Implications of proposed changes in bulk tank somatic cell count regulations

Several changes in bulk tank SCC (BTSCC) regulations were proposed at the 1998 annual meeting of the National Conference of Interstate Milk Shippers (NCIMS) by the National Mastitis Council and other proponents. Proposals included 1) using a geometric mean BTSCC in place of the arithmetic mean, reducing the current limit for BTSCC from 750,000 to 400,000, and modifying current regulatory protocols. The purpose of this research was to evaluate possible impacts of proposed changes upon producers in warm climates. Data were monthly BTSCC values, provided by state regulatory agencies in West Texas, Louisiana, and Mississippi. Fifty producers from each state were selected by lot, and all 1998 monthly records were included (n = 1602). Computer simulation was used to compare regulatory actions that would have resulted under current and proposed regulations. Possible regulatory actions were 1) notification of noncompliance and 2) suspension of permits to sell milk. At the 750,000 BTSCC limit, both programs resulted in 41 regulatory actions, but the proposed program had a higher rate of suspensions to notices. A twofold increase in regulatory actions per 100,000 incremental decrease in BTSCC limit below 750,000 resulted under both programs. Actual results could be lower due to the assumption that no management adjustments were made by producers in response to changes in regulations. However, the magnitude of increased actions against producers indicated that lowering limits quickly could be disruptive if producers failed to adjust management quickly and effectively to comply with lower limits.

Impact of nosocomial infection on length of stay and functional improvement among patients admitted to an acute rehabilitation unit

OBJECTIVE

To identify factors predictive of length of stay (LOS) and the level of functional improvement achieved among patients admitted to an acute rehabilitation unit for the first time, with special reference to the role of nosocomial infection.

SETTING

A 40-bed acute rehabilitation unit within a 300-bed, tertiary-care, public, university-affiliated hospital.

STUDY POPULATION

All patients admitted to the unit between January 1997 and July 1998.

DESIGN

Prospective cohort study in which demographic and clinical data, including occurrence of nosocomial infection, were collected during the entire unit admission of each patient. Multivariate linear regression analysis was used to identify factors predictive of unit LOS or improvement in functional status as measured by the change in the Functional Independence Measure (FIM) score between admission and discharge (deltaFIM).

RESULTS

There were 423 admissions to the rehabilitation unit during the study period, of which 91 (21.5%) had spinal cord injury (SCI) as a principal diagnosis. One hundred seven nosocomial infections occurred during 84 (19.9%) of the 423 admissions. The most common infections were urinary tract (31.8% of all infections), surgical-site (18.5%), and Clostridium difficile diarrhea (15%). Only one patient died of infection. After controlling for severity of illness on admission, functional status on admission, age, and other clinical factors, the significant positive predictors of unit LOS were as follows: SCI (P<.001), pressure ulcer (.002), and nosocomial infection (<.001). Significant negative predictors of deltaFIM were age (P<.001), FIM score on admission (<.001), prior hospital LOS (.002), and nosocomial infection (.007).

CONCLUSIONS

Several variables were identified as contributing to a longer LOS or to a smaller improvement in functional status among patients admitted for the first time to an acute rehabilitation unit. Of these variables, only nosocomial infection has the potential for modification. Studies of new approaches to prevent infections among patients undergoing acute rehabilitation should be pursued.

MDC-9 (ADAM-9/Meltrin gamma) functions as an adhesion molecule by binding the alpha(v)beta(5) integrin

MDC-9 is a widely expressed member of the metalloproteinase/disintegrin/cysteine-rich protein family. The disintegrin domain of MDC-9 lacks an RGD motif but has recently been reported to bind the alpha(6)beta(1) integrin; however, it is unclear whether MDC-9 can bind other integrins. In the present study myeloma cells, but not lymphoblastoid cells, were shown to bind to immobilised, recombinantly expressed MDC-9 disintegrin domain (A9dis). Binding was divalent cation-dependent, being supported by Mn(2+) and Ca(2+). Adhesion of myeloma cells to A9dis was completely inhibited by an antibody to the alpha(v)beta(5) integrin but not by antibodies to other subunits. RGD-containing peptides had no effect on binding, suggesting that MDC-9 interacts with alpha(v)beta(5) in an RGD-independent manner. Flow cytometric analyses demonstrated that myeloma cells, but not lymphoblastoid cells, expressed alpha(v)beta(5) on the cell membrane. These data indicated that the disintegrin domain of MDC-9 can function as an adhesion molecule by interacting with an alpha(v)beta(5) integrin.

Echocardiographic aspects of percutaneous atrial septal defect closure in adults

Echocardiography plays an integral role in the diagnosis and management of atrial septal defects. With percutaneous closure of secundum defects becoming widespread, transoesophageal echocardiography in particular has assumed an important role in patient selection, as well as being central to the device deployment procedure, and an important tool in patient follow up.

Prospective surveillance for antibiotic-resistant organisms in patients with spinal cord injury admitted to an acute rehabilitation unit

BACKGROUND

The objective of this study was to evaluate the epidemiology of antibiotic-resistant organisms among patients with spinal cord injury admitted to an acute rehabilitation unit for the first time.

METHODS

After informed consent, 63 patients with spinal cord injury admitted to an acute rehabilitation unit between January 1997 and July 1998 had surveillance cultures (nares, urine, wounds or ulcers, and perineum) done on admission and every 2 weeks thereafter until discharge or as long as 6 weeks after admission.

RESULTS

Of the 4 surveillance sites, perineal cultures most commonly grew one or more potential pathogens; however, antibiotic-resistant organisms were most often isolated from wounds or ulcers and least often in urine cultures. Staphylococcus aureus (methicillin-sensitive plus methicillin-resistant) and enterococci represented 44% of all organisms isolated in surveillance cultures. Methicillin-resistant S aureus was the most common resistant organism isolated. Less than 30% of the gram-negative bacilli isolated were considered antibiotic-resistant strains. Nosocomial infection as a result of any resistant organism was infrequent. After adjusting for various confounding factors in a logistic regression model, only the presence of a pressure ulcer predicted carriage of any resistant organism on admission to the rehabilitation unit. Acquisition of a resistant organism after admission to the unit at one or more surveillance sites occurred in 8 (22%) of 36 patients not colonized on admission.

CONCLUSIONS

Methicillin-resistant S aureus was the most common resistant organism colonizing patients with spinal cord injury at the time of admission to an acute rehabilitation unit and throughout their stay. However, acquisition of any resistant organism after admission was uncommon on this unit, which used Standard Precautions in the routine care of patients. These findings have implications for the type of isolation procedures on acute rehabilitation units. The low rate of acquisition and infection with MRSA after admission argues against attempts at eradication as a method of control.

Do selective serotonin re-uptake inhibitors enhance the efficacy of very brief cognitive behavioral therapy for panic disorder? A pilot study

Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behavioral therapies (CBTs) are both considered as first-line treatments for panic disorder, but the advantages of a combined therapy have yet to be definitively demonstrated. We evaluated in this pilot study the effects of combining SSRIs (vs. a placebo) with a very brief form of cognitive-behavioral therapy provided to all participants. Thirty-three subjects with DSM-IV panic disorder, with or without agoraphobia, were randomized to receive either paroxetine or a placebo with flexible dosing (10-50 mg/day). Medication visits were brief (15 min), infrequent (6 in total) and non-directive. An expert cognitive-behavior therapist administered one initial 45-min session and one subsequent 30-min session of very brief CBT (vbCBT) at weeks 5 and 7, respectively. Sessions were supplemented with educational and directive reading materials. Patients in both groups (i.e. vbCBT+paroxetine; vbCBT+placebo) improved similarly and substantially on most measures during the 10 weeks of acute treatment. At week 10, the proportion of panic-free patients was significantly higher in the paroxetine-treated group than in the placebo group (80 vs. 25%; P<0.007), as was the proportion of subjects who rated themselves as 'very much improved' at week 10 (60 vs. 13%; P<0.017). These findings point to the need for additional studies to confirm the effectiveness of very brief forms of CBT, and to document the circumstances in which combined treatment with an SSRI would be warranted.

Epidemiology of nosocomial infection and resistant organisms in patients admitted for the first time to an acute rehabilitation unit

The objectives of this study were to define the epidemiology of nosocomial bacterial colonization and infection and to define predictors of nosocomial infection among a cohort (n=423) of admissions to an acute rehabilitation unit. Overall, methicillin-resistant Staphylococcus aureus (MRSA) and enterococci were the most commonly identified colonizing organisms. Escherichia coli and Pseudomonas aeruginosa were the most commonly identified colonizing gram-negative bacilli. During 70 (16.5%) of the 423 hospitalizations in the unit, 94 nosocomial infections occurred. The most common infections were those of the urinary tract (30% of 94 infections) or a surgical site (17%), Clostridium difficile diarrhea (15%), and bloodstream infection (12.8%). Antibiotic-resistant bacteria most commonly caused bloodstream infection (41.7%) and surgical site infection (56.3%). Independent predictors of nosocomial infection at the time of admission were functional status (measured with the functional independence measure), APACHE III score, and spinal cord injury. In conclusion, gram-positive organisms were the predominant strains causing nosocomial colonization and infection. The logistic model, if verified, may be useful in defining patients who should be targeted for measures to prevent nosocomial infection.

Fluid resuscitation of patients with multiple injuries and severe closed head injury: experience with an aggressive fluid resuscitation strategy

BACKGROUND

Despite increasing experimental and clinical evidence to the contrary, a dichotomy of management strategies of the patient with multiple injuries still exists, based on the presence or absence of traumatic brain injury. Many still advocate fluid restriction or small volume resuscitation if traumatic brain injury is present.

PURPOSE

To demonstrate results of aggressive fluid resuscitation in a prospective case series of patients with multiple injuries and with severe head injury.

METHODS

Thirty-four patients with Glasgow Coma Scale score < or = 8 and Injury Severity Score > or = 16 were enrolled into the study over a period of 18 months. Fluid resuscitation was guided in part by cerebral perfusion pressures (mean cerebral perfusion pressures > 80) as well as by hemodynamic monitoring and evidence of end organ perfusion. Overall fluid intake, intensive care unit fluid balance, presence or absence of hypoxia, hypotension, or both, were analyzed. Ninety- and 180-day Glasgow Outcome Scale and Disability Rating Scale scores were also obtained.

RESULTS

By using an aggressive fluid resuscitation strategy, secondary insults were avoided in 74% of the patients. A good functional outcome was achieved in 74% and mortality was impressively low at 6%.

CONCLUSION

Fluid restriction is not necessary to achieve good results in the severely injured patient who also has a severe head injury.

Seroprevalence of West Nile, Rift Valley, and sandfly arboviruses in Hashimiah, Jordan

We conducted a serosurvey among patients of a health center in Hashimiah, a Jordanian town of 30,000 inhabitants located near a wastewater treatment plant and its effluent channel. Serum samples from 261 patients >/=5 years of age were assessed for immunoglobulin G (IgG) and IgM antibodies against West Nile, sandfly Sicilian, sandfly Naples, and Rift Valley viruses; the seroprevalence of IgG antibodies was 8%, 47%, 30%, and 0%, respectively. Female participants were more likely to have been infected than male. Persons living within 2 km of the treatment plant were more likely to have been infected with West Nile (p=0.016) and sandfly Sicilian (p=0.010) viruses. Raising domestic animals within the house was a risk factor for sandfly Sicilian (p=0.003) but not for sandfly Naples virus (p=0.148). All serum samples were negative for IgM antibodies against the tested viruses. Our study is the first documentation of West Nile and sandfly viruses in Jordan and calls attention to the possible health hazards of living close to wastewater treatment plants and their effluent channels.

Retroperitoneoscopic surgery is not associated with increased carbon dioxide absorption

PURPOSE

Previous studies have suggested that retroperitoneal laparoscopy is associated with greater carbon dioxide absorption and related postoperative morbidity, such as subcutaneous emphysema and pneumothorax. We prospectively compared the effects of carbon dioxide absorption during transperitoneal and retroperitoneal laparoscopic renal and adrenal surgery at our institution.

MATERIALS AND METHODS

Data were collected prospectively on 51 patients who underwent laparoscopic renal (26) or adrenal (25) surgery via the transperitoneal (18) or retroperitoneal (33) approach from September 1997 to February 1998.

RESULTS

There was no significant difference in carbon dioxide elimination in patients who underwent transperitoneal laparoscopy compared to retroperitoneoscopy at any interval. Subcutaneous emphysema occurred in 12.5% of the transperitoneal and 45% of the retroperitoneal group (p = 0.09). Patients with subcutaneous emphysema had greater carbon dioxide elimination during the first 2.5 hours of insufflation compared to those without subcutaneous emphysema and, thereafter, carbon dioxide elimination decreased to baseline.

CONCLUSIONS

In contrast to previous reports our prospective nonrandomized study suggests that retroperitoneoscopy is not associated with greater carbon dioxide absorption compared to transperitoneal laparoscopy. Patients with subcutaneous emphysema exhibited only transient increases in carbon dioxide absorption above control levels.

Entry of US medical school graduates into family practice residencies: 1998-1999 and 3-year summary

This is the 18th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family practice residency programs. Approximately 15.4% of the 16,114 graduates of US medical schools between July 1997 and June 1998 were first-year family practice-residents in October 1998, compared with 16.6% in 1997 and 15.9% in 1996. Medical school graduates from publicly funded medical schools were almost twice as likely to be first-year family practice residents in October 1998 than were residents from privately funded schools, 18.8% compared with 10.7%. The Mountain region reported the highest percentage of medical school graduates who were first-year residents in family practice programs in October 1998 at 22.0%; the Middle Atlantic and New England regions reported the lowest percentages at 9.9% and 8.7%, respectively. Half of the medical school graduates (50.0%) entering a family practice residency program as first-year residents in October 1998 entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the average percentage for each medical school for the last 3 years. Also reported are the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Council for Graduate Medical Education-accredited family practice residency programs, based on estimates provided by the American Association of Colleges of Osteopathic Medicine.

Use of auditory icons as emergency warnings: evaluation within a vehicle collision avoidance application

In the context of emergency warnings, auditory icons, which convey information about system events by analogy with everyday events, have the potential to be understood more quickly and easily than abstract sounds. To test this proposal, an experiment was carried out to evaluate the use of auditory icons for an in-vehicle collision avoidance application. Two icons, the sounds of a car horn and of skidding tyres, were compared with two conventional warnings, a simple tone and a voice saying 'ahead'. Participants sat in an experimental vehicle with a road scene projected ahead, and they were required to brake in response to on-screen collision situations and their accompanying warning sounds. The auditory icons produced significantly faster reaction times than the conventional warnings, but suffered from more inappropriate responses, where drivers reacted with a brake press to a non-collision situation. The findings are explained relative to the perceived urgency and inherent meaning of each sound. It is argued that optimal warnings could be achieved by adjusting certain sound attributes of auditory icons, as part of a structured, user-centred design and evaluation procedure.

Results of the 1999 National Resident Matching Program: family practice

The 1999 National Resident Matching Program (NRMP) results reflect continued volatility in the perceptions and career choices of physicians entering graduate medical education in the United States. A total of 117 fewer positions (155 fewer US seniors) were filled in family practice residency programs in 1999, as well as 23 fewer (29 fewer US seniors) in primary care internal medicine and 38 fewer (27 fewer US seniors) in internal medicine-pediatric programs. In contrast, nine more positions (19 more US seniors) were filled in anesthesiology and one more (10 more US seniors) in diagnostic radiology, two "marker" disciplines that have recently been market sensitive. Seventy-three more positions (but 67 fewer US seniors) were also filled in categorical internal medicine, while 30 more positions (40 more US seniors) were filled in categorical pediatrics programs, where trainees are "pluripotential" with perceived options for practicing as generalists or entering subspecialty fellowships, depending on the market. While the demands of managed care and the needs of rural and underserved populations continue to offer a market for family physicians, family practice experienced a second year of "primary care backlash" through the 1999 NRMP. In addition, current forces appear to be influencing some students to choose subspecialty rather than primary care careers.

An investigation of hypomagnesemia among ambulatory urban African Americans

BACKGROUND

Magnesium represents the fourth most abundant cation in the body and plays an integral role in intracellular metabolism. Although magnesium deficiency states have been associated with a variety of medical conditions, the prevalence of hypomagnesemia has not been well studied, particularly in ambulatory settings.

METHODS

We performed a period prevalence study using 120 patients seen for routine medical care at an urban family medicine center. Chart reviews were completed for these subjects. We used univariate and multivariate analyses to correlate magnesium levels with demographic and clinical factors.

RESULTS

There was a 20% overall prevalence of hypomagnesemia among this predominantly female, African American population. The prevalence of hypomagnesemia was greatest among patients with a history of alcoholism (odds ratio [OR] = 6.00; 95% confidence interval [CI], 1.41-26.1) and among those having 1 or more of the following medical conditions: diabetes, hyperlipidemia, hypertension, renal disease, and asthma (OR = 4.69; 95% CI, 1.37-17.65).

CONCLUSIONS

The prevalence of hypomagnesemia among patients from this urban minority community exceeds that reported in previous studies of the general population. This may be reflective of greater comorbidity, diminished nutritional status, or poorer overall health among patients from this community. The association between hyperlipidemia and magnesium deficiency warrants further investigation.