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PubMed1997

Outcomes of stroke patients in Medicare fee for service and managed care.

CONTEXT: Increasing numbers of Medicare beneficiaries have been enrolling in health maintenance organizations (HMOs) because HMO participation reduces out-of-pocket expenses, and the federal government views HMOs as a way to contain Medicare costs. However, results comparing outcomes and quality of care in HMOs vs fee for service (FFS) have been mixed, and outcomes after stroke have not been adequately assessed. OBJECTIVE: To compare discharge destinations and survival rates following stroke in Medicare HMOs with similar FFS settings. DESIGN: An observational study for 2 groups evaluating stroke patients' discharge destinations and survival times from the date of hospital admission. SETTING: A total of 19 HMOs were selected from 12 states. The FFS sample was drawn from the same geographic areas. PATIENTS: The sample included 402 HMO patients from 71 hospitals and 408 FFS patients from 60 hospitals. PROCESS AND OUTCOME MEASURES: Data were abstracted from medical records on demographics, clinical characteristics of stroke, comorbid illnesses, and discharge destinations following hospitalization. Data on survival were obtained from Medicare files and included 25 to 37 months of follow-up (median, 30.4 months, HMO; 31.1 months, FFS) from the date of hospital admission. RESULTS: There were 109 patients who died during the hospitalization (49 HMO, 12.2%; 60 FFS, 14.7%), and a total of 410 patients had died by the end of follow-up (191 HMO, 47.5%; 219 FFS, 53.7%). Approximately one fourth of both groups had do-not-resuscitate orders (HMO, 25.4%; FFS, 27.9%; P=.68). After controlling for age, marital status, and characteristics of dependency at discharge, HMO patients were more likely than FFS patients to be sent to nursing homes (HMO, 41.8%; FFS, 27.9%; P=.001) and less likely to be discharged to rehabilitation hospitals or units (HMO, 16.2%; FFS, 23.4%; P=.03). At follow-up, no significant differences in relative risk of dying were found between HMO and FFS groups (relative risk, 0.96; 95% confidence interval, 0.73-1.26; P=.77). CONCLUSIONS: Patients in Medicare HMOs who experience strokes are more likely to be discharged to nursing homes and less likely to go to rehabilitation facilities following the acute event. However, they have similar survival patterns compared with comparable patients in FFS settings after adjusting for other factors.

Aged↗

PubMed1997

[Immunocompromised travelers].

More and more immunocompromised people travel abroad especially in tropical countries where infectious risks are high. Before leaving, these subjects must consult their general practitioner who will determine their fitness in function of type of immunodeficiency, travel destination, availability of medical care at the destination, and possibility of medical evacuation. Counseling should also be provided concerning the precautions necessary to avoid the hazards of exposure to fecal material, venereal disease, insect bites, and sun. Antimalarial drug prophylaxis is the same as for uncompromised subjects. Advising immunocompromised subjects about vaccinations is difficult since there is no consensus on the subject. Administration of inert vaccines is usually recommended but their effectiveness is often diminished and harmful effects have been observed in HIV-infected subjects. Administration of live vaccines is always contraindicated in severely immunocompromised subjects but some live vaccines can be used in moderately immunocompromised subjects. The guidelines for vaccination differ depending on the underlying cause of immunodeficiency: congenital defects, cancer, hemopathy, treatment with immunosuppressors or corticosteroids (transplant patients and patients with systemic disease), HIV-infection, or spleen dysfunction. If there is a high risk of contracting a disease for which vaccination is contraindicated, drug prophylaxis or administration of immunoglobulins can be an alternative. If not, travel should either be postponed or the destination should be changed.

Counseling↗

PubMed1976

Port health problems.

As quarantine control of international travellers dies away, health screening of immigrants becomes more important. Port health controls attempt to identify the sick immigrant, thereby limiting disease spread among susceptibles and sparking early treatment. Port health controls also ease the impact of immigrants arriving at destinations by alerting relevant authorities so that they can begin health education procedures early, if they wish. Two problems arise: some destination authorities make little attempt to trace their immigrants and even those that do cannot find more than 70 per cent so notified. For receiving communities the most important disease the immigrant may carry or later develop is tuberculosis. In the indigenous population the incidence of this disease is decaying exponentially but, in communities of recent immigrants, may be stable or even rising. This means that in about ten years the great majority of new tuberculosis cases will be in recent immigrants, unless better preventive techniques are used. The overall trend is likely to be a fall in the number of cases, but the disproportion may provoke problems. What can be done? Assuming incoming immigrants are typical of their country of origin, many must enter Britain mantoux-negative, a fact supported by various destination authorities here which have performed testing. So, the logical solution is to ensure that all receive BCG vaccination, preferably before they migrate or otherwise as they enter Britain, and to ensure their babies born later in Britain also receive the protection of BCG vaccination. Consumption of medical services by the travelling public increases with the number of travellers and, as more people penetrate romantic but unhealthy areas formerly inaccessible, importation of communicable disease also increases. Many of these diseases could be prevented by good advice but, unfortunately, unfamiliarity blunts the edge of prophylaxis and diagnosis. Airport experience indicates that the general practitioner could help his patient more, particularly the overlander, by discussing sanitary precautions and suggesting anti-malarial drugs and immunization against typhoid and infectious hepatitis, when appropriate. Vaccination against smallpox, cholera or yellow fever may be obligatory and a valid certificate required; inoculation against diphtheria, poliomyelitis or tetanus may be sensible, and against rabies if the traveller may come into contact with animals abroad. Although complex queries about health hazards abroad should be addressed to such research centres as the Ross Institute, I suggest much practical advice can be obtained by phoning Heathrow health control 01-759 4361.

Communicable Disease Control↗

PubMed1997

Internal migration patterns for U.S. foreign-born, 1985-1990.

"Using 1990 census data, this paper calculates the flow [of the foreign-born population in the United States] between states and from abroad; also, a multinomial logistic regression model of destination choice is estimated for resettlers and for migrants from abroad. There are three major findings. Firstly, Florida and California are the largest recipients of foreign-born resettlers; New York is the biggest loser of secondary migrants. Secondly, the presence of large communities of Mexicans in California and Cubans in Florida are very attractive to both resettlers and migrants from abroad. Thirdly, immigrants that are most in need of ethnic support networks (i.e. new arrivals or immigrants with low human capital resources) are most likely to choose one of the traditional immigration states as a destination."

Americas↗

PubMed1997

The selection of internal migration models for European regions.

"A full multiregional projection model requires migration data that are simultaneously classified by age and gender and region of origin and region of destination. Except for a very small number of regions, these data requirements are so high that aggregation of the data (which is equivalent to simplification of the model) is called for. This paper investigates the extent to which the full internal migration matrix can be simplified without seriously affecting the performance of the resulting multiregional model. Using IPF (iterative proportional fitting) methods, a log-linear analysis of alternative model specifications is made, using data for Italy, the Netherlands and the UK....A reasonable balance between goodness-of-fit and parsimony is found for the model in which time interacts with the main effects only (i.e. with age/sex, with origin and with destination)."

Age Factors↗

PubMed1998

Leaving home in Spain: a regional analysis.

"This paper compares regional patterns of leaving home in Spain during the 1970s and 1980s based on analysis of the 1991 Spanish Sociodemographic Survey. The purpose of this analysis is to demonstrate that while nationally Spain is representative of a southern European pattern of leaving home, (i.e. relatively late and closely associated with partnership formation), there is considerable regional variation in timing, incidence and initial destinations on leaving home. These differences are explored using hazard rates of leaving home by destination and birth cohort for 11 Spanish regions."

Cohort Studies↗

PubMed1989

Use and misuse of the allocation rate in models of population migration.

In empirical work on population migration, researchers have utilized many different measures of migration. 1 measure that is used periodically is an "an allocation rate", most commonly defined as the number of persons moving from origin i to destination j during the period. While an allocation rate is a valid and interesting measure, it has been misunderstood in several instances, leading to some empirical results that are difficult to interpret. In this paper, previous work on allocation rates is discussed, and 1 study is replicated for the 1975 to 1980 period. It is demonstrated that inclusion of origin variables in such models is theoretically incorrect and results in substantial biases in empirical work. Inclusion of ratios of destination-to-origin variables is valid only with a very narrow interpretation.

Bias↗

PubMed1997

Explaining hierarchical and interprovincial migrations of Chinese young adults by personal factors and place attributes: a nested logit analysis.

"This paper uses a two-level nested logit model to explain the inter-stratum (city, town and rural county) and interprovincial migration behaviors of the young adults (aged 17-29) in China during a three-year period (1985-87), based on the micro data of the 1987 National Population Survey. The migration propensity of each person is represented by a departure probability and a destination choice probability. These probabilities are then expressed as functions of personal factors and place attributes. The main findings are that personal factors are of paramount importance in explaining the departure behaviors, and that both departure and destination behaviors responded to market forces in a sensible way, despite government control on territorial movements."

Asia↗

PubMed1988

Socio-economic stratification generated by international migration loops.

This paper analyzes the migration phenomenon within a framework that treats migration movements as continuous loops, from the country of origin to the destination and back. Significant social-psychological factors at each step of the loop process contribute to the development of migration streams along a predictable pattern. The general model of the loop process shows that the migration stream is 1st sparked when labor is recruited from less developed countries for work in developed industrialized countries. Once the social process of migration has begun, it tends to acquire a self-feeding character. Social and economic change in sending and receiving societies brought about by migration make further migration more likely. The case of the Mexico-US-Mexico loop process is analyzed. This case illustrates the effects of socioeconomic stratification that occurs in communities where the migration loop process reaches a certain level of maturity. The majority of a town's population may become committed to migration as a way of life. Eventually, wealth becomes concentrated in the hands of those that are most able to migrate. Thus, migrants may become a new elite segment of rural populations that were once relatively homogenous societies. Further research of the migration loop process should be conducted. At least in the case of Mexico, the socioeconomic stratification in the villages and towns acting as sources of migration loops with destinations in the US have significant internal economic, social, and political implications.

Americas↗

PubMed1987

[Selectivity of rural migrants from the Sierra of Ecuador].

"This paper examines characteristics of recent rural-urban out-migrants leaving households in the Sierra of Ecuador. A large, household survey focussing specifically on migration is utilized, allowing detailed crosstabulations by sex and origin-destination combination and providing information about migrants generally not found in more generic surveys or censuses. Differences are noted between migrants and non-migrants in basic demographic characteristics, reasons for migrating, and economic activities prior to and subsequent to moving. Differences in the characteristics of migrants moving between various types of place of origin and place of destination are also noted." (SUMMARY IN ENG)

Americas↗

PubMed1994

Income redistribution and migration.

"This paper analyses redistribution policies that transfer income between owners of immobile factors of production and workers in a given region. The menu of income distribution possibilities attainable through tax/transfer policy in the presence of labour mobility is characterized. Simple general equilibrium analysis shows that migration can lead to Pareto-inferior outcomes in the destination region if immigrants are the beneficiaries of redistributive transfers. All residents of the destination region may gain, however, if transfer payments are also paid to workers in the source region so as to reduce the level of immigration." (SUMMARY IN FRE)

Demography↗

PubMed1994

Explaining immigrant naturalization.

"Prior research on immigrant naturalization has focused mainly on the effects of immigrants' adaptation experiences and demographic characteristics on their propensity to naturalize. This article proposes a broader analytical framework which incorporates immigrants' individual characteristics and larger social contexts in the country of origin and the country of destination to explain the likelihood of citizenship acquisition. The framework is tested for a cohort of recent immigrants, using the PUMS data from the 1980 U.S. census. The results show that economic, political, social, cultural and geographical conditions in the country of origin, and immigrants ethnic communities and urban concentration in the country of destination, to a large extent influence immigrants' propensity for naturalization and that, net of the contextual factors, many of the immigrants' adaptation and demographic characteristics are also significant predictors of citizenship acquisition."

Acculturation↗

PubMedDate not supplied

Etiology and outcome of fever after a stay in the tropics.

BACKGROUND: Information on epidemiology and prognosis of imported fever is scarce and almost exclusively limited to hospital settings. METHODS: From 2000 to 2005, all travelers presenting at our referral outpatient and inpatient centers with ongoing fever within 12 months after a stay in the tropics were prospectively followed. Case definitions and treatment were based on international recommendations. Outcome was assessed by at least 1 follow-up consultation or telephone call within 3 months after initial contact. RESULTS: A total of 1842 fever episodes were included, involving 1743 patients. Regions of exposure were mainly sub-Saharan Africa (68%) and the Southeast Asia-Pacific region (12%). Tropical diseases accounted for 39% of all cases and cosmopolitan infections for 34%. Diagnosis often remained unknown (24%). The pattern of tropical diseases was mainly influenced by the travel destination, with malaria (35%, mainly Plasmodium falciparum) and rickettsial infection (4%) as the leading diagnoses after a stay in Africa; dengue (12%), malaria (9%), and enteric fever (4%) after travel to Asia; and dengue (8%) and malaria (4%) on return from Latin America. Disease pattern varied also according to the category of travelers, the delay between exposure and fever onset, and the setting. Hospitalization was required for 503 fever episodes (27%). Plasmodium falciparum malaria accounted for 36% of all admissions and was the only tropical cause of death (5 of 9 patients). Fever of unknown cause had invariably a favorable outcome. CONCLUSION: The clinical spectrum of imported fever is highly destination specific but also depends on other factors. Plasmodium falciparum malaria was the leading cause of mortality in the study population.

Adolescent↗

PubMed2001

Prediction of hemorrhagic transformation following acute stroke: role of diffusion- and perfusion-weighted magnetic resonance imaging.

BACKGROUND: Acute diffusion-weighted (DWI) and perfusion-weighted (PWI) magnetic resonance imaging (MRI) findings may correlate with secondary hemorrhagic transformation (HT) risk in patients with stroke. This information could be of value, particularly in individuals being considered for thrombolytic therapy. OBJECTIVE: To determine the relationship between DWI and PWI findings and the risk of secondary HT in patients with acute stroke. DESIGN: Retrospective case series. SETTING: Academic medical center. PATIENTS: Twenty-seven patients with acute stroke capable of being evaluated with DWI/PWI 8 hours or less after symptom onset. MAIN OUTCOME MEASURES: Apparent diffusion coefficient values, perfusion delay measurements, and subsequent MRI or computed tomographic scans detected HT. RESULTS: The mean +/- SD apparent diffusion coefficient of ischemic regions that experienced HT was significantly lower than the overall mean +/- SD apparent diffusion coefficient of all ischemic areas analyzed (0.510 +/- 0.140 x 10(-3) mm(2)/s vs 623 +/- 0.113 x 10(-3) mm(2)/s; P =.004). This difference remained significant when comparing the HT-destined ischemic areas with the non-HT-destined areas within the same ischemic lesion (P =.02). Patients receiving recombinant tissue-type plasminogen activator (rt-PA) experienced HT significantly earlier than patients not receiving rt-PA (P =.002). Moreover, a persistent perfusion deficit in the area of subsequent hemorrhage at 3 to 6 hours after the initial MRI scan was identified in significantly more patients who experienced HT than in those who did not (83% vs 30%; P =.03). CONCLUSION: Both DWI and PWI scans detect abnormalities that are associated with HT. These findings support a role for MRI in identifying patients who are at increased risk for secondary HT following acute ischemic stroke.

Acute Disease↗

PubMed2004

Prediction of hospital disposition after thrombolysis for acute ischemic stroke using the National Institutes of Health Stroke Scale.

BACKGROUND: Early determination of discharge destination after acute stroke may promote earlier rehabilitation and reduce costs by shortening the duration of hospitalization. OBJECTIVE: To determine whether the National Institutes of Health Stroke Scale (NIHSS) score predicts disposition in stroke patients treated with thrombolysis. DESIGN: Cohort study. SETTING: Academic and community hospitals from 3 countries. PATIENTS: Five hundred forty-six patients with acute ischemic stroke treated with recombinant tissue plasminogen activator (rt-PA). INTERVENTIONS: Medical records were reviewed for demographic information, vascular risk factors, location of stroke, initial NIHSS score, acute hospital disposition, and complications of symptomatic or asymptomatic intracerebral hemorrhage (ICH). MAIN OUTCOME MEASURE: Discharge destination to home, acute rehabilitation, or nursing facility. RESULTS: In multinomial regression analysis, increasing NIHSS score was a robust and independent predictor of discharge to rehabilitation or nursing facilities, roughly doubling for each 5-point increment. Patients who developed symptomatic ICH were never discharged to home, but asymptomatic ICH had no significant independent effect on disposition. CONCLUSIONS: Stroke severity as determined by the admission NIHSS score is the major independent predictor of disposition after hospitalization and treatment with rt-PA for acute stroke in a broad-based population. However, symptomatic ICH after rt-PA is a catastrophic event that may preclude discharge to home.

Acute Disease↗

PubMed1999

Embryological origin of interstitial cells of Cajal.

Until recently, the embryological origin of the interstitial cells of Cajal (ICC) within the intestine was unclear. An origin from the neural crest or from the mesenchyme was considered possible because ICC possess some characteristics in common with neural crest-derived cells, and some characteristics in common with cells derived from the mesenchyme. Experiments in both mammalian and avian species, in which segments of embryonic gut were removed prior to the arrival of neural crest cells and grown in organ culture, have now shown that ICC do not arise from the neural crest. It appears that ICC and smooth muscle cells arise from common mesenchymal precursor cells. From mid-embryonic stages, ICC precursors express Kit, which is a receptor tyrosine kinase. Both ICC and many smooth muscle cell precursors initially express Kit, and then the cells destined to become smooth muscle cells down-regulate Kit and up-regulate the synthesis of myofilament proteins, whereas cells destined to differentiate into ICC maintain their expression of Kit. Adult mice with mutations that block the activity of Kit have disrupted arrays of ICC, whereas normal ICC are present until shortly after birth in such mice. It, therefore, appears that the Kit signalling pathway in not necessary for the embryonic development of ICC, but rather the post-natal proliferation of ICC.

Animals↗

PubMed1997

Mechanistic studies of the degradation of juvenile hormone esterase in Manduca sexta.

The mechanisms of degradation of juvenile hormone esterase (JHE) were investigated in larvae of the tobacco hornworm, Manduca sexta. JHE is removed from the hemolymph by the pericardial cells by receptor-mediated endocytosis and is ultimately degraded in the lysosomes. Immunoprecipitation experiments and native PAGE followed by Western blotting showed that JHE associates with a putative heat shock cognate protein (Hsp). Approximately 25% of the active JHE in the pericardial cell complex is associated with the putative Hsp 1 h postinjection of affinity purified JHE. Electron microscope analysis revealed that the putative Hsp is located in the trans-Golgi network of pericardial cells, where it is hypothesized to be involved in sorting of proteins destined for the lysosomes, from those destined for the cell membrane. Data acquired from immunoprecipitation and Western blotting experiments argue against the involvement of ubiquitin in the degradation of JHE. Injection of radiolabeled JHE into larvae of M. sexta followed by SDS-PAGE of pericardial cell homogenates revealed covalent binding of an unidentified protein to JHE in the pericardial cell complex.

Animals↗

PubMed1999

Quantitative magnetic resonance imaging assessment of cerebral ischemia in rat using on-resonance T(1) in the rotating frame.

Sensitivity of T(1) in the rotating frame (T(1rho)) to both transient cerebral ischemia and cortical hypoperfusion was studied in rats. T(1rho) is believed to probe water in close contact with macromolecules, revealing water spins with restricted rotational mobility relative to bulk water. It is shown that T(1rho) increases within minutes of occlusion, thereby demonstrating it as a new, sensitive indicator of ischemia. After reperfusion at 90 minutes of middle cerebral artery occlusion, T(1rho) remains elevated or increases in tissue destined to neuronal damage but returns to the normal level if no neuronal damage develops within 24 hours. T(1rho) determined during the first 2 hours of reperfusion shows a significant positive correlation with the ultimate neuronal damage score. However, T(1rho) is not affected by acute hypoperfusion. These data show that, by combining three magnetic resonance imaging coefficients, i.e. T(1rho), T(2), and diffusion, viable hypoperfused areas that do not develop neuronal damage within 24 hours can be distinguished correctly from tissue already destined for neuronal damage. Magn Reson Med 42:268-276, 1999.

Animals↗