Chronic Health Conditions Among US Veterans Discharged From Military Service for Misconduct.

Veterans who are discharged from military service due to misconduct are vulnerable to negative health-related outcomes, including homelessness, incarceration, and suicide. We used national data from the Veterans Health Administration for 218,608 veterans of conflicts in Iraq and Afghanistan that took place after the events of September 11, 2001, to compare clinical diagnoses between routinely-discharged (n = 203,174) and misconduct-discharged (n = 15,433) veterans. Misconduct-discharged veterans had significantly higher risk for all mental health conditions (adjusted odds ratio [AOR] range, 2.5-8.0) and several behaviorally linked chronic health conditions (AOR range, 1.2-5.9). Misconduct-discharged veterans have serious and complex health care needs; prevention efforts should focus on behavioral risk factors to prevent the development and exacerbation of chronic health conditions among this vulnerable population.

Sexual Risk Taking among Survivors of U.S. Military Sexual Assault: Associations with PTSD Symptom Severity and Alcohol Use.

Sexual risk taking may be heightened among U.S. service members and veterans reporting military sexual assault (MSA) exposure. MSA increases the risk for posttraumatic stress disorder (PTSD), which is a common correlate of sexual risk taking among civilians. PTSD may relate to sexual risk taking through its association with alcohol use, which increases impulsivity and risky behavioral engagement. Male survivors may be at notably higher risk given greater overall alcohol use and engagement in sexual risk taking relative to female survivors. This study assessed whether higher alcohol use mediated the association between PTSD and sexual risk taking among MSA survivors, and whether this effect differed by sex. Participants included 200 male and 200 female service members and veterans (age: M = 35.89, SD = 5.56) who completed measures of PTSD symptoms, alcohol use, sexual risk taking, and a demographic inventory. In a moderated mediation analysis using linear regression, higher PTSD severity was associated with higher alcohol use, and higher alcohol use was associated with higher sexual risk taking. A significant indirect effect of alcohol use was observed, which was stronger among men. To reduce sexual risk taking among MSA survivors, it may be beneficial to target PTSD symptoms and alcohol use with sex-specific interventions. This line of inquiry would be strengthened by longitudinal studies that explore the fluidity of these experiences to identify periods of elevated risk. Studies that examine alcohol use expectancies and sexual delay discounting could expand our understanding of these associations.

Collagenous gastritis in children: A national cohort.

BACKGROUND: Collagen gastritis is a rare disease that manifests in children mainly as isolated gastric involvement associated with martial deficiency anemia. There are no recommendations for the management and follow-up of these patients. We aimed to describe the clinical data, endoscopic findings, and treatments deployed in France's children with collagenous gastritis. METHODS: All French pediatric gastroenterology centers and pediatric centers for rare digestive diseases (Centres de Maladies Rares Digestives) were contacted to collect cases of collagenous gastritis, defined on gastric biopsies and diagnosed before 18 years of age. RESULTS: A total of 12 cases diagnosed (4 males and 8 females) between 1995 and 2022 could be analyzed. The median age at diagnosis was 12.5 years (7-15.2). The most frequent clinical presentation was abdominal pain (6/11) and/or nonspecific symptomatology attributed to anemia (8/10). Anemia was present in all children (11/11; Hb 2.8-9.1 g/dL). Nodular gastritis was present in 10 patients (antrum: 2; fundus: 4; in antrum and fundus: 4). All patients had a basement membrane thickening (from 19 to 100 µm). The treatments received were PPI (11), oral or intravenous martial supplementation (12), budesonide (1), and prednisone (1). Martial supplementation improved anemia in all cases. At discontinuation, nine of 10 patients had a recurrence of anemia. CONCLUSION: Collagenous gastritis is an exceptional condition, clinically manifested in children as abdominal pain and iron deficiency anemia probably of hemorrhagic origin. Patients require long-term follow-up and monitoring of their disease to describe the risk of progression better.

Hip fracture in the elderly: does counting time from fracture to surgery or from hospital admission to surgery matter when studying in-hospital mortality?

UNLABELLED: This study aims to analyze whether the interval from hospital admission to surgery may be used as a surrogate of the actual gap from fracture to surgery when investigating in-hospital hip fracture mortality. After analyzing 3,754 hip fracture admissions, we concluded that those intervals might be used interchangeably without misinterpretation bias. INTRODUCTION: The debate regarding the influence of time to surgery in hip fracture (HF) mortality is one of the most controversial issues in the HF medical literature. Most previous investigations actually analyzed the time from hospital admission to surgery as a surrogate of the less easily available gap from fracture to surgery. Notwithstanding, the assumption of equivalency between those intervals remains untested. METHODS: We analyzed 3,754 hospital admissions of elderly patients due to HF in Quebec, Canada. We compared the performance as predictors of in-hospital mortality of the delay from admission to surgery and the actual gap from fracture to surgery using univariate and multiple logistic regression analysis. RESULTS: The mean times from fracture to surgery and from admission to surgery were 1.84 and 1.02 days (P < 0.001), respectively. On univariate logistic regression, both times were slightly significant as mortality predictors, yielding similar odds ratios of 1.08 (P < 0.001) for time from fracture to surgery and 1.11 (P < 0.001) for time from admission to surgery. After accounting for other covariates, neither times remained significant mortality predictors. CONCLUSION: The gap from admission to surgery may be used as a surrogate of the actual delay from fracture to surgery when studying in-hospital HF mortality.

Association of nursing overtime, nurse staffing and unit occupancy with medical incidents and outcomes of very preterm infants.

OBJECTIVE: To examine the association of nursing overtime, nursing provision and unit occupancy rate with medical incident rates in the neonatal intensive care unit (NICU) and the risk of mortality or major morbidity among very preterm infants. STUDY DESIGN: Single center retrospective cohort study of infants born within 23 to 29 weeks of gestational age or birth weight <1000 g admitted at a 56 bed, level III NICU. Nursing overtime ratios (nursing overtime hours/total nursing hours), nursing provision ratios (nursing hours/recommended nursing hours based on patient dependency categories) and unit occupancy rates were pooled for all shifts during NICU hospitalization of each infant. Log-binomial models assessed their association with the composite outcome (mortality or major morbidity). RESULTS: Of the 257 infants that met the inclusion criteria, 131 (51%) developed the composite outcome. In the adjusted multivariable analyses, high (>3.4%) relative to low nursing overtime ratios (⩽3.4%) were not associated with the composite outcome (relative risk (RR): 0.93; 95% confidence interval (CI): 0.86 to 1.02). High nursing provision ratios (>1) were associated with a lower risk of the composite outcome relative to low ones (⩽1) (RR: 0.81; 95% CI: 0.74 to 0.90). NICU occupancy rates were not associated with the composite outcome (RR: 0.98; 95% CI: 0.89 to 1.07, high (>100%) vs low (⩽100%)). Days with high nursing provision ratios (>1) were also associated with lower risk of having medical incidents (RR: 0.91; 95% CI: 0.82 to 0.99). CONCLUSION: High nursing provision ratio during NICU hospitalization is associated with a lower risk of a composite adverse outcome in very preterm infants.

Physicians' attitudes to the pharmacological treatment of patients with stable angina pectoris.

BACKGROUND: Little is known about how physicians' knowledge of and attitudes to practice guidelines for stable angina may influence their implementation. AIM: To explore the association between physicians' demographics, their knowledge, and opinions about stable angina and their self-reported adherence to guideline recommendations. DESIGN: Questionnaire-based survey. METHODS: We surveyed 1228 Quebec physicians using a questionnaire based on the 'awareness-to-adherence' conceptual framework to measure their adherence with recommendations for the pharmacological treatment of stable angina. Independent predictors of adherence with the targeted recommendations were determined by stepwise linear regression analysis. RESULTS: We received 877 (71.4%) responses from the 1228 eligible physicians. More than 90% of respondents were aware of and agreed with the targeted recommendations. However, the adoption rate varied, even among physicians who generally agreed with the guidelines. Factor analysis indicated that most physicians agreed with recommendations concerning ASA. More negative attitudes were expressed toward beta-blockers and hypolipaemic drugs. Respondents trusted the recommendations of a variety of scientific and professional organizations. Awareness, agreement, and adoption were the strongest predictors of adherence for the three recommendations. Physician demographics and practice characteristics did not predict adherence. DISCUSSION: Physicians were aware of and agreed with the recommendations, so additional large-scale dissemination of the guidelines would be unlikely to improve prescription patterns. However, negative attitudes about beta-blockers and hypolipaemic therapy affected adherence to recommendations for these drugs. Continuing medical education interventions involving local opinion leaders might address some of the obstacles identified.

Abnormal relation of extracellular fluid volume and exchangeable sodium with systemic arterial pressure in early borderline essential hypertension.

Interrelations between systemic arterial pressure, extracellular fluid (ECF) volume, exchangeable sodium (Na) and the renin-angiotensin-aldosterone system were studied in 38 young patients with borderline hypertension and in 37 age- and sex-matched control subjects. ECF volume and exchangeable Na were subnormal (not significant) in borderline hypertension. In normal subjects, volume data did not relate to arterial pressure; in contrast, negative correlations were observed between arterial pressure and ECF volume or exchangeable Na in patients with borderline hypertension (in hypertensive women, r greater than or equal to 0.7, p less than 0.01). Plasma renin activity was consistently elevated in borderline hypertension, mainly in the upright posture, and these values were inversely correlated with ECF volume and exchangeable Na. No correlation was observed between arterial pressure and plasma renin activity. These results show that slight elevation of arterial pressure in the early stage of hypertension induces a proportional decrease in ECF volume, suggesting that the phenomenon of pressure-natriuresis is operative in young borderline hypertensive persons. The renin-angiotensin system is activated in these patients, in part to preserve sodium homeostasis.

Internal mammary lymphoscintigraphy in breast carcinoma--a surgeon's perspective.

Internal mammary lymphoscintigraphy (IML) should now be considered a standard staging procedure in the present state of the art of the management of the patient with breast carcinoma. It provides clues for assessing the extent of disease and helps one to select individualized therapy. The interpretation is reliable enough in expert hands, to rule out the necessity of internal mammary node histopathologic diagnosis. In view of the significance of nodal invasion in relation to distant spread of the disease, one would be entitled to use this test as an indication for complementary systemic therapy when positive. On the other hand, if systemic therapy is to be employed without selection according to the multitude of relevant criteria, there may be no need to carry out this staging procedure prior to a management decision. The authors have reviewed their experience with more than 1000 examinations and have shown some of the practical implications of IML as a staging procedure as well as a guide to therapy.

Ambulatory use of inhaled beta(2)-agonists for the treatment of asthma in Quebec : a population-based utilization review.

STUDY OBJECTIVES: To assess whether the utilization of inhaled short-acting beta(2)-agonists (ISAB) and inhaled long-acting beta(2)-agonists (ILAB) for the treatment of asthma was appropriate according to the 1996 Canadian Asthma Consensus Conference recommendations. DESIGN: Population-based retrospective drug utilization review using pharmacists' billing data of the Prescription Drug Insurance Plan administered by the Quebec health insurance board. However, the database used did not contain complete patient clinical information to accurately assess severity of asthma. SETTING: Province of Quebec, Canada. PATIENTS: Persons who received at least one outpatient prescription of ISAB (age range, 5 to 45 years) or ILAB (age range, 12 to 45 years) for the treatment of asthma between August 1997 and April 1998. MEASUREMENTS: Percentages of patients whose use was appropriate according to three criteria regarding the average daily dose of ISAB (criterion 1), the renewal interval of ILAB (criterion 2), and the concomitant daily use of corticosteroids for the expected length of utilization of ILAB (criterion 3). RESULTS: Overall proportions of appropriate use according to criterion 1 were as follows: 75% (without inhaled corticosteroids [ICS]) and 84% and 43% (with one or more than one prescription of ICS, respectively). Appropriateness was slightly higher for female patients, younger patients (5 to 18 years old), and those treated by pediatricians. However, appropriateness was only 9% among patients who received at least two prescriptions of ISAB during the study period. The proportion of appropriate use was 19% according to criterion 2 and 15% according to criterion 3; there were few differences by gender or by age, but the appropriateness according to criterion 2 was somewhat higher for patients of respirologists. CONCLUSION: Compared to the 1996 Canadian asthma consensus conference recommendations, ISAB are overused, ICS are underused, and ILAB are often used improperly. Close collaboration between health professionals and patients is essential to improve the pharmacotherapy of asthma.

Drug treatment of stable angina pectoris and mass dissemination of therapeutic guidelines: a randomized controlled trial.

BACKGROUND: Public agencies responsible for implementing health care policies often adapt and disseminate clinical practice guidelines, but the effectiveness of mass dissemination of guidelines is unknown. AIM: To study the effects of guideline dissemination on physicians' prescribing practices for the treatment of stable angina pectoris. DESIGN: Randomized controlled trial. METHODS: A sample of 3293 Quebec physicians were randomly assigned to receive a one-page summary of clinical practice guidelines on the treatment of stable angina (in February 1999), to receive the summary and a reminder (in February and March 1999, respectively), or to receive no intervention (controls). The prescribing profiles of participants, as well as sociodemographic characteristics of the physicians and their patients, were examined for June-December 1999. RESULTS: The intervention had no effect on prescription rates of beta-blockers, antiplatelet agents, or hypolipaemic drugs. Compared to 1997 data for the same physicians, there was an overall 10% increase in appropriate prescription rates, irrespective of the intervention. DISCUSSION: In-house production and dissemination of clinical practice guidelines may not improve physicians' practice patterns if there is pre-existing substantial scientific consensus on the issue.

Are patients suffering from stable angina receiving optimal medical treatment?

There is good evidence for the use of antiplatelet, beta-blocker and lipid-lowering drugs in the treatment of ischaemic heart disease, but few data on how these medications are used in treating stable angina pectoris. We examined prescription profiles for a sample of patients aged > or =65 years with stable angina, to compare the profiles to local guidelines and to explore the determinants of these profiles, in a cross-sectional study. We identified 11 141 individuals from the Quebec provincial out-patient pharmaceutical database for the period 1 June 1996 to 31 May 1997, and examined the percentage of these patients with and without associated co-morbidities receiving antiplatelet, beta-blocker and lipid-lowering medications. We used hierarchical modelling to examine the role of patient and physician characteristics in explaining the variation in the use of these medications. Calcium-channel blockers were the class of anti-ischaemic drugs most prescribed (63%). Beta-blockers were prescribed in 52.1% of patients. Antiplatelet and lipid-lowering drugs were prescribed to 56.8% and 32.6%, respectively. Increasing age and female gender made patients less likely to be prescribed these treatments. General practitioners were less likely than cardiologists to prescribe beta-blockers and lipid-lowering drugs (OR 0.79, CI 95% 0.68-0.91 and OR 0.77, CI 95% 0.66-0.91, respectively). There is a general under-use of antiplatelet, beta-blocker and lipid-lowering medications in the treatment of stable angina pectoris patients, possibly leading to adverse patient outcomes.

A variable speed translating couch technique for total body irradiation.

We have developed a variable speed translating patient couch system for the delivery of total body irradiation (TBI). For a whole body Rando-type phantom, dose variation at mid-plane relative to the prescription point (navel) can be as high as 15% (neck or legs) with a constant velocity. By taking into account variations in body thickness, the intensity modulation radiation therapy, resulting from variable velocities, effectively delivers a uniform dose distribution at mid plane. The couch control user interface, technical aspects and dose planning optimization procedure for determining velocity distribution are described.

Vapors from collodion and acetone in an EEG laboratory.

In the many EEG laboratories, the collodion-acetone technique has lost favor because of offensive vapors. We measured vapor concentrations of diethyl ether and acetone, the two principal vapors from this technique, to determine whether they reached toxic levels. We found that diethyl ether vapors usually reached the olfactory threshold, but acetone concentration did not. Neither reached concentrations that were systemically toxic. We then developed an inexpensive, effective method of reducing concentrated vapors during electrode application and removal and documented a significant reduction in vapor concentrations. With this information and with an inexpensive, "in house" vapor extraction system, technologist and patient satisfaction with the collodion method should greatly improve.

Do ethnic groups use health services like the majority of the population? A study from Quebec, Canada.

The purpose of this study was to compare the use of medical services over a period of one year by members of ethnic groups and native Quebecers in Canada, while controlling for a number of confounding factors. The objective was to determine whether the two groups made the same number of medical visits to the same sites (private offices, outpatient clinic and emergency room and hospital inpatient care) and the same types of physicians (general practitioners, specialists). Two sources of data were used. The first was the Quebec Health Survey conducted in 1987 on a representative sample of 31,995 noninstitutionalized persons. Through personal interviews and self-administered questionnaires, data were collected on the demographic characteristics and health status of the respondents. The second source of data was the Quebec physician claims database, which contains a complete registry of services paid to physicians on a fee for service basis in the 12 months prior to the survey. The two databases were linked at the individual level (success rate is 88%). Members of ethnic groups aged 15 years and older were then individually matched to native Quebecers having the same six characteristics (age, gender, household income, access to health care facilities, perceived health and overall health). Final sample size was 1182 (divided equally into the two study groups). Results showed that neither the average number of medical services used over a year by the two groups nor the number of users differed. However, ethnic groups made more visits to specialists in private offices. Although not definite, possible explanations of these results are discussed. It is concluded that health care professionals should be sensitive to the particular needs of ethnic groups in order to provide them with accessible and appropriate services.

Efficacy of autotransfusion in spine surgery: comparison of autotransfusion alone and with hemodilution and apheresis.

STUDY DESIGN: Two prospective groups of patients received intraoperative autologous transfusion during reconstructive spine surgery. Before intraoperative autologous transfusion, one group underwent normovolemic hemodilution and apheresis of blood components in the operating room while being prepared for surgery. The allogeneic blood products needed for transfusion by each group were studied and compared with those of a retrospective group of patients receiving conventional transfusion therapy. OBJECTIVES: To determine if a combination of intraoperative autologous transfusion and hemodilution and apheresis decreases reliance on allogeneic blood products and increases autologous transfusions. SUMMARY OF BACKGROUND DATA: Transfusion rates of allogeneic red blood cells, which were unchanged by intraoperative autologous transfusion alone, were lowered when treatment included transfusion of these cells and preoperative autologous deposit. However, donor exposures from transfusions of allogeneic platelets and fresh frozen plasma have not been addressed. METHOD: Preoperative hemodilution and apheresis of autologous red blood cells, fresh plasma, and platelets, performed during induction of anesthesia for spine surgery was followed by intraoperative autologous transfusion using the same supplies. Intra- and postoperative transfusion of blood products to each group were evaluated and compared; allogeneic transfusions were given to a retrospective cohort of patients who received conventional transfusion therapy. RESULTS: Hemodilution and apheresis followed by intraoperative autologous transfusion reduced exposures to individual blood donor products resulting in fewer transfusions and in transfusion of significantly fewer blood products. Intraoperative autologous transfusion alone decreased the number of red blood cells transfused, but required the same donor exposures for fresh frozen plasma and platelet support as the cohort of patients who received conventional transfusion therapy. CONCLUSIONS: A combination of hemodilution and apheresis and intraoperative autologous transfusion significantly decreased transfusion of allogeneic blood products and reliance on preoperative autologous deposit. Autologous transfusion of all blood products was significantly increased.

Blastomycotic osteomyelitis of the pelvis: a case report.

Blastomycosis dermatitis is an unusual fungal infection that can become a diagnostic dilemma if a high index of suspicion is not maintained in patients who present with a chronic granulomatous infection of bone and soft tissue. We present a patient with a long history of pain, systemic manifestations of chronic infection, a draining sinus, and lytic changes on plain films to illustrate the difficulty in establishing the diagnosis. Appropriate staging studies and a bone biopsy led to the correct diagnosis in the patient.

Evaluation of the midwifery pilot projects in Quebec: an overview. L'Equipe d'Evaluation des Projets-Pilotes Sages-Femmes.

In 1990, the province of Quebec adopted a law authorizing the evaluation of the practice of midwifery through eight pilot projects. The projects, which took the form of birth centres outside hospitals, started operating in 1994. The objectives of the evaluation were 1) to compare midwives' services to current physician services with regard to maternal and neonatal mortality and morbidity, the use of obstetrical intervention, individualization and continuity of care as perceived by clients, and cost; and 2) to identify the professional and organizational factors associated with the integration of midwives into the health care system. A mixed evaluative design was used: a multiple case study with each pilot project representing a case and a cohort study where 1,000 women followed by midwives in the birth centres were matched with 1,000 women followed by physicians in the usual hospital-based services. Various quantitative and qualitative data collection instruments were used. Overall, many results were favourable to midwifery practice, while some were favourable to medical care. Following the evaluation, the Government of Quebec decided to legalize the practice of midwifery.

How different are users and non-users of alternative medicine?

PURPOSE: To determine whether users and non-users of alternative medicine in the province of Quebec differ in terms of demographic characteristics, health profile or utilization of medical services. METHODS: The Quebec Health Insurance Board (QHIB) medical service records of the Quebec Health Survey (1987) respondents for the 12 months before the survey were linked with respondents' survey answers. Those who saw an alternative medicine practitioner at their last professional consultation (the "users", n = 169) were matched by diagnosis and area of residence with those who saw a physician instead (the "non-users", n = 169). RESULTS: Users and non-users of alternative medicine differed in age, activity, education and income. After adjustment for age, education and income, the two groups had a similar health profile, but users of alternative medicine had made fewer medical visits in the previous year. CONCLUSION: Alternative medicine attracts a particular clientele. More research is needed to understand the reasons people look to alternative therapies instead of conventional medicine.

Cost-effectiveness of midwifery services vs. medical services in Quebec. LEquipe dEvaluation des Projets-Pilotes Sages-Femmes.

This study compared the cost-effectiveness of midwife services provided in birth centres operating as pilot projects with current hospital-based medical services in the province of Quebec. One thousand midwives' clients were matched with 1,000 physicians' clients on the basis of socio-demographic characteristics and obstetrical risk. Direct costs for the prenatal, intrapartum and postpartum periods were estimated. Effectiveness was assessed on the basis of three clinical indicators and four indices related to the individualization of care as assessed by women. Results show that the costs of midwife services were barely lower than or equal to those of physician services, but cost-effectiveness ratios were to the advantage of the midwife group, except for one clinical indicator (neonatal ventilation). Overall, this study provides rational support for the process of legalizing midwifery in the province.

Integration of midwives into the Quebec health care system. L'Equipe d'Evaluation des Projets-Pilotes Sages-Femmes.

This paper reports on one aspect of the evaluation of the midwifery pilot projects in Quebec: the identification of the professional and organizational factors, as well as the mode of integrating midwives into the maternity care system, that would promote the best outcomes and the autonomy of midwives. The research strategy involved a multiple-case study, in which each midwifery pilot project represented a case. Based on a qualitative approach, the study employed various sources of data: individual interviews and focus groups with key informants, site observations and analyses of written documents. Results show that midwives were poorly integrated into the health care system during the evaluation. Four main reasons were identified: lack of knowledge about the practice of midwifery on the part of other health care providers; deficiencies in the legal and organizational structure of the pilot projects; competition over professional territories; and gaps between the midwives' and other providers' professional cultures. Recommendations are provided to facilitate the integration of midwives into the health care system.