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Rationale and design of the AngeLmed for Early Recognition and Treatment of STEMI trial: A randomized, prospective clinical investigation

Significant improvements in door-to-balloon times have led to a reduction in mortality in ST-segment elevation myocardial infarction; however, mean symptom-to-door times remain at 2 to 3 hours. An intracardiac electrogram monitoring device may be beneficial in high-risk patients by alerting them to rapidly progressive ST-segment changes indicative of acute coronary occlusion. The Cardiosaver and DETECT phase I clinical studies demonstrated the safety, feasibility, and potential benefit of using an intracardiac electrogram monitoring device to alert the patient to seek medical attention. The goal of the randomized, prospective ALERTS Trial (Clinicaltrials.gov no. NCT00781118) is to evaluate the efficacy of an implantable monitoring device (IMD) in reducing the composite of either cardiac or unexplained death, new Q-wave myocardial infarction, or symptom-to-door time of >2 hours for confirmed thrombotic events. The IMD alerts the patient in real time when ST-segment deviation from a personalized baseline exceeds the trigger threshold. The trial is designed to enroll high-risk post-acute coronary syndrome patients or patients with previous multivessel coronary artery bypass surgery. All patients have the IMD implanted, with 1:1 unblinded randomization to the alerting feature being either turned on versus turned off for the first 6 months. Randomization occurs at the first follow-up visit, 7 to 14 days after the implantation of the IMD. Subjects then return for follow-up visits at months 1, 3, and 6 and thereafter every 6 months until closure of the investigational device exemption. Subjects who cannot be implanted successfully or who have the device explanted are removed from the study and followed up for a minimum of 30 days post-procedure. If a subject experiences a device-related complication and/or adverse experience, the subject is followed up until resolution or until the condition becomes stable and no further change is anticipated.

Partner Violence and Abortion Characteristics

We conducted a retrospective cohort study using randomly selected medical charts of women reporting a history of partner violence and women with no history of partner violence at the time of a family planning or abortion appointment (n = 6,564 per group). We analyzed lifetime history of partner violence for odds of lifetime history of abortion and miscarriage number, and birth control problems. To more closely match timing, we analyzed a subsample of 2,186 women reporting current violence versus not at the time of an abortion appointment for differences in gestational age, medical versus surgical method choice, and return for follow-up visit. After adjusting for years at risk and demographic characteristics, women with a past history of partner violence were not more likely to have ever had one abortion, but they were more likely to have had problems with birth control, repeat abortions, and miscarriages than women with no history of violence. Women with current partner violence were also more likely to be receiving an abortion at a later gestational age. We found no differences between the groups in return for abortion follow-up visit or choice of surgical versus medication abortion. Findings support screening for the influence of partner violence on reproductive health and related safety planning.

Pessimistic orientation in relation to telomere length in older men: The VA Normative Aging Study

Recent research suggests pessimistic orientation is associated with shorter leukocyte telomere length (LTL). However, this is the first study to look not only at effects of pessimistic orientation on average LTL at multiple time points, but also at effects on the rate of change in LTL over time. Participants were older men from the VA Normative Aging Study (n=490). The life orientation test (LOT) was used to measure optimistic and pessimistic orientations at study baseline, and relative LTL by telomere to single copy gene ratio (T:S ratio) was obtained repeatedly over the course of the study (1999-2008). A total of 1010 observations were included in the analysis. Linear mixed effect models with a random subject intercept were used to estimate associations. Higher pessimistic orientation scores were associated with shorter average LTL (percent difference by 1-SD increase in pessimistic orientation (95% CI): -3.08 (-5.62, -0.46)), and the finding was maintained after adjusting for the higher likelihood that healthier individuals return for follow-up visits (-3.44 (-5.95, -0.86)). However, pessimistic orientation scores were not associated with rate of change in LTL over time. No associations were found between overall optimism and optimistic orientation subscale scores and LTL. Higher pessimistic orientation scores were associated with shorter LTL in older men. While there was no evidence that pessimistic orientation was associated with rate of change in LTL over time, higher levels of pessimistic orientation were associated with shorter LTL at baseline and this association persisted over time.

Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial

Post-thrombotic syndrome (PTS) is a common and burdensome complication of deep venous thrombosis (DVT). Previous trials suggesting benefit of elastic compression stockings (ECS) to prevent PTS were small, single-centre studies without placebo control. We aimed to assess the efficacy of ECS, compared with placebo stockings, for the prevention of PTS. We did a multicentre randomised placebo-controlled trial of active versus placebo ECS used for 2 years to prevent PTS after a first proximal DVT in centres in Canada and the USA. Patients were randomly assigned to study groups with a web-based randomisation system. Patients presenting with a first symptomatic, proximal DVT were potentially eligible to participate. They were excluded if the use of compression stockings was contraindicated, they had an expected lifespan of less than 6 months, geographical inaccessibility precluded return for follow-up visits, they were unable to apply stockings, or they received thrombolytic therapy for the initial treatment of acute DVT. The primary outcome was PTS diagnosed at 6 months or later using Ginsberg's criteria (leg pain and swelling of ≥1 month duration). We used a modified intention to treat Cox regression analysis, supplemented by a prespecified per-protocol analysis of patients who reported frequent use of their allocated treatment. This study is registered with ClinicalTrials.gov, number NCT00143598, and Current Controlled Trials, number ISRCTN71334751. From 2004 to 2010, 410 patients were randomly assigned to receive active ECS and 396 placebo ECS. The cumulative incidence of PTS was 14·2% in active ECS versus 12·7% in placebo ECS (hazard ratio adjusted for centre 1·13, 95% CI 0·73-1·76; p=0·58). Results were similar in a prespecified per-protocol analysis of patients who reported frequent use of stockings. ECS did not prevent PTS after a first proximal DVT, hence our findings do not support routine wearing of ECS after DVT. Canadian Institutes of Health Research.

Marijuana Use and Health in Primary Care

To The Editor: With the increased in prevalence of marijuana use in the past 20 years in the United States, and recent trends suggesting it may continue to rise,1 there is a great need for research that will improve our understanding and highlight the range of effects associated with marijuana use. Consequently, the article by Fuster et al.2 in your September issue was an interesting and timely piece. The authors found no significant association between frequency of current marijuana use and health care utilization and health among primary care patients identified by screening positive for use of any illicit drug. However, a few reservations remain. The study was a secondary analysis of data originally collected for a randomized trial. The large number of participants that were excluded as a result of ineligibility and refusal to participate make the study subject to selection bias. The authors reported that of the 270 subjects that were excluded due to ineligibility to the randomized trial and therefore their study, unwillingness/inability to return for visits was the reason for 77 % (209). It is possible that these excluded subjects were frequent users of marijuana, had poor health, and were more likely to have significant comorbidities that may have made them unable to return for visits. Also, another 428 subjects were excluded for refusal to participate. While the authors attempted to ascertain the homogeneity of this group to their study sample, based on age, gender and substance use, other variables that could potentially be associated with the study’s outcomes, including income, educational status, ethnicity, accessibility to care and depressive symptoms3 were not considered in their analysis. Also, the lack of appropriate comparison groups, which should include non-drug using individuals or limited drug users, in all sub-group analysis, including those with exclusive marijuana use, make drawing any substantive conclusion from the study problematic. Yet, in their discussion, the authors state that among exclusive marijuana users, cutting down use may have little measurable effect on health status or health utilization.2 Given that marijuana is perceived as having minimal health problems among users,4 and as the authors rightly state, there is a lack of research on its impact in health care utilization, more studies with convincing evidence are warranted.

HIV burden in men who have sex with men: a prospective cohort study during 2007–12 in Beijing, China

BackgroundThe burden of HIV is high in men who have sex with men (MSM), but the factors associated with increased disease burden are not fully understood. We did a prospective cohort study among MSM in Beijing, China, to explore these issues further. MethodsThe study took place between May 1, 2007, and Dec 31, 2012. Participants were recruited from HIV-infected MSM seeking care at Youan Hospital, Beijing. After discharge, study participants agreed to be trained and were hired to distribute study recruitment flyers at venues frequented by MSM, including clubs, bars, parks, and bathhouses. Participants were also encouraged to refer their peers to enrol into the study. MSM were eligible to participate in the study if they were aged 18 years and older, reported sexual behaviours including vaginal or anal intercourse in the past 6 months, and had received no previous serological test for HIV antibody or an antibody-negative result. After enrolment, HIV-negative MSMs were encouraged to return for study visits, which included a standardised interview about sexual behaviour at 3 months. A service package was provided at each visit, including HIV antibody and syphilis tests, free condoms, an allowance of 50 CNY (US$7·40) for transport, and counselling on use of condoms to prevent HIV transmission. Primary outcomes were HIV infection at initial screening and during the 5-year follow-up, and the effect of condom use against acquisition of HIV infection according to consistency of condom use (50%, 75%, and 100%). Factors associated with increased disease burden were also examined with a Cox proportional hazards model. FindingsAt enrolment, among 5800 MSM we identified 484 (8·3%) prevalent cases of HIV infection and 293 (5·1%) prevalent cases of syphilis. 2045 (64%) of 3178 MSM were aged between 18 and 30 years, 2320 (73%) of 3178 had attained at least high school education, and 2166 (68%) of 3178 had never married. 466 (26%) of 1758 reported being in only steady partnerships, 642 (37%) of 1758 reported both steady and casual partnerships, and 650 (37%) of 1758 reported only casual partnerships. Among 3178 MSM who were HIV negative at enrolment and who had also completed at least one follow-up interview, 387 infections were observed in up to 5467 person-years of follow-up, implying an incidence of 7·1 per 100 person-years (95% CI 6·2–7·6), with median follow-up of 1·7 years (IQR 0·5–2·7) and an average retention rate of 84% per 6 month interval. Most study participants (2317 [84%] of 2766) were migrants, with major reasons for drop out being leaving Beijing, seroconversion, or feeling that testing was unnecessary. Comparing the final visit to the baseline visit, the probability of reporting 100% condom use increased by 47% among those in steady partnerships (from 322 of 969 participants to 624 of 1281 participants) and 42% in MSM in casual partnerships (from 414 of 1090 to 574 of 1068). Consistent condom use within steady partnerships was associated with lower HIV incidence than was inconsistent use: incidence was 11·5 per 100 person-years (95% CI 6·8–16·2), 9·4 per 100 person-years (5·9–12·9), and 8·7 per 100 person-years (6·0–11·3) in those reporting 50%, 75%, and 100% condom use, respectively. InterpretationOverall HIV incidence and baseline levels of risk were high in this sample of Chinese MSM. During the study, preventive efforts increased, and condom promotion was associated with reduced risk. However, reliance on self-reported condom use is an important limitation. Further interventions (eg, sexually transmitted disease treatment and pre-exposure prophylaxis) might be needed to curtail the spread of HIV in this population. FundingThe study was funded by the Chinese Government 12th Five-Year Plan (2012ZX10001-003, 2012ZX10001-006, and 2012ZX10004904-002-002), National Natural Science Foundation (number 81372958), and Beijing Key Laboratory (number BZ0089). The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Assessment of the Effect of Casein Phosphopeptide–amorphous Calcium Phosphate on Postoperative Sensitivity Associated With In-office Vital Tooth Whitening

The aim of this study was to evaluate the efficacy of tooth mousse containing 10% casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) in reducing tooth sensitivity associated with in-office vital tooth whitening. In-office tooth whitening was performed for 51 participants using 35% hydrogen peroxide gel in a single visit. After the procedure, each participant was randomly assigned to one of three groups: gel without desensitizing agent (n=17), gel with 2% sodium fluoride (n=17), gel with 10% CPP-ACP (n=17). A small amount of the desensitizing gel assigned for each participant was applied directly on the labial surfaces of teeth and left undisturbed for three minutes. The participants were asked to apply the gel assigned to them for three minutes twice daily after brushing their teeth, and to continue this for 14 days. The participants were asked to return for follow-up visits after 24 hours and on days 3, 7, and 14, at which time teeth shade changes were assessed by one evaluator using a value-oriented Vita classic shade guide. The incidence, duration, and intensity of tooth sensitivity experienced was self-assessed on a daily basis for the 14-day study period using a visual analog scale (VAS). The effect of the three gels on tooth sensitivity was assessed using one-way analysis of variance and a χ (2) test (α=0.05). The general linear model was used to compare intensity-level differences in the three studied groups and for shade stability over the follow-up period. The results of this study showed that all three gels decreased the intensity of sensitivity associated with tooth whitening. The intensity of sensitivity was lower in the fluoride group than in the other two groups; however, it was not statistically significant (p=0.112 and p=0.532 on day 1 and day 2, respectively). The average shade change was 6.8. None of the tested materials affected the efficacy of tooth whitening, but the shade change among the fluoride group showed more color stability than that of the other two groups. This study suggested that using a gel after tooth whitening can reduce the intensity of tooth sensitivity associated with in-office whitening procedures without affecting the efficiency of tooth whitening. However, it failed to demonstrate that using a 10% CPP-ACP could provide additional therapeutic benefits.

FRI0396 Double-blind comparison of mycophenolate mofetil and oral cyclophosphamide for treatment of scleroderma-related interstitial lung disease (scleroderma lung study [SLS] II): rationale, design, methods, baseline characteristics and patient disposition

BackgroundCyclophosphamide (CYC), is the only therapy that has been shown thus far to be efficacious in scleroderma-related interstitial lung disease (SSc-ILD). However, the utility of CYC is constrained by its...

O059 STATE OF SYSTEM PRODUCTION OF GROWTH AND APOPTOSIS FACTORS IN ADOLESCENT GIRLS WITH UTERINE BLEEDINGS

Objectives: 1) Evaluate the acceptability, effectiveness, and safety of a harm-reduction model of service provision, designed to alleviate morbidity and mortality from unsafe abortion, for women with unintended pregnancies in Peru; 2) Assess the acceptability and effectiveness of a telephone follow-up visit as a less burdensome alternative to an in-person follow-up visit; 3) Understand the reasons why women do not return for follow-up visits, comparing reasons between women who receive telephone vs. in-person follow-up. Materials: This is a prospective cohort, mixed methods study, conducted with women with unintended pregnancies receiving harm-reduction services in 3 NGO clinics in Lima and Chimbote, Peru. It includes 400 questionnaires conducted via telephone, 25 indepth interviews with a subset of the participants, and collection of clinical data from clinic records. Data collection is currently under way. Methods: The clinical data will be merged with the questionnaire data, and univariate and multivariate analyses will be conducted. In-depth interviews will be coded and analyzed by key themes. The main quantitative outcomes that will be analyzed include: descriptive statistics of population accessing services (including gestational age); proportion that decide to take misoprostol and associated sociodemographic covariates; and proportion that choose to have telephone follow-up instead of in-person follow-up and associated sociodemographic covariates, among others. The following outcomes will be compared between those choosing telephone and in-person follow-up: satisfaction with service, effectiveness (not needing a surgical procedure to complete the abortion), safety (adverse events), and contraceptive use. The qualitative portion of the study will provide more in-depth details regarding satisfaction and acceptability of service; motivation for returning, or choosing not to return to clinic for follow-up; and decision-making process regarding decision to use misoprostol or not. Results: To date, 37 women have been enrolled in the study. Of the 5 telephone questionnaires that have been completed, 3 women reported choosing in-person follow-up, 1 reported choosing telephone follow-up, and 1 did not remember being offered a choice. Additional results will be available by October and presented at the Congress. Conclusions: The study findings will guide efforts to scale up the harm-reduction model and telephone follow-up in Peru and other settings.

Discussions on oral health care among elderly Chinese immigrants in Melbourne and Vancouver

This study explored how elderly Chinese immigrants value and relate to how acculturation influences oral health and subsequent service use. Elders who had immigrated to Melbourne and Vancouver within the previous 15 years were recruited from local community centres and assigned to focus groups of 5-7 participants in Vancouver (4 groups) or Melbourne (5 groups). Following an iterative process of thematic analysis, the discussions revealed that immigrants care about the comfort and appearance of their teeth, and they value Western dentistry as a supplement to traditional remedies, but they have difficulty getting culturally sensitive information about oral health care. Accessing dentistry, they explained, is distressing because of language problems and financial costs that impose on their children. Consequently, many immigrants obtain dental treatment in China when they return for occasional visits. They felt that separation of dentistry from national health care programmes in Canada and Australia disregards natural links between oral health and general health. The similarity of concerns in both cities suggests that dissemination of information and availability of services are the important themes influencing oral health, and that, beliefs developed over a lifetime play an important role in interpreting oral health in the host country.

P2-S9.13 African- and Mexican-American adolescent women with sti and a history of abuse: biological outcome of a randomised trial of behavioural intervention

BackgroundTo implement a randomised trial of a risk-reduction intervention consisting of small group sessions, individual counselling and support groups for African- and Mexican-American adolescent women with STI and abuse history...

Confidentiality With Adolescents in the Medical Setting: What Do Parents Think?

When confidential health care is provided to adolescents they are more likely to seek care, disclose sensitive information, and return for future visits. Guidelines for health professionals recommend seeing young people alone to facilitate confidential care. We sought to document parental views regarding confidentiality with adolescents, aiming to identify topics that parents believe they should be informed about despite an assurance of confidentiality between their child and the doctor. We also aimed to document harms and benefits that parents associate with adolescents seeing doctors alone. A sample of 86 parents attending an adolescent medicine clinic with their son/daughter was surveyed using a brief, anonymous questionnaire. Parents identified several benefits associated with confidential care, yet also believed they should be informed about a wide range of topics, even if their children did not want them to know. Parents' primary concern about confidentiality was a fear of not being informed about important information. Parental views concerning confidentiality are complex and conflicting and differ from current guidance provided to health professionals. Ensuring that parents accurately understand the limits to confidentiality and support the notion of confidential care for their children is a challenging yet vital task for health professionals.

Can Autologous Platelet-Rich Plasma Gel Enhance Healing After Surgical Extraction of Mandibular Third Molars?

This investigation assesses the effect of platelet-rich plasma (PRP) gel on postoperative pain, swelling, and trismus as well as healing and bone regeneration potential on mandibular third molar extraction sockets. A prospective randomized comparative clinical study was undertaken over a 2-year period. Patients requiring surgical extraction of a single impacted third molar and who fell within the inclusion criteria and indicated willingness to return for recall visits were recruited. The predictor variable was application of PRP gel to the socket of the third molar in the test group, whereas the control group had no PRP. The outcome variables were pain, swelling, and maximum mouth opening, which were measured using a 10-point visual analog scale, tape, and millimeter caliper, respectively. Socket healing was assessed radiographically by allocating scores for lamina dura, overall density, and trabecular pattern. Quantitative data were presented as mean. Mann-Whitney test was used to compare means between groups for continuous variables, whereas Fischer exact test was used for categorical variables. Statistical significance was inferred at P < .05. Sixty patients aged 19 to 35 years (mean: 24.7 ± 3.6 years) were divided into both test and control groups of 30 patients each. The mean postoperative pain score (visual analog scale) was lower for the PRP group at all time points and this was statistically significant (P < .05). Although the figures for swelling and interincisal mouth opening were lower in the test group, this difference was not statistically significant. Similarly, the scores for lamina dura, trabecular pattern, and bone density were better among patients in the PRP group. This difference was also not statistically significant. The PRP group recorded reduced pain, swelling, and trismus as well as enhanced and faster bone healing compared with those in the control. Hence the study showed that topical application of PRP gel has a beneficial effect in enhancing socket healing after third molar surgery.

Wisconsin Medicaid enrollees’ recurrent use of emergency departments and physicians’ offices for treatment of nontraumatic dental conditions

Medicaid enrollees experience a number of barriers that prevent them from seeking care in dental offices, leading some to repeatedly seek treatment for nontraumatic dental conditions (NTDCs) in emergency departments (EDs) and physicians' offices (POs). The authors examined the rate of return visits to EDs and POs for treatment of NTDCs among Wisconsin Medicaid enrollees and sought to characterize frequent and typical users of such care in this population. The authors conducted a retrospective analysis of all Wisconsin Medicaid dental claims for NTDCs to EDs and POs from 2001 through 2003. They used finite mixture models, allowing for covariate dependence, to model separate rates of return for NTDC-related visits corresponding to typical and frequent users of EDs and POs. Overall, 23,999 enrollees had made NTDC-related visits to EDs and POs, with 6.5 percent estimated to be frequent users of such care. Typical and frequent users had a mean (± standard error) rate of return visits of 0.2 ± 0.01 and 4.0 ± 0.08 per year, respectively. Male enrollees and people aged 19 to 42 years were more likely to be frequent users, with African American and Hispanic enrollees having lower odds of being frequent users than did white enrollees. The effect of living in an area with a shortage of dental health care professionals did not affect the likelihood of being a frequent user of EDs and POs for such care. Male and middle-aged enrollees were significantly more likely to be frequent users of EDs and POs for treatment of NTDCs. Compared with white enrollees, African American and Hispanic enrollees were less likely to be frequent users and had lower rates of recurrent visits for NTDCs among typical users. Improved access to dental care for Medicaid enrollees that is best managed by dental care providers should reduce the rates of recurrent NTDC-related visits to EDs and POs.

Lack of Patient Preparation for the Postpartum Period and Patients’ Satisfaction With Their Obstetric Clinicians

To assess whether lack of patient preparation for common physical and emotional postpartum symptoms is associated with patient satisfaction with obstetric clinicians. We conducted a telephone survey of 724 postpartum women. Women were interviewed 2 weeks postpartum to assess self-perceived preparation for 11 common physical and emotional postpartum symptoms, overall preparation for the postpartum experience, physical and emotional symptoms, experience with the health care system, satisfaction with clinician, and other factors. The associations of patient satisfaction with preparation, access to care, demographics, and other factors were examined. Many women were not prepared to expect common postpartum physical and emotional symptoms. Only 24% of the women surveyed were prepared to expect urinary incontinence, and fewer than half were prepared to expect breastfeeding problems, hair loss, hemorrhoids, large mood swings, and anxiety. Lack of preparation for common physical and emotional symptoms was associated with lower satisfaction with the clinician. After adjusting for demographic factors, having a regular doctor, access, physical and emotional symptom status, and other factors, rating the clinician as excellent was associated with preparation for common physical and emotional symptoms (odds ratio 1.08, 95% confidence interval 1.01-1.16), more access, and overall preparation for the postpartum experience. Satisfaction with the clinician was associated with return for postpartum visit within 3 months of delivery (P<.001). Lack of preparation for the postpartum experience, including failure to discuss common physical and emotional symptoms, is associated with reduced patient satisfaction with obstetric clinicians. II.

Mass Mobilization to Direct Engagement: American Jews' Changing Relationship to Israel

Mass Mobilization to Direct Engagement:American Jews' Changing Relationship to Israel Theodore Sasson (bio) The practices of American Jews relative to Israel seem increasingly to break with patterns established during the second half of the 20th century. Lobbying by American Jewish organizations on the political left and right increasingly competes with the consensus-oriented efforts of organizations such as AIPAC and the Conference of Presidents of Major American Jewish Organizations (CPMAJO). Direct giving to Israeli civil society organizations has replaced the federations' annual campaigns as the primary vehicle for diaspora philanthropy. The number of American Jewish teens and young adults visiting Israel has surged, but most are going with private tour companies under the auspices of Birthright Israel rather than programs of the North American denominations. Aliyah is up, but managed by Nefesh b'Nefesh, a private not-for-profit organization, rather than the Jewish Agency for Israel. In short, how American Jews relate to Israel is very much in flux. This study argues that the mass mobilization model that organized American Jewish practices relative to Israel since the founding of state has declined, and a new direct engagement model has emerged alongside it. Increasingly American Jews relate to Israel directly, by advocating their own political views, funding favored causes, visiting frequently or living there part time, consuming Israeli news and entertainment, and expressing a distinctively "realistic" rather than idealistic orientation toward the Jewish state. Their new homeland practices have given rise to (and been encouraged by) a new set of organizations that operate privately, beyond the orbit of the semi-public agencies of the established American Jewish polity. These developments are described against the backdrop of the waning mass mobilization paradigm, and their significance for diaspora Jewish organizations and Israeli democratic institutions is examined. [End Page 173] The article is also meant as a contribution to the field of diaspora studies. Not all diasporas but many—including Jews, Greeks, Irish, and Armenians—maintain links to ancestral homelands. Most scholarly literature on the diaspora-homeland relationship emphasizes the political sphere and treats "state-linked" diasporas as more or less unitary actors vis-à-vis host and homeland governments.1 The dominant emphasis in this literature has been on diaspora lobbying of host government on behalf of homeland interests.2 A secondary emphasis, largely corrective, highlights the influence of diaspora groups on their homelands, especially their efforts to bring homeland policies into harmony with host country interests.3 Few studies have explored the circumstances under which diaspora political activity becomes partisan and plural—in which diasporas become sites for waging homeland political struggles.4 In contrast, immigration research increasingly emphasizes the diverse ties migrants establish and maintain with their countries of origin. For example, Basch, Glick Schiller, and Szanton-Blanc describe the "process by which immigrants forge and sustain multi-stranded social relations that link together their societies of origin and settlement."5 Dufoix further describes how "transmigrants develop and maintain all sorts of relations—familial, religious, economic, and political—with the place they come from, thereby laying the foundations for non-territorial nations"6 According to this literature, migrants send home remittances, participate in homeland political parties, reproduce homeland cultural practices, and return for frequent visits.7 Although the definitional debate goes far beyond the scope of this article, the substantive overlap between diasporas and transnational immigrant communities is clearly considerable. The fact that many transnational immigrant communities qualify as diasporas is reason enough to extend the typology of diaspora-homeland relationships to include a broader range of possible connections. By distinguishing "mass mobilization" from "direct engagement", I show that there is variability in how diasporas are organized with respect to homelands, and explore the transition from one model to another in a single case. Mass Mobilization The mass mobilization paradigm typified the relationship between American Jews and Israel during the period between the early 1950s and the late 1980s.8 During the earlier years, responsibility for the diaspora-homeland [End Page 174] relationship shifted from Zionist organizations to the large, centralized, core organizations of American Jewry, including the American Jewish Committee (AJC), the Anti-Defamation League (ADL), the Council of Jewish Federations, and the CPMAJO. New organizations were also established...

Redefining the Brain Drain

For many years, China's government worried about the ‘brain drain’. But beginning in 1992, China began to encourage students settled abroad to return for short visits and en-gage in various programmes on the Chinese mainland. Then, in 2001, the government adopted a new policy, encouraging overseas mainlanders to contribute to China's modernisation, even if they stayed abroad, and outlining various ways they could help China. This policy mirrors the strategies of other countries who encourage ‘brain circulation’ and develop a ‘diaspora option’ in order to overcome the loss of talented people. But what forms does this assistance take? Why do people contribute to China's modernisation while remaining abroad? What are the characteristics of those who ‘serve China’, as compared to those who do not? We employ data from a survey in Silicon Valley, as well as two Web-based surveys carried out in Canada and the US with mainland Chinese academics to answer these questions.

The Frequency and Distribution of Cardiovascular Disease Risk Factors among Nebraska Women Enrolled in the WISEWOMAN Screening Program

To examine cardiovascular disease (CVD) risk factors and changes in the 10-year coronary heart disease (CHD) risk factors in women who participated in the WISEWOMAN program in Nebraska. Data for analysis were available for a total of 10,739 women who received CVD screening between September 2002 and December 2004. We examined the relationships between sociodemographic characteristics and CVD risk factors, including high cholesterol, high blood pressure, high body mass index (BMI), and diabetes. Additionally, we assessed the 10-year CHD risk and the change in risk factors for CVD. The incidence was 31 per 1000 for hyperglycemia, 66 per 1000 for hypertension, and 157 per 1000 for high cholesterol. The prevalence of obesity was 447 per 1000. Nonwhite, older, less educated, and rural women were more likely to be overweight or obese. Older, less educated, and overweight to obese women were more likely to have hyperglycemia and high blood pressure. Older and overweight to obese women were more likely to have high total cholesterol and an increased 10-year CHD risk. Race, age, and rural residence were related to CVD risk factors among low-income women in Nebraska. The effect of program eligibility requirements as a barrier to return visits should be more closely examined, and strategies to facilitate repeat screenings on WISEWOMAN projects should be undertaken. Additionally, women on the lower end of the socioeconomic spectrum were less likely to return for repeat visits, suggesting that further investigation is needed to understand why these women fail to return for screening services.

Healthcare Providers’ Satisfaction with a State Children’s Health Insurance Program (SCHIP)

This study's purpose was to understand how experiences with and perceptions of the health care plan characteristics influence provider satisfaction with a State Children's Health Insurance Program (SCHIP). Physicians and other health care providers participating in one program (ALL Kids) were mailed a survey (n = 500). Pediatricians were the most likely to return the survey. We used frequencies, chi-square and logistic regression analysis to explore relationships. The odds of being less satisfied with the program among providers who perceived that reimbursement in the ALL Kids program was less compared to private insurance were almost 7 times (OR = 6.81; 95% CI = (1.88-24.73)) greater than for those who perceived that reimbursement was more or the same in ALL Kids. Likewise, respondents who perceived that All Kids families were less likely than families with private insurance to return for follow-up visits were less satisfied with ALL Kids (OR = 17.42; 95% CI = (1.85-164.70)). The stigma of SCHIP may be less than that often associated with Medicaid; however, this investigation should be considered with others that have identified barriers for provider's participation. This study indicates that provider satisfaction is related to their perceptions of SCHIP policies and families, though it does not tell us what factors might contribute to this perception, such as, previous experience with public insurance (Medicaid) and publicly insured patients. Increasing reimbursement rates may not address perceptions that affect provider views of publicly-supported health plans and the participating families.

Extending Medicaid Coverage for Family Planning Services: Alabama's First Four Years

This study examines whether Alabama's Medicaid family planning demonstration program reaches a different segment of the population than the health department-based Title X family planning program, whether service use rates differ across clients using care within and outside of the Title X provider system, and whether additional risk assessment and care coordination services provided by health department personnel increase the likelihood that family planning clients return for follow-up visits over time. Administrative data from four years of operation of the program were used to examine characteristics of the clientele, differences in services used across provider types included in the program, and the impact of risk assessments and care coordination on return visit rates. The number of family planning service users increased dramatically over the four-year period, but were more similar demographically to Title X clients than to Medicaid maternity clients. Growth was greatest among clients of non-Title X providers. Newly covered services, including risk assessments and care coordination, were available mostly to Title X clients, and these services were associated with a greater likelihood that clients returned for care in subsequent years. Expanded provider networks can increase the number of low income women using family planning services while risk assessment and care coordination can improve the effectiveness of these services. However, enhanced services may not be equally available across provider systems. Additional outreach efforts are needed to reach women eligible for publicly supported family planning services who are not currently using these services.