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Background Laparoscopic cholecystectomy (LC) is the gold standard for the treatment of cholelithiasis in most countries of the world. The objective of this study was to evaluate the outcomes of LC in the surgery department of Cure International Hospital, Kabul, Afghanistan. Methods A retrospective study was conducted on 1430 LC cases performed by the general surgery department of Cure International Hospital. Data was collected from patient files and the operation theatre registry for whom LC was performed during January 2008 through December, 2019. Results Mean age was 45.77 ± 13.45 years (14–90 years), with male/female ratio of 1:4.7. One third (33%) had comorbidities. Most of patients (~ 97%) were classified as ASA grade I and II. Of all patients, 26.8% of males and 13.2% of females had gallbladder inflammation (OR = 2.203, 95% CI 1.56–2.61, P = 0.000). Overall mean duration of anesthesia was 75 ± 25.6 min. The conversion rate to OC was 4.6% (N = 66), most commonly dense adhesions at Callot’s triangle (3.8%). The intraoperative complication rate was 17.5% (N = 249), where bile/stone spillage was the most common indication (N = 235, 16.4%). Immediate postoperative complication rate was 2.4% (N = 35). Average length of stay (ALOS) after LC was 2.23 ± 1.43 days (1–19 days). Conclusion This study shows that elective LC can be performed safely in Afghanistan with comparable outcomes in terms of complications, conversion rates, and ALOS to other countries of the region and the world. Proper case selection and careful preoperative evaluation and management can decrease further conversion, intra- and postoperative complications.

Rationale Food allergy is documented to result in considerable morbidity, negative impact on quality of life, and substantial medical care costs. Although anecdotal data suggest widely varying practices in the diagnosis and management of food allergies, the diversity and relative frequency of these practices have not been documented. Methods A questionnaire was developed evaluating allergists’ management approaches of individuals with peanut allergy (PA) in Germany (DE), France (FR), and the United Kingdom (UK). Results Here, we report the survey results from a total of 109 allergists from DE, FR and the UK. They reported to confirm PA at initial diagnosis using skin prick test (≥60%), while allergists from DE and FR reported using allergen-specific IgE testing more (>86%) compared to the UK (75%). Half of the responders reported assessing the patient’s quality of life. 63% allergists reported retesting for PA resolution at a later date, with 45% allergists indicated to recommend ingestion of a normal serving of peanut regularly upon resolution. Lack of effective PA treatment was reported to be a ‘very significant’ barrier for optimal PA treatment, with allergists being less than ‘moderately familiar’ with data from clinical trials testing new treatments options for PA. Lastly, allergists stated that the severity of patient’s PA ranked as the most important factor in their decision to recommend oral immunotherapy for PA treatment. Conclusions This survey provides essential insights into the practice of allergists and highlights some areas that would inform strategies for education and improving PA healthcare.

Smoking remains a common habit among the general population. Despite the well-established risks of smoking, relatively few studies have been undertaken to assess the understanding of these risks among the general population. We intended to assess the understanding of smoking as a risk factor for various conditions in a urology outpatient cohort to assess the level of knowledge as well as particular strengths and weaknesses they possess. A four-page questionnaire was distributed among urology outpatients over a 5 month period. The questionnaire captured information regarding the knowledge of smoking as a risk factor for various urological and non-urological conditions. Results were collated and stratified according to patient’s cancer history as well as smoking status. A total of 112 participants were included in our analytical sample. Our study demonstrated a deficiency in knowledge regarding smoking and urological conditions. When ranked by level of knowledge, four of the bottom five conditions were urological in nature. Furthermore, we found that patients with a personal cancer history demonstrated generally poorer knowledge of smoking as a risk factor compared to patients without a cancer history. Conversely, smokers themselves demonstrated a greater understanding of risks compared to non-smokers. Our study suggests there is much work to be done in the education of patients on the risks of smoking from a urological point of view. We believe more initiative needs to be taken by the specialists treating such patients to achieve an improved level of knowledge.

Multiparametric magnetic resonance imaging (mpMRI) has added to the armamentarium for the diagnosis and surveillance for organ-confined prostate cancer. Atypical small acinar proliferation and high-grade prostatic intraepithelial neoplasia (HGPIN) are premalignant prostatic lesions. The management of such lesions remains contentious, and the addition of mpMRI introduces further uncertainty, given its ability to pick up indolent lesions and its use in targeted biopsy. We aimed to perform a comprehensive review of current evidence regarding atypical small acinar proliferation, high-grade prostatic intraepithelial neoplasia, and mpMRI to ascertain a consensus for a current management algorithm.

Purpose of review Up to 70% of prostate biopsies are negative in men with suspected prostate cancer. Because of inherent limitations in biopsy strategies, a significant proportion of cancers are missed on initial biopsy. Following negative biopsy, men frequently exhibit persistently elevated prostate-specific antigen - raising concerns for missed diagnosis. We highlight the recent updates in the management of negative prostate biopsy. Recent findings Advances in noninvasive diagnostics are available and assist clinicians in further substratifying risk of prostate cancer. Despite limited data, urinary prostate cancer antigen 3 and transmembrane protease serine 2 appear to have a promising predictive value for patients suspected of prostate cancer. The advent of multiparametricMRI allows the visualization of intermediate and high-grade prostate cancer, particularly in the troublesome anterior prostate. This modality may further provide the potential for magnetic resonance-guided targeted biopsies. Current data suggest that in the presence of suspicious radiological findings, magnetic resonance-guided biopsies have superior sensitivity profiles compared with traditional rebiopsy approaches. In the absence of multiparametricMRI or suspicious findings, traditional saturation biopsies are sufficient. Summary The management of negative biopsies is evolving rapidly with emerging diagnostics to stratify risk of prostate cancer in men with previous negative biopsies. An increasing body of information supports the use of magnetic resonance-guided biopsies.

True metastatic ureteric lesions are exceptionally rare when sourced from any primary tumour. Primary prostatic cancer metastasis to the ureter is understandably even more atypical with very few cases reported in current literature. True intramural ureteric metastatic disease deposited from prostate cancer is an even rarer occurrence. We present a case of a man in his mid-60s with left-sided hydronephrosis in the setting of biochemical recurrence of Gleason 9 prostate cancer. Initially misdiagnosed as obstruction secondary to mass effect from a large trigonal lesion, subsequent investigation revealed solid intramural metastatic deposit of prostate primary tumour in the distal ureter. We detail current hypotheses regarding the subsequent pathophysiology of the disease and its common clinical presentations. Our case highlights that prostatic metastasis should be considered as a differential in coexisting prostate cancer and ureteric obstruction despite its low incidence.

Because the effect of physician supply on utilization remains controversial, literature based on non-Medicare populations is sparse, and a physician supply expansion is under way, the potential for physician-induced demand across diverse populations is important to understand. A substantial proportion of gastrointestinal endoscopies may be inappropriate. The authors analyzed the impact of physician supply, practice patterns, and clinical history on esophagogastroduodenoscopy (EGD, defined as discretionary) among patients hospitalized with lower gastrointestinal bleeding (LGIB).Among 34,344 patients hospitalized for LGIB from 2004 to 2009, 43.1% and 21.3% had a colonoscopy or EGD, respectively, during the index hospitalization or within 6 months after. Linking to the Dartmouth Atlas via patients' hospital referral region, gastroenterologist density and hospital care intensity (HCI) index were ascertained. Adjusting for age, gender, comorbidities, and race/education indicators, the association of gastroenterologist density, HCI index, and history of upper gastrointestinal disease with EGD was estimated using logistic regression.EGD was not associated with gastroenterologist density or HCI index, but was associated with a history of upper gastrointestinal disease (OR 2.30; 95% CI 2.17-2.43), peptic ulcer disease (OR 4.82; 95% CI 4.26-5.45), and liver disease (OR 1.34; 95% CI 1.18-1.54).Among patients hospitalized with LGIB, large variation in gastroenterologist density did not predict EGD, but relevant clinical history did, with association strengths commensurate with risk for upper gastrointestinal bleeding. In the scenario studied, no evidence was found that specialty physician supply increases will result in more discretionary care within commercially insured populations.

In penile cancer, the optimal diagnostics and management of metastatic lymph nodes are not clear. Advances in minimally invasive staging, including dynamic sentinel lymph node biopsy, have widened the diagnostic repertoire of the urologist. We aimed to provide an objective update of the recent trends in the management of penile squamous cell carcinoma, and inguinal and pelvic lymph node metastases.We systematically reviewed several medical databases, including the Web of Science® (with MEDLINE®), Embase® and Cochrane databases, according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. The search terms used were penile cancer, lymph node, sentinel node, minimally invasive, surgery and outcomes, alone and in combination. Articles pertaining to the management of lymph nodes in penile cancer were reviewed, including original research, reviews and clinical guidelines published between 1980 and 2016.Accurate and minimally invasive lymph node staging is of the utmost importance in the surgical management of penile squamous cell carcinoma. In patients with clinically node negative disease, a growing body of evidence supports the use of sentinel lymph node biopsies. Dynamic sentinel lymph node biopsy exposes the patient to minimal risk, and results in superior sensitivity and specificity profiles compared to alternate nodal staging techniques. In the presence of locoregional disease, improvements in inguinal or pelvic lymphadenectomy have reduced morbidity and improved oncologic outcomes. A multimodal approach of chemotherapy and surgery has demonstrated a survival benefit for patients with advanced disease.Recent developments in lymph node management have occurred in penile cancer, such as minimally invasive lymph node diagnosis and intervention strategies. These advances have been met with a degree of controversy in the contemporary literature. Current data suggest that dynamic sentinel lymph node biopsy provides excellent sensitivity and specificity for detecting lymph node metastases. More robust long-term data on multicenter patient cohorts are required to determine the optimal management of lymph nodes in penile cancer.

Radiological imaging remains the cornerstone of follow-up of patients with urolithiasis. Plain abdominal X-ray (XRKUB) of these patients is largely becoming obsolete in favor of noncontrast computed tomography of the abdomen and pelvis (CTKUB), which offers superior sensitivity and specificity. Contentiousness exists, however, related to the radiation doses associated with CT. Calcium oxalate remains the most common stone composition across most populations. These calculi are radiopaque and thus follow-up with XRKUB may be appropriate in some settings, avoiding the higher radiation doses associated with standard protocol CT. With the emergence of low-dose CT, however, and the modest accuracy of XRKUB, the ongoing role for XRKUB in the management of urolithiasis is debatable. In this study, we assessed the proportion of pure calcium urolithiasis visible on XRKUB to assess the utility of XRKUB for follow-up of pure calcium urolithiasis. Hospital laboratory databases were analysed to identify patients who had undergone urological intervention and extraction of urolithiasis composed of pure calcium salts, who had undergone CTKUB and XRKUB during the same episode for diagnosis of the calculus. One hundred five calculi were included and the imaging for each patient analyzed. 79/105 calculi (75%) identified on CT were visible on XRKUB. The median calculus visible on XRKUB was 7.0 mm (interquartile range [IQR] 5.0-10.0 mm), the median calculus not seen was 4.25 mm (IQR 3.5-7.0 mm) as measured on CT (p 0.01). XRKUB accuracy varied according to calculus position within the renal tract. Calculi were most often visible in the renal pelvis and proximal ureter (86%), 50% of mid-ureteral and 72% of distal ureteral calculi were visible (p = 0.01). Until low-dose CT protocols become widely adopted, XRKUB still has a limited role in the management of pure calcium urolithiasis in selected patients. Due to its modest accuracy in many settings, this role is limited mainly to larger proximal urolithiasis.

Two studies examined the nature and processes underlying the joint role of interparental aggression and maternal antisocial personality as predictors of children's disruptive behavior problems. Participants for both studies included a high-risk sample of 201 mothers and their 2-year-old children in a longitudinal, multimethod design. Addressing the form of the interplay between interparental aggression and maternal antisocial personality as risk factors for concurrent and prospective levels of child disruptive problems, the Study 1 findings indicated that maternal antisocial personality was a predictor of the initial levels of preschooler's disruptive problems independent of the effects of interparental violence, comorbid forms of maternal psychopathology, and socioeconomic factors. In attesting to the salience of interparental aggression in the lives of young children, latent difference score analyses further revealed that interparental aggression mediated the link between maternal antisocial personality and subsequent changes in child disruptive problems over a 1-year period. To identify the family mechanisms that account for the two forms of intergenerational transmission of disruptive problems identified in Study 1, Study 2 explored the role of children's difficult temperament, emotional reactivity to interparental conflict, adrenocortical reactivity in a challenging parent–child task, and experiences with maternal parenting as mediating processes. Analyses identified child emotional reactivity to conflict and maternal unresponsiveness as mediators in pathways between interparental aggression and preschooler's disruptive problems. The findings further supported the role of blunted adrenocortical reactivity as an allostatic mediator of the associations between parental unresponsiveness and child disruptive problems.

To examine longitudinal changes in Medicare-eligible veterans' reliance on the Department of Veterans Affairs (VA) healthcare system for primary and specialty care over 4 years.We merged VA administrative and Medicare claims data to examine outpatient use during fiscal years (FY) 2001 to 2004 by 15,520 Medicare-eligible veterans who used VA primary care in FY2000. Reliance on VA outpatient care was defined as the proportion of total (VA/Medicare) visits received in VA for primary or specialty care.Of 869,000 primary and specialty care visits in the study period, 39% occurred within VA and 77% were specialty care. Reliance on VA primary care was substantially higher than specialty care (66% vs. 50% in FY2001; P0.001). Reliance on VA primary and specialty care decreased over time (57% vs. 31% in FY2004; P0.001). Significant shifts occurred at both extremes of VA reliance. From FY2001 to FY2004, the proportion of patients in the top decile of reliance on VA primary care decreased from 39% to 31%, whereas the proportion in the bottom decile doubled from 8% to 18%. Similarly, the proportion of patients in the top decile of reliance on VA specialty care decreased from 24% to 13%, whereas the proportion in the bottom decile doubled from 22% to 47%.Reliance on VA primary and specialty care among VA primary care patients decreased substantially over time, particularly for specialty care. Increasing use of non-VA services may complicate VA's implementation of patient-centered medical home models and performance measurement.

While 25 percent of Americans in the 55–64 age group experience gaps in health insurance coverage (Baker and Sudano 2005), starting at age 65 virtually all Americans have affordable, comprehensive health insurance coverage through the Medicare program. By reducing the out-of-pocket costs for medical care including that which would be otherwise unaffordable, Medicare for the previously uninsured increases medical service use for the previously uninsured (McWilliams et al. 2007a). Whether this increase in medical care for the previously uninsured ultimately results in health status gains remains an open question (Ross and Mirowsky 2000; Card, Dobkin, and Maestas 2004; McWilliams et al. 2007b). A negative association between lacking health insurance and health has been well established in hundreds of studies reviewed by Brown, Bindman, and Lurie (1998), Hadley (2003), and the Institute of Medicine (2002). While many of these studies have been cross-sectional in design, this association has also been shown in longitudinal studies (Franks, Clancy, and Gold 1993; Sorlie et al. 1994; Baker et al. 2001). While the RAND Health Insurance Experiment (HIE), the only randomized experiment of the effect of health insurance, also examined this issue it is of limited use for our purposes because (1) it did not include a study group with no health insurance; and (2) it excluded the Medicare-eligible population and thus excluded the elderly population. In this paper, we use a quasi-experimental approach to establish the effects of Medicare insurance coverage on the health trajectories of the previously uninsured. Experimental designs are critical to the study of health and insurance because the observed association between health insurance and health may reflect the effects of health on health insurance (reverse causation/selection) or the effects of some other unobserved third factor on both health insurance and health (residual confounding) (Levy and Meltzer 2004). This is because individuals under age 65 who acquire or drop health insurance typically do so for a reason related to a recent or projected change in health status: for example, they may enroll in a health plan because of a predicted health expense, they may lose their job and its health insurance coverage as a result of a health event, or they may qualify for public coverage as a result of poverty or disability. By contrast, because government policy restricts entry into Medicare until age 65 for most Americans, those who take up Medicare insurance (at age 65, but not those before age 65) do so for reasons other than changes in health status (of eligible aged beneficiaries, 99 percent enroll in Medicare Part A and 94 percent enroll in Medicare Part B). Thus, aging into insurance at 65 creates the natural experiment to assess the effect of health insurance on the health of the previously uninsured. The previously uninsured may be particularly vulnerable to any contraction in Medicare coverage because Medicare arrives at an age when affordable coverage is difficult to find for those lacking health insurance, especially if they have existing health conditions. As a result, several policy proposals have emerged to address being uninsured in the 55–64 age group including providing them with early access to the Medicare program. Understanding whether there is a health benefit to the near-elderly uninsured from the Medicare program is an important aspect of policy debates regarding expanding and limiting Medicare coverage.

This study examined mental health service utilization and costs associated with the California Assembly Bill 2034 housing-first program for homeless persons in San Diego County: Reaching Out and Engaging to Achieve Consumer Health (REACH).Encounter data were used to identify REACH clients and a control group that was matched by propensity score. Mental health services costs for case management, outpatient services, inpatient and emergency services, criminal justice system services, and total services were summarized for two-year periods before and after clients initiated REACH. Incremental costs of the program were calculated as the difference in cost among clients in the REACH group, from pre- to postintervention, less the difference in cost among those in the control group from pre- to postintervention.A total of 177 REACH clients and 161 clients in a control group matched by propensity score were identified. Among REACH participants, case management costs increased by $6,403 (p.001) from pre- to postintervention, inpatient plus emergency services costs declined by $6,103 (p=.034), and costs for mental health services provided by the criminal justice system declined by $570 (p=.020) compared with the control group. The standardized difference-in-difference estimate of the total costs between REACH clients and the control group was not significant.Participation in REACH was associated with substantial increases in outpatient services as well as cost offsets in inpatient and emergency services and criminal justice system services. The net cost of services, $417 over two years, was substantially lower than the total cost of services ($20,241).

Diabetes care has become increasingly complex. We set out to quantify recent trends in the complexity of medication regimens and test ordering for diabetes patients continuously enrolled in health plans affiliated with a large, regional US health maintenance organization, with representation in the South and Midwest.We provide descriptive trends analysis of overall diabetes care complexity (number of components [i.e., glucose, blood pressure, cholesterol control], number of medications/tests) from 1995 to 2003 for adults with diabetes (N = 304,233).The main outcomes were (1) the proportion of patients receiving diabetes-related medications (blood glucose, blood pressure, and cholesterol control agents), (2) the average number of medications, (3) the proportion of patients receiving diabetes-related tests (glycosylated hemoglobin [HbA1c], urine microalbumin, and serum cholesterol), (4) and the average number of tests ordered within the first year that a patient had any indication of diabetes.The proportion of patients on cholesterol lowering drugs (18% --39%, p0.01) and blood pressure lowering drugs (51% --62%, p = 0.04) rose significantly, while the proportion on glucose lowering drugs fell (76% --47%, p0.01). Among patients prescribed medications, the average total number of diabetes-related medications rose from 2.96 to 3.70 medications (p0.01) with smaller increases seen for glucose lowering (1.45 --1.65, p0.01) and blood pressure lowering regimens (2.14 --2.51, p0.01), and no change for cholesterol lowering drugs (1.23 --1.19, p = 0.19). For laboratory tests, the proportion receiving cholesterol (40% --58%), and urine microalbumin (4% --18%) (all p's0.01) rose significantly, while the testing rates for HbA(1c) remained unchanged. The average total number of tests ordered per year increased significantly from 3.34 to 4.10 (p0.01) with more modest increases observed for individual tests.Trends analyses are unadjusted for many clinical characteristics that might influence the complexity of diabetes care.Diabetes care grew more complex with the largest change in the number of patients receiving multi-component diabetes care. While the use of blood pressure and cholesterol lowering drugs rose overall, the proportion of patients using glucose lowering drugs declined and the average number of prescribed glucose lowering drugs did not increase in a clinically significant manner.

The Medical Countermeasures against Radiological Threats (MCART) consortium has established a dose response relationship for the hematopoietic acute radiation syndrome (HARS) in the rhesus macaque conducted under an individualized supportive care protocol, including blood transfusions. Application of this animal model as a platform for demonstrating efficacy of candidate medical countermeasures is significantly strengthened when the model is independently validated at multiple institutions. The study reported here describes implementation of standard operating procedures at an institute outside the consortium in order to evaluate the ability to establish an equivalent radiation dose response relationship in a selected species. Validation of the animal model is a significant component for consideration of the model protocol as an FDA-recommended drug development tool in the context of the "Animal Rule." In the current study, 48 male rhesus macaques (4-8 kg) were exposed to total-body irradiation (TBI) using 6 MV photon energy at a dose rate of approximately 0.8 Gy min. Results show that onset and duration of the hematological response, including anemia, neutropenia, and thrombocytopenia, following TBI ranging from 6.25 to 8.75 Gy correlate well with previously reported findings. The lethality values at 60 d following TBI were estimated to be 6.88 Gy (LD30/60), 7.43 Gy (LD50/60), and 7.98 Gy (LD70/60). These values are equivalent to those published previously of 7.06 Gy (LD30/60), 7.52 Gy (LD50/60), and 7.99 Gy (LD70/60); the DRR slope (p = 0.68) and y-intercepts show agreement along the complete dose range for HARS. The ability to replicate the previously established institutional lethality profile (PROBIT) and model outcomes through careful implementation of defined procedures is a testament to the robustness of the model and highlights the need for consistency in procedures.

Relatively few studies have used self-reported health status in models to predict medical expenditures, and many of these have used the SF-36.We sought to examine the ability of the briefer SF-12 measure of health status to predict medical expenditures in a nationally representative sample.We used data from the 2000-2001 panel of the Medical Expenditure Panel Study. Respondents (n = 5542) completed the SF-12 in a questionnaire. Interviews obtained data on demographics and selected chronic conditions. Data on expenditures incurred subsequent to the interview were obtained in part from provider records. We examined different regression model specifications and compared different statistical estimation techniques.Adding the SF-12 to a regression model improved the prediction of subsequent medical expenditures. In a model with only age and gender, adding the SF-12 increased R from 0.06 to 0.13. The coefficients for the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of the SF-12 for this model were -0.045 (P0.01) and -0.012 (P0.01), respectively. In a model including demographic characteristics, chronic conditions, and previous expenditures, adding the SF-12 increased the R from 0.26 to 0.29. The coefficients for the PCS and the MCS for this model were -0.025 (P0.001) and -0.005 (P = 0.15), respectively. A single general health status question performed almost as well as the full SF-12. Models estimated using ordinary least squares had undesirable properties. In terms of R, a generalized linear model (GLM) with a Poisson variance function was consistently superior to a GLM with a gamma variance function.Information on self-reported health status is useful in predicting medical expenditures. The extent to which the SF-12 adds predictive power over a comprehensive array of diagnostic data remains to be examined.

This study examined sensitive parenting as a protective factor in relations between interparental violence and children’s coping and psychological adjustment. Using a multi-method approach, a high risk sample of 201 two-year olds and their mothers participated in three annual waves of data collection. Moderator analyses revealed that sensitive parenting buffered the risk posed by interparental violence on children’s changes in externalizing and prosocial development over a two year period. Tests of mediated moderation further indicated that sensitive parenting protected children from the vulnerability of growing up in a violent home through its association with lower levels of children’s angry reactivity to interparental conflict. Results highlight the significance of identifying the mechanisms that mediate protective factors in models of family adversity.

Limited evidence exists on whether expanding home care saves money overall or how much institutional long-term care can be reduced. This paper estimates the causal effect of Medicaid-financed home care services on the costs and utilization of institutional long-term care using Medicaid claims data. A unique instrumental variable was applied to address the potential bias caused by omitted variables or reverse effect of institutional care use. We find that the use of Medicaid-financed home care services significantly reduced but only partially offset utilization and Medicaid expenditures on nursing facility services. A $1000 increase in Medicaid home care expenditures avoided 2.75 days in nursing facilities and reduced annual Medicaid nursing facility costs by $351 among people over age 65 when selection bias is addressed. Failure to address selection biases would misestimate the substitution and offset effects.

Background Mobile atheroma are associated with increased perioperative strokes in patients undergoing coronary artery bypass surgery. Peripheral embolization is an additional risk. Transesophageal echocardiography (TEE) accurately identifies mobile atheroma. Recent reports have discussed the possible influence of anticoagulant therapy in promoting peripheral cholesterol embolization. Methods Fourteen patients with mobile atheroma were treated with anticoagulation. A review of literature reporting results and complications of anticoagulation in the treatment of this condition was compared with our recent experience. Results Between 1994 and 1996, 14 patients with peripheral embolization and mobile atheroma confirmed by TEE were anticoagulated. Clinical follow-up between 6 to 30 months has demonstrated no further evidence of systemic embolization since anticoagulation. Furthermore, repeat TEE in 3 of 14 patients no longer visualized mobile atheroma. Conclusions Mobile atheroma are recognized sources for embolization. Patients with generalized atherosclerosis should be screened for this condition in cases of systemic embolization. Anticoagulation may have therapeutic considerations in the management of this condition.

The patterns of health care utilization in the United States pose well-established challenges for public policy. Although economic and sociological research has resulted in considerable knowledge about what influences the use of health services, the psychological literature in this area is underdeveloped. Importantly, it is not known whether personality traits are associated with older adults' use of acute and long-term care services.Data were collected from 1,074 community-dwelling seniors participating in a Medicare demonstration. First they completed a self-report questionnaire measuring the "Big Five" personality traits: Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness. During the next two years, the participants maintained daily journals of their use of health care services. We used regression models based on the Andersen behavioral model of health care utilization to test for associations.Our hypothesis that higher Neuroticism would be associated with greater health care use was confirmed for three services-probability of any emergency department (ED) use, likelihood of any custodial nursing home use, and more skilled nursing facility (SNF) days for SNF users-but was disconfirmed for hospital days for those hospitalized. Higher Openness to Experience was associated with a greater likelihood of custodial home care use, and higher Agreeableness and lower Conscientiousness with a higher probability of custodial nursing home use. For users, lower Openness was associated with more ED visits and SNF days, and lower Conscientiousness with more ED visits. For many traits with significant associations, the predicted use was 16 to 30 percent greater for people high (low) versus low (high) in specific traits.Personality traits are associated with Medicare beneficiaries' use of many expensive health care services, findings that have implications for health services research and policy. Accordingly, person-centered interventions, population-based translational effectiveness programs, and other personalized approaches that leverage the profound advances in personality psychology in recent decades should be considered.

There are a number of situations in which health services researchers can encounter data with a bimodal (U-shaped) distribution. When such a situation arises, it may be beneficial to adopt an analytic approach that explicitly incorporates the bimodal nature of the distribution. One useful tool for this is beta-binomial regression, which has been rarely used in health services research but has the flexibility to fit various distributions, including bimodal data. This article describes some of the key issues that arise with beta-binomial regression and illustrates the use of this technique in a real-world application. One situation in which a bimodal distribution could arise is when patients have two alternative choices of health care provider, and data measure the share of times patients use one of the providers. A recent study showed that reliance on the Department of Veterans Affairs (VA) health care system, that is, the proportion of primary care received in the VA, among Medicare-eligible veterans had a bimodal distribution and residuals had a nonnormal distribution (Liu et al. 2011). This VA reliance measure was not only bimodal but also followed a U-shaped distribution, because most veterans tended to be either mostly or entirely reliant on VA, or hardly or not at all reliant on VA; while there was a significant proportion remaining using both VA and Medicare services. For example, from the study by Liu and colleagues, 40% of veterans had a VA reliance measure for primary care greater than 0.8; 25% had a VA reliance measure less than 0.2 in 2004; and 35% of veterans had a VA reliance measure in between 0.2 and 0.8 (Liu et al. 2011). Beta-binomial regression is a rarely used model in health services research that has the flexibility to fit various distributions, including bimodal and U-shaped distributions. The purpose of this article was to illustrate how to model bimodally distributed utilization using a beta-binomial regression. First, we describe the basic properties of the beta-binomial distribution. Second, we describe the process that can be employed to estimate a beta-binomial regression using the statistical model developed by Guimaraes, using a fixed effect negative binomial model in Stata (xtnbreg) (Guimaraes 2005). Finally, we compare the predicted mean and predicted distributions from beta-binomial, ordinary least squares (OLS), and binomial regressions to illustrate how the different models fit the bimodally distributed VA reliance outcome, showing the superiority of the beta-binomial approach in this example.

Over 120 loci are known to cause inherited hearing loss in humans. The deafness gene has been identified for only half of these loci. With the aim of identifying some of the remaining deafness genes, we performed an ethylnitrosourea mutagenesis screen for deaf mice. We isolated two mutants with semi-dominant hearing loss, Deaf11 and Deaf13. Both contained causative mutations in Atp2b2, which encodes the plasma membrane calcium ATPase 2. The Atp2b2 (Deaf11) mutation leads to a p. I1023S substitution in the tenth transmembrane domain. The Atp2b2 (Deaf13) mutation leads to a p. R561S substitution in the catalytic core. Mice homozygous for these mutations display profound hearing loss. Heterozygotes display mild to moderate, progressive hearing loss.

Background Intravascular ultrasound (IVUS) has been described as interesting technology in search of a clinical application by some and by others as a valuable diagnostic tool for many endovascular interventions. Its clinical usefulness has yet to be fully defined. When used during endovascutar interventions, it can provide structural and diagnostic information, assess effectiveness of the therapy, and identify treatment-related complications. Methods Thirty-two consecutive patients with atherosclerotic aortoiliac occlusive disease who presented with 40 separate arterial lesions were evaluated with IVUS before and after balloon angioplasty and intraluminal stent placement. Information obtained from IVUS was compared with similar data obtained from simultaneous angiographic images. Both techniques were evaluated with respect to assessment of vessel size, lesion location, adequacy of therapy, and identification of complications. Results Real time IVUS imaging compared with angiographic imaging showed that in 62% of the patients, vessel diameter was underassessed using angiographic criteria alone. More importantly, 40% (16 of the 40 lesions) had underdeployed stents by IVUS evaluation that appeared adequately expanded by angiographic criteria. Further stent expansion with a larger balloon was necessary to achieve accurate stent to vessel wall apposition. This was found to be significant by an exact binomial 95% confidence interval. Incomplete stent deployment has been identified as a possible cause for restenosis and vessel occlusion. Information obtained from IVUS imaging substantially altered the endovascular therapy in approximately 40% of our patients and provided valuable vessel sizing and lesion composition information in 62% of the patients. Conclusion Intravascular ultrasound can provide important diagnostic information that can alter the conduct of selected endovascular procedures. It is especially useful when the procedure requires deployment of arterial stents.

Although Americans pay much more for a day in the hospital than Canadians, we know little about whether inpatient physician practice patterns might explain some of this difference. The authors compared the utilization of all diagnostic imaging (plain radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) scanning, ultrasound, nuclear medicine and vascular studies) and selected laboratory tests (hematology, basic biochemistry, and advanced biochemistry) for all patients discharged with selected medical and surgical diagnoses in 1990 and 1991 from four university hospitals and four community hospitals in Canada (n = 6,491) and the United States (n = 7,980). Overall, US medical patients received 22% more diagnostic tests than their Canadian counterparts (544.2 relative value units [RVUs] vs. 446.5 RVUs in Canada, P < 0.001), which was mainly the result of higher radiology use. Although mean radiology use was 40% higher in the United States (370.0 vs. 264.5 RVUs in Canada, P < 0.05), there was little difference in the use of laboratory tests between countries (174.2 vs. 182.4 RVUs in Canada, P = 0.3). Within radiology, only CT and MRI use differed significantly between countries (US patients received 119% more tests than Canadians). These findings were consistent after adjustments for age, gender, diagnosis-related group, and university status. Differences in test use between countries were mainly the result of more testing among the US elderly than counterparts in Canada. Among surgical patients, there was little difference between countries for radiology (76.3 vs. 67.3 RVUs in Canada, P < 0.05) and laboratory (83.6 vs. 91.4 RVUs in Canada, P < 0.05). Comparable inpatients admitted to US hospitals received more diagnostic tests than their Canadian counterparts even in hospitals with similar availability of technology. Differences between countries were larger for high-cost tests than for lower-cost tests. Much of the difference in test use is explained by more intensive use for the elderly in the United States.

We analyzed switches between prepaid and fee-for-service health care plans among depressed outpatients in the longitudinal part of the Medical Outcomes Study. Patients of mental health specialists in fee-for-service plans had the lowest adjusted rate of plan switching (8.1%), compared to fee-for-service general medical patients (13.5%) and prepaid patients of both types of providers (10.1% to 11.7%). Although there were no substantial differences in initial sickness by payment system among enrolled patients, differing switching rates by provider specialty and payment system indicated biased selection over time. In addition, we found that married, nonwhite, and wealthier individuals were significantly more likely to leave fee-for-service than prepaid care plans. We analyzed whether system switching had an effect on patient satisfaction and outcomes. None of the results were highly significant, but the power of the data to analyze this issue was limited. Nevertheless, it appears that patients switching from prepaid to fee-for-service may be at risk for poorer functioning outcomes, although there was no similar effect on mental health status.

Our goal in the present study was to examine the specificity of pathways among interparental violence, maternal emotional unavailability, and children's cortisol reactivity to emotional stressors within interparental and parent-child relationships. The study also tested whether detrimental family contexts were associated, on average, with hypocortisolism or hypercortisolism responses to stressful family interactions in young children. Participants included 201 toddlers and their mothers who were from impoverished backgrounds and who experienced disproportionate levels of family violence. Assessments of interparental violence were derived from maternal surveys and interviews, whereas maternal emotional unavailability was assessed through maternal reports and observer ratings of caregiving. Salivary cortisol levels were sampled at 3 time points before and after laboratory paradigms designed to elicit children's reactivity to stressful interparental and parent-child contexts. Results indicated that interparental violence and the mother's emotional unavailability were differentially associated with children's adrenocorticol stress reactivity. Furthermore, these family risk contexts predicted lower cortisol change in response to distress. The results are interpreted in the context of risky family and emotional security theory conceptualizations that underscore how family contexts differentially impact children's physiological regulatory capacities.

Healthcare for end-stage renal disease (ESRD) is intensive, expensive, and provided in both the public and private sector. Using a societal perspective, we examined healthcare costs and health outcomes for Department of Veterans Affairs (VA) ESRD patients comparing those who received hemodialysis care at VA versus private sector facilities.Dialysis patients were recruited from 8 VA medical centers from 2001 through 2003 and followed for 12 months in a prospective cohort study. Patient demographics, clinical characteristics, quality of life, healthcare use, and cost data were collected. Healthcare data included utilization (VA), claims (Medicare), and patient self-report. Costs included VA calculated costs, Medicare dialysis facility reports and reimbursement rates, and patient self-report. Multivariable regression was used to compare costs between patients receiving dialysis at VA versus private sector facilities.The cohort comprised 334 patients: 170 patients in the VA dialysis group and 164 patients in the private sector group. The VA dialysis group had more comorbidities at baseline, outpatient and emergency visits, prescriptions, and longer hospital stays; they also had more conservative anemia management and lower baseline urea reduction ratio (67% vs. 72%; P0.001), although levels were consistent with guidelines (Kt/V≥1.2). In adjusted analysis, the VA dialysis group had $36,431 higher costs than those in the private sector dialysis group (P0.001).Continued research addressing costs and effectiveness of care across public and private sector settings is critical in informing health policy options for patients with complex chronic illnesses such as ESRD.

This study evaluated the utility of (S)-N-[(1-ethyl-2-pyrrolidinyl)methyl]-5-(3-[18F]fluoropropyl)-2,3-dimethoxybenzamide ([18F]fluoropropylepidepride), [18F]5-FPrEpid, as a ligar d for PET studies of cerebral dopamine D2 receptors. The in vitro affinity for the rat striatal dopamine D2 receptor, KD 138 pM, was determined by Scatchard analysis of in vitro binding to rat striatal homogenate. The apparent lipophilicity, log kw 1.6, was measured with reverse phase HPLC at pH 7.5. The receptor specificity was determined by competitive displacement of [18F]5-FPrEpid by a variety of neurotransmitter ligands. Only dopamine D2 ligands displaced [18F]5-FPrEpid with high affinity. Positron tomographic imaging studies in primates of [18F]5-FPrEpid demonstrated a stable striatal uptake. of 0.02% injected dose/ml for up to 5 h after injection. The striatal: cerebellar ratio increased from 2 at 15 min, to 7 at 200 min, and to 10 at 300 min. Striatal uptake was displaceable by haloperidol (1 mg/kg) or raclopride (2.5 mg/kg) to cerebellar levels with a t1/2 of washout of 9 or 15 min. Striatal uptake was mildly susceptible to displacement by d-amphetamine (1–2 mg/kg) released endogenous dopamine; d-amphetamine administration produced a 10%/h increase in the rate of striatal washout. Although uptake in the striatum is reversible, an equilibrium between receptor bound [18F]5-FPrEpid in striatum and [18F]5-FPrEpid in plasma is not reached within 5 h postinjection. © 1993 Wiley-Liss. Inc.

Many analyses of healthcare costs involve use of data with varying periods of observation and right censoring of cases before death or at the end of the episode of illness. The prominence of observations with no expenditure for some short periods of observation and the extreme skewness typical of these data raise concerns about the robustness of estimators based on inverse probability weighting (IPW) with the survival from censoring probabilities. These estimators also cannot distinguish between the effects of covariates on survival and intensity of utilization, which jointly determine costs. In this paper, we propose a new estimator that extends the class of two-part models to deal with random right censoring and for continuous death and censoring times. Our model also addresses issues about the time to death in these analyses and separates the survival effects from the intensity effects. Using simulations, we compare our proposed estimator to the inverse probability estimator, which shows bias when censoring is large and covariates affect survival. We find our estimator to be unbiased and also more efficient for these designs. We apply our method and compare it with the IPW method using data from the Medicare-SEER files on prostate cancer.

Chronically homeless adults with severe mental illness are heavy users of costly inpatient and emergency psychiatric services. Full-service partnerships (FSPs) provide housing and engage clients in treatment.To examine changes in recovery outcomes, mental health service use and costs, and quality of life associated with participation in FSPs.A quasi-experimental, difference-in-difference design with a propensity score-matched control group was used to compare mental health service use and costs of FSP with public mental health services. Recovery outcomes were compared before and after services use, and quality of life was compared cross-sectionally.San Diego County, California, from October 2005 through June 2008.Two hundred nine FSP clients and 154 clients receiving public mental health services.Recovery outcomes (housing, financial support, and employment), mental health service use (use of outpatient, inpatient, emergency, and justice system services), and mental health services and housing costs from the perspective of the public mental health system.Among FSP participants, the mean number of days spent homeless per year declined 129 days from 191 to 62 days; the probability of receiving inpatient, emergency, and justice system services declined by 14, 32, and 17 percentage points, respectively; and outpatient mental health visits increased by 78 visits (P.001 each). Outpatient costs increased by $9180; inpatient costs declined by $6882; emergency service costs declined by $1721; jail mental health services costs declined by $1641; and housing costs increased by $3180 (P.003 each). Quality of life was greater among FSP clients than among homeless clients receiving services in outpatient programs.Participation in an FSP was associated with substantial increases in outpatient services and days spent in housing. Reductions in costs of inpatient/emergency and justice system services offset 82% of the cost of the FSP.

Utilization review (UR) programs have become an integral part of efforts to contain health care costs for private health insurers, employers, and health care organizations. While some studies have measured the overall performance of these programs, important information in the prior level of the health care utilization has not been used in estimating the effectiveness of the program for micro units (e.g., employer groups). In this article, the authors present a model to determine how the impact of the hospital UR program on health care utilization for specific groups varies with historical use patterns. The estimation approach used in this article can be used to determine the effect of UR for specific employer groups without having to rely on the average effectiveness measures for all. Claims obtained from Aetna Health Plans provided data for more than 5,300 employer accounts covering approximately 580,000 employees, 44% of whom had the UR program sometime during the period 1987 to 1990. Because of regression to the mean, UR savings were greater for units with higher prior use and smaller for units with lower use. In addition to prior use, the size of the group also determined the extent of regression to the mean. Groups with smaller number of enrollees had greater potential to save from the UR because of UR's ability to reduce the outliers.

Background: This paper examined children’s fearful, sad, and angry reactivity to interparental conflict as mediators of associations between their exposure to interparental aggression and physiological functioning. Methods: Participants included 200 toddlers and their mothers. Assessments of interparental aggression and children’s emotional reactivity were derived from maternal surveys and a semi‐structured interview. Cortisol levels and cardiac indices of sympathetic nervous system (SNS) and parasympathetic nervous system (PNS) activity were used to assess toddler physiological functioning. Results: Results indicated that toddler exposure to interparental aggression was associated with greater cortisol levels and PNS activity and diminished SNS activity. Toddler angry emotional reactivity mediated associations between interparental aggression and cortisol and PNS functioning. Fearful emotional reactivity was a mediator of the link between interparental aggression and SNS functioning. Conclusions: The results are interpreted within conceptualizations of how exposure and reactivity to family risk organize individual differences in physiological functioning.

Epidepride, (S)-N-[(1-ethyl-2-pyrrolidinyl)methyl]-5-iodo-2,3-dimethoxybenzamide+ ++, the iodine analogue of isoremoxipride (FLB 457), was found to be a very potent dopamine D2 receptor antagonist. Optimal in vitro binding required incubation at 25 degrees C for 4 h at pH 7.4 in a buffer containing 120 mM NaCl, 5 mM KCl, 2 mM CaCl2 and 1 mM MgCl2. Scatchard analysis of in vitro binding to striatal, medial frontal cortical, hippocampal and cerebellar membranes revealed a KD of 24 pM in all regions, with Bmax's of 36.7, 1.04, 0.85, and 0.37 pmol/g tissue, respectively. The Hill coefficients ranged from 0.91-1.00 in all four regions. The IC50's for inhibition of [125I]epidepride binding to striatal, medial frontal cortical, and hippocampal membranes for SCH 23390, SKF 83566, serotonin, ketanserin, mianserin, naloxone, QNB, prasozin, clonidine, alprenolol, and norepinephrine ranged from 1 microM to greater than 10 microM. Partial displacement of [125I]epidepride by nanomolar concentrations of clonidine was noted in the frontal cortex and hippocampus, but not in the striatum. Scatchard analysis of epidepride binding to alpha 2 noradrenergic receptors in the frontal cortex and hippocampus revealed an apparent KD of 9 nM. At an epidepride concentration equal to the KD for the D2 receptor, i.e. 25 pM, no striatal alpha 2 binding was seen and only 7% of the specific epidepride binding in the cortex or hippocampus was due to binding at the alpha 2 site. Correlation of inhibition of [3H]spiperone and [125I]epidepride binding to striatal membranes by a variety of D2 ligands revealed a correlation coefficient of 0.99, indicating that epidepride labels a D2 site. In vitro autoradiography revealed high densities of receptor binding in layers V and VI of prefrontal and cingulate cortices as well as in striatum. In vivo rat brain uptake revealed a hippocampal:cerebellar and frontal cortical:cerebellar ratio of 2.2:1 which fell to 1.1:1 following haloperidol pretreatment. These properties suggest that [125I]epidepride is a superior radioligand for the in vitro and in vivo study of striatal and extrastriatal dopamine D2 receptors.

Background: Mobile atheromas of the aortic arch are associated with otherwise unexplained strokes and transient ischemic attacks (TIA). They are associated with increased perioperative strokes in patients undergoing coronary artery bypass surgery. Peripheral embolization is an additional risk. Transesophageal echocardiography (TEE) accurately identifies mobile atheroma. Anticoagulant therapy may have therapeutic considerations in the management of this condition. However, the risk of significant carotid artery disease associated with mobile atheromas is unknown. Methods: Between March 1994 and July 1998, 40 patients with mobile atheromas by TEE and evidence of embolization were studied. All patients were captured prospectively in a vascular registry and were retrospectively reviewed. Carotid artery disease was evaluated using carotid duplex imaging in an accredited vascular laboratory. All patients with significant carotid disease, 70% or greater stenosis, underwent arteriography. Patients with significant carotid artery stenosis then underwent carotid endarterectomy. All patients with mobile atheromas were maintained on anticoagulation. Results: Forty patients with mobile atheromas of the aortic arch were diagnosed with TEE. All 40 patients had evidence of embolization. Patient age ranged from 57 to 73 years (mean 68.4). There were 22 men and 18 women. Twenty of 40 (50%) patients presented with symptoms of TIA. Eleven of 40 (28%) patients presented with diffuse atheroembolization (lower extremity embolization and renal insufficiency). Six of 40 (15%) patients presented with a completed stroke. Three of 20 (7%) patients presented with acute extremity ischemia secondary to a peripheral embolus. Twenty-three of 40 (58%) of patients had significant carotid artery stenosis, 70% or greater stenosis. These 23 patients underwent both arteriography and carotid endarterectomy without complication. All patients were treated with anticoagulation and have remained anticoagulated. Clinical follow-up between 2 to 48 months (mean 18) has demonstrated no further evidence of systemic embolization in these 40 patients. Repeat TEE was performed in 6 of 40 patients. These follow-up studies no longer visualized mobile atheromas. Conclusions: Mobile atheromas are recognized sources for embolization. Routine carotid duplex imaging should be performed in patients found to have mobile atheromas of the aortic arch. Carotid endarterectomy appears to be safe in patients who have combined carotid artery stenosis and mobile atheromas. Anticoagulation may have therapeutic considerations in the management of this condition.

To determine the relation between patient and provider characteristics and inappropriate hospital use, we examined adult nonpregnancy hospitalizations from a randomized trial of health insurance conducted in six sites in the United States. Appropriateness of inpatient treatment was based on medical record review; patient characteristics on sociodemographic, economic, and health status; and provider characteristics on descriptors of physician practice and hospital facilities. Twenty-seven percent of admissions attended by physicians licensed for more than 15 years were judged inappropriate, compared to 20 percent for younger physicians. Admissions were more likely to be inappropriate if the patient was female (27 percent compared with 18 percent). Controlling for patient and provider characteristics reduces but does not eliminate the differences in the appropriateness of inpatient care across the study's six sites. Differences in available provider and patient characteristics do not account for geographic differences in inappropriate hospitalization in this study.

A 25-year-old man was brought to the emergency room after being found unconscious. Electrocardiography (ECG) showed changes classical of tricyclic antidepressant (TCA) poisoning. These included sinus tachycardia, QTc prolongation, QRS complex widening, right axis deviation and positive R waves in lead aVR. This unique ECG highlights the importance of lead aVR, which often tends to be ignored. Treatment is started based on ECG findings.

Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question.Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease-related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors.In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease-related and total charges were lower by 10,367 dollars and 15,318 dollars compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends.001). Analyses by sex showed similar patterns.Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life.

To examine associations in nondiabetic individuals of 1-h postload plasma glucose measured in young adulthood and middle age with subsequent Medicare expenditures for cardiovascular disease (CVD), diabetes, cancer, and all health care at age 65 years or older using data from the Chicago Heart Association Detection Project in Industry (CHA).Medicare data (1984-2000) were linked with CHA baseline records (1967-1973) for 8,580 men and 6,723 women ages 33-64 years who were free of coronary heart disease, diabetes, and major electrocardiogram (ECG) abnormalities and who were Medicare eligible (65+ years) for at least 2 years. Participants were classified based on 1-h postload plasma glucose levels120, 120-199, oror =200 mg/dl.With adjustment for baseline age, cigarette smoking, serum cholesterol, systolic blood pressure, BMI, ethnicity, education, and minor ECG abnormalities, the average annual and cumulative Medicare, total, and diabetes- and CVD-related charges were significantly higher with higher baseline plasma glucose in women, while only diabetes-related charges were significantly higher in men. For example, in women, multivariate-adjusted CVD-related cumulative charges were, respectively, USD 14,260, 18,909, and 21,183 for the three postload plasma glucose categories (P value for trend = 0.035).These findings suggest that maintaining low glucose levels early in life has the potential to reduce health care costs in older age.

Increasing prevalence of overweight/obesity and rapid aging of the US population have raised concerns of increasing health care costs, with important implications for Medicare. However, little is known about the impact of body mass index (BMI) earlier in life on Medicare expenditures (cardiovascular disease [CVD]-related, diabetes-related, and total) in older age.To examine relationships of BMI in young adulthood and middle age to subsequent health care expenditures at ages 65 years and older.Medicare data (1984-2002) were linked with baseline data from the Chicago Heart Association Detection Project in Industry (CHA) (1967-1973) for 9978 men (mean age, 46.0 years) and 7623 women (mean age, 48.4 years) (baseline overall age range, 33 to 64 years) who were free of coronary heart disease, diabetes, and major electrocardiographic abnormalities, were not underweight (BMI18.5), and were Medicare-eligible (or =65 years) for at least 2 years during 1984-2002. Participants were classified by their baseline BMI as nonoverweight (BMI, 18.5-24.9), overweight (25.0-29.9), obese (30.0-34.9), and severely obese (or =35.0).Cardiovascular disease-related, diabetes-related, and total average annual Medicare charges, and cumulative Medicare charges from age 65 years to death or to age 83 years.In multivariate analyses, average annual and cumulative Medicare charges (CVD-related, diabetes-related, and total) were significantly higher by higher baseline BMI for both men and women. Thus, with adjustment for baseline age, race, education, and smoking, total average annual charges for nonoverweight, overweight, obese, and severely obese women were, respectively, 6224 dollars, 7653 dollars, 9612 dollars, and 12,342 dollars (P.001 for trend); corresponding total cumulative charges were 76, 866 dollars, 100,959 dollars, 125,470 dollars, and 174,752 dollars (P.001 for trend). For nonoverweight, overweight, obese, and severely obese men, total average annual charges were, respectively, 7205 dollars, 8390 dollars, 10,128 dollars, and 13,674 dollars (P.001 for trend). Corresponding total cumulative charges were 100,431 dollars, 109,098 dollars, 119,318 dollars, and 176,947 dollars (P.001 for trend).Overweight/obesity in young adulthood and middle age has long-term adverse consequences for health care costs in older age.

Background High fruit and vegetable intake is associated with lower risk of hypertension, cardiovascular disease, and cancer. Little is known about the relationship of fruit and vegetable intake to health care expenditures. Objective Examine whether fruit and vegetable intake among middle-aged adults is related to Medicare charges—total, cardiovascular disease, cancer-related—in older age. Design Participants were grouped into one of three strata according to fruit and vegetable intake, determined from detailed dietary history (1958-1959): less than 14 cups per month, 14 to 42 cups per month, or more than 42 cups per month. Combined intake was classified as low, medium, or high. Medicare claims data (1984-2000) were used to estimate mean annual spending for eligible surviving participants (65 years and older) from the Chicago Western Electric Study: 1,063 men age 40 to 55 and without coronary heart disease, diabetes, and cancer at baseline (1957-1958). Cumulative charges before death (n=401) were also calculated. Results Higher fruit and fruit plus vegetable intakes were associated with lower mean annual and cumulative Medicare charges ( P values for trend .019 to .862). For example, with adjustment for baseline age, education, total energy intake, and multiple baseline risk factors, annual cardiovascular disease–related charges were $3,128 vs $4,223 for men with high vs low intake of fruit plus vegetables. Corresponding figures were $1,352 vs $1,640 for cancer-related charges and $10,024 vs $12,211 for total charges. Results were generally similar for vegetable intake. Conclusion These findings, albeit mostly not statistically significant, suggest that for men high intake of fruits and fruits plus vegetables earlier in life has potential not only for better health status but also for lower health care costs in older age.

Objectives: Persons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period. Methods: Inpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility. Results: Interruptions in Medicaid coverage were associated with an average of .63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days. Conclusions: Medicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness. (Psychiatric Services 54: 999–1005, 2003)

Childhood injuries cause significant mortality and morbidity in Singapore. With injury surveillance, patterns of repeated injury can be identified and injury prevention strategies devised.We conducted a retrospective study of all children aged 12 and below seen for trauma in an Emergency Department over one year. Data captured in the real-time computer system was studied with regards to patient profile, mechanism of injury and patient disposition. Clinical summaries were extracted with follow-up telephone interviews done.Two thousand five hundred and seventeen children aged 12 and below were seen for accidental trauma in 1999, accounting for 37.1% of the total attendance for that age. Mean age was 7.7 years with males making up 62.7%. Home injuries (56.4%) were the most common, followed by road-related (14.4%), sports (8.2%) and playground injuries (7.4%). 48.5% sustained head and face injuries. Pre-school children (age5) were more likely to sustain home injuries (p0.0001), a higher proportion of head injuries (p0.0001), foreign bodies, burns and poisoning compared to school-going children (age 6-12), who were more likely to sustain injuries in road accidents, sports, at playgrounds or schools, with more limb, trunk and multi-trauma. We highlight drownings, falls from height, rollover falls from beds, slamming door injuries, the low use of child car restraints, bicycle injuries and playground falls as areas of concern.Several injury prevention strategies have been suggested and it is hoped these may contribute to addressing preventable childhood injuries in Singapore. We also advocate the establishment of a national childhood injury surveillance database.

It is often difficult to interpret the clinical or policy significance of findings from mental health research when results are presented only in terms of statistical significance. Results expressed in terms of p values or as a metric corresponding to a mental health status scale are seldom intuitively meaningful. To help interpret the significance of research results, we demonstrate a social validity approach that relates scores on mental health status scales to four subsequent major life events. A logistic regression model is used to estimate the relation between mental health status scores and the probability of subsequent major life events, using data obtained on Medicaid beneficiaries with schizophrenia from an evaluation of the Utah Prepaid Mental Health Plan. Using this relatively simple approach will demonstrate to policy makers, clinicians, and researchers the social impact of an outcome, thereby aiding in the interpretation of the significance of results.

Background Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care. Methods Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years. A 2-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n = 218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months) were converted to measures of "depression-free days." Health services utilization and costs were estimated using health plan–standardized claims. Results The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848-$3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47). Conclusions Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.

Background: Previous reports suggest that earlier hospital discharges and reduced postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an effort to determine the most cost efficient method for aortic surgery in our institution, while maintaining high standards of care and outcome, we compared the retroperitoneal approach to the conventional transperitoneal aortic operation. Patients and methods: Between December 1995 and April 1998, 120 patients underwent aortic surgery by either the transperitoneal (n=60) or retroperitoneal approach (n=60). All patients were enrolled prospectively in a vascular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons. A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated with respect to demographics, comorbidities, preoperative risk stratification, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic surgery were similar in both groups — 64% for aneurysm disease and 36% for occlusive disease. Both symptomatic and asymptomatic aneurysms were included and size ranged from 4.4 to 14 cm. All aortic reconstructions were done in the standard manner using knitted Dacron velour prostheses in either the aortic tube, bi-iliac or bi-femoral configuration. Statistical analysis of means and medians was accomplished using the Wilcoxin Rank-sum test and percentages were compared using Fisher's Exact test. P values less than 0.05 indicate statistical significance. Results: There were no statistically significant differences in patient demographics. The incidence of atherosclerotic coronary artery disease, obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lower extremity occlusive disease and the results of chemical myocardial stress evaluations were similar in both groups. Comorbidities of pre-existing renal insufficiency/failure and morbid obesity were increased in the retroperitoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal group. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2–3 l more intraoperative intravenous (IV) crystalloid than the retroperitoneal group (P

[123I]Epidepride, a potent and selective dopamine D2 radioligand, was administered to a 27 year old normal male volunteer. Single photon tomography revealed that peak striatal uptake occurred at 4 h after injection with a striatal:cerebellar ratio of 7.8 rising to over 100 at 18 h post injection. Uptake above the levels seen in cerebellum was also noted in the thalamus, pituitary, hypothalamus and temporal lobe, particularly medially. Single photon tomography with [123I]epidepride allows visualization of extrastriatal dopamine D2 receptors in man.

Clinical studies and the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines suggest that a target hematocrit of 33% to less than 36% is appropriate for patient benefit. Previous studies have shown an association of lower risks for death and hospitalization when hematocrits were 33% to less than 36%. In this study, we assessed the relationship between hematocrit value and associated Medicare expenditures, analyzing incident Medicare hemodialysis patients from January 1, 1991, through June 30, 1995. All patients survived at least 90 days to normalize eligibility and an additional 6-month entry period to assess comorbidity and hematocrit values. All patients were followed up from July 1, 1991, through December 31, 1996. We assessed the association between hematocrit values in the 6-month entry period and the Medicare-allowable Part A and Part B per-member-per-month (PMPM) expenditures in the follow-up period, controlling for other variables, including patient demographic characteristics, comorbid conditions, and severity of disease. We found that hematocrits of 33% to less than 36% and 36% and higher were associated with lower Medicare-allowable payments in the follow-up period. Compared with reference patients with hematocrits of 30% to less than 33%, the Medicare-allowable PMPM expenditures were significantly greater for patients with hematocrits less than 27% and 27% to less than 30% (12.7% and 5.3%, respectively), and the Medicare-allowable PMPMs were significantly less for patients with hematocrits of 33% to less than 36% and 36% and higher (6.0% and 8.2%, respectively). Although these findings suggest that the treatment of anemia may be associated with significant savings in total patient Medicare expenditures, caution should be considered because these findings are associations and should not be deemed as showing causality.

BACKGROUND High utilizers of nonpsychiatric health care services have disproportionally high rates of undiagnosed or undertreated depression. OBJECTIVE To determine the impact of offering a systematic primary care-based depression treatment program to depressed "high utilizers" not in active treatment. DESIGN Randomized clinical trial. SETTING One hundred sixty-three primary care practices in 3 health maintenance organizations located in different geographic regions of the United States. PATIENTS A group of 1465 health maintenance organization members were identified as depressed high utilizers using a 2-stage telephone screening process. Eligibility criteria were met by 410 patients and 407 agreed to enroll: 218 in the depression management program (DMP) practices and 189 in the usual care (UC) group. INTERVENTION The DMP included patient education materials, physician education programs, telephone-based treatment coordination, and antidepressant pharmacotherapy initiated and managed by patients' primary care physicians. MAIN OUTCOME MEASURES Depression severity was measured using the Hamilton Depression Rating Scale (Ham-D) and functional status using the Medical Outcomes Study 20-item short form (SF-20) subscales. Outpatient visit and hospitalization rates were measured using the health plan's encounter data. RESULTS Based on an intent-to-treat analysis, at least 3 antidepressant prescriptions were filled in the first 6 months by 151 (69.3%) of 218 of DMP patients vs 35 (18.5%) of 189 in UC (P < .001). Improvements in Ham-D scores were significantly greater in the intervention group at 6 weeks (P = .04), 3 months (P = .02), 6 months (P < .001), and 12 months (P < .001). At 12 months, DMP intervention patients were more improved than UC patients on the mental health, social functioning, and general health perceptions scales of the SF-20 (P < .05 for all). CONCLUSION In depressed high utilizers not already in active treatment, a systematic primary care-based treatment program can substantially increase adequate antidepressant treatment, decrease depression severity, and improve general health status compared with usual care.

Little is known about how well individuals are compensated for injuries. This study uses data from a 1989 survey to estimate both the lifetime costs and compensation for injuries. Our findings show that about 55% of the cost is compensated by public or private programs. Compensation rates are lower for disabling injuries and those of long duration. The results also suggest that compensation system reforms that would place stricter limits on maximum compensation might not be a distributionally fair solution. The reasons are that costs are highly skewed, and the share of costs recovered by compensation programs is currently lowest for injuries that are long term, disabling, and the most expensive.