A structured 2-week follow-up visit in the cascade of care for TB increases case detection

OBJECTIVES

Delayed detection in TB due to structural and diagnostic shortcomings is pivotal for disease transmission, morbidity and mortality. We investigated whether an inclusive screening, followed by a structured clinical follow-up (FU) could improve case-finding.

METHODS

Patients were recruited from health centres in Bissau, Guinea-Bissau, and Gondar, Ethiopia. A routine FU was done at Week 2. If persisting symptoms were found, patients were investigated using chest X-ray (CXR) and Xpert® MTB/RIF, followed by a medical consultation. The main outcome were additional TB patients diagnosed by applying the FU strategy.

RESULTS

Of 3,571 adults, 3,285 (95%) were examined at Week 2 FU, where 2,491 (72%) were asymptomatic. Screening patients presenting with cough >2 weeks alone contributed to the diagnosis of 93 patients (45% of all patients diagnosed here), whereas a TBscore >3 increased this by 18 (9%); adding a Week 2 FU yielded an additional 94 (46%) patients. Among the 794 (24%) with persisting symptoms, 25 were diagnosed using Xpert and 69 at clinical FU, which constituted 46% (94/205) of the total TB patients diagnosed.

CONCLUSION

A Week 2 FU visit, which can be nested into routine healthcare, increased the diagnosis of TB patients by two-fold and avoids diagnostic gaps in the cascade-of-care..

TB-related deaths among adults in Guinea-Bissau

SETTING: In an urban demographic, high TB burden surveillance site in Guinea-Bissau, most deaths occur at home, and information on cause of death (CoD) is lacking.OBJECTIVE: To examine CoD and the proportion of TB deaths in three groups: among patients examined for TB without a verified diagnosis after diagnostic workup, described as "assumed TB-negative" (aTBneg), among patients with a confirmed diagnosis of TB and in a sample of the background population.DESIGN: Verbal autopsies (VAs) were obtained for registered deaths occurring between 1 January 2010 and 15 June 2016. All deaths among aTBneg and patients with TB, and a sample of deaths in the background population were included.RESULTS: VAs were obtained from 104/112 aTBneg patients, 140/155 patients with TB, and 172/219 from the general population. The leading CoD was TB in respectively 20%, 69% and 9% of the cohorts. HIV/AIDS-related deaths were the most frequent CoD among aTBneg patients (45%) and in the background population (27%), and accounted for 9% of patients with TB.CONCLUSION: TB was shown to be a frequent CoD, not only among patients diagnosed with TB, but also among aTBneg patients and the background population. This indicates a low TB case detection rate.

A self-rated health score predicts severe disease and high mortality in patients with pulmonary TB

BACKGROUND: Health-related quality of life (HRQoL) in patients with pulmonary TB may be predictive of disease outcome; however, HRQoL instruments are often complicated and unsuitable for use in low-resource settings. A single-item self-rated health (SRH) score may represent a simpler alternative which could be used in clinical decision-making.AIMS: To evaluate internal and external validity of SRH and its correlation with TBscore/TBscoreII in a low-resource setting.METHODS: We used data from our ongoing prospective TB cohort study in Guinea-Bissau. Cohen´s d was used to assess internal validity, and receiver-operating characteristics and mortality statistics to assess external validity. Correlation between SRH and TBscore/TBscoreII was estimated using linear regression.RESULTS: SRH showed satisfactory internal validity and ability to discriminate between fatal cases at high and low scores, although not at middling scores. SRH and TBscore/TBscoreII correlated well at each examination but changes in scores did not, which may be due to ceiling/floor effects and a lag between disease severity and HRQoL.CONCLUSION: SRH shows potential as a quick and simple method to identify patients in need of intensified follow-up during treatment provision. More research is needed to assess its generalisability beyond our setting and to develop models for clinical use of SRH.

Hypertension is associated with increased mortality in patients with tuberculosis in Guinea-Bissau

OBJECTIVES

Tuberculosis (TB) is associated with a number of non-communicable co-morbidities, which can complicate treatment and impair outcome. The aim of this study was to assess the impact of hypertension on disease severity, treatment outcome and survival in a cohort of patients with TB.

METHODS

A retrospective cohort study was conducted in Guinea-Bissau. Patients newly diagnosed with TB between November 2003 and June 2016 were included. Hypertension was defined as blood pressure ≥140/90 mmHg. Disease severity was assessed using the Bandim TBscore. Survival was assessed at the end of treatment and 2 years after treatment initiation.

RESULTS

In total, 1544 patients were included in this study. Hypertension was present in 12.8% of patients at inclusion. Patients with hypertension had slightly less severe TB, but were less likely to have a successful treatment outcome and had 64% higher mortality at 2-year follow-up (adjusted hazard ratio 1.64, 95% confidence interval 1.15-2.34). Mortality rates were highest in hypertensive female patients and patients aged ≥ 45 years.

CONCLUSION

Patients with high blood pressure at the start of TB treatment had a higher mortality rate at 2-year follow-up. Mortality rates were highest in hypertensive females and patients aged ≥ 45 years.

Tuberculosis case finding and mortality prediction: added value of the clinical TBscore and biomarker suPAR

SETTING

A suburban area of Bissau, the capital of Guinea-Bissau; the study was conducted among presumptive pulmonary tuberculosis (prePTB) patients seeking medical care for signs and symptoms suggestive of PTB.

OBJECTIVE

To determine if a clinical TB score and a biomarker suPAR (soluble urokinase plasminogen activator receptor) have separate and composite ability to predict PTB diagnosis and mortality in prePTB patients.

DESIGN

Observational prospective follow-up study conducted from August 2010 to August 2012.

RESULTS

We included 1011 prePTB patients (mean age 34 years, 95%CI 33-35); 55% (n = 559) were female and 161 (16%) had human immunodeficiency virus (HIV) infection. Of all included patients, 10% (n = 101) were diagnosed with PTB. Mortality during follow-up was 5% (n = 48), with a mean survival time of 158 days (95%CI 27-289) in prePTB patients diagnosed with PTB vs. 144 days (95%CI 109-178) in those not diagnosed with PTB (P = 0.774). After adjusting for HIV status and age, the best separate predictor was suPAR 5 ng/ml, with a hazard ratio (HR) of 4.6 (95%CI 2.1-9.9) for mortality and 6.7 (95%CI 4.0-11.2) for TB diagnosis. All patients who died had a TBscore II + suPAR 7; the HR of the composite score for subsequent PTB diagnosis was 33.0 (95%CI 4.6-236.6).

CONCLUSION

The proposed composite score of suPAR + TBscore II 7 can improve TB case finding and clinical monitoring.

Low prevalence of malnourishment among household contacts of patients with tuberculosis in Guinea-Bissau

SETTING

An urban demographic surveillance site in Bissau, the capital of Guinea-Bissau, West Africa.BACKGROUND We hypothesised that if previous malnutrition plays a part in acquiring active tuberculosis (TB) disease, households of TB cases would have a higher prevalence of malnutrition than those of healthy controls.

DESIGN

A cross-sectional study comparing nutritional and socio-economic status of all newly diagnosed patients with TB in 2014 with household contacts (persons residing in the household of TB cases) and random controls. Exclusion criteria were extra-pulmonary TB, age <15 years and pregnancy.

RESULTS

Prevalence of malnutrition was 5% in household contacts and healthy controls, and 51% in patients with TB. Patients with TB had 22% (95%CI 19-25) lower body weight, 22% (95%CI 20-25) lower body mass index and 22% (95%CI 19-24) lower mid-upper arm circumference than healthy controls (P < 0.001); household contacts and healthy controls were comparable for all measures. The socio-economic status of households with TB cases was lower.

CONCLUSIONS

We did not find a higher prevalence of malnourishment in households with TB cases. This finding did not support the hypothesis that malnourishment was an important causative factor for the development of active TB among patients in this study.

Impact of HIV-1, HIV-2, and HIV-1+2 dual infection on the outcome of tuberculosis

BACKGROUND

HIV-1 infection has been shown to impact the outcome of patients with tuberculosis (TB), but data regarding the impact of HIV-2 on TB outcomes are limited. The aim of this study was to assess the impact of HIV types on mortality among TB patients in Guinea-Bissau and to examine the predictive ability of the TBscoreII, a clinical score used to assess disease severity.

METHODS

In a prospective follow-up study, we examined the prevalence of HIV-1, HIV-2, and HIV-1+2 co-infection in TB patients in Guinea-Bissau, and the impact on outcomes at 12 months of follow-up. We included all adult TB patients in an observational TB cohort at the Bandim Health Project (BHP) in Guinea-Bissau between 2003 and 2013 and assessed survival status at 12 months after the start of treatment.

RESULTS

A total 1312 patients were included; 499 (38%) were female (male/female ratio 1.6). Three hundred and seventy-nine patients were HIV-infected: 241 had HIV-1, 93 had HIV-2, and 45 were HIV-1+2 dual infected. The HIV type-associated risk of TB was 6-fold higher for HIV-1, 7-fold higher for HIV-1+2 dual infection, and 2-fold higher for HIV-2 compared with the HIV-uninfected. Of the patients included, 144 (11%) died, 62 (12%) among females and 82 (9%) among males (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.64-1.30; p=0.596). Compared to male patients, female patients were younger (1 year younger, 95% CI 0.5-2; p=0.04), reported a longer duration of symptoms (14 days longer, 95% CI 4-25; p=0.003), and had a higher TBscoreII (0.5 points more, 95% CI 0.3-0.7; p<0.001). More females than males were HIV-infected (36% vs. 25%; p<0.001) and more females had a body mass index (BMI) <15 kg/m(2) (11% vs. 6%; p<0.001) and a mid upper arm circumference (MUAC) <200 mm (13% vs. 7%; p < 0.001). HIV infection increased the mortality risk, with HIV-1 infection displaying the highest HR (5.0, 95% CI 3.5-7.1), followed by HIV-1+2 (HR 4.2, 95% CI 2.2-7.8) and HIV-2 (HR 2.1, 95% CI 1.2-3.8). A TBscoreII ≥4 was associated with increased mortality (HR 2.2, 95% CI 1.5-3.1). Significantly increased HRs were found for signs of wasting; a BMI <18 kg/m(2) was associated with a HR of 1.8 (95% CI 1.3-2.6) and a MUAC <220 mm with a HR of 3.8 (95% CI 2.7-5.2).

CONCLUSION

The HIV type-associated risk of TB was much higher for HIV-1 patients and higher but less so for HIV-2 patients, compared with the HIV-uninfected. Clinical severity at presentation was also higher for HIV-infected patients, although less so for HIV-2-infected patients, and all HIV-infected patients had a poorer outcome than the uninfected; mortality was 4-5-fold higher for HIV-1 and dually infected patients and two-fold higher for HIV-2-infected patients. These differences between HIV types did not disappear after adjusting for CD4 count.

Decline in overall, smear-negative and HIV-positive TB incidence while smear-positive incidence stays stable in Guinea-Bissau 2004-2011

OBJECTIVE

To calculate Tuberculosis (TB) incidence rates in Guinea-Bissau over an 8-year period.

METHODS

Since 2003, a surveillance system has registered all TB cases in six suburban districts of Bissau. In this population-based prospective follow-up study, 1205 cases of pulmonary TB were identified between January 2004 and December 2011. Incidence rates were calculated using census data from the Bandim Health and Demographic Surveillance System (HDSS).

RESULTS

The overall incidence of pulmonary TB was 279 per 100,000 person-years of observation; the male incidence being 385, and the female 191. TB incidence rates increased significantly with age in both sexes, regardless of smear or HIV status. Despite a peak with unknown cause of 352 per 100,000 in 2007, the overall incidence of pulmonary TB declined over the period. The incidence of HIV infected TB cases declined significantly from 108 to 39 per 100,000, while the incidence of smear-positive TB cases remained stable; the overall figure was 188 per 100,000.

CONCLUSIONS

Overall incidence of pulmonary TB in Guinea-Bissau has declined from 2004 to 2011. The decline was also seen in the subgroups of smear-negative and HIV-positive TB cases, probably due to antiretroviral treatment. Smear-positive TB incidence remains stable over the period.

Treatment delay affects clinical severity of tuberculosis: a longitudinal cohort study

OBJECTIVES

To describe the risk factors for treatment delay and the effect of delay on the severity of tuberculosis (TB) in a prospectively followed TB cohort at the Bandim Health Project in Guinea-Bissau.

BACKGROUND

Treatment delay in patients with TB is associated with increased mortality and transmission of disease. However, it is not well described whether delay influences clinical severity at diagnosis. Previously reported risk factors for treatment delay vary in different geographical and cultural settings. Such information has never been investigated in our setting. Change in delay over time is rarely reported and our prospectively followed TB cohort gives an opportunity to present such data.

PARTICIPANTS

Patients were included at the time of diagnosis at three local TB clinics and the national TB reference hospital. Inclusion criteria were age >15 years and diagnosis of TB by either sputum examination or by the WHO clinical criteria. Patients with extrapulmonary TB were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was treatment delay. Delay was assessed by patient questionnaires. The secondary outcome was Bandim TBscore as a measure of TB morbidity and all-cause mortality.

RESULTS

A total of 1424 persons were diagnosed with TB in the study area between 2003 and 2010. We included 973 patients with TB in the study. The median treatment delay was 12.1 weeks. Risk factors for delay were low educational level, HIV-1+HIV-2 dual infection and negative sputum smear. TB treatment delay decreased by 10.3% (7.9-12.6%) per year during the study period. Delay was significantly associated with clinical severity at presentation with 20.8% severe TB cases in the low delay quartile compared with 33.9% if delay was over the median of 12.1 weeks.

CONCLUSIONS

Long treatment delay was associated with more severe clinical presentation. Treatment delay in TB cases is decreasing in Guinea-Bissau.

Twitch-potentiation increases calcium in peripheral more than in central mitochondria of guinea-pig ventricular myocytes

1. The mitochondrial total calcium content ([Ca]mt) was studied with electron probe microanalysis (EPMA) in isolated guinea-pig ventricular myocytes in order to answer the question of whether electrical stimulation increases [Ca]mt in subsarcolemmal and central mitochondria to a different extent. 2. In unstimulated myocytes subsarcolemmal [Ca]mt was (mean +/- s.e.m.) 535 +/- 229 micromol (kg dry weight (DW))-1 and central [Ca]mt was 513 +/- 162 micromol (kg DW)-1. These values do not differ and correspond to approximately 180 micromol calcium per litre of mitochondria or 180 microM. 3. Contractions were potentiated to an optimum by stimulation with trains of 12 paired stimuli. After potentiation with 12 paired action potentials, cells were shock-frozen 120 ms after the start of the first action potential of the 13th pair. Subsarcolemmal [Ca]mt was 1.3 +/- 0.4 mmol (kg DW)-1 (433 microM) and central [Ca]mt was 227 +/- 104 micromol (kg DW)-1 (76 microM). The difference was significant. 4. After potentiation with 12 paired voltage-clamp pulses, cells were shock-frozen 120 ms after the start of the first pulse of the 13th pair. Subsarcolemmal [Ca]mt was 2.2 +/- 1.0 mmol (kg DW)-1 (733 microM) and central [Ca]mt was 630 +/- 180 micromol (kg DW)-1 (210 microM). After removal of extracellular K+, five paired voltage-clamp pulses increased subsarcolemmal [Ca]mt to 2.1 +/- 0.8 mmol (kg DW)-1 (700 microM), which was significantly higher than the central [Ca]mt of 389 +/- 88 micromol (kg DW) -1 or 130 microM. 5. In unstimulated cells, [Na] and [K] in subsarcolemmal and central mitochondria were not different. In potentiated myocytes, subsarcolemmal [Na]mt was 236 +/- 20 mmol (kg DW)-1 or 79 mM, which is significantly higher than the central [Na]mt of 50 +/- 5 mmol (kg DW)-1 or 16 mM. 6. The differences in [Ca]mt and [Na]mt are attributed to subsarcolemmal cytosolic microdomains of elevated [Ca2+] and [Na+] generated during contractile potentiation by transmembrane Ca2+ and Na+ fluxes.

Improvement in Quantitative X-ray Microanalysis of Biological Cryosections

: The accuracy of Na measurements in biological cryosections has been improved through replacement of the 8 µm Be window of the Si(Li) detector with a Super Atmospheric Thin Window (SuperATW) window mounted on a germanium electron microscope (GEM) detector. Greater accuracy of Ca measurements was also attained when a GEM detector instead of an Si(Li) detector was used for analysis of total Ca concentrations in cardiac muscle. Although the advantage of improved sensitivity for Na and Ca is lost in spot mode analysis because of the overriding contribution of biological variability, this advantage becomes important in X-ray mapping. We compared the two systems by analyzing cryosections of identical biological material under comparable conditions. We found that Si contamination in thin biological cryosections is unpredictable; it may be widespread and differ in degree in various cell compartments of the same cell. Hence, a correction for Si contamination should be included in the calculations of elemental concentrations. We suggest here a procedure for measuring and subtracting Si contamination from elemental spectra.

[Changes in interleukin-2 receptor levels in active and inactive pulmonary sarcoidosis]

Current concepts of the immunopathology of sarcoidosis claim a central role for activated pulmonary T-lymphocytes in the maintenance of inflammatory processes. We hypothesized that the pulmonary sarcoidosis disease activity could be monitored by the measurement of serum levels of sIL-2R. We evaluated the sIL-2R in 28 sarcoidosis patients at multiple time points before, during and after therapy and compared the results with the clinical activity of the disease. Before therapy out of 24 episodes with active disease 20 exhibited elevated levels of sIL-2R. Six out of 21 episodes with inactive disease after tappering off corticoid therapy had sIL-2R levels above the upper limit of the normal range. Disease activity under therapy as well segregated with the sIL-2R serum level. Our results demonstrate that the activity of pulmonary sarcoidosis is reflected accurately by the serum level of sIL-2R suggesting that phenomenons of T-cell activation determining the course of the disease are monitored by this approach.