Estudio de contactos de pacientes con tuberculosis en España: análisis de costes / Tuberculosis Contacts Tracing in Spain: Cost Analysis

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[Translated article] Tuberculosis contacts tracing in Spain: Cost analysis / Estudio de contactos de pacientes con tuberculosis en España: analisis de costes

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Organización del control de la tuberculosis en España: evaluación de una estrategia dirigida a fomentar la acreditación de unidades de tuberculosis / Organization of Tuberculosis Control in Spain: Evaluation of a Strategy Aimed at Promoting the Accreditation of Tuberculosis Units

INTRODUCCIÓN: Un buen control de la tuberculosis (TB) requiere disponer de personal multidisciplinario bien coordinado. El objetivo fue evaluar el impacto de la acreditación de unidades de TB (UTB) fomentada por la Sociedad Española de Neumología (SEPAR) y ver las diferencias entre los centros que se acreditaron y los que no. MATERIAL Y MÉTODOS: DISEÑO: Estudio observacional descriptivo basado en una encuesta autoadministrada entre octubre de 2014 y febrero de 2018 a 139 responsables de neumología registrados por SEPAR, antes y después de la acreditación. VARIABLES: demográficas, epidemiológicas y sobre estudio de contactos, entre otras. Análisis: descriptiva básica, cálculo de medianas para variables continuas y proporciones para categóricas. Se compararon las variables mediante el test chi-cuadrado y regresión logística. RESULTADOS: La tasa de respuesta fue del 54,7 y del 43,2% en el período pre- y postacreditación de UTB, respectivamente. No se observaron cambios en los diferentes ámbitos de atención y coordinación entre la encuesta pre- y postacreditación, ni tampoco en la organización, al analizar los centros acreditados. Al comparar los centros que se acreditaron con los que no, se detectaron diferencias significativas con relación a recogida de conclusión final, manejo de resistencias, coordinación con otros servicios, estudios de contactos o tratamiento directamente observado. CONCLUSIONES: Se ha objetivado cómo abordan la TB diferentes profesionales, se han detectado aspectos positivos y otros mejorables, y se han observando indicadores de mejor funcionamiento en los centros que se acreditaron frente a los que no lo hicieron. Se precisa una supervisión cercana de las UTB para mejorar su efectividad

INTRODUCTION: Well-coordinated multidisciplinary teams are essential for better tuberculosis (TB) control. Our objective was to evaluate the impact of Spanish Society of Pneumology (SEPAR) accreditation of TB Units (TBU) and to determine differences between the accredited and non-accredited centers. MATERIAL AND METHODS: Design Observational descriptive study based on a self-administered survey from October 2014 to February 2018 completed by 139 heads of respiratory medicine departments collected by SEPAR, before and after TBU accreditation. VARIABLES: demographic, epidemiological and contact tracing (CT) variables, among others. Analysis: basic descriptive analysis, and calculation of medians for continuous variables and proportions for categorical variables. The variables were compared using the Chi-squared test and logistic regression. RESULTS: The response rate was 54.7% and 43.2% in the pre- and post-TBU accreditation period, respectively. No differences were observed in the care and coordination variables between the pre- and post-accreditation survey, nor in the organization when only accredited centers were analyzed. When we compared the accredited and non-accredited centers, significant differences were detected in the collection of the final conclusion, management of resistance, coordination with other departments, contact tracing, and directly observed treatment

Organization of Tuberculosis Control in Spain: Evaluation of a Strategy Aimed at Promoting the Accreditation of Tuberculosis Units. / Organización del control de la tuberculosis en España: evaluación de una estrategia dirigida a fomentar la acreditación de unidades de tuberculosis.

INTRODUCTION: Well-coordinated multidisciplinary teams are essential for better tuberculosis (TB) control. Our objective was to evaluate the impact of Spanish Society of Pneumology (SEPAR) accreditation of TB Units (TBU) and to determine differences between the accredited and non-accredited centers. DESIGN: Observational descriptive study based on a self-administered survey from October 2014 to February 2018 completed by 139 heads of respiratory medicine departments collected by SEPAR, before and after TBU accreditation. VARIABLES: demographic, epidemiological and contact tracing (CT) variables, among others. ANALYSIS: basic descriptive analysis, and calculation of medians for continuous variables and proportions for categorical variables. The variables were compared using the Chi-squared test and logistic regression. RESULTS: The response rate was 54.7% and 43.2% in the pre- and post-TBU accreditation period, respectively. No differences were observed in the care and coordination variables between the pre- and post-accreditation survey, nor in the organization when only accredited centers were analyzed. When we compared the accredited and non-accredited centers, significant differences were detected in the collection of the final conclusion, management of resistance, coordination with other departments, contact tracing, and directly observed treatment. CONCLUSIONS: The approach of different professionals with regard to TB has been addressed. Positive aspects and areas for improvement have been detected, and better results were observed in the accredited versus non-accredited centers. A closer supervision of TBUs is necessary to improve their effectiveness.

IGRA testing in patients with immune-mediated inflammatory diseases: which factors influence the results?

Diagnosis of latent tuberculosis infection in patients with immune-mediated inflammatory chronic diseases (IMIDs) can be challenged as diagnostic test reliability could be impaired by immunosuppression. We retrospectively analyzed the Quantiferon Gold-Test in-Tube (QFT-G-IT) results of all patients with IMIDs seen at the Department of Internal Medicine of Son Llàtzer Hospital, Palma de Mallorca (Spain), looking for the factors related to QFT-G-IT indeterminate results. During the study period (2008-2015), 520 patients met the inclusion criteria. Factors associated with indeterminate QFT-G-IT results in a univariate analysis were inflammatory bowel disease, disease activity, lymphopenia, and medium-to-high doses of corticosteroids. In a subsequent multivariate analysis, only lymphopenia (defined as < 1500 cells) was associated with indeterminate QFT-G-IT results. Lymphocyte count was the only factor independently associated with an increased number of indeterminate QFT-G-IT results in patients with different autoimmune diseases. Others factors such as the use of medium-to-high doses of corticosteroids should be considered before testing with QFT-G-IT.

Documento de consenso sobre la prevención y el tratamiento de la tuberculosis en pacientes candidatos a tratamiento biológico / Consensus Document on Prevention and Treatment of Tuberculosis in Patients for Biological Treatment

El riesgo de enfermar de tuberculosis ha aumentado en los pacientes con enfermedades inflamatorias crónicas que reciben tratamiento inmunosupresor, en particular en aquellos tratados con terapia anti-TNF (del inglés tumor necrosis factor). En estos pacientes es obligatoria la detección de la infección tuberculosa latente y el tratamiento de dicha infección, dirigido a reducir el riesgo de progresión a enfermedad tuberculosa. Este documento de consenso resume la opinión de expertos y los conocimientos actuales sobre tratamientos biológicos, incluidos los bloqueantes del TNF. Se establecen recomendaciones para la utilización de las técnicas de liberación de interferón-gamma (IGRA) y la prueba de la tuberculina (PT) para el diagnóstico y el tratamiento de la infección tuberculosa latent

Tuberculosis risk is increased in patients with chronic inflammatory diseases receiving any immunosuppressive treatment, notably tumor necrosis factor (TNF) antagonists therapy. Screening for the presence of latent infection with Mycobacterium tuberculosis and targeted preventive treatment to reduce the risk of progression to TB is mandatory in these patients. This Consensus Document summarizes the current knowledge and expert opinion of biologic therapies including TNF-blocking treatments. It provides recommendations for the use of interferon-gamma release assays (IGRA) and tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection in these patients, and for the type and duration of preventive therapy

Consensus Document on Prevention and Treatment of Tuberculosis in Patients for Biological Treatment.

Tuberculosis risk is increased in patients with chronic inflammatory diseases receiving any immunosuppressive treatment, notably tumor necrosis factor (TNF) antagonists therapy. Screening for the presence of latent infection with Mycobacterium tuberculosis and targeted preventive treatment to reduce the risk of progression to TB is mandatory in these patients. This Consensus Document summarizes the current knowledge and expert opinion of biologic therapies including TNF-blocking treatments. It provides recommendations for the use of interferon-gamma release assays (IGRA) and tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection in these patients, and for the type and duration of preventive therapy.

Role of QuantiFERON(®)-TB Gold In-Tube in tuberculosis contact investigation: experience in a tuberculosis unit.

BACKGROUND: Interferon-γ release assays (IGRAs) are increasingly used for the diagnosis of latent tuberculosis infection (LTBI). Because of the lack of a gold standard for the diagnosis of LTBI, IGRAs are compared to the tuberculin skin test (TST) and yield conflicting results. We assessed the usefulness of an IGRA test, QuantiFERON(®)-TB Gold In-Tube (QFT-G-IT), for diagnosing LTBI compared with TST in the setting of a contact screening study. METHODS: A prospective comparison between the QFT-G-IT and the TST in TB contact subjects in a low TB burden area was conducted sequentially between January 2006 and December 2012. RESULTS: A moderate concordance between the two tests (κ = 0.44 for TST cut-off of 5 mm and κ = 0.56 for TST cut-off of 15 mm) was found. A better agreement was shown in younger contacts and in non-vaccinated contacts when using a TST of 15 mm. Independent risk factors for a TST(+)/QFT-G-IT(-) discordance were history of BCG vaccination and age between 31 and 59 years. Discordance was also more frequent using a TST cut-off value of 5 mm. QFT-G-IT(+)/TST(-) was infrequent and was found in older contacts. CONCLUSIONS: Based on our data, we cannot recommend the use of QFT-G-IT as the only test to rule out LTBI, especially in older patients.

Differential Effect of Modified Medical Research Council Dyspnea, COPD Assessment Test, and Clinical COPD Questionnaire for Symptoms Evaluation Within the New GOLD Staging and Mortality in COPD.

OBJECTIVE: The modified Medical Research Council (mMRC) dyspnea, the COPD Assessment Test (CAT), and the Clinical COPD Questionnaire (CCQ) have been interchangeably proposed by GOLD (Global Initiative for Chronic Obstructive Lung Disease) for assessing symptoms in patients with COPD. However, there are no data on the prognostic value of these tools in terms of mortality. We endeavored to evaluate the prognostic value of the CAT and CCQ scores and compare them with mMRC dyspnea. METHODS: We analyzed the ability of these tests to predict mortality in an observational cohort of 768 patients with COPD (82% men; FEV1, 60%) from the COPD History Assessment in Spain (CHAIN) study, a multicenter observational Spanish cohort, who were monitored annually for a mean follow-up time of 38 months. RESULTS: Subjects who died (n = 73; 9.5%) had higher CAT (14 vs 11, P = .022), CCQ (1.6 vs 1.3, P = .033), and mMRC dyspnea scores (2 vs 1, P < .001) than survivors. Receiver operating characteristic analysis showed that higher CAT, CCQ, and mMRC dyspnea scores were associated with higher mortality (area under the curve: 0.589, 0.588, and 0.649, respectively). CAT scores ≥ 17 and CCQ scores > 2.5 provided a similar sensitivity than mMRC dyspnea scores ≥ 2 to predict all-cause mortality. CONCLUSIONS: The CAT and the CCQ have similar ability for predicting all-cause mortality in patients with COPD, but were inferior to mMRC dyspnea scores. We suggest new thresholds for CAT and CCQ scores based on mortality risk that could be useful for the new GOLD grading classification. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov.

Clinical application of the COPD assessment test: longitudinal data from the COPD History Assessment in Spain (CHAIN) cohort.

OBJECTIVE: The COPD Assessment Test (CAT) has been proposed for assessing health status in COPD, but little is known about its longitudinal changes. The objective of this study was to evaluate 1-year CAT variability in patients with stable COPD and to relate its variations to changes in other disease markers. METHODS: We evaluated the following variables in smokers with and without COPD at baseline and after 1 year: CAT score, age, sex, smoking status, pack-year history, BMI, modified Medical Research Council (mMRC) scale, 6-min walk distance (6MWD), lung function, BODE (BMI, obstruction, dyspnea, exercise capacity) index, hospital admissions, Hospital and Depression Scale, and the Charlson comorbidity index. In patients with COPD, we explored the association of CAT scores and 1-year changes in the studied parameters. RESULTS: A total of 824 smokers with COPD and 126 without COPD were evaluated at baseline and 441 smokers with COPD and 66 without COPD 1 year later. At 1 year, CAT scores for patients with COPD were similar (± 4 points) in 56%, higher in 27%, and lower in 17%. Of note, mMRC scale scores were similar (± 1 point) in 46% of patients, worse in 36%, and better in 18% at 1 year. One-year CAT changes were best predicted by changes in mMRC scale scores (ß-coefficient, 0.47; P < .001). Similar results were found for CAT and mMRC scale score in smokers without COPD. CONCLUSIONS: One-year longitudinal data show variability in CAT scores among patients with stable COPD similar to mMRC scale score, which is the best predictor of 1-year CAT changes. Further longitudinal studies should confirm long-term CAT variability and its clinical applicability. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01122758; URL: www.clinicaltrials.gov.

New GOLD classification: longitudinal data on group assignment.

RATIONALE: Little is known about the longitudinal changes associated with using the 2013 update of the multidimensional GOLD strategy for chronic obstructive pulmonary disease (COPD). OBJECTIVE: To determine the COPD patient distribution of the new GOLD proposal and evaluate how this classification changes over one year compared with the previous GOLD staging based on spirometry only. METHODS: We analyzed data from the CHAIN study, a multicenter observational Spanish cohort of COPD patients who are monitored annually. Categories were defined according to the proposed GOLD: FEV1%, mMRC dyspnea, COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ), and exacerbations-hospitalizations. One-year follow-up information was available for all variables except CCQ data. RESULTS: At baseline, 828 stable COPD patients were evaluated. On the basis of mMRC dyspnea versus CAT, the patients were distributed as follows: 38.2% vs. 27.2% in group A, 17.6% vs. 28.3% in group B, 15.8% vs. 12.9% in group C, and 28.4% vs. 31.6% in group D. Information was available for 526 patients at one year: 64.2% of patients remained in the same group but groups C and D show different degrees of variability. The annual progression by group was mainly associated with one-year changes in CAT scores (RR, 1.138; 95%CI: 1.074-1.206) and BODE index values (RR, 2.012; 95%CI: 1.487-2.722). CONCLUSIONS: In the new GOLD grading classification, the type of tool used to determine the level of symptoms can substantially alter the group assignment. A change in category after one year was associated with longitudinal changes in the CAT and BODE index.

Valor de QuantiFERON-TB Gold Test in Tube en el diagnóstico de tuberculosis pulmonar y extrapulmonar / Quantiferon-TB-gold in tube test in the diagnosis of pulmonary and extra-pulmonary tuberculosis

Introducción Los test de detección in vitro de Interferón-gamma frente a Mycobacterium tuberculosis (MTB) podrían ser una herramienta útil en el diagnóstico de enfermedad tuberculosa activa. Métodos Se realiza el test QuantiFERON-TB-Gold test in Tube (QFG-IT) en la sangre de 118 pacientes con tuberculosis pulmonar activa y se compara el resultado con la prueba de tuberculina. Resultados El estudio de QFG-IT fue positivo en 94 casos (79,7%), negativo en 17 (14,4%) e indeterminado en 7 (5,9%). QFG-IT negativo o indeterminado fue más frecuente en pacientes más ancianos (p=0,017) y en los casos de baciloscopia (..) (AU)

Introduction: The Interferon-gamma in vitro detection tests could be a useful tool in the diagnosis of active tuberculosis compared to Mycobacterium tuberculosis (MTB). Methods: The QuantiFERON-TB-Gold in Tube (QFG-IT) test was performed on the blood of 118 patients with active tuberculosis and the results compared with the tuberculin test. Results: The QFG-IT test was positive in (..) (AU)

[Quantiferon-TB Gold In-Tube test in the diagnosis of pulmonary and extra-pulmonary tuberculosis]. / Valor de QuantiFERON-TB Gold Test in Tube en el diagnóstico de tuberculosis pulmonar y extrapulmonar.

INTRODUCTION: The Interferon-γ in vitro detection tests could be a useful tool in the diagnosis of active tuberculosis compared to Mycobacterium tuberculosis (MTB). METHODS: The QuantiFERON-TB-Gold in Tube (QFG-IT) test was performed on the blood of 118 patients with active tuberculosis and the results compared with the tuberculin test. RESULTS: The QFG-IT test was positive in 94 cases (79.7%), negative in 17 (14.4%) and indeterminate in 7 (5.9%). A negative or indeterminate QFG-IT test was more common in older patients (P=0.017) and in cases with negative smear tests (P=0.041). The kappa agreement between the tuberculin and QFG-IT tests was 74.5% with a kappa value of 0.45 (SE:0.136). Thirteen of the patients studied were infected with HIV and the tuberculin was positive in 5 of the 12 cases (38.5%) in whom it was performed, with the QFG-IT being positive in 9/13 (69.2%). CONCLUSIONS: The QFG-IT test may be a useful complimentary tool to the tuberculin test in the diagnosis of tuberculosis.