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Drug-resistant tuberculosis
discover unknown unconscious sexual fears before giving them
zolpidem? Luis M Iruela, Vicente Ibañez-Rojo, Department of Psychiatry, Hospital 28035 Madrid, Spain
1 2 3 4 5
Enrique Baca
Puerta de Hierro, Universidad Autonoma de
Madrid,
WHO SCAN glossary. Spanish adaptation. Madrid: Meditor ed, 1993 121. Jaspers K. Psicopatologia general. Buenos Aires: Editorial beta, 1955: 175. Kaplan HI, Sadock JS, eds. Comprehensive textbook of psychiatry, 5th ed. Baltimore: Williams & Wilkins, 1989. Ansseau M, Pitchot W, Hansene M, Gonzalez-Moreno A. Psychotic reactions to zolpidem. Lancet 1992; 339: 809. Weintraub M, de Oliveira G, Moscucci M, Kelvie W, Surasky S. A two night preference technique for assessing the dose response and efficacy of hypnotics in insomniac patients. In: Sauvenet JP, Langer SZ, Morselli PL, eds. Imidazopyridines in sleep disorders. New York Raven Press, 1988: 249.
1991 to 1992 should be noted. The absolute value of the plotted results should not be taken as a serious basis of generalisation. The nature of the sampling process precludes this, since the population are those who came to Bellevue. It should be pointed out, however, that a large portion of the tuberculosis patients in New York City come to Bellevue. Nonetheless, we believe the variation of the percent resistance is likely to be indicative of the underlying dynamics of the incidence of multidrug resistant M tuberculosis. We remind readers that the focus of this discussion is the relative frequency of multidrug resistant M tuberculosis among tuberculosis patients and not the increasing incidence of tuberculosis in general. Bruce A
1
2
Drug-resistant tuberculosis SIR-Recent reportsn2 of a substantial increase in multidrugresistant strains of Mycobacterium tuberculosis among tuberculosis patients are cause for serious public concern.3 Much of the data were derived from patients who had positive specimens collected during the past few years, which is a rather short view over time. Bellevue Hospital is a large municipal centre mainly serving the indigent population of New York City, among whom the incidence of tuberculosis has historically been high. For more than two decades, the mycobacteriology laboratory at Bellevue has done drug susceptibility tests by the method of proportions4 and kept a file of results. A total of 6674 patients are represented in the file. We derived some statistics from this file of the test results for isoniazid and rifampicin. For these calculations, a patient’s specimen is considered to contain a resistant strain if any degree of resistance is detected for any of the drug concentrations tested. Each patient is counted only once in any analysis over the entire 21-year span. Two calculations were made with two criteria to determine a patient’s drug susceptibility status: the status of the patient was determined from the first (chronological) specimen; and the patient was counted as having multidrug resistant M tuberculosis if any of his/her tests from a single specimen within the file showed resistance to isoniazid and rifampicin (figure). The most obvious feature of the graph is that the resistance ratio has its ups and downs. In particular, the downturn from
Hanna, Stanley Bonk, Leo K Tick
NYU Medical Center, New York, NY 10016, USA; and Bellevue New York, USA
3 4
World Congress on Tuberculosis. November 16-19, 1992. Bethesda, MD, USA. Freiden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW. The emergence of drug-resistant tuberculosis in New York City. N Engl J Med 1993; 328: 521-26. National action plan to combat multidrug resistant tuberculosis. MMWR, June 19, 1992; 41. Kent PT, Kubica GP. Public health mycobacteriology: a guide for the level III laboratory. Atlanta: Department of Health and Human Services, 1985.
IDDM and rainfall SIR-Lee (Oct 9, p 927) shows a negative correlation between the incidence of diabetes and rainfall in Allegheny county, Pennsylvania, USA. We are interested in the influence of the environment on insulin-dependent diabetes mellitus (IDDM) development, and we have shown in an animal model that low temperature may increase diabetes incidence.1 Since 1989 a registry of all new cases of IDDM diagnosed in patients less than 15 years of age has been established in the Lazio region, Italy, which include the capital Rome, as part of the Eurodiab subarea A study. Data recorded since then with respect to the incidence of the disease have been remarkably constant.3 The analysis of incidence figures of four consecutive years confirmed seasonal variations (peaks in late autumn and spring), with the exception of the summer period June/July, 1992, when an unexpected rise of new cases was recorded (n = 15 vs an average of 8.7 in other years). The rainfall in the 4 years of the registry was within expected values for the season (15 mm). However, average rainfall in May/June 1992 was ten times higher (118 mm) than the previous 43 years, with only a modest reduction in temperature. Although the two types of analysis are not comparable, our findings do not support the Lee data. We think that the unexpected rise in the frequency of IDDM in our region may have been attributable to changes in environmental factors (in this case increased rainfall), which may in turn have favoured the development of intercurrent diseases, a well-known precipitating factor for the clinical onset of IDDM. Paolo Pozzilli, Natalia Raffaella Buzzetti
Visalli, Antonietta Suppa,
Instituto di Clinica Medica II, Universita’ di Roma "La
1
2
3
Figure: Variation in resistance of M tuberculosis to INH (isonlazid) and RIF (rifampicin) 1496
Hospital Center,
Sapienza", 00161 Rome, Italy
Williams AJK, Krug J, Lampeter EF, et al. Raised temperature reduces the incidence of diabetes in the NOD mouse. Diabetologia 1990; 33: 635-37. Green A, Gale EAM, Patterson CC, for the EURODIAB ACE Study Group. Incidence of childhood-onset insulin-dependent diabetes mellitus: the EURODIAB ACE study. Lancet 1992; 339: 905-09. Sebastiani ML, Suppa A, Fioriti E, et al. A record of type 1 diabetes over four consecutive years: evidence for climatic influence on diabetes incidence. Diabetologia 1993; 36: 670 (abstr).
zolpidem? Luis M Iruela, Vicente Ibañez-Rojo, Department of Psychiatry, Hospital 28035 Madrid, Spain
1 2 3 4 5
Enrique Baca
Puerta de Hierro, Universidad Autonoma de
Madrid,
WHO SCAN glossary. Spanish adaptation. Madrid: Meditor ed, 1993 121. Jaspers K. Psicopatologia general. Buenos Aires: Editorial beta, 1955: 175. Kaplan HI, Sadock JS, eds. Comprehensive textbook of psychiatry, 5th ed. Baltimore: Williams & Wilkins, 1989. Ansseau M, Pitchot W, Hansene M, Gonzalez-Moreno A. Psychotic reactions to zolpidem. Lancet 1992; 339: 809. Weintraub M, de Oliveira G, Moscucci M, Kelvie W, Surasky S. A two night preference technique for assessing the dose response and efficacy of hypnotics in insomniac patients. In: Sauvenet JP, Langer SZ, Morselli PL, eds. Imidazopyridines in sleep disorders. New York Raven Press, 1988: 249.
1991 to 1992 should be noted. The absolute value of the plotted results should not be taken as a serious basis of generalisation. The nature of the sampling process precludes this, since the population are those who came to Bellevue. It should be pointed out, however, that a large portion of the tuberculosis patients in New York City come to Bellevue. Nonetheless, we believe the variation of the percent resistance is likely to be indicative of the underlying dynamics of the incidence of multidrug resistant M tuberculosis. We remind readers that the focus of this discussion is the relative frequency of multidrug resistant M tuberculosis among tuberculosis patients and not the increasing incidence of tuberculosis in general. Bruce A
1
2
Drug-resistant tuberculosis SIR-Recent reportsn2 of a substantial increase in multidrugresistant strains of Mycobacterium tuberculosis among tuberculosis patients are cause for serious public concern.3 Much of the data were derived from patients who had positive specimens collected during the past few years, which is a rather short view over time. Bellevue Hospital is a large municipal centre mainly serving the indigent population of New York City, among whom the incidence of tuberculosis has historically been high. For more than two decades, the mycobacteriology laboratory at Bellevue has done drug susceptibility tests by the method of proportions4 and kept a file of results. A total of 6674 patients are represented in the file. We derived some statistics from this file of the test results for isoniazid and rifampicin. For these calculations, a patient’s specimen is considered to contain a resistant strain if any degree of resistance is detected for any of the drug concentrations tested. Each patient is counted only once in any analysis over the entire 21-year span. Two calculations were made with two criteria to determine a patient’s drug susceptibility status: the status of the patient was determined from the first (chronological) specimen; and the patient was counted as having multidrug resistant M tuberculosis if any of his/her tests from a single specimen within the file showed resistance to isoniazid and rifampicin (figure). The most obvious feature of the graph is that the resistance ratio has its ups and downs. In particular, the downturn from
Hanna, Stanley Bonk, Leo K Tick
NYU Medical Center, New York, NY 10016, USA; and Bellevue New York, USA
3 4
World Congress on Tuberculosis. November 16-19, 1992. Bethesda, MD, USA. Freiden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW. The emergence of drug-resistant tuberculosis in New York City. N Engl J Med 1993; 328: 521-26. National action plan to combat multidrug resistant tuberculosis. MMWR, June 19, 1992; 41. Kent PT, Kubica GP. Public health mycobacteriology: a guide for the level III laboratory. Atlanta: Department of Health and Human Services, 1985.
IDDM and rainfall SIR-Lee (Oct 9, p 927) shows a negative correlation between the incidence of diabetes and rainfall in Allegheny county, Pennsylvania, USA. We are interested in the influence of the environment on insulin-dependent diabetes mellitus (IDDM) development, and we have shown in an animal model that low temperature may increase diabetes incidence.1 Since 1989 a registry of all new cases of IDDM diagnosed in patients less than 15 years of age has been established in the Lazio region, Italy, which include the capital Rome, as part of the Eurodiab subarea A study. Data recorded since then with respect to the incidence of the disease have been remarkably constant.3 The analysis of incidence figures of four consecutive years confirmed seasonal variations (peaks in late autumn and spring), with the exception of the summer period June/July, 1992, when an unexpected rise of new cases was recorded (n = 15 vs an average of 8.7 in other years). The rainfall in the 4 years of the registry was within expected values for the season (15 mm). However, average rainfall in May/June 1992 was ten times higher (118 mm) than the previous 43 years, with only a modest reduction in temperature. Although the two types of analysis are not comparable, our findings do not support the Lee data. We think that the unexpected rise in the frequency of IDDM in our region may have been attributable to changes in environmental factors (in this case increased rainfall), which may in turn have favoured the development of intercurrent diseases, a well-known precipitating factor for the clinical onset of IDDM. Paolo Pozzilli, Natalia Raffaella Buzzetti
Visalli, Antonietta Suppa,
Instituto di Clinica Medica II, Universita’ di Roma "La
1
2
3
Figure: Variation in resistance of M tuberculosis to INH (isonlazid) and RIF (rifampicin) 1496
Hospital Center,
Sapienza", 00161 Rome, Italy
Williams AJK, Krug J, Lampeter EF, et al. Raised temperature reduces the incidence of diabetes in the NOD mouse. Diabetologia 1990; 33: 635-37. Green A, Gale EAM, Patterson CC, for the EURODIAB ACE Study Group. Incidence of childhood-onset insulin-dependent diabetes mellitus: the EURODIAB ACE study. Lancet 1992; 339: 905-09. Sebastiani ML, Suppa A, Fioriti E, et al. A record of type 1 diabetes over four consecutive years: evidence for climatic influence on diabetes incidence. Diabetologia 1993; 36: 670 (abstr).