BACKGROUND & AIMS: BACKGROUND:Somatizing patients have maladaptive and increased rates of medical care utilization. If there were a way of routinely identifying such patients, one that did not require intensive, case-by-case review, they could be targeted for specific interventions to improve their use of medical care. OBJECTIVE:We sought to identify patterns of medical care utilization that would distinguish somatizing and nonsomatizing medical outpatients with acceptable sensitivity and specificity. DESIGN:Subjects completed questionnaires assessing somatization and sociodemographic characteristics. Their medical care utilization was obtained for the 12 months preceding the index visit. We then used multivariable logistic regression and recursive partitioning to identify patients with a provisional diagnosis of somatoform disorder. These exploratory models used various patterns of medical care utilization and sociodemographic characteristics as the independent variables. SUBJECTS:We studied consecutive adults attending 2 primary care practices on randomly chosen days. MEASURES:The provisional diagnosis of a somatoform disorder was assessed with a 15-item self-report questionnaire. The number of primary care visits, specialty visits, mental health visits, emergency visits, and inpatient and outpatient costs were obtained for the 12 months preceding the index visit from our hospital's automated medical records, which also provided a rating of aggregate medical morbidity. Self-reported utilization outside our hospital system was obtained from a subsample of patients. RESULTS:Complete data were obtained on 1440 patients. Somatizing patients had more specialty care than primary care visits, higher outpatient than inpatient costs, and more emergency visits than nonsomatizing patients. A regression model containing 7 measures of utilization and 4 sociodemographic characteristics distinguished somatizing and nonsomatizing patients with a c-statistic = 0.73. Recursive partitioning identified 10 terminal nodes with a very high specificity (99%) but a very low sensitivity (15%). CONCLUSIONS:We identified 7 discrete patterns of medical care utilization that distinguished somatizing and nonsomatizing patients. However, they did so with only modest specificity and sensitivity. This algorithm might be used effectively as the first step in a 2-step screening procedure whose second step would entail more intensive screening or individual, case-by-case review to identify somatizing patients in primary care practice.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:This study reviewed whether participants who were given a continence education package, which included a Continence Educational Brochure (CEB), and who indicated that they were bothered by incontinence symptoms changed health-seeking behaviors about their incontinence problem because of being given the brochure. METHOD:This study used a descriptive and exploratory design. Participants were given the CEB and asked to read the information. They were also asked to complete a continence questionnaire and mail this back to the research team. Participants who indicated that they were bothered by a continence problem and consented to being interviewed were telephoned 2 to 3 months later. They were asked questions to determine their actions and progress in relation to managing their continence problem and whether the CEB had influenced their behavior. SETTING AND SUBJECT:A total of 631 participants (352 females, 55.8%; 279 males, 44.2%) from 4 rural and regional settings in Victoria, Australia, participated. Of this sample, 111 participants (78 females, 70.3%; 33 males, 29.7%) who reported that they were bothered by a continence problem were interviewed 3 months after being given the CEB. RESULTS:Two thirds of the total sample of participants (n=111) sought help for their continence problem. Approximately 70.3% (n=78) continued to have a continence problem. Of this group, 84.6% were still bothered by the continence problem and 65.4% had taken action to treat their incontinence. Forty-nine participants (44.1%) indicated that they had discussed the issue of bladder or bowel problems with someone directly because of this study or the information contained in the brochure. More than 94% of participants who remembered the CEB indicated that they believed the brochure would be helpful if given to other people. CONCLUSIONS:These findings suggest that the CEB prompted individuals to discuss their continence problem and in fewer cases to seek professional help. Given these findings, distribution of a continence education package is advocated as a continence health promotion strategy.

背景与目标：

BACKGROUND & AIMS: :This study aimed to clarify the effectiveness of post-operative oral care, including tooth brushing, denture cleaning and tongue cleaning, after digestive tract surgery. Subjects included 30 elderly patients aged 60-98 years (74.9 +/- 7.8 years) who underwent digestive tract surgery. Subjects were randomly divided into an intervention group and a control group. In the intervention group, the following oral care was provided daily over a 5-min period in the morning starting at baseline (day of surgery) and continued for 5 days: gargling with povidone iodine, tooth brushing, denture cleaning using a special brush and tongue cleaning using a tongue brush. In the control group, the subjects only gargled with povidone iodine. We compared the following variables between the two groups at baseline and 5 days later: the sensation of dry mouth, intra-oral gas concentration, pulmonary sounds, body temperature and bacterial flora. The number of patients with abnormal pulmonary sounds (dry or moist rales) increased from 1 to 2 in the intervention group and from 0 to 4 in the control group (P < 0.05). The average number of bacterial species per subject for the control group was 3.64 +/- 1.34 pre-operatively and 3.50 +/- 1.74 post-operatively, whereas that for the intervention group was 3.08 +/- 0.95 pre-operatively and 2.62 +/- 0.65 post-operatively. In the intervention group, there was a significant decrease in the number of bacterial species (P < 0.05). These findings indicate that post-operative oral care in elderly patients undergoing digestive tract surgery lowers the number of bacterial species found in the oral cavity. This effect, in turn, might improve respiratory function.

背景与目标： : 本研究旨在阐明消化道手术后口腔护理的有效性，包括刷牙，义齿清洁和舌头清洁。受试者包括30名60-98岁 (74.9 +/- 7.8岁) 接受消化道手术的老年患者。受试者随机分为干预组和对照组。在干预组中，从基线 (手术当天) 开始，在早晨的5分钟内每天提供以下口腔护理，并持续5天: 用聚维酮碘漱口，刷牙，使用特殊刷子清洁义齿和使用舌头刷子清洁舌头。在对照组中，受试者仅用聚维酮碘漱液。我们在基线和5天后比较了两组之间的以下变量: 口干感，口内气体浓度，肺音，体温和细菌菌群。肺音异常 (干或湿啰音) 的患者数量在干预组从1增加到2，在对照组从0增加到4 (P <0.05)。对照组每个受试者的平均细菌种类数术前为3.64 +/- 1.34，术后为3.50 +/- 1.74，而干预组的平均细菌种类数术前为3.08 +/- 0.95，术后为2.62 +/- 0.65。干预组细菌种类显著减少 (P <0.05)。这些发现表明，接受消化道手术的老年患者的术后口腔护理降低了口腔中发现的细菌种类的数量。反过来，这种作用可能会改善呼吸功能。

BACKGROUND & AIMS: :The oxidative deamination of serotonin (5-HT) to 5-hydroxyindoleacetic acid (5-HIAA) by rat primary astrocyte cultures was investigated in intact cells using HPLC. All detectable 5-HIAA accumulated in the extracellular medium, and its rate of production was proportional to the 5-HT concentration over the tested range of 5 x 10(-7) to 10(-4) M. At 5 x 10(-7) M 5-HT, intracellular 5-HT was detectable only in astrocytes treated with monoamine oxidase (MAO) inhibitors. These findings are consistent with the idea that 5-HT taken up into astrocytes is not stored for re-release, but is rapidly metabolized to 5-HIAA, which is then extruded from the cell. At 5 x 10(-7) M 5-HT, 5-HIAA formation in intact cells was blocked 63% by the selective high-affinity 5-HT uptake inhibitor fluoxetine. 5-HT oxidation to 5-HIAA is carried out principally by MAO-A, because clorgyline was more effective at inhibiting the production of 5-HIAA than was pargyline. Radioenzymatic determinations of MAO activity in cell homogenates supported these findings, because under these conditions clorgyline was 1,000-fold more effective than pargyline at inhibiting MAO activity toward 14C-labelled 5-HT. However, the relatively selective MAO-B substrate beta-phenylethylamine (PEA) was also oxidized, showing that these cultures also contained MAO-B activity; the Km values for MAO-A oxidation of 5-HT and MAO-B oxidation of PEA were 135 and 45 microM, and Vmax values were 88 and 91 nmol/mg of total cell protein/h, respectively. Higher concentrations of PEA (greater than 20 microM) were oxidized by both MAO-A and MAO-B isozymes.(ABSTRACT TRUNCATED AT 250 WORDS)

背景与目标： : 使用HPLC在完整细胞中研究了大鼠原代星形胶质细胞培养物将5-羟色胺 (5-HT) 氧化脱氨为5-羟基吲哚乙酸 (5-HIAA)。所有可检测到的5-HIAA都积累在细胞外培养基中，在5x10(-7) 至10(-4) M的测试范围内，其产生速率与5-HT浓度成正比。在5x10(-7) M 5-HT时，仅在用单胺氧化酶 (MAO) 抑制剂处理的星形胶质细胞中可检测到细胞内5-HT。这些发现与以下观点一致: 吸收到星形胶质细胞中的5-HT不会储存以重新释放，而是会迅速代谢为5-HIAA，然后从细胞中挤出。在5 × 10(-7) m5-ht时，选择性高亲和力5-HT摄取抑制剂氟西汀63% 阻断完整细胞中的5-HIAA形成。5-HT氧化为5-HIAA主要由MAO-A进行，因为clorgyline比pargyline更有效地抑制5-HIAA的产生。细胞匀浆中MAO活性的放射酶测定支持了这些发现，因为在这些条件下，clorgyline在抑制针对14c标记的5-HT的MAO活性方面比pargyline有效1,000倍。然而，相对选择性的MAO-B底物 β-苯乙胺 (PEA) 也被氧化，表明这些培养物也含有MAO-B活性; 5-HT的MAO-A氧化和PEA的MAO-B氧化的Km值分别为135和45微米，vmax值分别为88和91 nmol/mg的总细胞蛋白/h。较高浓度的豌豆 (大于20微米) 被MAO-A和MAO-B同工酶氧化。(摘要截短于250字)

BACKGROUND & AIMS: An important step in the processing of visual patterns is the segmentation of the retinal image. Neuronal responses evoked by the contours of individual objects need to be identified and associated for further joint processing. These grouping operations are based on a number of Gestalt criteria. Here we report that connections in the visual cortex of the cat exhibit a highly significant anisotropy, preferentially linking neurons activated by contours that have similar orientation and are aligned colinearly. These anatomical data suggest a close relation between the perceptual grouping criterion of colinearity and the topology of tangential intracortical connections. We propose that tangential intracortical connections support perceptual grouping by modulating the saliency of distributed cortical responses in a context-dependent way. The present data are compatible with the hypothesis that the criteria for this grouping operation are determined by the architecture of the tangential connections.

背景与目标： 视觉图案处理中的一个重要步骤是视网膜图像的分割。需要识别并关联单个物体轮廓引起的神经元反应，以进行进一步的关节处理。这些分组操作基于许多格式塔标准。在这里，我们报告说，猫的视觉皮层中的连接表现出高度显着的各向异性，优先连接由具有相似方向且对齐的轮廓激活的神经元。这些解剖学数据表明共线性的感知分组标准与切向皮质内连接的拓扑之间存在密切关系。我们建议，切向皮质内连接通过以上下文相关的方式调节分布式皮质反应的显着性来支持感知分组。当前数据与以下假设兼容: 该分组操作的标准由切向连接的体系结构确定。

BACKGROUND & AIMS: :In Escherichia coli at least five enzyme activities required for the beta-oxidation of fatty acids are associated with a multienzyme complex composed of two subunits in alpha 2 beta 2 conformation (A. Pramanik et al., J. Bacteriol. 137:469-473, 1979). In the present work, the DNA sequence of the genes encoding these two subunits, fadB and fadA, has been determined. The direction of transcription was from fadB to fadA rather than from fadA to fadB, as suggested previously (S. K. Spratt et al., J. Bacteriol. 158:535-542, 1984). Only 10 nucleotides separated the coding sequences for the two peptides, confirming the suggestion that these genes form an operon. The peptides encoded by fadB and fadA were 729 amino acids and 387 amino acids, respectively, in length. The larger and smaller peptides had predicted molecular masses of 79,678 and 40,876 Da, respectively. Recently, the sequence of the fadA gene was published in a separate report (Yang et al., J. Biol. Chem. 265:10424-10429, 1990). In this work, most of the DNA sequence for fadA was confirmed, and 10 errors were corrected. Three of these nucleotide changes resulted in five amino acid residue changes predicted in the carboxy terminus of the fadA-encoded peptide. By comparison to other peptide sequences, the alpha subunit encoded within fadB had 31% perfect identity with the rat peroxisomal enoyl-coenzyme A:hydratase-3-hydroxyacyl-coenzyme A dehydrogenase trifunctional enzyme over the entire length of the two peptides. In agreement with the work of Yang et al., the beta subunit encoded within fadA had 35 to 45% perfect identity with five thiolase genes from different eucaryotic sources over the entire length of the peptide.

背景与目标： 在大肠杆菌中，脂肪酸的 β-氧化所需的至少五种酶活性与由 α2β2构象中的两个亚基组成的多酶复合物相关 (a.Pramanik等人，J. Bacteriol. 137:469-473，1979)。在本工作中，已经确定了编码这两个亚基fadB和fadA的基因的DNA序列。转录的方向是从fadB到fadA，而不是从fadA到fadB，如前所述 (S. K. Spratt等人，J. Bacteriol. 158:535-542，1984)。只有10个核苷酸分离了两个肽的编码序列，证实了这些基因形成操纵子的暗示。fadB和fadA编码的肽长度分别为729个氨基酸和387个氨基酸。较大和较小的肽分别预测79,678和40,876 Da的分子量。最近，fadA基因的序列发表在单独的报告中 (Yang等人，J. Biol. Chem. 265:10424-10429，1990)。在这项工作中，fadA的大部分DNA序列得到了确认，并纠正了10个错误。这些核苷酸变化中的三个导致fadA编码肽的羧基末端预测的五个氨基酸残基变化。与其他肽序列相比，fadB内编码的 α 亚基与大鼠过氧化物酶体烯酰辅酶a具有31% 完美的同一性: 在两个肽的整个长度上hydratase-3-hydroxyacyl-coenzyme脱氢酶三官能酶。与Yang等人的工作一致，在fadA内编码的 β 亚基在肽的整个长度上与来自不同真核来源的五个硫解酶基因具有35至45% 完美的同一性。

BACKGROUND & AIMS: BACKGROUND:Despite increasing numbers of morbidly obese patients admitted to acute care facilities for surgery or treatment of nonsurgical conditions, there is little evidence of the problems nurses face in providing care to these patients. Anecdotal evidence suggests that the care of these patients is more demanding than the care of nonobese patients. The objective of this study was to describe nurses' perceptions of the challenges that they face when caring for morbidly obese patients. METHODS:Focus groups of nurses from a tertiary care facility were convened. A trained facilitator posed questions to the group concerning various aspects of care for morbidly obese patients. Comments of respondents were categorized using NVIVO software. RESULTS:Nurses reported concerns about the increased staffing needs required for care of these patients and the particular challenges of the physical care. Concerns also included the availability, placement, and use of specialized equipment. Room size and the absence of some equipment were also problematic. Finally, nurses perceived safety issues, both for themselves and their patients. CONCLUSIONS:Morbidly obese patients in the acute care setting require specialized nursing care in terms of techniques, levels of staffing required, and the use of specialized equipment.

背景与目标：

BACKGROUND & AIMS: :Descriptions of primary HIV-1 infection have so far been based on Caucasians living in industrialized nations. Due to studies of leptospirosis in the predominantly black population of Barbados, serum was available for patients admitted with acute febrile illnesses to the Queen Elizabeth Hospital (QEH). By searching the medical records of 510 adult patients with known HIV-1 infection we identified 10 patients who had stored serum from an admission for an acute febrile illness that predated or coincided with their first HIV-1-positive test. Serological testing confirmed primary HIV-1 infection in 9 and was suggestive in the 10th patient. The clinical features of these 10 patients were in keeping with previous descriptions of primary HIV-1 infection but differed from leptospirosis cases seen at the QEH. One patient died during his seroconversion illness and another died 3 months after seroconversion. The findings suggest that severe primary HIV-1 infection could be a relatively uncommon occurrence, that the condition may be misdiagnosed, and that cases may not occur until the AIDS epidemic is established. :A retrospective review was conducted of the medical records of 510 HIV-1-positive adult patients who had attended the Queen Elizabeth Hospital (QEH) to determine whether any had been admitted for an illness compatible with a diagnosis of primary HIV-1 infection. A serum bank, created from patients who had been admitted with acute febrile illnesses and investigated for leptospirosis, provided serological evidence for primary HIV-1 infection in 10 patients. Serological testing of the serum samples confirmed primary HIV-1 infection in nine patients and was suggestive in the tenth. The clinical features of the 10 patients fit the earlier descriptions of primary HIV-1 infection, but differed from the leptospirosis cases seen at the QEH. One patient died during his seroconversion illness and another died 3 months after seroconversion. These findings suggest that severe primary HIV-1 infection could be a relatively uncommon occurrence, that the condition may be misdiagnosed, and that cases may not occur until the AIDS epidemic is established.

背景与目标：

BACKGROUND & AIMS: :Priority setting of health interventions is often ad-hoc and resources are not used to an optimal extent. Underlying problem is that multiple criteria play a role and decisions are complex. Interventions may be chosen to maximize general population health, to reduce health inequalities of disadvantaged or vulnerable groups, ad/or to respond to life-threatening situations, all with respect to practical and budgetary constraints. This is the type of problem that policy makers are typically bad at solving rationally, unaided. They tend to use heuristic or intuitive approaches to simplify complexity, and in the process, important information is ignored. Next, policy makers may select interventions for only political motives. This indicates the need for rational and transparent approaches to priority setting. Over the past decades, a number of approaches have been developed, including evidence-based medicine, burden of disease analyses, cost-effectiveness analyses, and equity analyses. However, these approaches concentrate on single criteria only, whereas in reality, policy makers need to make choices taking into account multiple criteria simultaneously. Moreover, they do not cover all criteria that are relevant to policy makers. Therefore, the development of a multi-criteria approach to priority setting is necessary, and this has indeed recently been identified as one of the most important issues in health system research. In other scientific disciplines, multi-criteria decision analysis is well developed, has gained widespread acceptance and is routinely used. This paper presents the main principles of multi-criteria decision analysis. There are only a very few applications to guide resource allocation decisions in health. We call for a shift away from present priority setting tools in health--that tend to focus on single criteria--towards transparent and systematic approaches that take into account all relevant criteria simultaneously.

背景与目标： : 卫生干预措施的优先级设定通常是临时性的，资源的使用没有达到最佳程度。潜在的问题是，多个标准发挥作用，决策很复杂。可以选择干预措施，以最大程度地提高总体人口健康水平，减少弱势或弱势群体的健康不平等，ad/或应对威胁生命的情况，所有这些都涉及实际和预算方面的限制。这是政策制定者通常不善于理性地、没有帮助地解决的问题。他们倾向于使用启发式或直观的方法来简化复杂性，在此过程中，重要的信息被忽略。接下来，政策制定者可能只出于政治动机选择干预措施。这表明需要合理和透明的方法来确定优先级。在过去的几十年中，已经开发了许多方法，包括循证医学，疾病负担分析，成本效益分析和公平性分析。但是，这些方法仅集中在单个标准上，而实际上，决策者需要同时考虑多个标准来做出选择。此外，它们并未涵盖与决策者相关的所有标准。因此，有必要开发一种多标准方法来确定优先级，并且最近确实已将其确定为卫生系统研究中最重要的问题之一。在其他科学学科中，多准则决策分析得到了很好的发展，得到了广泛的认可，并被常规使用。本文介绍了多准则决策分析的主要原理。只有很少的应用程序来指导健康中的资源分配决策。我们呼吁从目前的卫生优先事项设定工具 (往往侧重于单一标准) 转向透明和系统的方法，同时考虑到所有相关标准。

BACKGROUND & AIMS: PURPOSE:Making good consumer decisions requires having good information. This study compared long-term-care recommendations among various types of health professionals. DESIGN AND METHODS:We gave randomly varied scenarios to a convenience national sample of 211 professionals from varying disciplines and work locations. For each scenario, we asked the professional to recommend the appropriate forms of long-term care. RESULTS:Although the professional respondents used the full spectrum of options offered to them, some professionals tended to favor the sector they worked in. Advanced practice nurses recommended day care and homemaking more and adult foster care less. Gerontologists used skilled nursing-facility placement more actively and rehabilitation, homemaking, and home health care less actively. Geriatricians and primary care physicians both favored rehabilitation and skilled nursing-facility care and were both less enthusiastic about assisted living, homemaking, and informal care, but the geriatricians favored day care more than did the primary care physicians. Registered nurses were highly supportive of assisted living, adult foster care, homemaking, and home health care, and they opposed skilled nursing-facility care. Social workers were less likely than other participants to endorse rehabilitation and adult foster care. IMPLICATIONS:Because consumer preference should be a major factor in making long-term-care decisions, many consumers need information about what options may best fit their situation. In the absence of empirical data on which types of long-term care work best for whom, consumers have to rely on expert judgment-but that judgment varies. Clients should be aware that an expert's background (as defined by discipline and work situation) may affect his or her recommendations. Each discipline appears to have its own set of experiences and beliefs that may influence recommendations.

背景与目标：

BACKGROUND & AIMS: :In the last few decades, the importance of selenium in human health has been the subject of numerous studies. It is believed that the physiological effects of selenium occur mainly through the function of selenoproteins, which incorporate selenium in the form of one or more selenocysteine residues. Recent advances in understanding the complex regulation of selenoprotein synthesis and functional characterization of several members of the selenoprotein family have contributed to an improved comprehension of the role(s) of selenium in human health and the great diversity of physiological pathways influenced by this trace element.

背景与目标： : 在过去的几十年中，硒在人类健康中的重要性一直是众多研究的主题。据信，硒的生理作用主要通过硒蛋白的功能发生，硒蛋白以一个或多个硒代半胱氨酸残基的形式掺入硒。了解硒蛋白合成的复杂调控和硒蛋白家族几个成员的功能表征的最新进展有助于更好地理解硒在人类健康中的作用以及受该微量元素影响的生理途径的多样性。

BACKGROUND & AIMS: :A prospective collection of positive antimicrobial cultures was performed over 12 consecutive months in the medical intensive care unit of a cancer hospital. In all, 144 infections and 163 pathogens were documented during 87 of the 528 admissions. Lung, urinary, ENT (ear, nose and throat) infections and bacteraemia were the most frequently documented. Staphylococcus species, Streptococcus species, Escherichia coli, Klebsiella species and Pseudomonas species were the most common pathogens. Gram-positive strains were observed predominantly during monomicrobial bacteraemia (48.9%). Methicillin-resistant Staphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) were found in 58% and 92% of the isolated strains respectively. No particular outbreak was identified. A further prospective study will be necessary to evaluate the impact of the antibiotic use on the selection of resistant strains in our ICU.

背景与目标： : 在癌症医院的医疗重症监护病房中连续12个月进行了阳性抗菌培养的前瞻性收集。在528的87例入院期间，共记录了144例感染和163例病原体。肺，泌尿，耳鼻喉科 (耳，鼻和喉) 感染和菌血症是最常见的记录。最常见的病原体是葡萄球菌，链球菌，大肠杆菌，克雷伯菌和假单胞菌。革兰氏阳性菌株主要在单株菌血症期间观察到 (48.9%)。分离株的58% 和92% 中分别发现了耐甲氧西林金黄色葡萄球菌 (MRSA) 和表皮葡萄球菌 (MRSE)。没有发现特别的爆发。需要进行进一步的前瞻性研究，以评估抗生素使用对我们ICU中耐药菌株选择的影响。

BACKGROUND & AIMS: :The health issues of young adulthood have received relatively little attention compared with those of adolescence, although the critical issues in young adulthood parallel those of adolescence. Young adults often fare worse than adolescents on health indicators, with many measures of negative outcomes--including rates of injury, homicide, and substance use--peaking during the young adult years. The contextual factors shaping health status and access to care in young adulthood differ significantly from the context of adolescence. This article synthesizes national data to present a health profile of young adults, reviewing social indicators that describe the context of young adulthood and presenting measures of health status. We examine mortality, morbidity, risky behaviors, and health care access and utilization, identifying the most significant gender and racial/ethnic disparities. The article also identifies limitations of existing data and offers suggestions for future research and health monitoring in this area. We conclude with a discussion of current efforts to address the health and well-being of young adults and argue for creating a national health agenda for young adults that includes research, programs and policies to address health issues during this period of the lifespan.

背景与目标： : 与青春期相比，成年后的健康问题受到的关注相对较少，尽管成年后的关键问题与青春期的问题平行。在健康指标上，年轻人的表现通常比青少年差，许多负面结果指标 (包括受伤，凶杀和吸毒的发生率) 在年轻人时期达到顶峰。影响成年后健康状况和获得护理的背景因素与青春期的背景有很大不同。本文综合了国家数据，以提供年轻人的健康状况，回顾了描述年轻人成年背景的社会指标，并提出了健康状况的衡量标准。我们检查了死亡率，发病率，危险行为以及医疗保健的获取和利用情况，以确定最重要的性别和种族/种族差异。本文还指出了现有数据的局限性，并为该领域的未来研究和健康监测提供了建议。最后，我们讨论了当前为解决年轻人的健康和福祉所做的努力，并主张为年轻人制定国家健康议程，其中包括研究，计划和政策，以解决这一生命周期中的健康问题。

BACKGROUND & AIMS: OBJECTIVE:To investigate the effects of local labor market conditions and the availability of employer-sponsored health insurance on exits from the Medicaid program. DATA SOURCE:Data for this project come from a unique administrative database containing a 2 percent sample of all cases on California's Medicaid program in 1987 and a 2 percent sample of all new cases starting each year between 1987 and 1995. STUDY DESIGN:The results are estimated using a discrete duration model where the monthly exit probability is a function of demographic characteristics, local labor market variables, the probability of having employer-sponsored insurance, and fixed year and county effects. PRINCIPAL FINDINGS:Improvements in labor market opportunities (i.e., employment growth, wage growth, and increases in the availability of employer-sponsored health insurance) promote exits off the Medicaid program. A 2.5 percentage point increase in the availability of employer-sponsored insurance leads to a 6 percent increase in the probability that a completed spell lasts no more than 2 years. It would take a 2 percentage point decrease in unemployment rates or a 10 percent increase in average quarterly earnings to yield an equivalent increase in the likelihood of exiting Medicaid within 2 years. These effects are robust to the inclusion of county-level fixed effects and time effects. CONCLUSIONS:Medicaid expenditures and caseloads are sensitive to local economic fluctuations and secular trends in the availability of health insurance. Continued decreases in employer-based health insurance coverage will greatly increase the demand for public insurance coverage and the financial pressures on state governments.

背景与目标：

BACKGROUND & AIMS: :Spiritual issues arise frequently in the care of dying patients, yet health care professionals may not recognize them, may not believe they have a duty to address these issues, and may not understand how best to respond to their patients' spiritual needs. The case of a patient with a strong religious belief in a miraculous cure of metastatic pancreatic cancer is used to explore how better understanding of this belief and more explicitly spiritual conversation with the patient by his treating team might have provided opportunities for an improved plan of care. This article distinguishes spirituality from religion; describes the salient spiritual needs of patients at the end of life as encompassing questions of meaning, value, and relationship; delineates the role physicians ought to play in ascertaining and responding to those needs; and discusses the particular issue of miracles, arguing that expectations of miraculous cure ought not preclude referral to hospice care.

背景与目标： : 精神问题经常出现在临终病人的护理中，然而医疗保健专业人员可能不认识他们，可能不相信他们有责任解决这些问题，也可能不了解如何最好地应对患者的精神需求。对转移性胰腺癌的奇迹般治愈具有强烈宗教信仰的患者的案例被用来探索如何更好地理解这种信仰以及他的治疗团队与患者进行更明确的精神对话可能会为改善护理计划提供机会。本文将灵性与宗教区分开来; 描述了生命末期患者的显着精神需求，包括意义，价值和关系问题; 描述了医生在确定和应对这些需求时应扮演的角色; 并讨论了奇迹的特殊问题，认为对奇迹般的治愈的期望不应排除转诊至临终关怀。