Sputum Collection Research Articles

Sputum and tongue swab molecular testing for the in-home diagnosis of tuberculosis in unselected household contacts: a cost and cost-effectiveness analysis.

Delayed and missed diagnosis are a persistent barrier to tuberculosis control, partly driven by limitations associated with sputum collection and an unmet need for decentralized testing. Household contact investigation with point-of-care testing of non-invasive specimens like tongue swabs are hitherto undescribed and may be a cost-effective solution to enable community-based active case finding. In-home, molecular point-of-care testing was conducted using sputum and tongue specimens collected from all household contacts of confirmed tuberculosis cases. A health economic assessment was executed to estimate and compare the cost and cost-effectiveness of different in-home, point-of-care testing strategies. Incremental cost effectiveness ratios of strategies utilizing different combination testing algorithms using sputum and/or tongue swab specimens were compared. The total implementation cost of delivering the standard of care for a 2-year period was $84 962. Strategies integrating in-home point-of-care testing ranged between $87 844 - $93 969. The cost-per-test for in-home, POC testing of sputum was the highest at $20·08 per test. Two strategies, Point-of-Care Sputum Testing and Point-of-Care Combined Sputum and Individual Tongue Swab Testing were the most cost-effective with ICERs of $543·74 and $547·29 respectively, both below a $2,760 willingness-to-pay threshold. An in-home, point-of-care molecular testing strategy utilizing combination testing of tongue swabs and sputum specimens would incur an additional 10.6% program cost, compared to SOC, over a 2-year period. The increased sample yield from tongue swabs combined with immediate result notification following, in-home POC testing would increase the number of new TB cases detected and linked to care by more than 800%. Evidence before this study: We searched PubMed for original research published between January 1, 1950 and June 30, 2024 that evaluated the cost-effectiveness of in-home POC molecular testing, as part of HCI strategies for tuberculosis. PubMed search terms used included ["household contact investigation" OR "household contact tracing"] AND "tuberculosis" AND "cost-effectiveness". The search revealed 8 studies, of which one was removed as HCIs were leveraged for the provision of short course preventative therapy and not tuberculosis testing. None of the studies were conducted in South Africa. All seven remaining studies relied on a hub-and-spoke model of sputum collection and transportation with sputum tested at a centralized laboratory facility. Although active case finding strategies like HCIs are endorsed by the WHO to improve early case detection and treatment initiation, limited research has been done to assess its cost-effectiveness in low- and middle-income countries.Added value of this study: To our knowledge, this is the first example of in-home molecular point-of-care (POC) testing as part of HCI. The use of primary data to estimate and compare the incremental cost effectiveness of different combination, in-home testing strategies utilizing alternative sample types equips policy makers with a selection of strategy options to choose from. The tradeoff between sample types with high collection yield and those with increased accuracy becomes evident in the economic analysis, highlighting the need to consider both yield and accuracy in effective clinical decision making and use-case development. The success of in-home, POC tongue swab testing of all contacts, irrespective of symptom presentation shows great promise for universal testing programs.Implications of all available evidence: Results from our economic modeling provide evidence in support for the integration of in-home, POC tuberculosis (TB) testing during HCI. The use of less invasive tongue swab samples to increase sample yield in the absence of sputum expectoration highlights the value of combination testing strategies. Immediate result notification resulting from rapid, in-home POC testing shows great promise for increasing early case detection and improving treatment uptake. In-home, POC testing strategies, when incorporated into HCI could curb ongoing community transmission and reduce the overall burden of TB. Considerations for adopting novel POC testing strategies in future active case finding programs like HCI should strongly be considered. We evaluated the cost-effectiveness of in-home, point-of-care TB testing of household contacts. The findings indicate that combined testing strategies using tongue swab and sputum specimens could significantly increase TB case detection, with modest additional program costs.

2246 Mind the HAP – an initiative to improve the diagnosis, management and prevention of hospital acquired pneumonia on elderly care

Abstract Introduction The commonest nosocomial infection in the UK is Hospital Acquired Pneumonia (HAP), associated with prolonged length of stay and mortality. The HAP incidence on Elderly care wards was >5% of admissions, exceeding the national average. An initiative ‘Mind the HAP’ was launched which included doctors, nurses, pharmacists, SLTs, physiotherapists and coders to improve HAP diagnosis, management and prevention. Methods To monitor the effectiveness of the interventions 3 audit cycles were performed between 2019 and 2023. Several interventions were implemented between 2019–2023.A multidisciplinary steering committee was formed with 3 work streams (diagnosis, management and prevention). To improve the accuracy of diagnosis and management of HAP, focused educational sessions were conducted for junior doctors with monthly meetings with coders. Nurses championed implementing the HAP prevention strategies i.e. hand hygiene, mouth care and positioning at 30–45 degrees. Regular comprehensive training sessions were held. HAP awareness and education campaign was launched. Daily nursing huddles helped to identify high risk patients. Physiotherapists provide chest physiotherapy to yield sputum sample collection among pneumonia patients. An electronic dashboard of incidence of HAP against the preventative measures and sputum culture reports has been launched with help from informatics. Information leaflets on HAP were created for patient awareness. An electronic HAP power plan to facilitate diagnosis and management of HAP will be launched from February 2024. Results HAP incidence has dropped to <2%, diagnostic accuracy improved from 35% to 81%, and sputum collection has increased from 9% to 24%. The HAP Quality Improvement Project received first prize for the most impactful Quality Improvement initiative at the Trust-wide conference in 2023. The results have been shared with the regional Microbiologists. Conclusion The collaborative efforts coupled with effective leadership and guidance, have been pivotal to the success of ‘Mind the HAP’ project.

Measuring Carbon Content in Airway Macrophages Exposed to Carbon-Containing Particulate Matters.

Pulmonary macrophages exhibit a dose-dependent pattern in phagocytizing particles. Following engulfment, these macrophages are subsequently excreted with sputum, rendering macrophages and particles visible and quantifiable under light microscopy. Notably, elemental carbon within the mammalian body originates exclusively from external contaminants. Consequently, the carbon content in airway macrophages (CCAM) serves as a valid exposure biomarker, accurately estimating individual exposure to carbon-containing particulate matter (PM). This article delineates a protocol involving sputum collection, preservation, processing, slide preparation, and staining, as well as macrophage photo acquisition and analysis. After removing the macrophage nuclei, the proportion of cytoplasm area occupied by carbon particles (PCOC) was calculated to quantify carbon content in each macrophage. The results indicate an elevation in CCAM levels after exposure to carbon-containing PM. In summary, this non-invasive, precise, reliable, and standardized method enables the direct measurement of carbon particles within target cells and is utilized for large-scale quantification of individual CCAM through induced sputum.

An Improved Algorithm for the Detection of Ventilator Associated Pneumonia

Background: Ventilator associated pneumonia (VAP) is associated with significant rates of morbidity and all-cause mortality. Active VAP surveillance can identify risk factors for which targeted preventive measures can be implemented. However, surveillance efforts are complicated by challenges associated with accurate VAP diagnosis. We aimed to improve the accuracy and automation of existing VAP diagnostic algorithms to better identify patients at risk. Methods: The study was conducted at NYU Langone Health from June 2022 through December 2023. We created a semi-automated VAP surveillance system using the Centers for Disease Control & Prevention (CDC) ventilator associated event (VAE) definition as a base framework (Figure 1). We modified this definition to include additional elements, such as having a sputum culture ordered within 48 hours of worsening oxygen status, regardless of culture result. Using this algorithm—followed by manual clinician reviews—we retrospectively assessed possible VAP cases to determine the ability of our surveillance system to correctly identify VAP. Results: Of the 123 possible VAP cases identified through our automated system, 75 (61%) were correctly diagnosed as VAP after clinical review. This reflects a rate of 1.5 infections per 1000 ventilation days across the system and 1.85 infections per 100 patients ventilated for greater than 2 days. Of the 48 remaining patients without VAP after clinical review, 25% (n=12) were characterized as having hospital-acquired pneumonia, 21% (n=10) as acute respiratory distress syndrome or infection at another site and 10% (n=5) as pulmonary embolism/infarction. Among all patients identified through this automated system (VAP and non-VAP), 53% experienced in-hospital death. Discussion: Our automated VAP surveillance algorithm identified 123 cases of potential VAP, 61% of which were consistent with a clinical diagnosis of VAP upon manual chart review. Our VAP rate of 1.5 infections per 1000 ventilation days was similar to published rates at other North American hospital systems. The high in-hospital mortality rate among these patients highlights the need for improved surveillance systems and earlier interventions to reduce the risk of VAP. There are several limitations to the CDC’s VAE definition, including its requirement of a positive microbiologic culture and focus on sputum quality. This potentially misses cases of culture-negative VAP in patients receiving antibiotics prior to sputum collection. Our goal is to continue to validate and improve our algorithm’s ability to correctly identify patients with clinical VAP, so that targeted prevention efforts can be focused upon the patients with the highest risk for poor outcomes.Disclosure: Madeline DiLorenzo: Stocks - Abbvie, Amgen Inc., Becton Dickinson, Biogen Inc., Bristol Myers and Squibb, CVS Health, Davita Inc., Elevance Health, Gilead, Henry Schein, Hologic Inc., Humana Inc., Jazz Pharmaceuticals, Laboratory Corp, Merck and Co., Quest Diagnostics, ResMed Inc., Teladoc Health, Vertex Pharmaceuticals, West Pharmaceuticals

An independent, multi-country head-to-head accuracy comparison of automated chest x-ray algorithms for the triage of pulmonary tuberculosis.

Computer-aided detection (CAD) algorithms for automated chest X-ray (CXR) reading have been endorsed by the World Health Organization for tuberculosis (TB) triage, but independent, multi-country assessment and comparison of current products are needed to guide implementation. We conducted a head-to-head evaluation of five CAD algorithms for TB triage across seven countries. We included CXRs from adults who presented to outpatient facilities with at least two weeks of cough in India, Madagascar, the Philippines, South Africa, Tanzania, Uganda, and Vietnam. The participants completed a standard evaluation for pulmonary TB, including sputum collection for Xpert MTB/RIF Ultra and culture. Against a microbiological reference standard, we calculated and compared the accuracy overall, by country and key groups for five CAD algorithms: CAD4TB (Delft Imaging), INSIGHT CXR (Lunit), DrAid (Vinbrain), Genki (Deeptek), and qXR (qure.AI). We determined the area under the ROC curve (AUC) and if any CAD product could achieve the minimum target accuracy for a TB triage test (≥90% sensitivity and ≥70% specificity). We then applied country- and population-specific thresholds and recalculated accuracy to assess any improvement in performance. Of 3,927 individuals included, the median age was 41 years (IQR 29-54), 12.9% were people living with HIV (PLWH), 8.2% living with diabetes, and 21.2% had a prior history of TB. The overall AUC ranged from 0.774-0.819, and specificity ranged from 64.8-73.8% at 90% sensitivity. CAD4TB had the highest overall accuracy (73.8% specific, 95% CI 72.2-75.4, at 90% sensitivity), although qXR and INSIGHT CXR also achieved the target 70% specificity. There was heterogeneity in accuracy by country, and females and PLWH had lower sensitivity while males and people with a history of TB had lower specificity. The performance remained stable regardless of diabetes status. When country- and population-specific thresholds were applied, at least one CAD product could achieve or approach the target accuracy for each country and sub-group, except for PLWH and those with a history of TB. Multiple CAD algorithms can achieve or exceed the minimum target accuracy for a TB triage test, with improvement when using setting- or population-specific thresholds. Further efforts are needed to integrate CAD into routine TB case detection programs in high-burden communities.

In-home TB Testing Using GeneXpert Edge is Acceptable, Feasible, and Improves the Proportion of Symptomatic Household Contacts Tested for TB: A Proof-of-Concept Study.

Household contact investigations are effective for finding tuberculosis (TB) cases but are hindered by low referral uptake for clinic-based evaluation and testing. We assessed the acceptability and feasibility of in-home testing of household contacts (HHC) using the GeneXpert Edge platform. We conducted a 2-arm, randomized study in Eastern Cape, South Africa. HHCs were verbally assessed using the World Health Organization-recommended 4-symptom screen. Households with ≥1 eligible symptomatic contact were randomized. Intervention households received in-home GeneXpert MTB/RIF molecular testing. GeneXpert-positive HHCs were referred for clinic-based treatment. Standard-of-care households were referred for clinic-based sputum collection and testing. We defined acceptability as agreeing to in-home testing and feasibility as generation of valid Xpert MTB/RIF results. The proportion and timeliness of test results received was compared between groups. Eighty-four households were randomized (n = 42 per arm). Of 100 eligible HHCs identified, 98/100 (98%) provided consent. Of 51 HHCs allocated to the intervention arm, all accepted in-home testing; of those, 24/51 (47%) were sputum productive and 23/24 (96%) received their test results. Of 47 HCCs allocated to standard-of-care, 7 (15%) presented for clinic-based TB evaluation, 6/47 (13%) were tested, and 4/6 (67%) returned for their results. The median (interquartile range) number of days from screening to receiving test results was 0 (0) and 16.5 (11-15) in the intervention and standard-of-care arms, respectively. In-home testing for TB was acceptable, feasible, and increased HHCs with a molecular test result. In-home testing mitigates a major limitation of household contact investigations (dependency on clinic-based referral), revealing new strategies for enhancing early case detection.

Detection of <i>M. tuberculosis</i> Using Cartridge-Based Technology in Patients with Negative Sputum Microscopy Results in a Regional Laboratory

The objective: to evaluate results of M. tuberculosis detection and testing drug susceptibility to rifampicin using molecular genetic methods in tuberculosis patients with a negative sputum smear microscopy result.Subjects and Methods. Pulmonary tuberculosis patients registered in Arkhangelsk Region from 2016 to 2020 were enrolled in the study; those patients were notified as new cases and relapses with a negative sputum smear microscopy result before treatment and had results of molecular genetic testing (MGT) (Xpert MTB/RIF MTB/RIF) and BACTEC MGIT 960 available.Results. 479 people (40%) were registered as pulmonary tuberculosis cases with a negative sputum smear microscopy result. MGT was performed in 327 (68%) patients. A positive result of MGT was received in 120 (37%) patients, a positive result of BACTEC MGIT 960 was received in 165 (50%) people. Concordance of results was observed in 70% of cases. In 136 (41%) people, both tests did not detect Mycobacterium tuberculosis, in 95 (29%) both tests showed a positive result. Discrepancies between the results of two tests were observed in 30% of cases. In 71 (22%) cases, culture growth was observed in BACTEC MGIT 960 with negative results of MGT. In 8% of cases, DNA of Mycobacterium tuberculosis was detected, but there was no culture growth on the nutrient medium. 43/120 (36%) cases of resistance to rifampicin were detected. The median time from sputum collection to initiation of MDR-TB treatment based on sputum MGT results made 18 (IQR 10–29) days. Molecular genetic testing makes it possible to promptly detect the majority of TB patients with a negative sputum smear result, and reduce the time for drug susceptibility testing, which allows this testing to be used as the first test when examining for pulmonary TB.

45 Evaluation of Drug-Resistant Tuberculosis Guidelines and Outcomes by Treatment Site in South Africa

OBJECTIVES/GOALS: DR-TB care in South Africa includes decentralized treatment with shorter, all-oral regimens. Treatment guidelines direct regular clinical and laboratory evaluation to assess patient improvement. We therefore measured sputum collection frequency and follow-up time to assess fidelity to these guidelines in Gauteng Province, South Africa. METHODS/STUDY POPULATION: We included Rifampicin-resistant (RR) sputum specimens from the South African National Health Laboratory Service, which provides pathology services to 80% of the population, submitted between August 2022-September 2023. Patient data were obtained from a DR-TB registry and additional sputum specimen data were collected from follow-up laboratory worksheets. Follow-up spanned from first sputum collection date (baseline) to patient outcome date (e.g., completion, lost) or study closure date (if still on treatment). Monthly sputum submission rate was measured for those with ≥1 additional sputum submitted. We compared patient data by treatment site: at the specialized hospital vs. any other site, using Wilcoxon ranksum and χ2 tests. RESULTS/ANTICIPATED RESULTS: Baseline RR-TB specimens were available for 142 patients, of whom 28 (20%) had specimens submitted from the specialized hospital. Patients at the specialized hospital were older (median age 41 vs. 35.5 years, p=0.03), had higher baseline fluoroquinolone resistance (10% vs. 1%, p=0.01), and longer follow-up (median 5.2 vs. 3.5 months, p=0.01) compared to patients elsewhere. Further, 43 (30%) patients had ≥1 additional sputum submitted during follow-up. Among these, monthly sputum collection rates did not differ by site (0.3 vs. 0.3 sputum per month, p=0.89). We anticipate that increased sputum frequency will be associated with successful TB treatment outcomes based on preliminary findings. DISCUSSION/SIGNIFICANCE: These findings highlight ongoing challenges with routine laboratory follow-up according to DR-TB guidelines across treatment sites in South Africa. Future research is needed to determine reasons for low sputum collection rates, such as low patient adherence, variation in practice of healthcare workers, loss to follow-up, and clinical challenges.

Bronchoscopic Strategies to Improve Diagnostic Yield in Pulmonary Tuberculosis Patients.

In cases where pulmonary tuberculosis (PTB) is not microbiologically diagnosed via sputum specimens, bronchoscopy has been the conventional method to enhance diagnostic rates. Although the additional benefit of bronchoscopy in diagnosing PTB is well-known, its overall effectiveness remains suboptimal. This review introduces several strategies for improving PTB diagnosis via bronchoscopy. First, it discusses how bronchoalveolar lavage or an increased number of bronchial washings can increase specimen abundance. Second, it explores how thin or ultrathin bronchoscopes can achieve specimen acquisition closer to tuberculosis (TB) lesions. Third, it highlights the importance of conducting more sensitive TB-polymerase chain reaction tests on bronchoscopic specimens, including the Xpert MTB/RIF assay and the Xpert MTB/RIF Ultra assay. Finally, it surveys the implementation of endobronchial ultrasound with a guide sheath for tuberculomas, collection of post-bronchoscopy sputum, and reduced use of lidocaine for local anesthesia. A strategic combination of these approaches may enhance the diagnostic rates in PTB patients undergoing bronchoscopy.

Diagnostic accuracy of tongue swab testing on two automated tuberculosis diagnostic platforms, Cepheid Xpert MTB/RIF Ultra and Molbio Truenat MTB Ultima.

Tongue dorsum swabbing is a promising alternative to sputum collection for tuberculosis (TB) testing. Our results lend further support for tongue swabs as exceptionally easy-to-collect samples for high-throughput TB testing.

Microbiology of cystic fibrosis persons not chronically infected with P. aeruginosa: A quasi-experimental study on two different upper airways’ sampling methods

BackgroundThe upper airways of cystic fibrosis (CF) persons are an evolutionary niche where genetically adapted bacterial strains are selected for lung infection. The microbiological studies conducted up to now on the upper airways are not easily comparable. MethodsUsing classical culture methods, we simultaneously studied the microbiological status of upper and lower airways in persons not chronically infected with P. aeruginosa. Each person had a single upper airways sampling and a concomitant lower airways sampling. Lower airways sampling was performed by oropharyngeal swab or sputum collection. Using a quasi-experimental design of study, we evaluated the performance of 2 different upper airways’ sampling methods, nasal lavage according to method described by Mainz or nasal lavage with a rhino-set. Pain was measured with appropriate scales. ResultsA total of 194 persons were enrolled in this study. Pathogenic flora was found in 128 (6.6%) of 194 upper airways samples and in 164 (84.6%) lower airways samples. A statistically significant difference between the upper airways and the lower airways was found in the isolation of S. aureus and non-fermenter gram negatives. Nasal lavage according to Mainz resulted in the isolation of more non-fermenter gramnegatives than the rhino-set (p < 0.05). No differences were found in the pain caused bythe two methods. ConclusionsIn our study population, cultures of the upper airway and lower airway differ in CF persons. In people sampled with nasal lavage according to Mainz more non-fermenter gram negatives were detected than with rhino-set. The two sampling methods were comparable with regard to the caused pain, nasal lavage according to Mainz method being quicker to perform.

Use of the Lung Flute ECO to assist in sputum collection for tuberculosis testing: a randomised crossover trial.

The Lung Flute ECO, a self-powered, low-cost oscillatory positive expiratory pressure device, assisted people with presumptive tuberculosis to produce an adequate sputum volume for diagnostic testing and was well tolerated https://bit.ly/47sDq8W.

Diagnosis and Therapy of Community-Acquired Pneumonia in the Emergency Department: A Retrospective Observational Study and Medical Audit.

Despite advances in therapy, community-acquired pneumonia (CAP) is still associated with significant morbidity and mortality. Several studies conducted in different countries have reported suboptimal adherence to the guidelines. However, there are currently no available data on adherence to CAP guidelines specifically in Switzerland. The aim of this study was to audit the quality of diagnosis and therapy of CAP at a Swiss general hospital. A retrospective, observational, single-center cohort study was conducted, including patients older than 18 years diagnosed with CAP and admitted to a medical ward throughout 2019 without prior antibiotic therapy prescribed by their general practitioner (GP). The baseline characteristics of the patients were analyzed, and the diagnostic workup and treatment were compared to the Swiss guidelines for CAP. A total of 254 patients diagnosed with CAP were included in this study (median age 78 years, 51.6% males). Atypical pneumonia was diagnosed in 4% of patients, while an organism was identified in 33% of cases, with Streptococcus pneumoniae being the most frequently detected pathogen (57%). A chest image was taken in almost all patients. Documentation of respiratory rate was missing in 23% of cases. Procalcitonin was measured in 23.2% of cases. Pneumococcal and legionella urinary antigen testing was performed on approximately 90% of all patients and blood cultures were drawn in approximately 80% of patients. In 39% of cases, arterial blood gas analysis was performed. Guideline adherence for the administration of empiric antibiotics was documented/recorded in 75% of cases. Twelve different antibiotic regimens were administered, and they were mostly amoxicillin/clavulanate with or without macrolides, as suggested by the guidelines. In particular, the use of ceftriaxone was higher (19.7%) compared to the Swiss guidelines. The average length of antibiotic therapy was longer (8.2 days) compared to the guidelines (5-7 days). Oral steroid therapy was administered to 29.1% of patients, including to 75% of those diagnosed with COPD. Overall, guideline adherence was moderately low, especially with regards to the assessment of respiratory rate, performance of arterial blood gas analysis, and sputum collection. Regarding antibiotic therapy, the use of ceftriaxone and the length of antibiotic therapy should be reduced. Further research is needed to identify the reasons for guideline non-adherence, and to find effective measures for the improvement of guideline adherence.

Evaluation of Induced Sputum against Gastric Juice Aspirate in the Diagnosis of Tuberculosis in Children: A Cross-sectional Study

Introduction: Diagnosing Tuberculosis (TB) in children is difficult as they do not expectorate sputum on their own, and the sample is usually paucibacillary. Hence, alternative sampling methods like Gastric juice Aspiration (GA), which is the widely accepted method, and Induced Sputum (IS) collection, a more novel approach, are used. The IS method has several advantages, such as being less invasive, not requiring inpatient admission, causing less discomfort, and not necessitating overnight fasting, compared to the GA method. Aim: To evaluate IS against GA for diagnosing TB using XpertMTB/ RIF assay, as well as mycobacterial culture, in children aged between 2 and 15 years. Materials and Methods: This cross-sectional study was conducted in the Department of Paediatrics at Christian Medical College and Hospital, Vellore, Tamil Nadu, India from June 2019 to March 2020, involving 138 children aged between 2 and 15 years who were being evaluated for TB. GA samples were collected after an overnight fast, and on the same day, atleast two hours later, IS samples were collected by trained staff. Both samples underwent mycobacterial smear and culture using the Mycobacteria Growth Indicator Tube (MGIT) method and Xpert MTB/RIF assay. Confirmation of pulmonary TB was based on atleast one of these tests being positive. The ‘Wong-Baker’ Visual Analogue Scale (VAS) was individually administered to each patient to compare the discomfort associated with GA and IS procedures. The differences in yield between IS and GA were tested for significance using the Two-sample test of proportions with a significance level set at 5%. McNemar's χ2 test was employed to compare matched observations. The MannWhitney test was used for comparing continuous variables, and the Chi-Square test for categorical variables. Cohen’s Kappa (κ) was used to assess interobserver agreement between the sampling methods using the different tests. Results: Out of the 138 cases recruited with suspected pulmonary TB, the diagnosis was microbiologically confirmed in 13 cases (9.4%). The overall diagnostic yield was 12/138 (8.7%) for GA and 10/138 (7.2%) for IS. In children under 10 years, GA outperformed IS with all three cases being positive by GA and none by IS. For those aged 10 years and above, 10 children (100%) tested positive with IS, while nine children (90%) were positive with GA. According to the Wong-Baker VAS measuring discomfort during the procedure, IS was favoured over GA (p-value&lt;0.0001). Conclusion: IS performs similarly or better than GA in children over 10 years, while GA performs better than IS in children under 10 years of age. IS is reported to cause less discomfort than GA on the Wong-Baker VAS.

Bacteria and viruses and clinical outcomes of asthma-bronchiectasis overlap syndrome: A cohort study.

Despite the high prevalence of co-existing bronchiectasis and asthma (asthma-bronchiectasis overlap syndrome [ABOS]), little is known regarding the dominant pathogens and clinical correlates. To investigate the bacteria and viruses which differentially dominate in ABOS (including its subtypes) compared with bronchiectasis alone, and determine their relevance with bronchiectasis severity and exacerbations. This was a prospective observational cohort study conducted between March 2017 and August 2023. We included 81 patients with ABOS and 107 patients with bronchiectasis alone. At steady-state baseline, patients underwent comprehensive assessments and sputum collection for bacterial culture and viral detection (quantitative polymerase-chain-reaction). Patients were followed-up to record exacerbation and spirometry. Patients with ABOS had significantly higher symptom burden and exacerbation frequency than those with bronchiectasis alone. Despite similar pathogen spectrum, the rate of bacteria-virus co-detection increased less substantially at acute exacerbations (AE) onset than at steady-state compared with bronchiectasis alone. Pathogenic bacteria (particularly Pseudomonas aeruginosa) were detected fairly common (exceeding 50%) in ABOS and were associated with greater severity of bronchiectasis when stable and conferred greater exacerbation risks at follow-up. Viral but not bacterial compositions changed substantially at AE onset compared with clinical stability. Higher blood eosinophil count, moderate-to-severe bronchiectasis and non-atopy were associated with higher odds of bacterial, but not viral, detection (all p<0.05). Detection of bacteria or virus is associated with bronchiectasis severity or clinical outcomes in ABOS. This highlights the importance of integrating sputum microbial assessment for ascertaining the dominant pathophysiology (atopy vs. infection) and longitudinal trajectory prediction in ABOS.

No extraction? No problem. Direct to PCR processing of tongue swabs for diagnosis of tuberculosis disease as an alternative to sputum collection.

Tuberculosis (TB) remains one of the world's leading infectious disease killers, despite available treatments. Although highly sensitive molecular diagnostics are available, expensive equipment and poor infrastructure have hindered their implementation in low-resource settings. Furthermore, the collection of sputum poses challenges as it is difficult for patients to produce and creates dangerous aerosols. This manuscript explores tongue swabs as a promising alternative to sputum collection. While previous studies have explored the sensitivity of tongue swabs as compared to sputum, existing literature has not addressed the need to standardize and simplify laboratory processing for easy implementation in high TB burden areas. This manuscript provides the first evidence that detection of TB from a tongue swab is possible without the use of DNA extraction or purification steps. The data provided in this manuscript will improve the collection and testing of tongue swabs for the diagnosis of TB disease.

Evidence for Tuberculosis in Individuals With Xpert Ultra "Trace" Sputum During Screening of High-Burden Communities.

"Trace" results on Xpert MTB/RIF Ultra ("Ultra"; Cepheid) -a molecular diagnostic test for tuberculosis (TB)-are often interpreted as an indication for TB treatment, but may also represent detection of nonviable bacilli or analytical error. In community-screening settings where individual TB risk is low, there is limited guidance on how to interpret Ultra-trace results. We conducted systematic Ultra TB screening of adults and adolescents (≥15 years) in Kampala, Uganda, through door-to-door and event-based sputum collection. We enrolled individuals with trace-positive sputum for detailed clinical, radiographic, and microbiological (including 2 sputum cultures, repeat Ultra, and for people with HIV, urine lipoarabinomannan) evaluation, and compared those findings with similar evaluations in controls with Ultra-negative and Ultra-positive (non-trace) sputum. Of 21 957 people screened with Ultra, 211 (1.0%) tested positive, including 96 (46% of positives) with trace results. Of 92 people enrolled with trace-positive sputum; 12% (11/92) were HIV-positive and 14% (13/92) had prior TB. The prevalence of TB among participants with trace-positive sputum results was 14% (13/92) by culture, 24% (22/92) using broader microbiological criteria, and 26% (24/92) after accounting for clinical diagnosis. The prevalence of cough and of abnormal chest computed tomography (CT) findings were 32% and 26%, respectively, if Ultra-negative; 34% and 54% if trace-positive/non-microbiologically confirmed; 72% and 95% if trace-positive/microbiologically confirmed; and 71% and 93% if Ultra-positive (more than trace). Most individuals with trace-positive sputum in Ugandan communities did not have microbiologically confirmed TB but had more symptoms and chest CT abnormalities than people with Ultra-negative sputum.

Implementation of The Pulmonary Tuberculosis Control Program at Sikumana Public Health Center

Introduction: According to the East Nusa Tenggara Provincial Health Office, Kupang City is the city with the highest contribution to pulmonary TB cases in 2021 with 491 cases and the Sikumana Health Center is the Public Health Center with the highest number of TB cases with 88 cases, patient recovery rate of 68.2%, and not reached the national target of 100%. The purpose of this study was to analyze the implementation of the pulmonary TB control program at the Sikumana Health Center. Methods : The research study was qualitative research using in-depth interview techniques. The number of informants was 11 informants. This research was conducted at the Sikumana Health Center, District Maulafa, City of Kupang from February to April 2023.Results: In the input aspect, the funds program, and human resources are sufficient, and the facilities for implementing the TB program are incomplete. In the process aspect, the planning and implementation stages have been going according to the proposed activity plan, but in the monitoring and supervision activities, it is still lacking because it is administrative and based on recording and reporting only. In the output aspect, the coverage of case detection in 2022 is 58.5%, the notification rate for all cases is 22.8%, the treatment success rate is 94.2%, and the cure rate is 98.2%.Conclusion: The Pulmonary Tuberculosis program implementation in Sikumana Health Center wasn’t implemented successfully because of process and input problems such as facilities and human resources. There should be regular training for TB program implementing officers, a special room for sputum collection, and routine supervision to the laboratory.

Knowledge Among Junior Doctors About the Collection and Transport of Samples for Tuberculosis Diagnosis in a Medical College Hospital in Coastal Karnataka, India.

Background The accuracy of the TB diagnosis depends on the quality of the collected and transported samples. Inadequate knowledge and practices regarding the collection and transport of sputum samples can lead to false-negative results and delay the diagnosis and treatment of TB.This study was conducted to assess the knowledge of residents and interns about the collection and transport of sputum and other samples for the diagnosis of tuberculosis in a medical college hospital. Methods This was a cross-sectional study conducted among 120 medical interns and postgraduate residents of a medical college hospital in coastal Karnataka, India. Participants were interviewed using a pre-designed and structured questionnaire. The data was analyzed using IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. Descriptive statistics like the mean, standard deviation, and chi-square test were used. A p-value less than 0.05 was considered statistically significant. Results Most of the study participants (76, 63.3%) belonged to the age group of 22 to 25 years and were interns. Nearly three-quarters of the participants (85, 70.8%) were female. Based on the mean score, 69.2% of the participants exhibited good knowledge. Among the socio-demographic characteristics, being a postgraduate resident was associated with good knowledge about the collection and transport of samples (p-value< 0.05). Conclusion Seven out of ten participants had good knowledge about the collection and transport of sputum and other samples for the diagnosis of tuberculosis. Strengthening the training of this category of health workers needs to be prioritized.

Diagnostic Value of Pepsin Measurements in Dysphonia Attributed to Laryngopharyngeal Reflux Disease

To investigate the diagnostic value of pepsin test in detecting laryngopharyngeal reflux (LPR) in patients with suspected LPR-induced dysphonia. Dysphonic and non-dysphonic patients with LPR at the 24-hour hypopharyngeal-esophageal impedance-pH monitoring (HEMII-pH) were recruited from January 2019 to November 2022. Patients collected saliva/sputum samples to measure pepsin concentrations. Symptoms and findings were studied through reflux symptom score (RSS) and reflux sign assessment (RSA). Voice quality was assessed with maximum phonation time, GRBAS, voice handicap index (VHI), and acoustic parameters at baseline and 3-month post-treatment. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of pepsin tests for dysphonia-related to LPR were calculated at ≥16ng/mL cutoff. The relationship between HEMII-pH, clinical features, voice quality outcomes, and pepsin measurement was investigated. Sixty-seven patients with LPR at the HEMII-pH completed the evaluations accounting for 30 patients consulting for dysphonia. Dysphonic patients reported higher RSS than non-dysphonic patients. RSS, RSA, laryngeal findings, VHI, and grade of dysphonia significantly improved from baseline to 3-month posttreatment. Pepsin test detected LPR in 73% of dysphonic cases. The pepsin test was 73.3 sensitive and 18.9 specific when considering the highest pepsin level of morning, postlunch, and postdinner sputum collections. Sensitivity, specificity, PPV, and NPV varied regarding the time of sputum collections. There was a strong significant association between the concentration of the morning pepsin test and the severity of laryngeal RSA score (P=0.018). The morning pepsin saliva test concentration was predictive of the 3-month otolaryngological RSS (P=0.014). Pepsin test is a sensitive but poorly specific diagnostic approach for patients with dysphonia attributed to LPR. Multiple pepsin measurements may increase the sensitivity and predictive value of pepsin test. Future large-cohort studies are needed to investigate the accuracy of pepsin test in this population.