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Chikovore J, Boffa J, Moyo S, Mak A, Gavu Z, Salomon A, Pai M, Daftary A. Provider perspectives on empirical antibiotic treatment for tuberculosis-like symptoms in South Africa's private general practice sector: A qualitative study in two cities. PLOS GLOBAL PUBLIC HEALTH 2025; 5:e0004742. [PMID: 40554547 PMCID: PMC12186942 DOI: 10.1371/journal.pgph.0004742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Accepted: 05/15/2025] [Indexed: 06/28/2025]
Abstract
While tuberculosis (TB) in South Africa is commonly treated in the public sector, some clients first seek care in the private sector. Research has demonstrated that private general practitioners (GPs) perform less well than do public sector care providers in TB testing and drug-dispensing practices. We aimed to describe GPs' decision-making practices related to empiric antibiotic treatment when presented with symptoms that may be related to TB, to inform potential interventions. Within a larger study on private sector TB management, we qualitatively interviewed 30 purposively selected GPs, who varied by gender, age, practice community, and how they managed TB and HIV in the parent study. Data were analysed through coding and constant comparison. GPs acknowledged the common use of broad-spectrum antibiotics for respiratory symptoms, driven by experience treating presumed bacterial infections and by a desire to rule out other causes before referring clients for potentially inconvenient TB tests in the private or public sector. Management decisions were susceptible to perceived or expressed pressure from clients, who may expect on-the-spot treatment. Additionally, GPs indicated using antibiotics to mitigate financial strain on economically vulnerable clients. Empirical antibiotic treatment for presentations that may be related to TB in the private sector, which can delay TB diagnosis, could be explained by the absence of accessible and affordable TB and general bacteriologic tests at the point of care, leading GPs to, among others, seek to 'rule out' possible bacterial infection. Potential interventions include increasing the salience of inappropriate antibiotic use, heightening GPs' suspicion index for TB, and linking GPs directly to public sector TB tests for clients.
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Affiliation(s)
- Jeremiah Chikovore
- Human Sciences Research Council (HSRC), Public Health, Society and Belonging (PHSB) Division, Durban, South Africa
| | - Jody Boffa
- The Aurum Institute, Johannesburg, South Africa
| | - Sizulu Moyo
- HSRC, PHSB Division, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Angela Mak
- Cumming School of Medicine, University of Calgary, Calgary, Canada
- Dahdaleh Institute of Global Health Research, York University, Toronto, Canada
| | - Zimasa Gavu
- Human Sciences Research Council (HSRC), Public Health, Society and Belonging (PHSB) Division, Durban, South Africa
| | - Angela Salomon
- McGill University Health Centre, McGill University, Montréal, Canada
| | - Madhukar Pai
- McGill University Health Centre, McGill University, Montréal, Canada
- Department of Global and Public Health and McGill International TB Centre, McGill University, Montréal, Canada
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, York University, Toronto, Canada
- School of Global Health, York University, Toronto, Canada
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
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Mendelsohn SC, Mulenga H, Tameris M, Moloantoa T, Malherbe ST, Katona A, Maruri F, Noor F, Panchia R, Hlongwane K, Stanley K, van der Heijden YF, Hadley K, Ariefdien DT, Chegou NN, Walzl G, Scriba TJ, Sterling TR, Hatherill M. Screening for Asymptomatic Tuberculosis among Adults with Household Exposure to a Patient with Pulmonary Tuberculosis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2025:2025.01.20.25320843. [PMID: 39974049 PMCID: PMC11838980 DOI: 10.1101/2025.01.20.25320843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2025]
Abstract
Background More than half of tuberculosis (TB) detected by community prevalence surveys is classified as asymptomatic. We evaluated yield of symptom and chest radiograph (CXR) screening of TB-exposed household contacts (HHC) in South Africa. Methods Adult volunteers (≥18 years) with household exposure to pulmonary TB patients were enrolled at three sites. Systematic screening of TB symptoms (any duration), CXR (any abnormality), and sputum microscopy, Xpert Ultra, and liquid culture were performed. Serum C-reactive protein (CRP) was measured by multiplex bead array. Prevalent TB was microbiologically-confirmed (Xpert Ultra or culture). Symptomatic and asymptomatic TB were defined as prevalent TB with and without reported symptoms, respectively. Results Between March 2021 - December 2022, 979 HHC were enrolled; 185 (18.9%) living with HIV and 187 (19.1%) with previous TB. Prevalent TB occurred in 51 (5.2%) and was asymptomatic in 42/51 (82.4%). Only 13/42 (31.0%) asymptomatic TB cases were smear-positive [8/13 (61.5%) graded scanty or 1+]. CRP did not discriminate healthy HHC from those with asymptomatic TB (AUC 0.60; 95%CI 0.47-0.73). An abnormal CXR was observed in 23/41 asymptomatic (sensitivity 56.1%, 95%CI 41.0-70.1%) versus 8/9 symptomatic (sensitivity 88.9%, 95%CI 56.5-98.0%) TB cases. Sensitivity of CXR in combination with symptom screening was 64.0% (32/50, 95%CI 50.1-75.9%) for all prevalent TB. Conclusions More than 80% of confirmed TB cases among HHC were asymptomatic. CXR screening missed more than 40% of these asymptomatic cases. Community prevalence surveys reliant on symptom- and CXR-based approaches may significantly underestimate the prevalence of asymptomatic TB in endemic countries. Funding Supported by RePORT South Africa through funding from the U.S. National Institutes of Health, CRDF Global, and the South African Medical Research Council. RESEARCH IN CONTEXT Evidence before this study: World Health Organisation (WHO) guidelines for systematic tuberculosis (TB) screening recommend symptom screening and chest radiography (CXR), based on a Cochrane meta-analysis reporting 70.6% sensitivity (any TB symptom) and 94.7% sensitivity (any CXR abnormality) for bacteriologically-confirmed pulmonary TB. National TB prevalence surveys rely on a positive symptom screen or abnormal CXR to trigger diagnostic sputum testing. This approach to community screening would, by definition, miss asymptomatic TB cases without CXR evidence of disease. We reviewed the reference list of the aforementioned meta-analysis for active case-finding studies of adolescents and adults aged 15 years and older in community and contact-tracing settings. We performed forward citation-tracking and searched reference lists, including studies published in English between Jan 1, 1980, and November 1, 2024. We excluded studies that included children <15 years; or that exclusively enrolled people with additional risk factors (HIV; diabetes; latent TB infection; prior TB). We found 28 studies that performed universal sputum testing for bacteriologically-confirmed pulmonary TB and reported 51.8% (95%CI 49.9-53.7%; I 2 = 89.2%) pooled sensitivity for symptom screening (any symptom; 24 studies, 2,969 TB cases) and 62.4% (95%CI 59.3-65.3%; I 2 = 88.3%) pooled sensitivity for CXR (any abnormality; 10 studies, 1,123 TB cases). Only four studies (145 TB cases) reported accuracy of symptom screening in parallel with chest radiography (pooled sensitivity 67.3%, 95%CI 57.3-75.9%; I 2 = 87.1%), but these studies did not disaggregate symptomatic and asymptomatic disease. Added value of this study: We performed systematic screening using universal sputum microbiological testing of 978 household contacts of pulmonary TB patients in three South African communities and compared symptom (any duration) and CXR (any abnormality) screening approaches against a microbiological reference standard. We detected confirmed pulmonary TB in 5.2% of household contacts, and 82.4% of these TB cases reported no TB symptoms. Asymptomatic TB in household contacts was pauci-bacillary and associated with low serum CRP levels that were indistinguishable from healthy controls, but distinct from symptomatic TB in a comparator group of clinic attendees. Sensitivity of CXR screening for asymptomatic TB was only 56.1%; sensitivity of combined symptom and CXR screening for all TB was marginally higher at 64.0%.Implications of all the available evidence: Our findings from household contacts suggest that symptom- and CXR-based approaches are inadequate for community TB screening in South Africa and do not meet the WHO Target Product Profile for a TB screening test (minimum 90% sensitivity; 70% specificity). National TB Prevalence Surveys that omit universal sputum microbiological testing may significantly underestimate the prevalence of asymptomatic TB in high-burden countries.
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Sarkar M. Incipient and subclinical tuberculosis: a narrative review. Monaldi Arch Chest Dis 2025. [PMID: 39783831 DOI: 10.4081/monaldi.2025.2982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 10/21/2024] [Indexed: 01/12/2025] Open
Abstract
Mycobacterium tuberculosis has been known to infect humans for eons. It is an airborne infectious disease transmitted through droplet nuclei of 1 to 5 µm in diameter. Historically, tuberculosis (TB) was considered a distinct condition characterized by TB infection and active TB disease. However, recently, the concept of a dynamic spectrum of infection has emerged, wherein the pathogen is initially eradicated by the innate or adaptive immune system, either in conjunction with or independently of T cell priming. Other categories within this spectrum include TB infection, incipient TB, subclinical TB, and active TB disease. Various host- and pathogen-related factors influence these categories. Furthermore, subclinical TB can facilitate the spread of infection within the community. Due to its asymptomatic nature, there is a risk of delayed diagnosis, and some patients may remain undiagnosed. Individuals with subclinical TB may stay in this stage for an indeterminate period without progressing to active TB disease, and some may even experience regression. Early diagnosis and treatment of TB are essential to meet the 2035 targets outlined in the end-TB strategy. This strategy should also include incipient and subclinical TB. This review will focus on the definition, natural history, burden, trajectory, transmissibility, detection, and management of early-stage TB.
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Affiliation(s)
- Malay Sarkar
- Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh
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Balkrishna A, Gohel V, Tomer M, Dev R, Varshney A. Herbo-vitamin medicine Livogrit Vital ameliorates isoniazid induced liver injury (IILI) in human liver (HepG2) cells by decreasing isoniazid accumulation and oxidative stress driven hepatotoxicity. BMC Complement Med Ther 2024; 24:386. [PMID: 39516811 PMCID: PMC11545855 DOI: 10.1186/s12906-024-04685-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 10/25/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) is a leading cause of infection related mortality. Isoniazid is one of the frontline drugs for anti-TB therapy. Hepatotoxicity induced by isoniazid is a major cause of drug-discontinuation which may lead to development of resistant TB or increased mortality. PURPOSE To characterize pharmacological properties of plant-based prescription medicine, Livogrit Vital (LVV) against isoniazid-induced liver injury (IILI) using HepG2 cells. METHOD Phytometabolite characterization of LVV was performed by High-performance liquid chromatography (HPLC). The effects of LVV on cytosafety, IC50 shift, oxidative stress, ER stress, apoptosis, liver injury markers, and accumulation of isoniazid and hydrazine was performed on HepG2 cells induced with isoniazid. Silymarin was used as the positive control. RESULTS HPLC based phytometabolite characterization of LVV revealed the presence of several anti-oxidant, anti-apoptotic, and hepatoprotective compounds. In isoniazid-induced HepG2 cells, LVV reduced cytotoxicity of isoniazid and shifted its IC50 value. Treatment with LVV reduced ROS generation and lipid peroxidation; enhanced GSH enzyme levels in isoniazid-induced HepG2 cells. As per the mechanistic evaluation, LVV modulated gene expression level of Caspase-3, FGF21, and IRE-1α. LVV treatment also normalized isoniazid-induced elevated Caspase-3 activity and cPARP1 protein levels, indicating its potentials to regulate liver cell apoptosis. Concomitantly, biomarkers of hepatotoxicity, ALT and GGT, also decreased by LVV treatment. Interestingly, LVV treatment reduced intracellular accumulation of isoniazid and its toxic metabolite hydrazine, in isoniazid-stimulated HepG2 cells. CONCLUSION Treatment of hepatic cells with the herbo-vitamin medicine, Livogrit Vital, regulates IILI by modulation of oxidative and ER stress, apoptosis, and bioaccumulation of isoniazid and hydrazine. Collectively, Livogrit Vital could well be explored as an adjuvant hepatoprotective agent alongwith anti-TB medicines.
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Affiliation(s)
- Acharya Balkrishna
- Drug Discovery and Development Division, Patanjali Research Foundation, NH-58, Haridwar, Uttarakhand, 249405, India
- Department of Allied and Applied Sciences, University of Patanjali, Patanjali Yog Peeth, Roorkee-Haridwar Road, Haridwar, Uttarakhand, 249405, India
- Patanjali Yog Peeth (UK) Trust, 40 Lambhill Street, Kinning Park, Glasgow, G411AU, UK
| | - Vivek Gohel
- Drug Discovery and Development Division, Patanjali Research Foundation, NH-58, Haridwar, Uttarakhand, 249405, India
| | - Meenu Tomer
- Drug Discovery and Development Division, Patanjali Research Foundation, NH-58, Haridwar, Uttarakhand, 249405, India
| | - Rishabh Dev
- Drug Discovery and Development Division, Patanjali Research Foundation, NH-58, Haridwar, Uttarakhand, 249405, India
| | - Anurag Varshney
- Drug Discovery and Development Division, Patanjali Research Foundation, NH-58, Haridwar, Uttarakhand, 249405, India.
- Department of Allied and Applied Sciences, University of Patanjali, Patanjali Yog Peeth, Roorkee-Haridwar Road, Haridwar, Uttarakhand, 249405, India.
- Special Centre for Systems Medicine, Jawaharlal Nehru University, New Delhi, 110067, India.
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Coleman M, Lowbridge C, du Cros P, Marais BJ. Community-Wide Active Case Finding for Tuberculosis: Time to Use the Evidence We Have. Trop Med Infect Dis 2024; 9:214. [PMID: 39330903 PMCID: PMC11436250 DOI: 10.3390/tropicalmed9090214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 09/06/2024] [Accepted: 09/06/2024] [Indexed: 09/28/2024] Open
Abstract
Tuberculosis, caused by the Mycobacterium tuberculosis (Mtb) bacteria, is one of the world's deadliest infectious diseases. Despite being the world's oldest pandemic, tuberculosis is very much a challenge of the modern era. In high-incidence settings, all people are at risk, irrespective of whether they have common vulnerabilities to the disease warranting the current WHO recommendations for community-wide tuberculosis active case finding in these settings. Despite good evidence of effectiveness in reducing tuberculosis transmission, uptake of this strategy has been lacking in the communities that would derive greatest benefit. We consider the various complexities in eliminating tuberculosis from the first principles of the disease, including diagnostic and other challenges that must be navigated under an elimination agenda. We make the case that community-wide tuberculosis active case finding is the best strategy currently available to drive elimination forward in high-incidence settings and that no time should be lost in its implementation. Recognizing that high-incidence communities vary in their epidemiology and spatiosocial characteristics, tuberculosis research and funding must now shift towards radically supporting local implementation and operational research in communities. This "preparing of the ground" for scaling up to community-wide intervention centers the local knowledge and local experience of community epidemiology to optimize implementation practices and accelerate reductions in community-level tuberculosis transmission.
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Affiliation(s)
- Mikaela Coleman
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW 2050, Australia
- Bordeaux Population Health, University of Bordeaux, 33076 Bordeaux, France
| | - Chris Lowbridge
- Division of Global & Tropical Health, Menzies School of Health Research, Charles Darwin University, Casuarina, NT 0810, Australia
| | - Philipp du Cros
- International Health, Burnet Institute, Melbourne, VIC 3004, Australia
- Department of Infectious Diseases, Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Ben J Marais
- Sydney Infectious Diseases Institute, University of Sydney, Sydney, NSW 2050, Australia
- WHO Collaborating Centre for Tuberculosis, Sydney, NSW 2145, Australia
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Mazahir F, Yadav AK. Recent progress in engineered extracellular vesicles and their biomedical applications. Life Sci 2024; 350:122747. [PMID: 38797364 DOI: 10.1016/j.lfs.2024.122747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/14/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
AIMS To present the recent update on the isolation, engineering techniques for extracellular vesicles, limitations associated with different isolation techniques, different biomedical applications, and challenges of engineered extracellular vesicles for the benefit of researchers from academic, industry, etc. MATERIALS AND METHODS: Peer-reviewed articles from most recognized journals were collected, and presented information was analyzed to discuss collection, chemical, electroporation, cellular, and membrane surface engineering to design extracellular vesicles for various therapeutic applications. In addition, we present the applications and limitations of techniques for the collection of extracellular vesicles. KEY FINDINGS There is a need for isolation techniques with the gold standard. However, advanced extracellular vesicle isolation techniques showed improved recovery, and purity of extracellular vesicles. Tumor therapy is a major part of the therapy section that illustrates the role of engineered extracellular vesicles in synergetic therapy such as phototherapy, theragnostic, and delivery of genetic materials. In addition, extracellular vesicles have shown their potential in the treatment of retinal disorders, neurodegenerative disease, tuberculosis, osteoporosis, inflammatory bowel disease, vaccine production, and wound healing. SIGNIFICANCE Engineered extracellular vesicles can deliver cargo to the specific cells, elicit an immune response and could be used for the development of the vaccines in the future. However, the progress is at the initial stage. Overall, this review will provide a comprehensive understanding and could serve as a reference for researchers in the clinical translation of engineered extracellular vesicles in different biomedical fields.
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Affiliation(s)
- Farhan Mazahir
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research Raebareli, A Transit Campus, Bijnor-Sisendi Road, Bijnor, Lucknow-226002, India
| | - Awesh K Yadav
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research Raebareli, A Transit Campus, Bijnor-Sisendi Road, Bijnor, Lucknow-226002, India.
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Zaidi SMA, Mahfooz A, Latif A, Nawaz N, Fatima R, Rehman FU, Reza TE, Emmanuel F. Geographical targeting of active case finding for tuberculosis in Pakistan using hotspots identified by artificial intelligence software (SPOT-TB): study protocol for a pragmatic stepped wedge cluster randomised control trial. BMJ Open Respir Res 2024; 11:e002079. [PMID: 38991950 PMCID: PMC11243128 DOI: 10.1136/bmjresp-2023-002079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 06/24/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION Pakistan has significantly strengthened its capacity for active case finding (ACF) for tuberculosis (TB) that is being implemented at scale in the country. However, yields of ACF have been lower than expected, raising concerns on its effectiveness in the programmatic setting. Distribution of TB in communities is likely to be spatially heterogeneous and targeting of ACF in areas with higher TB prevalence may help improve yields. The primary aim of SPOT-TB is to investigate whether a policy change to use a geographically targeted approach towards ACF supported by an artificial intelligence (AI) software, MATCH-AI, can improve yields in Pakistan. METHODS AND ANALYSIS SPOT-TB will use a pragmatic, stepped wedge cluster randomised design. A total of 30 mobile X-ray units and their field teams will be randomised to receive the intervention. Site selection for ACF in the intervention areas will be guided primarily through the use of MATCH-AI software that models subdistrict TB prevalence and identifies potential disease hotspots. Control areas will use existing approaches towards site selection that are based on staff knowledge, experience and analysis of historical data. The primary outcome measure is the difference in bacteriologically confirmed incident TB detected in the intervention relative to control areas. All remaining ACF-related procedures and algorithms will remain unaffected by this trial. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Health Services Academy, Islamabad, Pakistan (7-82/IERC-HSA/2022-52) and from the Common Management Unit for TB, HIV and Malaria, Ministry of Health Services, Regulation and Coordination, Islamabad, Pakistan (26-IRB-CMU-2023). Findings from this study will be disseminated through publications in peer-reviewed journals and stakeholder meetings in Pakistan with the implementing partners and public-sector officials. Findings will also be presented at local and international medical and public health conferences. TRIAL REGISTRATION NUMBER NCT06017843.
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Affiliation(s)
- Syed Mohammad Asad Zaidi
- WHO Centre for Tuberculosis Research and Innovation, Institute for Global Health, University College London, London, UK
| | - Amna Mahfooz
- Center for Global Public Health, Islamabad, Pakistan
| | | | | | - Razia Fatima
- Ministry of National Health Services Regulation and Coordination, Islamabad, Pakistan
| | | | | | - Faran Emmanuel
- Center for Global Public Health, Islamabad, Pakistan
- University of Manitoba, Winnipeg, Manitoba, Canada
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Stuck L, Klinkenberg E, Abdelgadir Ali N, Basheir Abukaraig EA, Adusi-Poku Y, Alebachew Wagaw Z, Fatima R, Kapata N, Kapata-Chanda P, Kirenga B, Maama-Maime LB, Mfinanga SG, Moyo S, Mvusi L, Nandjebo N, Nguyen HV, Nguyen HB, Obasanya J, Adedapo Olufemi B, Patrobas Dashi P, Raleting Letsie TJ, Ruswa N, Rutebemberwa E, Senkoro M, Sivanna T, Yuda HC, Law I, Onozaki I, Tiemersma E, Cobelens F. Prevalence of subclinical pulmonary tuberculosis in adults in community settings: an individual participant data meta-analysis. THE LANCET. INFECTIOUS DISEASES 2024; 24:726-736. [PMID: 38490237 DOI: 10.1016/s1473-3099(24)00011-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/17/2023] [Accepted: 01/09/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Subclinical pulmonary tuberculosis, which presents without recognisable symptoms, is frequently detected in community screening. However, the disease category is poorly clinically defined. We explored the prevalence of subclinical pulmonary tuberculosis according to different case definitions. METHODS We did a one-stage individual participant data meta-analysis of nationally representative surveys that were conducted in countries with high incidence of tuberculosis between 2007 and 2020, that reported the prevalence of pulmonary tuberculosis based on chest x-ray and symptom screening in participants aged 15 years and older. Screening and diagnostic criteria were standardised across the surveys, and tuberculosis was defined by positive Mycobacterium tuberculosis sputum culture. We estimated proportions of subclinical tuberculosis for three case definitions: no persistent cough (ie, duration ≥2 weeks), no cough at all, and no symptoms (ie, absence of cough, fever, chest pain, night sweats, and weight loss), both unadjusted and adjusted for false-negative chest x-rays and uninterpretable culture results. FINDINGS We identified 34 surveys, of which 31 were eligible. Individual participant data were obtained and included for 12 surveys (620 682 participants) across eight countries in Africa and four in Asia. Data on 602 863 participants were analysed, of whom 1944 had tuberculosis. The unadjusted proportion of subclinical tuberculosis was 59·1% (n=1149/1944; 95% CI 55·8-62·3) for no persistent cough and 39·8% (773/1944; 36·6-43·0) for no cough of any duration. The adjusted proportions were 82·8% (95% CI 78·6-86·6) for no persistent cough and 62·5% (56·6-68·7) for no cough at all. In a subset of four surveys, the proportion of participants with tuberculosis but without any symptoms was 20·3% (n=111/547; 95% CI 15·5-25·1) before adjustment and 27·7% (95% CI 21·0-36·4) after adjustment. Tuberculosis without cough, irrespective of its duration, was more frequent among women (no persistent cough: adjusted odds ratio 0·79, 95% CI 0·63-0·97; no cough: adjusted odds ratio 0·76, 95% CI 0·62-0·93). Among participants with tuberculosis, 29·1% (95% CI 25·2-33·3) of those without persistent cough and 23·1% (18·8-27·4) of those without any cough had positive smear examinations. INTERPRETATION The majority of people in the community who have pulmonary tuberculosis do not report cough, a quarter report no tuberculosis-suggestive symptoms at all, and a quarter of those not reporting any cough have positive sputum smears, suggesting infectiousness. In high-incidence settings, subclinical tuberculosis could contribute considerably to the tuberculosis burden and to Mycobacterium tuberculosis transmission. FUNDING Mr Willem Bakhuys Roozeboom Foundation.
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Affiliation(s)
- Logan Stuck
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Eveline Klinkenberg
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Nahid Abdelgadir Ali
- Global Fund Project Management Unit, International Health, Federal Ministry of Health, Khartoum, Sudan
| | | | - Yaw Adusi-Poku
- National Tuberculosis Control Programme, Ghana Health Service, Accra, Ghana
| | | | - Razia Fatima
- Research Unit, Common Management Unit [TB, HIV/AIDS & Malaria], Islamabad, Pakistan
| | - Nathan Kapata
- Ministry of Health, Lusaka, Zambia; Zambia National Public Health Institute, Lusaka, Zambia
| | | | - Bruce Kirenga
- Makerere University Lung Institute & Division of Pulmonary Medicine, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Sayoki G Mfinanga
- National Institute for Medical Research, Muhimbili Research Centre, Dar es Salaam, Tanzania; University College London, London, UK; Alliance for Africa Health and Research (A4A), Dar es Salaam, Tanzania
| | - Sizulu Moyo
- Human Sciences Research Council, Cape Town, South Africa
| | - Lindiwe Mvusi
- Tuberculosis Programme, National Department of Health, Pretoria, South Africa
| | | | | | - Hoa Binh Nguyen
- National Lung Hospital, National Tuberculosis Control Programme, Ha Noi, Viet Nam
| | | | - Bashorun Adedapo Olufemi
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | | | - Nunurai Ruswa
- Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Mbazi Senkoro
- National Institute for Medical Research, Muhimbili Research Centre, Dar es Salaam, Tanzania
| | - Tieng Sivanna
- National Center for TB and Leprosy Control, Phnom Penh, Cambodia
| | - Huot Chan Yuda
- National Center for TB and Leprosy Control, Phnom Penh, Cambodia
| | - Irwin Law
- Global Tuberculosis Programme, WHO, Geneva, Switzerland
| | - Ikushi Onozaki
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | | | - Frank Cobelens
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.
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Dartois V, Dick T. Therapeutic developments for tuberculosis and nontuberculous mycobacterial lung disease. Nat Rev Drug Discov 2024; 23:381-403. [PMID: 38418662 PMCID: PMC11078618 DOI: 10.1038/s41573-024-00897-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
Tuberculosis (TB) drug discovery and development has undergone nothing short of a revolution over the past 20 years. Successful public-private partnerships and sustained funding have delivered a much-improved understanding of mycobacterial disease biology and pharmacology and a healthy pipeline that can tolerate inevitable attrition. Preclinical and clinical development has evolved from decade-old concepts to adaptive designs that permit rapid evaluation of regimens that might greatly shorten treatment duration over the next decade. But the past 20 years also saw the rise of a fatal and difficult-to-cure lung disease caused by nontuberculous mycobacteria (NTM), for which the drug development pipeline is nearly empty. Here, we discuss the similarities and differences between TB and NTM lung diseases, compare the preclinical and clinical advances, and identify major knowledge gaps and areas of cross-fertilization. We argue that applying paradigms and networks that have proved successful for TB, from basic research to clinical trials, will help to populate the pipeline and accelerate curative regimen development for NTM disease.
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Affiliation(s)
- Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA.
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Thomas Dick
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Department of Microbiology and Immunology, Georgetown University, Washington, DC, USA
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Sun H, Ma Z, Ai F, Han B, Li P, Liu J, Wu Y, Wang Y, Li B, Qi D, Pang Y. Insidious transmission of Mycobacterium tuberculosis in Ordos, China: a molecular epidemiology study. Eur J Clin Microbiol Infect Dis 2024; 43:305-312. [PMID: 38055064 DOI: 10.1007/s10096-023-04730-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND In this study, we conducted this population-based study to evaluate the genetic diversity and clustering rate of Mycobacterium tuberculosis (MTB) strains using the whole-genome sequencing (WGS), to better understand its transmission in Ordos. METHODS All patients with culture-positive TB notified in Ordos from January 2021 to December 2022 were recruited. WGS was performed to analyze single-nucleotide polymorphism (SNP) and to identify genotypic drug susceptibilities of MTB isolates. RESULTS Overall, a total of 186 patients were included in the present study, of whom 35 (18.8%) had no symptoms suggestive of active TB. Lineage 2 was the predominant MTB sublineage, accounting for 186 of isolates tested. When the pairwise SNP difference ≤ 12 was used as the cutoff for WGS-based clusters, we identified 17 genotypic clusters, and 38 isolates belonged to these 17 clusters, resulting in a clustering rate of 20.4%. The Beijing genotype was an independent factor associating with genomic-clustering (adjusted OR 4.219, 95% CI 0.962-18.502). The overall sensitivity on WGS-based resistance prediction was 85.7% for rifampicin, 73.1% for isoniazid, 60.0% for Ethambutol, 72.7% for streptomycin, and 72.7% for fluoroquinolones. CONCLUSION To conclude, the present study demonstrates the extensive recent transmission of Beijing genotype strains in the community of Ordos. The failure to provide a comprehensive pattern of transmission indicated the missed diagnosis of active TB within the community. A substantial proportion of subclinical TB cases are recognized in the bacteria-positive cases, emphasizing that we must interrupt transmission by finding people with active TB before they infect others.
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Affiliation(s)
- Hailin Sun
- Department of Tuberculosis, The Second People Hospital of Ordos, Ordos, China
| | - Zichun Ma
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Postal No 9, Beiguan Street, Tongzhou District, Beijing, 101149, People's Republic of China
| | - Fuli Ai
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Postal No 9, Beiguan Street, Tongzhou District, Beijing, 101149, People's Republic of China
| | - Bing Han
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Postal No 9, Beiguan Street, Tongzhou District, Beijing, 101149, People's Republic of China
| | - Peng Li
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Postal No 9, Beiguan Street, Tongzhou District, Beijing, 101149, People's Republic of China
| | - Juan Liu
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Postal No 9, Beiguan Street, Tongzhou District, Beijing, 101149, People's Republic of China
| | - Yiheng Wu
- Department of Tuberculosis, The Second People Hospital of Ordos, Ordos, China
| | - Yufeng Wang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Postal No 9, Beiguan Street, Tongzhou District, Beijing, 101149, People's Republic of China
| | - Bing Li
- Ordos Center for Disease Control and Prevention, Ordos, China
| | - Dan Qi
- Ordos Center for Disease Control and Prevention, Ordos, China
| | - Yu Pang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Postal No 9, Beiguan Street, Tongzhou District, Beijing, 101149, People's Republic of China.
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11
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Okada K, Yamada N, Takayanagi K, Hiasa Y, Kitamura Y, Hoshino Y, Hirao S, Yoshiyama T, Onozaki I, Kato S. Applicability of artificial intelligence-based computer-aided detection (AI-CAD) for pulmonary tuberculosis to community-based active case finding. Trop Med Health 2024; 52:2. [PMID: 38163868 PMCID: PMC10759734 DOI: 10.1186/s41182-023-00560-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/02/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Artificial intelligence-based computer-aided detection (AI-CAD) for tuberculosis (TB) has become commercially available and several studies have been conducted to evaluate the performance of AI-CAD for pulmonary tuberculosis (TB) in clinical settings. However, little is known about its applicability to community-based active case-finding (ACF) for TB. METHODS We analysed an anonymized data set obtained from a community-based ACF in Cambodia, targeting persons aged 55 years or over, persons with any TB symptoms, such as chronic cough, and persons at risk of TB, including household contacts. All of the participants in the ACF were screened by chest radiography (CXR) by Cambodian doctors, followed by Xpert test when they were eligible for sputum examination. Interpretation by an experienced chest physician and abnormality scoring by a newly developed AI-CAD were retrospectively conducted for the CXR images. With a reference of Xpert-positive TB or human interpretations, receiver operating characteristic (ROC) curves were drawn to evaluate the AI-CAD performance by area under the ROC curve (AUROC). In addition, its applicability to community-based ACFs in Cambodia was examined. RESULTS TB scores of the AI-CAD were significantly associated with the CXR classifications as indicated by the severity of TB disease, and its AUROC as the bacteriological reference was 0.86 (95% confidence interval 0.83-0.89). Using a threshold for triage purposes, the human reading and bacteriological examination needed fell to 21% and 15%, respectively, detecting 95% of Xpert-positive TB in ACF. For screening purposes, we could detect 98% of Xpert-positive TB cases. CONCLUSIONS AI-CAD is applicable to community-based ACF in high TB burden settings, where experienced human readers for CXR images are scarce. The use of AI-CAD in developing countries has the potential to expand CXR screening in community-based ACFs, with a substantial decrease in the workload on human readers and laboratory labour. Further studies are needed to generalize the results to other countries by increasing the sample size and comparing the AI-CAD performance with that of more human readers.
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Affiliation(s)
- Kosuke Okada
- The Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan.
- Department of International Programme, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan.
| | - Norio Yamada
- The Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Kiyoko Takayanagi
- Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Yuta Hiasa
- Imaging Technology Center, ICT Strategy Division, Fujifilm Corporation, Tokyo, Japan
| | - Yoshiro Kitamura
- Imaging Technology Center, ICT Strategy Division, Fujifilm Corporation, Tokyo, Japan
| | - Yutaka Hoshino
- The Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Susumu Hirao
- The Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Takashi Yoshiyama
- The Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
- Fukujuji Hospital, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Ikushi Onozaki
- The Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
- Department of International Programme, Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
| | - Seiya Kato
- The Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA), Tokyo, Japan
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12
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Zaidi SM, Coussens AK, Seddon JA, Kredo T, Warner D, Houben RM, Esmail H. Beyond latent and active tuberculosis: a scoping review of conceptual frameworks. EClinicalMedicine 2023; 66:102332. [PMID: 38192591 PMCID: PMC10772263 DOI: 10.1016/j.eclinm.2023.102332] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 01/10/2024] Open
Abstract
There is growing recognition that tuberculosis (TB) infection and disease exists as a spectrum of states beyond the current binary classification of latent and active TB. Our aim was to systematically map and synthesize published conceptual frameworks for TB states. We searched MEDLINE, Embase and EMcare for review articles from 1946 to September 2023. We included 40 articles that explicitly described greater than two states for TB. We identified that terminology, definitions and diagnostic criteria for additional TB states within these articles were inconsistent. Eight broad conceptual themes were identified that were used to categorize TB states: State 0: Mycobacterium tuberculosis (Mtb) elimination with innate immune response (n = 25/40, 63%); State I: Mtb elimination by acquired immune response (n = 31/40, 78%); State II: Mtb infection not eliminated but controlled (n = 37/40, 93%); State III: Mtb infection not controlled (n = 24/40, 60%); State IV: bacteriologically positive without symptoms (n = 26/40, 65%); State V: signs or symptoms associated with TB (n = 39/40, 98%); State VI: severe or disseminated TB disease (n = 11/40, 28%); and State VII: previous history of TB (n = 5/40, 13%). Consensus on a non-binary framework that includes additional TB states is required to standardize scientific communication and to inform advancements in research, clinical and public health practice.
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Affiliation(s)
- Syed M.A. Zaidi
- WHO Centre for Tuberculosis Research and Innovation, Institute for Global Health, University College London, UK
- MRC Clinical Trials Unit at University College London, UK
- Department of Public Health, National University of Medical Sciences, Pakistan
| | - Anna K. Coussens
- Division of Infectious Diseases and Immune Defence, Walter and Eliza Hall Institute of Medical Research, Australia
- Department of Medical Biology, University of Melbourne, Australia
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - James A. Seddon
- Department of Infectious Disease, Imperial College London, UK
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, South Africa
| | - Tamara Kredo
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Digby Warner
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- Molecular Mycobacteriology Research Unit and Division of Medical Microbiology, Department of Pathology, University of Cape Town, South Africa
| | - Rein M.G.J. Houben
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, UK
| | - Hanif Esmail
- WHO Centre for Tuberculosis Research and Innovation, Institute for Global Health, University College London, UK
- MRC Clinical Trials Unit at University College London, UK
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
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13
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Horton KC, Richards AS, Emery JC, Esmail H, Houben RMGJ. Reevaluating progression and pathways following Mycobacterium tuberculosis infection within the spectrum of tuberculosis. Proc Natl Acad Sci U S A 2023; 120:e2221186120. [PMID: 37963250 PMCID: PMC10666121 DOI: 10.1073/pnas.2221186120] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 09/12/2023] [Indexed: 11/16/2023] Open
Abstract
Traditional understanding of the risk of progression from Mycobacterium tuberculosis (Mtb) infection to tuberculosis (TB) overlooks diverse presentations across a spectrum of disease. We developed a deterministic model of Mtb infection and minimal (pathological damage but not infectious), subclinical (infectious but no reported symptoms), and clinical (infectious and symptomatic) TB, informed by a rigorous evaluation of data from a systematic review of TB natural history. Using a Bayesian approach, we calibrated the model to data from historical cohorts that followed tuberculin-negative individuals to tuberculin conversion and TB, as well as data from cohorts that followed progression and regression between disease states, disease state prevalence ratios, disease duration, and mortality. We estimated incidence, pathways, and 10-y outcomes following Mtb infection for a simulated cohort. Then, 92.0% (95% uncertainty interval, UI, 91.4 to 92.5) of individuals self-cleared within 10 y of infection, while 7.9% (95% UI 7.4 to 8.5) progressed to TB. Of those, 68.6% (95% UI 65.4 to 72.0) developed infectious disease, and 33.2% (95% UI 29.9 to 36.4) progressed to clinical disease. While 98% of progression to minimal disease occurred within 2 y of infection, only 71% and 44% of subclinical and clinical disease, respectively, occurred within this period. Multiple progression pathways from infection were necessary to calibrate the model and 49.5% (95% UI 45.6 to 53.7) of those who developed infectious disease undulated between disease states. We identified heterogeneous pathways across disease states after Mtb infection, highlighting the need for clearly defined disease thresholds to inform more effective prevention and treatment efforts to end TB.
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Affiliation(s)
- Katherine C. Horton
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, United Kingdom
| | - Alexandra S. Richards
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, United Kingdom
| | - Jon C. Emery
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, United Kingdom
| | - Hanif Esmail
- Clinical Trials Unit, University College London, LondonWC1V 6LJ, United Kingdom
| | - Rein M. G. J. Houben
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, United Kingdom
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Jha DK, Gupta P, Neelam PB, Kumar R, Krishnaraju VS, Rohilla M, Prasad AS, Dutta U, Sharma V. Clinical and Radiological Parameters to Discriminate Tuberculous Peritonitis and Peritoneal Carcinomatosis. Diagnostics (Basel) 2023; 13:3206. [PMID: 37892027 PMCID: PMC10605989 DOI: 10.3390/diagnostics13203206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
It is challenging to differentiate between tuberculous peritonitis and peritoneal carcinomatosis due to their insidious nature and intersecting symptoms. Computed tomography (CT) is the modality of choice in evaluating diffuse peritoneal disease. We conducted an ambispective analysis of patients suspected as having tuberculous peritonitis or peritoneal tuberculosis between Jan 2020 to Dec 2021. The study aimed to identify the clinical and radiological features differentiating the two entities. We included 44 cases of tuberculous peritonitis and 45 cases of peritoneal carcinomatosis, with a median age of 31.5 (23.5-40) and 52 (46-61) years, respectively (p ≤ 0.001). Fever, past history of tuberculosis, and loss of weight were significantly associated with tuberculous peritonitis (p ≤ 0.001, p = 0.038 and p = 0.001). Pain in the abdomen and history of malignancy were significantly associated with peritoneal carcinomatosis (p = 0.038 and p ≤ 0.001). Ascites was the most common radiological finding. Loculated ascites, splenomegaly and conglomeration of lymph nodes predicted tuberculous peritonitis significantly (p ≤ 0.001, p = 0.010, p = 0.038). Focal liver lesion(s) and nodular omental involvement were significantly associated with peritoneal carcinomatosis (p = 0.011, p = 0.029). The use of clinical features in conjunction with radiological findings provide better diagnostic yields because of overlapping imaging findings.
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Affiliation(s)
- Daya K. Jha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (D.K.J.); (P.B.N.); (U.D.)
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India;
| | - Pardhu B. Neelam
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (D.K.J.); (P.B.N.); (U.D.)
| | - Rajender Kumar
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (R.K.); (V.S.K.)
| | - Venkata S. Krishnaraju
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (R.K.); (V.S.K.)
| | - Manish Rohilla
- Department of Cytopathology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India;
| | - Ajay S. Prasad
- Department of Gastroenterology, Army Hospital Research and Referral, New Delhi 110010, India;
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (D.K.J.); (P.B.N.); (U.D.)
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (D.K.J.); (P.B.N.); (U.D.)
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15
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Ovarian Reserve Disorders, Can We Prevent Them? A Review. Int J Mol Sci 2022; 23:ijms232315426. [PMID: 36499748 PMCID: PMC9737352 DOI: 10.3390/ijms232315426] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
The ovarian reserve is finite and begins declining from its peak at mid-gestation until only residual follicles remain as women approach menopause. Reduced ovarian reserve, or its extreme form, premature ovarian insufficiency, stems from multiple factors, including developmental, genetic, environmental exposures, autoimmune disease, or medical/surgical treatment. In many cases, the cause remains unknown and resulting infertility is not ultimately addressed by assisted reproductive technologies. Deciphering the mechanisms that underlie disorders of ovarian reserve could improve the outcomes for patients struggling with infertility, but these disorders are diverse and can be categorized in multiple ways. In this review, we will explore the topic from a perspective that emphasizes the prevention or mitigation of ovarian damage. The most desirable mode of fertoprotection is primary prevention (intervening before ablative influence occurs), as identifying toxic influences and deciphering the mechanisms by which they exert their effect can reduce or eliminate exposure and damage. Secondary prevention in the form of screening is not recommended broadly. Nevertheless, in some instances where a known genetic background exists in discrete families, screening is advised. As part of prenatal care, screening panels include some genetic diseases that can lead to infertility or subfertility. In these patients, early diagnosis could enable fertility preservation or changes in family-building plans. Finally, Tertiary Prevention (managing disease post-diagnosis) is critical. Reduced ovarian reserve has a major influence on physiology beyond fertility, including delayed/absent puberty or premature menopause. In these instances, proper diagnosis and medical therapy can reduce adverse effects. Here, we elaborate on these modes of prevention as well as proposed mechanisms that underlie ovarian reserve disorders.
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