Voluntary Health Insurance Coverage in California, 1961: A Report of the Bureau of Research and Planning, California Medical Association

Almost 7 out of every 10 of the estimated population of 16.2 million persons in California, were covered under some form of voluntary health insurance at the end of 1961. The forms of protection included hospital, surgical, regular medical and major medical expense benefits. The per cent of the civilian population of California covered for surgical benefits was slightly over 66 per cent, while 56 per cent were covered for regular medical expense benefits. Comparable percentages for the United States are approximately 74 per cent (hospital), 69 per cent (surgical), and 51 per cent (regular medical). While the percentage of the State's population covered for hospital and surgical expenses is below that for the United States, it is higher for regular medical expense benefits. The rate of increase in coverage for the different forms of health care protection in California exceeded the rate of population growth during the one-year period ending 1961. The foregoing summary and the information in the accompanying text, does not reflect the total number of persons in California who receive or are eligible for health care services. A large variety of government financed programs on local, state and federal levels either finance or provide such services to an estimated 40 to 50 per cent of the California population, which does not have voluntary health insurance coverage. No current data are available regarding the number of persons who do not desire voluntary health insurance coverage for a variety of personal or financial reasons.     

Current therapy of cutaneous melanoma

Melanoma is a growing public health problem. Optimal care of the melanoma patient is multidisciplinary, but plastic surgeons and other surgical specialties play a central role in the management of these patients. Although surgery remains the mainstay of therapy for melanoma, several recent clinical studies have helped to clarify the biology of the disease and have changed the patterns of care for patients with melanoma. The advent of lymphatic mapping for interrogation of regional lymph nodes and interferon as the first effective postsurgical adjuvant therapy have had a major impact on the care of melanoma in the United States and elsewhere. This article will review the current clinical approach and therapy for cutaneous melanoma. The diagnosis, prognostic variables, staging evaluation, current surgical and medical treatment, and follow-up guidelines for patients with all stages of melanoma are reviewed. Recent studies, controversies, and directions of future investigational therapies will be discussed.     

Medicine's Role in Health Care Cost Containment

During the 20th century, medicine has confronted a series of problems threatening health care delivery in the United States. Historically, crises developed related first to quality of care, later to access and finally to the current issue of cost. Factors responsible for the large increases in health care expenditures in the United States during the last decade include increased medical care costs, population and demand for care. Additionally, economy-wide inflation, advanced medical technologies, an aging population, the growth of health care facilities, expansion of third-party payment systems including Medicare and Medicaid and rising incomes per capita have occurred. Programs now exist, and others are being planned, through which physicians, individually in private practice and collectively through organized medicine, may confront this major challenge now threatening the very foundations of health care delivery in the United States.     

Vilray P. Blair, his surgical descendants, and their roles in plastic surgical development.

Perhaps one of the most historically well-known plastic surgeons is Vilray P. Blair. As commander of the U.S. Army corps of head and neck surgeons during World War I, he became well known for his work in posttraumatic reconstruction. Blair's efforts in the early part of this century helped to develop plastic surgery as a distinct surgical subspecialty in the United States. His prowess as a surgeon allowed him to build one of the largest plastic surgery centers in the country and to train many of the top young American surgeons. Blair excelled as a teacher. He produced academic surgeons such as James Barrett Brown and Bradford Cannon, who took the lead in the care of wartime injuries during World War II. At Valley Forge General Hospital, Blair's trainees dedicated themselves to the reconstruction of injured patients and trained other young plastic surgeons in the care of postwar trauma. This exceptional level of patient care resulted in the U.S. government recognizing plastic surgery as a subspecialty following World War II. Since that time, Blair's surgical descendants at Washington University have led the country in the development of new training concepts and ideals and have gone on to become leaders in plastic surgery worldwide.     

Reproduction in Hemophilia

Patterns of marriage and parenthood were studied in the families of 250 patients with severe hemophilia. The incidence of marriage among adult hemophiliacs was 82.5 percent that of age-matched males of the general United States population, as of 1968. Married hemophiliacs 30 years old or older had an average of 2.1 children each, as of 1971. In the periods 1950-1954 and 1960-1964, the numbers of children sired by hemophiliacs were 25 and 38 percent, respectively, of the numbers expected of age-matched men of the general United States population. This indicates a lesser ability or willingness to have children. The number of additional births to women who were already mothers of hemophiliacs was compared with that expected for women of the general population of the United States, matched for age and parity. In the years 1940 through 1954, the birthrates for the two groups were similar. However, in the years 1955-1968, the birthrate among carriers declined more rapidly than that in the general population. The improved medical treatment of hemophilia has apparently not resulted in a greater willingness of affected persons to transmit the defective gene.     

Non-surgical methods of contraception and sterilization

The Humane Society of the United States estimates that each year between 8 and 10 million dogs and cats enter shelters and 4-5 million of these animals are euthanized due to lack of homes. Many veterinarians within the United States recommend surgical sterilization for population control in dogs and cats. However, there are non-surgical methods to control reproduction. Pharmacologic methods of contraception and sterilization can be safe, reliable and reversible. Hormonal treatments using progestins, androgens, or gonadotropin releasing hormone (GnRH) analogs act to either directly block reproductive hormone receptor-mediated events, or indirectly block conception via negative feedback mechanisms. Immunocontraception, via vaccination against GnRH, the luteinizing hormone receptor or zona pellucida proteins, is also possible. Intratesticular or intraepididymal injections provide a method for non-surgical sterilization of the male dog and cat. Additional methods have been employed for mechanical disruption of fertility including intravaginal and intrauterine devices and ultrasound testicular ablation. Alternative approaches to surgical sterilization will be reviewed.     

Hispanic rhinoplasty in the United States,with emphasis on the Mexican American nose

Because an increasing number of Hispanic patients are seeking nasal surgical treatment, a critical analysis of 25 consecutive Hispanic rhinoplasties was performed. After a review of the patient data and preoperative photographs, a new classification was developed, based on the type of deformity rather than geographical origins (as previously used). A treatment paradigm is offered for each type of deformity. Type I involves a high radix, a high dorsum, and a nearly normal tip and is often referred to as a Castilian nose. Treatment consists of a closed functional reduction rhinoplasty, with dorsal reduction and minor tip changes. Type II involves a low radix, a normal dorsum, and a dependent tip and is a new designation. Treatment consists of a finesse rhinoplasty with a radix graft, minimal dorsal changes, use of a columellar strut for support, and open tip suturing. Type III involves a broad base, thick skin, and a wide tip deformity, with its worst expression in the mestizo nose. Treatment consists of a balanced rhinoplasty with minimal dorsal alteration but maximal lobular reduction and an open-structure tip graft. The following conclusions with respect to Hispanic rhinoplasty in the United States are important: (1) an enormous anatomical diversity of deformities is present, in contrast to Asian and black noses; (2) three distinct types of deformities have been identified, each of which requires a different surgical approach; (3) a wide variety of surgical techniques are necessary, in contrast to other ethnic noses; (4) conservative dorsal reduction is essential for type II and III noses; and (5) limitations imposed by the skin envelope are far less than presupposed, and the results are better than generally recognized. As the Hispanic population grows and becomes more prosperous, plastic surgeons in the United States can expect to encounter an increasing number of Hispanic patients requesting rhinoplasty.     

Where does blood go? Prospective observational study of red cell transfusion in north England

ObjectiveTo collect population based information on transfusion of red blood cells.DesignProspective observational study over 28 days.SettingHospital blood banks in the north of England (population 2.9 million).ParticipantsAll patients who received a red cell transfusion during the study period. Data completed by hospital blood bank staff.ResultsThe destination of 9848 units was recorded (97% of expected blood use). In total 9774 units were transfused: 5047 (51.6%) units were given to medical patients, 3982 (40.7%) to surgical patients, and 612 (6.3%) to obstetric and gynaecology patients. Nearly half (49.3%) of all blood is given to female recipients, and the mean age of recipients of individual units was 62.7 years. The most common surgical indications for transfusion were total hip replacement (4.6% of all blood transfused) and coronary artery bypass grafting (4.1%). Haematological disorders accounted for 15.5% of use. Overall use was 4274 units per 100 000 population per year.ConclusionIn the north east of England more than half of red cell units are transfused for medical indications. Demand for red cell transfusion increases with age. With anticipated changes in the age structure of the population the demand for blood will increase by 4.9% by 2008.

What is already known on this topic

There have been no systematic population based surveys on use of red cells in the United KingdomStudies in France and the United States have shown that more than half of transfused red cells go to surgical patients

What this study adds

In the north of England over half of red cells are given for medical indicationsRates of red cell transfusion rise steeply with advancing ageSmall increases in the number of elderly people will have large effects on demand     

BRONCHIAL ASTHMA—Patterns of Morbidity and Mortality in the United States, 1951-1959

On a nationwide basis, bronchial asthma occurs at the rate of 23 cases per 1,000 population. Young males develop bronchial asthma more readily and more severely than young females. Males dying from asthma outnumber females 2 to 1.Eight per cent of the asthmatic persons in the United States have not sought medical attention for this condition. Repeated attacks of severe bronchial asthma increase the likelihood of premature death.Approximately 6,000 deaths due to asthma occur annually in the United States, with a seasonal increase during the winter months. The estimated fatality rate of asthma in the general population is 1.5 deaths per 1,000 asthmatics.     

The diminutive supercolony: the Argentine ants of the southeastern United States

Native to Argentina and Brazil, the Argentine ant (Linepithema humile) is an invasive species that has become established on six continents and many oceanic islands. In several parts of its introduced range, including the western United States, southern Europe and Chile, the Argentine ant is unicolonial, forming extensive supercolonies. We examined population genetic structure and intercolony aggression in two regions of the introduced range of this species in the United States: California and the southeastern United States. Our results show that the southeastern L. humile population has high genotypic variability and strong intercolony aggression relative to the California population. In the California population, intercolony aggression was absent and 23 alleles were found across seven polymorphic microsatellite loci. However, in the Southeast, aggression between colonies was high and 47 alleles were present across the same seven loci in an equal number of colonies. We suggest that distinctly different colonization patterns for California and the Southeast may be responsible for the striking disparity in the genetic diversity of introduced populations. Southeastern colonies may have descended from multiple, independent introductions from the native range, undergoing a bottleneck at each introduction. In contrast, the California supercolony may have originated from one or more colonies inhabiting the southeastern United States, thus experiencing a double bottleneck. The differences in present-day distribution patterns between California and the Southeast may be due to the combined effect of two factors: lower winter temperatures in the Southeast and/or competition with another successful and widely distributed ant invader, the fire ant Solenopsis invicta.     

Flexner at 100: a brief view from Oxford

Of all the principles set out by Flexner in 1910, the most fundamental, that of academic and scientific excellence, is more relevant to medical education in the United Kingdom today than ever before. To realize this, undergraduate medical education (UGME) at Oxford has evolved to incorporate the tutorial method of teaching to promote independent and critical thought. Coupled with the usual didactic experiences, each medical student is also required to complete a 26-week research experience before going on to clinical study. Outcome measures reveal that Oxford graduates have consistently achieved highest marks in the U.K. equivalent of the United States Medical Licensing Examination. In contrast to UGME in the United Kingdom, postgraduate medical education (PGME) occurs largely outside the academy and often emphasizes the practical at the expense of the underlying Flexnarian principles of academic excellence. A reassertion of Flexner's belief that universities and medical schools should be the center for all medical education would greatly benefit PGME in the United Kingdom and be a tribute to Flexner's enduring legacy.     

Characterization of polymorphic microsatellites for the invasive grass Microstegium vimineum (Poaceae)

? Premise of the study: Microsatellite markers were developed for the invasive plant Microstegium vimineum (Poaceae) to assess its population structure and to facilitate tracking of invasion expansion. ? Methods and Results: Using 454 sequencing, 11 polymorphic and six monomorphic microsatellite primer sets were developed for M. vimineum. The primer sets were tested on individuals sampled from six populations in the United States and China. The polymorphic primers amplified di-, tri-, and tetranucleotide repeats with three to 10 alleles per locus. ? Conclusions: These markers will be useful for a variety of applications including tracking of invasion dynamics and population genetics studies.     

中国和美国大豆疫霉群体遗传结构的ISSR分析

为探究中国和美国大豆疫霉的遗传关系, 采用简单序列重复区间扩增多态性(ISSR)技术, 对来自中国黑龙江省、福建省和美国的3个大豆疫霉地理群体的遗传多样性进行了分析。通过13个ISSR引物对供试的111株大豆疫霉菌株进行扩增, 共得到102个ISSR条带, 其中多态性条带为88个, 占86%。遗传变异分析表明, 美国群体具有更高的遗传变异度; Nei’s 遗传相似性和主成分分析均显示, 中国福建群体与美国群体间的遗传相似性最高, 而福建群体与黑龙江群体间遗传相似性最低; 聚类分析显示, 供试菌株在88%的相似性水平上可区分为7个聚类组, 且美国群体分布于更多的聚类组中; Shannon-Wiener多样性指数也表明美国群体的遗传多样性最为丰富。综合分析表明, 本研究的结果不支持关于美国的大豆疫霉可能来源于中国的推测。     

An American's view of Canadian medical education.

Undergraduate medical education in Canada and the United States is remarkably similar, except for the fact that Canadian medical schools are supported by their provincial governments. However, the systems diverge sharply at the postgraduate level. In Canada, the number and specialty mix of residents are negotiated by medical schools in response to educational and social needs; in the United States, these factors are largely determined by hospital service needs. The Canadian systems of accreditation, certification and payment for medical education after graduation are much simpler than those of the United States, and the accreditation and certification systems are more objective. In addition, the US system promotes subspecialization and a costly specialty imbalance, whereas Canada''s system has achieved an appropriate balance of specialists and generalists. In general, Canadian medical education appears to be simpler, more accountable and more socially responsive.     

Estimating prehistoric American Indian population size for united states area: Implications of the nineteenth century population decline and nadir

Implications of a revised United States American Indian nadir population and the pattern of decline leading to it are examined. Substituting the new nadir for that used by Dobyns (1966) lowers by several million his estimates of Indian population for the United States (and Canada) area. These estimates then become more compatible with ones currently being suggested by other scholars. The nineteenth century decline leading to this nadir is found to be remarkably linear. Assuming linearity in decline from initial European contact through the eighteenth century, an aboriginal population estimate of 1,845,183 for the United States area may be extrapolated, along with estimates for intervening years. The nineteenth century decline is then graphed with the data extrapolated to 1492. The resulting pattern of population decline is quite different from the ones suggested by Mooney (1928) and Dobyns (1966).     

Africanization in the United States: replacement of feral European honeybees (Apis mellifera L.) by an African hybrid swarm

The expansion of Africanized honeybees from South America to the southwestern United States in <50 years is considered one of the most spectacular biological invasions yet documented. In the American tropics, it has been shown that during their expansion Africanized honeybees have low levels of introgressed alleles from resident European populations. In the United States, it has been speculated, but not shown, that Africanized honeybees would hybridize extensively with European honeybees. Here we report a continuous 11-year study investigating temporal changes in the genetic structure of a feral population from the southern United States undergoing Africanization. Our microsatellite data showed that (1) the process of Africanization involved both maternal and paternal bidirectional gene flow between European and Africanized honeybees and (2) the panmitic European population was replaced by panmitic mixtures of A. m. scutellata and European genes within 5 years after Africanization. The post-Africanization gene pool (1998-2001) was composed of a diverse array of recombinant classes with a substantial European genetic contribution (mean 25-37%). Therefore, the resulting feral honeybee population of south Texas was best viewed as a hybrid swarm.     

Incentivizing Patient Choices: The Ethics of Inclusive Shared Savings

Is it ethical to pay patients for selecting cheaper medical treatments? The healthcare system in the United States is notoriously profligate, at least in part because when insurers foot the bill, patients have little incentive to avoid wasteful treatments. One familiar means for dealing with this problem is for insurers to offer reduced co‐pays to patients who select cheaper treatments. Would it be ethical to take this one step further, beyond the zero bound, sharing the savings of cheaper treatments by positively paying the patients who select them? Schmidt & Emanuel recently proposed this policy of ‘Inclusive Shared Savings’ (ISS). This article examines various ethical objections to the idea.     

Canadian-Trained Medical Scientists View Canadian Academia From Their American Laboratories

Interviews with 98 Canadian-trained basic medical scientists currently employed in the United States reveal that they were attracted to the United States by the belief that greater career opportunities exist in the United States than in Canada.They attributed the failure on the part of Canada to attract scientists to Canada and to retain their own graduates to: (1) Poor recruiting methods and a failure on the part of Canadian employees to keep in touch with Canadian scientists in American graduate and postgraduate training positions. (2) Scarcity of research funds. (3) Lack of opportunity in Canada occasioned by the smaller number of medical schools and medical research institutions as compared to the United States. (4) The negative conservatism of Canadian academic circles occasioned by academic inbreeding, anti-Semitism, Anglophilia and the tight control of research, research funds and university appointments by an oldguard “establishment”.     

Factors influencing the emigration of physicians from Canada to the United States.

OBJECTIVE: To determine whether location of postgraduate medical training and other factors are associated with the emigration of physicians from Canada to the United States. DESIGN: Case-control study, physicians were surveyed with the use of a questionnaire mailed in May 1994 (with a reminder sent in September 1994), responses to which were accepted until Dec. 31, 1994. PARTICIPANTS: Physicians randomly selected from the CMA database, 4000 with addresses in Canada and 4000 with current addresses in the United States and previous addresses in Canada. OUTCOME MEASURES: Sex, age, location of undergraduate and postgraduate medical training, qualifications, practice location, opinions concerning residence decisions, current satisfaction and plans. RESULTS: The overall response rate was 49.6% (50.0% among physicians in the United States and 49.2% among those in Canada). Age and sex distributions were similar among the 8000 questionnaire recipients and the nearly 4000 respondents. Physicians living in the United States were more likely to be older (mean 53.2 v. 49.6 years of age), male (87% v. 75%) and specialists (79% v. 52%) than those practising in Canada. Postgraduate training in the United States was associated with subsequent emigration (odds ratio 9.2, 95% confidence interval 7.8 to 10.7). However, in rating the importance of nine factors in the decision to emigrate or remain in Canada, there was no significant difference between the two groups in the rating assigned to location of postgraduate training. Professional factors rated most important by most physicians in both groups were professional/clinical autonomy, availability of medical facilities and job availability. Remuneration was considered an equally important factor by those in Canada and in the United States. Six of seven personal/family factors were rated as more important to their choice of practice location by respondents in Canada than by those in the United States. Current satisfaction was significantly higher among respondents in the United States. Most physicians in each group planned to continue practising at their current location. Of Canadian respondents, 22% indicated that they were more likely to move to the United States than they were a year beforehand, whereas 4% of US respondents indicated that they were more likely to return to Canada. CONCLUSIONS: Factors affecting the decision to move to the United States or remain in Canada can be categorized as "push" factors (e.g., government involvement) and "pull" factors (e.g., better geographic climate in the US). Factors can also be categorized by whether they are amenable to change (e.g., availability of medical facilities) or cannot be managed (e.g., proximity of relatives). An understanding of the reasons why physicians immigrate to the United States or remain in Canada is essential to planning physician resources nationally.     

Environmental lead reduces the resilience of bald eagle populations

Bald eagles (Haliaeetus leucocephalus) are considered a recovery success in the United States after rebounding from near extirpation due to widespread use of the insecticide dichlorodiphenyltrichloroethane (DDT) in the twentieth century. Although abundances of bald eagles have increased since DDT was banned, other contaminants have remained in the environment with unknown influence on eagle population trends. Ingestion of spent lead (Pb) ammunition, the source of Pb most available to eagles and other scavengers in the United States, is known to kill individual eagles, but the influence of the contaminant on overall population dynamics remains unclear, resulting in longstanding controversy over the continued legality of the use of Pb in terrestrial hunting ammunition. We hypothesized that mortalities from the ingestion of Pb reduced the long-term growth rate and resiliency of bald eagles in the northeast United States over the last 3 decades. We used Holling's definition of resilience (the ability of a system to absorb changes of state variables, driving variables, and parameters and still persist) to quantify how reduction in survival from Pb-associated mortalities reduced the likelihood of population persistence. We used a population matrix model and necropsy records gathered between 1990 and 2018 from a 7-state area to compare population dynamics under current versus hypothetical Pb-reduced and Pb-free scenarios. Despite a robust increase in eagle abundances in the northeast United States over that period, we estimated that deaths arising from ingestion of Pb was associated with a 4.2% (females) and 6.3% (males) reduction in the asymptotic long-term growth rate (lambda). Comparison between real (current) and counterfactual (Pb-reduced and Pb-free) population dynamics indicated that the deaths from acute Pb poisoning were additive because the mortality events were associated with marked reduction in annual survival performance of hatchlings and reproductive females. These shifts in survival performance were further associated with a reduction in resilience for hatchling (95.4%) and breeding (81.6%) female eagles. Counterintuitively, the current conditions produced an increase in resilience (68.9%) for immature and non-breeding female eagles over hypothetical Pb-free conditions, suggesting that the population of eagles in the northeast United States reorganized (in a population dynamics sense) to ensure population expansion despite additive mortalities associated with Pb. This study can be used by state and federal wildlife managers or non-governmental organizations to inform policy surrounding the use of lead ammunition or to educate hunters on the population-scale effects of their ammunition choices.