ABSTRACT
OBJECTIVES: To determine predictive factors for changes in standard anti-tuberculosis chemotherapy at the time of diagnosis. METHODS: A prospective study was performed among tuberculosis (TB) patients treated at specialised centres during 2008-2009. Treatment outcome was monitored per standard guidelines. Treatment was considered successful if the patient was cured or completed treatment. Factors associated with treatment modification were analysed at the bivariate and multivariate levels using logistic regression. RESULTS: A total of 427 patients were included in the study. The initial standard treatment regimen was retained for 249 patients (58.3%), extended to 9 months for 36 (8.4%) and changed for 142 (33.3%). Factors associated with a change of regimen at the multivariate level were female sex, age ≥ 50 years, human immunodeficiency virus infection, comorbidities, alcoholism, hospitalisation and culture-positive sputum. Drug resistance and toxicity were analysed independently. Treatment outcome was successful in 97.2% of cases without a regimen change and in 87.3% of those with a changed regimen (P < 0.001). CONCLUSION: Factors associated with changes in the initial anti-tuberculosis regimen should be considered for rigorous follow-up. Results obtained through individualised treatment provided by specialists were good despite the complexity of the cases treated.
Subject(s)
Antitubercular Agents/therapeutic use , Drug Substitution , Tuberculosis/drug therapy , Adult , Age Factors , Antitubercular Agents/adverse effects , Comorbidity , Drug Resistance, Multiple, Bacterial , Drug Therapy, Combination , Female , Guideline Adherence , Humans , Logistic Models , Male , Middle Aged , Multivariate Analysis , Odds Ratio , Practice Guidelines as Topic , Prospective Studies , Remission Induction , Sex Factors , Spain/epidemiology , Time Factors , Treatment Outcome , Tuberculosis/diagnosis , Tuberculosis/epidemiology , Tuberculosis, Multidrug-Resistant/diagnosis , Tuberculosis, Multidrug-Resistant/drug therapy , Tuberculosis, Multidrug-Resistant/epidemiologyABSTRACT
The aim of the present study was to compare the performance of the interferon (IFN)-γ tests (QuantiFERON®-TB Gold In-Tube (QFT-G-IT) and T-SPOT®.TB) with the tuberculin skin test (TST) in diagnosing tuberculosis (TB) infection in children, and to analyse discordant results. This was a prospective study including 98 children from contact-tracing studies and 68 children with TST indurations ≥ 5 mm recruited during public health screenings. Positive IFN-γ tests results were associated with risk of exposure (p<0.0001). T-SPOT.TB was positive in 11 (78.6%) out of 14 cases with active TB and QFT-G-IT in nine (64.3%) out of 14 cases. Sensitised T-cells against Mycobacterium avium were detected in six out of 12 children not vaccinated with bacille Calmette-Guérin (BCG), a TST induration 5-9 mm in diameter and both IFN-γ tests negative. In concordant IFN-γ tests results, a positive correlation was found (p = 0.0001) between the number of responding cells and the amount of IFN-γ released. However, in discordant IFN-γ tests results this correlation was negative (p = 0.371): an increase in the number of spot-forming cells correlated with a decrease in the amount of IFN-γ released. The use of IFN-γ tests is helpful for the diagnosis of TB infection, avoiding cross-reactions with BCG immunisation and nontuberculous mycobacterial infections. The analysis of highly discordant results requires further investigation to elucidate possible clinical implications.
Subject(s)
Interferon-gamma/metabolism , Tuberculin Test , Tuberculosis/diagnosis , Adolescent , BCG Vaccine/immunology , Child , Child, Preschool , Contact Tracing , Female , Humans , Male , Mass Screening , Prospective Studies , Sensitivity and Specificity , T-Lymphocytes/immunology , Tuberculosis/immunology , Tuberculosis/prevention & controlABSTRACT
No disponible
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Humans , Tracheotomy , Respiration, Artificial/methods , Intubation, Intratracheal/methodsABSTRACT
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Humans , Female , Contraception , Pregnancy , Pregnancy, Unwanted , Preventive Medicine , Women's HealthABSTRACT
OBJECTIVE: Assess the opinion of health care professions on the awarding of resources when the patient has a bad prognosis. DESIGN: Survey type test where a scenario of a patient with a 6 month life prognosis is posed, differentiating between good and bad quality of life. It is evaluated if the following resources would be indicated if necessary: admission to ICU, hemodialysis, hip prosthesis, transplant, Hospital admission, antibiotics for bacterial infection, permanent pacemaker and surgery. To analyze the possible association between the variables, the Pearson's Chi Square Test or that of linear tendency was used. To determine if each person interviewed was appropriate in a different way based on the patient's quality of life status, the McNemar test was used. SETTING: University Hospital of 480 beds. PARTICIPANTS: Sample of 256 volunteers (physicians and nurses) from the Emergency Service, Intensive Care Unit and Operating Room. INTERVENTIONS: A responsible physician was in charge of personally distributing the survey during a 2-week period and to explain the possible doubts that could arise on it. RESULTS: A total of 23.8% of those surveyed considered that transplant would be indicated and 79.8% that permanent pacemaker would be indicated if the patient had a good quality of life. If there was bad quality of life, 9.1% would have always indicated hemodialysis (60.5% never), 2.8% hip prosthesis (81.1% never) and 4% complex surgery (78.8% never). There were also significant differences in all the variables studied, depending on whether the patient had good or bad quality of life. CONCLUSION: There is great variability on the allotment of resources for patients with limited possibilities of survival.
Subject(s)
Attitude of Health Personnel , Nurses/psychology , Physicians/psychology , Prognosis , Resource Allocation , Adult , Anti-Bacterial Agents/therapeutic use , Arthroplasty, Replacement, Hip/psychology , Bacterial Infections/drug therapy , Bacterial Infections/psychology , Data Collection , Dissent and Disputes , Emergency Service, Hospital , Female , Hospitals, University , Humans , Intensive Care Units , Life Expectancy , Male , Medical Futility/psychology , Middle Aged , Organ Transplantation/psychology , Pacemaker, Artificial/psychology , Quality of Life , Resource Allocation/standards , Surgery Department, Hospital , Surgical Procedures, Operative/psychologySubject(s)
Contraception , Female , Humans , Pregnancy , Pregnancy, Unwanted , Preventive Medicine , Women's HealthABSTRACT
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Humans , Pulmonary Disease, Chronic Obstructive/therapy , Respiration, Artificial , Decision Making , PrognosisABSTRACT
OBJECTIVE: This study examined the incidence and mortality of multiple organ dysfunction syndrome (MODS) in intensive care units, evaluated the limitation of life support in these patients, and determined whether daily measurement of the Sequential Organ Failure Assessment (SOFA) is useful for decision making. DESIGN AND SETTING: Prospective, observational study in 79 intensive care units. PATIENTS AND PARTICIPANTS: Of the 7,615 patients admitted during a 2-month period we found 1,340 patients to have MODS. MEASUREMENTS AND RESULTS: We recorded mortality and length of stay in the intensive care unit and the hospital and the maximum and minimum total SOFA scores during MODS. Limitation of life support in MODS patients was also evaluated. Stepwise logistic regression was used to determine the factors predicting mortality. The in-hospital mortality rate in patients with MODS was 44.6%, and some type of limitation of life support was applied in 70.6% of the patients who died. The predictive model maximizing specificity included the following variables: maximum SOFA score, minimum SOFA score, trend of the SOFA for 5 consecutive days, and age over 60 years. The model diagnostic yield was: specificity 100%, sensitivity 7.2%, positive predictive value 100%, and negative predictive value 57.3%; the area under the receiver operating characteristic curve was 0.807. CONCLUSIONS: This model showed that in our population with MODS those older than 60 years and with SOFA score higher than 9 for at least 5 days were unlikely to survive.
Subject(s)
Intensive Care Units , Life Support Care , Multiple Organ Failure/mortality , Decision Making , Female , Humans , Incidence , Length of Stay , Logistic Models , Male , Middle Aged , Models, Biological , Multiple Organ Failure/epidemiology , Multiple Organ Failure/therapy , Predictive Value of Tests , ROC Curve , Severity of Illness Index , Spain/epidemiologyABSTRACT
Gastro-oesophageal reflux (GOR) and bronchoaspiration of gastric content are risk factors linked with ventilator-associated pneumonia. This study was aimed at evaluating the effect of a nasogastric tube (NGT) incorporating a low-pressure oesophageal balloon on GOR and bronchoaspiration in patients receiving mechanical ventilation. Fourteen patients were studied in a semi-recumbent position for 2 consecutive days. Inflation or deflation of the oesophageal balloon was randomised. Samples of blood, gastric content, and oropharyngeal and bronchial secretions were taken every 2 h over a period of 8 h. A radioactively labelled nutritional solution was continuously administered through the NGT. The magnitude of both the GOR and bronchoaspiration was measured by radioactivity counting of oropharyngeal and bronchial secretion samples, respectively. Inflation of the oesophageal balloon resulted in a significant decrease of both GOR and bronchoaspiration of gastric content. This protective effect was statistically significant from 4 h following inflation throughout the duration of the study. This study demonstrates that an inflated oesophageal balloon delays and decreases gastro-oesophageal and bronchial aspiration of gastric content in patients carrying a nasogastric tube and receiving enteral nutrition during mechanical ventilation. Although the method was found to be safe when applied for 8 h, longer times should be considered with caution.
Subject(s)
Gastroesophageal Reflux/etiology , Gastroesophageal Reflux/prevention & control , Intubation, Gastrointestinal/instrumentation , Pneumonia, Aspiration/etiology , Pneumonia, Aspiration/prevention & control , Respiration, Artificial/adverse effects , Aged , Aged, 80 and over , Enteral Nutrition/adverse effects , Esophagus , Female , Humans , Male , Middle Aged , PostureSubject(s)
Climacteric , Estrogen Replacement Therapy , Fractures, Bone/prevention & control , Osteoporosis, Postmenopausal/prevention & control , Age Factors , Aged , Aged, 80 and over , Bone Density , Densitometry , Estrogen Replacement Therapy/adverse effects , Female , Humans , Mass Screening , Middle Aged , Osteoporosis, Postmenopausal/diagnosis , Osteoporosis, Postmenopausal/epidemiology , Prevalence , Risk Factors , Spinal Fractures/prevention & controlABSTRACT
BACKGROUND: The homeless are at very high risk of suffering tuberculosis (TB). The aims of this study were to determine the prevalence and risk factors for tuberculosis infection and disease among the homeless in Barcelona and to evaluate the roles of case finding and contact investigation. METHODS: Observational prevalence study carried out between 1997 and 1998. PARTICIPANTS: 447 homeless patients (394 men and 53 women) were evaluated before admission to shelters and free-meal services. At the same time, 48 co-residents with smear-positive TB patients in 2 long-term shelters were evaluated too. A chest X-ray and Tuberculin Skin Test were performed on all subjects. Sputum smears were processed by the Ziehl-Neelsen and Löwenstein-Jensen procedures in patients with radiographic findings consistent with pulmonary TB. RESULTS: Of the 447 homeless examined, 335 (75%) were infected with Mycobacterium tuberculosis. Active pulmonary TB was diagnosed in five persons (1.11%), and 62 (13.8%) had radiographic evidence of inactive pulmonary TB. Tuberculosis infection was associated with age and smoking, but not with sex or alcohol abuse. No significant differences in infection rates were found between the main group and 48 homeless co-residents of smear-positive subjects. Only 16.9% of the homeless with active TB in Barcelona in the same period were diagnosed through active case-finding, the remainder being mainly detected in hospitals (69.8%) and other several centres (13.3%). CONCLUSIONS: Homeless individuals have a very high risk of TB infection and disease and contact investigation requires specific methods for them. Programmes of screening and supervised treatment should be ensured in this group.
Subject(s)
Ill-Housed Persons , Tuberculosis, Pulmonary/epidemiology , Adolescent , Adult , Age Factors , Aged , Alcoholism , Female , Humans , Male , Mass Screening , Middle Aged , Prevalence , Risk Factors , Sex Factors , Smoking/adverse effects , Spain/epidemiology , Tuberculin Test , Tuberculosis, Pulmonary/diagnosisSubject(s)
Intensive Care Units , Pulmonary Disease, Chronic Obstructive/therapy , Respiration, Artificial , APACHE , Age Factors , Aged , Aged, 80 and over , Female , Forced Expiratory Volume , Humans , Male , Middle Aged , Patient Admission , Patient Selection , Prognosis , Pulmonary Disease, Chronic Obstructive/diagnosis , Quality of Life , Sex FactorsABSTRACT
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Subject(s)
Middle Aged , Aged, 80 and over , Aged , Male , Female , Humans , Respiration, Artificial , Intensive Care Units , Sex Factors , APACHE , Patient Selection , Patient Admission , Quality of Life , Prognosis , Pulmonary Disease, Chronic Obstructive , Age Factors , Forced Expiratory VolumeABSTRACT
The purpose of this study was to determine whether auditory warnings in the intensive care unit (ICU) were properly adjusted. An intervention study (before- and-after assessment) was conducted in a 12-bed medical-surgical ICU of an acute-care teaching hospital in Barcelona, Spain. A total of 100 patients with stable haemodynamic and respiratory parameters were included. In the first 3-month phase of the study, minimum and maximum alarm parameters of breathing rate, expired volume/min, airway pressure, SaO(2), arterial blood pressure and heart rate were recorded. In the second 12-month phase of the study, the same alarm parameters were recorded every 4 hours in the patient's medical record. In the third 3-month phase of the study, alarm readings were recorded again as in the first phase. The change throughout coefficient of variation (CV) and the 95% confidence interval (CI) for each alarm were calculated. Following the intervention, there was a statistically significant improvement in alarm readings for expired volume, heart rate and systolic blood pressure, so that alarms had been more properly adjusted to the patient's real value. Nursing staff should be aware that auditory warnings in ICU stable patients are frequently set very far from suitable values. Recording of alarm parameters in the patient's medical record as a routine daily activity was an effective intervention for improving adjustment of auditory warnings.
Subject(s)
Intensive Care Units/standards , Telemetry/instrumentation , Telemetry/standards , Calibration , Critical Care/methods , Critical Care/standards , Equipment Failure , Equipment Safety , Hospitals, Teaching , Humans , Maintenance , Risk Management , Spain , Total Quality ManagementABSTRACT
SETTING: Molecular epidemiology has underlined the importance of recent tuberculosis (TB) transmission and has uncovered notable discrepancies compared with conventional epidemiology. OBJECTIVES: 1) To determine, by RFLP analysis, the percentage of clustered cases in an inner city district with a high incidence of TB (163/100,000) and the groups at risk of being clustered; and 2) to compare the role of conventional contact tracing (CCT) with that of RFLP. DESIGN: RFLP was carried out using the IS6110 and pTBN12 (PGRS) sequences of 165 cultures positive for Mycobacterium tuberculosis in the Ciutat Vella district of Barcelona during 1997-1998. Contact tracing was carried out in 171 of 251 declared cases (68.1%). Associations were assessed by calculating odds ratios (OR) with 95% confidence intervals (CI). Logistic regression was used for multivariate analysis. RESULTS: Using RFLP, 76 (46.0%) strains were found to be clustered by IS6110 and PGRS. From CCT, 30 new patients were found among 858 contacts (3.5%) and 57 patients were linked. In terms of RFLP and CCT, the main risk factor was intravenous drug use (IVDU). In 44 cases who lived alone and were not involved in CCT, 50% were in RFLP clusters. The concordance rate between RFLP and CCT was 8/13 (61.5%); the disagreement corresponded to a cluster of five recent immigrants from Africa. Subsequent to RFLP, an epidemiological connection was found in 15/55 cases (27.2%). CONCLUSIONS: The percentage of clustered cases is very high. CCT was useful for identifying new cases, but it was insufficient for detecting the pathways of transmission. CCT coverage needs to be improved in marginalized individuals, and the results correlated with those of RFLP.
