Neglect, Sexual Abuse, and Witnessing Intimate Partner Violence During Childhood Predicts Later Life Violent Attitudes Against Children Among Kenyan Women: Evidence of Intergenerational Risk Transmission From Cross-Sectional Data.

Violence against children, including corporal punishment, remains a global concern. Understanding sources of support for corporal punishment within cultures, and the potential for intergenerational transmission of child maltreatment, is essential for policy-development and community engagement to protect children. In this study, we use data from a cross-section of women in Meru County, Kenya (n = 1,974) to profile attitudes toward violence against children using the Velicer Attitudes Towards Violence-Child subscale. We find reported histories of sexual abuse, emotional and physical neglect, and witnessing interpersonal violence during childhood predict more violent attitudes toward children in adulthood. The pathway between these forms of child maltreatment and violent attitudes is significantly mediated by family function, perceived stress, and attitudes toward violence against women. Interventions to prevent sexual abuse, intimate partner violence, and promote attachments between parents and children may benefit future generations in this population. Furthermore, secondary prevention of the effects of these childhood adversities may require development of social support, improving family function and challenging violent attitudes against women.

Racial Disparities in Type of Heart Failure and Hospitalization.

Heart failure (HF) is one of the leading causes of hospitalization and readmissions. Our study aimed to examine racial disparities in heart failure patients including onset, mortality, length of stay (LOS), direct costs, and readmission rates. This is a secondary data analysis. We analyzed the risk-adjusted inpatient data of all patients admitted with HF to one health academic center. We compared five health outcomes among three racial groups (white, black, and Hispanic). There were 1006 adult patients making 1605 visits from 10/01/2011 to 09/30/2015. Most black patients were admitted in younger age than other racial groups which indicates the needs for more public health preventions. With risk adjustments, the racial differences in LOS and readmission rates remain. We stratified health outcomes by race/ethnic and type of HF. The findings suggest that further studies to uncover underlying causes of these disparities are necessary. Using risk-adjusted hospitalization data allows for comparisons of quality of care across three racial groups. The study suggests that more prevention and protection services are needed for African American patients with heart failure.

Exploring Pathways Between HIV+ Status and Excellent Overall Health Among Kenyan Women: Family Functioning, Meaningfulness of Life, Seroconcordance, Social Support and Considering the Need for Integrated Care.

As people living with HIV/AIDS (PLWHA) live longer, and HIV incidence declines, health systems are transitioning from vertical-only care delivery to horizontal integration with social and other services. This is essential to responding to the chronic nature of the disease, and health systems must respond to full-breadth of socio-economic conditions facing PLWHA. We use excellent self-rated health as a referent, and assess the role of non-biomedical conditions in mediating HIV+ status and excellent overall health among a large community sample of Kenyan women. After controlling for age and wealth, we found significant mediation by social support, partner HIV status, meaningfulness of life, family functioning, food sufficiency, and monthly income. If the goal of health systems is to help all people attain the highest level of health, integrating vertical HIV services with socio-economic support and empowerment may be required. Further investigation of the relative contribution of social support, family functioning, food and financial sufficiency should be conducted longitudinally, ideally in collaboration with HIV clinical services.

Community-based case management for uninsured patients with chronic diseases: effects on acute care utilization and costs.

PURPOSE OF THE STUDY: To examine the effects of a community-based case management program on acute health care utilization and associated costs in uninsured patients with 1 or more chronic diseases. PRIMARY PRACTICE SETTING: Large regional academic medical center that provides health care services for the vast majority of indigent patients in the area. METHODOLOGY AND SAMPLE: This was a retrospective study of 83 patients who enrolled in a case management program between April 2007 and August 2008 on the basis of 1 or more emergency department visits or acute hospitalizations. Paired t tests were used to compare utilization and costs before and after enrollment. RESULTS: Overall, acute outpatient encounters decreased by 62% and inpatient admissions by 53%, whereas primary care visits increased by 162%. Participation in the case management program was also associated with a 41% reduction in overall aggregate costs, from $16,208 preintervention to $9,541 postintervention (p = .004). IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The results of this study suggest that intensive case management can reduce acute care utilization and costs and increase primary care follow-up among uninsured patients with certain chronic diseases.

University of Texas Medical Branch telemedicine disaster response and recovery: lessons learned from hurricane Ike.

Despite previous efforts and expenditure of tremendous resources on creating and simulating disaster response scenarios, true disaster response, specifically for healthcare, has been inadequate. In addition, none of the >200 local and statewide telemedicine programs in the United States has ever responded to a large-scale disaster, let alone, experienced one directly. Based on its experience with hurricanes Rita and, most recently, Ike, the University of Texas Medical Branch (UTMB) experienced its most challenging trials. Although there were significant disruptions to a majority of UTMB's physical and operational infrastructures, its telemedicine services were able to resume near normal activities within the first week of the post-Ike recovery period, an unimaginable feat in the face of such remarkable devastation. This was primarily due in part to the flexibility of its data network, the rapid response, and plasticity of its telemedicine program. UTMB's experiences in providing rapid and effective medical services in the face of such a disaster offer valuable lessons for local, state, and national disaster preparations, policy, and remote medical delivery models and programs.

Hepatocellular carcinoma prevalence and mortality in a male state prison population.

OBJECTIVES: The incidence of hepatocellular carcinoma (HCC) in the United States has increased dramatically over the last two decades, largely because of an increase in the number of people with advanced hepatitis C virus (HCV) infection. U.S. prisoners are at high risk for HCC, given their elevated rates of HCV infection, comorbid hepatitis B virus (HBV) infection, and alcoholic liver disease. The purpose of our study was to examine the prevalence and mortality of HCC in the nation's largest state prison system. METHODS: The study population consisted of 325,477 male Texas Department of Criminal Justice (TDCJ) inmates who were incarcerated between January 1, 2003, and July 31, 2006. Information on medical conditions and demographic characteristics was obtained from an institution-wide medical information system. RESULTS: During the 3.5-year study period, 176 male TDCJ inmates (54 per 100,000) were diagnosed with HCC and 108 (33 per 100,000) died as a result of HCC. Inmates who were Hispanic, older, and infected with HCV, HBV, or human immunodeficiency virus had elevated rates of both HCC prevalence and mortality. After adjusting for all study covariates, HCC prevalence, but not mortality, was modestly elevated among inmates with diabetes. CONCLUSIONS: Our study showed that the Texas male prison population had a sevenfold higher prevalence of HCC than the general U.S. male population and a fourfold higher death rate from HCC. These findings likely reflect the high concentration of HCC-related risk factors, particularly HCV, among prisoners.

Emergency department usage by uninsured patients in Galveston County, Texas.

The number of uninsured Texas residents who rely on the medical emergency department as their primary health care provider continues to increase. Unfortunately, little information about the characteristics of this group of emergency department users is available. Using an administrative billing database, we conducted a descriptive study to examine the demographic and clinical features of 17,110 consecutive patients without medical insurance who presented to the emergency department of the University of Texas Medical Branch in Galveston over a 12-month period. We also analyzed the risk of multiple emergency department visits or hospitalization according to demographic characteristics. Twenty percent of the study population made two or more emergency department visits during the study period; 19% of the population was admitted to the hospital via the emergency department. The risk of multiple emergency department visits was significantly elevated among African Americans and increased in a stepwise fashion according to age. The risk of being hospitalized was significantly reduced among females, African Americans, and Hispanics. There was an age-related monotonic increase in the risk of hospitalization. Abdominal pain, cellulitis, and spinal disorders were the most common primary diagnoses in patients who made multiple emergency department visits. Hospitalization occurred most frequently in patients with a primary diagnosis of chest pain, nonischemic heart disease, or an affective disorder. Additional studies of emergency department usage by uninsured patients from other regions of Texas are warranted. Such data may prove helpful in developing effective community-based alternatives to the emergency department for this growing segment of our population. Local policymakers who are responsible for the development of safety net programs throughout the state should find this information particularly useful.

End-stage liver disease in a state prison population.

OBJECTIVES: Information on the epidemiology of end-stage liver disease (ESLD) in US correctional populations is limited. We examined the prevalence, mortality and clinical characteristics of ESLD in the nation's second largest state prison system. METHODS: We collected and analyzed medical and demographic data from 370,511 offenders incarcerated in Texas' prison system during a 3.5-year period. RESULTS: ESLD was diagnosed in 484 inmates (131/100,000); 213 (57/100,000) died of ESLD. Offenders who were Hispanic, 30-49 years of age, > or =50 years of age, HIV monoinfected, hepatitis C virus (HCV) monoinfected, or HIV/HCV coinfected had elevated ESLD prevalence and mortality rates. CONCLUSIONS: ESLD mortality in Texas' prison population is approximately 3 times higher than that of the general population, reflecting elevated rates of HCV and HIV/HCV coinfection among prisoners. Ultimately, the only viable treatment option for many prisoners with ESLD will be liver transplantation. The enormous costs of organ transplantation and immunosuppressive therapy are staggering and have the potential to decimate the healthcare budgets of most prison systems. Consequently, it is imperative that correctional healthcare programs expand HCV treatment and prevention strategies.

Health care delivery in the Texas prison system: the role of academic medicine.

Faced with explosive growth in its prison population and a legal mandate to improve medical care for incarcerated offenders, the state of Texas implemented a novel correctional managed health care program in 1994. The organizational structure of the program is based on a series of contractual relationships between the state prison system, 2 of the state's academic medical centers, and a separate governing body composed of 9 appointed members, which include 5 physicians. All medical, dental, and psychiatric care for more than 145,000 offenders, incarcerated under the jurisdiction of the Texas Department of Criminal Justice, is provided by the University of Texas Medical Branch and Texas Tech University Health Sciences Center. The health delivery system is composed of several levels of care, including primary ambulatory care clinics in each prison unit, 16 infirmaries at strategic locations throughout the state, several regional medical facilities, and a dedicated prison hospital with a full range of services. Specialized treatment programs have been established at various units for patients with chronic conditions, such as hypertension, diabetes mellitus, major psychiatric disorders, hepatitis, and human immunodeficiency virus infection. Significant improvements in health outcomes have occurred since the managed care program was established.