Hispanic physicians' tobacco intervention practices: a cross-sectional survey study

Background U.S. Hispanic physicians constitute a considerable professional collective, and they may be most suited to attend to the health education needs of the growing U.S. Hispanic population. These educational needs include tobacco use prevention and smoking cessation. However, there is a lack of information on Hispanic physicians' tobacco intervention practices, their level of awareness and use of cessation protocols, and the type of programs that would best address their tobacco training needs. The purpose of this study was to assess the tobacco intervention practices and training needs of Hispanic physicians. Methods Data was collected through a validated survey instrument among a cross-sectional sample of self-reported Hispanic physicians. Data analyses included frequencies, descriptive statistics, and factorial analyses of variance. Results The response rate was 55.5%. The majority of respondents (73.3%) were middle-age males. Less than half of respondents routinely performed the most basic intervention: asking patients about smoking status (44.4%) and advising smoking patients to quit (42.2%). Twenty-five percent assisted smoking patients by talking to them about the health risks of smoking, providing education materials or referring them to cessation programs. Only 4.4% routinely arranged follow-up visits or phone calls for smoking patients. The majority of respondents (64.4%) indicated that they prescribe cessation treatments to less than 20% of smoking patients. A few (4.4%) routinely used behavioral change techniques or programs. A minority (15.6%) indicated that they routinely ask their patients about exposure to tobacco smoke, and 6.7% assisted patients exposed to secondhand smoke in understanding the health risks associated with environmental tobacco smoke (ETS). The most frequently encountered barriers preventing respondents from intervening with patients who smoke included: time, lack of training, lack of receptivity by patients, and lack of reimbursement by third party payers. There was no significant main effect of type of physician, nor was there an interaction effect (gender by type of physician), on tobacco-related practices. Conclusion The results indicate that Hispanic physicians, similarly to U.S. physicians in general, do not meet the level of intervention recommended by health care agencies. The results presented will assist in the development of tobacco training initiatives for Hispanic physicians.

Association of maternal sphinganine:sphingosine ratio and folate levels with neural tube defects along the South Texas border

Neural tube defects (NTDs) remain elevated in Hispanic women along the South Texas Border, despite folate supplementation and folate fortification of cereal products. Missmer et al. examined the relationships between fumonisins, a class of corn mycotoxin, and NTDs in Hispanic women who ate corn tortillas and found increased odds ratios with increasing exposure, as measured by serum sphinganine:sphingosine (sa:so) ratios. This study examined the interactions between categorized maternal serum folate levels and stratified sa:so ratios and the resultant odds ratios of NTDs, stratified by type (anencephaly and spina bifida). The hypothesis was that the above normal folate category would have lower odds ratios of NTDs at given sa:so ratio categories and that there would be a difference in odds ratio patterns for anencephaly and spina bifida. Methods. Data for 406 Hispanic women were obtained from the Missmer case-control study. Sa:so ratios were calculated and subjects were stratified into “below normal,” “normal,” and above normal range for folate. A logistic regression model was applied, controlling for BMI, serum B12, lab batch, and conception date. Results. While OR’s of NTDs increased for increasing sa:so ratios, OR’s for “above normal” folate were not decreased at any sa:so ratio and there was no statistically significant difference between OR’s of anencephaly and spina bifida. Conclusion. Folate does not appear to be protective against the potential teratogenic effect of fumonisins and did not differ in effect on OR’s of NTD by type. More research is necessary to determine the extent of fumonisin exposure in Hispanic women along the South Texas Border.^

Nonpurging binge eaters versus nonbinge eaters and treatment retention for adult obesity

Dropout from obesity treatment has been a major factor associated with weight control failure, with few reliable predictors of dropouts or completers. Previous studies have tended to treat obese people as a homogeneous group with standard behavior modification-based interventions. Current research indicates there may be subgroups within the obese population, binge eaters and nonbinge eaters, who have different dropout rates. Current studies also recommend focusing on the subset of this subgroup that does not engage in purging (vomiting, laxative abuse, or excessive exercise) to compensate for binge eating. This research uses a secondary dataset (N = 156) from a prospective study in which participants were randomized to a Food Dependency (FD) and a Behavioral Self-Management (BSM) group for weight reduction. Criteria for subjects in the original study included (1) scoring higher on the existing Binge Eating Scale (BES) in order to ensure enrollment of more binge eaters and (2) no compensatory purging behavior for binge eating. Subjects were then reclassified in this study as binge eaters or nonbinge eaters using the more stringent proposed 1994 DSM-IV criteria for Binge Eating Disorder (BED). Subjects were followed for dropout. Variables studied were binge status, age at obesity onset, age at study baseline, class instructor, number of previous weight loss attempts, race, marital status, body mass index (BMI kg/m$\sp2$), type of intervention, work status, educational level, and social support. Stepwise backward regression Cox survival analysis indicated binge status had a consistent, statistically significant protective effect on dropout in which binge eaters were half as likely to dropout versus nonbinge eaters (p = 0.04). Cox proportional hazards analysis indicated no statistical difference in dropout by type of intervention (FD, p = 0.13; BSM, p = 0.80) when controlling for binge status. All other variables did not reach significance, which is consistent with the literature. Implications of these findings suggest that (1) the proposed 1994 DSM-IV criteria for BED is a more useful classification that the existing DSM-III-R criteria, and (2) the identification of subgroups among obese subjects is an important step in dropout and weight loss intervention research. Future research can confirm this finding. ^

Women physicians' specialty choices

Three hypotheses have been offered to explain the historical specialty selection by women physicians. They are: (1) women choose the specialty for which the training requirements and working conditions interfere least with their commitments to marriage and children; (2) women tend to select the more "feminine" specialties such as pediatrics and psychiatry, and to avoid the "masculine" fields such as surgery; and (3) women have been deliberately excluded from male-dominated fields such as surgery. While the above hypotheses may be true to a greater or lesser degree, none of them has been adequately tested.^ The major study hypotheses are as follows: (1) female physicians' choice of specialty is influenced by the following reasons: (a) family responsibilities; (b) sex role expectations; and (c) sex discrimination; (2) female physicians' choice of specialty is also influenced by their age and ethnicity; and (3) the primary reasons for choosing a given specialty vary by type of specialty.^ The reasons for specialty selection will be explored based on a survey of women graduates of one of the oldest medical schools in the United States, The University of Texas Medical Branch (UTMB) in Galveston, Texas (n = 930). The survey response rate was 75.3% (700 respondents).^ The results for the first study hypothesis showed that fewer than 14% of the respondents agreed that sex role expectations, sex discrimination and family responsibilities played a role in their choice of specialty. Fifty nine percent of the respondents disagreed with the idea that sex role expectations influenced specialty selection and 64% disagreed that family responsibilities had an effect on the selection of their specialty. Around half (49%) were uncertain of the influence of sex discrimination. It was concluded that sex discrimination, sex role expectations and family responsibilities did not have a major impact on specialty selection.^ With respect to the second hypothesis, age was significant in Internal Medicine, Obstetrics/Gynecology and Psychiatry. Women physicians in Internal Medicine and Obstetrics/Gynecology were significantly younger (less than 45 years old) while physicians in Psychiatry were significantly older (45 years or older) than other specialties studied.^ The third hypothesis was confirmed: the reasons for choosing a given specialty varied by specialty.^ Respondents' comments written on the survey provided insight into other possible reasons for specialty selection including exploration of the role of mentoring and job satisfaction.^ The retrospective cross-sectional study design used in this study does not adequately capture the fact that different reasons may be given for the choice of specialty at different points in time, e.g., as the time of choosing a residency program versus several years into the future.^ In conclusion, approaches that explore the range of reasons that women elect to enter and stay within a given specialty must be explored to gain richer understanding of the complex and dynamic nature of women physicians' professional lives. (Abstract shortened by UMI.) ^

Evaluation of web-based resources for HIV+ youth

Given current rates of the Human Immunodeficiency Virus (HIV) in youth ages 15–24, comprehensive care is imperative in order to manage the virus and to prevent further transmission. In the past decade, the Internet has become an immensely popular source for information, including health information. Due to the increase in Internet use for this purpose, the assessment of the quality, accuracy, and timeliness of health information on the Internet is necessary since the information delivered may not be current or accurate. The purpose of this study was to determine the quantity and quality of websites containing health information and resources directed specifically towards HIV positive youth. Three general search terms, “HIV + teens”, “HIV teens info”, and “HIV infected teens,” were searched using the current top three search engines: Google, Yahoo!, and MSN/Bing. The first hundred hits of each search were then categorized by type of website. The examination of the search results yielded 7 sites that met the inclusion criteria. These sites were consequently evaluated on functionality and content using an adapted version of a pre-existing instrument. The functionality analysis revealed that no websites that contained self management information were dedicated specifically to HIV positive youth. The content analysis showed that the sites chosen for evaluation were mostly consistent with the guidelines provided by the Department of Health and Human Services. The most discussed topics in the sites included the importance of safer sexual behavior, HIV counseling, partner notification, safer behavior choices, such as condom use, and mental health. These results highlight the need for the development of accessible websites that contain accurate information targeting youth infected with HIV. This study provides a snapshot of the available web-based resources and health information for HIV positive youth, and is relevant for health educators, care providers, researchers, and others intervening with HIV+ youth. ^

Depressed type 1 cytokine synthesis by superantigen-activated CD4+ T cells of women with human papillomavirus-related high-grade squamous intraepithelial lesions.

Carcinoma of the cervix is causally related to infection with the human papillomavirus (HPV), and T cells play a pivotal role in the immune response of the host to rid itself of HPV infection. Therefore, we assessed the T-cell function of women with HPV-related cervical neoplasia against a superantigen, Staphylococcus enterotoxin B (SEB). Each woman provided a cervical brush specimen for HPV DNA testing and Papanicolaou (Pap) smears for the staging of cervical lesions. They also provided a blood specimen for determination of the ability of CD4(+) T and CD8(+) T cells to synthesize Th1 (interleukin-2 [IL-2], gamma interferon [IFN-gamma], and tumor necrosis factor alpha [TNF-alpha]) and Th2 (IL-10) cytokines in response to activation with SEB. Compared with control subjects with self-attested negative Pap smears, women with high-grade squamous intraepithelial lesions (HSIL) had significantly lower percentages of activated CD4(+) T cells that produced IL-2 (P = 0.045), IFN-gamma (P = 0.040), and TNF-alpha (P = 0.015) and a significantly lower percentage of activated CD8(+) T cells that produced IL-2 (P < 0.01). These data indicate that women with HPV-related cervical HSIL show a decrease in Th1 cytokine production by activated CD4(+) T cells and suggested that compromised T-helper functions may negatively impact the function of cytotoxic CD8(+) T cells.

Maternal and neonatal outcomes by labor onset type and gestational age.

OBJECTIVE: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

{\it In vivo\/} induction of cytotoxic T lymphocytes against human immunodeficiency virus type 1 by synthetic viral peptides

Cytotoxic T lymphocytes (CTLs) play an important role in the suppression of initial viremia after acute infection with the human immunodeficiency virus (HIV), the causative agent of acquired immune deficiency syndrome (AIDS). Most HIV-infected individuals attain a high titer of anti-HIV antibodies within weeks of infection; however this antibody-mediated immune response appears not to be protective. In addition, anti-HIV antibodies can be detrimental to the immune response to HIV through enhancement of infection and participating in autoimmune reactions as a result of HIV protein mimicry of self antigens. Thus induction and maintenance of a strong HIV-specific CTL immune response in the absence of anti-HIV antibodies has been proposed to be the most effective means of controlling of HIV infection. Immunization with synthetic peptides representing HIV-specific CTL epitopes provides a way to induce specific CTL responses, while avoiding stimulation of anti-HIV antibody. This dissertation examines the capacity of synthetic peptides from the V3 loop region of the gp120 envelope protein from several different strain of HIV-1 to induce HIV-specific, MHC-restricted CD8$\sp+$ CTL response in vivo in a mouse model. Seven synthetic peptides representative of sequences found throughout North America, Europe, and Central Africa have been shown to prime CTLs in vivo. In the case of the MN strain of HIV-1, a 13 amino acid sequence defining the epitope is most efficient for optimal induction of specific CTL, whereas eight to nine amino acid sequences that could define the epitope were not immunogenic. In addition, synthesis of peptides with specific amino acid substitutions that are important for either MHC binding or T cell receptor recognition resulted in peptides that exhibited increased immunogenicity and induced CTLs that displayed altered specificity. V3 loop peptides from HIV-1 MN, SC, and Z321 induced a CTL population that was broadly cross-reactive against strains of HIV-1 found throughout the world. This research confirms the potential efficacy of using synthetic peptides for in vivo immunization to induce HIV-specific CTL-mediated responses and provides a basis for further research into development of synthetic peptide-based vaccines. ^

Border intervention by Promotores for type 2 diabetes

Purpose of the study. This study had two components. The first component of the study was the development and implementation of an infrastructure that integrated Promotores who teach diabetes self-management into a community clinic. The second component was a six-month randomized clinical trial (RCT) designed to test the effectiveness of the Promotores in changing knowledge, beliefs, and HbA1c levels among Mexican American patients with type 2 diabetes. ^ Methods. Starfield's adaptation of the Donbedian structure, process, and outcome methodology was used to develop a clinic infrastructure that allowed the integration of Promotores as diabetes educators. The RCT of the culturally sensitive Promotores-led 10-week diabetes self-management program compared the outcomes of 63 patients in the intervention group with 68 patients in a wait-list, usual care control group. Participants were Mexican Americans, at least 18 years of age, with type 2 diabetes, who were patients at a Federally Qualified Health Center on the Texas-Mexico border. At baseline, three months, and six months, data were collected using the Diabetes Knowledge Questionnaire (DKQ, the Health Beliefs Questionnaire (HBQ, and HbA1c levels were drawn by the clinic laboratory. A mixed model methodology was used to analyze the data. ^ Results. The infrastructure to support a Promotores-led diabetes self-management course designed in concert with administration, the physicians, and the CDE, resulted in (1) employment of Promotores to teach diabetes self-management courses; (2) integration of provider and nurse oversight of course design and implementation; (3) management of Promotora training, and the development of teaching competencies and skills; (4) coordination of care through communication and documentation policies and procedures; (5) utilization of quality control mechanisms to maintain patient safety; and (6) promotion of a culturally competent approach to the educational process. The RCT resulted in a significant improvement in the intervention group's DKQ scores over time (F [1, 129] = 4.77, p = 0.0308), and in treatment by time (F [2, 168] = 5.85, p = 0.0035). Neither the HBQ scores nor the HbA1c changed over time. However, the baseline HbA1c was 7.49, almost at the therapeutic level. The DKQ, HBQ, and HbA1c results were significantly affected by age; the DKQ and HbA1c by years with diabetes. ^ Conclusions. The clinic model provides a systematic approach to safely address the educational needs of large numbers of patients with type 2 diabetes who live in communities that suffer from a lack of health care professionals. The Promotores-led diabetes self-management course improved the knowledge of patients with diabetes and may be a culturally sensitive strategy for meeting patient educational needs. The low baseline HbA1c levels in this border community suggested that patients in this Federally Qualified Health Center on the Texas-Mexico border were experiencing good medical management of their diabetes. ^

Charity care and community benefits by hospital type in Texas

Hospital care is the largest component of the health care sector. This industry is made up of for profit hospital (FPH) organizations, not for profit (NFP) hospitals, and government (GOV) run hospital facilities. Objectives of this analysis were: (a) to conduct a literature review on NFP hospital legislation at the state level in Texas and at the federal level in the broader U.S.; and (b) to describe the types of charity care and community benefits currently being provided: by NFP hospitals compared to FPH hospitals and GOV hospitals; by hospitals geographic proximity to the Texas-Mexico border; and by hospital community type (rural, suburban, and urban); and (c) propose specific policy changes that may be needed to improve the current Texas State statute. Methods. In describing the historical and current policy context of NFP hospital legislation in the United States, federal legislation was reviewed from 1913 to the present and Texas State legislation was reviewed from 1980 to the present. In describing the provision of charity care, data from the 2008 Annual Cooperative Hospital Survey were examined by hospital organizational type, size, proximity to the border, and community type using linear regression and chi-squared tests to assess differences in charity care and community benefits. Results. The data included 123 NFP hospitals, 114 GOV hospitals, and 123 FPH. Results. Small sized (p<0.001) and medium sized (p<0.001) NFP hospitals provide a greater percent of total charity care when compared to FPH hospitals and to both GOV and FPH hospitals respectively; however, no significant difference in total charity care was found among large sized NFP hospitals when compared to FPH hospitals alone (p=.345) and both GOV and FPH facilities (p=.214). The amount of charity care provided was not found to be different based on proximity to the border or community type. Community benefit planning and budgeting was found to be similar regardless of community type and proximity to the border. Conclusion. No differences in charity care in Texas were found for large sized NFP hospitals compared to FPH and GOV hospitals. Contrary to widely held beliefs, this study did not find the border region to provide a greater amount of charity care or bad debt. Charity care also did not vary by community type. These findings underscore the need for continued collection of transparent data from all hospitals in order to provide policy makers and consumers with information on utilization trends to ensure benefits are being provided to the community. Policy changes or revoking tax-benefits may occur as charity care utilization declines with the implementation of health reform in the next few years.^

RELATION OF TYPE OF REPORTED ILLNESSES TO PATTERN OF USE OF THE STUDENT HEALTH CENTER BY THE INTERNATIONAL STUDENTS AT TEXAS SOUTHERN UNIVERSITY, HOUSTON, TEXAS

The state of knowledge on the relation of stress factors, health problems and health service utilization among university students is limited. Special problems of stress exist for the international students due to their having to adjust to a new environment. It is this latter problem area that provides the focus for this study. Recognizing there are special stress factors affecting the international students, it is first necessary to see if the problems of cultural adaptation affect them to any greater degree than American students attending the same university.^ To make the comparison, the study identified a number of health problems of both American and international students and related their frequency to the use of the Student Health Center. The expectation was that there would be an association between the number of health problems and the number of life change events experienced by these students and between the number of health problems and stresses from social factors. It was also expected that the number of health problems would decline with the amount of social support.^ The population chosen were students newly enrolled in Texas Southern University, Houston, Texas in the Fall Semester of 1979. Two groups were selected at random: 126 international and 126 American students. The survey instrument was a self-administered questionnaire. The response rate was 90% (114) for the international and 94% (118) for the American students.^ Data analyses consisted of both descriptive and inferential statistics. Chi-squares and correlation coefficients were the statistics used in comparing the international students and the American students.^ There was a weak association between the number of health problems and the number of life change events, as reported by both the international and the American students. The study failed to show any statistically significant association between the number of stress from social factors and the number of health problems. It also failed to show an association between the number of health problems and the amount of social support. These findings applied to both the international and the American students.^ One unexpected finding was that certain health problems were reported by more American than international students. There were: cough, diarrhea, and trouble in sleeping. Another finding was that those students with health insurance had a higher level of utilization of the Health Center than those without health insurance. More international than American students utilized the Student Health Center.^ In comparing the women students, there was no statistical significant difference in their reported fertility related health problems.^ The investigator recommends that in follow-up studies, instead of grouping all international students together, that they be divided by major nationalities represented in the student body; that is, Iranians, Nigerians and others. ^