Monitoring telehealth vomiting calls as a potential public health early warning system for seasonal norovirus activity in Ontario, Canada.

Norovirus is a predominant cause of infectious gastroenteritis in countries worldwide [1-5]. It accounts for approximately 50% of acute gastroenteritis (AGE) and >90% of viral gastroenteritis outbreaks [6, 7]. The incubation period ranges between 10 and 48 h and illness duration is generally 1-3 days with self-limiting symptoms; however, this duration is often longer (e.g. 4-6 days) in vulnerable populations such as hospital patients or young children [2, 8]. Symptomatic infection of norovirus presents as acute vomiting, diarrhoea, abdominal cramps and nausea, with severe vomiting and diarrhoea (non-bloody) being most common [2, 5, 9].

FIT & STRONG! PLUS: DESCRIPTIVE DEMOGRAPHIC AND RISK CHARACTERISTICS IN A COMPARATIVE EFFECTIVENESS TRIAL FOR OLDER AFRICAN-AMERICAN ADULTS WITH OSTEOARTHRITIS.

OBJECTIVES: The prevalence of osteoarthritis (OA) has increased in the US. We report on a comparative effectiveness trial that compares Fit & Strong!, an existing evidence-based physical activity (PA) program, to Fit & Strong! Plus, which combines the Fit & Strong! intervention with a weight management intervention. METHODS: Participants included 413 overweight/obese (BMI 25-50 kg/m2) adults with lower extremity (LE) OA. The majority of the sample was African-American and female. Both interventions met 3 times weekly for 8 weeks. Primary measures included diet and weight. RESULTS: The baseline mean BMI for all participants was 34.8 kg/m², percentage of calories from fat was high, and self-reported PA was low. DISCUSSION: This sample of overweight/obese African-American adults had lifestyle patterns at baseline that were less than healthful, and there were differences between self-report and performance-based measures as a function of age.

Characterization of microsatellite loci for the endangered cactus Echinocactus grusonii, and their cross-species utilization.

Echinocactus grusonii is common in trade but critically endangered in its natural habitat. With the ultimate aim of developing a certification scheme to aid in the conservation of this species, we have isolated E. grusonii microsatellites from a nonenriched library. Fifty-seven sequences contained a microsatellite array, of which 12 were polymorphic among 30 individuals from a single wild population. All 12 microsatellite primer pairs amplified product in one or more species in a screen of 27 other cactus species.

Characterization of microsatellite loci for the critically endangered cactus Ariocarpus bravoanus.

Ariocarpus bravoanus is common in trade but critically endangered in its natural habitat. With the ultimate aim of developing a certification scheme to aid in the conservation of this species, we have isolated A. bravoanus microsatellites from a nonenriched library. Fifty-four sequences contained a microsatellite array, of which eight were polymorphic among 23 individuals, 20 from one population and three plants from trade.

Hormonal responses to a 160-km race across frozen Alaska.

BACKGROUND: Severe physical and environmental stress seems to have a suppressive effect on the hypothalamic-pituitary-gonadal (HPG) axis in men. Examining hormonal responses to an extreme 160-km competition across frozen Alaska provides a unique opportunity to study this intense stress. OBJECTIVE: To examine hormonal responses to an ultra-endurance race. METHODS: Blood samples were obtained from 16 men before and after racing and analyzed for testosterone, interleukin-6 (IL-6), growth hormone (GH) and cortisol. Six subjects (mean (SD) age 42 (7) years; body mass 78.9 (7.1) kg; height 1.78 (0.05) m raced by bicycle (cyclists) and 10 subjects (age 35 (9) years; body mass 77.9 (10.6) kg; height, 1.82 (0.05) m) raced by foot (runners). Mean (SD) finish times were 21.83 (6.27) and 33.98 (6.12) h, respectively. RESULTS: In cyclists there were significant (p< or =0.05) mean (SD) pre-race to post-race increases in cortisol (254.83 (135.26) to 535.99 (232.22) nmol/l), GH (0.12 (0.23) to 3.21 (3.33) microg/ml) and IL-6 (2.36 (0.42) to 10.15 (3.28) pg/ml), and a significant decrease in testosterone (13.81 (3.19) to 5.59 (3.74) nmol/l). Similarly, in runners there were significant pre-race to post-race increases in cortisol (142.09 (50.74) to 452.21 (163.40) ng/ml), GH (0.12 (0.23) to 3.21 (3.33) microg/ml) and IL-6 (2.42 (0.68) to 12.25 (1.78) pg/ml), and a significant decrease in testosterone (12.32 (4.47) to 6.96 (3.19) nmol/l). There were no significant differences in the hormonal levels between cyclists and runners (p>0.05). CONCLUSIONS: These data suggest a suppression of the hypopituitary-gonadal axis potentially mediated by amplification of adrenal stress responses to such an ultra-endurance race in environmentally stressful conditions.

Genetic mapping of the novel Turnip mosaic virus resistance gene TuRB03 in Brassica napus.

A new source of resistance to the pathotype 4 isolate of Turnip mosaic virus (TuMV) CDN 1 has been identified in Brassica napus (oilseed rape). Analysis of segregation of resistance to TuMV isolate CDN 1 in a backcross generation following a cross between a resistant and a susceptible B. napus line showed that the resistance was dominant and monogenic. Molecular markers linked to this dominant resistance were identified using amplified fragment length polymorphism (AFLP) and microsatellite bulk segregant analysis. Bulks consisted of individuals from a BC(1) population with the resistant or the susceptible phenotype following challenge with CDN 1. One AFLP and six microsatellite markers were associated with the resistance locus, named TuRB03, and these mapped to the same region on chromosome N6 as a previously mapped TuMV resistance gene TuRB01. Further testing of TuRB03 with other TuMV isolates showed that it was not effective against all pathotype 4 isolates. It was effective against some, but not all pathotype 3 isolates tested. It provided further resolution of TuMV pathotypes by sub-dividing pathotypes 3 and 4. TuRB03 also provides a new source of resistance for combining with other resistances in our attempts to generate durable resistance to this virus.

Spoligotype diversity of Mycobacterium bovis strains isolated in France from 1979 to 2000.

The molecular fingerprints of 1,349 isolates of Mycobacterium bovis received between 1979 and August 2000 at Agence Française de Sécurité Sanitaire des Aliments (Afssa) have been obtained by spoligotyping. The majority of the isolates (1,266) were obtained from cattle living in France. An apparently high level of heterogeneity was observed between isolates. One hundred sixty-one spoligotypes were observed in total, of which 153 were from French isolates. The two predominant spoligotypes, designated BCG-like and GB54, accounted for 26 and 12% of the isolates, respectively. In addition, 84% of the spoligotypes were found fewer than 10 times. Analysis of the results by clustering and parsimony-based algorithms revealed that the majority of the spoligotypes were closely related. The predominant spoligotype was identical to that of the vaccine strain Mycobacterium bovis BCG, which was isolated in France at the end of the 19th century. Some spoligotypes were closely associated with restricted geographical areas. Interestingly, some spoligotypes, which were frequently observed in France, were also observed in neighboring countries. Conversely, few spoligotypes were common to France and England, and those that were shared were observed at very different frequencies. This last point illustrates the potential role for an international data bank, which could help trace the spread of M. bovis across national borders.

Understanding costs of home and community based services.

With detailed cost information, home and community-based services (HCBS) providers can make intelligent choices that reduce costs without compromising quality and outcomes. Using cost and utilization data from a large HCBS program, monthly costs are estimated and related to demographic and clinical variables. HCBS costs are positively related to disability and cognitive impairment, but not to available social support. Costs vary significantly across the nursing home-eligible population, indicating that caution is warranted when seeking to capitate HCBS services. Per capita costs are strongly related to program volume and experience, falling from $508 to $423 (16.7 percent) over the course of the program.

The involvement of physicians in VA home care: results from a national survey.

OBJECTIVES: To examine the role of physicians in the Veteran Affairs (VA) home-based primary care (HBPC) program and to identify variables that predict whether physicians make home visits and volume of home visits made. DESIGN: Descriptive and regression analyses of responses from a mail survey. PARTICIPANTS: Forty-five physicians affiliated with VA HBPC programs. MAIN SURVEY TOPICS: Self-reported work load, attitudes toward home care, reasons for home visits, administrative policies regarding physicians' role in patient care management, and time commitment to home care. RESULTS: A majority of physicians believed strongly in the importance of home care and made home visits for reasons consistent with their training. Physician attitude toward home care and preoccupation with office or hospital practice were related to whether or not physicians made home visits. Degree of preoccupation with office practice and amount of salary support from VA HBPC were significant predictors of the number of visits made (R2 = 0.44). CONCLUSIONS: These findings indicate that most physicians will make home visits if they believe that home care is valuable and if their time commitment is supported financially. Managed care plans that own and operate home care programs and have the capacity to transfer primary care management to physicians who derive financial support from the programs should find this information particularly relevant.

Effectiveness of team-managed home-based primary care: a randomized multicenter trial.

CONTEXT: Although home-based health care has grown over the past decade, its effectiveness remains controversial. A prior trial of Veterans Affairs (VA) Team-Managed Home-Based Primary Care (TM/HBPC) found favorable outcomes, but the replicability of the model and generalizability of the findings are unknown. OBJECTIVES: To assess the impact of TM/HBPC on functional status, health-related quality of life (HR-QoL), satisfaction with care, and cost of care. DESIGN AND SETTING: Multisite randomized controlled trial conducted from October 1994 to September 1998 in 16 VA medical centers with HBPC programs. PARTICIPANTS: A total of 1966 patients with a mean age of 70 years who had 2 or more activities of daily living impairments or a terminal illness, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). Intervention Home-based primary care (n=981), including a primary care manager, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning, vs customary VA and private sector care (n=985). MAIN OUTCOME MEASURES: Patient functional status, patient and caregiver HR-QoL and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months. RESULTS: Functional status as assessed by the Barthel Index did not differ for terminal (P=.40) or nonterminal (those with severe disability or who had CHF or COPD) (P=.17) patients by treatment group. Significant improvements were seen in terminal TM/HBPC patients in HR-QoL scales of emotional role function, social function, bodily pain, mental health, vitality, and general health. Team-Managed HBPC nonterminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales. The caregivers of terminal patients in the TM/HBPC group improved significantly in HR-QoL measures except for vitality and general health. Caregivers of nonterminal patients improved significantly in QoL measures and reported reduced caregiver burden (P=.008). Team-Managed HBPC patients with severe disability experienced a 22% relative decrease (0.7 readmissions/patient for TM/HBPC group vs 0.9 readmissions/patient for control group) in hospital readmissions (P=.03) at 6 months that was not sustained at 12 months. Total mean per person costs were 6.8% higher in the TM/HBPC group at 6 months ($19190 vs $17971) and 12.1% higher at 12 months ($31401 vs $28008). CONCLUSIONS: The TM/HBPC intervention improved most HR-QoL measures among terminally ill patients and satisfaction among non-terminally ill patients. It improved caregiver HR-QoL, satisfaction with care, and caregiver burden and reduced hospital readmissions at 6 months, but it did not substitute for other forms of care. The higher costs of TM/HBPC should be weighed against these benefits.

Relationship between caregiver burden and health-related quality of life.

This study tested the cross-sectional relationship between caregiver burden and health-related quality of life (HRQOL) among 1,594 caregivers of veterans identified to qualify for formal home care. A two-stage model found that familial relationship, coresidence, and low income predicted objective burden. Coresidence also predicted subjective burden, whereas being African American was protective. In the full model, spousal relationship, low income, and burden were associated with poor HRQOL scores. Total variance explained in HRQOL ranged from 14% to 29%, with objective burden contributing more than subjective burden. These findings suggest a direct effect of objective burden on caregiver HRQOL, indicating a need among caregivers for assistance in caring for disabled family members.

Nursing facilities and managed care.

OBJECTIVE: To examine the extent to which Illinois nursing facilities have developed relationships with other healthcare providers, particularly managed care organizations (MCOs). STUDY DESIGN: A cross-sectional survey of nursing facilities designed to determine: 1) relationship objectives; 2) obstacles to developing relationships; 3) currently available services; 4) staffing for these services and; 5) nursing facility approaches to networking. The survey was sent to a census sample of 867 nursing facilities serving the elderly in Illinois. Descriptive and multivariate logistic regression analyses of relationships determined to be formal/risk-sharing were performed. STUDY POPULATION: The sample included 523 Illinois nursing facilities. A total response rate of 60% was achieved (523/867). RESULTS: Higher strategic goals, urban location, nonprofit ownership status, higher percentages of private pay and/or Medicare clients (vs Medicaid), and provision of home care and subacute services were all significant predictors of formal or risk-sharing relationships with MCOs. CONCLUSIONS: Facilities with more relationships and higher goals have more formal/risk-sharing relationships with MCOs. Facilities in urban areas have more relationships, likely due to the fact that rural facilities have fewer options and operate in different markets. In addition, nursing facilities rely on Medicare referrals from hospitals, and these Medicare patients, especially those in urban areas, are increasingly controlled by MCOs.

Home medical equipment receipt in a home care appropriate population.

OBJECTIVES: This study examines home medical equipment (HME) receipt for 1,040 veterans considered appropriate for home health services. METHODS: HME receipt was monitored for 12 months using the Department of Veterans Affairs' Prosthetics database. RESULTS: Eighty-three percent received at least one item; averaging 7.4 items (SD = 6.8). The most common items included commodes/bath benches (9%), canes/walkers (7%), safety equipment (7%), liquid oxygen (6%), and wheelchairs (6%). Two functional status variables, home care use and race, correctly classified 69% of HME recipients. Logistic regressions were run for specific equipment; c-indices ranged from .64 to .75. Age, race, income, functional status, risk of hospital readmission, and home care use were significant predictors. DISCUSSION: HME accounted for $4.5 billion in sales (16% of total) for medical products in 1996. As the HME market continues to expand, the characteristics of HME recipients are necessary to project future HME needs in a growing, elderly population.

Impact of joint impairment on disability-specific domains at four years.

The objective of this study was to assess the longitudinal impact of joint impairment on overall disability and crossing domain-specific thresholds for physical activity, mobility, dexterity, instrumental activities of daily living (IADL), and activities of daily living (ADL) that are associated with use of long-term care. This 4-year longitudinal study observed 484 persons older than age 60. Logistic regression assessed the contribution of demographics, psychological mediators, lower- and upper-extremity joint impairment, and comorbidities to increased domain-specific self-reported disability above a threshold associated with use of long-term care. Lower-extremity joint impairment and age predicted crossing thresholds by year 4 in physical activity, mobility, IADL, and ADL disability that were associated with use of long-term care. Lower-extremity joint impairment is a strong risk factor for future disability that is associated with use of long-term care.

Impact of home care on hospital days: a meta analysis.

OBJECTIVE: To examine the impact of home care on hospital days. DATA SOURCES: Search of automated databases covering 1964-1994 using the key words "home care," "hospice," and "healthcare for the elderly." Home care literature review references also were inspected for additional citations. STUDY SELECTION: Of 412 articles that examined impact on hospital use/cost, those dealing with generic home care that reported hospital admissions/cost and used a comparison group receiving customary care were selected (N = 20). STUDY DESIGN: A meta-analytic analysis used secondary data sources between 1967 and 1992. DATA EXTRACTION: Study characteristics that could have an impact on effect size (i.e., country of origin, study design, disease characteristics of study sample, and length of follow-up) were abstracted and coded to serve as independent variables. Available statistics on hospital days necessary to calculate an effect size were extracted. If necessary information was missing, the authors of the articles were contacted. METHODS: Effect sizes and homogeneity of variance measures were calculated using Dstat software, weighted for sample size. Overall effect sizes were compared by the study characteristics described above. PRINCIPAL FINDINGS: Effect sizes indicate a small to moderate positive impact of home care in reducing hospital days, ranging from 2.5 to 6 days (effect sizes of -.159 and -.379, respectively), depending on the inclusion of a large quasi-experimental study with a large treatment effect. When this outlier was removed from analysis, the effect size for studies that targeted terminally ill patients exclusively was homogeneous across study subcategories; however, the effect size of studies that targeted nonterminal patients was heterogeneous, indicating that unmeasured variables or interactions account for variability. CONCLUSION: Although effect sizes were small to moderate, the consistent pattern of reduced hospital days across a majority of studies suggests for the first time that home care has a significant impact on this costly outcome.

Disability in activities of daily living: patterns of change and a hierarchy of disability.

OBJECTIVES: This paper examines longitudinal data over 6 years to evaluate incidence rates of disability and the pattern of dependency in activities of daily living. METHODS: The Longitudinal Study of Aging (n = 5151) was used to evaluate incidence of disability in activities of daily living; biennial interview data from 1984 through 1990 were used. The median age to disability onset for individual activities was estimated from survival analysis. A prevalent ordering of incident disability was identified from patterns of disability onset within individuals. RESULTS: The progression of incident disability among the elderly supported by longitudinal data, based on both the ordering of median ages to disability onset and patterns of incident disability, was as follows: walking, bathing, transferring, dressing, toileting, feeding. Gender differences were found in disability incidence rates. CONCLUSIONS: This study provides a mathematical picture of physical functioning as people age. These findings, based on longitudinal data, indicate a different hierarchical structure of disability than found in previous reports using cross-sectional data. Furthermore, the study documents gender differences in incident impairment, which indicate that although women outlive men, they spend more time in a disabled state.

Partial identification of spirochaetes from two dairy cows with digital dermatitis by polymerase chain reaction analysis of the 16S ribosomal RNA gene.

Specimens taken postmortem from typical lesions of digital dermatitis in two dairy cows were tested by the polymerase chain reaction (PCR) for the presence of a spirochaetal 16S rRNA gene. Seven different assays detected the gene in the samples from both cows. Two of the PCR products were sequenced and a comparison of the nucleotide sequences revealed that the spirochaete belonged to the genus Treponema and was closely related to Treponema denticola. A PCR specific for the detection of the digital dermatitis-associated treponeme was developed.

Evaluation of a prospective payment system for VA contract nursing homes.

An evaluation of a pilot program for community nursing home care reimbursement by Department of Veterans Affairs Medical Centers (VAMCs) was undertaken. Eight VAMCs began using the Enhanced Prospective Payment System (EPPS) in 1992. These sites were compared to eight customary payment sites in a pretest/posttest quasi-experimental design. Outcomes included access to care, administrative workload, quality of care, and cost. As expected, per diem costs were significantly higher for EPPS than customary reimbursement patients ($106 vs. $87). However, EPPS sites placed veterans more quickly (81 days vs. 113 days; p < .01) than comparison sites and reduced administrative workload associated with placement. EPPS sites also increased the number of Medicare-certified homes under contract (76% vs. 54%) and placed significantly more veterans who received therapy (20% vs. < 1%). Savings in hospital days more than offset the increased cost of nursing home placement. Because the findings were attributed largely to a few veterans with long lengths of hospital stay, the early success of EPPS may diminish as the backlog of these long-stay patients decreases.

The prevalence and impact of arthritis in older persons.

OBJECTIVE: To review that what is known about the prevalence and impact of arthritis on disability and health care expenditures incurred by older persons. METHODS: The current prevalence estimates of osteoarthritis and osteoporosis in the US are examined, and what is known about the relationship of arthritis, broadly defined to disability, and the impact of arthritis-specific disability on home care and nursing home use by older persons are reviewed. RESULTS: Arthritis is a major contributor to disability among older people and is especially disabling for older women, who have higher prevalence rates and greater disability than their male counterparts. Studies of the relationship of arthritis to long-term care use indicate that arthritis can be a risk factor insofar as it can cause disability that results in homeboundedness, which, in turn is a risk factor for nursing home use. It is possible that previous analyses that included arthritis and disability as competing risk factors for nursing home use underestimate the contribution of arthritis because arthritis is a risk factor for disability; thus, the two variables may be strongly correlated. CONCLUSIONS: More study is needed to understand the contribution of sex to prevalence of arthritis and severity of arthritis-specific disability. The route through which arthritis affects long-term care use also needs careful longitudinal study. If arthritis is confirmed to be a major risk factor for disability that leads to long-term care use, the development and testing of interventions to prevent/minimize arthritis-specific disability should be a major research priority.

Epizootic bovine abortion in a dairy herd: characterization of a Chlamydia psittaci isolate and antibody response.

A chlamydial agent was recovered from the placental cotyledons of an aborting cow from a 100-cow dairy herd in Cumbria. Immunoblotting analysis of purified elementary bodies of the isolate revealed a reactivity pattern typical of serotype I Chlamydia psittaci strains. Nucleotide sequencing of the major outer membrane protein (MOMP) gene further confirmed the isolate, BA1, as a serotype I strain. The sequence was identical to that of the type strain of ovine enzootic abortion, B577. In both the antigenic and MOMP sequencing analyses BA1 was distinguishable from serotype II C. pecorum strains. A sequential series of sera obtained from the aborting cow, from which BA1 was recovered, was analysed by immunoblotting against the homologous isolate, and demonstrated reactivity to major chlamydial antigens over a 110-day period. Close contact between ruminant species on the farm suggested that the C. psittaci strain may have been transmitted to cattle from infected sheep.