Improving postpartum glucose monitoring in women with gestational diabetes.

OBJECTIVE: To improve 6-week postpartum visit attendance, glucose test ordering and test completion among postpartum patients with a history of gestational diabetes (GDM). METHODS: Pre- and post-intervention GDM women at Mount Sinai Hospital were studied via chart review. Interventions included advanced order sets for glucose monitoring at the 35-week pregnancy visit, educational modules, and nutritionist phone calls reminding patients to attend postpartum visits fasting. RESULTS: One hundred and seven pre-intervention and 42 post-intervention women were studied. Percentages of orders placed for postpartum testing was higher post-intervention vs. pre-intervention (57% vs. 42%, p = 0.03). There were higher test completion rates post-intervention vs. pre-intervention (36% vs. 17%, p = 0.01). Postpartum visit attendance rates did not vary between the groups (73% vs. 69% p = 0.60). Six percent of patients pre-intervention fasted for postpartum visits vs. 60% post-intervention. CONCLUSION: There was no observed increase in women attending their 6-week postpartum visits, yet rates of completed orders for postpartum testing, women attending visits fasting, and postpartum test completions were higher post-intervention. More research may identify the barriers to attendance at 6-week postpartum visits.

Incident hypertension in older women and men with or at risk for HIV infection.

OBJECTIVES: Antiretroviral (ARV) therapy has prolonged the life expectancy of HIV-infected persons, increasing their risk of age-associated diseases, including atherosclerosis (AS). Decreased risk of AS has been associated with the prevention and control of hypertension (HTN). We conducted a cohort study of perimenopausal women and older men with or at risk of HIV infection to identify risk factors for incident HTN. METHODS: Standardized interviews, physical examinations, and laboratory examinations were scheduled at 6-month intervals. Interview data included demographics, medical, family, sexual behaviour and drug use histories, and physical activity. RESULTS: There were 330 women and 329 men eligible for inclusion in the study; 27% and 35% of participants developed HTN during a median follow-up period of 1080 and 1071 days, respectively. In gender-stratified analysis, adjusting for traditional HTN risk factors (age, race, body mass index, smoking, diabetes, family history of HTN, alcohol dependence, physical activity and high cholesterol), HIV infection was not associated with incident HTN in women [hazard ratio (HR) 1.31; 95% confidence interval (CI) 0.56, 3.06] or men (HR 1.67; 95% CI 0.75, 3.74). Among HIV-infected women, although exposure to ARVs was not significantly associated with incident HTN (HR 0.72; 95% CI 0.26, 1.99), CD4 T-cell count was positively associated with incident HTN (HR 1.15 per 100 cells/µL; 95% CI 1.03, 1.28). Among physically active HIV-infected men, exposure to ARVs was negatively associated with incident HTN (HR 0.15; 95% CI 0.03, 0.78). CONCLUSIONS: HIV infection was not associated with incident HTN in older men or women. This study provides additional evidence supporting a causal relationship between immune function and incident HTN, which warrants further study.

Severe acute respiratory syndrome (SARS): knowledge, attitudes, practices and sources of information among physicians answering a SARS fever hotline service.

In June 2003, Taiwan introduced a severe acute respiratory syndrome (SARS) telephone hotline service to provide concerned callers with rapid access to information, advice and appropriate referral where necessary. This paper reports an evaluation of the knowledge, attitude, practices and sources of information relating to SARS among physicians who staffed the SARS fever hotline service. A retrospective survey was conducted using a self-administered postal questionnaire. Participants were physicians who staffed a SARS hotline during the SARS epidemic in Taipei, Taiwan from June 1 to 10, 2003. A response rate of 83% was obtained. All respondents knew the causative agent of SARS, and knowledge regarding SARS features and preventive practices was good. However, only 54% of respondents knew the incubation period of SARS. Hospital guidelines and news media were the major information sources. In responding to two case scenarios most physicians were likely to triage callers at high risk of SARS appropriately, but not callers at low risk. Less than half of all respondents answered both scenarios correctly. The results obtained suggest that knowledge of SARS was generally good although obtained from both medical and non-medical sources. Specific knowledge was however lacking in certain areas and this affected the ability to appropriately triage callers. Standardized education and assessment of prior knowledge of SARS could improve the ability of physicians to triage callers in future outbreaks.

Collaboration among community members, local health service providers, and researchers in an urban research center in Harlem, New York.

The Urban Research Center at the Center for Urban Epidemiologic Studies brings together community members and researchers working in Harlem, New York. A Community Advisory Board (CAB) composed of community members, service providers, public health professionals, and researchers was formed to assist the Center's research and interventions and to guide community partnerships. Through a collaborative process, the CAB identified three public health problems-substance use, infectious diseases, and asthma-as action priorities. To deal with substance use, the Center created a Web-based resource guide for service providers and a "survival guide" for substance users, designed to improve access to community services. To deal with infectious diseases, the Center is collaborating with local community-based organizations on an intervention that trains injection drug users to serve as peer mentors to motivate behavior change among other injection drug users. To deal with asthma, the Center is collaborating with community child care providers on an educational intervention to increase asthma awareness among day care teaching staff, enhance communication between staff and families, and improve the self-management skills of children with asthma. The Center's experience has demonstrated that active communities and responsive researchers can establish partnerships that improve community health.

Diagnosis and management of febrile children using the WHO/UNICEF guidelines for IMCI in Dhaka, Bangladesh.

OBJECTIVE: To determine whether the fever module in the WHO/UNICEF guidelines for the integrated management of childhood illness (IMCI) identifies children with bacterial infections in an area of low malaria prevalence. METHODS: Physicians assessed a systematic sample of 669 sick children aged 2-59 months who presented to the outpatient department of Dhaka Shishu Hospital, Bangladesh. FINDINGS: Had IMCI guidelines been used to evaluate the children, 78% of those with bacterial infections would have received antibiotics: the majority of children with meningitis (100%), pneumonia (95%), otitis media (95%) and urinary tract infection (83%); and 50% or less of children with bacteraemia (50%), dysentery (48%), and skin infections (30%). The current fever module identified only one additional case of meningitis. Children with bacteraemia were more likely to be febrile, feel hot, and have a history of fever than those with dysentery and skin infections. Fever combined with parental perception of fast breathing provided a more sensitive fever module for the detection of bacteraemia than the current IMCI module. CONCLUSIONS: In an area of low malaria prevalence, the IMCI guidelines provide antibiotics to the majority of children with bacterial infections, but improvements in the fever module are possible.

Effects of hospital policies based on 1996 group B streptococcal disease consensus guidelines. The Active Bacterial Core Surveillance Team.

OBJECTIVE: To determine whether the 1996 consensus guidelines for prevention of early-onset group B streptococcal disease developed by the Centers for Disease Control and Prevention, ACOG, and the American Academy of Pediatrics are affecting obstetric practice and disease occurrence. METHODS: Personnel in hospitals with obstetric services in seven surveillance areas completed surveys about their programs, patient populations, and group B streptococcal disease prevention policies. Survey results were linked to group B streptococcal disease cases identified by active surveillance in 1996 and 1997. An early onset case was defined as a case in which group B streptococci were isolated from a sterile site in the 1st 6 days of life. The number of cases in 1996 and 1997 were compared using a paired t test. Linear regression was used to assess hospital characteristics associated with group B streptococcal disease cases. RESULTS: Of 177 hospitals, 165 (93%) responded, and 96 (58%) of those had group B streptococcal disease prevention policies. Hospitals that established or revised their policies in 1996 had a lower mean number of cases in 1997 than in 1996 (0.58 versus 1.29, P = .006). Linear regression analysis, controlling for number of births, indicated that a hospital's having more black mothers and location in particular states were associated with more cases of disease. Citing the 1996 ACOG reference as the source for hospital group B streptococcal disease prevention policy was associated with fewer cases of group B streptococcal disease (P = .038). CONCLUSION: The publication and adoption of the guidelines were associated with decreasing occurrence of group B streptococcal disease.

New York City pharmacists' attitudes toward sale of needles/syringes to injection drug users before implementation of law expanding syringe access.

In May 2000, New York State passed legislation permitting the sale, purchase, and possession of up to 10 needles and syringes (hereafter "syringes") without a prescription, intended to reduce blood-borne pathogen transmission among injection drug users (IDUs). To obtain baseline data on pharmacists' attitudes and practices related to human immunodeficiency virus (HIV) prevention and IDUs, a telephone survey was administered to 130 pharmacists systematically selected in New York City. Less than half of pharmacists were aware of the new law; 49.6% were willing to or supported providing nonprescription sales of syringes to IDUs. Pharmacists in support tended to be less likely to consider customer appearance "very important." Managing and supervising pharmacists were more likely than staff pharmacists to support syringe sales to IDUs. Managing and supervising pharmacists who stocked packs of 10 syringes and personal sharps disposal containers, pharmacists who supported syringe exchange in the pharmacy, and pharmacists who were willing to sell syringes to diabetics without a prescription were more likely to support syringe sales to IDUs. Syringe disposal was a prominent concern among all pharmacists. Those not in support of syringe sales to IDUs tended to be more likely to believe the practice would increase drug use. These data suggest the need for initiatives to address concerns about syringe disposal and tailored continuing education classes for pharmacists on HIV and viral hepatitis prevention among IDUs.

Impact of a risk-based prevention policy on neonatal group B streptococcal disease.

OBJECTIVE: Neonatal group B streptococcal infections can be prevented by intrapartum antibiotic prophylaxis. Beginning in 1992, women with obstetric risk factors at University of Miami-Jackson Memorial Medical Center were targeted to receive intrapartum antibiotic prophylaxis. We evaluated these preventive efforts. STUDY DESIGN: A case was defined as isolation of group B streptococci from a sterile site in an infant <7 days old born during the study period, 1992-1995. We reviewed systematic samples of women with preterm delivery and prolonged rupture of membranes to assess use of intrapartum antibiotic prophylaxis. RESULTS: Group B streptococcal cases declined from 1.7 cases/1000 live births to 0.2 cases/1000 live births (Poisson regression, P =.002). Intrapartum antibiotic prophylaxis use increased from 13% of preterm deliveries in 1992 to 42% in 1995, and from 20% of deliveries with prolonged rupture of membranes in 1992 to 72% in 1995 (chi2 test for linear trend P =.007 and P <.001, respectively). CONCLUSION: Provision of intrapartum antibiotic prophylaxis on the basis of risk factors was associated with decreased group B streptococcal disease.

Viral hepatitis in health care personnel at The Johns Hopkins Hospital. The seroprevalence of and risk factors for hepatitis B virus and hepatitis C virus infection.

BACKGROUND: Health care personnel are at increased risk of occupational acquisition of hepatitis B virus (HBV) infection. While effective vaccination for HBV is widely available, the prevalence of HBV and vaccine acceptance in hospital personnel have not been recently assessed. In addition, hepatitis C virus (HCV) is a newly recognized cause of parenterally acquired hepatitis, and the risk of HCV transmission to health care personnel remains unclear. METHODS: From April to December 1991, health care personnel at The Johns Hopkins Hospital, Baltimore, Md, were offered anonymous testing for HBV and HCV and were asked to complete a confidential questionnaire. Serum samples were tested for HBV surface antigen and antibodies to HBV core antigen, HBV surface antigen, and HCV. Seroprevalence rates were compared with those detected in local blood donors during the same year. RESULTS: Antibodies to HBV core antigen were found in 59 (6.2%) of 943 health care workers compared with 1879 (1.8%) of 104,239 local blood donors (P < .001). In contrast, antibodies to HCV were found in seven (0.7%) of 943 health care workers and 0.4% of local blood donors (P = .10). Infection with HBV was associated with age (> or = 33 years) (P < .001), black race (P < .001), type of health care worker (nurse) (P = .02), 10 ore more years of clinical employment (P = .003), and lack of HBV vaccination (P < .001). After logistic regression, only absence of HBV vaccination was independently associated with HBV infection (P < .001). CONCLUSION: These data suggest that the prevalence of HCV infection in health care personnel at The Johns Hopkins Hospital is similar to that observed in local blood donors, and that HBV may be more efficiently transmitted than HCV in the health care setting. Efforts to vaccinate health care personnel against HBV should be vigorously pursued since 23% remain unvaccinated after 9 years of HBV vaccine availability.