Mortality among tuberculosis patients in New York City.

OBJECTIVES: To quantify tuberculosis (TB) related mortality among TB patients in New York City (NYC), NY, USA, and identify risk factors associated with TB-related mortality. DESIGN: We performed a retrospective analysis of verified TB patients in NYC, 2004-2013. NYC Office of Vital Statistics death certificate data and TB surveillance data were matched. Death certificate data were used to identify TB-related deaths. Risk factors for TB-related death for US-born and non-US-born populations were evaluated using multivariable logistic regression. RESULTS: Of 8209 TB patients in NYC, 168 (2%) suffered TB-related deaths before or during anti-tuberculosis treatment. Of these, 62% occurred among non-US-born patients, and 38% occurred among US-born patients. Among the latter, TB-related death was associated with increased age (65 vs. 18-44 years, adjusted OR [aOR] 8.27, 95%CI 3.47-19.71), being culture-positive (aOR 6.79, 95%CI 2.10-21.97), and having both pulmonary and extra-pulmonary disease (aOR 5.06, 95%CI 1.91-13.40). The same factors were also significant among non-US-born patients; TB-related death was also associated with male sex (aOR 1.80, 95%CI 1.11-2.91), history of TB disease (aOR 3.16, 95%CI 1.28-7.77), alcohol use (aOR 1.85, 95%CI 1.00-3.43), homelessness (aOR 2.66 95%CI 1.15-6.19), and unknown human immunodeficiency virus status (aOR 3.91, 95%CI 2.43-6.29). CONCLUSION: Different risk factors between the US- and non-US-born populations were identified. Interventions specific to each population may be needed for reducing TB-related mortality.

Errors in isolation of patients with infectious tuberculosis at a public teaching hospital in New York.

BACKGROUND: Studies report variability in the rates and causes of isolation errors among in-patients with active tuberculosis (TB). We reviewed our experience with delays or premature discontinuation of airborne infection isolation (AII). METHODS: Medical records of patients admitted to the Bellevue Hospital Center, New York City Health & Hospitals, New York, NY, USA, between January 2006 and July 2012 with a positive respiratory culture for Mycobacterium tuberculosis were reviewed. Patients who were out of AII despite being infectious were identified, as the episodes had prompted a contact investigation. RESULTS: Of 246 admissions with positive respiratory cultures, 35 AII errors were identified among 27 patients. Most patients had signs or symptoms of TB on admission. Only four patients had positive sputum smears. In 16 (46%) episodes, the patients had never been isolated, 11 (31%) had delayed isolation, and 8 (23%) were prematurely taken off AII. The most common reasons for patients being off AII while infectious were an incorrect alternative diagnosis (15/35, 43%) or a dual diagnosis (9/35, 26%). CONCLUSIONS: Particularly in smear-negative cases, AII errors due to TB may occur when providers conclude that another diagnosis explains their findings. In many cases, that diagnosis is correct, but TB is also present. This error rate might be a useful quality indicator.

Congenital tuberculosis and management of exposure in three neonatal intensive care units.

Congenital tuberculosis (TB) is uncommon, and diagnosis may be delayed. We report a case of congenital TB and the management of exposure in three different neonatal intensive care units. This case demonstrates the need for a high index of suspicion, active communication among maternal and neonatal medical providers, and timely provider reporting of maternal disease, and emphasizes the relatively greater risk of transmission to health care workers versus infants in this setting.

Effect of atrial radiofrequency ablation designed to cure atrial fibrillation on atrial mechanical function.

INTRODUCTION: The effects of linear radiofrequency lesions in the atria for cure of atrial fibrillation on atrial contraction have not previously been quantified. METHODS AND RESULTS: Atrial function was measured before and 30 +/- 24 days after a biatrial ablation procedure designed to cure atrial fibrillation in eight dogs and after a sham procedure in three dogs. Atrial mechanical function was assessed using Doppler diastolic blood flow velocities, atrial systolic pressure wave amplitude, and assessment of atrial contribution to cardiac output estimated by comparison of AV sequential pacing to ventricular pacing at the same heart rate. The mitral Doppler A/E velocity ratio was 1.03 +/- 0.45 before and 0.72 +/- 0.43 after ablation (P = 0.048). The tricuspid A/E ratio was 0.88 +/- 0.17 before and 0.71 +/- 0.12 after ablation (P = 0.04). The estimated atrial contribution to cardiac output was 18% +/- 9% before and 5% +/- 4% after ablation (P < 0.01). The left atrial systolic pressure wave amplitude was 2.8 +/- 1.5 mmHg before and 1.7 +/- 1.0 mmHg after ablation (P = 0.1). These changes were not observed in control dogs. Lesions covered 25% +/- 6% of the atrial endocardial surface. CONCLUSION: Multiple linear radiofrequency lesions in the atria designed to cure atrial fibrillation may impair atrial contractility. Reduced atrial function is partly due to loss of atrial myocardial mass, but regional delays in atrial activation and splinting of the atria by scarring also may contribute.

Metabolite-intermediate complexation and inhibition of microsomal CYP3A in rat liver by diltiazem.

1. The formation of metabolite intermediate (MI)-complexes between cytochrome P450 (CYP) and the alkylamine-substituted drugs diltiazem (DTZ) and desipramine (DES) and their effect on CYP activities was investigated in rat liver. 2. Dexamethasone and phenobarbitone pretreatment enhanced MI-complexation by DTZ (36% and 11% of total CYP complexed, respectively), whereas beta-naphthoflavone induction was without effect. All three treatments decreased MI-complexation produced by DES. 3. After a preincubation step in NADPH-supplemented microsomes DTZ and DES were effective inhibitors of the activities of CYPs 3A and 2C11 (testosterone 6beta- and 16alpha-hydroxylations, respectively). 4. Although MI-complexation by DTZ was more extensive in microsomes from dexamethasone-induced rats, the apparent inhibition potency of the drug toward CYP activity was unchanged. By comparison, inhibition of CYP activity by DES was less pronounced than in control liver. 5. These findings indicate that drug-mediated MI-complexation of CYPs does not necessarily potentiate the inhibitory effect on monooxygenase activity, although the duration of inhibition is longer. The extent of inhibition produced by stable drug metabolites may be similar to that from MI-complexation. but their duration of action is limited by diffusion from the active site of the enzyme.