Cognitive control of attention is differentially affected in trauma-exposed individuals with and without post-traumatic stress disorder.

BACKGROUND: This study aimed to determine whether patients with post-traumatic stress disorder (PTSD) show difficulty in recruitment of the regions of the frontal and parietal cortex implicated in top-down attentional control in the presence and absence of emotional distracters. METHOD: Unmedicated individuals with PTSD (n = 14), and age-, IQ- and gender-matched individuals exposed to trauma (n = 15) and healthy controls (n = 19) were tested on the affective number Stroop task. In addition, blood oxygen level-dependent responses, as measured via functional magnetic resonance imaging, were recorded. RESULTS: Patients with PTSD showed disrupted recruitment of lateral regions of the superior and inferior frontal cortex as well as the parietal cortex in the presence of negative distracters. Trauma-comparison individuals showed indications of a heightened ability to recruit fronto-parietal regions implicated in top-down attentional control across distracter conditions. CONCLUSIONS: These results are consistent with suggestions that emotional responsiveness can interfere with the recruitment of regions implicated in top-down attentional control; the heightened emotional responding of patients with PTSD may lead to the heightened interference in the recruitment of these regions.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea.

BACKGROUND: The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking. AIM: To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards. METHODS: A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively. FINDINGS: Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset. CONCLUSION: HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Tolerability and efficacy of carvedilol in patients with New York Heart Association class IV heart failure.

OBJECTIVES: The purpose of this study was to assess the tolerability and efficacy of carvedilol in patients with New York Heart Association (NYHA) functional class IV symptoms. BACKGROUND: Carvedilol, a nonselective beta-adrenergic blocking drug with alpha-adrenergic blocking and antioxidant properties, has been shown to improve left ventricular function and clinical outcome in patients with mild to moderate chronic heart failure. METHODS: We retrospectively analyzed the outcomes of 230 patients with heart failure treated with carvedilol who were stratified according to baseline functional class: 63 patients were NYHA class IV and 167 were NYHA class I, II or III. Carvedilol was commenced at 3.125 mg b.i.d. and titrated to 25 mg b.i.d. as tolerated. Patients with class IV symptoms were older (p = 0.03), had lower left ventricular fractional shortening (p < 0.001), had lower six-min walk distance (p < 0.001) and were receiving more heart failure medications at baseline compared with less symptomatic patients. RESULTS: Nonfatal adverse events while taking carvedilol occurred more frequently in class IV patients (43% vs. 24%, p < 0.0001), and more often resulted in permanent withdrawal of the drug (25% vs. 13%, p < 0.01). Thirty-seven (59%) patients who were NYHA class IV at baseline had improved by one or more functional class at 3 months, 8 (13%) were unchanged and 18 (29%) had deteriorated or died. Among the less symptomatic group, 62 (37%) patients had improved their NYHA status at 3 months, 73 (44%) were unchanged and 32 (19%) had deteriorated or died. The differences in symptomatic outcome at three months between the two groups were statistically significant (p = 0.001, chi-square analysis). Both groups demonstrated similar significant improvements in left ventricular dimensions and systolic function. CONCLUSIONS: Patients with chronic NYHA class IV heart failure are more likely to develop adverse events during initiation and dose titration when compared with less symptomatic patients but are more likely to show symptomatic improvement in the long term. We conclude that carvedilol is a useful adjunctive therapy for patients with NYHA class IV heart failure; however, they require close observation during initiation and titration of the drug.

A national survey of the home visiting practice and attitudes of family physicians and internists.

BACKGROUND: Over the past decade, while physician home visiting has continued to decline, the home care industry has been experiencing dramatic growth. In response, several major physician organizations have been encouraging increased physician education and involvement in home care and urging related health policy changes. This study provides the first in-depth, nationally representative descriptive data on the current home visiting practice and related attitudes of physicians. METHODS: Data were gathered through a structured 15-minute telephone survey, consisting of 141 items covering physician's general practice, personal home visiting practice, interaction with other home care providers, and attitudes regarding home care issues. Subjects were a nationally representative, randomly selected sample of 2200 family practice physicians (FPs) and internal medicine physicians (IMs) currently in active practice with at least 10 hours per week of professional time spent in ambulatory care. RESULTS: Sixty-five percent of eligible participants completed the survey. Of all physicians surveyed, 65% of FPs and 44% of IMs reported that they may make house calls (P less than .001). Mean number of visits per year was 21.2 (median, 10) for FPs, and it was 15.7 (median, 6) for IMs. Physicians in rural practice were more likely to make home visits (P less than .001). Physician attitudes related to home care reflect a strong dissatisfaction with reimbursement, but positive opinions about the use of other home care professionals and the importance of home visits for selected patients. Logistic regression analysis comparing home-visiting physicians with non-visiting physicians allowed for prediction of the correct classification 73% of the time, and it revealed six variables that were significant predictors of home visiting. The strongest of these predictors were the physician's positive attitude regarding the importance of home visits for selected patients and his or her perception of having time available for home visits. Other significant variables predictive of home visiting were family practice specialty, rural location of practice, greater numbers of referrals to home care agencies, and, interestingly, dissatisfaction with reimbursement. CONCLUSIONS: Although the great majority (over 75%) of FPs and IMs still regard the physician home visit as important for the care of selected patients, only about half report making one or more home visits within a 12-month period. Family physicians generally report a greater involvement in home care than do IMs. Physician reimbursement for home visits is perceived to be inadequate, and almost half (45%) indicate that they would do more home visits if reimbursement were increased. Most physicians (over 80%) have the opinion that home care agencies should be used more.

An epic year for a great society.

As 2005 comes to a close, I have been asked to summarize the year's accomplishments and efforts at the County level. In many ways HCMS reminds me of "the little engine that could"-aided by a single, extremely dedicated and talented staffer and bolstered by an all volunteer army of selfless professionals with a focused Executive Committee at the helm, we have indeed "chugged up that big hill" in taking on a variety of traditional and not-so-traditional challenges.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection.

OBJECTIVE: Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV. METHOD: The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study. RESULTS: HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder. CONCLUSIONS: Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV Cost and Services Utilization Study.

PURPOSE: To measure health-related quality of life among adult patients with human immunodeficiency virus (HIV) disease; to compare the health-related quality of life of adults with HIV with that of the general population and with patients with other chronic conditions; and to determine the associations of demographic variables and disease severity with health-related quality of life. SUBJECTS AND METHODS: We studied 2,864 HIV-infected adults participating in the HIV Cost and Services Utilization Study, a probability sample of adults with HIV receiving health care in the contiguous United States (excluding military hospitals, prisons, or emergency rooms). A battery of 28 items covering eight domains of health (physical functioning, emotional well-being, role functioning, pain, general health perceptions, social functioning, energy, disability days) was administered. The eight domains were combined into physical and mental health summary scores. SF-36 physical functioning and emotional well-being scales were compared with the US general population and patients with other chronic diseases on a 0 to 100 scale. RESULTS: Physical functioning was about the same for adults with asymptomatic HIV disease as for the US population [mean (+/- SD) of 92+/-16 versus 90+/-17) but was much worse for those with symptomatic HIV disease (76+/-28) or who met criteria for the acquired immunodeficiency syndrome (AIDS; 58+/-31). Patients with AIDS had worse physical functioning than those with other chronic diseases (epilepsy, gastroesophageal reflux disease, clinically localized prostate cancer, clinical depression, diabetes) for which comparable data were available. Emotional well-being was comparable among patients with various stages of HIV disease (asymptomatic, 62+/-9; symptomatic, 59+/-11; AIDS, 59+/-11), but was significantly worse than the general population and patients with other chronic diseases except depression. In multivariate analyses, HIV-related symptoms were strongly associated with physical and mental health, whereas race, sex, health insurance status, disease stage, and CD4 count were at most weakly associated with physical and mental health. CONCLUSIONS: There is substantial morbidity associated with HIV disease in adults. The variability in health-related quality of life according to disease progression is relevant for health policy and allocation of resources, and merits the attention of clinicians who treat patients with HIV disease.

Optimization of left ventricular function with carvedilol before high-risk cardiac surgery.

Patients with severe left ventricular dysfunction and symptomatic heart failure caused by ischemic or valvular heart disease face a high morbidity and mortality risk from cardiac surgery. We present data showing that excellent surgical outcome can be achieved after pre-treatment of such patients with carvedilol.

Screening elders for risk of hospital admission.

OBJECTIVE: To define a set of screening criteria that identifies elders who are at high risk for repeated hospital admission in the future. DESIGN: Longitudinal cohort study. Logistic regression analysis of data from half of the subjects was used to identify risk factors for repeated hospital admission. The ability of these risk factors to identify elders who are at high risk for repeated hospitalization in the future was then tested using data from the other half of the subjects. SETTING: United States. PARTICIPANTS: A subsample (n = 5876) of a multistage probability sample of all non-institutionalized U.S. civilians who were 70 years or older in 1984. MEASUREMENTS: At baseline (1984), elderly subjects were asked about their demographic, socioeconomic, medical, and functional characteristics and about their recent use of health services. Their subsequent hospital admissions and mortality were then monitored through the records of the Medicare program and the National Death Index (1985-88). RESULTS: Among the subjects in the first half of the sample, eight factors emerged as risk factors for repeated admission: older age, male sex, poor self-rated general health, availability of an informal caregiver, having ever had coronary artery disease, and having had, during the previous year, a hospital admission, more than six doctor visits, or diabetes. Based on the presence or absence of these factors in 1984, 7.2% of the subjects in the second half of the sample were estimated to have a high probability of repeated admission (Pra > or = 0.5) during 1985-1988. In comparison with subjects estimated to have a low risk (Pra < 0.5), this high-risk group's actual experiences during 1985-1988 included a higher cumulative incidence of repeated admission (41.8% vs 26.2%, P < 0.0001), a higher cumulative rate of mortality (44.2% vs 19.0%, P < 0.0001), more hospital days per person-year survived (5.2 vs 2.6), and higher hospital charges per person-year survived ($3731 vs $1841). CONCLUSION: Eight easily ascertained risk factors affect elders' probability of being hospitalized repeatedly within four years. In the future, brief surveys about the presence of these factors could be used to estimate elders' risk of future hospitalization and, thereby, to identify some of those who may derive the greatest benefit from interventions designed to avert the need for hospitalization.

Changes in health-promoting behavior following diagnosis with HIV: prevalence and correlates in a national probability sample.

Diet, exercise, smoking, and substance use patterns affect the course of illness and quality of life for people with HIV. In interviews with a national probability sample of 2,864 persons receiving HIV care, it was found that most had made health-promoting changes in one or more of these behaviors since diagnosis. Many reported increased physical activity (43%) and improved diet (59%). Forty-nine percent of cigarette smokers quit or cut down; 80% of substance users did so. Desire for involvement in one's HIV care and information seeking-positive coping were the most consistent correlates of change. Other correlates varied by health practice but included health status, emotional well-being, demographics, and attitudes toward other aspects of HIV care. Most people with HIV improve their health behavior following diagnosis, but more might be helped to do so by targeting these behaviors in future interventions.

Hardcore drug users claim to be occasional users: drug use frequency underreporting.

Self-reports of drug use frequency are central to treatment outcome evaluations, estimates of the prevalence of heavy use, estimates of treatment need, and other questions with direct relevance to drug policies. Nevertheless, surprisingly little is known about the validity of these self-reports. This study examines the accuracy of 701 frequency self-reports made by a sample of methadone maintenance clients. Self-report accuracy is evaluated by comparing rates of positive urinalyses found for each case with rates that would be expected had drug use occurred only as often as reported. Expected rates of positive urinalyses are derived from conservative Monte Carlo models of drug use for each case. This procedure reveals extensive heroin and cocaine use frequency underreporting. After adjusting for frequency underreporting, 51% of 279 cases reporting only occasional heroin use (1-10 days in the past 30), and 22% of the 157 cases reporting occasional cocaine use, are found to be using these drugs with frequencies corresponding to what the Office of National Drug Control Policy defines as 'hardcore use' (more than 10 days in the past 30). Drug use frequency underreporting appears substantial, and might constitute an important threat to the validity of some treatment outcome evaluations, needs assessments and other analyses that rely on drug use frequency self-reports.

Allocative efficiency of case managers for the elderly.

This study presents an analysis of the allocative efficiency of case managers for the community-based elderly in an environment in which case management and a range of home and community-based services were available and directly linked to a mandatory preadmission screening program for nursing home applicants. We collected data for a one-year follow-up period on client placement, health and functional status, informal support, and use of health and social services for clients in two urban and two rural counties that participated in the Minnesota Pre-Admission Screening/Alternative Care Grants Program (PAS/ACG). We found that among those receiving ACG-supported services, the relationship between variation in the level of support for home and community-based services and the length of time elderly clients remained in the community suggested that case managers were allocating home and community-based services in a reasonably efficient manner. This finding offers support for using case managers to target services to the elderly.

National probability samples in studies of low-prevalence diseases. Part II: Designing and implementing the HIV cost and services utilization study sample.

OBJECTIVE: The design and implementation of a nationally representative probability sample of persons with a low-prevalence disease, HIV/AIDS. DATA SOURCES/STUDY SETTING: One of the most significant roadblocks to the generalizability of primary data collected about persons with a low-prevalence disease is the lack of a complete methodology for efficiently generating and enrolling probability samples. The methodology developed by the HCSUS consortium uses a flexible, provider-based approach to multistage sampling that minimizes the quantity of data necessary for implementation. STUDY DESIGN: To produce a valid national probability sample, we combined a provider-based multistage design with the M.D.-colleague recruitment model often used in non-probability site-specific studies. DATA COLLECTION: Across the contiguous United States, reported AIDS cases for metropolitan areas and rural counties. In selected areas, caseloads for known providers for HIV patients and a random sample of other providers. For selected providers, anonymous patient visit records. PRINCIPAL FINDINGS: It was possible to obtain all data necessary to implement a multistage design for sampling individual HIV-infected persons under medical care with known probabilities. Taking account of both patient and provider nonresponse, we succeeded in obtaining in-person or proxy interviews from subjects representing over 70 percent of the eligible target population. CONCLUSIONS: It is possible to design and implement a national probability sample of persons with a low-prevalence disease, even if it is stigmatized.

Racial differences in functional status among elderly U.S. migrants from the South.

This study describes patterns of functional status among older blacks and whites by their history of birth in and migration out of the South. We used multivariate regression to analyze data on functional status of US-born non-Hispanic blacks (N = 1868) and whites (N = 13469) age 60 years or above. In general, the functional status of blacks who were born in the South and migrated was similar to that of blacks born outside the South and better than those born in the South who did not migrate. Whites who migrated from the South had functional status similar to those who did not migrate and worse than those born outside of the South. Socioeconomic status did not explain differences by race and migration history. These results differ sharply from mortality studies, which have found a consistent pattern of high mortality among black migrants from the South. Differences among race groups by migration history vary across health measures. Selective migration and selective survival may account for the complex patterns of racial differences in geographic distributions of function and health.

Effects of incentive size and timing on response rates to a follow-up wave of a longitudinal mailed survey.

Young adults who had previously participated in a longitudinal survey of youth were sent a questionnaire. They were randomly assigned to receive a $20 prepayment, a $20 postpayment, or a $25 postpayment for participation in the latest survey. Those in the large incentive condition were 7 percentage points more likely to return a survey than those in the smaller, postpayment group. Prepayment had a smaller, less reliable effect. Effects of incentive magnitude and timing were consistent at each month of the study period; only better high school grades distinguished early responders from late responders. Nonresponders had characteristics suggestive of low social conformity and were more likely than responders to be African American and male and have low SES. The discussion centers on motivations for participating in research and differences in the incentives likely to promote continued response versus initial study enrollment.

A clinical trial of the American Heart Association step one diet for treatment of hypercholesterolemia.

BACKGROUND: Although diet therapy is the primary treatment for hypercholesterolemia, a trial to determine the effectiveness of the new American Heart Association Step One Diet (AHA diet) in lowering cholesterol has to our knowledge never been carried out. METHODS: A clinical trial was conducted to assess the plasma lipids response and adherence to the AHA diet in 120 men and women with hypercholesterolemia. All subjects were advised to follow the AHA diet for 18 weeks. RESULTS: After 6 weeks of the AHA diet intervention, there were modest but significant reductions in plasma total cholesterol (-2.6%) and low-density lipoprotein (LDL) cholesterol (-3.5%), but no further significant reductions were observed thereafter. Rather, there was a tendency to return to and even exceed baseline levels of total cholesterol and LDL cholesterol over the subsequent 12 weeks, in spite of the subjects' reported continued adherence to the AHA diet and maintenance of weight loss throughout the entire study period. Nevertheless, 51% of the subjects had experienced improvement (-0.2% to -26.3%) in their plasma LDL cholesterol levels by the end of the study. CONCLUSIONS: A probable reason for the limited response of the diet was low baseline levels in intake of saturated fat and cholesterol by participants. The subjects who were older and had higher levels of plasma LDL cholesterol and total fat intake at baseline experienced better plasma LDL cholesterol response to the AHA diet. Thus, practicing physicians should consider assessing the baseline dietary fat and cholesterol intake of patients with hypercholesterolemia before starting the AHA diet, since patients may already be following a relatively prudent self-selected diet. Additional dietary gains in lipid management might well require a more severe restriction of dietary fats and cholesterol. Long-term efficacy of the AHA diet should also be evaluated clinically with periodic lipid profiles.

A clinical trial of oat bran and niacin in the treatment of hyperlipidemia.

BACKGROUND: Previous studies have demonstrated the lipid-lowering potential of wax-matrix controlled-release forms of nicotinic acid, but questions have been raised about the risks associated with long-term use. This report describes a 38-week trial that was designed as a follow-up to a shorter 16-week clinical trial of wax-matrix controlled-release niacin. The present study also tested the hypothesis that niacin (1500 mg/d) and oat bran (56 g/d [2 oz/day]) may have a synergistic effect on improving serum lipid levels. METHODS: Ninety-eight subjects began the following protocol: oat bran alone (6 weeks), oat bran plus niacin (6 weeks), and niacin alone (32 weeks). Blood lipids, blood chemistries, nutritional variables, and side-effect profiles were monitored throughout the study. Sixty-nine (70%) subjects completed the trial taking the full dose of niacin (1500 mg/d); 8 subjects completed the trial taking a reduced dose of niacin (average 906 mg/d); 11 discontinued taking any niacin because of either intolerable side effects (n = 7) or liver enzyme abnormalities (n = 4). RESULTS: Generally, oat bran-niacin synergism was not found. Only 10% of subjects who completed the study showed greater than expected lipid improvement on combination therapy. From baseline to the end of the final phase, significant reductions (P less than .05) occurred for total cholesterol (-10%) and low-density lipoprotein cholesterol (-16%). High-density lipoprotein cholesterol rose significantly at the end of the oat bran plus niacin phase, but returned to near baseline by the end of the study. The liver enzymes alkaline phosphatase, lactate dehydrogenase, and aspartate aminotransferase all showed a tendency to rise throughout the study. CONCLUSIONS: The results of this 38-week trial suggest that the relatively inexpensive wax-matrix form of niacin is effective and reasonably well tolerated. Approximately 8% of subjects were unable to continue taking niacin because of side effects, and 4% discontinued taking niacin because of liver enzyme elevations. A small group of subjects (10%) experienced greater than expected lipid improvements (synergism) on combined oat-bran and niacin therapy. Liver function monitoring with long-term use of niacin is warranted.

Pseudarthrosis of femoral neck stress fracture treated with open reduction, sliding hip screw and bone morphogenic protein.

INTRODUCTION: Pseudarthrosis of femoral neck stress fractures in young adults are associated with a high incidence of complications and revision surgery. The majority are treated urgently with closed reduction and internal fixation. PRESENTATION OF CASE: We describe a displaced tension-type femoral neck fatigue fracture presenting late. Pseudarthrosis formation prior to surgery resulted in resorption and shortening of the femoral neck. Open reduction and internal fixation was performed, with adjuvant recombinant human bone morphogenic protein-7 therapy. Radiological union was achieved by twelve weeks and by one year the patient was asymptomatic. DISCUSSION: Reports of successful management of femoral neck fatigue fracture non-unions are rare. Meyer's muscle pedicle graft, valgus subtrochanteric osteotomy, and cannulated screw fixation with autologous iliac crest bone graftare alternative procedures. CONCLUSION: This extremely rare fracture type merits open reduction to enable accurate fracture reduction. Supplementing sliding hip screw fixation with an orthobiological agent was successful in this challenging situation.