Dental clinical attire and infection-control procedures. Patients' attitudes.

BACKGROUND: The authors surveyed adults in military and civilian dental practices about infection-control procedures and clinical attire to see if patients' attitudes had changed with the alteration of infection-control procedures over the last two decades. METHODS: The authors surveyed 1,500 adults, using a written questionnaire at two military hospital dental practices and at four civilian dental offices, which included two general practices, one periodontal practice and one orthodontic practice. RESULTS: The authors found that the use of name tags and patient safety glasses during treatment were preferred by 52.0 percent and 53.4 percent, respectively, of respondents in military facilities. Respondents had no preference about dentists' clothing, use of protective glasses for examinations or head cover use. A majority of respondents preferred that dentists wear glasses when performing treatment (54.1 percent), and 77.4 percent of respondents preferred that dentists wear masks when providing their care. Respondents preferred the use of plastic barriers, and 63.0 percent said it made them feel confident that proper infection-control procedures were followed. A majority of respondents (52.3 percent) said they would be concerned if barriers were not used. CONCLUSIONS: Military and civilian respondents had similar perceptions of infection-control procedures. Respondents said they preferred that dentists wear name tags in group practices and use masks and protective glasses when performing treatment. The use of plastic barriers made respondents feel confident that proper infection-control procedures were being followed. PRACTICE IMPLICATIONS: This study can be used by dental practices to review their infection-control procedures and how patients perceive them. Dentists may decide to implement some of these procedures, especially those that are not required, and that improve customer satisfaction.

Should intravenous tocolysis be considered beyond 34 weeks' gestation?

OBJECTIVE: Our purpose was to assess the incidence of respiratory distress syndrome in nonindigent women with uncomplicated preterm labor between 34 and 36 weeks' gestation. STUDY DESIGN: All women seen between June 1, 1992, and April 15, 1999, with uncomplicated preterm labor and intact membranes and delivering between 34 and 36 weeks' gestation were analyzed. Rates of respiratory distress syndrome after delivery were calculated. A chi(2) analysis was performed, and a P value of <.05 was considered statistically significant. RESULTS: Respiratory distress syndrome was noted in 8 (17.4%) of 46 infants delivered at 34 weeks' gestation, in comparison with 5 (6.3%) of 80 infants and 7 (4.2%) of 165 infants delivered at 35 and 36 weeks' gestation, respectively (P =.008). The rate of respiratory distress syndrome after delivery at 34 weeks was significantly higher than at 35 weeks (P =.048). CONCLUSION: The rate of respiratory distress syndrome after delivery at 34 weeks is significantly higher than at either 35 or 36 weeks' gestation in our population.

Childhood fever education in a military population: is education enough?

PURPOSE: Parental knowledge of childhood fever and clinic and emergency room utilization were studied in a military pediatric clinic population to determine if intervention would improve parental understanding and management of childhood fever. METHODS: Multiple choice tests evaluating childhood fever knowledge were given to control and intervention groups. Clinic and emergency room utilization were tracked for appropriateness of visits based on criteria used in previous similar studies. RESULTS: Initial test scores showed no difference between the two groups. Subsequent test scores revealed a difference between the two groups as reflected by improved test scores. Evaluation of clinic and emergency room utilization of the groups did not show an overall improvement except in one subgroup analyzed. CONCLUSION: Intervention improved parental knowledge; however, intervention did not translate into anticipated improvement in clinic and emergency room utilization patterns. Emphasis on education and preventative services are important in both civilian and military pediatric practice. Results of this study highlight the need to discuss and reinforce fever education as a topic in pediatric preventive health care visits.

Tuberculosis vaccination versus isoniazid preventive therapy: a decision analysis to determine the preferred strategy of tuberculosis prevention in HIV-infected adults in the developing world.

SETTING: The developing world. OBJECTIVE: To compare the strategy of TB vaccination with that of tuberculin skin-testing in conjunction with isoniazid (INH) in preventing tuberculosis in HIV-infected persons. For any clinical scenarios in which immunization would be more effective than INH preventive therapy, to determine the minimum necessary vaccine safety and effectiveness required. DESIGN: Decision analysis. A hypothetical cohort of 10000 HIV-infected persons, 65% of whom were tuberculin positive, living in the developing world, was studied. Probability estimates were based on BCG vaccine for the baseline analysis, and it was assumed that the vaccine cannot protect if given after infection. RESULTS: Under the probability estimates and assumptions of the analysis, tuberculin skin testing/INH preventive therapy would prevent 458 more cases of TB and 45 more deaths due to TB than TB vaccination. One- and two-way sensitivity analyses revealed no thresholds at which TB vaccination would be the preferred strategy. Vaccine safety did not impact the outcome of the analysis. Three-way sensitivity analysis revealed that if the prevalence of anergy were 35% and the risk of progression to active TB among anergic persons 12.2 cases per 100 person-years, a vaccine would have to be at least 87% effective to be preferred over INH preventive therapy. CONCLUSIONS: Under the conditions of the analysis, which did not account for cost or logistics, tuberculin skin testing/INH preventive therapy would be more effective than TB vaccination in preventing TB among HIV-infected persons. The hypothesized TB vaccine would prevent more TB than INH preventive therapy only in areas where the prevalence of anergy and risk of active TB if anergic were high, and vaccine effectiveness exceeded 87%.

Effectiveness of a worksite smoking cessation program in the military. Program evaluation.

1. A program evaluation was conducted to evaluate the effectiveness of the smoking cessation program. Substantiating data enhances the value of health promotion programs as key components of the health care delivery system. 2. Persons enrolled in the 8 week smoking cessation program and members of a comparison group were administered an evaluation tool prior to participating in the program, with a second evaluation tool upon completion of the program. Afterward, the smoking status of the members of both groups was evaluated at 3 month intervals for a period of 1 year. 3. Of the participants, 26.7% were not smoking 12 months after the program, compared to 6.9% of the comparison group. Of those participants who resumed smoking, 64% smoked less than half the amount they smoked before taking the class.

Economic consequences of tobacco use for the Department of Defense, 1995.

This study used Centers for Disease Control and Prevention methodology to analyze the costs of smoking-attributable mortality and morbidity within the Department of Defense (DoD) based on health care costs, characteristics of the beneficiary population, and disease characteristics. Direct health care costs attributed to smoking were estimated at $584 million. Smoking-attributable disease accounted for 16% of the deaths as well as approximately 10% of all hospital bed days and 1.5% of all active duty hospitalizations. Lost productivity among active duty personnel for hospitalization and smoke breaks was valued at $346 million. A significant portion of DoD health care resources is spent caring for smoking-attributable disease, which is preventable. This report reinforces the benefits possible from the new emphasis on wellness promotion within the DoD. Efforts are needed to prevent the initiation of smoking and encourage smoking cessation in order to reduce health care costs and increase the probability for long and healthy lives for DoD beneficiaries.

Physical and sexual abuse in female patients with fibromyalgia.

Sexual and physical abuse during childhood seem to be common. The purpose of this study was to determine the prevalence of sexual and physical abuse reported by female fibromyalgia (FM) patients in a referral-based rheumatology practice, and whether patients with FM report greater frequencies of abuse than do patients with rheumatoid arthritis (RA).Patients from two tertiary care centers, 205 with FM and 84 with RA, were mailed a self-administered questionnaire requesting information about demographics, mental health care use, and history of sexual and/ or physical abuse. There were responses from 105 FM and 44 RA patients.A history of sexual or physical abuse was reported by 54% of the sample. Any type of abuse was significantly more prevalent among patients with FM (62%) compared with those with RA (34%, p = 0.02). FM patients had a significantly increased prevalence of both sexual abuse (51% vs. 32%, p = 0.028) and physical abuse (39 vs. 16%, p = 0.006) compared with RA patients. FM patients were more likely than RA patients to report a history of multiple sexual abusers, increased duration of sexual abuse, and more violent physical abuse. Irritable bowel syndrome was more common in FM (44%) than RA patients (9%, p < 0.001), and 57% of FM patients had seen a mental health professional compared with 30% of RA patients (p = 0.002).

Diagnosis and treatment of ventilator-associated pneumonia--impact on survival. A decision analysis.

STUDY OBJECTIVE: To determine the impact of antibiotic treatment of ventilator-associated pneumonia (VAP) on survival. DESIGN: Decision analysis. PATIENTS: A hypothetical cohort of immunocompetent patients receiving mechanical ventilation who have suspected bacterial pneumonia. The analysis was performed separately for the following diagnostic techniques: clinical criteria, bronchoscopic protected specimen brush (PSB), and nonbronchoscopic protected BAL (pBAL). Additional factors accounted for in the analysis included the presence or absence of prior antibiotic use, mortality of antibiotic-treated and untreated pneumonia, mortality attributable to VAP, development of antibiotic resistance, and mortality due to adverse drug reactions. MEASUREMENTS AND RESULTS: The overall survival of patients who receive antibiotic therapy was compared to survival if antibiotic therapy had been withheld. Antibiotic treatment of clinically diagnosed VAP was associated with lower overall survival than withholding treatment. Antibiotic treatment of VAP diagnosed by invasive (PSB) or semi-invasive (pBAL) techniques was associated with better survival than withholding treatment, although withholding antibiotic therapy was favored as the mortality rate of antibiotic-treated VAP approached 70%. CONCLUSIONS: Invasive or semi-invasive diagnostic techniques should be used to diagnose VAP, guide therapy, and thereby potentially improve survival. A prospective, randomized trial assessing outcome according to diagnostic technique is needed.

Equal effectiveness of very-low-intensity anticoagulation and standard low-intensity anticoagulation: a pilot study.

We compared the efficacy of very-low-intensity oral anticoagulation (OA) with that of the recommended standard low-intensity oral anticoagulation, using international normalized ratios (INRs). We enrolled 101 patients into a pilot study--51 patients in the very-low-intensity anticoagulation arm (INR 1.4 to 2.0) and 50 in the standard low-intensity anticoagulation arm (INR 2.0 to 3.0). They were monitored for thrombotic/embolic and hemorrhagic complications for an average follow-up of 1.5 years. Two thrombotic/embolic events occurred in the very-low-intensity group; no thrombotic/embolic events occurred in the standard low-intensity group. No major bleeding occurred in the very-low-intensity group; one major hemorrhagic event occurred in the standard low-intensity group. These findings did not achieve a statistically significant difference in major complications between the two groups. It appears that very-low-intensity OA (INR 1.4 to 2.0) is as effective in preventing thromboses as standard low-intensity OA (INR 2.0 to 3.0).

Isoniazid preventive therapy in areas of high isoniazid resistance.

BACKGROUND: Previous decision analyses of isoniazid preventive therapy for low-risk tuberculin reactors aged 20 to 34 years have not accounted for the recently increased isoniazid resistance rate. Drug resistance trends could also affect the decision to use isoniazid preventive therapy for patients with recent conversion of tuberculin skin tests who are seronegative for human immunodeficiency virus. METHODS: A decision analysis was performed with a Markov simulation to assess the difference in life expectancy between those who receive isoniazid preventive therapy and those who do not. Probability estimates were determined from a review of the literature. RESULTS: For tuberculin reactors aged 20 to 34 years living in areas with 26% isoniazid resistance, isoniazid preventive therapy increases life expectancy by 2 days. Withholding isoniazid is clearly favored if the isoniazid hepatitis rate is 1.1% and the hepatitis fatality rate exceeds 2.8%. For recent tuberculin converters, isoniazid preventive therapy increases life expectancy by 14 to 17 days, depending on patient age. Withholding isoniazid from converters is favored only if the isoniazid resistance rate exceeds 90% to 98%, according to patient age. Two-way sensitivity analysis of isoniazid-associated hepatitis and hepatitis-related fatality rate did not affect the decision to use isoniazid for recent converters. CONCLUSIONS: For tuberculin reactors aged 20 to 34 years who are seronegative for human immunodeficiency virus and living in areas with high isoniazid resistance, there is minimal net benefit of isoniazid preventive therapy. The current recommendation to provide isoniazid preventive therapy to this patient population should be reexamined. For recent tuberculin converters aged 20 to 64 years who are seronegative for human immunodeficiency virus, isoniazid preventive therapy provides a small increase in life expectancy. Withholding isoniazid preventive therapy for human immunodeficiency virus-seronegative skin test converters at high risk for isoniazid-induced hepatitis may be considered; preventive therapy is advisable for all other recent converters.

Early life-stage effects in medaka (Oryzias latipes) following in ovo exposure to polyamine biosynthetic inhibitors.

Medaka, Oryzias latipes, were exposed in ovo to the polyamine (PA) biosynthesis inhibitors alpha-difluoromethylornithine (DFMO) and methylglyoxal bis(guanylhydrazone) (MGBG). In an additional group, spermine, the end product of the PA pathway, was added with DFMO and MGBG for a "rescue" treatment. At 4 days posthatch, length, DNA and RNA content, and swimming endurance were measured. The only parameter affected by treatment was swimming endurance which revealed decreased latent time to fatigue with increased dose, although not statistically significant. The rescue group, however, did demonstrate a statistically significant decrease in fatigue latency as compared to controls.