RESUMO
BACKGROUND: Patients undergoing tumour necrosis factor (TNF)-α antagonist therapy are at increased risk of latent tuberculosis infection (LTBI) reactivation. The aim of this study was to determine the optimum available screening strategy for identifying patients for tuberculosis (TB) chemoprophylaxis. METHODS: We conducted a prospective observational study of consecutive adults with chronic rheumatological disease referred for LTBI screening prior to commencement of TNF-α antagonist therapy. All patients included had calculation of TB risk according to age, ethnicity and year of UK entry, as described in the 2005 British Thoracic Society (BTS) guidelines and measurement of tuberculin skin test (TST) and T.Spot.TB. RESULTS: There were 187 patients included in the study, with 157 patients (84%) taking immunosuppressants. 137 patients would require further risk stratification according to the BTS algorithm, with 110 (80.3%) classified as being at low risk of having LTBI. There were 39 patients (35.5%) who were categorised as low risk but were either TST and/or T.Spot positive and would not have received chemoprophylaxis according to the BTS algorithm. Combination of all three methods (risk stratification and/or positive T.Spot and/or positive TST) identified 66 patients out of 137 who would potentially be offered chemoprophylaxis, which was greater than any single test or two-test combination. CONCLUSION: Performing both a TST and T.Spot in patients on immunosuppressants prior to commencement of TNF-α antagonist therapy gives an additional yield of potential LTBI compared with use of risk stratification tables alone. Our results suggest that use of all three screening modalities gives the highest yield of patients potentially requiring chemoprophylaxis.
Assuntos
Imunossupressores/efeitos adversos , Tuberculose Latente/diagnóstico , Tuberculose Latente/prevenção & controle , Programas de Rastreamento/métodos , Doenças Reumáticas/tratamento farmacológico , Teste Tuberculínico/métodos , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adulto , Idoso , Antituberculosos/uso terapêutico , Quimioprevenção , Doença Crônica , Feminino , Humanos , Tuberculose Latente/complicações , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doenças Reumáticas/complicações , Medição de Risco , Reino UnidoRESUMO
A compelling body of evidence points to pulmonary thrombosis and thromboembolism as a key feature of COVID-19. As the pandemic spread across the globe over the past few months, a timely call to arms was issued by a team of clinicians to consider the prospect of long-lasting pulmonary fibrotic damage and plan for structured follow-up. However, the component of post-thrombotic sequelae has been less widely considered. Although the long-term outcomes of COVID-19 are not known, should pulmonary vascular sequelae prove to be clinically significant, these have the potential to become a public health problem. In this Personal View, we propose a proactive follow-up strategy to evaluate residual clot burden, small vessel injury, and potential haemodynamic sequelae. A nuanced and physiological approach to follow-up imaging that looks beyond the clot, at the state of perfusion of lung tissue, is proposed as a key triage tool, with the potential to inform therapeutic strategies.
Assuntos
COVID-19/complicações , COVID-19/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Fibrose Pulmonar/diagnóstico por imagem , Trombose/diagnóstico por imagem , Cintilografia de Ventilação/Perfusão/métodos , Assistência ao Convalescente , COVID-19/fisiopatologia , Doença Crônica , Meios de Contraste , Humanos , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/fisiopatologia , Pulmão/irrigação sanguínea , Pulmão/diagnóstico por imagem , Pulmão/fisiopatologia , Imagem de Perfusão , Embolia Pulmonar/etiologia , Embolia Pulmonar/fisiopatologia , Fibrose Pulmonar/etiologia , Fibrose Pulmonar/fisiopatologia , Testes de Função Respiratória , SARS-CoV-2 , Trombose/etiologia , Trombose/fisiopatologia , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Tomografia Computadorizada por Raios X/métodos , Síndrome de COVID-19 Pós-AgudaRESUMO
BACKGROUND: The symptoms, radiography, biochemistry and healthcare utilisation of patients with COVID-19 following discharge from hospital have not been well described. METHODS: Retrospective analysis of 401 adult patients attending a clinic following an index hospital admission or emergency department attendance with COVID-19. Regression models were used to assess the association between characteristics and persistent abnormal chest radiographs or breathlessness. RESULTS: 75.1% of patients were symptomatic at a median of 53 days post discharge and 72 days after symptom onset and chest radiographs were abnormal in 47.4%. Symptoms and radiographic abnormalities were similar in PCR-positive and PCR-negative patients. Severity of COVID-19 was significantly associated with persistent radiographic abnormalities and breathlessness. 18.5% of patients had unscheduled healthcare visits in the 30 days post discharge. CONCLUSIONS: Patients with COVID-19 experience persistent symptoms and abnormal blood biomarkers with a gradual resolution of radiological abnormalities over time. These findings can inform patients and clinicians about expected recovery times and plan services for follow-up of patients with COVID-19.
Assuntos
Assistência ao Convalescente , Biomarcadores/análise , COVID-19 , Alta do Paciente/normas , Radiografia Torácica , Avaliação de Sintomas , Assistência ao Convalescente/métodos , Assistência ao Convalescente/organização & administração , COVID-19/sangue , COVID-19/diagnóstico por imagem , COVID-19/epidemiologia , COVID-19/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Radiografia Torácica/métodos , Radiografia Torácica/estatística & dados numéricos , Recuperação de Função Fisiológica , Estudos Retrospectivos , SARS-CoV-2 , Índice de Gravidade de Doença , Avaliação de Sintomas/métodos , Avaliação de Sintomas/estatística & dados numéricos , Fatores de Tempo , Reino Unido/epidemiologiaRESUMO
OBJECTIVES: Prioritisation of oral bedaquiline over the injectable agents in the treatment of multidrug-resistant Tuberculosis (MDR-TB) in the World Health Organisations (WHO) 2019 guidelines prompted this UK analysis of cost implications. The objective was to estimate the costs of amikacin versus bedaquiline in MDR TB treatment regimens using a historical cohort where the injectable agents were the standard of care. METHODS: This was a retrospective study using a known cohort of UK patients treated with an injectable agent, with data available on resource use, costs for the use of amikacin were compared with those for bedaquiline, based on recommended monitoring for bedaquiline. RESULTS: The estimated cost of treatment per patient had mean (sd) of £27,236 (4952) for the observed injectable group, £30,264 (3392) and 36,309 (3901) for the 6 and 8 month amikacin groups, and £31,760 (2092) for the bedaquiline group. The cost in the bedaquiline group was £30,772 (1855) with a 10% reduction and £27,079 (1234) with a 33% reduction in-patient stay. CONCLUSIONS: In most scenarios, bedaquiline is close to cost neutral compared with injectable therapy, especially if, as expected, some reduction in duration of admission is possible as a result of bedaquiline's more rapid culture conversion.