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Maximum-containment laboratories are a unique and essential component of the bioeconomy of the United States. These facilities play a critical role in the national infrastructure, supporting research on a select set of especially dangerous pathogens, as well as novel, emerging diseases. Understanding the ecology, biology, and pathology at the human-animal interface of zoonotic spillover events is fundamental to efficient control and elimination of disease. The use of animals as human surrogate models or as target-host models in research is an integral part of unraveling the interrelated components involved in these dynamic systems. These models can prove vitally important in determining both viral- and host-factors associated with virus transmission, providing invaluable information that can be developed into better risk mitigation strategies. In this article, we focus on the use of livestock in maximum-containment, biosafety level-4 agriculture (BSL-4Ag) research involving zoonotic, risk group 4 pathogens and we provide an overview of historical associated research and contributions. Livestock are most commonly used as target-host models in high-consequence, maximum-containment research and are routinely used to establish data to assist in risk assessments. This article highlights the importance of animal use, insights gained, and how this type of research is essential for protecting animal health, food security, and the agriculture economy, as well as human public health in the face of emerging zoonotic pathogens. The utilization of animal models in high-consequence pathogen research and continued expansion to include available species of agricultural importance is essential to deciphering the ecology of emerging and re-emerging infectious diseases, as well as for emergency response and mitigation preparedness.

Youth with foster care experience are far more likely to face mental health challenges than their peers in the general population. Non-talk alternative treatments such as art therapy, movement therapy, music therapy, and equine-assisted psychotherapy show promise for these youth. However, as of now, there is no clear agreement between or guidance offered to states on whether alternative therapies are covered by Medicaid, which is the primary insurance for most youth with foster care experience. This paper offers policy recommendations on this issue in order to achieve equitable access to mental health care for youth with foster care experience.

Livestock research is paramount to understanding the risks associated with unintentional and intentional introductions of emerging, reemerging, and transboundary animal diseases, including their relationship to both the security of the economy and the nation’s food supply. Research involving large animal species conducted in maximum containment Biosafety Level (BSL)-3Ag and BSL-4 facilities include Health and Human Services and United States Department of Agriculture Select Agents that can have severe consequences on both animal agricultural industry and public health. This themed issue of ILARspans the spectrum of concerns related to this special niche within the animal research community with an emphasis on a review of available research, current trends, and novel approaches relevant to those conducting large animal research with high-risk agents and those charged with regulating those facilities and programs. Articles are authored by those embedded in the high- and maximum-containment community, directly involved with the work, detailing the unique challenges associated with BSL-3 and BSL-4 livestock research.

Objective. The purpose of this study was to determine the health status of adults with developmental disabilities residing in community settings and the quality of the preventive, medical, dental, and psychiatric services they receive.Methods. Data were collected on a sample of 353 adults residing in Los Angeles, California, in 1997. Historical data were obtained from study subjects or caregivers, physical and dental examinations were performed, blood was drawn for analysis, and a psychiatrist reviewed medical records for reports of psychiatric diagnoses and consultations.Results. Health markers, such as rates of obesity, and laboratory test results of routine screening panels including blood cell counts, hemoglobin, and hematocrits; blood concentrations of liver enzymes and other enzymes, cholesterol, and tryglycerides; and urinalyses were within normal limits for an adult population. However, preventive services were notably lacking, especially for individuals living at home. Fewer than half of the study subjects had received influenza vaccine; only a third of those living alone or with family or friends had received this vaccination. Chart audits revealed that about a third received psychotropic medications, but only 24% of these individuals had psychiatric consultations noted in their record. Further, 36% of this medicated group received psychotropic drugs without any identifiable diagnosis, and simultaneous receipt of two or more antipsychotics was not uncommon.Conclusions. Given that the U.S. health care system fails to ensure the provision of preventive services for all people, including the developmentally disabled, a systematic overhaul is necessary to establish an effective quality assurance program that will provide preventive medical, dental, and psychiatric services for people with developmental disabilities.

• To understand the educational needs of faculty general internists in academic hospital environments, surveys of general internal medicine division chiefs, department of medicine chairmen, and members of the Society for Research and Education in Primary Care Internal Medicine were undertaken. Results indicated considerable interest in faculty development activities among all physicians sampled. Division chiefs and department chairmen viewed such activities as feasible, potentially effective, and were willing to assume considerable responsibility in providing educational opportunities to their faculty. Although some physicians viewed self-learning as a potentially effective educational method, the vast majority preferred learning in a small group taught by an expert. Specific content areas for faculty development were assessed, as were the skills thought to be essential for personal job satisfaction, academic promotion, and organizational effectiveness.(Arch Intern Med 1987;147:1446-1451)

The content of care provided by 30 graduates of the UCLA Primex (Family Nurse Practitioner) program was examined. An encounter form similar to that used in the National Ambulatory Medical Care Survey was employed to code patients' complaints. These practitioners had been specifically trained to provide care for ambulatory patients. Data were collected one year after the completion of the university didactic phase of the program. We found that Primex practitioners spent more time with patients, more often employed traditional nursing functions, and more often used medical investigative procedures, such as x-rays and laboratory tests than did the physicians in the NAMC survey. Although the types of problems seen varied according to the organizational setting, these nurse practitioners were more often assigned routine health examinations and less often saw certain kinds of acute health care problems than had been anticipated in their training; 116 different types of symptoms or problems were presented, with a total of 1,170 encounters.

To compare three different approaches to the measurement of patients' expectations for care, we conducted a randomized controlled trial. Medical outpatients (n = 318) of a small (six-physician), single-specialty (internal medicine), academically affiliated private practice in Sacramento, California, were contacted by telephone the night before a scheduled office visit and enrolled over a 5-month period in early 1994. Patients were randomly assigned to receive: (1) a self-administered, structured, previsit questionnaire combined with a postvisit questionnaire; (2) an interviewer-administered, semistructured, previsit interview combined with a postvisit questionnaire; or (3) a postvisit questionnaire only. We assessed the number and content of patients' expectations by previsit questionnaire versus interview; the interaction between sociodemographic characteristics and survey method in predicting number of reported expectations; the effect of unfulfilled expectations elicited by questionnaire and interview on visit satisfaction; and the effect of unfulfilled expectations elicited directly and indirectly on visit satisfaction. Patients reported more expectations by structured questionnaire than semistructured interview (median 12 vs 3, p = .0001). Although there was no main effect of sociodemographic characteristics on expectations, nonwhite patients reported more expectations than white patients by questionnaire and fewer by interview. The number of interventions desired before the visit but not received (indirectly reported unfulfilled expectations) was associated with lower visit satisfaction regardless of whether a questionnaire or interview was used to elicit previsit expectations (p value for the interaction between number of expectations and survey method, & gt; .20). Having more indirectly reported unfulfilled expectations was significantly associated with lower visit satisfaction even after controlling for the number of directly reported unfulfilled expectations (p = .021), but the incremental change in classification accuracy was small (increase in receiver-operating characteristic curve area, 3%). In conclusion, studies of patients' expectations for care must contend with a substantial "method effect." In this study from a single group practice, patients checked off more expectations using a structured questionnaire than they disclosed in a semistructured interview, but both formats predicted visit satisfaction. Asking patients about interventions received in relation to their previsit expectations added little to simply asking them directly about omitted care. The interaction of survey method with ethnicity and other sociodemographic characteristics requires further study.

OBJECTIVE: To conduct a randomized clinical trial of the Spanish version of an educational program designed to be an adjuvant to adequate medical care of children with asthma. DESIGN: Randomized, clinical trial. SETTING: Los Angeles County, Calif. PARTICIPANTS: One hundred thirty-eight Hispanic children, ages 7 to 12 years, from disadvantaged families. All had used emergency facilities of major local hospitals in the previous year. MEASUREMENT/MAIN RESULTS: As the study proceeded, it became apparent that subjects were receiving inadequate medical and nursing care and had numerous barriers to applying knowledge and self-care skills gained from the program. Realizing this, we considered it unethical to allow the control children to suffer for the duration of the trial (1 year). Therefore, all children received "adequate" care from the research staff, and the randomized clinical trial, as originally designed, was ended. The emergency department/hospital use by both groups was significantly reduced compared with previous experience. CONCLUSION: Those researchers conducting randomized trials involving poor children should be aware of the potential ethical problems inherent in such ventures.(Arch Pediatr Adolesc Med. 1994;148:364-367)

To compare three different approaches to the measurement of patients' expectations for care, we conducted a randomized controlled trial. Medical outpatients (n = 318) of a small (six-physician), single-specialty (internal medicine), academically affiliated private practice in Sacramento, California, were contacted by telephone the night before a scheduled office visit and enrolled over a 5-month period in early 1994. Patients were randomly assigned to receive: (1) a self-administered, structured, previsit questionnaire combined with a postvisit questionnaire; (2) an interviewer-administered, semistructured, previsit interview combined with a postvisit questionnaire; or (3) a postvisit questionnaire only. We assessed the number and content of patients' expectations by previsit questionnaire versus interview; the interaction between sociodemographic characteristics and survey method in predicting number of reported expectations; the effect of unfulfilled expectations elicited by questionnaire and interview on visit satisfaction; and the effect of unfulfilled expectations elicited directly and indirectly on visit satisfaction. Patients reported more expectations by structured questionnaire than semistructured interview (median 12 vs 3, p = .0001). Although there was no main effect of sociodemographic characteristics on expectations, nonwhite patients reported more expectations than white patients by questionnaire and fewer by interview. The number of interventions desired before the visit but not received (indirectly reported unfulfilled expectations) was associated with lower visit satisfaction regardless of whether a questionnaire or interview was used to elicit previsit expectations (p value for the interaction between number of expectations and survey method, & gt; .20). Having more indirectly reported unfulfilled expectations was significantly associated with lower visit satisfaction even after controlling for the number of directly reported unfulfilled expectations (p = .021), but the incremental change in classification accuracy was small (increase in receiver-operating characteristic curve area, 3%). In conclusion, studies of patients' expectations for care must contend with a substantial "method effect." In this study from a single group practice, patients checked off more expectations using a structured questionnaire than they disclosed in a semistructured interview, but both formats predicted visit satisfaction. Asking patients about interventions received in relation to their previsit expectations added little to simply asking them directly about omitted care. The interaction of survey method with ethnicity and other sociodemographic characteristics requires further study.

A randomized clinical trial is in progress to evaluate an asthma educational program for Latino children and their parents. The intervention, "ACT—Asma Control y Trata miento Para Ninos,"was adapted from ACT for Kids,an asthma self-management pro gram for English-speaking families. Results of a pilot study indicated that socioeco nomic status was a critical variable to be considered in the design of such programs. Latino children and parents encounter significant barriers to access and continuity of medical care. Therefore, the intervention was redesigned to include "linkages" using a nurse to reduce barriers and to coordinate care. The lesson plans emphasize concrete, experimental learning experiences, with repetition of key points in each session.

This study responds to a Centers for Disease Control request to develop innovative case-finding methods and asks two questions 1) Will men participate in an anonymous telephone interview containing detailed questions about their sexual practices to enable screening for HIV-related risk? 2) Will individuals told they are at increased risk follow up by calling a toll-free number for additional AIDS information, counseling, or medical evaluation? Random-digit-dialed interviews were completed with 1610 adult men in Los Angeles County; the completion rate among eligible men was 68.3%. Nearly 43% of men were assessed at increased risk, half of whom described behaviors that placed them only at moderate risk and half of whom reported behaviors placing them at higher risk. Although the study found men were willing to provide personal risk-assessment information, only 14 of 343 men were willing to initiate a follow-up telephone call to the project counselors as the next step in case-finding.

In the United States, activities related to assessment of the quality of care have completed a cycle, first concerned with end-results or outcomes, then structural attributes (qualifications of institutions and providers), and processes of care. Over a half-century later, the importance of assessing outcomes of care is being re-examined. A review of existing approaches suggests that the results of surveillance are dependent upon the methods used. Process criteria should reflect the decision-making activities of providers, not a consensus of ignorance. Those outcomes of care that are dependent upon patients behaviors (change in habits, use of medication, etc) should be studied as a function of the types of provider-consumer interactions employed. Perhaps only individual consumer involvementcontrol in the processes of care will result in improved outcomes.

An attempt was made to introduce an innovation (nurse practitioners) into an organization (an outpatient clinic) using the format of a clinical trial. Staff physicians evaluated patients as to their acceptability for care by nurse practitioners before and after a 12-month trial. “Acceptable” patients were randomly assigned to control (regular clinic) and experimental groups (nurse practitioner care).

A private clinic was established in Los Angeles in late 1972 to perform acupuncture. Most individuals seeking treatment were middle-aged and well educated. All had considerable experience with traditional medical care for their problem. The principal reason for seeking care was relief from chronic pain. Thirteen per cent had received other nontraditional forms of therapy; over one-third indicated that they sought acupuncture as a "last resort." The results of certain psychological tests taken by these patients were within the range of normal. On completion of six or more treatments, 74 per cent said they had been helped; 54 per cent of those followed for three months and 24 per cent contacted one year later were improved. A subgroup of patients who received only temporary improvement had significantly different scores on psychological scales suggesting the results noted in this group may have been due to a "placebo" effect. A significant proportion of those who dropped out of treatment did so because they had achieved the desired benefits.

During a repeat of a previous study of nurse practitioners conducted at the University of Kansas, an opportunity occurred to examine the impact of two different styles of care provided by nurse practitioners on patients and physicians with whom they worked. The two nurse practitioners involved had similar backgrounds in terms of work experience. They participated in the same training program for nurse practitioners, practiced in the same environment, and cared for patients randomly allocated to one or the other practitioner. One practitioner saw her patients more often and for longer periods of time, ordered more medications, and less often sought physician consultation. She also was most optimistic regarding the impact of her services on patients' conditions. The other was more dependent upon physicians for validation of her actions. Physicians did not distinguish between the two practitioners in terms of their performance. However, patients cared for by the practitioner whose behavior suggested an integration of medical and nursing care processes saw nurses as a more common source of information about illness and demonstrated more significant shifts in preferences for services provided by nurses rather than physicians. No significant changes were noted from pretest values among patients cared for by the other nurse practitioner.

A major feature of a national survey of medical and surgical specialties is the development and application of an algorithm for classifying patient care services provided by physicians. The care classification reflects much of prevailing opinion regarding what constitutes primary and nonprimary care. The classification system provides a powerful tool for the analysis of patient care services, since it is based on conditions of access to care, the physician's role in providing the care, measures associated with continuity of care, and a proxy measure of comprehensiveness of care. Furthermore, it is based on the recordings by physicians of actual patient-encounter characteristics and is not operationally dependent on physician characteristics or propensities.(JAMA 241:2180-2185, 1979)

The authors developed and tested a model of two dimensions of physicians' behavior in counseling patients about four health habits (smoking, weight control, alcohol consumption, and regular exercise). The two dimensions are the indications for routine counseling and the aggressiveness of counseling style. To test these dimensions, a questionnaire was administered to a random sample of members of a Western County Medical Society in 1978. The response rate was 76. Indications and Aggressiveness subscales were developed for each habit. Reliability and discriminant validity for all subscales was excellent. Descriptive results were consistent with expectations, e.g., physicians counseled more about smoking and weight control than about alcohol and exercise. The results support the dimensions and suggest that the questionnaire will be useful for future research on counseling behavior.

Attitudes of physicians toward counseling patients about their smoking habits may influence whether and how counseling occurs. In this paper, the authors develop and test a conceptual model of these attitudes. The model includes four attitude dimensions physicians' motivations to counsel, perceived health risk of smoking, perceived skills in counseling, and perceived costs and benefits to the physician of counseling. A self-report questionnaire including a 40-item measure of these attitudes was delivered to a random sample of male general practitioners, internists, surgeons, and obstetrician—gynecologists who were members of a western county medical society in 1978. The response rate was 76. Based on factor analyses, 10 subscales and 3 global scales were formed by summing items. The item contents of scales are consistent with the authors' model, and reliability and item-discriminant validity are excellent. The authors' model may be useful in understanding the factors that affect the process and outcomes of physician counseling about smoking.

Clinical preventive medicine, efforts by clinicians to prevent disease in individual patients, is an important component of preventive medicine as a whole. Yet clinicians, including internists, apparently do not provide many preventive services of established effectiveness. This paper describes one approach to improving the practice of clinical preventive medicine: increased cooperation between general internists—one of the nation’s largest groups of primary care physicians—and specialists in preventive/community medicine. The paper summarizes a larger report prepared by two societies representing these disciplines: the Society for Research and Education in Primary Care Internal Medicine and the Association of Teachers of Preventive Medicine. It was found that the two disciplines have many common goals, and much to offer each other, but do not often collaborate. The report concludes with 14 recommendations for improving the practice of clinical preventive medicine, which suggest that such improvement can be achieved in part through strengthening working relationships between general internists and preventive/community medicine specialists.

A study was carried out to determine the extent of compliance of women with recommendations of physicians for annual Papanicolaou examinations. Eighty-six of 22,464 clinic patients seen at a teaching hospital returned for five successive annual examinations. The average annual rate of return was approximately 25 per cent. Review of office records from the practice of two groups of specialists providing care for upper-middle-class women demonstrated that in one practice 34 per cent of patients returned for an annual Papanicolaou smear. In the other, where letters were written to remind patients that they were due for such an examination, 48 per cent returned. Interviews conducted with a random sample of women seen by the private practitioners revealed no differences between compliant and noncompliant groups with reference to knowledge of the procedure, opinions about the value of test, personal experience with cancer, exposure to health education on cancer prevention, and attitudes regarding the prevention of cancer. Compliant patients more often admitted they were afraid of hearing the results of the examination.

Of 1,500 medical students at four medical schools, 1,053 anonymously and voluntarily completed questionnaires eliciting information on their knowledge and attitudes toward the Medicare program. Their responses indicate that 80% of them have little or no knowledge regarding the details of the program. Despite this lack of information, a large majority of the students have opinions which are, in general, negative. The attitudes and opinions expressed were remarkably homogeneous in each of the four classes at each school. There were differences between the schools which may depend upon the ecology of the school, ie, socioeconomic background of students and types of careers pursued by the graduates. On the basis of data available, it would seem that a significant proportion of medical students believe that their career plans have been altered by this legislation. This ranges from a high of 24.6% in the fourth-year class of school C to a low of 3.5% of the first-year class in school B.

A method for estimating the effectiveness of systems designed to monitor the occurrence of events within a population is described. Specific application of this model to the analysis of a control program for the surveillance of infectious disease in a university hospital is presented. A reporting system with three sources—physicians, nurses, and bacteriology laboratory—was instituted. The effectiveness of the system ranged from 61 to S3 per cent over a period of 12 months. There was considerable variation among the three sources in terms of their relative effectiveness in identification of patients with infections. Under the circumstances described, the most effective two–source reporting system would have been the physicians' discharge reports and bacteriology laboratory records.

An "epidemic" of polymer-fume fever involved 36 of 61 employees in one industry over a 90-day period. All of those involved demonstrated the classic history of an influenza-like syndrome, with fever and chills occuring several hours after exposure to the products of pyrolysis of polytetrafluoroethylene (Teflon). The majority of cases resulted from the smoking of cigarettes which were contaminated with a fine dust of this material. A study of pulmonary function of all workers involved demonstrated changes that could be accounted for only on the basis of smoking habits. Three persons experienced changes in pulmonary function consistant with mild obstruction of the airways, in association with the onset of symptoms. While no serious consequences were observed, the effects of these illnesses upon the health and productivity of the group could have been prevented.

A study, using the four-electrode impedance plethysmograph system, was completed to evaluate simultaneous variations in conduction of upper and lower body segments relative to displacement of blood volume during change in body position. Measurements of cardiac output were compared with simultaneous results by dye dilution methods as a means of assessing the use of impedance techniques to determine cardiac output during tilt table studies. Two groups, 48 healthy private pilots and 22 patients with diabetes mellitus, were tested and the results were compared.

A miniature respiratory rate and volume sensor has been developed and flight qualified at the Flight Research Center. This device weighs only 172 grams, is sufficiently rugged to perform in the flight environment, and small enough to be worn as an integral part of the pilot's personal equipment. The safe operation of this system in an hyperbaric, pure oxygen atmosphere, is demonstrated. Details for the fabrication of the system are described. Operational experience over a two year period is reported.