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Interferon-gamma release assays for the diagnosis of latent tuberculosis infection in HIV-infected individuals - A systematic review and meta-analysis.

OBJECTIVE:: To determine whether interferon-gamma release assays (IGRAs) improve the identification of HIV-infected individuals who could benefit from LTBI therapy.

DESIGN:: Systematic review and meta-analysis.

METHODS:: We searched multiple databases through May 2010 for studies evaluating the performance of the newest commercial IGRAs (QuantiFERON-Gold In-tube [QFT-GIT] and T-SPOT.TB [TSPOT]) in HIV-infected individuals. We assessed the quality of all studies included in the review, summarized results in pre-specified sub-groups using forest plots, and where appropriate, calculated pooled estimates using random effects models.

RESULTS:: The search identified 37 studies that included 5736 HIV-infected individuals. In 3 longitudinal studies, the risk of active TB was higher in HIV-infected individuals with positive versus negative IGRA results. However, the risk difference was not statistically significant in the 2 studies that reported IGRA results according to manufacturer-recommended criteria. In persons with active TB (a surrogate reference standard for LTBI), pooled sensitivity estimates were heterogeneous, but higher for TSPOT (72%, 95% CI 62-81%) than for QFT-GIT (61%, 95% CI 41-75%). However, neither IGRA was consistently more sensitive than the tuberculin skin test (TST) in head-to-head comparisons. While TSPOT appeared to be less affected by immunosuppression than QFT-GIT and TST, overall, differences between the three tests were small or inconclusive.

CONCLUSIONS:: Current evidence suggests that IGRAs perform similarly to the TST at identifying HIV-infected individuals with LTBI. Given that both tests have modest predictive value and sub-optimal sensitivity, the decision to use either test should be based on country guidelines and resource and logistical considerations.

Tuberculosis-Associated Secondary Pneumothorax, a Retrospective Study of 53 Cases.

Pneumothorax secondary to pulmonary tuberculosis (PTB) is a well known complication, particularly in patients with advanced disease. In this study we were able to demonstrate the association between PTB and pneumothorax at our national TB referral hospital.

Methods A retrospective study was performed reviewing patients at the sole national referral center for TB in Iran from 2003 to 2008. Personal characteristics, type of disease and patients, clinical and radiological manifestations, the surgical intervention, and the outcomes were retrieved and analyzed by chi-squared test, Fishers Exact Test, and T-test. The study included 53 TB patients with pneumothorax in the experimental group which was compared to the control group consisting of 106 confirmed TB cases without pneumothorax.

Results Of the 53 total cases of TB with pneumothorax, 34(64.2%) were male . The mean age was 33.5 years (Range: 14-76 years). In total, 36(67.9%) patients were new TB cases without any history of previous TB. Development of pneumothorax was not significantly associated with gender difference, smoking, or drug use (P>0.05). Pneumothorax was found to be significantly more common among patients aged less than 50 years (P<0.001). In terms of radiological manifestations, 20(37.7%)) cases had cavitary lesions, while pulmonary infiltration and effusion were present in 19(35.8%)) and 17(32.1%)) patients respectively. Notably, having a cavitary lesion was significantly higher among patients with pneumothroax (P=0.006) by chi-sq test. Overall, 47(88.6%)) were relieved with chest tube insertion while the others were only observed. All these values of the experimental group were compared to the control group of 106 cases.

Conclusion In patients less than 50 years of age or with cavitary lesions, worsening of the respiratory condition should prompt consideration of pneumothorax. However, further studies with larger sample sizes are crucial, particularly in order to determine the risk factors and prognosis associated with pneumothorax.

Clinical usefulness of B-type natriuretic peptide in the diagnosis of pleural effusions due to heart failure.

Plasma and pleural fluid B-type natriuretic peptide concentrations were determined in 77 patients with pleural effusions and were shown to be useful in identifying effusions with a cardiac aetiology.

Background and objective:  Light's criteria are frequently used to evaluate the exudative or transudative nature of pleural effusions. However, misclassification resulting from the use of Light's criteria has been reported, especially in the setting of diuretic use in patients with heart failure (HF). The objective of this study was to evaluate the utility of B-type natriuretic peptide (BNP) measurements as a diagnostic tool for determining the cardiac aetiology of pleural effusions.

Methods:  Patients with pleural effusions attributable to HF (n= 34), hepatic hydrothorax (n= 10), pleural effusions due to cancer (n= 21), and pleural effusions due to tuberculosis (n= 12) were studied. Diagnostic thoracentesis was performed for all 77 patients. Receiver operating characteristic (ROC) curves were constructed to determine the diagnostic accuracy of plasma BNP and pleural fluid BNP for the prediction of HF.

Results:  The areas under the ROC curves were 0.987 (95% CI 0.93 - 0.998) for plasma BNP and 0.949 (95% CI 0.874 - 0.986) for pleural fluid BNP, for distinguishing between patients with pleural effusions caused by HF (n= 34) and those with pleural effusions attributable to other causes (n= 43). The cut-off concentrations with the highest diagnostic accuracy for the diagnosis of HF as the cause of pleural effusion were 132 pg/mL for plasma BNP (sensitivity 97.1%, specificity 97.4%) and 127 pg/mL for pleural fluid BNP (sensitivity 97.1%, specificity 87.8%).

Conclusions:  In patients with pleural effusions of suspected cardiac origin, measurements of BNP in plasma and pleural fluid may be useful for the diagnosis of HF as the underlying cause.

An official american thoracic society statement: treatment of fungal infections in adult pulmonary and critical care patients.

With increasing numbers of immune-compromised patients with malignancy, hematologic disease, and HIV, as well as those receiving immunosupressive drug regimens for the management of organ transplantation or autoimmune inflammatory conditions, the incidence of fungal infections has dramatically increased over recent years.

Definitive diagnosis of pulmonary fungal infections has also been substantially assisted by the development of newer diagnostic methods and techniques, including the use of antigen detection, polymerase chain reaction, serologies, computed tomography and positron emission tomography scans, bronchoscopy, mediastinoscopy,...

Trends in Cause-Specific Mortality in Oxygen-Dependent COPD.

In oxygen-dependent COPD, mortality has increased over time both overall and of non-respiratory causes, including cardiovascular disease. This highlights the importance of optimized diagnostics and treatment of co-morbidities in order to decrease morbidity and mortality.

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