Racial, gender and geographic disparities of antiretroviral treatment among US Medicaid enrolees in 1998.

BACKGROUND: In 1998, highly active antiretroviral therapy (HAART) was widespread, but the diffusion of these life-saving treatments was not uniform. As half of all AIDS patients in the USA have Medicaid coverage, this study of a multistate Medicaid claims dataset was undertaken to assess disparities in the rates of HAART. METHODS: Data came from 1998 Medicaid claims files from five states with varying HIV prevalence. ICD-9 codes were used to identify people with a diagnosis of HIV/AIDS or AIDS-defining illness. Multivariate analyses assessed associations between age, gender, race and state of residence for antiretroviral regimens consistent with HAART, as defined by 1998 Centers for Disease Control and Prevention (CDC) guidelines. RESULTS: Among 7202 Medicaid enrolees with a diagnosis of HIV/AIDS or AIDS, 62% received HAART and 25% received no antiretroviral therapy. Multivariate analyses showed that age, race, gender and state were all significant predictors of receiving HAART: white, non-Hispanic patients were most likely to receive HAART (68.3%), with lower rates in Hispanic and black, non-Hispanic segments of the population (59.3% and 57.5%, respectively, p<0.001). Women were less likely to receive HAART than men (51.8% vs 69.3%, p<0.001). CONCLUSION: Despite similar insurance coverage and drug benefits, life-saving treatments for HIV/AIDS diffused at widely varying rates in different segments of the Medicaid population. Research is needed to determine the extent to which racial, gender, interstate and region disparities currently correspond to barriers to such care.

Development of a questionnaire measuring treatment concerns in regular dental patients.

OBJECTIVES: The aim of this study was to develop an instrument measuring core concerns about dental treatment guided by Reiss' expectancy theory of fear. This would include the content domains of injury, somatic reaction and interpersonal concerns, to study the underlying factorial structure, and to determine the test quality of the resulting subscales. METHODS: A total of 555 regular dental patients answered the item pool. Subsamples filled in the Dental Anxiety Scale (DAS) (n = 346) and the Anxiety-Present Scale of the state-form of the State-Trait Anxiety Inventory (STAI-S) (n = 187). A second sample (n = 89) was used to determine test-retest reliability and bias for social desirability [Self Disclosure Scale of the Freiburg Personality Inventory (FPI)]. RESULTS: Exploratory and confirmatory factor analyses identified a stable three-dimensional structure underlying the items convergent to the content domains of interpersonal, injury and somatic reaction concerns. Internal consistencies of the resulting subscales were between alpha = 0.84 and alpha = 0.87, test-retest reliabilities were from r(tt) = 0.72-0.78. No evidence for a social desirability response bias was found. All subscales discriminated between patients with low and high dental trait anxiety at a level of P < 0.00001. Dental treatment concerns predicted 36% of variations in actual anxiety during treatment. CONCLUSIONS: The results suggest that the proposed instrument, namely the Dental Treatment Concerns Inventory, shows good test qualities according to construct, discriminant and predictive validity, and may be a promising tool for research and clinical applications.

[Virtual colonoscopy--chances for a screening procedure?]. / Virtuelle Koloskopie--Chancen für ein Screeningverfahren?

In principle, virtual colonoscopy is capable to be used as method for early detection of colorectal cancer (CRC), even if the accuracy of the method and radiation exposure are matters discussion in the radiological community. Virtual colonoscopy is able to detect any pathology which is relevant for early detection of CRC especially when using multislice CT, but also with single slice CT. The diagnosis of small lesions, less than 7 mm in diameter (polyps and flat lesions) is still problematic as it is in conventional colonoscopy. The exposure to x-rays in asymptomatic patients, without any increased risk of developing cancer is highly problematic and should be reduced to a minimum. Using special post processing filters on the volume dataset it can be shown that a tube current of 20 mAs is sufficient without any loss in accuracy. Measurements on the Alderson-phantom showed, that an effective dose exposure of 1.2 mSv is obtained using these reduced mAs values. It has to be differentiated between virtual colonoscopy for early detection of polyps and CRC in individual patients or as a screening examination of a large population. Virtual colonoscopy as a screening examination necessitates reduction of radiation dose, a high degree of automatization in 3D reconstructions as well as the assessment of the entire mucosa. High risk patients, whom refuse fibreoptic colonoscopy should undergo virtual colonoscopy. Virtual colonoscopy has a good chance to become an accepted tool for general screening, if efficient dose reduction, complete visualization of the colon mucosa and automatization of the post processing procedures can be achieved.

Multi-slice computed tomography as a screening tool for colon cancer, lung cancer and coronary artery disease.

Recent promising trials that use low-dose CT for the early detection of lung cancer have reinvigorated the interest in screening approaches. At the same time the development of fast image acquisition techniques, such as multislice CT, have sparked renewed interest in cardiac imaging within the radiological community. In addition to special cardiac capabilities, multislice CT has several other features such as high acquisition speed and low-dose requirements that may make this modality a universal radiological screening tool. Non-invasive disease detection is the radiologist's domain. In this paper we identify criteria for effective screening and apply these criteria to screening approaches with multislice CT when used for detection of three disease entities: colon cancer; lung cancer; and cardiovascular disease.

Does breastfeeding protect children from asthma? Analysis of NHANES III survey data.

We sought to determine whether breastfeeding (yes/no) or its duration protects against the development of childhood asthma, its severity or age of onset. We conducted a secondary analysis of youth files of the National Health and Nutrition Examination Survey III (1988-94), and reviewed data from 6,783 children age 2 months to 6 years (3,316 breastfed), excluding children with a history of low birth weight or treatment in a neonatal intensive care unit. Study participants were breastfed an average of 157 days. The average age at onset of asthma was 14.3 months. In the logistic regression model, "ever breast-fed" was not a significant protective factor for developing asthma. Significant predictive factors were the mother's age at child's birth (beta = -0.08, p < 0.01), and a parent having asthma or hayfever (beta = 0.46, p < 0.01). In the linear regression model, the duration of breastfeeding was not a predictor for age at onset of asthma (beta = 0.01, p = 0.53). Only maternal smoking during pregnancy was a significant predictor of age at onset of asthma (beta = -7.59, p < 0.01). Breastfeeding does not appear to prevent asthma, delay its onset, or reduce its severity. However, breastfeeding is still recommended for its many other benefits.

[Virtual large intestine imaging with multi-level CT. Pain free coloscopy--that works!]. / Virtuelle Dickdarmspiegelung mit der Mehrschicht-CT. Schmerzfrei koloskopieren--das geht!

Provided that the bowel is carefully cleansed, virtual colonoscopy permits a safe, reliable and painfree diagnosis of the large bowel. It requires distension of the bowel with ambient air. Contraindications include pregnancy, acute inflammation of the bowel and recent surgery. Tumors and large polyps (10 mm and more) can be diagnosed with certainty, while polyps measuring 5 mm and more are detected with a high degree of sensitivity. It goes without saying that virtual colonoscopy does not allow for the taking of biopsy material or the performance of therapeutic measures, so that positive or suspicious findings must be clarified by conventional colonoscopy. In principle, virtual colonoscopy is also suitable for use as a screening procedure. Whether the radiation exposure associated with the conventional examination protocol can be considered acceptable for screening purposes is questionable. However, using mathematical means, the radiation dose can be reduced to one-tenth of the usual dose.

[Virtual coloscopy with multi-slice computerized tomography. Preliminary results]. / Virtuelle Koloskopie mit der Mehrschichtcomputertomographie. Vorläufige Ergebnisse.

SUBJECT: Using multi-slice computed tomography (MSCT) large body areas can scanned with high spatial resolution. In this study, MSCT was employed for virtual colonoscopy in various pathologies of the colon. MATERIALS AND METHODS: For MSCT a Somatom Plus 4, Volume Zoom scanner, (Siemens, Forchheim) was employed, equipped with four parallel detector rows. Twenty-five patients were included in this trial, prior to colonoscopy or partial colon resection. After cleaning the colon, distension was achieved by insufflation of room air using a rectal tube. The parameters of acquisition and reconstruction were as follows: collimation 4 x 1 mm and 4 x 2.5 mm respectively; tube charge per slice: 140-160 mAs; pitch 5-6; i.v. contrast medium: 120 ml Ultravist 300 (Schering) with a flow rate of 3 ml/s; delay: 35 s. For 3D reconstruction we used edge-enhanced volume rendering, virtual colonoscopy and extraluminal views of volume-rendered images. RESULTS: Nine polyps and four of five colon carcinomas were detected using MSCT virtual colonoscopy. In three patients with ulcerative colitis virtual coloscopy revealed morphological alterations compatible with this disease. In two of four patients with multiple diverticula of the colon the true extent of the disorder could be assessed in virtual colonoscopy. CONCLUSION: Utilizing virtual MSCT colonoscopy polyps and cancer of the colon can be reliably detected, if proper cleaning and distension is provided. On axial images alone smaller polyps may be assessed. The high z-axis resolution of MSCT offers superior conditions for CT-based virtual colonoscopy.

[Multislice computed tomography of the small intestine. Preliminary results]. / Mehrschicht-Computertomographie des Dünndarms. Vorläufige Ergebnisse.

SUBJECT: Spiral computer tomography (SCT) became an important supplement to the Sellink examination. Multi slice computer tomography (MSCT) achieves a z-axis resolution of 1-2 mm without considerable increase in the acquisition time. In this paper, examination technique in first clinical results of CT-Sellink examination with MSCT, including the 3D-reconstruction are presented. MATERIALS AND METHODS: The investigations were carried out with the Somatom Plus 4 Volume Zoom (Siemens, Forchheim) scanner. The following parameters were employed: 4 parallel detector ledges, collimation 4 x 1 mm, tube power 140 mA, tube voltage 120 kV, pitch 5 up to 6 mm, slice thickness 1 mm and 2 mm, reconstruction with 50% overlap. Via a duodenal tube, the small intestine was distended by means of 1.5 up to 2.5 l methyl-cellulose suspension. The data were acquired 35 s after injection of 120 ml contrast media (Ultravist). Various methods of postprocessing were applied on a workstation. RESULTS: As of yet, 16 patients were examined with MSCT-Sellink. In 4 cases pathological findings were detected with MSCT-Sellink, which were not recognized with X-ray Sellink. CONCLUSION: Due to high z-axis resolution and short acquisition time, the morphological details of the small intestine can be visualized utilizing MSCT-Sellink. The data set is well suited for 3D postprocessing. Improvement of diagnostic accuracy can be anticipated.

[Computed tomography of the abdomen with multidetector-array CT]. / Computertomographie des Abdomens mit der Mehrzeilen-Detektor Spiral-CT.

BACKGROUND: The advent of multidetector CT (MDCT) constitutes a quantum leap creating a wealth of new opportunities in medical imaging. However, while the basic principles of spiral CT still apply, we are now challenged to rethink our strategies in planning a CT study to take full advantage of the increased capabilities of MDCT. MATERIALS AND METHODS: We report here our preliminary experiences with MDCT for abdominal CT imaging within a 5-month period. During this time, suitable protocols for investigation of the abdomen using MDCT were developed. The capabilities of MDCT allow for tailoring dedicated CT protocols for routine applications as well as for biphasic liver studies and CT angiography of the aorta and abdominal vessels. RESULTS: The speed of MDCT can either be used to reduce the time needed to cover a given volume, or to use narrower beam collimations to increase the resolution of detail along the z-axis and reduce volume averaging. Higher scan speed allows reduction of the amount of contrast material in vascular applications and suppression of motion artifacts. Higher spatial resolution with thinner collimations reduces volume averaging and improves the detection of small hepatic and pancreatic lesions. Detailed analysis of vascular structures and high-quality three-dimensional reformations become feasible. New problems arise from the large amount of data generated by MDCT. CONCLUSIONS: MDCT offers a wealth of new opportunities that help us to come to a fast and accurate diagnosis in suspected abdominal disease. Traditional indications for performing CT are reemphasized and new clinical applications can be exploited.

Asthma care in community health centers: a study by the southeast regional clinicians' network.

Federally funded community health centers (CHCs) were surveyed to assess their ability to serve low-income asthma patients in the southeastern United States. Data were collected on CHC clinicians, pharmacy services, and patient characteristics. Twenty-six (74%) of 35 participating CHCs provided data on 83 distinct clinic sites in eight states, representing 898,977 billable patient visits to 318,920 people during the one-year study period. Participating CHCs provided 23% of all CHC patient visits in Region IV in 1995. Sixty-two percent of patients had a family income below poverty level. Almost 75% of the patients were uninsured or receiving Medicaid. Asthma was the diagnosis code for 2.04% of all medical encounters. Twenty-nine percent of sites were unable to provide medications for uninsured asthma patients, while 66% could provide drug samples. Thirty-three percent of CHCs had in-house pharmacies and 33% offered pharmacy vouchers. Eighty-two percent could provide beta-agonist inhalers, 54% could provide steroid inhalers, and 17% could provide peak flow meters. Federally funded CHCs provide care to many asthma patients from the highest risk segments of the population, but often do not have the resources needed to follow current clinical guidelines.

The Morehouse Faculty Development Program: methods and 3-year outcomes.

BACKGROUND AND OBJECTIVES: Faculty development is an established method for increasing the number and effectiveness of faculty in family medicine. However, few published studies focus specifically on the use of faculty development to increase minority representation among faculty. Underrepresented minorities comprise 20% of the nation's population but only 3% of medical school faculty. In the entire nation, only 52 full-time teachers of family medicine are African-Americans. Morehouse School of Medicine has developed an effective model for training large numbers of underrepresented minority physicians to become academic family physicians. From 1993-1996, we trained 23 community-based physicians, three new faculty, six existing faculty, and three full-time fellows as teachers of family medicine. Of 35 participants, 33 were underrepresented minorities. Cultural issues in teaching and communication are an integral part of the curriculum. Seventy-three percent of graduates now teach medical students or residents either full-time or part-time. Further studies are needed to test the replicability of this model in non-minority institutions, as well as to achieve greater cost-effectiveness and improve academic outcomes such as publications and research. Significant faculty diversity is necessary and achievable, if institutions are willing to commit significant resources and network with minority health professionals and institutions.

Acute exertional rhabdomyolysis.

Acute exertional rhabdomyolysis is caused by a skeletal muscle injury that results in the release of myoglobin and other cellular contents into the circulatory system. Recent reports suggest that acute exertional rhabdomyolysis is more common and more serious than previously realized. Mild to moderate acute exertional rhabdomyolysis can result in hyperkalemia, hypernatremia, lactic acidosis and hyperphosphatemia. Disseminated intravascular coagulation, renal failure and compartmental syndrome may also occur. The physician should maintain a high index of suspicion for acute exertional rhabdomyolysis in patients who present with symptoms of an overexertion injury, most commonly pain and swelling in the affected muscles. Special attention should be given to evaluating the history for occupational, recreational, environmental and medical risk factors for rhabdomyolysis. Screening may be performed with a simple urine dipstick test; if the urine is orthotoluidine-positive, the diagnosis should be confirmed with measurement of the serum creatine kinase level. Early intervention with aggressive hydration and close monitoring for metabolic, renal or hematologic complications may prevent serious injury or death.

Beta-subunits co-determine the sensitivity of rat neuronal nicotinic receptors to antagonists.

We have investigated the effect of 4 ganglionic cholinergic antagonists (hexamethonium, mecamylamine, pentolinium, trimetaphan) on rat alpha 3 beta 2 and alpha 3 beta 4 neuronal nicotinic acetylcholine receptors (nAChRs) expressed in Xenopus oocytes. Current responses were elicited by fast application of acetylcholine on voltage-clamped oocytes (holding potentialVh = -80mV). Concentration-inhibition curves were used to get estimates of IC50, the antagonist concentration yielding 50% reduction of the peak current. The KB's of the antagonists were calculated using estimates of the apparent KD of acetylcholine. The order of affinity of the antagonists was similar for both receptor subtypes: mecamylamine approximately pentolinium > hexamethonium > trimetaphan. However, alpha 3 beta 4 neuronal nAChRs were 9 to 22 times more sensitive to each of the 4 antagonists than alpha 3 beta 2 receptors. These results further underline the importance of the beta-subunit as co-determinant of the functional properties of neuronal nAChRs.