The US health system: on the brink of major change?

The US system has both considerable strengths and notable weaknesses. It has a large and well-trained health workforce, a wide range of high-quality medical specialists as well as secondary and tertiary institutions, a robust health sector research program, and, for selected services, among the best medical outcomes in the world. But it also suffers from incomplete coverage of its citizenry, health expenditures levels per person far exceeding all other countries, poor objective and subjective indicators of quality and outcomes, and an unequal distribution of resources and outcomes across the country and among different population groups. Because of the adoption of the Affordable Care Act in 2010, and subsequent revisions to it, the US is facing a period of enormous change. There is a great need to improve coverage and improve equity, better ensure quality outcomes, and find ways to better control expenditures.

Geography of the circadian gene clock and photoperiodic response in western North American populations of the three-spined stickleback Gasterosteus aculeatus

Controlled laboratory experiments were used to show that Oregon and Alaskan three-spined stickleback Gasterosteus aculeatus, collected from locations differing by 18° of latitude, exhibited no significant variation in length of the polyglutamine domain of the clock protein or in photoperiodic response within or between latitudes despite the fact that male and female G. aculeatus are photoperiodic at both latitudes. Hence, caution is urged when interpreting variation in the polyglutamine repeat (PolyQ) domain of the gene clock in the context of seasonal activities or in relationship to photoperiodism along geographical gradients.

Licensed nursing staff reductions and substitutions in Pennsylvania hospitals, 1991-1997

Nurses report a decline in RN/patient and skill mix in the 1990s while quantitative studies fail to confirm this. This study examines aggregate hospital nursing staff in Pennsylvania from 1991-1997, focusing on changes in licensed nursing staff. It finds that licensed nursing staff declined while nursing assistants increased in this period. With adjustment for patient acuity, there was a slight decrease in RN/adjusted patient days of care (APDC), a 23% decrease in LPN/APDC, and a 4% decrease in licensed nurse/APDC. The RN/nurse ratio increased slightly, and licensed nurse/nurse fell slightly. Since RNs often operate in environments which make use of teams of licensed staff, nurses' perceptions of a decline in the RN/patient ratio is a result of the decline in licensed staff/APDC, and of an increase in patient acuity.

Clinical efficacy of doxycycline for pleurodesis

To determine the efficacy of doxycycline as a pleural sclerosing agent, we examined the outcomes in 31 patients (aged 31 to 87 years) receiving doxycycline (500 to 1,000 mg) through a chest tube for malignant pleural effusions or persistent bronchopleural fistulae. Of the 27 patients with malignant pleural effusions, 21 patients had a complete short-term response (no fluid reaccumulation during the initial hospitalization); 5 of the 6 short-term nonresponders had partial control of effusions, with improvement in respiratory symptoms. Of the 23 patients who survived longer than 1 month, 15 patients did not have reaccumulation of fluid during follow-up. All four patients with persistent bronchopleural fistulae had resolution of their air leaks; one patient had recurrence with a partial pneumothorax. Pleural pain controllable with narcotic therapy was the only important complication. Thus, doxycycline is a suitable substitute for tetracycline as a pleural sclerosing agent.

Detection of carcinogen-DNA adducts in exfoliated urothelial cells of cigarette smokers: association with smoking, hemoglobin adducts, and urinary mutagenicity

The presence of covalent modifications in DNA obtained from exfoliated urothelial cells of smokers and nonsmokers was determined using 32P postlabeling methods. Urine and blood samples were procured from 73 persons. Cells were removed from the urine by filtration. DNA was isolated using an enzyme-solvent extraction method and then coprecipitated with glycogen. Sufficient DNA to detect 1 carcinogen-DNA adduct/10(9) normal nucleotides was obtained from 40 of the 73 samples. DNA was hydrolyzed to 3'-phosphodeoxynucleotides and then 32P postlabeled under conditions of excess [32P]ATP. Carcinogen-DNA adducts were resolved using anion-exchange thin-layer chromatography and visualized by autoradiography; film exposures lasted as long as 7 days. Twelve different carcinogen-DNA adducts and a diagonal zone of radioactivity could be found, but no sample contained all adducts. At least four adducts appeared to be cigarette smoking related. These adducts were from 2 to 20 times higher in the smokers than the nonsmokers. Two carcinogen-DNA adducts were qualitatively very similar to adducts described earlier in a study of human bladder biopsies. One of these corresponded to N-(deoxyguanosin-8-yl)-4-aminobiphenyl. Adducts were correlated significantly with the levels of 4-aminobiphenyl hemoglobin adducts and number of cigarettes smoked. In addition, levels of the putative N-(deoxyguanosin-8-yl)-4-aminobiphenyl adduct and a measure of total adducts were correlated with the mutagenic activity of the individual's urine. These data suggest that noninvasive, biological monitoring techniques can be applied to the study of carcinogen-DNA adducts in humans at high risk for bladder cancer.