Radiomics based on enhanced CT for differentiating between pulmonary tuberculosis and pulmonary adenocarcinoma presenting as solid nodules or masses.

PURPOSE: To investigate the incremental value of enhanced CT-based radiomics in discriminating between pulmonary tuberculosis (PTB) and pulmonary adenocarcinoma (PAC) presenting as solid nodules or masses and to develop an optimal radiomics model. METHODS: A total of 128 lesions (from 123 patients) from three hospitals were retrospectively analyzed and were randomly divided into training and test datasets at a ratio of 7:3. Independent predictors in subjective image features were used to develop the subjective image model (SIM). The plain CT-based and enhanced CT-based radiomics features were screened by the correlation coefficient method, univariate analysis, and the least absolute shrinkage and selection operator, then used to build the plain CT radiomics model (PRM) and enhanced CT radiomics model (ERM), respectively. Finally, the combined model (CM) combining PRM and ERM was established. In addition, the performance of three radiologists and one respiratory physician was evaluated. The areas under the receiver operating characteristic curve (AUCs) were used to assess the performance of each model. RESULTS: The differential diagnostic capability of the ERM (training: AUC = 0.933; test: AUC = 0.881) was better than that of the PRM (training: AUC = 0.861; test: AUC = 0.756) and the SIM (training: AUC = 0.760; test: AUC = 0.611). The CM was optimal (training: AUC = 0.948; test: AUC = 0.917) and outperformed the respiratory physician and most radiologists. CONCLUSIONS: The ERM was more helpful than the PRM for identifying PTB and PAC that present as solid nodules or masses, and the CM was the best.

The adding value of contrast-enhanced CT radiomics: Differentiating tuberculosis from non-tuberculous infectious lesions presenting as solid pulmonary nodules or masses.

Purpose: To compare the value of contrast-enhanced CT (CECT) and non-contrast-enhanced CT (NCECT) radiomics models in differentiating tuberculosis (TB) from non-tuberculous infectious lesions (NTIL) presenting as solid pulmonary nodules or masses, and develop a combine radiomics model (RM). Materials and methods: This study was a retrospective analysis of 101 lesions in 95 patients, including 49 lesions (from 45 patients) in the TB group and 52 lesions (from 50 patients) in the NTIL group. Lesions were randomly divided into training and test sets in the ratio of 7:3. Conventional imaging features were used to construct a conventional imaging model (IM). Radiomics features screening and NCECT or CECT RM construction were carried out by correlation analysis and gradient boosting decision tree, and logistic regression. Finally, conventional IM, NCECT RM, and CECT RM were used for combine RM construction. Additionally, we recruited three radiologists for independent diagnosis. The differential diagnostic performance of each model was assessed using the areas under the receiver operating characteristic curve (AUCs). Results: The CECT RM (training AUC, 0.874; test AUC, 0.796) outperformed the conventional IM (training AUC, 0.792; test AUC, 0.708), the NCECT RM (training AUC, 0.835; test AUC, 0.704), and three radiologists. The diagnostic efficacy of the combine RM (training AUC, 0.922; test AUC, 0.833) was best in the training and test sets. Conclusions: The diagnostic efficacy of the CECT RM was superior to that of the NCECT RM in identifying TB from NTIL presenting as solid pulmonary nodules or masses. The combine RM had the best performance and may outperform expert radiologists.

New Approaches in the Classification and Prognosis of Sign Clusters on Pulmonary CT Images in Patients With Multidrug-Resistant Tuberculosis.

Background: To date, radiographic sign clusters of multidrug-resistant pulmonary tuberculosis (MDR-TB) patients have not been reported. We conducted a study to investigate the classification and prognosis of sign clusters in pulmonary Computed Tomography (CT) images from patients with MDR-TB for the first time by using principal component analysis (PCA). Methods: The clinical data and pulmonary CT findings of 108 patients with MDR-TB in the Liupanshui Third Hospital were collected (from January 2018 to December 2020). PCA was used to analyze the sign clusters on pulmonary CT, and receiver operating characteristic (ROC) analysis was used to analyze the predictive value of the treatment outcome of MDR-TB patients. Results: Six cluster signs of MDR-TB were determined by PCA: nodules, infiltration, consolidation, cavities, destroyed lung and non-active lesions. Nine months after treatment, the area under the ROC curve (AUC) of MDR-TB patients with a cavity sign cluster was 0.818 (95% CI: 0.733-0.886), and the positive predictive value (PPV) and negative predictive value (NPV) of the treatment outcome were 79.6% (95% CI: 65.7-89.8%) and 72.9% (95% CI: 59.7-83.6%), respectively. Conclusion: PCA plays an important role in the classification of sign groups on pulmonary CT images of MDR-TB patients, and the sign clusters obtained from PCA are of great significance in predicting the treatment outcome.

Illustration of a number of atypical computed tomography manifestations of active pulmonary tuberculosis.

Tuberculosis is a serious public health challenge facing mankind and one of the top ten causes of death. Diagnostic imaging plays an important role, particularly for the diagnosis and treatment planning of tuberculosis patients with negative microbiology results. This article illustrates a number of atypical computed tomography (CT) appearances of pulmonary tuberculosis (PTB), including (I) clustered micronodules (CMNs) sign; (II) reversed halo sign (RHS); (III) tuberculous pneumatocele; (IV) hematogenously disseminated PTB with predominantly diffuse ground glass opacity manifestation; (V) hematogenously disseminated PTB with randomly distributed non-miliary nodules; (VI) PTB changes occur on the background of emphysema or honeycomb changes of interstitial pneumonia; and (VII) PTB manifesting as organizing pneumonia. While the overall incidence of PTB is decreasing globally, the incidence of atypical manifestations of tuberculosis is increasing. A good understanding of the atypical CT imaging changes of active PTB shall help the diagnosis and differential diagnosis of PTB in clinical practice.

Prevalence of Multidrug-Resistant Tuberculosis in Dalian, China: A Retrospective Study.

PURPOSE: Multidrug-resistant tuberculosis (MDR-TB) is the cause of serious health and economic burdens worldwide. The present study aimed to explore the initial and acquired drug-resistance rates among TB patients from 2012 to 2019 in Dalian, China. The effectiveness of MDR-TB prevention and control strategies were then evaluated. PATIENTS AND METHODS: Drug susceptibility testing (DST) was performed for 6429 diagnosed, culture-positive, Mycobacterium tuberculosis (MTB) strains, including 4661 new cases and 1768 previously treated cases. Descriptive statistics were employed to calculate the frequencies and percentages of TB strains, and the average annual growth rates (AAGRs) for each strain were calculated. The Chi-square test was applied to examine the significance of linear drug-resistance trends over time during the study period. RESULTS: Over the eight-year study period, the percentages of both initial (from 9.01% to 4.82%) and acquired (from 40.85% to 9.09%) MDR-TB cases decreased significantly, AAGRs of 8.55% and 19.32%, respectively. Among new and previously treated TB patients, significant downtrends were observed for the rates of both initial and acquired MDR-TB among young and middle-aged individuals (P < 0.05). Additionally, among both new and previously treated TB patients, the percentages of individuals with drug resistance against isoniazid (INH), rifampicin (RFP), ofloxacin (OFX), and amikacin (AMK) decreased significantly (P < 0.05) from 2012 to 2019 in Dalian, China. CONCLUSION: The initial and acquired multidrug resistance rates exhibited significantly decreasing trends from 2012 to 2019, suggesting that MDR-TB prevalence has been controlled effectively in Dalian, China. The MDR-TB epidemic was reversed in the short term by establishing feasible strategies for detection, diagnosis, treatment, and infection control.

Cut-off Points of Treatment Delay to Predict Poor Outcomes Among New Pulmonary Tuberculosis Cases in Dalian, China: A Cohort Study.

PURPOSE: Despite increasing literature on the association between treatment delay and outcomes, cut-off point (1 month or median) selection in almost all studies for treatment delay is too subjective. This study explored more scientific cut-off points of treatment delay for poor treatment outcomes and death at the clinical level. PATIENTS AND METHODS: A total of 18,100 newly confirmed pulmonary tuberculosis (TB) cases in Dalian, China were used in the final analysis. A 3-knotted restricted cubic spline (RCS) fitted for Cox proportional hazard regression models is used to analyse the effects of cut-off points of treatment delay on incident poor treatment outcomes. To explore the moderating effects of age, gender and diabetes, we added the interaction terms of these moderating variables and treatment delay to Cox proportional hazard regression models. RESULTS: The median time of treatment initiation was 30 days (IQR: 14-59 days). The risk of incident poor treatment outcomes increased when the time was greater than cut-off point 1 (53 days; adjusted HR: 1.26; 95% CI: 1.00-1.60) of treatment delay, and the risk of incident death events increased when the time was greater than cut-off point 2 (103 days; adjusted HR: 1.56; 95% CI: 1.00-2.44) of delay. In addition, treatment delay was associated with an increased risk of incident poor treatment outcomes and death, and older age, male sex, and diabetes may increase the risk of treatment delay for poor outcomes. CONCLUSION: This study is the first to identify scientific cut-off points of treatment delay for poor treatment outcomes and death, and this method of exploration should be popularized. In addition, the knowledge of tuberculosis must be spread to every adult. Moreover, the tuberculosis diagnosis level of community level health workers should be enhanced.

Determinants of Medication Adherence for Pulmonary Tuberculosis Patients During Continuation Phase in Dalian, Northeast China.

PURPOSE: Medication adherence is crucial for decreasing the burden of tuberculosis, but few relevant studies have been conducted in northeast China. This study aimed to explore the level of medication adherence among pulmonary tuberculosis outpatients and the predictive factors based on the bio-psycho-social medical model. PATIENTS AND METHODS: A cross-sectional multi-center survey was conducted in four tuberculosis medical institutions in Dalian, northeast China. Medication adherence was measured using the eight-item Chinese version of the Morisky Medication Adherence Scale, which divides adherence into three levels. The independent variables consisted of sociodemographic characteristics, treatment factors, knowledge about TB, mental health, and behavioral characteristics. Descriptive statistics, the chi-square test, and multivariate ordinal logistic regression were applied to analyze the data using Stata/MP 14.0. RESULTS: Among the 564 eligible participants, 236 (41.84%) and 183 (32.45%) exhibited high and medium medication adherence, respectively, but 145 (25.71%) exhibited low medication adherence. Multivariate ordinal logistic regression showed that patients who were older (OR: 1.02, p=0.013) were employed (OR: 1.61, p=0.011), had better tuberculosis knowledge (OR: 1.34, p<0.001), and did not consume alcohol (OR: 1.84, p=0.032) exhibited higher medication adherence. However, patients who did not follow their doctors' advice to take adjuvant drugs (OR: 0.44, p=0.001), had a history of TB treatment (OR: 1.76, p=0.009), experienced adverse drug reactions (OR: 0.65, p=0.017), experienced stigma (OR: 0.67, p=0.032), and needed supervised treatment (OR: 0.66, p=0.012) exhibited lower medication adherence. CONCLUSION: Tuberculosis patients' medication adherence was not very high and it was influenced by diverse and complex factors involving sociodemographic characteristics, treatment factors, knowledge about TB, mental health, and behavioral characteristics.

ESMPE: A combined strategy for school tuberculosis prevention and control proposed by Dalian, China.

BACKGROUND: Although China has paid more attention on the prevention and control of tuberculosis (TB) in schools, several unsolved questions in this field still threaten the progress of TB control. Therefore, there is an urgent need to develop a systematic and practical strategy for Chinese school TB prevention and control system. In this study, we aimed to assess the feasibility of a combined strategy named ESMPE (examination, screening, monitoring, prevention and education) that adhere to the basic principles of Chinese schools TB control strategy. METHODS: The ESMPE strategy included five sections, namely TB screening during physical examination for the school freshmen entrances, screening of close contacts, monitoring of high-risk schools, preventive treatment and TB education. The effectiveness of ESMPE strategy was evaluated from 2011 to 2016. The original data were provided by the Dalian Tuberculosis Hospital. Descriptive analysis and nonparametric tests were used for comparing statistical differences of results between different years. RESULTS: The detection rate of active pulmonary TB in school freshmen was decreased from 2011 to 2016 (χ2 = 41.941, P = 6.0551E-8). 97.22% (17,043/17,530) of close contacts experienced close contacts screening, and the secondary attack rate (SAR) of TB in schools fell by 146.35/105 from 2011 to 2012, and finally reduced to 85.57/105 in 2016. There was a significant correlation between SAR of student TB and the rate of screened close contacts (r = -0.924, P = 0.009). TB incidence of five monitored schools had a substantial decline after receiving monitoring, and this declining trend continued in 2016. Due to the TB education and advanced screening methods, the mean of diagnostic delay time in students with TB was shortened (15.71 days), while still fewer latent TB infection students received preventive treatment (30.38%). CONCLUSIONS: The ESMPE strategy has shown a favorable effect on TB prevention and control in Dalian schools. More systematic evidence is needed on the effect of this strategy in reducing the incidence of TB in schools from other settings prior to its further scaling-up in China.

Prevalence and risk factors of multi-drug resistant tuberculosis in Dalian, China.

Objectives To investigate the prevalence and risk factors associated with multi-drug resistant tuberculosis (MDR-TB) in Dalian, China. Methods This was a retrospective review of data from patients attending a TB clinic in Dalian, China between 2012 and 2015. Demographic and drug susceptibility data were retrieved from TB treatment cards. Univariate logistic analysis was used to assess the association between risk factors and MDR-TB. Results Among the 3552 patients who were smear positive for Mycobacterium tuberculosis (MTB), 2918 (82.2%) had positive MTB cultures and 1106 (31.1%) had isolates that showed resistance to at least one drug. The overall prevalence of MDR-TB was 10.1% (359/3552; 131/2261 [5.8%] newly diagnosed and 228/1291 [17.7%] previously treated patients). Importantly, 75 extensively drug-resistant TB isolates were detected from 25 newly treated and 50 previously treated patients. In total, 215 (6.1%) patients were infected with a poly-resistant strain of MTB. Previously treated patients and older patients were more likely to develop MDR-TB. Conclusions The study showed a high prevalence of MDR-TB among the study population. History of previous TB treatment and older age were associated with MDR-TB.

Imaging Features of Pulmonary CT in Type 2 Diabetic Patients with Multidrug-Resistant Tuberculosis.

BACKGROUND: Until now, radiographic manifestations of multidrug-resistant pulmonary tuberculosis (MDR- TB) in patients with diabetes mellitus (DM) have not been reported. We conducted a study to investigate the imaging features of pulmonary computed tomography (CT) for type 2 diabetic (T2DM) patients with MDR-TB. METHODS: The clinical data and pulmonary CT findings of 39 type 2 diabetic patients with MDR-TB, 46 type 2 diabetic patients with drug-susceptible tuberculosis (DS-TB), and 72 pure drug-susceptible TB cases (without T2DM and MDR) treated at Dalian Tuberculosis Hospital from 2012 to 2015 were collected, and the clinical features and imaging differences of the three groups were compared. RESULTS: The clinical characteristics of the three groups of patients were not significantly different except with respect to age and previous treatment history. However, on imaging, the patients with MDR-TB showed consolidation in and above the pulmonary segments was significantly more extensive than that seen in the DS-TB group with or without T2DM. CONCLUSION: Consolidation in or above multiple pulmonary segments with multiple mouth-eaten cavities and bronchial damage on pulmonary CT images in type 2 diabetic patients with tuberculosis suggests the possibility of multi-drug resistance.

[Evaluation of tuberculin skin test conversion and interferon-gamma release assay in diagnosis of tuberculosis infection].

OBJECTIVE: To compare PPD conversion with γ-interferon release assay (IGRA) in determining the newly Mycobacterium tuberculosis (MTB) infection during a TB outbreak. METHODS: The 505 subjects exposed to a TB outbreak were divided into 3 groups based upon the induration diameters of PPD before the outbreak. The changes of PPD induration diameters were observed in different groups, and correlation between PPD conversion or IGRA and exposure levels were analyzed by logistic regression. RESULTS: In subjects with the highest exposure level, the increase in induration of PPD was (12 ± 5) mm, (7 ± 4) mm, and (5 ± 3) mm respectively among the previous PPD < 5 mm, 5 - < 10 mm, and ≥ 10 mm groups, the difference being significant among groups, χ(2) = 43.12, P < 0.01. Using logistic regression analysis, PPD conversion was related to the exposure level (OR = 4.70, P < 0.05) only in the PPD < 5 mm group, while IGRA positivity was closely related to the exposure levels in all 3 groups (OR values were 2.16 - 3.60, P < 0.05). In the high exposure group, the subjects with IGRA positivity combined with PPD conversion rate was 26.1% (31/119), and the subjects with IGRA positivity but no PPD conversion rate was 39.5% (47/119), while in the low exposure group the results were 6.5% (12/185) and 16.8% (31/185) respectively, the difference being significant (χ(2) = 22.82 and 19.63, P < 0.01). After 1 year of follow-up, the reversion rate of the subjects with IGRA positivity was 48.1% (91/189), while the mean increase value of PPD was (1.1 ± 4.0) mm. CONCLUSION: IGRA is superior to PPD conversion in the diagnosis of tuberculosis infection, and more valuable in the detection of newly infected cases.

Evaluation of a new interferon-gamma release assay and comparison to tuberculin skin test during a tuberculosis outbreak.

BACKGROUND: The tuberculin skin test (TST) is commonly used for the diagnosis of latent tuberculosis infection (LTBI) in non-bacille Calmette-Guérin (BCG) vaccination settings. In recent years, attention has been drawn to interferon-gamma release assays (IGRAs), especially in BCG-vaccinated populations. In this study, we evaluated the TST and a new whole blood IGRA in BCG-vaccinated individuals during a tuberculosis (TB) outbreak in China. METHODS: A TB outbreak occurred at a university in Dalian, China from March to November 2010. The TST and a whole blood IGRA were used to screen for TB infection. The correlation between exposure levels, TST, and the IGRA were evaluated. RESULTS: We found that agreement between the IGRA and TST was poor (kappa 0.182-0.290). IGRA positivity was associated with the level of exposure, and IGRA positivity and the level of exposure were risk factors for TB incidence. Neither the IGRA nor the TST alone picked up all TB incidences. However, if a 10 mm cutoff for the TST was used in the highest risk exposure group and IGRA positivity was used in the other risk groups, 19 of the 20 (95%) TB cases were identified. CONCLUSIONS: A recommended preventive treatment regimen for China should be based on the level of exposure in conjunction with IGRA and TST test results.