Benefit-Cost Analysis of the HHS COVID-19 Campaign: April 2021-March 2022

INTRODUCTION

This study estimated the benefits and costs of the U.S. Department of Health and Human Services' We Can Do This COVID-19 public education campaign (the Campaign) and associated vaccination-related impacts.

METHODS

Weekly media market and national Campaign expenditures were used to estimate weekly first-dose vaccinations that would not have occurred absent the Campaign, weekly Campaign-attributed complete vaccinations, and corresponding COVID-19 cases, hospitalizations, and deaths averted. Benefits were valued using estimated morbidity and mortality reductions and associated values of a statistical life and a statistical case. Costs were estimated using Campaign paid media expenditures and corresponding vaccination costs. The net Campaign and vaccination benefit and return on investment were calculated. Analyses were conducted from 2022 to 2024.

RESULTS

Between April 2021 and March 2022, an estimated 55.9 million doses of COVID-19 vaccines would not have been administered absent the Campaign. Campaign-attributed vaccinations resulted in 2,576,133 fewer mild COVID-19 cases, 243,979 fewer nonfatal COVID-19 hospitalizations, and 51,675 lives saved from COVID-19. The total Campaign benefit was $740.2 billion, and Campaign and vaccination costs totaled $8.3 billion, with net benefits of approximately $732.0 billion. For every $1 spent, the Campaign and corresponding vaccination costs resulted in benefits of approximately $89.54.

CONCLUSIONS

The We Can Do This COVID-19 public education campaign saved more than 50,000 lives and prevented hundreds of thousands of hospitalizations and millions of COVID-19 cases, representing hundreds of billions of dollars in benefits in less than one year. Findings suggest that public education campaigns are a cost-effective approach to reducing COVID-19 morbidity and mortality.

Association Between the United States Department of Health and Human Services' COVID-19 Public Education Campaign and Initial Adult COVID-19 Vaccination Uptake by Race and Ethnicity in the United States, 2020-2022

Non-Hispanic Black (Black) and Hispanic/Latino (Latino) populations face an increased risk of COVID-19 infection, hospitalization, and death from COVID-19 relative to non-Hispanic White (White) populations. When COVID-19 vaccines became available in December 2020, Black and Latino adults were less likely than White adults to get vaccinated due to factors such as racial discrimination and structural barriers to uptake. In April 2021, the U.S. HHS COVID-19 public education campaign (the Campaign) was launched to promote vaccination through general and audience-tailored messaging. As of March 2022, Black and Latino adults had reached parity with White adults in COVID-19 vaccine uptake. This study evaluated the relationship between Campaign exposure and subsequent vaccine uptake among Black, Latino, and White adults in the United States and assessed whether participant race/ethnicity moderated the relationship between Campaign exposure and vaccine uptake. Campaign media delivery data was merged with survey data collected from a sample of U.S. adults (n = 2,923) over four waves from January 2021 to March 2022. Logistic regression analysis showed that cumulative Campaign digital impressions had a positive, statistically significant association with COVID-19 vaccine uptake, and that participant race/ethnicity moderated this association. Compared with White adults, the magnitude of the relationship between cumulative impressions and vaccination was greater among Black and Latino adults. Results from a simulation model suggested that the Campaign may have been responsible for closing 5.0% of the gap in COVID-19 vaccination by race/ethnicity from April to mid-September 2021. We discuss implications for future public education campaigns that aim to reduce health disparities.

Evaluation of the "We Can Do This" Campaign Paid Media and COVID-19 Vaccination Uptake, United States, December 2020-January 2022

Public education campaigns are promising methods for promoting vaccine uptake. In April 2021, the U.S. Department of Health and Human Services launched the We Can Do This COVID-19 public education campaign. This study is one of the first evaluations of this COVID-19 public education campaign. We tested associations between channel-specific campaign exposure (i.e. digital, TV, radio, print, and out-of-home advertising) and COVID-19 first-dose vaccinations among a nationally representative online sample of 3,278 adults. The study introduces novel ways to simultaneously evaluate short- and long-term cumulative media dose, filling an important gap in campaign evaluation literature. We observed a positive, statistically significant relationship between the short-term change in digital media dose and the likelihood of first-dose vaccination, and a positive, statistically significant relationship between long-term cumulative TV dose and the likelihood of first-dose vaccination. Results suggest that both digital and TV ads contributed to vaccination, such that digital media was associated with more immediate behavioral changes, whereas TV gradually shifted behaviors over time. As findings varied by media channel, this study suggests that public education campaigns should consider delivering campaign messages across multiple media channels to enhance campaign reach across audiences.

Recalled Exposure to COVID-19 Public Education Campaign Advertisements Predicts COVID-19 Vaccine Confidence

This study examined the relationship between recalled exposure to the We Can Do This COVID-19 Public Education Campaign (the Campaign) and COVID-19 vaccine confidence (the likelihood of vaccination or vaccine uptake) in the general population, including vaccine-hesitant adults (the "Movable Middle"). Analyses used three waves of a triannual, nationally representative panel survey of adults in the U.S. fielded from January to November 2021 (n = 3,446). Proportional odds regression results demonstrated a positive, statistically significant relationship between past 4-month Campaign recall and vaccine confidence, controlling for lagged reports of Campaign recall and vaccine confidence; concurrent and lagged fictional campaign recall; survey wave; and sociodemographics. Results indicated that as one moves from no Campaign recall to infrequent recall, there is a 29% increase in the odds of being in a higher vaccine confidence category. Findings offer evidence of the impact of a COVID-19 public education campaign on increasing vaccine confidence.

Small Fiber Neuropathy

PURPOSE OF REVIEW

This narrative review aims to summarize advances in the field of small fiber neuropathy made over the last decade, with emphasis on novel research highlighting the distinctive features of SFN.

RECENT FINDINGS

While the management of SFNs is ideally aimed at treating the underlying cause, most patients will require pain control via multiple, concurrent therapies. Herein, we highlight the most up-to-date information for diagnosis, medication management, interventional management, and novel therapies on the horizon. Despite the prevalence of small fiber neuropathies, there is no clear consensus on guidelines specific for the treatment of SFN. Despite the lack of specific guidelines for SFN treatment, the most recent general neuropathic pain guidelines are based on Cochrane studies and randomized controlled trials (RCTs) which have individually examined therapies used for the more commonly studied SFNs, such as painful diabetic neuropathy and HIV neuropathy. The recommendations from current guidelines are based on variables such as number needed to treat (NNT), safety, ease of use, and effect on quality of life.

Effectiveness of Behaviorally Informed Letters on Health Insurance Marketplace Enrollment

Question

How much do behaviorally informed letters increase health insurance enrollment?

Findings

In this randomized clinical trial that included 744 510 individuals on the HealthCare.gov platform during the final 2 weeks of the 2015 open enrollment period, use of a single behaviorally informed letter caused a statistically significant increase in health insurance enrollment. Letters that used action language caused larger effects, particularly among Black and Hispanic individuals in Medicaid expansion states.

Meaning

Policy makers can use low-cost letter nudges to increase enrollment across Affordable Care Act marketplaces.

Importance

Every year during the open enrollment period, hundreds of thousands of individuals across the Affordable Care Act marketplaces begin the enrollment process but fail to complete it, thereby resulting in coverage gaps or going uninsured.

Objective

To investigate if low-cost ($0.55 per person) letters can increase health insurance enrollment.

Design, Setting, and Participants

This intent-to-treat randomized clinical trial was conducted during the final 2 weeks of the 2015 open enrollment period among the 37 states on the HealthCare.gov platform. The trial targeted 744 510 individuals who started the enrollment process but had yet to complete it. Data were analyzed from January through August 2021.

Interventions

Study participants were randomized to either a no-letter control group or to 1 of 8 letter variants that drew on evidence from the behavioral sciences about what motivates individuals to take action.

Main Outcomes and Measures

The primary outcome was the health insurance enrollment rate at the end of the open enrollment period.

Results

Of the 744 510 individuals (mean [SD] age, 41.9 [19.6] years; 53.9% women), 136 122 (18.3%) were in the control group and 608 388 (81.7%) were in the treatment group. Most lived in Medicaid nonexpansion states (72.7%), and a plurality were between 30 and 50 years old (41.0%). For race and ethnicity, 3.0% self-identified as Asian, 14.0% as Black, 5.1% as Hispanic, 39.8% as non-Hispanic White, and 38.2% as other or unknown. By the end of the open enrollment period, 4.0% of the control group enrolled in health insurance coverage. Comparatively, the enrollment rate in the pooled treatment group was 4.3%, which demonstrated an increase of 0.3 percentage points (95% CI, 0.2-0.4 percentage points; P<.001), yielding 1753 marginal enrollments. Letters that used action language caused larger enrollment effects, particularly among Black individuals (increase of 1.6 percentage points; 95% CI, 0.6-2.7 percentage points; P = .003) and Hispanic individuals (increase of 1.5 percentage points; 95% CI, 0.0-3.0 percentage points; P = .046) in Medicaid expansion states.

Conclusions and Relevance

This randomized clinical trial shows that letters designed with best practices from the behavioral sciences literature were a low-cost way to increase health insurance enrollment in the Affordable Care Act marketplaces. More research is needed to understand what messages are most effective amid the recently passed American Rescue Plan.

Trial Registration

ClinicalTrials.gov Identifier: NCT05010395

Cytomegalovirus Enterocolitis secondary to experimental COVID-19 therapy

The novel coronavirus-2019 (COVID-19) has caused a global pandemic of historical proportions, infecting millions of people worldwide. Due to its high mortality rate and a paucity of clinical data, experimental therapies have been utilized with uncertain success and, unfortunately, poor outcomes. We describe a gentleman who was treated with experimental therapies and subsequently developed cytomegalovirus colitis and hypovolemic shock. Additionally, this case validates colonoscopy as a mode to rule out concurrent infectious etiologies causing diarrhea in COVID-19-positive patients.

Augmented primary repair of patellar ligament rupture in three dogs

Treatment of unilateral patellar ligament rupture resulting from laceration is described in three large dogs. Surgical repair involved debridement and suturing of the ligament ends. Augmentation was provided with encircling loops of 27 kg test monofilament nylon passed through transverse holes drilled in the patella and proximal tibial tuberosity. All of the dogs returned to a pre-injury level of activity without any lameness being observed when they were reevaluated five to 24 months after their operation. The method described is a useful technique for repair of patellar ligament rupture that produced excellent and enduring results in these cases.

Physical activity during video capsule endoscopy correlates with shorter bowel transit time

BACKGROUND AND STUDY AIM

 Video capsule endoscopy (VCE) is limited by reliance on bowel motility for propulsion, and lack of physical activity has been proposed as a cause of incomplete studies. Our aim was to prospectively investigate the association between physical activity and VCE bowel transit.

PATIENTS AND METHODS

 Ambulatory outpatients receiving VCE were eligible for the study. A pedometer was attached at the time of VCE ingestion and step count was recorded at the end of the procedure. VCE completion was assessed by logistic regression models, which included step count (500 steps as one unit). Total transit time was analyzed by Cox proportional hazards models. The hazard ratios (HR) with 95 % confidence interval (CI) indicated the "hazard" of completion, such that HRs > 1 indicated a reduced transit time.

RESULTS

 A total of 100 patients were included. VCE was completed in 93 patients (93 %). The median step count was 2782 steps. Step count was not significantly associated with VCE completion (odds ratio 1.45, 95 %CI 0.84, 2.49). Pedometer step count was significantly associated with shorter total, gastric, and small-bowel transit times (HR 1.09, 95 %CI 1.03, 1.16; HR 1.05, 95 %CI 1.00, 1.11; HR 1.07, 95 %CI 1.01, 1.14, respectively). Higher body mass index (BMI) was significantly associated with VCE completion (HR 1.87, 95 %CI 1.18, 2.97) and shorter bowel transit times (HR 1.05, 95 %CI 1.02, 1.08).

CONCLUSIONS

 Increased physical activity during outpatient VCE was associated with shorter bowel transit times but not with study completion. In addition, BMI was a previously unreported clinical characteristic associated with VCE completion and should be included as a variable of interest in future studies.

Blood metal ion levels are not a useful test for adverse reactions to metal debris: A systematic review and meta-analysis

Objectives

Alarm over the reported high failure rates for metal-on-metal (MoM) hip implants as well as their potential for locally aggressive Adverse Reactions to Metal Debris (ARMDs) has prompted government agencies, internationally, to recommend the monitoring of patients with MoM hip implants. Some have advised that a blood ion level >7 µg/L indicates potential for ARMDs. We report a systematic review and meta-analysis of the performance of metal ion testing for ARMDs.

Methods

We searched MEDLINE and EMBASE to identify articles from which it was possible to reconstruct a 2 × 2 table. Two readers independently reviewed all articles and extracted data using explicit criteria. We computed a summary receiver operating curve using a Bayesian random-effects hierarchical model.

Results

Our literature search returned 575 unique articles; only six met inclusion criteria defined a priori. The discriminative capacity of ion tests was homogeneous across studies but that there was substantial cut-point heterogeneity. Our best estimate of the “true” area under curve (AUC) for metal ion testing is 0.615, with a 95% credible interval of 0.480 to 0.735, thus we can state that the probability that metal ion testing is actually clinically useful with an AUC ≥ 0.75 is 1.7%.

Conclusion

Metal ion levels are not useful as a screening test for identifying high risk patients because ion testing will either lead to a large burden of false positive patients, or otherwise marginally modify the pre-test probability. With the availability of more accurate non-invasive tests, we did not find any evidence for using blood ion levels to diagnose symptomatic patients.

Cite this article: M. Pahuta, J. M. Smolders, J. L. van Susante, J. Peck, P. R. Kim, P. E. Beaule. Blood metal ion levels are not a useful test for adverse reactions to metal debris: a systematic review and meta-analysis. Bone Joint Res 2016;5:379–386. DOI: 10.1302/2046-3758.59.BJR-2016-0027.R1.

New Labourers? Making a New Deal for the ‘Workless Class’

The author presents a critical early appraisal of the British Labour Government's ‘New Deal’ welfare-to-work programme for 18–24 year-olds. A key element in the Government's strategy for tackling social exclusion, the New Deal represents a major financial and political commitment, yet perhaps more fundamentally it reflects a change in Labour's thinking about the underlying causes of, and appropriate remedies for, unemployment. Drawing on a behaviourist, supply-side, explanation of ‘welfare dependency’, the aim of the programme is not to create jobs (as it was for ‘Old Labour’) but to (re)create a work ethic — to raise ‘employ ability’ amongst young people. This does not take sufficient account of the demand-side, structural, causes of unemployment a fact which is likely to lead to difficulties (both in implementation and in the achievement of positive outcomes) in precisely those parts of the country where the need is greatest: high-unemployment areas in the large cities and lagging regions. The author argues, therefore, that particular attention needs to be paid to the emerging geographies of welfare-to-work because, as the New Deal ‘treads down’ differentially into local labour markets around the country, its effects will begin to diverge from those anticipated by national policymakers. In labour-market terms, the programme may even begin to dispense different regulatory functions in relatively depressed compared with buoyant local economies, with institutional containment emerging as the dominant function in the depressed areas and economic coercion the dominant function in buoyant local economies.

Exercises in Anatomy, Connectivity, and Morphology using Neuromorpho.org and the Allen Brain Atlas

Laboratory instruction of neuroscience is often limited by the lack of physical resources and supplies (e.g., brains specimens, dissection kits, physiological equipment). Online databases can serve as supplements to material labs by providing professionally collected images of brain specimens and their underlying cellular populations with resolution and quality that is extremely difficult to access for strictly pedagogical purposes. We describe a method using two online databases, the Neuromorpho.org and the Allen Brain Atlas (ABA), that freely provide access to data from working brain scientists that can be modified for laboratory instruction/exercises. Neuromorpho.org is the first neuronal morphology database that provides qualitative and quantitative data from reconstructed cells analyzed in published scientific reports. The Neuromorpho.org database contains cross species and multiple neuronal phenotype datasets which allows for comparative examinations. The ABA provides modules that allow students to study the anatomy of the rodent brain, as well as observe the different cellular phenotypes that exist using histochemical labeling. Using these tools in conjunction, advanced students can ask questions about qualitative and quantitative neuronal morphology, then examine the distribution of the same cell types across the entire brain to gain a full appreciation of the magnitude of the brain's complexity.

DNA quantification of exfoliated colonocytes as a novel screening tool for colorectal cancer

AIMS

Colorectal cancer (CRC) sheds viable cells in the mucocelluar layer overlaying the colonic mucosa which travels distally alongside the faecal stream. These cells can be retrieved from the surface of the rectal mucosa. DNA quantification of these cells may be a marker of CRC, assessment of which was aim of this study.

METHODS

A prospective double-blinded study of 467 consecutive patients referred with symptoms suggestive of CRC. Cells were collected from the surface of the rectal mucosa and total DNA quantified. DNA scores were compared with outcome after subjects had completed bowel investigations. Analysis of receiver operating characteristic (ROC) curves was performed to determine the optimum cut-off point for a positive result.

RESULTS

107 of the 467 patients were excluded due to; excessive faecal contamination of samples (n = 84); declined investigations (n = 17); inappropriate referral (n = 5); unfit (n = 1). 263 patients had lower GI endoscopy; 89 CT colonography and 8 barium enema. The diagnosis were; CRC (n = 23), inflammatory bowel disease (IBD) (n = 7), adenomatous polyps (AP) (n = 20) and no significant abnormality detected (n = 310). ROC analysis revealed that sensitivities at a specificity of 60% for detecting CRC were 91.3%; for CRC and IBD 86.7%; and for CRC, IBD and AP 72.0%.

CONCLUSION

In symptomatic patients DNA quantification of cells retrieved from the surface of the rectal mucosa is sensitive for the detection of CRC. Although faecal contamination is a limitation of this technique, refinement and application of other molecular tests hold promise for a better non invasive method for the detection of CRC.

Please Touch: Object Properties that Invite Touch

Touch has received increasing interest in marketing, given research indicating that contact with products influences evaluation and the tendency to purchase. However, little is known from the marketing or psychophysical literature about visible attributes of objects that elicit touch for hedonic purposes. In these studies, participants rated the tendency of pictured objects to invite touch, or "touch-ability." Rated touch-ability varied reliably with structural attributes of objects, and the structural influences were distinct from those on other ratings such as attractiveness and apparent expense. Although the trends varied across object sets, touch-ability generally declined as surface textures became markedly rough and shape complexity became extreme. Holding stimulus factors constant, touch-ability also varied with the specific hand movements that were anticipated. Finally, mean touch-ability ratings were correlated across participants with the "Need for Touch" scale, which measures an individual's tendency to touch products. The studies point to touch-ability as a potential factor that might be incorporated into product design.

HER2/neu may not be an interesting target in biliary cancers: results of an early phase II study with lapatinib

PURPOSE

Biliary cancers (BCs) respond poorly to chemotherapy. Lapatinib is a dual inhibitor of epidermal growth factor receptor (EGFR) and HER2/neu, both implicated in cholangiocarcinogenesis. This trial was designed to determine the safety and efficacy of lapatinib in BC.

METHODS

A Fleming phase II design with a single stage of 25 patients was used. The dose of lapatinib was 1,500 mg/day administered orally in 28-day cycles. Tumor and blood specimens were analyzed for expression of HER2/neu and EGFR.

RESULTS

Nine patients with BC enrolled in this study. The study was terminated early because of futility. The most common toxicities were nausea and fatigue (78%) and diarrhea (67%). No responses were observed. Of 8 evaluable patients, 4 (50%) had stable disease. Median progression-free survival was 2.6 months (95% CI 1.6-4.4) and median overall survival was 5.1 months (95% CI 2.0-16.5). No somatic mutations in EGFR (exons 18-21) or HER2/neu were found. We did not find evidence of HER2 overexpression.

CONCLUSIONS

Lapatinib is well tolerated but failed to show activity as a single agent in treating patients with BC. Despite the small patient population, our study is consistent with previous findings, suggesting that targeting HER2/neu does not appear to be an effective therapy for BC.

Developing a synagis clinic for respiratory syncytial virus prophylaxis

Respiratory Syncytial Virus (RSV) can be devastating to premature infants and children with chronic lung disease. Palivizumab (Synagis) is a monoclonal antibody that is administered monthly by injection to prevent RSV infection in infants at high risk. This article describes a nurse-run ambulatory clinic to provide RSV prophylaxis. Coordination with other agencies, including community neonatal intensive care units, was essential to the clinic's success. For each of its first 2 years of operation, 24 infants and their families attended the clinic once each month for 5 months throughout the RSV season. Outcomes for this patient population were compared to outcomes reported in the literature, and include reduced RSV-related hospitalizations and reduced days of hospitalization.

Comparison of carotid endarterectomy at high- and low-volume hospitals

BACKGROUND

Population-based studies have demonstrated better outcomes for carotid endarterectomies at high-volume hospitals.

METHODS

This is a 2-year retrospective review of carotid procedures at two low-volume hospitals (n = 156) and one high-volume hospital (n = 404) in the metropolitan area of Portland, Oregon.

RESULTS

There were no significant differences in 30-day mortality and stroke rates for carotid endarterectomies when comparing low- and high-volume hospitals (P = 0.59). These were comparable rates despite the fact that the low-volume hospitals had significantly older patients (P <0.001), more smokers (P <0.001), more patients with an indication of a previous nondisabling stroke (P <0.01), and fewer patients who were asymptomatic (P <0.01).

CONCLUSION

The regionalization of carotid endarterectomy into high-volume hospitals is not justified by the findings of this study. Carotid endarterectomy performed by well-trained, experienced surgeons in low-volume hospitals is a safe procedure.

The sequence of the human genome

A 2.91-billion base pair (bp) consensus sequence of the euchromatic portion of the human genome was generated by the whole-genome shotgun sequencing method. The 14.8-billion bp DNA sequence was generated over 9 months from 27,271,853 high-quality sequence reads (5.11-fold coverage of the genome) from both ends of plasmid clones made from the DNA of five individuals. Two assembly strategies-a whole-genome assembly and a regional chromosome assembly-were used, each combining sequence data from Celera and the publicly funded genome effort. The public data were shredded into 550-bp segments to create a 2.9-fold coverage of those genome regions that had been sequenced, without including biases inherent in the cloning and assembly procedure used by the publicly funded group. This brought the effective coverage in the assemblies to eightfold, reducing the number and size of gaps in the final assembly over what would be obtained with 5.11-fold coverage. The two assembly strategies yielded very similar results that largely agree with independent mapping data. The assemblies effectively cover the euchromatic regions of the human chromosomes. More than 90% of the genome is in scaffold assemblies of 100,000 bp or more, and 25% of the genome is in scaffolds of 10 million bp or larger. Analysis of the genome sequence revealed 26,588 protein-encoding transcripts for which there was strong corroborating evidence and an additional approximately 12,000 computationally derived genes with mouse matches or other weak supporting evidence. Although gene-dense clusters are obvious, almost half the genes are dispersed in low G+C sequence separated by large tracts of apparently noncoding sequence. Only 1.1% of the genome is spanned by exons, whereas 24% is in introns, with 75% of the genome being intergenic DNA. Duplications of segmental blocks, ranging in size up to chromosomal lengths, are abundant throughout the genome and reveal a complex evolutionary history. Comparative genomic analysis indicates vertebrate expansions of genes associated with neuronal function, with tissue-specific developmental regulation, and with the hemostasis and immune systems. DNA sequence comparisons between the consensus sequence and publicly funded genome data provided locations of 2.1 million single-nucleotide polymorphisms (SNPs). A random pair of human haploid genomes differed at a rate of 1 bp per 1250 on average, but there was marked heterogeneity in the level of polymorphism across the genome. Less than 1% of all SNPs resulted in variation in proteins, but the task of determining which SNPs have functional consequences remains an open challenge.

Prior hrt use, ethnicity and mammographic density

PURPOSE: Mammographic density has been strongly associated with breast cancer risk in several studies. To clarify possible pathogenic mechanisms underlying this relationship, we assessed factors affecting mammographic density in postmenopausal women.METHODS: Percent density (PD) was measured on pre-randomization mammograms from 425 participants in the Women's Health Initiative clinical trial; no women were currently using HRT. Trained observers used a previously validated computer-assisted thresholding technique to measure PD (ratio of dense areas to breast area) on craniocaudal films. Univariate relationships were assessed between PD and age, parity, education, history of HRT use, age at first birth, abortion history, alcohol use, serum cholesterol, physical activity, smoking, dietary fat intake, body-mass index (BMI), and waist-to-hip ratio (WHR). Multivariable regression was used to identify predictors of PD (log transformed), controlling for confounders.RESULTS: PD ranged from 0-60% with mean 8%. Age, gravidity, BMI, and WHR were negatively associated with PD. Mean PD in the highest tertiles of BMI and WHR was nearly half that in the lowest. Ethnicity (50% white, 28% black, and 19% Hispanic) and hysterectomy status (50% had intact uterus) were unassociated with PD. Controlling for age, BMI, WHR, smoking, hysterectomy status, prior HRT, and nulliparity, mean PD differed significantly by ethnicity, with black women having highest PD. However, the effect of prior HRT use differed by uterine status. In women with uteri intact, ethnicity, but not prior HRT use, was related to PD after controlling for age, BMI, and WHR. In hysterectomized women, ethnicity was unrelated to PD, while previous HRT was associated with lower PD.CONCLUSIONS: Gravidity, ethnicity and body shape and size are associated with mammographic density in postmenopausal women. Previous hormone use predicts lower PD, but only among hysterectomized women. This may be due to the higher frequency of oophorectomies in this group, which may lower PD and increase likelihood of HRT use. Planned analyses of entire sample of 1050 women will clarify the effect of these and other factors on density, and on density change in followup mammograms.

Mean arterial pressure, pregnancy induced hypertension, and preeclampsia. Evaluation as independent risk factors and as surrogates for high maternal serum alpha-protein in estimating breast cancer risk

PURPOSE: Data from a nested case-control study were analyzed to examine high mean arterial pressure (MAP), hypertension of pregnancy and preeclampsia as independent predictors, and as surrogate markers for elevated Alpha-fetoprotein (AFP) levels in evaluating breast cancer risk.METHODS: Cases (n = 205) were identified by the California Cancer Registry from a cohort of pregnant women who were part of the Kaiser Health Plan and took part in the Child Health and Development Studies initiated by the University of California, Berkeley, from June 1959 to September 1966. Controls (n = 337) were selected by randomized recruitment from the same cohort probability matched to cases by distribution of birth dates of cases.RESULTS: High MAP was associated with breast cancer risk, and was different across quartiles of age at first full term pregnancy. Odds Ratios across quartiles were 0.24 (95% CI = 0.08-0.71), 0.84 (95% CI = 0.39-1.66), 1.00 (referent), and 2.50 (95% CI = 1.21-5.13). Neither diagnosed preeclampsia nor hypertension of pregnancy showed any association with breast cancer risk. When both high Alpha-fetoprotein and high mean arterial pressure were entered into the same analysis neither changed the odds ratio for the other more than eight percent. Additionally, AFP level was not a linear function of MAP.CONCLUSIONS: Although the pattern of odds ratios across quartiles of age at first full term pregnancy were similar for the two variables it can not be concluded that high MAP is an adequate surrogate for high levels of maternal serum AFP, but rather represents some related process which is in and of itself a risk factor for breast cancer.

The clinical role of noncontrast helical computed tomography in the diagnosis of acute appendicitis

BACKGROUND

The accuracy of noncontrast helical computed tomography (CT) for appendicitis has recently been demonstrated. What is its clinical utility?

METHODS

This was a retrospective review of 443 consecutive community hospital patients evaluated for acute appendicitis over an 18-month period using limited pelvic CT scan or clinical acumen alone.

RESULTS

Appendicitis was pathologically proven in 158 patients. The negative appendectomy rate was 5.4%. The best radiological indicators for a positive CT for appendicitis were pericecal inflammation (88%) and appendicolith(57%). Appendiceal CT was found to have a 92% sensitivity, 99.6% specificity, and a 97.5% accuracy. There were 260 patients who had a negative CT; 243 of these were sent home. Alternative diagnoses were identified in 22% of patients.

CONCLUSIONS

The liberal use of noncontrast helical CT results in a low negative appendectomy rate and a high degree of confidence that a negative CT will allow patients to be sent home safely.

Bradycardia induced from stimulation of the left versus right central nucleus of the amygdala

Studies have demonstrated that the predominant effect of stimulation of the central nucleus of the amygdala is one of heart rate deceleration. Anatomical studies have shown that projections from the central nucleus to the cardioinhibitory neurons in the medulla are ipsilateral and that projections of the left or right vagal efferents to the heart innervate different nodal points. The results of this study suggest that stimulation of the central nucleus of the amygdala from either the left or right hemisphere produced similar increases in heart period. These results are discussed in terms of the effects of the localization of epileptic foci in the temporal lobes on the cardiovascular system.

Bifurcation, bursting, and spike frequency adaptation

Many neural systems display adaptive properties that occur on time scales that are slower than the time scales associated with repetitive firing of action potentials or bursting oscillations. Spike frequency adaptation is the name given to processes that reduce the frequency of rhythmic tonic firing of action potentials, sometimes leading to the termination of spiking and the cell becoming quiescent. This article examines these processes mathematically, within the context of singularly perturbed dynamical systems. We place emphasis on the lengths of successive interspike intervals during adaptation. Two different bifurcation mechanisms in singularly perturbed systems that correspond to the termination of firing are distinguished by the rate at which interspike intervals slow near the termination of firing. We compare theoretical predictions to measurement of spike frequency adaptation in a model of the LP cell of the lobster stomatogastric ganglion.

Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness

OBJECTIVE

To determine whether patients coinfected with Lyme disease and babesiosis in sites where both diseases are zoonotic experience a greater number of symptoms for a longer period of time than those with either infection alone.

DESIGN

Community-based, yearly serosurvey and clinic-based cohort study.

SETTING

Island community in Rhode Island and 2 Connecticut medical clinics from 1990 to 1994.

STUDY PARTICIPANTS

Long-term residents of the island community and patients seeking treatment at the clinics.

MAIN OUTCOME MEASURES

Seroreactivity to the agents of Lyme disease and babesiosis and number and duration of symptoms.

RESULTS

Of 1156 serosurvey subjects, 97 (8.4%) were seroreactive against Lyme disease spirochete antigen, of whom 14 (14%) also were seroreactive against babesial antigen. Of 240 patients diagnosed with Lyme disease, 26 (11%) were coinfected with babesiosis. Coinfected patients experienced fatigue (P = .002), headache (P < .001), sweats (P < .001), chills (P = .03), anorexia (P = .04), emotional lability (P = .02), nausea (P = .004), conjunctivitis (P = .04), and splenomegaly (P = .01) more frequently than those with Lyme disease alone. Thirteen (50%) of 26 coinfected patients were symptomatic for 3 months or longer compared with 7 (4%) of the 184 patients with Lyme disease alone from whom follow-up data were available (P < .001). Patients coinfected with Lyme disease experienced more symptoms and a more persistent episode of illness than did those (n = 10) experiencing babesial infection alone. Circulating spirochetal DNA was detected more than 3 times as often in coinfected patients as in those with Lyme disease alone (P = .06).

CONCLUSIONS

Approximately 10% of patients with Lyme disease in southern New England are coinfected with babesiosis in sites where both diseases are zoonotic. The number of symptoms and duration of illness in patients with concurrent Lyme disease and babesiosis are greater than in patients with either infection alone. In areas where both Lyme disease and babesiosis have been reported, the possibility of concomitant babesial infection should be considered when moderate to severe Lyme disease has been diagnosed.

The effect of amygdaloid kindling on heart period and heart period variability

Two studies were conducted on rats to assess the effects of amygdaloid kindling on baseline measures of heart period and heart period variance. The results indicate that seizure activity was associated with increased vagal influence on heart period marked by sinus bradycardia and decreased beat-to-beat variability. The resultant bradycardia was enhanced following each seizure and persisted for at least a one-week period of time. The results are discussed in terms of the role of vagal tone in influencing abnormal cardiac patterns which could result in sudden unexplained death in some epileptic patients.

Health care and AIDS

The acquired immune deficiency syndrome (AIDS) is a harbinger for change in health care. There are many powerful forces poised to transform the industrialized health care structure of the twentieth century, and AIDS may act as either a catalyst or an amplifier for these forces. AIDS could, for example, swamp local resources and thereby help trigger national reform in a health care system that has already lost public confidence. AIDS can also hasten the paradigm shift that is occurring throughout health care. Many of the choices society will confront when dealing with AIDS carry implications beyond health care. Information about who has the disease, for example, already pits traditional individual rights against group interests. Future information systems could make discrimination based upon medical records a nightmare for a growing number of individuals. Yet these systems also offer the hope of accelerated progress against not only AIDS but other major health threats as well. The policy choices that will define society's response to AIDS can best be made in the context of a clearly articulated vision of a society that reflects our deepest values.

Correlation between uropathogenic properties of Escherichia coli from urinary tract infections and the antibody-coated bacteria test and comparison with faecal strains

Strains of Escherichia coli isolated from adult females with symptomatic urinary tract infection were found to possess the following properties significantly more frequently than faecal strains: (i) high K-antigen titre: (ii) haemolysin; (iii) type 1 pili; (iv) mannose-resistant haemagglutination; (v) fermentation of dulcitol and salicin; (vi) O serotype 2, 6 and 75; (vii) H serotype 1. E. coli isolated form urine specimens containing significant numbers of antibody-coated bacteria were richer in these seven properties than strains from urines without detectable antibody coated bacteria. The O and H serotypes of E. coli obtained from patients with urinary tract infection in two New Zealand cities were compared with those reported in the world literature and found to be similar.