Prevalence of Latent Tuberculosis Infection (LTBI) in Mexican Patients With Rheumatoid Arthritis (RA).

INTRODUCTION: Patients with rheumatoid arthritis (RA) are at increased risk of developing tuberculosis, and even more so if they receive biological agents. In Mexico, the prevalence of latent tuberculosis infection (LTBI) in RA diagnosed by interferon-gamma release assay (IGRA) is largely unknown. The objective was to determine LTBI prevalence and the associated risk factors in rheumatoid arthritis patients. METHODS: A cross-sectional study was performed comprising 82 patients with RA who attended the rheumatology service at a second-level hospital. Demographic characteristics, comorbidity, Bacillus Calmette-Guerin (BCG) vaccination and smoking history, type of treatment, disease activity and functional capacity were investigated. The Disease Activity Score 28 and the Health Assessment Questionnaire-Disability Index were applied for the estimate of RA activity and functional capacity. Further information was compiled from the electronic medical records and personal interviews. LTBI was determined by QuantiFERON TB Gold Plus (QIAGEN, Germantown, USA). RESULTS: Prevalence of LTBI was 14% (95% confidence interval (CI): 8.6% to 23.9%). Factors associated with LTBI were history of smoking (odds ratio (OR) = 6.63 95% CI 1.01 to 43.3) and disability score (OR = 7.19 95%CI 1.41 to 36.6). CONCLUSIONS: The prevalence of LTBI in Mexican patients with RA was 14%. Our results suggest prevention of smoking and functional incapacity could reduce the risk of LTBI. Further research could endorse our results.

[Unnecessary routine laboratory tests in patients referred for surgical services]. / Exámenes de laboratorio de rutina innecesarios en pacientes referidos para atención por servicios quirúrgicos.

BACKGROUND: To question the usefulness of the lab analysis considered routine testing for the identification of abnormalities in the surgical care. OBJECTIVE: To determine the percentage of unnecessary laboratory tests in the preoperative assessment as well as to estimate the unnecessary expenses. MATERIALS AND METHODS: A descriptive, cross-sectional study of patients referred for surgical evaluation between January 1st and March 31st 2013. The database of laboratory testing and electronic files were reviewed. Reference criteria from surgical services were compared with the tests requested by the family doctor. RESULTS: In 65% of the patients (n=175) unnecessary examinations were requested, 25% (n=68) were not requested the tests that they required, and only 10% of the patients were requested laboratory tests in accordance with the reference criteria (n=27). The estimated cost in unnecessary examinations was $1,129,552 in a year. DISCUSSION: The results were similar to others related to this theme, however, they had not been revised from the perspective of the first level of attention regarding the importance of adherence to the reference criteria which could prevent major expenditures. CONCLUSION: It is a priority for leaders and operational consultants in medical units to establish strategies and lines of action that ensure compliance with institutional policies so as to contain spending on comprehensive services, and which in turn can improve the medical care.

Historia y actualidad del plombaje como tratamiento en la enfermedad pulmonar por tuberculosis multirresistente / History and News on Plombage as Treatment for Pulmonary Disease by Multi-Drug Resistant Tuberculosis

La cirugía torácica para la tuberculosis fue el tratamiento de elección desde comienzos del siglo XIX hasta su sustitución con la llegada de la quimioterapia antifímica. Actualmente, se han documentado múltiples complicaciones tardías de la tisiocirugía, así como sorprendentes resultados a largo plazo. En el presente artículo haremos una breve revisión de la colapsoterapia y uno de sus más importantes representantes el plombaje, su evolución, variantes, efectividad y criterios de aplicación. El plombaje implementó, a través del uso de múltiples materiales injertados en la cavidad torácica, una reacción tisular por hipoxia, que originaba un ambiente donde no puede sobrevivir el bacilo de la tuberculosis, lo que consigue una drástica mejoría inmediata en pacientes en estadios avanzados de la enfermedad. Fue califcado como el acto quirúrgico con menor número de desventajas porque limitaba la deformidad torácica en comparación con las toracoplastias, la necesidad de un menor tiempo de hospitalización, la posibilidad de realizar una delimitación de la zona pulmonar donde se localizaba la lesión por la enfermedad, etc. El procedimiento demostró en múltiples casos una supervivencia mayor a los 40 años. Al considerar los avances actuales en las técnicas quirúrgicas, las mejoras en los métodos de asepsia y esterilización, la mayor disponibilidad de materiales con menor número de complicaciones y la falta de efectividad de la quimioterapia en tuberculosis, la terapia quirúrgica como el plombaje reemerge como una alternativa de tratamiento factible en la actualidad.

Thoracic surgery for tuberculosis was the treatment of choice since the early nineteenth century until its replacement with the arrival of the antifimic chemotherapy. Currently they have documented multiple late complications of tisiosurgery also surprising long-term results. In this article we will briefly review the collapse therapy and one of its most important representant plombage, evolution, variants, effectiveness and application criteria. Plombage implemented through the use of multiple materials grafted into the thoracic cavity, a tissue reaction to hypoxia, which originated an environment where it cannot survive the TB bacillus, getting an immediate drastic improvement in patients in advanced stages of the disease. It was rated the surgery with fewer disadvantages because it restricted the chest deformity compared to thoracoplasty the need for a shorter hospital stay, the possibility of a delimitation of the lung area where the lesion was located by the disease, etc. The procedure demonstrated in many cases increased survival at 40 years. Considering current developments in surgical techniques, improved methods and aseptic sterilization, the increased availability of materials with fewer complications and lack of effectiveness of chemotherapy in tuberculosis, plombage rermerge as current feasible surgical treatment.

[Cost/benefit of preoperative examinations for routine elective surgery]. / Costo-beneficio de los exámenes preoperatorios de rutina en cirugía electiva.

INTRODUCTION: Preoperative exams are a common practice for surgeons; however, their use is not based on a scientific or medical basis. In the best of scenarios, it is an institutional policy. MATERIAL AND METHODS: We wanted to determine the utility and cost-effectiveness ratio of of preoperative routine tests (PRT) and we analyzed retrospectively the frequency of complications, hospital stay, and cost-effectiveness of PRT, in subjects with no concomitant disease, who were having elective surgery performed by the general surgery service. We included 141 male and female subjects, ages from 18 to 40 years, during 2002. RESULTS: There was no increase in complication frequency in patients with PRT abnormalities (6.2% versus 5.1%, OR 0.82, p = 0.78), or hospital stay time (2.37 versus 2.76, p = 0.55). PRT were repeated in 19.1%, expiration being the most frequent reason (46%). Urinalysis was the most frequent abnormal test (21.4%). We found only five clinically relevant abnormalities (3.5%). Only three patients required therapeutic intervention prior to surgery. The detection cost for PRT abnormalities requiring preoperative medical intervention was 22,732 Mexican pesos (approximately USD 2,022). CONCLUSIONS: The use of PRT in young clinically healthy subjects is an expensive and inefficient practice.

[Acute intestinal ischemia serum markers for the diagnosis of acute appendicitis]. / Marcadores séricos de isquemia intestinal aguda para el diagnóstico de apendicitis aguda.

INTRODUCTION: Acute appendicitis is the most common surgical emergency of the abdomen, but is still misdiagnosed in a large number of cases because of the the poor accuracy of the different radiologic and laboratory exams. Like in intestinal ischemia, an ischemic factor causes necrosis of the appendiceal wall and this favors the release of particular biochemical serum markers. OBJECTIVE: To evaluate the efficacy of intestinal ischemia serum markers as a diagnostic test for acute appendicitis. MATERIAL AND METHODS: Two hundred patients were studied prospectively. Depending on results of the examination by a surgeon, patients underwent surgery for acute appendicitis. Serum levels of amylase, lactic dehydrogenase, alkaline phosphatase, alanine transaminase, aspartate transaminase and leucocyte count were taken preoperatively. We then compared the results with histopathologic findings. RESULTS: Appendicitis was confirmed in 176 patients. Leukocytes had the highest sensitivity but very low specificity. Amylase and DHL were very specific but their sensitivity was poor. Differential leukocyte count had the highest positive predictive value. CONCLUSIONS: Serum enzymes of intestinal ischemia are not useful markers for the diagnosis of acute appendicitis. Leukocyte count is still the most useful serum marker of appendicitis.