Search

TB Is Black, the Grim Harvest of Decades of Complacency. The Greatest Fear Is a Multiple-Drug-Resistant Form Treatable Only Through Quarantine. THE WINTER OF 1820 WAS A BLEAK ONE FOR [...]

Since 1993, WHO has recommended a strategy through which national governments can meet their responsibility to treat patients and to prevent the spread of tuberculosis (TB). Four of the major [...]

A strategy needs to be developed for the treatment of tuberculosis in the US. The incidence of tuberculosis is increasing with more cases of drug-resistant tuberculosis. The HIV epidemic has been partially responsible for the resurgence of tuberculosis in the late 1980s. Other factors associated with this resurgence include homelessness and substance abuse. Directly observed treatment is one treatment strategy that may need to be used more. This strategy involves direct observation of patients taking their medication to ensure patient compliance. Patients are given a daily dose of medication the first two weeks followed by twice-weekly treatment for approximately six months. This program is affordable with a high rate of treatment success. An intermittent regimen involves the administration of drugs three times a week. A direct observation intermittent regime may be an effective treatment strategy especially for patients in large cities.

This section looks back to some ground-breaking contributions to public health, reproducing them in their original form and adding a commentary on their significance from a modern-day perspective. John Sbarbaro reviews the 1991 paper by A. Kochi on WHO's strategy to control tuberculosis. The original paper is reproduced from Tubercle by permission of Churchill Livingstone., An article written by Arata Kochi in 1991 (1) is reproduced on the following pages. In a world experiencing a multiplicity of journals, reports and scientific breakthroughs, the designation "classic" [...]

In its recent analysis of the reemergence of tuberculosis in the United States, the Congressional Office of Technology Assessment (OTA) concluded that the withdrawal of public health resources and the […]

Study Objective: To evaluate the efficacy and toxicity of a 62-dose, four-drug, 6-month, and directly observed regimen for treatment of pulmonary and extrapulmonary tuberculosis.Design: An open, nonblinded clinical trial, with intended follow-up of patients for 36 months after the completion of therapy.Setting: A metropolitan tuberculosis clinic in a public health department.Patients: From March 1981 through April 1989, we enrolled 160 patients with suspected or known tuberculosis; 35 of these patients were excluded from the analysis.Interventions: Isoniazid, rifampin, pyrazinamide, and streptomycin were administered daily for 2 weeks; these drugs were then given in higher doses twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 6 weeks, followed by isoniazid and rifampin twice weekly for 18 weeks. A total of 62 doses were administered, and all therapy was directly observed by a nurse or an outreach worker.Measurements and Main Results: Of the 125 evaluable patients, 101 (81%) had pulmonary tuberculosis, 7 (6%) had both pulmonary and extrapulmonary involvement, and 17 (13%) had extrapulmonary disease only. Seventy-one (57%) patients had a history of recent alcoholism. There were two relapses (1.6% +/- 2.2%), occurring 6 and 56 months after the completion of therapy. The time at which sputum samples became culture negative in pulmonary patients ranged from 1 to 19 weeks (median, 4.6 weeks); 40% +/- 9.6% of patients were culture-negative after 4 weeks of therapy, 75% +/- 8.5% after 8 weeks, 94% +/- 4.7% after 12 weeks, 97% +/- 3.3% after 16 weeks, and 100% after 20 weeks. Adverse drug reactions included hyperuricemia (greater than 178 mumol/L [3 mg/dL] above normal) secondary to pyrazinamide in 80 patients (64%), twofold or greater elevations of aspartate aminotransferase in 21 patients (17%), 1.5-fold or greater elevations of alkaline phosphatase in 33 patients (27%), cutaneous abnormalities in 8 patients (6%), nausea in five patients (4%), and dizziness in 1 patient (1%).Conclusions: This 62-dose, largely twice-weekly tuberculosis treatment regimen is efficacious and relatively nontoxic and is especially useful for patients in whom directly observed therapy is indicated. [ABSTRACT FROM AUTHOR]

Background: Abnormal pulmonary arterial pressure (PAP) responses to exercise have been described in select individuals; however, clinical and prognostic implications of exercise pulmonary hypertension (exPH) among broader samples remains unclear.Objectives: This study sought to investigate the association of exPH with clinical determinants and outcomes.Methods: The authors studied individuals with chronic exertional dyspnea and preserved ejection fraction who underwent cardiopulmonary exercise testing with invasive hemodynamic monitoring. Exercise pulmonary hypertension was ascertained using minute-by-minute PAP and cardiac output (CO) measurements to calculate a PAP/CO slope, and exPH defined as a PAP/CO slope >3 mm Hg/l/min. The primary outcome was cardiovascular (CV) hospitalization or all-cause mortality.Results: Among 714 individuals (age 57 years, 59% women), 296 (41%) had abnormal PAP/CO slopes. Over a mean follow-up of 3.7 ± 2.9 years, there were 208 CV or death events. Individuals with abnormal PAP/CO slope had a 2-fold increased hazard of future CV or death event (multivariable-adjusted hazard ratio: 2.03; 95% confidence interval: 1.48 to 2.78; p < 0.001). The association of abnormal PAP/CO slope with outcomes remained significant after excluding rest PH (n = 146, hazard ratio: 1.75; 95% confidence interval: 1.21 to 2.54; p = 0.003). Both pre- and post-capillary contributions to exPH independently predicted adverse events (p < 0.001 for both).Conclusions: Exercise pulmonary hypertension is independently associated with CV event-free survival among individuals undergoing evaluation of chronic dyspnea. These findings suggest incremental value of exercise hemodynamic assessment to resting measurements alone in characterizing the burden of PH in individuals with dyspnea. Whether PH and PH subtypes unmasked by exercise can be used to guide targeted therapeutic interventions requires further investigation. [ABSTRACT FROM AUTHOR]