Cost-effectiveness analysis of influenza and pneumococcal vaccination for Hong Kong elderly in long-term care facilities.

BACKGROUND: To compare cost and quality-adjusted life-years (QALYs) gained by influenza vaccination with or without pneumococcal vaccination in the elderly living in long-term care facilities (LTCFs). METHODS: Cost-effectiveness analysis based on Markov modelling over 5 years, from a Hong Kong public health provider's perspective, on a hypothetical cohort of LTCF residents aged > or = 65 years. Benefit-cost ratio (BCR) and net present value (NPV) of two vaccination strategies versus no vaccination were estimated. The cost and QALYs gained by two vaccination strategies were compared by Student's t-test in probabilistic sensitivity analysis (10,000 Monte Carlo simulations). RESULTS: Both vaccination strategies had high BCRs and NPVs (6.39 and US$334 for influenza vaccination; 5.10 and US$332 for influenza plus pneumococcal vaccination). In base case analysis, the two vaccination strategies were expected to cost less and gain higher QALYs than no vaccination. In probabilistic sensitivity analysis, the cost of combined vaccination and influenza vaccination was significantly lower (p<0.001) than the cost of no vaccination. Both vaccination strategies gained significantly higher (p<0.001) QALYs than no vaccination. The QALYs gained by combined vaccination were significantly higher (p = 0.030) than those gained by influenza vaccination alone. The total cost of combined vaccination was significantly lower (p = 0.011) than that of influenza vaccination. CONCLUSION: Influenza vaccination with or without pneumococcal vaccination appears to be less costly with higher QALYs gained than no vaccination, over a 5-year period, for elderly people living in LTCFs from the perspective of a Hong Kong public health organisation. Combined vaccination was more likely to gain higher QALYs with lower total cost than influenza vaccination alone.

Plasma inflammatory cytokines and chemokines in severe acute respiratory syndrome.

Severe acute respiratory syndrome (SARS) is a recently emerged infectious disease caused by a novel coronavirus, but its immunopathological mechanisms have not yet been fully elucidated. We investigated changes in plasma T helper (Th) cell cytokines, inflammatory cytokines and chemokines in 20 patients diagnosed with SARS. Cytokine profile of SARS patients showed marked elevation of Th1 cytokine interferon (IFN)-gamma, inflammatory cytokines interleukin (IL)-1, IL-6 and IL-12 for at least 2 weeks after disease onset, but there was no significant elevation of inflammatory cytokine tumour necrosis factor (TNF)-alpha, anti-inflammatory cytokine IL-10, Th1 cytokine IL-2 and Th2 cytokine IL-4. The chemokine profile demonstrated significant elevation of neutrophil chemokine IL-8, monocyte chemoattractant protein-1 (MCP-1), and Th1 chemokine IFN-gamma-inducible protein-10 (IP-10). Corticosteroid reduced significantly IL-8, MCP-1 and IP-10 concentrations from 5 to 8 days after treatment (all P < 0.001). Together, the elevation of Th1 cytokine IFN-gamma, inflammatory cytokines IL-1, IL-6 and IL-12 and chemokines IL-8, MCP-1 and IP-10 confirmed the activation of Th1 cell-mediated immunity and hyperinnate inflammatory response in SARS through the accumulation of monocytes/macrophages and neutrophils.

Stroke disease management--a framework for comprehensive stroke care.

Disease management is an approach to patient care that coordinates medical resources for the patient across the entire healthcare delivery system throughout the lifetime of the patient with the disease. Stroke is suitable for disease management as it is a well-known disease with a high prevalence, high cost, variable practice pattern, poor clinical outcome, and managed by a non-integrated healthcare system. It has measurable and actionable outcomes, with available local expertise and support of the Ministry of Health. Developing the programme requires a multidisciplinary team, baseline data on target populations and healthcare services, identification of core components, collaboration with key stakeholders, development of evidence-based clinical practice guidelines and carepaths, institution of care coordinators, use of information technology and continuous quality improvement to produce an effective plan. Core components include public education, risk factor screening and management, primary care and specialist clinics, acute stroke units, inpatient and outpatient rehabilitation facilities, and supportive community services including medical, nursing, therapy, home help and support groups for patients and carers. The family physician plays a key role. Coordination of services is best done by a network of hospital and community-based care managers, and is enhanced by a coordinating call centre. Continuous quality improvement is required, with audit of processes and outcomes, facilitated by a disease registry. Pitfalls include inappropriate exclusion of deserving patients, misuse, loss of physician and patient independence, over-estimation of benefits, and care fragmentation. Collaboration and cooperative among all parties will help ensure a successful and sustainable programme.

Frequency of policy recommendations in epidemiologic publications.

OBJECTIVES: The purpose of this study was to determine the frequency and character of policy statements in epidemiologic reports. METHODS: The first author followed a standardized protocol and reviewed a random sample of articles selected from the American Journal of Epidemiology, Annals of Epidemiology, and Epidemiology. The second author reviewed all articles with policy statements and a 10% sample without such statements. RESULTS: Overall, 23.8% of the articles contained policy statements. Annals of Epidemiology and the American Journal of Epidemiology had similar frequencies of articles with policy statements (30% and 26.7%, respectively), while Epidemiology evidenced the lowest frequency (8.3%). The majority of policy statements (55%) pertained to public health practice; 27.5% involved clinical practice, and the remainder (17.5%) focused on corporate policies, regulatory actions, or undefined arenas. The frequency of policy statements differed according to first author's affiliation, type of publication, area of research, research design, and study population. CONCLUSIONS: Although a minority of publications included policy statements, the inclusion of a statement seemed to be influenced by specific study characteristics.

Bladder cancer and drinking water: a population-based case-control study in Washington County, Maryland (United States).

A population-based case-control study was conducted in Washington County, Maryland (United States) to explore the association between incident bladder cancer and exposure to drinking water from chlorinated surface sources. Cancer cases were White residents, enumerated in a 1975 county census and reported to the Washington County Cancer Registry (n = 294) between 1975 and 1992. White controls, frequency matched by age (+/- 5 years) and gender, were selected randomly from the census (n = 2,326). Households receiving municipal water, which generally derived from chlorinated surface waters, were treated as having 'high exposure' and all others, as 'low exposure.' Duration of exposure to type of drinking water was based on length of residence in the census household prior to 1975. Odds ratios (OR) were calculated using logistic regression methods, adjusting for age, gender, tobacco use, and urbanicity. Bladder cancer risk was associated weakly in the general population with duration of exposure to municipal water. The association was limited to those who had smoked cigarettes. In ever-smokers compared with never-smokers with low exposure, the adjusted ORs for bladder cancer risk with increasing exposure were 1.3, 1.4, 1.4, 1.7, 2.2, 2.8, respectively, for 0, 1-10, 11-20, 21-30, 31-40, > 40 years' exposure duration. The ORs in smokers were not diminished after adjusting for smoking history and intensity.

Health care needs in the Tai Po district of Hong Kong initial indications from a population-based study.

The objective of this study was to obtain a representative profile of residents in Tai Po district, Hong Kong, with regard to their health status, health service use and socio- demographic characteristics. From October 1992 to February 1993, a cross-sectional telephone survey of 7573 Tai Po residents was undertaken. Acute illness episodes in the past month, chronic illness history, and treatment choices for acute and chronic illnesses were used as outcomes. Socio-demographic data were also obtained. Seventeen per cent of respondents reported having acute illness in the previous month, 66% of whom attended private clinics; 5.2% reported having chronic illness, 58.5% of whom attended public clinics. Most (88.5%) acute illness sufferers who used Western medical services for acute illness did so within Tai Po, while 52.7% of chronic illness sufferers used services outside of the district. Older, female, and lower income respondents were more likely to use public clinics. These preliminary findings help to reflect the health needs of residents in Tai Po.

Factors associated with the utilization of traditional Chinese medicine in a small town in Hong Kong.

The practice of Traditional Chinese Medicine (TCM) is largely unregulated in Hong Kong. Yet, as previous studies have shown, a sizable segment of the population consults TCM practitioners for health problems. This paper uses health care utilization data from a telephone health survey of 847 adult subjects in Tai Po District who had suffered from acute illness in the past month, to examine the profile of TCM users in the District. Women, older residents, unemployed workers, low skill laborers, current smokers and subjects dissatisfied with the quality of private sector clinics were significantly more likely to consult TCM practitioners.

Pharmacists' role in a smoking-cessation program at a managed health care organization.

A smoking-cessation program at a managed health care organization and the involvement of pharmacists are described. Kaiser Permanente Northwest Region is a prepaid group-practice managed health care organization serving more than 380,000 members in Oregon and southwest Washington. A multidepartmental team at Northwest Region designed and implemented a stepped-care approach to smoking cessation in March 1992. The program progresses from advising and helping patients to quit on their own to enrolling patients in a behavioral-modification course to referring them to nicotine-replacement therapy to be given concurrently with the behavioral modification. The program was established with the help of pharmacists, and pharmacists are deeply involved in its operation. They work closely with each patient, the health educator instructing the patient, and the prescribing physician. Pharmacists attend 5 of the 10 behavioral modification/nicotine-replacement course sessions and take responsibility for enrollees throughout the program. Pharmacists prescribe and monitor nicotine-replacement therapy by protocol. They also monitor each patient for the dose-response effect, adverse drug reactions, drug interactions, concurrent medical conditions, and progress and outcome. The physician is informed about any important changes in the patient's status. In 1992, more than 80 courses were held with nearly 1000 participants, and rates of long-term abstinence achieved compare favorably with literature rates for community-based group smoking-cessation programs. Satisfaction of patients, pharmacists, and physicians with the program has been high. Pharmacists at a managed health care organization participate in a smoking-cessation program by helping with behavioral modification, educating patients about nicotine-replacement therapy, and prescribing and monitoring therapy by protocol.

Laparoscopic fundoplication: an alternate approach in the surgical treatment of esophageal reflux (continuing education credit).

1. Laparoscopic fundoplication is more "patient friendly" than the comparable open procedure, affording shorter postoperative recovery and faster return of the patient to normal activity. 2. Laparoscopic fundoplication achieves the same results and is essentially the same procedure as open fundoplication, but with smaller incisions and less pain. 3. The procedure takes time to learn, but once mastered, it cuts the OR time to approximately the same as for the open fundoplication.

Reduced mortality among workers at a rubber plant.

We conducted a retrospective cohort study of mortality among current and former male employees of a modern tire manufacturing plant in Texas. Vital status was ascertained for more than 99% of the cohort of 2306 workers. Standardized mortality ratio analyses were completed based on 102 deaths. No significant excess for any disease-specific cause of death was identified, and significant deficits in all-cause mortality and deficits in cancer mortality were observed for both white and nonwhite men. The analyses were consistent in indicating that this work force has experienced no excessive disease-specific mortality.

The interplay of science, values, and experiences among scientists asked to evaluate the hazards of dioxin, radon, and environmental tobacco smoke.

To investigate the extent to which personal values and experiences among scientists might affect their assessment of risks from dioxin, radon, and environmental tobacco smoke (ETS), we conducted an experiment through a telephone survey of 1461 epidemiologists, toxicologists, physicians, and general scientists. Each participant was read a vignette designed to reflect the mainstream scientific thinking on one of the three substances. For half of the participants (group A) the substance was named. For the other half (group B), the substance was not named but was identified only as Substance X, Y, or Z. Knowing the name of the substance had little effect on the scientists' evaluation of dioxin, although those who knew the substance to be dioxin were more likely to rate the substance as a serious environmental health hazard (51% vs. 42%, p = 0.062). For radon, those who knew the substance by name were significantly more likely to consider it an environmental health hazard than were those who knew it as substance Z (91% vs. 78%, p less than 0.001). Participants who knew they were being asked about ETS rather than substance X were significantly more likely to consider the substance an environmental health hazard (88% vs. 66%, p less than 0.001), to consider the substance a serious environmental health hazard (70% vs. 33%, p less than 0.001), to believe that background exposure required public health intervention (85% vs. 41%, p less than 0.001), and to believe that above-background exposure required public health intervention (90% vs. 74%, p less than 0.001). These findings suggest that values and experiences may be influencing health risk assessments for these substances, and indicate the need for more study of this phenomenon.

Activation of ara operons by a truncated AraC protein does not require inducer.

The araC gene of Escherichia coli encodes a protein that binds the inducer L-arabinose to activate the transcription of three ara operons. In a study to determine the functional domains within the AraC protein, we have generated a set of overlapping deletions from the proximal end of the araC gene. We found that the removal of up to nearly 60% of the coding sequence of this protein still allows transcriptional activation of the ara operons in vivo, up to 27% that of the wild type. These truncated proteins, however, no longer require arabinose for induction. The ligand-induced conformational change apparently either releases or unmasks an existing functional domain within AraC, rather than generating a new conformation that is required for activation of the promoter of araBAD. Since the truncated protein of the mutant C154 (which lacks 153 amino acid residues from the N terminus) retains DNA binding specificity, the DNA-recognition domain is localized in the C-terminal half of the AraC protein. Truncated proteins were unable to repress araBAD or araC in vivo, even though they were able to bind all ara operators. We propose that the N-terminal half of AraC is essential for the formation of the DNA loops that are responsible for repression of araBAD and for autoregulation of araC.

Mechanism of araC autoregulation and the domains of two overlapping promoters, Pc and PBAD, in the L-arabinose regulatory region of Escherichia coli.

The DNA-protein contact sites in the ara regulatory region, which contains the promoters for araBAD and araC, have been determined for araC protein, the cyclic AMP-binding protein, and RNA polymerase, by using the methylation protection and DNase I protection methods. The functional significance of binding was assessed by correlating the state of occupancy of these sites with promoter activity in transcription initiation. Our results suggest that the basis for araC autoregulation is that araC protein, in either its activator (P2) or repressor (P1) form, acts as a repressor for araC, by binding to the RNA polymerase attachment site at the araC promoter. We also found that the araC and araBAD promoters share a common site of positive control by the cyclic AMP-binding protein, located 90 bases from the araBAD and 60 bases from the araC transcriptional start points. A model for the mechanism of regulation of araBAD and araC expression by the catabolite gene-activator protein, P1, and Pe is proposed. An earlier model proposed by Ogden et al. [Ogden S., Haggerty, D., Stoner, C. M., Kolodrubetz, D. & Schleif, R. (1980) Proc. Natl. Acad. Sci, USA 77, 3346-3350] is discussed in the light of the data presented in this paper.

Clinical presentation of nonhaemolytic transfusion reactions.

Due to the sophistication of red cell compatibility testing, the majority of transfusion reactions are non-haemolytic in origin. This paper reviews the clinical presentation of these reactions, emphasising that blood transfusion reaction must always be considered in the differential diagnosis when a patient develops unexpected complications during his hospital stay. Fever, allergic reactions, respiratory distress, hypotension and jaundice may all be manifestations of a transfusion reaction.