Mortality hazard and survival after tuberculosis treatment.

OBJECTIVES: We compared mortality among tuberculosis (TB) survivors and a similar population. METHODS: We used local health authority records from 3 US sites to identify 3853 persons who completed adequate treatment of TB and 7282 individuals diagnosed with latent TB infection 1993 to 2002. We then retrospectively observed mortality after 6 to 16 years of observation. We ascertained vital status as of December 31, 2008, using the Centers for Disease Control and Prevention's National Death Index. We analyzed mortality rates, hazards, and associations using Cox regression. RESULTS: We traced 11 135 individuals over 119 772 person-years of observation. We found more all-cause deaths (20.7% vs 3.1%) among posttreatment TB patients than among the comparison group, an adjusted average excess of 7.6 deaths per 1000 person-years (8.8 vs 1.2; P < .001). Mortality among posttreatment TB patients varied with observable factors such as race, site of disease, HIV status, and birth country. CONCLUSIONS: Fully treated TB is still associated with substantial mortality risk. Cure as currently understood may be insufficient protection against TB-associated mortality in the years after treatment, and TB prevention may be a valuable opportunity to modify this risk.

Epidemiology of tuberculosis in young children in the United States.

OBJECTIVES: To estimate tuberculosis (TB) rates among young children in the United States by children's and parents' birth origins and describe the epidemiology of TB among young children who are foreign-born or have at least 1 foreign-born parent. METHODS: Study subjects were children <5 years old diagnosed with TB in 20 US jurisdictions during 2005-2006. TB rates were calculated from jurisdictions' TB case counts and American Community Survey population estimates. An observational study collected demographics, immigration and travel histories, and clinical and source case details from parental interviews and health department and TB surveillance records. RESULTS: Compared with TB rates among US-born children with US-born parents, rates were 32 times higher in foreign-born children and 6 times higher in US-born children with foreign-born parents. Most TB cases (53%) were among the 29% of children who were US born with foreign-born parents. In the observational study, US-born children with foreign-born parents were more likely than foreign-born children to be infants (30% vs. 7%), Hispanic (73% vs. 37%), diagnosed through contact tracing (40% vs. 7%), and have an identified source case (61% vs. 19%); two-thirds of children were exposed in the United States. CONCLUSIONS: Young children who are US born of foreign-born parents have relatively high rates of TB and account for most cases in this age group. Prompt diagnosis and treatment of adult source cases, effective contact investigations prioritizing young contacts, and targeted testing and treatment of latent TB infection are necessary to reduce TB morbidity in this population.

Examining the impact of patient characteristics and symptomatology on knowledge, attitudes, and beliefs among foreign-born tuberculosis cases in the US and Canada.

Foreign-born individuals represent the majority of TB cases in the US/Canada. Little is known about their TB knowledge, attitudes, and beliefs (KAB). Cross-sectional survey was conducted in 22 sites in the US/Canada among foreign-born adults with active TB. Multiple regression was used to examine KAB factors against covariates. Of 1,475 participants interviewed, most answered the six knowledge items correctly. Significant predictors of correct knowledge included region of origin, education, income, age, visa status, place of diagnosis, BCG vaccination, and TB symptoms. Significant predictors of higher perceived risk/stigma scores included region of origin, age, place of diagnosis, English fluency, time in the US/Canada, TB symptoms, and household rooms. This study examines associations between TB KAB and patient and disease characteristics in foreign-born individuals in the US/Canada. The findings call for improved health education, along with efforts to reduce stigma and enhance realistic risk assessments.

Employment status among adult survivors in the Childhood Cancer Survivor Study.

BACKGROUND: With increased cure, childhood cancer survivors are reaching adulthood and seeking employment. Host, disease and treatment risk factors may contribute to inability to attain or maintain employment. PROCEDURE: The prevalence and risk factors for unemployment were evaluated using self-reported employment history in 10,399 childhood cancer survivors and 3,083 siblings >/= age 18 in the Childhood Cancer Survivor Study (CCSS). RESULTS: Among survivors, 5.6% reported unemployment, compared with 1.2% of siblings (odds ratio [OR] 3.7; 95% confidence interval [CI] 2.6, 5.1). Increased risks were observed within all cancer diagnoses. In multivariate analysis, diagnosis of central nervous system (CNS) tumor (OR 1.5; 95% CI 1.1, 2.1), bone cancer (OR 1.5; 95% CI 1.0, 2.1), treatment with >/=30 Gy cranial radiotherapy (OR 4.0; 95% CI 2.9, 5.5), female gender (OR 1.4; 95% CI 1.2, 1.7) and age < 4 years at diagnosis (OR 1.4; 95% CI 1.1, 1.8) increased risk. Diagnosis of CNS or bone tumor or cranial radiotherapy >/=30 Gy remained significant after adjusting for treatment, medical late effects, age and gender. Risk of unemployment decreased with attained age (OR((year)) 0.89; 95% CI 0.87, 0.91). CONCLUSIONS: Compared to siblings, adult childhood cancer survivors are at increased risk for unemployment with highest risk defined by diagnosis, treatment and demographic factors.

Prospective randomized trial of high thoracic epidural analgesia for coronary artery bypass surgery.

BACKGROUND: Postoperative pain may be severe after coronary artery bypass surgery. High thoracic epidural analgesia (HTEA) provides intense analgesia. METHODS: Eighty patients were randomized to HTEA or intravenous morphine analgesia (control). Patients received coronary artery bypass surgery (CABG) with cardiopulmonary bypass. Pain was measured by visual analogue scale 0 to 10. Psychologic morbidity, intraoperative hemodynamics, ventricular function, lung function, and physiotherapy cooperation were also assessed. On the third postoperative day HTEA and morphine were ceased and only oral medications were used. Acetaminophen, indomethacin, and tramadol were allowed as supplemental analgesics in both groups. RESULTS: The primary endpoint of pain scores was significantly less with HTEA on postoperative days 1 and 2 at rest, 0.02 +/- 0.2 versus 0.8 +/- 1.8 (p = 0.008) and 0.1 +/- 0.4 versus 1.2 +/- 2.7 (p = 0.022), respectively, and with coughing 1.2 +/- 1.7 versus 4.4 +/- 3.1 (p < 0.001) and 1.5 +/- 2.0 versus 3.6 +/- 3.1 (p = 0.001), respectively. When HTEA and morphine were ceased on day 3, there were no significant differences. The secondary endpoints of postoperative depression (p = 0.033) and posttraumatic stress subscales (p = 0.021) of the Minnesota Multiphasic Personality Inventory were lower with HTEA. Extubation occurred earlier with HTEA, 2.6 versus 5.4 hours (p < 0.001). HTEA showed improved physiotherapy cooperation (p < 0.001), arterial oxygen tension (p = 0.041), and peak expiratory flow rate (p = 0.001). Mean arterial pressure was lower with HTEA (p = 0.036), otherwise there were no differences in intraoperative hemodynamics or ventricular function. CONCLUSIONS: Epidural analgesia reduces pain after coronary operation and is associated with improved physiotherapy cooperation, earlier extubation, and reduced risk of depression and posttraumatic stress.

Outcomes of planned home births in Washington State: 1989-1996.

OBJECTIVE: To determine whether there was a difference between planned home births and planned hospital births in Washington State with regard to certain adverse infant outcomes (neonatal death, low Apgar score, need for ventilator support) and maternal outcomes (prolonged labor, postpartum bleeding). METHODS: We examined birth registry information from Washington State during 1989-1996 on uncomplicated singleton pregnancies of at least 34 weeks' gestation that either were delivered at home by a health professional (N = 5854) or were transferred to medical facilities after attempted delivery at home (N = 279). These intended home births were compared with births of singletons planned to be born in hospitals (N = 10,593) during the same years. RESULTS: Infants of planned home deliveries were at increased risk of neonatal death (adjusted relative risk [RR] 1.99, 95% confidence interval [CI] 1.06, 3.73), and Apgar score no higher than 3 at 5 minutes (RR 2.31, 95% CI 1.29, 4.16). These same relationships remained when the analysis was restricted to pregnancies of at least 37 weeks' gestation. Among nulliparous women only, these deliveries also were associated with an increased risk of prolonged labor (RR 1.73, 95% CI 1.28, 2.34) and postpartum bleeding (RR 2.76, 95% CI 1.74, 4.36). CONCLUSION: This study suggests that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births.