Health outcomes, quality improvement and cost-effectiveness of the Community Diabetes Education (CoDE) program: Results of a randomized controlled trial

The objectives of this dissertation were to evaluate health outcomes, quality improvement measures, and the long-term cost-effectiveness and impact on diabetes-related microvascular and macrovascular complications of a community health worker-led culturally tailored diabetes education and management intervention provided to uninsured Mexican Americans in an urban faith-based clinic. A prospective, randomized controlled repeated measures design was employed to compare the intervention effects between: (1) an intervention group (n=90) that participated in the Community Diabetes Education (CoDE) program along with usual medical care; and (2) a wait-listed comparison group (n=90) that received only usual medical care. Changes in hemoglobin A1c (HbA1c) and secondary outcomes (lipid status, blood pressure and body mass index) were assessed using linear mixed-models and an intention-to-treat approach. The CoDE group experienced greater reduction in HbA1c (-1.6%, p<.001) than the control group (-.9%, p<.001) over the 12 month study period. After adjusting for group-by-time interaction, antidiabetic medication use at baseline, changes made to the antidiabetic regime over the study period, duration of diabetes and baseline HbA1c, a statistically significant intervention effect on HbA1c (-.7%, p=.02) was observed for CoDE participants. Process and outcome quality measures were evaluated using multiple mixed-effects logistic regression models. Assessment of quality indicators revealed that the CoDE intervention group was significantly more likely to have received a dilated retinal examination than the control group, and 53% achieved a HbA1c below 7% compared with 38% of control group subjects. Long-term cost-effectiveness and impact on diabetes-related health outcomes were estimated through simulation modeling using the rigorously validated Archimedes Model. Over a 20 year time horizon, CoDE participants were forecasted to have less proliferative diabetic retinopathy, fewer foot ulcers, and reduced numbers of foot amputations than control group subjects who received usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life-year gained was estimated for CoDE intervention participants over the same time period. The results from the three areas of program evaluation: impact on short-term health outcomes, quantification of improvement in quality of diabetes care, and projection of long-term cost-effectiveness and impact on diabetes-related health outcomes provide evidence that a community health worker can be a valuable resource to reduce diabetes disparities for uninsured Mexican Americans. This evidence supports formal integration of community health workers as members of the diabetes care team.^

La historia clínica : marco legal

La historia clínica se considera un documento primordial en un sistema de salud, brindando información asistencial, preventiva y social, ya que constituye el registro completo de la atención prestada al paciente, de lo que se deriva su trascendencia como documento legal.

Minors’ Access to Contraceptive Services

Over the past 30 years, states have expanded minors’ authority to consent to health care, including care related to sexual activity. This trend reflects U.S. Supreme Court rulings extending the constitutional right to privacy to a minor’s decision to obtain contraceptives and concluding that rights do not “come into being magically only when one attains the state-defined age of majority.” It also reflects the recognition that while parental involvement is desirable, many minors will remain sexually active but not seek services if they have to tell their parents. As a result, confidentiality is vital to ensuring minors’ access to contraceptive services. Even when a state has no relevant policy or case law, physicians may commonly provide medical care to a mature minor without parental consent, particularly if the state allows a minor to consent to related health services.

Problemas de salud de los jornaleros tamaulipecos empleados con visas h-2a en Estados Unidos

Desde hace dos décadas los jornaleros tamaulipecos han recibido un considerable número de visas H-2A para trabajar en la agricultura en Estados Unidos. Los empleadores estadounidenses muestran una cierta preferencia por los jornaleros tamaulipecos, ya que la cercanía de Tamaulipas a la frontera disminuye los costos de transporte, que deben ser asumidos por los empleadores. Los programas de trabajadores huéspedes para mano de obra no cualificada exponen a los trabajadores foráneos al abuso y la explotación. La falta de cumplimiento con algunas regulaciones federales como el Estándar de Protección de los Trabajadores o el Seguro de Compensación Laboral incrementa el riesgo de envenenamiento por agroquímicos y accidentes entre los jornaleros, y aquellos que sufren accidentes laborales o enfermedades no reciben atención médica. Este artículo examina los problemas de salud sufridos por los trabajadores tamaulipecos empleados con visas H-2A en la agricultura estadounidense.

Problemas de salud de los jornaleros tamaulipecos empleados con visas h-2a en Estados Unidos

Desde hace dos décadas los jornaleros tamaulipecos han recibido un considerable número de visas H-2A para trabajar en la agricultura en Estados Unidos. Los empleadores estadounidenses muestran una cierta preferencia por los jornaleros tamaulipecos, ya que la cercanía de Tamaulipas a la frontera disminuye los costos de transporte, que deben ser asumidos por los empleadores. Los programas de trabajadores huéspedes para mano de obra no cualificada exponen a los trabajadores foráneos al abuso y la explotación. La falta de cumplimiento con algunas regulaciones federales como el Estándar de Protección de los Trabajadores o el Seguro de Compensación Laboral incrementa el riesgo de envenenamiento por agroquímicos y accidentes entre los jornaleros, y aquellos que sufren accidentes laborales o enfermedades no reciben atención médica. Este artículo examina los problemas de salud sufridos por los trabajadores tamaulipecos empleados con visas H-2A en la agricultura estadounidense.

Problemas de salud de los jornaleros tamaulipecos empleados con visas h-2a en Estados Unidos

Desde hace dos décadas los jornaleros tamaulipecos han recibido un considerable número de visas H-2A para trabajar en la agricultura en Estados Unidos. Los empleadores estadounidenses muestran una cierta preferencia por los jornaleros tamaulipecos, ya que la cercanía de Tamaulipas a la frontera disminuye los costos de transporte, que deben ser asumidos por los empleadores. Los programas de trabajadores huéspedes para mano de obra no cualificada exponen a los trabajadores foráneos al abuso y la explotación. La falta de cumplimiento con algunas regulaciones federales como el Estándar de Protección de los Trabajadores o el Seguro de Compensación Laboral incrementa el riesgo de envenenamiento por agroquímicos y accidentes entre los jornaleros, y aquellos que sufren accidentes laborales o enfermedades no reciben atención médica. Este artículo examina los problemas de salud sufridos por los trabajadores tamaulipecos empleados con visas H-2A en la agricultura estadounidense.

Who Develops Innovations in Medicine for the Poor? Trends in Patent Applications Related to Medicines for HIV/AIDS, Tuberculosis, Malaria and Neglected Diseases

Who invents medicines for the poor of the world? This question becomes very important where the WTO allows low income countries to be unbound by the TRIPS agreement. This agreement concerns medicines for infectious diseases such as HIV/AIDS, tuberculosis and malaria. These diseases cause serious damage to low income countries. Under these circumstances, some scholars wonder if anyone will continue innovative activities related to treating these diseases. This paper sought to answer this question by collecting and analyzing patent data of medicines and vaccines for diseases using the database of the Japan Patent Office. Results indicate that private firms have led in innovation not only for global diseases such as HIV/AIDS but also diseases such as malaria that are spreading exclusively in low income countries. Innovation for the three infectious diseases is diverse among firms, and frequent patent applications by high-performing pharmaceutical firms appear prominent even after R&D expenditure, economies of scale, and economies of scope are taken into account.

Cognitive strategies for security in wireless sensor networks

Las redes de sensores inalámbricas son uno de los sectores con más crecimiento dentro de las redes inalámbricas. La rápida adopción de estas redes como solución para muchas nuevas aplicaciones ha llevado a un creciente tráfico en el espectro radioeléctrico. Debido a que las redes inalámbricas de sensores operan en las bandas libres Industrial, Scientific and Medical (ISM) se ha producido una saturación del espectro que en pocos años no permitirá un buen funcionamiento. Con el objetivo de solucionar este tipo de problemas ha aparecido el paradigma de Radio Cognitiva (CR). La introducción de las capacidades cognitivas en las redes inalámbricas de sensores permite utilizar estas redes para aplicaciones con unos requisitos más estrictos respecto a fiabilidad, cobertura o calidad de servicio. Estas redes que aúnan todas estas características son llamadas redes de sensores inalámbricas cognitivas (CWSNs). La mejora en prestaciones de las CWSNs permite su utilización en aplicaciones críticas donde antes no podían ser utilizadas como monitorización de estructuras, de servicios médicos, en entornos militares o de vigilancia. Sin embargo, estas aplicaciones también requieren de otras características que la radio cognitiva no nos ofrece directamente como, por ejemplo, la seguridad. La seguridad en CWSNs es un aspecto poco desarrollado al ser una característica no esencial para su funcionamiento, como pueden serlo el sensado del espectro o la colaboración. Sin embargo, su estudio y mejora es esencial de cara al crecimiento de las CWSNs. Por tanto, esta tesis tiene como objetivo implementar contramedidas usando las nuevas capacidades cognitivas, especialmente en la capa física, teniendo en cuenta las limitaciones con las que cuentan las WSNs. En el ciclo de trabajo de esta tesis se han desarrollado dos estrategias de seguridad contra ataques de especial importancia en redes cognitivas: el ataque de simulación de usuario primario (PUE) y el ataque contra la privacidad eavesdropping. Para mitigar el ataque PUE se ha desarrollado una contramedida basada en la detección de anomalías. Se han implementado dos algoritmos diferentes para detectar este ataque: el algoritmo de Cumulative Sum y el algoritmo de Data Clustering. Una vez comprobado su validez se han comparado entre sí y se han investigado los efectos que pueden afectar al funcionamiento de los mismos. Para combatir el ataque de eavesdropping se ha desarrollado una contramedida basada en la inyección de ruido artificial de manera que el atacante no distinga las señales con información del ruido sin verse afectada la comunicación que nos interesa. También se ha estudiado el impacto que tiene esta contramedida en los recursos de la red. Como resultado paralelo se ha desarrollado un marco de pruebas para CWSNs que consta de un simulador y de una red de nodos cognitivos reales. Estas herramientas han sido esenciales para la implementación y extracción de resultados de la tesis. ABSTRACT Wireless Sensor Networks (WSNs) are one of the fastest growing sectors in wireless networks. The fast introduction of these networks as a solution in many new applications has increased the traffic in the radio spectrum. Due to the operation of WSNs in the free industrial, scientific, and medical (ISM) bands, saturation has ocurred in these frequencies that will make the same operation methods impossible in the future. Cognitive radio (CR) has appeared as a solution for this problem. The networks that join all the mentioned features together are called cognitive wireless sensor networks (CWSNs). The adoption of cognitive features in WSNs allows the use of these networks in applications with higher reliability, coverage, or quality of service requirements. The improvement of the performance of CWSNs allows their use in critical applications where they could not be used before such as structural monitoring, medical care, military scenarios, or security monitoring systems. Nevertheless, these applications also need other features that cognitive radio does not add directly, such as security. The security in CWSNs has not yet been explored fully because it is not necessary field for the main performance of these networks. Instead, other fields like spectrum sensing or collaboration have been explored deeply. However, the study of security in CWSNs is essential for their growth. Therefore, the main objective of this thesis is to study the impact of some cognitive radio attacks in CWSNs and to implement countermeasures using new cognitive capabilities, especially in the physical layer and considering the limitations of WSNs. Inside the work cycle of this thesis, security strategies against two important kinds of attacks in cognitive networks have been developed. These attacks are the primary user emulator (PUE) attack and the eavesdropping attack. A countermeasure against the PUE attack based on anomaly detection has been developed. Two different algorithms have been implemented: the cumulative sum algorithm and the data clustering algorithm. After the verification of these solutions, they have been compared and the side effects that can disturb their performance have been analyzed. The developed approach against the eavesdropping attack is based on the generation of artificial noise to conceal information messages. The impact of this countermeasure on network resources has also been studied. As a parallel result, a new framework for CWSNs has been developed. This includes a simulator and a real network with cognitive nodes. This framework has been crucial for the implementation and extraction of the results presented in this thesis.

Esquemas cognitivos, sintomas de ansiedade e depressão em mulheres de um Programa de Cessação de Tabagismo

O tabagismo é um problema de saúde pública em todo o mundo. Entre as mulheres, devido ao aumento da prevalência comparada aos homens, o tabagismo feminino tem merecido atenção. Para o enfrentamento, é necessário entender o fenômeno e criar estratégias mais adequadas que incluam aspectos emocionais e sociais da dependência do tabagismo. Este estudo buscou descrever os esquemas cognitivos, sintomas de ansiedade e depressão de 112 mulheres que procuraram tratamento para cessação do tabagismo e sua relação com o insucesso do tratamento. A coleta de dados incluiu roteiro de entrevista estruturada e escalas validadas para a população brasileira que têm o objetivo de avaliar os esquemas cognitivos, sintomas de ansiedade e de depressão, e aspectos da dependência do cigarro. O conhecimento de fatores emocionais envolvidos no tabagismo e sua cessação podem ser úteis às ações de apoio à mudança comportamental do fumante. Objetivo: Descrever o perfil psicológico de mulheres que buscam cessação do tabagismo quanto aos esquemas cognitivos, sintomas de ansiedade e depressão antes e depois do tratamento com Terapia Cognitivo- Comportamental em grupo, e analisar fatores que contribuem para o desfecho de cessação. O desenho do estudo foi longitudinal e transversal. Para avaliar os esquemas cognitivos, o Questionário de Esquemas de Young em sua forma curta foi utilizado. Os grupos de terapia cognitivo-comportamental foram realizados concomitantes ao cuidado usual por médicos do estudo. Esses profissionais foram treinados no protocolo do estudo e o seguimento foi realizado por telefone por um membro do estudo independente e cego. Resultados: Os resultados forneceram evidências de que esquemas cognitivos tiveram relação significativa com os sintomas de depressão e ansiedade, com a adesão e os resultados do tratamento (cessação do tabagismo)

Psychosocial Distress Screening in a Community Cancer Center: An Exploratory Study of Distress Screening Across the Cancer Treatment Continuum

Purpose: The primary goal of this exploratory study is to demonstrate that distress screening across the course of cancer treatment is possible and provides valuable information about patient needs over time. Distress screening is aligned with guidelines from national accrediting organizations and may lead to improved health-related quality of life, satisfaction with medical care, and possibly survival.Methods: Medical, surgical, and radiation oncology patients completed a screening instrument before their appointments during a six-month period. Patients indicated their level of distress on four domains (practical, emotional, health and social concerns). De-identified data was collected, aggregated and descriptive statistics were analyzed.Results: Approximately 3000 screens were collected and 1500 cancer patients were screened. Of patients who indicated distress, 54% demonstrated a distress level of five or greater. Distress level eight was the most frequent level of distress indicated. The Cancer Dietitian was the most commonly requested healthcare team provider. The Health Concern domain was most frequently endorsed.Conclusion: NCCN, IOM and COC guidelines recommend distress screening in all cancer treatment centers, however implementation has proven difficult. This study adds to the literature about distress in cancer patients, demonstrates the feasibility of repeated distress screening and provides a model program demonstrating the implementation of repeated distress screening at a community cancer center. Findings highlight the importance of supportive oncology services due to the prevalence of high levels of distress. Findings demonstrate the importance of the Cancer Dietitian in supportive cancer care. Additionally, the research reveals a potential perceived stigma in seeking psychosocial oncology services.

Psychological Perspectives on the Civil Liberties of Transgendered Inmates in a Prison Setting

As society becomes increasingly less binary, and moves towards a more spectrum based approach to mental illness, medical illness, and personality, it becomes necessary to address this shift within formerly rigid institutions. This paper explores this shift as it is occurring within correctional settings around the United States concerning the medical care, housing, and safety of transgendered inmates. As there is no legal standard for the housing or access to gender-affirming medical care (i.e., hormone therapy, sexual reassignment surgery), these issues are addressed on an institutional level, with very little consistency throughout the country. Currently, most institutions follow a genitalia-based system of classification. Within the system, core beliefs are held, some adaptive and some no longer adaptive, that drive the system's behavior and outcomes. With regard to transgendered inmates, several underlying beliefs within the system serve to maintain the status quo; however, the most basic underpinning is the system's reliance on a binary gender system. As views of humane treatment of the incarcerated expand and modernize, the role of mental health within corrections has also expanded. Psychologists, social workers, counselors, and psychiatrists are found in almost all correctional facilities, and have become a voice of advocacy for an often underserved population.

Perceived sexism as a health determinant in Spain

OBJECTIVES: The goals of the present study are to explore the association between perceived sexism and self-perceived health, health-related behaviors, and unmet medical care needs among women in Spain; to analyze whether higher levels of discrimination are associated with higher prevalence of poor health indicators and to examine whether these relationships are modified by country of origin and social class. MATERIALS AND METHODS: The study is based on a cross-sectional design using data from the 2006 Spanish Health Interview Survey. We included women aged 20-64 years (n = 10,927). Six dependent variables were examined: four of health (self-perceived health, mental health, hypertension, and having had an injury during the previous year), one health behavior (smoking), and another related to the use of the health services (unmet need for medical care). Perceived sexism was the main independent variable. Social class and country of origin were considered as effect modifiers. We obtained the prevalence of perceived sexism. Logistic regression models, adjusted for potential confounders, were fitted to study the association between sexism and poor health outcomes. Results: The prevalence of perceived sexism was 3.4%. Perceived sexism showed positive and consistent associations with four poor health outcomes (poor self-perceived health, poor mental health, injuries in the last 12 months, and smoking). The strength of these associations increased with increased scores for perceived sexism, and the patterns were found to be modified by country of origin and social class. CONCLUSION: This study shows a consistent association between perceived sexism and poor health outcomes in a country of southern Europe with a strong patriarchal tradition.