BMC Pediatrics
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A review of the current policies and guidance regarding Apgar scoring and the detection of jaundice and cyanosis concerning Black, Asian and ethnic minority neonates
The impact of non-pharmaceutical interventions on community non-SARS-CoV-2 respiratory infections in preschool children
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Children’s screen time and psychosocial symptoms at 5 years of age – the role of parental factors
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Sex-related change in BMI of 15- to 16-year-old Norwegian girls in cross-sectional studies in 2002 and 2017
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World Journal of Pediatrics
Published monthly, the World Journal of Pediatrics offers peer-reviewed original papers, reviews and special reports focusing on clinical practice and research in pediatrics. The journal presents contributions on new developments in all areas of the discipline from pediatricians worldwide. Coverage includes the most current progress in pediatrics, pediatric surgery, preventive health care in pediatrics, pharmacology, stomatology and biomedicine. The journal also covers basic sciences and experimental work, and provides a broad academic platform for the international exchange of medical results.
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Flnb haploinsufficiency-related short stature: a new syndrome or an expanded spectrum of larsen syndrome.
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ARHGAP4 variants are associated with X-linked early-onset temporal lobe epilepsy
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| Title | Type | --> | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | journal | 5.494 Q1 | 221 | 326 | 1151 | 6146 | 7253 | 369 | 6.52 | 18.85 | 55.43 | ||
| 2 | journal | 4.229 Q1 | 69 | 185 | 605 | 3903 | 4592 | 263 | 6.05 | 21.10 | 60.96 | ||
| 3 | journal | 3.133 Q1 | 243 | 223 | 487 | 10717 | 3597 | 379 | 6.47 | 48.06 | 61.71 | ||
| 4 | journal | 2.808 Q1 | 116 | 20 | 74 | 3639 | 621 | 74 | 7.31 | 181.95 | 63.08 | ||
| 5 | journal | 2.761 Q1 | 118 | 51 | 104 | 5425 | 885 | 103 | 6.56 | 106.37 | 68.78 | ||
| 6 | journal | 2.709 Q1 | 94 | 21 | 107 | 1021 | 858 | 107 | 6.32 | 48.62 | 65.31 | ||
| 7 | journal | 2.437 Q1 | 395 | 624 | 2481 | 19923 | 12326 | 1953 | 4.45 | 31.93 | 59.90 | ||
| 8 | journal | 2.265 Q1 | 193 | 386 | 1058 | 12298 | 5863 | 872 | 4.67 | 31.86 | 64.15 | ||
| 9 | journal | 2.229 Q1 | 34 | 36 | 75 | 3022 | 544 | 74 | 5.88 | 83.94 | 68.36 | ||
| 10 | journal | 2.197 Q1 | 29 | 317 | 560 | 10794 | 2646 | 340 | 4.65 | 34.05 | 44.13 | ||
| 11 | journal | 2.175 Q1 | 116 | 362 | 531 | 18898 | 3321 | 462 | 6.45 | 52.20 | 61.40 | ||
| 12 | journal | 2.082 Q1 | 289 | 172 | 621 | 11356 | 3257 | 614 | 4.57 | 66.02 | 61.38 | ||
| 13 | journal | 2.058 Q1 | 58 | 89 | 216 | 3203 | 926 | 101 | 4.66 | 35.99 | 61.51 | ||
| 14 | journal | 2.043 Q1 | 91 | 255 | 622 | 7609 | 2768 | 516 | 4.63 | 29.84 | 56.10 | ||
| 15 | journal | 1.685 Q1 | 174 | 386 | 1107 | 22880 | 5480 | 1051 | 3.95 | 59.27 | 64.86 | ||
| 16 | journal | 1.642 Q1 | 133 | 166 | 441 | 3963 | 1577 | 333 | 3.44 | 23.87 | 55.78 | ||
| 17 | journal | 1.540 Q1 | 61 | 135 | 231 | 7518 | 1212 | 226 | 3.66 | 55.69 | 58.86 | ||
| 18 | journal | 1.425 Q1 | 135 | 141 | 345 | 9303 | 1589 | 342 | 3.59 | 65.98 | 63.50 | ||
| 19 | journal | 1.422 Q1 | 61 | 42 | 160 | 2547 | 755 | 158 | 4.13 | 60.64 | 56.81 | ||
| 20 | journal | 1.420 Q1 | 75 | 50 | 180 | 2784 | 812 | 160 | 3.97 | 55.68 | 45.65 | ||
| 21 | journal | 1.399 Q1 | 98 | 97 | 165 | 5023 | 727 | 158 | 4.57 | 51.78 | 72.15 | ||
| 22 | journal | 1.313 Q1 | 25 | 67 | 238 | 2348 | 869 | 215 | 3.62 | 35.04 | 59.78 | ||
| 23 | journal | 1.251 Q1 | 168 | 314 | 924 | 8427 | 2394 | 537 | 2.55 | 26.84 | 60.57 | ||
| 24 | journal | 1.247 Q1 | 85 | 99 | 356 | 4608 | 1347 | 352 | 3.71 | 46.55 | 62.15 | ||
| 25 | journal | 1.245 Q1 | 96 | 62 | 479 | 2444 | 1702 | 450 | 3.65 | 39.42 | 60.18 | ||
| 26 | journal | 1.241 Q1 | 93 | 259 | 686 | 7043 | 1915 | 556 | 2.65 | 27.19 | 66.19 | ||
| 27 | journal | 1.226 Q1 | 106 | 260 | 934 | 7155 | 2321 | 620 | 2.53 | 27.52 | 49.66 | ||
| 28 | journal | 1.211 Q1 | 55 | 68 | 284 | 2981 | 1064 | 281 | 3.18 | 43.84 | 64.35 | ||
| 29 | journal | 1.202 Q1 | 82 | 141 | 505 | 6576 | 1919 | 494 | 3.77 | 46.64 | 63.33 | ||
| 30 | journal | 1.184 Q1 | 171 | 668 | 1485 | 26413 | 4570 | 1125 | 2.91 | 39.54 | 53.43 | ||
| 31 | journal | 1.181 Q1 | 71 | 26 | 72 | 1060 | 232 | 69 | 2.73 | 40.77 | 62.28 | ||
| 32 | journal | 1.148 Q1 | 75 | 298 | 364 | 17964 | 1266 | 362 | 2.78 | 60.28 | 66.84 | ||
| 33 | journal | 1.143 Q1 | 139 | 105 | 361 | 4305 | 1155 | 336 | 3.01 | 41.00 | 73.21 | ||
| 34 | journal | 1.124 Q1 | 101 | 99 | 290 | 3434 | 641 | 225 | 2.14 | 34.69 | 64.72 | ||
| 35 | journal | 1.057 Q1 | 108 | 50 | 201 | 2634 | 708 | 193 | 2.87 | 52.68 | 44.09 | ||
| 36 | journal | 1.050 Q1 | 103 | 157 | 702 | 6268 | 2176 | 471 | 3.00 | 39.92 | 57.94 | ||
| 37 | journal | 1.043 Q1 | 238 | 497 | 2234 | 14957 | 5802 | 1809 | 2.38 | 30.09 | 60.21 | ||
| 38 | journal | 1.035 Q1 | 111 | 79 | 247 | 5764 | 789 | 230 | 2.93 | 72.96 | 57.89 | ||
| 39 | journal | 1.026 Q1 | 113 | 304 | 960 | 9682 | 2678 | 842 | 2.45 | 31.85 | 63.59 | ||
| 40 | journal | 1.017 Q1 | 70 | 56 | 163 | 3652 | 629 | 158 | 3.52 | 65.21 | 53.18 | ||
| 41 | journal | 0.992 Q1 | 22 | 0 | 21 | 0 | 26 | 20 | 0.11 | 0.00 | 0.00 | ||
| 42 | journal | 0.992 Q1 | 128 | 754 | 1864 | 20321 | 3883 | 1296 | 1.88 | 26.95 | 57.78 | ||
| 43 | journal | 0.984 Q1 | 111 | 624 | 1102 | 22522 | 3582 | 1036 | 3.22 | 36.09 | 55.84 | ||
| 44 | journal | 0.982 Q1 | 101 | 105 | 311 | 5015 | 1031 | 285 | 2.35 | 47.76 | 63.68 | ||
| 45 | journal | 0.979 Q1 | 85 | 58 | 182 | 3460 | 526 | 156 | 2.37 | 59.66 | 59.35 | ||
| 46 | journal | 0.973 Q1 | 81 | 56 | 166 | 3492 | 391 | 166 | 2.13 | 62.36 | 70.30 | ||
| 47 | journal | 0.950 Q1 | 83 | 59 | 183 | 3416 | 508 | 182 | 2.55 | 57.90 | 77.59 | ||
| 48 | journal | 0.949 Q1 | 144 | 469 | 1523 | 11542 | 3613 | 1327 | 2.20 | 24.61 | 43.57 | ||
| 49 | journal | 0.935 Q1 | 164 | 300 | 1139 | 6097 | 2441 | 755 | 2.26 | 20.32 | 58.78 | ||
| 50 | journal | 0.918 Q1 | 50 | 119 | 472 | 2447 | 1161 | 422 | 2.31 | 20.56 | 55.68 |
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The prevalence of spontaneous resolution among pediatric trigger thumb: a systematic review and meta-analysis
- QingSong Tang 1 na1 ,
- XinLing Miao 2 na1 ,
- Kang Zhao 1 ,
- Jie Hu 1 &
- Xiang Ren 1
Journal of Orthopaedic Surgery and Research volume 19 , Article number: 461 ( 2024 ) Cite this article
Metrics details
Trigger thumb is a prevalent hand condition observed in children, and its management remains a topic of considerable debate, ranging from mere observation to surgical intervention. In recent times, there has been a growing interest in exploring nonoperative treatments as alternatives to surgical procedures for managing pediatric trigger thumb. Gaining insight into the prevalence of spontaneous resolution in pediatric trigger thumb is of paramount importance. However, the literature presents a wide variation in estimates regarding the prevalence of this spontaneous resolution, highlighting the need for further investigation and consensus. The aim of this review was to estimate the overall prevalence of spontaneous resolution among pediatric trigger thumb.
This study meticulously followed the PRISMA guidelines and registered in the PROSPERO. The PubMed, Embase, and Cochrane Library databases were searched for all relevant studies up to May 2024.Inclusion criteria were studies reported only observation spontaneous resolution pediatric trigger thumb, aged up to 14 years, reported at least 10 thumbs and followed up time at least 3 months. Confounded intervention treatment measure studies were excluded. To synthesize the prevalence rates from individual studies, we employed a random-effects meta-analysis. In order to uncover the sources of heterogeneity and to compare prevalence estimates across different groups, we performed sensitivity and subgroup analyses. To meticulously evaluate the quality of the included studies, the Joanna Briggs Institute’s quality assessment checklist was employed. Furthermore, to assess the heterogeneity among the studies, both Cochran’s Q test and the I² statistic were utilized.
A total of eleven studies were included for the final analysis, with 599 pediatric trigger thumbs. Our final meta-analysis showed that more than one-third of these pediatric trigger thumb cases resolved spontaneously, with a resolution rate of 43.5% (95% CI 29.6–58.6). Subgroup analyses showed that in terms of age at the first visit, the prevalence of spontaneous resolution in the less than 24 months group and in the 24 months or older group was 38.7%(95% CI 18.1–64.4)and 45.8%(95% CI 27.4–65.4), respectively. There was no significant difference between the two groups( P = 0.690). When analyzing follow up time, the prevalence of spontaneous resolution in the 24 months or longer group and in the less than 24 months group was 58.9%(95% CI 41.6–74.2)and 26.8%(95% CI 14.7–43.8), respectively.There was significant statistical differences between the two groups( P = 0.009). Based on the initial severity of interphalangeal (IP) joint flexion contracture, the prevalence of spontaneous resolution in the 30 degrees or less group and in the other measurements group was 54.1%(95% CI 31.5–75.1)and 37.1%(95% CI 21.9–55.4), respectively.There was no significant difference between the two groups( P = 0.259).
Our study demonstrates that a significant proportion of pediatric trigger thumbs resolve spontaneously. This finding highlights the benefits of early observation in managing this condition. By prioritizing non-operative observation, both parents and surgeons are better equipped to make informed decisions regarding the treatment of pediatric trigger thumb, potentially reducing the need for surgical intervention.
Introduction
Research findings indicate that the prevalence of pediatric trigger thumb (PTT) ranges from 0 to 3.3 per 1,000 live births [ 1 , 2 ].The etiology of pediatric trigger thumb remains ambiguous, with some scholars suggesting a combination of congenital and acquired factors [ 2 , 3 ]. It is plausible that the actual prevalence acquired may be higher than congenital, as numerous cases manifest after the age of 12 months. Typically, the average age at diagnosis falls between 6 and 24 months [ 4 ].The primary concern revolves around a developmental discordance between the flexor pollicis longus tendon and its encompassing sheath. Historically, the surgical release of the A1 pulley has been the conventional approach for treating pediatric trigger thumb. However, emerging research indicates that a non-surgical observational strategy may result in spontaneous resolution of the condition. Study has reported over half of the affected children can anticipate a natural recovery without surgical intervention, typically within an average follow up time of approximately four years [ 5 ]. In addition, surgical intervention involving A1 pulley release has demonstrated successful outcomes for children over the age of five, irrespective of their age at the time of the procedure [ 6 ]. However, national data reveal that the surgical management of pediatric trigger thumb is often conducted more frequently and at younger ages than what the current literature advocates. This tendency toward over-treatment not only poses potential harm to patients but also imposes unwarranted financial burdens on healthcare systems [ 7 ].
Therefore, comprehending the authentic rate of spontaneous resolution in pediatric trigger thumbs is of paramount importance. This understanding is essential for considering early observation as a viable approach, which could alleviate suffering and mitigate associated negative outcomes. Broadly speaking, the reported prevalence rates of spontaneous resolution exhibit considerable variability across different studies, ranging from no occurrences to nearly four out of every five cases resolving on their own [ 8 , 9 , 10 ].
No systematic review or meta-analysis has thoroughly estimated the consolidated incidence of spontaneous resolution in pediatric trigger thumb. Evidence derived from such a meta-analysis would offer robust insights into the epidemiology of spontaneous resolution in pediatric trigger thumb. This information could be invaluable for both parents and surgeons, aiding them in making informed decisions regarding the choice between nonoperative and operative treatments for pediatric trigger thumb.Therefore, the objective of this review is to undertake a comprehensive analysis of existing literature on the prevalence of spontaneous resolution in pediatric trigger thumb, employing both qualitative and quantitative methodologies.
Research design and method
This study meticulously followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines throughout its protocols. The systematic process of searching, assessing eligibility, evaluating quality, extracting data, and analyzing data was rigorously executed based on a predesigned protocol. Moreover, the study protocol was duly registered on the International Prospective Register of Systematic Reviews (PROSPERO) prior to the commencement of data extraction (Registration CRD42024550745).
Data source and selection process
The literature search was conducted on May, 2024, utilizing three major databases: PubMed, Embase, and The Cochrane Library. The search strategy employed a combination of MeSH terms and keywords, specifically targeting the following phrases: “spontaneous resolution” or “observe” or “conservative” and “child” or “infant” or “newborn” or “pediatric”and “trigger finger” or “trigger thumb”.To ensure comprehensive coverage, additional relevant studies were meticulously identified by thoroughly reviewing the reference lists of the selected eligible studies.
Eligibility criteria and study selection
In this comprehensive review, we included studies that adhered to the following criteria: (i) The study participants were children diagnosed with pediatric trigger thumb, aged up to 14 years, reported at least 10 thumbs and followed up time at least 3 months; (ii) The study either reported the prevalence of spontaneous resolution or provided sufficient data to calculate this prevalence; and (iii) The study was published in the English language. We excluded followed up time less than 3 months, confounded intervention treatment measure studies, reviews, commentaries, case reports, and studies conducted on animal subjects. Additionally, letters to the editor, conference papers, books, editorials, and notes were also excluded from our analysis.
Methods for data extraction and quality assessment
Two independent authors meticulously extracted pertinent data from the selected studies. The information collected from each study encompassed the following details: the name of the first author(s), the sample size, the year of publication, the age at the initial visit, the follow up time, the initial severity of interphalangeal (IP) joint flexion contracture, as well as the number of spontaneous resolution among pediatric trigger thumb and their corresponding prevalence estimates.
All search results were aggregated and subsequently subjected to an independent eligibility screening by two of the authors. In instances of disagreement, a third author intervened during a meeting with the screening authors to mediate and resolve conflicts. This was achieved by attentively listening to the arguments presented and fostering discussions until a consensus was reached. The screening process entailed a meticulous review of the abstracts for each result. Following the initial screening and elimination of duplicates, the studies deemed potentially relevant were subjected to a thorough full-text review to ascertain their suitability for inclusion.
To assess the quality of the studies incorporated into the final analysis, we employed the Joanna Briggs Institute Quality Assessment Tool. This tool evaluates individual studies based on frequency scales, with responses categorized as ‘yes,’ ‘no,’ ‘not clear,’ and ‘not applicable.’ The total quality score for each study was meticulously calculated by summing the number of positive responses.
Data synthesis and analysis
In this research, all statistical analyses were meticulously performed utilizing the Comprehensive Meta-Analysis Software, version 3.0. The prevalence rates derived from the individual studies were amalgamated through the application of a random-effects meta-analysis model [ 11 ].To evaluate the degree of heterogeneity between the studies, the I² statistic was employed [ 11 ].The interpretation of the I² values is as follows: a value of 75% indicates high heterogeneity, 50% signifies medium heterogeneity, and 25% denotes low heterogeneity [ 12 ]. To assess potential sources of heterogeneity across the studies, we considered three key factors: the age at the initial visit, the duration of follow-up, and the initial severity of interphalangeal (IP) joint flexion contracture. To evaluate the risk of publication bias, we employed Egger’s regression tests and funnel plots. For all statistical analyses, a P-value of 0.05 was established as the statistical significance.
Identifcation of relevant studies
Our comprehensive and meticulous search process initially identified a total of 123 studies. However, upon closer examination, we found that 52 of these were duplicates and consequently excluded them from our analysis. Subsequently, during the evaluation phase focusing on titles and abstracts, we removed an additional 47 records—24 based on their titles and 23 based on their abstracts—as they failed to meet our stringent inclusion criteria. As a result, we retained the full texts of 24 publications for more in-depth scrutiny. Ultimately, out of these, 11 publications were deemed suitable and qualified for inclusion in our current systematic review and meta-analysis(Fig. 1 ).
PRISMA flowchart of review search
Characteristics of included studies
The fundamental attributes of the studies encompassed in this systematic review and meta-analysis are delineated in Table 1 . In total, 11 articles [ 5 , 8 , 9 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ] were incorporated into the final analysis, encompassing 599 cases of pediatric trigger thumb that exhibited spontaneous resolution. The studies reviewed were published over a substantial period, spanning from 1974 to 2021. The sample sizes of these included studies varied significantly, ranging from as few as 12 pediatric cases to as many as 107. Furthermore, the age of the children at their initial visit for these studies spanned from 18 months to 57 months. The mean follow-up duration for the studies included in our analysis varied significantly, ranging from 3 months to an extended period of 59 months. Among these studies, four meticulously documented the average initial flexion deformity of the interphalangeal joint. This deformity was precisely measured using a goniometer, ensuring accuracy and consistency in the recorded data.
Quality of included studies
Table 2 presents a detailed analysis of the quality and potential biases inherent in the studies included in this review. Notably, four studies, representing 36% of the total, utilized an adequate sample size to accurately determine the prevalence of spontaneous resolution. Furthermore, approximately six studies, accounting for 54.5%, received positive evaluations concerning their response rates. Remarkably, all of the studies, encompassing 100%, employed appropriate statistical analyses to investigate the prevalence of spontaneous resolution. Drawing upon the Joanna Briggs Institute’s quality evaluation checklist, the articles selected for the final analysis exhibited a mean quality score of 7.36, with individual scores spanning from five to nine. Notably, five studies, constituting 45% of the total, were classified as high-quality, each achieving a score of 7.36 or above. The remaining articles, which scored between five and 7.36, were deemed to be of fair quality.
The prevalence of spontaneous resolution among pediatric trigger thumb (metaanalysis)
The pooled prevalence estimate of spontaneous resolution among pediatric trigger thumb was determined to be 43.5% (95% CI: 29.6–58.6), follow up time ranged from 3 to 59 months. However, significant heterogeneity was observed across the studies included in this analysis (I² = 90.462%; P = 0.000) (Fig. 2 ). Subgroup analyses showed that in terms of age at the first visit, the prevalence of spontaneous resolution in the less than 24 months group and in the 24 months or older group was 38.7%(95% CI 18.1–64.4)and 45.8%(95% CI 27.4–65.4), respectively. There was no significant difference between the two groups( P = 0.690)(Table 3 ). When analyzing follow up time, the prevalence of spontaneous resolution in the 24 months or longer group and in the less than 24 months group was 58.9%(95% CI 41.6–74.2)and 26.8%(95% CI 14.7–43.8), respectively.There was significant statistical differences between the two groups( P = 0.009)(Table 3 ). Based on the initial severity of interphalangeal (IP) joint flexion contracture, the prevalence of spontaneous resolution in the 30 degrees or less group and in the other measurements group was 54.1%(95% CI 31.5–75.1)and 37.1%(95% CI 21.9–55.4), respectively.There was no significant difference between the two groups( P = 0.259) (Table 3 ).
The prevalence of spontaneous resolution among pediatric trigger thumb: a random-effect meta-analysis (I 2 = 90.462%; P = 0.000;based on random effect model)
Sensitivity analysis
To identify potential sources of heterogeneity across the studies and to examine the differences between groups estimating spontaneous resolution among pediatric trigger thumb, we conducted a stratified analysis by categorizing participants based on three key variables: age at the first visit (less than 24 months versus 24 months or older), follow-up duration (less than 24 months versus 24 months or longer), and the initial severity of interphalangeal (IP) joint flexion contracture (30 degrees or less versus other measurements).
This analysis revealed that the observed variation in the prevalence of spontaneous resolution among pediatric trigger thumb, when examined across the aforementioned three variables (groups), did not show statistical significance for age at the first visit (less than 24 months versus 24 months or older) and initial severity of IP joint flexion contracture (30 degrees or less versus other measurements) ( P > 0.05)(Table 3 ). However, the follow up time (less than 24 months versus 24 months or longer) demonstrated a statistically significant difference ( P = 0.009)(Table 3 ). To further investigate the potential sources of heterogeneity among the studies included in our analysis, we conducted a leave-one-out sensitivity analysis. This rigorous approach demonstrated that the primary findings are robust and not unduly influenced by any single study. Upon excluding each study one at a time, the pooled estimated prevalence of spontaneous resolution among pediatric trigger thumb ranged from 39.6% (95% CI: 27.2–53.6) to 47.8% (95% CI: 34.8–61.2), thus affirming the stability of our results.
Publication bias
In our comprehensive systematic review and meta-analysis, we uncovered no indications of potential publication bias concerning the prevalence of spontaneous resolution in pediatric trigger thumb. This conclusion is substantiated by the symmetrical appearance of the funnel plot and corroborated by the results of regression tests associated with the funnel plot analysis(Egger’s test) (B = − 789, SE = 3.87, P = 0.843)(Fig. 3 ).
Funnel plot of the risk of publication bias for the prevalence of spontaneous resolution among pediatric trigger thumb
Key findings
To the best of our knowledge, this study represents the first comprehensive systematic review and meta-analysis aimed at estimating the prevalence of spontaneous resolution in pediatric trigger thumb. Our review encompassed 11 studies that investigated this phenomenon. Both our qualitative and quantitative analyses revealed that the existing scientific evidence on the prevalence of spontaneous resolution in pediatric trigger thumb exhibits substantial variability depending on the follow up time, the age at the initial consultation, and the initial severity of interphalangeal (IP) joint flexion contracture.
Our comprehensive meta-analysis revealed the pooled prevalence estimate of spontaneous resolution among pediatric trigger thumb was determined to be 43.5%. Notably, the follow up time played a crucial role, the prevalence of spontaneous resolution in the 24 months or longer group and in the less than 24 months group was 58.9%(95% CI 41.6–74.2)and 26.8%(95% CI 14.7–43.8), respectively.There was significant statistical differences between the two groups( P = 0.009). This notable difference in resolution rates can greatly assist both parents and surgeons in making informed decisions regarding the preference for nonoperative treatments over surgical interventions for managing pediatric trigger thumb.
Comparisons with the existing evidence
The current study’s prevalence estimates for spontaneous resolution of pediatric trigger thumb stand at 43.5%. Notably, when the follow up time in the 24 months or longer group, this rate increases to 58.9%. These figures are significantly higher than those reported by some authors, who found no cases of spontaneous recovery during their follow-up periods [ 10 , 21 ]. The findings of this study suggest that the duration of nonoperative care can be extensive and should be a topic of discussion, allowing parents to actively participate in the decision-making process regarding the choice between nonoperative and operative treatments. One plausible explanation for this phenomenon may be attributed to the fact that some surgeons do not adhere to the recommended 24 months waiting period. Instead, they may choose to pursue alternative therapeutic approaches if spontaneous resolution is not achieved within a shorter timeframe, as indicated by previous research.
This substantial variation can be attributed to several factors including (i) There are notable variations in the characteristics of the children involved in these studies. These differences encompass the initial severity of the interphalangeal joint flexion contracture associated with trigger thumb [ 20 ], the duration of follow up time [ 18 ], as well as the age at which the condition first presented and whether it affected the right or left side [ 20 , 22 ]; (ii) Significant discrepancies exist in the definitions of spontaneous resolution of trigger thumb across various studies [ 5 , 20 ]; (iii) The clinical characteristics of participants exhibit considerable variation, encompassing factors such as metacarpophalangeal joint laxity issues [ 4 ] and the diverse ethnic and cultural backgrounds of the participants [ 20 ].
This study has unveiled significant heterogeneity among studies investigating the spontaneous resolution of pediatric trigger thumb. This observed variability can be attributed to differences in participant characteristics as well as the methodologies employed in the included studies. Concerning methodological disparities, the studies varied in several respects: sample size, the instruments utilized to measure outcomes, the sampling procedures, as well as the source of population.
Strength and limitations
The present study has several strengths. Firstly, this systematic review and meta-analysis aims to determine the prevalence of spontaneous resolution in pediatric trigger thumb cases. By consolidating existing research, it provides a foundational understanding of this medical phenomenon. Secondly, the study estimates the prevalence rates of spontaneous resolution by considering specific subgroups based on critical factors such as the age at the first visit, follow up time, and the initial severity of interphalangeal (IP) joint flexion contracture. This approach allows for a more detailed and accurate assessment of the condition across different patient demographics. Thirdly, the study incorporates subgroup and sensitivity analyses to identify and mitigate potential biases, ensuring the reliability and validity of the findings. These methodological strengths collectively enhance the study’s contribution to the field of pediatric orthopedics, offering valuable insights for clinicians and researchers alike.
Several limitations inherent in this systematic review and meta-analysis warrant careful consideration. Firstly, the majority of the included studies had relatively small sample sizes. This limitation raises concerns that the reported prevalence of spontaneous resolution among pediatric trigger thumb cases in our current analysis may not accurately reflect the true prevalence in the broader population. Secondly, our review exclusively included studies published in the English language. Consequently, there is a possibility that relevant studies conducted in other languages were overlooked, potentially introducing a language bias into our findings.
The implication of the findings
The current study bears profound implications for both research and clinical practice. To begin with, future investigations are imperative to explore the underlying reasons for the elevated prevalence rates of spontaneous resolution observed in pediatric trigger thumb cases when the follow up time in the 24 months or longer group, as compared to those with in the less than 24 months group. Additionally, it is essential that subsequent studies encompass larger sample sizes and incorporate segmentation based on gender and the affected side, thereby ensuring a more comprehensive understanding of this condition. Finally, to mitigate the need for surgical interventions and alleviate the associated suffering, early screening and public education on the spontaneous resolution of pediatric trigger thumb should be prioritized through coordinated and integrated public health strategies.
This study has demonstrated that a significant proportion of pediatric trigger thumbs resolve spontaneously. The prevalence of spontaneous resolution in pediatric trigger thumb cases is significantly higher when the follow up time in the 24 months or longer group, compared to cases with in the less than 24 months group, suggesting substantial benefits associated with an early observation approach for this condition. By opting for a nonoperative strategy initially, both parents and surgeons may be better equipped to make informed decisions about the treatment plan, potentially avoiding unnecessary surgical interventions.
The average initial flexion deformity of the interphalangeal joint, was measured with use of a goniometer, with the wrist held in neutral extension, the thumb in 20 of palmar abduction, and the metacarpophalangeal joint in neutral extension.
Data availability
No datasets were generated or analysed during the current study.
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We thank research office staff at Chengdu Women’s and Children’s Central Hospital.
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Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
QingSong Tang, Kang Zhao, Jie Hu & Xiang Ren
School of Nursing, Chengdu university, Chengdu, China
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QingSong Tang and XinLing Miao equally to this work as co-first authors. Tang QS conceptualized the study, performed the search conducted analyses, conducted the quality assessment, write-up and approval of the final manuscript. Miao XL was involved in data extraction, read and approved the final manuscript. Ren X, Zhao K, andHu J was participated in discussion and consensus and approved the final manuscript. All authors read and approved the final manuscript.
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Tang, Q., Miao, X., Zhao, K. et al. The prevalence of spontaneous resolution among pediatric trigger thumb: a systematic review and meta-analysis. J Orthop Surg Res 19 , 461 (2024). https://doi.org/10.1186/s13018-024-04960-0
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DOI : https://doi.org/10.1186/s13018-024-04960-0
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An Integrated Approach to Rapid Diagnosis of Tuberculosis and Multidrug Resistance Using Liquid Culture and Molecular Methods in Russia
Yanina balabanova.
1 National Mycobacterium Reference Laboratory, Institute of Cell and Molecular Sciences, Queen Mary College, Barts and the London School of Medicine, University of London, London, United Kingdom
2 Samara Oblast Tuberculosis Dispensary, Samara, Russia
Francis Drobniewski
Vladyslav nikolayevskyy, annika kruuner, nadezhda malomanova, tatyana simak, nailya ilyina, svetlana zakharova.
3 Samara City Tuberculosis Service, Samara, Russia
Natalya Lebedeva
Heather l. alexander.
4 Foundation for Innovative New Diagnostic, Cointrin/Geneva, Switzerland
5 US Centers for Disease Control and Prevention, Division of TB Elimination, Atlanta, Georgia, United States of America
Rick O'Brien
Hojoon sohn, anastasia shakhmistova, ivan fedorin.
Conceived and designed the experiments: YB FD VN AK NM SZ NL HLA RO HS IF. Performed the experiments: YB FD VN AK NM TS NI SZ NL HLA HS. Analyzed the data: YB FD VN TS RO HS AS. Contributed reagents/materials/analysis tools: YB VN AK NM HLA RO HS IF. Wrote the paper: YB FD HLA RO.
To analyse the feasibility, cost and performance of rapid tuberculosis (TB) molecular and culture systems, in a high multidrug-resistant TB (MDR TB) middle-income region (Samara, Russia) and provide evidence for WHO policy change.
Performance and cost evaluation was conducted to compare the BACTEC™ MGIT™ 960 system for culture and drug susceptibility testing (DST) and molecular systems for TB diagnosis, resistance to isoniazid and rifampin, and MDR TB identification compared to conventional Lowenstein-Jensen culture assays.
698 consecutive patients (2487 sputum samples) with risk factors for drug-resistant tuberculosis were recruited. Overall M. tuberculosis complex culture positivity rates were 31.6% (787/2487) in MGIT and 27.1% (675/2487) in LJ (90.5% and 83.2% for smear-positive specimens). In total, 809 cultures of M. tuberculosis complex were isolated by any method. Median time to detection was 14 days for MGIT and 36 days for LJ (10 and 33 days for smear positive specimens) and indirect DST in MGIT took 9 days compared to 21 days on LJ. There was good concordance between DST on LJ and MGIT (96.8% for rifampin and 95.6% for isoniazid). Both molecular hybridization assay results correlated well with MGIT DST results, although molecular assays generally yielded higher rates of resistance (by approximately 3% for both isoniazid and rifampin).
With effective planning and logistics, the MGIT 960 and molecular based methodologies can be successfully introduced into a reference laboratory setting in a middle incidence country. High rates of MDR TB in the Russian Federation make the introduction of such assays particularly useful.
Introduction
Tuberculosis (TB) remains one of the leading causes of morbidity and mortality globally, focused principally, but not exclusively, in the non-industrialized world.
Timely diagnosis and prompt treatment of infectious cases are the key elements of the international effort to combat TB, providing cure of an individual patient and reducing the spread of TB by rendering infectious cases non-infectious.
Multidrug-resistant TB (MDR TB), i.e. resistance to at least isoniazid (Inh) and rifampin (Rif), and extensively drug-resistant TB (XDR TB), i.e. MDR plus resistance to amikacin, kanamycin or capreomycin and a fluoroquinolone, are the most problematic forms of resistance because treatment options are limited and the second-line drugs used for therapy are more toxic, less effective, more expensive, and must be administered for a longer period of time than standard first-line drug therapy [1] .
The highest rates of MDR TB in the world (approximately 10% in new and 25% in re-treatment cases), have been reported from the Baltic region and countries of the former Soviet Union [2] – [11] .
Conventional culture and DST on solid media is a slow process, and in high income, low-incidence countries these systems have been supplemented (or replaced) by automated liquid culture systems such as the Becton Dickinson BACTEC™ MGIT™ 960 system. Decreased time to detection, greater sensitivity than Lowenstein-Jensen (LJ) solid media, comparable sensitivity to the radiometric Bactec 460 system in detecting Mycobacteria in clinical specimens, and good concordance with both LJ and Bactec 460 DST for first-line drugs (FLD) have been demonstrated in several studies [12] – [16] .
Rapid molecular methods, including commercial or in-house DNA hybridisation or amplification methods [17] allow detection of TB and rifampin resistance (and, for some, assays isoniazid resistance as well) in clinical samples within 1–2 days [18] – [25] . Despite the demonstrated advantages, the limited data on the performance, role and value of rapid culture, DST and molecular detection systems, together with concerns of increased cost and contamination rates relative to conventional culture on solid media, have dampened interest and progress in implementing these systems in low to middle income settings. However, this situation is changing in response to the growing MDR TB epidemic and the recent WHO recommendations on the use of liquid culture and DST and line probe assays (LPAs) [26] , [27] .
This study describes the feasibility of introduction, diagnostic accuracy and costs of the MGIT rapid culture system for primary specimens and FLD DST, coupled with rapid molecular systems for TB culture identification and detection of resistance to isoniazid and rifampin in Samara, Russia, a middle income region with a high burden of MDR TB [5] , [9] , [28] . The project was undertaken with the intention (achieved) of producing evidence for the implementation of global health policy changes relating to TB diagnosis by the WHO.
Materials and Methods
Ethics statement.
The study was approved by the Samara Medical University Ethics Committee. The study received a waiver of informed consent because the study used samples that were routinely collected for use in approved routine tests on LJ media. The tests on the MGIT 960 system were performed in parallel with the approved routine tests on LJ media. All aspects related to culture and phenotypic DST were reviewed and approved by the U.S. Centers for Disease Control and Prevention as non-human subjects research which does not require informed consent.
Setting and Design
A programmatic intervention and evaluation was conducted to compare the feasibility, utility and performance characteristics (recovery rates, time-to-detection) of the MGIT culture and DST system (Becton Dickinson, Sparks, MD) and rapid molecular systems to conventional standard reference LJ-based assays in patients at high risk of MDR TB in the central TB laboratory of Samara Region (Category 3 level facility), Russia Federation. The study was preceded by development of an agreed customer support plan that included installation and maintenance of the BACTEC™ machine as well as an uninterrupted supply of reagents needed based on reduced pricing policy offered for Samara. Principles outlined by the Standards for the Reporting of Diagnostic accuracy studies (STARD) for diagnostic accuracy studies were followed.
Prior to implementation into routine practice, MGIT and molecular methods were quality controlled and validated by the Health Protection Agency National Mycobacterium Reference Unit (HPA NMRL) according to the WHO/IUATLD Supranational Reference Laboratory (SRL) proficiency testing criteria [29] using a panel of defined M. tuberculosis cultures provided through the WHO SRL mechanism. Once the laboratory achieved pre-determined minimum standard efficiency levels based on WHO/IUATLD Supranational Reference Laboratory proficiency testing criteria for performance [29] of 80% (E and S), 89% (Inh), and 95% (Rif) in performing MGIT DST, MGIT and LJ culture and FLD DST were performed in parallel and all results were made available to clinicians. All staff was formally trained in bacteriological and molecular methods. Staff performing molecular assays was blinded to culture results and both were blinded to epidemiological data. This study also evaluated the detailed costs associated with the introduction of MGIT for TB culture diagnosis and DST in comparison with conventional methods on solid LJ media.
Patient Population
Patients were enrolled from 8 TB clinics in Samara Oblast that are part of a specialised service which provides diagnostics and treatment for TB patients only. The clinics verify the diagnosis for patients referred by the general health care sector after initial screening with a high suspicion for TB. All confirmed or suspected pulmonary TB patients who were sputum smear-positive and/or at high risk for MDR TB (individuals with prior TB treatment, persistent smear-positivity after 3 months treatment and/or poor clinical improvement, relapse, default, repeated treatment interruptions, contacts of patients with confirmed MDR TB, homeless persons and former prisoners) were included.
Patients were excluded if they were currently receiving TB treatment and smear-converted or remained smear-negative, were known to be infected with an MDR TB strain, or were suspected of having extra-pulmonary TB without pulmonary involvement.
Enrolment commenced in April 2006 and continued through April 2008.
Specimen preparation and primary culture
At least three routine sputum samples were collected from each patient into 50 ml screw-cap centrifuge tubes (Falcon, Becton Dickenson, USA) prior to treatment initiation as well as during treatment as follow-up control samples. Sputum samples were sent daily from the clinics to the laboratory; specimens were stored at 4°C until processed.
Specimens were processed using the NaOH-NALC method [30] employing the Becton Dickinson MycoPrep™ kit as described by the manufacturer. The final concentration of NaOH (1.0% w/v) was determined during the validation phase to maintain contamination rates below 8–10%. Concentrated specimens were stained for the presence of acid-fast bacilli (AFB) according to the Ziehl-Nielsen method [31] .
All processed specimens were immediately inoculated on both MGIT (0.5 ml inoculum) and LJ media (0.2 ml inoculum).
The MGIT 960 was checked daily for positive and negative cultures and LJ cultures were checked at least weekly. Although this standard approach carried an observation bias for time to detection of positive cultures, it followed the accepted practice of periodic visual scanning of LJ slopes reported in all previous published studies of the MGIT and comparable systems and LJ culture. Tubes flagged as positive by the MGIT 960 instrument were examined visually for potential mycobacterial growth and growth was inoculated onto a blood agar plate, subcultured on an LJ slant and MGIT for DST, and an AFB smear was prepared.
Isolate identification
Cultures were identified as M. tuberculosis complex (MTC) according to colony morphology, microscopic appearance, and standard biochemical assays, as specified in the Russian Federal guidelines [31] .
Molecular tests also were used to decrease the time to identification of MTC. Previous studies suggested that liquid culture systems would increase the isolation of non-tuberculous mycobacteria (NTM) as well as M. tuberculosis [32] . Therefore, 327 consecutive mycobacterial cultures initially isolated on the MGIT 960 system were identified to species level using the GenoType® CM assay (Hain Lifesciences GmbH, Nehren, Germany).
First Line drug susceptibility (DST)
The drug concentrations used in the MGIT system were (µg/ml): streptomycin (S): 1.0; isoniazid (Inh): 0.1; rifampin (Rif): 1.0; ethambutol (E): 5.0; pyrazinamide (Z): 100.0 [31] , [33] . DST on LJ was performed according to the absolute concentration method, utilizing the following drug concentrations (µg/ml): S: 10.0; Inh: 1.0; Rif: 40.0; E: 2.0 [31] . Sensitivity to pyrazinamide is not routinely tested on LJ media according to Russian Federal guidelines [31] .
As the majority of isolates were MTC (see Results ), subsequent cultures were identified using an in-house macroarray, as described elsewhere [34] and/or a commercial “line probe” assay system for MTC identification and rifampin and isoniazid resistance (GenoType® MTBDR plus , Hain Lifesciences GmbH, Germany). Both systems employed the same basic principles i.e. polymerase chain reaction (PCR) amplification of relevant regions of genes including the katG and rpoB genes and inhA promoter region, followed by reverse phase hybridisation to probes immobilised on a solid phase membrane.
Cost analysis
All laboratory procedures for both LJ and MGIT culture and DST were broken down into their component parts and a detailed time-and-motion study was conducted [35] – [37] . Total salaries, consumables costs, and capital (including equipment) infrastructure costs, maintenance, administrative and overhead costs of the laboratory, as well as transport costs were included in the final analysis.
Prices were converted into US dollars (USD) for this analysis. International pricings for all relevant laboratory resources and consumables for our study were based on published manufacturer suggested retail prices (MSRP) in developed countries such as the US. For local price analysis, procurement pricings specific to Samara with exceptions to MGIT instrumentation and consumables (for which we used the FIND-Becton Dickinson (BD) negotiated price available in 2006) were used. The usage of equipment, reagents, and laboratory space were quantified as minute used per square meter of space and minutes used. Overhead costs were calculated and allocated based on time-observation data particular to building space and staff utilization for each laboratory procedures included in our cost analysis.
Statistical analysis
All data were obtained from records collected by the clinical and laboratory staff and entered in a password protected stand-alone database to maintain confidentiality.
Statistical analysis was performed using the SPSS version 15 package (SPSS, http://www.spss.com ). The difference between rates among different groups was assessed using chi-test (χ 2 ).
In total, 698 consecutive patients were recruited into the study and 2545 sputum samples were subjected to bacteriological examination on both LJ and MGIT media.
Initially, the MGIT 960 system yielded increased rates of culture contamination but rates were quickly lowered to 3.4% by meticulous adherence to the manufacturer's manual and protocols, and with rapid transport and/or refrigeration of samples. The samples collected from patients were immediately refrigerated and stored at +4 for a maximum time of 48 hours prior to decontamination and culture. All samples from participating study sites were transported in cool bags. Sterility checks of water, buffer and NALC solutions and disposables consumables (such as washes from sputum containers, cryovials and laboratory tubes used) were regularly run using blood agar plates. Negative controls of each batch of MGIT tubes and daily logs of all ready-made solutions were used to monitor any potential manufacturer's contamination. In order for any increased culture speed to be valuable, a rapid molecular identification method was essential to identify culture growth in 1 day; this also permitted TB identification in bacterially-contaminated cultures (data not shown). A proportion of cultures was also spoligotyped to exclude cross-contamination within the laboratory.
Of the first 327 consecutive patients with positive mycobacterial isolates, the applied GenoType® Mycobacterium CM assay demonstrated that the vast majority (96.6%) of isolates were M. tuberculosis complex ( Figure 1 ). Subsequently, molecular methods were used to test all subsequent isolates simply for the presence or absence of MTC. Since very few NTMs were isolated, this paper presents results for MTC only. The overall MTC culture positivity rate for MGIT and LJ was 31.6% and 27.1% respectively (χ 2 = 11.9, p = 0.001); for smear positive specimens it was 90.5% and 83.2% (χ 2 = 8.6, p = 0.003) and for smear negative specimens, 20.4% and 16.4% respectively (χ 2 = 10.7, p = 0.001) ( Table 1 ).
| Sputum smear status | MGIT pos, n, (%) | Contaminated,n (%) | Positive and contaminated, n(%) | LJ pos, n (%) | Contaminated,n (%) | Positive and contaminated, n(%) |
| Smear positive(n-399) | 361 (90.5%) | 4 (1.0%) | 2 (0.5%) | 332 (83.2%) | 2 (0.5%) | 0 |
| Smear negative(n-2088) | 426 (20.4%) | 81 (3.9%) | 11 (0.5%) | 343 (16.4%) | 8 (0.4%) | 1 (0.05%) |
| Total (n-2487) | 787 (31.6%) | 85 (3.4%) | 13 (0.5%) | 675 (27.1%) | 10 (0.4%) | 1 (0.04%) |
The overall proportion of the total MTC isolates (number confirmed positive cultures by MGIT or LJ/total number positive cultures by either method) which were positive by MGIT was 97.2% (786/809) compared to 81.1% (656/809) for LJ. Of all culture positive specimens, 99.2% of smear-positive and 95.5% of smear-negative specimens were positive by MGIT while LJ recovery rates were 90.9% for smear-positives and 73.2% for smear-negative specimens. The concordance of results between the two systems was high for isolating MTC (92.7%) ( Table 2 ).
| Recovery rates of each method compared to all positive cultures | Concordance of MGIT and LJ culture results | |||||||||||||
| , p | ||||||||||||||
| Smear+ (n-393) | 362 | 359 | 99.2% | 329 | 90.9% | 24.6, <0.001 | 326 | 31 | 357 | 90.8% | 33 | 3 | 36 | 9.2% |
| Smear- (n-2003) | 447 | 427 | 95.5% | 327 | 73.2% | 83.0, <0.001 | 307 | 1556 | 1863 | 93.0% | 120 | 20 | 140 | 7.0% |
| Total(n-2396) | 809 | 786 | 97.2% | 656 | 81.1% | 106.1, <0.001 | 633 | 1587 | 2220 | 92.7% | 153 | 23 | 176 | 7.3% |
(+) positive test, (−) negative test.
Among culture positives, the overall median time to detection of M. tuberculosis complex was 14 days and 36 days for MGIT and LJ, respectively. Indirect DST from isolates took an additional 9 days in MGIT and 21 days on LJ. Therefore, providing a rapid molecular identification method is available that takes 1–2 days to perform as in the case of the GenoType® MTBDR plus method and comparable methods such as in house in situ hybridisation methods [34] , [38] the overall turn-around time can be as short as 25 days for MGIT vs approximately 60 days for LJ ( Figure 2 ).
Comparative phenotypic DST data for both methods ( Table 3 ) on all bacteriologically confirmed TB strains demonstrate approximately 63%, 50%, 27%, 60%, and 10% of the patients were resistant to isoniazid, rifampin, ethambutol, streptomycin, and pyrazinamide, respectively. Approximately 50% of cultures were MDR TB and nearly all rifampin-resistant isolates (98.7% and 100% detected by LJ and MGIT, respectively) were MDR TB. There was good concordance between the results obtained by the LJ and MGIT methods ( Table 4 ) with agreement of 96.8% for rifampin, 95.6% for isoniazid but only 91.9% for ethambutol and for 89.5% for streptomycin.
| N | % | N | % | |
| Total Patients with DST results (Inh+Rif) | 319 | 100.0% | 317 | 100.0% |
| Any resistance | ||||
| 195 | 61.1% | 201 | 63.4% | |
| 158 | 49.5% | 158 | 49.8% | |
| 81 | 25.4% | 84 | 26.5% | |
| 184 | 57.7% | 192 | 60.6% | |
| 33 | 10.4% | |||
| Total Multi-Drug Resistance (MDR) | ||||
| Total poly-resistance other than MDR | ||||
| Total Susceptible | 107 | 33.5% | 104 | 32.6% |
| No of concordant resistant | Total No resistant any methods | % concor-dance | No of concordant sensitive | Total No sensitive any methods | % concor-dance | Total agreement (sensitive and resistant)% | |
| Inh (n-315) | 190 | 197 | 96.4% | 111 | 118 | 94.1% | 95.6% |
| Rif (n-313) | 153 | 158 | 96.8% | 150 | 155 | 96.8% | 96.8% |
| E (n-321) | 76 | 89 | 85.4% | 219 | 232 | 94.4% | 91.9% |
| S (n-325) | 176 | 193 | 91.2% | 115 | 132 | 87.1% | 89.5% |
* for cultures, on which DST results were available from both methods; 11 MGIT and 9 LJ subcultures were contaminated across all four drugs.
The overall Inh, Rif and MDR resistance rates in the population as determined by the in-house macroarray (65.7%, 54.6% and 51.0% respectively) and the Hain methods (66.6%, 54.8% and 53.2% respectively) were comparable.
There was good concordance for isoniazid and rifampin resistance between the commercial and in-house low-density array-based methods (88.5% and 80.7% for macroarray and 87.3% and 77.9% for Hain; 87.6% and 84.9% for macroarray and 84.4% and 82.2% for Hain respectively) compared with the MGIT culture or LJ systems The sensitivity and specificity of both methods when compared to either culture system were high: almost 93% and 94% for detection of isoniazid and approximately 87% and 94% for detection of rifampicin resistance against the MGIT system; approximately 92% and 93% for isoniazid and 90% and 93% for rifampicin against the LJ system respectively ( Tables 5 – 6 ).
| /Total No R by any method (%) | /Total No S by any method (%) | (S & R) % | , % | , % | , % | , % | ||
| MA (n-305) | Inh | 93.5% | 87.8% | |||||
| Rif | 94.2% | 86.2% | ||||||
| Hain (n-311) | Inh | 93.5% | 87.0% | |||||
| Rif | 94.4% | 84.9% |
MA-macroarray method; Hain - GenoType® MTBDR plus method (Hain Lifesciences GmbH, Germany).
Where R-resistant and S-sensitive, 1 – by the test method (Hain or Macroarray), 2 – by the reference method (MGIT).
| /Total No R by any method (%) | /Total No S by any method (%) | (S & R) % | , % | , % | , % | , % | ||
| MA (n-305) | Inh | |||||||
| Rif | ||||||||
| Hain (n-311) | Inh | |||||||
| Rif |
Where R-resistant and S-sensitive, 1 – by the test method (Hain or Macroarray), 2 – by the reference method (LJ).
Compared to the LJ method, MGIT culture was consistently more expensive than LJ regardless of pricing levels but the difference was small ( Table 7 ). However, the FIND-BD pricing agreement brings about a 40% reduction in overall costs for screening one specimen for full first line DST with MGIT at $32 as compared to $56 for full catalogue pricing. LJ methodology costs ranged from $17 to $20 in Samara and international prices; if only isoniazid and rifampin resistance was tested the equivalent costs for Samara and internationally were $13 and $15 for LJ and $17 and $28 for the MGIT system.
| Pricing and resource input | Prima-ry culture | FLD DST (SIRE) | FLD DST (IR) | Macroarray | |||||||||
| MGIT Int'l | LJ Int'l | MGIT FIND-BD/Local | LJ Local | MGIT Int'l | LJ Int'l | MGITFIND-BD/Local | LJ Local | MGIT Int'l | LJ Int'l | MGIT FIND-BD/Local | LJ Local | ||
| Decontamination | 3.32 | 3.32 | 2.76 | 2.76 | 3.32 | 3.32 | 2.76 | 2.76 | 3.32 | 3.32 | 2.76 | 2.76 | NA |
| Prep LJ | N/A | 0.22 | N/A | 0.10 | N/A | 1.08 | N/A | 0.49 | – | 0.65 | – | 0.29 | NA |
| Test | |||||||||||||
| Overhead | 1.94 | 4.95 | 1.94 | 4.95 | 3.42 | 7.93 | 3.42 | 7.93 | 1.37 | 5.97 | 1.37 | 5.97 | 1.57 |
| Building | 0.42 | 1.07 | 0.42 | 1.07 | 0.54 | 1.48 | 0.54 | 1.48 | 0.42 | 1.18 | 0.22 | 1.18 | 0.01 |
| Equipment | 1.92 | 0.50 | 1.45 | 0.24 | 4.69 | 2.69 | 2.45 | 1.11 | 2.40 | 1.35 | 1.21 | 0.66 | 0.22 |
| Staff | 0.51 | 1.34 | 0.51 | 1.34 | 1.66 | 2.96 | 1.66 | 2.96 | 0.66 | 2.02 | 0.66 | 2.02 | 1.66 |
| Medical supplies | 5.08 | 0.09 | 4.58 | 0.05 | 42.04 | 0.36 | 21.58 | 0.28 | 19.88 | 0.35 | 10.50 | 0.58 | 5.20 |
| Sub-total Test | 9.87 | 7.95 | 8.90 | 7.66 | 52.35 | 15.42 | 29.66 | 13.76 | 24.40 | 10.87 | 13.96 | 10.42 | 12.73 |
| Total | 13.74 | 11.49 | 11.66 | 10.50 | 55.68 | 19.83 | 32.42 | 17.00 | 27.73 | 14.84 | 16.71 | 13.47 | 14.30 |
≠ Macroarray steps include all steps from DNA extraction to reading/reporting of the results.
Int'L – international prices.
NA – not applicable.
The cost of performing the in-house method (macroarray) in Samara was calculated based on local wages and overhead costs: the overall average unit cost of the macroarray test was at about $15 per specimen. The total chemical and reagent components of the test was between $5–6 per specimen ( Table 6 ). The test-strips used for this method were produced at the HPA MRU, London; more detailed assessment of the total assay costs when produced in Russia is needed and is subject of another on-going study.
The costs of the GenoType® MTBDR plus assay were not assessed within this project.
This study describes the performance characteristics of rapid liquid culture (MGIT 960) and molecular assays for the identification of MTC, rifampin, isoniazid and MDR TB as well as costs of the MGIT 960 system when introduced into Samara, a region within the Russian Federation with high rates of drug resistance and MDR TB [11] .
The MGIT 960 method was quickly taken up by the staff and successfully introduced into practice in an escalating manner from primary culture to DST. An initially high contamination rate was lowered to 3.4% within a month of initiation of the project by meticulous adherence to manufacturer's instructions, use of standard protocols as well as a well-developed system of rapid sample collection and transport logistics. Coupled with high recovery rates, it demonstrates that decontamination procedure was not overly harsh and permitted adequate growth of mycobacteria while ensuring low contamination rates. A preliminary analysis presented here found that over 96% of positive cultures were M. tuberculosis complex, suggesting that frequent NTM isolation (as reported elsewhere [32] ) was unlikely to be a significant problem in this study population. This was probably due to the high proportion of smear-positivity and drug resistant TB among enrolled patients, lower HIV-positivity rates compared to African countries, and dominance of the Beijing family TB strains in the area. This strain family has been actively transmitted in the area and has a strong association with drug resistance [5] . Subsequent culture growth was identified using a second commercial rapid identification system and a non-commercial in house system for MTC, isoniazid and rifampin resistance which both employed the same principle of PCR amplification coupled with a reverse phase hybridisation detection system.
As reported in high-resource, low-TB incidence settings, a greater proportion of positive cultures from primary specimens grew in the MGIT system primarily due to increased culture sensitivity for smear-negative specimens.
The median time for culture isolation was significantly faster for the MGIT 960 compared to LJ at 14 days versus 36 days for all specimens in agreement with other international studies mainly from low incidence [32] , [39] – [42] .
The proportion of drug resistance was very high in the studied population – almost half of the isolates were MDR TB. Mono –resistance to rifampicin was very rarely seen and nearly all rifampin-resistant isolates were MDR TB suggesting that rifampin resistance may serve as a reliable surrogate marker for MDR TB in this population. The median time to obtain DST results from positive cultures was faster with the MGIT system at 9 versus 21 days for LJ based methods in line with previously published works mainly from countries with lower levels of drug resistance [43] . Therefore introduction of the MGIT method can significantly decrease the overall turn-around time to 25 days comparable to data reported elsewhere [44] ). However, within the project framework the turn-around-time for positive cultures and DST ranged from 13 to 87 days with a median of 38 days for the MGIT. Delays occurred due to logistical problems during the introduction of the MGIT system into routine use (e.g. reagents supply), training of additional personnel, contamination and delays between receiving a culture and subculturing for DST. One of the advantages of using the MGIT system was an opportunity to reliably determine sensitivity to pyrazinamide. This test is not routinely performed on LJ media in Russia due to the lack of standard protocols and variable standardization recommended on the national level.Although the MGIT system generated all FLD DST results more rapidly than the LJ methodology, the molecular methods provided results for isoniazid and rifampin resistance within one day. Another study performed in the same setting of the Samara Regional Tuberculosis Laboratory presented evidence for efficient use of molecular assays (GenoType® MTBDRplus) directly on smear-positive sputum samples [45] . The current study demonstrated that concordance of the commercial and in-house molecular methods for isoniazid and rifampin resistance was high, with very close but not complete agreement for isoniazid and rifampin resistance between the molecular and MGIT defined DST results. These methods could be implemented as an initial screen for MDR TB (directly on smear-positive samples or on mycobacterial cultures isolated from smear-negative samples), permitting the institution of infection control measures at an earlier stage, as well as more rapid provision of appropriate treatment in line with recent WHO recommendations that were developed with the support of the Samara project data [26] . The presence of mutations indicating resistance could be used as an indicator for simultaneously initiating first- and second-line resistance testing in MGIT, which could significantly reduce the delay in administering an appropriate drug regimen to an MDR TB (or XDR TB) case.
The economic analysis demonstrated that although the MGIT culture system was slightly more expensive than the LJ method ($12 versus $11 respectively), it would permit earlier diagnosis of TB and prompt treatment initiation (a reduction in median culture time of 22 days).
Similarly MGIT FLD DST was more expensive than LJ FLD DST ($56 versus $20 using international prices) but the difference allowed a significant decrease in diagnostic turn-around time resulting in earlier identification of drug resistance, including MDR TB, especially when FLD and SLD DST are set up simultaneously for isolates which were diagnosed as having mutations to rifampicin and isoniazid by molecular methods. Coupled with molecular systems for rapid identification and drug resistance detection, this would have a significant impact on a timely administration of an adequate treatment regimen and potentially improve treatment outcomes. Administration of timely therapy will render an individual non-infectious and interrupt transmission; molecular methods and/or MGIT based DST identify the many patients who have MDR TB (who will not be rendered non-infectious by standard TB therapy and so will continue to transmit MDR TB) and culture –based phenotypic methods are the only way of reliably identifying the antimicrobials that are able to render MDR TB individuals non-infectious.
This demonstration project provided much of the evidence underpinning the diagnostic policy changes relating to bacteriological culture adopted by the WHO in 2007-8. Currently WHO recommend the routine use of TB liquid culture and DST even in resource-limited settings to improve diagnosis of TB in general, MDR TB and smear-negative pulmonary TB including application of a rapid method of species identification [27] . The higher cost of the automated liquid culture media systems is currently being addressed by the manufacturers by introducing changes into the pricing policy for the public sector in lower income countries. This project showed that it is possible to successfully introduce this technology into resource-constrained settings but that to achieve satisfactory implementation and performance of the MGIT system (which is more prone to bacterial contamination due to the greater sensitivity of liquid media for culture of mycobacteria as well as other microorganisms compared with solid culture and for DST which is more complex to perform that using solid culture) key issues needed to be resolved. These include: (1) availability of appropriate Category 3 level laboratory infrastructure including an agreed maintenance plan for the BACTEC system; (2) repetitive on-site training of laboratory personnel in MGIT methodology (using detailed SOPs and the system manual) and molecular methods to create a multi-skilled cadre of staff; (3) initial expert observation of the performance and implementation of internal and external quality control of laboratory work; (4) development of effective logistics for timely collection, storage and transport of fresh sputum samples to the laboratory as well as the reporting of results; (5) the creation of algorithms for laboratory work flow and computerized laboratory record keeping; (6) timely maintenance of equipment and ensuring a safe continuous supply of reagents by establishing a commercial contract with a manufacturer and (7) introduction of a robust stock control system.
For these diagnostic culture systems to have a maximum therapeutic impact there must be rapid identification of cultures with the ability to analyse first and second-line DST phenotypically when molecular tests demonstrate the presence of mutations encoding rifampin (and possibly isoniazid) resistance in the original patient specimen or the resulting culture. This will significantly reduce the time between sputum collection and full susceptibility testing for MDR TB cases. Addressing timeliness in technological improvement should go in tandem with minimizing organizational delay. Clinicians need to make prompt therapeutic changes following rapid DST analysis.
With effective planning and logistics, an adequate decontamination protocol and careful training, the MGIT 960 and molecular-based methodologies can be successfully introduced into a reference laboratory setting in a middle TB incidence country. The high rates of MDR TB in the Russian Federation make the introduction of such assays particularly useful and are likely to translate to other settings with a high level of drug resistance or where the additional speed of diagnosis and increased diagnostic sensitivity are of value as in HIV associated tuberculosis.
Acknowledgments
The project was a close collaboration between the Samara TB service, the UK Health Protection Agency and Barts and the London Medical School, University of London, Hain Lifescience Gmbh and the Foundation for Innovative New Diagnostics (FIND).
We would like to thank Dr Olga Kurkina for help with participants' recruitment, Mrs Marina Korobova for performing a proportion of bacteriological work, Ms Olga Ignat'yeva and Ms Svetlana Mironova for performing molecular work on a proportion of isolates.
Competing Interests: The authors have declared that no competing interests exist.
Funding: The work was jointly funded by Foundation of Innovative New Diagnostics (FIND), Queen Mary College, University of London and Hain Lifesciences GmbH, Nehren, Germany. Neither Becton Dickenson Diagnostic Systems nor Hain Lifesciences GmbH had a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Life After Pediatric Hemorrhagic Stroke - Family Centered Outcomes
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Louis Barnett , Laura GREISS Hess , Alma Martinez Pamatz , Deana Vander Meulen , Sabrina Montano , Charissa Thompson; Life After Pediatric Hemorrhagic Stroke - Family Centered Outcomes. Am J Occup Ther August 2024, Vol. 78(Supplement_2), 7811500094p1. doi: https://doi.org/10.5014/ajot.2024.78S2-PO94
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- Ris (Zotero)
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Date Presented 03/22/24
This qualitative research examined lived experiences of children & families post pediatric hemorrhagic stroke and occupational engagement across naturalistic contexts. Findings challenge OT to think beyond traditional clinical and research models.
Primary Author and Speaker: Louis Barnett
Additional Authors and Speakers: Alma Martinez Pamatz, Deana Vander Meulen, Sabrina Montano, Charissa Thompson
Contributing Authors: Laura GREISS Hess
BACKGROUND: Pediatric hemorrhagic stroke (PHS) impacts occupational functioning for children and families. PHS research has focused on medical/rehabilitation models specifically, the patient’s impairments. Little work has focused on occupational performance or child/family issues.
PURPOSE: Examine lived experiences and occupational impact to life post PHS. Research questions: (1) What are the lived experiences (including opportunities, barriers, and challenges) of families with children who have experienced PHS faced after the transition from acute care to life at home, school, and in the community? (2) How can an in-depth examination of these phenomena inform child/family-centered care in OT and further collaboration with interprofessional teams of professionals in partnership with families?
DESIGN/METHOD: Qualitative research with 30-60 minute semi-structured interview. Participants were guardians of a child post PHS. Recruitment from UCSF Center of Excellence Hemorrhagic Stroke. Interviews recorded, transcribed, and analyzed using Dedoose. Interviews focused on PHS impacts in the contexts of home, school, and community. Current sample is 6 families post PHS.
RESULTS, CONCLUSION & IMPACT: Preliminary results include themes for impacting occupational engagement. Home themes include ‘patience and understanding,’ with understanding of family members’ current emotions being crucial. School themes include ‘feeling supported vs challenged,’ speaking to a wide range of experiences with schools. Community themes include ‘compassion vs stigma’ and new impact for families living with a disability in an ableist society. Home, school and community occupational engagement has impacts beyond traditional medical/rehab models. Our research supports considerations for OTs as members of interprofessional teams in support of children and families in their meaningful occupational engagement post PHS.
Cárdenas, J. F., Rho, J. M., & Kirton, A. (2011). Pediatric stroke. Child’s Nervous System, 27 (9), 1375–1390. https://doi.org/10.1007/s00381-010-1366-9
Johns Hopkins Medicine. (2023). Types of Stroke. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. https://www.hopkinsmedicine.org/health/conditions-and-diseases/stroke/types-of-stroke
Learn about brain injury. Learn About Brain Injuries | Shepherd Center Rehabilitation. (n.d.). https://www.shepherd.org/patient-programs/brain-injury/about
Malone, L. A., & Felling, R. J. (2020). Pediatric Stroke: Unique Implications of the Immature Brain on Injury and Recovery. Pediatric Neurology, 102 , 3–9. https://doi.org/10.1016/j.pediatrneurol.2019.06.016
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Miller M , Azrael D. Firearm Storage in US Households With Children : Findings From the 2021 National Firearm Survey . JAMA Netw Open. 2022;5(2):e2148823. doi:10.1001/jamanetworkopen.2021.48823
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Firearm Storage in US Households With Children : Findings From the 2021 National Firearm Survey
- 1 Bouvé College of Health Sciences, Department of Health Sciences, Northeastern University, Boston, Massachusetts
- 2 Harvard Injury Control Research Center, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
In 2015, one-third of all households with children contained firearms, 21% of which contained at least 1 firearm that was both loaded and unlocked. As a result, approximately 4.6 million children lived in a home with loaded and unlocked firearms. 1 The nationally representative survey study reported herein updates these estimates as of April 2021, 12 months into an unprecedented and sustained surge in firearm purchases. 2 , 3
Data are from a nationally representative survey of US adults conducted April 15 through 26, 2021, with respondents drawn from an online sampling frame of 55 000 US adults recruited using address-based sampling. A description of the survey methods is available elsewhere. 3 The institutional review boards at Northeastern University, Boston, Massachusetts, and Harvard’s School of Public Health, Boston, determined the survey did not require review because the deidentified data did not qualify as human participants research. We followed the American Association for Public Opinion Research ( AAPOR ) reporting guideline for survey studies.
Panel members were screened with questions about household firearm ownership, including whether they personally owned firearms. Panel members were asked (1) Do you personally own a working gun (yes/no)? and (2) Does anyone else in your household own a working gun (yes/no/don’t know)? Firearm owners were asked (1) Do you store any of the guns you keep in or around your home loaded (yes/no)? (2) Do you store any of the guns you keep in or around your home unlocked (yes/no)? and, if they answered yes to both questions, (3) Do you store any of the guns you keep in or around your home both loaded and unlocked (yes/no)? Race and ethnicity were self-reported, using profile categories supplied by the survey firm (Ipsos).
Poststratification weights were applied to adjust for nonresponse and undercoverage or overcoverage from the study-specific sample design relative to expected distributions from the US Census Current Population Survey and the American Community Survey. Analyses used the SVY suite of commands in Stata, version16 (StataCorp LLC) to produce prevalence estimates with 95% CIs.
Of the 29 985 adult panel members invited to participate, 19 049 (63.5%) did so. Among all respondents, 9144 (48.0%) were men, 9905 (52.0%) were women, 62.0% were White non-Hispanic, and 33.3% lived in households with children younger than 18 years. Of the adults with children, 40.4% (95% CI, 38.6%-42.2%) who responded to the survey lived in a household with firearms. Of these, 29.3% (95%, CI, 27.7%-30.9%) owned firearms, and 11.1% (95% CI, 9.9%-12.4%) lived in a home with firearms but did not personally own a firearm ( Table ). The mean number of children per firearm-owning household with children (1.9; 95% CI, 1.9-2.0) was comparable to that in households with children and no firearms (1.8).
Most of the firearm owners with children (n = 1363) were male, were White, were married, lived in either a rural or suburban area, and had attended some college ( Table ). Of these, 36.1% (95% CI, 32.0%-40.4%) had unlocked firearms, and 37.1% (95% CI, 33.1%-41.4%) had loaded firearms. Of these, 15.0% (95% CI, 12.3%-18.2%) stored at least 1 firearm loaded and unlocked (least safe), and 44.1% (95% CI, 39.8%-48.5%) stored all firearms unloaded and locked.
These results indicate that in April 2021, approximately 30 million children lived in households with firearms, 7 million more than in 2015. 1 , 2 Firearm owners with children were more likely to store all household firearms locked and unloaded in 2021 (44.1%) compared with 2015 (29%) 1 and were slightly less likely to have firearms that were both loaded and unlocked (15.0% vs 21% 1 ).
Nevertheless, the trend toward safer storage we observed in 2021 was offset by the increase in the proportion of adults with children who lived in households with firearms. As a result, our estimate of the number of children who lived in a household with loaded and unlocked firearms in 2021 (4.6 million) was not meaningfully different from the estimate reported in the 2015 National Firearms Survey.
Our study has limitations. This study’s results should be interpreted considering potential inaccuracies due to social desirability, with such bias likely underestimating the prevalence of unsafe storage.
The American Academy of Pediatrics recommends that all firearms in households with children should be unloaded and in locked storage, with ammunition stored separately. Our findings underscore the ongoing need for more effective efforts to reduce children’s exposure to unsafely stored firearms, especially considering recent increases in new firearm owners, including those with children. 2 - 5
Accepted for Publication: December 28, 2021.
Published: February 22, 2022. doi:10.1001/jamanetworkopen.2021.48823
Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Miller M et al. JAMA Network Open .
Corresponding Author: Matthew Miller, MD, MPH, ScD, Bouvé College of Health Sciences, Department of Health Sciences, Northeastern University, 360 Huntington Ave, Room 316 Robinson Hall, Boston, MA 02115 ( [email protected] ).
Author Contributions: Both authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Both authors.
Acquisition, analysis, or interpretation of data: Both authors.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important intellectual content: Azrael.
Statistical analysis: Both authors.
Obtained funding: Both authors.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported in part by the Joyce Foundation.
Role of the Funder/Sponsor: The Joyce Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Peer-reviewed
Research Article
An Integrated Approach to Rapid Diagnosis of Tuberculosis and Multidrug Resistance Using Liquid Culture and Molecular Methods in Russia
* E-mail: [email protected]
Affiliations National Mycobacterium Reference Laboratory, Institute of Cell and Molecular Sciences, Queen Mary College, Barts and the London School of Medicine, University of London, London, United Kingdom, Samara Oblast Tuberculosis Dispensary, Samara, Russia
Affiliation National Mycobacterium Reference Laboratory, Institute of Cell and Molecular Sciences, Queen Mary College, Barts and the London School of Medicine, University of London, London, United Kingdom
Affiliation Samara Oblast Tuberculosis Dispensary, Samara, Russia
Affiliation Samara City Tuberculosis Service, Samara, Russia
Affiliations Foundation for Innovative New Diagnostic, Cointrin/Geneva, Switzerland, US Centers for Disease Control and Prevention, Division of TB Elimination, Atlanta, Georgia, United States of America
Affiliation Foundation for Innovative New Diagnostic, Cointrin/Geneva, Switzerland
- Yanina Balabanova,
- Francis Drobniewski,
- Vladyslav Nikolayevskyy,
- Annika Kruuner,
- Nadezhda Malomanova,
- Tatyana Simak,
- Nailya Ilyina,
- Svetlana Zakharova,
- Natalya Lebedeva,
- Published: September 23, 2009
- https://doi.org/10.1371/journal.pone.0007129
- Reader Comments
To analyse the feasibility, cost and performance of rapid tuberculosis (TB) molecular and culture systems, in a high multidrug-resistant TB (MDR TB) middle-income region (Samara, Russia) and provide evidence for WHO policy change.
Performance and cost evaluation was conducted to compare the BACTEC™ MGIT™ 960 system for culture and drug susceptibility testing (DST) and molecular systems for TB diagnosis, resistance to isoniazid and rifampin, and MDR TB identification compared to conventional Lowenstein-Jensen culture assays.
698 consecutive patients (2487 sputum samples) with risk factors for drug-resistant tuberculosis were recruited. Overall M. tuberculosis complex culture positivity rates were 31.6% (787/2487) in MGIT and 27.1% (675/2487) in LJ (90.5% and 83.2% for smear-positive specimens). In total, 809 cultures of M. tuberculosis complex were isolated by any method. Median time to detection was 14 days for MGIT and 36 days for LJ (10 and 33 days for smear positive specimens) and indirect DST in MGIT took 9 days compared to 21 days on LJ. There was good concordance between DST on LJ and MGIT (96.8% for rifampin and 95.6% for isoniazid). Both molecular hybridization assay results correlated well with MGIT DST results, although molecular assays generally yielded higher rates of resistance (by approximately 3% for both isoniazid and rifampin).
With effective planning and logistics, the MGIT 960 and molecular based methodologies can be successfully introduced into a reference laboratory setting in a middle incidence country. High rates of MDR TB in the Russian Federation make the introduction of such assays particularly useful.
Citation: Balabanova Y, Drobniewski F, Nikolayevskyy V, Kruuner A, Malomanova N, Simak T, et al. (2009) An Integrated Approach to Rapid Diagnosis of Tuberculosis and Multidrug Resistance Using Liquid Culture and Molecular Methods in Russia. PLoS ONE 4(9): e7129. https://doi.org/10.1371/journal.pone.0007129
Editor: Keertan Dheda, University of Cape Town, South Africa
Received: March 18, 2009; Accepted: August 24, 2009; Published: September 23, 2009
Copyright: © 2009 Balabanova et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The work was jointly funded by Foundation of Innovative New Diagnostics (FIND), Queen Mary College, University of London and Hain Lifesciences GmbH, Nehren, Germany. Neither Becton Dickenson Diagnostic Systems nor Hain Lifesciences GmbH had a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Tuberculosis (TB) remains one of the leading causes of morbidity and mortality globally, focused principally, but not exclusively, in the non-industrialized world.
Timely diagnosis and prompt treatment of infectious cases are the key elements of the international effort to combat TB, providing cure of an individual patient and reducing the spread of TB by rendering infectious cases non-infectious.
Multidrug-resistant TB (MDR TB), i.e. resistance to at least isoniazid (Inh) and rifampin (Rif), and extensively drug-resistant TB (XDR TB), i.e. MDR plus resistance to amikacin, kanamycin or capreomycin and a fluoroquinolone, are the most problematic forms of resistance because treatment options are limited and the second-line drugs used for therapy are more toxic, less effective, more expensive, and must be administered for a longer period of time than standard first-line drug therapy [1] .
The highest rates of MDR TB in the world (approximately 10% in new and 25% in re-treatment cases), have been reported from the Baltic region and countries of the former Soviet Union [2] – [11] .
Conventional culture and DST on solid media is a slow process, and in high income, low-incidence countries these systems have been supplemented (or replaced) by automated liquid culture systems such as the Becton Dickinson BACTEC™ MGIT™ 960 system. Decreased time to detection, greater sensitivity than Lowenstein-Jensen (LJ) solid media, comparable sensitivity to the radiometric Bactec 460 system in detecting Mycobacteria in clinical specimens, and good concordance with both LJ and Bactec 460 DST for first-line drugs (FLD) have been demonstrated in several studies [12] – [16] .
Rapid molecular methods, including commercial or in-house DNA hybridisation or amplification methods [17] allow detection of TB and rifampin resistance (and, for some, assays isoniazid resistance as well) in clinical samples within 1–2 days [18] – [25] . Despite the demonstrated advantages, the limited data on the performance, role and value of rapid culture, DST and molecular detection systems, together with concerns of increased cost and contamination rates relative to conventional culture on solid media, have dampened interest and progress in implementing these systems in low to middle income settings. However, this situation is changing in response to the growing MDR TB epidemic and the recent WHO recommendations on the use of liquid culture and DST and line probe assays (LPAs) [26] , [27] .
This study describes the feasibility of introduction, diagnostic accuracy and costs of the MGIT rapid culture system for primary specimens and FLD DST, coupled with rapid molecular systems for TB culture identification and detection of resistance to isoniazid and rifampin in Samara, Russia, a middle income region with a high burden of MDR TB [5] , [9] , [28] . The project was undertaken with the intention (achieved) of producing evidence for the implementation of global health policy changes relating to TB diagnosis by the WHO.
Materials and Methods
Ethics statement.
The study was approved by the Samara Medical University Ethics Committee. The study received a waiver of informed consent because the study used samples that were routinely collected for use in approved routine tests on LJ media. The tests on the MGIT 960 system were performed in parallel with the approved routine tests on LJ media. All aspects related to culture and phenotypic DST were reviewed and approved by the U.S. Centers for Disease Control and Prevention as non-human subjects research which does not require informed consent.
Setting and Design
A programmatic intervention and evaluation was conducted to compare the feasibility, utility and performance characteristics (recovery rates, time-to-detection) of the MGIT culture and DST system (Becton Dickinson, Sparks, MD) and rapid molecular systems to conventional standard reference LJ-based assays in patients at high risk of MDR TB in the central TB laboratory of Samara Region (Category 3 level facility), Russia Federation. The study was preceded by development of an agreed customer support plan that included installation and maintenance of the BACTEC™ machine as well as an uninterrupted supply of reagents needed based on reduced pricing policy offered for Samara. Principles outlined by the Standards for the Reporting of Diagnostic accuracy studies (STARD) for diagnostic accuracy studies were followed.
Prior to implementation into routine practice, MGIT and molecular methods were quality controlled and validated by the Health Protection Agency National Mycobacterium Reference Unit (HPA NMRL) according to the WHO/IUATLD Supranational Reference Laboratory (SRL) proficiency testing criteria [29] using a panel of defined M. tuberculosis cultures provided through the WHO SRL mechanism. Once the laboratory achieved pre-determined minimum standard efficiency levels based on WHO/IUATLD Supranational Reference Laboratory proficiency testing criteria for performance [29] of 80% (E and S), 89% (Inh), and 95% (Rif) in performing MGIT DST, MGIT and LJ culture and FLD DST were performed in parallel and all results were made available to clinicians. All staff was formally trained in bacteriological and molecular methods. Staff performing molecular assays was blinded to culture results and both were blinded to epidemiological data. This study also evaluated the detailed costs associated with the introduction of MGIT for TB culture diagnosis and DST in comparison with conventional methods on solid LJ media.
Patient Population
Patients were enrolled from 8 TB clinics in Samara Oblast that are part of a specialised service which provides diagnostics and treatment for TB patients only. The clinics verify the diagnosis for patients referred by the general health care sector after initial screening with a high suspicion for TB. All confirmed or suspected pulmonary TB patients who were sputum smear-positive and/or at high risk for MDR TB (individuals with prior TB treatment, persistent smear-positivity after 3 months treatment and/or poor clinical improvement, relapse, default, repeated treatment interruptions, contacts of patients with confirmed MDR TB, homeless persons and former prisoners) were included.
Patients were excluded if they were currently receiving TB treatment and smear-converted or remained smear-negative, were known to be infected with an MDR TB strain, or were suspected of having extra-pulmonary TB without pulmonary involvement.
Enrolment commenced in April 2006 and continued through April 2008.
Specimen preparation and primary culture
At least three routine sputum samples were collected from each patient into 50 ml screw-cap centrifuge tubes (Falcon, Becton Dickenson, USA) prior to treatment initiation as well as during treatment as follow-up control samples. Sputum samples were sent daily from the clinics to the laboratory; specimens were stored at 4°C until processed.
Specimens were processed using the NaOH-NALC method [30] employing the Becton Dickinson MycoPrep™ kit as described by the manufacturer. The final concentration of NaOH (1.0% w/v) was determined during the validation phase to maintain contamination rates below 8–10%. Concentrated specimens were stained for the presence of acid-fast bacilli (AFB) according to the Ziehl-Nielsen method [31] .
All processed specimens were immediately inoculated on both MGIT (0.5 ml inoculum) and LJ media (0.2 ml inoculum).
The MGIT 960 was checked daily for positive and negative cultures and LJ cultures were checked at least weekly. Although this standard approach carried an observation bias for time to detection of positive cultures, it followed the accepted practice of periodic visual scanning of LJ slopes reported in all previous published studies of the MGIT and comparable systems and LJ culture. Tubes flagged as positive by the MGIT 960 instrument were examined visually for potential mycobacterial growth and growth was inoculated onto a blood agar plate, subcultured on an LJ slant and MGIT for DST, and an AFB smear was prepared.
Isolate identification
Cultures were identified as M. tuberculosis complex (MTC) according to colony morphology, microscopic appearance, and standard biochemical assays, as specified in the Russian Federal guidelines [31] .
Molecular tests also were used to decrease the time to identification of MTC. Previous studies suggested that liquid culture systems would increase the isolation of non-tuberculous mycobacteria (NTM) as well as M. tuberculosis [32] . Therefore, 327 consecutive mycobacterial cultures initially isolated on the MGIT 960 system were identified to species level using the GenoType® CM assay (Hain Lifesciences GmbH, Nehren, Germany).
First Line drug susceptibility (DST)
The drug concentrations used in the MGIT system were (µg/ml): streptomycin (S): 1.0; isoniazid (Inh): 0.1; rifampin (Rif): 1.0; ethambutol (E): 5.0; pyrazinamide (Z): 100.0 [31] , [33] . DST on LJ was performed according to the absolute concentration method, utilizing the following drug concentrations (µg/ml): S: 10.0; Inh: 1.0; Rif: 40.0; E: 2.0 [31] . Sensitivity to pyrazinamide is not routinely tested on LJ media according to Russian Federal guidelines [31] .
As the majority of isolates were MTC (see Results ), subsequent cultures were identified using an in-house macroarray, as described elsewhere [34] and/or a commercial “line probe” assay system for MTC identification and rifampin and isoniazid resistance (GenoType® MTBDR plus , Hain Lifesciences GmbH, Germany). Both systems employed the same basic principles i.e. polymerase chain reaction (PCR) amplification of relevant regions of genes including the katG and rpoB genes and inhA promoter region, followed by reverse phase hybridisation to probes immobilised on a solid phase membrane.
Cost analysis
All laboratory procedures for both LJ and MGIT culture and DST were broken down into their component parts and a detailed time-and-motion study was conducted [35] – [37] . Total salaries, consumables costs, and capital (including equipment) infrastructure costs, maintenance, administrative and overhead costs of the laboratory, as well as transport costs were included in the final analysis.
Prices were converted into US dollars (USD) for this analysis. International pricings for all relevant laboratory resources and consumables for our study were based on published manufacturer suggested retail prices (MSRP) in developed countries such as the US. For local price analysis, procurement pricings specific to Samara with exceptions to MGIT instrumentation and consumables (for which we used the FIND-Becton Dickinson (BD) negotiated price available in 2006) were used. The usage of equipment, reagents, and laboratory space were quantified as minute used per square meter of space and minutes used. Overhead costs were calculated and allocated based on time-observation data particular to building space and staff utilization for each laboratory procedures included in our cost analysis.
Statistical analysis
All data were obtained from records collected by the clinical and laboratory staff and entered in a password protected stand-alone database to maintain confidentiality.
Statistical analysis was performed using the SPSS version 15 package (SPSS, http://www.spss.com ). The difference between rates among different groups was assessed using chi-test (χ 2 ).
In total, 698 consecutive patients were recruited into the study and 2545 sputum samples were subjected to bacteriological examination on both LJ and MGIT media.
Initially, the MGIT 960 system yielded increased rates of culture contamination but rates were quickly lowered to 3.4% by meticulous adherence to the manufacturer's manual and protocols, and with rapid transport and/or refrigeration of samples. The samples collected from patients were immediately refrigerated and stored at +4 for a maximum time of 48 hours prior to decontamination and culture. All samples from participating study sites were transported in cool bags. Sterility checks of water, buffer and NALC solutions and disposables consumables (such as washes from sputum containers, cryovials and laboratory tubes used) were regularly run using blood agar plates. Negative controls of each batch of MGIT tubes and daily logs of all ready-made solutions were used to monitor any potential manufacturer's contamination. In order for any increased culture speed to be valuable, a rapid molecular identification method was essential to identify culture growth in 1 day; this also permitted TB identification in bacterially-contaminated cultures (data not shown). A proportion of cultures was also spoligotyped to exclude cross-contamination within the laboratory.
Of the first 327 consecutive patients with positive mycobacterial isolates, the applied GenoType® Mycobacterium CM assay demonstrated that the vast majority (96.6%) of isolates were M. tuberculosis complex ( Figure 1 ). Subsequently, molecular methods were used to test all subsequent isolates simply for the presence or absence of MTC. Since very few NTMs were isolated, this paper presents results for MTC only. The overall MTC culture positivity rate for MGIT and LJ was 31.6% and 27.1% respectively (χ 2 = 11.9, p = 0.001); for smear positive specimens it was 90.5% and 83.2% (χ 2 = 8.6, p = 0.003) and for smear negative specimens, 20.4% and 16.4% respectively (χ 2 = 10.7, p = 0.001) ( Table 1 ).
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The overall proportion of the total MTC isolates (number confirmed positive cultures by MGIT or LJ/total number positive cultures by either method) which were positive by MGIT was 97.2% (786/809) compared to 81.1% (656/809) for LJ. Of all culture positive specimens, 99.2% of smear-positive and 95.5% of smear-negative specimens were positive by MGIT while LJ recovery rates were 90.9% for smear-positives and 73.2% for smear-negative specimens. The concordance of results between the two systems was high for isolating MTC (92.7%) ( Table 2 ).
https://doi.org/10.1371/journal.pone.0007129.t002
Among culture positives, the overall median time to detection of M. tuberculosis complex was 14 days and 36 days for MGIT and LJ, respectively. Indirect DST from isolates took an additional 9 days in MGIT and 21 days on LJ. Therefore, providing a rapid molecular identification method is available that takes 1–2 days to perform as in the case of the GenoType® MTBDR plus method and comparable methods such as in house in situ hybridisation methods [34] , [38] the overall turn-around time can be as short as 25 days for MGIT vs approximately 60 days for LJ ( Figure 2 ).
https://doi.org/10.1371/journal.pone.0007129.g002
Comparative phenotypic DST data for both methods ( Table 3 ) on all bacteriologically confirmed TB strains demonstrate approximately 63%, 50%, 27%, 60%, and 10% of the patients were resistant to isoniazid, rifampin, ethambutol, streptomycin, and pyrazinamide, respectively. Approximately 50% of cultures were MDR TB and nearly all rifampin-resistant isolates (98.7% and 100% detected by LJ and MGIT, respectively) were MDR TB. There was good concordance between the results obtained by the LJ and MGIT methods ( Table 4 ) with agreement of 96.8% for rifampin, 95.6% for isoniazid but only 91.9% for ethambutol and for 89.5% for streptomycin.
https://doi.org/10.1371/journal.pone.0007129.t003
https://doi.org/10.1371/journal.pone.0007129.t004
The overall Inh, Rif and MDR resistance rates in the population as determined by the in-house macroarray (65.7%, 54.6% and 51.0% respectively) and the Hain methods (66.6%, 54.8% and 53.2% respectively) were comparable.
There was good concordance for isoniazid and rifampin resistance between the commercial and in-house low-density array-based methods (88.5% and 80.7% for macroarray and 87.3% and 77.9% for Hain; 87.6% and 84.9% for macroarray and 84.4% and 82.2% for Hain respectively) compared with the MGIT culture or LJ systems The sensitivity and specificity of both methods when compared to either culture system were high: almost 93% and 94% for detection of isoniazid and approximately 87% and 94% for detection of rifampicin resistance against the MGIT system; approximately 92% and 93% for isoniazid and 90% and 93% for rifampicin against the LJ system respectively ( Tables 5 – 6 ).
https://doi.org/10.1371/journal.pone.0007129.t005
https://doi.org/10.1371/journal.pone.0007129.t006
Compared to the LJ method, MGIT culture was consistently more expensive than LJ regardless of pricing levels but the difference was small ( Table 7 ). However, the FIND-BD pricing agreement brings about a 40% reduction in overall costs for screening one specimen for full first line DST with MGIT at $32 as compared to $56 for full catalogue pricing. LJ methodology costs ranged from $17 to $20 in Samara and international prices; if only isoniazid and rifampin resistance was tested the equivalent costs for Samara and internationally were $13 and $15 for LJ and $17 and $28 for the MGIT system.
https://doi.org/10.1371/journal.pone.0007129.t007
The cost of performing the in-house method (macroarray) in Samara was calculated based on local wages and overhead costs: the overall average unit cost of the macroarray test was at about $15 per specimen. The total chemical and reagent components of the test was between $5–6 per specimen ( Table 6 ). The test-strips used for this method were produced at the HPA MRU, London; more detailed assessment of the total assay costs when produced in Russia is needed and is subject of another on-going study.
The costs of the GenoType® MTBDR plus assay were not assessed within this project.
This study describes the performance characteristics of rapid liquid culture (MGIT 960) and molecular assays for the identification of MTC, rifampin, isoniazid and MDR TB as well as costs of the MGIT 960 system when introduced into Samara, a region within the Russian Federation with high rates of drug resistance and MDR TB [11] .
The MGIT 960 method was quickly taken up by the staff and successfully introduced into practice in an escalating manner from primary culture to DST. An initially high contamination rate was lowered to 3.4% within a month of initiation of the project by meticulous adherence to manufacturer's instructions, use of standard protocols as well as a well-developed system of rapid sample collection and transport logistics. Coupled with high recovery rates, it demonstrates that decontamination procedure was not overly harsh and permitted adequate growth of mycobacteria while ensuring low contamination rates. A preliminary analysis presented here found that over 96% of positive cultures were M. tuberculosis complex, suggesting that frequent NTM isolation (as reported elsewhere [32] ) was unlikely to be a significant problem in this study population. This was probably due to the high proportion of smear-positivity and drug resistant TB among enrolled patients, lower HIV-positivity rates compared to African countries, and dominance of the Beijing family TB strains in the area. This strain family has been actively transmitted in the area and has a strong association with drug resistance [5] . Subsequent culture growth was identified using a second commercial rapid identification system and a non-commercial in house system for MTC, isoniazid and rifampin resistance which both employed the same principle of PCR amplification coupled with a reverse phase hybridisation detection system.
As reported in high-resource, low-TB incidence settings, a greater proportion of positive cultures from primary specimens grew in the MGIT system primarily due to increased culture sensitivity for smear-negative specimens.
The median time for culture isolation was significantly faster for the MGIT 960 compared to LJ at 14 days versus 36 days for all specimens in agreement with other international studies mainly from low incidence [32] , [39] – [42] .
The proportion of drug resistance was very high in the studied population – almost half of the isolates were MDR TB. Mono –resistance to rifampicin was very rarely seen and nearly all rifampin-resistant isolates were MDR TB suggesting that rifampin resistance may serve as a reliable surrogate marker for MDR TB in this population. The median time to obtain DST results from positive cultures was faster with the MGIT system at 9 versus 21 days for LJ based methods in line with previously published works mainly from countries with lower levels of drug resistance [43] . Therefore introduction of the MGIT method can significantly decrease the overall turn-around time to 25 days comparable to data reported elsewhere [44] ). However, within the project framework the turn-around-time for positive cultures and DST ranged from 13 to 87 days with a median of 38 days for the MGIT. Delays occurred due to logistical problems during the introduction of the MGIT system into routine use (e.g. reagents supply), training of additional personnel, contamination and delays between receiving a culture and subculturing for DST. One of the advantages of using the MGIT system was an opportunity to reliably determine sensitivity to pyrazinamide. This test is not routinely performed on LJ media in Russia due to the lack of standard protocols and variable standardization recommended on the national level.Although the MGIT system generated all FLD DST results more rapidly than the LJ methodology, the molecular methods provided results for isoniazid and rifampin resistance within one day. Another study performed in the same setting of the Samara Regional Tuberculosis Laboratory presented evidence for efficient use of molecular assays (GenoType® MTBDRplus) directly on smear-positive sputum samples [45] . The current study demonstrated that concordance of the commercial and in-house molecular methods for isoniazid and rifampin resistance was high, with very close but not complete agreement for isoniazid and rifampin resistance between the molecular and MGIT defined DST results. These methods could be implemented as an initial screen for MDR TB (directly on smear-positive samples or on mycobacterial cultures isolated from smear-negative samples), permitting the institution of infection control measures at an earlier stage, as well as more rapid provision of appropriate treatment in line with recent WHO recommendations that were developed with the support of the Samara project data [26] . The presence of mutations indicating resistance could be used as an indicator for simultaneously initiating first- and second-line resistance testing in MGIT, which could significantly reduce the delay in administering an appropriate drug regimen to an MDR TB (or XDR TB) case.
The economic analysis demonstrated that although the MGIT culture system was slightly more expensive than the LJ method ($12 versus $11 respectively), it would permit earlier diagnosis of TB and prompt treatment initiation (a reduction in median culture time of 22 days).
Similarly MGIT FLD DST was more expensive than LJ FLD DST ($56 versus $20 using international prices) but the difference allowed a significant decrease in diagnostic turn-around time resulting in earlier identification of drug resistance, including MDR TB, especially when FLD and SLD DST are set up simultaneously for isolates which were diagnosed as having mutations to rifampicin and isoniazid by molecular methods. Coupled with molecular systems for rapid identification and drug resistance detection, this would have a significant impact on a timely administration of an adequate treatment regimen and potentially improve treatment outcomes. Administration of timely therapy will render an individual non-infectious and interrupt transmission; molecular methods and/or MGIT based DST identify the many patients who have MDR TB (who will not be rendered non-infectious by standard TB therapy and so will continue to transmit MDR TB) and culture –based phenotypic methods are the only way of reliably identifying the antimicrobials that are able to render MDR TB individuals non-infectious.
This demonstration project provided much of the evidence underpinning the diagnostic policy changes relating to bacteriological culture adopted by the WHO in 2007-8. Currently WHO recommend the routine use of TB liquid culture and DST even in resource-limited settings to improve diagnosis of TB in general, MDR TB and smear-negative pulmonary TB including application of a rapid method of species identification [27] . The higher cost of the automated liquid culture media systems is currently being addressed by the manufacturers by introducing changes into the pricing policy for the public sector in lower income countries. This project showed that it is possible to successfully introduce this technology into resource-constrained settings but that to achieve satisfactory implementation and performance of the MGIT system (which is more prone to bacterial contamination due to the greater sensitivity of liquid media for culture of mycobacteria as well as other microorganisms compared with solid culture and for DST which is more complex to perform that using solid culture) key issues needed to be resolved. These include: (1) availability of appropriate Category 3 level laboratory infrastructure including an agreed maintenance plan for the BACTEC system; (2) repetitive on-site training of laboratory personnel in MGIT methodology (using detailed SOPs and the system manual) and molecular methods to create a multi-skilled cadre of staff; (3) initial expert observation of the performance and implementation of internal and external quality control of laboratory work; (4) development of effective logistics for timely collection, storage and transport of fresh sputum samples to the laboratory as well as the reporting of results; (5) the creation of algorithms for laboratory work flow and computerized laboratory record keeping; (6) timely maintenance of equipment and ensuring a safe continuous supply of reagents by establishing a commercial contract with a manufacturer and (7) introduction of a robust stock control system.
For these diagnostic culture systems to have a maximum therapeutic impact there must be rapid identification of cultures with the ability to analyse first and second-line DST phenotypically when molecular tests demonstrate the presence of mutations encoding rifampin (and possibly isoniazid) resistance in the original patient specimen or the resulting culture. This will significantly reduce the time between sputum collection and full susceptibility testing for MDR TB cases. Addressing timeliness in technological improvement should go in tandem with minimizing organizational delay. Clinicians need to make prompt therapeutic changes following rapid DST analysis.
With effective planning and logistics, an adequate decontamination protocol and careful training, the MGIT 960 and molecular-based methodologies can be successfully introduced into a reference laboratory setting in a middle TB incidence country. The high rates of MDR TB in the Russian Federation make the introduction of such assays particularly useful and are likely to translate to other settings with a high level of drug resistance or where the additional speed of diagnosis and increased diagnostic sensitivity are of value as in HIV associated tuberculosis.
Acknowledgments
The project was a close collaboration between the Samara TB service, the UK Health Protection Agency and Barts and the London Medical School, University of London, Hain Lifescience Gmbh and the Foundation for Innovative New Diagnostics (FIND).
We would like to thank Dr Olga Kurkina for help with participants' recruitment, Mrs Marina Korobova for performing a proportion of bacteriological work, Ms Olga Ignat'yeva and Ms Svetlana Mironova for performing molecular work on a proportion of isolates.
Author Contributions
Conceived and designed the experiments: YB FD VN AK NM SZ NL HLA RO HS IF. Performed the experiments: YB FD VN AK NM TS NI SZ NL HLA HS. Analyzed the data: YB FD VN TS RO HS AS. Contributed reagents/materials/analysis tools: YB VN AK NM HLA RO HS IF. Wrote the paper: YB FD HLA RO.
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Findings. 698 consecutive patients (2487 sputum samples) with risk factors for drug-resistant tuberculosis were recruited. Overall M. tuberculosis complex culture positivity rates were 31.6% (787/2487) in MGIT and 27.1% (675/2487) in LJ (90.5% and 83.2% for smear-positive specimens). In total, 809 cultures of M. tuberculosis complex were isolated by any method.
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Can you help me find this street in Samara Revolutcionnaya [email protected]
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