Functional impact of sequelae in drug-susceptible and multidrug-resistant tuberculosis.

BACKGROUND: Evidence on the impact of tuberculosis (TB) treatment on lung function is scarce. The aim of this study was to evaluate post-treatment sequelae in drug-susceptible and drug-resistant-TB (DR-TB) cases in Mexico and Italy.METHODS: At the end of TB treatment the patients underwent complete clinical assessment, functional evaluation of respiratory mechanics, gas exchange and a 6-minute walking test. Treatment regimens (and definitions) recommended by the World Health Organization were used throughout.RESULTS: Of 61 patients, 65.6% had functional impairment, with obstruction in 24/61 patients (39.4%), and 78% with no bronchodilator response. These effects were more prevalent among DR-TB cases (forced expiratory volume in 1 s/forced vital capacity [FEV1/FVC] < lower limit of normality, 14/24 vs. 10/34; P = 0.075). DR-TB patients showed moderately severe (FEV1 < 60%) and severe obstruction (FEV1 < 50%) (P = 0.008). Pre- and post-bronchodilator FEV1 and FEV1/FVC (% of predicted) were significantly lower among DR-TB cases. Plethysmography abnormalities (restriction, hyperinflation and/or air trapping) were more frequent among DR-TB cases (P = 0.001), along with abnormal carbon monoxide diffusing capacity (DLCO) (P = 0.003).CONCLUSION: The majority of TB patients suffer the consequences of post-treatment sequelae (of differing levels), which compromise quality of life, exercise tolerance and long-term prognosis. It is therefore important that lung function is comprehensively evaluated post-treatment to identify patient needs for future medication and pulmonary rehabilitation.

Comparison of bacteriological conversion and treatment outcomes among MDR-TB patients with and without diabetes in Mexico: Preliminary data.

Diabetes mellitus (DM) is a well-known risk factor for tuberculosis (TB). However, it is not known to what extent DM affects the outcome in patients with multidrug-resistant (MDR-TB) and extensively drug-resistant TB (XDR-TB) treated with second-line anti-TB drugs. The objective of this study was to compare the microbiological evolution (sputum smear and culture conversion) and final outcomes of MDR/XDR-TB patients with and without DM, managed at the national TB reference centre in Mexico City. RESULTS: Ninety patients were enrolled between 2010 and 2015: 73 with MDR-TB (81.1%), 11 with pre-XDR-TB (e.g. MDR-TB with additional resistance to one injectable drug or a fluoroquinolone, 12.2%) and 6 (6.7%) with XDR-TB. Out of these, 49 (54.4%) had DM and 42 (86%) were undergoing insulin treatment. No statistically significant differences were found in treatment outcomes comparing DM vs. non-DM MDR-TB cases: 18/32 (56.3%) of DM cases and 19/24 (79.2%) non DM patients achieved treatment success (p=0.07). The time to sputum smear and culture conversion was longer (although not statistically) in patients without DM, as follows: the mean (±SD) time to sputum smear conversion was 53.9 (±31.4) days in DM patients and 65.2 (±34.8) days in non-DM ones (p=0.15), while the time to culture conversion was 66.2 (±27.6) days for DM and 81.4 (±37.7) days for non-DM MDR-TB cases (p=0.06). CONCLUSIONS: The study results support the Mexican National TB programme to strengthen its collaboration with the DM programme, as an entry point for TB (and latent TB infection) screening and management.

Diabetes modifies the male:female ratio in pulmonary tuberculosis.

SETTING: Socio-cultural factors have been invoked to explain the male predominance among patients with pulmonary tuberculosis, but there is no conclusive evidence of their role. OBJECTIVE: To assess male predominance in a group of diabetics with pulmonary tuberculosis compared with patients with pulmonary tuberculosis alone. DESIGN: Clinical records of in-patients with pulmonary tuberculosis and with (TBDM group, n = 202) or without (TB group, n = 226) diabetes mellitus were reviewed, and the male percentages in each of six age groups (15-29, 30-39, 40-49, 50-59, 60-69, > or = 70 years) calculated. RESULTS: In the TB group, no gender difference (51% males) was found in the first age period, followed by a male predominance thereafter (71%, 68%, 75%, 63% and 58%). The TBDM group showed a similar pattern in the first two age groups (56% and 74%), followed by a steadily decline (r(S) = -0.90, P = 0.04) in male percentage (60%, 44%, 45%, 27%), leading to a female predominance after age 50. The association of age and gender was also corroborated by logistic regression in TBDM (P = 0.02), but not in TB (P = 0.19) patients. CONCLUSIONS: Diabetes was associated with a progressive shift of male predominance in pulmonary tuberculosis. Because diabetes is a disease that affects social activities similarly in men and women, our results suggest that factors other than socio-cultural ones are also important for determining the male predominance in pulmonary tuberculosis.

Results of a 12-month regimen for drug-resistant pulmonary tuberculosis.

SETTING: Several therapeutic regimens for drug-resistant tuberculosis have been suggested, most of them with a total duration of 18-24 months. OBJECTIVE: To report our experience using a shorter regimen. DESIGN: Fifty patients with drug-resistant pulmonary tuberculosis were managed by withdrawing all anti-tuberculosis drugs until the results of a drug sensitivity test were obtained (approximately 3 months), and then a 12-month self-administered regimen with four to six anti-tuberculosis drugs at full daily doses was initiated, based primarily on the sensitivity test and secondarily on the history of previous treatment. RESULTS: In 31 patients treatment was completed as planned, in six it was irregular and 13 definitively abandoned it. In the best scenario, 90.3% (28/31) of patients with full treatment were cured; this outcome was similar for both multidrug-resistant (MDR, n = 18, 88.9%) and non-MDR (n = 13, 92.3%) patients. Six months later, the relapse rate was 4.8%, and after a 5-year follow-up 14 out of 18 cured patients who were located remained asymptomatic (77.8%). If the worst scenario was applied, a 62.0% cure rate (31/50) was obtained. CONCLUSIONS: A 12-month regimen with a minimum of four anti-tuberculosis agents at full dose, essentially selected on drug sensitivity testing, could be an alternative option for the treatment of drug-resistant pulmonary tuberculosis.

Atypical radiological images of pulmonary tuberculosis in 192 diabetic patients: a comparative study.

SETTING: Comparative studies of pulmonary tuberculosis images in diabetics have yielded conflicting results. OBJECTIVE: To assess radiological images of pulmonary tuberculosis in a large population of diabetic patients. DESIGN: Radiographs from in-patients admitted with pulmonary tuberculosis and diabetes (TBDM group, n = 192) were reviewed and compared with a control group of patients with pulmonary tuberculosis alone (TB group, n = 130). RESULTS: Both groups had a similar evolution time of tuberculosis (approximately 2 years). Statistical differences were observed as follows: TBDM patients were older (51.3+/-0.9 vs. TB group 44.9+/-1.8 years, mean +/- SEM), and had a decreased frequency of upper (17% vs. 56%), and an increased frequency of lower (19% vs. 7%) and upper + lower (64% vs. 36%) lung field lesions. More TBDM patients developed cavitations (82% vs. 59%) more often in the lower lung fields (29% vs. 3%). More multiple cavities were seen in TBDM patients (25% vs. 2%). TBDM group had a lower total leukocyte count (8836.7+/-219.5 vs. 10013.1+/-345.2 cells/mm3), mainly due to a lower number of non-lymphocyte cells (6815.8+/-221.8 vs. 8095.7+/-321.9 cells/mm3). Multiple logistic regression showed that being a diabetic patient was the most important factor determining lower lung field lesions and cavities. CONCLUSIONS: This study in a large number of diabetics with pulmonary tuberculosis confirmed that their chest X-ray images significantly depart from the typical presentation. Clinicians must keep this in mind to avoid misdiagnosis.

Progressive age-related changes in pulmonary tuberculosis images and the effect of diabetes.

Atypical radiologic images of pulmonary tuberculosis are common in elderly and in diabetic patients. To investigate the relationship of chest radiographic findings of tuberculosis to age in diabetic and nondiabetic patients, we compared the chest radiographic findings of 192 inpatients with pulmonary tuberculosis and diabetes with those of 130 patients with pulmonary tuberculosis alone. The proportion of patients with lower lung field lesions progressively increased with age (r(S) = 0.89, p < 0.01), whereas the frequency of cavitation steadily decreased with age (r(S) = -0.79, p < 0.05). In diabetic patients, a high frequency of lower lung lesions and cavitation was observed in all age groups. We speculated that, in older patients and in diabetics, the increased alveolar oxygen pressure in the lower lobes favors development of lower lobe disease in these groups.

Outcome of bone marrow transplantation patients requiring mechanical ventilation.

OBJECTIVE: To identify outcome predictors in bone marrow transplantation (BMT) patients admitted to the intensive care unit (ICU) of The University of Texas M. D. Anderson Cancer Center who required endotracheal intubation and mechanical ventilation. DESIGN: Retrospective, comparative study. SETTING: A 16-bed medical intensive care unit in a university teaching cancer center. PATIENTS: The records of 60 consecutive BMT patients who developed respiratory failure requiring mechanical ventilation were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The most frequent complication leading to respiratory failure was pneumonia (41%) followed by diffuse alveolar hemorrhage (37%). Eighteen percent of the patients were extubated and discharged from the ICU, but only 5% were alive at 6 months. Graft vs. host disease was a predictor of a poor outcome (p < .05). Breast cancer as an underlying disease and pulmonary edema as a complication were favorable predictive factors (p < .05). Five of 26 patients with diffuse alveolar hemorrhage and four of 33 patients with pneumonia survived. We found no relationship between survival and age, gender, BMT type, or Acute Physiology and Chronic Health Evaluation II score. Prolonged mechanical ventilation (> or =15 days) and late development of respiratory failure (>30 days after BMT) were associated with poor prognosis. CONCLUSIONS: The ICU survival rate of BMT patients who developed pulmonary complications and required mechanical ventilation was 18%. Prognostic factors were described identifying patients with a substantial survival rate as well as those in whom mechanical ventilation was futile.

Immediate objectives in the teaching of ophthalmology and otorhinolaryngology

The several objectives in teaching under-graduates ophthalmology and otorhinolaryngology which I have previously outlined must of course be different from the objectives in post-graduate teaching. And because most of the students will become general medical practitioners, our main objectives may boil down to this: Students must have a fair knowledge of diagnosis and a sufficient command of ophthalmology and otorhinolaryngology to refer cases intelligently to specialists at the proper time, and to enable them to take care of the simple, common ailments of the eyes, ears, nose, and throat. We do not aim to make eye, ear, nose, and throat specialists out of them.(Summary)

Does aging modify pulmonary tuberculosis?: A meta-analytical review.

STUDY OBJECTIVES: To evaluate the differences in the clinical, radiologic, and laboratory features of pulmonary tuberculosis (TB) in older patients, as compared to younger patients. DESIGN: A meta-analysis (the Schmidt-Hunter method) of published works found in MEDLINE and other sources was performed. A total of 12 studies were collected, and each variable was submitted to meta-analysis. RESULTS: No differences were found between older (>/= 60 years old) and younger TB patients with respect to male predominance, evolution time before diagnosis, prevalence of cough, sputum production, weight loss, fatigue/malaise, radiographic upper lobes lesions, positive acid-fast bacilli in sputum, anemia or hemoglobin level, and serum aminotransferases. A lower prevalence of fever, sweating, hemoptysis, cavitary disease, and positive purified protein derivative, as well as lower levels of serum albumin and blood leukocytes were noticed among older patients. In addition, the older population had a greater prevalence of dyspnea and some concomitant conditions, such as cardiovascular disorders, COPD, diabetes, gastrectomy history, and malignancies. CONCLUSIONS: This meta-analytical review identified the main differences of older TB patients, as compared to younger TB patients, that should be considered during the diagnostic evaluation. Most of these differences are explained by the already known physiologic changes that occur during aging.

Diagnostic methods of primary tuberculous pleural effusion in a region with high prevalence of tuberculosis. A study in Mexican population.

STUDY OBJECTIVES: 1) To determine the age distribution of the patients with pleural tuberculosis in a region with high prevalence of tuberculosis; and 2) to evaluate the efficiency of the methods used in its diagnosis. SETTING: The National Institute of Respiratory Diseases in Mexico City, a tertiary reference center for pulmonary diseases. DESIGN: A retrospective study. PATIENTS: 452 consecutive inpatients with diagnosis of pleural effusion from January 1991 to September 1996 were reviewed: 133 patients had a diagnosis of tuberculous pleural effusion of primary origin without parenchymal abnormalities by chest roetgenogram. The others were excluded because of reactivated tuberculosis or non-tuberculous effusion. MEASUREMENTS AND RESULTS: The patients had a mean age of 42 +/- 17 years (98 male, 35 female). Pleural granulomas in the morphological study were found in 87% whereas the baciloscopy and the culture of the fluid were positive in only 8% and 19% respectively. The determination of adenosine deaminase (ADA) gave a diagnostic yield of 84%. CONCLUSIONS: 1) Primary tuberculosis pleural effusion, reported in the English literature, was also present in our adults; 2) the pleural biopsy continued to be the most effective method in the diagnosis of the pathology; and 3) the determination of ADA in an area with high prevalence of the disease was a reliable and unexpensive diagnostic method.

PIP: It is often difficult to diagnose tuberculosis (TB) pleural effusion because the search for Mycobacterium tuberculosis in fluid, or the identification of historical alterations in the pleural biopsy are often false negative. The diagnosis, however, must be timely since 43-65% of patients may develop an active pulmonary TB in the next 3-5 years. To determine the age distribution of patients with pleural TB, the authors reviewed the charts of 452 consecutive inpatients from January 1991 to September 1996 hospitalized at Mexico's National Institute of Respiratory Diseases with a diagnosis of the condition. 133 patients were diagnosed with TB pleural effusion of primary origin without parenchymal abnormalities according to chest roentgenogram. These 98 men and 35 women were of mean age 42 years. Pleural granulomas were identified in 87% of subjects while fluid baciloscopy and culture were positive in only 8% and 19%, respectively. The determination of adenosine deaminase (ADA) produced a diagnostic yield of 84%. Based upon their findings, the authors stress that primary TB pleural effusion may also be seen in adults, closed pleural biopsy remains the most effective diagnostic method, and ADA level is a cheap diagnostic method in countries with a high prevalence of TB.

Origen del asma, teoría del desequilibrio calórico / Astha etiology, theory of caloric

La teoría del "desequilibrio calórico" propone que en el paciente asmático, la pérdida del calor producida sería mayor que la intensidad del calor perdido, ésta produciría pérdida del equilibrio calórico que determina una hiperreactividad de los tres mecanismos principales para bajar la temperatura: "El bloqueo simpático, la estimulación de la sudación y la inhibición de la termogénesis" de estos mecanismos se originaría la aparición de signos y síntomas del asma. Además tomando como base la teoría sustentada, se relaciona el asma con algunos factores desencadenantes como el ejercicio, la edad, las drogas, alimentos, clima desfavorable, alteración del sistema nervioso y endocrino.

Aorto-left atrial fistula.

The authors present a case of fistula between the ascending aorta and the left atrium, with four large aneurysmal sacs and marked enlargement of the left atrium. The 10-year-old patient was treated by closing the fistula with a Dacron patch. The results were satisfactory in this extremely rare case of a congenital cardiac lesion.

Effect of 4-aminopyridine on cardiovascular functions in the dog.

The drug 4-aminopyridine (4-AP) at a dose of 0.2 mg . kg-1 body weight intravenously is an effective antagonist of non-depolarizing neuromuscular blockade. We studied its cardiovascular effects in the canine heart using a right-heart bypass with extracorporeal circulation in seven dogs. This study demonstrates that 4-aminopyridine significantly augments arterial blood pressure, left ventricular dp/dt maximum, as well as left ventricular pressure at dp/dt mx. The highest values were obtained between two and 20 minutes after administration of 4-AP. Left ventricular end-diastolic pressure diminished slightly, but this was not statistically significant. Although the exact mechanism of action of 4-AP is not known, its positive inotropic effects may be of value in the reversal of non-depolarizing neuromuscular blockade in patients with impaired myocardial function of diverse aetiologies and it would be contra-indicated in patients with arterial hypertension and/or coronary artery disease.

Effect of sodium bicarbonate on canine left ventricular function.

Left ventricular performance was evaluated in seven canine right heart bypass preparations during and after the intraauricular administration of sodium bicarbonate (100 ml, 1100 Osm, 60 mEq). Under conditions of constant cardiac input and left ventricular volume, sodium bicarbonate produced mild and brief left ventricular depression, as manifested by a decline of left ventricular dp/dt with simultaneous rise of left ventricular end-diastrolic and left atrial pressures. These findings occurred as aortic impedance fell. Identical results accrued in paced and unpaced preparations. The data lends credence to the proposition that a sudden rise in blood pCO2 produces increased transport of CO2 across the cardiac membranes with intracellular acidosis. However, the data is also compatible with hyperosmolality induced contractile depression. Possible clinical implications are discussed.

Effects of ketamine on canine cardiovascular function.

Left ventricular contractility was assessed before and during the peak effect of ketamine in eight canine right heart bypass preparations. Myocardial contractility was defined in terms of maximum left ventricular dp/dt, the ejection fraction, and left ventricular end-diastolic and left atrial pressures at constant heart rate and cardiac inflow. Ketamine produced significant decreases in contractility and there were some indications of a dose-response pattern. The action of ketamine was dependent partly on changes in arterial pressure, as the drug caused a mild but sustained vasodilatation which was not dose-dependent. These data offer further evidence of a small and transient negative inotropic effect of ketamine.