Workplace screening for hand dermatitis: a pilot study.

BACKGROUND: Health care workers (HCWs) are at increased risk for developing occupational skin disease (OSD) such as dermatitis primarily due to exposure to wet work. Identification of risk factors and workplace screening can help early detection of OSD to avoid the condition becoming chronic. AIMS: To determine risk factors and clinical findings for hand dermatitis using a workplace screening tool. METHODS: Employees at a large teaching hospital in Toronto, Canada, were invited to complete a two-part hand dermatitis screening tool. Part 1 inquired about hand hygiene practices and Part 2 comprised a visual assessment of participants' hands by a health professional and classification as (i) normal, (ii) mild dermatitis or (iii) moderate/severe dermatitis. Risk factors were determined using chi-square and Cochran-Armitage analysis on a dichotomous variable, where Yes represented either a mild or moderate/severe disease classification. RESULTS: There were 183 participants out of 643 eligible employees; response rate 28%. Mild or moderate/severe dermatitis was present in 72% of participants. These employees were more likely to work directly with patients, have worked longer in a health care setting, wash hands and change gloves more frequently, wear gloves for more hours per day, have a history of eczema or dermatitis and report a current rash on the hands or rash in the past 12 months. CONCLUSIONS: There was a high percentage of HCWs with dermatitis and risk factors for dermatitis. These findings argue for increased attention to prevention and early identification of hand dermatitis and support further testing of the workplace screening tool.

Epidemiology of vancomycin-resistant enterococci in Canadian hospitals (CANWARD study, 2007 to 2013).

Of 1,927 Enterococcus species isolates collected across Canada from 2007 to 2013, 80 (4.2%) were identified as vancomycin-resistant enterococci (VRE). VRE infections during this time tripled in Canadian hospitals, from 1.8% to 6.0% (P = 0.03). All VRE were Enterococcus faecium, with 90% possessing vanA. The prevalence of vanB decreased from 37.5% in 2007 to 0% in 2013 (P < 0.05). The VRE were multidrug resistant, but 70.6%, 86.3%, and 100% were susceptible to doxycycline, linezolid, and daptomycin, respectively.

HIP1, a human homologue of S. cerevisiae Sla2p, interacts with membrane-associated huntingtin in the brain.

Huntington disease (HD) is associated with the expansion of a polyglutamine tract, greater than 35 repeats, in the HD gene product, huntingtin. Here we describe a novel huntingtin interacting protein, HIP1, which co-localizes with huntingtin and shares sequence homology and biochemical characteristics with Sla2p, a protein essential for function of the cytoskeleton in Saccharomyces cerevisiae. The huntingtin-HIP1 interaction is restricted to the brain and is inversely correlated to the polyglutamine length in huntingtin. This provides the first molecular link between huntingtin and the neuronal cytoskeleton and suggests that, in HD, loss of normal huntingtin-HIP1 interaction may contribute to a defect in membrane-cytoskeletal integrity in the brain.

Testing the joint health and safety committee assessment tool in the education sector.

Joint Health and Safety Committee (JHSC) effectiveness has been identified as an area of concern for Ontario's education sector. The JHSC Assessment Tool has been previously tested in hospitals with positive results. This study assessed the feasibility and usability of the JHSC Assessment Tool in the education sector. Members of multi-workplace JHSCs from Ontario school boards used the tool to assess their committees' effectiveness before, during and after a committee meeting with usability testing conducted pre and post meeting. Results suggested that the JHSC Assessment Tool was feasible to use during a regular JHSC meeting, groups were able to come to consensus on the majority of items, and usability scores were high overall. Participant feedback provided insight that informed the development of a version relevant to multi-workplace committees.

In vitro activity of colistin (polymyxin E) against 3,480 isolates of gram-negative bacilli obtained from patients in Canadian hospitals in the CANWARD study, 2007-2008.

The in vitro activity of colistin was evaluated versus 3,480 isolates of gram-negative bacilli using CLSI broth microdilution methods. The MIC(90) of colistin was < or = 2 microg/ml against a variety of clinically important gram-negative bacilli, including Escherichia coli, Klebsiella spp., Enterobacter spp., Acinetobacter baumannii, and Pseudomonas aeruginosa. All multidrug-resistant (n = 76) P. aeruginosa isolates were susceptible to colistin (MIC, < or = 2 microg/ml). These data support a role for colistin in the treatment of infections caused by multidrug-resistant P. aeruginosa.

Short-term exercise in aged Tg2576 mice alters neuroinflammation and improves cognition.

Exercise is a treatment paradigm that can ameliorate cognitive dysfunction in Alzheimer disease (AD) and AD mouse models. Since exercise is also known to alter the peripheral immune response, one potential mechanism for the cognitive improvement following exercise may be by modulating the inflammatory repertoire in the central nervous system. We investigated the effects of voluntary exercise in the Tg2576 mouse model of AD at a time-point at which pathology has already developed. Inflammatory mRNA markers are increased in sedentary Tg2576 mice versus non-transgenic controls. We demonstrate that short-term voluntary wheel running improved spatial learning in aged transgenic mice as compared to sedentary Tg2576 controls. Inflammatory profiles of the Tg2576 and non-transgenic mice were different following exercise with the non-transgenic mice showing a broader response as compared to the Tg2576. Notably, exercising Tg2576 exhibited increases in a few markers including CXCL1 and CXCL12, two chemokines that may affect cognition.

Frequency of p53 mutations in breast carcinomas from Ashkenazi Jewish carriers of BRCA1 mutations.

BACKGROUND: Breast carcinomas occurring in carriers of BRCA1 gene mutations may have a distinctly different pathway of molecular pathogenesis from those occurring in noncarriers. Data from murine models implicate loss of p53 (also known as TP53) gene function as a critical early event in the malignant transformation of cells with a BRCA1 mutation. Therefore, breast tumors from BRCA1 mutation carriers might be expected to exhibit a high frequency of p53 mutations. This study examined the frequency of p53 mutations in the breast tumors of Ashkenazi Jewish carriers and noncarriers of BRCA1 mutations. METHODS: Tumor DNA from carriers and noncarriers of BRCA1 mutations was screened for mutations in exons 4 through 10 of the p53 gene by use of the polymerase chain reaction and single-strand conformation polymorphism (SSCP) analysis of the amplified DNA. Direct sequencing was performed on gene fragments that showed altered mobility in SSCP analysis. RESULTS: Mutations in the p53 gene were detected in 10 of 13 tumors from BRCA1 mutation carriers versus 10 of 33 tumors from non-carriers (two-sided P = .007). The p53 mutations were distributed throughout exons 4 through 10 and included both protein-truncating and missense mutations in both groups. CONCLUSIONS: A statistically significantly higher frequency of p53 mutations was found in breast tumors from carriers of BRCA1 mutations than from noncarriers, which adds to the accumulating evidence that loss of p53 function is an important step in the molecular pathogenesis of BRCA1 mutation-associated breast tumors. This finding may have implications for understanding phenotypic differences and potential prognostic differences between BRCA1 mutation-associated hereditary breast cancers and sporadic cancers.

Cost-benefit analysis of a strategy to vaccinate healthy working adults against influenza.

BACKGROUND: Influenza is a major cause of illness, disruption to daily life, and work absenteeism among healthy working adults aged between 18 and 64 years. This group is not included among the traditional priority groups for annual vaccination. Immunization rates remain low. OBJECTIVE: To assess the economic implications of a strategy for annual vaccination of this group. METHODS: Using the societal perspective, this cost-benefit analysis included the direct and indirect costs associated with vaccination as well as the direct and indirect costs prevented by vaccination. Clinical and economic variable estimates were derived primarily from the published literature. For this model, it was assumed that vaccination occurred in efficient, low-cost settings such as at the work site. Monte Carlo simulation was used to calculate the mean net costs or savings along with the 95% probability interval, and sensitivity analyses explored the sensitivity of the cost model to different values of the input variables. RESULTS: Vaccinating healthy working adults was on average cost saving, with mean savings of $13.66 per person vaccinated (95% probability interval: net savings of $32.97 to net costs of $2.18), with vaccination generating net savings 95% of the time. The model was most sensitive to the influenza illness rate, the work absenteeism rate due to influenza, and hourly wages. In the worst-case scenario vaccination was not cost saving. Vaccination also generated net costs to society during years with a poor vaccine-circulating virus strain match. In all of the other sensitivity analysis scenarios, vaccination was cost saving. CONCLUSION: Influenza vaccination of healthy working adults on average is cost saving. These findings support a strategy of routine, annual vaccination for this group, especially when vaccination occurs in efficient and low-cost sites.

Excess mortality due to pneumonia or influenza during influenza seasons among persons with acquired immunodeficiency syndrome.

BACKGROUND: Anecdotal reports suggest that influenza-related morbidity may be high among persons with acquired immunodeficiency syndrome (AIDS), but little information is available concerning the population-level impact of influenza on mortality in persons with AIDS. METHODS: Using the Multiple Cause-of-Death data files, which contain information on all deaths occurring in the United States each year, we calculated the numbers of excess deaths and rates of excess death due to pneumonia or influenza among persons with AIDS aged 13 years and older during the influenza seasons 1991-1992 through 1993-1994. For comparison, numbers of excess deaths and excess death rates were also calculated for several other groups including the general US population aged 13 years and older and the general US population aged 65 years and older. RESULTS: During the 1991-1992, 1992-1993, and 1993-1994 influenza seasons, there were 261, 254, and 191 excess deaths due to pneumonia or influenza in persons with AIDS and excess death rates of 19.74, 15.38, and 10.17 deaths per 10 000 persons, respectively, compared with a summer baseline period. For the same seasons, we observed excess death rates of 1.40, 1.62, and 1.48 for the general US population aged 13 years and older and 8.10, 9.28, and 8.54 for the general US population aged 65 years and older. Thus, persons with AIDS had excess death rates substantially higher than the general US population and similar to, if not somewhat higher than, the general US population aged 65 years and older, a group that is already targeted for annual vaccination. The findings were similar when we compared the preinfluenza season with the influenza season. CONCLUSIONS: Persons with AIDS have significant excess mortality due to pneumonia or influenza during influenza seasons and should be considered a high-risk group that is targeted for the prevention of influenza.

Medical students' exposure and immunity to vaccine-preventable diseases.

BACKGROUND: This study was conducted to assess medical students' immunity to vaccine-preventable diseases, their exposure to these diseases, and their attitudes toward immunity to vaccine-preventable diseases. METHODS: A cross-sectional, mailed survey was conducted of all 249 senior medical students in the 1991 graduating class at the University of Minnesota, Minneapolis. Two mailings were sent during the autumn of their senior year. RESULTS: The response rate was 77.5%. More than 90% of the students reported that they were immune to measles, mumps, rubella, and hepatitis B but only 23% were immune to influenza. Fewer than half of the students had ever been queried about their immune status prior to clinical clerkships. One third of the students had had a needlestick exposure during their clinical training (including 8% to a known hepatitis B carrier) and only 52% of these were reported by the student. Ten percent to 20% of the students felt that immunity to measles, mumps, and rubella was only somewhat or not very important. Less than one third of the students felt that immunity to influenza was important for themselves as health care providers. CONCLUSION: This study documented inadequate levels of immunity among medical students to certain vaccine-preventable diseases, that exposure to vaccine-preventable diseases was fairly common during clinical training, and that medical students often had inadequate attitudes about immunity to vaccine-preventable diseases. These findings have implications for medical school immunization policies and curriculum content.

Medical students as sources of rubella and measles outbreaks.

Medical students demonstrate a high degree of susceptibility to rubella and measles, and hence are at risk for infection and transmission of these viruses. The purpose of our study was to examine the role medical students play as sources or vectors in rubella and measles outbreaks. We conducted a survey of all US and Canadian public health departments to determine how often students were implicated in outbreaks (response rate, 88.7%). We also performed a literature search to identify any cases not reported to health departments, as well as examined the medical, social, and economic consequences of such outbreaks in the medical setting. Since 1981, 9% of health departments have recorded at least one outbreak of rubella or measles in which medical students were specifically implicated as sources or vectors. Increased morbidity, mortality, and adverse economic consequences resulted from these outbreaks. Our data confirm that medical students are important sources/vectors in rubella and measles outbreaks. We recommend that all medical students be immune to these viruses.

Generalist and subspecialist physicians' knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey.

BACKGROUND: Influenza and pneumococcal vaccination rates remain too low. This survey assessed generalist and subspecialist physicians' knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for high-risk patients. METHODS: A self-administered questionnaire was mailed to 6000 physicians randomly selected from a national database. RESULTS: After 3 mailings, 1874 physicians (32%) of the 5858 eligible responded. Although most physicians thought that it was very important for their high-risk patients be current on influenza and pneumococcal vaccinations, only 86% and 75% of generalists and subspecialists, respectively, very strongly recommended influenza vaccinations to their elderly patients and only 81% and 64%, respectively, very strongly recommended pneumococcal vaccinations to their elderly patients (P<.001 for both). After multivariate logistic regression, factors significantly associated with strongly recommending vaccinations to elderly patients in the influenza and pneumococcal vaccination models included female sex of provider, the provider having received an influenza vaccination, the provider's beliefs about vaccine effectiveness and cost-effectiveness, a patient's risk for illness, and ease of targeting patients. In addition, generalists were more likely than subspecialists to strongly recommend pneumococcal vaccinations to their patients. Patient reminders, special clinics, and standing orders were each used by fewer than 30% of respondents, although generalists were more likely than subspecialists to use such strategies. CONCLUSIONS: Nontrivial proportions of generalist and subspecialist physicians fail to strongly recommend influenza and pneumococcal vaccinations to their elderly and high-risk patients. Other effective strategies for promoting vaccine delivery are also used relatively infrequently. These findings suggest areas for improvement if vaccination rates are to reach national goals.

Influenza vaccination. Knowledge, attitudes, and behavior among high-risk outpatients.

The Minneapolis and Pittsburgh Veterans Affairs Medical Centers conduct virtually identical institution-wide influenza vaccination programs that include annual educational and publicity mailings to all outpatients. Despite these efforts, 40% to 50% of high-risk outpatients at both centers fail to receive influenza vaccine each year. To assess differences between high-risk vaccine recipients and nonrecipients, a self-administered questionnaire was mailed to 500 randomly selected outpatients from each site. The questionnaire asked about risk factors, vaccination status, and knowledge and attitudes regarding influenza and "flu shots." Patient risk characteristics and vaccination rates in Minneapolis and Pittsburgh were similar with 75.6% and 76.3% reporting high-risk conditions and 65.6% and 56.1% of high-risk respondents reporting influenza vaccination, respectively. High-risk vaccine recipients and nonrecipients had similar knowledge but different attitudes about influenza and "flu shots." Using stepwise logistic regression, factors positively associated with vaccination behavior were: intention to follow physician or nurse recommendations for "flu shots" (odds ratio [OR] = 7.09); previous vaccination behavior (OR = 6.36); and physician or nurse recommendations for a "flu shot" (OR = 4.29). Factors negatively associated with vaccination behavior were difficulty in coming to the medical center (OR = 0.42) and previous side effects from the vaccine (OR = 0.19). These findings suggest areas in need of additional emphasis if influenza vaccination rates are to be improved.

Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens.

BACKGROUND: Vaccination rates for healthy senior citizens are lower than those for senior citizens with underlying medical conditions such as chronic heart or lung disease. Uncertainty about the benefits of influenza vaccination for healthy senior citizens may contribute to lower rates of utilization in this group. OBJECTIVE: To clarify the benefits of influenza vaccination among low-risk senior citizens while concurrently assessing the benefits for intermediate- and high-risk senior citizens. METHODS: All elderly members of a large health maintenance organization were included in each of 6 consecutive study cohorts. Subjects were grouped according to risk status: high risk (having heart or lung disease), intermediate risk (having diabetes, renal disease, stroke and/or dementia, or rheumatologic disease), and low risk. Outcomes were compared between vaccinated and unvaccinated subjects after controlling for baseline demographic and health characteristics. RESULTS: There were more than 20000 subjects in each of the 6 cohorts who provided 147551 person-periods of observation. The pooled vaccination rate was 60%. There were 101 619 person-periods of observation for low-risk subjects, 15 482 for intermediate-risk, and 30 450 for high-risk subjects. Vaccination over the 6 seasons was associated with an overall reduction of 39% for pneumonia hospitalizations (P<.001), a 32% decrease in hospitalizations for all respiratory conditions (P<.001), and a 27% decrease in hospitalizations for congestive heart failure (P<.001). Immunization was also associated with a 50% reduction in all-cause mortality (P<.001). Within the risk subgroups, vaccine effectiveness was 29%, 32%, and 49% for high-, intermediate-, and low-risk senior citizens for reducing hospitalizations for pneumonia and influenza (for high and low risk, P< or =.002; for intermediate risk, P = .11). Effectiveness was 19%, 39%, and 33% (for each, P< or =.008), respectively, for reducing hospitalizations for all respiratory conditions and 49%, 64%, and 55% for reducing deaths from all causes (for each, P<.001). Vaccination was also associated with direct medical care cost savings of $73 per individual vaccinated for all subjects combined (P = .002). Estimates of cost savings within each risk group suggest that vaccination would be cost saving for each subgroup (range of cost savings of $171 per individual vaccinated for high risk to $7 for low risk), although within the subgroups these findings did not reach statistical significance (for each, P> or =.05). CONCLUSIONS: This study confirms that healthy senior citizens as well as senior citizens with underlying medical conditions are at risk for the serious complications of influenza and benefit from vaccination. All individuals 65 years or older should be immunized with this vaccine.

The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease.

BACKGROUND: More than 50% of the elderly population has not received pneumococcal vaccination. Uncertainty regarding the benefits of immunization, particularly for noninvasive disease, may contribute to the underuse of pneumococcal vaccine. OBJECTIVE: To assess the health and economic benefits associated with pneumococcal vaccination. METHODS: We conducted a 2-year retrospective cohort study among all elderly members of a staff-model managed care organization who had a baseline diagnosis of chronic lung disease. The study outcomes were assessed over 2 years, from November 15, 1993, through November 14, 1995, and included hospitalizations for pneumonia and influenza, death, and hospitalization costs. Using administrative data, we compared these outcomes for vaccinated and unvaccinated subjects using multivariate models to control for subjects' baseline demographic and health characteristics. The additive benefits of combined influenza and pneumococcal vaccination were also assessed for the 2 influenza seasons included in the study. RESULTS: There were 1898 subjects. Pneumococcal vaccination was associated with significantly lower risks for pneumonia hospitalizations (adjusted risk ratio [RR], 0.57; 95% confidence interval [CI], 0.38-0.84; P=.005) and for death (adjusted RR, 0.71; 95% CI, 0.56-0.91; P = .008). For the control outcome of all nonpneumonia hospitalizations, rates did not differ significantly between the 2 groups (adjusted RR, 0.91; 95% CI, 0.77-1.07; P= .24). During the influenza seasons included in the study, the benefits of pneumococcal and influenza vaccinations were additive, with an adjusted RR of 0.28 (95% CI, 0.14-0.58; P<.001) for the number of hospitalizations for pneumonia and influenza among persons who had received both vaccinations compared with those who had received neither and an adjusted odds ratio of 0.18 (95% CI, 0.11-0.31; P<.001) for death. Over the 2-year outcome period, pneumococcal vaccination was also associated with direct medical care cost savings. CONCLUSIONS: Pneumococcal vaccination of elderly persons with chronic lung disease was associated with fewer hospitalizations for pneumonia, fewer deaths, and direct medical care cost savings.

Immune function and vaccine responses in healthy advanced elderly patients.

BACKGROUND: Decline in immune function has been reported to predictably accompany advancing age. However, to our knowledge, few studies have specifically characterized the rapidly expanding advanced elderly population or controlled adequately for concurrent diseases. OBJECTIVE: To assess whether successfully reaching an advanced age in good health is associated with preserved immune function. METHODS: We prospectively compared in vivo with in vitro variables of immune function in 29 healthy, independently living elderly subjects (mean age, 80 years; age range, 75-103 years) and in 21 healthy young control subjects (mean age, 29 years; age range, 25-35 years) in a Veterans Affairs Medical Center. RESULTS: In vivo, among elderly and young subjects, numbers of total white blood cells, monocytes, lymphocytes, and lymphocyte subsets (CD4(+) and CD8(+) T lymphocytes and CD20(+) B cells) were similar, as were levels of total serum IgG and IgM. Only levels of serum IgA were higher in the elderly subjects (3.0 vs 1.7 g/L; P=.001). Functionally, both groups showed vigorous responses to protein (tetanus and diphtheria toxoids) and polysaccharide (23-valent pneumococcal) vaccines. Although levels varied, the fold increases in vaccine antigen-specific IgG were not significantly different in young and elderly subjects, and the avidities of IgG to pneumococcal polysaccharides 14 and 19F were similar before and after vaccination. In vitro, proliferative responses of blood mononuclear cells to T-lymphocyte and B-cell mitogens (pokeweed mitogen, Staphylococcus aureus Cowan strain I, and S aureus Cowan strain I plus interleukin 2), and lipopolysaccharide-induced production of tumor necrosis factor alpha, were comparable in elderly vs young subjects. CONCLUSION: Successful aging, defined by reaching an advanced age with one's overall health intact, may be associated with preserved immune function and adequate responses to vaccines.

Side effects associated with influenza vaccination in healthy working adults. A randomized, placebo-controlled trial.

BACKGROUND: Concern about side effects is a barrier to influenza vaccination. This randomized, double-blind, placebo-controlled trial assessed side effects following vaccination among healthy working adults. METHODS: Healthy working adults were recruited during October and November 1994 and were randomized to receive influenza vaccine or placebo injections. Local and systemic symptoms during the week following the injection were evaluated through structured telephone interviews. RESULTS: Of 849 subjects enrolled in the study, 425 received a placebo and 424 received influenza vaccine. Baseline characteristics were similar between the groups, and 99% of subjects completed interviews to assess side effects after the study injection. No differences were seen between the 2 groups for the systemic symptoms of fever, myalgias, fatigue, malaise, or headaches. Overall, 35.2% of placebo and 34.1% of vaccine recipients reported at least 1 of these systemic symptoms (P = .78, chi 2). Vaccine recipients reported a higher rate of arm soreness at the injection site than did placebo recipients (63.8% vs 24.1%, P < .001). Local reactions were mild in both groups and infrequently resulted in decreased use of the arm. After logistic regression, female sex (odds ratio [OR], 1.5;95% confidence interval [CI], 1.1-2.1), age younger than 40 years (OR, 1.6;95% CI, 1.2-2.2), and coincidental upper respiratory tract illness (OR, 4.6; 95% CI, 3.2-6.6) were independently associated with higher rates of systemic symptoms. In the multivariate model, vaccine again was not associated with systemic symptoms (OR, 0.9; 95% CI, 0.7-1.2). CONCLUSIONS: Influenza vaccination of healthy working adults is not associated with higher rates of systemic symptoms when compared with placebo injection. These findings should be useful to physicians and other health care providers as they counsel patients to take advantage of an important opportunity for disease prevention and health protection.

Bcl-2 family protein behavior in frontotemporal dementia implies vascular involvement.

Frontotemporal dementia (FTD) is a neurodegenerative disease associated with aging for which the etiology is unclear. Relatively little is known about the pathology of this disease, which has only recently been a topic of investigation for dementia researchers. Though the known pathology of FTD includes neuron loss, the mechanism of neuronal death is not known. In this study, the authors investigated apoptotic pathways as a possible mechanism of neuronal cell death in FTD. They evaluated immunoreactivity for Bcl-2 family protein members Bcl-x and Bax in postmortem frontal cortex from FTD, AD, and control cases. Bcl-x(L), Bcl-x(S), and Bax all exhibited altered immunoreactivity in FTD cases as compared with control cases. Bcl-x immunoreactivity varied widely among both controls and FTD cases. However, Bcl-x(L) showed strong white matter immunoreactivity in all FTD cases, whereas white matter immunoreactivity was absent in controls. These trends in Bcl-x immunoreactivity suggest a strong white matter involvement in the pathology of FTD. Bax immunoreactivity also varied across all cases. Bax immunoreactivity was observed in terminal transferase dUTP nick ending labeling (TUNEL) positive neurons in both FTD and AD cases. However, one notable finding was immunoreactivity to Bax in astrocytes of FTD cases, as well as endothelial cells of the cerebrovasculature. Neither astrocytic nor endothelial cell immunoreactivity to Bax was exhibited in control or AD cases. Because Bax is a pro-apoptotic protein, this finding suggests the presence of a cerebrovascular component in the pathology of FTD. These findings, coupled with the proposed functions of the Bcl-2 family proteins, suggest that an apoptotic pathway may be responsible for neuron, and possibly astrocyte, death in FTD.

Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults.

PURPOSE: Influenza and pneumococcal vaccines are underused. Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates. Little has been published on the long-term success and durability of such efforts. METHODS: We performed a 10-year time-series study to examine the durability and success of an ongoing, multifaceted, institution-wide influenza and pneumococcal vaccination program. The program was first implemented at the Minneapolis Department of Veterans Affairs (VA) Medical Center in 1987-88 following the demonstration that a clinic-based standing order policy was much more successful than provider education for improving vaccine delivery. The program ensures that vaccine is offered to all high-risk patients followed up at the medical center, promotes convenient access for patients, and facilitates efficient administration of vaccine. Specific elements include an annual mailing to patients, standing orders for nurses, walk-in clinics, and the use of standardized, preprinted documentation forms. Initially the program targeted high-risk outpatients for influenza vaccination. It was extended to include inpatients in 1989-90. Pneumococcal vaccinations were added to the program in 1994-95. Vaccination rates are estimated each year from surveys mailed to randomly selected patients, and vaccine utilization is monitored through pharmacy logs. RESULTS: The survey response rates have exceeded 75% each year. Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58% following the 1987-88 vaccination season to 84% in 1996-97 (P < 0.001). Pneumococcal vaccination rates have also increased from 34% in 1994-95 to 63% in 1996-97 (P < 0.001). Vaccination rates are similar for inpatients and outpatients, but rates for high-risk patients < 65 years of age remain lower than for the elderly: 69% versus 89% for influenza, 1996-97 (P < 0.001); 52% versus 66% for pneumococcal, 1996-97 (P = 0.05). For elderly patients followed up at the medical center, influenza (89% versus 67%, P < 0.0001) and pneumococcal (66% versus 43%, P < 0.0001) vaccination rates significantly exceeded those for the state of Minnesota in 1996-97. The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987-88 to more than 22,000 in 1996-97; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994-95 through 1996-97. CONCLUSION: This simple, multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid. Similar strategies if implemented in other settings may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized.

Improving influenza vaccination rates for high-risk inpatients.

PURPOSE: In 1987, the Minneapolis Veterans Affairs Medical Center implemented an ongoing, multifaceted influenza vaccination program that targeted all high-risk outpatients followed at the medical center. While the program achieved and sustained vaccination rates of 60% or more for high-risk outpatients, vaccination rates for high-risk inpatients continued to be 25% or less. Beginning with the 1989-1990 immunization season, the "flu shot" program was extended to include all high-risk inpatients. Both the outpatient and inpatient components of the Minneapolis Flu Shot Program emphasized administrative and organizational elements. The program's goal was to achieve vaccination rates of at least 60% for both high-risk outpatients and inpatients. This study assesses the effectiveness of the inpatient program among elderly patients hospitalized on the medical service during the immunization season. PATIENTS AND METHODS: To estimate patient risk characteristics and vaccination rates, 50% of elderly patients who were discharged from the medical service during the immunization season were surveyed using a validated postcard questionnaire. Their responses were compared with the responses of elderly patients to the annual outpatient survey conducted to assess the "flu shot" program. RESULTS: Overall, 78.6% of elderly respondents discharged from the medical service during the immunization season were vaccinated. Vaccination rates within various high-risk subgroups all exceeded 70%. None of these vaccination rates for inpatient groups differed significantly from the rates for corresponding outpatients. CONCLUSION: An outpatient "flu shot" program that emphasizes administrative and organizational elements can be successfully expanded to high-risk inpatients. The vaccination rates attained with such a program may not only achieve but exceed the national health objective for influenza vaccination.