Some potential errors in the measurement of mercury gas exchange at the soil surface using a dynamic flux chamber

A series of controlled environment experiments were conducted to examine the use of a dynamic flux chamber to measure soil emission and absorption of total gaseous mercury (TGM). Uncertainty about the appropriate airflow rates through the chamber and chamber exposure to ambient wind are shown to be major sources of potential error. Soil surface mercury flux measurements over a range of chamber airflow rates showed a positive linear relationship between flux rates and airflow rate through the chamber. Mercury flux measurements using the chamber in an environmental wind tunnel showed that exposure of the system to ambient winds decreased the measured flux rates by 40% at a wind speed of 1.0 m s(-1) and 90% at a wind speed of 2 m s(-1). Wind tunnel measurements also showed that the chamber footprint was limited to the area of soil inside the chamber and there is little uncertainty of the footprint size in dry soil.

A sensitivity analysis on the atmospheric transformation and deposition of mercury in north-eastern USA

This paper presents the results of a sensitivity analysis on the factors that affect dry and wet deposition of atmospheric mercury (Hg), using a regional scale air quality model. Simulations were conducted for the north-eastern USA during a summer week and a winter week in 1997. Simulation results for the summer week and the winter week in general showed similar responses to changes in emission, environmental conditions, and alternative chemical mechanisms. Reduction of the ambient concentrations of soot or ozone was shown to reduce the wet deposition of Hg. When averaged over the summer and the winter week, the total deposition to the simulation domain would be reduced by 26% by reducing Hg emission from anthropogenic sources within the domain by 50%. For individual grids, however, only locations near local sources obtained noticeable reductions in ambient concentration and wet deposition due to the influence of re-emission from the natural surfaces and regional/global scale transport. The reduction in deposition would reach 36% if all Hg(II) emitted from anthropogenic sources were attached to particles. The total deposition was predicted to decrease by 22% when the gas phase Hg(II)-Hg(p) partitioning was included in the model. Only small changes in total deposition were observed by including the gas-phase ozone-Hg(0), reaction and the aqueous phase chlorine-Hg(0), reaction, and by lowering ambient concentrations of Hg(II) and Hg(p) at the upper lateral boundaries. During the summer week, Hg(II) deposition contributed 40% or more to the total deposition. The contribution increased to 70% in the winter week.

Cumulation characteristics of cisatracurium and rocuronium during continuous infusion

PURPOSE

The dissimilar pharmacokinetic properties of cisatracurium (CIS) and rocuronium (ROC) predict different potential for drug cumulation when these drugs are administered by continuous infusion. A study was therefore undertaken to compare cumulation potential of CIS and ROC during surgical procedures of relatively long duration (2-4 hr).

METHODS

Sufentanil/propofol-N2O anesthesia was administered to 40 ASA I and II adults. In a double-blind protocol, patients were randomly allocated to receive a continuous i.v. infusion of either CIS or ROC, titrated in progressive increments or decrements as required to achieve and maintain 95 +/- 5% depression of the T1 response of the adductor pollicis muscle, using a Datex NMT-100 Relaxograph EMG monitor applied at the wrist. At the end of surgery, 60 microg x kg(-1) neostigmine plus 15 microg x kg(-1) atropine were administered for reversal.

RESULTS

The duration of infusion was 104 +/- 33 min in group CIS and 110 +/- 23 min in group ROC (P=NS). In both groups, a progressive decrease in potency-adjusted infusion rates was observed after 30 min, then stabilized beyond 60 min. When allowing for an initial period of stabilization, mean potency-adjusted infusion requirements were: CIS 0.81 +/- 0.02 microg x kg(-1) x min(-1) and ROC 5.58 +/- 1.94 microg x kg(-1) x min(-1). There were no differences between groups at any time with regard to potency-adjusted infusion requirements necessary to maintain 90-99% block (P=NS). However, drug costs/hr for maintenance of neuromuscular block were less with CIS ($3.57 +/- 0.09) than with ROC ($6.03 +/- 0.27), P < 0.001.

CONCLUSION

When adjusted to equipotency, infusion requirements of CIS and ROC vary at similar rates during general anesthesia. Despite pharmacokinetic differences, neither drug demonstrates cumulation for infusion lasting up to 3.5 hr.

Comparing the health status of male and female veterans who use VA health care: results from the VA Women's Health Project

BACKGROUND

In recent years the number of women serving in the military has increased substantially, resulting in more demand for VA services by women veterans. This paper describes the characteristics and health status of women veterans who use VA ambulatory services.

METHODS

Respondents in the VA Women's Health Project (n = 719) represent a randomly selected subsample from all women who had an ambulatory visit between July 1, 1994 and June 30, 1995 at a large tertiary care VA facility in the Boston area. Summary statistics on eight dimensions of health status (using the SF-36) for women veterans who use VA ambulatory care are provided. Comparisons are made between women veterans and men veterans who use VA services.

RESULTS

Women veterans reported consistently low scores on health status across multiple dimensions, reflecting considerable health needs. Among veterans using VA services, women were younger, better educated, and less likely to be married than male veterans. Women veterans who use VA ambulatory services scored lower on every scale except physical functioning and general health perceptions when compared to male VA users. There were more pronounced differences for women on scales measuring emotional health.

CONCLUSIONS

Health status among women veterans is moderate to poor. Important differences in health status are observed between men and women who use VA services which have implications for improving health care to women veterans at VA facilities. These findings strongly indicate that increased mental health services need to be available for women veterans seeking VA health care.

Quality and accountability: Children's emergency services in a managed care environment

The fast pace of change in the health care system has sparked growing interest among purchasers, consumers, providers, health plans, and others in evaluating and improving the quality of health services. The Emergency Medical Services for Children Program's Managed Care Task Force recommended the development of a white paper to focus on issues related to quality and accountability in children's emergency medical services in a managed care environment. A literature review was conducted, and a panel reviewed and discussed relevant materials. The panelists then developed recommendations as a resource for managed care organizations, providers of care, professional associations, and federal, state, and local policymakers.

Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: the Veterans Health Study

OBJECTIVE

The authors examined the self-reported presence and treatment of current depressive disorder, posttraumatic stress disorder (PTSD), and alcohol-related disorder in a group of outpatient veterans.

METHOD

Data were obtained from the Veterans Health Study, a longitudinal investigation of male veterans' health. A representative sample of 2,160 outpatients (mean age = 62 years) was drawn from Boston-area U.S. Department of Veterans Affairs (VA) outpatient facilities. The participants completed screening measures for depression, PTSD, and alcohol-related disorder. Mental health treatment was assessed by interviews.

RESULTS

The screening criteria for at least one current mental disorder were satisfied by 40% (N = 856) of the patients. Screening rates were 31% (N = 676) for depression, 20% (N = 426) for PTSD, and 12% (N = 264) for alcohol-related disorder. Patients who screened positively for current mental disorders were younger, less likely to be married or employed, and more likely to report traumatic exposure than were those without mental disorders. Of those who met the screening criteria for any of the targeted mental disorders, 68% (N = 579) reported receiving mental health treatment. Younger, Caucasian men and those who reported more traumatic exposure were more likely to report receiving mental health treatment than were others who screened positively for mental disorders.

CONCLUSIONS

Screening rates of depression and PTSD and rates of mental health treatment were considerably higher among these VA outpatients than among similar patients in primary care in the private sector. Although the VA is currently meeting the mental health care needs of its patients, future fiscal constraints could affect most adversely the treatment of non-Caucasian and older patients and those with a history of traumatic exposure.

Screening for malignant melanoma: A cost-effectiveness analysis

BACKGROUND

Skin cancer is the most common cancer in the United States. Increasing evidence suggests that screening for malignant melanoma is effective, but its cost-effectiveness has not been determined.

OBJECTIVE

We attempted to determine the effectiveness and costs of a visual screen to diagnose malignant melanoma in high-risk persons.

METHODS

We developed a decision analysis comparing no skin cancer screen with a single screen by a dermatologist. Clinical outcomes included malignant melanoma, nonmelanoma skin cancer, or no skin cancer. Life expectancy and costs of care were projected on the basis of clinical findings.

RESULTS

Skin cancer screening increased average discounted life expectancy from 15.0963 years to 15.0975 years. Based on the prevalence of malignant melanoma, however, this translates into an increased discounted life expectancy of 0.9231 years for each person with diagnosed melanoma. Using a cost of $30 per screen, total skin cancer-related costs for a cohort of 1 million people increased from $826 million with no screen to $861 million with screening, with an increase of 1200 years of life. This results in an incremental cost-effectiveness ratio of $29,170 per year of life saved (YLS) with screening. Sensitivity analysis showed that the cost-effectiveness ratio for screening remained below $50,000/YLS if the prevalence of melanoma in the screened population was at least 0. 0009, the probability that a melanoma detected in screening was localized was at least 94.8%, or the cost of each screen was below $57.

CONCLUSION

Skin cancer screening in high-risk patients is likely to be associated with a small increase in discounted life expectancy and is reasonably cost-effective compared with other cancer screening strategies.

Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military

Among a national sample of 3,632 women VA outpatients, we determined self-reported prevalence of sexual assault experienced during military service and compared screening prevalence for current symptoms of depression and alcohol abuse between those who did and did not report this history. Data were obtained by mailed questionnaire. Military-related sexual assault was reported by 23%. Screening prevalence for symptoms of current depression was 3 times higher and for current alcohol abuse was 2 times higher among those who reported experiencing military-related sexual assault. Recent mental health treatment was reported by 50% of those who reported experiencing sexual assault during military service and screened positive for symptoms of depression, and by 40% of those who screened positive for symptoms of alcohol abuse.

Medical profile of women Veterans Administration outpatients who report a history of sexual assault occurring while in the military

To profile differences in current physical symptoms and medical conditions among women users of Veterans Administration (VA) health services with and without a self-reported history of sexual assault sustained during military service, we conducted a cross-sectional analysis of a nationally representative, random sample of women veterans using VA outpatient services (n = 3632). A self-administered, mailed survey asked whether women had sustained sexual assault while in the military and requested information about a spectrum of physical symptoms and medical conditions. A history of sexual assault while in the military was reported by 23% of women VA users and was associated with current physical symptoms and medical conditions in every domain assessed. For example, women who reported sexual assault were more likely to indicate that they had a "heart attack" within the past year, even after adjusting for age, hypertension, diabetes, and smoking history (OR 2.3, 95% CI 1.3-4.0). Among women reporting a history of sexual assault while in the military, 26% endorsed > or = 12 of 24 symptoms/conditions, compared with 11% of women with no reported sexual assault while in the military (p < 0.001). Clinicians need to be attuned to the high frequency of sexual assault occurring while in the military reported by women VA users and its associated array of current physical symptoms and medical conditions. Clinicians should consider screening both younger and older patients for a sexual violence history, especially patients with multiple physical symptoms.

The Falmouth Safe Skin Project: evaluation of a community program to promote sun protection in youth

A multidimensional community-based skin cancer prevention program was conducted in Falmouth, Massachusetts, combining community activism with publicity campaigns and behavioral interventions to improve sun protection knowledge; attitudes; and practices in parents, caregivers, and children. The program was associated with improvements in target outcomes, based on two telephone surveys of random samples of parents (n = 401, 404). After program implementation, fewer parents reported sunburning of their children, particularly among children 6 years old or younger (18.6% in 1994 vs. 3.2% in 1997), and more parents reported children using sunscreen, particularly continuous use at the beach (from 47.4% to 69.9% in younger children). Hat and shirt use did not increase. Improvements also were seen in parent role modeling of sun protection practices, parents' self-efficacy in protecting children from the sun, and sun protection knowledge. While these findings must be interpreted cautiously, they do suggest that this project was effective in promoting sun protection.

The New Moms Project: educating mothers about sun protection in newborn nurseries

Sun protection habits should begin early in life and be taught as part of routine preventive health care. Early teaching of parents aims to introduce an easily achieved means of sun protection with the goal of instilling these practices as habits in the parents and their young children. We developed a maternity nurse-led intervention for 187 mothers at newborn nurseries in Falmouth, Massachusetts, combining educational material and personal discussions. One year after the intervention we successfully contacted 73% of the mothers. Nearly 90% recalled the informational program and equal numbers stated that receiving educational materials in the newborn nursery was timely. Nearly two-thirds of mothers reported that this was the only sun protection information received from a provider in the past year.

Participant satisfaction and value in American Academy of Dermatology and American Cancer Society skin cancer screening programs in Massachusetts

BACKGROUND

More than 1 million Americans have attended the American Academy of Dermatology's Melanoma/Skin Cancer Screening Programs since 1985. However, there have been no reports of the participants' perceived value, satisfaction, and benefits of skin cancer screening.

OBJECTIVE

We attempted to measure the benefits and subsequent screening practices of persons with presumptive positive screening diagnoses.

METHODS

A self-administered questionnaire was sent to participants with positive screening diagnoses in Massachusetts.

RESULTS

Of the 643 respondents, 81% rated their satisfaction as high and 84% had similar ratings for the value of the screening. Screenings apparently led to an increase in self-screening (60% before screening compared with 84% after screening).

CONCLUSION

Although screening appears to have relatively strong benefits, further studies should be conducted nationally.

Emergency medical services outcomes project I (EMSOP I): prioritizing conditions for outcomes research

Over the past several years, out-of-hospital EMS have come under increased scrutiny regarding the value of the range of EMS as currently provided. We used frequency data and expert opinion to rank-order EMS conditions for children and adults based on their potential value for the study of effectiveness of EMS care. Relief of discomfort was the outcome parameter EMS professionals identified as having the most potential impact for the majority of children and adults in the top quartile conditions. Future work from this project will identify appropriate severity and outcome measures that can be used to study these priority conditions. The results from the first year of this project will assist those interested in EMS outcomes research to focus their efforts. Furthermore, the results suggest that nonmortality out-come measures, such as relief of discomfort, may be important parameters in determining EMS effectiveness.

Patient satisfaction with Department of Veterans Affairs health care: do women differ from men?

This study compared the patient satisfaction of female and male veterans using Department of Veterans Affairs health care and examined the relationship between sociodemographic characteristics and satisfaction in men and women. Using data from the Department of Veterans Affairs Women's Health Project (N = 719) and the Veterans Health Study (N = 600), we examined women's and men's unadjusted and adjusted mean scores on three dimensions of satisfaction: location of health care facility, access to health care, and prescription services. Although the unadjusted results indicated that women were less satisfied with both location and access, there were no differences in satisfaction with prescription services. After adjusting for age and then for both age and a recent physician visit, women remained less satisfied with location but were more satisfied with prescription services; there were no differences on access ratings. In an exploratory analysis, we examined the relationships between sociodemographic, military experience, and health characteristics and satisfaction within each sample. Older age was the only characteristic consistently positively associated with each dimension of satisfaction among both women and men. General health perceptions were positively associated with all three dimensions of women's satisfaction but with only the location dimension for men. Although other characteristics were associated with satisfaction within each sample, these differed for women and men. The results suggest that although there were not consistent differences in mean satisfaction ratings by gender, the characteristics associated with satisfaction differed for men and women.

Health status in VA patients: results from the Veterans Health Study

Recently, the Veterans Administration (VA) Under Secretary for Health has designated functional status as one of the domains of value for the system, given its increasing importance for clinical care. The Veterans Health Study (VHS) was designed to assist the VA in monitoring outcomes and measuring the case mix of patients who use the VA. The Veterans SF-36 (short form functional status assessment for veterans) was administered to 2425 veterans receiving ambulatory care. Measures of the Veterans SF-36 were strongly correlated with sociodemographics and morbidities of the veterans. Young veterans had poorer mental health status than older veterans. Veterans who used ambulatory care in the VHS reported lower levels of health status, reflecting more disease than a non-VA civilian population. These measures of health are important indicators of the disease burden or case mix of the patients and are pertinent to health systems such as the VA for resource allocation decisions and as outcomes of care.

Update on the incidence and mortality from melanoma in the United States

BACKGROUND

Increases in the incidence of malignant melanoma have been among the largest of all cancers in the United States.

OBJECTIVE

We report updated trends in melanoma rates among the US white population.

METHODS

Incidence and mortality rates were calculated for 1973 to 1994. Trends were examined with stratification by state, age, and sex, and by anatomic site, stage, and melanoma thickness at diagnosis.

RESULTS

Melanoma incidence and mortality rates increased dramatically from 1973 to 1994, rising 120.5% and 38.9%, respectively. In recent years, however, rates for most age-sex groups appeared to stabilize or even decline. Male patients continued to have higher incidence and mortality rates than female patients, but for both male and female patients the largest increases by site were for the trunk. A large proportion of melanomas were detected in the local stage and with a thickness less than 0.75 mm.

CONCLUSION

Prevention of sun exposure is recommended to reverse the high incidence rates of melanoma.

Phase I/II trial of the safety and efficacy of shark cartilage in the treatment of advanced cancer

PURPOSE

Patients with cancer and chronic inflammatory disorders have used shark cartilage (SC) preparations for many years. Preclinical studies that support their beneficial effects are scanty, and reports of clinical trials have been anecdotal. The proposed mechanisms of antitumor action include direct or indirect inhibition of angiogenesis. Because of the emerging use of SC as an alternative to conventional cancer therapy, this trial was launched to evaluate the safety and efficacy of SC.

PATIENTS AND METHODS

Sixty adult patients with advanced previously treated cancer (breast, 16 patients; colorectal, 16 patients; lung, 14 patients; prostate, eight patients; non-Hodgkin lymphoma, three patients; brain, one patient; and unknown primary tumor, two patients) were enrolled. Eligibility criteria included confirmation of diagnosis, resistance to conventional therapy, objective measurable disease, life expectancy of 12 weeks or greater, Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2, no recent or concomitant anticancer therapy, no prior SC, and informed consent. Patients underwent evaluation of the extent of disease, quality-of-life score (Functional Assessment of Cancer Therapy-General [FACT-G] scale), and hematologic, biochemical, and selected immune function studies at baseline and after 6 and 12 weeks of SC therapy. The dose of SC was 1 g/kg daily orally in three divided doses. Standard criteria were used to evaluate adverse events and response.

RESULTS

Ten of 60 patients were lost to follow-up(LTFU) or refused further treatment (RFT) before the 6-week evaluation and were not assessable for toxicity and response. Three patients with stable disease at 6 weeks were LTFU or RFT thereafter. Of the 47 fully assessable patients, five were taken off study because of gastrointestinal toxicity or intolerance to SC. Progressive disease (PD) at 6 or 12 weeks occurred in 22 and five patients, respectively. Five patients died of PD while undergoing SC therapy. No complete (CRs) or partial responses (PRs) were noted. Median time to tumor progression in the entire study population was 7+/-9.7 weeks (mean, 11.4 weeks; range, 3.7 to 45.7 weeks). Ten (20%) of 50 assessable patients, or 16.7% of the 60 intent-to-treat patients, had stable disease (SD) for 12 weeks or more. The median time to tumor progression was 27 weeks, the mean was 28.8+/-9.9 weeks, and the range was 18.6 to 45.7 weeks. In this subset, FACT-G scores improved in four patients, were unchanged in four patients, and declined in two patients. Twenty-one adverse events (grade 1, eight events; grade 2, seven events; and grade 3, six events) were recorded, 14 of which were gastroenterologic (nausea, vomiting, constipation).

CONCLUSION

Under the specific conditions of this study, SC as a single agent was inactive in patients with advanced-stage cancer and had no salutary effect on quality of life. The 16.7% rate of SD was similar to results in patients with advanced cancer treated with supportive care alone.

Symptom severity of osteoarthritis of the knee: a patient-based measure developed in the veterans health study

BACKGROUND

Our objective was to develop a patient-based measure of the severity of osteoarthritis of the knee, focusing on symptomatology, that may be used in conjunction with measures of health-related quality of life in monitoring the health status of outpatients.

METHODS

We surveyed a random sample of male outpatients at Boston-area Veterans Affairs medical centers who were identified as having osteoarthritis of the knee according to a three-question screen. Structured interviews included 12 items covering five domains of symptoms (global severity, 4 items; pain with activity, 3 items; pain at rest, 2 items; impaired mobility, 2 items; and sensations of crepitus, 1 item), which were derived from clinical texts, consensus statements, and previously developed severity indices. Interviews also included a detailed medical history. Health-related quality of life was measured by the Medical Outcomes Study Health Status Survey (SF-36). Factor analysis and evaluation of multiattribute scales were used to evaluate the structural relationships between and within the five domains of symptoms.

RESULTS

We identified 415 of the 1770 screened outpatients as having osteoarthritis of the knee. Internal consistencies of the five domains ranged from .50 to .72, with substantial convergence between domains. The 12 items comprise a summary index with high internal consistency (alpha = .88). Overall severity, defined as the mean of the 12 items after standardization, was moderately correlated with the SF-36 component summaries: r = -.48 for physical; r = -.30 for mental.

CONCLUSIONS

Our measure provides a reliable index that represents symptomatic severity of osteoarthritis of the knee, which may be useful in comparing patient groups and assessing health outcomes; subscales may help characterize temporal changes, including responses to treatment.

Factors associated with smoking among children and adolescents in Connecticut

INTRODUCTION

The age of smoking initiation has dropped over the past four decades. Since behaviors and attitudes adopted in late childhood or early adolescence predict future smoking, it is important to understand the smoking and other risk-taking behaviors and attitudes of children aged 12 and younger. The goal of the analyses presented here was to describe behavioral and attitudinal factors associated with smoking among elementary school (grades 4-6), middle school (grade 7-8), and high school (grades 9-12) students in Connecticut.

METHODS

We have used data from 8 years (1988-1996) of an anonymous, self-administered health risk appraisal survey given to children and adolescents in self-selected public and private schools. We compared the proportion of smokers and nonsmokers who reported various behaviors and attitudes and compared them with the chi-square test.

RESULTS

Fifteen percent (n = 4,884) of the total population (n = 31, 861) were current smokers. At all grade levels, current smokers were more likely than nonsmokers to engage in risk-taking behaviors, and to report more stress and depression. Indicators of risk-taking and stress were also associated with the intent to smoke among children in grades 4-6.

CONCLUSIONS

Smoking occurs within the context of other risk-taking behavior and psychological distress, among both children and older adolescents. Our data provide support for the idea of early identification and targeting of children at high risk of smoking in elementary school, possibly as early as grade four.

Varicella susceptibility and vaccination strategies in young adults

BACKGROUND

Varicella infection causes substantial morbidity in young adults. Most military basic trainees are 18 to 21 years old, yet the Army has no varicella vaccination policy. We therefore determined varicella susceptibility in a population of Army basic trainees, examined variables that might predict antibody status, and developed a vaccination strategies model.

METHODS

Fifteen-hundred ninety-five trainees completed a demographic and historical questionnaire. Varicella antibody status was determined on 1201 volunteers. These data plus information from the literature were used to construct a decision tree of vaccination strategies that was applied to the total population of Army basic trainees in 1995 (n = 65,298).

RESULTS

Fifty (4.2 percent) of 1201 soldiers were antibody negative. Trainees who lived with no or 1 sibling while growing up were most likely to be seronegative (P < 0.01). The positive predictive value of a history of varicella was 98.5 percent, whereas the negative predictive value of a negative history of varicella was 23 percent. In the vaccination strategies model, serologically testing soldiers with a negative history of varicella and vaccinating those without protective antibodies was the most cost-effective approach.

CONCLUSIONS

In young adults a positive varicella history accurately predicts immunity, but verification of a negative history with antibody testing is recommended before vaccination.

Influence of arrhythmias on accuracy of non-invasive blood pressure monitors

PURPOSE

To compare the accuracy of non-invasive blood pressure (NIBP) monitors in response to common cardiac arrhythmias.

METHODS

Simulated signals of normal sinus rhythm (NSR), premature ventricular contractions (PVCs), atrial fibrillation (AF) and missed beats (MB) were generated from a Cufflink (Dynatech Nevada) NIBP simulator. Using these signals, the Critikon 1846SX (C1846), Critikon 845xt (C845). Critikon Vital Signs (CVIT), and Hewlett Packard M1008a (HP1008) were studied at a standard dynamic blood pressure of 120/90/80 mmHg, in order to compare monitor accuracy and signal response times.

RESULTS

The C845 monitors most closely estimated a simulated SBP of 120 mmHg, although SBP was greater during PVCs and AF than NSR (P < 0.05). The Critikon 1846, Critikon Vital Signs, and Hewlett Packard systematically underestimated SBP during these arrhythmias, but variability was modest, as reflected by small coefficients of variation (< 2% for SBP) with all monitor types. In general, MAP and DBP were less sensitive to the effects of these arrhythmias. Finally, missed beats prolonged signal response times with all four monitor types (P < 0.05), whereas PVCs and AF did not alter this parameter.

CONCLUSIONS

This study demonstrates the extent to which the accuracy of NIBP monitors is altered by common cardiac arrhythmias. Differences in the electromechanical characteristics of these devices may help to explain the observed similarities and discrepancies.

Comparing the impact of oral disease in two populations of older adults: application of the geriatric oral health assessment index

OBJECTIVES

This study compares the distributional and psychometric properties of the Geriatric Oral Health Assessment Index (GOHAI) in two samples of older adults, and examines how the self-perceived impact of oral disease, as measured by the GOHAI, varies in accordance with sample sociodemographic and health characteristics.

METHODS

Results are based on survey data from two samples of older men: a Medicare sample of patients using community physicians (n = 799; mean age = 74) and users of VA ambulatory health care (n = 542; mean age = 72).

RESULTS

The findings indicate significant differences between samples in mean GOHAI scores, with the VA sample exhibiting worse scores. A number of similarities in psychometric properties of the instrument across the two samples were found: high internal consistency reliability and similar inter-item and item-scale correlations. Factors analyses revealed somewhat different structures between the two samples, but explained similar amounts of variance; regression analyses indicated that income and self-rated oral health were significant predictors of GOHAI scores in both samples.

CONCLUSIONS

The GOHAI exhibits satisfactory psychometric properties in both samples of older men. Results suggest continued use of the GOHAI as an indicator of the impact of oral conditions on functioning and well-being in a variety of samples.

Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study

BACKGROUND

The Department of Veterans Affairs Health Care System (VA) is the largest integrated single payer system in the United States. To date, there has been no systematic measurement of health status in the VA. The Veterans Health Study has developed methods to assess patient-based health status in ambulatory populations.

OBJECTIVES

To describe the health status of veterans and examine the relationships between their health-related quality of life, age, comorbidity, and socioeconomic and service-connected disability status.

METHODS

Participants in the Veterans Health Study, a 2-year longitudinal study, were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities in the New England region. The Veterans Health Study patients received questionnaires of health status, including the Medical Outcomes Study Short Form 36-Item Health Survey; and a health examination, clinical assessments, and medical history taking. Sixteen hundred sixty-seven patients for whom we conducted baseline assessments are described.

RESULTS

The VA outpatients had poor health status scores across all measures of the Medical Outcomes Study Short Form 36-Item Health Survey compared with scores in non-VA populations (at least 50% of 1 SD worse). Striking differences also were found with the sample stratified by age group (20-49 years, 50-64 years, and 65-90 years). For 7 of the 8 scales (role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health), scores were considerably lower among the younger patients; for the eighth scale (physical function), scores of the young veterans (aged 20-49 years) were almost comparable with the levels in the old veterans (>65 years). The mental health scores of young veterans were substantially worse than all other age groups (P<.001) and scores of screening measures for depression were significantly higher in the youngest age group (51%) compared with the oldest age groups (33% and 16%) (P<.001).

CONCLUSIONS

The VA outpatients have substantially worse health status than non-VA populations. Mental health differences between the young and old veterans who use the VA health care system are sharply contrasting; the young veterans are sicker, suggesting substantially higher resource needs. Mental health differences may explain much of the worse health-related quality of life in young veterans. As health care systems continue to undergo a radical transformation, the Department of Veterans Affairs should focus on the provision of mental health services for its younger veteran.

The interaction of patient perception of overmedication with drug compliance and side effects

OBJECTIVE

Little is known about the significance of patient-perceived overmedication. We sought to determine its prevalence and relation to medication compliance, adverse drug reactions, health-related quality of life (HRQOL), and burden of illness.

DESIGN

Analysis of self-reported questionnaire data. PATIENTS/PARTICIPANT: There were 1,648 participants in a longitudinal study of male veterans.

INTERVENTION

Participants listed each of their medications with indication, missed doses, adverse reactions, and whether their amount of medication was "too much, the right amount, or too little." The survey included questions about medication adherence, "problems with medications," common symptoms, and screening questions for a number of chronic conditions. We assessed HRQOL with the Multiple Outcomes Study 36-Item Short Form Health Study (SF-36).

MEASUREMENTS AND MAIN RESULTS

Of the 1,256 respondents, 1,007 (80%) had taken medication within 4 weeks. Forty (4%) thought they were taking too much. They reported a 1.6-fold increase in prescription medications, a 5-8 fold increase in adverse effects, a 1.5-2 fold decrease in compliance, an increase in each of seven measured symptoms, and a decrease in six of eight SF-36 domains (p < .05 for all comparisons), the exceptions being the mental health and role-emotional scales. There was also a slight increase in the report of any chronic illness (95% vs 86%, p > .05).

CONCLUSIONS

Patient perception of overmedication correlates with self-report of decreased compliance, adverse drug reactions, decreased HRQOL, and an increase in symptomatology that is compatible with unrecognized side effects of medication. Such patients warrant careful evaluation.

EMS agenda for the future: where we are ... where we want to be. EMS Agenda for the Future Steering Committee

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the "EMS Agenda for the Future." Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are Integration of Health Services, EMS Research, Legislation and Regulation, System Finance, Human Resources, Medical Direction, Education Systems, Public Education, Prevention, Public Access, Communication Systems, Clinical Care, Information Systems, and Evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.