Epidemic serogroup B meningococcal disease in Oregon: the evolving epidemiology of the ET-5 strain

CONTEXT: In 1993, Oregon's incidence of serogroup B meningococcal disease began to rise because of a highly clonal group of strains designated enzyme type 5 (ET-5), the first such increase observed in the United States. OBJECTIVE: To evaluate the impact that the ET-5 strain has had on the epidemiology of meningococcal disease in Oregon. DESIGN AND SETTING: Epidemiologic analysis of surveillance data on Oregon meningococcal disease cases from 1987 through 1996 and multilocus enzyme electrophoresis typing of serogroup B isolates from June 1993 through April 1995 and from April through June 1996. PATIENTS: A total of 836 persons with invasive meningococcal disease. MAIN OUTCOME MEASURES: Disease frequency and clonality of strains. RESULTS: Serogroup B disease incidence rates more than doubled from the preepidemic period in 1987-1992 (1.0 case per 100000 population) to the recent epidemic period in 1995-1996 (2.2 cases per 100000). The age-specific incidence rate of serogroup B disease among those 15 through 19 years old increased 13-fold between the preepidemic period (0.5 case per 100000) and 1995-1996 (6.4 cases per 100000). However, the proportion of cases with meningococcemia and the case-fatality rate did not change. Of 99 Neisseria meningitidis isolates obtained from 1993-1995, 88 (89%) belonged to the ET-5 complex. Of these, 69 (78%) were a single clone, designated 301. Of 20 serogroup B isolates from 1996, 18 (90%) belonged to the ET-5 complex; 17 (94%) were the 301 clone. CONCLUSION: Serogroup B meningococcal disease incidence continues at high levels in Oregon with increasing predominance of the ET-5 clonal strains.     

Trends in hospitalization associated with traumatic brain injury.

CONTEXT: Traumatic brain injury (TBI) is associated with more than 50000 deaths in the United States each year, and recent observations suggest a substantial decline in TBI-related hospitalizations and deaths. OBJECTIVE: To analyze long-term trends in TBI-related hospitalization in the United States. DESIGN, SETTING, AND PARTICIPANTS: Analysis of existing data from 1980 through 1995 from the National Hospital Discharge Survey, an annual survey representing the US general population. The number of participating hospitals ranged from 400 to 494. MAIN OUTCOME MEASURES: Annual rates of TBI-related hospitalization, stratified by age, sex, severity of injury, and outcome. RESULTS: The annual number of TBI cases identified from the sample during the study period ranged from 1611 to 3129. Overall rates of hospitalization for TBI declined an estimated 51%, from 199 to 98 per 100000 per year. When analyzed by severity of injury, mild TBIs declined most during this period, from 130 to 51 hospitalizations per 100000 per year (61% decline; P<.001 compared with intermediate and severe TBI). The decline was greatest among those aged 5-14 years (-66%) and least among those aged 65 years or older (-9%). The ratio of male to female rates showed little variation during the study period (ratio, 1.8; 95% confidence interval [CI], 1.6-2.0), as did the in-hospital mortality rate (mean, 5.3 per 100000; 95% CI, 3.6-7.1). CONCLUSIONS: Changes in hospital practices may be a major factor in the declining rates of TBI-related hospital admissions. These practices increasingly appear to exclude persons with less severe TBI from hospital admission and shift their care to outpatient settings.     

Strategies to decrease tuberculosis in us homeless populations: a computer simulation model

CONTEXT: The rate of tuberculosis (TB) among US homeless persons may be 20 times that of the general adult population. Studies suggest that the majority of urban homeless TB cases are attributable to ongoing transmission of TB. Optimal TB-control strategies in both chronically and transiently homeless populations are not known. OBJECTIVE: To examine the effects of TB-control strategies on projected TB cases and deaths in US homeless populations using a computer-based simulation model. DESIGN, SETTING, AND POPULATION: The US general population and a theoretical population of 2 million homeless individuals in 1995 were divided into 18 clinical states based on the risk for or presence of TB and human immunodeficiency virus (HIV) infection in a semi-Markov model. MAIN OUTCOME MEASURES: Prevalence of transiently and chronically homeless individuals with active TB and deaths from TB as a function of public health measures taken to control and eliminate TB, including improvement of treatment effectiveness, improvement in access to treatment, and vaccination with BCG. RESULTS: A 10% increase in access to treatment among homeless persons with active TB produced larger declines in predicted TB cases and deaths after 10 years (cases and deaths among chronically homeless persons decreased 12.5% and 19.8% and among transiently homeless persons dropped 35.9% and 32.4%, respectively) than improvements in the effectiveness of treatment programs (cases and deaths among chronically homeless persons declined 7.2% and 3.1% and among transiently homeless persons dropped 10.9% and 4.1%, respectively). A 10% increase in access to treatment among homeless persons with latent TB infection led to a 6.7% decline in TB among chronically homeless persons and a 5.7% decline among transiently homeless persons, while a 10% improvement in effectiveness of treatment for latent TB infection was associated with declines of 3.0% and 3.3%, respectively. When treatment for latent TB infection was modeled to be the same in vaccinated and nonvaccinated populations, BCG vaccination led to TB case declines of 15.4% and 21.5% in chronically and transiently homeless populations, respectively. CONCLUSIONS: Overcoming barriers faced by homeless individuals in accessing TB treatment programs will be crucial to reducing the burden of TB in this high-risk group. Increased treatment access, improvement in the effectiveness of treatment programs, and BCG vaccination of HIV-negative homeless individuals have the best chance to markedly decrease TB morbidity and mortality.     

Epidemiology of persistent tuberculosis in DeKalb County, Georgia, 1990-1996

BACKGROUND: In DeKalb County, Georgia, during 1990 to 1996, tuberculosis incidence rates fluctuated between 15.3 cases/100,000 person-years (PY) and 19.2 cases/100,000 PY. These rates are approximately 1.5 to 2 times higher than those measured for the United States as a whole, and do not reflect the decline observed nationally since 1993. We reviewed DeKalb tuberculosis registry to investigate risk factors for tuberculosis and describe trends of tuberculosis incidence over time. METHODS: We compared average annual tuberculosis case counts and incidence rates in DeKalb before and after 1993. We calculated rates of tuberculosis incidence using race, age and sex stratified population estimates from the U.S. Bureau of the Census. We compared these rates for the periods 1990-1992 and 1993-1996 using Poisson regressions. RESULTS: Between both time periods, tuberculosis case counts decreased by 6% among whites, by 2% among blacks, and increased by 34% among Asians. Despite this large increase in case numbers, tuberculosis incidence rates among Asians only increased by 4%. For all three race groups, tuberculosis incidence almost doubled for those younger than 15 years of age. CONCLUSIONS: Trends of tuberculosis incidence in DeKalb County varied between different population groups. Migration from countries with a high prevalence of tuberculosis accounted for a larger number of foreign-born cases in recent years. However, increasing tuberculosis incidence rates found among the youngest age groups suggest that active transmission of Mycobacterium tuberculosis also took place.     

鹤山市结核病控制项目实施效果评价

目的总结我市2002-2008年度实施广东省结核病控制项目的效果和经验。方法根据我市2002-2008年度的结核病报表及有关总结材料进行分析。结果在项目实施期间(2002-2008年)发现涂阳患者1 101例,治愈1 001例,新涂阳患者登记率平均为36.3/10万,初、复治涂阳患者治愈率平均为91.6%和88.7%。结论我市实施广东省结核病控制项目效果显著,现代结核病控制理论和技术对结核病疫情的控制具有重要的指导作用。     

Imported measles in the United States

In the period 1980-1981, two hundred nine imported measles cases were reported in the United States. These cases represent 1.3% of the total of 16,630 cases of measles reported to the Centers for Disease Control (CDC) during that period. An average of two imported measles cases were reported each week. The travelers with imported measles were United States citizens and foreign nationals who arrived from 47 different countries throughout the world. However, returning United States citizens have accounted for a rising proportion of imported measles cases. Approximately half (49.3%) of the imported cases were reported by four areas: California, New York State exclusive of New York City, New York City, and Florida. Seven measles outbreaks occurring following importations during the two-year period were identified. In addition to 114 imported measles cases reported to the CDC in 1981, 437 measles cases were reported to be caused directly or indirectly by those importations. The actual number of import-associated cases may have been considerably higher. Imported measles and associated cases together accounted for at least 17% (551/3,124) of reported measles cases in 1981.     

Trends in perinatal transmission of HIV/AIDS in the United States.

CONTEXT: Since 1994, the US Public Health Service (PHS) has recommended routine, voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine therapy to reduce perinatal HIV transmission. OBJECTIVE: To describe trends in incidence of perinatal AIDS and factors contributing to these trends, particularly the effect of PHS perinatal HIV recommendations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of nationwide AIDS surveillance data and data from HIV-reporting states through June 1998. MAIN OUTCOME MEASURES: Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger than 1 year from US natality data for birth cohorts 1988 to 1996; expected number of infants with AIDS from national serosurvey data; and zidovudine use data from selected HIV-reporting states. RESULTS: Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992 through 1997, including an 80% decline in infants and a 66% decline in children aged 1 to 5 years. Rates of AIDS among infants (per 100000 births) declined 69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births to HIV-infected women from 1992 (n = 6990) to 1995 (n = 5797). Among infants, PCP rates per 100000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar to the decline in other AIDS conditions. The percentage of perinatally exposed children born from 1993 through 1997 whose mothers were tested for HIV before giving birth increased from 70% to 94%; the percentage who received zidovudine increased from 7% to 91%. CONCLUSIONS: According to these data, substantial declines in AIDS incidence were temporally associated with an increase in zidovudine use to reduce perinatal HIV transmission, demonstrating substantial success in implementing PHS guidelines. Reductions in the numbers of births and effects of therapy in delaying AIDS do not explain the decline.     

1993～2001年永州市零陵区世界银行贷款结核病控制项目工作效果评价

目的对永州市零陵区世界银行贷款结核病控制项目工作效果进行评价,为制定零陵区结核病控制对策提供依据。方法利用1993～2001年项目工作资料进行总结分析。结果9年间共接诊疑似肺结核症状者9766例,发现活动性结核病人2628例,其中涂阳病人1351例,涂阳病人登记率26.5/10万。初治涂阳病人治愈率为92.06%,复治涂阳病人治愈率为85.00%。结论结控项目的病人发现和治疗效果显著,但如何提高疑似肺结核症状者就诊率是当前急需解决的主要问题。     

Increase in presentations and procedure rates for hyperparathyroidism in Northern Sydney and New South Wales

OBJECTIVE: To examine changes in presentation of primary hyperparathyroidism and rates of parathyroidectomy in Northern Sydney (the Northern Sydney Area Heath Service) and New South Wales (NSW). DESIGN: Retrospective case series January 1962 - December 2001 and audit of the NSW Department of Health inpatient database (1993-1999). SETTING: University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital. PARTICIPANTS: 1613 patients undergoing parathyroidectomy during the study period. MAIN OUTCOME MEASURES: Age-standardised parathyroidectomy rates and indications for surgical intervention. RESULTS: The age-standardised rates of parathyroidectomy for primary hyperparathyroidism in women have increased significantly in Northern Sydney from 0.14 cases per 100,000 in 1976 to 7.7 cases per 100,000 in 1996 (P < 0.001). In NSW there has been an increase in parathyroidectomy rates in women from 5.1 cases per 100,000 in 1993 to 12.3 cases per 100,000 in 1998 (P < 0.001). Osteoporosis was the most common overall indication for surgery in Northern Sydney, accounting for 27% of all cases. The proportion of cases presenting with osteoporosis increased significantly from 4% in 1962-1980 to 34% over the past decade (P < 0.001). CONCLUSIONS: The rate of parathyroidectomy procedures has increased markedly in Northern Sydney and in NSW. The investigation of osteoporosis has led to the diagnosis of primary hyperparathyroidism in an increasing proportion of cases and has contributed to the growing surgical referral rates.     

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

CONTEXT: Atrial fibrillation is the most common arrhythmia in elderly persons and a potent risk factor for stroke. However, recent prevalence and projected future numbers of persons with atrial fibrillation are not well described. OBJECTIVE: To estimate prevalence of atrial fibrillation and US national projections of the numbers of persons with atrial fibrillation through the year 2050. DESIGN, SETTING, AND PATIENTS: Cross-sectional study of adults aged 20 years or older who were enrolled in a large health maintenance organization in California and who had atrial fibrillation diagnosed between July 1, 1996, and December 31, 1997. MAIN OUTCOME MEASURES: Prevalence of atrial fibrillation in the study population of 1.89 million; projected number of persons in the United States with atrial fibrillation between 1995-2050. RESULTS: A total of 17 974 adults with diagnosed atrial fibrillation were identified during the study period; 45% were aged 75 years or older. The prevalence of atrial fibrillation was 0.95% (95% confidence interval, 0.94%-0.96%). Atrial fibrillation was more common in men than in women (1.1% vs 0.8%; P<.001). Prevalence increased from 0.1% among adults younger than 55 years to 9.0% in persons aged 80 years or older. Among persons aged 50 years or older, prevalence of atrial fibrillation was higher in whites than in blacks (2.2% vs 1.5%; P<.001). We estimate approximately 2.3 million US adults currently have atrial fibrillation. We project that this will increase to more than 5.6 million (lower bound, 5.0; upper bound, 6.3) by the year 2050, with more than 50% of affected individuals aged 80 years or older. CONCLUSIONS: Our study confirms that atrial fibrillation is common among older adults and provides a contemporary basis for estimates of prevalence in the United States. The number of patients with atrial fibrillation is likely to increase 2.5-fold during the next 50 years, reflecting the growing proportion of elderly individuals. Coordinated efforts are needed to face the increasing challenge of optimal stroke prevention and rhythm management in patients with atrial fibrillation.     

Update on the treatment of tuberculosis and latent tuberculosis infection

Henry M. Blumberg, MD; Michael K. Leonard, Jr, MD; Robert M. Jasmer, MD

JAMA. 2005;293:2776-2784.

Tuberculosis (TB) has emerged as a global public health epidemic. Despite decreasing numbers of cases in the United States since 1992, TB remains a serious public health problem among certain patient populations and is highly prevalent in many urban areas. The responsibility for prescribing an appropriate drug regimen and ensuring that treatment is completed is assigned to the public health program or the clinician not to the patient. The initial prescribed regimen for the treatment of TB usually consists of 4 drugs: isoniazid, rifampin, pyrazinamide, and ethambutol. The minimum length for the treatment of drug-susceptible TB with a rifampin-based regimen is 6 to 9 months. Providing medications directly to the patient and watching him/her swallow the anti-TB drugs, which is termed directly observed therapy, is recommended for all patients diagnosed with TB and can help ensure higher completion rates, prevent the emergence of drug resistant TB, and enhance TB control. There has been renewed interest in the treatment of those with latent TB infection as a TB-control strategy in the United States for eliminating the large reservoir of individuals at risk for progression to TB. The 2 broad categories of persons who should be tested for latent TB infection are those who are likely to have been recently infected (such as contacts to infectious TB cases) and persons who are at increased risk of progression to TB disease following infection with Mycobacterium tuberculosis (eg, human immunodeficiency virus infection and selected medical conditions; recent immigrants to the United States from high TB-burden countries). The preferred regimen for the treatment of latent TB infection is 9 months of isoniazid. There is now renewed interest in and great need for the development of new drugs to treat TB and latent TB infection.

     

Macrolide resistance among invasive Streptococcus pneumoniae isolates

CONTEXT: Macrolide antibiotics, including erythromycin, clarithromycin, and azithromycin, are the mainstays of empirical pneumonia therapy. Macrolide resistance among Streptococcus pneumoniae, the most common cause of community-acquired pneumonia, is increasing in the United States. Whether resistance is a significant problem or whether macrolides remain useful for treatment of most resistant strains is unknown. OBJECTIVE: To examine the epidemiology of macrolide-resistant pneumococci in the United States. DESIGN AND SETTING: Analysis of 15 481 invasive isolates from 1995 to 1999 collected by the Centers for Disease Control and Prevention's Active Bacterial Core surveillance system in 8 states. MAIN OUTCOME MEASURES: Trends in macrolide use (1993-1999) and resistance and factors associated with resistance, including examination of 2 subtypes, the M phenotype, associated with moderate minimum inhibitory concentrations (MICs), and the MLS(B) phenotype, associated with high MICs and clindamycin resistance. RESULTS: From 1993 to 1999, macrolide use increased 13%; macrolide use increased 320% among children younger than 5 years. Macrolide resistance increased from 10.6% in 1995 to 20.4% in 1999. M phenotype isolates increased from 7.4% to 16.5% (P<.001), while the proportion with the MLS(B) phenotype was stable (3%-4%). The median erythromycin MIC (MIC(50)) of M phenotype isolates increased from 4 microg/mL to 8 microg/mL. In 1999, M phenotype strains were more often from children than persons 5 years or older (25.2% vs 12.6%; P<.001) and from whites than blacks (19.3% vs 11.2%; P<.001). CONCLUSIONS: In the setting of increasing macrolide use, pneumococcal resistance has become common. Most resistant strains have MICs in the range in which treatment failures have been reported. Further study and surveillance are critical to understanding the clinical implications of our findings.     

Standard short-course chemotherapy for drug-resistant tuberculosis: treatment outcomes in 6 countries

CONTEXT: No large-scale study has investigated the impact of multidrug-resistant tuberculosis (TB) on the outcome of standard short-course chemotherapy under routine countrywide TB control program conditions in the World Health Organization's (WHO) directly observed treatment short-course strategy for TB control. OBJECTIVE: To assess the results of treatment with first-line drugs for patients enrolled in the WHO and the International Union Against Tuberculosis and Lung Disease's global project on drug-resistance surveillance. DESIGN AND SETTING: Retrospective cohort study of patients with TB in the Dominican Republic, Hong Kong Special Administrative Region (People's Republic of China), Italy, Ivanovo Oblast (Russian Federation), the Republic of Korea, and Peru. PATIENTS: New and retreatment TB cases who received short-course chemotherapy with isoniazid, rifampicin, pyrazinamide, and either ethambutol or streptomycin between 1994 and 1996. MAIN OUTCOME MEASURE: Treatment response according to WHO treatment outcome categories (cured; died; completed, defaulted, or failed treatment; or transferred). RESULTS: Of the 6402 culture-positive TB cases evaluated, 5526 (86%) were new cases and 876 (14%) were retreatment cases. A total of 1148 (20.8%) new cases and 390 (44.5%) retreatment cases were drug resistant, including 184 and 169 cases of multidrug-resistant TB, respectively. Of the new cases 4585 (83%) were treated successfully, 138 (2%) died, and 151 (3%) experienced short-course chemotherapy failure. Overall, treatment failure (relative risk [RR], 15.4; 95% confidence interval [CI], 10.6-22.4; P<.001) and mortality (RR, 3.73; 95% CI, 2.13-6.53; P<.001) were higher among new multidrug-resistant TB cases than among new susceptible cases. Even in settings using 100% direct observation, cases with multidrug resistance had a significantly higher failure rate than those who were susceptible (9/94 [10%] vs 8/1410 [0.7%]; RR, 16.9; 95% CI, 6.6-42.7; P<.001). Treatment failure was also higher among patients with any rifampicin resistance (n=115) other than multidrug resistance (RR, 5.48; 95% CI, 3.04-9.87; P<.001), any isoniazid resistance (n=457) other than multidrug resistance (RR, 3. 06; 95% CI, 1.85-5.05; P<.001), and among patients with TB resistant to rifampicin only (n=76) (RR, 5.47; 95% CI, 2.68-11.2; P<.001). Of the retreatment cases, 497 (57%) were treated successfully, 51 (6%) died, and 124 (14%) failed short-course chemotherapy treatment. Failure rates among retreatment cases were higher in those with multidrug-resistant TB, with any isoniazid resistance other than multidrug resistance, and in cases with TB resistant to isoniazid only. CONCLUSIONS: These data suggest that standard short-course chemotherapy, based on first-line drugs, is an inadequate treatment for some patients with drug-resistant TB. Although the directly observed treatment short-course strategy is the basis of good TB control, the strategy should be modified in some settings to identify drug-resistant cases sooner, and to make use of second-line drugs in appropriate treatment regimens. JAMA. 2000;283:2537-2545     

The imminent threat of multidrug-resistant tuberculosis in Singapore

The global emergence of multidrugresistant (MDR) tuberculosis (TB) and extensively drug-resistant (XDR)-TB threatens to derail the efforts of TB control programmes worldwide. From 2000 to 2010, 161 pulmonary MDR-TB cases (including six XDR-TB cases) were reported in Singapore, and of these, 80% occurred among the foreign-born, with an increasing trend seen after 2004. Among new pulmonary TB cases, the highest incidence of MDR-TB occurred among patients from Myanmar (8%), followed by Vietnam (4.4%) and China (2.3%), while among those previously treated, the highest incidence was found in patients from Vietnam (50%), followed by Indonesia (33%) and Bangladesh (33%). Although the proportion of Singapore-born pulmonary TB cases with MDR-TB has remained comparatively low (0.2% and 1.3% in new and previously treated cases, respectively), there is no room for complacency. Top priority must be accorded toward the proper treatment of drug-susceptible TB cases under strict programme conditions so as to prevent the development of MDR-TB in the first place.     

Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995-1998: Opportunities for prevention in the conjugate vaccine era

CONTEXT: Pneumococcal polysaccharide vaccine is recommended for elderly persons and adults with certain chronic illnesses. Additionally, a recently licensed pneumococcal 7-valent conjugate vaccine has been recommended for use in young children and could dramatically change the epidemiology of pneumococcal disease. OBJECTIVES: To assess pneumococcal disease burden in the United States, estimate the potential impact of new vaccines, and identify gaps in vaccine recommendations. DESIGN AND SETTING: Analysis of data from the Active Bacterial Core Surveillance (ABCs)/Emerging Infections Program Network, an active, population-based system in 9 states. PATIENTS: A total of 15 860 cases of invasive pneumococcal disease occurring between January 1, 1995, and December 31, 1998. MAIN OUTCOME MEASURES: Age- and race-specific pneumoccocal disease incidence rates per 100 000 persons, case-fatality rates, and vaccine preventability. RESULTS: In 1998, overall incidence was 23.2 cases per 100 000, corresponding to an estimated 62 840 cases in the United States. Incidence was highest among children younger than 2 years (166.9) and adults aged 65 years or older (59.7). Incidence among blacks was 2.6 times higher than among whites (95% confidence interval [CI], 2.4-2.8). Overall, 28.6% of case-patients were at least 65 years old and 85.9% of cases in this age group were due to serotypes included in the 23-valent polysaccharide vaccine; 19.3% of case-patients were younger than 2 years and 82.2% of cases in this age group were due to serotypes included in the 7-valent conjugate vaccine. Among patients aged 2 to 64 years, 50.6% had a vaccine indication as defined by the Advisory Committee on Immunization Practices (ACIP). The case-fatality rate among patients aged 18 to 64 years with an ACIP indication was 12.1% compared with 5.4% for those without an indication (relative risk, 2.2; 95% CI, 1.7-2.9). CONCLUSIONS: Young children, elderly persons, and black persons of all ages are disproportionately affected by invasive pneumococcal disease. Current ACIP recommendations do not address a subset of persons aged 18 to 64 years but do include those at highest risk for death from invasive pneumococcal disease.     

Educational programs in US medical schools, 1999-2000

We used data from the 1999-2000 Liaison Committee on Medical Education Annual Medical School Questionnaire, which had a 100% response rate, and other sources to describe the status of medical education programs in the United States. In 1999-2000, the number of full-time faculty members was 102,446, a 4.3% increase from 1998-1999. The number of basic science faculty increased by less than 0.5%, while the number of clinical faculty increased by about 5%. There were 38,529 medical school applicants in 1999, a 6% decrease from 1998. Women constituted 45.8% and underrepresented minorities made up 12.1% of the 1999-2000 first-year class. New content, such as alternative medicine and cultural competence, and new methods of instruction, such as computer-based learning, are being incorporated by many schools. Seventy schools (56% of the total) require students to pass both Step 1 and Step 2 of the US Medical Licensing Examination for advancement or graduation, an increase from 62 schools (50%) in 1998-1999. The use of standardized methods of assessment, such as objective structured clinical examinations, to evaluate students' clinical performance was highly variable among schools. JAMA. 2000;284:1114-1120     

Proportionate mortality trends: 1950 through 1986

Mortality trends in the United States from 1950 through 1986 were analyzed for the conditions that are or have recently been among the six leading causes of death. The age-adjusted mortality rate for all causes has decreased from 841.5 to 541.7 per 100,000 population. Cause-specific, age-adjusted mortality rates have declined from 1950 through 1986 for cerebrovascular disease, injuries, perinatal conditions, heart disease, and influenza and pneumonia. Time trends in the proportion of persons dying of each of these diseases, however, have varied; the proportion dying of cerebrovascular disease, injuries, and perinatal conditions has decreased, and the proportion of persons dying of heart disease and influenza and pneumonia has remained fairly stable from 1950 through 1986. During this same time, age-adjusted death rates have increased for chronic obstructive pulmonary disease and have remained fairly stable for malignant neoplasms, while the proportions of persons dying of chronic obstructive pulmonary disease and malignant neoplasms have increased dramatically. For people aged 35 to 64 years, malignant neoplasms have now overtaken heart disease as the leading cause of death. For those aged 65 years and older, heart disease remains the leading cause of death, accounting for almost 50% of all deaths in persons 85 years and older.     

Licit psychostimulant consumption in Australia, 1984-2000: international and jurisdictional comparison

OBJECTIVES: To examine trends in the licit consumption of the psychostimulants dexamphetamine and methylphenidate in Australia and nine other countries from 1994 to 2000 and in each State and Territory of Australia from 1984 to 2000. DESIGN: Annual rates of consumption of psychostimulants were compared using Poisson regression models. All drug consumption was standardised to defined daily doses per 1000 population per day. MAIN OUTCOME MEASURES: Rates of consumption of each psychostimulant in each country and in each Australian State and Territory. RESULTS: For the 10 countries from 1994 to 2000, total psychostimulant consumption increased by an average 12% per year, with the highest increase from 1998 to 2000. Australia and New Zealand ranked third in total psychostimulant use after the United States and Canada. Australia consumed significantly more than the United Kingdom, Sweden, Spain, the Netherlands, France or Denmark. In Australia, from 1984 to 2000, the rate of consumption of licit psychostimulants increased by 26% per year, with an 8.46-fold increase from 1994 to 2000. Western Australia ranked first, with nearly twice the consumption rate of total psychostimulants as New South Wales, which ranked second. Methylphenidate is the main psychostimulant consumed in the US and Canada, and dexamphetamine in Australia. CONCLUSIONS: The consumption of psychostimulants in Australia is high internationally and varies significantly between States and Territories. The results imply varied jurisdictional prescribing determinants and supply processes throughout Australia, which may require new national prescribing standards and access to online patient data for prescribers and dispensers.     

Peripatetic plague

Cases of plague continue to occur in various parts of the world, including the western United States, where plague is endemic among the wild rodent population. In 1980, a case of plague acquired in New Mexico and hospitalized in Nebraska illustrated the problem of plague occurring in persons traveling from the state in which they become infected to another state. Nine cases of plague in travelers were identified among the 166 cases of plague reported in the United States from 1950 to 1980. Physicians should be aware of natural plague foci in the western United States and should obtain a travel history from patients with an illness clinically compatible with plague.