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Background Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. Methods Trauma patients with temperatures Results 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) ( P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity ( P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia ( P = .44). Conclusion Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

BACKGROUND Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an underrecognized clinical problem in patients presenting with acute coronary syndrome. Various clinical disorders lead to MINOCA thus making treatment and diagnosis a challenge. We aimed to compare the clinical factors and outcomes of patients with MINOCA versus obstructive disease [myocardial infarction due to coronary artery disease (MI-CAD)] in a largely rural health system. METHODS Between May 1, 2009 and June 24, 2019, all consecutive ST-segment elevation myocardial infarction patients at Essentia Health were prospectively examined. We categorized patients into MI-CAD (obstructive plaque ≥ 50% with revascularization) or MINOCA (obstructive plaque < 50% with exclusion of other alternative cause). Outcomes included 30-day and 1-year all-cause mortality, 30-day all-cause readmission and 30-day cardiac readmission. RESULTS There were 2170 patients included in the study; 2097 (96.6 %) had MI-CAD and 73 (3.4%) met the definition of MINOCA. Within the MINOCA group, the 3 most common presentations were supply-demand mismatch (28.8%), spontaneous coronary artery dissection (9.6%), and other etiology (60.3%). Only 10 (13 %) MINOCA patients had cardiac magnetic resonance imaging studies obtained within 6 months. MINOCA patients were younger 61.6 versus 63.4 years with higher left ventricular function 51.6% versus 50.4% with less likelihood of prior myocardial infarction 4.1% versus 15.5% or congestive heart failure 2.7% versus 6.3% (P < 0.05). Compared with MI-CAD patients, MINOCA patients had similar 30-day mortality (7.1% vs. 8.2%; P = 0.70), 1-year mortality (10.4% vs. 8.2 %; P = 0.55), and 30-day cardiac readmission (8.7% vs. 9.6%; P = 0.29). MINOCA patients were less likely to be discharged on aspirin, betablockers, angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, or statins (P < 0.05). CONCLUSION Though there was no difference in readmission and mortality between MINOCA and MI-CAD; use of secondary prevention medications and cardiac rehabilitation referral was low in MINOCA patients. Prospective studies will be relevant to assess effective medical therapy to improve outcomes in MINOCA patients.

Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia. Chest pain is the determinant symptom, often measured using an 11-point scale (0-10). Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. This retrospective observational cohort study considered consecutive STEMI patients from May 02, 2009 to December 31, 2018. Analysis of standard STEMI metrics included positive electrocardiogram-to-device and first medical contact-to-device times, presence of comorbidities, false-positive diagnosis, 30-day and 1-year mortality, and 30-day readmission. Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7 years). Of these, 251 (17.8%) had no obstructive lesion, consistent with false-positive STEMI. Four hundred sixty-six (33.1%) reported chest pain rating of 0 on admission, 378 (26.8%) reported mild pain (1-3), 300 (21.3%) moderate (4-6), and 265 (18.8%) severe (7-10). Patients presenting without chest pain had a significantly higher rate of false-positive STEMI diagnosis. Increasing chest pain severity was associated with decreased time from first medical contact to device, and decreased in-hospital, 30-day and 1-year mortality. Severity of chest pain on admission did not correlate to the likelihood of a true-positive STEMI diagnosis, although it was associated with improved patient prognosis, in the form of improved outcomes, and shorter times to reperfusion.

The purpose of this project was to develop and evaluate a collaborative nursing/therapist protocol for early mobility in a medical-surgical intensive care unit (MICU) in a regional level II trauma center. Data for patients in the MICU were compared for the periods August 3, 2015-August 2, 2016, and August 3, 2014-August 2, 2015. Semistructured interviews were conducted with 10 nurses and 1 therapist. Average MICU length of stay decreased from 3.81 to 3.50 days (P = .057). Mean time in mobility chairs did not change (0.12 days vs 0.11 days, P = .389). Mean number of days to first documented level 2-5 activity decreased significantly, from 1.81 to 1.51 days (P = .036). The percentage of hospitalizations with any documented level 3 or 4 activity increased significantly (from 3.8% to 7.4% and from 61.5% to 66.7%, P = .003 and P = .031, respectively). Barriers/challenges to implementation included having enough people to assist, space, documentation, having to coax the physician to place order for upright mobility, availability of therapists for later stages of protocol, patient variability, fear of patient falls, availability of therapy chairs, staff changes, time, and patient refusal. A multidisciplinary approach to protocol development for early mobility in an intensive care unit was successfully implemented at a regional level II trauma center.

Introduction Pharmacogenetics, in hand with precision medicine in oncology, represents an opportunity to holistically tailor a patient’s treatment regimen using both somatic and germline variants to improve efficacy and decrease toxicity. Colorectal cancer patients represent a population with frequent use of fluoropyrimidine and irinotecan and are an ideal opportunity for implementation of preemptive pharmacogenetics as evidence supports pharmacogenetic testing for DPYD and UGT1A1 to reduce fluoropyrimidine and irinotecan toxicities. Methods This was a single arm proof-of-concept study at a large community-based health system. Participants provided samples for pharmacogenetic testing via an external vendor prior to chemotherapy initiation and an oncology pharmacist was responsible for pharmacogenetic interpretation and pharmacogenetic-guided therapeutic recommendation to the treating provider. Results A total of 24 (60%) participants had a UGT1A1 variant. All participants (100%) were DPYD*1/*1. Results were available and interpreted for 29/40 (72.5%) participants prior to scheduled chemotherapy initiation (p value Conclusions In conclusion, we were able to show that implementation of preemptive pharmacogenetic testing into a community oncology clinic with results interpretation available prior to scheduled initiation of chemotherapy was feasible. As pharmacogenetic testing in oncology expands, pharmacists should be prepared to optimize supportive medication regimens as well as chemotherapy with pharmacogenetic results.

ObjectivesTo evaluate the predictive utility of the Activity Measure for Post-Acute Care ‘6-Clicks’ daily activity and basic mobility functional assessment short forms on inpatient discharge to home compared with skilled nursing facilities, including by diagnostic group (trauma injury, major lower joint replacement/reattachment, spinal fusion excluding cervical), as well as assess the effect of the short forms on 30-day inpatient readmissions.DesignRetrospective, observational cohort study of electronic health record data.SettingFive hospitals in a multistate, integrated healthcare system serving a large, rural US population.ParticipantsThe population-based adult (age ≥18) sample of acute care hospitalised patients receiving rehabilitation services included 10 316 patients with 12 314 hospital admissions from the year prior to 6-Clicks implementation (1 June 2015–31 May 2016) (pre-6-Clicks cohort) and 10 931 patients with 13 241 admissions from the year after 6-Clicks implementation (1 January 2017–31 December 2017) (post-6-Clicks cohort). Patients were admitted for major lower joint replacement/reattachment, spinal fusion excluding cervical, trauma injury or another reason.InterventionOccupational and physical therapist use of 6-Clicks daily activity and basic mobility short forms in the post-6-Clicks cohort.Primary and secondary outcomesDischarge disposition (home, including to assisted living, or skilled nursing facility, including swing beds) and 30-day inpatient readmissions.ResultsAreas under the receiver operating characteristic curve were 0.82–0.92 (daily activity) and 0.87–0.94 (basic mobility) for discharge to home or skilled nursing facilities, with trauma and spinal fusion patients having the highest values. Daily activity and basic mobility standardised positive and negative predictive values were highest for the three diagnostic groups compared with the full study sample. Few significant differences in 30-day readmissions were seen between pre- and post-6-Clicks cohorts.Conclusions6-Clicks performed well when distinguishing between discharge home or skilled nursing facilities, especially by diagnostic group, supporting use by occupational and physical therapists in discharge planning. Future research could assess where additional intervention or training may reduce 30-day readmissions.

BackgroundBlunt traumatic brachial plexus injuries (BTBPI) are severe peripheral nerve injuries which present in a small portion of trauma patients but can result in long-term neurological disability and severe chronic pain.ObjectiveThe goal of this study was to describe the epidemiology of BTBPI in a northern rural setting caused by motor-powered collisions, and to determine the relative risk of these injuries in shielded (cars, trucks, vans, and so on) and unshielded vehicles (snowmobiles, all-terrain vehicles and motorcycles).MethodsThis retrospective study describes the epidemiology of BTBPI caused by motor-powered collisions and treated at two level II trauma centers in northeast Minnesota and determines the relative risk of these injuries in shielded (cars, trucks, vans, and so on) and unshielded vehicles (snowmobiles, all-terrain vehicles and motorcycles). We hypothesized unshielded motor vehicle crashes in rural areas are at an increased risk of incurring BTBPI.ResultsOut of all injuries resulting from motor-powered collisions in a 20-year period (9951), BTBPIs were found in 63 trauma patients, a prevalence of 0.6%. The rate of BTBPI involving unshielded vehicles (1.0%) was significantly higher than those involving a shielded vehicle (0.4%) and primarily occurred in rural areas (70%).ConclusionsUnshielded vehicle crashes, particularly snowmobiles, have the highest risk for BTBPI in our rural region. The overall incidence of these injuries appears to be declining.Level of evidenceLevel III.

To document neuromuscular training (NMT) availability and its relationship to anterior cruciate ligament (ACL) injuries in 4 major high school sports by gender, sport, and rural/urban geography, with the hypothesis that increased exposure to NMT would be associated with fewer ACL injuries.A retrospective cohort study.All Minnesota high schools identified in the Minnesota State High School League (MSHSL) database for fall 2014 boys' football and soccer, and girls' volleyball and soccer.All high school athletic directors were surveyed to report their school's fall 2014 experience; 53.5% returned the survey reporting experience with one or more of the sports.Athletic directors documented each sport's preseason and in-season exposure to NMT (plyometric exercises, proximal/core muscle strengthening, education and feedback regarding proper body mechanics, and aerobics) and licensed athletic trainers.Reported ACL injuries by sport, gender and rural/urban.More than two-thirds of teams incorporated facets of NMT into their sport. Among male athletes, soccer players exposed to licensed athletic trainers experienced significantly fewer ACL injuries (P0.005), and NMT was associated with significantly fewer ACL injuries in football (P0.05) and soccer (P0.05). Female athletes did not demonstrate similar associated improvements, with volleyball injuries associated with increased NMT (P0.001), and soccer injuries not associated with NMT. However, girl soccer players in rural settings reported fewer ACL injures compared with urban teams (P0.001).Most fall high school sports teams were exposed to NMT, which was associated with fewer ACL injuries for male, but not for female athletes. Improved gender- and sport-specific preventive training programs are indicated.

The use of screening and brief interventions (SBI) has been proposed to reduce future alcohol misuse and injury in traumatic brain injury (TBI) patients. As a result a SBI protocol for TBI patients was introduced with nursing training at a community hospital. In the 2 years following the implementation of a SBI protocol and nursing training, the number of patients with positive alcohol results decreased. The number of brief interventions increased to 83 (40.1%, 95% confidence limit [CL] = 33.4, 46.8), and CAGE questionnaire screenings decreased to 88 (42.5%, 95% CL = 35.8, 49.2), with 31 (35.2%) having positive results. These results highlight the need to assess processes and training in the emergency department to ensure that SBIs occur.

Objective This study was designed to evaluate predictors of hospital length of stay (LOS) and readmissions among nonsurgical ischemic stroke patient, and the impact of inpatient medication management. Methods This retrospective cohort study includes adult patients (≥18 years) hospitalized with a diagnosis of nonsurgical ischemic stroke from November 2007 to March 2013. In November 2011, an inpatient medication management model was implemented in the stroke unit. At the end of the study period, patients were matched before and after implementation of the inpatient medication management model (non-PHC [pharmacist–hospitalist collaborative] and PHC, respectively) to evaluate change in outcomes. The primary outcome of the study is an evaluation of predictive factors affecting LOS and readmissions. Additionally, changes in LOS and all-cause readmission at 30, 60, and 90 days when compared between PHC and non-PHC were evaluated. Findings A total of 151 PHC patients were matched to 248 non-PHC patients. There was no difference in LOS between the PHC and non-PHC patients (mean adjusted difference −.14; P = .66). Similar finding was observed for readmissions ( P > .05). Insurance type was a significant predictor of LOS, with Medicare patients having an extended LOS compared to patients with private insurance (mean difference −1.00; P = .005). Patients taking statins and patients aged less than 80 years had a lower 30-day readmission rate compared to nonstatin users and patients aged 80 years or older, respectively ( P Conclusions Insurance type and severity of illness are important predictors of LOS, whereas readmissions are mostly influenced by age and statin use.

Same-day discharge (SDD) following percutaneous coronary intervention (PCI) is demonstratively safe, yet the nationwide rate of SDD remains low. The safety of SDD in the high-risk population is underexplored and the impact that rural/urban residency has on the safety of SDD is unknown. The objective

Objective To determine whether online exercise-associated collapse (EAC) prevention education decreases medical tent EAC visits among first-time marathoners. Design A prospective controlled study, with age- and sex-stratified randomization, evaluated rates of medical tent diagnosed EAC among runners randomized to the intervention group and intervention participants, compared with a control group. Setting Grandma's Marathon Medical Tent in Duluth, MN, June 2016. Participants Runners in the 2016 Grandma's Marathon who never previously ran a marathon (n = 2943), randomized into control (n = 1482) and intervention (n = 1461) groups. Intervention participants opened the EAC prevention video (n = 590). Interventions Online EAC education included an introductory webpage and 5-minute professional video describing EAC and prevention. Main outcome measures Medical tent visit with EAC diagnosis. Results Intervention participants had no decreased likelihood of EAC, compared with controls [odds ratio (OR), 0.88, 95% confidence interval (CI), 0.46-1.69]. Exercise-associated collapse occurred less frequently in those with longer race times (OR, 0.58, 95% CI, 0.43-0.79). Intervention participation was associated with longer race times (OR, 1.12, 95% CI, 1.10-1.23). Conclusions Those opening the EAC prevention video and controls had similar EAC rates. Slower running speed was associated with lower EAC rates. Video viewing was a predictor of slower running pace.

Background: There is little information on the impact of statins on hospital length of stay (LOS) or readmission among patients with sepsis. Objective: The objective of this study is to evaluate the association between statin use and LOS and all-cause readmissions among sepsis patients hospitalized in the medical unit. Methods: The design was a retrospective propensity score–matched study of adult patients with a primary diagnosis of sepsis from 2007 to 2013. Information was extracted from the electronic health record. Sepsis patients were identified using ICD-9CM codes. Propensity scores estimated the probability that a patient would be on statins, and patients who were on statins were then matched with those who were not, within ±0.05. Additional greedy matching criteria were organ dysfunction (yes/no) and all patient refined diagnosis-related group (APR-DRG) medical/surgical. The primary outcome was LOS, and the secondary outcomes were all-cause readmission at 30, 60, and 90 days, adjusted for age, sex, modified Deyo-Charlson comorbidity index, APR-DRG severity of illness (SOI), and APR-DRG medical/surgical, as appropriate. Results: Patients taking statins had a shorter LOS than patients not taking statins, 8.7 ± 3.7 and 10.3 ± 2.7 days, respectively (P value = 0.018). There was no significant difference (P> 0.05) in all cause readmissions between statin and nonstatin patients. Presence of comorbidities and SOI were significant factors for 60- and 90-day readmissions. Conclusions: The use of statins among patients admitted with primary sepsis in the medical unit was associated with shorter length of hospital stay. However, it did not affect frequency of readmissions.

BACKGROUND: The implementation of the Patient Protection and Affordable Care Act is anticipated to increase the frequency of emergency department (ED) visits. Therefore, there is a critical need to improve the quality of care transitions among ED patients from ED to outpatient services. OBJECTIVE: To evaluate the effect of systematic implementation of a pharmacist-led patient-centered approach to medication therapy management and reconciliation service (MRS) in the ED on patient utilization of available health care services. METHODS: A single institution prospective randomized cohort study with 90-day postvisit observation randomized patients into 2 groups: (1) medication therapy management reconciliation service following a patient-centered approach (MRS) or (2) usual care provided by the institution (non-MRS). To align patient enrollment with availability of other primary care services, subjects were enrolled during weekday daytime hours. Data for the 90 days before and after the index ED visit were matched in all analyses. Generalized estimating equations evaluated any primary care (PC), urgent care (UC), and ED visits during the 90 days post-index ED visit, adjusted by age and sex and weighted by survival time. Generalized linear models evaluated the average number of ED visits during that period, adjusted by age and sex and weighted by survival time. Data were analyzed for all adult patients (ADLTS), aged ≥ 18 years, and the subpopulation taking 1 or more prescribed daily medication at the time of the index ED visit (ADLTS1+)—the patients expected to receive greatest benefit from an MRS program. RESULTS: ADLTS MRS patients were 1.9 more likely than non-MRS patients to visit their PC providers (mean difference 0.15, P < 0.001). Similarly, ADLTS1+ MRS patients were 1.5 times more likely to visit their PC providers (mean difference 0.10, P = 0.026). Although ADLT MRS patients were less likely to visit the UC, this was not significant. However, ADLTS1+ MRS patients were significantly less likely than non-MRS patients (OR = 0.5, 95% CI = 0.3-0.9) to visit the UC. No significant difference was seen in ED visits. CONCLUSIONS: The implementation of a patient-centered approach to medication therapy management and reconciliation improved the odds of patients visiting their PC providers, a positive first step in transitioning patients toward an appropriate use of PC services. J Manag Care Spec Pharm. 2015;21(4):298-306

Objective. To evaluate the effectiveness of a whole-foods, plant-based diet (WFPB) to reduce symptoms of osteoarthritis. Methods. Six-week, prospective randomized open-label study of patients aged 19–70 with osteoarthritis. Participants were randomized to a WFPB (intervention) or continuing current diet (control). Outcomes were assessed by mixed models analysis of participant self-assessed weekly SF-36v2 domain t scores, weekly Patient Global Impression of Change (PGIC) scales, and mean weekly Visual Analog Scale (VAS) pain assessment. Mixed models analysis also evaluated pre-post change from baseline level for standard clinical measures: weight, BMI, body temperature, pulse, and blood pressure. Results. Forty participants were randomized. Thirty-seven of them, 18 control and 19 intervention, completed the study. The intervention group reported a significantly greater improvement than the control group in SF-36v2 energy/vitality, physical functioning, role physical, and the physical component summary scale. The differences between the intervention and control PGIC scales were statistically significant over time. Intervention group improvement in VAS weekly mean was also significantly greater than that of the control group from week 2 onward. Conclusion. Study results suggest that a whole-foods, plant-based diet significantly improves self-assessed measures of functional status among osteoarthritis patients.

Characterization studies of the metal micro-detector TimePix measuring dose distribution at the Minibeam Radiation Therapy setup (Bio-Medical Beamline ID17, ESRF) were performed. The results obtained for high intensity synchrotron radiation minibeams illustrate an excellent performance of the TimePix providing in real time 2D image of the dose distribution over many beams in a 14×14 mm 2 area. Peak-to-Valley–Dose–Ratios measured by TimePix and gafhromic films agree well.

Purpose The implementation and effects of an initiative to refer patients to receive medication therapy management (MTM) services after hospital discharge are described. Methods A check box to order an MTM appointment was added to the discharge medication order form printed for hospitalized patients in an integrated health system. Hospitalists were informed about MTM services and encouraged to refer hospitalized patients to the service who were at risk for adverse drug events or medication nonadherence. A retrospective case series review was conducted to evaluate documented MTM encounters, comparing the number of patients seen at the MTM practice for hospital follow-up during the four months before and after the initiative’s implementation. Secondary endpoints included revenue generated by MTM encounters and the percentage of patients with documented drug therapy problems due to medication nonadherence. Results A total of 313 encounters were included in the analysis (142 preimplementation and 171 postimplementation). The percentage of MTM hospital follow-up encounters significantly increased from the preimplementation period to the post-implementation period, from 30.28% ( n = 43) to 63.74% ( n = 109) ( p < 0.001). After the referral initiative was implemented, MTM hospital follow-up encounters were more likely to reveal medication nonadherence, compared with regular office visits (odds ratio, 2.1; 95% confidence interval, 1.01–4.34; p = 0.039). Conclusion The implementation of an initiative to refer hospitalized patients to an MTM service in an integrated health system increased the percentage of recently discharged patients seen in an MTM practice; patients seen postimplementation were more likely to be nonadherent to their medication regimen.

Purpose The implementation of a pharmacist-led anticoagulation management service (AMS) and the clinical outcomes of inpatients receiving warfarin management are described. Summary An AMS was established at St. Mary’s Medical Center (SMMC) in Duluth, Minnesota, in November 2003 at the request of orthopedic surgeons to manage warfarin for their patients postoperatively. The AMS was also available to other inpatients by physician request. All AMS pharmacists received didactic and experiential training. Each day, the managing pharmacist, usually the decentralized pharmacist, was responsible for checking the patients’ International Normalized Ratio (INR); reviewing other pertinent laboratory test values, any medication changes, and vital signs; monitoring changes in the patients’ clinical status, and writing an order for a warfarin dose. A database was created to help monitor patients managed by the AMS and to analyze monthly outcomes data. Clinical outcomes data were evaluated to identify areas of improvement for the AMS. All hospitalizations for patients who received anticoagulation therapy with warfarin managed by the AMS from January 1, 2006, through August 31, 2007, were analyzed. Primary endpoints, including thrombosis and bleeding complications during hospitalization, were identified for inclusion in the final hospital discharge data. Of the 2794 hospitalizations for patients managed by the AMS evaluated, 59 complications were identified. Of these, 14 (0.5%) were thrombosis events and 45 (1.6%) were bleeding events. INR results were also analyzed as secondary endpoints. Conclusion The evaluation of outcomes of the inpatient-based AMS at SMMC provided critical information to the anticoagulation subcommittee for consideration of quality-improvement efforts.

Objective: To determine if an internal employee health program (IEHP), including transitional work, with early access to physical medicine and rehabilitation provided by athletic trainers, will reduce missed workdays following work-related injury. Methods: A retrospective review of health system workers’ compensation data were conducted for injuries sustained 23month period preceding (PP) (N = 713) and following IEHP implementation (N = 661). Results: Sixty-two PP and 128 IEHP events resulted in lost workdays (LWDs), P < 0.001. For LWDs events, mean days lost decreased from 100.3 ± 119.7 PP to 44.6 ± 69.0 IEHP, P = 0.001, with 2.2 (95% confidence interval [CI]: 1.1–4.2) IEHP 3-week odds of returning to work.Conclusions: Internal employee health program reduced LWDs. Internal employee health program was associated with more than 10% increase in LWDs events, but LWDs event mean days lost decreased by more than 50%, with 3-week odds of returning to work more than 2.0.

Tissue perfusion and oxygenation changes following radiotherapy may result from and/or contribute to the toxicity of treatment. Breast tissue oxygenation levels were determined in the treated and non-treated breast 1 year after radiotherapy for breast conserving treatment. Transcutaneous oxygenation varied between subjects in both treated and non-treated breast. Subjects without diabetes mellitus (n=16) had an average oxygenation level of 64.8 ± 19.9mmHg in the irradiated breast and an average of 72.3 ± 18.1mmHg (p=0.018) at the corresponding location in the control breast. Patients with diabetes (n=4) showed a different oxygenation pattern, with lower oxygenation levels in control tissue and no decrease in the irradiated breast. This study suggests oxygenation levels in normal tissues vary between patients and may respond differently after radiotherapy.

Despite the proven benefit of implantable cardioverter-defibrillators (ICDs), inappropriate shocks remain a significant problem. Recent trends have shown an increased incidence of lead failure and an increased exposure of devices to extreme electromagnetic interference environments.The goal of the current study is to evaluate the spectral characteristics of ventricular fibrillation (VF) detected in an ICD at time of defibrillation threshold testing and use of the findings to predict event types from a population of clinical VF and artefact events.A modelling group was created from induced VF and artefact events at time of ICD implantation and DFT testing. Power spectral density evaluation was performed on each event and used to calculate an energy ratio (ER; the ratio of energy under the first three harmonics to the entire spectrum). The model was then applied to a database of clinical VF and artefact events to determine its sensitivity and specificity. The far-field ER of the modelling group was significantly larger for VF (0.888 ± 0.110) than artefact (0.265 ± 0.156, P0.0001). In the test group, the far-field ER of VF (0.882 ± 0.088) was also significantly larger than artefact (0.344 ± 0.128, P0.0001). At a cut-off of0.526, the far-field ER had a sensitivity of 100% [confidence interval (CI) 100-100%] and a specificity of 92.4% (CI 84.9-98.5%) to distinguish clinical VF from clinical artefact.Far-field signal during VF detected by an ICD has a distinct spectral pattern that can distinguish VF from artefact.

BACKGROUND The incidence of skin cancer is not well established in the French West Indies, aside from old data concerning cutaneous melanoma. METHOD A prospective study was performed over a 3-month period in late 2007 in the French West Indies. The number of new cases of histologically confirmed skin cancer was determined using a questionnaire. RESULTS The rate of participation of dermatologists was 82 %. During the study period, 166 skin cancers were diagnosed in 134 patients (66 women and 68 men: mean age=63.3 years, SD=2.5), including 137 basal cell carcinomas, 12 melanomas, seven squamous cell carcinomas, six Bowen's disease, one B lymphoma and one Paget's disease. The raw incidence of skin cancers detected by dermatologists was calculated as 64.6 cases/100 000 inhabitants/year for basal cell carcinoma, 5.7 cases/100 000 inhabitants/year for melanoma, 3.3 cases/100 000 inhabitants/year for squamous cell carcinoma, and 2.8 cases/100 000 inhabitants/year for Bowen's disease. Seven melanomas (almost exclusively of plantar topography) and seven basal cell carcinomas were diagnosed in patients of phototype V or VI. DISCUSSION Although lower than in metropolitan France, the number of skin cancers diagnosed by dermatologists in the French West Indies is fairly high. In addition, this study indicates the significant incidence of basal cell carcinomas and melanomas in subjects with phototype V or VI, underreported in the literature. These findings highlight the need to begin longer-term studies and to include skin carcinomas in the cancer registry of the French West Indies in order to better identify their characteristics among the Caribbean population.

OBJECTIVES: The goal was to investigate the relationships of income and income inequality with neonatal and infant health outcomes in the United States. METHODS: The 2000–2004 state data were extracted from the Kids Count Data Center. Health indicators included proportion of preterm births (PTBs), proportion of infants with low birth weight (LBW), proportion of infants with very low birth weight (VLBW), and infant mortality rate (IMR). Income was evaluated on the basis of median family income and proportion of federal poverty levels; income inequality was measured by using the Gini coefficient. Pearson correlations evaluated associations between the proportion of children living in poverty and the health indicators. Linear regression evaluated predictive relationships between median household income, proportion of children living in poverty, and income inequality for the 4 health indicators. RESULTS: Median family income was negatively correlated with all birth outcomes (PTB, r = −0.481; LBW, r = −0.295; VLBW, r = −0.133; IMR, r = −0.432), and the Gini coefficient was positively correlated (PTB, r = 0.339; LBW, r = 0.398; VLBW, r = 0.460; IMR, r = 0.114). The Gini coefficient explained a significant proportion of the variance in rate for each outcome in linear regression models with median family income. Among children living in poverty, the role of income decreased as the degree of poverty decreased, whereas the role of income inequality increased. CONCLUSIONS: Both income and income inequality affect infant health outcomes in the United States. The health of the poorest infants was affected more by absolute wealth than relative wealth.

Purpose Results of a study of hospitalization outcomes with the use of a pharmacist–hospitalist collaborative (PHC) model of care as an alternative to multidisciplinary rounds (MDR) are reported. Methods In a retrospective matched-cohort study, data on more than 2000 adults discharged from two medical units of a community teaching hospital were analyzed to compare selected outcomes before and after the units augmented traditional hospitalist care (usual care) with either MDR or a PHC care model emphasizing pharmacist involvement in case review and medication management. The study cohorts were matched for primary diagnosis, severity of illness, and other variables. The outcomes were mean length of stay (LOS) and rates of all-cause readmission during designated preintervention and intervention periods. Results Among patients admitted to the unit that implemented the PHC care model, those admitted during the preintervention period had a longer mean LOS than matched intervention-phase patients: 5.5 days (95% confidence interval [CI], 5.0–6.0 days) versus 4.7 days (95% CI, 4.2–5.3 days); p = 0.002. Patients admitted to the MDR unit during the preintervention period also had a significantly longer mean LOS than those in the matched intervention-phase cohort. There were no significant between-group differences in all-cause readmissions. Conclusion Systematic implementation of either the PHC or the MDR model of care was associated with a decreased mean hospital LOS relative to LOS values with usual care only. No significant differences in readmissions at 30, 60, and 90 days were attributable to implementation of the PHC or the MDR model.

Background Little is known about how individuals with a predisposition for rosacea appear in childhood. This retrospective, matched control, longitudinal study examined the relationship between childhood stye and adult rosacea. Methods The records of the Rochester Epidemiology Project were examined to identify patients who received care for stye or blepharitis between ages 2 and 17 years, and received care for any cause at age 40 years or older. Patients were matched by group to control subjects (1:2). Results Patients with stye during childhood (N = 201) had a higher prevalence of adult rosacea than did control subjects (5.5% vs 1.5%, P = .01). Patients who had other childhood eye conditions without stye (N = 504) were not at higher risk. Limitations The study population included few minority patients. Conclusions The association between childhood stye and adult rosacea appears to be significant and should be examined further. Rosacea prevalence in adults may be lower (2.1%) than previously reported.

Background Tractor-related injuries are among the most severe of agricultural injuries. This study identifies the incidence, consequences, and potential risk factors for tractor injuries among 3,765 agricultural households in a five-state region. Methods Demographic, injury, and exposure data were collected for two 6-month recall periods in 1999 using computer assisted telephone interviews. A causal model served as a basis for survey design, data analysis, and interpretation of results; associated directed acyclic graphs guided development of multivariate models. Results The overall injury rate was 9.6 events per 1,000 persons per year. Increased personal risk was observed for males and prior agricultural injury experience. Compared with ages 35–44, decreased risks were identified for those less than 5, 5–9, 10–14, 15–19, and 20–24. Conclusions Risk of tractor injury among agricultural household members varied by gender, age, and prior injury experience. Am. J. Ind. Med. 47:254–264, 2005. © 2005 Wiley-Liss, Inc.

In order to reduce the number of multiple pregnancies following IVF, the Belgian government agreed to reimburse laboratory expenses for six IVF cycles up to the age of 42 years, in exchange for restriction of the number of embryos replaced. Data on assisted reproduction outcome before and after the introduction of this new legislation were analysed retrospectively in terms of implantation, pregnancy and multiple pregnancy rates. After the introduction of the new law, the percentage of single embryo transfer increased from 14 to 49%. Implantation rates were 25.9 and 23% respectively. There was no difference in the overall pregnancy rate before and after the introduction (36 versus 37%). Twin pregnancies, however, decreased from 19 to 3%. These findings indicate that elective single embryo transfer significantly decreases the twin pregnancy rate without a reduction in the overall pregnancy rate.

In a double-blind, placebo-controlled, randomized study, 55 anovulatory subjects received a single s.c. injection of placebo (n = 10) or recombinant long-acting FSH [FSH-carboxy terminal peptide (CTP), ORG 36286, corifollitropin alfa; NV Organon, The Netherlands] in doses of 7.5 (n = 13), 15 (n = 10), 30 (n = 11), or 60 microg (n = 11). The injection was given 2 or 3 d after the onset of a spontaneous or progestagen-induced withdrawal bleed. After drug administration, the induced follicular response varied widely among subjects in each dose group. The percentage of subjects with a follicular response (at least one follicle > or = 10.0 mm) increased with the dose (P < 0.01) and was 10, 31, 70, 73, and 82% in the placebo and 7.5-, 15-, 30-, and 60-microg treatment groups, respectively. In responding subjects, the average maximum number of follicles was 4.0, 7.6, 13.4, and 20.0, respectively, which was reached at 6.5, 6.9, 6.6, and 8.2 d after a single dose of 7.5, 15, 30, and 60 microg FSH-CTP, respectively. The dose-response for the number of follicles was statistically significant within the dose range tested (P < 0.01). Peak serum inhibin-B levels were significantly correlated with serum estradiol (E2) levels (r = 0.84, P < 0.01), and peak concentrations of inhibin-B and E2 correlated with the number of follicles observed at the same time point (for both hormones; r = 0.47, P < 0.01). Overall per treatment group, serum E2 and inhibin B concentrations significantly increased only in the two highest FSH-CTP dose groups, reaching peak concentrations at d 3 in the 30-microg group and at d 5 in the 60-microg group. Thereafter these hormone values declined rapidly, returning to baseline within 1 wk after FSH-CTP administration. In total, nine of the 55 treated subjects (16.4%) ovulated after drug administration: one subject in the placebo group, two subjects in the 7.5-microg group, three subjects in the 15-microg group, two in the 30-microg group, and one in the 60-microg group. Three subjects had monofollicular ovulation after placebo (n = 1) and a single dose of 15 microg FSH-CTP (n = 2). In two subjects with too many preovulatory follicles, (multiple) ovulation was prevented by GnRH antagonist administration. Thus, a single low dose of long-acting FSH-CTP was able to induce one or more follicles to grow up to ovulatory sizes, but the anovulatory status was not reversed because the incidence of subsequent (mono)ovulations was low.

Background There are no standardized measures for the severity of rosacea. Objectives To determine what clinical signs correlate best with global severity of rosacea, and to examine inter-rater reliability. Methods Four clinicians each made 82 assessments of rosacea patients. Each assessment used 60 0-to-10 Likert-like scales for the signs of rosacea. Subjects also assessed the severity of their rosacea. Results The clinicians' assessment of global severity correlated strongly with erythema, especially on the cheeks. Subjects' assessment of global severity correlated more strongly with papules/pustules. Different methods of assessing severity—estimation of area involved, intensity, or lesion counts—did not produce significantly different results. Inter-rater reliability was low on 11-point (0-10) scales, but improved when scales were collapsed to 5 or 4 points. Conclusions Clinicians and patients assess severity of rosacea differently, with clinicians focusing on erythema and patients focusing on papules/pustules. New instruments for assessing severity must address inter-rater reliability.

This study analyzed the impact of eight common chronic medical conditions on cancer patients' health-related quality of life (HRQoL) as measured by the functional living index-cancer (FLIC). The FLIC was administered to a population of 405 people in 14 communities in the North Central US within 4–8 weeks of diagnosis with breast or colorectal cancer. At that time, patients also self-reported any other health conditions for which they had been receiving medical treatment. The impact of the selected chronic conditions on the FLIC scores was analyzed using Student's t-tests and linear multiple regression. In the bivariate analysis, patients with heart/circulation problems had lower FLIC total scores (p < 0.05), physical well-being subscale scores (p < 0.05), and nausea subscale scores (p < 0.01). Patients with diabetes had lower nausea subscale scores (p < 0.05). The social well-being subscale score was higher with the report of arthritis/joint problems (p = 0.001). In multivariate analysis adjusted for age, arthritis/joint problems were predictive of the social well-being (p < 0.01) and hardship due to cancer (p < 0.05) subscale scores; heart/circulation problems (p < 0.001) and diabetes were predictive of the nausea subscale scores. ECOG performance status was significant predictor for the FLIC total and all of the subscale scores. HRQoL as measured with the FLIC scores in patients with cancer is impacted by the presence of other concurrent health conditions; this finding has implications for HRQoL theory and application.

Context Significant barriers exist in the delivery of state-of-the-art cancer care to rural populations. Rural providers' knowledge and practices, their rural health care delivery systems, and linkages to cancer specialists are not optimal; therefore, rural cancer patient outcomes are less than achievable. Purpose To test the effects of a strategy targeting rural providers and their practice environment on patient travel for care, satisfaction, economic barriers, and health-related quality of life. Methods A group-randomized trial was conducted with 18 rural communities in the north-central United States. Twelve of these communities were included and defined as the unit of analysis for the patient outcomes portion of the study. The intervention targeted rural providers and their practice environment. The subjects were patients with breast, colorectal, lung, and prostate cancers from the rural communities. The main outcomes were patients' travel to obtain health care, satisfaction with care, perceptions of economic barriers to care, and health-related quality of life. In total, 881 patients were included. Results Group randomization was balanced. Travel for health care was significantly reduced in the community group exposed to the intervention during months 13 to 24 following cancer diagnosis. The mean miles traveled per patient were 1,326 (SE = 306) for the experimental group and 2,186 (SE = 347) for the control group (P = 0.03). No significant differences in satisfaction with care, economic barriers to care, or health-related quality of life were found. Conclusions The intervention significantly reduced cancer patient travel for health care, which suggests that access to care improved in the experimental group. The results of this study do not allow conclusion that there was no effect on other patient outcomes. The results supported the study's conceptual framework and many of its hypotheses.

BACKGROUND: The impact of providing cognitive pharmacy services following hospital discharge has been studied with various results. This study is specifically focused on comprehensive medication management services delivered postdischarge in an interprofessional team environment to patients aged > 65 years. OBJECTIVE: To determine if delivery of comprehensive medication management services postdischarge will prevent hospital readmissions or emergency department visits within 6 months following discharge in patients aged > 65 years. Secondary endpoints included 30-day and 60-day postdischarge events. METHODS: This was a prospective group matched-controlled study of patients aged > 65 years with selected diagnoses identified as high risk for readmission. The intervention group received comprehensive medication management that was provided face-to-face in the patient’s primary care clinic within 2 weeks of discharge. RESULTS: No statistically significant difference was found between intervention and control groups in hospital readmissions or emergency department visits at 30 days, 60 days, or 6 months after discharge. No statistically significant difference was seen in mortality between groups. CONCLUSIONS: Provision of comprehensive medication management services did not reduce emergency department visits or readmissions in this study. This study was limited by multiple other changes occurring in the health system during the time of this study that potentially confounded results. In addition, the study may have been too small to detect a difference.

Background/Aims The study aims to discover the prevalence of PHQ-9 use in primary care provider (PCP) clinical practice over a 7-year timeframe, and to determine the effect of PHQ-9 data on PCP diagnosing clinical depression and prescribing antidepressant drugs in clinical practice.

Brain injury, a leading cause of mortality, morbidity and disability in the United States, has serious consequences and substantial costs. Although previous studies have assessed a variety of outcomes subsequent to brain injury, documentation of performance prior to brain injury using a case-control approach has not been included; preinjury performance differences may confound the estimate of the effects of brain injury on performance. The primary objective of this study was to compare academic performance before and after brain injury in a population of university undergraduate students to determine the extent to which the academic career of the brain-injured person was altered from what would have been expected in the absence of such an injury. Cases included all undergraduate students in a major university, between the ages of 17 and 27, who incurred a brain injury requiring hospitalization between 1980 and 1984 (n = 99). Two comparison groups were used to determine whether changes in academic performance were specifically related to brain injuries or injuries in general: (1) injured controls, i.e. 121 students between the ages of 17 and 27 years, hospitalized for injuries other than to the central nervous system, and (2) uninjured academic controls, i.e. 198 students with out injuries requiring hospitalization during the study period, matched 2:1 to the brain-injured students by age, gender, and completed course credits categorized as90,or = 90. Although there were no differences when the total groups, including both males and females, were compared, there was a significant pre- to postinjury decrease in the grade point average for female cases when compared to their uninjured academic controls (p0.02). This difference was related to the effects of brain injury, and not to the effects of injury in general. No such difference was observed for the males. There were also no differences when the total groups, including males and females, were compared relevant to return to school. However, a significantly higher proportion of the female cases, compared with their uninjured academic controls, did not return to school after their injury; similar findings were identified for the injured controls as well. Thus, these differences were not specific to brain injury but rather to injury in general. In spite of this observation, the difference between female cases who returned and those who did not return was associated with neurological deficits, especially upper left limb motor deficits, as the time of hospital discharge. The findings from this effort are suggestive of gender differences in the consequences of brain injury and serve as a basis for further studies to evaluate the magnitude of this problem.

Although tractors account for the majority of fatal farming-related injuries, little is known about the magnitude of this problem. The study population in this article was obtained from the five state Regional Rural Injury Study-I (RRIS-I) database that included 3939 farm households and 13,144 persons interviewed during 1990. Rates were calculated for sociodemographic variables and various exposures; logistic regression was used to calculate the relative risks and respective confidence intervals. Among the total farming-related injury events (n = 764), 65 (8.4%) were related to regular tractor (or = 20 horsepower) use (495 injured persons per 100,000 persons per year). The rates increased incrementally for those persons working between 20 to 39 and 60 to 79 hours per week (range, 529 to 1430 per 100,000 persons). Among the 12 rollover events, there were only three injuries. The majority of injury events occurred while persons were mounting or dismounting the tractor (42%). Although only 7% of the cases were hospitalized, 83% required some type of health care. Among all injured persons, 43% were restricted from regular activities for 1 week or more and 20% were restricted for 1 month or more; 28% continued to have persistent problems. The finding of the large proportion of events associated with activities of mounting and dismounting suggests a need to investigate specific design characteristics of the tractors associated with these events and, in general, the tractors to which the population is exposed.

Objective: The primary objective of this case study was to evaluate the impact of a medication reconciliation service (MRS) provided by student pharmacists in an emergency department (ED). Methods: Eligible patients were assigned to two groups, MRS or non-MRS. Patients in the MRS group were seen by student pharmacists while the non-MRS group followed usual care. As part of the services provided by the student pharmacists, medication reconciliation was provided under the supervision of a clinical pharmacist. At the conclusion of their ED visit, patients were asked to complete a survey addressing knowledge of medications, confidence in medication taking and patient satisfaction. To evaluate the impact of provision of MRS by student pharmacists on readmission rates in the ED, the electronic health records of the institution were queried for subsequent inpatient hospitalizations and ED visits. Results: Based on the study, patients in MRS group were more likely to be satisfied with the education provided to them in the ED (p=0.016) and had greater confidence in taking their medications (p=0.03). Sixty days post ED visit MRS group readmissions were significantly lower compared to non-MRS group (P= 0.047). Conclusions: Students' participation in the provision of medication reconciliation led to reduction of readmission in the tertiary care ED, improved patient satisfaction and confidence in medication use. Type: Case Study

Background/Aims The Essentia Health Heart Failure Program (HFP) began in 1998, with the primary goal of improving care, with the expectation that both mortality and rehospitalization would be better controlled. This effort reviewed the electronic health records (EHR) of Essentia Health East heart failure patients ages 65 and over (65+), following hospital discharge, to assess the relationships between HFP participation and post-discharge survival (all-cause mortality) 30 days, six months and one year, and rehospitalization at 30 and 60 days.

Synchrotron radiation (SR) therapy is a promising alternative to treat brain tumors, whose management is limited due to the high morbidity of the surrounding healthy tissues. Several approaches are being explored by using SR at the European Synchrotron Radiation Facility (ESRF), where three techniques are under development Synchrotron Stereotactic Radiation Therapy (SSRT), Microbeam Radiation Therapy (MRT) and Minibeam Radiation Therapy (MBRT).The sucess of the preclinical studies on SSRT and MRT has paved the way to clinical trials currently in preparation at the ESRF. With this aim, different dosimetric aspects from both theoretical and experimental points of view have been assessed. In particular, the definition of safe irradiation protocols, the beam energy providing the best balance between tumor treatment and healthy tissue sparing in MRT and MBRT, the special dosimetric considerations for small field dosimetry, etc will be described. In addition, for the clinical trials, the definition of appropiate dosimetry protocols for patients according to the well established European Medical Physics recommendations will be discussed. Finally, the state of the art of the MBRT technical developments at the ESRF will be presented. In 2006 A. Dilmanian and collaborators proposed the use of thicker microbeams (0.36-0.68 mm). This new type of radiotherapymore » is the most recently implemented technique at the ESRF and it has been called MBRT. The main advantage of MBRT with respect to MRT is that it does not require high dose rates. Therefore it can be more easily applied and extended outside synchrotron sources in the future.« less

Background This study examined potential associations between parental safety beliefs and children’s chore assignments or risk of agricultural injury. Methods Analyses were based on nested case–control data collected by the 1999 and 2001 Regional Rural Injury Study-II (RRIS-II) surveillance efforts. Cases (n ¼ 425, reporting injuries) and controls (n ¼ 1,886, no injuries; selected using incidence density sampling) were persons younger than 20 years of age from Midwestern agricultural households. A causal model served as the basis for multivariate data analysis. Results Decreased risks of injury (odds ratio [OR] and 95% confidence intervals [CI]) were observed for working-aged children with ‘‘moderate,’’ compared to ‘‘very strict’’ parental monitoring (0.60; 0.40–0.90), and with parents believing in the importance of physical (0.80; 0.60–0.95) and cognitive readiness (0.70, 0.50–0.90, all children; 0.30, 0.20–0.50, females) when assigning new tasks. Parents’ safety beliefs were not associated with chore assignments. Conclusions Parents’ safety beliefs were associated with reduced risk of childhood agricultural injury; the association was not mediated by chore assignments. Am. J. Ind. Med. 52:724–733, 2009. 2009 Wiley-Liss, Inc.

In a large and open prospective multicenter trial of 12,250 cycles from 2,378 women, contraceptive efficacy, clinical tolerance and acceptability of a new monophasic contraceptive combination containing 75 mcg gestodene (delta-5-levonorgestrel) and 30 mcg ethinyl oestradiol were studied. The objective was to assess efficacy, safety, side effects and cycle control of this oral contraceptive on healthy women using no other additional birth control methods. Two women became pregnant (0.016%) during the trial; both were patient failures. There was no effect on systolic or diastolic pressures. An average weight increase of 0.3 kg was noted. Cycle control was excellent with 95% of the cycles free of spotting and 98% free of breakthrough bleeding after six cycles. No serious complications occurred. There was an overall incidence of 14% reported side effects (after six cycles), indicating that the hormonal combination is well tolerated. It should be noted that 41.4% of the patients had some complaint before starting the treatment. For all complaints, a highly significant improvement was seen during the treatment.In a large and open prospective multicenter trial of 12,250 cycles from 2378 women, contraceptive efficacy, clinical tolerance, and acceptability of a new monophasic oral contraceptive (OC) containing 75 mcg gestodene (delta-5-levonorgestrel) and 30 mcg ethinyl estradiol (EE) were studied. The objective was to assess efficacy, safety, side effects, and cycle control for this OC on healthy women using no other additional birth control methods. 2 women became pregnant (0.016%) during the trial; both were patient failures. There were no side effects on systolic or diastolic pressure. An average weight increase of 0.3 kg was noted. Cycle control was excellent with 95% of the cycles free of spotting and 98% free of breakthrough bleeding after 6 cycles. no serious complications occurred. There was an overall incidence of 14% who reported side effects after 6 cycles, indicating that the hormonal combination is well-tolerated. It should be noted that 41.4% of the patients had some complaint prior to the start of treatment. For all complaints, a highly significant improvement was seen during treatment.

Objective: To evaluate whether children’s agricultural work practices were associated with agricultural injury and to identify injury and work practice predictors. Design: Analyses were based on nested case–control data collected by the Regional Rural Injury Study-II (RRIS-II) surveillance study in 1999 and 2001 by computer-assisted telephone interviews. Subjects: Cases (n = 425) and controls (n = 1886) were persons younger than 20 years of age from Midwestern agricultural households. Those reporting agricultural injuries became cases; controls (no injury) were selected using incidence density sampling. Main outcome measures: Multivariate logistic regression was used to estimate the risks of injury associated with agricultural work, performing chores earlier than developmentally appropriate, hours worked per week, and number of chores performed. Results: Increased risks of injury were observed for children who performed chores 2–3 years younger than recommended, compared to being “age-appropriate” (odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.4–4.5); performed any agricultural work (3.9 (2.6–5.6)); performed seven to ten chores per month compared to one chore (2.2 (1.3–3.5)); and worked 11–30 or 31–40 h per week compared to 1–10 h (1.6 (1.2–2.1) and 2.2 (1.3–3.7), respectively). Decreased risks of injury were observed for non-working children compared to children performing what are commonly considered safe levels of agricultural work. Conclusions: This study demonstrated elevated risks of agricultural injury among children who perform developmentally inappropriate chores. Results suggest that the efficacy of age restrictions for preventing the occurrence of childhood agricultural injuries warrants further evaluation.

This was a prospective study designed to examine the potential of massage to reduce agitation in cognitively impaired nursing home residents. Subjects were identified as susceptible to agitation by nursing home staff or by Minimum Data Set (MDS) report. Data was collected during baseline (3 days), intervention (6 days), and at follow-up. Five aspects of agitation were assessed: Wandering, Verbally Agitated/Abusive, Physically Agitated/Abusive, Socially Inappropriate/Disruptive, and Resists Care. At each observation, agitation was scored 5 times during the 1-hour window of observation. Subjects' agitation was lower during the massage intervention than at baseline (2.05 vs. 1.22, P < .001), and remained lower at follow-up. Of the 5 agitated behaviors examined in this study, massage was associated with significant improvement for 4: Wandering (0.38 vs. 0.16, P < .001), Verbally Agitated/Abusive (0.59 vs. 0.49, P = .002), Physically Agitated/Abusive (0.82 vs. 0.40, P < .001), and Resists Care (0.10 vs. 0.09, P = .022). When analysis was restricted to residents with significant levels of agitation at baseline, the observed effects of massage on agitation increased. Massage is an accessible, easily learned intervention that is effective in controlling some types of agitation in elders with cognitive impairment. Massage should be studied further as a nonpharmacological intervention in such patients.

Objectives: To identify the incidence, severity, and potential risk factors for sports/recreational injuries incurred by children and adults in a five state, rural, Midwest, agricultural household population. Methods: Computer assisted telephone interviews that included questions about all injuries were completed for eligible, participating households for 1999; 16 538 people participated, including 8488 children less than 20 years of age. Rates and 95% confidence intervals were calculated, and causal models guided multivariate models. Results: Of a total of 2586 injuries, 1301 (50%) were not related to agricultural activity. Among these, 733 (28%) were associated with sports/recreational activities including multiple person sports (64%), general play activities (19%), and single person sports (14%). The overall rate was 46.4 injury events per 1000 persons per year. Rates for children were 99.4 for boys and 64.3 for girls. For adults (aged 20 and above), rates were 11.9 for men and 4.8 for women. For children, 93% received health care, 44% were restricted for seven or more days, and 18% lost agricultural work time of seven or more days; the respective proportions for adults were 88%, 45%, and 17%. Multivariate analysis for children showed increased risks for Nebraska residents, males, and those 10–14 or 15–19 years. For adults, increased risks were identified for males and those 20–24 years; decreased risks were observed for Nebraska residents and those 45–54 years. Conclusions: Sports/recreational activities are an important source of injury with relevant consequences for this population, including significant restricted daily activity and lost agricultural work time. Key findings provide a basis for further study to address these burdens.

Aims To determine the axillary recurrence rate in breast cancer patients with negative sentinel lymph nodes (SLN) who did not undergo further axillary lymph node dissection (ALND), and to establish whether this conservative axillary approach leads to an increased recourse to diagnostic axillary biopsy during the follow-up period because of the clinical suspicion of nodal recurrence. Methods In 479 patients, operated on for early breast cancer between 1998 and 2002 in five institutions, SLN biopsy was negative and no further axillary surgery was performed. SLN was localized using subdermal injection with 30–50 MBq of 99m-Tc-colloidal albumin. Follow-up controls were performed at 6-monthly intervals. Results The mean number of SLNs removed was 1.4 per patient. Most patients (90.6%) were given adjuvant systemic therapy, based on the primary tumour characteristics. At a median follow-up of 35.8 months, no clinical axillary recurrence was found. No patient underwent surgical axillary biopsy for suspicious clinical or ultrasonographic findings. Conclusions Our results confirm that SLN biopsy without ALND in SLN-negative patients with early breast cancer is not followed by clinically evident axillary recurrence in the short-term.

Objective. Depression is a major barrier to effective pain relief. The SF-36 Health Survey may be useful as an outcome measure for chronic pain patients with and without depression. The study purpose was to determine the correlation between the SF-36 Mental Composite Scale t -score and depression type in chronic pain patients and the positive predictive value of the SF-36 in classifying depression type in chronic pain patients. Design. Cross-sectional survey of chronic pain patients at baseline assessment. Setting. Interdisciplinary pain management center in the North Central United States. Patients. Two hundred forty-two consecutive, chronic noncancer pain patients. Interventions. Assessments of patient-reported health-related quality of life (SF-36), pain, pain type and diagnoses, mental health diagnoses, and patient demographics. Outcome Measures. SF-36 Health Survey, pain diagnoses, and depression diagnoses. Results. Study participants were 160 women (66%) and 82 men (34%), 95% Caucasian, whose mean age was 46 (±0.8 SD) years (range: 19–83). All types and diagnoses of chronic pain were represented. The prevalence of major depressive disorder was 52%. The type of depression was highly correlated with SF-36 score ( r =−0.567; P < 0.001). All chronic pain patients had very low SF-36 scores. Compared with U.S. population norms, chronic pain patients with and without depression had significantly lower SF-36 scores as measured by z -scores. Chronic pain patients with major depressive disorder had a significantly lower Mental Composite Score t -score than those with minor or no depression—34.1 and 47.6, respectively ( P < 0.001). The positive predictive value of the SF-36 for differentiating major depression from minor or no depression was 98% (sensitivity=84.4%, specificity=93.9%). Conclusions. The SF-36 Mental Composite Score and all subscales were highly correlated with depression type in chronic pain patients. The positive predictive value of the SF-36 in classifying depression type was high. The SF-36 may be a useful clinical tool to measure health-related quality of life in chronic pain patients. In addition, the SF-36 was able to detect major depression and demonstrate a dose-effect relationship between depression type (severity) and health-related quality of life in chronic pain patients.

PURPOSE: Effective methods that encourage rural primary-care physicians to adopt state-of-the-art cancer management practices are needed. The purpose of this study was to evaluate educational and systems strategies to improve rural primary-care physicians' cancer practice behaviors. DESCRIPTION OF STUDY: The Lake Superior Rural Cancer Care Project was a group-randomized, controlled trial conducted with 18 rural communities in the North Central United States over 4 years. Although the unit of analysis was the community, the subjects were 104 primary-care physicians and 2089 rural patients with cancer. The intervention was educational and comprised systems strategies that targeted rural primary-care physicians and their healthcare delivery systems. The outcome measures reported here were physician practice behaviors regarding cancer diagnosis, staging, treatment, clinical trial participation, and post-treatment surveillance. RESULTS: The intervention significantly improved 5 of the 37 cancer practice end points. The overall result of the study did not support the majority of the study hypotheses. Because 16 practice end points were found to be at acceptable performance levels, the possibility of a measurable intervention effect was limited. CLINICAL IMPLICATIONS: Earlier, the authors reported the results of the intervention on providers' cancer management knowledge, which showed significant improvement. The present study findings demonstrated that improving provider knowledge does not necessarily improve practice performance. Changing practice behaviors sarily improve practice performance. Changing practice behaviors requires much more effort. Furthermore, interventions found to be effective in other diseases, types of providers, or settings may not work on rural providers for cancer management.