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In this study we investigated how ophiophagous snakes are able to ingest prey snakes that equal or exceed their own length. We used X-ray video, standard video, dissection, and still X-rays to document the process of ophiophagy in kingsnakes (Lampropeltis getula) feeding on corn snakes (Elaphe guttata). Most kingsnakes readily accepted the prey snakes, subdued them by constriction, and swallowed them head first. In agreement with previous observations of ophiophagy, we found that the predator snake forces the vertebral column of the prey snake to bend into waves. These waves shorten the prey's body axis and allow it to fit inside the gastrointestinal (GI) tract and body cavity of the predator. Dissection of a kingsnake immediately following ingestion revealed extensive longitudinal stretching of the anterior portion of the GI tract (oesophagus and stomach), and no visible incursion of the prey into the intestine. X-ray video of ingestion showed that the primary mechanism of prey transport was the pterygoid walk, with some contribution from concertina-like compression and extension cycles of the predator's vertebral column in two out of three observations. Complete digestion was observed in only one individual, as others regurgitated before digestion was finished. X-ray stills taken every 4 days following ingestion revealed that the corn snakes were about half digested within the first 4 days, and digestion was complete within 15 days.
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Using community-based surveillance data for pediatric human immunodeficiency virus (HIV) infection, we examined disease progression using survival analysis among perinatally HIV-infected children and children HIV-infected through a neonatal blood transfusion. As of December 31, 1991, 238 HIV-infected children (classified P-1 or P-2 according to the Centers for Disease Control and Prevention classification system) were identified. Median symptom-free survival time from birth to symptomatic infection (P-2) was different for perinatally acquired (n = 166) and neonatal transfusion-acquired (n = 72) infection (6.4 months vs. 17.8 months, respectively; P < 0.001). Survival after development of symptomatic infection (P-2) did not differ by transmission mode. Survival differences from birth to death were significant at P < 0.05 (75% of perinatally HIV-infected children survived 44 months vs. 71 months for transfusion-associated children). Although survival estimates improved for those receiving antiretroviral treatment, differences by mode were still observed. For perinatally HIV-infected children, mortality was highest in the first year of life (12%). Those remaining symptom-free beyond their first year demonstrated survival experiences similar to those for children with transfusion-associated infection.
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A number of modifications in patient selection, operative technique, and immunosuppressive management have greatly contributed to the success of the liver transplant program at CPMC. Graft rejection and the timely detection of EBV infection are ongoing problems in hepatic transplantation that are foci of active research in our field. To address these issues, our group is investigating the activity of cytokines and adhesion molecules using sophisticated molecular techniques, and we are developing a sensitive assay for EBV markers in blood. These and other projects currently in progress will continue when we move our liver transplant program to Stanford University Medical Center in January 1995.
This Special Report examines why the uninsured rate is so much higher in California than it is in the rest of the United States; it focuses on labor market and demographic characteristics that may explain the differential in health insurance coverage. California has the third-highest rate of uninsured for the nonelderly population in the United States, accounting for 16.6 percent of the total U.S. uninsured population. In 1998, 24.4 percent of the nonelderly population in California (both workers and nonworkers under age 65) was uninsured, compared with 18.4 percent uninsured in the United States as a whole. Only Arizona (with 27.2 percent) and Texas (with 27.0 percent) had higher uninsured rates than California. Among California workers ages 18-64, nearly 24 percent (or 3.8 million workers) were uninsured in 1998. Eleven years earlier, in 1987, 19.3 percent (or 2.7 million workers) were uninsured. During the decade 1987-1997, the percentage of California workers with employment-based health insurance declined from 68.5 percent to 64.2 percent. But more recently, between 1997 and 1998, the percentage of workers with employment-based coverage increased slightly from 64.2 percent to 65.5 percent. Fifty-three percent of California workers employed in the agriculture sector were uninsured in 1998. Overall, agriculture accounts for 4 percent of the jobs in California; however, agricultural workers accounted for 8 percent of the uninsured. Demographics are a key factor affecting California's rate of uninsured. Twenty-seven percent of California workers are Hispanic, more than three times the proportion in the rest of the United States. Compared with the rest of the country, California has fewer workers who are white (54 percent vs. 76 percent) or black (6 percent vs. 12 percent), and more workers who are Asian (12 percent vs. 3 percent). More than 43 percent of Hispanic workers in California were uninsured in 1998, compared with 14 percent of white workers, 24 percent of black workers, and 21 percent of Asian workers. California workers--and Hispanic workers in particular--are more likely to be employed by small firms, which are significantly less likely to offer health benefits than large firms. Forty-four percent of the California work force was employed by firms with fewer than 100 employees, or was self-employed, compared with 40 percent of the work force in the rest of the United States. Sixteen percent of all workers in California did not graduate from high school. Among Hispanic workers, 44 percent did not graduate from high school; among white workers, 13 percent did not graduate. In comparison, 18 percent of Asian workers and 7 percent of black workers did not graduate from high school. In California, 60 percent of Hispanics earning less than $7 per hour were uninsured in 1998. In contrast, 26 percent of whites, 46 percent of blacks, and 41 percent of Asians earning less than $7 per hour were uninsured.
OBJECTIVE: To evaluate the present and future supply of veterinarians in California, in light of changing trends in animal ownership. DESIGN: Database analysis. SAMPLE POPULATION: Human and animal populations, including populations of veterinarians, throughout the United States. PROCEDURES: Data on animal and human populations were compiled from a number of sources, including the US Census Bureau, American Veterinary Medical Association, State of California Department of Finance, and State of California Veterinary Medical Board. The distribution of veterinarians in California was contrasted with other health professionals in California and with that of veterinarians in other states. Recent changes in veterinary medical demographics in California were quantified and used to develop in-state projections about the supply of veterinarians for the next 20 years. RESULTS: Although California is the most populous of the 50 states, only 7 states had fewer veterinarians per capita. Furthermore, California ranked next to last among states in increase of number of veterinarians between 1990 and 1995. Los Angeles County had the smallest per-capita number of veterinarians among 9 populous California counties. During that period, California had a net gain of only 6 veterinarians who were exclusively or predominantly large-animal or mixed-animal practitioners. CONCLUSIONS AND CLINICAL RELEVANCE: If current trends continue, the per-capita number of veterinarians will continue to decrease in California. To maintain the current ratio of 17.8 veterinarians/100,000 people in California in the future, we estimate that an additional 50 veterinarians above the currently predicted increase will be required annually.
PURPOSE: Over the past 2 years, concerns have arisen about the adequacy of the supply of RNs in California and the rest of the United States. Nurse leaders have called upon the California State Legislature to respond to concerns by increasing funding for RN education at public colleges and universities. DESIGN: Descriptive--to ascertain whether California faces a shortage of RNs and whether greater state government funding of RN educational programs is necessary to alleviate such a shortage. Secondary data from several sources were analyzed. METHODS: Cross-sectional analysis of data from the 1996 National Sample Survey of Registered Nurses concerning California RNs' demographic characteristics and employment patterns was conducted. Longitudinal analysis of data was examined for trends in California's population, utilization of RNs, and graduations from RN education programs. FINDINGS: Approximately 230,000 RNs lived in and were licensed to practice in California; 77% of California RNs were employed in nursing (70% working full-time; 30% part-time). Only a small number of California RNs were not currently working in nursing but were likely to enter the labor market. Most RNs who were not working were older retired women. CONCLUSIONS: A large increase in the RN workforce is needed to keep pace with the rapid growth of California's population. For California to maintain a stable ratio of RNs to population, we estimated an additional 43,000 RNs will be needed by 2010, and an additional 74,000 will be needed by 2020. Educators, employers, and state policymakers should implement concerted and coordinated efforts to avert a shortage. The magnitude of the impending shortage of RNs in California is too large for the RN labor market to resolve. State government should provide additional resources for basic RN education programs.
According to the Centers for Disease Control (CDC) Survey of Dialysis Associated Diseases, California, which includes Network 17 and 18, had one of the lowest hepatitis B vaccination rates in the country for 1994, 1995, and 1996. With 3 outbreaks of hepatitis B (HBV) in California in 1994, hepatitis B vaccination was chosen as a quality improvement project in both Network 17 and 18. With input from both Medical Review Boards and HCFA Region X, a project was formulated which focused on the improvement of the number of facilities which had hepatitis B vaccination rates which are greater than 50%. The overall purpose of both projects was to: (1) achieve access to preventative services for end-stage renal disease (ESRD) Medicare beneficiaries; (2) increase the number of ESRD patients in California who are vaccinated for HBV; (3) eliminate dialysis in California as an independent risk factor for contracting HBV; (4) decrease the number of ESRD facilities with HBV vaccination rates of 0%; and (5) increase the number of ESRD facilities with HBV vaccination rates greater than 50%. In 1998, both Network 17 and 18 denominators were adjusted to reflect the population which is eligible for vaccination. Because of historically low vaccination rate in California, the 1998 data collection sought to ascertain precise numbers for the ESRD patient population. Data were used from the 1996 and 1997 CDC Survey of Dialysis Associated Diseases from baseline measurements of HBV vaccination rates for all facilities in both Network 17 and 18. The CDC did not conduct a survey in 1998, however, Network 17 and 18 conducted a survey of dialysis associated diseases for all of California ESRD facilities. A data collection tool was designed to gather information on processes and outcomes in each facility. This allowed a continuous quality improvement (CQI)-based approach to analyze the problem, where tools like cause/effect and Pareto diagrams provided information on factors and issues affecting low HBV vaccination rates. Interventions were designed to target those specific factors. Interventions included creation of the "Hepatitis Booklet" (Network 18) and the "Hepatitis Resource Guide" (Network 17); mailing of the resource material to all providers (Network 18), and with vaccination rates less than 50% (Network 17); development of facility specific profiles; and policy statements by both Medical Review Boards on Hepatitis B Vaccination. The number of ESRD patients in California who are vaccinated for HBV increased to 53% or 11,412 patients of 21,617 eligible patients in both Networks. The number of ESRD patients in California who are vaccinated plus those in the process of receiving the series brought the California vaccination rate of 72% or 15,653 for 21,617 eligible patients in both Networks. The number of ESRD facilities in California with HBV vaccination rates of 0% decreased to 10 facilities in 1998, from 75 facilities in 1997, and 135 facilities in 1996. The number of ESRD facilities in California with HBV vaccination rates more than 50% increased to 175 facilities, from 87 facilities in 1997, and 52 in 1996. The number of patients developing antibodies post-vaccine was 62% (Network 18). Facilities in Network 17 with vaccination rates exceeding 50% who did not receive the Hepatitis B Resource Guide vaccinated 44% of all patients vaccinated or in progress in Network 17 in 1998. Facilities in Network 17 with vaccination rates less than 50% who did receive the Hepatitis B Resource Guide vaccinated 57% of all patients vaccinated or in progress in Network 17. For the first time, vaccination rates were collected on peritoneal dialysis (PD) patients. In Network 17, 51% of PD patients are vaccinated versus 59% of hemodialysis patients. In Network 18, 48% of PD patients are vaccinated versus 48% of hemodialysis patients. Resource material and feedback reports developed by both Networks facilitated improvements in Hepatitis B vaccination of ESRD patients in Ca