The patient-centered medical home: a case study in transforming the military health system.

This case study describes the Military Health System's (MHS) patient-centered medical home (PCMH) initiative and how it is being delivered across the MHS by the Army, Navy, and Air Force. The MHS, an integrated delivery model that includes both military treatment facilities and civilian providers and health care institutions, is transforming its primary care platforms from the traditional acute, episodic system to the PCMH model of care to maximize patient experience, satisfaction, health care quality, and readiness and to control cost growth. Preliminary performance measures are analyzed to assess the impact of PCMH implementation on the core primary care processes of the MHS. This study also discusses lessons learned and recommendations for improving health care performance through the PCMH care model.

Gene expression profiling in male genital lichen sclerosus.

Male genital lichen sclerosus (MGLSc) has a bimodal distribution in boys and men. It is associated with squamous cell carcinoma (SCC). The pathogenesis of MGLSc is unknown. HPV and autoimmune mechanisms have been mooted. Anti extracellular matrix protein (ECM)1 antibodies have been identified in women with GLSc. The gene expression pattern of LSc is unknown. Using DNA microarrays we studied differences in gene expression in healthy and diseased prepuces obtained at circumcision in adult males with MGLSc (n = 4), paediatric LSc (n = 2) and normal healthy paediatric foreskin (n = 4). In adult samples 51 genes with significantly increased expression and 87 genes with significantly reduced expression were identified; paediatric samples revealed 190 genes with significantly increased expression and 148 genes with significantly reduced expression. Concordance of expression profiles between adult and paediatric samples indicates the same disease process. Functional analysis revealed increased expression in the adult and child MGSLc samples in the immune response/cellular defence gene ontology (GO) category and reduced expression in other categories including genes related to squamous cancer. No specific HPV, autoimmune or squamous carcinogenesis-associated gene expression patterns were found. ECM1 and CABLES1 expression were significantly reduced in paediatric and adult samples respectively.

The prevalence of human leucocyte antigen and human papillomavirus DNA in penile intraepithelial neoplasia in England 2011-2012.

BACKGROUND: The pathogenesis of penile intraepithelial neoplasia (PeIN) is unclear but human papillomavirus (HPV) infection and polymorphisms in human leucocyte antigen (HLA). OBJECTIVES: To examine the prevalence of HPV DNA and HLA in PeIN. METHODS: Adult Caucasian men with a clinical and histological diagnosis of PeIN, that is, Bowenoid papulosis (BP), Bowen's disease of penis (BDP) and erythroplasia of Queyrat (EQ) were selected and phenotyped from the clinical records. DNA was extracted from blood and paraffin-embedded sections for HLA and HPV typing, respectively. Human leucocyte antigen allele frequencies were compared with those derived from the UK-based Caucasian population. RESULTS: Seventy-two cases of PeIN (20 BP, 34 BDP and 18 EQ) were studied. Human papillomavirus DNA was identified in 65/72 (90.2%) PeIN; Alphapapillomavirus types were detected in 62/72 (85%) followed by Betapapillomavirus types in 9/72 (12.5%) and cutaneous types in 7/72 (9.7%); HPV16 was the most prevalent genotype at 35/72 (48.6%) followed by HPV33 at 7/72 (9.7%); multiple infections were seen in 18/72 (25%) PeIN. HLA-C*15 (Bonferroni corrected p = 0.049) confers susceptibility to PeIN, whereas HLA-DQA1*01 (corrected p = 0.02) protects against PeIN. HPV16-associated PeIN cases showed no statistically significant association with HLA genotype after multiple corrections. CONCLUSION: Human papillomavirus is involved in the pathogenesis of PeIN. Immunogenotype may play a role in the pathogenesis of PeIN.

Immunogenetics and human papillomavirus (HPV) in male genital lichen sclerosus (MGLSc).

BackgroundThe pathogenesis of male genital lichen sclerosus (MGLSc) is controversial. Incriminated factors include infection with human papillomavirus (HPV) and autoimmunity (e.g. Human Leukocyte Antigen [HLA]). To address the roles of HLA and HPV in MGLSc we studied adult Caucasian males with a clinical and histological diagnosis of MGLSc. The men in the study attended two specialised Male Genital Dermatoses Clinics between July 2011 and September 2012 and were selected and phenotyped from the clinical records. DNA was extracted from blood and paraffin-embedded biopsy sections, for HLA and HPV typing, respectively. HLA allele frequencies were compared with those derived from the UK-based Caucasian population. Eighty-eight cases of MGLSc were identified. HPV DNA was detected in 33/88 (37.5%) cases of MGLSc. HPV16 was the most prevalent type found: 11/88 (12.5%) MGLSc. No statistically significant HLA associations were established but HLA-B*35, -B*51, -C*15, -DRB1*04, -DRB1*10 (predisposition) and -DQA1*01 (protection) were revealed as alleles of interest. HPV16-associated MGLSc cases showed no statistically significant association with HLA genotype. The relationship between HPV and MGLSc suggests a passenger effect rather than a pathogenic role. HLA is not associated with MGLSc nor co-existent HPV16.

Parental Iraq/Afghanistan deployment and child psychiatric hospitalization in the U.S. military.

OBJECTIVE: Members of the US armed forces have been heavily deployed in support of wars in Afghanistan and Iraq. This study examined the affect of a parent's deployment to war on the rate of psychiatric hospitalization among their children. METHODS: This was a retrospective cohort study. Records of children of active duty personnel during fiscal years 2007 through 2009 were linked with their parent's deployment records. Psychiatric hospitalizations were identified using International Classification of Diseases, Ninth Revision codes on admission. Odds ratios (OR) of hospitalization were determined using both univariate and multivariate logistic regression. Lengths of hospital stay were also compared by linear regression using Duan's smearing estimate method. RESULTS: A total of 377,565 children aged 9-17 years were included along with data on both their active duty and civilian parent. Mean child age was 12.53 years (S.D.: 2.5 years); 51% were male. Mean age of active duty parent was 37.8 years (S.D.: 5.2 years); 93% were male, 90% were married and 62% were white. In the study, 2533 children were hospitalized for a mental or behavioral health disorder in fiscal year 2009 with a median length of stay of 8 days. After adjusting for demographic data and past psychiatric history of the child, active duty parent and civilian parent, the OR of hospitalization for children with a recently deployed parent was 1.10 (95% confidence interval: 1.01-1.19). The OR of hospitalization increased with increasing length of deployment with a positive test of trend. There was no statistically significant difference in distribution of admission diagnoses or length of hospital stay based on deployment by the active duty parent. CONCLUSIONS: Psychiatric hospitalization increased by 10% among children aged 9-17 years when a military parent was recently deployed. The odds of hospitalization increased with increasing length of a parent's deployment.