Evaluation of the electrolarynx in the short-term hospital setting.

We evaluated the effectiveness of the electrolarynx as a communication tool in the short-term hospital setting with 22 tracheostomized patients. Following an initial training period, we found that 14 of 22 patients achieved good results in communicating with the electrolarynx, three patients had fair results, and five patients had poor results. There were no differences in success rates for older or younger patients or for men or women; we could not correlate specific disease diagnosis with success or failure. The instrument could be effectively cleaned at the bedside. With the exception of patients who are severely confused or who have undergone extensive head and neck surgery, all tracheostomized patients can be considered candidates for this method of communication.

Tuberculin and anergy skin testing of patients receiving long-term hemodialysis.

STUDY OBJECTIVES: Immunocompromised patients with chronic renal failure requiring hemodialysis (HD) are at increased risk of developing tuberculosis (TB). Routine TB screening of this population is recommended. This study examined the frequency of TB reactions and anergy in HD patients in a community with a high prevalence of TB. DESIGN: Outpatients in a hospital-based HD center were screened with tuberculin, Candida, and mumps antigen. RESULTS: Forty percent of patients were anergic and 19% were tuberculin reactors. No demographic factors correlated with either test results. CONCLUSIONS: There was a high rate of TB infection and anergy in this HD center. Despite the high rate of anergy, tuberculin testing remains a useful test in this population. Anergic patients require further clinical evaluation for TB. Other HD programs should tuberculin and anergy test their patients to determine prevalence in their populations.

Directly observed therapy in an inner city hospital.

SETTING: A directly observed therapy (DOT) tuberculosis (TB) program in a large urban teaching hospital in the East Harlem section of New York City. OBJECTIVE: In response to an emergent epidemic of TB, the State Department of Health mobilized a coalition of providers outside the public sector to provide DOT and medical care for people with TB, with the goal of treatment until cure. The results of the first 150 patients of one program are reviewed. DESIGN: A multidisciplinary DOT team coordinated treatment at several sites within and without the institution, according to established medical regimens. RESULTS: The program served a hard-to-reach population, 63% human immunodeficiency virus (HIV) positive, 64% substance users, 17% inadequately housed and 15% indigent. In the program's first three years there was 85% overall compliance with DOT visits. Using the completion of therapy index, 66% of patients completed therapy, 13% remained on treatment, 7% transferred to self medication and 1% were lost to follow up. No patient on DOT developed a drug resistant organism. There were no hospital readmissions for TB. CONCLUSION: The experience of this program demonstrates the efficacy of an intensive, personalized DOT program in ensuring treatment until cure.

Hospital-acquired tuberculosis: addressing the challenge.

Treating contagious patients as outpatients is, of course, the best way to prevent nosocomial transmission. When hospitalized, they should be confined to areas with specified ventilation systems. Guidelines for monitoring exposed persons are presented. Immune status and drug-resistant organisms are prime considerations in managing both the exposed and those with active TB.

Interpretation of the tuberculin skin test.

OBJECTIVE: To reinterpret epidemiologic information about the tuberculin test (purified protein derivative) in terms of modern approaches to test characteristics; to clarify why different cutpoints of induration should be used to define a positive test in different populations; and to calculate test characteristics of the intermediate-strength tuberculin skin test, the probability of Mycobacterium tuberculosis infection at various induration sizes, the area under the receiver operating characteristic (ROC) curve, and optimal cutpoints for positivity. METHODS: Standard epidemiologic assumptions were used to distinguish M. tuberculosis-infected from -uninfected persons; also used were data from the U.S. Navy recruit and World Health Organization tuberculosis surveys; and Bayesian analysis. RESULTS: In the general U.S. population, the test's sensitivity is 0.59 to 1.0, the specificity is 0.95 to 1.0, and the positive predictive value is 0.44 to 1.0, depending on the cutpoint. Among tuberculosis patients, the sensitivity is nearly the same as in the general population; the positive predictive value is 1.0. The area under the ROC curve is 0.997. The probability of M. tuberculosis infection at each induration size varies widely, depending on the prevalence. The optimal cutpoint varies from 2 mm to 16 mm and is dependent on prevalence and the purpose for testing. CONCLUSIONS: The operating characteristics of the tuberculin test are superior to those of nearly all commonly used screening and diagnostic tests. The tuberculin test has an excellent ability to distinguish M. tuberculosis-infected from -uninfected persons. Interpretation requires consideration of prevalence and the purpose for testing. These findings support the recommendation to use different cutpoints for various populations. Even more accurate information can be gotten by interpreting induration size as indicating a probability of M. tuberculosis infection.

Public health campaign funds provide a "safety net" for indigent tuberculosis patients at the Mount Sinai Hospital.

This article describes the development of a partnership between a voluntary health care institution and a state agency for a focused public health program providing vital clinical, public health, and social supportive services. In addition to the historical development of this alliance, the article illustrates joint problem-solving processes to address complex issues. Since its inception in 1992, this collaboration has resulted in significant improvements in the health status of a high-risk, difficult-to-serve, indigent population that would otherwise pose a public health threat to the community. Demographics of 17 indigent patients are described. Nine have completed treatment for tuberculosis under directly observed therapy and completion is in sight for six others. None have been lost to follow-up.

Hospital care of tuberculosis patients referred for directly observed therapy in New York City: identifying factors in prolonged stays.

Individuals hospitalized and treated for tuberculosis (TB) who were then enrolled into TB directly observed therapy at four study hospitals in New York City (NYC) were identified. Review of hospital medical records determined whether the hospitalizations were warranted and whether lengths of stay were prolonged. Most hospitalizations were appropriate but over 70 percent of cases analyzed had prolonged stays. Of these, almost half were to document bacteriologic response to anti-TB treatment. Some were prolonged due to misunderstanding of state recommendations. Focused educational efforts could significantly reduce lengths of stay and save up to $9.7 million annually in NYC hospitalization costs.