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Biomedical subjects

D C Perlman

Publications and source records attributed to D C Perlman.

At least 37 records · Page 2Linked to original sources
PubMed1997

Implementation of universal directly observed therapy at a New York City hospital and evaluation of an out-patient directly observed therapy program.

SETTING: Directly observed therapy (DOT) program for tuberculosis (TB) at a New York City hospital. OBJECTIVE: To describe a specific TB DOT program model utilizing active prospective identification of inpatients, and identify factors associated with patient acceptance of voluntary DOT and with their retention in therapy. METHODS: Recruitment for DOT by daily surveillance of in-patients. DOT was offered as the patient's choice together with concrete services and incentives. On-site DOT was offered in an out-patient clinic. Outreach efforts were initiated when a patient missed one or more DOT visit. RESULTS: During the study period, 95% of 176 in-patients with TB were evaluated for DOT. Of the 137 who were eligible for DOT, 85% (95% confidence interval [CI], 77.5% to 90%) elected to receive DOT. Illicit drug use was independently associated with a higher likelihood of acceptance of DOT (odds ratio[OR], 4.88; 95% CI, 1.5-15.7). Among the 101 patients who received onsite DOT, illicit drug use (OR, 0.21; 95% CI, 0.08-0.6) and previous TB therapy (OR, 0.27; 95% CI, 0.27-0.7) were both independently associated with lower retention in therapy. However, with intensive case management, only 1% of this cohort was lost to follow-up and the overall treatment completion index was 98%. CONCLUSION: In-patient surveillance is a highly effective DOT recruitment strategy. A DOT model which elicits patient participation in discharge plans and offers incentives can yield a high rate of voluntary acceptance. Outpatient case management is a highly effective means of ensuring treatment completion, especially in those at risk for poor retention.

Adult↗
PubMed1995

Predictors and outcome of multidrug-resistant tuberculosis.

We identify early predictors of multidrug-resistant tuberculosis and describe improved clinical outcomes, including survival, for patients with human immunodeficiency virus (HIV)-related multidrug-resistant tuberculosis (MDR-TB) when they are prospectively identified and receive treatment under direct observation. Analysis by means of a Cox proportional hazards model revealed that failure to defervesce while receiving a standard four-drug antituberculous regimen was independently associated with multidrug resistance (P = .004). When patients with HIV-related MDR-TB were prospectively identified and treated with at least two agents that were active in vitro, 100% bacteriologic conversion and improved survival (> or = 4 months for 88% of patients and > or = 1 year for 59% of patients) were observed. For patients with HIV-related tuberculosis, poorer survival was associated with a CD4+ lymphocyte count of < 25 mm3 (P = .03); multidrug resistance was not a predictor of poor outcome (P = .82). These data suggest that patients with prolonged fever who are receiving antituberculous therapy may be an appropriate subgroup to target for broader empirical therapy. The findings also demonstrate that improved outcomes can be achieved with HIV-related MDR-TB when patients are prospectively identified and treated with agents that are active in vitro.

AIDS-Related Opportunistic Infections↗
PubMed1995

Tuberculosis in drug users.

The rise in tuberculosis (TB) has disproportionately affected specific populations. Historically, many patients with TB became iatrogenic opiate addicts through therapeutic use of these drugs for symptom control. Demographic trends reshaped the relationship between drug use and TB into one in which drug use became a risk factor for tuberculosis as a result of the overlap of epidemiological and social factors associated with both drug use and TB. The spread of human immunodeficiency virus infection has amplified the spread of TB among drug users. We review the epidemiology of TB in drug users as well as the factors relevant to screening and compliance in drug-using populations. Drug users constitute a high-risk group for whom screening, prevention of infection, diagnosis, and treatment pose particular challenges. The development of TB services capable of engaging drug users (those both in and out of drug treatment programs) has potential for disrupting a significant chain of rapid TB transmission.

AIDS-Related Opportunistic Infections↗
PubMed1994

Two-stage tuberculin skin testing in an HIV-infected population: a preliminary report.

To identify differences in purified protein derivative (PPD) tuberculin positivity rates and to assess the utility of sequential PPD testing among persons with HIV infection, we performed two sequential administrations of 5 tuberculin units of PPD in a group of persons with HIV infection. Eligible patients were skin-tested with the tuberculin using the Mantoux method. Patients who tested < 5 mm of induration were skin-tested seven days later along with Candida and mumps antigens. Of 37 tested patients, only 18 (49%) returned to have the first test read. Using a > or = 5 mm cutoff, 5 (28%) tested positive. Positivity varied markedly between patients with CD4+ cell counts under and at or over 400 cells/mm3 (0% vs. 56%). Among patients who had a reaction to the first test, the reaction was smaller in patients with CD4+ cell counts under 400 than in those with counts at or over 400 cells/mm3 (mean induration: 2.8 vs. 30.4 mm). Positivity was also less frequent in intravenous drug users than in nonusers (9% vs. 57%); these two groups did not differ with respect to CD4+ cell counts. Of the 13 patients who tested < 5 mm, only 8 (62%) kept their appointments to have the second test placed and read. Only 1 of these, a drug user with a CD4+ count of 6 cells/mm3, had a positive reaction with boosting from 4 mm on the first test to 10 mm on the second. These data indicate that PPD testing may be unreliable in screening for tuberculosis infection in persons with CD4+ counts < 400 cell/mm3.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Drug-resistant tuberculosis: factors associated with rise in resistance in an HIV-infected urban population.

Our objective was to characterize the population with tuberculosis (TB) and to identify factors predictive of resistance to anti-TB agents in an area of high prevalence of human immunodeficiency virus infection. We reviewed microbiology and clinical records from 1988 to 1991 at Beth Israel Medical Center, New York City, for patients with culture-proved TB and analyzed the frequency of resistance to anti-TB agents with respect to demographic and clinical variables. Of 360 patients with TB, 17.5% had drug-resistant isolates. Of the 333 patients on whom the information was available, 72% reported HIV risk factors, 54% injectable drug use, and nearly one-third homelessness. The majority (56%) had documented HIV infection. Between 1988 and 1991, acquired resistance to isoniazid (INH) alone rose from 5% to 21% and initial resistance to INH alone rose from 0% to 19%. Drug resistance was more likely in previously treated patients; 61% of the previously treated patients admitted noncompliance with therapy. Cavitary lung disease was the strongest predictor of acquired drug resistance. Initial drug resistance was more likely in patients with HIV infection. Among persons with HIV infection, none of the analyzed factors was found to be predictive of drug resistance. Noncompliance with therapy and the HIV epidemic played a major role in the rise of drug resistance in our population. HIV infection confounds the epidemiologic factors that might otherwise allow clinical prediction of resistance.

Adult↗
PubMed1992

Concomitant high-level vancomycin and penicillin resistance in clinical isolates of enterococci.

Enterococci are important nosocomial pathogens among which resistance to multiple antibiotics is being recognized with increasing frequency. We characterized three clinical isolates from three New York City hospitals that demonstrated concomitant resistance to vancomycin (one VanA, two VanB phenotypes) and high-level resistance to penicillin. Two Enterococcus faecium strains were intrinsically highly resistant to penicillin and showed very low affinity for penicillin of penicillin-binding protein 5. Unlike previously described glycopeptide-resistant enterococci, these strains were not hypersusceptible to beta-lactam agents after vancomycin induction, and combinations of penicillin and vancomycin were not synergistic against them. A third isolate, Enterococcus faecalis, produced beta-lactamase. Two of the three strains were also highly resistant to all aminoglycosides. Emergence of concomitant high-level resistance to multiple antibiotic classes among enterococci considerably narrows the therapeutic options for treatment of infections due to these opportunistic pathogens.

Aged↗
PubMed1992

Community-acquired methicillin-resistant Staphylococcus aureus infections in otolaryngology.

Soon after the introduction of methicillin, strains of Staphylococcus aureus resistant to methicillin were reported. Methicillin-resistant Staphylococcus aureus (MRSA) has become a common hospital pathogen, often resistant to multiple antibiotics, while causing significant morbidity and mortality. Community-acquired MRSA infections have been infrequently documented. Most reports have been associated with intravenous drug abuse. This report reviews 15 patients with community-acquired MRSA infections of the head and neck. None admitted to intravenous drug use. Additionally, no patient was known to be a healthcare worker. The MRSA strains showed antibiotic susceptibility and resistance profiles different from typical hospital-acquired MRSA isolates. All but one infection resolved with adequate surgical or appropriate antibiotic therapy. Clinicians should become aware of the possibility of community-acquired MRSA in the patient who has had continued infection despite antibiotic therapy.

Abscess↗
PubMed1992

Pneumocystis colitis in a patient with the acquired immunodeficiency syndrome.

We report a case of colonic pneumocystosis in a human immunodeficiency virus (HIV)-positive homosexual male who presented with fever and diarrhea. Stool cultures for bacterial pathogens and examinations for ova and parasites were negative. The diagnosis was made by colonoscopic biopsy which revealed Pneumocystis carinii organisms in the lamina propria of the cecum, descending colon, and sigmoid colon. The patient subsequently developed pulmonary and ocular abnormalities consistent with P. carinii involvement of these organs. The diarrhea and other manifestations resolved with antipneumocystis therapy. Many sites of extrapulmonary pneumocystosis have been reported, but we believe this is the first report of colonic P. carinii found in the evaluation of persistent diarrhea in a patient with the acquired immunodeficiency syndrome.

Acquired Immunodeficiency Syndrome↗
PubMed1991

Aspergillosis in the acquired immunodeficiency syndrome.

The role of Aspergillus species as a pathogen in acquired immunodeficiency syndrome (AIDS) has not been clearly defined. From 1984 to 1989, more than 2,000 AIDS patients were seen at Beth Israel Medical Center, New York. Aspergillus was isolated in ten patients; seven had invasive disease and three had noninvasive disease. Invasive pulmonary aspergillosis (IPA) was diagnosed in six patients and invasive renal aspergillosis was found in one patient. Five were homosexual men and two were intravenous drug users. At presentation, all ten had fever, seven had cough, eight had dyspnea, and five had pleuritic chest pain. Chest roentgenograms revealed focal infiltrates in six patients, bilateral interstitial infiltrates in two patients, and bilateral pneumothoraces in one patient. Predisposing conditions included corticosteroid therapy in four, granulocytopenia (less than 1,000/cu m) in two, and broad-spectrum antibiotic therapy in five. Three of the four patients receiving corticosteroids received them as adjuvant therapy for Pneumocystis carinii pneumonia (PCP). Aspergillus was identified antemortem in eight patients, in bronchoalveolar lavage (BAL) fluid in six, in transbronchial biopsy specimen in three, in open lung biopsy specimen in one, and postmortem in one patient. Six of seven patients had at least one concomitant pulmonary process. Six underwent necropsy and findings showed IPA in three, disseminated aspergillosis in two, and PCP in one. Invasive aspergillosis, although significant, is uncommon in AIDS. When Aspergillus is isolated in the setting of corticosteroid therapy, antibiotics, or granulocytopenia, one must suspect invasive disease.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Isospora belli infection: treatment with pyrimethamine.

Isosporiasis is an uncommon but important diarrheal disease of humans that, like cryptosporidiosis, is life-threatening in patients with the acquired immunodeficiency syndrome (AIDS). Isospora belli infection responds rapidly to therapy with trimethoprim-sulfamethoxazole, but patients with AIDS have a high rate of adverse reactions to this therapy. The cases of two patients with AIDS, sulfonamide allergy, and I. belli infection are reported. They were treated successfully with pyrimethamine alone, 75 mg/d, and recurrence was prevented with daily pyrimethamine therapy, 25 mg/d. In patients with AIDS with sulfonamide allergy or intolerance, pyrimethamine alone seems to be a reasonable alternative therapy for I. belli infection.

Adult↗
PubMed1988

A focus of Rocky Mountain spotted fever within New York City.

In the spring and summer of 1987, four persons acquired Rocky Mountain spotted fever within New York City, an area in which the disease had not previously been known to be endemic. Three of the four patients were residents of the Soundview area of the Bronx. All diagnoses were confirmed by indirect fluorescent-antibody tests. Environmental investigation revealed that the tick vector for Rickettsia rickettsii, Dermacentor variabilis, was present in a local park. Of the 66 specimens of D. variabilis collected, 5 (8 percent) were positive for rickettsiae from the spotted fever group. Of an additional 96 specimens of D. variabilis, 5 (5 percent) were found positive for rickettsiae by a more specific monoclonal antibody assay. Eight additional New York City parks in all five boroughs were searched for ticks. D. variabilis was found in only one other park; of the 147 ticks collected there, none were positive for rickettsiae. These findings emphasize the focal nature of Rocky Mountain spotted fever and the need to consider that disease in the differential diagnosis of any obscure acute febrile illness, even in the absence of a history of travel to known endemic areas.

Adult↗
PubMedDate not supplied

"Shotgunning" as an illicit drug smoking practice.

There has been a rise in illicit drug smoking in the United States. "Shotgunning" drugs (or "doing a shotgun") refers to the practice of inhaling smoke and then exhaling it into another individual's mouth, a practice with the potential for the efficient transmission of respiratory pathogens. Three hundred fifty-four drug users (239 from a syringe exchange and 115 from a drug detoxification program) were interviewed about shotgunning and screened for tuberculosis (TB). Fifty-nine (17%; 95% CI 12.9%-20.9%) reported shotgunning while smoking crack cocaine (68%), marijuana (41%), or heroin (2%). In multivariate analysis, age < or = 35 years (OR 2.0, 95% CI 1.05-3.9), white race (OR 1.2, 95% CI 1.2-4.8), drinking alcohol to intoxication (OR 2.2, 95% CI 1.1-4.3), having engaged in high-risk sex (OR 2.6, 95% CI 1.04-6.7), and crack use (OR 6.0, 95% CI 3.0-12) were independently associated with shotgunning. Shotgunning is a frequent drug smoking practice with the potential to transmit respiratory pathogens, underscoring the need for education of drug users about the risks of specific drug use practices, and the ongoing need for TB control among active drug users.

Adult↗
PubMedDate not supplied

Organizational issues in conducting tuberculosis screening at a syringe exchange program.

There has been a rise in tuberculosis (TB) cases in the United States and there is a potent link between human immunodeficiency virus (HIV) and tuberculosis. In New City it is estimated that 40% of the 200,000 injecting drug users are infected with HIV. In addition, the tuberculosis case rate is approximately four times the national average, and one third of these cases occurred in those persons infected with HIV. Drug users have a high prevalence of latent tuberculous infection and are at high risk for progression to active tuberculosis. Drug users are at high risk for both HIV and TB. Although studies have shown the value of incorporating TB services into drug treatment programs, the majority of drug users in the United States are not in drug treatment. We have been evaluating the feasibility of conducting TB screening and directly observed TB preventive therapy for active injecting drug users at a syringe exchange program in New York City. This paper describes issues relating to the implementation of the TB screening program and discusses general and operational issues relevant to integrating medical and public health programs into existing programs serving drug using individuals.

AIDS-Related Opportunistic Infections↗
PubMedDate not supplied

The experience of respiratory isolation for HIV-infected persons with tuberculosis.

A recent resurgence of tuberculosis (TB) has been driven mostly by the HIV epidemic. The initial inpatient experience for individuals with HIV-related TB may be pivotal to the acceptance of and participation in ongoing TB care. The purpose of this study was to develop an understanding of the experience of respiratory isolation for HIV-infected patients with TB in order to identify strategies for enhancing quality of life and participation in care. Respondents (N = 18) identified 12 major themes related to the isolation and reported more mood disturbances during their confinement than the norm. This study suggests that staff behaviors which foster human connections may enhance the patient's quality of life and promote adherence to therapy.

Adaptation, Psychological↗