No abstract

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

OBJECTIVE -Determining modifiable risks factors for cognitive decline and dementia are a public health priority as we seek to prevent dementia. Type 2 diabetes and related disorders such as hyperinsulinemia increase with aging and are increasing in the U.S. population. Our objective was to determine whether hyperinsulinemia is associated with cognitive decline among middleaged adults without type 2 diabetes, dementia, or stroke in the Atherosclerosis Risk in Communities (ARIC) cohort.RESEARCH DESIGN AND METHODS -Middle-aged adults (aged 45-64 years at baseline) in the ARIC cohort had fasting insulin and glucose assessed between 1987 and 1989. Subjects with dementia, type 2 diabetes, or stroke at baseline were excluded from analysis. Three tests of cognitive function available at baseline and 6 years later were delayed word recall (DWR), digit symbol subtest (DSS), and first letter word fluency (WF). Cross-sectional comparisons and linear regression models were computed for cognitive tests at baseline and change in cognitive test scores to determine whether cognitive function was associated with two measures of insulin resistance, fasting insulin and homeostasis model assessment (HOMA). Linear regression models controlled for age, sex, race, marital status, education level, smoking status, alcohol use, depression, hypertension, and hyperlipidemia.RESULTS -In unadjusted and adjusted analyses, hyperinsulinemia based on fasting insulin and HOMA at baseline was associated with significantly lower baseline DWR, DSS, and WF scores and a greater decline over 6 years in DWR and WF.CONCLUSIONS -Insulin resistance is a potentially modifiable midlife risk factor for cognitive decline and dementia. Diabetes Care 29:2688 -2693, 2006D etermining modifiable risks factors for cognitive decline and dementia is a public health priority as we seek to prevent dementia, which affects at least 4 million individuals in the U.S. (1). Current therapies, such as cholinesterase inhibitors, may slow cognitive decline in some patients, although the absolute changes in disease trajectory are modest (2-4). Type 2 diabetes and related disorders such as hyperinsulinemia increase with aging and are increasing in the U.S. population (5,6). Previous studies have produced conflicting evidence linking diabetes, glucose intolerance, and hyperinsulinemia to cognitive decline and Alzheimer's dementia (7). Previous epidemiologic studies relate hyperinsulinemia or type 2 diabetes to Alzheimer's dementia cross-sectionally in older adults (8 -12), whereas only a few studies have evaluated the longitudinal association between hyperinsulinemia and Alzheimer's dementia (13-15). None of these studies investigated an association between hyperinsulinemia and cognitive decline in middle-aged adults.Insulin resistance is known to be associated with the development of agerelated diseases including hypertension, coronary heart disease, stroke, cancer, and type 2 diabetes (16). People with insulin resistance are at an approximately fivefold risk for diabetes, but this...

Background: Recent data has suggested the use of antibiotics acquired without a prescription by Latinos in the United States. We explored Latino adults' experience in treating common infections particularly in regards to self-medication with antibiotics.Methods: We conducted 3 focus groups (n ‫؍‬ 28) in Charleston, South Carolina, with Latino adults (>18 years of age) recruited throughout the community: 12 women and 16 men, ranging in age from 18 to 52 years. All of the participants were immigrants, 89% noted Mexico as their country of origin. Focus groups were conducted in Spanish and audiotaped. Transcripts were translated into English and then translated back to Spanish to assure consistency of the language. Themes were identified using an editing style.Results: Participants' previous experiences in countries with limited restrictions on antibiotics influenced acquisition of antibiotics without a prescription in the United States. Participants believed that physician visits for a diagnosis and prescription were unnecessary when the patient was familiar with the symptom and it had previously responded to antibiotic treatment. Access to care was not reported to be a significant barrier to a physician visit when individuals felt they were "sick" or children were the patients. Participants reported using local tiendas (small stores in Latino neighborhoods that sell ethnically consistent and imported products) and importation of medication to meet their need for selfmedication with antibiotics. The role of self-medication in the development of antibiotic resistance was essentially unknown among the participants.

Ethnic differences exist in the crude prevalence of diabetes, even in those characterized as normal weight by BMI. Thus, clinicians need to exercise caution in interpreting diabetes risk associated with a normal BMI. The use of other anthropometric measures, such as WC or WHR, may improve risk determination across different ethnic groups. More research is needed to determine the thresholds for different anthropometric measures that improve diabetes risk determination.