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1.  Inpatient Rehabilitation Centers and Concern for Increasing Volume of Ischemic Stroke Patients Requiring Rehabilitation 
Southern medical journal  2013;106(12):693-696.
Objectives
To determine whether prolonged length of stay (pLOS) in ischemic stroke is related to delays in discharge disposition arrangement.
Methods
We designed a retrospective study to compare patients with acute ischemic stroke (AIS) who experienced pLOS to those who did not experience pLOS. Patients who have had AIS between July 2008 and December 2010 were included unless they arrived >48 hours after time last seen normal, had an unknown last seen normal, or experienced an in-hospital stroke. pLOS was defined in our prospective stroke registry (before the generation of this research question) as hospitalization extended for ≥24 hours more than necessary to determine neurologic stability and next level of care/disposition for a given patient. We characterized the frequency of each cause of pLOS and further investigated the destinations that were more frequently associated with pLOS among patients with delay resulting from arranging discharge disposition.
Results
Of the 274 patients included, 106 (31.9%) had pLOS. Reasons for pLOS were discharge disposition (48.1%), non-neurologic medical complications (36.8%), delays in imaging studies (20.8%), awaiting procedure (10.4%), and neurologic complications (9.4%). Among patients with pLOS caused by delayed disposition, more than half were awaiting placement in an inpatient rehabilitation facility.
Conclusions
For the majority of our patients, pLOS was caused by acquired medical complications and delayed disposition, most commonly inpatient rehabilitation. Further efforts are needed to prevent complications and further investigation is necessary to identify the factors that may contribute to delayed discharge to inpatient rehabilitation facilities, which may include delayed planning or heightened scrutiny of insurance companies regarding their beneficiaries.
doi:10.1097/SMJ.0000000000000036
PMCID: PMC3902106  PMID: 24305530
stroke; inpatient rehabilitation; length of stay; complications; discharge disposition
2.  Sexual Abuse History and Pelvic Floor Disorders in Women 
Southern medical journal  2013;106(12):675-678.
Objectives
Sexual abuse rates in the general female population range between 15% and 25%, and sexual abuse is known to have a long-term impact on a woman’s health. The aim of this study was to report the prevalence of sexual abuse history in women presenting to clinicians for pelvic floor disorders (PFD) and to determine whether a history of sexual abuse is associated with a specific type of PFD.
Methods
We conducted a retrospective chart review of new urogynecology patients seen at the University of New Mexico Hospital. All women underwent a standardized history and physical examination and completed symptom severity and quality-of-life measures. Univariate and multivariable analyses were conducted to determine which PFDs were associated with a history of sexual abuse among women with and without a history of sexual abuse.
Results
A total of 1899 new urogynecology patients with complete information were identified from January 2007 and October 2011; 1260 (66%) were asked about a history of sexual abuse. The prevalence of sexual abuse was 213/1260 (17%). In the multivariable analysis, only chronic pelvic pain remained significantly associated with a history of sexual abuse.
Conclusions
A history of sexual abuse is common among women with PFDs, and these women were more likely to have chronic pelvic pain.
doi:10.1097/SMJ.0000000000000029
PMCID: PMC3902107  PMID: 24305526
pelvic floor disorders; sexual abuse
3.  Routine HIV Screening in North Carolina in the Era of the Affordable Care Act: Update on Laws, Reimbursement, and Tests 
Southern medical journal  2013;106(11):10.1097/SMJ.0000000000000017.
Eighteen percent of the 1.2 million human immunodeficiency virus (HIV)–infected individuals in the United States are undiagnosed, with North Carolina accounting for the eighth largest number of new HIV diagnoses in 2011. In an effort to identify more HIV-infected individuals by reducing physician barriers to HIV testing, the Centers for Disease Control and Prevention have expanded their HIV screening recommendations to adolescents and adults without HIV risk factors or behaviors, eliminated federal requirements for pretest counseling, and modified the informed consent process. In 2010, the Office of National AIDS (acquired immunodeficiency syndrome) Policy released the first-ever national HIV/AIDS strategy, with the goal of reducing new infections, increasing access to care, improving HIV outcomes, and reducing HIV racial/ethnic disparities. In 2013, the US Preventive Services Task Force released A-level recommendations recommending nonrisk-based HIV screening for adults and adolescents that are consistent with the recommendations of the Centers for Disease Control and Prevention. In concert with these federal recommendations, the majority of states have modified their consent and counseling requirements. The implementation of the Patient Protection and Affordable Care Act will add requirements and incentives for federal (Medicare), state (Medicaid), and private (insurance) payers to reimburse physicians and patients for nonrisk-based HIV screening.
doi:10.1097/SMJ.0000000000000017
PMCID: PMC3842190  PMID: 24192596
routine human immunodeficiency virus screening; cost-effectiveness; recommendations; written consent; pretest counseling; posttest counseling
4.  Hepatitis B Screening Practice among Older Chinese in the Greater Washington, DC, Area 
Southern medical journal  2014;107(10):655-660.
Objectives
Older Chinese Americans are at greater risk of contracting hepatitis B virus (HBV) because they were born before the implementation of universal childhood vaccination policies. This study examined the prevalence of HBV screening, test results, and predictors of HBV screening among older Chinese.
Methods
Two hundred fifty-two Chinese immigrants (older than 50 years) recruited from Chinese-speaking physicians’ offices in the Washington, DC, area participated in a cancer screening questionnaire. Descriptive statistics and hierarchical logistic regressions were conducted.
Results
Among the 164 participants (65%) who underwent HBV screening, 66% reported that they were susceptible to HBV infection. Stronger self-care beliefs, longer US residency, lower HBV knowledge, and lack of physician recommendations were independently and negatively associated with HBV screening.
Conclusions
Many older Chinese did not adhere to HBV screening guidelines because of cultural views and information deficiency. Culturally appropriate interventions aimed to enhance their knowledge and communication with physicians about HBV is needed for promoting screening
doi:10.14423/SMJ.0000000000000177
PMCID: PMC4205542  PMID: 25279872
hepatitis B screening; hepatitis B virus infection; Chinese Americans; self-care beliefs
5.  Sharpening the Tandem Walking Test for Screening Peripheral Neuropathy 
Southern medical journal  2013;106(10):565-569.
Objective
Few tests of functional motor behavior are useful for rapidly screening people for lower extremity peripheral neuropathy. The goal of this study was to improve the widely used Tandem Walking test (TW).
Methods
We tested adult normals and ambulatory peripheral neuropathy patients (PN) with eyes open and eyes closed, while they performed TW on industrial carpeting, in sock-covered feet. Each subject wore a torso-mounted inertial motion unit to measure kinematic data. PN subjects’ data were also compared to historical data on patients with vestibular impairments (VI).
Results
The normal and PN groups differed significantly on TW on the number of steps completed. PN and VI data also differed significantly on both visual conditions. Kinematic data showed that PN patients were more unstable than normals. For the number of steps taken during the eyes open condition receiver operating characteristic (ROC) values were only 0.81. For the number of steps taken during the eyes closed condition, however, ROC=0.88. Although not optimal, this ROC value is better. Sensitivity and specificity at a cut-off of 2 steps were 0.81 and 0.92, respectively, and at a cut-off of 3 steps was 0.86 and 0.75, respectively. ROC values for kinematic data were all < 0.8 and, when combined with the ROC value for the number of steps, the total ROC value did not improve appreciably.
Conclusions
Although not ideal for screening patients who may have peripheral neuropathy, counting the number of steps during TW is a quick and useful clinical test. TW is most sensitive to peripheral neuropathy patients when they are tested with eyes closed.
doi:10.1097/SMJ.0000000000000009
PMCID: PMC3801263  PMID: 24096950
balance testing; tandem gait; neurology testing; clinical examination; sensitivity and specificity
6.  Alcohol Use and Religiousness/Spirituality Among Adolescents 
Southern medical journal  2007;100(4):349-355.
Background
Previous studies indicate that religiousness is associated with lower levels of substance use among adolescents, but less is known about the relationship between spirituality and substance use. The objective of this study was to determine the association between adolescents’ use of alcohol and specific aspects of religiousness and spirituality.
Methods
Twelve- to 18-year-old patients coming for routine medical care at three primary care sites completed a modified Brief Multidimensional Measure of Religiousness/Spirituality; the Spiritual Connectedness Scale; and a past-90-days alcohol use Timeline Followback calendar. We used multiple logistic regression analysis to assess the association between each religiousness/spirituality measure and odds of any past-90-days alcohol use, controlling for age, gender, race/ethnicity, and clinic site. Timeline Followback data were dichotomized to indicate any past-90-days alcohol use and religiousness/spirituality scale scores were z-transformed for analysis.
Results
Participants (n = 305) were 67% female, 74% Hispanic or black, and 45% from two-parent families. Mean ± SD age was 16.0 ± 1.8 years. Approximately 1/3 (34%) reported past-90-day alcohol use. After controlling for demographics and clinic site, Religiousness/Spirituality scales that were not significantly associated with alcohol use included: Commitment (OR = 0.81, 95% CI 0.36, 1.79), Organizational Religiousness (OR = 0.83, 95% CI 0.64, 1.07), Private Religious Practices (OR = 0.94, 95% CI 0.80, 1.10), and Religious and Spiritual Coping – Negative (OR = 1.07, 95% CI 0.91, 1.23). All of these are measures of religiousness, except for Religious and Spiritual Coping – Negative. Scales that were significantly and negatively associated with alcohol use included: Forgiveness (OR = 0.55, 95% CI 0.42–0.73), Religious and Spiritual Coping –Positive (OR = 0.67, 95% CI 0.51–0.84), Daily Spiritual Experiences (OR = 0.67, 95% CI 0.54–0.84), and Belief (OR = 0.76, 95% CI 0.68–0.83), which are all measures of spirituality. In a multivariable model that included all significant measures, however, only Forgiveness remained as a significant negative correlate of alcohol use (OR = 0.56, 95% CI 0.41, 0.74).
Conclusions
Forgiveness is associated with a lowered risk of drinking during adolescence.
doi:10.1097/SMJ.0b013e3180316a32
PMCID: PMC4143181  PMID: 17458392
spirituality; religion; substance-related disorders; alcoholism; adolescence
7.  Long-term Impact of Environmental Public Health Disaster on Health System Performance: Experiences from the Graniteville, South Carolina Chlorine Spill 
Southern medical journal  2013;106(1):74-81.
Objective
In the aftermath of an Environmental Public Health Disaster (EPHD) a healthcare system may be the least equipped to respond. Preventable visits for ambulatory care sensitive conditions (ACSCs) may be used as a population-based indicator to monitor health system access post-disaster. The objective of this study was to examine whether ACSCs rates among vulnerable sub-populations are sensitive to the impact of a disaster.
Methods
We conducted a retrospective analysis using Poisson regression with generalized estimating equations to calculate change in monthly ACSC visits at the disaster site in the post-disaster period compared to the pre-disaster period after adjusting for parallel changes in two control groups.
Results
The adjusted rate of an ACSC hospital visit pre-disaster for the direct group was 1.68 times the rate for the primary control group (95% CI: 1.47, 1.93), while the adjusted ACSC hospital rate post-disaster for the direct group was 3.10 times the rate for the primary control group (95% CI: 1.97, 5.18). For emergency department ACSC visits, the adjusted rate among those directly affected pre-disaster were 1.82 times the rate for the primary control group (95% CI: 1.61, 2.08), while the adjusted ACSC rate post-disaster was 2.81 times the rate for the primary control group (95% CI: 1.92, 5.17).
Conclusions
Results revealed increased demand on the health system altered health services delivery for vulnerable populations directly impacted by the disaster. Preventable visits for ACSCs may advance meaningful use practice and public health surveillance by identifying and characterizing healthcare disparities during disaster recovery.
doi:10.1097/SMJ.0b013e31827c54fc
PMCID: PMC4104410  PMID: 23263318
8.  Public Perceptions of Substance Abuse and How Problems are Resolved: Implications for Medical and Public Health Services 
Southern medical journal  2008;101(8):786-790.
Background
Increasing utilization and appeal of substance abuse services requires understanding public perceptions of substance abuse and problem resolution.
Method
A statewide survey (N = 439) assessed public views of the prevalence of problems, service utilization, and outcomes using random digit dialing sampling.
Results
Compared to population data, the sample over-estimated the prevalence of alcohol and drug problems, accurately gauged rates of help-seeking for substance-related problems, and under-estimated rates of recovery, particularly natural resolutions without treatment. Perceived influences on help-seeking included extrinsic pressures like legal problems and wanting help with problems of living related to substance misuse.
Conclusions
Substance abuse is less prevalent and less intractable than the public perceives, and natural resolutions are common, but appear to be largely hidden from the public view. Implications for reducing barriers and expanding services in health care and public health settings are discussed.
doi:10.1097/SMJ.0b013e31817c931c
PMCID: PMC4082986  PMID: 19365299
Substance Abuse; Services; Help-seeking; Consumers; Survey
9.  Providing Guidance to Patients: Physicians’ Views About the Relative Responsibilities of Doctors and Religious Communities 
Southern medical journal  2013;106(7):399-406.
Objectives
Patients’ religious communities often influence their medical decisions. To date, no study has examined what physicians think about the responsibilities borne by religious communities to provide guidance to patients in different clinical contexts.
Methods
We mailed a confidential, self-administered survey to a stratified random sample of 1504 US primary care physicians (PCPs). Criterion variables were PCPs’ assessment of the responsibility that physicians and religious communities bear in providing guidance to patients in four different clinical scenarios. Predictors were physicians’ demographic and religious characteristics.
Results
The overall response rate was 63%. PCPs indicated that once all medical options have been presented, physicians and religious communities both are responsible for providing guidance to patients about which option to choose (mean responsibility between “some” and “a lot” in all scenarios). Religious communities were believed to have the most responsibility in scenarios in which the patient will die within a few weeks or in which the patient faces a morally complex medical decision. PCPs who were older, Hispanic, or more religious tended to rate religious community responsibility more highly. Compared with physicians of other affiliations, evangelical Protestants tended to rate religious community responsibility highest relative to the responsibility of physicians.
Conclusions
PCPs ascribe more responsibility to religious communities when medicine has less to offer (death is imminent) or the patient faces a decision that science cannot settle (a morally complex decision). Physicians’ ideas about the clinical role of religious communities are associated with the religious characteristics of physicians themselves.
doi:10.1097/SMJ.0b013e31829ba64f
PMCID: PMC3731943  PMID: 23820319
religious community; doctor–patient relationship; religion/spirituality; patient guidance; complementary and alternative medicine
10.  Fibrinolytic Therapy Versus Primary Percutaneous Coronary Interventions for ST-Segment Elevation Myocardial Infarction in Kentucky: Time to Establish Systems of Care? 
Southern medical journal  2013;106(7):391-398.
Background
Fibrinolytic therapy is recommended for ST-segment myocardial infarctions (STEMI) when primary percutaneous coronary intervention (PPCI) is not available or cannot be performed in a timely manner. Despite this recommendation, patients often are transferred to PPCI centers with prolonged transfer times, leading to delayed reperfusion. Regional approaches have been developed with success and we sought to increase guideline compliance in Kentucky.
Methods
A total of 191 consecutive STEMI patients presented to the University of Kentucky (UK) Chandler Medical Center between July 1, 2009 and June 30, 2011. The primary outcome was in-hospital mortality and the secondary outcomes were major adverse cardiovascular events, extent of myocardial injury, bleeding, and 4) length of stay. Patients were analyzed by presenting facility—the UK hospital versus an outside hospital (OSH)—and treatment strategy (PPCI vs fibrinolytic therapy). Further analyses assessed primary and secondary outcomes by treatment strategy within transfer distance and compliance with American Heart Association guidelines.
Results
Patients presenting directly to the UK hospital had significantly shorter door-to-balloon times than those presenting to an OSH (83 vs 170 minutes; P < 0.001). This did not affect short-term mortality or secondary outcomes. By comparison, OSH patients treated with fibrinolytic therapy had a numeric reduction in mortality (4.0% vs 12.3%; P = 0.45). Overall, only 20% of OSH patients received timely reperfusion, 13% PPCI, and 42% fibrinolytics. In a multivariable model, delayed reperfusion significantly predicted major adverse cardiovascular events (odds ratio 3.87, 95% confidence interval 1.15–13.0; P = 0.02), whereas the presenting institution did not.
Conclusions
In contemporary treatment of STEMI in Kentucky, ongoing delays to reperfusion therapy remain regardless of treatment strategy. For further improvement in care, acceptance of transfer delays is necessary and institutions should adopt standardized protocols in association with a regional system of care.
doi:10.1097/SMJ.0b013e31829ba880
PMCID: PMC3746985  PMID: 23820318
primary percutaneous coronary intervention; fibrinolytic therapy; ST-segment myocardial infarction; systems of care
11.  Hemoptysis requiring bronchial artery embolization in pulmonary arterial hypertension: one center experience 
Southern medical journal  2010;103(9):887-891.
Introduction
Hemoptysis is an uncommon complication in patients with pulmonary arterial hypertension (PAH). Although the mechanism of hemoptysis is unknown, treatment with bronchial artery embolization (BAE) is proposed as a safe and reliable method of treatment. We report Baylor PH Center experience in treating PAH patients presenting with acute hemoptysis that required multiple BAEs.
Results
Three female and one male PAH patients ages 45±9 years (mean±SD) presented with acute hemoptysis. Right ventricular systolic pressure and cardiac index at the time of first episode of hemoptysis was 85±17 mm Hg and 2.7±.7 L/min/m2 respectively. Two of the four patients had recurrent episode of hemoptysis requiring multiple BAEs. All four were on intravenous prostacyclin analogue. None were receiving warfarin or endothelin receptor antagonist at the time of the episode. During each episode of hemoptysis INR was 1.09 ±0.11 units and platelet count was 124,000±47,000 per microliter. Each episode of hemoptysis was acutely terminated with BAE. In majority of cases, patients had multiple aberrant bronchial arteries embolized and an average of 2.3 arteries was embolized per session (1–4 embolized arteries). Each BAE was performed utilizing polyvinyl alcohol particles ranging from 250–500 microns. There were no reported complications of the 14 BAE procedures performed.
Conclusion
Although the incidence of hemoptysis is unknown and likely underreported, we report our experience where recurrent hemoptysis was treated with multiple BAE procedures. This report emphasizes the efficacy and safety of BAE in terminating episodes of recurrent hemoptysis in patients with severe PAH.
doi:10.1097/SMJ.0b013e3181eb5649
PMCID: PMC4039206  PMID: 20689485
right ventricular systolic pressure; echocardiogram; right heart catheterization
12.  Integrated Models of Education and Service Involving Community-Based Health Care for Underserved Populations: Tulane Student-Run Free Clinics 
Southern medical journal  2013;106(3):217-223.
Objectives
Throughout the United States numerous models of local programs, including student-run clinics, exist to address the issue of access to care. The role of these clinics in serving the local community and contributing to medical education has been documented only in limited detail, however. The purpose of this article is to describe the clinic models, patient demographics, and services provided by four student-run clinics in New Orleans.
Methods
This is a retrospective, multisite chart review study of adult patients examined at student-run clinics between January 1, 2010 and July 31, 2011.
Results
During a 19-month period, 859 patients collectively were seen at the clinics, for a total of 1455 visits. The most common reasons for seeking care were medication refills (21.6%) and musculoskeletal pain (12.0%). Counseling and health education were provided primarily for smoking cessation (9.0%), diabetes management (7.1%), and hypertension management (5.8%). Nearly one-fifth of patients were given a referral to primary care services. In the 2010–2011 academic year, 87.6% of preclinical medical students volunteered at ≥1 of these clinics and spent 4508 hours during 1478 shifts.
Conclusions
This article highlights the role of student-run clinics in the community, the safety-net healthcare system, and medical education. Future directions include the establishment of a new clinic, fundraising, and prospective studies to further assess the impact of student-run clinics.
doi:10.1097/SMJ.0b013e318287fe9a
PMCID: PMC3988527  PMID: 23462491
ambulatory care facilities; community medicine; delivery of health care; medical students; undergraduate medical education
13.  Short-Term Trends in Heart Failure-Related Hospitalizations in a High-Risk State 
Southern medical journal  2013;106(2):147-154.
Objectives
We sought to determine whether there are signs of improvement in the rates of heart failure (HF) hospitalizations given the recent reports of improvement in national trends.
Methods
HF admissions data from the Tennessee Hospital Discharge Data System were analyzed.
Results
Hospitalization for primary diagnosis of HF (HFPD) in adults (aged 20 years old or older) decreased from 4.5% in 2006 to 4.2% in 2008. Similarly, age-adjusted HF hospitalization (per 10,000 population) declined by 19.1% (from 45.5 in 2006 to 36.8 in 2008). The age-adjusted rates remain higher among blacks than whites and higher among men than women. Notably, the rate ratio of black-to-white men ages 20 to 34 years admitted with HFPD increased from 8.5 in 2006 to 11.1 in 2008; similarly, the adjusted odds ratios for HFPD were 4.75 (95% confidence interval 3.29–6.86) and 5.61 (95% confidence interval 3.70–8.49), respectively. There was, however, a significant improvement in odds ratio for HF rates among young black women, as evidenced by a decrease from 4.60 to 3.97 (aged 20–34 years) and 4.21 to 3.12 (aged 35–44 years) between 2006 and 2008, respectively. Among patients aged 20 to 34 and 35 to 44 years, hypertension was the strongest independent predictor for HF. Diabetes and myocardial infarction emerged as predictors for HF among patients aged 35 years and older.
Conclusions
The overall rate of HF hospitalization declined during the period surveyed, but the persistent disproportionate involvement of blacks with evidence of worsening among younger black men, requires close attention.
doi:10.1097/SMJ.0b013e3182804fa4
PMCID: PMC3565177  PMID: 23380751
heart failure; prevention; blacks; disparities; risk factors
14.  Noninvasive Assessment of Right Heart Function and Hemodynamics during Exercise in Patients with Pulmonary Arterial Hypertension 
Southern medical journal  2013;106(2):141-146.
Objectives
Noninvasive assessment of right heart function and hemodynamics in patients with pulmonary arterial hypertension (PAH) is most often performed at rest, whereas the symptoms, in general, present with exertion. Assessment during exertion is limited to symptom assessment and the 6-minute walk distance. We investigated the feasibility of obtaining echocardiographic data that could accurately reflect pulmonary artery pressures (PAP), particularly mean PAP and right ventricular function during exercise in patients with PAH.
Methods
We investigated right ventricular function and hemodynamics using echocardiography during symptom-limited exercise in 10 consecutive patients undergoing right heart catheterization (RHC) as part of their clinical evaluation for PAH. We further assessed these measurements for correlation with known predictors of outcome in PAH in an exploratory analysis.
Results
We were able to successfully obtain complete right heart measurements by echocardiography, including mean PAP, in the majority (9 of 10) of the subjects. One patient had an incomplete tricuspid regurgitation jet at rest and with exercise. Echocardiographic pulmonary vascular resistance correlated with RHC cardiac output and brain natriuretic peptide level, whereas tricuspid annular plane systolic excursion during exercise correlated with right atrial pressure on RHC, brain natriuretic peptide, and 6-minute walk distance. Tricuspid regurgitation velocity and mean PAP with exercise correlated moderately with mean PAP and cardiac output by RHC.
Conclusions
Exercise echocardiography can provide meaningful data in patients with PAH, including measuring mean PAP. The presence of correlations in this small number of patients indicates promising targets for future investigation.
doi:10.1097/SMJ.0b013e3182805165
PMCID: PMC3626433  PMID: 23380750
pulmonary arterial hypertension; exercise echocardiography; right ventricular function
15.  Pharmaceuticals Companies’ Medication Assistance Programs: Potentially Useful but Too Burdensome to Use? 
Southern medical journal  2009;102(2):10.1097/SMJ.0b013e31818bbe5e.
Objectives
This study examined how physicians perceive pharmaceutical companies’ medication assistance programs (MAPs).
Methods
The study was conducted using a survey of 373 primary care physicians from four southern states; they were surveyed within the formative evaluation phase of a larger study (MI-Plus). Respondents were queried about use and usefulness of MAPs for patients who cannot afford drugs, and barriers to using them. Bivariate associations between physician-level variables (patients without drug coverage) and usefulness and barriers to using MAPs were assessed using Chi square tests. Independence of associations was assessed using multiple logistic regressions.
Results
Of the 364 (97.6%) respondents who used MAPs, 70% used them regularly, the rest occasionally; 63% found MAPs very useful in caring for patients who cannot afford drugs. About 89% reported one or more barriers to using MAPs; 47% saw “inability of patients to apply directly;” and 57% saw “enrollment process being time-consuming for staff” as barriers. Compared to physicians with fewer elderly patients without drug coverage, those with more of these patients were less likely to find MAPs very useful; less likely to report no barriers to using MAPs; and more likely to see “low income thresholds” and “inability of patients to apply directly” as barriers.
Conclusion
While MAPs are considered useful in caring for patients in need of assistance, there are many barriers to their use. Pharmaceutical companies should address these barriers. Limitations include a low response rate (about 10%).
doi:10.1097/SMJ.0b013e31818bbe5e
PMCID: PMC3858081  PMID: 19139695
drug affordability; indigent patients; pharmaceutical medication assistance programs; primary care physician
16.  Comparison of Florida Skin Cancer Screening Rates with Those in Different US Regions 
Southern medical journal  2012;105(10):524-529.
Objectives
Florida has the second highest incidence of melanoma in the United States, and more than 600 Floridians die from melanoma annually. Given the lack of population-based data on skin cancer screening among the different US geographic regions, we compared skin cancer screening rates among Floridians to those in the rest of the South, the Northeast, the Midwest, and the West.
Methods
We used data from the 2000 and 2005 National Health Interview Survey. Data were grouped according to whether participants reported ever receiving a skin cancer examination in their lifetime. Data were pooled, and analyses accounted for sample weights and design effects. Multivariable logistic regression analyses were performed with self-reported skin screening as the outcome of interest.
Results
Results showed that compared to the rest of the US, Floridians who were women 70 years old and older, reported being of “other” race, of non-Hispanic ethnicity, having a high school education, having health insurance, and employed in the service industry or unemployed, had significantly higher lifetime skin cancer screening rates than their subgroup counterparts residing in the other regions. Multivariable logistic regression showed that Floridians remained significantly more likely to have ever been screened for skin cancer compared to the other US regions after controlling for a variety of sociodemographic variables.
Conclusions
Increasing melanoma detection remains a national cancer goal for the US, and future identification of underlying causal factors for higher screening rates in Florida could inform intervention strategies in the other US regions.
doi:10.1097/SMJ.0b013e318268cf63
PMCID: PMC3465561  PMID: 23038483
skin cancer screening; cancer surveillance; Florida; US geographic regions; melanoma
17.  Comparison of Patient and Physician Opinion of Patient Centered Medical Home Fundamentals 
Southern medical journal  2012;105(4):238-241.
Objective
Although conceptually there is agreement on how the Patient Centered Medical Home (PCMH) should be organized, there is no such agreement on what components constitute a PCMH. Considering that patients perspectives should be included in the design of a PCMH we evaluated patient opinion on PCMH based on National Committee for Quality Assurance (NCQA) elements.
Methods
An anonymous, voluntary survey was administered to patients at three US Academic Medical Centers. Questions sought opinion on the NCQA key components of essential elements of the PCMH. Analysis of the survey responses was conducted using SAS version 9.1
Results
780 surveys were returned. There were no differences in response to the survey according to age, by sex, race, or site. Differences did exist in patient insurance status by site (chi-sq<.0001) and by race (chi-sq<.0012). Patients felt strongly that the ability to coordinate care, the ability to help patients manage their own disease, and the ability to rack lab results were important. Patients listed care coordination, patient self-management, and improved access to care as one of their top 5 attributes of a PCMH.
Conclusions
Patients were consistent in their opinions that care coordination, and patient self-management we important elements of a PCMH. They also believe that improved access to care is another core component.
doi:10.1097/SMJ.0b013e31824f32ac
PMCID: PMC3781237  PMID: 22475677
18.  Acute Respiratory Distress Syndrome, Sepsis, and Cognitive Decline: A Review and Case Study 
Southern medical journal  2009;102(11):1150-1157.
The objective of this investigation is to review existing research pertaining to cognitive impairment and decline following critical illness and describe a case involving a 49-year-old female with sepsis and acute respiratory distress syndrome (ARDS) with no prior neurologic history who, compared to baseline neuropsychological test data, experienced dramatic cognitive decline and brain atrophy following treatment in the medical intensive care unit (ICU) at Vanderbilt University Medical Center. The patient participated in detailed clinical interviews and underwent comprehensive neuropsychological testing and neurological magnetic resonance imaging (MRI) at approximately 8 months and 3.5 years after ICU discharge. Compared to pre-ICU baseline test data, her intellectual function declined approximately 2 standard deviations from 139 to 106 (from the 99th to the 61st percentile) on a standardized intelligence test 8 months post-discharge, with little subsequent improvement. Initial diffusion tensor brain magnetic resonance imaging (DT-MRI) at the end of ICU hospitalization showed diffuse abnormal hyperintense areas involving predominately white matter in both hemispheres and the left cerebellum. A brain MRI nearly 4 years after ICU discharge demonstrated interval development of profound and generalized atrophy with sulcal widening and ventricular enlargement. The magnitude of cognitive decline experienced by ICU survivors is difficult to quantify due to the unavailability of pre-morbid neuropsychological data. The current case, conducted on a patient with baseline neuropsychological data, illustrates the trajectory of decline occurring after critical illness and ICU-associated brain injury with marked atrophy and concomitant cognitive impairments.
doi:10.1097/SMJ.0b013e3181b6a592
PMCID: PMC3776422  PMID: 19864995
ARDS; brain injury; critical care; executive dysfunction; sepsis
19.  Explaining and Improving Breast Cancer Information Acquisition among African American Women in the Deep South 
Southern Medical Journal  2012;105(6):294-299.
Objectives
A major challenge facing contemporary cancer educators is how to optimize the dissemination of breast cancer prevention and control information to African American women in the Deep South who are believed to be cancer free. The purpose of this research was to provide insight into the breast cancer information-acquisition experiences of African American women in Alabama and Mississippi and to make recommendations on ways to better reach members of this high-risk, underserved population.
Methods
Focus group methodology was used in a repeated, cross-sectional research design with 64 African American women, 35 years old or older who lived in one of four urban or rural counties in Alabama and Mississippi.
Results
Axial-coded themes emerged around sources of cancer information, patterns of information acquisition, characteristics of preferred sources, and characteristics of least-preferred sources.
Conclusions
It is important to invest in lay health educators to optimize the dissemination of breast cancer information to African American women who are believed to be cancer free in the Deep South.
doi:10.1097/SMJ.0b013e318255d8aa
PMCID: PMC3384536  PMID: 22665151
African American women; breast cancer; focus group; information acquisition
20.  [No title available] 
PMCID: PMC3638814  PMID: 19373153
21.  Factors Associated with Recently Transmitted Mycobacterium tuberculosis strain MS0006 in Hinds County, Mississippi 
Southern medical journal  2011;104(12):819-826.
Objective
The objective of this study was to investigate risk factors associated with tuberculosis (TB) transmission that was caused by Mycobacterium tuberculosis strain MS0006 from 2004 to 2009 in Hinds County, Mississippi.
Methods
DNA fingerprinting using spoligotyping, mycobacterial interspersed repetitive unit, and IS6110-based restriction fragment length polymorphism of culture-confirmed cases of TB was performed. Clinical and demographic factors associated with strain MS0006 were analyzed by univariate and multivariate analysis.
Results
Of the 144 cases of TB diagnosed during the study period, 117 were culture positive with fingerprints available. There were 48 different strains, of which 6 clustered strains were distributed among 74 patients. The MS0006 strain accounted for 46.2% of all culture-confirmed cases. Risk factors for having the MS0006 strain in a univariate analysis included homelessness, HIV co-infection, sputum smear negativity, tuberculin skin test negativity, and noninjectable drug use. Multivariate analysis identified homelessness (odds ratio 7.88, 95% confidence interval 2.90-21.35) and African American race (odds ratio 5.80, 95% confidence interval 1.37-24.55) as independent predictors of having TB caused by the MS0006 strain of M tuberculosis.
Conclusions
Our findings suggest that a majority of recently transmitted TB in the studied county was caused by the MS0006 strain. African American race and homelessness were significant risk factors for inclusion in the cluster. Molecular epidemiology techniques continue to provide in-depth analysis of disease transmission and play a vital role in effective contact tracing and interruption of ongoing transmission.
doi:10.1097/SMJ.0b013e3182383166
PMCID: PMC3220880  PMID: 22089361
tuberculosis; HIV; Mississippi; homeless; molecular epidemiology
22.  Differences in National Antiretroviral Prescribing Patterns between Black and White Patients with HIV/AIDS, 1996–2006 
Southern medical journal  2011;104(12):794-800.
Objectives
The benefit of improved health outcomes for blacks receiving highly active antiretroviral therapy (HAART) lags behind that of whites. This project therefore sought to determine whether the reason for this discrepancy in health outcomes could be attributed to disparities in use of antiretroviral therapy between black and white patients with HIV.
Materials and Methods
The 1996–2006 National Hospital Ambulatory Medical Care Surveys were used to identify hospital outpatient visits that documented antiretrovirals. Patients younger than 18 years, of nonblack or nonwhite race, and lacking documentation of antiretrovirals were excluded. A multivariable logistic regression model was constructed with race as the independent variable and use of HAART as the dependent variable.
Results
Approximately 3 million HIV/AIDS patient visits were evaluated. Blacks were less likely than whites to use HAART and protease inhibitors (odds ratio, 95% CI 0.81 [0.81–0.82] and 0.67 [0.67–0.68], respectively). More blacks than whites used non-nucleoside reverse transcriptase inhibitors (odds ratio, 95% CI 1.18 [1.17–1.18]). In 1996, the crude rates of HAART were relatively low for both black and white cohorts (5% vs 6%). The rise in HAART for blacks appeared to lag behind that of whites for several years, until 2002, when the proportion of blacks receiving HAART slightly exceeded the proportion of whites receiving HAART. In later years, the rates of HAART were similar for blacks and whites (81% vs 82% in 2006). Blacks appeared less likely than whites to use protease inhibitors and more likely than whites to use non-nucleoside reverse transcriptase inhibitors from 2000 to 2004.
Conclusions
Blacks experienced a lag in the use of antiretrovirals at the beginning of the study; this discrepancy dissipated in more recent years.
doi:10.1097/SMJ.0b013e318236c23a
PMCID: PMC3222681  PMID: 22089356
HIV/AIDS; highly active antiretroviral therapy; racial disparities
23.  Prevalence of Colorectal Cancer Screening among a Multimorbid Rural Appalachian Population 
Southern medical journal  2011;104(12):811-818.
Objectives
The purpose of this study was to determine the relation among multiple morbidities and the prevalence of colorectal cancer (CRC) screening among older adult Appalachian residents of Kentucky. This is the first known study to address multiple morbidities exclusively with a health-disparities population.
Methods
This was a cross-sectional study of 1153 subjects, aged 50 to 76 years, from Appalachian Kentucky.
Results
White race, post–high school education, and perception of having more than enough income on which to survive were associated with higher rates of any guideline concordant CRC screening. Statistically significant trends in the outcome of adjusted odds ratios for colonoscopy with greater number of morbidities (P < 0.05) were noted; the higher number of morbidities, the higher rates of screening.
Conclusions
Contrary to much existing research, within a health-disparities population, we found a dose-response relation between comorbidities and greater likelihood of CRC screening. Future research in this area should focus on explanations for this seldom-described finding. In addition, this finding has meaningful clinical and behavioral implications, including ensuring provider screening recommendation during routine office visits and outreach, perhaps through community clinics and public health departments, to extremely vulnerable populations lacking access to preventive care.
doi:10.1097/SMJ.0b013e31823a8879
PMCID: PMC3233263  PMID: 22089360
colorectal cancer; screening; multimorbidity; epidemiology
24.  The Role of Sociocultural Factors in Hepatitis B Screening Among Asian Americans 
Southern Medical Journal  2011;104(7):466-472.
doi:10.1097/SMJ.0b013e31821f8ab0
PMCID: PMC3298880  PMID: 21886043
Hepatitis B (HBV) screening; Asian Americans; sociocultural factors
25.  Primary Care Practice Addressing Child Overweight and Obesity: A Survey of Primary Care Physicians at Four Clinics in Southern Appalachia 
Southern medical journal  2011;104(1):14-19.
Background
The prevalence of childhood overweight and obesity in southern Appalachia is among the highest in the United States (US). Primary care providers are in a unique position to address the problem; however, little is known about attitudes and practices in these settings.
Methods
A 61-item healthcare provider questionnaire assessing current practices, attitudes, perceived barriers, and skill levels in managing childhood overweight and obesity was distributed to physicians in four primary care clinics. Questionnaires were obtained from 36 physicians.
Results
Physicians’ practices to address childhood overweight and obesity were limited, despite the fact that most physicians shared the attitude that childhood overweight and obesity need attention. While 71% of physicians reported talking about eating and physical activity habits with parents of overweight or obese children, only 19% reported giving these parents the tools they needed to make changes. Approximately 42% determined the parents’ readiness to make small changes for their overweight or obese children. Physicians’ self-perceived skill level in managing childhood overweight and obesity was found to be a key factor for childhood overweight and obesity related practices.
Conclusion
Primary care physicians in southern Appalachia currently play a limited role in prevention/intervention of childhood overweight and obesity. Training physicians to improve their skills in managing childhood overweight and obesity may lead to an improvement in practice.
doi:10.1097/SMJ.0b013e3181fc968a
PMCID: PMC3072042  PMID: 21119559

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