Tuberculosis transmission among five school bus drives and students in two New York countries

OBJECTIVE: Between November 1994 and April 1995, more than 3300 students in 49 schools in two countries in New York were potentially exposed to five school bus drivers with tuberculosis. This investigation was carried out to determine the extent of transmission of Mycobacterium tuberculosis among students. METHODS: Components of the epidemiologic investigation included tuberculin skin-test screening and collection of demographic information for students exposed to a driver with tuberculosis, chest radiography and medical evaluation of individuals with positive skin tests, and DNA fingerprinting of M tuberculosis isolates. A positive skin test was defined as >/=10 mm induration, and a converter was an individual with an increase in reaction size of >/=10 mm in the past 2 years. RESULTS: The rates of positive skin tests were 0.8 percent, 0.3 percent, 9.9 percent, 1.1 percent and 0.7 percent among US-born student exposed to drivers 1 through 5, respectively. The relative risk for a positive tuberculin skin test was significant only for student expose to driver 3 and the only secondary case identified among students was exposed to driver 3. The DNA fingerprinting patterns of isolates from drivers 3 and 4 matched. CONCLUSION: There was no clear evidence of transmission of M tuberculosis to students from driver 1, 2, 4, or 5. However, evidence suggests the driver 3 transmitted M tuberculosis to students and another driver. Routine annual tuberculin skin-test screening of drivers would not have prevented these tuberculosis exposures(AU)

Tuberculosis transmission among five school bus drivers and students in two New York counties.

OBJECTIVE: Between November 1994 and April 1995, more than 3300 students in 49 schools in two counties in New York were potentially exposed to five school bus drivers with tuberculosis. This investigation was carried out to determine the extent of transmission of Mycobacterium tuberculosis among students. METHODS: Components of the epidemiologic investigation included tuberculin skin-test screening and collection of demographic information for students exposed to a driver with tuberculosis, chest radiography and medical evaluation of individuals with positive skin tests, and DNA fingerprinting of M tuberculosis isolates. A positive skin test was defined as >/=10 mm induration, and a converter was an individual with an increase in reaction size of >/=10 mm in the past 2 years. RESULTS: The rates of positive skin tests were 0.8%, 0.3%, 9.9%, 1.1%, and 0.7% among US-born students exposed to drivers 1 through 5, respectively. The relative risk for a positive tuberculin skin test was significant only for students exposed to driver 3, and the only secondary case identified among students was exposed to driver 3. The DNA fingerprint patterns of isolates from drivers 3 and 4 matched. CONCLUSION: There was no clear evidence of transmission of M tuberculosis to students from drivers 1, 2, 4, or 5. However, evidence suggests that driver 3 transmitted M tuberculosis to students and another driver. Routine annual tuberculin skin-test screening of drivers would not have prevented these tuberculosis exposures.

Assessment of renal function during pregnancy using a random urine protein to creatinine ratio and Cockcroft-Gault formula.

The current standard for assessment of renal function in pregnant women is a 24-hour urine collection to determine creatinine clearance and proteinuria. It is easier to use the random urine protein to creatinine (P:C) ratio and the Cockcroft-Gault (CG) formula to estimate protein excretion and glomerular filtration rate, but the reliability of these formulae in combination for assessing renal function in pregnant women with renal disease is unknown. We compared the results of the P:C ratio with the 24-hour urinary protein excretion and the results of the CG clearance estimate with the 24-hour urine creatinine clearance in 34 pregnant women with underlying renal disease. Comparisons were made once in each trimester and postpartum. Prepregnancy weights were used in the CG formula: (140 - age x weight [kg] x 0.85)/72 x serum creatinine (mg/dL). Twenty-six first trimester, 33 second trimester, 21 third trimester, and 15 postpartum comparisons were made for creatinine clearance and 16 first trimester, 29 second trimester, 15 third trimester, and 15 postpartum comparisons were made for protein excretion. Measured creatinine clearance for the three trimesters combined (105 +/- 40 mL/min [mean +/- SD]) correlated significantly with CG clearances (113 +/- 52 mL/min; r = 0.87). The mean P:C values (2.03 +/- 3.15) for the three trimesters combined correlated significantly with 24-hour urine protein (2.25 +/- 4.21 g; r = 0.92). Our study demonstrates excellent correlations between the CG formula using prepregnancy weights and 24-hour creatinine clearance and between the P:C and 24-hour urinary protein in this population.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemoperitoneum complicating chronic peritoneal dialysis: single-center experience and literature review.

Hemoperitoneum is a well-recognized, if uncommon, complication of chronic peritoneal dialysis. In this review of 424 patients maintained on peritoneal dialysis at a single center during an 11-year period, 26 patients (6.1%) developed one or more episodes of hemoperitoneum. Three patients had hemoperitoneum on two separate occasions with different etiologies. One additional patient was seen on a hospital consultative service. Three types of bleeding episodes were observed. Twenty-one of 30 (70%) were benign, consisting of pink-tinged dialysate with little clinical consequence (group 1). Three (10%) consisted of minor hemoperitoneum associated with significant intra-abdominal pathology (group 2), and six (20%) required active intervention (group 3). The most frequent cause of hemoperitoneum was bleeding related to menstruation or ovulation; hemoperitoneum was more common in women than in men. Two patients had hemoperitoneum occurring after more than 6 years on dialysis. In both, the etiology was sclerosing peritonitis, an association not previously noted. The less common etiologies of hemoperitoneum encountered in our patients were similar to those in reports from other centers and are compiled here.

Resolution of cirrhotic glomerulonephritis following successful liver transplantation.

A 38-year-old man with liver failure due to Laennec's cirrhosis developed nephrotic range proteinuria and hematuria. Renal biopsy showed membranoproliferative glomerulonephritis with 2+ staining for IgA and complement consistent with cirrhotic glomerulonephritis. After orthotopic liver transplantation, proteinuria and hematuria rapidly resolved. This case indicates that glomerulonephritis associated with cirrhosis may be successfully treated with hepatic transplantation. Whether the improvement in glomerular abnormalities resulted from immunosuppression therapy or from restoration of normal hepatic function is unknown.

Atheroembolic involvement of renal allografts.

Renal atheroembolism is a well-recognized cause of renal insufficiency. Two renal allograft recipients with cholesterol atheroemboli in their allograft biopsies are described. In one patient, the origin of the atheroemboli was the recipient aorta while in the second patient the source was the donor. Renal allograft atheroembolism should be considered in elderly recipients or recipients of kidneys from older donors.

Hypercalcemia in patients with advanced chronic renal failure not yet requiring dialysis.

Six patients with progressive chronic renal failure not yet requiring dialysis and not consuming supplemental calcium or vitamin D developed hypercalcemia. Three had proven and 1 suspected tertiary hyperparathyroidism, 1 parathyroid carcinoma and 1 aplastic bone. None of the 3 patients who underwent bone biopsy had heavy bone aluminum staining. The patients with proven parathyroid-mediated hypercalcemia had marked elevation of C-terminal parathyroid hormone and alkaline phosphatase values and, when performed, radiographs consistent with osteitis fibrosa. When these findings are absent or the diagnosis is otherwise uncertain, a bone biopsy may provide a definitive diagnosis and guide management.

Variant of Bartter's syndrome with a distal tubular rather than loop of Henle defect.

A 19-year-old normotensive patient had all of the clinical features of Bartter's syndrome: hypokalemia, elevated renin and aldosterone levels and increased excretion of prostaglandin E. In contrast to the patients described by Bartter, the patient had a normal capacity to form solute-free water, suggesting intact loop of Henle function. Baseline potassium and chloride excretion rates were higher than those observed in 5 normal subjects, but the response to intravenous chlorothiazide, a drug which acts in the early distal convolute tubule, was abnormal. While chloride excretion rose by only 61% in this patient, it increased sixfold in the normal subjects. Sodium excretion quadrupled in the controls but less than doubled in this patients. Roughly equivalent increments in potassium excretion occurred in normals and controls, suggesting that the patient's distal potassium-secretory mechanism was intact. Review of the literature indicates that whether the site of the abnormal renal tubular potassium (chloride) leak is the proximal tubule, the loop of Henle or the distal convoluted tubule, patients may achieve features indistinguishable from those previously reported as characteristic for Bartter's syndrome. If loop of Henle malfunction is required to diagnose classical Bartter's syndrome, then our patient (and several reported elsewhere) has a variant form.

Chronic effects of nitrendipine on renal hemodynamics and tubular transport.

The effects of nitrendipine (10 mg, during acute clearance experiments) given both acutely and after 2 weeks of administration were examined in normal and hypertensive subjects. At the initiation of therapy, nitrendipine caused an increase in glomerular filtration rate and effective renal plasma flow in the hypertensive, but not in the normal, group. Percentage excretion rates of sodium (%ENa) and phosphate (%EPi) and free water clearance (CW) increased in both groups at the initiation of therapy. After 2 weeks of nitrendipine therapy repeat acute clearance studies showed that the drug no longer increased glomerular filtration rate or effective renal plasma flow in hypertensive subjects, the increases in %ENa and CW persisted in normal subjects and trended upward in hypertensive subjects, and the increase in %EPi persisted in both normal and hypertensive individuals. We conclude that nitrendipine is not sodium retentive after chronic therapy and the acute increase in %ENa, %EPi, and CW after its initial administration suggests a proximal tubular effect.

Evaluation of serological cross-reactivity between antibodies to Plasmodium and HTLV-III/LAV.

Serum samples from 460 patients with existing or previous Plasmodium infections, high antimalarial antibody titres, and no apparent risk of exposure to human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) were assayed for HTLV-III/LAV antibody; only 1 sample, from a 21-year-old African woman, was strongly reactive by enzyme-linked immunosorbent assay (ELISA) and positive by western blot. Conversely, no sample from 100 HTLV-III/LAV-positive American homosexual men was strongly reactive for antibodies to the four Plasmodium species that infect human beings by an indirect fluorescent antibody technique, or for antibodies to Plasmodium falciparum by an ELISA technique. Thus, exposure to Plasmodium does not result in HTLV-III/LAV seropositivity, and HTLV-III/LAV antibodies are not strongly cross-reactive with malarial antigens.