Access to health services, geographic distribution of medical doctors and their orientating programs.
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Adult↗
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The micrograph data processing program.
MDPP is a fully featured general-purpose image processing package primarily written to support research in structural biology using data gathered by electron microscopy. It has focused on the analysis of images using Fourier techniques, particularly periodic plane-layer and helical structures, but has extensive tools for other processing options (e.g., point-counting, image quantitation, DNA sequencing, and display). Three-dimensional reconstruction methods are supported, including iterative deconvolution schemes for light micrographs. The basic program is command line-driven, but the user can choose to write sophisticated command scripts and use a menu-driven full-screen or Motif interface to call them. Color images are supported with both color palette and RGB options. Extensive documentation is accessible from within the program as online HELP and also as HTML. Care has been taken to support interfaces to other image processing packages, e.g., MacIntosh applications via the TIFF image format, and other EM-targeted image processing packages. The paper provides an overview of the program, its design, and implementation and outlines future plans for software development. Some general issues concerning image processing program design are discussed.
Computer Simulation↗
Family planning clinic services in the United States, 1994.
In 1994, almost 6.6 million women received contraceptive services from more than 7,000 subsidized family planning clinics; these providers were located in 85% of U.S. counties. Health department clinics and Planned Parenthood sites served the largest proportions of these women (32% and 30%, respectively), followed by hospital outpatient sites (16%), independent clinics (13%) and community or migrant health centers (9%). The mix of agency types varied considerably by region and state, and the average annual number of contraceptive clients served per clinic also varied from fewer than 500 at community and migrant health centers to more than 2,000 at Planned Parenthood clinics. Nearly two-thirds of all women served (4.2 million) obtained care at one of the 4,200 clinics receiving funds from the federal Title X family planning program. Health department sites were the most likely to receive Title X funding (78%), followed by independent clinics and Planned Parenthood sites (66% each), hospital clinics (28%) and community and migrant health centers (18%). Overall, clinics receiving Title X funds serve an average of 25% more contraceptive clients than do clinics not receiving such funds.
Adolescent↗
Physician perspectives on a pilot prescription monitoring program.
In 2003, during implementation of a pilot electronic prescription monitoring program in southwest Virginia, a survey was mailed to 672 physicians to learn about their knowledge of and attitudes toward the program and its impact on their opioid prescribing behaviors. A total of 275 surveys were returned yielding a response rate of 41%. Less than one-half had previously heard about the prescription monitoring program. Nearly 60% believed their prescribing behaviors were being monitored more closely as a result of the program; of these, 23% reported that this had a negative impact on their ability to help patients manage their pain. Sixty-eight percent reported that the prescription monitoring program was useful for monitoring patients' prescription histories and decreasing doctor shopping; however, only 11% had requested information from the prescription monitoring program database, primarily due to access barriers. Recommendations include education to increase physician awareness of and utilization of the program and to address their concerns about scrutiny of practice and collection of relevant data that examines the impact of the program on diversion, abuse, and quality of patient care for persons in pain.
Attitude of Health Personnel↗
Urologist-acquired renal access for percutaneous renal surgery.
OBJECTIVES: In most endourology programs an interventional radiologist is employed to acquire renal access for percutaneous renal surgery. Over the last 13 years the senior endourologist at Oregon Health Sciences University has acquired access without employing a radiologist. We report our experience with urologist-acquired renal access for percutaneous renal surgery in 522 cases. METHODS: We reviewed the records of all patients at our hospital who underwent percutaneous renal surgery between August 1983 and December 1996 with renal access being obtained in the operating room by a urologist. RESULTS: Four hundred fifty-six patients underwent 522 procedures. Indications for percutaneous renal surgery were renal and proximal ureteral calculi (n = 516), retained ureteral stent (n = 3), and intrarenal collecting system tumor (n = 3). We were successful in gaining access to 513 of 522 kidneys (98.3%). Access was obtained via a subcostal approach in 344 procedures, over the 12th rib in 152 procedures, over the 11th rib in 15 procedures, and transabdominally in 2 procedures. Sixty-five patients (12.7%) required a second or multiple sites to facilitate complete removal of calculi. Our overall complication rate was 15.3%. Blood transfusion was required in 5.4% of the cases, ileus developed in 1.9%, pneumothorax in 1.1%, intraoperative hydrothorax in 1.1%, postoperative pleural effusion requiring aspiration in 0.9%, and septic shock in 0.9%. Our overall success rate for stone removal was 94.5%. CONCLUSIONS: In our experience, the urologist is able to safely and effectively obtain percutaneous access to the collecting system for percutaneous renal surgery as a one-stage procedure without the aid of interventional radiologists.
Adolescent↗
Position of the American Dietetic Association: child and adolescent food and nutrition programs.
It is the position of the American Dietetic Association that all children and adolescents, regardless of age; gender; socioeconomic status; racial, ethnic, or linguistic diversity; or health status should have access to food and nutrition programs that ensure the availability of a safe and adequate food supply that promotes optimal physical, cognitive, and social growth and development. Appropriate food and nutrition programs include food assistance and meal programs, nutrition education initiatives, nutrition screening and assessment followed by appropriate nutrition intervention, and anticipatory guidance to promote optimal nutrition status. Malnutrition has been linked to delayed physical, psychosocial, and cognitive development and is now recognized as a major contributor to the growing problem of overweight and obesity in the child and adolescent population. Food and nutrition programs create a safety net that ensures that children and adolescents at risk for poor nutritional intakes have access to a safe, adequate, and nutritious food supply and nutrition screening, assessment evaluation, and intervention. It is important that continued funding be provided for these programs, which have been consistently shown to have a positive impact on child and adolescent well-being. Food and nutrition programs will continue to serve not only as a means to combat hunger and food insecurity but also as a vehicle for nutrition education and promotion of physical activity designed to combat overweight and prevent chronic disease. It is the role of the credentialed dietetics professional to support permanent, adequate funding to food and nutrition programs, universal health-care reimbursement for nutrition services, and the use of research and surveillance programs to justify, evaluate, and improve these programs. In addition, the dietetics professional is responsible for serving as a nutrition resource to all groups and individuals working with children and adolescents, acting as an advocate for the establishment of child-care, school, and community settings conducive to the development of good nutrition habits. J Am Diet Assoc. 2003;103:887-893.
Adolescent↗
Pharmacy access to sterile syringes for injection drug users: attitudes of participants in a syringe exchange program.
OBJECTIVE: To examine attitudes of participants of a van-based syringe exchange program (SEP) toward the hypothetical prospect of pharmacy-based syringe access. DESIGN: One-time, cross-sectional survey. SETTING: Baltimore, Maryland. PARTICIPANTS: 206 injection drug users who participate in the Baltimore SEP. INTERVENTIONS: Face-to-face interviews. MAIN OUTCOME MEASURES: Location preferred for obtaining syringes, drug and syringe use, past experience with pharmacies, and willingness to pay. RESULTS: The sample was 67% men, 95% African American, and 95% unemployed; mean age was 39.8 years. A total of 19% of respondents had bought syringes at a pharmacy during the prior six months. Some 37% reported having been turned down when asking for syringes at a pharmacy, most commonly due to lack of identification to prove diabetic status (50%). If legal restrictions were lifted, 92% of respondents would obtain syringes from pharmacies, and would be willing to pay a mean price of $0.80 (median = $1.00) per syringe. Women were more likely than men to report the intention to switch from van-based SEP to pharmacy (57% versus 38%, p = .045). CONCLUSION: If current legal restrictions were lifted, pharmacies would be a viable syringe source appealing particularly to women, suggesting gender-specific access issues that should be addressed. The per-syringe price that study participants would be willing to pay exceeds typical retail prices, suggesting that pharmacists could charge enough per syringe to recoup operational costs.
Adult↗
Evaluation of the North Country on the Job Network: a model of facilitated care for injured workers in rural upstate New York.
We describe the evaluation of a community-based program designed to facilitate access to care and return to work for injured workers in a rural, medically underserved area in upstate New York. Providers are recruited to provide easily accessible care and are oriented to concepts of transitional duty and rapid return to work as medically appropriate; companies are recruited with the agreement to provide transitional work for injured employees. Registered nurses, hired by the local hospital, serve as case coordinators to facilitate care and coordinate communications among all parties. Over 3000 injured workers received care through the program in the first 56 months, with a decline in the number of transitional days over time. The number of days that the cases remain open has steadily declined, and the number of return-to-work cases has increased. The success of this initiative provides an excellent background for continued improvement in delivery of care to injured workers and proactive efforts at improving workplace safety and health in a rural area.
Accidents, Occupational↗
Preventing pregnancy and improving health care access among teenagers: an evaluation of the children's aid society-carrera program.
CONTEXT: Despite the recent declines in rates of teenage pregnancy, relatively little is known about the few programs that have been successful in reducing adolescent pregnancy. METHODS: Six agencies in New York City each randomly assigned 100 disadvantaged 13-15-year-olds to their usual youth program or to the intervention being tested--the Children's Aid Society-Carrera program, a year-round afterschool program with a comprehensive youth development orientation. Both program and control youth were followed for three years. Multivariate regression analyses assessed the effects of program participation on the odds of current sexual activity, use of a condom along with a hormonal contraceptive, pregnancy and access to good health care. RESULTS: Seventy-nine percent of participants remained in the program for three full years. Female program participants had significantly lower odds than controls of being sexually active (odds ratio, 0.5) and of having experienced a pregnancy (0.3). They had significantly elevated odds of having used a condom and a hormonal method at last coitus (2.4). However, participation in the program created no significant impact on males' sexual and reproductive behavior outcomes. Nonetheless, program participants of both genders had elevated odds of having received good primary health care (2.0-2.1). CONCLUSIONS: This program is one of only four whose evaluation has successfully documented declines in teenage pregnancy using a random-assignment design. Better outcomes among males may be achieved if programs reach them even earlier than their teenage years.
Adolescent↗
Position of the American Dietetic Association: child and adolescent food and nutrition programs.
It is the position of the American Dietetic Association that all children and adolescents, regardless of age, sex, socioeconomic status, racial diversity, ethnic diversity, linguistic diversity, or health status, should have access to food and nutrition programs that ensure the availability of a safe and adequate food supply that promotes optimal physical, cognitive, social, and emotional growth and development. Appropriate food and nutrition programs include food assistance and meal programs, nutrition education initiatives, and nutrition screening and assessment followed by appropriate nutrition intervention and anticipatory guidance to promote optimal nutrition status. Food and nutrition programs create a safety net that ensures that children and adolescents at risk for poor nutritional intakes have access to a safe, adequate, and nutritious food supply and nutrition screening, assessment, and intervention. It is important that continued funding be provided for these programs, which consistently have been shown to have a positive impact on child and adolescent health and well-being. Food and nutrition programs serve as a means to prevent or reduce hunger and food insecurity, but also as a vehicle for nutrition education and promotion of physical activity designed to prevent or reduce overweight and prevent chronic disease. It is the role of the registered dietitian to support adequate and sustained funding for food and nutrition programs, universal health care reimbursement for nutrition services, and the use of research and surveillance programs to evaluate and improve these programs. In addition, the registered dietitian and dietetic technician, registered, are responsible for serving as a nutrition resource to all groups and individuals providing services to children and adolescents, acting as an advocate for the establishment of child-care, school, and community settings conducive to the development of good nutrition habits.
Adolescent↗
Cognitive/behavioral treatment for sexual offenders: an examination of recidivism.
Recent research in the treatment of sexual offenders suggests that comprehensive cognitive/behavioral approaches may yield lower recidivism. This study reviewed such a program, existing in Jackson County, Oregon, since 1982. Offenders were mandated into this community-based program upon conviction of a felony or misdemeanor sexual offense, and averaged 2-3 years of participation. A group of offender who participated in the Jackson County program between 1985 and 1995 was identified through archival data from the Oregon Department of Corrections. The data revealed success or nonsuccess in treatment, and any new convictions for sexual or nonsexual offenses. A control group of nonsexual offenders in Jackson County, and a group of sexual offenders in Linn County who did not have access to any treatment program were also studied. As hypothesized, those Jackson County offenders who successfully completed treatment had lower recidivism rates than those who were unsuccessful in the program. The observed effect of the program was particularly strong for offenders who remained in treatment for 1 year or more. When review was restricted to those participants, the reoffense rate for Jackson County offenders was reduced by over 40% when compared with Linn County offenders.
Adult↗
The legal environment impeding access to sterile syringes and needles: the conflict between law enforcement and public health.
This article examines the legal environment for programs to prevent transmission of HIV and other blood-borne diseases among injection drug users (IDUs). Cost-effective public health programs often have questionable legal authority, and health professionals, community activists, and IDUs may be subject to arrest and prosecution. Legal impediments to the sale and distribution of syringes exist in every state: 47 states have drug paraphernalia statutes, 8 states have syringe prescription statutes, and 23 states have pharmacy regulations or practice guidelines. The Mail Order Drug Paraphernalia Act permits federal enforcement against individuals who knowingly sell or distribute syringes to IDUs. Congress has prohibited the use of federal funds for syringe exchange programs (SEPs). Legal restrictions on access to sterile syringes present formidable obstacles to public health prevention. These restrictions render it much more difficult for pharmacists to sell syringes over the counter or for physicians to prescribe syringes, create a chilling effect on IDUs seeking to comply with medical advice and protect themselves and their partners from disease, and place significant obstacles on the lawful establishment and operation of SEPs. Public health authorities have only sometimes creatively circumvented legal restrictions through judicial declarations of lawfulness, municipal declarations of a "state of emergency," and by use of the "necessity" defense. I recommend repeal of syringe prescription statutes and reform of drug paraphernalia statutes and pharmacy regulations.
Blood-Borne Pathogens↗
Effect of patient notification of formulary change on formulary adherence.
OBJECTIVE: To evaluate the impact of patient notification of impending formulary changes on formulary adherence. METHODS: This pilot program in a large, Midwest-based health insurer utilized a randomized controlled trial research design. A list of 30 chronic-use medications that were to change formulary status were selected for the pilot. A review of adjudicated pharmacy claims records was performed to identify patients receiving one or more of the formulary change medications on the list. Members of 112 individual health plans of this large health insurer, all of whom were subject to the same drug formulary, were randomized to either the intervention (letter) or control arm. Patients in the intervention arm were sent a targeted communication that described the patient.s formulary change medication(s) and provided therapeutic option(s) for the formulary change medication(s). Pharmacy claims for patients in both arms were examined at 110 days after the date of the mailing to determine if there was a switch to a formulary alternative. Multivariate regression modeling was performed to adjust for baseline differences between the arms. RESULTS: A total of 7,247 unique formulary change medication regimens were identified (3,817 in the control arm and 3,430 in the letter arm) for 6,518 subjects (3,387 in the control arm and 3,131 in the letter arm). A higher proportion of formulary change medication regimens in the intervention arm were switched to a formulary alternative compared with the control arm (19.2% vs. 12.0%, P<0.001). After adjustment for baseline differences, regression modeling indicated that subjects in the intervention arm were 1.33 times more likely to switch to a formulary alternative (P<0.001). CONCLUSION: A letter-based, formulary change notification program is a pragmatic and effective strategy to increase drug formulary adherence. Such a program does not restrict access to medications but, rather, provides education and personalized information that may allow patients to participate more actively in their pharmacotherapy decision making.
Female↗
Applicability of the ADA to "Ticket to Work" employment networks. Americans with Disabilities Act.
This article examines the applicability of the antidiscrimination provisions of the Americans with Disabilities Act (ADA) of 1990 to The Ticket to Work and Work Incentives Improvement Act (TWWIIA) passed in 1999. Among other policy changes, under the Ticket to Work program, eligible recipients of disability insurance (SSDI) and supplemental income (SSI) receive a voucher or "ticket" to obtain services from qualified employment networks (ENs). ENs provide employment services and supports to designated beneficiaries and must meet certain qualification requirements. The ADA is applicable to ENs in several ways: primarily, in the EN's responsibility to provide appropriate access and services to program participants. This article discusses application of the ADA to the Ticket Program as ENs begin to serve program beneficiaries.
Consumer Advocacy↗
The otter annotation system.
With the completion of the human genome sequence and genome sequence available for other vertebrate genomes, the task of manual annotation at the large genome scale has become a priority. Possibly even more important, is the requirement to curate and improve this annotation in the light of future data. For this to be possible, there is a need for tools to access and manage the annotation. Ensembl provides an excellent means for storing gene structures, genome features, and sequence, but it does not support the extra textual data necessary for manual annotation. We have extended Ensembl to create the Otter manual annotation system. This comprises a relational database schema for storing the manual annotation data, an application-programming interface (API) to access it, an extensible markup language (XML) format to allow transfer of the data, and a server to allow multiuser/multimachine access to the data. We have also written a data-adaptor plugin for the Apollo Browser/Editor to enable it to utilize an Otter server. The otter database is currently used by the Vertebrate Genome Annotation (VEGA) site (http://vega.sanger.ac.uk), which provides access to manually curated human chromosomes. Support is also being developed for using the AceDB annotation editor, FMap, via a perl wrapper called Lace. The Human and Vertebrate Annotation (HAVANA) group annotators at the Sanger center are using this to annotate human chromosomes 1 and 20.
Computational Biology↗
Epidemiologic programs for computers and calculators. Inferences on odds ratios, relative risks, and risk differences based on standard regression programs.
Statistical analyses of the joint effects of several factors (covariates) on the risk of disease, death, or other dichotomous outcomes, are frequently based on a model that relates the effect of the covariates to some function of the probability of the outcome. The odds ratio, relative risk, and the difference in risks are among the simplest candidates for the outcome function. Each can be specified as a special case of the generalized linear model, but their use has been limited to researchers with access to specialized computer programs that are not yet generally available in standard computer packages. The purpose of this communication is to describe how to implement the maximum likelihood estimation procedures and hypothesis testing associated with the generalized linear model using any computer program that can perform weighted least squares analyses. The procedure is applied specifically to models for relative risks, risk differences, and odds ratios. The techniques are illustrated with SAS and SPSSx programs for data sets previously presented.
Computers↗
Identification of estrogen-responsive genes using a genome-wide analysis of promoter elements for transcription factor binding sites.
We developed a pipeline to identify novel genes regulated by the steroid hormone-dependent transcription factor, estrogen receptor, through a systematic analysis of upstream regions of all human and mouse genes. We built a data base of putative promoter regions for 23,077 human and 19,984 mouse transcripts from National Center for Biotechnology Information annotation and 8793 human and 6785 mouse promoters from the Data Base of Transcriptional Start Sites. We used this data base of putative promoters to identify potential targets of estrogen receptor by identifying estrogen response elements (EREs) in their promoters. Our program correctly identified EREs in genes known to be regulated by estrogen in addition to several new genes whose putative promoters contained EREs. We validated six genes (KIAA1243, NRIP1, MADH9, NME3, TPD52L, and ABCG2) to be estrogen-responsive in MCF7 cells using reverse transcription PCR. To allow for extensibility of our program in identifying targets of other transcription factors, we have built a Web interface to access our data base and programs. Our Web-based program for Promoter Analysis of Genome, PAGen@UIC, allows a user to identify putative target genes for vertebrate transcription factors through the analysis of their upstream sequences. The interface allows the user to search the human and mouse promoter data bases for potential target genes containing one or more listed transcription factor binding sites (TFBSs) in their upstream elements, using either regular expression-based consensus or position weight matrices. The data base can also be searched for promoters harboring user-defined TFBSs given as a consensus or a position weight matrix. Furthermore, the user can retrieve putative promoter sequences for any given gene together with identified TFBSs located on its promoter. Orthologous promoters are also analyzed to determine conserved elements.
Algorithms↗
Mortality from cervical carcinoma in Mexico: impact of screening, 1980-1990.
OBJECTIVE: To determine the temporal mortality trends of uterine cervical cancer in Mexico for the period 1980-1990. STUDY DESIGN: In Mexico, data from death certificates are collected in a national repository at the National Institute of Statistics, Geography and Informatics. These data were analyzed to obtain mortality trends, and regional variations were obtained for the same period using a Poisson regression model. RESULTS: The official mortality figure for cervical cancer for the study period was 37,982 cases. Subregistration due to misclassification was evident, particularly in the first five years of the study period; however, poor quality of information was proportionally distributed across the different age groups. A standardized analysis by quinquennia showed a steady mortality trend during the last 10 years, with slightly upward significant trends within some age groups (beta=0, P<.05). High regional variations in cervical cancer mortality risks were found using a Poisson regression model. Twenty-four states in Mexico showed an increased mortality risk when compared with Mexico City; seven states showed a steady or downward trend. CONCLUSION: The results show the ineffectiveness of the cancer screening program, underscoring the need to ensure access to and the quality of the cervical cancer screening program in order to decrease mortality rates.
Adult↗