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Fulltext Clinical-radiological features and diagnostic modalities for mediastinal melioidosis

Nyanti LE, Lee SSY, Shanmugam V, Muien MZBA, Othman AA, Chia YL, et al.

Int J Tuberc Lung Dis, 2023 Oct 01;27(10):724-728.
PMID: 37749834 DOI: 10.5588/ijtld.23.0079

Melioidosis is a potentially life-threatening infection caused by the Gram-negative bacillus Burkholderia pseudomallei. Mediastinal melioidosis has a range of clinical presentations, making it difficult to diagnose: we therefore reviewed the evidence on the clinical characteristics, radiological features and invasive diagnostic modalities or interventions. An electronic search was conducted on three databases (PubMed, SCOPUS, Google Scholar) from November to December 2022. The initial search yielded 120 results, of which 34 studies met the inclusion criteria, but only 31 full-texts were retrievable. Among these, 4 were cohort studies, 26 case reports or series and 1 a conference abstract. The four main themes covered were mediastinal melioidosis as a diagnostic dilemma, unexpected complications, invasive interventions or an accompanying thoracic feature. Radiological manifestations included matting, necrosis and abscess-like collection. Severe presentations of mediastinal melioidosis included superior vena cava obstruction, sinus tract formation and pericardial tamponade. Transbronchial needle aspiration was the most common invasive diagnostic modality. Further research is needed to understand the relationship between the thoracic features of melioidosis on patient prognosis, its relationship to melioidosis transmission and potential preventive measures.
Fulltext Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

Jayasooriya S, Stolbrink M, Khoo EM, Sunte IT, Awuru JI, Cohen M, et al.

Int J Tuberc Lung Dis, 2023 Sep 01;27(9):658-667.
PMID: 37608484 DOI: 10.5588/ijtld.23.0203

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.
Key messages and partnerships to raise awareness and improve outcomes for people with asthma and COPD in low- and middle-income countries

Rylance S, Bateman ED, Boulet L, Cohen M, El Sony A, Halpin DMG, et al.

Int J Tuberc Lung Dis, 2022 Dec 01;26(12):1106-1108.
PMID: 36447314 DOI: 10.5588/ijtld.22.0544
Fulltext Improving access to affordable quality-assured inhaled medicines in low- and middle-income countries

Stolbrink M, Chinouya MJ, Jayasooriya S, Nightingale R, Evans-Hill L, Allan K, et al.

Int J Tuberc Lung Dis, 2022 Nov 01;26(11):1023-1032.
PMID: 36281039 DOI: 10.5588/ijtld.22.0270

BACKGROUND: Access to affordable inhaled medicines for chronic respiratory diseases (CRDs) is severely limited in low- and middle-income countries (LMICs), causing avoidable morbidity and mortality. The International Union Against Tuberculosis and Lung Disease convened a stakeholder meeting on this topic in February 2022.METHODS: Focused group discussions were informed by literature and presentations summarising experiences of obtaining inhaled medicines in LMICs. The virtual meeting was moderated using a topic guide around barriers and solutions to improve access. The thematic framework approach was used for analysis.RESULTS: A total of 58 key stakeholders, including patients, healthcare practitioners, members of national and international organisations, industry and WHO representatives attended the meeting. There were 20 pre-meeting material submissions. The main barriers identified were 1) low awareness of CRDs; 2) limited data on CRD burden and treatments in LMICs; 3) ineffective procurement and distribution networks; and 4) poor communication of the needs of people with CRDs. Solutions discussed were 1) generation of data to inform policy and practice; 2) capacity building; 3) improved procurement mechanisms; 4) strengthened advocacy practices; and 5) a World Health Assembly Resolution.CONCLUSION: There are opportunities to achieve improved access to affordable, quality-assured inhaled medicines in LMICs through coordinated, multi-stakeholder, collaborative efforts.
Observations on malnutrition and anti-TB drugs in Ghana

Muyou AJ, Kunasagran PD, Syed Abdul Rahim SS, Avoi R, Hayati F

Int J Tuberc Lung Dis, 2021 Sep 01;25(9):778-779.
PMID: 34802506 DOI: 10.5588/ijtld.21.0258
Fulltext A partially randomised trial of pretomanid, moxifloxacin and pyrazinamide for pulmonary TB

Tweed CD, Wills GH, Crook AM, Amukoye E, Balanag V, Ban AYL, et al.

Int J Tuberc Lung Dis, 2021 Apr 01;25(4):305-314.
PMID: 33762075 DOI: 10.5588/ijtld.20.0513

BACKGROUND: Treatment for TB is lengthy and toxic, and new regimens are needed.METHODS: Participants with pulmonary drug-susceptible TB (DS-TB) were randomised to receive: 200 mg pretomanid (Pa, PMD) daily, 400 mg moxifloxacin (M) and 1500 mg pyrazinamide (Z) for 6 months (6Pa200MZ) or 4 months (4Pa200MZ); 100 mg pretomanid daily for 4 months in the same combination (4Pa100MZ); or standard DS-TB treatment for 6 months. The primary outcome was treatment failure or relapse at 12 months post-randomisation. The non-inferiority margin for between-group differences was 12.0%. Recruitment was paused following three deaths and not resumed.RESULTS: Respectively 4/47 (8.5%), 11/57 (19.3%), 14/52 (26.9%) and 1/53 (1.9%) DS-TB outcomes were unfavourable in patients on 6Pa200MZ, 4Pa200MZ, 4Pa100MZ and controls. There was a 6.6% (95% CI -2.2% to 15.4%) difference per protocol and 9.9% (95%CI -4.1% to 23.9%) modified intention-to-treat difference in unfavourable responses between the control and 6Pa200MZ arms. Grade 3+ adverse events affected 68/203 (33.5%) receiving experimental regimens, and 19/68 (27.9%) on control. Ten of 203 (4.9%) participants on experimental arms and 2/68 (2.9%) controls died.CONCLUSION: PaMZ regimens did not achieve non-inferiority in this under-powered trial. An ongoing evaluation of PMD remains a priority.
The diagnosis of lung cancer in the era of interventional pulmonology

Liam CK, Lee P, Yu CJ, Bai C, Yasufuku K

Int J Tuberc Lung Dis, 2021 01 01;25(1):6-15.
PMID: 33384039 DOI: 10.5588/ijtld.20.0588

Advances in bronchoscopic and other interventional pulmonology technologies have expanded the sampling procedures pulmonologist can use to diagnose lung cancer and accurately stage the mediastinum. Among the modalities available to the interventional pulmonologist are endobronchial ultrasound-guided transbronchial needles aspiration (EBUS-TBNA) and transoesophageal bronchoscopic ultrasound-guided fine-needle aspiration (EUS-B-FNA) for sampling peribronchial/perioesophageal central lesions and for mediastinal lymph node staging, as well as navigational bronchoscopy and radial probe endobronchial ultrasound (RP-EBUS) for the diagnosis of peripheral lung cancer. The role of the interventional pulmonologist in this setting is to apply these procedures based on the correct interpretation of clinical and radiological findings in order to maximise the chances of achieving the diagnosis and obtaining sufficient tissue for molecular biomarker testing to guide targeted therapies for advanced non-small cell lung cancer. The safest and the highest diagnosis-yielding modality should be chosen to avoid a repeat sampling procedure if the first one is non-diagnostic. The choice of site and biopsy modality are influenced by tumour location, patient comorbidities, availability of equipment and local expertise. This review provides a concise state-of-the art account of the interventional pulmonology procedures in the diagnosis and staging of lung cancer.
Common concerns in managing bronchial asthma during the COVID-19 pandemic

Chai CS, Liam CK

Int J Tuberc Lung Dis, 2020 Jul 01;24(7):750-752.
PMID: 32718416 DOI: 10.5588/ijtld.20.0378
Associations between air pollutants and peak expiratory flow and fractional exhaled nitric oxide in students

Adman MA, Hashim JH, Manaf MRA, Norback D

Int J Tuberc Lung Dis, 2020 02 01;24(2):189-195.
PMID: 32127103 DOI: 10.5588/ijtld.19.0096

BACKGROUND: Studies on the effects of outdoor air pollution on the respiratory health of students in tropical countries such as Malaysia are limited.OBJECTIVE: To assess associations between outdoor air pollutants and peak expiratory flow (PEF) and fractional exhaled nitric oxide (FeNO).METHOD: PEF and FeNO levels of 487 students recruited in Melaka and Putrajaya, Malaysia, were measured in April and June 2014. Multiple linear regression with mutual adjustment was used to analyse the associations between exposure to air pollution and health.RESULTS: PEF was significantly associated with ozone for 1-day exposure (β = -13.3 l/min, 95% CI -22.7 to -3.8), carbon monoxide for 2-day exposure (β = -57.2 l/min, 95% CI -90.7 to -23.7) and particulate matter ≦10 μm in diameter for 3-day exposure (β = -6.0 l/min, 95% CI -9.2 to -2.8) and 7-day exposure (β = -8.6 l/min, 95% CI -13.0 to -4.1). Stratified analysis showed that associations between PEF and outdoor air pollutant exposures were similar in students with and without elevated FeNO levels.CONCLUSION: Outdoor air pollution in Malaysia may cause airway obstruction unrelated to eosinophilic airway inflammation among students as measured using FeNO.
Respiratory health among office workers in Malaysia and endotoxin and (1,3)-β-glucan in office dust

Lim FL, Hashim Z, Than LTL, Md Said S, Hashim JH, Norbäck D

Int J Tuberc Lung Dis, 2019 11 01;23(11):1171-1177.
PMID: 31718753 DOI: 10.5588/ijtld.18.0668

OBJECTIVE: To examine the associations between endotoxin and (1,3)-β-glucan concentrations in office dust and respiratory symptoms and airway inflammation among 695 office workers in Malaysia.METHODS: Health data were collected using a questionnaire, sensitisation testing and measurement of fractional exhaled nitric oxide (FeNO). Indoor temperature, relative air humidity (RH) and carbon dioxide (CO₂) were measured in the offices and settled dust was vacuumed and analysed for endotoxin and (1,3)-β-glucan concentrations. Associations were analysed by two level multiple logistic regression.RESULTS: Overall, 9.6% of the workers had doctor-diagnosed asthma, 15.5% had wheeze, 18.4% had daytime attacks of breathlessness and 25.8% had elevated FeNO (≥25 ppb). The median levels in office dust were 11.3 EU/mg endotoxin and 62.9 ng/g (1,3)-β-glucan. After adjusting for personal and home environment factors, endotoxin concentration in dust was associated with wheeze (P = 0.02) and rhinoconjunctivitis (P = 0.007). The amount of surface dust (P = 0.04) and (1,3)-β-glucan concentration dust (P = 0.03) were associated with elevated FeNO.CONCLUSION: Endotoxin in office dust could be a risk factor for wheeze and rhinoconjunctivitis among office workers in mechanically ventilated offices in a tropical country. The amount of dust and (1,3)-β-glucan (a marker of indoor mould exposure) were associated with Th2 driven airway inflammation.
Fulltext Association between diabetes mellitus and mortality among patients with tuberculosis

Brož J, Jarošová B, Salih SFA, Brabec M, Salih FMA

Int J Tuberc Lung Dis, 2019 05 01;23(5):638.
PMID: 31097076 DOI: 10.5588/ijtld.18.0796
Identification of chronic obstructive pulmonary disease subgroups in 13 Asian cities

Kim WJ, Gupta V, Nishimura M, Makita H, Idolor L, Roa C, et al.

Int J Tuberc Lung Dis, 2018 07 01;22(7):820-826.
PMID: 29914609 DOI: 10.5588/ijtld.17.0524

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition that can differ in its clinical manifestation, structural changes and response to treatment.
OBJECTIVE: To identify subgroups of COPD with distinct phenotypes, evaluate the distribution of phenotypes in four related regions and calculate the 1-year change in lung function and quality of life according to subgroup.
METHODS: Using clinical characteristics, we performed factor analysis and hierarchical cluster analysis in a cohort of 1676 COPD patients from 13 Asian cities. We compared the 1-year change in forced expiratory volume in one second (FEV1), modified Medical Research Council dyspnoea scale score, St George's Respiratory Questionnaire (SGRQ) score and exacerbations according to subgroup derived from cluster analysis.
RESULTS: Factor analysis revealed that body mass index, Charlson comorbidity index, SGRQ total score and FEV1 were principal factors. Using these four factors, cluster analysis identified three distinct subgroups with differing disease severity and symptoms. Among the three subgroups, patients in subgroup 2 (severe disease and more symptoms) had the most frequent exacerbations, most rapid FEV1 decline and greatest decline in SGRQ total score.
CONCLUSION: Three subgroups with differing severities and symptoms were identified in Asian COPD subjects.
Fulltext Socio-economic status and risk of tuberculosis: a case-control study of HIV-infected patients in Asia

Jiamsakul A, Lee MP, Nguyen KV, Merati TP, Cuong DD, Ditangco R, et al.

Int J Tuberc Lung Dis, 2018 02 01;22(2):179-186.
PMID: 29506614 DOI: 10.5588/ijtld.17.0348

SETTING: Tuberculosis (TB) is the most common human immunodeficiency virus (HIV) related opportunistic infection and cause of acquired immune-deficiency syndrome related death. TB often affects those from a low socio-economic background.
OBJECTIVE: To assess the socio-economic determinants of TB in HIV-infected patients in Asia.
DESIGN: This was a matched case-control study. HIV-positive, TB-positive cases were matched to HIV-positive, TB-negative controls according to age, sex and CD4 cell count. A socio-economic questionnaire comprising 23 questions, including education level, employment, housing and substance use, was distributed. Socio-economic risk factors for TB were analysed using conditional logistic regression analysis.
RESULTS: A total of 340 patients (170 matched pairs) were recruited, with 262 (77.1%) matched for all three criteria. Pulmonary TB was the predominant type (n = 115, 67.6%). The main risk factor for TB was not having a university level education (OR 4.45, 95%CI 1.50-13.17, P = 0.007). Burning wood or coal regularly inside the house and living in the same place of origin were weakly associated with TB diagnosis.
CONCLUSIONS: These data suggest that lower socio-economic status is associated with an increased risk of TB in Asia. Integrating clinical and socio-economic factors into HIV treatment may help in the prevention of opportunistic infections and disease progression.
Diagnostic accuracy of the Xpert® MTB/RIF cycle threshold level to predict smear positivity: a meta-analysis

Lange B, Khan P, Kalmambetova G, Al-Darraji HA, Alland D, Antonenka U, et al.

Int J Tuberc Lung Dis, 2017 05 01;21(5):493-502.
PMID: 28399963 DOI: 10.5588/ijtld.16.0702

SETTING: Xpert® MTB/RIF is the most widely used molecular assay for rapid diagnosis of tuberculosis (TB). The number of polymerase chain reaction cycles after which detectable product is generated (cycle threshold value, CT) correlates with the bacillary burden.OBJECTIVE To investigate the association between Xpert CT values and smear status through a systematic review and individual-level data meta-analysis.
DESIGN: Studies on the association between CT values and smear status were included in a descriptive systematic review. Authors of studies including smear, culture and Xpert results were asked for individual-level data, and receiver operating characteristic curves were calculated.
RESULTS: Of 918 citations, 10 were included in the descriptive systematic review. Fifteen data sets from studies potentially relevant for individual-level data meta-analysis provided individual-level data (7511 samples from 4447 patients); 1212 patients had positive Xpert results for at least one respiratory sample (1859 samples overall). ROC analysis revealed an area under the curve (AUC) of 0.85 (95%CI 0.82-0.87). Cut-off CT values of 27.7 and 31.8 yielded sensitivities of 85% (95%CI 83-87) and 95% (95%CI 94-96) and specificities of 67% (95%CI 66-77) and 35% (95%CI 30-41) for smear-positive samples.
CONCLUSION: Xpert CT values and smear status were strongly associated. However, diagnostic accuracy at set cut-off CT values of 27.7 or 31.8 would not replace smear microscopy. How CT values compare with smear microscopy in predicting infectiousness remains to be seen.
Pattern of first- and second-line drug resistance among pulmonary tuberculosis retreatment cases in Pakistan

Javaid A, Hasan R, Zafar A, Chaudry MA, Qayyum S, Qadeer E, et al.

Int J Tuberc Lung Dis, 2017 03 01;21(3):303-308.
PMID: 28225340 DOI: 10.5588/ijtld.16.0444

BACKGROUND: Drug resistance in general, and multidrug-resistant tuberculosis (MDR-TB) in particular, threatens global tuberculosis (TB) control efforts. Population-based estimates of drug resistance are needed to develop strategies for controlling drug-resistant TB in Pakistan.
OBJECTIVE: To obtain population-based data on Mycobacterium tuberculosis drug resistance in Pakistan.
METHODS: To obtain drug resistance data, we conducted a population-based study of TB cases in all provinces of Pakistan. We performed culture and drug susceptibility testing on M. tuberculosis isolates from patients with a prior history of anti-tuberculosis treatment (retreatment cases) from all over the country.
RESULTS: Of 544 isolates from previously treated cases, 289 (53.1%) were susceptible to all first-line drugs, 255 (46.9%) were resistant to at least one anti-tuberculosis drug and 132 (24.3%) were MDR-TB. Among MDR-TB isolates, 47.0% were ofloxacin (OFX) resistant. Extensively drug-resistant TB was found in two (0.4%) isolates.
CONCLUSION: Prevalence of drug resistance in retreatment isolates was high. The alarmingly high prevalence of OFX resistance among MDR-TB isolates may threaten the success of efforts to control and treat MDR-TB.
Management and treatment outcomes of MDR-TB: results from a setting with high rates of drug resistance

Ahmad N, Javaid A, Basit A, Afridi AK, Khan MA, Ahmad I, et al.

Int J Tuberc Lung Dis, 2015 Sep;19(9):1109-14, i-ii.
PMID: 26260834 DOI: 10.5588/ijtld.15.0167

Although Pakistan has a high burden of multidrug-resistant tuberculosis (MDR-TB), little is known about the management and treatment outcomes of MDR-TB patients in Pakistan.
Fulltext Tuberculosis in Malaysia: predictors of treatment outcomes in a national registry

Liew SM, Khoo EM, Ho BK, Lee YK, Mimi O, Fazlina MY, et al.

Int J Tuberc Lung Dis, 2015 Jul;19(7):764-71.
PMID: 26056099 DOI: 10.5588/ijtld.14.0767

OBJECTIVES: To determine treatment outcomes and associated predictors of all patients registered in 2012 with the Malaysian National Tuberculosis (TB) Surveillance Registry.
METHODS: Sociodemographic and clinical data were analysed. Unfavourable outcomes included treatment failure, transferred out and lost to follow-up, treatment defaulters, those not evaluated and all-cause mortality.
RESULTS: In total, 21 582 patients were registered. The mean age was 42.36 ± 17.77 years, and 14.2% were non-Malaysians. The majority were new cases (93.6%). One fifth (21.5%) had unfavourable outcomes; of these, 46% died, 49% transferred out or defaulted and 1% failed treatment. Predictors of unfavourable outcomes were older age, male sex, foreign citizenship, lower education, no bacille Calmette-Guérin (BCG) vaccination scar, treatment in tertiary settings, smoking, previous anti-tuberculosis treatment, human immunodeficiency virus infection, not receiving directly observed treatment, advanced chest radiography findings, multidrug-resistant TB (MDR-TB) and extra-pulmonary TB. For all-cause mortality, predictors were similar except for rural dwelling and nationality (higher mortality among locals). Absence of BCG scar, previous treatment for TB and MDR-TB were not found to be predictors of all-cause mortality. Indigenous populations in East Malaysia had lower rates of unfavourable treatment outcomes.
CONCLUSIONS: One fifth of TB patients had unfavourable outcomes. Intervention strategies should target those at increased risk of unfavourable outcomes and all-cause mortality.
A prospective study of mycobacterial viability in refrigerated, unpreserved sputum batched for up to 8 weeks

Rashid Ali MR, Parameswaran U, William T, Bird E, Wilkes CS, Lee WK, et al.

Int J Tuberc Lung Dis, 2015 May;19(5):620-1.
PMID: 25868033 DOI: 10.5588/ijtld.14.0938
Fulltext Knowledge, attitude and perception of second-hand smoke and factors promoting smoking in Malaysian adolescents

Abidin NZ, Zulkifli A, Abidin EZ, Rasdi I, Ismail SN, Rahman AA, et al.

Int J Tuberc Lung Dis, 2014 Jul;18(7):856-61.
PMID: 24902566 DOI: 10.5588/ijtld.13.0906

OBJECTIVE: To identify the relationship between knowledge, attitude and perception regarding environmental tobacco smoke (ETS) and smoking among Malaysian adolescents living in states with complete or partial smoke-free legislation (SFL).
METHODS: A total of 898 respondents aged 13-14 years were randomly selected from 21 secondary schools. The Malay version of the modified Global Youth Tobacco Survey questionnaire was used. Hierarchical logistic regression was performed in examining predictors of smoking attempt among adolescents.
RESULTS: Participants exposed to ETS >5 h/day were more likely to have smoked compared to those exposed to ETS <1 h/day (OR 4.1, 95%CI 1.03-16.0). Living in a state with partial SFL was associated with a two-fold increase in self-reported smoking attempts (OR 1.95, 95%CI 1.10-3.43) compared to living in a state with complete SFL. Negative attitudes and perceptions towards smoking and ETS exposure were linked to lower smoking attempts in states with complete SFL.
CONCLUSIONS: Adolescents with limited ETS exposure who lived in a state with complete SFL were less likely to attempt smoking compared to those exposed more regularly to ETS and living in a state with partial SFL. Preventing adolescents from becoming smokers is the key to reducing national prevalence rates in smoking. There is a need to implement comprehensive smoke-free legislation nationally across Malaysia.
Fulltext Delays in diagnosis and treatment of pulmonary tuberculosis in India: a systematic review

Sreeramareddy CT, Qin ZZ, Satyanarayana S, Subbaraman R, Pai M

Int J Tuberc Lung Dis, 2014 Mar;18(3):255-66.
PMID: 24670558 DOI: 10.5588/ijtld.13.0585

OBJECTIVE: To systematically review Indian literature on delays in tuberculosis (TB) diagnosis and treatment.
METHODS: We searched multiple sources for studies on delays in patients with pulmonary TB and those with chest symptoms. Studies were included if numeric data on any delay were reported. Patient delay was defined as the interval between onset of symptoms and the patient's first contact with a health care provider. Diagnostic delay was defined as the interval between the first consultation with a health care provider and diagnosis. Treatment delay was defined as the interval between diagnosis and initiation of anti-tuberculosis treatment. Total delay was defined as time interval from the onset of symptoms until treatment initiation.
RESULTS: Among 541 potential citations identified, 23 studies met the inclusion criteria. Included studies used a variety of definitions for onset of symptoms and delays. Median estimates of patient, diagnostic and treatment delay were respectively 18.4 (IQR 14.3-27.0), 31.0 (IQR 24.5-35.4) and 2.5 days (IQR 1.9-3.6) for patients with TB and those with chest symptoms combined. The median total delay was 55.3 days (IQR 46.5-61.5). About 48% of all patients first consulted private providers; an average of 2.7 health care providers were consulted before diagnosis. Number and type of provider first consulted were the most important risk factors for delay.
CONCLUSIONS: These findings underscore the need to develop novel strategies for reducing patient and diagnostic delays and engaging first-contact health care providers.

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