Background Although cigarette smoking may have a negative impact on the clinical outcome of pulmonary tuberculosis (PTB), few studies have investigated the impact of smoking-associated lung diseases. Emphysema is a major pathological finding of smoking-related lung damage. We aimed to clarify the effect of emphysema on sputum culture conversion rate for Mycobacterium tuberculosis (MTB).Methods We retrospectively studied 79 male patients with PTB confirmed by acid-fast bacillus smear and culture at Jikei University Daisan Hospital between January 2015 and December 2018. We investigated the sputum culture conversion rates for MTB after starting standard anti-TB treatment in patients with or without emphysema. Emphysema was defined as Goddard score ≥1 based on low attenuation area < -950 Hounsfield Unit (HU) using computed tomography (CT). We also evaluated the effect on PTB-related CT findings prior to anti-TB treatment.Results Mycobacterial median time to culture conversion (TCC) in 39 PTB patients with emphysema was 52.0 days [interquartile range (IQR) 29.0–66.0 days], which was significantly delayed compared with that in 40 patients without emphysema (28.0 days, IQR 14.0–42.0 days) (p<0.001, log-rank test). Multivariate Cox proportional hazards analysis showed that the following were associated with delayed TCC: emphysema [hazard ratio (HR): 2.50; 95% confidence interval (CI): 1.24–5.04; p=0.011), cavities (HR: 2.20; 95% CI: 1.22–3.97; p=0.009) and baseline time to TB detection within 2 weeks (HR: 2.85; 95% CI: 1.60–5.08; p<0.0001). Cavities were more often identified by CT in PTB patients with than without emphysema (69.2% vs 45.0%; p=0.03).Conclusions This study suggests that emphysema poses an increased risk of delayed TCC in PTB. Emphysema detection by CT might be a useful method for prediction of the duration of PTB treatment required for sputum negative conversion.
Background
Although cigarette smoking may have a negative impact on the clinical outcome of pulmonary tuberculosis (PTB), few studies have investigated the impact of smoking-associated lung diseases. Emphysema is a major pathological finding of smoking-related lung damage. We aimed to clarify the effect of emphysema on sputum culture conversion rate for Mycobacterium tuberculosis (MTB).
Methods
We retrospectively studied 79 male patients with PTB confirmed by acid-fast bacillus smear and culture at Jikei University Daisan Hospital between January 2015 and December 2018. We investigated the sputum culture conversion rates for MTB after starting standard anti-TB treatment in patients with or without emphysema. Emphysema was defined as Goddard score ≥ 1 based on low attenuation area < − 950 Hounsfield Unit (HU) using computed tomography (CT). We also evaluated the effect on PTB-related CT findings prior to anti-TB treatment.
Results
Mycobacterial median time to culture conversion (TCC) in 38 PTB patients with emphysema was 52.0 days [interquartile range (IQR) 29.0–66.0 days], which was significantly delayed compared with that in 41 patients without emphysema (28.0 days, IQR 14.0–42.0 days) (p < 0.001, log-rank test). Multivariate Cox proportional hazards analysis showed that the following were associated with delayed TCC: emphysema [hazard ratio (HR): 2.43; 95% confidence interval (CI): 1.18–4.97; p = 0.015), cavities (HR: 2.15; 95% CI: 1.83–3.89; p = 0.012) and baseline time to TB detection within 2 weeks (HR: 2.95; 95% CI: 1.64–5.31; p < 0.0001). Cavities and consolidation were more often identified by CT in PTB patients with than without emphysema (71.05% vs 43.90%; p = 0.015, and 84.21% vs 60.98%; p = 0.021, respectively).
Conclusions
This study suggests that emphysema poses an increased risk of delayed TCC in PTB. Emphysema detection by CT might be a useful method for prediction of the duration of PTB treatment required for sputum negative conversion.
The far lateral approach includes exposure of the C1 transverse process, vertebral artery, posterior arch of the atlas, and occipital condyle. We designed a method for systematic muscular-stage dissection and present our experience with this approach. We used a horseshoe scalp flap that was reflected downward and medially. The lateral muscle layers were separated layer to layer to expose the suboccipital triangle. The medial muscle layers were separated in the midline and reflected in a single layer. At this stage, the midline of the C1 process and the foramen magnum were identified. The rectus capitis posterior major muscle was reflected to expose the posterior arch of the atlas. The C1 transverse process and vertebral artery were identified by reflection of the superior oblique muscle. The occipital condyle was separated accordingly. We used this method of muscular dissection in 10 patients (foramen magnum meningioma, = 5; hypoglossal schwannoma, = 2; others, = 3). Systematic muscular-stage dissection facilitates identification of the anatomical landmarks with no vertebral artery injury. Gross total removal was obtained in all 9 patients with complex tumors. The patient with vertebral artery dissection successfully underwent proximal clipping. Our muscular-stage dissection could contribute to safe and effective surgery for the far lateral approach.
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