Homograft repair of a tuberculous pseudoaneurysm of the ascending aorta.

A 34-year-old HIV-positive black man with pulmonary tuberculosis developed progressive widening of the mediastinum. Evaluation by CT and two-dimensional echocardiography demonstrated a large saccular aneurysm of the ascending aorta. This was repaired with a 26-mm aortic homograft using deep hypothermic circulatory arrest. The microbiology of the aneurysm contents showed this to be a tuberculous pseudoaneurysm.

Long-term hospitalization for tuberculosis control. Experience with a medical-psychosocial inpatient unit.

CONTEXT: Patients with tuberculosis (TB) who are nonadherent to therapy or have complicated medical or social problems pose a threat to public health. In some cases, hospitalization may be a necessary component of a comprehensive TB control program. OBJECTIVE: To describe experience with a new inpatient program for TB control. DESIGN: Retrospective review. SETTING: Eighteen-bed, secure, TB treatment unit in a state public health hospital providing a spectrum of acute and chronic care services. PATIENTS: Patients with known or suspected TB who were unable to be treated as outpatients and were hospitalized from 1990 through 1995. INTERVENTIONS: Voluntary or involuntary hospitalization, with medical, psychosocial, and legal services. MAIN OUTCOME MEASURES: Admissions, treatment completion, and disposition. RESULTS: A total of 166 patients with a confirmed diagnosis of TB accounted for 214 hospitalizations for TB. The mean age was 42 years, 132 (79.5%) were men, 84 (50.6%) were nonwhite, and 45 (27.1%) were foreign born. At the time of admission, 58 patients (34.5%) were homeless, 116 (69.9%) had a history of abuse of alcohol or other drugs, and 46 (31.7%) were positive for human immunodeficiency virus. The mean length of stay was 119.7 days (median, 70 days; range, 7-656 days), and was higher among homeless patients than nonhomeless patients (168.8 vs 93.4 days). Of 48 patients (28.9%) who were admitted involuntarily, 21 required long-term confinement under court order. Admission indications (not mutually exclusive) changed over 5 years: nonadherence decreased (95% to 34%), medical complexity increased (14% to 77%), short-term isolation increased (19% to 39%), and involuntary admission decreased (54% to 13%). Of 157 patients with positive cultures for Mycobacterium tuberculosis, 36 (23.1%) were resistant to at least 1 drug, including 16 who were multidrug resistant. A total of 123 patients (74.7%) were discharged to an outpatient setting to complete therapy, 40 (24.1%) required inpatient care to complete therapy, and 3 died (1 from TB) before discharge. CONCLUSIONS: A high proportion of patients with TB who failed outpatient therapy completed treatment in a combined medical and psychosocial inpatient unit. During the 5-year study period, involuntary admissions decreased and most patients completed therapy as outpatients. In Massachusetts, this program plays an important role in protecting public health and in providing specialized medical management for patients to complete therapy in a safe and supportive environment.