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We compared the cost-effectiveness (CE) of an active case-finding (ACF) programme for household contacts of tuberculosis (TB) cases enrolled in first-line treatment to routine passive case-finding (PCF) within an established national TB programme in Peru. Decision analysis was used to model detection of TB in household contacts through: (1) self-report of symptomatic cases for evaluation (PCF), (2) a provider-initiated ACF programme, (3) addition of an Xpert MTB/RIF diagnostic test for a single sputum sample from household contacts, and (4) all strategies combined. CE was calculated as the incremental cost-effectiveness ratio (ICER) in terms of US dollars per disability-adjusted life years (DALYs) averted. Compared to PCF alone, ACF for household contacts resulted in an ICER of $2155 per DALY averted. The addition of the Xpert MTB/RIF diagnostic test resulted in an ICER of $3275 per DALY averted within a PCF programme and $3399 per DALY averted when an ACF programme was included. Provider-initiated ACF of household contacts in an urban setting of Lima, Peru can be highly cost-effective, even including costs to seek out contacts and perform an Xpert/MTB RIF test. ACF including Xpert MTB/RIF was not cost-effective if TB cases detected had high rates of default from treatment or poor outcomes.

© 2015 Shah et al. Background: We designed a pragmatic stepped-wedge cluster randomized controlled trial in order to evaluate provider-initiated evaluation of household contacts (HCs) of smear positive tuberculosis (TB) cases within a routine TB program in Lima, Peru. Methods/Design: National TB program (NTP) officers of San Juan de Lurigancho District (Lima, Peru) and university-based researchers jointly designed a pragmatic stepped-wedge cluster randomized trial design in order to evaluate a planned active case finding (ACF) program for all HCs of smear-positive TB cases in 34 district healthcare centres. Randomization of time to intervention initiation was stratified by health centre TB case rate. The ACF intervention included provider-initiated home visits of all new sputum smear positive TB patients in order to evaluate household contacts for active TB. Active TB was diagnosed using symptom screening, sputum screening, chest x-ray and clinical evaluation. Once initiated, ACF was provided by NTP staff and integrated into the routine DOTS TB program activities. Discussion: This study protocol describes the pragmatic stepped-wedge cluster randomized trial of active household contact evaluations within an NTP. The stepped-wedge design met overlapping needs of local TB programmers and researchers to adequately evaluate the large-scale roll out of a new control program in a TB endemic setting. Multiple planning meetings were required to develop the necessary networks and in order to understand the operations, needs and goals of the NTP staff and researchers collaborating on this project. The advantages and challenges of using this study design in practice and within existing routine TB programs in a middle-income country context are discussed. Trial registration: ClinicalTrials.gov NCT02174380. Registered 24 Jun 2014

SettingPeru reports among the highest multidrug-resistant tuberculosis (MDR-TB) rates in the Americas, with a growing proportion in previously untreated tuberculosis (TB) cases. The identification of clusters of primary MDR-TB compared with drug-susceptible TB (DS-TB) could help prioritize interventions.ObjectiveTo examine the clustering of primary MDR-TB case residences and their proximity to high-risk locations in San Juan de Lurigancho District, Lima, Peru.DesignEnrolled primary MDR-TB and primary DS-TB cases were interviewed and their primary residence was recorded using handheld Global Positioning System devices. Kuldorff's spatial scan statistic was used for cluster detection (SaTScan(TM), v. 9.1.1). Identified clusters were visualized in Quantum Geographic Information Systems software (v1.8.0). The following cluster centers were tested: a health centre with the highest TB and MDR-TB rates (Clinic X), a hospital and two prisons. Using regression analyses, we examined predictors of primary MDR-TB cases.ResultsA statistically significant cluster of primary MDR-TB cases was identified within a 2.29 km radius around Clinic X. Proximity to Clinic X remained a significant predictor of primary MDR-TB in adjusted regression analyses.ConclusionWe identified a hotspot of primary MDR-TB cases around Clinic X in a TB-endemic area. Causes of this clustering require investigation; targeted interventions for this high-risk area should be considered.

Background Before 2012, few studies had addressed pregnancy outcomes following maternal influenza vaccination; however, the number of publications on this topic has increased recently. Objectives To review comparative studies evaluating fetal death or preterm birth associated with influenza vaccination during pregnancy. Search strategy We searched bibliographic databases from inception to April 2014. Selection criteria Experimental or observational studies assessing the relationship between influenza vaccination during pregnancy and fetal death or preterm birth. Data collection and analysis Two reviewers independently abstracted data from studies meeting the inclusion criteria. Main results We included one randomised clinical trial and 26 observational studies. Meta-analyses were not considered appropriate because of high clinical and statistical heterogeneity. Three studies of fetal death at any gestational age reported adjusted effect estimates in the range 0.56-0.79, and four of five studies of fetal death at <20 weeks reported adjusted estimates between 0.89 and 1.23, all with confidence intervals including 1.0. Adjusted effect estimates for four of five studies of fetal death at ≥20 weeks ranged from 0.44 to 0.77 (two with confidence intervals not crossing 1.0), whereas a fifth reported a non-significant effect in the opposite direction. Among 19 studies of preterm birth, there was no strong evidence suggesting any increased risk, and meta-regression did not explain the moderate between-study heterogeneity ( I2 = 57%). Authors' conclusions Most studies reported no association between fetal death or preterm birth and influenza vaccination during pregnancy. Although several reported risk reductions, results may be biased by methodological shortcomings of observational studies of influenza vaccine effectiveness. [ABSTRACT FROM AUTHOR]

Patients who initiate chronic dialysis with a functional arteriovenous (AV) fistula survive longer and experience fewer complications after initiation of dialysis than those who require a catheter. However, more than 80% of patients in this country begin chronic dialysis with a catheter rather than a fistula, either because they do not have a permanent access or their permanent access is not ready for use. Increasing rates of predialysis AV fistula placement is thus considered a priority area for predialysis care in this country. However, achievement of a functional AV fistula by the time of dialysis initiation is not always an easy proposition. We here outline the limitations of currently recommended approaches toward timing of AV fistula placement. We also highlight the potential complexity of patient and clinician decision making in this area. Particularly in the presence of advanced age and a high burden of comorbidity and disability, it is often uncertain whether patients will need, want, or benefit from chronic dialysis. Adding to this uncertainty, it is often not known whether, when, and after how many revisions an AV fistula will be sufficiently mature to support dialysis. We argue that it is important to acknowledge the complexity of medical decision making in this area and the limitations of currently available prognostic tools to guide such decision making. We conclude that initiation of dialysis with a catheter is appropriate for patients in whom the perceived harms of preemptive fistula placement outweigh the expected benefit. [ABSTRACT FROM AUTHOR]

In the United States, black women are at much greater risk for obesity than black men. We explored whether adolescent behaviors (family dinners, hours of television, playing sports with mother, playing sports with father, bouts of physical activity) were associated with gender disparity in 6-year obesity incidence in young adulthood. We used data from the nationally representative National Longitudinal Study of Adolescent Health to examine adolescent behaviors in nonimmigrant black (n = 1,503) and white (n = 4,452) youths in 1994-95 (aged 11-19 years) and 1995-96 (aged 12-20). We assessed gender disparity in obesity incidence (female incidence minus male incidence) during young adulthood (2001-02; aged 18-26). Standardized gender disparities were calculated using race- and gender-stratified, covariate-adjusted logistic regression models in which males and females were set to the same distributions of adolescent behaviors. In adolescence, black females reported less leisure-time physical activity and lower likelihood of playing sports with either parent compared with black males. Setting adolescent behaviors equal for black males and females did not reduce the estimated gender disparity in obesity incidence (nonstandardized: 9.8 percentage points (95% confidence interval (CI): 4.5, 15.1); fully standardized: 10.2 percentage points (5.2, 15.2)). There was little gender disparity in whites before or after adjustments. To our knowledge, this is the first study to examine to what extent behavioral differences during adolescence might account for gender disparity in obesity incidence in black young adults. Male-female differences in these adolescent behaviors did not appear to underlie the gender gap in young adult obesity. [ABSTRACT FROM AUTHOR]

Background: Individuals with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) have high plasma total homocysteine (tHcy) levels, which may be a risk factor for cognitive impairment. Whether treatment with high-dose B vitamins to decrease high tHcy levels improves cognition in persons with kidney disease is unknown.Study Design: Randomized controlled trial.Setting& Participants: A substudy of 659 patients (mean age, 67.3 +/- 11.7 years) who participated in a randomized double-blind clinical trial 5 years in duration conducted in 36 US Department of Veterans Affairs medical centers of the effect on all-cause mortality of vitamin-induced lowering of plasma tHcy level. 236 (35.8%) were treated by using dialysis (ESRD) and 423 (64.2%) had a Cockcroft-Gault estimated creatinine clearance of 30 mL/min or less (advanced CKD). All had high tHcy levels (> or =15 micromol/L) at baseline. Cognitive assessments began during the follow-up period of the main trial 3 years after treatment began; participants subsequently were retested 1 year later to assess cognitive change.Intervention: Daily high-dose B vitamin capsule (40 mg of folic acid, 100 mg of vitamin B(6), and 2 mg of vitamin B(12)) or placebo.Outcomes: Cognitive function at initial assessment and 1 year later.Measurements: Telephone Interview of Cognitive Status-modified, supplemented with attention, working memory, and executive function tests.Results: Initial cognitive function was impaired in approximately 19% of patients regardless of treatment assignment (vitamin or placebo) or kidney disease status (advanced CKD or ESRD). Treatment decreased tHcy levels by 26.7%. Unadjusted and adjusted analyses showed that treatment did not improve initial cognitive outcomes or affect subsequent cognitive status 1 year later.Limitations: Cognitive assessments began after treatment was initiated; cognitive assessment was limited.Conclusion: Treatment with high daily doses of B vitamins, which decreased tHcy levels, did not affect cognitive outcomes in patients with advanced CKD and ESRD. [ABSTRACT FROM AUTHOR]

BACKGROUND: Abnormalities in the gene regulating methylenetetrahydrofolate reductase (MTHFR) are associated with increased homocysteine levels and increased mortality in normal and chronic kidney disease (CKD) populations. STUDY DESIGN: Gene association study. SETTING & PARTICIPANTS: This was a substudy of 677 patients from 21 Veterans Affairs medical centers participating in a randomized clinical trial (Homocysteinemia in Kidney and End-Stage Renal Disease [HOST]) of the effect on all-cause mortality of vitamin-induced lowering of plasma homocysteine levels. Of 677 patients, 213 (31%) were treated by using dialysis (end-stage renal disease [ESRD]) and 464 (69%) had a Cockcroft-Gault estimated creatinine clearance less than 30 mL/min (advanced CKD). PREDICTOR: Polymorphisms C677T (rs1801133) and A1298C (rs1801131) of the MTHFR gene. OUTCOMES: Unadjusted and adjusted all-cause mortality. MEASUREMENTS: DNA was extracted from blood samples and amplified by means of polymerase chain reaction. RESULTS: The adjusted hazard ratio in a recessive model of the relationship between the C677T polymorphism and all-cause mortality in all patients was 1.47 (95% confidence interval, 1.00 to 2.16; P = 0.05). In patients with ESRD with the mutant TT genotype, the adjusted hazard ratio for mortality in all patients was 2.27 (95% confidence interval, 1.07 to 4.84; P = 0.03); patients with advanced CKD showed a similar, although not significant, trend. The risk of myocardial infarction (P = 0.05) and composite risk of myocardial infarction, stroke, lower-extremity amputation, and mortality (P = 0.02) were greater in patients with ESRD with the mutant T allele at nucleotide 677. The overall relationship between the A1298C polymorphism and mortality was not significant (P = 0.6). LIMITATIONS: Participants were 98% men; DNA samples were not obtained at enrollment in HOST; linkage disequilibrium with another causal polymorphism is a potential confounding factor; and power was reduced by the limited number of participants. CONCLUSIONS: These findings provide additional support for the hypothesis that the mutant TT genotype at nucleotide 677 of the gene regulating MTHFR activity may increase the mortality risk in patients with ESRD. Copyright © 2009 National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

BACKGROUND: Differences in the association of socioeconomic status (SES) with obesity may underlie the racial/ethnic disparities in obesity that increase dramatically across the transition to adulthood in the United States. The aim of this study was to examine racial/ethnic differences in the influence of life course SES on longitudinal obesity patterns from adolescence to adulthood. METHODS: Latent class analysis was used on a nationally representative, diverse sample of 12 940 adolescents followed into young adulthood (mean age = 21.7 years) to identify life course SES group profiles based on SES data in adolescence and young adulthood. Gender-stratified multinomial logistic regression models estimated the association of SES groups with obesity incidence and persistence versus staying non-obese. RESULTS: No significant interactions with race/ethnicity were observed, although racial/ethnic minorities had the highest obesity risk across SES groups. Racial/ethnic-pooled associations between disadvantaged SES exposure and higher obesity risk were strong but differed by gender. Males with a disadvantaged background who experienced early transitions into the labour force, marriage and residential independence had the highest risk of obesity incidence (relative risk ratio (RRR) = 1.64; 95% confidence interval (CI) 1.12 to 2.40), while females exposed to persistent adversity were at highest risk (RRR = 3.01, 95% CI 1.95 to 4.66). In general, SES group membership had a stronger relationship with obesity persistence than incidence. CONCLUSIONS: The relationship between SES and obesity patterns is similar across race/ethnicity and differs by gender during the transition to adulthood. However, stronger associations with obesity persistence and enduring racial/ethnic disparities in obesity risk across SES groups suggest that these social factors play a larger role in disparities earlier in the life course. [ABSTRACT FROM AUTHOR]

The U.S. Food and Drug Administration's (FDA) rationale for supporting the development and approval of BiDil (a combination of hydralazine hydrochloride and isosorbide dinitrate; H-I) for heart failure specifically in black patients was based on under-powered, post hoc subgroup analyses of two relatively old trials (V-HeFT I and II), which were further complicated by substantial covariate imbalances between racial groups. Indeed, the only statistically significant difference observed between black and white patients was found without any adjustment for potential confounders in samples that were unlikely to have been adequately randomized. Meanwhile, because the accepted baseline therapy for heart failure has substantially improved since these trials took place, their results cannot be combined with data from the more recent trial (A-HeFT) amongst black patients alone. There is therefore little scientific evidence to support the approval of BiDil only for use in black patients, and the FDA's rationale fails to consider the ethical consequences of recognizing racial categories as valid markers of innate biological difference, and permitting the development of group-specific therapies that are subject to commercial incentives rather than scientific evidence or therapeutic imperatives. This paper reviews the limitations in the scientific evidence used to support the approval of BiDil only for use in black patients; calls for further analysis of the V-HeFT I and II data which might clarify whether responses to H-I vary by race; and evaluates the consequences of commercial incentives to develop racialized medicines. We recommend that the FDA revise the procedures they use to examine applications for race-based therapies to ensure that these are based on robust scientific claims and do not undermine the aims of the 1992 Revitalization Act. [ABSTRACT FROM AUTHOR]

Context: The arteriovenous fistula is the preferred type of vascular access for hemodialysis because of lower thrombosis and infection rates and lower health care expenditures compared with synthetic grafts or central venous catheters. Early failure of fistulas due to thrombosis or inadequate maturation is a barrier to increasing the prevalence of fistulas among patients treated with hemodialysis. Small, inconclusive trials have suggested that antiplatelet agents may reduce thrombosis of new fistulas.Objective: To determine whether clopidogrel reduces early failure of hemodialysis fistulas.Design, Setting, and Participants: Randomized, double-blind, placebo-controlled trial conducted at 9 US centers composed of academic and community nephrology practices in 2003-2007. Eight hundred seventy-seven participants with end-stage renal disease or advanced chronic kidney disease were followed up until 150 to 180 days after fistula creation or 30 days after initiation of dialysis, whichever occurred later.Intervention: Participants were randomly assigned to receive clopidogrel (300-mg loading dose followed by daily dose of 75 mg; n = 441) or placebo (n = 436) for 6 weeks starting within 1 day after fistula creation.Main Outcome Measures: The primary outcome was fistula thrombosis, determined by physical examination at 6 weeks. The secondary outcome was failure of the fistula to become suitable for dialysis. Suitability was defined as use of the fistula at a dialysis machine blood pump rate of 300 mL/min or more during 8 of 12 dialysis sessions.Results: Enrollment was stopped after 877 participants were randomized based on a stopping rule for intervention efficacy. Fistula thrombosis occurred in 53 (12.2%) participants assigned to clopidogrel compared with 84 (19.5%) participants assigned to placebo (relative risk, 0.63; 95% confidence interval, 0.46-0.97; P = .018). Failure to attain suitability for dialysis did not differ between the clopidogrel and placebo groups (61.8% vs 59.5%, respectively; relative risk, 1.05; 95% confidence interval, 0.94-1.17; P = .40).Conclusion: Clopidogrel reduces the frequency of early thrombosis of new arteriovenous fistulas but does not increase the proportion of fistulas that become suitable for dialysis. Trial Registration clinicaltrials.gov Identifier: NCT00067119. [ABSTRACT FROM AUTHOR]

Disparities in preterm birth by race and ethnic group have been demonstrated in the United States. Recent research has focused on the impact of neighborhood context on racial disparities in pregnancy outcomes. The authors utilized vital-record birth certificate data and US Census data from eight geographic areas in four states (Maryland, Michigan, North Carolina, and Pennsylvania) to examine the relation between neighborhood deprivation and preterm birth among non-Hispanic White and Black women. The years covered by the data varied by site and ranged from 1995 to 2001. Results were adjusted for maternal age and education, and specific attention was paid to racial and geographic differences in the relation between neighborhood deprivation and preterm birth. Preterm birth rates were higher for non-Hispanic Blacks (10.42-15.97%) than for non-Hispanic Whites (5.77-9.13%), and neighborhood deprivation index values varied substantially across the eight areas. A significant association was found between neighborhood deprivation and risk of preterm birth; for the first quintile of the deprivation index versus the fifth, the adjusted summary odds ratio was 1.57 (95% confidence interval: 1.41, 1.74) for non-Hispanic Whites and 1.15 (95% confidence interval: 1.08, 1.23) for non-Hispanic Blacks. In this study, deprivation at the neighborhood level was significantly associated with increased risk of preterm birth among both non-Hispanic White women and non-Hispanic Black women. [ABSTRACT FROM AUTHOR]

Objective: Recent research indicates that n-3 fatty acids can inhibit cognitive decline, perhaps differentially by hypertensive status.Design: We tested these hypotheses in a prospective cohort study (the Atherosclerosis Risk in Communities). Dietary assessment using a food-frequency questionnaire and plasma fatty acid exposure by gas chromatography were completed in 1987-1989 (visit 1), while cognitive assessment with three screening tools--the Delayed Word Recall Test, the Digit Symbol Substitution Test of the Wechsler Adult Intelligence Scale-Revised and the Word Fluency Test (WFT)--was completed in 1990-1992 (visit 2) and 1996-1998 (visit 4). Regression calibration and simulation extrapolation were used to control for measurement error in dietary exposures.Setting: Four US communities--Forsyth County (North Carolina), Jackson (Mississippi), suburbs of Minneapolis (Minnesota) and Washington County (Maryland).Subjects: Men and women aged 50-65 years at visit 1 with complete dietary data (n = 7814); white men and women in same age group in the Minnesota field centre with complete plasma fatty acid data (n = 2251).Results: Findings indicated that an increase of one standard deviation in dietary long-chain n-3 fatty acids (% of energy intake) and balancing long-chain n-3/n-6 decreased the risk of 6-year cognitive decline in verbal fluency with an odds ratio (95% confidence interval) of 0.79 (0.66-0.95) and 0.81 (0.68-0.96), respectively, among hypertensives. An interaction with hypertensive status was found for dietary long-chain n-3 fatty acids (g day-1) and WFT decline (likelihood ratio test, P = 0.06). This exposure in plasma cholesteryl esters was also protective against WFT decline, particularly among hypertensives (OR = 0.51, P < 0.05).Conclusion: One implication from our study is that diets rich in fatty acids of marine origin should be considered for middle-aged hypertensive subjects. To this end, randomised clinical trials are needed. [ABSTRACT FROM AUTHOR]

Context: High plasma homocysteine levels are a risk factor for mortality and vascular disease in observational studies of patients with chronic kidney disease. Folic acid and B vitamins decrease homocysteine levels in this population but whether they lower mortality is unknown.Objective: To determine whether high doses of folic acid and B vitamins administered daily reduce mortality in patients with chronic kidney disease.Design, Setting, and Participants: Double-blind randomized controlled trial (2001-2006) in 36 US Department of Veterans Affairs medical centers. Median follow-up was 3.2 years for 2056 participants aged 21 years or older with advanced chronic kidney disease (estimated creatinine clearance < or =30 mL/min) (n = 1305) or end-stage renal disease (n = 751) and high homocysteine levels (> or = 15 micromol/L).Intervention: Participants received a daily capsule containing 40 mg of folic acid, 100 mg of pyridoxine hydrochloride (vitamin B6), and 2 mg of cyanocobalamin (vitamin B12) or a placebo.Main Outcome Measures: The primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke, amputation of all or part of a lower extremity, a composite of these 3 plus all-cause mortality, time to initiation of dialysis, and time to thrombosis of arteriovenous access in hemodialysis patients.Results: Mean baseline homocysteine level was 24.0 micromol/L in the vitamin group and 24.2 micromol/L in the placebo group. It was lowered 6.3 micromol/L (25.8%; P < .001) in the vitamin group and 0.4 micromol/L (1.7%; P = .14) in the placebo group at 3 months, but there was no significant effect on mortality (448 vitamin group deaths vs 436 placebo group deaths) (hazard ratio [HR], 1.04; 95% CI, 0.91-1.18). No significant effects were demonstrated for secondary outcomes or adverse events: there were 129 MIs in the vitamin group vs 150 for placebo (HR, 0.86; 95% CI, 0.67-1.08), 37 strokes in the vitamin group vs 41 for placebo (HR, 0.90; 95% CI, 0.58-1.40), and 60 amputations in the vitamin group vs 53 for placebo (HR, 1.14; 95% CI, 0.79-1.64). In addition, the composite of MI, stroke, and amputations plus mortality (P = .85), time to dialysis (P = .38), and time to thrombosis in hemodialysis patients (P = .97) did not differ between the vitamin and placebo groups.Conclusion: Treatment with high doses of folic acid and B vitamins did not improve survival or reduce the incidence of vascular disease in patients with advanced chronic kidney disease or end-stage renal disease.Trial Registration: clinicaltrials.gov Identifier: NCT00032435. [ABSTRACT FROM AUTHOR]

BACKGROUND: Persons belonging to the working class or living in an adverse social environment at particular periods of their life course may have an increased risk of chronic kidney disease (CKD). METHODS: This hypothesis was examined among participants of the Life Course Socioeconomic Status Study, an ancillary study of the Atherosclerosis Risk in Communities Study, conducted in 2001 (mean age, 67.4 years; N = 12,631). CKD was defined by hospital discharge diagnosis and/or estimated glomerular filtration rate less than 45 mL/min/1.73 m(2) (<0.75 mL/s/1.73 m(2)). Social class was categorized as working class or non-working class at ages 30, 40, or 50 years. Area-level socioeconomic status was based on a composite of census scores during the same period. Adjusted odds ratios were obtained within strata of white and African-American race. RESULTS: The adjusted odds ratio of CKD for persons belonging to the working class versus non-working class at age 30 was 1.4 (95% confidence interval, 1.0 to 2.0) in whites and 1.9 (95% confidence interval, 1.1 to 3.0) in African Americans. Working class membership was associated with CKD, even at earlier stages of adult life, and class was associated more strongly with CKD than was education. Working class membership also suggested a stronger association with CKD among African Americans than whites, independent of diabetes and hypertension status. At later periods in the life course, area socioeconomic status was associated with CKD. CONCLUSION: Socioeconomic factors, including area socioeconomic status and social class, are associated with CKD and may account for some of the racial disparity in kidney disease. Copyright © 2007 by the National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

PurposeBreast cancer incidence rates are reported to be higher in urban compared with rural areas in the United States. We investigated the relationship between urbanization and breast cancer in North Carolina (1995-1999), and considered hospital characteristics as an explanation.MethodsWe calculated age-adjusted in situ and invasive female breast cancer incidence rates stratified by race, urbanization (Urban Influence Codes), and the presence of a hospital with a cancer registry and cancer program approval in a county.ResultsFor white women, incidence rate ratios (IRRs) comparing the most urban with the most rural counties were 1.60 for in situ and 1.18 for invasive cancer. For non-white women, IRRs were 1.27 and 0.99, respectively. IRRs for incidence in registry hospital counties versus those without were all > 1.00 and differences were greater for in situ cancer than invasive. For most strata, urban excesses were attenuated when further stratified by registry hospital status.ConclusionsFor most strata, we observed excess incidence in urban counties, but it appeared to be explained through the urban preponderance of registry hospitals. Counties with these hospitals may have higher incidence because of increased detection. Area hospital characteristics should be considered when evaluating geographic patterns of breast cancer incidence. [ABSTRACT FROM AUTHOR]

Background: Drug provision within the German statutory health insurance system has undergone several reforms, including the introduction of drug macrobudgets in 1993.Objective: The objective of this study was to investigate the extent to which statutorily (SHI) and fully privately (PHI) health-insured patients were provided with new medication recommended by professional bodies in an equitable fashion using the example of migraine patients.Research Design: We conducted a retrospective cohort study.Setting: A total of 367 primary-care practices (MediPlus, IMS Health) in Germany in the second year of the HealthCare Structural Reform Act were studied.Subjects: Subjected consisted of 7703 SHI and 470 PHI migraineurs (International Classification of Diseases, 10th edition G43) aged 18 to 65 years at their first migraine prescription visit in 1994.Outcome Measure: We compared prescription of oral or subcutaneous serotonin 5HT1B/1D receptor agonist sumatriptan with nonserotoninergic migraine therapy.Results: In multiplicative risk regression with variance estimation accounting for clustering of patients within practices, PHI patients were 2.3 times (95% confidence interval [CI], 1.6-3.3) more likely to receive sumatriptan than their SHI counterparts at the mean age of the cohorts (43 years) adjusted for incident versus prevalent migraine treatment, the gender of the patient, the age, gender, and primary care specialist group of the physician, and the type and the community size class of the practice. This disparity widened by 38% (95% CI, 1-88%) every 10 years of patient age.Conclusion: Even though virtually everyone in Germany has health insurance and drug coverage, use of new and recommended migraine medicines was less common among those with SHI compared with their privately insured counterparts. Systematic studies of access to health care recommended by professional bodies will be critically important to ensure delivery of high-quality health care for all patients. [ABSTRACT FROM AUTHOR]

Purpose: We demonstrate modeling of community-level socioeconomic influences on risk of preterm birth (< 37 weeks gestation) in the Pregnancy, Infection, and Nutrition (PIN) Study.Methods: Community-level information from the US Census was linked to 930 White and 817 African-American (Black) participants from a prospective cohort in central North Carolina through geocoded addresses, providing 123 census tracts with community-level and individual-level data for multi-level statistical analyses.Results: Preterm delivery was experienced by 12.1% of Black and 10.4% of White participants. No appreciable aggregation of risk by community was discernable for White women. For Black women, random-coefficient logistic regression tract-specific preterm prevalence estimates ranged from 10.1% to 14.5%, "shrunk" from observed prevalences of 0% to 100%. Adding tract-level variables to the model representing median splits for household income and percent of single women heads of households with dependents, adjusting for individual-level maternal age and household income, accounted for much of the remaining between-tracts variation.Conclusions: Residing in a wealthier tract (> $30,000/year median income) was associated with reduced risk for Black women, adjusted OR = 0.59 (95% CI: 0.36, 0.96). The estimated conditional effect of lower community prevalence of female headed households was OR = 0.71 (95% CI: 0.43, 1.17). [ABSTRACT FROM AUTHOR]

Many organizations are interested in empowerment, believing that empowered workers will be more effective in reaching their goals. What does it mean to be empowered, and how do people achieve this state? Using qualitative data, we applied the developmental model proposed by Kieffer to a sample of 14 worker-trainers. We found that Kieffer's model worked well with this sample, with some modification. One is that workers did not have to feel personally threatened in order to become activists, as did Kieffer's original sample. A second is that not all workers followed the four stages in the order proposed. Our data also suggested that worker-trainers who had reached a more advanced stage of empowerment were more successful at their task. Finally, based on the model, we also highlight ways to design interventions to help people further develop their stage of empowerment. [ABSTRACT FROM AUTHOR]