School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
Royal Free Hospital, London, United Kingdom.
PLoS One. 2019 Jun 27;14(6):e0218193. doi: 10.1371/journal.pone.0218193. eCollection 2019.
The Philippines is ranked 3rd globally for tuberculosis incidence (554/100,000 population). The tuberculosis ward at San Lazaro Hospital, Manila receives 1,800-2,000 admissions of acutely unwell patients per year with high mortality. Objectives of this prospective cohort study were to quantify the association of under-nutrition (primary) and diabetes (secondary) with inpatient mortality occurring between 3-28 days of hospital admission in patients with suspected or previously diagnosed TB.
We enrolled 360 adults (≥18 years); 348 were eligible for the primary analysis (alive on day 3). Clinical, laboratory, anthropometric and enhanced tuberculosis diagnostic data were collected at admission with telephone tracing for mortality up to 6 months post-discharge. In the primary analysis population (mean age 45 years, SD = 15.0 years, 70% male), 58 (16.7%) deaths occurred between day 3-28 of admission; 70 (20.1%) between day 3 and discharge and documented total post-day 3 mortality including follow-up was 96 (27.6%). In those in whom it could be assessed, body mass index (BMI) ranged from 11.2-30.6 kg/m2 and 141/303 (46.5%) had moderate/severe undernutrition (BMI<17 kg/m2). A sex-specific cut-off for mid-upper arm circumference predictive of BMI<17 kg/m2 was associated with inpatient Day 3-28 mortality in males (AOR = 5.04, 95% CI: 1.50-16.86; p = 0.009; p = 0.032 for interaction by sex). The inability to stand for weight/height for BMI assessment was also associated with mortality (AOR = 5.59; 95% CI 2.25-13.89; p<0.001) as was severe compared to normal/mild anaemia (AOR = 9.67; 95% CI 2.48-37.76; p<0.001). No TB specific variables were associated with Day 3-28 mortality, nor was diabetes (HbA1c ≥6.5% or diabetes treatment). Similar effects were observed when the same multivariable model was applied to confirmed TB patients only and to the outcome of all post-day 3 in-patient mortality.
This research supports the use of mid-upper arm circumference for triaging acutely unwell patients and the design and testing of nutrition-based interventions to improve patient outcomes.
菲律宾的结核病发病率在全球排名第三（每 10 万人中有 554 人）。马尼拉圣拉扎罗医院的结核病病房每年接收 1800-2000 名急性重病患者入院，死亡率很高。本前瞻性队列研究的目的是量化营养不良（主要因素）和糖尿病（次要因素）与疑似或先前诊断为结核病的患者入院后 3-28 天住院死亡率之间的关联。
我们纳入了 360 名成年人（≥18 岁）；348 名符合主要分析标准（第 3 天存活）。在入院时收集临床、实验室、人体测量和强化结核病诊断数据，并通过电话追踪至出院后 6 个月的死亡率。在主要分析人群中（平均年龄 45 岁，标准差为 15.0 岁，70%为男性），58 人（16.7%）在入院后第 3-28 天死亡；70 人（20.1%）在第 3 天和出院之间，包括随访在内的第 3 天以后的总死亡率为 96 人（27.6%）。在可以评估的人群中，体重指数（BMI）范围为 11.2-30.6kg/m2，141/303（46.5%）有中度/重度营养不良（BMI<17kg/m2）。性别特异性的中上臂围截断值预测 BMI<17kg/m2，与男性第 3-28 天住院死亡率相关（优势比=5.04，95%CI：1.50-16.86；p=0.009；p=0.032 按性别分层）。无法站立测量体重/身高以评估 BMI 也与死亡率相关（优势比=5.59；95%CI 2.25-13.89；p<0.001），与严重贫血相比，正常/轻度贫血（优势比=9.67；95%CI 2.48-37.76；p<0.001）也是如此。没有任何特定的结核病变量与第 3-28 天的死亡率相关，也没有糖尿病（HbA1c≥6.5%或糖尿病治疗）。当同样的多变量模型应用于确诊的结核病患者和所有第 3 天以后的住院内死亡率时，也观察到了类似的效果。
这项研究支持使用中上臂围来对急性重病患者进行分诊，并设计和测试基于营养的干预措施来改善患者的结局。
