The Cash Dividend Garcia, Marito; Moore, Charity M. T
2012, 2011, 02-21-2012, 20120101
eBook, Book
Open access
The Cash Dividend: The Rise of Cash Transfer Programs in Sub-Saharan Africa assimilates results of a thorough review of the recent use of cash transfer programs in Sub-Saharan Africa. Drawing from ...sources including program documentation, policy papers, peer-reviewed publications, and interviews, it paints a picture of the evolution and current state of cash transfers, which include unconditional and conditional cash transfers and emergency- and development-focused transfers. It presents analysis from data collected and describes broad trends in design features and implementation, including objectives, targeting, benefits, payment mechanisms, conditions, monitoring, evaluation, institutional location, program costs, and more. It also addresses political economy issues relevant to cash transfer programs, discusses the challenges to implementing cash transfer programs in Sub-Saharan Africa, and highlights lessons learned from existing African cash transfer programs. The comprehensive nature of the review, and its thorough analysis of previously unassimilated data, fills a gap in knowledge related to cash transfer programs in the region. The book is expected to benefit the donor community and domestic policymakers involved in cash transfers in Sub-Saharan Africa, guiding both program design and future research. It will help shift the debate on cash transfers in Africa from whether they are possible to how they can best be implemented.
Introduction: A pulmonary embolism (PE) is a leading cause of mortality in hospitalized patients, yet the prevalence of PE in sickle cell disease (SCD) and its relation to disease severity or ...intrinsic hypercoagulability are not established.
Methods: We estimated inpatient PE incidence and prevalence among SCD and non‐SCD populations in Pennsylvania, and compared severity of illness and mortality, using Pennsylvania Health Care Cost Containment Council (PHC4) discharge data, 2001–2006. Risk factors for PE were assessed in a case–control study of discharges from the University of Pittsburgh Medical Archival Records System (MARS).
Results: The incidence of inpatient PE was higher in the SCD PA population than in the non‐SCD Pennsylvania population, 2001–2006. The PE prevalence among SCD discharges ≤ 50 years of age, 0.57%, was similar to that in non‐SCD Pennsylvania discharges, 0.60%, and unchanged after adjustment for race. Among SCD discharges, those developing PE were significantly older, with a longer length of stay, greater severity of illness and higher mortality, P < 0.001, than SCD without a PE. Among PE discharges, SCD had a similar severity of illness, P = 0.77, and mortality, P = 0.39, but underwent fewer computerized tomographic scans, P = 0.006, than non‐SCD with PE. In the local case–control study, no clinical or laboratory feature was associated with PE.
Conclusions: The incidence of PE is higher and chest computed tomography (CT) utilization is lower in SCD than non‐SCD inpatients, suggesting that PE may be under‐diagnosed.
The oral cavity is a common site of complications related to the cytotoxic effect of high-dose chemotherapy and radiation therapy. Considering our limited understanding of the burden of illness in ...the oral cavity from various cytotoxic therapies, it is difficult to produce evidence-based, preventive and management protocols. A prospective multicenter study is necessary to collect data on the burden of illness from various cytotoxic regimens.
The objectives of this prospective international observational multicenter study in hematopoietic stem cell transplant (HSCT) patients are to establish the nature, incidence and temporal relationship of oral complications related to conditioning regimens (chemotherapy with or without total body irradiation), stem cell transplantation and the immunologic reactions (mainly graft-vs-host-disease) that may follow, and to determine what subjective and objective oral complications related to treatment can predict negative clinical and economic outcomes and reduced quality of life.
Adult patients at six study sites receiving full intensity conditioning, reduced intensity conditioning or nonmyeloablative conditioning, followed by autologous or allogeneic hematopoietic stem cell infusion, are included. A pre-treatment assessment includes medical conditions, planned chemo- and radiation therapy regimen, medications, allergies, social history, patient report of oral problems, dental history, subjective oral complaints, objective measures of oral conditions, current laboratory values, dental treatment recommended and untreated dental disease. Starting 1-3 days after hematopoietic stem cell infusion, a bedside assessment is completed 3 days per week until resolution of neutropenia. A patient questionnaire is also completed during hospitalization. Beyond this time, patients with continued oral mucositis or other oral problems are followed 1 day per week in an inpatient or outpatient setting. Additional visits for urgent care for acute oral problems after hospitalization are documented. Autologous transplant patients are being followed up at 100 days (SD 30 days) and at 1 year (SD 30 days) post-transplantation to identify any long-term side effects. Patients treated with allogeneic transplantation are being followed at 100 days (SD 30 days), 6 months (SD 30 days), and 12 months (SD 30 days). The follow-up assessments include cancer response to therapy, current medical conditions, medications, subjective and objective oral findings, quality of life measures and laboratory values. The targeted enrollment is 254 patients who have received HSCT.
A total of 260 participants have been enrolled, with 233 (91%) who have received HSCT. We anticipate enrollment of 20-30 additional participants to obtain the sample size of 254 enrolled participants who have received HSCT.
The results of the ongoing prospective study will provide a unique dataset to understand the impact of oral complications on patients undergoing HSCT and provide needed evidence for guidelines regarding the management of this patient cohort.
Background In people with early autosomal dominant polycystic kidney disease (ADPKD), average total kidney volume (TKV) is 3 times normal and increases by an average of 5% per year despite a ...seemingly normal glomerular filtration rate (GFR). We hypothesized that increased TKV would be a source of morbidity and diminished quality of life that would be worse in patients with more advanced disease. Study Design Cross-sectional. Setting & Participants 1,043 patients with ADPKD, hypertension, and a baseline estimated GFR (eGFR) > 20 mL/min/1.73 m2. Predictors (1) eGFR, (2) height-adjusted TKV (htTKV) in patients with eGFR > 60 mL/min/1.73 m2. Outcomes 36-Item Short Form Health Survey (SF-36) and the Wisconsin Brief Pain Survey. Measurements Questionnaires were self-administered. GFR was estimated from serum creatinine using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. htTKV was measured by magnetic resonance imaging. Results Back pain was reported by 50% of patients, and 20% experienced it “often, usually, or always.” In patients with early disease (eGFR > 60 mL/min/1.73 m2 ), there was no association between pain and htTKV, except in patients with large kidneys (htTKV > 1,000 mL/m). Comparing across eGFR levels and including patients with eGFRs < 60 mL/min/1.73 m2 , patients with eGFRs of 20-44 mL/min/1.73 m2 were significantly more likely to report that pain impacted on their daily lives and had lower SF-36 scores than patients with eGFRs of 45-60 and ≥60 mL/min/1.73 m2 . Symptoms relating to abdominal fullness were reported by 20% of patients and were related significantly to lower eGFRs in women, but not men. Limitations TKV and liver volume were not measured in patients with eGFR < 60 mL/min/1.73 m2 . The number of patients with eGFRs < 30 mL/min/1.73 m2 is small. Causal inferences are limited by cross-sectional design. Conclusions Pain is a common early symptom in the course of ADPKD, although it is not related to kidney size in early disease (eGFR > 60 mL/min/1.73 m2 ), except in individuals with large kidneys (htTKV > 1,000 mL/m). Symptoms relating to abdominal fullness and pain are greater in patients with more advanced (eGFR, 20-45 mL/min/1.73 m2 ) disease and may be due to organ enlargement, especially in women. More research about the role of TKV in quality of life and outcomes of patients with ADPKD is warranted.
To further define the role of mast cells in the idiopathic inflammatory bowel diseases, mediator release from intestinal mast cells derived from actively inflamed and relatively quiescent areas of ...ulcerative colitis was studied. It was hypothesized that mast cells in the actively diseased segments would indicate involvement in the disease process by releasing a different profile of mediators than cells in uninflammed tissue. Mast cell-containing suspensions derived from matched segments of 12 ulcerative colitis specimens were compared for responsiveness to the mast cell stimulus goat anti-human immunoglobulin E. Supernatants from challenged cells were analyzed for levels of three mast cell mediators, histamine, prostaglandin D2, and the sulfidopeptide leukotriene C. Mast cells from the actively involved areas released significantly greater amounts of histamine, prostaglandin D2, and sulfidopeptide leukotriene. The difference in histamine release was not a result of greater stores of histamine in the active tissue cells, because the total histamine content of the mast cells from the active areas was not significantly greater. The enhanced release of both preformed and newly generated mediators indicates activation of those cells in the course of the disease and points to the mast cell contribution to the inflammatory process in these disorders.
Parkinson disease is a progressive neurologic disorder. Limited evidence suggests endurance exercise modifies disease severity, particularly high-intensity exercise.
To examine the feasibility and ...safety of high-intensity treadmill exercise in patients with de novo Parkinson disease who are not taking medication and whether the effect on motor symptoms warrants a phase 3 trial.
The Study in Parkinson Disease of Exercise (SPARX) was a phase 2, multicenter randomized clinical trial with 3 groups and masked assessors. Individuals from outpatient and community-based clinics were enrolled from May 1, 2012, through November 30, 2015, with the primary end point at 6 months. Individuals with idiopathic Parkinson disease (Hoehn and Yahr stages 1 or 2) aged 40 to 80 years within 5 years of diagnosis who were not exercising at moderate intensity greater than 3 times per week and not expected to need dopaminergic medication within 6 months participated in this study. A total of 384 volunteers were screened by telephone; 128 were randomly assigned to 1 of 3 groups (high-intensity exercise, moderate-intensity exercise, or control).
High-intensity treadmill exercise (4 days per week, 80%-85% maximum heart rate n = 43), moderate-intensity treadmill exercise (4 days per week, 60%-65% maximum heart rate n = 45), or wait-list control (n = 40) for 6 months.
Feasibility measures were adherence to prescribed heart rate and exercise frequency of 3 days per week and safety. The clinical outcome was 6-month change in Unified Parkinson's Disease Rating Scale motor score.
A total of 128 patients were included in the study (mean SD age, 64 9 years; age range, 40-80 years; 73 57.0% male; and 108 84.4% non-Hispanic white). Exercise rates were 2.8 (95% CI, 2.4-3.2) days per week at 80.2% (95% CI, 78.8%-81.7%) maximum heart rate in the high-intensity group and 3.2 (95% CI, 2.8-3.6; P = .13) days per week at 65.9% (95% CI, 64.2%-67.7%) maximum heart rate in the moderate-intensity group (P < .001). The mean change in Unified Parkinson's Disease Rating Scale motor score in the high-intensity group was 0.3 (95% CI, -1.7 to 2.3) compared with 3.2 (95% CI, 1.4 to 5.1) in the usual care group (P = .03). The high-intensity group, but not the moderate-intensity group, reached the predefined nonfutility threshold compared with the control group. Anticipated adverse musculoskeletal events were not severe.
High-intensity treadmill exercise may be feasible and prescribed safely for patients with Parkinson disease. An efficacy trial is warranted to determine whether high-intensity treadmill exercise produces meaningful clinical benefits in de novo Parkinson disease.
clinicaltrials.gov Identifier: NCT01506479.
Autosomal dominant polycystic kidney disease (ADPKD) often results in ESRD but with a highly variable course. Mutations to PKD1 or PKD2 cause ADPKD; both loci have high levels of allelic ...heterogeneity. We evaluated genotype-phenotype correlations in 1119 patients (945 families) from the HALT Progression of PKD Study and the Consortium of Radiologic Imaging Study of PKD Study. The population was defined as: 77.7% PKD1, 14.7% PKD2, and 7.6% with no mutation detected (NMD). Phenotypic end points were sex, eGFR, height-adjusted total kidney volume (htTKV), and liver cyst volume. Analysis of the eGFR and htTKV measures showed that the PKD1 group had more severe disease than the PKD2 group, whereas the NMD group had a PKD2-like phenotype. In both the PKD1 and PKD2 populations, men had more severe renal disease, but women had larger liver cyst volumes. Compared with nontruncating PKD1 mutations, truncating PKD1 mutations associated with lower eGFR, but the mutation groups were not differentiated by htTKV. PKD1 nontruncating mutations were evaluated for conservation and chemical change and subdivided into strong (mutation strength group 2 MSG2) and weak (MSG3) mutation groups. Analysis of eGFR and htTKV measures showed that patients with MSG3 but not MSG2 mutations had significantly milder disease than patients with truncating cases (MSG1), an association especially evident in extreme decile populations. Overall, we have quantified the contribution of genic and PKD1 allelic effects and sex to the ADPKD phenotype. Intrafamilial correlation analysis showed that other factors shared by families influence htTKV, with these additional genetic/environmental factors significantly affecting the ADPKD phenotype.
Abstract Context Medicaid populations have low rates of advance care planning (ACP). Potential policy interventions include financial incentives. Objective To test the effectiveness of patient plus ...provider financial incentive compared to provider financial incentive alone for increasing ACP discussions among Medicaid patients. Methods Between April 2014-July 2015 we conducted two sequential assessor-blinded pragmatic randomized trials in a health plan that pays PCPs $100 to discuss ACP: 1) a parallel cluster trial ( provider-delivered patient incentive); and 2) an individual-level trial ( mail-delivered patient incentive). Control and intervention arms included encouragement to complete ACP, instructions for using an online ACP tool, and (in the intervention arm) $50 for completing the online ACP tool and a small probability of $1000 (i.e., lottery) for discussing ACP with their PCP. The primary outcome was provider-reported ACP discussion within 3 months. Results In the provider-delivered patient incentive study, 38 PCPs were randomized to the intervention (n=18) or control (n=20) and given 10 patient packets each to distribute. Using an intention-to-treat analysis, there were 27/180 (15%) ACP discussions in the intervention group and 5/200 (2.5%) in the control group (p=0.0391). In the mail-delivered patient incentive study, there were 5/187 (2.7%) ACP discussions in the intervention group and 5/189 (2.6%) in the control group (p=0.99). Conclusion ACP rates were low despite an existing provider financial incentive. Adding a provider-delivered patient financial incentive, but not a mail-delivered patient incentive, modestly increased ACP discussions. PCP encouragement combined with a patient incentive may be more powerful than either encouragement or incentive alone.
Treatment of chronic low back pain (LBP) in older adults is limited by the adverse effects of analgesics. Effective nonpharmacologic treatment options are needed.
To determine the effectiveness of a ...mind-body program at increasing function and reducing pain in older adults with chronic LBP.
This single-blind, randomized clinical trial compared a mind-body program (n = 140) with a health education program (n = 142). Community-dwelling older adults residing within the Pittsburgh metropolitan area were recruited from February 14, 2011, to June 30, 2014, with 6-month follow-up completed by April 9, 2015. Eligible participants were 65 years or older with functional limitations owing to their chronic LBP (≥11 points on the Roland and Morris Disability Questionnaire) and chronic pain (duration ≥3 months) of moderate intensity. Data were analyzed from March 1 to July 1, 2015.
The intervention and control groups received an 8-week group program followed by 6 monthly sessions. The intervention was modeled on the Mindfulness-Based Stress Reduction program; the control program, on the "10 Keys" to Healthy Aging.
Follow-up occurred at program completion and 6 months later. The score on the Roland and Morris Disability Questionnaire was the primary outcome and measured functional limitations owing to LBP. Pain (current, mean, and most severe in the past week) was measured with the Numeric Pain Rating Scale. Secondary outcomes included quality of life, pain self-efficacy, and mindfulness. Intent-to-treat analyses were conducted.
Of 1160 persons who underwent screening, 282 participants enrolled in the trial (95 men 33.7% and 187 women 66.3%; mean SD age,74.5 6.6 years). The baseline mean (SD) Roland and Morris Disability Questionnaire scores for the intervention and control groups were 15.6 (3.0) and 15.4 (3.0), respectively. Compared with the control group, intervention participants improved an additional -1.1 (mean, 12.1 vs 13.1) points at 8 weeks and -0.04 (mean, 12.2 vs 12.6) points at 6 months (effect sizes, -0.23 and -0.08, respectively) on the Roland and Morris Disability Questionnaire. By 6 months, the intervention participants improved on the Numeric Pain Rating Scale current and most severe pain measures an additional -1.8 points (95% CI, -3.1 to -0.05 points; effect size, -0.33) and -1.0 points (95% CI, -2.1 to 0.2 points; effect size, -0.19), respectively. The changes in Numeric Pain Rating Scale mean pain measure after the intervention were not significant (-0.1 95% CI, -1.1 to 1.0 at 8 weeks and -1.1 95% CI, -2.2 to -0.01 at 6 months; effect size, -0.01 and -0.22, respectively).
A mind-body program for chronic LBP improved short-term function and long-term current and most severe pain. The functional improvement was not sustained, suggesting that future development of the intervention could focus on durability.
clinicaltrials.gov Identifier: NCT01405716.
Primary care management decisions for patients with symptomatic lumbar spinal stenosis (LSS) are challenging, and nonsurgical guidance is limited by lack of evidence.
To compare surgical ...decompression with physical therapy (PT) for LSS and evaluate sex differences.
Multisite randomized, controlled trial. (ClinicalTrials.gov: NCT00022776).
Neurologic and orthopedic surgery departments and PT clinics.
Surgical candidates with LSS aged 50 years or older who consented to surgery.
Surgical decompression or PT.
Primary outcome was physical function score on the Short Form-36 Health Survey at 2 years assessed by masked testers.
The study took place from November 2000 to September 2007. A total of 169 participants were randomly assigned and stratified by surgeon and sex (87 to surgery and 82 to PT), with 24-month follow-up completed by 74 and 73 participants in the surgery and PT groups, respectively. Mean improvement in physical function for the surgery and PT groups was 22.4 (95% CI, 16.9 to 27.9) and 19.2 (CI, 13.6 to 24.8), respectively. Intention-to-treat analyses revealed no difference between groups (24-month difference, 0.9 CI, -7.9 to 9.6). Sensitivity analyses using causal-effects methods to account for the high proportion of crossovers from PT to surgery (57%) showed no significant differences in physical function between groups.
Without a control group, it is not possible to judge success attributable to either intervention.
Surgical decompression yielded similar effects to a PT regimen among patients with LSS who were surgical candidates. Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS.
National Institutes of Health and National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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