Probiotics and prevention of Clostridium difficile infection.

The role of probiotics as adjunctive measures in the prevention of Clostridium difficile infection (CDI) has been controversial. However, a growing body of evidence has suggested that they have a role in primary prevention of CDI. Elements of this controversy are reviewed and the proposed mechanisms of action, the value and cost effectiveness of probiotics are addressed with a focus on three agents, Saccharomyces boulardii, Lactobacillus rhamnosus GG and the combination of Lactobacillus acidophilus CL1285, Lactobacillus casei LBC80R, Lactobacillus rhamnosus CLR2 (Bio-K+).

Vaccine allocation in a declining epidemic.

Sizeable quantities of 2009 pandemic influenza A/H1N1 (H1N1pdm) vaccine in the USA became available at the end of 2009 when the autumn wave of the epidemic was declining. At that point, risk factors for H1N1-related mortality for some of the high-risk groups, particularly adults with underlying health conditions, could be estimated. Although those high-risk groups are natural candidates for being in the top priority tier for vaccine allocation, another candidate group is school-aged children through their role as vectors for transmission affecting the whole community. In this paper, we investigate the question of prioritization for vaccine allocation in a declining epidemic between two groups-a group with a high risk of mortality versus a 'core' group with a relatively low risk of mortality but fuelling transmission in the community. We show that epidemic data can be used, under certain assumptions on future decline, seasonality and vaccine efficacy in different population groups, to give a criterion when initial prioritization of a population group with a sufficiently high risk of epidemic-associated mortality is advisable over the policy of prioritizing the core group.

Reporting of CAHPS quality information to medicare beneficiaries.

OBJECTIVES: To assess which Consumer Assessment of Health Plans (CAHPS) survey measures Medicare beneficiaries find the most meaningful, how beneficiaries and information intermediaries interpret different formats for presenting CAHPS information, and how beneficiaries have reacted to the CAHPS information included in the annual mailing to beneficiaries called Medicare & You 2000. DATA SOURCES: Fourteen focus groups of beneficiaries and State Health Insurance Assistance Program counselors, more than 200 cognitive interviews, and 122 mall-intercept interviews with beneficiaries were conducted from spring 1998 through winter 2000. STUDY DESIGN: In 1998 focus groups and cognitive interviews were conducted with Medicare beneficiaries and State Health Insurance Assistance Program counselors to determine which CAHPS measures to report to Medicare beneficiaries and how to report this information. In 1999 additional focus groups and mall-intercept interviews were conducted to determine which measures to include in Medicare & You 2000. To obtain feedback on the CAHPS information in Medicare & You 2000 additional focus groups were conducted in winter 2000. PRINCIPAL FINDINGS: Focus group participants indicated that getting the care they need quickly, having access to specialists, and communicating well with doctors were more important to them than nonmedical characteristics of plans. Most beneficiaries had problems interpreting quality information. Many misinterpreted star charts, and while bar charts appear easier to read, many beneficiaries still had trouble interpreting the information on these charts. Most beneficiaries did not consider quality information important to them and most were unaware of the availability of CAHPS information. CONCLUSIONS: Many challenges lie ahead in making quality information meaningful to Medicare beneficiaries. These challenges include increasing awareness of the existence of this information, educating beneficiaries about how this information can help in choosing a health plan, continuing to simplify reporting formats, assuring beneficiaries that this information comes from a credible source, and providing guidance to beneficiaries about how quality information can help with health care decisions.

Use of Medicaid 1915(c) home- and community-based care waivers to reconfigure state long-term care systems.

Since Congressional authorization in 1981, Medicaid 1915(c) home- and community-based care waivers have influenced states' efforts to transform their long-term care systems. In 1997, every state participated in the 1915(c) waiver program, while waiver expenditures, at $8.1 billion, represented 59.6 percent of all Medicaid community-based care expenditures. To explore state-level factors that appear related to these expenditures, the authors turn to a body of work on Medicaid resource allocation. They compare the influence of five factors--sociodemographic, supply, economic, programmatic, and political environment--on states' allocations to long-term care expenditures and 1915(c) waiver expenditures. The state economic environment was an important influence on total, as well as waiver expenditures. State regulation of long-term care supply demonstrated the most substantive relationship, increasing the share of dollars supporting 1915(c) waivers from 11.6 to 20.0 over the study period, all else equal.

Lessons learned from the National Medicare & You Education Program.

In fall 1998 CMS implemented the National Medicare Education Program (NMEP) to educate beneficiaries about their Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS has been monitoring the implementation of the NMEP in six case study sites as well as monitoring each of the information channels for communicating with beneficiaries. This article describes select findings from the case studies, and highlights from assessment activities related to the Medicare & You handbook, the toll-free 1-800-MEDICARE Helpline, Internet, and Regional Education About Choices in Health (REACH).

Health status during the transition in Central and Eastern Europe: development in reverse?

This paper reports on a study of the cross-national trends in health status during the economic transition and associated health sector reforms in Central and Eastern Europe (CEE). The central premise is that before long-run gains in health status are realized, the transition towards a market economy and adoption of democratic forms of government should lead to short-run deterioration as a result of: (i) reduction in real income and widening income disparities; (ii) stress and stress-related behaviour; (iii) lax regulation of environmental and occupational risks; and (iv) breakdown in basic health services. Analysis focused on three broad indicators of health status: life expectancy at birth, infant mortality rate and the probability of dying between the ages of 15 and 65 years, shown by the notation '50q15'. The study revealed significant new information about health status and the health sector which could not have been obtained without a proper cross-national study. Infant mortality rates in former socialist economies (FSE) follow the global trend, declining as per capita income rises. However, rates are lower than would be predicted given their income levels. Despite declining infant mortality, life expectancy at birth in the former socialist economies decreases as per capita income rises, in marked contrast to global trends. This is because rising income level is associated with greater probability of death between the ages of 15 and 65: the wealthier the society, the less healthy is its population, particularly for its males. Causes of death in the FSE follow global trends: higher death rates due to infectious and parasitic diseases in poorer countries, and higher death rates due to chronic diseases in wealthier countries. However, age-standardized death rates for chronic diseases generally associated with unhealthy lifestyles and environmental risk factors are very high when compared with wealthier established market economies (EME). Policies and procedures which alter the effectiveness of health services have had a demonstrable but mixed impact on health status during the early phase of transition. Effective preventive health strategies must be formulated and implemented to reverse the adverse trends observed in Central and Eastern Europe.

Outcomes of anorectal disease in a health maintenance organization setting. The need for colorectal surgeons.

PURPOSE: The current trend in health delivery is managed care, in which the primary care provider (PCP) manages patient care and triages specialty referrals. It has not been established, however, that PCPs can accurately diagnose, treat, or triage anorectal disorders. MATERIALS AND METHODS: A retrospective study was undertaken at a health maintenance organization that hired a colon and rectal surgeon. Charts of the first 100 consecutive consultations for anorectal complaints were analyzed for accuracy of diagnosis and appropriateness of care. RESULTS: Correct diagnoses were made by 45 of 85 (53 percent) PCP physicians, 6 of 15 (40 percent) PCP physician assistants, and 8 of 15 (53 percent) general surgeons. A delay to diagnosis or appropriate treatment occurred in 25 patients (25 percent), resulting in an adverse outcome in 15 people. Of these, five complications were caused by delayed diagnosis, and ten patients had symptoms that persisted from 5 months to 14 years (mean, 4.5 years). Seven unnecessary referrals to a gastroenterologist resulted in three unnecessary colonoscopies. Of 19 patients evaluated by a general surgeon, 4 had inadequate/inappropriate operations, 5 were untreated because of misdiagnosis, 3 correctly diagnosed were untreated, 3 had inappropriate follow-up, 1 was referred to a gastroenterologist, and 2 were advised to have appropriate treatment. SUMMARY: The PCP correctly diagnosed anorectal disorders in 51 percent of cases and referred patients promptly 75 percent of the time. Of the 25 percent with delay, 60 percent experienced a complication of persistent symptoms. Fifteen of 19 (79 percent) patients seen by a general surgeon were inappropriately managed.

Are serum levels of vancomycin useful in the first week of therapy?

Controversy exists regarding the need to monitor serum concentrations of vancomycin with some investigators recommending measurement of peak and trough concentrations in the first week of therapy and regularly thereafter, whereas others contend that empiric dosing produces safe and effective drug concentrations so that testing is unnecessary. Since vancomycin concentrations are measured, routinely in our hospital in the first week of therapy, we conducted a 12 month study to assess their clinical value in patients who were treated when gram positive cocci were detected in blood culture smears. One-hundred-five patients had gram positive cocci on blood culture smears. These bacteria were pathogens in 15 patients with Staphylococcus aureus and in 18 with coagulase negative staphylococci based on microbiologic criteria and a chart review confirming their clinical significance. Ten patients with S. aureus and 8 patients with coagulase negative staphylococci that were pathogens and 10 patients with coagulase negative staphylococci that were contaminants were treated with vancomycin. Serum peak and trough concentrations of vancomycin obtained within the first 5 days of therapy in these 28 patients were 14 to 40 micrograms/ml and 4.8 to 20 micrograms/ml. These concentrations were much above the MIC's of the microorganisms (< 4 micrograms/ml). Five patients had increases of serum creatinine of more than 0.6 mg% and in each patient the increases were attributable to other causes-shock, heart failure, and preexisting renal failure. Fifty five peak and trough concentrations 19 of which were drawn in patients with contaminated cultures were measured at a cost of $2,475.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaerobes under assault: from cottage industry to industrialization of medicine and microbiology.

More than 100 years have elapsed since the initial discovery of anaerobiosis, the first anaerobic microbiological isolation, and the first clinical descriptions of human anaerobic infection. New species are still being discovered, the important role of anaerobes as normal flora and in the maintenance of health is becoming increasingly appreciated, and the development of resistance by anaerobes to virtually all antimicrobials has recently accelerated. Anaerobes and their products have been employed widely and at times have been associated with political evolution, such as the establishment of the state of Israel. Despite all this, the current era of recession and health care economizing threatens the field of anaerobic bacteriology with funding cutbacks and diminished recognition. In order to prevent stagnation in the field and its decline, anaerobists must remain committed and vigilant and must take an increasingly active stance in education, publication, and research.

Subcutaneous morphine pump for postoperative hemorrhoidectomy pain management.

PURPOSE: Many anorectal procedures are currently being performed on an outpatient basis, hemorrhoidectomy being the exception because of the need for parenteral narcotics postoperatively. We investigated the effectiveness of a subcutaneous morphine pump (SQMP) for outpatient posthemorrhoidectomy pain control. METHODS: In Phase 1 of our study, 22 patients undergoing radical hemorrhoidectomy were started on an SQMP protocol postoperatively. Twenty-nine patients received conventional postoperative narcotic dosing. In Phase 2, 19 patients enrolled in an SQMP protocol underwent hemorrhoidectomy in an ambulatory setting. Length of hospitalization, catheterization rate, and pain control were evaluated. RESULTS: In Phase 1, zero patients in the study group and two in the control group required additional hospitalization beyond 23 hours for pain control. The rates of catheterization were similar between the two groups. Pain control was considered satisfactory in 21 of 22 study patients. There was no correlation between pain level and morphine dose. Eighteen of 22 patients experienced minor side effects, necessitating pump removal in two patients. In Phase 2, 18 of 19 patients on the SQMP were discharged from the recovery room. Cost analysis shows the combination of outpatient hemorrhoidectomy and the SQMP to be cost-effective in comparison with an inpatient stay. CONCLUSIONS: The SQMP enables hemorrhoidectomy to be done on an outpatient basis. It provides effective pain control, enjoys high patient acceptance, and is cost-effective.

Assessment of the excess risk of Salmonella dublin infection associated with the use of certified raw milk.

The risk of serious illness attributable to infection with Salmonella dublin associated with the consumption of certified raw milk in California was evaluated. Data were derived from case reports of S. dublin isolations from persons in the State of California during the period 1980-83 and from production figures for raw milk from the major supplier. It is estimated that more than one-third of reported S. dublin infections in California in the first 4 years of this decade were attributable to raw milk consumption. Among raw milk consumers, it is estimated that more than 95 percent of reported S. dublin infections were acquired from raw milk; this proportion corresponds to a rate of reported S. dublin infections acquired from raw milk in the range of 8 to 35 cases per 100,000 users per year. It appears that immunocompromised persons are at exceptionally high risk of becoming seriously ill or dying from S. dublin exposure, and therefore raw milk is a particular health hazard for such persons.