PreView: a Randomized Trial of a Multi-site Intervention in Diverse Primary Care to Increase Rates of Age-Appropriate Cancer Screening.

BACKGROUND: Women aged 50-70 should receive breast, cervical (until age 65), and colorectal cancer (CRC) screening; men aged 50-70 should receive CRC screening and should discuss prostate cancer screening (PSA). PreView, an interactive, individually tailored Video Doctor Plus Provider Alert Intervention, adresses all cancers for which average risk 50-70-year-old individuals are due for screening or screening discussion. METHODS: We conducted a randomized controlled trial in 6 clinical sites. Participants were randomized to PreView or a video about healthy lifestyle. Intervention group participants completed PreView before their appointment and their clinicians received a "Provider Alert." Primary outcomes were receipt of mammography, Pap tests (with or without HPV testing), CRC screening (FIT in last year or colonoscopy in last 10 years), and PSA screening discussion. Additional outcomes included breast, cervical, and CRC screening discussion. RESULTS: A total of 508 individuals participated, 257 in the control group and 251 in the intervention group. Screening rates were relatively high at baseline. Compared with baseline screening rates, there was no significant increase in mammography or Pap smear screening, and a nonsignificant increase (18% vs 12%) in CRC screening. Intervention participants reported a higher rate of PSA discussion than did control participants (58% vs 36%: P < 0.01). Similar increases were seen in discussions about mammography, cervical cancer, and CRC screening. CONCLUSION: In clinics with relatively high overall screening rates at baseline, PreView did not result in significant increases in breast, cervical, or CRC screening. PreView led to an increase in PSA screening discussion. Clinician-patient discussion of all cancer screenings significantly increased, suggesting that interventions like PreView may be most useful when discussion of the pros and cons of screening is recommended and/or with patients reluctant to undergo screening. Future research should investigate PreView's impact on those who are hesitant or reluctant to undergo screening. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02264782.

The Efficacy of an Antioppression Curriculum for Health Professionals.

BACKGROUND AND OBJECTIVES: Health professionals increasingly recognize the role that social determinants play in health disparities. However, little focus is placed on how health care professionals themselves contribute to disparities through biased care. We have developed a curriculum based on an antioppression framework which encourages health professionals to evaluate their biases and combat health care disparities through an active process of allyship. METHODS: Teaching methods emphasize skill building and include lectures, guided reflections, and facilitated discussions. Pre- and postsurveys were administered to assess participants' confidence level to recognize unconscious bias and to be an ally to colleagues, patients, and staff. In total, we conducted 20 workshops with a total of 468 participants across multiple disciplines. RESULTS: The survey response rate was 80%. Using a paired t-test, the mean difference in the pre- and postsurveys revealed a statistically significant improvement across all measures. Participants showed the greatest improvements (large effect size d>0.8) in their understanding of the process of allyship, their ability to describe strategies to address, assess, and recognize unconscious bias, and their knowledge of managing situations in which prejudice, power, and privilege are involved. CONCLUSIONS: Results show that an antioppression curriculum can enhance health professionals' confidence in addressing bias in health care through allyship. For those who value social justice and equity, moving from the role of bystander to a place of awareness and solidarity allows for one's behaviors to mirror these values. Allyship is an accessible tool that all health professionals can use in order to facilitate this process.

Use of agave bagasse for production of an organic fertilizer by pretreatment with Bjerkandera adusta and vermicomposting with Eisenia fetida.

Agave tequilana Weber is used in tequila and fructans production, with agave bagasse generated as a solid waste. The main use of bagasse is to produce compost in tequila factories with a long traditional composting that lasts 6-8 months. The aim of this study was to evaluate the degradation of agave bagasse by combining a pretreatment with fungi and vermicomposting. Experiments were carried out with fractionated or whole bagasse, sterilized or not, subjecting it to a pretreatment with Bjerkandera adusta alone or combined with native fungi, or only with native bagasse fungi (non-sterilized), for 45 days. This was followed by a vermicomposting with Eisenia fetida and sewage sludge, for another 45 days. Physicochemical parameters, lignocellulose degradation, stability and maturity changes were measured. The results indicated that up to 90% of the residual sugars in bagasse were eliminated after 30 days in all treatments. The highest degradation rate in pretreatment was observed in non-sterilized, fractionated bagasse with native fungi plus B. adusta (BNFns) (71% hemicellulose, 43% cellulose and 71% lignin) at 45 days. The highest total degradation rates after vermicomposting were in fractionated bagasse pre-treated with native fungi (94% hemicellulose, 86% cellulose and 91% lignin). However, the treatment BNFns showed better maturity and stability parameters compared to that reported for traditional composts. Thus, it seems that a process involving vermicomposting and pretreatment with B. adusta could reduce the degradation time of bagasse to 3 months, compared to the traditional composting process, which requires from 6 to 8 months.

Actualización en el manejo de cáncer de tiroides y embarazo / Update on the management of thyroid cancer and pregnancy

La patología oncológica en el embarazo siempre representa un reto para el médico y el paciente que debe ser abordado multidisciplinariamente, obtando por el abordaje que procure la mejor situación respecto a riesgo y beneficio tanto para la madre como para el producto. La patología endocrinológica maligna no es infrecuente en mujeres en edad fértil, siendo el cáncer de tiroides la causa más común...

Creating an ideal social and behavioural sciences curriculum for medical students.

OBJECTIVES: Undergraduate medical education programmes universally struggle with overfull curricula that make curricular changes quite challenging. Final content decisions are often influenced by available faculty staff, vocal champions or institutional culture. We present a multi-modal process for identifying 'need-to-know' content while leveraging curricular change, using the social and behavioural sciences (SBS) as an exemplar. METHODS: Several multi-modal approaches were used to identify and triangulate core SBS curricula, including: a national survey of 204 faculty members who ranked the content importance of each of the SBS content areas; a comprehensive review of leading medical SBS textbooks; development of an algorithm to assess the strength of evidence for and potential clinical impact of each SBS construct; solicitation of student input, and review of guidelines from national advocacy organisations. To leverage curricular change, curriculum mapping was used to compare the school's 'actual' SBS curriculum with an 'ideal' SBS curriculum to highlight educational needs and areas for revision. Clinical clerkship directors assisted in translating core SBS content into relevant clinical competencies. RESULTS: Essential SBS content areas were identified along with more effective and efficient ways of teaching SBS within a medical setting. The triangulation of several methods to identify content raised confidence in the resulting content list. Mapping actual versus ideal SBS curricula highlighted both current strengths and weaknesses and identified opportunities for change. CONCLUSIONS: This multi-modal, several-stage process of generating need-to-know curricular content and comparing it with current practices helped promote curricular changes in SBS, a content area that has been traditionally difficult to teach and is often under-represented. It is likely that this process can be generalised to other emerging or under-represented topic areas.

Healthy colon, healthy life: a novel colorectal cancer screening intervention.

BACKGROUND: Colorectal cancer (CRC) screening rates are increasing, but they are still low, particularly in ethnic minority groups. In many resource-poor settings, fecal occult blood test (FOBT) is the main screening option. INTERVENTION: Culturally tailored telephone counseling by community health advisors employed by a community-based organization, culturally tailored brochures, and customized FOBT kits. DESIGN: RCT. Participants were randomized to (1) basic intervention: culturally tailored brochure plus FOBT kit (n=765); (2) enhanced intervention: brochure, FOBT plus telephone counseling (n=768); or (3) usual care (n=256). SETTING/PARTICIPANTS: Latino and Vietnamese primary care patients at a large public hospital. MAIN OUTCOME MEASURES: Self-reported receipt of FOBT or any CRC screening at 1-year follow-up. RESULTS: 1358 individuals (718 Latinos and 640 Vietnamese) completed the follow-up survey. Self-reported FOBT screening rates increased by 7.8% in the control group, by 15.1% in the brochure group, and by 25.1% in the brochure/telephone counseling group (p<0.01 for differences between each intervention and usual care and for the difference between brochure/telephone counseling and brochure alone). For any CRC screening, rates increased by 4.1% in the usual care group, by 11.9% in the FOBT/brochure group, and by 21.4% in the brochure/telephone counseling group (p<0.01 for differences between each intervention and usual care and for the difference between the basic and the enhanced intervention). CONCLUSIONS: An intervention that included culturally tailored brochures and tailored telephone counseling increased CRC screening in Latinos and the Vietnamese. Brochure and telephone counseling together had the greatest impact. Future research should address replication and dissemination of this model for Latinos and Vietnamese in other communities, and adaptation of the model for other groups.

Healthy colon, healthy life (colon sano, vida sana): colorectal cancer screening among Latinos in Santa Clara, California.

Colorectal cancer (CRC) screening rates are low among Latinos. To identify factors associated with CRC screening, we conducted a telephone survey of Latino primary care patients aged 50-79 years. Among 1,013 participants, 38% were up-to-date (UTD) with fecal occult blood test (FOBT); 66% were UTD with any CRC screening (FOBT, sigmoidoscopy, or colonoscopy). Individuals less than 65, females, those less acculturated, and patients of female physicians were more likely to be UTD with FOBT. CRC screening among Latinos is low. Younger patients, women, and patients of female physicians receive more screening.

Venezuela's Barrio Adentro: an alternative to neoliberalism in health care.

Throughout the 1990s, all Latin American countries but Cuba implemented health care sector reforms based on a neoliberal paradigm that redefined health care less as a social right and more as a market commodity. These reforms were couched in the broader structural adjustment of Latin American welfare states as prescribed by international financial institutions since the mid-1980s. However, since 2003, Venezuela has been developing an alternative to this neoliberal trend through its health care reform program, Misión Barrio Adentro (Inside the Neighborhood). In this article, the authors review the main features of the Venezuelan health care reform, analyzing, within their broader sociopolitical and economic contexts, previous neoliberal health care reforms that mainly benefited transnational capital and domestic Latin American elites. They explain the emergence of the new health care program, Misión Barrio Adentro, examining its historical, social, and political underpinnings and the central role played by popular resistance to neoliberalism. This program not only provides a compelling model of health care reform for other low- to middle-income countries but also offers policy lessons to wealthy countries.

Challenging the neoliberal trend: the Venezuelan health care reform alternative.

Throughout the 1990s, all Latin American countries but Cuba implemented to varying degrees health care sector reforms underpinned by a neoliberal paradigm that redefined health care as less of a social right and more of a market commodity. These health care sector reforms were couched in the broader structural adjustment of Latin American welfare states prescribed consistently by international financial institutions since the mid-1980s. However, since 2003, Venezuela has been developing an alternative to this neoliberal trend through its health care reform program called Misión Barrio Adentro (Inside the Neighbourhood). In this article, we introduce Misión Barrio Adentro in its historical, political, and economic contexts. We begin by analyzing Latin American neoliberal health sector reforms in their political economic context, with a focus on Venezuela. The analysis reveals that the major beneficiaries of both broader structural adjustment of Latin American welfare states and neoliberal health reforms have been transnational capital interests and domestic Latin American elites. We then provide a detailed description of Misión Barrio Adentro as a challenge to neoliberalism in health care in its political economic context, noting the role played in its development by popular resistance to neoliberalism and the unique international cooperation model upon which it is based. Finally, we suggest that the Venezuelan experience may offer valuable lessons not only to other low- to middle-income countries, but also to countries such as Canada.

Promoting use of colorectal cancer screening tests. Can we change physician behavior?

BACKGROUND: Colorectal cancer (CRC) screening is underutilized despite evidence that screening reduces mortality. OBJECTIVE: To assess the effect of an intervention targeting physicians and their patients on rates of CRC screening. DESIGN: A randomized clinical trial of community physicians and their patients. PARTICIPANTS: Ninety-four community primary care physicians randomly assigned to an intervention consisting of academic detailing and direct mailings to patients or a control group. Patients aged 50 to 79 years in the intervention group physicians received a letter from their physician, a brochure on CRC screening, and a packet of fecal occult blood test (FOBT) cards. MEASUREMENTS: After 1 year we measured receipt of the following: (1) FOBT in the past 2 years, (2) flexible sigmoidoscopy (SIG) or colonoscopy (COL) in the previous 5 years, and (3) any CRC screening. We report the percent change from baseline in both groups. RESULTS: 9,652 patients were enrolled for 2 years, and 3,732 patients were enrolled for 5 years. There was no increase in any CRC screening that occurred in the intervention group for patients enrolled for 2 years (12.7 increase vs 12.5%, P=.51). Similar results were seen for any CRC screening among patients enrolled for 5 years (9.7% increase vs 8.6%, P=.45). The only outcome on which the intervention had an effect was on patient rates of screening SIG (7.4% increase vs 4.4%, P<.01). CONCLUSION: With the exception of an increase in rates of SIG in the intervention group, the intervention had no effect on rates of CRC screening. Future interventions should assess innovative approaches to increase rates of CRC screening.

Issues in achieving compliance with antihypertensive treatment in the Latino population.

Latino Americans are the largest growing ethnic minority group in the United States. The level of awareness and control of hypertension among Latino Americans has remained virtually unchanged in the past 20 years. Untreated hypertension often progresses and is a major risk factor for cardiovascular disease. Hypertension control can be achieved with simple and well-tolerated medication regimens that are cost-effective and reduce morbidity and mortality in all populations studied. Clinicians can work to increase compliance by developing a basic understanding of the social, demographic, and historical conditions that affect Latino Americans. Language proficiency, cultural scripts, and health beliefs and attitudes influence patient-clinician communication in specific ways among Latino patients. Health care systems and plans should work on creating culturally competent health care programs to serve the needs of this diverse population.