HIV testing among tuberculosis patients in the era of antiretroviral therapy: a population-based study in Brazil.

SETTING: Rio de Janeiro, Brazil, a city with 29862 cases of tuberculosis (TB) reported between January 1995 and June 1998. OBJECTIVES: To evaluate the counseling and testing practices for human immunodeficiency virus (HIV) infection among TB patients, and to identify the patient characteristics associated with HIV screening as antiretroviral therapy was introduced. DESIGN: Cross-sectional study of patients with TB who were reported to the health department and who initiated anti-TB treatment. The main outcome measure was screened versus not screened for HIV. RESULTS: The proportion of TB patients who received HIV screening increased from January 1995 through June 1998 (P < 0.001). Among young adults aged 20-49 years with TB, the independent predictors of HIV screening were a diagnosis of both pulmonary and extrapulmonary TB (odds ratio [OR] = 2.4, 95% confidence interval [CI] 2.1-2.8); TB meningitis (OR = 13.5, 95%CI 6.5-31.5); disseminated TB (OR = 8.2, 95%CI 5.3-12.9); lymphatic TB (OR = 5.6, 95%CI 4.7-6.6); and male sex (OR = 1.4, 95%CI 1.3-1.6). Patients with newly diagnosed TB who were women, lived in a low income neighborhood (OR = 0.7, 95%CI, 0.6-0.7), and sought TB treatment in their own residential neighborhood (OR = 0.3, 95%CI 0.3-0.4) were less likely to receive HIV counseling and testing. CONCLUSION: Health care providers in Rio de Janeiro selectively offered HIV counseling and testing to persons they perceived to be at risk for HIV and those with advanced stages of TB. HIV counseling and testing should be expanded and offered to all TB patients.     

Tolerability of anti-tuberculosis treatment and HIV serostatus.

SETTING: Tuberculosis (TB) is frequent in human immunodeficiency virus (HIV) infected patients, but its treatment is hampered by adverse events and paradoxical reactions. OBJECTIVE: To examine the impact of HIV infection and other factors on the risk and spectrum of adverse events related to anti-tuberculosis treatment in a prospective cohort study conducted between January 2003 and August 2004. RESULTS: Of 105 patients treated for TB, 30 were HIV-infected. The overall incidence of adverse events was 122.5 +/- 18.5 per 100 patient-years (py) and the incidence of severe adverse events was 45.2 +/- 11.3/100 py. Age >50 years (OR 2.2, 95%CI 1.01-4.8, P = 0.046) and HIV infection (OR 3.9, 95%CI 2.1-7.5, P < 0.001) were independently associated with a higher risk of adverse events. Hepatitis (30.5/100 py) and neuropathy (28.6/100 py) were the most frequent adverse events. Hepatitis C virus infection was associated with hepatitis (OR 4.2, 95%CI 1.2-15.0, P = 0.028) and neuropathy with HIV infection (OR 3.8, 95%CI 1.1-13.7, P = 0.040). CONCLUSION: Adverse reactions to anti-tuberculosis drugs are frequent. HIV infection and age >50 years are factors associated with such reactions, while hepatitis C virus infection is a risk factor for hepatitis.     

Predictors of development and outcome in patients with acute respiratory distress syndrome due to tuberculosis.

OBJECTIVE: To study the predictors of development and determinants of outcome in patients with acute respiratory distress syndrome (ARDS) due to tuberculosis (TB). METHODS: Retrospective case-control study of demographic, clinical and laboratory data of hospitalised adult patients with active TB. RESULTS: Of 2733 TB patients treated during 1980-2003, 29 (1.06%; 1.21 patients/year; mean age 31.6 +/- 10.9 years; 16 males) developed ARDS (cases). Seven had pulmonary TB and 22 had miliary TB (MTB); 298 (mean age 32.0 +/- 14.2 years; 110 males) who did not develop ARDS constituted controls. Presence of MTB (OR 4.6, 95%CI 1.2-17.8; P = 0.02), duration of illness beyond 30 days at presentation (OR 177.9, 95%CI 39-811.7; P < 0.001), absolute lymphocyte count < 1625/ mm3 (OR 4.5, 95%CI 1.1-19.3; P = 0.04) and serum ALT > 100 IU (OR 15.7, 95%CI 3.0-81.1, P < 0.001) were independent predictors of ARDS development. Twelve cases died (41.4%). Patients with APACHE II score >18; those with APACHE II score <18 in the presence of hyponatraemia and PaO2/FIO2 ratio <108.5 were likely to die. CONCLUSIONS: In patients with TB, prolonged illness, MTB, absolute lymphocytopaenia and elevated ALT are independently associated with ARDS development. APACHE II score, serum sodium and PaO2/FIO2 ratio are determinants of outcome.     

Genetic variants of interferon regulatory factor 5 associated with chronic hepatitis B infection

AIM To investigate possible effects of IRF5 polymorphisms in the 3' UTR region of the IFR5 locus on susceptibilityto hepatitis B virus(HBV) infection and progression of liver diseases among clinically classified Vietnamese patients.METHODS Four IFR5 SNPs(rs13242262 A/T, rs77416878 C/T, rs10488630 A/G, and rs2280714 T/C) were genotyped in clinically classified HBV patients [chronic hepatitis B(CHB). n = 99; liver cirrhosis(LC), n = 131; hepatocellular carcinoma(HCC), n = 149] and in 242 healthy controls by direct sequencing and Taq Man realtime PCR assays. RESULTS Comparing patients and controls, no significant association was observed for the four IFR5 variants. However, the alleles rs13242262 T and rs10488630 G contributed to an increased risk of liver cirrhosis(LC vs CHB: OR = 1.5, 95%CI: 1.1-2.3, adjusted P = 0.04; LC vs CHB: OR = 1.7, 95%CI: 1.1-2.6, adjusted P = 0.019). Haplotype IRF5*TCGT constructed from 4 SNPs was observed frequently in LC compared to CHB patients(OR = 2.1, 95%CI: 1.2-3.3, adjusted P = 0.008). Haplotype IRF5*TCAT occurred rather among CHB patients than in the other HBV patient groups(LC vs CHB: OR = 0.4, 95%CI: 0.2-0.8, adjusted P = 0.03; HCC vs CHB: OR = 0.3, 95%CI: 0.15-0.7, adjusted P = 0.003). The IRF5*TCAT haplotype was also associated with increased levels of ALT, AST and bilirubin. CONCLUSION Our study shows that IFR5 variants may contribute as a host factor in determining the pathogenesis in chronic HBV infections.     

Persistent Abnormal Coronary Flow Reserve in Association with Abnormal Glucose Metabolism Affects Prognosis in Acute Myocardial Infarction

Objectives: To evaluate changes in coronary flow reserve (CFR) over time after acute myocardial infarction (AMI) in relation to left ventricular (LV) function and glucometabolic state and prognostic implication of abnormal CFR. Methods: 154 patients with first time AMI had a comprehensive assessment of the LV function and CFR at baseline and after 3 months of follow‐up. CFR was measured noninvasively in left descending artery by transthoracic echocardiography. Results: Eighty‐five patients had an abnormal CFR at baseline. At baseline patients with persistently normal CFR had higher wall motion score index (WMI), ejection fraction (EF) and S′ compared with patients with abnormal CFR. At follow‐up patients with persistently normal CFR had higher WMI, EF, S′ and lower end‐systolic diameter compared with patients with abnormal microcirculation. Performing univariate logistical regression baseline CFR (P = 0.004), S′ (P = 0.045) and abnormal glucose metabolism (P = 0.001) were predictors of a decreased CFR at 3 months of follow‐up. In multivariate analyses abnormal glucose metabolism (OR: 5.3; 95%CI: 1.9–14.4; P = 0.001) remained a predictor of decreased CFR at follow‐up, furthermore baseline CFR (OR: 0.5; 95%CI: 0.25–0.94; P = 0.032) and S′ (OR: 0.67; 95% CI: 0.47–0.94; P = 0.021) was predictors of decreased CFR. Finally, CFR was associated with a lower risk of cardiac events in patients with normal glucose metabolism (HR: 0.64; 95% CI: 0.22–1.9; P = 0.42) than in patients with abnormal glucose metabolism (HR: 2.9; 95% CI: 1.1–7.6; P = 0.03), suggesting significant effect modification (Pinteraction = 0.03). Conclusions: Abnormal glucose metabolism is associated with poorer recovery of microvascular integrity after AMI. In addition, there seem to exist a prognostic interaction between glucometabolic state and abnormal CFR. (Echocardiography 2011;28:210‐218)     

Meta-analysis on the association of TIRAP S180L variant and tuberculosis susceptibility

The missense variant S180L in TIRAP (Toll-interleukin-1 receptor domain-containing adaptor protein) gene is implicated in attenuating TLRs signal transaction and may affect individual response to Mycobacterium tuberculosis infection. Several studies investigated the association between TIRAP S180L and risk of tuberculosis (TB), but the results were controversial. In this study, we quantitatively synthesized nine studies relevant to the association between TIRAP S180L polymorphism and TB risk with total 6584 TB cases and 7294 controls using meta-analysis. We found that the variant allele Leu180 and heterozygous genotype Ser/Leu were not significantly associated with risk of TB (allelic OR = 0.99, 95%CI: 0.88-1.11; Ser/Leu vs Ser/Ser: OR = 0.99, 95%CI: 0.87-1.13) with heterogeneity P values > 0.05. In subgroup analysis, none of the significant associations were observed for S180L and TB risk in Africans (allelic OR = 0.58, 95%CI: 0.29-1.61; heterozygous OR = 0.65, 95%CI: 0.32-1.32) or Asians (allelic OR = 1.30, 95%CI: 0.97-1.74; heterozygous OR = 1.17, 95%CI: 0.84-1.65) or risk of pulmonary tuberculosis (PTB) (allelic OR = 0.92, 95%CI: 0.69-1.22; heterozygous OR = 0.98, 95%CI: 0.86-1.12). This meta-analysis indicates that TIRAP S180L polymorphism is unlikely to substantially contribute to TB susceptibility.     

Factors contributing to treatment success among tuberculosis patients: a prospective cohort study in Bangkok

SETTING: Chest Clinic, Ministry of Public Health and health care centres, Bangkok Metropolitan Administration. OBJECTIVE: To determine patient factors predicting successful tuberculosis (TB) treatment. DESIGN: A prospective cohort was conducted during May 2004 to November 2005. Newly diagnosed TB patients aged > or = 15 years were recruited after giving informed consent. Three sets of questionnaires were used to collect data from the patients three times. Data were also gathered from treatment cards. RESULTS: Of 1241 patients, 81.1% were successfully treated. Bivariate analysis indicated that patients' sex, education, occupation, level of knowledge about TB and adverse effects were associated with treatment success. Unconditional logistic regression analysis showed that females had a higher success rate than males (OR = 1.9, 95%CI 1.2-2.9). Patients with regular incomes had twice the likelihood of success of the unemployed (OR = 2.0, 95%CI 1.1-3.5). Patients with high knowledge levels were more likely to complete treatment (OR = 2.0, 95%CI 1.2-3.4), while those with adverse effects were less likely to adhere (OR = 0.6, 95%CI 0.4-0.9). CONCLUSION: The current low treatment success rate may be partly due to inadequate knowledge about TB among patients. Improvements in health education and early detection and management of adverse effects should be prioritised by the National Tuberculosis Programme.     

Computed tomography findings for predicting severe acute hepatitis with prolonged cholestasis

AIM: To evaluate the significance of computed tomography (CT) findings in relation to liver chemistry and the clinical course of acute hepatitis. METHODS: Four hundred and twelve patients with acute hepatitis who underwent enhanced CT scanning were enrolled retrospectively. Imaging findings were analyzed for the following variables: gallbladder wall thickness (GWT), arterial heterogeneity, periportal tracking, number and maximum size of lymph nodes, presence of ascites, and size of spleen. The serum levels of alanine aminotransferase, alkaline phosphatase, bilirubin, albumin, and prothrombin time were measured on the day of admission and CT scan, and laboratory data were evaluated every 2-4 d for all subjects during hospitalization. RESULTS: The mean age of patients was 34.4 years, and the most common cause of hepatitis was hepatitis A virus (77.4%). The mean GWT was 5.2 mm. The number of patients who had findings of arterial heterogeneity, periportal tracking, lymph node enlargement > 7 mm, and ascites was 294 (80.1%), 348 (84.7%), 346 (84.5%), and 56 (13.6%), respectively. On multivariate logistic regression, male gender [odds ratio (OR) = 2.569, 95%CI: 1.477-4.469, P = 0.001], toxic hepatitis (OR = 3.531, 95%CI: 1.444-8.635, P = 0.006), level of albumin (OR = 2.154, 95%CI: 1.279-3.629, P = 0.004), and GWT (OR = 1.061, 95%CI: 1.015-1.110, P = 0.009) were independent predictive factors for severe hepatitis. The level of bilirubin (OR = 1.628, 95%CI: 1.331-1.991, P < 0.001) and GWT (OR = 1.172, 95%CI: 1.024-1.342,P = 0.021) were independent factors for prolonged cholestasis in multivariate analysis. CONCLUSION: In patients with acute hepatitis, GWT on CT scan was an independent predictor of severe hepatitis and prolonged cholestasis.     

Characteristics of patients with delayed diagnosis of infectious pulmonary tuberculosis

OBJECTIVE: The aim of this study was to identify patient and disease characteristics associated with delayed diagnosis of infectious pulmonary tuberculosis (TB). METHODOLOGY: A retrospective analysis of 375 adult patients with culture-positive pulmonary TB and cough, treated at the Singapore Tuberculosis Control Unit (TBCU) in 2000, was carried out using data extracted from the TB notification registry and clinical records of the TBCU. Demographic, social, clinical and disease characteristics of patients with reported cough of duration less than, and exceeding, the median duration for the study population were compared. RESULTS: The median duration of cough reported at TB notification was 4 weeks (range, 1-156 weeks). By multivariate analysis, patients with cough > 4 weeks were more likely to be < 65 years old (adjusted odds ratio (OR), 1.8; 95% CI, 1.1-2.9; P = 0.02), of Chinese ethnicity (adjusted OR, 2.0; 95% CI, 1.2-3; P = 0.004), more likely to be sputum acid-fast bacilli smear-positive (adjusted OR, 1.7; 95% CI, 1.1-2.7; P = 0.016), and to have weight loss (adjusted OR, 2.6; 95% CI, 1.7-4; P < 0.01). CONCLUSION: Further studies are needed to identify the possible reasons for delayed diagnosis of TB among those < 65 years old, in the Chinese population in Singapore.     

Normal vitamin D levels are associated with spontaneous hepatitis B surface antigen seroclearance

AIM: To investigate a possible association between serum vitamin D levels and spontaneous hepatitis B surface antigen (HBsAg) seroclearance.METHODS: Fifty-three patients diagnosed with chronic inactive hepatitis B and spontaneous HBsAg seroclearance were followed up in two Israeli liver units between 2007 and 2012. This retrospective study reviewed medical charts of all the patients, extracting demographic, serological and vitamin D rates in the serum, as well as medical conditions and current medical therapy. Spontaneous HBsAg seroclearance was defined as the loss of serum HBsAg indefinitely. Vitamin D levels were compared to all patients who underwent spontaneous HBsAg seroclearance.RESULTS: Out of the 53 patients who underwent hepatitis B antigen seroclearance, 44 patients (83%) had normal levels of 25-hydroxyvitamin vitamin D compared to 9 patients (17%) who had below normal levels. Multivariate analysis showed that age (> 35 years) OR = 1.7 (95%CI: 1.25-2.8, P = 0.05), serum vitamin D levels (> 20 ng/mL) OR = 2.6 (95%CI: 2.4-3.2, P = 0.02), hepatitis B e antigen negativity OR = 2.1 (95%CI: 2.2-3.1, P = 0.02), low viral load (hepatitis B virus DNA < 100 IU/mL) OR = 3 (95%CI: 2.6-4.2, P = 0.01) and duration of HBsAg seropositivity (> 8 years) OR = 1.6 (95%CI: 1.15-2.6, P = 0.04) were also associated with spontaneous HBsAg seroclearance.CONCLUSION: We found a strong correlation between normal vitamin D levels and spontaneous HBsAg seroclearance.     

Risk factors for new onset diabetes mellitus after liver transplantation: A meta-analysis

AIM: To determine the risk factors for new-onset diabetes mellitus(NODM) after liver transplantation by conducting a systematic review and meta-analysis.METHODS: We electronically searched the databases of MEDLINE, EMBASE and the Cochrane Library from January 1980 to December 2013 to identify relevant studies reporting risk factors for NODM after liver transplantation. Two authors independently assessed the trials for inclusion and extracted the data. Discrepancies were resolved in consultation with a third reviewer. All statistical analyses were performed with the Rev Man5.0 software(The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios(OR) or weighted mean differences(WMD) with 95% confidence intervals(CIs) were calculated using either a fixed effects or a random effects model, based on the presence(I2 50%) or absence(I2 50%) of significant heterogeneity. RESULTS: Twenty studies with 4580 patients were included in the meta-analysis, all of which were retrospective. The meta-analysis identified the following significant risk factors: hepatitis C virus(HCV) infection(OR = 2.68; 95%CI: 1.92-3.72); a family history of diabetes(OR = 1.69, 95%CI: 1.09-2.63, P 0.00001); male gender(OR = 1.53; 95%CI: 1.24-1.90; P 0.0001); impaired fasting glucose(IFG; OR = 3.27; 95%CI: 1.84-5.81; P 0.0001); a family history of diabetes(OR = 1.69; 95%CI: 1.09-2.63; P = 0.02); use of tacrolimus(OR = 1.34; 95%CI: 1.03-1.76; P = 0.03) and body mass index(BMI)(WMD = 1.19, 95%CI: 0.69-1.68, P 0.00001). Other factors, such as hepatitis B virus infection and alcoholism, were not found to be associated with the incidence of NODM.CONCLUSION: The study showed that HCV infection, IFG, a family history of diabetes, male gender, tacrolimus and BMI are risk factors for NODM after liver transplantation.     

Lamivudine monotherapy for spontaneous severe acute exacerbation of chronic hepatitis B

BACKGROUND: Severe acute exacerbations of chronic hepatitis B virus (HBV) infection can spontaneously occur and rapidly progress to fatal hepatic failure. The purpose of the present paper was to identify factors that could influence the rapid progression of liver disease to hepatic failure, and assess the effects of lamivudine on serious disease. METHODS: Twenty-five patients with spontaneous severe acute exacerbation (accompanied by jaundice and coagulopathy) were consecutively treated with lamivudine. Their clinical outcomes were compared with those of 25 lamivudine-untreated patients, as historical controls. RESULTS: Six lamivudine-treated patients (24%)and seven controls (28%) rapidly developed hepatic failure. Lamivudine monotherapy did not significantly prevent progression to hepatic failure. Multivariate analysis identified baseline serum bilirubin >/=6 mg/dL (odds ratio [OR]: 5.61; 95% confidence interval [CI]: 1.66-21.61; P = 0.018), pre-existing cirrhosis (OR: 4.52; 95%CI: 1.26-30.42; P = 0.034), and baseline prothrombin time <40% (OR: 3.75; 95%CI: 1.03-43.86; P = 0.045) as independent determinants of the event. Of the aforementioned patients with hepatic failure, three lamivudine-treated patients (50%) and two controls (29%) survived (P > 0.15). However, lamivudine induced a sustained normalization of liver function and inhibited the development of cirrhosis in survivors. CONCLUSIONS: Lamivudine monotherapy conferred no significant protection against rapid progression of the disease to hepatic failure, but it resulted in long-term benefits. Lamivudine combined with other drugs could be more beneficial for patients with the aforementioned risk factors.     

Socio-economic determinants of knowledge and attitudes about tuberculosis among the general population of Metro Manila, Philippines.

SETTING: Five urban communities in Metro Manila with different socio-economic status. OBJECTIVE: To investigate general knowledge about tuberculosis (TB) and intended health-seeking behaviour for TB symptoms among the general population of Metro Manila, and how they are determined by socioeconomic factors. DESIGN AND METHOD: Subjects aged 18 years and over were interviewed in a cross-sectional survey. Data on TB knowledge and intended health-seeking behaviour were stratified by sex, age, educational background, occupation, average family income and place of residence. A TB knowledge score was constructed based on 10 selected questions. Multivariate analysis with standard logistic regression showed those factors that were independently correlated to understanding of the disease, and to attitudes in case of TB symptoms. The TB knowledge score was also analysed by TB information source. RESULTS: Completed surveys were obtained from 3970 subjects. They scored low in general knowledge about TB (3.64 +/- 1.67, range 0-10). A higher score was independently associated with college education (OR = 4.35, 95%CI 6.60-2.87, P < 0.0001). There was no significant difference in TB knowledge acquired through several sources. No intention of seeking health care and intention to self-treat in case of TB disease were significantly correlated to low family monthly income (OR = 7.10, 95%CI 8.25-6.11, P < 0.0001 and OR = 1.74, 95%CI 2.06-1.46, P < 0.0001, respectively). CONCLUSION: Socio-economic factors should be taken into account in the design of TB information campaigns and in prioritising public health interventions about TB.     

Incidence of and risk factors for severe liver toxicity in HIV-infected patients on anti-tuberculosis treatment.

OBJECTIVE: To assess the incidence and risk factors for severe liver toxicity in human immunodeficiency virus (HIV) infected patients on anti-tuberculosis treatment and the impact of patients' characteristics and concomitant medications instituted during the first week of antituberculosis treatment. METHODS: HIV-infected patients referred to six French hospitals between 1 January 1992 and 31 December 2004, with confirmed or 'presumptive' tuberculosis (TB). Liver toxicity was studied during the first 2 months of TB treatment. RESULTS: During the 12 years of the study period, 144 patients were enrolled. Severe liver toxicity developed in 15 (10.7%). The median time to development of liver toxicity was 14 days. In the univariate analysis, high baseline bilirubin levels (P = 0.004), CD4 cell counts between 50 and 100 cells/mm3 (P = 0.022) and the use of fluconazole (P = 0.0005) were associated with liver toxicity. In the multivariate analysis, independent risk factors were abnormal baseline alanine aminotransferase (ALT) (P = 0.028) and bilirubin levels (P = 0.033) and the use of fluconazole (P = 0.008). CONCLUSION: Severe liver toxicity is frequent, and occurs early in the course of anti-tuberculosis treatment. ALT and bilirubin levels should be closely monitored during the first month of treatment, especially in patients with high baseline ALT or bilirubin levels. We suggest caution when prescribing fluconazole and anti-tuberculosis drugs concomitantly, although this needs to be confirmed and further investigated.     

Risk factors associated with default among new pulmonary TB patients and social support in six Russian regions.

SETTING: Tuberculosis (TB) services in six Russian regions in which social support programmes for TB patients were implemented. OBJECTIVE: To identify risk factors for default and to evaluate possible impact of social support. METHODS: Retrospective study of new pulmonary smear-positive and smear-negative TB patients registered during the second and third quarters of the 2003. Data were analysed in a case-control study including default patients as cases and successfully treated patients as controls, using multivariate logistic regression modelling. RESULTS: A total of 1805 cases of pulmonary TB were enrolled. Default rates in the regions were 2.3-6.3%. On multivariate analysis, risk factors independently associated with default outcome included: unemployment (OR 4.44; 95%CI 2.23-8.86), alcohol abuse (OR 1.99; 95%CI 1.04-3.81), and homelessness (OR 3.49; 95%CI 1.25-9.77). Social support reduced the default outcome (OR 0.13; 95%CI 0.06-0.28), controlling for age, sex, region, residence and acid-fast bacilli (AFB) smear of sputum. CONCLUSION: Unemployment, alcohol abuse and homelessness were associated with increased default outcome among new TB patients, while social support for TB patients reduced default. Further prospective randomised studies are necessary to evaluate the impact and to determine the most cost-effective social support for improving treatment outcomes of TB in patients in Russia, especially among populations at risk of default.     

重庆市梁平县肺结核患者就诊延迟及其相关因素分析

目的了解重庆市梁平县肺结核患者就诊延迟情况,探索与就诊延迟相关的主要因素。方法从结核病信息管理系统导出重庆市梁平县2005--2012年登记的结核病患者的个案资料共计3365例,采用描述性分析就诊延迟率;采用秩和检验分析不同性别、年龄、职业、患者来源、登记类型的就诊延迟是否有差异,以P〈0．05为差异有统计学意义;采用logistic回归分析性别、年龄、职业、患者来源、登记类型是否与就诊延迟相关（P〈0．05为差异有统计学意义）。结果重庆市梁平县肺结核患者就诊延迟率为73．14％（2461／3365）,就诊延迟中位数为32d,有52．84％（1778／3365）的肺结核患者就诊延迟在1个月以上。职业、患者来源和登记类型与就诊延迟相关,农民就诊延迟高于其他职业（OR=1．513,95％CI=1．279～1．778,P〈0．05）;因症推荐患者就诊延迟高于转诊患者（OR=2．170,95％CI=1．798~2．618,P〈0．05）;复发患者就诊延迟高于新患者（OR=1．222,95％CI=0．9501．572,P〈0．05）。结论重庆市梁平县肺结核患者就诊延迟率高,就诊延迟与患者职业、来源和登记类型相关,建议采取综合有效措施,减少该地区的肺结核患者就诊延迟现象。     

HTLV-1 infection is frequent among out-patients with pulmonary tuberculosis in northern Lima, Peru.

SETTING: Tuberculosis (TB) and human T-lymphotropic virus 1 (HTLV-1) are frequent in Peru. The prevalence of HTLV-1 among Peruvian TB patients is unknown. OBJECTIVE: To determine the prevalence of HTLV-1, HTLV-2 and the human immunodeficiency virus (HIV) in out-patients with TB and to compare HTLV-1-infected patients with seronegative patients. DESIGN: Cross-sectional study including subjects aged 18-65 years diagnosed with smear-positive pulmonary TB at health centres in northern Lima from November 2004 to August 2005. HTLV and HIV screening was performed using enzyme-linked immunosorbent assay; HTLV-1 and HTLV-2 were confirmed using line immunoassay. RESULTS: There were 311 participants with a median age of 29 years; 173 (56%) were men. HTLV-1 prevalence was 5.8% (18/311, 95%CI 3.2-8.4) and HIV prevalence was 1.3% (4/304, 95%CI 0.4-3.3). HTLV-2 was not diagnosed. In comparison with HIV- and HTLV-seronegative patients, HTLV-1-infected subjects were older (median age 44 vs. 28, P < 0.001) and were more likely to have been born in the southern Andes (OR 4.4, 95%CI 1.6-11.9). They were also more likely to report a history of TB deaths in the family (OR 5.4, 95%CI 1.7-16.8) and had more sputum smear results graded as 3+ (OR 4.1, 95%CI 1.5-11.2). CONCLUSION: HTLV-1 screening among Peruvian TB patients is important. Because 3+ sputum smears are frequent and mortality is high among relatives, families of HTLV-1/TB-positive cases merit special attention.     

Current state and clinical outcome in Turkish patients with hepatocellular carcinoma

AIM To investigate clinical, etiological, and prognostic features in patients with hepatocellular carcinoma.METHODS Patients with hepatocellular carcinoma who were followed-up from 2001 to 2011 were included in the study. The diagnosis was established by histopathological and/or radiological criteria. We retrospectively reviewed clinical and laboratory data, etiology of primary liver disease, imaging characteristics and treatments. ChildPugh and Barcelona Clinic Liver Cancer stage was determined at initial diagnosis. Kaplan-Meier survival analysis was done to find out treatment effect on survival. Risk factors for vascular invasion and overall survival were investigated by multivariate Cox regression analyses. RESULTS Five hundred and forty-five patients with hepatocellular carcinoma were included in the study. Viral hepatitis was prevalent and 68 patients either had normal liver or were non-cirrhotic. Overall median survival was 16(13-19) mo. Presence of extrahepatic metastasis was associated with larger tumor size(OR = 3.19, 95%CI: 1.14-10.6). Independent predictor variables of vascular invasion were AFP(OR = 2.95, 95%CI: 1.38-6.31), total tumor diameter(OR = 3.14, 95%CI: 1.01-9.77), and hepatitis B infection( OR = 5.37, 95 % CI : 1.23-23.39). Liver functional reserve, tumor size/extension, AFP level and primary treatment modality were independent predictors of overall survival. Transarterial chemoembolization(HR = 0.38, 95%CI: 0.28-0.51) and radioembolization(HR = 0.36, 95%CI: 0.18-0.74) provided a comparable survival benefit in the real life setting. Surgical treatments as resection and transplantation were found to be associated with the best survival compared with loco-regional treatments(log-rank, P 0.001).CONCLUSION Baseline liver function, oncologic features including AFP level and primary treatment modality determines overall survival in patients with hepatocellular carcinoma.     

Determinants of drug-resistant tuberculosis: analysis of 11 countries.

SETTING: Eleven countries/territories. OBJECTIVES: Global information on the determinants of drug-resistant tuberculosis (TB) based on representative data is not available. We therefore studied the relationship between demographic characteristics, prior TB treatment, and human immunodeficiency virus (HIV) infection with anti-tuberculosis drug resistance. METHODS: Population-based representative data on new and previously treated patients with TB collected within an international drug resistance surveillance network. RESULTS: Of 9,615 patients, 8,222 (85.5%) were new cases of TB and 1,393 (14.5%) were previously treated cases. Compared with new cases, previously treated cases were significantly more likely to have resistance to one (OR = 2.5,95% CI 2.1-3.0; P < 0.001), two (OR = 4.6, 95%CI 3.7-5.6; P < 0.001), three (OR = 11.5, 95%CI 8.6-15.3; P < 0.001), and four (OR = 18.5, 95% CI 12.0-28.5; P < 0.001) drugs. An approximately linear increase in the likelihood of having multidrug-resistant tuberculosis (MDR-TB) was observed as the total time (measured in months) of prior anti-tuberculosis treatment increased (P < 0.001, chi2 for trend). In multivariate analysis, prior TB treatment for 6-11 months (OR = 7.6, 95% CI 2.6, 22.4; P < 0.001) and > or = 12 months (OR 13.7, 95% CI 4.5-41.6; P < 0.001), but not HIV positivity, was associated with MDR-TB. CONCLUSION: This study shows that prior but ineffective treatment is a strong predictor of drug resistance, and that HIV is not an independent risk factor for MDR-TB. The association between length of treatment and drug resistance may reflect longer treatment as a result of treatment failure in patients with drug resistance; it may also reflect irregular prior treatment for TB, leading to drug resistance.     

Clinical and laboratory features of disseminated histoplasmosis in HIV patients from Brazil

OBJECTIVES: To identify the main clinical and laboratory features of disseminated histoplasmosis (DH) in human immunodeficiency virus (HIV) patients and compare them with those of HIV patients with other opportunistic diseases. METHODS: Retrospective study of HIV patients comparing the clinical and laboratory data of patients with and without DH. Univariate and multivariate analyses were performed to verify the risk factors related to DH. RESULTS: In total, 378 HIV patients were included, 164 with DH and 214 with other opportunistic diseases. Acute renal failure, respiratory insufficiency and septic shock were more frequent in DH patients, who also had a higher mortality (32%vs. 14%, P < 0.001). Independent risk factors for DH were: acute renal failure [odds ratio (OR) 5.2; 95% confidence interval (CI) 3.2-8.5; P < 0.001], splenomegaly (OR 3.4; 95% CI 1.19-9.9; P < 0.001), respiratory insufficiency (OR 2.7 95% CI 1.5-5.0; P < 0.001), proteinuria (OR 2.7; 95% CI 1.3-5.2; P = 0.03), hypotension (OR 2.5; 95% CI 1.2-5.0; P = 0.008), hepatomegaly (OR 2.4; 95% CI 1.2-4.8; P = 0.01), cutaneous lesions (OR, 1.9; 95% CI 1.0-3.3; P = 0.02) and weight loss (OR 1.8; 95% CI 1.0-3.1; P = 0.03). CONCLUSION: Our results suggest that DH is a severe opportunistic disease with high mortality rate, which should be promptly recognized in order to provide early specific treatment.