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The ability to think creatively is a vital transition skill for students with learning disabilities in the 21st century. Participation in careers with a high level of creative thinking ability not only sets the individual student up for success but also the community in which they live. Creative self-efficacy is the belief in one’s ability to be creative and is a basic component of creativity. A positive relationship is indicated between higher creative self-efficacy and higher creative production. Thus, the development of a positive creative self serves as a supportive element for students with learning disabilities in their current and future endeavors. This article describes the importance of and need for creative thinking and creative self-efficacy development in education and suggests the use of questioning techniques as a strategy for developing these important skills when working with students with learning disabilities.

IntroductionLow-dose CT (LDCT) screening of high-risk smokers reduces lung cancer (LC) specific mortality. Determining screening eligibility using individualised risk may improve screening effectiveness and reduce harm. Here, we compare the performance of two risk prediction models (PLCOM2012 and Liverpool Lung Project model (LLPv2)) and National Lung Screening Trial (NLST) eligibility criteria in a community-based screening programme.MethodsEver-smokers aged 55–74, from deprived areas of Manchester, were invited to a Lung Health Check (LHC). Individuals at higher risk (PLCOM2012 score ≥1.51%) were offered annual LDCT screening over two rounds. LLPv2 score was calculated but not used for screening selection; ≥2.5% and ≥5% thresholds were used for analysis.ResultsPLCOM2012 ≥1.51% selected 56% (n=1429) of LHC attendees for screening. LLPv2 ≥2.5% also selected 56% (n=1430) whereas NLST (47%, n=1188) and LLPv2 ≥5% (33%, n=826) selected fewer. Over two screening rounds 62 individuals were diagnosed with LC; representing 87% (n=62/71) of 6-year incidence predicted by mean PLCOM2012 score (5.0%). 26% (n=16/62) of individuals with LC were not eligible for screening using LLPv2 ≥5%, 18% (n=11/62) with NLST criteria and 7% (n=5/62) with LLPv2 ≥2.5%. NLST eligible Manchester attendees had 2.5 times the LC detection rate than NLST participants after two annual screens (≈4.3% (n=51/1188) vs 1.7% (n=438/26 309); padjOR 2.50, 95% CI 1.11 to 5.64; p=0.028).ConclusionProspective comparisons of risk prediction tools are required to optimise screening selection in different settings. The PLCOM2012 model may underestimate risk in deprived UK populations; further research focused on model calibration is required.

BackgroundCOPD is a major cause of morbidity and mortality in populations eligible for lung cancer screening. We investigated the role of spirometry in a community-based lung cancer screening programme.MethodsEver smokers, age 55–74, resident in three deprived areas of Manchester were invited to a ‘Lung Health Check’ (LHC) based in convenient community locations. Spirometry was incorporated into the LHCs alongside lung cancer risk estimation (Prostate, Lung, Colorectal and Ovarian Study Risk Prediction Model, 2012 version (PLCOM2012)), symptom assessment and smoking cessation advice. Those at high risk of lung cancer (PLCOM2012 ≥1.51%) were eligible for annual low-dose CT screening over two screening rounds. Airflow obstruction was defined as FEV1/FVCResults99.4% (n=2525) of LHC attendees successfully performed spirometry; mean age was 64.1±5.5, 51% were women, 35% were current smokers. 37.4% (n=944) had airflow obstruction of which 49.7% (n=469) had no previous diagnosis of COPD. 53.3% of those without a prior diagnosis were symptomatic (n=250/469). After multivariate analysis, the detection of airflow obstruction without a prior COPD diagnosis was associated with male sex (adjOR 1.84, 95% CI 1.37 to 2.47; p1/FVC ratio (adjOR 4.19, 95% CI 2.95 to 5.95; padjOR 2.80, 95% CI 1.60 to 8.42; p=0.002).ConclusionsIncorporating spirometry into a community-based targeted lung cancer screening programme is feasible and identifies a significant number of individuals with airflow obstruction who do not have a prior diagnosis of COPD.

Amidation of indole 2-carboxylate 1 with ammonia gas via the imidazolide 2 gave GSK2248761A API 3, which was in development for the treatment of HIV. Three significant impurities, namely the phosphinic acid 4, the N-acyl urea 8, and the indoloyl carboxamide 6, were formed during the reaction, and the original process was unable to produce API within clinical specification when run at scale. Investigation into the origin, fate, and control of these impurities led to a new process which was able to produce API within clinical specification.

Resuscitative hysterotomy is a daunting and rarely performed procedure in the emergency department (ED). Given the paucity of clinical exposure to this intervention, resuscitative hysterotomy is an ideal opportunity for simulation-mediated deliberate practice. The authors propose a novel training program using a homegrown, realistic, simulation device as a means to practice resuscitative hysterotomy. Two high-fidelity, tissue-based task-trainer models were constructed and tested on a convenience sample of 14 emergency medicine (EM) residents. The simulated human placenta, bladder, amniotic sac, and uterus were constructed through the use of porcine skin, porcine stomach, transparent plastic bag, Foley tubing, and squid mantle, all secured with nylon sutures. A Gaumard S500 Articulating Newborn was inserted in the simulated uterus, and the entire model was placed into a Gaumard S500 Childbirth Simulator. Each model required less than 1 h for assembly. Emergent hysterotomy was first demonstrated by an EM faculty facilitator, followed by hands-on deliberate practice. Formal feedback on the learners’ self-reported confidence and satisfaction levels was solicited at the end of the workshop through a survey previously cited for use with a low-fidelity resuscitative hysterotomy. Quantitative evaluation of the simulated training session was extracted through a 5-item questionnaire using a 5-point Likert-type scale (i.e., from 1, strongly disagree, to 5, strongly agree). Item scores were added for a cumulative total score, with a possible maximum score of 25 and minimum score of 5. Responses were overwhelmingly positive [24.13 (± 1.36)]. Qualitative feedback was extracted from the survey through open-ended questions; these responses highlighted learners’ appreciation for hands-on practice and the development of a novel, tissue-based simulation task trainer. All participants recommended the training session be available to future learners. Resuscitative hysterotomy is a high-stakes, low-frequency procedure that demands provider practice and confidence. Our hybrid, tissue-based hysterotomy model represents a feasible opportunity for training. The model is cost conscious, easily reproducible, and portable and allows for ample deliberate practice. Electronic supplementary material The online version of this article (10.1186/s41077-018-0078-1) contains supplementary material, which is available to authorized users.

We report results from the second annual screening round (T1) of Manchester’s ‘Lung Health Check’ pilot of community-based lung cancer screening in deprived areas (undertaken June to August 2017). Screening adherence was 90% (n=1194/1323): 92% of CT scans were classified negative, 6% indeterminate and 2.5% positive; there were no interval cancers. Lung cancer incidence was 1.6% (n=19), 79% stage I, treatments included surgery (42%, n=9), stereotactic ablative radiotherapy (26%, n=5) and radical radiotherapy (5%, n=1). False-positive rate was 34.5% (n=10/29), representing 0.8% of T1 participants (n=10/1194). Targeted community-based lung cancer screening promotes high screening adherence and detects high rates of early stage lung cancer.

The mutagenic-impurity control strategy for a second generation manufacturing route to the non-mutagenic antipneumocystic agent atovaquone (2-((1R,4R)-4-(4-chlorophenyl)cyclohexyl)-3-hydroxynaphthalene-1,4-dione) 1 is described. Preliminary assessment highlighted multiple materials of concern which were largely discharged either through returning a negative bacterial mutagenicity assay or through confidence that the impurity would be purged during the downstream processing from when it was first introduced. Additional genotoxicity testing highlighted two materials of concern where initial assessment suggested that testing for these impurities at trace levels within the drug substance would be required. Following a thorough review of process purging detail, spiking and purging experimentation, and an understanding of the process parameters to which they were exposed an ICH M7 Option 4 approach could be justified for their control. The development of two 1H NMR spectroscopy methods for measurement of these impurities is also described as well as a proposed summary table for describing the underlying rationale for ICH M7 control rationales to regulators. This manuscript demonstrates that process purging of potential mutagenic impurities can be realised even when they are introduced in the later stages of a process and highlights the importance of scientific understanding rather than relying on a stage-counting approach.

Background: Cardiovascular disease (CVD) is a major cause of morbidity and mortality in populations eligible for lung cancer screening. The aim of this study was to determine whether a brief CV risk assessment, delivered as part of a targeted community-based lung cancer screening programme, was effective in identifying individuals at high risk who might benefit from primary prevention. Methods: The Manchester Lung Screening Pilot consisted of annual low dose CT (LDCT) over 2 screening rounds, targeted at individuals in deprived areas at high risk of lung cancer (age 55–74 and 6-year risk ≥1.51%, using PLCOM2012 risk model). All participants of the second screening round were eligible to take part in the study. Ten-year CV risk was estimated using QRISK2 in participants without CVD and compared to age (±5 years) and sex matched Health Survey for England (HSE) controls; high risk was defined as QRISK2 score ≥10%. Coronary artery calcification (CAC) was assessed on LDCT scans and compared to QRISK2 score. Results: Seventy-seven percent (n=920/1,194) of screening attendees were included in the analysis; mean age 65.6 ± 5.4 and 50.4% female. QRISK2 and lung cancer risk (PLCOM2012) scores were correlated (r = 0.26, p < 0.001). Median QRISK2 score was 21.1% (IQR 14.9–29.6) in those without established CVD (77.6%, n = 714/920), double that of HSE controls (10.3%, IQR 6.6–16.2; n = 714) (p < 0.001). QRISK2 score was significantly higher in those with CAC (p < 0.001). Screening attendees were 10-fold more likely to be classified high risk (OR 10.2 [95% CI 7.3–14.0]). One third (33.7%, n = 310/920) of all study participants were high risk but not receiving statin therapy for primary CVD prevention. Discussion: Opportunistic CVD risk assessment within a targeted lung cancer screening programme is feasible and is likely to identify a very large number of individuals suitable for primary prevention.

Aim: To study early changes in fatigue, disease activity and cytokines within individual patients with rheumatoid arthritis (RA) following etanercept treatment. Methods: 12-week prospective observational study of 21 RA patients starting etanercept therapy. DAS28, fatigue, IL-1β, IL-4, IL-6, IL-8 and IL-1ra were measured. Results: DAS28, fatigue and IL-6 improved significantly by 40% compared with baseline values in the first 4 weeks (P < 0.05), but followed different time courses. The main improvement in IL-6 occurred by week 2, fatigue (BRAF MDQ) by week 3 and DAS28 by week 4. At week 3 improvement of DAS28 (24%) was significantly less than BRAF MDQ (42%, P < 0.003) and IL-6 (43%, P < 0.03). Conclusion: Fatigue improved faster than disease activity, suggesting that fatigue may be mediated via a different pathway.

We report baseline results of a community-based, targeted, low-dose CT (LDCT) lung cancer screening pilot in deprived areas of Manchester. Ever smokers, aged 55–74 years, were invited to ‘lung health checks’ (LHCs) next to local shopping centres, with immediate access to LDCT for those at high risk (6-year risk ≥1.51%, PLCOM2012 calculator). 75% of attendees (n=1893/2541) were ranked in the lowest deprivation quintile; 56% were high risk and of 1384 individuals screened, 3% (95% CI 2.3% to 4.1%) had lung cancer (80% early stage) of whom 65% had surgical resection. Taking lung cancer screening into communities, with an LHC approach, is effective and engages populations in deprived areas.

Immune evasion is a hallmark of cancer. Losing the ability to present neoantigens through human leukocyte antigen (HLA) loss may facilitate immune evasion. However, the polymorphic nature of the locus has precluded accurate HLA copy-number analysis. Here, we present loss of heterozygosity in human leukocyte antigen (LOHHLA), a computational tool to determine HLA allele-specific copy number from sequencing data. Using LOHHLA, we find that HLA LOH occurs in 40% of non-small-cell lung cancers (NSCLCs) and is associated with a high subclonal neoantigen burden, APOBEC-mediated mutagenesis, upregulation of cytolytic activity, and PD-L1 positivity. The focal nature of HLA LOH alterations, their subclonal frequencies, enrichment in metastatic sites, and occurrence as parallel events suggests that HLA LOH is an immune escape mechanism that is subject to strong microenvironmental selection pressures later in tumor evolution. Characterizing HLA LOH with LOHHLA refines neoantigen prediction and may have implications for our understanding of resistance mechanisms and immunotherapeutic approaches targeting neoantigens. VIDEO ABSTRACT.

This article presents an innovative model of Continuing Professional Development (CPD) that has been used in Scotland to encourage research and to develop research skills amongst applied educational (school) psychologists. 1 This is a process-based CPD model rather than the traditional `attendance at CPD workshops' model, leading to active learning and knowledge creation for the professional and the profession. Data collected from educational psychologists and stakeholders suggests that it is very effective but there is room for improvement. The lessons learnt over the 13 years of its operation and through a recently commissioned evaluation will hopefully be of interest to other applied educational psychologists internationally, as well as related professions.

Background The influence of grief and bereavement on the lives of people with intellectual disabilities is currently receiving much interest. Many of the long-standing rituals associated with bereavement are still practised in Ireland, probably more than in many other Western countries. The present authors were interested in studying the experience of bereavement for people with intellectual disabilities in Ireland, and in making international comparisons. Method This mixed method study was carried out using two questionnaires. The first was used to study national service and organisational approaches to bereavement. The second questionnaire (based on Murray et al. 2000) was used to study a staff group working in Ireland, assessing staff knowledge and understanding of the grieving process. The results were compared with a UK staff group who were assessed using the same questionnaire (Murray et al. 2000). Results Staff and service attitudes were found to be very positive in supporting people with intellectual disabilities who have been bereaved. There is considerable understanding of the needs of bereaved individuals, and there is a high level of support in the participation in grief rituals. When compared with a UK staff group, Irish staffs were more inclined to encourage individuals to take part in bereavement rituals, though they had less actual experience in supporting bereaved people. Only one service had written bereavement guidelines. Conclusions There appears to be cultural differences in the experience of bereavement for people with intellectual disabilities. This is important in the context of staff training and policy development in grief and bereavement.

Background: Detection of urothelial carcinoma (UC) by urine cytology can be challenging. Recently, ProEx C has been studied as a marker to improve detection of UC. ProEx C is an assay targeting expression of topoisomerase IIa and minichromosome maintenance protein-2 and is currently utilized to assist in diagnoses of the gynecological specimens. In this study, we compared the utility of ProEx C and UroVysion in urine specimens. Materials and Methods: Twenty-seven urine specimens with UroVysion assay analysis and surgical biopsy follow-up were selected. The smears were stained with ProEx C. ProEx C and UroVysion assay results were separated into two categories based on surgical biopsy follow-up (benign or neoplastic). Surgical biopsy diagnoses were used as the gold standard for comparative evaluation of the two assays. The surgical follow-up was 9 benign, 2 low grade, and 16 high grade UCs. Results: The sensitivity was 88.9% for ProEx C and 55.6% for UroVysion, while the specificity was 77.8% for ProEx C and 44.4% for UroVysion. Positive predictive value was 88.9% for ProEx C and 66.7% for UroVysion. Negative predictive value was 77.8% and 33.3% for ProEx C and UroVysion, respectively. Using the two-tailed paired t-test, P value of 0.033 was obtained when ProEx C stain was compared with the UroVysion assay. Conclusion: ProEx C immunocytochemistry has a more favorable performance than fluorescent in-situ hybridization with a significant difference between the two assays using paired two-tail t-test (P = 0.0033).

TRACERx, a prospective study of patients with primary non-small cell lung cancer, aims to map the genomic landscape of lung cancer by tracking clonal heterogeneity and tumour evolution from diagnosis to relapse., The importance of intratumour genetic and functional heterogeneity is increasingly recognised as a driver of cancer progression and survival outcome. Understanding how tumour clonal heterogeneity impacts upon therapeutic outcome, however, is still an area of unmet clinical and scientific need. TRACERx (TRAcking non-small cell lung Cancer Evolution through therapy [Rx]), a prospective study of patients with primary non-small cell lung cancer (NSCLC), aims to define the evolutionary trajectories of lung cancer in both space and time through multiregion and longitudinal tumour sampling and genetic analysis. By following cancers from diagnosis to relapse, tracking the evolutionary trajectories of tumours in relation to therapeutic interventions, and determining the impact of clonal heterogeneity on clinical outcomes, TRACERx may help to identify novel therapeutic targets for NSCLC and may also serve as a model applicable to other cancer types.

Idiopathic pulmonary fibrosis (IPF) has a poor prognosis and therapeutic options are limited with a 5-year survival of less than 50%. This report includes a case of histologically confirmed IPF in a patient whose native lung showed objective improvement as measured by high-resolution CT while he was receiving cyclosporine-based immunosuppressive therapy after single-lung transplantation.

Joint hypermobility is a rarely recognised aetiology for focal or diffuse musculoskeletal symptoms. To assess the occurrence and importance of joint hypermobility in adult patients referred to a rheumatologist, we prospectively evaluated 130 consecutive new patients for joint hypermobility. Twenty women (15%) had joint hypermobility at three or more locations (greater than or equal to 5 points on a 9 point scale). Most patients with joint hypermobility had common musculoskeletal problems as the reason for referral. Two patients referred with a diagnosis of rheumatoid arthritis were correctly reassigned a diagnosis of hypermobility syndrome. Three patients with systemic lupus erythematosus had diffuse joint hypermobility. There was a statistically significant association between diffuse joint hypermobility and osteoarthritis. Most patients (65%) had first degree family members with a history of joint hypermobility. These results show that joint hypermobility is common, familial, found in association with common rheumatic disorders, and statistically associated with osteoarthritis. The findings support the hypothesis that joint hypermobility predisposes to musculoskeletal disorders, especially osteoarthritis.

Although cigarette smoking and alcohol consumption increase risk for head and neck cancers, there have been few attempts to model risks quantitatively and to formally evaluate cancer site-specific risks. The authors pooled data from 15 case-control studies and modeled the excess odds ratio (EOR) to assess risk by total exposure (pack-years and drink-years) and its modification by exposure rate (cigarettes/day and drinks/day). The smoking analysis included 1,761 laryngeal, 2,453 pharyngeal, and 1,990 oral cavity cancers, and the alcohol analysis included 2,551 laryngeal, 3,693 pharyngeal, and 3,116 oval cavity cancers, with over 8,000 controls. Above 15 cigarettes/day, the EOR/pack-year decreased with increasing cigarettes/day, suggesting that greater cigarettes/day for a shorter duration was less deleterious than fewer cigarettes/day for a longer duration. Estimates of EOR/pack-year were homogeneous across sites, while the effects of cigarettes/day varied, indicating that the greater laryngeal cancer risk derived from differential cigarettes/day effects and not pack-years. EOR/drink-year estimates increased through 10 drinks/day, suggesting that greater drinks/day for a shorter duration was more deleterious than fewer drinks/day for a longer duration. Above 10 drinks/day, data were limited. EOR/drink-year estimates varied by site, while drinks/day effects were homogeneous, indicating that the greater pharyngeal/oral cavity cancer risk with alcohol consumption derived from the differential effects of drink-years and not drinks/day.

Background: At least 75% of head and neck cancers are attributable to a combination of cigarette smoking and alcohol drinking. A precise understanding of the independent association of each of these factors in the absence of the other with the risk of head and neck cancer is needed to elucidate mechanisms of head and neck carcinogenesis and to assess the efficacy of interventions aimed at controlling either risk factor. Methods: We examined the extent to which head and neck cancer is associated with cigarette smoking among never drinkers and with alcohol drinking among never users of tobacco. We pooled individual-level data from 15 case - control studies that included 10 244 head and neck cancer case subjects and 15 227 control subjects, of whom 1072 case subjects and 5775 control subjects were never users of tobacco and 1598 case subjects and 4051 control subjects were never drinkers of alcohol. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using unconditional logistic regression models. All statistical tests were two-sided. Results: Among never drinkers, cigarette smoking was associated with an increased risk of head and neck cancer (OR for ever versus never smoking = 2.13, 95% CI = 1.52 to 2.98), and there were clear dose - response relationships for the frequency, duration, and number of pack-years of cigarette smoking. Approximately 24% (95% CI = 16% to 31%) of head and neck cancer cases among nondrinkers in this study would have been prevented if these individuals had not smoked cigarettes. Among never users of tobacco, alcohol consumption was associated with an increased risk of head and neck cancer only when alcohol was consumed at high frequency (OR for three or more drinks per day versus never drinking = 2.04, 95% CI = 1.29 to 3.21). The association with high-frequency alcohol intake was limited to cancers of the oropharynx/hypopharynx and larynx. Conclusions: Our results represent the most precise estimates available of the independent association of each of the two main risk factors of head and neck cancer, and they exemplify the strengths of large-scale consortia in cancer epidemiology. © The Author 2007. Published by Oxford University Press.

101 Background: Cancer patients (pts) are burdened by symptoms related to the disease itself or to the toxicities of treatment. The ASCO clinical oncology guideline adaptation recommends all health care providers routinely screen for the presence of emotional distress and specifically symptoms of anxiety from the point of diagnosis onward [Andersen BL, 2014].At Cancer Treatment Centers of America (CTCA) we perform screening assessments using a Symptom Inventory Tool (SIT) composed of 27 questions. Pts with moderate and severe levels of anxiety are evaluated by the Integrative Resource Assessment Program (IRAP) and subsequently referred to integrative oncology consultation. Methods: The SIT is an assessment tool that captures pts’ perceived symptom burden for real-time clinical intervention, taken at the point of no intervention (baseline) and every 21 days or greater. The SIT is comprised of 27 questions utilizing the M.D. Anderson Symptom Inventory tool (MDASI) and validated assessment instrument with 8 questions and a free text box added by CTCA. Symptoms were rated “at the worst” on an 11-point numeric scale ranging from 0 (“no present”) to 10 (“as bad as you can imagine”) in the previous 24 hours. Results: Between 9/1/2014 and 2/27/2015, 842 pts with multiple types of cancer were screened for distress and 435 (51.6%) scored 5 or greater, of which 212 completed a second screening assessment.58 breast cancer pts provided SIT distress scores at baseline and then again at least 23 days after the initial assessment. The average reduction in the distress scores for breast cancer patients was 2 (1st SIT mean = 6.2, 2ndSIT mean = 4.2) with 40 pts (69%) reporting a decrease, 7 pts (12%) having no change, and 11 pts (19%) reporting an increase in distress. The 4 interventions most frequently referred and completed by the pts were mind body therapy (100%), rehabilitation (66%), acupuncture (50%), and massage therapy (45%). Conclusions: Distress is a relevant symptom reported by cancer pts. This study demonstrates that early intervention in breast cancer pts using integrative oncology approaches will reduce the distress in 69% of cases.

Purpose Thalidomide is effective for the treatment of severe cutaneous lupus. Our aim was to study the safety and efficacy of different doses of thalidomide in this condition. Methods We studied patients with severe cutaneous lupus that was unresponsive to antimalarials, prednisolone, methotrexate, azathioprine, and cyclosporin A. Starting doses of 100 mg daily (n = 16 patients), 50 mg daily (n = 17), or 50 mg on alternate days (n = 15) were compared. The response to thalidomide was categorized as complete remission, partial remission, or no visible improvement. All patients received a baseline electromyogram (EMG) followed by repeat EMG every 3 to 6 months, or sooner if neuropathic symptoms developed. Results Forty-eight patients (46 female; mean [± SD] age, 44 ± 12 years; range, 22 to 71 years) with discoid lupus (n = 18), subacute cutaneous lupus (n = 6), or systemic lupus erythematosus with skin involvement (n = 24) were included. The response rate was 81%, including 29 patients (60%) in complete remission and 10 (21%) in partial remission. Nine patients (19%) failed to respond. Thirteen patients (27%) developed peripheral neuropathy, which was EMG-proven in 11, including 4 patients in the 50-mg alternate-day group. Other side effects included drowsiness, constipation or abdominal pain, and amenorrhea. The relapse rate after stopping thalidomide was 67% (26/39). There was no association between a positive response to the drug and either starting doses or cumulative dose. Similarly, no association was found between peripheral neuropathy and the starting or cumulative dose. Conclusion Thalidomide is effective for the treatment of severe cutaneous lupus. There were no clear dose-dependent effects. However, the high incidence of neurotoxicity, even at low doses, suggests that it may be most useful as a remission-inducing drug.

Work in the construction industry involves about a threefold increased risk of fatal injury compared with all industries combined. The purpose of this study was to identify potential risk factors for fatal injury in the construction industry in New Jersey. Multiple data sources including death certificates, medical examiner reports, Occupational Safety and Health fatality files, and Workers' Compensation reports were used to identify 200 construction-related fatalities in New Jersey during the years 1983 to 1989. All deaths were in men. The death rate was 14.5 per 100,000 employed person-years over the study period. Death rates tended to diminish with increasing age after 34 until age 65 when the death rate was the highest (27.7). Death rates were higher for Hispanics (34.8) and African-Americans (24) than whites (10.6). Ironworkers and roofers had highest rates (109.0 and 56.2, respectively) among specific occupational groups within the construction industry. The leading cause of death was falls (46%). These data suggest that intervention efforts directed toward workers at heights is needed. Further research is warranted to elucidate the factors contributing to the elevated fatality rate of workers over age 65, and to Hispanic and African-American workers. Language: en

About 19,000 finger amputations occur at work each year in the United States. Twenty percent of these injuries are severe enough to require hospitalization. Hospital discharge data from New Jersey (1985, 1986) were used to describe the demographic characteristics of persons with such injuries and to identify potential subjects for telephone interview. A total of 637 persons hospitalized for finger amputations were sent letters asking for their participation. Of 637 persons, 355 (56%) were contacted and 228 (36%) were interviewed, of whom 134 (59%) said their injury occurred at work. The annual rate of finger amputations at work was 9.3 per 100,000 employed persons. The rate was higher for males (14.7) than females (1.9). The age-adjusted rates were higher for Hispanic (52.8) and black (28.9) males than for white males (9.5). Persons working with machines or maintaining them in the manufacturing industry were at highest risk. Unjamming or repairing machinery (e.g., presses, saws, or slicers) while in operation was particularly hazardous. These data can be used to target occupations and industries for specific worksite intervention to prevent finger amputations. One limitation of this study, however, is that hospitalized occupational finger amputations may not be representative of all finger amputations, the majority of which are less severe and do not require hospitalization. Language: en

A 5-month-old girl given an allogeneic bone marrow transplant for Hurler's syndrome succumbed to fatal pneumonia 5 weeks after the transplant. Adenovirus type 2 was isolated from her urine before she died. Immunoperoxidase and electron microscopical studies of liver and lungs post mortem confirmed a disseminated adenovirus infection. The serological findings and the patient's young age suggested that the infection was a primary one. The importance of considering exogenous sources of adenovirus infection in bone marrow transplant recipients is discussed.

Computerized population-based hospital discharge data in New Jersey offer new opportunities for surveillance of serious work-related injuries. This database was evaluated for its potential in identifying selected injuries that occurred at work during 1985 and 1986. Hospital discharge data were compared with data collected by telephone interview of discharged patients. A total of 1,575 unique hospital discharge records for the selected injuries included finger amputation (1,041), thumb amputation (209), crush injury of the lower limb (208), toxic effects of heavy metals (69), and eye burns (48). Of 809 study subjects sent letters, 445 (55%) could be contacted and 289 (36%) were interviewed for the study. Sixty-one percent (175) said their injury was work related. A comparison was made between self-reported injury at work, and the presence of workers' compensation payer codes on the discharge database. The agreement beyond chance (Kappa) was 0.78 (95% CI = 0.67, 0.89). The sensitivity of this indicator of work relatedness was 83%; specificity was 98%. These data suggest that workers' compensation payment on the hospital discharge database may be a good to excellent proxy indicator of the work relatedness of these injuries. However, this proxy indicator will underestimate the number of work-related injuries by about 20%. Only 11% of hospital discharge records had external cause of injury codes (E-codes), which reduces the utility of the database for understanding the causal mechanisms of work-related injuries. Language: en

Cost-containment strategies initiated in the early 1980s caused a major shift in site of care delivery for persons needing nursing care. Where once the majority of clients were cared for in the acute-care setting until they were self-sufficient, now most are discharged to the home environment still requiring acute-care nursing interventions as well as community health nursing skills. This rapid shift in practice sites has placed severe strain on community health nursing agencies. Not only are more nurses required to fill the increased demand for services, but the demand comes at a time when we are experiencing a severe nursing shortage. This has forced many agencies to hire acute care nurses who have little or no community health nursing experience. These nurses come to community health nursing expecting to use the same set of skills and knowledge base used in their acute-care practice; however, the skill levels and concepts required for community health nursing are quite different from the acute care setting. Educational preparation has not kept pace with this shift in practice. Consequently, many nurses are not adequately prepared to enter community health nursing. Preparation must include theoretical and experiential components that focus on assessment skills (of the community and individual), decision making, case management, health systems management, teaching, and leadership. Collaborative efforts between community health organizations and educational institutions would seem to be one solution that would ensure adequately prepared nurses for community health nursing. The establishment and maintenance of strong staff-development programs within community health nursing agencies are also required.

The language therapy program described arose from the authors' desire to teach adolescents to express their thoughts and feelings and also to interpret appropriately the feelings of others. The program was designed for use with behavior disordered (BD) adolescents and was used concurrently with a group of language/learning disabled (L/LD) adolescents. Line drawings depicting facial expressions were used to train the abstract concepts of feelings. Schemas were developed for identifying ranges of similar emotions within categories, and new vocabulary was introduced. Special behavior considerations for use of the program with BD adolescents are discussed.

Brief, behaviorally oriented treatment of sexual dysfunction is gaining increasing acceptance in medicine and psychiatry. However, relatively few clinics have published their treatment results. During a 2 1/2-year period, 36 couples with diagnoses of sexual dysfunction were treated with a modified Masters and Johnson protocol. The initial success rate was 83%, but the degree of improvement reported by the couples varied from marked to equivocal. Eighty-nine percent of the male partners and 83% of the female partners manifested psychologic signs or symptoms that either warranted a psychiatric diagnosis or were noted as significant traits or symptoms. With an average of 7.9 months of follow-up, the failure rate increased from 17% to 38%. This increase was attributed in part to the degree of combined psychosexual disorder identified in the patients. The etiologic relationships between psychiatric conditions and sexual dysfunctions are not fully understood and will require further study.

Peripheral neuropathy and hypertension caused by lead intoxication are reported in two children with sickle cell anemia. One child had generalized weakness in the initial occurrence and distal paralysis during a relapse two years later. The second child had foot and wrist drop. Both had slow peripheral nerve conduction velocities during the episodes. Chelation therapy was successful and resulted in a return of strength (over a period of several months) and a normalization of the blood pressures. Children with sickle cell anemia who are subjected to lead intoxication appear to be predisposed to peripheral nerve damage.

The Impact of DRGs on Health Care Workers and Their Clients It has been clear for some time that the United States has needed to come up with a system for allocating its health care resources. DRGs, as an attempt at cost containment, however, are a system that presents many problems for providers and consumers. The hospital system has been translated into an equation that includes dollars and pathology but not persons. This narrowness forces a reversal of professional priorities that places cost containment first, raising a number of dilemmas for providers and clients. Cutting Care One of the goals of DRGs is a shorter hospital stay. Hospitalization is a crisis for any patient and family; knowing there is a time frame for discharge increases the stress for the patient and for those trying to promote his or her recovery. A shorter hospital stay allows less time for that which is the essence of nursing care within a hospital setting--promotion of optimal health. Consider, for example, the policy of same-day admission for surgery. The "luxury" of a day for preoperative testing, teaching, and adaption is gone. While the preoperative testing can be done on an outpatient basis, it is unlikely that there will be a nurse in the laboratory to teach the patient how to cough and deep breathe in preparation for postoperative recovery. From the social work perspective, a shorter hospital stay minimizes further the opportunity to develop a therapeutic alliance, the first step in effective discharge planning. Exploring and clarifying the patient's wishes as a joint effort of patient, family, and discharge planner are sacrificed in the diagnosis-to-reimbursement concept of treatment. Personal autonomy, a basic ingredient of a just system, moves far down the order of priorities. Prior to the DRG prospective payment system, bedside practitioners had the time to plan discharge care with patients and families. For example, the length of stay for a coronary bypass graft (CABG) patient was nine to eleven days. On day five, it is typical for a patient who has successfully undergone open-heart surgery to be teary and somewhat depressed. This is an expected natural phenomenon related to surviving the surgery along with increased physical activities. Before DRGs, nurses caring for these patients spent days five and six reassuring both the patient and significant others that all was well and the feelings were to be expected. With the onset of DRGs, the length of stay for CABG patients decreased to seven to nine days. Now on days five and six, the practitioner must review medications, teach about leg wound care, and about chest clinic appointments, etc. The patient is denied the emotional time needed to recover. Since the patient is not "listening" to what is being taught and often cannot verbalize what has been said, significant others become frantic over what is happening to their loved one while verbalizing their own fears about not knowing enough to take the patient home. The practitioner in her turn gets frustrated because she knows the patient is not "hearing" what is taught and she no longer has the time to re-teach or reinforce what was said. Moreover, DRGs and other systems of cost containment based on reimbursement often pit caregivers against the patients for whom they are supposed to be advocates. Nurses and social workers, who believe one of their primary roles is that of patient advocate, may be particularly affected. As employees, these workers may be obligated to promote the earliest possible discharge for their patients, even if they do not feel that is in the patient's best interest. The patient may perceive the main concern of the caregivers to be the discharge date rather than his state of preparedness for discharge. Consequently, the patient may feel isolated and abandoned by hospital staff rather than supported. Inadequate Community Resources A shorter hospital stay has led many to believe that patients are being discharged "sicker and quicker. …