A randomized trial to promote pharmacotherapy use and smoking cessation in a Medicaid population (United States)

OBJECTIVE

To evaluate the impact of three different intervention conditions designed to increase use of the Medicaid smoking cessation pharmacotherapy benefit and promote smoking cessation among Medicaid clients.

METHODS

In 2002, 608 current smokers receiving Medicaid benefits were recruited from the reception areas at the Department of Social Services in Erie County, New York, USA. Participants were randomized to one of three interventions: Minimal (verbal information on the Medicaid pharmacotherapy benefit), Self Help (verbal information plus self-help information materials), or Case Management (verbal information, self-help information, plus case management assistance to facilitate access to the pharmacotherapy benefit). Outcomes included (a) use of a stop-smoking medication during the three month follow-up period, (b) self-reported 7-day point prevalence abstinence at three months and (c) bioverified non-smoking status at three months (bio-chemically validated by expired Carbon Monoxide (CO) < or =8 ppm).

RESULTS

14.6% reported using a stop-smoking medication and staying off cigarettes for 24 h, 4.6% self-reported being smoke-free at three months, and 1.8% were bioverified as smoke-free. There were no differences by intervention group for these outcomes.

CONCLUSIONS

An intensive intervention designed to promote pharmacotherapy use and smoking cessation among Medicaid smokers was no more effective than less intensive interventions.

Unsuspected Klinefelter syndrome diagnosed during oncologic evaluation: a case series

Klinefelter syndrome is an underdiagnosed chromosomal disorder that has significant implications for health and for medical management. This report presents 5 adult male patients diagnosed with previously unsuspected Klinefelter syndrome as a result of cytogenetic testing for suspected hematologic malignancies. This case series highlights the importance of maintaining a comprehensive and holistic approach to medical care. The medical, genetic, and psychosocial implications of the Klinefelter diagnosis are discussed.

Care of cancer survivors

Cancer survivors are at increased risk for recurrence of their original malignancy; development of second primary malignancies; and medical, developmental, and psychologic problems resulting from cancer therapy, genetic predisposition to cancer, and other risk factors. Surveillance following curative cancer treatment generally includes interval history and physical examinations every six months for five years. Thereafter, histories and examinations are recommended annually for breast cancer; every three months for two years, then every six months for three to five years for colorectal cancer; and every six months for five years, then annually for prostate cancer. Recommended laboratory tests and ancillary procedures include annual mammography of preserved breast tissue in breast cancer survivors, carcinoembryonic antigen level monitoring in conjunction with annual colonoscopy in colorectal cancer patients, and prostate-specific antigen measurements every six months for five years and then annually in prostate cancer survivors. In addition, family physicians should be attentive to concerns about altered body image or sexuality issues following curative surgical procedures. Continued emphasis on preventive health practices is encouraged. Physicians should remain alert to nonspecific symptoms or physical findings (e.g., mass, adenopathy) that can indicate cancer recurrence. In childhood cancer survivors, periodic evaluation that includes a plan for surveillance and prevention, incorporating risks based on previous cancer, therapy, genetic predispositions, personal behaviors, and comorbid health conditions, is recommended.

American Indian cancer survivors: exploring social network topology and perceived social supports

BACKGROUND

The literature on social networks and social supports attests to the powerful influence of social relationships on health; there is a dearth of such studies with American Indians/Alaska Natives.

METHOD

This exploratory study assesses the social network topology and perceived social supports received among American Indian cancer survivors and matched controls.

RESULTS

Although there did not appear to be marked differences overall among cases and controls, expressive social supports (eg, companionship, moral support, encouragement, advice, and friendship) were ranked highly across each component of the network.

CONCLUSIONS

The family appears to be the principal source of social supports relative to either best/closest friend or church/community.

The Chernobyl childhood leukemia study: background & lessons learned

Many challenges emerged during completion of a study to examine radiation dose and acute leukemia among children in areas of the former Soviet Union. In an era of globalization, our experiences might benefit others involved in multinational investigations.

Thyroid cancer incidence trends in Belarus: examining the impact of Chernobyl

BACKGROUND

While prior studies of thyroid cancer incidence within Belarus have increased since the 1986 Chernobyl reactor accident, the magnitude of increase is not well quantified.

METHODS

Using Belarussian national cancer registry data, trends in average annual age-adjusted thyroid cancer incidence rates were examined by calendar year and gender. Incidence rates were also examined across specified time intervals, for specific age groups at diagnosis, and in 'higher exposure' regions compared with 'lower exposure' areas.

RESULTS

Age-adjusted thyroid cancer incidence rates (adjusted to the WHO 2000 world population) have increased between 1970 and 2001 from 0.4 per 100 000 to 3.5 per 100 000 among males (+775%) and from 0.8 per 100 000 to 16.2 per 100 000 among females (+1925%). The relative increase among males (+1020%) and females (+3286%) in 'high exposure' areas exceeded increases among males (+571%) and females (+250%) in 'lower exposure' areas of Belarus. Dramatic increases in thyroid cancer incidence rate ratios were noted among both males and females and in all age groups. The highest incidence rate ratios were observed among people from 'higher exposure' areas ages 0-14 yr at time of diagnosis.

CONCLUSIONS

Marked increases in the incidence of thyroid cancer have occurred over a relatively limited period of observation in all areas of the Republic of Belarus and among all age categories. The greatest increases have occurred among children, suggesting that a high prevalence of pre-existing iodine deficiency in combination with unique susceptibility among younger people might have contributed to potential carcinogenic exposures to the thyroid.

Infant mortality trends in a region of Belarus, 1980-2000

BACKGROUND

The Chernobyl disaster in 1986 and the breakup of the former Soviet Union (FSU) in 1991 challenged the public health infrastructure in the former Soviet republic of Belarus. Because infant mortality is regarded as a sensitive measure of the overall health of a population, patterns of neonatal and postneonatal deaths were examined within the Mogilev region of Belarus between 1980 and 2000.

METHODS

Employing administrative death files, this study utilized a regional cohort design that included all infant deaths occurring among persons residing within the Mogilev oblast of Belarus between 1980 and 2000. Patterns of death and death rates were examined across 3 intervals: 1980-1985 (pre-Chernobyl), 1986-1991 (post-Chernobyl & pre-FSU breakup), and 1992-2000 (post-Chernobyl & post-FSU breakup).

RESULTS

Annual infant mortality rates declined during the 1980s, increased during the early 1990s, and have remained stable thereafter. While infant mortality rates in Mogilev have decreased since the period 1980-1985 among both males and females, this decrement appears due to decreases in postneonatal mortality. Rates of postneonatal mortality in Mogilev have decreased since the period 1980-1985 among both males and females. Analyses of trends for infant mortality and neonatal mortality demonstrated continuous decreases between 1990, followed by a bell-shaped excess in the 1990's. Compared to rates of infant mortality for other countries, rates in the Mogilev region are generally higher than rates for the United States, but lower than rates in Russia. During the 1990s, rates for both neonatal and postneonatal mortality in Mogilev were two times the comparable rates for East and West Germany.

CONCLUSIONS

While neonatal mortality rates in Mogilev have remained stable, rates for postneonatal mortality have decreased among both males and females during the period examined. Infant mortality rates in the Mogilev region of Belarus remain elevated compared to rates for other western countries, but lower than rates in Russia. The public health infrastructure might attempt to assure that prenatal, maternal, and postnatal care is maximized.

Approaches to Breast Cancer Screening Among Nurse Practitioners

PURPOSE

To determine nurse practitioners' (NPs') knowledge and reported practices regarding breast cancer screening in a climate of conflicting guidelines.

DATA SOURCE

A descriptive, cross-sectional survey design was used to examine approaches to cancer screening among NPs in western New York.

CONCLUSIONS

Among the 175 NP respondents, agreement with the accepted answers for the individual breast cancer-screening items ranged from 51% to 80%; responses did not vary by age group or gender. Overall, 54% demonstrated agreement with three or more of four breast cancer-screening items.

IMPLICATIONS FOR PRACTICE

These findings suggest the need to implement educational interventions as one means of decreasing variation in breast cancer screening among NPs. Also, the development and endorsement of a single set of evidence-based breast cancer-screening guidelines would promote adoption of a single screening recommendation.

An unusual presentation of Castleman's disease:a case report

BACKGROUND

Castleman's disease (CD), a rare condition of uncertain etiology, involves a massive proliferation of lymphoid tissues and typically presents as mediastinal masses. We describe a patient with CD who presented with diffuse adenopathy involving the inguinal, paratracheal, retroperitoneal, axillary, and pelvic regions.

CASE PRESENTATION

Case report describing presentation, work-up, management and clinical course of a patient with Castleman's disease in the setting of a county hospital in metropolitan area. Patient was treated with chemotherapeutic agents.

CONCLUSIONS

To our knowledge, this represents the first case of CD involving an HIV-positive patient with a negative Human Herpes Virus (HHV-8) viral panel. Because patients with similar clinical histories are at high risk for the development of non-Hodgkin's lymphoma and Kaposi sarcoma, regular medical surveillance is recommended.

Nurse Practitioners' Knowledge, Practice and Attitudes About Tobacco Cessation & Lung Cancer Screening

PURPOSE

To determine nurse practitioners' (NPs') knowledge, practice, and attitudes about tobacco cessation counseling and lung cancer early detection.

DATA SOURCE

A descriptive, cross-sectional survey design was used to examine NPs' approaches to primary and secondary prevention of tobacco use among patients in western New York.

CONCLUSIONS

Among the 175 respondents, NPs appropriately counseled tobacco users on tobacco cessation. However, there was limited understanding of first-line pharmacological agents used for tobacco cessation and of how to manage treatment for a patient at high risk for lung cancer.

IMPLICATIONS FOR PRACTICE

These findings suggest the need to implement professional educational programs aimed at conveying not only the importance of tobacco cessation counseling but also information on the most effective first-line pharmacological agents and appropriate management options for patients at increased risk of developing lung cancer.

Impact of economic policies on reducing tobacco use among Medicaid clients in New York

BACKGROUND

New York State (NYS) recently implemented Medicaid coverage for prescription pharmacologic adjuncts for cessation and a 55-cent excise tax on a pack of cigarettes. This study examined awareness and use of stop smoking medications and changes in smoking/purchasing behavior among Medicaid clients.

METHODS

Participants (n = 173) were English-speaking Medicaid clients ages 18-64 years who currently smoked cigarettes and volunteered to be interviewed while waiting to reregister with the NYC Medicaid Office during early 2001. Data were collected using a brief (10-min) interviewer-administered questionnaire.

RESULTS

Over 80% of Medicaid clients reported some desire to stop smoking and 40% intended to stop smoking in the next 6 months. Awareness of Medicaid coverage for tobacco cessation pharmacotherapy was 7% for nicotine replacement therapy and 13% for bupropion. Use of these stop smoking medications varied across products but in general was low (<10%). Half of the Medicaid clients reported changing their smoking behavior as a result of the cigarette tax increase.

CONCLUSIONS

The majority of Medicaid clients report a desire to stop smoking, but these economic influences alone are insufficient to substantially reduce smoking in this population. These findings emphasize the importance of allocating a portion of tobacco tax revenue to promote both expanded awareness of this prescription benefit among Medicaid clients and to support programs to further assist low-income smokers in their attempts to stop smoking.

Explaining the de-prioritization of primary prevention: physicians' perceptions of their role in the delivery of primary care

BACKGROUND

While physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery.

METHODS

A focus group with regional primary care physician (PCP) Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine) participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology.

RESULTS

The PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care.

CONCLUSIONS

The secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration.

Magnesium deficiency in African-Americans: does it contribute to increased cardiovascular risk factors?

African-Americans are known to be disproportionately impacted by many chronic diseases such as diabetes, hypertension, cardiovascular, and renal disease. Lower levels of dietary and serum magnesium have been associated with an increased prevalence of hypertension, insulin resistance, and diabetes. Studies suggest a greater prevalence of occult magnesium deficiency among African-Americans compared to other populations. This increased prevalence of hypomagnesemia may contribute to increased insulin resistance leading to accelerated atherosclerosis and premature death. Trials that correct magnesium status/levels among African-Americans, whether through dietary intervention or direct magnesium replacement/supplementation need to be completed to characterize this relationship more completely.

Smallpox: clinical highlights and considerations for vaccination

Smallpox virus has gained considerable attention as a potential bioterrorism agent. Recommendations for smallpox (vaccinia) vaccination presume a low risk for use of smallpox as a terrorist biological agent and vaccination is currently recommended for selected groups of individuals such as health care workers, public health authorities, and emergency/rescue workers, among others. Information about adverse reactions to the smallpox vaccine is based upon studies completed during the 1950s and 1960s. The prevalence of various diseases has changed over the last four decades and new disease entities have been described during this period. The smallpox vaccination may be contra-indicated in many of these conditions. This has made pre-screening of potential vaccines necessary. It is believed that at present, the risks of vaccine-associated complications far outweigh the potential benefits of vaccination in the general population.

Evaluation of a childhood lead questionnaire in predicting elevated blood lead levels in a rural community

The accuracy of a lead screening questionnaire in predicting elevated blood lead levels was examined in a pediatric practice in a rural part of New York state. A retrospective chart review was used to collect data on children ages 9 to 24 months who presented for well-child visits. Children with both questionnaire and lead level results available in the chart were included in the study (n = 171). The mean blood lead level among all children was 1.6 microg/dl (median = 2.0 microg/dl, range 0 to 24 microg/dl). Four children (2.3%) had elevated lead levels (greater than 10 microg/dl), with levels for two of these children being greater than 20 microg/dl. Although our lead screening questionnaire was expanded from the standard 1991 CDC questionnaire by the inclusion of six additional items, it was not especially useful in predicting elevated blood lead levels above 10 microg/dl. However, the questionnaire exhibited some utility in predicting marked elevations in blood lead levels (over 20 microg/dl). Although results in other geographic areas might differ, the lead questionnaire may have value by enhancing parents' awareness of potential lead hazards in their children's environment and may prove to be more useful in areas of high risk to lead exposure.

Breast cancer screening beliefs by practice location

BACKGROUND

This study examines variations in breast cancer screening among primary care clinicians by geographic location of clinical practice.

METHODS

A cross-sectional survey design was used to examine approaches to breast cancer screening among physicians, nurse practitioners, and physician assistants involved in primary care practice. A summary index of beliefs about breast cancer screening was created by summing the total number of responses in agreement with each of four survey items; values for this summary variable ranged between zero and four. Respondents were classified into urban, rural and suburban categories based upon practise location.

RESULTS

Among the 428 respondents, agreement with "correct" responses ranged from 50% to 71% for the individual survey items; overall, half agreed with three or more of the four breast cancer screening items. While no significant differences were noted by practice location, variation in responses were evident. Reported use of written breast cancer guidelines was less in both suburban (OR = 0.51) and urban areas (OR = 0.56) when compared to clinicians in rural areas.

CONCLUSION

Development of an evidence-based consensus statement regarding breast cancer screening would support a single set of unambiguous guidelines for implementation in all primary care settings, thus decreasing variations in how breast cancer screening is approached across varied clinical settings.

Vaccines and bioterrorism: smallpox and anthrax

Because of the success of vaccination and the ring strategy in eradicating smallpox from the world, smallpox vaccine has not been recommended for the United States civilian populations for decades. Given the low but possible threat of bioterrorism, smallpox vaccination is now recommended for those teams investigating potential smallpox cases and for selected personnel of acute-care hospitals who would be needed to care for victims in the event of a terrorist attack. Treatment and post-exposure prophylaxis for anthrax are ciprofloxacin or doxycycline. Anthrax vaccine alone is not effective for post-exposure prevention of anthrax; vaccination is accompanied by 60 days of antibiotic therapy. In addition to military use, anthrax vaccine is recommended for pre-exposure use in those persons whose work involves repeated exposure to Bacillus anthracis spores.

Colorectal cancer screening practices among attendees at a cancer screening clinic

BACKGROUND

Little is known about colorectal cancer (CRC) screening behaviors among patients seen in a general cancer screening clinic.

METHODS

Age-eligible respondents completed a brief self-administered survey examining self-reported compliance with CRC screening recommendations and beliefs about the benefits of CRC screening.

RESULTS

Overall compliance with CRC screening among respondents was 43%. Although compliance did not differ by gender, persons aged 65+ years were more than five times more likely to be compliant with CRC screening (OR = 5.29, CI = 2.06-13.58). While a majority of respondents (87%) reported that they would complete CRC screening if recommended by a doctor, only 54% had talked with their doctors about examinations for CRC. Males were more likely to report they would complete testing if recommended by their doctors (OR = 6.81, CI = 1.46-31.8) and twice as likely to report having talked to their doctors about CRC testing (OR = 2.71, CI = 1.32-5.56).

CONCLUSIONS

Efforts to enhance CRC screening behaviors among motivated subpopulations seeking preventive care might consider opportunities to augment physician-patient dialogues regarding the need for screening tests. In addition, the dissonance between the recognized need for CRC testing and lack of compliance warrants further examination.

A cancer genetics education campaign: delivering parallel messages to clinicians and the public

BACKGROUND

Up to 10% of all cancers are thought to have a familial basis through complex interactions between genes and environment.

METHODS

A community-wide education campaign was conducted that included several elements: a five part television news series; an educational newsletter; web site pages and links to educational materials; a Continuing Medical Education (CME) program for professionals; and an evaluation survey.

RESULTS

Survey estimates revealed that 39000 households recalled seeing the series; 14800 households changed their views about the risks of hereditary cancers; and about 9900 households were made more aware/informed about cancer and hereditary risk.

CONCLUSION

This awareness campaign broadened public knowledge about the myths and realities associated with genetic factors and cancer risk. It reinforced the importance of early screening for persons at high risk of cancer due to hereditary factors.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.