Case management is associated with improved antiretroviral adherence and CD4+ cell counts in homeless and marginally housed individuals with HIV infection.

BACKGROUND: Case management (CM) coordinates care for persons with complex health care needs. It is not known whether CM is effective at improving biological outcomes among homeless and marginally housed persons with human immunodeficiency virus (HIV) infection. Our goal was to determine whether CM is associated with reduced acute medical care use and improved biological outcomes in homeless and marginally housed persons with HIV infection. METHODS: We conducted a prospective observational cohort study in a probability-based community sample of HIV-infected homeless and marginally housed adults in San Francisco, California. The primary independent variable was CM, defined as none or rare (any CM in 25% but 75%). The dependent variables were 3 self-reported health service use measures (receipt of primary care, emergency department visits and hospitalizations, and antiretroviral therapy adherence) and 2 biological measures (increase in CD4(+) cell count of >or=50% and geometric mean HIV load of or=50% improvements in CD4(+) cell count. CM was not associated with geometric HIV load <400 copies/mL when antiretroviral therapy adherence was included in the model. Study limitations include a lack of randomization. CONCLUSION: CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV-infected homeless and marginally housed adults.

Cause of death in men diagnosed with prostate carcinoma.

BACKGROUND: Prostate carcinoma is one of the leading causes of death in men. Although the mortality rate is high, it still may underestimate the number of deaths associated with the disease. This study was conducted to compare causes of death among men previously diagnosed with prostate carcinoma and to examine the extent to which differences in cause of death (death from prostate carcinoma vs. death from other causes) varied by age, race, clinical factors, and comorbid conditions. METHODS: A review was conducted of the medical records of decedent members of the Kaiser Permanente Medical Care program who previously were diagnosed with prostate carcinoma between January 1980 and December 1984 (n=584). The review focused on demographic factors, symptoms, diagnostic tests, stage of disease, and treatment. Data on comorbidity were obtained from a computerized discharge summary. Logistic regression analysis was used to estimate odds ratios. RESULTS: Approximately 54% of the decedent prostate carcinoma patients died of their prostate carcinoma. Decedents who were black, age < or = 65 years, diagnosed with more advanced disease stage, recipients of hormonal therapy, and whose death occurred > 6 months after diagnosis were more likely than others to die of prostate carcinoma. In contrast, the likelihood of dying of some other cause was associated with concurrent cardiovascular disease, after adjustment for the effects of race, age, and disease stage. There also were significant two-way age-race and age-time-to-death interactions. CONCLUSIONS: The prognostic significance of cardiovascular disease in prostate carcinoma patients should be investigated in subsequent survival studies. A number of questions need to be addressed delineating the complex relations between coexisting diseases and their treatment.

Breast cancer detection: maps of 2 San Francisco Bay area counties.

OBJECTIVES: This study describes the incidence of late-stage and in situ breast cancer among White women, using specialized mapping techniques that reflect incidence adjusted for the population at risk, and applies these maps to characterize areas with high and low risk of breast cancer. METHODS: Data from the Surveillance, Epidemiology, and End Results (SEER) database and the US Census Bureau were used to study the geographic distribution of breast cancer at the census-tract level in 2 San Francisco Bay Area counties for the years 1978 through 1982. Sociodemographic characteristics of areas with high and low incidence of the stage-specific disease were compared by means of a linear discriminant function. RESULTS: For late-stage breast cancer, the most important variables in discriminating high-risk from low-risk areas were college education, percentage of residents over age 65, and median income. The strongest ecologic indicators of high risk for in situ breast cancer were median income and percentage unemployed. CONCLUSIONS: This study demonstrates the usefulness of census tracts and sociodemographic measures of income and education in describing in situ and late-stage breast cancer.

Geographic issues in the analysis of a county-wide survey.

Surveys are used by county public health departments to obtain data for purposes such as risk factor inventories and program planning. Geographic data are often collected from respondents in order to make sub-county estimates and to ensure that the sample is representative of the population. This article addresses geographic issues that arise in analyzing such surveys including: (1) the assignment of respondents to geographic units, (2) the number of respondents necessary per unit, (3) geographically appropriate questions, and (4) geographic definitions. Data from a county-wide survey that highlight these issues are presented and suggestions for improvements are made.

Single-payer health insurance systems: national myths and immovable mountains.

Leaders in both government and the health-care industry have strong and varied opinions regarding the present US health-care system, but concur that health-care financing and organization need restructuring. The single-payer system offers the best framework for improving health-care universality, delivery, quality, access, choice, and cost effectiveness. However, the single-payer alternative often is dismissed early in debates on health-care reform. Popular aversion to collective governmental funding of health-care costs and the economic interests of the management, insurance, information, and profit sectors of the health-care industry are the critical impediments to adoption of single-payer insurance systems. This article examines the psychosocial and economic obstacles that prevent development of an efficient and effective health-care system and preclude recognition of the single-payer system as the best answer to health-care reform.

Urinary catheter-related infections among home care patients.

Urinary catheterization is a common indication for home care nursing services among older adults, and catheter-related urinary tract infections commonly occur among these patients. The purpose of this study was to determine the rate of urinary catheter-related infections among a group of elderly adults cared for in the home, the characteristics of those who acquire urinary tract infections as opposed to those who do not become infected, and the influence of the interval between catheter changes on the incidence of urinary tract infections.

Surveillance of intravenous catheter-related infections among home care clients.

BACKGROUND: Infection control in home care is an important area of study, and infection related to home infusion therapy is one component. METHODS: According to billed supplies from a 6-month period, we identified clients receiving intravenous care and conducted a chart review to determine characteristics and infection status. We reviewed each client from the start of a continuous home care period through April 30, 1992. RESULTS: Care of the catheters was done by nurses, family care givers, or the clients themselves. Intravenous catheter-related infections-site infections and bacteremia-occurred in three (4.5%) of the sample of 67; bacteremia occurred in one (1.5%). Incidence density was 12.5 infections per 10,000 catheter days (4.2 bacteremias per 10,000 days). Among those with central lines who remained without infection, 22.9% had the same line in place for 90 days or more. Among those with peripheral lines who remained without infection, 14.3% had a peripheral line, which was changed during home care, for 30 days or longer. CONCLUSIONS: Home care agencies seeking accreditation from the Joint Commission on the Accreditation of Healthcare Organizations need to establish surveillance systems; this may be one method to monitor device-related infections and to determine baseline rates.

Effects of supplemental protein source on ruminal fermentation, protein degradation, and amino acid absorption in steers and on growth and feed efficiency in steers and heifers.

In Exp. 1, four Holstein steers with cannulas in the rumen, abomasum and terminal ileum were used to determine the effects of 1) soybean meal (SBM), 2) heated SBM (HSBM), 3) corn gluten meal (CGM), or 4) a combination of HSBM and CGM (COMBO) as protein supplements on ruminal and total tract nutrient digestibilities and intestinal amino acid flows and absorption. In Exp. 2, 24 Holstein steers and 16 Holstein heifers were used in a 56-d growth trial to study the effects of these protein supplements on growth, feed efficiency, and apparent digestibility of DM, OM, CP, and fiber components. Increasing undegradable intake protein (UIP) in diets with HSBM, CGM, and COMBO decreased ruminal fluid ammonia N concentrations (P < .05) and ruminal DM and OM digestion (P < .05) and increased flow to the abomasum and absorption from the small intestine of CP (P < .05), total amino acids (P < .05), and total essential amino acids (P < .01). Increasing UIP increased bacterial and nonbacterial CP and amino acids flowing to the abomasum (P < .05). However, UIP supplementation did not affect DMI, ADG, or feed efficiency in steers or heifers (P < .05).

Black-white differences in stage-specific cancer survival: analysis of seven selected sites.

A number of researchers have noted that the black population in the United States generally has less favorable cancer survival than does the white population. It is not clear, however, whether this difference is fully explained by differences in stage of disease at diagnosis. This study uses Surveillance, Epidemiology, and End Results program data from the San Francisco-Oakland (California) Metropolitan Statistical Area for the years 1974-1985 to study survival differences between blacks and whites while controlling for both stage and age at diagnosis. The cancer sites examined are those for which mortality is considered avoidable by early detection and treatment, namely the colon, rectum, bladder, breast, cervix, uterine corpus, and prostate. Stage-specific (local, regional, and remote) survival curves are examined for each cancer site. The site- and stage-specific curves for colon, male rectal, and prostate cancer, supplemented by proportional hazards analyses, indicate no significant stage-specific racial differentials. Stage-specific survival differentials persist for male bladder, female rectal, and breast cancer. The relation between race and stage is more complex for female bladder, cervical, and uterine corpus cancer; for these sites, there is a racial difference at some stages but not all. The consequences for secondary intervention programs are considered for the seven sites in light of these findings.

The onset of decline in ischemic heart disease mortality in the United States.

Temporal and spatial patterns of the onset of the decline in ischemic heart disease mortality in the United States for each of the 48 contiguous US states and the District of Columbia are examined for the years 1955-1978 for age-sex-race-specific mortality. Mortality rates are derived from National Center for Health Statistics mortality data, and a polynomial interpolation is used to estimate intercensal population counts employing 1950, 1960, 1970, and 1980 US Census data. A quadratic regression equation is used to estimate the date of highest rate, which marks the beginning of the decline for each of the US states. The temporal distribution of the onset of the decline among men occurred primarily between 1960 and 1965. Among women, the onset of decline was more variable. Furthermore, strong and regular spatial patterns were seen among the groups examined and these impressions are supported by statistical analysis. California, Maryland, and the District of Columbia were early decliners in most groups studied, whereas states in the southeast were consistently among the last to experience the onset of decline. These patterns suggest the existence of an underlying phenomenon accounting for the spread or diffusion of the onset of decline in ischemic heart disease mortality.

Emissions from unvented kerosene heaters.

Vapor-phase polynuclear aromatic hydrocarbon (PAH) emissions from unvented kerosene heaters were measured. During normal heater operations, tri- and tetra-cyclic PAHs were observed, whereas penta-, hexa- and hepta-cyclic PAHs were not observed. The convective-type heaters had significantly less PAH emissions than the radiant-type heaters. Emissions of particulate soot were also measured. The soot did not contain PAH. A two-compartment model is presented and used to simulate heater operation in a home. Certain simulated PAH levels are similar to that measured in the ambient air of large cities.