Time spent by primary care practices on pediatric influenza vaccination visits: implications for universal influenza vaccination

OBJECTIVE: To measure the time currently spent by primary care practice personnel, and the examination room occupancy time for childhood influenza vaccination visits, to assess the practicality of annual influenza vaccination of all preschool children. SETTING: Seven primary care practices serving one fourth of the children living in Rochester, NY. PATIENTS: Ninety-two children seen for influenza vaccination visits in the 2000-2001 vaccination season. METHODS: Using a standardized protocol, practice staff measured the time spent on check-in, nurse or physician examination, and the actual influenza vaccination process. Waiting and "hands-on" times were determined, as well as total visit and room occupancy times. Nonparametric tests and multivariable models were used to analyze the time spent for components of the visits and to compare time spent by different age groups and practice types (suburban or urban). RESULTS: The median duration of the influenza vaccination visit was 14 minutes (25th to 75th percentiles range, 9-25 minutes) across the 7 practices, with visits to urban practices being longer (22 minutes) than visits to suburban practices (9 minutes). Eighty percent of patient time involved waiting, primarily in examination rooms. The major components of influenza vaccination visits included waiting room time (4 minutes in suburban practices vs 8 minutes in urban practices; P<.01), and time in the examination room (5 minutes vs 14 minutes, respectively; P<.001), during which only 1 to 2 minutes (for both suburban and urban practices) were for hands-on vaccinations. Only 5% of visits were examined by a physician or nurse practitioner. Visit times did not vary by age. CONCLUSIONS: Although the personnel time for influenza vaccination visits was short, there was substantial patient waiting and long occupancy of examination rooms. If universal influenza vaccination is to be efficiently managed in primary care practices, it may be necessary to implement "vaccination clinics" or sessions in which large numbers of children are scheduled for influenza vaccinations at times when adequate rooms and dedicated nursing staff are available.     

CT in the evaluation of patients on ECMO due to acute respiratory failure

BACKGROUND: In patients with acute severe respiratory failure (ARF) treated with extracorporeal membrane oxygenation (ECMO) the radiological evaluation has until now almost exclusively relied on bedside radiography and US. At St. G?ran/Karolinska ECMO centre CT has become a routine complement to bedside examinations. OBJECTIVE: To review retrospectively the frequency, indications and findings on CT of patients with ARF on ECMO and to evaluate the risk of complications associated with transportation for CT examinations. MATERIALS AND METHODS: One hundred twelve neonates, children and adults were treated with ECMO from May 1994 to January 2001. Forty-six per cent of these patients had CT examinations on one or more occasions during ECMO, giving a total number of 238 examination sites on 104 occasions. All CT examinations were performed in the Paediatric Radiology Department and included a 10-min transport using a mobile ECMO system. RESULTS: CT was more often performed in older patients and in patients with long ECMO runs. The main indications were suspected complications of ECMO and/or the underlying disease or a delay in clinical improvement. In 57% of the CT occasions, significant findings affecting treatment were revealed. There were no complications associated with the examinations or transport. CONCLUSIONS: CT is safe and useful in evaluation of patients with ARF during ECMO.     

Renal transplantation in patients with hemolytic uremic syndrome: high rate of recurrence and increased incidence of acute rejections

BACKGROUND: The reported outcome of renal transplantation in patients with the hemolytic uremic syndrome (HUS) varies greatly, probably related to the diverse causes of HUS. In this single-center retrospective study, we have analyzed the recurrence rate, the incidence of acute rejections, and graft survival in patients suffering from adult-onset and childhood-onset HUS. METHODS: The medical records of 35 patients with end-stage renal disease caused by HUS, who received 50 renal allografts, were reviewed. A definite recurrence of HUS was diagnosed if both clinical and histologic signs of thrombotic microangiopathy (TMA) were present in the absence of any endovasculitis. If there were signs of mild endovasculitis, a probable recurrence was diagnosed. RESULTS: After first renal transplantation, 0 definite and 1 (6%) probable recurrence occurred in 18 patients with childhood-onset HUS, as opposed to 7 (41%) definite and 3 (18%) probable recurrences in 17 adult-onset HUS patients (odds ratio [OR], 13.4; 95% confidence interval [CI], 1.7-105.7). In the latter patients, early use of cyclosporine A increased the risk for recurrence. The incidence of acute rejections was increased compared with matched controls (OR, 1.52; 95% CI, 1.05-2.19 for adult-onset HUS and OR, 1.88; 95% CI, 1.34-2.62 for childhood-onset HUS). One-year graft survival in adult-onset HUS was poor (29%), whereas 1-year graft survival in childhood-onset HUS was comparable to matched controls. CONCLUSIONS: In adult-onset HUS, the recurrence rate and the incidence of acute rejections are high, resulting in a detrimental graft survival. In childhood-onset HUS, the recurrence rate is low, but the posttransplantation course is complicated by an increased incidence of acute rejections.     

Positional vertigo and cochlear implantation.

OBJECTIVE: To identify patients developing positional vertigo after cochlear implantation. STUDY DESIGN: Prospective study on a cohort of patients undergoing cochlear implantation. SETTING: Academic tertiary referral center. PATIENTS: The study included 70 consecutive patients who underwent vestibular evaluation before and after cochlear implantation. INTERVENTION: Medical record review. MAIN OUTCOME MEASURE: Recorded vestibular symptoms after cochlear implantation. Patients with positional vertigo were considered case subjects, whereas those without vestibular symptoms were considered case controls. RESULTS: Benign paroxysmal positional vertigo (BPPV) occurred in 8 patients (on the cochlear implant [CI] side in 7 patients, and in the other ear in 1). One patient had BPPV of the lateral semicircular canal on the implanted side, and 7 patients had BPPV of the posterior semicircular canal (on the same CI side in 6 patients, and on the opposite side in 1), which were detected and presented during the last examination. In 5 patients, the onset of symptoms varied from 7 to 130 days after implant activation; in 2 patients, the onset occurred before activation. CONCLUSION: Three different mechanisms are proposed for the occurrence of BPPV in patients with CI. The first focuses on the fall of bone dust particles into the cochlea during cochleostomy. In the second, the vibration caused by drilling the cochlea would be sufficient to dislodge otoconia into the labyrinth. The third hypothesis suggests dislodging of an otolith because of the electric stimulation. In our patients, conservative approaches have been used with a minimal invasive cochleostomy and without perilymph suction. Thus, the vibratory trauma affecting the cochlea during cochleostomy seems to play a fundamental role in the development of paroxysmal vertigo in patients with implant.     

Low platelet MAO activity associated with high dysfunctional impulsivity and antisocial behavior: evidence from drunk drivers

Rationale Low platelet monoamine oxidase (MAO) activity is associated with problem drinking and other deviant behaviors. Since the majority of alcohol abusers are smokers, and tobacco smoke has a direct inhibitory effect on the enzyme, these associations may not be meaningful.Objective The authors compared platelet MAO activity and impulsivity in police-referred subjects caught driving while intoxicated and in control subjects, controlling for smoking.Methods Platelet MAO activity was measured radioenzymatically and impulsivity scores obtained from questionnaires. Smoking status was self-reported.Results Subjects caught driving while intoxicated had significantly higher dysfunctional impulsivity and lower platelet MAO activity than control subjects. This difference in platelet MAO activity between the two groups was significant in non-smokers and ex-smokers.Conclusions These findings demonstrate that platelet MAO activity is lower in subjects with socially deviant behavior, and the association of low platelet MAO and problem drinking is not an artifact of smoking.     

Effects of gender and moderate smoking on the pharmacokinetics and effects of the CYP1A2 substrate tizanidine

Objective We studied the effects of gender and smoking on the pharmacokinetics and effects of the cytochrome P450 (CYP) 1A2 substrate tizanidine. Methods Seventy-one healthy young volunteers (male and female nonsmokers, male smokers) ingested 4 mg tizanidine. Plasma concentrations and pharmacodynamics of tizanidine were measured, and a caffeine test was performed. Results Among nonsmokers, the peak concentration (C_max) and area under concentration-time curve from 0 to infinity [AUC(0-∞)] of tizanidine did not differ significantly between females and males. However, the half-life (t_1/2) was 9% shorter in female nonsmokers than in male nonsmokers (P < 0.05). In male smokers, the t_1/2 was 10% shorter and the weight-adjusted AUC(0-∞) 33% smaller than in male nonsmokers (P < 0.05). The caffeine/paraxanthine ratio was 35–40% smaller (P = 0.001) in male smokers than in nonsmoking males or females, but did not differ between males and females. Tizanidine lowered blood pressure and caused drowsiness significantly (P < 0.05) more in females than in either male groups. The effects on blood pressure were smallest in male smokers (P < 0.05). Conclusions Gender by itself seems to have no clinically significant effect on the pharmacokinetics of tizanidine, whereas smoking reduces plasma concentrations and effects of tizanidine. Any possible effect of gender and smoking is largely outweighed by individual variability in CYP1A2 activity due to genetic and environmental factors and in body weight. Careful dosing of tizanidine is warranted in small females, whereas male smokers can require higher than average doses. This study was supported by grants from the Helsinki University Central Hospital Research Fund, the National Technology Agency, and the Sigrid Jusélius Foundation, Finland.     

Exposure to dioxin-like pollutants via different food commodities in Swedish children and young adults

The dietary intake of polychlorinated dibenzo-p-dioxins (PCDDs), dibenzofurans (PCDFs) and biphenyls (PCBs) in terms of toxic equivalents (TEQs) was investigated in Swedish children and young adults. Exposure was estimated from concentration data of six groups of individual food commodities (meat, fish, dairy products, egg, edible fats and other foodstuff) combined with food intake data from a 7-day record book obtained from 670 individuals aged 1–24 years. The results showed that Swedish boys and girls, up to the age of ten, had a median TEQ intake that exceeded the tolerable daily intake (TDI) of 2 pg TEQ/kg body weight. Children exceeding the TDI varied from almost all individuals among the youngest children to about 20% among young men and women. Dairy and fish products were the main sources of exposure for the average child, accounting for 59% of the total TEQ intake. The individuals most highly exposed were, on the other hand, characterized by a high consumption of fish. Since children constitute a vulnerable group, results obtained from the present study show that it is essential to perform age specific dietary intake assessments of pollutants and more carefully consider sensitive and/or highly exposed groups in the population in the risk management processes.     

Mediterranean Diet Adherence and Subjective Well-Being in a Sample of Portuguese Adults

The Mediterranean diet (MD) and other lifestyle characteristics have been associated with well-being, a broad multiparameter concept that includes individual’s subjective assessment of their own well-being (SWB). Some studies have suggested that diet influences SWB, thus, this work aimed to add novel information on the association of MD and SWB in a sample of Portuguese adults. Data on sociodemographic, economic, lifestyle, diet, and SWB were collected through a self-filled online questionnaire. MD adherence was assessed by the Mediterranean Diet Adherence Screener (MEDAS) score. Results showed a moderate adherence to the MD in 490 Portuguese adults (mean MEDAS of 7.4 ± 2.1). A higher MD adherence was found to be significantly positively associated with women, employed individuals, a higher number of meals per day, and those with frequent contact with nature (p-value < 0.0025, using Bonferroni adjustment). As a novelty, this study divided the participants into low SWB, medium SWB, and medium to high SWB profiles (3.9 ± 1.0; 6.2 ± 1.0; 8.2 ± 1.3, respectively; p-value < 0.05), which reported significantly increasing MEDAS scores (6.5 ± 2.1; 7.3 ± 2.1; 7.8 ± 1.9; respectively, p-value < 0.05).