Residents' perceptions of effective community representation in local health decision-making

Community participation in local health decision-making has been envisioned as a key strategy to improve the design and delivery of health services in the USA. While much literature has sought to understand this participatory approach, considerably fewer studies have engaged the essential first-order question: How would we know who the appropriate community representatives are? An important first analytic step is to learn from community members themselves what characteristics they feel a ‘good' representative should possess. Two primary research questions are addressed: 1) To what degree can low-income adults identify and articulate what they believe constitutes an effective community health representative and 2) What do low-income adults believe are the specific characteristics an effective community health representative should possess? In-depth, open-ended interviews were conducted with 14 African-American and Latino residents of four low-income communities on the Southside of Chicago, USA. A theoretical sampling strategy was used with residents varying by age, education, employment, and years of residence on the Southside. We found that respondents had difficulty articulating what a community health representative might do or generating the names of potential representatives, but were able to express clear preferences for what would constitute good representation when given meaningful choices. Three primary characteristics were identified: 1) outcomes 2) expertise, and 3) active communication. These characteristics did not operate in isolation but together communicated the trust and commitment that respondents found fundamental to representation. In exploring this essential yet often neglected question, we sought to build an empirical foundation to more fully examine the precursors to effective community health representation. These data provide important clues as to how to build an inclusive process that expands rather than constrains the pool of community-based representatives.     

Reliability of colonoscopy

In an effort to determine the reliability of colonoscopy the authors retrospectively reviewed preoperative colonoscopic findings and compared them with the postoperative pathologic specimen reports. Only lesions greater than 0.5 cm were included in the comparison. Over a 13-year period, 429 patients with colorectal cancer underwent preoperative colonoscopy. Four hundred thirteen (97 percent) of the colonoscopic examinations correlated with the pathologic specimen, but, in 16 cases (3 percent), lesions were missed. In total, 17 adenomatous polyps and 3 cancers were found in the surgical specimens that were not documented at colonoscopy. Eighteen patients had total preopecative colonoscopy and total abdominal colectomy, which makes for a reliable model to judge the accuracy of colonoscopy. In these 18 patients, 17 of the pathologic specimens correlated with the endoscopic findings, which yields an accuracy rate of 94 percent. Blind areas in the colon, plus misjudgment that the scope had reached the cecum, are responsible for the majority of colonoscopic errors Read at the meeting of the American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.     

Ethnic differences in the prognostic value of coronary artery calcification for all-cause mortality.

OBJECTIVES: The purpose of this study was to evaluate the prognostic value of coronary artery calcium (CAC), a known marker of subclinical atherosclerosis, in a large, ethnically diverse cohort of 14,812 patients for the prediction of all-cause mortality. BACKGROUND: Disparities in case fatality rates for heart disease among ethnic groups are well known. In 2001, rates of death from heart disease were 30% higher among African Americans (AA) than non-Hispanic whites (NHW). Some of this variability may be due to differing pathophysiological mechanisms and effects of underlying atherosclerosis. METHODS: Ten-year death rates from all causes (total deaths = 505) were compared using risk-adjusted Cox proportional hazards models in AA (n = 637), Hispanic (HS, n = 1,334), Asian (AS, n = 1,065), and NHW (n = 11,776) populations. RESULTS: Ethnic minority patients were generally younger (0.3 to 4 years), more often persons with diabetes (p < 0.0001), hypertensive (p < 0.0001), and female (p < 0.0001). The prevalence of CAC scores > or =100 was highest in NHW (31%) and lowest for HS (18%) (p < 0.0001). Overall survival was 96%, 93%, and 92% for AS, NHW, and HS, respectively, as compared with 83% for AA (p < 0.0001). When comparing prognosis by CAC scores in ethnic minorities as compared with NHW, relative risk ratios were highest for AA with CAC scores > or =400 exceeding 16.1 (p < 0.0001). Hispanics with CAC scores > or =400 had relative risk ratios from 7.9 to 9.0, whereas AS with CAC scores > or =1,000 had relative risk ratios 6.6-fold higher than NHW (p < 0.0001). CONCLUSIONS: Consistent with population evidence, AA with increasing burden of subclinical coronary artery disease were the highest-risk ethnic minority population. These data support a growing body of evidence noting substantial differences in cardiovascular risk by ethnicity.     

Observations on 261 consecutive patients with inflammatory bowel disease seen in the southwest United States

Two hundred and sixty-one consecutive patients with inflammatory bowel disease (IBD) were seen at a private medical and surgical clinic affiliated with Baylor College of Medicine in Houston, Texas, between November 1, 1975, and March 1, 1979. We collected social, and demographic data concerning date and place of birth, sex, race, religion, marital status, date and place of disease onset and occupation, in order to determine whether the presetation of IBD in the southwest United States differs from that in other regions. Clinical data concerning presenting symptoms, area of bowel involvement, and number of hospitalizations were tabulated in order to evaluate the mortality and morbidity of disease. Where applicable statistical analysis of the data was accomplished by computer to determine the significance of the findings. Inflammatory bowel disease was noted to be a disease predominantly of whites, with relative sparing of blacks and Latin Americans. Thirteen cases of IBD occurred in a neighboring white, non-Jewish community of Orange, Texas, during the period of study. In the 261 cases morbidity was severe, but the mortality rate was low. There was one death from suicide. No surgical mortalities were noted in 106 patients who underwent one to ten surgical procedures.These studies were supported by a grant from the Kelsey-Leary Foundation.Computational assistance was provided by the Clinfo Project, funded by the Division of Research Resources of the N.I.H. under grant number RR-00350.     

Left ventricular structure and diastolic function with human ageing. Relation to habitual exercise and arterial stiffness.

AIMS: We sought to determine if attenuation of the age-associated increase in arterial stiffness by habitual aerobic-endurance exercise would have corresponding effects on left ventricular (LV) structure and diastolic function. METHODS AND RESULTS: We performed a cross-sectional study on 138 young, middle-aged, and older men who were either sedentary, recreationally active, or endurance exercise-trained. Ageing was associated with increased large artery stiffness (aortic pulse wave velocity) and habitual aerobic-endurance exercise was associated with decreased large artery stiffness (lower aortic pulse wave velocity; all P<0.05). Ageing was associated with increased mean LV wall thickness, chamber diameter, mass, concentric remodelling, and a decline in LV diastolic function (all P<0.05). Habitual aerobic-endurance exercise was independently associated with increased LV wall thickness, chamber diameter, and mass (echocardiography; P=0.05 or better). The largest LV mass was seen in older endurance trained men, suggesting an additive effect of exercise training and ageing on the LV. Indices of LV diastolic function declined with age, irrespective of habitual physical activity status. Aortic pulse wave velocity was an independent predictor of concentric LV remodelling in the pooled sample, but did not predict other properties of LV structure and diastolic function. In general, habitual aerobic-endurance exercise status was not uniformly associated with favourable modulation of age-associated changes in LV structure and diastolic function. CONCLUSIONS: We conclude that in contrast to its ability to favourably modulate the stiffness of large elastic arteries, regular aerobic-endurance exercise does not consistently modulate the changes in LV structure and diastolic function that occur with physiological ageing in men.     

Bleeding risk of platelet glycoprotein IIb/IIIa receptor antagonists in broad-based practice (results from the Society for Cardiac Angiography and Interventions Registry)

Randomized trials of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors in patients who have undergone percutaneous coronary intervention (PCI) have shown a modest increase in bleeding risk associated with GP IIb/IIIa inhibitor use. Because clinical trials often enroll highly selected patient populations and are performed in high-volume experienced centers, these results may not apply to a nonclinical trial population, thus altering the risk-benefit ratio of the drugs. Given the widespread use of these agents, we sought to determine bleeding risks in a broad-based population of patients who underwent PCI. We performed a retrospective cohort study of GP IIb/IIIa inhibitors and bleeding in 18,821 procedures from June 1, 1996 to December 31, 1998 using the Society for Cardiac Angiography and Interventions Registry. The primary outcome was bleeding events, defined as clinically significant hematoma formation or hemorrhage. Bleeding risk was 1.9% in the 2,525 patients who received GP IIb/IIIa inhibitors compared with 1.0% in the 16,296 who did not (unadjusted odds ratio [OR] 1.87, 95% confidence interval [CI] 1.35 to 2.59, p <0.001). After adjustment for multiple clinical and procedural variables, the effect was attenuated, with at most a twofold bleeding risk associated with GP IIb/IIIa inhibitor use (adjusted OR 1.39, 95% CI 0.96 to 2.03, p = 0.083). The small increase in absolute risk of bleeding from GP IIb/IIIa inhibitor use in this study is similar to the risk observed in clinical trials. Assuming these agents are as effective as shown in these trials, the risk-benefit ratio of GP IIb/IIIa inhibitors in broad-based PCI practice should be favorable.