Specificity of the Tuberculin Skin Test and the T-SPOT.TB Assay Among Students in a Low–Tuberculosis Incidence Setting

Abstract

Objective: Interferon-γ release assays (IGRAs) are an important tool for detecting latent Mycobacterium tuberculosis infection (LTBI). Insufficient data exist about IGRA specificity in college health centers, most of which screen students for LTBI using the tuberculin skin test (TST). Participants: Students at a low–TB incidence college health center. Methods: TST and T-SPOT.TB were performed on prospectively recruited students. TB exposure risk was assessed using a questionnaire: Those at low risk were assumed to not have LTBI in order to calculate test specificity. Results: Of 184 students enrolled, 143 had results available for both TST and T-SPOT.TB. Agreement of the tests was 97% (kappa statistic 0.717; 95% confidence interval, 0.399–1.00). Among 124 low-risk students, specificity for TST and T-SPOT.TB were 98.4% and 100%, respectively. Conclusions: T-SPOT.TB specificity was high among low-risk students. Additional studies such as cost-effectiveness analyses using T-SPOT.TB as a single or confirmatory test to TST are needed to contribute to LTBI screening policy decisions.     

Collegiate-Based Emergency Medical Service: Impact on Alcohol-Related Emergency Department Transports at a Small Liberal Arts College

Abstract

Objective: The authors examined the impact of a collegiate-based emergency medical service (CBEMS) on the frequency of emergency department (ED) transports. Participants: Students transported to the ED for acute alcohol intoxication during the Fall 2008 and the Fall 2009 semesters (N = 50). Methods: The frequency of students receiving transportation to a hospital ED and the reported blood alcohol content (BAC) levels during the initial operational semester of the CBEMS were compared to those values over the same time period the previous year. Results: More than twice the number of students was transported to the ED following the introduction of CBEMS. There was no change in mean BAC levels. Conclusions: CBEMS could promote a culture conducive to increased reporting behavior, which makes the campus safer. Similar BAC levels suggest that the degree of intoxication was similar for the 2 reporting periods, but students sought emergency assistance more frequently following the inception of CBEMS.     

Elder Abuse Research: A Systematic Review

The purpose of this research was to provide a systematic review of, and assign an evidence grade to, the research articles on elder abuse. Sixteen health care and criminal justice literature databases were searched. Publications were reviewed by at least two independent readers who graded each from A (evidence of well-designed meta-analysis) to D (evidence from expert opinion or multiple case reports) on the quality of the evidence gained from the research. Of 6,676 titles identified in the search, 1,700 publications met inclusion criteria; omitting duplicates, 590 publications were annotated and graded.     

Neuropsychological Correlates of Performance Based Functional Status in Elder Adult Protective Services Referrals for Capacity Assessments

We have previously described high rates of executive function impairment in clients referred by Adult Protective Services (APS) to geriatric psychiatry for decision-making capacity assessments. The purpose of this study was to determine the independent relationship between neuropsychological screening instruments, particularly instruments sensitive to executive function, and performance-based functional tasks in elder referrals. Our retrospective medical review (n = 75/157 referrals completed all neuropsychological and functional assessments) revealed that only the Executive Interview (EXIT25) contributed independent variance to money management performance (R² = 0.29, p < 0.001), telephone use ability (R² = 0.39, p < 0.001), and summed performance (R² = 0.45, p < 0.001). Executive instruments may specifically inform decision-making capacity assessments.     

The Use of Chemical Restraints for Older Long-Term Hospital Patients: A Case Report from Finland

The purpose of this study was to describe the use and concomitant use of psychotropics and other drugs as chemical restraints in the aged in long-term hospital care. The study consisted of 154 patients (42 men, 112 women) hospitalized in five long-term care wards in Pori City Hospital, Finland. Three or more psychotropics were regularly given to 33% of the patients and regularly or irregularly to 53% of the patients. Two or more benzodiazepine derivatives or related drugs were regularly given to 24% of the patients and regularly or irregularly to 46% of the patients. The very poor cognitive and functional abilities of the patients, the common concomitant use of psychotropic drugs, the use of psychotropics to control the behavior of the patients, and the lack of documentation of the effects and side effects of the drugs give rise to the conclusion that psychotropics were used as chemical restraints in these long-term care wards.     

Assessing Capacity Within a Context of Abuse or Neglect

In 2000, with the implementation of Part III of the Adult Guardianship Act: Support and Assistance for Abused and Neglected Adults, British Columbia formally recognized the need to examine issues of decisional capacity of older adults within a context of abuse or neglect. Interestingly, however, although the test of capacity was clearly laid out under this piece of legislation, the potential influence that living in a situation of abuse or neglect may have on how the person makes decisions is not explicitly addressed. Similarly, this is a missing link throughout the literature discussing decisional capacity in older adults. This gap exists despite the fact that determining the “protection” needs of someone who is being abused and/or neglected often hinges directly on that person's decisional capacity. The purpose of this article is to examine the unique aspects associated with assessing and determining capacity for older adults who are living in a situation of abuse or neglect. The specific objectives are to: (a) examine how living in a situation of abuse or neglect may influence the determination of capacity and (b) explore the implications of conducting an assessment within a potentially abusive context. The legal notion of undue influence and the psychological concept of relational connection are introduced as potentially important for considering decision making within this context.     

Elder Abuse Telephone Screen Reliability and Validity

Purposes: (a) To identify reliable and valid questions that identify elder abuse, (b) to assess the reliability and validity of extant self-reported elder abuse screens in a high-risk elderly population, and (c) to describe difficulties of completing and interpreting screens in a high-need elderly population. Design and Methods: All elders referred to research-trained social workers in a community service agency were asked to participate. Of the 70 elders asked, 49 participated, 44 completed the first questionnaire, and 32 completed the duplicate second questionnaire. A research assistant administered the telephone questionnaires. Results: Twenty-nine (42%) persons were judged abused, 12 (17%) had abuse reported, and 4 (6%) had abuse substantiated. The elder abuse screen instruments were not found to be predictive of assessed abuse or as predictors of reported abuse; the measures tended toward being inversely predictive. Two questions regarding harm and taking of belongings were significantly different for the assessed abused group. Implications: In this small group of high-need community-dwelling elders, the screens were not effective in discriminating between abused and nonabused groups. Better instruments are needed to assess for elder abuse.     

Multidisciplinary Team Legislative Language Associated With Elder Abuse Investigations

Professionals from different disciplines providing care and services to persons at risk for or victims of elder abuse have formed various multidisciplinary teams (MDTs). The purpose of the study was to identify the adult protective services–related statutory trends in presence of MDT content and to determine the association of MDT legislation on the rates of reported, investigated, and substantiated domestic elder abuse. Aggregate reports of elder abuse and state statutes for 1999 and 2007 were retrieved from 50 states and the District of Columbia. Statutes of eight states in 2000 and nine in 2008 included text about MDTs. In 2007, investigation rates for those states having MDT text in the statutes were significantly higher than those states without. The incidence of MDTs in the country is unknown. Legislative text is but one factor associated with differences in elder abuse report, investigation, or substantiation rates.     

The Future of Financing for Long-Term Care: The Own Your Future Campaign

The purpose of this study was to examine the outreach effort and impact of a joint federal-state campaign, Own Your Future, promoting awareness and planning for long-term care (LTC) in the state of Washington. The study applied survey methodology to evaluate the extent of campaign dissemination, evidence of its impact on LTC planning behaviors, and barriers to purchasing private LTC insurance. A total of 3,198 survey responses from a randomly selected community sample and a Washington State employee sample (ages 51 to 71) were analyzed. Results indicated that the impact of the campaign was limited, both with respect to awareness of the campaign itself and to initiation of LTC planning behaviors. Quantitative data revealed a high prevalence of health-related problems (e.g., obesity, diabetes), inadequate knowledge of basic LTC-related information (e.g., cost, payers), and negative attitudes toward purchasing LTC insurance among respondents. Qualitative analyses suggested that respondents perceived significant problems related to affordability and accountability within the current LTC insurance industry. These possible barriers to the purchase of LTC insurance suggest targets to be addressed by policy makers seeking to find ways to offset the public costs of LTC.     

The Quality Indicator Survey: Background,Implementation, and Widespread Change

The Quality Indicator Survey (QIS) is the most comprehensive regulatory change to the nursing home survey process since the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). In this article we describe the policy evolution that led to the QIS, summarize the QIS method and implementation, and profile the QIS survey results. Following over a decade of development, in 2007 the Centers for Medicare and Medicaid Services (CMS) began the national rollout of QIS. The intent was to improve consistency in the nursing home survey and to render the survey process more resident-centered and aligned with the intent of OBRA-87. We reviewed policy reports and firsthand accounts from the lead developer of the QIS methodology and leader of the national training contract for QIS. Changes in survey findings are profiled based on analysis of the publicly available Nursing Home Compare database from 2004 to 2010. Nineteen states implemented the QIS between 2007 and 2010, with nearly 20% of U.S. nursing homes receiving QIS surveys in 2010. Nursing homes surveyed with the QIS received more survey deficiencies on average than in the traditional survey; however, average numbers of deficiencies across states became more similar over the early implementation of QIS, with lower-than-average geographic areas experiencing increases and higher-than-average geographic areas experiencing decreases in survey deficiencies. The explicit and structured questioning of residents in the QIS is associated with increases in deficiencies related to choice, dignity, dental care, and nurse staffing. We describe ways in which the QIS affected the regulatory agencies, providers, and resident communities, although these effects are difficult to quantify. CMS's implementation of QIS is a significant step toward a more resident-centered, comprehensive, and consistent survey process. Substantial changes, however, are required not only among regulators but also among nursing homes. We argue that these new expectations and norms surrounding quality assessment and quality assurance are an important component of achieving culture change in U.S. nursing homes.