Mixed state discrimination using optimal control.

We present theory and experiment for the task of discriminating two nonorthogonal states, given multiple copies. We implement several local measurement schemes, on both pure states and states mixed by depolarizing noise. We find that schemes which are optimal (or have optimal scaling) without noise perform worse with noise than simply repeating the optimal single-copy measurement. Applying optimal control theory, we derive the globally optimal local measurement strategy, which outperforms all other local schemes, and experimentally implement it for various levels of noise.

Functional impairment and co-occurring psychiatric disorders in medically hospitalized men.

BACKGROUND: Although previous research has described a high prevalence of psychiatric comorbidity among general medical and surgical patients, prevalence estimates based on diagnostic criteria and the assessment of health care outcomes including functional status has not been conducted for a broad range of psychiatric disorders. METHODS: A random sample of male medical and surgical admissions to 3 Department of Veterans Affairs Medical Centers was enrolled in the study. Subjects were administered a computerized structured psychiatric diagnostic interview and completed a multidimensional measure of health-related functioning, the Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: Of 1007 medical and surgical inpatients, almost half (46.6%) met lifetime criteria for at least 1 Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition disorder, most commonly for alcohol abuse or dependence (32.5%), posttraumatic stress disorder (10.0%), and major depression or dysthymia (9.0%). Almost one fifth reported recent symptoms, most frequently for major depression or dysthymia (7.0%). Co-occurring psychiatric disorders were associated with substantial and significant (P<.001) impairment on all dimensions of functioning, with the greatest decrements observed in physical and emotional role functioning. Anxiety and mood disorders were associated with the most and somewhat similar reductions in functioning. CONCLUSIONS: The prevalence of co-occurring psychiatric disorders was substantial but consistent with other studies of populations receiving health services. Given the observed additional burden of psychiatric disorders on functioning in medically hospitalized patients, the study indicates the importance of identification and treatment of co-occurring psychiatric disorders in this high-risk and clinically challenging group of patients.

Water intakes of lactating women.

Women are commonly advised to increase their water intake during lactation, even though empirical data describing fluid intakes of successfully lactating women is lacking. Water intake from solid food and beverage was determined from 135 food records completed by 26 lactating women who had fully breast-fed their infants for 3 to 4 mo. Inter-subject variability in total water intake, food water, and beverage was significantly greater (one-way analysis of variance, p less than 0.01) than intra-subject variability. Total water consumption/subject (mean +/- SEM) was 2860 +/- 108 g/day, with 640 +/- 48 g/day from food and 2220 +/- 110 g/day from beverage. One-third of the subjects consumed less than the 1 g of water/kcal of energy need described in the current Recommended Dietary Allowances. Thus, it appears that while many successfully lactating women consume large quantities of water, many do not consume enough to satisfy theoretical recommendations. Results indicate that estimation of water intake must include water available in food as well as in beverage.

Prolonged maternal fluid supplementation in breast-feeding.

A randomized, crossover study design was used to evaluate the effect of prolonged maternal fluid supplementation on the milk supply of breast-feeding women. A total of 19 well-nourished women whose infants were solely breast-fed and thriving were enrolled when their infants were 90 to 120 days of age. Of this group, 15 women consumed at least a 25% increase in fluids above baseline for 7 days. Mean daily milk production was 767 +/- 178 mL for the baseline period and 744 +/- 138 mL for the increased fluid period. There was no significant change in milk production between baseline and increased fluid periods. No significant linear relationship between the percentage increase in fluid intake and percentage change in milk production was found.

Health-related consequences of physical and sexual violence: women in the military.

OBJECTIVES: To identify differences in health-related quality of life among women veterans who were raped, physically assaulted (not in the context of rape or domestic violence), both, or neither during military service. METHODS: We did a cross-sectional telephone survey of a national sample of 558 women veterans who served in Vietnam and subsequent eras of military service. A stratified survey design selected subjects according to era of service and location. The interview included socioeconomic information, lifetime violence history, the Women's Military Environment Survey to assess women's military experiences, and the Medical Outcomes Study Short Form-36 to assess health-related quality of life. RESULTS: Five hundred thirty-seven women completed the interview. Half (48%) experienced violence during military service, including rape (30%), physical assault (35%), or both (16%). Women who were raped or dually victimized were more likely to report chronic health problems, prescription medication use for emotional problems, failure to complete college, and annual incomes less than $25,000 (P <.05). Women who were physically assaulted or raped reported significantly lower health-related quality of life (P <.05). Those who had both traumas reported the most severe impairment, comparable to women with chronic illnesses. CONCLUSION: This study suggests that the sequelae of violence against women are an important public health concern. More than a decade after rape or physical assault during military service, women reported severely decreased health-related quality of life, with limitations of physical and emotional health, educational and financial attainment, and severe, recurrent problems with work and social activities.

Effects of sucralfate vs antacids on gastric pathogens: results of a double-blind clinical trial.

BACKGROUND: Unblinded studies suggested that sucralfate prophylaxis for stress ulcers is associated with a lower rate of nosocomial pneumonia than acid-reducing approaches. We performed a randomized, double-blind, double-sham clinical trial comparing the exact microbial effects of each treatment. METHODS: One hundred forty patients entered this study before major elective surgery, allowing baseline cultures of gastric and pulmonary secretions to be obtained intraoperatively. Postoperatively, the patients were treated with standard doses of either sucralfate or antacids, plus a sham of the other drug. Cultures were repeated twice daily for 3 days. Molecular epidemiological typing was used to track the appearance of specific microbes and their transmission from site to site, and clinical end points were compared. The number of patients chosen was for sufficient statistical power to detect differences in the microbial measures, as detecting differences in clinical measures would have required increasing the sample size by an order of magnitude. RESULTS: Gastric pH was affected by the form of stress ulcer prophylaxis throughout the study, and this pH effect affected the number of new gastric organisms appearing in the 2 different groups. Colonization of the airway with new gastric organisms occurred more frequently in the antacid than in the sucralfate group, and colonization of the airway with organisms of gastric origin was associated with occurrence of postoperative pneumonia. CONCLUSIONS: Both sucralfate and antacids offered safe and effective stress ulcer prophylaxis in this double-blind clinical trial of postoperative patients in an intensive care unit. In association with the drug's effects on gastric pH, more new pathogens appeared in the gastric contents of antacid-treated than sucralfate-treated patients.

Diagnosing depression in the medically ill: validity of a lay-administered structured diagnostic interview.

Understanding the validity of structured psychiatric diagnostic interviews in medically ill patients will advance the ability to conduct research into the treatment and management of these disorders in general medical settings. We compared the University of Michigan version of the CIDI (Composite International Diagnostic Interview) for major depression to a clinical gold standard, derived through Spitzer's Longitudinal, Expert, All Data (LEAD) criteria based on the SCID-III-R. A convenience sample of medical inpatients was administered the SCID-III-R and the CIDI for major depression in random order. A physician panel reviewed the SCID interview and other pertinent data and determined whether patients had a lifetime or current (past month) diagnosis of major depression. The CIDI was scored with and without hierarchical exclusions for mania, hypomania, substance use, or medical illness. When the UM-CIDI was scored for a lifetime diagnosis of major depression without hierarchical exclusions, agreement above chance (kappa) was very good (kappa = 0.67) between the CIDI and the physician panel and good (kappa = 0.46) when the UM-CIDI was scored with exclusions. Agreement above chance for diagnosis of a recent disorder was better for UM-CIDI scoring with exclusions (kappa = 0.51) compared to scoring without exclusions (kappa = 0.43). Predictive value-positive was excellent in both scoring versions for a lifetime diagnosis (82%) and good to very good for current depression (46% and 62%). In all cases predictive value-negative was very good to excellent (77-93%). Discordant cases were almost uniformly due to difficulties in attribution of symptoms to medical illnesses. We conclude that the CIDI can perform acceptably as a research instrument to diagnose major depression in medically ill patients, potentially supplemented by clinician review of cases identified by the CIDI with current disorder.

Appropriateness of admissions and discharges among readmitted patients.

This study examined the relationships between appropriateness of readmission within two weeks of discharge and appropriateness of previous admission and discharge, bed section, type of readmission, and patient demographic, medical condition, and hospital stay characteristics. Using the Department of Veterans Affairs (VA) Patient Treatment File and medical records, 445 readmissions to a highly affiliated midwestern VA Medical Center in fiscal year 1984 were examined. Appropriateness was determined by four trained medical record abstractors using InterQual admission and discharge standards. Type of readmission was based on a pilot-tested flowchart. Appropriateness of readmission was significantly associated with that of the previous admission and discharge, with the relationship varying by admission, discharge, and readmission bed sections. Reasons for inappropriate admissions, discharges, and readmissions also varied by bed section. For the majority of inappropriate readmissions, there was clear written evidence in the medical record during the previous hospital stay that the patient was directed to return for readmission. Inappropriate readmissions were more likely than appropriate readmissions to have a primary diagnosis of neoplasm or digestive disorder. These results indicate the importance of examining both the operational efficiencies during the previous admission and the clinical criteria for admitting, discharging, and readmitting patients in assessing the appropriateness of readmissions.

Investigation of a model for the initiation of breastfeeding in primigravida women.

Primigravida women are faced with the decision about how they will feed their infants. Many will decide to breastfeed but the motivation for this choice is unclear. While certain beliefs and worries about breastfeeding appear to predict women who will choose to breastfeed, such concepts are influenced by a combination of other values, support resources and socioeconomic background. The main goal of this research was to demonstrate how multivariate analysis can be applied to the infant-feeding decision and how it can lend a theoretical interpretation to social issues such as the initiation of breastfeeding. One hundred completely breastfeeding and 57 bottle feeding primigravida women were enrolled in the study and completed a pretested Likert-type questionnaire. Three primary predictors for the initiation of breastfeeding were identified: positive maternal beliefs about breastfeeding; the absence of maternal worries about breastfeeding; and higher levels of maternal education. Secondary psychosocial predictors significantly associated with maternal breastfeeding beliefs included maternal beliefs in increased personal satisfaction from breastfeeding and maternal beliefs in preventive health measures. Secondary psychosocial predictors significantly related to maternal worries about breastfeeding before breastfeeding began. Over half of the strength of the direct psychosocial predictors for breastfeeding initiation could be attributed to their respective groups of indirect predictors. Thus, the main contribution of this research has been to shift the emphasis of past research away from differences between groups of bottle feeders and breastfeeders to focus more precisely on the decision-making process involved in the infant feeding choice.(ABSTRACT TRUNCATED AT 250 WORDS)

The military environment: risk factors for women's non-fatal assaults.

Little is known regarding environmental exposures for non-fatal violence toward women in the workplace. We sought to identify factors associated with non-fatal physical assault occurring to women during military service. A cross-sectional telephone survey of a national sample of 558 women veterans who served in Vietnam and subsequent eras of military service was conducted; 537 women were interviewed. Twenty-three percent experienced non-fatal physical assault during military service. Rates of assault were consistent across eras of service. Military environmental exposures, including sexual harassment allowed by officers (P < 0.0001) and unwanted sexual advances while on duty (P < .0001) and in sleeping quarters (P < 0.0001), were independent risk factors for assault. Environmental factors in the military workplace, including leadership behavior, appeared to promote violence toward military women. Such occupational factors can be identified and should be eliminated.

Depression after alcohol treatment as a risk factor for relapse among male veterans.

We examined the association between relapse-to-drinking and depressive symptomatology measured during inpatient treatment for alcohol disorder and 3 months posttreatment. Data were obtained from 298 veterans who completed 21-day inpatient treatment. Follow-up interviews were conducted at 3, 6, 9, and 12 months posttreatment. We used multiple logistic regression to assess the association between relapse and baseline/3-month posttreatment measures of depression (Beck Depression Inventory; BDI), controlling for important covariates. Our results showed that (a) the mild-to-moderately symptomatic participants (BDI = 14-19) at 3 months posttreatment were on average 2.9 times more likely than the nondepressed to have relapsed across follow-ups, and (b) the severely symptomatic participants (BDI = 20+) at 3 months posttreatment were on average 4.9 times more likely to have relapsed across follow-ups. Other analyses revealed that those with persistent depressive symptomatology reported at both baseline and 3 months posttreatment did not experience worse outcomes that those who reported symptomatology at 3 months posttreatment alone.

A comparison of substance abuse patients' and counselors' perceptions of relapse risk: relationship to actual relapse.

This study compared substance abuse patients' and their counselors' perceptions of relapse risk during treatment and evaluated whether these perceptions predict actual relapse 2 years later. Participants (N = 240) completed the Relapse Risk Index (RRI), which assesses confidence in abilities and need for services across four domains: coping skills, social support, resources, and leisure activities. Participants reported greater confidence and greater needs than counselors reported. Determinants of counselors' relapse risk perceptions included income, whereas participants' perceptions were related to polysubstance use. Counselors' ratings of coping skills predicted alcohol relapse; counselors' ratings did not predict drug relapse. Participants' ratings of coping skills and leisure activities predicted alcohol relapse; social support predicted drug relapse. When including background characteristics, counselors' ratings did not predict alcohol or drug relapse; participants' ratings predicted alcohol relapse but not drug relapse. Findings suggest the potential utility of considering patient perceptions to understand and possibly prevent relapse.

Risk factors for AMA discharge from VA inpatient alcoholism treatment programs.

This study was designed to identify those risk factors associated with discharge from inpatient alcoholism treatment against medical advice (AMA) and the underlying reasons for these discharges. Data on the characteristics of patients and their index hospitalization were obtained from the systematic review of medical records for 186 alcoholics who were discharged AMA and 201 alcoholics who completed treatment. Comorbid medical diagnosis reduced the risk of AMA discharge by one quarter, whereas court referral to treatment reduced the risk by one half. A college education, vocational or other training, being employed, and having a history of previous AMA discharges significantly increased the risk. The most common reasons for AMA discharge, as perceived by treatment providers, were psychosocial problems, difficulties in the treatment program, and lack of interest in treatment. The clinical implications of these findings for the inpatient treatment of alcoholics are discussed.

Outcome of domiciliary care after inpatient alcoholism treatment in male veterans.

Current literature is ambiguous as to the impact of extended treatment services following hospitalization on outcomes such as abstinence. This study compares the outcomes of care for 276 veterans who completed inpatient treatment for alcoholism, 77 of whom (28%) were transferred to a domiciliary and the remainder of whom were discharged directly into the community. The domiciliary group of alcoholics differed at baseline from alcoholics discharged to the community with significantly higher psychiatric comorbidity and lower social support, both negative predictors of treatment outcome. A multiple logistic regression model was used to assess the impact of domiciliary placement on: (a) 3-month abstinence comparing the time after discharge from either the domiciliary or the inpatient treatment unit and (b) 12-month abstinence after discharge from the inpatient treatment unit, including patients placed in the domiciliary. Controlling for baseline differences, domiciliary placement was found to be a significant predictor of abstinence (odds ratios of 2.3 for 3-month and 2.5 for 12-month abstinence, p < or = 0.01). In a survival analysis, domiciliary placement was also a significant predictor of time to readmission after treatment discharge with a risk ratio of 0.2 (p < 0.01). Our results demonstrate a protective effect of domiciliary after-care for high risk alcoholics after inpatient treatment.

Variation among VA hospitals in length of stay for treatment of depression.

OBJECTIVE: The purpose of the study was to determine the degree of interhospital variation in length of stay for patients treated for depressive disorders in Department of Veterans Affairs (VA) medical centers and to identify the number of hospitals with significantly longer or shorter than average lengths of stay (outlier hospitals). METHODS: The sample included 6,374 veterans discharged from acute psychiatric inpatient units at 107 medical centers in 1992 with a primary diagnosis of major depressive disorder or depressive disorder not otherwise specified. To identify statistical outliers, the average length of stay at each medical center was compared with the overall sample mean while controlling for differences in case mix between hospitals. RESULTS: Patients' demographic characteristics, treatment history, and severity of illness all significantly predicted length of stay at the patient level. After case mix factors were controlled for statistically, approximately 29 percent of the medical centers were found to have mean lengths of stay significantly different (p < .01) from the sample mean. Specifically, 15 percent of the medical centers were short-stay outliers, and 14 percent were long-stay outliers. CONCLUSIONS: Despite the fact that the treatment regimen for depression is relatively standardized and all VA medical centers operate under the same administrative model and reimbursement system, a high degree of interhospital variation was found in treatment duration for depression. Results led to the tentative postulation that variations in treatment duration reflect differences in physicians' practice styles. Substantial opportunities may exist for reducing expenditures for the treatment of depression within the VA health care system.

Age, ethnicity, and comorbidity in a national sample of hospitalized alcohol-dependent women veterans.

OBJECTIVE: Treatment patterns in a national sample of hospitalized women veterans diagnosed with alcohol dependence were identified with the goal of improving health services to women veterans with alcohol-related disorders. METHODS: Information from VA's patient treatment file for fiscal year 1993 was used to identify 854 women veterans diagnosed with alcohol dependence. Of that group, 546 received a primary diagnosis of alcohol dependence, and 308 received a secondary diagnosis of alcohol dependence after they sought treatment for other health problems. Chi square tests and multivariate logistic regression analyses were used to examine relationships between the sociodemographic profiles of these women and the types of services they received. RESULTS: The study population's largest age group (49 percent) was 30 to 39 years old. Fifty-two percent of the women were divorced or separated, and 62 percent were Caucasian. The overwhelming majority of comorbid diagnoses were of psychiatric disorders. Overall, only 47 percent of the 854 patients received formal treatment for their alcohol disorder, and only 34 percent completed alcohol treatment. Women over age 60 were significantly less likely than women in other age groups to enter or complete formal treatment. Native-American women were significantly more likely than Caucasians or African Americans to receive formal alcohol treatment services. CONCLUSIONS: The results indicate a need for targeting interventions more effectively in certain groups of women veterans diagnosed with alcoholism. Low completion rates also suggest a need for greater incentives for patients to complete treatment programs.

Medication noncompliance and substance abuse among patients with schizophrenia.

OBJECTIVE: The study examined the effect of medication noncompliance and substance abuse on symptoms of schizophrenia. METHODS: Short-term inpatients with a diagnosis of schizophrenia were enrolled in a longitudinal outcomes study and continued to receive standard care after discharge. At baseline and six-month follow-up, Brief Psychiatric Rating Scale (BPRS) scores and data on subjects' reported medication compliance, drug and alcohol abuse, usual living arrangements, and observed side effects were obtained. The number of outpatient contacts during the follow-up period was obtained from medical records. Relationships between the dependent variables-medication noncompliance and follow-up BPRS scores-and the independent variables were analyzed using logistic and linear regression models. RESULTS: Medication noncompliance was significantly associated with substance abuse. Subjects who abused substances, had no outpatient contact, and were noncompliant with medication had significantly greater symptom severity than other groups. CONCLUSIONS: Substance abuse is strongly associated with medication noncompliance among patients with schizophrenia. The combination of substance abuse, medication noncompliance, and lack of outpatient contact appears to define a particularly high-risk group.

Implementing a statewide outcomes management system for consumers of public mental health services.

The authors describe the development and implementation of an outcomes management system designed to measure outcomes and processes of care for public mental health consumers in Arkansas. The public-academic project was implemented in 1995 and is based on the Shewhart-Deming model of continuous quality improvement. All 15 community mental health centers (CMHCs) in the state participate in the project, which prospectively measures longitudinal outcomes of care for the tracer conditions of major depression and schizophrenia. Multiperspective measurement tools are used to measure patients' psychiatric status and general health status at periodic intervals; information is gathered on functioning, symptoms, severity of illness, social factors, demographic characteristics, and quality of life. A problem encountered during implementation was the relatively low rate of referral of patients with the tracer conditions for monitoring. Voluntary rather than mandatory participation in the outcomes management system by the CMHCs as well as clinicians' misperceptions about the system's purpose and concerns about confidentiality may have partly accounted for the low rate.

Patient factors predicting early alcohol-related readmissions for alcoholics: role of alcoholism severity and psychiatric co-morbidity.

The current study was undertaken primarily to identify whether psychiatric co-morbidity was associated with the rate and time of alcohol-related inpatient readmissions for a group of 255 patients discharged from alcoholism treatment at a midwestern rural medical center. A structured interview obtained information regarding psychiatric disorders, including depression, antisocial personality disorders and polysubstance abuse, as well as alcohol history and sociodemographics. Ninety-eight subjects (38.4% of sample) were readmitted for alcoholism-related diagnoses within 15 months of discharge. Patients with a long history of heavy drinking, high daily alcohol consumption and history of previous alcoholism treatment were most likely to be readmitted with an alcoholism-related primary diagnosis. Once these variables were controlled for, other major psychiatric disorders, polysubstances abuse and sociodemographic variables did not appear to predict time to readmission. However, other potentially more sensitive outcome measures such as return to drinking were not evaluated in the present study.

Rural at-risk drinkers: correlates and one-year use of alcoholism treatment services.

OBJECTIVE: The purpose of this study was to identify a community sample of rural and urban at-risk drinkers, to compare them in terms of sociodemographics, access measures and severity of illness, and to study them prospectively to identify rural/urban differences in use of 12-month alcoholism treatment services. METHOD: A brief telephone screening interview of over 12,000 respondents in six southern states identified a sample of at-risk drinkers. A baseline interview was administered to 733 individuals (67% men, 50% rural residents) that obtained information on substance use and psychiatric disorders, psychosocial factors, social support, four dimensions of access to alcoholism treatment services and prior alcoholism service use. Interviews at 6 and 12 months obtained self-reports of subsequent receipt of alcoholism treatment services. RESULTS: We identified modest differences between rural and urban at-risk drinkers. The rural sample was significantly less well-educated and reported significantly less affordability, accessibility and acceptability of some treatment services (p < .05). Rural at-risk drinkers also appeared to possess significantly greater illness characteristics, including more lifetime DSM-IV criteria for alcohol use disorders, more frequent recent alcohol disorders and more chronic medical problems (p < .05). The longitudinal sample comprised 579 participants, of whom 7% reported receiving some form of alcoholism treatment services in the year after the initial interview. In bivariate analysis, rural drinkers in the sample reported greater use of help for their drinking, more use of psychiatrists and more use of inpatient, outpatient and ER treatment settings than did their urban counterparts. However, significant independent predictors of 12-month alcoholism treatment use in multiple logistic regression were female gender (OR = 0.3), greater social support (OR = 2.2) and illness or severity characteristics including recent diagnosis of alcohol dependence (OR = 3.3), social consequences of drinking (OR = 1.7), concurrent medical problems (OR = 2.1) and prior treatment experience (OR = 4.4). CONCLUSIONS: We found modest differences among rural and urban at-risk drinkers and some evidence of greater barriers to treatment and greater illness severity among rural inhabitants. Further research is needed to know whether community interventions with social networks and other interventions to improve social support may help bring at-risk drinkers into treatment in both urban and rural settings as well as provide other support for sobriety.