Evaluation of tuberculosis diagnostics in children: 1. Proposed clinical case definitions for classification of intrathoracic tuberculosis disease. Consensus from an expert panel

There is a critical need for improved diagnosis of tuberculosis in children, particularly in young children with intrathoracic disease as this represents the most common type of tuberculosis in children and the greatest diagnostic challenge. There is also a need for standardized clinical case definitions for the evaluation of diagnostics in prospective clinical research studies that include children in whom tuberculosis is suspected but not confirmed by culture of Mycobacterium tuberculosis. A panel representing a wide range of expertise and child tuberculosis research experience aimed to develop standardized clinical research case definitions for intrathoracic tuberculosis in children to enable harmonized evaluation of new tuberculosis diagnostic technologies in pediatric populations. Draft definitions and statements were proposed and circulated widely for feedback. An expert panel then considered each of the proposed definitions and statements relating to clinical definitions. Formal group consensus rules were established and consensus was reached for each statement. The definitions presented in this article are intended for use in clinical research to evaluate diagnostic assays and not for individual patient diagnosis or treatment decisions. A complementary article addresses methodological issues to consider for research of diagnostics in children with suspected tuberculosis.     

Prevalence, awareness, treatment, and control of hypertension among Canadian adults with diabetes, 2007 to 2009

Background

Prior national surveys suggested that treatment and control of hypertension were poor in individuals with diabetes. Using measured blood pressures, we estimated prevalence, awareness, treatment, and control of hypertension between 2007 and 2009 among Canadians with diabetes and sought to determine whether a treatment gap still exists for individuals with diabetes.

Methods

Using data from cycle 1 of the Canadian Health Measures Survey, estimates of hypertension prevalence, awareness, treatment, and control were described and compared between individuals with and without self-reported diabetes.

Results

Three-quarters of individuals reporting diabetes also had hypertension; of these, 89% (95% confidence interval [CI], 80%-98%) were aware, 88% (95% CI, 81%-94%) were treated, and 56% (95% CI, 45%-66%) were controlled to < 130/80 mm Hg. Among those treated with pharmacotherapy, 39% (95% CI, 31%-48%) were using monotherapy, 29% (95% CI, 18%-40%) were taking 2 medications, and 31% (95% CI, 22%-39%) were taking 3 or more medications; control to < 130/80 mm Hg was achieved by 63% (95% CI, 53%-74%). Among those treated, individuals with diabetes were significantly less likely to be treated to their recommended target (< 130/80 mm Hg) compared with individuals without diabetes (< 140/90 mm Hg; odds ratio_adjusted 0.3; 95% CI, 0.2-0.6).

Conclusions

Hypertension treatment and control among people with diabetes have improved in Canada during the past 2 decades. Nonetheless, nearly half of people with diabetes are above the treatment target. Health care professionals should continue to increase their efforts in supporting patients with diabetes in achieving blood pressure control, with emphasis on lifestyle management and pharmacotherapy.     

Transmission Dynamics of Extended-Spectrum β-lactamase-Producing Enterobacteriaceae in the Tertiary Care Hospital and the Household Setting

Background.?Studies about transmission rates of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in hospitals and households are scarce. Methods.?Eighty-two index patients with new carriage of ESBL-producing Escherichia coli (ESBL-Ec; n?=?72) or ESBL-producing Klebsiella pneumoniae (ESBL-Kp; n?=?10) and their hospital (n?=?112) and household (n?=?96) contacts were studied prospectively from May 2008 through September 2010. Isolates were phenotypically and molecularly characterized (sequencing of bla genes, repetitive extragenic palindromic polymerase chain reaction, pulse-field gel electrophoresis, and multilocus sequence typing). Transmission was defined as carriage of a clonally-related ESBL producer with identical bla(ESBL) gene(s) in the index patient and his or her contact(s). Results.?CTX-M-15 was the most prevalent ESBL in ESBL-Ec (58%) and ESBL-Kp (70%) in the index patients. Twenty (28%) ESBL-Ec isolates were of the hyperepidemic clone ST131. In the hospital, transmission rates were 4.5% (ESBL-Ec) and 8.3% (ESBL-Kp) and the incidences of transmissions were 5.6 (Ec) and 13.9 (Kp) per 1000 exposure days, respectively. Incidence of ESBL-Kp hospital transmission was significantly higher than that of ESBL-Ec (P?相似文献   

Variation in reported neonatal group B streptococcal disease incidence in developing countries

Group B Streptococcus (GBS) is a leading cause of neonatal sepsis in developed countries. Its burden in the developing world is less clear. Studies reporting neonatal GBS disease incidence from developing countries were identified from 5 literature databases. Studies were assessed with respect to case finding and culture methods. Only 20 studies were identified. The GBS incidence ranged 0-3.06 per 1000 live births with variation within and between geographic regions. All but 1 study identified GBS cases within a hospital setting, despite the potential for births in the community. Possible case under-ascertainment was only discussed in 2 studies. A higher GBS incidence was reported when using automated culture methods. Prospective, population-based surveillance is urgently needed in developing countries to provide an accurate assessment of the neonatal GBS disease burden. This will be crucial for the design of interventions, including novel vaccines, and the understanding of their potential to impact mortality from neonatal sepsis.     

Anti-<Emphasis Type="Italic">Saccharomyces cerevisiae</Emphasis> (ASCA) and anti-endomysial antibodies in spondyloarthritis

Spondyloarthritis (SpA) are diseases with increased gut inflammation. To search for (anti-Saccharomyces cerevisiae) ASCA IgA, ASCA IgG, and anti-endomysial antibodies (EmA-IgA) in a cohort of 70 patients with SpA, we found 18.6% (13/70) positive for IgA-ASCA in the SpA group and 3/57 (5.2%) in the control group (P = 0.031). ASCA IgG and EmA-IgA were found at the same frequency in SpA and controls. No relationship of ASCA IgA positivity could be established with disease activity (measured by ESR, C-reactive protein, and BASDAI), presence of uveitis, or peripheral arthritis neither with functional status measured by BASFI. SpA patients present an increase in the IgA-ASCA positivity without any relationship to disease activity, functional index, clinical profile or the presence of HLA-B27. There is no evidence of higher prevalence of EmA-IgA in SpA patients in the studied sample.     

Explained variance for blood gases in a population with COPD

Introduction: Variation of blood gas levels in chronic obstructive pulmonary disease (COPD) patients has not been extensively reported and there is limited knowledge about predictors of chronic respiratory failure in COPD patients. Objectives: The aim of this study was to identify predictors of hypoxemia, hypercapnia and increased alveolar‐arterial oxygen difference in COPD patients. We hypothesized that prediction of arterial blood gases will be improved in multivariate models including measurements of lung function, anthropometry and systemic inflammation. Methods: A cross‐sectional sample of 382 Norwegian COPD patients, age 40–76, Global Initiative for Chronic Obstructive Lung Disease stage II–IV, with a smoking history of at least 10 pack‐years, underwent extensive measurements, including medical examination, arterial blood gases, systemic inflammatory markers, spirometry, plethysmography, respiratory impedance and bioelectrical impedance. Possible predictors of arterial oxygen (PaO₂), arterial carbon dioxide (PaCO₂) and alveolar‐arterial oxygen difference (AaO₂) were analyzed with both bivariate and multiple regression methods. Results: We found that various lung function measurements were significantly associated with PaO2, PaCO₂ and AaO₂. In addition, heart rate and Fat Mass Index were predictors of PaO₂ and AaO₂, while heart failure and current smoking status were associated with PaCO₂. The explained variance (R²) in the final multivariate regression models was 0.14–0.20. Conclusions: With a wide assortment of possible clinical predictors, we could explain 14–20% of the variation in blood gas measurements in COPD patients. Please cite this paper as: Saure EW, Eagan TML, Jensen RL, Voll‐Aanerud M, Aukrust P, Bakke PS and Hardie JA. Explained variance for blood gases in a population with COPD. Clin Respir J 2012; 6: 72–80.     

Characterization of P2x1 purinoreceptors on rat platelets: effect of clopidogrel

This study aimed to determine the binding characteristics of [³H]α,β-Me-ATP, a specific ligand of the P2x1 receptors to rat platelets, and to investigate the effect of clopidogrel, a thienopyridine compound which has been found to selectively inhibit ADP-induced platelet aggregation and adenylyl cyclase ex vivo . Binding of [³H]α,β-Me-ATP to rat platelets was time-dependent and saturable. Scatchard analysis of the saturation binding data indicated that [³H]α,β-Me-ATP bound to one population of specific binding sites with high affinity ( K _D  =  23.6 ± 1.6 n m ; B _max = 690 ± 24 fmole/10⁸cells) ( n= 3). Unlabelled α,β-Me-ATP as well as 2-MeS-ADP and ADP competitively inhibited the specific binding of [³H]α,β-Me-ATP with IC₅₀ values of 19.0 ± 6.6, 103 ± 20 and 1120 ± 80 n m respectively ( n= 3). Other nucleotide analogues such as ATP, ATP-γS, UTP and GTP also antagonized [³H]α,β-Me-ATP binding. When administered orally (10 mg/kg, p.o.), clopidogrel inhibited ADP- or 2-MeS-ADP-induced platelet aggregation but did not affect the binding of [³H]α,β-Me-ATP to rat platelets ex vivo. In vitro , α,β-Me-ATP did not induce the aggregation or shape change of rat platelets and did not interfere with ADP-induced platelet aggregation.     

Redesigning Primary Care Processes to Improve the Offering of Mammography: The Use of Clinic Protocols by Nonphysicians

OBJECTIVE: To develop, within the framework of continuous quality improvement, new processes for offering mammography and determine whether protocols executed completely by nonphysicians would increase mammography utilization. DESIGN: A prospective follow-up study with patients from an intervention clinic and two control clinics. SETTING: Three general internal medicine clinics in a large, urban teaching hospital in Detroit, Michigan. PATIENTS/PARTICIPANTS: A total of 5,934 women, aged 40 through 75 years, making 16,546 visits to one of the clinics during the study period (September 1, 1992, through November 31, 1993). INTERVENTION: Medical assistants and licensed practical nurses in the intervention clinic were trained to identify women due for screening mammography, and to directly offer and order a mammogram if patients agreed. MEASUREMENTS AND MAIN RESULTS: Patients were considered up-to-date with screening if they had a mammogram within 1 year (if age 50-75) or 2 years (if age 40-49) prior to the visit or a mammogram within 60 days after the visit. The proportion of visits each month in which a woman was up-to-date with mammography was calculated using computerized billing records. Prior to the intervention, the proportion of visits in which women were up-to-date was 68% (95% confidence interval [CI] 63%, 73%) in the intervention clinic and 66% (95% CI 61%, 71%) in each of the control clinics. At the end of the evaluation, there was an absolute increase of 9% (95% CI 2%, 16%) in the intervention clinic, and a difference of 1% (95% CI -5%, 7%) in one of the control clinics and -2% (95% CI -3%, 5%) in the other. In the intervention clinic, the proportion of visits in which women were up-to-date with mammography increased over time and was consistent with a linear trend (p = .004). CONCLUSIONS: Redesigning clinic processes to make offering of mammography by medical assistants and licensed practical nurses a routine part of the clinic encounter can lead to mammography rates that are superior to those seen in physicians' usual practice, even when screening levels are already fairly high. Physicians need not be considered the sole, or even the primary, member of the health care team who can effectively deliver some preventive health measures.     

Is there a role for glycosuria testing in sub-Saharan Africa?

BACKGROUND: With increasing urbanization and westernization, rates of diabetes in sub-Saharan Africa (sSA) are likely to rise. Early detection and intervention plays an important role in delaying development of complications. In sSA in particular there is need for an affordable, reliable, safe, feasible test to avert human suffering and exhausting already stressed health facilities. METHODS: Data from two large community-based studies were used to assess the value of glycosuria testing in the detection of diabetes in adults in a sub-Saharan country. A first study (A) tested participants for glycosuria by dipstick; if positive, fasting capillary glucose was measured. A later study (B) measured glucose concentration in venous blood 2 h after a 75-g glucose load; if glycaemia was > or = 10 mmol/l, urine was tested for glycosuria. RESULTS: The positive predictive value of glycosuria for a diagnosis of diabetes (fasting glucose > or = 6.7 mmol/l) was 48%. Sensitivity was 64% (57% if a 2-h-value > or = 10 mmol/l was used as gold standard). Sensitivity was higher among overweight and/or hypertensive subjects, among elderly people in the urban area, and among subjects with higher blood glucose levels. Extrapolated specificity was 99.7%, and the likelihood ratio 190. CONCLUSIONS: Glycosuria testing can identify a considerable number of undiagnosed diabetic patients when specially targeted at high-risk groups (obese, hypertensive, or elderly people). Dipstick glycosuria testing is an appropriate, safe, feasible test for sSA, where the prevalence of diabetes is expected to increase considerably in the near future.