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Heffernan C, Barrie J, Doroshenko A, Egedahl ML, Paulsen C, Senthilselvan A, Long R. Prompt recognition of infectious pulmonary tuberculosis is critical to achieving elimination goals: a retrospective cohort study. BMJ Open Respir Res 2020; 7:7/1/e000521. [PMID: 32448785 PMCID: PMC7252995 DOI: 10.1136/bmjresp-2019-000521] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/16/2020] [Accepted: 04/29/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION All pulmonary tuberculosis (PTB) cases are presumed to be infectious to some degree. This spectrum of infectiousness is independently described by both the acid-fast bacilli smear and radiographic findings. Smear-positive patients with chest radiographic findings that are typical for adult-type PTB are believed to be most infectious. HYPOTHESIS Characterisation of the presumed most infectious PTB case is possible by reference to readily available clinical features and laboratory results. METHODS Retrospective cohort study of adult, culture-positive PTB cases (151 smear-positive; 162 smear-negative) diagnosed between 1 January 2013 and 30 April 2017 in Canada. We describe cases according to demographic, clinical and laboratory features. We use multivariable multinomial logistic regression to estimate the relative risk ratio (RRR) with 95% CI of features associated with an outcome of smear-positive PTB, characterised by 'typical' chest radiograph findings. RESULTS Being Canadian-born, symptomatic, having a subacute duration of symptoms and broad-spectrum antibiotic prescriptions were all more commonly associated with smear-positive than smear-negative disease (36% vs 20%; 95% vs 63%; 88% vs 54%; and 59% vs 28%, respectively). After combining smear status and radiographic features, we show that smear-positive patients with typical chest radiographs were younger, had a longer duration of symptoms (RRR 2.41; 95% CI 1.01 to 5.74 and 2.93; 95% CI 1.20 to 7.11, respectively) and were less likely to be foreign-born, or have a moderate to high-risk factor for reactivation (RRR 0.40; 95% CI 0.17 to 0.92 and 0.18; 95% CI 0.04 to 0.71, respectively) compared with smear-negative patients with atypical chest radiograph findings. CONCLUSION A clear picture of the presumed most infectious PTB case emerges from available historical and laboratory information; vigilance for this presentation by front-line providers will support elimination strategies aimed at reducing transmission.
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Affiliation(s)
- Courtney Heffernan
- Department of Medicine; Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - James Barrie
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Doroshenko
- Department of Medicine; Division of Preventive Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mary Lou Egedahl
- Department of Medicine; Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine Paulsen
- Department of Medicine; Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Richard Long
- Department of Medicine; Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
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Abbara A, Collin SM, Kon OM, Buell K, Sullivan A, Barrett J, Corrah T, McGregor A, Hansel T, John L, Davidson RN. Time to diagnosis of tuberculosis is greater in older patients: a retrospective cohort review. ERJ Open Res 2019; 5:00228-2018. [PMID: 31720296 PMCID: PMC6826249 DOI: 10.1183/23120541.00228-2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 07/29/2019] [Indexed: 11/05/2022] Open
Abstract
Introduction Age-related immunosenescence influences the presentation of tuberculosis (TB) in older patients. Here, we explore the clinical and radiological presentation of TB in the elderly and the factors associated with time to treatment for TB. Methods This is a retrospective cohort study comparing the clinical, radiological and demographic characteristics of TB patients aged ≥65 years with TB patients aged 18–64 years in a large cohort of TB patients in the UK. Factors associated with the time to presentation and time to treatment were identified using a multivariable analysis model. Results 1023 patients were included in the analyses: 679 patients aged 18–64 years and 344 patients aged ≥65 years. “Classical” symptoms of TB (cough, haemoptysis, fever, nights sweats and weight loss) were less common among older patients with pulmonary TB (PTB) (p<0.05), but dyspnoea was more common among older patients (p=0.001). Time from presenting in secondary care to starting treatment was shorter in younger compared with older patients: 3 versus 15 days (p=0.001). When adjusted for age, factors associated with shorter time to treatment from symptom onset include sex (male versus female) (hazard ratio (HR) 1.23 (95% CI 1.05–1.46)), UK born (HR 1.23 (95% CI 1.05–1.46)) and HIV (HR 2.07 (95% CI 1.30–3.29)). Only age remained an independent predictor of time to treatment in a multivariable model (HR 0.98 (95% CI 0.98–0.99)). For those with PTB, chest radiography findings showed that cavitation and lymphadenopathy were more common among younger patients (p=0.001). Conclusions Older patients aged ≥65 years with TB had fewer “classical” clinical and radiological presentations of TB, which may explain longer times to starting treatment from symptom onset compared with younger patients aged <65 years. A retrospective UK study in patients with TB shows only age remains an independent predictor of time to treatment in a multivariable model. Older patients have fewer of the “classical” clinical and radiological features of TB compared with younger patients.http://bit.ly/2yHc0OL
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Affiliation(s)
- Aula Abbara
- London North West University Healthcare NHS Trust, London, UK.,Dept of Infection, Imperial College London, London, UK
| | | | - Onn M Kon
- Dept of Infection, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Kevin Buell
- Dept of Infection, Imperial College London, London, UK
| | - Adam Sullivan
- Dept of Infection, Imperial College London, London, UK
| | - Jessica Barrett
- London North West University Healthcare NHS Trust, London, UK
| | - Tumena Corrah
- London North West University Healthcare NHS Trust, London, UK
| | | | - Trevor Hansel
- Dept of Infection, Imperial College London, London, UK
| | - Laurence John
- London North West University Healthcare NHS Trust, London, UK
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QuantiFERON-TB Gold Plus Is a More Sensitive Screening Tool than QuantiFERON-TB Gold In-Tube for Latent Tuberculosis Infection among Older Adults in Long-Term Care Facilities. J Clin Microbiol 2018; 56:JCM.00427-18. [PMID: 29793966 DOI: 10.1128/jcm.00427-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/12/2018] [Indexed: 12/31/2022] Open
Abstract
We investigated the prevalence of latent tuberculosis infection (LTBI) among the residents in seven long-term care facilities (LTCFs) located in different regions of Taiwan and compared the performance of two interferon gamma release assays, i.e., QuantiFERON-TB Gold In-Tube (QFT-GIT) and QuantiFERON-TB Gold Plus (QFT-Plus) for screening LTBI. We also assessed the diagnostic performance against a composite reference standard (subjects with persistent-positive, transient-positive, and negative results from QFTs during reproducibility analysis were classified as definite, possible, and not LTBI, respectively). Two hundred forty-four residents were enrolled, and 229 subjects were included in the analysis. The median age was 80 years (range, 60 to 102 years old), and 117 (51.1%) were male. Among them, 66 (28.8%) and 74 (32.3%) subjects had positive results from QFT-GIT and QFT-Plus, respectively, and the results for 215 (93.9%) subjects showed agreement. Using the composite reference standard, 66 (28.8%), 11 (4.8%), and 152 (66.4%) were classified as definite, possible, and not LTBI, respectively. For definite LTBI, the sensitivity, specificity, positive predictive value, and negative predictive value of QFT-GIT were 89.4%, 95.7%, 89.4%, and 95.7%, respectively, and those for QFT-Plus were 100.0%, 95.1%, 89.2%, and 100.0%, respectively. The sensitivity of QFT-GIT decreased gradually with patient age. Compared to QFT-GIT, QFT-Plus displayed significantly higher sensitivity (100.0% versus 89.4%, P = 0.013) and similar specificity (95.1% versus 95.7%). In conclusion, a high prevalence of LTBI was found among elders in LTCFs in Taiwan. The new QFT-Plus test demonstrated a higher sensitivity than QFT-GIT in the older adults in LTCFs.
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Li J, Yip BHK, Leung C, Chung W, Kwok KO, Chan EYY, Yeoh E, Chung P. Screening for latent and active tuberculosis infection in the elderly at admission to residential care homes: A cost-effectiveness analysis in an intermediate disease burden area. PLoS One 2018; 13:e0189531. [PMID: 29293514 PMCID: PMC5749681 DOI: 10.1371/journal.pone.0189531] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in the elderly remains a challenge in intermediate disease burden areas like Hong Kong. Given a higher TB burden in the elderly and limited impact of current case-finding strategy by patient-initiated pathway, proactive screening approaches for the high-risk group could be optimal and increasingly need targeted economic evaluations. In this study, we examined whether and under what circumstance the screening strategies are cost-effective compared with no screening strategy for the elderly at admission to residential care homes. METHODS A decision analytic process based on Markov model was adopted to evaluate the cost-effectiveness of four strategies: (i) no screening, (ii) TB screening (CXR) and (iii) TB screening (Xpert) represent screening for TB in symptomatic elderly by chest X-ray and Xpert® MTB/RIF respectively, and (iv) LTBI/TB screening represents screening for latent and active TB infection by QuantiFERON®-TB Gold In-Tube and chest X-ray. The target population was a hypothetical cohort of 65-year-old people, using a health service provider perspective and a time horizon of 20 years. The outcomes were direct medical costs, life-years and quality-adjusted life-years (QALYs) measured by incremental cost-effectiveness ratio (ICER). RESULTS In the base-case analysis, no screening was the most cost-saving; TB screening (CXR) was dominated by TB screening (Xpert); LTBI/TB screening resulted in more life-years and QALYs accrued. The ICERs of LTBI/TB screening were US$19,712 and US$29,951 per QALY gained compared with no screening and TB screening (Xpert), respectively. At the willingness-to-pay threshold of US$50,000 per QALY gained, LTBI/TB screening was the most cost-effective when the probability of annual LTBI reactivation was greater than 0.155% and acceptability of LTBI/TB screening was greater than 38%. In 1,000 iterations of Monte Carlo simulation, the probabilities of no screening, TB screening (CXR), TB screening (Xpert), and LTBI/TB screening to be cost-effective were 0, 1.3%, 20.1%, and 78.6% respectively. CONCLUSIONS Screening for latent and active TB infection in Hong Kong elderly people at admission to residential care homes appears to be highly effective and cost-effective. The key findings may be the next key factor to bring down TB endemic in the elderly population among intermediate TB burden areas.
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Affiliation(s)
- Jun Li
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Benjamin H. K. Yip
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Chichiu Leung
- Tuberculosis and Chest Service, Department of Health, Hong Kong, China
| | - Wankyo Chung
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, South Korea
| | - Kin On Kwok
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Emily Y. Y. Chan
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Engkiong Yeoh
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Puihong Chung
- Jockey School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
- * E-mail:
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Lee CH, Wang JY, Lin HC, Lin PY, Chang JH, Suk CW, Lee LN, Lan CC, Bai KJ. Treatment delay and fatal outcomes of pulmonary tuberculosis in advanced age: a retrospective nationwide cohort study. BMC Infect Dis 2017; 17:449. [PMID: 28646854 PMCID: PMC5483299 DOI: 10.1186/s12879-017-2554-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 06/16/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Studies focusing on pulmonary tuberculosis in advanced age (≥80 years) are lacking. This study aimed to explore treatment delay, outcomes and their predictors in this group. METHODS Adult (≥20 years) patients with pulmonary tuberculosis were identified from the National Health Insurance Research Database of Taiwan from 2004 to 2009. Treatment completion and mortality rates were noted at one year after treatment. RESULTS Among the 81,081 patients with pulmonary tuberculosis identified, 13,923 (17.2%) were aged ≥80 years, and 26,897 (33.2%) were aged 65-79 years. The treatment completion, mortality rates and treatment delay were 54.8%, 34.7% and 61 (12-128) [median, (1st-3rd quartiles)] days in patients aged ≥80 years, 68.3%, 18.5% and 53 (8-122) days in patients aged 65-79 years, and 78.9%, 6.5% and 21 (1-84) days in patients aged <65 years, respectively. The elder patients were more likely to receive second-line anti-tuberculosis agents. The treatment completion rate decreased with older age, female sex, comorbidities, low income, requiring second-line anti-tuberculosis agents, severity of pulmonary tuberculosis and longer treatment delay. Older age, female sex, comorbidities, low income, and not undergoing rapid molecular diagnostic tests were independently associated with longer treatment delays. CONCLUSIONS Pulmonary tuberculosis in advanced age has a longer treatment delay and a higher mortality rate. Applying rapid molecular diagnostic tools may reduce treatment delay and should be integrated into the diagnostic algorithm for pulmonary tuberculosis, particularly in elderly patients.
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Affiliation(s)
- Chih-Hsin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Wanfang Hospital, Taipei Medical University, No. 111, Sec. 3, Hsing-Long Rd., Taipei, 116 Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, No. 250, Wuxing St., Taipei, 110 Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, No.7, Chung Shan S. Rd., Taipei, 100 Taiwan
| | - Hsien-Chun Lin
- Division of Pulmonary Medicine, Department of Internal Medicine, Wanfang Hospital, Taipei Medical University, No. 111, Sec. 3, Hsing-Long Rd., Taipei, 116 Taiwan
| | - Pai-Yang Lin
- Division of Pulmonary Medicine, Department of Internal Medicine, Wanfang Hospital, Taipei Medical University, No. 111, Sec. 3, Hsing-Long Rd., Taipei, 116 Taiwan
| | - Jer-Hwa Chang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wanfang Hospital, Taipei Medical University, No. 111, Sec. 3, Hsing-Long Rd., Taipei, 116 Taiwan
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, No. 250, Wuxing St., Taipei, 110 Taiwan
| | - Chi-Won Suk
- Division of Pulmonary Medicine, Department of Internal Medicine, Wanfang Hospital, Taipei Medical University, No. 111, Sec. 3, Hsing-Long Rd., Taipei, 116 Taiwan
| | - Li-Na Lee
- Department of Laboratory Medicine, National Taiwan University Hospital, No.7, Chung Shan S. Rd., Taipei, 100 Taiwan
| | - Chou-Chin Lan
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 289, Jianguo Rd., Xindian Dist, New Taipei, 231 Taiwan
- School of Medicine, Tzu Chi University, No.701, Sec. 3, Zhongyang Rd., Hualien, 970 Taiwan
| | - Kuan-Jen Bai
- Division of Pulmonary Medicine, Department of Internal Medicine, Wanfang Hospital, Taipei Medical University, No. 111, Sec. 3, Hsing-Long Rd., Taipei, 116 Taiwan
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, No. 250, Wuxing St., Taipei, 110 Taiwan
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6
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Reddy D, Walker J, White LF, Brandeis GH, Russell ML, Horsburgh CR, Hochberg NS. Latent Tuberculosis Infection Testing Practices in Long-Term Care Facilities, Boston, Massachusetts. J Am Geriatr Soc 2017; 65:1145-1151. [PMID: 28467605 DOI: 10.1111/jgs.14696] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe latent tuberculosis infection (LTBI) testing practices in long-term care facilities (LTCFs). DESIGN Retrospective cohort study. SETTING Three Boston-area LTCFs. PARTICIPANTS Residents admitted between January 1 and December 31, 2011. MEASUREMENTS Resident demographic characteristics, comorbidities, LTCF stay, and LTBI testing and treatment. RESULTS Data for 291 LTCF residents admitted in 2011 were reviewed. Of the 257 without a history of LTBI and with documentation of testing, 162 (63%) were tested; 114 of 186 (61%) with a stay less than 90 days and 48 of 71 (68%) with a stay of 90 days or longer were tested. Of 196 residents with data on prior LTBI testing, 39 (19.9%) had LTBI; 12 of these (30.8%) were diagnosed at the LTCF. Hispanic participants were more likely than black participants to undergo LTBI testing (adjusted odds ratio (aOR) = 2.4, P = .003). Having a length of stay of less than 90 days (aOR = 0.7, P < .001) and history of illicit drug use (aOR = 0.7, P < .001) were associated with lower odds of LTBI testing. CONCLUSION One-fifth of LTCF residents had LTBI, but testing was not always performed. The high prevalence of LTBI in older adults combined with the risk of an outbreak if a case of tuberculosis occurs in a LTCF make LTBI testing and treatment an important prevention opportunity. The importance of LTBI testing in LTCFs needs to be reinforced.
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Affiliation(s)
- Divya Reddy
- Section of Pulmonary, Allergy, Sleep and Critical Care, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Jacob Walker
- School of Medicine, Boston University, Boston, Massachusetts
| | - Laura F White
- Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts
| | - Gary H Brandeis
- Section of Geriatric Medicine, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Matthew L Russell
- Section of Geriatric Medicine, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Charles R Horsburgh
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts.,Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Natasha S Hochberg
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts.,Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
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Hogeweg L, Sánchez CI, Maduskar P, Philipsen R, Story A, Dawson R, Theron G, Dheda K, Peters-Bax L, van Ginneken B. Automatic Detection of Tuberculosis in Chest Radiographs Using a Combination of Textural, Focal, and Shape Abnormality Analysis. IEEE TRANSACTIONS ON MEDICAL IMAGING 2015; 34:2429-2442. [PMID: 25706581 DOI: 10.1109/tmi.2015.2405761] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Tuberculosis (TB) is a common disease with high mortality and morbidity rates worldwide. Automatic systems to detect TB on chest radiographs (CXRs) can improve the efficiency of diagnostic algorithms for pulmonary TB. The diverse manifestation of TB on CXRs from different populations requires a system that can be adapted to deal with different types of abnormalities. A computer aided detection (CAD) system was developed which combines several subscores of supervised subsystems detecting textural, shape, and focal abnormalities into one TB score. A general framework was developed to combine an arbitrary number of subscores: subscores were normalized, collected in a feature vector and then combined using a supervised classifier into one combined score. The method was evaluated on two databases, both consisting of 200 digital CXRs, from: (A) Western high-risk group screening, (B) TB suspect screening in Africa. The subscores and combined score were compared to (1) an external, non-radiological, reference and (2) a radiological reference determined by a human expert. Performance was measured using Receiver Operator Characteristic (ROC) analysis. Different subscores performed best in the two databases. The combined TB score performed better than the individual subscores, except for the external reference in database B. The performances of the independent observer were slightly higher than the combined TB score. Compared to the external reference, differences in performance between the combined TB score and the independent observer were not significant in both databases. Supervised combination to compute an overall TB score allows for a necessary adaptation of the CAD system to different settings or different operational requirements.
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Cherif J, Mjid M, Ladhar A, Toujani S, Mokadem S, Louzir B, Mehiri N, Béji M. [Diagnosis delay of pleural and pulmonary tuberculosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2014; 70:189-194. [PMID: 24874402 DOI: 10.1016/j.pneumo.2013.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 10/08/2013] [Accepted: 10/26/2013] [Indexed: 06/03/2023]
Abstract
Tuberculosis (TB) is still being endemic in our country. Time until management determines both evolution and prognosis of this condition. The aim of this work is to evaluate the delay in diagnosis of TB in a respiratory unit from a university hospital series. The authors conducted a cross-sectional study including patients with pulmonary TBC and/or pleural. An evaluation of time management was conducted from the beginning of symptoms and various consultations with reference to the date of hospitalization and treatment set up. One hundred patients were included (pulmonary TB: 68 cases, pleural TB 23 cases, miliary pulmonary TB: 4 cases, pulmonary TB associated with other extrathoracic locations: 5 cases). The mean time of patient delay and total delay institution were respectively 43.6, 25.7 and 69.3 days. Variables responsible for long delays were: number of consultations more than 3 before hospitalization, empirical antibiotic therapy, of a regional hospital first consultation and the presence of extra-respiratory impairment. The patient delay was considered long. A reorganization of the TB control program, in particular by partial decentralization of care and health education is imperative in order to improve the quality of tuberculosis management in our country.
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Affiliation(s)
- J Cherif
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie.
| | - M Mjid
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie
| | - A Ladhar
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie
| | - S Toujani
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie
| | - S Mokadem
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie
| | - B Louzir
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie
| | - N Mehiri
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie
| | - M Béji
- Service de pneumologie allergologie, unité de recherche 99/UR/08-21, faculté de médecine de Tunis, université de Tunis El Manar, CHU La Rabta, 1007 Tunis, Tunisie
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9
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Vasakova M. Challenges of antituberculosis treatment in patients with difficult clinical conditions. CLINICAL RESPIRATORY JOURNAL 2014; 9:143-52. [DOI: 10.1111/crj.12119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 01/30/2014] [Accepted: 02/06/2014] [Indexed: 02/04/2023]
Affiliation(s)
- Martina Vasakova
- Department of Respiratory Medicine; Thomayer Hospital Prague; Prague Czech Republic
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10
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Chiang CY, Lee JJ, Chien ST, Enarson DA, Chang YC, Chen YT, Hu TY, Lin CB, Suk CW, Tao JM, Bai KJ. Glycemic control and radiographic manifestations of tuberculosis in diabetic patients. PLoS One 2014; 9:e93397. [PMID: 24699457 PMCID: PMC3974751 DOI: 10.1371/journal.pone.0093397] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 03/04/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Radiographic manifestations of pulmonary tuberculosis (TB) in patients with diabetes mellitus (DM) have previously been reported, with inconsistent results. We conducted a study to investigate whether glycemic control has an impact on radiographic manifestations of pulmonary TB. METHODS Consecutive patients with culture-positive pulmonary TB who had DM in three tertiary care hospitals from 2005-2010 were selected for review and compared with a similar number without DM. Glycemic control was assessed by glycated haemoglobin A1C (HbA1C). A pre-treatment chest radiograph was read independently by two qualified pulmonologists blinded to patients' diabetic status. Films with any discordant reading were read by a third reader. RESULTS 1209 culture positive pulmonary TB patients (581 with DM and 628 without DM) were enrolled. Compared with those without DM, TB patients with DM were significantly more likely to have opacity over lower lung fields, extensive parenchymal lesions, any cavity, multiple cavities and large cavities (>3 cm). The relative risk of lower lung field opacities was 0.80 (95% CI 0.46-1.42) for those with DM with A1C<7%, 2.32 (95% CI 1.36 - 3.98) for A1C 7%-9%, and 1.62 (95% CI 1.12-2.36) for A1C>9%; and that of any cavity over no cavity was 0.87 (95% CI 0.46-1.62) for patients with DM with A1C<7%, 1.84 (95% CI 1.20-2.84) for A1C 7%-9%, and 3.71 (95% CI 2.64-5.22) for A1C>9%, relative to patients without DM. CONCLUSIONS Glycemic control significantly influenced radiographic manifestations of pulmonary TB in patients with DM.
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Affiliation(s)
- Chen-Yuan Chiang
- International Union Against Tuberculosis and Lung Disease, Paris, France
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jen-Jyh Lee
- Department of Internal Medicine, Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Shun-Tien Chien
- Chest Hospital, Department of Health and Welfare, Tainan County, Taiwan
| | - Donald A. Enarson
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - You-Cheng Chang
- Chest Hospital, Department of Health and Welfare, Tainan County, Taiwan
| | - Yi-Ting Chen
- Department of Internal Medicine, Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Ting-Yu Hu
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chih-Bin Lin
- Department of Internal Medicine, Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Chi-Won Suk
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jui-Ming Tao
- Chest Hospital, Department of Health and Welfare, Tainan County, Taiwan
| | - Kuan-Jen Bai
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail:
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Mamo JP, Brij SO. Treating tuberculosis in the elderly population: a lesson in multi-disciplinary care. Scott Med J 2013; 58:e15-6. [PMID: 24215051 DOI: 10.1177/0036933013508045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION It is estimated that the risk of reactivation of previously untreated healed or latent tuberculosis is around 0.04 cases per 100 person-years. The incidence of active tuberculosis in Peterborough is 28.0 per 100,000 population compared with 8.3 in the East of England region. The majority of patients are of Indian or Pakistani origin and aged between 15 and 65. CASE PRESENTATION Here, we present the case of an 88-year-old gentleman who successfully completed anti-tuberculous therapy for smear-negative tuberculosis and discuss some of the issues encountered in his management, with particular emphasis on drug surveillance, tolerance of anti-tuberculous therapy and drug interactions. CONCLUSION Elderly persons presenting with tuberculosis are more likely to present atypically and may need a staged initiation of therapy with continued pharmacist advice, due to high risk of interactions.
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Affiliation(s)
- J P Mamo
- Medical Senior House Officer, Department of Medicine, Peterborough City Hospital, UK
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12
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Hussein MT, Yousef LM, Abusedera MA. Pattern of pulmonary tuberculosis in elderly patients in Sohag Governorate: Hospital based study. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kwon YS, Chi SY, Oh IJ, Kim KS, Kim YI, Lim SC, Kim YC. Clinical characteristics and treatment outcomes of tuberculosis in the elderly: a case control study. BMC Infect Dis 2013; 13:121. [PMID: 23510403 PMCID: PMC3599150 DOI: 10.1186/1471-2334-13-121] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 03/01/2013] [Indexed: 01/15/2023] Open
Abstract
Background The purpose of this study was to evaluate the differences in clinical characteristics and treatment outcomes between older and younger tuberculosis (TB) patients in Korea. Methods We retrospectively analyzed the medical records of 271 younger (20–64 years old at diagnosis) and 199 older (≥65 years) TB patients who had been newly diagnosed and treated at Chonnam National University Hospital from May 2008 to August 2010. Results Dyspnea and comorbid medical conditions were more frequent and positive TB culture rates were higher in older TB patients. In chest computed tomography (CT) scans of pulmonary TB patients, older patients were less likely to have micronodules (<7 mm in diameter), nodules (<30 mm in diameter), masses (>30 mm in diameter), and cavities compared with younger patients, but were more likely to have consolidations. Incidence of adverse drug reactions did not differ between the two groups, except for severe gastrointestinal disorders. There were no significant differences in favorable treatment outcomes between younger and older TB patients (97% vs. 94%, respectively; p = 0.251). Conclusions Older TB patients had more frequent dyspnea and less frequent active TB findings on chest CT. Treatment success and adverse drug reaction rates were similar in older and younger TB patients.
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Affiliation(s)
- Yong Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea.
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Tatar D, Senol G, Alptekin S, Anar C, Aydın M, Arslangiray S. Tuberculosis in older adults. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2012.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Touré NO, Dia Kane Y, Diatta A, Ba Diop S, Niang A, Ndiaye EM, Thiam K, Mbaye FBR, Badiane M, Hane AA. [Tuberculosis in elderly persons]. Rev Mal Respir 2010; 27:1062-8. [PMID: 21111277 DOI: 10.1016/j.rmr.2010.04.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 04/14/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the epidemiology, clinical features and clinical course of primary presentations with pulmonary tuberculosis occurring in older and younger patients. PATIENTS AND METHODS We undertook a prospective, comparative study in the Pneumology clinic of the National University Hospital of Fann in Dakar, from April 1, 2005 to March 31, 2006, collecting data on all patients presenting with a first episode of bacterially confirmed pulmonary tuberculosis. RESULTS We studied 187 first presentations with confirmed pulmonary tuberculosis including 12.8% (n=24) elderly (>55 years) subjects (20 men and four women) and 87.2% (n=163) younger subjects (105 men and 58 women). In the older subjects, patients were more commonly men (sex-ratio: 5), without formal education, and working in the primary or informal sector. Comorbidities were more frequent in the older group, including smoking (P=0.002), alcohol consumption (P=0.01), diabetes (37.5%) (P<0.005) and obesity with BMI superior than 20 in 25%. Pulmonary shadowing was common (41.7% of the cases), P=0.008 and generally bilateral P=0.0001 with cavitation, but this observation was not statistically significant. COMPLICATIONS Complications were more frequent in the older patient (20.8%), as was mortality (29.3%, P=0.000) and rate of clinical improvement in response to treatment was less satisfactory (50%) there.
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Affiliation(s)
- N O Touré
- Service de pneumologie, CHN de Fann, Dakar, Sénégal.
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Dujaili JA, Syed Sulaiman SA, Awaisu A, Muttalif AR, Blebil AQ. Outcomes of tuberculosis treatment: a retrospective cohort analysis of smoking versus non-smoking patients in Penang, Malaysia. J Public Health (Oxf) 2010. [DOI: 10.1007/s10389-010-0365-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
ABSTRACT Although tuberculosis (TB) has its highest burden among young adults, especially since the advent of HIV infection, two other groups with low immunity, the very young (<1 year) with immature immunity and the elderly (>65 years) with waning immunity, are vulnerable groups not to be forgotten. This review describes the epidemiology, clinical aspects, public health aspects and outcome of TB in patients at the extremes of age. The epidemiology differs therein that TB in infants occurs in developing countries with high incidences of TB and HIV, while TB in the elderly occurs in developed countries with ageing populations. The clinical presentation may be non-specific, history of contact with TB is often not known and TB is often not considered at these age extremes, and when the diagnosis is considered, disease progression may already be advanced. Anti-TB treatment regimens are the same as in other age groups, but drug dosages may need adjustment according to weight, renal function, liver function and other potentially complicating factors. Adverse events are more difficult to observe and both the young and the elderly are reliant on others for adherence to treatment. Mortality at both age extremes is higher than in the general TB population. For all the above reasons, public health measures to: prevent transmission of infection; identify those infected and providing preventive therapy; high index of suspicion in order to make an early diagnosis; and timely initiation of treatment are important in both the very young and the elderly.
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Affiliation(s)
- H Simon Schaaf
- Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University and Tygerberg Children's Hospital, Tygerberg, South Africa
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Geriatrics in the Rest of the World. BROCKLEHURST'S TEXTBOOK OF GERIATRIC MEDICINE AND GERONTOLOGY 2010. [PMCID: PMC7151792 DOI: 10.1016/b978-1-4160-6231-8.10120-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hwang HG, Jung EJ, Lim GI, Yang SB, Im HH. A Case of Atypical Distribution of Pulmonary Tuberculosis in Bedridden Patient with Quadriplegia. Tuberc Respir Dis (Seoul) 2010. [DOI: 10.4046/trd.2010.69.1.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Hun Gyu Hwang
- Respiratory Division, Department of Internal Medicine, Gumi, Korea
| | - Eun Jung Jung
- Respiratory Division, Department of Internal Medicine, Gumi, Korea
| | - Gune Il Lim
- Respiratory Division, Department of Internal Medicine, Gumi, Korea
| | - Seung Boo Yang
- Department of Radiology, Soonchunhyang University Gumi Hospital, Soonchunhyang University School of Medicine, Gumi, Korea
| | - Han Hyeok Im
- Department of Radiology, Soonchunhyang University Gumi Hospital, Soonchunhyang University School of Medicine, Gumi, Korea
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Roubaud-Baudron C, Godard M, Greffard S, Boddaert J, Verny M. LYMPH NODE TUBERCULOSIS AND PARADOXICAL EVOLUTION. J Am Geriatr Soc 2010; 58:192-3. [DOI: 10.1111/j.1532-5415.2009.02635.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cantalice Filho JP, Bóia MN, Sant Anna CC. [Analysis of the treatment of pulmonary tuberculosis in elderly patients at a university hospital in Rio de Janeiro, Brazil]. J Bras Pneumol 2008; 33:691-8. [PMID: 18200370 DOI: 10.1590/s1806-37132007000600013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 04/03/2007] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To describe the clinical and therapeutic aspects of pulmonary tuberculosis and compare the adverse effects of the treatment and its outcome in elderly and nonelderly patients. METHODS This was a case-control study of 117 elderly individuals (over the age of 60 years) and 464 nonelderly individuals (aged 15-49 years). All subjects presented pulmonary tuberculosis that had been diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 1980 and 1996. RESULTS In the elderly group, pulmonary tuberculosis was found to be correlated with diabetes (OR = 3.98; 95% CI = 2.07-7.65; p = 0.001), lung disease (OR = 7.24; 95% CI = 3.64-14.46; p = 0.001) and heart disease (OR = 5.86; 95% CI = 2.88-11.95; p = 0.001). Smoking (OR = 2.07; 95% CI = 1.26-3.42; p = 0.002) and alcohol abuse (OR = 1.63; 95% CI = 1.01-2.68; p = 0.041) were also more common in the elderly group. In the elderly group, the treatment more frequently resulted in adverse reactions (OR = 1.62; 95% CI = 1.04-2.54; p = 0.024), especially gastrointestinal reactions (OR = 1.64; 95% CI = 1.01-2.77; p = 0.047), and treatment efficacy was lower: cure rate, 51%; mortality rate, 24%. Treatment adherence was low (approximately 77%) in both groups. CONCLUSIONS In the elderly group, adverse reactions were more common, treatment outcomes were less favorable, there was a greater frequency of clinical complications and deaths related to drug toxicity, and the prevalence of concomitant diseases was higher.
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The impact of age on the demographic, clinical, radiographic characteristics and treatment outcomes of pulmonary tuberculosis patients in Taiwan. Infection 2008; 36:335-40. [PMID: 18629436 DOI: 10.1007/s15010-008-7199-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 11/13/2007] [Indexed: 10/21/2022]
Abstract
BACKGROUND The characteristics of pulmonary tuberculosis (TB) in the elderly are different from young patients. This leads to delay in diagnosis and higher mortality from TB in the aged population. The aim of this study was to investigate the impact of age on the demographic, clinical, radiographic characteristics, and treatment outcomes of pulmonary TB patients in Taiwan. MATERIALS AND METHODS We performed a retrospective analysis of the medical charts and chest radiographs of 83 elderly (> or =60 years old) and 74 young (< 60 years old) culture-proven pulmonary TB patients from 1 August 2003 to 31 July 2006. RESULTS Elderly patients showed lower frequencies of infectious TB contact history, alcoholism, cavity, and positive acid-fast bacilli sputum smears. In contrast, the elderly population had higher frequencies of chronic obstructive lung disease, heart failure, stroke, dyspnea, lower lung field involvement, pleural effusion and mortality. There were no differences between these two groups regarding sex, initial body weight, previous TB disease, hospital admission, diabetes mellitus, end-stage renal disease, neoplasm, liver cirrhosis, upper lung field involvement, cure, and treatment completion. Furthermore, age of 60 and older, lower initial body weight less than 50 kg, coexisting medical diseases, and extensive radiographic disease were factors independently associated with unfavorable outcomes. CONCLUSIONS Elderly patients with pulmonary TB are more likely to present with negative sputum smears, cavity-negative lesions, lower lung field involvement and pleural effusion on chest radiographs. The prognosis is poor for the elderly pulmonary TB patients with lower body weight, coexisting medical diseases, and extensive radiographic disease.
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Clinical Characteristics of Pulmonary Tuberculosis Patients from a Southern Taiwan Hospital-based Survey. Kaohsiung J Med Sci 2008; 24:17-24. [DOI: 10.1016/s1607-551x(08)70068-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Chan-Yeung M, Chan FHW, Cheung AHK, Dai DLK, Chu LW, Lam WK, Leung CC, Kam KM, Tam CM. Prevalence of tuberculous infection and active tuberculosis in old age homes in Hong Kong. J Am Geriatr Soc 2006; 54:1334-40. [PMID: 16970639 DOI: 10.1111/j.1532-5415.2006.00850.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the prevalence of tuberculous infection and active tuberculosis (TB) in old age homes in Hong Kong and to determine whether there is institutional transmission in these homes. DESIGN Cross-sectional. SETTING Old age homes. PARTICIPANTS Total of 2,243 residents, representing 84.6% of all residents in 15 old age homes; 1,698 were women, and 545 were men, with an average age of 82. MEASUREMENTS All residents had a questionnaire-based interview, medical record review, two-stage tuberculin testing using two units purified protein derivative-RT23, and a chest x-ray. Those with radiological abnormalities had sputum examined for acid-fast bacilli. RESULTS The estimated prevalence rate of active TB in this population was 669 per 100,000, significantly higher in men than in women (1,101 per 100,000 vs 530 per 100,000). The proportion with positive tuberculin reactivity (> or =10 mm induration) after two-stage testing was 68.6%, significantly higher in men than in women. There was no evidence of active transmission of disease in these old age homes, with restriction fragment length polymorphism (RFLP) analysis performed on five cases of active pulmonary TB in the home with the highest rate of TB showing unique RFLP patterns. CONCLUSION The rate of active TB and TB infection in old age homes in Hong Kong is still high. Because treatment for latent TB carries a high risk for liver dysfunction in this population, clinicians and other healthcare workers need a high index of suspicion and to diagnose and treat this disease as early as possible to prevent transmission.
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Affiliation(s)
- Moira Chan-Yeung
- Respiratory Division, Department of Medicine, University of Hong Kong, Hong Kong, China.
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Yu MC, Bai KJ, Chang JH, Lee CN. Age Transition of Tuberculosis Patients in Taiwan, 1957-2001. J Formos Med Assoc 2006; 105:25-30. [PMID: 16440067 DOI: 10.1016/s0929-6646(09)60105-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The incidence of tuberculosis (TB) has been falling in many developed countries; however, there is a trend of an increasing proportion of TB among the elderly. The aim of this study was to evaluate the age transition of patients with TB in Taiwan from 1957 to 2001. METHODS Data on the number of TB cases and patient age were collected from the National Tuberculosis Registry for three different 5-year periods: 1957-1961, 1977-1981, and 1997-2001. The distribution of TB cases in these three different periods was analyzed. RESULTS The age distributions of TB patients were different among the 1957-61 (n = 26,000), 1977-81 (n = 31,363) and 1997-2001 (n = 71,447) groups. During the 1957-61 period, the most common age group was 25-44 years (50.9%). During 1977-81, the most common age group was 45-64 years (44.9%). In 1997-2001, the most common age group had shifted to people aged 65 years or older (43.7%). For the whole period from 1957 to 2001, after adjusting for age shifts in the general population, the proportion of TB patients had significantly increased in persons 65 years or older, slightly increased in persons aged 0-14 years, and decreased in the 15-24, 25-44, and 45-64-year-old age groups. For the period 1977-2001, age-specific registered case rates increased with age. CONCLUSION The age of TB patients in Taiwan showed a rising trend from 1957 to 2001. A high index of suspicion and prompt investigation of elderly patients with signs and symptoms characteristic of TB may allow earlier diagnosis and treatment.
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Affiliation(s)
- Ming-Chih Yu
- Department of Internal Medicine, Taipei Medical University-Municipal Wan Fang Hospital, Taipei, Taiwan, R.O.C
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Abstract
To identify differences in the clinical, radiologic, and microbiologic features of pulmonary tuberculosis (TB) in the young (<64 yr) and elderly (> or =65 yr), we performed a retrospective analysis of the medical charts and chest radiographs of 207 young and 119 elderly pulmonary TB patients. Hemoptysis and a febrile sense were more frequent in the young, whereas weakness, dyspnea, anorexia, and mental change were more frequent in the elderly. Elderly patients showed higher frequencies of cardiovascular and chronic lung diseases, whereas the young showed a higher proportion of underlying liver disease. In addition, chest radiography showed a significantly higher frequency of mid or lower lung involvement by TB lesions in the elderly (10.6% vs. 22.7%, p<0.05). Lesions were frequently misdiagnosed as pneumonia or lung cancer in the elderly. However, there was no difference between these two groups in terms of sputum acid-fast bacilli positivity. The elderly showed a higher frequency of adverse drug reactions (18.5% vs. 40.7%, p<0.05), and higher TB-related mortality (1.3% vs. 11.1%, p<0.05). In conclusion this study showed that young and elderly pulmonary TB patients have similar microbiologic features; however, the elderly showed higher frequencies of atypical clinical and radiologic presentations, adverse drug reactions, and higher TB-related mortality.
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Affiliation(s)
- Jae Ho Lee
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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Abstract
Pneumonia is a major medical problem in the very old. The increased frequency and severity of pneumonia in the elderly is largely explained by the ageing of organ systems (in particular the respiratory tract, immune system, and digestive tract) and the presence of comorbidities due to age-associated diseases. The most striking characteristic of pneumonia in the very old is its clinical presentation: falls and confusion are frequently encountered, while classic symptoms of pneumonia are often absent. Community-acquired pneumonia (CAP) and nursing-home acquired pneumonia (NHAP) have to be distinguished. Although there are no fundamental differences in pathophysiology and microbiology of the two entities, NHAP tends to be much more severe, because milder cases are not referred to the hospital, and residents of nursing homes often suffer from dementia, multiple comorbidities, and decreased functional status. The immune response decays with age, yet pneumococcal and influenza vaccines have their place for the prevention of pneumonia in the very old. Pneumonia in older individuals without terminal disease has to be distinguished from end-of-life pneumonia. In the latter setting, the attributable mortality of pneumonia is low and antibiotics have little effect on life expectancy and should be used only if they provide the best means to alleviate suffering. In this review, we focus on recent publications relative to CAP and NHAP in the very old, and discuss predisposing factors, microorganisms, diagnostic procedures, specific aspects of treatment, prevention, and ethical issues concerning end-of-life pneumonia.
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Affiliation(s)
- Jean-Paul Janssens
- Division of Lung Diseases and Department of Geriatrics, Geneva University Hospitals, Geneva, Switzerland.
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Kobashi Y, Matsushima T. Clinical analysis of recent lower lung field tuberculosis. J Infect Chemother 2003; 9:272-5. [PMID: 14513400 DOI: 10.1007/s10156-003-0249-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2002] [Accepted: 04/23/2003] [Indexed: 10/26/2022]
Abstract
Because the incidence of lower lung field tuberculosis has recently increased in our affiliated hospitals, we carried out an analysis of its clinical characteristics during the past 10 years. We experienced 15 patients (7.5%) with lower lung field tuberculosis among 201 patients treated between April 1992 and March 1997, and 27 patients (11.1%) with the same condition among 243 patients treated between April 1997 and March 2002. The changes in clinical characteristics shown in the later period were as follows: (1) an increase in the percentage of elderly patients, (2) an increase in the incidence in patients who had received corticosteroid drugs for underlying disease, (3) atypical radiographic findings, such as homogeneous shadows resembling bacterial pneumonia, (4) an increase in microbiologically smear-positive patients, because more bronchoscopic examinations were performed, and (5) a high mortality rate (21.7%) with the increase being due to complications. Because there is a significant problem with nosocomial infections, patients with homogeneous shadows resembling bacterial pneumonia on admission should be examined for acid-fast bacilli containing Mycobacterium tuberculosis. We consider this problem to be not so difficult considering the progress in diagnostic methods for M. tuberculosis.
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Affiliation(s)
- Yoshihiro Kobashi
- Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School, 577, Matsushima, Kurashiki 701-0192, Japan.
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Abstract
As the result of the strengthening of TB-control programs nationwide, a decline in the overall number of reported TB cases in the United States has been observed within the last 10 years. Despite these declines in absolute numbers, the elderly continue to account for a disproportionate share of the cases. The high number of cases diagnosed at autopsy among the elderly suggests that this condition often remains unrecognized, possibly due to the subtle clinical manifestations in this age group. Evidence suggests that, compared with their community-dwelling counterparts, the institutionalized elderly are at a greater risk for re-activation of latent TB and for the acquisition of new TB infection. More studies are needed to make final conclusions. New guidelines for the treatment of LTBI emphasize targeted TST among persons at high risk for development of active TB and no longer use age as an exclusionary condition. All nursing home residents must therefore be regularly screened for LTBI and treated if necessary. Even though elderly persons are at greater risk for hepatic toxicity from TB treatment, the poor outcome of untreated TB in this age group warrants more aggressive treatment of this condition.
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Affiliation(s)
- Mabel Zevallos
- Department of Medicine, Bronx-Lebanon Hospital Center, 1650 Grand Concourse, Bronx, NY 10457, USA
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Van den Brande P, Vernies T, Verwerft J, Van Bleyenber R, Vanhoenacker F, Demedts M. Impact of age and radiographic presentation on the presumptive diagnosis of pulmonary tuberculosis. Respir Med 2002; 96:979-83. [PMID: 12477211 DOI: 10.1053/rmed.2002.1400] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We compared delay in presumptive diagnosing pulmonary tuberculosis (PTB) in elderly and younger patents, yield of diagnosis and whether the yield is influenced by the radiographic presentation, even when PTB was suspected. Time from first complaints to first consideration of PTB was determined as suspicion interval (SI) and from first consideration to diagnosis as recognition interval (RI). Presumptive diagnosis was defined as positive staining for acid-fast bacilli or presence of granulomatous lesions in pulmonary specimens. Inthe elderly and in the younger patients, the mean SI was 111.1 and 878 days respectively (P = NS), and the mean RI was 5.9 and 8.3 days, respectively (P = NS). The mean RI was longer in uncharacteristic than in characteristic radiographic findings in both elderly (8.2 and 4.6 days; P = 0.007) and younger patients (10.6 and 3.9 days; P=0.0001). A diagnosis was obtained in 89/113 elderly (79%) and in 109/138 younger (79%) patients (P=NS) and also in 59/80 (73%) patients with uncharacteristic findings and in 139/170 (82%) patients with characteristic findings (P = NS). In the latter, sputum contributed for 66% ofdiagnosis, whereas it was only 31% in patients with uncharacteristic findings (P < 0.005). In elderly patients with uncharacteristic radiographic findings, diagnosis was obtained from sputum in 41% and from other specimens in 35% (P = NS); in the younger group diagnosis was obtained from sputum in 23% and from other specimens in 48% (P < 0.05). In conclusion, there was no difference in SI and RI in elderly patients in comparison with younger patients. Uncharacteristic radiographic findings increased RI in both age groups. Age or radiographic presentation did not influence diagnosing PTB. In patients with characteristic radiographic findings, diagnosis was especially made from examination of sputum, whereas in those with uncharacteristic findings, diagnosis was more often obtained from the complementary investigation of other specimens.
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Affiliation(s)
- P Van den Brande
- Division of Pulmonology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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Leung CC, Yew WW, Chan CK, Chau CH, Tam CM, Lam CW, Tam WO, Lau KS, Liu WT. Tuberculosis in older people: a retrospective and comparative study from Hong Kong. J Am Geriatr Soc 2002; 50:1219-26. [PMID: 12133016 DOI: 10.1046/j.1532-5415.2002.50308.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare tuberculosis (TB) in older and younger patients. DESIGN A retrospective and comparative observational study. SETTING Four chest clinics and two chest hospitals in Hong Kong. PARTICIPANTS All notifications from the participating hospitals and clinics in 1996 were extracted from the TB notification registry. The characteristics of patients aged 65 and older were compared with a one-in-three random sampling of those aged 16 to 64. MEASUREMENTS Demographic, clinical, radiological, and laboratory data of the two groups were compared alongside treatment and outcomes. RESULTS Older people with TB were more likely to be male, to smoke, to have had TB previously, to have coexisting medical diseases, to be socioeconomically disadvantaged, and to weigh less than younger people with TB. Dyspnea, weight loss, and malaise were more common, whereas extrathoracic lymph node enlargement was less common. Chest radiograph showed more extensive disease and lower zone involvement. Positive tuberculin test was present in only 61.9%. Sputum bacteriology was more likely to be positive. There was a longer delay in presentation and commencement of treatment, and 77.2% required at least one admission. Adverse effects of treatment, notably hepatic dysfunction, occurred more commonly. Fluoroquinolones appeared well tolerated. Only 72.5% of the older people were cured or completed their treatment. Mortality was 16%. Age of 65 and older, comorbidity, socioeconomic disadvantage, moderate-extensive disease, positive sputum smear, and poor adherence were factors independently associated with unfavorable outcomes (P <.001 to P = .01; odds ratios = 1.61-27.02). CONCLUSION Substantial differences were found between older and younger TB patients. Many of these were associated with unfavorable outcome. Increased awareness in disease recognition and better medical and social support are therefore needed in addressing the growing problem of TB in older people.
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Affiliation(s)
- Chi C Leung
- Tuberculosis and Chest Service, Department of Health, Hong Kong, China.
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Perez-Guzman C, Torres-Cruz A, Villarreal-Velarde H, Vargas MH. Progressive age-related changes in pulmonary tuberculosis images and the effect of diabetes. Am J Respir Crit Care Med 2000; 162:1738-40. [PMID: 11069805 DOI: 10.1164/ajrccm.162.5.2001040] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Atypical radiologic images of pulmonary tuberculosis are common in elderly and in diabetic patients. To investigate the relationship of chest radiographic findings of tuberculosis to age in diabetic and nondiabetic patients, we compared the chest radiographic findings of 192 inpatients with pulmonary tuberculosis and diabetes with those of 130 patients with pulmonary tuberculosis alone. The proportion of patients with lower lung field lesions progressively increased with age (r(S) = 0.89, p < 0.01), whereas the frequency of cavitation steadily decreased with age (r(S) = -0.79, p < 0.05). In diabetic patients, a high frequency of lower lung lesions and cavitation was observed in all age groups. We speculated that, in older patients and in diabetics, the increased alveolar oxygen pressure in the lower lobes favors development of lower lobe disease in these groups.
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Affiliation(s)
- C Perez-Guzman
- Instituto Nacional de Enfermedades Respiratorias, México DF, Mexico
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Pérez-Guzmán C, Vargas MH, Torres-Cruz A, Villarreal-Velarde H. Does aging modify pulmonary tuberculosis?: A meta-analytical review. Chest 1999; 116:961-7. [PMID: 10531160 DOI: 10.1378/chest.116.4.961] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the differences in the clinical, radiologic, and laboratory features of pulmonary tuberculosis (TB) in older patients, as compared to younger patients. DESIGN A meta-analysis (the Schmidt-Hunter method) of published works found in MEDLINE and other sources was performed. A total of 12 studies were collected, and each variable was submitted to meta-analysis. RESULTS No differences were found between older (>/= 60 years old) and younger TB patients with respect to male predominance, evolution time before diagnosis, prevalence of cough, sputum production, weight loss, fatigue/malaise, radiographic upper lobes lesions, positive acid-fast bacilli in sputum, anemia or hemoglobin level, and serum aminotransferases. A lower prevalence of fever, sweating, hemoptysis, cavitary disease, and positive purified protein derivative, as well as lower levels of serum albumin and blood leukocytes were noticed among older patients. In addition, the older population had a greater prevalence of dyspnea and some concomitant conditions, such as cardiovascular disorders, COPD, diabetes, gastrectomy history, and malignancies. CONCLUSIONS This meta-analytical review identified the main differences of older TB patients, as compared to younger TB patients, that should be considered during the diagnostic evaluation. Most of these differences are explained by the already known physiologic changes that occur during aging.
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Affiliation(s)
- C Pérez-Guzmán
- Instituto Nacional de Enfermedades Respiratorias, México DF, México
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Schwenk A. [What should be done in weight loss of unknown origin?]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1998; 93:719-25. [PMID: 10024839 DOI: 10.1007/bf03044808] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
DIFFERENTIAL DIAGNOSIS Involuntary weight loss is associated with increased mortality and morbidity. Differential diagnosis includes more than 50 disease entities; therefore the diagnostic strategy is determined by additional symptoms. THE SYNDROME OF "CONSUMPTION", i.e. weight loss as an isolated symptom or together with malaise, may indicate tumors (lung, pancreas, kidney cancer, malignant lymphoma), infections (tuberculosis, HIV), immunologic diseases (lupus erythematosus, vasculitis), hyperthyroidism, extraintestinal Crohn's disease, or psychogenic disease (depression, psychogenic eating disorders). CONCLUSION Recognition of the underlying disease is often delayed by a lack of awareness for weight changes, both by physicians and by patients. Nutritional counselling and treatment should be initiated in time.
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Affiliation(s)
- A Schwenk
- Klinik 1 für Innere Medizin, Universität zu Köln.
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Affiliation(s)
- Y Elad
- Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029-6574, USA
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