Infection with the human immunodeficiency virus in prisoners: meeting the health care challenge.

The magnitude and the scope of health care problems posed by human prison inmates seropositive for the human immunodeficiency virus (HIV) are enormous. Prisoners represent a substantial proportion of HIV-infected individuals in North America. A high proportion of prisoners are intravenous drug users who often have not received appropriate health care or HIV-directed services prior to incarceration. Health care of HIV-seropositive prisoners and follow-up medical care after prison release has often been less than optimal. Among inmates at the prison facility in Rhode Island, 4% of the men and 12% of the women are HIV seropositive. The Brown University medical community, in conjunction with the Rhode Island Department of Health and Corrections, has developed an effective program for the health care of such prisoners, both during incarceration and after release from prison. Academic medical centers are uniquely poised to assume the leading role in meeting this obligation. We believe that this general approach, with region-specific modifications, may be effectively applied in many correctional institutions in North America.

The Breast Cancer Screening Program in Rhode Island.

The Rhode Island Department of Health has undertaken a Breast Cancer Screening Program which incorporates assessment, policy development, and assurance functions, following the model proposed in the Institute of Medicine (IOM) report, The Future of Public Health. With the community's help, projects have been implemented to increase screening capacity with dedicated, state-of-the-art equipment, to increase screening accessibility, to publicize the need for mammography, and to minimize false test results. In the program's first 15 months, the proportion of women ages 40 and over who were screened with mammography according to current guidelines increased from 35 to 46 percent (from 38 to 49 percent among women ages 40-49; from 31 to 43 percent among women ages 50 and over), including 15 percent who received their first screening mammogram. Providers' recommendations and knowledge of screening guidelines were important in explaining first-time use. The Department plans to apply the IOM model in other program areas. Its adoption by others is urged.

Investigation of a staphylococcal food poisoning outbreak in a centralized school lunch program.

The trend in many communities toward centralized school lunch preparation potentially increases the risk of foodborne illness. Foods often are prepared long before serving and may be distributed to satellite schools by persons with little formal training in safe techniques of food preparation or food service. In May 1990, an outbreak of staphylococcal food poisoning occurred in elementary schools in a Rhode Island community participating in such a program. In the investigation of the outbreak, students in schools that reported cases were interviewed. Food preparation, handling, and distribution were reviewed. At School E, 662 lunches were prepared and distributed to 4 additional schools (schools A-D). Schools A and B accounted for nearly all cases of the food poisoning, with rates of 47 percent and 18 percent. Eating ham increased the risk of illness (62 percent of those consuming ham and 3 percent of those who did not, relative risk = 18.0, 95 percent confidence interval = 4.0, 313.4). Large amounts of Staphylococcus aureus were cultured, and preformed enterotoxin A was identified in leftover ham. A food handler, who tested positive for the implicated enterotoxic strain S. aureus, reported having removed the casings from two of nine warm ham rolls 48 hours prior to service. Because of improper refrigeration, prolonged handling, and inadequate reheating, the ham was held at temperatures estimated at 10-49 degrees Celsius (50-120 degrees Fahrenheit) for a minimum of 15 hours. The potential for larger outbreaks prompted a statewide training program in safe food preparation for school lunch personnel, which may have applications for other communities.

A study guided by the Health Belief Model of the predictors of breast cancer screening of women ages 40 and older.

In late 1987, a total of 852 Rhode Island women ages 40 and older were interviewed by telephone (78 percent response rate) to measure their use of breast cancer screening and to investigate potential predictors of use. Predictors included the women's socioeconomic status, use of medical care, a provider's reported recommendations for screening, and the women's health beliefs about breast cancer and mammography. The Health Belief Model guided the construction of the interview questions and data analysis. Logistic regression was used to identify leading independent predictors of breast cancer screening according to contemporary recommendations: reporting that a medical provider had ever recommended a screening mammogram (odds ratio [OR] = 18.77), having received gynecological care in the previous year (OR = 4.92), having a regular source of gynecological care (OR = 2.63), having ever had a diagnostic mammogram (OR = 2.32), and perceiving mammography as safe enough to have annually (OR = 1.93). The findings suggest that programs intended to increase the use of breast cancer screening should include "inreach" and "outreach" elements; inreach to patients with established patient-provider relationships, by assuring that physicians recommend screening to all eligible patients, and outreach to all eligible women, by helping them overcome barriers to effective primary care, and by promoting mammography, emphasizing its effectiveness and safety. The findings also suggest that socioeconomically disadvantaged women, who are less likely to be screened than other women, should become special targets of inreach and outreach interventions.

Improving urban health.

New York's public health priorities initiative, Communities Working Together for a Healthier New York, creates a framework for communities, including urban areas, to identify and address their most pressing public health problems. It is both a call to action and a guide for the state's communities. The priorities identified in this initiative were the product of extensive public input across the state. Interestingly, the priorities identified by rural counties were consistent with those identified in the New York City workshop. To a great extent, urban and rural dwellers have the same health problems, such as teenage pregnancy, substance abuse, and tobacco use, although to different degrees. Accordingly, we need to recognize that we are a global society, in which the line separating urban and rural has thinned, if not disappeared. Improving health status in our communities, whether urban or rural, requires broad-based collaboration. It requires setting special interests aside and focusing on the good of the whole community. It requires sharing resources and expertise, as was done in the asthma study. By developing a shared vision of what our health priorities are, by forming partnerships in our communities to address them, and by employing the use of effective and innovative interventions, we will improve health status in our communities.

Immunizations: the promise and the pitfalls.

Despite our success with eradicating smallpox and possibly poliomyelitis, the United States faces unacceptably low immunization levels among preschool-age children. The problems associated with ensuring complete protection of children from vaccine-preventable diseases are multifaceted. Many children remain at risk for potentially fatal diseases, and the easy transmissibility of these agents increases the threat of disease outbreaks. This commentary examines steps needed to improve immunization levels and pediatric primary care, access.

Acute bacterial meningitis in Rhode Island: a survey of the years 1976 to 1985.

There were 667 recorded cases of bacterial meningitis in the hospitals of Rhode Island during the ten year interval of 1976 to 1985 yielding an average annual incidence rate of 6.9 cases per 100,000 population, and a case fatality rate of 10.3%. These rates are similar to those generated in other retrospective surveys in the United States. This survey corroborates the well-established observation that bacterial meningitis is largely a disease of early childhood. But these data also suggest that meningitis in the very elderly is more common than had previously been assumed. Many of the elderly cases in this series, particularly those caused by the coliform organisms, followed shortly after body trauma or appeared in individuals burdened by disseminated cancer or diabetes mellitus.

Plasmid, serotypic, and enterotoxin analysis of Bacillus cereus in an outbreak setting.

Bacillus cereus is a recognized agent of food-borne disease. In this report we describe an outbreak of B. cereus gastroenteritis associated with consumption of beef stew among patients and staff at a Rhode Island nursing home. The beef had been improperly stored after preparation. The predominant symptoms of the illness were cramps and diarrhea; it lasted an average of 16 h. No deaths occurred. The organism was recovered from 10 of 23 stools collected from ill patients and 1 of 21 stools collected from controls (P = 0.0044, Fisher's two-tailed exact test). All isolates had the same biotype and serotype, newly designated H.26; all elaborated the diarrheal B. cereus enterotoxin when tested in rabbits by the vascular permeability reaction; and all had identical plasmid profiles, which differed from those of B. cereus strains selected randomly from other outbreaks. Plasmid analysis may prove to be a useful new tool in investigating outbreaks of B. cereus food poisoning.

Analysis of an outbreak of penicillinase-producing Neisseria gonorrhoeae in Rhode Island, 1987.

In June of 1987, an outbreak of penicillinase-producing Neisseria gonorrhoeae (PPNG) occurred in Rhode Island. PPNG persists as an endemic pathogen despite a concerted statewide effort to eradicate the organism. Detailed analysis of PPNG isolates demonstrated that multiple strains are circulating concurrently, complicating control measures.

Public release of cardiac surgery outcomes data in New York: what do New York state cardiologists think of it?

BACKGROUND AND OBJECTIVE: Since 1990, risk-adjusted outcomes for patients undergoing coronary artery bypass graft surgery in New York state have been released to the public. The purpose of this study was to assess the extent to which referring cardiologists share these data with patients and use these data to make referrals. METHODS: A survey questionnaire was sent to all cardiologists in New York in the New York State Chapter of the American College of Cardiology. RESULTS: Four hundred fifty cardiologists responded to the survey. Most (94%) found the report "easy to read." A majority (67%) found the report to be "very accurate" or "somewhat accurate" in capturing differences in the performance of cardiac surgeons, whereas 33% found it to be "not at all accurate." Twenty-two percent reported that they "routinely discuss the reports with their patients," and 38% responded that the information has affected their referrals to surgeons "very much" or "somewhat." CONCLUSIONS: A majority of cardiologists has not generally changed their well-established referral patterns as a result of the New York coronary artery bypass graft surgery reports. However, there has been a modest impact on referrals resulting from the distribution of these reports. The findings also suggest that increased dialogue between clinicians and policy makers regarding the format and structure of public releases would be a valuable undertaking.

Affordability considerations in certificate-of-need hospital capital expenditure review determinations.

Beginning in 1984, public affordability became a central standard along with public need in the review of hospital proposals for capital development in Rhode Island's certificate-of-need (CON) program.

Breast biopsy rate and positivity in Rhode Island.

Breast biopsy is a common procedure for which few age-specific, population-based data are available. We identified all women who underwent breast biopsy in Rhode Island in 1989 by reviewing the specimen logs at each of 13 pathology laboratories. Among 425,000 women aged 15-97 years, 2685 underwent breast biopsy, for an overall rate of 6/1000. The rate increased with age, peaking among 45- to 54-year-olds and then declining in women over 75. Among those biopsied, 726 were diagnosed with breast cancer, for an overall biopsy positivity of 27%. In contrast to rate, positivity increased steadily with age. These results are within the range of estimates produced by smaller group studies.

Sexual behavior of college women in 1975, 1986, and 1989.

To compare sexual practices in college women before and after the start of the current epidemics of Chlamydia trachomatis, genital herpesvirus, and human immunodeficiency virus type 1 infection, we surveyed 486 college women who consulted gynecologists at a student health service in 1975, 161 in 1986, and 132 in 1989 at the same university. There were no statistically significant differences in age, age at menarche, or reason for visiting the gynecologist. The percentages of women in this population who were sexually experienced were the same in all three years (88 percent in 1975, 87 percent in 1986, and 87 percent in 1989). Oral contraceptives were used by 55 percent of the women in 1975, 34 percent in 1986, and 42 percent in 1989; the use of condoms as the usual method of birth control increased (6 percent in 1975, 14 percent in 1986, and 25 percent in 1989; P less than 0.001). In 1975, only 12 percent reported the regular use of condoms during sexual intercourse, in some cases in conjunction with other methods of contraception, as compared with 21 percent in 1986 and 41 percent in 1989 (P = 0.0014). No significant differences were found in the three surveys in the number of male sexual partners or the frequency of fellatio, cunnilingus, or anal intercourse. An additional sample of 189 college women who did not consult the health service was surveyed in 1989, and similar sexual behavior was reported by those who were sexually experienced (65 percent). We conclude that in this population there has been little change in sexual practices in response to new and serious epidemics of sexually transmitted diseases, with the exception of an increase in the use of condoms (which still does not reach 50 percent).

PIP: To compare sexual practices in college women before and after the start of the current epidemics of Chlamydia trachomatis, genital herpesvirus and human immunodeficiency virus type 1 infection, we surveyed 486 college women who consulted gynecologists at a student health service in 1975, 161 in 1986, and 132 in 1989 at the same university. There were no statistically significant differences in age, age at menarche, or reason for visiting the gynecologist. The percentages of women in this population who were sexually experienced were the same in all 3 years (88% in 1975, 87% in 1986 and 87% in 1989). Oral contraceptives were used by 55% of the women in 1975, 34% in 1986 and 42% in 1989; the use of condoms as the usual method of birth control increased (6% in 1975, 14% in 1986 and 25% in 1989; p 0.001). In 1975 only 12% reported the regular use of condoms during sexual intercourse, in some cases in conjunction with other methods of contraception, as compared with 21% in 1986 and 41% in 1989 (P = 0.0014). No significant differences were found in the 3 surveys in the number of male sexual partners or the frequency of fellatio, cunnilingus, or anal intercourse. An additional sample of 189 college women who did not consult the health service was surveyed in 1989, and similar sexual behavior was reported by those who were sexually experienced (65%). We conclude that in this population there has been little change in sexual practices in response to new and serious epidemics of sexually transmitted diseases, with the exception of an increase in the use of condoms (which still does no reach 50%).

Public release of cardiac surgery outcomes data in New York: what do New York state cardiologists think of it?

BACKGROUND AND OBJECTIVE: Since 1990, risk-adjusted outcomes for patients undergoing coronary artery bypass graft surgery in New York state have been released to the public. The purpose of this study was to assess the extent to which referring cardiologists share these data with patients and use these data to make referrals. METHODS: A survey questionnaire was sent to all cardiologists in New York in the New York State Chapter of the American College of Cardiology. RESULTS: Four hundred fifty cardiologists responded to the survey. Most (94%) found the report "easy to read." A majority (67%) found the report to be "very accurate" or "somewhat accurate" in capturing differences in the performance of cardiac surgeons, whereas 33% found it to be "not at all accurate." Twenty-two percent reported that they "routinely discuss the reports with their patients," and 38% responded that the information has affected their referrals to surgeons "very much" or "somewhat." CONCLUSIONS: A majority of cardiologists has not generally changed their well-established referral patterns as a result of the New York coronary artery bypass graft surgery reports. However, there has been a modest impact on referrals resulting from the distribution of these reports. The findings also suggest that increased dialogue between clinicians and policy makers regarding the format and structure of public releases would be a valuable undertaking.

Coronary artery bypass graft surgery in Ontario and New York State: which rate is right? Steering Committee of the Cardiac Care Network of Ontario.

BACKGROUND: Previous studies have shown that the rate of coronary artery bypass graft (CABG) surgery is much higher in New York State than in Ontario. OBJECTIVE: To compare the service context and clinical characteristics of patients having CABG surgery in New York and Ontario. DESIGN: Retrospective analysis of data from cardiac surgery registries in New York and Ontario. PATIENTS: All 16,690 patients in New York and 5517 patients in Ontario who had isolated CABG surgery in 1993. MEASUREMENTS: Clinical characteristics of patients having CABG surgery and rates of CABG surgery by coronary anatomy. RESULTS: The overall age-adjusted rate of isolated CABG surgery was 1.79 times (95% CI, 1.74 to 1.85) greater in New York than in Ontario. Patients who had CABG surgery in New York were more likely to be elderly and female and to have recently had myocardial infarction (P < 0.001), whereas patients who had CABG surgery in Ontario were more likely to have had left ventricular dysfunction and severe coronary artery disease (two-vessel disease with proximal left anterior descending disease, three-vessel disease, or left main disease) (P < 0.001). The relative rate of CABG surgery for left main disease was 2.53 times (CI, 2.35 to 2.73) greater in New York than in Ontario but was 8.97 times (CI, 8.01 to 10.06) greater for patients with limited coronary artery disease (one-vessel or two-vessel disease without proximal left anterior descending disease). CONCLUSIONS: The higher rates of CABG surgery in New York are associated with higher rates of CABG surgery among the elderly, women, and patients who recently had myocardial infarction. Potential underservicing in Ontario is suggested by a lower rate of CABG surgery for left main disease; however, the higher rate of CABG surgery in New York is also associated with a strikingly higher rate of surgery in patients with limited coronary disease. Such trade-offs highlight the difficulty of defining an optimal rate of CABG surgery.