Tài liệu Detection of Pulmonary tuberculosis: comparing MR imaging with HRCT pptx

... RESEARCH ARTICLE Open Access Detection of Pulmonary tuberculosis: comparing MR imaging with HRCT Elisa Busi Rizzi1*, Vincenzo Schinina’1, Massimo Cristofaro1, Delia Goletti2, Fabrizio ... purpose of our study was to compare MRI with high resolution CT (HRCT) for assessing pulmonary tuberculosis.Methods: 50 patients with culture-proven pulmonary tuberculosis underwent chest HRCT ... standard of reference and were evaluated by MRI within 24 h after HRCT. Altogether we performed 60 CT and MRIexaminations, because 10 patients were also examined by CT and MRI at follow- up. Pulmonary...

... patients with PTBwho had concomitant evidence of extrapulmonary TB(EPTB). The diagnosis of EPTB was based on clinicaland radiological features suggestive of TB concerningthe involved site with ... Amongpatients with PTB who also had EPTB, the mostcommon site of extra pulmonary involvement wasTable 1. Demographic characteristics of elderly (Group I) andyoung (Group II) patients with pulmonary ... the enrollment was by means of enrollment of fixed number (n = 50) of consecutivepatients with PTB in each group rather than byconsecutive enrollment of all patients with PTB, thecurrent study...

... pathogenesis of a variety of diseases. However, whether KIR polymorphism is associated with susceptibility to pulmonary tuberculosis was unknown. We examined a possible association of KIR polymorphism ... carried out with 10 Association of KIR with pulmonary tuberculosis©FUNPEC-RP www.funpecrp.com.brGenetics and Molecular Research 11 (2) 1370-1378 (2012)1373cycles at a melting temperature of 94°C ... annually (Doherty et al., 2009). Because of the increasing mobility of the population, the changing environment, and the biology of bacilli, the prevalence of TB is higher in China. Epidemiological...

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... pecteddisease,theriskapproximated15per-centforNegroesand5percentforwhites.Forolderpersons with minimalorsuspectedtuber-culosis,theriskwasapproximately4percentforNegroesand2percentforwhites.Therisk of reactivationamongNegroeswasnotassociated with degree of skinpigmentation.Long-termfollowup of persons with inactivediseaseappearstobeanimportantmeans of detectingactivetuberculosis.NOTE:Personsinterestedinthetablesgivingmoredetails of thelifetableanalysesmayobtainthemfromtheauthor.REFERENCES(1)Puffer,R.R.,Stewart,H.C.,andGass,R.S.:TuberculosisstudiesinTennessee.Subsequentcourse of casesobservedinWilliamsonCounty.Am.J.Hyg.28:490-507(1938).(2)Reisner,D.,andDownes,J.:Minimaltubercu-louslesions of thelung;theirclinicalsignifi-cance.Am.Rev.Tuberc.51:393-412(1945).(8)Lincoln,N.S.,Bosworth,E.B.,andAlling,D.W.:Theafter-history of pulmonary tuberculosis.III.Minimaltuberculosis.Am.Rev.Tuberc.70:15-31(1954).(4)Kallquist,I.:Long-termprognosisin pulmonary tuberculosisdetectedbymassradiography.Acounty-widesurvey with controlsandacom-parisonbetweentwomasssurveys with aseven-yearinterval.Actatuberc.scandinav.,1958,supp.44,p.177.(5)Groth-Petersen,E.,Knudsen,J.,andWilbek,E.:Epidemiologicbasis of tuberculosiseradicationinanadvancedcountry.Bull.WorldHealthOrgan.21:549(1959).(6)Frimodt-M0ller,J.:Acommunity-widetuber-culosisstudyinasouthIndianruralpopula-tion.Bull.WorldHealthOrgan.22:61-170(1960).(7)Comstock,G.W.:TuberculosisstudiesinMuscogeeCounty,Georgia.I.Community-widetuberculosisresearch.Pub.HealthRep.64:259-263(1949).(8)Burke,M.H.,Schenck,H.C.,andThrash,J.A.:TuberculosisstudiesinMuscogeeCounty,Georgia.II.X-rayfindingsinacommunity-widesurveyanditscoverageasdeterminedbyapopulationcensus.Pub.HealthRep.64:263-290(1949).(9)Palmer,C.E.,Shaw,L.W.,andComstock,G.W.:Communitytrials of BCGvaccination.Am.Rev.Tuberc.77:877-907(1958).(10)Edwards,L.B.,andPalmer,C.E.:Isolation of "atypical"mycobacteriafromhealthypersonsAm.Rev.Resp.Dis.80:747-749(1959).(11)NationalTuberculosisAssociation:Diagnosticstandardsandclassification of tuberculosis.NewYork,N.Y.,1961.(12)Newell,R.R.,Chamberlain,W.E.,andRigler,L.:Descriptiveclassification of pulmonary shad-ows.Arevelation of unreliabilityintheroentgenographicdiagnosis of tuberculosis.Am.Rev.Tuberc.69:566-584(1954).(13)Yerushalmy,J.,etal.:Anevaluation of therole of serialchestroentgenogramsinestimat-ingtheprogress of diseaseinpatients with pulmonary tuberculosis.Am.Rev.Tuberc.64:225-248(1951).GraduateTrainingTheConference of BiologicalEditorsatitsannualmeetinginNewOrleansinMarch1962votedto:1.EndorsetheprinciplethatEnglishdepartmentsinsecondaryschoolsandcollegesgivetraininginwritingscientificreports.2.Recommendthatteachers of biologicalsciencesrequirewrittenreportsbystudentsintheircourses.3.Recommendthatteachers of sciencecorrecttheEnglishinsciencereportswrittenfortheircourses.4.Endorseanexploration of possibilities of greatercooperationbetweendepartments of Englishorjournalismanddepartments of biologicalsciences.Anexamplewouldbetopermitatermpaperonasciencesubjecttoservebothdepartments.5.Endorsetheprinciplethatthewritingandpublication of reportsberegardedasanessentialandintegralphase of fulfilledresearch.470PublicHealthReportsUntreatedInactive Pulmonary TuberculosisRisk of ReactivationGEORGEW.COMSTOCK,M.D.,Dr.P.H.THERELAPSINGTENDENCY of pul¬monarytuberculosisiswidelyknownandwelldocumented.In1938,Puffer,Stewart,andGass(1)reportedfromtheWilliamsonCounty(Tenn.)TuberculosisStudythat12percent of whitepersonsclassifiedashavingminimalarrestedtuberculosisand15percent of thosehavinglatentapicaltuberculosishadbe¬comeworseduringa3-yearperiod of observa¬tion.EeisnerandDownes(2)investigatedtherelapserateamongasample of persons with productive,fibrotic,orcalcificminimaltubercu¬losiswhoattendedtheambulatorychestclinics of theNewYorkCityDepartment of Health.Theyfound5percent of whitesand14percent of nonwhiteshaddevelopedactivediseasein5years.Amongagroup of upstateNewYorkpatients,diagnosedbythestaff of HermannM.BiggsMemorialHospitalbetween1937and1947ashavingminimalarrestedtuberculosis,therisk of developingactivetuberculosisdur¬ingthe10yearsfollowingdiagnosiswas13percent(3).Similarstudieshavebeenmadeinothercountries.Kallquist(^),reportingfromSwe¬denontheexperience of 312personsconsideredtohaveinactiveorprobablyinactivetubercu¬losis,notedthat8percenthadshownevidence of activediseasewithinaperiod of 8years.AcomprehensivereportontheDanishTubercu¬losisIndexbyGroth-Petersen,Knudsen,andDr.Comstockis with theTuberculosisBranch of theCommunicableDiseaseCenter,PublicHealthService,Washington,D.C.Wilbek(5)includedobservationson560per¬sonsneverpreviouslyreportedastuberculosiscasesbecausetheirchestroentgenogramswereconsideredtoshowfibrosisonly.Within4years,nearly2percenthaddevelopedactivedisease.InsouthIndia,Frimodt-M^ller(6)foundanaverageannualreactivationrate of 6percentforpersonsclassifiedasprobablyhavinginactivetuberculosisand1percentforthoseinitiallyconsideredtohaveclinicallyin-significant,inactivedisease.Althoughtheforegoingstudieshaveindi¬catedconsiderablevariationintheaveragean¬nualreactivationrate,avariationthatcouldberelatedbothtodifferencesinthedefinitions of acaseandinthelivingconditions of thestudypopulations,allagreedthattherisk of reactivationwassubstantial.Andyetthereissurprisingvariationintheperiod of observa¬tionrecommendedforpersons with inactive pulmonary tuberculosis.Somehealthdepart¬mentsdonotadviseanyfollowup of persons with newlydiagnosedminimalinactivedisease;othersadviseperiodicexaminationsfor ... 5yearsorlonger.Suchvariationinpublichealthpracticesuggestedtheneedforfurtherinfor¬mationontheimportance of relapsesamongpersons with inactivediseaseasasource of activetuberculosis.InformationgatheredbytheMuscogeeCountyTuberculosisStudywasusedtoesti¬matetheprognosis of untreatedinactivepul¬monarytuberculosis.Thediscoveryandpro¬longedobservation of allcases of tuberculosisinthecommunityhasbeenone of themajorVol.77,No.6,June1962461goals of thisstudysinceitsinceptionin1946(7).Consequently,casefindingactivitiesinthisareahavebeenmoreextensivethanisoftenpossible.Communitywidephotofluorographicsurveyswereconductedin1946andagainin1950(8$).Inaddition,thenumber of chestX-rayexaminationsmadebythehealthde¬partmenteachyearapproximatedone-sixth of thetotalpopulation.Themedicalprofessionandalliedagenciesinthecommunityhavebeenhighlycooperativeinreportingtuberculosiscases,usuallyrelinquishingresponsibilityforfollowupsupervisiontothestudy.Asaresult,itisbelievedthatnearlyallknowncaseshavebeenreportedtoandsupervisedbythestudy.Allpersons with definiteorsuspectedtuber¬culosiswereadvisedtoobtainquarterlyorsemiannualexaminationsuntiltheirdiseasehadshownnoevidence of activityforatleast5years.Althoughroutinefollowupwasthendiscontinued,subjectswereadvisedtobeex¬aminedannuallyandweresentreminders of theseexaminationsaslongastheycontinuedtoliveinthearea.Facilitiesforsputumexami¬nationshavealsobeenreadilyavailable, with culturesformycobacteriaaroutinepart of theexaminationsince1947.Sputumspecimenswererequestedatthebeginningandend of theroutinefollowupperiod,andalsowheneverclinicalorroentgenographicevidence of pos¬siblyactivediseasewasnoted.Almostallpa¬tients with ahistory of productivecoughcomplied with therequestsforspecimens.Many,however,deniedthissymptomandfailedtosubmitspecimens.Gastriclavageswererarelyperformed.InitialStudyPopulationThepopulationfromwhichthecases of un¬treatedinactive pulmonary tuberculosisweredrawncomprisesallpersonswhowerefirstreportedtotheMuscogeeCountyTuberculosisStudyashavingdefiniteorsuspectedtuber¬culosisbetweenJanuary1,1946,andJanuary1,1956,andwhoalsometthefollowingcriteria:(a)atthetimethesepersonswerereported,theylivedinMuscogeeCounty,andwere15-65years of age;(b)beforebeingreported,theyhadneverbeenadvisedtobehospitalizedfortuberculosis;(c)2yearsafterthefirstreport,Table1.Yearinwhichmembers of initialstudypopulationwerereportedtotheMuscogeeCountyTuberculosisStudyastuberculosiscasesorsuspectstheywerestillregisteredashavingsuspectedordefinite pulmonary tuberculosisandwerenotknowntohaveextra -pulmonary tuberculosis.Atotal of 1,327personsmetthesecriteria.Theyearinwhichtheywerefirstreportedtothestudyisshownintable1.Morethanone-thirdweredetectedin1946,theyear of thefirstcommunitysurvey.One-sixthcametoatten¬tionin1950,largelyastheresult of thesecondsurvey.Althoughtheproportiondiscoveredineach of theotheryearshasbeenquitecon¬stant,thisactuallyreflectsadeclineinthemor¬bidityrateowingtotheincreaseinpopulation of MuscogeeCounty,Ga.,from95,638personsin1946to158,623in1960.Thecomposition of theinitialstudypopula¬tionandthetype of examinationwhichledtotherecognition of tuberculosisareshownintable2.Almost70percent of thecaseswereinwhitesand30percentinNegroes.However,sinceconsiderablyfewerNegroesthanwhitesresideinthecounty,themorbidityratewasslightlyhigheramongNegroes.Slightlymorethanhalf of thewhitesbutonlyone-third of theNegroeswereovertheage of 45years.Amuchhigherproportion of Negroesthanwhiteswereclassifiedashavingadvanceddisease,44percentcontrasted with 23percent.Forbothraces,theproportion of advancedtuberculosiswaslargeramongtheyoungeragegroups.Almosthalf of thegroupwasbroughtundersupervisionastheresult of thetwomasssur¬veys.Ifpersonsdetectedbysurvey-likepro¬ceduressuchaspreemploymentandfoodhandler462PublicHealthReportsexaminationsarealsoincluded,morethanthree-fifthswerefoundamongpresumablyhealthygroups.Onlyafewwereidentifiedbecausetheyhadbeenincontact with acase of activetuberculosis.Athird of thetotalgroupwasclassifiedassymptomatic,havingbeenreferredforexaminationbyprivatephysiciansorhos¬pitalclinicsorself-referred.Manycontactswereinthecategory of symptomaticreferrals.Thesepersonshadnoevidence of tuberculosisonroutinecontactexaminations,butreturnedforreexaminationwhensymptomsdevelopedratherthanwaitingfortheirnextroutinefol¬lowupexamination.Asmightbeanticipated,ahighpercentage of advancedcasescamefromthegroup of symptomaticreferrals.Althougholderpersonsdidnotparticipatewellinthecommunitysurveys,asurprisinglylargepro¬portion of those with minimalorsuspecteddiseasesamongthemwerediscoveredthisway.ActiveandInactiveTuberculosisArrivingatanappropriatedefinition of ac¬tivetuberculosiswasnotassimpleasmightap¬pearatfirstglance.Primarily,adefinitionwasdesiredwhichwoulddesignatepersonswhoweretrulyillandwhosetuberculosiswassufficientlyseveretorequireamajorchangeintheirlives.Itdidnotseemimportanttostudytheincidence of diseasemanifestedonlybyisolateddemon¬strations of acid-fastbacilliorbyminorroent-genographicchanges.Nosinglecriterionseemedadequatetodes¬ignatesignificantlyactivetuberculosis.Eventhefinding of acid-fastbacilli with theculturalcharacteristics of Mycobacteriumtuberculosiswasfarfromsatisfactory.Inthispart of theworld,acid-fastbacillihavebeenisolated with considerablefrequencyfromcertainhealthypopulationgroups(10).Some of theseor¬ganismscouldhavebeenmistakenforM.tuber-culosis,particularlyintheearlierdays of thestudy.Butthemajorreasonfornotacceptingthissinglecriterionwasthefactthattuberclebacilliwereisolatedfromasizablesegment of thisstudygroupononlyasingleoccasion, with nootherevidence of activediseaseonprolongedbacteriologicalandroentgenographicobserva¬tion.Althoughonewidelyusedstandardwouldautomaticallyclassifythesepersonsashavingactivetuberculosis(ii),theirdiseasedidnotthenandhasnotyetshownanyevidence of be¬comingarealhealthproblem.Theuse of roentgenographicchangealsoseemedinadequateastheonlycriterionforac¬tivedisease,particularlyinview of thedemon¬strateddifficultiesingettingagreementevenamongexpertsinclassifyingtuberculosisfromchestroentgenograms(12,13).AndagainthereTable2.Percentage of tuberculosiscasesininitialstudypopulationdiscoveredbyspecifiedtypes of examination,byrace,stage of disease,andagegroupVol.77,No.6,June1962463wereanumber of persons with roentgeno¬graphicevidence of activetuberculosisbut with nootherevidence of activediseaseevenonpro¬longedfollowup.Aftercarefulconsideration,itappearedthatthemostappropriateweighting of thevariousdiagnosticfactorscouldbeachievedbydefiningtheonset of significantlyactivediseaseasthetimewhenhospitaltreatmentwasfirstrecom¬mended.Thisdefinitionhadseveraladvan¬tages.Firsttherecommendationforhospital¬izationwasaneventwhichcouldbeclearlyrecognizedanddatedfromtherecords.Mostimportant,thedecisiontorecommendhos¬pitalizationindicatedtherecognition of asig¬nificantadversechangeinapatient'scondition.Whilebacteriologicalandroentgenographicfindingsobviouslyinfluencedthisdecisionmuchmorethananyotherfactor,theuse of clinicaljudgmentmanifestedintherec¬ommendationforhospitaltreatmentappearedtobethemostsatisfactorymethod of discount-ingisolatedorinconsistentfindingswhichmightotherwiseinflatetheproportion of in-significantlyactivecases.Kecommendationsforhospitalizationwerenotmateriallyaffectedbytheavailability of hospitalbedsorbyenthu-siasmforambulatorytreatment.Throughouttheperiod of thisstudy,hospitalbedswereavailable with littleornodelayforMuscogeeCountypatients.Furthermore,hospitaltreat¬mentwasalmostalwaysrecommendedforper¬sonsbelievedtohaveactiveprogressivetuber¬culosis,onlyafewexceptionshavingoccurredinrecentyears.Inactivetuberculosiswasdefinedastheab¬sence of significantlyactivetuberculosisforatleast2yearsaftertheindividualwasreportedtothestudyasatuberculosiscaseorsuspect.Theclassification of the1,327personsintheinitialstudypopulation2yearsaftertheyhadfirstbeenreportedasatuberculosiscaseorsuspectisshownintable3.Inthisperiod,314personswerethoughttohaveactivetuberculosis,themajoritywithinafewweeks of initialreport.Fivepersonswithoutevidence of activediseaseareknowntohavediedduringthis2-yearperiod;theremaining1,008comprisetheinac¬tivecasesforthisanalysis.Themajorityhadonlysuspectedorminimaldiseaseinitially.Relativelyfew of thepersons with inactivedis¬easehadadvancedtuberculosisbecausetherewerenotmanyadvancedcasesintheinitialstudygroup.Moreover,70percentwereclassi¬fiedashavingactivediseasebefore2yearshadelapsed.Method of AnalysisTheanalysisincludesobservationsonallper¬sonsinthestudypopulationthroughJune30,Table3.Classification of studypopulation2yearsafterinitialreportastuberculosiscaseorsus¬pect,byrace,initialstage of disease,andagegroup464PublicHealthReports1960, with thetotalperiod of observationrang¬ingfrom4^toltyfayears.Because2yearshadtoelapsebeforeapersoncouldbeclassifiedashavinginactivedisease,thepotentialrange of observationforcases of inactivetuberculosiswas2%to12i/£years.Twomodificationsweremadeinapplyingthelifetablemethod of analysistothefindings of thisstudy.Thefirstmodificationwastheuse of twodifferentas-sumptionsregardingthedevelopment of activetuberculosisamongpersonswithdrawnfromobservationbecausetheymovedawayordis¬continuedexamination.Assumption1isthatthedevelopment of activediseasecouldonlybedeterminedduringtheperiodinwhichthesubjectswereunderobservation.Theperiod of observationwouldtherebybecountedfromthedate of reporttothedate of lastexaminationbeforeJuly1,1960.Thisassumptionunder-statestheperson-years of observationandthusoverestimatestherisk of developingactivedisease.Assumption2isthatsignificantreac¬tivationwouldbecomeknownforsurvivingmembers of thestudypopulationeveniftheydidnotcontinuetobeexaminedbythestudy,andthattheirexperiencecanthusbecountedthroughJune30,1960.Thisassumptionisbasedontheprobabilitythatpersonsdevelop¬ingsignificantlyactivetuberculosisafterdis-continuingobservationwouldseekmedicalcare,andthattheirphysicianswouldthenre¬questtheirpreviouschestroentgenograms.Inthisway,thestudywouldlearnthatreactiva¬tionhadoccurred.Assumption2overstatestheperson-years of observation,mainlybe¬causemostdeathswhichoccurredamongper¬sonswhomovedawaydidnotbecomeknowntothestudy.Itprobablyalsounderstatesthenumber of reactivations.Onbothcounts,as¬sumption2tendstounderestimatetherisk of reactivation.Thesecondmodification of theusuallifetabletechniquewastoapplyitintwosteps.First,thestandardapproachwasusedintheanalysis of thefindingsforthefirst2years of observa¬tion.Forthosewhopassedthroughthis2-yearperiodwithouthavingactivetuberculosisandwhoweretherebydesignatedashavinginactivetuberculosis,thecalculation of time-specificandcumulativeriskswasagainunder¬taken, with thebeginning of thethirdyearasthestartingperiod.Suspectedandminimaltuberculosiswerecombinedintoasinglecategorybecausetheriskwasessentiallythesameforboth of them.Moderatelyandfaradvancedtuberculosiswerecombinedbecause of thesmallnumbersineachgroup.Forpersons with advancedtuberculosis,sofewsurvivedthefirst2yearswithouthavingactivedisease,thatthetwoagegroupshadtobecombined;evenso,thenumbers of advancedinactivecasesaresmall.ResultsThebacteriologicalandroentgenographicfindingsforthe1,008personsclassifiedashav¬inginactivetuberculosisareshownintable4. Of the68forwhomhospitaltreatmentfortuberculosiswasrecommended,60hadbothpositivebacteriologicalandroentgenographicevidence of activetuberculosisatsometime;only1hadneither of thesetwocriteria. Of the940personsforwhomhospitaltreatmentwasneverrecommended,2hadbothbacteriologicalorroentgenographicevidence of activedisease.Vol.77,No.6,June1962465Cumulativeprobability of reactivation of inactive pulmonary tuberculosis,byrace,age,andinitialstage of disease,accordingtotwodifferentassumptions(1and2)regardingfollowupobservationsWHITENEGRO15-44years of ageatinitialreport, with minimalorsuspectedtuberculosis2yearslater.30r.25.20.15.10.05S.004)Oa>.35ru.30K.25.20.15.10.05.0045-64years of ageatinitialreport, with minimalorsuspectedtuberculosis2yearslater15-64years of ageatinitialreport, with advancedtuberculosis2yearslaterJ_LJ_I10121402468Yearsafterinitialreport101214Note:Heavylineindicatesthatthepopulationbaseis50ormorepersons;thinlineindicatesthatthebaseis20-50persons.466PublicHealthReportsTheuse of positivebacteriologicalandroent¬genographicfindingstogetherasacriterion of activetuberculosiswouldhavealteredbutlittletheproportion of personsclassifiedashavingreactivateddisease.Parenthetically,itmaybenotedthatamajorfactorinthedis¬crepancybetweenpositivebacteriologicalfind¬ingsandtheroentgenographicclassification of activetuberculosiswastheconsciousattempttorecordtheinterpretations of chestroent¬genogramswithoutregardtootherfindings.Hadtheseinterpretationsbeencompletelyindependent,it ... 5yearsorlonger.Suchvariationinpublichealthpracticesuggestedtheneedforfurtherinfor¬mationontheimportance of relapsesamongpersons with inactivediseaseasasource of activetuberculosis.InformationgatheredbytheMuscogeeCountyTuberculosisStudywasusedtoesti¬matetheprognosis of untreatedinactivepul¬monarytuberculosis.Thediscoveryandpro¬longedobservation of allcases of tuberculosisinthecommunityhasbeenone of themajorVol.77,No.6,June1962461goals of thisstudysinceitsinceptionin1946(7).Consequently,casefindingactivitiesinthisareahavebeenmoreextensivethanisoftenpossible.Communitywidephotofluorographicsurveyswereconductedin1946andagainin1950(8$).Inaddition,thenumber of chestX-rayexaminationsmadebythehealthde¬partmenteachyearapproximatedone-sixth of thetotalpopulation.Themedicalprofessionandalliedagenciesinthecommunityhavebeenhighlycooperativeinreportingtuberculosiscases,usuallyrelinquishingresponsibilityforfollowupsupervisiontothestudy.Asaresult,itisbelievedthatnearlyallknowncaseshavebeenreportedtoandsupervisedbythestudy.Allpersons with definiteorsuspectedtuber¬culosiswereadvisedtoobtainquarterlyorsemiannualexaminationsuntiltheirdiseasehadshownnoevidence of activityforatleast5years.Althoughroutinefollowupwasthendiscontinued,subjectswereadvisedtobeex¬aminedannuallyandweresentreminders of theseexaminationsaslongastheycontinuedtoliveinthearea.Facilitiesforsputumexami¬nationshavealsobeenreadilyavailable, with culturesformycobacteriaaroutinepart of theexaminationsince1947.Sputumspecimenswererequestedatthebeginningandend of theroutinefollowupperiod,andalsowheneverclinicalorroentgenographicevidence of pos¬siblyactivediseasewasnoted.Almostallpa¬tients with ahistory of productivecoughcomplied with therequestsforspecimens.Many,however,deniedthissymptomandfailedtosubmitspecimens.Gastriclavageswererarelyperformed.InitialStudyPopulationThepopulationfromwhichthecases of un¬treatedinactive pulmonary tuberculosisweredrawncomprisesallpersonswhowerefirstreportedtotheMuscogeeCountyTuberculosisStudyashavingdefiniteorsuspectedtuber¬culosisbetweenJanuary1,1946,andJanuary1,1956,andwhoalsometthefollowingcriteria:(a)atthetimethesepersonswerereported,theylivedinMuscogeeCounty,andwere15-65years of age;(b)beforebeingreported,theyhadneverbeenadvisedtobehospitalizedfortuberculosis;(c)2yearsafterthefirstreport,Table1.Yearinwhichmembers of initialstudypopulationwerereportedtotheMuscogeeCountyTuberculosisStudyastuberculosiscasesorsuspectstheywerestillregisteredashavingsuspectedordefinite pulmonary tuberculosisandwerenotknowntohaveextra -pulmonary tuberculosis.Atotal of 1,327personsmetthesecriteria.Theyearinwhichtheywerefirstreportedtothestudyisshownintable1.Morethanone-thirdweredetectedin1946,theyear of thefirstcommunitysurvey.One-sixthcametoatten¬tionin1950,largelyastheresult of thesecondsurvey.Althoughtheproportiondiscoveredineach of theotheryearshasbeenquitecon¬stant,thisactuallyreflectsadeclineinthemor¬bidityrateowingtotheincreaseinpopulation of MuscogeeCounty,Ga.,from95,638personsin1946to158,623in1960.Thecomposition of theinitialstudypopula¬tionandthetype of examinationwhichledtotherecognition of tuberculosisareshownintable2.Almost70percent of thecaseswereinwhitesand30percentinNegroes.However,sinceconsiderablyfewerNegroesthanwhitesresideinthecounty,themorbidityratewasslightlyhigheramongNegroes.Slightlymorethanhalf of thewhitesbutonlyone-third of theNegroeswereovertheage of 45years.Amuchhigherproportion of Negroesthanwhiteswereclassifiedashavingadvanceddisease,44percentcontrasted with 23percent.Forbothraces,theproportion of advancedtuberculosiswaslargeramongtheyoungeragegroups.Almosthalf of thegroupwasbroughtundersupervisionastheresult of thetwomasssur¬veys.Ifpersonsdetectedbysurvey-likepro¬ceduressuchaspreemploymentandfoodhandler462PublicHealthReportsexaminationsarealsoincluded,morethanthree-fifthswerefoundamongpresumablyhealthygroups.Onlyafewwereidentifiedbecausetheyhadbeenincontact with acase of activetuberculosis.Athird of thetotalgroupwasclassifiedassymptomatic,havingbeenreferredforexaminationbyprivatephysiciansorhos¬pitalclinicsorself-referred.Manycontactswereinthecategory of symptomaticreferrals.Thesepersonshadnoevidence of tuberculosisonroutinecontactexaminations,butreturnedforreexaminationwhensymptomsdevelopedratherthanwaitingfortheirnextroutinefol¬lowupexamination.Asmightbeanticipated,ahighpercentage of advancedcasescamefromthegroup of symptomaticreferrals.Althougholderpersonsdidnotparticipatewellinthecommunitysurveys,asurprisinglylargepro¬portion of those with minimalorsuspecteddiseasesamongthemwerediscoveredthisway.ActiveandInactiveTuberculosisArrivingatanappropriatedefinition of ac¬tivetuberculosiswasnotassimpleasmightap¬pearatfirstglance.Primarily,adefinitionwasdesiredwhichwoulddesignatepersonswhoweretrulyillandwhosetuberculosiswassufficientlyseveretorequireamajorchangeintheirlives.Itdidnotseemimportanttostudytheincidence of diseasemanifestedonlybyisolateddemon¬strations of acid-fastbacilliorbyminorroent-genographicchanges.Nosinglecriterionseemedadequatetodes¬ignatesignificantlyactivetuberculosis.Eventhefinding of acid-fastbacilli with theculturalcharacteristics of Mycobacteriumtuberculosiswasfarfromsatisfactory.Inthispart of theworld,acid-fastbacillihavebeenisolated with considerablefrequencyfromcertainhealthypopulationgroups(10).Some of theseor¬ganismscouldhavebeenmistakenforM.tuber-culosis,particularlyintheearlierdays of thestudy.Butthemajorreasonfornotacceptingthissinglecriterionwasthefactthattuberclebacilliwereisolatedfromasizablesegment of thisstudygroupononlyasingleoccasion, with nootherevidence of activediseaseonprolongedbacteriologicalandroentgenographicobserva¬tion.Althoughonewidelyusedstandardwouldautomaticallyclassifythesepersonsashavingactivetuberculosis(ii),theirdiseasedidnotthenandhasnotyetshownanyevidence of be¬comingarealhealthproblem.Theuse of roentgenographicchangealsoseemedinadequateastheonlycriterionforac¬tivedisease,particularlyinview of thedemon¬strateddifficultiesingettingagreementevenamongexpertsinclassifyingtuberculosisfromchestroentgenograms(12,13).AndagainthereTable2.Percentage of tuberculosiscasesininitialstudypopulationdiscoveredbyspecifiedtypes of examination,byrace,stage of disease,andagegroupVol.77,No.6,June1962463wereanumber of persons with roentgeno¬graphicevidence of activetuberculosisbut with nootherevidence of activediseaseevenonpro¬longedfollowup.Aftercarefulconsideration,itappearedthatthemostappropriateweighting of thevariousdiagnosticfactorscouldbeachievedbydefiningtheonset of significantlyactivediseaseasthetimewhenhospitaltreatmentwasfirstrecom¬mended.Thisdefinitionhadseveraladvan¬tages.Firsttherecommendationforhospital¬izationwasaneventwhichcouldbeclearlyrecognizedanddatedfromtherecords.Mostimportant,thedecisiontorecommendhos¬pitalizationindicatedtherecognition of asig¬nificantadversechangeinapatient'scondition.Whilebacteriologicalandroentgenographicfindingsobviouslyinfluencedthisdecisionmuchmorethananyotherfactor,theuse of clinicaljudgmentmanifestedintherec¬ommendationforhospitaltreatmentappearedtobethemostsatisfactorymethod of discount-ingisolatedorinconsistentfindingswhichmightotherwiseinflatetheproportion of in-significantlyactivecases.Kecommendationsforhospitalizationwerenotmateriallyaffectedbytheavailability of hospitalbedsorbyenthu-siasmforambulatorytreatment.Throughouttheperiod of thisstudy,hospitalbedswereavailable with littleornodelayforMuscogeeCountypatients.Furthermore,hospitaltreat¬mentwasalmostalwaysrecommendedforper¬sonsbelievedtohaveactiveprogressivetuber¬culosis,onlyafewexceptionshavingoccurredinrecentyears.Inactivetuberculosiswasdefinedastheab¬sence of significantlyactivetuberculosisforatleast2yearsaftertheindividualwasreportedtothestudyasatuberculosiscaseorsuspect.Theclassification of the1,327personsintheinitialstudypopulation2yearsaftertheyhadfirstbeenreportedasatuberculosiscaseorsuspectisshownintable3.Inthisperiod,314personswerethoughttohaveactivetuberculosis,themajoritywithinafewweeks of initialreport.Fivepersonswithoutevidence of activediseaseareknowntohavediedduringthis2-yearperiod;theremaining1,008comprisetheinac¬tivecasesforthisanalysis.Themajorityhadonlysuspectedorminimaldiseaseinitially.Relativelyfew of thepersons with inactivedis¬easehadadvancedtuberculosisbecausetherewerenotmanyadvancedcasesintheinitialstudygroup.Moreover,70percentwereclassi¬fiedashavingactivediseasebefore2yearshadelapsed.Method of AnalysisTheanalysisincludesobservationsonallper¬sonsinthestudypopulationthroughJune30,Table3.Classification of studypopulation2yearsafterinitialreportastuberculosiscaseorsus¬pect,byrace,initialstage of disease,andagegroup464PublicHealthReports1960, with thetotalperiod of observationrang¬ingfrom4^toltyfayears.Because2yearshadtoelapsebeforeapersoncouldbeclassifiedashavinginactivedisease,thepotentialrange of observationforcases of inactivetuberculosiswas2%to12i/£years.Twomodificationsweremadeinapplyingthelifetablemethod of analysistothefindings of thisstudy.Thefirstmodificationwastheuse of twodifferentas-sumptionsregardingthedevelopment of activetuberculosisamongpersonswithdrawnfromobservationbecausetheymovedawayordis¬continuedexamination.Assumption1isthatthedevelopment of activediseasecouldonlybedeterminedduringtheperiodinwhichthesubjectswereunderobservation.Theperiod of observationwouldtherebybecountedfromthedate of reporttothedate of lastexaminationbeforeJuly1,1960.Thisassumptionunder-statestheperson-years of observationandthusoverestimatestherisk of developingactivedisease.Assumption2isthatsignificantreac¬tivationwouldbecomeknownforsurvivingmembers of thestudypopulationeveniftheydidnotcontinuetobeexaminedbythestudy,andthattheirexperiencecanthusbecountedthroughJune30,1960.Thisassumptionisbasedontheprobabilitythatpersonsdevelop¬ingsignificantlyactivetuberculosisafterdis-continuingobservationwouldseekmedicalcare,andthattheirphysicianswouldthenre¬questtheirpreviouschestroentgenograms.Inthisway,thestudywouldlearnthatreactiva¬tionhadoccurred.Assumption2overstatestheperson-years of observation,mainlybe¬causemostdeathswhichoccurredamongper¬sonswhomovedawaydidnotbecomeknowntothestudy.Itprobablyalsounderstatesthenumber of reactivations.Onbothcounts,as¬sumption2tendstounderestimatetherisk of reactivation.Thesecondmodification of theusuallifetabletechniquewastoapplyitintwosteps.First,thestandardapproachwasusedintheanalysis of thefindingsforthefirst2years of observa¬tion.Forthosewhopassedthroughthis2-yearperiodwithouthavingactivetuberculosisandwhoweretherebydesignatedashavinginactivetuberculosis,thecalculation of time-specificandcumulativeriskswasagainunder¬taken, with thebeginning of thethirdyearasthestartingperiod.Suspectedandminimaltuberculosiswerecombinedintoasinglecategorybecausetheriskwasessentiallythesameforboth of them.Moderatelyandfaradvancedtuberculosiswerecombinedbecause of thesmallnumbersineachgroup.Forpersons with advancedtuberculosis,sofewsurvivedthefirst2yearswithouthavingactivedisease,thatthetwoagegroupshadtobecombined;evenso,thenumbers of advancedinactivecasesaresmall.ResultsThebacteriologicalandroentgenographicfindingsforthe1,008personsclassifiedashav¬inginactivetuberculosisareshownintable4. Of the68forwhomhospitaltreatmentfortuberculosiswasrecommended,60hadbothpositivebacteriologicalandroentgenographicevidence of activetuberculosisatsometime;only1hadneither of thesetwocriteria. Of the940personsforwhomhospitaltreatmentwasneverrecommended,2hadbothbacteriologicalorroentgenographicevidence of activedisease.Vol.77,No.6,June1962465Cumulativeprobability of reactivation of inactive pulmonary tuberculosis,byrace,age,andinitialstage of disease,accordingtotwodifferentassumptions(1and2)regardingfollowupobservationsWHITENEGRO15-44years of ageatinitialreport, with minimalorsuspectedtuberculosis2yearslater.30r.25.20.15.10.05S.004)Oa>.35ru.30K.25.20.15.10.05.0045-64years of ageatinitialreport, with minimalorsuspectedtuberculosis2yearslater15-64years of ageatinitialreport, with advancedtuberculosis2yearslaterJ_LJ_I10121402468Yearsafterinitialreport101214Note:Heavylineindicatesthatthepopulationbaseis50ormorepersons;thinlineindicatesthatthebaseis20-50persons.466PublicHealthReportsTheuse of positivebacteriologicalandroent¬genographicfindingstogetherasacriterion of activetuberculosiswouldhavealteredbutlittletheproportion of personsclassifiedashavingreactivateddisease.Parenthetically,itmaybenotedthatamajorfactorinthedis¬crepancybetweenpositivebacteriologicalfind¬ingsandtheroentgenographicclassification of activetuberculosiswastheconsciousattempttorecordtheinterpretations of chestroent¬genogramswithoutregardtootherfindings.Hadtheseinterpretationsbeencompletelyindependent,it...

... implementation of active case finding program. We assessed the effect of Cough Officer Screening (an active screening system) on the rate of TB detection and health care system delays over the course of ... statistical software(SPSS Inc, Chicago, IL, USA).ResultsFigure 1 summarizes the results of our TB detection pro-gram from the time of patient admission to initiation of treatment under our cough-officer-screening ... identified 11,323 of 78,872 patients(14%) with alarms in Stage II. Physicians examined 6,221 of these 11,323 patients (55%). A total of 125 of these6,221 patients (2.0%) were diagnosed with TB. However,doctors...

... include patients with a histor y of TB, patients on TB treatment for pulmonary TBwithout sputum conversion, and symptomatic contacts of patients with known MDR-TB.Three categories of participants ... percentage of contaminated cultures; review questionB: the name and manufacturer of the reference standard.• Details of index test: software version of test.• Details of comparator: type of microscopy: ... unrepresentative of spectrum of patients with pulmonary TBUnclear if patient characteristics or setting are inadequately de-scribedReview question B: Yes, if persons suspected of having pulmonary TB...

... of infection by early detection of patients with pulmonary TB and the use of DOTS. Mycobacterium tuberculosis culture and drug susceptibility testing are not yet available in Laos. Case detection ... the sensitivity of detection by 50%,10 the number of samples was calculated for theoretical sensitivity rates of 44% (direct method) and 66% (bleach method). With an average of 12% AFB-positive ... determined.CONCLUSIONOur study, conducted in a population with a low prevalence of HIV/AIDS, con rms the bene ts of the bleach method for the microscopic case detection of pulmonary TB. This rustic, simple and...

... Bureau of Consumer Services at 717-783-6688.Very truly yours,James J. McNultySecretarycc: Office of Executive DirectorBureau of Consumer ServicesBureau of Fixed Utility ServicesLaw BureauOffice ... period of four months, in addition to current charges.In view of the Commission’s desire to facilitate an orderly processing of any make-up billsissued for EGS charges resulting from a failure of ... to residential customers is in violation of that provision,and is subject to the imposition of civil monetary penalties. Additionally, through a series of orders at Docket No. M-00960890F.0015...

... mode, (b): with OBW mode. Fig. 8 Experimental results of seven subjects with OBW mode and without OBW mode. Fig. 9 Overage errors of seven subjects with OBW mode and without OBW ... term of the sense of touch. 2.2 Feedback force implementation: According to previous research [9], [10], the steering system of forklifts is developed. Moreover, driving torque of forklift ... behavior of the motor at a constant voltage U is shown in fig 5. Fig. 5 Speed-torque line of DC motor With reference to the mentioned equations, motor characteristic, and 16bits DAC of...