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Objective. We aim to test the hypothesis that college students provide Democratic candidates with greater electoral support and whether this varies among federal, state, and local elections.We also test whether college students mobilized by presidential campaigns are more likely to abstain from voting for state and local elections. Methods. To examine these questions, we employedOLS and difference-of-means tests to analyze the distribution of votes cast in competitive elections for the November 2008 elections in 86 precincts located on 42 college campuses across five states as compared to the distribution of votes cast in noncollege precincts. College precincts were identified by representatives from each community's local Board of Elections. Results. In line with conventional wisdom, the results of the analyses indicate Democratic candidates for federal offices do consistently receive greater electoral support from precincts located on college campuses as compared to noncollege precincts. However, the analyses of state and local elections highlight substantial variation in the level of support that Democratic candidates receive from precincts located on college campuses. Moreover, we found many college students in 2008 cast their ballots for Obama, but chose not to participate in lower-level elections. Conclusion. Republican fears regarding college students turning small towns on their heads via the ballot box are not supported by our analyses.On average, students vote more democratically than nonstudents but they are also more likely to simply choose not to vote for local candidates. By and large, they come to the polls to vote for national offices, not local ones. [ABSTRACT FROM AUTHOR]

The article evaluates evidence for the clinical effectiveness of non-nucleoside reverse transcriptase inhibitors (NNRTI) in the treatment of HIV infections. NNRTI is a potent class of drugs which act by inhibiting HIV-1 reverse transcriptase. The properties and toxicity of NNRTI used in Great Britain, Canada and the U.S. are discussed.

This study aimed to examine the association between body mass index (BMI; weight [kilogram]/height2 [meter]) and type 2 diabetes mellitus (T2DM) among the largest three largest racial/ethnic groups in the United States. We compiled 10 waves of the continuous National Health and Nutrition Examination Survey from 1999–2000 through 2017–2018. Participants (N = 45,514) were those who had data on BMI, HbA 1c , and demographics. We estimated associations between BMI and prediabetes/T2DM odds for Black, Latine, and White participants. BMI was associated with 10% higher odds of prediabetes/T2DM vs. having normal HbA 1c levels (odds ratio = 1.10, 95% confidence interval = 1.10–1.11) for Latine and White individuals. However, the association between BMI and prediabetes/T2DM was significantly weaker among Black individuals. When focusing on T2DM prevalence, the association with BMI for Black participants was even weaker (odds ratio = 0.97, 95% confidence interval = 0.95–0.98). The unstable associations between BMI and T2DM across race indicate that BMI has received unwarranted focus as a prime predictor of T2DM. Relying on BMI introduces bias in T2DM risk estimations especially in Black individuals. Focusing on BMI places the onus on individuals to change and increases weight stigma, which can worsen health outcomes. Instead, policymakers should focus on social determinants of T2DM and its concomitant racial/ethnic disparities. [ABSTRACT FROM AUTHOR]

The black community contends daily with the phenomena of suicide and homicide. However, it is the killing of black males that constitutes the heaviest burden for the group. Black suicide rates, on the other hand, continue to be lower than white suicide rates. Nevertheless, it is the black male group between the ages of 25 and 34 years that bears the brunt of both suicide and homicide. This article reviews the major theories advanced to explain the existence of these serious public health problems in the black community, suggests ways of attacking these problems, and also delineates significant areas for future research. [ABSTRACT FROM AUTHOR]

The article presents a report on a man who was infected with rabies on November 24, 2008 in Missouri. Upon suspicion of the Missouri State Public Health Laboratory of a possible rabies infection, the Centers for Disease Control and Prevention (CDC) was notified of the situation. It was found that the man was infected with a rabies virus variant associated with silver-haired bats. In spite of treatment using the Milwaukee protocol, the man died on November 30, 2009.

Context: Historical comparisons indicate that US hospitals are more expensive than Canadian hospitals, but health care system reform might have changed the relative costs and timeliness of health care in the 2 countries.Objective: To estimate the price and convenience of selected hospital services in the United States and Canada for patients in 1997 had they paid out-of-pocket.Design: Cross-sectional telephone survey conducted May 1996 to April 1997.Participants: The 2 largest acute care general hospitals from every city in the United States and Canada with a population greater than 500000.Measures: Each hospital was telephoned and asked their price and waiting time for 7 services: magnetic resonance imaging of the head without gadolinium; a screening mammogram; a 12-lead electrocardiogram; a prothrombin time measurement; a session of hemodialysis; a screening colonoscopy; and a total knee replacement. Waiting times were measured in days until earliest appointment and charges were converted to American currency.Results: Overall, 48 US and 18 Canadian hospitals were surveyed. Median waiting times were significantly shorter in American hospitals for 4 services, particularly a magnetic resonance imaging of the head (3 days vs 150 days; P<.001). Median charges were significantly higher in American hospitals for 6 services, particularly for a total knee replacement ($26805 vs $10651; P<.001). Individual services showed no association between shorter waiting times and higher prices within each country, with the exception of a total knee replacement in the United States.Conclusion: US hospitals still provide higher prices and faster care than Canadian hospitals for patients who pay out-of-pocket. [ABSTRACT FROM AUTHOR]

A measurement study was conducted in 2023 to derive operator-specific emission factors for natural gas driven pneumatic devices at onshore production facilities in the United States. A total of 369 intermittent bleed and 26 continuous low-bleed pneumatic devices were measured using a high-volume sampler. Considering all intermittent bleed devices, the emission factor from this study was statistically lower than the factor in the revised Greenhouse Gas Reporting Rule (GHGRP) issued May 6, 2024. Intermittent devices were classified by inspection with an optical gas imaging camera as functioning or malfunctioning. Measurements of functioning intermittent bleed devices were statistically higher while measurements of malfunctioning intermittent bleed devices were statistically lower than the corresponding emission factor in the final revisions to the GHGRP. Measurements of continuous low-bleed pneumatic devices were statistically lower than the updated factor in the final revisions to GHGRP. Additionally, a Monte Carlo analysis was conducted to investigate the potential impact of measurement duration and sample size on emission factors derived for intermittent bleed devices. We conclude that while a short measurement duration may miss actuations of properly operating devices with low vent frequencies, potentially resulting in an emission factor with low bias, the sample size of greater than 300 measurements each greater than 3 min in duration, as included in this study, is unlikely to be biased low in a statistically significant manner, particularly when one considers the material contribution of malfunctioning devices.

Relatively little is known about the association between school discipline and student health and well-being. Using CDC's 2023 Youth Risk Behavior Survey, CDC analyzed the prevalence of report of unfair discipline at school and associations with experiences at school, mental health, suicidal thoughts and behaviors, and health risk behaviors among high school students overall and stratified by race and ethnicity. Prevalence estimates, prevalence differences, and prevalence ratios adjusted for race (in overall models), grade, and sex were calculated. Overall, 19.3% of students reported receiving unfair discipline during the previous 12 months; Black or African American students had a higher prevalence (23.1%) compared with Hispanic or Latino students (18.4%) and White students (18.1%). Unfair discipline was reported among a majority of students who describe their sexual identity in some other way (besides gay, heterosexual, lesbian, bisexual, or questioning) for American Indian or Alaska Native (81.7%) and multiracial (57.1%) subgroups. Overall, report of unfair discipline was associated with every health risk behavior and experience examined, including being bullied at school or electronically, skipping school due to feeling unsafe, carrying a weapon at school, prescription opioid misuse, poor mental health, persistent feelings of sadness or hopelessness, seriously considered attempting suicide, and attempted suicide. This pattern of association was similar among most student groups in models stratified by race and ethnicity. This analysis is the first to demonstrate, among a nationally representative sample of high school students, that reports of unfair discipline are associated with various health risk behaviors and experiences. With these findings, public health and education practitioners can create interventions that equitably promote safe, supportive, and inclusive school environments for student health., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Jonetta J. Mpofu reported being a board member of the American School Health Association. No other potential conflicts of interest were disclosed.

Background: The transition to menopause is a significant event affecting health, well-being, and quality of life. Menopause typically occurs between the ages of 44-57, accompanied by symptoms such as hot flashes, mood changes, and sleep disturbances. Being postmenopausal also increases the risk of cardiovascular disease, stroke, and osteoporosis. Despite its importance, menopause is under-researched and under-discussed, particularly concerning the impact of chronic psychosocial stress., Methods: A scoping review of qualitative, quantitative, and mixed methods research was conducted to map existing literature on the transition to menopause among populations experiencing chronic psychosocial stress in the United States. The review followed the PRISMA-ScR methodology, systematically searching literature in PubMed and SCOPUS databases using MeSH terms. Studies were included which focused on menopausal symptoms and psychosocial stressors. Data extraction and charting were performed using Covidence software., Results: Fifteen studies were included, highlighting relationships between socioeconomic status, intimate partner violence, childhood abuse, and racial disparities which influenced menopausal experiences. Lower- income, higher perceived stress, and negative attitudes towards menopause were associated with increased psychological and somatic symptoms and early onset of menopause (prior to age 45). African American women were found to experience earlier onset and more severe vasomotor symptoms compared to their White counterparts. Women veterans used hormone therapy more frequently than the general population, particularly those with mood or anxiety disorders. The review also identified a geographic bias, with most studies conducted in the Northeast, Midwest, and Western regions of the United States., Conclusions: This review underscores the necessity of considering social, cultural, and environmental factors in understanding menopausal experiences and addressing health disparities. Future research should aim to include diverse populations and adopt longitudinal and qualitative study designs to capture the dynamic nature of menopausal experiences. Policies and interventions directed at improving the well-being of women experiencing menopause in the context of chronic psychosocial stress are warranted., Trial Registration: N/A., (© 2024. The Author(s).)

A shift in focus towards healthy reproductive outcomes may reveal opportunities for novel interventions and strategies to promote optimal health. Using variables from the National Center for Health Statistics restricted use natality files, we calculated Empirical Bayes smoothed (EBS) rates of optimal birth for the all live births-both overall and by maternal race/ethnicity-by applying the smoothing tool in GeoDa version 1.18.0.10 We defined counties achieving greater racial birth equity as those where the overall EBS optimal birth rate was greater than the national 75th percentile and the absolute difference between maternal racial/ethnic categories was smaller than the national 25th percentile difference. During the study period, 49.80% of overall births could be classified as an optimal birth according to the study definition. Of the 3140 US counties, only 282 (8.98%) appeared to advance White-Black equity in optimal births, and 205 (6.53%) appeared to advance White-Hispanic equity in optimal births. In the effort improve maternal health, we should focus not only on the absence of negative outcomes, but also the occurrence of positive outcomes. Our analytic results suggest that optimal births can be measured and that geographic inequities by race occur., (© 2022. The Author(s).)

Introduction: Surveillance of SARS-CoV-2 among university employees is an important part of mitigation strategies to prevent asymptomatic transmission and ensure a safe learning and work environment. Here, we assess the feasibility and performance of a program that relies on monitored self-collected nasal swabs to detect SARS-CoV-2 among asymptomatic faculty and staff., Methods: We recruited 1,030 faculty and staff via rolling enrollment who completed the required University of Wisconsin-Madison employee COVID-19 training and reported working on campus. Asymptomatic participants visited a designated location during a specified timeframe each week where they self-collected nasal swabs supervised by study staff. Specimens were stored in a cooler between 2 °C and 8 °C, then transported to the Wisconsin Veterinary Diagnostic Laboratory for polymerase chain reaction testing. Symptomatic participants or participants with a known exposure were advised to test elsewhere and follow quarantine guidelines from the Centers for Disease Control and Prevention., Results: Over the course of 31 weeks, 1,030 participants self-collected 17,323 monitored nasal swabs resulting in high participation (90%). SARS-CoV-2 was detected in 16 specimens. Eight specimens were inconclusive but were treated as positive results because of the implied detection of 1 or more SARS-CoV-2 genes. There were no invalid tests. Weekly SARS-CoV-2 incidence among participants ranged from 0 to 1.54% (x̄ = 0.20%). The SARS-CoV-2 incidence among participants was similar to estimated incidence in the greater university employee population., Conclusion: Weekly SARS-CoV-2 surveillance of asymptomatic faculty and staff on campus allowed for estimation of weekly SARS-CoV-2 incidence among on-campus employees. This surveillance protocol presents a low-cost, effective, and scalable option to identify asymptomatic cases of SARS-CoV-2 among university employees., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Background: Female surgeons, representing 6.5% of the American Academy of Orthopaedic Surgeons, are particularly vulnerable to work-family conflict. This conflict may deter women from considering orthopaedic surgery as a specialty. The study objective was to identify differences in work-family integration between female and male orthopaedic surgeons in the United States., Methods: An anonymous survey collecting data within the domains of work, family, and satisfaction was completed by 347 orthopaedic surgeons (153 female, 194 male). Differences in responses between males and females were identified., Results: Female surgeons were younger than males (mean, 41.1 versus 50.1 years; p < 0.001) and earlier in their careers, with 60.3% of males in practice >10 years compared with 26.1% of females (p < 0.001). Consulting (7.8% versus 31.4%; p < 0.001), course faculty positions (19.0% versus 39.2%; p < 0.001), and academic and leadership titles (30.7% versus 47.4%; p = 0.002) were significantly less common among females. There was a significant income disparity between females (mean yearly income, $300,000 to $400,000) and males (mean, $400,000 to $500,000; p < 0.001). Females were more likely to have never married (12.4% versus 2.6%; p < 0.001), or they married at a later mean age (30.2 ± 4.7 versus 28.3 ± 3.9 years; p < 0.001). Females were more likely to have no children (29.4% versus 7.8%; p < 0.001), require fertility treatment (32.0% versus 11.9%; p < 0.001), and not have children until after completing their medical training (63.0% versus 31.1%; p < 0.001). Female surgeons reported more responsibility in parenting (p < 0.001) and household duties (p < 0.001) than males. Work-family balance satisfaction was 72.3% in females and 82.1% in males (p = 0.081)., Conclusions: This study highlights deficiencies in work-family integration that appear to uniquely impact female orthopaedic surgeons. Female surgeons delay starting a family, more frequently require fertility treatments, carry more responsibility at home, have fewer academic and leadership roles, earn lower incomes, and are less satisfied with work-family balance relative to males. The discrepancy in work-family integration must be addressed to attract, support, and retain women as successful orthopaedic surgeons., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G812)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Electronic cigarettes (E-cigarettes) have become increasingly popular around the world. Currently, dental professionals' knowledge and attitudes are varied with many clinicians unclear regarding the impact of E-cigarette products on the oral and general health of their patients. With developing social and health-related challenges, advice of dental and medical associations and other regulatory bodies on E-cigarette use is changing. Growing evidence demonstrating the risks of E-cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E-cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non-smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E-cigarette use, the latest position of dental associations and the oral health implications of E-cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E-cigarette use., (© 2021 Australian Dental Association.)

Introduction: In the United States, most women presenting in spontaneous labor undergo intravenous (IV) cannulation on admission to hospital labor and birth units. There is limited evidence for this routine practice in pregnant women at low risk for adverse outcomes during labor or birth., Methods: A retrospective, exploratory, descriptive study of an indication-only practice of IV cannulation on admission for women presenting in spontaneous labor and cared for by a nurse-midwife service was performed. Descriptive data included the timing of IV cannula placement (admission, during labor or postpartum period, or not at all) and indications for placement. Maternal outcomes of interest were estimated blood loss, postpartum hemorrhage rates, and management; neonatal outcome was 5-minute Apgar scores., Results: Records for 1069 women cared for by nurse-midwives who presented in spontaneous labor were reviewed. In this cohort, 445 (41.6%) had IV access established on admission, 325 (30.4%) had an IV cannula placed during labor or postpartum, and 299 (28%) never had IV access during their hospital stay. For the 325 women with IV cannulas placed after admission, 25 (7.7%) were placed urgently for excessive postpartum bleeding. Further analysis of the subset of women who had a postpartum hemorrhage after vaginal birth (defined as >500 mL estimated blood loss) indicated that urgent IV cannulation was not associated with a lower mean postpartum hemoglobin or hematocrit or an increase in blood transfusion rate when compared with women who had an IV cannula placed earlier in their labor course., Discussion: Indication-only IV cannulation for women experiencing an uncomplicated labor and birth is a reasonable practice in settings where IV access can be established urgently if needed., (© 2019 by the American College of Nurse-Midwives.)

Introduction : Systemic corticosteroids (SCS) are effective anti-inflammatory therapies for patients with severe or persistent asthma. Use of SCS reduces blood eosinophil counts; the magnitude and duration of reduction in real-world settings needs further investigation. Objective : To examine the SCS effect on blood eosinophil counts over time among patients with asthma in a real-world setting. Methods : This retrospective study used Reliant Medical Group (Worcester, MA) electronic medical records between January 2011 and December 2015. Patients aged ≥12 years with ≥1 SCS prescription (first: index date), ≥1 asthma diagnosis, and ≥1 eosinophil count in each 12-month pre- and post-index periods were included for the study. Endpoints included SCS treatment patterns, time to SCS discontinuation, and changes in index blood eosinophil counts (≥150, ≥300, and ≥400 cells/µL) with SCS initiation and discontinuation. Results : At index visit, 642 of 1198 included patients had a blood eosinophil count ≥150 cells/µL. After an average initial SCS prescription of 35 mg/day, mean (% change) eosinophil counts at month 1 in the ≥150, ≥300, and≥400 cells/µL subgroups decreased from index by 112 (-30%), 202 (-34%), and 290 (-36%) cells/µL, respectively. Of the patients with an eosinophil count ≥150 cells/µL at index, who discontinued SCS within 7, 14, or 21 days after the index date, 21%, 26%, and 25% had an eosinophil count <150 cells/µL 1-month post-index, respectively. Conclusion : Blood eosinophil counts decreased following initiation of SCS therapy and had not returned to index levels several weeks after SCS discontinuation. The time frame of SCS discontinuation is an important consideration when identifying patients with eosinophilic asthma.

Significant racial disparities in physical activity-a key protective health factor against obesity and cardiovascular disease-exist in the United States. Using data from the 1999-2004 National Health and Nutrition Examination Survey and the 2000 United States (US) Census, we estimated the impact of race, individual-level poverty, neighborhood-level poverty, and neighborhood racial composition on the odds of being physically active for 19,678 adults. Compared to whites, blacks had lower odds of being physically active. Individual poverty and neighborhood poverty were associated with decreased odds of being physically active among both whites and blacks. These findings underscore the importance of social context in understanding racial disparities in physical activity and suggest the need for future research to determine specific elements of the social context that drive disparities.

The multiple sclerosis (MS) treatment landscape in the United States has changed dramatically over the past decade. While many disease-modifying therapies (DMTs) have been approved by the US Food and Drug Administration (FDA) for the treatment of relapsing forms of MS, DMT costs continue to rise. The availability of generics and biosimilars in the MS-treatment landscape is unlikely to have a major impact on clinical benefit. However, their availability will provide alternative treatment options and potentially lower costs through competition, thus increasing the affordability of and access to these drugs. In April 2015, the first generic version of the complex drug glatiramer acetate (Glatopa® 20 mg/mL) injection was approved in the United States as a fully substitutable generic for all approved indications of the 20 mg/mL branded glatiramer acetate (Copaxone®) dosage form. Despite glatiramer acetate's complex nature-being a chemically synthesized (ie, nonbiologic) mixture of peptides-the approval occurred without conducting any clinical trials. Rather, extensive structural and functional characterization was performed to demonstrate therapeutic equivalence to the innovator drug. The approval of Glatopa signifies an important milestone in the US MS-treatment landscape, with the hope that the introduction of generic DMTs and eventually biosimilar DMTs will lead to future improvements in the affordability and access of these much-needed treatments for MS.

Racial/ethnic disparities exist in obesity prevalence among men, with Hispanic men exhibiting the highest prevalence compared with non-Hispanic White and non-Hispanic Black men. Most studies do not parse out Hispanic groups; therefore, it is unclear whether the increases in obesity rates among Hispanic men applies to all groups or if there are particular groups of Hispanic men that are driving the increase. The goal of this study is to examine the variations in obesity among men of diverse racial/ethnic backgrounds and determine if obesity is affected by nativity. The data used in this study were from 11 years (2002-2012) of the National Health Interview Survey. Logistic regression was used to examine the relationship between race/ethnicity, obesity, and nativity. After adjusting for covariates, there are differences in obesity prevalence, with the largest prevalence among Puerto Rican men and Mexican American men. Consistent with previous literature, it has been suggested that men born in the United States are more likely to be obese than men born outside the United States. This study underscores the importance of distinguishing Hispanic groups when examining obesity, and provides information for future, targeted intervention strategies related to obesity among high-risk groups.

Because there are many potential risks in the MR environment and reports of adverse incidents involving patients, equipment and personnel, the need for a guidance document on MR safe practices emerged. Initially published in 2002, the ACR MR Safe Practices Guidelines established de facto industry standards for safe and responsible practices in clinical and research MR environments. As the MR industry changes the document is reviewed, modified and updated. The most recent version will reflect these changes., (Copyright © 2013 Wiley Periodicals, Inc.)

McLean Hospital's College Mental Health Program was established four years ago as an institutional response to escalating, national college mental health concerns. The critical factors underlying the college mental health crisis in this country have been debated, examined, and addressed almost exclusively within college and university settings. McLean Hospital is the first psychiatric hospital to develop a comprehensive college student program that bridges the gap between a psychiatric hospital and multiple campus settings as an attempt to address the specific needs of college student-patients across levels of psychiatric care and diagnostic areas/programs. Using a bioecological systems framework, this review examines (1) the strategic clinical, education/outreach, and research efforts that collectively represent a paradigm shift to extend responsibility for addressing serious college mental health challenges beyond college and university campuses, (2) the challenges and benefits of creating stronger multi-campus/hospital collaborations in order to improve our understanding of college students with serious mental illness, and (3) the progress in addressing these needs more effectively and in establishing documented best practices and policies through effective and innovative partnerships.

Anecdotal evidence abounds that conflicts between two individuals can spread across networks to involve a multitude of others. We advance a cultural transmission model of intergroup conflict where conflict contagion is seen as a consequence of universal human traits (ingroup preference, outgroup hostility; i.e. parochial altruism) which give their strongest expression in particular cultural contexts. Qualitative interviews conducted in the Middle East, USA and Canada suggest that parochial altruism processes vary across cultural groups and are most likely to occur in collectivistic cultural contexts that have high ingroup loyalty. Implications for future neuroscience and computational research needed to understand the emergence of intergroup conflict are discussed.

Purpose: The objective of this study was to develop and validate a patient-reported outcome instrument to comprehensively assess the consequences of inadequate sleep for use in insomnia-related studies., Methods: To inform item development, relevant constructs were identified through patient focus groups, literature review, and expert input. Following a translatability assessment for United States (US) English, US Spanish, and French, the draft items were refined through iterative sets of patient interviews in the United States and France. Psychometric properties were evaluated using patient responses from a validation study including 432 participants with either a diagnosis of primary insomnia or no history of insomnia., Results: Psychometric analyses supported item reduction from 38 to 26 items, yielding a unidimensional scale and preserving the original content (mood, tiredness/energy, memory/concentration, motivation, daily performance, social interaction, sexual functioning). Evidence of internal consistency (coefficient α = 0.97), convergent validity, and known-groups validity also was documented., Conclusions: The Sleep Functional Impact Scale (SFIS) is a psychometrically sound measure targeting the impact of insomnia on patient functioning. When administered with a sleep diary, this instrument has the ability to provide a more comprehensive assessment of treatment response in clinical studies.

Objective: To examine trends in the prevalence of rheumatoid vasculitis in a national US population comprising both hospitalized and ambulatory patients with rheumatoid arthritis (RA)., Methods: In this serial cross-sectional study, we analyzed data on hospitalized and ambulatory patients spanning 22 years (1985-2006) and 10 years (1997-2006), respectively, to determine the prevalence of rheumatoid vasculitis, as defined by the International Classification of Diseases, Ninth Revision. Our search encompassed data collected on a predominantly male study population during 10 million hospitalizations and outpatient visits, and included annual data on >37,000 RA patients. To test for a decrease in rheumatoid vasculitis prevalence, breakpoint analysis was performed using stepwise Chow and Durbin-Watson tests., Results: There was a clear decline in the prevalence of rheumatoid vasculitis, and this decline remained evident even after accounting for a decreased number of hospitalizations among RA patients. Peak prevalence occurred among hospitalized patients in the 1980s, and prevalence gradually declined throughout the 1990s. Furthermore, simultaneous breakpoints representing a significant drop in rheumatoid vasculitis prevalence between the years 2000 and 2001 were demonstrated for both inpatients (P < 0.000) and outpatients (P < 0.003). The prevalence of vasculitis dropped 53% among inpatients and 31% among outpatients between 2000 and 2001., Conclusion: Our results demonstrate a significant decline in rheumatoid vasculitis prevalence after 2000 in this nationwide sample of hospitalized and ambulatory patients. The clear, consistent drop in prevalence provides an opportunity for the formulation of causal hypotheses, including consideration of the impact of biologic agents used to treat RA, on rheumatoid vasculitis.

Background: Before the introduction of the immunomodulatory therapies for multiple sclerosis (MS), treatment options for MS consisted of symptomatic management (physical therapy and pharmacological treatment for symptom management). Symptomatic management for MS has been supplemented in the past decade by 2 new classes of immunomodulatory therapies that have been approved as first-line treatments for relapsing-remitting multiple sclerosis (RRMS): subcutaneous glatiramer acetate (SC GA) and 3 beta-interferons: intramuscular interferon beta-1a (IM IFNbeta-1a), SC IFNbeta-1a, and SC IFNbeta-1b., Objective: To estimate the economic outcomes of 5 treatment strategies: symptom management alone, symptom management combined with SC GA, IM IFNbeta1-a, SC IFNbeta1-a, or SC IFNbeta1-b in patients diagnosed with RRMS., Methods: A literature-based Markov model was developed to assess the cost-effectiveness of 5 treatment strategies for managing a hypothetical cohort of patients diagnosed with RRMS in the United States--4 immunomodulatory drug therapies and symptom management alone. Health states were based on the Kurtzke Expanded Disability Status Scale (EDSS), a widely accepted scale for assessing RRMS (higher EDSS scores = increased disease severity). Baseline relapse and disease progression transition probabilities for symptom management were obtained from natural history studies. Treatment effects of the immunomodulatory therapies were estimated by applying a percentage reduction to the symptom management transition probabilities for relapse (27% reduction) and disease progression (30% reduction). Transition probabilities were subsequently adjusted to account for (1) the effects of neutralizing antibodies, specifically on relapse rates by assuming no additional therapy benefits after the second year of continuous therapy, and (2) treatment discontinuation. Therapy-specific data were obtained from clinical trials and long-term follow-up observational studies. Transitions among health states occurred in 1-month cycles for the lifetime of a patient. Costs (2005 US$) and outcomes were discounted at 3% annually., Results: The incremental cost per quality-adjusted life-year for the 4 immunomodulatory therapies is $258,465, $303,968, $416,301, and $310,691 for SC GA, IM IFNbeta-1a, SC IFNbeta-1a, and SC IFNbeta-1b, respectively, compared with symptom management alone. Sensitivity analyses demonstrated that results were sensitive to changes in utilities, disease progression rates, time horizon, and immunomodulatory therapy cost., Conclusions: The pharmacoeconomic model determined that SC GA was the best strategy of the 4 immunomodulatory therapies used to manage MS and resulted in better outcomes than symptom management alone. Sensitivity analyses indicated that the model was sensitive to changes in a number of key parameters, and thus changes in these key parameters would likely influence the estimated cost-effectiveness results. Head-to-head randomized clinical trials comparing the immunomodulatory therapies for the treatment of MS are necessary to validate the projections from the pharmacoeconomic analyses, particularly since the results available today from the clinical trials do not account adequately for treatment dropouts.

Background: Different medical and social conditions have been associated with primary and recurrent hernias. Possible predictors of recurrence after elective umbilical hernia repair have not been defined clearly. The aim of this study was to determine factors that predict recurrence in patients after elective repair of umbilical hernias., Methods: A 6-year retrospective review of patients with elective umbilical hernia repair at the Dallas VA Medical Center was performed. Clinical and pathologic data were evaluated by univariate analysis to identify predictive factors for recurrence., Results: A total of 244 patients underwent elective hernia repair within the study period (male, 96%; mean age, 56 y; Caucasian, 74%; African American, 14%; Hispanic, 8%). Because 15 patients were not compliant with follow-up requirements, 229 were eligible for the study. Ninety-seven underwent suture repair (42.4%) and 132 underwent mesh repair (57.3%). Eleven recurrences were identified (4.8%): 7 in the suture repair group (7.7%) and 4 in the mesh repair group (3%). Univariate analysis showed that patients likely to develop recurrences were as follows: African American (15.6% vs. 3.5%; P = .017), type II diabetics (14.2% vs. 2.6%; P = .002), patients with hyperlipidemia (9.2% vs. 2.6%; P = .028), and human immunodeficiency virus-positive patients (66.6% vs. 3.9%; P = .000)., Conclusions: Smoking, obesity, size of hernia, type of repair, or chronic obstructive pulmonary disease do not seem to predict recurrence of hernias in our VA population. African Americans, patients with type II diabetes, hyperlipidemia, and positive for human immunodeficiency virus, may have a higher risk for recurrence after elective umbilical hernia repair.

Objective: To determine the association between serum 25-hydroxyvitamin D (25OHD) and diabetes risk and whether it varies by ethnicity., Research Design and Methods: We performed an analysis of data from participants who attended the morning examination of the Third National Health and Nutrition Examination Survey (1988-1994), a cross-sectional survey of a nationally representative sample of the U.S. population. Serum levels of 25OHD, which reflect vitamin D status, were available from 6,228 people (2,766 non-Hispanic whites, 1,736 non-Hispanic blacks, and 1,726 Mexican Americans) aged > or =20 years with fasting and/or 2-h plasma glucose and serum insulin measurements., Results: Adjusting for sex, age, BMI, leisure activity, and quarter of year, ethnicity-specific odds ratios (ORs) for diabetes (fasting glucose > or =7.0 mmol/l) varied inversely across quartiles of 25OHD in a dose-dependent pattern (OR 0.25 [95% CI 0.11-0.60] for non-Hispanic whites and 0.17 [0.08-0.37] for Mexican Americans) in the highest vitamin D quartile (25OHD > or =81.0 nmol/l) compared with the lowest 25OHD (< or =43.9 nmol/l). This inverse association was not observed in non-Hispanic blacks. Homeostasis model assessment of insulin resistance (log e) was inversely associated with serum 25OHD in Mexican Americans (P=0.0024) and non-Hispanic whites (P=0.058) but not non-Hispanic blacks (P=0.93), adjusting for confounders., Conclusions: These results show an inverse association between vitamin D status and diabetes, possibly involving insulin resistance, in non-Hispanic whites and Mexican Americans. The lack of an inverse association in non-Hispanic blacks may reflect decreased sensitivity to vitamin D and/or related hormones such as the parathyroid hormone.

In response to the Surgeon General's request for more research on racial disparities in mental health care, especially research that includes high-need populations (e.g., the homeless, incarcerated, children in foster care, and substance abusers), we examined racial disparities in the provision of mental health counseling, psychotherapy, and pharmacotherapy in hospital outpatient settings using nationally representative data from the 1997 National Hospital Ambulatory Medical Care Survey (NHAMCS). After controlling for diagnosis and other factors, we found that African Americans were less likely than whites to receive mental health counseling and psychotherapy, but more likely than whites to receive pharmacotherapy. We also found that substance abuse clinics were more likely than primary care and specialty mental health clinics to provide mental health counseling and psychotherapy. However, specialty mental health clinics were the only clinics to provide pharmacotherapy. Future research should examine racial disparities in a variety of settings, controlling for diagnosis as well as other factors.

Purpose: To assess relative risks by gender of reported serious injuries and deaths associated with the use of hemostasis devices, stratified by year of report, type of injury, and type of device., Methods: Reports from the Food and Drug Administration's Medical Device Reporting system and National Center for Health Statistics data on use of cardiac catheterization were used to estimate relative risks of reported serious injuries and deaths by gender., Results: Estimated risks of reported serious injuries and deaths associated with hemostasis devices were two to three times greater in females than in males for hemorrhage and hematoma (p < 0.0001), but there was no significant difference in risks by gender for infection., Conclusions: Cardiac catheterization is sometimes associated with serious injuries and deaths. Among patients who receive hemostasis devices, the risk of these events are disproportionately greater in women.

A new class of asthma drugs modifying the leukotriene pathway was introduced in 1996. The authors investigated outcome changes associated with use of the leukotriene-receptor antagonist zafirlukast. The study group included patients with asthma (12-64 yr), most with mild-to-moderate, persistent asthma, who had at least two zafirlukast prescriptions within 90 days after the start of zafirlukast treatment. Zafirlukast treatment was associated with reductions in occurrence of outpatient visits, emergency department visits, inpatient stays, and prescriptions for short-acting beta-adrenergic agonists in the next six months (all P < .05). A 12-month pre- and post-zafirlukast treatment comparison in a smaller group of patients and a classification of patients into three mutually exclusive outcome groups (increase, decrease, or no change in outcome events) verified the majority of the findings. A cost analysis from a third-party perspective indicated that costs of zafirlukast treatment were more than offset by cost savings associated with the reductions in outcome events.

This article addresses the increasing need within urban communities for effective, culturally relevant HIV prevention programs. The recruitment efforts of a family-based prevention program aimed at promoting health and preventing HIV risk exposure in urban, African American fourth and fifth grade children living in a community with high rates of HIV infection is detailed. The program, referred to as the CHAMP (Chicago HIV Prevention and Adolescent Mental Health Project) Family Program, is overseen by a collaborative partnership of community parents, school staff, and university-based researchers (Paikoff & McKay, 1995). The recruitment strategies developed as a result of this community-research collaboration are described. Preliminary results of the project's efforts to reach out to families within the targeted, inner-city community are presented.

This article describes the development of a family-based, longitudinal HIV prevention program targeting urban, African American fourth- and fifth-grade children and their families living in areas with high rates of HIV infection. The intervention is based on the research findings of the Chicago HIV Prevention and Adolescent Mental Health Family Study, a longitudinal study of 315 urban, African American families with preadolescent children (Paikoff, 1997). Results from this study informed the development of a 12-week, family-based preventive intervention-the Chicago HIV-Prevention and Adolescent Mental Health Project (CHAMP) Family Program. The development and implementation of the program also was guided by a collaborative partnership between university researchers and community members (parents and school staff). A description of the process by which collaboration influenced the development of the intervention is provided. This article is meant to serve as a model for the integration of empirical findings and community collaboration into the development of HIV prevention programs.

Background: Cost-effectiveness analyses of clinical preventive services are a potential means to aid public health resource allocation. Cost-utility analysis (CUA) is a specific form of cost-effectiveness analysis where results are expressed in terms of cost per quality-adjusted life year (QALY) gained. To increase the transparency and comparability of CUAs, standardization of methods has been recommended., Objectives: The purposes of this study were as follows: (1) identify published articles with original CUAs of primary and secondary clinical preventive services, (2) summarize the ratios found in these analyses, (3) identify articles employing comparable methods, and (4) explore analytic methods employed over time., Methods: As part of a larger study we conducted a comprehensive search of published CUAs in the area of clinical preventive services and systematically collected data on the results of the analyses and analytic methods employed. Cost-effectiveness ratios were standardized and organized into a table., Results: We found 50 CUAs pertaining to clinical preventive services (primary, n=22, 44%; and secondary, n=28, 56%) and 174 cost-effectiveness ratios. These ratios ranged from cost-savings up to $27,000,000/QALY, with a median of $14,000/QALY. Only three (6%) of the CUAs met minimum reference case requirements. There was no apparent improvement of methods over time., Conclusions: Immunizations and chemoprophylaxis have the most favorable cost-effectiveness ratios, and preventive services are more cost-effective when targeted at high-risk populations. However, there is wide variation in the methods used in these analyses. This study allows us to define where improvements in methodologic rigor need to occur, provides a base-line for future audits, and highlights disease areas in clinical preventive services that have been omitted or underevaluated.

Type 2 diabetes is a serious, genetically influenced disease for which no fully effective treatments are available. Identification of biochemical or regulatory pathways involved in the disease syndrome could lead to innovative therapeutic interventions. One way to identify such pathways is the genetic analysis of families with multiple affected members where disease predisposing genes are likely to be segregating. We undertook a genomewide screen (389-395 microsatellite markers) in samples of 835 white, 591 Mexican American, 229 black, and 128 Japanese American individuals collected as part of the American Diabetes Association's GENNID study. Multipoint nonparametric linkage analyses were performed with diabetes, and diabetes or impaired glucose homeostasis (IH). Linkage to diabetes or IH was detected near markers D5S1404 (map position 77 cM, LOD = 2.80), D12S853 (map position 82 cM, LOD = 2.81) and GATA172D05 (X-chromosome map position 130 cM, LOD = 2.99) in whites, near marker D3S2432 (map position 51 cM, LOD = 3.91) in Mexican Americans, and near marker D10S1412 (map position 14 cM, LOD = 2.39) in African Americans mainly collected in phase 1 of the study. Further analyses showed evidence for interactions between the chromosome 5 locus and region on chromosome 12 containing the MODY 3 gene (map position 132 cM) and between the X-chromosome locus and region near D12S853 (map position 82 cM) in whites. Although these results were not replicated in samples collected in phase 2 of the GENNID study, the region on chromosome 12 was replicated in samples from whites described by Bektas et al. (1999).

Background: The United States has a high proportion of people without health insurance (15%) and a low proportion of people without employment (5%), resulting in millions who lack insurance but have some ability to pay. We tested whether hospitals charge similar prices for well-specified elective services to individuals paying out-of-pocket for medical care., Methods: We surveyed the 2 largest general hospitals from every large city (population >500 000) in the United States and Canada. At each hospital we evaluated 5 diagnostic, 7 therapeutic, and 3 nonclinical services to determine the total charge to patients who pay directly., Results: Overall, 66 hospitals were included (average, 758 beds; not-for-profit, 97% [n = 64]; teaching, 80% [n = 53]). The range in charges was substantial; for example, a screening mammogram was $40 at one hospital in Los Angeles, Calif, and $346 at one hospital in Quebec City. Charges for a screening mammogram were relatively stable between 1996 and 1997 (r=0.79; 95% confidence interval, 0.68-0.87) and unrelated to the hospital's location or charges for other services. The relative amount of variation in charges was similar for high-priced and low-priced services, similar for diagnostic and therapeutic services, and similar for the United States and Canada., Conclusions: Charges for the same hospital service vary substantially. Greater visibility might reduce some variation by bringing outliers into closer scrutiny. Patients seeking care and paying out-of-pocket could save financially by comparison shopping.

African Americans constitute about 12 percent of the United States population. Sixty percent of African Americans live in urban areas, and 25 percent have incomes below the poverty level. Issues in the psychiatric assessment and evaluation of African-American patients include diagnostic bias that has resulted in overdiagnosis of schizophrenia. Use of screening instruments can help standardize assessment, but appropriate screening instruments that have been evaluated and found reliable in this population must be used. Issues in treatment and outcome for African Americans include challenges in establishing rapport in interethnic situations, racial identity as a focus in psychotherapy, and awareness of biological characteristics that affect response to medications. Many African Americans live in high-crime areas where high rates of drug abuse and violence create chronic stresses. Patients with dual diagnoses of chronic mental illness and substance use or abuse need targeted interventions. Strategies for prevention and treatment of the effects of having experienced or witnessed violence have been proposed. Additional research is needed to clarify the true prevalence of specific mental disorders among African Americans and to determine the most effective combinations of treatment strategies for various disorders.