The perceived costs and benefits of mentoring college students with intellectual disability on stereotype consistent and inconsistent tasks.

BACKGROUND: According to the stereotype content model, individuals with intellectual disability are perceived as having greater warmth-related traits (e.g. sociable and humorous) and fewer competence-related traits (e.g. independence and intelligence). METHODS: We examined college students' perceived costs and benefits of mentoring peers with intellectual disability on stereotype-consistent (i.e. socially oriented) or inconsistent (i.e. academically oriented) tasks. Participants read about peer mentoring programmes that helped college students with or without intellectual disability on socially or academically oriented tasks before reporting their perceived costs and benefits of peer mentoring. RESULTS: Mentoring students with intellectual disability was associated with greater benefits (i.e. connectedness between mentors and students, student utility and mentor benefits) on academically oriented tasks but greater costs for mentors on socially oriented tasks. Additionally, participants reported that they would experience greater positive feelings if they were to mentor a student with an intellectual disability. However, the perceived benefits to the student and some costs (i.e. discomfort, paternalism and costs to student) were not influenced by whether the student had an intellectual disability and the type of mentoring task. DISCUSSION: Results indicate individuals find greater rewards working with individuals with intellectual disability on stereotype-inconsistent tasks and offer suggestions for postsecondary education peer mentoring programmes.

Utility of state-level influenza disease burden and severity estimates to investigate an apparent increase in reported severe cases of influenza A(H1N1) pdm09 - Arizona, 2015-2016.

The Arizona Department of Health Services identified unusually high levels of influenza activity and severe complications during the 2015-2016 influenza season leading to concerns about potential increased disease severity compared with prior seasons. We estimated state-level burden and severity to compare across three seasons using multiple data sources for community-level illness, hospitalisation and death. Severity ratios were calculated as the number of hospitalisations or deaths per community case. Community influenza-like illness rates, hospitalisation rates and mortality rates in 2015-2016 were higher than the previous two seasons. However, ratios of severe disease to community illness were similar. Arizona experienced overall increased disease burden in 2015-2016, but not increased severity compared with prior seasons. Timely estimates of state-specific burden and severity are potentially feasible and may provide important information during seemingly unusual influenza seasons or pandemic situations.

Costs and Resource Use Associated with Alzheimer's Disease in Italy: Results from an Observational Study.

BACKGROUND: The GERAS II study aimed to assess societal costs and resource use associated with Alzheimer's disease (AD) for patients and their primary caregivers in Italy and Spain, stratified for different severity stages of AD at baseline. This report presents baseline results for Italy. DESIGN: GERAS II was a prospective, multicentre, observational study of routine care in AD. SETTING: Community-dwelling patients attending specialist secondary care centres (memory clinics/Alzheimer's Evaluation Units) and their primary informal caregivers were recruited into the study. PARTICIPANTS: Patients were aged ≥55 years, presented within the normal course of care, had a diagnosis of probable AD and a Mini-Mental State Examination (MMSE) score of ≤26. Patients and caregivers were stratified according to patient AD dementia severity at baseline: mild, MMSE score 21-26; moderate, MMSE score 15-20; or moderately severe/severe, MMSE score <15. MEASUREMENTS: Data collected for patients and caregivers included demographics/clinical characteristics; current medication; patient cognitive, functional and behavioural assessments; patient and caregiver health-related quality of life (HRQoL); and patient and caregiver resource use. The costs associated with the resources used were calculated. Costs were broken down into patient healthcare costs, patient social care costs and caregiver informal care costs. RESULTS: Of 198 patients enrolled from Italy, 29 (15%) had mild AD dementia, 80 (40%) had moderate AD dementia, and 89 (45%) had moderately severe/severe AD dementia. Patient and caregiver characteristics showed some differences between AD dementia severity groups; for example, a numerically higher proportion of patients with mild and moderately severe/severe AD dementia were taking memantine compared with those with moderate AD dementia. Patient functioning and behavioural and psychological symptoms worsened with increasing AD dementia severity (p<0.05 between groups for all measures). No significant difference between the disease severity groups was observed in patient HRQoL, and there was no clear pattern in resource use. However, all measures of caregiver time spent helping the patient differed significantly between groups (p<0.05) and were highest in patients with moderately severe/severe AD dementia. Mean (standard deviation) total monthly societal costs per patient (2013 values) were €1850 (1901), €1552 (1322) and €2728 (2184) for patients with mild, moderate and moderately severe/severe AD dementia, respectively (p<0.001 between groups). Caregiver informal care costs were the greatest contributor to total societal costs and amounted to €1370, €1223 and €2223 per patient per month for mild, moderate and moderately severe/severe AD dementia groups, respectively (p<0.001 between groups). CONCLUSION: Total Italian societal costs generally increased with increasing AD dementia severity. However, costs were slightly lower for moderate than for mild AD dementia, possibly reflecting the observed unusual trend of greater caregiver time and higher memantine use in patients with mild versus moderate AD dementia.

Impact of a pharmacist-led vaccine recommendation program for pediatric kidney transplant candidates.

Pediatric transplant recipients commonly have deficient vaccination status at the time of transplantation. Utilizing transplant pharmacists to improve vaccination rates has not previously been described. This single-center, retrospective study evaluated the impact of transplant pharmacist interventions on the completion rate of vaccination schedules at time of kidney transplant. Patients who received pharmacist-led vaccination recommendations prior to transplant were compared to patients without pharmacist recommendations. Forty-seven pediatric patients were included: 24 intervention patients and 23 control patients. The median percentage of up-to-date vaccinations at time of transplant was significantly higher in intervention group (91%; IQR 86%-100%) vs. control group (80%; IQR 71%-80%) (P<.0001). The median change in up-to-date vaccinations from time of evaluation to time of transplant was also significantly higher in the intervention group (7.5%) compared to the control group (0%) (P<.0001). There was no difference in live vaccination rates. No patients in either group were readmitted for a vaccine-preventable disease within 6 months post-transplant. With pharmacist intervention, significantly more patients were up to date with vaccination schedules at the time of transplant. These results suggest that a transplant pharmacist may serve as a valuable resource to increase vaccination schedule compliance between time of evaluation and transplantation.

Analysis of burden in caregivers of people with Alzheimer's disease using self-report and supervision hours.

OBJECTIVES: This study aimed to describe the baseline characteristics of informal carers of community-living Alzheimer's disease (AD) patients by AD severity group and to identify factors associated with two measures of caregiver burden. DESIGN AND SETTING: GERAS is a prospective observational study in France, Germany, and the UK, designed to assess costs and resource use associated with AD, for patients and their caregivers, stratified by disease severity. PARTICIPANTS: 1497 community-dwelling AD patients and their primary caregivers. MEASUREMENTS: Subjective caregiver burden assessed using the Zarit Burden Interview [ZBI] and time spent supervising patients (an objective measure of burden recorded using the Resource Utilization in Dementia instrument) during the month before the baseline visit were recorded. Separate multiple linear regression analyses using ZBI total score and caregiver supervision time as dependent variables were performed to identify patient and caregiver factors independently associated with caregiver burden. RESULTS: Increasing AD severity was associated with both subjective caregiver burden (ZBI total score) and overall caregiver time, which includes supervision time (both p<0.001, ANOVA). Better patient functioning (on instrumental activities of daily living) was independently associated with both a lower ZBI total score and less supervision time, whereas higher levels of caregiver distress due to patient behavior were associated with greater caregiver burden. Other factors independently associated with an increased ZBI total score included younger caregiver age, caregiver self-reported depression, caring for a male patient, and longer time since AD diagnosis. Caregivers living with the patient, being a male caregiver, patient living in a rural location, higher patient behavioral problem subdomain scores for apathy and psychosis, more patient emergency room visits, not receiving food delivery and receiving financial support for caregiving were all associated with greater caregiver supervision time. CONCLUSION: Our results show that subjective caregiver burden and caregiver time are influenced by different factors, reinforcing the need to consider both aspects of caregiving when trying to minimize the burden of AD. However, interventions that minimize caregiver distress and improve patient functioning may impact on both subjective and objective burden.

Assessment of medication adherence in a cohort of patients with bipolar disorder.

INTRODUCTION: This study aimed to identify factors associated with medication adherence in bipolar disorder (BPD) patients. METHODS: EMBLEM is a 2-year, prospective, observational study on the outcomes of BPD patients initiating or changing treatment for a manic/mixed episode. Data were collected at baseline, during the first 12 weeks of treatment (acute phase) and up to 24 months of follow-up (maintenance phase). Adherence was assessed by investigators at every visit. Repeated measures logistic regression analyses identified variables associated with adherence. RESULTS: Of 1,831 patients included in the analysis, 76.6% were adherent and 23.4% were non-adherent with their BPD medication during the maintenance phase. Patients were more likely to be adherent if they had insight into their illness at week 12. Patients were less likely to be adherent if they had cannabis abuse/dependence during the acute phase, work impairment or higher CGI hallucinations/delusions at baseline DISCUSSION: Psychotic symptoms, poor insight, cannabis abuse/dependence and work impairment are negatively related to medication adherence during maintenance therapy of bipolar disorder. Patients with these characteristics may need a different therapeutic approach.

Cost-efficacy of endoscopic ultrasonography with fine-needle aspiration vs. mediastinotomy in patients with lung cancer and suspected mediastinal adenopathy.

BACKGROUND AND STUDY AIMS: The use of endoscopic ultrasonography (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has become an important aid in the staging of bronchogenic carcinoma. In many cases, it may be an alternative to mediastinoscopy/mediastinotomy (MED), but the cost-effectiveness of the two techniques has not been compared. The aim of this study was to apply a decision-analysis model to compare the cost-effectiveness of EUS and MED in the preoperative staging of patients with non-small-cell lung cancer. PATIENTS AND METHODS: A decision-analysis model was designed, taking as entry criteria lung cancer and abnormal mediastinal lymph nodes verified by computerized tomography (CT). Performance characteristics of MED and EUS were retrieved from the published literature, as were life expectancy data. Direct actual costs of the relevant procedures were retrieved from the billing system of our hospital. RESULTS: The cost per year of expected survival is US$ 1.729 with the EUS strategy, and US$ 2.411 with the MED strategy. The advantage conferred by EUS remains even when the negative predictive value of EUS is as low as 0.22. CONCLUSION: Because of its low cost and high yield, EUS-guided FNA is a cost-effective aid assessing mediastinal lymphadenopathy.

Recent trends and controversies in industry-sponsored clinical trials.

In recent years, industry has become an important source of funding for biomedical research. Industry-sponsored clinical trials are a particular source of controversy. In light of recent developments, the authors reevaluate the 1995 SAEM guidelines for investigator involvement in industry-sponsored clinical trials. The authors divide industry-funded clinical trials into two categories: investigator-initiated and industry-initiated, and discuss the differences between them. They examine several areas of ethical debate, including exclusivity contracts between a principal investigator and a corporate sponsor, the size of per-patient reimbursements for recruiting patients into clinical trials, and authorship criteria. Finally, the authors oppose the assumption that industry-sponsored research is automatically biased, and suggest that multiple levels of review will help to uncover bias, whatever the source. Once mutual respect for ethical guidelines and practices are established, collaboration between emergency medicine researchers and industry should be encouraged.

Allergic rhinitis in Rochester, Minnesota residents with asthma: frequency and impact on health care charges.

BACKGROUND: Asthma is a common and costly condition. Concomitant asthma and allergic rhinitis (AR) have been shown to increase the medication costs for people with asthma. No studies have compared medical care costs of those with and without concomitant AR. OBJECTIVES: We sought to determine the prevalence and incremental medical care costs of concomitant AR. METHODS: For each member of a population-based asthma cohort, we used all their medical charts within Olmsted County to record age at first diagnosis of asthma; the presence and age of any diagnosis of AR; and the total, ambulatory, and respiratory care-related costs of medical care. Costs were compared for age- and sex-specific strata of people with asthma who did and did not have AR. RESULTS: AR was most commonly diagnosed in people whose asthma was diagnosed before age 25 (prevalence of 59%) and uncommonly diagnosed in anyone after age 40 (prevalence <15%). Yearly medical care charges were on average 46% higher for those with asthma and concomitant AR than for persons with asthma alone, controlling for age and sex. We were unable to assess the impact of treatment of AR on medical care charges. CONCLUSIONS: Physicians should consider the diagnosis of AR (prevalence >50%) in all symptomatic children and young adults with asthma. Further evaluation is necessary to evaluate the ability of treatment to decrease the incremental costs of AR in persons with asthma.

Ragweed immunotherapy in adult asthma.

BACKGROUND: Although allergen immunotherapy is effective for allergic rhinitis, its role in treating asthma is unclear. METHODS: We examined the efficacy of immunotherapy for asthma exacerbated by seasonal ragweed exposure. During an observation phase, adults with asthma who were sensitive to ragweed kept daily diaries and recorded peak expiratory flow rates between July and October. Those who reported seasonal asthma symptoms and medication use as well as decreased peak expiratory flow were randomly assigned to receive placebo or ragweed-extract immunotherapy in doses that increased weekly for an additional two years. RESULTS: During the observation phase, the mean (+/- SE) peak expiratory flow rate measured in the morning during the three weeks representing the height of the pollination season was 454 +/- 20 liters per minute in the immunotherapy group and 444 +/- 16 liters per minute in the placebo group. Of the 77 patients who began the treatment phase, 64 completed one year of the study treatment and 53 completed two years. During the two treatment years, the mean peak expiratory flow rate was higher in the immunotherapy group (489 +/- 16 liters per minute, vs. 453 +/- 17 in the placebo group [P = 0.06] during the first year, and 480 +/- 12 liters per minute, vs. 461 +/- 13 in the placebo group [P = 0.03] during the second). Medication use was higher in the immunotherapy group than in the placebo group during observation and lower during the first treatment year (P = 0.01) but did not differ in the two groups during the second year (P = 0.7). Asthma-symptom scores were similar in the two groups (P = 0.08 in year 1 and P = 0.3 in year 2). The immunotherapy group had reduced hay-fever symptoms, skin-test sensitivity to ragweed, and sensitivity to bronchial challenges and increased IgG antibodies to ragweed as compared with the placebo group; there was no longer a seasonal increase in IgE antibodies to ragweed allergen in the immunotherapy group after two years of treatment. Reduced medication costs were counterbalanced by the costs of immunotherapy. CONCLUSIONS: Although immunotherapy for adults with asthma exacerbated by seasonal ragweed exposure had positive effects on objective measures of asthma and allergy, the clinical effects were limited and many were not sustained for two years.

The role of midlevel providers in cancer screening.

Data indicate that midlevel providers are more likely to provide health promotion and disease prevention counseling, health education, and preventive health and screening services as well as use more community resources. Although the literature is sparse regarding cancer screening activities by midlevel providers, such activities are routinely taught in midlevel educational programs, and midlevel providers see these activities as consistent with their roles. Therefore, it is only logical to assume that use of midlevel providers, who have already been shown to focus on health promotion and disease prevention, would be an effective way to provide quality, cost-effective cancer screening. In fact, models of this sort exist around the United States at the present time, such as the one at Moffitt Cancer Center's Lifetime Cancer Screening Program in Tampa, Florida. In such programs, midlevel providers are successfully conducting comprehensive cancer screening activities. Outcome data from these programs have yet to be published, however. In a collaborative practice environment, the delivery of preventive care, including cancer screening activities, is best accomplished when both the physician and the midlevel provider agree on the importance of these screening activities and work together as a team to integrate these preventive health activities into their office practice. Office systems that are sensitive to patient preferences and that promote preventive care, such as protocols and checklists or health maintenance flowsheets, along with appropriate education tailored to patients' ages and to their social, cultural, and educational backgrounds also help to improve compliance with cancer screening guidelines. More than ever before, health care reform has been the focus of national debate. Most of the health care reform proposals that have been advanced recognize the importance of primary and preventive health care and the role that midlevel providers could and should be playing in such a system. As competent providers, NPs, CNMs, and PAs have the ability to enhance medicine's effectiveness in preventive care, through improved outreach and more thorough screening.

Health Promotion Schools of Excellence: a model program for Kentucky and the nation.

This article reviews the development and progress of an innovative, comprehensive school health project in the Jefferson County school district known as the Health Promotion Schools of Excellence (HPSE). This project features unique working relationships between public and private entities seeking a common goal: "A Healthier Community." The goals and development of HPSE have been formulated to coincide with the emerging directives of the Kentucky Education Reform Act (KERA) as well as the growing pressures to control health care costs through effective preventive measures. The results of testing following the first and second years of the project show an encouraging trend of improved physical fitness levels for all students (grades K-12) and improving levels of health knowledge and attitudes in elementary level children (grades 4-8) as well as school faculty and staff. These initial results, although encouraging, will only be meaningful if they translate over time into a healthier, more responsible cohort of adolescents and young adults when compared to their peers not involved in the project. The project, while only in its third year of development, has already been recognized at regional and national levels as a successful model of a comprehensive school health program. As the project continues and grows, the authors anticipate developing one of the nation's largest and most comprehensive longitudinal data bases of childhood and adolescent health information.

Assessment of right ventricular contractile performance after pulmonary resection.

Right ventricular (RV) performance deteriorates after pulmonary resection. The mechanism remains unclear and could be related to changes in loading conditions or contractility. To assess the role of alteration in RV contractility, we developed a simple and reliable means to measure RV contractile performance in adult patients. Using thermodilution methods and rapid volume infusion in the preoperative setting, the relationship between RV stroke work (RVSWI) and end-diastolic volume (RVEDVI), termed the preload recruitable stroke work relation, was plotted using linear regression. Experimental studies have demonstrated that the preload recruitable stroke work relation is a linear and load-insensitive index of RV contractile performance. Our study confirms this finding in adult patients: RVSWI = 0.33 (RVEDVI) - 20.4 (n = 108; r = 0.94; p < 0.01). Examination of RV pump function and hemodynamic parameters in the early postresection period (up to 24 hours postoperatively) revealed significant changes in loading conditions, but isochronal RVEDVI and RVSWI values were within the confidence limits of the preload recruitable stroke work relation. Thus, depressed RV contractility does not appear to play a predominant role in this early postoperative period. Further study in a larger patient population will be required to verify this observation and to assess RV performance beyond 24 hours after resection.

Assessment of physicians' office pathology testing: organisational considerations.

In this paper we consider organizational and design aspects of an assessment of physicians' office pathology testing, and discuss difficulties in measuring the level of performance and effectiveness of such diagnostic services. A major consideration is the trade-off between compliance with a well-defined protocol, and use of the technology in a way which resembles normal operating practice.

Assessment of tachyphylaxis following prolonged therapy of asthma with inhaled albuterol aerosol.

Controversy exists concerning possible tachyphylaxis of the acute bronchodilating effect of albuterol, especially with regard to the duration of its acute bronchodilating action. We evaluated 140 patients with bronchial asthma in a prospective double-blind controlled study of possible tachyphylaxis to albuterol aerosol as compared to isoproterenol aerosol. We demonstrated statistically significant tachyphylaxis with regard to duration of acute bronchodilating effect. We believe that this tachyphylaxis is not clinically significant because there was no tachyphylaxis with regard to peak bronchodilating effect and because the duration of bronchodilating effect remains significantly greater, both quantitatively and statistically, when compared to isoproterenol aerosol. Moreover, it appeared that most of the tachyphylaxis was present at four weeks of therapy. There was a small increment of tachyphylaxis after eight weeks of therapy, but no further increase in tachyphylaxis was demonstrated after 13 weeks of inhaled albuterol therapy. We therefore feel that clinically significant tachyphylaxis to inhaled albuterol aerosol must be quite unusual and that chronic therapy with inhaled albuterol aerosol is probably both safe and efficacious for bronchospastic disorders.

The epidemiology of heat-related deaths, Texas--1950, 1970-79, and 1980.

A study of the deaths during a 1980 heat wave in Texas revealed death rates that were highest in males, the elderly, Blacks and those engaged in heavy labor, the latter two factors perhaps reflecting socioeconomic status. The data suggest that persistent high temperatures were related to death to a greater degree than the temperature peaks reached. Higher heat death rates in earlier years are believed to be attributable to the limited availability of air conditioning in those years.