Epidemiology of extra-pulmonary tuberculosis in Israel, 1999-2010.

SETTING: The Israeli national tuberculosis (TB) surveillance system. OBJECTIVES: To describe the epidemiology of extra-pulmonary tuberculosis (EPTB) in Israel between 1999 and 2010 and identify more susceptible populations. DESIGN: Data were retrieved from the National Tuberculosis Registry and the Israeli Bureau of Statistics. RESULTS: During the study period, 995 EPTB patients were notified, corresponding to 19.6% of all TB cases. The average annual male:female ratio was 0.8, and the human immunodeficiency virus (HIV) infection rate was 5%. Most EPTB affected the lymph nodes (39.8%), pleura (16.9%) and urinary system (11.1%). Most EPTB patients (81.8%) were non-Israeli born. The estimated average annual incidence in Israeli-born citizens, non-Israeli-born citizens and migrant workers was respectively 0.23, 2.2 and 7.5 per 100,000 population. The ratio of non-Israeli-born migrant workers to non-Israeli-born citizens with EPTB decreased from 1:6.3 in 1999 to 1:0.78 in 2010. Culture results were obtained for 624 (62.9%) of all cases. Of these, 41 (6.6%) were resistant to at least one first-line anti-tuberculosis drug and 8 (1.3%) were multidrug-resistant. Treatment success was achieved in 86.5%. CONCLUSIONS: Physicians should be aware of the possibility of EPTB in older patients, especially in the non-Israeli-born. Innovative screening procedures should be implemented for migrants from high-burden countries.

Adult tuberculosis in Israel and migration: trends and challenges between 1999 and 2010.

BACKGROUND: Israel absorbs many migrants from countries with a high prevalence of tuberculosis (TB). OBJECTIVES: To describe the epidemiology of TB among adults in Israel between 1999 and 2010 and identify populations with a high TB burden. DESIGN: Data were retrieved from the National Tuberculosis Registry and the Israeli Bureau of Statistics. RESULTS: A total of 4652 adult TB patients were notified during the study period, with rates decreasing annually from 7.5 per 100,000 population in 1999 to 4.3 in 2010. Most (n = 3745, 80.5%) had pulmonary TB, the average female:male ratio was 1:1.4, and 227 (5.1%) were infected with the human immunodeficiency virus. Of all TB patients, 4079 (87.6%) were born outside Israel; of these, 3338 were citizens and 741 non-citizen migrant workers (MWs). The average annual rates of TB among Israeli-born citizens, foreign-born citizens and MWs were respectively 0.86, 11.9 and 27/100,000. The ratio of MWs to foreign-born citizens fell from 1:11.7 in 1999 to 1:1.5 in 2010. TB was diagnosed 13.9 ± 7.5 years following entry to Israel, mostly during the first year. Of 3551 isolates, 222 (4.5%) were multidrug-resistant; most (95.6%) were from foreign-born patients. The average treatment success rate for smear-positive pulmonary TB was 84.3%. CONCLUSION: TB rates have decreased, while the proportion of foreign-born subjects, particularly MWs, has increased. Adherence to preventive treatment can prevent TB in these cases.

Ischemic threshold during two exercise testing protocols and during ambulatory electrocardiographic monitoring.

OBJECTIVES: The aim of this study was to examine the dependence of the ischemic threshold during exercise testing on the exercise protocol employed and to determine the relation between the ischemic thresholds observed during exercise and during daily activity. BACKGROUND: The ischemic threshold (heart rate at 1-mm ST segment depression) during daily activity has been reported to be lower than that observed during exercise testing. Recent reports have hypothesized that this difference is probably dependent on the exercise protocol employed. METHODS: Twenty-two patients with known coronary artery disease, not receiving antianginal medications, were evaluated by repeated exercise testing according to the Bruce and the modified Davidson protocols and by 48-h ambulatory electrocardiographic monitoring. RESULTS: Although the heart rate at 1-mm ST segment depression was somewhat lower with the Davidson than with the Bruce protocol (112 +/- 14 vs. 115 +/- 14 beats/min), the rate-pressure product at 1-mm ST segment depression was similar during the two protocols (16,900 +/- 4,000 vs. 17,700 +/- 3,600). The mean heart rate (100 + 12 beats/min) at 1-mm ST segment depression during ambulatory ischemic episodes (n = 137) was significantly lower than that observed during both exercise protocols (p < 0.001 for both comparisons). CONCLUSIONS: Exercise-induced ischemia occurs at a relatively fixed threshold that is mainly dependent on myocardial oxygen demand and is independent of the exercise protocol employed. Ischemia on ambulatory monitoring, however, occurs at a much more variable threshold that is commonly lower than that observed during exercise and is therefore dependent on other factors in addition to increased demand.