Developing community health worker diabetes training.

We designed, implemented and evaluated a 48-hour training program for community health workers (CHWs) deployed to diabetes care teams in community health centers (CHCs). The curriculum included core knowledge/skills with diabetes content to assist CHWs in developing patient self-management goals. Our qualitative evaluation included pre/post-knowledge outcomes and encounter data from the field. CHWs and their supervisors were interviewed providing qualitative outcome data of the training process and program implementation. There were statistically significant increases in the scores of CHWs' self-reported knowledge in 8 of 15 curricular domains. Qualitative analysis revealed that CHWs preferred skill-based and case-based teaching, shorter training days but more contact hours. CHWs reported that pre-deployment training alone is insufficient for successful integration into care teams. CHW supervisors reported that CHC's readiness to accept CHWs as members of the care team was as important to successful deployment as training. With respect to implementation, supervision by social workers was deemed more successful than nursing supervision. Field data showed that patient encounters lasted less than 30 min and self-management goals focused on appointment keeping, diet, exercise and glucose testing. Integration and analysis of qualitative and descriptive field data provide an opportunity to continuously evaluate the effectiveness of implementation.

Sedative-hypnotic drugs and the risk of hip fracture.

A retrospective cohort study was conducted in individuals 65 years of age and older using Medicaid-reimbursed claims to assess the risk of hip fracture in users of two sedative-hypnotic drugs, triazolam and temazepam. Using the triazolam cohort as the referent group, the rate ratio was 0.92 (95% confidence interval, 0.72 to 1.17) for hip fracture with temazepam. Stratifying by age, sex, race, residence, time enrolled in Medicaid, prescription number, combinations of these, and several other potential confounding variables did not materially change the results. Compared with the short-acting benzodiazepine hypnotic temazepam, use of triazolam, an ultra-short-acting benzodiazepine hypnotic, did not decrease the risk of hip fracture. This study did not determine that either drug, compared with no use in an insomniac control group, increases the risk of hip fracture. However, because sedative-hypnotic drugs have been found in other studies to increase the risk of falling and hip fracture, they should be used with caution, especially in the elderly.

A foot in the door: art therapy in the nursing home.

Inclusion of art therapy in the residential nursing home and a day-care facility had positive effects on the elderly. Socialization, self-esteem, and memory retrieval were enhanced by the art experience. In addition, the staff and administrators of both the nursing home and day-care facility found art therapy to be valuable and arranged to continue the program. The funding agent for the pilot project was particularly interested in supporting a program that included an educational component, and the university recognized this program as an excellent training opportunity. The five art therapy interns gained experience in working with a population that will need increased professional services in the future, and the successful addition of part-time art therapists at the two pilot agencies will assure a continuation of intern training sites for art therapy students interested in gerontology. By developing sites for art therapy interns, we have opened the door to a method which will not only train professionals to work with older adults but will also offer job sharing between nursing homes. It has been suggested by the administrator of the nursing home in the program that we investigate the possibility of one art therapist serving two or three nursing homes on a part-time/full-time employment basis. Programs would then be affordable at most sites, and thus more people would be able to benefit from art therapy.

Oral contraceptive estrogen dose and the risk of deep venous thromboembolic disease.

Despite the well-recognized association between oral contraceptives and deep venous thromboembolism, little is known about the risks associated with currently marketed formulations containing less than 50 micrograms of estrogen. To assess the venous thrombogenicity of low-estrogen oral contraceptives (those containing less than 50 micrograms of estrogen) relative to intermediate-dose (50 micrograms of estrogen) and high-dose (greater than 50 micrograms of estrogen) formulations, we conducted a cohort study of oral contraceptive users between the ages of 15 and 44 years in the Michigan Medicaid population. The period of the study was from 1980 through the third quarter of 1986. A total of 2,739,400 oral contraceptive prescriptions received by 234,218 women were analyzed. Using the low-estrogen cohort as the referent group, the age and calendar period adjusted relative risk of venous thromboembolism in users of intermediate-dose formulations was 1.5 (95% confidence interval (CI) 1.0-2.1, p = 0.04), and the relative risk in users of high-dose formulations was 1.7 (95% CI 0.9-3.0, p = 0.06). These data provide evidence that the dose-response relation between oral contraceptive estrogen and venous thromboembolism extends from 50 to 30 micrograms of estrogen, the dose range of currently marketed formulations.

Oral contraceptive oestrogen and progestin potencies and the incidence of deep venous thromboembolism.

To assess possible differences in the incidence of venous thrombosis and pulmonary embolism associated with oral contraceptives of varying hormonal potencies, the authors conducted a retrospective cohort study in the 15-44 year old Michigan Medicaid population. Cohorts were defined by the progestin- and oestrogen-potencies of oral contraceptives in use at the time of follow-up as classified by an oral contraceptive potency scheme. Using the low-oestrogen-/low-progestin-potency formulations for reference (rate ratio = 1), adjusted rate ratios of 0.8 (95% CI: 0.5 to 1.3, P = 0.41) and 0.6 (95% CI 0.4 to 1.2, P = 0.13) were observed for intermediate-progestin-potency and high-progestin-potency formulations, respectively. Adjusted rate ratios of 1.4 (95% CI: 0.8 to 2.3, P = 0.21) and 2.6 (95% CI: 1.2 to 5.5, P = 0.01) were observed for intermediate- and high-oestrogen-potency formulations. These data suggest a dose-response relationship between oral contraceptive oestrogen potency and venous thromboembolism, whereas no such evidence for a dose-response relationship between oral contraceptive progestin potency and venous thrombo-embolism was found.

Synthesis of dextroamphetamine sulfate and methamphetamine hydrochloride from D-phenylalanine.

Starting from D-phenylalanine, dextroamphetamine sulfate and methamphetamine hydrochloride were synthesized. The reaction sequence proceeds through three intermediates, in which the absolute configuration of the asymmetric carbon atom is changed but the relative configuration remains the same. Either product can be obtained from a common intermediate by altering the reductive conditions employed for the removal of a carbamate protecting group.