Predictors of drug-resistance in patients with pulmonary tuberculosis / 결핵

BACKGROUND: The drug-resistant tuberculosis has recently decreased in Korea, but it is still one of the major obstacles in the treatment of pulmonary tuberculosis. Unfortunately there are no reliable ways to figure out the drug sensitivity pattern of the M. tuberculosis in the starting point of treatment. At least several months which is critical for the success of treatment have to be passed away before getting the report of drug-sensitivity test. The aim of this study was to find out the clinical and radiological parameters that make it possible to predict the drug-resistant pulmonary tuberculosis and to make a correct decision on the antituberculosis drug regimens. METHOD: We studied 253 pulmonary TB patients with sputum and/or bronchial washing fluid culture-positive diagnosed at the Chung-Ang University Young-San Hospital in the period of 1989-1994. The differences in the clinical and raiological variables between the drug-sensitive and the drug-resistant tuberculosis patients were evaluated. RESULTS: In 66 out of 253 patients(26.1%), drug resistant tuberculosis to at least one antituberculosis drug were found. Patients with retreatment showed higher resistance rate than those with initial treatment (30/69,43.5% vs 36/184, 19.5%, p<0.01). Patients with cavitary TB showed higher resistance rate than those with non-cavitary TB( (24/54, 44.4% vs 42/199, 21.1%, p<0.05). Among patients with initial treatment, those with far-advanced TB showed a higher drug resistance rate than those with minimal lesion(9/23, 36.9% vs 10/82, 12.5%, p<0.05). Patients with culture positive only in the bronchial washing fluid showed lower resistance rate than those with sputum culture positive(7/63, 11.1% vs 59/190, 31.1%, p<0.05) CONCLUSION: Prior treatment history for pulmonary tuberculosis, the presence of cavity & far advanced tuberculosis in the radiologic exam, sputum rather than solely bronchial washing culture positivity would be the related factors to the drug resistance. So in the patients with such characteristics, it is needed to try to find out the drug sensitivity pattern of the infecting tuberculosis organism as soon as possible.

The Long-term Follow-up Study of Therapeutic Effects of 8 French Catheter for Spontaneous Pneumothorax / 결핵

BACKGROUND: Spontaneous pneumothoraces(SP) are divided into primary spontaneous pneumothoraces(PSP) which develop in healthy individuals without underlying pulmonary disorders and secondary spontaneous pneumothoraces(SSP) which occur in those who have underlying disorders such as tuberculosis or chronic obstructive lung diseases. Yet there is no established standard therapeutic approach to this disorder, i.e., from the spectrum of noninvasive treatment such as clinical observation with or without oxygen therapy, to aggressively invasive thoracoscopic bullectomy or open thoracotomy. Although chest tube thoracostomy has been most widely used, the patients should overcome pain in the initiation of tube insertion or during indwelling it potential infection and subcutaneous emphysema. Thus smaller-caliber tube has been challenged for the treatment of pneumothorax. Previously, we studied the therapeutic efficacy of 8 French catheter for spontaneous pneumothorax. But there has been few data for effectiveness of small-caliber catheterization in comparison with that of chest tube. In this study, we intended to observe the long-term effectiveness of 8 French catheter for the treatment of spontaneous pneumothoraces in comparison with that of chest tube thoracostomy. METHODS: From January, 1990 to January, 1996, sixty two patients with spontaneous pneumothoraces treated at Chung-Ang University Hospital were reviewed retrospectively. The patients were sub-divided into a group treated with 8 French catheter(n=23) and the other one with chest tube insertion(n=39). The clinical data were reviewed(age, sex, underlying pulmonary disorders, past history of pneumothorax, size of pneumothorax, follow-up period). And therapeutic effect of two groups was compared by treatment duration(duration of indwelling catheter or tube), treatment-associated complications and recurrence rate. RESULTS: The follow-up period(median) of 8 French catheter group and chest tube group was 28 and 22 months, which had no statistical significance. Their was no statistically significant difference of clinical characteristics between two groups with SP, PSP, SSP. The indwelling time of 8 French catheter group was 6.2+/-3.8 days, which was significantly shorter than that of chest tube group in SP, 9.1+/-7.5 days(p=0.047). In comparison of treatment-related complication in PSP, 8 French catheter group as 6.25% of complication showed lower tendency than the other group as 23.8% (p= 0.041 ; one-tailed, p=0.053 ; two-tailed). The recurrence rate in each group of SP was 17.4%, 10.3%, which did not show any statistically significant difference. CONCLUSION: Treatment with 8 French catheter resulted in shorter indwelling time in sponteous pneumothorax, and lower incidence of treatment-related complication in primary spontaneous pneumothorax. And the recurrence rate in each of treatment group showed no statistically significant difference. So, we can recommend the 8 French small-caliber catheter for the initial therapy for spontaneous pneumothorax for the replacement of conventional chest tube thoracostomy. But further prospective study with more subjects of spontaneous pneumothorax will be needed for the evaluation of effectiveness of 8 French cateter.

Follow-Up Study of 6-Month Short Course Chemotherapyfor Pulmonary Tuberculosis with 2SKHRZ/4HRZ / 결핵

Background: Many clinicians have experienced the difficulty of decision on termination of antituberculosis chemotherapy after the 6th month due to relapse of disease. There is still controversy in the effect of 2S(K)HRZ/4HRZ 6-month short course chemotherapy including pyrazinamide for 6 months in patients with pulmonary tuberculosis. And there is no long term follow-up study of 6-month short course chemotherapy for pulmonary tuberculosis in korea. So we had performed the study to find the result of 6-month antituberculosis chemotherapy for 4 years. Method: We studied prospectively the effect of 2S(K)HRZ/4HRZ in one hundred-fifty patients with pulmonary tuberculosis and followed up fifty-nine patients for more than 1 year to 4 years after the completion of 6-month short course therapy. Results: 1) Out of one hundred-fifty patients, seventy-two patients(48%) completed the prescribed 6-month chemotherapy. Sixty-eight patients(45.3%) have experienced premature discontinuation and the most common cause of premature discontinuation was drop-out against advice(thirty-six patients, 24%). Ten patients(6.7%) were treated beyond the 6 months mainly due to irregular treatment. 2) Fifty-nine patients(81.9%) among seventy-two patients with completed treatment have been followed up for more than 1 year and 32 patients(44.4%) for more than 4 years. There was three relapse patients of whom two patients have experienced relapse of pulmonary tuberculosis within 1 year after the termination of chemotherapy. 3) Among one hundred-thirty-four patients who have been assessible for more than two months of chemotherapy, including the patients who experienced within 2 months, there were eighty-two patients(61.2%) who have experienced adverse reactions and the treament regimen was changed only in thirteen patients(9.7%). The most frequent cause of adverse reactions was arthralgia and/or hyperuricemia, which had occurred in 33 patients(24.6%). Conclusion: In a university hospital in Korea, 6-month short course chemotherapy of 2S(K)HRZ/4HRZ had unnegligible relapses and premature discontinuation. Therefore, change of the regimen might be carefully considered by drug susceptibility results. Close monitoring of patients, retrial of sputum exam and radiologic evaluation during treatment might be required in the endemic area of drug resistant strains like in Korea. Further study about the effect of 6-month short course chemotherapy including pyrazinamide for 6-month might be needed.