Assessing the validity of tuberculin skin test readings by trained professionals and patients.

STUDY OBJECTIVES: To assess the validity of purified protein derivative (PPD) readings by patients and trained health-care professionals as compared with a calibrated model. DESIGN AND PARTICIPANTS: Survey of a group of patients, nurses, medical assistants, and physicians at five neighborhood health centers in the Bronx, NY. INTERVENTIONS: Participants were asked to read a calibrated model with four PPD indurations measuring 0 mm, 3 mm, 7 mm, and 13 mm. Indurations > or = 5 mm were to be considered "positive" reactions. MEASUREMENTS AND RESULTS: Data were obtained from 233 patients and 80 trained professionals. All patients correctly measured the 0-mm induration site and were able to detect the presence of an induration in 99.3% of possible observations. Compared with professionals, patients had more variability in measurements and interpretations of the 3-, 7-, and 13-mm sites. Professionals detected 100% of all indurations. Patients' specificity for the 0- and 3-mm sites was 97.4% and 62.7%, respectively; whereas sensitivity for the 7- and 13-mm sites was 68.2% and 89.3%, respectively. Professionals' specificity for the 0- and 3-mm sites was 98.7% and 65.3%, respectively; their sensitivity for the 7- and 13-mm sites was 86.7% and 97.3%, respectively. Seventy percent of professionals agreed that the model was a realistic representation of PPD indurations. CONCLUSIONS: Patients can reliably distinguish between the presence and absence of an induration at a PPD injection site. They are not as reliable in the measurement and interpretation of test reactions. Professionals had considerable variability in their assessments of PPDs but were more precise overall in their assessments than patients.

Impact of problem-based learning on residents' self-directed learning.

OBJECTIVE: To examine the effect of a problem-based learning (PBL) curriculum on self-directed learning behaviors among a group of pediatric residents. METHODS: A controlled comparison study was conducted with 80 pediatric residents at a large urban academic medical center. Residents were observed over 3 distinct but consecutive periods. First, all residents participated in a 3-month-long daily lecture series (pre-exposure phase). Then, for another 3 months, 39 residents (PBL group) were exposed to twice-weekly PBL sessions while 41 residents continued with the daily lectures (lecture-based group) and served as controls. Problem-based learning was withdrawn after 3 months and all residents returned to the lecture series (follow-up phase). Residents' self-directed learning behaviors were assessed through self-administered questionnaires during the pre-exposure, exposure, and follow-up phases. RESULTS: There were no significant preexposure differences in self-directed learning behaviors between the groups. During the exposure phase, the PBL group had significantly higher self-directed learning: 5 or more hours of independent study (26% vs 7%) [corrected] (P=.001); 5 or more hours of medical discussions (28% vs 4%) (P=.008); 2 or more computer literature searches (51% vs 30%) (P=.005); and total hours of self-study per week (6 vs 4 hours) (P<.05). At the 3-month follow-up, the PBL group had returned to baseline levels of self-directed learning and there were no significant differences between the groups. CONCLUSION: Residents exposed to PBL engaged in significantly higher levels of self-directed learning than their counterparts.

Folk use of elemental mercury: a potential hazard for children?

Human beings have used elemental mercury (also known as metallic mercury) for thousands of years. Early ignorance of its potential toxicity resulted in devastating adverse effects, including neurodevelopmental and behavioral deficits among exposed persons. These adverse effects most commonly resulted from exposure to the vapor of elemental mercury. Recognition of the toxicity of elemental mercury has led to strict regulation of its use in occupational settings.

Outcomes of training pediatricians to serve the underserved: social pediatrics.

The Residency Training Program in Social Pediatrics (RPSP) was established in 1970 as part of the Residency Training Program in Social Medicine administered by Montefiore Medical Center in the South Bronx of New York City in response to local need for physicians to practice in underserved populations in the inner-city setting. We report on an analysis of the first 25 years of the RPSP, based on periodic surveys of all program graduates and demographic data. We conclude that our Social Pediatrics training program has been clearly successful in meeting its stated goal of producing physicians who will make a lifetime commitment to the practice of medicine in underserved communities.

After-hours telephone calls by parents at an inner-city community health center.

After-hours telephone consultation is a well-established component of the practice of pediatric medicine. We describe an assessment of the propriety of after-hours telephone calls made by parents at an inner-city pediatric clinic. We conclude that an inner-city pediatric clinic experienced neither more frequent nor less urgent calls in comparison to the data published for private practice suburban settings.

Evaluation of a risk assessment questionnaire used to target tuberculin skin testing in children.

CONTEXT: Universal tuberculin skin testing of children has been shown to be costly and inefficient. In response, several authorities have recommended targeted screening based on epidemiological risk. In 1996, the New York City Department of Health (NYCDOH) developed questions to identify children who require a tuberculin skin test. OBJECTIVE: To determine the sensitivity, specificity, and predictive validity of the NYCDOH tuberculosis risk assessment questionnaire. DESIGN: Prospective criterion standard study in which tuberculin skin tests and the NYCDOH questionnaire were administered simultaneously between August 1996 and January 1998. Specific questions asked about contact with a tuberculosis case, birth in or travel to endemic areas, regular contact with high-risk adults, and human immunodeficiency virus infection in the child. SETTING: Ambulatory clinic in South Bronx, New York, NY. PARTICIPANTS: Consecutive sample of 2920 children aged 1 to 18 years. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values of the questionnaire, and odds ratio (OR) of reactive skin test results. RESULTS: The NYCDOH questionnaire identified 413 children (14%) as having at least 1 risk factor. Of these, 23 (5.6%) had a positive skin test result; 4 (0.16%) of the 2507 without risk factors had a positive result. Results for the full NYCDOH questionnaire were sensitivity, 85.2%; specificity, 86.0%; negative predictive value, 99.8%; positive predictive value, 5.4%; and OR, 35.2 (95% confidence interval, 12.1-102.4). CONCLUSION: The NYCDOH questionnaire is a valid instrument for identifying children for tuberculin skin testing.