Aircraft cabin air recirculation and symptoms of the common cold

Context  In recent years, new commercial aircraft have been designed to recirculate approximately 50% of the cabin air to increase fuel efficiency. Some older aircraft use only fresh air. Whether air recirculation increases the transmission of infectious disease is unknown; some studies have demonstrated higher rates of the common cold among persons working in buildings that recirculate air. Objective  To evaluate the role of air recirculation as a predictor of postflight upper respiratory tract infections (URIs). Design, Setting, and Participants  A natural experiment conducted among 1100 passengers departing the San Francisco Bay area in California and traveling to Denver, Colo, during January through early April 1999, and who completed a questionnaire in the boarding area and a follow-up telephone interview 5 to 7 days later. Forty-seven percent traveled aboard airplanes using 100% fresh air for ventilation, and 53% traveled aboard aircraft that recirculated cabin air. Main Outcome Measure  Incidence of reporting new URI symptoms within 1 week of the flight. Results  Passengers on airplanes that did and did not recirculate air had similar rates of postflight respiratory symptoms. The rates of reporting a cold were 19% vs 21% (P = .34); a runny nose and a cold, 10% vs 11%, (P = .70); and an aggregation of 8 URI symptoms, 3% in both groups (P>.99). Results were similar after statistical adjustment for potential confounders. Conclusion  We found no evidence that aircraft cabin air recirculation increases the risk for URI symptoms in passengers traveling aboard commercial jets.      

Functional decline in peripheral arterial disease: associations with the ankle brachial index and leg symptoms

Context  Among individuals with lower-extremity peripheral arterial disease (PAD), specific leg symptoms and the ankle brachial index (ABI) are cross-sectionally related to the degree of functional impairment. However, relations between these clinical characteristics and objectively measured functional decline are unknown. Objective  To define whether PAD, ABI, and specific leg symptoms predict functional decline at 2-year follow-up. Design, Setting, and Participants  Prospective cohort study among 676 consecutively identified individuals (aged 55 years) with and without PAD (n = 417 and n = 259, respectively), with baseline functional assessments occurring between October 1, 1998, and January 31, 2000, and follow-up assessments scheduled 1 and 2 years thereafter. PAD was defined as ABI less than 0.90, and participants with PAD were categorized at baseline into 1 of 5 mutually exclusive symptom groups. Main Outcome Measures  Mean annual changes in 6-minute walk performance and in usual-paced and fast-paced 4-m walking velocity, adjusted for age, sex, race, prior-year functioning, comorbid diseases, body mass index, pack-years of cigarette smoking, and patterns of missing data. Results  Lower baseline ABI values were associated with greater mean (95% confidence interval) annual decline in 6-minute walk performance (–73.0 [–142 to –4.2] ft for ABI <0.50 vs –58.8 [–83.5 to –34.0] ft for ABI 0.50 to <0.90 vs –12.6 [–40.3 to 15.1] ft for ABI 0.90-1.50, P = .02). Compared with participants without PAD, PAD participants with leg pain on exertion and rest at baseline had greater mean annual decline in 6-minute walk performance (–111 [–173 to –50.0] ft vs –8.67 [–36.9 to 19.5] ft, P = .004), usual-pace 4-meter walking velocity (–0.06 [–0.09 to –0.02] m/sec vs –0.01 (–0.03 to 0.003] m/sec, P = .02), and fastest-pace 4-meter walking velocity (–0.07 [–0.11 to –0.03] m/sec vs –0.02 [–0.04 to –0.006] m/sec, P = .046). Compared with participants without PAD, asymptomatic PAD was associated with greater mean annual decline in 6-minute walk performance (–76.8 (–135 to –18.6] ft vs –8.67 (–36.9 to 19.5] ft, P = .04) and an increased odds ratio for becoming unable to walk for 6 minutes continuously (3.63; 95% confidence interval, 1.58-8.36; P = .002). Conclusions  Baseline ABI and the nature of leg symptoms predict the degree of functional decline at 2-year follow-up. Previously reported lack of worsening in claudication symptoms over time in patients with PAD may be more related to declining functional performance to than lack of disease progression.      

Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial

Context  Carpal tunnel syndrome (CTS) can be treated with nonsurgical or surgical options. However, there is no consensus on the most effective method of treatment. Objective  To compare the short-term and long-term efficacy of splinting and surgery for relieving the symptoms of CTS. Design, Setting, and Patients  A randomized controlled trial conducted from October 1998 to April 2000 at 13 neurological outpatient clinics in the Netherlands. A total of 176 patients with clinically and electrophysiologically confirmed idiopathic CTS were assigned to wrist splinting during the night for at least 6 weeks (89 patients) or open carpal tunnel release (87 patients); 147 patients (84%) completed the final follow-up assessment 18 months after randomization. Main Outcome Measures  General improvement, number of nights waking up due to symptoms, and severity of symptoms. Results  In the intention-to-treat analyses, surgery was more effective than splinting on all outcome measures. The success rates (based on general improvement) after 3 months were 80% for the surgery group (62/78 patients) vs 54% for the splinting group (46/86 patients), which is a difference of 26% (95% confidence interval [CI], 12%-40%; P<.001). After 18 months, the success rates increased to 90% for the surgery group (61/68 patients) vs 75% for the splinting group (59/79 patients), which is a difference of 15% (95% CI, 3%-27%; P = .02). However, by that time 41% of patients (32/79) in the splint group had also received the surgery treatment. Conclusion  Treatment with open carpal tunnel release surgery resulted in better outcomes than treatment with wrist splinting for patients with CTS.      

Frequency of symptoms of ovarian cancer in women presenting to primary care clinics

Context  Women with ovarian cancer frequently report symptoms prior to diagnosis, but distinguishing these symptoms from those that normally occur in women remains problematic. Objective  To compare the frequency, severity, and duration of symptoms between women with ovarian cancer and women presenting to primary care clinics. Design, Setting, and Patients  A prospective case-control study of women who visited 2 primary care clinics (N = 1709) and completed an anonymous survey of symptoms experienced over the past year (July 2001-January 2002). Severity of symptoms was rated on a 5-point scale, duration was recorded, and frequency was indicated as number of episodes per month. An identical survey was administered preoperatively to 128 women with a pelvic mass (84 benign and 44 malignant). Main Outcome Measures  Comparison of self-reported symptoms between ovarian cancer patients and women seeking care in primary care clinics. Results  In the clinic population, 72% of women had recurring symptoms with a median number of 2 symptoms. The most common were back pain (45%), fatigue (34%), bloating (27%), constipation (24%), abdominal pain (22%), and urinary symptoms (16%). Comparing ovarian cancer cases to clinic controls resulted in an odds ratio of 7.4 (95% confidence interval [CI], 3.8-14.2) for increased abdominal size; 3.6 (95% CI, 1.8-7.0) for bloating; 2.5 (95% CI, 1.3-4.8) for urinary urgency; and 2.2 (95% CI, 1.2-3.9) for pelvic pain. Women with malignant masses typically experienced symptoms 20 to 30 times per month and had significantly more symptoms of higher severity and more recent onset than women with benign masses or controls. The combination of bloating, increased abdominal size, and urinary symptoms was found in 43% of those with cancer but in only 8% of those presenting to primary care clinics. Conclusions  Symptoms that are more severe or frequent than expected and of recent onset warrant further diagnostic investigation because they are more likely to be associated with both benign and malignant ovarian masses.      

Effects of decision aids for menorrhagia on treatment choices,health outcomes,and costs: a randomized controlled trial

Context  Decision aids can increase patient involvement in treatment decision making. However, questions remain regarding their effects and cost implications. Objective  To evaluate the effects of information, with and without a structured preference elicitation interview, on treatment choices, health outcomes, and costs. Design, Setting, and Participants  A randomized controlled trial with 2 years of follow-up. Between October 1996 and February 1998, 894 women with uncomplicated menorrhagia were recruited from 6 hospitals in southwest England. Women were randomized to the control group, information alone group (information), or information plus interview group (interview). Interventions  Women in both intervention groups were sent an information pack (a booklet and complementary videotape) 6 weeks before their specialist consultation. Immediately before their consultation, women in the interview group underwent structured interview, to clarify and elicit their preferences. Main Outcome Measures  Self-reported health status was the main outcome; secondary outcomes included treatments received and costs. Cost analyses adopted a UK health service (payer) perspective, and were based on patient-reported resource use data and are reported in 1999-2000 US dollars. Results  The interventions had no consistent effect on health status. Hysterectomy rates were lower for women in the interview group (38%) (adjusted odds ratio [OR], 0.60; 95% confidence interval [CI], 0.38-0.96) than in the control group (48%) and women who received the information alone (48%) (adjusted OR, 0.52; 95% CI, 0.33-0.82). The interview group had lower mean costs ($1566) than the control group ($2751) (mean difference, $1184; 95% CI, $684-$2110) and the information group $2026 (mean difference, $461; 95% CI, $236-$696). Conclusions  Neither intervention had an effect on health status. Providing women with information alone did not affect treatment choices; however, the addition of an interview to clarify values and elicit preferences had a significant effect on women's management and resulted in reduced costs.      

Association of low-level ozone and fine particles with respiratory symptoms in children with asthma

Context  Exposure to ozone and particulate matter of 2.5 µm or less (PM_2.5) in air at levels above current US Environmental Protection Agency (EPA) standards is a risk factor for respiratory symptoms in children with asthma. Objective  To examine simultaneous effects of ozone and PM_2.5 at levels below EPA standards on daily respiratory symptoms and rescue medication use among children with asthma. Design, Setting, and Participants  Daily respiratory symptoms and medication use were examined prospectively for 271 children younger than 12 years with physician-diagnosed, active asthma residing in southern New England. Exposure to ambient concentrations of ozone and PM_2.5 from April 1 through September 30, 2001, was assessed using ozone (peak 1-hour and 8-hour) and 24-hour PM_2.5. Logistic regression analyses using generalized estimating equations were performed separately for maintenance medication users (n = 130) and nonusers (n = 141). Associations between pollutants (adjusted for temperature, controlling for same- and previous-day levels) and respiratory symptoms and use of rescue medication were evaluated. Main Outcome Measures  Respiratory symptoms and rescue medication use recorded on calendars by subjects' mothers. Results  Mean (SD) levels were 59 (19) ppb (1-hour average) and 51 (16) ppb (8-hour average) for ozone and 13 (8) µg/m³ for PM_2.5. In copollutant models, ozone level but not PM_2.5 was significantly associated with respiratory symptoms and rescue medication use among children using maintenance medication; a 50-ppb increase in 1-hour ozone was associated with increased likelihood of wheeze (by 35%) and chest tightness (by 47%). The highest levels of ozone (1-hour or 8-hour averages) were associated with increased shortness of breath and rescue medication use. No significant, exposure-dependent associations were observed for any outcome by any pollutant among children who did not use maintenance medication. Conclusion  Asthmatic children using maintenance medication are particularly vulnerable to ozone, controlling for exposure to fine particles, at levels below EPA standards.      

Cognitive and motor outcomes of cocaine-exposed infants

Context  Maternal use of cocaine during pregnancy remains a significant public health problem, particularly in urban areas of the United States and among women of low socioeconomic status. Few longitudinal studies have examined cocaine-exposed infants, however, and findings are contradictory because of methodologic limitations. Objective  To assess the effects of prenatal cocaine exposure on child developmental outcomes. Design  Longitudinal, prospective, masked, comparison birth cohort study with recruitment in 1994-1996. Setting  Obstetric unit of a large US urban teaching hospital. Participants  Four hundred fifteen consecutively enrolled infants (218 cocaine-exposed and 197 unexposed) identified from a high-risk, low–socioeconomic status, primarily black (80%) population screened through clinical interview and urine and meconium samples for drug use. The retention rate was 94% at 2 years of age. Main Outcome Measures  The Bayley Mental and Motor Scales of Infant Development, assessed at 6.5, 12, and 24 months of corrected age. Results  Controlled for confounding variables, cocaine exposure had significant effects on cognitive development, accounting for a 6-point deficit in Bayley Mental and Motor Scales of Infant Development scores at 2 years, with cocaine-exposed children twice as likely to have significant delay (mental development index <80) (odds ratio, 1.98; 95% confidence interval, 1.21-3.24; P = .006). For motor outcomes, there were no significant cocaine effects. Conclusions  Cocaine-exposed children had significant cognitive deficits and a doubling of the rate of developmental delay during the first 2 years of life. Because 2-year outcomes are predictive of later cognitive outcomes, it is possible that these children will continue to have learning difficulties at school age.      

Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly

Context  Elderly persons with psychiatric disorders are less likely than younger adults to be diagnosed as having a mental disorder and receive needed mental health treatment. Lack of access to care is 1 possible cause of this disparity. Objective  To determine whether a nurse-based mobile outreach program to seriously mentally ill elderly persons is more effective than usual care in diminishing levels of depression, psychiatric symptoms, and undesirable moves (eg, nursing home placement, eviction, board and care placement). Design  Prospective randomized trial conducted between March 1993 and April 1996 to assess the effectiveness of the Psychogeriatric Assessment and Treatment in City Housing (PATCH) program. Setting  Six urban public housing sites for elderly persons in Baltimore, Md. Participants  A total of 945 (83%) of 1195 residents in the 6 sites underwent screening for psychiatric illness. Among those screened, 342 screened positive and 603 screened negative. All screen-positive subjects aged 60 years and older (n=310) and a 10% random sample of screen-negative subjects aged 60 years and older (n=61) were selected for a structured psychiatric interview. Eleven subjects moved or died; 245 (82%) of those who screened positive and 53 (88%) of those who screened negative were evaluated to determine who had a psychiatric disorder. Data were weighted to estimate the prevalence of psychiatric disorders at the 6 sites. Intervention  Among the 6 sites, residents in 3 buildings were randomized to receive the PATCH model intervention, which included educating building staff to be case finders, performing assessment in residents' apartments, and providing care when indicated; and residents in the remaining 3 buildings were randomized to receive usual care (comparison group). Main Outcome Measures  Number of undesirable moves and scores on the Montgomery-Asberg Depression Rating Scale (MADRS), a measure of depressive symptoms, and the Brief Psychiatric Rating Scale (BPRS), a measure of psychiatric symptoms and behavioral disorder, in intervention vs comparison sites. Results  Based on weighted data, at 26 months of follow-up, psychiatric cases at the intervention sites had significantly lower (F₁=31.18; P<.001) MADRS scores (9.1 vs 15.2) and significantly lower (F₁=17.35; P<.001) BPRS scores (27.4 vs 33.9) than those at the nontreatment comparison sites. There was no significant difference between the groups in undesirable moves (relative risk, 0.97; 95% confidence interval, 0.44-2.17). Conclusions  These results indicate that the PATCH intervention was more effective than usual care in reducing psychiatric symptoms in persons with psychiatric disorders and those with elevated levels of psychiatric symptoms.      

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

Context  Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. Objectives  To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process. Data Sources  MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies. Study Selection  Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18). Data Extraction  Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer. Data Synthesis  Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents. Conclusions  Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.      

Improving the use of hospice services in nursing homes: a randomized controlled trial

Context  Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients’ preferences. Objective  To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care. Design, Setting, and Participants  Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes. Intervention  A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents’ physicians were notified and asked to authorize a hospice informational visit. Main Outcome Measures  The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families’ ratings of the quality of care for residents who died during the 6-month follow-up period. Results  Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident’s care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]). Conclusion  A simple communication intervention can increase rates of hospice referrals and families’ ratings of end-of-life care and may also decrease utilization of acute care resources.      

Relationships between poverty and psychopathology: a natural experiment

Context  Social causation (adversity and stress) vs social selection (downward mobility from familial liability to mental illness) are competing theories about the origins of mental illness. Objective  To test the role of social selection vs social causation of childhood psychopathology using a natural experiment. Design  Quasi-experimental, longitudinal study. Population and Setting  A representative population sample of 1420 rural children aged 9 to 13 years at intake were given annual psychiatric assessments for 8 years (1993-2000). One quarter of the sample were American Indian, and the remaining were predominantly white. Halfway through the study, a casino opening on the Indian reservation gave every American Indian an income supplement that increased annually. This increase moved 14% of study families out of poverty, while 53% remained poor, and 32% were never poor. Incomes of non-Indian families were unaffected. Main Outcome Measures  Levels of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, psychiatric symptoms in the never-poor, persistently poor, and ex-poor children were compared for the 4 years before and after the casino opened. Results  Before the casino opened, the persistently poor and ex-poor children had more psychiatric symptoms (4.38 and 4.28, respectively) than the never-poor children (2.75), but after the opening levels among the ex-poor fell to those of the never-poor children, while levels among those who were persistently poor remained high (odds ratio, 1.50; 95% confidence interval, 1.08-2.09; and odds ratio, 0.91; 95% confidence interval, 0.77-1.07, respectively). The effect was specific to symptoms of conduct and oppositional defiant disorders. Anxiety and depression symptoms were unaffected. Similar results were found in non-Indian children whose families moved out of poverty during the same period. Conclusions  An income intervention that moved families out of poverty for reasons that cannot be ascribed to family characteristics had a major effect on some types of children's psychiatric disorders, but not on others. Results support a social causation explanation for conduct and oppositional disorder, but not for anxiety or depression.      

Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation

Context  Recent studies of drug-eluting intracoronary stents suggest that current antiplatelet regimens may not be sufficient to prevent late stent thrombosis. Objective  To assess the association between clopidogrel use and long-term clinical outcomes of patients receiving drug-eluting stents (DES) and bare-metal stents (BMS) for treatment of coronary artery disease. Design, Setting, and Patients  An observational study examining consecutive patients receiving intracoronary stents at Duke Heart Center, a tertiary care medical center in Durham, NC, between January 1, 2000, and July 31, 2005, with follow-up contact at 6, 12, and 24 months through September 7, 2006. Study population included 4666 patients undergoing initial percutaneous coronary intervention with BMS (n = 3165) or DES (n = 1501). Landmark analyses were performed among patients who were event-free (no death, myocardial infarction [MI], or revascularization) at 6- and 12-month follow-up. At these points, patients were divided into 4 groups based on stent type and self-reported clopidogrel use: DES with clopidogrel, DES without clopidogrel, BMS with clopidogrel, and BMS without clopidogrel. Main Outcome Measures  Death, nonfatal MI, and the composite of death or MI at 24-month follow-up. Results  Among patients with DES who were event-free at 6 months (637 with and 579 without clopidogrel), clopidogrel use was a significant predictor of lower adjusted rates of death (2.0% with vs 5.3% without; difference, –3.3%; 95% CI, –6.3% to –0.3%; P = .03) and death or MI (3.1% vs 7.2%; difference, –4.1%; 95% CI, –7.6% to –0.6%; P = .02) at 24 months. However, among patients with BMS (417 with and 1976 without clopidogrel), there were no differences in death (3.7% vs 4.5%; difference, –0.7%; 95% CI, –2.9% to 1.4%; P = .50) and death or MI (5.5% vs 6.0%; difference, –0.5%; 95% CI, –3.2% to 2.2%; P = .70). Among patients with DES who were event-free at 12 months (252 with and 276 without clopidogrel), clopidogrel use continued to predict lower rates of death (0% vs 3.5%; difference, –3.5%; 95% CI, –5.9% to –1.1%; P = .004) and death or MI (0% vs 4.5%; difference, –4.5%; 95% CI, –7.1% to –1.9%; P<.001) at 24 months. However, among patients with BMS (346 with and 1644 without clopidogrel), there continued to be no differences in death (3.3% vs 2.7%; difference, 0.6%; 95% CI, –1.5% to 2.8%; P = .57) and death or MI (4.7% vs 3.6%; difference, 1.0%; 95% CI, –1.6% to 3.6%; P = .44). Conclusions  The extended use of clopidogrel in patients with DES may be associated with a reduced risk for death and death or MI. However, the appropriate duration for clopidogrel administration can only be determined within the context of a large-scale randomized clinical trial.      

Mental health, social functioning, and disability in postwar Afghanistan

Context  More than 2 decades of conflict have led to widespread human suffering and population displacement in Afghanistan. In 2002, the Centers for Disease Control and Prevention and other collaborating partners performed a national population-based mental health survey in Afghanistan. Objective  To provide national estimates of mental health status of the disabled (any restriction or lack of ability to perform an activity in the manner considered normal for a human being) and nondisabled Afghan population aged at least 15 years. Design, Setting, and Participants  A national multistage, cluster, population-based mental health survey of 799 adult household members (699 nondisabled and 100 disabled respondents) aged 15 years or older conducted from July to September 2002. Fifty district-level clusters were selected based on probability proportional to size sampling. One village was randomly selected in each cluster and 15 households were randomly selected in each village, yielding 750 households. Main Outcome Measures  Demographics, social functioning as measured by selected questions from the Medical Outcomes Study 36-Item Short-Form Health Survey, depressive symptoms measured by the Hopkins Symptoms Checklist-25, trauma events and symptoms of posttraumatic stress disorder (PTSD) measured by the Harvard Trauma Questionnaire, and culture-specific symptoms of mental illness and coping mechanisms. Results  A total of 407 respondents (62.0%) reported experiencing at least 4 trauma events during the previous 10 years. The most common trauma events experienced by the respondents were lack of food and water (56.1%) for nondisabled persons and lack of shelter (69.7%) for disabled persons. The prevalence of respondents with symptoms of depression was 67.7% (95% confidence interval [CI], 54.6%-80.7%) and 71.7% (95% CI, 65.0%-78.4%), and symptoms of anxiety 72.2% (95% CI, 63.8%-80.7%) and 84.6% (95% CI, 74.1%-95.0%) for nondisabled and disabled respondents, respectively. The prevalence of symptoms of PTSD was similar for both groups (nondisabled, 42.1%; 95% CI, 34.2%-50.1%; and disabled, 42.2%; 95% CI, 29.2%-55.2%). Women had significantly poorer mental health status than men did. Respondents who were disabled had significantly lower social functioning and poorer mental health status than those who were nondisabled. Feelings of hatred were high (84% of nondisabled and 81% of disabled respondents). Coping mechanisms included religious and spiritual practices; focusing on basic needs, such as higher income, better housing, and more food; and seeking medical assistance. Conclusions  In this nationally representative survey of Afghans, prevalence rates of symptoms of depression, anxiety, and PTSD were high. These data underscore the need for donors and health care planners to address the current lack of mental health care resources, facilities, and trained mental health care professionals in Afghanistan.      

Transmission and clinical features of enterovirus 71 infections in household contacts in Taiwan

Context  Although enterovirus 71 has caused epidemics associated with significant morbidity and mortality, its transmission has not been thoroughly investigated. Objectives  To investigate enterovirus 71 transmission and determine clinical outcomes within households. Design, Setting, and Participants  Prospective family cohort study to investigate patients at a children's hospital in Taiwan and family members of these patients who had signs and symptoms suggestive of enterovirus 71 between February 2001 and August 2002. Patients and household members underwent clinical evaluations, virological studies, questionnaire-based interviews, and were followed up for 6 months. Main Outcome Measures  Enterovirus 71 infection, defined as a positive viral culture from a throat or rectal swab, or the presence of IgM or a 4-fold increase in neutralizing antibody in serum; and clinical syndromes, defined as asymptomatic; uncomplicated symptomatic; and complicated; with unfavorable outcomes of sequelae or death. Results  Ninety-four families (433 family members) had at least 1 family member with evidence of enterovirus 71 infection. The overall enterovirus 71 transmission rate to household contacts was 52% (176/339 household contacts). Transmission rates were 84% for siblings (70/83); 83%, cousins (19/23); 41%, parents (72/175); 28%, grandparents (10/36); and 26%, uncles and aunts (5/19). Of 183 infected children, 11 (6%) were asymptomatic and 133 (73%) had uncomplicated illnesses (hand, foot, and mouth disease, herpangina, nonspecific febrile illness, upper respiratory tract infection, enteritis, or viral exanthema). Twenty-one percent (39/183) experienced complicated syndromes including the central nervous system or cardiopulmonary failure. During the 6-month follow-up, 10 died and 13 had long-term sequelae consisting of dysfunction in swallowing, cranial nerve palsies, central hypoventilation, or limb weakness and atrophy. Age younger than 3 years was the most significant factor associated with an unfavorable outcome in children (P = .004). Among 87 infected adults, 46 (53%) were asymptomatic, 34 (39%) had nonspecific illnesses of fever, sore throat, or gastrointestinal discomfort, and 7 (8%) had hand, foot, and mouth disease. There were no complicated cases in adults. Conclusions  Enterovirus 71 household transmission rates were high for children in Taiwan and severe disease with serious complications, sequelae, and death occurred frequently. In contrast, adults had a much lower rate of acquisition of the infection and much less adverse sequelae.      

Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial

Context  Pulmonary artery catheters (PACs) have been used to guide therapy in multiple settings, but recent studies have raised concerns that PACs may lead to increased mortality in hospitalized patients. Objective  To determine whether PAC use is safe and improves clinical outcomes in patients hospitalized with severe symptomatic and recurrent heart failure. Design, Setting, and Participants  The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) was a randomized controlled trial of 433 patients at 26 sites conducted from January 18, 2000, to November 17, 2003. Patients were assigned to receive therapy guided by clinical assessment and a PAC or clinical assessment alone. The target in both groups was resolution of clinical congestion, with additional PAC targets of a pulmonary capillary wedge pressure of 15 mm Hg and a right atrial pressure of 8 mm Hg. Medications were not specified, but inotrope use was explicitly discouraged. Main Outcome Measures  The primary end point was days alive out of the hospital during the first 6 months, with secondary end points of exercise, quality of life, biochemical, and echocardiographic changes. Results  Severity of illness was reflected by the following values: average left ventricular ejection fraction, 19%; systolic blood pressure, 106 mm Hg; sodium level, 137 mEq/L; urea nitrogen, 35 mg/dL (12.40 mmol/L); and creatinine, 1.5 mg/dL (132.6 µmol/L). Therapy in both groups led to substantial reduction in symptoms, jugular venous pressure, and edema. Use of the PAC did not significantly affect the primary end point of days alive and out of the hospital during the first 6 months (133 days vs 135 days; hazard ratio [HR], 1.00 [95% confidence interval {CI}, 0.82-1.21]; P = .99), mortality (43 patients [10%] vs 38 patients [9%]; odds ratio [OR], 1.26 [95% CI, 0.78-2.03]; P = .35), or the number of days hospitalized (8.7 vs 8.3; HR, 1.04 [95% CI, 0.86-1.27]; P = .67). In-hospital adverse events were more common among patients in the PAC group (47 [21.9%] vs 25 [11.5%]; P = .04). There were no deaths related to PAC use, and no difference for in-hospital plus 30-day mortality (10 [4.7%] vs 11 [5.0%]; OR, 0.97 [95% CI, 0.38-2.22]; P = .97). Exercise and quality of life end points improved in both groups with a trend toward greater improvement with the PAC, which reached significance for the time trade-off at all time points after randomization. Conclusions  Therapy to reduce volume overload during hospitalization for heart failure led to marked improvement in signs and symptoms of elevated filling pressures with or without the PAC. Addition of the PAC to careful clinical assessment increased anticipated adverse events, but did not affect overall mortality and hospitalization. Future trials should test noninvasive assessments with specific treatment strategies that could be used to better tailor therapy for both survival time and survival quality as valued by patients.      

Menopausal hormone replacement therapy and risk of ovarian cancer

Context  The association between menopausal hormone replacement therapy and ovariancancer is unclear. Objective  To determine whether hormone replacement therapy using estrogen only,estrogen-progestin only, or both estrogen only and estrogen-progestin increasesovarian cancer risk. Design  A 1979-1998 cohort study of former participants in the Breast CancerDetection Demonstration Project, a nationwide breast cancer screening program. Setting  Twenty-nine US clinical centers. Participants  A total of 44 241 postmenopausal women (mean age at start of follow-up,56.6 years). Main Outcome Measure  Incident ovarian cancer. Results  We identified 329 women who developed ovarian cancer during follow-up.In time-dependent analyses adjusted for age, menopause type, and oral contraceptiveuse, ever use of estrogen only was significantly associated with ovarian cancer(rate ratio [RR], 1.6; 95% confidence interval [CI], 1.2-2.0). Increasingduration of estrogen-only use was significantly associated with ovarian cancer:RRs for 10 to 19 years and 20 or more years were 1.8 (95% CI, 1.1-3.0) and3.2 (95% CI, 1.7-5.7), respectively (P value fortrend <.001), and we observed a 7% (95% CI, 2%-13%) increase in RR peryear of use. We observed significantly elevated RRs with increasing durationof estrogen-only use across all strata of other ovarian cancer risk factors,including women with hysterectomy. The RR for estrogen-progestin use afterprior estrogen-only use was 1.5 (95% CI, 0.91-2.4), but the RR for estrogen-progestin–onlyuse was 1.1 (95% CI, 0.64-1.7). The RRs for less than 2 years and 2 or moreyears of estrogen-progestin–only use were 1.6 (95% CI, 0.78-3.3) and0.80 (95% CI, 0.35-1.8), respectively, and there was no evidence of a durationresponse (P value for trend = .30). Conclusion  Women who used estrogen-only replacement therapy, particularly for 10or more years, were at significantly increased risk of ovarian cancer in thisstudy. Women who used short-term estrogen-progestin–only replacementtherapy were not at increased risk, but risk associated with short-term andlonger-term estrogen-progestin replacement therapy warrants further investigation.      

Hormone replacement therapy and incidence of Alzheimer disease in older women: the Cache County Study

Context  Previous studies have shown a sex-specific increased risk of Alzheimer disease (AD) in women older than 80 years. Basic neuroscience findings suggest that hormone replacement therapy (HRT) could reduce a woman's risk of AD. Epidemiologic findings on AD and HRT are mixed. Objective  To examine the relationship between use of HRT and risk of AD among elderly women. Design, Setting, and Participants  Prospective study of incident dementia among 1357 men (mean age, 73.2 years) and 1889 women (mean age, 74.5 years) residing in a single county in Utah. Participants were first assessed in 1995-1997, with follow-up conducted in 1998-2000. History of women's current and former use of HRT, as well as of calcium and multivitamin supplements, was ascertained at the initial contact. Main Outcome Measure  Diagnosis of incident AD. Results  Thirty-five men (2.6%) and 88 women (4.7%) developed AD between the initial interview and time of the follow-up (3 years). Incidence among women increased after age 80 years and exceeded the risk among men of similar age (adjusted hazard ratio [HR], 2.11; 95% confidence interval [CI], 1.22-3.86). Women who used HRT had a reduced risk of AD (26 cases among 1066 women) compared with non-HRT users (58 cases among 800 women) (adjusted HR, 0.59; 95% CI, 0.36-0.96). Risk varied with duration of HRT use, so that a woman's sex-specific increase in risk disappeared entirely with more than 10 years of treatment (7 cases among 427 women). Adjusted HRs were 0.41 (95% CI, 0.17-0.86) for HRT users compared with nonusers and 0.77 (95% CI, 0.31-1.67) compared with men. No similar effect was seen with calcium or multivitamin use. Almost all of the HRT-related reduction in incidence reflected former use of HRT (9 cases among 490 women; adjusted HR, 0.33 [95% CI, 0.15-0.65]). There was no effect with current HRT use (17 cases among 576 women; adjusted HR, 1.08 [95% CI, 0.59-1.91]) unless duration of treatment exceeded 10 years (6 cases among 344 women; adjusted HR, 0.55 [95% CI, 0.21-1.23]). Conclusions  Prior HRT use is associated with reduced risk of AD, but there is no apparent benefit with current HRT use unless such use has exceeded 10 years.      

Racial disparities in the quality of care for enrollees in medicare managed care

Context  Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care. Objective  To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans. Design and Setting  Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness). Participants  A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older. Main Outcome Measures  Rates of breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Results  Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P = .02), -blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Conclusion  Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.      

Outcomes and complications associated with off-label and untested use of drug-eluting stents

Context  Limited data exist regarding use of drug-eluting stents outside of approved indications in real-world settings. Objectives  To determine the frequency, safety, and effectiveness of drug-eluting stents for off-label (restenosis, bypass graft lesion, long lesions, vessel size outside of information for use recommendation) and untested (left main, ostial, bifurcation, or total occlusion lesions) indications in percutaneous coronary intervention (PCI). Design, Setting, and Patients  Observational, prospective, multicenter registry to evaluate in-hospital, 30-day, and 1-year outcomes among patients undergoing PCI between January and June 2005 in 140 US academic and community medical centers. Of 7752 PCI-treated patients, 6993 (90%) received drug-eluting stents; of these, 5851 (84%) received no other devices. Standard, off-label, and untested use was determined in 5541 (95%) of these 5851 patients, constituting the study cohort. Main Outcome Measures  Frequency of off-label and untested use, 1-year repeat target vessel revascularization, and composite of death, myocardial infarction (MI), or stent thrombosis at in-hospital follow-up and during 1 year of follow-up. Results  Of 5541 patients receiving drug-eluting stents, 2588 (47%) received stents for off-label or untested indications. Adjusted in-hospital risk of death, MI, or stent thrombosis was not statistically different with off-label or untested vs standard use. At 30 days, the risk of this composite end point was significantly higher with off-label use (adjusted hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.24-3.48; P = .005) but not untested use (adjusted HR, 1.45; 95% CI, 0.79-2.67; P = .23). Excluding early events, this end point was not different at 1 year with off-label use (adjusted HR, 1.10; 95% CI, 0.79-1.54; P = .57) or untested use (adjusted HR, 0.91; 95% CI, 0.60-1.38; P = .66). At 1 year, compared with standard use, significantly higher rates of target vessel revascularization were associated with off-label use (adjusted HR, 1.49; 95% CI, 1.13-1.98; P = .005) and untested use (adjusted HR, 1.49; 95% CI, 1.10-2.02; P = .01), although absolute rates were low (standard, 4.4% [n = 113]; off-label, 7.6% [n = 95]; untested, 6.7% [n = 72]). Conclusions  In contemporary US practice, off-label and untested use of drug-eluting stents is common. Compared with standard use, relative early safety is lower with off-label use, and the long-term effectiveness is lower with both off-label and untested use. However, the absolute event rates remain low.      

Symptoms of posttraumatic stress disorder and depression among children in tsunami-affected areas in southern Thailand

Context  On December 26, 2004, an undersea earthquake occurred off the northwestern coast of Sumatra, Indonesia. The tsunami that followed severely impacted all 6 southwestern provinces of Thailand, where approximately 20 000 children were directly affected. Objective  To assess trauma experiences and the prevalence of symptoms of posttraumatic stress disorder (PTSD) and depression among children in tsunami-affected provinces in southern Thailand. Design, Setting, and Participants  Population-based mental health surveys were conducted among children aged 7 to 14 years in Phang Nga, Phuket, and Krabi provinces from February 15-22, 2005 (2 months posttsunami), and September 7-12, 2005 (9 months posttsunami). Main Outcome Measures  Trauma experiences and symptoms of PTSD and depression as measured by a tsunami-modified version of the PsySTART Rapid Triage System, the UCLA PTSD Reaction Index, and the Birleson Depression Self-Rating Scale. Results  A total of 371 children (167 displaced and living in camps, 99 not displaced from villages affected by the tsunami, and 105 not displaced from unaffected villages) participated in the first survey. The prevalence rates of PTSD symptoms were 13% among children living in camps, 11% among children from affected villages, and 6% among children from unaffected villages (camps vs unaffected villages, P = .25); for depression symptoms, the prevalence rates were 11%, 5%, and 8%, respectively (P = .39). In multivariate analysis of the first assessment, having had a delayed evacuation, having felt one's own or a family member's life to have been in danger, and having felt extreme panic or fear were significantly associated with PTSD symptoms. Older age and having felt that their own or a family member's life had been in danger were significantly associated with depression symptoms. In the follow-up survey, 72% (151/210) of children from Phang Nga participated. Prevalence rates of symptoms of PTSD and depression among these children did not decrease significantly over time. Conclusions  This assessment documents the prevalence of mental health problems among children in tsunami-affected provinces in southern Thailand at 2 and 9 months posttsunami. Traumatic events experienced during the tsunami were significantly associated with symptoms of PTSD and depression. These data may be useful to target mental health services for children and may inform the design of these interventions.