Table of Content

10 May 2019, Volume 41 Issue 5

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Expert Note

Regulating tuberculosis medical care and achieving no affected families facing catastrophic costs due to tuberculosis

Biao XU

Chinese Journal of Antituberculosis. 2019, 41(5):  485-487.  doi:10.3969/j.issn.1000-6621.2019.05.004

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Tuberculosis (TB) is a disease closely related to poverty. With the government commitment, TB medical care are financed by government with free of charge services in many high TB-burden countries at present. However, the economic burden of TB patients for medical care is still heavy in some countries and the situation of catastrophic health costs due to TB is not optimistic. Direct medical cost has been the main economic burden to TB patients in China. An in-depth analysis on the composition of direct medical cost and the details of medical service could provide evidences on quality of TB medical care, and the relevance and necessity of each service. Understanding the direct medical costs is the premise to reduce the economic burden of TB patients and achieve the targets of “End TB” strategy.

Original Articles

The value of protective lung ventilation during anesthesia for tuberculous destructuve pneumonectomy

Zhi-guo SHI,Yan-hua SONG,Ling-hai LI,Wen-ting ZHAI,Tao LIU,Bin CHEN

Chinese Journal of Antituberculosis. 2019, 41(5):  488-493.  doi:10.3969/j.issn.1000-6621.2019.05.005

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Objective To discuss the impact of respiratory mechanics, intrapulmonary shunt (Qs/Qt), PaO₂ and postoperative pulmonary infection during one-lung ventilation (OLV) using small tidal volume and positive end-expiratory pressure (PEEP) with pressure controlled ventilation (PCV) in total pneumonectomy with tuberculous destroyed lung (TDL). Methods TThe present study was approved by the medical ethics committee of Beijing Chest Hospital affiliated to Capital Medical University. The study enrolled 48 TDL patients receiving selective thoracotomic total pneumonectomy from August 2016 to March 2018. A random number table was used to divide the patients into observation group and control group, 24 cases in each group. The tidal volume of the observation group was 6 ml/kg during OLV, and PCV was administered immediately from the beginning of OLV followed by PEEP at 7cm H₂O (1cm H₂O=0.0098kPa). The tidal volume of the control group was 8 ml/kg during OLV. Airway peak pressure (P_peak) and plateau pressure (P_plat) before OLV (T₁), 30 min after OLV (T₂) and 5 min after total pneumonectomy (T₃) were recorded. Arterial and venous blood samples were collected at T₁, T₂, T₃ and at 6h after surgery (T₄), the blood gas indicators pH, PaCO₂ and PaO₂ were measured, and Qs/Qt ratio was calculated. Clinical pulmonary infection was scored at day 1 and day 7 after surgery. Measurements were compared between the two groups; paired t-test was used for the comparison if there was homogeneity of variance; otherwise, t'-test was used. Repeated-measures analysis of variance was performed for intragroup comparisons. Counting data were analyzed by χ² test, P<0.05 was statistically significant. Results Compared with the control group, P_peak (observation group: (21.0±2.2)cm H₂O; control group: (22.4±2.2)cm H₂O; t=-2.446, P=0.021)and P_plat (observation group: (19.7±2.2)cm H₂O; control group: (21.0±2.7)cm H₂O; t=-3.610, P=0.001) in the observation group decreased significantly at T₂ and the pH value of the observation group at T₃ decreased significantly (observation group: 7.34±0.053; control group: 7.37±0.047; t=-3.000, P=0.006). At T₂, PaCO₂ of the observation group was significantly higher than that of the control group (observation group: (44.0±2.2)mm Hg (1mm Hg=0.133kPa); control group: (35.7±4.0)mm Hg; t=7.091, P=0.000), while Qs/Qt ratio decreased significantly (observation group: (21.4±5.4)%; control group: (25.4±6.8)%; t=-0.256, P=0.020). Compared with the control group at T₄, the PaO₂/FiO₂ ratio of the observation group increased significantly (observation group: (181.2±29.0)mm Hg; control group: (159.1±25.2)mm Hg; t=2.938, P=0.009). At the first day post operation, the pulmonary infection scores of the observation group decreased significantly compared with that of the control group (observation group: 4.7±0.6; control group: 5.2±0.9; t=-2.567, P=0.017).Conclusion Small tidal volume and PEEP with PCV could effectively reduce airway pressure and Qs/Qt ratio during OLV for thoracotomic total pneumonectomy, and improve PaO₂ and pulmonary infection scores of TDL patients at the first day postoperative.

The application value of interventional bronchosopic techniques in treating the middle lobe syndrome due to tracheobronchial tuberculosis

Qian SHI,Rong-rong WANG,Guang-yu ZHANG,Zhi CHEN

Chinese Journal of Antituberculosis. 2019, 41(5):  494-498.  doi:10.3969/j.issn.1000-6621.2019.05.006

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Objective To investigate the application value of interventional bronchosopic techniques in treating the middle lobe syndrome due to tracheobronchial tuberculosis.Methods The date of 118 cases who were diagnosed the middle lobe syndrome due to tracheobronchial tuberculosis from November 2015 to December 2017 in the 8th Medical Center of Chinese PLA General hospital were analyzed retrospectively. The patients were divided into discovery group (n=82) and control group (n=36) by different treatment schedules. The asymptomatic, imaging appearances, bronchoscopy, ratings of short breath and effects of treatment were compared between the two groups.Results The ratings of short breath at 6 months after discharge in the discovery group and control group was (0.74±0.12) and (1.36±0.07), respectively, and the difference was statistically significant (t=2.791,P=0.006). The overall effective rate in the two groups was 80.5% (66/82) and 61.1% (22/36), respectively, and the difference was statistically significant (χ ²=12.743, P= 0.002). Conclusion The interventional bronchoscopic technique is an important treatment of patients with middle lobe syndrome due to tracheobronchial tuberculosis, and can improve the effective rate.

Tuberculous pyothorax combined with pleural angiosarcoma:a case report and review of the literature

Bin ZHAO,Gao-feng QIAO,Feng JIN,Cheng WANG,Lei SUN,Xiu-zhen. YANG

Chinese Journal of Antituberculosis. 2019, 41(5):  499-509.  doi:10.3969/j.issn.1000-6621.2019.05.007

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Objective The clinical features of tuberculous pyothorax combined with pleural angiosarcoma were summarized and analyzed in order to improve clinical diagnosis and treatment.Methods The clinical manifestation, laboratory findings, treatment and prognosis of one case with tuberculous pyothorax combined with pleural angiosarcoma who were admitted to Shandong Provincial Chest Hospital Affiliated to Shandong University in September 2016 were reported, and the corresponding domestic and foreign literatures were reviewed and analyzed. The PubMed, Wanfang, and CNKI databases were searched by using “pleural angiosarcoma” and “pleura; angiosarcoma” as search terms and the date of retrieval was set from January 1995 to November 2018. The patient’s general condition, past medical history, imaging performance, pathological immunohistochemistry results, treatments, outcome and duration of disease were collected.Results The 56-year-old male patient complained of dyspnea, cough for more than one month, and blood-stained sputum for 20 days. The patient underwent multiple thoracotomies. The pathological diagnosis was tuberculous empyema complicated with pleural angiosarcoma. The patient died after 17 months of onset. A total of 31 articles were retrieved through literatures review. Data on 32 patients with pleural angiosarcoma were obtained. The total number of subjects was 33 cases including the case reported in this study. There were 23 males and 10 females, who aged from 24-87 years (average 64.12±13.90 years). For past medical history, 9 cases had a tuberculous pyothorax history and 1 case had a pyothorax history; 2 cases had received chemoradiotherapy and 1 case had received radiotherapy only; and 1 case had a history of dust exposure. The lesions were located in the right hemithorax in 14 cases, the left hemithorax in 12 cases, and in bilateral thorax in 7 cases. There were 4 cases with pleural fluid only, 12 cases with pleura-thicking and pleural mass, and 17 cases with both plrural fluid, pleura-thinking and pleural mass; 16 cases were confirmed with hemothorax; 5 cases deve-loped metastases; 27 cases were positive with CD31, 17 cases positive with CD34, 15 cases positive with Vimentin, and 9 cases positive with Factor Ⅷ-related antigen. The therapy methods included surgery, chemotherapy, radiotherapy, interventional arterial embolism, microwave ablation, pleural immobilization, vascular-targeted drugs. All of the 33 cases were diagnosed by pathology. The therapies included surgery (14 cases), chemotherapy (10 cases), radiotherapy (6 cases), interventional arterial embolization (2 cases), microwave ablation (1 case), pleural fixation (3 cases), and targeted drug therapy (5 cases). Duration of disease were 2 months to 15 years, with a media time of 7 months. At last, 24 patients died, 3 had unknown outcome, 3 lost were lost to follow-up, and 3 patients were still alive at the last follow-up.Conclusion The clinical manifestations of pleural angiosarcoma are not typical. Tuberculous pyothorax is high risk factor for pleural angiosarcoma. Pleural angiosarcoma should been taken into considera-tion when unexplained osmolar lesion occurs in tuberculous pyothorax.

Analysis of risk factors of postoperative non-healing of spinal tuberculosis patients

Bang-yin LI,Yu PU,Min HE,Xi JIANG,Hai LI,Lin LIU,Lei HE,Ming-cang HUAN,Yu-guo CAI,Yong LIU

Chinese Journal of Antituberculosis. 2019, 41(5):  510-514. 

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Objective To explore the influencing factors of postoperative non-healing of patients with spinal tuberculosis.Methods A total of 312 patients with spinal tuberculosis admitted to the Chengdu Public Health Clinical Medical Center from January 2012 to December 2016 were included in the study. Among them, 24 were unhealed by surgery and 288 were cured. Data on gender, age, nutritional status, time from onset to visit, surgical approach, anti-tuberculosis drug treatment plan, patient compliance, spinal lesion segment, whether concurrent with other parts of the tuberculosis, drug resistance, lesion removal, internal fixed stability, duration of preoperative standard anti-tuberculosis treatment, follow-up of the whole process, assessment of anti-tuberculosis efficacy were collected. The factors that led to the non-healing after surgery were analyzed.Results In the unhealed group, patients with nonstandard anti-tuberculosis drugs, spinal lesions more than two segments, drug-resistant tuberculosis, incomplete removal of lesions, irregular follow-up of the whole process, invalid efficacy of anti-tuberculosis therapy, interval from onset to visit of longer than 12months, and posterior surgery accounted for 75.0% (18/24), 66.7% (16/24), 41.7% (10/24), 66.7% (16/24), 58.3% (14/24), 58.3% (14/24), 41.7% (10/24), and 66.6% (16/24), which were higher than those of the patients in the cured group (27.4% (79/288), 35.8% (103/288), 12.1% (35/288), 35.8% (103/288), 26.4% (76/288), 29.2% (84/288), 4.9% (14/288), and 17.7% (51/288)); the differences were statistically significant (χ ² values were 10.11, 7.19, 15.64, 8.97, 11.01, 8.75, 12.14, 12.29, all P values ＜0.05). Multivariate logistic regression analysis showed that irregular antituberculous drugs (OR (95%CI)=3.15 (1.03-9.64)), spinal lesions more than two segments (OR (95%CI)=2.52 (1.29-4.94)), drug-resistant tuberculosis (OR (95%CI)=4.31 (1.25-14.88)), incomplete removal of the lesion (OR (95%CI)=4.90 (1.39-17.27)), irregular follow-up throughout the course (OR (95%CI)=3.99 (1.39-17.27)), invalid efficacy of anti-tuberculosis therapy (OR (95%CI)=4.46 (1.34-11.84)), onset to visit interval >12months (OR (95%CI)=12.30 (2.20-68.80)), and posterior approach (OR (95%CI)=6.51 (1.77-23.91)) were the risk factors for postoperative non-healing of spinal tuberculosis patients. Conclusion Early diagnosis and treatment, standardized anti-tuberculosis program, avoiding adaptive drug resistance, choosing anterior approach as much as possible, removing the lesion thoroughly, paying attention to regular follow-up after surgery, and adjusting irrational anti-tuberculosis drug program can reduce the rate of postoperative non-healing of tuberculosis.

The effect of retrograde resistance exercise on postoperative rehabilitation of middle-aged and elderly patients with spinal tuberculosis complicated with osteoporosis

Ya-juan AI,Na BI,Xing-yan YU,Ying ZHANG,Ya-ru ZHANG,Le-le WANG,Xiao-bo. LUO

Chinese Journal of Antituberculosis. 2019, 41(5):  515-520.  doi:10.3969/j.issn.1000-6621.2019.05.009

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Objective To explore the long-term effect of retrograde resistance exercise on postoperative rehabilitation of middle-aged and elderly patients with spinal tuberculosis complicated with osteoporosis.Methods From May 2014 to September 2016, 108 cases of middle-aged and old patients with spinal tuberculosis complicated with osteoporosis were admitted to the Spinal Minimally Invasive Department of the Eighth Medical Center of PLA General Hospital (the 309th Hospital of PLA), among whom 40 cases were selected randomly (control group). From October 2016 to May 2018, 92 middle-aged and old patients with spinal tuberculosis complicated with osteoporosis were admitted to the same department, among whom 40 patients were selected randomly (observation group). In the control group, the patients received routine functional exercise after the debridement and bone graft fixation, and patients of the observation group received retrograde resistance exercise by wearing a brace in the condition that the plate was well fixed by CT examination on the 14th day after the surgery. Disability index (ODI), intervertebral bone graft block total integration, functional recoveryⅠlevel degree, bone mineral density (BMD) of the right femoral neck were compared between the two groups of patients after 1 month, 3 months and 6 months discharged from hospital.Results The ODI of the patients of observation group were (10.35±3.26), (8.86±2.94) and (6.78±2.84) respectively after 1 month, 3 months and 6 months discharge, which were significantly lower than those of the control group ((12.34±3.56), (10.95±3.12) and (8.94±2.76) respectively) (t=2.607, 3.083, 3.449, P=0.005, 0.001, 0.000). The numbers of patients with the intervertebral bone graft fusion of recorery Ⅱ level in observation group were 5 (12.5%), 30 (75.0%) and 40 (100.0%) after 1 month, 3 months and 6 months respectively, which were significantly higher than those in control group (0 (0.0%), 20 (50.0%) and 34 (85.0%) respectively) (χ ²=5.333, 5.333, 6.486, P=0.021, 0.021, 0.011). The numbers of patients with the function of recovery I level in observation group were 5 (12.5%), 15 (37.5%) and 35 (87.5%) respectively, which were also significantly better than those in control group (0 (0.0%), 6 (15.0%), and 26 (70.0%)) (t=5.333, 5.230, 5.591, P=0.021, 0.022, 0.018). The BMD of the right femoral neck in observation group were (0.45±0.02)g/cm ², (0.47±0.02)g/cm ² and (0.47±0.03)g/cm ² respectively after 1 month, 3 months and 6 months, which were lower than those of control group ((0.46±0.01)g/cm ², (0.46±0.03)g/cm ², (0.46±0.02)g/cm ²)). There were significant differences of BMD of the right femoral neck after 3 months and 6 months between the two groups (t=1.701, 1.682, P=0.046, 0.048). Conclusion The intervention of retrograde resistance movement is conducive to postoperative functional recovery, complete fusion recovery of intervertebral bone grafts, and increase of bone density in the right femoral neck, and in order to promote the recovery of patients.

Efficacy of anterior revision on failure in patients with thoracolumbar tuberculosis underwent posterior fixation

Xin ZHONG,Qiang ZHANG,Zu-yuan XU,De-jian. FANG

Chinese Journal of Antituberculosis. 2019, 41(5):  521-528.  doi:10.3969/j.issn.1000-6621.2019.05.010

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Objective To investigate the efficacy of anterior revision, which is complete focus debridement and/or bone graft fusion, on failure in patients with thoracolumbar tuberculosis underwent posterior fixation.Methods The clinical data were collected from 32 failure patients with thoracolumbar tuberculosis underwent anterior revision and performed anterior revision in Guangzhou City chest hospital during March 2011 to January 2017. Operative treatment scheme was evaluated and the clinical manifestations, erythrocyte sedimentation rates (ESR), pain visual analogue scale (VAS) before operation and three months after operation were compared. At last follow up, neurological function and bone graft fusion were evaluated according to the criteria approved by American Spinal Injury Association (ASIA). SPSS 19.0 software was used for statistical analysis of the data. The data were measured by paired t-test. The difference was statistically significant when P less than 0.05.Results All the patients were treated with anti-tuberculosis drugs for 1.5-2 years after operation and followed up for 2-2.5 years. During the follow-up period, no loosening of internal fixation, obvious displacement of bone graft and rupture of bone graft were observed by X-ray and CT. At the last follow-up, all patients were cured and no case was relapse. At the time of discharge, 2 patients with a long sinus had not completely healed, but they were cured underwent dressing change for 2 to 3 months, the others were good healing. The VAS score(1.25±0.87) and the ESR value ((7.09±3.59)mm/1h) at the third month after operation were significantly lower than those ((6.06±1.60) in VAS score and (69.21±25.76)mm/1h in ESR) before operation with significant statistically difference(t=18.004 and 13.766,Ps<0.05). The ASIA neurological function was improved from grade E in 29 cases, grade D in one case and grade C in 2 cases before operation to grade E in 29 cases, grade D in 3 cases and no case with grade C after operation. The bone graft fusion according to Brantigan fusion standard was grade E in 31 cases and grade C in one case.Conclusion Anterior revision is an effective treatment for failure patients with thoracolumbar tuberculosis underwent posterior fixation.

Analysis of epidemic characteristics of non-tuberculous mycobacterium strains in Shenzhen between 2013-2017

Chuang-yue HONG,Jin-li LI,Guang-lu ZHAO,Jing GUI,Yu-mei ZHU,Zheng YANG,Wei-ye. YU

Chinese Journal of Antituberculosis. 2019, 41(5):  529-533.  doi:10.3969/j.issn.1000-6621.2019.05.011

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Objective To explore epidemiologic characteristics of non-tuberculous mycobacterium (NTM) in Shenzhen to provide the basis for the control strategies of NTM.Methods Sputum were collected from 37630 suspected tuberculosis patients selected from Shenzhen Center for Chronic Disease Control or each County Chronic Disease Control Hospital from 2013 to 2017. All the samples were cultured using BACTEC MGIT 960 and traditional culture, of them, 8850 strains were detected positive. MPB64 method and traditional PNB test were used to identify Mycobacterium tuberculosis complex and NTM preliminary. The initial NTM was further identified by the HAIN genotyping method. The year of onset, sex, age, infection types, regions, household registration source and the distribution characteristics of NTM strains were analyzd using Chi-squeare test, P<0.05 was considered statistically significant.Results With prevalence of 4.14% (366/8850),366 initial NTM strains were identified by 8850 mycobacterial strains. Two hundred and ninety-three NTM were further identified with the identification rate of 80.05% (293/366) by HAIN genotyping method. The prevalence of NTM showed a slight upward trend from 2013 to 2017 in Shenzhen (3.81% (71/1864)-4.50% (82/1821)), but there was no statistically significant difference (χ ²=1.159, P=0.885). In 366 NTM patients, the prevalence for female (4.87% (144/2957)) was more higher than male(3.77% (222/5893)) (χ ²=6.038,P=0.014). The infection peak age of NTM patients was 25-34-year-old for both male and female (28.83% (64/222) and 23.61% (34/144)), but no statistically significant was found (χ ²=1.213,P=0.271). The NTM rates in new patients, suburban patients, floating patients and suburban floating patients (2.31% (187/8104), 1.77% (105/5909), 3.89% (324/8323)and 1.61% (91/5663), respectively) were significantly lower than those of retreatment patients (23.99% (179/746)), downtown patients (8.87% (261/2941)), register patients (7.97%(42/527)) and downtown floating patients (8.77% (235/2681)) (χ ²=810.400, 249.512, 20.778 and 248.418, respectively, all P=0.000). Of the 293 NTM, Mycobacterium abscessus (41.64% (122/293)), Mycobacterium avium (22.18% (65/293)) and Mycobacterium kansas (16.04% (47/293)) were most common. In addition, mixed infection were found in 7 cases (2.39%(7/293)). Conclusion The prevalence of NTM has been stable in Shenzhen in recent years and NTM is various. Mycobacterium abscessus, Mycobacterium avium and Mycobacterium kansasii are the main strains isolated and the prevalence is higher in young adults. The epidemic situation of female patients, retreatment patients, downtown patients, register patients and downtown patients should be paid more attention.

Analysis of strains identification and drug susceptibility characteristics of non-tuberculous mycobacterium isolated in Guangzhou

Dong-xin LIU,Hui-wen ZHENG,Wen-cong HE,Yi-meng SONG,Ping HE,Bing ZHAO,Xi-chao OU,Chun-fa LIU,Yan-Lin ZHAO

Chinese Journal of Antituberculosis. 2019, 41(5):  534-540.  doi:10.3969/j.issn.1000-6621.2019.05.012

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Objective To evaluate the species of non-tuberculous mycobacterium (NTM) isolated from Guangzhou Chest Hospital and perform drug susceptibility testing on these strains, to provide scientific basis for the diagnosis and treatment of NTM disease. Methods In 2016, 717 clinical mycobacterium isolates were collected from Guangzhou Chest Hospital, obtained from 1250 sputum species. All isolates were subjected to pnitrobenzoic acid (PNB) and 2 thiophene carborylic acid hydrazide (TCH) testing to distinguish Mycobacterium tuberculosis (MTB) from NTM. Then multi-locus polymerase chain reaction sequencing analysis was carried out to identify the NTM strains (confirmed by PNB and TCH) to species level. Furthermore, microporous plate method contained 18 antimicrobials was conducted to confirm the minimal inhibitory concentrations (MICs) of different NTM species. Results Among the 717 clinical mycobacterium isolates, 106 (14.4%, 106/717) NTM isolates were confirmed, and 103 isolates were available. According to the species identification assay, the most frequently isolated NTM species was Mycobacterium abscessus (34.0%, 35/103), followed by Mycobacterium intracellulare (25.2%, 26/103), Mycobacterium massiliense (20.4%, 21/103), Mycobacterium avium (9.7%, 10/103), Mycobacterium Kansasii (5.8%, 6/103), Mycobacterium fortuitum (1.9%, 2/103), Mycobacterium flavobacteriae (0.9%, 1/103), Mycobacterium porcine (0.9%, 1/103) and Mycobacterium acapulcensis (0.9%, 1/103) in Guangzhou. According to the drug susceptibility testing results of 98 NTM strains, amikacin (93.9%, 92/98), clarithromycin (91.8%, 90/98) and azithromycin (71.4%, 70/98) were the three most effective agents for NTM infection. However,rifampicin (89.8%,88/98), levofloxacin (83.7%,82/98) and imipenem (77.6%,76/98) were the most resistant drugs to NTM. Furthermore, the different drug susceptibility profiles of different NTM species was also characterized. Conclusion The NTM incidence in Guangzhou is much higher than other regions in China, Mycobacterium abscessus and Mycobacterium intracellular are the two most prevalent NTM species. Clarithromycin and amikacin are the preferred antimicrobials for treatment of NTM disease, doctors should pay more attention to the resistante of rifampicin and levofloxacin in clinical.

Analysis of drug susceptibility and drug resistance gene locus mutation in 958 tuberculosis patients

Xiao-li CUI,Han YANG,Xia WU,Dan ZHENG,Zhen-yu YOU,Li-yun. DANG

Chinese Journal of Antituberculosis. 2019, 41(5):  541-545.  doi:10.3969/j.issn.1000-6621.2019.05.013

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Objective Analysis of mutation sites of drug resistance genes in 958 M.tuberculosis clinical isolates.Methods The positive mycobacterial cultures of 2718 patients were collected from various clinical specimens such as sputum, tissue, and pleural effusion in Xi’an Chest Hospital from January to December 2017. Forty-one cases of non-tuberculous mycobacterial infection and 2677 cases of Mycobacterium tuberculosis infection were distinguished by strains identification.The information including results of M.tuberculosis cultures and drug susceptibility test (“drug sensitivity test”) by MGIT 960 liquid and drug resistance test by gene chip in 958 patients were collected.The coincidence rate of mutation sites and phenotypic drug susceptibility test results were analyzed. The count data were analyzed by χ² test, and P<0.05 was considered statistically significant.Results The mutation rate of a single site was 19.52% (187/958) in all of the clinical isolates.The ropB gene mutation rates in the 5-, 21-, 41-, 61-83 age groups were 7.89% (9/114), 13.52% (63/466), 18.27% (38/208), and 9.41% (16/170), respectively. The mutation rate of the ropB in the middle-aged group was statistically different from that in the adolescent group (χ²=6.358, P=0.013) and the elderly group (χ²=5.994, P=0.018). The mutation rate at any one site was 19.45% (121/622) in the male population and 19.05% (64/336) in the female population.There was no significant difference between the male and female groups (χ²=0.023, P=0.932). There was a higher coincidence rate in mutation of rifampicin ropB 531 (C-T) (96.10%, 74/77) and isoniazid katG 315 (G-C) (98.45%, 127/129) and the phenotypic susceptibility. However, ropB 511 (T-C) was inferior coincidence rate to rifampicin phenotype (0.00%,0/10).Conclusion T here was a statistically significant difference in the mutation rate of ropB gene locus in patients of different age groups.The mutation rate of ropB gene happened in the middle-aged group was the highest. There was no significant difference in the mutation rate between the different gender groups.Diagnosis should be done by drug gene mutation combined with phenotypic susceptibility.

Diagnostic value of three molecular techniques for children pulmonary tuberculosis

Lian-zhi WANG,Jing ZHANG,Ying-ying LI,Lin-chuan LANG,Hui JIANG,Jun SUN,Lan-wei CUI,Bin-ying JI

Chinese Journal of Antituberculosis. 2019, 41(5):  546-551.  doi:10.3969/j.issn.1000-6621.2019.05.014

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Objective To investigate the diagnostic efficacy of three molecular diagnostic techniques for children pulmonary tuberculosis in order to find a simple, rapid and accurate method for the diagnosis of tuberculosis in children.Methods A total of 186 children from 2 months to 14 years old with suspected pulmonary tuberculosis who were admitted to the Children’s Tuberculosis Department of Harbin Chest Hospital, Respiratory Department of Harbin Children’s Hospital, Department of Pediatrics, the First Affiliated Hospital of Harbin Medical University from September 2016 to June 2018. Finally 119 cases were diagnosed as tuberculosis, including 54 cases (45.4%) of younger children, 65 cases (54.6%) of elderly children, compared with 31 cases (42.3%) of younger children and 36 cases (53.7%) of elderly children in 67 non-tuberculosis children. Real-time fluorescence quantitative PCR (FQ-PCR), simultaneous amplification and testing (SAT) and drug-resistant gene chip technology were used to detect Mycobacterium tuberculosis in gastric juice and sputum (older children) respectively to observe the diagnostic efficacy of each method.Results According to the clinical diagnosis, the sensitivity of FQ-PCR, SAT and drug-resistant gene chip detection of gastric juice were 81.51% (97/119), 78.15% (93/119), 73.11% (87/119), and the specificity were 86.57% (58/67), 98.51% (66/67), 92.54% (62/67) respectively, Kappa values were 0.653, 0.709, 0.603. The sensitivity of the three methods for detecting gastric juice in elderly children was 80.00% (52/65), 73.85% (48/65) and 67.69% (44/65), and the specificity was 75.00% (27/36), 97.22%(35/36) and 88.89% (32/36) respectively. The sensitivity of detecting sputum in elderly children was 47.69% (31/65), 41.54% (27/65), 36.92% (24/65), and the specificity was 88.89% (32/36), 97.22% (35/36) and 91.67% (33/36) respectively. The sensitivity of gastric juice detected by each method was higher than that of sputum, and the difference was statistically significant (χ ² values were 14.696, 13.898, 12.334, P values were 0.000). The specificity of each detection method was not statistical significance between gastric juice and sputum (χ ² values were 2.347, 0.000, 0.158, respectively, P values were 0.126, 1.000, 0.691). The total positive rate of gastric juice was 87.69% (57/65), and the sputum was 58.46% (38/65), the difference was statistically significant (χ ²=14.114, P=0.000). Conclusion FQ-PCR, SAT and drug-resistant gene chip detection methods have high sensitivity and specificity in the detection of Mycobacterium tuberculosis in gastric juice and sputum of children with suspected pulmonary tuberculosis, which is of great value in the diagnosis of tuberculosis in children.

Analysis of the effect of enteral nutrition support in patients with multidrug-resistant tuberculosis and malnutrition

Sheng-kang ZHANG,Han-mei TANG,Gui-zhi ZHOU,Hui-zhen LI,Heng-zhong YI,Mi YAN,Ran-che WU,Xi-liang TANG

Chinese Journal of Antituberculosis. 2019, 41(5):  552-555.  doi:10.3969/j.issn.1000-6621.2019.05.015

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Objective To investigate the clinical effects of enteral nutrition on patients with multidrug-resistant tuberculosis (MDR-PTB) complicated by malnutrition.Methods A total of 128 patients with MDR-PTB complicated by malnutrition who accepted special drug resistance treatment in Hunan Provincial Tuberculosis Control Institute from November 2016 to November 2018 were collected as subjects, including 103 males (80.5%) and 25 females (19.5%), the age range was between 21 to 72 years, with the average of (48.48±13.10) years. Patients were divided into observation group (64 cases) and control group (64 cases) according to random number table method. Patients in the observation group were given enteral nutrition therapy combined with conventional diet, and in the control group were given a regular diet. Differences between the two groups on indexes such as serum total protein (TP), serum albumin (ALB), hemoglobin (Hb), percentage change in ideal body weight, and body mass index (BMI), were compared before treatment and after two weeks of treatment, as well as differences on hospital stay, infection efficacy, and hospitalization costs.Results After two weeks of treatment, the Hb, ALB, TP and BMI of the observation group were higher than that before treatment (before treatment: (106.00±18.08)g/L, (32.74±3.88)g/L, (64.54±5.09)g/L, 16.88±2.25, respectively; after treatment: (113.61±14.62)g/L, (35.65±3.64)g/L, (67.76±5.04)g/L, 17.36±2.08), respectively; and the difference was statistically significant (t values were 5.23, 9.44, 5.02, 6.91, respectively, and P values were all <0.01). The BMI level after two week of treatment in the control group (17.63±1.89) was significantly higher than that before treatment (17.50±1.94), and the difference was statistically significant (t=2.97, P=0.004). After two weeks of treatment, the levels of Hb, ALB and TP in the observation group were higher than those in the control group ((100.36±12.96)g/L, (32.43±5.08)g/L, (62.65±6.99)g/L)), the difference was statistically significant (t values were 5.43, 4.12, 4.74, and P values were all <0.01). The percentage change in ideal body weight (M(Q₁, Q₃)) in the observation group was 2.04% (0.00%, 3.95%), higher than that in the control group (0.00% (0.00%, 1.81%)), and the difference was statistically significant (U=1092.50, P<0.01). After two weeks of treatment, the improvement rate of patients complicated by other pulmonary infection in the control group (34.9%, 15/43) was lower compared with the observation group (56.5%, 26/46), and the difference was statistically significant (χ ²=4.12, P=0.041). The hospital stay (M(Q₁,Q₃)) in the observation group was 34.00 (28.25, 38.00)d, less than that in the control group (37.00 (29.25, 45.00)d), and the difference was statistically significant (U=1601.00, P=0.033); the hospitalization cost (M(Q₁,Q₃)) in the observation group was 24.1 (20.6, 26.6) thousand yuan, less than the control group (25.2 (22.8, 33.4) thousand yuan), the difference was statistically significant (U=1416.00, P=0.003). Conclusion MDR-PTB patients with malnutrition have high clinical value by adopting enteral nutrition therapy, which can effectively improve the nutritional index of patients, increase the BMI of patients, and shorten hospitalization time and hospitalization expenses.

Analysis on direct medical expenses and payment methods for smear-positive pulmonary tuberculosis outpatients in designated medical institutions—a cohort study based on tuberculosis patients in Jiangsu and Sichuan Provinces

Lin YANG,Zhu NING,Cheng CHEN,Yi HU,Qi ZHAO,Hui ZHANG,Xu-bin1 ZHENG,Zheng-dong ZHANG,Biao XU

Chinese Journal of Antituberculosis. 2019, 41(5):  556-563.  doi:10.3969/j.issn.1000-6621.2019.05.016

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Objective To analyze the direct medical expenses and payment methods for smear-positive pulmonary tuberculosis outpatients in some counties in Jiangsu and Sichuan provinces, and to trace the source of medical examination expenses of patients.Methods From 2014 to 2016, the diagnosed smear-positive pulmonary tuberculosis patients in two counties in City A in Jiangsu Province and three districts in City B in Sichuan Province that were included for 24 consecutive months at designated medical instructions were set as subjects, including 430 cases: 313 patients from Jiangsu Province and 117 from Sichuan Province, with the average age of (49.0±21.2) years. The sociodemographic characteristics and general treatment information of patients were obtained by baseline questionnaire survey. The cohort of patients was followed up to the end of treatment, and information such as the direct medical expenses, drug adverse reactions, complications and treatment outcomes during the follow-up were collected by hospital outpatient information system and medical record card.Results The median direct medical expenses per patient (M(Q₁, Q₃)) were 1609.0 (1160.5, 2534.0) and 1761.0 (839.5, 3052.0) yuan in Jiangsu and Sichuan, respectively. The out-of-pocket payments (M(Q₁, Q₃)) were 1186.0 (829.5, 2092.0) yuan in Jiangsu Province, accounting for 73.7% (1186.0/1609.0) of the direct medical expenses; and those in Sichuan Province were 1302.0 (36.0, 2158.5) yuan, accounting for 73.9% (1302.0/1761.0) of direct medical expenses. The out-of-pocket payment per patient in Sichuan Province was significantly higher than that in Jiangsu Province (Z=1.98, P=0.047). It was estimated that the incidence of catastrophic health costs (the ratio of out-of-pocket payment per patient to annual household income ≥40%) was 18.1% (78/430). The average out-of-pocket payments (M(Q₁,Q₃)) of treatment-naive and relapsed patients were 1208.0 (689.0, 2085.3) and 1008.0 (684.8, 2292.5) yuan, respectively, without significant difference (Z=0.04, P=0.971). There were 41 treatment-naive patients prolonged the course of treatment. The average out-of-pocket payments (M(Q₁, Q₃)) per patient for medical examinations and other drug-related expenses of 99 patients with drug adverse reactions were 635.0 (528.0, 925.0) and 515.5 (0.0, 1545.0) yuan, respectively, which were significantly higher than those of 331 patients without drug adverse reactions: 585.0 (210.0, 829.0) yuan for medical examinations (Z=3.07, P<0.01) and 40.0 (0.0, 518.0) yuan for other drug-related expenses (Z=4.88, P<0.01). The average medical examination expenses per patient and the corresponding out-of-pocket payments (M(Q₁,Q₃)) of 98 patients with chronic comorbidities such as diabetes and chronic pulmonary disease (COPD) were 1009.5 (732.5, 1278.5) and 680.0 (394.5, 905.3) yuan, which were significantly higher than those of 332 patients without chronic comorbidities: 936.0 (588.5, 1183.8) yuan for average medical examination expense (Z=-2.29, P=0.022) and 585.0 (281.3, 835.5) for the out-of-pocket payment (Z=-2.17, P=0.030). Compared to the service package of tuberculosis patients recommended by the “Ministry of Health of the People’s Republic of China - Bill Gates Foundation Tuberculosis Prevention and Control Project” (the second phase), it was found that the per capita expense of the medical examinations in the basic service package (468.5 (360.0, 620.0) yuan) was significantly higher than those in outsource service package (310.0 (244.0, 644.0) yuan) (Z=-4.77, P<0.01).Conclusion The direct medical economic burden of smear-positive pulmonary tuberculosis patients of some districts in Jiangsu and Sichuan provinces was heavy, with the total out-of-pocket payments of outpatient more than 1000 yuan. The medical examinations and treatment drugs could cause out-of-pocket payments with different ratios. Drug-related adverse reactions had a relatively important impact on the increasing of out-of-pocket payments for pulmonary tuberculosis patients.

Epidemic and influencing factors of drug-resistant tuberculosis in border and non-border area of Guangxi

Xi LONG,Mei LIN,Ru-shu LAN,Zhe-zhe CUI,Da-bin LIANG,Ding-wen LIN,Dan LUO,Jing YE,Hui-fang QIN,Li-wen HUANG,Min-ying HUANG

Chinese Journal of Antituberculosis. 2019, 41(5):  564-568.  doi:10.3969/j.issn.1000-6621.2019.05.017

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Objective To explore the epidemic and influencing factors of drug-resistant tuberculosis in border and non-border area of Guangxi.Methods From February 2016 to June 2017, five cities including Guilin, Guigang, Chongzuo, Baise and Fangchenggang located on East, West, South, North and Central of Guangxi were selected as the research sites. Among them, three cities including Baise, Chongzuo and Fangchenggang bordering Vietnam were in the border group, and the other two cities, Guilin and Guigang, which are not bordering Vietnam, were in the non-border group. Tuberculosis patients registered at the survey site during the study, positive for sputum smear and isolated Mycobacterium tuberculosis, were included in the study. Proportional method was used to test drug resistance of the clinical isolates in two groups. A total of 1306 patients were enrolled in the study, including 631 in the border group and 675 in the non-border group. Univariate and multivariate logistic regression were used to analyze influencing factors of drug resistance in the two groups.Results The rates of total drug resistance (18.1%, 114/631), single drug resistant (SDR) (9.5%,60/631), poly-drug resistant (PDR) (2.7%,17/631) and multidrug resistant (MDR) (5.9%,37/631) in the border group are higher than those in the non-border group ((11.1%,75/675), (7.7%,52/675), (1.8%,12/675), and (1.6%,11/675), respectively). The differences of the total resistance rate and MDR rate were statistically significant between the two groups ( {\chi }_{\mathrm{total}}^2 =12.75, {\chi }_{\mathrm{MDR}}^2 =16.52, Ps<0.05). Results of multivariate logistic regression analysis showed that the influencing factor of tuberculosis resistance in border areas and non-border areas were patient types, and retreatment was a risk factor for drug resistance in tuberculosis patients in two groups. The OR values were 1.86 (95%CI: 1.13-3.05, Wald χ ²=5.97, P=0.015) in the border group and 2.72 (95%CI: 1.39-5.33, Wald χ ²=8.45, P=0.004) in the non-border group. Conclusion The drug resistance rate of tuberculosis patients in border area is higher than that in non-border area in Guangxi, retreatment was the influencing factor of drug resistance in both regions.

Short Articles

Analysis of efficacy and adverse reactions of interventional cryotherapy via fiberoptic bronchoscope for endobronchial tuberculosis

Zhi-gang WANG,Yuan-yuan LIU

Chinese Journal of Antituberculosis. 2019, 41(5):  569-574.  doi:10.3969/j.issn.1000-6621.2019.05.018

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Sixty-four cases of ulcerative necrotizing and granulation proliferative endobronchial tuberculosis were collected from May 2015 to June 2018 in Panjin Infectious Diseases Hospital. All patients were treated with standardized antituberculosis drugs, aerosol inhalation, debridement through fiberoptic bronchoscope, and local perfusion of isoniazid injection. Among them, 31 patients who were admitted in March 2017 or before and did not receive bronchoscopy interventional cryotherapy were included as control group, and 33 patients who were admitted in April 2017 and later and underwent interventional cryotherapy via fiberoptic bronchoscope were included as observation group. The sputum negative conversion rate, microscopic manifestations, clinical symptoms, chest CT findings, shortness of breath index, treatment times and adverse reactions were observed. The sputum negative conversion rate, clinical treatment efficiency, microscopic efficiency and imaging efficiency of the observation group were 96.8% (30/31), 97.0% (32/33), 93.9% (31/33) and 90.9% (30/33), respectively, which were significantly higher than those of the control group (65.5% (19/29), 74.2% (23/31), 64.5% (20/31) and 67.7% (21/31)), and the differences were statistically significant (χ ² values were 9.78, 5.11, 8.55 and 5.30, P values were 0.002, 0.024, 0.003 and 0.021). The median number of interventions (quartile) (M(Q₁,Q₃)) and shortness of breath index after treatment in the observation group were 5 (4, 6) times and 1 (0, 1) scores, which were significantly lower than those in the control group (9 (8, 10) times and 2 (1, 2) scores), and the difference was statistically significant (Z values were 6.05 and 3.37, all P values <0.001). The incidence of adverse reactions in the observation group was 24.2% (8/33), compared with 25.8% (8/31) of the control group, there was no significant difference (χ ²=0.02, P=0.885). It is concluded that interventional cryotherapy with fiberoptic bronchoscope is a safe and effective treatment for ulcerative necrotizing and granulation proliferative endobronchial tuberculosis, with a high sputum negative conversion rate and a low incidence of adverse reactions.

Evaluation of airway management program among pulmonary tuberculosis patients with respiratory failure

Xiu-jun WANG,Xue-hui SHANG,Ya-feng FU,En-dong WU

Chinese Journal of Antituberculosis. 2019, 41(5):  575-578.  doi:10.3969/j.issn.1000-6621.2019.05.019

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Fifty-six patients with pulmonary tuberculosis complicated with respiratory failure who were treated in the Intensive Care Unit of Beijing Chest Hospital, Capital Medical University from January 2017 to June 2018 were retrospectively analyzed, and to carry out airway management program and analyze the incidence of complications related to mechanical ventilation, nursing adverse events and treatment outcome. Among the 56 patients, 7.1% (4/56) were complicated with ventilator-associated pneumonia; the rate of adverse events related to endotracheal intubation was 12.5% (7/56), all responded promptly and properly; no case occurred respiratory tract mucosa dryness and airway blockage. Thirty-two patients transferred out of ICU after improvement, the rescue success rate was 57.1%; twenty-four cases died, the mortality rate was 42.9%. Our study show that airway management program for pulmonary tuberculosis patients complicated with respiratory failure has lower incidence of complications, and which has a certain promoting effect on improving prognosis.