Reauthorization of the Indian Health Care Improvement Act

Purpose The purposes of this publication are to: 1) recognize and publicize outstanding examples of the application of managed care principles to direct care services in Indian health programs; 2) stimulate other innovative Indian Health Service (IHS) and tribal management efforts; and 3) demonstrate to others that IHS and tribal health programs have a commitment to managed care. Methods Experiences with managed care in Indian health programs are documented in this monograph. Specific program examples are provided from the following areas of the IHS: 1) Alaska Area; 2) Albuquerque Area; 3) Aberdeen Area; 4) Billings Area; 5) California Area; 6) Headquarters West; 7) Nashville Area; 8) Navajo Area; 9) Oklahoma City Area; and 10)Portland Area. Results The tools of managed care include utilization review, case management, provider contracting, and information technology. Applications of managed care principles reviewed in this monograph include: 1) pharmaceutical costs; 2) tribal program management; 3) mental health services; 4) telemedicine; 5) cancer screening services; 6) electronic clinical record; and 7) teleradiology. Conclusion Managed care flexibility provides a dynamic process for developing a cost-effective, high quality health care delivery system tailored to meet the very specific and unique needs of the American Indian and Alaska Native populations. The challenge to those involved in the delivery of health care to American Indians and Alaska Natives is to develop strategies to ensure the delivery of cost-effective, high quality health care

A Round Table Conference on Indian Adolescent Wellness in a Holistic Context- A Consensus Statement Final Report

This report summarizes the results of a meeting of experts in the area of Indian adolescent health and wellness. The group produced a consensus statement described in this final report. The Adolescent Health Roundtable participants refocused the mission of the roundtable from Adolescent Health to Adolescent Wellness. There was agreement among the participants that the term health is too often defined with statistics of morbidity and mortality indicating the absence of health. The group took the position that Indian adolescent wellness is much more than the disease and death statistics; the wellness of Indian adolescents is very much influenced by other aspects of family and community life.Understanding the historical, spiritual, and psychosocial factors affecting Indian adolescent wellness was the foundation for this Roundtable\\u27s consensus statements

City of Rockville bicycle master plan update : final report

116 p. Illustrations, Map

Regional differences in Indian health - 1997

This study (1) determined the present health status of the urban Indian population in the State of Arizona, and determined the extent of use and availability of all health resources for that population, (2) identified the health needs of the population and the barrier\\u27s that exist in addressing those needs, and (3) provided accurate and timely information that will serve as an objective base for decision making in addressing the identified needs and problems.A needs assessment approach was used with an overall framework represented by the model: Health Status (minus-) Health Resources Used (plus+) Barriers/Health Resources Not Used (equals=) Health Needs. The study also incorporated the PRECEDE model developed by Lawrence Green of the University of Texas and the Needs Assessment for Prevention Planning developed by the Alcohol, Drug Abuse and Mental Health Administration of the PHS. The study used data compiled on the Phoenix Service Unit for Phoenix and the Pima County urban census tract mortality data for Tucson. Interview data and other sources were also used.The health status of urban Indians in Arizona is poor, and three of the six major causes of death - accidents, alcoholism, homicide - are complex problems with which medical technology has had little success. Heart disease, cancer and diabetes, the other leading causes of death are chronic conditions requiring long-term health monitoring. Urban Indian reported high prevalence of vision problems (40.5%), overweight (37.3%), dental (30.7%), and back problems (21.7%). Mental health problems affected many in the Indian community - 14.5% reported anxiety and depression and 13.5% reported fatigue and exhaustion. Infant mortality rates for urban Indians are well above the rate of the Arizona general population and the overall Arizona Indian population. The urban Indian infant mortality rate exceeds the 1990 U.S. Surgeon General\\u27s Objective for the nation by 60%. Health risk factor levels are high among the Arizona urban Indian community. High blood pressure readings in the Indian males combined with the low numbers taking blood pressure medication point to the importance of screening and follow-up for heart health risks. Levels of obesity, binge drinking and diabetes are also elevated within the urban Indian community in Arizona. Other health risks of urban Indians include high driving speeds, driving while intoxicated, and sedentary life-styles. The major source of health care for urban Indians is the IHS. Other sources such as county medical facilities, community health centers, and private providers are rarely used. Over 40% of the urban Indian community went to the emergency room for health care during 1988. However, many of these visits represent inappropriate use of the emergency facilities. Social services in the metropolitan areas are under-utilized by the Indian community. Indian-specific programs with the exception of alcohol-related services and Women, Infants, and Children (WIC) nutrition services are not available. Both WIC and the alcohol-related programs are among the few used by the Indian community, indicating that services geared toward Indian people will have greater utilization than those not culturally specific. American Indians living in urban areas with limited access to phones and transportation are best reached by the word-of-mouth about services. American Indian staff in urban health programs, particularly the Community Health Representatives, provide an important link to the urban Indian community. They are able to outreach through their work in both homes and community health. They can follow the movement of clients through their family and friends within the community. Most of the urban health programs provide transportation services that enable urban Indians to access services they would otherwise forego. Barriers to care were identified in the categories of socioeconomic factors, lack of health insurance, complexity of Medicaid program requirements, limited availability of services for low-income Indians in urban areas, and limited accessibility and acceptability of services for urban Indians. The combination of poor health status, underutilization of services, and numerous barriers to services leave the urban Indian community with service requirements for medical items, prescriptions, emergency care, pediatric care, and overnight hospital stays. In addition, culturally sensitive mental health programs are needed based on the high prevalence of anxiety, depression, and exhaustion within the community. There is a critical need for basic preventive, family-centered medical services, and for comprehensive perinatal care. Because of the high number of young children, there is a great need for well-child clinics focusing on preventive medicine. Clinics providing culturally-specific services need to be incorporated into the health plan for the urban Indian community. Low-cost ambulatory clinic facilities with eye and dental care are needed. Prevention programs targeting diabetes, alcohol and drug abuse, sexually transmitted diseases, violence, and accidental injuries should be established to assuage the high costs of such conditions among urban Indian communities in Arizona. Transition programs for new residents in each urban area would help bring Indians into the service stream and avoid the downward spiral into despairing poverty. Indian-specific mental health services are needed to deal with the high rate of homicide and suicide among Indian youth, the high rates of alcohol and substance abuse, and reported mental health problems. In policy terms, there is a need for a Medicaid education program and a coalition of efforts among the tribes, IHS, state, and private agencies. Arizona should be addressed as a contract care state since legislation has been already passed; but no funding has been allocated to carry out the legislation. The role of the Phoenix Indian Medical Center needs to the clarified to establish whether it functions as a referral hospital (as originally intended) or as an outpatient clinic (as it is currently utilized but without adequate resources). The IHS needs to explore the feasibility of shared service in Arizona between urban Indian health care delivery programs and local service units. Full-time urban Indian positions at the state and federal levels need to be established

IHS Capital Financing and Health Care Reform

This document is the primary publication of a 1984-1986 management review of the Indian Health Service (IHS)-sponsored alcohol programs serving American Indians and Alaska Natives. The IHS Alcoholism/Substance Abuse Prevention Initiative: Background, Plenary Session, and Action Plan is the manifesto of the alcohol/substance abuse programs for the future. The overall purposes of the review were: 1) to define the scope of alcohol treatment and prevention efforts at all levels; 2) to identify existing program strengths; 3) to identify unique approaches to be considered for broader application; 4) to identify deficiencies; 5) to set forth the actual steps to remedy the deficiencies; and 6) to make recommendations for the mission and future direction of the IHS and alcoholism program efforts. The Background section is designed to expose the trends and issues affecting the alcoholism programs prior to 1984. The Plenary Session documents the proceedings of the second stage of the alcoholism programs management review. The Action Plan is a presentation of the recommendations developed by the contributors in the plenary session. The Action Plan was designed to address all of the relevant managerial functions, including planning, standards setting, monitoring, evaluation, resource management, operations, coordination, research, and training. The complete document provides the rationale, structures, and strategies necessary to chart a new direction that will demand enhancement of treatment program effectiveness and a realignment of resources in response to advancements in institutional knowledge and experience.This document comprises the published results of a management review of the IHS alcoholism programs that was requested by the Director of the IHS, Everett R. Rhodes, M.D., and initiated in the summer of 1984. Participants in this comprehensive program review included: 1) tribal leader representatives from each area; 2) alcohol program representatives from each area or program office; 3) IHS area alcoholism coordinators; 4) IHS line and staff officials; 5) individuals knowledgeable in the field of alcohol/substance abuse but not directly connected to IHS or tribal programs; and 6) 30 individuals from the outside who expressed interest in contributing to the process. The three major tasks of the reviewers were to: 1) develop a briefing book; 2) complete a plenary session with a set of recommendations; and 3) develop and gain the approval for an action plan based upon the recommendations coming out of the plenary session.The Director, IHS, asserted that many IHS physical plants were currently inappropriate for providing alcohol services. He concluded that these problems are solvable. In addition, he called for better horizontal and vertical communications between and within the IHS health care system and the alcohol programs. Various IHS staff, substance abuse program professionals, Federal officials, researchers, and academicians contributed their perspectives on the future direction of alcohol prevention and treatment efforts in the American Indian community. Highlights of these perspectives included: 1) community-based programs and coordination with other agencies; 2) the need for both residential and outpatient treatment services; 3) tribal leadership involvement in the recognition of alcohol as a problem; 4) good professional education for IHS doctors and nurses; 5) the importance of standardized recordkeeping for the purposes of comparison and evaluation; 6) the use of traditional healers; 7) the need to provide incentives for those programs that excel, and the continued support for those that do not function well or at all; 8) the emphasis on culture to the success and failure of different programs; 8) identification of generalizable attributes associated with the success of alcoholism prevention efforts among American Indians; and 9) the view of alcoholism as a psychosocial medical disease requiring an holistic approach to treatment.The Action Plan was developed with the assistance of the information disseminated during the Plenary Session. Specific activities, and a specific timeline for their implementation, were itemized for all nine essential management functions (listed above). Specific recommendations focused on managing scarce resources, finding additional resources, focusing on prevention, targeting youth and women for prevention activities, improving training for IHS professionals and staff to incorporate a clear understanding of alcoholism as a disease and to heighten cultural awareness. A management information system was initiated as a result of this review, and research priorities were established. Also, a plan was outlined to facilitate the monitoring of programs, and establishing a system for supporting the demands of the evaluation process. A persistent recommendation appearing throughout the review was the need to bring tribal governments into all facets of IHS involvement in alcoholism treatment and prevention, and to find ways to further involve Congressional delegates in the process

Affinity Purification of Biologically Active andInactive Forms of Recombinant Human Protein C Produced in Porcine Mammary Gland

Recombinant human protein C (rhPC) secreted in the milk of transgenic pigs was studied. \u27Ikansgenes having different regulatory elements of the murine milk protein, whey acidic protein, were used with cDNA and genomic human protein C (hPC) DNA sequences to obtain lower and higher expressing animals. The cDNA pigs had a range of expression of about 0.1-0.5 g/l milk. Two different genomic hPC pig lines have expressed 0.3 and 1-2 g/l, respectively. The rhPC was first purified at yields greater than 60 per cent using a monoclonal antibody (mAb) to the activation site on the heavy chain of hPC. Subsequent immunopurification with a calcium-dependent mAb directed to the y-carboxyglutamic acid domain of the light chain of hPC was used to fractionate a population having a higher specific anticoagulant activity in vW. The higher percentages of Ca2+-dependent conformers isolated from the total rhPC by immunopurification correlated well with higher specific activity and lower expression. A rate limitation in y-carboxylation of rhPC was clearly identified for the higher expressing animals. Thus, transgenic animals with high expression levels of complex recombinant proteins produced a lower percentage of biologically active protein

Neutralizing antibody vaccine for pandemic and pre-emergent coronaviruses

Betacoronaviruses (betaCoVs) caused the severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, and the SARS-CoV-2 pandemic1–4. Vaccines that elicit protective immunity against SARS-CoV-2 and betaCoVs circulating in animals have the potential to prevent future betaCoV pandemics. Here, we show that macaque immunization with a multimeric SARS-CoV-2 receptor binding domain (RBD) nanoparticle adjuvanted with 3M-052/Alum elicited cross-neutralizing antibody (cross-nAb) responses against batCoVs, SARS-CoV-1, SARS-CoV-2, and SARS-CoV-2 variants B.1.1.7, P.1, and B.1.351. Nanoparticle vaccination resulted in a SARS-CoV-2 reciprocal geometric mean neutralization ID50 titer of 47,216, and protection against SARS-CoV-2 in macaque upper and lower respiratory tracts. Importantly, nucleoside-modified mRNA encoding a stabilized transmembrane spike or monomeric RBD also induced SARS-CoV-1 and batCoV cross-nAbs, albeit at lower titers. These results demonstrate current mRNA vaccines may provide some protection from future zoonotic betaCoV outbreaks, and provide a platform for further development of pan-betaCoV vaccines

Effectiveness of screening preschool children for amblyopia: a systematic review

<p>Abstract</p> <p>Background</p> <p>Amblyopia and amblyogenic factors like strabismus and refractive errors are the most common vision disorders in children. Although different studies suggest that preschool vision screening is associated with a reduced prevalence rate of amblyopia, the value of these programmes is the subject of a continuing scientific and health policy discussion. Therefore, this systematic review focuses on the question of whether screening for amblyopia in children up to the age of six years leads to better vision outcomes.</p> <p>Methods</p> <p>Ten bibliographic databases were searched for randomised controlled trials, non-randomised controlled trials and cohort studies with no limitations to a specific year of publication and language. The searches were supplemented by handsearching the bibliographies of included studies and reviews to identify articles not captured through our main search strategy.</p> <p>Results</p> <p>Five studies met the inclusion criteria. Of these, three studies suggested that screening is associated with an absolute reduction in the prevalence of amblyopia between 0.9% and 1.6% (relative reduction: between 45% and 62%). However, the studies showed weaknesses, limiting the validity and reliability of their findings. The main limitation was that studies with significant results considered only a proportion of the originally recruited children in their analysis. On the other hand, retrospective sample size calculation indicated that the power based on the cohort size was not sufficient to detect small changes between the groups. Outcome parameters such as quality of life or adverse effects of screening have not been adequately investigated in the literature currently available.</p> <p>Conclusion</p> <p>Population based preschool vision screening programmes cannot be sufficiently assessed by the literature currently available. However, it is most likely that the present systematic review contains the most detailed description of the main limitations in current available literature evaluating these programmes. Therefore, future research work should be guided by the findings of this publication.</p

Allelic Heterogeneity at the CRP Locus Identified by Whole-Genome Sequencing in Multi-ancestry Cohorts

Whole-genome sequencing (WGS) can improve assessment of low-frequency and rare variants, particularly in non-European populations that have been underrepresented in existing genomic studies. The genetic determinants of C-reactive protein (CRP), a biomarker of chronic inflammation, have been extensively studied, with existing genome-wide association studies (GWASs) conducted in >200,000 individuals of European ancestry. In order to discover novel loci associated with CRP levels, we examined a multi-ancestry population (n = 23,279) with WGS (∼38× coverage) from the Trans-Omics for Precision Medicine (TOPMed) program. We found evidence for eight distinct associations at the CRP locus, including two variants that have not been identified previously (rs11265259 and rs181704186), both of which are non-coding and more common in individuals of African ancestry (∼10% and ∼1% minor allele frequency, respectively, and rare or monomorphic in 1000 Genomes populations of East Asian, South Asian, and European ancestry). We show that the minor (G) allele of rs181704186 is associated with lower CRP levels and decreased transcriptional activity and protein binding in vitro, providing a plausible molecular mechanism for this African ancestry-specific signal. The individuals homozygous for rs181704186-G have a mean CRP level of 0.23 mg/L, in contrast to individuals heterozygous for rs181704186 with mean CRP of 2.97 mg/L and major allele homozygotes with mean CRP of 4.11 mg/L. This study demonstrates the utility of WGS in multi-ethnic populations to drive discovery of complex trait associations of large effect and to identify functional alleles in noncoding regulatory regions