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PubMed2005

Patient reminder and patient recall systems to improve immunization rates.

BACKGROUND: Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result of low immunization rates, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care and large demands on primary care physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g. all children who should receive the measles vaccine) and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g., patient reminders), provider interventions and system interventions. One intervention strategy involves patient reminder and recall systems. OBJECTIVES: To assess the effectiveness of patient reminder and recall systems in improving immunization rates and compare the effects of various types of reminders in different settings or patient populations. SEARCH STRATEGY: A systematic search was performed for the initial review using MEDLINE (1966-1998) and four other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of The Effective Practice and Organisation of Care (EPOC) register in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings and files of study collaborators were also searched for references. In December 2004 the EPOC register was searched to identify relevant articles to update the review. SELECTION CRITERIA STUDY DESIGN: Randomized controlled trials (RCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies written in English. TYPES OF PARTICIPANTS: Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting. TYPES OF INTERVENTIONS: Any intervention that falls within the EPOC scope (See Group Details) and that includes patient reminder or recall systems, or both, in at least one arm of the study. TYPES OF OUTCOME MEASURES: Immunization rates or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g. influenza vaccination) or standard combinations of recommended vaccinations (e.g. all recommended vaccinations by a specific date or age). DATA COLLECTION AND ANALYSIS DATA COLLECTION: Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus. ANALYSIS: Results are presented for individual studies as relative rates for randomized controlled trials and as absolute changes in percentage points for controlled before and after studies. Pooled results for RCTs only were presented using the random effects model. MAIN RESULTS: Five new studies were added for this update. Increases in immunization rates due to reminders were in the range of 1 to 20 percentage points. Reminders were effective for childhood vaccinations (OR = 1.45, 95% CI =1.28, 1.66), childhood influenza vaccinations (OR = 2.87, 95% CI = 1.65, 4.98), adult pneumococcus, tetanus, and Hepatitis B (OR = 2.19, 95% CI = 1.21, 3.99), and adult influenza vaccinations (OR = 1.66, 95% CI = 1.31, 2.09). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but most costly. AUTHORS' CONCLUSIONS: Patient reminder and recall systems in primary care settings are effective in improving immunization rates within developed countries.

Adult↗
PubMed2005

Risk factors for completed suicide in schizophrenia.

OBJECTIVE: Schizophrenic patients in Taiwan have lower comorbidity of substance use disorders than do those in Western countries, and most of them live with their families. This study investigated the risk factors for completed suicide in this population with inherently lower rates of the confounding variables of substance abuse and social isolation. METHOD: 4237 acute inpatients with DSM-III, DSM-III-R, or DSM-IV schizophrenia admitted from January 1, 1985, to December 31, 2000, were followed through 2001 by record linkage to the Death Certification System. Seventy-eight subjects who died from suicide during this period were matched with living controls randomly for age (+/- 5 years), sex, and the same year of index admission. Demographic and clinical variables were collected from medical records and formally confirmed at every admission and outpatient follow-up. RESULTS: Among 78 case-control pairs, the lifetime prevalence of substance use disorders was 7.1%, and 93.6% of the subjects lived with their families. Approximately half of the completed suicides occurred within 4 years after the first admission. Conditional logistic regression analysis revealed a strong association with the following 3 variables: depressive syndrome in residual phase (adjusted odds ratio [OR] = 23.07, p < .005), higher suicide intensity (adjusted OR = 2.78, p < .05), and later age at onset (increase per year, adjusted OR = 1.07, p < .05). Fasting cholesterol level and clozapine use had no association with completed suicide. CONCLUSIONS: The peak period for completed suicide was early years after the first admission. The target population for additional measures to prevent suicide should include patients with depressive syndrome in residual phase, higher suicide intensity, and later onset of illness.

Adult↗
PubMed2000

Participation in a program that helps families with one teen pregnancy prevent others.

STUDY OBJECTIVE: To define the optimal target population for a home- and clinic-based mentoring program designed to help one teen pregnancy-families prevent others, by prospectively determining who might be willing to participate in an intervention of this type. DESIGN/SETTING/PARTICIPANTS: Pregnant 13-to-19 year olds in a comprehensive, adolescent-oriented maternity program and their younger, nulliparous, 10-to-16 year old sisters were asked to participate in the intervention. RESULTS: Only 27 (61%) of the 44 eligible families agreed to participate and 9 (33%) of these 27 families withdrew within 6 months. Older sisters from nonparticipating families were significantly more likely to be over 16 years of age at conception (53% compared to 15%; P =.01), and younger sisters from families that withdrew were significantly more likely to be over 14 years of age or under 12 years of age at enrollment (63% vs 22%; P =.03). Ultimately, 75% of the families in which the older sister was less than 17 years of age at conception joined the program and only 16% of the families in which the younger sister was 12-to-14 years of age at enrollment withdrew within 6 months. CONCLUSIONS: Investigators testing the efficacy of programs for preventing pregnancies among teen mothers and their nulliparous, younger sisters could minimize selection bias by prospectively targeting families in which the older sister became pregnant before she was 17 years old and the younger sister is 12 to 14 years old.

Adolescent↗
PubMed2003

Isfahan Healthy Heart Programme: a comprehensive integrated community-based programme for cardiovascular disease prevention and control. Design, methods and initial experience.

The Isfahan Healthy Heart Programme (IHHP) is a five to six year comprehensive integrated community-based programme for cardiovascular diseases (CVD) prevention and control via reducing CVD risk factors and improvement of cardiovascular healthy behaviour in a target population. IHHP started late in 1999 and will be finished in 2005-2006. A primary survey was done to collect baseline data from interventional (Isfahan and Najaf-Abad) and reference (Arak) communities. In a two-stage sampling method, we randomly selected 5 to 10 percent of households from randomly selected clusters. Then individuals aged > or = 19 years were selected for the survey. This way, data from 12,600 individuals (6300 in interventional counties and 6300 in the reference county) was collected and stratified according to living area (urban vs. rural) and different age and sex groups. The samples underwent a 30-minute interview to complete validated questionnaires containing questions on demography, socioeconomic status, smoking behaviour, physical activity, nutritional habits and other behaviour regarding CVD. Blood pressure and body mass index (BMI) measurements were done and fasting blood samples were taken for two hours post load plasma glucose (2 hpp), serum (total, HDL and LDL) cholesterol and triglyceride levels. A twelve-lead electrocardiogram was recorded in all persons above 35 years of age. Community-wide surveillance of deaths, hospital discharges, myocardial infarction and stroke registry was carried out in the intervention and control areas. Four to five years of interventions based on different categories such as mass media, community partnerships, health system involvement and policy and legislation have started in the intervention area while Arak will be followed without intervention. Considering the results of the baseline surveys, (assessments needed, the objectives, existing resources and the possibility of national implementation) the interventions were planned. They were set based on specific target groups like school children, women, work-site, health personnel, high-risk persons, and community leaders were actively engaged as decision makers. A series of teams was arranged for planning and implementation of the intervention strategies. Monitoring will be done on small samples to assess the effect of different interventions in the intervention area. While four periodic surveys will be conducted on independent samples to assess health behaviours related to CVD risk factors in the intervention and reference areas, the original pre-intervention subjects aged more than 35 years will be followed in both areas to assess the individual effect of interventions and outcomes like sudden death, fatal and nonfatal MI and stroke. The whole baseline survey will be repeated on the original and an independent sample in both communities at the end of the study.

Adult↗
PubMed2006

Emergence of Clostridium difficile-associated disease in North America and Europe.

The clinical spectrum of Clostridium difficile-associated disease (CDAD) ranges from diarrhoea to severe life-threatening pseudomembranous colitis. Although not always associated with previous antibiotic exposure, it is in the majority of cases. CDAD is recognised increasingly in a variety of animal species and in individuals previously not considered to be predisposed. C. difficile can be transmitted via personal contact or environmentally. The role of patients and healthcare workers who are symptom-free but colonised with C. difficile in the intestinal tract is unclear. C. difficile, with more than 150 PCR ribotypes and 24 toxinotypes, has a pathogenicity locus (PaLoc) with genes encoding enterotoxin A (tcdA) and cytotoxin B (tcdB). Genes for the binary toxin are located outside the PaLoc, but the role of this toxin is unclear. The recently completed genome sequence of C. difficile 630 revealed a large proportion of 11% of mobile genetic elements, mainly in the form of conjugative transposons. Diagnostic assays include tests for the detection of C. difficile products or genes and culture methods for isolation of a toxin-producing bacterium. Enzyme immunoassays to detect toxin in faeces are widely available, with varying sensitivities and specificities. Despite practical drawbacks and sensitivity less than 100%, the cell cytototoxicity assay is still considered to be the standard. Rapid diagnostic assays are available on a limited scale and require much improvement. Molecular tests enable the detection of carriers of toxigenic and non-toxigenic strains, as does culture. It is highly recommended to culture C. difficile from toxin-positive faeces samples and to store isolates for future characterisation and typing. The financial impact of CDAD on the healthcare system is substantial (5-15,000 euro/case in England and $1.1 billion/year in the USA). Assuming a European Union population of 457 million, the potential cost of CDAD can be estimated to be 3000 million euro/year, and is expected to almost double over the next four decades. In North America, increasing rates of CDAD have been reported in Canada and the USA since March 2003, involving a more severe course, higher mortality, increased risk of relapse and more complications. This increased virulence is presumably associated with higher levels of toxin production by fluoroquinolone-resistant strains belonging to PCR ribotype 027, pulsed-field gel electrophoresis (PFGE) type NAP1, REA (restriction endonuclease analysis) type BI and toxinotype III. In Europe, outbreaks of CDAD due to the new, highly virulent strain of C. difficile PCR ribotype 027, toxinotype III have been recognised in 75 hospitals in England, 16 hospitals in The Netherlands, 13 healthcare facilities in Belgium and nine healthcare facilities in France. These outbreaks are very difficult to control, and preliminary results from case-control studies indicate a correlation with fluoroquinolones and cephalosporins. Information concerning community-acquired cases of ribotype 027 is lacking, and data concerning its incidence in nursing homes are limited. European countries should first develop early-warning and response capabilities at a national level. Depending on the nature of the notifications received, countries should implement laboratory-based or patient-based surveillance systems in specific, targeted populations.

Animals↗
PubMed2004

[Hypertension in women: study in mothers of students from Jaboatão dos Guararapes, Pernambuco, Brazil].

OBJECTIVE: The purpose of this research was to study the prevalence of hypertension in apparently healthy women community with a view preparing a program for primary prevention of hypertension. METHODS: The population survey involved a representative sample of mothers of 126.800 students enrolled at schools of Jaboatão dos Guararapes, Pernambuco, Brasil. The population size (1.273 students) was selected from a 5% +/- 2% expected frequency of the hypertension in children with a confidence level of 99.9%. This study comprised 21 schools and a random sample of 986 mothers of 1.601 students). Two blood pressure measurements separated by 2 minutes were carried out in the schools on two subsequent visits. The corporal mass index was determined in 893 mothers. In a group of 671 mothers, a midstream urine specimen was collected and the dip - stick was used to assess the presence of urinary abnormalities. RESULTS: The prevalence of the hypertension was 27.7% and it was significantly higher (p<0.01) in overweight (28.5%) and obese women (57%) than normal weight women (14%) and underweight women (12%). There was significant difference regarding the presence of glucosuria between the hypertensives and the normotensives women (3% and 0%, respectively). In a group of 62 hypertensives women with followup at 3 to 12 month interval, the blood pressure has been controlled in 13 (21%) and remains below the initial hypertensive stage in 27 (43.5%). CONCLUSIONS: The prevalence of hypertension (27,7%) do agree with the data in the literature concerning hypertension in women (26%), showing a higher tendency in overweight and obese women. We are continuing the followup of the hypertensive women as well as developing a community program for primary prevention of hypertension in the target population.

Adult↗
PubMed2005

Use of drug-eluting stents for the treatment of in-stent restenosis in routine clinical practice.

BACKGROUND: Although target lesion revascularization (TLR) has been dramatically decreased by using drug-eluting stents (DESs) in de-novo lesions, their efficacy for in-stent restenosis (ISR) has not yet been well established. METHODS: We retrospectively analysed patients treated for ISR with DESs from three referral hospitals. RESULTS: Eighty-seven consecutive patients, from June 2002 to April 2004, were included, with a mean age of 64+/-11 years; 83% were men, 32% had diabetes, 47% had had a previous myocardial infarction and 16% had low left ventricular ejection fraction. Angiographic characteristics were as follows: mean vessel diameter, 3.05+/-0.4 mm; lesion length, 17.8+/-7.7 mm; diameter stenosis, 84.0+/-10.7%; and complex lesion, 81%. The restenosis was focal in 45%, diffuse/proliferative in 51.3% and total occlusion in 3.7% of the cases. Sirolimus- and paclitaxel-eluting stents were used in 42 and 58% of the patients, respectively. Stent diameter was 3.1+/-0.3 mm and the length was 26.1+/-5.8 mm. Angiographic success was achieved in all patients, with one patient experiencing a post-procedural non-Q-wave myocardial infarction. At 6-month clinical follow-up, two patients had died from non-cardiac deaths, five had experienced a new TLR (5.7%, four percutaneous and one coronary artery bypass graft) and eight (9.2%) had had major adverse cardiac events. A stress test was performed in 60% of the population; target vessel ischemia was observed in one patient (3.3%). CONCLUSION: In this non-select cohort of patients, the use of DESs is a safe and effective strategy for ISR lesions.

Aged↗
PubMedDate not supplied

[Sun exposure behavior of children between 3-15 years of age living in Montpellier].

OBJECTIVE: Increasing prevalence of skin cancer over the past few decades and their relationship with childhood sun exposure, show that educational campaigns on sun protection are urgently needed. The aim of this study is to estimate the degree of children's sun exposure in the south of France (43 degrees latitude north) and to study sun protection behaviors according to phenotypic characteristics. POPULATION AND METHODS: The population was a randomly selected sample of 573 schoolchildren between 3 and 15 years of age living in Montpellier. The questionnaire provided information about sociodemographic characteristics, summer sun exposure and sun protection. Phenotypic characteristics, reactivity to sunlight and number of sunburns since birth were also reported. RESULTS: Exposure time was very high: half of children spend over 6 hours per day outside in summer. The youngest children were the most protected either by sunscreen, or by shirt. On the beach, sunscreens were used more than half of the time of exposure by 70 p. 100 of the children. At the swimming pool, sunscreens were used by 45 p. 100 of the children and only by 14 p. 100 of them during other outdoor activities. A tee-shirt was only wore by 50 p. 100 of the children when playing on the beach, and by 75 p. 100 of them at the swimming pool. In addition, the application of sunscreen varied by body site. The adolescents, although they were exposed less than the youngest children, were very poorly protected. Light skinned children who do not tan easily had highest risk of sunburns, although they were generally more protected. CONCLUSION: The parents are able to identify highly sensitive children according to phenotype, but in practice the use of sunscreens and tee-shirt is very low. Parents and adolescents must be the target population but also insufficiently protected children. Health education at school must be an important measure for prevention.

Adolescent↗
PubMed2006

Identification of "substrate fibrillators" and "trigger fibrillators" by pacemaker diagnostics.

BACKGROUND: The population of patients likely to respond to selected pacing algorithms for maintenance of sinus rhythm is unknown. OBJECTIVES: The purpose of this study was to identify patients with specific onset patterns of paroxysmal atrial fibrillation (AF). METHODS: Dual-chamber pacemakers with advanced diagnostic functions were implanted in 112 patients with conventional indications for antibradycardia pacing and a history of paroxysmal AF. Pacemaker diagnostic data were analyzed after 97.5 +/- 40.9 days. According to the frequency of premature atrial contractions (PACs) during the 5 minutes before AF onset, patients were assigned to one of three groups: group A (high PAC activity), group B (moderate PAC activity), or group C (low PAC activity). RESULTS: AF burden was lower in group A (4.6% +/- 2.4%) than group B (15.8% +/- 3.0%, P = .003) and group C (15.5% +/- 3.1%, P = .003). Fewer AF episodes occurred in group A (2.1 +/- 1.3 per day) than group B (3.8 +/- 1.2 per day, P = .006). Mean AF episode duration was shorter in group A (11.4 +/- 10.2 hours) than group C (41.4 +/- 27.5 hours, P = .03). CONCLUSION: The coincidence of low PAC activity before AF onset, high AF burden, and extended arrhythmia episode duration appears to be the consequence of a high atrial substrate factor. In these "substrate fibrillators," the efficacy of pacing algorithms for maintenance of sinus rhythm may be limited. In contrast, "trigger fibrillators" exhibiting low AF burden despite high PAC incidence may represent the target population for specific PAC-suppressing pacing algorithms.

Aged↗
PubMed1989

Distal splenorenal shunt with splenopancreatic disconnection. A 4-year assessment.

The aims of distal splenorenal shunt with splenopancreatic disconnection (DSRS-SPD) were to improve maintenance of portal flow and prevent siphoning of hepatotrophic factors from the pancreas, as occurs after standard DSRS. The main patient population targeted for improvement were alcoholic cirrhotics, who have poorer survival than nonalcoholic cirrhotics and greater loss of portal flow (60%) after standard DSRS. Seventy-eight patients had DSRS-SPD during the study period 1983 to 1987: thirty-two patients were Child's A, 25 were Child's B, and 21 were Child's C. The 35 patients with alcoholic cirrhosis were a significantly poorer risk group by Child's class and galactose elimination capacity (GEC) than the 39 patients with nonalcoholic cirrhosis. Four patients had portal vein thrombosis. At 4-year follow-up, portal perfusion is maintained in 84% alcoholic and 90% nonalcoholic patients, with hepatic and systemic hemodynamics showing identical patterns for both groups. Hepatic function measured by GEC was maintained in alcoholic patients (290 +/- 68 mg/min to 303 +/- 74 mg/min) and nonalcoholics patients (342 +/- 92 to 320 +/- 118 mg/min). Gastric variceal rebleeding occurred in 10 patients--4 early (less than 2 months) and 6 late (18 to 54 months), leading to operation in 4 and transhepatic embolization in 4 patients: 2 of these patients died from this complication. Survival data show an operative mortality rate of 6.4% and overall mortality rate of 30%, with no significant difference between alcoholic and nonalcoholic cirrhotics. DSRS-SPD has significantly improved maintenance of portal perfusion and survival in patients with alcoholic cirrhosis requiring selective shunt for variceal bleeding when compared to standard DSRS. In this population DSRS-SPD is the operation of choice. In patients with nonalcoholic cirrhosis, the current data have not shown DSRS-SPD to have advantage over standard DSRS.

Angiography↗
PubMed1999

Factors associated with use of community support services in an older Australian population.

OBJECTIVE: To assess prevalence and risk factors associated with use of community support services in a representative older Australian population. METHODS: The Blue Mountains Eye Study surveyed 3,654 people aged > or = 49 years, 82.4% of eligible residents from an area west of Sydney during 1992-94. Questions about use of community support services were asked during face-to-face interview. Information on marital and living status, socio-economic status measures, past medical history and self-ranked health status were also collected. RESULTS: 186 (5.4%) persons including 124 women (6.3%) and 62 men (4.2%) reported regular use of community support services, including Meals-on-Wheels (n = 52), Home Care (n = 147) or visits from a community nurse (n = 63). All three services were used by 17 persons and two services by 42 persons. There was a marked age-related increase in use of services from 1.8% in persons aged < 60 years to 25.3% in persons aged 80+ years. Factors significantly associated with use of community services in a multivariate model were: age (OR 1.7 per age decade), living alone (OR 2.5), walking disability (OR 4.1), visual impairment (OR 3.0), stroke history (OR 2.2), arthritis history (OR 1.8), low perceived health status (OR 1.7), cancer history (OR 1.7) and a history of any falls in the past 12 months (OR 1.6). CONCLUSIONS: Our study has found a wide range of health-related factors that impact on the use of community support services, particularly conditions causing difficulty in walking. IMPLICATIONS: These data may assist health planners in identifying target populations for the provision of community support services.

Age Distribution↗
PubMed2004

The potential role of NaFeEDTA as an iron fortificant.

Ethylene diamine tetraacetic acid (EDTA) is a hexadentate chelator, which can combine with virtually every metal in the periodic table. CaNa2EDTA and Na2EDTA (ADI 2.5 mg EDTA/kg body weight/day) are widely used as sequestering agents in canned products, while NaFeEDTA is a promising iron fortificant. Binding of EDTA with iron is favored in the acid milieu of the stomach, irrespective of whether the EDTA is administered as CaNa2EDTA, Na2EDTA, or NaFeEDTA, but in the more alkaline medium of the duodenum the iron is exchanged, in part, with other metals. The iron released from EDTA is absorbed by the normal physiological mechanisms. When NaFeEDTA is present in a meal, the iron moiety exchanges with the intrinsic food iron and the EDTA partially protects the iron in this common non-heme iron pool from the effects of inhibitors of iron absorption, such as phytates and polyphenols. When iron is added as NaFeEDTA to an inhibitory meal, it is two to three times better absorbed than is iron added as ferrous sulfate. It also has a similar effect on the intrinsic food iron in the meal. Fortification with NaFeEDTA is most efficacious when administered with cereal- and legume-based diets but offers no advantages over other fortificants when added to meals of high bioavailability. Its potential as a fortificant has been confirmed in five extended fortification trials carried out in developing countries. There is no evidence that NaFeEDTA in the dose range proposed for food fortificants (5 to 10 mg iron daily) will have any direct toxic effects. Na2EDTA and CaNa2EDTA have proved safe over a number of years, while the Joint FAO/WHO Expert Committee on Food Additives concluded in 1999 that NaFeEDTA "could be considered safe when used in supervised fortification programs". Animal and human studies, including the results of two fortification trials, suggest that NaFeEDTA has little or no effect on overall zinc metabolism. Indeed, if anything, it increases zinc and possibly copper absorption. Data on potentially toxic metals, such as lead mercury, aluminum, and manganese, are limited but the evidence that is available is uniformly negative thus far. Further studies in this field are desirable. The long-term potential of NaFeEDTA fortification to cause iron overload is conjectural but the available evidence suggests that homeostatic controls would prevent excess iron accumulation in the normal population. NaFeEDTA, which is pale yellow in color, causes fewer organoleptic changes in a number of stored vehicles, including cereals, than do other soluble iron salts. Other potential vehicles include condiments, several of which have been successfully used in fortification trials. What is currently lacking is a consolidated body of published evidence on the stability of NaFeEDTA during processing, storage, and household cooking in widely consumed food vehicles, coupled with standardized testing of consumer acceptance of each fortified vehicle. While NaFeEDTA seems to be an appropriate fortificant for developing countries, its cost is about six to eight times that of ferrous sulfate in terms of equivalent amounts of iron. Its better absorption (a factor of 2-3) might make it possible to halve the daily fortification level but, it still remains expensive and there is a pressing need for food grade NaFeEDTA at more affordable prices. Another possible option is the use of other salts of EDTA (Na2EDTA or Ca Na2EDTA) together with a soluble source of iron, such as ferrous sulfate. The combination has been shown to be as effective as NaFeEDTA when the EDTA:Fe molar ratio is between 1:2 and 1:1. This approach is, however, only feasible with vehicles that are stored for short periods because of ferrous sulfate's propensity to cause organoleptic changes. The search for an iron source that is more stable but at the same time available to combine with EDTA has been unsuccessful thus far. Target populations for fortification with NaFeEDTA include all those that subsist on cereal- and legume-based diets, with the most appropriate vehicles being cereal products and condiments. The fortification of infant milk and cereal formulas with NaFeEDTA does not seem appropriate, since the amounts of NaFeEDTA required for effective fortification would be close to the acceptable daily intake (ADI) of 2.5 mg EDTA/kg body weight/day.

Absorption↗
PubMed2004

Clinical practice guideline: Otitis media with effusion.

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM). The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown). The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Acoustic Impedance Tests↗
PubMed2004

Otitis media with effusion.

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children 1 to 3 years old with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced-practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media. The subcommittee made recommendations that clinicians should 1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME, 2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk, and 3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known) or diagnosis (if onset is unknown). The subcommittee also made recommendations that 4) hearing testing be conducted when OME persists for 3 months or longer or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME, 5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected, and 6) when a child becomes a surgical candidate (tympanostomy tube insertion is the preferred initial procedure). Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that 1) population-based screening programs for OME not be performed in healthy, asymptomatic children, and 2) because antihistamines and decongestants are ineffective for OME, they should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that 1) tympanometry can be used to confirm the diagnosis of OME and 2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery) and provide additional relevant information such as history of acute otitis media and developmental status of the child. The subcommittee made no recommendations for 1) complementary and alternative medicine as a treatment for OME, based on a lack of scientific evidence documenting efficacy, or 2) allergy management as a treatment for OME, based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children more than 12 years old, because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child-development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition and may not provide the only appropriate approach to diagnosing and managing this problem.

Acoustic Impedance Tests↗
PubMed2000

Attack rates of human papillomavirus type 16 and cervical neoplasia in primiparous women and field trial designs for HPV16 vaccination.

BACKGROUND: Identification of human papillomavirus type 16 (HPV16) as the major risk factor for cervical neoplasia, and mass production of DNA free HPV capsids have paved the way to preventive vaccination trials. Design of such trials requires reliable attack rate data. OBJECTIVE: Determination of (1) HPV16 and (2) cervical neoplasia attack rates in primiparous women. Estimation of actuarial sample sizes for HPV16 vaccination phase IV trials. DESIGN: A longitudinal cohort study. METHODS: Population based Finnish Maternity Cohort (FMC) and Finnish Cancer Registry (FCR) were linked for the identification of two cohorts of primiparous women: (1) a random subsample of the FMC: 1656 women with two pregnancies between 1983-9 or 1990-6 and living in the Helsinki metropolitan area, and (2) all 72,791 primiparous women living in the same area during 1983-94. Attack rate for persistent HPV16 infection (1) was estimated in 1279 seronegative women by proportion of seroconversions between the first and the second pregnancy. Comparable 10 year cumulative incidence rate (CR) of cervical intraepithelial neoplasia grade III and cervical cancer (CIN III+) (2) was estimated based on cases registered at the FCR during 1991-4. RESULTS: The HPV16 attack rates were 13.8% (< 18 years), 7.0% (18-19 years), 2.3% (21 years), 2.4% (23 years), and 4.5% (< 25 years). Number of vaccinees required for a 5 year efficacy trial with persistent HPV16 infection as the end point ranged between 1000 and 3900, assuming 80% power, 90%-70% vaccine efficacy (VE), and misclassification. The CRs of CIN III+ were 0.33% (< 18 years), 0.44% (18-19 years), 0.21% (20-24 years), and 0.28% (< 25 years). Number of vaccinees required for a 10 year efficacy trial with HPV16 positive CIN III+ as the end point was 15,000 assuming 80% power, 90% VE, and 75% aetiological fraction of CIN III+ for HPV16. CONCLUSIONS: The attack rates of HPV16 and CIN III+ identify primiparous women under 25 years of age among target populations for postnatal HPV vaccination at phase II/III trials.

Adolescent↗
PubMedDate not supplied

[Risk behaviours and seroprevalence to HIV, HBV and HCV in patients of the AIDS information and prevention center in Valencia, Spain].

OBJECTIVE: The purpose of this study was to describe the sociodemographic and serologic profiles in a first time consultant population at the Information and AIDS Prevention Center of Valencia (Spain). In addition, the HIV infection risk factors were analyzed. METHOD: A cross-sectional study was performed on 1,573 persons who consulted during the year 1995. Sociodemographic and infection risk practices data were recorded and serologic information about HIV, HBV and HCV infection were obtained. Exact binomial method with a 95% interval confidence was used to calculate infection prevalence and the chi square test to make comparisons between qualitative variables. RESULTS: Sex distribution was 66,1% males and 31,9% females; mean age was 29,01 (SD: 9.2) years. Sexual intercourse without condom (25.2%) and parenteral drug abusers (22.6%) were the more frequent risk groups seeking consultation about HIV infection. Global HIV infection prevalence was 12.7% (95% CI= 11,2-14,5%). Among HIV seropositive patients, sexual transmission accounted for 30.8% of cases, of which 69.4% were heterosexual relations. The HIV infection prevalence for different risk groups were the following: parenteral drug abusers 36.8% (95% CI= 31,7-42%), heterosexual intercourse with an HIV-infected partner 24.1% (95% CI= 17,1-32,2%) and homosexual intercourse between men 9,5% (95% CI= 5,8-14,5%). HCV antibody prevalence for parenteral drug abusers was 81.2% (95% CI= 76,7-85,1%). Risk practices with a statistically significant association with HIV infection were: being an injecting drug abuser, as well as having an HIV infected and/or a injecting drug abuser partner. CONCLUSIONS: Drug parenteral abusers are still the target population for prevention programs. Data suggest that prevention and sexual education programs must continue. The main effort should be focused on the young population and on sexual partners of injecting drug abusers and/or HIV seropositive partners.

Adolescent↗
PubMed2004

Pilot study of ER utilization at Tulsa hospitals.

CONTEXT: The Tulsa Community Access Program (TCAP) project has been developed to address the health care needs of the uninsured and underinsured population in the Tulsa MSA. One of the objectives is the development of a 24/7 Care Center. OBJECTIVE: To complete a pilot study on patient demographics and utilization patterns in the Emergency Room (ER) to determine if a 24/7 clinic is needed or would be used as an alternative site for treatment. DESIGN: A survey was randomly administered to ER clients from March 2003 to April 2003 and included 45 open-ended, closed-ended, and Likert scale questions. Acuity level of care was verified by a hospital professional. SETTING: Hillcrest Medical Center, Tulsa, provides a significant amount of indigent care; four time periods were picked for peak and varied ER usage. PARTICIPANTS: 200 ER clients, 50 per time period; survey administration and data analysis were done by University of Oklahoma-Tulsa graduate students. MAIN OUTCOME MEASURE(S): Prior assumptions: uninsured/underinsured use the ER for primary care; demographics of the ER client are low income/unemployed, low education; majority of ER clients are non-urgent/non-emergency and would use a 24/7 clinic. RESULTS: 56% have used ER 1-2 times in past year; 89% of cases were non-urgent/non-emergency; 46% graduated high school; 48% work full-time; 42% have family income 15,000 dollars or less; 76.5% favor an after hours primary care clinic. CONCLUSIONS: This survey is an important tool to determine the needs and patterns of ER utilization; there is a need for a 24/7 clinic and it would be used by the target population.

Adult↗
PubMed2002

Epidemiology, risk factors, and natural history of hepatocellular carcinoma.

The incidence of hepatocellular carcinoma is increasing in many countries. The estimated number of new cases annually is over 500,000, and the yearly incidence comprises between 2.5 and 7% of patients with liver cirrhosis. The incidence varies between different geographic areas, being higher in developing areas; males are predominantly affected, with a 2:3 male/female ratio. The heterogeneous geographic distribution reflects the epidemiologic impact of the main etiologic factors and environmental risk, which are the hepatitis B (HBV) and hepatitis C (HCV) viruses. The percentage of cases of hepatocellular carcinoma attributable to HBV worldwide is 52.3% and is higher in Asia where the seroprevalence of HBsAg in the population is high. However, the vaccination campaign against this virus in some eastern countries has tended to lower the incidence of new cases of hepatocellular carcinoma. The percentage of cases of hepatocellular carcinoma attributable to HCV is 25%, and it is more prevalent in Japan, Spain, and Italy where the association between hepatocellular carcinoma and antibodies to HCV ranges between 50 and 70%. In most cases hepatocellular carcinoma develops in cirrhotic livers, where the persistent proliferation of liver cells represents the key factor of progression to hepatocellular carcinoma independent of the etiology. Another minor risk factor is aflatoxin B1 consumption, which is responsible for most cases of hepatocellular carcinoma in Africa, where the consumption of contaminated foods is common. Other known risk factors are some hereditary diseases, such as hemochromatosis, porphyria cutanea tarda, hereditary tyrosinemia, and alpha1 anti-trypsin deficiency. The natural history of hepatocellular carcinoma is heterogeneous and is influenced by nodule dimension, the mono- or plurifocality of lesions at diagnosis, the growth rate of the tumor, and the stage of the underlying cirrhosis. Available data to date suggest that tumor growth in a cirrhotic liver is variable and that the time in which a lesion in undetectable until it becomes 2 cm is between 4 and 12 months. Therefore, the suggested interval for surveillance screening with ultrasound in patients with liver cirrhosis has been set at 6 months. Patients who should benefit from screening programs are those who would be treated with curative therapy if diagnosed with hepatocellular carcinoma. Thus, the ideal target population should be limited to Child-Pugh's class A cirrhotic patients without significant comorbidity.

Aflatoxin B1↗