Table of Content

20 June 2018, Volume 40 Issue 6

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Original Articles

Retrospective analysis of diagnosis and treatment of multidrug-resistant tuberculosis in 6 Global Fund supported pro-vinces (or autonomous regions) in China

Cai-hong XU,Hui ZHANG,Yun-zhou RUAN,Yu-long GAO,Xiu-lei ZHANG,Shuang-yi HOU,Ying PENG,Jian-wei LI,Hui-yi HU,Ren-zhong. LI

Chinese Journal of Antituberculosis. 2018, 40(6):  559-563.  doi:10.3969/j.issn.1000-6621.2018.06.003

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To analyze the diagnosis, treatment, outcome, and prognostic factors of multidrug-resistant tuberculosis (MDR-TB) in 6 Global Fund supported provinces (or autonomous regions) in China.

A retrospective survey was conducted on 19056 high-risk MDR-TB patients who were involved in the Global Fund Project in 6 provinces (autonomous regions) including Inner-Mongolia, Shandong, Henan, Hubei, Zhejiang and Guangdong from January 2010 to December 2011. The data regarding screening, treatment, and outcome of MDR-TB were collected and the prognostic factors for MDR-TB were analyzed.

19056 high-risk MDR-TB cases were screened, and MDR-TB detection rate was 12.3% (2338/19056). Of the 2338 confirmed MDR-TB cases, 68.4% (1599/2338) were enrolled in the treatment project; 739 cases were not included in the project, mainly due to their rejection (19.9%, 147/739). Among the 1599 cases who were enrolled into the treatment project, the conversion rate at the end of 6 month of treatment was 63.9% (1022/1599). New cases (70.8%, 206/291) got higher conversion rate than retreatment failure cases (56.5%, 187/331); difference was statistically significant (χ ²=17.11, P=0.009). With the increase in age, the conversion rate at the end of 6 months of treatment was gradually decreased. The conversion rate of 0-24 years age group (72.2%, 130/180) was much higher than that of 45-64 years age group (62.0%, 376/606) and older than 65 years age group (44.5%, 69/155); difference was statistically significant (χ ²=36.20, P<0.01). The treatment success rate was 43.2% (691/1599) among patients enrolled in treatment. New cases (48.5%, 141/291) achieved higher success rate than retreatment failure cases (38.1%, 126/331); difference was statistically significant (χ ²=15.37, P=0.018). The successful rate of females (47.4%, 213/449) was much higher than that of males (41.6%, 478/1150); difference was statistically significant (χ ²=4.54, P=0.033). With the increase in age, the successful rate was gradually decreased. The successful rate of 0-24 years age group (54.4%, 98/180) was much higher than that of 45-64 years age group (38.4%, 233/606) and older than 65 years age group (23.2%, 36/155); the difference was statistically significant (χ ²=49.83, P<0.01).

We should pay more attention to the screening of MDR-TB suspects. The treatment outcome of MDR-TB using standardized regimen did not reach the expectation level, especially for retreatment failure, male and elderly patients.

Analysis on effects of isoniazid treatment in patients with rifampicin mono-/poly-drug-resistant tuberculosis

Xiao-qi DAI,Ren-zhong LI,Yun-zhou RUAN,Wei SU,Zhong-dong WANG,Li-xia. WANG

Chinese Journal of Antituberculosis. 2018, 40(6):  564-569.  doi:10.3969/j.issn.1000-6621.2018.06.004

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To analyze the therapeutic effects of isoniazid for the patients with rifampicin mono-resistant tuberculosis (RMR-TB) and rifampicin poly-drug-resistant tuberculosis (RPR-TB), and to provide re-ference basis for developing the effective treatments as well as the prevention and control measures to those patients.

The four research sites, where a comprehensive China-Gates Collaborative TB Project was implemented, were involved in this study. During the project implementation period (from January 1, 2011 to December 31, 2011), a total of 50 patients, who were confirmed to have RMR or RPR pulmonary TB and met the recruitment criteria, were enrolled and the relevant information were collected from those patients. And then based on the collected information, 14 patients were excluded due to incompletely information on treatment, such as lost during treatment or unevaluated or failed on forming an effective treatment regimen, while the remaining 36 patients’ clinical data and information were analyzed. Among them, 11 patients (30.56%) were treated with isoniazid which was added in their treatment regimens after 3 or 4 months of treatment (3-6 Am-Lfx-H-PZA-EMB/9-12 Lfx-H-PZA-EMB), which was called “isoniazid group”; 25 cases (69.44%) were not supplemented with isoniazid (6 PZA-Am (Cm)-Lfx(Mfx)-PAS(EMB)-Pto/18 PZA-Lfx(Mfx)-PAS(EMB)-Pto), which was called “standard group”. Descriptive analysis was used for the patients’ basic information. The categorical variables were studied by using Fisher exact test, α=0.05.

The incidence of adverse drug reactions in the isoniazid group (54.55% (6/11)) was lower than that in the standard group (60.00% (15/25)), but there was no statistically significant difference between the two groups (Fisher exact test, P=1.000). The treatment success rate in the isoniazid group and the standard group was 90.91% (10/11) and 48.00% (12/25)) respectively; the treatment failure rate was 0.00% (0/11) and 44.00% (11/25) respectively in the isoniazid group and the standard group; the mortality was 9.09% (1/11) in the isoniazid group and 8.00% (2/25) in the standard group. The difference of treatment success rate and failure rate between the two groups was statistically significant (Fisher exact test, P=0.025, P=0.015).

By adding isoniazid into the patients’ treatment regimens, the number of adverse drug reactions of the patients does not increase, and the treatment outcomes of the patients with isoniazid is better than that of patients without isoniazid. In order to improve the treatment outcomes of the patients, it is suggested that isoniazid should be timely added into the patients’ treatment regimens if isoniazid resistance is not confirmed or if the patients are determined to have RMR-TB/RPR-TB.

Trend analysis of the pulmonary tuberculosis registration in China from 2011 to 2015

Dong-mei HU,Cai-hong XU,Xue LI,Xiao-qiu LIU

Chinese Journal of Antituberculosis. 2018, 40(6):  570-577.  doi:10.3969/j.issn.1000-6621.2018.06.005

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To analyze the trend of the registration of active pulmonary tuberculosis (PTB) patients and new smear positive PTB patients in China (Excluding Hong Kong, Macao and Taiwan) from 2011 to 2015, and to provide reference for the evaluation of case detection and registration during the Twelfth Five-year TB Control Programme.

The numbers of active PTB and new smear positive PTB patients from 2011 to 2015 from the National Tuberculosis Information Management System were 4268687 and 1415537 respectively. The annual registration rates of active PTB and smear positive PTB patients, as well as the proportion of new smear positive PTB in active PTB were calculated and compared both nationwide and by provinces.

In 2011 and 2015, the proportions of new smear positive PTB in active PTB were 41.6% (377005/905344) and 26.4% (210581/798927) respectively. The registration rates of active PTB and new smear positive PTB in 2011 were 67.5/100000 (905344/1340910000) and 28.1/100000 (377005/1340910000) respectively, while those in 2015 were 58.4/100000 (798927/1367820000) and 15.4/100000 (210581/1367820000) respectively. The registration rate of active PTB decreased by 1.2% from 2011 to 2012, 5.0% from 2012 to 2013, 3.4% from 2013 to 2014 and 2.6% from 2014 to 2015, so did that of new smear positive PTB (by 16.1% from 2011 to 2012, 12.8% from 2012 to 2013, 14.6% from 2013 to 2014 and 10.7% from 2014 to 2015). The proportion of new smear positive PTB in active PTB of 31 provinces ranged from 24.1% to 66.3% in 2011, from 20.7% to 63.1% in 2012, from 17.8% to 60.6% in 2013, from 13.8% to 49.6% in 2014 and from 12.3% to 48.1% in 2015.

There is a steady decline in the registration rate of active PTB but a significant decline in that of new smear positive PTB during the Twelfth Five-year TB Control Programme. Various measures need to be implemented to improve PTB case detection and registration.

Investigation and analysis on the status of registration and management of multidrug-resistant pulmonary tuberculosis in Heilongjiang province

Zhong-xi YANG,Yan-ling YU,Xing-lu YAN,Xiao-nan. WANG

Chinese Journal of Antituberculosis. 2018, 40(6):  578-582.  doi:10.3969/j.issn.1000-6621.2018.06.006

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To analyze the current status of the registration and treatment management of multidrug-resistant pulmonary tuberculosis (MDR-PTB) in Heilongjiang province, and to provide reference for the following MDR-PTB control in Heilongjiang province.

Seven hundred and ninety-six MDR-PTB cases were collected from the Tuberculosis Information Management System (TIMS) of Chinese Center for Disease Control and Prevention (CCDCP) and the province’s 7 large tuberculosis specialized hospitals between July 1, 2014 and June 30, 2015. Among them, there were 150 cases from CCDCP and 646 cases from specialized hospitals. A total of 393 patients with detailed address were screened out, including 150 cases from CCDCP and 243 cases from specialized hospitals. The household survey using a standardized questionnaire was conducted on 278 MDR-PTB cases who consented to the survey. The items of the questionnaire included the basic information, situation of visits, registration and entry, treatment and financial burden. Data of registration, treatment and current status of treatment of the MDR-PTB patients were analyzed.

Among the patients surveyed, 100.0% (150/150) of the MDR-PTB patients from CCDCP were registered and entered in the TIMS, while only 2.2% (14/646) of the MDR-PTB patients from specialized hospitals were registered and entered in the TIMS; the difference was statistically significant (χ ²=712.27, P<0.01). The treatment rate of the patients identified by CCDCP was 54.8% (63/115), and the treatment rate of the patients identified by the specialized hospitals was 92.6% (151/163); the difference between was statistically significant (χ ²=54.34, P<0.01). The adherence rate to treatment was 69.8% (44/63) and 78.1% (118/151) for patients identified by the CCDCP and specialized hospitals, respectively, with no statistical significance (χ ²=1.66,P=0.198). The main factor affecting patients’ adherence to treatment was economic burden (63.5% (33/52) and 75.1% (9/12) of the patients from the CCDCP and specialized hospitals), followed by inconvenient access to medicine (26.9% (14/52) and 8.3% (1/12) of the patients from the CCDCP and specialized hospitals).

The rate of patient registration and information entry in tuberculosis hospital is low. Thus, we need to establish a seamless medical defense and cooperation mechanism. The main reason for treatment interruption is economic burden. It is necessary to strive for the support of the local medical insurance policy, improve the reimbursement rate and reduce the burden of patients.

Exploration of the application of new diagnostic techniques for tuberculosis in Liuzhou and Kashi Region

Yun-zhou RUAN,Ren-zhong LI,Wei SU,Yan-lin ZHAO,Li-xia WANG,Xu WEI,Yi-yao LIU,Qi-zhi. LIAO

Chinese Journal of Antituberculosis. 2018, 40(6):  583-588.  doi:10.3969/j.issn.1000-6621.2018.06.007

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To explore the application of light-emitting diode fluorescence (LED) microscope and linear probe resistance detection in China frontier minority areas.

A typical survey was conducted. Liuzhou of Guangxi Zhuang Autonomous Region and Kashi of Xinjiang Uygur Autonomous Region were selected as two research sites. The subjects were all tuberculosis (TB) suspects who first visited the local TB prevention and treatment centers from January 1, 2013 to December 31, 2016. There were 14337 suspected pulmonary TB cases in Liuzhou and 32022 in Kashi before the application of new diagnostic techniques (2013), while after the application of new diagnostic techniques for 3 years (2014-2016), the average annual number of suspected cases in Liuzhou and Kashi was 12796 and 36649, respectively. The measures of new diagnostic techniques were based on the LED microscopes equipped at the county level centers to diagnose spear positive cases and active cases through examination of sputum specimens of suspects, and the linear probe resistance detection equipment and reagents in the city level centers for detection of resistance to first-line anti-TB drugs (rifampicin and isoniazid) through examination of sputum spear positive specimens. The data before the application of new diagnostic techniques were retrospectively collected, and the data after the application of new diagnostic techniques were prospectively collected. The changes in the sputum examination rate of TB suspects and the screening rate of drug resistant in high-risk populations were compared before and after the application of new diagnostic techniques.

The sputum examination rate of TB suspects was increased from 54.15% (7763/14337) to 64.25% (8221/12796) in Liuzhou and 65.36% (20930/32022) to 74.34% (27246/36649) in Kashi after the application of new diagnostic techniques, respectively; the differences were statistically significant (χ ²=285.00, P<0.001 and χ ²=658.00, P<0.001). Among them, the proportion of sputum examination with LED microscope was increased from 0.00% to 79.36% (6524/8221) and 92.88% (25307/27246), showing significant differences (Fisher exact test, Ps<0.001). The screening rate of drug resistant in high-risk populations was increased from 0.00% to 94.61% (158/167) and 74.96% (494/659) in the two cities, respectively; the differences were statistically significant (Fisher exact test, Ps<0.001). The proportion detected by linear probes was increased from 0.00% to 80.38% (127/158) and 52.83% (261/494). The proportion of rifampicin resistance (multidrug resistance included) diagnosed by linear probes was increased from 0.00% to 81.82% (9/11) and 53.06% (26/49).

The new diagnostic technologies for TB helps the frontier minority areas achieve the TB prevention and control goals. They are feasible but still require long-term support.

Analysis of the treatment outcome and survival of 46 multidrug-resistant tuberculosis patients in Kashi Region of Xinjiang Uygur Autonomous Region

Xiao-wang PENG,Abulimiti Gulimina,Ren-zhong LI,Wei SU,Xiao-qi DAI,Yun-zhou RUAN,Hui-hui. LIU

Chinese Journal of Antituberculosis. 2018, 40(6):  589-592.  doi:10.3969/j.issn.1000-6621.2018.06.008

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To investigate the treatment and long-term survival of multidrug-resistant tuberculosis (MDR-TB) patients diagnosed during the Global Fund Project in Kashi region of Xinjiang Uygur Autonomous Region.

Using the method of retrospective analysis, we collected the clinical data of 46 MDR-TB patients who were confirmed in the Pulmonary Hospital in Kashi region (Kashi region MDR-TB designated medical institution). The treatment status, outcome and survival of patients were analyzed.

Among the 46 patients, 37 (80.4%) were treated, while 9 (19.6%) were not. Among the patients who received treatment, one case was cured, and 15 patients completed the course of treatment. The success rate was 43.2% (16/37). 56.8% (19/37) of the treated patients had bad outcome, of which 14 patients died, 5 patients failed and 2 patients were lost to follow-up. During the intensive phase, the mortality was 5.4% (2/37) among the treated patients. The 24-month cumulative mortality was 45.9% (17/37). The 4-year cumulative mortality of the 46 patients with MDR-TB was 58.7% (27/46). The 4-year cumulative mortality was 48.6% (18/37) for the treated cases and 100.0% (9/9) for the un-treated cases. The results of Kaplan-Meier analysis showed that receiving treatment was a protective factor for death (χ ²=15.54, P<0.01).

During the implementation of the Global Fund Project, the proportion of treated patients was high. But the treatment success rate was low, and the mortality was high.

Analysis of treatment outcomes and influencing factors of 208 multidrug-resistant pulmonary tuberculosis patients

Wei SU,Ren-zhong LI,Yun-zhou RUAN,Cai-hong XU,Ming-ting. CHEN

Chinese Journal of Antituberculosis. 2018, 40(6):  593-598.  doi:10.3969/j.issn.1000-6621.2018.06.009

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To analyze the factors that affect the treatment outcomes of multidrug-resistant tuberculosis (MDR-TB) patients based on the free treatment of MDR-TB patients.

From 2009 to 2010, 208 multidrug-resistant pulmonary tuberculosis patients were enrolled as research subjects from Wuhan City, Hubei Province, Zhenjiang City, Jiangsu Province, and Liaocheng City, Shandong Province during the implementation of the Global Fund Project. A retrospective survey was conducted to analyze the outcomes of treatment and its influencing factors.

Of the 208 patients, 103 (49.5%) were successful, 47 (22.6%) were lost to follow-up, 32 (15.4%) failed and 26 (12.5%) died; 72.1%(150 cases) of patients were remained after 12 months of treatment and 61.1% (127 cases) of patients were remained after 18 months of treatment; patients lost from treatment were mainly due to self-discontinued (51.1%, 24/47) and working elsewhere (21.3%, 10/47); Age ≥60 years old (OR=5.964,95%CI=2.517-14.133), farmers (OR=2.871,95%CI=1.530-5.389), used second-line antituberculosis drugs (OR=2.158,95%CI=1.156-4.028) were the risk factors for successful treatment of MDR-TB.

Based on the free treatment for MDR-TB patients, the successful rate of treatment is not high, there is a high rate of tracking loss during treatment. The suggestion is that it is necessary to explore strategies to shorten the course of treatment and diagnostic time for MDR-TB and pay attention to the treatment and management of special groups such as the elderly and farmers as well as regulate the use of second-line anti-tuberculosis drugs.

Analysis of drug-resistant tuberculosis situation in 5 districts of Qingdao city

Zhi-sheng REN,Xiao-qin DAI,Zhong-dong WANG,Hai-yan SUN,Hua-qiang ZHANG,Bai XUE

Chinese Journal of Antituberculosis. 2018, 40(6):  599-603.  doi:10.3969/j.issn.1000-6621.2018.06.010

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Based on the current epidemic situation and the collected data on drug resistant tuberculosis (TB) in the 5 districts of Qingdao city, to conduct analysis and provide scientific evidences for the formulation of targeted chemotherapy regimens and drug-resistant TB control strategy.

An epidemiological investigation was conducted among 926 smear positive pulmonary TB patients, who were newly registered from January 2012 to December 2013 in the 5 districts (Huangdao, Pingdu, Jimo, Jiaonan and Jiaozhou) of Qingdao City. The sputum culture and drug susceptibility testing (DST) by using proportion method were performed to all recruited patients. Finally, a total of 490 patients were culture positive and had completely baseline information; among them, the strains from 337 patients were performed DST while the DST was failed to be done to the strains from 153 patients due to contaminations. We divided the patients into two category groups: initiated treatment patient group and re-treatment patient group, the analysis were done in the two patient groups. SPSS 20.0 was used for statistical analysis. The basic information analysis was conducted by using the prescription method. The count data were analyzed by using χ ² test or Fisher exact test, and the level of the test was α=0.05.

The overall drug resistant TB rate in the 5 districts was 19.88% (67/337), the overall mono-drug resistant TB rate was 11.87% (40/337), the overall poly-drug resistant TB rate was 2.97% (10/337), and the overall multidrug-resistant (MDR) TB rate was 5.04% (17/337). The poly-drug resistant rates in the initiated treatment patient group (2.19%, 7/319) and retreatment patient group (16.67%, 3/18) were significantly different (Fisher exact test, P=0.012); the MDR rates in the initiated treatment patient group (4.08%, 13/319) and the re-treatment patient group (22.22%, 4/18) had statistically significant difference (Fisher exact test, P=0.009). In this study, the DST results of 337 strains showed the drug-resistant rates to the first-line anti-TB drugs as follows which ranked from high to low: H resistant rate (12.17%, 41/337), R resistant rate (9.20%, 31/337), S resistant rate (5.64%, 19/337) and E resistant rate (2.37%, 8/337). Among 67 TB patients with drug resistance, there were 11 drug resistance spectrums with a high proportion of H resistance (22.39%), R resistance (19.40%) and H+R resistance (19.40%); in the initiated treatment patient group, the higher drug resistant rate was to H (21.67%, 13/60), R (20.00%, 12/60), H+R (20.00%, 12/60), and in the re-treatment patient group, the higher drug resistant rate was to H (28.57%, 2/7). 19.40% (13/67) of patients was with rifampicin resistant, and the proportion of patients with MDR-TB was 25.37% (17/67).

The TB control program in Qingdao has achieved certain success, but the MDR-TB situation is still a serious problem.

Analysis of the drug-resistant status of 870 patients with pulmonary tuberculosis from 2013 to 2016

Yu-qin LI,Min XIANG,Ling CHNE,Jian-yong ZHANG,Yue-juan HE,Na-na. LI

Chinese Journal of Antituberculosis. 2018, 40(6):  604-608.  doi:10.3969/j.issn.1000-6621.2018.06.011

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To understand the situation of drug resistant tuberculosis in the Affiliated Hospital of Zunyi Medical College in order to provide scientific evidence for the drug resistant tuberculosis prevention and control strategies.

A total of 870 Mycobacterium tuberculosis isolates composed of sputum and bronchoalveolar lavage fluid were collected from patients with pulmonary tuberculosis (PTB) in the Affiliated Hospital of Zunyi Medical College during the years of 2013 to 2016. Drug sensitivity tests against 4 anti-TB drugs (rifampicin, isoniazid, ethambutol and streptomycin) were performed using the Roche culture and proportion method. The demographic and drug resistance information were collected.

Among the 870 cases, 611 cases were new patients and 259 cases were previously treated patients. The total rates of drug resistant and multidrug-resistant (MDR) were 26.6% (231/870) and 12.1% (105/870),respectively. The total drug resistant rates of new and previously treated patients were 16.4% (100/611) and 50.6% (131/259),respectively, and the difference was statistically significant (χ ²=56.74,P<0.01). The single drug resistance rates of new and previously treated patients were 9.7% (59/611) and 10.0% (26/259), respectively, and the difference was not statistically significant (χ ²=0.03, P=0.862). The polyresistance rates of new and previously treated patients were 3.1% (19/611) and 8.5% (22/259),respectively. The difference was statistically significant (χ ²=11.74, P<0.01). The MDR rates of new and previously treated patients were 3.6% (22/611) and 32.0% (83/259), respectively. And the difference was statistically significant (χ ²=138.69, P<0.01).

Retreatment would increase the risk of TB’s resis-tance to drugs. Consequently, there is a urgent call for the improvement of drug resistance screening and standar-dized treatment for retreated PTB patients.

Investigation and analysis on the medical expenses and economic burden of pulmonary tuberculosis patients in five counties in Xinjiang

Shi-chang DU,Cai-hong XU,Li WANG,Hui ZHANG,Wei. CHEN

Chinese Journal of Antituberculosis. 2018, 40(6):  609-615.  doi:10.3969/j.issn.1000-6621.2018.06.012

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To understand the medical expenses and family economic burden of the patients with pulmonary tuberculosis in 5 counties of Xinjiang.

From Dec. 2016 to June 2017, relying on the “Baseline survey on household catastrophic health expenditure due to TB in China”, a multi stage stratified cluster sampling was used to extract 251 tuberculosis patients at the designated hospital of tuberculosis from Yizhou District, Artux city, High-tech Zone, Yining County, Zapp County in Xinjiang Uygur Autonomous Region. Through face-to-face questionnaire survey and export of data from the hospital electronic medical records database, the social classics of patients were collected. A total of 251 questionnaires were sent out and 251 valid questionnaires were collected. Descriptive analysis was made on the demographic characteristics, expenses and disastrous expenses of the patients.

The median (quartile(Q₁, Q₃)) of the total cost of patients in five counties was 3949.4 (1648.6,10721.9), the direct medical cost was 1416.4 (440.0,5063.3) yuan, the direct non-medical cost was 640.6 (358.2,1336.0) yuan, and the indirect cost was 495.7 (81.4,2696.2) yuan. The direct medical expenses of the patients in the five counties accounted for 46.3% (4298.5/9291.7) of the total cost of self-payment, and the indirect cost accounted for 37.2% (1539.3/9291.7) of the total cost of self-payment. The proportion of catastrophic expenditure in five counties was 59.8% (150/251). The proportion of catastrophic expenditure in Yizhou, ITU, Hi-tech, Yining and Zip counties were 60.8% (31/51), 74.0% (37/50), 56.0% (28/50), 50.0% (25/50), 58.0% (29/50), respectively. and there was no significant difference between five counties (χ ²=6.58,P=0.16). The proportion of catastrophic expenditure was 80.6% (29/36) and 56.3% (121/215) in patients with hospitalized history and no hospitalization history, respectively. The proportion of catastrophic expenditure in the two groups was significantly different (χ ²=7.56,P=0.006). The rate of catastrophic expenditure for workers and farmers and herdsmen was 66.7% (102/153), and the proportion of catastrophic expenditure for household chores, retirees and students was 49.0% (48/98), and the proportion of catastrophic expenditure in these two types of patients was significantly different (χ ²=7.77, P=0.005). The proportion of catastrophic expenditure for illiterate or semi illiterate patients and non-illiterate patients was 77.5% (31/40) and 56.4% (119/211) respectively. The difference in the proportion of catastrophic expenditure in the two types of patients was significant (χ ²=6.23, P=0.013).

The direct medical and indirect costs of tuberculosis patients in the five counties are high, resulting in TB patients (and their households) catastrophic expenditure.

Ra1362 modulates biofilm development and dormancy of Mycobacterium tuberculosis through c-di-GMP in H37Ra

Xiao-juan DING,Yi LIU,Tao SUN,Xiao-dan ZHOU,Chuan-you LI,Hai-hong FANG

Chinese Journal of Antituberculosis. 2018, 40(6):  616-621.  doi:10.3969/j.issn.1000-6621.2018.06.013

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The aim of this study was to explore the modulation of Ra1362, the encoding gene of cyclic guanylic acid (c-di-GMP) synthesis, during the biofilm development and dormancy of Mycobacterium tuberculosis (MTB) in H37Ra by knocking out Ra1362.

MTB H37Ra strain was selected as the original strain, and the Ra1362 knock out strain (△Ra1362) was constructed. Change in biofilm formation was compared in vitro; gene expression differences between the wild type (WT) strain and △Ra1362 were detected by transcriptional microarray and real-time fluorescent quantitative PCR experiments. Also, rapid anaerobic dormancy model (RADM) was established in vitro to compare the formation of clones, expression of dormancy-related genes and result of live-cell staining.

△ Ra1362 strian had formed a thicker biofilm in the sputum tube on the 26th day of culture, and the formation speed was 5 days faster than that of WT strain. The results of transcriptional microarray and real-time fluorescent quantitative PCR showed that the expression levels of 19 dormancy-related genes were downregulated in △Ra1362, which could be recovered in Ra1362 complementary strain or after adding exogenous c-di-GMP. In the RADM, it was found that the oxygen consumption in △Ra1362 was 12 h faster than that in WT after the lag phase, and the strians were in a dormant state in which normal growth could not be restored.

Ra1362 can modulate the biofilm development and dormancy of MTB H37Ra in vitro, which is based on the gene expression of DosR regulons under hypoxic condition by sensing hypoxia or oxidation-reduction pressure through controling c-di-GMP synthesis.

The correlation between sense of coherence and job burnout among the tubercular nursing staffs

Li FU,Xia ZHAO,Xu-jue XIAO,Li ZENG,Li-mei. LEI

Chinese Journal of Antituberculosis. 2018, 40(6):  622-627.  doi:10.3969/j.issn.1000-6621.2018.06.014

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To investigate the levels of psychological coherence and job burnout among tubercular nurses, and to understand the correlation between them.

From March 1, 2017 to March 15, 2017, an electronic questionnaire (including general situation questionnaire, psychological coherence scale, and job burnout scale) was used to conduct questionnaire survey on 156 nurses from the Public Health Clinical Center of Chengdu. One hundred and fifty-six valid questionnaires were recovered, and the recovery rate was 100.00%. The correlation between sense of coherence and job burnout was analyzed by partial correlation analysis.

Sense of cohe-rence: for the 156 nurses, the total score was (60.33±12.38), and the scores of three dimensions (i.e. sense of value, understanding ability, and processing or management ability) were (4.70±1.09), (4.62±1.02), and (4.61±1.10), respectively. Among the 156 respondents, 91 (58.33%) nurses had a low level of psychological coherence, 55 (35.26%) were at a medium level, and 10 (6.41%) were at a high level. Job burnout: of the 156 nurses, there were 127 (81.41%) nurses with job burnout: 51 (32.69%) with mild, 26 (16.67%) with moderate, and 50 (32.05%) with severe. As to the various dimensions, the scores of nurses were (27.31±10.09) in the emotional exhaustion dimension, (28.31±7.14) in dimension of personal sense of accomplishment, and (8.31±5.38) in the dimension of depersonalization. Partial correlation analysis represented a negative correlation of psychological coherence with emotional exhaustion and depersonalization (r=-0.64, -0.58; P<0.001) and a positive correlation with personal sense of accomplishment (r=0.58, P<0.001).

The job burnout of tubercular nursing staffs is serious, and there is a significant correlation between sense of coherence and job burnout. The higher the level of the tubercular nurses’ sense of coherence, the lower the level of job burnout.

Analysis on intervention effectiveness of tuberculosis counseling services using patient-centered approach

Chuan LU,Feng-qin YANG,Yu DENG,Wei-xing CHEN,Xiu-xia MA,Hong-xia AN,Guo-qing CHEN,Gui-yun. MENG

Chinese Journal of Antituberculosis. 2018, 40(6):  628-633.  doi:10.3969/j.issn.1000-6621.2018.06.015

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To analyze the effectiveness before and after the tuberculosis (TB) counseling services using a patient-centered approach were provided to the patients.

The cluster random sampling method was used and 124 patients with TB, who stayed at the Xinjiang Uygur Autonomous Region Chest Hospital for TB treatment from April to October 2016, were randomly sampled and involved in this study. The TB consultation services were provided to the enrolled patients and a patient-centered approach was used during this intervention. The related information was collected before and after the intervention was carried out, and the situation of TB knowledge awareness and the degree of patients’ satisfaction to the counseling services were analyzed and compared. SPSS 17.0 version software package was used for the descriptive analysis of the data. The Chi-square test was used to compare the rates and P<0.05 was regarded to have statistically significant difference.

The overall rate of the patients who gave correct answers to the TB related knowledge in 124 cases was significantly improved from 54.23% (1614/2976) before the intervention to 77.79% (2315/2976) after the intervention (χ ²=12.37, P=0.000). Before the intervention, the highest awareness rate (78.23% (97/124)) to the single TB related knowledge in 124 patients was regarding to the knowledge of “TB can be cured” while this rate was the lowest (12.90% (16/124)) regarding to the knowledge of “Sputum examination time during the treatment of susceptible pulmonary TB patients”; after the intervention, the highest awareness rate (99.19% (123/124)) to the single TB related knowledge in 124 patients was regarding to the knowledge of “TB can be transmitted through the air” while this rate was the lowest (45.16% (56/124)) regarding to the knowledge of “Sputum examination time during the treatment of susceptible pulmonary TB patients”. The awareness rate of the patients regarding to the following TB related knowledge were significantly increased after the intervention compared to those before the intervention, including the knowledge related to TB treatment (80.65% (700/868) vs 57.60% (500/868); χ ²=12.45, P=0.000), the knowledge related to the modes of TB transmission (78.76% (293/372) vs 56.45% (210/372); χ ²=11.36, P=0.000), the knowledge related to the measures for preventing TB transmission (82.80% (616/744) vs 59.95% (446/744); χ ²=12.78, P=0.000), the knowledge related to the common symptoms of TB (77.02% (382/496) vs 55.85% (277/496); χ ²=10.05, P=0.002), and the knowledge related to the reasons of drug resistant TB development (65.32% (324/496) vs 36.49% (181/496); χ ²=16.63, P=0.000). The overall satisfaction rate of the patients to the counseling services was 93.55% (116/124); the patients’ satisfaction rate to the “Attitude of the consulting services providers” was the lowest (87.10%, 108/124).

The counseling services providing to the patients with TB can help the patients to better understand the knowledge related to TB prevention and treatment, change their behaviors and improve their treatment adherence.

Review Articles

Study progress of stigma in patients with tuberculosis

Ce TIAN,Hong ZHAO

Chinese Journal of Antituberculosis. 2018, 40(6):  634-638.  doi:10.3969/j.issn.1000-6621.2018.06.016

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Stigma is a kind of negative emotional experience that patients experience as a result of their illness. Due to the lack of disease knowledge and the public’s discriminatory attitude toward TB patients, stigma is widespread in tuberculosis patients and seriously affects their physical and mental health. Many foreign scholars have paid attention to it and compiled some assessing tools, and the most widely used one is the tuberculosis-related stigma scale compiled by Van et al. The level of stigma in tuberculosis patients is related to the patient’s gender, place of residence, educational level, marital status, family income and so on. Reducing the level of stigma is important for the rehabilitation of patients, but a few intervention studies are currently available. It is recommended that future studies focus on interventions that effectively reduce the stigma of tuberculosis patients.

Short Articles

Analysis of curative effect of short-term chemotherapy regimen and standard chemotherapy regimen on first-time retreated multidrug-resistant pulmonary tuberculosis patients

Bi-tong WU,Lan TAO,Yan-qiong LI,Guo-biao LIU,Jing ZHONG,Kun-hong JIANG,Li-qian HE,Shou-yong TAN

Chinese Journal of Antituberculosis. 2018, 40(6):  639-643.  doi:10.3969/j.issn.1000-6621.2018.06.017

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To explore and compare the curative effect of short-term chemotherapy regimen and standard chemotherapy regimen on first-time retreated multidrug-resistant pulmonary tuberculosis (MDR-PTB) patients, a total of 236 cases of first-time retreated MDR-PTB patients admitted to the Outpatient Department of Guangzhou Chest Hospital from March 2009 to March 2014 who had previous tuberculosis history, no basic disease, and no serious complications were enrolled in this study. These patients were diagnosed by the laboratory test and had only received regular first-line anti-tuberculosis drugs for more than one month. All these subjects were randomly divided into two groups, group A and group B, according to their visiting order. Each group had 118 cases. Multidrug screening was performed in both groups, respectively, and altogether 36 cases were diagnosed as MDR-PTB, among which 21 cases of group A received short-term chemotherapy regimen 2-3H-R-Z-E/6H-R-E (short-term group) and 15 cases of group B received multidrug-resistant standard retreatment regimen 6Am-Z-Lfx-PAS(Cs)-Pto/18Z-Lfx-PAS(Cs)-Pto (standard group). We analyzed the short and long-term clinical therapeutic effect of the two groups after treatment, including the sputum negative conversion rate, lesion absorption rate, adverse reactions, and prognosis. The Fisher’s exact probability statistics was used to compare the enumeration data between the two groups. The results showed that after being treated for 9 months the sputum negative conversion rate in the short-term group (85.7%, 18/21) was significantly higher than that in the standard group (46.2%, 6/13) (P=0.017).There was no statistically significant difference in the sputum negative conversion rate (85.7% (18/21) vs 84.6% (11/13), P=0.373), absorption rate of lesions (47.6% (10/21) vs 23.1% (3/13), P=0.109), cavity closure rate (25.0% (3/12) vs 18.2% (2/11), P=0.360), treatment success rate (76.2% (16/21) vs 53.8% (7/13), P=0.122), and treatment failure rate (23.8% (5/21) vs 46.2% (6/13), P=0.122) between the two groups after the termination of treatment. No suspension of treatment due to serious adverse reactions occurred in the two groups. One case in the standard group showed drug-induced hepatitis, the patient was relieved after being treated with hepatoprotective agents. Five cases in the standard group showed increased serum uric acid, since there was no symptom of joint pain, so no relevant treatment was performed in these patients. Four cases in the short-term group showed increased serum uric acid, while only one case was relieved after symptomatic treatment of joint pain, and two patients who showed gastrointestinal response were relieved after adjusting the frequency of medication. Our results indicated that the short-term clinical efficacy of short-term retreatment chemotherapy regimen was better than multidrug-resistant standard chemotherapy regimen in treating the first-time retreated MDR-PTB patients, but the long-term efficacy was not statistically significant. It is suggested that for the first-time retreated MDR-PTB patients the short-term retreatment chemotherapy regimen is a preferred choice, since the short-term retreatment chemotherapy regimen is short course with cheap and accessible drugs and no increased serious adverse reactions.

Evaluation of case management model in the management of patients with tuberculous meningitis

Kui-li CUI,Jun-hua JIAO,Wei-guo LIU,Pan-hua ZHANG,Ai-jie. ZHOU

Chinese Journal of Antituberculosis. 2018, 40(6):  644-648.  doi:10.3969/j.issn.1000-6621.2018.06.018

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The 60 patients with tuberculous meningitis, who were newly treated at the First Affiliated Hospitail of Xinxiang Medical University from 1 January 2015 to 31 December 2016, were selected as the research subjects. The 60 patients were hospitalized in four wards of tuberculosis department. Thirty patients in the first and second wards were selected as the observation group and another 30 patients in the third and fourth wards as control group. The control group was applied with routine health education pattern including notifying the patients of rules of hospitalization, common inspections, and laboratory tests and offering them with health education materials. The observation group was applied with case management model on the basis of the routine health education. Personal health education profile was established, individual assessment was conducted by the nurse in charge, and the individual management plan was also drawn up and implemented. At discharge, all the patients in the observation group were satisfied with the nurse (completely satisfied in 25 (83.3%) cases, basically satisfied in 5 (16.7%) cases, and dissatisfied in 0 (0.0%) cases), and only 86.7% of the patients in control group were satisfied with the nurse (completely satisfied 15 (50.0%) cases, basically satisfied with 11 (36.7%) cases, and dissatisfied with 4 (13.3%) cases). The difference in the degree of satisfaction for nurse was statistically significant (χ ²=8.75, P=0.013) between two groups. In the observation group, the scores for knowledge acquisition of treatment of tuberculous meningitis, dietary knowledge, notices for rest and exercise, knowledge of drugs, and knowledge acquisition of measures to prevent drug resistance were (18.54±0.23), (19.14±0.32), (18.54±0.31), (19.01±0.11), and (19.16±0.25), which were significantly higher than those in the control group ((13.41±0.43), (15.21±0.33), (15.21±0.56), (14.54±0.14), and (15.76±0.34)). The differences were statistically significant (t=12.48, P=0.005; t=11.63, P=0.012; t=8.91, P=0.021; t=11.98, P=0.010; t=10.30, P=0.016). At 1, 3, and 6 months after discharge, the treatment compliance rate in the observation group were 100.0% (30/30), 93.3% (28/30), and 86.7% (26/30), respectively, which were significantly higher than those in the control group (85.7% (24/28), 60.7% (17/28), and 53.6% (15/28), respectively); the difference was statistically significant (χ ²=4.60, P=0.032; χ ²=8.86, P=0.003; χ ²=7.66, P=0.006). In conclusion, the application of case management model in the management of patients with tuberculous meningitis could greatly improve the degree of patient’s satisfaction with nursing care, enhance the knowledge acquisition of the disease, and improve the treatment compliance.

Application of self-made pleural cannula dressing in the nursing care of tuberculous pleurisy

Hui SUN,Hong-lan XU,Xiao-ling. LIU

Chinese Journal of Antituberculosis. 2018, 40(6):  649-651.  doi:10.3969/j.issn.1000-6621.2018.06.019

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Sixty-eight cases with tuberculous pleurisy, who were treated by closed thoracic drainage with single vena cava catheter in the Tangshan Branch of the Second Hospital of Nanjing from June 2017 to January 2018, were selected as the subjects of this study. The subjects were divided into experimental group (33 cases) and control group (35 cases). The experimental group used self-made pleural cannula dressing to fix the closed thoracic drainage tube, while the control group used conventional transparent dressing. The comfort score of the experimental group was (2.42±0.56), which was significantly higher than that of the control group (2.06±0.48); there was a statistically significant difference (t=-2.89,P=0.005). The dressing interval of the experimental group was (7.00±1.23)d, significantly longer than that of the control group (3.77±1.33)d, and the difference was statistically significant (t=-10.49,P<0.01). The unplanned extubation rate in the control group was 11.4% (4/35), and there was no unplanned extubation in the experimental group. The difference between the two groups was statistically significant (χ ²=5.55,P=0.018). The self-made pleural cannula dressing has obvious clinical effects in terms of comfort, frequency of dressing change and preventing unplanned extubation.

Effect of diversified health education model on postoperative limb functional exercise in patients with tuberculous empyema

Ying LIU,Yu QI,Jiao BI

Chinese Journal of Antituberculosis. 2018, 40(6):  652-655.  doi:10.3969/j.issn.1000-6621.2018.06.020

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The clinical data of 175 male patients with tuberculous empyema who underwent pleural fibreboard stripping surgery from January 2016 to December 2017 at the First Department of Thoracic Surgery of Shenyang Chest Hospital was analyzed retrospectively. Seventy-five patients from January to December of 2016 were defined as pre implementation group and applied routine health education model after surgery. One hundred patients from January to December of 2017 were defined as post implementation group and applied diversified health education model after surgery. The patient’s compliance of functional exercise in the pre implementation group was 65.3% (49/75), which was lower than that in the post implementation group (84.0% (84/100)), and the difference was statistically significant (χ ²=8.19, P=0.004). The satisfactory degrees of patients on the nursing care in the pre implementation group (93.3% (70/75)) was lower than that in the post implementation group (100.0% (100/100)), and the difference was statistically significant (χ ²=9.29, P=0.010). For patients with tuberculous empyema after operation, the diversified health education significantly improves the patient’s compliance of postoperative limb functional exercises and increases the satisfactory degrees of patients on the nursing care.

Assessment on psychological needs of patient’s relatives after patients with tuberculous meningitis admitted to emergency intensive care unit

Cui-hong GAO,Yu-yu CAO,Qiu-ling. JI

Chinese Journal of Antituberculosis. 2018, 40(6):  656-658.  doi:10.3969/j.issn.1000-6621.2018.06.021

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The assessment on the psychological needs were conducted to 97 family relatives of 62 patients, who were admitted to the Emergency Intensive Care Unit (EICU) of Xinjiang Chest Hospital from April 2016 to May 2017 and diagnosed as tuberculous meningitis (TBM), when the patients had just been hospitalized, during the treatment and before they were discharged from the hospital. The results showed that the patients’ relatives all had serious psychological stress responses (100.0% (97/97) family members wanted to accompany the patients); the proportion of the patients’ relatives who wanted to know the knowledge of the disease was quite high (81.4% (79/97) of the family members expected to get some health education materials related to the disease while 100.0% (97/97) of the family members wanted to know the attentions after the patients were discharge from the hospital); the needs on social and economic supports were obvious in the patients’ relatives (97.9% (95/97) of them worried that the treatment of the patient might be disrupted due to financial barriers); the patients’ relatives had strong psychological needs to be concerned (100.0% (97/97) of the family members of the patients wanted the clinical doctors to be able to explain clearly and patiently about the patient’s conditions and prognosis). Medical staff should pay more attention to the psychological needs of the family members of the patients with severe TBM who were admitted to the ICU, and try to meet the needs of the severe patients’ relatives through the individualized and targeted interventions.

Analysis of drug resistance status in 499 sputum culture-positive tuberculosis patients combined with diabetes mellitus

Ying XI,Lian. SHI

Chinese Journal of Antituberculosis. 2018, 40(6):  659-662.  doi:10.3969/j.issn.1000-6621.2018.06.022

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The drug susceptibility testing (DST) results and relevant information were collected from 499 patients who were diagnosed as sputum culture-positive pulmonary tuberculosis (TB), identified as Mycobacterium tuberculosis (MTB) infection and combined with diabetes mellitus (DM), were hospitalized at Shenyang Chest Hospital for treatment from July 2016 to June 2017. The DST results and the related information were retrospective analyzed. Among those enrolled patients, 235 patients were initial treatment cases (initial treatment group) while 264 patients were retreatment cases (re-treatment group). The DST was performed by absolute concentration method for 11 anti-TB drugs. The results showed that the overall drug resistant rate was 50.70% (253/499); the overall drug resistant rate in the initial treatment group (29.79%, 70/235) was statistically significant lower than that in the re-treatment group (69.32%, 183/264) (χ ²=79.32, P<0.01). The mono-drug-resistant rate in 499 MTB strains was 14.83% (74/499); this rate in the initial treatment group and the re-treatment group was 14.04% (33/235) and 15.53% (41/264) respectively, there was no statistically significant difference between the two groups (χ ²=0.22, P=0.641). The poly-drug-resistant rate in 499 MTB strains was 12.63% (63/499); this rate in the initial treatment group (2.98%, 7/235) was statistically significant lower than that in the re-treatment group (21.21%, 56/264) (χ ²=37.47, P<0.01). The multidrug-resistant (MDR) rate in 499 MTB strains was 23.25% (116/499); the MDR rate in the initial treatment group and the re-treatment group was 12.77% (30/235) and 32.58% (86/264) respectively, the former was statistically significant lower than the latter (χ ²=27.35, P<0.01). The extensively drug-resistant (XDR) rate in 499 MTB strains was 3.01% (15/499); the XDR rate in the initial treatment group and the re-treatment group was 0.85% (2/235) and 4.92% (13/264) respectively, and the former was statistically significant lower than the latter (χ ²=7.08, P=0.008). The drug resistant rate of rifampicin was 29.26% (146/499); this rate was 15.74% (37/235) in the initial treatment group, and was statistically significant lower than that in the re-treatment group (41.29%, 109/264) (χ ²=39.19, P<0.01). According to the DST results, the reasonable and effective treatment regimens for drug resistant TB can be established, which can also provide reference for the formulation of clinical chemotherapy regimens and the development of drug-resistant TB prevention and control strategy.