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Biomedical subjects

L B Reichman

Publications and source records attributed to L B Reichman.

At least 73 records · Page 4Linked to original sources
PubMed1991

Isoniazid as preventive therapy in HIV-infected intravenous drug abusers. A decision analysis.

Tuberculin skin testing is a notoriously poor marker of tuberculosis infection in patients who are serologically positive for the human immunodeficiency virus. A decision analysis was performed to determine if and when isoniazid should be prescribed to prevent tuberculosis in these patients. The decision was analyzed for an intravenous drug abuser who may have been anergic, while tuberculin test status, race, and gender were varied. The assumptions and parameter estimates selected for this investigation represent a highly conservative vantage point opposing the use of isoniazid as a preventive therapy. Nevertheless, results showed a benefit from the use of isoniazid as a preventive therapy for all groups, even without tuberculin testing, except tuberculin-negative black women. This benefit of isoniazid therapy increased patient life expectancy as much as 285 days. Further, the decisions continue to favor prescribing isoniazid even when the suspected incidence of tuberculosis infection falls as low as 3% to 8%. Tuberculin testing appears important primarily for black women, since those who have negative tuberculin skin tests may not be candidates for isoniazid therapy.

Adult↗
PubMed1991

Isoniazid preventive therapy for tuberculosis. Decision analysis considering ethnicity and gender.

The decision to prescribe or withhold isoniazid (INH) preventive therapy for low-risk tuberculin reactors has been highly controversial, primarily due to isoniazid's possible hepatotoxic effects. Previous analyses have explored the INH decision only from the perspective of patient age, recognizing that the risks of INH-induced hepatotoxicity are age related. Decision analyses presented in this paper assess the impact of gender and ethnic group, as well as age, on the INH decision. Results for low-risk patients favor prescribing INH preventive therapy for all 20-yr-olds, all 35-yr-olds except black women, and no 50-yr-olds, projecting life expectancy benefits that range from 3 to 19 days. A comparison set of analyses performed for high-risk patients favors prescribing INH for all groups except 50-yr-old black women. These findings suggest that ethnicity, gender, and age should be considered when making the decision to prescribe or withhold INH preventive therapy.

Adult↗
PubMed1991

Tuberculosis and the atypical pneumonia syndrome.

Literature over the last 30 years has warned of the atypical or unusual characteristics of pulmonary TB. Shifts in the demographic distribution of the disease in the US are ascribed in part to the occurrence of HIV disease outbreaks in group settings, and to recent influxes of immigrants from developing countries. Unsuspected pulmonary TB is particularly common among the elderly. Socioeconomic categories not traditionally thought of as being high risk also are affected. In the low-risk setting, TB can be treacherous because misdiagnosis is likely. Tuberculosis is a great mimicker, and it can appear to be any acute community-acquired pneumonia such as atypical pneumonia. Symptoms and signs are few. A high index of awareness is therefore essential. The approach to atypical pneumonia emphasizes the need to include TB in the differential diagnosis to be aware of the total disease spectrum of TB and understand the risk factors. The atypical pneumonia syndrome is only a portion of the clinical spectrum of TB.

Acquired Immunodeficiency Syndrome↗
PubMed1991

Pulmonary tuberculosis in the HIV-positive patients.

Tuberculosis associated with human immunodeficiency virus (HIV) infection continues to represent a serious medical and public health problem. Physicians' awareness of this entity is important because the diagnosis requires a high index of suspicion. A continuing increase in the cases of tuberculosis associated with HIV infection is predicted unless extensive efforts are directed toward detection of this dual infection and implementation of effective tuberculosis preventive therapy and treatment programs.

HIV Infections↗
PubMed1991

Treatment of tuberculosis.

The incidence of tuberculosis is increasing in the United States. Although the lung is still the most common site of infection, extrapulmonary disease is becoming more prevalent, particularly in patients infected with human immunodeficiency virus (HIV). Clinically active tuberculosis is treated with a combination of drugs. Recommended therapy consists of a six-month regimen of isoniazid and rifampin, with pyrazinamide given for the first two months. Longer regimens are used in patients infected with HIV. Monthly monitoring for adverse effects and treatment response is necessary. Compliance is the most important factor for successful treatment. Treatment failure usually requires the use of more toxic second-line drugs. In such cases, drug susceptibility studies may be useful.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Occupational tuberculous infections among pulmonary physicians in training.

The invasion of the lower respiratory tract by procedures and support measures such as fiberoptic bronchoscopy, endotracheal intubation, and mechanical ventilation generates respiratory aerosols. These aerosols have a potential for the transmission of tuberculosis and other infections. The follow-up of tuberculin skin test status among staff with exposure to this millieu was observed in hope of delineating whether a significant problem does exist. A questionnaire survey of tuberculin skin test status of graduating pulmonary fellows was performed. Graduating Infectious Disease Fellows formed the control group. Training programs situated in the top 25 cities for tuberculosis in 1983 were chosen if the Fellows spent a major proportion of their time in a large receiving/public hospital. The data returned were analyzed if the individual programs had both Pulmonary and Infectious Disease Fellows in training. Fourteen training programs supplied usable data over a 3-yr period. Seven of 62 (11%) of Pulmonary Fellows at risk converted their tuberculin skin test as opposed to one of 42 (2.4%) of Infectious Disease Fellows. This observation raises concern that more fastidious precautions are needed to isolate patients under these conditions of respiratory aerosol generation. The available armamentarium of nonrecirculated fresh air ventilation and ultraviolet light irradiation in addition to simply wearing face masks should be increasingly utilized. Further studies are warranted to substantiate the applicability of these measures to the current situation.

Communicable Diseases↗
PubMed1990

Severe anemia is an important negative predictor for survival with disseminated Mycobacterium avium-intracellulare in acquired immunodeficiency syndrome.

Disseminated Mycobacterium avium-intracellulare (MAI) in patients with the acquired immunodeficiency syndrome (AIDS) is usually unresponsive to antimycobacterial therapy. We examined clinical and laboratory characteristics of MAI organisms and their relationship to the length of survival. We studied factors influencing survival and compared these in 76 patients with AIDS with and without MAI. Serum levels of p24 antigen and erythropoietin, and CD4-positive helper T-lymphocytes in blood were assessed in 36 additional patients with various clinical stages of HIV infection. In patients with MAI infection, survival was significantly related only to total lymphocyte count, hematocrit, platelet count, and sex. Of these, hematocrit and total lymphocyte count were the only linear predictors of survival. Anemia was significantly more profound in patients with AIDS and MAI than in the other patients. This anemia in patients with MAI could not be ascribed to increased peripheral destruction of red cells, deficient nutritional factors, or erythropoietin production, HIV viral or bacterial load, or a general effect on other blood elements such as neutrophils or platelets. The influence of MAI on survival in patients with AIDS did depend upon whether the MAI occurred as an index infection or was preceded by other opportunistic infections. Patients with other preceding opportunistic infection lived for a much shorter duration from the time of diagnosis of MAI.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Once-daily versus twice-daily dosing of theophylline. A decision analysis approach to evaluating theophylline blood levels and compliance.

The question of whether to prescribe once-daily or twice-daily theophylline was investigated using decision-analysis techniques with sensitivity procedures. While the relative efficacies of the two theophylline preparations have been examined in a number of studies, previous efforts have not assessed the impact of compliance on therapeutic effectiveness. When a blood theophylline level of 10 to 20 micrograms is taken to constitute the therapeutic range, twice-daily has been shown to yield 15% greater efficacy than once-daily dosing. However, results of the present investigation suggest that a drop in compliance greater than 4 to 14%, associated with once- versus twice-daily dosing, would be sufficient to obliterate the apparent advantage of the twice-daily preparation. The existing empirical evidence suggests that selecting twice-daily over once-daily dosing will incur a drop in compliance that is substantially greater than 14%. Consequently, when the impact of compliance is incorporated into a decision analysis, once-daily dosing is favored over twice-daily dosing for most patients. The decision will favor twice-daily theophylline only in the unusual case in which continuity of contact with a given patient provides strong evidence that he/she is more than 80% likely to comply with the twice-daily regimen. Decision analyses applied to this topic would benefit greatly from better studies of compliance in asthmatic patients and more careful correlations of symptoms with varying medication usage.

Asthma↗
PubMed1989

Mycobacterial disease in patients infected with the human immunodeficiency virus.

Mycobacterial disease is an increasingly common and serious problem in patients infected with the human immunodeficiency virus. Whereas Mycobacterium avium complex organisms are noncommunicable and extremely difficult to treat, Mycobacterium tuberculosis is transmissible to patients who do not have the acquired immunodeficiency syndrome, but is preventable and treatable.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Tuberculosis skin testing and preventive therapy.

Tuberculin skin testing is a reliable tool for the detection of tuberculous infection and the eventual prevention of tuberculous disease. False-negative tests may occur in individuals with a compromised immune system, including those with human immunodeficiency virus (HIV) infection, persons taking immunosuppressive drugs (eg. corticosteroids), the severely malnourished, and the elderly. Nevertheless, it still is useful in detecting infection in those persons who are in close contact with patients with tuberculous disease, including family members, hospital personnel, and those from high risk areas. Once a skin test is found to be reactive, further diagnostic studies should be done to rule out tuberculous disease. Once ruled out, preventive therapy with isoniazid should be instituted. Suitable candidates for prophylaxis include all individuals with reactive tuberculin skin tests who are (1) household contacts of patients with tuberculous disease, (2) recent tuberculin test convertors, (3) individuals with prior tuberculosis (TB) who did not receive adequate chemotherapy, (4) all individuals under the age of 35, and (5) individuals in special clinical circumstances who are over the age of 35. Newer, shorter course regimens are currently being studied. TB cannot be eliminated until the importance of preventive therapy is recognized by all.

Humans↗