Normal chest radiography in pulmonary tuberculosis: implications for obtaining respiratory specimen cultures.

SETTING: Urban tuberculosis (TB) clinic, Nashville, Tennessee, USA. OBJECTIVE: Chest radiographs (CXRs) help in the diagnosis of pulmonary TB, but may be normal. Mycobacterium tuberculosis in culture is diagnostic of TB, but cultures are not routinely obtained in resource-poor settings. We examined rates and risk factors for pulmonary TB associated with normal CXR. DESIGN: An observational cohort study was performed among all respiratory culture-positive TB cases referred to the Nashville Health Department from October 1992 to July 2003. Clinical factors, demographics and underlying medical conditions were assessed. RESULTS: Of 601 study patients, 53 (9%) had normal CXRs: 31/138 (22%) were human immunodeficiency virus (HIV) infected and 22/463 (5%) were non-HIV-infected/unknown (P<0.001). Among HIV-infected patients, normal CXR was more likely in persons with renal failure (13% vs. 3%, P=0.048). Among non-HIV-infected/unknown patients, normal CXR was more likely in those who were asymptomatic at presentation (32% vs. 13%, P=0.022). In multivariable logistic regression analysis, HIV infection was associated with an increased risk of normal CXR (odds ratio [OR] 6.61, P<0.0001); factors associated with reduced risk were dyspnea (OR 0.24, P=0.026), positive sputum smear (OR 0.45, P=0.028) and cough (OR 0.48, P=0.038). CONCLUSIONS: The rate of normal CXR among persons with culture-confirmed pulmonary TB was high. Respiratory specimen cultures should be obtained in TB suspects with a normal CXR, particularly HIV-infected persons.

Evaluation of a patient teaching skills course disseminated through staff developers.

Effective Patient Teaching (EPT), a course designed to improve health professionals' and health professions students' teaching skills, reliably produces gains in participants' skills when presented by its developers. The objective of this dissemination research study was to investigate whether, using a 'training of trainers' approach, seven nurses with staff development responsibilities in five different sites could teach EPT with similar effectiveness. The evaluation included pre- and post-course analysis of audiotaped patient education sessions conducted by 48 health professional participants who took EPT from one of the trainers in their home institutions. Post-course participant satisfaction surveys were also administered. EPT resulted in teaching skill improvements in four of five sites, and overall teaching skills scores improved significantly (P < 0.01). EPT can improve participants' teaching skills when taught by health professional trainers with staff development responsibilities who have recently received EPT training.