Differences in clinical presentation among persons with pulmonary tuberculosis: a comparison of documented and undocumented foreign-born versus US-born persons.

BACKGROUND: Most cases of tuberculosis (TB) in the United States are diagnosed in foreign-born persons, and undocumented foreign-born persons may face particular barriers to timely access to health care services. This study investigates whether differences in clinical presentations among persons with pulmonary TB are associated with foreign birth or documentation status. METHODS: In this cross-sectional study, we reviewed the medical records of patients who had received a diagnosis of microbiologically proven pulmonary TB at a New York City public hospital during the period April 1999 through March 2005. Three groups of patients with pulmonary TB (US-born persons, foreign-born persons with documents, and undocumented, foreign-born persons) were defined and compared at presentation. Odds ratios (ORs) for a symptom duration >or=8 weeks before hospital admission for each group were estimated using logistic regression. RESULTS: Among 194 subjects with newly diagnosed pulmonary TB, 61 (31%) were US born, 62 (32%) were documented foreign-born persons, and 71 (37%) were undocumented foreign-born persons. Undocumented foreign-born persons presented with significantly higher frequencies of cough (P = .020) and hemoptysis P = .012 and had a significantly longer median duration of symptoms, compared with US-born persons (8 vs. 4 weeks; P = .023). No statistically significant differences between documented foreign-born and US-born persons were observed. Multivariate analysis revealed that undocumented status (compared with being US born; adjusted OR, 4.1; 95% confidence interval, 1.7-10.2; P = .0002) and being unemployed (adjusted OR, 2.2; 95% CI, 1.1-4.5; P = .023) were independently associated with a prolonged symptom duration (i.e., >or=8 weeks). CONCLUSIONS: Undocumented status was associated with an increased frequency of cough and hemoptysis and a longer duration of symptoms before medical evaluation for pulmonary TB. Whether reducing barriers to health services for undocumented foreign-born persons could enhance TB control deserves additional study.

Mycobacterium tuberculosis malate synthase- and MPT51-based serodiagnostic assay as an adjunct to rapid identification of pulmonary tuberculosis.

The 81-kDa malate synthase (MS; Rv 1837c) and the 27-kDa MPT51 (Rv 3803c) of Mycobacterium tuberculosis are immunodominant antigens recognized by serum antibodies from approximately 80% of human immunodeficiency virus-negative smear-positive tuberculosis patients from India. We now provide evidence that the use of the MS/MPT51-based serodiagnostic assay can serve as an adjunct to sputum microscopy in the rapid diagnosis of pulmonary tuberculosis.

Abnormal predicted diffusion capacities in healthy Asians: an inequality with a solution.

BACKGROUND: Asian lung volumes are 10-15% less than those of Caucasians. OBJECTIVES: To test the hypothesis that healthy Asians might be labeled as abnormal using three commonly used Caucasian-derived prediction equation estimates (PEE) of DLCO currently used. In addition, a Chinese-derived PEE of DLCO was tested to determine its validity in non-Chinese Asians. METHODS: Forty-one healthy Asians underwent DLCO testing. Controls consisted of the PEE and 12 healthy Caucasians. Measured DLCO was compared with the Miller, Knudson, Crapo and one Chinese PEE. Abnormal was defined as a DLCO <80% predicted. Gas dilution and plethysmography estimated alveolar volume. Proportions in parentheses in the results below are DLCO adjusted for alveolar volume. RESULTS: The average Asian DLCO was 25.75 +/- 5.55 ml/min/mm Hg, no different than the predicted DLCO of 25.29 +/- 5.53 seen with Chinese PEE. This was different (p < 0.01) than the predicted DLCO of 27.82 +/- 5.09, 33.66 +/- 6.29, and 31.64 +/- 5.33 for the Miller, Knudson, and Crapo equations, respectively. This resulted in 4/41 (0/41), 27/39 (2/39), 21/41 (3/41) and 1/41 (0/41) DLCO measurements being defined as abnormal using Miller, Knudson, Crapo and Chinese PEE, respectively. In Caucasians, the measured DLCO was similar to the Miller but significantly lower than the Knudson and Crapo PEE. Measured lung volumes were significantly smaller compared to predicted for the three Caucasian PEE in Asians, with no difference in Caucasians. There was no difference in measured lung volumes and Chinese PEE. CONCLUSIONS: Current Caucasian PEE for DLCO when used in healthy Asians result in an abnormal reading that is incorrect from 10 to 50% of the time. This PEE failure is related to a reduction in lung volume not accounted for. The Chinese PEE for DLCO works for non-Chinese Asians and should replace Caucasian PEE in the US in all Asians.

Pneumococcal Vaccination in Adults.

Pneumococci remain the most common etiology of community-acquired pneumonia in adults, with significant attendant mortality in the elderly. With the recognition of increasing rates of drug-resistant Streptococcus pneumoniae in recent years, efforts to prevent disease through vaccination have gained greater impetus. The 23-valent pneumococcal vaccine is used widely in the United States and provides effective protection against bacteremic pneumococcal disease, particularly in the immunocompetent host. The 7-valent pneumococcal conjugate vaccine, licensed in the United States in 2000, has had a dramatic impact on pneumococcal disease in the pediatric population, and its use in children has had effects on incidence rates in nonimmunized adults as well. Future directions include efforts to improve vaccination coverage in targeted populations and the development of more immunogenic and efficacious vaccines for high-risk groups.