Blood lead levels and growth status among African-American and Hispanic children in Dallas, Texas--1980 and 2002: Dallas Lead Project II.

OBJECTIVE: The purpose of this investigation is to analyze childhood blood lead levels and growth status (ages 2-12) in Dallas, Texas lead smelter communities in the 1980s and 2002, where smelters operated from 1936 to 1990. METHODS AND MATERIALS: A sample of convenience study design was used in two cohorts (n=360): 1980-1989 (n=191) and 2002 (n=169). Multivariate analysis of variance and covariance and tandem multiple regressions were used to evaluate the association between stature and blood lead level in two time periods. RESULTS: In 2002 average child blood lead level (1.6 microg/dL+/-0.2 SE) was significantly (p<0.001) lower compared to the 1980 cohort mean level (23.6 microg/dL+/-1.3 SE). Average height and weight in 2002 were 4.5 cm and 4.0 kg greater, respectively, than in 1980. Lowered blood lead level was associated with 3.9 cm, 3.5 kg and 1.1 units greater height, weight and body mass index (BMI), respectively. Cohort effect was associated with greater height (0.6 cm), weight (0.5 kg) and BMI (0.1). CONCLUSION: This investigation reports on child growth in a community before and after the transition from high to low blood lead levels over several decades. Using child growth as a proxy, health status of Dallas's lead smelter communities increased markedly over the past two decades, primarily because of lower blood lead levels, while the poverty rate was only marginally lower.

The quest for quality: perspectives from the safety net.

The American healthcare system is in need of fundamental change. With more than a decade of annual forums on quality improvement in healthcare and alarming statistics ranking medical errors among the top 10 causes of death in the United States, hospitals and health systems across the country are responding with a coordinated approach to quality improvement. Parkland Health & Hospital System believes the ideal public hospital system requires three critical components to achieve the Institute of Medicine's quality aims: (I) an emphasis on quality that is embraced by senior leadership, (2) careful measurement selection, and (3) the development of a robust infrastructure for outcomes research. This article describes Parkland's approach to each component and takes a look at selected processes and outcomes.

The role of U.S. public hospitals in urban health.

Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.

Clinical audit. Watching the detectives.

An audit of a trust's audit department, first established eight years ago, showed that most managers and clinicians viewed it positively. But it was not seen as capable, on its own, of producing changes in practice. Some departments were unsure about the services of the audit department. A standard form for audit reports is to be adopted in the trust. The evaluation will be repeated in a year's time.

Dietary caffeine, fluid intake and urinary incontinence in older rural women.

Forty-one women completed the first phase (self-monitoring) of the Behavioral Management for Continence (BMC) intervention, while working with a nurse during home visits to reduce involuntary urine loss as part of the parent study involving older, rural women living at home. A decrease in dietary caffeine intake and an increase in fluid intake were most frequently recommended. The relationship between a decrease in the amount of dietary caffeine consumed and fewer daytime episodes of involuntary urine loss approached significance -P = 0.0744- whereas an increase in the average amount of fluid intake was significantly related to an increase in the average volume of urine voided -P = 0.0479- and not to involuntary urine loss.

Toward a new urban health model: moving beyond the safety net to save the safety net--resetting priorities for healthy communities.

Parkland Health and Hospital System has been successful by every measure of comparison among its peer institutions, yet it recognizes the imperative of adapting to changes in the regulatory, legislative, and market environments. Given its mandate and a desire to preserve its multiple missions and its partnerships with a highly rated medical school, the playing field for achieving robust survival is very uneven. This article describes the evolution of one of the best "sick care systems" in the United States into an integrated, excellent health care system for the 21st century. The problems faced by the safety net in many urban areas of this country are similar. Many problems are structural in nature and will, therefore, require structural solutions at the local, state, and national levels. Parkland will continue and will be needed for many years as the tertiary and quaternary center of a comprehensive service network made up also of a series of outreach Community Oriented Primary Care clinics and special populations projects. In addition, we hope to help create a community-oriented managed-care plan that encompasses the desire to work with both denominator and numerator populations in a real partnership with many other stake-holders.

Bone marrow necrosis at transformation of chronic granulocytic leukaemia treated with interferon.

A patient with chronic myeloid leukaemia was treated with interferon without using conventional cytotoxic agents. Bone marrow necrosis developed at the onset of blast transformation. It is suggested that cytotoxic drugs should be given before treatment with interferon for chronic myeloid leukaemia. Cytotoxic drugs may also be needed to prevent rapid bone marrow growth once interferon has been withdrawn.

The decade for natural disaster reduction: the role of health care workers.

Disasters are occurring more frequently these days. Pickens, a Geneva-based journalist, examines how the World Health Organization suggests to cope with disasters.

Actinobacillus actinomycetemcomitans endocarditis in hypertrophic obstructive cardiomyopathy.

We report a case of bacterial endocarditis due to Actinobacillus actinomycetemcomitans in a man with hypertrophic obstructive cardiomyopathy complicated by a mycotic aneurysm and thrombosis of the right common iliac artery. The patient was successfully treated with a combination of ampicillin and gentamicin, but was left with residual mitral incompetence.

Case oriented group discussions for family physicians.

Curriculum in family medicine and primary care includes various areas of concern for educators in the behavioral sciences. Most of this concerns the physician-patient relationship as the focus for teaching and learning. This paper outlines the work of a longitudinal, case oriented group of family physicians as it reflects the correlation between the actualities of practice and the curriculum in behavioral science for family practice residents. Also discussed is the issue of potential "typologies" as elaborated in the family physicians' reasons for case presentations. Such groups assist faculty and practitioners in their own awareness of educational and patient care issues in the physician-patient relationship as well as serve as a foundation for building a relevant behavioral science curriculum for residents and students.

Fatality after hepatic angiography in Zieve's syndrome.

A patient with Zieve's syndrome is described. Following hepatic angiography, the patient became shocked and eventually died. The hazards of hepatic angiography are discussed and its use in ill patients questioned.

Infectious mononucleosis in the elderly.

Infectious mononucleosis (IM) was diagnosed in four patients over the age of 50 years. Their age, absence of splenomegaly, lack of significant lymphadenopathy in three and an atypical presentation in one all contributed to a delay in the diagnosis. In two patients, in whom complications occurred, the Paul-Bunnell test was repeatedly negative. Confirmation of the diagnosis was made by the measurement of the Epstein-Barr virus IgM using differential sucrose gradient centrifugation. Because the presentation and clinical features of IM can be misleading in the elderly, we believe that a significant number of cases may go unrecognized.

The effects of pre-admission antibiotics on the bacteriological diagnosis of pyogenic meningitis.

To assess the effects of pre-admission antibiotics on the accuracy of bacterial diagnosis in pyogenic meningitis, the case records of 154 patients admitted to an infectious diseases unit during a 10-year period (1966-1975) were reviewed. The causative organism was identified in 140 patients (91%). Although 63 patients had received antibiotics before admission, a bacteriological diagnosis was still possible in 57 of these (90%).

Morbidity and mortality in salmonella food poisoning. A review of 47 in-patient cases.

Forty-seven new patients with salmonella food poisoning were admitted to the Infectious Diseases Unit at the City Hospital, Edinburgh, during 1975. Although all the patients had diarrhoea at some stage of their illness, the wide variety of presenting symptoms caused some diagnostic difficulties prior to the isolation of the organism. A probable predisposing factor to serious disease was recognised in 15 patients. Twenty patients (42.5%) were seriously ill and 4 patients (8.5%) died. This series stresses the potential severity of this common disease.