Anthrax as a biological weapon: medical and public health management. Working Group on Civilian Biodefense.

OBJECTIVE: To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of anthrax as a biological weapon against a civilian population. PARTICIPANTS: The working group included 21 representatives from staff of major academic medical centers and research, government, military, public health, and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to April 1998, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of references identified by this search led to identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. CONSENSUS PROCESS: The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. Members of the working group provided formal written comments which were incorporated into the second draft of the statement. The working group reviewed the second draft on June 12, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. CONCLUSIONS: Specific consensus recommendations are made regarding the diagnosis of anthrax, indications for vaccination, therapy for those exposed, postexposure prophylaxis, decontamination of the environment, and additional research needs.     

Hemorrhagic fever viruses as biological weapons: medical and public health management

OBJECTIVE: To develop consensus-based recommendations for measures to be taken by medical and public health professionals if hemorrhagic fever viruses (HFVs) are used as biological weapons against a civilian population. PARTICIPANTS: The Working Group on Civilian Biodefense included 26 representatives from academic medical centers, public health, military services, governmental agencies, and other emergency management institutions. EVIDENCE: MEDLINE was searched from January 1966 to January 2002. Retrieved references, relevant material published prior to 1966, and additional sources identified by participants were reviewed. CONSENSUS PROCESS: Three formal drafts of the statement that synthesized information obtained in the evidence-gathering process were reviewed by the working group. Each draft incorporated comments and judgments of the members. All members approved the final draft. CONCLUSIONS: Weapons disseminating a number of HFVs could cause an outbreak of an undifferentiated febrile illness 2 to 21 days later, associated with clinical manifestations that could include rash, hemorrhagic diathesis, and shock. The mode of transmission and clinical course would vary depending on the specific pathogen. Diagnosis may be delayed given clinicians' unfamiliarity with these diseases, heterogeneous clinical presentation within an infected cohort, and lack of widely available diagnostic tests. Initiation of ribavirin therapy in the early phases of illness may be useful in treatment of some of these viruses, although extensive experience is lacking. There are no licensed vaccines to treat the diseases caused by HFVs.     

Tularemia as a biological weapon: medical and public health management

OBJECTIVE: The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals if tularemia is used as a biological weapon against a civilian population. PARTICIPANTS: The working group included 25 representatives from academic medical centers, civilian and military governmental agencies, and other public health and emergency management institutions and agencies. EVIDENCE: MEDLINE databases were searched from January 1966 to October 2000, using the Medical Subject Headings Francisella tularensis, Pasteurella tularensis, biological weapon, biological terrorism, bioterrorism, biological warfare, and biowarfare. Review of these references led to identification of relevant materials published prior to 1966. In addition, participants identified other references and sources. CONSENSUS PROCESS: Three formal drafts of the statement that synthesized information obtained in the formal evidence-gathering process were reviewed by members of the working group. Consensus was achieved on the final draft. CONCLUSIONS: A weapon using airborne tularemia would likely result 3 to 5 days later in an outbreak of acute, undifferentiated febrile illness with incipient pneumonia, pleuritis, and hilar lymphadenopathy. Specific epidemiological, clinical, and microbiological findings should lead to early suspicion of intentional tularemia in an alert health system; laboratory confirmation of agent could be delayed. Without treatment, the clinical course could progress to respiratory failure, shock, and death. Prompt treatment with streptomycin, gentamicin, doxycycline, or ciprofloxacin is recommended. Prophylactic use of doxycycline or ciprofloxacin may be useful in the early postexposure period.     

Botulinum toxin as a biological weapon: medical and public health management

OBJECTIVE: The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals if botulinum toxin is used as a biological weapon against a civilian population. PARTICIPANTS: The working group included 23 representatives from academic, government, and private institutions with expertise in public health, emergency management, and clinical medicine. EVIDENCE: The primary authors (S.S.A. and R.S.) searched OLDMEDLINE and MEDLINE (1960-March 1999) and their professional collections for literature concerning use of botulinum toxin as a bioweapon. The literature was reviewed, and opinions were sought from the working group and other experts on diagnosis and management of botulism. Additional MEDLINE searches were conducted through April 2000 during the review and revisions of the consensus statement. CONSENSUS PROCESS: The first draft of the working group's consensus statement was a synthesis of information obtained in the formal evidence-gathering process. The working group convened to review the first draft in May 1999. Working group members reviewed subsequent drafts and suggested additional revisions. The final statement incorporates all relevant evidence obtained in the literature search in conjunction with final consensus recommendations supported by all working group members. CONCLUSIONS: An aerosolized or foodborne botulinum toxin weapon would cause acute symmetric, descending flaccid paralysis with prominent bulbar palsies such as diplopia, dysarthria, dysphonia, and dysphagia that would typically present 12 to 72 hours after exposure. Effective response to a deliberate release of botulinum toxin will depend on timely clinical diagnosis, case reporting, and epidemiological investigation. Persons potentially exposed to botulinum toxin should be closely observed, and those with signs of botulism require prompt treatment with antitoxin and supportive care that may include assisted ventilation for weeks or months. Treatment with antitoxin should not be delayed for microbiological testing.     

Smallpox as a Biological Weapon: Medical and Public Health Management

Objective  To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of smallpox as a biological weapon against a civilian population. Participants  The working group included 21 representatives from staff of major medical centers and research, government, military, public health, and emergency management institutions and agencies. Evidence  The first author (D.A.H.) conducted a literature search in conjunction with the preparation of another publication on smallpox as well as this article. The literature identified was reviewed and opinions were sought from experts in the diagnosis and management of smallpox, including members of the working group. Consensus Process  The first draft of the consensus statement was a synthesis of information obtained in the evidence-gathering process. Members of the working group provided formal written comments that were incorporated into the second draft of the statement. The working group reviewed the second draft on October 30, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. Conclusions  Specific recommendations are made regarding smallpox vaccination, therapy, postexposure isolation and infection control, hospital epidemiology and infection control, home care, decontamination of the environment, and additional research needs. In the event of an actual release of smallpox and subsequent epidemic, early detection, isolation of infected individuals, surveillance of contacts, and a focused selective vaccination program will be the essential items of an effective control program.      

Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense

Objective  The Working Group on Civilian Biodefense has developed consensus-based recommendations for measures to be taken by medical and public health professionals following the use of plague as a biological weapon against a civilian population. Participants  The working group included 25 representatives from major academic medical centers and research, government, military, public health, and emergency management institutions and agencies. Evidence  MEDLINE databases were searched from January 1966 to June 1998 for the Medical Subject Headings plague, Yersinia pestis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of the bibliographies of the references identified by this search led to subsequent identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources. Additional MEDLINE searches were conducted through January 2000. Consensus Process  The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. The working group was convened to review drafts of the document in October 1998 and May 1999. The final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members. Conclusions  An aerosolized plague weapon could cause fever, cough, chest pain, and hemoptysis with signs consistent with severe pneumonia 1 to 6 days after exposure. Rapid evolution of disease would occur in the 2 to 4 days after symptom onset and would lead to septic shock with high mortality without early treatment. Early treatment and prophylaxis with streptomycin or gentamicin or the tetracycline or fluoroquinolone classes of antimicrobials would be advised.      

Why don't physicians follow clinical practice guidelines? A framework for improvement.

CONTEXT: Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines. OBJECTIVE: To review barriers to physician adherence to clinical practice guidelines. DATA SOURCES: We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence. STUDY SELECTION: Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. DATA EXTRACTION: Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators. DATA SYNTHESIS: The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier. CONCLUSIONS: Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.     

An informatics agenda for public health: summarized recommendations from the 2011 AMIA PHI Conference

The AMIA Public Health Informatics 2011 Conference brought together members of the public health and health informatics communities to revisit the national agenda developed at the AMIA Spring Congress in 2001, assess the progress that has been made in the past decade, and develop recommendations to further guide the field. Participants met in five discussion tracks: technical framework; research and evaluation; ethics; education, professional training, and workforce development; and sustainability. Participants identified 62 recommendations, which clustered into three key themes related to the need to (1) enhance communication and information sharing within the public health informatics community, (2) improve the consistency of public health informatics through common public health terminologies, rigorous evaluation methodologies, and competency-based training, and (3) promote effective coordination and leadership that will champion and drive the field forward. The agenda and recommendations from the meeting will be disseminated and discussed throughout the public health and informatics communities. Both communities stand to gain much by working together to use these recommendations to further advance the application of information technology to improve health.     

The Contributions of Biomedical Informatics to the Fight Against Bioterrorism

A comprehensive and timely response to current and future bioterrorist attacks requires a data acquisition, threat detection, and response infrastructure with unprecedented scope in time and space. Fortunately, biomedical informaticians have developed and implemented architectures, methodologies, and tools at the local and the regional levels that can be immediately pressed into service for the protection of our populations from these attacks. These unique contributions of the discipline of biomedical informatics are reviewed here.Current outbreaks of anthrax exposure and cases test our health care delivery and public health systems with threats of large spatial scope—the entire nation—that demand a very short temporal latency in our responses. Other potential bioterrorist attacks only increase the dimensions of this unprecedented challenge. The dimensions, however, are not unprecedented; rather, they are quite familiar to many researchers in biomedical informatics over the last 40 years. The task of comprehensive real-time monitoring on the regional and national scale has been the subject of full-fledged design and large-scale implementations led by biomedical informaticians.Nonetheless, we run the risk that the knowledge gained in the decades of informatics research will not, in the appropriate haste to safeguard the population of the United States from the threats of bioterrorism, be reflected in the national public health information infrastructure. And that may result not only in wasteful expenditures but also in ineffective measures to prevent future attacks on the health of the U.S. population. This is, therefore, a timely juncture to review some of the most germane contributions from the biomedical informatics armamentarium to the tasks at hand, particularly data acquisition, threat detection, and response.     

《2018多学科共识声明：成人糖尿病患者的预防接种》解读

糖尿病是世界范围内的公共卫生问题之一,糖尿病慢性并发症所导致的发病率和死亡率增加,已经给社会、经济和医疗带来了巨大的负担。虽然有关糖尿病管理方面有许多指南出台,但对于成人糖尿病患者多种疫苗的预防接种,既往还没有共识/指南全面提及过。2018年意大利卫生、预防医学和公共卫生协会联合意大利医学糖尿病专家协会、意大利全科医生联合会、意大利糖尿病学会、意大利全科医学社团和初级保健学会共同发表了成人糖尿病患者的预防接种的多学科共识声明,即《2018多学科共识声明：成人糖尿病患者的预防接种》。这篇共识声明阐述了成人糖尿病患者易患感染的机制,以及流感疫苗、肺炎球菌疫苗、带状疱疹病毒疫苗、脑膜炎球菌疫苗、百日咳-白喉-破伤风疫苗等疫苗接种的意义和接种频率,并强调了糖尿病医师及全科医师在督导成人糖尿病患者进行疫苗接种中的重要作用。我国尚缺乏相应的临床指南或共识,但由于糖尿病患者越来越多,带来的卫生经济学负担越来越重,本文就意大利发表的这篇共识声明要点进行解读,旨在为我国成人糖尿病感染性疾病的预防接种政策制定及临床工作提供参考。     

A consensus action agenda for achieving the national health information infrastructure

BackgroundImproving the safety, quality, and efficiency of health care will require immediate and ubiquitous access to complete patient information and decision support provided through a National Health Information Infrastructure (NHII).MethodsTo help define the action steps needed to achieve an NHII, the U.S. Department of Health and Human Services sponsored a national consensus conference in July 2003.ResultsAttendees favored a public–private coordination group to guide NHII activities, provide education, share resources, and monitor relevant metrics to mark progress. They identified financial incentives, health information standards, and overcoming a few important legal obstacles as key NHII enablers. Community and regional implementation projects, including consumer access to a personal health record, were seen as necessary to demonstrate comprehensive functional systems that can serve as models for the entire nation. Finally, the participants identified the need for increased funding for research on the impact of health information technology on patient safety and quality of care. Individuals, organizations, and federal agencies are using these consensus recommendations to guide NHII efforts.     

CONSORT 2010说明与详述：报告平行对照随机临床试验指南的更新

大量证据显示随机对照临床试验（randomised controlled trial,RCT）的报告质量不理想。报告不透明,则读者既不能评判试验结果是否真实可靠,也不能从中提取可用于系统综述的信息。最近的方法学分析表明,报告不充分和设计不合理与对治疗效果产生评价偏倚有关。这种系统误差对RCT损害严重,而RCT正是以其能减少或避免偏倚而被视为评价干预措施的金标准。为了提高RCT的报告质量,一个由专家和编辑组成的工作组制定了临床试验报告的统一标准（Consolidated Standards of Reporting Trials,CONSORT）声明。CONSORT声明于1996年首次发表,并于2001年更新。声明由对照检查清单和流程图组成,供作者在报告RCT时使用。许多核心医学期刊和主要国际性编辑组织都已认可CONSORT声明。该声明促进了对RCT的严格评价和解释。2001年,在对CONSORT进行修订时,人们就已经清楚地认识到,解释和说明制定CONSORT声明的原理,有助于研究人员等撰写或评价临床试验报告。一篇CONSORT说明与详述文章于2001年同2001版CONSORT声明一起发表。2007年1月的专家会议之后,对CONSORT声明作了进一步修订并已发表,即＂CONSORT2010声明＂。这次更新对原版对照检查清单作了文字上的修改,使其更为明晰,并收入了与一些新近才认识到的主题相关的建议,如选择性报告结局产生的偏倚。说明与详述文件旨在加强人们对CONSORT声明的理解、应用和传播,这次也作了大量修订,对每一项新增或更新的清单条目的含义和增改理由进行了解释,提供了优秀的报告实例,还尽可能地提供了相关的经验性研究的参考文献。文中收入了若干流程图实例。＂CONSORT2010声明＂、其说明与详述文件,以及相关网站（www.consort-statement.org）,对于改进随机临床试验报告必将有所裨益。     

炭疽毒素小分子抑制剂

炭疽病是由炭疽芽孢杆菌(Bacillus anthracis)引起的恶性传染病,炭疽菌进入宿主后产生的炭疽毒素是感染者致死的主要原因.炭疽毒素含有2种具有酶催化活性的蛋白质——致死因子和水肿因子,以及1种共同的结合和转运蛋白质——炭疽保护性抗原,炭疽保护性抗原分别与上述两种因子组成致死毒素和水肿毒素.现阶段治疗炭疽病的主要药物为抗生素,但抗生素只能杀灭人体组织内的部分炭疽热孢子和细菌,不能抵抗孢子和细菌在体内产生的毒素,因而需要开发抑制炭疽毒素的新型药物.本文主要综述近年来国际上对靶向保护性抗原、致死因子和水肿因子的炭疽毒素小分子抑制剂的主要研究进展.     

城市炭疽气溶胶恐怖事件医学处置效果评估方法

目的 构建一种炭疽气溶胶恐怖事件医学处置效果的量化评估方法。方法 首先构建炭疽暴露后医学干预的决策树模型、关键资源消耗配置模型及不同干预措施下人群状态转移模型,从而形成一个资源约束下炭疽事件医学处置效果的评估框架。然后基于离散事件仿真技术,以我国大城市遭受炭疽恐怖袭击为情景,分析评估52种干预策略对发病人数、峰值、死亡人数的影响。结果 干预效果对介入延迟时间和资源储备量2个因素均敏感。在仿真案例中,当介入延迟时间为事发后1 h时,将资源储备量从25%提高到100%可减少约59.91%的死亡人数;当介入延迟时间为事发后145时,将资源储备量从25%提高到100%只能减少约7.33%的死亡人数。干预策略对发病人数达到峰值的时间影响很小,最大值为10.52 d,最小值为9.67 d;对峰值人数影响较大,最大值为255 072人,最小值为103 943人。结论 建立了一种炭疽气溶胶恐怖事件医学处置效果的定量评估方法,在医学救援能力建设、应急策略选择方面具有一定的参考价值。     

Clinical bioinformatics

Clinical bioinformatics provides biological and medical information to allow for individualized healthcare. In this review, we describe the uses of clinical bioinformatics. After the analysis of the complete human genome sequences, clinical bioinformatics enables researchers to search online biological databases and use the biological information in their medical practices. The data obtained from using microarray is extremely complicated. In clinical bioinformatics, selecting appropriate software to analyze the microarray data for medical decision making is crucial. Proteomics strategy tools usually focus on similarity searches, structure prediction, and protein modeling. In clinical bioinformatics, the proteomic data only have meaning if they are integrated with clinical data. In pharmacogenomics, clinical bioinformatics includes elaborate studies of bioinformatics tools and various facets of proteomics related to drug target identification and clinical validation. Using clinical bioinformatics, researchers apply computational and high-throughput experimental techniques to cancer research and systems biology. Meanwhile, researchers of bioinformatics and medical information have incorporated clinical bioinformatics to improve health care, using biological and medical information. Using the high volume of biological information from clinical bioinformatics will contribute to changes in practice standards in the healthcare system. We believe that clinical bioinformatics provides benefits of improving healthcare, disease prevention and health maintenance as we move toward the era of personalized medicine.     

Lead pollution and amelioration measures in the community of Frazers Content,St Catherine,Jamaica

Lead poisoning, especially in children, is a preventable disease. Many children are exposed to this hazard, especially in poor communities, because of a paucity of information on lead poisoning and increasing economic hardships. In 1994, the case of the poor suburban community of Frazers Content, St Catherine, Jamaica, came to the public attention because of the high frequency of hospital admissions, or outpatient treatment, of children for lead poisoning. This paper reviews a Blue Cross of Jamaica-led-initiative aimed at the clean up and education of the Frazers Content community. The following four-pronged approach was employed: environmental and biological sampling and sample analysis, health education, decontamination and community clean up and entrepreneurial activities. The project outputs included: training of 17 community wardens and 22 schoolteachers; the clean up of 64 residences which had lead levels in excess of 500 ppm; the establishment of an entombment site for the contaminated soil in accordance with the Jamaica Natural Resources Conservation Authority and training of residents in entrepreneurial skills, chicken and rabbit rearing and nursery establishment. The paper includes discussion of the lessons learnt and recommendations for future action.     

Recommendations for ensuring early thrombolytic therapy for acute myocardial infarction. The Heart and Stroke Foundation of Canada, the Canadian Cardiovascular Society and the Canadian Association of Emergency Physicians for the Emergency Cardiac Care Coalition.

OBJECTIVE: To recommend practical steps to ensure early thrombolytic therapy and thereby reduce mortality and morbidity associated with acute myocardial infarction (AMI). OPTIONS: Various factors were considered that influence time to thrombolysis related to patients, independent practitioners and health care systems. OUTCOMES: Reduction in morbidity and mortality associated with AMI. EVIDENCE: Early initiation of thrombolytic therapy reduces morbidity and mortality associated with AMI. The ECC Coalition analysed the factors that might impede early implementation of thrombolytic therapy. VALUES: Published data were reviewed, and recommendations were based on consensus opinion of the Emergency Cardiac Care (ECC) Coalition. The ECC Coalition comprises 20 professional, nongovernment and government organizations and has a mandate to improve emergency cardiac care services through collaboration. BENEFITS, HARMS AND COSTS: Early thrombolytic therapy reduces morbidity and mortality associated with AMI. Implementation of the recommendations will result in reduced time to thrombolytic therapy, streamlining of current practices and enhanced cooperation among health care professionals to expedite care. Depending on existing practices, implementation may require protocol development, and public and professional education. Although costs are associated with educating the public and health care professionals, they are outweighed by the financial and social benefits of reduced morbidity and mortality. RECOMMENDATIONS: Early recognition of AMI symptoms by the public and health care professionals, early access to the emergency medical services system and early action by emergency care providers in administering thrombolytic therapy (within 30 minutes after the patient's arrival at the emergency department). VALIDATION: No similar consensus statements or practice guidelines for thrombolytic therapy in Canada are available for comparison.     

Seven legal barriers to end-of-life care: myths, realities, and grains of truth

OBJECTIVE: The American College of Physicians-American Society of Internal Medicine (ACP-ASIM) End-of-Life Care Consensus Panel was convened in 1997 to identify clinical, ethical, and policy problems in end-of-life care, to analyze critically the available evidence and guidelines, and to offer consensus recommendations on how to improve care of the dying. Topic selection and content presentation were carefully debated to maximize the project's focus on providing practical clinical and other guidance to clinicians who are not specialists in palliative care. This statement examines current legal myths, realities, and grains of truth in end-of-life care. PARTICIPANTS: The Consensus Panel comprises 13 medical and bioethics experts, clinicians, and educators in care at the end of life selected by the Ethics and Human Rights Committee, College leadership, and the Center for Ethics and Professionalism at the ACP-ASIM. EVIDENCE: A literature review including a MEDLINE search of articles from 1970-1998 and review of end-of-life care literature and organizational bibliographies was conducted. Unpublished sources were also identified by participants, as was anecdotal clinical experience. CONSENSUS PROCESS: The draft statement was debated by panel members over a series of 3 to 4 meetings. For this statement, the initial draft and subsequent revised drafts were discussed in 1998-1999. The statement then underwent external peer review and revision before panel approval and the journal peer review process. CONCLUSIONS: Legal myths about end-of-life care can undermine good care and ethical medical practice. In addition, at times ethics, clinical judgment, and the law conflict. Patients (or families) and physicians can find themselves considering clinical actions that are ethically appropriate, but raise legal concerns. The 7 major legal myths regarding end-of-life care are: (1) forgoing life-sustaining treatment for patients without decision-making capacity requires evidence that this was the patient's actual wish; (2) withholding or withdrawing of artificial fluids and nutrition from terminally ill or permanently unconscious patients is illegal; (3) risk management personnel must be consulted before life-sustaining medical treatment may be terminated; (4) advance directives must comply with specific forms, are not transferable between states, and govern all future treatment decisions; oral advance directives are unenforceable; (5) if a physician prescribes or administers high doses of medication to relieve pain or other discomfort in a terminally ill patient, resulting in death, he/she will be criminally prosecuted; (6) when a terminally ill patient's suffering is overwhelming despite palliative care, and he/she requests a hastened death, there are no legally permissible options to ease suffering; and (7) the 1997 Supreme Court decisions outlawed physician-assisted suicide. Many legal barriers to end-of-life care are more mythical than real, but sometimes there is a grain of truth. Physicians must know the law of the state in which they practice. JAMA. 2000;284:2495-2501.     

One-year health assessment of adult survivors of Bacillus anthracis infection

Context  Little is known about potential long-term health effects of bioterrorism-related Bacillus anthracis infection. Objective  To describe the relationship between anthrax infection and persistent somatic symptoms among adults surviving bioterrorism-related anthrax disease approximately 1 year after illness onset in 2001. Design, Setting, and Participants  Cross-sectional study of 15 of 16 adult survivors from September through December 2002 using a clinical interview, a medical review-of-system questionnaire, 2 standardized self-administered questionnaires, and a review of available medical records. Main Outcome Measures  Health complaints summarized by the body system affected and by symptom categories; psychological distress measured by the Revised 90-Item Symptom Checklist; and health-related quality-of-life indices by the Medical Outcomes Study 36-Item Short-Form Health Survey (version 2). Results  The anthrax survivors reported symptoms affecting multiple body systems, significantly greater overall psychological distress (P<.001), and significantly reduced health-related quality-of-life indices compared with US referent populations. Eight survivors (53%) had not returned to work since their infection. Comparing disease manifestations, inhalational survivors reported significantly lower overall physical health than cutaneous survivors (mean scores, 30 vs 41; P = .02). Available medical records could not explain the persisting health complaints. Conclusion  The anthrax survivors continued to report significant health problems and poor life adjustment 1 year after onset of bioterrorism–related anthrax disease.      

Sterilization and disinfection in the physician's office.

OBJECTIVE: To review the principles and practice of sterilization and disinfection of medical instruments in the office setting. DATA SOURCES: Searches of MEDLINE for articles published from 1980 to 1990 on disinfection, sterilization, cross infection, surgical instruments and iatrogenic disease, bibliographies, standard texts and reference material located in a central processing department. STUDY SELECTION: We reviewed surveys of decontamination practices in physicians' offices, reviews of current recommendations for office decontamination procedures, case reports of cross infection in offices and much of the standard reference material on decontamination theory and practice. DATA SYNTHESIS: There have been few surveys of physicians' decontamination practices and few case reports of cross infection. Office practitioners have little access to practical information on sterilization and disinfection. CONCLUSION: The increasing threat of cross infection from medical instruments calls for greater knowledge about decontamination. We have adapted material from various sources and offer a primer on the subject.