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Human neuroimaging studies and complementary animal experiments now identify the gross elements of the brain involved in the chronification of pain. We briefly review these advances in relation to somatic and orofacial persistent pain conditions. First, we emphasize the importance of reverse translational research for understanding chronic pain—that is, the power of deriving hypotheses directly from human brain imaging of clinical conditions that can be invasively and mechanistically studied in animal models. We then review recent findings demonstrating the importance of the emotional brain (i.e., the corticolimbic system) in the modulation of acute pain and in the prediction and amplification of chronic pain, contrasting this evidence with recent findings regarding the role of central sensitization in pain chronification, especially for orofacial pain. We next elaborate on the corticolimbic circuitry and underlying mechanisms that determine the transition to chronic pain. Given this knowledge, we advance a new mechanistic definition of chronic pain and discuss the clinical implications of this new definition as well as novel therapeutic potentials suggested by these advances.

Objectives Veterans experience a particularly heavy burden with smoking rates higher than the general population, and the smoking prevalence for women Veterans has increased in recent years. We examined differences in smoking prevalence and treatment by gender for Veterans receiving at least some of their care at a VA facility, and examined the degree to which organizational factors may be associated with reductions in gender disparities in smoking cessation treatment. Methods We merged national organizational-level data focused on primary care (sites = 225) and women’s health (sites = 195) with patient-level survey data (n = 15,033 smokers). Organizational measures focused on smoking cessation-specific structure and processes in primary care and women’s health. Primary outcomes were patient-reported receipt of smoking cessation treatments—advised to quit, medication recommendation, and other treatment recommendation. We used multi-level, random-intercept logistic regression. Results In 2007, 29% of women and 23% of men were smokers. Overall, 83% of smokers reported they had been advised to quit, 62% recommended medications, and 60% recommended other treatments. Women were more likely to report being advised to quit (odds ratio, 1.33; 95% confidence interval, 1.07–1.64) but equally likely as men to have medications or other treatment recommended. Organizational factors did not eliminate the gender differences in being advised to quit. Conclusion Despite having equivalent or higher smoking cessation treatment rates, women Veterans were more likely to smoke than men. With the rapid growth of women entering VA care, the need for effective gender-focused and gender-sensitive smoking cessation care arrangements is critical for the future health of women who have served.

Research into the pathophysiology of chronic prostatitis/chronic pelvic pain syndrome has primarily focused on markers of peripheral dysfunction. We present the first neuroimaging investigation to our knowledge to characterize brain function and anatomy in chronic prostatitis/chronic pelvic pain syndrome.We collected data from 19 male patients with chronic prostatitis/chronic pelvic pain syndrome, and 16 healthy age and gender matched controls. Functional magnetic resonance imaging data were obtained from 14 patients with chronic prostatitis/chronic pelvic pain syndrome as they rated spontaneous pain inside the scanner. Group differences (16 patients per group) in gray matter total volume and regional density were evaluated using voxel-based morphometry, and white matter integrity was studied with diffusion tensor imaging to measure fractional anisotropy. Functional and anatomical imaging outcomes were correlated with the clinical characteristics of chronic prostatitis/chronic pelvic pain syndrome.Spontaneous pelvic pain was uniquely characterized by functional activation within the right anterior insula, which correlated with clinical pain intensity. No group differences were found in regional gray matter volume, yet density of gray matter in pain relevant regions (anterior insula and anterior cingulate cortices) positively correlated with pain intensity and extent of pain chronicity. Moreover the correlation between white matter anisotropy and neocortical gray matter volume was disrupted in chronic prostatitis/chronic pelvic pain syndrome.We provide novel evidence that the pain of chronic prostatitis/chronic pelvic pain syndrome is associated with a chronic pelvic pain syndrome specific pattern of functional brain activation and brain anatomical reorganization. These findings necessitate further investigations into the role of central mechanisms in the initiation and maintenance of chronic prostatitis/chronic pelvic pain syndrome.

Recent research on the impact of religiosity on sexuality has highlighted the role of the individual, and suggests that the effects of religious group and sexual attitudes and fantasy may be mediated through individual differences in spirituality. The present study investigated the role of religion in an ethnically diverse young adult sample (N = 1413, 69% women) using religious group as well as several religiosity domains: spirituality, intrinsic religiosity, paranormal beliefs, and fundamentalism. Differences between religious groups in conservative sexual attitudes were statistically significant but small; as predicted, spirituality mediated these effects. In contrast to the weak effects of religious group, spirituality, intrinsic religiosity, and fundamentalism were strong predictors of women's conservative sexual attitudes; for men, intrinsic religiosity predicted sexual attitude conservatism but spirituality predicted attitudinal liberalism. For women, both religious group and religiosity domains were significant predictors of frequency of sexual fantasies while, for men, only religiosity domains were significant predictors. These results indicate that individual differences in religiosity domains were better predictors of sexual attitudes and fantasy than religious group and that these associations are moderated by gender.

We designed a patient-centered smoking cessation program for women in 2004/2005, incorporating women's preferences and expert opinion. Our four-step process included: (1) concept-development focus groups; (2) an expert panel; (3) concept-testing focus groups, and (4) a pilot study. Data analyses occurred in 2004-2007. The new program offered options: the traditional Veterans Health Administration (VA) male-dominated program was the least selected option in the pilot study. Patients can be effectively involved in program development. The study's implications and limitations are noted. This research (conducted in Los Angeles, California) was funded by the American Legacy Foundation with additional VA support.

Background: Stakeholders in quality improvement agree on the need for augmenting and synthesising the scientific literature supporting it. The diversity of perspectives, approaches, and contexts critical to advancing quality improvement science, however, creates challenges. The paper explores the heterogeneity in clinical quality improvement intervention (QII) publications. Methods: A preliminary classification framework was developed for QII articles, aiming for categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. QII experts were asked to identify articles important to QII science. The framework was tested and revised by applying it to the article set. The final framework screened articles into (1) empirical literature on development and testing of QIIs; (2) QII stories, theories, and frameworks; (3) QII literature syntheses and meta-analyses; or (4) development and testing of QII-related tools. To achieve homogeneity, category (1) required division into (1a) development of QIIs; 1(b) history, documentation, or description of QIIs; or (1c) success, effectiveness or impact of QIIs. Results: By discussing unique issues and established standards relevant to each category, QII stakeholders can advance QII practice and science, including the scope and conduct of systematic literature reviews.

Tobacco use is the leading preventable cause of mortality, accounting for 435,000 deaths in the United States (Mokdad et al. 2004) and 4.8 million deaths due to tobacco worldwide (Ezzati and Lopez 2003). In the United States alone, smoking is responsible for $157 billion in annual health-related economic losses, which translates into each pack of cigarettes sold in the United States leading to $3.45 in medical expenditures and $3.73 in lost productivity (MMWR 2002). While the prevalence of tobacco use has decreased dramatically over the last 40 years chiefly through public health interventions (MMWR 2003), we have not seen further declines in the past decade despite the availability of an increasing array of efficacious treatments (Ranney et al. 2006). Routine treatment of smokers by physicians has been a national health objective, but physician detection of smokers, counseling of smokers to quit, and prescription of pharmacotherapy to aid them in quitting have been well below quality standards (Thorndike et al. 1998). Dissemination of smoking cessation clinical practice guidelines during the mid-1990s offered substantial promise for making greater inroads by promoting evidence-based recommendations targeting changes in physician behavior and adaptive changes in health care settings. In particular, the guidelines reflect strong empirical evidence of the value of systematic screening for tobacco use, advising smokers to quit, and providing smoking cessation treatment (both counseling and medications) (Cromwell et al. 1997; Fiore 2000). The guidelines offer an explicit roadmap for integrating interventions with demonstrated effectiveness into routine clinical care (Fiore, Jorenby, and Baker 1997; Raw, McNeil, and West 1999). However, most guideline dissemination efforts have met with only limited success. While early dissemination encouraged primary care physicians to ask about smoking and advise their patients to quit, few practicing physicians met criteria for adequate counseling to help smokers quit and fewer still provided smokers with necessary assistance or arranged follow-up services (Goldstein et al. 1998; DePue et al. 2002). System-level interventions have generally been recommended to help individual clinicians adopt guideline-adherent practices (Bero et al. 1998; Solberg 2000). These include improved forms of documentation to record smoking status (e.g., intake forms, “vital sign” stamps, stickers), clinician prompts or reminder systems for fostering guideline-adherent actions, provision of on-site educational materials, designation of a coordinator or clinical “champion,” training of nurses/support staff in person or by phone to replace physician counseling, audit-and-feedback of clinician guideline adherence, computerized decision support, and incentives (Lichtenstein et al. 1996; Katz et al. 2004; An et al. 2006). Adoption of these approaches into practice settings, however, involves organizational change (Wensing and Grol 1994; Oxman et al. 1995). There is growing consensus that implementing research into practice through organizational change (Stone et al. 2002) depends in large part on the degree to which they account for or are adapted to the context of individual practices (Grol 1992, 1997) to facilitate diffusion (Rogers 1995). Quality improvement (QI) methods assist practices in implementing improvements that are synchronous with local needs, priorities, and resources. Evidence-based quality improvement (EBQI) methods are based on the premise that practices will have greater success in achieving true improvements through organizational change using prior evidence from the literature as a guide for their activities. The objective of this study was to evaluate the effectiveness of an EBQI method for enabling health care managers, rather than researchers, to implement evidence-based smoking cessation interventions in the context of local practice needs and under routine conditions and to determine its impact on practice-level smoking cessation.

BACKGROUND Despite the growing recognition of the importance of colorectal cancer (CRC) screening in reducing cancer mortality, national screening rates are low, indicating a critical need to understand the barriers and remedies for underutilization of CRC screening tests. METHODS Using results from independent cross-sectional telephone surveys with patients aged ≥50 years performed before (2000; n = 498) and after (2003; n = 482) a quality improvement intervention for CRC screening within a large managed care health plan, the trends and predictors of CRC screening with fecal occult blood test (FOBT) and/or endoscopy (flexible sigmoidoscopy/colonoscopy) were examined from a patient perspective. RESULTS In 2000, patient reported screening rates within guidelines were 38% for any test, 23% for endoscopy, and 22% for FOBT. In 2003, screening rates increased to 50% for any test, 39% for endoscopy, and 24% for FOBT. Having discussed CRC with a doctor significantly increased the odds of being screened (FOBT: odds ratio [OR], 2.09 [95% confidence interval (95% CI), 1.47–2.96]; endoscopy: OR, 2.33 [95% CI, 1.67–3.26]; and any test: OR, 2.86 [95% CI, 2.06–3.96]), and reporting barriers to CRC in general decreased the odds of being screened (FOBT: OR, 0.76 [95% CI, 0.60–0.95]; endoscopy: OR, 0.74 [95% CI, 0.60–0.92]; and any test: OR, 0.66 [95% CI, 0.54–0.80]). CONCLUSIONS Although screening rates increased over the 3-year period, evidence was found of ongoing underutilization of CRC screening. The 2 strongest determinants of obtaining CRC screening were provider influence and patient barriers related to CRC screening in general, pointing to the need for multilevel interventions that target both the provider and patient. Cancer 2008. © 2008 American Cancer Society.

Smoking cessation programs are very effective, but little is known about how to get smokers to attend these programs.To evaluate whether an "on-call" counselor increased smoking cessation program referrals and attendance.We randomly assigned 1 of 2 primary care teams at the Sepulveda VA Ambulatory Care Center to intervention and the other to usual care. The intervention team had access to an on-call counselor who provided counseling and care coordination. Social marketing efforts included educational outreach, provider feedback, and financial incentives.Baseline telephone interviews with a sample of 482 smokers were conducted, covering smoking history, health status, and smoking cessation treatments. Follow-up surveys were conducted at mid-intervention (n = 251) and post-intervention (n = 251).Two hundred ninety-six patients were referred to the on-call counselor, who counseled each patient in person and provided follow-up calls. The counselor referred 45% to the on-site program, and 27% to telephone counseling; of these, half followed through on the referral; 28% declined referral. Patients on the intervention team were more likely to report being counseled about smoking (68% vs 56%; odds ratio [OR] 1.7, CI 1.0-2.9) and referred to a cessation program (38% vs 23%; OR 2.1, CI 1.2-3.6); having attended the program (11% vs 4%; OR 3.6, CI 1.2-10.5); and receiving a prescription for bupropion (17% vs 8%) (OR 2.3, CI 1.1-5.1). The effect was not sustained after the case management period.Having access to an on-call counselor with case management increased rates of smoking cessation counseling, referral, and treatment. The intervention could be reproduced by other health care systems.

Introduction Female sexual function reflects a dynamic interplay of central and peripheral nervous, vascular, and endocrine systems. The primary challenge in the development of novel treatments for female sexual dysfunction is the identification and targeted modulation of excitatory sexual circuits using pharmacologic treatments that facilitate the synthesis, release, and/or receptor binding of neurochemicals, peptides, and hormones that promote female sexual function. Aim To develop an evidence-based state-of-the-art consensus report that critically integrates current knowledge of the therapeutic potential for known molecular and cellular targets to facilitate the physiologic processes underlying female sexual function. Methods State-of-the-art review representing the opinions of international experts developed in a consensus process during a 1-year period. Main Outcome Measures Expert opinion was established by grading the evidence-based medical literature, intensive internal committee discussion, public presentation, and debate. Results Scientific investigation is urgently needed to expand knowledge and foster development of future treatments that maintain genital tissue integrity, enhance genital physiologic responsiveness, and optimize positive subjective appraisal of internal and external sexual cues. This article critically condenses the current knowledge of therapeutic manipulation of molecular and cellular targets within biological systems responsible for female sexual physiologic function. Conclusion Future treatment targets include pharmacologic modulation of emotional learning circuits, restoration of normal tactile sensation, growth factor therapy, gene therapy, stem cell–based therapies, and regenerative medicine. Concurrent use of centrally and peripherally acting therapies could optimize treatment response.

Background The purpose of this review is to study the effect of school-based interventions on smoking prevention for girls. Methods We performed a systematic review of articles published since 1992 on school-based tobacco-control interventions in controlled trials for smoking prevention among children. We searched the databases of PubMed, Embase, Web of Science, The Cochrane Databases, CINAHL, Social Science Abstracts, and PsycInfo. Two reviewers independently assessed trials for inclusion and quality and extracted data. A pooled random-effects estimate was estimated of the overall relative risk. Results Thirty-seven trials were included, of which 16 trials with 24,210 girls were included in the pooled analysis. The overall pooled effect was a relative risk (RR) of 0.96 (95 % confidence interval (CI) 0.86-1.08; I2=75 %). One study in which a school-based intervention was combined with a mass media intervention showed more promising results compared to only school-based prevention, and four studies with girl-specific interventions, that could not be included in the pooled analysis, reported statistically significant benefits for attitudes and intentions about smoking and quit rates. Conclusions There was no evidence that school-based smoking prevention programs have a significant effect on preventing adolescent girls from smoking. Combining school-based programs with mass media interventions, and developing girl-specific interventions, deserve additional study as potentially more effective interventions compared to school-based-only intervention programs. Systematic review registration PROSPERO CRD42012002322 Electronic supplementary material The online version of this article (doi:10.1186/s13643-015-0082-7) contains supplementary material, which is available to authorized users.

Altered resting-state (RS) brain activity, as a measure of functional connectivity (FC), is commonly observed in chronic pain. Identifying a reliable signature pattern of altered RS activity for chronic pain could provide strong mechanistic insights and serve as a highly beneficial neuroimaging-based diagnostic tool. We collected and analyzed RS functional magnetic resonance imaging data from female patients with urologic chronic pelvic pain syndrome (N = 45) and matched healthy participants (N = 45) as part of an NIDDK-funded multicenter project (www.mappnetwork.org). Using dual regression and seed-based analyses, we observed significantly decreased FC of the default mode network to 2 regions in the posterior medial cortex (PMC): the posterior cingulate cortex (PCC) and the left precuneus (threshold-free cluster enhancement, family-wise error corrected P < 0.05). Further investigation revealed that patients demonstrated increased FC between the PCC and several brain regions implicated in pain, sensory, motor, and emotion regulation processes (eg, insular cortex, dorsolateral prefrontal cortex, thalamus, globus pallidus, putamen, amygdala, hippocampus). The left precuneus demonstrated decreased FC to several regions of pain processing, reward, and higher executive functioning within the prefrontal (orbitofrontal, anterior cingulate, ventromedial prefrontal) and parietal cortices (angular gyrus, superior and inferior parietal lobules). The altered PMC connectivity was associated with several phenotype measures, including pain and urologic symptom intensity, depression, anxiety, quality of relationships, and self-esteem levels in patients. Collectively, these findings indicate that in patients with urologic chronic pelvic pain syndrome, regions of the PMC are detached from the default mode network, whereas neurological processes of self-referential thought and introspection may be joined to pain and emotion regulatory processes.

The influence of brain imaging, primarily human brain imaging on the science of pain mechanisms, is discussed. Early studies emphasized the presence of a cortical signal associated with perception of pain, and extensive literature examined regional activity properties in the hope of identifying functional specializations for theoretical components that comprise pain. Recently, more sophisticated studies challenge these localizationist ideas. Another important advancement has been the incorporation of the clinical pain patient, especially those with chronic pain, into the studies of brain properties. This line of work has generated exciting new mechanistic ideas that promise to directly impact clinical practice.

A multitude of factors influence condom use self-efficacy, including age, gender, ethnicity, condom use attitudes and barriers, sexual experience, and partner characteristics. The current study integrated past research by evaluating these factors in a large, ethnically diverse university sample of women and men (N = 665). The role of gender on condom use and sexuality variables was assessed across ethnic groups. Hierarchical linear regressions were then calculated to explain levels of condom use self-efficacy using the hypothesized sexual predictors in nonvirgin, sexually active, and recent condom use subsamples. Predictors explained 18–45% of variance in condom use self-efficacy. Findings suggest that a few key variables accounted for the majority of variance in condom use self-efficacy: condom use attitudes, condom use barriers, satisfaction with sexual communication, anticipated number of sexual partners, one-time sexual encounters, and ethnic identity. Significant gender differences emerged in condom use self-efficacy, condom use attitudes, and condom use behaviors. Ethnic differences were found in range of sexual experience and sexual partner characteristics. It is recommended that future studies examining sexual risk behavior incorporate the diverse sexual factors that affect condom use self-efficacy.

BACKGROUND Colorectal cancer (CRC) is the third most common cause of cancer deaths; however, rates of regular screening for this cancer are low. A quality improvement (QI) program to increase CRC screening was developed for use in a managed care health plan. METHODS Thirty-six provider organizations (POs) contracting with the health plan were recruited for a randomized controlled effectiveness trial testing the QI program. The intervention was delivered over a 2-year period, and its effectiveness was assessed by chart review of a random sample of patients from each PO. RESULTS Thirty-two of the 36 POs were evaluable for outcome assessment. During the 2-year intervention period, only 26% of the eligible patients received any CRC screening test. Twenty-nine percent of patients had any CRC screening test within guidelines, with no differences between the intervention or control POs. Significant predictors of having received CRC screening within guidelines were older age (P = 0.0004), receiving care in an integrated medical group (P < 0.0001) and having had a physical examination within the past 2 years (P < 0.0001). CONCLUSIONS A facilitated QI intervention program for CRC screening that focused on the PO did not increase rates of CRC screening. Overall CRC screening rates are low and are in need of improvement. Cancer 2005. © 2005 American Cancer Society.

Mainstream psychologists have not pursued sexology with the enthusiasm aimed at other areas of psychological research. Ambivalence is evident in the ideological marginalization of sexology by mainstream psychology. The authors argue that scientific conflicts between the disciplines in part reflect divergent interpretations of how each discipline approaches the scientific method. By aligning psychology with positivism and sexology with postpositivism, a discussion of cultural, scientific, and normative conflicts between the two disciplines is presented as evidence for these differences in scientific ideology. To address these conflicts, future directions for scientific progress are proposed for sexology and psychology. Specifically, by capitalizing on the strengths of each discipline, collaboration can lead to the validation of sexology as a science and the enhancement of both disciplines.

Neuroimaging studies have shown that changes in brain morphology often accompany chronic pain conditions. However, brain biomarkers that are sensitive and specific to chronic pelvic pain (CPP) have not yet been adequately identified. Using data from the Trans-MAPP Research Network, we examined the changes in brain morphology associated with CPP. We used a multivariate pattern classification approach to detect these changes and to identify patterns that could be used to distinguish participants with CPP from age-matched healthy controls. In particular, we used a linear support vector machine (SVM) algorithm to differentiate gray matter images from the two groups. Regions of positive SVM weight included several regions within the primary somatosensory cortex, pre-supplementary motor area, hippocampus, and amygdala were identified as important drivers of the classification with 73% overall accuracy. Thus, we have identified a preliminary classifier based on brain structure that is able to predict the presence of CPP with a good degree of predictive power. Our regional findings suggest that in individuals with CPP, greater gray matter density may be found in the identified distributed brain regions, which are consistent with some previous investigations in visceral pain syndromes. Future studies are needed to improve upon our identified preliminary classifier with integration of additional variables and to assess whether the observed differences in brain structure are unique to CPP or generalizable to other chronic pain conditions.

PurposeInterstitial cystitis is a highly prevalent pain condition estimated to affect 3% to 6% of women in the United States. Emerging data suggest there are central neurobiological components to the etiology of this disease. We report the first brain structural imaging findings from the MAPP network with data on more than 300 participants.Materials and methodsWe used voxel based morphometry to determine whether human patients with chronic interstitial cystitis display changes in brain morphology compared to healthy controls. A total of 33 female patients with interstitial cystitis without comorbidities and 33 age and gender matched controls taken from the larger sample underwent structural magnetic resonance imaging at 5 MAPP sites across the United States.ResultsCompared to controls, females with interstitial cystitis displayed significant increased gray matter volume in several regions of the brain including the right primary somatosensory cortex, the superior parietal lobule bilaterally and the right supplementary motor area. Gray matter volume in the right primary somatosensory cortex was associated with greater pain, mood (anxiety) and urological symptoms. We explored these correlations in a linear regression model, and found independent effects of these 3 measures on primary somatosensory cortex gray matter volume, namely clinical pain (McGill pain sensory total), a measure of urgency and anxiety (HADS).ConclusionsThese data support the notion that changes in somatosensory gray matter may have an important role in pain sensitivity as well as affective and sensory aspects of interstitial cystitis. Further studies are needed to confirm the generalizability of these findings to other pain conditions.

While the potential of patient-centered medical homes (PCMH) is promising, little is known empirically about the frontline challenges that primary care (PC) leaders face before making the decision to implement PCMH, let alone in making it a reality.Prior to the design and implementation of the Veterans Health Administration's (VA) national PCMH model--Patient Aligned Care Teams (PACT)--we identified the top challenges faced by PC directors and examined the organizational and area level factors that influenced those challenges.A national cross-sectional key informant organizational survey was fielded to the census of PC directors at VA medical centers and large community-based outpatient clinics (final sample n = 229 sites).PC directors were asked to rate the degree to which they faced 48 management challenges in eight PCMH-related domains (access, preventive care, chronic diseases requiring care in PC, challenging medical conditions, mental health/substance abuse, special populations, PC coordination of care, and clinical informatics). Responses were dichotomized as moderately-to-extremely challenging versus somewhat-slightly-not at all challenging. Items were rank ordered; chi square or regression techniques were used to examine variations in facility size, type, urban/rural location, and region.On average, VA PC directors reported 16 moderate-to-extreme challenges, and the top 20 challenges spanned all eight PCMH domains. Four of the top 20 challenges, including the top two challenges, were from the clinical informatics domain. Management of chronic non-malignant pain requiring opiate therapy was the third most reported challenge nationwide. Significant organizational and area level variations in reported challenges were found especially for care coordination.Better understanding of PC challenges ahead of PCMH implementation provides important context for strategic planning and redesign efforts. As a national healthcare system, the VA provides a unique opportunity to examine organizational and area determinants relevant to other PCMH models.

Objectives To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians. Methods Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training. Results Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence. Conclusions Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency. Practice implications Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians.

BACKGROUND Patients in health maintenance organizations (HMOs) appear to have higher utilization of cancer screening tests than patients with fee-for-service insurance. METHODS The authors surveyed the medical directors of 174 physician organizations in a California network model HMO to obtain information regarding their organizational structure, implementation of guidelines, and use of systems to increase cancer screening. RESULTS The majority of independent practice associations (IPAs) and medical groups (IMGs) in this California HMO had guidelines and office systems aimed at improving cancer screening. These activities were reported more frequently for mammography and Papanicolaou (Pap) smears than for colorectal carcinoma screening. IMGs reported using flow sheets more often than IPAs. Chart audits were performed more frequently for mammography (48% for IMGs and 40% for IPAs) and Pap smears (45% and 40%, respectively) than for colorectal carcinoma screening (38% and 30%, respectively). Approximately 50% of IPAs and IMGs reported mailing reminders to patients for mammography and Pap smears, but only a few did so for colorectal carcinoma screening. Annual fecal occult blood testing was believed by most medical directors to be a reasonable strategy for managed care patients (86% of IPAs and 96% of IMGs); however, fewer believed that screening sigmoidoscopy for patients ages 50–70 years was a reasonable expectation (71% and 78%, respectively). CONCLUSIONS The majority of IPAs and IMGs in this California HMO reported using both guidelines and office systems to improve cancer screening rates. Further research is needed to understand the effect of these systems, as well their complex interactions with competing incentives, on cancer screening in managed care patients. Cancer 2000;88:2824–31. © 2000 American Cancer Society.

The reproductive machinery is evolutionarily precious. As a result, physiological mechanisms evolved to protect reproductive organs from common environmental threats. Ongoing exposure to potentially pathogenic fungi, bacteria, and viruses has made the female lower reproductive tract a veritable battleground for immune defense. The external vulva and vaginal canal express a unique immune profile that differs from other mucosal sites and elsewhere in the periphery, and this specialization is preserved across species [10]. It therefore follows that pain induced by inflammation may also show vulvovaginal-specific properties. The elegant work presented by Foster and colleagues [6] expands our understanding of the complex relationship between pain and immune function with the novel observation that the vulvar vestibule—a thin band of tissue demarcating the entrance to the vagina—exhibits a highly localized and tissue-specific pro-inflammatory response in healthy women. This response is further amplified in women with localized provoked vulvodynia (LPV), a common type of chronic pelvic pain that afflicts 9–16% of premenopausal women [8]. LPV is characterized by sharp, burning pain localized to the vulvar vestibule in response to light pressure (i.e., mechanical allodynia) and is accompanied by enhanced vulvar pain perception (i.e., mechanical hyperalgesia) and continued pain that is temporally dissociated from its stimulus (i.e., “after sensation”). The mechanisms underlying LPV remain unknown, despite equivocal evidence for low-grade vulvar inflammation, altered peptidergic vulvar innervation, and genetic susceptibilities that contribute to abnormal inflammatory cascades. Candida albicans is a known inflammogen across species and is implicated in over 90% of vulvovaginal yeast infections in women. The high incidence of recurrent yeast infections in women with LPV prompted the hypothesis that yeast-induced vulvovaginal inflammation may underlie peripheral (and potentially central) sensitization of primary afferent nerve endings at the vestibule. This hypothesis allows for experience-dependent inflammatory insults to play a role in the initiation and/or maintenance of LPV (supported by direct activation of nociceptors by pathogenic bacteria, see [3]), as well as genetic polymorphisms that are frequently identified in this population [2]. The former point is supported by an experimental mouse model of LPV that confirmed that repeated vulvovaginal infections with C. albicans are sufficient to cause chronic vulvar pain behavior and increased vulvar peptidergic innervation, a finding that parallels observations in the clinical literature [2,4]. Furthermore, some women with chronic vulvar pain may be exceptionally vulnerable to C. albicans exposure, as indicated by enhanced contact sensitivity to intradermal C. albicans injections and increased fibroblast-mediated cytokine production [7,11]. The question remains, how does the vestibule uniquely mediate these symptoms, and how can we differentiate normal vulvar nociceptive processes from pathological ones? To address these questions, Foster et al. [6] evaluated women with and without chronic vulvar pain with vulvar quantitative sensory testing (QST) and examined vulvar tissue variability in fibroblast-mediated cytokine release. Women were assessed for alterations in pain perception associated with vulvar mechanical allodynia (via algometry) and hyperalgesia (via the cotton swab test). Mechanical pain threshold and suprathreshold levels were measured at the vestibule and an adjacent vulvar control site, and tissue biopsies were obtained from the same regions. In normal vulvar tissue of healthy women, fibroblast exposure to Candida and non-Candida yeast elicited modest fibroblast-mediated inflammation, as measured by interleukin-6 (IL-6) and prostglandin E2 (PGE2) levels. Importantly, a robust increase in the magnitude of this pro-inflammatory response was evident at the vestibule, compared to adjacent vulvar tissue. These observations strongly support the vulvar vestibule as immunologically unique tissue that exhibits enhanced inflammatory responsiveness to multiple genera of fungi, mediated in part by specialized fibroblasts. In women with LPV, exaggerated IL-6 and PGE2 levels were observed at both vulvar sites following Candida exposures. Vestibule fibroblasts, in particular, induced a profound increase of pro-inflammatory mediators in response to all yeast stimuli. Therefore the vulvar tissue of women with and without LPV were differentiated by the degree of naturally occurring inflammation. Given the increasing focus on peripheral and central immune factors underlying acute and chronic pain, this work is a timely and topical advance in our understanding of site-specific mucosal immunity. The unique inflammatory properties of the vestibule appear to facilitate the rapid detection of pathogens at a critical anatomical gateway to the reproductive tract. It is feasible that other structures derived from the endoderm, including the bladder and anterior urethral wall, may also exhibit unique immune properties. Notably, the high incidence of comorbid vulvar and bladder pain in young women, in some cases, may reflect vulnerabilities of endoderm-derived tissue [1,5]. These possibilities require a shift in our understanding of inflammation as it relates to pain pathology, a sort of immunopathological relativism: the clinical significance of inflammation depends on its anatomical context. For instance, the magnitude of a pro-inflammatory response—rather than its presence alone—may be critical in differentiating pelvic pain populations from healthy individuals, and from one another. Long after the original nociceptive stimuli are gone, in vivo and in vitro pathogen/irritant challenges that evoke pro-inflammatory responses can provide an ideal diagnostic strategy for examining such responses. Clinically, the correlations between self-reported vulvar pain sensitivity and distinct fibroblast-mediated pro-inflammatory factors reported by Foster et al. [6] provides some tantalizing results. Matching such specialized immune mechanisms to clinical symptoms is the closest the field has come to identifying an objective marker of pathology of LPV. This finding in part reflects the authors’ painstaking efforts to obtain tissue from patient-identified sites of vulvar pain. Furthermore, the data presented in Tables 2 and 3 raise the possibility that levels of IL-6 and PGE2 are associated with distinct sensory aspects of LPV. Fibroblast-mediated IL-6 levels appear to uniquely relate to pain threshold and, by extension, mechanical allodynia, whereas PGE2 production tended to preferentially reflect suprathreshold pain evoked during the cotton swab test (8/10 mean pain rating in this sample). These speculations, as well as other novel hypotheses raised by the authors, would require larger samples of women with LPV who are carefully phenotyped. The likely existence of distinct subtypes of LPV suggests that a principle components analysis would be needed to identify women who show sensitized inflammatory responses, as any clinical sample may contain mechanistically distinct variants of LPV (see [9]). Furthermore, the use of zymosan as an inflammatory stimulus can be applied across laboratories without the need for biohazard safety measures required for handling Candida. This convenience facilitates its use in animal model development to better understand the acute and chronic impact of vulvovaginal yeast versus bacterial exposure, the genetic mediation of this impact, as well as the prevention and treatment of resulting vulvar pain behavior. Without mincing words, I believe that Foster and colleagues’ proof of concept is one of the most significant advances in vulvodynia research over the past 20 years. Their work answers longstanding questions about the significance of vulvar inflammation in women with and without LPV pain, establishes tissue-specific fibroblasts as sufficient and sensitive mediators of cytokine release, and relates fibroblast-mediated cytokine levels with clinically meaningful behavioral outcomes used in the assessment and diagnosis of LPV. This work is the closest we have come to identifying objective and quantifiable indicators of peripheral pathology underlying persistent vulvar pain. Moving forward, it will be important to integrate these findings with information on peripheral afferent sensitization, spinally-mediated central sensitization, and supraspinal processes underlying emotional learning of the chronic pain state.

Longitudinal data from a 15-year national survey of adults are used to test the double jeopardy to health hypothesis as well as the alternative hypotheses that aging levels ethnic differences and that health inequalities persist across the life course. Findings show that African Americans began the study in poorer health and manifested higher mortality. Among survivors, young and middle-aged Black adults developed more serious illness and their subjective health declined more rapidly than their Whites counterparts during the first 10 years of the study. Among subjects with heart failure, Black people were also more likely than Whites to become more disabled over time. Depending upon the health measure considered and the analytic strategy applied, there was evidence for all three processes, but the weight of the evidence shows persistent health inequality over the life course. Indeed, evidence for the age-as-leveler thesis was eliminated by accounting for mortality during the study.

We briefly summarize recent advances regarding brain functional representation of chronic pain, reorganization of resting state brain activity, and of brain anatomy with chronic pain. Based on these observations and recent theoretical advances regarding network architecture properties, we develop a general concept of the dynamic interplay between anatomy and function as the brain progresses into persistent pain, and outline the role of mesolimbic learning mechanisms that are likely involved in maintenance of chronic pain.

Provoked vestibulodynia, the most common form of vulvodynia (unexplained pain of the vulva), is a prevalent, idiopathic pain disorder associated with a history of recurrent candidiasis (yeast infections). It is characterized by vulvar allodynia (painful hypersensitivity to touch) and hyperinnervation. We tested whether repeated, localized exposure of the vulva to a common fungal pathogen can lead to the development of chronic pain. A subset of female mice subjected to recurrent Candida albicans infection developed mechanical allodynia localized to the vulva. The mice with allodynia also exhibited hyperinnervation with peptidergic nociceptor and sympathetic fibers (as indicated by increased protein gene product 9.5, calcitonin gene-related peptide, and vesicular monoamine transporter 2 immunoreactivity in the vaginal epithelium). Long-lasting behavioral allodynia in a subset of mice was also observed after a single, extended Candida infection, as well as after repeated vulvar (but not hind paw) inflammation induced with zymosan, a mixture of fungal antigens. The hypersensitivity and hyperinnervation were both present at least 3 weeks after the resolution of infection and inflammation. Our data show that infection can cause persistent pain long after its resolution and that recurrent yeast infection replicates important features of human provoked vulvodynia in the mouse.

Hypoactive Sexual Desire Disorder (HSDD) is diagnosed when an individual indicates persistent or recurrent blunted levels of sexual desire and/or a lack of sexual fantasies that cause marked distress and/or interpersonal difficulties [1]. This diagnosis is intended to include only individuals who experience dissatisfaction with their low levels of sexual desire. Women with this condition will often report that they “want to want” more sex, while women with low levels of sexual desire that do not meet HSDD criteria will indicate no bother or concerns with the frequency of their sexual desire. The subjective experience of distress caused by low desire is a critical component of the diagnosis of HSDD because many individuals are not alarmed by low levels of sexual desire. Indeed, an epidemiological study conducted in Australia demonstrated that 32% of women who are 20–70 years old report low sexual desire, but only 16% report distress caused by the low sexual desire [2].

Background The diversity of quality improvement interventions (QIIs) has impeded the use of evidence review to advance quality improvement activities. An agreed-upon framework for identifying QII articles would facilitate evidence review and consensus around best practices. Aim To adapt and test evidence review methods for identifying empirical QII evaluations that would be suitable for assessing QII effectiveness, impact or success. Design Literature search with measurement of multilevel inter-rater agreement and review of disagreement. Methods Ten journals (2005-2007) were searched electronically and the output was screened based on title and abstract. Three pairs of reviewers then independently rated 22 articles, randomly selected from the screened list. Kappa statistics and percentage agreement were assessed. 12 stakeholders in quality improvement, including QII experts and journal editors, rated and discussed publications about which reviewers disagreed. Results The level of agreement among reviewers for identifying empirical evaluations of QII development, implementation or results was 73% (with a paradoxically low kappa of 0.041). Discussion by raters and stakeholders regarding how to improve agreement focused on three controversial article selection issues: no data on patient health, provider behaviour or process of care outcomes; no evidence for adaptation of an intervention to a local context; and a design using only observational methods, as correlational analyses, with no comparison group. Conclusion The level of reviewer agreement was only moderate. Reliable identification of relevant articles is an initial step in assessing published evidence. Advancement in quality improvement will depend on the theory- and consensus-based development and testing of a generalizable framework for identifying QII evaluations.

Background Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial. Methods Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator. Results Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups. Conclusions Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.

We used a consumer-driven approach to develop a model smoking-cessation program for women. Four focus groups (N = 23 [5-7/group]), each lasting 2 hours, were led by a professional moderator and audiotaped in 2004. Researchers reviewed transcripts; key themes were identified using scrutiny techniques (Ryan and Bernard, 2003). Necessary elements of a smoking-cessation program for women included support and choice (i.e., control over the program components), suggesting the need for an individualized program. Identifying appropriate components is a critical step in the development of efficacious programs that target substance-abusing populations; focus group methodology is useful in this endeavor. The study's implications and limitations are noted.

To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p.0001), we found no intervention effect on smoking cessation.EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Studies have suggested chronic pain syndromes are associated with neural reorganization in specific regions associated with perception, processing, and integration of pain. Urological chronic pelvic pain syndrome (UCPPS) represents a collection of pain syndromes characterized by pelvic pain, namely Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) and Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS), that are both poorly understood in their pathophysiology, and treated ineffectively. We hypothesized patients with UCPPS may have microstructural differences in the brain compared with healthy control subjects (HCs), as well as patients with irritable bowel syndrome (IBS), a common gastrointestinal pain disorder. In the current study we performed population-based voxel-wise DTI and super-resolution track density imaging (TDI) in a large, two-center sample of phenotyped patients from the multicenter cohort with UCPPS (N = 45), IBS (N = 39), and HCs (N = 56) as part of the MAPP Research Network. Compared with HCs, UCPPS patients had lower fractional anisotropy (FA), lower generalized anisotropy (GA), lower track density, and higher mean diffusivity (MD) in brain regions commonly associated with perception and integration of pain information. Results also showed significant differences in specific anatomical regions in UCPPS patients when compared with IBS patients, consistent with microstructural alterations specific to UCPPS. While IBS patients showed clear sex related differences in FA, MD, GA, and track density consistent with previous reports, few such differences were observed in UCPPS patients. Heat maps illustrating the correlation between specific regions of interest and various pain and urinary symptom scores showed clustering of significant associations along the cortico-basal ganglia-thalamic-cortical loop associated with pain integration, modulation, and perception. Together, results suggest patients with UCPPS have extensive microstructural differences within the brain, many specific to syndrome UCPPS versus IBS, that appear to be localized to regions associated with perception and integration of sensory information and pain modulation, and seem to be a consequence of longstanding pain.

Previous literature on religion and sexual behavior has focused on narrow definitions of religiosity, including religious affiliation, religious participation, or forms of religiousness (e.g., intrinsic religiosity). Trends toward more permissive premarital sexual activity in the North American Christian-Judeo religion support the secularization hypothesis of religion, which posits an increasing gap between religious doctrine and behavior. However, the recent rise of fundamentalist and new age religious movements calls for a reexamination of the current link between religion and sexual behavior. The use of dual definitions of religiosity, including religious affiliation and dimensional subtypes, may further characterize this link. The present cross-sectional study evaluated patterns of sexual behavior in a young adult sample (N = 1302, M age = 18.77 years) in the context of the secularization hypothesis using religious affiliation and a liberal-conservative continuum of religious subtypes: paranormal belief, spirituality, intrinsic religiosity, and fundamentalism. Results indicated few affiliation differences in sexual behavior in men or women. Sexual behaviors were statistically predicted by spirituality, fundamentalism, and paranormal belief, and the endorsement of fundamentalism in particular was correlated with lower levels of female sexual behavior. The secularization hypothesis was supported by consistent levels of sexual activity across affiliations and is contradicted by the differential impact of religiosity subtypes on sexual behavior. Findings suggested that the use of religious subtypes to evaluate religious differences, rather than solely affiliation, may yield useful insights into the link between religion and sexual behavior.

Despite the high prevalence of genital pain in healthy young adult women, limited research has addressed genital pain during intercourse using contemporary models of multidimensional sexual function. The objectives of this study were threefold: (1) to identify differences in sexual functioning in women who experience genital pain compared to pain free women; (2) to identify predictors of sexual functioning in women with and without genital pain; and (3) to identify predictors of sexual satisfaction in women with and without genital pain. Sexually active female undergraduates (n = 651) were administered the Female Sexual Function Index and the Derogatis Sexual Functioning Inventory. We evaluated the sexual factors that impact the sexual function of women with any pain (including high and low pain groups) versus women with no history of pain. Women with genital pain reported greater rates of sexual dysfunction as compared to pain-free women; however, sexual functioning in the high versus low pain groups was distinguished primarily by vaginal lubrication. Women in the high pain group showed negative correlations between domains of sexual satisfaction and genital pain frequency and intensity that were not found in the low pain group. For pain-free women, intercourse played a strong role in sexual satisfaction, whereas non-intercourse sexual behavior was central to sexual satisfaction in women who reported pain. The evaluation of levels of genital pain may provide insight into the mechanisms underlying the impairment of sexual function, sexual behavior, and sexual satisfaction.

Racial health inequality is related to socioeconomic status (SES), but debate ensues on the nature of the relationship. Using the US National Health and Nutrition Examination Survey I and the subsequent follow-up interviews, this research examines health disparities between white and black adults and whether the SES/health gradient differs across the two groups in the USA. Two competing mechanisms for the conditional or interactive relationship between race and SES on health are examined during a 20-year period for black and white Americans. Results show that black adults began the study with more serious illnesses and poorer self-rated health than white adults and that the disparity continued over the 20 years. Significant interactions were found between race and education as well as race and employment status on health outcomes. The interaction effect of race and education showed that the racial disparity in self-rated health was largest at the higher levels of SES, providing some evidence for the "diminishing returns" hypothesis; as education levels increased, black adults did not have the same improvement in self-rated health as white adults. Overall, the findings provide evidence for the continuing significance of both race and SES in determining health status over time.

BACKGROUND Colorectal cancer (CRC) screening tests (e.g., fecal occult blood testing [FOBT], flexible sigmoidoscopy [FS], etc.) are underused. Primary care providers (PCPs) play a critical role in screening, but barriers to and facilitators of screening as perceived by PCPs in managed care settings are poorly understood. The objectives of the current study were to describe current CRC screening practices and to explore determinants of test use by PCPs in a managed care setting. METHODS In 2000, a self-administered survey was mailed to a stratified, random sample of 1340 PCPs in a large, network model health maintenance organization in California. RESULTS The survey response rate was 67%. PCPs indicated that 79% of their standard-risk patients were screened for CRC. PCP-reported median rates of recommendation for the use of specific screening tests were 90% for FOBT and 70% for FS. In logistic regression models, perceived barriers to the use of FOBT and FS included patient characteristics (e.g., education) and PCP-related barriers (e.g., failure to recall that patients were due for testing). Perceived facilitators of the use of FOBT and FS included interventions targeting certain aspects of the health care system (e.g., reimbursement) and interventions targeting certain aspects of the tests themselves (e.g., provision of evidence of a test's effectiveness). Assignment of high priority to screening, integrated medical group (as opposed to independent practice association) affiliation, and the proportion of patients receiving routine health maintenance examinations were positively associated with reported test use. CONCLUSIONS CRC screening tests appear to be underused in the managed care setting examined in the current study. The perceived barriers and facilitators that were identified can be used to guide interventions aimed at increasing recommendations for, as well as actual performance of, CRC screening. Cancer 2004. © 2004 American Cancer Society.

Evidence-based guidelines recommend regular colorectal cancer (CRC) screening for adults 50 years and older, yet screening rates remain very low. In this paper we describe the challenges associated with recruitment and retention of provider organizations (POs) for a group randomized, controlled effectiveness trial to increase CRC screening, among patients in a managed care health insurance plan. Using the health plan as the sampling frame, we recruited POs to test a facilitated quality improvement program to increase CRC screening. Defined eligibility and recruitment procedures were used as part of this process. We successfully recruited 36 POs over the course of 9 months; however, there were many challenges associated with the recruitment and retention process, including difficulties in (a) identifying the PO medical director and the individual authorized to agree to study participation, (b) making contact with the medical director, and (c) obtaining the materials necessary to initiate the study. All of these factors delayed the research substantially. Retention activities were also a major challenge in that one-third of the medical directors changed during the course of the intervention. This study benefited from a strong partnership between the health plan and the research group. Although many challenges exist, there are tremendous opportunities that result from the design and conduct of effectiveness research in existing POs. Successful implementation of programs that are feasible and take advantage of existing quality improvement mechanisms within the PO has potential to improve CRC screening rates and can have a major public health impact.

Most sociological and epidemiological studies of health status in adulthood rely on reports of morbidity from respondents to social surveys. This study compares self-reported morbidity with indicators of morbidity from physicians' evaluations and examines the predictive validity of each indicator on self-assessed health and mortality in adulthood. Special attention is given to differences in the measures between white and African American adults. Adults from a large national survey received a detailed medical examination by a physician; they also were asked about the presence of 36 health conditions. Results indicate that self-reported morbidity is equal or superior to physician-evaluated morbidity in a prognostic sense. Both types of morbidity predict self-assessed health for white respondents, but physician-evaluated morbidity is not related to either self-assessed health or mortality for African American respondents

Administrative records from the Medicare Program of the Health Care Financing Administration provide a valuable source of information for research on medical and public policy issues. This administrative database contains information on utilization of covered medical services, diagnoses, episodes of illness, and Medicare-covered costs of health care. Combining such data with information from national surveys on health status, demographics, and socioeconomic attributes substantially expands the scope of potential research questions that can be addressed. This article discusses the benefits and difficulties of linking Medicare administrative data with survey data and provides brief summaries of five national surveys of elderly U.S. citizens. These surveys can be valuable resources for examining the health status and life experiences of the Medicare population.

Stress is a common experience in modern society, and it can affect both physical and mental health. Recognizing that not all stress is detrimental to health, this research examines the relationship between perceptions of distress and perceived health within a longitudinal framework. Using two waves of a nationally representative panel study, the National Health and Nutrition Examination Survey I (NHANES I), structural equation modeling revealed that distress leads to more negative health perceptions. In addition, perceived health was found to impact distress levels at the following wave suggesting a cycle of decline between distress and perceived health. Finally, perceived health was found to have predictive validity in determining future functional disability even when considering distress.

Disability has long been identified as a predictor of self-assessed health, but some studies suggest the opposite causal direction. The aim of this study is to examine the dynamic relationships between physical disability and assessments of health among Black and White adults while simultaneously considering changing morbidity. Research questions include: Do more negative health assessments lead to greater morbidity and physical disability? Do negative health assessments lead to a cycle of health decline over time? These questions were addressed for Black and White respondents over 15 years using data from three waves of the National Health and Nutrition Examination Survey I: Epidemiologic Follow-Up Study. Results from structural equation modeling reveal that self-assessed health predicts subsequent change in health, suggesting a cycle between health problems and negative health assessments for both White and Black adults. In addition, self-assessed health among African Americans declined at a faster rate than was the case for White adults.

Considerable research on minority health has examined whether members of a minority group experience more rapid health declines than the White majority when both groups reach later life. Researchers have sought to determine if being both old and a member of a minority creates a double disadvantage to health. The primary purpose of this research is to test the double jeopardy to health hypothesis among Black and White Americans using data from a 15-year panel study of adults: National Health and Nutrition Examination Survey I: Epidemiological Follow-up Study (NHEFS). African Americans have poorer health at all three times on a variety of health status measures, but no evidence for double jeopardy was uncovered. There were important racial differences for change in health status but Black Americans of all ages -- including Black older adults -- suffered from growing disability and more negative ratings of health. Black adults are more likely to develop serious illness, and their ratings of health decline more rapidly than is the case for White respondents. While there is little support for the double jeopardy hypothesis as originally stated, there is overwhelming evidence to show that the health of Black Americans of all ages declines at a faster rate. The formulation of the double jeopardy hypothesis is critiqued on several points: ontogenetic fallacy, attribution of discrimination, and selective mortality.

BACKGROUND Heart disease is the leading cause of death for women in the United States, accounting for 24.5 % of all deaths among women. Earlier research has demonstrated racial/ethnic differences in prevalence of cardiovascular (CVD) risk factors. OBJECTIVE To empirically examine the prevalence of CVD risk factors among a national sample of women Veterans by race/ethnicity, providing the first portrait of women Veterans’ cardiovascular care needs. DESIGN AND PARTICIPANTS Cross-sectional, national population-based telephone survey of 3,611 women Veterans. MEASUREMENTS Women Veterans were queried about presence of diabetes, hypertension, obesity, tobacco use and physical activity. Four racial/ethnic categories were created: Hispanic, Non-Hispanic White (White), Non-Hispanic Black (Black), and Other. Logistic regressions were conducted for each risk factor to test for racial/ethnic differences, controlling for age (under 40 vs. 40 and over). KEY RESULTS Racial/ethnic differences in CVD risk factors persisted after adjusting for age. Black women Veterans were more likely to report a diagnosis of diabetes (OR: 2.58, 95 % CI: 1.07, 6.21) or hypertension (OR: 2.31, 95 % CI: 1.10, 4.83) and be obese (OR: 2.06, 95 % CI: 1.05, 3.91) than White women Veterans. Hispanic women Veterans were more likely than White women Veterans to report diabetes (OR: 4.20, 95 % CI: 1.15, 15.39) and daily smoking (OR: 3.38, 95 % CI: 1.01, 11.30), but less likely to report a hypertension diagnosis (OR 0.21, 95% CI: 0.07, 0.64) or to be obese (OR: 0.39, 95 % CI: 0.18, 0.81). CONCLUSIONS Among women Veterans, CVD risks vary by race/ethnicity. Black women Veterans consistently face higher CVD risk compared to White women Veterans, while results are mixed for Hispanic women Veterans.