Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial

BACKGROUND

Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals.

METHODS

A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes.

DISCUSSION

We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas.

TRIAL REGISTRATION

ACTRN12622000028707. Registered 14 January, 2022.

89Factors associated with pneumococcal nasopharyngeal carriage: a systematic review

Background

Pneumococcal disease is a major contributor to global childhood morbidity and mortality. Pneumococcal carriage is a prerequisite for pneumococcal disease. Identifying factors associated with pneumococcal carriage can aid public health intervention programs. It is unknown if risk factors for pneumococcal carriage differ between low, middle, and high-income countries. We present preliminary findings of our systematic review of factors associated with pneumococcal carriage in community settings, in all ages.

Methods

A systematic search for pneumococcal nasopharyngeal carriage studies, published in English before July 2019. Two researchers independently reviewed studies that described factors associated with pneumococcal nasopharyngeal carriage. Study quality was assessed using the NIH Study Quality Assessment Tools. Results are presented as narrative summaries due to heterogeneity amongst factor definitions.

Results

Preliminary results are shown. Sixty-seven studies were included. 49% were conducted in high-income countries. Pneumococcal prevalence ranged from 0.3%-97%, 2.6%-89.6%, 14%-73%, 1.6%-82.4% in low-, lower-middle, upper-middle, and high-income classifications. Age, respiratory tract infection symptoms, living with young children, poverty, exposure to smoke, and season were positively associated with pneumococcal carriage in all income classifications.

Conclusions

Pneumococcal carriage prevalence was highest in low-income classifications. Pneumococcal carriage is associated with similar factors across income classifications. Differences in prevalence of risk factors associated with pneumococcal carriage by income classification may contribute to differences in carriage prevalence by income classifications.

Key messages

Pneumococcal carriage is considered a prerequisite for pneumococcal disease. Pneumococcal carriage prevalence is highest in low-income countries, however preliminary results suggest risk factors for carriage may be similar across income classifications.

90Factors associated with pneumococcal carriage in children and adults in Fiji, using four cross-sectional surveys

Background

Pneumococcal disease is preceded by carriage of pneumococci. We describe factors associated with pneumococcal nasopharyngeal carriage in Fiji, using data from annual (2012-2015) cross-sectional surveys, pre- and post-introduction of ten-valent pneumococcal conjugate vaccine (PCV10).

Methods

Infants (5-8 weeks), toddlers (12-23 months), children (2-6 years), and their caregivers participated. Pneumococci were detected using lytA qPCR, with molecular serotyping by microarray. We used logistic regression to determine predictors of carriage and density.

Results

There were 8,109 participants. Pneumococcal carriage was associated with: years post-PCV10 introduction (global P<0.001), iTaukei ethnicity (aOR 2.74 [95% CI 2.17-3.45] P<0.001); young age (global P<0.001); urban residence (aOR 1.45 [95% CI 1.30-2.57] P<0.001); living with >2 children <5 years (aOR 1.42 [95% CI 1.27-1.59] P<0.001); poverty (aOR 1.44 [95% CI 1.28-1.62] P<0.001); and upper respiratory tract infection (URTI) symptoms (aOR 1.77 [95% CI 1.57-2.01] P<0.001). Factors associated with PCV10 and non-PCV10 carriage were similar to those associated with overall carriage. Additionally, PCV10 carriage was associated with PCV10 vaccination (0.58 [95% CI 0.41-0.82] P=0.002) and cigarette smoke exposure (aOR 1.21 [95% CI 1.02-1.43] P=0.031. Non-PCV10 carriage was not associated with years post-PCV10 introduction.

Conclusions

Introduction of PCV10 reduced the odds of overall and PCV10 pneumococcal carriage in Fiji. ITaukei ethnicity was positively associated with carriage after adjustment for PCV10.

Key messages

PCV10 introduction was associated with reduced odds of overall and PCV10 pneumococcal carriage in Fiji. Despite high and similar PCV10 coverage rates, iTaukei ethnicity is positively associated with pneumococcal carriage, compared with Fijian of Indian Descent populations.

Solar-powered oxygen, quality improvement and child pneumonia deaths: a large-scale effectiveness study

BACKGROUND

Pneumonia is the largest cause of child deaths in low-income countries. Lack of availability of oxygen in small rural hospitals results in avoidable deaths and unnecessary and unsafe referrals.

METHOD

We evaluated a programme for improving reliable oxygen therapy using oxygen concentrators, pulse oximeters and sustainable solar power in 38 remote health facilities in nine provinces in Papua New Guinea. The programme included a quality improvement approach with training, identification of gaps, problem solving and corrective measures. Admissions and deaths from pneumonia and overall paediatric admissions, deaths and referrals were recorded using routine health information data for 2-4 years prior to the intervention and 2-4 years after. Using Poisson regression we calculated incidence rates (IRs) preintervention and postintervention, and incidence rate ratios (IRR).

RESULTS

There were 18 933 pneumonia admissions and 530 pneumonia deaths. Pneumonia admission numbers were significantly lower in the postintervention era than in the preintervention era. The IRs for pneumonia deaths preintervention and postintervention were 2.83 (1.98-4.06) and 1.17 (0.48-1.86) per 100 pneumonia admissions: the IRR for pneumonia deaths was 0.41 (0.24-0.71, p<0.005). There were 58 324 paediatric admissions and 2259 paediatric deaths. The IR for child deaths preintervention and postintervention were 3.22 (2.42-4.28) and 1.94 (1.23-2.65) per 100 paediatric admissions: IRR 0.60 (0.45-0.81, p<0.005). In the years postintervention period, an estimated 348 lives were saved, at a cost of US$6435 per life saved and over 1500 referrals were avoided.

CONCLUSIONS

Solar-powered oxygen systems supported by continuous quality improvement can be achieved at large scale in rural and remote hospitals and health care facilities, and was associated with reduced child deaths and reduced referrals. Variability of effectiveness in different contexts calls for strengthening of quality improvement in rural health facilities.

TRIAL REGISTRATION NUMBER

ACTRN12616001469404.

Diagnosis of pneumonia and malaria in Nigerian hospitals: A prospective cohort study

BACKGROUND

Pneumonia and malaria are the leading causes of global childhood mortality. We describe the clinical presentation of children diagnosed with pneumonia and/or malaria, and identify possible missed cases and diagnostic predictors.

METHODS

Prospective cohort study involving children (aged 28 days to 15 years) admitted to 12 secondary-level hospitals in south-west Nigeria, from November 2015 to October 2017. We described children diagnosed with malaria and/or pneumonia on admission and identified potential missed cases using WHO criteria. We used logistic regression models to identify associations between clinical features and severe pneumonia and malaria diagnoses.

RESULTS

Of 16 432 admitted children, 16 184 (98.5%) had adequate data for analysis. Two-thirds (10 561, 65.4%) of children were diagnosed with malaria and/or pneumonia by the admitting doctor; 31.5% (567/1799) of those with pneumonia were also diagnosed with malaria. Of 1345 (8.3%) children who met WHO severe pneumonia criteria, 557 (41.4%) lacked a pneumonia diagnosis. Compared with "potential missed" diagnoses of severe pneumonia, children with "detected" severe pneumonia were more likely to receive antibiotics (odds ratio [OR], 4.03; 2.63-6.16, P < .001), and less likely to die (OR, 0.72; 0.51-1.02, P = .067). Of 2299 (14.2%) children who met WHO severe malaria criteria, 365 (15.9%) lacked a malaria diagnosis. Compared with "potential missed" diagnoses of severe malaria, children with "detected" severe malaria were less likely to die (OR, 0.59; 0.38-0.91, P = 0.017), with no observed difference in antimalarial administration (OR, 0.29; 0.87-1.93, P = .374). We identified predictors of severe pneumonia and malaria diagnosis.

CONCLUSION

Pneumonia should be considered in all severely unwell children with respiratory signs, regardless of treatment for malaria or other conditions.

Prevalence of Low Birth Weight and Prematurity and Associated Factors in Neonates in Ethiopia: Results from a Hospital-based Observational Study

Background

Low birth weight and prematurity are associated with increased morbidity, mortality and multiple short and long-term complications, exerting impacts on the individual, the families, the community and the health care system. Fetal, maternal and environmental factors have been associated with low birth weight and prematurity, based primarily on researches from high-income countries. It is unknown whether these risk factors are the same in low and middle income countries. The aims of this study are to determine the prevalence of low birth weight and prematurity and associated factors in Jimma University Specialized Hospital, Ethiopia.

Methods

This observational study was conducted at Jimma University Specialized Hospital, Ethiopia, from December 2014 to September 2016. Multivariable logistic regression was used to determine the associated factors, with results reported as odds ratios (OR) and 95% confidence intervals (CI).

Results

The prevalence of low birth weight and prematurity were 14.6% and 10.2%, respectively. The mean birth weight was 2,975g (standard deviation 494). Prematurity (OR 23.54, 95%CI 15.35-36.08, p<0.001) and unmarried marital status (OR 5.73, 95%CI 1.61-20.40, p=0.007) were positively associated with low birth weight. Female sex (OR 1.69, 95%CI 1.18-2.42, p=0.004) and unmarried marital status (OR 4.07, 95%CI 1.17-14.14, p=0.027) were positively associated with prematurity.

Conclusion

The prevalence of lower birth weight and prematurity in this study is lower than other studies reported from similar facilities. Prematurity and unmarried marital status are associated with LBW whereas female sex and unmarried marital status are associated with prematurity in this population.

Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals

BACKGROUND

Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria.

METHODS

We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not).

FINDINGS

Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming ∼3500 L of oxygen per admission.

INTERPRETATION

Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children.

Solar powered oxygen systems in remote health centers in Papua New Guinea: a large scale implementation effectiveness trial

BACKGROUND

Pneumonia is the largest cause of child deaths in Papua New Guinea (PNG), and hypoxaemia is the major complication causing death in childhood pneumonia, and hypoxaemia is a major factor in deaths from many other common conditions, including bronchiolitis, asthma, sepsis, malaria, trauma, perinatal problems, and obstetric emergencies. A reliable source of oxygen therapy can reduce mortality from pneumonia by up to 35%. However, in low and middle income countries throughout the world, improved oxygen systems have not been implemented at large scale in remote, difficult to access health care settings, and oxygen is often unavailable at smaller rural hospitals or district health centers which serve as the first point of referral for childhood illnesses. These hospitals are hampered by lack of reliable power, staff training and other basic services.

METHODS

We report the methodology of a large implementation effectiveness trial involving sustainable and renewable oxygen and power systems in 36 health facilities in remote rural areas of PNG. The methodology is a before-and after evaluation involving continuous quality improvement, and a health systems approach. We describe this model of implementation as the considerations and steps involved have wider implications in health systems in other countries.

RESULTS

The implementation steps include: defining the criteria for where such an intervention is appropriate, assessment of power supplies and power requirements, the optimal design of a solar power system, specifications for oxygen concentrators and other oxygen equipment that will function in remote environments, installation logistics in remote settings, the role of oxygen analyzers in monitoring oxygen concentrator performance, the engineering capacity required to sustain a program at scale, clinical guidelines and training on oxygen equipment and the treatment of children with severe respiratory infection and other critical illnesses, program costs, and measurement of processes and outcomes to support continuous quality improvement.

CONCLUSIONS

This study will evaluate the feasibility and sustainability issues in improving oxygen systems and providing reliable power on a large scale in remote rural settings in PNG, and the impact of this on child mortality from pneumonia over 3 years post-intervention. Taking a continuous quality improvement approach can be transformational for remote health services.

Improving oxygen therapy for children and neonates in secondary hospitals in Nigeria: study protocol for a stepped-wedge cluster randomised trial

BACKGROUND

Oxygen is a life-saving, essential medicine that is important for the treatment of many common childhood conditions. Improved oxygen systems can reduce childhood pneumonia mortality substantially. However, providing oxygen to children is challenging, especially in small hospitals with weak infrastructure and low human resource capacity.

METHODS/DESIGN

This trial will evaluate the implementation of improved oxygen systems at secondary-level hospitals in southwest Nigeria. The improved oxygen system includes: a standardised equipment package; training of clinical and technical staff; infrastructure support (including improved power supply); and quality improvement activities such as supportive supervision. Phase 1 will involve the introduction of pulse oximetry alone; phase 2 will involve the introduction of the full, improved oxygen system package. We have based the intervention design on a theory-based analysis of previous oxygen projects, and used quality improvement principles, evidence-based teaching methods, and behaviour-change strategies. We are using a stepped-wedge cluster randomised design with participating hospitals randomised to receive an improved oxygen system at 4-month steps (three hospitals per step). Our mixed-methods evaluation will evaluate effectiveness, impact, sustainability, process and fidelity. Our primary outcome measures are childhood pneumonia case fatality rate and inpatient neonatal mortality rate. Secondary outcome measures include a range of clinical, quality of care, technical, and health systems outcomes. The planned study duration is from 2015 to 2018.

DISCUSSION

Our study will provide quality evidence on the effectiveness of improved oxygen systems, and how to better implement and scale-up oxygen systems in resource-limited settings. Our results should have important implications for policy-makers, hospital administrators, and child health organisations in Africa and globally.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12617000341325 . Retrospectively registered on 6 March 2017.

Activity of the immunologic doublet of lenalidomide plus obinutuzumab in relapsed follicular lymphoma: Results of a phase I/II study

7531

Background: Relapsed follicular lymphoma (FL) remains a challenge and salvage regimens are associated with toxicity and limited control. Outcomes are linked to the immune microenvironment and lenalidomide and rituximab are highly active in FL. Obinutuzumab has increased ADCC compared to rituximab in preclinical models and is approved for relapsed FL. We hypothesized that the immunologic properties of obinutuzumab and lenalidomide would be synergistic. The study objective was to determine the MTD of lenalidomide with obinutuzumab in relapsed FL and describe the efficacy of the combination. Methods: This open label phase I/II study enrolled Gr 1-3a FL. Transformation was excluded. Lenalidomide was given on D 2-22 with 1000mg obinutuzumab on D1, 8, 15, and 22 of cycle 1 and on D1 for up to 12 cycles (28 days/cycle). Obinutuzumab was given every 2 months thereafter for up to 30 months in pts who responded following doublet therapy. During dose escalation, 3 cohorts were planned with 10, 15 and 20mg of lenalidomide. Phase II planned to enroll 30 pts at MTD with efficacy and safety as primary endpoints. Results: All 36 pts with FL enrolled (6 in dose escalation and 30 at MTD), and are eligible for efficacy and safety analysis. The median age was 65 with a median of 2 prior therapies. No DLTs were observed in phase I, and 20 mg of lenalidomide was used for phase II. To date, the most common all grade non-heme toxicities were fatigue(83%), diarrhea(67%) and rash(53%). Grade 3+ toxicities included neutropenia (23%), infection (11%) and fatigue (8%). The overall response rate was 100% with 78% (95%CI 60.85-89.88%) of pts attaining complete response (CR/Cru). All pts with rituximab refractory FL (13) responded. At a median follow up of 14 months, 10 pts progressed. The estimated 24 month PFS is 61% (95% CI 43-87%). Conclusions: Lenalidomide and obinutuzumab is highly active with durable remissions in relapsed FL, with all pts responding and 78% achieving CR. The majority of pts remain on therapy and the combination appeared safe. Correlatives are ongoing to identify biomarkers of response and frontline studies of the combination are currently enrolling. Clinical trial information: NCT01995669.

High ten-year remission rates following rituximab, fludarabine, mitoxantrone and dexamethasone (R-FND) with interferon maintenance in indolent lymphoma: Results of a randomized Study

We report a single-centre, randomized study evaluating the efficacy and safety of concurrent fludarabine, mitoxantrone, dexamethasone (FND) and rituximab versus sequential FND followed by rituximab in 158 patients with advanced stage, previously untreated indolent lymphoma, enrolled between 1997 and 2002. Patients were randomized to 6-8 cycles of FND followed by 6 monthly doses of rituximab or 6 doses of rituximab given concurrently with FND. All patients who achieved at least a partial response received 12 months of interferon (IFN) maintenance. Median ages were 54 and 55 years. The two groups were comparable with the exception of a higher percentage of females (65% vs. 43%) and baseline anaemia (23% vs. 11%) in the FND followed by rituximab group. Complete response/unconfirmed complete response rates were 89% and 93%. The most frequent grade ≥ 3 toxicity was neutropenia (86% vs. 96%). Neutropenic fever occurred in 21% and 16%. Late toxicity included myelodysplastic syndrome (n = 3) and acute myeloid leukaemia (n = 5). With 12·5 years of follow-up, no significant differences based on treatment schedule were observed. 10-year overall survival estimates were 76% and 73%. 10-year progression-free survival estimates were 52% and 51%. FND with concurrent or sequential rituximab, and IFN maintenance in indolent lymphoma demonstrated high response rates and robust survival.

Perceptions of community nutrition and health needs in the Lower Mississippi Delta: a key informant approach

OBJECTIVE

Key informants' perceptions of nutrition and health needs in their southern rural communities were assessed prior to nutrition intervention planning.

DESIGN

This cross-sectional survey used in-person interviews.

SUBJECTS/SETTINGS

A sample of 490 individuals from 12 professional and lay roles in 8 community sectors in 36 counties in Arkansas, Louisiana, and Mississippi was chosen.

STATISTICAL ANALYSES PERFORMED

Factor analysis was carried out on reported food, nutrition, and health problems and contributing factors. The General Linear Models procedure identified within- and between-subject effects for factors. Tukey's post hoc tests identified differences between sectors and states. Frequencies and weighted rankings were computed for health problems.

RESULTS

Key informants rated individual-level factors (food choices, education, willingness to change, health behavior) as more important than community-level factors (food and health care access, resources) with regard to nutrition and health problems and contributors to problems. The number one health problem was hypertension.

IMPLICATIONS

Key informants are knowledgeable about nutrition and health problems, contributing factors, and available resources. Individual factors were perceived as more important contributors to nutrition and health problems providing valuable information for planning nutrition interventions.

Utilization of evidence-based teaching in U.S. dental hygiene curricula

PURPOSE

The purpose of this research was to survey U.S. dental hygiene program directors to determine: (1) demographic information, (2) specific Evidence-Based (EB) student instruction methods used, (3) if and how programs use an EB philosophy, (4) perceptions of faculty skills in incorporating EB instruction, and (5) opinions and attitudes regarding future need to incorporate EB philosophies in dental hygiene education.

METHODS

Data were gathered by surveying all 235 United States dental hygiene program directors in 1999. The survey included 20 closed items and 1 open-ended item. Initially, the survey was pilot tested using a convenience sample of seven U.S. dental hygiene program directors. A final, revised survey was mailed to the cohort population. A response rate of 70% (n = 164) was achieved after two mailings, and responses were analyzed using descriptive statistics.

RESULTS

The demographic results of this study revealed the majority of respondents were from associate degree/certificate dental hygiene programs (77%). Results revealed that most dental hygiene programs are beginning to include some fundamental EB concepts and skills into their curriculum, primarily by incorporating analysis of scientific literature. Most programs provide students with formal library orientation (88%), instruct students in the use of library indices or library databases (86%), and teach the use of the Internet for conducting literature searches (79%). Respondents indicated the major barriers for fully incorporating an EB approach in their dental hygiene program were: lack of faculty skills (37%), no available time (34%), lack of financial resources (33%), and lack of technical support (28%).

CONCLUSION

Findings of this study suggest dental hygiene educators have made small strides in creating an EB philosophy dental hygiene curriculum. However, the future of dental hygiene education must address the need for faculty development and training in areas such as computer utilization in core dental hygiene courses, strategies to improve the curriculum to stimulate students' critical thinking skills, and to develop educators' skills in the use of evidence for clinical decision-making.

Validity of a telephone-administered 24-hour dietary recall in telephone and non-telephone households in the rural Lower Mississippi Delta region

OBJECTIVE

To determine if 24-hour dietary recall data are influenced by whether data are collected by telephone or face-to-face interviews in telephone and non-telephone households.

DESIGN

Dual sampling frame of telephone and non-telephone households. In telephone households, participants completed a 24-hour dietary recall either by face-to-face interview or telephone interview. In non-telephone households, participants completed a 24-hour dietary recall either by face-to-face interview or by using a cellular telephone provided by a field interviewer.

SUBJECTS/SETTING

Four hundred nine participants from the rural Delta region of Arkansas, Louisiana, and Mississippi.

MAIN OUTCOME MEASURES

Mean energy and protein intakes.

STATISTICAL ANALYSES PERFORMED

Comparison of telephone and non-telephone households, controlling for type of interview, and comparison of telephone and face-to-face interviews in each household type using unpaired t tests and linear regression, adjusting for gender, age, and body mass index.

RESULTS

Mean differences between telephone and face-to-face interviews for telephone households were -171 kcal (P = 0.1) and -6.9 g protein (P = 0.2), and for non-telephone households -143 kcal (P = 0.6) and 0.4 g protein (P = 1.0). Mean differences between telephone and non-telephone households for telephone interviews were 0 kcal (P = 1.0) and -0.9 g protein (P = 0.9), and for face-to-face interviews 28 kcal (P = 0.9) and 6.4 g protein (P = 0.5). Findings persisted when adjusted for gender, age, and body mass index. No statistically significant differences were detected for mean energy or protein intake between telephone and face-to-face interviews or between telephone and non-telephone households.

APPLICATIONS/CONCLUSIONS

These data provide support that telephone surveys adequately describe energy and protein intakes for a rural, low-income population.

Prolonged fever associated with inhalation of multiple pyrolysis products

A case of smoke inhalation with a self-limited but prolonged febrile course, including headaches and chills, is reported. A final diagnosis of polymer fume fever was made, although the duration of fever was longer than generally has been reported with this syndrome. Pyrolysis products involved included those of polyurethane, methylene chloride, and polytetrafluoroethylene ("Teflon"). The results of toxicological testing are reported and discussed.