Measuring Active and Healthy Ageing: Applying a GENERIC Interdisciplinary Assessment Model Incorporating ICF.

OBJECTIVES: In this study we compared the chronological and bio-functional age between two German speaking cohorts 30 years apart applying a comprehensive and generic Active and Healthy Aging (AHA) assessment model incorporating ICF. METHODS: Single-centre, cross-sectional, observational, non-interventional, non-randomized trial at an University based women's hospital, division of Gynecological Endocrinology and Reproductive Medicine. All participants followed a standardized, holistic battery of biopsychosocial assessments consisting of bio-functional status (BFS), bio-functional age (BFA) and additional validated psychometric questionnaires. RESULTS: 462 non-pediatric, non-geriatric females were in the BeCS-14 cohort. The measured mean BFA was lower than the chronological age within the BeCS-14 cohort (regression coefficient 0.58) and comparable in the female LeCS-84 subcohort (regression coefficient age 0.85, communality age 76%). In detail, within the decades 35-45 years and 55-65 years the gradient of BFA increase (aging rate) was similar in both cohorts (decade 35-45 years: LeCS-84 4.08 ± 1.03 year equivalents and BeCS-14 4.78 ± 1.67 year equivalents; decade 55-65 years: LeCS-84 6.21 ± 1.29 year equivalents and BeCS-14 5.25 ± 1.18 year equivalents). Remarkably, within the LeCS-84 cohort the mean aging rate within the decade 45-55 years was significantly different from all other aging rates in both cohorts: 13.02 ± 1.05 year equivalents. However, within the BeCS-14 cohort the corresponding value was 4.83 ± 1.02 year equivalents thus indicating a continuous aging process across the adult life course. In BeCS-14, there was a significant age-related effect for cardiovascular performance and social stress exposition and younger age was associated with better cardiovascular performance while level of social stress exposition decreased in aging women. CONCLUSION: When comparing BeCS-14 and LeCS-84, the aging process seemed to be accelerated in women in LeCS-84 between 45 and 54 years of age. We can only speculate on the reasons, such as differences in the health care, political and social system. However, the differences observed support the use of our BFS/BFA assessment tool not only on an individual level (strengths/resources) but also population level following EIP-AHA requirements. Yet, it remains to be developed how the assessed health strengths/resources-profile may be integrated into AHA management.

Empirical therapies among adults hospitalized for community-acquired upper urinary tract infections: A decision-tree analysis of mortality, costs, and resistance.

BACKGROUND: Poor outcomes occur when patients with serious infections receive antibiotics to which the organisms are resistant. METHODS: Decision trees simulated in-hospital mortality, costs, incremental cost-effectiveness ratio per life year saved, and carbapenem resistance according to 3 empirical antibiotic strategies among adults hospitalized for community-acquired (CA) upper urinary tract infections (UTIs): ceftriaxone (CRO) plus gentamicin (GM) in the intensive care unit (ICU), imipenem (IMP), and individualized choice (IMP or CRO) based on clinical risk factors for CA- extended-spectrum ß-lactamase (ESBL). RESULTS: The estimated prevalence of CA-ESBL on admission was 5% (range, 1.3%-17.6%); 3% and 97% were admitted to the ICU and medical ward (MW), respectively. In the ICU, CRO plus GM was dominated; IMP was cost-effective (incremental cost-effectiveness ratio: €4,400 per life year saved compared with individualized choice). In the MW, IMP had no impact on mortality and was less costly (-€142 per patient vs CRO, -€38 vs individualized choice). The dominance of IMP was consistent in sensitivity analyses. Compared with CRO, colonization by carbapenem-resistant pathogens increased by an odds ratio of 4.5 in the IMP strategy. CONCLUSION: Among the ICU patients, empirical IMP therapy reduces mortality at an acceptable cost. Among MW patients, individualized choice or CRO is preferred to limit carbapenem resistance at a reasonable cost.

Audit of carbapenem prescriptions comparing 2 assessment periods.

OBJECTIVE: The emergence of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae has resulted in the increase of carbapenem prescriptions. The objective of our study was to determine the appropriateness of carbapenem prescriptions from initiation to reassessment of treatment, between 2009 and 2011. PATIENTS AND METHOD: A questionnaire drafted by infectious diseases specialists (IDS) and microbiologists was used to collect clinical and microbiological data concerning carbapenem prescriptions in 2009 and 2011. An IDS then compared the results to assess carbapenem prescription compliance with our hospital's local recommendations. RESULTS: Seventy-one prescriptions were included in 2009 and 32 in 2011. The carbapenem treatment had been most frequently probabilistic to treat nosocomial infections. The microbiological data revealed that the number of multidrug-resistant (MDR) infections had increased between 2009 and 2011, especially infections involving ESBL-producing Enterobacteriaceae. At treatment reassessment, in 2009 and 2011, 15 (21%) and 12 (38%) carbapenem prescriptions were appropriate and continued. Overall, when comparing the 2 periods, prescriptions complied with local guidelines from initiation to reassessment of treatment without any statistically significant difference (68% in 2009 and 75% in 2011). CONCLUSION: Our study results showed that MDR infections had increased and especially infections due to ESBL-producing Enterobacteriaceae; this was consistent with epidemiological data. We also proved that most carbapenem prescriptions were compliant with recommendations. The increased mobile IDS interventions in medical and surgical departments helped reach this rate of compliance. Carbapenem stewardship may be promoted even in a difficult epidemiological context, especially with IDS interventions for the duration of treatment or at treatment reassessment.

Quality of life assessment among HIV-positive persons entering the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial.

OBJECTIVES: With HIV treatment prolonging survival and HIV infection now managed as a chronic illness, quality of life (QOL) is important to evaluate in persons living with HIV (PLWH). We assessed at study entry the QOL of antiretroviral-naïve PLWH with CD4 counts > 500 cells/µL in the Strategic Timing of AntiRetroviral Treatment (START) clinical trial. METHODS: QOL was assessed with: (1) a visual analogue scale (VAS) for self-assessment of overall current health; (2) the Short-Form 12-Item Version 2 Health Survey(®) (SF-12V2), for which responses are summarized into eight individual QOL domains plus component summary scores for physical health [the Physical Health Component Summary (PCS)] and mental health [the Mental Health Component Summary (MCS)]. The VAS and eight domain scores were scaled from 0 to 100. Mean QOL measures were calculated overall and by demographic, clinical and behavioural factors. RESULTS: A total of 4631 participants completed the VAS and 4119 the SF-12. The mean VAS score (with standard deviation) was 80.9 ± 15.7. Mean SF-12 domain scores were lowest for vitality (66.3 ± 26.4) and mental health (68.6 ± 21.4), and highest for physical functioning (89.3 ± 23.0) and bodily pain (88.0 ± 21.4). Using multiple linear regression, PCS scores were lower (P < 0.001) for Asians, North Americans, female participants, older participants, and those with less education, longer duration of known HIV infection, alcoholism/substance dependence and body mass index ≥ 30 kg/m(2) . MCS scores were highest (P < 0.001) for Africans, South Americans and older participants, and lowest for female participants, current smokers and those with alcoholism/substance dependence. CONCLUSIONS: In this primarily healthy population, QOL was mostly favourable, emphasizing that it is important that HIV treatments do not negatively impact QOL. Self-assessed physical health summary scores were higher than mental health scores. Factors such as older age and geographical region had different effects on perceived physical and mental health.

Assessment of panobacumab as adjunctive immunotherapy for the treatment of nosocomial Pseudomonas aeruginosa pneumonia.

The fully human anti-lipopolysaccharide (LPS) immunoglobulin M (IgM) monoclonal antibody panobacumab was developed as an adjunctive immunotherapy for the treatment of O11 serotype Pseudomonas aeruginosa infections. We evaluated the potential clinical efficacy of panobacumab in the treatment of nosocomial pneumonia. We performed a post-hoc analysis of a multicenter phase IIa trial (NCT00851435) designed to prospectively evaluate the safety and pharmacokinetics of panobacumab. Patients treated with panobacumab (n = 17), including 13 patients receiving the full treatment (three doses of 1.2 mg/kg), were compared to 14 patients who did not receive the antibody. Overall, the 17 patients receiving panobacumab were more ill. They were an average of 72 years old [interquartile range (IQR): 64-79] versus an average of 50 years old (IQR: 30-73) (p = 0.024) and had Acute Physiology and Chronic Health Evaluation II (APACHE II) scores of 17 (IQR: 16-22) versus 15 (IQR: 10-19) (p = 0.043). Adjunctive immunotherapy resulted in an improved clinical outcome in the group receiving the full three-course panobacumab treatment, with a resolution rate of 85 % (11/13) versus 64 % (9/14) (p = 0.048). The Kaplan-Meier survival curve showed a statistically significantly shorter time to clinical resolution in this group of patients (8.0 [IQR: 7.0-11.5] versus 18.5 [IQR: 8-30] days in those who did not receive the antibody; p = 0.004). Panobacumab adjunctive immunotherapy may improve clinical outcome in a shorter time if patients receive the full treatment (three doses). These preliminary results suggest that passive immunotherapy targeting LPS may be a complementary strategy for the treatment of nosocomial O11 P. aeruginosa pneumonia.

A retrospective study of daptomycin use in a Paris teaching-hospital.

OBJECTIVE: We retrospectively studied daptomycin use during 2010 at the Bichat-Claude-Bernard teaching-hospital (Paris) to observe the evolution of daptomycin prescriptions. PATIENTS AND METHODS: Twenty-one patients were included and several parameters were documented: site of infection, bacterial species involved, reason for daptomycin use, dose and clinical outcome. RESULTS: Ninety-five percent of daptomycin prescritions were off-label and most did not comply with local guidelines. Fifteen of the 21 patients were cured (71%), including 9 patients of the 12 with off-label and off-local recommendation prescriptions (75%). Osteitis and Enterococcus spp endocarditis were the new indications. Daptomycin was increasingly used at higher doses: 52% of our patients were given doses above 6mg/kg. Staphylococcus spp. was the most frequent pathogen responsible for infection is our patients, followed by Enterococcus spp. CONCLUSION: Daptomycin use is likely to evolve because of its effectiveness in the treatment of osteitis, left-sided and Enterococcus spp. infective endocarditis. It is generally used at higher doses, which are well tolerated. However, therapeutic monitoring needs to be developed. The antibiotic commission of our hospital gave new recommendations for daptomycin use in 2011.

The association between parental perception of neighborhood safety and asthma diagnosis in ethnic minority urban children.

Low-income populations, minorities, and children living in inner cities have high rates of asthma. Recent studies have emphasized the role of psychosocial stress in development of asthma. Residence in unsafe neighborhoods is one potential source of increased stress. The study objective was to examine the association between parental perception of neighborhood safety and asthma diagnosis among inner city, minority children. Cross-sectional data from a community-based study of 6-8-year-old New York City children were used. Asthma was defined as parental report of physician-diagnosed asthma and at least one asthma-related symptom. Parental perceptions of neighborhood safety were assessed with a questionnaire. Associations between perceived neighborhood safety and asthma were examined using chi-squared tests. Multivariate logistic regression analyses were then performed. Five hundred four children were included with 79% female, 26.5% non-Hispanic Black, and 73.5% Hispanic. Asthma was present in 23.8% of children. There was an inverse association between feeling safe walking in the neighborhood and asthma with 45.7% of parents of asthmatic children reporting they felt safe compared to 60.9% of parents of non-asthmatic children (p = 0.006). Fewer parents of asthmatic children than of non-asthmatic children reported that their neighborhood was safe from crime (21.7% versus 33.9%, p = 0.018). In multivariate analyses adjusting for race/ethnicity, age, gender, socioeconomic status, number of smokers in the home and breastfeeding history, parents reporting feeling unsafe walking in the neighborhood were more likely to have a child diagnosed with asthma (OR = 1.89, 95%CI 1.13-3.14). Psychosocial stressors such as living in unsafe neighborhoods may be associated with asthma diagnosis in urban ethnic minority children. Addressing the increased asthma burden in certain communities may require interventions to decrease urban stressors.

[Scoring systems in intensive care medicine : principles, models, application and limits]. / Scoring-Systeme in der Intensivmedizin : Grundlagen, Modelle, Anwendung und Grenzen.

Scoring systems are used in all diagnostic areas of medicine. Several parameters are evaluated and rated with points according to their value in order to simplify a complex clinical situation with a score. The application ranges from the classification of disease severity through determining the number of staff for the intensive care unit (ICU) to the evaluation of new therapies under study conditions. Since the introduction of scoring systems in the 1980's a variety of different score models has been developed. The scoring systems that are employed in intensive care and are discussed in this article can be categorized into prognostic scores, expenses scores and disease-specific scores. Since the introduction of compulsory recording of two scoring systems for accounting in the German diagnosis-related groups (DRG) system, these tools have gained more importance for all intensive care physicians. Problems remain in the valid calculation of scores and interpretation of the results.

Surgical technique and validation of outcome assessment in sagittal synostosis.

BACKGROUND: Aim of the study was to evaluate the outcome of children operated for sagittal synostosis, with special attention paid to the postoperative aesthetic result, as seen from the parents' and the treating medical doctors' perspective, and to assess the time point for operative correction. METHODS: A retrospective chart review of 87 patients operated over 15 years was performed. Data included age at the time of operation, perioperative complications, duration of hospital stay, intraoperative blood loss, transfusion volume, neurological outcome, and postoperative skull growth. Aesthetic outcome was assessed at 6, 12 and 18 months after surgery separately by the treating medical team and the children's parents. RESULTS: Sagittal synostosis was diagnosed in 98.9% of cases in the first six months of life. We performed the same operative technique in all children with bilateral total removal of parietal bones. The median age at operation was 5 months. There was no correlation between age at the time of operation and blood loss (p<0.602). 5.7% of the children presented with significant postoperative skull asymmetries. All of these children had undergone operation in the first four months of life (p<0.01). The evaluation of the postoperative aesthetic outcome as seen by parents and doctors was highly convergent, with 79.3% of children in the excellent or good outcome group CONCLUSIONS: Our results suggest that the feasible time period for the method used by us is around the 5th - 6th month of life, with satisfying results. With regard to the aesthetic outcome assessment we recommend our approach using validation by parents as a valuable new principle.

[Liver transplantation in Germany]. / Lebertransplantation in Deutschland.

As in other western countries the major challenge of liver transplantation in Germany is to expand the number of liver transplantations in respect to the increasing disparity of qualified patients on the waiting list and the still static availability of brain death donor organs. The problem of death on the waiting list has become overt since the German transplantation law has been installed, which has changed the former center-oriented to a patient-oriented allocation weighting waiting time over medical urgency criteria. The more liberal acceptance of so called marginal cadaveric donor livers will probably impair further improvements in the acute and long-term outcome of liver transplantation. This problem can be partially compensated by the use of novel surgical techniques, such as splitting a donor liver to be transplanted into two adult recipients or, more commonly and safe, into an adult and one child. Another alternative to increase the donor pool is living donor liver transplantation, which was first introduced for pediatric recipients but is now increasingly used in adults. In 2001, a constant number of 757 liver transplantations were performed in Germany, including 12.5 % living donor transplantations. Recently, general guidelines for the selection of patients with end-stage liver disease and acute liver failure have been published by the Bundesärztekammer. Additional developments have contributed to improve the results of liver replacement including individualized immunosuppression strategies and novel treatment options to avoid recurrent viral disease following transplantation.

Cost-effectiveness analysis of an intranasal influenza vaccine for the prevention of influenza in healthy children.

OBJECTIVE: Intranasal influenza vaccine has proven clinical efficacy and may be better tolerated by young children and their families than an injectable vaccine. This study determined the potential cost-effectiveness (CE) of an intranasal influenza vaccine among healthy children. METHODS: We conducted a CE analysis of data collected between 1996 and 1998 during a prospective 2-year efficacy trial of intranasal influenza vaccine, supplemented with data from the literature. The CE analysis included both direct and indirect costs. We enrolled 1602 healthy children aged 15 to 71 months in year 1, 1358 of whom were enrolled in year 2. One or 2 doses of intranasal influenza vaccine or placebo were administered to measure the cost per febrile influenza-like illness (ILI) day avoided. RESULTS: During the 2-year study period, vaccinated children had an average of 1.2 fewer ILI fever days/child than unvaccinated children. In an individual-based vaccine delivery scenario with vaccine given twice in the first year and once each year thereafter at an assumed base case total cost of $20 for the vaccine and its administration (ie, per dose), CE was approximately $30/febrile ILI day avoided. CE ranged from $10 to $69/febrile ILI day avoided at $10 to $40/dose, respectively. In a group-based delivery scenario, vaccination was cost saving compared with placebo and remained so if vaccine cost was <$28 (the break-even price per dose). In the individual-based scenario, vaccination was cost saving if vaccine cost was <$5. In this scenario, nearly half of lost productivity in the vaccine group was attributable to vaccine visits, which overshadowed the relatively modest savings in ILI-associated costs averted. CONCLUSIONS: Routine use of intranasal influenza vaccine among healthy children may be cost-effective and may be maximized by using group-based vaccination approaches. cost-effectiveness, influenza, vaccine, children.

Building effective community-academic partnerships to improve health: a qualitative study of perspectives from communities.

PURPOSE: To identify, through a qualitative study, community perspectives on the critical factors that facilitate the development, effectiveness, and sustainability of community-academic partnerships. METHOD: Between June 1998 and April 1999, 25 semistructured interviews were conducted with community members who represented eight partnerships at five academic health centers. Content analysis and open coding were performed on the data, and patterns of ideas and concepts were categorized. RESULTS: After review of the data, responses from three partnerships were excluded. Nine major themes that community respondents thought strongly influenced the effectiveness of community-academic partnerships emerged from respondents from the remaining five partnerships: (1) creation and nurturing of trust; (2) respect for a community's knowledge; (3) community-defined and prioritized needs and goals; (4) mutual division of roles and responsibilities; (5) continuous flexibility, compromise, and feedback; (6) strengthening of community capacity; (7) joint and equitable allocation of resources; (8) sustainability and community ownership; and (9) insufficient funding periods. CONCLUSION: The themes that emerged from this study of the perceptions and experiences of the community partners in community-academic partnerships can be critical to further developing and evolving these partnerships.

[Prospective, randomized, comparative study of the efficacy, safety and cost of cefuroxime versus cephradine in acute pyelonephritis during pregnancy]. / Estudio prospectivo, randomizado, comparativo de la eficacia, seguridad y costos de cefuroxima vs cefradina en la pielonefritis aguda del embarazo.

BACKGROUND: Second generation cephalosporins (CFPs) are more active in the treatment of acute pyelonephritis during pregnancy but their cost is considerably higher than their predecessors. Cefuroxime, a second generation CFP with oral and parenteral presentations, might offer significant advantages and become a first choice antimicrobial in this setting. AIM: To compare the efficacy, safety and cost of cefuroxime and cephradine in the treatment of acute pyelonephritis in pregnancy. PATIENTS AND METHODS: Hospitalized women with 12 to 34 weeks of pregnancy, with clinical and bacteriological diagnosis of acute pyelonephritis, were randomly assigned to receive cefuroxime (Curocef(r), Glaxo Wellcome) 750 mg t.i.d, i.v. or cephradine 1 g q.i.d., i.v. If the isolated organism was resistant to the assigned drug the patient was excluded. Once patients were afebrile, they were switched to an oral form of the same antimicrobial. They were discharged according to the clinical status and treated for a total of 14 days. laboratory tests, including urine culture were requested during controls and at the end of follow-up at 28 days. RESULTS: One hundred and one patients were randomized: 49 to receive cephradine and 52 to receive cefuroxime. Patients in the cefuroxime group hed fewer febrile days (mean 1.7 vs 2.2, p < 0.05), faster clinical recovery (mean 2.7 vs 3.1 days, p < 0.05), a higher rate of bacteriological cure at 28 days (78.8% and 59.2%, p < 0.05) and lower rate of failure (21.2% vs 40.8% p < 0.05). The rate of resistance of isolated uropathogens was 14% to cephradine and 1% to cefuroxime. CONCLUSIONS: Cefuroxime can be considered as a first choice option in the treatment of acute pyelonephritis during pregnancy due to its tolerance, microbiological activity and efficacy.

Comparison of direct examination of three types of bronchoscopy specimens used to diagnose nosocomial pneumonia.

OBJECTIVE: To compare direct examination of bronchial aspirate and plugged telescopic catheter specimens (PTC) with infected cell counts in bronchoalveolar lavage (BAL) specimens for the diagnosis of nosocomial pneumonia. DESIGN: Prospective study of critically ill patients. SETTING: Intensive care unit in a university hospital. PATIENTS: A total of 64 patients hospitalized for >48 hrs with suspected nosocomial pneumonia. INTERVENTIONS: Fiberoptic bronchoscopy with bronchial aspirate and quantitative protected specimen brush, PTC, and BAL cultures. PTC and bronchial aspirate specimens were Gram-stained. BAL specimens for infected cell counts were examined as described previously in the literature. MEASUREMENTS AND MAIN RESULTS: Nosocomial pneumonia was diagnosed by the medical staff based on all available clinical, radiologic, laboratory test, and microbiological data and on the course before and after appropriate therapy. A total of 71% of patients were ventilated, and 70.1% were receiving antibiotics. Nosocomial pneumonia was diagnosed in 54% of the cases. On direct examination, sensitivity (Se) and specificity (Sp) of bronchial aspirate specimens were Se, 82% and Sp, 60%; of BAL with 5% infected cells, Se, 56% and Sp, 100%; of BAL with 3% infected cells, Se, 74% and Sp, 96%; of PTC specimens, Se, 65% and Sp, 76%; and of PTC specimens plus BAL with 3% infected cells, Se, 83% and Sp, 78%. BAL with 3% infected cells was significantly better for predicting nosocomial pneumonia than direct examination of bronchial aspirate or PTC specimens (p = .0012). When the BAL showed 3% infected cells, neither direct examination of bronchial aspirate nor direct examination of PTC specimens was useful (p = .24 and p = .38, respectively). Combined use of direct examination of PTC specimens plus BAL with 3% infected cells markedly improved sensitivity. The total cost of each procedure was taken into account for the final evaluation. CONCLUSIONS: Our data suggest that BAL with 3% infected cells is currently the only test whose predictive value for nosocomial pneumonia is sufficiently high to be of use for guiding the initial choice of antimicrobial class while waiting for quantitative culture results.

US family physicians' experiences with practice guidelines.

BACKGROUND: Practice guidelines were developed to improve medical outcomes and cost-effectiveness. The experiences of family physicians, who may need to use multiple guidelines in their practices, are crucial for effective development and implementation of practice guidelines. We surveyed a national sample of US family physicians about factors that affect their adoption and use of practice guidelines. METHODS: We mailed a structured survey to a national random sample of 400 family physician members of the American Academy of Family Physicians. RESULTS: The response rate was 51%. Most respondents (69%) reported a positive attitude about practice guidelines, but only 44% reported using any guidelines. More younger physicians thought that guidelines could be useful tools. Most preferred guidelines that could be modified (87%) and that were no longer than two pages. Only 27% of respondents knew where to locate a guideline on a particular topic. Forty-three percent of respondents reported that it would be useful if guidelines were a component of an electronic medical record. CONCLUSIONS: If guidelines are to be used by practicing family physicians, a generalist perspective needs to be considered in future guideline development and implementation. Younger physicians had more positive attitudes toward guidelines.

Activating patients to practice skin cancer prevention: response to mailed materials from physicians versus HMOs.

OBJECTIVES: We investigated whether the source and emphasis of mailed messages about skin cancer would differentially activate patients to initiate skin cancer prevention by calling a toll-free number. METHODS: We mailed a questionnaire to 981 randomly selected patients of a large medical group to assess their concern about and risk for skin cancer: 48 were returned undeliverable (n = 933). The booklet was accompanied by a letter inviting patients to call a toll-free number. Patients received the letter from one of three sources: (1) their physician, (2) their HMO, or (3) a fictitious junk mail organization. Patients received one of three different messages emphasizing the effects of ultraviolet (UV) rays on (1) the risk of skin cancer, (2) aging and wrinkling of the skin, or (3) aging and wrinkling accompanied by a book further emphasizing these harmful effects of the sun. RESULTS: The overall activation rate was low (7%); nevertheless, the source of the preventive message significantly affected whether patients called in. Messages from physicians and HMOs were more activating than messages from the junk mail organization (odds ratio [OR] = 3.40, confidence intervals [CI] = 1.66, 6.97), but messages from physicians were not more activating than messages from HMOs (OR = 1.56, CI = .90, 2.72). The emphasis of the message did not significantly affect call-in rates. Risk for skin cancer was positively associated with patient activation, but attitudes and beliefs about skin cancer prevention were unrelated to activation. CONCLUSIONS: These results should encourage HMOs and physicians to continue their preventive health outreach as one aspect of multicomponent prevention efforts. The results also suggest that HMOs and physicians can activate patients most at risk for skin cancer by emphasizing both risks of cancer and aging and wrinkling when they deliver a skin cancer preventive message.

Demersal fish assemblages along the Pacific coast of Costa Rica: a quantitative and multivariate assessment based on the Victor Hensen Costa Rica expedition (1993/1994).

During two cruise legs with the RV Victor Hensen (December 1993, February 1994), the demersal fish assemblages of the Golfo de Nicoya (GN), Bahía Coronado-Sierpe Terraba (ST) and Golfo Dulce (GD) areas were assessed from nearshore (approximately 20 m) to shelf edge (approximately 200 m) waters. 44 Beam- and 29 otter trawl collections were made on an area of 2,119,405 m2, yielding a total of 242 species of fish. Despite the lower number of samples taken, more species were collected by the otter trawl (189 compared to 160), due to a wider area swept. As revealed by the species-area curve and a longnormal-curve constructed from the pooled (log) abundance data, the fish assemblage appeared as well sampled and a theoretical species richness (SR) of-306 was estimated for the whole area. Mean species number per collection and mean biomass per area were much lower in the GD-area (9.3 species, 0.36 g/m2) compared to the ST (15.4, 0.81 g/m2) and GN (17.3, 0.74 g/m2) areas, indicating a depauperate fish assemblage in the former. Lowest species numbers and biomass were found in the central deep part of GD with increasing values towards the sill area at the opening of the gulf and towards the shallow stations above the thermocline. Average biomass was an order of magnitude higher in the interior part of GN compared to the other areas with values up to 18.1 g/m2. Based on results of a multivariate analysis of the collections, the GN area can be divided into (1) an interior shallow area above the thermocline (< 50 m) characterized by scianids, sea carfishes, stingrays, flatfishes, sea robins, (2) an outer part (> 100 m) characterized by cods, scorpionfishes, gobies, cutlassfishes, serranids, anglerfishes and flatfishes and (3) a transition zone of the central and lateral parts with a mixed species assemblage with carangids, pufferfish, snappers, several flatfish species and the lizardfish as common elements. Characteristic for the deep basin of GD were small species of the genera Cynoscion and Porichthys. These occurred in low densities, suggesting a reduced carrying capacity of this deep basin for fish biomass in terms of food and oxygen. Species occurring at the shallow stations of GD are also found at a similar depth in the other areas, but many species are missing, namely ariids and many scianids found in the GN area. The species assemblage of the ST area resembles that of GN. Ariids, however, are missing here too. Biotic station parameters like species richness, biomass, abundance and production were not significantly correlated with abiotic parameters (temperature, oxygen, nutrients) suggesting that other habitat factors not evaluated in this study like habitat heterogeneity, distance to the open ocean, current regime and food availability probably are important factors for the structure of the fish assemblage.

Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer.

BACKGROUND AND DESIGN: This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. RESULTS: Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. CONCLUSIONS: Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers.

[Use of recombinant erythropoietin in surgery--are the costs justified?]. / Einsatz von rekombinantem Erythropoietin in der Chirurgie--Sind die Kosten gerechtfertigt?

The combination of autologous blood donation and rHuEPO therapy is rarely justified for medical and economic reasons. Adequate alternative indications for the use of rHuEPO perioperatively have yet to be studied. Therefore, in addition to the increasing costs of safe homologous blood products and the decreasing costs of recombinant proteins, a reevaluation of the cost-effectivity relationship will be mandatory for rHuEPO in surgery.