John Billimek

Prevalence and Significance of Fluoroquinolone Resistant Escherichia coli in Patients Undergoing Transrectal Ultrasound Guided Prostate Needle Biopsy

PURPOSE We estimated the prevalence of fluoroquinolone resistant Escherichia coli in patients undergoing repeat transrectal ultrasound guided prostate needle biopsy and identified high risk groups. MATERIALS AND METHODS From January 2009 to March 2010 rectal swabs of 136 men from 3 institutions undergoing transrectal ultrasound guided prostate needle biopsy were obtained. There were 33 men with no previous biopsy who served as the controls. Participants completed questionnaires and rectal swab culture was obtained just before performing the prostate biopsy. Selective media was used to specifically isolate fluoroquinolone resistant E. coli and sensitivities were obtained. The patients were contacted via telephone 7 days after the procedure for a followup questionnaire. RESULTS A total of 30 patients had cultures positive for fluoroquinolone resistant bacteria for an overall rate of 22% (95% CI 15, 29). Patients with diabetes and Asian ethnicity had higher risks of resistant rectal flora colonization (OR 2.3 and 2.8, respectively). However, differences did not reach statistical significance (p = 0.09 and p = 0.08, respectively). Patients with no prior biopsy had a positive rate of 15% (5 of 33) compared to 24% (25 of 103) in those with 1 or more prior biopsies (OR 1.8, p = 0.27). Five patients (3.6%) had post-biopsy fever while only 1 of those patients had a positive rectal swab. CONCLUSIONS Using selective media to isolate fluoroquinolone resistant E. coli from the rectum before transrectal ultrasound guided prostate biopsy, we isolated organisms in 22% of patients with a wide resistance pattern. This protocol may be used to provide information regarding targeted antibiotic prophylaxis before transrectal prostate biopsies.

Underdiagnosed and Undertreated Depression Among Racially/Ethnically Diverse Patients With Type 2 Diabetes

OBJECTIVE To examine racial/ethnic differences in the prevalence of depressive symptoms and in provider recognition of depression among Latino, Asian, and non-Hispanic white patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Patients (n = 1,209) with type 2 diabetes were recruited from five university-affiliated primary care clinics for an observational study. RESULTS Vietnamese American (133, 59.4%) and Mexican American (351, 50.2%) patients were more likely to report symptoms consistent with clinical depression (Center for Epidemiological Studies Depression [CES-D] scale score ≥22) than non-Hispanic whites (119, 41.6%; F [2, 1206] = 8.05, P < 0.001). Despite comparable diabetes care, Vietnamese and Mexican patients with high depressive symptoms were less likely to be diagnosed and treated than non-Hispanic whites (all P values < 0.001). Minority patients who reported low levels of trust in their provider were less likely to have been diagnosed or treated for depression (adjusted odds ratio 0.65, 95% CI 0.44–0.98, P < 0.05). CONCLUSIONS Innovative strategies are needed to improve recognition of depressive symptoms in minority patients.

Estimating the Health Impacts of Tobacco Harm Reduction Policies: A Simulation Modeling Approach

With adult smoking prevalence rates declining too slowly to reach national objectives, opinion leaders are considering policies to improve tobacco-related outcomes by regulating the composition of cigarettes to be (1) less harmful and/or (2) less addictive. Because harm reduction efforts may actually encourage higher cigarette consumption by promoting a safer image, and addictiveness reduction may increase the harmfulness of cigarettes by encouraging compensatory smoking behaviors, policymakers must consider the tradeoffs between these two approaches when proposing legislation to control cigarette content. To estimate health impacts, we developed a dynamic computer model simulating changes in the age- and gender-specific smoking behaviors of the U.S. population over time. Secondary data for model parameters were obtained from publicly available sources. Population health impacts were measured as change in smoking prevalence and the change in cumulative quality-adjusted life-years (QALYs) in the U.S. population over 75 years. According to the risk-use threshold matrix generated by the simulation, modifying cigarettes to reduce their harmfulness and/or addictiveness could result in important gains to the nations health. Addictiveness reduction efforts producing a 60% improvement in smoking behavior change probabilities would produce a net gain in population health at every plausible level of increase of smoking-related harm that was modeled. A 40% reduction in smoking-related harm would produce a net QALY gain at every level of behavior change considered. This research should prove useful to policymakers as they contemplate giving the FDA the authority to regulate the composition of cigarettes.

Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes

BACKGROUNDFew studies have explored the association between neighborhood characteristics and adherence to diabetes self-management behaviors, and none have examined the influence of neighborhood safety on adherence to treatment regimens among patients with diabetes.OBJECTIVETo assess whether neighborhood safety is associated with self-reports of technical quality of care and with nonadherence to diabetes treatment regimens.DESIGNA cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression models were used to examine the association of self-reported neighborhood safety with technical quality of care and treatment nonadherence, adjusted for sociodemographic characteristics, barriers to access to care, and health status.PARTICIPANTSAdults with type 2 diabetes currently receiving medical treatment.MAIN MEASURESPatient-reported neighborhood safety, performance of recommended processes of care by provider, treatment nonadherence (patient delays in filling prescriptions and obtaining needed medical care).KEY RESULTSSelf-reported neighborhood safety was not associated with process measures of technical quality of care, but was associated with treatment nonadherence. Specifically, compared to those who report living in a safe neighborhood, a higher proportion of patients living in unsafe neighborhoods reported delays in filling a prescription for any reason (21.9% vs. 12.8%, aOR = 1.69, 95%CI 1.19, 2.40) and delays in filling a prescription due to cost (12.2% vs. 6.8%, aOR = 1.63, 95%CI 1.02, 2.62).CONCLUSIONSContextual factors, such as neighborhood safety, may contribute to treatment nonadherence in daily life, even when the technical quality of care delivered in the clinic is not diminished.

Dietary Behaviors of a Racially and Ethnically Diverse Sample of Overweight and Obese Californians

Objectives. To examine racial/ethnic differences in the dietary behaviors of overweight or obese adults using the 2007 California Health Interview Survey. Method. Data were obtained from the 2007 California Health Interview Survey, a population-based sample of noninstitutionalized adults in California. The sample included 26,721 adults aged 18 years and older whose body mass index status indicated that they were overweight or obese (body mass index ≥ 25), with 19,264 non-Hispanic White; 1,749 African American/Black; 1,616 Asian/Pacific Islander; and 4,092 Latino respondents. Respondents were compared with regard to consumption of five categories of food: fruits, vegetables, French fries, soft drinks, and fast-food. Multivariable regression analyses were conducted to examine racial/ethnic differences in dietary behaviors, with and without adjustment for age, gender, nativity, marital status, education, income, and food insecurity. Results. The findings suggested there were significant racial/ethnic differences in food preferences and that English proficiency, in part, explained some of these differences. Overweight/obese African American/Black respondents reported eating fruit (aBeta = −0.73, [95% confidence interval = −1.29, −0.17]) and vegetables (aBeta = −0.71 [−1.18, −0.24]) fewer times per day and fast-food (aBeta = 0.21, [0.04, 0.38]) more times per day compared with their non-Hispanic White counterparts. Irrespective of language proficiency, Asian/Pacific Islanders reported eating significantly less fruit compared with non-Hispanic Whites. Limited English proficient (LEP) Asian/Pacific Islanders were found to eat vegetables (aBeta = 1.41, [0.47, 2.63]) more times per day than non-Hispanic Whites, in contrast to English proficient Asian/Pacific Islanders who were found to eat vegetables (aBeta = −0.64, [−1.11, −0.18]) fewer times per day compared with non-Hispanic Whites. Both LEP and English proficient Latinos ate vegetables less often and drank soft drinks and ate fast-food more often than non-Hispanic Whites. Conclusions. Efforts to intervene with individuals who are overweight or obese must include culturally and linguistically tailored interventions that consider how individuals’ dietary behaviors are influenced by their racial/ethnic backgrounds.

Costs and beliefs: Understanding individual- and neighborhood-level correlates of medication nonadherence among Mexican Americans with type 2 diabetes.

OBJECTIVE High rates of medication nonadherence observed in disadvantaged populations are often attributed to socioeconomic factors. Little is known, however, about how a persons neighborhood environment may contribute to nonadherence beyond what can be explained by a lack of individual resources to pay for medications. This study considered the reasons patients reported for deviating from their medication regimens to understand how individual-level and neighborhood-level indicators of socioeconomic status (SES) may each influence adherence behavior. METHOD Cross-sectional data were collected between 2006 and 2011 from a sample of Mexican American patients with type 2 diabetes (N = 749) treated at university-affiliated clinics in Southern California. Measures included individual-level SES (years of education, health insurance type, and household income), neighborhood deprivation, and medication nonadherence (for reasons related to cost and reasons related to beliefs about medications). Neighborhood deprivation was assessed using the Neighborhood Socioeconomic Status Index (Dubowitz et al., 2011), a validated aggregate of census tract-level indicators linked to each participants home address. RESULTS RESULTS from multilevel logistic regression models revealed that individual-level SES was associated with nonadherence related to cost (annual household income <

Quantifying the Exposure to Antibiotic-Resistant Pathogens Among Patients Discharged From a Single Hospital Across All California Healthcare Facilities

20,000 vs. >

Effect of genetic subtypes and growth hormone treatment on bone mineral density in Prader-Willi syndrome.

40,000, p = .001; Medicare vs. commercial health insurance, p < .001), whereas neighborhood deprivation was associated with nonadherence related to beliefs about medications (p = .011). CONCLUSION Findings from this study suggest that an individuals lack of resources may contribute to nonadherence related to cost, whereas elements of the broader social environment may promote nonadherence related to negative beliefs about medications.

Patient complexity and risk factor control among multimorbid patients with type 2 diabetes: results from the R2D2C2 study.

OBJECTIVE To assess the time-dependent exposure of California healthcare facilities to patients harboring methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae, and Clostridium difficile infection (CDI) upon discharge from 1 hospital. METHODS Retrospective multiple-cohort study of adults discharged from 1 hospital in 2005-2009, counting hospitals, nursing homes, cities, and counties in which carriers were readmitted, and comparing the number and length of stay of readmissions and the number of distinct readmission facilities among carriers versus noncarriers. RESULTS We evaluated 45,772 inpatients including those with MRSA (N=1,198), VRE (N=547), ESBL (N=121), and CDI (N=300). Within 1 year of discharge, MRSA, VRE, and ESBL carriers exposed 137, 117, and 45 hospitals and 103, 83, and 37 nursing homes, generating 58,804, 33,486, and 15,508 total exposure-days, respectively. Within 90 days of discharge, CDI patients exposed 36 hospitals and 35 nursing homes, generating 7,318 total exposure-days. Compared with noncarriers, carriers had more readmissions to hospitals (MRSA:1.8 vs 0.9/patient; VRE: 2.6 vs 0.9; ESBL: 2.3 vs 0.9; CDI: 0.8 vs 0.4; all P<.001) and nursing homes (MRSA: 0.4 vs 0.1/patient; VRE: 0.7 vs 0.1; ESBL: 0.7 vs 0.1; CDI: 0.3 vs 0.1; all P<.001) and longer hospital readmissions (MRSA: 8.9 vs 7.3 days; VRE: 8.9 vs 7.4; ESBL: 9.6 vs 7.5; CDI: 12.3 vs 8.2; all P<.01). CONCLUSIONS Patients harboring antibiotic-resistant pathogens rapidly expose numerous facilities during readmissions; regional containment strategies are needed.

Differences in Self-Reported Physical Activity and Body Mass Index Among Older Hispanic and Non-Hispanic White Men and Women: Findings from the 2009 California Health Interview Survey

Abstract Background: Currently, there is limited information on the effects of growth hormone and of the different genetic subtypes on bone mineral density (BMD) in Prader-Willi syndrome (PWS). Methods: We evaluated BMD in 79 individuals with the common subtypes of PWS (48 with deletion and 27 with UPD) and the effect of growth hormone treatment (n=46) vs. no growth hormone treatment. Results: Forty-four percent of the individuals studied had whole body, hip, or spine BMD <–1 standard deviation (SD) and 10% had a BMD <–2 SD. BMD Z-scores and total BMD (g/cm2) of the spine were significantly higher in the growth hormone group. With each year of growth hormone treatment, these values increased by a factor of 0.207 and 0.011 (p=0.006 and 0.032), respectively. Individuals with uniparental disomy revealed higher spine BMD compared with deletion subclass; however, the differences were not significant. Conclusion: This study emphasizes the importance of evaluating bone mineralization in individuals with PWS and the beneficial effects of prolonged treatment with growth hormone. There was a trend for a higher BMD in individuals with uniparental disomy.