemann S, Peloquin CA, Reimann M, Schaible UE, Schaub D, Schleusener V, Thye T, Schön T. Perspectives for personalized therapy for patients with multidrug-resistant tuberculosis. J Intern Med 2018; 284:163-188. [PMID: 29806961 DOI: 10.1111/joim.12780] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
According to the World Health Organization (WHO), tuberculosis is the leading cause of death attributed to a single microbial pathogen worldwide. In addition to the large number of patients affected by tuberculosis, the emergence of Mycobacterium tuberculosis drug-resistance is complicating tuberculosis control in many high-burden countries. During the past 5 years, the global number of patients identified with multidrug-resistant tuberculosis (MDR-TB), defined as bacillary resistance at least against rifampicin and isoniazid, the two most active drugs in a treatment regimen, has increased by more than 20% annually. Today we experience a historical peak in the number of patients affected by MDR-TB. The management of MDR-TB is characterized by delayed diagnosis, uncertainty of the extent of bacillary drug-resistance, imprecise standardized drug regimens and dosages, very long duration of therapy and high frequency of adverse events which all translate into a poor prognosis for many of the affected patients. Major scientific and technological advances in recent years provide new perspectives through treatment regimens tailor-made to individual needs. Where available, such personalized treatment has major implications on the treatment outcomes of patients with MDR-TB. The challenge now is to bring these adances to those patients that need them most.
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Affiliation(s)
- C Lange
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
- Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - W A Alghamdi
- Department of Pharmacotherapy and Translational Research, Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - M H Al-Shaer
- Department of Pharmacotherapy and Translational Research, Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - S Brighenti
- Department of Medicine, Center for Infectious Medicine (CIM), Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - A H Diacon
- Task Applied Science, Bellville, South Africa
- Division of Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - A R DiNardo
- Section of Global and Immigrant Health, Baylor College of Medicine, Houston, TX, USA
| | - H P Grobbel
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - M I Gröschel
- Department of Pumonary Diseases & Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | | | - M Hauptmann
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- Cellular Microbiology, Research Center Borstel, Borstel, Germany
| | - J Heyckendorf
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - N Köhler
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - T A Kohl
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - M Merker
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - S Niemann
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - C A Peloquin
- Department of Pharmacotherapy and Translational Research, Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - M Reimann
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - U E Schaible
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- Cellular Microbiology, Research Center Borstel, Borstel, Germany
- Biochemical Microbiology & Immunochemistry, University of Lübeck, Lübeck, Germany
- LRA INFECTIONS'21, Borstel, Germany
| | - D Schaub
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- Tuberculosis Unit, German Center for Infection Research (DZIF), Borstel, Germany
- International Health/Infectious Diseases, University of Lübeck, Lübeck, Germany
| | - V Schleusener
- Molecular and Experimental Mycobacteriology, National Reference Center for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - T Thye
- Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - T Schön
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
- Department of Clinical Microbiology and Infectious Diseases, Kalmar County Hospital, Linköping University, Linköping, Sweden
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Mfokazi A, Wright CA, Louw M, Von Groote-Bidlingmaier F, Schubert PT, Koegelenberg CFN, Diacon AH. Direct comparison of liquid-based and smear-based cytology with and without rapid on-site evaluation for fine needle aspirates of thoracic tumors. Diagn Cytopathol 2016; 44:363-8. [PMID: 26853711 DOI: 10.1002/dc.23447] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 12/19/2015] [Accepted: 01/19/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Liquid-based cytology (LBC) and rapid on-site evaluation (ROSE) are proposed to improve the quality of fine needle aspirates (FNA) and their diagnostic yield compared with conventional smear cytology (CSC). This prospective study directly compared outcomes of sonar-guided FNA of thoracic tumors supported by LBC, CSC, or CSC with ROSE. METHODS Three aspirates each for both LBC and CSC with separate 22G spinal needles in a randomized, alternating sequence during 64 transthoracic FNA of thoracic tumors were collected. Smears were prepared by cytology staff on site but evaluated with ROSE only when all six samples had been collected. If no diagnostic material was found on the first three CSC additional needle passes guided by ROSE were performed. RESULTS Final diagnoses were non-small cell lung cancer in 50 (78.1%), small cell lung cancer in 11 (17.2%), mesothelioma in 1 (1.6%), and inflammation in 2 cases (3.1%), respectively. LBC and CSC were diagnostic in 42 (65.6%) and 49 (76.6%) cases, respectively (P = 0.039), with both methods diagnostic in 41 cases (64.1%). Fifteen cases (23.4%) remained undiagnosed following three passes for CSC but 9 (14.1%) of these were diagnosed using FNA and ROSE with a total yield of 58 cases (90.6%; P < 0.001). CONCLUSION The diagnostic yield of transthoracic FNA submitted for LBC is significantly lower than with CSC when slides are prepared professionally. ROSE significantly increases the yield of transthoracic FNA.
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Affiliation(s)
- A Mfokazi
- Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and NHLS, Tygerberg Academic Hospital, Tygerberg, South Africa
| | - C A Wright
- Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and NHLS, Tygerberg Academic Hospital, Tygerberg, South Africa.,NHLS, Port Elizabeth, South Africa
| | - M Louw
- Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and NHLS, Tygerberg Academic Hospital, Tygerberg, South Africa
| | - F Von Groote-Bidlingmaier
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - P T Schubert
- Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and NHLS, Tygerberg Academic Hospital, Tygerberg, South Africa
| | - C F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - A H Diacon
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.,Division of Medical Physiology, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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7
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Solomons RS, Visser DH, Friedrich SO, Diacon AH, Hoek KGP, Marais BJ, Schoeman JF, van Furth AM. Improved diagnosis of childhood tuberculous meningitis using more than one nucleic acid amplification test. Int J Tuberc Lung Dis 2015; 19:74-80. [PMID: 25519794 DOI: 10.5588/ijtld.14.0394] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early treatment is critical to reducing tuberculous meningitis (TBM) related morbidity and mortality. Diagnosis based on cerebrospinal fluid (CSF) culture is impractical due to slow turnaround times, while microscopy has poor sensitivity. Enhanced detection methods are essential to guide early treatment initiation, especially in vulnerable young children. METHODS We assessed the diagnostic accuracy of the GenoType(®) MTBDRplus and Xpert(®) MTB/RIF assays on CSF collected from paediatric meningitis suspects prospectively enrolled at Tygerberg Hospital, Cape Town, South Africa. Fluorescent auramine-O microscopy, liquid culture for Mycobacterium tuberculosis, GenoType and Xpert assays were performed on all CSF samples. RESULTS Of 101 meningitis suspects, 55 were diagnosed with TBM and 46 served as non-TBM controls. Using a pre-defined TBM case definition as reference standard, sensitivities and specificities were 4% and 100% for fluorescent microscopy, 22% and 100% for culture, 33% and 98% for GenoType, 26% and 100% for Xpert, 22% and 100% for microscopy and culture combined and 49% and 98% for GenoType and Xpert combined. Culture, GenoType and Xpert combined performed best, with 56% sensitivity and 98% specificity. CONCLUSION Although commercial nucleic-acid amplification tests performed on CSF revealed incrementally improved diagnostic accuracy, providing rapid microbiological confirmation, they cannot serve as a rule-out test.
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Affiliation(s)
- R S Solomons
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - D H Visser
- Department of Paediatric Infectious Diseases and Immunology, Vrije Universiteit University Medical Center, Amsterdam, The Netherlands
| | - S O Friedrich
- Division of Medical Physiology, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A H Diacon
- Division of Medical Physiology, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - K G P Hoek
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - B J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity Institute, The Children's Hospital at Westmead, The University of Sydney, Sydney, New South Wales, Australia
| | - J F Schoeman
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - A M van Furth
- Department of Paediatric Infectious Diseases and Immunology, Vrije Universiteit University Medical Center, Amsterdam, The Netherlands
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8
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Becker KW, Scheffer C, Blanckenberg MM, Diacon AH. Analysis of adventitious lung sounds originating from pulmonary tuberculosis. Annu Int Conf IEEE Eng Med Biol Soc 2015; 2013:4334-7. [PMID: 24110692 DOI: 10.1109/embc.2013.6610505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Tuberculosis is a common and potentially deadly infectious disease, usually affecting the respiratory system and causing the sound properties of symptomatic infected lungs to differ from non-infected lungs. Auscultation is often ruled out as a reliable diagnostic technique for TB due to the random distribution of the infection and the varying severity of damage to the lungs. However, advancements in signal processing techniques for respiratory sounds can improve the potential of auscultation far beyond the capabilities of the conventional mechanical stethoscope. Though computer-based signal analysis of respiratory sounds has produced a significant body of research, there have not been any recent investigations into the computer-aided analysis of lung sounds associated with pulmonary Tuberculosis (TB), despite the severity of the disease in many countries. In this paper, respiratory sounds were recorded from 14 locations around the posterior and anterior chest walls of healthy volunteers and patients infected with pulmonary TB. The most significant signal features in both the time and frequency domains associated with the presence of TB, were identified by using the statistical overlap factor (SOF). These features were then employed to train a neural network to automatically classify the auscultation recordings into their respective healthy or TB-origin categories. The neural network yielded a diagnostic accuracy of 73%, but it is believed that automated filtering of the noise in the clinics, more training samples and perhaps other signal processing methods can improve the results of future studies. This work demonstrates the potential of computer-aided auscultation as an aid for the diagnosis and treatment of TB.
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9
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Van Rensburg A, Neethling GS, Schubert PT, Koegelenberg CFN, Wright CA, Bolliger CT, Bernasconi M, Diacon AH. Impact of routine sputum cytology in a population at high risk for bronchial carcinoma. Int J Tuberc Lung Dis 2015; 18:607-12. [PMID: 24903800 DOI: 10.5588/ijtld.13.0806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Sub-Saharan Africa carries a high burden of lung cancer, with limited access to specialised health care. OBJECTIVE To investigate the diagnostic value of sputum cytology and its potential in reducing the need for invasive diagnostic procedures in a high-risk population. DESIGN We collected spontaneously expectorated sputum from 108 patients referred for a diagnostic procedure for suspected lung cancer between June 2010 and June 2012, and examined the diagnostic yield of sputum cytology for malignant cells as well as factors predicting a positive result. RESULTS Bronchial carcinoma was diagnosed in 90 patients (83.3%), of whom 35 (38.9%) had sputum cytology positive for malignant cells with 100% diagnostic accuracy. Positive sputum cytology was significantly associated with endobronchial tumour and obstruction seen during bronchoscopy (OR 4.69 and OR 8.89, respectively), and with a histology of squamous cell carcinoma (OR 1.9). All but one patient with positive sputum were inoperable (97.1%), and we estimated that up to a third of all invasive procedures could be avoided if sputum cytology was used for triage. CONCLUSION Sputum cytology had a high yield and accuracy in this high-risk group. Its routine use in selected patients is likely to result in reduced costs and less patient risk and discomfort.
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Affiliation(s)
- A Van Rensburg
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - G S Neethling
- Department of Anatomical Pathology and National Health Laboratory Service, Stellenbosch University, Cape Town, South Africa
| | - P T Schubert
- Department of Anatomical Pathology and National Health Laboratory Service, Stellenbosch University, Cape Town, South Africa
| | - C F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - C A Wright
- Department of Anatomical Pathology and National Health Laboratory Service, Stellenbosch University, Cape Town, South Africa
| | - C T Bolliger
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - M Bernasconi
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - A H Diacon
- Division of Pulmonology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
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Kolwijck E, Friedrich SO, Karinja MN, van Ingen J, Warren RM, Diacon AH. Early stationary phase culture supernatant accelerates growth of sputum cultures collected after initiation of anti-tuberculosis treatment. Clin Microbiol Infect 2013; 20:O418-20. [PMID: 24188165 DOI: 10.1111/1469-0691.12441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 11/28/2022]
Abstract
We investigated the effect of Mycobacterium tuberculosis culture supernatant added to sputum cultures collected during the first 8 weeks of anti-tuberculosis treatment. With ongoing treatment duration, time to culture positivity decreased significantly in supernatant-enriched cultures, possibly due to stimulation of dormant or slowly metabolizing M. tuberculosis cells.
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Affiliation(s)
- E Kolwijck
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; Division of Medical Physiology, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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11
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Liwa AC, Schaaf HS, Rosenkranz B, Seifart HI, Diacon AH, Donald PR. Para-aminosalicylic acid plasma concentrations in children in comparison with adults after receiving a granular slow-release preparation. J Trop Pediatr 2013; 59:90-4. [PMID: 23174991 DOI: 10.1093/tropej/fms053] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
There are no paediatric data regarding slow-release para-aminosalicylic acid (PAS). We studied PAS plasma concentrations in 10 children receiving a single 150 mg/kg dose daily or 75 mg/kg twice daily and 12 adults receiving 4 g twice daily. Blood specimens pre-dose and 2, 4, 6, 8 and 12 h post-dose from the children and 2, 3, 4, 5, 6, 8 and 12 h post-dose from the adults were analysed by high performance liquid chromatography MS/MS. The mean Cmax in children receiving PAS 75 mg/kg and 150 mg/kg and adults receiving 4 g was 45.40, 56.49 and 51.3 µg/ml, respectively (p = 0.614); the AUC0-12 was 233.3, 277.9 and 368.0 µg/h/ml (p = 0.587). No parameters differed significantly between children and adults nor between the two doses in the same children. A 150 mg/kg PAS dosage given as one or two daily doses leads to plasma concentrations in children similar to those of adults receiving 4 g PAS twice daily.
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Affiliation(s)
- A C Liwa
- Division of Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
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12
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Macingwana L, Baker B, Ngwane AH, Harper C, Cotton MF, Hesseling A, Diacon AH, van Helden P, Wiid I. Sulfamethoxazole enhances the antimycobacterial activity of rifampicin. J Antimicrob Chemother 2012; 67:2908-11. [DOI: 10.1093/jac/dks306] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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13
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Brundyn K, Koegelenberg CFN, Diacon AH, Louw M, Schubert P, Bolliger CT, van den Heuvel MM, Wright CA. Transbronchial fine needle aspiration biopsy and rapid on-site evaluation in the setting of superior vena cava syndrome. Diagn Cytopathol 2011; 41:324-9. [PMID: 22102539 DOI: 10.1002/dc.21857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 10/07/2011] [Indexed: 11/06/2022]
Abstract
There is a paucity of prospective data on flexible bronchoscopy with rapid on-site evaluation (ROSE) in the setting of superior vena cava (SVC) syndrome. The aims of this prospective study were to assess the diagnostic yield and safety of these investigations and specifically to evaluate the role of ROSE in limiting the need for tissue biopsies. Over a 5-year period 48 patients (57.4 ± 9.7 years) with SVC syndrome secondary to intrathoracic tumors underwent flexible bronchoscopy with TBNA and ROSE. Endobronchial Forceps biopsy was reserved for visible endobronchial tumors with no on-site confirmation of diagnostic material. ROSE confirmed diagnostic material in 41 cases (85.4%), and in only one of the remaining cases did the addition of a forceps biopsy increase the diagnostic yield (overall diagnostic yield of 87.5%). No serious complications were noted. The final diagnoses made included nonsmall lung cancer (n = 27), small cell lung cancer (n = 16), and metastatic carcinoma (n = 3). Two undiagnosed cases died of suspected advanced neoplasms (unknown primary tumors). We conclude that TBNA has a high diagnostic yield and is safe in the setting of SVC syndrome. With the addition of ROSE, tissue biopsy is required in the minority of cases.
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Affiliation(s)
- K Brundyn
- Division of Anatomical Pathology, Department of Pathology, University of Stellenbosch and National Health Laboratory Services, Cape Town, South Africa
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14
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Diacon AH, Dawson R, Hanekom M, Narunsky K, Venter A, Hittel N, Geiter LJ, Wells CD, Paccaly AJ, Donald PR. Early bactericidal activity of delamanid (OPC-67683) in smear-positive pulmonary tuberculosis patients. Int J Tuberc Lung Dis 2011; 15:949-54. [PMID: 21682970 DOI: 10.5588/ijtld.10.0616] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delamanid (OPC-67683) is a novel mycolic acid biosynthesis inhibitor active against Mycobacterium tuberculosis at a low minimum inhibitory concentration. METHODS Forty-eight patients with smear-positive tuberculosis (63% male; 54.7 ± 9.9 kg; 30.7 ± 10.8 years) were randomly assigned to receive delamanid 100, 200, 300 or 400 mg daily for 14 days. Colony forming units (cfu) of M. tuberculosis were counted on agar plates from overnight sputum collections to calculate early bactericidal activity (EBA), defined as fall in log(10) cfu/ml sputum/day. RESULTS The EBA of delamanid was monophasic and not significantly different between dosages; however, more patients receiving 200 mg (70%) and 300 mg (80%) experienced a response of ≥0.9 log(10) cfu/ml sputum decline over 14 days than those receiving 100 mg (45%) and 400 mg (27%). The average EBA of all dosages combined (0.040 ± 0.056 log(10) cfu/ml sputum/day) was significant from day 2 onward. Delamanid exposure was less than dosage-proportional, reaching a plateau at 300 mg, likely due to dose-limited absorption. Moderate but significant correlation was found between C(max) and EBA, indicating exposure dependence. Delamanid was well tolerated without significant toxicity. CONCLUSIONS Delamanid at all dosages was safe, well tolerated and demonstrated significant exposure-dependent EBA over 14 days, supporting further investigation of its pharmacokinetics and anti-tuberculosis activity.
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Affiliation(s)
- A H Diacon
- Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.
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15
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Bernasconi M, Bolliger CT, Irusen E, Diacon AH. A left hemithorax mystery. Diaphragmatic hernia after penetrating left thoracic stab wound. Respiration 2011; 82:557-9. [PMID: 21934276 DOI: 10.1159/000330594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 07/02/2011] [Indexed: 11/19/2022] Open
Affiliation(s)
- M Bernasconi
- Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
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16
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Donald PR, Maritz JS, Diacon AH. Pyrazinamide pharmacokinetics and efficacy in adults and children. Tuberculosis (Edinb) 2011; 92:1-8. [PMID: 21795116 DOI: 10.1016/j.tube.2011.05.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/12/2011] [Accepted: 05/24/2011] [Indexed: 11/28/2022]
Abstract
Pyrazinamide (PZA) is an essential sterilizing drug and with rifampicin enables six-month short-course antituberculosis chemotherapy. Despite routine use for nearly forty years uncertainty remains regarding the most appropriate PZA dosage for children. In view of this uncertainty literature relating to the efficacy and pharmacokinetics of PZA in children treated for tuberculosis and in adult volunteers and patients was reviewed. Making use of the PZA maximum concentration (C(max)) following various PZA dosages in different groups straight line regression of concentration on dosage was fitted through the origin by least squares and weighted for the numbers of subjects. The fitted line offers an approximation of the likely PZA C(max) that would result from a particular dosage. The slopes of C(max)/dosage of the fitted lines are 1.32 (SE 0.099) for paediatric patients, 1.36 (SE 0.051) for adult volunteers and 1.35 (SE 0.037) for adult patients; there is little difference between the C(max) concentrations achieved in children and adults, whether patients or healthy volunteers, following various mg/kg body weight dosages, suggesting that children and adults receiving the same mg/kg body weight PZA dosage will reach a similar C(max). Children can receive the same mg/kg body weight PZA dosage as adults.
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Affiliation(s)
- P R Donald
- Department of Paediatrics and Child Health, Stellenbosch University, PO Box 19063, 7505 Tygerberg, South Africa.
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van Ingen J, Aarnoutse RE, Donald PR, Diacon AH, Dawson R, Plemper van Balen G, Gillespie SH, Boeree MJ. Why Do We Use 600 mg of Rifampicin in Tuberculosis Treatment? Clin Infect Dis 2011; 52:e194-9. [DOI: 10.1093/cid/cir184] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Donald PR, Maritz JS, Diacon AH. The pharmacokinetics and pharmacodynamics of rifampicin in adults and children in relation to the dosage recommended for children. Tuberculosis (Edinb) 2011; 91:196-207. [PMID: 21429802 DOI: 10.1016/j.tube.2011.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 02/07/2011] [Accepted: 02/08/2011] [Indexed: 11/29/2022]
Abstract
The dosages of antituberculosis agents recommended for treatment of childhood tuberculosis often reflect those for adult patients with similar mg/kg body weight dosages and ranges advised. Literature relating to the pharmacokinetics and pharmacodynamics of rifampicin (RMP) is reviewed and the serum concentrations reached by adults, both patients and healthy volunteers and children, established or not established on RMP, compared. Straight line regression of maximum RMP serum concentrations (C(max)) on dosage, weighted for the number of individuals, found slopes (SE) of 1.025 (0.067) and 0.881 (0.046) respectively for adult volunteers not established and established on RMP (P = 0.076), and similarly 0.748 (0.057) and 0.684 (0.038) respectively for adult patients (P < 0.001) and 0.622 (0.050) and 0.368 (0.041) respectively for children (P < 0.001). These results indicate that for equivalent RMP dosages adult patients reach a lower C(max) than adult volunteers and that adults, both volunteers and patients established on RMP reach higher C(max) values than children; children established on RMP require approximately twice the mg/kg body weight dosage of RMP to reach serum concentrations equivalent to those of adults. It is noteworthy that many adult patients receiving currently recommended RMP dosages also do not reach the often recommended RMP 2 h serum concentration of 8 μg/mL.
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Affiliation(s)
- P R Donald
- Department of Paediatrics and Child Health and Tygerberg Children's Hospital, Faculty of Health Sciences, Stellenbosch University, South Africa.
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19
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Diacon AH, Maritz JS, Venter A, van Helden PD, Andries K, McNeeley DF, Donald PR. Time to detection of the growth of Mycobacterium tuberculosis in MGIT 960 for determining the early bactericidal activity of antituberculosis agents. Eur J Clin Microbiol Infect Dis 2010; 29:1561-5. [PMID: 20820832 DOI: 10.1007/s10096-010-1043-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 08/10/2010] [Indexed: 11/27/2022]
Abstract
Evaluation of early bactericidal activity (EBA) by the determination of a fall in viable colony-forming units (CFU) of Mycobacterium tuberculosis in sputum is a first step in the clinical study of new antituberculosis agents. The time to detection (TTD) of growth in liquid media is more sensitive and could substitute for CFU counting on solid media. Overnight sputum samples collected during the evaluation of the novel agent TMC207 in comparison to isoniazid and rifampicin were studied. For the determination of CFU, we incubated 10-fold dilutions of homogenized sputum on selective 7H10 agar. The TTD was measured by incubating decontaminated sputum in the BACTEC MGIT 960 system. The fall in bacillary load over 7 days determined by CFU counting closely matched the prolongation of the TTD in the BACTEC MGIT 960 system. The CFU counts correlated significantly with the TTD. While the ranking of agents and different dosages of TMC207 was similar, the highest dose of TMC207 showed markedly better activity when measured by the TTD than CFU counting when compared to the activity of isoniazid. Automated TTD could augment, or, in future, replace, CFU counting to determine sputum bacillary load in EBA clinical trials pending a more formal evaluation of the correlation of the measurements.
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Affiliation(s)
- A H Diacon
- Department of Molecular Biology and Human Genetics, and MRC Centre for Molecular and Cellular Biology, DST/NRF Centre of Excellence for Biomedical TB Research, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa.
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20
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Koegelenberg CFN, Irusen EM, Cooper R, Diacon AH, Taljaard JJ, Mowlana A, von Groote-Bidlingmaier F, Bolliger CT. High mortality from respiratory failure secondary to swine-origin influenza A (H1N1) in South Africa. QJM 2010; 103:319-25. [PMID: 20219780 DOI: 10.1093/qjmed/hcq022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The novel influenza A (H1N1) pandemic affected South Africa late during the 2009 Southern hemisphere winter and placed an extra burden on a health care system already dealing with a high prevalence of chronic lung diseases and human immunodeficiency virus (HIV) infection. AIM The aim of this study was to describe the epidemiological characteristics, clinical features, management and outcomes of patients with confirmed influenza A (H1N1) infection complicated by respiratory failure. METHODS We included all adult patients with confirmed influenza A (H1N1) infection that were referred to the medical intensive care unit of a large academic hospital in Cape Town for ventilatory support in this prospective observational study. RESULTS A total of 19 patients (39.5 +/- 14.8 years) needed ventilatory support over a 6-week period. Of these, 15 were female and 16 had identifiable risk factors for severe disease, including pregnancy (n = 6), type 2 diabetes mellitus (n = 6), obesity (n = 4), HIV infection (n = 3), immunosuppressive therapy (n = 3) and active pulmonary tuberculosis (n = 2). The most frequent complications were acute renal failure (n = 13), acute respiratory distress syndrome (n = 12) and ventilator associated pneumonia (n = 10). Thirteen patients died (mortality: 68.4%). Fatal cases were significantly associated with an APACHE II score >or=20 (P = 0.034), but not with a P(a)O(2)/F(I)O(2) <200 (P = 0.085) and a chest radiograph score >or=12 (P = 0.134). CONCLUSION The majority of patients with respiratory failure secondary to influenza A (H1N1) infection were young females and had an underlying risk factor for severe disease. The condition had a high mortality, particularly amongst patients with an APACHE II score >or=20.
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Affiliation(s)
- C F N Koegelenberg
- Division of Pulmonology, Department of Medicine, University of Stellenbosch, PO Box 19063, Tygerberg, 7505, Cape Town, South Africa.
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21
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Diacon AH, Koegelenberg CFN, Schubert P, Brundyn K, Louw M, Wright CA, Bolliger CT. Rapid on-site evaluation of transbronchial aspirates: randomised comparison of two methods. Eur Respir J 2009; 35:1216-20. [DOI: 10.1183/09031936.00050809] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Koegelenberg CFN, Bolliger CT, Plekker D, Wright CA, Brundyn K, Louw M, Schubert P, van den Heuvel MM, Diacon AH. Diagnostic yield and safety of ultrasound-assisted biopsies in superior vena cava syndrome. Eur Respir J 2009; 33:1389-95. [PMID: 19213788 DOI: 10.1183/09031936.00128108] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Plekker D, Ellis T, Irusen EM, Bolliger CT, Diacon AH. Clinical and Radiological Grading of Superior Vena Cava Obstruction. Respiration 2008; 76:69-75. [PMID: 17895621 DOI: 10.1159/000108921] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 07/04/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Superior vena cava obstruction (SVCO) is commonly caused by neoplastic venous compression and presents with typical symptoms and signs. Its clinical severity presumably depends on the degree of obstruction and the adequacy of venous collateral formation. OBJECTIVES The development of novel clinical and radiological scoring systems based on the postulate that a reproducible relationship exists between the degree of SVCO, the presence of collateral circulation and the extent of clinical symptoms. METHODS We prospectively evaluated consecutive cases of acute and subacute SVCO with a newly developed clinical scoring system, which is based on easily detectable clinical symptoms and signs of SVCO. In parallel, we recorded and scored the degree of SVCO and the extent of collaterals visible on contrast-enhanced computed tomography (CT). RESULTS Thirty-four cases of SVCO were evaluated: 8 (23.5%) were clinically mild, 16 (47%) moderate and 10 (29.5%) severe. Lung cancer was the underlying histological diagnosis in 94% of cases. Radiologically, 53% had complete SVCO. A well-developed collateral system was found in 14 (41%). A scoring system subtracting a 'collateral score' from an 'obstruction score' showed a significant correlation with the clinical score (r = 0.75, p < 0.01). CONCLUSIONS Clinical severity of SVCO depends upon the degree of SVCO and is ameliorated by collateral formation. The novel clinical scoring system can predict the underlying CT features in SVCO and may be valuable in the bedside assessment of SVCO severity.
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Affiliation(s)
- D Plekker
- Division of Pulmonology, Department of Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa.
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24
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Lubbe WW, Bolliger CT, Barnard BJ, Diacon AH. Cardiac arrest following pneumonectomy. Respiration 2007; 76:225-7. [PMID: 18089937 DOI: 10.1159/000112792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 09/26/2007] [Indexed: 11/19/2022] Open
Affiliation(s)
- W W Lubbe
- Department of Medicine, Tygerberg Academic Hospital and University of Stellenbosch, Cape Town, South Africa
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25
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Schuurmans MM, Ellmann A, Bouma H, Diacon AH, Dyckmans K, Bolliger CT. Solitary pulmonary nodule evaluation with 99mTc-methoxy isobutyl isonitrile in a tuberculosis-endemic area. Eur Respir J 2007; 30:1090-5. [PMID: 17804448 DOI: 10.1183/09031936.00046107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High prevalence of tuberculosis increases the odds for nonmalignant solitary pulmonary nodules (SPNs). Positron emission tomography (PET) using (18)F-fluorodeoxyglucose is the method of choice for the identification of malignant SPNs requiring curative surgery. However, PET is not widely available. Technetium-99m methoxy isobutyl isonitrile (MIBI) is inexpensive, widely available and shows increased uptake in malignant SPNs. The aim of the present study was to prospectively evaluate the diagnostic value of MIBI single photon emission computed tomography to distinguish between benign and malignant SPNs in a tuberculosis-endemic area. In total, 49 patients with radiologically indeterminate SPNs (single lesion < or =6 cm in diameter) were prospectively evaluated with MIBI. The final diagnosis was established with bronchoscopy, fine-needle aspiration, surgical resection or clinical follow-up for > or =2 yrs. A total of 12 (92%) out of 13 malignant lesions showed increased uptake of MIBI, while no uptake was observed in 33 (92%) out of 36 benign lesions. MIBI uptake indicated malignancy with a sensitivity and specificity of 92% and a negative predictive value of 97%. In this tuberculosis-endemic area, technetium-99m methoxy isobutyl isonitrile single photon emission computed tomography evaluation of solitary pulmonary nodules had a high negative predictive value. Therefore, it has the potential to prevent unnecessary surgical resections of benign nodules and serve as a low-cost alternative when positron emission tomography is not available.
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Affiliation(s)
- M M Schuurmans
- Dept of Internal Medicine, Tygerberg Academic Hospital, Stellenbosch University, Faculty of Health Sciences, Francie van Zijl Drive, 7505 Tygerberg, Cape Town, South Africa.
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van den Heuvel MM, Els Z, Koegelenberg CF, Naidu KM, Bolliger CT, Diacon AH. Risk factors for recurrence of haemoptysis following bronchial artery embolisation for life-threatening haemoptysis. Int J Tuberc Lung Dis 2007; 11:909-14. [PMID: 17705959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
SETTING Life-threatening haemoptysis is a frequent and often fatal complication in areas with a high prevalence of tuberculosis (TB). Bronchial artery embolisation remains the standard initial treatment. Subsequent curative measures, such as surgical resection of the focus of haemorrhage, are generally recommended to prevent recurrence, but risk-based selection criteria have not been established. OBJECTIVES To identify risk factors for the recurrence of haemoptysis following embolisation. DESIGN Baseline characteristics were obtained from consecutive patients with life-threatening haemoptysis who were successfully embolised and followed up for at least 12 months. RESULTS Recurrence of haemoptysis was observed in 47% and was associated with increased mortality compared to patients without recurrence (31% vs. 10%, P = 0.021). Patients with recurrence experienced residual mild haemoptysis beyond the first week after embolisation (odds ratio [OR] 7.2), received blood transfusions (OR 5.3) or presented with an aspergilloma (OR 5.1). Conversely, the presence of active TB amenable to treatment (OR 0.3) protected patients from these events. Radiographic or angiographic appearance did not predict recurrence. CONCLUSIONS Recurrence of haemoptysis following embolisation for life-threatening haemoptysis is common and is associated with high mortality. The results of this study can contribute to the risk assessment of these patients and guide decisions regarding the urgency of definitive therapy.
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Affiliation(s)
- M M van den Heuvel
- Department of Medicine, Tygerberg Academic Hospital and the University of Stellenbosch, Cape Town, South Africa
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Diacon AH, Patientia RF, Venter A, van Helden PD, Smith PJ, McIlleron H, Maritz JS, Donald PR. Early bactericidal activity of high-dose rifampin in patients with pulmonary tuberculosis evidenced by positive sputum smears. Antimicrob Agents Chemother 2007; 51:2994-6. [PMID: 17517849 PMCID: PMC1932511 DOI: 10.1128/aac.01474-06] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We studied the early bactericidal activity of twice the standard dose of rifampin in subjects with pulmonary tuberculosis evidenced by positive smears. The observed mean 2-day activity was almost double that reported at the standard dose. Further studies are warranted to establish whether higher rifampin doses might assist in shortening tuberculosis treatment.
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Affiliation(s)
- A H Diacon
- Department of Internal Medicine, Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa.
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28
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Diacon AH, Theron J, Schubert P, Brundyn K, Louw M, Wright CA, Bolliger CT. Ultrasound-assisted transthoracic biopsy: fine-needle aspiration or cutting-needle biopsy? Eur Respir J 2006; 29:357-62. [PMID: 17079257 DOI: 10.1183/09031936.00077706] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The present study compared the diagnostic yield of ultrasound-assisted cutting-needle biopsy (CNB) and fine-needle aspiration biopsy (FNAB) in chest lesions. A physician performed ultrasound and FNAB with a 22-G spinal needle in all patients, directly followed by a 14-G CNB in patients without contraindication. A total of 155 consecutive lesions arising from the lung (74%), pleura (12%), mediastinum (11%) or chest wall (3%) in patients with a final diagnosis of lung carcinoma (74%), other malignant tumours (12%), non-neoplastic disease (9%) or unknown (5%) were prospectively included. The overall diagnostic yield was 87%. Combined specimens were obtained in 123 lesions (79%). In these, yields of FNAB, CNB and both methods combined were 82, 76 and 89%, respectively. FNAB was significantly better than CNB in lung carcinoma (95 versus 81%) but CNB was superior in noncarcinomatous tumours and in benign lesions. On-site cytology was 90% sensitive and 100% specific for predicting a positive FNAB. One patient required drainage for pneumothorax (0.6%). Ultrasound-assisted fine-needle aspiration biopsy performed by chest physicians is an accurate and safe initial diagnostic procedure in patients with a high clinical probability of lung carcinoma. All other patients should undergo concurrent fine-needle aspiration biopsy and cutting-needle biopsy.
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Affiliation(s)
- A H Diacon
- Department of Internal Medicine, Tygerberg Academic Hospital, Tygerberg, South Africa.
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Abstract
Transbronchial needle aspiration is a bronchoscopic sampling method for a variety of bronchial and pulmonary lesions. The present study investigated whether and how serial needle passes contribute to the yield of transbronchial needle aspiration at specific target sites. A total of 1,562 needle passes, performed at 374 target sites in 245 patients with neoplastic disease (82%), non-neoplastic disease (15%) or undiagnosed lesions (3%), were prospectively recorded and rated for anatomical location, size, bronchoscopic appearance and underlying disease. Positive aspirates were obtained in 75% of patients and at 68% of target sites. A diagnosis was established with the first, second, third and fourth needle pass at 64, 87, 95 and 98% of targets, respectively. The absolute yield varied strongly with target site features, but the stepwise increment to the maximum yield provided by serial passes was similar across target sites. In conclusion, three transbronchial needle passes per site are appropriate when only a tissue diagnosis is sought and when alternative sites or sampling modalities are available. At least four or five passes should be carried out at lymph node stations critical for the staging of lung cancer.
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Affiliation(s)
- A H Diacon
- Department of Internal Medicine, Tygerberg Academic Hospital, University of Stellenbosch, Cape Town, South Africa.
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30
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Koegelenberg CFN, Theron J, Brundyn K, Bolliger CT, Marais AD, Diacon AH. A patient with a persistent pleural effusion. Respiration 2005; 73:120-3. [PMID: 16113514 DOI: 10.1159/000087687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2004] [Accepted: 02/03/2005] [Indexed: 11/19/2022] Open
Affiliation(s)
- C F N Koegelenberg
- Department of Internal Medicine, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa.
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Diacon AH, Schuurmans MM, Theron J, Schubert PT, Wright CA, Bolliger CT. Safety and Yield of Ultrasound-Assisted Transthoracic Biopsy Performed by Pulmonologists. Respiration 2004; 71:519-22. [PMID: 15467331 DOI: 10.1159/000080638] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2003] [Accepted: 02/02/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transthoracic ultrasound (US) has gained popularity as a tool for visualizing pleural effusions and assisting thoracentesis or chest drain placement. In the absence of effusion, US just as well demonstrates solid masses involving or abutting the pleura, yet biopsy of such lesions is not widely performed by chest physicians. OBJECTIVE To assess the feasibility and the safety of US-assisted cutting needle biopsy performed by chest physicians in routine practice. METHODS Lesions involving or abutting the pleura > or =20 mm in diameter on US were sampled with a 14-gauge cutting needle under local anesthesia. Biopsy site, needle direction and depth of penetration were determined with US. The procedure was performed without direct US guidance in 'free-hand' technique. RESULTS Ninety-one patients underwent 96 cutting-needle biopsies for suspected peripheral lung tumors (n = 44, 46%), pleural-based (n = 39, 41%), mediastinal (n = 10, 10%), or chest wall lesions (n = 3, 3%), which were single in 71%, multiple in 6% and diffuse in 23%. Sensitivity for malignant neoplasms (n = 65) was 85.5% and 100% for mesothelioma (n = 10). Pneumothorax occurred in 4%. CONCLUSIONS US-assisted cutting-needle biopsy of lesions > or =20 mm in diameter is safe in the hands of pulmonologists. The yield for neoplastic disease including mesothelioma is high.
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Affiliation(s)
- A H Diacon
- Department of Internal Medicine, Tygerberg Academic Hospital and Stellenbosch University, Cape Town, South Africa.
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Abstract
Thoracoscopy is the most accurate yet most expensive tool for establishing the diagnosis of tuberculous (TB) pleurisy. However, most high TB-incidence regions have limited financial resources, lack the infrastructure needed for routine thoracoscopy and require an alternative, cost-effective diagnostic approach for pleural effusions. Altogether, 51 patients with undiagnosed exudative pleural effusions were recruited for a prospective, direct comparison between bronchial wash, pleural fluid microbiology and biochemistry (adenosine deaminase (ADA) and cell count), closed needle biopsy, and medical thoracoscopy. The final diagnosis was TB in 42 patients (82%), malignancy in five (10%) and idiopathic in four patients (8%). Sensitivity of histology, culture and combined histology/culture was 66, 48 and 79%, respectively for closed needle biopsy and 100, 76 and 100%, respectively for thoracoscopy. Both were 100% specific. Pleural fluid ADA of > or = 50 U x L(-1) was 95% sensitive and 89% specific. Combined ADA, lymphocyte/neutrophil ratio > or = 0.75 plus closed needle biopsy reached 93% sensitivity and 100% specificity. A combination of pleural fluid adenosine deaminase, differential cell count and closed needle biopsy has a high diagnostic accuracy in undiagnosed exudative pleural effusions in areas with high incidences of tuberculosis and might substitute medical thoracoscopy at considerably lower expense in resource-poor countries.
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Affiliation(s)
- A H Diacon
- Institute of Internal Medicine, University of Stellenbosch Medical School, Tyberberg Hospital, Cape Town, South Africa.
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Davel S, Bolliger CT, Diacon AH, Irusen EM. Hemoptysis and hypoxemia in an asthmatic. Respiration 2004; 70:426-30. [PMID: 14512682 DOI: 10.1159/000072910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2002] [Accepted: 12/10/2002] [Indexed: 11/19/2022] Open
Affiliation(s)
- S Davel
- Lung Unit, Department of Internal Medicine, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa.
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Diacon AH, Bolliger CT. Functional evaluation before and after interventional bronchoscopy in patients with malignant central airway obstruction. Monaldi Arch Chest Dis 2001; 56:67-73. [PMID: 11407214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
Rigid or flexible interventional bronchoscopy is increasingly accepted for treating central tracheal or bronchial obstruction caused by incurable pulmonary malignancy. Immediate and sustained symptomatic relief and improvement of quality of life can be offered to patients suffering from dyspnoea and facing death by suffocation. Selection of patients based on functional aspects is of central importance for success in endoscopic treatment. A thorough workup is conducted with close cooperation between the various specialists involved in thoracic oncology (pulmonologist, oncologist, radio-oncologist, thoracic and upper airway surgeon). Careful history taking, clinical examination, pulmonary function testing (PFT) and radiologic imaging are needed to assess the general condition of the patient and give information of type and stage of the underlying malignancy. In eligible patients, timing and method of the intervention depend on the acuteness of the presentation and the endoscopic assessment of the lesion responsible for the obstruction. Regular postinterventional follow-up should be conducted by the patient's doctor and consist of clinical examination, PFT and chest radiography. Close cooperation with the specialist centre is necessary to refer patients for repeat bronchoscopy and management of suspected recurrences or complications.
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Affiliation(s)
- A H Diacon
- Lung Unit, Dept of Internal Medicine, University of Stellenbosch, 7505 Tygerberg, Cape Town, South Africa
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Diacon AH, Wyser C, Bolliger CT, Tamm M, Pless M, Perruchoud AP, Solèr M. Prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions. Am J Respir Crit Care Med 2000; 162:1445-9. [PMID: 11029359 DOI: 10.1164/ajrccm.162.4.2002030] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Induction of pleurodesis offers benefit for patients with metastatic tumors and symptomatic malignant pleural effusions, but the best method for achieving this is still unknown. In this prospective, randomized comparison of two well-established pleurodesis procedures, 36 patients with malignant pleural effusions, expanded lungs after drainage, and expected survival of > 1 mo received either bleomycin instillation (60E) via a small-bore thoracostomy tube or thoracoscopic talc poudrage (5 g) under local anesthesia. Efficacy, safety, and cost could be evaluated for 32 treatments (17 bleomycin, 15 talc) in 31 patients. Recurrence rates of effusion with bleomycin and talc poudrage after 30 d were 41% and 13% (p = 0.12), respectively, those after 90 d were 59% and 13%, respectively (p = 0.01), and those after 180 d were 65% and 13% (p = 0.005), respectively. Neither procedure showed any major adverse effect, and both were equally well tolerated. Cost estimation favored thoracoscopic talc poudrage, both for the initial hospitalization and with regard to recurrences. In conclusion, thoracoscopic talc pleurodesis under local anesthesia is superior to bleomycin instillation for pleurodesis in cases of malignant pleural effusion.
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Affiliation(s)
- A H Diacon
- Department of Internal Medicine, University Hospital, Basel, Switzerland
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