Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injury does not mandate celiotomy.

BACKGROUND: Mandatory celiotomy has been proposed for all patients with unexplained free fluid on abdominal computed tomography (CT) scanning after blunt abdominal injury. This recommendation has been based upon retrospective data and concerns over the potential morbidity from the late diagnosis of blunt intestinal injury. This study examined the rate of intestinal injury in patients with free fluid on abdominal CT after blunt abdominal trauma. METHODS: This study was a multicenter prospective series of all patients with blunt abdominal trauma admitted to four level I trauma centers over 22 months. Data were collected concurrently at the time of patient enrollment and included demographics, injury severity score, findings on CT scan, and presence or absence of blunt intestinal injury. This database was specifically queried for those patients who had free fluid without solid organ injury. RESULTS: In all, 2,299 patients were evaluated. Free fluid was present in 265. Of these, 90 patients had isolated free fluid with only 7 having a blunt intestinal injury. Conversely, 91% of patients with free fluid did not. All patients with free fluid were observed for a mean of 8 days (95% confidence interval 6.1 to 10.4, range 1 to 131). There were no missed injuries. CONCLUSIONS: Free fluid on abdominal CT scan does not mandate celiotomy. Serial observation with the possible use of other adjunctive tests is recommended.

Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury.

OBJECTIVE: To determine the negative predictive value of cranial computed tomography (CT) scanning in a prospective series of patients and whether hospital admission for observation is mandatory after a negative diagnostic evaluation after minimal head injury (MHI). SUMMARY BACKGROUND DATA: Hospital admission for observation is a current standard of practice for patients who have sustained MHI, despite having undergone diagnostic studies that exclude the presence of an intracranial injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that admission will allow prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. METHODS: In a prospective, multiinstitutional study during a 22-month period at four level I trauma centers, all patients with MHI were evaluated using the following protocol: a standardized physical and neurologic examination in the emergency department, cranial CT scanning, and then admission for observation. MHI was defined as either a documented loss of consciousness or evidence of posttraumatic amnesia and an emergency department Glasgow Coma Scale score of 14 or 15. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, need for craniotomy, and death. RESULTS: Two thousand one hundred fifty-two consecutive patients fulfilled the study protocol. The CT was interpreted as negative for intracranial injury in 1,788, positive in 217, and equivocal in 119. Five patients with CT scans initially interpreted as negative required intervention. There was one craniotomy in a patient whose CT scan was initially interpreted as negative. This patient had facial fractures that required surgical intervention and elevation of depressed intracranial fracture fragments. The negative predictive power of a cranial CT scan based on the preliminary reading of the CT scan and defined by the subsequent need for neurosurgical intervention in the population fully satisfying the protocol was 99.70%. CONCLUSIONS: Patients with a cranial CT scan, obtained on a helical CT scanner, that shows no intracerebral injury and who do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation. Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually.

Dietary intake and health outcomes among young children attending 2 urban day-care centers.

OBJECTIVE: To assess the impact of the Child and Adult Care Food Program (CACFP) on diet and 3 health outcomes--weight-for-height status, dental caries (tooth decay) score, and number of days of illness--among preschool children attending 2 urban day care centers. DESIGN: Dietary intake and health outcome measures were assessed and compared for children attending 2 day-care centers in an urban community. Data were obtained for 14 days of dietary intake, which were analyzed for energy and 15 nutrients and 6 food groups; anthropometric measures, including weight-for-height; dental caries; and days of illness. SUBJECTS/SETTING: Forty 3- to 5-year-old black children from 2 day-care centers participated. One center participates in the CACFP. At the other center, children bring all meals and snacks from home. STATISTICAL ANALYSES PERFORMED: Data from the 2 groups of children were compared using parameteric and nonparametric t tests. RESULTS: Children receiving CACFP meals at day care had significantly higher mean daily intakes of vitamin A (804 +/- 191 vs 595 +/- 268 retinol equivalents), riboflavin (1.45 +/- 0.32 vs 1.21 +/- 0.22 mg), and calcium (714 +/- 180 vs 503 +/- 143 mg) than the children who brought all of their meals and snacks from home. Children who received CACFP meals also consumed significantly more servings of milk (2.9 +/- 0.9 servings vs 1.5 +/- 0.7) and vegetables (1.8 +/- 0.5 vs 1.2 +/- 0.5 servings) and significantly fewer servings of fats/sweets (4.6 +/- 1.3 vs 5.4 +/- 1.1 servings) than children who brought their meals. Weight-for-height status and dental caries scores did not differ between the 2 groups. Children from the center participating in the CACFP have significantly fewer days of illness (median 6.5 vs 10.5 days) than children from the nonparticipating center. APPLICATIONS: Nutritious meals provided by the CACFP can improve diets and may promote health among young, urban children. Registered dietitians can contribute to food assistance programs by intervening to enhance the quality of meals served and by examining the impact of participation on measures of diet quality and diet-related health outcomes.

Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial.

OBJECTIVES: Hospitalization for observation is the current standard of practice for patients who have sustained blunt abdominal trauma and who do not require emergent operation, despite having undergone diagnostic studies that exclude the presence of an intra-abdominal injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that hospitalization will allow for the prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. The focus of this study was to determine whether hospitalization for observation is necessary after a negative diagnostic evaluation after blunt abdominal trauma, to determine the negative predictive value of abdominal computed tomographic (CT) scanning in a prospective series of patients, and to identify which patients can be safely released from the emergency department without observation or hospitalization after blunt abdominal trauma. METHODS: In a prospective, multi-institutional study over 22 months at four Level I trauma centers, all patients with blunt abdominal trauma suspected by either physical examination or mechanism of injury were evaluated using the following protocol: physical examination in the emergency department, followed by abdominal CT scanning, followed by hospitalization for observation. The standardized physical examination was repeated between 4 and 8 hours. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, the need for celiotomy, and mortality. Other data collected included demographics, mechanism of injury, and findings on physical examination and abdominal CT scanning. RESULTS: Three thousand eight hundred twenty-two consecutive patients with suspected abdominal trauma presented to the four trauma centers. Two thousand seven hundred seventy-four of these met study eligibility criteria and were prospectively enrolled. Of these, 2299 fulfilled the entire study protocol. CT scan was negative in 1,809 patients, positive for organ injury or abdominal fluid in 389 patients, and nondiagnostic in 78 patients. Abdominal tenderness or bruising was present in 1,380 patients (61%), but only 22% had a positive CT scan. Nineteen percent of patients with a positive CT scan had no tenderness. Computed tomography detected 22 of the 25 blunt intestinal injuries in this series. Free intraperitoneal fluid without solid visceral injury was present in 90 patients, and but only 7 patients had intestinal injuries. There were nine celiotomies in patients whose CT scan was initially interpreted as negative: six were therapeutic (intestine in three, bladder in one, kidney in one, and diaphragm in one), two were nontherapeutic, and one was negative. The negative predictive power of an abdominal CT scan based on the preliminary reading and as defined by the subsequent need for a celiotomy in the population fully satisfying the protocol was 99.63% (lower 95 and 99% confidence bounds of 99.31 and 99.16%, respectively). CONCLUSION: These data indicate that abdominal tenderness is not predictive of an abdominal injury and that patients with a negative CT scan after suspected blunt abdominal trauma do not benefit from hospital admission and prolonged observation.

Effect of mitral regurgitation on left ventricular thrombus formation in dilated cardiomyopathy.

To assess whether the presence of mitral regurgitation has a protective effect on left ventricular thrombus formation in a heterogeneous group of patients with dilated cardiomyopathy, a group of 103 patients with dilated cardiomyopathy identified by means of echocardiographic criteria was assembled over 1 year. The purpose of the study was to define a subgroup of patients with dilated cardiomyopathy from whom long-term anticoagulation might be withheld. Each echocardiogram was evaluated for the presence of left ventricular thrombus, presence and severity of mitral regurgitation, and ejection fraction. The role of clinical factors and clotting factors in left ventricular thrombus formation was assessed. Left ventricular thrombus was not present in 91 patients (group A) and was present in 12 patients (group B). Group B had larger left atrial and left ventricular systolic dimensions and decreased left ventricular systolic function. Mitral regurgitation jet area and ratio between mitral regurgitation jet area and left atrial area were lower (signifying less severe mitral regurgitation) among patients in group B. Although mitral regurgitation was equally present in group A and group B, severe mitral regurgitation was found only in group A patients ( 11 of 91 patients). Among patients with dilated cardiomyopathy, left ventricular ejection fraction is the factor most associated with left ventricular thrombus formation. The presence of severe mitral regurgitation may have a protective role in left ventricular thrombus formation.

Mycobacterium tuberculosis miniepidemic in a church gospel choir.

BACKGROUND: Conventional contact investigation and molecular fingerprinting of Mycobacterium tuberculosis isolates in tuberculosis (TB) outbreaks have facilitated recognition as well as application of public health control activities. Singing in a choir as an activity that promotes TB transmission has been occasionally recognized. Such avocational transmission in a middle class community can occur with attendant difficulties encountered in contact investigation. METHODS: Five cases of TB (one index case; three secondary cases; one unassociated case) were identified among members of a famous church gospel choir in Newark, NJ. DNA fingerprinting and susceptibility testing were done on all retrieved strains. Of 306 choir members who had tuberculin tests, 19% were reactors. The presumed outbreak site was investigated. RESULTS: Four of the five patients were tenors, and one was an alto. Tenors were approximately twice as likely to be tuberculin reactors than subjects with other vocal ranges combined (relative risk, 2.04; 95% confidence interval, 1.17 to 3.56). An air ventilation outlet was directly in front of the tenor section. Some limited extra-church activity between choir members may have contributed to transmission. CONCLUSION: Conventional contact investigation must be supplemented by newer techniques, such as DNA fingerprinting, in identifying possible outbreak transmission. Singing, location of a ventilation outlet, and exposure time may have contributed to TB transmission in this outbreak. Transmission need not only be in congregate settings among well-defined socioeconomic groups but may occur unexpectedly in middle class communities.

An incentive in tuberculosis preventive therapy for an inner city population.

SETTING: Measures known to improve adherence such as short course chemoprophylaxis and directly observed therapy can be enhanced to a significant extent/by the use of incentives. Adherence to tuberculosis therapy is influenced by several factors, including the health care system, complexity of therapeutic regimens and patient's characteristics. Individual factors that negatively influence patient's adherence are the most difficult to counter. Preventive tuberculosis therapy is doubly challenging because the benefit of treatment is not felt, while toxicity from the medication, when it occurs, is experienced immediately. Ingenious incentives therefore have to make it worth the patient's while. During a study on preventive regimens, a request for an incentive, Sustacal, was observed to help completion of preventive regimens. Components of individual TB programs may help in patient adherence; it is important for health care staff to identify these aspects and, if they are successful, utilize these as an incentive to complete treatment.

Lymphocyte immunoregulatory cells present in semen from human immunodeficiency virus (HIV)-infected individuals: a report from the HIV Heterosexual Transmission Study.

The purpose of this study was to determine the types and distribution of immune subsets present in semen from human immunodeficiency virus (HIV)-infected (HIV+) individuals and to compare these values with those measures in semen from HIV-negative (HIV-) individuals. To accomplish this, a direct three-color monoclonal antibody labeling technique was employed to identify immune cells in fresh ejaculates. Once labeled, the percent of each immune subset present in the ejaculate was determined by flow cytometric analysis. The percent of CD3+ cells present in the semen of the HIV+ group showed no significant difference when compared with semen from the HIV- group. Analysis of the CD4+ subset yielded a significantly lower percent in the HIV+ group than in the HIV- group. The analysis of the CD8+ subset yielded a higher percent of cells present in semen from HIV+ individuals. The CD8 higher value along with lower CD4 value results in a lower CD4/CD8 ratio in the HIV+ group. Further subset studies showed that the percent of cells expressing naive (CD4+ CD45RA+) and memory (CD4+ CD45RO+) markers was lower in the HIV+ group. This study provides additional data supporting the utility of flow cytometry and monoclonal antibodies to immunophenotypic cells present in semen ejaculates. It is also the first reported application of the technique to a disease-based model and may be useful to better understand issues of mucosal immunity and transmission of sexually transmitted diseases such as HIV.

Evaluation of T-lymphocyte subsets present in semen and peripheral blood of healthy donors: a report from the heterosexual transmission study.

The purpose of this study was to accurately determine the T-lymphocyte subsets found in semen from healthy volunteers, to evaluate the impact of repeated ejaculation on the frequency or type of immune cells present in semen, and to compare subset analysis in semen to that in the peripheral blood. To accomplish this, a flow cytometric method was developed to identify and count immunophenotypically distinct cells present in semen. Fresh semen samples and peripheral blood were collected over three consecutive days from nine healthy donors. Donors had normal ejaculate volume, sperm count, sperm motility, morphology, and leukocyte count. No significant intra-donor differences were seen in these parameters over time. No significant differences were observed in the percentage of CD3+ cells, CD4+ cells, CD8+ cells, and the CD4:CD8 ratio in semen on consecutive days. However, within the CD4+ subset, when naive and memory CD4+ cells were measured, some day to day variability was suggested. No significant differences in CD3+, CD4+, CD8+, CD4/CD8 ratio, or naive and memory subsets were seen in the peripheral blood between sampling days. When semen was compared to peripheral blood some differences in immune subset values were observed, with an increase in the percentage of memory CD4+ cells in semen being the most striking. This finding may be relevant to HIV transmission, since others have shown that this cell may be preferentially infected with HIV and is the primary reservoir for virus in infected individuals.

Health risk factors and health promoting behavior of medical, dental and nursing students.

The assumption of this study is: the preventive care beliefs and practices of health science students stand-out among the general public. To test this assumption, a survey of beliefs, behaviors and disease prevention practices of medical, dental, undergraduate and graduate nursing students in three health science schools was carried out in New Jersey. All students in these three schools were included in the study. A questionnaire which consisted of information on socio-demographic, life style patterns, health risk factors, and preventive cares was used. Results showed that 99% of the students knew their blood pressure, 10% were cigarette smokers and 3% were heavy drinkers. Approximately 68% of the students exercised regularly and 78% of them used seat belts. About 81 and 79% of the female students had regular clinical breast examinations (CBE) and pelvic examinations, respectively. It is worth noting that 10% of medical and dental students had driven an automobile under the influence of alcohol. About 77% of all students did not know their cholesterol levels, and 14% of dental students reported no concern about fat consumption. Only 38% of the female students reported monthly breast self examination (BSE). Over 27% of undergraduate nursing and 14% of all students never had a Papanicolaou (Pap) test. The main reasons for never having a Pap test, CBE, and pelvic examinations were: they did not think it was necessary and they believed that they were not at risk. The major reason for not performing BSE was forgetfulness.(ABSTRACT TRUNCATED AT 250 WORDS)

Preventive therapy for contacts of multidrug-resistant tuberculosis. A Delphi survey.

OBJECTIVE: Several outbreaks of multidrug resistant tuberculosis (MDR-TB) have recently occurred in which healthcare workers and others have become infected. Given the lack of clinical data to guide preventive therapy for such contacts, a Delphi survey of a panel of 31 TB therapy experts was undertaken to identify a consensus regimen. DESIGN: An initial questionnaire presented three scenarios describing persons with significant exposure to MDR-TB and with new tuberculin skin test reactions > 15 mm (except one anergic patient) without evidence of disease. Panelists were asked to suggest possible preventive therapy regimens. METHODS: During a second round survey, the panel members were asked to review the suggested regimens provided for each scenario and to rank them from one to nine as extremely inappropriate to extremely appropriate. Results of this second survey were tabulated and shared with the members of the panel who were then asked to rerank each regimen in light of the previous cumulative panel responses. RESULTS: No specific regimen achieved initial positive consensus by predefined criteria. In two of the three scenarios the no treatment option, however, was deemed clearly inappropriate. The data were also analyzed by what percentage of respondents who ranked a regimen as at all appropriate (ie, six or more on the nine point scale). For scenarios involving a nurse, an HIV-positive tuberculin reactor, and a patient who was anergic HIV-positive, treatment with pyrazinamide 1,500 mg daily with ciprofloxacin 750 mg twice a day for 4 months received a somewhat appropriate rating from more than 50 percent of respondents. CONCLUSIONS: The management of persons exposed to and infected by patients with MDR-TB has become a serious problem in the context of MDR-TB outbreaks. This panel of experts agreed that some form of preventive therapy was warranted; however, they were not able to reach defined consensus on what regimen should be used, although a regimen of pyrazinamide 1,500 mg daily with ciprofloxacin 750 mg twice a day for 4 months was considered somewhat appropriate. Clinical data on the efficacy of alternative preventive therapy regimens for such contacts are urgently needed.

Altered coagulability: an aid to selective breast biopsy.

Difficulty in discriminating nonadvanced breast cancer from benign breast disease results in many cancer negative biopsies. Development of a test to better differentiate between these two entities to reduce the number of cancer negative biopsies was the purpose of this blind study. The clue that prompted the development of this test resides in the state of hypercoagulability in cancer. Hypercoagulability can be measured by assessing tissue factor-mediated altered coagulability. The amount of tissue factor release is contingent on prior activation of the monocyte (the only blood cell that generates tissue factor) in vivo.

Preventive therapy for the patient with both universal indication and contraindication for isoniazid.

BACKGROUND: The delphi method of decision making was used to address an unusual clinical case in which various aspects of the case required opposing management strategies. METHODS: A panel of 30 pulmonary experts was surveyed repeatedly until a convergence of treatment approaches was reached for a patient who was considered to have both a universal indication for and a universal contraindication against prevention therapy. Participants were asked to evaluate the appropriateness of proposed treatments on a scale from 1 to 9, with 1 being extremely inappropriate, 5 being equivocal, and 9 being extremely appropriate. The delphi survey data responses were compared using measures of central tendency (ie, the mean and median) and measures of variability (ie, the standard deviation and interquartile range). RESULTS: Although no treatment was wholeheartedly supported by the experts, analysis of the three-round delphi survey responses resulted in two possible treatments: rifampin, 600 mg daily, for four months, or no treatment with close observation. Interestingly, the experts working in a non-university setting favored the rifampin treatment, and those working in a university setting favored no treatment with close observation. CONCLUSIONS: The delphi method has the potential to be used for clinical decision making.

Responses of health care professionals to proposed mandatory HIV testing.

OBJECTIVE: to survey active health professionals to assess the response to and impact of a mandatory human immunodeficiency virus (HIV) testing policy on health care providers and the communities in which they practice. DESIGN AND SETTING: Anonymous four-page survey of active health professionals at 13 hospitals in northern and central New Jersey. PARTICIPANTS: 1557 physicians and nurses responded to the survey. Response rate was approximately 41%. INTERVENTION: Hypothetical intervention. MAIN OUTCOME MEASURES: Responses to a series of questions relating to a hypothetical mandatory HIV testing policy for health professionals. RESULTS: Approximately three fourths of all surveyed health professionals stated that a mandatory testing policy would persuade individuals in their profession not to work in high-prevalence areas. Among those who currently work in high-prevalence HIV/acquired immunodeficiency syndrome (AIDS) areas, only 51% said that they would definitely or probably remain in that area should such a policy be instituted. Among those practicing surgery or performing invasive procedures, 7% currently avoid HIV-positive patients, and an additional 34% said that they would do so under the proposed testing policy. Finally, 4% of these professionals currently advice others to stop working in high-prevalence areas, and an additional 22% state that they would definitely do so if the proposed policy were instituted. CONCLUSIONS: If physicians and nurses behaved in accordance with their survey responses, institution of a mandatory HIV testing policy would create a shortage of physicians and nurses in high-prevalence HIV/AIDS areas.

How much do health care providers know about AIDS?

We sent a survey to more than 8,000 New Jersey health professionals to collect information on their knowledge level, attitudes, and prevention practices relating to the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS). The surveys were distributed through the mail in three separate waves with a postcard reminder. A total of 2,725 individuals provided completed questionnaires (34% response rate). We assessed the AIDS and HIV-related knowledge level of these health professionals, compared their knowledge levels, and identified variables that predict a high level of knowledge. The overall test scores indicate a definite need for AIDS education among these health professionals; on average, doctors answered 71% of the knowledge items correctly; dentists, 66%; and nurses, 65%. Doctors scored higher than the other health professionals on almost all of the 38 items relating to the epidemiological aspects of HIV, transmission, identification and reporting of HIV disease and AIDS, and assessment of HIV-associated risks. The multivariate regression model explained 24% of the variability in knowledge score (P = .0001) and identified the following independent variables as significant predictors of knowledge score: age, race, marital status, religious beliefs, political orientation, professional group, average number of hours worked each week, experience with HIV+/AIDS patients, knowledge self-assessment, and sources of AIDS information.

The making of a smoke-free hospital may not be as easy as you think.

Literature describing experiences in the implementation of a smoke-free policy in a hospital suggests that, with careful preparation and close monitoring, a smoke-free policy can be successfully instituted. Despite this pervasive viewpoint, any hospital personnel considering the adoption of a smoke-free policy should be aware that the institution of such a policy may be quite difficult. The experience at University Hospital suggests that a strong policy statement, administrative support, and a comprehensive implementation plan have helped to achieve widespread compliance with the smoke-free policy among hospital employees. Unfortunately, the smoke-free policy has been less successful changing the smoking activities of the patients. Although others have not reported this compliance problem, we believe it is a real problem that many institutions will face. We present methods used to identify, combat, and monitor this compliance problem.

AIDS education in drug user treatment programs.

This paper presents the results of an AIDS educational intervention for intravenous drug users (IVDUs) who participated in the New Jersey State Department of Health's Coupon program. An examination of the data showed that those with high pre-intervention test scores were more likely to have been White and to have been in treatment since 1981. Furthermore, the 1-hour AIDS educational intervention produced significantly higher post-intervention test scores (overall and for 27 of the 31 individual test items). Finally, none of the demographic and drug history variables used in this analysis were found to contribute significantly to the effectiveness of the educational session.

A coupon program--drug treatment and AIDS education.

The New Jersey State Department of Health developed a program to test the following hypotheses: (1) numerous heroin addicts will respond to free detoxification treatment offered through a coupon program, (2) a substantial number of these patients will continue in treatment beyond the free detoxification attempt, and (3) participation in an AIDS education session can increase the knowledge level of intravenous drug abusers regarding this disease. Eighty-four percent of the 970 distributed coupons were redeemed for detoxification treatment. Twenty-eight percent of the program participants continued in treatment after the free detoxification period, and the AIDS information session significantly increased the knowledge of participating addicts.