[Clinico-statistical notes on a chest x-ray survey made in a school population of several nursery, elementary, intermediate and high schools of Perugia].
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Data Collection↗
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The epidemiology of tuberculosis in Gran Canaria, Canary Islands, 1988-92: effectiveness of control measures.
SETTING: Since there is no national programme for tuberculosis control in Spain and the epidemiological situation in this country is unknown, a programme against tuberculosis in Gran Canaria (Canary Islands) was started in 1987. OBJECTIVE: To analyze the impact of this control programme, particularly the trend of new cases of tuberculosis by age groups and risk factors for 1988-92. DESIGN: A detailed search of all new cases of tuberculosis was carried out by examining the files of all public and private hospitals and outpatient clinics of the island, the records of the Services of Clinical Microbiology and Pathology of the public hospitals, and the registers of patients with AIDS. RESULTS: The annual rates of new cases of tuberculosis per 100,000 were 32.2 in 1988 (214 cases), 26.2 in 1990 (174 cases), and 29.4 in 1992 (196 cases), and the rates of sputum-positive cases 13.3 (89 cases), 12 (80 cases) and 15 (100 cases), respectively. The distribution of tuberculosis cases by age peaked in the age groups 40-49 and 30-39 years. Between 1988 and 1992, statistically significant differences were found in the percentage of cured patients (21% [45/214] vs 85.7% [168/196]), patients with a delay in diagnosis > 3 months (40.2% [86/214] vs 21.9% [43/196]), and contacts evaluated (45.3% [97/214] vs 90.3% [177/196]). However, an upward trend in the incidence of tuberculosis for 1990-92 was found in association with an increase of new cases among the homeless, immigrants, and HIV-infected people. When these three population groups were excluded from the analysis, the annual rate for the total population showed a progressive decline from 1988-92. CONCLUSIONS: The data studied here show that successful priority control measures (cure rate, early diagnosis, study of contacts) have been achieved in this island. It is necessary, however, to develop strategies for combating the tuberculosis problem in specific high risk populations.
Adolescent↗
A comparison of interview data and medical records for previous medical conditions and surgery.
Although interview information is usually the sole source of data in case-control studies, the accuracy of such data is infrequently assessed. We compared interview data on selected medical conditions and surgical procedures with medical records of subjects with chronic lymphocytic leukemia. We examined agreement by type of respondent (self or surrogate), age, sex, race, and type of hospital. The strength of agreement between the two data sources (as measured by kappa statistics) was substantial kappa greater than 0.6) for splenectomy, appendectomy, asthma, and systemic lupus erythematosus; moderate kappa greater than 0.4) for tonsillectomy/adenoidectomy, tuberculosis, diverticulitis, hepatitis, rheumatic fever, and drug allergy; and poor kappa less than 0.3) for chronic bronchitis, chronic sinusitis, psoriasis, rheumatoid arthritis, and most other types of allergy. In general, self respondents had more accurate recall than surrogate respondents. Among self respondents the strength of agreement tended to be greater for males than females, for whites than blacks, and for subjects from referral hospitals than for community hospitals. No consistent patterns were apparent by age. Despite a number of limitations, the findings of the study provide an addition to the scant epidemiologic literature on this topic, and suggest that for certain conditions medical record data collection may be needed to supplement interview information.
Aged↗
The influence of selected herd factors and a badger-intervention tuberculosis-control programme on the risk of a herd-level trade restriction to a bovine population in Ireland.
The risk of a trade restriction to cattle herds between 1990-1994, as a result of failing the tuberculin skin test or disclosure of visible lesions in the abattoir, was compared in two areas in East Offaly, Ireland. Cattle herds from the Project area where badgers were systematically removed over a 7-year period (1989-1995) were compared to herds from a Control area where no wildlife-intervention programme had taken place. A Cox proportional hazard model indicated, for example, that the risk of a herd-level trade restriction to herds with 30 animals in the Control area was 1.4 times the risk to similar-sized herds in the Project area. The study provides evidence that a badger-control programme is effective in reducing the risk of a trade restriction to cattle herds as the badger represents an important reservoir of Mycobacterium bovis infection for cattle.
Animals↗
Killing of macrophage-ingested mycobacteria by rifampicin, pyrazinamide, and pyrazinoic acid alone and in combination.
A study was undertaken with the aim of assessing the killing capacity of rifampicin, pyrazinamide, and pyrazinoic acid on macrophage-ingested, live Mycobacterium tuberculosis. The 3 drugs were used at concentrations corresponding to the average peak levels observed in humans after administration of therapeutic doses that had been found to penetrate into macrophages in a previous study. The degree of killing was studied after exposure of the cell cultures to the individual drugs and their combinations for 3, 18, 24, 48, and 72 h. Comparing the degree of killing in the control, drug-free cultures with that observed in the drug-containing systems, over a period of 3 to 24 h, indicated that in these a greater, more rapid, although not statistically significant, killing of intracellular mycobacteria took place. At 48 h the degree of killing was similar in the control and in the drug-containing cell cultures. Between 48 and 72 h, however, a marked growth of intracellular mycobacteria was observed in the control cultures. This phenomenon was much less evident in the drug-containing cultures. No major increase in the killing effect with respect to that observed with the individual drugs was found after exposure of the macrophages to all possible combinations of the 3 drugs.
Animals↗
Demographic changes in tuberculosis: high risk groups.
We conducted a statistical analysis of all verifiable tuberculosis (TB) cases in Tennessee from 1990 through 1996 to determine the demographic changes in TB. We studied variables, including age, sex, race, site of the disease, and possible impact of known risk factors such as human immunodeficiency virus (HIV) infection, homelessness, foreign birth, and residency in extended care facility. The percentage increase in all such categories, except in the nursing home population, had a statistically significant increase. Unlike national epidemiologic findings, foreign-born TB comprised less than 1% of the total cases. Association of HIV as a co-infection increased from 16 (2.7%) in 1990 to 41 (8.1%) in 1996. These findings will have significant impact on TB control measures and the clinical practice of TB cases in Tennessee and other areas of the southeastern US.
Acquired Immunodeficiency Syndrome↗
Circulating tuberculostearic acid in tuberculosis patients.
Tuberculostearic acid (TBSA), a mycobacterial cell wall constituent, was measured in plasma samples using a highly sensitive high-performance liquid chromatography method. Plasma TBSA concentrations in patients with active tuberculosis (20 [0.5-347] nmol/l; n = 125) were higher than in patients with a variety of non-tuberculous pulmonary and extrapulmonary inflammatory conditions (0.1 [0-29] nmol/l; n = 116) and in healthy controls (0 [0-2] nmol/l; n = 102) (p = < 0.001). The calculated sensitivity, specificity, positive and negative predictive values for tuberculosis were 95.2%, 87.9%, 89.5% and 94.4%, respectively, indicating that assay of plasma TBSA might be a valuable complementary diagnostic tool.
Adolescent↗
Antibodies against mycobacterial antigens in the synovial fluid of patients with temporomandibular disorders.
In the absence of active pulmonary disease, mycobacterial infection frequently causes arthritis and can be considered to initiate autoimmune diseases such as rheumatoid arthritis. Temporomandibular disorder (TMD) is a disease in which pain and impaired mandibular movement appear to arise directly from degenerative or inflammatory changes within the temporomandibular joint, but its precise pathogeny has not been elucidated. Here we examined whether mycobacterial infection is related to the pathology of TMD. The antibody levels against mycobacterial antigen in the synovial fluid (SF) of patients with TMD were assessed by enzyme-linked immunosorbent assay (ELISA). Six of 17 TMD patients (35%) were found to possess mycobacterial antigen-specific immunoglobulin (Ig) G but not IgM, while the six healthy volunteers possessed neither. Western-blot analysis was used to isolate the reacted antigen, and the IgG reacted strongly to 44-kDa antigen. The first 14 N-terminal amino acid sequences were determined, and computer analysis revealed that it was homologous to translational elongation factor Tu (EF-Tu) of Mycobacterium tuberculosis, which was a major target antigen for these antibodies. The 44-kDa protein of Mycobacterium bovis BCG (BCG) was identical with the EF-Tu of M. tuberculosis. We cloned the gene encoding the EF-Tu of BCG by using the synthesized oligonucleotide primers by means of polymerase chain-reaction. The gene was expressed in Escherichia coli. The protein was purified, and the antibody levels against this recombinant protein in the SF of TMD patients were assessed by ELISA. Our findings suggest that some cases of TMD are concerned with the synovial IgG against the EF-Tu of M. tuberculosis, and that the existence of the antibody is a clinical indication of TMD.
Adolescent↗
[Lipid peroxidation -- antioxidants -- proteinase inhibitors in osteoarticular tuberculosis].
The multidimensional statistical analysis was used to thoroughly study the status of lipid peroxidation, the antioxidative system and proteolytic inhibitors in 22 patients with an active and 26 with a metatuberculous deforming osteoarticular process. In both cases, enhanced lipid peroxidation is followed by various changes in the systems of endogenous antioxidants and inhibitors of proteolysis. Imbalance of these systems in the active process, unlike the deforming osteoarticular one, requires a differential approach when proteolytic antioxidants and inhibitors are used.
Antioxidants↗
Inactive hepatitis B surface antigen carrier state and hepatotoxicity during antituberculosis chemotherapy.
STUDY OBJECTIVES: To determine whether inactive hepatitis B surface antigen (HBsAg) carriers are at a higher risk of drug-induced hepatotoxicity than control subjects during antituberculosis treatment with standard short-course regimens of isoniazid, rifampin, ethambutol, and/or pyrazinamide. DESIGN: Retrospective case-control study. SETTING: Tertiary university medical center. PATIENTS: One hundred ten inactive HBsAg carriers with newly diagnosed active tuberculosis who had been treated with isoniazid, rifampin, ethambutol, and/or pyrazinamide were included in the study population. Inactive HBsAg carriers were defined as follows: (1) positive for HbsAg; (2) negative for hepatitis B e antigen (HBeAg), positive for antibody to HBeAg; (3) < 10(5) copies per mL of serum hepatitis B virus DNA; and (4) normal pretreatment aspartate aminotransferase (AST)/alanine aminotransferase (ALT) levels. Ninety-seven HBsAg-negative patients who received standard antituberculosis medication were selected as control subjects. RESULTS: The baseline characteristics of the 110 inactive HBsAg carriers were similar to those of the 97 noncarriers. A total of 85% of persons in both groups had received an initial treatment regimen that included pyrazinamide. Thirty-eight inactive HBsAg carriers (35%) and 19 control subjects (20%) exhibited elevated liver enzyme levels during antituberculosis treatment (p = 0.016). Drug-induced hepatotoxicity, which was defined as a liver transaminase level of >/= 120 IU/L, occurred more frequently in HBsAg carriers (9 of 110 carriers; 8%) than in control subjects (4 of 97 control subjects; 4%), although this was not a statistically significant discrepancy (p = 0.230). More importantly, HBsAg carriers (n = 9; 8%) who received antituberculosis therapy evidenced a higher proportion of moderate-to-severe drug-induced hepatotoxicity when compared with the control subjects (n = 2; 2%; p = 0.05). Isoniazid and rifampin were reintroduced as therapy after AST/ALT levels returned to baseline values in 10 patients (6 HBsAg carriers and 4 control subjects) among the 13 patients exhibiting drug-induced hepatotoxicity, and these retrials proved to be successful in 7 patients (5 HBsAg carriers and 2 control subjects). CONCLUSIONS: Tuberculosis treatment in HBsAg-positive and HBeAg-negative inactive carriers could be pursued in the usual manner, using standard short-course regimens of isoniazid, rifampin, ethambutol, and/or pyrazinamide, with the condition that monthly liver function tests are performed.
Adult↗
Diazepam interaction with antituberculosis drugs.
The influence of antituberculosis drugs on diazepam disposition was assessed in a series of volunteers and patients who received single intravenous doses of diazepam. In study 1, nine healthy subjects received diazepam in the drug-free control state and again during treatment with isoniazid (INH), 180 mg/day. INH did not alter diazepam volume of distribution (Vd) or protein binding, but prolonged mean elimination half-life (t1/2) from 34 to 45 hr (p less than 0.02), and reduced total clearance from 0.54 to 0.40 ml/min/kg (p less than 0.02). In study 2, diazepam disposition in a group of seven tuberculous patients on triple therapy with INH, ethambutol (EMB), and rifampin (RIF) was compared with that in healty drug-free controls matched for age and sex. Diazepam Vd and protein binding were nearly identical between groups, but mean t1/2 among patients (14 hr) was significantly shorter than in controls (58 hr, p less than 0.01) and total clearance correspondingly increased (to 1.50 from 0.37 ml/min/kg, p less than 0.01). Study 3 compared six newly diagnoses tuberculous patients receiving initial therapy with EMB alone with age- and sex-matched controls. Diazepam unbound fraction in patients tended to be higher than in controls, and diazepam Vd and clearance tended to be lower but the differences were not statistically significant. Thus, diazepam clearance is impaired and t1/2 prolonged by administration of INH alone. Markedly increased clearance and shortened t1/2 in triple-therapy patients is probably due to enzyme-inducing effects of RIF. Dosage of diazepam may require adjustment in patients with tuberculosis on chemotherapy.
Adult↗
Detection of serum antibodies in tuberculosis patients.
Sera of 14 bacteriological confirmed pulmonary tuberculosis and 16 non-tuberculotic or healthy controls were sampled in Ignace Deen University Hospital in Conakry, Quinea. Samples were examined for IgG and IgM antibodies by means of enzyme-linked immunosorbent assay (ELISA) using sonicated M. bovis BCG and M. avium antigens and were tested for antibodies to HIV-1/HIV-2 as well. Median of IgG antibody titres to M. bovis BCG antigen was 1:445 and differed significantly from that of the control group (1:149). The median of IgM antibody titres was 1:79.1 and did not differ statistically from that of control group (1:69.3) as well as the antibody titres against M. avium antigen in the IgG and IgM classes for both analyzed serum groups. Seven of tested TB patients sera were positive for antibodies against HIV-1. The median of IgG antibody titres against M. bovis BCG antigen was 1:442 not differing significantly from values of remaining TB patients as well as the IgM antibody titre (1:109).
Adult↗
Treatment of pulmonary tuberculosis with short course chemotherapy in south India--5-year follow up.
A controlled clinical trial of three short-course chemotherapy regimens was undertaken in patients with newly diagnosed bacteriologically positive pulmonary tuberculosis. The patients were randomly allocated to receive one of three regimens: rifampicin, streptomycin, isoniazid and pyrazinamide daily for 2 months, followed by streptomycin, isoniazid and pyrazinamide twice weekly for 3 months (R/5) or for 5 months (R/7), or the same regimen as R/7 but without rifampicin (Z/7). A bacteriological relapse requiring retreatment occurred by 5 years in 7.1% of 126 R/5, 4.0% of 124 R/7 and 6.7% of 253 Z/7 patients with organisms initially sensitive to streptomycin and isoniazid; none of these differences is statistically significant. Of the 31 relapses, 16 occurred within 2 years of the completion of chemotherapy and the remaining 15 between 2 and 5 years. Among 65 patients with initial drug resistance to streptomycin or isoniazid or both, there were six bacteriological relapses requiring retreatment.
Adolescent↗
Rifampicin bioavailability: a review of its pharmacology and the chemotherapeutic necessity for ensuring optimal absorption.
The World Health Organization encourages the use of fixed dose combinations (FDCs) of rifampicin (RMP) and isoniazid together with pyrazinamide or pyrazinamide plus ethambutol for the treatment of tuberculosis. The main advantages of such FDCs are the simplification of procurement and prescribing practices and the protection they afford against the potential selection of RMP-resistant strains of Mycobacterium tuberculosis. There is convincing evidence, however, that the rifampicin absorption from FDCs manufactured under suboptimal conditions may be significantly impaired, and this appears to be especially problematic with combined formulations of rifampicin, isoniazid and pyrazinamide. In view of the marked dose-dependence of rifampicin's bacterial sterilizing action, it is therefore essential that tuberculosis control programmes only use rifampicin-containing FDCs with proven rifampicin bioavailability. The comprehensive literature on the pharmacology of rifampicin is reviewed, together with the methods employed for determining it and its most important metabolite, desacetyl-rifampicin, in either serum or urine. By contrast, published information concerning the absorption of rifampicin from currently marketed combined formulations and on laboratory methods for precisely assessing their bioavailability is very sparse. There is therefore a crucial need to establish the quality of currently marketed rifampicin-containing FDCs in studies using adequate numbers of volunteers, precise analytical techniques and sophisticated statistical techniques.
Absorption↗
Evaluation of the ICT Tuberculosis test for the routine diagnosis of tuberculosis.
BACKGROUND: Rapid and accurate diagnosis of tuberculosis (TB) is crucial to facilitate early treatment of infectious cases and thus to reduce its spread. To improve the diagnosis of TB, more rapid diagnostic techniques such as antibody detection methods including enzyme-linked immunosorbent assay (ELISA)-based serological tests and immunochromatographic methods were developed. This study was designed to evaluate the validity of an immunochromatographic assay, ICT Tuberculosis test for the serologic diagnosis of TB in Antalya, Turkey. METHODS: Sera from 72 patients with active pulmonary (53 smear-positive and 19 smear-negative cases) and eight extrapulmonary (6 smear-positive and 2 smear-negative cases) TB, and 54 controls from different outpatient clinics with similar demographic characteristics as patients were tested by ICT Tuberculosis test. RESULTS: The sensitivity, specificity, and negative predictive value of the ICT Tuberculosis test for pulmonary TB were 33.3%, 100%, and 52.9%, respectively. Smear-positive pulmonary TB patients showed a higher positivity rate for antibodies than smear-negative patients, but the difference was not statistically significant. Of the eight patients with extrapulmonary TB, antibody was detected in four patients. CONCLUSION: Our results suggest that ICT Tuberculosis test can be used to aid TB diagnosis in smear-positive patients until the culture results are available.
Adolescent↗
Identifying early treatment failure on category I therapy for pulmonary tuberculosis in Lima Ciudad, Peru.
SETTING: Ambulatory, public tuberculosis treatment facilities, central Lima, Peru. OBJECTIVE: To identify risk factors for failure on directly observed Category I therapy. DESIGN: Case-control study. All failures of Category I (2HREZ/4H2R2) therapy in 2000 (2.9% of smear-positive TB patients) were included as cases; two controls per case were matched on health center and approximate time of treatment initiation. RESULTS: The study included 38 cases and 76 controls, all new smear-positive, pulmonary TB patients treated with Category I therapy in central Lima in 2000. Neither treatment irregularity nor incidence of adverse events predicted failure in the study group. Mean baseline body mass index was lower in cases than in controls (P = 0.06). Cases gained less weight during therapy (P = 0.01). Smear positivity at 2 months of therapy was strongly associated with failure (OR 11.7; 95%CI 2.4-57.5). No controls had positive smears at or after 3 months of therapy (OR [corrected] 144.9; 95%CI 8.4-2500). Nearly 75% of cases with isolates tested for susceptibility to first-line drugs had multidrug-resistant TB (MDR-TB). CONCLUSION: A large proportion of failures on Category I therapy can be identified early. As three-quarters of patients with susceptibility results have MDR-TB, early referral for culture and drug susceptibility testing is critical for prompt initiation of appropriate therapy and improved outcomes.
Adolescent↗
[BCG vaccines for the prevention of tuberculosis in the world].
The BCG vaccines will celebrate the 100th anniversary of their discovery in a decade at the beginning of the next century since Albert Calmette and Camille Guerin had presented it before the Academie des Sciences in 1908. At present tuberculosis kills more people than any other infectious disease about 3 million people a year, including almost 300,000 children under 15, and is producing over 7,000 deaths and over 24,000 new cases every day. Therefore, WHO declared a global health emergency in 1993. More worse, recently multi-drug resistant tubercle bacilli are emerging rapidly making TB patients incurable. Under these situations we need a potent anti-tuberculosis vaccine. So first of all, we must check the century-old BCG before proceeding further. At moment, the BCG vaccines are being used worldwide in the largest quantities in the world, but still most controversial vaccines anywhere. I would like to describe here their success and failure in the combat against the white plague. 1. The Expanded Programme on Immunization (EPI). In 1974, when the EPI was launched by WHO, less than 5% of the world children were immunized against six infectious diseases including tuberculosis. In 1995 statistics, BCG gave the highest vaccination coverage, 87% higher than any other 5 vaccines of EPI for children. The BCG in EPI must have saved a lot of infants as the vaccine, has been proved to be most effective against the blood-born tuberculosis of child type. 2. The efficacy of BCG vaccination against tuberculosis. Results of each 10 of randomized controlled trials (RCT) and Case-control studies (CCS) showed the protective efficacy against tuberculosis as uncertain, unpredictable, as protective efficacy varied from 80% to 0%. More recently, a Meta-analysis of selected papers on BCG field trials which were so far collected. They recalculated vaccine protective effect separately for pulmonary TB and for meningeal/miliary TB in the trials. As the result, it was found that protective effect against pulmonary TB could not be calculated, but protective effect against meningeal and miliary TB was calculated as 86%, 75% respectively, in RCT and CCS, being higher than against pulmonary TB. 3. The duration of BCG efficacy against tuberculosis was confirmed to continue for 15 years after vaccination. The incidence of every form of tuberculosis decreased steeply during the 15 years following vaccination. 4. BCG revaccination. A WHO statement was issued in 1995 mentioning that there is no definitive evidence that repeated BCG vaccination confers additional protection against tuberculosis. Therefore WHO has not recommended to repeat BCG vaccination because of no scientific evidence to support this practice. Multiple BCG revaccinations are not indicated in any persons. 5. Complications with BCG Second IUATLD study (1988) on complications induced by BCG was reviewed, especially following two points: 1-2) Regional suppurative lymphadenitis 3) Generalized lesions: fatal cases 1-2 Several African regions had experienced that the risk of outbreak of suppurative BCG lymphadenitis was low for vaccines with Glaxo and Japanese strains, but much higher for vaccines with Pasteur. This experience in nineteen eighties has led EPI to replace the Pasteur BCG vaccine with less reactogenic BCG, Japanese or Glaxo BCG to solve the outbreak of suppurative adenitis complication. 3 At moment, the only contra-indication of EPI BCG vaccination is symptomatic HIV infection (AIDS), but in the future asymptomatic HIV infection should be placed on alert, because fatal BCG generalized disseminations have already been experienced by HIV positive vaccinees although in a few cases in USA. 6. BCG seed lots for use of vaccination in the world. Nearly 10 seed lots (BCG) are being used in the world at present. However, they are more or less different each other in various characteristics: morphological, biochemical, biophysical, immunological, vaccinological and so on. None of them is the same
BCG Vaccine↗
Tuberculous lesions of the lumbosacral region. A 15-year follow-up of patients treated by ambulant chemotherapy.
STUDY DESIGN: A 15-year clinical follow-up of tuberculous lesions of the lumbosacral region. OBJECTIVES: To verify the hypothesis that the lumbar lordosis and the specific biomechanics of the lumbosacral region influence and alter the healing pattern and progress of the disease when compared with their effects in other regions of the spine. SUMMARY OF BACKGROUND DATA: An estimated 2 million or more patients have active spinal tuberculosis, and the global incidence of the disease is increasing. The involvement of the lower lumbar region and the lumbosacral junction is relatively rare, with few reports in English literature. METHODS: Of a total of 304 patients forming a part of a controlled clinical trial comparing two forms of therapy in spinal tuberculosis, 53 patients had involvement of L3 and below. The following data were studied in these patients: age at start of treatment, number of vertebra involved, vertebral body loss, progress of the angle of kyphosis, and anterior and posterior growth of the involved segment during a period of 15 years. Student's t test for independent samples was used for statistical analysis. RESULTS: The fourth lumbar vertebra was the most common vertebral segment involved, and the lumbosacral junction was affected in 12 patients. The average pretreatment kyphosis was 6.4 degrees and increased to 10.2 degrees at the end of 15 years. The average kyphotio angle per vertebral body loss was 4.9 degrees, far less than in the dorsolumbar region in which kyphotic angles of 27-30 degrees have been reported. Children younger than 10 years old differed in clinical appearance and progress compared with those older than 17 years. They not only showed more extensive involvement but also had more deformity with the same vertebral loss. Twelve patients less than 10 years old had an average involvement of 3.1 vertebral bodies and an average vertebral loss of 2.2 bodies. In comparison, the average number of vertebrae involved was 1.9 (P < 0.01) and the vertebral body loss was only 0.87 (P < 0.01) in patients older than 17 years. Also, the average kyphosis was 6.4 degrees compared with only 4.2 degrees (P < 0.01) in adults. In patients older than 17 years, there was no change after 2 years, by which time the collapse was complete. Four of 12 patients less than 10 years old, showed progressive kyphosis caused by continued growth of posterior parts of the body (i.e., sequestrated hemivertebrae). CONCLUSIONS: In tuberculosis of the lumbosacral region, the development of kyphosis is minimal in patients older than 17 years, when growth has already stopped, and deformity is expressed more as foreshortening of the trunk. Children younger than 10 years old have more severe involvement with increased tendency toward greater kyphosis. They are also prone to progressive deformity through the years when the anterior growth plates are destroyed. Surgery is indicated in this group to prevent greater deformity.
Adolescent↗