Dr. David Vance’s ability to develop and maintain his vector of research is well illustrated in a recent publication with co-authors from the Departments of Psychology and Medicine (Gerontology) at UAB, Pariya Fazeli, Lesley Ross, Virginia Wadley and Karlene Ball in the Journal of the Association of Nurses in AIDS Care.  The article entitled “Speed of processing training with middle-age and older adults with HIV:  A pilot study” examines the efficacy and feasibility of using a cognitive remediation therapy which has proven results in improving speed of processing in the geriatric population and applying it to middle-aged patients with HIV who experience similar deficits.

The advent of improved pharmacological therapies (ART) has resulted in a dramatic shift in the age distribution of patients with HIV.  Currently, more than 25% of patients with HIV in the United States are aged 50 or older and It is expected that this will increase to nearly 50% by 2015.  As a result of both the disease and the treatment, however, patients with HIV are particularly vulnerable to age-related medical and cognitive changes and may experience them at an earlier age than is typical.  Cognitive changes in older patients with HIV are particularly important as they influence factors such as adherence to a complex medication regimen, financial management, activities of daily living, and even driving.  Speed of processing is one example of a cognitive process that is known to be affected in both the aging and the HIV populations.

Speed of processing training has been used for over a decade in older adults.  It has been shown to improve both speed of processing itself and to generalize to other areas of cognition.  In addition, older adults who have completed speed of processing training have shown other benefits including improved self-reported health, reduced depression scores, improved performance on activities of daily living and safer driving  These benefits have persisted for up to five years following training.

Dr. Vance’s current study involved comparing an intervention group which received speed of processing training to a control group which did not.  The intervention consisted of playing four computer games designed to tap speed of processing and visual attention by requiring the participant to identify both central and peripheral stimuli on a computer screen.  The games involve four levels of difficulty and automatically adjust either up or down so that players are always near the threshold of their ability.  The intervention condition consisted of 22 subjects with a mean age of 51.5 years while the control condition consisted of 24 subjects who did not differ demographically from the intervention group.  Both groups of subjects received a brief neuropsychological examination prior to the intervention and again following the training. 

Analysis of the neuropsychological test results revealed that subjects who received the speed of processing training showed improvement on the Useful Field of Vistion test (which is a measure of speed of processing) and the Timed Activities of Daily Living test (which is a measure of everyday functioning).  Participants also indicated that they felt the training had resulted in useful improvements.  In conclusion, cognitive remediation therapies such as speed of processing training are feasible and effective, cost effective and medically acceptable for improving cognitive abilities in HIV patients with neurologic sequelae or accelerated aging.  This work reflects Dr. Vance’s vector of research on maintaining and improving cognition in vulnerable populations.

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Article summary by Jennifer Frank, PhD (This email address is being protected from spambots. You need JavaScript enabled to view it. )



The out of pocket cost of breast cancer survivors: a review


Pisu M, Azuero A, McNees P, Burkhardt J, Benz R, Meneses K.


School of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL USA.




Out of pocket (OOP) costs add to the burden facing breast cancer survivors but remain an understudied area of costs. Current turbulent economic climate increases the urgency to better understand this burden. Few studies or systematic reviews focus on OOP costs.


Methods: PubMed search was conducted for articles in English containing: (1) MESH terms breast neoplasms and economics, and (2) words "breast cancer" and "cost" or "costs," "expenditure," or "out of pocket." Limits included: publication dates from January 1, 1980 to December 16, 2009, and populations aged > or = 45 years old. Articles were excluded based on title, abstract, and full text reviews. Citation searches and searches of reference lists were also conducted. Three articles were selected for this review.


Results: Medical direct OOP costs (e.g., for physician fees) ranged from $300 to $1,180 per month during active treatment, and were about $500 per month 1 year post diagnosis. Non-medical direct OOP costs (e.g., for transportation to doctor's office, parking etc.) ranged from $137 to $174 per month in the year post diagnosis; and $200-$509 per month 1 year or more after diagnosis. Different types of costs were identified.


Conclusion: OOP costs represent a significant burden for survivors even after initial treatment. The nature and extent of OOP costs need further evaluation. IMPLICATIONS FOR CANCER SURVIVORS: OOP costs are rarely considered. However, as OOP costs affect the well being of cancer survivors, they should be understood more fully and possibly addressed in interventions aimed at improving quality of life.



Out of pocket cost comparison between Caucasian and minority breast cancer survivors in the Breast Cancer Education Intervention (BCEI).

Pisu M, Azuero A, Meneses K, Burkhardt J, McNees P.

School of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA. This email address is being protected from spambots. You need JavaScript enabled to view it.


The purpose of this article is to: (1) describe out of pocket (OOP) costs among minority and Caucasian participants in the BCEI, the Breast Cancer Education Intervention, a randomized clinical trial of psychoeducational quality of life interventions for breast cancer survivors (BCS); and (2) examine the OOP burden, as measured by the proportion of income spent OOP, between the two racial/ethnic groups. We examined baseline OOP costs reported by 261 early-stage I and II breast cancer survivors who participated in the BCEI trial. Data were collected using the Breast Cancer Finances Survey and the Breast Cancer Sociodemographic and Treatment Tool. OOP costs averaged $316 per month since diagnosis. Direct medical costs were $281, and direct non-medical were $66. There were no significant differences in total OOP costs or direct medical and non-medical OOP costs between minority and Caucasian BCS. Minority BCS with incomes of $40,000 or less spent a greater proportion of income in total OOP and direct medical OOP costs (31.4 and 27% for BCS with incomes ≤ $20,000; 19.5 and 18.8% for BCS with incomes $20,001-40,0000) compared to their Caucasian counterparts (12.6 and 9.2% for BCS with incomes ≤ $20,000; 8.7 and 8.2% for BCS with incomes $20,001-40,0000). OOP costs can be a considerable burden for breast cancer survivors representing as much as 31% of monthly income depending on BCS' income levels. Future studies can investigate how this burden affects the quality of life of breast cancer survivors, especially minorities.


Link to PubMed

Safety and tolerability of early noninvasive ventilatory correction using bilevel positive airway pressure in acute ischemic stroke.

Tsivgoulis G, Zhang Y, Alexandrov AW, Harrigan MR, Sisson A, Zhao L, Brethour M, Cava L, Balucani C, Barlinn K, Patterson DE, Giannopoulos S, DeWolfe J, Alexandrov AV.

Comprehensive Stroke Center, University of Alabama at Birmingham Hospital, Birmingham, AL, USA.

Hypercapnia can induce intracranial blood-flow steal from ischemic brain tissues, and early initiation of noninvasive ventilator correction (NIVC) may improve cerebral hemodynamics in acute ischemic stroke. We sought to determine safety and tolerability of NIVC initiated on hospital admission without polysomnography study.

Consecutive acute ischemic stroke patients were evaluated for the presence of a proximal arterial occlusion, daytime sleepiness, or history of obstructive sleep apnea, and acceptable pulse oximetry readings while awake (96%-100% on 2 to 4 L supplemental oxygen delivered by nasal cannula). NIVC was started on hospital admission as standard of care when considered necessary by treating physicians. NIVC was initiated using bilevel positive airway pressure at 10 cmH(2)O inspiratory positive airway pressure and 5 cmH(2)O expiratory positive airway pressure in combination with 40% fraction of inspired oxygen. All potential adverse events were prospectively documented.

Among 356 acute ischemic stroke patients (median NIHSS score, 5; interquartile range, 2-13), 64 cases (18%) received NIVC (median NIHSS score, 12; interquartile range, 6-17). Baseline stroke severity was higher and proximal arterial occlusions were more frequent in NIVC patients compared to the rest (P<0.001). NIVC was not tolerated by 4 patients (7%). Adverse events in NIVC included vomiting (n=1), aspiration pneumonia (n=1), respiratory failure/intubation (n=1), hypotension requiring pressors (n=1), and facial skin breakdown (n=3). The in-hospital mortality rate was 13% in NIVC patients and 8% in the rest (P=0.195). Neurological improvement during hospitalization tended to be greater in the NIVC group (median NIHSS score decrease, 2 points; interquartile range, 0-4) compared to the rest (median NIHSS score decrease, 1; interquartile range, 0-2; P=0.078).

In acute ischemic stroke patients with proximal arterial occlusion and excessive sleepiness or obstructive sleep apnea, NIVC can be initiated early with good tolerability and a relatively small risk of serious complications.