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1.  “All the Money in the World …” Patient Perspectives Regarding the Influence of Financial Incentives” 
Health Services Research  2011;46(6 Pt 1):1986-2004.
To analyze patient perspectives of the use of financial incentives in a hypertension intervention.
Study Setting
Twelve Veterans Affairs primary care clinics over a 9-month period.
Study Design
Qualitative semistructured interviews conducted with 54 hypertensive veterans participating in an intervention to promote guideline-consistent therapy. Intervention components included an intervention letter requesting patients talk with their providers, an offer of U.S.$20 to bring in the letter to their provider, and a health educator phone call.
Data Collection Methods
Semistructured interviews were conducted. Transcripts were coded for thematic content. The financial incentive theme was then subcoded for more detailed analysis.
Principle Findings
Most participants (n = 48; 88.9 percent) stated the incentive had (or would have) no effect on their decision to initiate a discussion with their provider. Some participants articulated reservations about the effectiveness and/or appropriateness of financial incentives in health care decisions; however, a few expressed the opinion that there may be some potential benefits to the use of financial incentives if they encourage patients to be active in their health care.
The findings of this study raise questions about the appropriateness and unintended consequences of employing patient-directed financial incentives in health care settings.
PMCID: PMC3393021  PMID: 21689098
Hypertension; veterans; financial incentives; qualitative
2.  Prospective assessment of lymphatic dissemination in endometrial cancer: A paradigm shift in surgical staging 
Gynecologic oncology  2008;109(1):11-18.
To prospectively assess pelvic and para-aortic lymph node metastases in endometrial cancer with lymphatic dissemination, emphasizing the examination of para-aortic metastases relative to the inferior mesenteric artery (IMA).
Over 36 months, 422 consecutive patients were managed by predefined surgical guidelines differentiating low-risk patients from patients at risk for dissemination requiring systematic lymphadenectomy. Low risk was defined as grade 1 or 2 endometrioid type with myometrial invasion (MI) ≤50% and primary tumor diameter (PTD) ≤2 cm. Pelvic and para-aortic lymph nodes were submitted separately, with nodes identified from all 8 pelvic and 4 para-aortic node-bearing basins. Surgical quality assessments examined median node counts (primary surrogate for quality) and nodes harvested above and below the IMA and excised gonadal veins (secondary surrogates).
Lymphadenectomy was not required in 27% of patients (all low risk) and in 33% (n=112) of endometrioid cases. However, 22 patients (20%) of this latter cohort had lymphadenectomy and all lymph nodes were negative. Sixty-three (22%) of 281 patients undergoing lymphadenectomy had lymph node metastases: both pelvic and para-aortic in 51%, only pelvic in 33%, and isolated to the para-aortic area in 16%. Therefore, 67% of patients with lymphatic dissemination had para-aortic lymph node metastases. Furthermore, 77% of patients with para-aortic node involvement had metastases above the IMA, whereas nodes in the ipsilateral para-aortic area below the IMA and ipsilateral common iliac basin were declared negative in 60% and 71%, respectively. Gonadal veins were excised in 25 patients with para-aortic node metastases; 7 patients (28%) had documented metastatic involvement of gonadal veins or surrounding soft tissue.
The high rate of lymphatic metastasis above the IMA indicates the need for systematic pelvic and para-aortic lymphadenectomy (vs sampling) up to the renal vessels. The latter should include consideration of excision of the gonadal veins. Conversely, lymphadenectomy does not benefit patients with grade 1 and 2 endometrioid lesions with MI ≤50% and PTD ≤2 cm.
PMCID: PMC3667391  PMID: 18304622
Endometrial neoplasms; Lymph node excision; Lymphatic metastasis; Outcomes assessment
3.  Adherence to Physician Recommendation to Colorectal Cancer Screening Colonoscopy Among Hispanics 
Journal of General Internal Medicine  2011;26(10):1124-1130.
Colorectal cancer (CRC) is the second most commonly diagnosed cancer among Hispanics in the United States (US), yet the use of CRC screening is low in this population. Physician recommendation has consistently shown to improve CRC screening.
To identify the characteristics of Hispanic patients who adhere or do not adhere to their physician’s recommendation to have a screening colonoscopy.
A cross-sectional study featuring face-to-face interviews by culturally matched interviewers was conducted in primary healthcare clinics and community centers in New York City.
Four hundred Hispanic men and women aged 50 or older, at average risk for CRC, were interviewed. Two hundred and eighty (70%) reported receipt of a physician’s recommendation for screening colonoscopy and are included in this study.
Dependent variable: self report of having had screening colonoscopy. Independent variables: sociodemographics, healthcare and health promotion factors.
Of the 280 participants, 25% did not adhere to their physician’s recommendation. Factors found to be associated with non-adherence were younger age, being born in the US, preference for completing interviews in English, higher acculturation, and greater reported fear of colonoscopy testing. The source of colonoscopy recommendation (whether it came from their usual healthcare provider or not, and whether it occurred in a community or academic healthcare facility) for CRC screening was not associated with adherence.
This study indicates that potentially identifiable subgroups of Hispanics may be less likely to follow their physician recommendation to have a screening colonoscopy and thus may decrease their likelihood of an early diagnosis and prompt treatment. Raising physicians’ awareness to such patients’ characteristics could help them anticipate patients who may be less adherent and who may need additional encouragement to undergo screening colonoscopy.
PMCID: PMC3181293  PMID: 21541795
colon cancer; colorectal cancer screening; Hispanics; physician recommendation; colonoscopy
4.  Histone deacetylase inhibitors induce apoptosis in both Type I and Type II endometrial cancer cells 
Gynecologic Oncology  2007;105(2):493-500.
To characterize the molecular pathways involved in apoptosis following administration of histone deacetylase inhibitors to Type I and II endometrial cancer cells.
Ark2, Ishikawa, and AN3 cell lines representing both Type I and II endometrial cancers were treated with various concentrations of oxamflatin and HDAC inhibitor-1. Cell apoptosis was determined by flow cytometry, nuclear staining, Western blotting, and mitochondrial membrane potential assays.
Compared to controls, there was a 95% reduction in the growth of Ark2 cells following administration of histone deacetylase inhibitors and this response was dose-dependent. These agents also caused profound morphologic changes and loss of mitochondrial membrane potentials consistent with the induction of apoptosis. Cleavage of PARP, caspase-9, and caspase-8 was detected, confirming the activation of apoptotic cascades in endometrial carcinoma cells. This effect was present in both serous and endometrioid cell types.
Our results suggest that oxamflatin and HDAC inhibitor-1 have potent cytotoxicity in endometrial cancer cells by inducing cell apoptosis. Histone deacetylase inhibitors are promising agents for the treatment of both Type I and II endometrial carcinoma.
PMCID: PMC3273418  PMID: 17303224
Histone deacetylase; Endometrial cancer; Apoptosis
5.  Parental Monitoring and Changes in Substance Use Among Latino/a and Non-Latino/a Pre-adolescents in the Southwest 
Substance use & misuse  2010;45(14):2524-2550.
The family is one of the most important contexts for children’s development and well-being. Parents play a central role in the family, and the degree to which parents monitor their children’s behaviors has been shown to be associated with fewer risky behaviors, especially substance use. Prior research on parental monitoring and substance use, however, has several limitations. Most studies have focused on older adolescents, as well as adolescents from primarily White, Euro-American heritage. Prior studies largely have been cross-sectional and unable to test if parental monitoring decreases substance use over time. This article explicitly addresses these limitations by examining a longitudinal sample of primarily Latino youth in pre-adolescence (5th grade). Using an Ecodevelopmental framework, we hypothesized that parental monitoring will be associated with lower levels of youth substance use and more beneficial substance use intentions, norms, and attitudes. We further hypothesized that the effects of parental monitoring may differ by gender and between Latino and non-Latino youth. The data came from a school-based randomized trial of a substance use prevention program in Phoenix, AZ. To test our hypotheses, we use regression models, with adjustments for clustering and multiple imputation of missing data. The results show that parental monitoring has significant beneficial and longitudinal effects on youth’s substance use and related substance use intentions, norms, and attitudes. These beneficial effects of parental monitoring are invariant to the youth’s gender or Latino ethnicity, except in the case of marijuana use: parental monitoring is significantly more effective in reducing girls’ marijuana use.
PMCID: PMC3108798  PMID: 20394523
parental monitoring; Latino/a; pre-adolescence
6.  Improving Underrepresented Minority Medical Student Recruitment with Health Disparities Curriculum 
Journal of General Internal Medicine  2010;25(Suppl 2):82-85.
Diversity improves all students’ academic experiences and their abilities to work with patients from differing backgrounds. Little is known about what makes minority students select one medical school over another.
To measure the impact of the existence of a health disparities course in the medical school curriculum on recruitment of underrepresented minority (URM) college students to the University of Chicago Pritzker School of Medicine.
All medical school applicants interviewed in academic years 2007 and 2008 at the University of Chicago Pritzker School of Medicine (PSOM) attended an orientation that detailed a required health care disparities curriculum introduced in 2006. Matriculants completed a precourse survey measuring the impact of the existence of the course on their decision to attend PSOM. URM was defined by the American Association of Medical Colleges as Black, American Indian/Alaskan Native, Native Hawaiian, Mexican American, and Mainland Puerto Rican.
Precourse survey responses were 100% and 96% for entering classes of 2007 and 2008, respectively. Among those students reporting knowledge of the course (128/210, 61%), URM students (27/37, 73%) were more likely than non-URM students (38/91, 42%) to report that knowledge of the existence of the course influenced their decision to attend PSOM (p = 0.002). Analysis of qualitative responses revealed that students felt that the curriculum gave the school a reputation for placing importance on health disparities and social justice issues. URM student enrollment at PSOM, which had remained stable from years 2005 and 2006 at 12% and 11% of the total incoming classes, respectively, increased to 22% of the total class size in 2007 (p = 0.03) and 19 percent in 2008.
The required health disparities course may have contributed to the increased enrollment of URM students at PSOM in 2007 and 2008.
PMCID: PMC2847120  PMID: 20352498
health disparities; curriculum; education; medical students; underserved
7.  Inherited Determinants of Ovarian Cancer Survival 
Due to variation of outcome among cases, we sought to examine whether overall survival in ovarian cancer was associated with common inherited variants in 227 candidate genes from ovarian cancer-related pathways including angiogenesis, inflammation, detoxification, glycosylation, one-carbon transfer, apoptosis, cell cycle regulation, and cellular senescence.
Experimental Design
Blood samples were obtained from 325 women with invasive epithelial ovarian cancer diagnosed at the Mayo Clinic from 1999 to 2006. During a median follow-up of 3.8 years (range, 0.1 – 8.6 years), 157 deaths were observed. Germline DNA was analyzed at 1,416 single nucleotide polymorphisms (SNPs). For all patients, and for 203 with serous subtype, we assessed the overall significance of each gene and pathway, and estimated risk of death via hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for known prognostic factors.
Variation within angiogenesis was most strongly associated with survival time overall (p=0.03) and among patients with serous cancer (p=0.05), particularly for EIF2B5 rs4912474 (all patients HR 0.69, 95% CI 0.54-0.89, p=0.004), VEGFC rs17697305 (serous subtype HR 2.29, 95% CI 1.34-3.92, p=0.003), and four SNPs in VHL. Variation within the inflammation pathway was borderline significant (all patients, p=0.09), and SNPs in CCR3, IL1B, IL18, CCL2, and ALOX5 which correlated with survival time are worthy of follow-up.
An extensive multiple-pathway assessment found evidence that inherited differences may play a role in outcome of ovarian cancer patients, particularly in genes within the angiogenesis and inflammation pathways. Our work supports efforts to target such mediators for therapeutic gain.
PMCID: PMC2818685  PMID: 20103664
ovarian cancer; angiogenesis; survival; epidemiology; apoptosis
8.  DNA repair genes XRCC1 and XRCC3 polymorphisms and their relationship with the level of micronuclei in breast cancer patients 
Genetics and Molecular Biology  2010;33(4):637-640.
Breast cancer (BC) is the most prevalent type worldwide, besides being one of the most common causes of death among women. It has been suggested that sporadic BC is most likely caused by low-penetrance genes, including those involved in DNA repair mechanisms. Furthermore, the accumulation of DNA damage may contribute to breast carcinogenesis. In the present study, the relationship between two DNA repair genes, viz., XRCC1 (Arg399Gln) and XRCC3 (Thr241Met) polymorphisms, and the levels of chromosome damage detected in 65 untreated BC women and 85 healthy controls, was investigated. Chromosome damage was evaluated through micronucleus assaying, and genotypes determined by PCR-RFLP methodology. The results showed no alteration in the risk of BC and DNA damage brought about by either XRCC1 (Arg399Gln) or XRCC3 (Thr241Met) action in either of the two groups. Nevertheless, on evaluating BC risk in women presenting levels of chromosome damage above the mean, the XRCC3Thr241Met polymorphism was found to be more frequent in the BC group than in the control, thereby leading to the conclusion that there is a slight association between XRCC3 (241 C/T) genotypes and BC risk in the subgroups with higher levels of chromosome damage.
PMCID: PMC3036161  PMID: 21637570
DNA repair polymorphisms; breast cancer; micronucleus assay
9.  A 1q42 Deletion Involving DISC1, DISC2, and TSNAX in an Autism Spectrum Disorder 
Individuals with autism spectrum disorders have impairments in social, communicative, and behavior development that are often accompanied by abnormalities in cognitive functioning, learning, attention, and sensory processing. In this report, we describe a 3-year-old male child with an autism spectrum disorder who carries a 2Mb deletion of chromosome 1q42. Array comparative genome hybridization revealed that this deletion involves at least three genes—DISC1, DISC2, and TSNAX—which have been found to be associated with neuropsychiatric disorders and are likely to play key roles in normal CNS development. Further studies revealed that the deletion was inherited from his unaffected mother. This suggests that other genetic and/or environmental factors, some of which may be sex specific, may modify the phenotypic effects of this deletion. While this case provides evidence for the potential role of DISC1, DISC2, and TSNAX in the development of autism spectrum disorders, it is equally clear that caution must be taken when providing families with prognostic information and genetic counseling regarding such deletions.
PMCID: PMC2909829  PMID: 19606485
DISC1; DISC2; TSNAX; autism spectrum disorder; chromosome 1q42
10.  Assessing the Quality of Prescribing and Monitoring Erythropoiesis Stimulating Agents in the Nursing Home Setting 
As many as 50% of all nursing home (NH) residents meet the World Health Organization criteria for anemia. The objectives of this study were to determine the prevalence and appropriateness of prescribing and monitoring of erythropoiesis stimulating agents (ESAs) used to treat anemia in the NH setting.
Cross-sectional, one-month study of all NH residents in four community-based, university-affiliated NHs between January and February 2008. Residents were included in the analysis if they received at least one dose of an ESA during the study duration. Data collected through chart review included basic demographic information, ESA indication, ESA dosage, concurrent administration of iron supplements, hemoglobin (Hgb) monitoring, and blood pressure measurements.
A total of 4.5% (22/485) of NH residents received at least one dose of an ESA. Residents who received ESAs had a mean age of 80.4 (± 14.5) years. Most residents who received ESAs were female (64% [14/22]), white (68% [15/22]), and had a mean weight of 72.0 (± 20.84) kg. Only 27% (6/22) of residents were prescribed an ESA for a FDA-approved indication. Darbepoetin alfa was the most commonly prescribed ESA (64% [14/22]) with a mean weekly dose of 70.8 (± 68.1) mcg, followed by epoetin alfa (37% [8/22]) with a mean weekly dose of 22,625 (± 21,232) units. More than one-quarter, (27% [6/22]) of those who received an ESA had a Hgb value ≥ 12 g/dL, the maximum recommended threshold for use of these medications. Of the 18 residents that had blood pressure measurements, 18% (2/18) were hypertensive.
Suboptimal prescribing and monitoring of ESAs were common in the NHs we studied. Future studies are needed to determine if the development and use of computerized decision support systems can improve prescribing and monitoring of ESAs in the NH setting.
PMCID: PMC2846620  PMID: 19560723
Hematologic agents; hematinics; nursing homes; aged
11.  Complement-dependent neutrophil recruitment is critical for the development of elastase-induced abdominal aortic aneurysm 
Circulation  2009;119(13):1805-1813.
We previously established that neutrophils play a critical role in the development of experimental abdominal aortic aneurysm (AAA). The signal that initiates the influx of neutrophils to the aortic wall, however, remains unknown. In this study we tested the hypothesis that complement participates in the development of AAA by providing the necessary chemotactic signal that recruits neutrophils to the aortic wall.
Methods and Results
Using an elastase-induced model of AAA we showed that pre-treatment of C57BL/6 mice with cobra venom factor (CVF) that depleted serum of complement activity protected mice from AAA development. Whereas control mice exhibited a mean aortic diameter (AD) of 156 ± 2% on day 14 after elastase perfusion, CVF-treated mice exhibited a mean AD of 90 ± 4% (P < 0.001). Examination of mice deficient in factor B (fB) further indicated that the alternative pathway of complement played a major role in this process (mean AD of 105 ± 4%, P < 0.001 compared with controls). Activation of the alternative pathway led to the generation of the anaphylatoxins C3a and C5a that recruited neutrophils to the aortic wall. Moreover, antagonism of both C3a and C5a activities was required to block AAA, suggesting that each can independently promote the aneurysmal phenotype. In addition, we demonstrated that complement alternative pathway involvement was not restricted to this experimental model but was also evident in human AAAs.
The identification of the complement system involvement in the pathophysiology of AAA provides a new target for therapeutic intervention in this common disease.
PMCID: PMC2758616  PMID: 19307471
aneurysm; immune system; inflammation; leukocytes; complement system
12.  Part I, Patient perspective: activating patients to engage their providers in the use of evidence-based medicine: a qualitative evaluation of the VA Project to Implement Diuretics (VAPID) 
This qualitative evaluation follows a randomized-control trial of a patient activation intervention in which hypertensive patients received a letter in the mail asking them to discuss thiazide diuretics with their provider. Results of the parent study indicated that the intervention was effective at facilitating discussions between patients and providers and enhancing thiazide prescribing rates. In the research presented here, our objective was to interview patients to determine their receptivity to patient activation, a potential leverage point for implementing interventions.
Semi-structured phone interviews were conducted with 54 patients, purposefully sampled from a randomized controlled trial of a patient activation intervention. All subjects had a history of hypertension and received primary care from one of twelve Veterans Affairs primary care clinics. All interviews were transcribed verbatim and reviewed by the interviewer. Interviews were independently coded by three qualitative researchers until consensus was attained, and relevant themes and responses were identified, grouped, and compared. NVivo 8.0 was used for data management and analysis.
Data from this qualitative study revealed that most participants held favorable opinions toward the patient activation intervention used in the clinical trial. Most (82%) stated they had a positive reaction. Patients emphasized they liked the intervention because it was straightforward and encouraged them to initiate discussions with their provider. Also, by being active participants in their healthcare, patients felt more invested. Of the few patients offering negative feedback (11%), their main concern was discomfort with possibly challenging their providers' healthcare practices. Another outcome of interest was the patients' perceptions of why they were or were not prescribed a thiazide diuretic, for which several clinically relevant reasons were provided.
Patients' perceptions of the intervention indicated it was effective via the encouragement of dialogue between themselves and their provider regarding evidence-based treatment options for hypertension. Additionally, patients' experiences with thiazide prescribing discussions shed light on the facilitators and barriers to implementing clinical practice guidelines regarding thiazides as first-line therapy for hypertension.
Trial registration
National Clinical Trial Registry number NCT00265538
PMCID: PMC2850871  PMID: 20298563
13.  Part II, Provider perspectives: should patients be activated to request evidence-based medicine? a qualitative study of the VA project to implement diuretics (VAPID) 
Hypertension guidelines recommend the use of thiazide diuretics as first-line therapy for uncomplicated hypertension, yet diuretics are under-prescribed, and hypertension is frequently inadequately treated. This qualitative evaluation of provider attitudes follows a randomized controlled trial of a patient activation strategy in which hypertensive patients received letters and incentives to discuss thiazides with their provider. The strategy prompted high discussion rates and enhanced thiazide-prescribing rates. Our objective was to interview providers to understand the effectiveness and acceptability of the intervention from their perspective, as well as the suitability of patient activation for more widespread guideline implementation.
Semi-structured phone interviews were conducted with 21 primary care providers. Interviews were transcribed verbatim and reviewed by the interviewer before being analyzed for content. Interviews were coded, and relevant themes and specific responses were identified, grouped, and compared.
Of the 21 providers interviewed, 20 (95%) had a positive opinion of the intervention, and 18 of 20 (90%) thought the strategy was suitable for wider use. In explaining their opinions of the intervention, many providers discussed a positive effect on treatment, but they more often focused on the process of patient activation itself, describing how the intervention facilitated discussions by informing patients and making them more pro-active. Regarding effectiveness, providers suggested the intervention worked like a reminder, highlighted oversights, or changed their approach to hypertension management. Many providers also explained that the intervention 'aligned' patients' objectives with theirs, or made patients more likely to accept a change in medications. Negative aspects were mentioned infrequently, but concerns about the use of financial incentives were most common. Relevant barriers to initiating thiazide treatment included a hesitancy to switch medications if the patient was at or near goal blood pressure on a different anti-hypertensive.
Patient activation was acceptable to providers as a guideline implementation strategy, with considerable value placed on the activation process itself. By 'aligning' patients' objectives with those of their providers, this process also facilitated part of the effectiveness of the intervention. Patient activation shows promise for wider use as an implementation strategy, and should be tested in other areas of evidence-based medicine.
Trial registration
National Clinical Trial Registry number NCT00265538
PMCID: PMC2856519  PMID: 20298564
14.  Brazilian Network for HIV Drug Resistance Surveillance: a survey of individuals recently diagnosed with HIV 
Use of antiretrovirals is widespread in Brazil, where more than 200,000 individuals are under treatment. Although general prevalence of primary antiretroviral resistance in Brazil is low, systematic sampling in large metropolitan areas has not being performed.
The HIV Threshold Survey methodology (HIV-THS, WHO) was utilized, targeting Brazil's four major regions and selecting the six most populated state capitals: Sao Paulo, Rio de Janeiro, Salvador, Porto Alegre, Brasilia and Belem. We were able to sequence samples from 210 individuals with recent HIV diagnosis, 17 of them (8.1%) carrying HIV isolates with primary antiretroviral resistance mutations. Five, nine and four isolates showed mutations related to resistance to nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs), respectively. Using HIV-THS, we could find an intermediate level of transmitted resistance (5% to 15%) in Belem/Brasilia, Sao Paulo and Rio de Janeiro. Lower level of transmitted resistance (<5%) were observed in the other areas. Despite the extensive antiretroviral exposure and high rates of virologic antiretroviral failure in Brazil, the general prevalence of primary resistance is still low. However, an intermediate level of primary resistance was found in the four major Brazilian cities, confirming the critical need to start larger sampling surveys to better define the risk factors associated with transmission of resistant HIV.
PMCID: PMC2759910  PMID: 19765271
15.  Financial impact of reducing door-to-balloon time in ST-elevation myocardial infarction: a single hospital experience 
The impact of reducing door-to-balloon time on hospital revenues, costs, and net income is unknown.
We prospectively determined the impact on hospital finances of (1) emergency department physician activation of the catheterization lab and (2) immediate transfer of the patient to an immediately available catheterization lab by an in-house transfer team consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. We collected financial data for 52 consecutive ST-elevation myocardial infarction patients undergoing emergency percutaneous intervention from October 1, 2004–August 31, 2005 and compared this group to 80 consecutive ST-elevation myocardial infarction patients from September 1, 2005–June 26, 2006 after protocol implementation.
Per hospital admission, insurance payments (hospital revenue) decreased ($35,043 ± $36,670 vs. $25,329 ± $16,185, P = 0.039) along with total hospital costs ($28,082 ± $31,453 vs. $18,195 ± $9,242, P = 0.009). Hospital net income per admission was unchanged ($6962 vs. $7134, P = 0.95) as the drop in hospital revenue equaled the drop in costs. For every $1000 reduction in total hospital costs, insurance payments (hospital revenue) dropped $1077 for private payers and $1199 for Medicare/Medicaid. A decrease in hospital charges ($70,430 ± $74,033 vs. $53,514 ± $23,378, P = 0.059), diagnosis related group relative weight (3.7479 ± 2.6731 vs. 2.9729 ± 0.8545, P = 0.017) and outlier payments with hospital revenue>$100,000 (7.7% vs. 0%, P = 0.022) all contributed to decreasing ST-elevation myocardial infarction hospitalization revenue. One-year post-discharge financial follow-up revealed similar results: Insurance payments: $49,959 ± $53,741 vs. $35,937 ± $23,125, P = 0.044; Total hospital costs: $39,974 ± $37,434 vs. $26,778 ± $15,561, P = 0.007; Net Income: $9984 vs. $9159, P = 0.855.
All of the financial benefits of reducing door-to-balloon time in ST-elevation myocardial infarction go to payers both during initial hospitalization and after one-year follow-up.
Trial Registration ID: NCT00800163
PMCID: PMC2731056  PMID: 19631001
16.  Innovative Health Care Disparities Curriculum for Incoming Medical Students 
Journal of General Internal Medicine  2008;23(7):1028-1032.
1) To pilot a health disparities curriculum for incoming first year medical students and evaluate changes in knowledge. 2) To help students become aware of personal biases regarding racial and ethnic minorities. 3) To inspire students to commit to serving indigent populations.
First year students participated in a 5-day elective course held before orientation week. The course used the curricular goals that had been developed by the Society of General Internal Medicine Health Disparities Task Force. Thirty-two faculty members from multiple institutions and different disciplinary backgrounds taught the course. Teaching modalities included didactic lectures, small group discussions, off-site expeditions to local free clinics, community hospitals and clinics, and student-led poster session workshops. The course was evaluated by pre-post surveys.
Sixty-four students (60% of matriculating class) participated. Survey response rates were 97–100%. Students’ factual knowledge (76 to 89%, p < .0009) about health disparities and abilities to address disparities issues improved after the course. This curriculum received the highest rating of any course at the medical school (overall mean 4.9, 1 = poor, 5 = excellent).
This innovative course provided students an opportunity for learning and exploration of a comprehensive curriculum on health disparities at a critical formative time.
PMCID: PMC2517917  PMID: 18612738
health disparities; curriculum; education; medical students; underserved
17.  Polymerase chain reaction in the detection of an ‘outbreak’ of asymptomatic viral infections in a community birth cohort in south India 
Epidemiology and infection  2007;136(3):399-405.
Asymptomatic enteric infections are important where sequelae or protection from subsequent illness is an outcome measure. The use of reverse transcription–polymerase chain reaction (RT–PCR) to identify asymptomatic enteric infections in a birth cohort followed for rotaviral infections in a south Indian urban slum is reported. Of 1191 non-diarrhoeal samples from 371 children collected in May–June 2003, 22 (1·9%) were positive by ELISA. A total of 147 (40·6%) of 362 samples tested by VP6 RT–PCR were positive. In those samples that could be typed, a high diversity of G types including G1, G2, G4, G8, G9 and G10, and a high proportion (34·4%) of mixed infections were detected. Noroviruses were identified in 6/28 (21·4%) samples tested. The identification of infections undetectable by conventional techniques indicates the importance of the use of sensitive diagnostic techniques in research studies. Asymptomatically infected children may also act as a source of infection for other susceptible hosts.
PMCID: PMC2467457  PMID: 17521476
18.  Vascularization of the dorsal root ganglia and peripheral nerve of the mouse: Implications for chemical-induced peripheral sensory neuropathies 
Molecular Pain  2008;4:10.
Although a variety of industrial chemicals, as well as several chemotherapeutic agents used to treat cancer or HIV, preferentially induce a peripheral sensory neuropathy what remains unclear is why these agents induce a sensory vs. a motor or mixed neuropathy. Previous studies have shown that the endothelial cells that vascularize the dorsal root ganglion (DRG), which houses the primary afferent sensory neurons, are unique in that they have large fenestrations and are permeable to a variety of low and high molecular weight agents. In the present report we used whole-mount preparations, immunohistochemistry, and confocal laser scanning microscopy to show that the cell body-rich area of the L4 mouse DRG has a 7 fold higher density of CD31+ capillaries than cell fiber rich area of the DRG or the distal or proximal aspect of the sciatic nerve. This dense vascularization, coupled with the high permeability of these capillaries, may synergistically contribute, and in part explain, why many potentially neurotoxic agents preferentially accumulate and injure cells within the DRG. Currently, cancer survivors and HIV patients constitute the largest and most rapidly expanding groups that have chemically induced peripheral sensory neuropathy. Understanding the unique aspects of the vascularization of the DRG and closing the endothelial fenestrations of the rich vascular bed of capillaries that vascularize the DRG before intravenous administration of anti-neoplastic or anti-HIV therapies, may offer a mechanism based approach to attenuate these chemically induced peripheral neuropathies in these patients.
PMCID: PMC2289805  PMID: 18353190

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