1.  

Kabra SK, Lodha R, Seth V. Some current concepts on childhood tuberculosis. Indian J Med Res. 2004 Oct; 120(4):387-97. Review.

Department of Pediatrics, All India Institute of Medical Sciences, D II/23, An sari Nagger, New Delhi 110-029, India. skkabra@hotmail.com

As children acquire infection with Mycobacterium tuberculosis from adults in their environment, the epidemiology of childhood tuberculosis (TB) follows that in adults. While global burden of childhood tuberculosis is unclear, in developing countries the annual risk of tuberculosis infection in children is 2- 5 per cent. Nearly 8-20 per cent of the deaths caused by tuberculosis occur in children. It has been suggested that BCG vaccination is responsible for decrease in the occurrence of disseminated and severe disease. Localized forms of illness, e.g., intrathoracic lymphadenopathy, and localized CNS disease have been reported to occur with greater frequency in vaccinated children. Human immunodeficiency virus (HIV) infected children are at an increased risk of tuberculosis, particularly disseminated disease. Diagnosis of TB in children presents special problems as the sputum is generally not available for examination. Diagnostic algorithms include scoring system utilizing clinical parameters and results of investigations. Various diagnostic techniques such as improved culture techniques, serodiagnosis, and nucleic acid amplification have been developed and evaluated to improve diagnosis of childhood tuberculosis. Serodiagnosis is an attractive investigation but till date none of the tests showed desirable sensitivity and specificity. Tests based on nucleic acid amplification are a promising development. Relatively less experience in children, need for technical expertise and high cost are the limiting factors for their use in childhood tuberculosis. Short-course chemotherapy for childhood tuberculosis is well established. Treatment with intermittent regimens is comparable to daily regimens. Directly observed treatment strategy (DOTS) has also shown encouraging results. Pattern of drug resistance among children with TB tends to reflect those found among adults in the same population. The rates of drug resistance to any drug vary from 20 to 80 per cent in different geographic regions.

2.  

Misra UK, Kalita J. The role of sensory and motor evoked potentials in the prognosis of Pott's paraplegia. Clin Neurophysiol. 2004 Oct; 115(10):2267-73.

Department of Neurology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Raebareily Road, Lucknow-26014, India. ukmisra@sgpgi.ac.in

OBJECTIVE: In view of paucity of evoked potential changes in Pott's paraplegia, it is proposed to evaluate the role of motor and somatosensory evoked potentials in predicting the outcome. METHODS: Consecutive patients with Pott's paraplegia during 1993-2003 were subjected to detailed clinical, radiological and evoked potential study. The latter comprised of tibial somatosensory evoked potential (SEP) and motor evoked potential (MEP) study to tibialis anterior. The patients were clinically evaluated at 6 and 12 months and the outcome was defined into poor (bed ridden), partial (dependent for activities of daily living) and complete recovery (independent). The evoked potential findings were correlated with clinical and radiological findings and outcome. RESULTS: There were 39 patients whose age ranged between 16 and 70 (mean 42.1) years and 22 were females. The mean duration of symptoms was 8.2 months. Sensory motor deficit was present in 18 and pure motor signs in 21 patients. Five patients had quadriplegia and remaining had paraplegia. The muscle weakness was severe in 12 and moderate in 15 patients. In 12 patients, lower limb power was normal but they had lower limb hyper-reflexia with or without spasticity suggesting pyramidal dysfunction. Pinprick and joint position sensations were abnormal in 18 patients. MRI was abnormal in all and revealed cervical involvement in 7, thoracic in 22 and lumbar in 10 patients. Paravertebral soft tissue shadow was present in 36 and cord compression in 30 patients. Motor evoked potential was abnormal in 19 patients (unrecordable in 11 patients, 21 sides and prolonged in 8 patients, 14 sides). SEP was abnormal in 18 patients (unrecordable in 15 patients, 25 sides and prolonged central conduction in 8 patients, 9 sides). Both MEP and SEP were abnormal in 16, normal in 18, and only MEP was abnormal in 3 and only SEP in 2 patients. At 6 month 25 patients had complete, 9 partial and 5 poor recovery. At 1 year 33 had complete and 4 partial recovery. SEP and MEP abnormalities correlated with respective sensory and motor functions, vertebral level and outcome at 6 and 12 months. CONCLUSIONS: MEP and SEP both are helpful in predicting 6-month outcome. Combining SEP and MEP gives stronger correlation with 6-month outcome compared to only MEP or SEP. The potential role of evoked potentials in deciding different therapeutic strategies needs further studies.

3.  

Gupta S, Shende N, Kumar S, Harinath BC. Isolation of excretory secretory protein 6 kDa antigen (ES-6) and its seroreactivity in patients with different stages of pulmonary tuberculosis and healthy household contacts. Biomedical Research, 2005; 16(1): 23-27.

An Excretory Secretory protein antigen of 6 kDa (ES-6) was isolated from Mycobacterium tuberculosis H₃₇Ra culture filtrate by gel filtration using fast protein liquid chromatography. Seroreactivity of ES-6 antigen was compared with earlier reported diagnostically useful ES-31 and ES-43 antigens at different stage of pulmonary tuberculosis and in household contacts of the patients. The ES-31 and ES-43 antigens showed good immune response in chronic and relapse cases respectively while ES-6 antigen has shown comparatively low immune response in these cases. However ES-6 showed increased seroreactivity in household contacts of pulmonary tuberculosis patients. These results suggest the heterogeneous responses of antigens in different disease conditions and immune response to   ES-6 antigen may be associated with latent infection for predicting active disease in course of time, as observed in the follow up of these individuals.

1.  

1.                      Bhatia AS, Gupta S, Shende N, Kumar S.Harinath BC.Serodiagnosis of childhood tuberculosis by ELISA. Indian J Pediat 2005 May, 72, 383-87.

JB Tropical Disease Research Centre & Dept. of Biochemistry, MGIMS, Sevagram - 442102, Wardha, MS. India.

Objective:  Diagnosis of childhood tuberculosis remains an enigma despite the many recent technological developments.  The present study has been taken up with the aim to assess the diagnostic potential of mycobacterium tuberculosis excretory-secretory ES-31 antigen and affinity purified anti ES-31 antibodies in the serodiagnosis of different spectrum of childhood tuberculosis. Methods: Mycobacterium tuberculosis H₃₇Ra excretory-secretory antigen (ES-31) and affinity purified goat anti ES-31 antibodies were used in stick penicillinase ELISA for IgG antibody detection and stick Sandwich penicillinase ELISA for detection of circulating free and immune complexed antigen in the sera of 230 children.  Results:  Analysis of tubercular antibody, circulating free and immune complexed antigen (CIC-Ag) was done in both pulmonary and extrapulmonary form of childhood tuberculosis and overall sensitivity of 81.4% with a specificity of 93% was achieved for detection of antitubercular IgG antibodies.  Of the five cases of pulmonary tuberculosis showing absence of IgG antibody, 3 showed the presence of CIC-Ag and one was found positive for both free and CIC-Ag.  Similarly out of 8 cases of extrapulmonary childhood tuberculosis missed by IgG detection 5 were found to be positive for CIC-Ag and 1 showed the positive reaction for both free and immune complexed antigens.  Conclusion:  IgG antibody to excretory-secretory antigen ES-31 is found to be having good specificity with acceptable sensitivity in detecting different forms of childhood tuberculosis. Further detection of circulating free and / or immunecomplexed antigen can be used as an adjunct tool in the diagnosis of childhood tuberculosis. 

2.  

Gupta S, Shende N, Kumar S, Harinath BC. Detection of antibodies to a cocktail of mycobacterial excretory�secretory antigens in tuberculosis by ELISA and immunoblotting. Current Science, 2005 June 10;88(11):1825-1827.

           JB Tropical Disease Research Centre & Dept. of Biochemistry, MGIMS, Sevagram - 442102, Wardha, MS. India.

The seroreactivity of a cocktail of purified mycobacterial excretory�secretory (ES) antigens ES-31, ES-41 and ES-43 was assessed by ELISA and immunoblotting in patients with pulmonary tuberculosis. The ES-31 antigen was isolated by affinity chromatography and ES-41 and ES-43 were isolated by fast protein liquid chromatography from Mycobacterium tuberculosis H₃₇Ra culture filtrate. Seven of 27 pulmonary tuberculosis sera were not reactive to ES-31 antigen by ELISA. However, 6 out of 7 turned positive, when a cocktail of ES-31, ES-41 and ES-43 antigens was used in ELISA. Seroreactivity pattern of cocktail antigen was studied in immunoblotting using tuberculous sera. Addition of ES-41 and ES-43 antigens helped in increasing the sensitivity compared to ES- 31 alone. Further, ELISA was observed to be more sensitive than immunoblotting using a cocktail of antigens.

3.  

Perez-Guzman C, Vargas MH, Quinonez F, Bazavilvazo N, Aguilar A. A cholesterol-rich diet accelerates bacteriologic sterilization in pulmonary tuberculosis. Chest. 2005 Feb;127(2):643-51.

Instituto Nacional de Enfermedades Respiratorias, Tlalpan 4502, CP 14080, Mexico City, Mexico.

BACKGROUND: Hypocholesterolemia is common among tuberculous patients and is associated with mortality in miliary cases. Some in vitro studies have shown that cholesterol is necessary for the good functioning of macrophages and lymphocytes. STUDY OBJECTIVES: To determine whether a cholesterol-rich diet could accelerate sputum sterilization in patients with pulmonary tuberculosis. DESIGN: An 8-week follow-up, randomized, controlled trial carried out from March 2001 to January 2002. SETTING: A third-level hospital for respiratory diseases in Mexico City. PATIENTS AND INTERVENTIONS: Adult patients with newly diagnosed pulmonary tuberculosis were hospitalized for 8 weeks and randomly assigned to receive a cholesterol-rich diet (800 mg/d cholesterol [experimental group]) or a normal diet (250 mg/d cholesterol [control group]). All patients received the same four-drug antitubercular regimen (ie, isoniazid, rifampin, pyrazinamide, and ethambutol). MEASUREMENTS AND RESULTS: Every week, a quantitative sputum culture and laboratory tests were done and respiratory symptoms were recorded. Patients in the experimental group (10 patients) and the control group (11 subjects) were HIV-negative and harbored Mycobacterium tuberculosis that was fully sensitive to antitubercular drugs. Sterilization of the sputum culture was achieved faster in the experimental group, as demonstrated either by the percentage of negative culture findings in week 2 (80%; control group, 9%; p = 0.0019) or by the Gehan-Breslow test for Kaplan-Meier curves (p = 0.0037). Likewise, the bacillary population decreased faster (p = 0.0002) in the experimental group. Respiratory symptoms improved in both groups, but sputum production decreased faster in the experimental group (p < 0.05). Laboratory test results did not differ between the groups. CONCLUSIONS: A cholesterol-rich diet accelerated the sterilization rate of sputum cultures in pulmonary tuberculosis patients, suggesting that cholesterol should be used as a complementary measure in antitubercular treatment.

1.  

 Almagro M, Del Pozo J, Rodriguez-Lozano J, Silva JG, Yebra-Pimentel MT, Fonseca E. Metastatic tuberculous abscesses in an immunocompetent patient. Clin Exp Dermatol. 2005 May;30(3):247-9.

Department of Dermatology, Hospital Juan Canalejo, A Coruna, Spain.

The decreased incidence of infectious diseases in developed countries may make their diagnosis difficult. Cutaneous tuberculosis is an example of this fact. A 44-year-old man presented with two painful abscesses on his lower extremities, which developed into chronic ulcers. A cutaneous biopsy revealed necrotizing granulomas in the dermis. Ziehl-Neelsen and periodic acid-Schiff stain were negative. Mantoux test was positive. Tc-99m scintigraphy showed increased uptake in the bone tissue of the left ankle and right tibiae, without direct relation to cutaneous lesions. Chest X-ray showed micronodular, apical, bilateral infiltrates, reduced volume of the right lung, and cavitation of the right superior lobe. Mycobacterium tuberculosis was grown from sputum and skin biopsy samples. Isoniazid, rifampin and pyrazinamide treatment for 2 months, followed by isoniazid and rifampin for 12 months, resulted in complete resolution. The clinical features of cutaneous tuberculosis in our patient were characteristic of tuberculous abscesses. Some uncommon findings, such as the low number of lesions, negative acid-fast resistant stains in cutaneous biopsy samples and his preserved general state of health, may be explained by a higher competence of the immune system than is usual in this clinical subset of disseminated tuberculosis. Cutaneous tuberculosis should be included in the differential diagnosis of cutaneous abscesses in immunocompetent patients.

2.  

Donald PR, Schaaf HS, Schoeman JF Tuberculous meningitis and miliary tuberculosis: the Rich focus revisited. J Infect. 2005 Apr;50(3):193-5.

The Department of Paediatrics and Child Health, Tygerberg Children's Hospital and The Faculty of Health Sciences, The University of Stellenbosch, P.O. Box 19063, 7505 Tygerberg, South Africa. prd@sun.ac.za

Tuberculous meningitis (TBM) develops most often when a caseating meningeal or sub-cortical focus, the Rich focus, discharges its contents into the subarachnoid space. It is recognized that TBM is frequently accompanied by miliary tuberculosis, but the relationship between the development of the Rich focus and miliary tuberculosis remains controversial. The original descriptions of Arnold Rich and Howard McCordock are reviewed together with the work of other pathologists and the observations of the natural history of tuberculosis by astute clinicians such as Arvid Wallgren and Edith Lincoln. Rich and McCordock dissociated miliary tuberculosis from a role in the pathogenesis of TBM, and this view continues to appear in reviews and textbooks dealing with TBM. We suggest, particularly in childhood, that miliary tuberculosis is indeed directly involved in the pathogenesis of TBM in as much as that the overwhelming bacillaemia that accompanies miliary tuberculosis serves to increase the likelihood that a meningeal or sub-cortical Rich focus will be established, which may in its turn caseate and give rise to TBM.

3.  

DeRiemer K, Garcia-Garcia L, Bobadilla-del-Valle M, Palacios-Martinez M, Martinez-Gamboa A, Small PM, Sifuentes-Osornio J, Ponce-de-Leon A.Does DOTS work in populations with drug-resistant tuberculosis? Lancet. 2005 Apr 2-8;365(9466):1239-45.

Division of Infectious Diseases and Geographic Medicine, Stanford University Medical Center, Stanford, CA, USA.

BACKGROUND: Directly observed therapy (DOTS) is the main strategy for prevention and control of tuberculosis worldwide. However, its effect on tuberculosis transmission in populations with moderate rates of drug-resistant disease is not known. METHODS: This population-based prospective study in southern Mexico between March, 1995, and February, 2000, was based on passive case finding and detection of acid-fast bacilli in sputum samples to diagnose pulmonary tuberculosis. We also used cultures, drug-susceptibility testing, bacterial genotyping, and monitoring of treatment outcomes. FINDINGS: We enrolled 436 patients; the HIV seroprevalence rate was 2%. We used three indicators to monitor continuing tuberculosis transmission: the incidence rate of pulmonary tuberculosis, which decreased by 54.4% between 1995 and 2000, from 42.1 to 19.2 per 10(5) population (p=0.00048); the percentage of clustered pulmonary tuberculosis cases, which decreased by 62.6% from 22% to 8% (p=0.02); and the rate of primary drug resistance, which decreased by 84.0% from 9.4 to 1.5 per 10(5) population (p=0.004). Rates of multidrug-resistant (MDR) tuberculosis also decreased (p<0.0001). The case-fatality ratio was 12% for MDR tuberculosis (five of 41), 7% for strains resistant to at least one drug after exclusion of MDR (four of 55), and 3% for pansusceptible strains (nine of 272). There were 13 treatment failures (11%) in 1995 and one (2%) in 2000 (p=0.012). INTERPRETATION: Even in settings with moderate rates of MDR tuberculosis, DOTS can rapidly reduce the transmission and incidence of both drug-susceptible and drug-resistant tuberculosis. However, further interventions, such as drug-susceptibility testing and standardised or individualised treatment regimens, are needed to reduce mortality rates for MDR tuberculosis.

4.

Geng E, Kreiswirth B, Burzynski J, Schluger NW. Clinical and radiographic correlates of primary and reactivation tuberculosis: a molecular epidemiology study. JAMA. 2005 Jun 8;293(22):2740-5.

College of Physicians and Surgeons, Columbia University, New York, NY, USA.

CONTEXT: The traditional teaching that pulmonary tuberculosis characterized by lymphadenopathy, effusions, and lower or mid lung zone infiltrates on chest radiography represents "primary" disease from recently acquired infection, whereas upper lobe infiltrates and cavities represent secondary or reactivation disease acquired in the more distant past, is not based on well-established clinical evidence. Furthermore, it is not known whether the atypical radiograph common in human immunodeficiency virus (HIV)-associated tuberculosis is due to a preponderance of primary progressive disease or altered immunity. OBJECTIVE: To analyze the relationship between recently acquired and remotely acquired pulmonary tuberculosis, clinical and demographic variables, and radiographic features by using molecular fingerprinting and conventional epidemiology. DESIGN, SETTING, AND POPULATION: A retrospective, hospital-based series of 456 patients treated at a New York City medical center between 1990 and 1999. Eligible patients had to have had at least 1 positive respiratory culture for Mycobacterium tuberculosis and available radiographic data. MAIN OUTCOME MEASURES: Radiographic appearance as measured by the presence or absence of 6 features: upper lobe infiltrate, cavitary lesion, adenopathy, effusions, lower or mid lung zone infiltrate, and miliary pattern. Radiographs were considered typical if they had an upper lobe infiltrate or cavity whether or not other features were present. Atypical radiographs were those that had adenopathy, effusion, or mid lower lung zone infiltrates or had none of the above features. RESULTS: Human immunodeficiency virus infection was most commonly associated with an atypical radiographic appearance on chest radiograph with an odds ratio of 0.20 (95% confidence interval, 0.13-0.31). Although a clustered fingerprint, representing recently acquired disease, was associated with typical radiograph in univariate analysis (odds ratio, 0.68; 95% confidence interval, 0.47-0.99), the association was lost when adjusted for HIV status. CONCLUSIONS: Time from acquisition of infection to development of clinical disease does not reliably predict the radiographic appearance of tuberculosis. Human immunodeficiency virus status, a probable surrogate for the integrity of the host immune response, is the only independent predictor of radiographic appearance. The altered radiographic appearance of pulmonary tuberculosis in HIV is due to altered immunity rather than recent acquisition of infection and progression to active disease.

5.

Immanuel C, Victor L, Chelvi KS, Padmapriyadarsini C, Rehman F, Iliayas S, Swaminathan S. Serum neopterin levels in HIV infected patients with & without tuberculosis. Indian J Med Res. 2005 Apr;121(4):220-5.

Tuberculosis Research Centre (ICMR), Mayor V.R. Ramanthan Road, Chetput, Chennai, India.

BACKGROUND & OBJECTIVE: Three categories of prognostic markers are best documented as having significance in relation to prognosis of HIV infection. These include HIV viral load, CD4 T-cell levels and plasma levels of soluble markers of immune activation. The plasma activation markers, like neopterin, tumor necrosis factor alpha (TNF-alpha), interleukins etc., are products of cytokine activity and represent immunologic changes throughout the body. There is not much information available on serum neopterin estimation in patients infected with both HIV and tuberculosis (TB), though neopterin levels are known to be elevated in pulmonary TB patients. In this study we attempted to correlate neopterin levels with the presence of tuberculosis in HIV infected and uninfected individuals and studied the changes after antituberculosis treatment. METHODS: Serum neopterin concentrations were measured by high performance liquid chromatography (HPLC) in 25 HIV-seropositive (HIV-TB) and 10-seronegative (TB) patients with tuberculosis before, during and at the end of antituberculosis therapy (ATT). S-neo was also measured in 10 HIV-seropositive asymptomatic individuals and 10 healthy controls. The results were correlated with clinical, bacteriological and immunological status. RESULTS: All TB patients regardless of HIV status had elevated s-neo concentrations at diagnosis, which declined gradually during treatment. Patients with HIV/TB with CD4 counts < 200/mm(3) had the highest levels at baseline with a steep fall during treatment. The median level at the end of treatment was significantly higher in HIV/TB than in TB patients, despite clinical improvement and bacteriological clearance of Mycobacterium tuberculosis. HIV infected asymptomatic individuals had neopterin levels that were higher than healthy controls but lower than HIV-TB patients. INTERPRETATION & CONCLUSION: Serum neopterin levels are elevated in HIV-positive patients, with the highest levels in those with tuberculosis and CD4 counts < 200/mm(3). Though the levels decrease with anti tuberculosis therapy, persistently elevated levels indicate progressive HIV disease and a poor prognosis.

6.

Pai M, Gokhale K, Joshi R, Dogra S, Kalantri S, Mendiratta DK, Narang P, Daley CL, Granich RM, Mazurek GH, Reingold AL, Riley LW, Colford JM Jr Mycobacterium tuberculosis infection in health care workers in rural India: comparison of a whole-blood interferon gamma assay with tuberculin skin testing. JAMA. 2005 Jun 8;293(22):2746-55.

Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, India. madhupai@berkeley.edu

CONTEXT: Mycobacterium tuberculosis infection in health care workers has not been adequately studied in developing countries using newer diagnostic tests. OBJECTIVES: To estimate latent tuberculosis infection prevalence in health care workers using the tuberculin skin test (TST) and a whole-blood interferon gamma (IFN-gamma) assay; to determine agreement between the tests; and to compare their correlation with risk factors. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional comparison study of 726 health care workers aged 18 to 61 years (median age, 22 years) with no history of active tuberculosis conducted from January to May 2004, at a rural medical school in India. A total of 493 (68%) of the health care workers had direct contact with patients with tuberculosis and 514 (71%) had BCG vaccine scars. INTERVENTIONS: Tuberculin skin testing was performed using 1-TU dose of purified protein derivative RT23, and the IFN-gamma assay was performed by measuring IFN-gamma response to early secreted antigenic target 6, culture filtrate protein 10, and a portion of tuberculosis antigen TB7.7. MAIN OUTCOME MEASURES: Agreement between TST and the IFN-gamma assay, and comparison of the tests with respect to their association with risk factors. RESULTS: A large proportion of the health care workers were latently infected; 360 (50%) were positive by either TST or IFN-gamma assay, and 226 (31%) were positive by both tests. The prevalence estimates of TST and IFN-gamma assay positivity were comparable (41%; 95% confidence interval [CI], 38%-45% and 40%; 95% CI, 37%-43%, respectively). Agreement between the tests was high (81.4%; kappa = 0.61; 95% CI, 0.56-0.67). Increasing age and years in the health profession were significant risk factors for both IFN-gamma assay and TST positivity. BCG vaccination had little impact on TST and IFN-gamma assay results. CONCLUSIONS: Our study showed high latent tuberculosis infection prevalence in Indian health care workers, high agreement between TST and IFN-gamma assay, and similar association between positive test results and risk factors. Although TST and IFN-gamma assay appear comparable in this population, they have different performance and operational characteristics; therefore, the decision to select one test over the other will depend on the population, purpose of testing, and resource availability.

7.

Shende N, Gupta S, Bhatia AS, Kumar S, Harinath BC. Detection of free and immune complexed serine protease and its antibody in patients of tuberculosis with and without HIV co-infection. Int J Tuberc Lung Dis. 2005 Aug;9(8):915-9.

Jamnalal Bajaj Tropical Disease Research Centre & Department of Biochemistry, MGIMS, Sevagram � 442 102, Wardha, MS, India. jbtdrc_wda@sancharnet.in

OBJECTIVE: To understand the usefulness of detecting tu�berculous IgG antibodies against mycobacterial excretory�-secretory 31 kDa serine protease antigen (SEVA TB ES-31) and circulating free and circulating immune-complexed (CIC) serine protease in TB patients with and without HIV infection.

DESIGN: Serum was collected from 144 individuals: pa�tients with TB, with TB-HIV co-infection and HIV infec�tion only, and ill and healthy controls. SEVA TB ES-31 antigen, a serine protease isolated from Mycobacterium tuberculosis H₃₇Ra culture fluid, was used in indirect penicillinase ELISA to detect tuberculous antibodies. Similarly, affinity purified anti-ES-31 antibody was used in sandwich ELISA to detect circulating free and CIC serine protease,

RESULTS: There was less sensitivity for tuberculous antibody in HIV-infected TB patients (46%) than in those with TB alone (87%) using mycobacterial serine protease. However, the sensitivity of detection of TB in the presence of HIV increased to 87% by concomitant detec�tion of circulating free and CIC serine protease antigen.

CONCLUSION: Detection of free and CIC tuberculous serine protease antigen along with antibody is more use�ful far detecting TB in the presence of HIV co-infection.

8.

Steele AW, Eisert S, Davidson A, Sandison T, Lyons P, Garrett N, Gabow P, Ortiz E.Using computerized clinical decision support for latent tuberculosis infection screening. Am J Prev Med. 2005 Apr;28(3):281-4.

Information Services, Denver Health (1932), 660 Bannock Street, Denver, CO 80218, USA. asteele@dhha.org

BACKGROUND: The Centers for Disease Control and Prevention (CDC) has published guidelines recommending screening high-risk groups for latent tuberculosis infection (LTBI). The goal of this study was to determine the impact of computerized clinical decision support and guided web-based documentation on screening rates for LTBI. DESIGN: Nonrandomized, prospective, intervention study. SETTING AND PARTICIPANTS: Participants were 8463 patients seen at two primary care, outpatient, public community health center clinics in late 2002 and early 2003. INTERVENTION: The CDC's LTBI guidelines were encoded into a computerized clinical decision support system that provided an alert recommending further assessment of LTBI risk if certain guideline criteria were met (birth in a high-risk TB country and aged <40). A guided web-based documentation tool was provided to facilitate appropriate adherence to the LTBI screening guideline and to promote accurate documentation and evaluation. Baseline data were collected for 15 weeks and study-phase data were collected for 12 weeks. MAIN OUTCOME MEASURES: Appropriate LTBI screening according to CDC guidelines based on chart review. RESULTS: Among 4135 patients registering during the post-intervention phase, 73% had at least one CDC-defined risk factor, and 610 met the alert criteria (birth in a high-risk TB country and aged <40 years) for potential screening for LTBI. Adherence with the LTBI screening guideline improved significantly from 8.9% at baseline to 25.2% during the study phase (183% increase, p < 0.001). CONCLUSIONS: This study demonstrated that computerized, clinical decision support using alerts and guided web-based documentation increased screening of high-risk patients for LTBI. This type of technology could lead to an improvement in LTBI screening in the United States and also holds promise for improved care for other preventive and chronic conditions.