Ten-year experience of bone and joint tuberculosis in Blackburn 1978-1987

A retrospective review of 70 cases of bone and joint tuberculosis seen between 1978 and 1987 is reported. Forty-nine of the cases were patients of Indian subcontinent ethnic origin. There was a wide range of sites affected. Pain, swelling or sinus formation were the commonest presenting features. Delay in diagnosis from the first hospital visit was significantly longer in the Caucasian population (mean delay; Caucasian 17.6 weeks, Indian subcontinent 2.8 weeks). Drug treatment was used in all cases, combined with biopsy in 21 cases and more radical surgery in 28 cases. The results of treatment were good with low morbidity and mortality, long-term problems have been few, and no relapses have occurred. Nine months of chemotherapy and the joint system of orthopaedic and medical management employed locally are strongly recommended.     

Changing pattern of respiratory tuberculosis in the UK in adult patients from the Indian subcontinent

BACKGROUND: Clinical observations over a 12 year period have suggested a changing pattern of adult respiratory tuberculosis in patients from the Indian subcontinent in two districts of the United Kingdom with a high incidence of tuberculosis. METHODS: Details of all patients for the period 1981-92 residing in the Newham and Blackburn districts aged 15 and over whose ethnic origin was from the Indian subcontinent (n = 1308) were analysed by stepwise logistic regression to determine the relationship between sputum smear positivity, sputum culture positivity, and isolated mediastinal lymphadenopathy, year of notification, age, sex, ethnic group (Indian or Pakistani), and whether the patient had visited the Indian subcontinent within the last three years. RESULTS: The proportion of cases who were smear positive rose over the 12 years of the study, as did the proportion of culture positive cases. The proportion with isolated mediastinal lymphadenopathy fell. These changes took place in both districts. They were not explained by demographic changes in age, sex, or ethnic group, nor was there evidence that smear and culture positivity increased in those who had recently visited India or Pakistan. CONCLUSIONS: The pattern of tuberculosis in adult patients originating from the Indian subcontinent has altered over time towards that seen in the white population in the UK.




     

Management and outcome of pulmonary tuberculosis in adults notified in England and Wales in 1983. Medical Research Council Tuberculosis and Chest Diseases Unit.

The management and outcome of treatment were studied, two years or more after notification, in previously untreated adult patients of white and Indian subcontinent (Indian, Pakistani, and Bangladeshi) ethnic origin with pulmonary tuberculosis notified in England and Wales in the first six months of 1983. Of the 1068 patients, 10% had died, 3% defaulted, and 1% left the UK before completing chemotherapy. Of the 917 patients who completed chemotherapy, 90% were prescribed rifampicin and isoniazid throughout, most having ethambutol in addition either in the initial phase only (72%) or throughout (3%); 18% had pyrazinamide. The outcome of chemotherapy at the time the patient was last seen was reported by the clinician. Of those completing treatment, most were classified as cured after the primary course of chemotherapy (86%) or after modification of chemotherapy because of toxicity (10%) or therapeutic failure (2%). Altogether, 28 patients were classified as therapeutic failures because of a slow response, deterioration, or failure during chemotherapy or relapse after stopping chemotherapy. A further 151 patients, however, failed to complete chemotherapy, some for reasons attributable to a failure of the routine clinical services. This should prompt continued efforts to maximise the efficiency of the services for tuberculosis. The main differences between the findings of this survey and those of the previous Medical Research Council survey (of patients starting chemotherapy in 1978-9) were an increased use of pyrazinamide and a reduction in the duration of the chemotherapy prescribed.     

Tuberculosis in England and Wales in 1993: results of a national survey. Public Health Laboratory Service/British Thoracic Society/Department of Health Collaborative Group

BACKGROUND: A national survey of tuberculosis notifications in England and Wales was carried out in 1993 to determine the notification rate of tuberculosis and the trends in the occurrence of disease by ethnic group in comparison with the findings of similar surveys in 1978/79, 1983, and 1988. The prevalence of HIV infection in adults notified with tuberculosis in the survey period was also estimated. METHODS: Clinical, bacteriological, and sociodemographic information was obtained on all newly notified cases of tuberculosis in England and Wales during the six months from 2 January to 2 July 1993. The prevalence of HIV infection in 16-54 year old patients with tuberculosis notified throughout 1993 was assessed using "unlinked anonymous" testing supplemented by matching of the register of patients with tuberculosis with that of patients with AIDS reported to the PHLS AIDS centre. Annual notification rates were calculated using population estimates from the 1993 Labour Force Survey. RESULTS: A total of 2706 newly notified patients was eligible for inclusion in the survey of whom 2458 were previously untreated the comparable figures for 1988 were 2408 and 2163. The number of patients of white ethnic origin decreased from 1142 (53%) in 1988 to 1088 (44%) in 1993 whereas those of patients of Indian, Pakistani, or Bangladeshi (Indian subcontinent (ISC)) ethnic origin increased from 843 (39%) in 1988 to 1014 (41%) and those of "other" (non-white, non-ISC) ethnic origins increased from 178 (8%) to 356 (14%). The largest increase was seen in the black African ethnic group from 37 in 1988 to 171 in 1993. Forty nine per cent of patients had been born abroad and the highest rates were seen in those who had recently arrived in this country. The overall annual notification rate for previously untreated tuberculosis in England and Wales increased between 1988 and 1993 from 8.4 to 9.2 per 100,000 population. The rate declined in the white, Indian, and black Caribbean ethnic groups and increased in all other groups. In the white group the rate of decline has slowed since the last survey: in several age groups the rates were higher in 1993 than 1988 but the numbers in these groups were small. Thirty six (4.1%) of the 882 previously untreated respiratory cases were resistant to isoniazid and three (0.3%) to isoniazid and rifampicin. Sixty two (2.3%) adults aged 16-54 years were estimated to be HIV-infected. Evidence of under-reporting of HIV positive tuberculosis patients was found. CONCLUSIONS: The number of cases and annual notification rate for previously untreated tuberculosis increased between 1988 and 1993. Although the decline in rates in the white population has continued, the rate of decline has slowed. The high rates in the ISC ethnic group population have continued to decline since 1988 whereas rates in the black African group have increased. An increased proportion of cases were found among people born abroad, particularly those recently arrived in this country. In previously untreated cases the level of drug resistance remains low and multi-drug resistance is rare. A small proportion of adults with tuberculosis were infected with HIV but there may be selective undernotification of tuberculosis in these patients.


     

Scottish national survey of tuberculosis notifications 1993 with special reference to the prevalence of HIV seropositivity.

BACKGROUND: The study sought to determine the contribution of HIV seropositivity to the arrest of decline in tuberculosis notifications in Scotland. METHODS: Survey forms relating to each tuberculosis notification in 1993 were completed by the notifying consultant. Voluntary anonymous HIV testing of tuberculosis cases aged under 65 was requested. Age, sex, ethnic status, country of birth, employment status, occupation, previous tuberculosis, contact status, risk factors for HIV infection, HIV serostatus of cases aged under 65, site, radiological extent, and bacteriological status of tuberculous disease were determined. RESULTS: Five hundred and seventy four cases of tuberculosis were originally notified, of which 77 (14%) subsequently proved to be non-tuberculous and were therefore denotified. Of the 497 cases 423 (85%) were white and 58 (12%) were from the Indian subcontinent. Eighty five per cent of patients from the Indian subcontinent were aged < 55 years whereas 64% of white patients were aged > 55 years. Pulmonary disease was found in 74%, non-pulmonary in 22%, and combined disease in 4% of patients. Of 242 HIV tests performed, three were positive and five other HIV positive patients were known, giving an HIV positivity rate of 1.6% of all tuberculosis notifications in 1993. Annual notification rates for Scotland were 9.7 per 10(5) before and 8.7 per 10(5) after exclusion of previously treated cases; rates were 8.4 per 10(5) for the white population and 179 per 10(5) for those from the Indian subcontinent. CONCLUSIONS: The study documents the distribution of tuberculous disease in Scotland by age, sex, site, and ethnic group for the first time. Notification practices, with respect to denotification, need to be improved. Infection with HIV is presently uncommon in cases of tuberculosis in Scotland but continued vigilance is essential.     

Skeletal tuberculosis of the wrist and hand: A study of 27 cases

The 27 cases of skeletal tuberculosis in the hand and wrist reported represented 6.9% of the skeletal tuberculosis seen at our hospital and 32% of the skeletal tuberculosis found in the upper extremity. In a majority of these patients a single bone or joint was involved and 18.5% of the patients had bone and/or joint involvement outside the hand. Pulmonary tuberculosis was present in 10.7% of these cases. The clinical picture of tuberculosis is similar to that of other infections and tumorous conditions, but a history of absent bacille Calmette Guerin protection and positive tine test should arouse one's suspicion to the condition. Eight-six percent of our patients had x-ray findings that included bone atrophy, bone or joint destruction with discrete periostitis, or the presence of the typical spina ventosa. We found no case of resistance to various combinations of the usual drugs in any patients. Supportive orthopaedic splints were used over short periods (3 months) and surgery was used for diagnostic purposes (biopsies) and in treatment by fusion of two wrists in this patient series. Finger joint involvement responded satisfactorily to drug and conservative orthopaedic treatment and in no case were these joints fused or replaced by a prosthesis.     

Drug resistance in Mycobacterium tuberculosis: a survey over 25 years in Blackburn.

Over the past 25 years the incidence of tuberculosis in Blackburn has changed from one that was below the national average to one which is consistently in the 10 highest local authority areas in England and Wales. A survey of primary and acquired drug resistance over the same period included 974 ethnic white patients and 538 of Indian subcontinent ethnic origin. Primary drug resistance in the white population has fallen consistently from 1965 onwards and is now zero. Only one case of acquired resistance has occurred in the last five years. Primary resistance in the immigrant community has been 11-15% from 1965 onwards, and five cases of acquired resistance have occurred since 1970. The pattern of drug resistance over this period supports the view that there is no evidence of cross infection between the native white and immigrant ethnic groups.     

Peripheral tuberculous lymphadenopathy: a review of 67 cases.

Peripheral tuberculous lymphadenopathy is the commonest form of extrapulmonary tuberculosis. Sixty-seven patients with peripheral tuberculous lymphadenopathy who presented to general surgeons and underwent lymph node biopsy between 1979 and 1989 are reviewed. Fifty-four patients (81 per cent) were of Indian subcontinent ethnic origin and 13 (19 per cent) were of white ethnic origin. The sites most commonly affected were the cervical lymph nodes. Biopsy specimens obtained by open operation were sent for microbiological examination in all but 13 cases, of whom seven were patients of white ethnic origin. Tuberculous lymphadenopathy remains an important differential diagnosis of cervical lymphadenopathy and it is essential that peripheral lymph node biopsies are examined both histologically and microbiologically.     

Treatment of pulmonary tuberculosis in patients notified in England and Wales in 1978-9: chemotherapy and hospital admission. Medical Research Council Tuberculosis and Chest Diseases Unit.

The treatment of adult patients, both white and of Indian, Pakistani, or Bangladeshi ethnic origin, with previously untreated pulmonary tuberculosis who were notified in England and Wales from 1 October 1978 to 31 March 1979 has been surveyed. Chemotherapy was completed as planned by the physician in charge in 820 (65%) of the 1253 patients. Eleven per cent of patients died before chemotherapy could be completed, 8% defaulted, and 6% had chemotherapy modified because of drug toxicity, and for 8% there were miscellaneous reasons for failure to complete chemotherapy. Of the 1003 patients who completed chemotherapy, 804 (80%) were prescribed isoniazid and rifampicin throughout, 667 (67%) receiving ethambutol in addition, either in the initial phase (550) or throughout chemotherapy (117). A further 129 (13%) had a regimen based on isoniazid and ethambutol throughout, and the remaining 70 had miscellaneous combinations of drugs. For the 544 patients who received a two phase regimen of isoniazid and rifampicin throughout with one or two additional drugs initially and who completed chemotherapy as planned, the median duration of chemotherapy was 10.8 months, 122 (22%) patients being treated for more than 12 months. For all 1001 patients who completed chemotherapy (whether or not as planned) and for whom the duration was known, the median duration was 11.8 months and 311 (31%) had more than 12 months' treatment. The great majority (79%) of the patients were admitted to hospital initially, the commonest reason being for investigation and diagnosis.     

National survey of notifications of tuberculosis in England and Wales in 1988. Medical Research Council Cardiothoracic Epidemiology Group.

BACKGROUND: A survey was undertaken to determine the distribution of tuberculosis in England and Wales and, by comparison with the findings of similar surveys in 1978-9 and 1983, to study trends in the incidence of the disease by ethnic group over the decade. METHODS: The survey included all cases of tuberculosis in England and Wales newly notified to the medical officers for environmental health during the six months from 2 January to 1 July 1988. Notification rates were calculated from population estimates from the 1988 Labour Force Survey. RESULTS: Clinical details were obtained from the clinician for 2149 (99.4%) of the 2163 newly notified and previously untreated patients. Over 90% were either white (53%) or of Indian, Pakistani, or Bangladeshi ethnic origin (39%). The notification rate in the white population was 4.7/100,000/year, a decline of 7.2% per year since 1978. The rate was 134.6/100,000/year in the population of Indian ethnic origin, and 100.5/100,000/year in that of Pakistani or Bangladeshi ethnic origin, a decline of 6% a year since 1978 for the two groups combined (standardised for age, country of birth, and length of time in the UK). In all ethnic groups rates of disease were much higher in the elderly than in the young. Bacteriological results were available in 1161 (80%) of the 1443 pulmonary cases. In 939 (81%) Mycobacterium tuberculosis was cultured; 614 cases (53%) also had positive smears, of which 424 (69%) were from white patients. CONCLUSIONS: Notification rates for tuberculosis in England and Wales declined over the decade, but major differences remained between ethnic groups.     

Tuberculosis at the end of the 20th century in England and Wales: results of a national survey in 1998

BACKGROUND: A national survey of tuberculosis was conducted in England and Wales in 1998 to obtain detailed information on the occurrence of the disease and recent trends. This survey also piloted the methodology for enhanced tuberculosis surveillance in England and Wales and investigated the prevalence of HIV infection in adults with tuberculosis. METHODS: Clinical and demographic data for all cases diagnosed during 1998 were obtained, together with microbiological data where available. Annual incidence rates in the population were estimated by age, sex, ethnic group, and geographical region using denominators from the 1998 Labour Force Survey. Incidence rates in different subgroups of the population were compared with the rates observed in previous surveys. The tuberculosis survey database for 1998 was matched against the Communicable Disease Surveillance Centre HIV/AIDS database to estimate the prevalence of HIV co-infection in adult patients with tuberculosis. RESULTS: A total of 5658 patients with tuberculosis were included in the survey in England and Wales (94% of all formally notified cases during the same period), giving an annual rate of 10.93 per 100 000 population (95% CI 10.87 to 10.99). This represented an increase of 11% in the number of cases since the survey in 1993 and 21% since 1988. In many regions case numbers have remained little changed since 1988, but in London an increase of 71% was observed. The number of children with tuberculosis has decreased by 10% since 1993. Annual rates of tuberculosis per 100 000 population have continued to decline among the white population (4.38) and those from the Indian subcontinent, although the rate for the latter has remained high at 121 per 100 000. Annual rates per 100 000 have increased in all other ethnic groups, especially among those of black African (210) and Chinese (77.3) origin. Over 50% of all patients were born outside the UK. Recent entrants to the UK had higher rates of the disease than those who had been in the country for more than 5 years or who had been born in the UK. An estimated 3.3% of all adults with tuberculosis were co-infected with HIV. CONCLUSIONS: The epidemiology of tuberculosis continues to change in England and Wales and the annual number of cases is rising. More than one third of cases now occur in young adults and rates are particularly high in those recently arrived from high prevalence areas of the world. The geographical distribution is uneven with urban centres having the highest rates. The increase in the number of cases in London is particularly large. Tuberculosis in patients co-infected with HIV makes a small but important contribution to the overall increase, particularly in London. To be most effective and to make the most efficient use of resources, tuberculosis prevention and control measures must be based on accurate and timely information on the occurrence of disease. A new system of continuous enhanced tuberculosis surveillance was introduced in 1999, based on the methodology developed in this national survey.     

Vegetarian diet as a risk factor for tuberculosis in immigrant south London Asians.

BACKGROUND--In a previous retrospective study of tuberculosis in south London among Asian immigrants from the Indian subcontinent Hindu Asians were found to have a significantly increased risk for tuberculosis compared with Muslims. This finding has been further investigated by examining the role of socioeconomic and lifestyle variables, including diet, as risk factors for tuberculosis in Asian immigrants from the Indian subcontinent resident in south London. METHODS--Using a case-control study technique Asian immigrants from the Indian subcontinent diagnosed with tuberculosis during the past 10 years and two Asian control groups (community and outpatient clinic controls) from the Indian subcontinent were investigated. Cases and community controls were approached by letter. A structured questionnaire concerning a range of demographic, migration, socioeconomic, dietary, and health topics was administered by a single trained interviewer to subjects (56 cases and 100 controls) who agreed to participate. RESULTS--The results confirmed earlier findings that Hindu Asians had an increased risk of tuberculosis compared with Muslims. However, further analysis revealed that religion had no independent influence after adjustment for vegetarianism (common among Hindu Asians). Unadjusted odds ratios for tuberculosis among vegetarians were 2.7 (95% CI 1.1 to 6.4) using community controls, and 4.3 (95% CI 1.8 to 10.4) using clinic controls. There was a trend of increasing risk of tuberculosis with decreasing frequency of meat or fish consumption. Lactovegetarians had an 8.5 fold risk (95% CI 1.6 to 45.4) compared with daily meat/fish eaters. Adjustment for a range of other socioeconomic, migration, and lifestyle variables made little difference to the relative risks derived using either community or clinic controls. CONCLUSIONS--These results indicate that a vegetarian diet is an independent risk factor for tuberculosis in immigrant Asians. The mechanism is unexplained. However, vitamin D deficiency, common among vegetarian Asians in south London, is known to affect immunological competence. Decreased immunocompetence associated with a vegetarian diet might result in increased mycobacterial reactivation among Asians from the Indian subcontinent.     

Pulmonary tuberculosis among political asylum seekers screened at Heathrow Airport, London, 1995-9

BACKGROUND: Over 50% of cases of tuberculosis (TB) in the UK occur in people born overseas, and new entrants to the country are screened for TB. A study was undertaken to determine the prevalence and disease characteristics of pulmonary TB in new entrants to the UK seeking political asylum. METHODS: A retrospective analysis of the results of screening 53 911 political asylum seekers arriving at Heathrow Airport between 1995 and 1999 was performed by studying Airport Health Control Unit records and hospital medical records. Outcome measures were chest radiograph abnormalities, sputum smear, culture, and drug resistance data for Mycobacterium tuberculosis. RESULTS: The overall prevalence of active TB in political asylum seekers was 241 per 100 000. There were large variations in prevalences of TB between asylum seekers from different regions, with low rates from the Middle East and high rates from the Indian subcontinent and sub-Saharan Africa. The frequency of drug resistance was high; 22.6% of culture positive cases were isoniazid resistant, 7.5% were multidrug resistant (resistant to both isoniazid and rifampicin), and 4% of cases diagnosed with active disease had multidrug resistant TB. CONCLUSIONS: The prevalence rate of TB in political asylum seekers entering the UK through Heathrow Airport is high and more M tuberculosis isolates from asylum seekers are drug resistant than in the UK population. Extrapolating these figures, it is estimated that 101 political asylum seekers with active pulmonary TB enter the UK every year, of whom about 25 would have smear positive disease.     

Tuberculosis diagnosed during pregnancy: a prospective study from London

BACKGROUND: A study was undertaken to characterise the presentation of tuberculosis in pregnancy and the difficulties in diagnosis in an area of the UK with a high incidence of tuberculosis. METHODS: A prospective case series was investigated at Northwick Park Hospital, a university affiliated district general hospital in Brent and Harrow health authority in north-west London which incorporates a regional infectious diseases unit. Patients diagnosed with tuberculosis over the study period were included if the onset of symptoms occurred during pregnancy. RESULTS: Thirteen patients were diagnosed during a 30 month period from December 1995 to May 1998 during which 9069 mothers were delivered, a prevalence of 143.3/100 000 deliveries. Symptoms began at a median of 22 weeks gestation (range 9-40 weeks). All patients were recent immigrants of Indian subcontinent or Somali origin and their median duration of residence in the UK was 31 months (range 1-72). Prevalence broken down for racial origin of mothers was 466.3/100 000 for mothers of black African origin and 239.1/100 000 for mothers of Indian origin. Nine of the 13 patients had extrapulmonary tuberculosis. Four patients with widely disseminated disease had a negative Mantoux response and five with localised disease had a strongly positive Mantoux response. HIV co-infection was absent. The median delay between the onset of symptoms and diagnosis was seven weeks (range 2-30). The response to standard treatment was excellent and all patients were cured. CONCLUSIONS: Tuberculosis occurring in pregnancy is common in recent immigrants. Diagnosis during pregnancy is delayed because the disease is frequently extrapulmonary with few symptoms.     

短程化疗与植骨内固定治疗胸腰椎脊柱结核

目的探讨胸腰椎脊柱结核短程化疗以及前路和前后路联合结合植骨内固定治疗的临床疗效。方法对38例胸腰椎脊柱结核患者行3个月四联抗结核药物强化治疗,三联药物6个月持续治疗;其中前路病灶清除植骨内固定21例,后路椎弓根钉棒系统内固定、前路病灶清除椎间植骨17例。观察结核治愈率、术后神经功能的改善情况及植骨融合情况。结果35例获得随访,时间1年2个月～3年。脊柱结核均治愈,无全身及局部并发症,脊髓功能损伤恢复,植骨块愈合,植骨均融合,时间4～7个月。内固定无松动、断裂。结论短程化疗结合选择前路或前后路联合手术方式治疗脊柱结核,可加强脊柱稳定性,改善畸形,利于神经功能恢复和植骨愈合。     

Tuberculosis in London: a decade and a half of no decline [corrected

BACKGROUND: London accounts for nearly half of the national burden of tuberculosis. The incidence of tuberculosis has more than doubled in London in the past 15 years. METHODS: Data from the enhanced tuberculosis surveillance 1999-2003, the national tuberculosis surveys of 1993 and 1998, and tuberculosis notifications were compared and analysed. RESULTS: In 2003, 3048 patients with tuberculosis were reported in London, 45% of the national total. This represents an incidence of 41.3/100,000, five times higher than the rest of England and Wales, and in parts of London the incidence of tuberculosis is nine times the national average. 75% of people with tuberculosis in London are born abroad; nearly half have lived in the UK for <5 years, but a third for >10 years. 86% are from an ethnic minority group, and the incidence is highest in black Africans at 283/100,000 compared with 141, 141 and 8/100,000 for Pakistanis, Indians and whites, respectively. In absolute terms, a third of patients with tuberculosis in London are from Africa and nearly a third from the Indian subcontinent. Specific groups affected also include the homeless, prisoners, and hard drug and alcohol users as well as the immunosuppressed. CONCLUSIONS: London reflects the worldwide rise in tuberculosis, with increasing incidence in ethnic minorities. Work has been carried out to combat this rise, but more is needed. Tuberculosis control and prevention strategies should be mindful of the changing epidemiology of tuberculosis in London, and provide information, diagnosis and treatment tailored to the specific needs of the capital and its at-risk groups.     

Prereferral evaluation of patients with suspected bone and soft tissue tumors

One hundred consecutive patients referred to an orthopaedic oncology practice for evaluation of suspected bone or soft tissue tumors were studied prospectively. There were 76 patients with bone lesions and 24 patients with soft tissue lesions. At the time of initial consultation, information regarding the referring diagnosis, number of prior physician office visits, and prereferral imaging studies obtained was collected. There were 50 patients with benign tumors, 17 patients with primary malignant tumors, 11 patients with metastatic tumors, and 22 patients with nonneoplastic conditions. The average number of physician visits before referral for the entire group was 4.8 visits and was highest for patients with malignant bone tumors (6.2 visits). Imaging studies obtained before referral included plain radiographs, magnetic resonance imaging, bone scans, computed tomography scans, and ultrasound. None of the plain radiographs were thought to be unnecessary; however, 26 of 76 (34.2%) magnetic resonance imaging scans, 17 of 40 (42.5%) bone scans, and 13 of 36 (36.1%) computed tomography scans were excessive and did not contribute to the evaluation of the lesion. Although only 58% of the study group included patients with benign bone tumors and nonneoplastic bone lesions, they accounted for the majority (79%) of unnecessary imaging studies. Primary care physicians and general orthopaedic physicians were equally likely to order unnecessary imaging studies (48% and 52%, respectively).     

Short-course chemotherapy for tuberculosis of the spine. A comparison between ambulant treatment and radical surgery--ten-year report

We performed a randomised, controlled clinical trial to compare ambulant short-course chemotherapy with anterior spinal fusion plus short-course chemotherapy for spinal tuberculosis without paraplegia. Patients with active disease of vertebral bodies were randomly allocated to one of three regimens: a) radical anterior resection with bone grafting plus six months of daily isoniazid plus rifampicin (Rad6); b) ambulant chemotherapy for six months with daily isoniazid plus rifampicin (Amb6); or c) similar to b) but with chemotherapy for nine months (Amb9). Ten years from the onset of treatment, 90% of 78 Rad6, 94% of 78 Amb6 and 99% of 79 Amb9 patients had a favourable status. Ambulant chemotherapy for a period of six months with daily isoniazid plus rifampicin (Amb6) was an effective treatment for spinal tuberculosis except in patients aged less than 15 years with an initial angle of kyphosis of more than 30 degrees whose kyphosis increased substantially.     

Scrofuloderma of the lower extremity treated with wide resection: a case report and review of the literature.

Scrofuloderma is tuberculosis of subcutaneous tissue that ulcerates and drains through the overlying skin. It most commonly occurs in the neck from a cervical lymph node source. Although such lymphatic spread is the usual clinical picture, there are sporadic reports in the literature of direct hematogenous seeding of subcutaneous tissue forming a tuberculoma, or "cold abscess." Definitive diagnosis requires the identification of Mycobacterium tuberculosis within the suspect lesion. Surgical intervention is necessary in any draining lesion and should be accompanied by appropriate antituberculous chemotherapy. Accounts of bone and joint involvement are numerous, but the orthopedic surgeon must also be aware of the soft-tissue manifestations of tuberculosis and the indications for surgery. We report on an immunocompromised patient who presented with a rare case of scrofuloderma of the lower extremity, which was treated with wide resection.     

Geographical distribution of tuberculosis notifications in national surveys of England and Wales in 1988 and 1993: report of the Public Health Laboratory Service/British Thoracic Society/Department of Health Collaborative Group

BACKGROUND—The geographical distribution oftuberculosis in England and Wales and changes since 1983 were examinedusing data from the 1988 and 1993 national surveys of tuberculosis notifications.
METHODS—Notification rates for England and Walesin 1988 and 1993 were calculated for geographical areas using Officefor National Statistics (ONS) mid year population estimates. Those forthe standard regions and the Greater London boroughs were calculated for the main ethnic groups. Those for the counties and localauthorities were calculated for all ethnic groups combined. These werecompared using data from the 1983 national survey as a baseline.
RESULTS—Wide regional variations innotification rates persist with Greater London having the highestrates. Rates in the ethnic group from the Indian subcontinent (ISC)were high in all regions, whilst those of the white ethnic group variedfourfold. Twenty seven of the 33 London boroughs showed increased ratesin 1993 compared with 1988. In general, those local authority areaswith high rates had high proportions of notifications in individuals ofISC ethnic origin, emphasising the continuing important contribution ofethnic minority groups to local tuberculosis rates. The number of local authority areas with notification rates four times the national averageincreased, but the number of areas with low or zero rates increasedeven more.
CONCLUSIONS—The distribution of tuberculosis inEngland and Wales continues to vary markedly by geographical area. Thedistribution is becoming increasingly polarised with a growth in thenumber of areas with very high rates of notifications and a greaterincrease in the number of areas with very few notifications. Patientsfrom ethnic minorities continued to contribute a substantial andincreasing proportion of all reported tuberculosis cases in mostregions in 1988 and 1993. These findings have important implicationsfor the provision of tuberculosis services in England and Wales.