Infection with the human immunodeficiency virus in prisoners: meeting the health care challenge.

The magnitude and the scope of health care problems posed by human prison inmates seropositive for the human immunodeficiency virus (HIV) are enormous. Prisoners represent a substantial proportion of HIV-infected individuals in North America. A high proportion of prisoners are intravenous drug users who often have not received appropriate health care or HIV-directed services prior to incarceration. Health care of HIV-seropositive prisoners and follow-up medical care after prison release has often been less than optimal. Among inmates at the prison facility in Rhode Island, 4% of the men and 12% of the women are HIV seropositive. The Brown University medical community, in conjunction with the Rhode Island Department of Health and Corrections, has developed an effective program for the health care of such prisoners, both during incarceration and after release from prison. Academic medical centers are uniquely poised to assume the leading role in meeting this obligation. We believe that this general approach, with region-specific modifications, may be effectively applied in many correctional institutions in North America.

Decisions to hospitalize and operate: a socioeconomic perspective in an urban state.

Rates of hospital discharges for selected surgical procedures and some medical conditions were compared by socioeconomic status (SES) of patients for all 1972 hospital discharges from the 13 voluntary general hospitals located in Rhode Island. Socioeconomic status was determined by scoring the census tract of patient residence with such variables as median family income, housing status, etc. Many frequently performed surgical procedures had similar rates for the high, middle, low, and poverty socioeconomic groups. Procedures performed more frequently on the poverty than on the high SES group were tonsillectomy and upper gastrointestinal, heart, hemorrhoid, and cataract procedures. Dental procedures were performed more frequently on the high SES group. The over-all rate of hospital admissions showed a steady decline from the rate of 156 per 1,000 for the poverty census tracts to 104 for the high SES census tracts. This trend was reflected in the admission rates for several conditions requiring primary medical management, such as infections, diabetes, and skin problems. The population-based frame of reference used in this study can be a useful tool for raising pertinent questions for both professional standards review organizations and health planning groups.

Smoking rates among Rhode Island physicians: achieving a smoke-free society.

Over a 25-year period, regular surveys of physicians licensed in Rhode Island have recorded their smoking behavior. The six surveys show a decrease in the rate of cigarette smoking from 33% in 1963 to 4.6% in 1988. In the most recent survey, 65% of respondents reported never having smoked, and 87% of those who had ever smoked reported having quit. However, the statistic for the maximum number of cigarettes smoked regularly was higher for current smokers than for former smokers. Among physicians in the 1988 survey, most former smokers (85%) reported using only unassisted personal effort in quitting, whereas nearly half (48%) of current smokers tried methods involving assistance, such as self-help programs, group programs, or nicotine gum. Among former smokers who quit after 1983, the percentage trying assisted methods (34%) was closer to the percentage among current smokers. Apparently, remaining smokers include many heavy smokers who require more potent interventions in order to quit. Physicians in Rhode Island have almost become a smoke-free group. Their experience, coupled with their involvement in smoking prevention and cessation for their patients, can lead the rest of society on its path to becoming smoke-free.

The future of public health: a survey of the states.

A survey of state health agencies was conducted to determine agreement and disagreement of state health officers with the recommendations contained in The Future of Public Health issued by the Institute of Medicine in 1988. The survey also measured the extent to which the IOM recommendations were judged currently in place or in the process of being implemented in the states. The survey showed almost unanimous consensus among the nation's state health officers for the vast majority of the recommendations. There was less consensus concerning the appropriateness of locating substance abuse, Medicaid, mental health, and regulation of health professions within state departments of health. However, a significant proportion of health officers favored a health agency location for these responsibilities (72%, 52%, 48%, and 38% respectively).

The Breast Cancer Screening Program in Rhode Island.

The Rhode Island Department of Health has undertaken a Breast Cancer Screening Program which incorporates assessment, policy development, and assurance functions, following the model proposed in the Institute of Medicine (IOM) report, The Future of Public Health. With the community's help, projects have been implemented to increase screening capacity with dedicated, state-of-the-art equipment, to increase screening accessibility, to publicize the need for mammography, and to minimize false test results. In the program's first 15 months, the proportion of women ages 40 and over who were screened with mammography according to current guidelines increased from 35 to 46 percent (from 38 to 49 percent among women ages 40-49; from 31 to 43 percent among women ages 50 and over), including 15 percent who received their first screening mammogram. Providers' recommendations and knowledge of screening guidelines were important in explaining first-time use. The Department plans to apply the IOM model in other program areas. Its adoption by others is urged.

Statins for the reduction of risk of Alzheimer's disease.

BACKGROUND: : Two recent clinical reports describe an association between statin therapy and a reduction in the occurrence of Alzheimer's disease by as much as 70 %. One report is a cross-sectional analysis of discharges among three hospitals, and the other is a nested case control study drawn from ambulatory patients of general practitioners in the UK. Because neither study is a randomized trial, the association noted between statin therapy and a reduced incidence of Alzheimer's disease may have occurred because other factors, unaccounted for in the studies, may be present (so called bias) and be responsible for the observed association. However, there is an expanding body of biological and epidemiological data that makes it plausible that statin therapy may retard or prevent the pathogenesis and clinical expression of Alzheimer's disease. This review was initiated in order to find other clinical evidence that might support or refute the hypothesized benefit of statin therapy. OBJECTIVES: : The purpose is to review the evidence that treatment with statins reduces the risk of Alzheimer's disease. SEARCH STRATEGY: : The following data bases were searched: Specialised Register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (1966-2000/12), EMBASE (1980-2000/12), and Psych Info (1987-2000/11). Search terms included statins,lovastatin, pravastatin, simvastatin, alzheimer*, dement*, cogn*. SELECTION CRITERIA: : In order to be selected, trials needed to be randomized, doubled blinded, and of sufficient duration( probably years rather than weeks or months) to ascertain the preventive potential of statin therapy. DATA COLLECTION AND ANALYSIS: : Data were to be extracted independently by two reviewers and pooled where appropriate and possible. The pooled odds ratios (95% CI) or the average differences were to be estimated. MAIN RESULTS: : There were no randomized trials found in the search. REVIEWER'S CONCLUSIONS: : There is no good evidence to recommend statins for reducing the risk of Alzheimer's disease. There is, however, a growing body of biological, epidemiological, and limited but non-randomized clinical evidence that lowering serum cholesterol may retard the pathogenesis of Alzheimer's disease. Mounting the clinical studies to determine the potential benefit of statin therapy should be a high priority for future research agendas.

Statins for the prevention of Alzheimer's disease.

BACKGROUND: : Two recent clinical reports describe an association between statin therapy and a reduction in the occurrence of Alzheimer's disease by as much as 70 %. One report is a cross-sectional analysis of discharges among three hospitals, and the other is a nested case control study drawn from ambulatory patients of general practitioners in the UK. Because neither study is a randomized trial, the association noted between statin therapy and a reduced incidence of Alzheimer's disease may have occurred because other factors, unaccounted for in the studies, may be present (so called bias) and be responsible for the observed association. However, there is an expanding body of biological and epidemiological data that makes it plausible that statin therapy may retard or prevent the pathogenesis and clinical expression of Alzheimer's disease. This review was initiated in order to find other clinical evidence that might support or refute the hypothesized benefit of statin therapy. OBJECTIVES: : The purpose is to review the evidence that treatment with statins reduces the risk of Alzheimer's disease. SEARCH STRATEGY: : The following data bases were searched: Specialised Register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (1966-2000/12), EMBASE (1980-2000/12), and Psych Info (1987-2000/11). Search terms included statins,lovastatin, pravastatin, simvastatin, alzheimer*, dement*, cogn*. SELECTION CRITERIA: : In order to be selected, trials needed to be randomized, doubled blinded, and of sufficient duration( probably years rather than weeks or months) to ascertain the preventive potential of statin therapy. DATA COLLECTION AND ANALYSIS: : Data were to be extracted independently by two reviewers and pooled where appropriate and possible. The pooled odds ratios (95% CI) or the average differences were to be estimated. MAIN RESULTS: : There were no randomized trials found in the search. REVIEWER'S CONCLUSIONS: : There is no good evidence to recommend statins for reducing the risk of Alzheimer's disease. There is, however, a growing body of biological, epidemiological, and limited but non-randomized clinical evidence that lowering serum cholesterol may retard the pathogenesis of Alzheimer's disease. Mounting the clinical studies to determine the potential benefit of statin therapy should be a high priority for future research agendas.

Predicting hazardous lifestyles among adolescents based on health-risk assessment data.

Abstract The Rhode Island Department of Health has developed simple and convenient health risk appraisal (HRA) systems for adults, high-school students and college students. Using HRA data collected on 11,652 high-school students, this paper examines the discriminatory power of two mental health questions as predictors of high risk, unhealthy or dangerous behavior. Both questions, when examined separately, show that students who respond that "life is never worth living" and who report that "they never have emotional support available" take proportionally more and greater risks than their fellow students who have happier outlooks and long-term emotional support. By combining responses from both questions, a typology was developed that might identify a more vulnerable, higher risk-taking subgroup; that is, students who felt life was not worth living and who also had no available emotional support. Further refinement of this approach could produce a useful predictive tool to identify students who are at serious risk for premature disability and death and who could benefit from early therapeutic help.

WIC program participation--a marketing approach.

Recent evaluation studies have described the benefits accruing to low-income women and children who participate in the Special Supplemental Food Program for Women, Infants, and Children (WIC). However, participation is not uniform among all groups of eligible persons. This study examines the geographic variation in WIC participation rates of eligible pregnant women in Rhode Island to determine whether the program is effective in reaching the neediest segments of the population. Eight groups of small geographic areas in Rhode Island (census tracts) were formed on the basis of need for maternal and child health services, as determined from a statistical method employing factor and cluster analysis of existing health and sociodemographic data. Among these eight groups, participation rates in WIC during 1983-84 ranged from 46 percent to more than 100 percent of estimated eligible pregnant women. The rates were positively correlated with measures of need, strongly (r = 0.92) with an index of maternal risk, and less strongly (r = 0.79) with an index of birth outcomes. The results of this study have enabled the Rhode Island WIC Program to direct its outreach efforts more specifically to geographic areas where the need for the program's assistance is greatest. The procedures described in this report comprise a technique that can be generally applied to measure program effectiveness in marketing and outreach where relevant data are available by small geographic areas. The data requirements are (a) population-based estimates of program need and (b) program utilization measures. If these data can be aggregated to a common set of small geographic areas, the use of marketing analysis techniques becomes possible, and program benefits in the area of outreach and recruitment can be realized.

A study guided by the Health Belief Model of the predictors of breast cancer screening of women ages 40 and older.

In late 1987, a total of 852 Rhode Island women ages 40 and older were interviewed by telephone (78 percent response rate) to measure their use of breast cancer screening and to investigate potential predictors of use. Predictors included the women's socioeconomic status, use of medical care, a provider's reported recommendations for screening, and the women's health beliefs about breast cancer and mammography. The Health Belief Model guided the construction of the interview questions and data analysis. Logistic regression was used to identify leading independent predictors of breast cancer screening according to contemporary recommendations: reporting that a medical provider had ever recommended a screening mammogram (odds ratio [OR] = 18.77), having received gynecological care in the previous year (OR = 4.92), having a regular source of gynecological care (OR = 2.63), having ever had a diagnostic mammogram (OR = 2.32), and perceiving mammography as safe enough to have annually (OR = 1.93). The findings suggest that programs intended to increase the use of breast cancer screening should include "inreach" and "outreach" elements; inreach to patients with established patient-provider relationships, by assuring that physicians recommend screening to all eligible patients, and outreach to all eligible women, by helping them overcome barriers to effective primary care, and by promoting mammography, emphasizing its effectiveness and safety. The findings also suggest that socioeconomically disadvantaged women, who are less likely to be screened than other women, should become special targets of inreach and outreach interventions.

Effect of Irrigation and Soil Water Stress on Densities of Macrophomina phaseolina in Soil and Roots of Two Soybean Cultivars.

The effects of irrigation and soil water stress on Macrophomina phaseolina microsclerotial (MS) densities in the soil and roots of soybean were studied in 1988, 1989, and 1990. Soybean cvs. Davis and Lloyd received irrigation until flowering (TAR2), after flowering (IAR2), full season (FSI), or not at all (NI). Soil water matric potentials at 15- and 30-cm depths were recorded throughout the growing season and used to schedule irrigation. Soil MS densities were determined at the beginning of each season. Root MS densities were determined periodically throughout the growing season. Microsclerotia were present in the roots of irrigated as well as nonirrigated soybean within 6 weeks after planting. By vegetative growth stage V13, these densities reached relatively stable levels in the NI and FSI treatments (2.23 to 2.35 and 1.35 to 1.63 log [microsclerotia per gram of dry root], respectively) through reproductive growth stage R6. After R6, irrigation was discontinued and root densities of microsclerotia increased in all treatments. Initiation (IAR2) or termination (TAR2) of irrigation at R2 resulted in significant changes in root MS densities, with densities reaching levels intermediate between those of FSI and NI treatments. Year to year differences in root colonization reflected differences in soil moisture due to rainfall. The rate of root colonization in response to soil moisture stress decreased with plant age. Root colonization was significantly greater in Davis than Lloyd at R5 and R8. This was reflected in a trend toward higher soil densities of M. phaseolina at planting in plots planted with Davis than in plots planted with Lloyd. Although no charcoal rot symptoms in the plant were observed in this study, these results indicated that water management can limit, but not prevent, colonization of soybean by M. phaseolina, that cultivars differ in colonization, and that these differences may affect soil densities of the fungus.

Response of soybean in cyst nematode-infested soils at three soil water regimes.

Large pot (2 years) and field experiments (1 year) were conducted to determine the response of susceptible soybean Glycine max (L.) Merr. cultivars (Essex and Hutcheson) grown in soybean-cyst-nematode (SCN), Heterodera glycines-infested soils at three soil water regimes. The soil water regimes were irrigation whenever soil water potential ([psi]s) 0.30-m deep was i) -30 kPa (I-30) or ii) - 50 kPa (I-50), and iii) no irrigation. Cyst nematode levels in the pot experiment were either 0 or 20,000 second-stage juveniles (J2) per pot. The field experiment was conducted on soil naturally infested with a population of 145 to 475 cysts L(1) of soil. All growth parameters studied were drastically affected in the presence of SCN under nonirrigated conditions for the large pot tests; however, SCN did not influence growth parameters in the field experiment. Seed yield was lowest in the no irrigation treatment when all treatments were compared in both the pot and field experiments. The infested no irrigation treatment in the pot experiment had the lowest yield among soil water treatments.

Location of Heterodera glycines-induced Syncytia in Soybean as Affected by Soil Water Regimes.

Locations of syncytia induced by the soybean cyst nematode (SCN), Heterodera glycines race 3, were compared in roots of 'Essex', a susceptible soybean (Glycine max (L.) Merr.) cultivar, at three soil water regimes. The plants were grown in wet (-5 to -20 kPa), moderately wet (-30 to -50 kPa), and moderately dry (-60 to -80kPa) autoclaved Captina silt loam soil (Typic Fragiudult). In the moderately dry soil, syncytia were found only in the stele, but in moderately wet and wet soils, syncytia occurred primarily in the cortex and occasionally in the stele. The location of syncytia in the cortical tissue of roots growing in wet and moderately wet soils may account for the tolerance of susceptible soybean cultivars grown under well-irrigated conditions where there is less interference with water transport through roots. Cell-wall perforations and dense cytoplasm were characteristic of syncytial cells observed in root tissues of all treatments.

The Uniform Clinical Data Set: an evaluation of the proposed national database for Medicare's quality review program.

The accuracy, reliability, and validity of the Medicare Peer Review Organization (PRO) review process have all been questioned. Evidence concerning the PRO program's effect on cost and quality of care remains lacking. The Health Care Financing Administration has thus committed itself to reform, and the Uniform Clinical Data Set (UCDS) has been proposed as the national database for Medicare's quality review program. The UCDS is an automated, computerized data set designed to standardize the evaluation of quality. It should allow an objective, consistent, and efficient process for peer review, based on explicit decision criteria and on aggregated information about patterns of care and quality. But is this truly so? We review the existing evidence on the UCDS and compare it with the current PRO reviews of quality, concluding that although the UCDS can potentially improve the accuracy and the reliability of data abstraction and the validity of reviews, this remains to be shown. Preliminary data on the UCDS suggest that work is needed before it can meet appropriate expectations for a national database for quality assessments. We also propose a model for reviews of quality in which we show that reviews of care done in the context of internal quality improvement programs will differ in goals and intensity from reviews of care done at the national level. We suggest that the UCDS has a unique, but limited role--that of national surveillance of practice patterns. Detailed assessments of quality are more appropriately done at local or institutional levels.

Cancer control in Rhode Island: blueprint for the 1990s.

Rhode Island has one of the highest cancer mortality rates in the nation. In an average year, about 5000 new cancers are reported to the Rhode Island Cancer Registry, and more than 2300 Rhode Islanders succumb to the disease. In response to this problem the Rhode Island Department of Health assembled cancer experts from around the state to plan priority cancer control activities for the 1990s. Their plan for 1990-1992 is the subject of this report. Five cancers were selected as the foci of cancer control activities: cancers of the lung, colon-rectum, breast, cervix, and oral cavity. The plan proposes prevention, screening, and treatment interventions to reduce morbidity and mortality from these diseases. Rhode Islanders will have to work together to achieve the 33% reduction in cancer mortality proposed as a goal for the year 2000. Surveillance suggests progress on some fronts, but marching in place on others.

Physicians helping the underserved: the Reach Out program.

In the current health care environment of competition and market forces, concern has arisen that the classic principle of serving disadvantaged persons may not be fulfilled due to pressures from managed care. Reach Out, a $12 million national program of the Robert Wood Johnson Foundation, was developed to recruit leaders from among practicing physicians to organize projects to care for the uninsured and underserved. Physician volunteerism was a key component of all projects. Thirty-nine Reach Out projects were implemented and carried out across the United States, with average funding per project of $300000 distributed over a period of 4 years. Seven model types emerged, the most common of which, the free clinic and the referral network, accounted for two thirds of the total. At the program's conclusion, 199584 patients were enrolled and 11252 physicians recruited. Project execution was more complex than initially supposed, and major progress commonly was not evident until the third or fourth year, but at least two thirds of the projects are likely to continue with local support. With strong physician leadership and a funded administrative core, organized community efforts can develop and sustain an effective program. Programs such as Reach Out cannot solve the national problem of access to health care, but they can make a small but important impact on the number of uninsured and underserved persons without access to health care.

A large outbreak of acupuncture-associated hepatitis B.

An epidemiologic investigation of an acupuncturist's practice in Rhode Island identified 35 patients who were infected with hepatitis B virus during 1984. Of 366 patients seen by the acupuncturist during 1984, 316 (86%) completed questionnaires and submitted serum for hepatitis B serology. Use of tests for immunoglobulin M antibody to hepatitis B core antigen (IgM anti-HBc) identified 17 case-patients who otherwise may have gone undetected. Thirty-four of the 35 case-patients were treated in only one of the two clinics run by the acupuncturist. Patients who received a greater number of acupuncture needles during their treatment course were more likely to have been infected; the attack rate for patients who received less than 150 needles was 9%, compared with 33% for patients who received greater than or equal to 450 needles (p less than 0.001). Attack rates were higher during a one-month period when the index case-patient was more likely to have been viremic than during any other period in 1984 (relative risk = 4.1, 95% confidence interval = 2.3-7.3). While observing the acupuncturist's technique, the investigators noted several potential mechanisms for needle contamination. This study highlights the potential for transmission of hepatitis B in situations of repeated needle use.

22. Some successes and failures with long-term care data systems: the Rhode Island experience.

A project by Rhode Island Health Services Research (SEARCH) to develop, adapt, and improve data systems in several Rhode Island long-term care settings includes skilled nursing and intermediate care facilities, two chronic care hospitals, mental health institutions, and home health agencies. A successful medical review system was developed for Medicaid nursing home patients which is now a program funded by the state, as well as a good abstracting system for the two chronic hospitals. Also, steps were taken to correct omissions and inaccuracies found in mental health data used in the Multi-State Information System (MSIS), and to modify a limited management information system used by home health agencies. In retrospect, the project would have been better served had it attempted to be less comprehensive and instead focused its resources in areas of high visibility and unequivocal public concern. The approach would have given the state population-based information of much greater power than is currently available, despite the recognized successes of the project in the nursing home and chronic hospital areas.