Self injection of organophosphorous insecticide.
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Adolescent↗
Biomedical subjects
A K Dutt
Publications and source records attributed to A K Dutt.
Tuberculosis. Part I.
Tuberculosis has been a disease of human beings for thousands of years. In recent times it has waxed to become the feared White Plague of the eighteenth and nineteenth centuries and waned under the impact of effective chemotherapy until its elimination seemed possible by the early twenty-first century. The resurgence of tuberculosis in the past 10 to 15 years, caused by unanticipated events such as the appearance of the human immunodeficiency virus and deteriorating social conditions, also brought with it the problem of multiple drug resistance. Control measures such as tuberculin skin testing, perhaps somewhat forgotten when tuberculosis seemed to be a disease of the past, again became first-line defenses against spread of the disease. Environmental controls must be well understood and used effectively. Diagnosis of tuberculosis requires knowledge of the strengths and shortcomings of the various diagnostic methods and experience in their use. Practitioners are cautioned to remember that no diagnostic method, by itself, can be relied on to confirm or rule out tuberculosis. Well-tested diagnostic methods of chest radiograph, tuberculin skin testing, smear, and culture have been recently supplemented by rapid diagnostic tests based on amplification of bacterial RNA and DNA. More invasive diagnostic methods are sometimes required to diagnose extrapulmonary disease. Two-drug up to seven-drug therapy may be indicated for a case of tuberculosis, depending on evidence of the presence of multiple drug resistance. Duration of treatment can range from 6 to 12 months, also depending on identification of drug-sensitive or drug-resistant organisms. Failure of compliance can be a significant problem in patients who are homeless, or drug abusers, or who for various reasons cannot or will not complete a course of therapy. Directly observed therapy is strongly recommended for these patients, and for assistance in its administration the physician must cooperate with the local or state health department. The health department also must be notified whenever a case of tuberculosis is identified.
AIDS-Related Opportunistic Infections↗
Tuberculosis. Part II.
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Antitubercular Agents↗
Fixed-dose combinations of antituberculous medications to prevent drug resistance.
The treatment of tuberculosis requires at least two drugs to retard the development of drug resistance. Unfortunately, patients may take only one drug (monotherapy) when more than one is prescribed. Fixed-dose combinations with two or more antituberculous drugs in one capsule or tablet are available to prevent this. In the United States, these drugs are Rifamate (Marion Merrell Dow), which contains isoniazid plus rifampin, and Rifater (Marion Merrell Dow), which contains isoniazid plus rifampin and pyrazinamide. Because these preparations make monotherapy impossible, they are clearly preferable to individual drugs. In the United States in 1993, however, only 15% to 18% of rifampin was sold in the form of fixed-dose combinations. To correct this deficiency, fixed-dose combinations should be widely promoted and accepted as a primary way to prevent drug-resistant tuberculosis. There are two caveats regarding these preparations. First, many fixed-dose combinations, especially those in developing countries, achieve inadequate blood levels of one or more of the component drugs, especially rifampin. Our recommendations apply only to preparations with proven bioavailability. Second, because the name Rifamate is similar to the name rifampin, mistakes in prescribing and dispensing can result in the patient receiving rifampin alone when Rifamate is intended. A name change from Rifamate to a highly distinctive name such as Rif-Isoniazid is needed to prevent such occurrences.
Antitubercular Agents↗
Outbreak of tuberculosis in a church.
A 48-year-old white man (index case) with an abnormal chest radiograph remained undiagnosed for tuberculosis for 4 years. Investigation by purified protein derivative (PPD) tuberculin test revealed positive tuberculin reactions (> or = 10 mm induration) in seven of eight (88%) initial close contacts, and in 12 of 46 (26%) coworkers. On the suspicion that transmission had also occurred among members of the index case's church congregation, a PPD tuberculin test survey of 184 of 200 of the members revealed 77 (42%) positive reactors. Thirty percent of the members under the age of 35 years were infected, suggesting transmission of infection. Eight cases of active tuberculosis (including the index case) were detected, yielding a high case rate (4.3%) among the parishioners. Three of the cases were confirmed recent PPD converters. Although bacteriologic findings were available in only three of the eight cases, two cases had phage typing of organism identical to the index case; the third had recrudescent tuberculous disease. Of the remaining five cases without bacteriologic confirmation, two had pleural tuberculosis, one child had progressive primary tuberculosis, and two persons had localized pulmonary nodules suggestive of primary infection progressing to disease. Because transmission of tuberculous infection may occur in any closed environment, including a church, physicians must be conversant with tuberculosis control measures and preventive therapy guidelines to preclude unforeseen transmission of disease.
Adult↗
Smear-negative pulmonary tuberculosis.
Diagnostic difficulties arise when sputum smears are negative for acid-fast bacilli in tuberculin-positive patients with compatible symptoms and chest radiographs for tuberculosis. Many of these smear-negative patients yield positive cultures for M tuberculosis, whereas others remain culturally negative. Several studies have shown that many smear-negative/culture-negative patients will develop bacteriologically positive disease later. Often, physicians are unable to decide whether to initiate chemotherapy or to wait for the culture results. Also, if treatment is initiated in smear negative patients, what should be the drug regimen and duration of therapy. A positive smear signifies a very large bacterial population in the lung lesions whereas several negative smears suggest a smaller bacterial load. Such smear-negative cases do not require the same intensity and duration of treatment as smear-positive cases. Therapy should be initiated for tuberculosis after other causes for abnormal chest x-ray have been excluded. However, duration of therapy may be shortened in these cases. The British Medical Research Council (BMRC) study has shown that intensive treatment of smear-negative/culture-positive disease with streptomycin (SM), isoniazid (INH), rifampin (RIF), and pyrazinamide (PZA) for 4 months was uniformly successful. This regimen is routinely recommended in Hong Kong. Because primary drug resistance is low (< 3%) in Arkansas, we treated these cases with INH and RIF for 6 months with good results. This is now a routine drug regimen. For smear-negative/culture-negative cases, the BMRC study has shown that daily or thrice weekly treatment with SM, INH, RIF, and PZA for 4 months is effective.(ABSTRACT TRUNCATED AT 250 WORDS)
Antitubercular Agents↗
Tuberculin skin testing: present status.
The incidence of tuberculosis is on the rise, with a reported 18% increase between 1985 and 1992. There is every reason to think that this trend will continue in the 1990s. Expectedly, there is a renewed interest in early detection and prevention of this potentially life threatening disease. Tuberculin skin testing remains a valuable diagnostic tool for the detection, control, and elimination of tuberculosis. It involves the intracutaneous injection of culture extracts of tubercle bacilli as a classic example of delayed hypersensitivity reaction. Despite proper technique and interpretation of the test, its usefulness is limited by cross-reaction caused by other mycobacterial antigens. False-negative reaction is a common confounding problem. It is therefore important to interpret the test based on the overall clinical context of the individual being tested. This article aims to review the basic immunology, proper technique, interpretation, and indication for the test.
Aged↗
Rank-size distribution and primate city characteristics in India--a temporal analysis.
"This paper is an analysis of the historical change in city size distribution in India....Rank-size distribution at national level and primate city-size distribution at regional levels are examined....The paper also examines, in the Indian context, the relation between rank-size distribution and an integrated urban system, and the normative nature of the latter as a spatial organization of human society. Finally, we have made a modest attempt to locate the research on city-size distribution...."
Asia↗
Tuberculosis in the elderly.
Elderly persons of today are survivors of a time when most adults were infected with tuberculosis. Although many people died at that time, others survived the initial infection but continued to harbor viable bacilli in dormant caseous and calcified lesions. This article discusses the tuberculin test in the elderly, transmission and risk of infection in nursing homes, clinical manifestations, diagnosis, management considerations, preventive therapy, and surveillance of tuberculosis in nursing homes.
Aged↗
Tuberculous pleural effusion: 6-month therapy with isoniazid and rifampin.
We have shown that 6-month therapy with isoniazid (INH) and rifampin (RIF) is adequate for pulmonary tuberculosis when tubercle bacilli are less numerous, i.e., smear negative, culture positive. Tuberculous exudative pleural effusion contains small bacterial populations, as often demonstrated by negative smears and fewer positive cultures. Therefore, in 1980, we started treating tuberculous pleural effusion with a therapy protocol consisting of INH 300 mg plus RIF 600 mg daily for 1 month, followed by INH 900 mg plus RIF 600 mg twice weekly for another 5 months (total, 6 months). From January 1980 to September 1990, 198 patients with an average age of 62.6 years were treated in this manner. Associated pulmonary infiltration was present in 92 patients, of whom 50% yielded positive sputum cultures. Other medical conditions as "risk factors" were present in 30%. Therapy was not completed in 36 patients because of death, relocation, noncompliance, and drug side effects. Treatment failed during therapy in only 1 patient. Side effects of the drugs occurred in 13 (6.6%) patients, but major side effects were encountered in only three (1.5%), two with toxic hepatitis and one with thrombocytopenia. The full 6-month therapy was completed by 161 patients. During follow-up from 2 to 133 months (median, 46 months), none of the 161 patients had relapse. An overall success rate of 99% was achieved in 162 patients with only 1 failure during therapy. Thus, 6-month therapy with INH plus RIF is adequate in tuberculous exudative pleural effusion, even when associated with smear-negative (3 specimens) culture-positive pulmonary tuberculosis.
Arkansas↗
Tuberculosis.
In the United States, the incidence of tuberculosis (TB) is higher in elderly persons than in any other segment of the population, except in HIV-infected persons. The diagnosis of TB, however, is all too often not considered in geriatric patients. Although elderly nursing home residents are at a greater risk for TB than the aging population in the community setting, the majority (80%) of active TB cases in elderly persons occur in community dwellers. The diagnosis, treatment, and prevention of TB are reviewed in this article.
Age Factors↗
Tuberculosis in elderly persons.
As tuberculosis has been controlled in the western world, it has retreated into enclaves. The largest of these is among persons who are now over age 65, many of whom carry tubercle bacilli in dormant lesions implanted in earlier years and still capable of causing tuberculosis as life forces wane. The diagnosis is all too often not thought of in this age group; as a result, a patient with what was thought to be an episode of bronchitis or bronchopneumonia may die after having exposed a number of young health workers to tuberculosis in a country where it should have been eliminated several years ago. The purpose of this paper is to heighten the index of suspicion of tuberculosis among physicians caring for the elderly.
Aged↗
Smear-negative, culture-positive pulmonary tuberculosis. Six-month chemotherapy with isoniazid and rifampin.
We have shown in Arkansas that 9 months of therapy with isoniazid (INH) and rifampin (RIF) can achieve lasting success in 95% of cases with sputum-smear-positive pulmonary tuberculosis. It seemed likely that when the tubercle bacilli were less numerous, i.e., could not be seen on microscopy, less therapy would suffice. Thus, in January 1980, we began giving only 6 months of treatment to patients in whom at least one sputum culture showed M. tuberculosis but at least three sputum smears showed no organisms. The regimen for adults is INH 300 mg and RIF 600 mg daily for 1 month followed by INH 900 mg and RIF 600 mg twice weekly for another 5 months. To date, 286 patients with an average age of 68.2 yr have been treated in this manner. Associated medical conditions were present as "risk factors" in 23.7%. The full course of therapy could not be completed in 75 patients (26.2%), largely because of side effects of the drugs and non-TB deaths in this group of elderly patients. Side effects of the drugs requiring change of drug(s) occurred in 33 patients (11.5%), but major side effects occurred in only eight (2.8%), four (1.4%) with toxic hepatitis and four with hematologic toxicity. The side effects in 25 patients (8.7%) were not life-threatening and were due to drug intolerance. Treatment failed during therapy in only one patient. The full 6-month course of therapy was completed by 211 patients. During follow-up from 3 to 107 months (median, 45 months), five of 211 patients (2.4%) relapsed, all with drug-susceptible organisms.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Smear- and culture-negative pulmonary tuberculosis: four-month short-course chemotherapy.
Patients with positive tuberculin reaction, abnormal chest radiograph, and negative bacteriology are often treated empirically for tuberculosis (TB) after exclusion of other causes. Therapy generally consists of two bactericidal drugs (rifampin [RIF] and isoniazid [INH]) for 9 months or INH for 9 to 12 months. With such a small bacillary population, even less therapy might suffice. Thus we began in January 1980 to discontinue therapy at 4 months when there was sufficient evidence of a paucity of bacilli demonstrated by at least three negative smears and cultures for TB at the start of therapy. To date, 452 such patients have been so treated. Radiographic abnormalities included pulmonary infiltration of varying extent, pleural residuals, and hilar adenopathy. The full course of therapy could not be completed in 38 (8.4%) patients due to death, relocation, or drug toxicity. Side effects of the drugs occurred in 21 (4.7%) patients, but toxic hepatitis occurred in only four (0.9%) patients. Thus, 414 patients completed the full 4-month course of therapy. Of these, 126 (30.4%) patients showed radiographic and/or clinical response suggesting active infection. The remainder showed no such improvement, suggesting either a mistake in diagnosis or dormant TB. During follow-up of the 414 patients from 6 to 78 months (median, 44 months), five (1.2%) patients relapsed: three among responders and two among nonresponders. Thus, among persons suspected of having TB but with negative bacteriology, 4 months of chemotherapy with INH and RIF gave results comparable to those achieved with 9 months of therapy in smear- and culture-positive cases.
Adult↗
Update in tuberculosis: an overview.
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Cross-Sectional Studies↗
Tuberculosis in the elderly.
During the past 25 years, the age distribution of tuberculosis (TB) in the United States has shifted remarkably from younger age to the later decades, ie, in persons over 70 years of age. Elderly persons, although infected many years ago, exhibit a positive tuberculin reaction in only 20% to 25% upon entry into nursing homes. Among members of this infected elderly population, case rates as high as 500 to 1,000 per 100,000 population are found. Endogenous breakdown of older lesions is the common mechanism for the development of the disease. Of the remaining 70% to 80% tuberculin-negative population, 10% are immunoincompetent and die soon upon entry into the nursing home. The remaining 90% of the nonreactors who survive are again susceptible to new infection. The point prevalence of positive tuberculin reactors approximately doubles after more than a 6 months stay at the nursing home. This inadvertent exposure usually occurs in the nursing home due to reactivation of old lesions among old reactors. Although 5% of persons over 65 years of age live in nursing homes, they account for 20% of TB cases. This gives a rate four times greater than the rate among the elderly living at home, or twelve times greater than in persons 40 to 60 years of age. In Arkansas, more than 53% of active cases occurred in persons over 65 years of age, who account for only 14% of the population. Diagnosis of TB in the elderly may be considerably delayed or even totally missed.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Treatment of extrapulmonary tuberculosis.
The duration of therapy for pulmonary tuberculosis (TB) is now shortened to 6 or 9 months with the use of bactericidal drugs. There are few reports on the results of short course chemotherapy (SCC) in extrapulmonary tuberculosis (EP). It is unlikely that many controlled studies shall be forthcoming in the future because of involvement of many sites with the disease, each of which has special problems. However, available controlled studies and clinical experiences in EP indicate early success. The site of the disease appears to be less important since the bacterial population is much smaller in EP than in TB and is easily amenable to the bactericidal drugs. Present bactericidal drugs (isoniazid [INH], rifampin [RIF], pyrazinamide [PZA]) penetrate well into tissues and attain bactericidal levels to kill the organisms. Our experience with 9-month SCC consisting of INH 300 mg and RIF 600 mg daily for one month, followed by INH 900 mg and RIF 600 mg twice weekly for another 8 months in 478 cases of EP showed overall success in over 95% of those patients who completed therapy over a median follow-up of 42 months. The drugs may be given daily throughout with the same success. Thus, 9-month therapy with INH and RIF is highly effective in EP due to drug sensitive organisms. In TB, the duration may be shortened to 6-months with initial intensive four-drug therapy consisting of INH, RIF, PZA and streptomycin (SM) or ethambutol (EMB) daily for 2 months, followed by INH and RIF daily or twice weekly for another 4 months.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Isoniazid preventive therapy for tuberculosis. Are we losing our enthusiasm?
Contact investigation activities of the Tennessee Department of Health and Environment (TDHE) Tuberculosis (TB) Control Program from 1979 to 1985 were reviewed. Out of 32,722 identified contacts, 6,030 (20.1 percent) were infected (positive purified protein derivative [PPD]). Only 2,731 (45 percent) of the infected contacts were started on preventive therapy. Both the absolute number and the relative percentage of infected contacts starting on INH prevention therapy have gradually declined over the years. While 569 (67 percent) of the infected contacts were started on preventive treatment in 1979, only 296 (37.5 percent) received isoniazid (INH) preventive therapy in 1985. Although an increasing percentage of those starting preventive therapy completed the prescribed course, the enthusiasm for recommending preventive therapy has declined for the infected individuals above the age of 15. More enthusiasm and efforts are needed from physicians in initiating and maintaining INH preventive therapy to accomplish tuberculosis eradication.
Adolescent↗