A self-help smoking cessation program for inner-city African Americans: results from the Harlem Health Connection Project.

The authors develop and test a culturally sensitive, low-intensity smoking cessation intervention for low-socioeconomic African Americans. African American adult smokers were randomly assigned to receive either a multicomponent smoking cessation intervention comprising a printed guide, a video, and a telephone booster call or health education materials not directly addressing tobacco use. The results of the study were mixed. Although no significant effects were observed for the entire treatment cohort, the results of post hoc analyses suggest that culturally sensitive self-help smoking cessation materials plus a single phone contact can produce short-term cessation rates similar to those reported for majority populations. This conclusion should be tempered by the low completion rate for the booster call and several design limitations of the study.

Distribution of adenomatous polyps in African-Americans.

OBJECTIVES: Previous research has suggested that polyps and colon cancer occur more commonly in the right colon in African-Americans compared with the general population. The purpose of this study is to determine the pattern of distribution of colonic polyps in African-Americans. METHODS: We retrospectively evaluated 141 colonoscopies in which 179 polypectomies were done. The polyps were described on the basis of anatomical distribution, gross description, size, and histology. Sixty-nine males and 72 females had colonoscopic polypectomies. The mean age was 67 yr (range, 43-91 yr). RESULTS: Seventy-seven (43%) were classified as left sided, and 102 (57%) were right sided. Left-sided polyps were more likely to be pedunculated than right-sided polyps (p < 0.01). Larger polyps were more common on the left side than the right side (p < 0.01), but villous histology was almost as high on the right side as on the left side. Polyps that had the highest malignant potential were found almost as commonly on the right side as on the left side. CONCLUSIONS: This study supports previous work that suggests that there is a significant shift to the right in the anatomical distribution of polyps in African-Americans. It also shows that the malignant potential is as high for right-sided polyps as it is for those on the left. Current screening recommendations may not be effective enough for preventing colon cancer in this population.

Pneumatic antishock garment-associated compartment syndrome in uninjured lower extremities.

Pneumatic antishock garment-associated compartment syndrome is a rare and yet underrecognized complication that when it occurs, frequently results in myonecrosis and loss of limb function, and occasionally loss of a limb or even death. We report a case of pneumatic antishock garment-associated compartment syndrome in a trauma patient without lower extremity injury and review similar published reports. It is only with a high index of suspicion, early recognition, and prompt treatment of this complication by fasciotomy and proper wound care that associated morbidity and potential mortality of this complication can be prevented or minimized.

Physician- and nurse-assisted smoking cessation in Harlem.

This study was designed to increase smoking cessation rates, quit attempts, and cutting down among low-income African Americans using brief clinician advice in conjunction with socioculturally appropriate self-help smoking cessation/relapse prevention materials. Physicians and nurses were instructed in the National Cancer Institute's smoking intervention at inservice sessions. Smokers interviewed in a Harlem, New York clinic waiting room were recontacted 7 months later by telephone or mail (77% response). Residents receiving the intervention reported a 21% cessation rate at follow-up. An additional 27% decreased cigarette intake by at least 50%. Those reporting follow-up abstinence were significantly more likely to designate a quit date at baseline. They were also more likely to be men, employed, and have a nonsmoking partner. Smokers who decreased their cigarette intake significantly were older, employed, less nicotine-dependent (eg, delayed their wake-up cigarette), and more likely to use project materials. Physician advice had a significant impact both on patients' cutting down at least 50% and patients' watching the project video. Designation of a quit date and using project materials had a significant impact on making serious quit attempts. Results corroborate large sample, randomized, controlled trials with noninner-city physicians. We conclude that clinician smoking advice for every patient is warranted.

Expanding access to cancer screening and clinical follow-up among the medically underserved.

Blacks have the highest cancer incidences and mortality rates in the United States. Higher mortality rates appear due to higher incidence in some sites and to later-stage diagnoses in others. To address these problems, expanded cancer screening in an inner-city public hospital and a patient navigator intervention were proposed. Patient navigators acted as patient advocates for patients with abnormal screening findings. One thousand thirty-four females and 102 males were screened from July 1990 through November 1992; seven breast cancers and one cervical cancer were found. Patient navigators were significantly more likely to have seen patients with suspicious findings than patients with non-suspicious findings. However, even among those with suspicious findings, almost 70% were not seen by a patient navigator. Of those navigated, 87.5% completed recommended breast biopsies, compared with 56.6% of the non-navigated patients. Among those with a biopsy, navigated patients did so in significantly less time than those not navigated. Navigation is one of three phases proposed to reduce cancer mortality among medically underserved populations.

The impact of clinical trial protocols on patient care systems in a large city hospital. Access for the socially disadvantaged.

Some Americans suffer a higher cancer incidence and mortality than those in mainstream American society, and, in general, do not enjoy the same health status. Black Americans, for example, have higher cancer incidence and lower survival rates than do white Americans. To date, there is no known genetic basis to account for the disparities in cancer incidence and outcome between these races. Controlling for socioeconomic status greatly reduces, and sometimes nearly eliminates, the apparent contrast in cancer mortality and incidence between ethnic groups. Poverty clearly is associated with diminished access to health care, an increased incidence of cancer, and 10-15% lower 5-year survival rates. Diminished access often is manifested by low quality and inadequate continuity of health care, as well as insufficient access to methods of disease detection, diagnosis, treatment, and rehabilitation. Poor people tend to concentrate on day-to-day survival, often feel hopeless and powerless, and may become socially isolated. It is more difficult to conduct cancer treatment trials in a population characterized by such dramatic socioeconomic and cultural differences. Lack of insurance and lack of compliance become trial-limiting issues. This paper examines what must be done to tear down the economic and cultural barriers to prevention, early detection, and treatment of cancer.

Carcinoid tumors.

The authors carried out a retrospective study of 32 patients (23 M, 9 F) with carcinoid tumors who were diagnosed and treated at Harlem Hospital Center, New York, from 1967 to 1988. All the patients were black and the commonest sites were the ileum (28.1%), rectosigmoid and rectum (21.9%), and the appendix and lung (15.6% each). Metastasis correlated with site, size, and depth of the primary tumor and occurred in 12 patients (38%), most frequently to the regional lymph nodes and liver. Carcinoid syndrome developed in 12.5% (3 F, 1 M). Surgical resection for cure or palliation was the mainstay of treatment. Overall 5 year survival rate was 66%, and for those with metastases was 0%. The poorer survival rates are probably related to the socioeconomic status of our patient population. The only observed racial difference compared to other series is the preponderance of males, and the disproportionately higher ratio of females with the carcinoid syndrome.

Hydroxyethyl starch macromolecules reduce myocardial reperfusion injury.

We assessed the value of a fraction of hydroxyethyl starch (HES Pz) in reducing the myocardial reperfusion injury in a canine open-chest model in which 1 hour of left anterior descending coronary artery occlusion was followed by 24 hours of reperfusion. Three treatment infusions (5% of blood volume) were compared: Ringer's lactate, serum albumin, and HES Pz (70% of the macromolecules between 100,000 and 1,000,000 d). When compared with Ringer's lactate and albumin, HES Pz significantly reduced the ratio of 24-hour infarct size to pretreatment area at risk (3% vs 19% and 16%, respectively) and myocardial water content (0.5% vs 3% and 1%). Potassium content differences between injured and normal myocardium were significantly less in the infarct regions of animals receiving HES Pz. In the canine model, HES Pz reduced 1-hour myocardial ischemia reperfusion injury significantly.

Excess mortality in Harlem.

In recent decades mortality rates have declined for both white and nonwhite Americans, but national averages obscure the extremely high mortality rates in many inner-city communities. Using data from the 1980 census and from death certificates in 1979, 1980, and 1981, we examined mortality rates in New York City's Central Harlem health district, where 96 percent of the inhabitants are black and 41 percent live below the poverty line. For Harlem, the age-adjusted rate of mortality from all causes was the highest in New York City, more than double that of U.S. whites and 50 percent higher than that of U.S. blacks. Almost all the excess mortality was among those less than 65 years old. With rates for the white population as the basis for comparison, the standardized (adjusted for age) mortality ratios (SMRs) for deaths under the age of 65 in Harlem were 2.91 for male residents and 2.70 for female residents. The highest ratios were for women 25 to 34 years old (SMR, 6.13) and men 35 to 44 years old (SMR, 5.98). The chief causes of this excess mortality were cardiovascular disease (23.5 percent of the excess deaths; SMR, 2.23), cirrhosis (17.9 percent; SMR, 10.5), homicide (14.9 percent; SMR, 14.2), and neoplasms (12.6 percent; SMR, 1.77). Survival analysis showed that black men in Harlem were less likely to reach the age of 65 than men in Bangladesh. Of the 353 health areas in New York, 54 (with a total population of 650,000) had mortality rates for persons under 65 years old that were at lest twice the expected rate. All but one of these areas of high mortality were predominantly black or Hispanic. We conclude that Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas.