Derivation of a tuberculosis screening rule for sub-Saharan African prisons.

SETTING: Lusaka Central Prison, Zambia. OBJECTIVE: To derive screening rules for tuberculosis (TB) using data collected during a prison-wide TB and human immunodeficiency virus (HIV) screening program. DESIGN: We derived rules with two methodologies: logistic regression and classification and regression trees (C&RT). We evaluated the performance of the derived rules as well as existing World Health Organization (WHO) screening recommendations in our cohort of inmates, as measured by sensitivity, specificity, and positive and negative predictive values. RESULTS: The C&RT-derived rule recommended diagnostic testing of all inmates who were underweight (defined as body mass index [BMI] < 18.5 kg/m(2)] or HIV-infected; the C&RT-derived rule had 60% sensitivity and 71% specificity. The logistic regression-derived rule recommended diagnostic testing of inmates who were underweight, HIV-infected or had chest pain; the logistic regression-derived rule had 74% sensitivity and 57% specificity. Two of the WHO recommendations had sensitivities that were similar to our logistic regression rule but had poorer specificities, resulting in a greater testing burden. CONCLUSION: Low BMI and HIV infection were the most robust predictors of TB in our inmates; chest pain was additionally retained in one model. BMI and HIV should be further evaluated as the basis for TB screening rules for inmates, with modification as needed to improve the performance of the rules.

Expression of T cell receptor variable region families by bone marrow gammadelta T cells in patients with IgA nephropathy.

IgA nephropathy (IgAN) is characterized by mesangial deposition of polymeric IgA (pIgA). Abnormalities of the IgA system include reduced mucosal and increased bone marrow (BM) pIgA production. Gammadelta T cells are regulators of mucosal IgA production and oral tolerance. We have described previously a deficiency of gammadelta T cells expressing Vgamma3 and Vdelta3 from the duodenal mucosa in IgAN. Since pIgA production is displaced to the BM, we have now studied BM gammadelta T cells in IgAN. Peripheral blood and BM aspirates were obtained from 14 patients with IgAN and 15 controls. Expression of TCR gamma and delta V region families was analysed by semiquantitative RT-PCR, and CDR3 spectratyping of Vgamma1-4 and Vdelta3 genes was performed. We found no difference between IgAN and controls in the V region usage of blood gammadelta T cells. However, in the BM of patients with IgAN, there was significantly reduced expression of the V region families Vgamma3 and Vdelta3, with the decrease in Vdelta3 being particularly striking. CDR3 spectratyping showed no abnormalities in blood or BM samples. Vgamma3 and Vdelta3 are underexpressed in the duodenum and the BM in IgAN. The combination of imbalanced mucosal and systemic pIgA production with deficient expression of gammadelta T cells using Vgamma3 and Vdelta3 in both sites may imply a role for these gammadelta T cells in the normal regulation of IgA immune responses, and in the complex immunopathogenesis of IgAN.

Is more better than less? An analysis of children's mental health services.

OBJECTIVE: To assess the dose-response relationship for outpatient therapy received by children and adolescents-that is, to determine the impact of added outpatient visits on key mental health outcomes (functioning and symptomatology). DATA SOURCES/STUDY SETTING: The results presented involve analyses of data from the Fort Bragg Demonstration and are based on a sample of 301 individuals using outpatient services. STUDY DESIGN: This article provides estimates of the impact of outpatient therapy based on comparisons of individuals receiving differing treatment doses. Those comparisons involve standard multiple regression analyses as well as instrumental variables estimation. The latter provides a means of adjusting comparisons for unobserved or unmeasured differences among individuals receiving differing doses, differences that would otherwise be confounded with the impact of treatment dose. DATA COLLECTION/EXTRACTION METHODS: Using structured diagnostic interviews and behavior checklists completed by the child and his or her caretaker, detailed data on psychopathology, symptomatology, and psychosocial functioning were collected on individuals included in these analyses. Information on the use of mental health services was taken from insurance claims and a management information system. Services data were used to describe the use of outpatient therapy within the year following entry into the study. PRINCIPAL FINDINGS/CONCLUSIONS: Instrumental variables estimation indicates that added outpatient therapy improves functioning among children and adolescents. The effect is statistically significant and of moderate practical magnitude. These results imply that conventional analyses of the dose-response relationship may understate the impact of additional treatment on functioning. This finding is robust to choice of functional form, length of time over which outcomes are measured, and model specification. Dose does not appear to influence symptomatology.

Refining the costs analyses of the Fort Bragg evaluation: the impact of cost offset and cost shifting.

A key aim of the evaluation of the Fort Bragg Demonstration was to determine whether delivering services through a continuum of care lowered expenditures on mental health services. The evaluation clearly showed that expenditures were actually higher in the Demonstration. Critics of the evaluation claimed that the evaluation's perspective on costs was too narrow-in particular, that the Demonstration produced cost shifting and cost offset that were not captured by the evaluation. New data allow us to include a broader array of costs: mental health services received outside the catchment areas, general medical services for the children themselves, and mental health services used by family members. Results showed that reductions in other costs do partially offset higher expenditures on mental health services for children at the Fort Bragg Demonstration. However, even when broader costs are included, total family expenditures are still substantially higher at the Demonstration.

Do aftercare services reduce inpatient psychiatric readmissions?

OBJECTIVE: To determine whether aftercare services reduce the likelihood that children and adolescents will be readmitted to inpatient psychiatric facilities. DATA SOURCES/STUDY SETTING: Analyses of data from the Fort Bragg Demonstration. Data were based on 204 sample individuals (children and adolescents), all of whom were discharged from inpatient facilities during the study period. STUDY DESIGN: These analyses use hazard modeling to examine the impact of aftercare services on the likelihood of readmission. Comparisons of individuals for whom the timing of aftercare services differ are adjusted for a wide range of individual characteristics, including client demographics, diagnosis, symptomatology, and psychosocial functioning. DATA COLLECTION/EXTRACTION METHODS: Detailed data on psychopathology, symptomatology, and psychosocial functioning were collected on individuals included in these analyses. This information was taken from structured diagnostic interviews and behavior checklists, including the Child Behavior Checklist and Diagnostic Interview Schedule for Children, completed by the child and his or her caretaker. Information on the use of mental health services was taken from insurance claims and a management information system, and was used to identify the period from discharge to readmission and to describe the client's use of outpatient therapy, case management, intermediate (or stepdown) services, and residential treatment centers during this period. PRINCIPAL FINDINGS/CONCLUSIONS: Using Cox models that allow for censoring and that include the use of aftercare services as time-varying covariates, we find that aftercare services generally do not influence the likelihood of inpatient readmission. For the lower middle class families included in this study, the estimated effect of aftercare is not statistically significant and has limited practical significance. When we look at specific forms of aftercare, we find that outpatient therapy has the largest effect and that stepdown services in intermediate settings have the smallest. We also identify family and individual characteristics that influence the likelihood of readmission.

Does the continuum of care improve the timing of follow-up services?

OBJECTIVE: To identify the impact of the continuum-of-care treatment philosophy on the timing of follow-up services received by individuals discharged from inpatient facilities. METHOD: Using data from the Fort Bragg Evaluation, the analyses involve hazard modeling of the timing of follow-up services. RESULTS: The continuum-of-care treatment philosophy greatly accelerated the receipt of follow-up services and strengthened the link between the timing of follow-up services and individual and family characteristics. CONCLUSIONS: Expanding available services and coordinating service use increases the use of follow-up services. The findings also highlight the importance of family resources in shaping service use.

Historical overview of key issues in food safety.

Foodborne transmission of pathogenic and toxigenic microorganisms has been a recognized hazard for decades. Even half a century ago we knew about the dangers of botulism from underprocessed canned foods; staphylococcal poisoning from unrefrigerated cream-filled pastries, sliced ham, meat, and poultry salads; and salmonellosis from infected animal products. Despite new protective measures, changes in preservation techniques and failure to follow recognized procedures have created new dangers. Moreover, we now recognize new organisms that can cause foodborne illness--Listeria monocytogenes, Escherichia coli O157:H7, Campylobacter jejuni, Vibrio parahaemolyticus, Yersinia enterocolitica, and others. Controlling these organisms will require widespread education and possibly new regulatory initiatives.

An economic analysis of developmental detection methods.

OBJECTIVE: To assess the costs and benefits of various approaches to early detection of developmental disabilities. DESIGN: Cost-benefit analyses based on data from previously published studies of developmental screening tests. SETTING: General pediatric practices and day care centers. PATIENTS AND OTHER PARTICIPANTS: A total of 247 parents and their 0- to 6-year-old children-103 from day care centers and 144 from pediatric practices. MAIN OUTCOME MEASURES: Licensed psychological examiners administered a screening test of parents' concerns about children's development and one or two direct screening tests: the Denver-II and/or the Battelle Developmental Inventory Screening Test. For the day care sample, examiners also administered to each child measures of intelligence, adaptive behavior, and language. In the pediatric sample, children were administered additional assessments. At the same time, diagnostic measures were administered to a randomly selected subsample to make determinations about developmental status. Each screening method was evaluated for its short-term costs (administration, interpretation, diagnosis, and treatment) and long-term benefits (impact of early intervention on adult functioning as inferred from longitudinal studies by other researchers). RESULTS: When the long-term costs and benefits were considered, none of the approaches emerged as markedly superior to another. When viewing the short-term costs, the various screening approaches differed markedly. The use of parents' concerns was by far the least costly for physicians to administer and interpret. CONCLUSION: Physicians can incur tremendous expenses when attempting to detect children with developmental problems. Although the benefits of early detection and intervention are substantial, physicians are not well-compensated for providing a critical service to society. Health policymakers and third-party payers must reconsider their minimal investment in early detection by health care providers. Nevertheless, our findings have encouraging implications for practice, because the use of parents' concerns as a screening technique offers substantial savings over and above other methods.

Economic correlates of nonmarital childbearing among adult women.

The growth of nonmarital childbearing among women who are beyond their teenage years is well documented. Very little is known, however, about the economic status of these women. Data for 1991 from the nationally representative Panel Study of Income Dynamics indicate that the socioeconomic status of women who have had a nonmarital birth as an adult is similar to that of women who had a birth as an adolescent: They have similar median income-to-needs ratios (2.29 vs. 2.17), and similar rates of poverty (20% vs. 23%) and welfare receipt (22% vs. 19%). Women who have had both teenage and postteenage nonmarital births fare particularly poorly: Their median family income is $11,280; nearly half receive welfare; and 55% are officially poor. However, women who first gave birth as adolescents but have not had subsequent nonmarital births do reasonably well: Fewer than 10% receive welfare, and their median income-to-needs ratio is 2.6.

Nonmarital childbearing in the 1980s: assessing the importance of women 25 and older.

Nonmarital births to women in their late 20s and 30s have attracted increasing attention in recent years. Marital and birth history data from the Panel Study of Income Dynamics confirm that births to unmarried women aged 25 and older accounted for a larger proportion of all nonmarital births in the 1980s than in the 1970s (36% vs. 22%). Most of these births were to women who had been previously married or who had other children: Births to never-married, first-time mothers aged 25 and older accounted for only 9% of all nonmarital births to older women in the 1980s. The majority of nonmarital births to older women in the 1980s-58%-involved women who began having children as teenagers.

PIP: This analysis of marital and birth history data from the 1985-91 US Panel Study of Income Dynamics focuses on nonmarital childbearing. The total sample included 733 nonmarital births to 595 women from 1970 to 1979 and 933 nonmarital births to 741 women from 1980 to 1989. The sample for this study is confined to women aged 25 years and older or 117 births to 96 women in the 1970s and 280 births to 217 women in the 1980s. The analysis is based on births and not women. Findings indicate a shift to a greater proportion of nonmarital births to women aged 25 years and older, from 22% in the 1970s to 36% in the 1980s. However, only 15% of births were to women who were childless during their 20s. 58% of nonmarital births were to women who began childbearing as teenagers, and 46% of nonmarital births were to never married women who began childbearing as adolescents. Over 40% of births among women aged 25 years and older were to women who had been previously married. 33% of births were to women who had a first birth as teenagers, and almost 20% were to women aged under 18 years with a first birth. 19% of nonmarital births were to women with a previous marital birth, which was a considerable decline from the 1970s. 7% of nonmarital births were to women who had a previous marital birth and a previous nonmarital birth. Only 25% of births to women aged 25 years and older were to women with first births. 16% were to never married women with first births, which was a considerable decline from the 1970s. Racial differences occurred in nonmarital births between the 1970s and the 1980s. There is concern about the increased number of never married women older than 25 years with nonmarital births, because the increase amounted to a rise of 60% between decades. The authors point out that the lack of a formal marriage did not rule out the absence of contact with a father.

The costs of mental health services under the Fort Bragg Demonstration.

This article examines the costs of treatment under the Fort Bragg Demonstration. It focuses on the direct costs of mental health services and suggests that expenditures on those services were much higher at the Demonstration. Increased access and greater "doses" of services provided at the Demonstration are identified as the proximal causes of the system-level cost difference. Consideration is given to whether these differences in costs and in service use can be attributed to the continuum of care per se or to differences in the financial arrangements under which care was provided. Supplemental analyses suggest that these expenditures were not offset by cost savings elsewhere. Implications for mental health policy are discussed.

Mental health services utilization in a children's mental health managed care demonstration.

Service delivery under two systems of care--a traditional Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) reimbursement system and an innovative continuum of care--was examined along six dimensions: access, type, mix, volume, timing, and continuity of services received by children and adolescents. It was found that the Demonstration served over three times as many children as the Comparison. In addition to serving more children, the Demonstration also provided more and different types of services to each child treated. Finally, the Demonstration appears to have delivered services in a more timely fashion and made a considerable effort to match children's and families' needs with services.

Who gets hospitalized in a continuum of care?

OBJECTIVE: To compare children and adolescents hospitalized under a continuum of care with those hospitalized under traditional insurance coverage. METHOD: With comprehensive data, logistic regressions were used to predict hospitalization and to identify its determinants. RESULTS: As expected, the probability of being hospitalized was much higher under traditional care. In addition, the predictors of hospitalization differed by site. Accuracy of predictions was high. CONCLUSIONS: Different kinds of children were hospitalized under a continuum of care than under a traditional insurance system. Hospitalizations under both systems were highly predictable.

Reevaluating the costs of teenage childbearing.

Teenage childbearing in the United States has long been regarded as an important social problem with substantial costs to teen mothers and their children. Recently, however, several researchers have argued that the apparent negative effects of teenage childbearing primarily reflect unmeasured family background rather than the true consequences of a teen birth. To distinguish the effect of teen childbearing from that of family background, we use data from the Panel Study of Income Dynamics and compare teen mothers with their sisters. We find that accounting for unobserved family background reduces, but does not eliminate, the estimated consequences of early childbearing. Statistically significant and quantitatively important effects of teen parenthood remain for high school graduation, family size, and economic well-being.

Determining the Safety of Enzymes Used in Food Processing.

Enzymes are proteins that catalyze chemical reactions. They are highly specific and needed in only minute quantities, Certain enzymes have long been used to produce specific foods (e.g., cheese). Today they have numerous applications and are increasing in commercial importance. There has never been a health problem traced to the use of an enzyme per se in food processing. However, it is important that scientific data be provided to show that enzyme preparations, particularly those lacking a long history of safe use, are in fact safe to consume. The purpose of this report is to propose guidelines for assessing enzyme safety. We conclude that the enzymes per se now used or likely to be used in the future in food processing are inherently nontoxic. Safety evaluation should focus on possible contaminants which could be present. Assuming that current Good Manufacturing Practices (CGMPs) are followed, toxic contaminants could only come from the enzyme source itself (animal, plant or microbial). Hence, the safety of the source organism should be the prime consideration. Enzymes from animals or plants commonly regarded as food need not be subjected to animal feeding studies. Some food plants produce toxins and chemical assays may be used in these cases to assess safety. For enzymes from bacteria, it should be shown that antibiotics and acute toxins active via the oral route (enterotoxins and certain neurotoxins) are absent. Small molecular weight toxins (< 500 daltons) may be produced by certain fungi and actinomycetes. It should be shown that enzymes from such organisms are free of these materials. If it is established that a microbial culture does not produce antibiotics or toxins active via the oral route, then enzymes manufactured from that culture using CGMPs may be regarded as safe for use in food processing.

Fate of Salmonella typhimurium and Staphylococcus aureus in Meat Salads Prepared with Mayonnaise.

Staphylococcus aureus and Salmonella typhimurium were tested for their ability to survive and to multiply in meat salads prepared with different concentrations of mayonnaise and held at 4, 22, and 32 C. When mayonnaise was added to meat salads in amounts recommended by recipes from a reputable cookbook, it inactivated a substantial portion of the initial population of both S. aureus (30-60%) and S. typhimurium (20-25%). Salads that were refrigerated at 4 C for 24 h evidenced very little growth of either organism whether mayonnaise was present or not. Storing salads at 22 or 32 C for 5 h resulted in <1.0 log10 increase of either organism with the greatest increase occurring in salads containing no mayonnaise. Mayonnaise retarded but did not prevent the growth of S. aureus or S. typhimurium in salads stored at 22 or 32 C for 24 h. Increasing the concentration of mayonnaise in salads increased the degree to which growth of these organisms was delayed. Contrary to popular belief, the presence of mayonnaise in meat salads tends to retard rather than enhance growth of food-borne pathogens. However, addition of mayonnaise should not be considered a substitute for refrigeration for preserving meat salads from the growth of food-borne pathogens.

Food Safety: Problems of the Past and Perspectives of the Future 1.

Historically, most bacterial food poisoning in the United States is associated with mishandling, either in the home or in the food service establishment. Outbreaks traceable to errors in processing plants are rare. When they do occur they are often associated with changes in processing or packaging technology whose effect is not determined before the product is on the market. Areas of future concern that need research include (1) a better understanding of the mycotoxins; (2) how to minimize Salmonella contamination in animal products; (3) how to prevent, or at least predict, red tides; (4) better bactericidal agents that can be applied to foods; (5) an understanding of the nature and significance of mutagenic agents that are produced in foods during cooking.

Inhibition of Botulinum Toxin Formation in Bacon by Acid Development.

Lactobacillus plantarum , as a producer of lactic acid, and sucrose as a fermentable carbohydrate were evaluated for use in lowering the amount of or eliminating sodium nitrite in bacon. This work was limited to effect on antibotulinal properties. Organoleptic effects were not considered. Slices of bacon were inoculated with spores of Clostridium botulinum types A and B with or without simultaneous inoculation with a culture of L. plantarum , vacuum-packaged and incubated at 27 C. Samples were taken after various periods of incubation and assayed for botulinal toxin. We found that (a) sodium nitrite alone, at 120 ppm, did not give bacon extended protection against development of botulinum toxin if a fermentable carbon source (sucrose in these instances) was not present; (b) without added lactic acid bacteria, the effectiveness of 120 ppm of sodium nitrite plus sugar was variable and depended upon growth of naturally contaminating bacteria and (c) lactic acid bacteria with an adequate amount of sucrose gave good protection against development of botulinal toxin. Upon temperature abuse, acid was produced and growth of C. botulinum was inhibited. Because the protective properties against development of botulinal toxin in the sugar-lactic acid bacteria system were not dependent on the presence of nitrite, nitrite can be lowered to the level necessary to make organoleptically acceptable products without sacrificing safety, thus less nitrosamine formation may be achieved.

Foodborne hazards of microbial origin.

Foods can serve as vehicles of many pathogenic and toxigenic agents of disease. Bacterial agents comprise three groups: 1) those that grow in the food and produce an active toxin before consumption (e.g., clostridium botulinium); 2) those that merely exist as contaminants in the food but are able to initiate infection when swallowed (e.g., Salmonella spp.); and 3) those that multiply and produce large numbers of vegetative cells in the food, then release an active enterotoxin when they sporulate in the gut. A few parasitic (e.g., Trichinella spiralis) and viral agents (e.g., hepatitis A) also can be transmitted by food. Botulinum poisoning is the deadliest foodborne disease. The potential danger of botulism from cured meats is a major factor in the argument over use of nitrites as meat curing agents. A new disease called infant botulism has been recognized since 1976. Apparently it is not foodborne but results from intraintestinal growth of C. botulinum in very young infants. Salmonellosis is the most important of the foodborne diseases from the standpoint of overall human health. The primary vehicles are contaminated raw meat, poultry, and eggs. Faulty food handling practices are responsible for most food poisoning in the United States.