Short-course chemotherapy for tuberculosis with mainly twice-weekly isoniazid and rifampin. Community physicians' seven-year experience with mainly outpatients.

The general medical community in the United States has been rather slow in adopting short-course bactericidal chemotherapy for tuberculosis despite the clear demonstration of the advantage by several carefully controlled clinical trials. Reported herein is experience between January 1976 and December 1982 in 1,028 patients with bacteriologically proved pulmonary tuberculosis treated for nine months with isoniazid (300 mg) and rifampin (600 mg) daily for one month followed by twice-weekly isoniazid (900 mg) and rifampin (600 mg) for the other eight months. They were treated by 45 local practitioners and supervised by public health nurses through 60 Arkansas Department of Health chest clinics in the state. Outpatient therapy was mostly self-administered in the routine treatment program. Overall success was achieved in 95 percent of the 751 patients who completed therapy; in 21 (2.8 percent), sputum cultures failed to convert to negative, and 15 (2.1 percent) have had relapse since therapy was stopped. Therapy could not be completed in 26.9 percent due to deaths, drug toxicities, relocation, refusal, etc. Of 21 bacteriologic failures, 18 patients developed isoniazid resistance and were treated with additional two bactericidal drugs. Most of the relapses (nine of 15) occurred within 12 months after chemotherapy was stopped. However, four relapses occurred quite late during follow-up. Only three of 15 patients with relapse showed isoniazid resistance. Side effects of the drugs were encountered in 10.3 percent, but major toxicities occurred in 3.2 percent (hepatitis in 2.6 percent, hematologic effects in 0.6 percent). Clinical surveillance for toxicity is preferred over routine and regular biochemical monitoring. Patient acceptance of the regimen was excellent, and compliance was good. Short-course chemotherapy is effective, with low drug toxicity, reduced cost of drugs, and ease of direct supervision when needed, and is acceptable to patients in routine treatment.

Short-course chemotherapy for tuberculosis in children.

Short-course, largely twice-weekly chemotherapy for tuberculosis was introduced in the United States for treatment of adults with pulmonary disease by the Arkansas State Department of Health in 1976. Since 1977, 50 children with tuberculosis have been treated with rifampin, 10 to 20 mg/kg, and isoniazid, 10 to 20 mg/kg daily for one month followed by 10 to 20 mg/kg of rifampin and 20 to 40 mg/kg of isoniazid twice a week for another 8 months. Ages ranged from 4 months to 15 years with a median age of 3 years. A presumptive diagnosis of tuberculosis was made on the basis of 10 mm or more of induration to 5 TU of purified protein derivative and a chest film or other findings compatible with tuberculosis. Three children had extrapulmonary disease (two had cervical adenitis, one had tuberculosis arthritis). Of the 47 children with pulmonary disease, 32 were asymptomatic. The results were excellent. Symptoms cleared in 1 to 2 months. Most pulmonary infiltrates had cleared by 10 months, but hilar adenopathy rarely cleared in less than 2 years. Drug toxicity occurred in only one patient (vomiting of rifampin). This treatment appears to be safe, effective, inexpensive, short and simple enough to ensure cooperation or to allow personnel to administer drugs directly to children from socially disorganized families.

Short-course chemotherapy of tuberculosis with largely twice-weekly isoniazid-rifampin.

Although short-course, largely twice weekly chemotherapy for treatment of tuberculosis has been shown to be effective in other countries, when given under closely controlled conditions, it has not been adopted in this country where most patients are older and are treated as outpatients. Since January, 1976, 315 patients (mean age 55.5 years) with proven pulmonary tuberculosis have been treated with rifampin (RIF) 600 mg and isoniazid (INH) 300 mg daily for one month, followed by RIF 600 mg and INH 900 mg twice-weekly for another eight months, self-administered except for a few patients. By three months, 95 percent had converted to negative culture. There were only ten failures among 185 patients in whom final results could be assessed. There has been only one relapse during 1-21 months of follow-up in 175 patients. Serious side effects were few: six instances of jaundice, two of "flu-like syndrome," and one of thrombocytopenia. This form of initial therapy for tuberculosis is safe, effective, and economical.

Short-course chemotherapy for pleural tuberculosis. Nine years' experience in routine treatment service.

Short-course chemotherapy (SCC) for pulmonary tuberculosis for nine months with isoniazid (INH) and rifampin (RIF) is well established. However, there is still no report on results of such therapy in pleural disease. From January 1976 through December 1984, we treated 201 patients (average age 61.6 years) for pleural tuberculosis, 143 with SCC for nine months of mainly INH and RIF and 58 with conventional therapy (CT) for 18 to 24 months. Findings indicated that SCC with INH and RIF was as effective as in pulmonary tuberculosis. The results were equivalent or even better than CT given for prolonged periods.

Follow-up of patients with tuberculosis treated in a general hospital program. Treatment largely as outpatients by community physicians.

As of December 1975, there had been 5 to 8 1/2 years of observation on 263 patients with bacteriologically proven tuberculosis who were initially admitted to a general hospital and were treated largely as outpatients by community physicians from July 1967 through December 1970. Ten patients died during hospitalization, and 253 were released to therapy as outpatients. Although smears or cultures of sputum remained positive at discharge in 136 (54 percent) of the 253 patients, no new infections were subsequently detected among their contacts. During initial therapy, 24 patients died of causes other than tuberculosis. Of the remaining 229 patients, the original 18-month treatment was successful in 197 (86 percent). The treatment failed initially in 11 patients, eight of whom represented relapses from previous therapy. During long-term follow-up of the 229 patients, there were only six relapses (3 percent) after the initial success. An overall rate of successful treatment of 92 percent (211/229) was achieved in the program, with 18 failures of treatment (8 percent); ie, 11 patients were lost to supervision, four died of tuberculosis, and in three, treatment was never successful.

Epidemic tuberculosis in a nursing home: a retrospective cohort study.

In a retrospective study, the results of tuberculin skin tests done in a nursing home were examined, where most residents admitted during 1972-1981 were tested using purified protein derivative of tuberculin administered intradermally. Of 514 residents who were tested at least once during the study period, results of the admission skin test were available for 254 and follow-up skin test results were available for 226. On admission, 13 per cent (35/254) were skin-test positive (greater than or equal to 10 mm induration at 48 hours). Skin test positivity for males was 16 per cent, females, 11 per cent, nonwhites, 19 per cent, and whites, 12 per cent. Highest skin test positivity was for persons received as transfers from other nursing homes (24 per cent) and lowest was for those entering from individual homes (8 per cent, P = 0.016, Fisher's Exact Test). On follow-up, 38/226 (17 per cent) residents who had been tuberculin-negative on at least two previous occasions were found to be positive; 24 (63 per cent) of these conversions occurred in a single year (1975) following detection of an infectious patient. The infection rate for persons residing in the nursing home during that year was 28 per cent (28/99) compared with 7.9 per cent (10/127) for persons either discharged before or admitted after 1975 (relative risk = 3.6, P less than 0.001). Ten to 15 per cent of new residents are tuberculin-positive (harbour a dormant tuberculous infection), leaving 85-90 per cent of newly admitted persons who are tuberculin-negative and thus susceptible to infection if exposed. The study shows that tuberculosis must be considered as a potential nosocomial infection in nursing homes.(ABSTRACT TRUNCATED AT 250 WORDS)

The networked health enterprise: a vision for 2008.

Informatics and information technology hold the promise of a consumer-centered health enterprise--one that provides quality care at a cost society is willing to pay; one where need-based, adaptive, competency-based learning results in cost-effectiveness of health education; one where team-based health and learning on demand, coupled with monitoring of process outcomes and network access to expertise, guarantee quality. The barriers to this promise are the professional guilds, the cross-subsidies that support the health enterprise of 1998, and the lack of respect for privacy. Collectively, the informatics community needs to develop a compelling vision that will galvanize the health community to action. If the health community does not step up to this challenge, consumers will take advantage of disintermediation. Empowered by the network, they will go outside the system into hands that meet their needs.

The evolution of the IAIMS: lessons for the next decade.

The Integrated Academic (Advanced) Information Management System (IAIMS) initiative emerged in the early 1980s to respond to trends in biomedical information, transfer and access, and to identify the implications for health sciences libraries. Three recurrent themes have emerged as being essential to the creation of IAIMs: changing the paradigm; redirecting expenditures to build reuseable infrastructure; and working across cultural boundaries. An IAIMS penetrates an organization in four stages: from creating awareness; through development of foundation infrastructure; through integration as an extra effort; to integration as a byproduct of organizational structure and information architecture. Extension of the IAIMS to support a regional area is a natural fifth stage that reapplies the processes of the first four stages and re-uses the infrastructure that has been built within the cooperating organizations. Area IAIMSs have the potential to transform biomedicine by enabling new paradigms for manpower development and publication of information.

Computer-based physician order entry: the state of the art.

Direct computer-based physician order entry has been the subject of debate for over 20 years. Many sites have implemented systems successfully. Others have failed outright or flirted with disaster, incurring substantial delays, cost overruns, and threatened work actions. The rationale for physician order entry includes process improvement, support of cost-conscious decision making, clinical decision support, and optimization of physicians' time. Barriers to physician order entry result from the changes required in practice patterns, roles within the care team, teaching patterns, and institutional policies. Key ingredients for successful implementation include: the system must be fast and easy to use, the user interface must behave consistently in all situations, the institution must have broad and committed involvement and direction by clinicians prior to implementation, the top leadership of the organization must be committed to the project, and a group of problem solvers and users must meet regularly to work out procedural issues. This article reviews the peer-reviewed scientific literature to present the current state of the art of computer-based physician order entry.

Health informatics: linking investment to value.

Informatics and information technology do not appear to be valued by the health industry to the degree that they are in other industries. The agenda for health informatics should be presented so that value to the health system is linked directly to required investment. The agenda should acknowledge the foundation provided by the current health system and the role of financial issues, system impediments, policy, and knowledge in effecting change. The desired outcomes should be compelling, such as improved public health, improved quality as perceived by consumers, and lower costs. Strategies to achieve these outcomes should derive from the differentia of health, opportunities to leverage other efforts, and lessons from successes inside and outside the health industry. Examples might include using logistics to improve quality, mass customization to adapt to individual values, and system thinking to change the game to one that can be won. The justification for the informatics infrastructure of a virtual health care data bank, a national health care knowledge base, and a personal clinical health record flows naturally from these strategies.

Integration and beyond: linking information from disparate sources and into workflow.

The vision of integrating information-from a variety of sources, into the way people work, to improve decisions and process-is one of the cornerstones of biomedical informatics. Thoughts on how this vision might be realized have evolved as improvements in information and communication technologies, together with discoveries in biomedical informatics, and have changed the art of the possible. This review identified three distinct generations of "integration" projects. First-generation projects create a database and use it for multiple purposes. Second-generation projects integrate by bringing information from various sources together through enterprise information architecture. Third-generation projects inter-relate disparate but accessible information sources to provide the appearance of integration. The review suggests that the ideas developed in the earlier generations have not been supplanted by ideas from subsequent generations. Instead, the ideas represent a continuum of progress along the three dimensions of workflow, structure, and extraction.

Preparing librarians to meet the challenges of today's health care environment.

OBJECTIVE: Refine the understanding of the desirable skills for health sciences librarians as a basis for developing a training program model that reflects the fundamental changes in health care delivery and information technology. DESIGN: A four-step needs assessment process: focus groups developed lists of desirable skills; the research team organized candidate skills into a taxonomy; a survey of a random sample of librarians and library users assessed perception of importance of individual skills; and the research team framed, as a unifying hypothesis, a training model. SURVEY METHODS: The survey was distributed to random samples of 150 librarians, stratified by type of library, and 150 library users, stratified by type of use. A non-randomized sample was obtained by mounting the survey on a World Wide Web server. The survey instrument included 96 distinct skills organized into 13 categories. Respondents rated the importance of each skill on a Likert scale and provided a separate ranking by identifying the ten most important skills for the profession. RESULTS: Among the participants, 51% of librarians and 36% of library users responded to the survey. All categories of skills were rated above the midpoint of priority on the Likert scale. All groups rated personality characteristics and skills as most important, with an understanding of the health sciences, education, and research being rated comparably to technical skills. CONCLUSIONS: Health sciences librarians need a new educational model that provides them with broad-based tools to discover new roles and new resources for acquiring individual skills as the need arises. A unifying training model would involve trainees in developing their learning plan in a way that promotes proactive inquiry and self-directed learning, and it would rotate the trainees through projects to provide skills and an understanding of end-user work processes.

The IAIMS--an essential infrastructure for increasing the competitiveness of health care practices.

The eighth annual workshop of the IAIMS Consortium was devoted to exploring how information technology might provide the tools to allow health care practices to compete in the new health care environment while maintaining independence. The options that were discussed included: optimizing care of the patient in the local setting; reducing practice overhead by improving efficiency and effectiveness; and finding innovative strategies for providing health care and new products.

The Vanderbilt University fast track to IAIMS: transition from planning to implementation.

Vanderbilt University Medical Center is implementing an Integrated Advanced Information Management System (IAIMS) using a fast-track approach. The elapsed time between start-up and completion of implementation will be 7.5 years. The Start-Up and Planning phases of the project are complete. The Implementation phase asks one question: How does an organization create an environment that redirects and coordinates a variety of individual activities so that they come together to provide an IAIMS? Four answers to this question are being tested. First, design resources to be "scalable"--i.e., capable of supporting enterprise-wide use. Second, provide information technology planning activities as ongoing core functions that direct local efforts. Third, design core infrastructure resources to be both reusable and expandable at the local level. Fourth, use milestones to measure progress toward selected endpoints to permit early refinement of plans and strategies.

Designing medical informatics research and library--resource projects to increase what is learned.

Careful study of medical informatics research and library-resource projects is necessary to increase the productivity of the research and development enterprise. Medical informatics research projects can present unique problems with respect to evaluation. It is not always possible to adapt directly the evaluation methods that are commonly employed in the natural and social sciences. Problems in evaluating medical informatics projects may be overcome by formulating system development work in terms of a testable hypothesis; subdividing complex projects into modules, each of which can be developed, tested and evaluated rigorously; and utilizing qualitative studies in situations where more definitive quantitative studies are impractical.

A computerized obstetric medical record.

Duke University has utilized computerized obstetric medical records since 1971. System evolution is described. Deficiencies in the current system appear to evolve from the computer/human interface rather than from basic system design. Critical elements in system success are physician acceptance of the appearance of data collection sheets and printed notes and continual rapid response in programing modification to allow for physician individuality and changes in medical practice. The limiting factor in the potential usefulness of such a system is the rate of incomplete data collection. It is suggested that if the physician were to enter data directly into the computer through a terminal, data collection would be more accurate and complete.

Variation in vulnerability to tuberculosis in America today: random, or legacies of different ancestral epidemics?

OBJECTIVE: To test the hypothesis that vulnerability to infection by Mycobacterium tuberculosis is the norm for mankind but innate resistance to the infection is common in the USA today as a legacy of TB epidemics survived by one's ancestors. MEASUREMENTS: A reaction of 10 mm or more to a tuberculin skin test (TST) was used to determine the prevalence of infection following community outbreaks of the disease. For further information, a survey was conducted of prevalence of tuberculin reactivity among health-care workers with frequent exposures to tuberculosis patients during bronchoscopy and sputum collection. RESULTS: Sixty per cent of African Americans exposed in 26 community outbreaks were TST positive compared to only 40% of whites following comparable exposures. Similarly only 56 (41.2%) of 136 heavily exposed white health-care workers were TST positive. CONCLUSIONS: When considered in conjunction with contrasting ancestral histories of exposure to TB, these observations suggest a difference in frequency of an innate ability to respond protectively to M. tuberculosis and to mount an effective mechanism to destroy it. This is best explained as a process of natural selection among largely separate heavily exposed ancestors. Several recent reports have identified genetically mediated mechanisms of immunity that could be involved with reduced vulnerability to tuberculosis. An understanding of these processes could aid in the development of immunomodulatory agents or vaccines.

Persistence of a strain of Mycobacterium tuberculosis in a prison system.

SETTING: A prison system with an average year-end census of 9084 inmates. OBJECTIVE: To determine transmission dynamics of tuberculosis over a long period; to establish whether Mycobacterium tuberculosis strains responsible for disease in a prison system persist; and to determine whether patients in a community whose isolates cluster with those in a prison system are linked. DESIGN: Retrospective epidemiologic analysis was performed on tuberculosis cases reported in a prison system over a 9-year period. In addition, IS6110 RFLP patterns of M. tuberculosis isolates obtained from prisoners were compared with those of other cases from the state at large. The results of the RFLP analysis and the epidemiologic investigation were compared. RESULTS: Approximately 80% of tuberculosis cases in the prison system were clustered. Over 9 years, a single strain of M. tuberculosis accounted for more than 50% of cases. Patients from the community at large who were infected with the same strain were linked to the prison system. CONCLUSION: In spite of intensive tuberculosis control efforts, a single strain of M. tuberculosis has persisted in the prison system. Its persistence is accounted for by activation of latent infection in patients who, prior to being diagnosed and treated, infected other patients, who then sustained the transmission chain.

The history of tuberculosis as a global epidemic.

TB should be thought of as a slowly progressing worldwide epidemic. Initially it was a disease of lower mammals, and the etiologic agent probably preceded the development of man on earth. It became an uncommon endemic disease in man about the time man began to settle in villages and develop agriculture. Crowding in European cities, and later the industrial revolution in Europe, provided the necessary environmental conditions for the endemic disease to become epidemic. For the next 400 years, the disease was spread by European empire-building and colonization. It came late to sub-Saharan Africa and to the Pacific Islands, and still later to the highlands of New Guinea. The epidemic gradually wanes within a large population group as resistant individuals survive and reproduce. This natural resistance is reflected in the ability of the macrophage to control intracellular growth of the organism. The resistant host shows a chronic infection primarily affecting the lungs, whereas the highly susceptible host shows a rapidly fatal illness with generalized spread of disease to many organs. Survivors of the initial infection then show another type of resistance to reinfection that is based on sensitized T cells. When this system is only partially successful, the host becomes infectious and capable of spreading the infection widely. The study of the epidemiology of TB and the evaluation of various public health measures to prevent or contain the disease requires that the investigator have an understanding of the nature and duration of the TB epidemic in the particular population under study. This factor is a much greater determinant of the course of an epidemic than any public health measure that man can institute, just as the currents in a river can have a more powerful effect on the course of a canoe than the most vigorous paddler.

Tuberculosis in the elderly.

Elderly persons of today are survivors of a time when most adults were infected with tuberculosis. Although many people died at that time, others survived the initial infection but continued to harbor viable bacilli in dormant caseous and calcified lesions. This article discusses the tuberculin test in the elderly, transmission and risk of infection in nursing homes, clinical manifestations, diagnosis, management considerations, preventive therapy, and surveillance of tuberculosis in nursing homes.