Retrospective Evaluation of Horses Diagnosed with Neuroborreliosis on Postmortem Examination: 16 Cases (2004-2015)

BACKGROUND

Equine neuroborreliosis (NB), Lyme disease, is difficult to diagnose and has limited description in the literature.

OBJECTIVE

Provide a detailed description of clinical signs, diagnostic, and pathologic findings of horses with NB.

ANIMALS

Sixteen horses with histologically confirmed NB.

METHODS

Retrospective review of medical records at the University of Pennsylvania and via an ACVIM listserv query with inclusion criteria requiring possible exposure to Borrelia burgdorferi and histologic findings consistent with previous reports of NB without evidence of other disease.

RESULTS

Sixteen horses were identified, 12 of which had additional evidence of NB. Clinical signs were variable including muscle atrophy or weight loss (12), cranial nerve deficits (11), ataxia (10), changes in behavior (9), dysphagia (7), fasciculations (6), neck stiffness (6), episodic respiratory distress (5), uveitis (5), fever (2), joint effusion (2), and cardiac arrhythmias (1). Serologic analysis was positive for B. burgdorferi infection in 6/13 cases tested. CSF abnormalities were present in 8/13 cases tested, including xanthochromia (4/13), increased total protein (5/13; median: 91 mg/dL, range: 25-219 mg/dL), and a neutrophilic (6/13) or lymphocytic (2/13) pleocytosis (median: 25 nucleated cells/μL, range: 0-922 nucleated cells/μL). PCR on CSF for B. burgdorferi was negative in the 7 cases that were tested.

CONCLUSION AND CLINICAL IMPORTANCE

Diagnosis of equine NB is challenging due to variable clinical presentation and lack of sensitive and specific diagnostic tests. Negative serology and normal CSF analysis do not exclude the diagnosis of NB.

Acquired factor V inhibitor after exposure to topical human thrombin related to an otorhinolaryngological procedure

Acquired factor V (FV) inhibitors occur rarely and classically develop after exposure to bovine thrombin. The clinical presentation is variable, ranging from asymptomatic with incidental laboratory abnormalities to significant bleeding. With the development of human-derived thrombin agents, bovine thrombin is less frequently used. We report a case of an acquired FV inhibitor that developed in a patient after exposure to human thrombin used as a hemostatic agent during an otorhinolaryngology surgical procedure. Our review of the literature revealed only one prior reported case of FV inhibitor after exposure to human thrombin. Hematologists and surgeons should be aware of this rare, but potentially life-threatening, complication in the postprocedural setting.

Obesity and oral disease - a challenge for dentistry

The prevalence of overweight and obesity is rising in many developed and developing countries and, most worryingly, among children. Within the EU, Scotland has the highest prevalence, more than twice that of the Netherlands, and in England almost a quarter of children now enter primary school either overweight or obese, rising to one in three on leaving at age 11 years. Whilst most epidemiological data is based on body mass index, this is not a reliable indicator of individual adiposity and morbidity risk. The association between excess adiposity and type 2 diabetes is well recognised and the latter carries implications for oral disease and dental treatment. Current research has not established a clear association between excess adiposity and caries prevalence, however, there is evidence for a higher prevalence of chronic periodontal disease in obese populations. There is some evidence that this is not mediated solely by diabetes, but by secretion by adipose tissue of chemical mediators of inflammation, including cytokines and hormones, which could modify the response of the periodontal tissues to the oral environment. Dental professionals must become aware of this growing problem, of the demands that the rising obesity prevalence will place on dental care services and the need for bariatric dental facilities. Together, with service providers, dental professionals must prepare for the challenge ahead.

Toll-like receptor alterations in myelodysplastic syndrome

Recent studies have implicated the innate immunity system in the pathogenesis of myelodysplastic syndromes (MDS). Toll-like receptor (TLR) genes encode key innate immunity signal initiators. We recently identified multiple genes, known to be regulated by TLRs, to be overexpressed in MDS bone marrow (BM) CD34+ cells, and hypothesized that TLR signaling is abnormally activated in MDS. We analyzed a large cohort of MDS cases and identified TLR1, TLR2 and TLR6 to be significantly overexpressed in MDS BM CD34+ cells. Deep sequencing followed by Sanger resequencing of TLR1, TLR2, TLR4 and TLR6 genes uncovered a recurrent genetic variant, TLR2-F217S, in 11% of 149 patients. Functionally, TLR2-F217S results in enhanced activation of downstream signaling including NF-κB activity after TLR2 agonist treatment. In cultured primary BM CD34+ cells of normal donors, TLR2 agonists induced histone demethylase JMJD3 and interleukin-8 gene expression. Inhibition of TLR2 in BM CD34+ cells from patients with lower-risk MDS using short hairpin RNA resulted in increased erythroid colony formation. Finally, RNA expression levels of TLR2 and TLR6, as well as presence of TLR2-F217S, are associated with distinct prognosis and clinical characteristics. These findings indicate that TLR2-centered signaling is deregulated in MDS, and that its targeting may have potential therapeutic benefit in MDS.

Safety, efficacy and biological predictors of response to sequential azacitidine and lenalidomide for elderly patients with acute myeloid leukemia

Acute myeloid leukemia (AML) is a disease of the elderly. Poor outcomes with standard therapies necessitate novel approaches. Outpatient regimens sufficiently potent and well tolerated to induce remissions and enable continuation therapy may be beneficial. In this phase-1 study, we determined the maximum tolerated dose (MTD) and the efficacy for sequential azacitidine and lenalidomide as remission induction and continuation therapy in elderly, previously untreated patients. We investigated the impact on global DNA methylation and bone marrow cytokines, and sought biological predictors of response. Eighteen patients were enrolled. The MTD was not reached. Median follow-up was 8.2 months (10.3 months for survivors). Common adverse events included fatigue, injection site reactions, constipation, nausea, pruritus and febrile neutropenia. Ten patients responded (56%), and the rate of complete remissions (CRs) or CRs with incomplete recovery of blood counts for evaluable patients was 44% (7/16). The median response duration was 6.2 months. DNA demethylation and changes in bone marrow cytokines were observed; responders had a unique cytokine profile and a trend towards lower methylation levels. Sequential azacitidine and lenalidomide was well tolerated with encouraging clinical and biological activity in previously untreated elderly AML patients. This trial is registered at ClinicalTrials.gov (NCT00890929).

Introducing new vaccines in the poorest countries: what did we learn from the GAVI experience with financial sustainability?

This paper reviews the experience of the Global Alliance for Vaccines and Immunization (GAVI) in introducing hepatitis B and Haemophilus influenzae type b vaccines in the poorest countries, and explores how financing for immunization has changed since GAVI Fund resources were made available during its first wave of support between 2000 and 2006. The analysis of Financial Sustainability Plans in 50 countries allowed for some of the original funding assumptions of the GAVI approach to be tested against the realities in a wide set of countries, and to highlight implications for future immunization efforts. While the initial GAVI experience with financial sustainability has proved successful through the development of plans, and many countries have been able to both introduce new vaccines and mobilize additional financing for immunization, for future GAVI supported vaccine introduction, some country co-financing of these will be needed upfront for the approach to be more sustainable.

Splenic Rupture: An Unusual Complication of Colonoscopy

Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.

Splenic rupture: an unusual complication of colonoscopy

Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.

Processes underlying young women's decisions to eat fruits and vegetables

OBJECTIVE

To relate the use of identified processes that college women use to eat enough fruits and enough vegetables to their stages of readiness to change and their fruit and vegetable (F/V) intakes.

METHOD

A cross-sectional assessment of college women 18-24 years of age (n = 236) was conducted to assess stage of readiness to eat F/V. Use of seven processes, earlier confirmed in a separate sample of college students the same age (health concerns, self-reevaluation, social liberation, health commitment/action, interpersonal control, external reinforcement and helping relationships) was compared with stage of change for F/V and 3 days of dietary intakes.

RESULTS

In these young college women, use of self-reevaluation, a cognitive process for change, peaked in the preparation stage for both F/V. Use of health commitment/action, a post-action process including counter-conditioning, peaked in those in action/maintenance for F/V. Weight concerns related to the counter-conditioning processes women used to eat more fruit.

CONCLUSION

Health practitioners should focus on weight management, appearance and health benefits of eating fruits and vegetables for this demographic group.

Muscle weakness is a significant problem in older patients receiving chemotherapy

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Background: Accurate prediction of toxicities from chemotherapy in the elderly could lead to improved decision making and supportive care. Methods: A large prospective multicentric cohort study of older cancer patients undergoing chemotherapy is underway to document the occurrence of chemotherapy toxicity and to develop a predictive score: the CRASH score (Chemotherapy Risk Assessment Score for High Age patients). Toxicity, including muscle weakness, is assessed using the Common Toxicity Criteria v.3.0. Results: An analysis of the first 200 patients entered in the study revealed an infrequently highlighted side effect: muscle weakness. Twenty patients were not evaluable for this analysis. Muscle weakness was reported by 22 patients. This represented 12.2% of the patients, of whom 13 (7.2%) had grade 3 muscle weakness. There was no grade 4 muscle weakness. This side effect appears to be independent from fatigue: only 4/22 patients reported concomitant severe (grade 3–4) fatigue, and among the 24 patients with severe fatigue, only 4 reported any muscle weakness. Muscle weakness occurred fairly early during the treatment: median 30 days (range 6–126 days). The muscle weakness was predominantly of two types: a generalized muscle weakness, or a weakness affecting the lower extremities. It was accompanied by falls in two patients. That weakness was present across tumor types, chemotherapy types, individual physicians, and oncology centers. Like the rest of the study population, the majority of these patients had advanced disease. Other frequent severe side effects were: grade 4 neutropenia 31.7%; grade 3–4: hypokalemia 8.8%, hyperglycemia 8.3%, hyponatremia 7.2%, febrile neutropenia 7.2%, diarrhea 7.2%, infection with neutropenia 6.7%. Conclusion: Muscle weakness is a frequent and clinically significant side effect of chemotherapy in the elderly, distinguishable from fatigue. This could be targeted by a preventive physical therapy intervention to prevent muscle deconditioning.

[Table: see text]

Measuring quality of care in the treatment of colorectal cancer: The Moffitt Network Initiative on Practice Quality (MNIPQ)

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Background: As the first step in a larger effort to improve quality of care among its member institutions, the MNIPQ sought to develop and implement methods to assess quality of care in the treatment of colorectal cancer. The current report focuses on our initial experience conducting quality assessments at 4 of 20 member institutions. Methods: Medical chart reviews were conducted of all patients diagnosed with colon or rectal cancer in 2004 and seen by a medical oncologist at the Moffitt Cancer Center or at any of three affiliate institutions. Abstractors, who were trained and periodically monitored, conducted the reviews using a web-based abstraction tool. Abstraction focused on assessing adherence to quality indicators consistent with evidence-, consensus-, and regulatory-based guidelines. Variability in adherence across sites was evaluated by conducting Fisher’s exact tests. The 186 patients whose charts were reviewed were predominantly female (57%) and diagnosed with colon cancer (74%). Results: Adherence was consistently (p values>.05) high across all four study sites for: presence of a pathology report confirming malignancy (91–100%); evidence of staging based on established criteria (88–94%); documentation of discussion or referral for chemotherapy in cases of lymph node (colon and rectal cancer) or rectal wall (rectal cancer) involvement (89–100%); and presence of chemotherapy flow sheets (92–100%). Adherence was consistently (p values>.05) lower across sites for: performance of complete colon evaluation within 12 months of surgery (24–47%) and performance of CEA test before (48–74%) or in the 6 months after (56–82%) surgery or chemotherapy. Adherence varied significantly (p < .001) across sites only for documentation of consent for patients treated with chemotherapy (41–100%). Discussion: Findings identified several areas where efforts should be made to improve the quality of colorectal cancer care at one or more member institutions. In addition, the methods developed have laid the groundwork for future efforts to measure and improve quality of care for other cancers and among a larger number of member institutions.

No significant financial relationships to disclose.

The TRENDS Project: development of a methodology to reliably monitor the obesity epidemic in childhood

AIMS

The government has set a target to halt the rise in childhood obesity in those aged under 11 by 2010, but no system is in place to ascertain if this has been achieved. We aimed to develop a simple and reproducible methodology to monitor trends in childhood obesity.

METHODS

A purposive sample of 10 primary schools and three secondary schools was selected. Children were measured with parental "opt out" consent in reception class, year 4, and year 8 (ages 5, 9, and 13 years, respectively). Measurements were compared with those obtained locally in 1996-2001. Calculations were then performed to ascertain the sample size required to confidently identify a halt in the rise in obesity using three growth measures.

RESULTS

A total of 999 children were measured with ascertainment of 95% in primary and 85% in secondary schools. The proportion of overweight and obese children aged 9 and 13 years had increased since 1996-2001, although only 9 year olds showed a significant rise. A general trend of an increase in obesity was observed with increasing age. Calculations showed that 1900-2400 children per age group are needed to detect a halt in the rise in obesity based on mean body mass index (BMI) standard deviation scores (SDS) by 2010 with 90% power, whereas 4200-10 500 children are needed for other measures.

CONCLUSION

We have developed a simple, cost effective methodology for accurately measuring the epidemic and recommend the use of mean BMI SDS for demonstrating if a halt has been achieved.

Subcutaneous phaeohyphomycosis caused by Lasiodiplodia theobromae and successfully treated surgically

While visiting Jamaica, a 50-year-old woman stumbled on an outdoor wooden staircase and sustained an injury to the right leg. The wound was cleaned topically and the patient was given antibacterial therapy. Five weeks later, in Canada, she presented with an ulcer at the injury site. An excisional biopsy showed copious broad, septate, melanized fungal filaments penetrating into tissue. Culture yielded a nonsporulating melanized mycelium. The isolate was strongly inhibited by cycloheximide and benomyl but grew at 37 degrees C. After 16 weeks cultivation on modified Leonian's agar at 25 degrees C, it developed pycnidia characteristic of Lasiodiplodia theobromae, a common tropical phytopathogen mainly known previously as a rare agent of keratitis and onychomycosis in humans. The patient was not given antifungal chemotherapy, and the ulcer, which had been broadly excised in the biopsy procedure, ultimately resolved after treatment with saline compresses. The six-month follow-up showed no sign of infection. This case, interpreted in light of previously reported cases, shows that on rare occasions L. theobromae is able to act as an agent of subcutaneous phaeohyphomycosis and that, when this occurs, debridement alone may be sufficient to eradicate it.

Fusion of NUP214 to ABL1 on amplified episomes in T-cell acute lymphoblastic leukemia

In T-cell acute lymphoblastic leukemia (T-ALL), transcription factors are known to be deregulated by chromosomal translocations, but mutations in protein tyrosine kinases have only rarely been identified. Here we describe the extrachromosomal (episomal) amplification of ABL1 in 5 of 90 (5.6%) individuals with T-ALL, an aberration that is not detectable by conventional cytogenetics. Molecular analyses delineated the amplicon as a 500-kb region from chromosome band 9q34, containing the oncogenes ABL1 and NUP214 (refs. 5,6). We identified a previously undescribed mechanism for activation of tyrosine kinases in cancer: the formation of episomes resulting in a fusion between NUP214 and ABL1. We detected the NUP214-ABL1 transcript in five individuals with the ABL1 amplification, in 5 of 85 (5.8%) additional individuals with T-ALL and in 3 of 22 T-ALL cell lines. The constitutively phosphorylated tyrosine kinase NUP214-ABL1 is sensitive to the tyrosine kinase inhibitor imatinib. The recurrent cryptic NUP214-ABL1 rearrangement is associated with increased HOX expression and deletion of CDKN2A, consistent with a multistep pathogenesis of T-ALL. NUP214-ABL1 expression defines a new subgroup of individuals with T-ALL who could benefit from treatment with imatinib.

Rising obesity and expanding waistlines in schoolchildren: a cohort study

A cohort of schoolchildren was followed up over 6 years from 1996 to 2001. In the final year, 315 of 500 targeted children were measured. Body mass index (BMI) increased substantially over time (p<0.001), indicating a further rise in obesity into the secondary school years. Two new indicators of obesity were also measured. Waist circumference scores rose as substantially as BMI (p<0.001), and may be of particular significance given the association between abdominal girth in adults and cardiovascular morbidity. International Obesity Task Force measures were found to be more stringent than previous criteria, with no significant change noted over the time period.

Effect of extraction of myosin binding protein C on contractility of rat heart

Human hearts with reduced or mutant myosin binding protein C (MyBP-C) undergo hypertrophy and dilation, suggesting that reduction or alteration of MyBP-C interferes with normal contraction. Extraction of 60-70% of MyBP-C over 1 h from a mechanically disrupted cardiac myocyte has been shown to increase Ca sensitivity but does not appear to impair development of maximum Ca-activated force (Fmax). To determine whether loss of MyBP-C over a longer period of time will decrease force development in a reversible manner, MyBP-C has been extracted from chemically skinned rat cardiac trabeculae for 1-4 h, and force production, Ca sensitivity, and thick filament structure were measured. Although extraction of MyBP-C for 1 h did not alter Fmax, after 4 h, myosin heads became disordered and Fmax decreased. At this point, incubation of the trabeculae with rat cardiac MyBP-C in a relaxing solution reversed the decline in Fmax and most of the change in order of myosin heads. Extraction of MyBP-C appears to produce a change in the orientation of myosin heads that is associated with a decreased ability of the contractile system to develop force.

Predictors of breast cancer screening in a panel study of African American women

PURPOSE

This study examines the predictors of breast cancer screening participation in a panel study of African American women over age 40. We examine the effect of depression, age, beliefs and concerns about breast cancer and its risk, communication with social networks regarding screening, marital status, participation in religious organizations, breast cancer family history, and participation in a breast cancer education program.

METHODS

Participants were recruited from 30 African American churches, two low-income housing projects, and from a health fair at a historically African American University (N = 364). Participants were interviewed upon recruitment, and three months later. Multinomial logistic regression models are estimated to assess the relative impact of covariates on the odds of getting a mammogram while controlling for other factors. We also assess predicted probabilities of screening at specific levels of covariates.

RESULTS

We find that age, marriage, an educational intervention, talking with friends, and believing that early detection can lead to cure had a positive impact on getting a mammogram between T1 and T2. In contrast, depression significantly reduces the odds of getting a mammogram. Family histories of breast cancer and church participation have no effect on rates of mammography net of other factors.

Emerging areas of research reported during the CDC National Conference on Pfiesteria: from biology to public health

Since its identification in 1996, the marine dinoflagellate Pfiesteria piscicida Steidinger & Burkholder has been the focus of intense scientific inquiry in disciplines ranging from estuarine ecology to epidemiology and from molecular biology to public health. Despite these research efforts, the extent of human exposure and the degree of human illness directly associated with Pfiesteria is still in the process of being defined. Unfortunately, during this same time Pfiesteria has also stimulated media coverage that in some instances jumped ahead of the science to conclude that Pfiesteria presents a widespread threat to human health. Political and economic forces also came into play when the tourism and seafood industries were adversely impacted by rumors of toxin-laden water in estuaries along the east coast of the United States. Amid this climate of evolving science and public concern, Pfiesteria has emerged as a highly controversial public health issue. In October 2000 Centers for Disease Control and Prevention sponsored the National Conference on Pfiesteria: From Biology to Public Health to bring together Pfiesteria researchers from many disparate disciplines. The goal of this meeting was to describe the state of the science and identify directions for future research. In preparation for the conference an expert peer-review panel was commissioned to review the existing literature and identify research gaps; the summary of their review is published in this monograph. During the meeting primary Pfiesteria researchers presented previously unpublished results. The majority of those presentations are included as peer-reviewed articles in this monograph. The discussion portion of the conference focused upon researcher-identified research gaps. This article details the discussion segments of the conference and makes reference to the presentations as it describes emerging areas of Pfiesteria research.

Multiple structures of thick filaments in resting cardiac muscle and their influence on cross-bridge interactions

Based on two criteria, the tightness of packing of myosin rods within the backbone of the filament and the degree of order of the myosin heads, thick filaments isolated from a control group of rat hearts had three different structures. Two of the structures of thick filaments had ordered myosin heads and were distinguishable from each other by the difference in tightness of packing of the myosin rods. Depending on the packing, their structure has been called loose or tight. The third structure had narrow shafts and disordered myosin heads extending at different angles from the backbone. This structure has been called disordered. After phosphorylation of myosin-binding protein C (MyBP-C) with protein kinase A (PKA), almost all thick filaments exhibited the loose structure. Transitions from one structure to another in quiescent muscles were produced by changing the concentration of extracellular Ca. The probability of interaction between isolated thick and thin filaments in control, PKA-treated preparations, and preparations exposed to different Ca concentrations was estimated by electron microscopy. Interactions were more frequent with phosphorylated thick filaments having the loose structure than with either the tight or disordered structure. In view of the presence of MgATP and the absence of Ca, the interaction between the myosin heads and the thin filaments was most likely the weak attachment that precedes the force-generating steps in the cross-bridge cycle. These results suggest that phosphorylation of MyBP-C in cardiac thick filaments increases the probability of cross-bridges forming weak attachments to thin filaments in the absence of activation. This mechanism may modulate the number of cross-bridges generating force during activation.

Carotid angioplasty and intra-arterial thrombolysis in acute carotid circulation stroke: A case report

BACKGROUND

Early treatment with intra-arterial thrombolysis has been shown to be effective in the treatment of acute ischemic stroke because of occlusion of the middle cerebral artery. It is unclear how to use this therapy, however, when there is also occlusion of the parent internal carotid artery.

CASE REPORT

A 43-year-old woman presented within 15 minutes of symptom onset caused by a large right anterior circulation ischemic stroke. Computed tomography scan showed a hyperdense right middle cerebral artery sign. Carotid angiography showed occlusion of the right internal carotid artery just distal to its origin. After balloon angioplasty of the internal carotid artery, the occluded right middle cerebral artery was successfully recanalized using intra-arterial tissue plasminogen activator. The patient had dramatic clinical improvement after the procedure, with almost complete resolution of her deficits.

CONCLUSION

Acute middle cerebral artery thrombosis is occasionally associated with acute thrombotic occlusion of the parent internal carotid artery. In this situation, carotid occlusion may be treated first with percutaneous transluminal balloon angioplasty. Intra-arterial thrombolysis may then be applied directly to the site of middle cerebral artery thrombosis, improving chances for overall recanalization and excellent clinical response.

Transesophageal echocardiographic evaluation of native aortic valve area: utility of the double-envelope technique

OBJECTIVE

To assess the accuracy of aortic valve area (AVA) calculations using the continuity equation with data obtained from the double envelope (DE) (simultaneously obtained left ventricular outflow tract [V1]) and aortic valve [V2] velocities) during intraoperative transesophageal echocardiography (TEE).

DESIGN

Prospective study; measurements were performed on-line.

SETTING

University hospital.

PARTICIPANTS

Cardiac and noncardiac surgical patients (n = 75) with recent aortic valve assessment (<3 months) undergoing general anesthesia or endotracheal intubation.

INTERVENTIONS

Intraoperative AVA was measured by the continuity equation using the DE technique (DE/TEE) and by planimetry (PL/TEE). Left ventricular outflow tract diameter was obtained from midesophageal views, whereas subvalvular (V1) and valvular (V2) velocities were obtained simultaneously using continuous-wave Doppler from transgastric views. V1 was also obtained using pulsed-wave Doppler. Measurements were compared with AVA obtained preoperatively by the Gorlin equation during cardiac catheterization (G/CATH) or by transthoracic echocardiography using the traditional continuity equation (C/TTE) (nonsimultaneously obtained V1 and V2).

MEASUREMENTS AND MAIN RESULTS

A DE was obtained in 73 of 75 patients (97%). Four patients had atrial fibrillation at the time of the examination, whereas the rest were in sinus rhythm. PL/TEE was performed in 54 of 71 patients with sinus rhythm (76%). Agreement was good between DE/TEE and G/CATH (mean bias, 0.02 cm(2) [SD, 0.24 cm(2)]), and C/TTE (mean bias, -0.05 cm(2) [SD, 0.16 cm(2)]). Agreement was not as good between PL/TEE and G/CATH (mean bias, -0.07 cm(2) [SD, 0.28 cm(2)]) and C/TTE (mean bias, -0.13 cm(2) [SD, 0.30 cm(2)]). V1 obtained by pulsed-wave Doppler and with DE closely agreed (mean bias, 0.01 m/sec [SD, 0.05 m/sec]).

CONCLUSION

TEE evaluation of native AVA using the DE technique is feasible and in good agreement with that obtained by C/TTE and G/CATH. Compared with DE/TEE, PL/TEE did not agree as well. Use of DE/TEE should simplify the continuity equation and may minimize errors resulting from beat-to-beat variability in stroke volume.

The changing epidemiology of viral hepatitis A in Israel

BACKGROUND

Between 1970 and 1979, there was an increase in the incidence of viral hepatitis in Israel with a shift of peak incidence to an older age in the Jewish population, followed by a declining trend during the early 1980s. In July 1999 universal immunization of infants against hepatitis A was introduced.

OBJECTIVE

To evaluate the chan-ges in the epidemiology of viral hepatitis A in Israel during the past decade.

METHODS

Viral hepatitis is a notifiable disease in Israel and cases are reported to the regional health offices, which in turn provide summary reports to the Ministry of Health's Department of Epidemiology. The data in this study were derived from the summary reports and from results of seroprevalence studies.

RESULTS

Following the increase in the incidence of reported viral hepatitis (mainly due to type A) between 1970 and 1979, the rates then stabilized and around 1984 began to decline until 1992. Since then there has been a slight increase. Whereas until 1987 the rates were consistently higher in the Jewish population, since then they are higher in the Arab population. The shift in the peak age-specific incidence from the 1-4 to the 5-9 year age group observed in the Jewish population around 1970 occurred 20 years later in the Arab population. The previously described seasonality is no longer evident. Recent seroprevalence studies indicate that by age 18 years only about 30-40% of the Jewish population have anti-hepatitis A antibodies.

CONCLUSIONS

The decline in the incidence of hepatitis probably reflects the changing socioeconomic condition occurring at different times in the two major population groups. Since hepatitis A accounts for almost all the acute viral hepatitis in Israel, the universal vaccination of infants introduced in 1999 should substantially lower the morbidity within the next few years.

Capitation: a strategy that could have a future

Capitation can be successful if hospitals, physicians, and payers share risk to align financial incentives to control costs. Payers need to help hospitals that accept risk to achieve success under managed care agreements. Many failures in hospital capitation might be preventable if hospitals improve internal operations and commit themselves to making the changes necessary for successful risk-based payment.