Manifestation Of Tuberculosis Research Articles

The Usefulness of Dramatics for Teaching Cutaneous Tuberculosis: An Edutainment Approach for Postgraduate Medical Students.

About 1.5% of tuberculosis manifestations is cutaneous and accounts for 0.1-0.9% of total OPD patients in India. Forty first-year postgraduate medical students were taught cutaneous TB though conventional PPT, 'Carousel Role Play' and 'Theatre of the Oppressed' technique. The statistically significant effectiveness of theatrical workshops was noted.

Osteoarticular tuberculosis in infants: A diagnostic and management challenge

Objectives: Musculoskeletal manifestations of tuberculosis in infants are rare and different both in etiopathological mechanism and clinical presentation. Radiological diagnosis of osteoarticular tuberculosis (TB) in infants is tricky due to the various differentials of a cystic lesion. Literature also mention it only in isolated case reports. We carried out this study with an aim to collate and study patterns of osteoarticlular TB in the appendicular skeleton and to highlight the difficulties in diagnosis and management. Material and Methods: We retrospectively reviewed the data at our hospital over the past 8 years. Microbiologically confirmed osteoarticular tuberculosis affecting appendicular skeleton in children below 1 year of age were included in the study. Cases with spine involvement were excluded. The delay to diagnosis from the onset of symptoms, the initial diagnosis and treatment given were noted. The resolution of radiological presentation and occurrence of deformities at the final follow up (atleast 1 year) were noted. Results: During the study period, 8 infants were diagnosed to have osteoarticular tuberculosis with median age at presentation of 8.7 months (range 3 to 12 months). Average duration of follow up was 4 years (range 1 to 8 years). Cystic, Erosive, infiltrative, spina ventosa and mortar pestle were the radiological appearances found. Three of the 8 cases were referred as suspected malignancy. All but one case were vaccinated with BCG. Curettage and anti-tubercular therapy (ATT) were the treatment in all cases. Three cases with a delay in diagnosis of more than 2 months, developed complications: 1 had limb length discrepancy (LLD) due to physeal involvement, 1 developed angular deformity and 1 child had perthe’s disease as a sequelae. Conclusion: Osteoarticular tuberculosis is an increasing possibility, shockingly, even in infancy and should be a differential in an endemic country like India. A delay to diagnosis of even 2 months of this condition can lead to devastating complications. Being mindful of the diagnosis and early treatment gives rewarding results.

PERITONEAL TUBERCULOSIS MIMIKING GASTROINTESTINAL STROMAL TUMOR

Abdominal TB is a common site of extrapulmonary tubercilosis, and peritoneal tuberculosis (PTB) is one of the most common manifestations of abdominal tuberculosis. The diagnosis of PTB can be made based on a combination of clinical, radiological, histological, and laboratory tests. The diagnosis can be easy in the presence of ascites with peritoneal granulations. some forms of PTB can make a differential diagnosis with peritoneal or digestive tract pathologies. some forms of PTB can make a differential diagnosis with peritoneal or digestive tract pathologies. We report a case of primary mesenteric tuberculosis mimicking gastrointestinal stromal tumor. The final diagnostic was performed using a combination of invasive and imaging techniques.

Radiographic characteristics of rifampicin-resistant tuberculosis in the STREAM stage 1 trial and their influence on time to culture conversion in the short regimen

BackgroundStage 1 of the STREAM trial demonstrated that the 9 month (Short) regimen developed in Bangladesh was non-inferior to the 20 month (Long) 2011 World Health Organization recommended regimen. We assess the association between HIV infection and radiographic manifestations of tuberculosis and factors associated with time to culture conversion in Stage 1 of the STREAM trial.MethodsReading of chest radiographs was undertaken independently by two clinicians, and films with discordant reading were read by a third reader. Recording of abnormal opacity of the lung parenchyma included location (right upper, right lower, left upper, and left lower) and extent of disease (minimal, moderately-advanced, and far advanced). Time to culture conversion was defined as the number of days from initiation of treatment to the first of two consecutive negative culture results, and compared using the log-rank test, stratified by country. Cox proportional hazards models, stratified by country and adjusted for HIV status, were used to identify factors associated with culture conversion.ResultsOf the 364 participants, all but one had an abnormal chest X-ray: 347 (95%) had opacities over upper lung fields, 318 (87%) had opacities over lower lung fields, 124 (34%) had far advanced pulmonary involvement, and 281 (77%) had cavitation. There was no significant association between HIV and locations of lung parenchymal opacities, extent of opacities, the presence of cavitation, and location of cavitation. Participants infected with HIV were significantly less likely to have the highest positivity grade (3+) of sputum culture (p = 0.035) as compared to participants not infected with HIV. Cavitation was significantly associated with high smear positivity grades (p < 0.001) and high culture positivity grades (p = 0.004) among all participants. Co-infection with HIV was associated with a shorter time to culture conversion (hazard ratio 1.59, 95% CI 1.05–2.40).ConclusionsRadiographic manifestations of tuberculosis among the HIV-infected in the era of anti-retroviral therapy may not differ from that among those who were not infected with HIV. Radiographic manifestations were not consistently associated with time to culture conversion, perhaps indicating that the Short regimen is sufficiently powerful in achieving sputum conversion across the spectrum of radiographic pulmonary involvements.Trial registrationISRCTN ISRCTN78372190. Registered 14/10/2010. The date of first registration 10/02/2016.

Recent Advances in Nanotechnology-Based Strategies for Bone Tuberculosis Management.

Bone tuberculosis, an extrapulmonary manifestation of tuberculosis, presents unique treatment challenges, including its insidious onset and complex pathology. While advancements in anti-tubercular therapy have been made, the efficacy is often limited by difficulties in achieving targeted drug concentrations and avoiding systemic toxicity. The intricate bone structure and presence of granulomas further impede effective drug delivery. Nano-drug delivery systems have emerged as a promising alternative, offering the enhanced targeting of anti-tubercular drugs. These systems, characterized by their minute size and adaptable surface properties, can be tailored to improve drug solubility, stability, and bioavailability, while also responding to specific stimuli within the bone TB microenvironment for controlled drug release. Nano-drug delivery systems can encapsulate drugs for precise delivery to the infection site. A significant innovation is their integration with prosthetics or biomaterials, which aids in both drug delivery and bone reconstruction, addressing the infection and its osteological consequences. This review provides a comprehensive overview of the pathophysiology of bone tuberculosis and its current treatments, emphasizing their limitations. It then delves into the advancements in nano-drug delivery systems, discussing their design, functionality, and role in bone TB therapy. The review assesses their potential in preclinical research, particularly in targeted drug delivery, treatment efficacy, and a reduction of side effects. Finally, it highlights the transformative promise of nanotechnology in bone TB treatments and suggests future research directions in this evolving field.

Kiosk 5Q-FA-04 - Looking for Zebras: Constrictive Pericarditis as a Manifestation of tuberculosis

Kiosk 5Q-FA-04 - Looking for Zebras: Constrictive Pericarditis as a Manifestation of tuberculosis

A case report on new-onset peritoneal tuberculosis in ankylosing spondylitis patient on adalimumab

Adalimumab, a widely employed tumor necrosis factor-alpha inhibitor for autoimmune diseases, raises concern about reactivating latent tuberculosis (TB) and new-onset TB. Despite its established efficacy in managing inflammation, clinicians must recognize and manage adalimumab-induced TB promptly to minimize associated morbidity. This case report explores guidelines for TB screening in adalimumab-treated patients, utilizing interferon-gamma release assays and tuberculin skin tests, and discusses treatment considerations. Increased TB incidence in adalimumab-treated patients necessitates vigilant screening for latent TB before therapy initiation. Therapeutic decisions must balance the need for continuing immunosuppressive therapy against the potential risks of uncontrolled TB. Diagnostic challenges arise from atypical presentations and the intricate interplay between adalimumab therapy and TB manifestations. Given adalimumab’s expanding use, clinicians should be mindful of potential TB reactivation, emphasizing thorough screening, diagnosis, and management for improved patient care and safety amidst immunosuppressive therapies. Here, we are presenting the case of adalimumab-induced peritoneal TB.

Radiological presentation of active pulmonary tuberculosis in kidney transplant recipients: a retrospective study of four cases and a review of the literature.

Although kidney transplantation is the best therapeutic option for patients with chronic kidney disease, the immunosuppression required greatly increases susceptibility to infections that are responsible for high post-transplant mortality. Pulmonary tuberculosis (TB) represents a major cause of such infections, and its early diagnosis is therefore quite important. In view of that, we researched the manifestations of active pulmonary TB in kidney transplant recipients, through chest X-ray and computed tomography (CT), as well as determining the number of cases of active pulmonary TB occurring over a 3.5-year period at our institution. We identified four cases of active pulmonary TB in kidney transplant recipients. The CT scans provided information complementary to the chest X-ray findings in all four of those cases. We compared our CT findings with those reported in the literature. We analyzed our experience in conjunction with an extensive review of the literature that was nevertheless limited because few studies have been carried out in lowand middle-income countries, where the incidence of TB is higher.

Mediastinal Lymphadenopathy Complicating into a Bronchonodal Fistula and Lung Abscess Formation – Rare Manifestation of Drug-resistant Tuberculosis

Pulmonary tuberculosis (TB) sometimes involves regional lymph nodes like mediastinal lymph nodes. These may resolve spontaneously or on treatment; or they may enlarge and result in various complications such as extrinsic bronchial inflammation, ulceration, or rarely erode through the bronchial wall. This erosion is seen radiologically as mediastinal widening or lymphadenopathy with atelectasis and consolidation termed “epituberculosis.” This is more frequently encountered in infants than older children and extremely rarely in adults. We hereby describe a rare case of a 14-year-old girl with mediastinal lymphadenopathy complicating into a bronchonodal fistula and lung abscess formation. A diagnosis of pulmonary rifampicin-resistant TB was obtained on repeated testing of sputum for GeneXpert. The patient was started on appropriate drug-resistant TB therapy and completed therapy successfully.

Coeliac lymph node abscess: A case report of a rare manifestation of extrapulmonary tuberculosis

Tuberculosis is a leading cause of death worldwide, especially in developing countries. It can affect any site in the body and have a myriad of presentations making diagnosis challenging. Tuberculous lymphadenitis in the abdomen is rare. We present a case of a 42-year-old man who presented with non-specific abdominal symptoms and was found to have an intraabdominal abscess on computed tomography scan of the abdomen. Endoscopic ultrasound-guided aspiration was performed, and tuberculosis was confirmed. This case highlights the importance of having a high clinical suspicion of tuberculosis even with vague symptoms in tuberculosis endemic countries. This would prevent unnecessary surgery as tuberculosis is responsive to anti-tuberculosis drugs.

Spectrum of Radiological Findings in Pulmonary Tuberculosis- A Tertiary Care Hospital-based Retrospective Descriptive Study

Introduction: Tuberculosis is a worldwide public health problem associated with high morbidity and mortality. Tuberculosis can manifest in active and latent forms. Improving the diagnosis, treatment, and screening of tuberculosis is crucial for effective tuberculosis control. Chest X-ray and Computed Tomography chest play a vital role in diagnosing and screening for tuberculosis. Aim: To analyse the spectrum of radiological findings in pulmonary tuberculosis. Materials and Methods: The present retrospective descriptive study was conducted at a teritary care hospital in the Department of Radiodiagnosis, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, Tamil Nadu, India. The data of 160 patients diagnosed with pulmonary tuberculosis between January 2019 and December 2020 were accessed and analysed. The recorded variables included forms of pulmonary tuberculosis, age/gender distribution, co-morbidities, Acid-fast Bacillus (AFB) smear status, and radiological findings and distribution. Descriptive statistics are presented in frequency and percentage. Results: Among the 160 cases of pulmonary tuberculosis, 30 (18.75%) cases were active primary tuberculosis, 105 (65.63%) cases were active post-primary tuberculosis, and 25 (15.62%) cases were inactive tuberculosis. Among the 30 cases of active primary tuberculosis, 14 (46.67%) cases had consolidation with air bronchogram, and 6 (20%) cases had consolidation without air bronchogram. Among the 105 cases of active post-primary tuberculosis, 65 (61.9%) cases had consolidation, 50 (47.62%) cases had cavities, and 56 (81.9%) cases had centrilobular nodules with a tree-in-bud appearance. Among the 25 cases of inactive tuberculosis, 18 (72%) cases had fibrosis with bronchiectasis, while 4 (16%) cases had fibrosis without bronchiectasis, and 3 (12%) cases had calcified granulomas. Conclusion: The study conclusively demonstrates the diverse radiological manifestations of pulmonary tuberculosis in different patient demographics. It highlights a higher incidence of active post-primary tuberculosis, especially in patients above 45 years, with varying radiological findings such as consolidation, cavitation, and fibrosis.

Incidental Primary Cystic Duct Lymph Node Tuberculosis in a 28-year-old Female: A Rare Case Report

Tuberculosis (TB) is an infectious disease caused by acid-fast bacilli Mycobacterium tuberculosis (MTB). The lung remains the most common site involved by it. Extrapulmonary sites of TB are lymph nodes, pleura, bone, joints, urogenital tract, and meninges. Isolated Cystic Duct Tubercular Lymphadenitis (CDL TB) without involving the gallbladder is an uncommon manifestation of TB that primarily affects the lymph nodes around the cystic duct. A multidisciplinary approach is essential for accurate diagnosis and successful management of such cases. The authors hereby present a case of a 28-year-old female, without any evidence of TB elsewhere and an incidental finding of CDL TB. “The patient was sent with a clinical diagnosis of Chronic Calculus Cholecystitis (CCC)”. This highlights the need for comprehensive clinical evaluation and diagnostic investigations to avoid misdiagnosis or delayed management. This underscores the significance of maintaining a high index of suspicion for extrapulmonary TB, particularly in regions where the disease remains endemic. Healthcare practitioners should be vigilant when encountering unusual clinical presentations or when dealing with atypical combinations of gallbladder pathologies, as illustrated by the concurrent occurrence of CDL TB with CC with evidence of Pyloric Metaplasia (PM) and cholesterolosis without cholelithiasis, as in the patient of the present case report.

Neural Networks based Smart e-Health Application for the Prediction of Tuberculosis using Serverless Computing.

The convergence of the Internet of Things (IoT) with e-health records is creating a new era of advancements in the diagnosis and treatment of disease, which is reshaping the modern landscape of healthcare. In this paper, we propose a neural networks-based smart e-health application for the prediction of Tuberculosis (TB) using serverless computing. The performance of various Convolution Neural Network (CNN) architectures using transfer learning is evaluated to prove that this technique holds promise for enhancing the capabilities of IoT and e-health systems in the future for predicting the manifestation of TB in the lungs. The work involves training, validating, and comparing Densenet-201, VGG-19, and Mobilenet-V3-Small architectures based on performance metrics such as test binary accuracy, test loss, intersection over union, precision, recall, and F1 score. The findings hint at the potential of integrating these advanced Machine Learning (ML) models within IoT and e-health frameworks, thereby paving the way for more comprehensive and data-driven approaches to enable smart healthcare. The best-performing model, VGG-19, is selected for different deployment strategies using server and serless-based environments. We used JMeter to measure the performance of the deployed model, including the average response rate, throughput, and error rate. This study provides valuable insights into the selection and deployment of ML models in healthcare, highlighting the advantages and challenges of different deployment options. Furthermore, it also allows future studies to integrate such models into IoT and e-health systems, which could enhance healthcare outcomes through more informed and timely treatments.

Tuberculosis of Penile ShaftA Rare Clinical Presentation

Tuberculosis (TB) is an opportunistic infection caused by Mycobacterium TB, and it has plagued mankind since ages, posing a major health concern in developing countries. Pulmonary TB is the most common form, but extrapulmonary TB is also not uncommon, with an incidence of 8-14%. Cutaneous manifestations of TB, known as lupus vulgaris, are extremely rare, constituting less than 1% of cases worldwide. Diagnosing a cutaneous lesion of TB poses a challenge for clinicians, as it requires both absolute and relative criteria. In the present case report, the author presents the case of a 15-year-old male from a low socio-economic background who presented with painless oedema over the penis for one and a half months. The patient had a history of dry cough and tested positive for Coronavirus Disease-2019 (COVID-19). Systemic examination was normal, and vital signs were stable. Local examination revealed oedema, redness, and phimosis over the penile shaft, along with non tender ulcerative lesions and deep cracks in the groin crease. A skin biopsy revealed lymphocytic infiltration with Langhanstype giant cells and epithelioid cell granulomas, suggesting TB of the skin overlying the penis. Laboratory investigations revealed a positive Mantoux test and an elevated Erythrocyte Sedimentation Rate (ESR) of 42. The patient was initiated on antitubercular therapy, comprising isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE). After one month of treatment, the oedema subsided, and the penile ulcers and groin skin cracks healed. Penile skin involvement in TB is rare, and the clinical appearance of such involvement may vary.

Mycobacterial Endocarditis, A Rare Form of Infective Endocarditis.

This research project delves into the multifaceted dynamics of Mycobacterium tuberculosis (M.tb) endocarditis, a significant yet uncommon manifestation of tuberculosis (TB). Beginning with an overview of M.tb and the global challenges posed by TB, we navigate through the bacterium's evolution, transmission modes, and the intricate host immune response. The pathology and pathophysiology of M.tb endocarditis are explored, emphasizing its complexities and the host's efforts to contain the pathogen. The study extends to atypical mycobacterial endocarditis, highlighting the emergence of species like M.chimaera, M.fortuitum, and M.chelonae, with a focus on their association with life-threatening mycobacterial endocarditis. Clinical presentations and complications of M.tb endocarditis are detailed, addressing challenges in diagnosis, drug-resistant, co-infections with Human Immunodeficiency Virus (HIV), and potential sepsis. The research underscores the need for a deeper understanding of M.tb endocarditis to enhance prevention, diagnosis, and treatment strategies. Examining the genetic and environmental factors influencing M.tb endocarditis, the study discusses the interplay of immune-related genes, environmental conditions, and predispositions contributing to infection susceptibility. Despite challenges in treatment due to its rarity, the research highlights current protocols, surgical interventions, and promising pharmaceutical developments. Lastly, unraveling these intricate factors is crucial for refining strategies and conducting large-scale trials to address this global health threat effectively.

Exploring the Oral Manifestations of Tuberculosis: A Comprehensive Analysis of Prevalence and Clinicopathological Characteristics of Oral Lesions.

The study aimed to report all cases of oral tuberculosis (TB), a rare manifestation of the fatal infectious disease primarily affecting the pulmonary system. The report also evaluated the clinicopathological characteristics of oral TB lesions. A total of 25 patients who presented with oral lesions between August 2013 and August 2023 were diagnosed with TB through surgical biopsy despite having no prior history of the disease. Their clinical symptoms, auxiliary examinations, treatments, and outcomes were recorded and analyzed for further study. In a study of 25 patients with oral TB, all patients were found to have the disease, with 16 males and 9 females affected. The gender distribution was skewed toward males, with a 1.77 male-to-female ratio. Twelve cases of the affected sites were reported in the mandible, six cases in the buccal mucosa, four in the lips, two in the gingiva, and one in the tongue. The age range of affected patients was 0-70 years old, and all lesions were indicative of primary TB. The appearance of the affected mucosa varied, with ulceration and swelling being the most common manifestations. Patients who present with oral ulcerations and swellings should be evaluated for the possibility of TB. To confirm and differentiate this condition from other diseases, obtaining a biopsy specimen for histological analysis and performing acid-fast stains and cultures is recommended. These tests will enable a precise diagnosis and guide appropriate treatment.

Chronic Cor Pulmonale in the Structure of Fatal Outcomes of Pulmonary Tuberculosis

The objective: to determine the significance of chronic cor pulmonale (CCP) as a cause of death in pulmonary tuberculosis patients.Subjects and Methods. Out of 194 autopsies of tuberculosis patients who died in Hospital no. 1 of Ulyanovsk Regional Clinical TB Dispensary in 2017-2020, autopsy reports of 87 patients with pathomorphological signs of chronic cor pulmonale were selected. The nature and prevalence of pathomorphological manifestations of tuberculosis and the causes of deaths were analyzed. Statistical analysis of the results was performed using the STATISTICA-10. The significance of differences in the frequency of events was determined using the χ2 criterion in a four-field 2х2 table.Results. Chronic cor pulmonale was confirmed pathomorphologically in 44.8% of deceased pulmonary tuberculosis patients. Chronic cor pulmonale was diagnosed in 67.8% of patients in their lifetime, and in 32.2%, it was diagnosed post mortem. Of 87 deceased patients with pulmonary tuberculosis complicated by chronic cor pulmonale, 28.7% had fibrous cavernous pulmonary tuberculosis, 26.4% had infiltrative form and 44.9% had disseminated form of the disease. Decompensated chronic cor pulmonale leading to death was detected in 42.5% of the deceased, and it was predominant in the structure of causes of death in fibrous cavernous tuberculosis (84%), and this pathology was also found in the patients with infiltrative (52.5%) and disseminated (10.3%) pulmonary tuberculosis.

Characteristics of subclinical tuberculosis compared to active symptomatic tuberculosis using nationwide registry cohort in Korea: prospective cohort study.

The clinical manifestations of tuberculosis (TB) range from asymptomatic to disseminated depending on the microbiological and immunological status, making the diagnosis challenging. To improve our understanding of the disease progression mechanism, we aimed to identify the characteristics of subclinical TB and important predictors of symptom development. From July 2018 to June 2019, we systemically collected data from the National Surveillance System of South Korea on patients with pulmonary TB, and compared the characteristics of subclinical and active symptomatic TB patients. A total of 4,636 patients with pulmonary TB were included, and the prevalence of subclinical TB was 37.1% (1,720/4,636). In subclinical TB patients, the positivity rates of acid-fast bacilli (AFB) smear and culture were 16.2 and 50.2%, respectively. Subclinical TB patients were younger (55.6 ± 19.2 vs. 60.7 ± 19.5, P < 0.001), had a higher body mass index (21.7 ± 3.1 vs. 21.0 ± 3.5, P < 0.001), less under Medicaid support, and had lower rates of chronic lung disease, AFB smear and culture positivity, and bilateral disease. Regarding the characteristic differences of individual TB-related symptoms, age was positively associated with dyspnoea and general weakness but negatively associated with chest pain, haemoptysis, and weight loss. Male patients were more prone to weight loss. Chronic lung disease was related to symptoms including cough/phlegm, dyspnoea, and haemoptysis, while autoimmune diseases were associated with fever and weight loss. The development of TB-related symptoms was associated with microbiological burden and clinical characteristics including underlying comorbidities, which should be evaluated carefully.

The pattern of neurological manifestations of tuberculosis among adult Sudanese patients attending multi-neurological centers and hospitals in Sudan: A hospital-based cross-sectional study

The pattern of neurological manifestations of tuberculosis among adult Sudanese patients attending multi-neurological centers and hospitals in Sudan: A hospital-based cross-sectional study

Comparison of The Diagnosis Peculiarities of Familial Tuberculosis

Objective — to compare the diagnostic features of individuals with family tuberculosis within the context of reorganizing the tuberculosis control service. Materials and methods. The study involved the analysis of diagnostic results and management of 406 patients within a cluster of family tuberculosis. Among them, 207 patients were identified as the source of tuberculosis (comparison group), and 199 were contacts who contracted the disease from individuals in the comparison group. Patients in the comparison group were examined by family doctors, while contacts were evaluated by phthisiologists. Results and discussion. Patients in the comparison group served as carriers of pulmonary tuberculosis in 201 (97.1 %) cases and extrapulmonary tuberculosis in 6 (2.9 %) cases. Concurrent illnesses were detected in 114 (55.1 %) individuals. Upon consulting family doctors within the first 5 days of examination, the diagnosis was not established in the comparison group. However, within 20 days, it was verified in 164 (79.2 %) patients. In the main group, pulmonary forms of the disease were observed in 173 (86.9 %) patients, while extrapulmonary forms were present in 26 (13.1 %). Diagnosis was established within 5 days in 94 (47.2 %) individuals and within 10 days in 77 (37.7 %). Overall, within the first 10 days, pulmonary diagnosis was verified in 173 (86.3 %) patients in the main group, as opposed to 18 (8.7 %) in the comparison group, representing a 9.9-fold difference (p &lt; 0.001). Conclusions. Given that 114 patients in the comparison group had concurrent illnesses over many years, their tuberculosis manifestation was treated as «known» to the patient and the attending physi­cian, leading to a delay in diagnosing pulmonary tuberculosis by more than 20 days. Patients in the main group sought medical attention by reporting contact with tuberculosis patients, resulting in consultations with phthisiologists and, consequently, a 9.9-fold faster verification of pulmonary tuberculosis. Screening of individuals suspected of tuberculosis should be promptly conducted by phthisiologists.