Acceptance and safety of directly observed versus self-administered isoniazid preventive therapy in aboriginal peoples in British Columbia

OBJECTIVE: To document experience with directly observed chemoprophylaxis (DOPT) compared to self-administered isoniazid (INH) among aboriginal persons in British Columbia. DESIGN: DOPT was compared to self-administered delivery (SAD) over a 3-year period. All aboriginal persons who received INH chemoprophylaxis in British Columbia between 1992 and 1994 were evaluated. Therapy completion rates and adverse outcomes associated with SAD were compared with DOPT. Treatment allocation was by patient choice. RESULTS: Of 608 people who received INH prophylaxis, 443 received SAD (mean age 31.6 years) and 165 received DOPT (mean age 23.9 years). Two hundred and seventy (60.9%) SAD compared to 124 (75.2%) in the DOPT group completed 6 months of INH (P = 0.0011). The 12-month completion rates were 162/443 (36.6%) for the SAD group and 84/165 (50.9%) for the DOPT group (P = 0.0014). Adverse reactions requiring discontinuation of medication occurred in 13.5% of the patients on SAD and 9.7% of those receiving DOPT (P = 0.202). The most common reason cited for failure to complete therapy was non-cooperation in both groups. There were three deaths in the SAD group, one of which was due to suicide by self-ingestion of INH. CONCLUSIONS: These data demonstrate that in aboriginal people compliance with preventive therapy can be improved by DOPT. Non random allocation to treatment groups might have influenced our findings, and further prospective randomized trials and cost-effectiveness analyses are required.     

Early experience with the contraceptive use of depot medroxyprogesterone acetate in an inner-city clinic population

There are few data on the experience of American women with the injectable depot medroxyprogesterone acetate (DMPA) since its recent approval by the Food and Drug Administration for contraceptive use in the United States. An exploratory study was conducted using chart reviews and telephone interviews of 261 women who initiated DMPA use between December 1992 and June 1994 at either a hospital-based (48%) or community-based (49%) clinic in New York City. Most DMPA users were single (70%), had had at least one birth (88%), had had at least one abortion (67%) and had ever practiced contraception (75% of those with available data). Life-table DMPA continuation rates were 63% at six months and 42% at 12 months and were not affected by the users' age, marital status, pregnancy history, clinic site or proximity of residence to the clinic. Among adults, the risk of DMPA discontinuation was highest during the three-month period following the second injection, while among adolescents, this risk increased throughout the duration of use. The most commonly reported reasons for method discontinuation were side effects, primarily menstrual irregularities (30%) and weight gain (24%).     

Blue-on-yellow perimetry using an Armaly glaucoma screening program

The purpose of the present investigation was to determine whether blue-on-yellow (B/Y) perimetry using a screening program can detect early glaucomatous change before it is evident with standard white-on-white (W/W) screening tests. The subjects included 25 normal, 20 ocular-hypertensive and 27 early glaucomatous eyes. From our results, even in normal subjects, B/Y perimetry alone demonstrated abnormal points in the nasal field in 10 eyes (40%). The Armaly central screening program was thought to be superior to the Armaly full-field program, because the former has less probabilities to detect a false-positive scotoma in the nasal field than the latter. In glaucomatous eyes, more abnormal points were detected by B/Y perimetry than by W/W perimetry. The screening program of B/Y perimetry is more advantageous than conventional tests in detecting early glaucomatous visual field defects.     

Concurrent and predictive validity of an early language screening program

MR imaging has fulfilled many of the dreams of the pediatric radiologist studying the hip: it has allowed depiction of detailed anatomy, evaluation of vascularity and perfusion, determination of synovial proliferation activity in chronic arthritis, and detection of bone marrow changes with great sensitivity. MR imaging also has brought some disenchantments; it lacks specificity, it is expensive and long, and it often requires sedation. MR imaging is operator dependent and hardware and software dependent. Finally, issues of cost-effectiveness and clinical efficacy in comparison with good physical examination and conventional radiography or ultrasound remain unresolved. Demonstration of its cost-effectiveness in the clinical setting is clearly the dominant challenge facing MR imaging today.     

A workplace breast cancer screening program. Costs and components

Screening for breast cancer can result in early detection of malignancies and lives saved. Many employers now offer periodic screening as an employee health benefit, and some have established screening programs in the workplace. This study was performed to identify the employer costs of breast cancer screening in the workplace, referrals for suspicious findings, and initial treatment of malignant disease. Additionally, the costs for these same services, had they been obtained outside of a workplace screening program, were estimated. Data on program components and associated costs for an established employer based breast cancer screening program were obtained. These costs were compared to those among a hypothetical cohort of women not enrolled in the workplace screening program. From 1989 through 1995, 1,416 women participated in the program. Nearly 2,500 screening mammograms and approximately 2,773 clinical breast examinations were performed, resulting in 292 referrals to physicians outside of the program for additional diagnostic procedures and treatment as needed. These referrals resulted in the detection of 12 malignancies: 8 Stage I; 3 Stage II; and 1 Stage III. Mammographic and clinical breast examination screening cost $249,041; referrals resulting in benign disease or no detectable disease cost $185,002; and referrals resulting in malignant disease, followed by initial treatment, cost $148,530. Therefore, the total cost was $582,573. Approximately 47% of the cost of referrals and initial treatment were due to employee lost productivity. Total cost in the hypothetical cohort was $1,067,948 under the assumptions that all women received screening outside of the workplace, and that the same number of malignancies were detected at the same stage as in the workplace program. These findings indicate referrals resulting in detection of benign disease or no disease accounted for a substantial proportion of the total cost of the program. In addition, employee lost productivity accounted for almost 50% of the cost of all referrals and initial treatment. Workplace screening is a relatively efficient approach for early detection of breast cancer when compared to off site screening or no screening. The efficiency could be improved with a reduction in the number and cost of unnecessary referrals.     

Depression screening scale validation in an elderly, community-dwelling population.

This study contrasted the relative effectiveness of an interviewer-rated instrument, the Hamilton Depression Rating Scale, and 2 self-report scales, the short form of the Beck Depression Inventory and the depression scale from the Brief Symptom Inventory, in identifying cases of depression. Cases of major depression, dysthymia, and depressive disorder not otherwise specified (NOS) were identified by means of the Structured Clinical Interview for DSM-III—R (SCID) in a sample of 177 elderly community-dwellers. Receiver operating curves were used to evaluate the relative abilities of the 3 screening instruments to identify cases of depression. All 3 instruments identified major depression and depressive disorder NOS. None was consistently sensitive to cases of dysthymia. The incremental utility of the interview-based instrument for screening was nonsignificant, suggesting that the increased expense in a community setting may not be justified. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of a social-problem-solving training program for suburban and inner-city third-grade children.

Assessed the effects of a 52-lesson, class-taught, social-problem-solving (SPS) training program, with 3 questions in mind: (a) Does training improve interpersonal problem-solving abilities? (b) Does it enhance behavioral adjustment? (c) Are problem solving and adjustive gains related? 243 suburban and inner-city program 3rd graders and controls were evaluated on a variety of problem-solving and behavioral-adjustment measures. Program Ss improved more than controls on several cognitive skills, including problem identification, alternative-solution thinking, and consequential thinking as well as on behavioral problem-solving performance. The intervention positively affected the adjustment of suburban but not urban Ss. However, relationships between problem-solving skill improvements and adjustive gains were not found. Variables such as program curriculum and the age and sociodemographic attributes of its targets must be better understood in exploring the potential of SPS training to promote behavioral adjustment. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Knowledge, beliefs, attitudes, and cancer screening among inner-city African-American women

Three hundred twenty-one inner-city African-American women were interviewed to determine their knowledge, attitudes, and beliefs regarding cancer and cancer screening, and their cancer screening histories. The women were recruited from a variety of sources in Atlanta and were interviewed in their homes by trained lay health workers. Half of the subjects had an annual household income of < $15,000. About half had received a Pap smear and clinical breast examination within the year preceding the interviews. For women > 35 years old, 35% had received a mammogram within the recommended interval. Younger women and women with higher incomes were more likely than older women and those with lower incomes to have received a Pap test and clinical breast examination within the preceding year, but income was not significantly associated with mammography histories. In general, women who were more knowledgeable about cancer and its prevention were more likely to have been appropriately screened. However, various attitudes and beliefs regarding cancer generally were not associated with screening histories. We conclude that cancer screening programs for inner-city minority women should focus on improving knowledge levels among older women rather than attempting to alter attitudes and beliefs.     

Feasibility of an emergency department-based, risk-targeted voluntary HIV screening program

Renal biopsies from 19 boys and 11 girls, most with moderate or severe forms of hemolytic uremic syndrome (HUS) of the classic diarrhea-associated type, were analyzed as part of their long-term follow-up. Patients were biopsied because of late or persistent proteinuria, hypertension, and prolonged renal failure. The median length of follow-up was 11.2 years (range 0.9-22.0 years). Four histological groups were identified: focal segmental glomerulosclerosis and hyalinosis (FSGSH) (17 patients), diffuse mesangial proliferative glomerulonephritis (DMPGN) (9 patients), diffuse glomerulosclerosis (2 patients), and minimal glomerular changes (2 patients). The median interval between the onset of disease and renal biopsy was significantly shorter in DMPGN than in FSGSH (P < 0.001). The pathological findings may be the expression of two different stages of the same dynamic process: a regular sequence of glomerular lesions consisting of early DMPGN, followed by FSGSH. This lesion would ultimately lead to the final stage of global glomerulosclerosis. At the last examination, only a quarter of the patients had normal renal function. These observations also confirm that prolonged oligoanuria during the acute stage of HUS frequently results in an unfavorable long-term prognosis.     

A self-help smoking cessation program for inner-city African Americans: results from the Harlem Health Connection Project

The authors develop and test a culturally sensitive, low-intensity smoking cessation intervention for low-socioeconomic African Americans. African American adult smokers were randomly assigned to receive either a multicomponent smoking cessation intervention comprising a printed guide, a video, and a telephone booster call or health education materials not directly addressing tobacco use. The results of the study were mixed. Although no significant effects were observed for the entire treatment cohort, the results of post hoc analyses suggest that culturally sensitive self-help smoking cessation materials plus a single phone contact can produce short-term cessation rates similar to those reported for majority populations. This conclusion should be tempered by the low completion rate for the booster call and several design limitations of the study.     

Treatment outcome and patient characteristics in an aversion therapy program for alcoholism.

Conducted 1- and 3-yr follow-ups of 685 alcoholic patients treated with aversive conditioning during a 2-wk inpatient program followed by periodic single-day reinforcement sessions. 63% of the Ss reported continuous abstinence for 1 yr, and 31% were still abstinent after 3 yrs. Results indicate that Ss were at highest risk for relapse 3–4 mo after treatment and that continued aftercare was an important component of successful treatment. Outcomes were better for older than younger males and for married than unmarried males. Few significant differences in outcomes for males and females were apparent, and outcome was also unrelated to prior treatment history, education, or occupation. Findings support the use of aversive techniques in the treatment of alcoholism. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Satisfaction of attenders during the establishment of an Australian mammography screening program

The production of Bordetella pertussis extracytoplasmic filamentous haemagglutinin (FHA) and pertussis toxin (PT) in a bioreactor under stirring conditions was studied in order to investigate the effect of hydromechanical forces on yields of both antigens. It was shown that FHA loses its haemagglutinin activity when the power transmitted by the agitator and the aerator per unit volume increases, whereas PT production is not affected. The loss of FHA activity can be explained by the action of shear forces on the filamentous structure of this antigen.     

Monitored isoniazid prophylaxis for low-risk tuberculin reactors older than 35 years of age: a risk-benefit and cost-effectiveness analysis

BACKGROUND: Isoniazid chemoprophylaxis effectively prevents the development of active infectious tuberculosis. Current guidelines recommend withholding this prophylaxis for low-risk tuberculin reactors older than 35 years of age because of the risk for fatal isoniazid-induced hepatitis. However, recent studies have shown that monitoring for hepatotoxicity can significantly reduce the risk for isoniazid-related death. OBJECTIVE: To evaluate the effectiveness and cost-effectiveness of monitored isoniazid prophylaxis for low-risk tuberculin reactors older than 35 years of age. DESIGN: A Markov model was used to compare the health and economic outcomes of prescribing or withholding a course of prophylaxis for low-risk reactors 35, 50, or 70 years of age. Subsequent analyses evaluated costs and benefits when the effect of transmission of Mycobacterium tuberculosis to contacts was included. MEASUREMENTS: Probability of survival at 1 year, number needed to treat, life expectancy, and cost per year of life gained for individual persons and total population. RESULTS: Isoniazid prophylaxis increased the probability of survival at 1 year and for all subsequent years. For 35-year old, 50-year-old, and 70-year-old tuberculin reactors, life expectancy increased by 4.9 days, 4.7 days, and 3.1 days, respectively, and costs per person decreased by $101, $69, and $11, respectively. When the effect of secondary transmission to contacts was included, the gains in life expectancy per person receiving prophylaxis were 10.0 days for 35-year-old reactors, 9.0 days for 50-year-old reactors, and 6.0 days for 70-year-old reactors. Costs per person for these cohorts decreased by $259, $203, and $100, respectively. The magnitude of the benefit of isoniazid prophylaxis is moderately sensitive to the effect of isoniazid on quality of life. The hypothetical provision of isoniazid prophylaxis for all low-risk reactors older than 35 years of age in the U.S. population could prevent 35,176 deaths and save $2.11 billion. CONCLUSIONS: Monitored isoniazid prophylaxis reduces mortality rates and health care costs for low-risk tuberculin reactors older than 35 years of age, although reductions for individual patients are small. For the U.S. population, however, the potential health benefits and economic savings resulting from wider use of monitored isoniazid prophylaxis are substantial. We should consider expanding current recommendations to include prophylaxis for tuberculin reactors of all ages with no contraindications.     

Compliance in a screening program for neuroblastoma

OBJECTIVES: Whether or not spermicides can reduce the risk of human immunodeficiency virus (HIV) transmission remains an important question for the control of heterosexual HIV transmission. The authors provide estimates from a reanalysis of one of the few observational studies on the efficacy of condoms and spermicides, used separately and together, per vaginal contact. METHODS: In this reanalysis, three different models were used to assess the efficacy of spermicides and condoms: linear (Pearl index), exponential (maximum likelihood), and monotonic (marginal likelihood). RESULTS: Reported use of barrier methods among 27,432 contacts was as follows: condoms plus nonoxynol-9, 39%; condoms alone, 25%; nonoxynol-9 alone, 24%; and unprotected, 11%. Under all three models, the results indicate a strong protective effect for spermicidal suppositories. The Pearl index indicated that spermicide alone is apparently efficacious, but the efficacy per contact cannot be quantified with this approach. Maximum likelihood estimates for the efficacy of nonoxynol-9 alone and condoms (with or without nonoxynol-9) were 100% (95% confidence interval [CI95] = 43%, 100%) and 92% (95% CI95 = 79%, 100%), respectively. CONCLUSIONS: The data from this observational study suggest that spermicides may be efficacious in reducing the risk of HIV transmission.     

A university freshman preventive intervention program: Report of a pilot project.

Describes a preventive intervention program with university freshmen for the development of greater emotional maturity, more successful adaptation to the college community, less psychological disability, and fewer dropouts. By means of an interactive process using special questionnaires which were distributed and analyzed, the 179 participating students were provided with membership in a group which had psychological reality, were given some reference facts with which to compare themselves, and were given some intellectual tools by which they might better understand the stresses acting on them and their reactions to these stresses. Evaluation of the pilot project was generally favorable, although differences between the experimental and a comparison group (n = 585) were not large even when statistically significant. Suggestions for an improved program are presented. (16 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)