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Educating medical students for Alaska.

Because Alaska does not have its own medical school, it has become part of WAMI (Washington, Alaska, Montana, Idaho), an educational agreement with the University of Washington School of Medicine (UWSM). Each year, 10 Alaskans are accepted into the entering class of UWSM and spend their first year at the University of Alaska Anchorage (UAA). UWSM third- and fourth-year medical students can obtain some of their clinical experience in Alaska. To meet the needs of Alaska, students are chosen based on academic and personal records, as well as the likelihood of their returning to Alaska for practice. To this end, over the last seven years 30% of accepted students have come from rural communities and 10% are Alaska Natives. The curriculum for the first year includes several sessions dedicated to Alaska health problems, cross-cultural issues, and Alaska's unique rural health care delivery system. Students do two preceptorships--one with a private primary care physician and one with a physician at the Alaska Native Medical Center. Additionally, students have the option to spend a week at a rural site to learn about the community's health care system. An Alaska track is being developed whereby an Alaskan UWSM student can do most of the third year in state via clerkships in family medicine, obstetrics/gynecology, psychiatry, internal medicine, and pediatrics. All UWSM students at the end of their first year can elect to participate for one month in the R/UOP (Rural/Underserved Opportunities Program), which includes several Alaska sites. The overall goals of these approaches are to educate UWSM students, especially Alaskans, about the state's health needs and health care system and to encourage UWSM graduates to practice in the state.

Alaska↗

End-of-life issues for American Indians/Alaska Natives: insights from one Indian Health Service area.

BACKGROUND: In the United States, the American Indian and Alaska Native (AI/AN) population is aging and the leading causes of death for those 55 and older are chronic diseases such as cancer, heart disease, and the complications of diabetes. Since 1955, the federally directed Indian Health Service, along with Tribal governments has been providing comprehensive health care to over 500 AI/AN communities. OBJECTIVE: This is the first study to examine end-of-life and palliative care issues broadly at selected Indian Health Service facilities in the Albuquerque area. DESIGN: Retrospective medical records review identified from randomized New Mexico Department of Health American Indian resident death certificates, 50 years of age and over, from 1994-1998. Interviews with hospital administrators, medical records personnel, and cultural advisors regarding end-of-life policies and procedures were conducted. RESULTS: The study documents very limited formal palliative care services available to rural and reservation-dwelling American Indians and Alaska Natives. However, new initiatives and training in palliative care are emerging. CONCLUSIONS: Recommendations for fostering expansion of end-of-life and palliative care services for AI/AN persons are discussed.

Aged↗

Endemic iron deficiency associated with Helicobacter pylori infection among school-aged children in Alaska.

OBJECTIVES: Rural Alaska Natives have a high prevalence of iron deficiency and Helicobacter pylori infection. The objective of this study was to estimate the prevalence of iron deficiency, iron-deficiency anemia, and active H pylori infection among school-aged children in rural Alaska. METHODS: We enrolled 68% (688) of the 7- to 11-year-old children from 10 predominantly Alaska Native villages in southwestern Alaska. We collected venous blood samples to assess iron deficiency and anemia. Each child was tested for active H pylori infection by 13C-urea breath test (UBT). Evaluated risk factors included age, gender, village of residence, number of household members, number of household members who were younger than 5 years, recent antibiotic use, and household water source. RESULTS: Of 688 enrolled children, iron deficiency was present in 38%, iron-deficiency anemia was present in 7.8%, and H pylori infection by UBT was present in 86%. Iron deficiency was independently associated with living in a household with >6 people and village of residence. H pylori infection by UBT was independently associated with child's age > or =10 years and village of residence. Ninety-one percent of children with iron deficiency had H pylori infection by UBT, and children with active H pylori infection were more likely to be iron deficient than uninfected children. Children with H pylori infection by UBT were also more likely to have iron-deficiency anemia than uninfected children. CONCLUSIONS: In this study of nearly 700 children in 10 different villages in Alaska, we confirmed that the high prevalence of iron deficiency persists among school-aged children. We found that active H pylori infection was independently associated with iron deficiency and iron-deficiency anemia among children in this region. H pylori infection may account for a portion of the iron deficiency and iron-deficiency anemia in rural Alaska and other areas with high prevalences of both conditions. Innovative approaches are critically needed to address the iron deficiency in high prevalence areas such as rural Alaska and most of the developing world.

Alaska↗

A model for providing prenatal health care to indigenous women living in remote areas.

OBJECTIVE: To describe a model for providing health care services for indigenous women of childbearing age who do not have ready access to health care. STUDY DESIGN: Program description and prospective annual survey medical records. RESULTS: Measures of the success of this model of prenatal care include prenatal care initiated in the first trimester of pregnancy, low preterm birth, and low out of hospital birth. In 1985, the first year statistics were maintained, 31 percent of women entered prenatal care in their first trimester, 58 percent in their second trimester and 11 percent in their third trimester. In 1999, ninety-one percent of women initiated prenatal care in their first trimester, 9 percent in their second trimester and none waited until their third trimester to initiate care. This compares favorably with Indian Health Service data indicating that in Alaska 77.4 percent of women with live births entered care in their first trimester of pregnancy. CONCLUSION: The Rural Maternal Child Health program at Alaska Native Medical Center has been successfully providing services to indigenous women and their families in 30 remote Alaska Native Villages.

Alaska↗

Intervening on the social determinants of cardiovascular disease and diabetes.

Heart disease, cerebrovascular diseases, and type 2 diabetes ranked first, third, and sixth, respectively, among the leading causes of death and disability in the United States in 2000. Racial and ethnic communities (i.e., African Americans, Hispanic-Latino Americans, Native Americans and Alaska Natives, and Asian Americans and Pacific Islanders) disproportionately suffer from these chronic conditions. Traditional behavior change strategies have had some positive, but limited effects and will not likely be sufficient to eliminate these health disparities at the population level. In this commentary, the authors argue for greater intervention research directed at the social determinants of cardiovascular disease and diabetes if we are to reverse current trends in chronic disease prevalence in communities of color. The authors also call for new research questions and study designs that will increase our understanding of the social, policy, and historic context in which disparities are created as a necessary first step in developing interventions aimed at social-contextual and psychosocial risk factors. Promising programs supported by the Centers for Disease Control and Prevention's Racial and Ethnic Approaches to Community Health (REACH 2010) program and the Division of Diabetes Translation are highlighted.

Cardiovascular Diseases↗

HLA alleles and haplotypes among the Lakota Sioux: report of the ASHI minority workshops, part III.

Human leukocyte antigen (HLA) class I and II alleles were defined for 302 Lakota Sioux American Indians as part of the American Society for Histocompatibility and Immunogenetics coordinated studies on minority populations. The study group was comprised of adult volunteers from the Cheyenne River and Ogala Sioux tribes residing, respectively, on the Cheyenne River and Pine Ridge Reservations in South Dakota. Of the participants, 263 (87%) claimed full American Indian ancestry through both maternal and paternal grandparents. The study group included 25 nuclear families that were informative for genotyping. HLA phenotypes from 202 adults with no other known first-degree relative included in the study were used for calculation of allele and haplotype frequencies by maximum likelihood estimation. HLA-A, -B, and -Cw alleles were found to be in Hardy Weinberg equilibrium. Deviation from equilibrium was observed for DRB1 alleles (p=0.01), but could be attributed to the sample size and the occurrence of some genotypes with low expected frequencies. Polymorphism among the Sioux was limited with four to seven alleles comprising >80% of those observed at each locus. Several alleles were found at high frequency (0.05-0.30) among the Sioux that are also prevalent in other Native Americans and Alaska Natives, including: A*2402, *3101, and *0206; B*3501,*3901, *5101, and *2705; Cw*0702, *0404, and *03041; DRB1*0407, *0404, *1402, and *16021; and DQB1*0301, *0302, and *0402. DRB1*0811, which has been only previously described in Navajo and Tlingit Indians, was found to occur at a frequency of 0.119 among the Sioux. Two new alleles were defined among the Sioux: Cw*0204 and DRB1*040703, which were found in two and four individuals, respectively. In the haplotype analyses, significant linkage disequilibrium (p<0.00001) was seen in all pairwise comparisons of loci and numerous two and three locus haplotypes were found to have strong, positive linkage disequilibrium values. The two most common extended haplotypes among the Sioux, determined by maximum likelihood estimation and genotyping were: A*31012, B*3501, Cw*0404, DRB1*0407; and A*24021, B*3501, Cw*0404, DRB1*0404.

Adult↗

Intervention assessment in an Indian health service pharmacy.

OBJECTIVE: To document and evaluate pharmacists' interventions in a setting that has complete and immediate access to patient information. DESIGN: Descriptive report evaluating self-reported interventions made by pharmacists during the conduct of routine dispensing activities. The data collection period was from February 15 to April 1, 1994. SETTING: Ambulatory care facility offering medical and dental care to high school residents, Native Americans, and Alaska Natives in Northwestern Oregon. MAIN OUTCOME MEASURES: Intervention rate per 100 new prescriptions dispensed. Each intervention was evaluated with regard to the information used to initiate it, when during the dispensing process it was initiated, and the intervention type. Outside evaluators determined the clinical significance of the interventions, including potential adverse health consequences, the likelihood of their occurrence, and the level of medical care that would have been required to treat the problem. RESULTS: Of 2,535 orders screened, 104 interventions (4.1%) were collected; 71% of these occurred during chart screening. Pharmacists most often used the medication order itself (60.6%) to detect prescribing problems, followed by other records in the patient's chart (29.8%). Outside evaluators identified 47.1% of the 104 interventions as clinically significant. The most common adverse health consequence prevented was inadequate control of the patient's condition. Outside evaluators also found that the most common level of corrective care that would have been needed if the intervention had not occurred, was a scheduled physician office visit (59.2%). CONCLUSION: This information suggests that pharmacists who have access to patient information may intervene at higher rates and that more of their interventions may be deemed clinically significant. However, larger, double-blinded, case-controlled studies are needed to definitively draw these conclusions.

Community Pharmacy Services↗

Transposable element ISHp608 of Helicobacter pylori: nonrandom geographic distribution, functional organization, and insertion specificity.

A new member of the IS605 transposable element family, designated ISHp608, was found by subtractive hybridization in Helicobacter pylori. Like the three other insertion sequences (ISs) known in this gastric pathogen, it contains two open reading frames (orfA and orfB), each related to putative transposase genes of simpler (one-gene) elements in other prokaryotes; orfB is also related to the Salmonella virulence gene gipA. PCR and hybridization tests showed that ISHp608 is nonrandomly distributed geographically: it was found in 21% of 194 European and African strains, 14% of 175 Bengali strains, 43% of 131 strains from native Peruvians and Alaska natives, but just 1% of 223 East Asian strains. ISHp608 also seemed more abundant in Peruvian gastric cancer strains than gastritis strains (9 of 14 versus 15 of 45, respectively; P = 0.04). Two ISHp608 types differing by approximately 11% in DNA sequence were identified: one was widely distributed geographically, and the other was found only in Peruvian and Alaskan strains. Isolates of a given type differed by < or = 2% in DNA sequence, but several recombinant elements were also found. ISHp608 marked with a resistance gene was found to (i) transpose in Escherichia coli; (ii) generate simple insertions during transposition, not cointegrates; (iii) insert downstream of the motif 5"-TTAC without duplicating target sequences; and (iv) require orfA but not orfB for its transposition. ISHp608 represents a widespread family of novel chimeric mobile DNA elements whose further analysis should provide new insights into transposition mechanisms and into microbial population genetic structure and genome evolution.

Amino Acid Sequence↗

Research Centers in Minority Institutions (RCMI).

The Research Centers in Minority Institutions (RCMI) Program was initiated in the United States of America in 1985 as a congressionally mandated program. The mission of the RCMI Program is to expand the national capacity for the conduct of biomedical and behavioral research by developing the research infrastructure at institutions granting doctoral degrees in health or health-related sciences, that have 50% or greater enrollment of minorities (African Americans, Hispanics, Native Hawaiians and Pacific Islanders, Native Americans and Alaska Natives) that are underrepresented in the biomedical sciences. The program administration is based in the National Center for Research Resources (NCRR), at the National Institutes of Health (NIH), an agency of the Department of Health and Human Services (DHHS). Since its inception, the program has provided critical resources (core research laboratories, equipment, personnel, supplies, etc.) at each of the RCMI-funded institutions. This article is intended to provide an overview of the RCMI Program, outline the research areas and list contact persons for additional information on research and core resources at each of the current RCMI sites.

Academies and Institutes↗

Cardiovascular disease risk factors in native Americans: a literature review.

Cardiovascular disease (CVD) has become the leading cause of death for Native Americans and Alaska Natives. CVD risk factors (diabetes, hypertension, obesity, hypercholesterolemia, smoking, and sedentary lifestyle) have been studied in a number of Native American tribes, and such studies are increasing as the CVD mortality rate rises. This article reviews the literature between 1980 and 1991 concerning the prevalence of CVD risk factors in this population. In addition to summarizing the data, we describe limitations inherent in comparison and address the need for standardization of methodology in future studies.

Adult↗

Tobacco use among Alaska youth.

The Youth Risk Behavior Survey (YRBS) is a national school-based survey used to monitor health risk behaviors that contribute to the leading causes of mortality, morbidity and social problems among youth and adults in the United States. Tobacco use is one of the behaviors monitored. Both high school and middle school surveys were administered to a representative group of Alaska high school and middle school students for the first time in 1995. Surveys were administered in a confidential and anonymous manner, taking care to assure student privacy. A total of 1,634 high school students and 1,265 middle school students completed surveys. The survey found that Alaska high school students have smoking rates higher than the national rate and that Alaska Native youth have even higher smoking rates. Furthermore, smoking is not uncommon among Alaska middle school students. Among high school students, 36.5% were current smokers (had smoked in the past 30 days) and 21.1% had smoked on 20 or more of the previous 30 days. Boys were more likely than girls to report having used chewing tobacco or snuff in the 30 days prior to the survey (23.5% of boys and 6.7% of girls). Smokeless tobacco use increased with grade level so that 29.1% of high school senior boys had used smokeless tobacco products within the previous 30 days. Over 60% of Alaska Native students reported smoking in the previous 30 days, 43.7% reported smoking 20 or more of the previous 30 days and 22.5% reported using chewing tobacco or snuff in the previous 30 days. Over half of middle school students reported having tried smoking at least once; about one-fourth smoked at least one day in the past 30 days and 5.6% smoked on 20 or more of the past 30 days.

Adolescent↗

Drug use in very rural Alaska villages.

The Alaska Native Preschool Project was centered in the Head Start Programs of two typical Alaska native villages near the Bering Sea. Data were collected over 5 years, 1990 to 1995, from preschool parents (N = 342) with surveys, a panel of villagers (N = 25 to 30) using qualitative interviews; villagers using participant observation; and a limited review of public records. The villages typify the changing life of Alaskan villagers who live in the Bering Straits area. Qualitative data indicated that a number of problems were associated with drug and alcohol use in the villages. The level of smokeless tobacco use from surveys in the previous month among preschool parents (41%) was self-reported to be almost 10 times greater than the national level reported in the 1995 National Household Survey. The use of marijuana reported by preschool parents in the previous month was almost 3 times higher than the 1995 National Household Survey estimates (19 vs 6.7%). Tobacco use in the previous month was reported at over 56%, a level that was over 1 1/2 times the level of use at 34.7% estimated from the 1995 National Household Survey. For 26-34 year olds, previous month alcohol use was lower for the village parents than estimated from the 1995 National Household Survey (38 vs 63%). The self-reported levels of other drug use among preschool parents were very low compared with overall United States rates.

Adult↗

Hepatitis B and hepatocellular carcinoma in Eskimo/Inuit population.

Hepatitis B virus (HBV) is major risk factor for the development of hepatocellular carcinoma (HCC) worldwide. Serologic surveys performed in the 1970s and 1980s have demonstrated that Alaskan Eskimos, Canadian Inuit, and Greenland Inuit have very high prevalence rates of HBV. In Alaska, a high incidence of HCC in Eskimos, especially males, has been reported. Alaska Natives chronically infected with HBV have a relative risk of HCC of 148 compared to Alaska Natives who are not chronically infected. In Canada the incidence of HCC is six times more frequent in elderly Inuit than in Canadians in general. However, an elevated rate of HCC has not been found in Greenland. Primary prevention programs to prevent HCC by vaccination against HBV are being conducted in Alaska, Canada, and Greenland. In addition, in Alaska a program to detect HCC earlier by screening persons chronically infected with HBV, using semiannual alpha-fetoprotein testing, has resulted in detecting over 60% of HCC early enough for surgical resection.

Adolescent↗

Foodborne botulism in the United States, 1990-2000.

Foodborne botulism, a potentially lethal neuroparalytic disease, is caused by ingesting preformed Clostridium botulinum neurotoxin. We reviewed surveillance data and reports from 1990 to 2000. Of 263 cases from 160 foodborne botulism events (episode of one or more related cases) in the United States, 103 (39%) cases and 58 events occurred in Alaska. Patients' median age was 48 years; 154 (59%) were female; the case-fatality rate was 4%. The median number of cases per event was 1 (range 1-17). Toxin type A caused 51% of all cases; toxin type E caused 90% of Alaska cases. A particular food was implicated in 126 (79%) events. In the lower 49 states, a noncommercial food item was implicated in 70 (91%) events, most commonly home-canned vegetables (44%). Two restaurant-associated outbreaks affected 25 persons. All Alaska cases were attributable to traditional Alaska Native foods. Botulism prevention efforts should be focused on those who preserve food at home, Alaska Natives, and restaurant workers.

Adolescent↗

Factors influencing the retention and attrition of community health aides/practitioners in Alaska.

CONTEXT: The Community Health Aide Program (CHAP) is a unique program employing local, indigenous peoples as primary care nonphysician providers in extremely remote frontier, tribal Alaskan communities. With attrition rates up to 20%, recommendations for improving retention are necessary to maintain access to health services for Alaska Natives in these communities. PURPOSE: The purpose of this study was to identify factors contributing to retention in Alaska's CHAP program. METHODS: Key informant interviews were conducted with 41 community health aides/practitioners (CHA/Ps) in 15 villages statewide. Efforts were made to ensure the sample included a mix of villages with high retention of health aides and villages with lower retention. Geographic and ethnic diversity were also considered. Transcripts were coded using NUD*IST software, and data were analyzed for differences between high retention and low retention villages and between more experienced and less experienced CHA/Ps. FINDINGS: Five fundamental needs of health aides were identified as crucial for retention of personnel. These needs include strong co-worker support, access to basic training, a fully staffed clinic, good community support, and supportive families. CONCLUSIONS: For 35 years, the CHAP program has worked to diminish health disparities for Alaska Natives. Though unique challenges associated with the job have factored into low retention of CHA/Ps, improved retention is possible with easier access to basic training, increased support from colleagues and community, enhanced team-building skills, and better on-call schedules.

Adult↗

Tobacco use among racial and ethnic population subgroups of adolescents in the United States.

INTRODUCTION: Limited data on cigarette smoking among population subgroups hinder the development and implementation of intervention strategies for those subgroups. Because of small sample sizes or inadequate study formats, cigarette smoking among youths has been studied mostly among broad racial or ethnic categories (e.g., Asian, Hispanic) instead of subgroups (e.g., Vietnamese, Cuban). The objective of this study was to evaluate cigarette smoking among U.S. youths by racial and ethnic subgroups. METHODS: The study used a nationally representative sample of youths aged 12 to 17 years who participated in the National Survey on Drug Use and Health in 1999, 2000, or 2001. Outcomes measured include prevalence of cigarette smoking, mean age of smoking initiation, and susceptibility to start smoking. RESULTS: The prevalence of smoking among youths aged 12 to 17 years varied among racial and ethnic subgroups, ranging from 27.9% for American Indians and Alaska Natives to 5.2% for Japanese. Among youths aged 12 to 17 years, the age of smoking initiation ranged from 11.5 years (American Indians and Alaska Natives) to 13.2 years (Japanese); the overall mean age of initiation was 12.3 years. White and African American youths were the only groups that showed a significant sex difference in age of initiation among all 14 subgroups; white and African American boys initiated smoking a few months earlier than white and African American girls. One of every four never-smokers aged 12 to 17 years was classified as susceptible to becoming a smoker. CONCLUSION: The prevalence of cigarette smoking among youths varies widely by racial and ethnic subgroup. There is a need for sustained, culturally appropriate interventions to prevent and control cigarette smoking among youths, particularly within racial and ethnic subgroups with a high prevalence of cigarette smoking.

Adolescent↗

Special Projects of National Significance and the Alaska Tribal Health System: an overview of the development of a best practice model for HIV/AIDS care and treatment in Alaska.

This article presents a discussion about the increased risk of the spread of HIV among Alaska Natives resulting from high-risk co-occurring conditions and social and cultural customs that create barriers to HIV/AIDS prevention education. Additionally, an overview of the unique structure of the Alaska Tribal Health System and how the Health Resources Service Administration's (HRSA) American Indian Alaska Native Special Projects of National Significance Initiatives (AI/AN SPNS) have been a critical component in creating the foundation for the development of a best practice model for HIV/AIDS care and treatment in Alaska is provided. This article is not a comparative analysis of the Indian Health Care System. Rather, it provides a discussion about tribal federalism, the Alaska Tribal Health System (ATHS), and the influence the AI/AN SPNS initiatives have had on the development of HIV/AIDS care and treatment in Alaska. In order to explain how the AI/AN SPNS initiatives have influenced the development of HIV/AIDS care and treatment in Alaska, it is also necessary to understand the evolution of the ATHS and how this system is unique compared to other tribal, private, and public health care systems throughout the United States.

Acquired Immunodeficiency Syndrome↗

Tuberculosis contact investigations in rural Alaska: a unique challenge.

Alaska Natives suffered extraordinary rates of disease and death from tuberculosis (TB) during the first half of the 20th century. Although the epidemic was largely controlled in the 1960s, rates of TB among Alaska Natives remain higher than for other Alaskans, and village outbreaks of TB continue to pose major threats. In 2000, a contact investigation around a case patient with infectious TB involved eight villages in south-western Alaska and found 26 additional persons with TB disease and 48 people with newly positive TB skin tests. Rural Alaska brings unique challenges to TB contact investigations not seen elsewhere in the United States because many villages are accessible only by small aircraft or boat. To conduct an investigation, a public health nurse must fly into the village, bring food and water, and sleep at the village clinic or school. In spite of these obstacles, over the past 4 years contact investigations have been initiated for all TB cases with acid-fast bacilli smear-positive sputum, and the proportion of adequately examined contacts has increased from 51% to 75%. The Alaska TB Program plans to improve contact investigations through ongoing reports to regional public health centers and through a statewide training workshop.

Alaska↗