Longitudinal adherence to annual colorectal cancer screening among Black persons living in the United States enrolled in a community-based randomized trial

BACKGROUND

This study examined repeat colorectal cancer screening rates at 12 and 24 months as part of a randomized intervention trial among Black persons living in the United States and factors associated with screening adherence.

METHODS

Participants completed a survey assessing demographics and Preventive Health Model (PHM) factors (e.g., self efficacy, susceptibility) and received either a culturally targeted photonovella plus free fecal immunochemical test (FIT) kits (intervention group) or a standard educational brochure plus free FIT kits (comparison group). FIT return was assessed at 6, 12, and 24 months. Descriptive statistics summarized patterns of repeat screening. Logistic regression models assessed FIT uptake overtime, and demographic and PHM factors associated with screening adherence.

RESULTS

Participants (N = 330) were U.S.-born (93%), non-Hispanic (97%), and male (52%). Initial FIT uptake within 6 months of enrollment was 86.6%, and subsequently dropped to 54.5% at 12 months and 36.6% at 24 months. Higher FIT return rates were observed for the brochure group at 24 months (51.5% vs 33.3% photonovella, p = .023). Multiple patterns of FIT kit return were observed: 37% completed FIT at all three time points (full adherence), 22% completed two of three (partial adherence), 29% completed one of three (partial adherence), and 12% did not return any FIT kits (complete nonadherence). Predictors of full adherence were higher levels of education and self-efficacy.

CONCLUSIONS

Full adherence to repeat screening was suboptimal. Most participants had partial adherence (one or two of three) to annual FIT screening. Future studies should focus on strategies to support repeat FIT screening.

Factors associated with prior completion of colorectal cancer and hepatitis C virus screenings among community health center patients: a cross-sectional study to inform a multi-behavioral educational intervention

BACKGROUND

Colorectal cancer (CRC) and liver cancer are two of the leading causes of cancer death in the United States and persistent disparities in CRC and liver cancer incidence and outcomes exist. Chronic hepatitis C virus (HCV) infection is one of the main contributors to liver cancer. Effective screening for both CRC and HCV exist and are recommended for individuals based upon age, regardless of gender or sex assigned at birth. Recommendations for both screening behaviors have been recently updated. However, screening rates for both CRC and HCV are suboptimal. Targeting adoption of multiple screening behaviors has the potential to reduce cancer mortality and disparities.

OBJECTIVE

To examine psychosocial factors associated with completion of CRC and HCV screenings in order to inform a multi-behavioral educational intervention that pairs CRC and HCV screening information.

METHODS

A cross-sectional survey was conducted with participants (N = 50) recruited at two community health centers in Florida (United States). Kruskal-Wallis and Fisher's exact tests were used to examine associations between completion of both CRC and HCV screening, CRC and HCV knowledge, Preventive Health Model constructs (e.g., salience and coherence, response efficacy, social influence), and sociodemographic variables.

RESULTS

Most participants were White (84%), female (56%), insured (80%), and reported a household income of $25,000 or less (53%). 30% reported ever previously completing both CRC and HCV screenings. Prior completion of both screening behaviors was associated with higher educational attainment (p = .014), having health insurance (p = .022), being U.S.-born (p = .043), and higher salience and coherence scores for CRC (p = .040) and HCV (p = .004).

CONCLUSIONS

Findings demonstrate limited uptake of both CRC and HCV screenings among adults born between 1945 and 1965. Uptake was associated with multiple sociodemographic factors and health beliefs related to salience and coherence. Salience and coherence are modifiable factors associated with completion of both screening tests, suggesting the importance of incorporating these health beliefs in a multi-behavioral cancer education intervention. Additionally, health providers could simultaneously recommend and order CRC and HCV screening to improve uptake among this age cohort.

Transcreation matters: A learner centric participatory approach for adapting cancer prevention messages for Latinos

BACKGROUND

Advancing health equity requires innovative patient education approaches for adapting English-language evidence-based interventions (EBIs) to resonate with multicultural, multilingual audiences.

OBJECTIVE

Examine the benefit, functionality, and practical considerations of transcreation (translation + cultural adaptation) as a critical and salient learner-centric process for developing a Spanish-language intervention (photonovella + video): Un examen sencillo para un colon saludable (A simple test for a healthy colon).

PATIENT/COMMUNITY INVOLVEMENT

We involved patients/community members in a participatory reflective process, from problem identification to intervention design, development, delivery, and impact measurement.

METHODS

A community-based participatory research (CBPR) approach involving formative research plus systematic iterative pretesting and learner verification checks augmented by a community advisory board guided the transcreation processes.

RESULTS

Data collected using a learner-centric approach effectively produced a new Spanish-language EBI and substantiated the value of co-learner/co-design methods. Learner-centric methods identified cultural nuances that were treated as knowledge and integrated into the intervention materials and study design. Pilot testing of the intervention among Latinos receiving care at community clinics demonstrated improved initial colorectal cancer screening uptake, awareness, and perceived susceptibility.

DISCUSSION

Inherent in the transcreation process was learner involvement that informed essential modification and adaptation of the materials. The transcreation methods led to the development of a culturally salient intervention that maintained theoretical integrity and message intent as well as behavioral activation. Findings have broad implications for the creation and transfer of EBIs to new audiences for greater adoption, engagement, and 'reach' of interventions.

PRACTICAL VALUE

Transcreation aligns with a growing paradigm shift in health communication science that brings to light the beneficial effect that construction and application of cultural knowledge has on patient education toward health equity.

A multilevel, low literacy dual language intervention to promote colorectal cancer screening in community clinics in Florida: A randomized controlled trial

One of the largest disparities in cancer mortality in the United States occurs with colorectal cancer (CRC). The objectives of this multilevel two-arm intervention trial were to compare the efficacy of two interventions to promote CRC screening (CRCS) with fecal immunochemical test (FIT) and examine sociodemographic and psychosocial predictors of FIT screening. Individuals ages 50-75 (n = 326) who were not up-to-date with CRCS, could understand English or Spanish, and were at average CRC risk were recruited from two federally qualified health centers (FQHCs) in Florida. Prior to intervention, CRCS rates in the FQHCs were 27.1% and 32.9%, respectively. Study enrollment occurred April 2018-November 2019. System-level intervention components included leveraging electronic medical record (EMR) systems and delivering patient reminders. Participants were randomized to C-CARES (education+FIT) or C-CARES Plus (C-CARES+personalized coaching [for those not completing FIT within 90 days]). Primary outcome was completed FIT returned <1 year. Primary outcome analyses were performed using logistic regression. 225 participants completed FIT (69.0% [95% CI: 64.0-74.0%]), with no significant difference in FIT uptake by intervention arm (67.3% C-CARES Plus vs. 70.8% C-CARES; p = .49). FIT uptake was significantly higher among patients who received intervention materials in Spanish (77.2%) compared to those who received materials in English (63.2%, p < .01). The personalized coaching in the C-CARES Plus arm did not appear to provide added benefit beyond the C-CARES intervention. Multilevel approaches that include EMR prompts, reminders, FIT access, and provision of low-literacy, language-concordant education can support efforts to improved community clinics' CRCS rates. Future efforts should focus on repeat FIT screening. Trial registration: The trial was registered at ClinicalTrials.gov (NCT03906110).

Online health information seeking and eHealth literacy among Spanish language- dominant Latinos receiving care in a community clinic (Preprint)

Background

eHealth literacy is the ability to seek, obtain, and decipher online health information (OHI) for health and disease management. Rapid developments in eHealth (eg, health care services and online information) place increased demands on patients to have high eHealth literacy levels. Yet, greater emphasis on eHealth may disproportionately affect groups with limited eHealth literacy. Cultural background, language, and eHealth literacy are influential considerations affecting health care and information access, health care use, and successful eHealth resource use, and they may influence OHI seeking for behavioral change toward cancer prevention.

Objective

This study aimed to characterize the extent of OHI seeking and eHealth literacy among Spanish-dominant (SD) Latino adults aged 50 to 75 years. Further, we aimed to examine potential associations between sociodemographic characteristics, Preventive Health Model (PHM) constructs, OHI-seeking behaviors, and eHealth literacy, separately.

Methods

Participants (N=76) self-identified as Latino, were enrolled in a colorectal cancer (CRC) screening intervention, were aged 50 to 75 years, were at average risk for CRC, were not up to date with CRC screening, and preferred receiving health information in Spanish. We describe participants’ sociodemographic characteristics, PHM constructs, OHI-seeking behaviors, and eHealth literacy—among those seeking OHI—assessed at enrollment. Descriptive analyses were first performed for all variables. Next, primary univariate logistic analyses explored possible associations with OHI seeking. Finally, using data from those seeking OHI, exploratory univariate analyses sought possible associations with eHealth literacy.

Results

A majority (51/76, 67%) of the participants were female, 62% (47/76) reported not having graduated high school, and 41% (31/76) reported being unemployed or having an annual income of less than US $10,000. Additionally, 75% (57/76) of the participants reported not having health insurance. In total, 71% (54/76) of the participants reported not having sought OHI for themselves or others. Univariate logistic regression suggested that higher educational attainment was significantly associated with an increased likelihood of having sought OHI (odds ratio 17.4, 95% CI 2.0-150.7; P=.009). Among those seeking OHI (22/76, 29%), 27% (6/22) were at risk of having low eHealth literacy based on an eHealth Literacy Scale score of less than 26. Among OHI seekers (22/76, 29%), an examination of associations found that higher eHealth literacy was associated with greater self-efficacy for screening with the fecal immunochemical test (β=1.20, 95% CI 0.14-2.26; P=.02).

Conclusions

Most SD Latino participants had not sought OHI for themselves or others (eg, family or friends), thus potentially limiting access to beneficial online resources. Preliminary findings convey that higher eHealth literacy occurs among those with higher self-efficacy for CRC screening. Findings inform areas of focus for future larger-scale investigations, including further exploration of reasons for not seeking OHI among SD Latino adults and an in-depth look at eHealth literacy and cancer screening behaviors.

Trial Registration

ClinicalTrials.gov NCT03078361; https://clinicaltrials.gov/ct2/show/NCT03078361

A culturally and linguistically salient pilot intervention to promote colorectal cancer screening among Latinos receiving care in a Federally Qualified Health Center

Despite established benefits, colorectal cancer (CRC) screening is underutilized among Latinos/Hispanics. We conducted a pilot 2-arm randomized controlled trial evaluating efficacy of two intervention conditions on CRC screening uptake among Latinos receiving care in community clinics. Participants (N = 76) were aged 50-75, most were foreign-born, preferred to receive their health information in Spanish, and not up-to-date with CRC screening. Participants were randomized to either a culturally linguistically targeted Spanish-language fotonovela booklet and DVD intervention plus fecal immunochemical test [FIT] (the LCARES, Latinos Colorectal Cancer Awareness, Research, Education and Screening intervention group); or a non-targeted intervention that included a standard Spanish-language booklet plus FIT (comparison group). Measures assessed socio-demographic variables, health literacy, CRC screening behavior, awareness and beliefs. Overall, FIT uptake was 87%, exceeding the National Colorectal Cancer Roundtable's goal of 80% by 2018. The LCARES intervention group had higher FIT uptake than did the comparison group (90% versus 83%), albeit not statistically significant (P = 0.379). The LCARES intervention group was associated with greater increases in CRC awareness (P = 0.046) and susceptibility (P = 0.013). In contrast, cancer worry increased more in the comparison group (P = 0.045). Providing educational materials and a FIT kit to Spanish-language preferring Latinos receiving care in community clinics is a promising strategy to bolster CRC screening uptake to meet national targets.

Examining the Durability of Colorectal Cancer Screening Awareness and Health Beliefs Among Medically Underserved Patients: Baseline to 12 months Post-Intervention

The current study examines changes in awareness and health beliefs from baseline to 12 months post-intervention following receipt of one of two colorectal cancer (CRC) educational interventions that aimed to promote CRC screening among a racially and ethnically diverse and medically underserved population. Participants (N = 270) were enrolled in a randomized controlled trial to increase CRC screening and completed both baseline and 12-month follow-up assessments. Participants were aged 50-75, at average CRC risk, not up-to-date with CRC screening guidelines, and receiving care at one of three community-based clinics. Participants were randomized to receive either a targeted, low-literacy intervention informed by the Preventive Health Model [PHM] (photonovella and DVD plus fecal immunochemical test [FIT]) or a non-targeted intervention (standard educational brochure plus FIT). Changes in CRC awareness and health beliefs from baseline to 12 months were examined both within and between intervention groups using Student's t tests. Participants in both intervention conditions demonstrated an increase in CRC awareness, PHM social influence, and trust in the healthcare system (all p's < .0001), with no significant between-group differences. Among those receiving the targeted intervention, there also was an increase in PHM salience (p < .05). Among individuals receiving the non-targeted intervention, there was an increase in PHM response efficacy (p < .01) and PHM self-efficacy (p < .0001). Both CRC screening interventions promoted positive changes in awareness and several health beliefs from baseline to 12 months, suggesting important benefits of CRC education. Regardless of whether education was targeted or non-targeted, providing CRC screening education successfully promoted durable changes in awareness and health beliefs.

Health Literacy among Medically Underserved: The Role of Demographic Factors, Social Influence, and Religious Beliefs

The current study examined the sociodemographic and psychosocial variables that predicted being at risk for low health literacy among a population of racially and ethnically diverse patients accessing primary care services at community-based clinics. Participants (N = 416) were aged 50-75 years, currently not up-to-date with colorectal cancer (CRC) screening, at average CRC risk, and enrolled in a randomized controlled trial (RCT) aimed at promoting CRC screening. Participants completed a baseline interview that assessed health literacy as measured by Rapid Estimate of Adult Literacy in Medicine-Revised, sociodemographic factors, and psychosocial variables (e.g., health beliefs) prior to randomization and receipt of an intervention. Thirty-six percent of the participants were found to be at risk for low health literacy. Sociodemographic and psychosocial variables were assessed as predictors of being at risk for low health literacy using logistic regression. In the final model, predictors were male gender, being from a racial/ethnic minority group, being unable to work, having higher social influence scores, and having higher religious belief scores. These findings suggest several patient characteristics that may be associated with low health literacy, and highlight the importance of supporting all patients through simplified and clear communications and information to improve understanding of CRC screening information.

Abstract A63: Changes in health beliefs among medically-underserved patients enrolled in a community-based randomized controlled trial to promote colorectal cancer screening

Marked health disparities exist in colorectal cancer (CRC) screening, incidence, and mortality among medically-underserved communities. Literature suggests certain health beliefs (e.g., perceived risk) may be related to screening behavior. This study examined changes in CRC health beliefs following receipt of one of two educational interventions aimed at promoting CRC screening uptake among a medically-underserved population. We compared changes in CRC health beliefs at baseline and 12 months later both within and between the two intervention groups.

Enrolled participants were aged 50-75, at average CRC risk, not up-to-date with CRC screening guidelines, enrolled in a randomized controlled trial to increase CRC screening that was conducted at community clinics in the Tampa Bay area, and completed both the baseline and 12 month follow-up assessments. Participants were randomized to receive either a culturally-targeted photonovella and DVD plus fecal immunochemical test (FIT) intervention (titled Colorectal Cancer Awareness, Research, Education and Screening, or CARES, intervention group condition) or a Centers for Disease Control and Prevention (CDC) standard educational brochure plus FIT intervention (comparison group condition). At both time points, participants completed a questionnaire that included multiple health-related beliefs including Preventive Health Model (PHM) constructs (i.e., perceived susceptibility, perceived salience, self-efficacy, response efficacy, cancer worry, social influence, and religious beliefs), CRC awareness, decisional conflict regarding CRC screening, cancer fatalism, trust in the healthcare system, and perceived discrimination. Changes in health belief scores and group differences in change were examined using Student's t-tests.

The majority of participants (n=270) were: female (58%); white (67%) or black (26%); insured (59%) including county health insurance; had a household income &lt;$10,000 (65%); and had a high school education (35%) or more than high school education (41%). In both intervention conditions, there was an increase in CRC awareness, PHM social influence, and trust in the healthcare system (all p's&lt;.0001). In the CARES intervention group, there also was an increase in PHM salience (p&lt;.05). Among individuals in the comparison group, there was an increase in PHM response efficacy (p&lt;.01) and PHM self-efficacy (p&lt;.0001). There were no significant between-group differences on any of the health belief change scores.

Both CRC screening interventions promoted positive changes in multiple health beliefs from baseline to 12 months which suggests clear benefits of educational interventions. The interventions had common positive effects (i.e., CRC awareness, PHM social influence, and trust in the healthcare system), but also unique effects on PHM salience (CARES condition) and PHM self-efficacy and PHM response efficacy (comparison condition). However, between-group intervention comparisons were not significant suggesting that both educational interventions are beneficial. Given that individuals in both intervention groups were provided with access to CRC screening via FIT kit, future analyses will examine whether changes in health beliefs were associated with higher CRC screening uptake.

Citation Format: Shannon M. Christy, Steven K. Sutton, Enmanuel Chavarria, Stacy N. Davis, Rania Abdulla, Gwendolyn P. Quinn, Susan T. Vadaparampil, Chitra Ravindra, Ida Schultz, Richard Roetzheim, David Shibata, Cathy D. Meade, Clement K. Gwede. Changes in health beliefs among medically-underserved patients enrolled in a community-based randomized controlled trial to promote colorectal cancer screening. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A63.

Abstract A25: A culturally-linguistically salient intervention to increase fecal immunochemical test uptake among Spanish-preferring Latino adults receiving care in community-based clinics

Background: Among Latinos in the US, colorectal cancer (CRC) is the third leading cause of cancer-related deaths. Despite the benefits of colorectal cancer screening (CRCS) being well recognized, screening is underutilized among Latino adults, ages 50-75. The availability of language and literacy appropriate educational information paired with an accessible, easy-to-use screening tool, such as fecal immunochemical test (FIT), within community health settings is a promising way to impact cancer-related disparities for Spanish-preferring Latino older adults. Formative qualitative efforts (focus groups, key informant interviews, and learner verification interviews) produced a culturally, and linguistically salient photonovella booklet and DVD titled, Latinos Colorectal Cancer Awareness, Research, Education and Screening (CARES).

Purpose: This pilot study compared the efficacy of two intervention conditions on FIT uptake among Spanish-preferring Latino adults receiving care in community clinics. Participants were randomized to receive either the Latinos CARES intervention + FIT or CDC Brochure + FIT. We report preliminary findings at 6 months.

Methods: Participants (N=76) were Latinos, accessing care at community-based clinics, prefer to receive their health information in Spanish, aged 50-75, at average CRC risk, and non-adherent to CRCS guidelines. Consented participants were administered a baseline interview assessing awareness of CRCS tests, preventive health model constructs, health literacy (consisting of two validated items), eHealth literacy (eHEALS), and sociodemographic variables. Following the baseline questionnaire, participants were randomized (1:1 allocation) to receive Latinos CARES intervention + FIT or CDC Brochure + FIT. The primary outcome was FIT kit screening uptake at 6 months.

Results: Participants were mostly female (67.8%), median age of 55, with less than a High school diploma (61.8%), annual income of less than $10,000 (48.7%), no medical insurance (75.0%), were unemployed or retired (45.3%), self-identified as “other” for race (67.1%), and born in a country other than the US (93.4%). For those born outside the US, the mean number of years spent in the US was 23.4 years. No significant differences on baseline characteristics were found between study conditions. Accrual rate was an average 11 participants per month for 7 months. To date, FIT uptake is 87% (for both groups), a rate that exceeds the Healthy People 2020 goal of 70.5%. One participant with abnormal FIT results was referred for a colonoscopy. Results of participant's colonoscopy indicated cancer was not present.

Conclusions: Providing educational materials (print and/or video), coupled with a FIT kit to Spanish-preferring Latinos receiving care in community clinics may be a promising strategy to bolster CRC screening uptake. The successful accrual rate is reflective of a high interest for education on CRCS among Spanish-preferring Latinos. Three-month follow-up for post-intervention assessments on awareness of CRCS tests, preventive health model constructs, and intervention use is currently underway, and assessment of intervention group differences is pending. Although preliminary, the high overall screening uptake among both study conditions far exceeds national targets and provides evidence to move to a larger scale RCT.

Citation Format: Enmanuel Antonio Chavarria, Rania Abdulla, Liliana Gutierrez, Lynne Klasko, Dinorah Martinez Tyson, Claudia Aguado Loi, Julian Sanchez, Cathy Meade, Clement Gwede. A culturally-linguistically salient intervention to increase fecal immunochemical test uptake among Spanish-preferring Latino adults receiving care in community-based clinics. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A25.

A randomized controlled trial of a multicomponent, targeted, low-literacy educational intervention compared with a nontargeted intervention to boost colorectal cancer screening with fecal immunochemical testing in community clinics

BACKGROUND

The objective of the current study was to improve colorectal cancer (CRC) screening uptake with the fecal immunochemical test (FIT). The current study investigated the differential impact of a multicomponent, targeted, low-literacy educational intervention compared with a standard, nontargeted educational intervention.

METHODS

Patients aged 50 to 75 years who were of average CRC risk and not up-to-date with CRC screening were recruited from either a federally qualified health center or a primary care community health clinic. Patients were randomized to the intervention condition (targeted photonovella booklet/DVD plus FIT kit) or comparison condition (standard Centers for Disease Control and Prevention brochure plus FIT kit). The main outcome was screening with FIT within 180 days of delivery of the intervention.

RESULTS

Of the 416 participants, 54% were female; the participants were racially and ethnically diverse (66% white, 10% Hispanic, and 28% African American), predominantly of low income, and insured (the majority had county health insurance). Overall, the FIT completion rate was 81%, with 78.1% of participants in the intervention versus 83.5% of those in the comparison condition completing FIT (P =  .17). In multivariate analysis, having health insurance was found to be the primary factor predicting a lack of FIT screening (adjusted odds ratio, 2.10; 95% confidence interval, 1.04-4.26 [P =  .04]).

CONCLUSIONS

The multicomponent, targeted, low-literacy materials were not found to be significantly different or more effective in increasing FIT uptake compared with the nontargeted materials. Provision of a FIT test plus education may provide a key impetus to improve the completion of CRC screening. The type of educational material (targeted vs nontargeted) may matter less. The findings of the current study provide a unique opportunity for clinics to adopt FIT and to choose the type of patient education materials based on clinic, provider, and patient preferences. Cancer 2017;123:1390-1400. © 2016 American Cancer Society.

Unmasking immune reconstitution inflammatory syndrome: a report of tuberculous epididymo-orchitis mimicking a testicular tumour in a Caucasian AIDS patient

Worldwide, it is estimated that 14.8% of all new tuberculosis cases in adults are attributable to HIV infection. Genitourinary tuberculosis is a known complication and is considered to be a severe form of extrapulmonary tuberculosis. Isolated tuberculous epididymo-orchitis is rare. We report a Caucasian HIV-positive heterosexual male with a clinical diagnosis of testicular tumour for which he underwent a right orchidectomy. Tuberculous epididymo-orchitis was confirmed by histology. In this case, all Immune Reconstitution Inflammatory Syndrome (IRIS) criteria were met. We want to convey the message that in HIV-positive patients presenting with testicular swelling, an infective aetiology should be considered. This will increase the possibility of early diagnosis and proper management.

Patients' perceptions of colorectal cancer screening tests and preparatory education in federally qualified health centers

This study explored federally qualified health center (FQHC) patients' perceptions about colorectal cancer screening (CRCS) tests, including immunochemical fecal occult blood tests (iFOBT), as well as preferences for receiving in-clinic education about CRCS. Eight mixed gender focus groups were conducted with 53 patients. Findings centered on three thematic factors: (1) motivators and impediments to CRCS, (2) test-specific preferences and receptivity to iFOBTs, and (3) preferences for entertaining and engaging plain language materials. Results informed the development of educational priming materials to increase CRCS using iFOBT in FQHCs.

Making it work: health care provider perspectives on strategies to increase colorectal cancer screening in federally qualified health centers

Colorectal cancer screening (CRCS) rates are low among men and women who seek health care at federally qualified health centers (FQHCs). This study explores health care providers' perspectives about their patient's motivators and impediments to CRCS and receptivity to preparatory education. A mixed methods design consisting of in-depth interviews, focus groups, and a short survey is used in this study. The participants of this study are 17 health care providers practicing in FQHCs in the Tampa Bay area. Test-specific patient impediments and motivations were identified including fear of abnormal findings, importance of offering less invasive fecal occult blood tests, and need for patient-centered test-specific educational materials in clinics. Opportunities to improve provider practices were identified including providers' reliance on patients' report of symptoms as a cue to recommend CRCS and overemphasis of clinic-based guaiac stool tests. This study adds to the literature on CRCS test-specific motivators and impediments. Providers offered unique approaches for motivating patients to follow through with recommended CRCS and were receptive to in-clinic patient education. Findings readily inform the design of educational materials and interventions to increase CRCS in FQHCs.

A cluster randomized trial of sun protection at elementary schools. Results from year 2

BACKGROUND

Elementary schools are one potential venue for sun protection interventions that reduce childhood sun exposure.

PURPOSE

To assess Year-2 results from a cluster randomized trial promoting hat use at schools.

DESIGN

Block randomization was used to assign intervention/control status to participating schools. Data were collected from 2006 to 2008 and analyzed in 2007-2010.

SETTING/PARTICIPANTS

Of the 24 schools in the School District of Hillsborough County, Florida enrolled, 4th-graders were targeted in the first year and followed through their 5th-grade year.

INTERVENTION

Classroom sessions were conducted to improve sun protection knowledge, foster more positive attitudes about hat use, and change the subjective norm of wearing hats when at school.

MAIN OUTCOME MEASURES

Year-2 outcomes assessed included hat use at school (measured by direct observation), hat use outside of school (measured by self-report) and skin pigmentation and nevi counts (measured for a subgroup of 439 students).

RESULTS

The percentage of students observed wearing hats at control schools remained unchanged during the 2-year period (range 0%-2%) but increased significantly at intervention schools (2% at baseline, 41% at end of Year 1, 19% at end of Year 2; p<0.001 for intervention effect). Measures of skin pigmentation, nevi counts, and self-reported use of hats outside of school did not change during the study period.

CONCLUSIONS

This intervention increased use of hats at school through Year 2 but had no measurable effect on skin pigmentation or nevi. Whether school-based interventions can ultimately prevent skin cancer is uncertain.

Abstract B91: Strategies toward improving the uptake of colorectal cancer screening among underserved communities: Providers’ perspectives

Purpose: Disparities in colorectal cancer screening (CRCS) are partially rooted in reduced access to health care and screening tests. One strategy under investigation within the Tampa Bay Community Cancer Network Community Network Program Center is the promotion of the now widely available and evidence-based immunochemical fecal occult blood test (i-FOBT or FIT) in community-based federally qualified health centers (FQHC) using easy-to-understand video and photo-novella materials customized for this setting. The purposes of this qualitative study were to identify key issues from the perspectives of providers regarding common barriers that patients face regarding the i-FOBT screening test, identify successful strategies to prime patients to use the i-FOBT test, and explore the best timing sequence of patient preparatory education about CRCS.

Methods: Two focus groups and three individual interviews were conducted among 17 community health care providers working with medically underserved populations in FQHCs in Hillsborough County, FL. A community-based participatory research (CBPR) methodology was used to develop the focus group guide and recruitment materials. Eighty two percent were either family medicine physicians, physician assistants or nurse practitioners. Other job titles included registered nurse (n=1) and certified nurse assistant/medical assistant (n=2). Using a semi-structured interview guide, providers were asked to discuss barriers patients may face regarding CRCS, issues related to educating patients in clinics about CRCS, and importance of communication in motivating patients to consider screening. Discussions were audio-taped and transcribed verbatim and lasted between 30–60 minutes. Transcriptions were independently hand-coded using priori codes from the guides and emergent themes were identified using a crystallized-immersion methodology, across multiple raters.

Results: Results showed the majority of providers agreed their patients could benefit from more health education prior to provider discussion about CRCS. Providers described the main concerns experienced by their patients as: lack of insurance, lack of transportation, fear and embarrassment associated with colonoscopy, lack of access to screening and the need for more resources for learning about CRC and CRC related services. The most compelling concern expressed among providers was that patients often feared screening results, and perceived they would not have access to further follow-up colonoscopy if i-FOBT was abnormal or resources to treat CRC. Most providers wanted to see more cultural and literacy relevant CRC educational materials in their clinics. In addition, when patients are informed about their risks, the importance of early detection, and are given examples of people to whom they can relate, providers felt that preparatory education could increase the likelihood of following through with recommended screening with i-FOBT as an initial strategy.

Conclusions: Findings from health care providers support the need for priming education to address patients’ concerns about CRC screenings. Results also reinforce the development of educational materials that address test-specific fears and how to access available resources. Timing of CRCS education of patients in clinics is crucial. Providers’ perspectives are an integral component of designing relevant educational materials and interventions.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B91.

Abstract A9: Patients’ perspectives on immunochemical fecal occult blood test (I-FOBT or FIT): Not your father's FOBT

Purpose: A promising strategy to increase colorectal cancer (CRC) screening includes the use of new generation high sensitivity-high specificity immunochemical fecal occult blood test (I-FOBT or FIT) among patients receiving primary care in Federally Qualified Health Centers (FQHC). This approach was recognized by the Tampa Bay Community Cancer Network (TBCCN) Community Network Program Center (CNPC) as a highly feasible method for impacting cancer health disparities in our community. Despite physician recommendations to increase screening uptake, finding effective ways to increase patients’ awareness about different types of CRC screening (CRCS) is needed. This study reports qualitative findings from focus groups with patients in FQHCs to inform the development of a low literacy DVD and photonovella booklet to prepare patients for provider discussions about CRCS, particularly I-FOBT use.

Methods: Six focus groups were conducted with men and women, of diverse background (ages 50–75 years) with no diagnosis of CRC. In collaboration with our community partners who identified a need to increase CRCS and using community-based participatory research (CBPR) methodology to develop a focus group guide and recruitment materials, participants were recruited from partnering FQHCs in Hillsborough County, FL. The focus group guide assessed patients’ knowledge and perceptions about CRC and screening, particularly I-FOBT and colonoscopy, as well as participants’ views about in clinic CRCS preparatory education process and factors that impede CRCS uptake. All focus groups were audio taped, transcribed verbatim and reviewed by two independent coders. Thematic coding, using a crystallized-immersion framework was conducted. A combination of hand-coding and Atlas TI software were employed using content from the patient focus group guide as priori codes.

Results: Thirty-nine patients participated in focus groups to date (51% male; 59% black; 36% white; 5% Hispanic/Latino; mean age = 56.18 years). Seventeen reported being up-to-date on CRCS per recommendations and 22 were not current. Consistent with previous studies, we found poor knowledge and awareness about CRC risks and different screening modalities. Commonly reported barriers included: 1) no doctor recommendation; 2) cost; 3) fear of the test or abnormal findings; and 4) a lack of symptoms. While all participants had heard of colonoscopy and traditional FOBT, very few were aware of I-FOBT. Concerns about colonoscopy included a dislike of the test prep and affordability. Most men reported feelings of embarrassment, personal invasion, and threatened masculinity regarding the colonoscopy procedure itself. Upon learning about I-FOBT the majority felt the test seemed to be simple, easy to do, and private. Most participants who had prior FOBT screening reported use of the older 3-card home test or office-based guaiac test. Reported limitations to the older version of FOBT included diet restrictions, dislike of “handling” one's own feces during sample collection and the complexity of multiple test applications. Doctor recommendation was the main reason participants completed CRCS tests.

Conclusions: Our findings suggest patients’ overall receptivity to I-FOBT, and provide a basis for developing educational content for an intervention that addresses test specific barriers, and promotes the more patient-friendly IFOBT. Results also show support for a preparatory education intervention that will educate patients in clinic before their provider visit about the need for CRCS. Such preparatory materials are expected to enhance patients’ awareness about CRCS, facilitate patient-provider communication, and contribute to the overall uptake of CRCS.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A9.

Abstract A31: Patient navigation for culturally diverse populations: The experience of the Moffitt Cancer Center's Patient Navigator Research Program (PNRP)

The purpose of the PNRP patient navigation is to provide individualized assistance to persons with abnormal cancer screening tests or cancer diagnosis by trained, culturally sensitive navigators familiar with the patient's community. The Moffitt Cancer Center is one of nine NCI-funded sites nationally to study the impact that patient navigation has on four main outcomes: 1) time from screening to definitive diagnosis; 2) time from definitive diagnosis to treatment; 3) patient satisfaction; and 4) cost effectiveness. Moffitt's patient navigators navigated over 640 patients referred from seven community clinics in four counties. The majority of the patients were female (93%), Hispanics (54%), with annual household income under $20,000 (80%), mostly unemployed (47.5%), and with an average of 8.8 years of education. Lay patient navigators familiar with the patients’ culture and language were trained to navigate patients with breast or colorectal cancer screening abnormalities. The navigators were asked to record in a log the barriers that they identified, along with the actions they took to assist the patients address such barriers. Navigators addressed 20 different types of barriers in an average of 10 encounters per patient. This presentation will 1) describe the processes of patient navigation utilized by Moffitt PNRP, including training requirements, and caseloads for patient navigators, and 2) discuss the most relevant barriers that navigators found among medically underserved patients to access cancer health services, and actions taken to address such barriers. Moffitt patient navigators engage in a number of actions to help address unique barriers faced by this population when trying to access cancer care services.

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A31.

Sun protection at elementary schools: a cluster randomized trial

BACKGROUND

Elementary schools represent both a source of childhood sun exposure and a setting for educational interventions.

METHODS

Sun Protection of Florida's Children was a cluster randomized trial promoting hat use at (primary outcome) and outside of schools among fourth-grade students during August 8, 2006, through May 22, 2007. Twenty-two schools were randomly assigned to the intervention (1115 students) or control group (1376 students). Intervention schools received classroom sessions targeting sun protection attitudes and social norms. Each student attending an intervention school received two free wide-brimmed hats. Hat use at school was measured by direct observation and hat use outside of school was measured by self-report. A subgroup of 378 students (178 in the intervention group and 200 in the control group) underwent serial measurements of skin pigmentation to explore potential physiological effects of the intervention. Generalized linear mixed models were used to evaluate the intervention effect by accounting for the cluster randomized trial design. All P values were two-sided and were claimed as statistically significant at a level of .05.

RESULTS

The percentage of students observed wearing hats at control schools remained essentially unchanged during the school year (baseline = 2%, fall = 0%, and spring = 1%) but increased statistically significantly at intervention schools (baseline = 2%, fall = 30%, and spring = 41%) (P < .001 for intervention effect comparing the change in rate of hat use over time at intervention vs control schools). Self-reported use of hats outside of school did not change statistically significantly during the study (control: baseline = 14%, fall = 14%, and spring = 11%; intervention: baseline = 24%, fall = 24%, and spring = 23%) nor did measures of skin pigmentation.

CONCLUSIONS

The intervention increased use of hats among fourth-grade students at school but had no effect on self-reported wide-brimmed hat use outside of school or on measures of skin pigmentation.

Assessment of elementary school students' sun protection behaviors

BACKGROUND/OBJECTIVES

Studies suggest that excessive sun exposure in childhood contributes to the development of skin cancer later in life.

METHODS

This study explores 4th grade student assessment of their sun protection behaviors. This study used baseline data collected in the Fall of 2006 for the Sun Protection for Florida's Children (SPF) project. In brief, the SPF project is a group randomized trial to test the effectiveness of a school based intervention promoting sun protection in general, and hat use in particular, in Hillsborough County Schools, Florida. The data reported in this study were collected at baseline before any intervention activities was initiated.

RESULTS

The self-reported use of various methods of sun protection was low. Only a small percentage of students wore long sleeves or a hat with a brim before leaving for school. In addition, few students wore a hat with a wide brim when outside but not at school. Students spent an average of 59.1 minutes per week outdoors while attending school and 35.5 minutes during peak sun exposure.

CONCLUSION

Sun exposure at school poses a significant risk to student health and more needs to be carried out to promote the use of a wide-brimmed hat and limiting student sun exposure.

Atrial septal defect: spectrum of care

Atrial septal defect (ASD) is a common congenital heart defect. Variability in management of this lesion exists among clinicians. A review of the literature reveals that there is lack of standard guidelines for the evaluation and management of patients with different types of ASDs. This survey-based study was conducted to test the uniformity of diagnostic and therapeutic approach to management of children with secundum, sinus venosus, and primum ASDs. Survey questionnaires were prepared to include questions regarding follow-up, diagnosis, and therapeutic intervention of different types and sizes of ASDs. Questions addressed follow-up visitations, type and frequency of investigative studies, pharmacological therapy, and choice of repair method. Surveys were sent out to all pediatric cardiology academic programs in the United States (n=48) and randomly selected international programs from Europe, Asia, and Australia (n=19). A total of 23 programs (34%) responded to the survey (15 from the United States and 8 internationally). A separate questionnaire was prepared for secundum, primum, and sinus venosus ASD. In each questionnaire, lesion types were subdivided into small, moderate, and large defect sizes to address differences of management approaches to each defect type and size. Results indicate that in secundum ASD, most participants use size of the defect and/or evidence of right-sided volume overload as criteria for defining small, moderate, and large defects. Frequency of follow-up does not vary with the type of lesion but is more frequent with larger defects. Most participants see patients with small defects at intervals of 6 months to 1 year and those with large defects at 3- to 6-month intervals. Age of patient and presence of symptoms determined the frequency of follow-up across all defects. Echocardiography was the most frequently used investigative modality in all defect sizes and types during follow-up visits (used by >80% for follow-up), followed by electrocardiography (ECG). There is a striking preference for the use of pharmacological therapy in primum ASD compared with secundum and sinus venosus ASD. The timing of repair was mainly dependent on patient age and symptomatology in different defects, with the presence of associated anomalies contributing to that in primum and sinus venosus ASD. Most participants use percutaneous approach to close secundum ASD (either as a first choice or as one of two choices depending on the presence of certain features). Before repair, participants use MRI or cardiac catheterization to fully evaluate a secundum ASD if it is large. These investigative modalities are not commonly used in primum and sinus venosus ASD. There is agreement on postoperative follow-up in different types of defects, with most participants continuing follow-up indefinitely, especially in larger defects.

Aortic stenosis: the spectrum of practice

There is significant variation in practice patterns in managing congenital aortic valve stenosis. Review of medical literature reveals no significant information regarding the current practice methods in the treatment of a simple lesion such as aortic stenosis (AS). Therefore, this survey-based study was conducted in an attempt to better understand the uniformity or heterogeneity of practice in treating AS. A questionnaire was prepared to evaluate the style of management of AS. This survey was designed to assess the practice of follow-up visitations, type and frequency of investigative studies, pharmacological therapy, and exercise recommendations. Questions about therapeutic intervention included those of timing and type of intervention. Questionnaires were sent to all academic pediatric cardiology programs in the United States (48 program) and selected international programs from Europe, Asia, and Australasia (19 program). The total number of surveys sent out was 67, and the total number of respondents was 25 (37%), 15 (31%) from the United States and 9 (53%) from outside the United States. The definition of moderate AS varied among respondents. The range provided for mild AS was identified as that with a peak-to-peak pressure gradient of < 25-30 mmHg, peak instantaneous Doppler gradient of < 36-50 mmHg, or mean Doppler gradient of < 25-40 mmHg. On the other hand, severe AS was defined as that with a peak-to-peak gradient of > 50-60 mmHg, peak instantaneous Doppler gradient of > 64-80 mmHg, or mean Doppler gradient of > 45-64 mmHg. In assessing follow-up patterns, 84% of respondents recommended seeing patients with mild AS annually, the longest time of follow-up listed in the questionnaire, whereas 20% suggested follow-up every 6 months. There was no consensus among survey centers regarding follow-up of patients with moderate AS. For severe AS, 16% recommend immediate intervention, 16% arrange follow-up every 6 months, and 56 and 28% recommend follow-up in 3 and 1 month(s), respectively. In making the decision to proceed with biventricular versus univentricular repair in patients with AS in the neonatal period, many factors were considered. Ninety-two percent of respondents rely on mitral valve z score, 84% on aortic valve z score, 52% on left ventricle length, 48% on the presence of antegrade ascending aorta flow, and only 32% considered significant endocardial fibroelastosis as a factor. Rhodes score was used by 20% of respondents in decision making regarding the approach to management of this subset of AS. This study shows that there is consensus in the management of mild and severe forms of AS. As expected, disagreement is present in the definition, evaluation, and therapy of moderate aortic valve stenosis. There is a tendency for catheter intervention except in the presence of dysplastic aortic valve or moderate to severe aortic regurgitation. There is also disagreement regarding methods used to determine biventricular versus univentricular repair of a borderline hypoplastic left heart.

Hybrid pediatric cardiac surgery

Minimally invasive strategies can be expanded by combining standard surgical and interventional techniques. We performed a longitudinal prospective study of all pediatric patients who have undergone hybrid cardiac surgery at the University of Chicago Children's Hospital. Hybrid cardiac surgery was defined as combined catheter-based and surgical interventions in either one setting or in a planned sequential fashion within 24 hours. Between June 2000 and June 2003, 25 patients were treated with hybrid approaches. Seventeen patients with muscular ventricular septal defects (mVSDs) (mean age, 4 months; range, 2 weeks-4 years) underwent either sequential Amplatzer device closure in the catheterization laboratory followed by surgical completion (group 1A, n = 9) or one-stage intraoperative off-pump device closure (group IB, n = 8) with subsequent repair of any concomitant heart lesions. Eight patients with branch pulmonary artery (PA) stenoses (group 2) underwent intraoperative PA stenting or stent balloon dilatation along with concomitant surgical procedures. All patients survived hospitalization. Complications from the hybrid approach were mostly confined to groups 1A and 2. At a mean follow-up of 18 months, 2 group 1A patients died suddenly several months after discharge. All other patients are doing well. Hybrid pediatric cardiac surgery performed in tandem by surgeons and cardiologists is safe and effective in reducing or eliminating cardiopulmonary bypass. Patients with mVSDs who are small, have poor vascular access, or have concomitant cardiac lesions are currently treated in one setting with the perventricular approach.

Long-term results from a randomized controlled trial to increase cancer screening among attendees of community health centers

PURPOSE

We assessed whether increased cancer screening rates that were observed with Cancer Screening Office Systems (Cancer SOS) could be maintained at 24 months' follow-up, a period in which clinics were expected to be largely self-sufficient in maintaining the intervention.

METHODS

Eight primary care clinics serving disadvantaged populations in Hills-borough County, Fla, agreed to take part in a cluster-randomized experimental trial. Charts of independent samples of established patients aged 50 to 75 years were abstracted, with data collected at baseline (n = 1,196) and at 24 months' follow-up (n = 1,296). Papanicolaou (Pap) smears, mammography, and fecal occult blood testing were assessed.

RESULTS

At 24 months of follow-up, intervention patients had received a greater number of cancer screening tests (mean 1.17 tests vs 0.94 tests, t test = 4.42, P <.0001). In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms slightly (odds ratio [OR]) = 1.26; 95% confidence interval [CI], 1.02-1.55; P = .03) but had no effect on fecal occult blood tests (OR = 1.17; 95% CI, 0.92-1.48; P =0.19) or Pap smears (OR = 0.88; 95% CI, 0.0.68-1.15; P = .34).

CONCLUSIONS

The Cancer SOS intervention had persistent, although modest, effects on screening at 24 months' follow-up, an effect that had clearly diminished from results reported at 12 months' follow-up. Further study is needed to develop successful intervention strategies that are either self-sustaining or that are able to produce long-term changes in screening behavior.

Multicenter experience with perventricular device closure of muscular ventricular septal defects

Hybrid procedures are becoming increasingly important, especially in the management of congenital heart lesions for which there are no ideal surgical or interventional options. This report describes a multicenter experience with perventricular muscular venticular septal defect (VSD) device closure. Three groups of patients (n = 12) were identified: infants with isolated muscular VSDs (n = 2), neonates with aortic coarctation and muscular VSDs (n = 3) or patients with muscular VSDs and other complex cardiac lesions (n = 2), and patients with muscular VSDs and pulmonary artery bands (n = 5). Via a sternotomy or a subxyphoid approach, the right ventricle (RV) free wall was punctured under transesophageal echocardiography guidance. A guidewire was introduced across the largest defect. A short delivery sheath was positioned in the left ventricle cavity. An Amplatzer muscular VSD occluding device was deployed across the VSD. Cardiopulmonary bypass was needed only for repair of concomitant lesions, such as double-outlet right ventricle, aortic coarctation, or pulmonary artery band removal. No complications were encountered using this technique. Discharge echocardiograms showed either mild or no significant shunting across the ventricular septum. At a median follow-up of 12 months, all patients were asymptomatic and 2 patients had mild residual ventricular level shunts. Perventricular closure of muscular VSDs is safe and effective for a variety of patients with muscular VSDs.

The pediatric cardiology pharmacopoeia: 2004 update

Seven years ago, Pediatric Cardiology published the first version of a review article outlining the various medications used in the field of heart diseases in children. This article is an update and expansion to what we have previously presented. Therapeutic intervention, both surgical and through cardiac catheterization, has enabled cure and palliation of an increasingly expanding spectrum of diseases at earlier ages and with more complex lesions. Refinement of these procedures includes more advanced tools as well as the support of an expanding armament of pharmacopoeia used to stabilize and support patients before, during, and after such procedures. In addition to updating previously published data regarding inotropes, antiarrhythmics, vasodilators, diuretics, sedatives, and analgesics as well as a variety of miscellaneous medications, this article describes the use of pulmonary medications frequently needed in patients with congestive heart failure, pulmonary edema, and chronic lung disease. We also describe the difficult management of withdrawal as a result of use of sedatives and analgesics. The most recent recommendation for subacute bacterial endocarditis prophylactic antibiotic regimens is also described.

A randomized controlled trial to increase cancer screening among attendees of community health centers

BACKGROUND

We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations.

METHODS

Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT).

RESULTS

In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07-9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65-4.0, P <.0001) with a trend toward greater use of Pap smears (OR = 1.57, 95% CI, 0.92-2.64, P = .096).

CONCLUSIONS

The Cancer SOS intervention significantly increased rates of cancer screening among primary care clinics serving disadvantaged populations. The Cancer SOS intervention is one option for providers or policy makers who wish to address cancer related health disparities.

Cardiovascular embryology

During the first 20 days of development, the human embryo has no cardiovascular structure. Over the next month, the heart and great vessels complete their development and look very much like they will at full gestation. This amazing process transforms isolated angiogenic cell islets into a complex, four-chambered structure. During this transformation, the single heart tube begins to beat at 23 days of development and by 30 days blood circulates through the embryo.

Colorectal Cancer Screening among a Sample of Community Health Center Attendees

To determine the rate of colorectal cancer screening in patients attending a sample of community health centers, medical records of 1,176 patients from eight community health centers were abstracted. Among the patients studied, 43.8% of patients had undergone at least one of the three colorectal screening tests (fecal occult blood test, colonoscopy, or flexible sigmoidoscopy) in the recommended interval. Colorectal screening in this community health center population was predicted by male gender, being African American, older age, having a greater number of chronic illnesses, a family history of colorectal cancer, and by having engaged in other preventive cancer screenings in the previous year. Although screening rates certainly were not optimal, they compare favorably to rates reported in national surveys for the general population. Our results add to a growing body of evidence that community health centers, despite serving disadvantaged populations, are able to deliver preventive care at rates comparable to health facilities used by the general population.

World wide web and scientific publishing

The relationship of scientific publishing and the world wide web steadily evolves as the internet technology advances in its sophistication and ability to reach an increasing number of people. Many well established medical publication currently publish their journal electronically as well as in print format. Forced by high volume of manuscript submissions as well as financial restraints, some journals publish a number of their articles on the internet alone, while others-such as this journal-are starting an entirely new publication in an electronic version only. The presentation of articles in the field of pediatric cardiology electronically has numerous advantages, particularly the ability to include movie clips, sound and animations in the published articles. This format of publication continues to have limitation. It is still not as widely available as a print journal could be and it is awkward to curl up in bed with a lap top, no matter how small or light it is.