Language barriers as a reported cause of prehospital care delay in Minnesota.

OBJECTIVE: Although anecdotal reports exist, the frequency of language barriers encountered between EMS providers and patients/families in the prehospital environment remains unknown. The purpose of this study was to determine the frequency of EMS provider-reported perceived delays in care due to language barrier and to characterize the nature of calls involved. METHODS: Retrospective analysis of the Minnesota State Ambulance Reporting system (MNSTAR) database, a mandated statewide EMS data collection tool. All EMS run reports submitted between January 1, 2004, and June 30, 2005, were reviewed to identify instances of reported treatment delay secondary to a language barrier. RESULTS: During the 18-month study period, 629,738 patient encounter reports were submitted to MNSTAR, of which 2,052 identified treatment delays secondary to language. The rate of language barrier care delays in the state of Minnesota is 3.3 per 1,000 prehospital patient encounters. CONCLUSION: EMS responses troubled by delays in care secondary to language barriers represent a small percentage of total runs in Minnesota. However, approximately 1,370 cases per year occur.

Universal influenza vaccination: the time to act is now.

Annual influenza epidemics create a significant public health burden each year in the United States. That influenza continues to pose a public health threat despite being largely preventable through vaccination is indicative of continuing weaknesses in the U.S.'s public health system. Moreover, the burden of annual influenza epidemics and the fragility and instability of the capacity to respond to them underscore the U.S.'s ongoing vulnerability to pandemic influenza and highlights gaps in bioterrorism preparedness and response efforts. This article examines the burden of annual influenza epidemics in the U.S., efforts to combat that burden with vaccination, shortcomings of influenza vaccination efforts, and how those shortcomings exemplify weaknesses in pandemic influenza and bioterrorism preparedness efforts. We make the case for establishing an annual universal influenza vaccination program to assure access to influenza vaccination to anyone who can safely receive vaccination and desires it. Such a program could greatly reduce the annual burden of influenza while advancing and maintaining U.S. pandemic influenza and bioterrorism preparedness and response efforts.

The burden of complex genetics in brain disorders.

BACKGROUND: Few data estimate the impact of complex genetics in neuropsychiatric illness, making it likely that this impact could be underappreciated. OBJECTIVE: To provide estimates of the impact of complex genetics in neuropsychiatric disorders in the United States, based on estimates of disease costs to US society, disease heritability, and mendelian contributions to disease. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION: Costs were estimated from literature sources and Lewin-National Foundation for Brain Research estimates updated for population growth and consumer price index inflation. Heritability estimates came from available twin data. Estimates of mendelian contributions came from the Online Mendelian Inheritance in Man database and our perspectives. CONCLUSIONS: Brain and nervous system disorders may cost the United States as much as US dollars 1.2 trillion annually, and affect many millions of Americans each year. Twin data suggest that more than 40% of the societal burden of brain disorders is likely to be genetically mediated. Most of this disease burden arises from complex multigene genetics as well as from environmental influences. The large sizes of these complex genetic burdens should encourage careful molecular and clinical work to link disease-vulnerability allelic variants with the pathogenesis, nosologic characteristics, prevention, diagnostics, and therapeutics of brain disorders.

Cases from the Osler Medical Service at Johns Hopkins University.

A 37-year-old woman presented with increasing abdominal pain and jaundice. Six weeks before admission, she developed persistent diarrhea and jaundice of the skin. She also bruised easily, and her gums bled. In the subsequent weeks, her appetite decreased, she was fatigued, and she had nausea, vomiting, and abdominal distension. She had a history of drinking 1 quart of vodka every day for 20 years, with brief periods of abstinence; she stopped consuming alcohol 11 days before admission because it no longer provided symptomatic relief. Her past medical history was also notable for depression, including a suicide attempt 4 years earlier. She did not smoke, use illicit drugs, or have unprotected sexual intercourse. She had received no blood transfusions and had not traveled recently. She took no medications, except for occasional ibuprofen. On physical examination, she was thin and deeply jaundiced, and she trembled and responded slowly to questions. She was afebrile but tachypneic, and she had orthostatic hypotension. Her HEENT examination was notable for scleral and sublingual icterus, as well as crusted blood on her gums and teeth. The jugular veins were flat. The cardiac examination revealed tachycardia (heart rate, 103 beats per minute) without murmurs, rubs, or gallops. The abdomen was nontender and protuberant, with hypoactive bowel sounds; the spleen was not palpable, and there was no fluid wave or caput medusae. The liver percussed to 18 cm, with a smooth edge extending 10 cm below the costal margin. She had cutaneous telangiectases on her chest and bilateral palmar erythema. There was no peripheral edema. The neurologic examination was notable for asterixis. Her stool was guaiac positive. Laboratory studies revealed the following values: hematocrit, 21.2%; white blood cells, 17,310/mm(3); ammonia, 42 micromol/L; serum creatinine, 3.9 mg/dL; serum urea nitrogen, 70 mg/dL; albumin, 2.1 g/dL; total bilirubin, 26.8 mg/dL; alanine aminotransferase, 14 U/L; aspartate aminotransferase, 77 U/L; alkaline phosphatase, 138 U/L; prothrombin time, 103 seconds (international normalized ratio, 10.6); and urinary sodium, <5 mg/dL. Urinalysis revealed an elevated specific gravity and numerous muddy granular casts. Hepatitis A, B, and C serologies were negative. On abdominal ultrasound examination, there was no ascites, and the liver was echogenic. The portal and hepatic veins were patent, and the hepatic arteries were normal. The spleen measured 14 cm. What is the diagnosis?