Disminución de la tuberculosis osteoarticular en España entre 1997 y 2018

Background and objectiveOsteoarticular tuberculosis represents 2-5% of the manifestations of tuberculosis. The objective was to calculate the incidence and describe the epidemiological characteristics of patients with osteoarticular tuberculosis who received hospital care in Spain between 1997-2018.MethodsA retrospective study was conducted of patients treated with osteoarticular tuberculosis in Spanish hospitals between 1997 and 2018, using the data from the Minimum Basic Data Set at hospital discharge, using the ICD-9-CM and ICD-10 codes.Results5710 patients with osteoarticular tuberculosis were detected over the 22 years in Spain. The mean annual incidence for the period was 6 cases per million inhabitants (95% CI 5.58-6.30). There was a significant difference between the mean annual incidence per million inhabitants of the first period (1997-2007) of 6.95 and that of the second (2008-2018) of 5.35 (p < .001).ConclusionsThe incidence of osteoarticular tuberculosis in Spain is low, has reduced over 22 years and predominates in men.     

The epidemiology of the primary systemic vasculitides in northwest Spain: implications of the Chapel Hill Consensus Conference definitions

OBJECTIVE: To assess the epidemiology of the primary systemic vasculitides (PSV) in a well-defined population of southern Europe over a 14-year period using the Chapel Hill Consensus Conference (CHCC) definitions. METHODS: The case records of all patients 15 years or older with vasculitis diagnosed between January 1988 and December 2001 at a single reference hospital in the Lugo region of northwest Spain were reviewed. Incidence rates were age- and sex-adjusted to the European standard population. Patients were classified as having PSV according to the CHCC definitions. RESULTS: Fifty-four Lugo residents (29 men) fulfilled the CHCC definitions for PSV. The mean age was 60.7 +/- 13.5 years (men: 61.0 +/- 13.4; women: 60.4 +/- 13.8 years). The overall annual incidence of PSV was 13.07/million (95% confidence interval [95% CI] 8.89-19.22). PSV were slightly more common in men. The age-specific incidence showed a clear increase with age. A peak in the 55-64 year age group for the whole group of patients with PSV was observed (34.9/million; 95% CI 28.6-42.6). Nonrandom periodical peaks of incidence every 3 years were only observed when the group of PSV was considered as a whole (P = 0.040). The annual incidence was 2.95/million (95% CI 1.44-6.05) for Wegener's granulomatosis (WG) and 7.91/million (95% CI 4.74-13.20) for microscopic polyangiitis (MPA) (P = 0.035). None of the patients with Churg Strauss syndrome (n = 4) lived in a rural area. CONCLUSION: Our observations support an increasing incidence of PSV with age. In patients from northwest Spain defined by the CHCC definitions, MPA is more common than WG.     

Systemic sclerosis in northwestern Spain: a 19-year epidemiologic study

To investigate the epidemiology of systemic sclerosis (SSc) in southern Europe, we assessed the incidence, prevalence, clinical spectrum, and survival of patients diagnosed with SSc in the Lugo region of northwestern Spain. Between January 1988 and December 2006, SSc was diagnosed in 78 Lugo residents according to the criteria proposed by LeRoy and Medsger and/or the 1980 American College of Rheumatology (ACR) preliminary criteria for the classification of SSc. However, only 44 (56.4%) of the 78 patients fulfilled the 1980 ACR criteria for the classification of SSc. The mean age at the time of disease diagnosis was 59.8 +/- 13.3 years. Twenty-three (29.5%) met definitions for diffuse SSc (dSSc), and 55 (70.5%) for limited SSc (lSSc). Patients with lSSc had a longer disease duration before the diagnosis (10.2 +/- 12.0 yr) than those with dSSc (3.7 +/- 3.2yr) (p < 0.001). Based on the criteria proposed by LeRoy and Medsger and/or the 1980 ACR criteria for the classification of SSc, the overall age- and sex-adjusted annual incidence rate over the 19-year study period was 2.3 (95% confidence interval [CI], 1.6-2.5) per 100,000 population aged 15 yr and older (women: 3.5 [95% CI, 2.3-3.9]; men: 1.0 [95% CI, 0.5-1.4]; p < 0.001). Using only the 1980 ACR criteria for SSc, the total annual-adjusted incidence rate was 1.2 (95% CI, 0.9-1.6) per 100,000 population aged 15 years and older (women: 1.8 [95% CI, 1.2-2.5]; men: 0.7 [95% CI, 0.3-1.2]; p < 0.001). The incidence increased significantly in individuals aged 45 years or older. The overall incidence rates of SSc increased over the length of the study (p for trend in the total incidence < 0.001). This was mainly due to a progressive increase of SSc in women between 1993 and 2002. By December 31, 2006, the overall age-adjusted SSc prevalence in the Lugo region of patients who met the criteria proposed by LeRoy and Medsger and/or the 1980 ACR criteria was 27.7 (95% CI, 21.1-35.84) per 100,000 population aged 15 years and older. Cardiopulmonary complications were the leading cause of death (13 of 20 cases). Compared with that in the general population, the probability of survival in patients with SSc was significantly reduced (p < 0.001).The current study establishes a baseline estimate of the incidence and clinical spectrum of SSc in northwestern Spain. According to our results, the incidence and prevalence of SSc in northwestern Spain are similar to those found in Greece and some regions of the United States. Our data confirm a reduced probability of survival in patients with SSc.     

Systemic lupus erythematosus in northwestern Spain: a 20-year epidemiologic study

To further investigate the epidemiology of systemic lupus erythematosus (SLE) in southern Europe, we assessed the incidence, prevalence, clinical spectrum of the disease, flares, and survival of patients diagnosed with SLE in the Lugo region of northwestern Spain. Between January 1987 and December 2006, 150 Lugo residents were diagnosed as having SLE according to the 1982 American College of Rheumatology criteria for the classification of SLE. Women outnumbered men (127 [84.7%] vs. 23 [15.3%]). The mean age at the time of disease diagnosis was 46.1 ± 19.6 years. The mean follow-up from the time of disease diagnosis was 7.8 ± 4.5 years. The age- and sex-adjusted annual incidence rate over the 20-year study period was 3.6 (95% confidence interval [CI], 3.0-4.2) per 100,000 population aged 15 years and older. The overall annual incidence rate over the 20-year study period in women (5.9/100,000 population aged ≥ 15 yr; 95% CI, 4.9-7.0) was higher than in men (1.1/100,000 population aged ≥ 15 yr; 95% CI, 0.7-1.7) (p < 0.001). By December 31, 2006, the overall age-adjusted SLE prevalence in the Lugo region for patients who fulfilled at least 4 of 1982 American College of Rheumatology criteria was 17.5 per 100,000 population aged 15 years and older (95% CI, 12.6-24.1). Prevalence in women (29.2/100,000 population aged ≥ 15 yr; 95% CI, 20.0-40.7) was higher than in men (5.8/100,000 population aged ≥ 15 yr; 95% CI, 2.0-12.0). The most frequent clinical manifestation was arthritis. As reported in population-based studies on SLE patients of European descent, renal disease was observed in only 27.3% of the patients. The rate of flares was 0.084/year. A younger age and the presence of nephritis at the time of disease diagnosis were associated with the development of flares during the follow-up of Lugo patients. Compared with the general population the probability of survival in patients with SLE was significantly reduced (p = 0.04). In conclusion, the present study establishes a baseline estimate of the incidence and clinical spectrum of SLE in northwestern Spain. According to our results, the incidence of SLE in northwestern Spain is slightly higher than that reported in most European regions. Patients with SLE from northwestern Spain have a later average age onset and a lower frequency of nephritis than in the African-American population. However, our data show a reduced probability of survival in Spanish patients with SLE.     

Giant cell arteritis in northwestern Spain: a 25-year epidemiologic study

To continue our investigation of the epidemiology of giant cell arteritis (GCA) in southern Europe, we assessed the potential presence of trends, peaks, and fluctuations in the incidence of this vasculitis over a 25-year period in the Lugo region of northwestern Spain. We also sought to determine whether changes in the clinical spectrum of the disease existed. From 1981 to 2005, biopsy-proven GCA was diagnosed in 255 Lugo residents. The age- and sex-adjusted annual incidence rate was 10.13 (95% confidence interval [CI], 8.93-11.46) per 100,000 population aged 50 years and older. The mean age +/- SD at the time of diagnosis was 75.0 +/- 6.9 years. The annual incidence rate in women (10.23; 95% CI, 8.60-12.08) was slightly greater than that in men (9.92; 95% CI, 8.19-11.89) (p = 0.15). The annual incidence rate increased with advancing age up to a maximum of 23.16 (95% CI, 19.52-27.28) in the 70-79 year age-group. A progressive increase in the incidence was observed from 1981 through 2000 (p = 0.001). However, the age- and sex-adjusted incidence rate for biopsy-proven GCA in the Lugo region did not show peaks in the annual incidence of GCA. Likewise, we observed no seasonal pattern for the diagnosis of the disease. Visual ischemic manifestations and irreversible visual loss were observed in 57 (22.4%) and 32 (12.5%) of the 255 patients, respectively. A negative trend manifested by a progressive decline in the number of patients with visual ischemic manifestations (p = 0.021) or permanent visual loss (p = 0.018) was found over the 25-year period of study. The decline in the frequency of visual manifestations of GCA could not be attributed to a shorter delay to diagnosis, as no significant differences were observed when the delays to diagnosis in the 5 consecutive 5-year periods were compared. In conclusion, the current study confirms a progressive increase in the incidence of biopsy-proven GCA in northwestern Spain, and suggests that there has been a change in the clinical spectrum of the disease.     

The changing pattern of tuberculosis and HIV co-infection in immigrants and Spaniards in the last 20 years

OBJECTIVES: To evaluate the impact of immigration on tuberculosis (TB)-HIV co-infection in Spain in a prospective cohort of HIV patients. METHODS: Among 7761 HIV patients, we evaluated 1284 with at least one episode of TB between 1987 and 2006. Variables were compared between immigrants and Spaniards. RESULTS: Incidence of TB decreased from 20 to five cases per 100 patient-years in 2006 (P<0.01) and was always higher in immigrants than in Spaniards. The proportion of immigrants increased, reaching almost 50% of both new cases of HIV and TB-HIV co-infection in 2006. In 34.4% of patients, TB and HIV infection were diagnosed within the same year; simultaneous diagnosis was more frequent in immigrants (83.3%vs. 16.7%, P<0.001). Mortality was associated independently with age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01-1.05], TB diagnosis before 1996 (HR 2.6, 95% CI 1.8-3.6), use of highly active antiretroviral treatment (HR 0.494, 95% CI 0.37-0.66) and CD4 cell count at TB diagnosis (HR 0.996, 95% CI 0.995-0.997). CONCLUSIONS: Immigrants have a major impact on the incidence of TB in HIV patients, slowing down the decreasing trend in Spain. Simultaneous diagnosis of the co-infection in immigrants reveals a need to intensify HIV case finding in immigrants in Spain.     

Incidence and Prevalence of Children's Diffuse Lung Disease in Spain

BackgroundChildren's diffuse lung disease, also known as children's Interstitial Lung Diseases (chILD), are a heterogeneous group of rare diseases with relevant morbidity and mortality, which diagnosis and classification are very complex. Epidemiological data are scarce. The aim of this study was to analyse incidence and prevalence of chILD in Spain.MethodsMulticentre observational prospective study in patients from 0 to 18 years of age with chILD to analyse its incidence and prevalence in Spain, based on data reported in 2018 and 2019.ResultsA total of 381 cases with chILD were notified from 51 paediatric pulmonology units all over Spain, covering the 91.7% of the paediatric population. The average incidence of chILD was 8.18 (CI 95% 6.28–10.48) new cases/million of children per year. The average prevalence of chILD was 46.53 (CI 95% 41.81–51.62) cases/million of children. The age group with the highest prevalence were children under 1 year of age. Different types of disorders were seen in children 2–18 years of age compared with children 0–2 years of age. Most frequent cases were: primary pulmonary interstitial glycogenosis in neonates (17/65), neuroendocrine cell hyperplasia of infancy in infants from 1 to 12 months (44/144), idiopathic pulmonary haemosiderosis in children from 1 to 5 years old (13/74), hypersensitivity pneumonitis in children from 5 to 10 years old (9/51), and scleroderma in older than 10 years old (8/47).ConclusionsWe found a higher incidence and prevalence of chILD than previously described probably due to greater understanding and increased clinician awareness of these rare diseases.     

Diagnosis of diabetic peripheral neuropathy among patients with type 1 and type 2 diabetes in France, Italy, Spain, and the United Kingdom

AIMS: The objective of this study was to describe the proportion and characteristics of patients with type 1 and type 2 diabetes diagnosed with diabetic peripheral neuropathy (DPN) in France, Italy, Spain, and the United Kingdom (UK). METHODS: A cross-sectional survey was administered to general practitioners and diabetes specialists. Existing physicians' records were used to quantify the frequency of DPN diagnoses, and notes from patients' medical charts were used to characterize symptoms. RESULTS: The average number of physicians per country was 41 (range of 34-49). The proportion of diabetes patients diagnosed with DPN ranged from 9.6% (95% CI, 7.1-12.2) in Spain to 23.1% (95% CI, 15.4-30.7) in Italy. Of 913 DPN study patients, 55.0% were male, and 78.5% had type 2 diabetes. Mean age was 64.5+/-12.5 years. A DPN diagnosis was based primarily on symptoms. Approximately 27% of patients had no documented neurological examination. "Prickling" was the most common DPN symptom recorded in France, Italy, and Spain, and "numbness" was the most common in the UK. CONCLUSIONS: Country-specific estimates of DPN diagnosis may reflect clinical management of diabetes and DPN. A substantial number of diagnoses were not associated with a record of a neurological examination.     

47例多发骨结核临床分析

目的 探讨多发骨结核临床特点。方法 总结1987年7月～2003年7月16年间住院的多发骨结核患者，对其影像、治疗等临床特点进行研究。结果 发现多发骨结核患者47例，约占骨结核患者总数的3％。其中病变仅位于脊柱者20例（42．6％），仅位于关节者9例（19．2％），有18例同时累及关节及脊柱（38.3％）。2例患者结核杆菌培养阳性。结论 多发骨结核多发于青壮年，以脊柱及负重大关节为常见部位；根据发病部位将多发骨结核分为三个类型。并对多发骨结核定义进行了补充；影像技术联合应用是诊断多发骨结核最理想的手段；多发骨结核的化疗时间应足够，且应注意耐药问题。     

Thermovision diagnosis of tuberculosis of the spine and large joints

A comprehensive study was carried out in 95 patients with different forms and stages of osteoarticular tuberculosis by using the thermographic diagnostic technique. The patients' age was 17 to 76 years. The study was undertaken to define the capacities of thermography for differential diagnosis of osteoarticular tuberculosis from noninflammatory disease of the skeleton and to evaluate the efficiency of treatment in phthisiorthopedic patients. The study has provided evidence for that thermography has great capacities to diagnose a specific inflammatory skeleton lesion and to evaluate the efficiency of treatment, which allows one not to carry out expensive and radiation load-carrying X-ray studies in some cases.     

Geographic variations in prevalence and underdiagnosis of COPD: results of the IBERPOC multicentre epidemiological study

OBJECTIVES: To ascertain the prevalence, diagnostic level, and treatment of COPD in Spain through a multicenter study comprising seven different geographic areas. Design and participants: This is an epidemiologic, multicenter, population-based study conducted in seven areas of Spain. A total of 4,035 men and women (age range, 40 to 69 years) who were randomly selected from a target population of 236,412 subjects participated in the study. INTERVENTIONS: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed, followed by a bronchodilator test when bronchial obstruction was present. RESULTS: The prevalence of COPD was 9.1% (95% confidence interval [CI], 8.1 to 10.2%), 15% in smokers (95% CI, 12.8 to 17.1%), 12.8% in ex-smokers (95% CI, 10.7 to 14.8%), and 4.1% in nonsmokers (95% CI, 3.3 to 5.1%). The prevalence in men was 14.3% (95% CI, 12.8 to 15. 9%) and 3.9% in women (95% CI, 3.1 to 4.8%). Marked differences were observed between sexes in smoking; the percentage of nonsmokers was 23% in men and 76.3% in women (p<0.0001). The prevalence of COPD varied among the areas, ranging from 4.9% (95% CI, 3.2 to 7.0%) in the area of the lowest prevalence to 18% (95% CI, 14.8 to 21.2%) in the area of the highest. There was no previous diagnosis of COPD in 78.2% of cases (284 of 363). Only 49.3% of patients with severe COPD, 11.8% of patients with moderate COPD, and 10% of patients with mild COPD were receiving some kind of treatment for COPD. Multivariate analysis showed that individuals had a higher probability of having received a previous diagnosis of COPD if they lived in urban areas, were of male gender, were > 60 years old, had higher educational levels, had > 15 pack-year smoking history, or had symptoms of chronic bronchitis. CONCLUSIONS: COPD is a very frequent disease in Spain, and presents significant geographic variations and a very low level of previous diagnosis and treatment, even in the most advanced cases.     

Drug-resistant tuberculosis in subjects included in the Second National Survey on Antituberculosis Drug Resistance in Porto Alegre, Brazil,

OBJECTIVE:

To describe the prevalence of multidrug-resistant tuberculosis (MDR-TB) among tuberculosis patients in a major Brazilian city, evaluated via the Second National Survey on Antituberculosis Drug Resistance, as well as the social, demographic, and clinical characteristics of those patients.

METHODS:

Clinical samples were collected from tuberculosis patients seen between 2006 to 2007 at three hospitals and five primary health care clinics participating in the survey in the city of Porto Alegre, Brazil. The samples were subjected to drug susceptibility testing. The species of mycobacteria was confirmed using biochemical methods.

RESULTS:

Of the 299 patients included, 221 (73.9%) were men and 77 (27.3%) had a history of tuberculosis. The mean age was 36 years. Of the 252 patients who underwent HIV testing, 66 (26.2%) tested positive. The prevalence of MDR-TB in the sample as a whole was 4.7% (95% CI: 2.3-7.1), whereas it was 2.2% (95% CI: 0.3-4.2) among the new cases of tuberculosis and 12.0% (95% CI: 4.5-19.5) among the patients with a history of tuberculosis treatment. The multivariate analysis showed that a history of tuberculosis and a longer time to diagnosis were both associated with MDR-TB.

CONCLUSIONS:

If our results are corroborated by other studies conducted in Brazil, a history of tuberculosis treatment and a longer time to diagnosis could be used as predictors of MDR-TB.     

Diagnosed diabetic retinopathy in France, Italy, Spain, and the United Kingdom

AIM: The objective of this study was to describe the proportion and characteristics of patients diagnosed with diabetic retinopathy (DR) in France, Italy, Spain, and the United Kingdom (UK). METHODS: To estimate the proportion of patients with type 1 and type 2 diabetes diagnosed with DR, we conducted a cross-sectional survey of general practitioners in each country using physician records. In addition, diabetes specialists were recruited in Italy and Spain. We extracted data from the medical notes of a sample of DR patients to characterize DR severity and clinical characteristics. RESULTS: The average number of physicians per country was 41 (range: 34-49). The proportion of diagnosed DR ranged from 10.3% (95% CI, 6.7-14.0%) in Spain to 19.6% (95% CI, 16.0-23.1%) in the UK. Of 752 DR patients studied, 53.9% were male; mean age (+/-SD) was 64.2+/-12.8 years. Consistently across countries, mild non-proliferative DR was the most common severity level of diagnosed DR. Proliferative DR (PDR) ranged from 19.7% (France) to 31.5% (UK). Diabetic macular oedema was reported in approximately 10% of patients. Hypertension (73.1%), dyslipidemia (63.2%), and neuropathy (52.1%) were the most common co-morbidities. CONCLUSIONS: Country-specific prevalence of diagnosed DR may reflect clinical management of diabetes, healthcare systems, or record-keeping accuracy. Across countries, up to 30% of DR patients had a diagnosis of PDR, which could suggest that patients are diagnosed only when their disease is advanced.     

177例儿童骨关节结核的临床特征分析

目的 了解骨关节结核患儿的临床特点,为提出防治策略提供参考。方法 收集2013—2017年四川大学华西医院收治的177例骨关节结核患儿的临床资料,对其临床特点(包括年收治患儿例数、性别及年龄分布、结核病病灶部位、患者来源及地区)进行统计分析。结果 2013—2017年,四川大学华西医院收治的177例骨关节结核患儿中,四川省内患儿143例;平均年收治患儿35.4例;男111例,女66例,男∶女=1.68∶1;年龄1~14岁,平均(6.4±3.6)岁,其中幼儿及学龄前期(1~6岁)患儿占56.5%(100/177),学龄期(7~12岁)患儿占37.3%(66/177),12岁以上患儿占6.2%(11/177)。儿童骨关节结核发生部位依次为髋关节(59例)、脊柱(54例)、膝关节(42例)、踝关节(10例)。凉山彝族自治州、甘孜藏族自治州、阿坝藏族自治州及四川省内其他地区骨关节结核患儿例数分别占我院收治四川省内骨关节结核患儿总数的50.3%(72/143)、13.3%(19/143)、11.2%(16/143)和25.2%(36/143)。结论 四川大学华西医院收治的四川省内骨关节结核患儿以凉山彝族自治州、甘孜藏族自治州及阿坝藏族自治州儿童居多,是儿童骨关节结核早期防治的重点区域。且患病儿童中低龄儿童较多,是预防和筛查的重点人群。     

Incidence of elbow involvement in rheumatoid arthritis. A 15 year endpoint study

OBJECTIVE: To evaluate the incidence of involvement and cause of destruction of humeroulnar (HU) and humeroradial (HR) joints in a prospectively followed cohort of 74 patients with seropositive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup standard anteroposterior and lateral radiographs of 148 elbow joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: Erosive involvement (Larsen grade 2) was observed in 75/148 (51%) elbows in 45/74 (61%) patients; 30 patients had bilateral and 15 unilateral involvement. The incidence of mild erosions (Larsen grade 2) was 49/148 (33%), and severe erosions (Larsen 3-5) 26/148 (18%). The 13 most severely involved (Larsen grade 4-5) joints were seen in 8 (11%) patients. Erosions were most often observed on the capitellum (64 joints) and the lateral epicondyle (58 joints) of the humerus (AP view) or on the olecranon of the ulna (52 joints). The Larsen score (0-100) for peripheral joints correlated significantly with the elbow joint Larsen grade on both sides: right, r = 0.53 (95% CI 0.34 to 0.68); left, r = 0.53 (95% CI 0.34 to 0.68). CONCLUSION: After 15 years more than half of the elbows and almost 2 of 3 patients with RA showed definite involvement of the elbow joint. Erosions were most often located on the capitellum and the lateral epicondyle of the humerus or the olecranon of the ulna. Severe destruction was most often bilateral.     

Correlates of the disability index of the health assessment questionnaire: a measure of functional impairment in systemic sclerosis.

OBJECTIVE: To evaluate functional impairment in systemic sclerosis (SSc) patients with diffuse cutaneous scleroderma at the time of entry into a trial of a therapeutic intervention (D-penicillamine). METHODS: The 20-item Disability Index of the Health Assessment Questionnaire (HAQ-DI) was administered to 134 patients as they entered a multicenter trial of high-dose versus low-dose D-penicillamine. All patients had diffuse SSc of < 18 months' duration. SSc patients who had severe organ system involvement and recent renal crisis and who were receiving prednisone > 10 mg/day were excluded from entry. Logistic regression modeling was used to examine the relationship of HAQ-DI scores to SSc skin and organ system involvement. Odds ratios (OR) and 95% confidence intervals (95% CI) were used to estimate effects. RESULTS: The mean (+/-SD) HAQ-DI score at entry was 1.04 +/- 0.67. Fifty-three percent of patients had HAQ-DI scores > or = 1.0 (signifying moderate-to-severe functional impairment). Multivariate logistic regression demonstrated that impaired fist closure > or = 23 mm (OR 4.24, 95% CI 1.68-10.70), reduced handspread < or = 175 mm (OR 4.5, 95% CI 1.80-11.24), joint tenderness count > or = 1.0 (OR 2.93, 95% CI 1.16-7.40), age > or = 43 years (OR 2.44, 95% CI 1.01-5.95), platelet count > or = 330,000/mm3 (OR 2.30, 95% CI 0.96-5.57), and female sex (OR 2.43, 95% CI 0.77-7.73) were the most important correlates of HAQ-DI scores > or = 1.0. CONCLUSION: Increased HAQ-DI scores at baseline were correlated with reduced fist closure, reduced hand-spread, elevated platelet count, presence of tender joints, older age, and female sex. The most important contributor to functional impairment was hand dysfunction. Even within the first 18 months after SSc onset, moderate-severe functional impairment (HAQ-DI scores > or = 1.0) was frequent (53%) in this group of diffuse SSc patients. In early diffuse SSc, the self-administered HAQ-DI is therefore a valuable assessment of function that correlates with objective physical and laboratory measures of SSc disease involvement. Abnormal HAQ-DI scores may support patient claims of functional impairment, help to focus physician attention on implementing measures to reduce functional impairment, and be useful in reflecting the disease course over time.     

Diagnostic yield of adenosine deaminase in bronchoalveolar lavage

Adenosine deaminase (ADA) activity rises in various body fluids in patients with tuberculosis. A prospective study was conducted to determine the diagnostic value of ADA activity in bronchoalveolar lavage. Between March 2001 and February 2003, 148 patients were enrolled in our study, mean age 55.6 years (SD 14.6), and a male to female ratio of 2.4:1. The mean duration of symptoms was 66.2 days. All patients were either sputum-smear negative for AFB or failed to produce sputum. The final diagnosis resulted in three patient groups: 43 with pulmonary tuberculosis, 70 malignancy, and 35 miscellaneous causes. The mean ADA activity in the bronchoalveolar lavage for the pulmonary tuberculosis, malignancy, and miscellaneous causes groups was 8.98 (95% CI, 3.79-14.17), 7.63 (95% CI, 4.12-11.14), and 11.61 U/l (95% CI, 3.59-19.62), respectively. No difference was detected in the ADA level in the pulmonary tuberculosis vs other groups (p=0.56, one-way ANOVA). A high level of ADA activity was found in non-tuberculous conditions such as bronchogenic carcinoma, pulmonary hemosiderosis, chronic pneumonia with empyema thoracis and chronic myeloid leukemia. We concluded that ADA activity in the bronchoalveolar lavage was not clearly diagnostic of smear-negative pulmonary tuberculosis. Early diagnosis required histopathology of biopsied transbronchial specimens obtained by fiberoptic bronchoscopy.     

Prevalence,incidence, survival,and disease characteristics of systemic sclerosis in a large US population

OBJECTIVE: To estimate the prevalence, incidence, survival, and disease characteristics of systemic sclerosis (SSc) in the Detroit tricounty area. METHODS: A census of SSc cases for the period 1989-1991 was conducted in the Detroit area, using multiple sources for case identification. Diagnoses were verified by medical record review. Capture-recapture analysis was used to estimate the total SSc population. Cases of localized scleroderma (morphea and linear disease) were excluded. RESULTS: Based on 706 verified cases of SSc, prevalence was initially estimated to be 242.0 cases per million adults (95% confidence interval [95% CI] 213-274), with an annual incidence of 19.3 new cases per million adults per year (95% CI 12.4-30.2). Capture-recapture analysis, based on the degree of overlap of verified cases among multiple sources, resulted in a revised prevalence estimate of 276 cases per million adults (95% CI 245-310). Sex- and race-specific prevalence estimates were significantly higher for women than for men, and for blacks than for whites. The average age at diagnosis was significantly younger for blacks than for whites. Compared with white patients, black patients were almost twice as likely to have diffuse disease (prevalence proportion ratio 1.86, 95% CI 1.48-2.35). Median survival was approximately 11 years. Factors negatively affecting survival included male sex (hazard ratio 1.81, 95% CI 1.29-2.55) and older age at diagnosis (hazard ratio 1.04, 95% CI 1.03-1.05). CONCLUSION: This study establishes baseline estimates of SSc occurrence and characteristics in a large US cohort consisting primarily of black adults and white adults. These data should facilitate research regarding the role of geographic, ethnic, racial, and environmental factors for this disease in comparison populations.     

Pulmonary tuberculosis presenting as community-acquired pneumonia

OBJECTIVE AND BACKGROUND: The aims of this study were to investigate the frequency of Mycobacterium tuberculosis as a cause of community-acquired pneumonia (CAP) requiring hospitalization in Malaysia, and to define the clinical features of pulmonary tuberculosis (PTB) that distinguish it from non-TB CAP. METHODS: A prospective study was performed on consecutive non-immunocompromised patients aged 12 years and older, who were hospitalized for CAP. RESULTS: Of a total of 346 patients hospitalized for CAP, the aetiological agent was identified in 163 patients (47.1%). M. tuberculosis was isolated in 17 patients (4.9%). Multivariate analysis revealed that the following features were significantly associated with culture-positive PTB: duration of symptoms of more than 2 weeks before hospital admission (odds ratio (OR) 25.10; 95% confidence interval (CI) 4.63-136.05; P<0.001), history of night sweats (OR 5.43; 95% CI 1.10-26.79; P=0.038), chest radiograph showing upper lobe involvement (OR 8.23; 95% CI 1.59-42.53; P=0.012) or cavitary infiltrates (OR 19.41; 95% CI 2.94-128.19; P=0.002), total white blood cell count on admission of 12x10(9)/L or less (OR 6.28; 95% CI 1.21-32.52; P=0.029) and lymphopenia (OR 4.73; 95% CI 1.08-20.85; P=0.040). CONCLUSION: Mycobacterium tuberculosis was not an uncommon cause of CAP requiring hospitalization in Malaysia. A longer duration of symptoms, history of night sweats, upper lobe involvement, cavitary infiltrates, lower total white blood cell count and lymphopenia were predictive of PTB.     

Epidemiology of Wegener's granulomatosis in northern Norway

OBJECTIVE: To determine if changes in the incidence, prevalence, and clinical presentation of Wegener's granulomatosis (WG) have occurred in the stable population of northern Norway during a 15-year period. METHODS: We performed a retrospective cohort study using hospital discharge records from all 11 hospitals in the region and the databases of the 2 pathology departments in the area. Only patients fulfilling the American College of Rheumatology 1990 criteria for WG were included in the study, and demographic and clinical data at diagnosis were recorded. Incidence, point prevalence, and period prevalence rates were estimated for three 5-year periods. RESULTS: Fifty-five patients (62% male) with a median age at diagnosis of 50 years (range 10-84 years) fulfilled the inclusion criteria. The annual incidence/ million population increased from 5.2 (95% confidence interval [95% CI] 2.7-9.0) during 1984-1988 to 12.0 (95% CI 8.0-17.3) during 1994-1998. The point prevalence/million increased from 30.4 (95% CI 16.6-51.0) to 95.1 (95% CI 69.1-129.0). The highest incidence rate occurred in men ages 65-74 years. There were no significant period differences in age, first organ involved, delay of diagnosis, or disease activity, but fewer patients had malaise and renal insufficiency during the earliest time period. No seasonal variation in the onset of WG was present, although we noted a pattern of annual fluctuation. CONCLUSION: The prevalence of WG has tripled in northern Norway over the last 15 years. While more efficacious therapy may explain part of this increase, we also found a significant trend toward increased incidence over that period. The incidence rate over the last 5 years is the highest reported so far, while the clinical presentation has remained unchanged.