Family practice in the United States: position and prospects.

Family practice became the 20th U.S. medical specialty in 1969. It has delivered on its promise to reverse the decline of general practice and care for people with diverse problems in all areas of the country. But many important health care problems remain unsolved, in part because of poor role delineation for family physicians, poor differentiation of family practice from other fields, and insufficient changes in the cultural and political environment. Family practice's problems include confusion about whether it is a reform movement or an incumbent specialty; disagreement about its role in controlling and assuring care; confusion about whether family physicians are generalists or specialists; lack of clarity about family practice as vital for all versus a possible option for some; misunderstanding about the knowledge requirements for family practice; and inadequate business models. Family practice's mistakes include expending much effort on justification and less on assuring practical means to accomplish its work; permitting an erosion of public trust; failing to strengthen relationships with interfacing specialties and organizations; and neglecting research. Nonetheless, there are promising opportunities to improve health and health care through strengthening family practice that depend in part on redesigning the family practice setting, defining carefully critical interactions with other elements of the health care system, fostering discovery of family practice, and further differentiating family practice as a scientific and caring field. Another period of adaptation by family practice is already under way; this may be the first time in history that its ambitious aspirations are actually achievable.     

Increased risk for lethal forms of liver disease among HBsAg-positive blood donors in the United States

We have used a death-record search to define the frequency of lethal outcomes of hepatitis B virus infection among a population of more than 15,000 overtly healthy blood donors found positive in routine HBsAg testing. We have compared the study population with a control group of some 18,000 donors selected on the basis of a negative test result. The index and control groups were observed for periods reflecting a total of 55 and 59 thousand person-years, respectively. Twenty percent of the 134 deaths identified among HBsAg positive donors were in some way liver related, including seven deaths due to hepatitis, seven to cirrhosis and six to hepatoma. In contrast, only one of the 95 deaths in the control population was liver related, and was due to fatty degeneration of the liver. The majority (four) of the hepatoma deaths occurred among blacks, three of whom were less than 35 at the time of death. In contrast, deaths from cirrhosis were all among whites. We conclude that there is significant mortality associated with the HBsAg positive state, even though the affected individuals may be asymptomatic and well enough to give blood at some stage. We estimate the standardised mortality ratio for hepatoma among HBsAg-positive persons in the United States is at least 27, confirming the association observed in other populations. The risk for hepatoma among young, HBsAg positive black males appears to approach that reported for HBsAg positive males in Taiwan. Data on the feasibility of AFP testing for early detection of hepatoma are included and discussed.     

Incidence of and risk factors for perioperative or periprocedural anaphylaxis in the United States from 2005 to 2014

BackgroundThe estimated worldwide incidence of perioperative or periprocedural anaphylaxis (PA) is between 1 in 1250 and 1 in 20,000 procedures.ObjectiveTo evaluate the incidence of PA in the United States and compare patient characteristics and underlying risk factors using a large national database.MethodsUsing deidentified data from the nationwide inpatient sample from 2005 to 2014, we identified cases of PA through the International Classification of Diseases, Ninth Revision, Clinical Modification codes and conducted a retrospective analysis.ResultsAmong 35,647,347 surgeries and procedures, there were 5458 (0.015%) PA cases identified. The incidence of PA was 15.3 cases per 100,000 procedures. When compared with controls, PA cases had an increased mortality (3.4% vs 1.4%; P < .001), median length of stay (5 vs 3 days; P < .001), and median hospital cost ($45,155 vs $24,734; P < .001). The age group between 18 and 34 years (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.13-1.58; P < .001) and female sex (OR, 1.40; 95% CI, 1.31-1.49; P < .001) were associated with increased odds of PA. Transplant (OR, 3.35; 95% CI, 2.59-4.34; P < .001), hematologic (OR, 1.63; 95% CI, 1.30-2.05; P < .001), vascular (OR, 1.49; 95% CI, 1.30-1.67; P < .001), and cardiac (OR, 1.47; 95% CI, 1.30-1.67; P < .001) procedures were at increased risk for PA. Several comorbidities were associated with PA including chronic pulmonary disease (OR, 1.41; 95% CI, 1.31-1.51; P < .001).ConclusionThe incidence of PA is 1 in 6531 procedures, with a mortality of 1 in 191,652 procedures. PA has worsening outcomes compared with controls. The risk factors of PA include age, sex, procedure type, and comorbidities.     

SORL1 is genetically associated with increased risk for late-onset Alzheimer disease in the Belgian population

SORL1 has recently been identified as a major genetic contributor to increased risk for late-onset Alzheimer disease (AD). Here we aimed at replicating this finding in a large, well-characterized group of 550 Belgian late-onset AD patients and 637 healthy control individuals using a gene-wide genotyping approach across the SORL1 locus. We observed significant associations, both for individual SNPs (SNPs 6, 8, 9, 10 and 27; p-values ranging from 0.001 to 0.040) and 3-SNP haplotypes (SNPs 5-6-7 and SNPs 25-26-27; p-values ranging from 0.008 to 0.035). Moreover, the associations at SNP 8, 9 and 10 represented a direct replication of the initial association data. Two signals in distinct regions of the gene were shown to be mutually independent, supporting allelic heterogeneity at the SORL1 locus in the Belgian population. Our findings confirm that genetic variants in SORL1 may be important risk factors for late-onset AD.     

Racial and ethnic disparities in cardiac catheterization for acute myocardial infarction in the United States, 1995--2001

OBJECTIVE: To examine recent trends in racial and ethnic disparities in cardiac catheterization for acute myocardial infarction (AMI) to determine whether disparities documented from the 1980s through mid-1990s persist, and evaluate whether patient and hospital characteristics are associated with any observed disparities METHODS: Cross-sectional analyses of 585,710 white, 51,369 black and 31,923 Hispanic discharges from hospitals in the Nationwide Inpatient Sample (which includes data on all discharges from 951 representative hospitals in 23 states) that had performed cardiac catheterization from 1995--2001 with a primary diagnosis of AMI. Adjusted procedure rates and prevalence ratios (PR) were computed to compare catheterization rates by race and ethnicity. MEASUREMENTS AND MAIN RESULTS: Catheterization rates were higher for whites than blacks for all years examined; rates among Hispanics increased during this period and approached the rate among whites. After adjustment for age, demographics, comorbidity, year and hospital characteristics, rates (per 100 discharges) were 58.4 for whites, 50.1 for blacks (PR 0.87; 95% CI 0.84-0.91) and 55.2 for Hispanics (PR 0.95; 95% CI 0.90-0.99). CONCLUSIONS: These nationwide data suggest blacks remain less likely than whites and Hispanics to undergo catheterization during a hospitalization for AMI. Whether this disparity stems from patient or provider factors remains to be determined.     

Auditory system dysfunction in Alzheimer disease and its prodromal states: A review

Recent findings suggest that both peripheral and central auditory system dysfunction occur in the prodromal stages of Alzheimer Disease (AD), and therefore may represent early indicators of the disease. In addition, loss of auditory function itself leads to communication difficulties, social isolation and poor quality of life for both patients with AD and their caregivers. Developing a greater understanding of auditory dysfunction in early AD may shed light on the mechanisms of disease progression and carry diagnostic and therapeutic importance. Herein, we review the literature on hearing abilities in AD and its prodromal stages investigated through methods such as pure-tone audiometry, dichotic listening tasks, and evoked response potentials. We propose that screening for peripheral and central auditory dysfunction in at-risk populations is a low-cost and effective means to identify early AD pathology and provides an entry point for therapeutic interventions that enhance the quality of life of AD patients.     

Prevalence, risk factors, and genetic diversity of Bartonella henselae infections in pet cats in four regions of the United States

Blood was collected from a convenience sample of 271 pet cats aged 3 months to 2 years (mean age, 8 months, median and mode, 6 months) between May 1997 and September 1998 in four areas of the United States (southern California, Florida, metropolitan Chicago, and metropolitan Washington, D.C.). Sixty-five (24%) cats had Bartonella henselae bacteremia, and 138 (51%) cats were seropositive for B. henselae. Regional prevalences for bacteremia and seropositivity were highest in Florida (33% and 67%, respectively) and California (28% and 62%, respectively) and lowest in the Washington, D.C. (12% and 28%, respectively) and Chicago (6% and 12%, respectively) areas. No cats bacteremic with B. clarridgeiae were found. The 16S rRNA type was determined for 49 B. henselae isolates. Fourteen of 49 cats (28.6%) were infected with 16S rRNA type I, 32 (65.3%) with 16S rRNA type II, and three (6.1%) were coinfected with 16S rRNA types I and II. Flea infestation was a significant risk factor for B. henselae bacteremia (odds ratio = 2.82, 95% confidence interval, 1.1 to 7.3). Cats >or=13 months old were significantly less likely to be bacteremic than cats 相似文献   

Relationship of internal-external control and United States suicide rates, 1973--1976.

Related annual variations in United States suicide rates between 1973 and 1976 to the concomitant annual variations in internal external (I-E) control scores obtained from a representative sample of the United States population. High scores indicated perceptions of external control. As predicted, I-E scores were correlated significantly with the increasing suicide rate of the total United States population and increased significantly for persons in the (15--24 and 25--34 year) age groups that displayed substantial linear increases in suicide rates, but did not increase significantly for Ss in the remaining age groups (which showed slight decreases in suicide rates). I-E scores were correlated significantly with the suicide rates of the other two (65--74, and 75--84 year) age groups that showed a linear decrease or substantial nonlinear fluctuation in suicide rates. Thus, linear or substantial nonlinear variations in suicide rates always were associated with corresponding variations in perceptions of external control.     

An expert system for diagnosis and therapy in lung transplantation

An expert system for diagnosis and therapy after lung transplantation has been developed and evaluated by domain experts. The system captures a total of 21 diagnoses encompassing rejection, pulmonary infection, and some diseases of gastrointestinal origin. The disease hypotheses are scored and ranked by their ability to explain the patient findings. A hypothesis is accepted as a candidate disease if it is ranked high on the list and is able to account for the cardinal findings of the disease. The therapy knowledge is captured in the form of rules. The results demonstrate the feasibility of an expert system for diagnosis and therapy after lung transplantation.     

Prevalence of cardiovascular and pulmonary diseases and risk factors by region and urbanization in the United States.

Cardiovascular and pulmonary mortality rates vary among US regions and places of varying levels of urbanization. Morbidity rarely has been analyzed within regions by urbanization level. Therefore, data from the National Health Interview Survey were examined for geographic patterns for 1983 through 1987. The most consistent finding was high rates of self-reported cardiovascular disease in non-metropolitan areas of the South. Otherwise, geographic variation of rates of self-reported disease prevalence with region and urbanization was not consistent across age and sex groups. Nor did rates consistently parallel patterns reported for mortality, with the exception of high rates in the nonmetropolitan South and relatively low rates in some groups in metropolitan areas outside central cities. Heart disease and ischemic heart disease patterns did not parallel patterns of high blood pressure, smoking, or low education, except for the tendency of all to be high in the nonmetropolitan South. In white men aged 45 to 64, the ischemic heart disease prevalence rate in the nonmetropolitan South was nearly twice that in the West or in the metropolitan Northeast. In blacks, rates of heart disease were lowest in metropolitan areas outside central cities and similar in central cities and nonmetropolitan areas. In the South, a similar pattern was seen in the only region with adequate numbers of nonmetropolitan-dwelling blacks in the sample. In blacks aged 45 to 64, rates of high blood pressure were lowest in metropolitan areas outside central cities and highest in nonmetropolitan areas, with little variation among regions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Serum paraoxonase activity is associated with variants in the PON gene cluster and risk of Alzheimer disease

Previous studies have shown association of single nucleotide polymorphisms (SNPs) in 3 contiguous genes (PON1, PON2, and PON3) encoding paraoxonase with risk of Alzheimer disease (AD). We evaluated the association of serum paraoxonase activity measured by phenyl acetate (PA) and thiobutyl butyrolactone (TBBL) with risk of AD and with 26 SNPs spanning the PON gene cluster in 266 AD cases and 306 sibling controls from the MIRAGE study. The odds of AD (adjusted for age, gender, and ethnicity) increased 20% for each standard deviation decrease in PA or TBBL activity. There were association signals with activity in all 3 genes. Haplotypes including SNPs spanning the PON genes were generally more significant than haplotypes comprising SNPs from 1 gene. Significant interactions were observed between SNP pairs located across the PON cluster with either serum activity measure as the outcome, and between several PON SNPs and PA activity with AD status as the outcome. Our results suggest that low serum paraoxonase activity is a risk factor for AD. Furthermore, multiple variants in PON influence serum paraoxonase activity and their effects may be synergistic.     

Cognitive behaviour therapy for schizophrenia -- a review of development, evidence and implementation

BACKGROUND: Schizophrenia and other psychotic disorders were once thought to be impervious to psychological treatments; however, there is accumulating evidence that cognitive behaviour therapy (CBT) can result in significant clinical benefit to these patients. AIM: This paper aims to describe the development and adaptation of CBT in the treatment of schizophrenia, to summarise the evidence to support CBT as a viable treatment and to outline some of the issues in 'rolling out' this treatment into normal clinical settings. RESULTS: A number of clinical models of CBT have been developed and these typically consist of a variety of clinical methods with different models providing differing emphasis. Twenty controlled trials of CBT in schizophrenia in which 739 patients were included are reviewed. These studies have a mean effect size for CBT of 0.37 (SD 0.39). There is consistent evidence that CBT reduces persistent positive symptoms in chronic patients and may have modest effects in speeding recovery in acutely ill patients. The evidence of CBT reducing relapse rates is equivocal, although targeted early intervention is promising. The available evidence suggests that CBT can be utilised effectively in routine clinical practice. However, the dissemination of novel psychological treatments into widespread clinical practice is not without difficulty, and issues pertaining to the 'roll-out' of CBT are discussed. CONCLUSIONS: CBT as an adjunct treatment shows considerable promise for the future treatment of schizophrenia.