Potential Intercontinental Movement of Influenza A(H7N9) Virus into North America by Wild Birds: Application of a Rapid Assessment Framework.

A critical question surrounding emergence of novel strains of avian influenza viruses (AIV) is the ability for wild migratory birds to translocate a complete (unreassorted whole genome) AIV intercontinentally. Virus translocation via migratory birds is suspected in outbreaks of highly pathogenic strain A(H5N1) in Asia, Africa and Europe. As a result, the potential intercontinental translocation of newly emerging AIV such as A(H7N9) from Eurasia to North America via migratory movements of birds remains a concern. An estimated 2.91 million aquatic birds move annually between Eurasia and North America with an estimated AIV prevalence as high as 32.2%. Here, we present a rapid assessment to address the likelihood of whole (unreassorted)-genome translocation of Eurasian strain AIV into North America. The scope of this assessment was limited specifically to assess the weight of evidence to support the movement of an unreassorted AIV intercontinentally by migratory aquatic birds. We developed a rapid assessment framework to assess the potential for intercontinental movement of avian influenzas by aquatic birds. This framework was iteratively reviewed by a multidisciplinary panel of scientific experts until a consensus was established. Our assessment framework identified four factors that may contribute to the potential for introduction of any AIV intercontinentally into North America by wild aquatic birds. These factors, in aggregate, provide a framework for evaluating the likelihood of new forms of AIV from Eurasia to be introduced by aquatic birds into North America. Based on our assessment, we determined that the potential for introduction of A(H7N9) into North America through aquatic migratory birds is possible, but the likelihood ranges from extremely low to low.

Drug-resistant malaria in Bangladesh: an in vitro assessment.

Forty-four Plasmodium falciparum isolates from Bangladesh and 22 from western Thailand were successfully tested for their drug susceptibility. High degrees of resistance were observed against chloroquine with geometric mean IC50s of 114.25 and 120.5 nM, respectively, for Bangladesh and western Thailand. Most isolates from both sites were sensitive to quinine, and all were sensitive to artesunate. Many isolates were considered in vitro resistant to mefloquine, but the geometric mean IC50 for the Thai isolates (98.79 nM) was 1.6 times (P = 0.002) higher than that of isolates from Bangladesh (60.3 nM). The high prevalence of in vitro mefloquine resistance in Bangladesh suggests that close surveillance is necessary to delay widespread multidrug resistant problems in the area.

Prophylactic inferior vena cava filters in trauma patients at high risk: follow-up examination and risk/benefit assessment.

PURPOSE: The efficacy of prophylactic inferior vena cava filters in selected trauma patients at high risk has come into question in relation to risk/benefit assessment. To evaluate the usefulness of prophylactic inferior vena cava filters, we reviewed our experience and overall complication rate. METHODS: From February 1991 to April 1998, the trauma registry identified 7333 admissions. One hundred eighty-seven prophylactic inferior vena cava filters were inserted. After the exclusion of 27 trauma-related deaths (none caused by thromboembolism), 160 patients were eligible for the study. The eligible patients were contacted and asked to complete a survey and return for a follow-up examination to include physical examination, Doppler scan study, vena cava duplex scanning, and fluoroscopic examination. The patients' hospital charts were reviewed in detail. The indications for prophylactic inferior vena cava filter insertion included prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. RESULTS: Of the 160 eligible patients, 127 were men, the mean age was 40.3 years, and the mean injury severity score was 26.1. The mean day of insertion was hospital day 6. Seventy-five patients (47%) returned for evaluation, with a mean follow-up period of 19.4 months after implantation (range, 7 to 60 months). On survey, patients had leg swelling (n = 27), lower extremity numbness (n = 14), shortness of breath (n = 9), chest pain (n = 7), and skin changes (n = 4). All the survey symptoms appeared to be attributable to patient injuries and not related to prophylactic inferior vena cava filter. Physical examination results revealed edema (n = 12) and skin changes (n = 2). Ten Doppler scan studies had results that were suggestive of venous insufficiency, nine of which had histories of deep vein thrombosis. With duplex scanning, 93% (70 of 75) of the vena cavas were visualized, and all were patent. Only 52% (39 of 75) of the prophylactic inferior vena cava filters were visualized with duplex scanning. All the prophylactic inferior vena cava filters were visualized with fluoroscopy, with no evidence of filter migration. Of the total 187 patients, 24 (12.8%) had deep vein thrombosis develop after prophylactic inferior vena cava filter insertion, including 10 of 75 (13.3%) in the follow-up group, and one patient had a nonfatal pulmonary embolism despite filter placement. Filter insertion complications occurred in 1.6% (three of 187) of patients and included one groin hematoma, one arteriovenous fistula, and one misplacement in the common iliac vein. CONCLUSION: This study's results show that prophylactic inferior vena cava filters can be placed safely with low morbidity and no attributable long-term disabilities. In this patient population with a high risk of pulmonary embolism, prophylactic inferior vena cava filters offered a 99.5% protection rate, with only one of 187 patients having a nonfatal pulmonary embolism.

Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound.

The efficacy and effectiveness of ultrasound (US) in evaluating patients suspected of having blunt abdominal trauma are near that of computed tomography (CT) and diagnostic peritoneal lavage (DPL). Because no cost-effectiveness study has been reported, the purpose of this study was to demonstrate that US is more efficient and cost-effective than CT/DPL in evaluating blunt abdominal trauma. Over a 9-month period, 331 patients suspected of sustaining blunt abdominal trauma were evaluated at a Level I trauma center by US, CT, and/or DPL. Cost data and time to disposition were determined for analysis. The sensitivity, specificity, and accuracy of US were similar to those reported in previous studies. There was a significant difference in time to disposition with the US group being significantly lower (P = 0.001). The total procedural cost was 2.8 times greater for the CT/DPL group than for the US group. US is not only effective in diagnosing blunt abdominal trauma, but it is also more efficient and cost-effective than is CT/DPL.

Graduate medical education, 1997-1998.

In response to growing concerns that continued unlimited governmental funding of graduate medical education (GME) would lead to a physician surplus, Congress enacted provisions in the Balanced Budget Act (BBA) of 1997 to limit further growth, as well as to encourage reductions in GME. The measures incorporated in this section of the BBA reflect recommendations made by a number of major professional associations. The question now is how effective these efforts will be and whether they will produce unintended or deleterious consequences. We report the changes occurring in GME from 1993 to 1997, focusing on changes prior to and since the enactment of the BBA. The total number of residents in GME programs has remained relatively constant from 1993 to 1997. The number of residents entering GME programs without prior GME experience has also remained constant; however, over the same period, the number entering a new program with some prior GME experience has fallen by 5.8%. The number of international medical graduates in all GME programs has increased 12.4% during this same period, while the number of US allopathic medical school graduates has decreased 4.4%. As federal and state initiatives are introduced to change the number and distribution of GME positions, it is critical that the American Medical Association and other professional organizations monitor GME tracking data more systematically and accurately than ever before.

Lowering hospital charges in the trauma intensive care unit while maintaining quality of care by increasing resident and attending physician awareness.

OBJECTIVE: The goal of this study was to determine if trauma intensive care unit (TICU) charges could be reduced through informal daily bedside resident-attending physician discussions regarding relative patient costs of diagnostic and therapeutic alternatives. DESIGN: This was a prospective pre- and postinterventional study. SETTING: The study took place in a TICU in a level I, community-based, university-affiliated teaching hospital. PATIENTS: Ninety-one consecutive patients were admitted to the TICU during a 6-month period. MATERIALS AND METHODS: The TICU charges were tracked over two consecutive 3-month periods. The first 3 months served as control. No attempt was made to alter cost of care, and residents were unaware that a study was in progress. During the ensuing 3-month period, attendings explicitly discussed with residents relative costs of diagnostic and therapeutic interventions in an attempt to lower charges. Composition of the surgical trauma team remained constant throughout the study. MEASUREMENT AND MAIN RESULTS: The median and mean age, Injury Severity Score, intensive care unit length of stay, and sex ratio were not statistically different between the two study groups. Total median daily charges of the postintervention group were reduced over the control group by $818/intensive care unit day (p = 0.0002). The major categories in which charges were reduced included medications ($151/day, p = 0.003), laboratory tests ($120/day, p = 0.072), chest x-ray films ($61/day, p = 0.001), respiratory therapy ($185/day, p = 0.21), and miscellaneous charges ($141/day, p = 0.055). Mortality rates and number of major complications were not statistically different between groups. CONCLUSIONS: Increased awareness of cost factors and specific attempts to achieve patient cost reduction resulted in a demonstrable decrease in daily TICU charges, without compromising the quality of care.

Participation of international medical graduates in graduate medical education and hospital care for the poor.

OBJECTIVE: To determine the impact of limiting international medical graduate (IMG) participation in US graduate medical education (GME) on the delivery of hospital care to the poor. METHODS: To ascertain the pattern of IMG participation in GME and the degree to which the principal teaching hospitals with programs with large IMG enrollments provide care to the poor, we used data from the American Medical Association 1993 Annual Survey of Graduate Medical Education Programs and Teaching Institutions to analyze the pattern of IMG participation in GME in the six core specialties of internal medicine, family practice, obstetrics and gynecology, surgery, pediatrics, and psychiatry. MAIN OUTCOME MEASURES: Programs were identified as IMG dependent if at least 50% of the resident physicians enrolled in the first year of the program were IMGs. All programs were linked to their principal teaching hospitals, and hospitals were assessed according to the number of programs based at each institution, the number of IMG-dependent programs at the institution, and whether no-pay patients and/or Medicaid/public assistance beneficiaries constituted more than 20% of the patients served. RESULTS: Of the 20,170 first-year resident physicians in the six core specialties, 31.8% were IMGs. The proportion of programs dependent on IMG enrollment was 27.7%, ranging from 5.2% in obstetrics and gynecology programs to 49.5% in psychiatry programs. About 72% of all first-year IMGs were in IMG-dependent programs. Of the 688 hospitals serving as principal teaching sites for programs in at least one of the six core specialties, 106 were categorized as dependent on IMG programs, but only 77 of those provided a disproportionate amount of care to the poor. Finally, 40% of the IMG-dependent GME programs and 36% of first-year IMG residents were based in hospitals that did not provide a disproportionate amount of care to the poor. CONCLUSIONS: Based on this analysis, 77 hospitals can arguably be considered dependent on IMG resident physicians to provide care to the poor. Moreover, a large number of IMG residents and IMG-dependent programs are in hospitals that do not provide a disproportionate amount of care to the poor. These findings show the scale of the problem policymakers must address if they choose to limit IMG access to GME while maintaining access of the poor to needed hospital care.

Do we practice what we preach? Comparing the patients of faculty and residents.

BACKGROUND AND OBJECTIVES: In academic family practice centers, the distribution of patients between faculty and residents influences the educational milieu. The medical literature has rarely addressed the differential case mix within the ambulatory medical educational setting. The goal of this study was to compare the characteristics of patient visits to resident and faculty physicians in seven community-based, university-affiliated family practice programs. METHODS: Using the National Ambulatory Care Survey instrument and protocol, 98 faculty and resident physicians recorded their ambulatory patient visits for one randomly selected week between July 1991 and June 1992 (n = 1,498). RESULTS: Patients of resident physicians were younger, more likely to be nonwhite (21.7% vs 9.8%, P < .001), and more likely to be reimbursed by Medicaid (34.2% vs 14.3%, P < .001) than patients of faculty physicians. Despite these patient differences, the spectrum of clinical problems was similar. There were minimal differences in the delivery of diagnostic services and therapeutic services. CONCLUSIONS: The patients seen by residents and faculty differ in important demographic characteristics. These differences could adversely affect the education of resident physicians. Academic family practice centers should actively monitor the age/gender/payment profile of resident and faculty patient panels and assign patients to achieve a desirable case mix for resident education. The differential racial distribution of faculty and resident visits suggests an unidentified systematic bias in patient assignment that warrants further investigation.

Does family practice at residency teaching sites reflect community practice?

BACKGROUND: Family medicine has aspired to train residents and conduct research in settings that closely resemble community practice. The purpose of this study was to compare the patient characteristics of the ambulatory teaching centers of a consortium of seven community-based university-affiliated family practice residency programs in northeast Ohio with the National Ambulatory Medical Care Survey (NAMCS) results for family physicians (FPs) and general practitioners (GPs). METHODS: Ninety-eight faculty and resident physicians at the residency training site of the Northeastern Ohio Universities College of Medicine collected data on all ambulatory patient visits (N = 1498) for one randomly chosen week between July 1, 1991, and June 30, 1992. We compared these data with patient visits reported in the 1990 NAMCS for FPs and GPs. RESULTS: The residency training sites saw slightly more children, women, blacks, and Medicare and Medicaid patients. The most common reason for an office visit in both populations was an undifferentiated symptom. Fifteen of the top 20 "reason for visit" codes were identical, as were 14 of the top 20 diagnoses. More preventive and therapeutic services were offered or performed at our residency training sites but fewer diagnostic services were performed. There were fewer consultations requested at our residency training sites but similar hospitalization rates for patients. The mean duration of visit differed by only 1 minute. CONCLUSIONS: The residency training sites of the Northeastern Ohio Universities College of Medicine provide patient care opportunities similar to those found in a national survey of family and general practitioners.

Factors influencing mammogram ordering at the time of the office visit.

BACKGROUND: Breast cancer is the second most common cause of cancer death in women, with mammographic screening the only modality shown to decrease the death rate. However, only 17% to 41% of women have ever been screened, and multiple barriers to screening have been identified. This study examined physician and patient factors at a single encounter to explore components influencing mammography ordering. METHODS: Ten family physicians in a primary care research network completed daily data cards on encounters with women presenting for annual examinations, chronic problems, or breast-related complaints. Information collected included patient age, personal or family history of breast cancer, physician's perception of expected compliance, previous mammogram results, breast examination, physician's perception of need for a mammogram, whether the mammogram was ordered, and the patient's method of payment for the test. RESULTS: Eight hundred thirty-nine patients were entered into the study, and 277 mammograms were ordered. Mammograms were ordered for a greater percentage of patients with insurance (36%) than for those without insurance (26%) (P < .001). A multivariate analysis indicated that several factors helped to correctly classify 90% of mammogram ordering: the patient was making a first visit, a breast-related visit, or a visit for an annual examination; the patient had had a previous mammogram; had a breast examination at the current visit or within the past year; and the physician believed the patient would comply and believed that a mammogram was indicated. CONCLUSIONS: Factors unique to a physician-patient visit influence the physician with regard to ordering a mammogram, including the type of visit, whether the physician believes a mammogram is indicated, and the cost.

The assessment of social intimacy.

Research exploring the psychological importance of closeness with others has been hampered by the absence of a reliable and valid measure of this variable. The development of the Miller Social Intimacy Scale (MSIS), a 17-item measure of the maximum level of intimacy currently experienced, is presented. Evidence for internal consistency and test-retest reliability as well as for convergent, discriminant and construct validity is discussed in the context of the need for further scientific exploration of this important phenomenon.

Prescribing psychotropic drugs: whose responsibility?

Through the use of a questionnaire it has been ascertained that a significant number of second-year graduate school social work students at the Columbia University School of Social Work are called upon to monitor and dispense psychotrophic drugs in various placements where they receive their practical clinical training. In some instances they may even fill out prescription blanks that are signed by psychiatrists who do not have the time to see the patients personally. This situation not only represents the abdication of medical responsibility, frequently leaving non-medical personnel with functions beyond their training and professional competence, but also raises important ethical and legal problems. Non-medical professionals in mental health settings should receive appropriate instruction in the essentials of psychopharmacology. Such training should not be left to chance as apparently is the case now. Non-medically trained members of the mental health team, if properly instructed, could cooperate more effectively with the psychiatrists who must in any event retain primary responsibility for pharmacotherapy.