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dc.contributor.authorMurthy, S. E.
dc.contributor.authorChatterjee, F.
dc.contributor.authorCrook, A.
dc.contributor.authorDawson, R.
dc.contributor.authorMendel, C.
dc.contributor.authorMurphy, M. E.
dc.contributor.authorMurray, S. R.
dc.contributor.authorNunn, A. J.
dc.contributor.authorPhillips, P. P. J.
dc.contributor.authorSingh, Kasha P.
dc.contributor.authorMcHugh, T. D.
dc.contributor.authorGillespie, S. H.
dc.contributor.authorREMoxTB Consortium
dc.identifier.citationMurthy , S E , Chatterjee , F , Crook , A , Dawson , R , Mendel , C , Murphy , M E , Murray , S R , Nunn , A J , Phillips , P P J , Singh , K P , McHugh , T D , Gillespie , S H & REMoxTB Consortium 2018 , ' Pretreatment chest x-ray severity and its relation to bacterial burden in smear positive pulmonary tuberculosis ' , BMC Medicine , vol. 16 , 73 .
dc.identifier.otherPURE: 253137300
dc.identifier.otherPURE UUID: fb4cd907-8d71-44a8-9946-cac3caaa1a14
dc.identifier.otherRIS: urn:A0B5DBB0745CD73AEE3BE1E5BBBBF5B9
dc.identifier.otherRIS: Murthy2018
dc.identifier.otherScopus: 85047143169
dc.identifier.otherORCID: /0000-0001-6537-7712/work/45160479
dc.identifier.otherWOS: 000433237400001
dc.description.abstractBackground:  Chest radiographs are used for diagnosis and severity assessment in tuberculosis (TB). The extent of disease as determined by smear grade and cavitation as a binary measure can predict 2-month smear results, but little has been done to determine whether radiological severity reflects the bacterial burden at diagnosis. Methods:  Pre-treatment chest x-rays from 1837 participants with smear-positive pulmonary TB enrolled into the REMoxTB trial (Gillespie et al., N Engl J Med 371:1577–87, 2014) were retrospectively reviewed. Two clinicians blinded to clinical details using the Ralph scoring system performed separate readings. An independent reader reviewed discrepant results for quality assessment and cavity presence. Cavitation presence was plotted against time to positivity (TTP) of sputum liquid cultures (MGIT 960). The Wilcoxon rank sum test was performed to calculate the difference in average TTP for these groups. The average lung field affected was compared to log 10 TTP by linear regression. Baseline markers of disease severity and patient characteristics were added in univariable regression analysis against radiological severity and a multivariable regression model was created to explore their relationship. Results:  For 1354 participants, the median TTP was 117 h (4.88 days), being 26 h longer (95% CI 16–30, p < 0.001) in patients without cavitation compared to those with cavitation. The median percentage of lung-field affected was 18.1% (IQR 11.3–28.8%). For every 10-fold increase in TTP, the area of lung field affected decreased by 11.4%. Multivariable models showed that serum albumin decreased significantly as the percentage of lung field area increased in both those with and without cavitation. In addition, BMI and logged TTP had a small but significant effect in those with cavitation and the number of severe TB symptoms in the non-cavitation group also had a small effect, whilst other factors found to be significant on univariable analysis lost this effect in the model. Conclusions:  The radiological severity of disease on chest x-ray prior to treatment in smear positive pulmonary TB patients is weakly associated with the bacterial burden. When compared against other variables at diagnosis, this effect is lost in those without cavitation. Radiological severity does reflect the overall disease severity in smear positive pulmonary TB, but we suggest that clinicians should be cautious in over-interpreting the significance of radiological disease extent at diagnosis.
dc.relation.ispartofBMC Medicineen
dc.rights© The Author(s). 2018. Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.en
dc.subjectPulmonary tuberculosisen
dc.subjectChest x-rayen
dc.subjectRA0421 Public health. Hygiene. Preventive Medicineen
dc.subjectRZ Other systems of medicineen
dc.subjectQR Microbiologyen
dc.subjectSDG 3 - Good Health and Well-beingen
dc.titlePretreatment chest x-ray severity and its relation to bacterial burden in smear positive pulmonary tuberculosisen
dc.typeJournal articleen
dc.description.versionPublisher PDFen
dc.contributor.institutionUniversity of St Andrews. School of Medicineen
dc.contributor.institutionUniversity of St Andrews. Infection and Global Health Divisionen
dc.contributor.institutionUniversity of St Andrews. Global Health Implementation Groupen
dc.contributor.institutionUniversity of St Andrews. Gillespie Groupen
dc.contributor.institutionUniversity of St Andrews. Biomedical Sciences Research Complexen
dc.contributor.institutionUniversity of St Andrews. Infection Groupen
dc.description.statusPeer revieweden

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