入学入托查验接种证对防控传染病效果评价

目的了解贵州省入托入学查验接种证工作在学校/托幼机构免疫规划针对传染病控制中的作用,为评价入学入托查验接种证实施效果提供依据。方法通过分析贵州省2004-2009年查验接种证工作统计报表、法定传染病报告系统和麻疹监测系统的相关数据,对中小学和托幼机构接种证查验率、查验疫苗接种情况及其与小学/托幼机构麻疹及其他常见传染病发生的关系进行分析。结果2004年贵州省小学和托幼机构的接种证入学查验率呈逐年上升趋势,并保持在95%的较高水平;入学入托补种以后被查验疫苗全程接种率较入学入托前均明显升高;麻疹/百白破类疫苗补种完成率与该年龄段麻疹/百日咳发病率、学校/托幼机构麻疹暴发占全人群暴发比例均呈负相关,且有统计学意义;3～6岁乙肝疫苗补种完成率与乙肝发病率相关无统计学意义,7～12岁乙肝疫苗补种完成率与乙肝发病率呈现正相关。结论规范开展查验接种证工作,保证被查验疫苗的全程接种率持续维持在较高水平,能有效控制学校/托幼机构免疫规划针对传染病的发病和暴发;有必要将乙肝疫苗纳入免费补种范围,同时逐步增加入学/入托查验疫苗的种类。     

Health programs struggling with complexity: a case study of the Dutch 'PreCare' project

This article aims to understand the effects of rationalized health programs (the basic components of which are efficiency, calculability, predictability and control) on local practices. We discuss how a successful U.S. intervention in preventive youth health care (the Nurse Family Partnership) has been translated and adapted within a Dutch setting. The Dutch version of the program is called 'PreCare'. The empirical analysis highlights the effects of rationalized health programs on local practices, in terms of the amount of work required, how local practices are disciplined, how these programs (re)draw boundaries, the 'travel expenditures' involved (and developed 'coping strategies'), and how local practices (try to) reshape the program. Our empirical analysis builds on a combination of qualitative methods. We conducted 16 semi-structured interviews with 19 people involved in the PreCare program. The majority of the interviews were conducted between July and November 2008. We also conducted an analysis of relevant documents related to the PreCare intervention and protocol. Furthermore, we observed at several meetings, including case conferences and management intervision meetings. The article makes a theoretical and practical contribution to the field. Theoretically, we show how the rationalization process is linked to a broader development of quantification and how both developments are based on a particularly modern ontology and epistemology in which what is considered 'real' and 'knowledgeable' becomes closely tied to what is measurable. The article offers a different conceptualization of rationalized health programs, one that acknowledges the need to standardize some elements, but also recognizes the need to be open and flexible toward local practices. We specifically focus on the tools that are able to deal with both the need to standardize and the need to be open toward local practices. We suggest that '(re)writing devices' are a fruitful category of tools for this purpose.     

Modeling insights into Haemophilus influenzae type b disease, transmission, and vaccine programs

In response to the 2007-2009 Haemophilus influenzae type b (Hib) vaccine shortage in the United States, we developed a flexible model of Hib transmission and disease for optimizing Hib vaccine programs in diverse populations and situations. The model classifies population members by age, colonization/disease status, and antibody levels, with movement across categories defined by differential equations. We implemented the model for the United States as a whole, England and Wales, and the Alaska Native population. This model accurately simulated Hib incidence in all 3 populations, including the increased incidence in England/Wales beginning in 1999 and the change in Hib incidence in Alaska Natives after switching Hib vaccines in 1996. The model suggests that a vaccine shortage requiring deferral of the booster dose could last 3 years in the United States before loss of herd immunity would result in increasing rates of invasive Hib disease in children <5 years of age.     

Diet Quality and Fruit,Vegetable, and Sugar-Sweetened Beverage Consumption by Household Food Insecurity among 8- to 12-Year-Old Children during Summer Months

BackgroundSchool-delivered nutrition assistance programs have improved dietary intake for children from food-insecure households during the school year. However, little is known about their diet quality and eating patterns during summer months.ObjectiveSchool-aged children’s summer month weekday and weekend day diet quality and eating patterns were assessed by household food insecurity.DesignSecondary analysis of cross-sectional data was employed.Participants/settingDuring the summers of 2011 through 2017, baseline data were collected from parent–child dyads participating in one of two community-based obesity prevention trials in metropolitan Minnesota (N=218). The mean age of children was 10 years; 50% were girls, 49% were nonwhite, and 25% were from food-insecure households.Main outcome measuresChildren from food-secure and food-insecure households were identified by using the short form of the US Household Food Security Survey. Healthy Eating Index 2015 and eating patterns—including energy intake and consumption of whole fruits, vegetables, 100% fruit/vegetable juice, and sugar-sweetened beverages—were estimated by means of 24-hour dietary recall interviews conducted on weekdays and weekend days.Statistical analysis performedGeneral linear modeling was used to examine diet quality and eating patterns by food insecurity, controlling for child age, child body mass index z score, and parent education.ResultsChildren from food-insecure and food-secure households had Healthy Eating Index 2015 scores less than 50. Children from food-insecure households reported less energy intake, fewer cups of whole fruit, and more sugar-sweetened beverage consumption for every 1,000 kcal consumed on a weekend day when compared with their counterparts from food-secure households (P<0.05). Similar results were not seen for weekday eating patterns.ConclusionsWhole fruit and sugar-sweetened beverage consumption varied by food insecurity on weekend days during summer months. Because children tend to gain weight during summer months, efforts to increase weekend access to whole fruits and promote water consumption may contribute to weight gain prevention and healthy development, especially for children from food-insecure households.     

Prolonged impact of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic,multicentre randomized trial cohort

Objectives

We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF).

Methods

We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay.

Results

280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n = 143) or clinic-based (n = 137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p = 0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p = 0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p = 0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p < 0.01 for rate and duration of hospital stay).

Conclusions

Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term.

Trial registration

Australian New Zealand Clinical Trials Registry number 12607000069459 (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803)     

Effects of functional electrical stimulation on quality of life and emotional stress in patients with chronic heart failure secondary to ischaemic or idiopathic dilated cardiomyopathy: a randomised, placebo-controlled trial

OBJECTIVE: Functional electrical stimulation (FES) improves exercise capacity and endothelial function in chronic heart failure (CHF) patients. This study evaluates the impact of FES on quality of life and emotional stress in patients with moderate to severe CHF. METHODS: Thirty patients with stable CHF (24 men; NYHA class II-III; left ventricular ejection fraction <35%) were randomly assigned (2:1) to a 6-week FES training program (n=20) or placebo (n=10). Questionnaires addressing quality of life [Kansas City Cardiomyopathy Questionnaire (KCCQ), functional and overall], and emotional stress [Zung self-rating depression scale (SDS), Beck Depression Inventory (BDI)], as well as plasma B-type natriuretic peptide (BNP) and 6-min walking distance test (6MWT) were assessed at baseline and after completion of training protocol. RESULTS: A significant improvement in KCCQ functional (F=76.666, p<0.001), KCCQ overall (F =41.508, p<0.001), BDI (F =17.768, p<0.001) and Zung SDS (F =27.098, p<0.001) was observed in the FES group compared to placebo. Patients in the FES group had also a significant increase in 6MWT (F =19.413, p<0.001) and a trend towards reduction in plasma BNP (F =4.252, p=0.053) compared to placebo. CONCLUSION: FES seems to have a beneficial effect on quality of life, exercise capacity and emotional stress in patients with moderate to severe CHF.     

The Gap in Laparoscopic Colorectal Experience Between Colon and Rectal and General Surgery Residency Training Programs

Purpose In this article, we review the laparoscopic experience of general surgery and colorectal residency training programs in the United States during the past 5 and 12 years, respectively. The purpose of this study was to determine whether an adequate experience was being provided, and at what level of training, to safely and effectively perform advanced laparoscopy. Methods General Surgery Operative Reports from the training years 2000 to 2004 were obtained from the Accreditation Council for Graduate Medical Education. Similarly, colorectal operative performance logs from the training years 1994 to 2005 were obtained from the American Board of Colon and Rectal Surgery. Results From 2000 to 2004, basic and advanced laparoscopic cases (as designated by the Accreditation Council for Graduate Medical Education) have increased from 10.1 to 12.2 percent and 2.1 to 3.7 percent, respectively. Within this period, the number of laparoscopic colon cases/resident/career has increased from 1.8 to 4.6. The percentage of cases performed laparoscopically increased from 3.9 to 22.5 percent from 1993–1994 to 2004–2005 training years. From 1993 to 2001, the average number of laparoscopic cases/resident increased from 6.3 to 16.1. In 2004, the average number of cases/resident increased to 45.3. Of this number, 30 were colon, 9.4 were rectal, and the remaining 5.9 were miscellaneous colorectal procedures. Conclusions Learning curves for laparoscopic colectomy are reported in the range of 20 to 60 cases. Based on the most recent data reviewed, colon and rectal resident experience is trending toward this threshold. Recent general surgery graduates may be lacking the appropriate volume to reach proficiency in laparoscopic colorectal surgery. Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 8, 2006.     

The Impact of Expressions of Treatment Efficacy and Out-of-pocket Expenses on Patient and Physician Interest in Osteoporosis Treatment: Implications for Pay-for-performance Programs

BACKGROUND Clinical practice guidelines (CPGs) are increasingly used as the basis for pay-for-performance (P4P) programs. It is unclear how support for guidelines varies when treatment efficacy is expressed in varying mathematically equivalent ways. OBJECTIVES To assess: (1) how patient and provider compliance with osteoporosis CPGs varies when pharmacotherapy efficacy is presented as relative risk reduction (RRR) versus absolute risk reduction (ARR) and (2) the impact of increasing out-of-pocket drug expenditures on acceptance of guideline concordant therapy. DESIGN Cross-sectional survey of patients and physicians. SUBJECTS AND SETTING Female patients age >50 years and providers drawn from academic and community outpatient clinics. MEASUREMENTS Patient and provider acceptance of pharmacotherapy when treatment efficacy (reduction in hip fractures) was expressed alternatively in relative terms (35% RRR) versus absolute terms (1% ARR); acceptance of pharmacotherapy as patient drug copayment increased from 0% to 100% of the total drug costs. RESULTS Compliance with CPGs fell significantly when the expression of treatment benefit was switched from RRR to ARR for both patients (86% vs 57% compliance; P < .001) and physicians (97% vs 56% compliance; P < .001). Increasing drug copayment from 0% to 10% of total drug cost decreased patient compliance with CPGs from 80% to 57% (P < .001) but did not impact physician compliance. With increasing levels of copay, both patient and provider interest in treatment decreased. LIMITATIONS Respondents may not have fully understood the risks and benefits associated with osteoporosis and its treatment. CONCLUSION Patient and provider interest in CPG-recommended treatment for osteoporosis is reduced when treatment benefit is expressed as ARR rather than RRR. In addition, minimal increases in drug copayment significantly decreased patient, but not provider, interest in osteoporosis treatment. Designers of P4P programs should consider details including expressions of treatment benefit and patients’ out-of-pocket costs when developing measures to assess quality-of-care. Dr. Sinsky presented this work at the 2006 national SGIM meeting in Los Angeles.