In spite of advances made in our understanding of the biology of the hepatitis C virus (HCV), the epidemiology and natural history of HCV infection, and the treatment of chronic hepatitis C, the development and worldwide implementation of a comprehensive prevention and control strategy remains necessary. A World Health Organization informal consultation with the Viral Hepatitis Prevention Board was convened and met in Geneva, Switzerland, 13-14 May 2002, to review epidemiological and public health aspects of HCV infection, and the various prevention and control strategies that are currently in place. Based on the presentations and discussions, a number of specific recommendations were made, which should be considered in conjunction with previously published recommendations.

As they age, adults experience less negative emotion, come to pay less attention to negative than to positive emotional stimuli, and become less likely to remember negative than positive emotional materials. This profile of findings suggests that, with age, the amygdala may show decreased reactivity to negative information while maintaining or increasing its reactivity to positive information. We used event-related functional magnetic resonance imaging to assess whether amygdala activation in response to positive and negative emotional pictures changes with age. Both older and younger adults showed greater activation in the amygdala for emotional than for neutral pictures; however, for older adults, seeing positive pictures led to greater amygdala activation than seeing negative pictures, whereas this was not the case for younger adults.

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the winter 2004 quarter. It features articles about CHP/PCOR faculty member Mark McClellan's new position as administrator of the federal Centers for Medicare and Medicaid Services; a report by the Stanford-UCSF Evidence-based Practice Center evaluating the regionalization of bioterrorism preparedness and response; the development of a research protocol for a World Health Organization study on the effectiveness of public-private partnerships in health care; a new design for CHP/PCOR's Web site; and a roundup of last quarter's media coverage highlighting the centers' research work.

This study reveals that older adults have a positivity effect in long-term autobiographical memory and that a positivity bias can be induced in younger adults by a heightened motivation to regulate current emotional well-being. Three hundred nuns, ages 47 to 102 years, recalled personal information originally reported 14 years earlier. They did so under experimental conditions that repeatedly primed them to focus on their current emotional states or on their memory accuracy, or that provided no instructional focus (control condition). Both older control participants and participants who were focused on emotional states showed a tendency to remember the past more positively than they originally reported in 1987. In contrast, both younger control participants and participants who were focused on accuracy tended to remember the past more negatively than originally reported.

Toward a 21st Century Health System is a collection of essays that explore a key element of the health care delivery system -- large multispecialty physician group practices. Edited by policy experts Alain Enthoven and Laura Tollen, and written by a panel of health policy scholars and leaders including Stephen Shortell, Hal Luft, Donald Berwick, James Robinson, and Helen Darling, this resource addresses a variety of topics, including:

• organized delivery systems
• quality of care in prepaid group practice versus other types of managed care
• the role of physician leadership and culture in group practice
• prepaid group practice and the formation of national health policy

The book also covers such topics as pharmacy benefit management, technology assessment, health services research, and employer purchasing of benefits, all as they relate to prepaid group practice.

When teaching my students about what goes into a good doctor-patient interaction, I tell them about the studies that show how quickly doctors interrupt their patients. Male physicians especially, I tell them, are notorious for stopping the patient mid-sentence to redirect the discussion. In one study that I came across, female primary care physicians waited an average of 3 minutes before interrupting the patient to redirect the discussion toward issues more relevant to diagnosis. Male physicians waited an average of 47 seconds.

How long do I wait, I wondered? I decided to try an experiment. I would let my next patient talk as long as he or she needed to explain his or her reason for seeing me. I would watch the clock and see how long a patient might naturally take to explain the presenting complaint. I would hold my tongue.

The patient was in her 70s and greeted me with a smile when I stepped behind the curtain to be with her. "Hello, I'm Dr. Barr. What's the problem that brings you in today?"

She began to describe the past several weeks of her life. As I recall, it had to do with a coworker noticing something, talking with her sister on the phone, and her reluctance to see doctors. The word "cough" surfaced for a second, then quickly became submerged again. Looking at the medicines on the shelf at the drug store and not knowing which to choose. ... Needing to dress warmly ... (Wasn't this weather we'd been having nasty?) ... Sometimes she had trouble sleeping ...

The nurse poked her head through the curtain and silently tapped her watch. The waiting room of our urgent care center was full, and things were starting to back up. I wouldn't budge, though - I turned back to the patient and nodded. However long it took, I would wait for the patient to stop of her own accord. I wouldn't butt in.

It was the cough that was keeping her awake. ... She always got colds more easily than other people. ... Her sister was just a worrier. ... She finally had agreed to come in to see a doctor, just to reassure her friends and family.

Twenty-two minutes, from start to finish. The nurses were never going to forgive me.

The lungs had left-sided rales. The fever was mild, but the white count suggested infection. The chest radiograph showed a large infiltrate on the left and what I feared was a mass. I called the pulmonary specialist across the street and asked if he could squeeze the patient in this afternoon. He did, only to confirm the worst. It appeared the patient had a tumor causing the infiltrate, and there probably were enlarged hilar nodes as well. She probably had lung cancer, and it was probably in an advanced stage. She needed antibiotics right away to get the infection under control, after which further testing would be arranged.

The patient came back to our center for the antibiotics. The specialist had told her what he had found and had given her an indication of the grave prognosis she faced. I stepped back into the patient's space and said with sadness, "This hasn't been a very good day for you, has it?"

She looked at me for a moment with an unmistakable smile on her face. She reached out her hand and patted me on the wrist.

"Oh, don't worry about all that. I've had a good life. But I just wanted you to know - this is the best doctor visit I've ever had. You're the only one who ever listened."

Variability in demand for hospital services may have important effects on hospital costs, but this has been difficult to examine because data on within-year variations in hospital use have not been available for large samples of hospitals. We measure daily occupancy in California hospitals and examine variation in hospital utilization at the daily level. We find substantial day-to-day variation in hospital utilization, and noticeable differences between hospitals in the amount of day-to-day variation in utilization. We examine the impact of variation on hospital costs, showing that increases in variance are associated with increases in hospital expenditures, but that the effects are qualitatively modest

Purpose: C-reactive protein (CRP), Chlamydia pneumonia, Helicobacter pylori, and cytomegalovirus (CMV) have each been associated with atherosclerosis. We assessed how infection and CRP related to risk for subsequent myocardial infarction (MI).

Methods: Using a nested case-control design, we assessed how these factors independently and jointly affected risk for myocardial infarction (MI). Cases of first MI (N = 121) were identified from among participants in a multiphasic health check-up cohort. Controls without MI (N = 204) were matched to cases by gender, age, race, and date of serum collection. Sera collected at enrollment were tested for antibodies to infection and for CRP.

Results: In multivariate analysis (mean follow-up of 5.1 years), CRP was associated with MI only in subjects older than 51 years (p = 0.004). Although H. pylori infection increased risk for MI, this association was modest (OR = 1.90, 95% CI = 0.97-3.71) and was not evident in non-smokers or when adjusted for education. No association between C. pneumoniae or cytomegalovirus and MI was observed, nor was the association between CRP and MI explained by these infections.

Conclusions: Elevated CRP is a risk factor for subsequent MI in older individuals. The relationship between Hp and MI may be due to confounding or co-linearity with socioeconomic status.

Traditional cost-effectiveness analysis (CEA) assumes that program costs and benefits scale linearly with investment-an unrealistic assumption for epidemic control programs. This paper combines epidemic modeling with optimization techniques to determine the optimal allocation of a limited resource for epidemic control among multiple noninteracting populations. We show that the optimal resource allocation depends on many factors including the size of each population, the state of the epidemic in each population before resources are allocated (e.g. infection prevalence and incidence), the length of the time horizon, and prevention program characteristics. We establish conditions that characterize the optimal solution in certain cases.