Effect of improved home ventilation on asthma control and house dust mite allergen levels.

BACKGROUND: The warm, humid environment in modern homes favours the dust mite population, but the effect of improved home ventilation on asthma control has not been established. We tested the hypothesis that a domestic mechanical heat recovery ventilation system (MHRV), in addition to allergen avoidance measures, can improve asthma control by attenuating re-colonization rates. METHODS: We conducted a randomized double-blind placebo-controlled parallel group trial of the installation of MHRV activated in half the homes of 120 adults with asthma, allergic to Dermatophagoides pteronyssinus. All homes had carpets steam cleaned and new bedding and mattress covers at baseline. The primary outcome was morning peak expiratory flow (PEF) at 12 months. RESULTS: At 12 months, the primary end-point; change in mean morning PEF as compared with baseline, did not differ between the MHRV group and the control group (mean difference 13.5 l/min, 95% CI: -2.6 to 29.8, P = 0.10). However, a secondary end-point; evening mean PEF, was significantly improved in the MHRV group (mean difference 24.5 l/min, 95% CI: 8.9-40.1, P = 0.002). Indoor relative humidity was reduced in MHRV homes, but there was no difference between the groups in Der p 1 levels, compared with baseline. CONCLUSIONS: The addition of MHRV to house dust mite eradication strategies did not achieve a reduction in mite allergen levels, but did improve evening PEF.

Use of telehealth technology to extend child protection team services.

OBJECTIVE: In response to increased referrals to Florida's Child Protection Teams and concern regarding statewide availability of medical expertise in the area of child abuse and neglect, Children's Medical Services of the Florida Department of Health established a telemedicine project to facilitate immediate expert medical evaluations of alleged child abuse or neglect. This article describes a baseline examination of the project, including the technique of concept mapping, to examine how larger systematic factors influence the adaptation of telemedicine technology in child abuse examination settings. METHODS: This study included interviews of key staff plus the incorporation of concept mapping, which takes qualitative data (individual statements and opinions) and quantifies them (sorts and ranks them by order of group importance). RESULTS: Findings from interviews revealed that the frequency of use of telehealth services varies across the state as a result of several factors, including space limitations and staff training. Patients, however, seem to be comfortable with the use of the new technology. The concept mapping exercise displayed a progression of issues that are perceived to have an impact on the use of this technology. CONCLUSIONS: Technology use is affected by unforeseen variables, such as physical space limitations and examination room availability. Family concerns about patient privacy issues were rare and were resolved quickly by the health care practitioner. Although using this equipment is not difficult, the search for user-friendliness should be continued. Staff engagement early in the process likely will result in a greater likelihood of use of the technology.telehealth, telemedicine, child protection, child abuse and neglect, concept mapping.

National Public Health Performance Standards: workforce development and agency effectiveness in Florida.

The Florida Department of Health (FDOH) was the first state to pilot test both the Centers for Disease Control and Prevention (CDC) state agency and local Public Health System Performance Standards. The standards were found to be complementary and supportive of the FDOH quality performance improvement system, which had been in place for a decade, and the new Quality Management initiative. The pilot test found uneven performance across the state's county health departments and identified several areas, especially workforce development, that required additional efforts. The FDOH, in collaboration with the Center for Leadership in Public Health Practice at the College of Public Health in the University of South Florida, have collaborated and will continue to collaborate to design and deliver training in critical workforce development areas.

Profiles in courage: evolution of Florida's quality improvement and performance measurement system.

As public health begins to embrace performance standards, it is important to critically examine state and local health department quality improvement and performance measurement systems. In this article, Florida's decade-long evolution of quality improvement and performance measurement as well as their integration are described. Lessons for other states are discussed along with implications for implementing performance standards for state and local health departments.

Changes in youth cigarette use and intentions following implementation of a tobacco control program: findings from the Florida Youth Tobacco Survey, 1998-2000.

CONTEXT: Many states are developing tobacco use prevention and reduction programs, and current data on tobacco use behaviors and how these change over time in response to program activities are needed for program design, implementation, and evaluation. OBJECTIVES: To assess changes in youth cigarette use and intentions following implementation of the Florida Pilot Program on Tobacco Control. DESIGN, SETTING, AND PARTICIPANTS: Self-administered survey conducted prior to program implementation (1998), and 1 and 2 years (1999, 2000) later among a sample of Florida public middle school and high school students who were classified as never users, experimenters, current users, and former users of cigarettes based on survey responses. MAIN OUTCOME MEASURES: Changes in cigarette use status, intentions, and behaviors among students over a 2-year period. RESULTS: Surveys were completed by 22,540, 20,978, and 23, 745 students attending 255, 242, and 243 Florida public middle and high schools in 1998, 1999 and 2000, respectively. Response rates for the 3 survey years ranged from 80% to 82% and 72% to 82% for the middle school and high school surveys, respectively. After 2 years, current cigarette use dropped from 18.5% to 11.1% (P<.001) among middle school students and from 27.4% to 22.6% (P =.01) among high school students. Prevalence of never use increased from 56.4% to 69. 3% (P<.001) and from 31.9% to 43.1% (P =.001) among middle school and high school students, respectively. Prevalence of experimenting decreased among middle school and high school students from 21.4% to 16.2% (P<.001) and from 32.8% to 28.2% (P<.001), respectively. Among never users, the percentage of committed nonsmokers increased from 67.4% to 76.9% (P<.001) and from 73.7% to 79.3% (P<.001) among middle school and high school students, respectively. Among experimenters, the percentage of students who said they will not smoke again increased from 30.4% to 42.0% (P<.001) in middle school and from 44.4% to 51.0% (P<.001) in high school. CONCLUSIONS: Progress toward reduction of youth tobacco use was observed in each of the 2 years of Florida's Pilot Program on Tobacco Control. Our results suggest that a comprehensive statewide program can be effective in preventing and reducing youth tobacco use. JAMA. 2000;284:723-728

Willingness to pay in arthritis: a Danish contribution.

OBJECTIVE: To explore the use of willingness-to-pay (WTP) methods with respect to an antagonist of tumour necrosis factor as an antirheumatic drug. METHODS: One hundred and fifteen rheumatoid arthritis (RA) patients at a tertiary care centre in Odense, Denmark were interviewed using two WTP approaches, the contingent ranking and double-bounded (closed-ended) methods. RESULTS: The average closed-ended WTP value was DKr581 and the average contingent ranking WTP was DKr643. There were no statistically significant differences in the WTP estimates between the two methods. CONCLUSION: It is feasible to use these methods with arthritis patients. If, as suggested in a number of recent reviews, a major effort is to be put into undertaking economic appraisals of arthritis programmes, then this should include more cost-benefit studies using WTP approaches of the kind illustrated in this paper.

The economics of preventing and treating pressure ulcers: a pilot study.

A pilot economic evaluation of a projected pressure ulcer prevention policy was carried out in a 252-bed geriatric unit in Glasgow. The aim was to set up a framework for evaluating and comparing the costs and benefits of current care and a potential prevention programme. Data were collated from prevalence and incidence studies. Prevalence results showed that 41% of the patient population suffered pressure damage to some extent and incidence data showed that 45% of these were potentially preventable. Evaluation of the costs and benefits shows that the prevention programme would be cost-effective. The cost would be between 17,606 Pounds and 28,669 Pounds but the benefits would range from 305,506 Pounds to 342,510 Pounds. The authors conclude that economic appraisal is feasible.

EuroQol: health-related quality of life measurement. Results of the Swedish questionnaire exercise.

The EuroQol Group, which currently comprises 7 centres in 5 countries, has been testing the feasibility of jointly developing a standardised non-disease-specific instrument for describing and valuing health-related quality of life. The instrument employs a visual analogue scale of the 'thermometer' type to allow respondents to rank a number of health states. As part of the Swedish IHE's contribution to the EuroQol Group's work, questionnaires were sent to 1000 people randomly selected to provide a representative sample of the Swedish population aged 16-84 years. 349 persons responded and 208 provided sufficient information for detailed analysis. From these 208 it proved possible to derive health status information in a quantitative form. The most interesting result was that the health state valuations from this survey indicated a striking similarity with those of EuroQol studies in Frome (England) and Bergen op Zoom (The Netherlands). The lessons learned from undertaking the survey are briefly discussed. The Swedish IHE is encouraged by the exercise to continue to play its part in the continuing developments of the EuroQol methodology.

Use of plasmid analysis and determination of aminoglycoside-modifying enzymes to characterize isolates from an outbreak of methicillin-resistant Staphylococcus aureus.

We compared disk susceptibility, plasmid analysis, aminoglycoside resistance patterns, and DNA hybridization for their usefulness in characterizing isolates from a hospital outbreak of methicillin-resistant Staphylococcus aureus. Fifteen isolates were susceptible (group 1) and 28 were resistant (group 2) to gentamicin. A total of 15 of 15 (100%) group 1 and 22 of 28 (79%) group 2 isolates carried a 21.5-megadalton plasmid. All group 2 isolates and none of the group 1 isolates possessed a 33-megadalton plasmid. Aminoglycoside resistance pattern determinations revealed the presence of the ANT(4')-I enzyme (aminoglycoside 4' adenyltransferase) in all group 1 isolates but was unable to demonstrate presence of this enzyme in group 2 organisms. The APH(2") + AAC(6')-II enzyme (aminoglycoside 2" phosphotransferase plus 6' acetyltransferase) was found in all of the group 2 isolates but in none of the group 1 isolates. Use of DNA hybridization revealed the presence of the ANT(4')-I enzyme in both groups (group 1, 14 of 15; group 2, 26 of 28). In this hospital outbreak, we found good correlation between disk susceptibility, plasmid profile, aminoglycoside resistance patterns, and DNA hybridization results. It was difficult to predict the presence of the ANT(4')-I enzyme in the presence of the bifunctional [APH(2") + AAC(6')-II] enzyme by the aminoglycoside resistance pattern method because of overlap of the substrate profile.

Prospective study of Candida endophthalmitis in hospitalized patients with candidemia.

To determine the frequency of endogenous Candida endophthalmitis in patients with candidemia, we prospectively evaluated 32 inpatients with fungemia by weekly indirect ophthalmoscopic examinations. Chorioretinitis compatible with Candida infection was found in 9 (28%) patients. Patient age, sex, underlying diseases, or hospital-acquired factors, such as presence of central venous or Foley catheters, bacteremia, use of multiple antibiotics, hyperalimentation, or surgery, did not distinguish between groups. Groups were also similar in number of sites colonized with yeast and species of Candida recovered. Patients with endophthalmitis tended to have more blood cultures positive for Candida (mean, 4.3) than the patients without endophthalmitis (mean, 2.8), but this trend did not reach statistical significance. Based on these results, we recommend periodic ophthalmoscopic examinations in all patients with documented candidemia.

Open lung biopsy in patients with non-Hodgkin's lymphoma and pulmonary infiltrates.

Patients with non-Hodgkin's lymphoma (NHL) are at increased risk for pulmonary infection with opportunistic pathogens associated with diminished cell mediated immunity. Open lung biopsy (OLB) frequently is recommended for diagnosis of pulmonary infiltrates in patients with NHL, but its usefulness for patient management and outcome has not been evaluated for patients with NHL. We reviewed the results of 20 consecutive OLB in 19 patients with previously diagnosed non-Hodgkin's lymphoma at Stanford University Medical Center during a nine-year period. Fifteen patients had known active lymphoma at time of OLB, and no patient had granulocytopenia. Ten of the 20 OLBs yielded specific diagnoses. A greater proportion of patients with stage I or II disease had specific diagnoses than patients with more advanced NHL. Five of 14 patients considered to have had a life threatening illness at the time of OLB had specific diagnoses from OLB vs five of six patients considered clinically stable. Chest roentgenograms that had discrete masses or nodules correlated with ability to establish a specific diagnosis by OLB. For patients in whom the results of OLB were nonspecific, management appeared unaffected by the OLB. The OLB in NHL appeared most useful for detecting recurrent NHL in clinically stable patients with discrete nodules or masses on chest roentgenogram. Pneumocystis pneumonia was the only infection identified by OLB.

Open lung biopsy in patients with Hodgkin's disease and pulmonary infiltrates.

Although open lung biopsy (OLB) is frequently employed for diagnosis of pulmonary lesions in patients with Hodgkin's disease, the actual efficacy of the procedure in establishing a diagnosis in these patients, and its effect on their treatment and clinical outcome, have not been evaluated. We reviewed the results of OLB in 41 patients with previously diagnosed Hodgkin's disease (17 with stage II disease, 10 with stage III, and 14 with stage IV) who had pulmonary opacification on chest roentgenogram. Nineteen (46%) diagnoses were specific and 22 nonspecific. The most common specific diagnosis was Hodgkin's disease (12 patients); the others were Pneumocystis carinii pneumonia (3), solitary fungal granuloma (2), cytomegalovirus pneumonia (1), and primary lung adenocarcinoma (1). Specific diagnoses were made in 11 (69%) of 16 patients with discrete nodules or masses but in only eight (32%) of the 25 patients with non-nodular radiographic opacification. Eleven (58%) of 19 patients who were asymptomatic or had had symptoms for longer than 4 wk had specific diagnoses, compared to one of six patients (17%) symptomatic for 1 wk or less. Survival of hospitalization correlated more with stage of Hodgkin's disease than with specific diagnosis. However, treatment was changed after biopsy in 22 (54%) of the patients. The results suggest that OLB can be helpful in the management of patients with Hodgkin's disease and pulmonary infiltrates, both in establishing a diagnosis and in assisting the patients' management. OLB appears to be more helpful in patients with Hodgkin's disease than in patients with acute nonlymphocytic leukemia or the acquired immunodeficiency syndrome and pulmonary infiltrates.

Comparison of a new rapid test (TestPack Rotavirus) with standard enzyme immunoassay and electron microscopy for the detection of rotavirus in symptomatic hospitalized children.

We compared a new, rapid, qualitative test for rotavirus (TestPack Rotavirus; Abbott Laboratories, North Chicago, Ill.) with another enzyme immunoassay (Pathfinder Rotavirus; Kallestad Laboratories, Inc., Austin, Tex.) and electron microscopy to determine its clinical utility in a population of symptomatic hospitalized children. In the first part of the study, 100 frozen stool samples were tested. The results after resolution with a blocking reagent showed a sensitivity of only 50% and a specificity of 88% for TestPack Rotavirus. In the second part of the study, we tested TestPack Rotavirus on 100 fresh, unfrozen samples. The results (sensitivity/specificity) were as follows: TestPack Rotavirus, 95/90%; Pathfinder Rotavirus, 84/98%; direct electron microscopy, 63/100%. Although it was not as sensitive or specific as immune electron microscopy, TestPack Rotavirus was more sensitive than direct electron microscopy or Kallestad Pathfinder Rotavirus. TestPack Rotavirus represents a rapid, qualitative method for the detection of rotavirus in stools of symptomatic children.

Hospital survey of antimicrobial prophylaxis to prevent endocarditis in patients with prosthetic heart valves.

The American Heart Association (AHA) has published guidelines for use of prophylactic antibiotics to prevent bacterial endocarditis, but few data are available about physician compliance with these guidelines. A retrospective review was conducted of the use of prophylactic antibiotics in patients with prosthetic heart valves who were undergoing diagnostic or operative procedures or heart catheterization at three hospitals. Compliance with AHA recommendations was only 30 percent (14 of 46) for procedures considered high risk for patients with prosthetic heart valves. Six (23 percent) of 26 patients who underwent right or left heart catheterization received prophylactic antibiotics (not recommended by AHA). Antibiotics were given to 42 (74 percent) of 57 patients who underwent surgical procedures considered at low risk of bacteremia, but only 33 (58 percent) received antibiotics that cover organisms commonly present at the site of the procedure. The results indicate that clinicians frequently do not administer prophylactic antibiotics in patients with prosthetic heart valves who are undergoing invasive procedures or do not follow published AHA guidelines when antibiotics are administered.

Role of serology in the diagnosis of toxoplasmic lymphadenopathy.

Serologic results obtained in 92 cases of toxoplasmic lymphadenopathy diagnosed by lymph node biopsy were reviewed, and guidelines for serologic diagnosis of this disease were established. When tests were first performed within six months of onset of lymphadenopathy, single high titers of IgG toxoplasma antibodies (suggestive of acute infection) were found with the Sabin-Feldman dye test and the direct agglutination test in 93% and 76% of cases, respectively. Observations of significant rises in titer were uncommon because of the late acquisition of sera. Within the first six months after the onset of lymphadenopathy, IgM toxoplasma antibody was demonstrable by the double-sandwich IgM enzyme-linked immunosorbent assay in 88% of cases and by the IgM-immunofluorescent antibody test in 78%. Twenty percent of patients who had serum samples drawn more than 12 months after onset lymphadenopathy still had IgM toxoplasma antibodies demonstrable by the enzyme-linked immunosorbent assay. No patient first tested six or more months after onset of lymphadenopathy was positive in the IgM-immunofluorescent antibody test. These results provide the basis for recommendations on the use of serologic tests for the diagnosis of acute toxoplasmic lymphadenopathy.

Clinical spectrum in 107 cases of toxoplasmic lymphadenopathy.

Lymphadenopathy is the most frequent clinical manifestation of acute acquired infection with Toxoplasma in the immunocompetent individual. One hundred seven cases of histologically verified toxoplasmic lymphadenitis were reviewed in an effort to determine the usual modes of clinical presentation and the incidence of extranodal disease. Toxoplasmic lymphadenitis most frequently involved a solitary lymph node in the head and neck regions, without systemic symptoms or extranodal disease and with a benign clinical course. However, serious extranodal disease did occur in some patients and included myocarditis, pneumonitis, encephalitis, chorioretinitis, and transmission of the infection to the fetus. Case histories are presented to illustrate important points with respect to clinical presentation, complications, and diagnosis.

Clinical efficacy and levels of ciprofloxacin in tissue in patients with soft tissue infection.

The clinical efficacy of ciprofloxacin was evaluated with 21 patients with soft tissue infection due mainly to gram-negative aerobic bacteria. Clinical cure was noted in 16 patients (76%), and clinical improvement was noted in the remaining 5 patients (24%). In addition, levels of ciprofloxacin were measured in the sera and tissues of 11 patients. Mean concentrations in tissue averaged 1.75 times the levels in serum. Ciprofloxacin should provide serum and soft tissue concentrations above the MICs for most gram-negative aerobic bacteria.

Encephalitis caused by Coxiella burnetii.

Acute infection with Coxiella burnetii usually results in a self-limited illness, but it can occasionally cause chronic endocarditis or hepatitis. Headache is a common presenting symptom of acute infection with this agent, but specific neurological abnormalities are rare. We report the case of a patient with acute Q fever that caused frank encephalitis. We also review the literature on central nervous system disease attributable to C. burnetii.