Report of two preventive medicine job market surveys.

INTRODUCTION: The American Association of Public Health Physicians (AAPHP) conducted two surveys to explore the value of general preventive medicine/public health (GPM) training and board certification to physicians seeking GPM jobs. METHODS: The first survey reviewed advertisements in recent issues of four medical journals. The second surveyed physician registrants at the Prevention 99 meeting. RESULTS: The first survey screened about 18, 500 job advertisements. Of these, 1427 (7.7%) met the study's GPM screening criteria. Only 145 (10.6%) preferred an MPH, management, or related degree. Forty-one (2.9%) preferred a doctorate (MD/DO/PhD) and an MPH, management, or related degree. Only one (0. 07%) required or preferred GPM board certification. Results were consistent across market sectors (federal, state/local, academic, health care delivery) and across job roles (management, direct service, research, technical). The second survey gathered credential, job search, and employment data from 140 physician registrants at Prevention 99 (annual joint meeting of the American College of Preventive Medicine and the Association of Teachers of Preventive Medicine in March 1999). Seventy-eight (55.7%) reported that GPM training was of major importance in securing their current employment. Only 18.5% of physicians holding GPM jobs secured their current employment by responding to an advertisement. CONCLUSION: GPM board certification is of little or no value when competing for the vast majority of GPM-related jobs. RECOMMENDATION: The AAPHP recommends prompt coordinated action by national organizations representing GPM physicians to increase the number of job offerings preferring or requiring physicians with GPM board certification. A six-point action plan is proposed.

Reliability of telemedicine examination.

OBJECTIVES: To assess the reliability of telemedicine examination and identify the issues to be addressed if the conduct of physical examination and the reading of images and tracings by telemedicine are to be as reliable as conventional examination and reading. METHODS: Patients were examined both conventionally and by telemedicine in 12 clinics, and the results were compared. There were 1826 matched pairs of observations. Cardiac auscultation, echocardiography, electrocardiography, electroencephalography, obstetric ultrasonography, ophthalmologic examination, physical therapy assessment, pulmonary auscultation, and the reading of chest radiographs with telemedicine cameras and monitors were studied. The main outcome measure was agreement between the telemedicine findings and a criterion standard. RESULTS: For ophthalmology, physical therapy, and cardiac auscultation, 91.2% of the conventional findings and 86.5% of the telemedicine findings were identical or similar to the criterion standard. The kappa coefficient on matched-pair analysis was 0.66. For pulmonary auscultation and reading of chest films with a telemedicine camera and monitor abnormalities were suppressed at default settings but subsequently revealed with extensive manipulation of system settings. For tracings and images, both conventional and telemedicine findings showed 92% reliability, with a kappa coefficient of 0.87. CONCLUSIONS: On the basis of these observations and the methods used, reliability varied with the type of examination, clinician experience with telemedicine, and participant knowledge of system limitations. Clinicians without experience or knowledge of system limitations missed findings of clinical importance. Improvements in equipment since the clinics were conducted in 1994 may have resolved some of these problems. Our findings raise doubts about the reliability of occasional telemedicine consultations by clinicians inexperienced in the technology.

Snow Mountain agent gastroenteritis from clams.

A 1983 investigation of two clambake-related gastroenteritis outbreaks in Rochester, New York, showed that 84 (43%) of 196 persons interviewed had an acute illness characterized by watery diarrhea, vomiting, and abdominal cramps. None of the ill persons were hospitalized or had complications. Illness was associated with eating raw (p = 0.002) or baked (p less than 0.01) hard-shell clams, with the risk of illness increasing with the total number of clams consumed (p less than 0.01). The median incubation period and duration of illness were 36 and 44 hours, respectively. Stool samples obtained 2-4 days after onset of illness were negative for commonly recognized bacterial and viral pathogens. However, of 31 persons whose stools were tested, the stool of only one ill person was positive by enzyme-linked immunosorbent assay for the Snow Mountain agent, one of the Norwalk-like viruses. Paired serum specimens from six (67%) of nine ill and two (29%) of seven well persons showed a fourfold or greater rise in antibody titer to Snow Mountain agent. Persons who ate clams were more likely to seroconvert to Snow Mountain agent (eight of 12) than were those who did not eat clams (zero of four) (p = 0.04). The clams were harvested off the coast of southern Massachusetts in late October, when harvest waters were documented to be contaminated by untreated municipal sewage. This report describes the first documented outbreak of shellfish-associated gastroenteritis attributed to Snow Mountain agent of which we are aware.

Single-dose cefuroxime axetil in the treatment of uncomplicated gonorrhea: a controlled trial.

One hundred eighty-four patients were enrolled in a randomized study that evaluated the efficacy and toxicity of a single dose of orally administered cefuroxine axetil in the treatment of men and women with uncomplicated gonorrhea. Sixty-two patients received cefuroxine axetil alone, 62 received cefuroxine axetil and probenecid, and 60 received amoxicillin plus probenecid. Cure rates in the three groups were 98%, 98%, 96%, respectively. Only 2% of patients who received cefuroxine axetil alone complained of nausea, as compared with 11% of those who received a regimen that contained probenecid (P less than .05). The results show that cefuroxime axetil is effective and nontoxic in the treatment of uncomplicated gonococcal infections in adults.

The selective utilization of prenatal genetic diagnosis. Experiences of a regional program in upstate New York during the 1970s.

The regional prenatal diagnosis program of the Finger Lakes Health Systems Area in upstate New York has been monitored since its start in 1971. By the end of 1980, more than 1,250 diagnostic procedures had been successfully completed. Based on analyses of regional vital statistics, genetic services data, repeated surveys of obstetricians, and an ongoing survey of recent mothers older than 34 years of age, the authors concluded that: 1) in the study region, most women with an indication for prenatal diagnosis because of age are aware of the possibility of prenatal diagnosis; 2) the majority of obstetricians discuss amniocentesis with their patients; 3) after a period of rapid growth the utilization rate in the study region reached about 40% in 1981; 4) nonuse of prenatal diagnosis is based mostly on a patient's decision rather than system deficiencies; and 5) a community approach to increase utilization will have to focus on how to provide a supportive social climate for these services rather than on increasing awareness among potential patients or more referrals by providers.

Kawasaki syndrome: description of two outbreaks in the United States.

Investigation of two outbreaks of Kawasaki syndrome (KS) in the United States in 1979 and in 1980 revealed no evidence of person-to-person transmission or of a common-source exposure among patients. Questionnaire data showed that KS was more likely to occur in children of middle and upper socioeconomic status than in those of lower status (P less than 0.05 and P less than 0.001 for the respective outbreaks) and that patients with KS had a higher incidence of an antecedent, primarily respiratory illness than did controls matched for age, sex, and race (83% of patients in the first outbreak vs. 30% of one control group, P less than 0.01, and vs. 36% of another control group, P less than 0.02; and 56% of patients in the second outbreak vs. 32% of their controls, P less than 0.02). However, laboratory studies did not identify an etiologic agent for either KS or for the antecedent illness that may be a risk factor for KS.

An evaluation of penicillin prophylaxis during an outbreak of foodborne streptococcal pharyngitis.

Between August 16 and 21, 1974, an outbreak of beta-hemolytic group A M-9 T-9 streptococcal pharyngitis affected 49% of a randomly selected group of inmates at a jail in southern Florida. Food-specific attack rates incriminated improperly stored egg salad served at lunch on August 16 as the vehicle of transmission. By August 20, 290 symptomatic inmates had been placed on penicillin or erythromycin; on that day fewer than 5% of throat cultures from 400 allegedly non-penicillin-allergic largely asymptomatic inmates, cultured just before penicillin prophylaxis, were positive for the epidemic strain. At the time prophylaxis was given, secondary transmission had accounted for only 3% of cases. No non-suppurative sequelae were observed but 5% of inmates who received penicillin prophylaxis experienced an adverse reaction to the drug. Although widespread penicillin prophylaxis during outbreaks of group A beta-hemolytic streptococcal pharyngitis will likely prevent transmission of these organisms, prompt treatment of all symptomatic cases may be equally as effective in controlling adult institutional foodborne outbreaks of streptococcal pharyngitis and will likely minimize the number of adverse reactions to penicillin which may be seen.

Waterborne typhoid fever in Dade County, Florida. Clinical and therapeutic evaluation of 105 bacteremic patients.

An extensive outbreak of waterborne typhoid fever occurred in 1973 at a migrant labor camp in Dade County, Florida. Blood cultures from 105 of the 188 patients with proved or presumptive cases of typhoid fever grew Salmonella typhi. The clinical and laboratory findings in these patients were reviewed. Fever, usually with temperatures above 38.8 degrees C and of the sustained type, was a primary manifestation of disease, although a majority of the patients also complained of headache and gastroenteric symptoms. Hepatic or splenic enlargement was present in 52 per cent and 42 per cent, respectively, whereas rose spots were detected in only 13 per cent. The total leukocyte count was normal in 74 per cent, but serum levels of liver and muscle enzymes were frequently elevated. Gastrointestinal, pulmonary and neurologic complications were infrequent; circulatory failure was not observed. Defervescence in response to antibiotic therapy was variable; however, the median response among 68 patients who received chloramphenicol was two days less than that in 34 patients treated with ampicillin. There was one possible treatment failure with ampicillin. The relapse rate of 10 per cent in chloramphenicol-treated patients was not significantly greater than the 3 per cent rate among those treated with ampicillin. Serologic studies for typhoid fever were of limited diagnostic value since the titer of agglutinins was 1:160 or higher in 49 per cent of the serums obtained before treatment, and a fourfold rise in titer occurred in only 24 per cent of 57 patients studied. The serologic response to chloramphenicol treatment did not differ from that to ampicillin.