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There are conflicting reports on the efficacy of exercise in chronic venous insufficiency (CVI). Exercise in water or aquatic activity (AA) can have additional advantages. We sought to evaluate the clinical effects of AA in CVI in a randomized prospective open label fashion.A total of 201 patients with advanced CVI were randomized to receive AA vs no such treatment. In the Aquatic Group (AG), 91 patients reached the 24-month follow-up point, and in the Control Group (CG), 90 patients did. The primary efficacy end point was a predefined reduction of ≥4 points in the modified Venous Clinical Severity Score (VCSS) at 3 months. Instruments of venous disease severity and quality of life were compared at baseline, 3 months, and 24 months between and within the two groups. These included the modified VCSS, Villalta score, leg and thigh circumference, the Physical Health Component of the 36-Item Short Form Health Survey, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life/Symptom scores. Aquatic activity consisted of a minimum of 15 minutes of walking in a swimming pool at 1 m/s, 3 times/wk for 3 months.The primary end point of 4-point reduction in the modified VCSS at 3 months was reached in 28% of AG and 3% of CG (odds ratio = 12.08; 95% confidence interval: 3.51, 41.59; P .001). Comparison of changes in secondary end points from baseline to 24 months between AG and CG demonstrated the following: modified VCSS -4.08 ± 2.08 vs -1.15 ± 1.26, Villalta score -4.00 ± 2.68 vs -1.01 ± 1.34, thigh circumference -3.40 ± 1.78 cm vs -1.40 ± 2.55 cm, leg circumference -1.27 ± 1.34 cm vs -0.49 ± 1.21 cm, Physical Health Component of the 36-Item Short Form Health Survey 3.82 ± 2.36 vs 1.16 ± 1.18, Venous Insufficiency Epidemiological and Economic Study Quality of Life 3.35 ± 1.67 vs 1.30 ± 1.43, and Venous Insufficiency Epidemiological and Economic Study Symptom 3.53 ± 1.71 vs 1.23 ± 1.26 (P .001 for all comparisons; ± denotes mean ± standard deviation).The addition of AA to the treatment of patients with advanced CVI is safe and effective, leading to a significant improvement in clinical status and quality of life. These beneficial changes occur rapidly within 3 months of initiation of AA and are continued at a slower rate of improvement from 3 months to 2 years.

Context: Concussions are shown to hinder multiple health dimensions, including health-related quality of life (HRQOL), suggesting a need for a whole-person approach to assessment and treatment. Patient-reported outcome measures are one method to gather the patient’s perspective regarding their HRQOL. Objective: To evaluate perceived HRQOL using the Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale in patients throughout concussion recovery. Design: Prospective cohort, descriptive survey. Setting: There were 9 high school athletic training facilities. Participants: A total of 70 patients with diagnosed concussions (51 males, 7 females, 12 unreported; age = 15.7 [0.9] y, height = 174.6 [8.4] cm, mass = 72.8 [14.8] kg, grade = 10.0 [0.9] level). Interventions: Patient-Reported Outcomes Measurement Information System Pediatric-25 was administered at 3 days, 10 days postconcussion, and return to play (RTP). Main Outcome Measures: Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale T scores and self-reported concussion history (yes/no). Results: A total of 70 patients completed the study. For the Pediatric-25 subscales, the severity of problems associated with Physical Function Mobility, Anxiety, Depression, Fatigue, and Pain Interference were highest 3 days postconcussion, decreasing at 10 days and RTP (all p p p > .05). Ceiling and floor effects were present in all subscales throughout each timepoint, except for Physical Function Mobility (14.7%), and pain interference (11.8%) at day 3 postinjury. Conclusions: Patients who had suffered a concussion improved from day 3 through RTP on multiple health domains as demonstrated through the Pediatric-25 subscales. These findings highlight the need for health care professionals to serially monitor HRQOL and social factors that may affect the patient postconcussion as part of a multifactorial assessment. Ceiling effects in high functioning adolescent athletes were present; thus, efforts should be made to identify appropriate scales for use in managing recovery in athletic populations.

Context Federally funded Community, Migrant, and Homeless Health Centers provide health services to the most vulnerable communities in the United States. However, little is known about their capabilities and processes for providing vaccinations to adults. Program We conducted the first national survey of health centers assessing their inventory, workflow, capacity for, and barriers to provision of routinely recommended adult vaccines. In addition, we asked health center leaders' perceptions regarding best practices and policy recommendations for adult vaccinations. Implementation A survey was developed on the basis of domains elicited from advisory panels and focus groups and was sent electronically to leaders of 762 health centers throughout the United States and its territories; data were collected and analyzed in 2018. Evaluation A total of 319 survey responses (42%) were obtained. Health centers reported stocking most routinely recommended vaccines for adults; zoster vaccines were not stocked regularly due to supply and storage issues. Respondents most commonly reported adequate reimbursement for vaccination services from private insurance and Medicaid. Most vaccinations were provided during primary care encounters; less than half of health centers reported providing vaccines during specialist visits. Vaccines administered at the health center were most commonly documented in an open field of the electronic health record (96%) or in an immunization information system (72%). Recommendations for best practices related to better documentation of vaccinations and communication with immunization information systems were provided. Discussion Health centers provide most adult vaccines to their patients despite financial and technological barriers to optimal provisioning. Further studies at point of care could help identify mechanisms for system improvements.

The purpose of this study was to evaluate midpalatal bone density (BD) by using cone-beam computed tomography (CBCT) according to gender, age, and vertical and horizontal skeletal patterns. CBCT images from 126 subjects (64 females and 62 males) were reoriented and analyzed in order to attain BD values at the midpalatal suture. Four age groups were used for classification (adolescence, 10 ≤ early < 14 years, 14 ≤ middle ≤ 17 years, and 17 < late ≤ 21 years; adult > 21 years). Vertical skeletal pattern categories were differentiated by the Frankfort horizontal line to mandibular plane angle (hypodivergent < 22°, 22° ≤ normovergent ≤ 28°, and 28° < hyperdivergent). Horizontal skeletal pattern differentiation was defined by ANB angle (Class III < 0°, 0° ≤ Class I ≤ 4°, and 4° < Class II). Females showed significantly higher BD than males (p < 0.001). As age increased, BD increased significantly (p < 0.001). There were no significant differences between vertical skeletal patterns. Class II showed significantly less BD than Class III (p < 0.05). With this information, clinicians can better understand BD trends of the midpalatal suture and, thus, better understand our patient’s anatomy and potential hurdles in successful treatment.

PURPOSE The purpose of this study was to evaluate potential benefits of use of an abdominal binder after cesarean birth. STUDY DESIGN AND METHODS A randomized controlled trial was conducted at a Magnet-designated, academic medical center in the southwest United States. English- and Spanish-speaking adult women scheduled for an elective cesarean birth were randomized to the intervention or control group. Outcomes were measured for the first 48 hours postoperatively, including pain, medication use, and self-reported symptom distress. RESULTS Randomization resulted in balanced groups. Women who used the abdominal binder after cesarean birth reported a decrease in pain after ambulation, whereas women in the control group reported an increase in pain after ambulation (p < .001). Women in the binder group reported less distress on the Breathe and Cough items of the Symptom Distress Scale than those in the control group. On postoperative day 2, women in the binder group used more ibuprofen (p = .002) and acetaminophen (p = .027) than the control group. CLINICAL IMPLICATIONS Use of an abdominal binder by women after cesarean birth can decrease pain, potentially enhancing speed of postoperative recovery. As a nursing intervention, abdominal binders may offer women a safe nonpharmacologic option to provide postoperative comfort.

Context:Altered diaphragm function is linked to decreased core stabilization, postural changes, and decreased function. Two clinical tests used to assess breathing are the Hi-lo and lateral rib expansion (LRE) tests. It is currently unknown how breathing classification based on these tests differ and how their results are affected by varying test positions.Objective:To compare the results of breathing tests when conducted in varying test positions.Design:Prospective cross-sectional study.Setting:University laboratory.Participants:A total of 50 healthy adults (females 31 and males 29; age 29.3 [4.1] y; height 170.0 [10.4] cm; weight70.7 [15.1] kg).Intervention(s):Hi-lo and LRE tests in supine, seated, standing, and half-kneeling body positions. All tests were recorded and later scored by a single examiner. A generalized estimating equations approach with breathing test and body position as factors was used for analysis. Pairwise comparison with Bonferroni correction was used to adjust for multiple tests. Statistical significance was set atP = .05, 2 tailed.Main Outcome Measures:Hi-lo and LRE tests were scored based on the presence or absence of abdominal excursion, LRE, and superior rib cage migration. Following scoring, results were classified as functional or dysfunctional based on observation of these criteria.Results:A significant breathing test × test position interaction (P P P P P = .52). In the LRE test, all positions were similar (P > .99) except for half-kneeling, which was significantly different from all other positions (P Conclusions:The Hi-lo test and LRE tests assess different breathing mechanics. Clinicians should use these tests in combination to gain a comprehensive understanding of a person’s breathing pattern. The Hi-lo test should be administered in multiple testing positions.

OBJECTIVE Our purpose was to determine the association between concussion recovery and health-related quality of life (HRQOL). SETTING Secondary school athletic training facilities. PARTICIPANTS Patients (N = 122) with a concussion. STUDY DESIGN Prospective, longitudinal cohort. MAIN MEASURES The Pediatric Quality-of-Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), and Headache Impact Test-6 (HIT-6) were completed at preseason and days 3 (D3), 10 (D10), and 30 (D30) postconcussion. The independent variable was the recovery group. RESULTS Interactions between group and time (P < .001) were noted for all PedsQL subscales, except Social Functioning (P = .75). Significantly lower scores were found among Prolonged than in Short on D3 (P < .05). Significant interactions (P < .001) were also noted for all MFS subscales. Pairwise comparisons for General and Sleep subscales revealed Prolonged had lower scores than Short and Moderate on D3 and D10. A group by time interaction was found for the HIT-6 (P < .001), with scores being higher (P < .01) in Prolonged than in Short on D3 and D10. CONCLUSIONS Adolescents with a prolonged recovery demonstrated lower HRQOL in the immediate days postinjury, particularly in physical and school functioning, fatigue, and headache. There was a strong association between recovery length and school functioning. Additional research is needed to understand how to minimize the impact of concussion on HRQOL.

We aimed to assess whether perceived pressure predicts concussion reporting intentions and behavior in youth, high school, and collegiate ice hockey athletes, and, secondarily, whether perceived pressure from stakeholders differed between sex or level of play.Online survey.One hundred fifty-two ice hockey athletes (males: n = 96, 63.2%; females: n = 55, 36.2%; missing: n = 1, 0.7%; age = 14.04 ± 3.6 years).Cross-sectional.Respondents answered a survey that elicited information about demography, perceived pressure from 6 stakeholders, and concussion reporting intentions and behavior. For the first aim, we used a generalized linear model to determine whether perceived pressure from any stakeholder predicted intention (symptom reporting, concussion reporting, and intention beliefs) or behavior ("all concussions," "not obvious concussions"; α.05) while controlling for level of play. To determine whether pressure from any stakeholder predicted symptom reporting behavior, we used logistic regression while controlling for level of play. For the second aim, to examine sex differences in perceived pressure from each stakeholder, we employed Mann-Whitney tests and to examine level of play differences, we used Kruskal-Wallis tests.Controlling for level of play, a 1-point increase in perceived pressure from parents and athletic administrators decreased concussion reporting intentions by 0.92 (P = .004) and 1.09 (P = .005) points, respectively. Perceived pressure from a sports medicine professional decreased intention beliefs by 0.17 (P = .029) points. Perceived pressure from stakeholders did not predict symptom reporting (P = .440) or "not obvious concussion" reporting (P = .655) behavior. We observed no difference in perceived pressure across stakeholders (all P values.05); however, collegiate ice hockey respondents perceived greater pressure from coaches than youth or high school athletes (P.001). We noted no other differences in perceived pressure across levels of play (all P values.05).Concussion reporting intentions were negatively influenced by perceived pressure from parents, athletic administrators, and sports medicine professionals, but these findings did not translate to reporting behavior.

Objective: The objective of this retrospective study was to investigate the relationship between mandibular symphysis bone density (BD) and mandibular growth direction in adolescent patients by facilitating the measurement of cortical and cancellous BDs at the mandibular symphysis using cone beam computed tomography (CBCT). Study Design: 224 adolescent patients (98 males and 126 females) were categorized by sex, age, and mandibular growth direction. Cortical and cancellous BDs were measured along with a sagittal slice at multiple locations. Results: Females exhibited higher cortical BD than males at menton (Me, P =0.002). Patients with a posterior growth direction exhibited a higher cortical BD than those with anterior and normal growth direction at Me (P

Accurately measuring tongue space is challenging, but this information can be useful to many dental specialties. This study was intended to estimate the reliability of using cone-beam computed tomography (CBCT) to measure tongue space, which includes tongue volume and the oral cavity air capacity.For this preliminary study, CBCT images from ten participants (five females and five males, mean age of 29.8 ± 3.3 years) were available for evaluation. Each participant was radiographed two times (T0 and T1). The average time between T0 and T1 was 15.8 ± 3.7 days. CBCT scans were standardized to reduce variability. Three-dimensional landmarks were established to identify tongue space and 3D image analysis software (SimPlantThe intra-rater and inter-rater ICCs of the CBCT measurements at T0 were excellent ( 0.90). Measurements for T0 vs. T1 show good (0.75-0.90) intra-rater and excellent ( 0.90) inter-rater reliability. Bland-Altman charts show that 90-95% of the total measurements fall within the 95% limits of agreement for both intra- and inter-rater pairs CONCLUSIONS: The results of this preliminary study suggest that the landmarks chosen to measure the overall tongue space are reproducible and can be measured clearly using CBCT.

The aim of this study was to evaluate the bone density of mandibular condyles in adolescents with varying skeletal patterns using cone-beam computed tomography. The null hypothesis was that there is no difference in the bone density of mandibular condyles in adolescents across various facial height ratios, ANB angle classifications, sexes, and age categories.We divided 120 adolescent patients, 56 boys and 64 girls, into 3 groups according to 3 criteria: (1) age (early, 10 to 14 years; middle, 14 to 17 years; late, 17 to 20 years); (2) facial height ratio or Jarabak quotient (hyperdivergent: facial height ratio, 62%; normovergent: facial height ratio, 62% to ≤65%; and hypodivergent: facial height ratio, 65%); and (3) ANB angle classification (Class I, 1° to ≤4°; Class II, (4°); and Class III, 1°). The total, cortical, and cancellous bone densities were measured and compared on the axial slice with the largest mediolateral diameter of the mandibular condyle using C-mode cone-beam computed tomography.Cortical bone density increased as age increased and showed statistically significant differences between the early and middle (P = 0.041) and the early and late adolescent groups (P = 0.031). Condylar bone density increased as facial height ratio decreased, and cancellous bone density showed statistically significant differences between the hyperdivergent and hypodivergent groups (P = 0.038). The cortical, cancellous, and total bone densities increased as ANB angle increased and showed statistically significant differences between the Class II and Class III groups (P = 0.022, P = 0.006, and P = 0.003, respectively).The null hypothesis was rejected. Condylar bone density increased as facial height ratio decreased and ANB angle increased. These findings may be useful in predicting the vertical and horizontal skeletal growth patterns of growing adolescents.

This study builds upon a project that developed clinical criteria to identify undiagnosed hypertension patients "hiding in plain sight" (HIPS) by examining patient characteristics to understand whether there are disparities in hypertension diagnosis. We examined electronic health record demographic data for patients identified by the HIPS criteria and subgroups at 3 Missouri health centers. Identified patients who returned for a follow-up visit and were subsequently diagnosed with hypertension tended to be older, black/African American, uninsured, and classified as having obesity. Younger, white, healthy weight females were less likely to be diagnosed. These findings point to exploring possible biases/other nonclinical factors in hypertension diagnosis.

ContextGymnastics trains fundamental movement skills but has high rates of early sport specialization. Early specialization is associated with increased injury risk. Gymnasts devote time to developing technical skill, but whether specialization status influences performance is unknown.ObjectiveTo describe the participation and specialization characteristics of youth club gymnastics participants and determine whether the level of specialization is associated with fitness and functional task performance.DesignRetrospective cross-sectional study.SettingA single gymnastics facility.Patients or Other ParticipantsData on youth gymnasts (n = 131; 84 females, 47 males; age = 10.9 ± 2.9 years, height = 142.14 ± 16.23 cm, mass = 38.15 ± 12.93 kg) were reviewed.Main Outcome Measure(s)Specialization was assessed using a 3-tiered classification. Fitness measurements consisted of the Gymnastics Functional Measurement Tool, Men's Gymnastics Functional Measurement Tool, and core strength. Functional tasks evaluated hop performance, dynamic balance, and jump-landing technique. Separate analyses of covariance, covaried by age, hours of training, and years of gymnastics participation, were used to identify differences in fitness and functional performance among specialization groups. Pearson product correlations were calculated to evaluate the relationships between training hours per week and years in gymnastics with fitness and functional performance.ResultsMost gymnasts were classified as moderately (50.4%, n = 66) or highly (35.1%, n = 46) specialized. Only 14.5% (n = 19) were classified as having a low level of specialization. Weak to moderate correlations were present between years in gymnastics and most fitness tasks. Moderate to strong correlations were noted between training hours per week and most fitness tasks. Low-specialization gymnasts scored lower on right lower extremity Y-balance (P = .004), upper left extremity Y-balance (P = .033), and right hop performance (P = .039) tests.ConclusionsGymnasts reported high proportions of moderate to high specialization, and many exceeded guidelines for hours participating in gymnastics per week. We did not observe clinically meaningful group differences among specialization status and fitness or functional movement tasks, indicating no clear benefit of gymnastics training to the exclusion of other sports for increased performance.

Context The “Appropriate Medical Coverage for Intercollegiate Athletics” (AMCIA) document was created to support assessment and calculation of athletic training personnel requirements. However, little is known regarding disparities between current and recommended staffing practices. Objective To identify the staffing and employment characteristics of athletic health care services at Football Bowl Subdivision-level institutions. Design Cross-sectional study. Setting Web-based survey. Patients or Other Participants Head athletic trainers and athletic training staff members who were knowledgeable about budget and staff. Main Outcome Measure(s) The survey, Assessment of Staffing Levels at National Collegiate Athletic Association Football Bowl Subdivision-Level Institutions, was used to evaluate personal, university, and staff demographics; staffing and employment topics; and AMCIA variables and use. Results The survey was accessed and partially completed by 104 individuals (response rate = 84.6%). A total of 79 athletic trainers (response rate = 76%) completed the entire survey. One-third of the respondents (34.2%, n = 26) met the recommended number of full-time equivalents (FTEs) for football, two-thirds of the respondents (65.7%, n = 50) failed to meet the recommendation, and 26.2% (n = 27) were missing data needed for FTE calculation. Among those who did not meet the recommended FTEs (n = 50), 38.0% (n = 19) were within 1 FTE of being compliant, 26.0% (n = 13) were within 2 FTEs, and 24.0% (n = 12) were within 3 FTEs. About one-third of respondents (35.9%, n = 37) reported not using the AMCIA, citing lack of funding (29.7%, n = 11), lack of administrative support (21.6%, n = 8), and other reasons (37.8%, n = 14). Conclusions The majority of institutions that used the AMCIA were able to provide justification for staffing. For most of the institutions that failed to meet their recommendation, adding 1–3 FTE athletic trainers for football would change their compliance status. A uniform definition of the term FTE within collegiate athletics is needed to allow for structured assessment and allocation of staffing and workloads.

Previous randomized controlled trials evaluating the efficacy of mycophenolate mofetil (MMF) in patients with immunoglobulin A nephropathy (IgAN) have produced varying results.Double-blind placebo-controlled randomized controlled trial.52 children, adolescents, and adults with biopsy-proven IgAN in 30 centers in the United States and Canada. Entry criteria: age older than 7 to younger than 70 years; urine protein-creatinine ratio (UPCR), ≥0.6g/g (males) or ≥0.8g/g (females); and estimated glomerular filtration rate ≥ 50mL/min/1.73m(2) (≥40mL/min/1.73m(2) if receiving angiotensin-converting enzyme inhibitor). Mean age, 32±12 (SD) years; 62% men; and 73% white.Lisinopril (or losartan) plus a highly purified omega-3 fatty acid (Omacor [Pronova Biocare]) was given to 94 patients for 3 months; 52 of the patients with persistent UPCR≥0.6g/g (males) and ≥0.8g/g (females) were randomly assigned to MMF or placebo (target dose, 25-36mg/kg/d) in addition to lisinopril/losartan plus Omacor.Change in UPCR after 6 and 12 months treatment with MMF/placebo and 12 months after the end of treatment.UPCR measured on 24-hour urine samples. Glomerular filtration rate estimated with the Schwartz (age 18 years) or Cockcroft-Gault (age ≥ 18 years) formula.44 patients completed 6 months of treatment with MMF (n=22) or placebo (n=22). The trial was terminated early at the recommendation of the Data Monitoring Committee because of the lack of benefit. No patient achieved a complete remission (UPCR0.2g/g). Mean UPCRs at randomization and after 6 months were 1.45 (95% CI, 1.16-1.75) and 1.40 (95% CI, 1.09-1.70) for MMF and 1.41 (95% CI, 1.17-1.65) and 1.58 (95% CI, 1.13-2.04) for placebo, respectively. The mean difference in UPCR change between these groups (MMF minus placebo) was -0.22 (95% CI, -0.75 to 0.31; P=0.4). Adverse events were rare apart from nausea (MMF, 8.7%; placebo, 3.7%); one of these MMF patients withdrew.Low patient enrollment and short follow-up.MMF did not reduce proteinuria significantly in patients with IgAN who had persistent proteinuria after lisinopril/losartan plus Omacor.

Background. Geographical location, socioeconomic status, and logistics surrounding transportation impede access of poststroke individuals to comprehensive rehabilitative services. Robotic therapy may enhance telerehabilitation by delivering consistent and state-of-the art therapy while allowing remote monitoring and adjusting therapy for underserved populations. The Hand Mentor Pro (HMP) was incorporated within a home exercise program (HEP) to improve upper-extremity (UE) functional capabilities poststroke. Objective. To determine the efficacy of a home-based telemonitored robotic-assisted therapy as part of a HEP compared with a dose-matched HEP-only intervention among individuals less than 6 months poststroke and characterized as underserved. Methods. In this prospective, single-blinded, multisite, randomized controlled trial, 99 hemiparetic participants with limited access to UE rehabilitation were randomized to either (1) the experimental group, which received combined HEP and HMP for 3 h/d ×5 days ×8 weeks, or (2) the control group, which received HEP only at an identical dosage. Weekly communication between the supervising therapist and participant promoted compliance and progression of the HEP and HMP prescription. The Action Research Arm Test and Wolf Motor Function Test along with the Fugl-Meyer Assessment (UE) were primary and secondary outcome measures, respectively, undertaken before and after the interventions. Results. Both groups demonstrated improvement across all UE outcomes. Conclusions. Robotic + HEP and HEP only were both effectively delivered remotely. There was no difference between groups in change in motor function over time. Additional research is necessary to determine the appropriate dosage of HMP and HEP.

Background: Effective use of patient-rated outcome measures to facilitate optimal patient care requires an understanding of the reference values of these measures within the population of interest. Little is known about reference values for commonly used patient-rated outcome measures in adolescent athletes. Purpose: To determine reference values for the Pediatric Quality of Life Inventory (PedsQL) and the Multidimensional Fatigue Scale (MFS) in adolescent athletes by sport and sex. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A convenience sample of interscholastic adolescent athletes from 9 sports was used. Participants completed the PedsQL and MFS during one testing session at the start of their sport season. Data were stratified by sport and sex. Dependent variables included the total PedsQL score and the 5 PedsQL subscale scores: physical functioning, psychosocial functioning, emotional functioning, social functioning, and school functioning. Dependent variables for the MFS included 3 subscale scores: general functioning, sleep functioning, and cognitive functioning. Summary statistics were reported for total and subscale scores by sport and sex. Results: Among 3574 males and 1329 female adolescent athletes, the PedsQL scores (100 possible points) generally indicated high levels of health regardless of sport played. Mean PedsQL total and subscales scores ranged from 82.6 to 95.7 for males and 83.9 to 95.2 for females. Mean MFS subscale scores (100 possible points) ranged from 74.2 to 90.9 for males and 72.8 to 87.4 for females. Conclusion: Healthy male and female adolescent athletes reported relatively high levels of health on the PedsQL subscales and total scores regardless of sport; no mean scores were lower than 82.6 points for males or 83.9 points for females. On the MFS, males and females tended to report low effect of general and cognitive fatigue regardless of sport; mean scores were higher than 83.5 points for males and 83.8 points for females. Clinically, athletes who score below the reference values for their sport have poorer health status than average adolescent athletes participating in that sport. Scores below reference values may warrant consideration of early intervention or treatment.

Context: Patient-rated outcome measures (PROMs) capture changes that are important and meaningful to patients, such as health-related quality of life (HRQOL). Although group differences in HRQOL have been reported, little is known about the effect of injury history on HRQOL in collegiate athletes. Objective: To determine whether knee-specific function (International Knee Documentation Committee Subjective Knee Evaluation Form [IKDC]) and HRQOL (Short Form 12 [SF-12]) differs in collegiate athletes based on sex and the severity of a previous knee injury. Design: Cross-sectional study. Setting: Athletic training facilities. Patients or Other Participants: Healthy collegiate athletes (n = 263) were grouped based on self-report of a previous knee injury: severe (n = 47), mild (n = 40), and no (n = 176) knee injury. Intervention(s): Participants completed the IKDC and SF-12 during their preparticipation examinations. Main Outcome Measure(s): Generalized linear models were used to assess interactions and main effects of all scores. Results: An interaction effect was observed for the SF-12 role physical subscale (P = .02), with men in the mild- and severe-injury groups reporting worse scores than men with no injury history. We noted a main effect for injury group for the IKDC total score (P < .001) and SF-12 physical functioning (P = .04) and role emotional (P = .04) subscales, with the severe-injury group reporting worse scores than the mild- and no-injury groups. No main effects of sex were reported (P > .05). Conclusions: Despite returning to full participation, collegiate athletes who previously sustained severe knee injuries tended to report worse knee-specific function and less ability to complete activities due to physical health. In addition, individuals with a history of severe knee injury tended to report more emotional concerns than athletes with a history of mild or no knee injury. Region-specific PROMs may be more sensitive in detecting deficits than generic PROMs after return to full participation. Researchers should investigate the role of PROMs, particularly region-specific PROMs, as potential screening tools for clinical care.

Context: Increased rates of sport participation and sport-related injury have led to greater emphasis on and attention to medical care of student-athletes in the secondary school setting. Access to athletic training services is seen as a critical factor for delivering adequate injury prevention and medical care to student-athletes. However, few data are available regarding practice characteristics of athletic trainers (ATs) in this setting. Objective: To characterize the practices of secondary school athletic trainers (ATs). Design: Descriptive study. Setting: Web-based survey. Patients or Other Participants: A total of 17 558 ATs with current National Athletic Trainers' Association membership were identified for survey distribution. Of these, 4232 ATs indicated that they practiced in the secondary school setting, and 4045 completed some part of the survey. Main Outcome Measure(s): A Web-based survey was used to obtain demographic information about ATs and their secondary schools and characteristics of athletic training practice. Descriptive data regarding the athletic trainer's personal characteristics, secondary school characteristics, and practice patterns are reported as percentages and frequencies. Results: Most respondents were in the early stages of their careers and relatively new to the secondary school practice setting. Nearly two-thirds (62.4%; n = 2522) of respondents had 10 or fewer years of experience as secondary school ATs, 52% (n = 2132) had been certified for 10 or fewer years, and 53.4% (n = 2164) had 10 or fewer years of experience in any practice setting. The majority of respondents (85%) worked in public schools with enrollment of 1000 to 1999 (35.5%) and with football (95.5%). More than half of respondents were employed directly by their school. Most respondents (50.6%) reported an athletic training budget of less than $4000. The majority of ATs performed evaluations (87.5%) on-site all of the time, with a smaller percentage providing treatments (73.3%) or rehabilitation (47.4%) services all of the time. Conclusions: This is the first study to describe secondary school athletic training that reflects national practice trends. To improve the quality of athletic training care and to support and improve current working conditions, the profession must examine how its members practice on a day-to-day basis.

Little is known about the relationship between post-concussion impairments and health-related quality-of-life (HRQoL). The primary purpose of this study was to determine the relationship between traditional concussion assessments and HRQoL in adolescent athletes post-concussion. The secondary purpose was to determine the association between HRQoL deficits and time lost.In total, 1134 athletes completed a baseline assessment battery. HRQoL measures included the Pediatric Quality of Life Inventory (PedsQL), Multidimensional Fatigue Scale (MFS) and Headache Impact Test-6. In total, 122 athletes sustained a concussion and underwent follow-up testing at 3 and 10 days post-injury.The strongest relationships were between symptom severity and HRQoL. For concurrent regression analyses at Day 3, PedsQL-Physical accounted for 17.9% of the variance in time lost beyond that accounted for by traditional measures. At Day 10, PedsQL-School accounted for 15.2% and symptom severity for 7.1% of this variance. In predictive analyses, at Day 3, PedsQL-Physical accounted for 3.9% and MFS-General for 3.3% of the variance in time lost beyond that accounted for by traditional measures. At Day 10, MFS-Cognitive accounted for 12.0% of this variance.HRQoL appears to play a role in time lost post-concussion and should be measured in combination with traditional concussion assessments.

Purpose The purpose of this study was to evaluate the efficacy of peanut ball use on duration of first stage labor and pushing time in women who were scheduled for elective induction of labor at ≥39 weeks gestation and planning an epidural. Study design and methods In this randomized controlled trial, women having labor induction and planning a labor epidural were assigned (1:1) to one of two groups: one group used a peanut ball and one group did not. Outcome variables were time spent in first stage labor and time spent pushing. Factors included group assignment (peanut ball, no peanut ball), parity (primiparous, multiparous), and race. Age and maximum oxytocin dose served as covariates. Results Among women having elective induction with epidural analgesia, use of a peanut ball reduced first stage labor duration for primiparous patients significantly more than multiparous patients, p = 0.018. There was no significant difference in the reduction of length of first stage labor for multiparous women, p = 0.057 with use of the peanut ball. Peanut ball use did not alter length of pushing time for either group, p > 0.05. Clinical implications Use of peanut balls may reduce total labor time to a greater degree in primiparous patients than multiparous patients having elective induction at ≥39 weeks with epidural analgesia.

Background: To improve and standardize the sideline evaluation of sports-related concussion, the Sport Concussion Assessment Tool 2 (SCAT2) was developed. This tool assesses concussion-related signs and symptoms, cognition, balance, and coordination. This newly published assessment tool has not established representative baseline data on adolescent athletes. Hypothesis: Representative baseline SCAT2 scores in adolescent athletes will differ by gender, grade in school, and self-reported concussion history. Study Design: Descriptive epidemiology study. Methods: Interscholastic athletes were administered the SCAT2 during a preseason concussion baseline testing session. The SCAT2 total score ranges from 0 to 100 points, with lower scores indicating poorer performance. Overall, representative values were calculated using descriptive statistics. Separate independent-samples t tests, with gender and concussion history as the independent variables, and a 1-way analysis of variance, with grade as the independent variable, were conducted to assess differences in SCAT2 total score ( P < .05). Results: There were 1134 high school athletes (872 male and 262 female) who participated. The SCAT2 total score across all participants was 88.3 ± 6.8 (range, 58-100); skewness was −0.86 ± 0.07, and kurtosis was 0.73 ± 0.14. Male athletes scored significantly lower on the SCAT2 total score ( P = .03; 87.7 ± 6.8 vs 88.7 ± 6.8), and 9th graders (86.9 ± 6.8) scored significantly lower than 11th (88.7 ± 7.0) and 12th (89.0 ± 6.6) graders ( P < .001). Athletes with a self-reported concussion history scored significantly lower on the SCAT2 total score than those with no concussion history ( P < .001; 87.0 ± 6.8 vs 88.7 ± 6.5). Conclusion: These data provide representative scores on the SCAT2 in adolescent athletes and show that male athletes, 9th graders, and those with a self-reported concussion history scored significantly lower than their female, upperclassmen, or nonconcussed peers. Clinical Relevance: These results suggest that healthy adolescent athletes display variability on the SCAT2 at baseline. Therefore, clinicians should administer baseline assessments of the SCAT2 because assuming a perfect baseline score of 100 points is not appropriate in an adolescent athlete population.

Context:Recurrent headaches significantly affect health-related quality of life (HRQOL) in adults; the impact of headache on HRQOL among adolescents is unknown, and the psychometric properties of headache-specific outcomes instruments have not been adequately studied in this population.Objective:To evaluate the psychometric properties of the Headache Impact Test (HIT-6) and Pediatric Migraine Disability Assessment (PedMIDAS) in healthy adolescent athletes.Design:Descriptive survey.Setting:High school athletic training facilities during the fall sports season.Participants:177 high school athletes (89 males and 88 females).Interventions:A survey consisting of a demographic and concussion-history questionnaire, a graded symptom scale, the HIT-6, and the PedMIDAS. Internal consistency (α), test–retest reliability (rs), Bland-Altman analyses, and the Mann-Whitney U test were used to evaluate psychometric properties and age and gender differences.Main Outcome Measures:The HIT-6 and PedMIDAS item and total scores.Results:Test–retest reliability for the HIT-6 total score was rs = .72, and reliability of individual items ranged from rs = .52 to .67. The test–retest reliability for the PedMIDAS total score was rs = .61, and reliability of individual items ranged from rs = .23 to .62. Both scales demonstrated acceptable internal consistency: HIT-6 α = .89−.90 and PedMIDAS α = .71−.75.Conclusions:The authors found moderate test–retest reliability for the HIT-6 and the PedMIDAS in a healthy adolescent athlete population. Research on the applicability and utility of the HIT-6 and PedMIDAS in concussed adolescents is warranted.

Context:Throwing-related arm injuries are common in softball pitchers and may lead to diminished health-related quality of life (HRQOL). Arm symptoms such as pain have been reported to be more common in healthy overhead athletes than nonoverhead athletes. Furthermore, more frequent shoulder symptoms and lower shoulder function have been demonstrated in athletes with self-reported history of shoulder injury.Objective:To evaluate the relationship between arm injury history, current pain rating, and HRQOL assessed via 2 region-specific patient self-report scales in high school and college softball pitchers.Design:Cross-sectional.Setting:High school and college athletic training facilities.Participants:25 female softball pitchers (10 high school, 15 college; 18 ± 2 y, 169 ± 7.6 cm, 67.5 ± 10.3 kg).Intervention:Self-reported arm injury history and rating of current pain and HRQOL were collected during the late season.Main Outcome Measures:A self-report questionnaire of arm injury history and current pain rating was used, and HRQOL was assessed via 2 region-specific scales: the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Functional Arm Scale for Throwers© (FAST©). Correlational analysis was used to evaluate the relationships between arm injury history, current pain rating, and the DASH total score and sport module and the FAST total score, pitching module, and subscales.Results:A history of arm injury from throwing was reported by 64% of participants, 31% of whom had to cease activity for more than 10 d. The most common site of arm time-loss injury was the shoulder (81%). Mild to severe shoulder pain during the competitive season was reported by 60% of respondents. The DASH and the FAST total scores were significantly correlated (r = .79, P < .001). Respondent rating of shoulder pain correlated significantly with the DASH total (r = .69) and sports module (r = .69) and the FAST total (r = .71), pitching module (r = .65), and pain (r = .73), impairment (r = .76), functional-limitation (r = .79), disability (r = .52), and societal-limitations (r = .46) subscales.Conclusion:History of arm injury is common in female high school and college softball pitchers. Severe injury and elevated pain are associated with lower HRQOL that extends beyond the playing field.

Context: Health-related quality of life (HRQOL) is a global concept that takes into account the physical, psychological, and social domains of health. Determining the extent to which injury affects HRQOL is an important aspect of rehabilitation practice, enabling comparisons of clinical outcomes across different conditions in diverse patient groups. Objective: To examine the extent to which a self-reported recent injury affected HRQOL in adolescent athletes using 2 generic patient self-report scales. Design: Cross-sectional study. Setting: High school classrooms and athletic training facilities. Patients or Other Participants: A convenience sample of uninjured (n = 160) and injured (n = 45) adolescent athletes. Intervention(s): The independent variable was injury status: uninjured versus injured. All participants completed a self-administered brief health status questionnaire and the Short Form–36 Health Survey Questionnaire (SF-36) and Pediatric Outcomes Data Collection Instrument (PODCI) in a counterbalanced manner. Main Outcome Measure(s): Dependent variables included 8 subscale and 2 composite scores of the SF-36 and 5 subscale scores and 1 global score of the PODCI. Group differences were assessed with the Mann-Whitney U test (P ≤ .05) and reported as median and interquartile range. Results: On the SF-36, the injured group demonstrated lower scores (P < .008) for physical functioning, limitations due to physical health problems, bodily pain, social functioning, and the physical composite. On the PODCI, the injured group reported lower scores (P < .01) on the pain and comfort subscale and the global score. Conclusions: Adolescent athletes with self-reported injuries demonstrated lower HRQOL than their uninjured peers. As expected, recent injury affected physical functioning and pain. Social functioning (on the SF-36) and global HRQOL (on the PODCI) also decreased, suggesting that injuries affected areas beyond the expected physical component of health. Clinicians need to recognize the full spectrum of negative influences that injuries may have on HRQOL in adolescent athletes.

Context:Clinicians often rely on the self-report symptoms of patients in making clinical decisions; hence it is important that these scales be reliable.Objective:To determine the test-retest reliability of healthy youth in completing a graded symptom scale (GSS), modified from the Head Injury Scale Self-Report Concussion Symptoms Scale (HIS).Design:Repeated-measures.Setting:Middle school classroom.Patients or Other Participants:126 middle school students.Intervention:A survey consisting of a demographic and life events questionnaire and a GSS asking about symptom severity and duration.Main Outcomes Measures:Score for each symptom on the severity and duration scale and a total symptom score (TSS) and the total number of symptoms endorsed (TSE) from the severity scale. Responses on a life events questionnaire were also recorded.Results:We found excellent reliability for TSS (ICC = .93) and TSE (ICC = .88) for the severity scale. We found moderate to excellent reliability on the individual symptoms of both the severity (ICC = .65-.89) and duration (ICC =.56-.96) scales.Conclusions:Healthy youth can reliably self-report symptoms using a GSS. This patient-oriented outcome measure should be incorporated into more investigations in this age group.

Serious burn injuries are a potential threat to patients with seizure disorder. There are limited studies addressing this issue. Therefore, a retrospective study was undertaken with two goals: one to develop better understanding of this potential threat and two to create a prevention message regarding seizure-related burns. The burn center registry was reviewed to ascertain the number of patients who sustained burn injury during or directly after a seizure from 2000 to 2005. Thirty-two patients were admitted (44% female, 56% male) with mean age of 39 years (SD +/- 10.4) after sustaining a burn during or after a seizure. Average TBSA was 8.3% (SD +/- 4.8) with 72% of patients experiencing full-thickness burns. The three most prevalent etiologies were falling into a stove while cooking (34%; n = 11), falling on hot pavement (31%; n = 10), and falling into a campfire (9%; n = 3). A full 88% of patients (n = 28) reported a previous diagnosis of seizure disorder, whereas the other 9% (n = 3) reported seizures related to alcohol consumption. Laboratory reports revealed 20 patients (63%) had subtherapeutic levels of antiseizure medication, 1 patient (3%) had toxic levels, and 5 patients (16%) were not being treated for seizures. Upon discharge, 23 patients went home with family, 5 were discharged to skilled nursing, 1 to a homeless shelter, 1 died, and 2 patients were lost to follow-up. Because of the severe burns observed in epileptic burn patients, a burn-prevention brochure was developed and is being distributed to seizure patients and their families.

Mandibular repositioning and subsequent neuromuscular signaling are proposed mechanisms of action for commercial mouthguards marketed for performance enhancement. A prospective cross-sectional study of 24 healthy adult weightlifters with normal occlusal relationships was designed to determine whether 2 self-fit performance mouthguards; a custom-fabricated, bilaterally balanced, dual-laminated mouthguard; and no mouthguard (control) differed in their effects on vertical dimension, muscle activation, and user preference during a 75% maximum power clean lift. Each subject was tested for each of the mouthguard categories: Power Balance POWERUP, Under Armour ArmourBite, custom, and no mouthguard. Interocclusal distance was measured at baseline and with each mouthguard. Mean and peak activity of the anterior temporalis, masseter, sternocleidomastoid, and cervical paraspinal muscles was measured during sitting and during a 75% maximum power clean lift. A mouthguard preference questionnaire was completed. Analyses were conducted to determine whether interocclusal distance differed among mouthguard type and to examine the effect of mouthguard type on mean and peak muscle activation during the clean lift. Interocclusal distance was affected by mouthguard type (P = 0.01). Mean and peak activity of the anterior temporalis and masseter muscles and mean activity of the sternocleidomastoid muscle differed among mouthguards (P0.05). Mouthguard type did not influence muscle activation of the cervical paraspinal muscle group. Overall, the Power Balance mouthguard produced more muscle activity. Participants preferred custom mouthguards nearly 2:1 over self-fit performance mouthguards (P = 0.05). Participants perceived that they were stronger and were less encumbered when using a custom mouthguard during submaximum power clean lifts.

Methods We performed a cross-sectional survey of 357 reproductive-aged women, mostly Hispanic (81.8%), presenting for ambulatory and hospital reproductive care in Phoenix, AZ, about their interest in natural family planning (NFP). Participants completed questionnaires, and responses were analyzed to determine predictors of interest in NFP. Results Sixty-one percent stated that they were likely or very likely to use NFP to avoid pregnancy, and 50% would use NFP to achieve pregnancy. Of factors studied, Hispanic ethnicity, lower level of acculturation, less education and recent use of condoms or withdrawal were independently associated with interest in using NFP to avoid pregnancy. Younger age and desire for future pregnancy were independently predictive of potential NFP use to achieve pregnancy. Conclusion This study suggests that Hispanic women find NFP to be an appealing family planning alternative.

Objective The purpose of this study was to determine if cesarean delivery is a risk factor for respiratory distress syndrome (RDS) and if this risk is modified by labor before cesarean. Study design This population-based case-control study compared 4778 cases of RDS to 5 times as many controls. Results Unadjusted, cesarean delivery was associated with RDS, odds ratio (OR) 3.5 (95% CI 3.2–3.8). After controlling for potential confounding variables, cesarean remained an independent risk factor, OR 2.3 (95% CI 2.1–2.6). Labor modified this risk significantly ( P =.02)—with labor, cesarean delivery had an OR of 1.9 (95% CI 2.2–2.9), without labor, the OR was 2.6 (95% CI 1.3–2.8). Conclusion Cesarean delivery was an independent risk factor for RDS. The risk was reduced with labor before cesarean, but still elevated. This supports the importance of being certain of fetal lung maturity before cesarean delivery, particularly when done before labor.

Objective This study was undertaken to use the Arizona State birth certificate database for Phoenix metropolitan hospitals, in conjunction with National Weather Service records to determine whether there is a relationship between birth rate and meteorologic or lunar conditions. This study attempts to dispel or lend significance to beliefs among hospital staff that the phase of the moon and/or meteorologic conditions are related to birth rate. Study design Birth records were limited to spontaneous vaginal deliveries, 37 to 40 weeks' gestation, in Phoenix, between 1995 and 2000 (n = 167,956). Daily birth counts were merged with daily surface weather statistics from the National Weather Service for Sky Harbor Airport, and records of lunar phase for the same period. Results The analyses revealed no significant correlates of birth rate. Conclusion Although there exists a popular belief that the phase of the lunar cycle and weather conditions affect birth rate, no such evidence was found in this study.

OBJECTIVES: Victims of domestic violence presenting for health care are frequently referred to medical specialists, but little is known about domestic violence screening among specialists. The aim of this study was to evaluate attitudes and behaviors concerning domestic violence of all physicians in Arizona. METHODS: A cross-sectional survey of 2244 physicians from 13 medical specialties describes domestic violence screening practices, attitudes, and behaviors of practicing physicians in Arizona. RESULTS: Among 976 respondents, 56% reported prior education on domestic violence screening; 50.5% rarely or never screen their female patients for domestic violence; and 52% reported their competence for providing treatment for victims as poor to fair. Physicians from emergency medicine, psychiatry, obstetrics/gynecology, and family practice reported higher rates of domestic violence education, screening, awareness of services, and competence at treating victims. Physical medicine/rehabilitation, anesthesiology/pain control, surgical subspecialty, medicine subspecialty, general surgery, and orthopedic physicians scored lowest on these characteristics. CONCLUSIONS: Differences in attitudes and behaviors regarding domestic violence screening were noted among specialty groups. Customizing physician training based on these findings may be beneficial.

Background: As domestic violence (DV) is frequently unrecognized by physicians, efforts to improve education on the topic have been undertaken. Purpose: To assess changes in medical education about DV. Methods: Incoming residents from 1995 (N = 52) and 2001 (N = 43) were surveyed regarding education and attitudes about DV. Results: The resident-reported emphasis on DV education increased significantly from 1995 to 2001. Hours devoted to the subject experienced no significant change. The likelihood they would ask female patients about DV and their competence in dealing with DV-specific situations experienced no significant improvement-both were rated below average. Conclusions: Although emphasis on medical education about DV has improved from 1995 to 2001, likelihood of screening and competence at dealing with DV has not improved. The content of undergraduate medical education about DV should be strengthened, and the educational process should continue during residency training.

•Objective To test the simultaneous effect of various established predictors of breast and cervical cancer screening (breast self-examination, clinical breast examination by a physician, Papanicolaou [Pap] smear, and pelvic examination) in a low-income, Mexican-American sample. •Material and Methods A total of 188 Mexican-American women participated in a face-to-face structured interview in their preferred language. We tested a model with four established predictors of breast and cervical cancer screening—communication skills, knowledge of cancer, access to health care (finances and availability of care), and anxiety about cancer. Simultaneous structural equations analysis was used to form latent variables and to control for the effect of all predictors concurrently. •Results Screening behavior was inversely associated with anxiety about cancer when all other predictors were statistically controlled. In addition, anxiety substantially affected the relationship between communication skills and screening behavior. Unexpectedly, knowledge of cancer was positively, rather than negatively, associated with anxiety about cancer. Predictors in the model demonstrated an excellent fit of the proposed model to the data. •Conclusion Successful cancer screening programs for Mexican-American women must address not only access barriers but also communication skills, knowledge, and, perhaps most importantly, anxiety.

This study aimed to determine the prevalence of long-term anxiety disorder in burn-injured youth. It is well documented that inpatient pediatric burn patients experience heightened anxiety. However, the prevalence of anxiety disorder in pediatric burn survivors warrants further investigation. Participants completed the Screen for Anxiety Related Disorders, a 41-item self-report measuring anxiety disorder symptomatology. Respondents included 197 pediatric burn survivors, 105 boys, 92 girls, who were between 8 and 18 years of age; the mean age was 12.4 ± 2.4 years. Mean age at time of injury was 5.8 ± 3.7 years, with 79% of youth reporting visible scars. There were 77 participants (39%) who screened positive for a possible anxiety disorder with a total anxiety score ≥25, and 28% with a total mean score of ≥30, more specific to the likely presence of anxiety disorder. Nearly half of the participants (44%) reported symptoms indicating the presence of separation anxiety with a mean score of ≥5, and 28% had symptoms indicating the presence of panic disorder and school avoidance disorder. Significant sex differences were observed for anxiety, with girls scoring significantly higher than boys on total anxiety P ≤ .001 and on all four subscales. Youth attending burn camps for ≥5 years reported significantly lower anxiety scores. This study supports the screening of burn-injured youth for anxiety disorder and highlights the importance of educating parents and burn care professionals regarding the symptoms of anxiety disorders. This can help to ensure that pediatric burn survivors receive treatment when anxiety disorder symptoms are present. Screening appears to be especially important for girls.

Context: Normative scores for patient-rated outcome (PRO) instruments are important for providing patient-centered, whole-person care and making informed clinical decisions. Although normative values for the Pediatric Quality of Life Generic Core Scale (PedsQL) have been established in the general, healthy adolescent population, whether adolescent athletes demonstrate similar values is unclear. Objective: To compare PedsQL scores between adolescent athletes and general, healthy adolescent individuals. Design: Cross-sectional study. Setting: Secondary schools. Patients or Other Participants: A convenience sample of 2659 interscholastic athletes (males = 2059, females = 600, age = 15.7 ± 1.1 years) represented the athlete group (ATH), and a previously published normative dataset represented the general, healthy adolescent group (GEN). Intervention(s): All participants completed the PedsQL during 1 testing session. Main Outcome Measure(s): The PedsQL consists of 2 summary scores (total, psychosocial) and 4 subscale scores (physical, emotional, social, school), with higher scores indicating better health-related quality of life (HRQOL). Groups were stratified by age (14, 15, or 16 years old). Independent-samples t tests were conducted to compare between-groups and sex differences. Results: The ATH group scored higher than the GEN group across all ages for total and psychosocial summary scores and for emotional and social functioning subscale scores (P ≤ .005). For physical functioning, scores of the 15-year-old ATH were higher than for their GEN counterparts (P = .001). Both 14- and 15-year-old ATH scored higher than their GEN counterparts for the school functioning subscale (P ≤ .013), but differences between 16-year olds were not significant (P = .228). Male adolescent athletes reported higher scores than female adolescent athletes across all scores (P ≤ .001) except for social functioning (P = .229). Conclusions: Adolescent athletes reported better HRQOL than GEN, particularly in emotional functioning. These findings further support the notion that ATH constitutes a unique population that requires its own set of normative values for self-reported, patient-rated outcome instruments.

Domestic violence is the most common cause of injury to women. Obstetrician-gynecologists, who most women consider their primary care physicians, have a unique role in identifying battered women. This study was designed to assess the extent and nature of current training curricula regarding domestic violence education in obstetrics and gynecology residencies.A survey sent to all obstetrics and gynecology residencies requested demographic data, the curriculum in respect to domestic violence, availability of interested faculty, the prevalence of battering among patients, satisfaction with the current teaching, and knowledge of pending legislation. Respondents were also asked which of 10 common clinical presentations would prompt their faculty to discuss the possibility the patient was being battered.Eighty-three percent of programs responded. The "typical" program was urban, had five residents per year, and had faculties of full-time academicians and part-time private practitioners. Twenty-eight percent reported having at least one faculty member with expertise in domestic violence. One third reported a prevalence of battering ofor = 1% with 6% estimating fewer than 1 in 1000. Seventy-five percent did not recognize at least one clinical scenario as suggestive of battering. The majority were dissatisfied with their teaching and wanted help in curriculum development. Forty percent were unaware of pending legislation linking federal support of medical education to including domestic violence in curricula.The results of this survey highlight deficiencies in the education of obstetrics and gynecology residents about domestic violence. Programs report limited faculty interest, underestimate prevalence, fail to recognize common presentations, and are dissatisfied with their current curriculum. We are not preparing obstetrics and gynecology residents to care for patients with a common problem--domestic violence.In the US, domestic violence is the most common cause of injury to women, and, because they are women's primary care physicians, obstetrician-gynecologists (OB-GYNs) are in a position to identify battered women. With legislation pending that would require federally-funded medical education to include domestic violence in its curriculum, a survey was conducted of all OB-GYN residencies to determine their current status in the provision of domestic violence education. With 83% of the programs responding (n = 264), it was found that 28% had at least one faculty member with expertise in domestic violence, that the incidence of domestic violence among clients was underestimated, and that 75% of respondents did not recognize at least 1 of the 10 common clinical scenarios as suggestive of battering (at least 44% failed to recognize the risk factors of no prenatal care, preterm labor, emergency room visits, and psychiatric diagnoses). Only 28% of respondents reported that they teach residents to ask all or almost all patients about battering. Most respondents expressed dissatisfaction with their coverage of this topic and asked for help in curriculum development. In addition, 40% were unaware of the pending federal legislation. This study concluded that there is a strong need to develop an OB-GYN curriculum that deals with domestic violence but that further study is needed to determine the optimal teaching methods.

Objective And Study Design: Ovarian needle diathermy was used in the treatment of clomiphene-resistant polycystic ovarian syndrome (PCOS). Factors predictive of pregnancy in our study group included younger age, lower body weight, and surgery before 1998. Results And Conclusion: Insulin resistance and adhesions at surgery were negatively associated with pregnancy. Sixty-six percent of the study group cycled spontaneously after surgery and 50% became pregnant. (Am J Obstet Gynecol 2003;188:1171-3.)

Anecdotally, burn camp has been reported to be a positive developmental and rehabilitative experience for attendees; there is little empirical data to support this belief. This study sought to explore whether burn camp either directly or indirectly elicits positive development outcomes in pediatric burn survivors or increases their psychosocial well-being and achievement. The Youth Experience Survey 2.0, a 66-item self-report inventory designed to measure developmental experiences in an organized youth activity, was administered to children aged 11 to 18 years attending summer burn camp. One hundred and ten burn-injured youth, 58 male and 52 female, reported that burn camp had positively impacted their lives through improved identity exploration, goal-setting and problem-solving abilities, increased physical activity, communication, emotional regulation, and time management skills (P.0001). Participants reported more positive experiences than the norm group and higher mean scores on 90% (48) of the 53 positive items. Attendance at burn camp for more than 5 years resulted in greater improvement. Study results support the burn camp experience as a far-reaching and positive developmental activity. Participants credited the camp experience with helping them with identity formation and reflection, improved social interactions, and increased initiative; all positive developmental outcomes for youth. Results suggest that burn camp participation not only helps burn-injured youth to deal with their burns but also assists them in the development of social and basic life skills, which will allow them to navigate the transition from youth to adulthood, more effectively and successfully.

Context Analysis of health care service models requires the collection and evaluation of basic practice characterization data. Practice-based research networks (PBRNs) provide a framework for gathering data useful in characterizing clinical practice. Objective To describe preliminary secondary school setting practice data from the Athletic Training Practice-Based Research Network (AT-PBRN). Design Descriptive study. Setting Secondary school athletic training facilities within the AT-PBRN. Patients or Other Participants Clinicians (n = 22) and their patients (n = 2523) from the AT-PBRN. Main Outcome Measure(s) A Web-based survey was used to obtain data on clinical practice site and clinician characteristics. Patient and practice characteristics were obtained via deidentified electronic medical record data collected between September 1, 2009, and April 1, 2011. Descriptive data regarding the clinician and CPS practice characteristics are reported as percentages and frequencies. Descriptive analysis of patient encounters and practice characteristic data was performed, with the percentages and frequencies of the type of injuries recorded at initial evaluation, type of treatment received at initial evaluation, daily treatment, and daily sign-in procedures. Results The AT-PBRN had secondary school sites in 7 states, and most athletic trainers at those sites (78.2%) had less than 5 years of experience. The secondary school sites within the AT-PBRN documented 2523 patients treated across 3140 encounters. Patients most frequently sought care for a current injury (61.3%), followed by preventive services (24.0%), and new injuries (14.7%). The most common diagnoses were ankle sprain/strain (17.9%), hip sprain/strain (12.5%), concussion (12.0%), and knee pain (2.5%). The most frequent procedures were athletic trainer evaluation (53.9%), hot- or cold-pack application (26.0%), strapping (10.3%), and therapeutic exercise (5.7%). The median number of treatments per injury was 3 (interquartile range = 2, 4; range = 2–19). Conclusions These preliminary data describe services provided by clinicians within the AT-PBRN and demonstrate the usefulness of the PBRN model for obtaining such data.

A causal role of mutations in multiple general transcription factors in neurodevelopmental disorders including autism suggested that alterations in global levels of gene expression regulation might also relate to disease risk in sporadic cases of autism. This premise can be tested by evaluating for changes in the overall distribution of gene expression levels. For instance, in mice, variability in hippocampal-dependent behaviors was associated with variability in the pattern of the overall distribution of gene expression levels, as assessed by variance in the distribution of gene expression levels in the hippocampus. We hypothesized that a similar change in variance might be found in children with autism. Gene expression microarrays covering greater than 47,000 unique RNA transcripts were done on RNA from peripheral blood lymphocytes (PBL) of children with autism (n = 82) and controls (n = 64). Variance in the distribution of gene expression levels from each microarray was compared between groups of children. Also tested was whether a risk factor for autism, increased paternal age, was associated with variance. A decrease in the variance in the distribution of gene expression levels in PBL was associated with the diagnosis of autism and a risk factor for autism, increased paternal age. Traditional approaches to microarray analysis of gene expression suggested a possible mechanism for decreased variance in gene expression. Gene expression pathways involved in transcriptional regulation were down-regulated in the blood of children with autism and children of older fathers. Thus, results from global and gene specific approaches to studying microarray data were complimentary and supported the hypothesis that alterations at the global level of gene expression regulation are related to autism and increased paternal age. Global regulation of transcription, thus, represents a possible point of convergence for multiple etiologies of autism and other neurodevelopmental disorders.

Context:Patient-oriented outcome measures such as the Medical Outcomes Short Form (SF-36) and the Pediatric Outcomes Data Collection Instrument (PODCI) are important tools for determining the impact of events like sport-related injury on health-related quality of life (HRQoL). Unfortunately, there are no published studies using these instruments that compare adolescent athletes with their nonathlete peers, making interpretations of these measures in this population difficult.Objective:To compare HRQoL in adolescent athletes and nonathletes using 2 common instruments.Design:Cross-sectional.Setting:7 high schools.Participants:219 athletes and 106 nonathletes.Intervention:None.Main Outcome Measures:The SF-36 and the PODCI were completed in a counterbalanced manner during 1 session. Dependent variables included the 8 subscale and 2 composite scores of the SF-36 and the 5 subscale scores and 1 global score of the PODCI.Results:On the SF-36, athletes reported higher scores on the physical function, general health, social functioning, and mental health subscales and the mental composite score and lower scores on the bodily pain subscale than nonathletes. On the PODCI, athletes reported higher scores on the sport and physical function and happiness subscales and lower scores on the pain/comfort subscale.Conclusions:Athletes reported higher scores on a number of SF-36 and PODCI subscales related to mental, emotional, and physical well-being than nonathletes. Our findings suggest that athletic involvement may be a benefit to the overall health status of adolescents and imply that athletes may be a distinct adolescent group requiring their own normative values when using the SF-36 and PODCI.

PURPOSE To test an educational intervention regarding domestic violence. METHOD Residents beginning their training in 1995 or 1996 were randomly assigned to attend, at their hospital orientation, either a 20-minute session emphasizing the importance of screening for domestic violence or a session on an unrelated topic. RESULTS Seventy-one percent of the residents in the experimental group diagnosed domestic violence; 52% in the control did so (RR, 1.35; 95% CI, 0.96-1.90; p = .07) in the nine to 12 months following the intervention. Rates of diagnosis differed by specialty (p < .01): 100% family practice, 90% emergency medicine, 80% obstetrics-gynecology, 63% pediatrics, 47% internal medicine, 0% surgery. Change in knowledge was assessed in 1996; significant improvement was noted (p = .002). CONCLUSION An intervention about domestic violence conducted at orientation for residents improved the rate of diagnosis of domestic violence. While the improvement was not statistically significant in this case, the intervention was brief and harmless. Other institutions should consider this kind of brief intervention.

Objective This study was undertaken to determine whether the association of intimate partner violence with urinary tract infection and pyelonephritis in pregnancy is due to a higher rate of asymptomatic bacteriuria in those suffering intimate partner violence. Study Design Women enrolling in prenatal care had urine collected for quantitative culture (n = 342) and completed 2 scales with a computer-based survey system: The Conflict Tactics Scale for verbal and physical abuse and the Castro survey for sexual abuse. Results The prevalence of verbal abuse during pregnancy was 46.9%, physical abuse, 7.6%, sexual abuse 5.8%. No significant associations were seen between quantitative culture of uropathogens and verbal, physical, or sexual abuse. Conclusion It is unlikely that the reason for the association of urinary tract infection and intimate partner violence is due to a higher number of uropathogens present in the urine of women with verbal, physical, or sexual abuse.

To compare endorsement rates obtained with audio computer-assisted self-interview versus routine prenatal history.A crosssectional study compared items captured with the routine history to those captured with a computer interview (computer screen displaying and computer audio reading questions, with responses entered by touch screen). The subjects were women (n=174) presenting to a public hospital clinic for prenatal care.The prevalence of positive responses using the computer interview was significantly greater (p0.01) than with the routine history for induced abortion (16.8% versus 4.0%), lifetime smoking (12.8% versus 5.2%), intimate partner violence (10.0% versus 2.4%), ectopic pregnancy (5.2% versus 1.1%) and family history of mental retardation (6.7% versus 0.6%). Significant differences were not found for history of spontaneous abortion, hypertension, epilepsy, thyroid disease, smoking during pregnancy, gynecologic surgery, abnormal Pap test, neural tube defect or cystic fibrosis family history. However, in all cases, prevalence was equal or greater with the computer interview.Women were more likely to report sensitive and high-risk behavior, such as smoking history, intimate partner violence and elective abortion, with the computer interview. The computer interview displayed equal or increased patient reporting of positive responses and may therefore be an accurate method of obtaining an initial history.

Objective This study was undertaken to identify risk factors for prolonged neonatal intensive care unit (NICU) stay in macrosomic (≥ 4000 g) neonates. Study design A population-based case-control study in which 799 cases of macrosomic neonates with a prolonged NICU stay were compared with macrosomic neonates without a prolonged stay (n = 1598). Results Significant risk factors included: 5-minute Apgar score less than 7: odds ratio (OR) = 43.1; fetal distress: OR = 3.0; birth length less than 20 inches: OR = 2.2; birth weight more than 5000 g: OR = 2.6; maternal diabetes: OR = 3.0; gestational age 37 to 38 weeks: OR = 2.2; cephalopelvic disproportion: OR = 2.5; primary cesarean: OR = 2.6; forceps/vacuum: OR = 1.7. No significant association was seen with labor induction/augmentation or dysfunctional/prolonged labor. Conclusion Prolonged stay in macrosomic neonates was related to fetal distress measures and less to factors related to prolonged labor. Attention to intrapartum fetal status during labor with suspected macrosomia appears to be especially warranted.

Background Breast cancer incidence and survival varies by race and ethnicity. There are limited data regarding breast cancer in Native American women. Methods A retrospective chart review was performed of 139 women diagnosed with breast cancer and treated at Phoenix Indian Medical Center in Phoenix, AZ between January 1, 1982 and December 31, 2003. Data points included tribal affiliation, and quantum (percentage American Indian Heritage) along with patient, tumor, and treatment characteristics. Results Most patients (79%) presented initially with physical symptoms. There were no significant differences based on tribal affiliation; however, higher quantum predicted both larger tumor size and more advanced stage at diagnosis. Obesity also significantly correlated with larger tumor size and more advanced stage. Treatment was inadequate in 21%; this was attributed to traditional beliefs, patient refusal, or financial issues. Conclusions When compared to national averages, Native American women presented at a later stage, underutilized screening, and had greater delays to treatment.

To compare risk factors and birth outcomes among low- and high-acculturated Hispanics and white non-Hispanics.Information on 1,172 women who delivered was collected in a cross-sectional study at a public hospital in Phoenix, Arizona. We compared 3 groups: low-(reference group) and high-acculturated Hispanics and white non-Hispanics. Acculturation was defined within Hispanics by predominant orientation: Latin America (low) or United States (high).Prevalence of substance abuse and interpersonal violence was highest in the white non-Hispanics when compared to low-acculturated Hispanics, and intermediate in the high-acculturation group. Births to women17 years old were highest in the high-acculturation group. Preterm labor and pregnancy-induced hypertension were more common in white non-Hispanics. Sexually transmitted disease was more likely in the high-acculturated Hispanic group. Diabetes was more common in both comparison groups, high-acculturated and white non-Hispanic.High-acculturated Hispanics, like high-risk white non-Hispanics, had more risk factors and adverse obstetric outcomes than the low-acculturated group. The acculturation process may lead to difficulty for Hispanics in the United States.

Objective: This study was undertaken to describe labor induction risk factors and consequences among women with term singleton gestations with vertex presentation. Study Design: Arizona births in 1997 (N = 65,607) were studied by means of stratified analysis and logistic regression. Results: Labor induction occurred in 20.3% (n = 13,288). Labor induction risk factors were as follows: race or ethnicity (white non-Hispanic 25.3%; Hispanic, 13.9%; foreign-born Hispanic, 10.3%; and US-born Hispanic, 18.5%), education ( 12 years, 24.6%), payor (private insurance, 24.5%; Medicaid, 16.7%), hospital type (government controlled, 13.7%; investor owned, 30.5%). Race or ethnicity and hospital type remained important determinants of labor induction in the multivariate analysis. Relative risks of cesarean delivery with labor induction were as follows: nulliparous, 1.38; parous with no previous cesarean delivery, 1.00; and parous with previous cesarean delivery, 0.50. Conclusion: Large variations in labor induction were noted across maternal ethnicity and hospital type categories. Labor induction increased cesarean delivery rates among nulliparous women, whereas no increase was seen among parous women with no previous cesarean delivery. Labor induction was used less often among those with previous cesarean delivery; when it was used in this group, however, it was associated with a lower cesarean delivery rate. (Am J Obstet Gynecol 2000;182:1355-62.)

Background : Two years ago the authors began to use Swan-Ganz catheters to generate more complex hemodynamic data as a better guide to resuscitation of burns. This study uses the information to identify differences between survivors and nonsurvivors. Patients and methods : Fifty-three consecutive patients with major burns were treated using Swan-Ganz-generated data. Additional information was collected, including demographics, intake and output, medications, and arterial blood gas (including calculated oxygen consumption). Statistical analysis incorporated adjustments for autocorrelation. Results : The patients included 38 men and 15 women, averaged 43.7 years of age, and had a mean burn size of 40%. Thirteen patients suffered severe inhalation injury. Data collected hourly over 3 days were collapsed across 6-hour observation periods. Mean values, when plotted across time, discriminated the 37 survivors from the 16 nonsurvivors. Poor response to resuscitation as evidenced by increased use of colloid fluid and cardiotonic drugs plus failure to maximize oxygen consumption were associated with nonsurvival. Conclusions : Unsustained or inadequate response to hyperdynamic resuscitation of burns was associated with nonsurvival.