Adjunctive corticosteroid therapy in patients with pulmonary tuberculosis

OBJECTIVES

In tuberculosis treatment, corticosteroids are used as adjuvants, especially in meningeal/pericardial tuberculosis. In other forms of the disease, especially in severe tuberculosis requiring mechanical ventilation, its use is controversial. The aim of the present study is to assess whether the use of corticosteroids in the treatment of pulmonary tuberculosis patients in mechanical ventilation is associated with in-hospital mortality.

METHODS

This is a retrospective cohort study. Tuberculosis patients >18 years requiring mechanical ventilation, admitted to the emergency department or intensive care unit, were included. Data on corticosteroid use and mortality were collected.

RESULTS

In total, 467 patients were included in the analysis; 399 used corticosteroids and 68 were noncorticosteroid users. The mortality rate was higher among corticosteroid users (59.9%) than in noncorticosteroid users (41.2%) (p=0.010). The total dose of corticosteroid in prednisone equivalents was not different between survivors and nonsurvivors (median [interquartile range]: 80 mg [5-56.6 mg] vs. 80 mg [50-135 mg]; p=0.881).

CONCLUSIONS

Tuberculosis patients in mechanical ventilation who used corticosteroids had a higher mortality rate than those who did not use corticosteroids. The role of corticosteroids in pulmonary tuberculosis, especially in critically ill patients, remains unclear and needs further evaluation in prospective studies.

Evaluation of the diagnostic accuracy of galactomannan from the bronchoalveolar lavage fluid of patients with suspected invasive pulmonary aspergillosis

BACKGROUND

Several studies to evaluate the accuracy of galactomannan (GM) in bronchoalveolar lavage fluid (BALF) as a diagnostic tool have been carried out; however, there are still controversies about the optimal cut-off point of BALF GM.

AIMS

The objective of this study was to determine the diagnostic accuracy and the optimal cut-off point on BALF GM from patients with suspected invasive pulmonary aspergillosis (IPA) in a tertiary care hospital.

METHODS

A cross-sectional study with 188 patients (≥18 years) that had undergone a bronchoscopy with BAL due to suspected IPA was carried out. IPA was diagnosed according to the EORTC/MSG guidelines.

RESULTS

The optimal optical density cut-off point for BALF GM was 0.67, with sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 70%, 32.3%, and 100%, respectively.

CONCLUSIONS

BALF GM detection proved to be a useful supplementary technique in the early diagnosis of IPA in both neutropenic and non-neutropenic patients.

Bright Polarized Single-Photon Source Based on a Linear Dipole

Semiconductor quantum dots in cavities are promising single-photon sources. Here, we present a path to deterministic operation, by harnessing the intrinsic linear dipole in a neutral quantum dot via phonon-assisted excitation. This enables emission of fully polarized single photons, with a measured degree of linear polarization up to 0.994±0.007, and high population inversion-85% as high as resonant excitation. We demonstrate a single-photon source with a polarized first lens brightness of 0.50±0.01, a single-photon purity of 0.954±0.001, and single-photon indistinguishability of 0.909±0.004.

Hong-Ou-Mandel Interference with Imperfect Single Photon Sources

Hong-Ou-Mandel interference is a cornerstone of optical quantum technologies. We explore both theoretically and experimentally how unwanted multiphoton components of single-photon sources affect the interference visibility, and find that the overlap between the single photons and the noise photons significantly impacts the interference. We apply our approach to quantum dot single-photon sources to access the mean wave packet overlap of the single-photon component. This study provides a consistent platform with which to diagnose the limitations of current single-photon sources on the route towards the ideal device.

Tuberculosis in the intensive care unit: alternative treatment regimens and association with mortality

OBJECTIVES

Adequate anti-tuberculosis (TB) treatment is an important factor that can affect the patient's outcome. Higher mortality is found in patients who do not receive optimal treatment that includes isoniazid and rifampicin. The objective of this study is to evaluate the association of use of alternative TB treatment regimens (without rifampicin and isoniazid) and mortality among patients requiring intensive care.

METHODS

Retrospective cohort study, from January 2010 to December 2018. Patients aged > 18 years with a TB diagnosis, admitted to the ICU of a general, tertiary care, university-affiliated hospital (Hospital de Clínicas de Porto Alegre - HCPA) were included. Data on TB treatment used and outcomes of treatment were collected.

RESULTS

462 patients met the inclusion criteria and were included in the analysis; 284 used the usual treatment regimen (rifampicin, isoniazid, pyrazinamide and ethambutol - all orally), and 178 used alternative treatment regimens (IV levofloxacin plus oral ethambutol plus IM streptomycin or IV amikacin, without rifampicin and isoniazid). The mortality was higher among users of alternative treatment regimens (63.5%) than among usual treatment regimen users (51.4%) (P = 0.011). In a multivariate analysis, age, albumin and death were independently associated with alternative treatment regimens use.

CONCLUSIONS

TB programmes in which IV rifampicin is not widely available should consider including it, especially for critically ill TB patients, for whom there may be improved survival.

Tuberculosis in Health Care Workers and the Impact of Implementation of Hospital Infection-Control Measures

Background: Most studies that have evaluated the impact of infection-control measures (ICM) reported a decrease in latent tuberculosis (TB) and not in TB. The objective of this study was to evaluate the impact of ICM on TB incidence among Health Care Workers (HCW's). Methods: We conducted a retrospective record review study in a general, tertiary care, university-affiliated hospital. All TB case reports among HCWs in the hospital from 2005 to 2018 were reviewed. The TB incidence was measured before and after 2012 to evaluate the impact of ICM implemented. Findings: In total, there were 53 TB cases. The number of TB cases before and after the implementation of ICM was 42 (incidence: 100.0 cases/100,000 HCWs/year) and 11 (incidence: 26.2 cases/100,000 HCWs/year), respectively (p < .0001). Conclusions/Application to Practice: TB incidence among HCWs reduced significantly after the implementation of ICM. The establishment of ICM, such as written TB infection control plan, monitoring, screening, training, and education, can reduce TB incidence.

Latent tuberculosis infection in patients with rheumatic diseases

Most people infected by Mycobacterium tuberculosis (Mtb) do not have any signs or disease symptoms, a condition known as latent tuberculosis infection (LTBI). The introduction of biological agents, mainly tumor necrosis factor (TNF) inhibitors, for the treatment of immune-mediated diseases such as Rheumatoid Arthritis (RA) and other rheumatic diseases, increased the risk of reactivation of LTBI, leading to development of active TB. Thus, this review will approach the aspects related to LTBI in patients with rheumatologic diseases, especially those using iTNF drugs. For this purpose it will be considered the definition and prevalence of LTBI, mechanisms associated with diseases and medications in use, criteria for screening, diagnosis and treatment. Considering that reactivation of LTBI accounts for a large proportion of the incidence of active TB, adequate diagnosis and treatment are crucial, especially in high-risk groups such as patients with rheumatologic diseases.

PrediCTC, liquid biopsy in precision oncology: a technology transfer experience in the Spanish health system

PURPOSE

Management of metastatic disease in oncology includes monitoring of therapy response principally by imaging techniques like CT scan. In addition to some limitations, the irruption of liquid biopsy and its application in personalized medicine has encouraged the development of more efficient technologies for prognosis and follow-up of patients in advanced disease.

METHODS

PrediCTC constitutes a panel of genes for the assessment of circulating tumor cells (CTC) in metastatic colorectal cancer patients, with demonstrated improved efficiency compared to CT scan for the evaluation of early therapy response in a multicenter prospective study. In this work, we designed and developed a technology transfer strategy to define the market opportunity for an eventual implementation of PrediCTC in the clinical practice.

RESULTS

This included the definition of the regulatory framework, the analysis of the regulatory roadmap needed for CE mark, a benchmarking study, the design of a product development strategy, a revision of intellectual property, a cost-effectiveness study and an expert panel consultation.

CONCLUSION

The definition and analysis of an appropriate technology transfer strategy and the correct balance among regulatory, financial and technical determinants are critical for the transformation of a promising technology into a viable technology, and for the decision of implementing liquid biopsy in the monitoring of therapy response in advanced disease.

Improving prescribing using a rule based prescribing system

OBJECTIVE

To test the hypothesis that the prescribing behaviour of doctors would improve after having experience with a computerised rule based prescribing system.

DESIGN

A prospective observational study of changes in prescribing habits resulting from the use of a computerised prescribing system in (1) a cohort of experienced users compared with a new cohort, and (2) a single cohort at the beginning and after 3 weeks of computer aided prescribing.

SETTING

64 bed renal unit in a teaching hospital.

INTERVENTION

Routine use of a computerised prescribing system by doctors and nurses on a renal unit from 1 July to 31 August 2001.

MAIN OUTCOME MEASURES

Number of warning messages generated by the system; proportion of warning messages overridden; comparison between doctors of different grades; comparison by doctors' familiarity with the system.

RESULTS

A total of 51,612 records relating to 5995 prescriptions made by 103 users, of whom 42 were doctors, were analysed. The prescriptions generated 15,853 messages, of which 6592 were warning messages indicating prescribing errors or problems. Doctors new to the system generated fewer warning messages after using the system for 3 weeks (0.81 warning messages per prescription v 0.42 after 3 weeks, p = 0.03). Doctors with more experience of the system were less likely to generate a warning message (Spearman's rho = -0.90, p = 0.04) but were more likely to disregard one (Spearman's rho = -1, p<0.01). Senior doctors were more likely than junior doctors to ignore a warning message.

CONCLUSIONS

Doctors are influenced by the experience of using a computerised prescribing system. When judged by the number of warning messages generated per prescription, their prescribing improves with time and number of prescriptions written. Consultants and registrars are more likely to use their clinical judgement to override warning messages regarding prescribed drugs.

Improving prescribing using a rule based prescribing system

OBJECTIVE

To test the hypothesis that the prescribing behaviour of doctors would improve after having experience with a computerised rule based prescribing system.

DESIGN

A prospective observational study of changes in prescribing habits resulting from the use of a computerised prescribing system in (1) a cohort of experienced users compared with a new cohort, and (2) a single cohort at the beginning and after 3 weeks of computer aided prescribing.

SETTING

64 bed renal unit in a teaching hospital.

INTERVENTION

Routine use of a computerised prescribing system by doctors and nurses on a renal unit from 1 July to 31 August 2001.

MAIN OUTCOME MEASURES

Number of warning messages generated by the system; proportion of warning messages overridden; comparison between doctors of different grades; comparison by doctors' familiarity with the system.

RESULTS

A total of 51,612 records relating to 5995 prescriptions made by 103 users, of whom 42 were doctors, were analysed. The prescriptions generated 15,853 messages, of which 6592 were warning messages indicating prescribing errors or problems. Doctors new to the system generated fewer warning messages after using the system for 3 weeks (0.81 warning messages per prescription v 0.42 after 3 weeks, p = 0.03). Doctors with more experience of the system were less likely to generate a warning message (Spearman's rho = -0.90, p = 0.04) but were more likely to disregard one (Spearman's rho = -1, p<0.01). Senior doctors were more likely than junior doctors to ignore a warning message.

CONCLUSIONS

Doctors are influenced by the experience of using a computerised prescribing system. When judged by the number of warning messages generated per prescription, their prescribing improves with time and number of prescriptions written. Consultants and registrars are more likely to use their clinical judgement to override warning messages regarding prescribed drugs.

[Cervugid ovules in cervico-vaginal infections and cervix uteri precancerous conditions treatment]

This medicine was authorized by the National Drug Agency (ANM, Bucureşti) in 2001.

PURPOSE

To evaluate the effectiveness and the tolerance to Cervugid-ovules, a preparation that combines the polyvalent local antiinflammatory action of chloramphenicol, metronidazole and nystatin with the effect of hydrocortisone acetate, an unspecific anti-inflammatory agent; they all are embedded in a Lipex-403, semisynthetic fat.

MATERIALS AND METHODS

The evaluation of 500 patients ages between 15 and 85 years with genital infections, registered in the files of "Cl. II Obst. and Gynecology" of the Cuza-Vodă Hospital from Iaşi has been studied. We studied the subjective manifestations (local discomfort and pelvic pains, local burning and dryness,vulvovaginal itching and dyspareunia) and objective manifestations (vaginal and cervical secretion, the cytotest performed and colored though the Papanicolaou method and reported in the Bethesda system).

RESULTS AND DISCUSSION

Healing of the subjective symptoms in 98%, healing of the leukorrhea--as a main objective symptom--in 95%; The Bethesda system cytotest was one of the inflammatory type in the most of the cases and there wew found in 85 cases: 6 ASCUS, 41 LSIL, and 37 HSIL. The use of Cervugid had a healing response in most of the cases when used in acute and chronic cervico-vaginal inflammatory processes. Cervugid may be considered as an important agent in the treatment of the precancerous affections af the cervix uteri on the following reasons: zhe cure of the infections caused by chlamydia, involved in the etiology of cervical neoplasms, the cure of the HPV infection under episome form, classified in the Bethesda system within the ASCUS, AGUS or LSIL classes. When the cytotest was in the HSIL class, a conization in the LLETZ method was performed.

CONCLUSIONS

Cervugid is conceived for those three main categories of pathogenic factors related to the etiology of cervico-vaginitis: microbia germs, protozoa and mycosis. In addition, it is active on chlamydia and mycoplasms, always sensitive to chloramphenicol therapy. That is why Cervugid with in local administration is indicated in the microbial, trichomoniasis and mycotic vaginitis caused by one category of pathogenic agents or by associated forms, in cervicitis, in the pelvic inflammatory processes (pelvic congestion, metritis, adnexitis, and inflammatory processes associated with benign or malignant tumors of the genital apparatus). The results obtained proved that Cervugid is highly effective medicine.

The safety of spironolactone treatment in patients with heart failure

INTRODUCTION

Spironolactone is increasingly being used in the treatment of heart failure. However, it has been associated with cases of hyperkalaemia. The common use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin-2 receptor (AT2) antagonists in heart failure increases the risk of hyperkalaemia.

OBJECTIVE

To identify the risk of spironolactone withdrawal, hyperkalaemia and severe hyperkalaemia in patients prescribed spironolactone together with either an ACE inhibitor or an AT2 antagonist.

METHODS

Retrospective identification and analysis of patients co-prescribed an ACE inhibitor or an AT2 antagonist with spironolactone. Patients' records were linked to their biochemical results and the doses of spironolactone, ACE inhibitor and AT2 antagonists received by them.

RESULTS

We found that a higher proportion of patients in our cohort stopped taking spironolactone compared with the Randomised Aldactone Evaluation Study and a higher proportion developed hyperkalaemia, a predicted adverse effect of spironolactone combination with an ACE inhibitor or an AT2 antagonist. Patients with diabetes mellitus and those with a haematocrit below 0.36, were more likely to develop hyperkalaemia than those without these traits.

CONCLUSIONS

Spironolactone is a common cause of hyperkalaemia when used in combination with either an ACE inhibitor or an AT2 antagonist. This reinforces the need for care when extrapolating the results of clinical trials to daily clinical practice.

Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example

AIMS

The nature and incidence of errors in prescribing and giving medicines have previously been estimated by trained observers, or by retrospective analysis of incidents in which patients have come to harm. We have examined prospectively in routine clinical practice the concentrations of intravenous infusions of a drug (acetylcysteine) which is given according to a complicated dosing schedule.

METHODS

We prospectively collected samples before and, where possible, after the infusion of acetylcysteine in 66 anonymous patients requiring treatment for acetaminophen (paracetamol) overdose in four centres in the United Kingdom. We measured the concentration in each infusion bag, and deduced from the weight of the patient the percentage of the anticipated dose that had actually been given.

RESULTS

The experimentally determined dose was within 10% of the anticipated dose in 68 of 184 individual bags (37%), and within 20% of the anticipated dose in 112 bags (61%). Doses in 17 bags were more than 50% from the anticipated doses. In three patients, values in all three bags appeared to be systematically wrong by 50% or more; in a further seven cases, individual bags differed by 50% or more from the anticipated value. The median difference between pre- and post-infusion samples was 0% [interquartile range -5.2% to +14.6%], but 9% showed a disparity of greater than +/- 50%.

CONCLUSIONS

Our data suggest that there is large random variation in administered dosage of intravenous infusions. Systematic calculation errors occur in about 5% [95% confidence interval 2, 8%] of cases, and major errors in drawing up in a further 3% [1, 7%], with inadequate mixing in 9% [4, 14%]. While we have no evidence that patients were adversely affected, and while the regime of administration of the drug studied (acetylcysteine) is complicated, these data suggest that the delivered dose often deviates from the intended dose, and that methods of quality control are needed.

[Gastroesophageal reflux during pregnancy: 24-hour esophageal ph monitoring]

Gastroesophageal reflux (GER) occurs in 30-50% of all pregnancies. The progressive rise in plasma progesterone has been suggested as a possible mediator of GER during pregnancy. Recent advances in technology have made it possible to detect GER through monitoring of esophageal pH for prolonged periods, including sleep. 24-hour pH monitoring is the proper method for diagnosing GER in pregnant women. If 24-hour esophageal pH monitoring is to be a useful diagnostic tool, it must reliably discriminate GER patients despite daily variations in distal esophageal acid exposure. To address this issue, we studied 62 women (30 healthy non-pregnant women without GER symptoms and 32 pregnant women with GER symptoms-heartburn, acid regurgitation) with 24-hour esophageal pH monitoring. Intrasubject reproducibility of three pH parameters to discriminate the presence of abnormal acid reflux was determined (DeMeester score, Kaye score, circadian one hour diagram for pH < 4). Each patient was interviewed, using a reliable questionnaire detailing individual habits, life style characteristics and symptoms, at four time points during the first, second, third trimesters of pregnancy and post-partum period. Symptoms of GER are common in pregnancy and although GER rarely endangers maternal or fetal health, it can significantly affect patient comfort and quality of life. We conclude: 1. GER is almost constantly present during pregnancy, increasing with gestational age. 2. The most important pH--parameter is DeMcester score. 3. Heartburn disappear after delivery. 4. 24-hour esophageal pH monitoring is the gold standard for measuring acid exposure and is a reproducible test for the diagnosis of GER in pregnancy.

Adverse drug reactions in patients admitted to hospital identified by discharge ICD-10 codes and by spontaneous reports

AIMS

We studied the international classification of disease (ICD) hospital discharge codes to find unreported adverse drug reactions (ADRs), and asked doctors about their attitudes to reporting some of these cases.

METHODS

We examined the ICD codes assigned on discharge to identify ADRs and compared these with spontaneous reports made to the Committee on Safety of Medicines (CSM). Doctors involved were sent brief résumés of cases and asked if they would report them.

RESULTS

49 of 21 365 patient episodes were coded on discharge as ADRs, of which 33 were 'reportable'. Fourteen spontaneous reports were received by the CSM during the same period. The two groups did not overlap. 25 of 60 doctors responded to our questionnaire, and would have reported only 8 of 75 cases outlined.

CONCLUSIONS

The ICD coding allowed us to identify important ADRs which most doctors would not report spontaneously.

[National statistical parameters of cervical cancer in Romania: 1992-1997]

Cervical cancer is an important health issue in Romania, as the 1990-1992 statistics of IARC mentioned it to be first in Europe as mortality through this neoplasia. We bring to 1997 the national statistical data regarding the cervical cancer.

MATERIAL AND METHODS

Our data provided by the Romanian Health Ministry statistical Office allowed estimations over the following parameters: incidence (crude and age-related), prevalence and number of deaths, and relationships between these parameters and age group, clinical stage, geographical distribution, etc. Usual statistical methods of interpretation are used, as well as prognosis using the parabola methods, and world-standardized incidence rates.

RESULTS

Between 1992-1997, there were 14743 new cases of cervical cancer diagnosed in Romania. The crude incidence per 100,000 was 21.27, and age-related incidence ranged between 0.27 per 100,000 for the under 20 to 46.73 in the 40-49 group. World standardized incidence rate indexed by age groups gave an incidence of 16.84. The mortality was 2.37, with world standardized age related deaths of 2.81. The clinical stage distribution showed stages 0 (15.02%), I (14.04%), II (34.91%), III (27.81%) and IV (8.19. The incidence and mortality data shows a better evolution for younger age groups, but a steady increase in 30-39 group for incidence and mortality.

CONCLUSIONS

The data above place Romania on a stable but high incidence of cervical cancer, with a high mortality due to late diagnostic and socio-economical conditions.

[Seizures during the treatment with interferon for chronic C hepatitis]

Interferon alpha (IFN-alpha) is a well-established first-line treatment for chronic viral hepatitis. Side effects of IFN-alpha therapy are common but generally mild and self-limited. Generalized seizures during IFN-alpha therapy are very uncommon and are present in clinical isolated cases and usually in association with high doses of IFN-alpha. In our case a female of 39 years old, seizures have occurred at low doses of IFN-alpha used as therapy for chronic C viral hepatitis. As it comes to our knowledge, till now, there were published only 4 cases of generalized seizures that occurred during treatment with IFN-alpha for chronic C viral hepatitis. The physiopathology of this complication is unknown. Generalized seizures can be reasonable due to IFN-alpha therapy, as long as the patient didn't have any seizure history, or other factors, which can develop seizures. Neurological examination, EEG and brain scan were normal. The recurrence of these seizures was absent stopping IFN-alpha therapy without any other seizure treatment.