Search

Study objectives: To describe the epidemiology and clinical consequences of noncompliance with directly observed therapy (DOT) for treatment of tuberculosis. Design: Retrospective review. Setting: An urban tuberculosis control program that emphasizes DOT. Patients: All patients treated with outpatient DOT from 1984 to 1994. Measurements and results: We defined noncompliance as follows: (1) missing [is greater than or equal to] 2 consecutive weeks of DOT; (2) prolongation of treatment [is greater than] 30 days due to sporadic missed doses; or (3) incarceration for presenting a threat to public health. Poor outcomes of therapy were defined as a microbiologic or clinical failure of initial therapy, relapse, or death due to tuberculosis. Fifty-two of 294 patients (18%) who received outpatient DOT fulfilled one or more criteria for noncompliance. Using multivariate logistic regression, risk factors for noncompliance were alcohol abuse (odds ratio, 3.0; 95% confidence interval, 1.2 to 7.5; p=0.02) and homelessness (odds ratio, 3.2; 95% confidence interval, 1.5 to 7.2; p=0.004). Noncompliant patients had poor outcomes from the initial course of therapy more often than compliant patients: 17 of 52 (32.7%) vs 8 of 242 (3.3%); relative risk was 9.9; 95% confidence interval was 4.5 to 21.7 (p [is less than] 0.001). Conclusions: In an urban tuberculosis control program, noncompliance with DOT was common and was closely associated with alcoholism and homelessness. Noncompliance was associated with a 10-fold increase in the occurrence of poor outcomes from treatment and accounted for most treatment failures. Innovative programs are needed to deal with alcoholism and homelessness in patients with tuberculosis. (CHEST 1997, 111:1168-73) Key words adherence; alcoholism; directly observed therapy; homelessness; noncompliance; tuberculosis Abbreviations: DOT = directly observed therapy, Noncompliance with self-administered multidrug tuberculosis treatment regimens is common and is the most important cause of failure of initial therapy and relapse.[1-6] Noncompliance may also result in acquired drug resistance,[6] [...]

PURPOSE: This study was designed to evaluate the immunogenicity of the 23-valent pneumococcal polysaccharide vaccine in Alaska Native chronic alcoholics and compare these responses with those in age- and sex-matched nonalcoholic, Native and non-Native control subjects. PATIENTS AND METHODS: Native alcoholic patients were recruited from the inpatient medical service and outpatient clinics. Healthy age- and sex-matched Alaska Native and non-Native non-alcoholics were recruited from hospital employees. At the initial visit, a standardized questionnaire, the Alcohol Dependency Scale, was administered to all participants. Participants were examined for liver disease; blood was drawn for liver function tests and prevaccination pneumococcal antibody levels. Charts of all Native participants were reviewed for alcohol-related disease. Participants received one dose of the 23-valent pneumococcal vaccine at the time of the initial visit and returned 20 to 55 days after immunization for liver function tests and pneumococcal antibody level measurement. Serotype-specific pneumococcal antibody levels were measured by radioimmunoassay. Logistic regression analysis was used to examine the proportion of persons whose serotype-specific antibody level doubled following vaccination. A model including adjustments for age, sex, and initial antibody level was used to examine the effect of alcohol status and ethnicity on response to the vaccine. Eighty-rive persons completed the study. Of these, 41 were chronic alcoholics and 44 were nonalcoholic. Of these, 21 were Alaska Natives and 23 were non-natives. RESULTS: Before vaccination, the geometric mean titers (GMTs) were similar in all 3 groups but were slightly higher in Native alcoholic participants for 11 of 12 serotypes tested. For 11 or more serotypes tested, 46% of alcoholics and 27% of nonalcoholics had total antibody levels at or above 500 nanograms of antibody nitrogen per milliliter (p = 0.11). After vaccination, the GMTs were higher in nonalcoholic than in alcoholic participants for serotypes 3, 7F, and 19F (p

Preclinical alcoholic cardiomyopathy, myocardial damage in the absence of overt congestive heart failure in chronic alcoholics, is well characterized at necropsy, but attempts to identify such a clinical entity before death have produced conflicting results. dying subjects only at rest, the inclusion of older alcoholics and limitations of noninvasive techniques may explain some of the disagreement. To determine if preclinical alcoholic cardiomyopathy could be identified independent of the aforementioned limitations, 2S asymptomatic chronic alcoholics aged S days per week for >S years, underwent radionuclide ventriculography for measurements of systolic and diastolic function at rest, peak supine exercise and during recovery, and echocardiography for assessment of chamber size, wall thickness and left ventricular mass. Red blood cell levels of selenium and thiamine were measured to determine whether abnormalities were present in these 2 potential mediators of alcoholic cardiomyopathy. For comparison, an age-matched group of healthy control subjects was also studied. For alcoholics and control subjects at rest, mean ejection fraction (67 +/- 7% vs 71 +/- 6%) and diastolic peak filling rate (3.4 +/- 0.6 vs 3.3 +/- 0.6 end-diastolc volumes per second [EDV/s]) were similar. At peak exercise, the mean ejection fraction 83 +/- 6 vs 82 4- 10), change in ejection fraction (14 /- 10 vs 14 7) and peak fining rate (8.9 +/- 2.0 vs 9.S +/- 1.9 EDV/s) were also similar, but election fraction failed to increase appropriately in 3 alcoholics (120/o), suggesting possible stress-induced myocardial dysfunction. Left ventricular chamber size, fractional shortening, wall thickness and ventricular mass by echocardiography were similar in the alcoholic and control groups, as were red blood cell levels of selenium and thiamine. Repeat studies aftor 4 weeks of abstinence from alcohol showed persistence of the exemise-induced abnormal response in 2 of the 3 alcoholics. These data suggest that the occurrence of preclinical cardiomyopathy in young, asymptomatic chronic alcoholics is rare and may require exercise stress testing to be detected. (Am J Cardiol 1991;67:183-187), Chronic alcoholism can result in heart disease and the appearance of clinical symptoms of congestive heart failure (weakness, breathlessness, abdominal discomfort, and pooling of blood in the extremities). This has been attributed to both a direct toxic effect of alcohol on the heart and the detrimental effect that chronic alcohol abuse has on nutritional status. The effects of alcoholism on the heart have been well documented at autopsy, but attempts to characterize the effects of excessive alcohol consumption on the heart before death have yielded conflicting results. To determine the effects of alcoholism on cardiovascular function in younger, relatively healthy alcoholics, 25 men under the age of 40 (average age 34 years) who had consumed one pint of whiskey or one six-pack of beer daily for at least five years were assessed. An age-matched group of nonalcoholic subjects served as a control group. On virtually all cardiovascular parameters measured (resting and exercise mean ejection fraction, diastolic peak filling rate, end-diastolic volumes per second, left ventricular size, wall thickness and mass, and red blood cell selenium and thiamine levels), there were no differences between alcoholics and control subjects. In three alcoholic subjects, exercise failed to induce an appropriate increase in ejection fraction (the percentage of blood ejected from the ventricle during maximal contraction of the heart), suggesting a possible dysfunction in these subjects. After four weeks of abstinence from alcohol, this deficit was still present in two of the three subjects. Hence, the occurrence of alcohol-induced cardiomyopathy in young alcoholics is quite rare, and may require exercise testing to be detected. (Consumer Summary produced by Reliance Medical Information, Inc.)