Winners and Losers in the Debate Over the Expansion of Medicare

Over its nearly sixty years, Medicare’s reach in terms of beneficiary groups and benefits has remained surprisingly stable, not for lack of attempts at expansion. This essay considers several of the most ambitious attempts at Medicare expansion, including adding benefits for prescription drugs, long-term care, and vision, dental, and hearing care. Some failures and some successful, these efforts considered in conjunction illuminate Medicare’s changing identity, drifting gradually yet fundamentally from its social insurance roots. Understanding the winners and losers in the debates over Medicare expansion reveals the changing political economy and collective understanding of Medicare as a cornerstone of the welfare state

Spatial analysis of learning and developmental disorders in upper Cape Cod, Massachusetts using generalized additive models

The spatial variability of three indicators of learning and developmental disability (LDD) was assessed for Cape Cod, Massachusetts. Maternal reports of receiving special education services, attention deficit hyperactivity disorder, and educational attainment were available for a birth cohort from 1969-1983. Using generalized additive models and residential history, maps of the odds of LDD were produced that also controlled for known risk factors. While results were not statistically significant, they suggest that children living in certain parts of Cape Cod were more likely to have a LDD. The spatial variation may be due to variation in the physical and social environment

Thyroid Doses and Risk of Thyroid Cancer from Exposure to I-131 from the Nevada Test Site

This report provides a set of look-up tables of representative thyroid doses and risks of thyroid cancer for individuals exposed to I-131 in fallout from nuclear weapons testing at the Nevada Test Site. These tables are intended to be used by people who do not have access to a computer. The look-up tables contain estimates of doses and risks for eight representative birth cohorts and sixty-seven locations in eight regions around the continental United States. They were obtained using a slightly modified version of the NCI’s online dose and risk calculator for exposures to I-131 in NTS fallout. The look-up tables provided here do not cover all possible exposure situations, but they can be used to estimate the general magnitude of a person’s thyroid dose and risk of thyroid cancer from NTS fallout according to birth cohort, gender, given residence history, and given amount and type of milk consumed. This research was completed money allocated during Round 2 of the Citizens’ Monitoring and Technical Assessment Fund (MTA Fund). Clark University was named conservator of these works. If you have any questions or concerns please contact us at [email protected]://commons.clarku.edu/radiochem/1000/thumbnail.jp

Community- and Individual-Level Socioeconomic Status and Breast Cancer Risk: Multilevel Modeling on Cape Cod, Massachusetts

BACKGROUND. Previous research demonstrated increased risk of breast cancer associated with higher socioeconomic status (SES) measured at both the individual and community levels. However, little attention has been paid to simultaneously examining both measures. OBJECTIVES. We evaluated the independent influences of individual and community SES on the risk of breast cancer using case-control data. Because our previous work suggests that associations may be stronger after including a latency period, we also assessed the effect of community-level SES assuming a 10-year latency period. METHODS. We obtained individual education for cases and matched controls diagnosed between 1987 and 1993 on Cape Cod, Massachusetts (USA). We acquired community-level SES from census data for 1980 and 1990. Using SES data at diagnosis and 10 years earlier, we constructed models for breast cancer risk using individual-level SES only, community-level SES only, and a multilevel analysis including both. We adjusted models for other individual-level risk factors. RESULTS. Women with the highest education were at greater risk of developing breast cancer in both 1980 and 1990 [odds ratio (OR) = 1.17 and 1.19, respectively]. Similarly, women living in the highest-SES communities in 1990 had greater risk (OR = 1.30). Results were stronger in the analyses considering a latency period (OR = 1.69). Adjusting for intragroup correlation had little effect on the analyses. CONCLUSIONS. Models including individual- or community-level measures of SES produced associations similar to those observed in previous research. Results for models including both measures are consistent with a contextual effect of SES on risk of breast cancer independent of individual SES.Boston University Center for Interdisciplinary Research in Environmental Exposures and Health; National Institute of Environmental Health (P42ES007381

Four Kinds of Hard: An Understanding of Cancer and Death among Latino Community Leaders

Early integration of palliative care after a diagnosis of cancer improves outcomes, yet such care for Latino populations is lacking in rural regions of the United States. We used a participatory action research design with Latino community leaders from emerging immigrant communities in North Carolina to explore sociocultural perspectives on cancer and death. Thematic analysis was conceptualized as Four Kinds of Hard represented by four themes: Receiving an Eviction Notice, Getting in the Good Book, Talking is (Sometimes) Taboo, and Seeing Their Pain Makes us Suffer. These themes captured fears of deportation, coping with cancer through faithfulness, ambivalence about advance care planning, and a desire to spare families from suffering. Findings suggest strategies to improve conversations about end-of-life wishes when facing advanced illness and death. This study demonstrates the importance of training Latino community leaders to improve palliative care and bridge service gaps for Latino families living in emerging rural communities.OA publication support through Carolina Consortium agreement with Sag

Sustained Sexual Behavior Change after Acute HIV Diagnosis in Malawi

Background Identification of acute HIV infection (AHI) allows for important opportunities for HIV prevention through behavior change and biomedical intervention. Here, we evaluate changes in sexual risk behaviors among persons with AHI enrolled in a combined behavioral and biomedical intervention designed to reduce onward transmission of HIV. Methods Participants were randomized to standard HIV counseling, a multisession behavioral intervention, or a multisession behavioral intervention plus antiretrovirals. Sexual behaviors were assessed periodically over 1 year. Results Four weeks after diagnosis, the predicted probability of reporting multiple sexual partners decreased from 24% to 9%, and the probability of reporting unprotected sex decreased from 71% to 27%. These declines in sexual risk behaviors were sustained over follow-up irrespective of study arm. Conclusions Diagnosis of AHI alone may be sufficient to achieve immediate and sustained behavior change during this highly infectious period

Human Immunodeficiency Virus (HIV)-1 Transmission among Persons with Acute HIV-1 Infection in Malawi: Demographic, Behavioral, and Phylogenetic Relationships

Background: Understanding sexual networks involving acute human immunodeficiency virus (HIV)-1 infections (AHI) may lead to prevention opportunities to mitigate high rates of onward transmission. We evaluated HIV-1 phylogenetic and behavioral characteristics among persons with AHI and their referred partners. Methods: Between 2012 and 2014, 46 persons with AHI in Malawi participated in a combined behavioral and biomedical intervention. Participants referred sexual partners by passive referral. Demographics and sexual behaviors were collected through interviews and HIV-1 genetic relationships were assessed with phylogenetics. Results: Among 45 AHI participants with HIV-1 sequences, none was phylogenetically-linked with another AHI index. There were 19 (42%) AHI participants who referred a single partner that returned for testing. Most partners (n = 17) were HIV-infected, with 15 (88%) presenting with an established infection. There were 14 index-partner pairs that had sequences available; 13 (93%) pairs were phylogenetically-linked dyads. The AHI index was female in 7/13 (54%) dyads. Age-disparate relationships among dyads were common (≥5-year age difference in 67% of dyads), including 3/6 dyads involving a male index and a younger woman. Index participants with a referred partner were more likely to report no casual partners and to be living with their current partner than participants not in dyads. Conclusions: Passive-partner referral successfully identified partners with genetically-similar HIV infections - the likely source of infection - but only 40% of index cases referred partners who presented for HIV-1 testing. Future work evaluating assisted partner notification may help reach susceptible partners or more people with untreated HIV-1 infections connected to acute transmission. Clinical Trials Registration: NCT01450189

Randomized Controlled Pilot Study of Antiretrovirals and a Behavioral Intervention for Persons with Acute HIV Infection: Opportunity for Interrupting Transmission

Background. Persons with acute HIV infection (AHI) have heightened transmission risk. We evaluated potential transmission reduction using behavioral and biomedical interventions in a randomized controlled pilot study in Malawi. Methods. Persons were randomized 1:2:2 to standard counseling (SC), 5-session behavioral intervention (BI), or behavioral intervention plus 12 weeks of antiretrovirals (ARVs; BIA). All were followed for 26-52 weeks and, regardless of arm, referred for treatment according to Malawi-ARV guidelines. Participants were asked to refer partners for testing. Results. Among 46 persons (9 SC, 18 BI, 19 BIA), the average age was 28; 61% were male. The median viral load (VL) was 5.9 log copies/mL at enrollment. 67% (10/15) of BIA participants were suppressed (<1000 copies/mL) at week 12 vs 25% BI and 50% SC (P = .07). Although the mean number of reported condomless sexual acts in the past week decreased from baseline across all arms (1.5 vs 0.3 acts), 36% experienced incident sexually transmitted infection by 52 weeks (12% SC, 28% BI, 18% BIA). Forty-one percent (19/46) of participants referred partners (44% SC, 44% BI, 37% BIA); 15 of the partners were HIV-infected. Conclusions. Diagnosis of AHI facilitates behavioral and biomedical risk reduction strategies during a high-transmission period that begins years before people are typically identified and started on ARVs. Sexually transmitted infection incidence in this cohort suggests ongoing risk behaviors, reinforcing the importance of early intervention with ARVs to reduce transmission. Early diagnosis coupled with standard AHI counseling and early ARV referral quickly suppresses viremia, may effectively change behavior, and could have tremendous public health benefit in reducing onward transmission

Deep-Sea Fishes of the Mid-Atlantic Ridge: Trophic Structure and Interactions

Because deep-sea fisheries are increasing as coastal fisheries decline, fisheries scientists need baseline data on deep-sea ecosystems prior to further development of deep-water fisheries. We present preliminary results and ongoing efforts to characterize the trophic structure and energy flow of the pelagic ecosystems of the northern Mid-Atlantic Ridge, from Iceland to the Azores. This study is one component of the international CoML field project MAR-ECO (www.mar-eco.no). We found a diverse deep-pelagic fish fauna (205 spp.), with unexpectedly high bathypelagic fish biomass and spatial complexity. Based on literature reports of species present, crustacean planktivory is the dominant trophic guild (79% of individuals 47% of species), primarily within the mesopelagial. Gelativory was second (12% ind., 4% spp.), primarily within the bathypelagial. Omnivory (3%, 13%), shrimpivory (2%, 4%), and piscivory (1%, 21%) were the remaining major feeding guilds. The diets of 22 spp., primarily bathypelagic, are unknown. Based on stable isotope analysis of fish tissue, two distinct trophic modes were identified: a mode at trophic level 4 (18%; crustacean and gelatinous planktivory) and a mode at trophic level 4.5-5.0 (58%; crustacean planktivory and piscivory). The top piscivores were bathypelagic fishes. In terms of fish biomass, the gelativorous taxa dominated, followed by crustacean zooplanktivores and piscivores. Quantitative comparisons of the different trophic pathways are not possible at present, given our limited knowledge of feeding rates of most species. However, microscopical and molecular analyses are currently ongoing to fill this void, including development of techniques to identify/quantify gelatinous prey as an alternate trophic pathway