Critical elements in the design of culturally appropriate interventions intended to reduce health disparities: immunization rates among Hispanic seniors in New Mexico

The importance of immunization in protecting seniors against influenza and pneumonia has long been recognized. Nevertheless, immunization rates among Medicare beneficiaries continue to fall short of what is both desirable and achievable. The problem is even more acute among certain racial and ethnic groups in the United States within which rates are below the rate for the country as a whole. This is true in New Mexico where 40 percent of the population is estimated to be Hispanic. As part of its work on behalf of the Centers for Medicare & Medicaid Services (CMS), the New Mexico Medical Review Association (NMMRA) undertook a project aimed both at reducing the disparities that exist in immunization status between the Hispanic and non-Hispanic population in the state and attempting to increase overall rates in the state for all groups. Developing interventions to reduce disparaties in immunization rates between Hispanic seniors and the rest of the senior population requires more than a straightforward review of the literature and must take into account not only the cultural differences that exist between Hispanics and non-Hispanics but, certainly, in the case of New Mexico, it must attempt to understand the richness and diversity that exists within the Hispanic communities across the state. To do otherwise runs the risk of designing interventions that are at best ineffective and at worst culturally insensitive and potentially damaging to future efforts to improve health status. This article describes the process undertaken by NMMRA, a Medicare Quality Improvement Organization (QIO), to collect qualitative data from three culturally different groups of Hispanics in New Mexico. The data are used to design interventions that will increase immunization rates for all Hispanics in New Mexico.     

Thoughts, attitudes, and feelings of HIV-positive MSM associated with high transmission-risk sex

This study presents survey data collected from a sample of HIV-positive men (N = 182) who had high transmission-risk sex, defined as unprotected anal intercourse with a man whose HIV-status was negative or unknown, in the previous 6 months. Despite the tremendous changes in HIV treatment and their impact on people living with HIV, little recent research has examined current trends in their thoughts toward unprotected anal intercourse. Here, the authors describe the self-justifications reported by HIV-positive men who have sex with men (MSM) in their current study conducted between 2006 and 2009 and explore key differences between the those of the HIV-positive MSM and those collected from a previous cohort of HIV-negative men (n = 124), who previously reported engaging in high transmission-risk sex. Whereas HIV-negative men focused on themes related to the impulsivity of and gratification from unprotected intercourse, HIV-positive men focused on themes regarding the deferral of responsibility/assumption the partner is positive (i.e., "If he's doing X, he must be positive . . ."), or the role of condomless sex fulfilling emotional needs. The findings highlight unique aspects of how HIV-positive men approach decision making regarding the use of condoms, as well as how they perceive issues of responsibility for initiating safer sex practices.     

Role of exposure with response prevention in cognitive-behavioral therapy for bulimia nervosa: three-year follow-up results

BACKGROUND: Previous studies have not reported the longer-term outcome of exposure-based treatments for bulimia nervosa. The current study evaluated the 3-year outcome of a randomized clinical trial that compared the additive efficacy of exposure-based versus nonexposure-based behavioral treatments (BT) with a core of cognitive-behavior therapy (CBT). METHODS: One hundred thirteen women participated in the original treatment trial and attended a 3-year follow-up assessment. Eating disorder diagnoses and primary, secondary, and tertiary outcome measures were assessed. The impact of treatment completion on symptomatology and the stability of treatment effects over time were evaluated. RESULTS: At the 3-year follow-up, 85% of the sample had no current diagnosis of bulimia nervosa and 69% had no current eating disorder diagnoses of any sort. Failure to complete CBT was associated with inferior outcome. No clear advantages were evident for participants who completed BT in addition to CBT. For subjects who did complete both CBT and BT, outcome was mostly stable from posttreatment to follow-up. No differential effects were found for exposure versus nonexposure-based treatments at 3-year follow-up. DISCUSSION: The results of the current study compare favorably with other treatment outcome studies for bulimia nervosa and suggest that treatment gains are maintained after 3 years.     

Beverages containing soluble fiber, caffeine, and green tea catechins suppress hunger and lead to less energy consumption at the next meal

Previous research has shown that beverages containing soluble fibers can decrease energy intake at the next meal among normal weight participants. Caffeine and green tea catechins have separately been associated with increased satiety. The present study examined the satiating power of a beverage containing soluble fiber as well as a beverage containing the same fiber, caffeine and green tea catechins. These two test beverages were evaluated in comparison to an equal calorie control beverage as well as a no-beverage control condition. All beverage preloads were presented three times for a total of 0.28-0.35MJ and 0-30g fiber. Dependent measures were appetite ratings and calorie intake at a test meal. The no-beverage condition was associated with the highest ratings for hunger and the lowest ratings for fullness when compared to the other three beverage conditions. Of the three beverage conditions, the beverage containing the fiber, green tea catechins, and caffeine created the lowest hunger and the highest fullness ratings. That condition was also associated with the lowest energy intake at the next meal. The present findings indicate that the beverage containing caffeine and green tea catechins in combination with soluble fiber decrease appetite and energy intake relative to a beverage with equal caloric content.     

Public health ethics: informing better public health practice

Public health ethics has emerged and grown as an independent discipline over the last decade. It involves using ethical theory and empirical analyses to determine and justify the right thing to do in public health. In this paper, we distinguish public health ethics from clinical ethics, research ethics, public health law and politics. We then discuss issues in public health ethics including: how to weigh up the benefits, harms and costs of intervening; how to ensure that public health interventions produce fair outcomes; the potential for public health to undermine or promote the rights of citizens; and the significance of being transparent and inclusive in public health interventions. We conclude that the explicit and systematic consideration of ethical issues will, and should, become central to every public health worker's daily practice.     

Titrating and evaluating multi-drug regimens within subjects

The dosing of combination therapies is commonly undertaken empirically by practising physicians, and a coherent algorithm to approach the problem of combination dosing is currently lacking. Current methods of evaluating multiple drug combinations in clinical trials fail to provide information regarding the location of more effective doses when the combination is not found to differ from the standard, even though the absence of a difference does not necessarily mean the new combination is ineffective. Moreover, in studies where the new combination is found more effective, often a large proportion of the study participants obtain no benefit from the trial. Even with early stopping rules, the time these subjects spend on inferior treatments can have lasting detrimental effects, leading to problems with patient enrolment and adherence to study protocol. This paper describes an evolutionary operation (EVOP) direct-search procedure to titrate combination doses within individual patients. The Nelder-Mead simplex direct-search algorithm is used to titrate combinations of drugs within individual subjects. Desirability functions are utilized to define the main response of interest and additional responses or constraints. Statistical methodology for determining whether the titrated treatment combination has resulted in an improvement in subject response and for evaluating for therapeutic synergism is developed. Inferences can then be made about the efficacy of the combination or about the individual drugs that comprise the combination. The advantages of this approach include affording every patient the potential to benefit from the combination under study and permitting the consideration of multiple endpoints simultaneously.     

"New century,new challenges"

The recently published report ‘New Century, New Challenges’from the Heads of Departments of General Practice and PrimaryCare sets out a vision for the development of academic generalpractice in the UK.¹ It reviews the substantial challenges nowfacing the academic departments and shows clearly how more investmentis essential if general practice and primary care services topatients are to be improved under the Government’s NHSPlan.² In 2001, there were 31 academic departments of general practiceand primary care in the UK compared with 24 departments in 1986.In the period since 1986, the number of professors of generalpractice increased from 16 to 66, and the proportion of non-clinical     

Obtaining advance beneficiary notices for Medicare physician providers

Medicare has established medical necessity rules that define the medical conditions that make beneficiaries eligible for particular services. These rules are codified in local medical review policies (LMRPs) that are established by Medicare claims payment contractors. If a beneficiary's provider does not inform the patient that a service may not be covered, the provider cannot subsequently bill the beneficiary for the service if it is denied. This article discusses the application of these policies. It illustrates the circumstances in which advance beneficiary notices (ABN) are required to ensure that patients have been notified that services rendered will not be covered by Medicare and will become their financial responsibility. The author also presents special applications of the ABN regulations as they apply to the EMTALA rules, anti-kickback, and other statutes. Samples of the official ABN forms are illustrated.     

Dynamic MR imaging of the sexual arousal response in women

The purpose of our studies was to evaluate whether MR imaging could be used to noninvasively observe and measure the sexual arousal response in normal women. We tested the feasibility as well as the reproducibility of rapid, dynamic, serial high-resolution MR imaging of the genital structures during presentation of neutral and sexually stimulating video material. Results show that these MRI techniques can visualize significant changes in clitoral volume during the stimulus segment of the video presentation. Quantitative measurements made of these changes were robust and reproducible. These studies suggest that MRI techniques may be a useful tool to improve our understanding of the physiology involved with the sexual arousal response in women. These MRI techniques may also prove useful as a surrogate end point marker for testing efficacy of future new treatments for women with sexual arousal disorder.     

Symptom screen: diagnostic usefulness in detecting pulmonary tuberculosis in HIV-infected pregnant women in Kenya

Objective:

To determine the diagnostic usefulness of tuberculosis (TB) symptom screening to detect active pulmonary TB among human immunodeficiency virus (HIV) infected pregnant women in two PMTCT (prevention of mother-to-child transmission) clinics in western Kenya that are supported by the United States Agency for International Development–Academic Model Providing Access to Healthcare partnership.

Design:

Cross-sectional study. Participants were interviewed for TB symptoms with a standardized questionnaire (cough >2 weeks, fever, night sweats, weight loss or failure to gain weight). Those with cough submitted sputum specimens for smear microscopy for acid-fast bacilli and mycobacterial culture. Women at >14 weeks gestation underwent shielded chest radiography (CXR).

Results:

Of 187 HIV-infected women, 38 (20%) were symptom screen-positive. Of these, 21 had a cough for >2 weeks, but all had negative sputum smears and mycobacterial cultures. CXRs were performed in 26 symptomatic women: three were suggestive of TB (1 miliary, 1 infiltrates and 1 cavitary). Of 149 women with a negative symptom screen, 100 had a CXR and seven had a CXR suggestive of TB (1 cavitary, 2 miliary and 4 infiltrates).

Conclusion:

This study did not support the utility of isolated symptom screening in identification of TB disease in our PMTCT setting. CXR was useful in identification of TB suspects in both symptomatic and asymptomatic women.