Three months of weekly rifapentine plus isoniazid for latent tuberculosis treatment in solid organ transplant candidates.

BACKGROUND: Isoniazid daily for 9 months is the recommended regimen for latent tuberculosis infection (LTBI) in solid organ transplant (SOT) candidates, but its use is controversial, due to reports of hepatotoxicity and low treatment completion rates. A 12-week course of once weekly directly observed therapy (DOT) with isoniazid plus rifapentine (3HP) is a new LTBI treatment regimen. Tolerability and safety data of 3HP LTBI treatment in SOT candidates are limited. METHODS: Twelve consecutive SOT candidates who underwent DOT with 3HP for LTBI at Westchester Medical Center, Valhalla, New York, USA, between January 2013 and August 2016 were prospectively evaluated for tolerability and safety of 3HP. The diagnosis of LTBI was made in a person with a positive interferon-gamma release test, without a history of previously treated active or latent tuberculosis infection, and without signs, symptoms, or radiographic evidence of active tuberculosis. Patients were followed up 1 month after treatment completion and at routine follow-up visits with their transplant providers. RESULTS: Eleven patients were men, and the median age was 60 years (range 44-72). Eight patients were liver, and four kidney transplant candidates. The median Model for End-Stage Liver Disease (MELD score) was 17 (range 10-31). All patients completed treatment. Only a single patient developed transaminitis greater than twice the baseline value. Three patients underwent liver transplantation. None of them developed tuberculosis at 9, 22, or 40 months following transplantation. CONCLUSION: Directly observed 3HP LTBI treatment was not associated with hepatotoxicity, even in patients with higher MELD scores. Further studies are needed to confirm the safety and efficacy of this LTBI treatment regimen in the SOT population.

A randomized trial of hypothesis-driven vs screening neurologic examination.

OBJECTIVE: We hypothesized that trainees would perform better using a hypothesis-driven rather than a traditional screening approach to the neurologic examination. METHODS: We randomly assigned 16 medical students to perform screening examinations of all major aspects of neurologic function or hypothesis-driven examinations focused on aspects suggested by the history. Each student examined 4 patients, 2 of whom had focal deficits. Outcomes of interest were the correct identification of patients with focal deficits, number of specific deficits detected, and examination duration. Outcomes were assessed by an investigator blinded to group assignments. The McNemar test was used to compare the sensitivity and specificity of the 2 examination methods. RESULTS: Sensitivity was higher with hypothesis-driven examinations than with screening examinations (78% vs 56%; p = 0.046), although specificity was lower (71% vs 100%; p = 0.046). The hypothesis-driven group identified 61% of specific examination abnormalities, whereas the screening group identified 53% (p = 0.008). Median examination duration was 1 minute shorter in the hypothesis-driven group (7.0 minutes vs 8.0 minutes; p = 0.13). CONCLUSIONS: In this randomized trial comparing 2 methods of neurologic examination, a hypothesis-driven approach resulted in greater sensitivity and a trend toward faster examinations, at the cost of lower specificity, compared with the traditional screening approach. Our findings suggest that a hypothesis-driven approach may be superior when the history is concerning for an acute focal neurologic process.

Frequency of respiratory disorders and bradycardia in essential tremor - consideration of treatment.

Essential tremor (ET) is a common movement disorder and the prevalence rate increases with age. The most frequently prescribed and perhaps the most effective drugs for symptomatic treatment of ET are beta-blocking drugs such as propranolol. Some beta blockers are contraindicated in respiratory disorders (RD) and in cardiac conditions such as bradycardia, the frequency of which is unknown in ET patients. We studied RD and bradycardia (BPM

The risk of hepatitis B transmission from staff to patients in hemodialysis units--an overrated problem?

The staff and patients in hemodialysis units have the greatest hospital risk of acquiring hepatitis B (HB) infection. We followed the patients of two dialysis nurses in two different dialysis units. One nurse dialyzed 19 patients a total of 50 times during the prodrome of acute HB. The second nurse was a known, asymptomatic carrier of HBsAg who was also HBeAg(+) and anti-HBc(+). Over a 2-year period, she dialyzed 30 patients a total of 742 times. Neither group of patients showed evidence of having acquired HB, suggesting that the risk of HB transmission from staff to patient is low even in the high-risk setting of a dialysis unit and a presumably highly infectious HBeAg(+) chronic carrier. In our study, the risk in this latter setting was less than 0.0040 (binomial probability p less than 0.05). The data do not support restricting care of patients by health workers who are chronic carriers of the virus.

Sulindac (Clinoril) hepatitis.

A patient with Sulindac-induced hepatitis is presented. Sulindac was confirmed as the cause of the patient's liver disease when hepatic dysfunction abruptly recurred after an inadvertent reexposure to Sulindac and quickly resolved when the drug was withdrawn. The prompt reappearance of fever, chills, pruritus, rash, tender hepatomegaly, and abnormal liver tests after only two doses of Sulindac suggested a hypersensitivity reaction.