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CenteringPregnancy emphasizes nutrition, learning, and peer support through a group meeting format in contrast to the standard of prenatal care that maximizes a pregnant patient's time with their provider. It was hypothesized that the program may yield a reduced risk of pregnancy-induced hypertension. In this observational study, authors examined the impacts of the CenteringPregnancy program versus those of standard of prenatal care on pregnancy-induced hypertension. In 2021, birth certificate data were linked to hospital discharge records of women who delivered in obstetric clinics in the Midlands of South Carolina between 2015 and 2019. Logistic regression models were used to estimate the association between CenteringPregnancy participation (n =547) and any pregnancy-induced hypertension and specific pregnancy-induced hypertension diagnoses (gestational hypertension/unspecified hypertension, mild pre-eclampsia, and severe pre-eclampsia/eclampsia). Propensity score techniques (e.g., inverse probability of treatment weighting) were used to adjust for self-selection into the program versus into standard of prenatal care. CenteringPregnancy participants had higher odds of developing any pregnancy-induced hypertension under all specifications (OR=1.48, 95% CI=1.15, 1.92) and specifically gestational hypertension/unspecified hypertension (OR=1.76, 95% CI=1.28, 2.42) than those in standard of prenatal care. However, CenteringPregnancy participants did not experience significantly higher odds of mild pre-eclampsia (OR=1.06, 95% CI=0.65, 1.78) and severe pre-eclampsia/eclampsia (OR=1.21, 95% CI=0.78, 1.89) compared with standard of prenatal care participants. Participation in CenteringPregnancy was associated with higher odds of pregnancy-induced hypertension, particularly gestational hypertension, than participation in standard of prenatal care. Additional research is warranted to definitely rule out selection bias and identify contributing factor(s) that increased pregnancy-induced hypertension despite efforts to improve pregnancy-related health outcomes among CenteringPregnancy participants. [ABSTRACT FROM AUTHOR]

Objectives. We aimed to describe the epidemiology of stroke among Alaska Natives, which is essential for designing effective stroke prevention and intervention efforts for this population. Methods. We conducted an analysis of death certificate data for the state of Alaska for the period 1984 to 2003, comparing age-standardized stroke mortality rates among Alaska Natives residing in Alaska vs US Whites by age category, gender, stroke type, and time. Results. Compared with US Whites, Alaska Natives had significantly elevated stroke mortality from 1994 to 2003 but not from 1984 to 1993. Alaska Native women of all age groups and Alaska Native men younger than 45 years of age had the highest risk, although the rates for those younger than 65 years were statistically imprecise. Over the 20-year study period, the stroke mortality rate was stable for Alaska Natives but declined for US Whites. Conclusions. Stroke mortality is higher among Alaska Natives, especially women, than among US Whites. Over the past 20 years, there has not been a significant decline in stroke mortality among Alaska Natives. [ABSTRACT FROM AUTHOR]

-- To promote health services research in stroke rehabilitation, we gathered information about stroke rehabilitation structures, processes, and outcomes (SPO), using extant databases and the Donabedian theoretical model of health services evaluation. We found that, in the United States, over $3.6 billion was spent by third-party payers in 1992 on rehabilitation, including stroke. Total disability-related costs now amount to over $170 billion per year. However, there are few studies identifying cost-effective stroke rehabilitation practices. Existing studies indicate that the organizational structure of rehabilitation influences stroke outcomes, but it is less clear exactly what organizational practices constitute optimal stroke rehabilitation. Data about specific, beneficial rehabilitation processes are scanty for stroke. There are a number of valid and reliable outcome measures pertinent to stroke rehabilitation health services research. We conclude that health services research in stroke rehabilitation is sparse. To be more informative, rehabilitation health services research should be guided by the SPO model. [ABSTRACT FROM AUTHOR]

Determines whether sociodemographic characteristics influence patterns of care and patient outcomes. Analysis of the use of diagnostic tests and anti-Pneumonia carinii pneumonia (PCP) medications; In-hospital mortality rates for persons who were hospitalized with human immunodeficiency virus-related PCP. INSET: Patients and methods..

Examines explanations for the observed racial difference in use of diagnostic and therapeutic procedures in the evaluation and treatment of patients with cerebrovascular disease. Role of clinical differences in disease; Role of economic factors; Role of patient decision making.

Focuses on the patient and hospital characteristics associated with variations in Pneumocystis carinii Pneumonia (PCP) care and outcomes. Severity of illness at admission, type of health insurance, risk-group membership, hospital ownership and PCP experience as the most significant determinants of the intensity and timing of medical care and outcomes.

This study, based on a random sample of adults in a rural North Carolina county, demonstrates racial differences in rural adults' attitudes relating to adolescent sexual issues. Blacks were 50% more likely than Whites to indicate that public schools should provide general health care services, including pregnancy testing and treatment of sexually transmitted diseases, to teenagers; however, they were only half as likely as Whites to approve of sexual experimentation by adolescents. The local community's attitudes must be considered in the implementation of rural adolescent health programs, including acquired immunodeficiency syndrome education. [ABSTRACT FROM AUTHOR]

This paper describes age-adjusted mortality from malignant neoplasms for Native Americans in North Carolina for 1968-72 and 1978-12. Sex-specific standardized mortality ratios were calculated from death certificate data, using the cancer mortality experience of White North Carolinians to obtain the number of expected deaths. For most categories and specific sites of cancer mortality was at or below the expected level, but higher than expected mortality was found for genitourinary cancers in males (SMR = 1.62, 95% CI = 1.15, 2.21) for the 1978-82 period; within this category, there was a higher than expected level of mortality from prostate cancer (SMR = 2.00; 95% CI = 1.36, 2.83) and cancer of the penis and other male genital organs (SMR = 9.09; 95% CI = 1.10, 32.84). Female Native Americans had an elevated mortality from cervical cancer (SMR = 2.27, 9.95% CI = 1.09, 4.17) for the 1968-72 period only. [ABSTRACT FROM AUTHOR]

Objective: To ascertain whether use of mechanical ventilation on admission to the hospital is a proxy indicator of coma (i.e., very severe stroke) among acute stroke patients.Methods: A secondary analysis of data from a medical record review on a nationally representative sample of 2,824 Medicare patients, ages 65 years or older, who were hospitalized for stroke in 1982-1983 or 1985-1986 in 297 acute care hospitals in 30 areas within five geographically dispersed states.Results: Use of mechanical ventilation on the first day of hospitalization was significantly associated with level of consciousness on admission: < 2 percent of noncomatose patients versus 17.5 percent of comatose (p < .001). With a high specificity and high likelihood ratio for a positive test, use of mechanical ventilation on the first day of hospitalization ruled-in coma. It was also significantly associated with severity of illness, prognostic indicators (i.e., admission through the emergency room, admission to intensive care, and having a "do-not-resuscitate" order written during the hospital stay), and with in-hospital death. Adjusting for patient demographics, stroke type, comorbidity, and process of care, early initiation of mechanical ventilation remained significantly associated with both coma and in-hospital death.Conclusions: A stroke patient's use of mechanical ventilation on the first day of hospitalization is a valid proxy indicator of level of consciousness. [ABSTRACT FROM AUTHOR]

Comments on an article which examines factors contributing to practice variation in post-stroke rehabilitation. Importance of sources of variation in patterns of post-stroke rehabilitation; Use of rehabilitation services among stroke patients; Implications of the study for chronic disease management.

Compares the initial characteristics, in-house treatment and outcomes of stroke patients managed by neurologists versus non-neurologists in the United States. Use of a prospective, hospital-based, multisite cohort study design; Prognostic profiles; Likelihood of dying within one and six months of stroke onset.

Introduction: The CenteringPregnancy (CP) program—proven to reduce preterm births—was modified to achieve more optimal gestational weight gain (GWG) by an intentional incorporation of nutrition education. We compared the effect of the modified CP program versus individual prenatal care (IPNC) on GWG. Methods: This observational study used linked birth certificate data and hospital discharge records of women who received prenatal care (PNC) in South Carolina Midlands' obstetric clinics between 2015 and 2019. Linear and multinomial logistic regressions were used to compare participants in CP (n = 568) versus IPNC on weight gain, measured by total GWG (delivery weight minus prepregnancy weight), weekly rate of weight gain, and meeting the Institute of Medicine's recommendations (inadequate, adequate, and excessive GWG). Nonrandom assignment to program was controlled by propensity scoring. Results: CP participants differed from IPNC participants in race, nulliparous, education, and type of health insurance, but not in parity or month PNC began (p-Value <0.05). CP and IPNC participants had a similar GWG experience: total GWG (coef(β) = −0.054; 95% confidence interval [CI] −0.78 to 0.6), total weekly weight gain (coef(β) = −0.004; 95% CI −0.03 to 0.03), total GWG category (inadequate GWG: RRR = 0.85, 95% CI 0.64–1.21, and excessive GWG: relative risk ratio (RRR) = 0.92, 95% CI 0.71–1.20 vs. adequate), and weekly weight gain category (inadequate GWG: RRR = 0.73, 95% CI 0.53–1.01, and excessive GWG: RRR = 0.83, 95% CI 0.61–1.13 vs. adequate). Conclusion: The CP program with an enhanced nutritional knowledge component was not associated with achieving recommended GWG. Further investigation is needed to explain the lack of impact. [ABSTRACT FROM AUTHOR]

The article expresses the author's view on the clearing up of the National Institutes of Health (NIH) Grant Application Process in the U.S. The author explains that the one should keep in mind that each center has its own culture to the business of funding good science and that NIH has 3 general mechanisms for executing its mission to improve the nation's health. He also stresses several other elements that make up good grantsmanship.

Rheumatoid arthritis is highly individualized in terms of its flare ups and periods of remission. Each patient's unique experience requires a high level of personalization in terms of treatment making it necessary to understand what their goals for living are. This study explores patient perceptions on how the burden of RA shapes patients' goals for living and their preferences for symptom and side-effect management within the United States. Fifteen patients diagnosed with RA with varying lengths of diagnosis were interviewed. A thematic analysis was conducted to construct a conceptual framework. Emerging themes identified disease burdens as: (1) inability to perform essential needs, (2) negative feelings about disease, and (3) its influence on relationships. These burdens shaped desired goals for living which guided the symptom and side-effect priorities the patient wanted managed. Practitioners should consider patient goals and preferences in conjunction with disease progression when engaging in treatment decisions. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility and concurrent validity of a new, mail-administered, stroke-specific outcome measure, the Stroke Impact Scale (SIS). Design: Observational cohort study. Setting and patients: Stroke patients who had lived independently in the community prior to their stroke and who were candidates for post-stroke rehabilitation were recruited from nine, high-volume, Department of Veteran Affairs Medical Centers. Methods: Two hundred and six patients were mailed the SIS after a six-month post-stroke telephone interview. Telephone assessments included the Functional Independence Measure, the Lawton IADL and the SF-36. Results: The response rate for the mailed SIS was 63%, with 45% of the responses from proxies. The average rate of missing item level scores per patient was 1.3 (range 0-20) resulting in an average rate of 0.13 missing domain scores per patient (range 0-3). Nonresponders to the mailed SIS had more severe strokes with lower functional status at the time of the survey than responders. Proxies were more likely to complete the survey if the subjects were older, married, cognitively impaired and more functionally limited. The SIS did not exhibit a high rate of floor and ceiling effects, particularly in physical function domains, as did the FIM and the SF-36. [ABSTRACT FROM AUTHOR]

PURPOSE: This study (1) assesses the level of clinical work intensity medical oncologists and oncologic nurse practitioners experience providing care and (2) identifies patient, provider, and practice factors mediating intensity. PATIENTS AND METHODS: Seventeen medical oncologists (12 physicians and five nurse practitioners) from five national sites national reported on the level of work intensity associated with 339 patient visits. Data collection at each site occurred over a 2- to 6 week period; for each provider, five visits were randomly selected from each of 4 randomly selected clinic days, yielding 20 visits per provider. Intensity was measured by the NASA–Task Load Index. Patient and visit characteristics were abstracted from the medical record; provider characteristics were self-reported by questionnaire. RESULTS: Clinical work intensity increased monotonically with level of service and was greatest when the visit involved discussion of either chemotherapy or terminal prognosis. Provider characteristics (including age, sex, and years of experience) were unrelated to intensity. Dimensions of work intensity that correlated directly with level of service included mental, physical, and temporal demand; effort; frustration; and stress. Perceptions of performance and of satisfaction with the visit were unrelated to level of service. Visits related to chemotherapy had greater mental, physical, and temporal demand, and effort, but worse perception of performance. When the visit involved a discussion of a terminal prognosis, greater intensity was reflected in all dimensions; stress was also greater, whereas visit satisfaction was significantly lower. CONCLUSION: Clinical work intensity increases with level of service provided and is greater for visits involving discussion of either terminal prognosis or chemotherapy. [ABSTRACT FROM AUTHOR]

The article provides an overview of the topics presented in the journal, which offer perspectives on women's military roles and prior women veteran's health research, new insights into the current health and health care of women veterans, and innovative prescriptions for future research directions. Two articles examine the influences on, and barriers to Veterans Affairs health care use by women veterans. Other articles examine health issues and health care use of women veteran VA health care users.

Abstract: The contracting, prompting and reinforcing (CPR) aftercare intervention has improved treatment adherence and outcomes in a number of clinical trials. In multisite randomized clinical trial 92 graduates of two intensive substance use disorder programs who received CPR were compared to 91 who received standard treatment (STX). The CPR group evidenced increased frequency of aftercare group therapy attendance and near significant findings suggested that more CPR than STX participants completed 3months (76 vs. 64%), 6months (48 vs. 35%), and 9months (35 vs. 22%) of aftercare. However, the groups did not differ on the majority of attendance measures and had similar abstinence rates at the 3-month (67% CPR vs. 71% STX), 6-month (52% CPR vs. 51% STX), and 12-month (the primary outcome measure; 48% CPR vs. 49% STX) follow-up points. Exploratory analyses suggest that CPR might be more effective among participants not required to attend aftercare. The incremental capital and labor cost of CPR compared to STX was $98.25 per participant. [Copyright &y& Elsevier]

The increased incidence of ALS in military veterans of the first Persian Gulf War raised speculation that they may have a 'Persian Gulf' variant of ALS with atypical clinical features. Medical records of military veterans with ALS, previously identified in our epidemiological study, were evaluated for clinical features (age and site of onset, race, unexplained atypical findings) and ventilator-free survival. Comparisons between deployed versus non-deployed cohorts were made with deployment status based on designation by the Department of Defense Manpower Data Center (DMDC) or by self-report. Other than the young age of onset in both cohorts (40.8 years overall mean; 40.1 years for DMDC deployed, 41.2 years for DMDC non-deployed), review of the medical records failed to document any atypical features. After adjusting for bulbar onset, median survival from symptom onset in those ≥40 years of age was 35.5 months (2.96 years) compared to 64.7 months (5.39 years) in the group <40 years of age (hazard ratio (HR)=0.47, 95% CI 0.30-0.73, p=0.0006). After adjusting for age, median survival was 45.4 months (3.78 years) and 54.8 months (4.57 years) in bulbar- versus non-bulbar onset groups, respectively (HR=1.41, 95% CI 0.83-2.39, p=0.20). After adjusting for age and site of onset, deployed veterans had significantly shorter survival than non-deployed (40.2 vs. 57.0 months, HR=0.62, 95% CI 0.40-0.96, p=0.03) using DMDC data. In conclusion, although veterans developing ALS after deployment to the Persian Gulf in 1990-1991 exhibited otherwise typical clinical features, they experienced shorter ventilator-free survival than non-deployed veterans. [ABSTRACT FROM AUTHOR]

Epidemiologists have utilized several health care systems with large numbers of enrollees and centralized databases to achieve their research aims. Although containing many of the features that have made certain health care systems valuable to the conduct of epidemiologic research, the US Department of Veterans Affairs (VA) medical care system has not been well utilized by epidemiologists. This article will describe existing and planned features of this health care system that should be of interest to epidemiologists, including centralized databases that capture hospital discharge and outpatient clinic diagnostic data, a planned enrollment file that would contain all persons eligible for VA medical care, and the size and national dispersion of VA medical care facilities. Also, VA leadership has demonstrated an interest in the promotion of epidemiologic research by initiating several new programs, including the creation of three Epidemiologic Research and Information Centers (ERICs) to foster VA epidemiologic research, and announcing a program to support investigator-initiated epidemiologic research projects with VA funding. Epidemiologists with interests in medical problems that afflict veterans should consider partnerships with VA investigators to achieve their research aims. Am J Epidemiol 2000; 151: 307–14. [ABSTRACT FROM PUBLISHER]

Abstract: Background: Veterans of the 1991 Gulf War have an increased risk of amyotrophic lateral sclerosis (ALS), but the etiology is unknown. Objectives: This study sought to identify geographic areas with elevated risk for the later development of ALS among military personnel who served in the first Gulf War. Methods: A unified geographic information system (GIS) was constructed to allow analysis of secondary data on troop movements in the 1991 Gulf War theatre in the Persian Gulf region including Iraq, northern Saudi Arabia, and Kuwait. We fit Bayesian Poisson regression models to adjust for potential risk factors, including one relatively discrete environmental exposure, and to identify areas associated with elevated risk of ALS. Results: We found that service in particular locations of the Gulf was associated with an elevated risk for later developing ALS, both before and after adjustment for branch of service and potential of exposure to chemical warfare agents in and around Khamisiyah, Iraq. Conclusions: Specific geographic locations of troop units within the 1991 Gulf War theatre are associated with an increased risk for the subsequent development of ALS among members of those units. The identified spatial locations represent the logical starting points in the search for potential etiologic factors of ALS among Gulf War veterans. Of note, for locations where the relative odds of subsequently developing ALS are among the highest, specific risk factors, whether environmental or occupationally related, have not been identified. The results of spatial models can be used to subsequently look for risk factors that follow the spatial pattern of elevated risk. [Copyright &y& Elsevier]

Abstract: We examine current understanding of the minority disadvantage in the clinical management of epilepsy. We performed an online literature search using several keywords (race, ethnicity, epilepsy, treatment, and quality of life) and identified additional literature through cross-referencing/manual search. The search produced 58 items published between 1977 and 2005. Of 49 original research studies, 38 were quantitative, 7 were qualitative, and 4 used mixed methods. Three or more articles were published in Epilepsia, Epilepsy &Behavior, Epilepsy Research, Neurology, and Seizure. Research concerning racial/ethnic differences in epilepsy treatment is scarce and limited by methodology, but suggests underutilization of state-of-the-art therapies by minorities. Racial/ethnic minorities also appear to have limited knowledge about epilepsy and its treatment, experience barriers to care, lack social support, and seek alternative therapies for epilepsy. We propose a framework to identify the array of disparities, points of intervention, and interventions. [Copyright &y& Elsevier]

OBJECTIVES: To determine fracture risk in U.S. stroke patients and identify patient characteristics that predict highest fracture risk in two complementary cohorts. DESIGN: Secondary analyses of two prospective cohorts. SETTING: Veterans Affairs (VA) Medical Centers. PARTICIPANTS: The VA Acute Stroke (VASt) cohort includes 1,073 veterans admitted to nine VA hospitals for stroke between April 1995 and March 1997. The Integrated Stroke Outcomes Database (ISOD) includes 6,578 veterans who received inpatient rehabilitation for stroke at 121 VA facilities during fiscal years 2001 and 2002. MEASUREMENTS: Fractures detected using International Classification of Diseases, 9th Revision, codes in the VA computerized patient record system; baseline patient characteristics and stroke features; Functional Independence Measures scores in ISOD. RESULTS: Estimated 2-year fracture rates after stroke in the VASt and ISOD cohorts were 6.1% and 4.7%, respectively. Longer hospitalizations for stroke ( P=.06) and new motor or sensory impairment ( P=.09) showed trends toward greater risk in the VASt cohort. Female sex ( P <.001), cognitive impairment ( P=.01), and nonblack race ( P=.04) were associated with higher fracture risk in the ISOD. Intermediate functional impairment conferred higher fracture risk than mild or severe functional impairment. CONCLUSION: Veterans who suffer a stroke are at high risk of subsequent fracture, which can lead to further disability. Women, nonblacks, and those with intermediate functional impairment were at particularly high risk of fracture. Future study should investigate therapies to decrease fracture risk in stroke patients. [ABSTRACT FROM AUTHOR]

Abstract--The purpose of this study was to: 1) examine the variation in organizational structure within rehabilitation bedservice units (RBU) in the Veterans Health Administration (VHA), and 2) evaluate the effects of RBU and parent hospital structure on stroke rehabilitation outcomes. Two VHA-wide surveys of acute and rehabilitation services for stroke were linked with 2 y of VHA rehabilitation outcomes for stroke patients. A random effects mixed model was used to adjust for patient level covariates, control for unique site effects, and test for facility level structural effects. After adjusting for patient covariates, four structural variables were associated with length of stay or patient functional gain. These results indicate that rehabilitation structure is important to rehabilitation outcome. The individual variables identified in this study, namely, diverse multidisciplinary staff, expert physician leadership, staff participation in team care, and richer rehabilitation equipment resources, may represent the distinct aspects of a successful, comprehensive rehabilitation unit. [ABSTRACT FROM AUTHOR]

Gulf War illness (GWI) is characterized by the persistence of inflammatory bowel disease, chronic fatigue, neuroinflammation, headache, cognitive impairment, and other medically unexplained conditions. Results using a murine model show that enteric viral populations especially bacteriophages were altered in GWI. The increased viral richness and alpha diversity correlated positively with gut bacterial dysbiosis and proinflammatory cytokines. Altered virome signature in GWI mice also had a concomitant weakening of intestinal epithelial tight junctions with a significant increase in Claudin-2 protein expression and decrease in ZO1 and Occludin mRNA expression. The altered virome signature in GWI, decreased tight junction protein level was followed by the presence an activation of innate immune responses such as increased Toll-like receptor (TLR) signaling pathways. The altered virome diversity had a positive correlation with serum IL-6, IL-1β, and IFN-γ, intestinal inflammation (IFN-γ), and decreased Brain-Derived Neurotrophic Factor (BDNF), a neurogenesis marker. The co-exposure of Gulf War chemical and antibiotic (for gut sterility) or Gulf War chemical and Ribavirin, an antiviral compound to suppress virus alteration in the gut showed significant improvement in epithelial tight junction protein, decreased intestinal-, systemic-, and neuroinflammation. These results showed that the observed enteric viral dysbiosis could activate enteric viral particle-induced innate immune response in GWI and could be a novel therapeutic target in GWI. [ABSTRACT FROM AUTHOR]

The article presents author's views on the quality of health care in the context of the Latino population in the U.S. The author says that there is a need to test ways to not only implement quality of care, but to also determine how to sustain these efforts. The author says that quality patient-centered care necessitates that clinicians assess patient needs, expectations and environment. The author says that one way to transform primary care is the use of the medical home model.