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In Botswana, an estimated 24% of adults ages 15-49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors. We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap > or =10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers. Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.

The Botswana government recently implemented a policy of routine or \"opt-out\" HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults. We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1-1.9), higher education (AOR = 2.0, 95% CI = 1.5-2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3-2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1-2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2-2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5-0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45-0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning one's status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%). Routine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing.

Background As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population. Objectives To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort. Participants In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%). Methods We measured respondents’ comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics. Results Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF (p < .001) and 35% for SCD (p > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD. Conclusions A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions.

Background: Tonsillectomy is the second most common inpatient procedure in US children. However, the factors that influence tonsillectomy-related costs are unknown. Objective: The objective of the study was to describe variation in US inpatient tonsillectomy costs and examine whether postoperative complications contribute to these disparities in costs. Research Design: This is a retrospective cohort study of the 2009 Nationwide Inpatient Sample. Hierarchical, mixed-effects linear regression modeling was used to analyze the association between postoperative complications and cost, controlling for clinically relevant characteristics such as age, number of chronic comorbidity indicators, and hospital mean complication rates. We also estimated the variance in cost attributable to the treating hospital using the intraclass correlation coefficient. Subjects: The study cohort comprised 12,512 adult and pediatric patients undergoing tonsillectomy or adenotonsillectomy in the inpatient setting. Measures: Cost, posttonsillectomy hemorrhage, and mechanical ventilator use at the individual encounter and at hospital level were evaluated. Results: The aggregate cost of tonsillectomies in the cohort was $94.2 million. The median cost per encounter across all hospitals was $4393 (interquartile range, $3279-$6981), whereas the mean cost was $7525 (95% confidence interval, $6453-$8597). Mechanical ventilation was associated with an adjusted increase of $30,081 per encounter (95% confidence interval, $18,199-$41,964). The intraclass correlation coefficient declined from 0.117 to 0.070 after adjusting for mean hospital mechanical ventilation rate, which accounted for 40.2% of the interhospital variation in cost. Conclusions: Use of mechanical ventilation significantly increases the cost of inpatient tonsillectomy care. Further research should examine risk factors contributing to higher rates of mechanical ventilation after tonsillectomy, which in turn can guide systemic quality improvement interventions to reduce costs.

American Muslims are a diverse and growing population, numbering nearly 200,000 in Southeast Michigan. Little empirical work exists on the influence of Islam upon the healthcare behaviors of American Muslims, and there is to date limited research on the roles that imams, Muslim religious leaders, play in the health of this community. Utilizing a community-based participatory research (CBPR) model through collaboration with four key community organizations, we conducted semi-structured interviews with 12 community leaders and explored their perceptions about the roles imams play in community health. Respondents identified four central roles for imams in healthcare: (1) encouraging healthy behaviors through scripture-based messages in sermons; (2) performing religious rituals around life events and illnesses; (3) advocating for Muslim patients and delivering cultural sensitivity training in hospitals; and (4) assisting in healthcare decisions for Muslims. Our analysis also suggests several challenges for imams stemming from medical uncertainty and ethical conflicts. Imams play key roles in framing concepts of health and disease and encouraging healthy lifestyles outside of the healthcare system, as well as advocating for Muslim patient needs and aiding in healthcare decisions within the hospital. Healthcare partnerships with these religious leaders and their institutions may be an important means to enhance the health of American Muslims.

The objective of this study is to inform medical home implementation in practices serving limited English proficiency Latino families by exploring limited English proficiency Latina mothers’ experiences with, and expectations for, pediatric primary care. In partnership with a federally-qualified community health center in an urban Latino neighborhood, we conducted semi-structured interviews with 38 low-income Latina mothers. Eligible participants identified a pediatric primary care provider for their child and had at least one child 3 years old or younger, to increase the probability of frequent recent interactions with health care providers. Interview transcripts were coded and analyzed through an iterative and collaborative process to identify participants’ satisfaction with and expectations for pediatric primary care. About half of the mothers interviewed were satisfied with their primary care experiences. Mothers suggested many ways to improve the quality of pediatric primary care for their children to better meet the needs of their families. These included: encouraging providers to invest more in their relationship with families, providing reliable same-day sick care, expanding hours, improving access to language services, and improving care coordination services. Limited English proficiency Latina mothers expect high-quality pediatric primary care consistent with the medical home model. Current efforts to improve primary care quality through application of the medical home model are thus relevant to this population, but should focus on the parent-provider relationship and timely access to care. Promoting this model among practices that serve limited English proficiency Latino families could improve engagement and satisfaction with primary care.

Objectives. Peer review is used to make final judgments about quality of care in many quality assurance activities. To overcome the low reliability of peer review, discussion between several reviewers is often recommended to point out overlooked information or allow for reconsideration of opinions and thus improve reliability. The authors assessed the impact of discussion between 2 reviewers on the reliability of peer review. Methods. A group of 13 board-certified physicians completed a total of 741 structured implicit record reviews of 95 records for patients who experienced severe adverse events related to laboratory abnormalities while in the hospital (hypokalemia, hyperkalemia, renal failure, hyponatremia, and digoxin toxicity). They independently assessed the degree to which each adverse event was caused by medical care and the quality of the care leading up to the adverse event. Working in pairs, they then discussed differences of opinion, clarified factual discrepancies, and rerated the record. The authors compared the reliability of each measure before and after discussion, and between and within pairs of reviewers, using the intraclass correlation coefficient for continuous ratings and the kappa statistic for a dichotomized rating. Results. The assessment of whether the laboratory abnormality was iatrogenic had a reliability of 0.46 before discussion and 0.71 after discussion between paired reviewers, indicating considerably improved agreement between the members of a pair. However, across reviewer pairs, the reviewer reliability was 0.36 before discussion and 0.40 after discussion. Similarly, for the rating of overall quality of care, reliability of physician review went from 0.35 before discussion to 0.58 after discussion as assessed by pair. However, across pairs the reliability increased only from 0.14 to 0.17. Even for prediscussion ratings, reliability was substantially higher between 2 members of a pair than across pairs, suggesting that reviewers who work in pairs learn to be more consistent with each other even before discussion, but this consistency also did not improve overall reliability across pairs. Conclusions. When 2 physicians discuss a record that they are reviewing, it substantially improves the agreement between those 2 physicians. However, this improvement is illusory, as discussion does not improve the overall reliability as assessed by examining the reliability between physicians who were part of different discussions. This finding may also have implications with regard to how disagreements are resolved on consensus panels, guideline committees, and reviews of literature quality for meta-analyses.