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BACKGROUND: Practice volume may affect the outcome of patients with breast carcinoma. Defining factors that influence the relation of volume and outcome for the diagnosis and treatment of breast carcinoma is important, because breast carcinoma is common, and care is decentralized. METHODS: Community-wide diagnosis and treatment of mammogram-detected breast carcinoma was examined using claims data from a single insurer representing 25% of the regional population. Among 1001 mammogram-directed breast biopsies, the rate of breast carcinoma diagnosed by stereotactic core needle biopsy (SCNB) or excisional biopsy with needle localization (EBNL) and the rate at which breast-conserving surgery (BCS) was used were analyzed. Outcome and practice volume were examined for surgeons, radiologists, and medical centers. RESULTS: Two hundred twenty-four tumors were diagnosed by EBNL (604 diagnoses) and SCNB (397 tumors), for a 22.4% positive biopsy rate. The median number of procedures per physician was one. Positive biopsy rates for radiologists, surgeons, and medical centers did not correlate with practice volume. Positive biopsy rates for high-volume physician providers and medical centers ranged from 9% to 46%. The BCS rate was 45% and 64% for surgeons treating one or more than one claim, respectively. Tumor stage and surgeon case volume were the only independent predictors of BCS (P < 0.05). CONCLUSIONS: There is wide variation in diagnosis and treatment outcomes for patients with mammogram-detected breast carcinoma. Overall, practice volume was correlated with the use of BCS but not with the rate of positive biopsy. A wide variation in the positive biopsy rate among high-volume providers and medical centers suggests that volume of practice is not a surrogate for quality in the diagnosis of breast carcinoma.
In adapting quality improvement techniques originally developed by industry to an HMO medical delivery system, Harvard Community Health Plan (HCHP) applied the Shewhart quality improvement cycle (QIC) to colorectal cancer detection. An initial increase in the number of members routinely tested led to a second QIC to improve consistency of clinical evaluation of members with positive fecal occult blood test results. The successful use of these QICs suggests that similar techniques have a role in improving basic clinical skills and in the evaluation and therapy of common clinical conditions.
This study substantiates a previous report concerning the importance of the urban community hospital, particularly its emergency room, in the detection of gonorrhoea in women. Pelvic inflammatory disease (PID), a major complication of gonorrhoea in women, significantly declined during a nine-year surveillance and control programme in the Memphis-Shelby County area. This suggests that the programme may have prevented PID developing in women through the early detection and treatment of asymptomatic infections.
Wastewater-based surveillance has garnered increasing attention as a valuable approach for capturing community-level infection dynamics that are often difficult to detect through clinical reporting systems alone. In this study, we analyzed human norovirus genotype distributions and whole-genome-level variations in wastewater samples collected in Gwangju, Korea. These results were interpreted in conjunction with a documented foodborne outbreak to evaluate the epidemiological relevance of wastewater-based monitoring. Human norovirus concentrations were quantified using TaqMan Array Card-based RT-qPCR, and whole-genome next-generation sequencing (NGS) was performed to obtain viral read counts and reads per kilobase per million filtered reads values. Overall, strong correlations were observed between RT-qPCR-based concentrations and NGS-derived metrics. Genotype dynamics varied among wastewater treatment plants, reflecting differences in catchment size and local population characteristics. In particular, the relative abundance of GII.17[P17] increased during epidemiological week 50, temporally coinciding with a documented local foodborne outbreak. Variant analysis revealed that wastewater samples exhibited mixed nucleotide patterns, with multiple alleles coexisting at varying relative frequencies rather than fixed substitutions. Notably, some nonsynonymous variants detected in clinical samples were also observed in wastewater samples collected surrounding the outbreak period. Together, these findings demonstrate that wastewater-based whole-genome surveillance can capture both genotype-level shifts and nucleotide-level dynamics at the population scale, highlighting its potential as a complementary tool for monitoring community-level norovirus circulation and outbreak-associated genotype dynamics.IMPORTANCEWastewater-based surveillance is increasingly recognized as a promising approach for capturing community-level infection dynamics that are often missed by clinical surveillance. In this study, we applied whole-genome sequencing to wastewater samples collected in Gwangju, South Korea, to comprehensively characterize human norovirus genotype distributions and genetic variation. Distinct genotype patterns were observed across wastewater treatment plants, reflecting differences in catchment population size and local characteristics. Notably, an increase in the GII.17[P17] genotype detected in wastewater coincided with a foodborne outbreak investigated in Gwangju, demonstrating the potential of wastewater surveillance to reflect ongoing community transmission and emerging outbreak-associated genotypes. In addition, wastewater samples contained diverse and coexisting genetic variants, capturing population-level viral diversity and evolutionary dynamics that are not readily detected through clinical surveillance alone. These findings highlight the value of wastewater-based whole-genome surveillance for monitoring community-level viral circulation and support its integration as a complementary strategy to existing clinical surveillance systems.
A liquid chromatography-tandem mass spectrometric (LC-MS/MS) method for the quantitative determination of diclazuril in poultry tissues and feed is presented. A simple clean up with an organic solvent was carried out. A reversed-phase C(18) column was used for the high-performance liquid chromatography (HPLC) to separate the analyte with a gradient of acetonitrile and water as mobile phase. The precursor ions produced by electrospray negative ionization were selected for collisional dissociation. Validation of the methods was performed based on Commission Decision 2002/657/EC (Off. J. Eur. Communities 2002, L221, 8-36). For the detection of diclazuril in poultry meat, the decision limit was found to be 0.5 microg/kg. An animal experiment was set up in which 70 chickens were held for 6 weeks. From day 22 until day 32, they were fed feed containing 730 microg/kg diclazuril. From day 33 until day 42, every day six chickens were slaughtered, and breast, thigh, and liver were analyzed. Average steady-state concentrations of 94, 135, and 722 microg/kg in breast, thigh, and liver were obtained, respectively. Nine days after withdrawal of the medicated feed, diclazuril was still present in the different sample types.
We aimed to detect new cases of konzo and monitor cyanogen exposure from cassava flour in communities previously affected by konzo epidemics in Nampula Province, northern Mozambique. Other objectives were to detect subclinical upper motor neuron damage in schoolchildren and test a new kit to measure urinary thiocyanate concentration. In 1999 and 2000, we carried out active and passive case detection for konzo in Memba and Mogincual Districts. In July and October, 1999, we collected cassava flour from 30 houses in three communities and measured cyanogen concentrations with a picrate kit. In October 1999, we examined all schoolchildren in three communities for ankle clonus and measured urinary thiocyanate concentration in thirty schoolchildren in each of five communities with a picrate kit. We found 27 new cases of konzo in Mogincual District. Mean total cyanogen concentrations in cassava flour varied between both seasons and years, but were always high, ranging from 26 to 186 ppm. Very high mean levels at three sites in November 1998 and July 1999 were probably due to low rainfall in the 1997-1998 season. The proportion of schoolchildren with ankle clonus varied from 8 to 17%. The new picrate kit for urinary thiocyanate worked well; mean concentrations in schoolchildren ranged from 225 to 384 micromol x l(-1). Konzo and sub-clinical upper motor neuron damage persist in poor rural communities in northern Mozambique, associated with high cyanogen concentrations in cassava flour and high urinary thiocyanate concentrations in schoolchildren.
INTRODUCTION: Identifying communities with lower rates of mammography screening is a critical step to providing targeted screening programs; however, population-based data necessary for identifying these geographic areas are limited. This study presents methods to identify geographic disparities in the early detection of breast cancer. METHODS: Data for all women residing in Dane County, Wisconsin, at the time of their breast cancer diagnosis from 1981 through 2000 (N = 4769) were obtained from the Wisconsin Cancer Reporting System (Wisconsin's tumor registry) by ZIP code of residence. Hierarchical logistic regression models for disease mapping were used to identify geographic differences in the early detection of breast cancer. RESULTS: The percentage of breast cancer cases diagnosed in situ (excluding lobular carcinoma in situ) increased from 1.3% in 1981 to 11.9% in 2000. This increase, reflecting increasing mammography use, occurred sooner in Dane County than in Wisconsin as a whole. From 1981 through 1985, the proportion of breast cancer diagnosed in situ in Dane county was universally low (2%-3%). From 1986 through 1990, urban and suburban ZIP codes had significantly higher rates (10%) compared with rural ZIP codes (5%). From 1991 through 1995, mammography screening had increased in rural ZIP codes (7% of breast cancer diagnosed in situ). From 1996 through 2000, mammography use was fairly homogeneous across the entire county (13%-14% of breast cancer diagnosed in situ). CONCLUSION: The percentage of breast cancer cases diagnosed in situ increased in the state and in all areas of Dane County from 1981 through 2000. Visual display of the geographic differences in the early detection of breast cancer demonstrates the diffusion of mammography use across the county over the 20-year period.
Mammography is an important tool in the early detection of breast cancer, but its use has been criticized for stimulating the performance of unnecessary breast biopsies. We retrospectively reviewed the results of breast biopsies preceded by abnormal mammograms at a community hospital for three 5-month periods--baseline, postintervention, and follow-up--to determine the effectiveness of algorithm-based care for patients with an abnormal mammogram. Cases in which there was a definite or implied recommendation for biopsy by a radiologist revealed a baseline positive predictive value of 4% (2/45), a postintervention positive predictive value of 21% (9/42), and a follow-up phase positive predictive value of 18% (5/28). A Fisher's exact test of the preintervention and postintervention positive predictive values after an abnormal mammogram with a "recommendation for biopsy" was significant (n = 87, P = .023). A Kruskal-Wallis analysis of variance to determine if there had been an increase in the mean lesion size of breast cancers detected over the 3 study periods was not significant. The results of this study suggest that developing a clinical algorithm under the leadership of an opinion leader combined with continuing medical education efforts may be efficacious in reducing the incidence of unnecessary surgical procedures.
OBJECTIVE: To evaluate the impact of interventions by a community-based organization on immunization rates. DESIGN: Controlled community intervention trial. SETTING AND PARTICIPANTS: Children aged 3 to 59 months in Fulton County, Georgia, who were patients of 1 of 4 public clinics (clinic based), or residents of 1 of 9 inner-city communities (residence based). INTERVENTIONS: (1) Clinic-based intervention included monthly review of clinic vaccination records to identify undervaccinated children followed by contact with family (reminder-recall strategy); (2) residence-based intervention included door-to-door assessment and education campaigns followed by mobile van vaccinations, temporary on-site vaccination stations, free child care and transportation to providers, incentives of food and baby products, focus groups, and coalitions with local organizations (community saturation with vaccination messages and opportunities). OUTCOME MEASURES: Change in vaccination rates after 1 year based on clinic record reviews and population surveys. RESULTS: For clinic-based intervention, series completion rates improved from 43% (87/204) to 58% (99/170) in intervention clinics (P=.003), while rates in control clinics did not change from the baseline of 52% (81/157 to 78/150), for a net difference between intervention and control arms of +15 percentage points (P=.046). For residence-based intervention, age-appropriate vaccination rates improved from 44% (154/347) to 61% (260/429) in intervention communities (+17 percentage points; P<.001) compared with improvement of 44% (78/178) to 58% (129/221) for control communities (+14 percentage points; P=.004), but the difference between arms was not significant (+3 percentage points, P=.78). CONCLUSIONS: Reminder-recall activities by the community-based organization improved vaccination rates in intervention clinics compared with control clinics. A statistically significant impact on vaccination rates could not be detected for residence-based interventions by the community-based organization.
OBJECTIVE: The objectives of this study were to 1. assess the knowledge and attitude of the 5th year female medical students towards the objective structured examination in general and in Community Medicine in particular prior to the exam, 2. Detect any change in students' knowledge and attitude after passing the exam, 3. Identify the students' evaluation for future objective structured examination in Community Medicine and Primary Health Care and 4. Compare the students' performance in the objective structured examination in Community Medicine and Primary Health Care to the results of multiple choice questions evaluation in the department. METHODS: There were 2 data sets, the first was collected by self-administered pre and post-objective structured examination questionnaires from all female medical students in the 5th year during the academic year 1996-1997 and the 2nd was copied from the students' results for objective structured examination and multiple choice questions in the department of Community Medicine and Primary Health Care during same academic year. RESULTS: All the 34 5th year female medical students were enrolled in the study. Most of them reported that they did not receive enough information prior to the objective structured examination and most of their knowledge came from side chats with friends or staff members which was confirmed by their weak knowledge and negative attitude towards the objective structured examination prior to the exam. After setting the objective structured examination, students' knowledge and attitude towards objective structured examination markedly improved and the majority displayed its advantage as an assessment tool and were convinced of its suitability for medical practice in general and community medicine in particular. Most students believed that objective structured examination in Community Medicine and Primary Health Care met their expectations and recommended it for the coming years. Also, students stated the negative and positive aspects that should be considered for future assessments. Moreover, the multiple choice questions were nearly similar and there was a significant correlation between both scores. CONCLUSION: The 5th year female medical students did not receive enough information and training on the objective structured examination which influenced their attitude prior to the exam. However, most of them showed a positive attitude after the experience and their marks in the objective structured examination were comparable to their marks in the multiple choice questions. The objective structured examination is a popular method of assessment in medical practice worldwide. The decision to discontinue its use after only one year did not allow space of time for evaluation of its appropriateness as an assessment tool. More research is recommended to study the main causes that lead to disregarding this type of medical assessment in the College of Medicine at King Abdulaziz University.
The effects of pollution by organic matter, oil or industrial waste on marine communities are remarkably similar. Diversity values fall, biomass and numbers of organisms initially rise and then fall as the pollution load is increased. Diversity indices are, however, insensitive to pollution-induced changes and have to be assessed subjectively. Departure from a log-normal distribution of individuals among species offers a sensitive and objective method of assessing perturbation effects on communities. Under severe pollution stress, the dominant species are those which have a flexible life-history ranging from direct development to a planktonic larva and the ability to undergo short-term genetic selection. Species have a somewhat less flexible life-history strategy show increased abundance under conditions of slight pollution. The increase in abundance of seven or eight neither rare nor common species, which gives the departure from a log-normal distribution, is suggested as being the most significant and the earliest detectable change caused by pollution in a community. Thus the presence of a species in a polluted area may be more a question of life-history strategy than the tolerance of adverse environmental conditions. If this hypothesis is correct, considerable doubt must beplaced on the ecological relevance of data from toxicity tests.
PURPOSE: High myopia in childhood is associated with important ocular and systemic conditions. However in the UK, high myopia in early childhood is not specifically identified in current ophthalmology, optometry, or orthoptic protocols for screening, referral, or investigation. An ongoing study in the West Midlands, UK, is investigating high myopia presenting to community health care clinics with the aim of compiling guidelines for assessment and subsequent referral. METHODS: Children with high myopia were identified from community optometric and orthoptic sources and invited for an ophthalmology and optometry examination to ascertain possible ocular or systemic disease. RESULTS: High myopia with no associated ocular or systemic condition was present in 15 (56%) of the children. In seven children (25%), associated ocular problems were found including unrecognized retinal dystrophies and amblyopia. Systemic disorders associated with high myopia were found in five children (19%) and included Sticklers syndrome, Weill-Marchesani syndrome, and homocystinuria. In one child, the diagnosis made before this study was found to be incorrect, and in another child, the results were inconclusive. In two cases, the diagnosis of a systemic condition in the child led to the identification of the disease in at least one relative. CONCLUSIONS: There is a high prevalence of ocular and systemic abnormality in young children seen in the community. Optometric and ophthalmologic assessment of children less than 10 years with myopia > or =5 D is likely to identify significant ocular or systemic disease, a proportion of which will respond to medical intervention. Detection and prompt referral of these cases by community health care services may be expected to prolong vision and possibly life expectancy.
To determine whether outpatient medical care obtained at federally funded rural community health centers (CHCs) in Maine acts primarily as a substitute or as a complement to inpatient care, a study of 36 communities served by CHCs was conducted. The hospital use of CHC users (age- and sex-adjusted admissions, days, and length of stay) was compared with that of nonusers from the same communities in 1980. Statistically lower rates of hospital admissions and days were observed for all CHC patients and for selected groups based on their age, sex, and insurance status (specifically Medicaid or Medicare). Hospital use of CHC community populations was then compared with that of 24 comparison communities without access to CHCs, using multiple linear regression in a pre/post design. The model tested, which included rates of health center use, insurance penetration, poverty, and hospital availability, among other factors, did not detect any differences in hospital use between CHC community and comparison populations. These results and additional data presented on selected hospital diagnoses and insurance coverage suggest that treatment, and hospitalization incentives, of CHC providers may reduce hospitalization. Clinic providers lack the economic, professional, and institutional incentives to hospitalize. Additional study to determine the actual substitutability effect is indicated.
A Bayesian approach to overcome the imperfections of an immunological test (an antibody-based ELISA) and a parasitological test (Kato-Katz) in the detection of Schistosoma japonicum infection, was used to estimate community prevalences of S. japonicum infection in China. At the same time, the similarity between the prevalence estimates based on data from ELISA alone and those using data from both ELISA and Kato-Katz tests was explored. The database from the third nationwide sampling survey of schistosomiasis in China, 2004, was used for analysis, in which a total of 239 endemic villages were sampled from seven endemic provinces through a stratified cluster sampling technique and 250,987 residents aged from 6 to 65 years, were examined by ELISA followed by a Kato-Katz test applied to the seropositives. Bayesian hierarchical models incorporating random effects to reflect the nested data structure and uncertainty about test properties were employed to analyse the data. Our analysis suggested that using data from ELISA alone or both ELISA and Kato-Katz tests resulted in similar prevalence estimates, probably owing to the lack of sensitivity of Kato-Katz and the fact that Kato-Katz was only applied to the seropositives. We conclude that it is feasible to employ only ELISA, instead of combined ELISA and Kato-Katz tests, to estimate prevalence of S. japonicum infection in large-scale epidemiological settings. This study confirmed heterogeneity in the prevalence of S. japonicum infection in space by the fact that the estimated prevalences of S. japonicum infection in the sampled villages ranged from 0.02% to about 56% (posterior median). It is indicated that the disease remains a threat in some areas along the Yangtze River, although great achievements have been made in the control programme of schistosomiasis in China.
A DNA macroarray was developed and evaluated for its potential to distinguish variants of the dinitrogenase reductase (nifH) gene. Diverse nifH gene fragments amplified from a clone library were spotted onto nylon membranes. Amplified, biotinylated nifH fragments from individual clones or a natural picoplankton community were hybridized to the array and detected by chemiluminescence. A hybridization test with six individual targets mixed in equal proportions resulted in comparable relative signal intensities for the corresponding probes (standard deviation, 14%). When the targets were mixed in unequal concentrations, there was a predictable, but nonlinear, relationship between target concentration and relative signal intensity. Results implied a detection limit of roughly 13 pg of target ml(-1), a half-saturation of signal at 0.26 ng ml(-1), and a dynamic range of about 2 orders of magnitude. The threshold for cross-hybridization varied between 78 and 88% sequence identity. Hybridization patterns were reproducible with significant correlations between signal intensities of duplicate probes (r = 0.98, P < 0.0001, n = 88). A mixed nifH target amplified from a natural Chesapeake Bay water sample hybridized strongly to 6 of 88 total probes and weakly to 17 additional probes. The natural community results were well simulated (r = 0.941, P < 0.0001, n = 88) by hybridizing a defined mixture of six individual targets corresponding to the strongly hybridizing probes. Our results indicate that macroarray hybridization can be a highly reproducible, semiquantitative method for assessing the diversity of functional genes represented in mixed pools of PCR products amplified from the environment.
OBJECTIVE: To examine local procedures for assessment of attention deficit hyperactivity disorder (ADHD) and its management with psychostimulant medication and to compare these with published practice guidelines. DESIGN: Retrospective postal survey. PARTICIPANTS: Parents of children living in the Hunter region of New South Wales first prescribed psychostimulants between 1992 and 1994. MAIN OUTCOME MEASURES: Procedures for diagnostic assessment, treatment monitoring and continuing management. RESULTS: 788 parents (60%) responded. Diagnostic assessment procedures complied with published guidelines for about 70%, and detection of comorbid conditions was consistent with community prevalence estimates. There was systematic assessment of treatment response with questionnaires in only a third. Some children with academic or behavioural problems (19%-24% and 32%, respectively), almost 50% with emotional problems and 63% with motor problems were not receiving treatment for these difficulties. Modal interval for review was six months. Trials off medication were most commonly during school holidays, contrary to recommendations of the New South Wales Health Department. Most parents reported considerable improvement in their children's quality of life with medication. CONCLUSIONS: Problems comorbid with ADHD are detected often. Areas of deficiency in management of ADHD include the low rate of contact with schools for diagnostic assessment and determining treatment efficacy, poor support for comorbid problems, infrequent review, and inadequate methods for determining need to continue treatment.
BACKGROUND: Sensitivity and specificity of latex agglutination test on samples obtained by transthoracic needle aspiration was evaluated for diagnosis of pneumococcal pneumonia by using the polymerase chain reaction as reference method. METHODS: Samples from 29 patients with community acquired pneumonia were processed for culture, antigen detection and polymerase chain reaction. The latex agglutination test was performed with a reagents kit (Slidex méningite kit, BioMérieux, France) using the procedure recommended by the manufacturer. The polymerase chain reaction was carried out by using two primers: Pn2x up and Pn2x down that amplify the PBP2x gene of Streptococcus pneumoniae. RESULTS: Culture was positive in 5 patients, antigen detection in 15 and polymerase chain reaction in 14 patients. The specificity of latex agglutination test was 93% compared with polymerase chain reaction as reference method. CONCLUSION: The pneumococcal antigen detection by latex agglutination test is as sensitive as the polymerase chain reaction, it seems to be highly specific, and it is rapid and easy to perform.