1,4-Dioxane as an emerging water contaminant: State of the science and evaluation of research needs.

1,4-Dioxane has historically been used to stabilize chlorinated solvents and more recently has been found as a contaminant of numerous consumer and food products. Once discharged into the environment, its physical and chemical characteristics facilitate migration in groundwater, resulting in widespread contamination of drinking water supplies. Over one-fifth of U.S. public drinking water supplies contain detectable levels of 1,4-dioxane. Remediation efforts using common adsorption and membrane filtration techniques have been ineffective, highlighting the need for alternative removal approaches. While the data evaluating human exposure and health effects are limited, animal studies have shown chronic exposure to cause carcinogenic responses in the liver across multiple species and routes of exposure. Based on this experimental evidence, the U.S. Environmental Protection Agency has listed 1,4-dioxane as a high priority chemical and classified it as a probable human carcinogen. Despite these health concerns, there are no federal or state maximum contaminant levels for 1,4-dioxane. Effective public health policy for this emerging contaminant requires additional information about human health effects, chemical interactions, environmental fate, analytical detection, and treatment technologies. This review highlights the current state of knowledge, key uncertainties, and data needs for future research on 1,4-dioxane.

Patient Navigators: Agents of Creating Community-Nested Patient-Centered Medical Homes for Cancer Care.

Patient navigation is an internationally utilized, culturally grounded, and multifaceted strategy to optimize patients' interface with the health-care team and system. The DuPage County Patient Navigation Collaborative (DPNC) is a campus-community partnership designed to improve access to care among uninsured breast and cervical cancer patients in DuPage County, IL. Importantly, the DPNC connects community-based social service delivery with the patient-centered medical home to achieve a community-nested patient-centered medical home model for cancer care. While the patient navigator experience has been qualitatively documented, the literature pertaining to patient navigation has largely focused on efficacy outcomes and program cost effectiveness. Here, we uniquely highlight stories of women enrolled in the DPNC, told from the perspective of patient navigators, to shed light on the myriad barriers that DPNC patients faced and document the strategies DPNC patient navigators implemented.

Evaluating a bilingual patient navigation program for uninsured women with abnormal screening tests for breast and cervical cancer: implications for future navigator research.

OBJECTIVES: The DuPage Patient Navigation Collaborative evaluated the Patient Navigation Research Program (PNRP) model for uninsured women receiving free breast or cervical cancer screening through the Illinois Breast and Cervical Cancer Program in DuPage County, Illinois. METHODS: We used medical records review and patient surveys of 477 women to compare median follow-up times with external Illinois Breast and Cervical Cancer Program and Chicago PNRP benchmarks of performance. We examined the extent to which we mitigated community-defined timeliness risk factors for delayed follow-up, with a focus on Spanish-speaking participants. RESULTS: Median follow-up time (29.0 days for breast and 56.5 days for cervical screening abnormalities) compared favorably to external benchmarks. Spanish-speaking patients had lower health literacy, lower patient activation, and more health care system distrust than did English-speaking patients, but despite the prevalence of timeliness risk factors, we observed no differences in likelihood of delayed (> 60 days) follow-up by language. CONCLUSIONS: Our successful replication and scaling of the PNRP navigation model to DuPage County illustrates a promising approach for future navigator research.

Community-campus partnership in action: lessons learned from the DuPage County Patient Navigation Collaborative.

BACKGROUND: Using community-based participatory research (CBPR), the DuPage County Patient Navigation Collaborative (DPNC) developed an academic campus-community research partnership aimed at increasing access to care for underserved breast and cervical cancer patients within DuPage County, a collar county of Chicago. Given rapidly shifting demographics, targeting CBPR initiatives among underserved suburban communities is essential. OBJECTIVES: To discuss the facilitating factors and lessons learned in forging the DPNC. METHODS: A patient navigation collaborative was formed to guide medically underserved women through diagnostic resolution and if necessary, treatment, after an abnormal breast or cervical cancer screening. LESSONS LEARNED: Facilitating factors included (1) fostering and maintaining collaborations within a suburban context, (2) a systems-based participatory research approach, (3) a truly equitable community-academic partnership, (4) funding adaptability, (5) culturally relevant navigation, and (6) emphasis on co-learning and capacity building. CONCLUSIONS: By highlighting the strategies that contributed to DPNC success, we envision the DPNC to serve as a feasible model for future health interventions.

Patient navigators' reflections on the navigator-patient relationship.

Patient navigation emerged as a strategy to reduce cancer disparities among low-income and minority patients and has demonstrated efficacy in improving clinical outcomes. Observational studies have contributed valuable evaluations of navigation processes and tasks; however, few have offered in-depth reflections about the relationship between patient and navigator from the navigators' perspective. These approaches have addressed the emotional and relational components of patient navigation through the lens of process factors, relegating the navigator-patient relationship to a siloed, compartmentalized functionality. To expand upon existing task-oriented definitions of navigation, we conducted qualitative interviews among community-based patient navigators who coordinated care for uninsured, predominantly Hispanic, women receiving cancer screening and follow-up care in a county outside Chicago. Interviews were recorded, transcribed, and analyzed for themes within the navigator-patient relationship domain. The main themes that emerged centered on relational roles, relational boundaries, and ideal navigator relational qualities. While patient navigators described engaging with patients in a manner similar to a friend, they stressed the importance of maintaining professional boundaries. Navigators' support assisted patients in bridging their hospital and community lives, a result of navigators' investment in both hemispheres. We conclude that the navigator-patient relationship is not a self-contained utility, but rather the medium through which all other navigator functions are enabled. These insights further characterize the navigator-patient relationship, which will help shape the development of future navigation programs and support the need for further research on the impact of relationship factors on clinical and psychosocial outcome measures.

Access to care outcomes: a telephone interview study of a suburban safety net program for the uninsured.

Access DuPage (AD) currently provides primary care for about 14,000 low income, uninsured residents of suburban DuPage County, IL, an area with a very limited healthcare safety net infrastructure. A telephone interview survey evaluated health care utilization, satisfaction, and health status outcomes and compared recent enrollees to individuals in the program for at least 1 year. Sequential new AD enrollees (n = 158) were asked about the previous year when uninsured, while randomly selected established AD enrollees (n = 135) were asked the same questions about the previous year when actively enrolled in AD. Established enrollees reported being more likely to get 'any kind of tests or treatment' (96.3 vs. 46.2 %, p < 0.0001), fewer cost (78.5 vs. 21.3 %, p < 0.0001) and transportation barriers to care, more preventive and mental health services, and better self-management care. However, established enrollees also reported 14 % greater use of hospital inpatient and 9 % greater use of emergency room care, as well as continued difficulty in accessing needed specialty and dental care services. Despite more (diagnosed) conditions, established enrollees were over 2.5 times more likely to report good to excellent health status and over three times more likely to rate their satisfaction with health care as good to excellent. Findings illustrate the substantial benefits of assuring access to care for the uninsured, but do not reflect immediate savings from reduced hospital utilization. Access to care programs will be an important tool to address the needs of the 30 million people who will continue to be uninsured in the United States.

Use of leukocyte counts in evaluation of early-onset neonatal sepsis.

BACKGROUND: Early-onset sepsis is a common diagnosis in neonatal intensive care units. Because of the low incidence, overtreatment is also common. OBJECTIVE: To measure the sensitivity and negative predictive value of 2 serial white blood cell counts and a negative blood culture at 24 hours in predicting a noninfected neonate in the evaluation of early-onset sepsis. METHODS: We performed a historical cohort study of neonates in the University of Massachusetts Newborn Nursery and neonatal intensive care unit born between 1999 and 2008 who had sepsis evaluations within the first 24 hours of life. RESULTS: Three thousand two hundred thirteen patients were identified; 59 were excluded due to missing data. Of the 3154 included neonates, 1539 (49%) had 2 normal immature to total neutrophil (I:T) ratios and a negative blood culture at 24 hours. Two of these blood cultures showed growth of bacteria after 24 hours but were considered contaminants, and antibiotics were stopped at 48 hours. None of the 1539 neonates with normal I:T ratios was subsequently diagnosed with sepsis (negative predictive value 100%; [95% confidence interval: 99.905%-100%]). CONCLUSIONS: In this study, the combination of 2 serial normal I:T ratios and a negative blood culture at 24 hours in the evaluation of early-onset sepsis shortly after birth is indicative of a noninfected neonate. This suggests that antibiotics can safely be stopped at 24 hours in these neonates, which comprises approximately 50% of our study population.

Predictors of nonsentinel lymph node metastasis in breast cancer patients.

BACKGROUND: In order to define a future subset of breast cancer patients in whom the axilla may be staged by sentinel lymph node biopsy alone, the conditions under which nonsentinel axillary lymph node metastases occur must be delineated. METHODS: A prospective database including 212 breast cancer patients who underwent sentinel lymph node biopsy followed by completion axillary dissection at our institution was reviewed. A multivariate, logistic, stepwise regression was performed to evaluate the relationship between nonsentinel lymph node metastasis and patient age, primary tumor size, presence of lymphatic invasion, use of radioisotope to identify the sentinel node and degree of metastasis in the sentinel node. RESULTS: Tumor size greater than 2 cm, lymphatic invasion of the primary tumor, macrometastasis in the sentinel node, and use of radioisotope all positively correlated independently with metastasis in the nonsentinel lymph node (P = 0.0001, P = 0.0483, P = 0.0008, P = 0.0271, respectively). CONCLUSIONS: Predictors of nonsentinel axillary node metastasis exist and are important in defining those patients in whom a sentinel lymph node biopsy alone may not be adequate.