Chronic Hepatitis C Infection in a Rural Medicaid HMO

CONTEXT: Chronic hepatitis C infection (CHCI) is an increasingly common problem, affecting about 2% of the US population. The cost and complexity of treatment and difficulties in communicating with the infected population are of concern to insurers and health planners. PURPOSE: To describe the clinical features of patients with CHCI in a rural Medicaid-covered population and to describe a method developed for treating CHCI in an underserved rural community. METHODS: We developed a disease management approach to patients with CHCI receiving insurance coverage through a Medicaid HMO in rural Oregon. A locally based multidisciplinary hepatitis committee was formed to develop a management protocol and a process for selecting patients for treatment. The committee met monthly to develop the treatment plan for individual patients. Day-to-day treatment was provided by a nurse under the supervision of the committee. FINDINGS: One hundred forty-three adults with CHCI were identified by their primary care physicians. About half the patients had a type 1 genotype. Treatment with pegylated interferon and ribavirin was completed on 21 persons, 11 (52%) of whom had a virologic cure. Problems with treatment toxicity were common. Patient satisfaction with the treatment by the nurse was high. CONCLUSIONS: CHCI is common in this rural, nonminority Medicaid-insured population. A locally based disease management model was developed that was well received by patients and was successful in delivering a high quality of care for people with CHCI in a rural area.     

Approach to sleep disorders in the nursing home setting. REVIEW ARTICLE

Evidence suggests that sleep disorders and sleep fragmentation are very common in nursing home residents. A variety of factors contribute to these sleeping difficulties, including age-related changes in sleep; the high prevalence of dementia, depression, medical illness and medications that affect sleep; and sleep disorders such as respiratory disturbance of sleep. Other important factors include common lifestyle characteristics in nursing home residents (such as inactivity, large amounts of time spent in bed, lack of bright light exposure, and poor sleep hygiene) and the disruptive night-time nursing home environment. Recent interventional studies suggest that improvement in the nursing home environment may be an important aspect of the management of sleeping difficulties. Assessment and management of sleeping problems in nursing home residents should involve comprehensive assessment and treatment of the multiple factors that can interfere with sleep. Residents who fail these interventions can be considered for treatment with sleeping medications. Unfortunately, there is little data on the effectiveness of sleeping medications and the specific management of sleep disorders in this setting. Future research should focus on clarifying the contribution of various environmental factors to sleep impairment, and the testing of these various interventions on sleep.     

Significant bacteremia associated with replacement of intrauterine contraceptive device

Blood culture samples were taken from 23 women at different stages when an intrauterine contraceptive device was replaced. Transient bacteremia resulting from vaginal organisms was found in 13% of women 4 to 6 minutes after insertion of the new device. Previous reports have failed to demonstrate bacteremia associated with either first insertion or removal of intrauterine contraceptive device. Our results show that replacement of an intrauterine contraceptive device, a more traumatic procedure, causes significant bacteremia, and chemoprophylaxis should be given to patients in the groups at risk.     

The extensive sexual violation and sexual abuse histories of incarcerated women

A growing body of research reports on the lifetime prevalence of sexual victimization experiences among incarcerated women. However, none of this research provides a detailed account of the many types and levels of sexual violations and sexual abuses, the age of occurrence, and the victim-offender relationship. This study used the Sexual Abuse Checklist (designed by the first author) and a modified version of the Sexual Experiences Survey (SES) to obtain a detailed account of 391 incarcerated women's self-reported sexual violation and abuse histories. Seventy percent of the women reported at least one violation consistent with what qualifies as "rape" in most states in the United States today, and half of the women reported child sexual abuse victimization. The most prevalent victim-offender relationships were male strangers, male lovers or boyfriends, male dates, husbands, uncles, brothers, male cousins, and stepfathers.     

Live birth following preimplantation genetic screening for trisomy 21. Should aneuploidy screening be offered to all older patients undergoing IVF?

A 42-year-old female patient with history of secondary infertility was referred to our assisted conception unit for in vitro fertilization (IVF). Before her referral, she had two cycles of IVF at another centre; the first was unsuccessful and, after conceiving at the second attempt, the pregnancy was terminated at 14 weeks' gestation following a positive nuchal translucency scan and a diagnosis of trisomy 21 (Down syndrome) by a chorionic villous biopsy performed in the first trimester. The screening tests for trisomy 21 were offered to the patient in view of her advanced age. Subsequent karyotyping revealed that both partners had a normal chromosomal complement. Following genetic counselling, the couple were offered IVF treatment along with preimplantation genetic screening for trisomy 21. Four of the five embryos were suitable for biopsy, and one blastomere from each embryo was analyzed using fluorescent in situ hybridization for chromosome 21. The analysis revealed that two embryos had trisomy 21, one had monosomy 21, and only one embryo was diploid for chromosome 21. The single diploid embryo was transferred to the uterus on day 3, and resulted in an uneventful pregnancy and delivery of a healthy live-born male.