Exercise to Reduce Posttraumatic Stress Disorder Symptoms in Veterans.

Background: Physical exercise offers benefits for treating psychological disorders, particularly depression. Exercise is associated with reduction of posttraumatic stress disorder (PTSD) symptoms in civilians. Given the comorbidities and unique trauma experiences of the veteran population, the current work aims to estimate the effect of exercise on PTSD symptoms in veteran samples. Observations: A systematic review identified 6 single-arm studies and 3 randomized controlled trials (RCTs) using exercise as an interventional treatment among veteran samples with full or subsyndromal PTSD. Most single-arm studies used yoga-based interventions, whereas RCTs showed more variety and included yoga, aerobic activity, and resistance exercises. Data synthesis of study results revealed a medium standardized mean difference for the single-arm trials (Hedges g, -0.60, P = .03) and a small-to-medium standardized mean difference for the RCTs (Hedges g, -0.40, P = .06). Single-arm studies were all rated at serious risk of bias. Only 1 RCT was rated at high risk of bias, although the remaining RCTs showed some concern of elevated bias. Conclusions: There is preliminary evidence that exercise may be a useful treatment option for PTSD symptom reduction in veterans. Our review also highlights the need for additional high-quality randomized trials to confirm the benefits of exercise for PTSD symptom reduction in veterans.

Prior pneumococcal and influenza vaccinations and in-hospital outcomes for community-acquired pneumonia in elderly veterans.

BACKGROUND: Studies of adults hospitalized for community-acquired pneumonia (CAP) reported better outcomes associated with prior pneumococcal vaccination (PV), suggesting potential additional benefits of PV in hospitalized CAP patients. Influenza (flu) vaccination (FV) could independently/additively improve CAP outcomes in hospitalized patients. OBJECTIVE: To examine the effect of prior PV and FV on in-hospital outcomes in elderly veterans hospitalized for CAP. DESIGN: Retrospective cohort study. SETTING AND PATIENTS: A total of 6,723 elderly veterans who were admitted to Veterans Affairs hospitals for CAP between October 1, 2002 and September 30, 2003. INTERVENTION: PV in the 5 years and FV in the 1 year before admission. MEASUREMENTS: The association of prior PV and/or FV with inpatient mortality and length of stay (LOS) (primary) and risk of any bacteremia and respiratory complications (secondary) were assessed using logistic regressions and generalized linear model, controlling for patient demographic and clinical characteristics. RESULTS: Prior PV alone was not associated with shortened LOS, or reduced risk of inpatient mortality or respiratory complications. Lower risk of bacteremia was associated with prior PV (odds ratio: 0.66; 95% confidence interval [CI]: 0.48-0.90). After adjusting for patients' characteristics, risk of inpatient mortality was not statistically significantly different across the vaccination groups, but having had both PV and FV before CAP admission was associated with a 10% reduction in LOS (95% CI: 0.86-0.95) compared to having had neither vaccinations. CONCLUSION: Significant survival benefit and improved in-hospital outcomes may not be expected among CAP-hospitalized elderly patients with prior PV alone. However, having both PV and FV before CAP admission may reduce LOS.

Cost-effectiveness and diagnostic effectiveness analyses of multiple algorithms for the diagnosis of Lynch syndrome.

BACKGROUND AND AIMS: The optimal algorithm to identify Lynch syndrome (LS) among patients with colorectal cancer (CRC) is unclear. The definitive test for LS, germline testing, is too expensive to be applied in all cases. Initial screening with the revised Bethesda Guidelines (RBG) cannot be applied in a considerable number of cases due to missing information. METHODS: We developed a model to evaluate the cost-effectiveness of 10 strategies for diagnosing LS. Three main issues are addressed: modeling estimates (20-40%) of RBG applicability; comparing sequential or parallel use of microsatellite instability (MSI) and immunohistochemistry (IHC); and a threshold analysis of the charge value below which universal germline testing becomes the most cost-effective strategy. RESULTS: LS detection rates in RBG-based strategies decreased to 64.1-70.6% with 20% inapplicable RBG. The strategy that uses MSI alone had lower yield, but also lower cost than strategies that use MSI sequentially or in parallel with IHC. The use of MSI and IHC in parallel was less affected by variations in the sensitivity and specificity of these tests. Universal germline testing had the highest yield and the highest cost of all strategies. The model estimated that if charges for germline testing drop to $633-1,518, universal testing of all newly diagnosed CRC cases becomes the most cost-effective strategy. CONCLUSIONS: The low applicability of RBG makes strategies employing initial laboratory-based testing more cost-effective. Of these strategies, parallel testing with MSI and IHC offers the most robust yield. With a considerable drop in cost, universal germline testing may become the most cost-effective strategy for the diagnosis of LS.

Bacteremia and mortality with urinary catheter-associated bacteriuria.

OBJECTIVE: Although catheter-associated urinary tract infection (CAUTI) and catheter-associated asymptomatic bacteriuria (CAABU) are clinically distinct conditions, most literature describing the risks of bacteriuria does not distinguish between them. We studied the relationship between catheter-associated bacteriuria and bacteremia from a urinary source in CAUTI relative to that in CAABU. Second, we investigated whether the presence or absence of urinary symptoms in catheterized patients with bacteriuria was associated with bacteremia from any source or mortality. Finally, we explored the effect of antimicrobial treatment of bacteriuria on subsequent bacteremia from any source and mortality. DESIGN: We performed a retrospective cohort study with 30 days of follow-up after an initial positive urine culture. CAUTI and CAABU were defined by Infectious Diseases Society of America guidelines. SETTING: A large tertiary care facility. PATIENTS: All inpatients with a urinary catheter (external or indwelling) and a positive urine culture between October 2010 and June 2011. RESULTS: We captured 444 episodes of catheter-associated bacteriuria in 308 patients; 128 (41.6%) patients had CAUTI, and 180 (58.4%) had CAABU. Three episodes of bacteriuria were followed by bacteremia from a urinary source (0.7%). CAUTI, rather than CAABU, was associated with bacteremia from any source, but neither CAUTI nor CAABU predicted subsequent mortality. Use of antimicrobial agents to treat bacteriuria was not associated with either bacteremia from any source or mortality. CONCLUSIONS: Bacteremia from a urinary source was infrequent, and there was no evidence of an association of mortality with symptomatic versus asymptomatic bacteriuria in this population. Antibiotic treatment of bacteriuria did not affect outcomes.