The Bandim tuberculosis score: reliability and comparison with the Karnofsky performance score.

BACKGROUND: This study was carried out in Guinea-Bissau's capital Bissau among inpatients and outpatients attending for tuberculosis (TB) treatment within the study area of the Bandim Health Project, a Health and Demographic Surveillance Site. Our aim was to assess the variability between 2 physicians in performing the Bandim tuberculosis score (TBscore), a clinical severity score for pulmonary TB (PTB), and to compare it to the Karnofsky performance score (KPS). METHOD: From December 2008 to July 2009 we assessed the TBscore and the KPS of 100 PTB patients at inclusion in the TB cohort and/or at 1 or more follow-up visits; 61 baseline and 130 follow-up double assessments were obtained. RESULTS: The inter-observer variability of the TBscore (5 symptoms and 6 clinical findings) varied from slight to almost perfect agreement. For the TBscore, all 3 severity classes (SC I-III) were observed, while the KPS only yielded 2 of its 3 possible classes. The grading of PTB patients into severity classes showed moderate agreement for both the TBscore (κ(w) = 0.52, 95% confidence interval 0.46-0.56) and the KPS (κ(w) = 0.49, 95% confidence interval 0.33-0.65). The intra-class correlation coefficient (ICC) was larger for the TBscore than for the KPS (0.822 vs 0.632). CONCLUSIONS: The Bandim TBscore had an acceptable inter-observer variability, seemed to be more disease-related, and performed better than the KPS.

TBscore: Signs and symptoms from tuberculosis patients in a low-resource setting have predictive value and may be used to assess clinical course.

We developed a clinical score to monitor tuberculosis patients in treatment and to assess clinical outcome. We used the WHO clinical manual to choose signs and symptoms, including cough, haemoptysis, dyspnoea, chest pain, night sweating, anaemia, tachycardia, lung-auscultation finding, fever, low body-mass index, low mid-upper arm circumference giving patients a TBscore from 0 to 13. We validated the score with data from a cohort of 698 TB patients, assessing sensitivity to change and ability to predict mortality. The TBscore declined for 96% of the surviving patients from initiation to end of treatment, and declined with a similar pattern in HIV-infected and HIV-uninfected patients, as well as in smear negative and smear positive patients. The risk of dying during treatment increased with higher TBscore at inclusion. For patients with a TBscore of >8 at inclusion, mortality during the 8 months treatment was 21% (45/218) versus 11% (55/480) for TBscore <8 (p< 0.001). TBscore assessed at end of treatment also strongly predicted subsequent mortality. The TBscore is a simple and low-cost tool for clinical monitoring of tuberculosis patients in low-resource settings and may be used to predict mortality risk. Low TBscore or fall in TBscore at treatment completion may be used as a measure of improvement.

Indirect immunofluorescence and real time PCR for detection of Simkania negevensis infection in Danish adults with persistent cough and in healthy controls.

Simkania negevensis is a recently discovered intracellular organism that has been associated with respiratory tract infections. To determine the seroprevalence of the organism in adult Danes and to study the association between the organism and persistent cough, we developed an immunofluorescence assay based on S. negevensis infected Hep2 cells for antibody determination and a real time PCR assay for direct detection of the organism. Among 100 healthy blood donors, 41 (41%) had IgG antibodies to S. negevensis (cut-off titre =1:16) and the antibody level increased with increasing age (correlation coefficient 0.124, p=0.037). 80 of 185 patients (43%) with chronic cough had IgG antibodies to S. negevensis which was no different from the 41% in the control population (Chi2=0.13, p=0.72). None of the patients or controls had any detectable IgA antibodies to S. negevensis. PCR was performed on nasopharyngeal aspirates from a subgroup of 176 patients with persistent cough and in none of these was S. negevensis DNA detected. We conclude that the seroprevalence of S. negevensis is high in Denmark and positively correlated with age. However, we were unable to show an association between S. negevensis and persistent cough.

Gender differences in hospitalization rates for respiratory tract infections in Danish youth.

Overall morbidity and mortality rates in childhood are reported to be higher in males than females. As respiratory tract infections constitute the leading cause of childhood hospitalization, we examined the gender difference in rates of hospitalization due to respiratory tract infections in Danish youth (under age 25). We studied a total of 64,049 hospitalizations for otitis media, pneumonia, influenza, and other acute respiratory tract infections from 1995 to 1999, with calculation of hospitalization rates by age and gender. The male-female hospitalization rate ratio (HRR) for admission due to a respiratory tract infection decreased from 1.45 (95% confidence interval (CI) 1.42-1.48) in the age group 0 - < 5 y, to 1.62 (95% CI 1.55-1.70) in the age group 5 - < 10 y, 1.13 (95% CI 1.04-1.22) in the age group 10 - < 15 y, 0.83 (95% CI 0.76-0.90) in the age group 15 - < 20 y, and 0.87 (95% CI 0.80-0.95) in the age group 20 - < 25 y. In young children, boys were hospitalized more often than girls, but the reverse applied in children and adolescents 15-25 y of age. The study generates the hypothesis that gender plays a role in the susceptibility for respiratory infections in early childhood.

A review of macrolide treatment of atherosclerosis and abdominal aortic aneurysms.

Seroepidemiological studies have shown an association between Chlamydia pneumoniae and atherosclerosis, the risk of acute myocardial infarction and abdominal aortic aneurysms (AAA). Several studies have detected C. pneumoniae in atherosclerotic lesions from coronary and carotid arteries, in AAA, and in sclerotic aortic valves. However, culturing of C. pneumoniae is difficult and has seldomly succeeded from atherosclerotic lesions. Thus, the pathogenicity is unknown, and the significance of detecting the organism is unresolved. Nevertheless, in a large observational study comparing the risk of cardiovascular events among recipients of macrolide versus pencillins, macrolide treatment reduced the risk of such events after relevant adjustment. Furthermore, in two out of three minor randomized clinical trials were patients with ischaemic heart disease were randomized into antibiotic treated and placebo groups, a significant reduction in serious end-points were noticed in patients receiving macrolide. Similarly, two other minor randomized trials showed that macrolide treatment inhibited growth of small AAA. Macrolide therapy thus seems potential to improve the outcome of severe ischaemic heart disease, and growth of AAA. If true, it not known whether this is transient because of macrolide's non-specific anti-inflammatory effect or latent infection, or permanent because of eradicating C. pneumoniae organisms. In order to clarify this, large and long term randomized trials are needed, as well as diagnostic methods that can differentiate between individuals who are or are not infected with C. pneumoniae. The latter are needed in order to clarify the impact of the presence of C. pneumoniae and to avoid overconsumption of antimicrobials, which can result in serious ecological problems.