Predicting the Development of Tuberculosis with the Tuberculin Skin Test and QuantiFERON Testing.

RATIONALE: The identification of patients with latent tuberculosis infection, who are at higher risk to develop active disease, is an important component of disease control. OBJECTIVES: We aim to compare the usefulness of the QuantiFERON-TB Gold in-tube assay and the tuberculin skin test to predict the development of active tuberculosis during follow-up, using positive and negative predictive values, positive likelihood ratios, and stratified level of risk. METHODS: The study included contacts of tuberculosis cases diagnosed between 2007 and 2009. All contacts included were from the first circle of exposure. Tuberculin skin test and QuantiFERON test were performed and a chest radiograph was obtained during the contact's study. MEASUREMENTS AND MAIN RESULTS: A total of 1,335 contacts were followed up for 4 years: a smear-positive index case was identified for 937 contacts, of whom 15 developed active tuberculosis and had initially presented with positive tuberculin skin test/QuantiFERON results, a normal chest radiograph, and no symptoms. The positive predictive value was 4% for QuantiFERON and 2% for the tuberculin skin test (when ≥5 mm). The probability of developing active disease was 2.36 times higher with a positive QuantiFERON, and 1.3 times higher with a positive tuberculin skin test. The positive predictive value was 17%, and the positive likelihood ratio was 7.53 for untreated contacts with a positive QuantiFERON. Stratifying according to initial QuantiFERON results showed a 6.36 times higher risk of developing active tuberculosis for patients with a QuantiFERON result greater than or equal to 10 IU/ml. Among bacillus Calmette-Guérin-vaccinated patients, a tuberculin skin test induration greater than or equal to 15 mm correlated better with a positive QuantiFERON. CONCLUSIONS: QuantiFERON results were more accurate than tuberculin skin test results in predicting tuberculosis. Although all contacts with QuantiFERON-positive results are at risk of developing tuberculosis, those with a tuberculin skin test induration greater than or equal to 15 mm and QuantiFERON greater than or equal to 10 IU/ml are at highest risk. This has important implications in the clinical management of tuberculosis contacts.

Immunogenicity of 60 novel latency-related antigens of Mycobacterium tuberculosis.

The aim of our work here was to evaluate the immunogenicity of 60 mycobacterial antigens, some of which have not been previously assessed, notably a novel series of in vivo-expressed Mycobacterium tuberculosis (IVE-TB) antigens. We enrolled 505 subjects and separated them in individuals with and without latent tuberculosis infection (LTBI) vs. patients with active tuberculosis (TB). Following an overnight and 7 days stimulation of whole blood with purified recombinant M. tuberculosis antigens, interferon-γ (IFN-γ) levels were determined by ELISA. Several antigens could statistically significantly differentiate the groups of individuals. We obtained promising antigens from all studied antigen groups [dormancy survival regulon (DosR regulon) encoded antigens; resuscitation-promoting factors (Rpf) antigens; IVE-TB antigens; reactivation associated antigens]. Rv1733, which is a probable conserved transmembrane protein encoded in DosR regulon, turned out to be very immunogenic and able to discriminate between the three defined TB status, thus considered a candidate biomarker. Rv2389 and Rv2435n, belonging to Rpf family and IVE-TB group of antigens, respectively, also stood out as LTBI biomarkers. Although more studies are needed to support our findings, the combined use of these antigens would be an interesting approach to TB immunodiagnosis candidates.

Correlation between tuberculin skin test and IGRAs with risk factors for the spread of infection in close contacts with sputum smear positive in pulmonary tuberculosis.

BACKGROUND: The aim of the study was to assess the correlation between the tuberculin skin test (TST) and in vitro interferon-gamma released assays (IGRAs) with risk factors for the spread of infection in smear positive pulmonary tuberculosis (TB) contacts. METHODS: We recruited prospective contacts with smear positive pulmonary TB cases. We looked at human immunodeficiency virus (HIV) infection and other conditions of immunosuppression, presence of BCG vaccination and the degree of exposure to the index case. Patients underwent the TST, chest radiography, sputum analysis when necessary, and IGRA assays (QFN-G-IT and T-SPOT.TB). Presence of cough, diagnostic delay (days between first symptoms and TB diagnostic), contact conditions: room size (square meters) and index of overcrowding (square meters per person) were investigated in the index case. RESULTS: 156 contacts (119 adults, 37 children) of 66 TB patients were enrolled, 2.4 (1-14) contacts per TB case. The positivity of the TST did not correlate with the risk factors studied: presence of cough (p = 0.929); delayed diagnosis (p = 0.244); room size (p = 0.462); overcrowding (p = 0.800). Both QFN-G-IT and T-SPOT.TB, showed significant association with cough (p = 0.001, and p = 0.007) and room size (p = 0.020, and p = 0.023), respectively. CONCLUSIONS: Both IGRA associated better than TST with certain host-related risk factors involved in the transmission of disease, such as the presence of cough.

[Diabetic mastopathy in diabetes mellitus type 2]. / Mastopatía diabética en diabetes mellitus tipo 2.

Diabetic mastopathy is a little known entity and can easily be mistaken for breast carcinoma. This entity has mainly been described in patients with diabetes type 1 and, to a much lesser extent, in those with other endocrine disorders. We describe a case of diabetic mastopathy associated with diabetes mellitus type 2, which showed a rapid clinical course. Lack of awareness of this entity can lead to inappropriate management. Because there are no specific histological or clinical features for diabetic mastopathy, patients may receive an incorrect diagnosis or undergo unnecessary investigations. A high index of suspicion is required to reach a correct diagnosis and provide appropriate treatment. The results of diagnostic tests are non-specific and the key to diagnosis is core needle biopsy.

Mastopatía diabética en diabetes mellitus tipo 2 / Diabetic mastopathy in diabetes mellitus type 2

La mastopatía diabética es una entidad muy poco conocida y, por ello, poco descrita que puede confundirse fácilmente con carcinoma mamario. Ha sido descrita principalmente en pacientes con diabetes mellitus tipo 1 y, en mucho menor medida, otras endocrinopatías. En este artículo se muestra un caso clínico en el que la mastopatía diabética se encuentra asociada a diabetes mellitus tipo 2 y presenta una evolución muy rápida en muy poco tiempo. El gran desconocimiento de esta entidad puede llevar a multitud de actuaciones clínicas equívocas. Al no reconocer histológicamente la lesión y carecer de datos clínicos de sospecha, es posible emitir un diagnóstico negativo de neoplasia. se puede juzgar de errónea la toma de muestras y requerir una nueva prueba innecesaria. Únicamente sospechándola se puede llegar a un diagnóstico correcto y a la actuación clínica adecuada. Los resultados de las pruebas diagnósticas son inespecíficos, y la biopsia con aguja gruesa es la clave diagnóstica(AU)

Diabetic mastopathy is a little known entity and can easily be mistaken for breast carcinoma. This entity has mainly been described in patients with diabetes type 1 and, to a much lesser extent, in those with other endocrine disorders. We describe a case of diabetic mastopathy associated with diabetes mellitus type 2, which showed a rapid clinical course. Lack of awareness of this entity can lead to inappropriate management. Because there are no specific histological or clinical features for diabetic mastopathy, patients may receive an incorrect diagnosis or undergo unnecessary investigations. A high index of suspicion is required to reach a correct diagnosis and provide appropriate treatment. The results of diagnostic tests are non-specific and the key to diagnosis is core needle biopsy(AU)

Hernia estrangulada. ¿Todavía mortal en el siglo XXI? / Strangulated hernia. Still fatal in the XXI century?

Introducción. El conocimiento de los factores que predisponen a la aparición de complicaciones tras cirugía herniaria urgente es de gran importancia tanto para la priorización de la cirugía electiva como para seleccionar los casos que pueden ser susceptibles de seguimiento clínico. Objetivos. Analizar los factores que condicionan la morbilidad y la mortalidad de la resección intestinal asociada a la reparación herniaria urgente. Pacientes y método. Revisión retrospectiva de las historias clínicas de los pacientes intervenidos urgentemente por afección herniaria desde enero de 2000 hasta diciembre de 2005. Se compararon los resultados obtenidos en función de si fue o no necesaria una resección intestinal. Resultados. De un total de 2.367 pacientes intervenidos por hernias en ese período, en 362 (15,3%; media de edad, 69,5 años; 146 varones y 216 mujeres) fue de forma urgente. Precisaron resección intestinal 60 (16,6%). Presentaron complicaciones 108 (29,8%) y 17 (4,7%) fallecieron tras la intervención. El límite de 70 años discriminó una mortalidad significativamente mayor (el 7 frente al 2%, entre mayores y menores de 70 años, respectivamente; p = 0,01). El grupo de pacientes que precisó resección intestinal tenía una media de edad mayor (75,4 frente a 68,3 años; p = 0,002), más prevalencia de complicaciones totales (el 40,7 frente al 6,2%; p < 0,0001) y una mortalidad significativamente mayor (el 20 frente al 1,6%; p < 0,0001). El análisis de discriminación identificó la resección intestinal como variable independiente predictiva de mortalidad (l de Wilks = 0,89; p = 0,0001; valor predictivo del 85%). Conclusiones. La morbilidad y la mortalidad de la cirugía herniaria urgente que precisa resección intestinal son muy elevadas, especialmente en pacientes de edad avanzada y cuando se trata de hernias crurales (AU)

Introduction. Knowledge of the risk factors that may lead to complications after emergency hernia repair is of great importance, as much for the prioritisation of the elective surgery, as selecting those cases that require clinical follow up. Objectives. To analyse the factors conditioning the morbidity and mortality of bowel resection associated to emergency hernia repair. Patients and method. A retrospective review was carried out on the clinical histories of patients who had emergency operations for hernia problems from January 2000 to December of 2005. The clinical results obtained were compared based on whether or not a bowel resection was required. Results. A total of 2367 patients were operated for hernia in this period, 362 of them (15.3%); for a complicated hernia (mean age 69.5 years; 146 males/216 females); 60 patients needed bowel resection. Complications appeared in 108 patients (29.8%) and 17 (4.7%) died after operation. The limit of 70 years discriminated a significantly greater mortality (> 70: 7% vs < 70 2%; p = 0.01).The group of patients who needed bowel resection showed differences in statistical analysis both in age (75.4 vs 68.3 years; p = 0.002), prevalence of complications (40.7% vs 6.2%; p < 0.0001), and mortality (20% vs 1.6%; p < 0.0001). The discriminant analysis identified bowel resection as the only predictive independent variable of mortality (l Wilks = 0.89; p = 0.0001; predictive value, 85%). Conclusions. Morbidity and the mortality of urgent hernia surgery, when bowel resection was required, are elevated; especially in older patients, and in crural hernias (AU)

[Strangulated hernia. Still fatal in the XXI century?]. / Hernia estrangulada. Todavía mortal en el siglo XXI?

INTRODUCTION: Knowledge of the risk factors that may lead to complications after emergency hernia repair is of great importance, as much for the prioritisation of the elective surgery, as selecting those cases that require clinical follow up. OBJECTIVES: To analyse the factors conditioning the morbidity and mortality of bowel resection associated to emergency hernia repair. PATIENTS AND METHOD: A retrospective review was carried out on the clinical histories of patients who had emergency operations for hernia problems from January 2000 to December of 2005. The clinical results obtained were compared based on whether or not a bowel resection was required. RESULTS: A total of 2367 patients were operated for hernia in this period, 362 of them (15.3%); for a complicated hernia (mean age 69.5 years; 146 males/216 females); 60 patients needed bowel resection. Complications appeared in 108 patients (29.8%) and 17 (4.7%) died after operation. The limit of 70 years discriminated a significantly greater mortality (> 70: 7% vs < 70 2%; p = 0.01). The group of patients who needed bowel resection showed differences in statistical analysis both in age (75.4 vs 68.3 years; p = 0.002), prevalence of complications (40.7% vs 6.2%; p < 0.0001), and mortality (20% vs 1.6%; p < 0.0001). The discriminant analysis identified bowel resection as the only predictive independent variable of mortality (lambda Wilks = 0.89; p = 0.0001; predictive value, 85%). CONCLUSIONS: Morbidity and the mortality of urgent hernia surgery, when bowel resection was required, are elevated; especially in older patients, and in crural hernias.

[Impact of the availability of an external nuclear medicine service in the application of sentinel lymph node biopsy in breast cancer surgery]. / Impacto de la disponibilidad de un servicio externo de medicina nuclear en la aplicación de la biopsia del ganglio centinela en cirugía del cáncer de mama.

INTRODUCTION: To perform sentinel lymph node biopsy (SLNB), nuclear medicine services that have previously undergone a validation phase are required. The aim of the present study was to analyze the possibility of performing this technique with a previously validated, external nuclear medicine service and to study its impact on the indication for radical axillary lymphadenectomy (RAL) and on length of postoperative hospital stay. PATIENTS AND METHODS: We performed a prospective study in a cohort of patients with breast cancer starting from the introduction of SLNB in our center, which was made possible by collaboration with an external nuclear medicine service that performed lymphoscintigraphy and sentinel node detection. Intraoperative detection was performed through a portable probe. The feasibility of the project and its clinical impact were analyzed, taking a reduction in the number of lymphadenectomies and length of hospital stay as endpoints. RESULTS: A total of 196 patients with 201 breast carcinomas were treated. The most frequent interventions were tumorectomy (TC) with SLNB in 124 patients (62%), and TC with SLNB and RAL in 62 patients (31%). Sentinel node visualization on lymphoscintigraphy was achieved in 187/201 carcinomas (93.1%) and sentinel nodes were detected during the intervention in 182/187 carcinomas (97.4%). Sentinel node detection in the internal mammary chain was achieved in 23/201 carcinomas (11.4%). RAL was avoided in 131 of the 201 carcinomas (65%). Days of postoperative hospital stay with or without RAL showed a mean difference of 1.8 days (3.1 vs. 1.3; P < .001). CONCLUSION: SLNB is feasible with the collaboration of an external nuclear medicine service. This technique avoids 65% of RAL and reduces length of postoperative stay by 1.8 days.

Impacto de la disponibilidad de un servicio externo de medicina nuclear en la aplicación de la biopsia del ganglio centinela en cirugía del cáncer de mama / Impact of the availability of an external nuclear medicine service in the application of sentinel lymph node biopsy in breast cancer surgery

Introducción. La realización de la técnica de la biopsia selectiva del ganglio centinela (BSGC) en el tratamiento del cáncer de mama requiere disponer de un servicio de medicina nuclear (SMN) y de la validación de su técnica. El objetivo del presente estudio es analizar la posibilidad de realizar esta técnica con un SMN externo ya validado, y estudiar su impacto en la indicación de la linfadenectomía axilar radical (LAR) y en la estancia postoperatoria. Pacientes y métodos. Estudio prospectivo en una cohorte de pacientes con cáncer de mama a partir de la implantación en nuestro centro de la técnica de la BSGC gracias a la colaboración de un SMN externo que realizaba la linfogammagrafía y la detección del ganglio centinela (GC), en tanto que su identificación intraoperatoria se llevaba a cabo mediante una sonda portátil. Se analiza la viabilidad del proyecto y su impacto clínico tomando como resultados finales la disminución del número de linfadenectomías y la estancia hospitalaria. Resultados. Se ha tratado a 196 pacientes, con 201 carcinomas de mama. Las intervenciones mayoritarias fueron la tumorectomía (TC) con BSGC en 124 casos (62%), y la TC con BSGC y LAR en 62 casos (31%). La visualización del GC en la linfogammagrafía se obtuvo en 187 de 201 casos (93,1%) y se ha detectado el GC durante la intervención en 182 de los 187 (97,4%) casos. La detección de GC en la cadena mamaria interna se ha producido en 23 de los 201 casos (11,4%). Se ha evitado la LAR en 131 de los 201 casos (65%). La diferencia de días de ingreso postoperatorio con o sin LAR fue de una media de 1,8 días (3,1 frente a 1,3; p < 0,001). Conclusiones. La técnica de BSGC ha sido factible con la colaboración de un SMN externo; se evitó el 65% de las LAR y disminuyó la estancia media en 1,8 días (AU)

Introduction. To perform sentinel lymph node biopsy (SLNB), nuclear medicine services that have previously undergone a validation phase are required. The aim of the present study was to analyze the possibility of performing this technique with a previously validated, external nuclear medicine service and to study its impact on the indication for radical axillary lymphadenectomy (RAL) and on length of postoperative hospital stay. Patients and methods. We performed a prospective study in a cohort of patients with breast cancer starting from the introduction of SLNB in our center, which was made possible by collaboration with an external nuclear medicine service that performed lymphoscintigraphy and sentinel node detection. Intraoperative detection was performed through a portable probe. The feasibility of the project and its clinical impact were analyzed, taking a reduction in the number of lymphadenectomies and length of hospital stay as endpoints. Results. A total of 196 patients with 201 breast carcinomas were treated. The most frequent interventions were tumorectomy (TC) with SLNB in 124 patients (62%), and TC with SLNB and RAL in 62 patients (31%). Sentinel node visualization on lymphoscintigraphy was achieved in 187/201 carcinomas (93.1 %) and sentinel nodes were detected during the intervention in 182/187 carcinomas (97.4%). Sentinel node detection in the internal mammary chain was achieved in 23/201 carcinomas (11.4%). RAL was avoided in 131 of the 201 carcinomas (65%). Days of postoperative hospital stay with or without RAL showed a mean difference of 1.8 days (3.1 vs. 1.3; P<.001). Conclusion. SLNB is feasible with the collaboration of an external nuclear medicine service. This technique avoids 65% of RAL and reduces length of postoperative stay by 1.8 days (AU)