George D. Harris

Predictors of Three Dose On-Time Compliance with HPV4 Vaccination in a Disadvantaged, Underserved, Safety Net Population in the US Midwest

Background HPV4 is approved as a series of three timed doses expected to result in efficacy against specific HPV infections. Completion rates in the US are quite low at the same time the structure of health care delivery is changing. The aim of this study was to determine how the patient-, clinic- and systems-level characteristics facilitate or hinder the timely completion of three HPV4 doses in both adolescent and adult female populations in a high-risk safety net population. Methods This is a retrospective study in which patient-, clinic- and systems-level data are abstracted from the electronic medical record (EMR) for all females 10–26 years of age receiving at least one dose of HPV4 between July 1, 2006 and October 1, 2009. Results Adults were more likely to complete the three dose series if they had at least one health care visit in addition to their HPV4 visit, (aOR = 1.54 (95% CI:1.10, 2.15). Adults were less likely to complete the three dose series if they received their second HPV4 dose at an acute health care, preventive care or postpartum visits compared to an HPV4-only visit (aOR = 0.31 (95% CI: 0.13, 0.72), 0.12 (0.04, 0.35), 0.30 (0.14, 0.62), respectively). Hispanic adults were less likely than whites to complete the series (aOR = 0.24 (95% CI:0.10, 0.59). 39% of adolescents who completed two doses completed the series. Conclusions HPV4 is more likely to be effectively administered to adults in a safety net population if multiple health care needs can be met within the health care system.

Attention deficit hyperactivity disorder and athletes

Context: Attention deficit hyperactivity disorder (ADHD) is common in the general population, and many individuals with this condition participate in sports activity at all competition levels. Evidence Acquisition: Related studies were selected through literature searches of PubMed, MEDLINE, and Cochrane databases for the years 1991 to 2011. Key search terms were ADD, ADHD, sports, athletes, athletics, guidelines, NCAA, WADA, IOC, college, concussion, diagnosis, management, treatment, evaluation, return-to-play, pharmacotherapy, adult, adolescent, student, screening, injury, risk, neuropsychiatry, TBI, traumatic brain injury, and epidemiology. Study Design: Literature review. Level of Evidence: Level 4. Results: ADHD usually has an early onset, with delayed diagnosis in some patients due to heterogeneous presentations. Suspected cases can be evaluated with available diagnostic tools and confirmed clinically. Athletes with ADHD may participate at all competition levels. Conclusion: Athletes with ADHD are able to participate at all competition levels by following published guidelines and requirements. Exercise benefits many athletes with ADHD. The relationship between ADHD and concussion syndromes is currently under investigation.

The influence of free quadrivalent human papillomavirus vaccine (HPV4) on the timely completion of the three dose series

OBJECTIVE Economic incentives can positively influence social determinants to improve the health care of the uninsured and underserved populations. The aim of this study was to determine if free HPV4 vaccine would lead to on-time series completion in our safety net health care system in the US Midwest. METHODS A nested retrospective cohort study of females receiving HPV4 vaccine between 2006 and 2009 was conducted. Patient characteristics and payor source for each of the three HPV4 doses were abstracted from electronic records. Logistic regression was used to predict on-time completion rates. RESULTS The proportion of adolescent and adult females completing three on-time HPV4 doses was equal (21% (28/136) vs. 18% (66/358), respectively) from among the 494 females receiving 927 HPV4 doses in this study. No adolescent receiving free HPV4 vaccine completed three doses. Grant sponsorship of at least one HPV4 dose among adults did not predict three dose on-time completion (OR=1.56, 95%CI: 0.80, 3.06). Neither was adult grant sponsorship of HPV4 significant when analyzing exclusive payor sources vs. a combination of payor sources (OR=0.72, 95%CI: 0.10, 5.17). CONCLUSIONS Free HPV4 vaccine does not influence the on-time completion rates among adults.

3q26 Amplification Is an Effective Negative Triage Test for LSIL: A Historical Prospective Study

Background Women with low grade squamous intraepithelial lesions (LSIL) at cervical cancer screening are currently referred for further diagnostic work up despite 80% having no precancerous lesion. The primary purpose of this study is to measure the test characteristics of 3q26 chromosome gain (3q26 gain) as a host marker of carcinogenesis in women with LSIL. A negative triage test may allow these women to be followed by cytology alone without immediate referral to colposcopy. Methods and Findings A historical prospective study was designed to measure 3q26 gain from the archived liquid cytology specimens diagnosed as LSIL among women attending colposcopy between 2007 and 2009. 3q26 gain was assessed on the index liquid sample; and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were measured at immediate triage and at 6–16 months after colposcopic biopsy. The sensitivity of 3q26 gain measured at immediate triage from automated and manually reviewed tests in 65 non-pregnant unique women was 70% (95% CI: 35, 93) with a NPV of 89% (95% CI: 78, 96). The sensitivity and NPV increased to 80% (95% CI: 28, 99) and 98% (95% CI: 87, 100), respectively, when only the automated method of detecting 3q26 gain was used. Conclusions 3q26 gain demonstrates high sensitivity and NPV as a negative triage test for women with LSIL, allowing possible guideline changes to routine surveillance instead of immediate colposcopy. Prospective studies are ongoing to establish the sensitivity, specificity, PPV and NPV of 3q26 gain for LSIL over time.

Diabetes in the Competitive Athlete

Diabetes mellitus is the most common group of metabolic diseases and is characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Most patients with diabetes are type 2 (90%); the remaining patients have type 1 disease. Athletes with diabetes range from the athlete participating in various youth sports to the competitive Olympic athlete and present a significant challenge to themselves and the medical staff who care for them on a daily basis. Each sport and the type of exercise have their own effects on diabetes management with numerous factors that significantly affect glucose levels, including stress, level of hydration, the rate of glycogenolysis and gluconeogenesis, and the secretion of counter-regulatory hormones. This article provides a general overview of diabetes mellitus, the effects of exercise on glucose levels, and a detailed review of the potential complications encountered in the management of diabetes in the athlete.

In a Safety Net Population HPV4 Vaccine Adherence Worsens as BMI Increases

Objectives Obesity adversely inhibits antibody response to vaccination. Three doses of HPV4 may or may not provide adequate long term protection against HPV 16/18 in obese females. The aim of this study was to determine whether adherence to HPV4 vaccination in a safety net population was reduced with increasing body mass index (BMI). Methods We designed a historical prospective study evaluating the number and dates of HPV4 dosing that occurred from July 1, 2006 through October 1, 2009 by the demographic characteristics of the 10–26 year old recipient females. The defined dosing intervals were adapted from the literature and obesity categories were defined by the WHO. Results 1240 females with BMI measurements received at least one dose of HPV4; 38% were obese (class I, II and III) and 25% were overweight. Females with normal BMI received on-time triplet dosing significantly more often than did the obese class II and III females (30% vs. 18%, p<0.001). Obese class II/III females have a significant 45% less chance of completing the on-time triplet HPV4 series than normal women (OR = 0.55, 95% CI: 0.37, 0.83). Pregnancy history has a significant influence on BMI and HPV4 dosing compliance in this safety net population where 71% had been gravid. Hispanic females were less likely to complete HPV4 dosing regardless of BMI (aOR = 0.39, 95% CI: 0.16, 0.95). Conclusions Obesity, as well as gravidity and Hispanic race, are risk factors for lack of HPV4 vaccine adherence among young females in a safety net population.

Urban and Rural Safety Net Health Care System Clinics: No Disparity in HPV4 Vaccine Completion Rates

Objective Safety net health care centers in the US serve vulnerable and underinsured females. The primary aim of this work was to determine if HPV4 dosing compliance differs between females who receive doses at rural vs. urban core safety net health care locations. Methods Females exclusively receiving health care in the Truman Medical Center (TMC) safety net system at the urban core and rural locations were identified by their HPV4 vaccine records. Dates and number of HPV4 doses as well as age, gravidity, parity and race/ethnicity were recorded from the electronic medical record (EMR). Appropriate HPV4 dosing intervals were referenced from the literature. Results 1259 females, 10–26 years of age, received HPV4 vaccination at either the rural (23%) or urban core location (77%). At the rural location, 23% received three doses on time, equal to the 24% at the urban core. Females seen in the urban core were more likely to receive on-time doublet dosing than on-time triplet dosing (82% vs. 67%, p<0.001). Mistimed doses occurred equally often among females receiving only two doses, as well as those receiving three doses. Conclusions Compliance with on-time HPV4 triplet dose completion was low at rural and urban core safety net health clinics, but did not differ by location.

Performance of the Exercise Test

Each year, over 1 million Americans experience a nonfatal or fatal myocardial infarction or sudden death from coronary heart disease (CHD) [1]. Unfortunately, death or myocardial infarction is the first symptom in 55% of patients with coronary artery disease [2] and is usually due to dislodgement of a plaque causing acute coronary occlusion. However, about 30% of these patients present with ischemia and have concurrent chest pain. In these individuals, exercise treadmill testing is a practical and the most commonly performed test to identify or confirm the presence of latent coronary artery disease [2]. In addition, an abnormal test has been shown to have definite predictive value. It is well known that when symptoms of typical angina are present, coronary disease can be predicted with considerable reliability. Even when there is no history of pain, there is still a strong possibility of significant coronary disease in patients with specific risk factors. Also, the reliability of the test in asymptomatic patients is improved when testing patients with a higher prevalence of the disease. Exercise testing may also be used to measure functional capacity, assess the patient’s prognosis in coronary artery disease, and evaluate the patient’s treatment for hypertension, certain arrhythmias, angina, and congestive heart failure. It can be beneficial for patients who will be involved in exercise rehabilitative programs. It may be useful for predicting mortality risk among patients who plan to start an exercise program, whose job affects public safety (airline pilot), or who have specific medical conditions (diabetes or chronic renal insufficiency). The inherent accuracy of the test is defined by the sensitivity and specificity. The results of the test when applied to an individual depend on the prevalence of disease in the population to which the patient belongs. So, the two most important factors in the analysis of patients undergoing stress testing are the pre-test prevalence of disease and the sensitivity and specificity of the test. Various types of chest pain affect the probability of disease in each patient. By dividing the patients into one