I can’t afford that!

When patients lack sufficient health care insurance, financial matters become integrally intertwined with biomedical considerations in the process of clinical decision making. With a growing medically indigent population, clinicians may be compelled to bend billing or reimbursement rules, lower standards, or turn patients away when they cannot afford the costs of care. This article focuses on 3 types of dilemmas that clinicians face when patients cannot pay for needed medical services: (1) whether to refer the individual to a safety net provider, such as a public clinic; (2) whether to forgo indicated tests and therapies because of cost; and (3) whether to reduce fees by fee waivers or other adjustments in billing. Clinicians' responses to these dilemmas impact on quality of care, continuity, safety net providers, and the liability risk of committing billing violations or offering nonstandard care. Caring for the underinsured in the current health care climate requires an understanding of billing regulations, a commitment to informed consent, and a beneficent approach to finding individualized solutions to each patient care/financial dilemma. To effect change, however, physicians must address issues of social justice outside of the office through political and social activism.     

131’I治疗Graves’病临床效果及其影响因素的研究

目的评价Graves’病131^I治疗1年后的临床效果,探讨影响其疗效的因素。方法182例131^I治疗患者疗效按成功治愈（正常＋甲减）、治疗失败（仍为甲亢＋复发）分组,比较两组的性别、年龄、甲状腺重量、摄碘率、FT3、FT4、给定的131^I即131^I治疗系数、131^I剂量、单位质量甲状腺组织131^I剂量。Logistic回归分析甲状腺重量、单位质量甲状腺组织131^I剂量、FT4、131^I治疗系数4个因素与成功治愈概率的关系。结果131^I治疗1年后共随访到114例,仍为甲亢者32例（28％）,恢复正常者41例（36％）,转为甲减者37例（32．5％）,复发者4例（3．5％）。成功治愈率为68．4％,失败率为31．6％。成功治愈组治疗前的甲状腺大小、FT4水平低于治疗失败组,131^I治疗系数、单位质量甲状腺组织131^I剂量明显高于治疗失败组。Logistic回归分析中,单位质量甲状腺组织131^I剂量对成功治愈有统计学意义（P=0．049）。结论Graves’病患者治疗前甲状腺重量、FT4水平、131^I治疗系数、单位质量甲状腺组织131^I剂量是影响131^I治疗效果的因素,并为评估预后的指标;单位质量甲状腺组织131^I剂量与成功治愈独立正相关。     

‘I thought if I marry the prophet I would not die’: The significance of religious affiliation on marriage,HIV testing,and reproductive health practices among young married women in Zimbabwe

This study examines the association between religious affiliation and reasons for marriage, perceived church attitudes, and reproductive health-seeking behaviors, including HIV testing, among young women in eastern rural Zimbabwe. The sample comprised women (N?=?35) who had married by 2012 while participating in a larger randomized controlled trial (RCT) to test the effects of school support on HIV-related risk. The RCT sample was identified in 2007 as all female sixth graders in 25 rural eastern Zimbabwe primary schools whose parents, one or both, had died (N?=?328). In our previous RCT analyses, we found that participants who affiliated with an Apostolic church were more than four times more likely to marry than those from non-Apostolic churches and that control group participants were twice as likely to marry as those in the intervention group. Other studies had found that marriage greatly increased the odds of HIV infection among adolescent women. Given the link between Apostolic affiliation and marriage, we conducted semi-structured interviews to explore type of marriage, reasons for marrying, church affiliation and attitudes, family planning, HIV testing, schooling, and family life. We were interested in differences, as perceived by our sample of young married women congregants, among Apostolic sects and other denominations in their attitudes about marriage and health-seeking behaviors. We were also interested in the influence of church affiliation on intervention participants’ decision to marry, since they had comprehensive school support and education is highly valued in Zimbabwe, but costly and often out of financial reach. Interviews were conducted from October 2012 through November 2013; data were analyzed using a general inductive approach. We found that pressure or perceived deception for coitus or marriage was reported only by intervention participants affiliated with Apostolic denominations. Other reasons for marriage were similar between Apostolic and non-Apostolic adherents, as well as intervention and control conditions. All participants believed HIV testing was important, but while all non-Apostolic denominations encouraged HIV testing and clinic/hospital care, there was considerable heterogeneity in attitudes among Apostolics, with ultraconservative denominations most likely to proscribe non-religious health care. We conclude that some, but not all, Apostolic-affiliated women are afforded discretion in their health-seeking behaviors. Since HIV screening and treatment depend on access to clinic/hospital care, continued public health efforts to engage Apostolic leaders is needed, along with monitoring of progress in access and outcomes.     

Anti-arrhythmic Effects of I Na, I Kr, and Combined I Kr–I CaL Blockade in an Experimental Model of Acute Stretch-Related Atrial Fibrillation

Introduction Atrial dilatation is commonly associated with atrial fibrillation (AF), but the electrophysiological mechanisms and the implications for anti-arrhythmic therapy are poorly understood. In a model of acute stretch-related AF in isolated rabbit hearts, we evaluated the electrophysiological effects of three different anti-arrhythmic drugs: dofetilide, flecainide and BRL-32872 (associating I _Kr and I _CaL blocking properties). Methods After 30 min of sustained stretch-related AF, we perfused BRL 10–7 M, BRL 3.10–7 M, BRL 10–6 M, flecainide 2.4 10–6 M and dofetilide 10–7 M and iteratively measured atrial effective refractory periods (ERPs), AF inducibility and AF cycle length (AFCL) 15, 30 and 60 min after drug perfusion, respectively. Results After a significant shortening of the ERPs by acute atrial stretch in the five groups individually (p < 0.001, stretch vs baseline for each group individually), drug perfusion led to a strong lengthening of AFCL, a very significant prolongation of ERPs (p < 0.001 vs stretch) and a reduction of AF inducibility (p < 0.01 vs control group) for each of the five experimental groups. The relative ERP increase was comparable in all groups, whereas a significantly lower AF inducibility was observed in the BRL 10–6 M group (p < 0.05 vs other BRL concentrations). Conclusion In a model of acute stretch-related AF, dofetilide, flecainide and BRL-32872 terminated AF and prevented its immediate reinduction after having comparatively prolonged AFCL and ERPs. These comparative results suggest that those drugs are equally efficacious, albeit with different mechanisms, in the setting of acute atrial stretch.     

I Can Use a Condom, I Just Don’t: The Importance of Motivation to Prevent HIV in Adolescent Seeking Psychiatric Care

Youth continue to show high HIV infection rates, and adolescents with mental health problems are especially at risk. We used longitudinal data to test a cognitive-behavioral model of risky sexual behavior among 175, ethnically diverse urban adolescents seeking mental health services. Path analyses of the cross-sectional data revealed that Motivation was a strong predictor of Behavioral Skills and Sexual Risk Taking. The model explained 42% of the variance in Sexual Risk Taking with age included—29% without age. In the longitudinal path analyses, Motivation had a significant negative effect on levels of Sexual Risk Taking 6 months later, controlling for Information, Behavioral Skills, age, and baseline levels of Sexual Risk Taking. These longitudinal effects explained 60% of the variance in Sexual Risk Taking. These results underscore the need to address motivational factors in HIV prevention programs designed for adolescents with mental health problems.     

Brief report: Internal medicine residents’, attendings’, and nurses’ perceptions of the night float system

BACKGROUND: Residency training programs use the night float system increasingly to meet the new resident work hour regulations. OBJECTIVE: To assess and compare residents', attendings', and nurses' perceptions of the night float system. DESIGN: A survey study. PARTICIPANTS: One hundred and seven residents, 48 attendings, and 69 nurses in a university-based multicenter internal medicine residency program. MEASUREMENTS: Perceived impact on patient care, resident training, and resident performance. RESULTS: The overall response rate was 75%. In general, more residents than both attendings and nurses had positive opinions regarding the night float system, particularly in relation to patient care. Only a small proportion of residents and attendings thought positively about the night float's impact on training quality (29.9%; 18.2%), daily feedback (23.0%; 9.1%), and end of rotation evaluation (21.8%; 6.1%). Less than half of the nurses had positive perceptions of the night residents' performance in terms of promptness (40.9%), physical availability (38.6%), familiarity with the patients' cases, and management plans (15.9%), communication of management plans to nurses (36.4%), professional respect and trust (43.2%), and teamwork (45.5%). CONCLUSIONS: Residents had more positive perceptions than attendings and nurses. Nurses, in particular, had negative perceptions of resident performance in the setting of the night float system.     

Graves’病患者^131I治疗前口服他巴唑效果观察

^131I是治疗Graves’病(GD)的首选药物，但部分患者用药后症状反而加重。为预防此现象发生，有学者采用^131I治疗前口服他巴唑。2002年10月～2004年7月，我们对^131I治疗前口服他巴唑的临床效果进行了观察，现将结果报告如下。     

“Estoy viejo” [I’m old]: Internalized Ageism as Self-Referential, Negative, Ageist Speech in the Republic of Panama

Ageism is a form of discrimination that anyone may experience at some point in life (Palmore 2004). Yet ageism is rarely the focus of behavioral research (Nelson 2005). Age can be understood as a social construct that reflects social norms (Lemus and Exposito 2005). Based on our review of the published literature, there were two studies on perceptions of aging among Latina/os in the United States (Beyene et al. 2002; Sarkisian et al. 2006). These studies investigated perceptions and expectations of aging among older Latina/o adults rather than direct experiences of ageism. It is important to note that Latina/os are not a homogenous group and that there are within-group differences. For this reason, this study explored internalized, negative ageism specifically in the Republic of Panama. Although Panama has unique characteristics, it also reflects Central American culture and therefore should provide initial insights regarding Central American self-referential, negative, ageist talk, which we labeled ??Estoy viejo.?? Flanagan??s Critical Incident Technique was used to access and understand participants?? (ages 18?C65) negative ageist talk (n?=?159). Participants who reported engaging in ??Estoy viejo.?? (46.3?% of those sampled) were significantly younger than participants who did not (p?<?.05). One potential explanation is that younger participants may have been more influenced by North American culture and its strongly negative ageist stereotypes than older participants, who may have identified primarily with Central American culture.     

A phase I/II study examining pentostatin, chlorambucil, and theophylline in patients with relapsed chronic lymphocytic leukemia and non-Hodgkin’s lymphoma

In an attempt to exploit bcl-2 overexpression and aberrant p53 function, two frequently encountered aberrations that predict marked treatment resistance and worse prognosis in patients with chronic lymphocytic leukemia (CLL) and non-Hodgkin’s lymphoma (NHL), we combined theophylline, pentostatin, and chlorambucil at two dose levels (cohort I: 30 mg/m²; cohort II: 20 mg/m²) on a 21-day cycle for up to six courses. We employed a phase I/II design to determine feasibility, define the maximum tolerated dose (MTD), and explore the impact of biologic modulation on response and time to progression (TTP) in 20 patients with relapsed or refractory CLL and NHL. Eight patients were enrolled in cohort I. They demonstrated a response rate (RR) of 28% and a 16.5-month TTP after receiving a median of two cycles. A 50% RR was observed in this cohort when patients with adverse histologies were excluded. Because of myelotoxicity, this dose level defined the MTD, and de-escalation occurred. All 12 patients in cohort II received 20 mg/m² chlorambucil. A 50% RR and an 18-month TTP were observed after a median of 5.5 cycles. An RR of 47% and a complete remission (CR) of 5% were observed for the entire group, although responses and TTP varied greatly by histology. Significant activity was observed in patients with B-cell CLL and follicular lymphoma (FL). RR and TTP for fludarabine-sensitive/naïve and fludarabine-refractory (FR) B-cell CLL patients were 66 vs 25% and 20 vs 8.5 months, respectively. Both FL patients responded (one with partial remission and one with CR), with a 22.5-monthly median TTP. For responding patients, median TTP and overall survival (OS) was 21 and 69 months, respectively, compared to a median TTP of 2 months and an OS of 13.5 months for nonresponders. The combination of pentostatin, chlorambucil, and theophylline is the active regimen in patients with FL and B-cell CLL.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Army or the Department of Defense.John Byrd, Michael Grever, Ian Flinn, and Jamie Waselenko have submitted a patent for this regimen.