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Letters to the Editor

Helicobacter pylori Serology in Evaluation of Dyspepsia

TO THE EDITOR: I agreed with the authors' recommendations for antibiotic selection and duration in the Helicobacter pylori article.¹ I also strongly agree that treatment should be individualized, and that patients with risk factors for malignancy or complicated disease should probably undergo early endoscopy.

However, I feel that the authors fail to appreciate the value of H. pylori serology in the evaluation of the outpatient with dyspepsia. They state, "Because of the high prevalence of H. pylori infection in persons over the age of 50 and the absence of ulcer disease in most of these persons, patients over the age of 50 should have documented ulcer disease before anti-Helicobacter therapy is initiated." While this statement is true for persons in the general population, the population that should be considered in this context is patients who present to their family physician with dyspepsia.

The table illustrates the relationship between ulcer and H. pylori infection in patients with dyspepsia (based on previous studies) and assumes a 45 percent prevalence of H. pylori infection in patients who are dyspeptic.²

Relationship Between Ulcer and H. pylori Infection H. pylori status Patients with gastric or duodenal ulcer Patients with non-ulcer dyspepsia Number of patients Positive for H. pylori 20 25 45 Negative for H. pylori 2 53 55 Total 22 78 100

The table shows that a positive H. pylori serology is a reasonably good test for ulcer: 44 percent of H. pylori­positive patients have ulcer, compared with about 4 percent of those with negative serology. The 45 percent overall rate of H. pylori­positive serology among dyspeptic patients is typical of an older population; younger groups (as the authors note) have a lower prevalence, making the test even better for distinguishing ulcer from nonulcer dyspepsia. Studies have confirmed this finding; one found that of 120 H. pylori­negative dyspeptic patients with no recent history of non-steroidal anti-inflammatory drug (NSAID) use, none had an ulcer on endoscopy.³ Thus, serology is a useful tool for identifying patients with little risk of ulcer (and probably little risk of malignancy as well) who do not require immediate endoscopy.

MARK H. EBELL, M.D.
Department of Family Practice
Michigan State University
B101 Clinical Center
East Lansing, MI 48824-1315

REFERENCES

1. Damianos AJ, McGarrity TJ. Treatment strategies for Helicobacter pylori infection. Am Fam Physician 1997;55:2765-74.
2. Ebell MH, Warbasse L, Brenner C. Evaluation of the dyspeptic patient: a cost-utility study. J Fam Pract 1997;44:545-55.
3. Fraser AG, Ali MR, McCullough S, Yeates NJ, Haystead A. Diagnostic tests for Helicobacter pylori--can they help select patients for endoscopy? New Zealand Med J 1996;109:95-8.

IN REPLY: The diagnostic challenge in dyspepsia is that a wide array of pathophysiology in the upper digestive tract can present with similar symptoms. Potential etiologies for dyspepsia include gastroesophageal reflux disease, peptic ulcer disease, malignancy, pancreaticobiliary disorders, and functional etiologies such as irritable bowel syndrome or nonulcer dyspepsia. To date, H. pylori has been shown to bear a significant relationship to peptic ulcer disease, gastric carcinomas and lymphomas. Given the high prevalence of H. pylori infection in older individuals, the utility of serology in identifying patients with significant organic disease is markedly diminished in patients over the age of 50. We would disagree that H. pylori positivity is a "reasonably good test" for ulcer. In the table noted by Dr. Ebell, only 44 percent of H. pylori­positive patients actually have an ulcer; 56 percent of positives do not. This makes a coin toss slightly more predictive than serology.

We agree that the absence of infection with H. pylori is strongly predictive of the absence of ulcer disease, especially when the use of NSAIDs has been rigorously excluded. Whether malignancy can be reliably excluded based simply on negative serology is controversial. The Fraser study¹ noted above found only one patient with gastric cancer and did not identify any patients with lymphoma, even among the H. pylori­positive subset. No conclusions can be drawn regarding risk of malignancy in seronegative subjects using such small sample sizes. Serology is of no benefit in identifying dyspeptic patients with symptoms based on gastroesophageal reflux. Thirty-six percent of seronegative subjects in the Fraser study had endoscopic evidence of esophagitis.

Finally, prompt endoscopy has been shown to be cost-effective in the evaluation of the patient with dyspepsia. In a study randomizing 414 patients with dyspepsia to either prompt endoscopy or empiric medical therapy (with later endoscopy only for medical failures), the prompt endoscopy group had significantly lower overall costs, primarily because of lower drug costs, fewer office visits and less time off from work.²

ARISTOTLE J. DAMIANOS, M.D.
Gastroenterology Department
Wausau Medical Center
2727 Plaza Dr.
Wausau, WI 54401

THOMAS J. MCGARRITY
Milton S. Hershey Medical Center
Hershey, PA 17033

REFERENCES

1. Fraser AG, Ali MR, McCullough S, Yeates NJ, Haystead A. Diagnostic tests for Helicobacter pylori--can they help select patients for endoscopy? New Zealand Med J 1996;109:95-8.
2. Bytzer P, Hansen JM, Schaffalitzky de Muckadell OB. Empiric H2-blocker therapy or prompt endoscopy in management of dyspepsia. Lancet 1994; 343:811-6.

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FIGURE 1. Radiograph of an anterior subcoracoid dislocation. Note the relationship of the humeral head and the glenoid. Although there are no bony avulsions, the physician must be aware of the possibility of rotator cuff injuries. FIGURE 2. Magnetic resonance imaging showing a tear of the rotator cuff. The open arrow shows retraction of the supraspinatus tendon toward the glenoid rim. The solid arrow shows the supraspinatus muscle belly. Atrophy of the muscle will show a decrease in signal along with fatty infiltrates.

Shoulder Dislocations in Patients Over 40: Rotator Cuff Tear?

TO THE EDITOR: Anterior traumatic shoulder dislocations carry a risk for rotator cuff tears.^2-4,6 Many of these tears are of the supraspinatus tendon, and quick diagnosis can give the patient options that make for a greater degree of function. If a tear is undetected, the tendons retract and the muscle atrophies to the point that repair of the rotator cuff would be tenuous.

A 75-year-old man was seen eight weeks after a fall which had resulted in an anterior dislocation of his right shoulder (Figure 1). This was easily reduced in the emergency department.

Subsequent follow-up visits demonstrated a persistent component of night pain and limited function. Physical examination revealed an inability to actively forward elevate or abduct. Strength on external rotation was compromised as well.

Treatment included a six-week course of physical therapy, without much improvement. Analgesics and anti-inflammatory medications were ineffective. The patient underwent magnetic resonance imaging (MRI) of the shoulder, which demonstrated a tear of the supraspinatus tendon with retraction of the tendon (Figure 2).

It was explained to the patient that he could choose to have surgery in an attempt to repair the rotator cuff or choose to accept his disability, knowing that repair at a later date would be difficult. The patient elected to have surgery, during which the retracted tendon was mobilized and repaired.

The patient was placed in a stepped rehabilitation program and has regained essentially normal motion and strength. He is able to perform activities of daily life and has minimal discomfort in the shoulder.

Index dislocations of the shoulder seldom occur after the age of 40; when they do, they should engender heightened suspicion of rotator cuff tears.^2-4,6 In this example, the initial trauma resulted in an index subcoracoid dislocation, readily reducible and without associated fracture. Occasionally a small avulsion fracture of the greater tuberosity in and of itself serves as a marker for rotator cuff tendon avulsion. In most cases, however, physical examination and clinical suspicion must be the physician's guides.

The typical course for a patient recovering from an uneventful index anterior dislocation is moderate pain that decreases by the end of the second week, during which motion and strength gradually return. In contrast, this patient had noted a high level of persistent pain, diminished motion and, most important, decreased strength on forward elevation and external rotation. The weakness on external rotation implied an injury not only to the supraspinatus, but also to the more posterior infraspinatus. This is an important physical finding and one which should alert the physician to the possibility of a rotator cuff injury.^1,2,5

A number of diagnostic tools are available for the patient who presents two to four weeks after dislocation. Radiographs, though helpful in identifying avulsion of the greater tuberosity, do not show rotator cuff tear. Arthrography and ultrasonography will show the presence of a tear (but not its size), the number of tendons involved, the degree of retraction or changes within the muscle bodies, such as fatty infiltration. MRI, on the other hand, will provide all the information needed to properly assess a tear. This is important in patients with prior shoulder problems. The treatment of these patients is based on a careful assessment of their needs, activity levels and the size of the tear. In most cases, an acute rotator cuff tendon tear is best repaired within the first four weeks to minimize the amount of retraction, fibrosis and atrophy. In rare cases, when the patient is older, is medically compromised or leads a functionally undemanding life, noninvasive care is offered. This consists of a gentle rehabilitation program aimed at restoration of function below the horizontal.

ROBERT H. BELL, M.D.
RUSSELL A. MOUNTS, R.N., P.A.-C.
Orthopaedic Surgeons, Inc.
Crystal Clinic
3975 Embassy Pkwy., Suite 102
Akron, OH 44333

REFERENCES

1. Codman EA. The shoulder; rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston: T. Todd, 1934.
2. DePalma AF. Surgery of the shoulder. 3d ed. Philadelphia: Lippincott, 1983.
3. Gonzalez D, Lopez R. Concurrent rotator-cuff-tear and brachial plexus palsy associated with anterior dislocation of the shoulder. A report of two cases. J Bone Joint Surg Am 1991;73:620-1.
4. Hawkins RJ, Bell RH, Koppert GJ. Anterior dislocation of the shoulder in the older patient. Clin Orthop 1986;206:192-5.
5. Byley I, Kessel L, eds. Shoulder surgery. New York: Springer-Verlag, 1982.
6. McLaughlin HL, MacLellan DI. Recurrent anterior dislocation of the shoulder. II. A comparative study. J Trauma 1967;7:191-201.

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Intrathecal Narcotics for Labor Analgesia

TO THE EDITOR: As Navy family physicians, we devote a great deal of time to the care of our pregnant patients. We therefore appreciated Drs. Stephens and Ford's¹ excellent outline of the advantages and disadvantages of intrathecal narcotics compared with epidural analgesia, as well as the differences in the effectiveness of both in the first and second stages of labor. We do feel that one point in the article needs clarification, however.

Drs. Stephens and Ford write, "The relationship between epidural analgesia and rates of cesarean delivery remains controversial."¹ However, published studies actually indicate a significant increase in cesarean deliveries associated with epidural analgesia. A randomized, controlled, prospective trial conducted from 1990 to 1992 found that 25 percent of patients who received epidural analgesia required cesarean delivery, compared with 2.2 percent of those who received intravenous narcotics.² In fact, this result was deemed so significant that after only 93 of a planned 200 patients were observed, the study was terminated because it would have been "unethical to continue randomization."² A meta-analysis of six studies conducted from 1989 to 1993 found significantly higher rates of cesarean deliveries under epidural analgesia in five of the six studies.³ From this literature, it seems clear that the woman undergoing labor with epidural analgesia faces a higher risk of cesarean section.

Unfortunately, there is little in the literature about the relative risks of cesarean section and operative vaginal delivery with each of the three common modes of analgesia--intrathecal narcotic analgesia, epidural analgesia and intravenous narcotic analgesia. Intrathecal narcotic analgesia is a promising tool of family-centered maternity care that warrants further research. Patient-oriented outcomes of great interest to us would be maternal and infant morbidity and mortality, risk of cesarean section and other operative interventions, quality of pain relief when compared to epidural analgesia in labor, costs and patient experience of the birth process. However, until outcomes-based studies are conducted, we can only say that intrathecal narcotic analgesia may offer a safe, effective alternative to epidural analgesia without the increased risk of cesarean section.

INGRID V. SHELDON, M.D., M.P.H.
HARRY TAYLOR, M.D.
Naval Hospital
2080 Child St.
Jacksonville, FL 32214

REFERENCES

1. Stephens MB, Ford RE. Intrathecal narcotics for labor analgesia. Am Fam Physician 1997;56:463-70.
2. Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993;169:851-8.
3. Morton SC, Williams MS, Keeler EB, Gambone JC, Kahn KL. Effect of epidural analgesia for labor on the cesarean delivery rate. Obstet Gynecol 1994;83:1045-52.

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TO THE EDITOR: We find several points in the article on intrathecal narcotics that are controversial and a few other points that could arguably result in patient death.

On page 463 the authors mention that epidural analgesia is unique in providing pain relief that blocks both visceral and somatic pain stimuli. The epidural is not unique, however; a somatic, visceral and sympathetic blockade also occurs with a subarachnoid block. The innervation of the birth process involves the sacral somatic nerves of the perineum, sympathetic afferent T10 through L1 for pain of uterine contractions and sympathetic efferent T6 through T10 to trigger and maintain uterine contractions. The early regional anesthesia for obstetrics was aimed toward getting anesthesia from T10 caudally and avoiding anesthesia above T10, to maintain good contractions. This was the principle of the "saddle block" spinal; sensory level to the umbilicus gave a painless delivery yet maintained contractions and the mother's ability to push and strain for a vaginal delivery.

On page 465 the article says in both Table 1 and in the text that a prolongation of labor can occur with continuous epidural placement. This statement is not proven, is extremely controversial and was debated recently at a meeting of the Society of Obstetric Anesthesia and Perinatology by Dr. David Chestnut (a board certified OB/GYN and anesthesiologist).¹

Under the subtitle "Combined Spinal-Epidural Analgesia," the authors do not mention that the epidural catheter needs to be tested. The epidural catheter must be tested prior to starting a continuous epidural infusion or before performing epidural intermittent bolus. Any epidural catheter has the potential for migration, especially when the dura is punctured, as in the combined spinal-epidural technique.

Under the subtitle "Intrathecal Narcotics," the statement "any woman who has reached the active phase of labor is a potential candidate for intrathecal narcotics" is inaccurate. A woman who is morbidly obese with a potential for difficult intubation is not a candidate because of the risk of respiratory depression. On the subject of respiratory depression, Table 2 has the dose of sufentanil (Sufenta) as 7.5 to 12.5 µg. The anesthesia literature has several case reports^2-4 that show 10 µg of sufentanil given intrathecally to cause maternal respiratory depression and a decrease in fetal heart rate.

Although the article says that no specific position is required after application of intrathecal narcotics, it should be emphasized that the supine position should be avoided, due to aortocaval compression leading to maternal hypotension syndrome, a decrease in uteroplacental blood flow and a possible decrease in fetal heart rate. A left uterine displacement is recommended to prevent maternal-hypotension syndrome.

ROBERT MILLER, D.O.
JAY JACOBY, M.D., PH.D.
Department of Anesthesiology
Ohio State University
410 W. 10th Ave.
Columbus, OH 43210-1228

REFERENCES

1. Society of Obstetric Anesthesia and Perinatology. Twenty-ninth annual meeting, April 13-17, 1997, Bermuda.
2. D'Angelo R, Anderson MT, Philip J, Eisenach JC. Intrathecal sufentanil compared to epidural bupivacaine for labor analgesia. Anesthesiology 1994; 80:1209-15.
3. Eisenach JC. Respiratory depression following intrathecal opioids [Letter]. Anesthesiology 1991;75:712.
4. Palmer CM. Early respiratory depression following intrathecal fentanyl-morphine combination. Anesthesiology 1991;74:1153-5.

TABLE 3 Withdrawal Reactions with SSRIs, Clomipramine (Anafranil) and Venlafaxine (Effexor) Incidence Variable* Onset Days (onset of withdrawal symptoms may be delayed one to three weeks after fluoxetine discontinuation) Duration One to two weeks † Symptoms Medical Gastrointestinal: abdominal pain, anorexia, diarrhea, dry mouth, increased appetite, nausea, vomiting Somatic: blurry or double vision, chest discomfort, chills, coryza, fatigue, flu-like syndrome, headache, malaise, myalgia, sweating, weakness Cardiovascular: palpitations, postural hypotension ‡ Neurologic Akathisia,§ disorientation, dizziness or vertigo, dyskinesia and dystonia,|| imbalance, jitteriness/tremor, impaired memory or thinking, paresthesias (burning, tingling or electric-shock sensations in limbs or perioral area), Lhermitte's sign (electric shock sensation in spine or limbs, elicited by neck flexion),¶ transient "rushing" or "buzzing" in head, migraine-like scotomas, tinnitus Sleep disorders: excessive, vivid and early-onset dreaming, insomnia, nightmares Psychiatric Anxiety, apathy, aggressiveness, confusion, depersonalization, hallucinations, lowered mood or depression, hypomania, irritability, panic SSRIs = selective serotonin reuptake inhibitors. *--A recent retrospective study40 of 171 patients revealed 21 cases of withdrawal reactions (12.3 percent) with the following incidence rate: clomipramine: 30.8 percent; paroxetine: 20 percent; fluvoxamine: 14 percent; sertraline: 2.2 percent, and fluoxetine: zero percent. In a review of adverse drug reactions42 the incidence of withdrawal reactions was higher with paroxetine (0.3 reports per 1000 prescriptions) than with sertraline and fluvoxamine (0.03), and least with fluoxetine (0.002), for a ratio of 150:15:1. Based on two studies19,23 that showed withdrawal reaction rates of approximately 35 percent with paroxetine, an estimate of SSRI withdrawal reactions can be calculated to be 35 percent with paroxetine, 3 to 4 percent with sertraline and fluvoxamine, and less than 0.5 percent with fluoxetine (this estimate may be too low for fluvoxamine; other studies13,14 have reported withdrawal rates from 24 to 86 percent with fluvoxamine). †--In rare cases, mild symptoms have persisted up to 13 weeks. ‡--Single case report on sertraline.32 §--Single case report on venlafaxine (illustrative case 2). ||--Single case report on fluoxetine.9 ¶--Single case report on paroxetine.25

IN REPLY: The comments of Drs. Sheldon and Taylor and Drs. Miller and Jacoby are appreciated. Again, the aim of the treatise on intrathecal narcotics was not to settle the debate about epidural anesthesia and mode of delivery. While the studies cited by Drs. Sheldon and Taylor suggest an increase in cesarean deliveries associated with epidural anesthesia, there is ample data to refute this view.^1,2 Additional outcomes-based data implicated with the use of epidural anesthesia include increased rates of maternal fever and intrapartum hemorrhage.³ Data have demonstrated a normal increase in maternal temperature following administration of epidural anesthetic, particularly in primiparous patients.⁴ This physiologic hyperthermia is not associated with an infectious process, and if interpreted in isolation, may lead to inappropriate use of antibiotic therapy.

An important issue raised by Drs. Sheldon and Taylor is the lack of prospective data delineating the association, if any, between the use of intrathecal narcotics and mode of delivery. To date, no such data has been published.

In regard to the letter from Drs. Miller and Jacoby, we would like to offer several points of clarification. The focus on intrathecal narcotic application was intended to broaden physician awareness, not to promote unqualified use of the procedure.

The saddle block described in the letter uses subarachnoid anesthetic agents rather than pure narcotics. The use of epidural or subarachnoid anesthetics should be attempted only with proper training.

The issue of prolongation of labor, increased instrumented or operative delivery rates and increased incidence of maternal fever with the application of epidural anesthesia is controversial, and will remain so pending definitive research data. Studies have indeed shown a prolongation of labor subsequent to epidural use.⁵ Other studies have shown no relationship between length of labor and epidural anesthesia.² Physicians caring for laboring patients need to be aware of the data so that patients can make informed decisions regarding their choices of labor analgesia.

The epidural catheter used with the combined spinal-epidural technique should indeed be tested prior to infusing or bolusing epidural anesthetic agents.

Data on sufentanil dosing is taken directly from the American Society of Anesthesiologists.⁶ Case reports noting adverse reactions with sufentanil were appropriately referenced in the article.^7-10 As a matter of preference, we use fentanyl at our facility because more reports of adverse reactions with sufentanil have been published.

The selection of a "morbidly obese" patient as an absolute contraindication to intrathecal narcotics is a poor one. Such a patient would potentially have complications whatever the analgesia. The selection of labor analgesia must be carefully tailored to each patient.

The procedure is typically performed in the seated or left lateral decubitus position. Following the procedure, the supine position should indeed be avoided to prevent aortocaval compression and uteroplacental compromise.

I appreciate the comments of Drs. Miller and Jacoby, as they highlight the importance of careful patient screening, meticulous counseling and patient education. Armed with such information, family physicians, obstetricians and anesthesiologists form a collaborative team to provide safe and effective comfort for laboring patients.

MARK B. STEPHENS, M.D., LCDR, MC, USN
Naval Medical Center San Diego Primary Care Group
2650 Stockton Rd., Bldg. #624
San Diego, CA 92106-6006

REFERENCES

1. Lurie S, Priscu V. Update on epidural analgesia during labor and delivery. Eur J Obstet Gynecol Reprod Biol 1993;49(3):147-53.
2. Chestnut DH, Vincent RD Jr, McGrath JM, Choi WW, Bates JN. Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin? Anesthesiology 1994;80:1193-200.
3. Ploeckinger B, Ulm MR, Chalubinski K, Gruber W. Epidural anaesthesia in labour: influence on surgical delivery rates, intrapartum fever and blood loss. Gynecol Obstet Invest 1995;39:24-7.
4. Mayer DC, Chescheir NC, Spielman FJ. Increased intrapartum antibiotic administration associated with epidural analgesia in labor. Am J Perinatol 1997;14:83-6.
5. Malone FD, Geary M, Chelmow D, Stronge J, Boylan P, D'Alton ME. Prolonged labor in nulliparas: lessons from the active management of labor. Obstet Gynecol 1996;88:211-5.
6. American Society of Anesthesiologists. 1994 annual meeting, October 15-19, 1994, San Francisco. Anesthesiology 1994;81(Suppl3A):A1142.
7. Hays RL, Palmer CM. Respiratory depression after intrathecal sufentanil during labor. Anesthesiology 1994;81:511-2.
8. Newman LM, Patel RV, Krolick T, Ivankovich AD. Muscular spasm in the lower limbs of laboring patients after intrathecal administration of epinephrine and sufentanil. Anesthesiology 1994;80:468-71.
9. Baker MN, Sarna MC. Respiratory arrest after second dose of intrathecal sufentanil [Letter]. Anesthesiology 1995;83:231-2.
10. Hamilton CL, Cohen SE. High sensory block after intrathecal sufentanil for labor analgesia. Anesthesiology 1995;83:1118-21.

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Corrections

Table 3 of the article "Antidepressant Withdrawal Reactions" (August 1997, page 457) contained several typographical errors. The corrected table is reprinted in the column to the left.

The "Letter to the Editor" on emergency medicine and family physicians written by W. Anthony Gerard, M.D. (August 1997, p. 382) contains an error. The fourth sentence in the fourth paragraph should have been stated as "The Board of Certification in Emergency Medicine (BCEM) offers a quality examination in emergency medicine that many feel is comparable to the ABEM examination. Many family physicians who have been excluded from the ABEM examination have been certified by this board." In addition, the correct address for the author is: Lebanon Emergency Physicians, Good Samaritan Hospital, 4th and Walnut Sts., Lebanon, PA 17042.

The article "Immunizations: Current Recommendations" (September 1, 1997, page 865) contained an error. In the section on Haemophilus influenzae type b, the article states that "No similar preparation combining the acellular pertussis component in a preparation withH. influenzae type b vaccine is currently available." In fact, Trihibit, which has been licensed since September 1996, offers in a kit a combination of one vial containing Haemophilus b tetanus toxoid conjugate and a second vial (or five single-dose vials) containing diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed. In addition, the text failed to mention ActHIB as one of the H. influenzae type b vaccines currently available.

Table 3 of the article "Occupational Infections in Health Care Workers: Prevention and Intervention" (December 1997, page 2295) contained an error. The correct table is published below.

TABLE 3 Interpretation of the Purified Protein Derivative (PPD) Skin Test for Tuberculosis An induration of 5 mm or more is classified as positive in the following: Persons who have human immunodeficiency virus (HIV) infection or who have risk factors for HIV infection but unknown HIV status. Persons who have had recent close contact with individuals who have active tuberculosis (recent close contact implies either household or social contact or unprotected occupational exposure similar in intensity and duration to household contact). Persons who have fibrotic chest radiographs (consistent with healed tuberculosis). An induration of 10 mm or more is classified as positive in all persons who do not meet any of the criteria in section I but who have other risk factors for tuberculosis, including the following: High-risk groups Injecting-drug users known to be HIV-seronegative Persons who have other medical conditions that reportedly increase the risk of progressing from latent tuberculous infection to active tuberculosis: Silicosis Gastrectomy or jejunoileal bypass Body weight that is 10 percent or more below the ideal for age and height Chronic renal failure with renal dialysis Diabetes mellitus High-dose corticosteroid or other immunosuppressive therapy Some hematologic disorders, including malignancies such as leukemia and lymphoma Other malignancies Children less than four years old High-prevalence groups Persons born in Asian, African, Caribbean and Latin American countries with a high prevalence of tuberculosis Persons from medically underserved, low-income populations Residents of facilities providing long-term care, such as correctional institutions and nursing homes Persons from high-risk populations in their communities, as determined by local public health authorities An induration of 15 mm or more is classified as positive in persons who do not meet any of the criteria in sections I and II. Recent converters are defined on the basis of both the size of the induration and the age of the person being tested. A 10-mm or greater increase in the induration size within a two-year period is classified as a recent conversion in persons younger than 35 years. A 15-mm or greater increase in the induration size within a two-year period is classified as a recent conversion in persons 35 years of age and older. PPD skin test results in health care workers: In general, the recommendations in sections I, II and III should be followed when interpreting skin test results in health care workers. The prevalence of tuberculosis in a facility should be considered when choosing the appropriate cutoff point for defining a positive PPD reaction. In facilities where the risk of exposure to Mycobacterium tuberculosis is minimal to very low, an induration of 15 mm or greater may be a suitable cutoff point for health care workers who have no other risk factors. In facilities where tuberculosis patients receive care, the cutoff point for health care workers with no other risk factors may be an induration of 10 mm or greater. Generally, recent conversion of a PPD test from negative to positive in a health care worker should be defined as a 10-mm or greater increase in the induration size within a two-year period. For health care workers who are employed in facilities where tuberculosis exposure is very unlikely (e.g., minimal-risk facilities), an induration increase of 15 mm or more within a two-year period may be more appropriate for defining a recent conversion, because of the lower positive predictive value of the test in such groups. Adapted with permission from Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities. MMWR Morb Mortal Wkly Rep 1994;43(RR-13):1-132.

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"Tips from Other Journals" are written by the medical editors of American Family Physician.

Copyright 1998 by the American Academy of Family Physicians.
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