Category - Part 5
Applied Medical Informatics for the Chest Physician
In the first installment in this series on applied medical informatics (AMI) for the chest physician, we reviewed the structure and basic function of the electronic medical record (EMR). Even to the casual observer of the technology of the EMR in American medicine, the following two realities are manifest: (1) recently, there has been a great deal more discussion in the medical literature, in national medical organizations, and in the lay press on the benefits and risks of the EMR; and (2) there has been a great deal more talk about the EMR than has been actual use and availability of these tools in daily practice. In this, part 2 of the series on AMI, we will examine the reasons for this important and frustrating conundrum, and how to understand and realize the benefits of the EMR and avoid its drawbacks. add comment
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Pulmonary Mycobacterium kansasii Infection in Israel, 1999-2004: Conclusion
The present report supports M kansasii susceptibility to clarithromycin and ofloxacin.2′ Ofloxacin was also superior to ciprofloxacin (Table 2). We believed that some isolates are susceptible to slightly higher ciprofloxacin concentrations; therefore, when clinically indicated, ciprofloxacin should be used regardless of the in vitro susceptibility results. M kansasii infection affects middle-aged men more than women. The most common associated lung disease in the present series was COPD, although approximately 40% of the patients had no recognized immune defect. This has been reported in other studies as well. The chest radiograph findings in M kansasii infection are very similar to pulmonary tuberculosis, including cavitary infiltrates with an upper-lobe predilection (82% vs 4% for the lower lobe in the present study). However, noncavitary lung disease has also been recognized as part of the spectrum of M kansasii mfection.> Our study showed that cavitary disease occurred only in 54%. Like in the report of Evans et al, none of our patients had pleural effusion or lymphadenopathy. Lower rate of cough, cavitation, and upper-lobe predominance on chest radiograph were noted in patients receiving immunosuppressive medications in our study compared to the same patients in other studies. However, the number of patients with recognized immune defect in our series was low (n = 8, 14%).
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Pulmonary Mycobacterium kansasii Infection in Israel, 1999-2004: Discussion
We noted several clinically significant findings. Series from the United States’ and Spain suggested a higher-than-normal rate of isolation of M kansasii from HIV-positive patients, and a study done between 1981 and 1987 reported a 200-fold higher incidence of disseminated M kansasii infection in people with AIDS (138 per 100,000) than in the general population of the United States. However, in the present study, only a small number of patients received immunosuppressive medications, and none were HIV positive. This was also true for the series of Evans et al. website
Another important finding was the relatively low rate of cavitation in our study compared to that of Evans et al (54% vs 75%). In other series,, rates of cavitary infiltrates were even higher (approximately 90%). This discrepancy might be explained by recent improvements in diagnosis and microbiological isolation of the organism.
The good outcome in our study compared to the earlier study (100% vs 79%) may be attributable to the fewer systemic comorbid diseases in our series compared to the reports of Evans et al. In addition, all deaths caused by mycobacterial disease in this study occurred either before or soon after treatment was started. These data provide support for the use of earlier treatment regimens in M kansasii infection.
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Pulmonary Mycobacterium kansasii Infection in Israel, 1999-2004: Molecular Characterizations
Twenty M kansasii isolates underwent molecular characterization. Eighteen isolates were found to be M kansasii type I, and 2 isolates were M kansasii type II.
Table 2 summarizes the drug sensitivity of the M kansasii isolates. All isolates were sensitive to rifam-picin, all but one isolate (borderline) were sensitive to ethambutol and ofloxacin, and all but two isolates (borderline) were sensitive to clarithromycin. Sensitivity rates to ethionamide and cycloserine were 91% and 94%, respectively, with one isolate resistant to each. A high rate of resistance was noted for ciprofloxacin (10 isolates, 29%) and capreomycin (26 isolates, 74%); 2 isolates (6%) were highly resistant to capreomycin. add comment
All our patients were treated with rifampicin (600 mg), ethambutol (25 mg/kg for the first 2 months, then 15 mg/kg), and clarithromycin (1,000 mg/d) administered daily for at least 12 months of negative sputum culture results. The mean duration of treatment was 21 ± 7.2 months.
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Pulmonary Mycobacterium kansasii Infection in Israel, 1999-2004: Statistical Analysis
Data on clinical features of the patients (including systemic comorbid disease and smoking status), radiologic findings, treatment, and outcome were obtained from the case notes and laboratory records by a single investigator. Chest radiographs obtained within 2 weeks of diagnosis of mycobacterial disease were read by an independent investigator who was blinded to the clinical findings. All the patients had been tested for HIV. The study was approved by the Ethics Committee of Rabin Medical Center.
Results are shown as mean ± SD. To statistically analyze differences between categorical variables, a x2 test or Fisher exact test were used, as appropriate. The Pearson correlation coefficient (r) and the significance for it (p value) were calculated between the variables; p < 0.05 was considered statistically significant.
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Pulmonary Mycobacterium kansasii Infection in Israel, 1999-2004: Materials and Methods
The study sample included 56 patients with a diagnosis of M kansasii lung infection who attended the tuberculosis centers in Tel Aviv and Rehovot, Israel, from April 1999 to April 2004. The diagnosis was based on the guidelines of the ATS, namely appropriate symptomatology, compatible radiographic abnormalities, and multiple culture-positive respiratory specimens for M kansasii.15 Patients in whom there was a high clinical suspicion of tuberculosis but negative sputum smear results underwent bronchoscopy with BAL and transbronchial biopsy to confirm the diagnosis.
Mycobacterial cultures were performed with standard meth-ods. Sputum smears were stained with auramine and examined using fluorescence microscopy, and the presence of acid-fast organisms was confirmed with Ziehl-Neelsen stain. Lowenstein-Jensen slopes were incubated for 12 weeks. All mycobacterial isolates were sent to the Public Health Laboratory Service, Mycobacterial Reference Unit in Tel Aviv for identification and sensitivity testing.
Pulmonary Mycobacterium kansasii Infection in Israel, 1999-2004
Mycobacterium kansasii has traditionally been considered the most virulent of the nontuber-culous mycobacteria.,2 It is the second most common nontuberculous mycobacterium after Mycobacterium avium complex3 and the most common cause of nontuberculous mycobacterial lung disease in the United Kingdom and Western Europe. Infection with M kansasii probably occurs via an aerosol route, Tap water is a major reservoir for M kansasii causing human infection. The incidence of M kansasii infection has a wide geographic variation, being highest in the central and southern United States, and England and Wales. Click Here
Isolation of M kansasii from tap water can be intermittent, which may explain why some investigators have failed to recover it from that source. No other environmental (water or soil) source of M kansasii has been identified. Risk factors include chronic lung disease, previous mycobacterial disease, malignancy, and alcoholism. In immunocompetent patients, pulmonary disease is the most frequent clinical manifestation, although approximately 40% have no associated illness. The prevalence of M kansasii infection may be very high in areas where HIV is common.
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