How does psychological processing relate to compliance behaviour after lung transplantation? A content analytical study.

Non-compliance is one of the crucial problems impairing outcome after transplantation. Fourteen lung transplant recipients were interviewed about their thoughts regarding transplant-related topics. Compliance was assessed by doctors. The psychological processing was investigated by content analysis. Highly compliant patients perceived more advantages by transplantation. In contrast, low-compliant patients reported either an emotional distance to the lung or a closer relationship to the donor. Furthermore, they showed a contradictory relationship to the medical staff. There are some indications that perception of advantages by transplantation is crucial to compliance. This experience takes place in the context of a good staff-patient relationship. Emotional distance to the lung or nearness to the donor are further contributing factors of non-compliance.

Isoniazid- and rifampin-resistant tuberculosis in San Diego County, California, United States, 1993-2002.

SETTING: A local tuberculosis (TB) control program. OBJECTIVES: To measure trends in isoniazid (INH) and rifampin (RMP) resistance and identify associated factors. DESIGN: Retrospective review. RESULTS: Of 2883 isolates obtained from TB patients reported between 1993 and 2002, 287 (10%) were resistant to INH, 11 (< 1%) were resistant to RMP, and 40 (1%) were resistant to both (multidrug resistance [MDR]). There were no linear trends over time. Eighty-one per cent of patients with INH resistance and 85% with MDR were born outside the United States. Sixty-three per cent of patients with drug resistance and prior TB treatment were treated outside the US. INH resistance was associated with race/ethnicity and prior treatment, RMP resistance with human immunodeficiency virus (HIV) infection, and MDR with non-US birth and prior treatment. Patients with INH- and RMP-susceptible or INH-resistant TB had higher percentages of treatment completion and sputum culture conversion than patients with RMP-resistant or MDR-TB. CONCLUSIONS: INH and RMP resistance remained stable between 1993 and 2002. Because most patients with drug resistance were infected or initially treated outside the US, future reductions in drug resistance will depend not only on local and national efforts, but also on the success of global interventions.

Structured behavioral intervention to increase children's adherence to treatment for latent tuberculosis infection.

SETTING: San Diego, California public health department tuberculosis clinic. OBJECTIVE: To evaluate the effectiveness of a behavioral intervention (the Treasure Chest) that employed the behavior modification techniques of self-monitoring and positive reinforcement to increase adherence to therapy for latent tuberculosis infection (LTBI) in children. DESIGN: A retrospective study utilizing a historical comparison group. The treatment adherence of children who attended San Diego County TB Control Program (SDCTBCP) clinics with positive tuberculin skin tests who were started on LTBI treatment prior to Treasure Chest program implementation (n=841) was compared to that of SDCTBCP children enrolled in the Treasure Chest program (n=741). RESULTS: Logistic regression analysis demonstrated that children who participated in the Treasure Chest program were 2.4 times more likely to complete therapy than those who did not receive the intervention. CONCLUSION: The Treasure Chest intervention is effective in increasing adherence to LTBI therapy in children.

Treatment of Mycobacterium bovis infected tuberculosis patients: San Diego County, California, United States, 1994-2003.

SETTING: A local tuberculosis control program. OBJECTIVE: To examine treatment completion rates of patients with Mycobacterium bovis disease and compare them with those of patients with M. tuberculosis disease. DESIGN: Retrospective review of data from a tuberculosis surveillance computer database. RESULTS: Data from 167 M. bovis patients and 928 M. tuberculosis patients were examined. Rates of treatment completion were not significantly different (78% vs. 82%, chi2 = 1.60, P = 0.174), although death was more frequent among M. bovis patients (15% vs. 7%). The median time to treatment completion was 94 days longer for M. bovis patients. CONCLUSION: Overall, treatment completion rates of M. bovis and M. tuberculosis patients were comparable, although the death rate was higher for M. bovis patients. The latter finding may be related to a particularly high death rate among HIV-infected M. bovis patients. Therapy duration was longer for M. bovis patients, probably because resistance to pyrazinamide prevented the use of a short-course (6-month) regimen.

Identification of a familial cluster of pulmonary Mycobacterium bovis disease.

SETTING: Local public health department. DESIGN: Retrospective review of a cluster of three pulmonary Mycobacterium bovis cases occurring in a family, with genotyping of M. bovis strains isolated from the family members. RESULTS: The genotypes of the M. bovis isolates were identical, as determined by three different methods: IS6110 restriction fragment length polymorphism, spoligoytping and mycobacterial interspersed repetitive units-variable number tandem repeat analyses. CONCLUSION: The identification of three acid-fast bacilli (AFB) smear-positive pulmonary M. bovis cases, presenting in a single family and caused by an identical strain, suggests that person-to-person transmission of this organism may have occurred, although infection of one or more family members through ingestion of a contaminated dairy product could not be excluded.

Contact investigation for cases of pulmonary Mycobacterium bovis.

SETTING: A local tuberculosis control program in San Diego County, California. OBJECTIVE: To determine the yield of contact investigations of pulmonary Mycobacterium bovis cases. DESIGN: Retrospective review of medical records comparing tuberculin skin test (TST) conversion rates found in contact investigations of pulmonary M. bovis cases to conversion rates found in contact investigations of pulmonary M. tuberculosis cases. RESULTS: For the years 1994-2001, we identified 77 contacts of pulmonary M. bovis cases and 469 contacts of M. tuberculosis cases that met the study criteria. TST conversion rates were not significantly different based on species of the source case (13% for M. bovis, 15% for M. tuberculosis, P = 0.20). This finding was also observed when the results were stratified by presence of a cavity on chest X-ray, history of cough at diagnosis and human immunodeficiency virus (HIV) status of the source case. CONCLUSION: These results suggest that contact investigations for pulmonary M. bovis cases should be conducted in the same manner as those conducted for pulmonary M. tuberculosis cases.

Epidemiology of Mycobacterium bovis disease in San Diego County, 1994-2000.

SETTING: Local public health department. OBJECTIVE: To examine the current epidemiology of Mycobacterium bovis disease in San Diego County and to compare patient characteristics to those of patients with M. tuberculosis disease. DESIGN: Retrospective review of surveillance and epidemiologic data. RESULTS: Between 1994 and 2000, 1,931 evaluable cases of culture-positive TB were identified; 129 were infected with M. bovis and 1,802 were infected with M. tuberculosis. More than 90% of M. bovis cases occurred in Hispanic persons. About 25% of patients were children, and the main site of disease was extra-pulmonary in 53% of patients. Twenty-three per cent had concurrent HIV infection. Compared to patients with M. tuberculosis, patients with M. bovis were more likely to be Hispanic, aged 0-14 years, have extra-pulmonary disease, or have HIV co-infection in a multivariate model. They were less likely to be born in countries outside of the US or Mexico. CONCLUSION: While human disease due to M. bovis has essentially been eliminated in many parts of the US and other industrialized countries, it persists in certain demographic groups, including Hispanic children and HIV-infected adults, in San Diego County.

Immigration and tuberculosis among children on the United States-Mexico border, County of San Diego, California.

OBJECTIVE: To identify factors contributing to a 400% increase in tuberculosis among children in San Diego County, California, from 1985 to 1993. DESIGN: Review of medical records of reported cases in 1989, 1991, and 1993 and their source case. RESULTS: Of 192 children with tuberculosis, the largest increase was observed in children younger than 5 years old, of whom 77.4% were born in the United States, 67.8% had a foreign-born parent, 73.1% came from a non-English-speaking household, and 46.2% were known to visit Mexico. Of 28 source cases, 82.1% were born outside the United States, primarily in Mexico (67.9%). Resistance to at least one first-line antituberculous drug was identified in 27.5% of isolates from children and in 33.3% of isolates from source cases. CONCLUSIONS: The increase in tuberculosis and high level of drug-resistance among children born in the United States may be attributed to transmission outside of the United States or within the United States from household contacts born in countries in which tuberculosis is highly endemic.

Tuberculosis screening at 2 San Diego high schools with high-risk populations.

BACKGROUND: High immigration rates contribute to the high incidence of pediatric tuberculosis (TB) in San Diego, Calif. Adolescents frequently have poor access to health care and may not receive appropriate TB screening. School-based screening has been ineffective in detecting TB in other parts of the country. OBJECTIVE: To determine the prevalence of TB infection and disease in a high-risk population of high school students through school-based screening. DESIGN AND PARTICIPANTS: Cross-sectional study of TB prevalence and an analysis of risk factors for TB infection in students attending 2 San Diego high schools with high percentages of non-US-born students. MAIN OUTCOME MEASURES: Positive induration (> or =10 mm) with Mantoux tuberculin skin test. A chest radiograph or clinical findings consistent with active TB. RESULTS: A total of 744 (36%) students at high school 1 and 860 (57%) students at high school 2 participated. Ninety-five (12.8%) and 207 (24.1%) students, respectively, had positive tuberculin skin test results. One student had a chest radiograph that showed active TB. Smear for acid-fast bacteria and culture for Mycobacterium tuberculosis had negative results. Vietnamese, Filipino, and Latino ethnic groups were significantly more likely to have positive tuberculin skin test results than the white population (P<.05). Non-US-born students were significantly more likely to have positive tuberculin skin test results than US-born students in all ethnic groups except the Latino group. CONCLUSION: Although treatment of TB coupled with aggressive public health investigation is the most cost-beneficial way of preventing TB, targeted school-based screening may be an effective way of detecting TB infection in high-risk populations with poor access to health care.

Epidemiology of trauma deaths: a reassessment.

OBJECTIVE: Recognizing the impact of the 1977 San Francisco study of trauma deaths in trauma care, our purpose was to reassess those findings in a contemporary trauma system. DESIGN: Cross-sectional. MATERIAL AND METHODS: All trauma deaths occurring in Denver City and County during 1992 were reviewed; data were obtained by cross-referencing four databases: paramedic trip reports, trauma registries, coroner autopsy reports and police reports. MEASUREMENTS AND MAIN RESULTS: There were 289 postinjury fatalities; mean age was 36.8 +/- 1.2 years and mean Injury Severity Score (ISS) was 35.7 +/- 1.2. Predominant injury mechanisms were gunshot wounds in 121 (42%), motorvehicle accidents in 75 (38%) and falls in 23 (8%) cases. Seven (2%) individuals sustained lethal burns. Ninety eight (34%) deaths occurred in the pre-hospital setting. The remaining 191 (66%) patients were transported to the hospital. Of these, 154 (81%) died in the first 48 hours (acute), 11 (6%) within three to seven days (early) and 26 (14%) after seven days (late). Central nervous system injuries were the most frequent cause of death (42%), followed by exsanguination (39%) and organ failure (7%). While acute and early deaths were mostly due to the first two causes, organ failure was the most common cause of late death (61%). CONCLUSIONS: In comparison with the previous report, we observed similar injury mechanisms, demographics and causes of death. However, in our experience, there was an improved access to the medical system, greater proportion of late deaths due to brain injury and lack of the classic trimodal distribution.

Indium-111-labeled platelets: effects of heparin on uptake by venous thrombi and relationship to the activated partial thromboplastin time.

The goal of heparin therapy in deep vein thrombosis is to prevent thrombus extension. The relationship between thrombus extension and the results of coagulation tests used to monitor heparin therapy is unclear. To explore this relationship, we studied the effect of several heparin regimens on the accretion of indium-111-labeled platelets on fresh venous thrombi, as detected by gamma imaging, and monitored the activated partial thromboplastin time (APTT). Six dogs were treated with a 300-U/kg bolus of heparin followed by a 90-U/kg/hour heparin infusion, a dose of heparin sufficient to increase the APTT to levels greater than eight times baseline (APTT ratio); platelet accretion (thrombus imaging) occurred only after the heparin effect was reversed with protamine sulfate. Nineteen dogs were treated with a 150-U/kg bolus of heparin followed by a 4-hour, 45-U/kg/hour heparin infusion; a thrombus was demonstrated only after protamine injection in 12 (mean APTT ratio 1.3 +/- 0.19) and before protamine injection in seven. In thirteen of these 19 dogs, 30 minutes separated the platelet injection from heparin therapy, while in six this duration was less than 30 minutes. In four of these six dogs, thrombi were demonstrated before protamine therapy and at APTT ratios greater than 3.0. Finally, 10 dogs were treated with a 100-U/kg bolus followed by a 3-hour, 50-U/kg/hour heparin infusion, after which the APTT was allowed to return to baseline values spontaneously. In all 10 dogs, a thrombus was demonstrated only after cessation of the heparin infusion, and at a mean APTT ratio of 1.4 +/- 0.15 times baseline. These results suggest that, except with very early platelet injection, platelet accretion by thrombi is consistently inhibited by heparin at APTT ratios greater than 2.5. Platelet accretion by venous thrombi occurs within narrow limits of heparin effect as reflected by the APTT.

Risk of complications during intravenous heparin therapy.

The records of all patients to whom heparin was dispensed by the pharmacy of the University of California Medical Center, San Diego, during the year 1979 were reviewed. A total of 131 patients above age 15 met the inclusion criteria-they had received more than 10,000 units of heparin per 24 hours for at least 24 hours. All 131 patients were administered heparin by continuous intravenous infusion by peristaltic pump. All heparin was porcine heparin from a single commercial source. The daily mean minimum dose averaged 19,700 units, the maximum, 25,600 units. The activated partial thromboplastin time, usually measured once a day, was the only test used to monitor the dose. Major complicating events occurred in 13 patients (10 percent), and minor complicating events occurred in 10 patients (7.6 percent). All major complicating events occurred in patients with serious concurrent diseases. In subpopulations of 58 patients without concurrent disease, and of 24 in whom heparin was initiated for suspicion of thromboembolism that was not confirmed, no major complicating events occurred. These data indicate that continuous, intravenous administration of heparin is associated with minimal risk, and that risk is concentrated among older patients with serious concurrent disease.