Biomedical subjects
Publications and source records attributed to C Rand.
We describe an unusual case of a postoperative bone cyst resulting from a retained fragment of surgical glove. We highlight some of the problems associated with gloves and suggest ways of safeguarding against similar complications.
Leproid granulomas from seven dogs in the United States were evaluated. Gross characteristics included nodular and ulcerated dermal and subcutaneous lesions primarily on the caudal aspects of the pinnae and to a lesser extent on the muzzle, face, and forelimbs. In all except one dog, there was complete regression of the lesions within 6 months, either with no therapy or after surgical resection. Cytology or histopathology revealed pyogranulomatous inflammation with few to many acid-fast mycobacterial bacilli within macrophages. The organisms could not be cultivated in vitro. DNA sequencing of part of the 16S ribosomal RNA gene region revealed 99-100% homology among fragments from five of these dogs and fragments from dogs in the south Pacific. This syndrome occurs in dogs in North America and the prognosis is excellent, in contrast to the prognosis for rapid-growing or tuberculous mycobacteriosis.
BACKGROUND: Although the importance of cockroach allergen in chronic asthma has now been well defined, little progress has been made in the control of cockroach allergen in infested homes. OBJECTIVE: The objective of this study was to examine the ability of a combination of professional pest extermination and household cleaning using a solution of sodium hypochlorite to reduce cockroach infestation and allergen levels in cockroach infested homes. METHODS: Seventeen cockroach-infested homes were studied with three homes serving as controls. In the intervention homes, a professional exterminator applied 0.05% abamectin twice at 2-week intervals at study entry and a professional cleaner cleaned the homes before and after the extermination. All washable surfaces were cleaned throughout the study with a solution of 0.5% hypochlorite. Monthly home visits were conducted to inspect the home, interview the homeowner, place passive cockroach traps, and to collect settled dust samples from the kitchen, bedroom, and TV/living room. RESULTS: The number of cockroaches in the passive traps decreased rapidly after the initial intervention in most homes. Median Blatella germanica allergen 1 levels in the settled dust samples fell by 91% in the kitchen, 78% in the bedroom, and 77% in the living room over the course of the study in the intervention homes but gradually rose in the control homes. The overall reductions were very similar to those seen in a previous study with a similar protocol except for the use of the sodium hypochlorite. CONCLUSIONS: Successful extermination is possible in most inner-city homes and cockroach allergen levels can be reduced by 80% to 90%. However, 0.5% sodium hypochlorite did not seem to improve allergen reduction, and in many homes, allergen levels remained above the proposed threshold of 8 U/g of dust throughout the study.
A total of 134 patients who had a cementless hydroxyapatite-coated total hip arthroplasty (THA) and had no recognized risk factors for heterotopic ossification (HO) were reviewed retrospectively. The average follow-up period was 83 months. Pharmacologic or radiotherapeutic prophylaxis against HO was not used. HO was seen in 90 (67.2%) of the 134 patients reviewed. HO was rated as Brooker class I in 68 (50.7%) patients, class II in 17 (12.7%) patients, class III in 3 (2.2%) patients, and class IV in 2 (1.5%) patients. The average Merle d' Aubigne score in patients with mild forms of HO (Brooker classes I and II) was 16 compared with 13.2 in patients with severe HO (Brooker classes III and IV). A statistically significant negative correlation was found between the presence of HO and the postoperative hip score. Based on our study findings and on a comparison with data in the literature, hydroxyapatite-coated cementless THA alone does not seem to increase the likelihood of HO over other types of THA. The presence of a hydroxyapatite coating does not result in more class III or IV HO, which are the only classes of HO with real clinical significance. Fear of HO should not be a factor in the choice of fixation for THA.
Asthma is a common disease of airway obstruction in school-aged children. Adequate management of asthma in children leads to fewer missed school days, fewer hospitalizations, fewer emergency room visits, and an increase in quality of life. Most asthma educational programs and evaluations have focused on urban rather than rural populations. The purpose of this study was to identify parental asthma needs, develop rural asthma education materials, and evaluate the effectiveness of these educational materials in improving the knowledge and asthma care effectiveness of parents of children with asthma in a rural community. Seven parents were contacted by telephone and administered a pre- and posttest questionnaire analyzing their level of knowledge about asthma and their quality of life. Asthma educational materials were mailed to all parents in the study before administering the posttest. Results indicated that all parents needed additional education about asthma, especially regarding medications. Pre- and posttest scores showed improvements in three areas of knowledge: long-term asthma medications, controlling roaches in the home, and daily peak flow monitoring. There was a significant improvement between pre- and posttest results from the activity domain of quality of life. Eighty-five percent of the parents reported that they had either initiated changes in their home, or planned to in the future, from reading the educational materials. The parents' response to the educational materials that they received by mail was positive, indicating that they may not have received enough information about how to care for children with asthma before our study. The data suggest that distribution of asthma educational materials in rural communities can increase parental knowledge about asthma and lead to positive changes in behavior that can improve their children's health.
We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.
Environmental, socioeconomic, psychological and familial factors in rural communities predispose children to asthma. This is not only the case in the US but also in the UK, New Zealand and other Western countries. Asthma prevalence ranges from 2.2 to 15%. Because children spend at least 6 hours of their day in school, school health personnel must be attentive to, and skilled in managing the needs and issues faced by children with asthma while at school. Rural school nurses or their deputies need to advise children with asthma about avoiding aeroallergens from hay, smoke, dust, grain in silos and animal dander from cattle and sheep. In the case of children with asthma in rural areas, symptoms may be accepted as long as the child can go to school and play. Parents in rural areas may not believe in routine preventive care for asthma as part of public health practice. Rural nurses need to be aware of current asthma guidelines and apply the concepts to prevention. They need to be proactive and engage in primary, secondary and tertiary prevention. Rural school nurses can begin by using existing resources and adapting these resources for use in rural school environments. Worldwide asthma education is fundamental to asthma patient management.
OBJECTIVE: To assess the frequency of nebulizer use, describe morbidity and patterns of medication administration, and examine the potential relationships between inhaled anti-inflammatory medication administration, asthma morbidity, and asthma management practices in children with asthma using a nebulizer compared with children with asthma not using a nebulizer. RESEARCH DESIGN: A cross-sectional, descriptive survey of previous events. SETTING: Elementary schools and participants' homes in Baltimore, Md, and Washington, DC. PARTICIPANTS: Six hundred eighty-six families of children aged 5 to 12 years with a diagnosis of at least mild, persistent asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Asthma morbidity, health care utilization, pattern of asthma medication administration, nebulizer use, and asthma management data were collected by telephone survey administered to caregivers. Nebulizer use was defined as use at least 1 or more days per month during the last 6 months. Of 686 children identified, 231 (33%) reported current nebulizer use. Nebulizer users had significantly increased lifetime hospital admissions, hospitalizations, and emergency department visits in the last 6 months compared with nonnebulizer users. Inhaled corticosteroid administration was low for both groups (nonnebulizer users, 8%; nebulizer users, 15%). In the nebulizer users group, administration of inhaled anti-inflammatory medications was associated with increased asthma morbidity (increased hospitalizations, days and nights with symptoms, and oral steroid use). CONCLUSIONS: Nebulizer use by inner-city children with asthma is higher than anticipated but is not associated with reduced asthma morbidity. This group of high-risk children was undertreated with inhaled corticosteroids for long-term control of asthma despite reports of adequate monitoring by a primary care physician.
OBJECTIVE: To test the hypotheses that the burden of childhood asthma compromises psychological adaptation and that the degree of compromise increases with disease severity. DESIGN: The Childhood Asthma Management Program (CAMP) is a multicenter randomized clinical trial initiated and funded by the National Heart, Lung, and Blood Institute. SETTING: Study sites were located in Albuquerque, NM, Baltimore, Md, Boston, Mass, Denver, Colo, St Louis, Mo, San Diego, Calif, Seattle, Wash, and Toronto, Ontario. PARTICIPANTS: A total of 1,041 children aged 5 to 12 years were randomized to the trial after confirming their mild to moderate asthma. MAIN OUTCOME MEASURES: Psychological questionnaires administered at baseline to parents and participants assessed anxiety, depression, behavioral competence, social support, and family functioning. RESULTS: Psychological difficulty was not increased in this group of asthmatic children and their families. Psychological adaptation in the children was associated with the psychological adaptation of the family but not with disease-related variables. Scores from the Impact on Family Scale, a measure of family quality of life related to the child's illness, were associated more strongly with the overall psychological characteristics of the family and child and very little with disease characteristics or severity. CONCLUSIONS: Mild to moderate asthma has imposed modest effects on the daily life but not the psychological health of this group of children. Variation in the psychological characteristics of these children was, as is the case for most children, traceable to the overall psychological adaptation of their families.
The complexity of adherence to pharmacological interventions is frequently underestimated. Consequently, little research has been done to understand, improve, or evaluate the effects of adherence to drug protocols. While efforts to better measure and increase adherence require dedicated resources, improved adherence in existing clinical research can potentially cut costs in trial size and length. This paper outlines strategies to facilitate research on adherence to pharmacological interventions including: reporting of adherence data, changing how we conceptualize adherence to pharmaceuticals, understanding issues unique to older adults' pill-taking behavior, and creating standardized methodologies to measure adherence. Further, we describe some promising research areas that may lead to effective interventions: adherence "typologies" and modality matching. Control Clin Trials 2000;21:218S-225S
BACKGROUND: Accurate assessment of medication adherence has been difficult to achieve but is essential to drug evaluation in clinical trials and improved outcomes in clinical care. OBJECTIVE: This study was conducted to compare four adherence assessment methods: child report, mother report, canister weight, and electronic measurements of metered dose inhaler (MDI) actuation. METHODS: Participants included 27 children with mild-to-moderate asthma who were followed prospectively for 6 months. All patients used an MDI equipped with an electronic Doser attached to their inhaled steroid. At each 2-month follow-up visit, Doser and canister weight data were recorded, while child and mother were interviewed separately regarding medication use. RESULTS: Children and mothers reported, on average, over 80% adherence with the prescribed inhaled steroid. Canister weight revealed, on average, adherence of 69%, significantly lower than self-report. When adherence recorded by the electronic Doser was truncated to no more than 100% of prescribed daily use, average adherence was 50%. Older children and adolescents, nonwhite children, and those from poorer functioning families were least adherent. CONCLUSIONS: Electronic adherence monitoring was significantly more accurate than self-report or canister weight measures. Such accuracy is an essential prerequisite to increasing understanding of the treatment, setting, and patient factors that influence adherence, and to the consequent design of effective intervention strategies.
This study investigated factors associated with early self-administration of inhaled asthma medications by minority children. Specifically, the study evaluated: (1) the reasons parents allow early administration of inhaled medications, (2) childhood activities associated with early medication administration, (3) parent's perception of the child's ability to use a metered-dose inhaler (MDI), (4) the child's actual ability to use an MDI, and (5) concordance/discordance between physician-parent reports and parent-child reports of asthma medications. Study results indicated that 93% of the children were taking inhaled asthma medications without adult supervision. Early self-administration of asthma medications was related to the parent's employment status and the performance of other childhood behaviors such as completion of homework independently and crossing the street alone. Only 7% of the children had effective MDI skills, but 60% of the parents rated their child's MDI skills as excellent. Twenty percent, 67%, and 50%, respectively, of the parents' reports of beta-agonists, daily inhaled steroids, and cromolyn were discordant with the physician's actual prescriptions. Sixty-two percent, 57%, and 79%, respectively, of the children's reports for inhaled beta-agonists, daily inhaled steroids, and cromolyn were discordant with their parents' reports. Implications for anticipatory guidance, future educational strategies, and supervision of MDI technique are provided.
BACKGROUND: The Model MC-311 MDI Chronolog (Medtrac Technologies, Lakewood, Colo) is an electronic device for monitoring adherence to metered-dose inhalers (MDIs). It is a thermistor-actuated, microprocessor-equipped device that dispenses inhaled medication while recording the date and time of each canister activation. OBJECTIVE: We evaluated the reliability of the MC-311 MDI Chronolog to determine whether the model could accurately record and report the date, time, and number of MDI actuations. METHODS: Twenty-four of the MC-311 Chronologs were discharged at 8 hourly intervals across 8 days. Battery voltage was assessed before and after the experiment. The mouthpieces of 12 Chronologs were washed daily. RESULTS: By using generous criteria for acceptable reliability, only 10 of 24 (42%) were rated as acceptable. None of these 10 Chronologs recorded 320 or greater actuations (mean +/- SD, 293.9 +/- 13.3; range, 266 to 308); all reliable Chronologs underestimated MDI activation. An additional 6 devices had an initial signature of erroneous recordings dating from device initialization. After removing this signature, the remaining data showed acceptable reliability. All the remaining Chronologs judged to be unacceptable showed time series patterns of seizures (ie, bursts of clustered, erroneous records). Seizures were distributed across trial days, were associated with washing, and preceded all 4 cases of battery failure. Damage to the thermistor is the likely cause of seizure-pattern failures. CONCLUSIONS: In summary, because of a combination of a clear underreporting bias with frequent initialization and seizure-pattern failures, the Model MC-311 MDI Chronolog is not recommended for use in clinical care or research
BACKGROUND: Allergen avoidance has been shown to improve the morbidity and physiology of asthma. Although cockroach allergen has been implicated in chronic asthma, little work has been reported on the feasibility of allergen removal from infested homes. OBJECTIVE: The objective of this study was to examine the effect of professional pest control and home cleaning on cockroach infestation and allergen concentrations in settled dust samples from the kitchens, bedrooms, and television-living rooms of inner-city homes. METHODS: Thirteen homes in inner-city Baltimore, Maryland, received a professional cleaning, with vacuuming and a thorough cleaning in the kitchen. Pest control technicians applied abamectin 0.05% gel to the kitchen and, to a limited extent, to the rest of the home and the cleaning was repeated. Technicians visited monthly from month 2 to month 8 to inspect, collect dust samples, and place passive cockroach traps. Bla g 1 concentrations in dust extract were measured by means of ELISA. RESULTS: The number of cockroaches captured in passive traps decreased rapidly in 11 homes, but complete extermination was achieved in only 7 homes. Bla g 1 concentrations were reduced by 93% in kitchens, 77% in television-living rooms, and 74% in bedrooms. The relative reduction in cockroach allergen was not related to successful extermination or to signs of poor house-cleaning. CONCLUSION: We concluded that cockroach extermination is feasible in inner-city homes but that standard house-cleaning procedures are only partially effective in removing residual allergen over 8 months.
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Adherence with inhaled beta-agonists and corticosteroids in 24 asthmatic children was tracked over 3 months utilizing the metered-dose inhaler chronolog (MDIC). Patients seldom took all of their medications as prescribed, and failed to take any inhaled corticosteroid doses on a median of 41.8% of days or inhaled beta-agonists on 28.1% of days despite prescribed daily use. Medication nonadherence was correlated with lower levels of asthma knowledge (Asthma Knowledge Questionnaire) and family dysfunction (Family Assessment Device), but not child behavior disorder (Child Behavior Checklist). Patients tended to dramatically over-report medication use. Improved identification of the markers of nonadherence can directly facilitate more efficient targeting of behavioral interventions, resulting in improved adherence, better illness control, and less requirement of urgent medication intervention.
LEARNING OBJECTIVES: Reading this article will reinforce the reader's awareness of the relationship between adherence and treatment outcome, of the causes of nonadherence, of methods of measurement, and of steps toward successful intervention. DATA SOURCES: Articles on adherence to asthma therapy were reviewed. A MEDLINE database using subject keywords was searched from 1990 through 1997. STUDY SELECTION: Pertinent articles were chosen, with preferential presentation of results from controlled studies. RESULTS: There is no evidence of recent improvement in the rates of nonadherence, and patients continue on average to take about 50% of prescribed medication. Nonadherence assessment is most accurate when it can be measured objectively, and relies neither on patient report nor physician estimate. The consequences of nonadherence are measured in patient suffering, financial cost, and serious compromise of clinical trial outcomes. Underlying causes of nonadherence are traced to characteristics of the disease, treatment, patient, and caregiver system. CONCLUSION: Improved adherence will lead to improved disease control, but only if medical care systems encourage and support the allocation of sufficient resources to allow barriers to self-management to be discussed and solutions negotiated. Attempts to improve adherence outside of the caregiver-patient relationship are less likely to succeed. Special programs for difficult-to-manage patients are necessary to change behavior, although significant illness improvement and cost savings are likely to result.
OBJECTIVE: To determine whether family physicians would participate in the Family Physician Model (FPM) recruitment strategy for mammography screening, whether participating physicians differed from non-participating physicians, and whether the strategy would recruit 70% of eligible women in the participating practices. DESIGN: Family physicians were invited to participate in the project. Staff from the Ontario Breast Screening Program-Hamilton Centre (OBSP-H) identified eligible women, prepared personalized letters recommending screening, and monitored compliance. Participating and non-participating physicians were asked to complete a questionnaire. SETTING: Family practices in Dundas, Ancaster, and Hamilton, Ont. PARTICIPANTS: Women aged 50 years and older who met eligibility criteria for screening. Family physicians in Dundas, Ancaster, and Hamilton. INTERVENTION: Family physicians were approached by the Health Promotion Officer at the OBSP-H about participating in the FPM. Eligible women in their practices were sent letters recommending breast screening. MAIN OUTCOME MEASURES: Percentage of family physicians agreeing to participate in the FPM, characteristics of participating and non-participating physicians, and percentage of eligible women who scheduled mammograms. RESULTS: Of the 114 family physicians approached, 76 (67%) agreed to participate. Significantly more participating than non-participating physicians were in group practice and had certification in family medicine. In response to the letters, 54% of eligible women obtained mammograms. Because 12% of women were ineligible since they had been referred for screening within the previous 12 months, 66% of women in the participating practices actually obtained mammograms over the 2-year period-almost the target 70%. CONCLUSION: The FPM is a successful recruitment strategy.