Context.-Recent studies suggest that one third of tuberculosis cases in urban areas result from recent transmission. Improved tuberculosis control measures such as uniform implementation of directly observed therapy might reduce the proportion of cases resulting from recent transmission. Objective.-To determine patterns of tuberculosis transmission in Baltimore, Md, after 15 years of community-based directly observed therapy. Design.-A 30-month (January 1994-June 1996), prospective, city-wide study of all cases of tuberculosis using traditional contact investigations, geographic information systems data, and molecular epidemiologic comparison of Mycobacterium tuberculosis isolates with 2 DNA probes. Patients.-One hundred eighty-two patients with culture-positive tuberculosis. Main Outcome Measures.-Proportion of disease defined as recently transmitted based on epidemiologic linkage by traditional contact tracing and molecular linkage by DNA fingerprint analysis of isolates; geographic foci of transmission based on linkage of residences by geographic information systems data. Results.-Of the 182 patients who had isolates of M tuberculosis available, 84 (46%) showed molecular clustering with 58 (32%) defined as being recently transmitted. Only 20 (24%) of 84 cases with clustered DNA fingerprints had epidemiologic evidence of recent contact. Geographic analysis showed significant spatial aggregation of the 20 clustered cases with epidemiologic links (PϽ.001), occurring in areas of low socioeconomic status and high drug use. The 64 cases with clustered DNA fingerprints but without epidemiologic links shared common risk factors and demographic features with the 20 clustered patients who did have epidemiologic links. Conclusions.-Recently transmitted tuberculosis accounts for a high proportion of tuberculosis cases in Baltimore. Recently transmitted cases occur in geographically distinct areas of Baltimore, and location-based control efforts may be more effective than contact tracing for the early identification of cases.

Using restriction fragment-length polymorphism data, we conducted a retrospective cohort study of 139 adult patients with pulmonary tuberculosis to investigate the clinical impact of Mycobacterium tuberculosis infection with a clustered isolate. The cumulative all-cause mortality rate during treatment was 21%. Patients with clustered DNA fingerprint patterns had a reduced risk of death, compared with patients with unique patterns (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.2-1.1), but this finding was confounded by age (adjusted HR, 0.8; 95% CI, 0.4-1.8). After adjustment for age, the strongest predictors of death were such underlying illnesses as diabetes mellitus, renal failure, chronic obstructive pulmonary disease, and human immunodeficiency virus infection. We conclude that comorbidity and immunosuppression are important predictors of survival for patients with pulmonary tuberculosis in an inner-city cohort. Recently transmitted infection, as determined by use of DNA fingerprinting to classify patients' isolates as being either clustered or unique, was not independently associated with death.

Background Sound levels in intensive care units can be high. Unfortunately, high levels of sound tend to result in poor sleep quality, which leads to slower healing, poorer immune response, and decreased cognitive function. Objectives To measure sound levels to which patients in intensive care units are typically exposed. Methods Peak sound pressure levels of alarms on medical devices set at different output levels were measured. Additionally, ambient sound pressure levels for durations of 10 to 24 hours were measured on 12 occasions in patients' rooms in the intensive care unit. Results Peak levels of equipment alarms measured inside a patient's room were high, and increased as the setting of the alarm level increased. The levels of these alarms when measured in an adjacent room did not increase with alarm output level. Mean sound levels inside the patient's room were generally less than 45 dB(A), but peak levels were often greater than 85 dB(C). Closing the door of the adjacent room did not decrease these peak levels. Peak and mean levels did not differ systematically during 24 hours of measurement. Conclusions High-intensity equipment alarms disturb patients' sleep but are critical in a medical emergency. However, nurses should not assume that raising the alarm output level will ensure that the alarm is audible from an adjacent room. Ambient noise measurements indicate high peak levels during both day and night. (American Journal of Critical Care. 2010;19:e88-e99)

Objective measures, not nursing judgment alone, are required to assess acoustic environments and to direct interventions that improve them.

Objective-To determine whether implementation of provider-initiated HIV counseling would increase the proportion of tuberculosis patients that received HIV counseling and testing. Design-Cluster-randomized trial with clinic as unit of randomizationSetting-Twenty, medium-sized primary care TB clinics in the Nelson Mandela Metropolitan Municipality, Port Elizabeth, Eastern Cape Province, South Africa Subjects-A total of 754 adults (≥ 18 years) newly registered as tuberculosis patients the twenty study clinics Intervention-Implementation of provider-initiated HIV counseling and testing. Main outcome measures-Percentage of TB patients HIV counseled and tested.Secondary-Percentage of patients HIV test positive and percentage of those that received cotrimoxazole and who were referred for HIV care.Results-A total of 754 adults newly registered as tuberculosis patients were enrolled. In clinics randomly assigned to implement provider-initiated HIV counseling and testing, 20.7% (73/352) patients were counseled versus 7.7% (31/402) in the control clinics (p = 0.011), and 20.2 % (n = 71) versus 6.5% (n = 26) underwent HIV testing (p = 0.009). Of those patients counseled, 97% in the intervention clinics accepted testing versus 79% in control clinics (p =0.12). The proportion of patients identified as HIV-infected in intervention clinics was 8.5% versus 2.5% in control clinics (p=0.044). Fewer than 40% of patients with a positive HIV test were prescribed cotrimoxazole or referred for HIV care in either study arm.Conclusions-Provider-initiated HIV counseling significantly increased the proportion of adult TB patients that received HIV counseling and testing, but the magnitude of the effect was small. Additional interventions to optimize HIV testing for TB patients urgently need to be evaluated.