Chelsea Hospital

BACKGROUND: Missed primary care appointments lead to poor disease control and later presentation to care. No-show rates are higher in clinics caring for underserved populations and may contribute to poorer health outcomes in this group. The objective of this study was to determine who were the patients not showing to primary care appointments and their reasons to no-show. METHODS: A retrospective study was conducted at a community health center serving a predominantly Latino, immigrant, low-income population. Adult patients >18 years old who did not show to primary care appointments during a 5-month period were called by a bilingual (English and Spanish) patient service coordinator. The patients' reported reason for missing the appointment was documented. Two-sided t test of proportions was used to compare demographic characteristics of the patients that showed to their appointments to patients that did not. RESULTS: Of 7508 scheduled appointments, 5604 were included in the analysis and 927 (16.5%) no-showed. There were 735 (79%) calls made to the patients who missed their appointments and 273 (37%) were reached. The 2 most common reasons for missing an appointment were forgetting (n = 97, 35.5%) and miscommunication (n = 86, 31.5%). When compared with patients who came to their appointments, patients who no-showed were younger (P < .0001), more likely to be black (P = .0423) or Hispanic (P = .0001), and to have Medicaid (P < .0001). CONCLUSIONS: No-show rates interfere with quality primary care. Interventions designed to target reasons for no-show are needed to help reduce the no-show rate, improve access and decrease health disparities in underserved patient populations.

The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of adults with HIV infection with antiretroviral therapy (ART). The scope includes: (i) guidance on the initiation of ART in those previously naïve to therapy; (ii)support of patients on treatment; (iii) management of patients experiencing virological failure; and (iv) recommendations in specific patient populations where other factors need to be taken into consideration. The guidelines are aimed at clinical professionals directly involved with and responsible for the care of adults with HIV infection and at community advocates responsible for promoting the best interests and care of HIV-positive adults. They should be read in conjunction with other published BHIVA guidelines.

BACKGROUND: A systematic review was undertaken to assess the safety and efficacy of laparoscopic live-donor nephrectomy (LLDN) compared with open live-donor nephrectomy (OLDN). METHODS: Literature databases were searched from inception to March 2003 inclusive. Comparative studies of LLDN versus OLDN (randomized and nonrandomized) were included. RESULTS: There were 44 included studies, and the quality of the available evidence was average. There was only one randomized controlled trial and six nonrandomized comparative studies with concurrent controls identified. In terms of safety, for donors, there did not seem to be any distinct difference between the laparoscopic and open approaches. No donor mortality was reported for either procedure, and the complication rates were similar although the types of complications experienced differed between the two procedures. The conversion rate for LLDN to an open procedure ranged from 0% to 13%. In terms of efficacy, LLDN seemed to be a slower operation with longer warm ischemia times than OLDN, but this did not seem to have resulted in increased rates of delayed graft function for recipients. Donor postoperative recovery and convalescence seemed to be superior for LLDN, making it a potentially more attractive operation for living donors. Although in the short-term, graft function and survival did not seem to differ between the two techniques, long-term complication rates and allograft function could not be determined and further long-term follow-up is required. CONCLUSIONS: LLDN seems to be at least as safe and efficacious as OLDN in the short-term. However, it remains a technique in evolution. Further high-quality studies are required to resolve some of the outstanding issues surrounding its use, in particular, long-term follow-up of donor complications and recipient graft function and survival.

School-based health centers (SBHC) have substantial potential to improve the recognition and treatment of adolescents' mental health problems. This study was undertaken as a quality improvement project to evaluate utility of the Pediatric Symptom Checklist when completed by youth (PSC-Y) among 383 adolescents seen at a SBHC, and the extent to which identification of psychosocial dysfunction and referral to mental health services improved academic functioning. Adolescents identified by the PSC-Y were significantly more likely to be insured by Medicaid, be a teen-age parent, and to have higher rates of absenteeism and tardiness in comparison to those not identified. Adolescents identified with the PSC-Y who were referred to mental health services significantly decreased their rates of absences and tardiness. Study results provide support for the utility of psychosocial screening and referral in the SBHC environment in facilitating recognition and treatment of adolescent mental health problems and improving student academic functioning.

OBJECTIVE: Previous work has focused attention on the prevalence of specific maternal health problems known to affect children, such as smoking or depression. However, the cumulative health burden experienced by mothers and the potential for a practical pediatric health services response have not been examined. The aims of this study were to characterize: 1) the prevalence and cumulative burden of maternal health behaviors and conditions, 2) maternal access to a source of comprehensive adult primary care, and 3) maternal perceptions of a pediatric role in screening and referral. METHODS: We surveyed 559 consecutive women bringing a child 18 months of age or less to one of four pediatric primary care sites between July 1996 and May 1997. The pediatric sites included one outpatient program in an academic hospital, one in a community health center, and two in-staff model practices of a managed care organization (these last two were combined for analysis). The self-administered questionnaire contained previously validated questions to assess health behaviors and conditions (smoking, alcohol abuse, depression, violence, risk for unintended pregnancy, serious illness, self-reported health) and access to care (regular source, regular provider, health insurance, care delayed or not received). Maternal attitudes toward a pediatric role in screening and referral were also elicited. RESULTS: In the three settings, response rates ranged from 75% to 84%. The average age of the women ranged from 25.1 to 32. 1 years and the average age of the children ranged from 6.5 to 8.0 months. Across the settings, the percentage of women reporting at least one health condition (66%-74%) was similarly high, despite significant demographic differences among sites. Many women reported more than one condition (31%-37%); among all women who smoked, 33% also screened positive for alcohol abuse, 31% for emotional or physical abuse, and 48% for depression. Access to comprehensive adult primary care was variable with 23% to 58% of women reporting one or more barriers depending on the site. Across all sites, >85% of mothers reported they would "not mind" or "would welcome" a pediatric role in screening and referral. CONCLUSIONS: Two-thirds of women bringing their children for pediatric care had health problems regardless of the site of care. Many women also reported substantial barriers to comprehensive health care. Most women reported acceptance of a pediatric role in screening and referral. Given the range and depth of maternal health needs, strategies to connect or reconnect mothers to comprehensive adult primary care from a variety of pediatric settings should be explored.

Twenty-four-hour ambulatory blood pressure measurements (ABPM) are likely to eliminate the stress of visits and observer bias in office blood pressure (BP) recordings, allow consideration of the circadian variability in BP, and correlate well with target organ damage. To define the prevalence of "white coat" hypertension in a rural community to a nonacademic setting, and to assess age and sex related differences, we studied 131 patients who had more than two prior office diastolic BP measurements greater than 90 mm Hg and less than 115 mm Hg. Blood pressure was measured every 10 to 60 min for 24 h using the SpaceLabs 90207 device. Office BP readings were higher than ABPM in the group as a whole, in individual age groups, and in both sexes. The differences were more pronounced at night. Average differences between office and ambulatory BP ranged between 14.4 +/- 1.7/2.9 +/- 2.0 (ABPM at 10:00), and 33.8 +/- 2.3/22.8 +/- 1.5 mm Hg (systolic/diastolic +/- SE) (ABPM at 01:00). The nighttime drop in systolic BP was not apparent in subjects more than 65 years old. Women had a proportionately higher mean office BP than men (115.0 +/- 0.9 office v 110.2 +/- 1.3 mm Hg ABPM in women and 112.3 +/- 0.9 v 104.3 +/- 1.1 mm Hg in men) (P = .013), and the elderly did not display the relationship between ambulatory and office mean BP seen in younger subjects (r = 0.15, P = .30 v r = 0.36, P = .0004, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVE: The diagnosis of autoimmune pancreatitis (AIP) is challenging. Sonographic and cross-sectional imaging findings of AIP closely mimic pancreatic ductal adenocarcinoma (PDAC) and techniques for tissue sampling of AIP are suboptimal. These limitations often result in delayed or failed diagnosis, which negatively impact patient management and outcomes. This study aimed to create an endoscopic ultrasound (EUS)-based convolutional neural network (CNN) model trained to differentiate AIP from PDAC, chronic pancreatitis (CP) and normal pancreas (NP), with sufficient performance to analyse EUS video in real time. DESIGN: A database of still image and video data obtained from EUS examinations of cases of AIP, PDAC, CP and NP was used to develop a CNN. Occlusion heatmap analysis was used to identify sonographic features the CNN valued when differentiating AIP from PDAC. RESULTS: From 583 patients (146 AIP, 292 PDAC, 72 CP and 73 NP), a total of 1 174 461 unique EUS images were extracted. For video data, the CNN processed 955 EUS frames per second and was: 99% sensitive, 98% specific for distinguishing AIP from NP; 94% sensitive, 71% specific for distinguishing AIP from CP; 90% sensitive, 93% specific for distinguishing AIP from PDAC; and 90% sensitive, 85% specific for distinguishing AIP from all studied conditions (ie, PDAC, CP and NP). CONCLUSION: The developed EUS-CNN model accurately differentiated AIP from PDAC and benign pancreatic conditions, thereby offering the capability of earlier and more accurate diagnosis. Use of this model offers the potential for more timely and appropriate patient care and improved outcome.

BACKGROUND: The aim of this systematic review was to compare the safety and efficacy of laparoscopic live donor nephrectomy with the "gold" standard of open live donor nephrectomy. SEARCH STRATEGY: Three search strategies were devised to enable literature retrieval from the Medline, Current Contents, Embase, and Cochrane Library databases up until, and including, February 2000. STUDY SELECTION: Inclusion of a report was determined on the basis of a predetermined protocol, independent assessment by two reviewers, and a final consensus decision. English language reports were selected and acceptable study designs included randomized-controlled trials, controlled clinical trials, case series, or case reports. Each report was required to provide information on at least one of several safety and efficacy outcomes as detailed in the protocol. DATA COLLECTION AND ANALYSIS: Twenty-five reports met the inclusion criteria. They were tabulated and critically appraised in terms of the methodology and design, sample size, outcomes, and the possible influence of bias, confounding, and chance. RESULTS: High level evidence comparing the safety and efficacy of laparoscopic live donor nephrectomy with open donor nephrectomy was not available at the time of this review. Limited low level evidence suggested that the laparoscopic approach might be advantageous regarding the donor's hospital stay, convalescence, pain, and resumption of employment. CONCLUSIONS: The ASERNIP-S Review Group concluded that the evidence-base for laparoscopic live donor nephrectomy was inadequate to make a safety and efficacy recommendation. Clinical and research recommendations were developed regarding the introduction and current practice of this procedure in Australia.

The decision to administer fluids to a dehydrated dying patient is often discussed primarily as an ethical issue, but sensible therapeutic choices should be based first on a clear appreciation of the clinical manifestations of water arid electrolyte disorders and of the potential benefits of treatment. Does dehydration cause symptoms? Are these symptoms distressing to the patient? Do fluid and electrolyte administration and other treatments help make dying patients comfortable? Dehydration, defined here as a loss of normal body water, is a term that is often used imprecisely to describe conditions with differing causes, symptoms, and management.1, 2 In general, research on fluid and electrolyte disorders has not been aimed at defining how water-depleted conditions of various types, severity, and duration are manifested symptomatically, nor at how symptoms respond to treatments. Currently, when fluid and electrolyte disorders are studied or reviewed, sodium metabolism tends to receive much greater attention than water depletion. Textbook presentations of the signs and symptoms of dehydration are often subsumed under discussions of hyponatremia (or hypoosmolality) and hypernatremia (or hyperosmolality). A questionable assumption is made that hyponatremia or hypernatremia associated with dehydration causes the same clinical picture as when these electrolyte disorders develop in patients with normal or increased body water. Classic studies by McCance3 and Nadal et al.4 of short-term, experimentally induced dehydration in a small series of normal subjects appear to be the only widely cited and somewhat systematic observations of the clinical manifestations of dehydration in adults. In the light of contemporary research design criteria, these studies (and many subsequent reports on the subjective response to dehydration) can be severely faulted. Nadal et al.,4 however, suggested the important notion that quite different clinical syndromes could be associated with two prototypical forms of dehydration: sodium depletion and pure water loss. One experimental form of water loss, pure salt or sodium depletion, develops when subjects undergo salt and water depletion in a setting in which only water is restored. This condition can be produced experimentally and clinically when lost sweat or gastroinestinal secretions are replaced with salt-free fluids. A similar pattern of clinical findings, perhaps best called hyponatremic or hypotonic dehydration, develops when salt and water in body fluids are lost, but either the loss of sodium is proportionately greater than the loss of fluid or, as occasionally occurs among patients on diuretics, the repletion of salt is inadequate. Salt is the principal cation of the extracellular fluid, so hyponatremic dehydration leads predominantly to salt and fluid loss from the intravascular and interstitial compartments. Sodium depletion is thus sometimes called volume depletion, a term that also is imprecise but that points to the prominence in this condition of signs of circulatory insufficiency. Azotemia, hyponatremia, and hemoconcentration (decreased intravascular fluid and increased red cell volume) are the principal laboratory findings in pure salt depletion. Patients with pure salt depletion exhibit weight loss, poor skin turgor, dry mucous membranes, diminished sweat, and postural hypotension. Neuropsychiatric manifestations, such as weakness, apathy, lethargy, restlessness, confusion, delirium, stupor, coma, and seizures, also occur, and primarily may reflect hyponatremia, as these symptoms also are seen when hyponatremia develops in the absence of volume depletion. The neuropsychiatric symptoms have been attributed to overhydration of brain cells, and are similar to clinical findings in other hypoosmolar states. Neuropsychiatric disorders occur especially when hyponatremia is severe or develops rapidly. A prompt lowering of serum sodium to 128 mmol/L can produce marked symptoms, whereas a gradual lowering to 110 mmol/L may go unnoticed. Hyponatremia also has been reported to cause psychosis and such localized neurologic findings as aphasia, ataxia, and focal weakness. Subjects engaged in physical labor or undergoing relatively rapid onset of hyponatremia may complain of muscle cramps. Anorexia, nausea, vomiting, and loss of taste have sometimes been noted in experimental and clinical subjects with hyponatremic dehydration. However, the frequency and severity of these symptoms with various degrees of hyponatremic dehydration has not been adequately characterized, and the possibility remains that they usually are contributing causes rather than the effects of salt and water deprivation. Notably, if hyponatremic dehydration produces symptoms that lead to diminished salt intake or increased salt loss through emesis, a vicious cycle of worsening salt depletion will occur.1 Thirst is provoked primarily by hyperosmolar states, and thus may be absent or mild in patients with hyponatremic dehydration. Although modest reductions in blood volume and blood pressure do not elicit thirst, marked volume loss and hypotension are generally regarded as stimuli for antidiuretic hormone (ADH) release and water craving, as is apparent in the early stages of hypovolemic shock.5 In a second experimental situation, subjects lose salt and water but have limited access to water while continuing to ingest salt. Clinically, this pattern of dehydration typically develops in confused or somnolent patients who have lost water disproportionately to salt or for whom water has been inadequately replaced. Similar findings may occur in patients with an osmotic or postobstructive diuresis or with fluid loss from burns. Because two-thirds of body water is in the intracellular fluid compartment, equilibration from losses of extracellular fluid will result in water loss from cells, a trigger for thirst and the release of ADH from the hypothalamus. Thus, pure water loss (pure water deprivation or hypernatremic or hypertonic dehydration) is characterized early in its development by intense thirst. Indeed, the perpetuation of this condition in situations in which water is available suggests a blunting of presumed normal mechanisms of thirst or the response to thirst. Extracellular fluid volume is fairly well maintained in states of pure water deprivation, so skin turgor, blood pressure, and pulse are relatively unchanged.4, 6 The major laboratory finding of pure water loss is hypernatremia. Once significant pure water loss develops, mental status changes ensue, beginning with mild confusion and progressing to obtundation and coma. The clinical presentation in this condition has been likened to the symptom complex in hyperglycemia and other hyperosmolar states that cause brain cell dehydration. Profound neurologic damage has been reported in children. The neuropsychiatric symptoms may affect the sense of thirst, and may further hinder the ability to replace fluids. Symptoms seem to be more severe when hypernatremia develops rapidly. Fatigue, muscular weakness, and low-grade fever also have been reported. Dehydrated terminally ill patients usually present with mixed disorders of salt and water depletion, resulting typically from abnormal gastrointestinal or renal losses; normal water losses from the skin, lungs, or kidneys; and from failure to replace these losses. Isotonic dehydration, a condition that regularly is overlooked in discussions of the symptoms of fluid and electrolyte disorders, may occur. Clinicians with a special interest in the care of the terminally ill7, 8 describe thirst and dry mouth in dehydrated patients, but do not report encountering the other worrisome symptoms, such as headache, nausea and vomiting, or cramps, which are cited in some reviews of water deprivation. Personal observation of hospice patients suggests that nausea and vomiting are not regular sequelae of hyponatremia dehydration (nor of other forms of dehydration), although these symptoms frequently cause fluid and electrolyte deficiency. In the author's experience, thirst and dry mouth are the only seriously troubling and commonly encountered symptoms that can be attributed to dehydration in terminally ill patients.9 These symptoms may be satisfactorily relieved by amounts of oral fluid too small to significantly reverse metabolic abnormalities3, 10 or by maintaining moisture in the mouth with water, ice chips, or various forms of artificial saliva.7-9 Postural hypotension may be bothersome in dehydrated patients who are ambulatory. Bedbound patients report primarily lethargy, drowsiness, and fatigue, but these symptoms are rarely a source of much distress. Disorders of thirst and the mental status changes that foster and perpetuate salt and water deficiencies may protect against discomfort or obliterate the awareness of suffering. Indeed, patients who become dehydrated may be too lethargic to be troubled by symptoms potentially produced by fluid deprivation. The decision to administer fluids to a dehydrated patient is often determined by the symbolic or emotional meaning of such measures to the patient, family, and caretakers. Even irreversibly comatose, terminally ill persons are commonly given intravenous fluids, sometimes at a “keep open” rate, which is physiologically almost useless. Maintenance of fluid and electrolyte balance may be considered ordinary (ie, standard or necessary, rather than extraordinary or heroic), whereas the withholding of such treatment may be viewed by the family and others as causing suffering or as evidence of not caring about the patient.11 However, insofar as the physical comfort of the patient guides management12-15 (or until more systematic studies are available on the subjective effects of dehydration and its treatment), fluid depletion in dying patients should be regarded as a disorder with relatively benign symptoms. Successful treatment of the discomfort of thirst and a dry mouth generally does not require rehydration. Administration of salt and water by enteral (oral or, sometimes, rectal), subcutaneous, or intravenous routes should be considered for the purpose of restoring health and prolonging life, and may be justified readily in selected patients (for instance, those who still enjoy meaningful well-being but either temporarily or permanently cannot ingest liquids). Correction of hypernatremia or hyponatremia occasionally may be indicated to provide symptomatic relief. However, when the goal of management is to promote comfort or relieve suffering, treatment generally can be confined to simple measures in the form of mouth care.

Lower torso ischemia and reperfusion leads to both local and remote tissue injuries. The purpose of this study was to assess the role of complement in mediating the local and remote microvascular permeability after bilateral hind limb tourniquet ischemia. Four hours of ischemia and 4 hours of reperfusion produced an increased skeletal muscle permeability index (muscle/blood 125I albumin ratio) of 2.90 +/- 0.35 compared with the index in nonischemic muscle of 0.25 +/- 0.02 (p < 0.01). Muscle wet-to-dry-weight ratio increased from 3.93 +/- 0.04 in sham to 5.55 +/- 0.09 in ischemic muscle (p < 0.0001). Lung permeability rose at 4 hours as indicated by the increased bronchoalveolar lavage (BAL)/blood 125I albumin ratio 4.36 +/- 0.41 x 10(-3) versus sham 2.64 +/- 0.28 x 10(-3) (p < 0.05) and neutrophil sequestration 0.28 +/- 0.02 U/g myeloperoxidase (MPO) versus sham 0.14 +/- 0.02 U/g (p < 0.001). Serum lytic activity of the classical but not the alternate complement pathway was reduced. The soluble complement receptor (sCR1) was used to inhibit complement activity and attenuated the increase in the permeability index after reperfusion in ischemic muscle 1.11 +/- 0.08 (p < 0.01) and reduced the lung BAL/blood 125I albumin ratio to sham levels 2.46 +/- 0.39 x 10(-3) (p < 0.05) at 6 mg/animal, without reducing the lung neutrophil sequestration, 0.24 +/- 0.02 U/g. The authors conclude that complement activation occurred during tourniquet ischemia and mediated permeability changes in the ischemic muscle and the lungs during reperfusion.

BACKGROUND: Women of lower socioeconomic status (SES) with early-stage breast cancer are more likely to report poorer physician-patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices. METHODS: We conducted a 3-arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon-level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence-based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre-consultation) to T5 (1-year after surgery. RESULTS: Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self-reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety. CONCLUSIONS: Paper-based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients. LAY SUMMARY: The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices. Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text-only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education. Conversation aids with pictures and text helped women make better breast cancer surgery choices.

We conducted a retrospective chart review of older (n = 48; mean age = 69) and younger (n = 36; mean age = 30) patients who were admitted to residential/inpatient treatment for alcohol withdrawal and dependence. Although the two age groups did not differ in terms of recent drinking history, the elderly group had significantly more withdrawal symptoms for a longer duration than the younger group. The elderly group also had more symptoms of cognitive impairment, daytime sleepiness, weakness, and high blood pressure. Finally, no significant differences were found between age groups in either the dosage or number of days of detoxification medication, although a trend was found for more days of medication in the elderly. We conclude that alcohol withdrawal may be more severe in elderly than in younger persons. Accordingly, treatment may take longer and should target the specific profile of symptoms that characterize alcohol withdrawal in the elderly.

INTRODUCTION: CollaboRATE is a brief patient survey focused on shared decision making. This paper aims to (i) provide insight on facilitators and challenges to implementing a real-time patient survey and (ii) evaluate CollaboRATE scores and response rates across multiple clinical settings with varied patient populations. METHOD: All adult patients at three United States primary care practices were eligible to complete CollaboRATE post-visit. To inform key learnings, we aggregated all mentions of unanticipated decisions, problems and administration errors from field notes and email communications. Mixed-effects logistic regression evaluated the impact of site, clinician, patient age and patient gender on the CollaboRATE score. RESULTS: While CollaboRATE score increased only slightly with increasing patient age (OR 1.018, 95% CI 1.014-1.021), female patient gender was associated with significantly higher CollaboRATE scores (OR 1.224, 95% CI 1.073-1.397). Clinician also predicts CollaboRATE score (random effect variance 0.146). Site-specific factors such as clinical workflow and checkout procedures play a key role in successful in-clinic implementation and are significantly related to CollaboRATE scores, with Site 3 scoring significantly higher than Site 1 (OR 1.759, 95% CI 1.216 to 2.545) or Site 2 (z=-2.71, 95% CI -1.114 to -0.178). DISCUSSION: This study demonstrates that CollaboRATE can be used in diverse primary care settings. A clinic's workflow plays a crucial role in implementation. Patient experience measurement risks becoming a burden to both patients and administrators. Episodic use of short measurement tools could reduce this burden.

Abstract Findings of a study that investigated conditions associated with introducing Geographic Information Systems (GIS) into pre-college curricula are described. Questionnaires, field observations, and interviews provided the principal data sources. Key implementation issues were organized into a conceptual model that integrates factors connected with educational applications of GIS. This article also introduces the GIS Readiness Survey, a self-administered questionnaire that enables potential users to assess the status of conditions associated with the classroom introduction of this technology.

IMPORTANCE: Patient navigation (PN) to improve cancer screening in low-income and racial/ethnic minority populations usually focuses on navigating for single cancers in community health center settings. OBJECTIVE: We evaluated PN for breast, cervical, and colorectal cancer screening using a population-based information technology (IT) system within a primary care network. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial conducted from April 2014 to December 2014 in 18 practices in an academic primary care network. All patients eligible and overdue for cancer screening were identified and managed using a population-based IT system. Those at high risk for nonadherence with completing screening were identified using an electronic algorithm (language spoken, number of overdue tests, no-show visit history), and randomized to a PN intervention (n = 792) or usual care (n = 820). Navigators used the IT system to track patients, contact them, and provide intense outreach to help them complete cancer screening. MAIN OUTCOMES AND MEASURES: Mean cancer screening test completion rate over 8-month trial for each eligible patient, with all overdue cancer screening tests combined using linear regression models. Secondary outcomes included the proportion of patients completing any and each overdue cancer screening test. RESULTS: Among 1612 patients (673 men and 975 women; median age, 57 years), baseline patient characteristics were similar among randomized groups. Of 792 intervention patients, patient navigators were unable to reach 151 (19%), deferred 246 (38%) (eg, patient declined, competing comorbidity), and navigated 202 (32%). The mean proportion of patients who were up to date with screening among all overdue screening examinations was higher in the intervention vs the control group for all cancers combined (10.2% vs 6.8%; 95% CI [for the difference], 1.5%-5.2%; P < .001), and for breast (14.7% vs 11.0%; 95% CI, 0.2%-7.3%; P = .04), cervical (11.1% vs 5.7%; 95% CI, 0.8%-5.2%; P = .002), and colon (7.6% vs 4.6%; 95% CI, 0.8%-5.2%; P = .01) cancer compared with control. The proportion of overdue patients who completed any cancer screening during follow-up was higher in the intervention group (25.5% vs 17.0%; 95% CI, 4.7%-12.7%; P < .001). The intervention group had more patients completing screening for breast (23.4% vs 16.6%; 95% CI, 1.8%-12.0%; P = .009), cervical (14.4% vs 8.6%; 95% CI, 1.6%-10.5%; P = .007), and colorectal (13.7% vs 7.0%; 95% CI, 3.2%-10.4%; P < .001) cancer. CONCLUSIONS AND RELEVANCE: Patient navigation as part of a population-based IT system significantly increased screening rates for breast, cervical, and colorectal cancer in patients at high risk for nonadherence with testing. Integrating patient navigation into population health management activities for low-income and racial/ethnic minority patients might improve equity of cancer care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02553538.

Summary The problem considered is that of estimating a functional relationship (assumed linear) between two unobservable mathematical quantities ξ and η from pairs of observations on these quantities when both sets of observations are subject to normal independent errors. The problem has attracted much interest over a long period and one reads repeatedly that the method of maximum likelihood yields unsatisfactory estimators in this case. In this note we show that in fact no maximum-likelihood solution exists for this problem, which ceases then to provide an example of unsatisfactory maximum-likelihood estimators and merely joins the queue of problems in which the likelihood approach fails to produce estimators. The distinction, although academic, is worth making.

BACKGROUND: The long-term effects of interventions to improve colorectal (CRC) screening in vulnerable populations are uncertain. The authors evaluated the impact of patient navigation (PN) on the equity of CRC prevention over a 5-year period. METHODS: A culturally tailored CRC screening PN program was implemented in 1 community health center (CHC) in 2007. In a primary care network, CRC screening rates from 2006 to 2010 among eligible patients from the CHC with PN were compared with the rates from other practices without PN. Multivariable logistic regression models for repeated measures were used to assess differences over time. RESULTS: Differences in CRC screening rates diminished among patients at the CHC with PN and at other practices between 2006 (49.2% vs 62.5%, respectively; P < .001) and 2010 (69.2% vs 73.6%, respectively; P < .001). The adjusted rate of increase over time was higher at the CHC versus other practices (5% vs 3.4% per year; P < .001). Among Latino patients at the CHC compared with other practices, lower CRC screening rates in 2006 (47.5% vs 52.1%, respectively; P = .02) were higher by 2010 (73.5% vs 67.3%, respectively; P < .001). Similar CRC screening rates among non-English speakers at the CHC and at other practices in 2006 (44.3% vs 44.7%, respectively; P = .79) were higher at the CHC by 2010 (70.6% vs 58.6%, respectively; P < .001). Adjusted screening rates increased more over time for Latino and non-English speakers at the CHC compared with other practices (both P < .001). CONCLUSIONS: A PN program increased CRC screening rates in a CHC and improved equity in vulnerable patients. Long-term funding of PN programs has the potential to reduce cancer screening disparities.

Fentanyl Overdose and Acute Amnestic Syndrome A syndrome of severe amnesia and medial temporal changes on magnetic resonance imaging after drug overdose has been reported with increasing frequency. Four additional cases are now reported in patients from Massachusetts who tested positive for fentanyl.

Abstract Over the past decade, public housing has become the nation's “housing of last resort.” This article examines the emergence of this social role and describes the conditions of resident economic and social distress that have accompanied it. In this context, the article also evaluates the problem assessment and recommendations of the National Commission on Severely Distressed Public Housing, which released its final report in August 1992. This evaluation is used as the basis for proposing a new social role for public housing defined around the concept of social capital. The commission correctly identified concentrations of resident distress, such as high proportions of extremely poor and female‐headed families, as a major problem facing distressed public housing. However, the recommendations of the commission were much less satisfying. Rather than confronting directly the tenant selection policies that have produced these aggregations of resident distress, the commission held to an unrealistic optimism that social services and economic development initiatives could relieve these conditions. For changes in public housing tenant selection policies to occur, an alternative social role for public housing must be defined. Under this alternative role, a primary objective of the public housing program would be to give residents access to social capital. Such an approach would ensure that families of the working poor are integrated with the nonworking poor in public housing developments, thereby fostering those sinews of community connection and trust the essential features of social capital and the sources of hope and opportunity.

Proximity to a park does not necessarily imply access or use, and the social environment may positively or negatively influence the positive intentions of the built environment. To investigate parks, park use and physical activity, and their associations with exposure to community violence, we interviewed residents (n = 354) of a densely populated urban community. Our findings indicate that proximity to any park is not associated with physical activity. However, proximity to the preferred park reported by residents to be conducive for physical activity (with walking paths, large fields, playgrounds for children and tennis courts) was associated with physical activity. Conversely, knowledge of sexual assault or rape in the neighborhood is inversely associated with every type of physical activity (park-based, outdoor, and indoor). Our findings suggest that improvements to the built environment (parks, green spaces) may be hindered by adverse social environments and both are necessary for consideration in the design of public health interventions.