Rafael Blanquer

Diagnóstico y tratamiento de la tuberculosis

Lamentablemente, las novedades en tuberculosis (TB) se producen de forma lenta, demasiado lenta. No obstante, han pasado bastantes anos desde las ultimas Normativas de la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) sobre el diagnostico y el tratamiento de la TB, y durante este periodo no solo se han producido avances en el diagnostico y el tratamiento, especialmente en el campo del diagnostico, sino que ademas hemos asistido a un importante cambio demografico en Espana motivado por el incremento de la inmigracion. En la actualidad el 10% del total de la poblacion espanola no ha nacido en el pais y el 30% de los casos de TB corresponden a pacientes inmigrantes. Por todo ello, nos ha parecido oportuno y necesario revisar nuestras guias para actualizarlas y adaptarlas a la presente configuracion social espanola. En un esfuerzo de simplificacion hemos decidido agrupar en una sola las normativas previas sobre diagnostico y tratamiento de la TB. Para la elaboracion de la presente guia hemos tenido en cuenta la evidencia cientifica disponible. El grado de recomendacion se clasifica como A, B, C y D. El grado A significa que la evidencia cientifica en que se basa es buena o muy buena (estudios de nivel 1); el B, que es razonablemente buena (estudios de nivel 2); el C, que es escasa (series y casos), y el D, que asienta en opiniones de expertos y consensos. Agradecemos al Comite Cientifico de la SEPAR la deferencia y la confianza que han otorgado al grupo de expertos para llevar a cabo la nueva Normativa y esperamos y deseamos que sea de utilidad para mejorar el control de la TB. DIAGNOSTICO DE LA INFECCION TUBERCULOSA

Documento de consenso sobre diagnóstico, tratamiento y prevención de la tuberculosis

Pulmonary TB should be suspected in patients with respiratory symptoms longer than 2-3 weeks. Immunosuppression may modify clinical and radiological presentation. Chest X-ray shows very suggestive, albeit sometimes atypical, signs of TB. Complex radiological tests (CT scan, MR) are more useful in extrapulmonary TB. At least 3 serial representative samples of the clinical location are used for diagnosis whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high TB suspicion. Administration of isoniazid, rifampicin, ethambutol and pyrazinamide (HREZ) for 2 months and HR for 4 additional months is recommended in new cases of TB, except in cases of meningitis in which treatment should continue for up to 12 months and up to 9 months in spinal TB with neurological involvement, and in silicosis. Appropriate adjustments with antiretroviral treatment should be made in HIV patients. Combined therapy is recommended to avoid development of resistance. An antibiogram to first line drugs should be performed in all the initial isolations of new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when >or=5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TT. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained.

Tuberculosis treatment adherence and fatality in Spain.

BackgroundThe adherence to long tuberculosis (TB) treatment is a key factor in TB control programs. Always some patients abandon the treatment or die. The objective of this study is to identify factors associated with defaulting from or dying during antituberculosis treatment.MethodsProspective study of a large cohort of TB cases diagnosed during 2006-2007 by 61 members of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR). Predictive factors of completion outcome (cured plus completed treatment vs. defaulters plus lost to follow-up) and fatality (died vs. the rest of patients) were based on logistic regression, calculating odds ratios (OR) and 95% confidence intervals (CI).ResultsOf the 1490 patients included, 29.7% were foreign-born. The treatment outcomes were: cured 792 (53.2%), completed treatment 540 (36.2%), failure 2 (0.1%), transfer-out 33 (2.2%), default 27 (1.8%), death 27 (1.8%), lost to follow-up 65 (4.4%), other 4 (0.3%). Completion outcome reached 93.5% and poor adherence was associated with: being an immigrant (OR = 2.03; CI:1.06-3.88), living alone (OR = 2.35; CI:1.05-5.26), residents of confined institutions (OR = 4.79; CI:1.74-13.14), previous treatment (OR = 2.93; CI:1.44-5.98), being an injecting drug user (IDU) (OR = 9.51; CI:2.70-33.47) and treatment comprehension difficulties (OR = 2.93; CI:1.44-5.98). Case fatality was 1.8% and it was associated with the following variables: age 50 or over (OR = 10.88; CI:1.12-105.01), retired (OR = 12.26;CI:1.74-86.04), HIV-infected (OR = 9.93; CI:1.48-66.34), comprehension difficulties (OR = 4.07; CI:1.24-13.29), IDU (OR = 23.59; CI:2.46-225.99) and Directly Observed Therapy (DOT) (OR = 3.54; CI:1.07-11.77).ConclusionImmigrants, those living alone, residents of confined institutions, patients treated previously, those with treatment comprehension difficulties, and IDU patients have poor adherence and should be targeted for DOT. To reduce fatality rates, stricter monitoring is required for patients who are retired, HIV-infected, IDU, and those with treatment comprehension difficulties.

[Consensus document on the diagnosis, treatment and prevention of tuberculosis].

Abstract Pulmonary tuberculosis must be suspected in patients with respiratory symptoms longer than 2–3 weeks. Immunosuppression may modify the clinical and radiological presentation. The chest X-ray is highly suggestive of tuberculosis (TB), but is occasionally atypical. The complex radiological tests (CT scan, MRI) are more useful in extrapulmonary TB. At least 3 consecutive representative samples from the clinical location are used for diagnosis, whenever possible. Bacilloscopy and liquid medium cultures are indicated in all cases. Genetic amplification techniques are coadjuvant in moderate or high suspicion of TB. In new cases of TB, administration of isoniazid, rifampin, ethambutol, and pyrazinamide (HREZ) for 2 months and isoniazid plus rifampin for 4 months is recommended. For meningitis cases, treatment should continue for up to 12 months, and up to 9 months in spinal TB with neurological affectation and silicosis. Appropriate adjustments with antiretroviral treatment must be made in HIV patients. Combined therapy is recommended to prevent development of resistance. An antibiogram for first line drugs should be performed in all initial extractions from new patients. Treatment control is one of the most important activities in TB management. The Tuberculin Skin Test (TST) is positive in TB infection when ≥ 5mm, and Interferon-Gamma Release Assays (IGRA) are recommended in combination with TST. The standard treatment schedule for infection is 6 months with isoniazid. In pulmonary TB, respiratory isolation is applied for 3 weeks or until 3 negative bacilloscopy samples are obtained.

Diagnosis and Treatment of Tuberculosis

Unfortunately, advances in the management of tuberculosis (TB) occur all too slowly. It has, however, been quite a few years since the last guidelines on the diagnosis and treatment of TB were published by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). During the intervening period, not only have advances been made in the treatment and, above all, the diagnosis of TB, but the demographic profile of Spain has also changed significantly as a result of increased immigration. Today, 10% of the country’s population is foreign born and 30% of TB cases involve immigrant patients. In this context, we considered it both timely and essential to update the society’s guidelines and adapt the recommendations to take into account these changes in the composition of Spanish society.. To simplify access to the information, we decided to combine all the society’s recommendations on the diagnosis and treatment of TB in a single practice guideline based on the scientific evidence currently available. Recommendations are graded as A, B, C, or D. A grade A classification indicates that the supporting scientific evidence is good or very good (level 1 trials); grade B indicates that the evidence is reasonably good (level 2 trials); grade C that the supporting evidence is scant (individual case reports and case series); and grade D that the recommendation is based on expert opinion or consensus. We would like to thank SEPAR’s Scientific Committee for their confidence in the ability of this group of experts to compile the new TB guidelines, and we hope that the resulting document will be of use in improving the management of TB. DIAGNOSIS OF TUBERCULOUS INFECTION

Social, Clinical and Microbiological Differential Characteristics of Tuberculosis among Immigrants in Spain

Background To identify the differential tuberculosis (TB) characteristics within the immigrant population with respect to natives in Spain. Methodology/Principal Findings A prospective cohort study design was implemented to examine the TB cases diagnosed and starting standard antituberculous treatment in Spain, between January 1st 2006 and March 31st 2007. A logistic regression analysis was performed to determine differential characteristics. 1,490 patients were included in the study population, 1,048 natives and 442 (29.7%) immigrants. According to the multivariate analysis, the following variables were significantly associated with immigrant TB cases: younger age (ORu200a=u200a3.79; CI:2.16–6.62), living in group situation (ORu200a=u200a7.61; CI:3.38–12.12), lower frequency of disabled (OR:0.08; CI:0.02–0.26) and retired (OR:0.21; CI:0.09–0.48) employment status, lower frequency of pulmonary disease presentation (ORu200a=u200a0.47; CI:0.24–0.92), primary or emergency care admission (ORu200a=u200a1.80; CI:1.05–3.06 and ORu200a=u200a2.16; CI:1.36–3.45), drug resistance (ORu200a=u200a1.86; CI:1.01–3.46), treatment default (OR:2.12; CI:1.18–3.81), lower frequency of alcohol and cigarette consumption (ORu200a=u200a2.10; CI:1.42–3.11 and ORu200a=u200a2.85; CI:2.10–3.87 respectively), more directly observed treatment (ORu200a=u200a1.68; CI:1.04–2.69), and poor understanding of TB disease and its treatment (ORu200a=u200a3.11; CI:1.86–5.20). The low percentage of primary MDR-TB in the native population (0.1% vs. 2.2% of immigrants) should be noted. Conclusions/Significance The differences show the need to introduce specific strategies in the management of TB within the immigrant population, including the improvement of social and work conditions.

Usefulness of Transcutaneous Carbon Dioxide Pressure Monitoring to Measure Blood Gases in Adults Hospitalized for Respiratory Disease

OBJECTIVEnTo evaluate the usefulness of transcutaneous carbon dioxide pressure (TcPCO2) monitoring in patients hospitalized for respiratory disease.nnnPATIENTS AND METHODSnWe used a SenTec TcPCO2 monitor that also determines transcutaneous oxygen saturation (SpO2) by means of a sensor placed behind the ear lobe at a temperature of 42 degrees C. We compared arterial blood gas measurements--PaCO2 and arterial oxygen saturation (SaO2)--with transcutaneous measurements and analyzed the correlation, regression line, and agreement between the 2 methods.nnnRESULTSnThirty patients (20 men and 10 women) with various respiratory diseases and a mean (SD) age of 71 (13) years were included in the study. The median TcPCO2 was 43.25 mm Hg and the median PaCO2 was 42.6 mm Hg with no significant differences between the 2 measurements. The correlation was significant (rho=0.979; P< .0001) and the corresponding regression equation was TcPCO2=-2.475+1.058 PaCO2. The mean difference was 0.16 mm Hg (95% confidence interval [CI], --0.74 to 1.06). The lower limit of agreement (mean -1.96 SD) was -4.64 mm Hg, and the upper limit (mean +1.96 SD) was 4.96 mm Hg. For SaO2, the median was 94% and for SpO2, 95%. The difference between the 2 medians was significant (P< .004). The correlation was also significant (rho=0.822; P< .0001) with SpO2=4.427+0.97 SaO2. The mean difference was 1.14% (95% CI, 0.381% to 1.899%). The lower limit of agreement (mean -1.96 SD) was --2.93% and the upper limit (mean +1.96 SD) was 5.21%nnnCONCLUSIONSnTranscutaneous determination of carbon dioxide pressure and oxygen saturation is useful for patients hospitalized for respiratory disease in view of its good correlation and agreement, although SpO2 does tend to overestimate SaO2.

Hypertension and sleep apnea–hypopnea syndrome: changes in echocardiographic abnormalities depending on the presence of hypertension and treatment with CPAP☆

INTRODUCTIONnSleep apnea-hypopnea syndrome (SAHS) is an emerging disease with high prevalence. There is controversy as to whether cardiac abnormalities are due to the disease itself or to the arterial hypertension frequently associated with this disease.nnnOBJECTIVESnTo analyze echocardiographic abnormalities in a population of SAHS patients depending on the presence or absence of hypertension at the time of diagnosis and after six months of treatment with continuous positive airway pressure (CPAP).nnnMETHODSnWe studied 85 consecutive patients diagnosed with SAHS who required treatment with CPAP (Hypertensive: 43, nonhypertensive: 42). We performed a baseline echocardiogram after six months of treatment. We analyzed morphological (wall thickness, diameters, ejection fraction) and functional (peak E- and A-wave velocities, deceleration time, Tei index) parameters of the left and right ventricles.nnnRESULTSnHypertensive patients were older and had higher blood pressure values, but there were no differences between groups in other clinical parameters. The hypertensive group had greater septal thickness (hypertensive: 12.1+/-2.3; nonhypertensive: 10.8+/-2.1mm; p=0.01). There were also differences in impairment of left (hypertensiveHT: 92.9%, nonhypertensive: 65%, p=0.002) and right (hypertensive: 74.4%, nonhypertensive: 42.1%, p=0.006) ventricular filling. After six months of treatment, an improvement of the myocardial performance index was noted in nonhypertensive patients (baseline Tei: 0.55+/-0.1 vs. 6-month Tei: 0.49+/-0.1; p=0.01), whereas no significant change was observed in hypertensive patients.nnnCONCLUSIONSnCardiac abnormalities in SAHS patients are increased in the presence of associated hypertension. Treatment with CPAP for six months improves cardiac abnormalities in nonhypertensive patients but not in hypertensive patients.

Disfunción miocárdica silente en pacientes con síndrome de apneas-hipopneas durante el sueño. Valor del índice de rendimiento miocárdico

Objetivo El sindrome de apneas-hipopneas durante el sueno (SAHS) es una enfermedad emergente con importante repercusion cardiovascular. El indice de rendimiento miocardico (IRM) es un parametro ecocardiografico util en la valoracion de la funcion miocardica global. El objetivo del estudio ha sido analizar si hay diferencias en el IRM entre pacientes con SAHS y un grupo control. Pacientes y metodos Hemos estudiado a 120 pacientes consecutivos remitidos por sospecha de SAHS a nuestra unidad. Una vez realizado el estudio nocturno y excluidos los hipertensos, cardiopatas o registros inadecuados, analizamos a 54 pacientes y 13 controles de similar edad e indice de masa corporal. Un cardiologo que desconocia la asignacion les realizo un ecocardiograma Doppler. Se midieron parametros de hipertrofia ventricular, funcion sistolica, function diastolica y el IRM. Los datos se compararon mediante el test de la χ2 y ANOVA. Resultados Los pacientes con SAHS presentaron mayor masa ventricular que el grupo control (media ± desviacion estandar: 183,17xa0±xa040,5 frente a 149xa0±xa026 g; pxa0=xa00,005). No se apreciaron diferencias entre ambos grupos en la funcion sistolica (un 78,5xa0±xa08,95 frente al 81,6xa0±xa07%; pxa0=xa00,2), pero un mayor porcentaje de pacientes con SAHS tenia alterada la funcion diastolica (un 71,2 frente al 38,5%; pxa0=xa00,049). El IRM fue significativamente mayor en el grupo con SAHS (0,54xa0±xa00,12 frente a 0,46xa0±xa00,07; pxa0=xa00,028). Conclusiones El SAHS por si mismo produce hipertrofia ventricular izquierda. La afectacion diastolica es importante en este grupo, pero tambien la presenta un numero importante de personas sanas con obesidad. El IRM esta incrementado en el SAHS y podria ser util para identificar a los pacientes con disfuncion miocardica silente antes de su progresion.

A predictive scoring instrument for tuberculosis lost to follow-up outcome

BackgroundAdherence to tuberculosis (TB) treatment is troublesome, due to long therapy duration, quick therapeutic response which allows the patient to disregard about the rest of their treatment and the lack of motivation on behalf of the patient for improved. The objective of this study was to develop and validate a scoring system to predict the probability of lost to follow-up outcome in TB patients as a way to identify patients suitable for directly observed treatments (DOT) and other interventions to improve adherence.MethodsTwo prospective cohorts, were used to develop and validate a logistic regression model. A scoring system was constructed, based on the coefficients of factors associated with a lost to follow-up outcome. The probability of lost to follow-up outcome associated with each score was calculated. Predictions in both cohorts were tested using receiver operating characteristic curves (ROC).ResultsThe best model to predict lost to follow-up outcome included the following characteristics: immigration (1 point value), living alone (1 point) or in an institution (2 points), previous anti-TB treatment (2 points), poor patient understanding (2 points), intravenous drugs use (IDU) (4 points) or unknown IDU status (1 point). Scores of 0, 1, 2, 3, 4 and 5 points were associated with a lost to follow-up probability of 2,2% 5,4% 9,9%, 16,4%, 15%, and 28%, respectively. The ROC curve for the validation group demonstrated a good fit (AUC: 0,67 [95% CI; 0,65-0,70]).ConclusionThis model has a good capacity to predict a lost to follow-up outcome. Its use could help TB Programs to determine which patients are good candidates for DOT and other strategies to improve TB treatment adherence.