Improving delivery of preventive health care with the comprehensive annotated reminder tool (CART).

OBJECTIVES: We assessed the effect of the Comprehensive Annotated Reminder Tool (CART) on physician adherence to preventive services recommendations. STUDY DESIGN: Using a randomized pretest/posttest control group design, we assigned physicians to the CART group or the control group, followed up prospectively, and evaluated for appropriate adherence to guidelines. The 3 age-specific versions of the CART annotated history and physical examination form contained up to 49 preventive services recommendations. POPULATION: All resident physicians in a large family practice residency program were studied over the course of 1 academic year. OUTCOMES MEASURED: We performed blinded chart reviews to assess the appropriateness of preventive services ordered by the physicians before the introduction of the CART, during its use, and after its removal. A multiple-choice test completed before and after the use of the CART forms assessed knowledge. RESULTS: When the CART was used, the appropriateness of physician preventive behavior increased by 21% overall. The appropriateness of history, physical examination, and laboratory interventions increased by 33%. When the CART was removed, physician behavior returned to baseline (P < or = .0025 for 16 of 20 interventions). No significant differences were observed in the control group over time. Knowledge increased over the study period for all physicians (P < or = .005) but did not differ significantly between the treatment and control groups (P = .608). CONCLUSIONS: Use of the CART significantly improved physician performance in the appropriate delivery of preventive care.

Role of peridomestic birds in the transmission of St. Louis encephalitis virus in southern California.

In response to the 1984 St. Louis encephalitis (SLE) epidemic in the Los Angeles Basin of southern California (USA), an investigative program was initiated to evaluate the interactive components of the SLE virus transmission cycle. From 1987 through 1996 (10 yr), 52,589 birds were bled and their sera tested for SLE and western equine encephalomyelitis (WEE) virus antibodies by the hemagglutination inhibition (HAI) test. Eighty-three percent of the birds tested were house finches (Carpodacus mexicanus) (48.7%) and house sparrows (Passer domesticus) (34.6%); 1.1% of these birds were positive for SLE antibodies. Prevalence of WEE antibodies was negligible. The analysis of 5,481 sera from rock doves (Columbia livia) yielded 3.6% SLE positives and 0.4% WEE positives. Collection sites were maintained as study sites when identified as positive bird, mosquito, and SLE virus activity localities; others were abandoned. Serial serum samples from 7,749 banded house sparrows and 9,428 banded house finches from these selected sites demonstrated year-round SLE virus transmission. One location exhibited significant numbers of house finches undergoing annual SLE seroconversion and a number of seroconversion-reversion-reconversion sequences suggesting either viral reinfection from mosquitoes or recrudescence by latent virus. A proportion of both bird species also lived for longer than 1 yr, thus, increasing the possibility of virus carry-over from autumn to spring. Assessment of concurrently collected mosquitoes indicated no correlative association between mosquito populations and SLE seroconversion and reconversion. European house sparrows introduced in the 1800's may have provided a supplemental link to the existing SLE virus enzootic cycle involving endemic house finches. Meteorological factors are reviewed as possible important correlates of SLE epidemics. The house finch/house sparrow serosurveillance system is also evaluated for use as an "Early Warning" indicator of SLE virus activity.

Arenavirus antibody in rodents indigenous to coastal southern California.

The purpose of this study was to extend our knowledge on the geographic and natural rodent host ranges of New World arenaviruses in California. Sera from 1,094 sigmodontine and 112 murine rodents were tested for antibody against Whitewater Arroyo and Amapari viruses. Antibody was found in 55 (4.6%) of the 1,206 rodents: 4 from northwestern San Diego County, 3 from Los Angeles County, and 48 from Orange County. The antibody-positive rodents included 8 (7.8%) of 103 Neotoma fuscipes, 1 (0.6%) of 180 Neotoma lepida, 1 (3.1%) of 32 Peromyscus boylii, 8 (11.0%) of 73 Peromyscus californicus, 1 (1.2%) of 85 Peromyscus eremicus, 30 (8.5%) of 353 Peromyscus maniculatus, and 6 (2.2%) of 268 Reithrodontomys megalotis. This study provides the first evidence that New World arenaviruses occur in Los Angeles and Orange counties and northwestern San Diego County, and the first evidence that Peromyscus and Reithrodontomys species are naturally infected with New World arenaviruses.

Hantavirus (Bunyaviridae) infections in rodents from Orange and San Diego counties, California.

During a screening program to determine the extent of hantavirus activity in Orange and San Diego Counties, California, serum samples from 2,365 rodents representing nine genera and 15 species were tested for hantavirus antibodies. A reverse transcription-polymerase chain reaction on selected seropositive rodents was used to identify the specific hantavirus. Rodents positive for Sin Nombre virus (SNV) antibodies by Western blot included 86 (9.1%) of 948 deer mice (Peromyscus maniculatus), four (1.5%) of 275 California mice (Peromyscus californicus), one (0.5%) of 196 cactus mice (Peromyscus eremicus), 51 (12.2%) of 417 harvest mice (Reithrodontomys megalotis), and five (12.5%) of 40 California voles (Microtus californicus). All other specimens tested were negative for hantavirus antibodies. There was a correlation between age and sex of the reservoir host and prevalence of SNV antibody, especially among male deer mice and harvest mice. Few seasonal trends in antibody prevalence were observed and continued maintenance of SNV and El Moro Canyon virus was found at several foci over a 4-5-year period. Isla Vista virus was also found in voles and represents the first recorded in Orange County. Microhabitat selection on the part of these rodents based on plant density, plant height, and availability of food plants may explain, to some extent, all of the hantavirus-positive foci throughout the study area over a broad geographic range and the lack of antibody-positive rodents in dense chaparral, woodland, and riparian areas. The majority of rodents positive for SNV was identified from localities along coastal bluffs and the foothills of the Santa Ana Mountains, where trap success was high and P. maniculatus represented 43% of all rodents collected. Several residential, commercial, and industrial sites exist in these areas and the potential health risk should not be overlooked. This study represents an in-depth analysis of the prevalence, host distribution, and characteristics of rodent populations infected by three hantaviruses within a small, well-defined, geographic area.

Carnitine as an essential nutrient.

Carnitine performs a critically important role in energy metabolism and is synthesized in the healthy adult predominantly in the liver and kidney. The typical well balanced American diet contains significant amounts of carnitine as well as the essential amino acids and micronutrients needed for carnitine biosynthesis. Thus carnitine is an infrequent problem in the healthy, well nourished adult population in the United States. However, carnitine can be a conditionally essential nutrient for several different types of individuals. Preterm infants require carnitine for life-sustaining metabolic processes but have a carnitine biosynthetic capability that is not fully developed. There is an increasing number of documented problems with carnitine metabolism in preterm infants not receiving an exogenous source of carnitine indicating that endogenous biosynthesis of carnitine is not adequate to meet the infant's need. Children with different forms of organic aciduria appear to have a greatly increased need for carnitine to function in the excretion of the accumulating organic acids. This need exceeds their dietary carnitine intake and carnitine biosynthetic capability. Renal patients treated with chronic hemodialysis appear to lose carnitine via the hemodialysis treatment, and this loss cannot be repleted simply by endogenous biosynthesis and dietary intake. Treatment with drugs such as valproic acid and metabolic stresses such as trauma, sepsis, organ failure, etc, can also result in a requirement for exogenous carnitine. Accurate assessment of the carnitine status of patients at risk for carnitine deficiency is fundamental to the identification of those patients who require carnitine as the result of altered metabolism.

Carnitine concentration of red blood cells.

The presence of significant concentrations of carnitine in red blood cells is documented using an assay procedure that is described in detail. Red blood cells can be prepared for assay by simple techniques and stored frozen. The reproducibility of the assay procedure is within acceptable limits. Usefulness of the procedure in an experimental setting has been documented with an investigation of both plasma and red blood cell carnitine concentrations of rats of different ages. Earlier studies have demonstrated that plasma carnitine concentrations are two-fold higher in adult male rats than in adult female rats. In agreement with that data, the adult male rat has a red blood cell carnitine concentration which is two-fold higher than that of adult female rats.