Immunization entry at the point of service improves quality, saves time, and is well-accepted.

OBJECTIVE: Computer-based immunization tracking is a routine part of many pediatric practices; however, data quality is inconsistent and entry often relies on dedicated data entry personnel and is time-consuming, expensive, or difficult. The purpose of this study was to evaluate data quality, nursing satisfaction, and reduction in documentation burden after the introduction of a point-of-service immunization entry system in an inner-city pediatric primary care center. DESIGN: Prospective preintervention and postintervention study. METHODS: Visit records from all pediatric nonurgent care visits for patients <5 years old were collected during a 2-week period before (preintervention) and after (postintervention) the introduction of a computer-based immunization entry system. Nurses used software designed to allow rapid entry during immunization preparation followed by printing 2 adhesive labels for documentation. Satisfaction was evaluated using an 8-question survey administered 3 months after the intervention. RESULTS: One hundred forty-seven (63.6%) of 231 preintervention and 132 (51.4%) of 257 postintervention children received at least 1 immunization (immunized) during the study visit. Gender and mean age were similar for immunized children in the 2 groups. In the preintervention group, 56 (37.9%) of 147 immunized children had at least 1 dose missing (a total of 128 of 343 doses administered) from the immunization tracking database compared with none in the postintervention group. Medical record review showed that 92.6% of preintervention and 91.4% of postintervention children were on-schedule after the study visit. However, missing data lead to the misclassification of preintervention children-only 68.4% were reported by the database to be on-schedule. All 9 nurses reported using the program all the time to enter immunizations, 89% said that the program required somewhat or a lot less time, and 100% strongly recommended continued use of the program. All 9 nurses also reported that they would be somewhat or very unenthusiastic about the system if labels were not available. During the 12 months after introduction of the system, 8273 forms containing immunization information were printed, preventing nurses from having to write >101,000 dates. CONCLUSIONS: Immunization entry by nurses at the time of immunization preparation improves the quality of tracking data, reduces misclassification of immunization needs, saves time, and can be well-accepted. It is likely that poor data quality in some tracking systems has led to falsely low immunization coverage estimates. Systems such as the one in this study can improve quality and should be integrated into routine clinical practice.

Immunosubtraction as a means of typing monoclonal and other proteins in serum and urine.

Serum and urine protein electrophoresis are used primarily to screen for the presence of monoclonal proteins found in conditions such as myeloma, non-Hodgkin's lymphoma, macroglobulinemia, and so on. Having demonstrated the presence of an abnormal band, further testing is required to identify both the immunoglobulin heavy- and light-chain types (e.g., IgG κ). With conventional agarose gel or cellulose acetate electrophoresis, this secondary testing is either by immunofixation (1-3) or immunoelectrophoresis (4). In both methods, serum or urine is electrophoresed, and antibodies to each of the immunoglobulin classes is reacted with the abnormal protein. Insoluble protein-antibody complexes are formed, which can be visualized by staining with dyes such as Coomassie blue. These methods are sensitive, but can be time-consuming and labor-intensive.

Confirmation of the presence of drugs of abuse in urine.

Urine screenings for drugs of abuse are performed for many reasons, two of the most common being workplace/employment screening and monitoring in drug-dependence treatment centers. In both, the initial screen is commonly an immunoassay. Negative results require no further action. Positive tests require a second different method to both confirm and identify which drug is present. Some perfectly legal preparations crossreact with immunoassays. Employment screening has more stringent requirements than does monitoring of known drug abusers (1), and gas chromatography-mass spectrometry (GC-MS) (2,3) is the method of choice. For the monitoring of known drug abusers attending drug-dependence centers, less sophisticated methods, such as thin layer chromatograghy (TLC) (4) and high-performance liquid chromatography (HPLC) (5,6), are frequently used. Capillary electrophoresis (CE) methods have been described for the detection of drugs of abuse in pharmacological/illicit street samples (7-9), and a few methods have been published using biological materials (10-12). This chapter describes a simple sample preparation method, followed by CE for the confirmation and identification in urine of opiates, methadone (and its main metabolite EDDP), and amphetamines. Samples are prepared by a solid phase extraction procedure using columns packed with a co-polymeric material. This is a silica-based material to which is bound a mixture of hydrophobic and ionic groups.

The association between health risk behaviors and sexual orientation among a school-based sample of adolescents.

OBJECTIVE: This study is one of the first to examine the association between sexual orientation and health risk behaviors among a representative, school-based sample of adolescents. DESIGN: This study was conducted on an anonymous, representative sample of 4159 9th- to 12th-grade students in public high schools from Massachusetts' expanded Centers for Disease Control and Prevention 1995 Youth Risk Behavior Survey. Sexual orientation was determined by the following question: "Which of the following best describes you?" A total of 104 students self-identified as gay, lesbian, or bisexual (GLB), representing 2.5% of the overall population. Of GLB youth, 66.7% were male and 70% were white (not Hispanic). Health risk and problem behaviors were analyzed comparing GLB youth and their peers. Those variables found to be significantly associated with GLB youth were then analyzed by multiple logistic regression models. RESULTS: GLB youth were more likely than their peers to have been victimized and threatened and to have been engaged in a variety of risk behaviors including suicidal ideation and attempts, multiple substance use, and sexual risk behaviors. Four separate logistic regression models were constructed. Model I, Onset of Behaviors Before Age 13, showed use of cocaine before age 13 years as strongly associated with GLB orientation (odds ratio [OR]: 6.10; 95% confidence interval [CI] = 2.45-15.20). Early initiation of sexual intercourse (2.15; 10.6-4.38), marijuana use (1.98; 1.04-4.09), and alcohol use (1.82; 1.03-3.23) also was associated with GLB orientation. Model II, Lifetime Frequencies of Behaviors, showed that frequency of crack cocaine use (1.38; 1.06-1.79), inhalant use (1.30; 1.05-1.61), and number of sexual partners (1.27; 1.06-1.43) was associated with GLB orientation. Model III, Frequency of Recent Behaviors, showed smokeless tobacco use in the past 30 days (1.38; 1. 20-1.59) and number of sexual partners in the previous 3 months (1. 47; 1.31-1.65) were associated with GLB orientation. Model IV, Frequency of Behaviors at School, showed having one's property stolen or deliberately damaged (1.23; 1.08-1.40) and using marijuana (1.29; 1.05-1.59) and smokeless tobacco (1.53; 1.30-1.81) were associated with GLB orientation. Overall, GLB respondents engaged disproportionately in multiple risk behaviors, reporting an increased mean number of risk behaviors (mean = 6.81 +/- 4.49) compared with the overall student population (mean = 3.45 +/- 3.15). CONCLUSION: GLB youth who self-identify during high school report disproportionate risk for a variety of health risk and problem behaviors, including suicide, victimization, sexual risk behaviors, and multiple substance use. In addition, these youth are more likely to report engaging in multiple risk behaviors and initiating risk behaviors at an earlier age than are their peers. These findings suggest that educational efforts, prevention programs, and health services must be designed to address the unique needs of GLB youth.

Anemia and elevated lead levels in underimmunized inner-city children.

OBJECTIVE: Underimmunized children are less frequently screened for anemia and elevated lead levels than those who are up-to-date (UTD). However, the association between underimmunization and actual disease (hemoglobin [Hgb] <11 g/dL or blood lead level [PbB] >/=10 microg/dL) has not been reported. The objective of this study was to evaluate the association between underimmunization, anemia, and elevated lead levels among children attending an inner-city clinic. STUDY DESIGN: Data from a computer-based immunization tracking system were integrated with primary care-based laboratory data. Cross-sectional data for immunization coverage, anemia, and elevated lead levels were evaluated for children who were 1, 2, 3, and 4 years of age. The first Hgb or PbB values obtained within 6 months of the child's birthday were used. SETTING: An inner-city hospital-affiliated pediatric primary care center. PATIENTS: A child was considered to be a pediatric primary care center patient if he/she had at least 3 immunizations in the immunization tracking system and at least 1 Hgb or PbB screening test during February 1993 through February 1996. RESULTS: A total of 4045 Hgb tests from 2672 children were available for analysis (1198, 1102, 945, and 800 at 1, 2, 3, and 4 years of age, respectively). Anemia was common during the first 4 years of life (21.2%, 15.8%, 11.0%, and 10.3% at 1, 2, 3, and 4 years of age, respectively). At 2 and 3 years of age, underimmunized children were significantly more likely to be anemic compared with UTD children (relative risk [RR] = 1.49, 95% confidence interval [CI] = 1.24-1.79 at 2 years of age; RR = 1.43, 95% CI = 1.12-1.83 at 3 years of age). Underimmunized children with anemia at 1 year of age were less likely than UTD children to resolve their anemia by 2 years of age (52.5% vs 20.8%, RR = 2.39; 95% CI = 1.47-3.87). Underimmunized children were also significantly more likely to have elevated lead levels at 2 years of age (RR = 1. 24; 95% CI = 1.03-1.5). CONCLUSION: Underimmunized children in the inner city are at especially high risk for anemia and elevated lead levels. These children need routine preventive health services, as well as immunization. Integrating laboratory screening data with immunization tracking systems would be an important step toward improving the health of inner-city children.

Assessment of functional ability in patients with scleroderma: a proposed new disability assessment instrument.

OBJECTIVE: To develop a simple assessment of functional ability in patients with scleroderma and to examine its reliability both as a patient self-administered instrument and when administered by a trained observer. METHODS: An 11 item, 4 grade, functional assessment questionnaire was developed after extensive consultation with patients, physiotherapists (PT), and occupational therapists (OT) with the aim of including all functional areas of relevance. The instrument was self-administered by patients after an interval of 7 days. In the interval, the patients were assessed using the same instrument by direct observation from both a PT and an OT. Forty-seven patients with scleroderma, of varying severity, were recruited from 2 centers. Results were similar for both centers and data were pooled for analysis. RESULTS: Agreement between the patients' first and 2nd assessment was good for all questions (estimated kappas 0.69 to 0.94) with no evidence of an order effect. Agreement was also good between therapists (estimated kappas 0.47 to 0.81). There was poor agreement between patients and therapists, with patients rating their disability substantially higher compared to the standardized therapist assessment. CONCLUSION: This assessment schedule has high face and content validity and has excellent reliability both between trained therapists and within patients over a short time period. Its administration either as a self-report or by a therapist depends, in part, on the type of investigation undertaken.

The postoperative inflammatory response to injury following laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy.

The magnitude of the inflammatory response to surgery depends on the degree of injury during surgical procedures. Laparoscopic techniques are generally associated with less postoperative pain and shorter hospital stay compared with open procedures, presumably due to less tissue injury and reduced inflammatory response. However, no study has been done, to our knowledge, to assess the inflammatory response to surgical trauma following laparoscopic assisted vaginal hysterectomy. We have, therefore, compared the magnitude of the inflammatory response to injury after laparoscopically assisted vaginal hysterectomy (11 patients) and abdominal hysterectomy (11 patients) by measuring serum C-reactive protein (CRP) and interleukin-6 (IL-6) on admission, and at 24 and 48 hours after the operation. Postoperatively, serum CRP rose significantly in both groups but levels in patients who underwent laparoscopically assisted vaginal hysterectomy were significantly lower than in those who underwent abdominal hysterectomy. Serum IL-6 rose significantly after abdominal hysterectomy but not after laparoscopically assisted vaginal hysterectomy. Our results show that the inflammatory response to surgical trauma was significantly less after laparoscopically assisted vaginal hysterectomy than after abdominal hysterectomy confirming that the laparoscopic procedure causes less tissue damage than the abdominal procedure.

A simple HPLC method for the separation of amphetamine isomers in urine and its application in differentiating between 'street' amphetamine and prescribed D-amphetamine.

D-amphetamine has been increasingly prescribed to treat amphetamine abusers. Prescribing D-amphetamine requires laboratory evidence or confirmation of current use of 'street' amphetamine, using a method which should be capable of differentiating between 'street' amphetamine and prescribed D-amphetamine. We have developed a simple high-performance liquid chromatography (HPLC) method for the separation of the two isomers of amphetamine in urine and have assessed its use in differentiating between 'street' amphetamine and prescribed D-amphetamine. The method is reproducible, free from interference and has a detection limit of 0.1 microgram/mL for each isomer. Urine from patients prescribed D-amphetamine contained only a trace amount of L-amphetamine (less than 4%) whereas urine from those taking 'street' amphetamine contained more than 50% L-amphetamine. The method is applicable to confirmation of 'street' amphetamine misuse and for monitoring patient compliance with treatment. The presence of 4% or less L-amphetamine in urine would suggest that the patient is only taking prescribed D-amphetamine whereas the presence of L-amphetamine in higher concentrations suggests that the patient is taking 'street' amphetamine, with or without prescribed D-amphetamine.

Variations in pediatric pneumonia and bronchitis/asthma admission rates. Is appropriateness a factor?

OBJECTIVE: To explore through a pilot study the relationship between appropriateness (medical necessity) and variations in pediatric hospital admission rates across several communities in the Boston (Mass) area for two common pediatric conditions with extremely variable admission rates: pneumonia and bronchitis/asthma. DESIGN: We identified five communities in the greater Boston area with high, average, and below-average ratios of observed to expected admissions for the study conditions. Diagnosis-specific, criteria-based utilization review instruments were developed by community-based pediatricians and applied by trained nurse reviewers to medical records. ADMISSIONS STUDIED: All admissions for pneumonia (diagnosis related group [DRG] 91) and bronchitis/asthma (DRG 98) of study area residents younger than 18 years to participating hospitals during fiscal year 1986. OUTCOME MEASURES: For each area, we calculated age-adjusted admission rates, age-adjusted observed to expected ratios, and rates of inappropriate admissions. We tested the hypothesis that admission rates and inappropriateness rates were directly related. RESULTS: We deemed 9.4% of pneumonia admissions and 4.4% of bronchitis/asthma admissions inappropriate. Rates of inappropriate admissions were not significantly associated with admission rates in this local pilot study for either study condition at P < .05. However, in one community both rates were high for both conditions. Feedback of findings to the key local hospital there resulted in sharp decreases in admission rates for DRGs 91 and 98 in subsequent years. CONCLUSIONS: Our results suggest that higher pediatric admission rates may not be associated with higher rates of inappropriateness. Further research is needed, with a larger number of communities, to differentiate practice patterns more precisely and explore patient and family preferences.

Screening for childhood lead poisoning: a cost-minimization analysis.

Decision analysis was used to compare the costs of three screening strategies for childhood lead poisoning: (1) venipuncture; (2) capillary sample with venipuncture confirmation if the blood lead level is elevated; (3) stratification by risk, with venipuncture for high-risk children and capillary sample for low-risk children. Under baseline conditions, the cost of screening by the venipuncture, stratification, and capillary strategies is $22, $25, and $27, respectively. Venipuncture remains the least expensive strategy unless the cost of venipuncture is more than three times that of capillary sampling. The annual cost of a national lead screening program that uses a single venipuncture sample would be $352 million. Initial screening with a capillary sample would cost $432 million, 23% more than venipuncture.

Network model for two-dimensional coupled laser arrays.

We have developed a network model for two-dimensional phase-locked arrays of coupled lasers that provides a basis for modeling arrays incorporating mixed coupling schemes. With this network approach we show that the modes of two-dimensional arrays that are evanescently coupled in the lateral direction and injection coupled in the longitudinal direction can be expressed in terms of the eigenvalues of matrices separately representing the lateral and longitudinal coupling. As an example, the modes and grating-coupled near-field patterns of a 3 x 3 array injection coupled through surface-emitting second-order Bragg reflectors are determined explicitly.

Dynamically stable 0 degrees phase mode operation of a grating-surface-emitting diode-laser array.

A coherent grating-surface-emitting diode-laser array has demonstrated dynamically stable operation in the 0 degrees phase mode. The array was operated under pulsed conditions, had a peak power output of 44 mW and a large central lobe on axis in the far field, and exhibited single-mode spectral output with better than 18-dB side-mode rejection.

Determination of 4-hydroxy-3-methoxymandelic acid in urine using HPLC with electrochemical detection.

A method is described for the assay of 4-hydroxy-3-methoxymandelic acid (HMMA) in urine using HPLC coupled with electrochemical detection. In this method acidified urine is extracted with ethyl acetate which is then washed with the chromatography solvent to back extract HMMA. The solvent is a pH 5.0 citrate buffer. At this pH, HMMA separates clearly from all other electroactive compounds present in urine.

Generation of 16-fsec frequency-tunable pulses by optical pulse compression.

Using a two-stage optical-fiber pulse compressor together with an optical amplifier, we have compressed the 5.4-psec pulses from a synchronously pumped mode-locked dye laser to 16-fsec duration. The compressed pulses had peak powers of 80 kW and a repetition rate of 200 Hz and were tunable over the wavelength of the dye laser.

Coherent coupling effects in pump-probe measurements with collinear, copropagating beams.

We demonstrate the existence of coherent coupling effects in pump-probe measurements with collinear, copropagating beams, despite the absence of any induced spatial gratings in this geometry. The coherent interaction, which is found to be similar but not identical to that for crossed beams, must be taken into account in analyzing relaxation processes occurring on the time scale of the laser pulse. These coherent effects cannot generally be eliminated by detecting the total change in energy in both the pump and probe beams.