Using a relative health indicator (RHI) metric to estimate health risk reductions in drinking water.

When a new drinking water regulation is being developed, the USEPA conducts a health risk reduction and cost analysis to, in part, estimate quantifiable and non-quantifiable cost and benefits of the various regulatory alternatives. Numerous methodologies are available for cumulative risk assessment ranging from primarily qualitative to primarily quantitative. This research developed a summary metric of relative cumulative health impacts resulting from drinking water, the relative health indicator (RHI). An intermediate level of quantification and modeling was chosen, one which retains the concept of an aggregated metric of public health impact and hence allows for comparisons to be made across "cups of water," but avoids the need for development and use of complex models that are beyond the existing state of the science. Using the USEPA Six-Year Review data and available national occurrence surveys of drinking water contaminants, the metric is used to test risk reduction as it pertains to the implementation of the arsenic and uranium maximum contaminant levels and quantify "meaningful" risk reduction. Uranium represented the threshold risk reduction against which national non-compliance risk reduction was compared for arsenic, nitrate, and radium. Arsenic non-compliance is most significant and efforts focused on bringing those non-compliant utilities into compliance with the 10 µg/L maximum contaminant level would meet the threshold for meaningful risk reduction.

What's next after 40 years of drinking water regulations?

The quality of drinking water in the United States has continued to improve over the past 40 years. The formation of the U.S. Environmental Protection Agency (USEPA) in 1971, the passage of the initial Safe Drinking Water Act (SDWA, PL 93-523) in 1974, and the passage of the 1996 SDWA Amendments (PL 104-208) represent significant progress in drinking water quality. While the widespread adoption of filtration and disinfection in the early 1900s virtually eliminated waterborne typhoid fever, some residual risks still remained 40 years ago. These national regulatory developments compelled USEPA and the drinking water community to address these remaining risks in drinking water and optimize risk reduction for the public.

Diagnostic utility of mammaglobin and GCDFP-15 in the identification of metastatic breast carcinoma in fluid specimens.

Morphologic differentiation of breast carcinoma from nonmammary malignancies in fluid specimens can be a diagnostic challenge. Immunocytochemistry is often employed in the differential diagnosis. In this study, we evaluated the expression of mammoglobin (MGB1) in body-cavity fluid specimens and compared its efficacy as a marker for metastatic breast carcinomas with that of gross cystic disease fluid protein-15 (GCDFP-15). Cell blocks from 40 fluid specimens were immunostained with monoclonal antibodies against MGB1 and GCDFP-15. They included 15 breast carcinomas and 25 nonmammary carcinomas (10 lungs, 10 ovaries, 3 gastrointestinal tracts, 1 kidney, and 1 urinary bladder). Positivity was defined as the presence of cytoplasmic staining in 10% or more carcinoma cells. Thirteen (87%) and seven (47%) breast carcinomas showed positive staining with MGB1 and GCDFP-15, respectively. Three (12%) nonmammary carcinomas (2 ovarian and 1 colonic) showed positive MGB1 staining; one (3%) nonmammary carcinoma demonstrated positive GCDFP-15 staining. The differences of MGB1 and GCDFP-15 staining between breast and nonmammary carcinomas were statistically significant (P < 0.05). Both MGB1 and GCDFP-15 are specific markers for metastatic breast carcinomas in cell block fluid specimens (88 vs. 96%). However, MGB1 is more sensitive than GCDFP-15 as a marker for metastatic breast carcinoma (87 vs. 46%).

Analytical specificity and sensitivity of a real-time polymerase chain reaction assay for identification of bovine mastitis pathogens.

Intramammary infection (IMI), also known as mastitis, is the most frequently occurring and economically the most important infectious disease in dairy cattle. This study provides a validation of the analytical specificity and sensitivity of a real-time PCR-based assay that identifies 11 major pathogen species or species groups responsible for IMI, and a gene coding for staphylococcal beta-lactamase production (penicillin resistance). Altogether, 643 culture isolates originating from clinical bovine mastitis, human, and companion animal samples were analyzed using the assay. The isolates represented 83 different species, groups, or families, and originated from 6 countries in Europe and North America. The analytical specificity and sensitivity of the assay was 100% in bacterial and beta-lactamase identification across all isolates originating from bovine mastitis (n = 454). When considering the entire culture collection (including also the isolates originating from human and companion animal samples), 4 Streptococcus pyogenes, 1 Streptococcus salivarius, and 1 Streptococcus sanguis strain of human origin were identified as Streptococcus uberis, and 3 Shigella spp. strains were identified as Escherichia coli, decreasing specificity to 99% in Strep. uberis and to 99.5% in E. coli. These false-positive results were confirmed by sequencing of the 16S rRNA gene. Specificity and sensitivity remained at 100% for all other bacterial targets across the entire culture collection. In conclusion, the real-time PCR assay shows excellent analytical accuracy and holds much promise for use in routine bovine IMI testing programs. This study provides the basis for evaluating the assay's diagnostic performance against the conventional bacterial culture method in clinical field trials using mastitis milk samples.

Clinical consequences of hyperglycemia during remission induction therapy for pediatric acute lymphoblastic leukemia.

Hyperglycemia adversely affects outcome in adult patients with acute lymphoblastic leukemia (ALL), but its impact on children with this disease is unknown. We evaluated the relationship between hyperglycemia during remission induction therapy and clinical outcomes among pediatric patients with ALL. We reviewed the records of patients enrolled on four consecutive ALL protocols (Total Therapy protocols XIIIA, XIIIB, XIV and XV) at St Jude Children's Research Hospital from 1991 to 2007 and identified those who experienced hyperglycemia (glucose >or=200 mg per 100 ml) during remission induction. Complete remission (CR) rates at the end of induction, event-free survival (EFS), overall survival (OS), cumulative incidence of relapse and occurrence of infections were compared between those who did and did not experience hyperglycemia. Of 871 patients analyzed, 141 (16%) experienced hyperglycemia during remission induction. Patients with hyperglycemia were significantly older than the other patients (P<0.0001). There was no significant difference in CR rate (P=0.92), EFS (P=0.80), OS (P=0.28), cumulative incidence of relapse (P=0.59) or in the probability or types of infection between patients who did and did not experience hyperglycemia. Pediatric patients with or without hyperglycemia during remission induction for ALL have similar clinical outcome. Occurrence of hyperglycemia does not warrant alteration of the antileukemic regimen.

Key attributes of health ministries in African American churches: an exploratory survey.

BACKGROUND: Church leaders are considered instrumental in the successful implementation of church-based health programs. However it is unknown which program attributes they perceive as important and which program attributes exist in their congregations. OBJECTIVE: To explore the perceived importance and existence of health ministry-related attributes in predominately African American churches. METHODS: Cross-sectional survey, with a convenience sample of 98 registered church leaders attending a conference on health and spirituality in Raleigh, NC. Attendees were asked to complete a brief survey assessing perceived importance (very important vs. somewhat or not important) and existence (yes vs. no) of 20, health ministry-related attributes in their churches. Percent perceived as very important, percent existence, and their differences were assessed for each attribute. RESULTS: Seventy-two (73.5%) of the attendees completed the survey. Attributes perceived as very important were: displaying health information in churches (73.6%); hosting health fairs for church members (73.2%); pastoral, church-based Internet access (70.8%); willingness to receive foundation funding for activities (66.7%); and incorporating health messages in Sunday bulletins (65.3%). For each of these program attributes, there was a gap between the proportion rating them "very important" and existence of the attribute in their own congregations (range diff in %: -8.3 to -22.2). LIMITATIONS: Lack of generalizability due to sample selection and homogeneity. CONCLUSIONS: Among leaders surveyed, despite perceived importance, attributes did not exist for all. Future studies should evaluate whether attributes considered important by church leadership parallel an increase in the development and maintenance of health program activities, and are associated with congregation health behaviors and health outcomes.

Hematologic responses in captive white-winged doves (Zenaida asiatica), induced by various radiotransmitter attachments.

White blood cell counts, heterophil-lymphocyte ratios, and leukocyte differentials of captive white-winged doves (Zenaida asiatica) from Texas equipped with different radiotransmitter attachment packages were monitored. Doves were segregated by gender and age by males, females, and hatching year; individuals housed in 30 large outdoor pens in groups of seven. Treatments consisted of controls, glue-on transmitters, body loop harnesses, surgically implanted intracoelomic transmitters, surgically implanted subcutaneous transmitters, intracoelomic surgery without implants, and subcutaneous surgery without implants. We used multivariate analysis of variance with pen as a blocking variable and gender nested and repeated measures analysis of variance to identify differences among any of the transmitter attachment techniques and the control for dependent variables. We found no difference in blood parameters between transmitter attachment technique versus a control.

Mild to moderate clinical mastitis: efficacy of intramammary amoxicillin, frequent milk-out, a combined intramammary amoxicillin, and frequent milk-out treatment versus no treatment.

Study objectives were to determine the efficacy of 4 methods (intramammary amoxicillin, frequent milk-out, a combined intramammary amoxicillin and frequent milk-out, and no treatment) of managing mild to moderate clinical mastitis in a university dairy herd. Clinical and microbiological cures, milk production, disease progression, and California Mastitis Tests scores were evaluated. Cows meeting the study criteria were assigned to one of four treatment options based on a systematic randomization scheme (blocked by stage of lactation). Treatments were initiated prior to knowledge of culture results. Cows were observed and evaluated on d 1 to 8, 15, 22, 29, and 36. Overall, treatments were not significantly different than controls. However, when efficacy was evaluated by pathogen group, differences were observed. Intramammary amoxicillin appeared to be the most efficacious treatment for environmental streptococci. Frequent milk-out appeared to be detrimental for environmental streptococci. Treatment method appeared to have little effect on Escherichia coli mastitis, as nearly all cases recovered within a short time frame. None of the treatments were satisfactory for cases of Klebsiella mastitis. When obtained in a timely manner, treatment selection for clinical mastitis should be based on culture results.

The effects of posteroventral pallidotomy on balance function in patients with Parkinson's disease.

Parkinson's disease is a chronic, progressive neurodegenerative disorder resulting from dopaminergic cell loss in the pars compacta of the substantia nigra. Conventional treatment of Parkinson's disease consists of pharmacological replacement of dopamine. A treatment alternative, posteroventral pallidotomy (PVP), has been used for medically intractable stages of the disease. The purpose of this study was to evaluate the effects of PVP on balance function, as measured by dynamic posturography, in patients with medically intractable Parkinson's disease. Five subjects were studied within 2 days prior to and within 6 months following PVP. Pretreatment abnormalities were found in vestibular, visual, and somatosensory processing in balance function. Posteroventral pallidotomy resulted in improvement in vestibular compensation of posture in some patients, which may be at least partially due to an improvement in latencies to respond to changes in stance. Dynamic posturography is an effective tool in the evaluation of balance and posture in patients with advanced Parkinson's disease.

Hearing improvement after middle fossa resection of vestibular schwannoma.

OBJECTIVE: The preoperative, intraoperative, and postoperative variables of patients experiencing hearing improvement after middle fossa resection of vestibular schwannomas were evaluated as potential prognostic indicators. STUDY DESIGN: Retrospective case review with new objective postoperative data collected on patients with documented hearing improvement. SETTING: California Ear Institute at Stanford and Stanford University Hospital, a tertiary referral center. PATIENTS: The patient group consisted of 30 consecutive patients undergoing middle fossa approach to vestibular schwannoma between October 24, 1994, and November 11, 1998. INTERVENTION: Hearing preservation surgery via the middle cranial fossa approach was performed on all patients. MAIN OUTCOME MEASURES: Pure-tone averages (PTAs) and speech discrimination scores (SDS) were used to document hearing preoperatively and postoperatively. Preoperative electrophysiologic studies of auditory brainstem response, electronystagmography, electrical neuronography, transient evoked otoacoustic emissions, and distortion product otoacoustic emissions were evaluated. Intraoperative continuous nerve action potential and auditory brainstem response tracings were reviewed. Postoperative auditory brainstem response and transient evoked otoacoustic emissions were obtained when possible on patients whose hearing improved. Statistical analysis was completed using Student's t test and chi-square test. RESULTS: Seventeen (57%) of 30 patients with tumors ranging from 2 to 31 mm maintained hearing postoperatively. Among patients with hearing preservation, 7 (41% or 23% of the overall group) exhibited hearing improvement (PTA 2 improved by > or =5 dB and/or SDS improved by > or =12%). Three of these 7 patients moved from nonfunctional (AAOHNS class C/D) to functional (AAOHNS class A/B) categories. All patients who enjoyed postoperative hearing improvement had preoperative absence or abnormality of ABRs. No patient with normal preoperative ABR experienced hearing improvement. Hearing improvement patients also had lower preoperative caloric function on electronystagmography compared with the entire group (p < 0.02) and were more likely to have superior vestibular nerve tumors. No differences were noted for electrical neurography and otoacoustic emissions. CONCLUSIONS: Middle fossa resection of vestibular schwannoma offers patients the possibility of hearing improvement after treatment. The chance of hearing improvement is significantly higher than with other forms of treatment such as radiation therapy or translabyrinthine surgery. Although preoperative ABR abnormality may be an indicator of poor prognosis for hearing preservation, those patients who enjoy hearing improvement come from the group of patients with abnormal preoperative ABRs. Other factors identified as associated with hearing improvement include poor SDS with more normal PTA 2, and significantly decreased electronystagmographic caloric function (as an indicator of superior vestibular nerve tumors). Hearing improvement to the functional range after surgical resection is possible in some patients previously thought to be poor candidates for hearing preservation attempts. Hearing improvement may continue for many months after surgery.

Prenatal diagnosis of 22q11.2 deletion when ultrasound examination reveals a heart defect.

PURPOSE: The incidence of 22q11.2 deletion syndrome is approximately 1 in 5,000 births, and accounts for 5-30% of all heart defects, making it one of the more common genetic conditions in the population. METHODS: We employed fluorescence in situ hybridization (FISH) to study the incidence of 22q11.2 deletions in fetuses with cardiac anomalies detected on ultrasound examination. RESULTS: Of 64 cases, 18 had visible chromosome anomalies. FISH testing for 22q11.2 deletion was performed on the remaining 46 cases, and five exhibited a 22q11.2 deletion. Three of the five had de novo deletions, one was maternally inherited, and one family declined testing. CONCLUSION: FISH analysis for 22q11.2 deletion should be performed on all fetuses with cardiac defects (excluding hypoplastic left heart and echogenic focus) and a normal G-banded karyotype.

Implementation of a clinical pathway in management of the postoperative vestibular schwannoma patient.

OBJECTIVE: The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibular schwannoma. The impact on duration of hospitalization and quality of care was evaluated. STUDY DESIGN: The study was a retrospective review of 59 consecutive patients undergoing surgical intervention for vestibular schwannoma between January 1995 and July 1999. METHODS: A new clinical pathway for management of postoperative vestibular schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995. All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period, data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of hospitalization and complications following surgical intervention. RESULTS: Fifty-nine patients underwent 35 middle fossa approaches and 24 translabyrinthine approaches to their tumors. The average patient age was 53 years; there were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperative complications were observed in 19% of patients, including eight (13%) cerebrospinal fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hematoma (1.6%), one postoperative fever (1.6%), and one dural tear with associated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days 1,5-7 and CSF leak complication rates of 7% to 15%.9,10 CONCLUSIONS: Implementation of a clinical pathway for management of the patient with postoperative vestibular schwannoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rates and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly important in a managed care-driven environment.

Complications of venous insufficiency after neurotologic-skull base surgery.

OBJECTIVE: To characterize the incidence and complications resulting from venous insufficiency after neurotologic-skull base surgery. STUDY DESIGN: Retrospective case review of >3,500 cases. SETTING: Tertiary referral center, inpatient surgery. PATIENTS: Six patients: four with complications related to chronic venous insufficiency and two with complications related to acute venous insufficiency. INTERVENTION(S): Medical (steroids, acetazolamide, hyperventilation, mannitol) and surgical (lumboperitoneal shunt, optic nerve decompression, embolectomy) interventions were undertaken. MAIN OUTCOME MEASURE(S): Chronic venous insufficiency: nonobstructive hydrocephalus manifested by headache, disequilibrium, and papilledema with resultant visual loss. Acute venous insufficiency: acute nonobstructive hydrocephalus resulting in mental status abnormalities in the postoperative period. CONCLUSIONS: (1) Incidence of 1.5 per 1,000 cases. (2) Acute and chronic forms with different pathogenesis. (3) Acute form presents postoperatively with change in consciousness and herniation, and may proceed to death. (4) Chronic form presents months or years postoperatively with headache, disequilibrium, and visual changes from papilledema. (5) Occurs almost solely in patients with preoperative abnormalities of the venous collecting system. (6) Causes mental status changes postoperatively.

Survival of Trichomonas gallinae in white-winged dove carcasses.

Survival of Trichomonas gallinae was examined in white-winged dove (Zenaida asiatica) carcasses to assess whether birds that have been dead up to 8 hr can be sampled reliably for this protozoan. Carcasses of 100 T. gallinae-positive white-winged doves were separated into four groups of 25 birds, representing 2, 4, 6, and 8 hr post mortem sampling intervals and placed into an environmental chamber maintained at 27 C and 75% relative humidity. Live T. gallinae were isolated in 96, 100, 100, and 92% of the carcasses at each of the respective post mortem intervals. The experiment was repeated with another 100 carcasses of T. gallinae-positive white-winged doves placed in the environmental chamber, this time maintained at 27 C and 40% relative humidity. Live T. gallinae occurred in 96, 100, 96, and 100% of the carcasses at each of the respective post mortem intervals. Across both trials, the overall ability to detect positive birds from sampling carcasses up to 8 hrs post mortem was 97%. An a posteriori experiment was conducted in which 23 and 18 carcasses from the second trial were maintained in the environmental chamber at 27 C and 40% relative humidity and resampled at 24 and 48 hr post mortem, respectively. Live trichomonads were isolated from 91 and 44% of the carcasses at 24 and 48 hr, respectively. Results suggest live T. gallinae can be obtained from dove carcasses reliably up to 8 hr and possibly up to 24 hr after host death. The ability for T. gallinae to survive within this time interval can aid wildlife personnel in monitoring this protozoan at hunter check stations or obtaining samples from recently killed birds.

Comparison of argon and CO2 laser stapedotomy in primary otosclerosis surgery.

PURPOSE: The primary use for the laser in otosclerosis surgery is to create a stapes footplate fenestration that obviates the need for mechanical footplate removal. Experimental studies that evaluate the potential safety of visible (argon and potassium-titanyl-phosphate [KTP]) and invisible (CO2) light laser systems in stapes surgery report conflicting results. The purpose of this study is to compare the clinical safety and efficacy of the CO2 and argon laser systems when used for primary laser stapedotomy. MATERIALS AND METHODS: A retrospective case review of 124 primary laser stapedotomies using either the argon (n = 59) or CO2 (n = 65) laser was performed. Data consisted of pre- and postoperative air and bone conduction audiometry, speech discrimination scores (SDS), intraoperative findings, and postoperative complications. Between group differences (argon v CO2) were sought using standard statistical methodology. RESULTS: The argon and CO2 laser groups were comparable with regards to age, sex, preoperative air-bone gap, and laterality. Mean preoperative air and bone conduction pure-tone average (PTA) and SDS were somewhat higher in the CO2 laser group (P < .05). Postoperatively, both groups showed similar results in mean change in air conduction PTA, air-bone gap, and SDS, as well as in the frequency of complications. There were no anacoustic ears in either group. CONCLUSIONS: The results suggest that the argon and CO2 laser systems are comparable with regards to safety and efficacy when used by experienced surgeons for stapedotomy.