Showing papers in "Medicine and health, Rhode Island in 2011"

Family caregiving in dementia.

Abstract: Alzheimer’s disease and related dementias are a major health problem. Currently, there are 5.3 million people with Alzheimer’s disease in the U.S. This number is expected to grow significantly as the baby-boomer generation enters old age, with estimates that 7.7 million people will be affected by 2030. It is estimated that 65 to 75% of dementia patients are cared for at home by family members, including both spouses and adult children.1 According to the 2010 Alzheimer’s Association Facts and Figures report, 10.9 million Americans provide unpaid care for persons with dementia. They are involved in 12.5 billion hours of care per year, which is valued at almost $144 million. In Rhode Island, it is estimated that 39,138 individuals are providing about 44 million hours of care per year. Providing care for an individual with dementia is extremely stressful and has far-reaching consequences. Because dementia involves relentless cognitive deterioration, family caregivers have to manage changing demands and unexpected problem behaviors. Caregivers often sacrifice their own needs and well-being to provide care for their loved one. The distress experienced by dementia caregivers is typically referred to as caregiver burden, which includes both objective aspects of providing care (e.g., time and physical aspects of providing caregiver) and subjective experience of caregiving (e.g., perceptions and emotional reactions to caregiving). Although there are strong correlations between caregiver burden and depression, they are not necessarily the same construct.2 Our view is that caregiver burden represents a stressor that if not ameliorated will lead to mental health consequences such as depression. In this article, I will review the consequences of caring for an individual with dementia, briefly discuss theoretical models of caregiver stress, highlight the current state of the literature on psychosocial interventions for dementia caregivers, and identify future directions for dementia caregiver research.

Opioid Overdose Prevention and Naloxone Distribution in Rhode Island

Abstract: Opioid overdose is a major public health concern that affects a diverse group of individuals across all categories of race, class, and geography.1 Overdose is the leading cause of adult accidental death in Rhode Island, making our state one of only 16 where overdose mortality exceeds that of motor vehicle accidents.2 Drug-related deaths, of which overdose is the largest component, claimed the lives of 193 Rhode Islanders in 2008.3 Opioid overdose (OD) occurs when opioids bind receptors in the brain stem, diminishing sensitivity to carbon dioxide and ultimately resulting in respiratory failure. Naloxone Hydrochloride (brand name Narcan®) is an opioid antagonist capable of reversing overdose due to opioids, such as heroin or prescription opioids.4 Naloxone has no potential for abuse; its only major contraindication, allergic reaction to prior administration, is rare.5 For more than three decades, emergency medical personnel have administered naloxone as a standard pre-hospital treatment for opioid overdose.4 Naloxone has been available, by prescription, to at-risk drug users and their family/friends since 1999 through select programs across the country. A common argument against the provision of naloxone to at-risk injection drug users (IDUs) is that the availability of naloxone will increase their risk behavior. To the contrary, Seal et al. observed a decline in heroin use in participants enrolled in their naloxone (and resuscitation) intervention in San Francisco, with a simultaneous increase in overdose prevention knowledge.6 In two different studies of drug users in Rhode Island, the majority expressed a willingness to administer naloxone to a peer in the event of an overdose.7–8 Evaluations of naloxone interventions in major US cities, including San Francisco, Baltimore, Chicago, and New York, have found a notable increase in overdose knowledge among drug users trained in opioid OD recognition and response, dissemination of this knowledge through peer networks, and successful usage of naloxone by study participants.9 Massachusetts instituted a statewide pilot OD prevention program in late 2007, which is operated by the Department of Public Health (DPH). The DPH purchases naloxone and distributes it to training centers, monitors the program, and tracks participant enrollment and naloxone use. The medical director has issued a standing order that allows non-medical personnel to distribute naloxone to trained lay responders in the community without a prescription. In Wilkes County, North Carolina, Project Lazarus began distributing naloxone through physicians in 2010, in collaboration with the state Medical Board. Naloxone is prescribed and distributed by physicians when patients with documented risk factors for overdose are prescribed opioid medications. This paper presents an overview and pilot evaluation of PONI (Preventing Overdose and Naloxone Intervention), the opioid overdose prevention program in Rhode Island.

The role of family caregivers for people with chronic illness.

Abstract: A chronic disease (e.g., diabetes, cardiovascular disease, stroke, hypertension, dementia, some cancers, rheumatological diseases, human immunodeficiency virus) can occur and cycle in flare ups throughout the lifetime. Chronic illnesses, with their effect on the patient’s symptoms, mood, and need for emotional and physical support, exert a burden on family members. Additionally, families influence a patient’s psychological adjustment and management of the illness, adoption of behaviors that influence recovery, functioning and adherence to treatments. 5 The authors, a family physician and a clinical social worker, have been counseling patients and families in a variety of health care and educational settings for 30 years. We have led psycho-educational and medical groups involving patients (and their caregivers) with cancer, chronic pain, diabetes, cognitive impairment and childhood congenital and genetic illnesses. We have seen how the involvement of families and caregivers improves the quality of life for the patient, eases caregivers’ burden, encourages adherence to treatments and increases patients’ ability to cope with the illness. The clinician’s attention to the caregiver can potentially improve family relationships and, therefore, decrease anxiety in the patient and his/her caregiver. Family caregivers function as advocates and provide physical, emotional and financial support, frequently without any training, often without recognition or support, and rarely with financial reimbursement. Many people living with chronic illness could not live independently without family caregivers. Gail Sheehy, in Passages in Caregiving: Turning Chaos Into Confidence, described a want ad for a family caregiver in her wry yet poignantly accurate style:

The ACGME core competencies: changing the way we educate and evaluate residents.

Abstract: Martha B. Mainiero, MD, and Ana P. Lourenco, MD  ThE aCGME oUTCoMEs proJECT While duty hour restrictions have garnered the most attention in discussions of graduate medical education, there is an elemental shift occurring in resident and fellow education that goes hand in hand with restrictions on duty hours and tightening of supervision requirements. Resident training is morphing from apprentice-style on-the-job training into a more formal educational process, along with all the pros and cons that transition entails. The Accreditation Council for Graduate Medical Education (ACGME) has defined six core competencies that all physicians need to practice in a changing health care environment, and all accredited training programs are now based upon these competencies. Despite the fact that teaching and evaluation of these competencies is required, many physicians and medical students are still not familiar with these competencies. 3 This article describes the rationale behind the changes, the educational concepts that now form the framework for residency and fellowship training, and the challenges and opportunities of training physicians within this framework. The ACGME, before instituting the first duty hour restrictions in 2003, approved a long term initiative called the “Outcomes Project” in 1999. The purpose of this initiative has been to increase the emphasis on educational outcomes in residency education. In other words, in the “old days” of the 20th century, the ACGME accredited residency programs based upon their potential to train residents. The type and volume of cases, facilities and credentials of the staff were evaluated but resident achievement was not actually measured. It was more or less assumed that if you had good patient material and good teachers, then resident training should be adequate and the result would be a competent physician. This apprentice model allowed the training program a great deal of autonomy and worked for a very long time. So what was the impetus for change? Probably the same thing that has led to duty hour restrictions: the need for public accountability. Because our system of graduate medical education relies heavily on public funding, the ACGME strives to assure the public that the accreditation process includes safeguards to protect the public from tired, poorly supervised and, most important, poorly trained residents.

Caregiving and elder abuse.

Abstract: to police-reported cases throughout the US and not based on a representa- tive sample of the population, from 2000-2005 there were 87,422 reported incidents of elder physical abuse with a 1:1 victim-offender ratio in the United States. Most abusers who commit police- reported physical assault are over the age of 45 (41.4%) with a mean age of 42. About 73% of offenders are white and 72.1% are males, while only 46.6% of victims are males. The abusers were children (23.9%); spouse (19.6%); other family (12.3% ); acquaintances (36.2%); and other (8.1%). 4 RISK FACTORS ASSOCIATED WITH PERPETRATION A number of studies have focused on caregivers and the risk factors associated with perpetration of abuse. Caregiver factors rather than care receiver factors may be more important in predicting abuse and neglect. 5 Being a caregiver

Overuse injuries in the young athlete.

Abstract: in the past quarter century, traditional “free play” situations for youth in neighborhood settings have largely been replaced by organized sports programs. Year-round training, sport specialization, and participation with multiple teams have replaced recreational activities which traditionally have provided young athletes opportunity to develop a wide range of skills. Consequently, as youth sports participation has become more specialized, the incidence of overuse injuries in children and adolescent athletes has been increasing. The purpose of this review is to provide clinicians an overview for educating young athletes, parents, and coaches about the causative factors, early recognition, and strategies for prevention of sports-related overuse injuries.

Genetics in autism diagnosis: adding molecular subtypes to neurobehavioral diagnoses.

Abstract: Autism is a heterogeneous neurodevelopmental disorder that affects people of all races, ethnicities, and backgrounds and is about four times more prevalent in males.1–3 The incidence of autism has risen so dramatically over the past few decades that this increase has been termed the “autism epidemic.” A recent surveillance study reported a 57% average increase in the number of autism diagnoses in specified regions of the United States from 2002 to 2006, and estimated the current prevalence to be one in 110 children.4 The increase in diagnosis can be at least partly attributed to greater awareness, broader diagnostic criteria5, 6 and improved services for autistic children.7 Regardless, more children than ever are in need of proper diagnosis, treatment and services for autism. This article focuses on recent progress in genetic studies relevant to autism diagnosis. This progress has highlighted the genetic heterogeneity of autism, which mirrors the variation in clinical presentation of behavioral symptoms. Genetic research has recently revealed that about 10% of autism diagnoses can be subtyped according to genetic abnormalities.8 Genetic testing has, therefore, entered the clinical arena. As the multiple genetic etiologies of autism continue to be elucidated and as molecular genetic testing becomes more widely available and less expensive, genetic subtyping of autism will become more common.

Immunization status of refugee children after resettlement.

Abstract: Delma-Jean Watts, MD, Jennifer F. Friedman, MD, MPH, PhD, Patrick M. Vivier, MD, PhD, Christine E. A. Tompkins, MD, MPH, and Anthony J. Alario, MD  IntrOductIOn Refugees arriving in the United States are a heterogeneous group and their medical needs vary based on their country of origin and transit, length of time as a refugee, and quality of health care prior to arrival. Refugee children are at risk for vaccine preventable diseases due to undervaccination, which can have individual as well as public health implications. In recent years, importation of infectious diseases has been of concern. For example, 89% of measles cases in the United States in the first half of 2008 were attributable to importations of disease. Three percent of imported measles between 1997 and 2001 occurred specifically in refugees. In 2006 there was an outbreak of wild poliovirus infection in Kenyan refugee camps where US-bound refugees were residing, highlighting the need for continued high rates of vaccination. Newly arrived refugees usually resettle near other recent arrivals within a city, increasing their potential exposure. Unlike other immigrants, many refugees arrive with no documentation of immunization. Meropol found that only 39% of a predominantly Vietnamese refugee population had evidence of adequate immunization at their initial visit. More recently, a study of adult and pediatric refugees in Minnesota found that most refugees lacked adequate vaccination at arrival. Although many refugees lack documentation, some may have natural immunity to these diseases or they may have received vaccination for which no documentation exists. However, with the exception of varicella, it is cost effective to re-start immigrant and refugee children on the catch-up immunization schedule if they lack documentation, rather than serotesting. Although studies have examined immunization status upon arrival, less is known about the adequacy of catch-up vaccination after resettlement. Adequate vaccination after resettlement is important for protection against the spread of vaccine preventable diseases, as well as for the individual child who requires these vaccines for school entry and change of immigration status to that of a legal permanent resident. Our primary objective for this study was to determine the percent of children up-to-date on vaccines after one year in the United States. Our secondary objective was to identify risk factors including age and primary care follow-up that predict under-immunization one year after resettlement.

Family caregiving at the end of life.

Abstract: A caregiver, defined as “a person who provides direct care (to children, elderly people or the chronically ill),” can be either formal (a trained health care worker) or informal (family or friend). In any given year, an estimated 29% of the United States population, or 65 million people, are caregivers. In Rhode Island, approximately 110,000 people were caregivers in 2004, 10% of the state’s population. The health care system depends on informal caregivers: they supply the bulk of physical and emotional care for individuals with chronic or terminal illnesses. There are not enough formal services to substitute for the informal caregivers. Yet caregiving brings emotional, physical and financial stressors. The clinician who understands these strains can better support both the caregiver and the patient. There is a large evidence base examining the effect of caregiving, most based on caregiving of frail older adults, especially those with dementia. The evidence, as described in this volume by Tremont, demonstrates high levels of stress amongst caregivers, both physical and emotional (i.e., physical strains from assisting with activities of daily living, higher rates of anxiety and depression). These caregivers also suffer financial strain and a substantial impact on employment and career. Caregivers often reduce work hours, miss days or take leave, while tapping into savings. These strains may well account for the higher mortality rate among stressed caregivers. Caregivers can experience the highest stress when caring for patients with a terminal illness at the end of life. These caregivers typically report the most strain, the highest number of hours of care, and assistance with the greatest number of activities of daily living. A study of caregivers of chronically disabled adults compared those whose patients died to those whose patients were still alive after a year: those involved in end-of-life care provided the most hours of care, a mean of 43 hours per week, 53.5% reported poor health themselves, and 28.9% reported emotional strain while 18.9% reported physical strain. Indeed, those caregivers had needs that often exceeded those of the dying patient. However, more than 70% of caregivers reported feeling good about being a caregiver, and that the provision of care was a positive experience. To help family caregivers, a clinician should ask three questions: First, what information and support will benefit family caregivers prior to bereavement? There are few longitudinal assessments of caregivers to dying adults but cross-sectional accounts provide useful information. A review by Docherty et al of 34 studies from eight nations found consistent evidence in support of caregivers’ need for greater education regarding pain management and improved communication between patient, caregiver and service provider. In the United States, similar reports from Teno, Wetle, Shield and others describe family concerns regarding patient pain, physician communication and insufficient staffing in institutional settings. Family members who receive longitudinal support from home care with hospice services or a dementia caregiving program appeared to show more resilience and reported more acceptance of their experience with the dying process and bereavement. Second, are there ways to identify caregivers at risk for complicated or prolonged bereavement, and may intervention be started prior to death? An estimated 10 – 20% of family caregivers are at risk for chronic depression or prolonged grief during bereavement. Increased burden and greater severity of the caregiver’s psychiatric symptoms prior to the care-recipient’s death are predictive factors for prolonged grief. Questions that may help a clinician identify a caregiver at risk for depression or prolonged grief are included in Table 1. Parental caregivers and dementia caregivers may also experience unique risks, as described below. Third, during the period just prior to death, and during bereavement, what is helpful? To support caregivers, it is important to understand who is the caregiver. The typical caregiver is a middle-aged woman who works either part or full-time, and has children at home. The National Family Caregiver Association reports that more than 37% of caregivers have children at home, and that 66% of caregivers are women. The typical person being cared for is an elderly parent. The average amount of time spent is 20 hours per week, though about 13% of caregivers dedicate over 40 hours per week. Both gender and role (e.g. daughter, spouse) play a part in determining caregiver burden. Studies have found that men are more adversely affected by caregiving in areas of financial and social consequence; however, women experience more depression, lower life satisfaction and higher caregiver strain and distress. Children as caregivers report greater reward or satisfaction drawn from caregiving, compared to spouses. Dying, moreover, occurs in a context. The clinician should understand the ethnic, socioeconomic and familial context. For example, what may be seen as pathological grief to a clinician can be normal and expected from the perspective of family. Also, and of perhaps more concern, a caregiver who appears to be doing “well” to clinicians, may, in the minds of family, be coping poorly. Ethnicity and socioeconomic status have been found to correlate with degree of caregiver burden and use of formal support services. Caucasians compared to African Americans report more difficulty adjusting to caregiving roles; however, African American caregivers use fewer formal support services and have worse health. Employed caregivers have higher stress levels and higher rates of depression than those who are retired or unemployed. However, lower socioeconomic status and lower educational

Fostering health: Health care for children and youth in foster care.

Abstract: children and adolescents placed into the foster care system have special health care needs. The physical and psychological consequences of abuse and neglect, as well as the trauma from being removed from their homes lead to physical, emotional and developmental problems. In addition, other risk factors associated with poor physical and mental health such as lack of medical care, poverty, homelessness, violence in the home, parental substance abuse, parental mental illness and premature birth, are often present and compound the child’s health risk. In 2010 in Rhode Island, there were 2,223 indicated investigations of child abuse and neglect involving 3,414 children. Among victims of child abuse and neglect in Rhode Island in 2010, 36% were age three and younger, 12% were ages four to five, 30% were ages six to 11, 15% were ages 12 to 15, and 7% were ages 16 and older. The vast majority (79%) of child maltreatment cases involved neglect. The greatest contributors to neglect are poverty, parental substance abuse and/or mental illness. As of December 31, 2010, there were 2,293 children under age 21 in the care of Rhode Island Department of Children, Youth and Families (DCYF) who were in out-of-home placement. Types of placements for these children varied, including 31% in non-relative/private agency foster care homes, 23% in relative foster homes, 13% in group homes, 12% in residential facilities, and approximately 2-5% in each of the following six settings: at the Rhode Island Training School, with relatives caring for children, in independent living/ supervised apartment, in DCYF shelter care, in psychiatric/medical hospital/ substance abuse treatment facility, or in other settings. Placement stability is a significant concern for children in foster care in Rhode Island and nationally. Changes in foster care placement jeopardize continuity of medical care and nurturing relationships. Placement instability has been associated with negative behavioral and mental health outcomes. In Federal Fiscal Year (FFY) 2010, 14.1% of the 1,694 children who had been in out-ofhome care for less than one year in Rhode Island had experienced three or more placements. Three or more placements were experienced by 35.4% of the 731 children who were in care between 12 and 24 months. Almost two-thirds (65.6%) of the 1,022 children who had been in care for two years or more experienced three or more placements. The percentage of children in the Rhode Island child welfare system who were reunified with their family of origin in less than 12 months from the time of removal from the home increased from 68% in FFY 2009 to 71% of children in FFY 2010 compared with the national standard of 76%.

Health care access, utilization, and needs in a predominantly Latino immigrant community in Providence, Rhode Island.

Abstract: MOre than 46 MIllIOn peOple In the us lack health insurance, as do 140,000 Rhode Islanders (16% of the state’s population under age 65). Most of the state’s uninsured are low income working adults, and thirtyeight percent are low-income childless adults who are not currently eligible for Medicaid. The number of uninsured individuals has been rising in the region, due to decreases in employer-based coverage. National and regional statistics do not account for individuals who are uninsured because they do not yet have citizenship status and are not eligible for company-associated programs or state health insurance. State-supported health care (RIte Care) has also been eroding. Rhode Island’s fiscal woes have led to loss of coverage for low-income children and families. The biggest changes have included i) removing eligibility for children who are undocumented immigrants, ii) removing children who have legal immigrant status but have been in the US for less than five years, iii) increasing the cost of monthly premiums, and iv) reducing parent eligibility. In 2009, reauthorization of the Children’s Health Insurance Program allowed states to receive federal matching funds for covering legally present immigrant children, resulting in RI restoring coverage for this group, who had previously been funded entirely with state dollars; the ACA contains a “Maintenance of Effort” requirement that has prevented RI for implementing monthly RIte Care premium increases that were contained in SFY 2012 budget. The revocation and restoration of coverage reflects the fragility of health care coverage in a time of economic down turn and state fiscal challenges. 4 Together, these changes caused at least 1,000 adults and 3,000 children to lose coverage in 2009. In the years before health reform is implemented, it is likely that the number of uninsured in Rhode Island will continue to rise, due to the erosion of RIte Care as well as the ongoing deterioration of employer-sponsored coverage. Furthermore, experts anticipate that health care reform will not eradicate the problem of the uninsured. While the number of uninsured is expected to decrease by 32 million if health reform is implemented, gaps will remain. Free clinics are one potential solution to health care access problems in the interim before health care reform, and may provide a longer-term solution to those individuals who will still be unable to access care after reform. Clinica Esperanza/Hope Clinic (CEHC) was established in 2007 to address the health problems of the uninsured in Rhode Island. Due to the founders’ commitment to providing linguistically appropriate, culturally attuned care, CEHC initially established temporary clinics in two church basements, serving a

Family and professional caregiving of individuals with dementia in long-term care.

Abstract: MEDICINE & HEALTH/RHODE ISLAND 6. Steadman P, Tremont G, Davis J. J Geriatr Psychiat 2007;20:115-9. 7. Tremont G, Davis J, Bishop D. Dement Geriatr Cogn 2006;21:170-4. 8. De Vugt M, Riedijik S, et al. Dement Geriatr Cogn 2006;22:35-41. 9. Leggett A, Zarit S, et al. Gerontologist 2010; in press. 10. Carter J, Stewart B, et al. Mov Disord 2008;23:1211-6. 11. Schulz R, McGinnis KA, et al. Alzheimer Dis Assoc Disord 2008;22:170-6. 12. Vitaliano P, Zhang J, Scanlan JM. Psychol Bull 2003;129:1-27. 13. Pinquart M, Sorensen S. J Gerontol B Psychol Sci Soc Sci 2007;62:126-37. 14. Pinquart M, Sorensen S. Gerontologist 2005;45:90-106. 15. S c h u l z R , B e a c h S R . J A M A 1999;282:2215-9. 16. Chr i s t ak i s NA, A l l i son PD. NEJM 2006;354:719-30. 17. Norton MC, Smith KR, et al. J Am Geriatr Soc 2010;58:895-900. 18. Hirst M. Carer distress. Soc Sci Med 2005;61:697708. 19. Gaugler JE, Kane RL, Kane RA. Psychol Aging 2005;20:100-16. 20. Tarlow BJ, Wisniewski SR, et al. Res Aging 2004;26:429-53. 21. Hilgeman MM, Allen RS, et al. Psychol Aging 2007;22:361-71. 22. Silverberg Koerner S, et al. Arch Gerontol Geriatr 2009;48:238-45. 23. Lazarus R, Folkman S. Stress, Appraisal, and Coping. New York: Springer; 1984. 24. Belle SH, Burgio LD, et al. Ann Int Med 2006;145:727-38. 25. Zarit S, Femia E. Am J Nurs 2008;108:47-53. 26. Brodaty H, Green A, Koschera A. J Am Geriatr Soc 2003;51:657-64. 27. Sorensen S, Pinquart M, Duberstein P. Gerontologist 2002;42:356-72. 28. Mittelman MS, Roth DL, et al. J Gerontol: Psychological Sciences 59B, P27-P34. 2004. 29. Mittelman MS, Roth DL, et al. Am J Psychiatr 2004;161:850-6. 30. Tremont G, Davis J, et al. Dementia 2008;7:503-20. Geoffrey Tremont, PhD, is Director of Neuropsychology, Rhode Island Hospital, and Assistant Professor of Psychiatry, The Warren Alpert Medical School of Brown University.

Knowledge, attitudes, and behaviors regarding the bone marrow registry among college and medical students in Rhode Island.

Abstract: Adam Vasconcellos, MD, Anthony Nunes, PhD, and Edward Feller, MD, FACP, FACG  IntrOductIOn A critical shortage exists for donors of bone marrow or peripheral stem cells. Each day, between 6,000 and 7,000 individuals nationally with leukemia, lymphoma and other blood disorders search for a potential match. As few as 30% are able to find a match within their own family; the remaining 70% depend on national or international registries to find potential donors to treat these deadly diseases. The “Be the Match” registry (formerly the National Marrow Donor Program), a national donor registry, is comprised of individuals ages 18-60 who join via a brief health questionnaire and a painless cheek swab used for human leukocyte antigen (HLA) typing, the technique employed to compare patients to potential donors. Joining the registry indicates willingness to donate marrow or peripheral stem cells in the future to anyone in need if they are discovered as a potential “match”. Recipients of transplanted cells from younger donors tend to have better outcomes and increased survival. Younger age at registration translates to more potential years on the registry. College and graduate students have become a key focus for marrow donor registration drives as students fit demographics of those most likely to donate—young, healthy, well educated, more open to new information, and part of a community. The racial and ethnic diversity of college campuses provide large pools of diverse registrants. Willingness to join the registry and follow through with donation may be linked to participation in prior blood donation drives, common on college campuses. Data also suggests that students are more influenced by studentled campaigns. Patients are more likely to find matches within their racial or ethnic group. As there are higher numbers of Caucasians on the national donor registry, Caucasian patients have a 50-70% chance of finding a matched, unrelated donor from the registry. Among African Americans and some other racial and ethnic minorities with lower representation on the national donor registry, however, patients find suitable matches in as few as 25-30% of cases. 2,6-10 A national effort exists to increase registration of racial and ethnic minority individuals. Survival after transplantation correlates with the strongest and most precise HLA matches resulting in increased survival. Expanding the registry pool results in more patients finding suitable HLA matches for transplants. The registry is bolstered by those who do not simply join, but actually follow through with donation if selected. Willingness to sign a letter of intent, however, does not correlate well with actual agreement to organ donation. Data indicates that less than 50% of college students indicating willingness to sign a letter of intent, actually did so. Further information is needed to target college-age individuals to improve low levels of registration and donation to improve survival for those with deadly disorders. Our study goal was to assess knowledge, attitudes and behaviors to identify barriers influencing willingness to donate among college and graduate level students. Prior data indicates that misconceptions and misinformation are widespread concerning the realities of this process. We compared responses among those who indicated “willingness” to join the registry with responses among those who indicated “unwillingness” to join.

The evolution of quality improvement.

Abstract: introduCtion With this issue, this column will now focus on quality improvement and patient safety, as the title suggests. In the coming months, we hope to explore concepts that will help physicians in and around Rhode Island improve the quality of health care delivered in their practices. We will also be publishing reports of projects developed and implemented by residents in the Warren Alpert Medical School of Brown University Internal Medicine Residency Program that, we hope, will serve as guides and/or points of interest to physicians practicing in our state. This column, though, is not intended to be just about what is happening in Providence—we encourage physicians across the state to submit descriptions of quality improvement-driven activities being implemented in their own practices, successful or otherwise. From time to time, we will also review published quality improvement research to provide evidence-based and historical background that speaks to the importance of these concepts for our daily medical practice.

Sexual orientation and health risk behaviors among Rhode Island public high school students, 2009

Abstract: nIne Percent (9%) of PublIc hIgh school stuDents resPonDIng to the 2009 Rhode Island Youth Risk Behavior Survey (YRBS) reported that they were lesbian, gay, bisexual or unsure (LGBU) of their sexual identity. This percentage represents approximately 4,600 students statewide. The authors examined whether there were any differences in health risk behaviors and exposures for this population versus their heterosexual peers.

Management of HIV-associated lymphomas.

Abstract: Since the beginning of the AIDS epidemic, HIV infection has been associated with the development of lymphomas. HIV-associated lymphomas are among the most common malignancies seen in these patients (second to Kaposi sarcoma), accounting for a substantial mortality. The pathogenesis of HIV-associated lymphomas relies on chronic antigenic stimulation, viral co-infection (e.g. EBV) and immunologic dysregulation, among others. Since the advent of highly active antiretroviral therapy (HAART) in the mid 1990s, the morbidity and mortality associated with HIV infection have decreased substantially, along with the incidence of HIV-associated lymphomas. In the last several years, our understanding of the biology of the disease and improvements of antiretroviral and supportive therapy have changed the treatment of patients with HIV-associated lymphoma. However, the treatment continues to represent a challenge to oncologists. The objective of this review is to highlight developments in the therapy of HIV-associated lymphomas.

Fraud in health care and organized crime.

Abstract: James F. Dube, JD  falSe ClaimS to mediCare and mediCaid are nothing new. Billions of dollars are being lost in Medicare and Medicaid programs to waste, fraud and abuse. Fraud has been characterized by the FBI as intentional deception or misrepresentation of facts to gain an illegitimate benefit. Abuse has been defined as unnecessary costs associated with actions and services that are inconsistent with accepted practices. There are countless schemes being perpetrated that take advantage of taxpayer dollars on both the state and federal levels. The schemes move from state to state and business to business in an attempt to avoid detection. They run for a limited time, referred to as a “rip-period.” New efforts aimed at helping those in need can also open the door to those seeking ways to take advantage of the system. The Global Medicaid Waiver in Rhode Island indeed will increase home health care and assist many people in a very positive way; however, it also undoubtedly will open up opportunities for fraudulent activity in that area. This article highlights some of the fraud risks in Rhode Island, as well as the state-level protections we have implemented to prevent it. Finally, we offer some recommendations to Rhode Island health care providers on how to avoid being ensnared in the local and federal law enforcement apparatus. To compound matters, it isn’t simply just individuals seeking to take advantage of the system. New organized groups are finding that health care fraud schemes are far less dangerous and more lucrative than other more dangerous crimes such as drug trafficking and the like. Health care fraud has grown over the years. As new people turn to crime, different schemes are uncovered. The fraud across the country is found in many different areas of practice. There are cases involving doctors, dentists, chiropractors, nurses, home health care aides, personal care attendants, nursing homes, ambulance companies, etc. If someone can think of a new way to perpetrate a fraud on our system, they give it a try. If successful, they keep on billing an already burdened system during a “rip-period,” then suddenly stop and move on to another scheme at a different location. On the state side, the single-state agency through which the Medical Assistance Program is administered is the Rhode Island Department of Human Services (DHS). The Rhode Island Department of Attorney General’s Medicaid Fraud and Patient Abuse Unit (MFCU) investigates many complaints and offenses. Among those, are allegations of fraud being perpetrated upon the system by individuals, corporations or other groups. The MFCU consists of two attorneys (Unit Chief / Director and Deputy Director), a case coordinator/paralegal, one chief investigator, one nurse investigator, one auditor, and five additional investigators. The MFCU handles both civil and criminal matters in the fight against fraud and abuse. Many investigations are opened through routine investigative efforts and complaints while others are started after billing anomalies are detected through data analysis and the use of various algorithms.

Acute myeloid leukemia in the elderly.

Abstract: Acute myeloid leukemia (AML) is a malignant stem cell disorder characterized by a disruption in hematopoiesis resulting in accumulation of immature or blast cells in the bone marrow and the peripheral blood. This leads to bone marrow failure, severe cytopenias and death if left untreated. The incidence of AML increases with age, with the majority of patients older than age 60. Elderly patients with AML have a particularly poor prognosis.

Less than optimal oral health care during pregnancy in Rhode Island women: oral health care as a part of prenatal care.

Abstract: it is well-documented that hormonal and immunologic changes during pregnancy predispose women to various oral health problems including gingival/periodontal swelling or inflammation, tooth erosion, and dental decay.,, The receipt of preventive and therapeutic oral health services can prevent further complications of dental diseases during pregnancy and the postpartum period. Furthermore, current evidence-based research demonstrates the potential benefits of maintaining good oral health during pregnancy to control other common pregnancy complications, such as gestational diabetes and preeclampsia (pregnancy-induced hypertension). Studies have suggested that gingival or periodontal infection-related bacteria can adversely affect the glycemic control of gestational diabetes and the pathogenesis of preeclampsia.,, In addition, evidence shows that cariogenic bacteria are typically transmitted from mother to her child., Pregnant women and potential caregivers who have extensive past or current tooth decay should be advised during pregnancy about the use of fluoride, antimicrobial products such as xylitol and chlorhexidine, dietary control, and behavioral changes and techniques to reduce cariogenic bacteria transmission to their babies. The Rhode Island Oral Health Program promotes a dental visit for all pregnant women to obtain counseling on oral health care and dental hygiene, preventive services, and treatment needed during their prenatal care period. However, no report has yet been available to assess oral health care access and utilization status of Rhode Island’s pregnant women. The objectives of this report are to (a) document the most recent estimates of Rhode Island women who received dental care during their pregnancy, (b) determine the prevalence of oral health care education provision for women in their prenatal care period, and (c) discuss how Rhode Island can ensure that all women obtain appropriate oral health care and education during their prenatal period.

Developing Family Resilience in Chronic Psychiatric Illnesses

Abstract: Caregiving for an ill family member can be both stressful and rewarding. Caring for a relative with a psychiatric illness adds the burden of social stigma, both for the patient and the family caregivers, especially in minority cultures. Families from minority cultures may have a different understanding of mental illness and have difficulties with language, discrimination, and accessing services. The appraisal of caregiving must be assessed separately from a caregiver’s coping style. For example, caregiving may be perceived as low stress but the caregiver’s coping skills may be poor, resulting in high caregiver burden. Low perceived stress with strong coping skills results in the most reward and the least burden. High levels of caregiver burden occur in caregivers of relatives with schizophrenia, bipolar disorder, and chronic or recurrent mood disorders. Caregiver burden tends to be worse and more persistent with relatives who suffer from depressive disorders compared to bipolar disorder. Children of caregivers may have difficult behavior, loss of appetite, sleeplessness, with less playing and less attention at school. Caregiver burden can be reduced and caregiver reward can be maximized by improving family resilience. The concept of family resilience explains why some families experience lower burden and greater reward. Family resilience includes the ability to develop adaptive interpersonal skills, such as differentiating the person from the illness, and positive family qualities, such as mutual acceptance and empathic involvement. These family strengths contribute to a sense of family wellnbeing and offset difficulties in other areas of family functioning. The wellbeing of the family unit ensures the best outcome for both patient and caregiver.

Partnering to improve hospital-physician office communication through implementing care transitions best practices.

Abstract: Quality Partners of Rhode Island, the Medicare Quality Improvement Organization, was awarded a Medicare contract to implement a three-year care transitions program. The Safe Transitions Project aimed to improve the safety of patient care transitions by translating effective patient and provider interventions into sustainable systems change. After testing evidencebased interventions locally and systematically gathering input on physicians’ preferences and needs, Quality Partners collaborated with physicians, health plans and community leaders to develop a series of best practices intended to elevate the quality of communication between hospitals and community physician offices. Best practices are evidence-based care processes proven to improve care transitions outcomes.

Preventable death: accidental drug overdose in Rhode Island.

Abstract: rhode islaNd is iN The midsT of a drug poisoNiNg epidemiC. Since 2005, the number of drug poisoning deaths has exceeded the number of motor vehicle accidents, falls, firearms, and fire death among adults <85 years of age. However, Rhode Island is not alone: 20 states now report similar statistics where drug poisonings dominate adult injury deaths. National survey data find that Rhode Island has the nation’s highest rate of past month illicit drug use , and nonmedical use of prescription pain pills ranks 3 in the country, behind Oklahoma and Oregon. The mechanism of death from overdose is respiratory depression, which deprives the victim’s brain of oxygen, causing death over a period of one to three hours. Proximal causal mechanisms and risk factors for accidental overdose include: (a) change in tolerance (i.e. due to voluntary or forced abstinence such as hospitalization, imprisonment, detoxification, selfimposed abstinence); (b) mixing opioids with other substances, especially central nervous system depressants like alcohol or benzodiazepines which worsen respiratory depression; (c) presence of illness, especially diseases that may affect drug metabolism such as hepatitis C or HIV, and breathing conditions like pneumonia or sleep apnea; and (d) using opioids alone, in the absence of others who may recognize a victim’s symptoms and act to intervene. Like all injuries, the majority of drug poisoning deaths are preventable. This surveillance brief provides an overview of state-level statistics describing the extent and nature of the drug poisoning epidemic in Rhode Island and will conclude with a summary of the local prevention initiatives being undertaken or considered.

Complications of monoclonal antibody therapy.

Abstract: iNfusioN reaCTioNs An infusion reaction may range from mild to lethal. The severity is given a rating on a scale of one (mild) to five (lethal). Most often the signs and symptoms are mild (grade one or two). Common signs and symptoms include fever, flushing, rigors, chest discomfort, abdominal pain, nausea, vomiting, diarrhea, and rashes. Rarely, MCAs can cause anaphlaxis. It may be initially difficult to distinguish a mild reaction from anaphylaxis. However, the presence of respiratory changes and urticaria are more specific to anaphylaxis and in contrast, myalgias are more likely to accompany a mild reaction. A generalized symptomatic response to infusion of MCAs typically occurs within the first two hours, but may be delayed up to 14 days after treatment. The highest risk of a reaction is during the first or second exposure to the MCA. The risk declines with repeated exposure, but 10-30% of reactions occur beyond the first two doses. MCAs most associated with early infusion reactions are infliximab, rituximab, gemtuzumab, alemtuzumab, trastuzumab, cetuximab, ofatumumab. Prevention of mild infusion reactions with premedication is routine; however, anaphylaxis may still occur. Commonly prescribed premedication regimens are diphenhydramine and acetaminophen. A patient with a mild reaction should temporarily stop the infusion, and receive symptom relief using an IV antihistamine with oral acetaminophen. They may be re-challenged at a reduced infusion rate (50%) after symptoms have resolved. If a patient develops repeated mild reactions then a referral to an allergy specialist for a desensitization protocol may be considered. A patient with a severe response consistent with anaphylaxis should not be re-challenged. Initial management of suspected anaphylaxis is to stop the infusion. Then intramuscular injection of epinephrine should be given while support is called. If there is no pulmonary contraindication the patient is placed in a supine position, given supplemental oxygen, and a safe airway should be maintained. Volume resuscitation, intravenous antihistamines, and bronchodilators may be administered.

The 'golden hour' treatment of acute ischemic stroke.

Abstract: Arshad Iqbal, MD  DAtA on the IncIDence of stroke, collected by the American Heart Association, indicate that in the United States there is a stroke about every 40 seconds and a person dies of stroke about every four minutes. At the moment, there are three to four million Americans who are stroke survivors. Each year, there are roughly 795,000 new strokes in the United States. The death rate is approximately 30% of all stroke victims.

Chronic lymphocytic leukemia: something old, something new and something borrowed...

Abstract: Chronic Lymphocytic Leukemia (CLL) is a disease of the elderly: almost 70% of diagnoses are made in patients older than 65 years. This indolent lymphoproliferative disorder, manifested by a clonal expansion of mature but functionally defective lymphocytes, is one of the most common leukemias of adults in Western countries. The incidence rate is roughly 2-6 cases per 100,000 persons per year, and increases with age reaching 12.8 cases per 100,000 at age 65 (the mean age at diagnosis). The disease is more common in men, with an incidence ratio of 1.5-2:1. It also has been found to be more common in the Caucasian population, compared to African American, Hispanic, Native American or Asian populations. There are no clear occupational or environmental risk factors for CLL. The prevalence in Caucasian populations suggests a genetic versus an environmental influence on the etiology. A recent study supports an association between blood transfusions and CLL development in 66% patients evaluated.3 However, among the strongest risk factors for the development of CLL is a family history of CLL or other lymphoid malignancy. Retrospective studies have noted increased incidence in first degree relatives. A term coined “genetic anticipation” has also been used to describe a process in which the median age at diagnosis in an affected family decreases in younger generations.2