Does engagement matter? The impact of patient and community engagement on implementation of cardiovascular health materials in primary care settings

BACKGROUND

Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT.

METHODS

EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT.

RESULTS

Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT.

CONCLUSIONS

In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters.

TRIAL REGISTRATION AND IRB

Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15-0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office.

Academic Medicine's Fourth Mission: Building on Community-Oriented Primary Care to Achieve Community-Engaged Health Care

A 2021 article, "Now is our time to act: Why academic medicine must embrace community collaboration as its fourth mission," by Association of American Medical Colleges (AAMC) authors, including AAMC president and CEO Dr. David J. Skorton, offers 2 aims that are highly related: community collaboration and health equity. The AAMC's call to prioritize community collaboration and health equity as pillars of the academic medicine mission echo earlier work on community-oriented primary care (COPC) and an even more robust model that builds on COPC, community-engaged health care (CEHC). COPC is a tested, systematic approach to health care by which a health clinic or system collaborates with a community to reshape priorities and services based on assessed health needs and determinants of health. COPC affirms health inequities' socioeconomic and political roots, emphasizing health care as a relationship, not a transaction or commodity. Communities where COPC is implemented often see reductions in health inequities, especially those related to socioeconomic, structural, and environmental factors. COPC was the foundation on which community health centers were built, and early models had demonstrable effects on community health and engagement. Several academic health centers build on COPC to achieve CEHC. In CEHC, primary care remains critical, but more of the academic health center's functions are pulled into community engagement and trust building. Thus, the AAMC has described and embraced a care and training model for which there are good, longitudinal examples among medical schools and teaching hospitals. Spreading CEHC and aligning the Community Health Needs Assessment requirements of academic health centers with the fourth mission could go a long way to improving equity, building trust, and repairing the social contract for health care.

POS1303 METHOTREXATE RESPONSE IN PEDIATRIC NON-INFECTIOUS UVEITIS

Background

Children with chronic non-infectious uveitis (NIU) are at risk for sight-threatening complications. Methotrexate (MTX) is the preferred first-line systemic treatment. Initial therapeutic response takes 3-6 months to achieve NIU control, leading to prolonged glucocorticoid use. Moreover, at least 50-70% of children fail to fully respond and may accrue ocular damage while awaiting MTX response.

Objectives

To identify features of children with NIU that are associated with MTX failure.

Methods

We included children who started MTX monotherapy for NIU. We collected demographics, NIU features (type, location, & complications), ANA status, and clinical examination. We characterized children as MTX responders or non-responders. MTX responders are those whose NIU was controlled, defined by: 1) inactive graded by SUN criteria, 2) absence of new or worsening complications, and 3) requirement for ≤2 drops of prednisolone acetate and no oral glucocorticoids.

Results

Of 47 NIU children, 68% were MTX non-responders (Table 1), having a longer duration of NIU (Odds Ratio [OR]=1.28, [CI=1.03-1.8], p =0.023) and developing more ocular complications (OR=1.95 [CI=1.23-3.38], p=0.017), (ROC Area Under the Curve = 0.85). MTX non-responders were more likely to have anterior and/or posterior synechiae (p = 0.001), cataracts (p=0.015), and ocular hypertension (p=0.039). Treatment included adalimumab: 27, infliximab: 14, tocilizumab: 5, golimumab: 4, etanercept: 3, and abatacept: 2.

Table 1.

Comparison of children with NIU based on MTX response.

Responders n=15Non-responders n=32Caucasian14 (93)27 (84)Hispanic or Latino0 (0)3 (9)Female12 (80)23 (72)Age of NIU onset, yrs, median (IQR)4.3 (2.9 – 12.3)4.6 (2.8 - 7.0)Duration of NIU, yrs, median, (IQR)4.1 (2.6 – 5.3)8.2 (4.7 - 11.3)JIA-NIU10 (67)25 (78)Idiopathic CAU2 (13)3 (9)Other3 (20)4 (12)Bilateral disease12 (80)23 (72)Anterior12 (86)29 (91)Presenting BCVA (LogMAR) worst eye, median (IQR)0.2 (0.1 – 0.3)0.1 (0.0 - 0.2)Average # of total complications/person, median (IQR)1 (0 – 2)2.5 (1.0 – 5.5)ANA positive10 (67)26 (81)Earliest ESR8 (6– 18)12 (8 - 18)Earliest Vitamin D32 (26 – 35)31 (23 - 35)Time on MTX, months, median (IQR)35 (19 - 64)19 (7 - 74)Time from systemic or NIU onset to MTX, yrs, median (IQR)0.3 (0.1 – 0.5)0.2 (0.0 - 0.8)MTX PO6 (40)19 (59)MTX SC13 (87)31 (97)

We performed a sub analysis of children with idiopathic chronic anterior NIU (CAU) and JIA-associated NIU that included children who failed MTX due to intolerance/toxicity (Figure 1). Using Cox proportional hazard regression, 8 idiopathic CAU failed MTX earlier than 38 JIA-associated NIU (HR 2.77, [CI-=1.06-7.27], p=0.039). Results were similar with the inclusion of other types of NIU (p=0.088) (e.g., HLA-B27, non-anterior idiopathic or with systemic disease).

Figure 1.

Kaplan-Meier curve showing freedom from TNFi (mos) stratified by diagnosis

Conclusion

Two out of three children with NIU fail initial MTX monotherapy, exposing them to increased accrual of ocular complications prior to biologic starts. The risk for delay in starting tumor necrosis factor α inhibitors (TNFi) seems higher with CAU. Future studies will examine risk factors that predict MTX response in NIU.

References

[1]McCracken C, Angeles-Han ST, et.al. Timing of infliximab and adalimumab initiation despite methotrexate in children with chronic non-infectious anterior uveitis. Eye (Lond). 2019;33(4):629-39.

[2]Henderson LA, Angeles-Han ST, et.al., Medication use in juvenile uveitis patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry. Pediatr Rheumatol Online J. 2016;14(1):9.

[3]Cooper A, et.al., Failure of methotrexate monotherapy and subsequent response to tumor necrosis factor inhibitors in pediatric non-infectious uveitis (abstract). Arthritis Rheumatol. 2020:72 (suppl 4).

Disclosure of Interests

Sheila Angeles-Han: None declared, Amy Cassedy: None declared, Theresa Hennard: None declared, Mekibib Altaye: None declared, Hermine Brunner Consultant of: Dr. Brunner’s affiliation Cincinnati Children’s Hospital Medical Center has received consulting fees or other remuneration from AstraZeneca, Boehringer Ingelheim, GSK, Roche, Novartis, Pfizer Inc, Takeda, and UBC for the work of Dr. Brunner. Dr. Brunner is a DSMB member for Janssen Pharmaceutical’s trial of ustekinumab pediatric Crohn and Ulcerative colitis., Grant/research support from: Dr. Brunner’s affiliation Cincinnati Children’s Hospital Medical Center has received research grants from BMS, Janssen, Novartis, Pfizer Inc, Roche, and UBC., Eniolami Dosunmu: None declared, Alexei Grom: None declared, Michael Henrickson: None declared, Jennifer Huggins: None declared, Sarah Lopper: None declared, Daniel J Lovell Consultant of: AstraZeneca, Boehringer Ingelheim, GSK, Roche, Novartis, Pfizer Inc, Takeda, and UBC, Grant/research support from: BMS, Janssen, Novartis, Pfizer Inc, Roche, and UBC, Robert Sisk Consultant of: AGTC, Gyroscope, and Leica, Tracy Ting: None declared, Adam Kaufman Consultant of: Consultant for Alcon, Bausch & Lomb, and 1800contacts, not related or relevant to study content., Virginia Utz: None declared

COVID-19 fosters social accountability in medical education

The COVID-19 pandemic has highlighted embedded inequities and fragmentation in our health systems. Traditionally, structural issues with health professional education perpetuate these. COVID-19 has highlighted inequities, but may also be a disruptor, allowing positive responses and system redesign. Examples from health professional schools in high and low- and middle-income countries illustrate pro-equity interventions of current relevance. We recommend that health professional schools and planners consider educational redesign to produce a health workforce well equipped to respond to pandemics and meet future need.

Two novel pathogenic variants in MED13L: one familial and one isolated case

BACKGROUND

Genetic variants involving the MED13L gene can lead to an autosomal dominant syndrome characterised by intellectual disability/developmental delay and facial dysmorphism.

METHODS

We investigated two cases (one familial and one isolated) of intellectual disability with speech delay and dysmorphic facial features by whole-exome sequencing analyses. Further, we performed a literature review about clinical and molecular aspects of MED13L gene and syndrome.

RESULTS

Two MED13L variants have been identified [MED13L(NM_015335.5):c.4417C>T and MED13L(NM_015335.5):c.2318delC] and were classified as pathogenic according to the ACMG (American College of Medical Genetics and Genomics) guidelines. One of the variants was present in sibs.

CONCLUSIONS

The two pathogenic variants identified have not been previously reported. Importantly, this is the first report of a familial case of MED13L nonsense mutation. Although the parents of the affected children were no longer available for analysis, their apparently normal phenotypes were surmised from familial verbal descriptions corresponding to normal mental behaviour and phenotype. In this situation, the familial component of mutation transmission might be caused by gonadal mosaicism of a MED13L mutation in a gonad from either the father or the mother. The case reports and the literature review presented in this manuscript can be useful for genetic counselling.

Baseline brain function in the preadolescents of the ABCD Study

The Adolescent Brain Cognitive Development (ABCD) Study® is a 10-year longitudinal study of children recruited at ages 9 and 10. A battery of neuroimaging tasks are administered biennially to track neurodevelopment and identify individual differences in brain function. This study reports activation patterns from functional MRI (fMRI) tasks completed at baseline, which were designed to measure cognitive impulse control with a stop signal task (SST; N = 5,547), reward anticipation and receipt with a monetary incentive delay (MID) task (N = 6,657) and working memory and emotion reactivity with an emotional N-back (EN-back) task (N = 6,009). Further, we report the spatial reproducibility of activation patterns by assessing between-group vertex/voxelwise correlations of blood oxygen level-dependent (BOLD) activation. Analyses reveal robust brain activations that are consistent with the published literature, vary across fMRI tasks/contrasts and slightly correlate with individual behavioral performance on the tasks. These results establish the preadolescent brain function baseline, guide interpretation of cross-sectional analyses and will enable the investigation of longitudinal changes during adolescent development.

Social Accountability and Graduate Medical Education

Because graduate medical education (GME) is largely publicly funded, it should be judged on how well it addresses the public's health needs. However, the current system distributes GME resources inequitably by specialty and geography, and neglects to focus on training physicians adequately in the care of populations while reducing health disparities. Instead, GME continues to concentrate training in hospital-based academic centers and in subspecialties, which often exacerbates disparities in health outcomes and access to care. GME can be more socially accountable by shifting incentive structures to support primary care, creating more equitable distribution of residency slots and funding, and promoting training programs that focus on social and structural determinants of health.

Deliberating Performance Targets: Follow-on workshop discussing PM10, NO2, CO, and SO2 air sensor targets

The use of air sensor technology is increasing worldwide for a variety of applications, however, with significant variability in data quality. The United States Environmental Protection Agency held a workshop in July 2019 to deliberate possible performance targets for air sensors measuring particles with aerodynamic diameters of 10 μm or less (PM10), nitrogen dioxide (NO2), carbon monoxide (CO), and sulfur dioxide (SO2). These performance targets were discussed from the perspective of non-regulatory applications and with the sensors operating primarily in a stationary mode in outdoor environments. Attendees included representatives from multiple levels of government organizations, sensor developers, environmental nonprofits, international organizations, and academia. The workshop addressed the current lack of sensor technology requirements, discussed fit-for-purpose data quality needs, and debated transparency issues. This paper highlights the purpose and key outcomes of the workshop. While more information on performance and applications of sensors is available than in past years, the performance metrics, or parameters used to describe data quality, vary among the studies reports and there is a need for more clear and consistent approaches for evaluating sensor performance. Organizations worldwide are increasingly considering, or are in the process of developing, sensor performance targets and testing protocols. Workshop participants suggested that these new guidelines are highly desirable, would help improve data quality, and would give users more confidence in their data. Given the wide variety of uses for sensors and user backgrounds, as well as varied sensor design features (e.g., communication approaches, data tools, processing/adjustment algorithms and calibration procedures), the need for transparency was a key workshop theme. Suggestions for increasing transparency included documenting and sharing testing and performance data, detailing best practices, and sharing data processing and correction approaches.

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.

Deliberating performance targets workshop: Potential paths for emerging PM2.5 and O3 air sensor progress

The United States Environmental Protection Agency held an international two-day workshop in June 2018 to deliberate possible performance targets for non-regulatory fine particulate matter (PM_2.5) and ozone (O₃) air sensors. The need for a workshop arose from the lack of any market-wide manufacturer requirement for Ozone documented sensor performance evaluations, the lack of any independent third party or government-based sensor performance certification program, and uncertainty among all users as to the general usability of air sensor data. A multi-sector subject matter expert panel was assembled to facilitate an open discussion on these issues with multiple stakeholders. This summary provides an overview of the workshop purpose, key findings from the deliberations, and considerations for future actions specific to sensors. Important findings concerning PM_2.5 and O₃ sensors included the lack of consistent performance indicators and statistical metrics as well as highly variable data quality requirements depending on the intended use. While the workshop did not attempt to yield consensus on any topic, a key message was that a number of possible future actions would be beneficial to all stakeholders regarding sensor technologies. These included documentation of best practices, sharing quality assurance results along with sensor data, and the development of a common performance target lexicon, performance targets, and test protocols.

Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension

Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.

Agriculture and Health Sectors Collaborate in Addressing Population Health

PURPOSE

Population health is of growing importance in the changing health care environment. The Cooperative Extension Service, housed in each state's land grant university, has a major impact on population health through its many community-based efforts, including the Supplemental Nutrition Assistance Program - Education (SNAP-Ed) nutrition programs, 4-H youth engagement, health and wellness education, and community development. Can the agricultural and health sectors, which usually operate in parallel, mostly unknown to each other, collaborate to address population health? We set out to provide an overview of the collaboration between the Cooperative Extension Service and the health sector in various states and describe a case study of 1 model as it developed in New Mexico.

METHODS

We conducted a literature review and personally contacted states in which the Cooperative Extension Service is collaborating on a "Health Extension" model with academic health centers or their health systems. We surveyed 6 states in which Health Extension models are being piloted as to their different approaches. For a case study of collaboration in New Mexico, we drew on interviews with the leadership of New Mexico State University's Cooperative Extension Service in the College of Agricultural, Consumer and Environmental Sciences; the University of New Mexico (UNM) Health Science Center's Office for Community Health; and the personal experiences of frontline Cooperative Extension agents and UNM Health Extension officers who collaborated on community projects.

RESULTS

A growing number of states are linking the agricultural Cooperative Extension Service with academic health centers and with the health care system. In New Mexico, the UNM academic health center has created "Health Extension Rural Offices" based on principles of the Cooperative Extension model. Today, these 2 systems are working collaboratively to address unmet population health needs in their communities. Nationally, the Cooperative Extension Service has formed a steering committee to guide its movement into the health arena.

CONCLUSION

Resources of the agricultural and health sectors offer communities complementary expertise and resources to address adverse population health outcomes. The collaboration between Cooperative Extension and the health sector is 1 manifestation of this emerging collaboration model termed Health Extension. Initial skepticism and protection of funding sources and leadership roles can be overcome with shared funding from new sources, shared priority setting and decision making, and the initiation of practical, collaborative projects that build personal relationships and trust.

Producing a socially accountable medical school: AMEE Guide No. 109

Health systems worldwide are confronted with challenges due to increased demand from their citizens, an aging population, a variety of health risks and limited resources. Key health stakeholders, including academic institutions and medical schools, are urged to develop a common vision for a more efficient and equitable health sector. It is in this environment that Boelen and Heck defined the concept of the "Social Accountability of Medical Schools" - a concept that encourages schools to produce not just highly competent professionals, but professionals who are equipped to respond to the changing challenges of healthcare through re-orientation of their education, research and service commitments, and be capable of demonstrating a positive effect upon the communities they serve. Social Accountability calls on the academic institution to demonstrate an impact on the communities served and thus make a contribution for a just and efficient health service, through mutually beneficial partnerships with other healthcare stakeholders. The purpose of this Guide is to explore the concept of Social Accountability, to explain it in more detail through examples and to identify ways to overcome obstacles to its development. Although in the Guide reference is frequently made to medical schools, the concept is equally applicable to all forms of education allied to healthcare.

Community Health Workers and Family Medicine Resident Education: Addressing the Social Determinants of Health

Neither the health care system nor the training of medical residents focus sufficiently on social determinants of health. Community health workers (CHWs) are a growing presence in health care settings. Culturally and linguistically competent, typically they are from underserved communities and spend more time addressing social determinants of health than others on the health care team. However, CHWs are an infrequent presence in resident clinical training environments. The University of New Mexico Family Medicine Residency placed family medicine residents at a community clinic in Albuquerque managed by CHWs, recognizing that CHWs' collaboration with residents would enhance resident competency in multiple domains. Residents gained skills from CHWs in inter-professional teamwork, cultural proficiency in patient care, effective communication, provision of cost-conscious care, and advocating for both individual and community health. Our model recognizes the value of CHW skills and knowledge and creates a powerful rationale for greater recognition of CHW expertise and integration of CHWs as members of the care team.

Relationships Among Rheological, Sensory Texture, and Swallowing Pressure Measurements of Hydrocolloid-Thickened Fluids

The objective of this study was to examine the relationships among three categories of measurements (rheological, sensory texture, and swallowing pressure) from fluids thickened to two different viscosities with 15 different hydrocolloids. Fluids at viscosities of 300 and 1500 cP (at 30 s(-1)) were targeted because these are the viscosities corresponding to the barium standards used in radiographic dysphagia diagnosis. Within the low viscosity (nectar) fluids (300 cP), the sensory properties thickness, stickiness, adhesiveness, mouth coating, and number of swallows were highly positively correlated with each other and highly positively correlated with the flow behavior index, n value (an indicator of shear-thinning behavior). Within the higher viscosity (thin honey) fluids (1500 cP), the sensory textures of adhesiveness, stickiness, mouth coating, and number of swallows correlated positively with rheological measures of n value. Swallowing pressures measured in the anterior oral cavity correlated negatively with the consistency coefficient k [shear stress/(shear rate) (n) ]. Samples that were more shear thinning (lower n values, higher k values) were generally perceived as less thick, with less adhesive properties (stickiness, adhesiveness, mouthcoating, and number of swallows). This information can be useful for selecting thickeners for people with dysphagia. A desirable thickener for many dysphagic patients would be one that allowed for a safe swallow by being viscous enough to reduce airway penetration, yet pleasant to drink, having the minimal perceived thickness and mouthcoating associated with greater shear thinning.

How medical schools can encourage students' interest in family medicine

The discipline of family medicine is essential to improving quality and reducing the cost of care in an effective health care system. Yet the slow growth of this field has not kept pace with national demand. In their study, Rodríguez and colleagues report on the influence of the social environment and academic discourses on medical students' identification with family medicine in four countries-the United Kingdom, Canada, France, and Spain. They conclude that these factors-the social environment and discursive activity within the medical school-influence students' specialty choices. While the discourses in Canada, France, and Spain were mostly negative, in the United Kingdom, family medicine was considered a prestigious academic discipline, well paying, and with a wide range of practice opportunities. Medical students in the United Kingdom also were exposed early and often to positive family medicine role models.In the United States, academic discourses about family medicine are more akin to those in Canada, France, and Spain. The hidden curriculum includes negative messages about family medicine, and "badmouthing" primary care occurs at many medical schools. National education initiatives highlight the importance of social determinants in medical education and the integration of public health and medicine in practice. Other initiatives expose students to family medicine role models and practice during their undergraduate training and promote primary care practice through new graduate medical education funding models. Together, these initiatives can reduce the negative effects of the social environment and create a more positive discourse about family medicine.

Vision 2020 measures University of New Mexico's success by health of its state

The University of New Mexico Health Sciences Center (UNMHSC) adopted a new Vision to work with community partners to help New Mexico make more progress in health and health equity than any other state by 2020. UNMHSC recognized it would be more successful in meeting communities' health priorities if it better aligned its own educational, research, and clinical missions with their needs. National measures that compare states on the basis of health determinants and outcomes were adopted in 2013 as part of Vision 2020 target measures for gauging progress toward improved health and health care in New Mexico. The Vision focused the institution's resources on strengthening community capacity and responding to community priorities via pipeline education, workforce development programs, community-driven and community-focused research, and community-based clinical service innovations, such as telehealth and "health extension." Initiatives with the greatest impact often cut across institutional silos in colleges, departments, and programs, yielding measurable community health benefits. Community leaders also facilitated collaboration by enlisting University of New Mexico educational and clinical resources to better respond to their local priorities. Early progress in New Mexico's health outcomes measures and state health ranking is a promising sign of movement toward Vision 2020.

The potential conflict between policy and ethics in caring for undocumented immigrants at academic health centers

Academic health centers (AHCs) are at the forefront of delivering care to the diverse medically underserved and uninsured populations in the United States, as well as training the majority of the health care workforce, who are professionally obligated to serve all patients regardless of race or immigration status. Despite AHCs' central leadership role in these endeavors, few consolidated efforts have emerged to resolve potential conflicts between national, state, and local policies that exclude certain classifications of immigrants from receiving federal public assistance and health professionals' social missions and ethical oath to serve humanity. For instance, whereas the 2010 Patient Protection and Affordable Care Act provides a pathway to insurance coverage for more than 30 million Americans, undocumented immigrants and legally documented immigrants residing in the United States for less than five years are ineligible for Medicaid and excluded from purchasing any type of coverage through state exchanges. To inform this debate, the authors describe their experience at the University of New Mexico Hospital (UNMH) and discuss how the UNMH has responded to this challenge and overcome barriers. They offer three recommendations for aligning AHCs' social missions and professional ethics with organizational policies: (1) that AHCs determine eligibility for financial assistance based on residency rather than citizenship, (2) that models of medical education and health professions training provide students with service-learning opportunities and applied community experience, and (3) that frontline staff and health care professionals receive standardized training on eligibility policies to minimize discrimination towards immigrant patients.

Social Workers as Research Psychotherapists in an Investigation of Cognitive-Behavioral Therapy among Rural Older Adults

A large proportion of service providers in our country are social workers. The use of social workers as mental health therapists however, has not been adequately evaluated in the literature. This aim of this study was to evaluate a sample of clinically trained, masters-level social workers in their delivery of in-home Cognitive Behavioral Therapy (CBT) to a group of primarily rural, medically frail older adults. The social workers in this study received extensive didactic and experiential CBT training. Audio-taped sessions were randomly selected and evaluated independently. Results showed that the social workers adequately delivered CBT as measured by the Cognitive Therapy Scale (CTS). Older adult participants also evidenced pre-post treatment improvements suggesting that the social workers' delivery of CBT facilitated improvement. These results suggest that social workers can be viable providers of CBT in clinical and research settings.

Prioritizing health disparities in medical education to improve care

Despite yearly advances in life-saving and preventive medicine, as well as strategic approaches by governmental and social agencies and groups, significant disparities remain in health, health quality, and access to health care within the United States. The determinants of these disparities include baseline health status, race and ethnicity, culture, gender identity and expression, socioeconomic status, region or geography, sexual orientation, and age. In order to renew the commitment of the medical community to address health disparities, particularly at the medical school level, we must remind ourselves of the roles of doctors and medical schools as the gatekeepers and the value setters for medicine. Within those roles are responsibilities toward the social mission of working to eliminate health disparities. This effort will require partnerships with communities as well as with academic centers to actively develop and to implement diversity and inclusion strategies. Besides improving the diversity of trainees in the pipeline, access to health care can be improved, and awareness can be raised regarding population-based health inequalities.

The primary care extension program: a catalyst for change

The Affordable Care Act authorized, but did not fund, the Primary Care Extension Program (PCEP). Much like the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care. It could also help achieve other goals such as integrating primary care with public health and translating research into practice. The urgency of these goals and their importance to achieving the Triple Aim for health care should increase interest in rapidly building the PCEP, much as the need to feed the country did a century ago.

Cumulative Heat Diffusion Using Volume Gradient Operator for Volume Analysis

We introduce a simple, yet powerful method called the Cumulative Heat Diffusion for shape-based volume analysis, while drastically reducing the computational cost compared to conventional heat diffusion. Unlike the conventional heat diffusion process, where the diffusion is carried out by considering each node separately as the source, we simultaneously consider all the voxels as sources and carry out the diffusion, hence the term cumulative heat diffusion. In addition, we introduce a new operator that is used in the evaluation of cumulative heat diffusion called the Volume Gradient Operator (VGO). VGO is a combination of the LBO and a data-driven operator which is a function of the half gradient. The half gradient is the absolute value of the difference between the voxel intensities. The VGO by its definition captures the local shape information and is used to assign the initial heat values. Furthermore, VGO is also used as the weighting parameter for the heat diffusion process. We demonstrate that our approach can robustly extract shape-based features and thus forms the basis for an improved classification and exploration of features based on shape.

Density and delay of punishment of free-operant avoidance

In two experiments, the free-operant shock-avoidance behavior of rats was punished by electric shock. Two aspects of the schedule of response-produced shock were varied: the frequency of punishment over time (punishment density) and the temporal interval between the punished response and the punishment (punishment delay). The general finding was that response-produced shock suppressed avoidance responding under most of the density-delay combinations studied, and suppression increased as a function of increases in density and decreases in delay. Rate increases of small magnitude also were observed, usually as an initial reaction to the lesser densities and longer delays. Response suppression, while decreasing the number of punishment shocks received, also increased the number of avoidance shocks, so that the total number of shocks received usually was greater than the minimal number possible. The results were discussed from the standpoint of similarities between the effects of punishing positively and negatively reinforced behavior. The finding that subjects did not minimize the total number of shocks suggested that when avoidance behavior is punished, responding is controlled more by the local consequences of responding than by overall shock frequencies during the course of the session.

Intermittent punishment of human responding maintained by intermittent reinforcement

To determine the effects of variable-interval shock punishment on behavior maintained by variable-interval and variable-ratio reinforcement, human subjects' key-pressing behavior was reinforced with money on a four-component multiple schedule. Components 1 and 2 were variable-interval 30-sec, and Components 3 and 4 were variable-ratio 210. After responding was stabilized, response-contingent electric shock was scheduled on a variable-interval 10-sec schedule during the second and fourth components of each cycle. Subjects instructed as to the reinforcement contingencies showed gradually increasing suppression of variable-interval responding at increasing shock intensities and either very high or very low rates of variable-ratio responding at higher intensities. Minimally instructed subjects showed suppression at higher shock intensities, but no clear differential suppression as a function of reinforcement schedule. Recovery from initial suppression was observed within sessions.

Effects of instructions and reinforcement-feedback on human operant behavior maintained by fixed-interval reinforcement

In three experiments, human subjects were trained on a five-component multiple schedule with different fixed intervals of monetary reinforcement scheduled in the different components. Subjects uninstructed about the fixed-interval schedules manifested high and generally equivalent rates regardless of the particular component. By comparison, subjects given instructions about the schedules showed orderly progressions of rates and temporal patterning as a function of the interreinforcement intervals, particularly when feedback about reinforcement was delivered but also when reinforcement-feedback was withheld. Administration of the instructions-reinforcement combination to subjects who had already developed poorly differentiated behavior, however, did not make their behavior substantially better differentiated. When cost was imposed for responding, both instructed and uninstructed subjects showed low and differentiated rates regardless of their prior histories. It was concluded that instructions can have major influences on the establishment and maintenance of human operant behavior.

[Demographic distribution and prevalence of overactive bladder in Venezuela]

OBJECTIVE

There is a lack of information regarding overactive bladder (OAB) in South America. Our aim in this study was to estimate the prevalence of overactive bladder (OAB) in Venezuela based on the 2002 International Continence Society (ICS) consensus criteria and also to verify its demographic distribution in this country.

SUBJECTS AND METHODS

We performed a multicentric prospective evaluation of patients from 2003 to 2007 in different cities in Venezuela. A number 3.407 adults (M:38%, F:62%) between 18 and 75 years of age (mean age 54 years) completed a physician guided questionnaire (V8) of urinary symptoms, bladder function, diet, general habits and general medical condition. Statistical procedures were carried out using software based on R programming for computational statistics.

RESULTS

The overall prevalence of OAB in Venezuela was determined as 21%. Female were more affected as compared to male (25.6% vs. 13.7% in men, p < 0.005) OAB was detected at early age (18 yrs) maintaining higher prevalence in women (M: 9%, F: 14%). In the studied cohort OAB shows its highest prevalence between the subgroup of 65 to 69 years of age. In all statistical tests the level of significance was defined as p < 0.005, with a confidence interval of 95%.

CONCLUSION

The OAB-V8 questionnaire aids to clearly identify patients with OAB symptoms. The overall prevalence of OAB in Venezuela is 21%. It is present in both genders, predominantly women and can be detected at early age.

The role of social and community service in medical education: the next 100 years

Abraham Flexner's focus on science in medical school curricula was not intended to exclude or marginalize the importance of service in training American physicians. The erosion of service in academic medicine in the century after his report was the result of forces as wide ranging as research priorities, health care financing, and industry's influence. The authors review the historical context of these changes and make the case that reintroducing service into medical school curricula has never been more important. They describe the impact that neglecting service has had on society, patients, the medical profession, medical students, and medical education. After defining what is meant by social, public, or community service, they go on to detail signature programs at University of Texas Medical Branch, University of New Mexico Health Sciences Center, and Mount Sinai School of Medicine, focusing on the two major categories of health care delivery and education. These examples, in geographically and demographically disparate schools of medicine, demonstrate that it is possible to successfully reintegrate service into the missions of academic medical centers and medical schools.

Health extension in new Mexico: an academic health center and the social determinants of disease

The Agricultural Cooperative Extension Service model offers academic health centers methodologies for community engagement that can address the social determinants of disease. The University of New Mexico Health Sciences Center developed Health Extension Rural Offices (HEROs) as a vehicle for its model of health extension. Health extension agents are located in rural communities across the state and are supported by regional coordinators and the Office of the Vice President for Community Health at the Health Sciences Center. The role of agents is to work with different sectors of the community in identifying high-priority health needs and linking those needs with university resources in education, clinical service and research. Community needs, interventions, and outcomes are monitored by county health report cards. The Health Sciences Center is a large and varied resource, the breadth and accessibility of which are mostly unknown to communities. Community health needs vary, and agents are able to tap into an array of existing health center resources to address those needs. Agents serve a broader purpose beyond immediate, strictly medical needs by addressing underlying social determinants of disease, such as school retention, food insecurity, and local economic development. Developing local capacity to address local needs has become an overriding concern. Community-based health extension agents can effectively bridge those needs with academic health center resources and extend those resources to address the underlying social determinants of disease.