Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China.

BACKGROUND: Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation. METHODS: We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed. RESULTS: A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes. CONCLUSIONS: Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

The Development of Surveillance Systems.

Surveillance systems in public health practice have increased in number and sophistication with advances in data collection, analysis, and communication. When the Communicable Disease Center (now the Centers for Disease Control and Prevention) was founded some 70 years ago, surveillance referred to the close observation of individuals with suspected smallpox, plague, or cholera. Alexander Langmuir, head of the Epidemiology Branch, redefined surveillance as the epidemiology-based critical factor in infectious disease control. I joined Langmuir as assistant chief in 1955 and was appointed chief of the Surveillance Section in 1961. In this paper, I describe Langmuir's redefinition of surveillance. Langmuir asserted that its proper use in public health meant the systematic reporting of infectious diseases, the analysis and epidemiologic interpretation of data, and both prompt and widespread dissemination of results. I outline the Communicable Disease Center's first surveillance systems for malaria, poliomyelitis, and influenza. I also discuss the role of surveillance in the global smallpox eradication program, emphasizing that the establishment of systematic reporting systems and prompt action based on results were critical factors of the program.

John Bartlett and bioterrorism.

Until 1997, the subject of bioterrorism was not discussed within the medical community and deliberately ignored in national planning efforts. Biological weapons were regarded as "morally repulsive." This complacency stemmed from a 1972 Biological Weapons Convention where all countries agreed to cease offensive biological weapons research. In the 1990s, however, the Soviet Union was discovered to have an extensive bioweapons program and a Japanese religious cult sought to launch an anthrax attack on Tokyo. Biological weapons such as smallpox and anthrax had the potential to cause a national catastrophe. However, little was done until John Bartlett in 1997 led a symposium and program to educate the medical community and the country of the need for definitive bioweapons programs. It was highly persuasive and received a final stimulus when the anthrax attack occurred in the United States in 2001.

Bayesian calibration of a stochastic kinetic computer model using multiple data sources.

In this article, we describe a Bayesian approach to the calibration of a stochastic computer model of chemical kinetics. As with many applications in the biological sciences, the data available to calibrate the model come from different sources. Furthermore, these data appear to provide somewhat conflicting information about the model parameters. We describe a modeling framework that allows us to synthesize this conflicting information and arrive at a consensus inference. In particular, we show how random effects can be incorporated into the model to account for between-individual heterogeneity that may be the source of the apparent conflict.

The looming threat of bioterrorism.

Biological weapons have recently attracted the attention and the resources of the nation. Discerning the nature of the threat of bioweapons as well as appropriate responses to them requires greater attention to the biological characteristics of these instruments of war and terror. The dominant paradigm of a weapon as a nuclear device that explodes or a chemical cloud that is set adrift leaves us ill-equipped conceptually and practically to assess and thus to prevent the potentially devastating effects of bioterrorism. Strengthening the public health and infectious disease infrastructure is an effective step toward averting the suffering that could be wrought by a terrorist's use of a biological agent.

Dissociation of glomerular hypertrophy, cell proliferation, and glomerulosclerosis in mouse strains heterozygous for a mutation (Os) which induces a 50% reduction in nephron number.

We reported that the Os mutation in ROP mice induced a 50% reduction in nephron number, glomerular hypertrophy, and severe glomerulosclerosis. We examined two mouse strains with the Os mutation, ROP Os/+ and C57 Os/+ mice, to determine whether the genetic background influenced the development of glomerulosclerosis. Nephron number was decreased by 50% in both ROP Os/+ and C57 Os/+ mice, and a glomerular volume and labeling index were two- to threefold increased in both. Whereas glomerulosclerosis was severe in ROP Os/+ mice, it was absent or minimal in C57 Os/+ mice. ROP Os/+ glomeruli had two- to threefold more type IV collagen, laminin, and tenascin than C57 Os/+ by immunofluorescence microscopy. Glomerular alpha 1IV collagen and tenascin mRNA levels were increased (2.8- and 1.7-fold) in ROP Os/+ and in C57 Os/+ (1.7- and 1.4-fold) mice. Both ROP Os/+ and C57 Os/+ mice had a slight increase (1.5- and 1.7-fold) in 72-kD collagenase mRNA levels. Whereas laminin B1 mRNA levels were twofold higher in ROP +/+ than in C57 +/+ mice, there was no further change in the presence of the Os mutation. Thus, the response to the Os mutation depended on the mouse strain, since severe glomerulosclerosis occurred only in ROP Os/+ mice, even though cell proliferation and glomerular hypertrophy also were present in C57 Os/+ mice.

Disease mitigation measures in the control of pandemic influenza.

The threat of an influenza pandemic has alarmed countries around the globe and given rise to an intense interest in disease mitigation measures. This article reviews what is known about the effectiveness and practical feasibility of a range of actions that might be taken in attempts to lessen the number of cases and deaths resulting from an influenza pandemic. The article also discusses potential adverse second- and third-order effects of mitigation actions that decision makers must take into account. Finally, the article summarizes the authors' judgments of the likely effectiveness and likely adverse consequences of the range of disease mitigation measures and suggests priorities and practical actions to be taken.

Improving performance of HVAC systems to reduce exposure to aerosolized infectious agents in buildings; recommendations to reduce risks posed by biological attacks.

The prospect of biological attacks is a growing strategic threat. Covert aerosol attacks inside a building are of particular concern. In the summer of 2005, the Center for Biosecurity of the University of Pittsburgh Medical Center convened a Working Group to determine what steps could be taken to reduce the risk of exposure of building occupants after an aerosol release of a biological weapon. The Working Group was composed of subject matter experts in air filtration, building ventilation and pressurization, air conditioning and air distribution, biosecurity, building design and operation, building decontamination and restoration, economics, medicine, public health, and public policy. The group focused on functions of the heating, ventilation, and air conditioning systems in commercial or public buildings that could reduce the risk of exposure to deleterious aerosols following biological attacks. The Working Group's recommendations for building owners are based on the use of currently available, off-the-shelf technologies. These recommendations are modest in expense and could be implemented immediately. It is also the Working Group's judgment that the commitment and stewardship of a lead government agency is essential to secure the necessary financial and human resources and to plan and build a comprehensive, effective program to reduce exposure to aerosolized infectious agents in buildings.

The statistical analysis of truncated data: application to the Sverdlovsk anthrax outbreak.

An outbreak of anthrax occurred in the city of Sverdlovsk in Russia in the spring of 1979. The outbreak was due to the inhalation of spores that were accidentally released from a military microbiology facility. In response to the outbreak a public health intervention was mounted that included distribution of antibiotics and vaccine. The objective of this paper is to develop and apply statistical methodology to analyse the Sverdlovsk outbreak, and in particular to estimate the incubation period of inhalational anthrax and the number of deaths that may have been prevented by the public health intervention. The data available for analysis from this common source epidemic are the incubation periods of reported deaths. The statistical problem is that incubation periods are truncated because some individuals may have had their deaths prevented by the public health interventions and thus are not included in the data. However, it is not known how many persons received the intervention or how efficacious was the intervention. A likelihood function is formulated that accounts for the effects of truncation. The likelihood is decomposed into a binomial likelihood with unknown sample size and a conditional likelihood for the incubation periods. The methods are extended to allow for a phase-in of the intervention over time. Assuming a lognormal model for the incubation period distribution, the median and mean incubation periods were estimated to be 11.0 and 14.2 days respectively. These estimates are longer than have been previously reported in the literature. The death toll from the Sverdlovsk anthrax outbreak could have been about 14% larger had there not been a public health intervention; however, the confidence intervals are wide (95% CI 0-61%). The sensitivity of the results to model assumptions and the parametric model for the incubation period distribution are investigated. The results are useful for determining how long antibiotic therapy should be continued in suspected anthrax cases and also for estimating the ultimate number of deaths in a new outbreak in the absence of any public health interventions.

Countering the posteradication threat of smallpox and polio.

After eradication, there is a small but finite risk that smallpox and/or poliomyelitis viruses could accidentally escape from a laboratory or be released intentionally. The reintroduction of either virus into a highly susceptible population could develop into a serious catastrophe. To counter such an occurrence will require the use of vaccine, perhaps in substantial quantities. In the United States, new stocks of smallpox vaccine are being procured and arrangements are being made for a standby production facility. Similar provisions need to be considered for polio. To counter an epidemic of polio will require the use of the oral vaccine, which is presently the World Health Organization-recommended vaccine of choice for countries throughout the developing world. In these countries, its continued use is advised because of its ability to induce intestinal immunity, its ability to spread to other susceptible household members and to protect them, its ease of administration, and its low cost.

Smallpox vaccination: a review, part I. Background, vaccination technique, normal vaccination and revaccination, and expected normal reactions.

Because smallpox could be a factor in bioterrorism, the United States has provided guidelines for smallpox vaccination of certain members of the population, including health care workers and first responders, as well as military personnel. A plan for more extensive vaccination, if it is needed in the event of a bioterrorist attack, is being developed under the aegis of the Centers for Disease Control and Prevention. The characteristics of smallpox vaccine, the technique of administration, and the expected reactions to primary vaccination and revaccination are outlined in this article.

Smallpox vaccination: a review, part II. Adverse events.

Smallpox vaccination of health care workers, military personnel, and some first responders has begun in the United States in 2002-2003 as one aspect of biopreparedness. Full understanding of the spectrum of adverse events and of their cause, frequency, identification, prevention, and treatment is imperative. This article describes known and suspected adverse events occurring after smallpox vaccination.

Effect of marginal zinc deficiency on the morphological characteristics of intestinal nascent chylomicrons and distribution of soluble apoproteins of lymph chylomicrons.

Effects of marginal zinc depletion on the compositional and morphological characteristics of chylomicrons were investigated in adult male rats fed 3 ppm of dietary zinc, as compared with pair-fed and ad-libitum controls given 30 ppm of zinc for 6 to 8 wk. Lymph was collected by cannulating the intestinal lymphatic duct during infusion of a 1:1 mixture of Intralipid and 150 mM NaCl via a duodenal catheter. Lymph chylomicrons were isolated by ultracentrifugation and further purified by agarose column chromatography. A marginal level of zinc deficiency produced decreases in the relative concentrations of apolipoproteins C and E, with an increase in apoprotein A-I and no change in apoprotein A-IV and no significant alterations in the lipid components. Nascent chylomicrons in the intestinal absorptive cells were irregular and larger in shape and size, as determined by light and electron microscopy. The present results suggest that the changes in chylomicron apoproteins produced by zinc deficiency are due in part to postsynthetic modification of intestinal chylomicrons upon their release into the lymph.

Delayed plasma clearance and hepatic uptake of lymph chylomicron 14C-cholesterol in marginally zinc-deficient rats.

Previously, chylomicrons from marginally zinc-deficient rats were shown to be abnormally large, with markedly reduced levels of apoproteins C and E. In the present study, effects of such changes on the plasma clearance and hepatic uptake of chylomicron cholesterol were investigated in rats fed 3 ppm of zinc (ZD), as compared with those fed 30 ppm of zinc (CT). The rate of plasma clearance was determined by plasma 14C-radioactivity at different intervals after intravenous injection of lymph chylomicrons labeled in vivo with 14C-cholesterol. The 14C-clearance curves were nonlinear, consisting of an initial rapid phase followed by a slow phase of clearance. The initial 14C-clearance was significantly (p less than 0.05) delayed whether the labeled chylomicrons from ZD donors were injected into ZD or CT recipients. The hepatic 14C-recovery in extracted lipids was also significantly lower in ZD rats. The present data provide first evidence that a marginal level of zinc deficiency produces a significant delay in the plasma clearance and hepatic uptake of chylomicron cholesterol. This may be attributable in part to the molecular alterations of chylomicrons induced by zinc deficiency.

American College of Epidemiology 10th annual scientific meeting. Disparities in health between minorities and nonminorities. Recommendations for future research and action.

As a nation, we must accept and appreciate the fact of the racial and cultural diversity that characterizes America. Such diversity dictates that fundamental approaches and solutions to social problems, including health, need to be specific to local areas. From addressing health problems, the least controversial of social challenges, a degree of mutual respect can evolve that permits other issues to be addressed as well. Resolving health problems will require a coordinated effort of local, city, state and federal resources, both medical and non-medical. In addressing such problems, three important principles need to be embraced: 1) the development of a surveillance system to measure the problem and assess progress in terms of ultimate outcomes; 2) the continuing use of surveillance data to assess and modify strategy and to allocate resources as needed; and 3) the need in health programs in particular to assign far higher priority to "consumer satisfaction."

Surveillance of smallpox.

An intensified global smallpox eradication programme was started by the World Health Organization in 1967. This paper describes the basic techniques employed and the experiences involved in implementing the procedures. Surveillance schemes have varied considerably in detail from country to country according to different health structures, and the emphasis is therefore placed on the more generally used approaches. Finally, important principles in the implementation of the smallpox surveillance programme are considered in relation to the development of such programmes for other communicable diseases.

Defining global medical education needs.

The graduates of medical education institutions should be, both in their numbers and in their acquired skills, appropriate to improving the health of the particular society they are intended to serve. Medical education should be tailored to deal with the diseases the physician is most apt to see--or at least apt to see in an academic medical center. Such logic does not prevail, however, in terms of either the numbers of physicians trained or the content of the medical curriculum. The Western model of a medical school curriculum has been adopted--but little adapted--for use by much of the Third World. Relevant subjects such as epidemiology, social sciences, and management are often either ineptly taught or omitted. A shift in attention from patient to community is recommended, accompanied by deliberate programs of education and health care to measure and improve the health of the community. Significant improvements in health in much of the world can be made only through community-based programs such as improved nutrition, education, sanitation, prevention of infectious diseases, and family planning. Two types of U.S. participation in international medical education are recommended: (1) specialty training of physicians from countries whose access to instrumentation and medical care support structures are similar to those in the United States, and (2) strengthening of institutions in developing countries in the areas of education, research, and practice appropriate to the particular needs of each of these countries.

Synthesis of ent-17-(prop-1-ynyl-17 beta-hydroxy-11 beta-(4-(N,N-dimethylamino)-phenyl)-4,9-estradien-3-one, the antipode of RU-38 486.

The title compound was synthesized and tested for its biological activities. It showed neither antiprogesterone nor antiglucocorticoid properties.