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General overview of PRRSV: a perspective from the United States.

Four years after the report of its discovery, porcine reproductive and respiratory syndrome virus (PRRSV) continues to challenge swine producers, veterinary practitioners, and animal health researchers in the United States. The prevalence of infection is high--60% to 80% of herds is a reasonable estimate--but the clinical effects of infection vary widely among farms. In many herds, infection is unapparent and productivity seemingly unaffected. Some infected herds report occasional respiratory disease outbreaks in young pigs, or periodic outbreaks of reproductive disease, and a few herds experience severe, chronic disease problems, particularly in young pigs. In these herds, secondary infections with viral or bacterial pathogens, particularly Salmonella choleraesuis, Streptococcus suis, or Haemophilus parasuis typically occur concurrently with PRRSV infections. Understanding why some herds undergo devastating episodes of clinical disease and others show no apparent effects is central to solving the problem of clinical PRRS for swine producers. Understanding the ecology and epidemiology of PRRSV is the key to preventing and controlling PRRSV in the future. The objective of this article is to review recent developments in these areas.

Abortion, Veterinary↗

The use of direct mail to increase clinician knowledge: an intervention study.

A probability sample of American general practitioner dentists, 40 years of age or older, in solo private practice, was the target of two direct mail interventions offered at two different times, to test whether knowledge regarding prophylaxis of patients at risk for infective endocarditis could be improved. Tests of knowledge were responses in a mail questionnaire to clinical vignettes, designed to elicit the content of antibiotic regimens used for patients at risk. The research design enabled detection of (1) the effect of the interventions; (2) the differences in their effect; (3) the attenuation of their effect; and (4) the effect of time. Where baseline knowledge was low, it was improved and did not rapidly disappear. Both mail interventions were equally effective, in most instances, and there was no attenuation of the interventions' effect and no effect of time on the control groups' knowledge over a 4 1/2 month period. The results suggest that it is possible to improve clinicians' knowledge of expert recommendations through direct mail intervention.

Adult↗

Risk factors for sexually transmitted disease amongst men in Harare, Zimbabwe.

A cross sectional survey was carried out among adult males attending a municipal polyclinic and two private practitioner surgeries in a Harare high density suburb, in order to identify risk factors for Sexually Transmitted Disease (STD). One hundred and twenty subjects participated, of whom 83 were cases (those with STD in the past six months) and 37 were controls (those with no STD). No association of STD was found with marital status, place of residence of wife, age, level of education or employment. STD was strongly associated with alcohol consumption (Odds Ratio = 7,1 [95 pc CI: 2,8-18,7]). These results strongly suggest that alcohol consumption is an important risk factor for STD. Further work is needed to explore the relationship between alcohol consumption and high risk sexual behaviour, and to test the impact of programmes aimed at targeting the reduction of alcohol use on the transmission of HIV infection.

Adult↗

Tattoos: counseling the adolescent.

In Western society, approximately 3% to 5% of the population has at least one decorative tattoo, and the number of new tattoos has increased dramatically over the last decade. Tattooing is becoming increasingly popular among adolescents. Pediatric nurse practitioners (PNPs) are in key positions to counsel preadolescents and adolescents about tattoos. PNPs should be knowledgeable about the care, potential adverse reactions, risks of blood-borne diseases, and removal of tattoos. PNPs should also have an understanding of who gets tattoos, why they get tattoos, and what type of regulations exist related to tattooing in the United States.

Adolescent↗

The experts speak. Studying the potential of tenofovir to prevent sexual transmission of HIV: first steps. Interview by Vicki Glaser.

Melanie Thompson, M.D., is Founder and Principal Investigator of the AIDS Research Consortium of Atlanta (ARCA), one of the first non-profit community-based HIV/AIDS research centers in the United States and the primary resource for HIV clinical research in Georgia. Dr. Thompson is also a private practitioner in Atlanta and serves on the International AIDS Society- USA's Antiretroviral Guidelines Panel. She is the past chair of the National Institutes of Health Office of AIDS Research Therapeutics Research Working Group. Dr. Thompson has served as ARCA's principal investigator for more than 200 studies involving more than 12,000 patients. To date, ARCA's studies have contributed to the FDA approval of 21 treatments for HIV and its complications.

Adenine↗

Trichinae certification in the United States pork industry.

Control of Trichinella infection in U.S. pork has traditionally been accomplished by inspection of individual carcasses at slaughter or by post-slaughter processing to inactivate parasites. We propose that an alternative to individual carcass testing or processing can be used when pigs are raised in production systems where risk of exposure to Trichinella spiralis has been mitigated. Declines in prevalence of this parasite in U.S. domestic swine during the last 30 years, coupled with improvements in pork production systems, now allow Trichinella control to be shifted to the farm through implementation of specific pork production practices. Knowledge of risk factors for exposure of swine to T. spiralis was used to develop an objective audit of risk that can be applied to pork production sites. In a pilot study, 461 production site audits were performed by trained veterinary practitioners. The on-farm audit included aspects of farm management, bio-security, feed and feed storage, rodent control programs and general hygiene. Of the 461 production site audits, 450 audits (97.6%) indicated compliance with the required good production practices. These sites are eligible for certification under the U.S. Trichinae Certification Program and will be audited regularly to maintain that status. The described trichinae certification mechanism will establish a process for ensuring the Trichinella safety of swine, and ultimately food products derived from swine, at the production level.

Animal Husbandry↗

Hydrotherapy in labor.

PURPOSE: To review the literature on hydrotherapy in labor to direct prescription of the intervention and design studies to test its effectiveness. METHODS: Studies of hydrotherapy were identified via searching literature and electronic databases. FINDINGS: A primary effect of immersion is a central blood volume bolus, which occurs almost immediately after bathing begins. Subjective maternal responses to bathing in labor have been favorable. No maternal or infant infections have been attributed to bathing by parturients with either intact or ruptured membranes. Maternal bathing in labor does not appear to affect infant Apgar scores or stress hormones at birth. No clear evidence exists to indicate that hydrotherapy increases cervical dilation, increases fetal descent, reduces uterine dyskinesia, shortens labor, decreases use of epidurals or analgesia, or decreases rates of operative delivery or hemorrhage. CONCLUSIONS: Study findings indicate support for using hydrotherapy for relief of rapid pain and anxiety in labor. A methodical approach must be taken to determine for whom and under what circumstances intervention with hydrotherapy in labor is efficacious. Studies of the maternal and fetal effects of hydrotherapy in labor, including mechanisms of action, as well as large, prospective, randomized clinical outcome trials with control for intervening variables, are needed to help practitioners decide whether to prescribe hydrotherapy.

Adult↗

Hepatitis, HIV infection and AIDS: some issues for the practitioner.

Hepatitis B virus and hepatitis delta virus among the viral causes of hepatitis are of principal concern to the dentist. A dentist previously infected with HBV is at risk from HDV for there are reservoirs of this infection in the population. Dentists will be most at risk from HBV because of per cutaneous inoculation but in the general population there is emphasis on the non-percutaneous transmission of the virus perinatally. Numerous carriers of HBV are being added to the population annually but their identification is often difficult. Immunization with a hepatitis B vaccine is a protection which all dentists should seek. A booster dose at 5 years is recommended. There is no evidence that hepatitis B vaccine transmits HIV. Transmission of this virus intraoperatively is much less likely than the transmission of HBV but a slight risk is there. To avoid the risk of HBV and HIV infections, full infection control precautions should be observed at all times.

Acquired Immunodeficiency Syndrome↗

The prevention of 'dry socket' with topical metronidazole in general dental practice.

OBJECTIVE: The purpose of the study was to determine if the intra-alveolar application of topical metronidazole gel could reduce the incidence of alveolar osteitis (dry socket) following routine tooth extraction in molar and premolar extraction sites. DESIGN: This was a multicentre, double blind, randomised, placebo-controlled clinical trial. A total of 302 patients took part, of which 23 returned with alveolar osteitis. Of these, eight had received the metronidazole gel and 15 the placebo. SETTING: The study was carried out in three general dental practices by general dental practitioners working in England over the period 2000-2003. MAIN OUTCOME MEASURES: Following extraction of either a molar or premolar tooth, either a 25% metronidazole gel or KY Jelly was syringed gently into the socket. A painful post operative complication was recorded if either a dry socket was present or the patient returned with pain. RESULTS AND CONCLUSIONS: The difference in the incidence of alveolar osteitis between the placebo and the active gel groups was not significant and it was concluded that 25% topical metronidazole gel was not effective in reducing the incidence of alveolar osteitis. It was found that the incidence of alveolar osteitis reduced with increasing age and was more likely to occur in a patient with a previous history of the condition.

Administration, Topical↗

Randomized, controlled trial of prescribing training in a South African province.

OBJECTIVES: Prescribing practices impact greatly on drug use and expenditure. The situation in developing countries is often compounded by a limited health budget. Furthermore, because of role substitution in these countries, prescribers are often not formally trained in rational prescribing. The study described in this paper assesses the effect of a prescribing training intervention for primary health care nurses. DESIGN: A generic training-of-trainers course and a 4-day effective prescribing course were presented to 24 provincial trainers. These trainers then conducted effective prescribing workshops for 20 primary health care nurses per workshop. In 1997, 457 prescribers were trained by this method in South Africa's Northern Province. The study investigated the impact of the training on prescribing practices for two target conditions, in a control and a study group of 11 clinics each, 1 month after and 3 months after the intervention. SETTING: Primary health care clinics in the Lowveld Region of the Northern Province of South Africa. RESULTS: Prescribing practices for the two conditions examined were significantly improved by the training. Changed behaviour was not only seen in prescribing for upper respiratory tract infections, used as an example condition, but also for diarrhoea and/or vomiting, a common condition in the region, which was not included in the training programme. These results show that prescribers not only retained the knowledge gained, but were also able to apply their new skills to other conditions (transfer effect). The change in the study group was maintained for 3 months after training, while there were no significant improvements in prescribing in the control group. INTERPRETATION: The training intervention had a beneficial effect on prescribing practices.

Drug Prescriptions↗

Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema.

OBJECTIVE: To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer. OPTIONS: Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments. OUTCOMES: Symptom control, quality of life, cosmetic results. EVIDENCE: Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000. RECOMMENDATIONS: Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles. Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out. Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema. One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone. Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight. [A patient version of these guidelines appears in Appendix 2.] VALIDATION: An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. SPONSOR: The steering committee was convened by Health Canada. COMPLETION DATE: October 2000.

Bandages↗

Choosing condoms.

Condoms for men are currently the most effective of the nonprescription contraceptive methods. They are readily available, simple to use, and relatively inexpensive, and they are not associated with major adverse effects. If used both properly and consistently, condoms can significantly reduce the risk of transmission of HIV and other STDs. The protection offered by the latex condom may be increased by the concurrent use of a vaginal foam or cream containing nonoxynol 9. The practicing pharmacist should know about the variety of condoms available, be able to explain their correct use to maximize effectiveness, and compare condom use with other types of contraceptives. The practitioner should be available to answer patrons' questions and provide counseling on contraceptives and "safe sex" practices.

Choice Behavior↗

Clinical evaluation of audiometric control root canal treatment: a retrospective case study.

OBJECTIVE: The purpose of this study was to retrospectively assess the success of endodontic treatment that had been guided by audiometric (electronic) measurement. METHOD AND MATERIALS: The lengths of 66 infected root canals that demonstrated periapical pathosis were accurately measured by the Sono-Explorer before root canal obturation. The results over time intervals of 1 month to 20 years were evaluated on the basis of radiographic examinations. RESULTS: The rate of successful treatment was 90.4% for short-filled root canals, 94.5% for flush-filled root canals, and a low 50.0% for long-filled root canals. The rate of successful endodontic therapy was 87.8% for restorations that did not exceed the apical foramen but reached the apical constriction and 95.3% if cases in which the apical radiolucencies were disappearing were included as successes. If cases of unintentional long-filling (overextension) were excluded, the success rate was as high as 98.4%. CONCLUSION: The poor performance of overfilled root canals indicates that practitioners should not overextend these restorations. Use of the Sono-Explorer aided successful treatment of infected root canals.

Adult↗

The female condom.

BACKGROUND: The female condom has been available in numerous countries for some years. It was launched in Australia on March 8th, 2000 and is an important addition to the range of barrier contraceptives. OBJECTIVE: This article aims to provide an overview of the female condom to enable GPs and nurse practitioners to advise clients and provide information about its use. DISCUSSION: The female condom is an effective form of contraception. When used correctly it has a failure rate of about 5%, which compares favourably with other forms of barrier contraception. It is important that users are instructed on insertion, in particular the need to guide the penis into the condom. Evidence shows that it reduces the incidence of sexually transmitted infections. There may also be additional benefit in reducing wart virus and herpes transmission, as there is greater protection to the vulva and the base of the penis, when compared with the male condom. The female condom has high user acceptability, and offers advantages in terms of sensitivity and also ease of use by men with erectile dysfunction. It is the only barrier protection under a woman's control, giving protection to the vagina and vulva as well as the cervix.

Australia↗

Attitudes, knowledge and behaviour of general practitioners in relation to HIV infection and AIDS. Commonwealth AIDS Research Grant Committee Working Party.

A stratified random sample of 655 Australian general practitioners (GPs) was surveyed to determine their attitudes, knowledge and behaviour in relation to the human immunodeficiency virus (HIV) pandemic. Of the 486 respondents, 22% had one or more patients with HIV infection in their practice and 80% had been asked for information on HIV infection in the past month by at least one patient. The majority of respondents viewed screening and education of patients as part of their role, but 24% did not want to maintain a therapeutic relationship with HIV-infected patients and 16% felt it was appropriate to refuse to treat this group. Although most respondents correctly identified the well known risk-taking behaviours for HIV infection in homosexual men and intravenous drug users, they underestimated the risk to heterosexuals and exaggerated that associated with activities generally considered not to involve risk. The knowledge of appropriate infection control procedures of approximately 60% of the respondents was inadequate. A lack of time in consulting was the most commonly cited barrier to the routine assessment of, or enquiry into, risk-taking behaviours of patients in the respondents' practices. Respondents noted that they required more knowledge of the clinical presentation and diagnosis of HIV infection, as well as education in counselling techniques and the risks of transmission associated with sexual and non-sexual activities. They felt such information could best be imparted through printed material. These results indicate that most GPs are willing to play an active role in the diagnosis, treatment and prevention of HIV disease, but they require more accurate information in order to fulfill this role appropriately. The study identifies and addresses several barriers to GPs playing a more active role in the management of HIV disease.

Acquired Immunodeficiency Syndrome↗

Nurses with blood-borne pathogens and the moral responsibilities of nurse regulating authorities.

This paper examines, for consideration by nurses and nurse regulating authorities (NRA), certain ethical and practice issues concerning registered/enrolled nurses with blood-borne pathogens (BBPs), such as Human Immunodeficiency Virus and Hepatitis Viruses. Under existing legislation, the identity and infectious status of a nurse with a BBP may be notified to a NRA by either a medical practitioner or another person. In the event of a notification being made, NRAs need to consider the question of how best to achieve a workable balance between protecting the significant moral interests of both the public and the nurse concerned. This paper clarifies how such a balance may be achieved, and provides recommendations on how the issue can be addressed in practice.

Acquired Immunodeficiency Syndrome↗

Variations in chemoprophylaxis for meningococcal disease: a retrospective case note review, analysis of routine prescribing data and questionnaire of general practitioners.

BACKGROUND: Invasive meningococcal disease is a significant cause of mortality and morbidity in the UK. Administration of chemoprophylaxis to close contacts reduces the risk of a secondary case. However, unnecessary chemoprophylaxis may be associated with adverse reactions, increased antibiotic resistance and removal of organisms, such as Neisseria lactamica, which help to protect against meningococcal disease. Limited evidence exists to suggest that overuse of chemoprophylaxis may occur. This study aimed to evaluate prescribing of chemoprophylaxis for contacts of meningococcal disease by general practitioners and hospital staff. METHODS: Retrospective case note review of cases of meningococcal disease was conducted in one health district from 1st September 1997 to 31st August 1999. Routine hospital and general practitioner prescribing data was searched for chemoprophylactic prescriptions of rifampicin and ciprofloxacin. A questionnaire of general practitioners was undertaken to obtain more detailed information. RESULTS: Prescribing by hospital doctors was in line with recommendations by the Consultant for Communicable Disease Control. General practitioners prescribed 118% more chemoprophylaxis than was recommended. Size of practice and training status did not affect the level of additional prescribing, but there were significant differences by geographical area. The highest levels of prescribing occurred in areas with high disease rates and associated publicity. However, some true close contacts did not appear to receive prophylaxis. CONCLUSIONS: Receipt of chemoprophylaxis is affected by a series of patient, doctor and community interactions. High publicity appears to increase demand for prophylaxis. Some true contacts do not receive appropriate chemoprophylaxis and are left at an unnecessarily increased risk.

Anti-Infective Agents↗

The antimicrobial potential of 14 natural herbal dentifrices: results of an in vitro diffusion method study.

BACKGROUND: Increasing numbers of Americans are using natural herbal products for general and oral health care. Few of these products, however, have undergone rigorous testing, as evidenced by the limited amount of information on their safety and efficacy in the literature. The authors conducted an in vitro study to evaluate the antimicrobial potential of 14 natural herbal dentifrices. METHODS: The authors used a diffusion method to evaluate the antimicrobial effectiveness of 14 natural herbal dentifrices against four microorganisms: Streptococcus mutans, Streptococcus sanguis, Actinomyces viscosus and Candida albicans. Colgate Total (Colgate-Palmolive, New York City) and sterile pyrogen-free water served as the positive and negative controls, respectively. The authors tested the natural herbal dentifrices at full strength and at 1:1 dilution. They measured the zones of inhibition at 24 and 48 hours to evaluate the antimicrobial potential of the dentifrices. RESULTS: Six herbal dentifrices were effective in inhibiting the growth of all four microorganisms. The positive control produced significantly sized inhibition zones with all four microorganisms, while the negative control produced no observable zones. Six herbal dentifrices produced larger inhibition zones with A. viscosus than did the positive control. Six herbal dentifrices were inhibitory against C. albicans at full strength, but at 1:1 dilution, only three had such inhibitory effect. One herbal dentifrice produced microbial growth around and over the samples, indicating possible microbial contamination of the toothpaste. Only one herbal dentifrice showed consistent antimicrobial activity against all four microorganisms. CONCLUSIONS: The variation in antimicrobial inhibition among the herbal dentifrices indicates that more research is needed to validate their effectiveness claims. CLINICAL IMPLICATIONS: This study provides practitioners with insight into the claims of natural herbal dentifrices' antimicrobial effects.

Actinomyces viscosus↗