A statewide assessment of tuberculin skin testing of preschool children enrolled in medicaid managed care

OBJECTIVES

This study examined tuberculosis screening among preschool children enrolled in a statewide Medicaid managed care program.

METHODS

A random sample of 2,000 was selected from 19 to 35 month old children who were continuously enrolled in Rhode Island's Medicaid managed care program for 1 year. Sociodemographic data were obtained from computerized administrative databases. Medical record audits were performed to obtain the dates and results of tuberculosis tests.

RESULTS

Data from the medical record audits were available for 1,988 of the study children. For 1,215 of the study children (1,215/1,988 = 61%) a tuberculin skin test had been performed, but a reading was only documented for 736 children (60% of children who received a tuberculin skin test) and only one child tested positive (0.1%).

CONCLUSIONS

A majority of preschool children in this population in which the prevalence of risk factors for tuberculosis is likely to be relatively high did have a tuberculosis test performed. However, in many cases the tuberculin skin test was either not read or the results not documented. The low rate of positivity is consistent with current AAP guidelines for selective tuberculin skin testing.

A success story: HIV prevention for injection drug users in Rhode Island

Background

New HIV diagnoses related to injection drug use (IDU) have declined in the United States. Access to clean syringes and decreasing HIV transmission among injection drug users have been HIV prevention priorities of the Rhode Island (RI) HIV community. To examine trends in IDU-related new HIV diagnoses in RI, we performed a retrospective analysis of new HIV diagnoses according to HIV risk factor from 1990–2003.

Results

There has been an 80% absolute reduction in IDU-related new HIV diagnoses in RI coincident with IDU-specific prevention efforts.

Conclusion

There has been a greater decline in IDU-related new HIV diagnoses in Rhode Island compared to national data reported by the Centers for Disease Control and Prevention. We hypothesize that this dramatic decline in Rhode Island is related to extensive HIV prevention efforts targeting IDUs. Further research is needed to examine the impact of specific HIV prevention interventions for injection drug users.

Antimicrobial Resistance of Community-acquired Bloodstream Isolates of Viridans Group Streptococci

Infections due to antimicrobial-resistant viridans group streptococci are increasing. The present study was done to determine the frequency of antibiotic resistance among community-acquired viridans group streptococci isolated from blood cultures and to identify the risk factors associated with acquiring antibiotic-resistant viridans group streptococci. Twenty-eight community-acquired viridans group streptococcal isolates were recovered from 27 patients, of which 89%, 86%, 79%, 61%, and 39% were susceptible to ceftriaxone, clindamycin, tetracycline, penicillin, and erythromycin, respectively; 100% were susceptible to levofloxacin and vancomycin. Among the patients with previous antibiotic use, 73% had penicillin non-susceptible viridans group streptococci, compared with 18% who did not receive prior antibiotics (p = 0.006). Patients with and without prior antibiotic use, 27% and 0%, respectively, had ceftriaxone non-susceptible viridans group streptococci isolates, respectively (p = 0.05). Patients with and without prior antibiotic use, 45% and 6%, respectively, had tetracycline non-susceptible viridans group streptococci isolates, respectively (p = 0.02). No other risk factors for isolation of non-susceptible viridans group streptococci were identified.

Atypical squamous cells of undetermined significance, human papillomavirus, and cervical intraepithelial neoplasia 2 or 3 in adolescents: ASC-US, age, and high-grade cervical neoplasia

OBJECTIVE

To determine rates of and factors associated with cervical intraepithelial neoplasia (CIN) 2 or 3 among women with atypical squamous cells of undetermined significance (ASC-US) and oncogenic human papillomavirus (HPV) infection.

MATERIALS AND METHODS

This is a retrospective review of 357 women with ASC-US and known high-risk HPV infection. To be eligible for inclusion, patients had to have subsequently undergone colposcopic-directed cervical biopsy and/or endocervical sampling. Univariate and multivariable regression analyses were used to estimate crude and adjusted odds ratios of CIN 2 or 3 by risk factors associated with HPV and CIN.

RESULTS

Thirty-three of 215 (15%) women with ASC-US and oncogenic HPV who underwent histological sampling demonstrated CIN 2 or 3. In the adjusted model, only nulliparity (adjusted odds ratio = 2.2, 95% CI = 1.0-4.8) retained a marginal association with the outcome. No significant age-related differences in the prevalence of high-grade disease emerged. The high-grade lesions seen in adolescents consisted of single, small lesions.

CONCLUSIONS

In the light of these findings, and in conjunction with the high rate of oncogenic HPV infection among adolescents with ASC-US, both reflex HPV testing and immediate colposcopy do not appear to be of benefit in the initial management of teenagers with this cytological diagnosis.

A novel approach to T classification in tumor-node-metastasis staging of breast cancer

BACKGROUND

The aim of this study was to examine the effect of measurement bias in breast cancer and to create a more rational T-size categorization in tumor-node-metastasis staging in response to smaller, screen-detected cancers and measurement bias.

METHODS

From 1987 to 2003, 10,853 invasive nonmetastatic breast cancers enlisted in the Rhode Island Cancer Registry with a known dimension were reviewed. Data analyzed by proposed classifications included the rate of lymph node metastases and the mortality rate from breast cancer.

RESULTS

The median diameter was 16 mm. Cancer measurements reflected the bias in pathologists' dimension recording, which is centered strongly about whole- and half-centimeter sizes. A new T classification is proposed with the following sizes and frequencies in the Rhode Island Cancer Registry: 1 to 2 mm = T1 mic (3% of registered cases); 3 to 7 mm = T1a (11%); 8 to 12 mm = T1b (23%); 13 to 17 mm = T1c (18%); 18 to 22 mm = T2a (17%); 23 to 27 mm = T2b (8%); 28 to 32 mm = T2c (8%); 33 to 42 mm = T3a (6%); 43 to 52 mm = T3b (3%), and greater than 52 mm = T3c (4%). The unadjusted odds ratio for the probability of node metastases was 1.43 (confidence interval, 1.40-1.46; P < .001) with each increase in proposed grouping. The range in the lymph node metastatic rate was 5.5% for tumors 1 to 2 mm to 64% for cancers greater than 52 mm. By Cox proportional hazard, the unadjusted hazard ratio for death from breast cancer for each increase in proposed grouping was 1.33 (confidence interval, 1.29-1.37; P < .001). The 10-year survival rate ranged from 98.3% for tumors 1 to 2 mm to 70.3% for cancers greater than 52 mm.

CONCLUSIONS

A more rational T category for use in tumor-node-metastasis staging is presented to reflect the much smaller invasive breast cancers encountered by screening and to account for the dimension recording bias of pathologists. This new T category shows a clinically and statistically significant linear relationship for both incidence of lymph node metastases and hazard ratio of death.

Psychological resources protect health: 5-year survival and immune function among HIV-infected women from four US cities

OBJECTIVE

Guided by Cognitive Adaptation Theory, the aim was to determine whether psychological resources (positive affect, positive expectancy regarding health outcomes, finding meaning in challenging circumstances) protect against HIV-related mortality and decline in CD4 lymphocyte counts among women with HIV.

DESIGN

The HIV Epidemiologic Research Study, a longitudinal prospective cohort study, with semi-annual interview, physical examination and laboratory assays.

METHODS

A total of 773 HIV-seropositive women aged 16 to 55 years were recruited from four academic medical centers in Baltimore, Maryland; Bronx, New York; Providence, Rhode Island; and Detroit, Michigan. Semi-annually for up to 5 years, the women were interviewed, underwent physical examination, medical record abstraction, and venipuncture. Primary outcomes for these analyses included HIV-related mortality and CD4 cell count slope decline over 5 years.

RESULTS

Psychological resources were inversely associated with HIV-related mortality and time to death, beyond the effects of potential confounding variables such as clinical status (e.g., HIV viral load, symptoms, antiretroviral therapy), sociodemographic characteristics (e.g. age, race), and depression at study entry (P < 0.05). Psychological resources also were inversely associated with CD4+ cell count decline (P < 0.01), serving as a possible mechanism linking resources to mortality.

CONCLUSIONS

Psychological resources may protect against HIV-related mortality and immune system decline. Findings have implications for understanding individual variability in HIV disease progression. Moreover, because psychological resources are potentially amenable to change, results can be applied to clinical interventions aimed at improving the health of women with HIV.

Disentangling depressive personality disorder from avoidant, borderline, and obsessive-compulsive personality disorders

Several studies have found that 3 personality disorders (PDs) tend to share moderate rates of comorbidity with depressive PD: avoidant, borderline, and obsessive-compulsive. This study sought to evaluate the diagnostic criteria of each disorder in an effort to understand where areas of overlap may occur and to modify criteria sets where reasonable to reduce any degree of overlap. One thousand two hundred psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality Disorders. The highest degree of comorbidity was observed between avoidant PD and depressive PD. Logistic regression analyses indicated that 2 criteria-avoidant criterion 5 and depressive criterion 2-could be removed from the diagnostic criteria sets and reduce the rates of overlap by as much as 15%. A factor analysis of the criteria of all 4 PDs indicated that there is a common clustering of many of the symptoms of avoidant, borderline, depressive, and obsessive-compulsive PDs and that borderline symptoms tend to cluster together most consistently. Avoidant and obsessive-compulsive personality symptoms clustered in ways that may reflect a problem of how to engage with others, suggestive of an approach-avoidance conflict. Depressive PD symptoms clustered in a way suggestive of problems with anger that is directed toward oneself and others. The factor analysis results suggest that an organization of symptoms around themes of conflict may provide useful ways of understanding the personality patterns of these 4 disorders.

Prevalence and Diagnostic Correlates of DSM-IV Pathological Gambling in Psychiatric Outpatients

Studies of the prevalence of pathological gambling (PG) in psychiatric and substance abusing patients suggest that the disorder is not rare. Most studies have been of substance abusers in treatment, and the rate of PG has been found to be several times higher than the rate found in community based epidemiological surveys. However, only one study has examined the prevalence of PG in a heterogeneous sample of patients, and this was a study of psychiatric inpatients. We are not aware of any prior study of the prevalence of PG in a psychiatric outpatient sample. In the present report from the Rhode Island Methods to Improve Diagnosis and Services (MIDAS) project we examined the current and lifetime prevalence of PG in 1,709 psychiatric outpatients interviewed with a semi-structured diagnostic interview that included a module to diagnose DSM-IV PG. Forty (2.3%) patients had a lifetime history of DSM-IV PG, all of whom had at least one other DSM-IV axis I disorder. Patients with PG had significantly more axis I disorders than patients without PG, and had significantly higher rates of bipolar disorder, social phobia, panic disorder with agoraphobia, alcohol use disorder, and other impulse control disorders. Possible reasons for the low prevalence of PG in our sample are discussed.

Examining a conceptual framework of intimate partner violence in men and women arrested for domestic violence

OBJECTIVE

There is a paucity of research developing and testing conceptual models of intimate partner violence, particularly for female perpetrators of aggression. Several theorists' conceptual frameworks hypothesize that distal factors-such as personality traits, drinking patterns, and marital discord-influence each other and work together to increase the likelihood of physical aggression. The purpose of the present study was to investigate these variables in a relatively large sample of men and women arrested for domestic violence and court-referred to violence intervention programs.

METHOD

We recruited 409 participants (272 men and 137 women) who were arrested for domestic violence. We assessed perpetrator alcohol problems, antisociality, trait anger, relationship discord, psychological aggression, and physical abuse. We also assessed the alcohol problems, psychological aggression, and physical abuse of their relationship partners. We used structural equation modeling to examine the interrelationships among these variables in both genders independently.

RESULTS

In men and women, alcohol problems in perpetrators and their partners contributed directly to physical abuse and indirectly via psychological aggression, even after perpetrator antisociality, perpetrator trait anger, perpetrator relationship discord, and perpetrator and partner psychological and physical aggression were included in the model. The only significant gender difference found was that, in male perpetrators, trait anger was significantly associated with relationship discord, but this path was not significant for women perpetrators.

CONCLUSIONS

The results of the study provide further evidence that alcohol problems in both partners are important in the evolution of psychological aggression and physical violence. There were minimal differences between men and women in the relationships of most distal risk factors with physical aggression, suggesting that the conceptual framework examined may fit equally well regardless of perpetrator gender. This finding suggests that, in arrested men and women, violence intervention programs might have improved outcomes if they offered adjunct or integrated alcohol treatment.

Clinical characteristics of perinatal psychiatric patients: a chart review study

Although postpartum depression and other perinatal disorders have been the subject of increased research attention, important questions remain regarding women who actively seek psychiatric treatment during pregnancy and the postpartum period. In this study, we examined clinical records of 500 perinatal psychiatric patients who received treatment in a psychiatric day hospital (N = 398) or outpatient behavioral health clinic (N = 102). Patients' presenting diagnoses, psychiatric history, treatment course, and depressive symptoms were recorded. The majority of women had major depression as their primary diagnosis, with an average Edinburgh Postnatal Depression Scale score of over 20. Many depressed patients were diagnosed with comorbid anxiety and substance abuse disorders. Although most women were willing to take psychotropic medications, a sizable minority were not, particularly those who were breast-feeding. For more than a third of the sample, the treatment sought while pregnant or postpartum represented their first contact with the mental health system. Treatment implications are discussed.

Reproductive health care and family planning needs among incarcerated women

OBJECTIVES

Women in correctional institutions have substantial reproductive health problems, yet they are underserved in receipt of reproductive health care. We assessed the level of risk for sexually transmitted diseases (STDs) and the reproductive health needs of 484 incarcerated women in Rhode Island to plan an intervention for women returning to the community.

METHODS

We used a 45-minute survey to assess medical histories, pregnancy and birth control use histories, current pregnancy intentions, substance use during the past 3 months, histories of childhood sexual abuse, and health attitudes and behaviors.

RESULTS

Participants had extremely high risks for STDs and pregnancy, which was characterized by inconsistent birth control (66.5%) and condom use (80.4%), multiple partners (38%), and a high prevalence of unplanned pregnancies (83.6%) and STDs (49%). Only 15.4% said it was not likely that they would have sexual relations with a man within 6 months after release.

CONCLUSION

Reproductive health services must be offered to incarcerated women. Such interventions will benefit the women, the criminal justice systems, and the communities to which the women will return.

Mental health services for homebound elders from home health nursing agencies and home care agencies

OBJECTIVE

This study examined the practices of home care agencies and home health nursing agencies in the management and treatment of homebound clients with behavioral problems, dementia, and undiagnosed mental illnesses.

METHODS

A survey was mailed to all 54 directors of agencies in Rhode Island in 2003; 53 responded, either by mail or telephone.

RESULTS

Data indicated a lack of psychiatric services, a reluctance to address behavioral problems, and a failure to identify undiagnosed disorders. There was also a bias against accepting individuals with primary psychiatric disorders.

CONCLUSIONS

Although the population of homebound elders with mental illness is increasing, their needs are not being met by these agencies.

Associations between health-related quality of life and demographics and health risks. Results from Rhode Island's 2002 behavioral risk factor survey

BACKGROUND

Health-Related Quality of Life (HRQOL) has received much attention in recent years. HRQOL indicators have been used to track population trends, identify health disparities, and monitor progress in achieving national health objectives for 2010. Prior studies have examined health risks and HRQOL at the national level as well as at the state level. This paper examines multiple indicators of HRQOL by demographic characteristics and selected health behaviors for Rhode Island adults.

METHODS

Data from Rhode Island's 2002 Behavioral Risk Factor Surveillance System (BRFSS), a random digit dialled telephone survey, were used for this study. The state wide sample contained a total of 3,843 respondents ages 18 and older. Multiple Imputation (MI) was applied to handle missing data, and data were modelled for each of 10 HRQOL indicators using multivariable logistic regression.

RESULTS

By examining HRQOL through a multivariable approach we identified the strongest predictors for multiple indicators of poor HRQOL as well as predictors for specific indicators of poor HRQOL. Predictors for multiple indicators of poor HRQOL were: disability, inability to work, unemployment, lower income, lack of exercise, asthma, and smoking (specifically associated with poor mental health).

CONCLUSION

Using multiple measures of HRQOL can help to assess the burden of poor health in a population, identify subgroups with unmet HRQOL needs, inform the development of targeted interventions, and monitor changes in a population's HRQOL over time. Use of these HRQOL measures in longitudinal and intervention studies is needed to increase our understanding of the causal relationships between demographics, health risk behaviors, and HRQOL.

Evaluating satellite sensor-derived indices for Lyme disease risk prediction

The wetness and greenness indices created using Landsat Thematic Mapper (TM) data from June 1995 and 1997 and July 2002 were tested for their ability to predict the location of sites with different levels of nymphal blacklegged tick, Ixodes scapularis Say, abundance in Rhode Island. In 1995, there were statistically significant differences in the mean of greenness and wetness indices between sites classified as low and moderate tick abundance areas (P = 0.005 and P = 0.041, respectively). In 1997, there also were statistically significant differences in the mean of the greenness and wetness indices, but these differences were between the grouping of low/moderate tick abundance and the high tick abundance category (P = 0.023 and P = 0.015, respectively). The same indices from the 2002 image were not significant predictors of tick abundance. It may be that Landsat TM-derived indices can be used to predict nymphal blacklegged tick abundance in years (e.g., 1995 and 1997) when tick abundance is lower than average but not in years when it is higher (e.g., 2002). Thus, it seems unlikely that these remotely sensed indices will be very useful for modeling nonperidomestic Lyme disease risk over a large region in Rhode Island.

Gun carrying and drug selling among young incarcerated men and women

This paper examines the relationship between illegal drug economy involvement, gun-related victimization, and recent gun carrying among young men and women incarcerated in a state prison in the United States. Interviews were conducted with 18- to 25-year old incarcerated men (n = 135) and women (n = 69) between July 1999 and October 2000. Forty-five percent of men and 16% of women reported carrying a gun in the year prior to incarceration. Respondents who sold crack cocaine or other drugs were more likely to have carried guns than those not selling drugs. However, hard drug use was not associated with gun carrying among men. All ten women who carried guns had used hard drugs. Sixty-seven percent of men and 28% of women had been shot at. Respondents who sold crack cocaine were at elevated risk of being shot at. Among men, selling crack (OR = 10.2, 95% CI = 2.5, 42.1) and ever being shot at (OR = 4.6, 95% CI = 1.7, 12.2), were associated with carrying guns. These findings provide further evidence of a link between crack selling (but not necessarily drug using) and gun carrying.

Effects of study area size on geographic characterizations of health events: prostate cancer incidence in Southern New England, USA, 1994-1998

BACKGROUND

We consider how representations of geographic variation in prostate cancer incidence across Southern New England, USA may be affected by selection of study area and/or properties of the statistical analysis.

METHOD

A spatial scan statistic was used to monitor geographic variation among 35,167 incident prostate cancer cases diagnosed in Massachusetts, Connecticut and Rhode Island from 1994 to 1998, in relation to the 1990 populations of men 20+ years of age living in that region. Results from the combined-states analysis were compared to those from single-states. Impact of scanning procedures set to examine up to 50% or no more than 10% of at-risk populations also was evaluated.

RESULTS

With scanning set to 50%, 5 locations in the combined-states analysis were identified with markedly distinct incidence rates. Fewer than expected cases were estimated for nearly all Connecticut, Rhode Island and West Central Massachusetts, whereas census tracts on and around Cape Cod, and areas of Southwestern Connecticut and adjacent to greater Boston were estimated to have yielded more than expected incidence. Results of single-state analyses exhibited several discrepancies from the combined-states analysis. More conservative scanning found many more locations with varying incidence, but discrepancies between the combined- and single-state analysis were fewer.

CONCLUSION

It is important to acknowledge the conditional nature of spatial analyses and carefully consider whether a true cluster of events is identified or artifact stemming from selection of study area size and/or scanning properties.