Postoperative delirium.

Delirium is a common complication during the postoperative period. Because of its significant associations with physical and cognitive morbidity, clinicians should be aware of the evidence-based practices relating to its diagnosis, treatment, and prevention. Here, we review select recent literature pertaining to the epidemiology and impact of postoperative delirium, the perioperative risk factors for its development and/or exacerbation, and the strategies for its management, with additional attention paid to the population of patients in intensive care units.

Barriers to mammography and Pap smear screening among women who recently had neither, one or both types of screening.

There is legitimate concern about whether cancer screening programs and other types of prevention and early detection programs are designed to reach those most in need of services. Previous research on barriers to screening has generally addressed screening for specific cancers. The purpose of this study was to evaluate and compare the types and strengths of barriers to both mammography and Pap smear screening experienced by three groups of women. Five hundred and twenty-two women, aged 52-69, who were members of a large health maintenance organization (HMO), completed a survey about cancer screening and associated barriers. Women with no mammogram in the preceding 2 years and with no Pap smear in 3 years were classified into a "safety net" program. We classified women as falling into both (Pap smear and mammography), one (Pap smear or mammography), or neither safety nets. Results consistently revealed that women needing both tests had more numerous and more intense barriers than other women to both types of screening. Factor analyses and descriptive analyses both showed that the types of barriers experienced were very similar for mammography and Pap smear screening. The discussion addresses intervention implications and the additional research needed on women who need both mammogram and Pap smear screening and who have much higher cancer risk than other women.

Sexual orientation and health: comparisons in the women's health initiative sample.

CONTEXT: Little is known about older lesbian and bisexual women. Existing research rarely compares characteristics of these women with comparable heterosexual women. OBJECTIVE: To compare heterosexual and nonheterosexual women 50 to 79 years on specific demographic characteristics, psychosocial risk factors, screening practices, and other health-related behaviors associated with increased risk for developing particular diseases or disease outcomes. DESIGN: Analysis of data from 93,311 participants in the Women's Health Initiative (WHI) study of health in postmenopausal women, comparing characteristics of 5 groups: heterosexuals, bisexuals, lifetime lesbians, adult lesbians, and those who never had sex as an adult. SETTING: Subjects were recruited at 40 WHI study centers nationwide representing a range of geographic and ethnic diversity. PARTICIPANTS: Postmenopausal women aged 50 to 79 years who met WHI eligibility criteria, signed an informed consent to participate in the WHI clinical trial(s) or observational study, and responded to the baseline questions on sexual orientation. MAIN OUTCOME MEASURES: Demographic characteristics, psychosocial risk factors, recency of screening tests, and other health-related behaviors as assessed on the WHI baseline questionnaire. RESULTS: Although of higher socioeconomic status than the heterosexuals, the lesbian and bisexual women more often used alcohol and cigarettes, exhibited other risk factors for reproductive cancers and cardiovascular disease, and scored lower on measures of mental health and social support. Notable is the 35% of lesbians and 81% of bisexual women who have been pregnant. Women reporting that they never had sex as an adult had lower rates of Papanicolaou screening and hormone replacement therapy use than other groups. CONCLUSIONS: This sample of older lesbian and bisexual women from WHI shows many of the same health behaviors, demographic, and psychosocial risk factors reported in the literature for their younger counterparts, despite their higher socioeconomic status and access to health care. The lower rates of recommended screening services and higher prevalence of obesity, smoking, alcohol use, and lower intake of fruit and vegetables among these women compared with heterosexual women indicate unmet needs that require effective interactions between care providers and nonheterosexual women.

A brief smoking cessation intervention for women in low-income planned parenthood clinics.

OBJECTIVES: The purpose of this study was to evaluate a brief smoking cessation intervention for women 15 to 35 years of age attending Planned Parenthood clinics. METHODS: Female smokers (n = 1154) were randomly assigned either to advice only or to a brief intervention that involved a 9-minute video, 12 to 15 minutes of behavioral counseling, clinician advice to quit, and follow-up telephone calls. RESULTS: Seventy-six percent of those eligible participated. Results revealed a clear, short-term intervention effect at the 6-week follow-up (7-day self-reported abstinence: 10.2% vs 6.9% for advice only, P < .05) and a more ambiguous effect at 6 months (30-day biochemically validated abstinence: 6.4% vs 3.8%, NS). CONCLUSIONS: This brief, clinic-based intervention appears to be effective in reaching and enhancing cessation among female smokers, a traditionally underserved population.

Concern about weight gain associated with quitting smoking: prevalence and association with outcome in a sample of young female smokers.

This study investigated the relationship between weight gain concern and outcomes of a large-scale smoking cessation study among 506 young female smokers attending Planned Parenthood clinics. Results of this prospective study did not support the clinical importance of weight gain concerns. Using an index of weight concern that was predictive in previous research, baseline weight concern was unrelated to smoking cessation efforts, whether participants made a quit attempt, reduced the number of cigarettes they smoked, or reported a change in self-efficacy for stopping smoking. Both the overall level of concern expressed in this sample of predominantly White young women and the lack of relationship between weight gain concern and smoking cessation outcomes suggest that weight gain concern may not be a critical factor for cessation programs targeting similar female smokers.

Recent patterns of hormone replacement therapy use in a large managed care organization.

Rates of hormone replacement therapy (HRT) in women have varied substantially over the last 25 years. Data on the impact of recent recommendations for widespread use to prevent cardiovascular disease and osteoporosis and factors that influence use are needed. We attempted to (1) describe recent trends in HRT use, (2) investigate the relationship between HRT use and prepaid drug benefit, and (3) detail prescribing frequencies by provider specialty. We conducted a cross-sectional analysis of annual HRT pharmacy dispensings from 1986 to 1995 in a large HMO to all female HMO members aged 45 years and older. HRT rates increased among all age categories, although the magnitude of change varied by age. Highest rates of use were found in those 50-59 years old. Although combined estrogen-progestin use increased, 57% of all estrogen users did not receive progestin in 1995. Unopposed estrogen use was largely limited to hysterectomized women. Women of all ages with no prepaid drug benefit as part of their HMO coverage had the lowest HRT rates. Internal medicine, obstetrics/gynecology, and family practice providers prescribed over 90% of HRT, and prescriber specialty varied with user age. HRT use increased in the HMO from 1986 to 1995, especially among younger women. In 1995, about half of women aged 50-64 years received one or more HRT dispensings. As the benefits, risks, and cost effectiveness of HRT depend on the duration of use, additional information on current use duration is needed. Combined estrogen-progestin use increased and appeared appropriate to hysterectomy status. Research is needed to determine if lower HRT use rates among women without a prepaid drug benefit indicate less prophylactic HRT use, particularly among younger women, for whom this lack of coverage was relatively common.

The medical care system and prevention: the need for a new paradigm.

The American medical care system falls to provide effective prevention services even though some prevention services are among the most cost-effective medical procedures available. Many prevention services are routinely delivered in inefficient or ineffective ways, and new technologies may be widely and aggressively implemented despite serious doubts about their efficacy and cost-effectiveness. The barriers to effective prevention services result from conceptual limitations in our model of medical care systems, particularly the lack of a population-based perspective. A change in paradigm is needed before reforms in our health care system can improve health without bankrupting the nation.

Reaching those most in need: participation in a Planned Parenthood smoking cessation program.

We evaluated the representativeness of women approached and enrolled in a brief smoking cessation intervention conducted in Planned Parenthood clinics. In this effectiveness study, regular clinic staff were trained to identify, offer participation, and counsel willing smoking clients as part of their clinic visit. Chart audits were conducted to determine the percent of clients who had smoking status identified, as well as the percent and characteristics of potentially eligible clients who were not approached. Baseline and non-participant questionnaires were analyzed to determine participation rate and characteristics of those participating versus those not participating. Smoking status was documented in 99% of charts. Seventy percent of eligible smokers were approached about study participation and 74% of those approached participated. There were no significant differences between those approached and those not approached or between those who participated versus those who did not on a host of sociodemographic variables. This project was able to approach and attract a representative sample of young, lower income women to participate in a brief, clinic-based smoking cessation program.

Does gender affect response to a brief clinic-based smoking intervention?

INTRODUCTION: Although recent reviews suggest few gender differences in smoking-cessation outcomes, it is important to establish whether gender differences exist in response to the brief interventions increasingly recommended as part of routine medical care. METHODS: We used data from an efficacious primary care-based smoking intervention to examine gender differences in smoking characteristics, use of intervention components, self-reported quitting activities, and cessation outcomes among all smokers randomized to receive clinician advice and nurse-assisted intervention (n = 1,978, 58% female). RESULTS: Although female and male smokers differed on a number of sociodemographic and smoking-related characteristics, they were equally likely to participate in each step of the recommended intervention. Female and male smokers were also equally likely to report quit attempts and cessation at 3, 12, and 3 and 12 months (combined long-term cessation endpoint). Similarly, no gender difference in relapse at 12 months was seen. Women attempting to quit used a greater number and variety of smoking-cessation strategies, suggesting that, although outcomes were similar, the processes of cessation may vary by gender. CONCLUSIONS: Since this brief intervention in primary care was equally efficacious and acceptable to female and male smokers, broader implementation in medical settings of this population-based approach to reducing tobacco use is warranted. Indeed, widespread implementation of smoking-cessation programs in medical settings may particularly benefit women, who are more likely than men to have contacts with the medical care system.

Firearm ownership and health care workers.

OBJECTIVE: Health professionals have increasingly become aware of the public health hazards caused by firearms. This study was designed to determine the firearm ownership and storage practices of a group of health care workers. METHODS: All 6436 nonphysician employees of a large health maintenance organization were surveyed as part of an ongoing effort to enhance the organization's effectiveness. Two questions regarding firearm ownership and storage practices were included in the 85-question survey instrument. A total of 4999 surveys were returned, for a response rate of 78%. RESULTS: Forty-two percent of the health workers surveyed reported keeping a firearm in their home, and 35% of firearm owners stored that firearm loaded. Men were more likely than women to report having a firearm in the home. Firearm ownership and storage of a loaded firearm decreased with higher levels of education in both sexes. A measure of increased alcohol consumption was related to higher rates of firearm ownership and storage of loaded firearms in men. CONCLUSIONS: A substantial number of health care workers had firearms in their homes and did not store them safely. Counseling regarding the risks associated with easy access to firearms should be considered for inclusion in employee health programs as well as in employee assistance and alcohol treatment programs.

Smoking characteristics of female veterans.

Recent studies suggest that the prevalence of smoking among active duty military women is higher than that of active duty military men or civilians of either gender. No data have been published on cessation rates among female veterans. We wanted to report such rates in a group of female veterans at Pettis VAMC Preventive Medicine Clinic and to study predictive factors for smoking cessation and prevention. We identified female patients at Pettis VAMC Preventive Medicine Women's Clinic who had received services in the past 3 years or who enrolled as new patients during the study period; 529 received questionnaires by mail or at the clinic; 409 returned completed surveys. A high proportion (32.5%) of our sample of female veterans were current smokers, and 67% of female veteran smokers reported smoking at least one pack daily. More than one-third of ever-smokers began smoking during military service. Thirty-nine percent of the female veteran sample had CES-D scores of 16 or greater, and current smokers had significantly greater mean CES-D scores than former smokers. Twenty-three percent of current smokers had high nicotine dependence scores (> 7). The highest proportion of CES-D scores compatible with depressive symptoms (55%) was seen among current smokers who consumed a pack or more of cigarettes per day. Ever-smokers who screened as depressed were significantly less likely to have quit than those with lower CES-D scores; however, in multivariate models, CES-D scores were not significantly related to cessation. The prevalence of current, ever, and heavy smoking was high among this sample of female veterans attending a VAMC Preventive Medicine clinic. An unexpectedly high prevalence of screening scores compatible with depression was found among this sample, particularly among smokers. This warrants further investigation, particularly in light of the reported relationship between depression and smoking.

Report from AMRA manpower survey. Part III: Non-management positions.

This is the third in a series of three articles reporting results of the 1986 AMRA Manpower Survey. The purpose of this article is to provide information on the following non-management positions: coding, transcription, record deficiency analysis, release of information, record retrieval/filing, and general clerical. The first article described the survey and provided information on directors of medical record departments. The second article addressed other management positions in the medical record department.

Comparative effects of cocaine and pseudococaine on EEG activities, cardiorespiratory functions, and self-administration behavior in the rhesus monkey.

The effects of cocaine and pseudococaine on the EEGs, heart and respiratory rates, and self-administration behavior were studied in rhesus monkeys. An intravenous injection of cocaine (2.5 and 4.0 mg/kg) in the monkey produced low-voltage fast waves (LVFWs) in the EEGs and behavioral hyperexcitation accompanied by marked increases in the heart and respiratory rates with mydriasis and excessive salivation. In contrast, pseudococaine produced high-voltage slow waves (HVSWs) in the EEGs and behavioral depression accompanied by the same symptoms of the autonomic functions as those produced by cocaine. Both isomers were self-administered by the monkeys. During cocaine self-administration sessions, the animals showed hyperexcitation in their overall behavior, while with pseudococaine they showed almost normal behavioral responses. These results suggest that cocaine produced excitatory effects and pseudococaine inhibitory effects on the EEGs and behavior. Both isomers stimulate the heart and respiratory rates, and were self-administered by the monkeys.

Radioimmunoassay of drugs subject to abuse: critical evaluation of urinary morphine-barbiturate, morphine, barbiturate, and amphetamine assays.

Radioimmunoassays for morphine-barbiturate (MOR-BARB), morphine, barbiturate, and amphetamine were evaluated by a direct comparison with differential elution extraction thin-layer chromatography, the "enzyme multiplied immunoassay technique," and XAD-2 resin extraction thin-layer chromatography for the detection in urine of drugs subject to abuse. Statistically significant (Psmaller than 0.01) concentrations for detection were: 50-100 mug/liter for MOR-BARB; 5 Mug/liter for morphine, 10 mug/liter for barbiturate, and 100 mug/liter for amphetamine. Unconfirmed and unaccounted-for radioimmunoassay positives (false) were: 0% for morphine in the radioimmunoassay for MOR-BARB and that for morphine alone; 2.8% for barbiturates in the MOR-BARB assay and that for barbiturates alone; 0-6% when a combination of these drugs was present in the MOR-BARB, morphine, or barbiturate assay; and 2.4% in the amphetamine radioimmunoassay. Less than 1% of all radioimmunoassay-negative samples were unconfirmed (false). Cross-reactivity was observed with drugs of a similar chemical structure in each of the radioimmunoassays tested. All the radio-immunoassays were easy to use, highly sensitive, and extremely reliable for detecting drug use or abuse.