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Scholars have devoted substantial attention to both the overrepresentation of black defendants on federal death row and the disproportionate number of federal defendants charged capitally for the murder of white victims. This attention has not explained (much less resolved) these disquieting racial disparities. Little research has addressed the unusual geography of the federal death penalty, in which a small number of jurisdictions are responsible for the vast majority of federal death sentences. By addressing the unique geography, we identify a possible explanation for the racial distortions in the federal death penalty: that federal death sentences are sought disproportionately where the expansion of the venire from the county to the district level has a dramatic demographic impact on the racial make-up of the jury. This inquiry demonstrates that the conversation concerning who should make up the jury of twelve neighbors and peers-a discussion begun well before the founding of our Constitution-continues to have relevance today. This Article documents the historical and racial relationships between place and the ability to seat an impartial jury. We then discuss the unique impact demographic shifts in the jury pool have on death penalty decision making. Finally, we propose three possible solutions: (1) a simple, democracyenhancing fix through a return to the historical conception of the county as the place of vicinage in federal capital trials; (2) a Batson-type three-step process for rooting out the influence of race on the decision to prosecute federally; and/or (3) voluntary measures by the Attorney General to mask demographic and location identifiers when deciding whether to provide federal death-authorization. We explain why a return to county-level jury pools in federal capital cases (whether through statutory construction, legislative change, or through the authority of a fair-minded Attorney General) prospectively limits the impact of race on the operation of the federal death penalty, without establishing the intractability of the federal death penalty as a whole. Finally, we observe that any effort to study the federal death penalty cannot merely address those federal cases in which the Attorney General has considered whether to approve an effort to seek the death penalty, but must also include an assessment of the cases prosecuted in state court that could be prosecuted federally and the prosecutorial decision concerning when and whether to prosecute in federal court. [ABSTRACT FROM AUTHOR]

The article focuses on the process of removing jurors based on their view of capital punishment in the U.S., referred to as "death-qualification." The authors examine how the death-qualification process arose, why the U.S. Supreme Court continues to justify its existence and how a proper understanding of the Sixth Amendment right to a jury trial requires the end of the process. They conclude that death qualification deprives a dependant of what the Constitution guarantees.

Racial, ethnic, and cultural factors influencing mental health in later life are important to study in their own right. However, they also offer an opportunity to expand our understanding of mental health and mental illness in older adults independent of race, ethnicity, or culture. Any time an opportunity arises to examine a problem from a different perspective, chances increase that new light will be shed on the problem. For example, while suicide is greatest in older Americans compared with any other US population group, it is less frequent in older blacks than older whites. Why? Among the different theories that have been advanced, one holds that older African Americans in reaching later life have surmounted more threats to self-esteem (compared with whites) and are thereby better adapted to new challenges associated with aging.1 Still, the discrepancy in suicide rates between older blacks and whites remains an important research question. In studying suicide with attention to racial and ethnic variables, the opportunity presents itself to gain a more fundamental understanding of suicide itself—to the benefit of all older adults, indeed to the benefit of all age groups.This paper focuses on some African American issues pertinent to geriatric psychiatry and identifies areas for further research. In addition to a selected literature review, the author draws on his own research from a 20-year longitudinal study, initiated in 1971, of a senior citizens' apartment building in Washington, DC, with a predominantly African American population.2 (1= Group for the Advancement of Psychiatry, Committee on Cultural Psychiatry: Suicide and Ethnicity in the United States. New York, Bruner/Mazel, 1989; and 2= Cohen GD: Lessons from longitudinal studies of mentally ill and mentally healthy elderly: A 17-year perspective, in Bergener M, Finkel SI (eds): Clinical and Scientific Psychogeriatrics, Vol. 1. New York, Springer, 1990.) [ABSTRACT FROM PUBLISHER]

Examines some misconceptions on the cost of the medical care of the aged in the U.S. Cost of terminal care; Cost of the use of high technology for the terminally ill, elderly patients; Federal budget for the medical care of the aged.

Recurrent or unresectable cutaneous cancers may have limited treatment options. Diffusing alpha-emitter Radiation Therapy (DaRT, AlphaTau Medical, Tel Aviv, Israel) is a novel method of treating solid tumors using alpha-particle interstitial radiotherapy. A prior study conducted outside the United States demonstrated the feasibility, safety and efficacy of DaRT in patients with squamous cell carcinoma of the skin or mucosa of the head and neck. In this prospective multicenter trial conducted in the United States, we tested the hypothesis that DaRT for recurrent and unresectable cutaneous cancers was feasible, and also characterized preliminary safety and efficacy. Patients with malignant skin or soft tissue tumors were recruited if they had limited treatment options, including recurrent disease, unresectable tumors, or those with metastases which could not be rendered disease-free with surgery. After baseline patient and tumor assessment, pre-treatment planning was performed. Patients underwent temporary DaRT placement to deliver a physical dose of 10 Gy to the tumor. Patients were followed for adverse events and tumor response 6, 12 and 24 weeks after removal. The primary objectives were to determine the feasibility of the procedure (based on successful implantation of DaRT device in the tumor) as well as the safety (based on adverse events (AEs) graded by CTCAE V5.0). Secondary objectives included response (based on RECIST V1.1 criteria), among others. Ten patients were recruited to the study and all successfully underwent the DaRT procedure, confirming feasibility. Median patient age was 72 years (range 57-92 years), with 6 men and 4 women participating. Six patients had recurrent disease, 4 were deemed unresectable and none had metastases. Tumors were located on the nose, chin, eyelid, scalp, neck, trunk, and extremities. The baseline mean tumor volume was 3.4 cm3 (range 0.65-12.65 cm3). Mean prescription dose coverage of the gross tumor volume was 91%, with all tumors having ≥85% coverage. No device-related grade 3 AEs were noted. Common AEs were grade 1-2 erythema, edema, and pruritis. At 12 weeks following treatment, there was a 100% complete response (CR) rate. Nine out of the ten CRs were confirmed by CT imaging. This trial demonstrated the feasibility, and preliminary safety and efficacy of DaRT in the treatment of recurrent or unresectable cutaneous cancers. The favorable safety profile and high response rate are promising. A pivotal US trial for marketing approval is expected to be underway by the time of this presentation. [ABSTRACT FROM AUTHOR]

Background: A growing literature documents how primary care practices adapted to the COVID-19 pandemic. We examine a topic that has received less attention-how participants in an advanced alternative payment model perceive the model influenced their ability to meet patients' care needs during the pandemic., Methods: Analysis of closed- and open-ended questions from a 2021 survey of 2496 practices participating in the Comprehensive Primary Care Plus (CPC+) model (92% response rate) and a 2021 survey of 993 randomly selected primary care physicians from these practices (55% response rate). Both surveys asked whether respondents agreed or disagreed that they or their practice was "better positioned to meet patients' care needs during the coronavirus pandemic" because of participation in CPC+. Both also included an open-ended question about CPC+'s effects., Results: Half of practices and one-third of physicians agreed or strongly agreed that participating in CPC+ better positioned them to meet patients' care needs during the pandemic. One in 10 practices and 2 in 10 physicians, disagreed or strongly disagreed, while 4 in 10 practices and slightly more than half of physicians neither agreed nor disagreed (or, for physicians, didn't know). The most commonly identified CPC+ activities that facilitated meeting patient care needs related to practices' work on care management (e.g., risk stratification), access (e.g., telehealth), payment outside of fee-for-service (FFS), and staffing (e.g., supporting care managers)., Conclusions: Most CPC+ practices and physicians were positive or neutral about participating in CPC+ in the context of COVID-19, indicating more benefit than risk to payment alternatives to FFS., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. Genna Cohen reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Nancy Duda reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Katie Morrison Lee reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Kaylyn Swankoski reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Gillian Giudice reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Maya Palakal reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Caroline Mack reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Ann S. O'Malley reports financial support was provided by U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To test the reliability of Medicare claims in measuring vertical integration. We assess the accuracy of a commonly used measure of integration, primary care physician (PCP) practices billing Medicare as a hospital outpatient department (HOPD) in claims., Data Sources and Study Setting: Medicare fee-for-service claims, IQVIA, and CPC+ practice surveys for this study., Study Design: We compare measures of integration from Medicare claims to self-reported indicators of integration from IQVIA and a survey of CPC+ participating practice sites., Data Collection/extraction Methods: We measure integration by using site-of-service billing in the 100% sample of Medicare Carrier claims from 2017-2020. In the IQVIA SK&A (2017-2018), OneKey (2019-2020), and practice survey data (2017-2019), we use self-reported responses to measure integration., Principal Findings: We find that currently most PCP practices sites that report themselves as being integrated with a health system do not bill as an HOPD. In 2017, 11% of CPC+ practices were identified as being vertically integrated in claims, while the equivalent numbers in SK&A and surveys were 52% and 54% integration, respectively. A t-test found that both datasets significantly differed from claims (Survey: 41.3%-45.1%; SK&A: 45.3%-51.1%); this gap persists in 2018-2019., Conclusion: Measuring physician-hospital vertical integration accurately is integral to determining consolidation. The overwhelming majority of PCP practice sites not billing as an HOPD may reflect Medicare regulatory changes that have reduced the financial incentives for doing so. These findings have implications for researchers that study the growth in PCP-hospital integration in health care markets., (© 2024 Health Research and Educational Trust.)

The task group (TG) on magnetic resonance imaging (MRI) implementation in high-dose-rate (HDR) brachytherapy (BT)-Considerations from simulation to treatment, TG 303, was constituted by the American Association of Physicists in Medicine's (AAPM's) Science Council under the direction of the Therapy Physics Committee, the Brachytherapy Subcommittee, and the Working Group on Brachytherapy Clinical Applications. The TG was charged with developing recommendations for commissioning, clinical implementation, and on-going quality assurance (QA). Additionally, the TG was charged with describing HDR BT workflows and evaluating practical consideration that arise when implementing MR imaging. For brevity, the report is focused on the treatment of gynecologic and prostate cancer. The TG report provides an introduction and rationale for MRI implementation in BT, a review of previous publications on topics including available applicators, clinical trials, previously published BT-related TG reports, and new image-guided recommendations beyond CT-based practices. The report describes MRI protocols and methodologies, including recommendations for the clinical implementation and logical considerations for MR imaging for HDR BT. Given the evolution from prescriptive to risk-based QA, an example of a risk-based analysis using MRI-based, prostate HDR BT is presented. In summary, the TG report is intended to provide clear and comprehensive guidelines and recommendations for commissioning, clinical implementation, and QA for MRI-based HDR BT that may be utilized by the medical physics community to streamline this process. This report is endorsed by the American Brachytherapy Society., (© 2022 American Association of Physicists in Medicine.)

Background : There is inconsistent evidence in the literature as to whether or not Alcohol Use Disorder (AUD) is a risk factor for Post-Traumatic Stress Disorder (PTSD). Objectives : We evaluated the risk of developing PTSD after trauma exposure in individuals with AUD. As a secondary analysis, we also tested if alcohol dependence or alcohol abuse separately increased the risk of PTSD development. We also explored the effect of AUD on exposure to various traumas. Methods : Longitudinal data was obtained from 30,180 individuals with and without AUD from National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) waves I and II. Using propensity score methods, we matched individuals with AUD (alcohol abuse and/or dependence using DSM-IV criteria) to those without AUD at baseline on demographic, familial, and clinical factors to estimate the risk of PTSD development after trauma exposure. Data were adjusted for complex survey methods. Results : Individuals with AUD had an increased risk of being exposed to various traumas between wave I and II (60.6% vs. 48.3% of controls). Among individuals exposed to trauma between the two waves (N = 14,107), AUD had no effect on subsequent PTSD development after matching and controlling for covariates (OR: 1.00; 95%CI: 0.72-1.39; p = .99). However, those with alcohol dependence only did have an effect on subsequent PTSD development (OR: 1.76; 95%CI: 1.05-2.95; p = .03). Conclusion : In individuals with alcohol dependence the experience of trauma increases the risk of developing PTSD. These findings suggest that prevention methods from PTSD after trauma exposure for individuals with alcohol dependence are needed.

Background The recommended maximum age and time window for intravenous alteplase treatment of acute ischemic stroke differs between the Europe Union and United States. Aims We compared the effects of alteplase in cohorts defined by the current Europe Union or United States marketing approval labels, and by hypothetical revisions of the labels that would remove the Europe Union upper age limit or extend the United States treatment time window to 4.5 h. Methods We assessed outcomes in an individual-patient-data meta-analysis of eight randomized trials of intravenous alteplase (0.9 mg/kg) versus control for acute ischemic stroke. Outcomes included: excellent outcome (modified Rankin score 0-1) at 3-6 months, the distribution of modified Rankin score, symptomatic intracerebral hemorrhage, and 90-day mortality. Results Alteplase increased the odds of modified Rankin score 0-1 among 2449/6136 (40%) patients who met the current European Union label and 3491 (57%) patients who met the age-revised label (odds ratio 1.42, 95% CI 1.21-1.68 and 1.43, 1.23-1.65, respectively), but not in those outside the age-revised label (1.06, 0.90-1.26). By 90 days, there was no increased mortality in the current and age-revised cohorts (hazard ratios 0.98, 95% CI 0.76-1.25 and 1.01, 0.86-1.19, respectively) but mortality remained higher outside the age-revised label (1.19, 0.99-1.42). Similarly, alteplase increased the odds of modified Rankin score 0-1 among 1174/6136 (19%) patients who met the current US approval and 3326 (54%) who met a 4.5-h revised approval (odds ratio 1.55, 1.19-2.01 and 1.37, 1.17-1.59, respectively), but not for those outside the 4.5-h revised approval (1.14, 0.97-1.34). By 90 days, no increased mortality remained for the current and 4.5-h revised label cohorts (hazard ratios 0.99, 0.77-1.26 and 1.02, 0.87-1.20, respectively) but mortality remained higher outside the 4.5-h revised approval (1.17, 0.98-1.41). Conclusions An age-revised European Union label or 4.5-h-revised United States label would each increase the number of patients deriving net benefit from alteplase by 90 days after acute ischemic stroke, without excess mortality.

Background: Physician well-being is a significant problem. Here we explore whether one factor, a resident's concern for being judged by one's gender, influences well-being., Methods: Over two years at one institution, we surveyed surgical residents on validated measures of well-being as well as the extent to which they felt they were judged because of their gender (gender judgment). We used correlations and linear regression to investigate the relationships between gender judgment and well-being., Results: There were 193 unique respondents (87% response rate). Women had significantly more concerns about gender judgment than men (M = 2.39, SD = 0.73 vs. M = 1.46, SD = 0.62, t = -9.47, p < 0.00001). In regression analyses, gender judgment concerns were significantly associated with all three well-being outcomes (Bs -0.34, 0.50, and 0.39, respectively for well-being, emotional exhaustion, and depersonalization, all p < 0.013)., Conclusions: The degree to which residents, both male and female, are concerned about being judged for their gender is significantly associated with worse well-being., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Anger is a common problem among veterans and has been associated with posttraumatic stress disorder (PTSD). This study aimed to improve understanding of how anger and PTSD co-occur by examining gender differences and differences by whether the triggering traumatic event is deployment-related vs. civilian-related in current service members. A representative cohort of Reserve and National Guard service personnel (n = 1293) were interviewed to assess for deployment- or civilian-related traumas, PTSD, and anger. The prevalence of self-reported anger problems was estimated among male (n = 1036) and female (n = 257) service members. Log Poisson regression models with robust standard errors were used to estimate the associations of problems with anger with PTSD and PTSD symptom severity for men and women. Self-reported anger problems were common among male (53.0%) and female (51.3%) service members. Adjusted prevalence ratios (PR) showed associations between anger and PTSD connected to both civilian- and deployment-related traumas (PR were 1.77 (95% CI 1.52-2.05) and 1.85 (95% CI 1.62-2.12), respectively). PTSD symptom severity was also associated with anger. This study was cross-sectional and so a causal relationship between PTSD and anger cannot be established. Problems with anger are common among male and female current Guard and Reserve members. These findings suggest that anger treatment should be made available to current service members and that clinicians should assess anger problems irrespective of gender. Future research should examine the effectiveness of anger treatment protocols by gender., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Under what circumstances should a citizen be able to avoid the penalties set by the citizen's home country's criminal law by going abroad to engage in the same activity where it is not criminally prohibited? Should we view the ability to engage in prohibited activities by traveling outside of the nation state as a way of accommodating cultural or political differences within our polity? These are general questions regarding the power and theory of extraterritorial application of domestic criminal law. In this Article, I examine the issues through a close exploration of one setting that urgently presents them: medical tourism. Medical tourism is a term used to describe the travel of patients who are citizens and residents of one country, the "home country," to another country, the "destination country," for medical treatment. This Article is the first to comprehensively examine a subcategory of medical tourism that I call "circumvention tourism," which involves patients who travel abroad for services that are legal in the patient's destination country but illegal in the patient's home country--that is, travel to circumvent domestic prohibitions on accessing certain medical services. The four examples of this phenomenon that I dwell on are circumvention medical tourism for female genital cutting (FGC), abortion, reproductive technology usage, and assisted suicide. I will briefly discuss the "can" question: assuming that a domestic prohibition on access to one of these services is lawful, as a matter of international law, is the home country forbidden, permitted, or mandated to extend its existing criminal prohibition extraterritorially to home country citizens who travel abroad to circumvent the home country's prohibition? Most of the Article, though, is devoted to the "ought" question: assuming that the domestic prohibition is viewed as normatively well-grounded, under what circumstances should the home country extend its existing criminal prohibition extraterritorially to its citizens who travel abroad to circumvent the prohibition? I show that, contrary to much of current practice, in most instances, home countries should seek to extend extraterritorially their criminal prohibitions on FGC, abortion, assisted suicide, and, to a lesser extent, reproductive technology use to their citizens who travel abroad to circumvent the prohibition. I also discuss the ways in which my analysis of these prohibitions can serve as scaffolding for a more general theory of circumvention tourism.

Objective: Individuals with mental health problems are at elevated risk for eating disorders. Veterans serving in support of the conflicts in Afghanistan and Iraq (OEF/OIF) have a high prevalence of deployment-related mental health problems, but little is known about their risk for eating disorders. Our aim was to determine rates of eating disorder diagnoses among OEF/OIF veterans with mental health problems, particularly among those with comorbid mental health problems., Methods: This retrospective, cross-sectional analysis of nationwide VA healthcare facilities used descriptive statistics and regression analyses to determine eating disorder rates in OEF/OIF veterans who were new users of VA healthcare from October 7, 2001 to December 31, 2010 (N = 593,739)., Results: Although the prevalence of eating disorder diagnoses was 0.007% (n = 465) in women and <0.001% (n = 192) in men, veterans diagnosed with mental health problems were significantly more likely to have an eating disorder than those without mental health diagnoses. Eating disorders were significantly more common in women with depression, posttraumatic stress disorder, and alcohol and/or drug use disorders than in women veterans without these mental health disorders. Among men, the associations between eating disorder diagnoses and comorbid mental health diagnoses closely paralleled those observed in women., Conclusions: Rates of eating disorders are significantly higher among returning veterans with comorbid mental health problems compared with those without mental health diagnoses. Further research should examine methods to improve detection and treatment of eating disorders in this population., (Published by Elsevier Inc.)

Objectives: To determine clinical and health-related quality of life outcomes, and to derive an "ideal" composite profile of children alive 10 years after pediatric liver transplantation (LT) performed in the US and Canada., Study Design: This was a multicenter cross-sectional analysis characterizing patients enrolled in the Studies of Pediatric Liver Transplantation database registry who have survived >10 years from LT., Results: A total of 167 10-year survivors were identified, all of whom received daily immunosuppression therapy. Comorbidities associated with the post-LT course included post-transplantation lymphoproliferative disease (in 5% of patients), renal dysfunction (9%), and impaired linear growth (23%). Health-related quality of life, as assessed by the PedsQL 4.0 Generic Core Scales, revealed lower patient self-reported total scale scores for 10-year survivors compared with matched healthy children (77.2±12.9 vs 84.9±11.7; P<.001). At 10 years post-LT, only 32% of patients achieved an ideal profile of a first allograft stable on immunosuppression monotherapy, normal growth, and absence of common immunosuppression-induced sequelae., Conclusion: Success after pediatric LT has moved beyond patient survival. Availability of an ideal composite profile at follow-up provides opportunities for patients, families, and healthcare providers to identify broader sets of outcomes at earlier stages, ultimately contributing to improved outcomes after pediatric LT., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Context: Record numbers of Iraq and Afghanistan veterans survive their war injuries and yet continue to experience pain and mental health problems, particularly posttraumatic stress disorder (PTSD). Little is known about the association of mental health disorders and prescription opioid use., Objective: To investigate the effect of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use., Design: Retrospective cohort study involving 141,029 Iraq and Afghanistan veterans who received at least 1 non-cancer-related pain diagnosis within 1 year of entering the Department of Veterans Affairs (VA) health care system from October 1, 2005, through December 31, 2010., Main Outcome Measures: Independent association of mental health disorders and the prescription of opioids, higher risk opioid use, and adverse clinical outcomes (eg, accidents and overdose) within 1 year of receiving a pain-related diagnosis., Results: A total of 15,676 veterans were prescribed opioids within 1 year of their initial pain diagnosis. Compared with 6.5% of veterans without mental health disorders, 17.8% (adjusted relative risk [RR], 2.58; 95% CI, 2.49-2.67) of veterans with PTSD and 11.7% (adjusted RR, 1.74; 95% CI, 1.67-1.82) with other mental health diagnoses but without PTSD were significantly more likely to receive opioids for pain diagnoses. Of those who were prescribed pain medication, veterans with PTSD were more likely than those without mental health disorders to receive higher-dose opioids (22.7% vs 15.9%, adjusted RR, 1.42; 95% CI, 1.31-1.54), receive 2 or more opioids concurrently (19.8% vs 10.7%, adjusted RR, 1.87; 95% CI, 1.70-2.06), receive sedative hypnotics concurrently (40.7% vs 7.6%, adjusted RR, 5.46; 95% CI, 4.91-6.07), or obtain early opioid refills (33.8% vs 20.4%; adjusted RR, 1.64; 95% CI, 1.53-1.75). Receiving prescription opioids (vs not) was associated with an increased risk of adverse clinical outcomes for all veterans (9.5% vs 4.1%; RR, 2.33; 95% CI, 2.20-2.46), which was most pronounced in veterans with PTSD., Conclusion: Among US veterans of Iraq and Afghanistan, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids for pain, high-risk opioid use, and adverse clinical outcomes.

Background: The prevalence and correlates of alcohol use disorder (AUD) and drug use disorder (DUD) diagnoses in Iraq and Afghanistan veterans who are new users of Department of Veterans Affairs (VA) healthcare nationwide has not been evaluated., Methods: VA administrative data were used in retrospective cross-sectional descriptive and multivariable analyses to determine the prevalence and independent correlates of AUD and DUD in 456,502 Iraq and Afghanistan veterans who were first-time users of VA healthcare between October 15, 2001 and September 30, 2009 and followed through January 1, 2010., Results: Over 11% received substance use disorder diagnoses: AUD, DUD or both; 10% received AUD diagnoses, 5% received DUD diagnoses and 3% received both. Male sex, age < 25 years, being never married or divorced, and proxies for greater combat exposure were independently associated with AUD and DUD diagnoses. Of those with AUD, DUD or both diagnoses, 55-75% also received PTSD or depression diagnoses. AUD, DUD or both diagnoses were 3-4.5 times more likely in veterans with PTSD and depression (p < 0.001)., Conclusions: Post-deployment AUD and DUD diagnoses were more prevalent in subgroups of Iraq and Afghanistan veterans and were highly comorbid with PTSD and depression. Stigma and lack of universal screening may have reduced the number of DUD diagnoses reported. There is a need for improved screening and diagnosis of substance use disorders and increased availability of integrated treatments that simultaneously address AUD and DUD in the context of PTSD and other deployment-related mental health disorders., (Published by Elsevier Ireland Ltd.)

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.

We interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has affected care delivery systems. The growth of hospitalist programs contributes to a loss of physicians' participation on hospital medical staffs, which increases the burden of coordination and blurs accountability for the quality of postdischarge care. Arrangements where companies and multispecialty medical groups employ hospitalists are more likely than others to establish routines for ensuring coordinated transitions upon hospital admission and discharge. Policymakers could support the development of guiding principles for care coordination, greater reliance on nonphysicians, and reintegration of inpatient and outpatient providers.

The incidence of cancer in the United States and other major industrialized nations has escalated to epidemic proportions over recent decades, and greater increases are expected. While smoking is the single largest cause of cancer, the incidence of childhood cancers and a wide range of predominantly non-smoking-related cancers in men and women has increased greatly. This modern epidemic does not reflect lack of resources of the U.S. cancer establishment, the National Cancer Institute and American Cancer Society; the NCI budget has increased 20-fold since passage of the 1971 National Cancer Act, while funding for research and public information on primary prevention remains minimal. The cancer establishment bears major responsibility for the cancer epidemic, due to its overwhelming fixation on damage control--screening, diagnosis, treatment, and related molecular research--and indifference to preventing a wide range of avoidable causes of cancer, other than faulty lifestyle, particularly smoking. This mindset is based on a discredited 1981 report by a prominent pro-industry epidemiologist, guesstimating that environmental and occupational exposures were responsible for only 5 percent of cancer mortality, even though a prior chemical industry report admitted that 20 percent was occupational in origin. This report still dominates public policy, despite overwhelming contrary scientific evidence on avoidable causes of cancer from involuntary exposures to a wide range of environmental carcinogens. Since 1998, the ACS has been planning to gain control of national cancer policy, now under federal authority. These plans, developed behind closed doors and under conditions of nontransparency, with recent well-intentioned but mistaken bipartisan Congressional support, pose a major and poorly reversible threat to cancer prevention and to winning the losing war against cancer.

Objective: Ethnic differences in birth outcomes are well established, but it is not clear whether differences in nutrition may partly explain unaccounted differences in birth outcomes. Our purpose was to evaluate the relationship of nutrition to ethnic differences in birth outcomes., Study Design: This was a multicenter, prospective study of 4589 healthy nulliparous women who were enrolled in the Calcium for Preeclampsia Prevention trial conducted from 1992 to 1995. Main outcome measures were birth weight, gestational age at delivery, preterm birth, and small for gestational age birth after the data were controlled for maternal characteristics and intake of total calories, protein, carbohydrate, fat, and 13 vitamin and mineral constituents that were obtained from a 24-hour recall at 13 to 21 weeks' gestation., Results: Black and non-Hispanic white women differed significantly in birth outcomes, with odds ratios of 2.06 (95% confidence interval, 1.48-2.86) for small for gestational age and 1.38 (95% confidence interval, 0.98-1.95) for preterm birth, after adjustment for maternal characteristics. These odds ratios were hardly changed by the further adjustment for all nutritional variables, even though there were substantial nutritional differences between black and white women. Differences in birth outcomes between Hispanic and non-Hispanic white women were small. Hispanic women who spoke only Spanish were better nourished than those Hispanic women who spoke English, but this had only a modest effect on birth outcomes., Conclusion: Nutritional variation among women in the United States does not appear to have a significant role in the explanation of ethnic differences in birth outcomes.

The Group for the Advancement of Psychiatry, Committee on Aging, believes that a crisis has emerged with respect to the understanding of the nature and treatment of schizophrenia in older persons. Moreover, critical gaps exist in clinical services for this population. In this article, we examine the epidemiology of aging and schizophrenia; life-course changes in psychopathology, cognitive function, social functioning, and physical health; and various concerns regarding treatment, services, and financing. Finally, we propose six research and policy recommendations and suggest methods for addressing the research questions that we have posed.

The objectives of this study were to compare the efficacy and safety of orally administered ondansetron 8 mg b.i.d., 24 mg q.d., and 32 mg q.d. in the prevention of nausea and vomiting associated with high-dose cisplatin-based chemotherapy (cisplatin > or = 50 mg/m2). This was a randomized, parallel-group, double-blind study conducted in North America. It was planned that all patients would receive one of the following orally administered ondansetron treatments 30 min before starting cisplatin dosing (administered over < or = 3 h): 8 mg b.i.d. with 8 h between doses (124 patients), 24 mg q.d. (116 patients), and 32 mg q.d. (117 patients). Use of prophylactic corticosteroids was not permitted. During the 24-h study period, the highest complete response rate (no emesis, rescue antiemetic therapy, or withdrawal) occurred in patients who received ondansetron 24 mg q.d.: 76/115 or 66%, as against 68/124 (55%) after ondansetron 8 mg b.i.d. and 64/117 (55%) after ondansetron 32 mg q.d. Complete control of nausea (no nausea, no rescue, no withdrawal) occurred in more patients in the ondansetron 24 mg q.d. group (64/114, 56%) than in the ondansetron 8 mg b.i.d. group (43/121, 36%) or in the ondansetron 32 mg group (55/117, 50%). These results demonstrate that following highly emetogenic cisplatin-based chemotherapy (> or =2 50 mg/m2), oral ondansetron 24 mg q.d. is more effective than 8 mg b.i.d. for overall control of nausea, and at least as effective if not more effective in the control of acute vomiting than 8 mg b.i.d. or 32 mg q.d. Ondansetron 24 mg q.d. was well tolerated, and no new or unexpected adverse events were identified.

Objective: To determine if pediatric residents and emergency department (ED) fellows could improve their ability to counsel and inform standardized patients (SPs) about bad news., Methodology: A crossover, self-controlled design in which trainees were their own control individuals, and SPs provided feedback after the first interview. The setting was the consultation room in the ED of a large children's hospital. The outcome measures included examining the counseling and informing skills of study participants., Results: Trainees improved their informing skills after being provided feedback in the broad areas of communication and follow-up and in the total number of content areas asked. Their counseling skills improved in two areas: 1) promoting more trust and 2) making parents feel less dependent. Those trainees who scored higher on counseling skills discussed more total and critical content issues with SPs in the study. Trainee feedback revealed a very high rating of the educational process, and the trainees also felt much more confident about their skills after the first and second sessions., Conclusions: Using SPs to teach residents and ED fellows to give bad news is an effective educational process that provides trainees with interactions that simulate real-life experience

Employee Assistance Programs (EAPs) provide a much-needed service to the employees of corporations. In these times of reduced benefits and diminished community resources, EAPs can dramatically compensate for those shortages. This article will explore the role of an EAP, the models of service available, and the selection process for choosing a program.

In the Canadian single-payer system, all hospital payments, including payments for cardiac operations, are negotiated with the government annually. Each hospital is required to remain within 50 cases of its negotiated surgical target. Physicians are paid on a capitated basis and are subject to penalties if negotiated targets are exceeded. There is a computerized waiting list for cardiac operation, with patients classified by an urgency rating scale and objectives set for the maximum period for any given urgency category. Experience has shown that many patients are delayed in the queue, waiting longer than expected for surgical procedures. Waiting times are not influenced by age, sex, or reoperative status, but are influenced by factors such as the presence of multiple risk factors, the number of diseased vessels, stability or unstability of angina, left main coronary artery disease, and recent angioplasty. Waiting time has not been shown to affect operative mortality, the incidence of postoperative low-output syndrome, or length of hospital stay. Canada's 30-year experience with the provision of cardiac services under managed care may provide useful information to hospitals and physicians in the United States currently confronting capitation. The following overview focuses on two critical issues: negotiation of costs and management of patient waiting lists.

The public debate on health care, as reported and carried on in the popular media, is frequently framed in terms of age. The assumption is that old age can be equated with high health care costs, and that increases in health care costs are determined solely by the growing numbers of older people in our society. A variety of studies suggest, however, that high-tech, high-cost care is not inevitably associated with advancing age. The public debate on health care must stop confusing demographic issues with health care cost issues, and focus instead on the real and complex problems of rising health care costs.

The Centers for Disease Control (CDC) have recently lowered the acceptable blood lead concentration in young children from < or = 25 to < or = 10 micrograms/dl (< or = 1.21 to < or = 0.48 mumol/L). The incidence of lead toxicity with respect to geographical areas and socioeconomic status has not yet been defined. We evaluated the incidence of increased lead concentration in inner-city, suburban, and rural children aged 9 months to 3 years. Seven hundred eighty of the 4,196 studied inner-city samples (18.6%) had lead concentrations > or = 10 micrograms/dl (0.48 mumol/L), of which only 71 (1.6%) had lead values > or = 25 micrograms/dl (1.21 mumol/L). Only 5 of the 212 studied children (2.4%) from suburbia and 7 of the 120 children (5.8%) from rural communities had blood lead concentrations > or = 10 micrograms/dl (0.48 mumol/L). None of these children, however, had a lead concentration > or = 15 micrograms/dl (0.73 mumol/L). In contrast, 276 inner-city subjects (6.6%) had lead values > or = 15 micrograms/dl (0.73 mumol/L). Our data indicate that a correlation exists between geographical location and blood lead concentration in young children. Government health agencies at all levels should prioritize their limited resources for those areas that are most at risk for lead poisoning.

The McMaster University Undergraduate MD Program participated with nine other schools in a pilot self-study of clinical evaluation under the auspices of the Association of American Medical Colleges. Clerkship planners and teaching faculty responded to questionnaires provided by the AAMC Clinical Evaluation Program, dealing with evaluation system problems. Top ranked problems, as perceived by the McMaster faculty, are presented and compared with the major problem areas seen by the overall group of the nine other schools. Two of these items deal with: (1) the lack of transmission of evaluative information about clerks from one unit to subsequent ones; and (2) faculty unwillingness to record negative evaluations. The former is seen as a serious problem both at McMaster and at the other schools; the latter only at McMaster. The discussion focuses on attempts to explain why these problems exist at McMaster and offers some suggestions for dealing with them.