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PubMed1990

Methods for reducing lead exposure in young children and other risk groups: an integrated summary of a report to the U.S. Congress on childhood lead poisoning.

As part of a Congressionally mandated report on U.S. childhood lead poisoning prepared by the Federal government (U.S. Agency for Toxic Substances and Disease Registry [ATSDR]), the authors have analyzed the relative effectiveness of measures to reduce source-specific lead exposure of U.S. children. An integrated overview of this analysis is presented in this article. Two national actions, the Federally mandated phasedown of lead in gasoline by the U.S. Environmental Protection Agency and the voluntary phasedown of lead use in domestic food can production, are examples of centrally directed initiatives that have been relatively successful in limiting childhood lead exposure in the U.S. Efforts to abate lead-based paint exposure of children have largely failed. This is especially true for the nation's 21 million residential units with the highest lead content paint. Similarly, abatement of lead exposure from contaminated dusts and soils has generally been unsuccessful. Comprehensive measures to reduce lead exposure from drinking water in residences and public facilities, e.g., elementary schools, are only now being promulgated or implemented. The full extent of their effectiveness remains to be demonstrated. There are many miscellaneous but potentially severe exposure sources that are difficult to control but require attention, such as poorly glazed foodware and ethno-specific preparations.

Air Pollution↗
PubMed2004

Race, employment, and spinal cord injury.

OBJECTIVES: To examine issues of employment and race for persons with spinal cord injury (SCI), by assessing the type of work that was being done before and after injury and by placing this in the context of patterns for the general population. DESIGN: Retrospective, cross-sectional analysis. SETTING: Centers funded as part of the federally sponsored Model Spinal Cord Injury Systems (MSCIS) Project. PARTICIPANTS: Two samples: 5925 African Americans and whites with SCI who are part of the MSCIS and a subset of 577 people with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic information, occupational status, employment rate, job census codes, Craig Hospital Assessment and Reporting Technique-Short Form, and Satisfaction With Life Scale. RESULTS: Racial disparities were found in employment rates before injury and at 1, 5, 10, 15, and 20 years after SCI. Differences were also found in the types of jobs that were held before SCI with patterns for participants similar to those of African Americans and whites in the general population. No differences were found in the types of jobs held by African Americans and whites with SCI at 1 year after injury. After injury, African Americans had lower economic self-sufficiency scores, regardless of employment status, and lower social integration scores among those who were not employed. CONCLUSIONS: Racial disparities found in employment patterns among persons with SCI mirrored patterns among the general population.

Adult↗
PubMed2006

U.S. Food Safety and Inspection Service testing for Salmonella in selected raw meat and poultry products in the United States, 1998 through 2003: analysis of set results.

The U.S. Food Safety and Inspection Service (FSIS) tests sets of samples of selected raw meat and poultry products for Salmonella to ensure that federally inspected establishments meet performance standards defined in the pathogen reduction-hazard analysis and critical control point system (PR-HACCP) final rule. In the present report, sample set results are described and associations between set failure and set and establishment characteristics are identified for 4,607 sample sets collected from 1998 through 2003. Sample sets were obtained from seven product classes: broiler chicken carcasses (n = 1,010), cow and bull carcasses (n = 240), market hog carcasses (n = 560), steer and heifer carcasses (n = 123), ground beef (n = 2,527), ground chicken (n = 31), and ground turkey (n = 116). Of these 4,607 sample sets, 92% (4,255) were collected as part of random testing efforts (A sets), and 93% (4,166) passed. However, the percentage of positive samples relative to the maximum number of positive results allowable in a set increased over time for broilers but decreased or stayed the same for the other product classes. Three factors associated with set failure were identified: establishment size, product class, and year. Set failures were more likely early in the testing program (relative to 2003). Small and very small establishments were more likely to fail than large ones. Set failure was less likely in ground beef than in other product classes. Despite an overall decline in set failures through 2003, these results highlight the need for continued vigilance to reduce Salmonella contamination in broiler chicken and continued implementation of programs designed to assist small and very small establishments with PR-HACCP compliance issues.

Animals↗
PubMed2004

Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality.

OBJECT: This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms. METHODS: In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated. The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I-III) and better Fisher Grade (1-3) and of patients with Fisher Grade 4 hemorrhage was performed. Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2-2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14-0.75) compared with that for endovascular embolization. CONCLUSIONS: Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.

Adolescent↗
PubMed1994

Intensive care treatment decisions: the roots of our confusion.

BACKGROUND: Decisions to withdraw or withhold treatment from infants and children are continuing concerns. Physicians voice confusion over perceived legal requirements. This confusion may lead to overtreatment of patients. Recent evidence suggests legal concerns still shape physician treatment decisions. OBJECTIVE: This study was undertaken to determine if the legal standard governing these medical decisions was clearly stated. DESIGN: Conventional legal research was performed. Because the 1984 Federal Child Abuse Amendments require these issues to be resolved by state laws, statues of the 50 states and the District of Columbia were reviewed to ascertain if they would support a charge of child abuse for the inappropriate withdrawal of life-support from a child. An electronic legal database was queried for all cases involving withdrawal of life-support in children since 1984; the cases were analyzed to determine if judges were applying the federal legal standard. RESULTS: Current child abuse reporting laws would support the federal standard in all 50 states and the District of Columbia. Six reported withdrawal cases were identified; none applied the federal standard. There is an emerging state legal standard that is flexible and subjective and allows a quality of life analysis because it is based on parental authority. This standard conflicts with the federal standard. CONCLUSIONS: The current law is unclear because two competing legal standards coexist; physicians cannot simultaneously meet both standards. Choosing to apply the state legal standard in clinical medical practice should support families in times of stress and relieve physicians of the burden of considering who is potentially overtreated.

Child↗
PubMed2000

[Tool for measuring occupational stress: a nurses' stress inventory].

We present an exploratory study aiming at constructing an inventory to measure occupational stress in nurses ("Inventário de Estresse em Enfermeiros"--IEE). A set of items was initially constructed from previously defined categories based on interviews with nurses and then improved through semantic analysis by referees and a pilot-test with nursing students. A sample of 461 nurses--workers from the public services of the Federal District--who answered the IEE was used in the study. Factorial analysis indicated the presence of a second-order global factor and three first-order factors: Interpersonal Relationships, Stressful Career Roles and Intrinsic Job Factors.

Adult↗
PubMed2006

The role played by a former federal government residential school in a First Nation community's alcohol abuse and impaired driving: results of a talking circle.

OBJECTIVES: The study's objective was to better understand alcohol abuse and impaired driving behaviors in a First Nations community as it reflects systemic issues linked to historical, family and community experiences. STUDY DESIGN AND METHODS: Fifteen 18- to 29-year-old drivers participated in an exploratory eight-hour Talking Circle held according to traditional cultural practice. Four First Nations researchers, trained in Talking Circle protocol, and a Band Elder facilitated the data collection, data analysis according to emerging themes, and data verification. RESULTS: Federal government residential schools contribute to intergenerational effects which impact impaired driving in a northern First Nations community. Traditional parental role modeling has changed dramatically. Rather than guide children through a communally shared development process, many parents now expect their children to assume adult roles by expecting them to take care of their guardians when they drink excessive amounts of alcohol. Because a wall of silence exists between the young and old, many young people seek refuge with friends and peers, who subsequently influence them to abuse alcohol and engage in impaired driving. Many older Band members no longer serve as leaders for young people. Instead, they behave like peers and engage in activities that facilitate alcohol abuse and impaired driving. CONCLUSIONS: Historical institutions like federal government residential schools have contributed to systemic socio cultural problems which influence alcohol abuse and impaired driving. Hence there is a need for community-based intervention strategies that promote cultural healing. The healing journey can start with First Nations communities providing their people opportunities to share their stresses and traumas in supporting and nurturing environments.

Adolescent↗
PubMed1998

Economic evaluation of the Cardiac Insufficiency Bisoprolol Study for the Federal Republic of Germany.

The Cardiac Insufficiency Bisoprolol Study (CIBIS) demonstrates that, for patients with heart failure of different aetiologies, administration of the beta 1-adrenoceptor blocker bisoprolol as an adjuvant to the standard therapy leads to a significant avoidance of hospital admissions. A pharmacoeconomic analysis of the results of the CIBIS was conducted for the Federal Republic of Germany, and was restricted to direct costs only. The costs of bisoprolol medication and inpatient treatment of heart failure were considered, the latter forming the major part of costs incurred. Per 1000 patient-years, adjuvant bisoprolol therapy resulted in overall cost savings of Deutschmarks (DM)157,272. Statutory Health Insurance had a net saving of DM186,719 in 1000 patient-years, while patients experienced additional net expenses of DM17,760 over 1000 patient-years. The economic advantage of adjuvant bisoprolol treatment was also borne out in the sensitivity analysis. Adjuvant therapy with bisoprolol was not only clinically beneficial for the patient with heart failure but was also economically advantageous.

Adrenergic beta-Antagonists↗
PubMed1998

Measuring mammography compliance: lessons learned from a survival analysis of screening behavior.

Data from a telephone survey of women participating in a federally funded screening program were used to demonstrate the sensitivity of mammography compliance estimates to varying definitions of the time interval within which women are considered compliant with screening guidelines and what constitutes a true screening (as opposed to diagnostic) mammogram. The survival analysis approach used reveals patterns concealed by other approaches to measuring mammography behavior and provides a means for quantifying the impact of various definitional choices on compliance estimates. The results suggest that, although variations in defining and excluding potential diagnostic mammograms lead to differences in compliance measures no greater than 6%, differences as small as 1 month in the screening interval definition used can produce differences in compliance estimates as large as 27%. These results call into question the comparability of estimates across studies and suggest that standard measures would greatly facilitate future efforts in understanding how to promote compliance with mammography screening guidelines.

Adult↗
PubMed2000

Arrhythmias in acute pericarditis. An endomyocardial biopsy study.

It is still controversial whether the arrhythmias in acute pericarditis are of myocardial or pericardial origin. The aim of the present study was to investigate the occurrence of arrhythmias and conduction disorders in patients with acute pericarditis with no endomyocardial biopsy evidence of myocarditis (group 1: 40 patients, 65% males, mean age 45.6 +/- 15.7 years, mean heart rate [HR] 98.7 +/- 22.2 beats per minute) in comparison to endomyocardial biopsy proven acute myocarditis/perimyocarditis (group 2: 10 patients, 3/10 with perimyocarditis, 70% males, mean age 46.1 +/- 15.8 years, mean heart rate 76.7 +/- 33.1 beats per minute). At the initial assessment all patients underwent comprehensive clinical work-up including echocardiography, cardiac catheterization, and endomyocardial biopsy. In all patients biventricular endomyocardial biopsy was performed using standard femoral approach and Schikumed 7 F or 8 F bioptomes. Tissue samples were stained by H & E, v. Gieson and independently reviewed by two cardiac pathologists. In addition immunohistochemistry and immunocytochemistry were performed, and only patients fulfilling Dallas and World Heart Federation criteria were selected for group 2. Comparative analysis of electrocardiograms and 24-hour Holter recordings at initial presentation revealed in group 1 vs group 2 significantly less frequent paroxysmal supraventricular tachyarrhythmias (5% vs 40%), and ventricular fibrillation (0 vs 20%), in contrast to atrial fibrillation that occurred more often (20% vs 0) (all p < 0.05). Furthermore, in the group 2 one patient died due to VF and two patients underwent ICD implantation. Low voltage (40% vs 30%) and ST/T wave changes (47.5% vs 30%), as well as the incidence of the II degree AV block (5% vs 0) and complete AV block (2.5% vs 10%) were not significantly different between the groups. In conclusion, patients with pericarditis and no endomyocardial biopsy indications of myocarditis had significantly less often life threatening rhythm disorders in contrast to patients with endomyocardial biopsy proven acute myocarditis/perimyocarditis. On the contrary, incidence of transitory atrial fibrillation was higher in acute pericarditis, than in myocarditis.

Acute Disease↗
PubMed2004

Measuring and comparing the (in)efficiency of German and Swiss hospitals.

A nonparametric data envelopment analysis (DEA) is performed on hospitals in the federal state of Saxony (Germany) and in Switzerland. This study is of interest from three points of view. First, contrary to most existing work, patient days are not treated as an output but as an input. Second, the usual DEA assumption of a homogeneous sample is tested and rejected for a large part of the observations. The proposed solution is to restrict DEA to comparable observations in the two countries. The finding continues to be that hospitals of Saxony have higher efficiency scores than their Swiss counterparts. The finding proves robust with regard to modifications of DEA that are motivated by differences in hospital planning in Germany and Switzerland.

Decision Making↗
PubMed1983

Deliveries after cesarean birth in two Asian university hospitals.

The task force of the consensus conference on cesarean birth of the National Institutes of Health, USA, has recommended substituting a trial of labor and vaginal delivery for elective repeat cesarean section in selected women. This paper assesses the benefits and risks associated with that recommendation using data from two Asian teaching hospitals, one in Jakarta, Indonesia and the other in Colombo, Sri Lanka. Data recorded on the Maternity Record Form designed by the International Fertility Research Program and the International Federation of Gynecology and Obstetrics were used for analysis. Consistent findings were derived from the two hospitals, in spite of the different medical care delivery systems in their countries. No significant increase in maternal and infant mortality and morbidity were associated with women having vaginal delivery subsequent to cesarean birth as compared to those with repeat cesarean section. Savings in medical cost were considerable in the former group.

Adult↗
PubMed2004

The role of muscle biopsy in analysis of the dystrophin gene in Duchenne muscular dystrophy: experience of a national referral centre.

Although the majority (65%) of boys with Duchenne muscular dystrophy (DMD) carry a deletion in the dystrophin gene, finding mutations in the remaining families is vital for counselling. We have provided a comprehensive mutation service as a national referral centre for France for over 10 years and we report here our experience. Mutation screening is on mRNA from a muscle biopsy. We have detected 79 mutations in 89 samples referred with a diagnosis of DMD, which is the most comprehensive survey to date of the full range of nondeletion mutations. Although some mutations were nonsense mutations, some frameshift mutations and some splicing mutations, all of them led to the generation of premature stop codons or a shortened product which could be detected using the Protein Truncation Test. We recommend a protocol which is robust and sensitive applied to the entire coding region reverse-transcribed from dystrophin transcripts from muscle biopsy.

Biopsy↗
PubMed2003

Staging of advanced cervical carcinoma using MRI-predictors of outcome after radical radiotherapy.

AIM: To assess the prognostic significance of imaging findings used in magnetic resonance imaging (MRI) staging of cervical carcinoma by correlation with survival after radiotherapy. MATERIALS AND METHODS: MRI examinations of 99 cervical carcinoma patients were reviewed. Tumour involvement of pelvic structures was assessed. Lymph node sites, short axis diameters and signal characteristics were recorded. MRI staging was compared with clinical [International Federation of Gynaecology and Obstetrics (FIGO)] staging. Univariate analysis was performed for MRI stage, clinical stage, nodal status and pelvic structure involvement against disease-specific (DSS) and disease-free survival (DFS). RESULTS: MRI staging correlated with DSS (p=0.006) and DFS (p=0.007) but clinical staging did not. Pelvic nodes > or = 10 mm and juxtaregional or distant nodes > or = 8 mm short axis were most strongly associated with survival (p=0.014, p=0.011 and p=0.001, respectively, for association with DSS). Tumour involvement of pelvic bowel loops, pelvic sidewall and bladder mucosa were significantly associated with poor DSS and DFS (p<0.05). Tumour dimensions and bladder muscle involvement alone were not associated with poor survival. CONCLUSION: MRI staging is a better predictor of survival than clinical staging in patients receiving radiotherapy for cervical carcinoma. MRI assessment of lymph node enlargement and tumour involvement of pelvic structures gives valuable prognostic information.

Adult↗