A Peer-to-Peer Mentoring Program for In-Center Hemodialysis: A Patient-Centered Quality Improvement Program

A patient-centered quality improvement program implemented in one Virginia hemodialysis facility sought to determine if peer-to-peer (P2P) programs can assist patients on in-center hemodialysis with self-management and improve outcomes. Using a single-arm, repeatedmeasurement, quasi-experimental design, 46 patients participated in a four-month P2P intervention. Outcomes include knowledge, self-management behaviors, and psychosocial health indicators: self-efficacy, perceived social support, hemodialysis social support, and healthrelated quality of life (HRQoL). Physiological health indicators included missed and shortened treatments, arteriovenous fistula placement, interdialytic weight gain, serum phosphorus, and hospitalizations. Mentees demonstrated increased knowledge, self-efficacy, perceived social support, hemodialysis social support, and HRQoL. Missed treatments decreased. Mentors experienced increases in knowledge, self-management, and social support. A P2P mentoring program for in-center hemodialysis can benefit both mentees and mentors.

Right TraC™ Post-Hospitalization Care Transitions Program to Reduce Readmissions for Hemodialysis Patients

BACKGROUND

Hemodialysis (HD) patients have high hospitalization rates. This nonrandomized trial tested the effect of a bundle of renal-specific "Right TraC™" strategies on 30-day all-cause readmission rates and, secondarily, 90-day readmissions and overall admissions among HD patients.

METHODS

Twenty-six Fresenius clinics in West Virginia, Ohio, and Kentucky participated in the interventions. Eighteen matched clinics served as controls; intervention clinics also served as their own controls. We deployed the intervention in 3 incremental phases focused on patient information exchange, post-hospital follow-up, and telephonic case management. Thirty-day hospital readmissions per patient year (ppy) were calculated by dividing the total number of readmissions within 30 days of index admission by the total number of patient-years in baseline (2012) and remeasurement (2014) periods. We also compared readmission rates from 2010 to 2015. We used repeated measures Poisson regression to compare outcomes between groups and time periods.

RESULTS

From 2012 to 2014, 30-day all-cause readmissions ppy declined for Right TraC clinics (from 0.88 to 0.66 [p < 0.001]; for controls, from 0.73 to 0.61 [p = 0.16]). Difference in change between groups was nonsignificant (p = 0.26). Overall admissions ppy declined: for Right TraC clinics from 2.51 to 1.97 (p < 0.001); for controls from 2.14 to1.92 (p = 0.21); difference in change between groups was significant (p = 0.01). For 2010, 2011, and 2012, Right TraC clinic 30-day readmissions ppy were unchanged: 0.89, 1.00, 0.88 (p = 0.61 and p = 0.49); they declined to 0.66 (p < 0.001) in 2014 (intervention year); rose to 0.70 (p = 0.06) in 2015 (interventions discontinued).

CONCLUSION

We conclude that Right TraC interventions may have been helpful in reducing hospital readmission rates.

Integrating Preventive Cardiovascular Healthcare Into Home Health: A Pilot Study

The viability of measuring and integrating preventive cardiovascular care into home healthcare was investigated through a pilot study fielded during 2013 and 2014. The study tested the feasibility of using a data registry to measure preventive cardiovascular care delivered in home healthcare, examined opportunities for quality improvement, and looked at the association between exposure to evidence-based tools and improvement in aspirin use and blood pressure screening and control among a convenience sample of 20 agencies. Based on promising results, the home healthcare cardiovascular quality initiative continues in alignment with Million Hearts® and offers tools that clinicians can use to understand the risks for heart attack and stroke within their agency's population of patients and respond with best practices.

Making a Dent in Undiagnosed and Untreated Depression among Older West Virginians

IMPORTANCE

Depression, a serious and debilitating disease, remains under-diagnosed and inadequately treated among older adults.

OBJECTIVE

To describe the prevalence of depression among older West Virginians and report the extent to which primary care providers screen Medicare beneficiaries for depression.

METHODOLOGY

Descriptive analysis using 2014 Behavioral Risk Factor Surveillance System to estimate depression prevalence; Medicare Part B claims, 2012 - 2014, to measure depression screening.

FINDINGS

In 2014, depression affected 10.1%, 95% CI [8.6%, 11.6%] of older West Virginians. While screening increased, less than 4% of Medicare beneficiaries seen in primary care that year were screened.

CONCLUSION

We have a significant opportunity to improve diagnosis, treatment and quality of life for older West Virginians with depression, and Medicare reimbursement for screening is available to primary care providers. Although many older depressed patients can be treated in the primary care setting, integration of behavioral health and primary care has distinct benefits.

Correlates of change in health care worker seasonal influenza vaccination rates among dialysis facilities

We conducted a campaign to increase seasonal influenza vaccination of dialysis health care workers (HCWs) in the District of Columbia, Maryland, Virginia, and West Virginia. Between the 2010-2011 and 2011-2012 influenza seasons we examined the correlates of change. HCW vaccination rates improved significantly (P < .01) from a mean ± standard deviation of 64.5 ± 27.4 to 72.7 ± 23.1. Evidence-based practices were in wide use and although we did not find an association between these and improvement, we did find that lower-performing facilities tended to improve more (P < .01) and there was a positive relationship between patient influenza vaccination rates and improvement in HCW rates (P < .01), with the mean ± standard deviation patient rate of 88.3 ± 7.9 exceeding the HCW rate during the 2011-2012 season (P < .01).

Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients

RATIONALE, AIMS AND OBJECTIVES

To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies.

METHOD

We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively).

RESULTS

Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates.

CONCLUSION

We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.

High one year mortality in adults with sickle cell disease and end-stage renal disease

Adequate pre-dialysis care reduces mortality among end-stage renal disease (ESRD) patients. We tested the hypothesis that individuals with ESRD due to sickle cell disease (SCD-ESRD) receiving pre-ESRD care have lower mortality compared to individuals without pre-ESRD care. We examined the association between mortality and pre-ESRD care in incident SCD-ESRD patients who started haemodialysis between 1 June, 2005 and 31 May, 2009 using data provided by the Centers for Medicare and Medicaid Services (CMS). SCD-ESRD was reported for 410 (0·1%) of 442 017 patients. One year after starting dialysis, 108 (26·3%) patients with incident ESRD attributed to SCD died; the hazard ratio (HR) for mortality among patients with SCD-ESRD compared to those without SCD as the primary cause of renal failure was 2·80 (95% confidence interval [CI] 2·31-3·38). Patients with SCD-ESRD receiving pre-dialysis nephrology care had a lower death rate than those with SCD-ESRD who did not receive pre-dialysis nephrology care (HR = 0·67, 95% CI 0·45-0·99). The one-year mortality rate following an ESRD diagnosis was almost three times higher in individuals with SCD when compared to those without SCD but with ESRD and could be attenuated by pre-dialysis nephrology care.

Prevalence of arteriovenous fistulas in incident hemodialysis patients: correlation with patient factors that may be associated with maturation failure

BACKGROUND

Lok et al previously reported a risk equation for arteriovenous fistula (AVF) maturation failure. It is unclear whether this model or a more comprehensive model correlates with incident AVF use in the US hemodialysis population.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

195,756 adult patients initiating outpatient hemodialysis therapy in the United States between July 1, 2005, and December 31, 2009, with 6 months or more prior nephrology care.

PREDICTOR

Patient characteristics (age, peripheral vascular disease, coronary artery disease, and race) populating the AVF maturation failure risk equation and other demographic and clinical variables from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report (CMS 2728).

OUTCOMES & MEASUREMENTS

AVF use at first outpatient dialysis treatment as recorded on the CMS 2728.

RESULTS

Using the risk categories defined by Lok et al, AVF use varied from 19.0% (very high risk) to 25.6% (low risk). In a model using only these risk categories, logistic regression showed lower ORs for moderate-, 0.90 (95% CI, 0.88-0.93); high-, 0.80 (95% CI, 0.78-0.83); and very high-risk patients, 0.68 (95% CI, 0.63-0.73) compared with low risk. In the expanded model, odds were lower for women, blacks, Hispanics, age older than 85 years, diabetes, peripheral vascular disease, congestive heart failure, other cardiac disease, and underweight. Odds were higher for hypertension, overweight, obesity, 12 months or more nephrologist care, most insurance types, and each successive year after 2005. Despite associations, the C statistic for the expanded model was 0.64.

LIMITATIONS

This analysis is limited by lack of access creation history before dialysis therapy initiation and minimal external validation of CMS 2728 data.

CONCLUSIONS

Clinical risk factors identified by Lok and expanded in this analysis have limited ability to predict incident AVF use. Even patients judged at highest risk can have successful AVF construction and initiate dialysis therapy through a functioning AVF.

Achieving the goal of the Fistula First breakthrough initiative for prevalent maintenance hemodialysis patients

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) established a national goal of 66% arteriovenous fistula (AVF) use in prevalent hemodialysis (HD) patients for the current Fistula First Breakthrough Initiative. The feasibility of achieving the goal has been debated. We examined contemporary patterns of AVF use in prevalent patients to assess the potential for attaining the goal by dialysis facilities and their associated End-Stage Renal Disease Networks in the United States.

STUDY DESIGN

Observational study.

SETTING & PARTICIPANTS

US dialysis facilities with a mean HD patient census of 10 or more during the 40-month study period, January 2007-April 2010.

OUTCOMES & MEASUREMENTS

Mean changes in facility-level AVF use and percentage of facilities achieving the 66% prevalent AVF goal within the United States and each network.

RESULTS

Mean prevalent AVF use within dialysis facilities increased from 45.3% to 55.5% (P < 0.001) in the United States, but varied substantially across regions. The percentage of facilities achieving the 66% AVF use goal increased from 6.4% to 19.0% (P < 0.001). During the 40 months, 35.9% of facilities achieved the CMS goal for at least 1 month. On average, these facilities sustained mean use ≥66% for 12.9 ± 11.7 (SD) months. Case-mix and other facility characteristics explained 20% of the variation in proportion of facility patients using an AVF in the last measured month, leaving substantial unexplained variability.

LIMITATIONS

This analysis is limited by the absence of facility case-mix data over time, and the national scope of the initiative precludes use of a comparison group.

CONCLUSIONS

Achieving the CMS goal of 66% prevalent AVF use is feasible for individual dialysis facilities. There is a need to decrease regional variation before the CMS goal can be fully realized for US HD facilities.

Measurement of antiplatelet inhibition during neurointerventional procedures: the effect of antithrombotic duration and loading dose

BACKGROUND/OBJECTIVE

Symptomatic thromboembolic events are the most common complications associated with aneurysm coiling, and carotid and intracranial stenting. Our objective is to assess the effect of aspirin (ASA) and clopidogrel dose and duration on platelet inhibition using a point of care assay in neurointerventional (NI) suite.

METHOD

The dose, duration, and point of care platelet function assay data for clopidogrel and aspirin therapy were prospectively collected between February 2006 and November 2007. Inadequate platelet inhibition for ASA was defined as >or=550 ASA reaction units (ARU), and for clopidogrel was defined as <or=50% inhibition of the P2Y12/ADP receptor

RESULTS

We collected data from 216 consecutive patients. Inadequate platelet inhibition was noted in 13% of patients on aspirin and 66% of patients on clopidogrel (P-value < .0001). Patients taking clopidogrel 75 mg for >or=7 days, 300 mg for 24 hours, and 600 mg same day load had a mean P2Y12/ADP inhibition of 45%, 35% (P-value = .09), and 16%, respectively (P-value = .005).

CONCLUSION

Premedication with clopidogrel, in contrast to aspirin, does not achieve adequate platelet inhibition in about two-third of the patients. Same day antiplatelet loading may be insufficient to achieve adequate platelet inhibition and should be avoided if clinically feasible.

Protective effect of apolipoprotein E-mimetic peptides on N-methyl-D-aspartate excitotoxicity in primary rat neuronal-glial cell cultures

Apolipoprotein E (apoE) is a 34-kD protein with multiple biological properties. Recent clinical and preclinical observations implicate a role for apoE in modifying the response of the brain to focal and global ischemia. One mechanism by which apoE might exert these effects is by reducing glutamate-induced excitotoxic neuronal injury associated with ischemic insults. We demonstrate that human recombinant apoE confers a mild neuroprotective effect in primary neuronal-glial cultures exposed to 100 microM N-methyl-D-aspartate. Furthermore, a peptide derived from the receptor-binding region of apoE (residues 133-149) maintained a significant helical population as assessed by circular dichroism, and completely suppressed the neuronal cell death and calcium influx associated with N-methyl-D-aspartate exposure. Neuroprotection was greatest when the peptide was added concurrently with N-methyl-D-aspartate; however, a significant protection was observed when peptide was preincubated and washed off prior to N-methyl-D-aspartate exposure. These results suggest that one mechanism by which apoE may modify the CNS response to ischemia is by partially blocking glutamate excitotoxicity. Moreover, small peptide fragments derived from the receptor-binding region of apoE have enhanced bioactivity compared with the intact holoprotein, and may represent a novel therapeutic strategy for the treatment of brain ischemia.

Apolipoprotein E modulates glial activation and the endogenous central nervous system inflammatory response

Apolipoprotein E (apoE) is a 299 amino acid protein that is associated with risk of developing Alzheimer's Disease (AD) and outcome after acute brain injury. To investigate the possibility that apoE modulates glial activation we studied the effect of endogenous apoE on inflammatory gene regulation in vitro and in vivo. Our results indicate that apoE downregulates CNS production of TNFalpha, Il-1beta, and Il-6 mRNA following stimulation with lipopolysaccharide (LPS). This effect of endogenous apoE on inflammatory gene regulation appears to be specific, and may account for the biological role that apoE plays in acute and chronic human neurological disease.

Quantitative level of protection offered to workers by ACGIH threshold limit values occupational exposure limits

The details of the example or modeling methodologies used herein are not critical to the general point of this article, which advises the estimation of residual risk at the OEL by using some quantitative modeling structure. Specifically, the authors believe that an explicit attempt to gauge the level of residual risk at the OEL based on conceptual stochastic models with transparent and testable assumptions could be seen as an important enhancement to the process. This is especially true in sharing the OEL deliberations and explaining OEL decisions to the stakeholders. Indeed, if this approach is used, it is critically important to understand and continually communicate that this "cloud of uncertainty" represents model estimates in which the true risk would most likely be less than worst case estimates and could possibly be zero. It is also possible but highly unlikely that it could be higher than the worst case upper-bound estimate. The above quantitative estimation scheme represents a possible improvement that could provide a reasoned attempt on the part of the risk assessors to use rational science (i.e., conceptual models with transparent and testable assumptions) to inform all of the OEL users and stakeholders of their meaning.

Survival and outcome after endotracheal intubation for acute stroke

OBJECTIVE

To assess survival and functional outcome in patients endotracheally intubated after ischemic stroke (IS) or spontaneous intracerebral hemorrhage (ICH).

BACKGROUND

Endotracheal intubation is both a necessary life support intervention and a measure of severity in IS or ICH. Knowledge of associated clinical variables may improve the estimation of early prognosis and guide management in these patients.

METHODS

We reviewed 131 charts of patients with IS or ICH who were admitted to the Neurosciences Intensive Care Unit at Duke University Medical Center between July 1994 and June 1997 and required endotracheal intubation. Stroke risk factors, stroke type (IS or ICH) and location (hemispheric, brainstem, or cerebellum), circumstances surrounding intubation, neurologic assessment (Glasgow Coma Score [GCS] and brainstem reflexes), comorbidities, and disposition at discharge were documented. Survivors were interviewed for Barthel Index (BI) scores.

RESULTS

Survival was 51% at 30 days and 39% overall. Variables that significantly correlated with 30-day survival in multivariate analysis included GCS at intubation (p = 0.03) and absent pupillary light response (p = 0.008). Increase in the GCS also correlated with improved functional outcome measured by the BI (p = 0.0003). In patients with IS, age and GCS at intubation predicted survival, and in patients with ICH, absent pupillary light response predicted survival.

CONCLUSIONS

Predictors for mortality differ between patients with IS and ICH; however, decreased level of consciousness is the most important determinant of increased mortality and poor functional outcome. Absent pupillary light responses also correspond with a poor prognosis for survival, but further validation of this finding is needed.

Hospital closure: an efficiency analysis

Logistic regression analysis was used to test the hypothesis that market forces have led to recent hospital closures. Specifically, inefficient and underutilized hospitals in competitive markets were hypothesized to be at greater risk for closure. While past studies used crude measures of hospital efficiency to predict closure, this study used data envelopment analysis to construct an efficiency index. Mixed support was found for the market forces hypothesis; however, contrary to expectations, inefficient hospitals were not shown to be at increased risk for closure. In fact, efficiency proved to be a weak, but positive, predictor of closure.

Surgical treatment of carpal tunnel syndrome in patients with peripheral neuropathy

Outcome after carpal tunnel surgery was studied retrospectively in 32 patients with peripheral neuropathy and carpal tunnel syndrome. Nocturnal paresthesias were almost universally relieved, followed in order of responsiveness by pain, numbness, and weakness. Twenty-five of 28 patients said they would have the surgery again if the outcome were the same. Patients with carpal tunnel syndrome and peripheral neuropathy benefit from surgical treatment of carpal tunnel syndrome.

Plantar medial subluxation of the medial cuneiform: case report of an uncommon variant of the Lisfranc injury

An uncommon injury of plantar medial subluxation of the medial cuneiform as a variant of the Lisfranc fracture subluxation is presented. The mechanism of injury is discussed and a comparison is made to previous case reports of variants of medial cuneiform injury.

A molecular approach to the stratification of cardiovascular risk in families with Marfan's syndrome

BACKGROUND

The fibrillin gene encodes a protein in the extracellular matrix, and this protein is widely distributed in elastic tissues. The fibrillin gene is the site of mutations causing Marfan's syndrome. This disorder shows a high degree of clinical variability both between and within families. Each family appears to have a unique mutation in the fibrillin gene, which precludes the routine use of mutation screening for presymptomatic diagnosis of the disorder. The goal of this study was to develop a widely applicable method of molecular diagnosis.

METHODS

We used three newly characterized intragenic sites of normal DNA repeat-sequence variation (i.e., polymorphisms) as markers to follow the inheritance pattern of specific copies (alleles) of the fibrillin gene in multiple kindreds with various clinical features of Marfan's syndrome.

RESULTS

The polymorphic markers allowed identification of the particular copy of the fibrillin gene that cosegregated with Marfan's syndrome in 13 of the 14 families tested. In 11 families a definite presymptomatic diagnosis of Marfan's syndrome could be made in family members who had only equivocal manifestations of the disorder. In two other families, some family members demonstrated either classic Marfan's syndrome or a milder but closely related phenotype. The copy of the fibrillin gene that cosegregated with classic Marfan's syndrome was not inherited by family members with the latter, atypical, form of the disease. These milder phenotypes, previously diagnosed as Marfan's syndrome, were not associated with aortic involvement.

CONCLUSIONS

These results document the usefulness of novel polymorphic DNA repeat sequences in the presymptomatic diagnosis of Marfan's syndrome. Our findings also demonstrate that the various clinical phenotypes seen in selected families may be due not to single fibrillin mutations, but rather to different genetic alterations. These findings underscore the need for a modification of the current diagnostic criteria for Marfan's syndrome in order to achieve accurate risk assessment.

A new missense mutation of fibrillin in a patient with Marfan syndrome

A patient with Marfan syndrome was shown to be heterozygous for a G to A transition at nucleotide 3952 of the FBNI gene. This would result in a cysteine to tyrosine substitution at amino acid 1223 in the fibrillin protein.

Genomic organization of the sequence coding for fibrillin, the defective gene product in Marfan syndrome

Marfan syndrome results from mutations in an extracellular matrix glycoprotein, fibrillin. Previous studies have characterized approximately 6.9-kb of the estimated 10-kb fibrillin transcript. We have now completed the primary structure of fibrillin, elucidated the exon/intron organization of the gene and derived a physical map of the genetic locus. Pre-fibrillin consists of 2,871 amino acids which, excluding the signal peptide, are arranged into five structurally distinct regions. The largest of these regions comprises about 75% of the entire protein and consists of numerous repeated cysteine-rich sequences homologous to the peptide motifs of the epidermal growth factor (EGF) and transforming growth factor-beta binding protein (TGF-bp). Forty-three of the forty-six EGF-like repeats contain a calcium binding consensus sequence (EGF-CB) conceivably mediating protein-protein interactions. Fibrillin exhibits a few additional cysteine-rich modules that are apparently unique to this macromolecule and may represent evolutionary variants of the EGF-CB and TGF-bp motifs. Almost all of the cysteine-rich repeats are encoded by single exons; consequently, the fibrillin gene is relatively large (approximately 110-kb) and highly fragmented (65 exons). This study provides the first comprehensive analysis of the fibrillin gene and relevant information for the full characterization of Marfan syndrome mutations.

Confirmation of genetic linkage between atopic IgE responses and chromosome 11q13

Genetic linkage between atopic IgE responses and chromosome 11q13 (D11S97) has been previously reported in a limited number of extended families. Difficulties of phenotyping in the older family members, poor family structure in some families, and genetic heterogeneity were proposed as possible explanations for the variability in lod scores. To test this finding a second linkage study of 64 young nuclear families was undertaken and gave a two point lod score of 3.8 at theta = 0.07 (assuming theta m = theta f). A test of genetic heterogeneity in the nuclear families shows that atopic IgE responses are linked to this locus in 60 to 100% of families (approximate 95% confidence limits).

Rural hospital closures: an inquiry into efficiency

The relationship between efficiency and rural hospital closure was examined by comparing the efficiency of nongovernment short-term general rural hospitals that closed in 1988 to that of their counterparts that remained opened. A similar comparison was made between the efficiency of open and closed urban facilities. Although no relationship between efficiency and closure was demonstrated, an examination of the surpluses and shortages in production among inefficient hospitals revealed that inefficient closed hospitals in both rural and urban areas experienced a lack of demand for inpatient services. Furthermore, a threshold value of 21 or 22 inpatient discharges per bed per year was identified as being related to closure regardless of whether a hospital was operating efficiently or not.

G/A polymorphism in an intron of the fibrillin gene FBNI

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Characterization of the breakpoint of a 3.5-kb deletion of the beta-globin gene

The precise extent and breakpoints of a deletion of the beta-globin gene in a Thai patient have been determined using direct sequencing of a PCR product. This lesion is not detectable by current screening methods using PCR to analyze the beta-globin genes and is, therefore, a potential source of error in the diagnosis and prenatal detection of beta-thalassemia.

Genetic analysis in cystic fibrosis using the amplification refractory mutation system (ARMS): the J3.11 MspI polymorphism

A new method of genetic analysis has been devised. The method, amplification refractory mutation system (ARMS), has been used to genotype the J3.11 MspI restriction fragment length polymorphism (RFLP) closely linked to cystic fibrosis (CF). The DNA sequence for both alleles of this dimorphism has been used to design ARMS primers. These allow genotyping of DNA isolated from blood, Guthrie cards, and buccal cells.

Prenatal diagnosis of osteogenesis imperfecta by identification of the concordant collagen 1 allele

Dominantly inherited osteogenesis imperfecta is consistently linked to the two loci encoding the alpha 1 and alpha 2 subunits of collagen 1, the predominant bone collagen. We have performed several prenatal diagnoses based on identification of the segregating allele at the concordant locus in chorionic villus samples both in families where the linkage can be independently shown and in those where it cannot. Especially in the latter category, calculation of the final risk must incorporate an estimate of genetic heterogeneity within the OI population to give a prior probability of linkage. This figure can then be modified for each family by additional information from concordant meioses.

The effects of for-profit multihospital system ownership on hospital financial and operating performance

The financial and operating performance of independent not-for-profit hospitals acquired by US for-profit multi-hospital systems in 10 Southern states between the years 1978 and 1982 was explored. The impact of system ownership on acquired hospitals was investigated by comparing the average financial performance of hospitals in the two years immediately prior to acquisition to the average for 1984 and 1985 and by comparing changes in the performance of acquired hospitals with changes in matched independent facilities. Findings suggest that for-profit multi-hospital systems were able to improve many of the financial and operating problems of acquired facilities. In comparison to independent not-for-profit hospitals, acquired hospitals were found to increase access to long-term debt, make improvements to plant and equipment, improve profitability, and increase efficiency to a greater extent. Prices in acquired hospitals rose more than those in independents and liquidity decreased to a greater extent.

The polymerase chain reaction: current and future clinical applications

The polymerase chain reaction has undergone rapid improvement since its initial development, such that the technique currently permits rapid, accurate, predictive tests to be made in the field of prenatal diagnosis and has greatly aided forensic medicine. It is anticipated that the polymerase chain reaction will also facilitate advances in other fields, in particular preimplantation diagnosis, virology, bacteriology, and cancer therapy.

Financial assessment of small multihospital systems

This article examines the financial performance of small multihospital systems relative to freestanding hospitals. Small systems, defined as seven or fewer hospital units, were analyzed for three ownership categories: investor owned, church related, and secular not-for-profit. Finding few statistically significant differences between system and independent hospitals indicates that small systems are unable to fulfill the financial promises of system affiliation.

Direct detection of haemoglobin E with MnlI

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Evolutionary relationships of human populations from an analysis of nuclear DNA polymorphisms

The genetic relationships of human populations have been studied by comparing gene frequency data for protein and blood-group loci of different populations. DNA analysis now promises to be more informative since not only do the DNA coding sequences have more variation than their corresponding proteins but, in addition, noncoding DNA sequences display more extensive polymorphism. We have now studied the frequency of a group of closely linked nuclear DNA polymorphisms (haplotypes) in the beta-globin gene cluster of normal (beta A) chromosomes of individuals from eight diverse populations. We have found that all non-African populations share a limited number of common haplotypes whereas Africans have predominantly a different haplotype not found in other populations. Genetic distance analysis based on these nuclear DNA polymorphisms indicates a major division of human populations into an African and a Eurasian group.

Evaluation of a rapid system for species identification of alpha-hemolytic streptococci

A new 4-h commercial system (API 20S; Analytab Products, Plainview, N.Y.) for the identification of streptococci was compared with the conventional biochemical profile method in the species identification of alpha-hemolytic streptococci. A total of 194 clinical isolates (including 74 isolated from blood cultures, 64 isolated from wound cultures, and 56 isolated from respiratory cultures) and 20 reference strains were tested. Only 4 of the 20 reference strains were correctly identified to species level by the API 20S system. Six were identified to group level (viridans), four were incorrectly identified, and six did not conform to the identification key. Of the 194 clinical isolates tested, 79 (39%) were correctly identified to species level, 34 (17.5%) were identified to group level, 34 (17.5%) were incorrectly identified, and 50 (25.8%) did not conform to the identification key. Of the 12 different species of alpha-hemolytic streptococci isolated from clinical specimens, the API 20S system consistently identified Streptococcus faecalis and Streptococcus faecium, but consistently misidentified the other 10 species, especially Streptococcus mitis. Our results indicate that for identification to species level, the API 20S system is of little value for alpha-hemolytic streptococci other than enterococci.

Occupational Health/Safety Program Accreditation Commission

This presents a brief history of programs for accrediting occupational health activities with discussion of weaknesses and strengths. The relatively short life of the Occupational Health/Safety Program Accreditation Commission is reviewed with emphasis on its charge, goals and accomplishments. The mechanisms for accreditating Occupational Health and Safety Programs is described and some reasons for seeking accreditation are given.