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PubMed1995

Prevalence of lead poisoning among two-year-old children in Vermont.

OBJECTIVES: The recent redefinition of childhood lead poisoning by the Centers for Disease Control and Prevention means that many more children are considered lead poisoned than previously. The primary purpose of this study was to determine how many 2-year-old children had lead levels of 10 micrograms/dL or more in a rural state. METHODS: Random samples of 334 children drawn from the birth certificate file and 350 children from Vermont Medicaid rosters submitted capillary blood specimens that were confirmed by venous tests if lead levels were 10 micrograms/dL or more. RESULTS: Participation rates were 63.9% in the birth certificate group and 66.4% in the Medicaid group. In the birth certificate sample, the percentages of children with confirmed lead levels 10 micrograms/dL or more, 15 micrograms/dL or more, and 20 micrograms/dL or more were 9.0 (95% confidence interval [CI], 6.2-12.6), 2.7 (95% CI, 1.2-5.0), and 1.5 (95% CI, 0.5-3.4), respectively. In the Medicaid sample, the corresponding percentages were 14.9 (95% CI, 11.4-19.2), 5.1 (95% CI, 3.1-8.0), and 2.0 (95% CI, 0.8-4.1), respectively. The percentage of children in the state's most urban county with lead levels of 10 micrograms/dL or more was significantly less than that in the rest of the state in both samples. CONCLUSIONS: The prevalence of elevated lead levels in 2-year-old children may be significant in rural states with old housing stock. Medicaid-enrolled children represent a readily identifiable high-risk group.

Child, Preschool↗
PubMed1994

Family physician management of HIV and AIDS: a Vermont study.

BACKGROUND: The purpose of this study was to survey family physicians regarding the barriers to providing primary care for persons with human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) in a small, rural state with a low incidence of infection. The study focused on issues facing family physicians, such as lack of training and experience, skill in managing the complications of HIV and AIDS, fears about transmission, patients' fears about seeing a physician who treats patients with HIV or AIDS, and lack of community consultative and ancillary services. METHODS: All 132 members of the Vermont Academy of Family Physicians were mailed a 33-item survey questionnaire; 106 (80%) responded. RESULTS: Fifty-seven percent of family physicians currently provide medical care for HIV-positive asymptomatic patients, and 45% provide care for symptomatic patients. Seventy-three percent of family physicians either currently manage or are willing to be trained to manage HIV complications. CONCLUSIONS: The results of this study indicate that a majority of physicians are willing to provide a wide spectrum of medical treatment and services to patients with HIV or AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Assessing bad debt in New Hampshire and Vermont office-based practices.

OBJECTIVE: Bad debt is one measure of the cost of medical indigence on health care institutions. This two-part study identifies a methodology for and presents findings from measuring bad debt in a collection of office-based practices. METHODS: In Part I of the study, data were gathered on site from 26 practices in Sullivan County, New Hampshire, after first conducting a survey of bad debt losses at these offices. Survey findings were compared to on-site findings and it was determined that only the practices with computerized record-keeping systems were able to supply accurate data by survey alone. In Part II, 71 randomly chosen computerized practices in New Hampshire and Vermont (identified in a screen of 275 practices) were surveyed on bad debt. RESULTS: The practices from Part II wrote off an average of $23,115 per physician in 1990 from bad debt in a region in which primary care physician income averages approximately $70,000. CONCLUSIONS: The author calculates that bad debt losses are greater than either Medicare or Medicaid losses. Uninsured patients account for 21.6% of office visits but 45% of practice write-offs. Bad debt accounts for a 16% loss from total earnings from regular office visits. Office-based practices in this study are shouldering a significant portion of the cost of care of their uninsured and underinsured patients.

Family Practice↗
PubMed1996

Hypothermia-related deaths--Vermont, October 1994-February 1996.

Hypothermia is a lowering of the core body temperature to < or = 95 F (< or = 35 degrees C). From 1979 through 1992, a total of 10,550 persons in the United States died from hypothermia, an average of 754 deaths per year (range: 557-1021 deaths). From October 1994 through February 1996, a total of 10 hypothermia-related deaths were reported by the chief medical examiner in Vermont. The average age of the 10 decedents was 62 years (range: 18-88 years); eight were men. Seven decedents were reported to have had histories of mental illness, and alcohol abuse was mentioned on the police or pathology report for two decedents. This report summarizes the investigation of three of these deaths and describes risk factors commonly associated with hypothermia.

Adolescent↗
PubMed1997

Pertussis outbreak -- Vermont, 1996.

Pertussis is increasingly recognized as a disease that affects older children and adults, including fully vaccinated persons. This report describes a statewide outbreak of pertussis in Vermont (1995 population: 584,771) in 1996 in a highly vaccinated population, affecting primarily school-aged children and adults, and underscores the need to include pertussis in the differential diagnosis of cough illness in persons of all ages.

Adolescent↗
PubMed2000

Hind limb malformations in free-living northern leopard frogs (Rana pipiens) from Maine, Minnesota, and Vermont suggest multiple etiologies.

BACKGROUND: Reports of malformed frogs have increased throughout the North American continent in recent years. Most of the observed malformations have involved the hind limbs. The goal of this study was to accurately characterize the hind limb malformations in wild frogs as an important step toward understanding the possible etiologies. METHODS: During 1997 and 1998, 182 recently metamorphosed northern leopard frogs (Rana pipiens) were collected from Minnesota, Vermont, and Maine. Malformed hind limbs were present in 157 (86%) of these frogs, which underwent necropsy and radiographic evaluation at the National Wildlife Health Center. These malformations are described in detail and classified into four major categories: (1) no limb (amelia); (2) multiple limbs or limb elements (polymelia, polydactyly, polyphalangy); (3) reduced limb segments or elements (phocomelia, ectromelia, ectrodactyly, and brachydactyly; and (4) distally complete but malformed limb (bone rotations, bridging, skin webbing, and micromelia). RESULTS: Amelia and reduced segments and/or elements were the most common finding. Frogs with bilateral hind limb malformations were not common, and in only eight of these 22 frogs were the malformations symmetrical. Malformations of a given type tended to occur in frogs collected from the same site, but the types of malformations varied widely among all three states, and between study sites within Minnesota. CONCLUSIONS: Clustering of malformation type suggests that developmental events may produce a variety of phenotypes depending on the timing, sequence, and severity of the environmental insult. Hind limb malformations in free-living frogs transcend current mechanistic explanations of tetrapod limb development.

Animals↗
PubMed1984

Endoscopic vesicourethropexy for stress urinary incontinence. Experience at the Medical Center Hospital of Vermont.

Forty-eight women with stress urinary incontinence underwent endoscopic vesicourethropexy between December, 1978, and December, 1982, at the Medical Center Hospital of Vermont or its affiliates. Four patients were lost to follow-up within six weeks, and 44 patients were followed for four to forty-one months. The overall success rate was 79.2 per cent. Failures occurred as late as fourteen months. The major complication rate was 33.3 per cent. Major complications included suprapubic abscess formation and prolonged urinary retention for up to six months. Though an obviously effective therapy for the correction of stress urinary incontinence, our success with endoscopic vesicourethropexy is less than that generally reported. Further, the incidence and nature of postoperative complications in our series provoke a greater awareness of the potential shortcomings of this procedure.

Abscess↗
PubMed2000

Morbidity and mortality among very-low-birth-weight neonates with intrauterine growth restriction. The Vermont Oxford Network.

OBJECTIVE: We sought to determine the associations between intrauterine growth restriction and neonatal morbidity and mortality, as well as the impact of prenatal glucocorticoid administration on the frequency of specific complications of prematurity among neonates with intrauterine growth restriction. STUDY DESIGN: We examined the association between intrauterine growth restriction and adverse neonatal outcomes in a population of 19,759 singleton very-low-birth-weight neonates without major birth defects. We included neonates from 25 to 30 weeks' gestation entered in the Vermont Oxford Network database between 1991 and 1996 by 196 institutions. Intrauterine growth restriction was defined as the 10th percentile for birth weight according to the 1993 US national statistics. Odds ratios were estimated according to stepwise logistic regression for each neonatal outcome. Potential explanatory variables included gestational age, intrauterine growth restriction, race, prenatal care, prenatal glucocorticoid administration, route of delivery, fetal sex, and birth within versus postnatal transfer to a network institution. RESULTS: There was a statistically significant association of intrauterine growth restriction with neonatal death (odds ratio, 2.77; 95% confidence interval, 2.31-3. 33), necrotizing enterocolitis (odds ratio, 1.27; 95% confidence interval, 1.05-1.53), and respiratory distress syndrome (odds ratio, 1.19; 95% confidence interval, 1.03-1.36). There was a trend (P <. 10) toward association of intrauterine growth restriction with increased risks of intraventricular hemorrhage (odds ratio, 1.13; 95% confidence interval, 0.99-1.29) and severe intraventricular hemorrhage (grades III and IV; odds ratio, 1.25; 95% confidence interval, 0.98-1.59). Maternal prenatal glucocorticoid administration was associated with significantly lower risks of respiratory distress syndrome (odds ratio, 0.51; 95% confidence interval, 0.44-0.58), intraventricular hemorrhage (odds ratio, 0.67; 95% confidence interval, 0.61-0.73), severe intraventricular hemorrhage (odds ratio, 0.50; 95% confidence interval, 0.43-0.57), and death (odds ratio, 0.54; 95% confidence interval, 0.48-0.62). The benefits of prenatal glucocorticoid therapy for growth-restricted newborns were similar to those among normally grown infants. CONCLUSIONS: Intrauterine growth restriction within the range of 501 to 1500 g birth weight is associated with increased risks of neonatal death, necrotizing enterocolitis, and respiratory distress syndrome. Prenatal corticosteroid use was associated with decreased risks of all outcomes studied except necrotizing enterocolitis. We found no evidence that this benefit was dependent on fetal size.

Cerebral Hemorrhage↗
PubMed1994

Successful aging of oldest old women in the Northeast Kingdom of Vermont.

Health lifeways of six oldest old women, who have lived in northeastern Vermont for an average of 70 years are described. Life histories were obtained using participant observation and intensive interviewing to identify dominant themes associated with successful aging: being a woman with family and friends, living off the land, dealing with difficult times, and working hard and staying active. Health values and practices as well as personal characteristics combined with a strong network of social support emerge as dimensions of successful aging and considerations for nursing practice.

Aged↗
PubMed2005

Bias in the Listeria monocytogenes enrichment procedure: lineage 2 strains outcompete lineage 1 strains in University of Vermont selective enrichments.

Listeria monocytogenes can be isolated from a range of food products and may cause food-borne outbreaks or sporadic cases of listeriosis. L. monocytogenes is divided into three genetic lineages and 13 serotypes. Strains of three serotypes (1/2a, 1/2b, and 4b) are associated with most human cases of listeriosis. Of these, strains of serotypes 1/2b and 4b belong to lineage 1, whereas strains of serotype 1/2a and many other strains isolated from foods belong to lineage 2. L. monocytogenes is isolated from foods by selective enrichment procedures and from patients by nonselective methods. The aim of the present study was to investigate if the selective enrichment procedure results in a true representation of the subtypes of L. monocytogenes present in a sample. Eight L. monocytogenes strains (four lineage 1 strains and four lineage 2 strains) and one Listeria innocua strain grew with identical growth rates in the nonselective medium brain heart infusion (BHI), but differed in their growth rate in the selective medium University of Vermont medium I (UVM I). When coinoculated in UVM I, some strains completely outgrew other strains. This outcome was dependent on the lineage of L. monocytogenes rather than the individual growth rate of the strains. When inoculated at identical cell densities in UVM I, L. innocua outcompeted L. monocytogenes lineage 1 strains but not lineage 2 strains. In addition, lineage 2 L. monocytogenes strains outcompeted lineage 1 L. monocytogenes strains in all combinations tested, indicating a bias in strains selected by the enrichment procedures. Bias also occurred when coinoculating two lineage 2 or lineage 1 strains; however, it did not appear to correlate with origin (clinical versus food). Identical coinoculation experiments in BHI suggested that the selective compounds in UVM I and II influenced this bias. The results of the present study demonstrate that the selective procedures used for isolation of L. monocytogenes may not allow a true representation of the types present in foods. Our results could have a significant impact on epidemiological studies, as lineage 1 strains, which are often isolated from clinical cases of listeriosis, may be suppressed during enrichment by other L. monocytogenes lineages present in a food sample.

Bacteriological Techniques↗
PubMed2005

Is the use of early nasal CPAP associated with lower rates of chronic lung disease and retinopathy of prematurity? Nine years of experience with the Vermont Oxford Neonatal Network.

OBJECTIVE: The neonatal regional tertiary care center of the University of Vienna (VC) has been a member of the Vermont Oxford Neonatal Network (VONN) since 1994. During the period 1994--2002, important differences between the VC and the VONN in both pre- and postnatal management and in late morbidities such as chronic lung disease (CLD) and severe retinopathy of prematurity (ROP) were observed. We hypothesize that stabilization of very-low-birth-weight (VLBW) infants on nasal continuous positive airway pressure (NCPAP) immediately after birth, combined with a restrictive use of artificial ventilation, might be responsible for lower rates of CLD and ROP. PATIENTS AND METHODS: Obstetric and neonatal data for all 1299 VLBW infants (401-1500 g) from the VC were compared with corresponding data for the 201,167 VLBW infants from the VONN for the period 1994--2002 with regard to respiratory management and patient outcome. Morbidity criteria were in accordance with VONN definitions. RESULTS: The percentage range for treatment and morbidity criteria for the VC and VONN are related to differences among various years within the observation period. Infants were stabilized at birth on NCPAP in 45-86% of cases in the VC vs. 37-63% in the VONN, the rate of mechanical ventilation was 40-59% vs. 66-74%, and use of surfactant was 31-50% vs. 55-64%. CLD was diagnosed in 14-32% of cases in the VC vs. 27-39% in the VONN, discharge on supplemental oxygen took place in 2-4% vs. 12-17% of cases and ROP (stages III and IV) was found in 1-10% vs. 8-12%. CONCLUSION: The association of lower rates of CLD and ROP in the VC compared to the VONN might be related to differences in early respiratory management of VLBW infants at high risk of development of respiratory distress syndrome. This needs to be confirmed in a large multicenter trial.

Austria↗
PubMed2004

Fetal infants: the fate of 4172 infants with birth weights of 401 to 500 grams--the Vermont Oxford Network experience (1996-2000).

OBJECTIVE: Improvement in the survival of extremely low birth weight infants requires that we evaluate the limits of our care and assess the impact of treatment on a population of infants who previously rarely survived. METHODS: A review was conducted of demographic and clinical data of infants who had birth weight 401 to 500 g and were entered in the Vermont Oxford Network Database between 1996 and 2000. RESULTS: A total of 4172 infants who weighed 401-500 g (mean gestational age: 23.3 +/- 2.1 weeks) were born at 346 participating centers. Overall, 17% survived until discharge. A total of 2186 (52%) died in the delivery room (DR), and 1986 (48%) were admitted to a neonatal intensive care unit (NICU). Compared with infants who died in the DR, infants who survived the DR and were admitted to the NICU were more likely to be female (58% vs 49%), to be small for gestational age (56% vs 11%), to have received prenatal steroids (61% vs 12%), and to have been delivered by cesarean section (55% vs 5%). Thirty-six percent of NICU admissions survived to discharge. Mean gestational age of the 690 NICU survivors was 25.3 +/- 2.0 weeks. These survivors experienced significant morbidity in the NICU. CONCLUSIONS: An appreciable number of these marginally viable fetal infants survive. They experienced a high rate of serious morbidities while in the NICU. There is very little information about long-term outcomes, as the medical and developmental status of few of these infants has been followed carefully. Parents should be made aware of the high incidence of serious problems, and concerted efforts should be made to follow the status of these infants.

Databases, Factual↗
PubMed2006

Management of high-order multiple births: application of lessons learned because of participation in Vermont Oxford Network collaboratives.

OBJECTIVES: The delivery and care of sextuplets is complex. Potentially better practices that were developed as part of the Vermont Oxford Network improvement collaboratives were used to prepare for a sextuplet delivery at Akron Children's Hospital. METHODS: The team used potentially better practices that were learned from the Neonatal Intensive Care Quality Improvement Collaborative 2002 using multidisciplinary teams. There was extensive media coverage of the delivery. RESULTS: The goal was to use nearly all potentially better practices that focused on the goals of reducing nosocomial infection, reducing chronic lung disease, reducing radiograph use, reducing length of stay, reducing blood gas use, promoting nutrition, reducing intraventricular hemorrhage, and enriching family-centered care. The center aimed to use these 97 potentially better practices. Of the 97 possible potential better practices as set by the Neonatal Intensive Care Quality Improvement Collaborative 2002, 96 (99%) were used. CONCLUSIONS: This is a blueprint that any center that is faced with high-order multiple births could use as a reference point to begin planning. The team created a benchmark to achieve in every birth of very low birth weight infants and not just a special situation of high-order multiple births.

Delivery, Obstetric↗
PubMed1988

Modification of the vermont test for monitoring fat adulteration of dairy products.

The Vermont test was developed for the routine screening of dairy products for vegetable fat adulteration. A slight modification of the test procedure made it more rapid and reduced costs. Gas-liquid chromatographic analysis of saponified fatty acids in the first and second Mojonnier extractions were proportional; thus, only the first extraction was needed to determine the purity of a milk lipid sample. This modification saves about 8 min/series of four samples and conserves 48% of the volume of organic solvents necessary to perform the classical Mojonnier extraction.

Butter↗
PubMed2001

Water quality response to riparian restoration in an agricultural watershed in Vermont, USA.

Achievement of management goals for Lake Champlain (Vermont/New York, USA and Quebec, Canada) will require reduction of agricultural phosphorus loads, the dominant nonpoint source in the Basin. Cost-effective phosphorus reduction strategies need reliable treatment techniques beyond basic cropland and waste management practices. The Lake Champlain Basin Agricultural Watersheds National Monitoring Program (NMP) Project evaluates the effectiveness of livestock exclusion, streambank protection, and riparian restoration practices in reducing concentrations and loads of nutrients, sediment, and bacteria in surface waters. Treatment and control watersheds in northwestern Vermont have been monitored since 1994 according to a paired-watershed design. Monitoring consists of continuous stream discharge recording, flow-proportional sampling for total P, total Kjeldahl N, and total suspended solids, grab sampling for indicator bacterial, and land use/agricultural monitoring. Strong statistical calibration between the control and treatment watersheds has been achieved. Installation of riparian fencing, protected stream crossings, and streambank bioengineering was completed in 1997. Early post-treatment data suggest significant reduction in P concentrations and loads and in bacteria counts in the treated watershed. Monitoring is scheduled to continue through 2000.

Agriculture↗
PubMed1996

A multicenter, randomized trial comparing synthetic surfactant with modified bovine surfactant extract in the treatment of neonatal respiratory distress syndrome. Vermont-Oxford Neonatal Network.

OBJECTIVE: To compare the efficacy of a synthetic surfactant (Exosurf Neonatal, Burroughs-Wellcome Co) and a modified bovine surfactant extract (Survanta, Ross Laboratories) in the treatment of neonatal respiratory distress syndrome (RDS). DESIGN: Multicenter, randomized trial. SETTING: Thirty-eight neonatal intensive care units participating in the Vermont-Oxford Neonatal Network. PATIENTS: Premature infants (n = 1296) weighing 501 to 1500 g with RDS requiring assisted ventilation with 30% oxygen or more were enrolled within 6 hours of birth. INTERVENTIONS: Infants were randomly assigned to receive up to four intratracheal doses of the synthetic surfactant (Exosurf Neonatal, n = 644) or the modified bovine surfactant extract (Survanta, n = 652). MAIN OUTCOME MEASURE: The primary outcome measure was the occurrence of death or chronic lung disease 28 days after birth. RESULTS: Death or chronic lung disease occurred in 57% of the infants treated with Exosurf Neonatal and in 54% of those infants treated with Survanta (relative risk [RR], 0.95; 95% confidence interval [CI], 0.86 to 1.04). Infants with birth weights of 1001 to 1500 g who received Survanta had a significantly lower risk of chronic lung disease or death at 28 days (Survanta, 27% vs Exosurf, 34%; RR, 0.78; 95% CI, 0.60 to 0.99). Treatment with Survanta led to significant improvement in several secondary outcome measures. Survanta-treated infants received less supplemental oxygen and had lower mean airway pressure 6 and 72 hours after treatment. Survanta-treated infants had significantly fewer pneumothoraces (Survanta, 9% vs Exosurf, 15%; RR, 0.60; 95% CI, 0.44 to 0.81). There were no differences between the groups in the incidence of other neonatal complications. CONCLUSION: Although no differences were noted between Survanta- and Exosurf-treated infants regarding the primary outcome of death or chronic lung disease at 28 days of age, the significant improvement in secondary clinical outcomes suggests that Survanta is more effective than Exosurf Neonatal in the treatment of established RDS.

Biological Products↗
PubMedDate not supplied

Increasing use of antenatal corticosteroid therapy between 1990 and 1993 in Vermont Oxford Network.

OBJECTIVE: The purpose of this study was to determine whether the frequency of antenatal corticosteroid treatment changed between 1990 and 1993 and to identify patient characteristics associated with the use of this treatment. STUDY DESIGN: A total of 17,335 infants born in the years 1990 to 1993 with birth weights of 1500 gm or less and gestational ages of 24 to 34 weeks who were cared for at one of the 94 institutions participating in the Vermont Oxford Network were included in the study. Ninety-one infants were excluded from analysis because of missing data, resulting in a final sample of 17,244 infants. RESULTS: The percentage of infants whose mothers received antenatal corticosteroid treatment increased steadily during the 4-year study period (19.3% in 1990, 24.8% in 1991, 28.6% in 1992, and 34.1% in 1993; p < 0.001 by chi square test for trend in proportions). The results of a logistic regression analysis indicated that increasing year of birth, inborn location of birth, prenatal care, and multiple birth were associated with an increased use of antenatal corticosteroid treatment; black race and small size for gestational age were associated with decreased use of the treatment. In 1993, the median percentage of infants at an individual institution whose mothers received antenatal corticosteroid treatment was 25%; 10% of institutions had percentages less than 7% and 10% had percentages higher than 60%. CONCLUSION: Although the use of antenatal corticosteroid treatment increased steadily during the study period, this treatment was still used infrequently at many institutions in 1993. Considerable improvements in outcomes for preterm infants can be achieved if the recommendations of the National Institutes of Health Consensus Development Panel regarding more widespread use of antenatal corticosteroid treatment are adopted by health professionals who provide medical care to pregnant women.

Adrenal Cortex Hormones↗