Patterns of E-Cigarette Use Among Primary Care Patients at an Urban Community Center

Tobacco use remains the leading cause of preventable disease and death in the US. The number of tobacco products has grown over the past decade. E-cigarette use has increased rapidly in recent years, but patterns and correlates of use have not been thoroughly assessed. We examined relationships among demographic factors, e-cigarette and conventional cigarette use in a large sample (N?=?12,409) of adult patients at a community health center in the Northeastern US. Overall, 13% (N?=?1675) of the sample reported ever using e-cigarettes. In logistic regression models, ever having used e-cigarettes was associated with younger age (ages 18–25; OR?=?3.5, p?<?0.001). Being transgender (OR?=?1.8, p?<?0.001), bisexual (OR?=?1.5, p?<?0.001), un-partnered (OR?=?1.5, p?<?0.001), having a lower income (OR?=?1.6, p?<?0.001) or a high BMI (OR?=?1.4, p?=?0.009) were associated with increased odds of use, whereas being a woman (OR?=?0.7, p?<?0.001) or Black/African American (OR?=?0.7, p?=?0.007) were associated with lower odds of use. Of the participants who reported e-cigarette use, a majority also endorsed current or former use of conventional cigarettes. Individuals who formerly used conventional cigarettes were nearly three times more likely to report daily e-cigarette use than current users. Among primary care patients at a community health center, e-cigarette use was reported by a sizeable portion of the sample. Overall, odds of use were higher in certain patient populations, and individuals who formally used cigarettes were more likely to report e-cigarette use than individuals who currently smoke, suggesting that e-cigarettes may be functioning as a cessation aid or a strategy to reduce conventional cigarette use.

     

Social HMOs and Other Capitated Arrangements for Children with Special Health Care Needs

Objective: Children with special health care needs are increasingly enrolling in managed care arrangements. However, existing managed care organizations, including traditional HMOs, are often poorly suited for caring for this population. In the adult health care area, new managed care entities, called Social HMOs (S/HMO) and Programs for the All-inclusive Care for the Elderly (PACE), have been created to integrate health and health-related services for chronically ill and disabled adults. We describe these models and assess their potential for serving children with special health care needs. Method: We reviewed the literature on managed care for children with special health care needs and evaluation findings from the S/HMO and PACE models for the elderly. Results: Evaluations of the S/HMO and PACE models have yielded mixed findings. Some of the more positive accomplishments include lower use and expenditures for long-term care services compared to other demonstration projects, greater integration of primary care physicians in decision making concerning long-term care, and improved management of transitions between care levels. On the negative side, start-up has been slow, prospective members have been hesitant to enroll, intermittent and sometimes frequent operating deficits have emerged, no discernible positive effects on health or social outcomes are apparent, and no significant overall savings have emerged. Conclusions: With mixed results so far, caution is required in applying these or similar models for vulnerable child populations. However, given the inadequacies of traditional managed care for this population, we believe experimentation with new models of care that integrate health and health-related services is important. Such experimentation should be fostered only to the extent that the models are carefully designed and then implemented in a manner that protects the interests of children with special health care needs.     

The effects of scheduled intern rotation on the cost and quality of teaching hospital care

We studied the effect of scheduled intern rotations on the cost and quality of inpatient care at one teaching hospital. For all discharges from the internal medicine service between 1980 and 1986, we identified 1,705 rotation patients and 3,141 no-rotation patients. Using linear or logistic regression analysis to control for baseline differences, we evaluated for the effect of rotation. We found that rotation was significantly related to longer length of hospital stay, b = 0.341 days, p = 0.001, and higher hospital charges (for log charges, b = 0.053, p = 0.016. Hospital deaths, nursing home placements, and 30-day readmissions were not significantly related to rotation, p > 0.1. These results suggest that the systematic discontinuity induced by scheduled intern rotations may be another source of increased health care costs experienced at teaching hospitals.     

Transfer of liposomal drug carriers from the blood to the peritoneal cavity of normal and ascitic tumor-bearing mice

Summary Previously we have demonstrated that the L1210 antitumor activity of liposomal doxorubicin increased significantly as the size of the liposomal carrier was reduced from 1.0 to 0.1 m. It is demonstrated herein that empty and drug-loaded small (0.1-m diameter) liposomes accumulate efficiently into the peritoneal cavity of normal and ascitic L1210 tumor-bearing animals following i.v. administration. In normal mice injected with 100 nm DSPC/chol liposomal doxorubicin (drug-to-lipid ratio of 0.2; wt/wt) approximately 2.8 g drug could be recovered from the peritoneal cavity following peritoneal lavage at 24 h. Although this represents only 0.7% of the injected doxorubicin dose, this level of drug is 2 orders of magnitude greater than that achieved following administration of an equivalent dose of free drug (20 mg/kg). The drug levels achieved within the peritoneal cavity are dependent on the physical characteristics (size, drug-to-lipid ratio and lipid composition) of the liposomes employed. Optimal delivery is obtained employing 100 nm DSPC/chol liposomal doxorubicin, a vesicle system that is known to retain entrapped drug following i.v. administration and exhibits extended circulation lifetimes. Analysis of drug and liposome distribution within the peritoneal cavity of normal mice indicates that as much as 50% of the measured doxorubicin and liposomal lipid is cell-associated. Flow cytometric analysis of the peritoneal cells demonstrated that cell-associated doxorubicin resides almost exclusively within resident peritoneal macrophages. The increased delivery of doxorubicin to the peritoneal cavity of normal mice following i.v. administration of small (0.1-m) liposomal doxorubicin is correlated with a pronounced (>90%) and prolonged (>14-day) suppression of resident peritoneal cells. Liposomal drug accumulation increased dramatically in animals with an established L1210 ascitic tumor. More than 5% of the injected dose was found in the peritoneal cavity of these animals 24 h after treatment with DSPC/chol liposomal doxorubicin as compared with a value of 0.03% of the injected dose achieved with free drug. It is proposed that accumulation of liposomes into the peritoneal cavity of normal and tumor-bearing mice may serve as a useful model for characterizing factors mediating the transfer of liposomes from the vascular compartment to extravascular sites.     

Models for forecasting chronic disease processes in adult and elderly populations: effects of stochasticity

BACKGROUND: Forecasting the population health burden of chronic diseases requires models consistent with the relation, over time and in an uncertain environment, of risk factors and diseases at the individual level. There is now sufficient longitudinal data, and scientific understanding, of some chronic diseases to construct detailed process-models to better predict their population health burden and more realistically describe the effects of interventions. A crucial clement in constructing models is the way in which stochastic influences are described, e.g. are they allowed to interact over time with deterministic model features? METHODS: A review of statistical and forecasting models aimed to establish what ancillary data and scientific insights are necessary to describe multivariate stochastic health processes and their response to interventions. For circulatory diseases and cancer there exists sufficient longitudinal data and biological insight to construct stochastic multivariate process models. For other diseases, biological knowledge is less complete and there are fewer data sets where multiple risk factors are assessed longitudinally. Forecasting models for those diseases will then rely more heavily on theoretical assumptions about disease behaviour.     

Spinal dural arteriovenous fistula with an associated feeding artery aneurysm: case report

OBJECTIVE AND IMPORTANCE: A case of a spinal dural arteriovenous fistula (DAVF) with two associated feeding artery aneurysms is reported. Intradural spinal arteriovenous malformations have been associated with aneurysms that present with subarachnoid hemorrhage and with venous varices that produce mass effect, but spinal DAVFs have not previously been described in association with feeding artery aneurysms. CLINICAL PRESENTATION: A 71-year-old man presented with progressive spastic paraparesis, constipation, and overflow incontinence. Magnetic resonance imaging demonstrated a spinal vascular lesion and venous ischemia in the lower spinal cord. Diagnostic spinal angiography revealed a DAVF originating from the left T11 radicular artery and having the unusual feature of two proximal feeding artery aneurysms. INTERVENTION: The patient deteriorated neurologically after undergoing angiography, prompting emergent surgery. The DAVF was resected through a T11 transpedicular approach. One aneurysm was dolichoectatic and therefore unclippable, requiring proximal occlusion of the parent artery after establishing tolerance of test occlusion using somatosensory evoked potentials; the second aneurysm was adjacent to the fistula and was resected with the DAVF. CONCLUSION: Feeding artery aneurysms in association with spinal DAVFs have not been previously reported. They present additional risk to patients and, with simple modifications of the standard operative approaches, can easily be treated as part of the surgery for the DAVF.     

Will you fit if you move to a job in another culture?

In today's health care environment, many health care managers choose to move to a new setting. Because environments vary from setting to setting, a manager who plans to move needs to evaluate potential "fit" in the new locality. An evaluation of "fit" includes an assessment of both the job culture and persons in the environment. The Giger-Davidhizar transcultural assessment model provides a model for evaluating a new job culture.     

Argon laser trabeculoplasty--the possibility for antiglaucoma treatment

The current role of argon laser trabeculoplasty in the treatment of open angle glaucoma is still open discussion. To evaluate the effectiveness of ALT we performed a study on 36 patients followed for 2 years. We noted a success rate of 61.11% after 2 years and noticed that the success rate decreased in time. ALT should be considered as an intermediate therapy in the management of open angle glaucoma, after drug therapy has failed and before filtering surgery is performed.     

The obligation of health care professionals and supervisors to report child sexual abuse

Child sexual abuse is a problem that often can be stopped or prevented if reported. This article summarizes child sexual abuse: its incidence, signs and symptoms. and legal and ethical issues. Through a case study, a five-step approach to the reporting of child sexual abuse is presented to help health care professionals and supervisors in fulfilling their ethical and legal obligations.     

The effects of hospital downsizing on staffing and quality of care

Hospital managers are making aggressive changes in their caregiver staffs to meet challenges such as reductions in utilization and capitated care. Managers are doing this to decrease the cost of care while maintaining or improving quality of care. However, the literature addressing the impact of hospital staffing practices on quality of care indicates that these changes may negatively influence quality. Department administrators must be cautious, yet proactive in their approach to patient care restructuring in order to ensure continued quality as well as cost-effectiveness.