Screening for Epstein-Barr virus (EBV) infection status in university freshmen: acceptability of a gingival swab method.

Prophylactic vaccines against Epstein-Barr virus (EBV) are under development. EBV-naïve college freshmen are ideal candidates for an efficacy trial, because their incidence of infectious mononucleosis (mono) during freshman year is as high as 20%. To assess perceptions about mono and a mono vaccine, and to learn if EBV immune status could be determined using a gingival swab rather than phlebotomy, we performed a cross-sectional study of 235 healthy students at the beginning of their freshman year. Subjects completed questionnaires and donated oral washes, gingival swabs and venous blood. Overall, 90% of students found the swab easy to use and 80% preferred the swab over venepuncture. Of the 193 students with sufficient samples, 108 (56%) had EBV antibodies in blood vs. 87 (45.1%) in the gingival swab. The sensitivity and specificity of the swab compared with blood for detecting EBV antibodies was 75.9% and 94.1%, respectively, with an accuracy of 89.3%. EBV DNA was detected in the oral wash and swab of 39.2% and 30.4% of blood-antibody-positive individuals, respectively. In conclusion, 44% of our freshmen were EBV-naïve and thus vaccine candidates, the gingival swab was an acceptable alternative to phlebotomy for detecting EBV antibody but needs improved sensitivity, and the perceived value of EBV vaccine was high (72% believed they would benefit).

Three-decade investigation of familial pheochromocytoma. An allele of von Hippel-Lindau disease?

BACKGROUND: Usually sporadic, pheochromocytoma can, on occasion, complicate genetic disorders, such as neurofibromatosis 1, von Hippel-Lindau disease, and multiple endocrine neoplasia 2; some families seem to have just pheochromocytoma, where it may have occurred by chance. The natural history of a large kindred believed to have an excess of pheochromocytoma 34 years ago was followed with the hypothesis that the predisposition was, in fact, present and that family education and surveillance would decrease mortality. METHODS: Prospective observation and diagnostic surveillance for pheochromocytoma were conducted on the inception cohort, defined as three branches of the kindred in 1960. Of 619 descendants of three (of 11) siblings of German origin, 333 were evaluated in person at least once in the three decades of surveillance. No pheochromocytomas were known to have occurred in the eight other branches. A total of 522 persons from the 11 branches were evaluated. RESULTS: Five of the eight initial patients with pheochromocytoma died of cardiovascular complications attributable to the tumor. In follow-up, eight additional relatives were newly diagnosed with pheochromocytomas (at an average age of 19 years), and others had additional or recurrent pheochromocytomas, meningioma, para-adrenal paraganglioma, and a functioning glomus vagale; none died. CONCLUSIONS: A continuing excess of pheochromocytoma seems present in the family. Whether the incompletely penetrant gene in this family is allelic to the von Hippel-Lindau gene on chromosome 3 or is a distinct locus remains to be resolved with molecular studies. Meanwhile, education and surveillance seem to decrease mortality from pheochromocytoma in this family.

Acute poisoning emergencies. Resolving the gastric decontamination controversy.

As in all medical emergencies, in acute poisoning the cornerstone of management is good supportive care. Aggressive support of the cardiovascular, respiratory, and central nervous systems, along with appropriate gastric decontamination, greatly reduces morbidity and mortality and improves patient outcome. Ipecac is generally reserved for home use, where it can be given to induce emesis immediately after ingestion of toxins, and it is given only in cases of mild or moderate toxicity. Activated charcoal should replace ipecac in the emergency department for cases of mild or moderate toxicity. Gastric lavage and administration of activated charcoal should be considered in cases with life-threatening potential. A cathartic should be considered after activated charcoal has been administered, but only in cases where it will not have a detrimental effect.

Health care delivery systems in review.

A reversal of HMOs' financial difficulties is likely to occur over the next few years. The era of physicians assuming financial risk and receiving incentive payments may end, due to physician sentiment and the outcome of federal legislation. The reimbursement rate for Medicare risk contracts is currently being revised, which may improve the bottom line of some HMOs. Overall, the industry is experiencing considerable consolidation and little, if any, expansion. This is a time of regrouping to improve profitability, tighten utilization mechanisms, and strengthen plan administration.

Pulmonary embolism.

Pulmonary thromboembolism is perhaps one of the most challenging diseases to recognize, diagnose, and treat appropriately in medicine today. Although the clinician is offered a variety of diagnostic modalities, a highly sensitive and specific diagnostic modality without significant risk does not yet exist. The newer noninvasive tests may offer valuable alternatives to the more invasive venogram and pulmonary angiogram. Figure 1 offers an algorithm for the diagnosis and management of thromboembolic disease. Failure to diagnose this entity can result in significant patient morbidity and mortality. Physicians must maintain a high index of suspicion as well as have an organized approach to diagnosis and management to improve survival of patients with thromboembolic disease.

Health care delivery systems in review.

The focus in the HMO and PPO industry has shifted from financial difficulties to accountability. Quality tracking and utilization review systems are being implemented on a local and state level, while on the national level, the JCAHO has devised applicable criteria. The relationship between physicians and HMOs continues to be tenuous. However, in plans where physicians play a greater role in decision making, the relationship improves. Changes to the HMO Act may mean lessened federal control over HMOs, while the extent of state legislation increases.

Health care delivery systems in review.

As physicians grapple with restrictive utilization review procedures, evidence indicates that these measures are not as cost effective as originally believed. Cost containment pressures from employers, limitations on price fixing and incentive arrangements all contribute to a further controlled environment for physicians practicing within HMOs. An SMG census reveals that HMO enrollment grew significantly in 1988, while the number of plans declined. The financial condition of the industry is improving, despite the demise of one of the largest plans. Successful plans are analyzing their market share and developing niche products to improve their position.

Health care delivery systems in review.

The defined HMO patient population is an ideal focus for quality of care studies. Current emphasis is on a combination of patient perception and clinical outcome data. HMOs are realizing the value of data not only in their internal operations, but in their marketing and sales efforts with employers and employees. HMOs' balance sheets are improving, and they are concentrating on new products to extend their market.

Health care delivery systems in review.

Physicians are seeking to maintain their practices in the midst of competitive pressures from various delivery systems. However, health maintenance organizations (HMOs) do not have the stronghold they had in the past. Several HMOs discontinued their Medicare risk contracts due to inadequate reimbursement rates, and others experienced financial losses in the October stock market crash. Independent practice associations (IPAs), the most popular HMO type, are particularly plagued by financial problems.

Financial woes and HMOs.

Reports emerging on the faltering viability of health maintenance organizations, as customers call for a closer analysis of trends and events affecting these providers

Growing pains. HMO market instability slows expansion.

While HMO financial performance continues to be weak and growth in the number of plans has slowed, enrollment showed surprising strength, confounding many experts who had predicted a drop off in people joining HMOs.

Health care delivery systems in review.

Plagued with insolvency, physician discontent, and employer demands, the health maintenance organization (HMO) industry is seeking solutions to their crippling ailments. As buyers are more difficult to find for troubled plans, some executives are forced to resign or face bankruptcy. Still other executives have been able to turn around their financial and physician staffing challenges. The preferred provider organization (PPO) industry remains in the background of the HMO turmoil, facing the issues of quality assurance and cost containment.

Health care delivery systems in review.

Health maintenance organizations (HMOs) exhibited serious financial problems in 1986, and the results for 1987 are anticipated to be similar. Solvency requirements for HMOs are under consideration in several states to prevent financial losses to providers and loss of health care to enrollees. Managers in HMOs will be paid higher salaries in the coming year than 3 years ago. This may add further to the financial burden of HMOs. In the meantime, Medicare and CHAMPUS contracts with the government may prove to be sources of new members for HMOs.

Health care delivery systems in review.

Health maintenance organizations (HMOs) continued to show financial distress throughout 1987, primarily due to higher utilization of outpatient services, rising costs of technology, and management of facilities. On the state level, concern over insolvent HMOs is resulting in proposed legislation for guaranty funds to ensure patient care and provider payment in the event of a bankrupt HMO. Ev en in light of these challenges, HMOs and their enrollment continue to climb, although not a past rates.

HMOs and PPOs in review.

The significance of the growth of health maintenance organizations (HMOs) and preferred provider organizations (PPOs) hinges on the reliability of the reported figures, which may not be accurate. The greatest changes in the industry over the past 3 months were evidenced in the areas of federal legislation regarding Medicare beneficiaries and military personnel, and within the industry itself, with numerous joint ventures and acquisitions. Dynamic changes continue, and the actors are becoming more clearly defined.

HMOs and PPOs in review.

The growth of health maintenance organizations (HMOs) and preferred provider organizations (PPOs) has continued in the past 3 months, marked by both an increase in numbers and enrollment. Independent practice associations (IPAs) have taken the lead as the dominant model type. The intensified activity and growth in HMOs have resulted in considerable discussion centering on cost containment and quality of care issues. Employers, enrollees, the Health Care Financing Administration, and the HMOs, each with its own vested interest in these issues, attempt to resolve the conflicts between the cost and quality of healthcare in prepaid plans.