Human case of bubonic plague resulting from the bite of a wild Gunnison's prairie dog during translocation from a plague-endemic area.

Plague is a zoonotic disease (transmitted mainly by fleas and maintained in nature by rodents) that causes severe acute illness in humans. We present a human plague case who became infected by the bite of a wild Gunnison's prairie dog, and a good practical example of the One Health approach that resulted in a rapid public health response. The exposure occurred while the animal was being transported for relocation to a wildlife refuge after being trapped in a plague enzootic area. This is the first report of a human plague case resulting from the bite of a Gunnison's prairie dog. Additionally, we present an observation of a longer incubation period for plague in captive prairie dogs, leading to a recommendation for a longer quarantine period for prairie dogs during translocation efforts.

Predicting successful intended vaginal delivery after previous caesarean section: external validation of two predictive models in a Dutch nationwide registration-based cohort with a high intended vaginal delivery rate.

OBJECTIVE: To externally validate two models from the USA (entry-to-care [ETC] and close-to-delivery [CTD]) that predict successful intended vaginal birth after caesarean (VBAC) for the Dutch population. DESIGN: A nationwide registration-based cohort study. SETTING: Seventeen hospitals in the Netherlands. POPULATION: Seven hundred and sixty-three pregnant women, each with one previous caesarean section and a viable singleton cephalic pregnancy without a contraindication for an intended VBAC. METHODS: The ETC model comprises the variables maternal age, prepregnancy body mass index (BMI), ethnicity, previous vaginal delivery, previous VBAC and previous nonprogressive labour. The CTD model replaces prepregnancy BMI with third-trimester BMI and adds estimated gestational age at delivery, hypertensive disease of pregnancy, cervical examination and induction of labour. We included consecutive medical records of eligible women who delivered in 2010. For validation, individual probabilities of women who had an intended VBAC were calculated. MAIN OUTCOME MEASURES: Discriminative performance was assessed with the area under the curve (AUC) of the receiver operating characteristic and predictive performance was assessed with calibration plots and the Hosmer-Lemeshow (H-L) statistic. RESULTS: Five hundred and fifteen (67%) of the 763 women had an intended VBAC; 72% of these (371) had an actual VBAC. The AUCs of the ETC and CTD models were 68% (95% CI 63-72%) and 72% (95% CI 67-76%), respectively. The H-L statistic showed a P-value of 0.167 for the ETC model and P = 0.356 for the CTD model, indicating no lack of fit. CONCLUSION: External validation of two predictive models developed in the USA revealed an adequate performance within the Dutch population.

Vaginal birth after a caesarean section: the development of a Western European population-based prediction model for deliveries at term.

OBJECTIVE: To develop and internally validate a model that predicts the outcome of an intended vaginal birth after caesarean (VBAC) for a Western European population that can be used to personalise counselling for deliveries at term. DESIGN: Registration-based retrospective cohort study. SETTING: Five university teaching hospitals, seven non-university teaching hospitals, and five non-university non-teaching hospitals in the Netherlands. POPULATION: A cohort of 515 women with a history of one caesarean section and a viable singleton pregnancy, without a contraindication for intended VBAC, who delivered at term. METHODS: Potential predictors for a vaginal delivery after caesarean section were chosen based on literature and expert opinions. We internally validated the prediction model using bootstrapping techniques. MAIN OUTCOME MEASURES: Predictors for VBAC. For model validation, the area under the receiver operating characteristic curve (AUC) for discriminative capacity and calibration-per-risk-quantile for accuracy were calculated. RESULTS: A total of 371 out of 515 women had a VBAC (72%). Variables included in the model were: estimated fetal weight greater than the 90(th) percentile in the third trimester; previous non-progressive labour; previous vaginal delivery; induction of labour; pre-pregnancy body mass index; and ethnicity. The AUC was 71% (95% confidence interval, 95% CI = 69-73%), indicating a good discriminative ability. The calibration plot shows that the predicted probabilities are well calibrated, especially from 65% up, which accounts for 77% of the total study population. CONCLUSION: We developed an appropriate Western European population-based prediction model that is aimed to personalise counselling for term deliveries.

Involving women in personalised decision-making on mode of delivery after caesarean section: the development and pilot testing of a patient decision aid.

OBJECTIVE: To develop a patient decision aid (PtDA) for mode of delivery after caesarean section that integrates personalised prediction of vaginal birth after caesarean (VBAC) with the elicitation of patient preferences and evidence-based information. DESIGN: A PtDA was developed and pilot tested using the International Patients Decision Aid Standards (IPDAS) criteria. SETTING: Obstetric health care in the Netherlands. POPULATION: A multidisciplinary steering group, an expert panel, and 25 future users of the PtDA, i.e. women with a previous caesarean section. METHODS: The development consisted of a construction phase (definition of scope and purpose, and selection of content, framework, and format) and a pilot testing phase by interview. The process was supervised by a multidisciplinary steering group. MAIN OUTCOME MEASURES: Usability, clarity, and relevance. RESULTS: The construction phase resulted in a booklet including unbiased balanced information on mode of birth after caesarean section, a preference elicitation exercise, and tailored risk information, including a prediction model for successful VBAC. During pilot testing, visualisation of risks and clarity formed the main basis for revisions. Pilot testing showed the availability of tailored structured information to be the main factor involving women in decision-making. The PtDA meets 39 out of 50 IPDAS criteria (78%): 23 out of 23 criteria for content (100%) and 16 out of 20 criteria for the development process (80%). Criteria for effectiveness (n = 7) were not evaluated. CONCLUSIONS: An evidence-based PtDA was developed, with the probability of successful VBAC and the availability of structured information as key items. It is likely that the PtDA enhances the quality of decision-making on mode of birth after caesarean section.

Parental compliance with multiple immunization injections.

OBJECTIVE: To assess parents' (or caretakers') willingness to allow multiple immunization injections at a single visit. DESIGN: A survey of parental demographics and a medical record review to determine immunization status. SETTING: An inner-city pediatric clinic in Philadelphia, Pa. PARTICIPANTS: A convenience sample of 1059 patients who were due to receive 2 to 5 immunization injections at a single visit and their parents. Patients were excluded if parents had not previously witnessed at least 1 immunization. MAIN OUTCOME MEASURES: The number of immunizations due, the number of immunizations received, and the reasons for failure to immunize completely. RESULTS: Almost all (98.8%) of the children included in the study received all immunizations indicated at their visit. CONCLUSION: Despite potential parental resistance to multiple simultaneous immunization injections, this innercity population overwhelmingly complied with physicians' recommendations.

Prevalence of elevated blood lead levels in an inner-city pediatric clinic population.

In November 1997, the Centers for Disease Control and Prevention (CDC) released revised guidelines for lead poisoning screening, including a recommendation that states and regions individualize screening policies based on local prevalence of elevated lead levels. The purpose of this study was to collect prevalence data for a Philadelphia, Pennsylvania, inner-city pediatric outpatient population previously not known to have elevated blood lead levels in order to determine its risk for lead exposure and screening requirements. Charts were reviewed for 817 children of 10 months through 6 years of age whose venous blood lead levels were obtained as part of their routine health care over a 12-month period ending October 1992. None of these children had a history of previously elevated lead levels. Prevalence of elevated lead levels was determined for this population and correlated with patient age, sex, race, and insurance type. More than two-thirds (68%) of the study patients had a blood lead level of [Greater than and equal to]10 microg/dl. Elevated blood lead levels were associated with black race (p<0.0001), but not with sex or insurance type. The percentage of children with elevated blood lead levels was highest at ages 37-48 months. A majority of the children screened had lead levels in excess of the CDC threshold for an abnormal lead level (10 microgram/dl). This is the highest reported prevalence within a U.S. pediatric clinic population. In view of this extremely high prevalence, clinicians and public health personnel caring for children in Philadelphia inner-city clinics must follow the intent of the new CDC guidelines by increasing their efforts in the areas of screening, follow-up, and environmental interventions. To ensure a lead-safe upbringing for children in the United States, state health officials nationwide should perform local risk assessments before considering policy transitions from universal to targeted screening.

Composition and preliminary evaluation of a hydrolyzed rice-based oral rehydration solution for the treatment of acute diarrhea in children.

OBJECTIVE: The purpose of this study was to experimentally develop and clinically evaluate the safety and potential usefulness of a rice-based, short glucose polymer oral rehydration solution (ORS), Amylyte, in the treatment of acute diarrhea. Amylyte has a similar osmolality but a higher caloric density than the WHO ORS. METHODS: Different amounts of rice were cooked in 500 ml of water containing salts (1.5 g NaCl, 600 mg KCl, and 150 mg CaCl2) with varying amounts of thermophilic amylase (252,500 modified Wohlgemuth units). Amylase (25 mg) thinned the gluey rice water when 100 g of rice was cooked in 500 ml of water for 10 minutes. The volume of the resultant supernatant (Amylyte) was approximately 250 ml. A two-part, clinical case study was performed. In study 1, 12 children with diarrhea and mild dehydration were studied to determine the safety of Amylyte. In study 2, Amylyte and the WHO ORS were given to 24 and 31 male children with acute diarrhea and moderate to severe dehydration, respectively. RESULTS: 92-96% of the rice amylose and amylopectin were converted to short polymers of glucose (3-9 molecules of glucose). The osmolality of 7,994 packages used to make the Amylyte solution ranged between 277-340 mOsm/kg. The mean electrolyte composition was Na+ = 68 mEq/L, K+ = 20 mEq/L, Cl = 73 mEq/L, the caloric density 425 kcal/L and rice proteins 0.7 g/L. In study 1, 12 children with diarrhea and mild dehydration were rehydrated successfully with Amylyte ORS and the diarrhea ceased within 48 hours. None developed clinical features of carbohydrate intolerance. In study 2, an open-label clinical case study, children with acute diarrhea given Amylyte ORS had significantly less stool output than children given the WHO ORS. CONCLUSIONS: Amylyte ORS has the advantages of a higher caloric density than the WHO ORS and shares a simple preparation of appropriate osmolality and electrolyte composition. It can safely and effectively rehydrate children with acute diarrhea and dehydration.

Multiple immunizations. Ouch!

The purpose of this study was to determine the stated willingness of parents/caretakers to allow the administration of multiple, injected immunizations to their children at a single visit. Two hundred eighty-one parents/caretakers accompanying their children to an inner-city pediatric clinic were presented with hypothetical situations in which their children would be due for two, three, or four injections to complete their series of age-appropriate immunizations. Given a scenario of two needed injections, 24 (8.5%) of the 281 parents/caretakers preferred to divide the injections between two visits; for three injections, 119 (42.3%) preferred two visits; and for four injections, 164 (58.4%) preferred two visits. The commonly stated preference of our predominantly minority parent/caretaker population to divide more than two injections between two visits seriously conflicts with the US Public Health Service's National Vaccine Advisory Committee's recommendations and potentially exacerbates immunization delays. Therefore, physicians must be prepared to strongly urge simultaneous administration of all needed vaccine doses at any opportunity.

Readability of the childhood immunization information forms.

OBJECTIVE: To compare the reading level required to understand childhood immunization information forms with the reading grade level of an inner-city parent/caretaker population. DESIGN: Descriptive study (parents/caretakers). SETTING: Inner-city pediatric clinic. PARTICIPANTS: One hundred fifty English-speaking, low-income parent/caretakers. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: The reading level of our parent population ranged from grades 2.9 to 13.3, with a median grade level of 6.90. The reading levels required for the three vaccine information pamphlets issued in 1992 by the Centers for Disease Control and Prevention (Atlanta, Ga) averaged 11.1 (approximately at the level of a high school junior). Eighty-six percent of our parents/caretakers did not have a reading level sufficient to cope with the easiest of the forms. CONCLUSIONS: The vaccine information pamphlets require a reading level beyond the capability of the vast majority of our parent population. Therefore, the goal of informed consent clearly is not being met.

Cost effectiveness in the choice of antibiotics for the initial treatment of otitis media in children: a decision analysis approach.

If the initial use of amoxicillin fails to cure otitis media, a family will be burdened with medical costs for a second medication, additional office visit fees and time lost from employment. For some families the initial choice of a more expensive but more effective antibiotic may be more cost effective. Using a decision analysis approach we compared the cost effectiveness of amoxicillin and cefaclor. As the amoxicillin efficacy rate decreases or as parental salaries are increased, the cost-effective advantage moves towards cefaclor. With the decision analysis method described, a practitioner can use costs and efficacy rates relevant to his or her practice to determine the most cost-effective initial antibiotic for a child with otitis media.