Refugees from Myanmar and their health care needs in the US: A qualitative study at a refugee-resettlement agency

In response to the recent rapid influx of refugees from Myanmar, Interfaith Ministries for Greater Houston (IM), a refugee resettlement agency, started to support them in June 2007. The study looked at the refugees' perspectives and identified the gaps in their understanding on US health care system, health seeking behaviors and challenges in utilizing health care in United States. The major issues identified were non-compliance with tuberculosis prevention medication due to barriers in obtaining medication refills, barriers in accessing specialty care services, transportation issues, written and oral language barrier, difficulties in the application for and use of Medicaid and Gold Card, misunderstanding of emergency health services, lack of resources for health education, self-treatment with Western medicine and income too low to buy private health insurance. In order to transform them to healthy citizens able to contribute to the US workforce, several multi-faceted and comprehensive approaches and better coordination among agencies are recommended. ^

The public health applications of law enforcement medical direction: A practical experience with the Dallas Police Department

In 2008, 132 law enforcement officers were killed in the line of duty in The United States. Additionally, some have explored both the public health implications of interactions with law enforcement as well as the potential benefits of the use of law enforcement officers as public health and emergency healthcare providers. By virtue of these novel analyses and techniques, professional medical direction of the emerging specialty of law enforcement medicine is needed. This paper, an analysis of law enforcement medical direction through a look at the Dallas Police Medical Direction Program, seeks to examine origins of law enforcement medicine through a comprehensive literature review, as well as begin to define to core competencies of law enforcement medical direction. ^ The unique intersection of public health, medicine and law enforcement, and the subsequent specialty that is developing to manage this interface, is in its relative infancy. An analysis of this nature is in order to begin to lay down the foundations necessary for future study and improvements in the field. ^

Effective interventions for lowering HbA1C in African Americans with type 2 diabetes: A review

This synthesis of the literature provides descriptive analysis and outlines current self-management interventions for African Americans with type 2 diabetes. Specifically, this study describes and explores the design of those studies whose interventions have been shown to lower HbA1C levels in this population by at least 0.5% points, an improvement that provides approximately 10% reduction in long term complications from this disease.^ Results. In total, 37 articles were reviewed and 17 articles met inclusion criteria for analysis. Analysis of each study's methodology and results was performed and selected studies with interventions that resulted in improvements in HbA1C outcomes equal to 0.5% or greater for both group 1 and 2 were summarized by intervention type in table format. Descriptive analysis, outlining the number and characteristics of proximal and distal mediating components addressed in Group 1 studies, was performed in order to determine whether mediating components may have had some relation to effectiveness of intervention on outcome HbA1C. Descriptive analysis revealed that no particular design is substantially more effective than another among Behavioral studies although, there may be an advantage in using culturally sensitive, group interventions that address greater numbers of distal mediating components. Among Process studies, structured approaches (i.e. algorithm care and scheduled follow up), as well as utilization of specialty and group care are represented as effective for African American populations. ^ Conclusions. It may be summarized that by targeting behavior and addressing provider delivery (i.e. algorithm use, group care, home care, and provider follow up) in this population, a greater yield in outcome improvements may be accomplished. However, many gaps exist in a review process that stratifies results and focuses on identifying group specific intervention successes and failures. Further research in different populations will aid researchers and practitioners in discovering the best evidence, and identifying models that could be utilized in practice to achieve the best diabetes management for at risk groups.^

The determinants of improvements in health outcomes and of cost reduction in hospital inpatient care

This study aims to address two research questions. First, ‘Can we identify factors that are determinants both of improved health outcomes and of reduced costs for hospitalized patients with one of six common diagnoses?’ Second, ‘Can we identify other factors that are determinants of improved health outcomes for such hospitalized patients but which are not associated with costs?’ The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database from 2003 to 2006 was employed in this study. The total study sample consisted of hospitals which had at least 30 patients each year for the given diagnosis: 954 hospitals for acute myocardial infarction (AMI), 1552 hospitals for congestive heart failure (CHF), 1120 hospitals for stroke (STR), 1283 hospitals for gastrointestinal hemorrhage (GIH), 979 hospitals for hip fracture (HIP), and 1716 hospitals for pneumonia (PNE). This study used simultaneous equations models to investigate the determinants of improvement in health outcomes and of cost reduction in hospital inpatient care for these six common diagnoses. In addition, the study used instrumental variables and two-stage least squares random effect model for unbalanced panel data estimation. The study concluded that a few factors were determinants of high quality and low cost. Specifically, high specialty was the determinant of high quality and low costs for CHF patients; small hospital size was the determinant of high quality and low costs for AMI patients. Furthermore, CHF patients who were treated in Midwest, South, and West region hospitals had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. Gastrointestinal hemorrhage and pneumonia patients who were treated in South region hospitals also had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. This study found that six non-cost factors were related to health outcomes for a few diagnoses: hospital volume, percentage emergency room admissions for a given diagnosis, hospital competition, specialty, bed size, and hospital region.^

A study to determine the association between medical decision-making and the performance of an institutional ethics committee

This study developed proxy measures to test the independent effects of medical specialty, institutional ethics committee (IEC) and the interaction between the two, upon a proxy for the dependent variable of the medical decision to withhold/withdraw care for the dying--the resuscitation index (R-index). Five clinical vignettes were constructed and validated to convey the realism and contextual factors implicit in the decision to withhold/withdraw care. A scale was developed to determine the range of contact by an IEC in terms of physician knowledge and use of IEC policy.^ This study was composed of a sample of 215 physicians in a teaching hospital in the Southwest where proxy measures were tested for two competing influences, medical specialty and IEC, which alternately oppose and support the decision to withhold/withdraw care for the dying. A sub-sample of surgeons supported the hypothesis that an IEC is influential in opposing the medical training imperative to prolong life.^ Those surgeons with a low IEC score were 326 percent more likely to continue care than were surgeons with a high IEC score when compared to all other specialties. IEC alone was also found to significantly predict the decision to withhold/withdraw care. Interaction of IEC with the specialty of surgery was found to be the best predictor for a decision to withhold/withdraw care for the dying. ^

Planning and implementation efficacy as a determinant of health risk communication outcomes: Case studies of the U.S. Public Health Service (PHS)

This study was conducted under the auspices of the Subcommittee on Risk Communication and Education of the Committee to Coordinate Environmental Health and Related Programs (CCEHRP) to determine how Public Health Service (PHS) agencies are communicating information about health risk, what factors contributed to effective communication efforts, and what specific principles, strategies, and practices best promote more effective health risk communication outcomes.^ Member agencies of the Subcommittee submitted examples of health risk communication activities or decisions they perceived to be effective and some examples of cases they thought had not been as effective as desired. Of the 10 case studies received, 7 were submitted as examples of effective health risk communication, and 3, as examples of less effective communication.^ Information contained in the 10 case studies describing the respective agencies' health risk communication strategies and practices was compared with EPA's Seven Cardinal Rules of Risk Communication, since similar rules were not found in any PHS agency. EPA's rules are: (1) Accept and involve the public as a legitimate partner. (2) Plan carefully and evaluate your efforts. (3) Listen to the public's specific concerns. (4) Be honest, frank, and open. (5) Coordinate and collaborate with other credible sources. (6) Meet the needs of the media. (7) Speak clearly and with compassion.^ On the basis of case studies analysis, the Subcommittee, in their attempts to design and implement effective health risk communication campaigns, identified a number of areas for improvement among the agencies. First, PHS agencies should consider developing a focus specific to health risk communication (i.e., office or specialty resource). Second, create a set of generally accepted practices and guidelines for effective implementation and evaluation of PHS health risk communication activities and products. Third, organize interagency initiatives aimed at increasing awareness and visibility of health risk communication issues and trends within and between PHS agencies.^ PHS agencies identified some specific implementation strategies the CCEHRP might consider pursuing to address the major recommendations. Implementation strategies common to PHS agencies emerged in the following five areas: (1) program development, (2) building partnerships, (3) developing training, (4) expanding information technologies, and (5) conducting research and evaluation. ^

MEDICAL CARE UTILIZATION IN TIME AMONG ELDERLY MEDICARE ENROLLEES IN AN HMO

Investigation into the medical care utilization of elderly Medicare enrollees in an HMO (Kaiser - Portland, Oregon): The specific research topics are: (1) The utilization of medical care by selected determinants such as: place of service, type of service, type of appointment, physician status, physician specialty and number of associated morbidities. (2) The attended prevalence of 3 chronic diseases: hypertension, diabetes and arthritis in addition to pneumonias as an example of acute diseases. The selection of these examples was based on their importance in morbidity/or mortality results among the elderly. The share of these diseases in outpatient and inpatient contacts was examined as an example of the relation between morbidity and medical care utilization. (3) The tendency of individual utilization patterns to persist in subsequent time periods. The concept of contagion or proneness was studied in a period of 2 years. Fitting the negative binomial and the Poisson distributions was applied to the utilization in the 2nd year conditional on that in the 1st year as regards outpatient and inpatient contacts.^ The present research is based on a longitudinal study of 20% random sample of elderly Medicare enrollees. The sample size is 1683 individuals during the period from August 1980-December 1982.^ The results of the research were: (1) The distribution of contacts by selected determinants did not reveal a consistent pattern between sexes and age groups. (2) The attended prevalence of hypertension and arthritis showed excess prevalence among females. For diabetes and pneumonias no female excess was noticed. Consistent increased prevalence with increasing age was not detected.^ There were important findings pertaining to the relatively big share of the combined 3 chronic diseases in utilization. They accounted for 20% of male outpatient contacts vs. 25% of female outpatients. For inpatient contacts, they consumed 20% in case of males vs. 24% in case of females. (3) Finding that the negative binomial distribution fit the utilization experience supported the research hypothesis concerning the concept of contagion in utilization. This important finding can be helpful in estimating liability functions needed for forecasting future utilization according to previous experience. Such information has its relevance to organization, administration and planning for medical care in general. (Abstract shortened with permission of author.) ^

THE MEASUREMENT OF HUMANISTIC AND DEHUMANISTIC BEHAVIORS IN HOSPITAL NURSING ENVIRONMENTS

The purpose of this investigation was to develop a reliable scale to measure the social environment of hospital nursing units according to the degree of humanistic and dehumanistic behaviors as perceived by nursing staff in hospitals. The study was based on a conceptual model proposed by Jan Howard, a sociologist. After reviewing the literature relevant to personalization of care, analyzing interviews with patients in various settings, and studying biological, psychological, and sociological frames of reference, Howard proposed the following necessary conditions for humanized health care. They were the dimensions of Irreplaceability, Holistic Selves, Freedom of Action, Status Equality, Shared Decision Making and Responsibility, Empathy, and Positive Affect.^ It was proposed that a scale composed of behaviors which reflected Howard's dimensions be developed within the framework of the social environment of nursing care units in hospitals. Nursing units were chosen because hospitals are traditionally organized around nursing care units and because patients spend the majority of their time in hospitals interacting with various levels of nursing personnel.^ Approximately 180 behaviors describing both patient and nursing staff behaviors which occur on nursing units were developed. Behaviors which were believed to be humanistic as well as dehumanistic were included. The items were classified under the dimensions of Howard's model by a purposively selected sample of 42 nurses representing a broad range of education, experience, and clinical areas. Those items with a high degree of agreement, at least 50%, were placed in the questionnaire. The questionnaire consisted of 169 items including six items from the Marlowe Crowne Social Desirability Scale (Short Form).^ The questionnaire, the Social Environment Scale, was distributed to the entire 7 to 3 shift nursing staff (603) of four hospitals including a public county specialty hospital, a public county general and acute hospital, a large university affiliated hospital with all services, and a small general community hospital. Staff were asked to report on a Likert type scale how often the listed behaviors occurred on their units. Three hundred and sixteen respondents (52% of the population) participated in the study.^ An item analysis was done in which each item was examined in relationship to its correlation to its own dimension total and to the totals of the other dimensions. As a result of this analysis, three dimensions, Positive Affect, Irreplaceability, and Freedom of Action were deleted from the scale. The final scale consisted of 70 items with 26 in Shared Decision Making and Responsibility, 25 in Holistic Selves, 12 in Status Equality, and seven in Empathy. The alpha coefficient was over .800 for all scales except Empathy which was .597.^ An analysis of variance by hospital was performed on the means of each dimension of the scale. There was a statistically significant difference between hospitals with a trend for the public hospitals to score lower on the scale than the university or community hospitals. That the scale scores should be lower in crowded, understaffed public hospitals was not unexpected and reflected that the scale had some discriminating ability. These differences were still observed after adjusting for the effect of Social Desirability.^ In summary, there is preliminary evidence based on this exploratory investigation that a reliable scale based on at least four dimensions from Howard's model could be developed to measure the concept of humanistic health care in hospital settings. ^

Gender disparities in utilization, unmet need and expenditure for mental health care

Objectives: To compare mental health care utilization regarding the source, types, and intensity of mental health services received, unmet need for services, and out of pocket cost among non-institutionalized psychologically distressed women and men. ^ Method: Cross-sectional data for 19,325 non-institutionalized mentally distressed adult respondents to the “The National Survey on Drug Use and Health” (NSDUH), for the years 2006 -2008, representing over twenty-nine millions U.S. adults was analyzed. To assess the relative odds for women compared to men, logistic regression analysis was used for source of service, for types of barriers, for unmet need and cost; zero inflated negative binomial regression for intensity of utilization; and ordinal logistic regression analysis for quantifying out-of-pocket expenditure. ^ Results: Overall, 43% of mentally distressed adults utilized a form of mental health treatment; representing 12.6 million U.S psychologically distressed adults. Females utilized more mental health care compared to males in the previous 12 months (OR: 1. 70; 95% CI: 1.54, 1.83). Similarly, females were 54% more likely to get help for psychological distress in an outpatient setting and females were associated with an increased probability of using medication for mental distress (OR: 1.72; 95% CI: 1.63, 1.98). Women were 1.25 times likelier to visit a mental health center (specialty care) than men. ^ Females were positively associated with unmet needs (OR: 1.50; 95% CI: 1.29, 1.75) after taking into account predisposing, enabling, and need (PEN) characteristics. Women with perceived unmet needs were 23% (OR: 0.77; 95% CI: 0.59, 0.99) less likely than men to report societal accommodation (stigma) as a barrier to mental health care. At any given cutoff point, women were 1.74 times likelier to be in the higher payment categories for inpatient out of pocket cost when other variables in the model are held constant. Conclusions: Women utilize more specialty mental healthcare, report more unmet need, and pay more inpatient out of pocket costs than men. These gender disparities exist even after controlling for predisposing, enabling, and need variables. Creating policies that not only provide mental health care access but also de-stigmatize mental illness will bring us one step closer to eliminating gender disparities in mental health care.^

Quality assessment in radiation oncology

Oncologic specialty societies and multidisciplinary collaborative groups have dedicated considerable effort to developing evidence-based quality indicators (QIs) to facilitate quality improvement, accreditation, benchmarking, reimbursement, maintenance of certification, and regulatory reporting. In particular, radiation oncology as a field has a long history of organized quality assessment efforts, and continues to work toward developing consensus quality standards in the face of continually evolving technologies and standards of care. The present report provides a comprehensive review of the current state of quality assessment in radiation oncology, with an emphasis on recent quality improvement efforts. Specifically, this report aims to highlight implications of the healthcare quality movement for radiation oncology and review existing efforts to define and measure quality in the field, with particular focus on dimensions of quality that are specific to radiation oncology within the "big picture" of oncologic quality improvement efforts.^

Relationships among epilepsy self-management, health outcomes, and socioeconomic status

The purpose of this study was to investigate the association between epilepsy self-management and disease control and socio-economic status. Study participants were adult patients at two epilepsy specialty clinics in Houston, Texas that serve demographically and socioeconomically diverse populations. Self-management behaviors- medication, information, safety, seizure, and lifestyle management were tested against emergency room visits, hospitalizations, and seizure occurrence. Overall self-management score was associated with a greater likelihood of hospitalizations over a prior twelve month time frame, but not for three months, and was not associated with seizure occurrence or emergency room visits, at all. Scores on specific self-management behaviors varied in their relationships to the different disease control indicators, over time. Contrary to expectations based on the findings of previous research, higher information management scores were associated with greater likelihood of emergency room visits and hospitalizations, over the study's twelve months. Higher lifestyle management scores were associated with lower likelihood of any emergency room visits, over the preceding twelve months and emergency room visits for the last three months. The positive associations between overall self-management scores and information management behaviors and disease control are contrary to published research. These findings may indicate that those with worse disease control in a prior period employ stronger self-management efforts to better control their epilepsy. Further research is needed to investigate this hypothesis.^

Attitudes and other barriers to the utilization of clinical research findings by American physicians: A systematic review

Background: The Institute of Medicine estimates that only a maximum of 25% of clinical research findings are incorporated into practice by physicians. To improve clinical practice, efforts have been made to promote evidence-based medicine and the use of clinical guidelines. Despite these efforts, the gap between research and clinical practice remains wide.^ Objective: To systematically review the literature describing the factors which influence the use of clinical research recommendations by American physicians.^ Hypothesis: Barriers exist in the application of clinical research into clinical practice, and are multifactorial. The establishment of the Clinical and Translational Awards (CTSA; special federal grants awarded to selected institutions to support clinical and translational research) has reduced the effect of these barriers and improved the process of clinical research translation into practice among American physicians.^ Aims: Identify barriers and facilitators of the use of research findings in clinical practice by American physicians. Contrast studies published six years before and after the creation of the CTSA.^ Methods: The sources of data include published literature from Medline, PubMed and PsycINFO. Selected studies must be qualitative, a survey of American clinicians, based on evidence-based medicine practice, clinical guidelines or treatment pathways. Systematic reviews and reports were excluded, as well as studies with less than 100 respondents.^ Results: In total, 1036 abstracts were reviewed; 115 full text potential articles were identified and reviewed, and a total of 31 studies met all criteria for inclusion in the final review.^ Conclusions: The barriers against the application of clinical research findings, in the forms of clinical guidelines, evidence-based medicine guides and clinical pathways, can be divided broadly into physician barriers, practice/system barriers and patient barriers. Physician barriers are the most common barriers, especially the lack of familiarity with guidelines and the lack of time. Of the factors which improve the use of research based guidelines, physician factors such as younger age, lower duration of clinical practice, specialty training, and practice in large group Health Maintenance Organization (HMO) settings with fewer patients seen were the most commonly cited.^

High Tunnel Production: Inputs, Labor, and Crop Productivity

The 30 × 12 × 96 ft (W × H × L, 2,880 ft 2 ) high tunnel was planted and maintained as part of a high tunnel production budget project funded by a Specialty Crop Grant through the Iowa Department of Agriculture and Land Stewardship. Six growers throughout the state participated in the project with the objectives of creating an enterprise budgeting tool that estimates the costs and revenues associated with producing specific crops in a high tunnel, either as a single crop or multi-crop system. The budgeting tool will estimate the production cost and net profit per square foot in a high tunnel from mono-culture (one crop per tunnel) or multi-cropping, successionplanted systems. This report summarizes the findings from the high tunnel at the ISU Horticulture Research Station. The plantings in this high tunnel were used to collect labor and yield data as well as demonstrate a continuous, multi-cropping production system. A publication containing the enterprise budgeting tool, using this data and data collected from the other six farms, will be available through Iowa State University Extension and Outreach in the fall of 2012.

Revista de Literaturas Modernas

La Revista de Literaturas Modernas (RLM) fue creada con el objetivo de reunir en una sola entrega anual una visión de conjunto del trabajo del entonces llamado Instituto de Lenguas y Literaturas Modernas de la Facultad de Filosofía y Letras (Universidad Nacional de Cuyo) y comenzó a aparecer anualmente desde 1956. En ella se priorizan las publicaciones circunscriptas a la especialidad de cada una de las secciones del Instituto que posteriormente se bifurcó en dos: Lingüística y Literaturas Modernas (área que sigue editando la RLM). Desde sus comienzos, esta publicación da a conocer los trabajos de los profesores de la Facultad, y también de colaboradores del exterior, cuyos aportes han sido y son acordes con la temática y jerarquía propuestas como objetivo. En sus artículos y notas, se apunta a relacionar la literatura con otras disciplinas para posibilitar un análisis dinámico de los textos, enmarcados en su contexto de producción cultural. Si bien la periodicidad se vio interrumpida en algunas ocasiones, actualmente existe el objetivo de publicar un número por año, con la meta siempre presente de su difusión internacional. Por último, cabe aclarar que las siglas que abrevian su título deben ser utilizadas en citas, notas a pie de página y referencias bibliográficas.

Gestión de efluentes y consumo de agua en bodega

Se estudió la gestión de efluentes y el consumo de agua en una bodega productora de vinos tintos ubicada en Maipú (Mendoza, Argentina) y se propusieron alternativas para mejorar la situación actual organizando y reduciendo el consumo de agua y disminuyendo el impacto ambiental que causan los efluentes. La empresa no mide con precisión el consumo de agua, estimándolo por las veces que se llena y vacía la pileta que recoge los efluentes. Con ese dato, y en función del volumen elaborado de vino, se infirió que el gasto de agua quintuplica aproximadamente al de un establecimiento similar en Francia. Tampoco son medidas la salinidad y la toxicidad de las aguas residuales. Los cambios propuestos se basaron en: • la medición de los flujos de aguas de lavado y efluentes; • la reducción del consumo de agua adaptando materiales y maquinarias; estableciendo protocolos de limpieza y sensibilizando e instruyendo al personal; • la separación de los efluentes tóxicos; • la separación eficiente de los residuos sólidos de los líquidos; • los tratamientos oxidativos en aguas efluentes; • la reutilización parcial de las aguas tratadas en usos no bromatológicos.