Improving fairness in coverage decisions: performance expectations for quality improvement

Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups.

The use of stimulated granulocyte transfusions to prevent recurrence of past severe infections after allogeneic stem cell transplantation

The predictable neutropenia that follows allogeneic stem cell transplantation (ASCT) may be associated with recurrence of previous life-threatening infection. We describe nine patients with either previous invasive aspergillosis (IA) or considered to be at high risk of developing IA who underwent ASCT with prophylactic granulocyte transfusions. The study group, when compared with a control group, had a significant reduction in the incidence and duration of fevers (P < 0.05) and maximum C-reactive protein (P < 0.05). There were significantly fewer days of neutropenia (P < 0.05). There was also radiological improvement of pulmonary infiltrates in four out of seven assessable patients. No serious toxicity was encountered in donors or recipients. We conclude that prophylactic granulocyte donations can be given safely, and that they significantly reduce the number of days of neutropenia. Further investigation is warranted to determine whether granulocyte donations can prevent the recurrence of IA in patients at risk of fungal infection.

Influenza and adult hospital admissions for respiratory conditions in England 1989-2001

Influenza is recognised as a major cause of excess hospital admissions during winter months. This study sets out to quantify admissions related to influenza during the last twelve winters and to examine the importance of age. Total admission data for respiratory disorders in adults for England during the years 1989 to 2001 have been used. Weekly admission data were examined in five-year age bands. Influenza epidemics were identified from clinical incidence data in the community. Baseline admission levels were determined by averaging weekly incidence data from weeks in which there was no clinical evidence of influenza activity. Excess admissions were estimated from the difference between observed and baseline admissions after adjusting the baseline in each group and year for the secular trend. Estimates for all adults were consolidated from the five-year age bands. Bed occupancy was estimated by applying data on average bed stay to excess admissions in age- and year-specific groups. We estimated 2.7% of all respiratory admissions were related to influenza. Excess admissions were strongly age related. Of the 16,227 annual average excess, 52% occurred in persons over 75 years. The excess admissions account for an average 145,544 bed days annually, two thirds (69%) in persons over 75 years. Annual excess bed occupancy was highest in 1999/2000 (39,512) though 30,000 excess admissions per year is not unusual. Hospital admissions due to influenza remain a major problem for health service delivery particularly in elderly populations. Though robust programmes of vaccination are needed, vaccination by itself will not eliminate the impact of influenza on hospital admissions in winter.

Harmonisation of national influenza surveillance morbidity data from EISS: a simple index

The European Influenza Surveillance Scheme is a collaboration with 18 member countries (2001/02) which monitors the activity and impact of influenza by collecting morbidity and virological data in primary care facilities throughout the winter season each year. Despite being in principle similar in the surveillance concept, the indicators used and observations made are very different. Different healthcare systems and organisational needs (eg a certificate of illness for the employer) influence the consultation behaviour. Furthermore, and partly as a result of differences in the healthcare systems, the definitions used for the numerator and denominator when calculating morbidity rates are different. Thus comparative interpretation of participating countries' morbidity data is extremely difficult. Reporting 'harmonisation' by using equivalent numerators and denominators is one option but is difficult to achieve in the short term. Moreover, several additional issues would need to be considered, for example, the need for continuity of surveillance and whether such steps would indeed result in direct comparability etc. A simple index was tested, through which the impact of influenza morbidity in any one year is compared with what is considered a 'usual' epidemic in that country. The index in principle describes numerically the extent to which the influenza-attributable excess morbidity in the current epidemic in each country is within, exceeds, or is less than a range typical for an influenza epidemic. In this pilot study, the usefulness of such an index is explored with the example of eight countries for the seasons 1999/2000 and 2000/01. A fine tuning of the methods has not yet been performed.

Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings

In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.

Sexual behaviors in an urban bathhouse 15 years into the HIV epidemic

OBJECTIVE

To characterize the population and sexual behaviors of men currently attending gay bathhouses.

METHODS

Men entering a bathhouse in Portland, Oregon, were asked to complete a one-page questionnaire. Data collection ended when 1000 surveys were obtained. Questionnaires assessed demographics, self-reported HIV status, drug and alcohol use, and sexual behavior in the preceding 30 days.

RESULTS

The estimated response rate was 80%-90%. Of 1000 respondents, 829 (83%) reported having anal or oral sex at a bathhouse in the previous 30 days, 715 (86%) engaged in oral sex, 420 (51%) in anal sex, and 89 (11%) in high-risk (unprotected anal) sex. In multivariate analysis, characteristics associated with men reporting high-risk sex compared with men reporting other sexual activities at the bathhouse were HIV infection (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.02-4.0); >or= 5 sexual partners in previous 30 days (OR, 3.2; 95% CI, 2.0-5.3); having anonymous sex at other sites (OR, 2.1; 95% CI, 1.2-3.8).

CONCLUSIONS

Although most bathhouse patrons engaged in lower risk activities, those reporting unprotected anal sex were more likely to report HIV infection and to have multiple sexual partners. Well into the HIV epidemic, bathhouses remain venues for ongoing spread of HIV and opportunities for intervention.

The clinical diagnosis of influenza

Effective management of influenza depends on early recognition of influenza in the community and on rapid diagnosis. Early recognition is achieved by integrated clinical and laboratory based surveillance programmes in representative populations. The recent introduction of 'near patient tests' for influenza provide increased opportunities for surveillance but diagnosis remains largely clinically based. The combination of cough and fever in conditons of known local influenza virus circulation provide a useful indicator of diagnosis to guide management.

A Nationwide Learning-Style Assessment of Undergraduate Athletic Training Students in CAAHEP-Accredited Athletic Training Programs

OBJECTIVE: To identify the learning styles and preferred environmental characteristics of undergraduate athletic training students in Commission on Accreditation of Allied Health Education Programs (CAAHEP)-accredited athletic training education programs and to determine if learning-style differences existed among geographic regions of the country. DESIGN AND SETTING: Fifty CAAHEP-accredited athletic training programs were randomly selected in proportion to the number of programs in each geographic region. Ten students from each school were selected to complete the Kolb Learning Style Inventory (LSI) and the Productivity Environmental Preference Survey (PEPS). SUBJECTS: A total of 193 undergraduate athletic training students (84 men, 109 women) with a mean age of 22.3 +/- 2.8 years completed the PEPS, while 188 students completed the LSI. MEASUREMENTS: We used chi-square analyses to determine if differences existed in learning-style type and if these differences were based on geographic location. We calculated analysis of variance to determine if there were any geographic differences in the mean overall combination scores of the LSI. Descriptive statistics were used to evaluate the PEPS. RESULTS: The overall return rate was 38%. The chi-square analyses revealed no significant difference in learning-style type for athletic training students, regardless of the geographic region. The LSI yielded a relatively even distribution of learning styles: 29.3% of the students were accommodators, 19.7% were divergers, 21.8% were convergers, and 29.3% were assimilators. The overall mean combination scores were 4.9 (abstract-concrete) and 4.9 (active-reflective), and analysis of variance indicated no significant difference in the mean combination scores among the geographic regions. The PEPS revealed that undergraduate athletic training students demonstrated a strong preference for learning in the afternoon. CONCLUSIONS: Undergraduate athletic training students demonstrated great diversity in learning style. Educators must strongly consider this diversity and incorporate teaching methods that will benefit all types of learners.

cDNA arrays and immunohistochemistry identification of CD10/CALLA expression in hepatocellular carcinoma

The histological diagnosis of hepatocellular carcinoma (HCC) can be complicated by difficulty in differentiation from cholangiocarcinoma and metastatic carcinoma. Immunohistochemical stains currently in use are suboptimal in terms of specificity and sensitivity. Using cDNA array analysis for differential gene expression, we demonstrated a significant increase in mRNA expression level of CD10/CALLA, a type 2 cell-surface metalloproteinase, in HCC, which was subsequently confirmed by reverse transcriptase-polymerase chain reaction and Western blotting analysis. To test the possibility of using CD10/CALLA as a diagnostic marker for HCC, various intrahepatic tumors were studied immunohistochemically using a monoclonal antibody for CD10. A characteristic canalicular-staining pattern was observed in normal hepatocytes and at the apical surface of bile duct epithelial cells. The canalicular expression of CD10 was identified in 9 of 15 HCCs examined (60%), whereas 10 cholangiocarcinomas and 8 of 9 metastatic carcinomas lacked this staining. In three of the six HCCs negative for CD10, the surrounding nonneoplastic liver tissue was also negative, suggesting fixation-associated loss of immunoreactivity. Six HCCs had stronger CD10 staining in tumor cells when compared to the surrounding nonneoplastic tissue. Three cases of benign bile duct adenomas also expressed CD10 at the luminal aspect. One of the MCs showed a diffuse, cytoplasmic staining for CD10, a pattern readily distinguishable from that of HCC. A panel of other immunohistochemical markers were also studied for comparison, including polyclonal anti-carcinoembryonic antigen, cytokeratin (CK) 7, CK20, and alpha-fetoprotein. Our results demonstrate that cDNA arrays can be effectively used to identify new diagnostic markers, and that CD10 is a reliable marker for identifying HCC, particularly when used in conjunction with a panel of immunohistochemical markers (polyclonal anti-carcinoembryonic antigen, CK7, CK20, and alpha-fetoprotein) and in the distinction from cholangiocarcinoma.

Resistance to glucocorticoid feedback in obesity

Increased hypothalamo-pituitary-adrenal axis drive has been reported in obese subjects but with paradoxically low or normal levels of plasma cortisol. Our current study was designed to investigate whether glucocorticoid feedback was altered in obesity, both under basal and stressed conditions. Plasma ACTH and cortisol concentrations in male control or obese subjects (age range 20-50 yr) were measured at frequent intervals over 24 h during infusion of saline or hydrocortisone at two physiological doses (7.5 and 15 mg/d) designed to occupy predominantly mineralocorticoid rather than glucocorticoid receptors. The same subjects then underwent insulin-induced hypoglycemia either in the morning or the evening. Obese subjects had significantly higher basal ACTH and lower cortisol concentrations throughout the 24 h infusion period, compared with controls (P < 0.05, two-way ANOVA followed by Newman-Keuls posthoc analysis). Basal plasma ACTH was decreased in obese groups given low- or high-dose hydrocortisone during the day (P < 0.05) but not during the night, unlike controls who responded to hydrocortisone both during the day and at night (P < 0.05). Obese subjects also showed resistance to steroid-induced inhibition of the ACTH response to hypoglycemia, compared with controls (P < 0.05). These data clearly show that obesity is associated with a relative insensitivity to glucocorticoid feedback, which is most marked during the night, and suggest that this condition is characterized by a decreased mineralocorticoid receptor response to circulating corticosteroids.

Effect of active limb movements on symptoms in patients with low back pain

STUDY DESIGN

A descriptive, correlational study of patients with mechanical low back pain (LBP).

OBJECTIVES

To assess the effect of active limb movements on symptoms in patients with LBP and to examine the relationship between symptoms with limb movements and select patient characteristics.

BACKGROUND

Limb movements result in forces applied to the spine and, thus, may be important in the examination and treatment of patients with LBP.

METHODS AND MEASURES

A total of 188 people with LBP, 84 men and 104 women, participated in a standardized examination. Six of the items required patients to move their limbs and note LBP symptoms as increased, remained the same, or decreased. The prevalence of various symptom responses with each limb movement test was calculated. Relationships between patient characteristics and reports of increased symptoms were examined with Cochran's linear trend statistic and the Spearman and Pearson correlation coefficients. Differences in characteristics of patients with and without increased symptoms were examined with chi2 test, Mann-Whitney U test, or Student's t test for independent groups.

RESULTS

An increase in symptoms was reported by 149 patients with at least 1 of the limb movement tests, and 3 of the patients reported a decrease in symptoms. Across the patient sample, the mean number of limb movement tests for which symptoms were reported as increased was 2.30 +/- 1.64. Patients with an increase in symptoms reported higher average pain intensity the week prior to the examination (median = 2; range: 1-5) and higher functional disability (mean = 0.25; SD = 0.15) than those without a change in symptoms (pain intensity: median = 1; range: 0-2 and functional disability: mean = 0.16; SD = 0.12). The correlation between the number of increased symptoms and the person's average pain intensity was r = 0.23; the correlation with the functional disability score was r = 0.36. Patients with a history of LBP tended to report an increase in symptoms with more of the limb movement tests (mean = 3.5; SD = 1.40) than those without a previous history of LBP (mean = 2.0; SD = 1.11).

CONCLUSIONS

Active limb movements performed during the examination primarily resulted in increased LBP symptoms. The presence and number of increased symptoms with the active limb movements was related to the patient's report of average pain intensity and functional disability. Tests of symptoms with active limb movements may provide insight into factors contributing to a LBP problem, as well as information to guide the treatment of patients with LBP.

Docetaxel-carboplatin as first line chemotherapy for epithelial ovarian cancer

A prospective, non-randomized, multicentre, open, dose-finding study of a carboplatin-docetaxel (C-D) combination as first-line chemotherapy in FIGO stage Ic-IV epithelial ovarian cancer. C-D was given 3-weekly for 6 planned cycles, with a 3-day prophylactic dexamethasone regimen (8 mg b.i.d.). 139 eligible patients (Pts) (median age 56 years, range 28-85) were given a total of 750 cycles of chemotherapy in 5 cohorts: Co1, 32 pts, 169 cycles (C at AUC 5 + D 60 mg/m(2)); Co2, 22 pts, 122 cycles (5 + 75), Co3, 29 pts, 156 cycles (6 + 75), Co4, 27 pts, 146 cycles (7 + 75), Co5, 30 pts, 157 cycles (6 + 85). 110 patients (79%) completed 6 cycles; 17 (12%) stopped due to toxicity. 104 patients (75%) had CTC grade IV neutropenia, and 5 patients (4%) had this associated with fever. There were 2 probable treatment-related deaths. Only 8 patients (6%) experienced grade II-III neurotoxicity (all sensory; no motor > grade I). The maximum tolerated dose was reached in cohorts 4 and 5, and the dose limiting toxicities were myelosuppression and diarrhoea. The overall response rate for the study was 66% (49/74); CA125 response was 75% (70/93). Median progression-free survival was 16.6 months (95% CI 13.3-19.1). Recommended doses are carboplatin AUC 5 (via(51)Cr EDTA) or AUC 6 (if calculated) plus docetaxel 75 mg/m(2). A randomized trial comparing this regimen with carboplatin-paclitaxel has just completed recruitment.

Influenza surveillance in England and Wales: October 1999 to May 2000

The period of increased influenza activity in England and Wales in the winter of 1999/2000 was associated with considerable morbidity and mortality and well-publicized pressure on hospital services. The influenza activity coincided with the regular annual increase in respiratory syncytial virus infections and the Christmas and New Year holiday period. Consultation rates with general practitioners for influenza-like illness did not reach 'epidemic' levels but were higher than seen in many winters and comparable with those seen in two out of the previous three winters. In common with those winters, attack rates for influenza-like illness and acute bronchitis were especially high in elderly people among whom complications of acute infection and hospital admissions increased. Excess mortality due to influenza during this period appeared to be substantial but was not as high as seen in the last epidemic (1989/90).

Neuraminidase inhibitors: progress in the management of influenza

Influenza is a serious respiratory illness and represents a significant clinical burden. As well as being debilitating, influenza can often cause complications leading to hospitalisation and death. Prophylaxis by vaccination is the preferred method of disease management, but because influenza viruses are constantly changing their antigenic properties, influenza outbreaks occur regularly as epidemics. Neuraminidase inhibitors are a new class of anti-influenza drugs designed to block influenza virus replication. Two neuraminidase inhibitors, zanamivir and oseltamivir, have been licensed for clinical use in the treatment of influenza. Both drugs significantly reduce the severity and duration of the illness when treatment is started within two days of the onset of symptoms. However, while zanamivir and oseltamivir have apparently similar efficacy, they differ in their modes of delivery and tolerability. Zanamivir is delivered direct to the lungs by inhalation and is well tolerated. Oseltamivir is taken in the form of a pill but has the side-effect of producing nausea and vomiting in some patients. In the absence of a demonstrable difference in efficacy, uptake of the two drugs will depend on evaluation of the relative merits of mode of delivery and tolerability.

Myelophthisis as a solitary manifestation of failure from rectal carcinoma. A Batson phenomenon?

Rectal carcinoma is uncommonly associated with systemic metastases in the absence of liver metastases, reflecting the predilection for spread via the portal system. Occasionally, isolated lung metastases are seen, which are usually attributed to spread via the portosystemic anastomoses in the distal rectum. However, myelophthisis is an unreported complication of rectal cancer as an isolated form of systemic failure. We present a case of fatal myelophthisis associated with otherwise localized rectal carcinoma secondary to metastatic rectal cancer. This observation led to the hypothesis that spread to the bone marrow occurred via a "third circulation," the Batson plexus, a network of deep pelvic veins with rich anastomoses to the vertebral plexus.

Rapid antibody response to influenza vaccination in "at risk" groups

Persons attending for routine influenza vaccination in an urban practice each provided three specimens of blood for evaluating their immunological response. 138 (67%) of the 206 persons were defined as "at risk" by reason of morbidity as given in the guidelines published by the Chief Medical Officer. The mean age was 67 yr and 65% were aged 65 yr or more. By day 7, 71% of 31 persons had protective H(1)N(1) titres, 61% H(3)N(2) and 42% B. These proportions were similar to those found at day 14 and at day 21 based on 159 persons. These findings suggest that an effective immune response is mounted within seven days of vaccination indicating that the vaccination of persons "at risk" is worthwhile even after an epidemic has established itself. This is not a reason to modify present policy of routine vaccination in early winter well before epidemics are likely to occur.

Scope and organization of the Guide to Community Preventive Services. The Task Force on Community Preventive Services

BACKGROUND

The diverse nature of the target audience (i.e., public health decision-makers) for the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) dictates that it must be broad in scope. In addition, for the Guide to be most useful for its target audience, its organization and format must be carefully considered.

DETERMINING THE SCOPE OF THE GUIDE

Healthy People objectives and actual causes of death were used to determine the contents of the Guide. A priority setting exercise resulted in the selection of 15 topics for systematic reviews using the following criteria: burden of the problem, preventability, relationship to other public health initiatives, usefulness of the package of topics selected and level of current research and intervention activity in public and private sectors. Interventions within each topic target state and local levels and include population-based strategies, individual strategies in other than clinical settings and group strategies.

ORGANIZATION OF THE GUIDE

The Guide is organized into: Introduction, Reviews and Recommendations (three sections: Changing Risk Behaviors, Reducing Diseases, Injuries, or Impairments, and Addressing Environmental and Ecosystem Challenges), Appendixes, and Indexes.

DISCUSSION

The scope and organization of the Guide were determined using relevant public health criteria and expert opinion to provide a useful and accessible document to a broad target audience. While the final contents of the Guide may change during development, the working table of contents described in this paper provides a framework for development of the Guide and conveys its scope and intention.

Influenza activity in England and Wales: October 1998 to June 1999

Influenza activity in England and Wales in the winter of 1998/1999 reached the highest weekly levels seen since the epidemic of 1989/1990. Activity peaked at Christmas and the New Year, adding to the winter pressures on general practitioner and hospital services. Adults aged 65 years and over consulted with general practitioners at the highest rates. Outbreaks of influenza or flu-like illness occurred in several schools and nursing homes and, in June 1999, on a British cruise ship in the Mediterranean. Deaths from all causes reached a higher peak in week 1 of 1999 than occurred in the peak week of the influenza epidemic of 1989/90.

Do influenza epidemics affect patterns of sickness absence among British hospital staff?

Influenza vaccination for healthcare workers is not recommended in Britain, but some hospitals offer vaccine to reduce sickness absence. However, in Nottingham, the influenza epidemics of 1993-94 and 1996-97 made no impact on staff absence. Annual vaccination of healthcare workers against influenza is unlikely to reduce absence most winters, but there may be gains in terms of preventing nosocomial infection.

Mandatory reporting of diseases and conditions by health care professionals and laboratories

CONTEXT

Surveillance is a key component of the core public health function of health assessment. Systematic reporting by health care professionals and laboratories, which may vary by state law, statute, or regulation, continues to provide essential data for assessing public health.

OBJECTIVE

To describe the state and territorial reporting requirements for diseases and conditions recommended for national public health surveillance.

DESIGN, SETTING, AND PARTICIPANTS

Between May and August 1997, the state and territorial epidemiologists from all 50 states, in addition to New York City, Puerto Rico, and Guam, completed questionnaires indicating which diseases and conditions were reportable by health care professionals and laboratories in their jurisdictions. The surveys were subsequently updated to reflect reporting requirements current as of January 1, 1999. The overall response rate for the survey was 100% for US states and 90% overall, including the territories.

MAIN OUTCOME MEASURE

State and territorial reporting requirements for diseases and conditions of public health concern.

RESULTS

Of the 58 diseases and conditions recommended for national reporting, 35 (60%) were reportable in greater than 90% of the states and territories, 15 (26%) were reportable in 75% to 90%, and 8 (14%) were reportable in less than 75%. Nineteen of the infectious diseases were reportable in all of the states and territories that responded.

CONCLUSIONS

Required reporting varies substantially by state or territory. Health care professionals are integral to public health efforts at the local, state, and national levels.