Department of Internal Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
Department of Radiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
Glob Health Sci Pract. 2020 Mar 31;8(1):28-37. doi: 10.9745/GHSP-D-19-00251. Print 2020 Mar 30.
The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi.
Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol.
A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; <.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%.
In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.
针对人类免疫缺陷病毒（HIV）相关结核病（TB）的超声焦点评估（FASH）方案已被广泛用于帮助临床医生诊断结核病。我们旨在量化 FASH 在马拉维 HIV 感染者中诊断 TB 的效用。
2016 年 3 月至 2017 年 8 月，从马拉维利隆圭的一家公共 HIV 诊所招募了 210 名 HIV 合并有 2 种或多种疑似结核病（发热、咳嗽、盗汗、体重减轻）症状的成年人。所有参与者的主治临床医生均对其进行病史、体格检查、FASH 方案和其他结核病评估（实验室诊断和胸部 X 线摄影）。主治临床医生根据所有现有信息做出最终治疗决策。在 6 个月的随访中，我们根据临床结果和诊断测试将参与者分为可能/确诊 TB 或不太可能 TB；使用 Fisher 精确检验计算 FASH 与可能/确诊 TB 的相关性。通过前瞻性询问临床医生在基线就诊的 2 个时间点是否开始治疗，确定 FASH 对经验性 TB 治疗的影响：（1）在初始病史和体格检查后；（2）在病史、体格检查和 FASH 方案后。
共有 181 名参与者进行了最终分析，其中 56 名被归类为可能/确诊 TB，125 名被归类为不太可能 TB。在可能/确诊 TB 患者中，FASH 方案阳性率为 71%（40/56），而不太可能 TB 患者中阳性率为 24%（30/125）（比值比=7.9，95%置信区间=3.9，16.1；<0.001）。在被归类为确诊/可能 TB 的患者中，FASH 使在获得任何其他诊断研究之前进行经验性 TB 治疗的可能性从 9%（5/56）增加到 46%（26/56）。对于不太可能 TB 的患者，FASH 使经验性治疗的可能性从 2%增加到 4%。
在 HIV 合并感染的情况下，FASH 可以作为一种有用的工具，增强临床医生及时诊断结核病的能力。
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