Cost-effectiveness of rifampin for 4 months and isoniazid for 9 months in the treatment of tuberculosis infection.

The purpose of this study was to evaluate the cost-effectiveness of the strategy of controlling the contacts of tuberculosis patients with latent tuberculosis infection by means of treatment with rifampin for 4 months or isoniazid for 9 months. The cost was the sum of the cost of treating latent tuberculosis infection in all contacts plus the cost of treating tuberculosis in whom the disease was not avoided. The effectiveness was expressed as cases avoided. The efficacy adopted was 90 % for rifampin for 4 months and 93 % for isoniazid for 9 months. We carried out a sensitivity analysis for efficacies of rifampin for 4 months of 80 %, 75 %, 69 % and 65 %. Of the 1,002 patients studied, 139 were treated with rifampin for 4 months and 863 were treated with isoniazid for 9 months. The cost-effectiveness was 436,842.83/50 cases avoided with rifampin for 4 months and 692,164.42/40 cases avoided with isoniazid for 9 months. Rifampin for 4 months was dominant. In the sensitivity analysis, rifampin for 4 months was dominant for efficacies of 75 % or greater. The cost-effectiveness analysis favoured the use of rifampin for 4 months when its efficacy was 75 % or greater.

Large-scale real-life analysis of survival and usage of therapies in multiple myeloma.

Survival in multiple myeloma has improved significantly in recent years, especially in young patients. We reviewed the evolution of the survival of patients with MM in three groups based on age at MM diagnosis over three time periods between 1999 and 2020 at our 12 de Octubre Hospital institution (H12O). Then, to confirm our results, we used data from TriNetx, a global health research platform that includes patients from Europe to US. Finally, we analysed differences in the patterns of treatment between networks across the world. Kaplan‒Meier analysis was used to estimate survival probabilities, and between-group differences were tested using the log-rank test and hazard ratio. For patients from H12O, the median OS was 35.61, 55.59 and 68.67 months for the 1999-2009, 2010-2014 and 2015-2020 cohorts, respectively (p = 0.0001). Among all patients included in the EMEA network, the median OS was 20.32 months versus 34.75 months from 1999-2009 versus 2010-2014. The median OS from the 2010-2014 versus 2015-2020 time cohorts was 34.75 months versus 54.43 months, respectively. In relation to the US cohort, the median OS from before 2010 versus 2010-2014 was not reached in either time cohort and neither when comparing the 2010-2014 versus 2015-2019 time cohorts. Bortezomib is the most commonly used drug in the EMEA cohort, while lenalidomide is the most commonly used drug in the US cohort. This large-scale study based on real-world data confirms the previous finding that MM patients have increased their survival in the last two decades.

Impact of COVID-19 in patients with multiple myeloma based on a global data network.

The COVID-19 pandemic has represented a major cause of morbidity/mortality worldwide, overstressing health systems. Multiple myeloma (MM) patients show an increased risk for infections and they are expected to be particularly vulnerable to SARS-CoV-2 infection. Here we have obtained a comprehensive picture of the impact of COVID-19 in MM patients on a local and a global scale using a federated data research network (TriNetX) that provided access to Electronic Medical Records (EMR) from Health Care Organizations (HCO) all over the world. Through propensity score matched analyses we found that the number of new diagnoses of MM was reduced in 2020 compared to 2019 (RR 0.86, 95%CI 0.76-0.96) and the survival of newly diagnosed MM cases decreased similarly (HR 0.61, 0.38-0.81). MM patients showed higher risk of SARS-CoV-2 infection (RR 2.09, 1.58-2.76) and a higher excess mortality in 2020 (difference in excess mortality 9%, 4.4-13.2) than non-MM patients. By interrogating large EMR datasets from HCO in Europe and globally, we confirmed that MM patients have been more severely impacted by COVID-19 pandemic than non-MM patients. This study highlights the necessity of extending preventive measures worlwide to protect vulnerable patients from SARS-CoV-2 infection by promoting social distancing and an intensive vaccination strategies.

Ozone-induced foliar injury in saplings of Psidium guajava 'Paluma' in São Paulo, Brazil.

Psidium guajava 'Paluma' was evaluated under field conditions as a tropical bioindicator species of ozone (O(3)). Three exposures of 90 days each were performed (June 21, 2004-March 19, 2005). In each one of them, saplings of 'Paluma' (n=30) were exposed to ambient air at a site in São Paulo (Brazil) with high ozone concentrations, and in a greenhouse with charcoal-filtered air. Ozone-like visible foliar injuries were observed during the winter, spring and summer exposures, when AOT40 reached 6166ppbh, 3504ppbh and 4828ppbh, respectively. No injuries were observed in the plants kept under filtered air. The injuries consisted in red stippling on adaxial leaf surfaces. They did not cover the veins and appeared first in older leaves, becoming more intense as the exposure period increased. Injury incidence, severity, and the cumulative exposure threshold at injury onset varied among the exposure periods. AOT40 explained partly the incidence, severity and leaf injury index LII (r(2)=0.52, 0.39, 0.38, respectively, p=0.002). The results confirm the potential of the species as an O(3)-sensitive bioindicator.

[LASIK results of IntraLase femtosecond laser to correct myopia: efficacy, security and predictability]. / Resultados de LASIK realizado con láser de femtosegundo (IntraLase) para corrección de miopía: eficacia, predictibilidad y seguridad.

PURPOSE: To evaluate LASIK results obtained with the IntraLase femtosecond laser to correct myopia. METHODS: This was a prospective, single masked observer study. Flaps were created with the IntraLase femtosecond laser (FS). All laser procedures were performed by the same surgeon using the Technolas 217 excimer laser (Bausch & Lomb). We have analysed the uncorrected visual acuity (UCVA) at 1 day, 1 week, 1 month and 3 months after surgery and best spectacle-corrected visual acuity (BSCVA) after 3 months. RESULTS: 485 eyes with myopia were treated and their results evaluated. The mean preoperative sphere was of -3.9 D (SD 2.0) and a mean astigmatism of -0.9 D (SD 0.9) with BSCVA 1.1 (SD 0.1). The UCVA results were 0.94 (SD 0.1) at the first day postoperatively visit, 0.96 (SD 0.1) at first week, 1.00 (SD 0.1) at one month and 1.00 (SD 0.2) at 3 months. The refractive error at 3 months was -0.02 D (SD 0.3) and -0.1 D (SD 0.3) of myopia and astigmatism respectively. At 3 months 96.9% of eyes were within +/-1.00D and 93.6% of the eyes were within + 0.50 D. CONCLUSIONS: LASIK to correct myopia is a safe, effective and predictable procedure using IntraLase FS to create the flap.

[Evaluation of the efficacy of long term topical steroid treatment to prevent regression after hyperopic LASIK]. / Valoración de la eficacia de tratamiento corticoideo tópico prolongado para prevenir regresión en LASIK hipermetrópico.

PURPOSE: To evaluate the efficacy of long-term versus short-term steroid treatment in preventing regression after hyperopic LASIK. MATERIAL AND METHODS: This is a prospective single masked study. Hyperopic patients who were candidates for LASIK surgery were randomized to be treated with one week (topical dexametasone) in control group or one month (topical dexametasone the first week and topical fluormetalone the next three weeks) in study group. The three month postoperative manifest refraction was compared between the two groups. RESULTS: 105 eyes were included in each group. The mean preoperative spherical equivalent was 3.17 D SD 2.82 D (standard deviation) and 3.39 D SD 2.65 D in the study and control group, respectively (p=0.6). The final manifest refraction in the three-month postoperative visit was 0.62 D SD 0.68 D and 0.6 D SD 0.3 D in the study and control group respectively (p=0.6). CONCLUSIONS: Long-term topical steroid therapy does not appear to improve the refractive result in hyperopic LASIK.

[Thoracic wounds: review of 90 cases]. / Heridas torácicas: revisión de 90 casos.

Our aim in reviewing all cases of chest wounds (CW) treated in our unit to analyze their causes, clinical characteristics and treatment. We performed a retrospective study of all CW patients admitted and/or treated by us between January 1986 and August 1997, studying causes, history, number and type of wounds, location, the association of chest and non-chest lesions, treatment, complications and length of hospital stay. The 90 CW patients treated in our unit accounted for 10.6% of all CW patients admitted during the study period. Eighty-five (94.4%) were men and five were women (5.6%) and mean age was 33.87 years. Physical attack was the most common cause of CW, accounting for 74 cases (82.2%) and stab wounds (77 cases, 85.6%) were more common than gunshot wounds (13 cases, 14.4%). Sixty-one (67.%) were deep and most were to the left hemithorax (46 cases, 51.1%). Besides damage to skin and soft tissues of the chest wall, lesions most often affected the pleura (59 cases, 65.5%) and parenchyma (27 cases, 30%). Local treatment of the wound was sufficient for 31 patients (34.4%) but 29 (32.3%) also required drainage and 30 (33.3%) required surgery. Complications developed in 8 cases (8.9%) and one patient died while in surgery. Mean duration of hospital stay was 8.64 days. CW in our practice is seen most commonly in young men and is caused by physical aggression, usually involving knives. Most wounds are stabs, usually to the left hemithorax. The prognosis for firearm wounds is poorer. One third of patients require thoracic drains and another third require chest surgery in addition to local treatment of CW and other wounds. The patient's hemodynamic status was the parameter that indicated need for surgical treatment.

[Surgical treatment of pulmonary metastasis: survival study]. / Tratamiento quirúrgico de las metástasis pulmonares: estudio de supervivencia.

OBJECTIVE: To study the results of surgical treatment of pulmonary metastases in our department. PATIENTS AND METHODS: We retrospectively studied 44 patients undergoing surgery between 1986 and 1999 for complete resection of pulmonary metastases. Primary tumors had been eradicated, no metastasis to other organs was evident, and functional respiratory capacity was adequate. The patients were assigned to different prognostic groups based on the criteria of the International Registry of Lung Metastases. RESULTS: Forty-eight operations were performed on the 44 patients (21 men and 23 women) whose mean age was 58 years (31-74 years). The most frequent type of primary tumor was epithelial (82%); other types in order of frequency were sarcoma (9%), thyroid gland (4.4%), germ cell (2.2%) and melanoma (2.2%). The mean disease-free interval was 37.7 months (0.168) and the median was 30 months. A single site of metastasis was seen in 66.7% of the cases whereas 33.3% had multiple metastases (17.9% of them bilateral). Posterolateral thoracotomy was the surgical approach in over half the cases (66.7%). We performed wedge resections in 86.6% and lobectomies in 11.1%. Perioperative mortality was 4.4%. Mean survival was 70 months, with 87% alive at one year and 29% at 10 years. For group I (resectable, no risk factors; n = 13) survival was 100% at one year and 75% at 10 years. For group II (resectable, one risk factor; n = 16) the actuarial survival was 78% at one year and 12% at 10 years. For group III (resectable, two risk factors; n = 8), survival was 87% at one year, 62% at three years, 15% at four years and 0% at five years (Log-rank chi 2 9.8 [df = 2)], p = 0.0097). CONCLUSIONS: Surgical resection of pulmonary metastasis is a treatment and diagnostic procedure associated with low mortality and good survival. Prognostic grouping that takes into account number of metastases, disease-free interval and resectability correlates significantly with expected survival regardless of histological typing of the primary tumor.

[Tuberculin test responses of tuberculosis patients]. / La respuesta a la prueba de la tuberculina en enfermos tuberculosos.

OBJECTIVE: To determine the response of tuberculosis patients to tuberculin skin tests. METHOD: The results of skin tests used for initial assessment of tuberculosis patients in Catalonia were reviewed (Multicenter Tuberculosis Research Project). Negative skin tests were those with indurations < 5 mm; positive tests were those with indurations measuring > or = 5 mm. Individuals were classed as having or not having risk factors for developing tuberculosis and those without risk factors were classified by age, location and extension of tuberculosis. RESULTS: Negative skin tests were seen in 1,566 patients (23%). Negative tests were more common in patients with risk factors, significantly so in those undergoing immunosuppressant therapy (50%) or with HIV infection (61%). Negative tests were less prevalent in patients with no risk factors (13%) and, among them, in children (1%), in patients between 15 and 29 years of age (10%) or in those with non-pulmonary forms (10%). Negative tests were significantly more prevalent among patients 60 to 74 years of age (27%), those over 74 (44%), and those whose disease was pulmonary and extrapulmonary (26%) or disseminated (64%). No significant differences in induration size of positive skin tests were observed for patients with and without risk factors (including HIV infection or non-infection). A normal distribution of induration size was observed in all groups. CONCLUSIONS: A negative tuberculin skin test for initial assessment should be interpreted in function of the presence or absence of risk factors, age, location or extension of tuberculosis. When a skin test is positive, the response will be similar whether or not an immunodepressant factor is present.

[Multifocal inflammatory pseudotumor of the lung with good response to corticoids]. / Seudotumor inflamatorio multifocal del pulmón con buena respuesta a corticoides.

A 75-year-old woman was admitted to our hospital with persistent fever, productive cough and systemic symptoms of two months' duration. A chest film showed bilateral infiltration in the form of subpleural plaques with multiple satellite nodules in both lung fields. The biopsy specimens taken by thoracoscopy were compatible with inflammatory pulmonary pseudotumor. Lung resection was ruled out because the lesions were bilateral and corticosteroid treatment was instated. The clinical and radiologic response was excellent and the patient was asymptomatic after 30 months of low-dose corticoid therapy.

[Booster effect in elderly patients living in geriatric institutions]. / Efecto empuje en pacientes de la tercera edad residentes en instituciones geriátricas.

BACKGROUND: Tuberculinic response is weaker in elderly patients. To know the real tuberculinic reactivity in elderly patients living in geriatric institutions in Catalonia, Spain, and to reduce the probability of false negatives this study was carried out to detect the booster effect. METHODS: Three hundred forty-three individuals with a mean age of 81 +/- 6.5 years, residing in four geriatric centers within the Central Health Care Region of Catalonia, were studied. After performing the first Mantoux intradermoreaction this was repeated at one week in case of negativity. A third test was carried out after one more week on persistence of negativity. Qualitative study was carried out on cell immunity in those patients whose first Mantoux test was negative. RESULTS: The first Mantoux test was positive in 163 patients (47.5%) and the performance of the second and third test in cases of negativity of the previous test increased the number of positivities by 12.5% and 4.1%, respectively, up to a total of 220 patients (64%). In the patients who did not react to the first intradermoreaction and who preserved cell immunity a booster effect was obtained in 57 (52.8%). The prevalence of tuberculous infection in this group of elderly patients calculated in the group with preserved cell immunity was 81.2% while the morbidity of tuberculous disease in the positive cases in the Mantoux test was 1.8%. CONCLUSIONS: Given the high frequency of the booster effect in elderly people, systematic testing is recommended to investigate tuberculinic reactivity in patients who are initially negative on Mantoux intradermoreaction.

Smoking in tuberculosis patients increases the risk of infection in their contacts.

OBJECTIVE: To determine the risk of latent tuberculous infection (LTBI) among contacts of smokers with tuberculosis (TB). METHODS: A study was conducted to determine the prevalence of LTBI among contacts of TB cases aged >14 years in Catalonia, Spain. A survey was carried out for each TB case and their contacts. LTBI was diagnosed using the tuberculin skin test (≥5 mm). The risk of LTBI associated with smoking was determined by multi-variate logistic regression analysis, with adjusted odds ratio (aOR) and their 95% confidence intervals (CI). RESULTS: The smoking prevalence among TB cases was 40.7% (439/1079). The prevalence of LTBI among their contacts was 29.7% (2281/7673). It was higher among contacts of smoking index cases (35.3%) than among those of non-smokers (25.7%). Smoking was independently associated with an increased risk of LTBI among contacts (aOR 1.5, 95%CI 1.3-1.7), and was estimated to be responsible for 12.8% of infections. CONCLUSIONS: Index case smoking increases the risk of LTBI and should be systematically investigated. A reduction in smoking could lower the risk of infection substantially.

Is isoniazid for 6 months more cost-effective than isoniazid for 9 months?

SETTING: The optimal treatment for latent tuberculosis infection consists of isoniazid (H, INH) for 9-12 months. Although INH for 6 months (6H) is more cost-effective than the 12-month regimen, the cost-effectiveness of the 6H regimen and that of INH for 9 months (9H) have not been compared. OBJECTIVE: To compare the cost-effectiveness of treatment with 6H and 9H. METHODS: Cost-effectiveness was evaluated using the ratio of the cost of preventing one tuberculosis case using 6H vs. 9H. The cost was estimated as the product of the number of patients to be treated to prevent one case using 6H or 9H × the cost of 6H or 9H. RESULTS: A total of 1039 patients were studied. The number of patients that needed to be treated to prevent one case was 33 (95%CI 21-83) using 6H and 26 (95%CI 18-50) using 9H. The cost of 6H and 9H was respectively €444.34 and €578.26, and the cost ratio of preventing one case with 6H/9H was 0.98 (95%CI 0.6-1.5). CONCLUSIONS: The cost-effectiveness of treatment with 6H and 9H is similar.

[Excess mortality due to tuberculosis and factors associated to death in and annual cohort of patients diagnosed of tuberculosis]. / Exceso de mortalidad por tuberculosis y factores asociados a la defunción en una cohorte anual de enfermos diagnosticados de tuberculosis.

OBJECTIVE: To calculate excess mortality in an annual cohort of tuberculosis patients and study the factors associated with death. MATERIAL AND METHOD: Cases of tuberculosis reported in Catalonia (May 1996-April 1997). Patients were classified as completed treatment/cured (compliant), non-compliant, failures, transfers out and deaths. Excess mortality was defined as the ratio actual deaths/expected deaths (according to general mortality figures for Catalonia, May 1996-April 1997). Factors associated with death were determined by a comparative study of variables (demographic, substance abuse, comorbidity, tuberculosis-related disease) in deaths after diagnosis and survivors. Time from diagnosis to death was recorded. RESULTS: Patients included: 2,085. Patients classified as: completed treatment/cured (compliant), 1,406 (67.43 %); noncompliant, 165 (7, 91%); failures, 5 (0.24%); transfers out, 25 (1.21%); deaths, 133 (6.38%), 28 of which occurred before diagnosis and 105 after diagnosis. Insufficient data in medical record for classification, 351 (16.83%) patients. Excess mortality: 5.98 (95% CI: 4.96-7.0). Factors associated with death: treatment with non-standardized guidelines, 46%; OR: 10.3 (6.2-17.4); HIV infection, 40%; OR: 13.0 (6.6-25.8); age greater than 64 years, 40%; OR: 14.6 (3.0-69.8); alcoholism, 25%; OR: 2.0 (1.1-3.6); neoplasm, 16%; OR: 3.9 (1.8-8.6; renal failure, 8%; OR: 10.1 (3.1-32.3). The shortest time from diagnosis to death was in patients with only one risk factor, except for HIV infection, where the time passed was the longest observed. CONCLUSIONS: We found substantial excess mortality in tuberculosis patients. Death was associated with the efficacy of treatment, HIV coinfection, advanced age, alcoholism and the coexistence of neoplasms or renal failure.