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PubMed1999

Service delivery for patients with HIV in a rural state: the Vermont model.

The incidence of human immunodeficiency virus (HIV) infection is increasing rapidly in rural areas of the United States. Barriers to health-care delivery for this patient population include the complexity of this rapidly changing field, inexperienced rural physicians, long travel distances to receive expert care, lack of psychosocial support systems, and concerns about confidentiality. Models of HIV care for rural areas have not been developed that remove these barriers. We present the philosophy, structure, implementation, and services of a model of care in Vermont that is designed to remove many of these barriers and bring HIV expertise into the rural areas of the state. Three HIV specialty clinics have been developed in regional hospitals throughout the state. The clinic team includes an HIV-trained nurse practitioner and social worker from the hospital, a client consultant from the regional AIDS service organization, and an infectious disease specialist who travels to each of the clinics monthly. Patient care will be centralized in these regionally located clinics. The dispersion of HIV care among numerous and inexperienced rural providers will be obviated. Confidentiality will be emphasized within the hospital environment. The model has the potential to provide a complete continuum of medical care and psychosocial case management, integrate patient care and regional provider education, and increase community awareness. Patients will be able to receive their care in their own community, avoiding long travel distances. This may encourage patients to seek care earlier in their illness. The model may be adaptable to other rural areas of the United States.

Case Management↗
PubMed1981

Nutrient intake, adiposity, plasma total cholesterol, and blood pressure of rural participants in the (Vermont) Nutrition Program for Older Americans (Title III).

The interrelationships of obesity, hypertension, elevated plasma cholesterol (risk factors), and intakes of selected nutrients were examined among elderly subjects attending a congregate meal program in Vermont. Mean nutrient intakes were significantly higher for 22 males compared to 69 females. Mean plasma cholesterol levels were higher in females. Age, systolic and diastolic blood pressure, and indices of adiposity showed no sex differences. Intakes of total fat and animal protein increased in males but plasma cholesterol decreased with age. Systolic blood pressure in females increased while body mass index decreased with age. A higher proportion of females had plasma cholesterol levels greater than or equal 260 mg/100 ml and a higher proportion of females than males greater than 73 yr of age had blood pressures at risk level. There was a greater proportion of females than males with both elevated plasma cholesterol levels and adiposity. Similarly the females had greater incidence of the combination of any two risks. No males, compared to 9% of females, were in the all three risk category.

Aged↗
PubMed1980

Enteroviruses in Vermont, 1969-1978: an important cause of illness throughout the year.

Enteroviruses continue to play an important role in both epidemic and sporadic febrile diseases. Of the clinical specimens submitted for diagnosis during a 10-year period (1969-1978) at the Medical Center of Vermont Hospital, Burlington, a wide variety of diseases were associated with the isolation of enteroviruses. Among these diseases were aseptic meningitis, hand-foot-and-mouth disease, diarrhea, pleurodynia, myocarditis, herpangia, and fevers. In 1972 a single enterovirus serotype, coxsackievirus B5, WAS SOLELY RESPONSIBLE FOR EPIDEMIC DISEASE. During the other nine years of the study, a variety of enteroviruses were isolated during epidemics. Although epidemics were always seen during the summer and early fall, enteroviruses which may cause sporadic disease were isolated in each of the 12 months. An awareness by both practicing physicians and health officers not only of the epidemic potential of enteroviruses in summer and fall but also throughout the year will aid in the diagnosis and therapy of these illnesses.

Adolescent↗
PubMed1984

Legionnaires' disease: the epidemiology of two outbreaks in Burlington, Vermont, 1980.

Eighty-five cases of Legionnaires' disease were diagnosed in two major outbreaks at a large regional medical center in Burlington, Vermont, in the summer of 1980. Cases in both outbreaks were positive for Legionella pneumophila, serogroup 1 by culture, serology, or direct fluorescent antibody tests. All cases had spent time in the city of Burlington in the 10 days before the onset of symptoms. Cases in both outbreaks were both hospital- and community-acquired. A case-control study identified no common in-hospital exposure, including shower use, that was associated with illness. Cases without previous exposure to the hospital were more likely to occur in persons with residences in neighborhoods just downwind of cooling tower A, but not throughout the municipal water system. Epidemiologic and environmental studies supported the association of this cooling tower, located 150 m from the hospital, with both outbreaks. Maintenance employees who worked with tower A had higher Legionella titers than those who worked with a comparison tower located 1.6 km away. Aerosolization of L. pneumophila by tower A and airborne spread to the hospital and community are postulated. The distance of airborne transmission of L. pneumophila in these consecutive outbreaks is greater than previously reported.

Cross Infection↗
PubMed1988

Downhill ski fatalities: the Vermont experience.

All ski-related accidental deaths in Vermont during the 1979-1980 through 1985-1986 ski seasons are reported. Sixteen deaths occurred in downhill skiers at major ski areas. During the same period 24.17 million skier-days were logged for an estimated rate of one death per 1.5 million skier-days. Of the skiers 81% were male, and 62% were between the ages of 15 and 26 years. Fourteen of 16 cases resulted from collisions with objects, most commonly trees. The predominance of head and upper body injuries was striking, and fractures of the lower extremities were uncommon. Lethal head/neck injuries accounted for all but two of the deaths. Only one skier was wearing a helmet. Speed and loss of control were the two major contributing factors identified in these accidents. The need for research and development in the prevention of this class of ski accidents is emphasized.

Adolescent↗
PubMed1994

Characteristics, costs, and effects of violence in Vermont.

Study of the distribution, characteristics, costs and effects involving 125 assaults, 22 attempted suicides (plus 5 completed out-of-hospital suicides), and 49 injuries of questionable intent was carried out among local area patients treated in a hospital serving 22 communities (150,000 population) in northern Vermont. Patients referred from the service areas of other hospitals were specifically excluded in order to provide a picture of injuries from violence in the community, rather than of injuries treated at the hospital. The percentages hospitalized were assault, 5%; attempted suicide, 50%; and unknown intent, 6%. Most assault injuries were to the head or upper extremity administered by fist; suicide attempts most often were by medication or a sharp instrument to arms, while injuries of unknown intent usually resulted from smashing a hand against a building structure. Alcohol use was noted for 26%, 38%, and 23% of patients aged 15 years or older in the three respective categories. Average hospital charges (excluding physicians' bills) for the three respective injury events were $420, $2639, and $388. Only 2% of hospital bills were paid by patients or their families, 25% were paid by commercial insurance, 19% by government sources, and 54% remained unpaid. One eighth of physicians' bills for hospital and followup care were paid by patients or their families, and about 60% were still unpaid a year after billing. Among assault patients who could be contacted for followup and who had been employed or in school previously, 27% had no disability for work or school and the remainder averaged 18 days of complete plus partial disability.

Adolescent↗
PubMedDate not supplied

Evidence for school transmission of Neisseria meningitidis during a Vermont outbreak.

A meningitis outbreak due to Neisseria meningitidis, serogroup C, serotype 2b, occurred in central Vermont in February, 1984. The highest incidence was in Northfield, where 7 cases occurred (129 per 100,000 population). Of these 7 cases 2 were students at Northfield High School and 5 were younger children; all had had close contact with Northfield High School students or staff in the week before illness. A case-control study demonstrated that these cases had significantly more exposure to Northfield High School students or staff in the 2 weeks before illness (112 hours) than did controls (8 hours) (P = 0.006). This finding was confirmed by a second case-control study designed to determine risk factors for the entire outbreak. School children in Northfield and their household contacts were given meningococcal A-C vaccine and sulfisoxazole prophylaxis. No further cases of meningococcal disease occurred in Northfield after the week that these control methods were initiated. Transmission of the outbreak strain of N. meningitidis appears to have occurred in a school setting with subsequent illness in household and close contacts of carriers of the outbreak strain.

Adolescent↗
PubMed1984

Salmonellosis outbreak at a Vermont hospital.

An outbreak of gastrointestinal illness occurred at a hospital in northern Vermont during September 1981. Of the 292 hospital employees surveyed, 43 had diarrheal illness; 12 of them had positive cultures for Salmonella, serotypes chester, tennessee, or habana. In addition, three individuals who were culture-positive but did not have diarrhea were counted among the cases. Illness was related to eating roast beef or cold cuts (P less than .01) in the month of September. One food specimen, an unopened package of precooked roast beef supplied by a New York processor, was found to be contaminated by Salmonella, serotypes chester, tennessee, and livingston. Cold cuts were believed to be secondarily contaminated by a meat slicer. Three of 80 patients whose charts were reviewed had nosocomial diarrhea; two of them had positive cultures for Salmonella, serotype chester. Secondary transmission of Salmonella from hospital staff was the likely source for at least two of the patients.

Animals↗
PubMed2001

Radiographic abnormalities in long-tenure Vermont granite workers and the permissible exposure limit for crystalline silica.

This study was undertaken to assess the prevalence of radiographic abnormalities consistent with silicosis in a group of 600 retired granite workers who were receiving pensions. Files of regional clinics and hospitals were searched for chest radiographs taken on these men, and 470 x-ray films suitable for interpretation were located. After exclusions (women, and men who had worked in the granite industry elsewhere), 408 x-ray films were independently read by three experienced readers using the 1980 International Labour Office scheme. Dust exposures were estimated for workers hired after 1940, when the dust-control standard of 10 million particles per cubic foot (mppcf) (equivalent to 0.1 mg/m3) was put in place and monitored by the Vermont Division of Industrial Hygiene. Dust levels were initially high but were gradually reduced from 1940 to 1954, after which average quartz exposures stabilized to a mean of approximately 0.05 to 0.06 mg/m3; however, about 10% to 15% of samples after 1954 exceeded 0.1 mg/m3. Of the 408 x-ray films, 58 were taken on workers hired before dust controls were instituted in 1940, and 25.9% showed abnormalities (a profusion score of 1/0 or greater). A total of 350 x-ray films were taken on workers hired in 1940 or after, and the prevalence in this group was 5.7%. The radiographic changes in workers hired after 1940 are likely due to excessive exposures during the first 15 years of dust control. We conclude that if the exposure standard of 0.1 mg/m3 is rigorously observed in the workplace, radiographic abnormalities caused by quartz dust in long-term workers will be rare.

Aged↗
PubMedDate not supplied

A case exercise: outbreak investigation at a Vermont community hospital.

Fifteen employees became ill with headaches, nausea, and vomiting due to chemical poisoning at a Vermont community hospital on January 3, 1980. An epidemiologic and environmental investigation was conducted to determine the source of the illness. The investigation discovered that the vapors of a chemical called xylene, which had previously been disposed of down a drain, were drawn back through the sewer into specific work areas. These vapors were determined to be the most likely cause of the illnesses. This outbreak investigation was used to create an exercise that has been used in a variety of teaching settings.

Adult↗
PubMed1982

Pseudomonas aeruginosa skin infections in persons using a whirlpool in Vermont.

Four guests at a ski resort in Vermont reported contracting a characteristic papular, pustular, or vesicular rash after using the resort's whirlpool. Pseudomonas aeruginosa serotype 1, bacteriophage type 86, was isolated from a pustule on one patient, water within the whirlpool, and the whirlpool diatomaceous earth filter. This appears to be the first outbreak of dermatitis associated with P. aeruginosa serotype 1. Previous reports of whirlpool-associated dermatitis outbreaks have identified serotype 9 and 11 isolates of P aeruginosa as the causative agents.

Adult↗
PubMed1991

Effects of work exposure, retirement, and smoking on bronchoalveolar lavage measurements of lung dust in Vermont granite workers.

Estimation of the exposure to respirable dust in the workplace is an important aspect of industrial hygiene. We performed bronchoalveolar lavage (BAL) on 42 healthy nonindustrial control subjects and 44 workers in the Barre, Vermont granite industry to determine whether BAL materials reflected occupational exposure. The granite workers held jobs with a range of dust exposure intensities and had employment histories from 1 to 43 yr; 12 workers were retired. None of the workers had radiologic evidence of silicosis. The granite dust content of BAL materials was measured by enumerating the percentage of cells positive for particulates by polarized light microscopy, by analysis for silicon by scanning electron microscopy with energy-dispersive X-ray spectrometry, and by chemical analysis. Minerals were present in greater quantity in the BAL cells from granite workers than from nonindustrial control subjects. Polarized light microscopy was comparable in sensitivity, specificity, and overall accuracy to electron microscopy; chemical analysis was less accurate than either microscopic technique. Tobacco smoking did not interfere with the detection of the occupationally related minerals or influence the quantity of dust present. The mineral in BAL cells was partially related to the intensity of exposure within the granite industry and to the duration of employment, but there was great individual variation among subjects. Retirement led to a decrease in BAL mineral content, but substantial dust remained for many years.

Bronchoalveolar Lavage Fluid↗
PubMed1985

Mineral dust and cell recovery from the bronchoalveolar lavage of healthy Vermont granite workers.

We characterized the bronchoalveolar lavage (BAL) from healthy Vermont granite workers to investigate the pulmonary response to a chronic exposure to an injurious agent. Nine granite workers with 4 to 36 yr of employment in the industry and 27 unexposed volunteers were normal by history, physical examination, electrocardiogram, blood count, spirometry, and chest radiograph. Lavage cell recovery and percent neutrophils were not different. Lymphocyte recovery in BAL was increased in the granite-exposed population. Granite dust was present within the majority of alveolar macrophages from granite workers compared with those from control subjects, as determined by polarizing light microscopy and confirmed by scanning electron microscopy with X-ray energy spectrometry. There were no differences in phagocytic function or viability of macrophages from granite workers compared with those from unexposed volunteers. We conclude that in exposed populations, granite dust can be detected and semiquantitated in lavage specimens within the alveolar macrophages, macrophage function is preserved, and the response to this exposure involves an influx of lymphocytes.

Adult↗
PubMed1986

Vermont adopts Tarasoff: a real barn-burner.

A recent Vermont Supreme Court decision adopts and extends the Tarasoff precedent. This paper emphasizes three aspects of the new precedent that are of possible consequence to providers of mental health care. First, the decision imposes the Tarasoff duty on all "mental health professionals". Second, it demonstrates a legal scenario that in effect permits a single standard of care to be applied to all mental health professionals. Third, it creates liability for property damage as well as for personal injury.

Adult↗
PubMed1987

The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later.

The authors report the latest findings from a 32-year longitudinal study of 269 back-ward patients from Vermont State Hospital. This intact cohort participated in a comprehensive rehabilitation program and was released to the community in a planned deinstitutionalization effort during the mid-1950s. At their 10-year follow-up mark, 70% of these patients remained out of the hospital but many were socially isolated and many were recidivists. Twenty to 25 years after their index release, 262 of these subjects were blindly assessed with structured and reliable protocols. One-half to two-thirds of them had achieved considerable improvement or recovery, which corroborates recent findings from Europe and elsewhere.

Adult↗
PubMed1987

The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia.

The authors present the findings from a long-term follow-up study of 118 patients from Vermont State Hospital who, when rediagnosed retrospectively, met DSM-III criteria for schizophrenia at their index hospitalization in the mid-1950s. The patients were studied with structured, reliable, multivariate instrument batteries by raters who were blind to information in their records. The rediagnostic process is described, and results of the follow-up are presented. Outcome varied widely, but one-half to two-thirds of the sample had achieved considerable improvement or recovered, in contrast to statements in DSM-III that predict a poor outcome for schizophrenic patients.

Adult↗
PubMed2002

Mortality of mental health service recipients in Vermont and Oklahoma.

The authors compared statewide mortality rates for people with severe mental illness who were served in public mental health systems of care in Vermont and Oklahoma. In both states, mortality rates for younger service recipients, but not for older recipients, were significantly higher than those for the general population. In interpreting cross-region comparisons, several possible causes of variation, including differences in caseload composition and causes outside the control of the public mental health authority, must be considered.

Adolescent↗
PubMed1987

A state mental health system with no state hospital: the Vermont Feasibility Study.

A comprehensive study of both the feasibility and the desirability of operating a state mental health system without a state hospital, except for a small forensic facility, was carried out in Vermont. Feasibility was examined in terms of client needs, service system capabilities, financing, human resource requirements, legal and rights protection issues, and political considerations. The study team concluded that developing comprehensive regional community support and rehabilitation services to replace the state hospital for all public mental health clients except forensic patients was both feasible and desirable since it would result in better services at a roughly equivalent cost to the state. The team also developed recommendations for optimizing the success of regionalization.

Community Mental Health Services↗