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Caroline K.
MD/PhD student w/ Masters in Biostatistics
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Stata
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Question:

Using variables x, y, and z, create a basic Cox proportional hazards model, adjust for age and sex after running the univariate model, run a log rank test, and then name and check the model assumptions for Cox models.

Caroline K.
Answer:

stset time died xi: stcox z xi: stcox z age sex sts test z Check proportional hazards assumption graphically and using Schoenfeld residuals. estat phtest Consider stratifying analysis or using time-varying covariates if proportional hazards assumption fails.

Public Health
TutorMe
Question:

Describe multi-drug resistance tuberculosis in Russia using an ecological framework.

Caroline K.
Answer:

Tuberculosis, and in particular, Multi-Drug Resistant Tuberculosis (MDRTB), remains a global epidemic, with 9.0 million new cases and 1.3 million deaths in 2013 (WHO, 2014). MDRTB very unfortunately meets the criteria for a disease significantly impacted by social determinants of health- too often, social status, government policy, and health system design contribute to the infection rates. Though each population that experiences MDRTB at disproportionate rates has some similar characteristics (especially related to pathophysiologic pathways, some individual risk factors, etc.,) I'd like to focus specifically on the Russian prison population for the purposes of this discussion post, whose MDRTB rates were among the highest in the world in 1997, when half of all prison deaths were said to be caused by Tuberculosis (Bobrick, 2005, p. 2). Pathophysiological Pathways There are two ways to contract MDRTB: you can either be treated inappropriately (wrong dose, wrong medicine, wrong timing) with antibiotics for non-drug resistant Tuberculosis, or you can catch the MDRTB strain from someone else. Antibiotic resistant infections, broadly speaking, are dangerous in countries with little regulation of their antibiotic protocols. In Nepal, for example, the significant influx of independent sellers of antibiotics and other medicines has contributed to antibiotic resistance there (CDDEP, 2015). Thus, the development of MDR infections to begin with is linked to social determinants- in countries where antibiotic distribution is well regulated and antibiotic regimens closely adhered to, it is more straightforward to prevent new MDR strains from developing. In this example, to help combat MDR infections in Russia, Russia has interestingly enough made it illegal to dispense antibiotics outside of hospital settings (Gelmanova, 2015, p. 309). Genetic/Constitutional Factors Specifically in Russian prisons, prisoners often have less than 3 meters of space to themselves, because of significant overcrowding (Bobrick, 2005, p. 7). This, combined with high levels of stress one might imagine runs parallel with a prison stay in a Russian prison, are likely significant contributors to the spread of MDRTB in Russian prisons. Individual Risk Factors Alcohol use, co-infection with HIV, and malnutrition are all risk factors associated with contracting MDRTB (WHO, 2014; Mayo Clinic, 2015; Ignatyeva, 2015). In fact, of the 1.3 million deaths from TB in 2013, around 800,000 people were also infected with HIV (WHO, 2014). Additionally, one study that looked at alcohol and cause-specific mortality in Russia found that tuberculosis was strongly associated with alcohol consumption in men (RR>3) amongst the heaviest alcohol consumers (Zaridze, 2009). It's outside the scope of this discussion post to discuss alcohol use in Russia in full, but essentially, following the fall of the Soviet Union, the government no longer controlled alcohol distribution in the country, and alcohol supply (and abuse rates) soared (Fedun, 2013). Alcohol abuse may contribute to malnutrition, non-compliance with medication, impaired judgment about risky sexual encounters, etc. It also can make tuberculosis more difficult to treat (Shin, 2006). Those with HIV who are not receiving adequate treatment may have diminished immune response to TB, making an infection more likely, as does malnutrition. Social Relationships Prisons are particularly harmful to mental, and often physical, health. In Russia, following the 1997 report about the significant prevalence of MDRTB in Russian prisons, TB hospitals were created, where prisoners are sent if they are found to have TB. The conditions in these hospitals is considered to be mostly humane, and treatment, especially in partnership with Partners in Health (PIH), has often been successful, providing not only TB care but also alcohol abuse treatment and other health interventions (Connery 2013). In fact, in Tomsk TB prison hospitals, PIH worked with the government to reduce MDRTB rates from 24% in year 1 to 0% the following year, a rate i.e. has since maintained (CGI 2015). Thus, the Russian government provides an example of an intervention that actually served to help negate the negative effects of being in the Russian prison system through a mechanism of social support external to the prison, and by removing prisoners from poor conditions. Living Conditions/Neighborhoods and Communities Stating that the living conditions in Russian prisons directly contributed to the rise of MDRTB in prisons since the 1990's is not profound. Rather, it is likely the direct setup of prisons, the social pressures including alcohol abuse and a lack of socioeconomic stability following the fall of the soviet Union that directly contributed to the significant presence of MDRTB in Russian prisons over the last 20 years. Though we often celebrate the end of the Soviet Union, it was undeniably disruptive for many in Russia. Unlike countries like Belarus who transitioned slowly away from communism and thus maintained a low unemployment rate, the extremely rapid transition away from communism is linked to an unemployment rate of 56% for Russian men post-Soviet Union. These statistics do not make for a healthy community, and likely contributed to prison rates and overcrowding to begin with (Stuckler & Basu, 2013, p. 31). Institutions/Social and Economic Policy Though this may not be inline with all current thought regarding incarceration, I very much believe that the prison and justice system should be held responsible for the TB deaths in Russian prisons to date. Incarceration is not an effective tool for much. Thus, first, the process through which Russians (and Americans, and Chinese) governments systematically imprison its citizens led to a situation where overcrowding and lack of access to essential medicines/health care could come to fruition. This is not always realized, though- only in places where there is a lack of regulation (polices and oversight) regarding how prisoners may live would we find overcrowding and a lack of medical care as bad as things were in Russia in 1997. Once ill, the lack of intervention of healthcare for prisoners there, either because of apathy, underfunding, understaffing, or a lack of policy that protected prisoners from unsafe living conditions, became, too often, a death sentence. Parts of this are especially true in light of the progress Russia has made to address TB since 1997, specifically in terms of the TB hospitals and policies related to antibiotic distribution and linkage to care post-prison release, which has helped significantly curb MDRTB in Russia. The problem still persists, though, and is ultimately still closely linked to social determinants of health. In summary, I once spoke to a physician who worked in Peru with MDRTB patients. Early in DOTS-plus research, when it was becoming very apparent that it was an effective way to treat MDRTB, Peru had policies in place that prohibited PIH from treating patients with it. The physician I spoke with had patients die because of this policy. I agree with this physician, who essentially said, "TB didn't kill my patient, because the TB was treatable. Policy did." Too often, for a lot of disease pathways globally, social determinants like policy (or institutions, or risk factors, etc.) still make this statement true. Bobrick, A., Danishevski, K., Eroshina, K., & McKee, M. (2005). Prison health in Russia: the larger picture. Journal of Public Health Policy, 1, 1-30. doi: 10.1057/palgrave.jphp.3200002 CDDEP. (2015). Global Antibiotic Resistance Partnership- Nepal 2015. Retrieved August 31, 2015, fromhttp://cddep.org/blog/posts/garp_nepal_painting_full_picture_antibiotic_resistance CGI 2015- Closing Panel Discussion with Paul Farmer [Video file]. Retrieved from https://www.youtube.com/watch?v=3_2LaWbsEcc Connery, H., Greenfield, S., Livchits, V., McGrady, L., Patrick, N., Lastimoso, C…. Heney, J. (2013). Training and fidelity monitoring of alcohol treatment interventions integrated into routine tuberculosis care in Tomsk, Russia: The IMPACT Effectiveness Trial. Substance Use and Misuse, 48, 784-92. Doi: 10.3109/10826084.2013.793715 Fedun. (2013). How Alcohol Conquered Russia. The Atlantic Online, http://www.theatlantic.com/international/archive/2013/09/how-alcohol-conquered-russia/279965/ Gelmanova, I. Y., Ahmad Khan, F., Becerra, M. C., Zemlyanya, N.A., Uankova, I., Andreev, Y.G…. Keshavjee, S. (2015). Low rates of recurrence after successful treatment of resistant tuberculosis in Tomsk, Russia. International Journal of Tuberculosis and Lung Diseases, 4, 309-405. doi:10.5588/ijtld.14.0415 Ignatyeva, O., Balbanova, Y., Nikolavevskyy, V., Koshkarova, E., Radilyte, B., Davidaviciene, E…. Drobniewski, F. (2015). Resistance profile and risk factors of drug resistant tuberculosis in the Baltic countries. Tuberculosis, 95, 581-585. Doi: 10.1016/j.tube.2015.05.018 Mayo Clinic. (2015). Tuberculosis Risk Factors. Retrieved August 31, 2015, from http://www.mayoclinic.org/diseases-conditions/tuberculosis/basics/risk-factors/con-20021761 Shin, S., Pasechnikov, A., Gelmanova, I., Peremitin, C., Strelis, A., Mischustin, S… Keshavjee, S. (2006). Treatment outcomes in an integrated civilian and prison MDR-TB treatment program in Russia. International Journal of Tuberculosis and Lung Diseases, 10, 402-408. Retrieved from http://bit.ly/1KAvYeF Stuckler, D., & Basu, S. (2013). The Body Economic: Why austerity kills. New York, NY: Basic Books. World Health Organization. (2014). Global Tuberculosis Report 2014. Retrieved August 31, 2015, from http://www.who.int/tb/publications/global_report/gtbr14_main_text.pdf?ua=1 Zaridze, D., Brennan, P., Boreham, J., Boroda, A., Karpov, R., Lazarev, A…. Peto, R. (2009). Alcohol and cause-specific mortality in Russia: a retrospective case–control study of 48 557 adult deaths. The Lancet, 373, 2201-2214. Doi: 10.1016/S0140-6736(09)61034-5

Gender Studies
TutorMe
Question:

Health disparities exist among LGBTQ populations. Discuss.

Caroline K.
Answer:

Though health disparities exist among LGBTQ populations, the challenges facing gender and sexual minorities are often grouped together, implying all non-cisgendered heteronormative populations experience the same disparities. On the contrary, while some disparities that result from oppressive power structures are present for many gender and sexual minorities (like disparities in mental health), many health disparities are present for specific identities (like higher prevalence of breast cancer among lesbians versus non-lesbians). Describing health disparities among LGBTQ peoples as effecting all LGBTQ populations, when in fact disparities exist within specific gender and sexual minority groups, reduces the potential effectiveness of interventions that could improve healthcare delivery for separate populations. LGBTQ people are often united only in the oppression they experience; health disparities should be examined in the context of those that experience them and not by implied to be experienced by all non-cisgendered heteronormative peoples.

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