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Category: Ankle Introduction/Purpose: Numerous studies have attempted to study outcomes after total ankle arthroplasty (TAA). The majority of these studies are clinical in nature. There have been some reports that rheumatoid patients have better outcomes after TAA although there are papers that are contradictory. Objective outcome studies of gait after TAA usually measure outcome against a control group or ankle arthrodesis. No studies have attempted to measure objective outcomes of TAA based upon the preoperative diagnosis. Without objectively studying outcomes for patients with osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis, it is unclear whether a difference exists in outcomes after TAA. This study aims to answer the question: Is preoperative diagnosis predictive of outcome after total ankle arthroplasty? Methods: A retrospective review of 75 patients who underwent isolated TAA with a minimum one-year follow-up, including patient demographics, pre-operative diagnosis, and pre and postoperative gait studies was conducted. Gait function was evaluated for postoperative improvement using multivariate analysis to determine the influence of patient variables on parameters of gait. ANOVA was conducted to compare improvement in gait based on preoperative diagnosis. P-values of < 0.05 were considered statisticallysignificant. Results: Outcomes/p-values are listed in table 1. While not reaching statistical significance, a meaningful clinically important difference was seen across numerous parameters. Temporal Spatial Parameters Patients with RA had the slowest preoperative cadence the fastest postoperative cadence. They also had the greatest improvement in walking speed. Patients with osteoarthritis had the greatest increase in walking speed. KinematicParameters Patients with RA had the greatest improvement in maximum plantarflexion and the least improvement in maximum dorsiflexion. Patients with osteoarthritis had the least improvement in maximum plantarflexion and the most improvement in mean maximum dorsiflexion. Patients with osteoarthritis had the greatest improvement in total ROM. Kinetic Parameters Patients with RA had the greatest improvement in peak ankle power while patients with osteoarthritis had the greatest post-operative power. Conclusion: There is a lack of data supporting the optimal candidate for TAA. While statistical significance was not reached across a number of the parameters of gait analysis, a number approached statistical significance. Given the relatively small sample size, it is possible that a larger cohort would reach statistical significance. Patients with osteoarthritis generally had superior preoperative and postoperative parameters of gait while patients with RA had the greatest improvement in parameters of gait. Patients with post-traumatic arthritis consistently had less improvement than patients with either osteoarthritis or RA.

Category: Ankle Arthritis. Introduction/Purpose: Although recent studies have shown comparability of gait function following total ankle arthroplasty (TAA) and ankle arthrodesis, TAA is regarded to be functionally advantageous by preserving tibiotalar motion. However, it is unknown whether arthritic ankles with severe loss of sagittal plane motion are appropriate surgical candidates for arthroplasty. This study was undertaken to address the question: Is there a rationale for motion-preserving surgery in patients with little or no preoperative sagittal plane motion? Methods: A retrospective review of 76 patients who underwent isolated TAA with a minimum one-year follow-up, including patient demographics and pre and postoperative gait studies was conducted. Using a linear regression model, an effect size for total preoperative sagittal ROM was calculated, as well as effects of age, and patient demographics. Gait function was evaluated for postoperative improvement using multivariate analysis to determine the influence the variable on parameters of gait. P-values of < 0.05 were considered statistically significant. Results: Outcomes/p-values are listed in table 1. Temporal Spatial Older patients had slower preoperative/postoperative walking speeds, and increased age resulted in diminished function. Increased preoperative ROM predicted greater preoperative and trended towards greater postoperative step length. Greater preoperative ROM predicted less total improvement. Kinematic Age was predictive of improved postoperative plantarflexion with negligible clinical significance. Preoperative ROM predicted greater postoperative ROM although less improvement was noted. Preoperative/postoperative sagittal angle at toe off was greater with increased preoperative ROM. No improvement was detected. Preoperative and postoperative plantarflexion/dorsiflexion were both greater with increased preoperative ROM. Less overall improvement in plantarflexion was noted with greater preoperative ROM. Kinetic Preoperative ROM was predictive of greater preoperative/postoperative ankle power. Greater preoperative ROM resulted in less improvement in power. Conclusion: Irrespective of preoperative total sagittal range of motion, there was a statistically and clinically significant improvement in function as measured by multiple, objective parameters of gait. While pre-operative range of motion was predictive of overall post-operative gait function, patients with greater pre-operative range of motion experienced less overall improvement in gait. The data show that TAA can offer statistically significant, and clinically meaningful improvement in gait function and is a reasonable treatment alternative even in patients with end-stage tibiotalar arthritis who have very limited preoperative sagittal range of motion.

The present causal-comparative study examined the relation between school climate, ethnic identity, and academic futility among racially and ethnically minoritized students. The sample included 1721 racially and ethnically minoritized students identifying as Black, Asian, Latine, and Multiracial from 11 schools in the northeastern region of the United States. Regression models indicated a direct relation between the school climate subscales including School Connectedness, Safety, Character, Peer Support, Adult Support, Cultural Acceptance, Physical Environment, and Order and Discipline and academic futility for all groups in the study. Ethnic identity moderated the relation between school climate subscales and academic futility, although the impact differed across racial and ethnic groups. The present study's results highlight the similarities and differences in the educational experiences of minoritized students. The discussion provides recommendations for cultivating educational environments that are culturally affirming and informed to meet the needs of an increasingly diverse student population. Limitations and future directions are discussed., (Copyright © 2024. Published by Elsevier Ltd.)

Competing Interests: Conflicts of interest R.P.D. receives editorial stipends (Journal of Medical Internet Research Dermatology), royalties (UpToDate) and expense reimbursement from Cochrane Skin. He is an editor for Cochrane Skin, a dermatology section editor for UpToDate, a social media editor for the Journal of the American Academy of Dermatology and editor-in-chief of the Journal of Medical Internet Research Dermatology. The other authors declare no conflicts of interest.

Competing Interests: Conflicts of interest R.P.D. is a joint coordinating editor for Cochrane Skin, a dermatology section editor for UpToDate, a social media editor for the Journal of the American Academy of Dermatology (JAAD), editor-in-chief of the Journal of Medical Internet Research Dermatology, and a coordinating editor representative on Cochrane Council. The other authors declare they have no conflicts of interest.

Setting: In 2007, the US Centers for Disease Control and Prevention (CDC) revised its tuberculosis (TB) technical instructions for panel physicians who administer mandatory medical examinations among US-bound immigrants. Many US-bound immigrants come from the Philippines, a high TB prevalence country., Objective: To quantify economic and health impacts of smear- vs. culture-based TB screening., Design: Decision tree modeling was used to compare three Filipino screening programs: 1) no screening, 2) smear-based screening, and 3) culture-based screening. The model incorporated pre-departure TB screening results from Filipino panel physicians and CDC databases with post-arrival follow-up outcomes. Costs (2013 $US) were examined from societal, immigrant, US Public Health Department and hospitalization perspectives., Results: With no screening, an annual cohort of 35 722 Filipino immigrants would include an estimated 450 TB patients with 264 hospitalizations, at a societal cost of US$9.90 million. Culture-based vs. smear-based screening would result in fewer imported cases (80.9 vs. 310.5), hospitalizations (19.7 vs. 68.1), and treatment costs (US$1.57 million vs. US$4.28 million). Societal screening costs, including US follow-up, were greater for culture-based screening (US$5.98 million) than for smear-based screening (US$3.38 million). Culture-based screening requirements increased immigrant costs by 61% (US$1.7 million), but reduced costs for the US Public Health Department (22%, US$750 000) and of hospitalization (70%, US$1 020 000)., Conclusion: Culture-based screening reduced imported TB and US costs among Filipino immigrants.

Background On August 24, 2011, 31 US-bound refugees from Kuala Lumpur, Malaysia (KL) arrived in Los Angeles. One of them was diagnosed with measles post-arrival. He exposed others during a flight, and persons in the community while disembarking and seeking medical care. As a result, 9 cases of measles were identified. Methods We estimated costs of response to this outbreak and conducted a comparative cost analysis examining what might have happened had all US-bound refugees been vaccinated before leaving Malaysia. Results State-by-state costs differed and variously included vaccination, hospitalization, medical visits, and contact tracing with costs ranging from $621 to $35,115. The total of domestic and IOM Malaysia reported costs for US-bound refugees were $137,505 [range: $134,531 - $142,777 from a sensitivity analysis]. Had all US-bound refugees been vaccinated while in Malaysia, it would have cost approximately $19,646 and could have prevented 8 measles cases. Conclusion A vaccination program for US-bound refugees, supporting a complete vaccination for US-bound refugees, could improve refugees' health, reduce importations of vaccine-preventable diseases in the United States, and avert measles response activities and costs.

Background: Many U.S.-bound refugees travel from countries where intestinal parasites (hookworm, Trichuris trichuria, Ascaris lumbricoides, and Strongyloides stercoralis) are endemic. These infections are rare in the United States and may be underdiagnosed or misdiagnosed, leading to potentially serious consequences. This evaluation examined the costs and benefits of combinations of overseas presumptive treatment of parasitic diseases vs. domestic screening/treating vs. no program., Methods: An economic decision tree model terminating in Markov processes was developed to estimate the cost and health impacts of four interventions on an annual cohort of 27,700 U.S.-bound Asian refugees: 1) "No Program," 2) U.S. "Domestic Screening and Treatment," 3) "Overseas Albendazole and Ivermectin" presumptive treatment, and 4) "Overseas Albendazole and Domestic Screening for Strongyloides". Markov transition state models were used to estimate long-term effects of parasitic infections. Health outcome measures (four parasites) included outpatient cases, hospitalizations, deaths, life years, and quality-adjusted life years (QALYs)., Results: The "No Program" option is the least expensive ($165,923 per cohort) and least effective option (145 outpatient cases, 4.0 hospitalizations, and 0.67 deaths discounted over a 60-year period for a one-year cohort). The "Overseas Albendazole and Ivermectin" option ($418,824) is less expensive than "Domestic Screening and Treatment" ($3,832,572) or "Overseas Albendazole and Domestic Screening for Strongyloides" ($2,182,483). According to the model outcomes, the most effective treatment option is "Overseas Albendazole and Ivermectin," which reduces outpatient cases, deaths and hospitalization by around 80% at an estimated net cost of $458,718 per death averted, or $2,219/$24,036 per QALY/life year gained relative to "No Program"., Discussion: Overseas presumptive treatment for U.S.-bound refugees is a cost-effective intervention that is less expensive and at least as effective as domestic screening and treatment programs. The addition of ivermectin to albendazole reduces the prevalence of chronic strongyloidiasis and the probability of rare, but potentially fatal, disseminated strongyloidiasis.

The Centers for Disease Control and Prevention (CDC) works in conjunction with state, territorial, local and tribal agencies (STLTAs) to prevent the transmission of infectious agents. Issuance of confinement agreements using CDC Form 75.37 'Notice to Owners and Importers of Dogs' to importers of dogs that are not vaccinated or incompletely vaccinated against rabies is part of the agency's regulatory programme to prevent the entry of dogs infected with rabies. Although this is a regulatory programme that depends heavily on partnerships between CDC and STLTAs, CDC had never formally evaluated the acceptability of the confinement agreement process with these partners. Thus, a short survey of nine STLTAs was conducted to evaluate whether these partners have enough personnel and resources to implement the regulation and their general opinions of the confinement agreement process. The results illustrate that CDC partners are dissatisfied to some extent with the process, and there are multiple issues limiting their success in enforcing the regulation., (© 2015 Blackwell Verlag GmbH.)

Background: This study explored the effect of screening and treatment of refugees for latent tuberculosis infection (LTBI) before entrance to the United States as a strategy for reducing active tuberculosis (TB). The purpose of this study was to estimate the costs and benefits of LTBI screening and treatment in United States bound refugees prior to arrival., Methods: Costs were included for foreign and domestic LTBI screening and treatment and the domestic treatment of active TB. A decision tree with multiple Markov nodes was developed to determine the total costs and number of active TB cases that occurred in refugee populations that tested 55, 35, and 20 % tuberculin skin test positive under two models: no overseas LTBI screening and overseas LTBI screening and treatment. For this analysis, refugees that tested 55, 35, and 20 % tuberculin skin test positive were divided into high, moderate, and low LTBI prevalence categories to denote their prevalence of LTBI relative to other refugee populations., Results: For a hypothetical 1-year cohort of 100,000 refugees arriving in the United States from regions with high, moderate, and low LTBI prevalence, implementation of overseas screening would be expected to prevent 440, 220, and 57 active TB cases in the United States during the first 20 years after arrival. The cost savings associated with treatment of these averted cases would offset the cost of LTBI screening and treatment for refugees from countries with high (net cost-saving: $4.9 million) and moderate (net cost-saving: $1.6 million) LTBI prevalence. For low LTBI prevalence populations, LTBI screening and treatment exceed expected future TB treatment cost savings (net cost of $780,000)., Conclusions: Implementing LTBI screening and treatment for United States bound refugees from countries with high or moderate LTBI prevalence would potentially save millions of dollars and contribute to United States TB elimination goals. These estimates are conservative since secondary transmission from tuberculosis cases in the United States was not considered in the model.

Introduction: The Centers for Disease Control and Prevention is considering implementation of overseas medical screening of student-visa applicants to reduce the numbers of active tuberculosis cases entering the United States., Objective: To evaluate the costs, cases averted, and cost-effectiveness of screening for, and treating, tuberculosis in United States-bound students from countries with varying tuberculosis prevalence., Methods: Costs and benefits were evaluated from two perspectives, combined and United States only. The combined perspective totaled overseas and United States costs and benefits from a societal perspective. The United States only perspective was a domestic measure of costs and benefits. A decision tree was developed to determine the cost-effectiveness of tuberculosis screening and treatment from the combined perspective., Results: From the United States only perspective, overseas screening programs of Chinese and Indian students would prevent the importation of 157 tuberculosis cases annually, and result in $2.7 million in savings. From the combined perspective, screening programs for Chinese students would cost more than $2.8 million annually and screening programs for Indian students nearly $440,000 annually. From the combined perspective, the incremental cost for each tuberculosis case averted by screening Chinese and Indian students was $22,187 and $15,063, respectively. Implementing screening programs for German students would prevent no cases in most years, and would result in increased costs both overseas and in the United States. The domestic costs would occur because public health departments would need to follow up on students identified overseas as having an elevated risk of tuberculosis., Conclusions: Tuberculosis screening and treatment programs for students seeking long term visas to attend United States schools would reduce the number of tuberculosis cases imported. Implementing screening in high-incidence countries could save the United States millions of dollars annually; however there would be increased costs incurred overseas for students and their families.

Background: Refugees are at an increased risk of chronic Hepatitis B virus (HBV) infection because many of their countries of origin, as well as host countries, have intermediate-to-high prevalence rates. Refugees arriving to the US are also at risk of serious sequelae from chronic HBV infection because they are not routinely screened for the virus overseas or in domestic post-arrival exams, and may live in the US for years without awareness of their infection status., Methods: A cohort of 26,548 refugees who arrived in Minnesota and Georgia during 2005-2010 was evaluated to determine the prevalence of chronic HBV infection. This prevalence information was then used in a cost-benefit analysis comparing two variations of a proposed overseas program to prevent or ameliorate the effects of HBV infection, titled 'Screen, then vaccinate or initiate management' (SVIM) and 'Vaccinate only' (VO). The analyses were performed in 2013. All values were converted to US 2012 dollars., Results: The estimated six year period-prevalence of chronic HBV infection was 6.8% in the overall refugee population arriving to Minnesota and Georgia and 7.1% in those ≥6 years of age. The SVIM program variation was more cost beneficial than VO. While the up-front costs of SVIM were higher than VO ($154,084 vs. $73,758; n=58,538 refugees), the SVIM proposal displayed a positive net benefit, ranging from $24 million to $130 million after only 5 years since program initiation, depending on domestic post-arrival screening rates in the VO proposal., Conclusions: Chronic HBV infection remains an important health problem in refugees resettling to the United States. An overseas screening policy for chronic HBV infection is more cost-beneficial than a 'Vaccination only' policy. The major benefit drivers for the screening policy are earlier medical management of chronic HBV infection and averted lost societal contributions from premature death., (Published by Elsevier Ltd.)

Background: In-flight transmission risk of Mycobacterium tuberculosis is not well defined, although studies suggest it is low. The impact of flight-related tuberculosis (TB) contact investigations (TBCIs) on TB prevention and control is not well established, and they compete for resources with activities with established benefits. We sought to determine the risks and cost-benefits of using more restrictive criteria in comparison to the Centers for Disease Control and Prevention (CDC) 2008 protocol for TBCIs., Methods: The risk-benefits of a modified CDC protocol were analyzed in comparison to the 2008 CDC protocol using data from flight-related TBCIs conducted in the United States from 2007 through 2009. We predicted the numbers and characteristics of case-travelers that would be identified using each protocol's criteria, and results of the associated passenger-contacts' TB screening tests. The economic analysis compared the costs of TBCIs to avoided costs of TB treatment and mortality using a Return on Investment model., Results: The estimated in-flight transmission risk using a modified CDC protocol was 1.4%-19% versus 1.1%-24% for the 2008 protocol. Numbers of TBCIs and immediate costs to health departments were reduced by half. Long-term cost-benefits were comparable., Conclusions: CDC's modified protocol appears to be a feasible alternative that will conserve public health resources without jeopardizing the public's health., (Published by Elsevier Ltd.)

Background: Pretravel health consultations help international travelers manage travel-related illness risks through education, vaccination, and medication. This study evaluated costs and benefits of that portion of the health consultation associated with malaria prevention provided to US travelers bound for West Africa., Methods: The estimated change in disease risk and associated costs and benefits resulting from traveler adherence to malaria chemoprophylaxis were calculated from 2 perspectives: the healthcare payer's and the traveler's. We used data from the Global TravEpiNet network of US travel clinics that collect de-identified pretravel data for international travelers. Disease risk and chemoprophylaxis effectiveness were estimated from published medical reports. Direct medical costs were obtained from the Nationwide Inpatient Sample and published literature., Results: We analyzed 1029 records from January 2009 to January 2011. Assuming full adherence to chemoprophylaxis regimens, consultations saved healthcare payers a per-traveler average of $14 (9-day trip) to $372 (30-day trip). For travelers, consultations resulted in a range of net cost of $20 (9-day trip) to a net savings of $32 (30-day trip). Differences were mostly driven by risk of malaria in the destination country., Conclusions: Our model suggests that healthcare payers save money for short- and longer-term trips, and that travelers save money for longer trips when travelers adhere to malaria recommendations and prophylactic regimens in West Africa. This is a potential incentive to healthcare payers to offer consistent pretravel preventive care to travelers. This financial benefit complements the medical benefit of reducing the risk of malaria.

Background: In 2011, the Centers for Disease Control and Prevention modified its 2008 protocol for flight-related tuberculosis contact investigation initiation. The 2011 Modified protocol was implemented and replaced the 2008 CDC protocol based on comparative epidemiologic and economic analyses; this publication reports the economic analysis results., Methods: A return on investment model compared relative changes in tuberculosis disease treatment costs resulting from expenditures on tuberculosis contact investigations and latent tuberculosis infection treatment for the 2008 CDC and Modified protocols., Results: At moderate/high rates of latent tuberculosis infection and tuberculosis disease, positive returns on investment indicated each $1.00 spent on tuberculosis contact investigations and latent tuberculosis treatment resulted in more than $1.00 of savings from reduced tuberculosis disease treatment costs. Low rates of latent tuberculosis infection and tuberculosis disease resulted in negative returns on investment, indicating economic losses from tuberculosis disease treatment costs. There were smaller economic losses at low latent tuberculosis infection and tuberculosis disease rates with the Modified protocol in comparison to the 2008 CDC protocol, while both identified comparable numbers of persons at risk for tuberculosis., Conclusion: The Modified protocol for conducting flight-related tuberculosis contact investigations represents a better use of resources and protects public health., (Published by Elsevier Ltd.)

Background: Approximately 70,000 refugees are resettled to the United States each year. Providing vaccination to arriving refugees is important to both reduce the health-related barriers to successful resettlement, and protect the health of communities where refugees resettle. It is crucial to understand the process and resources expended at the state/local and federal government levels to provide vaccinations to refugees resettling to the United States., Objectives: We estimated costs associated with delivering vaccines to refugees at the Board of Health Refugee Services, DeKalb county, Georgia (DeKalb clinic)., Methods: Vaccination costs were estimated from two perspectives: the federal government and the DeKalb clinic. Data were collected at the DeKalb clinic regarding resources used for vaccination: staff numbers and roles; type and number of vaccine doses administered; and number of patients. Clinic costs included labor and facility-related overhead. The federal government incurred costs for vaccine purchases and reimbursements for vaccine administration., Results: The DeKalb clinic average cost to administer the first dose of vaccine was $12.70, which is lower than Georgia Medicaid reimbursement ($14.81), but higher than the State of Georgia Refugee Health Program reimbursement ($8.00). Federal government incurred per-dose costs for vaccine products and administrative reimbursement were $42.45 (adults) and $46.74 (children)., Conclusions: The total costs to the DeKalb clinic for administering vaccines to refugees are covered, but with little surplus. Because the DeKalb clinic 'breaks even,' it is likely they will continue to vaccinate refugees as recommended by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Refugees are highly vulnerable populations with limited access to health care services. The United States accepts 50,000-75,000 refugees for resettlement annually. Despite residing in camps and other locations where vaccine-preventable disease outbreaks, such as measles, occur frequently, refugees are not required to have any vaccinations before they arrive in the United States., Purpose: We estimated the medical and public-health response costs of a case of measles imported into Kentucky by a refugee., Methods: The Kentucky Refugee Health Coordinator recorded the time and labor of local, state, and some federal personnel involved in caring for the refugee and implementing the public health response activities. Secondary sources were used to estimate the labor and medical care costs of the event., Results: The total costs to conduct the response to the disease event were approximately $25,000. All costs were incurred by government, either public health department or federal, because refugee health costs are paid by the federal government and the event response costs are covered by the public health department., Conclusion: A potentially preventable case of measles that was imported into the United States cost approximately $25,000 for the public health response., Recommendation: To maintain the elimination of measles transmission in the United States, U.S.-bound refugees should be vaccinated overseas. A refugee vaccination program administered during the overseas health assessment has the potential to reduce the risk of importation of measles and other vaccine-preventable disease and would eliminate costs associated with public health response to imported cases and outbreaks., (Published by Elsevier Ltd.)

Research and development of prophylactic vaccines carries a high risk of failure. In the past, industry experts have asserted that vaccines are riskier to produce than other pharmaceuticals. This assertion has not been critically examined. We assessed outcomes in pharmaceutical research and development from 1995 to 2011, using a global pharmaceutical database to identify prophylactic vaccines versus other pharmaceuticals in preclinical, Phase I, Phase II, or Phase III stages of development. Over 16 years of follow-up for 4367 products (132 prophylactic vaccines; 4235 other pharmaceuticals), we determined the failure-to-success ratios for prophylactic vaccines versus all other products. The overall ratio of failures to successes for prophylactic vaccines for the 1995 cohort over 16 years of follow-up was 8.3 (116/14) versus 7.7 (3650/475) for other pharmaceuticals. The probability of advancing through the development pipeline at each point was not significantly different for prophylactic vaccines than for other pharmaceuticals. Phase length was significantly longer for prophylactic vaccines than other pharmaceuticals for preclinical development (3.70 years vs 2.80 years; p<.0001), but was equivalent for all 3 human clinical trial phases between the two groups. We conclude that failure rates, phase transition probabilities, and most phase lengths for prophylactic vaccines are not significantly different from those of other pharmaceutical products, which may partially explain rapidly growing interest in prophylactic vaccines among major pharmaceutical manufacturers., (Copyright © 2011. Published by Elsevier Ltd.)

Recently, several new vaccines have been recommended for adults. Little is known regarding the immunization purchase and stocking practices of adult primary care physicians. To determine the proportion of family practice and internal medicine physicians who routinely stock specific adult vaccines and their rationale for those decisions, we conducted a cross-sectional survey in 2009 of a national random sample of 993 family physicians (FPs) and 997 general internists (IMs) in the US. Of the 1109 respondents, 886 reported that they provide primary care to adults aged 19-64 years and 96% of these physicians stock at least one vaccine recommended for adults. Of those, 2% plan to stop and 12% plan to increase vaccine purchases; the rest plan to maintain status quo. Of the respondents, 27% (31% FPs vs 20% IMs) stocked all adult vaccines. We conclude that many primary care physicians who provide care to adults do not stock all recommended immunizations. Efforts to improve adult immunization rates must address this fundamental issue., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To explore the knowledge and attitudes of mothers of school-aged children toward influenza vaccination and assess what methods of communication about vaccination and its delivery work best among this audience., Methods: The authors conducted focus groups with mothers of school-aged children. Prior to the focus groups, investigators agreed on key themes and discussion points. They independently reviewed transcripts using systematic content analysis and came to an agreement on outcome themes., Results: Many study participants had misunderstandings about influenza vaccines and the definition of influenza. A common perception was that flu is a catch-all term for a variety of undefined illnesses, ranging from a severe cold to stomach upset. Few participants saw a societal benefit in vaccinating children to protect other populations (eg, the elderly)., Conclusions: This study represents a first step in understanding how mothers perceive influenza vaccination and for crafting effective communication to increase vaccination among school-aged children.

Purpose: The purpose of this study was to test the effectiveness of a minimal, tailored diabetes prevention program for families that could be delivered in elementary school settings., Methods: Families were eligible for the program if they had at least one child aged 8 to 12 years old attending the elementary school who was at high risk of developing type 2 diabetes mellitus. Families attended ten 90-minute sessions with exercise, cooking demonstrations, and healthy lifestyle lessons. Height, weight, and self-reported behavior were assessed in parents and height and weight in children before and after classes., Results: A total of 82 parents (2% men, 98% women) and 62 children (47% boys and 53% girls) enrolled in the program across 3 replications. Parents had an average weight loss from baseline to the end of the program of 1.5 lb (P = .05). There was a large increase in the number of parents who self-reported engaging in leisure-time physical activity as a result of participating in the program (14% vs 64%; P < .01). There were no changes in children's body mass index percentile or z score as a result of the program., Conclusions: Delivering a diabetes prevention program in an elementary school setting was effective for increasing diabetes-related knowledge, chronic disease awareness, and self-reported healthy behavior in low-income Spanish-speaking families.

Successful launches of recently licensed vaccines contrast with pharmaceutical industry concerns about unfavorable market conditions, making the status and future of vaccine development uncertain. We assessed trends in private-sector vaccine research and development for the period 1995-2008, using a global pharmaceutical database to identify prophylactic vaccines in preclinical, Phase I, Phase II, or Phase III stages of development. We counted companies that research and/or manufacture vaccines ("vaccine originators") and their vaccine products in each year. The global number of vaccine originators doubled (to 136), as did the number of prophylactic vaccine products in development (to 354); the majority of this growth was in preclinical and early phase clinical research. Because rapid growth in earlier research phases has not yet led to growth in Phase III, it is not yet clear whether recent industry expansion will translate to an increase in the number of available vaccines in the near future., ((c) 2009 Elsevier Ltd. All rights reserved.)

Objective: The goal was to determine the net return (gain or loss after costs were subtracted from revenues) to private pediatric medical practices from investing time and resources in vaccines and vaccination of their patients., Methods: A cross-sectional survey of a convenience sample of private medical practices requested data on all financial and capacity aspects of the practices, including operating expenses; labor composition and wages/salaries; private- and public-purchase vaccine orders and inventories; Medicaid and private insurance reimbursements; patient population; numbers of providers; and numbers, types, and lengths of visits. Costs were assigned to vaccination visits and subtracted from reimbursements from public- and private-pay sources to determine net financial gains/losses from vaccination., Results: Thirty-four practices responded to the survey. More than one half of the respondents broke even or suffered financial losses from vaccinating patients. With greater proportions of Medicaid-enrolled patients served, greater financial loss was noted. On average, private insurance vaccine administration reimbursements did not cover administration costs unless a child received > or = 3 doses of vaccine in 1 visit. Finally, wide ranges of per-dose prices paid and reimbursements received for vaccines indicated that some practices might be losing money in purchasing and delivering vaccines for private-pay patients if they pay high purchase prices but receive low reimbursements., Conclusions: We conclude that the vaccination portion of the business model for primary care pediatric practices that serve private-pay patients results in little or no profit from vaccine delivery. When losses from vaccinating publicly insured children are included, most practices lose money.

Objectives: The goals were to estimate nationally representative pediatric practices' costs of providing influenza vaccination during the 2006-2007 season and to simulate the costs pediatric practices might incur when implementing universal influenza vaccination for US children aged 6 months to 18 years., Methods: We surveyed a stratified, random sample of New York State pediatric practices (N = 91) to obtain information from physicians and office managers about all practice resources associated with provision of influenza vaccination. We estimated vaccination costs for 2 practice sizes (small and large) and 3 geographic areas (urban, suburban, and rural). We adjusted these data to obtain national estimates of the total practice cost (in 2006 dollars) for providing 1 influenza vaccination to children aged 6 months to 18 years., Results: Among all respondents, the median total cost per vaccination was $28.62 (interquartile range: $18.67-45.28). The median component costs were as follows: clinical personnel labor costs, $2.01; nonclinical personnel labor costs, $7.96; all other (overhead) costs, $10.43. Vaccine purchase costs averaged $8.22. Smaller practices and urban practices had higher costs than larger or suburban practices. With the assumption of vaccine administration reimbursement for all Vaccines for Children (VFC)-eligible children at the current Medicaid median of $8.40, the financial loss across all US pediatric practices through delivery of VFC vaccines would be $98 million if one third of children received influenza vaccine., Conclusion: The total cost for pediatric practices to provide influenza vaccination is high, varies according to practice characteristics, and exceeds the average VFC reimbursement.

Objective: To estimate the additional primary care visits needed for universal influenza vaccination of all US children and adolescents if all vaccinations occurred in primary care settings., Design: Cross-sectional design., Setting: Well-child care and other visits to primary care practices from the 2003-2004 Medical Expenditure Panel Survey., Participants: Children aged 5 to 18 years (n = 3047) with a usual source of care. Main Outcome Measure Percentage of children needing 0, 1, or 2 additional visits to be immunized against influenza in a 3-, 4-, or 5-month vaccination window., Results: In a 3-month window, if only well-child care visits were used for first immunization, 97% of 5- and 6-year-olds and 98% of 7- and 8-year-olds would need 1 or 2 additional visits for complete vaccination; 95% of 9- to 18-year-olds would need 1 visit. If instead all visits were used for immunization, 90% of 5- and 6-year-olds and 91% of 7- and 8-year-olds would need 1 or 2 visits; 78% of 9- to 18-year-olds would need 1 visit. Expanding the window to 4 or 5 months slightly reduces the need for additional visits. Nationally, using all opportunities for vaccination, 42 million additional visits would be needed in a generous 5-month window., Conclusions: Most children and adolescents would need additional visits for universal influenza vaccination, even if all existing visits were used as vaccination opportunities. Efficient methods for vaccinating large numbers of children and adolescents are needed if primary care practices are to provide influenza vaccine for all children.

The Advisory Committee on Immunization Practices (ACIP) recently recommended that all children 6 months to 18 years be vaccinated annually against influenza. Because pediatricians will be critical for implementing this recommendation, we assessed the characteristics of immunization providers associated with the greatest efforts to vaccinate children against influenza. Using a cross-sectional survey of 35 private pediatric clinics in Georgia, we found that adding extra hours for immunization during the influenza vaccination season and having a policy of allowing six or more vaccines to be delivered at one appointment were characteristics associated with a greater intent to vaccinate children in the 2004-2005 influenza vaccination season. Most respondents indicated that for their clinic to implement a universal childhood vaccination policy it would be important to have a formal recommendation from the ACIP and American Academy of Pediatrics, and to be assured that they could receive credits or refunds for unused vaccine.

Although influenza and pneumonia are largely vaccine-preventable, vaccination coverage rates are well below Healthy People 2010 goals. The aim of this study was to examine the costs and cost-effectiveness of three provider-based vaccination interventions in the hospital setting: standing orders programs (SOPs), physician reminders (PRs), and pre-printed orders (PPOs). Data on program operating costs and the numbers of patients who received influenza or pneumococcal vaccinations were collected from nine North Carolina hospitals. Results demonstrated that the additional cost per patient vaccinated in 2004 was US dollars 58 for SOPs, US dollars 90 for PRs, and US dollars 412 for PPOs. These findings suggest that SOPs are a cost-effective approach for increasing adult vaccination coverage rates in hospital settings.

Background: Influenza vaccination levels in older patients have changed little since the mid-1990s. Despite frequent health care visits by a majority of older persons, many missed opportunities continue to occur., Methods: Patients were eligible for the study if they were age 50 and older, had not received influenza vaccine during the current season and were making a scheduled visit to one of the 13 study sites in California, New York, or New Mexico for purposes other than vaccination. Through direct observation, we determined if office staff inquired about vaccination status, discussed vaccination, or both. We defined missed opportunities as failure to administer influenza vaccine to patients for whom it was indicated., Results: Missed opportunities increased steadily from October to January (P < 0.0001), and were more common when there was no inquiry or discussion (P < 0.00001), among patients aged 50-64 (P < 0.0001) and in California and New Mexico (P = 0.001). A classification tree analysis revealed that lack of inquiry and week of visit contributed most to missed opportunities., Discussion: Early in the vaccination season, missed opportunities were uncommon and specific inquiries into or discussion of vaccination did not appear necessary. In December and January, patients tended to be vaccinated only when vaccination was addressed during the visit. Efforts to remind patients about vaccination later in the vaccination season may be essential to achieving higher coverage in the U.S.

Recent supply interruptions of childhood vaccines have had negative impacts on U.S. public health policies and vaccine delivery. To understand how manufacturers perceive production incentives and disincentives, the Centers for Disease Control and Prevention (CDC) met with the four pharmaceutical firms that sold vaccines through CDC-negotiated contracts during 2002 and 2003. These meetings shed light on the regulatory burden, high costs of the delay between initial investment and sales, and higher costs of new technologies versus older vaccines. All four manufacturers are investing more in research and development because new technologies have advanced their ability to create vaccines not thought possible before.

Potential business losses incurred vaccinating adults against influenza have not been defined because of a lack of estimates for medical practice costs incurred delivering vaccines. We collected data on vaccination labor time and other associated expenses. We modeled estimates of per-vaccination medical practice business costs associated with delivering adult influenza vaccine in different sized practices. Per-shot costs ranged from USD 13.87 to USD 46.27 (2001 dollars). When compared with average Medicare payments of USD 11.71, per-shot losses ranged from US$ 2.16 to USD 34.56. More research is needed to determine less expensive delivery settings and/or whether third-party payers need to make higher payments for adult vaccinations.

Background: The content and context of the process of vaccinating older adults against influenza in outpatient settings has not been adequately described. Failure to appreciate the causal antecedents or precursors to the act of provider recommendation may explain why so many efficacious interventions identified by the U.S. Task Force on Community Preventive Services fail to be routinely implemented and why influenza immunization rates have remained static over the past decade., Methods: This study used critical path analysis from data collected during standardized workflow observations of patients more than 50 years of age from a convenience sample of 16 ambulatory care settings in San Diego, California; Rochester, New York; and Albuquerque, New Mexico. Observations were made from October 23, 2001 to January 31, 2002., Results: In this study, 62% (151/243) of patients observed during scheduled extended visits received influenza vaccinations. When operational, temporal, and clinical factors are examined altogether through critical path analysis, a model of seven critical organizational support, temporal, and clinical activities emerges that is able to predict 93% of the immunizations. Variation from the model predicts 73% of the missed opportunities., Conclusions: Vaccination of adults should not be seen as simply an incremental activity added to the general health encounter. Assuring a high rate of vaccination requires adequate time and operational support. Provider-patient discussion is more productively viewed as the culmination of the immunization process, not the beginning. Finally, this study indicates the potential need to identify and compare processes of care associated with other specific preventive services.

A cDNA clone coding for avian terminal deoxynucleotidyl transferase (TdT) has been isolated and sequenced. The size of this cDNA was 2545 bp with an open reading frame of 1521 bp and a predicted translation product of 58 kDa. Comparison of this TdT sequence with other known TdT sequences has revealed a very high degree of homology at both the DNA and predicted amino acid levels. The chicken TdT cDNA was expressed in a bacterial system and the protein was purified by affinity chromatography. The purified recombinant enzyme, with a specific activity of approximately 1700 U/mg protein, was significantly less active than TdTs from mammalian species. This finding correlates with the observation that TdT isolated from avian thymus has lower activity than that isolated from any mammalian thymus source. Northern blot hybridization analyses and reverse transcription PCR of RNA preparations were carried out with the chicken cDNA. The data generated from these experiments revealed that the TdT RNA was only expressed in the thymus and not in the bone marrow or the bursa of Fabricius during pre- and post hatching chicken development. These data suggest that while TdT is probably involved in N region addition in chicken T-cell receptor genes, it is unlikely to play a role in diversification of immunoglobulin genes.