Prolonged positivity of sputum smears with negative cultures during treatment for pulmonary tuberculosis.

SETTING: Acid-fast bacilli (AFB) microscopy of sputum smears is the most widely used tool for both diagnosing pulmonary tuberculosis (PTB) and monitoring treatment response. It is not uncommon for patients who show clinical improvement to have prolonged positivity of sputum smears (i.e., ≥60 days after initiation of treatment) with corresponding negative cultures. OBJECTIVE: To assess treatment outcomes and characteristics associated with prolonged smear-positive, culture-negative status. DESIGN: A retrospective review was performed of all patients seen by the Cuyahoga County TB Program in Cleveland from 2000 to 2009. There were 159 consecutive smear-positive, drug-susceptible PTB cases with sufficient analyzable bacteriologic, clinical and radiographic data for study. RESULTS: A smear-positive, culture-negative pattern was seen in 51 patients (32.1%) ≥2 months after initiation of treatment. Age ≥46 years and extent of baseline chest X-ray abnormality were both significantly associated with a prolonged smear-positive, culture-negative pattern. No patients were culture-positive for Mycobacterium tuberculosis after ≥2 months. There was no increased risk of death in the prolonged smear-positive, culture-negative group, and no confirmed relapses. CONCLUSION: In our population of patients, in the absence of clinical or radiographic evidence of deterioration, late smear positivity usually has no clinical significance and requires no specific action.

Concordance of a positive tuberculin skin test and an interferon gamma release assay in bacille Calmette-Guérin vaccinated persons.

BACKGROUND: False-positive tuberculin skin test (TST) results due to prior bacille Calmette-Guérin (BCG) vaccination may lead to unnecessary treatment of presumed latent tuberculosis infection (LTBI). Recently approved interferon-gamma release assays (IGRAs) are more specific for LTBI in this group. METHODS: A total of 316 BCG-vaccinated foreign-born individuals with a positive TST had a commercially available IGRA (QuantiFERON®-TB Gold In-Tube) performed as part of a two-step procedure to determine the need for isoniazid therapy. Baseline demographic information and TST size were recorded and analyzed for characteristics associated with an increased likelihood of having a positive IGRA. RESULTS: Increasing age, male sex, origin from a country with a high prevalence of tuberculosis (TB), shorter time since arrival in the United States, and increasing TST size were all independently associated with a positive IGRA. CONCLUSION: Patient characteristics and TST size can help determine those at highest risk for LTBI. A two-step procedure for LTBI screening should be considered for foreign-born persons with prior BCG vaccination and a positive TST.

Sputum Mycobacterium tuberculosis mRNA as a marker of bacteriologic clearance in response to antituberculosis therapy.

mRNA is a marker of cell viability. Quantifying Mycobacterium tuberculosis mRNA in sputum is a promising tool for monitoring response to antituberculosis therapy and evaluating the efficacy of individual drugs. mRNA levels were measured in sputum specimens from patients with tuberculosis (TB) receiving monotherapy in an early bactericidal activity study of fluoroquinolones and in those receiving a standard rifampin-based regimen in an interleukin-2 (IL-2) trial. In the early bactericidal activity study, sputum for quantitative culture and mRNA analysis was collected for 2 days before and daily during 7 days of study drug administration. In the IL-2 trial, sputum was collected for quantitative culture, Bactec 460 liquid culture, and mRNA analysis throughout the intensive treatment phase. RNA was isolated from digested sputum and tested in quantitative reverse transcription-PCR assays for several gene targets. mRNA for the glyoxylate cycle enzyme isocitrate lyase declined at similar rates in patients receiving isoniazid, gatifloxicin, levofloxacin, and moxifloxacin monotherapy. Isocitrate lyase mRNA correlated highly with CFU in sputum prior to therapy and during 7 days of monotherapy in all treatment arms. Isocitrate lyase mRNA was detectable in sputum of culture-positive TB patients receiving a rifampin-based regimen for 1 month. At 2 months, sputum for isocitrate mRNA correlated more closely with growth in liquid culture than did growth on solid culture medium. Data suggest that isocitrate lyase mRNA is a reliable marker of M. tuberculosis viability.

Effect of teenage pregnancy on educational disabilities in kindergarten.

Teenage pregnancies have become a public health issue because of their observed negative effects on perinatal outcomes and long-term morbidity. The association of young maternal age and long-term morbidity is usually confounded, however, by the high prevalence of poverty, low level of education, and single marital status among teenage mothers. The authors assess the independent effect of teenage pregnancy on educational disabilities and educational problems in a total population of children who entered kindergarten in Florida in 1992--1994 and investigate how controlling for potentially confounding factors affects the relation between teenage pregnancies and poor outcome. When no other factors are taken into account, children of teenage mothers have significantly higher odds of placement in certain special education classes and significantly higher occurrence of milder education problems, but when maternal education, marital status, poverty level, and race are controlled, the detrimental effects disappear and even some protective effects are observed. Hence, the increased risk for educational problems and disabilities among children of teenage mothers is attributed not to the effect of young age but to the confounding influences of associated sociodemographic factors. In contrast to teen age, older maternal age has an adverse effect on a child's educational outcome regardless of whether other factors are controlled for or not.

Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving.

The Task Force on Community Preventive Services has conducted systematic reviews of interventions designed to increase use of child safety seats, increase use of safety belts, and reduce alcohol-impaired driving. The Task Force strongly recommends the following interventions: laws requiring use of child safety seats, distribution and education programs for child safety seats, laws requiring use of safety belts, both primary and enhanced enforcement of safety belt use laws, laws that lower the legal blood alcohol concentration (BAC) limit for adult drivers to 0.08%, laws that maintain the minimum legal drinking age at 21 years, and use of sobriety checkpoints. The Task Force recommends communitywide information and enforcement campaigns for use of child safety seats, incentive and education programs for use of child safety seats, and a lower legal BAC for young drivers (in the United States, those under the minimum legal drinking age). This report provides additional information regarding these recommendations, briefly describes how the reviews were conducted, and provides information to help apply the interventions locally.

How can performance standards strengthen accountability for public health?

Performance standards with both process and outcome measures can lead to greatly increased accountability for public health and a major leadership position in U.S. health care. Accreditation of health departments should become part of the accountability process.

Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services.

When the GUIDE TO COMMUNITY PREVENTIVE SERVICES: Systematic Reviews and Evidence-Based Recommendations (the Guide) is published in 2001, it will represent a significant national effort in encouraging evidence-based public health practice in defined populations (e.g., communities or members of specific managed care plans). The Guide will make recommendations regarding public health interventions to reduce illness, disability, premature death, and environmental hazards that impair community health and quality of life. The Guide is being developed under the guidance of the Task Force on Community Preventive Services (the Task Force)-a 15-member, nonfederal, independent panel of experts. Subject matter experts, methodologists, and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature reviews of evidence of effectiveness, economic efficiency, and feasibility on which to base recommendations for community action. Contributors to the Guide are building on the experience of others to confront methodologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonrandomized designs and diverse measures of outcome and effectiveness. Persons who plan, fund, and implement population-based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors. When the Guide is complete, readers are encouraged to consider critically the value and relevance of its contents, the implementation of interventions the Task Force recommends, the abandonment of interventions the Task Force does not recommend, and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness.

Scope and organization of the Guide to Community Preventive Services. The Task Force on Community Preventive Services.

BACKGROUND: The diverse nature of the target audience (i.e., public health decision-makers) for the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) dictates that it must be broad in scope. In addition, for the Guide to be most useful for its target audience, its organization and format must be carefully considered. DETERMINING THE SCOPE OF THE GUIDE: Healthy People objectives and actual causes of death were used to determine the contents of the Guide. A priority setting exercise resulted in the selection of 15 topics for systematic reviews using the following criteria: burden of the problem, preventability, relationship to other public health initiatives, usefulness of the package of topics selected and level of current research and intervention activity in public and private sectors. Interventions within each topic target state and local levels and include population-based strategies, individual strategies in other than clinical settings and group strategies. ORGANIZATION OF THE GUIDE: The Guide is organized into: Introduction, Reviews and Recommendations (three sections: Changing Risk Behaviors, Reducing Diseases, Injuries, or Impairments, and Addressing Environmental and Ecosystem Challenges), Appendixes, and Indexes. DISCUSSION: The scope and organization of the Guide were determined using relevant public health criteria and expert opinion to provide a useful and accessible document to a broad target audience. While the final contents of the Guide may change during development, the working table of contents described in this paper provides a framework for development of the Guide and conveys its scope and intention.

A bold new future for public health or implementing the "Alexander Haig" idea.

An amalgam of effort by public health practitioners and academics is needed to attain the goal of public health taking charge of U.S. health care early in the new millenium. Numerous ideas for joint collaborations in service, research, and teaching are presented. Goals, quality improvement and reporting, customer satisfaction, and leadership training are developing strengths in the field that will help make rapid progress toward the goal. Oversight of health services by public health is essential to the development of a successful U.S. health system.

The impact of low birth weight, perinatal conditions, and sociodemographic factors on educational outcome in kindergarten.

OBJECTIVE: To assess the relative effects and the impact of perinatal and sociodemographic risk factors on long-term morbidity within a total birth population in Florida. METHODS: School records for 339 171 children entering kindergarten in Florida public schools in the 1992-1993, 1993-1994, or 1994-1995 academic years were matched with Florida birth records from 1985 to 1990. Effects on long-term morbidity were assessed through a multivariate analysis of an educational outcome variable, defined as placement into 9 mutually exclusive categories in kindergarten. Of those categories, 7 were special education (SE) classifications determined by statewide standardized eligibility criteria, 1 was academic problems, and the reference category was regular classroom. Generalized logistic regression was used to simultaneously estimate the odds of placement in SE and academic problems. The impact of all risk factors was assessed via estimated attributable excess/deficit numbers, based on the multivariate analysis. RESULTS: Educational outcome was significantly influenced by both perinatal and sociodemographic factors. Perinatal factors had greater adverse effects on the most severe SE types, with birth weight <1000 g having the greatest effect. Sociodemographic predictors had greater effects on the mild educational disabilities. Because of their greater prevalence, the impact attributable to each of the factors (poverty, male gender, low maternal education, or non-white race) was between 5 and 10 times greater than that of low birth weight and >10 times greater than that of very low birth weight, presence of a congenital anomaly, or prenatal care. CONCLUSIONS: Results are consistent with the hypothesis that adverse perinatal conditions result in severe educational disabilities, whereas less severe outcomes are influenced by sociodemographic factors. Overall, sociodemographic factors have a greater total impact on adverse educational outcomes than perinatal factors.

Local health departments: planning for a changed role in the new health care environment.

Several reports have identified a series of public health planning tools that are helpful but not sufficiently comprehensive for planning in the current health care environment. This article describes the planning efforts of six local health departments (LHDs) in Florida and the results. These suggested that the LHDs would have benefited from using one of the approaches commonly found in the private sector, strategic planning. A strategic planning framework for LHDs is described and a series of relevant questions are suggested to aid in strategic planning.

Educational disabilities of neonatal intensive care graduates.

OBJECTIVE: To determine the relationship between perinatal and sociodemographic factors in low birth weight and sick infants hospitalized at regional neonatal intensive care units (NICUs) and subsequent educational disabilities. METHOD: NICU graduates born between 1980 and 1987 at nine statewide regionalized level III centers were located in Florida elementary schools (kindergarten through third grade) during academic year 1992-1993 (n = 9943). Educational disability was operationalized as placement into eight mutually exclusive types of special education (SE) classifications determined by statewide standardized eligibility criteria: physically impaired, sensory impaired (SI), profoundly mentally handicapped, trainable mentally handicapped, educable mentally handicapped, specific learning disabilities, emotionally handicapped, and speech and language impaired (SLI). Logistic regression was used to estimate the odds of placement in SE for selected perinatal and sociodemographic variables. RESULTS: Placement into SE ranged from .8% for SI to 9.9% for SLI. Placement was related to four perinatal factors (birth weight, transport, medical conditions [congenital anomalies, seizures or intraventricular hemorrhage] and ventilation), and five sociodemographic factors (child's sex, mother's marital status, mother's race, mother's educational level, and family income). Perinatal factors primarily were associated with placement in physically impaired, SI, profoundly mentally handicapped, and trainable mentally handicapped. Perinatal and sociodemographic factors both were associated with placement in educable mentally handicapped and specific learning disabilities whereas sociodemographic factors primarily were associated with placement in emotionally handicapped and SLI. CONCLUSIONS: Educational disabilities of NICU graduates are influenced differently by perinatal and sociodemographic variables. Researchers must take into account both sets of these variables to ascertain the long-term risk of educational disability for NICU graduates. Birth weight alone should not be used to assess NICU morbidity outcomes.

Changes in survival patterns of very low-birth-weight infants from 1980 to 1993.

OBJECTIVE: To determine changes in survival patterns among very low-birth-weight ( < 1500 g) infants between 1980 and 1993. METHODS: The records of 12,960 infants treated in nine perinatal intensive care centers in Florida were analyzed on the basis of survival (discharged alive from hospital) according to four independent variables: birth weight, race, sex, and transport status. Survival curves were generated using log linear regression techniques for each race by sex by transport status group. RESULTS: Race, sex, and transport status correlated significantly with survival: survival percentages were higher among black infants, female infants, and infants transported to the perinatal intensive care centers than among white infants, male infants, and those admitted initially to the tertiary care centers. After 1985, 95% of neonates with birth weights between 1200 and 1500 g survived. In addition, survival of 500- to 500-g transported black male infants increased from zero to near 80% during the 13-year period; that of 500- to 550-g inborn white female infants rose from 35% to 70%. CONCLUSIONS: These results illustrate the value of taking into account race, sex, and transport status in efforts to understand the contribution that neonatal intensive care of extremely low-birth-weight infants makes to the lowering of infant mortality, and of using multivariable statistical procedures to generate predicted survival probabilities for different subpopulations. These probabilities can be applied to (1) predicting survival for specific subgroups of extremely low-birth-weight infants, and (2) helping physicians develop clinical guidelines for extending care to infants at the threshold of viability.

Human peritoneal macrophage and T lymphocyte populations in mild and severe endometriosis.

PROBLEM: The aim of this study was to characterize the phenotype of peritoneal lymphocyte and macrophage populations in mild versus severe endometriosis. METHOD: Using dual staining, antigen expression on peritoneal leukocytes from 24 women with endometriosis and 21 control patients was analyzed by flow cytometry. RESULTS: All groups had CD4:CD8 ratios of 0.6, with subpopulations of CD8+ cells expressing cytotoxic marker S6F1. Mild and severe endometriosis patients had increased CD3/DR+ cells, relative to controls. Two populations of macrophages were identified by size in all groups. Mild endometriosis patients had increased percentages of small macrophages expressing CD14 and HLA DQ, compared to controls and severe disease patients. In severe disease patients, antigen expression on small macrophages did not differ from controls, but decreased percentages of large macrophages expressed CD14 relative to controls and mild disease patients. CONCLUSION: All women with endometriosis exhibit activated peritoneal lymphocytes, whereas macrophage expression of CD14 is differentially expressed as a function of disease stage. Alterations in the functional capacity of these cells may contribute to the pathophysiology of this disease.

D-penicillamine-induced myasthenia gravis: diagnosis obscured by coexisting chronic obstructive pulmonary disease.

D-penicillamine, a drug used to treat rheumatoid arthritis, Wilson's disease, and cystinuria, can cause myasthenia gravis. Fortunately, the myasthenia typically resolves after discontinuation of the drug. The diagnosis may be missed if weakness is blamed on a patient's underlying disease(s), in particular, rheumatoid arthritis. Reported here are the cases of two patients with chronic obstructive lung disease who were taking D-penicillamine for rheumatoid arthritis, then experienced increasing respiratory failure. At first, their problem seemed to stem from chronic lung disease, but further evaluation revealed the cause of the hypoventilation to be D-penicillamine-induced myasthenia gravis.

Physician attitudes toward nurse-midwives. Results of 1993 survey.

Physicians and certified nurse-midwives have worked together in hospitals, private practices, clinics and birth centers throughout Florida for over 20 years. A questionnaire was sent to all maternal health-care providers to develop an understanding of the perceived attitudes, benefits, or liabilities of the professional relationships between them. An analysis is provided of the 374 physician responses.