Professional Registered Nurses in the United States and California, 1962—Report of the Bureau of Research and Planning

• Figures on professional registered nurses recently made available indicate that the ratio of active nurses to population in California in 1962 was 327 per 100,000 persons. The comparable figure nationally was 298/100,000. California ranked twentieth out of the 50 states and the District of Columbia.The percentage of all nurses actively engaged in nursing is considerably lower in California than in the total United States: 60.4 per cent compared with 65.3 per cent. This indicates that the shortage of nurses in California is more attributable to underutilization of potential manpower than to its absence.There are some identifiable categories of nurses in California in which the utilization of personnel is particularly low, as compared with other states. In terms of rates of utilization, the group of nurses over 60 years of age are most noticeably under-utilized, while in terms of numbers, married nurses could provide the greatest supply of extra nurses were their employment rate in the state equal to the national rate.The recruiting potential is a very great one, however, as this report indicates.     

Mass surveys and selective case-finding; two tools for tuberculosis control

The productivity and effectiveness of the traditional mass x-ray survey method of tuberculosis case-finding were compared with those of a selective use of mobile miniature x-ray equipment. In Tulare County, California, two mobile miniature x-ray units were operated independently of each other. One unit conducted community-wide, pre-planned surveys, while the other unit operated a regular weekly schedule of mobile screening clinics in four cities in the county. THE MAIN FEATURES OF THE SELECTIVE SCREENING PROGRAM WERE: (1) Extensive use of the physician referral method; (2) utilization of the unit for contact contact investigation; (3) interpretation of the minifilm and mailing of film and report to the family physician one day after the screening clinic.RESULTS: Mass survey found one case of tuberculosis per 2,200 minifilms taken; cost per case found, $475. Selective screening program found one case per 292 minifilms taken; cost per case found, $111. Of all cases of tuberculosis reported in 1953, 8 per cent were found by mass survey and 18 per cent by selective screening.     

Voluntary Health Insurance Coverage in California, 1952 to 1963—Report of the Bureau of Research and Planning

More than seven out of every ten of an estimated civilian population of 17.3 million people in California were covered under some form of voluntary health insurance at the close of 1963.Between 1952 and 1963, the number of Californians covered for hospital expenses increased from 5.7 million to 12.3 million; for surgical expenses from 5.4 million to 11.6 million; and for regular medical expenses from 3.0 million to 10.1 million.The percentage covered by health insurance also rose significantly: for hospitalization, from 51.3 to 71.0 per cent; for surgical, from 48.2 to 67.1 per cent; and for regular medical from 27.2 to 57.9 per cent. The rate of increase in hospitalization coverage was slightly higher in California than in the total U.S.; however, the per cent of persons covered remains lower. For surgical coverage, both the rate of increase and the per cent covered are lower in California. For regular medical, growth rates in California and in the U.S. were similar, however the over-all per cent covered is significantly higher in California.Major medical coverage, which has shown the fastest growth rate, covered only 0.4 per cent of the U.S. population in 1952 and 17.1 per cent by the end of 1963. Comparable figures for California are not available.     

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.     

Results of irradiation in cancer of the lip,tongue and ear

CANCER OF THE LIP: The primary lesion can be controlled by irradiation in approximately 80 per cent of cases. For lesions with metastases there is only about a 25 per cent chance of five-year arrest (irradiation of the primary lesion followed by excision of involved nodes). CANCER OF THE TONGUE: Lesions in the anterior two-thirds are controllable by irradiation in about 50 per cent of cases if the nodes are not involved; the salvage is only about 15 per cent if the nodes are involved (nodes treated surgically). Lesions in the posterior third of the tongue are seldom controlled in the author's experience. CANCER OF THE EAR (AURICLE): Five-year arrest of basal-cell lesions should be attained by irradiation in about 80 per cent of cases; of squamous-cell lesions in about 60 per cent. If the lesion is extensive, radiation does not offer a superior cosmetic result to operation and entails danger of late chondronecrosis. Therefore extensive lesions are probably best treated surgically. In either event, it appears probable that results of irradiation can be improved by the use of more adequate fields and greater fractionation.     

Organization of Enzymes in the Polyaromatic Synthetic Pathway: Separability in Bacteria

ULTRACENTRIFUGATION IN SUCROSE DENSITY GRADIENTS WAS EMPLOYED TO ESTIMATE THE MOLECULAR WEIGHTS AND TO DETERMINE POSSIBLE PHYSICAL AGGREGATION OF THE FIVE ENZYMES CATALYZING STEPS TWO TO SIX IN THE PRECHORISMIC ACID PORTION OF THE POLYAROMATIC SYNTHETIC PATHWAY IN SIX SPECIES OF BACTERIA: Escherichia coli, Salmonella typhimurium, Aerobacter aerogenes, Bacillus subtilis, Pseudomonas aeruginosa, and Streptomyces coelicolor. The five enzymes were not aggregated in extracts of any of the species examined, nor are the genes encoding these enzymes clustered in those bacterial species for which genetic evidence exists. (An initial examination of the blue-green alga Anabaena variabilis indicates nonaggregation in this species also.) This situation in bacteria is in marked contrast to that found in Neurospora crassa and other fungi in which the same five enzymes are associated as an aggregate encoded (at least in the case of N. crassa) by a cluster of five genes. In addition, also in contrast to N. crassa, no evidence was obtained for more than one kind of dehydroquinase activity in any of the bacteria examined. These comparative results are discussed in relation to the origin, evolution, and functional significance of the gene-enzyme relationships existing in the early steps of aromatic biosynthesis in bacteria and fungi.     

MATERNAL AND PERINATAL DEATHS IN CALIFORNIA

In a 29-month period, 151 of 373 deaths of California women occurring during or within 90 days of termination of pregnancy were studied jointly by the California Medical Association and the California State Department of Public Health. Twenty-two per cent of the deaths reviewed were considered unavoidable. In 74 per cent, one or more avoidable factors were identified. Avoidable factors could not be identified in 4 per cent of the cases.Thirty-three per cent of the cases considered to have avoidable factors were attributed to be solely the responsibility of the attending physician. Inadequate hospital facilities were held responsible in less than 1 per cent of deaths, while responsibility in 26 per cent of the deaths was laid directly to patient error or refusal. In 40 per cent of the avoidable deaths, more than one avoidable factor was identified.Nonobstetric conditions accounted for the greatest proportion of the deaths, followed by hemorrhage, toxemia of pregnancy, sepsis, abortion and ectopic pregnancy.The findings of this study compare closely with those of similar studies in other states, including Minnesota and Massachusetts.     

Rate of potassium exchange of the human erythrocyte

1. The exchange of potassium by the human erythrocyte has been studied in vitro using radioactive potassium. 2. An incubation technique which maintains erythrocytes in an essentially normal state for over 48 hours was employed. 3. Exchange of radioactive potassium between the red cells and the extracellular fluid was regular and progressive, the specific activities of the intra- and extracellular fluids reaching equal values. This indicates that all the erythrocyte potassium is exchangeable and is exchanging at the same rate. 4. From these data, it was calculated that at 37 degrees C., 1.6 per cent of the erythrocyte potassium exchanges per hour, corresponding to an exchange of 1.5 mM of potassium per liter of red cells per hour. The time required for the exchange of 50 per cent of the red cell potassium is calculated to be 43 hours. 5. The temperature coefficient (Q(10)) of the potassium exchange rate is 2.2. This is the same as the temperature coefficient of the rate of utilization of glucose by the human erythrocyte. 6. Varying the percentage of red cells, plasma potassium concentration, initial glucose level, and pH between 7.0 and 7.7 had no effect on the potassium exchange rate.     

CALIFORNIA ENCEPHALITIS VIRUS—A Newly Described Agent

In three cases of encephalitis in humans that occurred in the area where the newly described California virus was isolated from mosquitoes, serological evidence seemed to indict the California virus as the etiological agent. In the case of an infant with very severe disease, the serological evidence was convincing; the evidence was almost as strong in the case of a seven-year-old boy; the results in an adult were equivocal.Inapparent infection in man is quite common as indicated by neutralization tests on the sera of nearly 600 residents of California, but encephalitic manifestations of infection are extremely rare. In Kern County, California, where the virus was discovered, approximately 11 per cent of the population has been infected. Infection rates are higher in adults than in very young children.Absence of neutralizing antibodies from 64 specimens of blood from persons in Japan, Washington, and other states supports the specificity of the neutralization test in man and suggests that this virus is absent or is not being similarly transmitted in some areas.Serological evidence from serial bleedings of two sick horses suggested, but did not definitely establish, that this virus leads to a naturally acquired encephalomyelitis in horses. Serological tests with the viruses of western equine and St. Louis encephalitis did not lead to any other etiological diagnosis in the sick animals studied.Results of neutralization tests on the sera of eight horses and three cows in Kern County suggested extremely high infection rates, and an immunity rate of 18 per cent was noted in rabbits and ground squirrels. In the natural biological cycle rabbits and ground squirrels are suspected as the possible counterpart of birds in the St. Louis and western equine virus cycles. There is no evidence from field or laboratory to indicate that birds become infected with the California virus.Sera from 33 mammals other than man were collected from Northern California and Washington. All were free from neutralizing antibodies, again supporting the specificity of positive findings from Kern County.     

California encephalitis virus,a newly described agent

In three cases of encephalitis in humans that occurred in the area where the newly described California virus was isolated from mosquitoes, serological evidence seemed to indict the California virus as the etiological agent. In the case of an infant with very severe disease, the serological evidence was convincing; the evidence was almost as strong in the case of a seven-year-old boy; the results in an adult were equivocal. Inapparent infection in man is quite common as indicated by neutralization tests on the sera of nearly 600 residents of California, but encephalitic manifestations of infection are extremely rare. In Kern County, California, where the virus was discovered, approximately 11 per cent of the population has been infected. Infection rates are higher in adults than in very young children. Absence of neutralizing antibodies from 64 specimens of blood from persons in Japan, Washington, and other states supports the specificity of the neutralization test in man and suggests that this virus is absent or is not being similarly transmitted in some areas. Serological evidence from serial bleedings of two sick horses suggested, but did not definitely establish, that this virus leads to a naturally acquired encephalomyelitis in horses. Serological tests with the viruses of western equine and St. Louis encephalitis did not lead to any other etiological diagnosis in the sick animals studied. Results of neutralization tests on the sera of eight horses and three cows in Kern County suggested extremely high infection rates, and an immunity rate of 18 per cent was noted in rabbits and ground squirrels. In the natural biological cycle rabbits and ground squirrels are suspected as the possible counterpart of birds in the St. Louis and western equine virus cycles. There is no evidence from field or laboratory to indicate that birds become infected with the California virus. Sera from 33 mammals other than man were collected from Northern California and Washington. All were free from neutralizing antibodies, again supporting the specificity of positive findings from Kern County.     

Earlier Diagnosis of Cervical Cancer—An Analysis of Reports to the California Tumor Registry from 1942 to 1963

The mortality rate for cervical cancer in California declined during the period 1950-64. Indirect evidence shows that the incidence is also declining, but it is difficult to assess this decline because of the effect of the increasing use of cytologic examination on incidence rates for cervical cancer.Cervical cancer, in the 57 hospitals reporting to the California Tumor Registry, is being diagnosed at an earlier stage than in previous years. The proportion of cases diagnosed with the lesion still in the in situ stage rose from zero in 1942 to 56 per cent in 1963, and invasive cervical cancer, as a proportion of all invasive cancer in women, decreased from 15 per cent to 9 per cent. There is wide variation among hospitals in the proportion of cervical cancer cases that are in situ at time of diagnosis.     

Utilization of modified waste from the antibiotic industry for the production of construction materials

Possible utilization of treated streptomycin fermentation broth modified with waste hydrochloric acid solution followed by lime neutralization was studied. Such a complex additive to concrete increased its strength by 36-41 per cent. With saving cement by 7 per cent the concrete strength increased by 22-29 per cent as compared to the control samples. Therefore, utilization of antibiotic industry waste in production of building material allowed not only to improve its quality but also to lower the environmental pollution.     

Are healthcare workers in England and Wales at increased risk of tuberculosis?

OBJECTIVE: To determine whether healthcare workers in England and Wales are at increased risk of tuberculosis and to examine the frequency of drug resistance in this population. DESIGN: Comparison of notification rates by occupation obtained from national tuberculosis notification surveys in 1988 and 1993, with denominators from the 1991 census. SUBJECTS: People with notified tuberculosis in professional and associate professional occupations from the two surveys. MAIN OUTCOME MEASURES: Rates of notified tuberculosis in health professionals (mainly doctors) and health associate professionals (mainly nurses) compared with rates in other professional and associate professional occupations, adjusted for ethnic group, sex, and age. RESULTS: 119 cases of tuberculosis were identified in healthcare workers, including 61 nurses and 42 doctors. The crude notification rate in healthcare workers was 11.8 per 100,000 per year (95% confidence interval 9.8 to 14.1) compared with 3.3 per 100,000 per year (2.9 to 3.6) in other professional and associate professional occupations; rate ratios were higher (range 1.7 to 3.2) in all ethnic groups. The relative risk adjusted for ethnic group, sex, and age was 2.4 (95% confidence interval 2.0 to 3.0), slightly higher for health professionals (2.7 (1.9 to 3.8)) than for associate professionals (2.0 (1.5 to 2.6)). No multiple drug resistant strains of tuberculosis were identified in healthcare workers. CONCLUSIONS: Better detection and notification of cases of tuberculosis in healthcare workers may account for some of the apparent increased risk, but these findings imply that tuberculosis remains a hazard for healthcare workers and highlight the importance of ensuring that occupational health monitoring and protection workers are not neglected.     

Environment Under the Federal Employees Health Benefits Program: A Report of the Bureau of Research and Planning, California Medical Association

Active and retired federal employees, together with their dependents, represent the single largest group of persons enrolled in any voluntary health insurance program in the United States. The extent of their coverage and enrollment is of particular interest to physicians in California since this state has the largest proportion of all federal employees enrolled among all states. Of the almost 5(3/4) million federal employees and their dependents, enrollment in California was almost 609,000 or slightly over 10 per cent of all those covered. Better than 3 out of 5 individuals covered were enrolled in service type plans both in the U.S. and in California. Of all persons enrolled in comprehensive group practice and individual practice plans in the U.S., almost one-half were in California alone. Almost 4 out of 5 individuals enrolled were in high option plans. "... an indication that most employees were satisfied with their initial choice of plans."     

Citrinin affects the oxidative metabolism of BHK-21 cells

The effects of citrinin on energy production along the respiratory chain and on glycolytic lactate production were examined in BHK-21 cultured cells. Citrinin inhibited the oxygen consumption rate by about 45 per cent. The respiratory rate of digitonin-treated cells energized with succinate, in the presence of ADP, was reduced by about 39 per cent. The mycotoxin inhibited the glucose utilization of BHK-21 cells by about 86 per cent. Cells treated with citrinin produced a small quantity of pyruvate, but were unable to produce lactate. It is concluded that BHK-21 cells cannot generate lactate when oxidative metabolism is inhibited by citrinin. The perturbations in BHK-21 cells caused by citrinin are due to alterations in mitochondrial function and in the glycolytic anaerobic pathway.     

COMMUNITY MENTAL HEALTH SERVICES—Operation in San Jose

Recent attempts to cope with the growing and costly problem of mental illness are progressively emphasizing prophylaxis and early detection and treatment. California has joined this trend forcefully since the passage of the Short-Doyle Act in 1957.San Jose is one of the communities with a Community Mental Health program, financed 50 per cent by the local government and 50 per cent by the State of California. It implements its program by offering consultative services to the city''s public health nurses, police officers, teachers, social workers, ministers, sanitarians and members of staffs of a number of public and private agencies.Results of the program have been: (1) Increased demand for education in mental health; (2) growing number of requests for case consultation in lieu of patient-referral to already overburdened psychiatric facilities, and (3) growing recognition by consultees of the importance of their own self-awareness.     

Coronary artery bypass grafting in Canada: What is its rate of use? Which rate is right?

We reviewed recent reports from administrative databases and clinical registries addressing the utilization of coronary artery bypass grafting (CABG) in Canada. The Canadian CABG rate per 100,000 people increased from 31.1 to 43.2 between 1981-82 and 1986-87. Between 1981 and 1986 the rate in the United States increased from 69.9 to 95.3 per 100,000, consistently about two times the Canadian rate. Provincial data have shown particular growth in utilization among elderly people. However, in the United States the 1985 CABG rate was twice as high as the aggregated age-specific rates for Ontario and Manitoba among people 65 to 74 years of age and four times higher among those 75 years or more. Limited registry data suggest that the Canadian CABG case mix is similar to the case mix in major US centres and that, utilization growth notwithstanding, the procedure is largely applied to patients who should, in theory, benefit (i.e., those with severe angina, impaired left ventricular function and left main-stem or triple-vessel disease). However, chart audits and registry evaluations using explicit criteria are needed to compare the use of CABG in Canada and the United States. In addition, Canadian data show moderate regional and municipal variations, the 1986-87 rates per 100,000 population in major census metropolitan areas varying from 19.5 to 46.9. Areas with consistently low rates raise particular concerns about impaired access to CABG. Reasons for variations should therefore be a research priority.     

Shall organized medicine be unified, or separate?

MEMBERS OF THE CALIFORNIA MEDICAL ASSOCIATION ARE TO BE CALLED UPON IN SEPTEMBER TO BALLOT ON A QUESTION OF GREAT IMPORTANCE TO THE FUTURE OF ORGANIZED MEDICINE: Shall membership in organized medicine-county medical society, California Medical Association, American Medical Association-be unified, or shall such membership be separate?In the July issue we published statements pro and con which the Informed Membership Poll Committee had prepared from statements of position on both sides of the question that the committee had solicited from county societies and individuals.Here, for the fuller information of our readers on this momentous question, we are presenting material representative of the arguments that the Committee digested in the statements printed in the July issue.     

Grapes and wine

About 20 per cent of the world’s table grapes and 40 per cent of the world’s raisins are produced in California, but less than 3 per cent of the wines of the world.     

POLIOMYELITIS VACCINE—Epidemiologic Observations on the Safety and Effectiveness in California in 1955

During the past year California has participated with other states in a nationwide field evaluation of the safety and effectiveness of poliomyelitis vaccine. Among 227,000 children who received Cutter vaccine, and the household contracts of these children, the incidence of poliomyelitis was higher during the early postvaccinal period than in comparable age groups of the population at large. Among 238,000 children who received poliomyelitis vaccine made by other manufacturers early in 1955 no increase in poliomyelitis was observed in the inoculated children or their household contacts.Subsequent observation on over 500,000 additional children vaccinated in California alone since September 1955 with vaccine that was made under revised safety standards has uncovered no evidence of unsafe vaccine. In children who received a single inoculation of vaccine prior to the onset of the poliomyelitis season in 1955 the incidence of paralytic poliomyelitis was about 60 per cent less than in unvaccinated children. Among those who received two inoculations an 85 per cent reduction was observed. The average reduction in paralytic poliomyelitis for the entire vaccinated group was approximately 75 per cent. Data thus far on children vaccinated since September 1955 with poliomyelitis vaccine made by methods now approved indicate that a similar overall effectiveness is still being maintained.