Ranzani Otavio T, Rodrigues Laura C, Waldman Eliseu A, Carvalho Carlos R R
Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas (HCFMUSP), Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil.
London School of Hygiene & Tropical Medicine (LSHTM), London, United Kingdom.
PLoS One. 2017 Nov 22;12(11):e0187585. doi: 10.1371/journal.pone.0187585. eCollection 2017.
Tuberculosis anatomical classification is inconsistent in the literature, which limits current tuberculosis knowledge and control. We aimed to evaluate whether tuberculosis classification impacts on treatment outcomes at patient and aggregate level.
We analyzed adults from São Paulo State, Brazil with newly diagnosed tuberculosis from 2010-2013. We used an extended clinical classification of tuberculosis, categorizing cases as pulmonary, pulmonary and extrapulmonary, extrapulmonary and miliary/disseminated. Our primary outcome was unsuccessful outcome of treatment. To investigate the reported treatment outcome at the aggregate level, we sampled 500 different "countries" from the dataset and compared the impact of pulmonary and extrapulmonary classifications on the reported treatment success.
Of 62,178 patients, 49,999 (80.4%) were pulmonary, 9,026 (14.5%) extrapulmonary, 1,651 (2.7%) pulmonary-extrapulmonary and 1,502 (2.4%) miliary/disseminated. Pulmonary-extrapulmonary cases had similar unsuccessful outcome of treatment compared with pulmonary (adjusted-OR 1.00, 95%CI, 0.88-1.13, p = 0.941), while extrapulmonary were associated with better (adjusted-OR 0.65, 95%CI, 0.60-0.71, p<0.001) and miliary/disseminated with worse outcomes (adjusted-OR 1.51, 95%CI, 1.33-1.71, p<0.001). We found that 60 (12%) countries would report a difference ≥10% in treatment success depending on whether they reported all clinical forms together (current WHO recommendation) or pulmonary forms alone, overestimating the treatment success of pulmonary forms.
The expanded anatomical classification of tuberculosis was strongly associated with treatment outcomes at the patient level. Remarkably, pulmonary with concomitant extrapulmonary forms had similar treatment outcomes compared with pulmonary forms after adjustment for potential confounders. At the aggregate level, reporting treatment success for all clinical forms together might hide differences in progress between pulmonary and extrapulmonary tuberculosis control.
结核病的解剖学分类在文献中并不一致，这限制了当前对结核病的认识和控制。我们旨在评估结核病分类在患者个体层面和总体层面是否会对治疗结果产生影响。
我们分析了2010年至2013年巴西圣保罗州新诊断为结核病的成年人。我们采用了扩展的结核病临床分类，将病例分为肺部、肺部合并肺外、肺外以及粟粒型/播散型。我们的主要结局是治疗失败。为了在总体层面研究报告的治疗结果，我们从数据集中抽取了500个不同的“国家”，并比较了肺部和肺外分类对报告的治疗成功率的影响。
在62178例患者中，49999例（80.4%）为肺部结核，9026例（14.5%）为肺外结核，1651例（2.7%）为肺部合并肺外结核，1502例（2.4%）为粟粒型/播散型结核。肺部合并肺外结核病例与肺部结核相比，治疗失败结局相似（调整后的比值比为1.00，95%置信区间为0.88-1.13，p = 0.941），而肺外结核与较好的结局相关（调整后的比值比为0.65，95%置信区间为0.60-0.71，p<0.001），粟粒型/播散型结核与较差的结局相关（调整后的比值比为1.51，95%置信区间为1.33-1.71，p<0.001）。我们发现，60个（12%）“国家”根据是将所有临床类型一起报告（当前世界卫生组织的建议）还是仅报告肺部类型，报告的治疗成功率差异≥10%，高估了肺部类型的治疗成功率。
扩展的结核病解剖学分类与患者个体层面的治疗结果密切相关。值得注意的是，在对潜在混杂因素进行调整后，肺部合并肺外结核与肺部结核的治疗结果相似。在总体层面，将所有临床类型的治疗成功率一起报告可能会掩盖肺部结核和肺外结核控制进展的差异。
