Evaluation of prediagnosis emergency department presentations in patients with active tuberculosis: the role of chest radiography, risk factors and symptoms

Profile of homeless people in emergency departments

OBJECTIVES

For homeless people, emergency departments (ED) are the place of medical care and satisfying physiological, safety and social needs. The treatment of the homeless in EDs is a common issue in many countries. The aim of study was to analyze selected parameters of health care to homeless people in EDs. The authors examined the frequency and the seasonality of admissions, their causes, stay duration, insurance status, and the type of radiological diagnostics performed.

MATERIAL AND METHODS

A retrospective analysis of stays of homeless patients in 3 EDs in one of the largest cities in Poland in 2013-2015 was carried out. Patients were qualified to the population of homeless people based of their registering in ED. Data was obtained on the total number of homeless patients' stays in all 3 EDs, which amounted to 3133.

RESULTS

During the 3 years of analysis: 1042 homeless individuals were identified staying 3133 times in EDs; 46.3% of the stays concerned uninsured homeless people; 31% were under influence of alcohol. On average, men used ED services 3 times, while women only twice. No significant seasonality of admissions was observed. Homeless people were admitted mainly for mental disorders and head injuries. Radiological tests were performed 1577 times, including 83% being CT scans. On average, women and those >30 stayed in EDs for the shortest time. The hospital wards admitted 9.3% of the patients.

CONCLUSIONS

Almost half of homeless patients repeatedly use ED services, regardless of the season. A patient's stay typically lasts 6 h. Half of them were uninsured. The main reasons for admission include mental and behavioral disorders, mostly due to alcohol use and head injuries. The primary radiological diagnostics used were CT scans. Int J Occup Med Environ Health. 2022;35(2):157-67.

Clinical spectrum and outcomes of geriatric tuberculosis emergencies in North India

OBJECTIVES:

Despite the acute and life-threatening repercussions that tuberculosis (TB) may have on the burgeoning older population in endemic countries like India, the spectrum of geriatric TB emergencies is not adequately understood.

METHODS:

We performed a prospective observational study at the emergency department of an academic hospital in north India between January 2019 and June 2020, investigating the clinical and laboratory features and outcomes of active TB in older patients aged 60 years and above.

RESULTS:

Out of 71 geriatric TB emergencies, central nervous system disease predominated (n = 41, 57.7%), followed by pulmonary (n = 16, 22.5%), pleural TB (n = 8, 11.3%), and multisite involvement (n = 6, 8.4%). Nearly 71.8% were male, and 77.4% belonged to low socioeconomic status (lower-middle or lower class). Usual predisposing factors were tobacco smoking (38.0%), chronic alcohol use (27.0%), and diabetes mellitus (23.9%). Atypical features were more frequent with extrapulmonary TB. Only 28.2% were microbiologically confirmed cases, and rifampicin resistance was seen in only one case. The mortality rate was considerably high (24.0%), highest with pulmonary TB (37.0%).

CONCLUSION:

Older patients with TB emergencies have atypical presentations, diagnostic difficulties, and high mortality.

Diagnostic challenges and Gene-Xpert utility in detecting Mycobacterium tuberculosis among suspected cases of Pulmonary tuberculosis

The incidence of pulmonary tuberculosis (PTB) can be reduced by preventing transmission with rapid and precise case detection and early treatment. The Gene-Xpert MTB/RIF assay is a useful tool for detecting Mycobacterium tuberculosis (MTB) with rifampicin resistance within approximately two hours by using a nucleic acid amplification technique. This study was designed to reduce the underdiagnosis of smear-negative pulmonary TB and to assess the clinical and radiological characteristics of PTB patients. This cross-sectional study included 235 participants who went to the Luyang primary health care clinic from September 2016 to June 2017. The demographic data were analyzed to investigate the association of patient gender, age group, and ethnicity by chi-square test. To assess the efficacy of the diagnostic test, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. The area under the curve for sputum for both AFB and gene-Xpert was analyzed to compare their accuracy in diagnosing TB. In this study, TB was more common in males than in females. The majority (50.71%) of the cases belonged to the 25-44-year-old age group and the Bajau ethnicity (57.74%). Out of 50 pulmonary TB cases (smear-positive with AFB staining), 49 samples were positive according to the Gene-Xpert MTB/RIF assay and was confirmed by MTB culture. However, out of 185 smear-negative presumptive cases, 21 cases were positive by Gene-Xpert MTB/RIF assay in that a sample showed drug resistance, and these results were confirmed by MTB culture, showing resistance to isoniazid. In comparison to sputum for AFB, Gene-Xpert showed more sensitivity and specificity with almost complete accuracy. The additional 21 PTB cases detection from the presumptive cases by GeneXpert had significant impact compared to initial observation by the routine tests which overcame the diagnostic challenges and ambiguities.

Individual and public health consequences associated with a missed diagnosis of pulmonary tuberculosis in the emergency department: A retrospective cohort study

Objectives

To determine: i) the emergency department (ED) utilization history of pulmonary tuberculosis (PTB) patients, and ii) the potential individual and public health consequences of a missed diagnosis of PTB in this setting.

Design

Retrospective observational cohort study.

Participants

Patients with PTB aged >16 years diagnosed between April 1, 2010 and December 31, 2016 in the Province of Alberta, Canada.

Methods

We identified valid new cases of PTB from a provincial registry and linked them to ED attendees in administrative databases. Visits are considered ‘PTB’, pulmonary ‘other’, and non-pulmonary based on the most responsible discharge diagnosis. Individual consequences of a missed diagnosis included health system delay and PTB-related death; public health consequences included nosocomial ED exposure time and secondary cases.

Results

Of 711 PTB patients, 378 (53%) made 845 ED visits in the six months immediately preceding the date of diagnosis. The most responsible ED discharge diagnosis was PTB in 92 (10.9%), pulmonary ‘other’ in 273 (32%) and non-pulmonary in 480 (56.8%). ED attendees had a median (IQR) health system delay of 27 (7,180) days and, compared to non-ED attendees were more likely to die a TB-related death 5.9% vs 1.2%, p = 0.001. Emergency attendees generated 3812 hours of ED nosocomial exposure time, and 31 secondary cases (60.8% of all secondary cases reported). Mycobacterium tuberculosis isolates from ED-attendees were more likely than non-attendees to be clustered–i.e., have an identical DNA fingerprint with another isolate (27% vs. 21%, p = 0.037).

Conclusions

ED utilization by PTB patients, and related consequences, are substantial. EDs are a potential resource for earlier PTB diagnosis.

The Accuracy of Emergency Physicians' Suspicions of Active Pulmonary Tuberculosis

Objective: To investigate factors associated with recognition and delayed isolation of pulmonary tuberculosis (PTB). Background: Precise identification of PTB in the emergency department (ED) remains challenging. Methods: Retrospectively reviewed PTB suspects admitted via the ED were divided into three groups based on the acid-fast bacilli culture report and whether they were isolated initially in the ED or general ward. Factors related to recognition and delayed isolation were statistically compared. Results: Only 24.94% (100/401) of PTB suspects were truly active PTB and 33.77% (51/151) of active PTB were unrecognized in the ED. Weight loss (p = 0.022), absence of dyspnea (p = 0.021), and left upper lobe field (p = 0.024) lesions on chest radiographs were related to truly active PTB. Malignancy (p = 0.015), chronic kidney disease (p = 0.047), absence of a history of PTB (p = 0.013), and lack of right upper lung (p ≤ 0.001) and left upper lung (p = 0.020) lesions were associated with PTB being missed in the ED. Conclusions: Weight loss, absence of dyspnea, and left upper lobe field lesions on chest radiographs were related to truly active PTB. Malignancy, chronic kidney disease, absence of a history of PTB, and absence of right and/or left upper lung lesions on chest radiography were associated with isolation delay.

Clinical characteristics of elderly pulmonary tuberculosis in an acute-care general hospital in Tokyo, Japan: A 12-year retrospective study

OBJECTIVE

A significant feature of tuberculosis (TB) in Japan is the fact that a high proportion of cases belong to the elderly population. Furthermore, previous reports have pointed out the delayed diagnosis of pulmonary TB in acute-care settings. We aimed to examine the clinical characteristics of pulmonary TB patients in an acute-care general hospital, particularly focusing on the elderly population.

METHODS

We retrospectively reviewed the medical records of patients with pulmonary TB who presented at our institution between May 2005 and December 2016. We described the overall clinical characteristics of these patients and compared them according to age.

RESULTS

Overall, 289 patients were eligible for the analysis, with a median age of 58 [42-73] years, and 29.4% being older than 70 years. Among the elderly patients, 42.4% were characterized by atypical presentation.

CONCLUSION

Our findings suggest that the elderly population tends to present as atypical cases lacking respiratory complaints, thereby being at a risk of misdiagnosis.

Difficulties in tuberculosis infection control in a general hospital of Vietnam: a knowledge, attitude, and practice survey and screening for latent tuberculosis infection among health professionals

BACKGROUND

In Vietnam, a country with a high tuberculosis (TB) burden, health professionals in both TB-specialized and non-TB-specialized general hospitals have a high risk of acquiring TB. The aims of the present study were to clarify the difficulties in TB infection control at non-TB specialized hospitals and whether any associated risks of latent TB infection exist among health professionals in Vietnam.

METHODS

We conducted a cross-sectional study in a national tertiary and general hospital of Hanoi, Vietnam. Participants were health professionals, including physicians, nurses, and other health professionals. We assessed difficulties in TB infection control by conducting a knowledge, attitude, and practice (KAP) survey. We also collected data on the results of tuberculin skin tests (TSTs) conducted during health check-ups for hospital staff to determine whether health professionals had latent TB infection or TB disease. KAP scores were compared among health professional groups (physicians vs. nurses vs. other health professionals). Factors influencing knowledge scores were evaluated using multiple regression analysis.

RESULTS

A total 440 health professionals at the study site participated in the KAP survey, and we collected the results of TSTs from a total of 299 health professionals. We observed a high prevalence of latent TB infection (74.2%), especially among participants in the emergency department. Although participants had high KAP scores, some topics were less understood, such as symptoms and risks of TB, proper use of protective equipment such as N95 respirators, and preventing transmission by patients with confirmed or suspected TB. Factors influencing knowledge scores associated with TB were age, a belief that TB is the most important infectious disease, being a medical professional, having previously attended workshops or seminars, and knowing that Vietnam has a high burden of TB.

CONCLUSION

In a non-TB specialized hospital of Vietnam, we observed a risk of TB infection among health professionals and difficulties in properly controlling TB infection. Early awareness regarding patients with suspected TB, to apply proper measures and prevent transmission, and education regarding obtaining updated knowledge through scientific information are crucial to enhancing TB infection control in general hospitals of Vietnam.