Changes in injection risk behavior associated with participation in the seattle needle-exchange program

We studied the influence of the Seattle, Washington, needle-exchange program on sharing of drug injection equipment (syringes, drug cookers, filtration cotton) to identify potential gaps in risk reduction and to understand in greater detail the lack of an association between exchange use and risk of hepatitis B or C virus transmission. In a cohort of 2,208 injection drug users who completed a 1-year follow-up visit, we measured the association between needle-exchange use at study enrollment (ever vs. never) and injection risk behavior at the follow-up. Control for confounding was carried out using both logistic regression and propensity score analytic methods to estimate the adjusted odds ratio (AOR). In both univariate and multivariate analyses ,needle-exchange use was associated with a lower likelihood of injection with a used syringe (AOR-0.7,95% confidence limit 0.5,0.9). There was no association between exchange use and cooker or cotton sharing (AOR-0.8,95% confidence limit 0.6, 1.1) or between exchange use and use of a common syringe to divide drugs (AOR=0.9). This analysis suggests that risk reduction measures adopted by users of the Seattle exchange may not be sufficient to prevent transmission of all blood-borne viruses, including hepatitis C virus. Creater awareness of the infection risk associated with these practices may help curb this type of equipment sharing and ultimately prevent disease transmission.     

Economic Analyses of the Be Fit Be Well Program: A Weight Loss Program for Community Health Centers

BACKGROUND

The U.S. Preventive Services Task Force has released new guidelines on obesity, urging primary care physicians to provide obese patients with intensive, multi-component behavioral interventions. However, there are few studies of weight loss in real world nonacademic primary care, and even fewer in largely racial/ethnic minority, low-income samples.

OBJECTIVE

To evaluate the recruitment, intervention and replications costs of a 2-year, moderate intensity weight loss and blood pressure control intervention.

DESIGN

A comprehensive cost analysis was conducted, associated with a weight loss and hypertension management program delivered in three community health centers as part of a pragmatic randomized trial.

PARTICIPANTS

Three hundred and sixty-five high risk, low-income, inner city, minority (71 % were Black/African American and 13 % were Hispanic) patients who were both hypertensive and obese.

MAIN MEASURES

Measures included total recruitment costs and intervention costs, cost per participant, and incremental costs per unit reduction in weight and blood pressure.

KEY RESULTS

Recruitment and intervention costs were estimated $2,359 per participant for the 2-year program. Compared to the control intervention, the cost per additional kilogram lost was $2,204 /kg, and for blood pressure, $621 /mmHg. Sensitivity analyses suggest that if the program was offered to a larger sample and minor modifications were made, the cost per participant could be reduced to the levels of many commercially available products.

CONCLUSIONS

The costs associated with the Be Fit Be Well program were found to be significantly more expensive than many commercially available products, and much higher than the amount that the Centers for Medicare and Medicaid reimburse physicians for obesity counseling. However, given the serious and costly health consequences associated with obesity in high risk, multimorbid and socioeconomically disadvantaged patients, the resources needed to provide interventions like those described here may still prove to be cost-effective with respect to producing long-term behavior change.     

Analysis of standard methods for diagnosing vaginitis: HIV infection does not complicate the diagnosis of vaginitis

OBJECTIVE: We sought to determine whether the standard diagnostic methods for vaginitis behave similarly among HIV-infected and at-risk seronegative women. MATERIALS AND METHODS: We performed pairwise comparisons over time (1994-2003) for the different diagnostic methods for bacterial vaginosis (BV) (Nugent score and Amsel criteria), vulvovaginal candidiasis (potassium hydroxide smear and Pap smear), and trichomoniasis (culture, wet mount, and Pap smear) among HIV-infected and at-risk HIV seronegative women in the Women's Interagency HIV Study cohort. We stratified subjects by HIV status and among the HIV-infected women by CD4+ cell count strata. RESULTS: For BV and trichomoniasis, kappa statistics comparing clinical diagnostic methods to laboratory-based methods improved after the first year. Significant differences in overall kappa statistics between HIV-infected and at-risk HIV-seronegative women were found only for vulvovaginal candidiasis where potassium hydroxide smear and Pap smear findings were more tightly correlated among HIV-infected women than among at-risk HIV-seronegative women; among these HIV-infected women, concordance was highest at lower CD4 cell counts. No significant differences in kappa statistics were found for the diagnostic methods of BV or trichomoniasis neither by HIV status nor CD4 cell count strata. CONCLUSIONS: The standard diagnostic tests for BV, vulvovaginal candidiasis, and trichomoniasis behave similarly in HIV-infected and at-risk seronegative women. Training and experience are critical for the accurate performance of the diagnostic methods that require clinician interpretation.     

Management of diabetic retinopathy by Australian optometrists

Purpose: To describe current practices related to the management of diabetic retinopathy by Australian optometrists. Setting and Methods: A two-page self-administered questionnaire was mailed to a random sample of 504 Australian optometrists. The survey included questions about the practice (such as size and location); current practice with regard to management of patients with diabetic retinopathy; barriers to use of dilating drops; and a number of patient scenarios related to screening, follow-up and treatment of diabetic retinopathy. Results: Completed questionnaires were returned by 407 of the 473 eligible optometrists (86%). They had been practising optometry between 1 and 50 years (median 14). Of the 243 optometrists who provided details about the location of their practices, 145 (37%) had at least one of their practices in a rural area. The estimated percentage of patients with diagnosed diabetes ranged from 0.5 to 40% (median = 5.0%). Three-hundred and twenty-two optometrists (79%) reported that they would often or almost always ask new patients over the age of 40 whether they have diabetes. The majority of optometrists (n = 387, 95%) would often or almost always ask their new patients with diabetes about their control of blood glucose levels and the majority of optometrists (n = 330, 81%) would often or almost always tell their patients with diabetes about the importance of strict glucose control in delaying retinopathy. The most common barrier to dilated ophthalmoscopy was patients not wanting to be dilated, with 38.1% of optometrists reporting this to be a moderate or major barrier. The next most common barrier was fear of precipitating angle closure glaucoma; 17.1% of optometrists reported this to be a moderate or major barrier. Conclusion: The National Health and Medical Research Council (NHMRC) guidelines for the management of diabetic retinopathy are timely in relation to the expressed desire of Australian optometrists to learn more about management of diabetic retinopathy. These data will be used prospectively to assess changes in management of patients with diabetic retinopathy as a result of the release of the NHMRC guidelines.