California Department of Health Care Services

Following disastrous earthquakes in Alaska and in Niigata, Japan in 1964, Professors H. B. Seed and I. M. Idriss developed and published a methodology termed the “simplified procedure” for evaluating liquefaction resistance of soils. This procedure has become a standard of practice throughout North America and much of the world. The methodology which is largely empirical, has evolved over years, primarily through summary papers by H. B. Seed and his colleagues. No general review or update of the procedure has occurred, however, since 1985, the time of the last major paper by Professor Seed and a report from a National Research Council workshop on liquefaction of soils. In 1996 a workshop sponsored by the National Center for Earthquake Engineering Research (NCEER) was convened by Professors T. L. Youd and I. M. Idriss with 20 experts to review developments over the previous 10 years. The purpose was to gain consensus on updates and augmentations to the simplified procedure. The following topics were reviewed and recommendations developed: (1) criteria based on standard penetration tests; (2) criteria based on cone penetration tests; (3) criteria based on shear-wave velocity measurements; (4) use of the Becker penetration test for gravelly soil; (4) magnitude scaling factors; (5) correction factors for overburden pressures and sloping ground; and (6) input values for earthquake magnitude and peak acceleration. Probabilistic and seismic energy analyses were reviewed but no recommendations were formulated.

INTRODUCTION: The effectiveness of any new technology is typically measured in order to determine whether it successfully achieves equal or superior objectives over what is currently offered. Research in telemental health-in this article mainly referring to telepsychiatry and psychological services-has advanced rapidly since 2003, and a new effectiveness review is needed. MATERIALS AND METHODS: The authors reviewed the published literature to synthesize information on what is and what is not effective related to telemental health. Terms for the search included, but were not limited to, telepsychiatry, effectiveness, mental health, e-health, videoconferencing, telemedicine, cost, access, and international. RESULTS: Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care. In addition, this review has identified new models of care (i.e., collaborative care, asynchronous, mobile) with equally positive outcomes. CONCLUSIONS: Telemental health is effective and increases access to care. Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost.

BACKGROUND: Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers. OBJECTIVES: The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patient's personal characteristics (age, gender, education, ethnicity); 2) the physician's communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty). RESEARCH DESIGN AND SUBJECTS: The authors conducted a post hoc cross-sectional analysis of 279 physician-patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas. MAIN OUTCOME MEASURES: The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations. RESULTS: The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients. CONCLUSIONS: Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physician's communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care.

BACKGROUND: Patients' trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. METHODS: We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physician's practice and to SPs. We used multilevel modeling to examine the associations between physicians' Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. RESULTS: Component 1 of the MPCC, which explored the patient's experience of the disease and illness, was independently associated with patient's rating of trust in their physician. A I SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02-0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001-0.02). Component 1 and visit length were also positively associated with SP trust ratings. CONCLUSIONS: Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians' exploration patients' experiences of disease and illness improves trust. Key Words: physician-patient relationship, patient-centered care, trust, physician behavior

BACKGROUND: Cancers of individual organs generally are composed of various histologic types, each with its own frequency and demographic patterns. For childhood cancers in particular, a classification of cancers by histologic type is important for understanding the etiology and progression of the disease. METHODS: Data from the Surveillance, Epidemiology, and End Results (SEER) Program on 9308 microscopically confirmed malignant neoplasms in children younger than age 15, newly diagnosed during 1973-1987, were made available for analysis. Tumors were grouped histologically according to a classification previously utilized in an international volume of childhood cancer incidence. RESULTS: The most frequent histologic types were acute lymphocytic leukemia (23.6%), astrocytoma (9.6%), neuroblastoma (6.6%), and Wilms' tumor (6.4%). Acute lymphocytic leukemia accounted for 75% of childhood leukemia. The most common form of Hodgkin's disease was the nodular sclerosing subtype, which was diagnosed in 56% of all cases. Burkitt's and Burkitt-like disease accounted for approximately one third of non-Hodgkin's lymphoma, the sex ratio (male to female) being unusually high (5.7). Among the brain tumors, glioma was of interest because 198 cases (excluded from this analysis) were diagnosed without histologic confirmation--due, no doubt, to their inaccessibility for biopsy because they were located in the brain stem. The most common histologic type of soft tissue sarcoma was rhabdomyosarcoma, which accounted for 51% of the total, more than half of which were of the embryonal type. To the authors' knowledge, this report offers for the first time the relative frequencies of rare types of leukemias, such as megakaryoblastic leukemia, in childhood. This report also includes the frequencies of 21 rarer forms of soft tissue sarcoma. Five forms of childhood cancer had a 5-year relative survival rate of 85% or better. Of the cancers with the poorest outcome, three had relative survival rates of 46.5-49%; the relative survival rate of acute myelogenous leukemia was only 26.4%. The trends in survival over time for 21 types of childhood cancer also are included in this report. CONCLUSIONS: Further refinements in classification now are available through laboratory techniques utilizing molecular biology, immunology, and cytogenetics, which are of importance in etiologic studies, diagnosis, treatment, and prognosis. It would be important in the future for cancer registries to record the results of relevant laboratory tests for further analysis by subtype.

UNLABELLED: Objectives. To examine multiple dimensions of socioeconomic status and breastfeeding among a large, random sample of ethnically diverse women. METHODS: This study used logistic regression analysis to examine the influence of a range of socioeconomic factors on the chances of ever breastfeeding among a stratified random sample of 10,519 women delivering live births in California for 1999 through 2001. Measures of socioeconomic status included family income as a percentage of the federal poverty level, maternal education, paternal education, maternal occupation, and paternal occupation. RESULTS: Consistent with previous research, there was a marked socioeconomic gradient in breastfeeding. Women with higher family incomes, those who had or whose partners had higher education levels, and women who had or whose partners had professional or executive occupations were more likely than their counterparts to breastfeed. After adjustment for many potential confounders, maternal and paternal education remained positively associated with breastfeeding, while income and occupation were no longer significant. Compared with other racial or ethnic groups, foreign-born Latina women were the most likely to breastfeed. CONCLUSIONS: The significant association of maternal and paternal education with breastfeeding, even after adjustment for income, occupation, and many other factors, suggests that social policies affecting educational attainment may be important factors in breastfeeding. Breastfeeding rates may be influenced by health education specifically or by more general levels of schooling among mothers and their partners. The continuing importance of racial/ethnic differences after adjustment for socioeconomic factors could reflect unmeasured socioeconomic effects, cultural differences, and/or policies in Latin American countries.

Telemental health, in the form of interactive videoconferencing, has become a critical tool in the delivery of mental health care. It has demonstrated the ability to increase access to and quality of care, and in some settings to do so more effectively than treatment delivered in-person. This article updates and consolidates previous guidance developed by The American Telemedicine Association (ATA) and The American Psychiatric Association (APA) on the development, implementation, administration, and provision of telemental health services. The guidance included in this article is intended to assist in the development and delivery of effective and safe telemental health services founded on expert consensus, research evidence, available resources, and patient needs. It is recommended that the material reviewed be contemplated in conjunction with APA and ATA resources, as well as the pertinent literature, for additional details on the topics covered.

West Nile virus (WNV) was first isolated in California during July 2003 from a pool of Culex tarsalis collected near El Centro, Imperial County. WNV transmission then increased and spread in Imperial and Coachella Valleys, where it was tracked by isolation from pools of Cx. tarsalis, seroconversions in sentinel chickens, and seroprevalence in free-ranging birds. WNV then dispersed to the city of Riverside, Riverside County, and to the Whittier Dam area of Los Angeles County, where it was detected in dead birds and pools of Cx. pipiens quinquefasciatus. By October, WNV was detected in dead birds collected from riparian corridors in Los Angeles, west to Long Beach, and through inland valleys south from Riverside to San Diego County. WNV was reported concurrently from Arizona in mid-August and from Baja, Mexico, in mid-November. Possible mechanisms for virus introduction, amplification, and dispersal are discussed.

Background. The prevalence and characteristics of persons with newly diagnosed human immunodeficiency virus (HIV) infections with or without evidence of mutations associated with drug resistance have not been well described. Methods. Drug-naive persons in whom HIV had been diagnosed during the previous 12 months and who did not have acquired immune deficiency syndrome were sequentially enrolled from 39 clinics and testing sites in 10 US cities during 1997–2001. Genotyping was conducted from HIV-amplification products, by automated sequencing. For specimens identified as having mutations previously associated with reduced antiretroviral-drug susceptibility, phenotypic testing was performed. Results. Of 1311 eligible participants, 1082 (83%) were enrolled and successfully tested; 8.3% had reverse transcriptase or major protease mutations associated with reduced antiretroviral-drug susceptibility. The prevalence of these mutations was 11.6% among men who had sex with men but was only 6.1% and 4.7% among women and heterosexual men, respectively. The prevalence was 5.4% and 7.9% among African American and Hispanic participants, respectively, and was 13.0% among whites. Among persons whose sexual partners reportedly took antiretroviral medications, the prevalence was 15.2%. Conclusions. Depending on the characteristics of the patients tested, HIV-genotype testing prior to the initiation of therapy would identify a substantial number of infected persons with mutations associated with reduced antiretroviral-drug susceptibility. Antiretroviral-drug resistance is an important cause of treatment failure in persons infected with HIV-1 and has been associated with increased mortality [1-4]. Although the transmission of drug-resistant strains of HIV has been well documented [5], the prevalence and characteristics of persons with or without mutations associated with drug resistance are less clear. A number of studies have examined the prevalence of mutations associated with resistance in small samples of recently or acutely infected persons, mostly white men who have sex with men (MSM) [6-13]. Fewer studies have assessed the prevalence of mutations in drug-naive persons with newly diagnosed infections whose infections are, for the most part, of unknown duration; these persons are more typical of HIV-infected patients presenting for initial evaluation and treatment. In addition, few studies have been sufficiently large and representative of newly diagnosed HIV to describe the characteristics of persons infected with drug-resistant strains of HIV. A concern with testing chronically infected patients is that, even if drug-resistant mutations are initially present, in the absence of drug selection pressures, drug-resistant mutations may become undetectable if the infecting strains revert to wild type or become overgrown by fitter wild-type viruses; persisting as archived viruses or as minority species, they may not be detectable by current assays [14], even though they may become problematic with the introduction of therapy and selective pressures on the predominant wild-type strains. Consequently, resistance testing prior to initiation of antiretroviral therapy in persons with established HIV infection, although recommended by some when duration of infection or regional prevalence can be established [15], has not been widely recommended in the United States [16]. To describe the prevalence and characteristics of persons with mutations associated with reduced drug susceptibility, we systematically enrolled, in multiple venues across the United States, drug-naive persons in whom HIV infection had been recently diagnosed. As a better understanding of patterns of antiretroviral-drug resistance in persons presenting for care emerges, this kind of information may help to guide recommendations for baseline resistance testing and, possibly, the selection of initial antiretroviral regimens.> Patients. HIV- 1-infected persons in whom the condition had been diagnosed during the previous 12 months were enrolled consecutively from 39 selected HIV care clinics, HIV counseling and testing sites, and other clinical settings in 10 US cities during 1997-2001. Eligibility criteria included age ⩾18 years, antiretroviral-drug-naive status according to medical chart review (if a chart was available) and personal interview, and no history of AIDS-defining conditions (including a CD4+ T cell count <200 cells/mm3). After informed consent was obtained, demographic, risk-behavior, and clinical information was obtained from medical charts, if available, and from standardized interviews. Blood specimens were obtained from each consenting participant. The study was approved by the institutional review board at the Centers for Disease Control and Prevention and by the local human-subject review boards affiliated with the clinics or other sites where participants were enrolled. Resistance testing. Reverse transcriptase (RT) and protease genotyping was conducted on the basis of HIV-amplification products, by automated sequencing (Applied Biosystems) at the Centers for Disease Control and Prevention (165 specimens [GenBank accession numbers AY471869-AY472017]), ViroLogic (249 specimens), and Virco (668 specimens) laboratories. The mutations included in the analysis that were identified by sequencing at the ViroLogic and Virco laboratories were based on the reports of mutations provided by those laboratories. The analysis considered (1) RT-gene mutations that have been associated with reduced susceptibility to RT inhibitors and (2) major protease-gene mutations that have been associated with reduced susceptibility to protease inhibitors, as reported by the International AIDS Society-USA in June 2002 [17]: RT-M41L, A62V, K65R, D67N, T69D, 69 insert, K70R, L74V, V75I, V75T, V75M, V75S, V75A, F77L, L100I, K103N, V106A, V108I, Y115F, F116Y, Q151M, Y181C, Y181I, M184V, M184I, Y188C, Y188L, Y188H, Y188C, G190A, G190S, L210W, T215Y, T215F, K219Q, K219E, P225H, M230L, and P236L; protease-D30N, M46I, M46L, G48V, I50V, V82A, V82S, V82F, V82T, I84V, and L90M. In addition, all RT mutations at codon 215 that were different from wild-type T215 were included [17, 18], as were the T69A/N/S mutations. Plasma specimens having an RT mutation or a major protease mutation associated with reduced drug susceptibility were tested phenotypically at the ViroLogic (29 specimens) or Virco (50 specimens) laboratories, by recombinant-virus assays [19, 20]. The following antiretroviral drugs approved by the Food and Drug Administration were tested: zidovudine, didanosine, zal-citabine, stavudine, lamivudine, abacavir, nevirapine, delavirdine, efavirenz, saquinavir, ritonavir, indinavir, and nelfinavir. Fold changes in the IC50 of the patient's virus, relative to that of the reference wild-type viruses, were used to categorize phenotypic results as either sensitive or resistant according to cutoff values established by the manufacturers [21, 22]. Additional HIV antibody testing for recency of infection. All specimens for which informed consent was provided were also tested by a modified version of the HIV-1 enzyme immunoassay (Vironostika HIV-1 EIA; bioMerieux) [23, 24]. This assay is less sensitive than the standard HIV-1 enzyme immunoassay-it becomes reactive ⩾170 days after the standard EIA becomes positive; thus, HIV-infected persons in whom the virus does not react by the modified EIA are considered to have been infected during the previous 4–6 months ("recent infection"). All testing by this assay was conducted at 1 laboratory (San Francisco Department of Public Health), where assay performance was monitored [25]. Statistical analysis. We used the Mantel Haenszel X2 test and, where appropriate, Fisher's exact test to compare proportions of different HIV-infected populations with mutations associated with reduced drug susceptibility. Because of the small numbers of persons enrolled in 1997 and 2001, trends were analyzed for 1998-2000 only. Only clinics submitting data for all 3 of these years were included in analyses of trends. All statistical analyses were performed by use of SAS version 6.12 (SAS Institute). Of 1311 persons eligible for enrollment in this study, 1104 (84%) agreed to participate, and viral sequences from 1082 (83%) were successfully amplified; the analysis focused on these 1082 HIV-1-infected individuals. Table 1 summarizes demographic and clinical characteristics of the study population. Most were male, and 46% were African American, whereas 22% were of Hispanic origin. Most participants were enrolled from HIV care clinics. A substantial proportion of male participants, 60%, reported being MSM. A modified version of the HIV-1 enzyme immunoassay found 19% (182 of 949 persons who provided informed consent for additional testing) to have been recently infected with HIV. Characteristics of total study population and of persons with mutations associated with reduced susceptibility to reverse-transcriptase (RT) or protease inhibitors, in 10 US cities during 1997–2001 Although the proportion of HIV-infected persons with mutations associated with reduced antiretroviral drug susceptibility did not vary significantly by age group, city, site of enrollment, CD4+ T cell count, or recency of infection, persons with these mutations were more likely to be white, to be MSM, and/or to have a partner taking antiretroviral medications (table 1). The overall prevalence of mutations associated with reduced antiretroviral drug susceptibility was 8.3%; however, it was 6.1% and 4.7% in women and heterosexual men, respectively, and was 12% in MSM. The prevalence was 5.4% and 7.9% in African American and Hispanic persons, respectively, and was 13% in whites. Figure 1 shows that, for both sexual orientations and for both sexes, whites had the highest prevalence of these mutations; white MSM had the highest overall prevalence (14%), and Hispanic and African American heterosexual men and African American women had the lowest prevalences (4.3%, 4.6%, and 4.9%, respectively). Prevalence of reverse-transcriptase and major protease mutations associated with reduced antiretroviral-drug susceptibility, by race/ethnicity and sexual orientation, in 1082 HIV-infected persons in 10 US cities during 1997–2001 The prevalence of these mutations also varied according to the drug class with which they are associated (table 2). Of the 90 persons with RT mutations or major protease mutations, 69 (77%) had RT mutations associated with reduced susceptibility to the nucleoside reverse-transcriptase inhibitors (NRTIs); 40 of these 69 persons had 1, 24 had 2, 3 had 3, and 2 persons had 4. The most commonly observed NRTI resistance-associated mutations were M41L (19 persons), K70R (9 persons), M184V (9 persons), and D67N (7 persons). There were 4 persons with T215Y or T215F mutations; 27 other persons had T215D/S/C/ E/I mutations, and 15 persons had T69D/N/S/A mutations. When persons with T215D/S/C/E/I or T69N/S/A mutations were excluded, 69 (6.4%) of 1082 persons had resistance-associated mutations, and 48 (4.4%) of 1082 had NRTI-associated mutations. Prevalence of mutations associated with reduced drug susceptibility, by drug class and phenotypic confirmation of genotypic findings, in 1082 HIV-1-infected persons in 10 US cities during 1997–2001. Nonnucleoside-associated reverse-transcriptase mutations were found in 18 (1.7%) of the 1082 study participants, and major protease mutations were found in 21 (1.9%). The most commonly observed nonnucleoside-associated mutation was K103N (10 persons), and the most commonly observed major protease mutations were L90M (10 persons) and M46I (8 persons). Only 14 persons (1.3%) had mutations associated with reduced susceptibility to antiretroviral medications in ⩾2 drug classes; these 14 persons, 10 of whom were MSM, were enrolled from 7 of the 10 study cities. The prevalence of mutations associated with reduced antiretroviral-drug susceptibility was higher in the 182 persons found to have been recently infected with HIV (12%) than in the rest of the study population (7.4%); however, this difference was not statistically significant. The prevalence of such mutations in MSM who had been recently infected with HIV was 15%, whereas that in MSM whose infections were not recent was 11%; this difference too was not statistically significant. Similarly, recently infected heterosexual men had a higher, but not statistically different, prevalence of mutations than did heterosexual men whose infections were not recent (7.3%, compared to 4.4%); also, the prevalence of such mutations in women whose infections were recent was not statistically different from that in women whose infections were not recent (3.3%, compared to 5.8%), and within each racial or ethnic group, the prevalence in persons whose infections were recent was not different than that in persons whose infections were not recent. Some mutations were more likely to be found in persons with recent infections. In persons in whom recency of infection was tested by the modified HIV-1 EIA, 6 of 8 with the M184V mutation and 5 of 8 with the K103N mutation were found to have been recently infected. In contrast, only 4 of 27 persons with HIV containing changes at codon 215, 2 of 13 persons with changes at codon 69, 5 of 17 persons with the M41L mutation, and 3 of 10 persons with the L90M mutation were found to have been recently infected. The prevalence of mutations in recently infected persons varied by year (7.1% in 1998, 14% in 1999, and 8.9% in 2000); these differences were not statistically significant. This prevalence increased over time in persons not recently infected, from 3.2% in 1998 to 9.0% in 1999 to 12% in 2000 (P = .004, X2for trend). Of the 79 persons with an RT mutation or major protease mutation who were successfully tested phenotypically, only 31 (39%) showed phenotypic evidence of decreased susceptibility to the drugs with which their mutations have been associated (table 2). This finding varied by drug class. Only 13 (22%) of the 58 persons where viruses had NRTI mutations were found to have phenotypic evidence of resistance. In this group, the presence of a large number of viruses, with T215D/S/C/E/I mutations, that had wild-type susceptibility to zidovudine contributed to the low proportion with decreased susceptibility. Additionally, of the 19 persons with virus having the M41L mutation, only 3 showed evidence of decreased susceptibility to zidovudine, and 2 of those persons had virus with the T215Y mutation as well. On the other hand, 6 of 8 persons with virus carrying the M184V mutation had phenotypic evidence of resistance to lamivudine, and all 10 persons with virus with the K103N mutation had phenotypic evidence of resistance to non-NRTIs. Persons with mutations associated with reduced antiretroviral drug susceptibility who also had phenotypic evidence of resistance were, like all persons with these mutations, statistically more likely to be white, to be MSM, and/or to report a partner taking antiretroviral medications than were persons with virus without these mutations. They were also more likely to have been recently infected (50%, compared to 18%; P<.001). In patients infected with HIV, the first therapeutic regimen is the most important one for producing a maximal and durable virologic response [16]. Optimizing that initial regimen is therefore critical, and, for this reason, testing for the presence of drug-resistant strains of HIV prior to the initiation of therapy may be beneficial to the patient and cost effective [26]. The findings of the present study of drug-naive persons with newly diagnosed infections suggest that such a strategy of resistance testing would identify a substantial number of persons with HIV containing mutations associated with reduced antiretro-viral-drug susceptibility. These findings document that many mutations remain detectable 4–6 months after infection and support previous studies' observation, in a few patients, that transmitted drug-re -sistant virus may persist for months or years [27, 28]. The continued presence of these mutations and the ability to detect them have important implications both for resistance testing in drug-naive patients with established infection and for the conduction of surveillance of mutations associated with reduced antiretroviral-drug susceptibility in this population. We did find that the prevalence of mutations associated with reduced antiretroviral-drug susceptibility in persons whose infections were recent is higher than that in persons whose infections were not. Although this difference is not statistically significant when all mutations are considered, some mutations, particularly those that could be confirmed phenotypically, are more likely to be found in recently infected persons. The shorter persistence of some mutations may be explained by decreased viral fitness and, thus, a faster rate of reversion to a more replication-competent variant [29, 30]. Of persons with detectable viral mutations identified in the present study, only 39% had phenotypic evidence of resistance. The inclusion of mutations that indicate prior drug exposure but do not actually confer drug resistance may account, in part, for the lower prevalence of phenotypic resistance observed in this and other studies [6, 7]. Although the presence of genotypic or phenotypic markers of resistance in recently infected persons has generally been linked to reduced virologic responses to antiretroviral therapy [6, 7], the clinical implications of many resistance-associated mutations are not fully defined. We therefore caution against using these prevalence data to imply rates of virologic failures that would occur in patients initiating therapy; however, close monitoring of treatment responses in patients infected with viruses with these mutations may be warranted. The largest proportion (41%) of persons with NRTI-associ-ated mutations had mutations at codon 215, such as T215D/ S/C/E/I, that differ from either wild type or the zidovudine/ stavudine-selected T215Y/F. These mutations are known to be revertants of T215Y, and, although they are phenotypically sensitive to zidovudine, the mutant viruses can acquire T215Y in vitro more rapidly than can wild-type HIV-1, likely reflecting the fact that only 1 nucleotide change is necessary for evolution to T215Y [17]. Preliminary data suggest that patients with these mutations, after initiating therapy, do have an increased risk of virologic failure [31]. The prevalence of mutations associated with reduced antiretroviral-drug susceptibility varies depending on the particular population being tested. We found that the prevalence of mutations associated with reduced drug susceptibility was higher in whites and MSM than in other populations. We also found that the prevalence of these mutations was higher in persons reporting partners who took antiretroviral medications, suggesting that these viruses may have been transmitted directly from treated persons. The higher prevalence in whites and MSM may reflect better access to health care and treatment in these populations [32, 33]. Our results help to explain the prevalence of mutations found by others, whose study populations consisted mostly of recently or acutely infected white MSM [6, 7, 13]. Although we did not observe evidence of an increasing prevalence of mutations associated with reduced drug susceptibility, over time, in recently infected individuals, the number of recently infected individuals in our study is small. We did see an increasing prevalence in persons who were not recently infected; however, these trend data should be regarded with some caution, because they are limited to just 3 years. We did not study a random sample of HIV-infected individuals; nevertheless, to date, this is the largest, most diverse population in the United States that has been studied for antiretroviral-drug resistance and, with the exception of the over-sampling of Hispanics (only 11.3% of persons reported with HIV nationally are Hispanic, compared to 22% in the present study), our study well reflects the demographic characteristics of persons reported with HIV as well as the proportion of MSM [34]. It should be noted that the persons in this study had CD4 T cell counts ⩾200 cells/mm3; according to current guidelines, many may not have had indications for starting antiretroviral therapy. Although the epidemiology of antiretroviral-drug resistance may reflect the HIV-infected populations that are seeking and receiving antiretroviral therapy, it also reflects, as others have noticed, the health care system's failures to prevent HIV transmission from these treated populations [6]. Recently reported increases in risky sexual behaviors, as evidenced by increases in sexually transmitted diseases in MSM with high rates of HIV coinfection [35-37], suggest that HIV infection rates may also be increasing in this group. Health care providers who are caring for HIV-infected patients can play a prominent role in helping to prevent the further transmission of HIV, including drug-resistant virus. In summary, HIV genotypic testing prior to the initiation of therapy in patients with newly diagnosed HIV infections and without AIDS would identify a substantial number of persons with virus with mutations associated with reduced antiretro-viral-drug susceptibility. The prevalence of these mutations varies depending on the characteristics of the patients tested and the duration of their infections. Continued surveillance for antiretroviral-drug resistance in sufficiently large, representative samples of persons with newly diagnosed HIV will be necessary to monitor changes, over time, in the prevalence and the populations affected. We are indebted to Janet Royalty, Toni Woods, Richard Res-pess, Brian Louie, Shannon Hagar, and J. Todd Weber, whose efforts helped make this study possible.

OBJECTIVES: The purpose of the study was to determine the clinical and economic impact of alternative contraceptive methods. METHODS: Direct medical costs (method use, side effects, and unintended pregnancies) associated with 15 contraceptive methods were modeled from the perspectives of a private payer and a publicly funded program. Cost data were drawn from a national claims database and MediCal. The main outcome measures included 1-year and 5-year costs and number of pregnancies avoided compared with use of no contraceptive method. RESULTS: All 15 contraceptives were more effective and less costly than no method. Over 5 years, the copper-T IUD, vasectomy, the contraceptive implant, and the injectable contraceptive were the most cost-effective, saving $14,122, $13,899, $13,813, and $13,373, respectively, and preventing approximately the same number of pregnancies (4.2) per person. Because of their high failure rates, barrier methods, spermicides, withdrawal, and periodic abstinence were costly but still saved from $8933 to $12,239 over 5 years. Oral contraceptives fell between these groups, costing $1784 over 5 years, saving $12,879, and preventing 4.1 pregnancies. CONCLUSIONS: Contraceptives save health care resources by preventing unintended pregnancies. Up-front acquisition costs are inaccurate predictors of the total economic costs of competing contraceptive methods.

BACKGROUND: Several quality assessment systems use administrative data to identify postoperative complications, with uncertain validity. OBJECTIVES: To determine how accurately postoperative complications are reported in administrative data, whether accuracy varies systematically across hospitals, and whether serious complications are more consistently reported. DESIGN: Retrospective cohort. SUBJECTS: Nine hundred ninety-one randomly sampled adults who underwent elective lumbar diskectomies at 30 nonfederal acute care hospitals in California in 1990 to 1991. Hospitals with especially low or high risk-adjusted complication rates, and patients who experienced complications, were over sampled. MEASURES: Postoperative complications were specified by reviewing medical literature and consulting clinical experts; each complication was mapped to ICD-9-CM. Hospital-reported complications were compared with our independent recoding of the same records. RESULTS: The weighted sensitivity, specificity, and positive and negative predictive values for reported complications were 35%, 98%, 82%, and 84%, respectively. The weighted sensitivity was 30% for serious, 40% for minor, and 10% for questionable complications. It varied from 21% among hospitals with fewer complications than expected to 45% among hospitals with more complications than expected. Only reoperation, bacteremia/sepsis, postoperative infection, and deep vein thrombosis were reported with at least 60% sensitivity. Half of the difference in risk-adjusted complication rates between low and high outlier hospitals was attributable to reporting variation. CONCLUSIONS: ICD-9-CM complications were underreported among diskectomy patients, especially at hospitals with low risk-adjusted complication rates. The validity of using coded complications to compare provider performance is questionable, even with careful efforts to identify serious events, although these results must be confirmed using more recent data.

BACKGROUND: The global tuberculosis epidemic results in nearly 2 million deaths and 9 million new cases of the disease a year. The vast majority of tuberculosis patients live in developing countries, where the diagnosis of tuberculosis relies on the identification of acid-fast bacilli on unprocessed sputum smears using conventional light microscopy. Microscopy has high specificity in tuberculosis-endemic countries, but modest sensitivity which varies among laboratories (range 20% to 80%). Moreover, the sensitivity is poor for paucibacillary disease (e.g., pediatric and HIV-associated tuberculosis). Thus, the development of rapid and accurate new diagnostic tools is imperative. Immune-based tests are potentially suitable for use in low-income countries as some test formats can be performed at the point of care without laboratory equipment. Currently, dozens of distinct commercial antibody detection tests are sold in developing countries. The question is "do they work?" METHODS AND FINDINGS: We conducted a systematic review to assess the accuracy of commercial antibody detection tests for the diagnosis of pulmonary tuberculosis. Studies from all countries using culture and/or microscopy smear for confirmation of pulmonary tuberculosis were eligible. Studies with fewer than 50 participants (25 patients and 25 control participants) were excluded. In a comprehensive search, we identified 68 studies. The results demonstrate that (1) overall, commercial tests vary widely in performance; (2) sensitivity is higher in smear-positive than smear-negative samples; (3) in studies of smear-positive patients, Anda-TB IgG by enzyme-linked immunosorbent assay shows limited sensitivity (range 63% to 85%) and inconsistent specificity (range 73% to 100%); (4) specificity is higher in healthy volunteers than in patients in whom tuberculosis disease is initially suspected and subsequently ruled out; and (5) there are insufficient data to determine the accuracy of most commercial tests in smear microscopy-negative patients, as well as their performance in children or persons with HIV infection. CONCLUSIONS: None of the commercial tests evaluated perform well enough to replace sputum smear microscopy. Thus, these tests have little or no role in the diagnosis of pulmonary tuberculosis. Lack of methodological rigor in these studies was identified as a concern. It will be important to review the basic science literature evaluating serological tests for the diagnosis of pulmonary tuberculosis to determine whether useful antigens have been described but their potential has not been fully exploited. Activities leading to the discovery of new antigens with immunodiagnostic potential need to be intensified.

BACKGROUND AND OBJECTIVES: Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS: In a retrospective cohort study of 52,061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles. RESULTS: Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile. CONCLUSIONS: Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

RATIONALE: Critically ill adults are at risk for a variety of distressing and consequential symptoms both during and after an ICU stay. Management of these symptoms can directly influence outcomes. OBJECTIVES: The objective was to update and expand the Society of Critical Care Medicine's 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. PANEL DESIGN: The interprofessional inclusive guidelines task force was composed of 24 individuals including nurses, physicians, pharmacists, physiotherapists, psychologists, and ICU survivors. The task force developed evidence-based recommendations using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including task force selection and voting. METHODS: The task force focused on five main content areas as they pertain to adult ICU patients: anxiety (new topic), agitation/sedation, delirium, immobility, and sleep disruption. Using the GRADE approach, we conducted a rigorous systematic review for each population, intervention, control, and outcome question to identify the best available evidence, statistically summarized the evidence, assessed the quality of evidence, and then performed the evidence-to-decision framework to formulate recommendations. RESULTS: The task force issued five statements related to the management of anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adults admitted to the ICU. In adult patients admitted to the ICU, the task force issued conditional recommendations to use dexmedetomidine over propofol for sedation, provide enhanced mobilization/rehabilitation over usual mobilization/rehabilitation, and administer melatonin. The task force was unable to issue recommendations on the administration of benzodiazepines to treat anxiety, and the use of antipsychotics to treat delirium. CONCLUSIONS: The guidelines task force provided recommendations for pharmacologic management of agitation/sedation and sleep, and nonpharmacologic management of immobility in critically ill adults. These recommendations are intended for consideration along with the patient's clinical status.

OBJECTIVE: Previous studies have addressed perinatal outcomes in Hispanic, black, and white non-Hispanic women and demonstrated that although foreign-born Mexican American women have many demographic and socioeconomic risk factors, their rates of low birth weight (LBW) infants and infant mortality are similar to those of white women. This phenomenon has been termed an epidemiologic paradox. There have been no population-based studies on women of Asian Indian origin, a relatively new, highly educated, and affluent immigrant group that has been reported to have a high rate of LBW infants. The objective of this study was to define the sociodemographic risk profile and perinatal outcomes in women of Asian Indian birth and to compare these outcomes to foreign-born Mexican American and US-born black and white women. METHODS: The vital records for self-reported foreign-born Asian Indian (0.8%) and Mexican women (26.7%) and US-born black (31.2%) and white women (31.2%) were extracted from California's 1 622 324 births, 1995-1997. Sociodemographic risk profiles; the percentage of LBW, very low birth weight (VLBW), prematurity, and intrauterine growth retardation (less than third percentile); and percentage of fetal, neonatal, and postneonatal death rates were compared. Logistic models were used to estimate the importance of selected sociodemographic and medical factors to the prediction of LBW infants in each racial/ethnic group. RESULTS: When compared with whites, US-born blacks and foreign-born Mexican mothers were at increased risk for adverse perinatal outcomes on the basis of higher levels of inadequate prenatal care, teen births, Medi-Cal paid delivery, and lower levels of maternal and paternal education. Foreign-born Asian Indian mothers had good prenatal care, were rarely teenagers, had dramatically higher levels of both maternal and paternal education, and had the lowest percentage of deliveries paid for by Medi-Cal. Black infants had the highest rates of prematurity; intrauterine growth retardation; LBW; and fetal, neonatal, and postneonatal mortality. Paradoxically, despite their high-risk profile, Mexicans did not have elevated levels of LBW or neonatal mortality. Conversely, Asian Indian infants, although seemingly of low sociodemographic risk, had high levels of LBW, growth retardation, and fetal mortality. Logistic regression analysis of independent risk factors for giving birth to an LBW infant showed higher maternal education, early access to prenatal care, and having private insurance to be protective in white non-Hispanic and black but not in Asian Indian and Mexican-born women. CONCLUSIONS: Despite their high socioeconomic status and early entry into care, foreign-born Asian Indian women have a paradoxically higher incidence of LBW infants and fetal deaths when compared with US-born whites. Factors that protect from giving birth to an LBW infant in white women were not protective among Asian Indian women. Current knowledge regarding factors that confer a perinatal advantage or disadvantage is unable to explain this new epidemiologic paradox. These findings highlight the need for additional research into both epidemiologic and biological risk factors that determine perinatal outcomes.

Patients seeking help for symptoms frequently worry about the underlying causes of their symptoms; have specific expectations for care; and request (or demand) time, information, and services. Understanding patients' concerns, expectations, and requests is important for clinicians, health care policymakers, and researchers. One obstacle to progress in this area has been disagreement over the most appropriate methods for identifying, monitoring, and classifying these phenomena. This article reviews the conceptual relationships linking patients' expectations, requests, and satisfaction with care; surveys contemporary approaches to the measurement of expectations and requests; and highlights recent empirical findings. The literature reviewed supports the conclusion that patients' expectations are wide ranging, can be measured, and have potentially important clinical consequences. For clinicians and policymakers alike, learning to elicit, evaluate, and understand patients' expectations will be a major task for the early part of the new century.

Salmonella enterica serotype Baildon, a rare serotype, was recovered from 86 persons in eight states; 87% of illnesses began during a 3-week period ending January 9, 1999. Raw restaurant-prepared tomatoes were implicated in multiple case-control studies. Contamination likely occurred on the farm or during packing; more effective disinfection and prevention strategies are needed.

In Brief Background: Greater hospital volume has been associated with lower mortality after colorectal cancer surgery. The contribution of surgeon volume to processes and outcomes of care is less well understood. We assessed the relation of surgeon and hospital volume to postoperative and overall mortality, colostomy rates, and use of adjuvant radiation therapy. Methods: From the California Cancer Registry, we studied 28,644 patients who underwent surgical resection of stage I to III colorectal cancer during 1996 to 1999 and were followed up to 6 years after surgery to assess 30-day postoperative mortality, overall long-term mortality, permanent colostomy, and use of adjuvant radiation therapy. Results: Across decreasing quartiles of hospital and surgeon volume, 30-day postoperative mortality ranged from 2.7% to 4.2% (P<0.001). Adjusting for age, stage, comorbidity, and median income among patients with colorectal cancer who survived at least 30 days, patients in the lowest quartile of surgeon volume had a higher adjusted overall mortality rate than those in the highest quartile (hazard ratio, 1.16; 95% confidence interval, 1.09–1.24), as did patients in the lowest quartile of hospital volume relative to those treated in the highest quartile (hazard ratio, 1.11; 95% confidence interval, 1.05–1.19). For rectal cancer, adjusted colostomy rates were significantly higher for low-volume surgeons, and the use of adjuvant radiation therapy was significantly lower for low-volume hospitals. Conclusions: Greater surgeon and hospital volumes were associated with improved outcomes for patients undergoing surgery for colorectal cancer. Further study of processes that led to these differences may improve the quality of colorectal cancer care. Relative contributions of surgeon and hospital volume to processes and outcomes of colorectal cancer care are poorly understood. A total of 28,644 patients who had stage I to III colorectal cancer during 1996 to 1999 were followed up 6 years. Greater surgeon and hospital volume were associated with improved outcomes for patients undergoing surgery for colorectal cancer.

PURPOSE: The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the influence of patient antidepressant requests. METHODS: Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%-61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specific, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality. RESULTS: Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P=.02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a significant physician variance component with rho = 0.57 (95% confidence interval, 0.45-0.68) indicating that there were additional, unspecified physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression. CONCLUSIONS: When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality.

Conventional diagnostic tests for tuberculosis have several limitations and are often unhelpful in establishing the diagnosis of extrapulmonary tuberculosis. Although commercial serological antibody based tests are available, their usefulness in the diagnosis of extrapulmonary tuberculosis is unknown. A systematic review was conducted to assess the accuracy of commercial serological antibody detection tests for the diagnosis of extrapulmonary tuberculosis. In a comprehensive search, 21 studies that reported data on sensitivity and specificity for extrapulmonary tuberculosis were identified. These studies evaluated seven different commercial tests, with Anda-TB IgG accounting for 48% of the studies. The results showed that (1) all commercial tests provided highly variable estimates of sensitivity (range 0.00-1.00) and specificity (range 0.59-1.00) for all extrapulmonary sites combined; (2) the Anda-TB IgG kit showed highly variable sensitivity (range 0.26-1.00) and specificity (range 0.59-1.00) for all extrapulmonary sites combined; (3) for all tests combined, sensitivity estimates for both lymph node tuberculosis (range 0.23-1.00) and pleural tuberculosis (range 0.26-0.59) were poor and inconsistent; and (4) there were no data to determine the accuracy of the tests in children or in patients with HIV infection, the two groups for which the test would be most useful. At present, commercial antibody detection tests for extrapulmonary tuberculosis have no role in clinical care or case detection.