Economic analysis of CDC's culture- and smear-based tuberculosis instructions for Filipino immigrants.

SETTING: In 2007, the US Centers for Disease Control and Prevention (CDC) revised its tuberculosis (TB) technical instructions for panel physicians who administer mandatory medical examinations among US-bound immigrants. Many US-bound immigrants come from the Philippines, a high TB prevalence country. OBJECTIVE: To quantify economic and health impacts of smear- vs. culture-based TB screening. DESIGN: Decision tree modeling was used to compare three Filipino screening programs: 1) no screening, 2) smear-based screening, and 3) culture-based screening. The model incorporated pre-departure TB screening results from Filipino panel physicians and CDC databases with post-arrival follow-up outcomes. Costs (2013 $US) were examined from societal, immigrant, US Public Health Department and hospitalization perspectives. RESULTS: With no screening, an annual cohort of 35 722 Filipino immigrants would include an estimated 450 TB patients with 264 hospitalizations, at a societal cost of US$9.90 million. Culture-based vs. smear-based screening would result in fewer imported cases (80.9 vs. 310.5), hospitalizations (19.7 vs. 68.1), and treatment costs (US$1.57 million vs. US$4.28 million). Societal screening costs, including US follow-up, were greater for culture-based screening (US$5.98 million) than for smear-based screening (US$3.38 million). Culture-based screening requirements increased immigrant costs by 61% (US$1.7 million), but reduced costs for the US Public Health Department (22%, US$750 000) and of hospitalization (70%, US$1 020 000). CONCLUSION: Culture-based screening reduced imported TB and US costs among Filipino immigrants.

A single-substrate model to interpret intra-annual stable isotope signals in tree-ring cellulose.

The carbon and oxygen stable isotope composition of wood cellulose (delta(13)C(cellulose) and delta(18)O(cellulose), respectively) reveal well-defined seasonal variations that contain valuable records of past climate, leaf gas exchange and carbon allocation dynamics within the trees. Here, we present a single-substrate model for wood growth to interpret seasonal isotopic signals collected in an even-aged maritime pine plantation growing in South-west France, where climate, soil and flux variables were also monitored. Observed seasonal patterns in delta(13)C(cellulose) and delta(18)O(cellulose) were different between years and individuals, and mostly captured by the model, suggesting that the single-substrate hypothesis is a good approximation for tree ring studies on Pinus pinaster, at least for the environmental conditions covered by this study. A sensitivity analysis revealed that the model was mostly affected by five isotopic discrimination factors and two leaf gas-exchange parameters. Modelled early wood signals were also very sensitive to the date when cell wall thickening begins (t(wt)). Our model could therefore be used to reconstruct t(wt) time series and improve our understanding of how climate influences this key parameter of xylogenesis.

Nocturnal stomatal conductance effects on the delta(18)O signatures of foliage gas exchange observed in two forest ecosystems.

We report field observations of oxygen isotope ((18)O) discrimination during nocturnal foliage respiration ((18)Delta(R)) in branch chambers in two forest ecosystems: a Sitka spruce (Picea sitchensis (Bong.) Carr.) plantation in Scotland; and a beech (Fagus sylvatica L.) forest in Germany. We used observations and modeling to examine the impact of nocturnal stomatal conductance on the (18)O/(16)O (delta(18)O) signatures of foliage gas exchange at night. We found that nocturnal stomatal conductance can influence the delta(18)O signature by affecting: (1) the bidirectional diffusion of CO(2) into and out of the leaf (with isotopic equilibration); and (2) the (18)O enrichment of the foliage water with which the CO(2) equilibrates. Both effects were manifest in high apparent (18)Delta(R) values and enriched delta(18)O signatures of foliage water at night. The effects were more pronounced for Sitka spruce because of its higher nocturnal stomatal conductance and higher specific leaf water content compared to beech. We found that taking the effects of nocturnal stomatal conductance into account may change the sign of the delta(18)O signature of nocturnal foliage respiration, generally thought to decrease the delta(18)O of atmospheric CO(2). We conclude that nocturnal stomatal exchange can have a profound effect on isotopic exchange depending on species and environmental conditions. These effects can be important when using delta(18)O signatures of canopy CO(2) to distinguish foliage and soil respiration, and when modeling the delta(18)O signature of CO(2) exchanged between ecosystems and the atmosphere.

Non-steady state effects in diurnal 180 discrimination by Picea sitchensis branches in the field.

We report diurnal variations in 18O discrimination (18 delta) during photosynthesis (18 delta A) and respiration (18 delta R) of Picea sitchensis branches measured in branch chambers in the field. These observations were compared with predicted 18 delta (18 delta pred) based on concurrent measurements of branch gas exchange to evaluate steady state and non-steady state (NSS) models of foliage water 18O enrichment for predicting the impact of this ecosystem on the Delta 18O of atmospheric CO2. The non-steady state approach substantially improved the agreement between 18 delta pred and observed 18 delta (18 delta obs) compared with the assumption of isotopic steady state (ISS) for the Delta 18O signature of foliage water. In addition, we found direct observational evidence for NSS effects: extremely high apparent 18 delta values at dusk, dawn and during nocturnal respiration. Our experiments also show the importance of bidirectional foliage gas exchange at night (isotopic equilibration in addition to the net flux). Taken together, neglecting these effects leads to an underestimation of daily net canopy isofluxes from this forest by up to 30%. We expect NSS effects to be most pronounced in species with high specific leaf water content such as conifers and when stomata are open at night or when there is high relative humidity, and we suggest modifications to ecosystem and global models of delta 18O of CO2.

The 1996 National Pilot Data Collection Project of the Association of Schools of Allied Health Professions.

In summary, it is evident that there is a great need for the collection of much more definitive data. I believe these data are essential to those in decision making positions and ASAHP would be an appropriate organization to collect and disseminate these data. I would urge you all, when you receive a survey from ASAHP asking for manpower related data, to be certain that the survey is completed, is accurate, and is returned. We will try to insure that the instructions are clear and precise. Perhaps we need to make our data collections state specific. We certainly need to include information regarding the level of managed care in each institution's area so that we can begin to examine the effects of managed care on the placement of our graduates. I also believe it is important to identify trends in employment because this makes possible rational decisions about program size and discontinuation and also insure the provision of programs that will benefit our graduates and the communities we serve. Although data from this survey were not presented in this article, the author would like to express her profound gratitude to Ms. Soon Merz, Director of Institutional Research and Planning and Ms. Amy Rhoads, Associate Director of Institutional Research and Planning at Kansas University Medical Center for their considerable work in analyzing and summarizing the data.

A survey of postoperative elbow immobilization approaches.

A survey of 200 North American burn units was designed to gather data about elbow immobilization positions and methods. Respondents were asked to identify the position of elbow and forearm immobilization after grafting to the upper extremity, the rationale for this, the location of the burn for the immobilization position chosen, who was responsible for immobilizing the patient's elbow after surgery, what type of material was used, and on what day range of motion to the elbow was resumed. Results indicated that elbow immobilization positions varied from full extension to more than 20 degrees of flexion, although full extension and slight flexion were used most, as was the forearm midposition. The rationale for immobilization that was most frequently given was prevention of contractures. Occupational therapists were most likely to be involved in or responsible for elbow immobilization, and thermoplastic materials were used most often. The day that range of motion was resumed also varied but was most frequently postoperative day 5.

Acute torticollis secondary to rupture of the sternocleidomastoid.

Trauma to the neck musculature and cervical spine is frequently caused by hyperextension injuries which may result in muscular spasm or rupture. Partial rupture of the sternocleidomastoid muscle with subsequent formation of a fibrotic band is an unusual cause of acute torticollis. The case of a 21-year-old man who developed an acute torticollis and cervical pain after a motor vehicle accident is presented. Computed tomography scan demonstrated 75% rupture of the left sternocleidomastoid muscle with fibrotic band replacing the absent muscle tissue. Neck range of motion was markedly decreased. The patient underwent a trial of muscle relaxants and intensive physical therapy with no significant improvement. Surgical release of the residual fibrotic band was performed, and the left deviation of the neck was reduced from 25 degrees preoperatively to 5 degrees postoperatively. With surgical release and intensive postoperative physical therapy, the patient regained full motion and strength of the cervical spine musculature.

Rehabilitation of the mastectomy patient: a randomized, blind, prospective study.

After biopsy confirmation of breast carcinoma, women who were scheduled to undergo a modified radical mastectomy had demographic data collected, goniometric measurements of shoulder flexion and abduction, and functional evaluation of the ipsilateral shoulder performed, and upper extremity circumferential measurements at five levels determined. Patients were then randomly assigned either to a group that received immediate postoperative physical therapy or to one that did not. Results represent the combination of data from a pilot study and this subsequent study following appropriate statistical analysis. Sixty-four women in the treatment group showed a statistically significant increase in shoulder range of motion in both abduction and flexion as compared to 51 women who received no physical therapy. The treated group also had fewer problems with five of the six upper extremity functional tasks that were assessed. There were no significant differences between the groups for length of hospital stay, postoperative complications, or upper extremity edema. The authors conclude that early physical therapy intervention makes a significant contribution to return to normal function without increasing the incidence of postoperative complications or prolonging hospital stay.

Sources of goniometric error at the elbow.

We assessed accuracy and potential sources of error in goniometry by using a photographic reference standard. Forty-six physical therapy students measured elbow positions using plastic or steel goniometers following three protocols: ALIGN, in which the investigator's elbow was splinted and bony landmarks were prelabeled; ASSIGN, in which the elbow remained splinted but labels were removed; and PROM, in which raters measured full passive flexion of the elbow. F ratios of variances indicated that alignment of goniometer, identification of landmarks, and variations in manual force during PROM contributed to goniometric error and that accuracy of joint angle measurement by photography (s +/- 0.7-1.1 degrees) was greater than by standard goniometry (s +/- 2.4-3.4 degrees). Analysis of variance and post-hoc test results unexpectedly indicated that all but one goniometric mean differed statistically (p less than .05) from associated photographic means. Small systematic errors in alignment of goniometers and identification of reference landmarks may have accounted for these differences. The results indicate that relatively inexperienced raters should be able to use goniometers accurately to measure elbow position when given standardized methods to follow.

Efficacy of physical therapy for patients who have undergone mastectomies. A prospective study.

This study was undertaken to determine if differences existed between a group of 49 patients who had undergone mastectomies and who received postoperative physical therapy and a group of 41 similar patients who did not. Preoperative and postoperative data were obtained for each patient from goniometric measurements of shoulder abduction, flexion, and external rotation; upper extremity circumferential measurements; and patient self-report on 10 functional assessment items. While age was controlled, an analysis of variance was used to test the effects of physical therapy and the side of surgery in relation to the dominant hand. No clinically significant differences were found between the groups for circumferential data. Goniometric measurements demonstrated that, postoperatively, the group receiving physical therapy had better shoulder range of motion and less difficulty with all functional assessment items. The results suggest that patients receiving postmastectomy physical therapy achieve better functional outcomes than those who do not.

The epidemiology of osteoporosis.

Osteoporosis is a major public health problem. National incidence and mortality rates for osteoporosis cannot be determined because data are unavailable. Epidemiology, one of the means by which this condition may be studied, and osteoporosis are defined, and the importance of primary and secondary prevention is discussed. Primary osteoporosis has four clinical forms: postmenopausal, senile, juvenile, and idiopathic; these are differentiated from other forms of bone disease. Predisposing factors and attendant morbidity are discussed with specific reference to problems associated with skeletal fractures. Age, sex, race, nutrition, body build and life style are identified as important variables. The importance of preventive measures is stressed because of the estimated incidence of 160,000 osteoporotic associated hip fractures with their attendant cost to society of more than one billion dollars per year. Preventive treatments studied to date are outlined. Emphasis is placed on the importance of primary and secondary prevention rather than tertiary care.