RESUMEN
REASONS FOR PERFORMING THE STUDY: A technique for minimally invasive repair of slab fractures of the third tarsal bone has not previously been reported. Results of third tarsal bone slab fracture repair in Thoroughbred racehorses are lacking. OBJECTIVES: To report the outcomes of repair of uniplanar frontal slab factures of the third tarsal bone using a single 3.5 mm cortex screw in lag fashion. STUDY DESIGN: Retrospective case series. METHODS: Case records of horses that had undergone this procedure were reviewed. RESULTS: Seventeen horses underwent surgery. Eighteen percent of cases had wedge shaped third tarsal bones. A point midway between the long and lateral digital extensor tendons and centrodistal and tarsometatarsal joints created a suitable entry site for implants. The fracture location, configuration and curvature of the third tarsal bone and associated joints requires a dorsolateral proximal-plantaromedial distal trajectory for the screw, which was determined by preplaced needles. There were no complications and fractures healed in all cases at 4-6 months post surgery. Seventy-nine percent of horses returned to racing and, at the time of reporting, 3 are in post operative rehabilitation programmes. CONCLUSION: The technique reported provides a safe, appropriate and repeatable means of repairing slab fractures of the third tarsal bone. Surgical repair is a viable alternative to conservative management.
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Tornillos Óseos/veterinaria , Fijación Interna de Fracturas/veterinaria , Fracturas Óseas/cirugía , Enfermedades de los Caballos/cirugía , Tarso Animal/patología , Animales , Femenino , Fijación Interna de Fracturas/instrumentación , Fijación Interna de Fracturas/métodos , Fracturas Óseas/patología , Caballos , Masculino , Estudios Retrospectivos , Tarso Animal/cirugíaRESUMEN
CASE DESCRIPTION: An 11-year-old male breeding alpaca was evaluated for a 2-day history of lowered head carriage and lethargy. CLINICAL FINDINGS: On initial examination, the alpaca had signs of lethargy and lowered carriage of the head and neck, but no specific neurologic deficits. Medical management improved the clinical signs, but 8 months later, the alpaca developed acute, progressive general proprioceptive ataxia affecting all 4 limbs and was referred for further evaluation and treatment. Magnetic resonance imaging and CT identified disruption of the normal osseous architecture of C7 and T1. Medical management was attempted, but because of a lack of improvement, the patient underwent surgery 14 months after initial examination. TREATMENT AND OUTCOME: A dorsal laminectomy of C7 and T1 via a dorsal midline approach was performed, and the spinous processes of both vertebrae were removed prior to removal of the overlying lamina. Free dorsal expansion of the spinal cord was ensured by resection of the ligamentum flavum. Six months after surgery, the alpaca had returned to successful breeding with 7 hembra bred in the first year after surgery, producing 6 crias, and 4 crias in the second year. The patient was eventually euthanized 28 months after surgery because of neurologic deterioration but was still ambulatory at that time. CONCLUSIONS AND CLINICAL RELEVANCE: A good outcome with adequate alleviation of clinical signs and breeding soundness for > 2 years following dorsal laminectomy was achieved in this camelid patient. The surgical approach was similar to that in other species and was associated with mild postoperative morbidity. Veterinarians treating camelids should be aware of the initial clinical signs and treatment options for cervical vertebral stenotic myelopathy. In acute cases, the signs of reduced cervical mobility and pain on manipulation should prompt investigation including appropriate diagnostic imaging. Timely surgical intervention should be considered in patients that respond poorly to medical treatment to avoid irreversible spinal cord injury and optimize outcome.
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Camélidos del Nuevo Mundo , Vértebras Cervicales/patología , Enfermedades de la Médula Espinal/veterinaria , Estenosis Espinal/veterinaria , Animales , Ataxia/etiología , Ataxia/cirugía , Ataxia/veterinaria , Vértebras Cervicales/cirugía , Laminectomía/veterinaria , Masculino , Postura , Enfermedades de la Médula Espinal/cirugía , Estenosis Espinal/cirugíaRESUMEN
INTRODUCTION: Accurate description of the calcaneal insertions of the superficial digital flexor tendon (SDFT) is lacking and inconsistent. The aim of this study was to undertake morphologic and morphometic evaluations of these structures to assist in elucidating their functional and pathogenic roles in displacement of the SDFT from the calcaneal tuber. METHOD: Dissections were performed on 10 normal cadaveric hindlimbs. The anatomy was photographed to allow measurements at repeatable locations and differences in SDFT dimensions at the various locations were compared using a paired student t-test. RESULTS: This study demonstrated that the calcaneal insertions of the SDFT are independent from the overlying tarsal insertions of the biceps femoris and semitendinosus, which blend into the plantar surface of the fibrocartilaginous cap (FCC) of the SDFT before inserting dorsal to the insertion of the SDFT on the calcaneal tuber. The lateral insertion of the SDFT is larger in cross-sectional area (median: 219 mm²) at its origin from the FCC than its medial counterpart (median: 159 mm², p = 0.004) and has a more complex fibre alignment. The lateral site of attachment of the SDFT on the calcaneal tuber is dorsolateral to the insertion of the gastrocnemius tendon and is larger (median: 525 mm²) than the medial insertion (median: 428 mm², p = 0.036), which inserts distal to the insertion of the gastrocnemius tendon. CONCLUSION: The features identified in this study suggest that the calcaneal insertions of the SDFT are complex and their morphological and morphometric differences are likely to contribute to clinical lesions identified at this site.
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Miembro Posterior/anatomía & histología , Caballos/anatomía & histología , Tendones/anatomía & histología , Animales , CadáverRESUMEN
BACKGROUND: Reproducible and accurate recognition of presence and severity of ataxia in horses with neurologic disease is important when establishing a diagnosis, assessing response to treatment, and making recommendations that might influence rider safety or a decision for euthanasia. OBJECTIVES: To determine the reproducibility and validity of the gait assessment component in the neurologic examination of horses. ANIMALS: Twenty-five horses referred to the Royal Veterinary College Equine Referral Hospital for neurological assessment (n = 15), purchased (without a history of gait abnormalities) for an unrelated study (n = 5), or donated because of perceived ataxia (n = 5). METHODS: Utilizing a prospective study design; a group of board-certified medicine (n = 2) and surgery (n = 2) clinicians and residents (n = 2) assessed components of the equine neurologic examination (live and video recorded) and assigned individual and overall neurologic gait deficit grades (0-4). Inter-rater agreement and assessment-reassessment reliability were quantified using intraclass correlation coefficients (ICC). RESULTS: The ICCs of the selected components of the neurologic examination ranged from 0 to 0.69. "Backing up" and "recognition of mistakes over obstacle" were the only components with an ICC > 0.6. Assessment-reassessment agreement was poor to fair. The agreement on gait grading was good overall (ICC = 0.74), but poor for grades ≤ 1 (ICC = 0.08) and fair for ataxia grades ≥ 2 (ICC = 0.43). Clinicians with prior knowledge of a possible gait abnormality were more likely to assign a grade higher than the median grade. CONCLUSION AND CLINICAL IMPORTANCE: Clinicians should be aware of poor agreement even between skilled observers of equine gait abnormalities, especially when the clinical signs are subtle.
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Ataxia/veterinaria , Marcha , Enfermedades de los Caballos/diagnóstico , Enfermedades del Sistema Nervioso/veterinaria , Animales , Ataxia/diagnóstico , Femenino , Caballos , Masculino , Enfermedades del Sistema Nervioso/diagnóstico , Variaciones Dependientes del Observador , Examen Físico/métodos , Examen Físico/normas , Examen Físico/veterinaria , Reproducibilidad de los Resultados , Grabación en VideoRESUMEN
REASONS FOR PERFORMING STUDY: The sensitivity of ultrasonography for the diagnosis of manica flexoria (MF) tears within the digital flexor tendon sheath (DFTS) is lower than for diagnosis of marginal tears of the deep digital flexor tendon (DDFT). Additional diagnostic tools would assist in appropriate decision making for either conservative or surgical management. OBJECTIVES: To evaluate the improvement in lameness of horses with MF or DDFT tears following intrathecal analgesia and to assess the sensitivity and specificity of contrast radiography for the diagnosis of these tears. METHODS: The case records of horses presented to a referral clinic over a 7-year period that underwent intrathecal diagnostic analgesia, or intrathecal analgesia and contrast radiography, of the DFTS with subsequent tenoscopy were examined. RESULTS: Fifty-three limbs had intrathecal diagnostic analgesia performed and 23 contrast tenograms were assessed in horses undergoing DFTS tenoscopy. Horses with DDFT tears were significantly more likely to respond positively to intrathecal diagnostic analgesia than those with MF tears (P = 0.02). Using contrast radiography, tears of the MF were predicted with an overall sensitivity of 96% and specificity of 80%; marginal tears of the DDFT were predicted with an overall sensitivity of 57% and specificity of 84%. CONCLUSIONS: The results of intrathecal analgesia of the DFTS in combination with contrast radiography have a high sensitivity for predicting MF tears. The sensitivity of contrast radiography for predicting tears of the DDFT is lower but the specificity remains high. POTENTIAL RELEVANCE: Contrast radiography performed at the same time as intrathecal analgesia provides useful information regarding the presence of MF tears and DDFT tears, which can assist in the decision of whether to manage the lameness conservatively or with tenoscopic evaluation.
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Anestésicos Locales/farmacología , Diatrizoato de Meglumina/farmacología , Enfermedades de los Caballos/diagnóstico por imagen , Mepivacaína/farmacología , Traumatismos de los Tendones/veterinaria , Anestésicos Locales/administración & dosificación , Animales , Medios de Contraste/farmacología , Femenino , Enfermedades de los Caballos/diagnóstico , Caballos , Masculino , Mepivacaína/administración & dosificación , Radiografía , Traumatismos de los Tendones/diagnóstico , Traumatismos de los Tendones/diagnóstico por imagenRESUMEN
REASONS FOR PERFORMING THE STUDY: Intra-articular soft tissue injuries of the equine tarsocrural joint have been poorly defined. METHODS: All horses that underwent arthroscopic surgery of a tarsocrural joint over a 10 year period were identified. Those with primary intra-articular soft tissue injuries were selected for inclusion and the cases evaluated retrospectively. RESULTS: Two hundred and eighty-one horses underwent tarsocrural joint arthroscopy during the study period, 30 of which met the inclusion criteria (30 joints). A combination of soft tissue lesions was more common than injury to a single structure. Injuries involved the joint capsule (n = 25), collateral ligaments (n = 20), dorsal plica (n = 8) and open communication between the tarsocrural joint and extensor bundle (n = 7). Following arthroscopic surgery and rehabilitation, 81% of horses were able to return to their previous function. CONCLUSION: Intra-articular soft tissue injuries of the tarsocrural joint may be associated with localising clinical signs of inflammation. This series represented 11% of the total number of arthroscopic procedures undertaken on that joint in a single referral hospital. Arthroscopic surgery allows accurate definition of the injuries and facilitates lesion management. Case outcome following arthroscopic debridement and a subsequent period of rehabilitation is favourable. POTENTIAL RELEVANCE: In lame horses with clinical signs localised to the tarsocrural joint, disrupted intra-articular soft tissues should be considered in the list of differential diagnoses. Attending clinicians should consider arthroscopic evaluation in cases where primary intra-articular soft tissue injuries are suspected to be causative.
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Artroscopía/veterinaria , Artropatías/veterinaria , Tarso Animal/patología , Animales , Femenino , Artropatías/patología , Artropatías/cirugía , Masculino , Tarso Animal/cirugíaRESUMEN
OBJECTIVE: The American Academy of Pediatrics (AAP) recommends oral rehydration therapy (ORT) for management of uncomplicated childhood gastroenteritis with mild-moderate dehydration. However, ORT is widely underused relative to their recommendations. We compared ORT use by directors of Pediatric Emergency Medicine (PEM) fellowship training programs with AAP recommendations, and sought to identify their barriers to ORT. METHODS: Mail/fax survey of the directors of U.S. and Canadian PEM fellowship programs. The survey included 10 scenarios of mild or moderately dehydrated children with gastroenteritis, a personal innovativeness scale, self-assessment of ORT experience and knowledge, and open-ended questions regarding perceived barriers to ORT use. RESULTS: 60/67 (89.6%) PEM fellowship program directors responded. All reported experience with and knowledge about ORT. Only 10/58 (17.2%) believe ORT is usually better than intravenous (i.v.) rehydration in all 10 clinical scenarios, and only 4/58 (6.7%) usually use ORT in all 10 scenarios. 18/58 (31%) usually use ORT for all mildly but no moderately dehydrated children. ORT use did not correlate with personal innovativeness scores. Important barriers cited by respondents include additional time requirements for ORT relative to i.v. rehydration (76.7%) and expectation of i.v. rehydration by parents (41.7%) or primary care physicians (10%). CONCLUSIONS: Relative to AAP recommendations, PEM fellowship directors underuse ORT, especially for moderately dehydrated children. Physician innovativeness does not influence ORT use. Further study of effectiveness, length of stay, staff requirements, and ORT acceptance in the emergency department setting, especially in children with moderate dehydration, may influence ORT use.
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Actitud del Personal de Salud , Conducta de Elección , Deshidratación/terapia , Medicina de Emergencia/métodos , Tratamiento de Urgencia/métodos , Becas , Fluidoterapia/métodos , Conocimientos, Actitudes y Práctica en Salud , Infusiones Intravenosas/métodos , Pediatría/métodos , Ejecutivos Médicos/psicología , Pautas de la Práctica en Medicina , Canadá , Deshidratación/etiología , Medicina de Emergencia/educación , Medicina de Emergencia/estadística & datos numéricos , Tratamiento de Urgencia/estadística & datos numéricos , Fluidoterapia/estadística & datos numéricos , Gastroenteritis/complicaciones , Adhesión a Directriz/estadística & datos numéricos , Humanos , Infusiones Intravenosas/estadística & datos numéricos , Pediatría/educación , Pediatría/estadística & datos numéricos , Ejecutivos Médicos/educación , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/estadística & datos numéricos , Encuestas y Cuestionarios , Estados UnidosRESUMEN
We describe the epidemiology of human rabies postexposure prophylaxis (PEP) in four upstate New York counties during the 1st and 2nd year of a raccoon rabies epizootic. We obtained data from records of 1,173 persons whose rabies PEP was reported to local health departments in 1993 and 1994. Mean annual PEP incidence rates were highest in rural counties, in summer, and in patients 10 to 14 and 35 to 44 years of age. PEP given after bites was primarily associated with unvaccinated dogs and cats, but most (70%) was not attributable to bites. Although pet vaccination and stray animal control, which target direct exposure, remain the cornerstones of human rabies prevention, the risk for rabies by the nonbite route (e. g., raccoon saliva on pet dogs' and cats' fur) should also be considered.
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Sueros Inmunes/administración & dosificación , Vacunas Antirrábicas/administración & dosificación , Virus de la Rabia/inmunología , Rabia , Mapaches/virología , Adolescente , Adulto , Animales , Animales Domésticos , Animales Salvajes , Mordeduras y Picaduras/complicaciones , Gatos , Niño , Brotes de Enfermedades/veterinaria , Perros , Femenino , Humanos , Inmunización , Incidencia , Masculino , New York/epidemiología , Rabia/epidemiología , Rabia/prevención & control , Rabia/terapia , Rabia/transmisión , Rabia/veterinaria , Factores de Riesgo , ZoonosisRESUMEN
BACKGROUND: Monroe County (MC) NY was one of 9 original sites for the 1988-1992 Medicare Influenza Vaccine Demonstration, which led to Medicare coverage of annual influenza vaccination. The "McFlu" project involved collaboration among university, health department, and practice community. METHODS: Community-wide systems for promoting and/or documenting influenza vaccine delivery and for conducting laboratory-based influenza surveillance were established in MC and in neighboring Onondaga County (OC), which served as a comparison site without Medicare coverage of vaccination. Vaccination utilization and virologic surveillance data collected from physician practices, hospitals, and nursing homes were furnished to national demonstration evaluators. RESULTS: Influenza vaccination rates among persons > or = 65 years of age increased from 41% to 74% in MC compared to an increase from 46% to 57% in OC. The greatest increase occurred in physician offices utilizing an innovative vaccination promotion and tracking strategy. Community-wide influenza A/H3N2 and B outbreaks were documented in three successive demonstration years, affording investigators the opportunity to better define influenza impact and vaccine effectiveness among the Medicare population. CONCLUSION: The McFlu project exemplifies the potential for linking the academic and public health sectors to complement each others' strengths in planning, implementing and documenting a targeted program for improving community health. This model of medicine and public health collaboration should be applicable to attaining other well articulated goals for the health of the public.
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Programas de Inmunización/organización & administración , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Medicare/organización & administración , Anciano , Femenino , Humanos , Programas de Inmunización/economía , Masculino , Medicare/economía , New York , Estudios de Casos Organizacionales , Proyectos Piloto , Vigilancia de la Población , Estados UnidosRESUMEN
OBJECTIVE: To investigate the effect of performance-based financial incentives on the influenza immunization rate in primary care physicians' offices. DESIGN: Randomized controlled trial during the 1991 influenza immunization season. SETTING: Rochester, New York, and surrounding Monroe County during the Medicare Influenza Vaccine Demonstration Project. PARTICIPANTS: A total of 54 solo or group practices that had participated in the 1990 Medicare Demonstration Project. INTERVENTIONS: All physicians in participating practices agreed to enumerate their ambulatory patients aged 65 or older who had been seen during the 1990 or 1991 calendar years, and to track the immunization rate on a weekly basis using a specially designed poster from September 1991 to January 1, 1992. Additionally, physicians agreed to be randomized, by practice group, to the control group or to the incentive group, which could receive an additional $.80 per shot or $1.60 per shot if an immunization rate of 70% or 85%, respectively, was attained. MEASUREMENTS: The main outcome measures are the 1991 immunization rate and the improvement in immunization rate from the 1990 to 1991 influenza seasons for each group practice. RESULTS: For practices in the incentive group, the mean immunization rate was 68.6% (SD 16.6%) compared with 62.7% (SD 18.0%) in the control group practices (P = .22). The median practice-specific improvement in immunization rate was +10.3% in the incentive group compared with +3.5% in the control group (P = .03). CONCLUSIONS: Despite high background immunization rates, this modest financial incentive was responsible for approximately 7% increase in immunization rate among the ambulatory elderly.
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Medicina Familiar y Comunitaria/estadística & datos numéricos , Programas de Inmunización/estadística & datos numéricos , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Reembolso de Incentivo/estadística & datos numéricos , Factores de Edad , Anciano , Factores de Confusión Epidemiológicos , Femenino , Humanos , Programas de Inmunización/economía , Vacunas contra la Influenza/economía , Modelos Lineales , Masculino , Medicare/economía , Medicare/estadística & datos numéricos , New York , Atención Primaria de Salud/estadística & datos numéricos , Reembolso de Incentivo/economía , Estados UnidosRESUMEN
BACKGROUND: Excess hospitalization and death are well-known impacts of influenza on older people; however, little is known regarding the impact of influenza on functional status. We hypothesized that frail older people are at risk of functional decline as an outcome of influenza. OBJECTIVE: To measure the effect of acute influenza on the physical and mental status of older patients residing in nursing homes. METHODS: Our study was conducted in 6 nursing homes that participated in the Medicare Influenza Vaccine Demonstration and experienced laboratory-confirmed outbreaks of influenza in 1991 and 1992. A case-comparison design was used. One hundred sixteen of 131 residents who developed influenza-like illness and survived at least 4 months served as the case subjects; 127 of 132 residents without influenza-like illness who survived served as the comparison subjects. Measures of functional status 1 to 2 months before outbreak and 1 to 2 months and 3 to 4 months after outbreak were collected from medical records. Matched pairs analyses were conducted to ascertain changes in selected measures of functional status within each of the study groups. Wilcoxon signed rank tests for statistical significance were used. RESULTS: Among surviving case subjects and comparison subjects, 25% and 15.7%, respectively, experienced decline in at least 1 major function (P=.04). Case subjects experienced significant decline in independence in bathing, dressing, and mobility while comparison subjects experienced decline in mental status. CONCLUSIONS: Within the limitations of this study, influenza is observed to cause decline in major physical functions in more than 9% of survivors. Such disabling outcomes constitute an important new measure of impact of influenza on the frail elderly.
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Actividades Cotidianas , Anciano Frágil , Gripe Humana/fisiopatología , Anciano , Anciano de 80 o más Años , Femenino , Hogares para Ancianos , Humanos , Masculino , Persona de Mediana Edad , Casas de SaludRESUMEN
To assess medical attention focused on hypertension (HBP) in the elderly, this study examines trends in HBP prevalence, treatment, and control status in a defined population of persons > or = 65 years of age enrolled in a large HMO. Random samples of approximately 400 persons were drawn for the years 1967, 1974, 1981, and 1988. First recorded ambulatory pressures, available on over 90% of subjects in each period, were obtained from medical records. Prevalence of HBP (SBP > or = 160 and/or DBP > or = 95, and/or taking anti-HBP drugs) ranged between 44% to 53%. Proportion with HBP on treatment increased from 25% in 1967 to 60% in 1988 (P<.001); proportion on treatment and controlled (SBP < 160, DBP < 95) increased from 8% to 34% (P<.001). Mean population SBP declined from 155.2 in 1967 to 144.0 in 1988 (P<.001); mean DBP declined from 85.2 to 81.2 (P<.001). Proportion with isolated systolic hypertension (ISH) (SBP > or = 160, DBP < 90) remained unchanged at 12% to 14%. Use of diuretics and adrenergic antagonist agents declined while use of beta blockers and newer classes of anti-HBP drugs increased significantly among treated hypertensives in the 1980s. These findings parallel HBP trends in younger adults from National Health Survey data though we find evidence of a substantial gap in addressing the problem in the elderly, who constitute the population at greatest risk of cardiovascular complications of HBP.
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Hipertensión/epidemiología , Antagonistas Adrenérgicos beta/uso terapéutico , Adulto , Factores de Edad , Anciano , Antihipertensivos/uso terapéutico , Diástole , Diuréticos/uso terapéutico , Femenino , Sistemas Prepagos de Salud , Humanos , Hipertensión/prevención & control , Hipertensión/terapia , Masculino , Registros Médicos , Noroeste de Estados Unidos/epidemiología , Prevalencia , Caracteres Sexuales , Factores Sexuales , SístoleRESUMEN
PURPOSE: To determine the long term effects of ribavirin therapy in children hospitalized for respiratory syncytial virus (RSV) lower respiratory tract infection. METHODS: Fifty-four of 60 children in randomized trials of ribavirin therapy were enrolled in a prospective follow-up study. Subjects were examined annually and had age-appropriate pulmonary function tests; interim histories were obtained from families and personal physicians. RESULTS: Recurrent lower respiratory tract illness was reported at least once for 79% of the ribavirin and 73% of placebo group. In the first 5 years after RSV, 54% of the ribavirin group and 50% of the placebo group reported wheezing. There were no significant differences between the groups in annual rates, timing, or severity of recurrent lower respiratory tract illness. No significant differences in pulmonary function were detected by tests of oxygen saturation, peak expiratory flow and spirometry. CONCLUSIONS: Children in the ribavirin treatment group did not have exacerbated respiratory symptoms compared with those in the control group, and their pulmonary function measurements were equal to those of the placebo-treated group, suggesting no long term adverse effect or benefit of ribavirin therapy.
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Antivirales/uso terapéutico , Infecciones por Virus Sincitial Respiratorio/tratamiento farmacológico , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Ribavirina/uso terapéutico , Niño , Preescolar , Femenino , Estudios de Seguimiento , Crecimiento , Hospitalización , Humanos , Masculino , RecurrenciaRESUMEN
BACKGROUND: Acute respiratory illnesses (ARIs) are the leading cause of medical visits for community-dwelling patients of all ages, but virologic and clinical descriptions of these illnesses in older adults are infrequent. OBJECTIVES: To determine the feasibility of influenza surveillance in a population of community-dwelling elderly, to compare the patterns of influenza infection in elderly persons with that observed in young populations in which surveillance is usually conducted, and to describe the clinical presentation of influenza infection in elderly outpatients who seek medical attention for ARI. DESIGN: Prospective clinical and viral surveillance of ARIs among ambulatory patients during 3 consecutive winter seasons. SETTING: Nine internal medicine and 3 pediatric practices in Upstate New York in cooperation with the Medicare Influenza Vaccine Demonstration Project. PATIENTS: Elderly (n=808) and pediatric (n=2080) outpatients with ARI office visits. MEASUREMENTS: Frequency of influenza and other respiratory virus isolates and clinical profile of influenza among older adults and children with ARIs. RESULTS: Influenza virus was the viral agent recovered most often from specimens obtained from patients in both age groups with ARI symptoms, especially those with fever. Influenza accounted for 11% of ARIs in adults (87 isolates) and 20% in children (408 isolates). At the initial illness visit, influenza infection was equally common in elderly individuals with or without underlying cardiopulmonary conditions. Lower respiratory tract signs occurred in 13% of the adults and in 7% of the children with influenza documented by laboratory studies. Other respiratory viruses were recovered from specimens obtained from 20 adults and from 259 children. CONCLUSIONS: Viruses are important agents of ARIs in elderly outpatients. Children and older adults experience similar patterns of influenza infection and other epidemic respiratory pathogens, such as parainfluenza and respiratory syncytial viruses. Viral identification is feasible in older adults seen in physicians' offices and may contribute to improved measures of effects of influenza and other respiratory viruses on ARIs.
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Gripe Humana/diagnóstico , Tamizaje Masivo , Infecciones del Sistema Respiratorio/virología , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Atención Ambulatoria , Niño , Preescolar , Diagnóstico Diferencial , Estudios de Factibilidad , Femenino , Humanos , Lactante , Gripe Humana/epidemiología , Masculino , Orthomyxoviridae/aislamiento & purificación , Vigilancia de la Población , Estudios Prospectivos , Características de la Residencia , Infecciones del Sistema Respiratorio/epidemiología , Estaciones del AñoRESUMEN
CONTEXT: Vaccines are underused in the United States, resulting in needless morbidity. Many experts have concluded that clinician education is critical to increasing the nation's vaccination rates. OBJECTIVE: To develop and evaluate case-based curricular materials on immunizations that promote preventive medicine skills. DESIGN: Before-and-after trial of an educational intervention. SETTING AND PARTICIPANTS: Medical schools and primary care residency programs from 20 institutions across the United States participated in the Teaching Immunization for Medical Education (TIME) project. INTERVENTION: A multidisciplinary team developed learning objectives, abstracted clinical cases, and created case-based modules that use contextual learning and small-group interaction to solve clinical and public health problems. The case-based methods are multistation clinical teaching scenarios (MCTS) and problem-based learning (PBL). MAIN OUTCOME MEASURES: Knowledge gained by learners from pretest to posttest and the overall ratings of the sessions by learners and facilitators based on evaluation questionnaires. RESULTS: Pretest and posttest results were obtained on a total of 1122 learners for all modules combined. For the MCTS method, mean scores increased from the 10-item pretest to the posttest by 3.1 items for measles, 3.8 for influenza, 1.8 for hepatitis B, 3.9 for pertussis, 1.9 for adult vaccination, 1.9 for childhood vaccination, and 2.6 for Haemophilus influenzae type b (P<.01 for each). For the PBL method, mean scores increased by 3.4 items for measles, 3.3 for influenza, 2.6 for hepatitis B, and 2.5 for pertussis (P<.01 for each). Most learners (MCTS, 98%; PBL, 89%) and most facilitators (MCTS, 97%; PBL, 100%) rated the sessions overall as very good or good. CONCLUSIONS: Use of TIME modules increases knowledge about immunizations, an essential step to improving vaccination practices of future clinicians. Given the realities of decreased faculty time and budgets, educators face major challenges in developing case-based curricula that prepare learners for the 21st century. Nationally tested libraries of cases such as the TIME modules address this dilemma.
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Curriculum , Medicina Familiar y Comunitaria/educación , Inmunización , Salud Pública/educación , Adulto , Niño , Humanos , Inmunización/estadística & datos numéricos , Internado y Residencia , Estudiantes de Medicina , Estados UnidosRESUMEN
BACKGROUND AND PURPOSE: Decline in stroke mortality in recent decades has been well documented in the United States and other countries. This study, based on a well-defined population with comprehensive medical records available for research purposes, seeks to explain decline in stroke mortality among older persons between 1967 and 1985. The study specifically explores the competing explanatory mechanisms of decreased incidence of stroke versus decreased case-fatality rate. METHODS: We conducted a retrospective analysis of three successive period cohorts (1967 through 1971, 1974 through 1978, and 1981 through 1985) of persons > or = 65 years of age enrolled in a large group model HMO in a metropolitan community. All new hospitalized and a sample of nonhospitalized strokes were ascertained, and samples of first-ever strokes were studied. Incidence, case-fatality rates, survival times, and comorbidities were compared across cohorts. RESULTS: There was no significant change in stroke incidence over time; however, 1-month case fatality declined dramatically from 33% in 1967 through 1971 to 18% in 1981 through 1985 (P < .01); median survival increased from 213 to 1092 days. Indices of reduced severity included declines in coma from 27% to 12% (P < .01) and in wheelchair- or bed-bound status from 40% to 30% (P = .067). Cases with and without CT scan in 1981 to 1985, when this procedure became widely available in the health plan, were similar in severity, thereby reducing the possibility of ascertainment bias. CONCLUSIONS: In this well-defined older population, stroke has become a less lethal and disabling though no less common disease. This finding fails to support the "compression of morbidity" hypothesis while supporting a model of delayed progression for stroke in this age group.
Asunto(s)
Trastornos Cerebrovasculares/epidemiología , Anciano , Anciano de 80 o más Años , California/epidemiología , Trastornos Cerebrovasculares/complicaciones , Trastornos Cerebrovasculares/mortalidad , Estudios de Cohortes , Comorbilidad , Femenino , Humanos , Incidencia , Masculino , Enfermedades del Sistema Nervioso/etiología , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
Respiratory syncytial virus (RSV) infections in the institutionalized elderly have been described; however, there is little information on the impact of RSV infection on community-dwelling elderly. The purpose of this study was to determine the relative numbers of hospitalizations associated with RSV infection and compare the clinical manifestations with influenza A infection. Between November and April during 1989-1992, persons > or = 65 years old hospitalized with acute cardiopulmonary conditions or influenza-like illnesses were evaluated. Evaluation included viral culture, RSV antigen detection, and serologic analysis; 159 (10%) of 1580 had RSV infection and 221 (11%) of 2091 had influenza A. RSV and influenza A cases occurred simultaneously throughout the 3 years. Clinical manifestations were similar; however, patients with RSV infection were more likely to receive therapy for bronchospasm. Death rates were 10% and 6% for RSV infection and influenza A, respectively. RSV infection is the cause of serious disease in community-dwelling older persons.
Asunto(s)
Hospitalización , Gripe Humana/epidemiología , Infecciones por Virus Sincitial Respiratorio/epidemiología , Anciano , Anciano de 80 o más Años , Antígenos Virales/análisis , Estudios de Cohortes , Femenino , Humanos , Gripe Humana/inmunología , Gripe Humana/mortalidad , Tiempo de Internación , Masculino , Infecciones por Virus Sincitial Respiratorio/inmunología , Infecciones por Virus Sincitial Respiratorio/mortalidad , Estaciones del Año , Resultado del TratamientoRESUMEN
We collected surveillance data as part of the Medicare Influenza Vaccine Demonstration to describe communitywide epidemiology of influenza, focusing on the elderly. Laboratory-based surveillance was established in medical practices, hospitals, and nursing homes in a two-county demonstration in upstate New York. Time course and intensity of epidemic influenza were compared between counties, between influenza A and B epidemics, and among several levels of surveillance involving elderly persons as well as children during the years 1989-1992. The counties experienced parallel epidemics during each of the three demonstration years. Influenza A/H3N2, predominant in 1989-1990 and 1991-1992, was equally intense among young and old, accounted for 11%-28% of acute cardiopulmonary hospitalizations of older persons, and caused focal outbreaks in 30%-40% of nursing homes in the respective epidemics. Influenza B, predominant in 1990-1991, showed modest impact among the elderly as compared with children. Influenza A/H1N1 occurred among children each year but was virtually absent among the elderly. Systematic surveillance during the "influenza season" consistently confirms widespread infection among older patients, both in the community and in institutions. However, much febrile respiratory illness in this age group during periods of epidemic influenza is culture-negative for influenza virus and thus may be caused by other respiratory pathogens.