Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine.

OBJECTIVE: An observational safety study of the quadrivalent human papillomavirus vaccine (HPV4) in women was conducted. This report presents findings from autoimmune surveillance. Design. Subjects were followed for 180days after each HPV4 dose for new diagnoses of 16 prespecified autoimmune conditions. SETTING: Two managed care organizations in California. Subjects. Number of 189,629 women who received ≥1 dose of HPV4 between 08/2006 and 03/2008. OUTCOME: Potential new-onset autoimmune condition cases amongst HPV4 recipients were identified by electronic medical records. Medical records of those with ≥12-month health plan membership prior to vaccination were reviewed by clinicians to confirm the diagnosis and determine the date of disease onset. The incidence of each autoimmune condition was estimated for unvaccinated women at one study site using multiple imputations and compared with that observed in vaccinated women. Incidence rate ratios (IRR) were calculated. Findings were reviewed by an independent Safety Review Committee (SRC). RESULTS: Overall, 1014 potential new-onset cases were electronically identified; 719 were eligible for case review; 31-40% were confirmed as new onset. Of these, no cluster of disease onset in relation to vaccination timing, dose sequence or age was found for any autoimmune condition. None of the estimated IRR was significantly elevated except Hashimoto's disease [IRR=1.29, 95% confidence interval: 1.08-1.56]. Further investigation of temporal relationship and biological plausibility revealed no consistent evidence for a safety signal for autoimmune thyroid conditions. The SRC and the investigators identified no autoimmune safety concerns in this study. CONCLUSIONS: No autoimmune safety signal was found in women vaccinated with HPV4.

Racial and ethnic differences in the use of cardiovascular procedures: findings from the California Cooperative Cardiovascular Project.

OBJECTIVES: This study used data from the California Cooperative Cardiovascular Project to examine the use of invasive and noninvasive cardiovascular procedures among Whites, African Americans, and Hispanics. METHODS: The use of catheterization, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG) surgery, and several noninvasive tests among all patients 65 years or older with a confirmed acute myocardial infarction in nonfederal hospitals from 1994 to 1995 was studied. RESULTS: African Americans (n = 527) were less likely than Whites (n = 9489) to have received catheterization (adjusted odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.50, 0.76), PTCA (OR = 0.64, 95% CI = 0.49, 0.85), or CABG surgery (OR = 0.42, 95% CI = 0.27, 0.64); somewhat more likely to have received a stress test or an echocardiogram; and equally likely to have received a multiple-gated acquisition scan. Hispanics (n = 689) also were less likely than Whites to have received catheterization (OR = 0.82, 95% CI = 0.68, 0.98) or PTCA (OR = 0.58, 95% CI = 0.45, 0.75). CONCLUSIONS: African Americans were less likely than Whites to undergo costly invasive cardiovascular procedures. In addition, Hispanics were less likely than Whites to have received catheterization and PTCA.

Outcome following acute myocardial infarction: are differences among physician specialties the result of quality of care or case mix?

BACKGROUND: Studies to determine whether care by cardiologists improves the survival of patients with acute myocardial infarction (MI) have produced conflicting results, and it is not known what accounts for differences in patient outcome by physician specialty. OBJECTIVES: To evaluate whether cardiologists provide more recommended therapies to elderly patients with acute MI and, if so, to determine whether variations in processes of care account for differences in patient outcome. DESIGN: Retrospective cohort study using medical chart data and administrative data files. SETTING: All nonfederal acute care hospitals in California. PATIENTS: A cohort of 7663 Medicare beneficiaries 65 years and older directly admitted to the hospital with a confirmed acute MI from April 1994 to July 1995 with complete data regarding potential contraindications to recommended therapies. MAIN OUTCOME MEASURES: Percentage of "good" and "ideal" candidates for a given acute MI therapy who actually received that therapy, percentage who received exercise stress testing or coronary angiography, percentage who underwent revascularization, and 1-year mortality, stratified by specialty of the attending physician. RESULTS: During hospitalization, good candidates for aspirin were more likely to receive aspirin if they were treated by cardiologists (87%) than by medical subspecialists (73%; P<.001), general internists (84%; P = .003), or family practitioners (81%; P<.001). Cardiologists were also more likely to treat good candidates with thrombolytic therapy (51%) than were medical subspecialists (29%; P<.001), general internists (40%; P<.001), or family practitioners (27%; P<.001). Patients of cardiologists were 2- to 4-fold more likely to undergo a revascularization procedure. Despite these differences in utilization, we found similar 30-day mortality rates across physician specialties. However, 1-year mortality rates were greater for patients treated by medical subspecialists (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.6-2.3), general internists (OR, 1.4; 95% CI, 1.3-1.6), and family practitioners (OR, 1.7; 95% CI, 1.4-1.9) than for those treated by cardiologists. Adjusting for differences in patient and hospital characteristics markedly reduced the ORs for those treated by medical subspecialists (OR, 1.2; 95% CI, 0.9-1.4), general internists (OR, 1.1; 95% CI, 1.0-1.3), and family practitioners (OR, 1.3; 95% CI, 1.1-1.6), whereas further adjustment for medication use and revascularization procedures had little effect. CONCLUSIONS: Differences in the use of recommended therapies by physician specialty are generally small and do not explain differences in patient outcome. In comparison, differences among patients treated by physicians of various specialties (case mix) have a large impact on patient outcome and may account for the residual survival advantage of patients treated by cardiologists. With the exception of the in-hospital use of aspirin, recommended MI therapies are markedly underused, regardless of the specialty of the physician.

Underutilization of pressure ulcer risk assessment in hip fracture patients.

Patients with hip fractures are at high risk for pressure ulcer development, yet few recent studies have addressed risk assessment in this population. In this retrospective medical record survey, records of a random sample of California Medicare beneficiaries with hip fractures admitted to acute care hospitals in 1995 were selected for abstraction. Medical record abstraction (n = 545) revealed that risk assessment was performed on only 44.2% (241/545) of patients. Among these, 64.3% were identified as at risk for pressure ulcer development. Accuracy of the risk assessment was evaluated independently and compared with those performed by the nursing staff; there was agreement in only 40% of cases. Ulcers developed in 19.1% of the sample, and pressure ulcer development was not related to risk status at hospital admission. Patients with longer hospital stays developed more ulcers than those discharged earlier. This study shows that risk assessment is underutilized, inaccurate, and unrelated to pressure ulcer development in hip fracture patients.

Gender differences in homicide in Contra Costa County, California: 1982-1993.

INTRODUCTION: Homicide is the third leading cause of injury death for women in the United States. However, few studies have examined the circumstances specific to female homicide. This study examines gender differences in circumstances surrounding homicides in Contra Costa County for a 12-year period. METHODS: Uniform Crime Reporting (UCR) data for Contra Costa County from 1982 through 1993 were analyzed. Variables examined were gender of the victim, victim-offender relationship, age of victim, weapon used, location of homicide, precipitating circumstances, and gender of the offender. RESULTS: Forty-six percent of the women were killed by their spouse, other family member, or intimate partner, compared to only 11.4% of men. In contrast, men were more likely to be killed by a stranger than women (17.9% versus 10.9%, P = .02). A higher percentage of women than men were killed with a blunt object, a personal weapon (i.e., fists, feet, and teeth), or other weapon (24.9% versus 10.6%, p < .01), and in a residence (60.1% versus 34.8%, P < .001). Men were more likely than women to be killed by a firearm, in a public place (i.e., a parking lot or street), and while a felony was being committed. CONCLUSIONS: These findings are consistent with the hypothesis that many female homicides may be the result of domestic violence, belying the myth that the principal perpetrators of homicides against women are strangers. The differences between female and male homicides indicate that gender-specific prevention strategies need to be pursued.

[Children who work on the streets of Tijuana. An epidemiological profile and the prevalence of experimentation with tobacco]. / Los niños que trabajan en las calles de Tijuana. Perfil epidemiológico y prevalencia de experimentación con tabaco.

OBJECTIVE: To develop an epidemiological profile of children that work in the streets of Tijuana, Mexico, and to determine the prevalence of cigarette smoking in this group, as well as the prevalence of those factors associated with tobacco experimentation. STUDY TYPE: cross-sectional. MATERIAL AND METHODS: Children aged 8 through 15, who work in the streets of Tijuana were included. Demographic, socioeconomic, and smoking related variables were analyzed. RESULTS: The study included 110 children, with a mean age of 11.43 years. Of these 91.7% live with one or both of their parents; 60% attend school and an additional 30% did so in the past. Only 6.4% of these children are the principal economic support of the household, and 51.8% reported an average daily income of $US 10 or less. Only 9.1% reported experimentation with tobacco, and 31% of them tobacco prompting (in the form of lighting up a cigarette) by an adult of the family; this is significantly more frequent on behalf of the father than of the mother (21.8% vs 4.5% p < 0.001). CONCLUSIONS: Most of the children under 15 years of age who work in the streets of Tijuana live with their parents and maintain close relationships with their family. Most of them attend school and work in the streets only to complement the family income. Their tobacco experimentation is not greater than that of other children of the same age group.

Parental influences to smoke in Latino youth.

BACKGROUND: Latino youth have been found to have a higher prevalence of tobacco use than do other ethnic groups, possibly due to cultural factors and parental influences. METHODS: Seventh-grade students (N = 589) were surveyed in San Diego, California, and Tijuana, Mexico, to assess parental influences to smoke. These parental influence variables were studied with logistic regression, adjusting for age, sex, and number of parents who smoke. RESULTS: Among those whose parents smoke, Mexican students were asked to strike a match to light their parents' cigarettes significantly more often (57%) than Mexican-American students (37%) and U.S. Others (37%) (P < 0.05). Seventeen percent of the Mexican students reported having lit a cigarette in their own mouth for their parents, compared to 18% of Mexican-Americans and only 3% of U.S. Others (P < 0.01). Mexicans reported buying cigarettes for their parents more often (62%), compared with 36% for Mexican-Americans and 30% for U.S. Others (P < 0.01). Child smoking was only associated with friend offers of tobacco and parental prompts to light cigarettes in their mouths. CONCLUSION: Latino parents are inadvertently prompting their children to smoke. Smoking prevention programs targeting Latino youth may need to include a parental tobacco education component.

Parental prompting of smoking among adolescents in Tijuana, Mexico.

Latino adolescents in the United States and Mexico may have higher rates of tobacco experimentation than other ethnic groups, possibly due to cultural factors and parental influences. This study examined three parental behaviors that may prompt smoking in children in Grades 3, 5, 7, and 9 in Tijuana. Mexico. Surveys were administered to 758 students in randomly selected classes in randomly selected schools in Tijuana. The most frequent prompt was the smoking parent asking the child to buy cigarettes (about two thirds), whereas about 60% asked the child to light the parent's cigarette, and about 20% of smoking parents asked the child to place the cigarette in his or her mouth to light it. Rates of prompting were very low among third graders but increased by Grade 5. Mother's smoking was associated with higher rates of all three types of parental prompting.