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Objective: To develop and validate a novel, mail-in semen analysis (SA) system., Design: Prospective cohort., Setting: Not applicable., Patient(s): Ejaculates from normospermic men., Intervention(s): One-hour SA, then repeat SAs (on same ejaculate) over 52 hours using a novel technique for maintaining sperm viability., Main Outcome Measure(s): World Health Organization SA parameters., Result(s): One-hour SA on 104 ejaculates in the validation phase of the study demonstrated normal semen parameters. With up to 52 hours of observation and four subsequent SA measurements/ejaculate, concentration remained stable, motility decreased by 0.39%/h, and normal morphology decreased by 0.1%/h. Measured 1-hour and calculated motility (correlation coefficients 0.87) and morphology (correlation coefficients 0.82) strongly were correlated., Conclusion: This novel, mail-in, Clinical Laboratory Improvement Amendments-approved SA testing system demonstrates a strong degree of correlation between 1-hour and delayed SA testing. Given the linear motility and morphology decrease and stability of sperm concentration, this test may be used in clinical practice to evaluate semen quality for fertility evaluations. Furthermore, this approach significantly improves the ease, comfort, and efficiency of obtaining a SA, likely breaking down early barriers to accessing successfully a male fertility evaluation., (Copyright © 2020. Published by Elsevier Inc.)

The Caring Contacts suicide prevention intervention has been promoted by the Joint Commission, given its effectiveness, high reach, and cost effectiveness. Despite its increased application, no study has examined whether patient characteristics influence perceptions of the intervention, which may inform implementation efforts and ultimately impact effectiveness. One hundred fifty-four veterans were recruited from a Veterans Affairs psychiatric inpatient unit. Participants completed a survey to provide feedback on preferences, including the message correspondent, format (e.g., postcard, email), the importance of handwriting (vs. typed), visual presentation, and schedule for mailings. Results demonstrated that Caring Contacts preferences did not differ by most variables, including military rank, combat deployment history, or most personal technology use characteristics. Some demographic differences were identified, especially by age. More older veterans preferred messages to be sent in a physical letter compared to younger veterans, but if messages were sent via postal mail, younger veterans had a stronger preference for messages to be handwritten and sent using real stamps and colorful envelopes. Overall, findings suggest that few Caring Contacts adaptations are needed based on patient characteristics. Programs targeting older cohorts should consider postal mail formats for Caring Contacts.

Background: Population mail-out bowel screening programs are a convenient, cost-effective and sensitive method of detecting colorectal cancer (CRC). Despite the increased survival rates associated with early detection of CRC, in many countries, 50% or more of eligible individuals do not participate in such programs. The current study systematically reviews interventions applied to increase fecal occult blood test (FOBT) kit return, specifically in population mail-out programs., Methods: Five electronic databases (PubMed, PsycINFO, Scopus, CINAHL, and ProQuest Dissertations and Theses) were searched for articles published before the 10th of March 2018. Studies were included if they reported the results of an intervention designed to increase the return rate of FOBT kits that had been mailed to individuals' homes. PRISMA systematic review reporting methods were applied and each study was assessed using Cochrane's Risk of Bias tool. Pooled effect sizes were calculated for each intervention type and the risk of bias was tested as a moderator for sensitivity analysis., Results: The review identified 53 interventions from 30 published studies from which nine distinct intervention strategy types emerged. Sensitivity analysis showed that the risk of bias marginally moderated the overall effect size. Pooled risk ratios and confidence intervals for each intervention type revealed that telephone contact RR = 1.23, 95% CI (1.08-1.40), GP endorsement RR = 1.19, 95% CI (1.10-1.29), simplified test procedures RR = 1.17, 95% CI (1.09-1.25), and advance notifications RR = 1.09, 95% CI (1.07-1.11) were effective intervention strategies with small to moderate effect sizes. Studies with a high risk of bias were removed and pooled effects remained relatively unchanged., Conclusions: Interventions that combine program-level changes incorporating the issue of advance notification and alternative screening tools with the involvement of primary health professionals through endorsement letters and telephone contact should lead to increases in kit return in mail-out CRC screening programs., Systematic Review Registration: This review is registered with PROSPERO; registration number CRD42017064652.

Importance: In the United States, more than 50% of cervical cancers are diagnosed in underscreened women. Cervical cancer screening guidelines now include primary human papillomavirus (HPV) testing as a recommended strategy. Home-based HPV self-sampling is a viable option for increasing screening compliance and effectiveness; however, US data are needed to inform health care system implementation., Objective: To evaluate effectiveness of mailed HPV self-sampling kits vs usual care reminders for in-clinic screening to increase detection and treatment of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and uptake of cervical cancer screening., Design, Setting, and Participants: Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Women aged 30 to 64 years with health plan enrollment for 3 years and 5 months or more, a primary care clinician, no Papanicolaou test within 3 years and 5 months, and no hysterectomy were identified through electronic medical records and enrolled from February 25, 2014, to August 29, 2016, with follow-up through February 26, 2018., Interventions: The control group received usual care (annual patient reminders and ad hoc outreach from primary care clinics). The intervention group received usual care plus a mailed HPV self-sampling kit., Main Outcomes and Measures: Two primary outcomes were (1) CIN2+ detection within 6 months of screening and (2) treatment within 6 months of CIN2+ detection. Screening uptake within 6 months of randomization was a secondary outcome., Results: A total of 19 851 women (mean [SD] age, 50.1 [9.5] years) were included, with 9960 randomized to the intervention group and 9891 randomized to the control group. All women randomized were included in analysis. In the intervention group, 12 participants with CIN2+ were detected compared with 8 in the control group (relative risk, 1.49; 95% CI, 0.61-3.64) and 12 cases were treated vs 7 in the control group (relative risk, 1.70; 95% CI, 0.67-4.32). Screening uptake was higher in the intervention group (2618 participants [26.3%] vs 1719 participants [17.4%]; relative risk, 1.51; 95% CI, 1.43-1.60)., Conclusions and Relevance: Mailing HPV kits to underscreened women increased screening uptake compared with usual care alone, with no significant differences in precancer detection or treatment. Results support the feasibility of mailing HPV kits to women who are overdue for screening as an outreach strategy to increase screening uptake in US health care systems. Efforts to increase kit uptake and follow-up of positive results are warranted to maximize detection and treatment of CIN2+., Trial Registration: ClinicalTrials.gov identifier: NCT02005510.

Importance: Colonoscopy and fecal immunochemical testing (FIT) are considered top-tier tests for colorectal cancer (CRC) screening. Behavioral economic insights about "choice architecture" suggest that participation could be influenced by how people are presented test options., Objective: To investigate response rates for offering colonoscopy only compared with sequential choice (colonoscopy and then FIT) or active choice (colonoscopy or FIT) through mailed outreach., Design, Setting, and Participants: Three-arm pragmatic randomized clinical trial conducted between November 14, 2017, and May 14, 2018. The setting was primary care practices at an academic health system. Patients aged 50 to 74 years with at least 2 primary care visits in the 2-year preenrollment period were included if they were eligible but not up to date on CRC screening., Interventions: Eligible patients received mailed outreach about CRC screening. Equal numbers of eligible patients were randomly assigned to 3 outreach groups to receive mailings about CRC screening with the following options: (1) direct phone number to call for scheduling colonoscopy (colonoscopy only), (2) direct phone number to call for colonoscopy and a mailed FIT kit if no response within 4 weeks (sequential choice), or (3) direct phone number to call for colonoscopy and a mailed FIT kit offered at the same time (active choice)., Main Outcomes and Measures: The primary outcome was CRC screening completion (FIT or colonoscopy) within 4 months of initial outreach. The secondary outcomes were CRC screening completion within 6 months of outreach and the choice of colonoscopy as a screening test., Results: In total, 438 patients were included in the intent-to-treat analysis, with a median age of 56 years (interquartile range, 52-63 years); 55.0% were women. At 4 months, the CRC screening completion rates were 14.4% (95% CI, 8.7%-20.1%) in the colonoscopy-only arm, 17.1% (95% CI, 11.0%-23.2%) in the sequential choice arm, and 19.9% (95% CI, 13.4%-26.4%) in the active choice arm. Neither choice arm achieved a screening rate statistically greater than that in the colonoscopy-alone arm. Among those who completed CRC screening at 4 months, 90.5% (95% CI, 78.0%-103.0%) chose colonoscopy in the colonoscopy-only arm, which was significantly higher than the 52.0% (95% CI, 32.4%-71.6%; P = .005) and 37.9% (95% CI, 20.2%-55.6%; P < .001) in the sequential choice and active choice arms, respectively., Conclusions and Relevance: There was no significant increase in CRC screening when offering sequential or active choice, but there was a lower rate of colonoscopy in the choice arms than in the colonoscopy-only arm. Subtle changes in sequencing or defaults can alter patient decision making related to preventive health., Trial Registration: ClinicalTrials.gov identifier: NCT03246438.

Objective: We conducted a trial embedded within the German National Cohort comparing the responses to study invitations sent in recycled envelopes of grey color vs. envelopes of white color. We analyzed paradata for reactions to the invitation letters by potential subjects, the duration between mailing date of the invitation and active responses, and study participation., Results: Grey envelopes only slightly increased the chance of active responses (OR 1.16, 95% CI 0.83, 1.62) to the invitation letter. Potential study subjects with German nationality (OR 3.75, 95% CI 2.07, 7.66) and age groups above 50 years (50-59: OR 1.78, 95% CI 1.19, 2.69; 60-69: OR 2.25, 95% CI 1.48, 3.43) were more likely to actively respond to the invitation letter. The duration between mailing date of the invitation and active response was not associated with envelope color, sex, nationality, or age. Our trial replicates previous observations that the color of the envelope of a study invitation does not influence the likelihood of an active response or study participation.

Importance: Colorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups., Objective: To examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates., Design, Setting, and Participants: This parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled., Interventions: Interventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion)., Main Outcomes and Measures: The primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures., Results: A total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%-15.1%) in the mail and monetary group and 7.1% (95% CI, -0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%-64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, -0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03)., Conclusions and Relevance: Financial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups., Trial Registration: ClinicalTrials.gov identifier: NCT00697047.

Background: Human papillomavirus (HPV) self-testing is an emerging cervical cancer screening strategy, yet few mail-based HPV self-testing programs have been implemented in the United States. We report the results of a pilot study of a mail-based program, the Health Outcomes through Motivation and Education Project., Methods: In 2015 to 2016, we recruited 103 women from Appalachian Ohio who were aged 30 to 65 years and had not received a Papanicolaou (Pap) test in at least 3 years. Women were mailed an HPV self-test and randomized to receive either (a) self-test instructions developed by the device manufacturer and a standard information brochure about cervical cancer (control group) or (b) self-test instructions developed by the Health Outcomes through Motivation and Education Project and a photo story information brochure about cervical cancer (intervention group). Logistic regression compared study arms on HPV self-test return and receipt of a Pap test., Results: Overall, 80 (78%) women returned their HPV self-test. Return was similar among the intervention and control groups (78% vs. 77%; odds ratio, 1.09; 95% confidence interval, 0.43-2.76). Among returners, 26% had an oncogenic HPV type detected in their sample. Women who returned their self-test reported high levels of satisfaction and positive experiences with the self-testing process. Few women overall received a Pap test (11%), and Pap testing was similar among the intervention and control groups (14% vs. 8%; odds ratio, 1.91; 95% confidence interval, 0.52-6.97)., Conclusions: Mail-based HPV self-testing programs are a potentially promising strategy for reaching underscreened women in Appalachia. Efforts are needed to better understand how to optimize the success of such programs.

The survival rate of those injured in combat in overseas contingency operations is higher than in previous conflicts. There is a need to assess the long-term psychosocial and quality of life outcomes of those injured in combat, yet surveying this population presents inherent challenges. As part of a large-scale, longitudinal examination of patient-reported outcomes of service members injured on deployment, the present manuscript evaluated the effectiveness of three postal strategies on response rates: (1) mailing a study prenotification postcard, (2) mailing the survey invitation in a larger envelope, and (3) including a small cash preincentive ($2). Evaluation of these strategies yielded mixed results in this population. Neither the prenotification postcard nor inclusion of a $2 cash preincentive significantly increased response rates. However, use of a larger envelope to mail the survey invitation significantly increased the response rate by 53.1%. Researchers interested in collecting patient-reported outcomes among military populations, including those with combat-related injuries, may find that increasing the visibility of recruitment materials is more effective for improving response rates than attempting to cognitively prime or offer prospective participants preincentives., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

This study quantified the biomechanical (movements and forces) and physiological (energy expenditure) demands of postal delivery performed with electrically assisted bicycles (EABs). Ten postal workers and 10 recreational athletes performed three simulated postal tasks (simulated mail delivery circuit, delivery distance [close vs. far], and 3-min stationary cycling) while carrying 0, 16 and 32 kg. Physiological (energy expenditure) and biomechanical (internal and external forces and joint angles) responses were calculated. Energy expenditure (10-20%; p < 0.05) and power output (30-44%; p < 0.05) increased with increasing mail loads. Ground reaction force increased (∼10%) for the far delivery distance, but joint reaction forces were unchanged. Lower hip flexion (p < 0.01), less hip abduction (p < 0.01) and larger spine anterior flexion (p < 0.01) were observed for the far delivery distance. Joint forces were not affected by the mail load transported (0-32 kg) or distance from the mailbox (close vs far). EABs can provide a suitable transportation method to assist mail delivery in terms of energy expenditure reduction., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Importance: Approximately 24 million US individuals receive care at federally qualified health centers, which historically have low rates of colorectal cancer screening. The US Preventive Services Task Force recommends routine colorectal cancer screening for individuals aged 50 to 75 years., Objective: To determine the effectiveness of an electronic health record (EHR)-embedded mailed fecal immunochemical test (FIT) outreach program implemented in health centers as part of standard care., Design, Setting, and Participants: This cluster randomized pragmatic clinical trial was conducted in 26 federally qualified health center clinics, representing 8 health centers in Oregon and California, randomized to intervention (n = 13) or usual care (n = 13). All participants were overdue for colorectal cancer screening during the accrual interval (February 4, 2014 to February 3, 2015)., Interventions: Electronic health record-embedded tools to identify eligible adults and to facilitate implementation of a stepwise mailed intervention involving (1) an introductory letter, (2) a mailed FIT, and (3) a reminder letter; training, collaborative learning, and facilitation through a practice improvement process., Main Outcomes and Measures: Effectiveness was measured as clinic-level proportions of adults who completed a FIT, and secondarily, any colorectal cancer screening within 12 months of accrual or by August 3, 2015. Implementation was measured as clinic-level proportions of adults who were mailed an introductory letter and ordered a FIT., Results: Twenty-six clinics with 41 193 adults (mean [SD] age, 58.5 [6.3] years; 22 994 women) were randomized to receive the direct mail colorectal screening intervention (13 clinics; 21 134 patients) or usual care (13 clinics; 20 059 patients). Compared with usual care clinics, intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs 10.4%; difference, 3.4 percentage points; 95% CI, 0.1%-6.8%) and any colorectal cancer screening (18.3% vs 14.5%; difference, 3.8 percentage points; 95% CI, 0.6%-7.0%). We observed large variation across health centers in effectiveness (FIT completion differences range, -7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%). The number needed to mail to achieve a completed FIT was 4.8 overall, and 4.0 in clinics that mailed a FIT reminder., Conclusions and Relevance: An EHR-embedded mailed FIT outreach intervention significantly improved rates of FIT completion and rates of any colorectal cancer screening. Higher rates of colorectal cancer screening occurred in clinics that successfully implemented the mailed outreach program., Trial Registration: ClinicalTrials.gov identifier: NCT01742065.

Background: Postal questionnaires remain an important method of collecting data in trials. However, a high non-response rate can lead to biases, which may undermine the validity of the study., Aims: To assess a simple method of trying to improve response rates in an occupational health trial evaluating an intervention to prevent hand dermatitis in nurses., Methods: The trial employed questionnaires at t = 0, t = 1 month and t = 12 months. The t = 1 month questionnaire was posted to study participants (student and intensive care nurses) together with a free postage reply envelope. After 2 weeks, an e-mail was sent to non-responders reinforcing the need for completed questionnaires to be returned. Two weeks later, non-responders were sent another hard copy of the questionnaire, along with an accompanying letter. Six weeks after posting the initial questionnaires, non-responders were sent an SMS text message or were telephoned to remind them to return the questionnaire., Results: The response rates for the 744 student nurses were 8% (no reminder), 27% (after first reminder), 22% (after second reminder) and 27% (after the third reminder), resulting in a response rate of 63%. The response rates for the 959 intensive care nurses were 9% (no reminder), 24% (after first reminder), 24% (after second reminder) and 31% (after third reminder), resulting in a final response rate of 63%., Conclusions: We found that a series of regular reminders including a third, personalized reminder by SMS text or telephone had a positive impact on non-responders., (© The Author 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Background: Higher medication adherence is associated with positive health outcomes, including reduction in hospitalizations and costs, and many interventions have been implemented to increase patient adherence., Objectives: To determine whether patients experience higher medication adherence by using mail-order or retail pharmacies., Methods: Articles pertaining to retail and mail-order pharmacies and medication adherence were collected from 3 literature databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and International Pharmaceutical Abstracts (IPA). Searches were created for each database and articles were compiled. Articles were screened for exclusion factors, and final articles (n=15) comparing medication adherence in patients utilizing mail and retail pharmacies were analyzed. For each study, various factors were identified including days supply, patients' out-of-pocket costs, prior adherence behavior, therapeutic class, measure of adherence, limitations, and results. Studies were then categorized by disease state, and relevant information from each study was compared and contrasted., Results: The majority of studies-14 out of the 15 reviewed-supported higher adherence through the mail-order dispensing channel rather than through retail pharmacies. There are a number of reasons for the differences in adherence between the channels. Study patients who used mail-order pharmacies were more likely to have substantially higher prior adherence behavior, socioeconomic status, and days supply of medicines received and were likely to be offered financial incentives to use mail-order. The few studies that attempted to statistically control for these factors also found that patients using mail-order services were more adherent but the size of the differences was smaller. The extent to which these results indicate an inherent adherence advantage of mail-order pharmacy (as distinct from adherence benefits due to greater days supply, lower copays, or more adherent patients selecting mail-order pharmacies) depends on how well the statistical controls adjusted for the substantial differences between the mail and retail samples., Conclusions: While the research strongly indicates that consumers who use mail-order pharmacies are more likely to be adherent, more research is needed before it can be conclusively determined that use of mail-order pharmacies causes higher adherence., Disclosures: No outside funding supported this study. Fernandez was partially funded by a Virginia Commonwealth University School of Pharmacy PharmD/PhD Summer Fellowship for work on this project. The authors declare no other potential conflicts of interest. Study concept and design were contributed by Carroll and Fernandez. Fernandez took the lead in data collection, along with Carroll and McDaniel, and data interpretation was performed by Carroll and Fernandez. The manuscript was written and revised by Carroll and Fernandez, with assistance from McDaniel.

Purpose: Although breast cancer survivors' lifestyle choices affect their subsequent health, a majority do not engage in healthy behaviors. Because treatment end is a "teachable moment" for potentially altering lifestyle change for breast cancer survivors, we developed and tested two mail-based interventions for women who recently completed primary treatment., Methods: One hundred seventy-three survivors were randomly assigned to (1) Targeting the Teachable Moment (TTMI, n = 57), (2) Standard Lifestyle Management (SLM, n = 58), or (3) usual care (UC, n = 58) control group. Participants who were assigned to TTMI and SLM received relevant treatment materials biweekly for 4 months. Participants were assessed at baseline (T1, before randomization), post-treatment (T2, 4 months), and follow-up (T3, 7 months). Fruit and vegetable (F/V) intake, fat intake, and moderate-to-vigorous physical activity (MVPA) were assessed., Results: Results showed promise for these mail-based interventions for changes in health behaviors: Survivors in TTMI (+.47) and SLM (+.45) reported increased F/V intake, whereas those in UC (-.1) reported decreased F/V intake from T1 to T2. Changes in minutes of MVPA from T1 to T2 were higher in SLM than UC and marginally higher in TTMI than UC. However, these differences were due to decreased MVPA in UC rather than increased MVPA in the intervention groups. There were no group differences regarding fat intake. Survivors reported high satisfaction and preference for mail-based interventions, supporting feasibility., Conclusions: Mail-based lifestyle interventions for breast cancer survivors may benefit F/V intake and physical activity. Further testing and optimizing of these interventions is warranted.

Objective: Few studies have reported the outcome of direct outreach methods for recruitment of research participants in population-based samples. We describe the relationship of outreach strategies that are tailored to specific community factors to recruitment and consent outcomes in 10 National Children's Study direct outreach study locations (all were single counties)., Methods: Each study center collected data from a target population of women who resided in selected county segments that were sampled based on a geographic area probability sampling design. Based on county characteristics of the 10 study locations, each study center used site-specific marketing approaches (direct mail, mass media, provider referrals, social networking) to recruit study participants. Recruitment success was measured by the number of recruited women as well as by a qualitative assessment of the effectiveness of various recruitment methods., Results: The number of women who consented varied from 67 to 792. The majority of women were pregnant at the time of consent. Community awareness varied from <1% to 70%. Although no significant associations were found between community characteristics and recruitment success, we found that certain types of outreach strategies enhanced recruitment., Conclusions: In a small sample of 10 US counties, recruitment success was not associated with community characteristics. It was, however, associated with certain types of outreach strategies that may be more effective in close-knit communities., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: To come into compliance with South Carolina statute, we changed how nurses handle medications (antibiotics, erythropoietin [EPO], calcitriol and heparin) in our outpatient home dialysis clinic. Nurses continued to administer medications in the clinic but no longer dispensed medications for patients to take home; instead, medications were dispensed from pharmacies to the patients by mail. We hypothesized that the abovementioned change in medication handling worsened clinical outcomes. There is very little medical literature on this topic., Materials and Methods: A retrospective case series of quality and safety in 31 patients in a community-based, medical center-affiliated home dialysis program was performed. We compared laboratory values and adverse clinical events relevant to the medications mentioned above during 4-8 months before and during 5 months after September 1, 2014 (the day when medication handling was changed)., Results: We observed no changes in the incidences of dialysis access dysfunction, access infections, antibiotic inaccessibility to patients for access-related infections, infection outcomes, parathyroid hormone concentrations, hemoglobin concentrations, monthly EPO dose and missed monthly clinic visits after September 1, 2014. However, we noted significantly fewer subcutaneous EPO administrations per month and less time between phlebotomy and laboratory review with patients by their nephrologists at monthly clinic visits after September 1, 2014., Conclusions: The change in handling of medications by nurses in our outpatient home dialysis program to comply with the state statute did not worsen patient outcomes relevant to the affected medications and in fact caused several unexpected improvements., (Published by Elsevier Inc.)

Background: This study aimed to characterise the factors relating to participation in a postal follow-up study in Aboriginal and non-Aboriginal individuals, given the need to quantify potential biases from loss to follow-up and the lack of evidence regarding postal surveys among Aboriginal people., Methods: The first 100,000 participants from the Sax Institute's 45 and Up Study, a large scale cohort study, were posted a follow-up questionnaire gathering general demographic, health and risk factor data, emphasising Social, Economic and Environmental Factors ("The SEEF Study"). For each variable of interest, percentages of those invited who went on to participate in follow-up were tabulated separately for Aboriginal and non-Aboriginal participants and age- and sex-adjusted participation rate ratios (aPRR) were calculated., Results: Of the 692 Aboriginal and 97,178 non-Aboriginal invitees to the study, 314 Aboriginal (45 %) and 59,175 non-Aboriginal (61 %) individuals responded. While Aboriginal people were less likely to respond than non-Aboriginal people (aPRR 0.72, 95 % CI 0.66-0.78), factors related to response were similar. Follow-up study participants were more likely than non-participants to have university versus no educational qualifications (1.6, 1.3-2.0 [Aboriginal]; 1.5, 1.5-1.5 [non-Aboriginal]) and an annual income of ≥70,000 versus < $20,000 (1.6, 1.3-2.0; 1.2, 1.2-1.3 [χ (2) = 7.7; p = 0.001]). Current smokers (0.55, 0.42-0.72; 0.76, 0.74-0.77 [χ (2) = 7.14; p = 0.03]), those reporting poor self-rated health (0.68, 0.47-0.99; 0.65, 0.61-0.69), poor quality of life (0.63, 0.41-0.97; 0.61, 0.57-0.66) and very high psychological distress (0.71, 0.68-0.75 [non-Aboriginal]) were less likely than other cohort members to respond., Conclusions: Relatively large numbers of Aboriginal and non-Aboriginal individuals participated in the first 45 and Up Study follow-up suggesting that postal surveys can be used to follow Aboriginal participants in cohort studies. Despite somewhat greater loss to follow-up in Aboriginal people (after considering socio-demographic and health characteristics), factors related to follow-up participation were similar in both groups: greater loss was observed in those experiencing disadvantage, ill-health and health risk, with implications for interpretation of future findings. Aboriginal low income earners and current regular smokers had a particularly elevated likelihood of non-participation compared to non-Aboriginal people. These findings highlight the importance of identifying and addressing barriers to participation among hard-to-reach population groups.

To reduce tobacco use and related harm in Korea, telephone based cessation services (Quitlines) began full operation to provide regular behavioral counseling for smoking cessation in 2006. After registration in the cessation program, at least 21 calls per year are given to each client to help quit and encourage maintenance. Tailored programs for males, females, and adolescent smokers have been offered taking into account smokers' characteristics and smoking behavior. Mailing self-help quit packs and e-mail and SMS services are allowable as additional services.A total of 23,201 smokers were registered on the Quitline program from 2006 to 2014. In 2014, an average of 13,343 calls per month have been received by 28 coaches, the 1 year abstinence rate of clients is 26%, and clients' satisfaction rate is 81.6%. After introduction of the call system in 2007, client convenience and effective operations have been achieved with high technology support of a computer-based telephone system. Systematic education and evaluation programs for quit coaches have contributed to quality assurance of the services. Currently, research into development of new programs and evaluation of Quitline performance is being undertaken. A Comprehensive Multi-channel Cessation Center (CMCC) has been suggested and is now planned as a next step in the national program for smoking cessation.

Depression in older adults erodes their health, quality of life and the economy. Existing interventions are not feasible for broad application at the community. Postcard intervention only requires a few resources, and previous studies have shown its effectiveness for patients following drug overdose, self-harm and hospitalisation for major depression. The purpose of the present study is to evaluate the effectiveness of a postcard intervention. Participants were community-dwelling individuals, aged 65 or older, who eat meals alone and with the score of 4 or higher on the 15-item Geriatric Depression Scale (GDS-15). We enrolled 184 eligible participants, with 93 in the intervention and 91 in the control arm. Postcards were sent to participants once a month for eight months. Primary outcome was the GDS-15 score at post-intervention. Secondary outcomes were quality of life and activities of daily living. There was no significant difference in primary and secondary outcomes between completers of the intervention and the control arm. However, most of the participants who received intervention thought the intervention was effective. The postcard intervention for depression in community-dwelling elderly people in Japan is neither feasible nor effective. However, the descriptive results suggest that the intervention may be effective given different parameters., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Timely follow-up of fecal occult blood screening with colonoscopy is essential for achieving colorectal cancer mortality reduction. This study evaluates the effectiveness of two ongoing interventions designed to improve colonoscopy uptake after a positive fecal occult blood test (FOBT) result within Ontario's population-wide ColonCancerCheck program. The first was a revision of mailed FOBT lab results to physicians to explicitly define a positive FOBT and to recommend colonoscopy. The second was a letter to participants informing them of the positive FOBT and urging them to seek appropriate follow-up., Methods: Prospective cohort study using Ontario's ColonCancerCheck program data sets (2008-2011), linked to provincial administrative health databases. Crude rate ratios were calculated to assess determinants of colonoscopy uptake among an Ontario-wide FOBT-positive cohort with rolling enrolment, followed from October 2008 through February 2011. Segmented time-series regression was used to assess the average additional change in colonoscopy uptake after FOBT-positive status following the introduction of two ongoing interventions among the same cohort., Results: A notification mailed directly to FOBT-positive screening participants was observed to increase colonoscopy uptake, beyond the modest average underlying increase throughout the study period, by an average of 3% per month (multivariable-adjusted RR: 1.03, 95% CI: 1.00-1.06). However, revision of the existing FOBT result notification to physicians was observed to have no effect., Conclusions: Direct participant notification of a positive FOBT result improved adherence with follow-up colonoscopy in Ontario's population-wide ColonCancerCheck program. Further participant-directed interventions may be effective means of maximizing adherence in population-wide screening.

Objectives: We examined the exposure to tobacco direct mail marketing and its effect on subsequent smoking behaviors in a US Midwest regional cohort of young adults., Methods: Data were collected from 2622 young adults (mean age = 24 years) in 2010 to 2011 (baseline) and 2011 to 2012 (follow-up). We collected information on demographics, tobacco use, and exposure to tobacco direct mail materials in the previous 6 months at baseline. Smoking behaviors were reassessed at follow-up. We investigated the characteristics associated with receiving these materials at baseline, and the associations between receiving cigarette coupons in the mail at baseline and smoking behaviors at follow-up., Results: Thirteen percent of participants reported receiving tobacco direct mail materials in the previous 6 months. Receipt of these materials was associated with age, education, and tobacco use (P < .05). Among those who received these materials, 77% and 56% reported receiving coupons for cigarettes and other tobacco products, respectively. Among baseline nonsmokers and ex-smokers, receiving coupons was associated with becoming current smokers at follow-up (P < .05). Among baseline current smokers, receiving coupons was associated with lower likelihood of smoking cessation at follow-up (P < .05)., Conclusions: Tobacco direct mail marketing promoted and sustained smoking behaviors among US Midwest young adults. Regulating this marketing strategy might reduce the prevalence of smoking in this population.

This article discusses the implications for health research of Canada Post's transition from door-to-door postal delivery to community mailboxes. We argue that using postal code data to geocode participants based on community mailboxes will result in positional and linkage errors. Positional errors involve misplacing people's residential location. Linkage errors result from incorrectly linking residential location from community mailboxes to census or health administrative data. The article discusses examples of how the transition to community mailboxes could have important implications for health research. We encourage research examining the extent of positional and linkage errors on the 11 pilot communities transitioning to community mailboxes in the fall of 2014.

Context/objective: Actionable Nuggets™ for spinal cord injury (SCI) are a knowledge translation tool facilitating evidence-based primary care practice, originally developed in 2010 and refined in 2013. Evaluation results from these two phases of development have informed the design of SkillScribe™, an innovative electronic platform intended to offer reflective continuing medical education (CME) programming through mobile devices in order to support the key features of the Actionable Nuggets™ approach. This brief article describes the ongoing development of Actionable Nuggets™ for SCI on SkillScribe™ by: (1) summarizing the work to date on Actionable Nuggets™; (2) describing evaluation results of Actionable Nuggets™; (3) placing SkillScribe™ in the context of adult education., Design: Developmental Research Design., Setting: Canadian primary care., Participants: Primary care physicians; specialist physicians., Interventions: Twenty educational modules on SCI., Outcome Measures: Pre- and post-test knowledge survey, feedback and use statistics, impact assessment survey, qualitative analysis of evaluation data., Results: In both hard copy and electronic form, physicians report that Actionable Nuggets™ are an acceptable and useful approach to providing CME for low-prevalence, high-impact conditions like SCI. The key elements of this tool are that they: offer evidence-based information in small, focused "nuggets"; position information where physicians most frequently seek it; offer information in a format that permits direct translation into action in primary care; allow time for reflection; attach practice tools; and offer CME credit., Conclusion: Actionable Nuggets™ for SCI, delivered using a convenient and portable electronic medium, with time-released content and interactive testing has the potential to improve the primary care of patients with SCI.

Objectives: Understanding attitudes to mental health issues can inform public health interventions. However, low response rates may contribute to nonresponse bias. In a randomized controlled trial we examined the effect of sending a prenotification postcard before the questionnaire and the placement of a short message on the survey envelope (teaser) on response rates to a mailed questionnaire about bulimia nervosa "mental health literacy"., Study Design and Setting: Questionnaires were mailed to 3,010 adults (50.6% female and 49.4% male) aged 18-65 years. In a 2 (pre-notification-present; absent) by 2 (teaser-present; absent) design, questionnaire recipients were randomly allocated to the experimental strategies. Outcomes considered were response rate, response time, and cost., Results: The overall response rate was 22.0%. Significant main effects showed higher response rates for the use of prenotification (present = 23.6%; absent = 20.3%), among female participants, and older participants. A significant interaction of teaser by gender indicated lower response rates for men who received the teaser but not for women. Older participants returned the questionnaire more promptly than younger participants. Females-but not males-who received the teaser were slower to return the questionnaire. Higher response rates for participants receiving the postcard compensated for increased costs, particularly for males and older participants., Conclusion: Response rates to a mental health postal survey can be increased through the use of prenotification., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background and Purpose: Different modes of administration are used to collect stroke outcomes, even within the same study, potentially leading to different results. We investigated the effect of administration mode (postal questionnaire; face-to-face interview) on self-reports of activities of daily living and mood., Methods: The study was nested within a poststroke motivational interviewing trial. Activities of daily living (Barthel; Nottingham Extended) and mood (General Health Questionnaire; Yale) were collected at 3 and 12 months via postal questionnaire. Participants were approached to respond again via face-to-face interview. Paired t tests (McNemar test) and intraclass correlation coefficients (Cohen κ) were used, with 95% CI, to compare scores (items)., Results: Forty-four participants consented. Only Barthel scores were significantly different; they were 1.0 (95% CI, 0.5-1.6) higher face-to-face. The intraclass correlation coefficient for the Barthel was 0.90; for the other scales it was between 0.83 and 0.87. The Yale κ was 0.72., Conclusions: Modes of administration might be used interchangeably, albeit in conjunction with corrections for the Barthel.

With the escalating use of pharmaceuticals in health care, there has been increasing anxiety over the potential health risks associated with pharmaceutical waste accumulating in the environment. This research provided nurses in a hospice care facility in Concord, California, with education and training to offer patients a medication disposal service through the use of mail-back envelopes. Over the 6-month study period, 160 of the 400 distributed mailers were returned for disposal. The total weight of pharmaceuticals diverted for incineration was 107 pounds, with an average weight of 0.66 pounds per mailer. This study suggests that the mailer system and proper education of medical staff have the potential to improve medical waste management, but alternative approaches may be necessary to increase the rate of envelop return.

In 2001, letters filled with a powder containing anthrax (Bacillus anthracis) spores were delivered by mail to a number of governmental and media locations within the United States. In response, the U.S. Centers for Disease Control and Prevention (CDC) provided guidelines for office personnel who might encounter a letter containing suspicious powder. These guidelines were developed during the crisis and in the absence of experimental data from laboratory or field investigations. An obvious need thus exists for quantitative and scientific verification for validation of these guidelines. This study attempts to address this need, adapting earlier work that used a multiple small office test site to create a model system in an open office test site in a vacated office building in which Bacillus atrophaeus spores (as a simulant for B. anthracis spores) were released by opening a letter. Using SF(6) as a tracer gas, smoke tubes (containing stannic chloride) to visualize airflow, culturable aerosol sampling, and aerosol spectrometry we were able to characterize airflow and unmitigated spore aerosol dissemination within the office test site. Subsequently, two scripted test scenarios were used to reproduce selected portions of the existing CDC response guidelines and a modified version where the contaminated letter opener warned co-workers to evacuate then waited 5 min before doing so himself. By not leaving together with other co-workers, the risk of the letter opener cross-contaminating others was eliminated. The total potential spore aerosol exposure of the letter opener was not affected by remaining still and waiting 5 min to allow co-workers to escape first before leaving the office. Closing office doors and quickly deactivating the heating, ventilation, and air conditioning system significantly reduced spore aerosol concentrations outside the main open office in which they had been released.

Using list-assisted random digit dialing (RDD) with telephone data collection and address-based sampling (ABS) with mail questionnaires are two survey designs that yield probability based inference, yet they are so different that they can yield entirely different results. The 2007 Health Information National Trends Survey (HINTS) provides a unique opportunity to evaluate the effect of these different designs on a variety of survey estimates and, even more importantly, the effect on individual sources of survey error. Understanding the difference in error structure between the two designs is important to survey practitioners in order to select the optimum design, and to data users who can anticipate which results may be affected and how. We first compared estimates between the two designs and then estimated the different sources of error. In addition to identified differences in estimates, we found that for some estimates the two designs can yield similar results merely due to the effect of similar biases. The error components were quite different between the two designs--while the ABS design yields almost complete coverage of the population compared to the RDD design, it was subjected to substantially higher nonresponse bias.

Background: Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the United States. Randomized controlled trials have shown that annual screening fecal occult blood testing (FOBT) reduces CRC mortality and incidence. However, patient compliance with FOBT is low., Objective: To determine whether a mailed educational reminder increases FOBT card return rates and to examine predictors of FOBT compliance., Design: Blinded, randomized, controlled trial at the Veteran Affairs Medical Center, San Diego, California., Patients: Seven hundred and seventy-five consecutive patients > or =50 years of age referred by their primary care physicians for FOBT., Intervention: Patients were randomly assigned to the usual care group or the intervention group. Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group only., Measurements: The primary outcome was proportion of returned FOBT cards after 6 months. Patient demographic, clinical characteristics and prior FOBT completed were collected for multivariate regression analysis., Results: At 6 months after card distribution, 64.6% of patients in the intervention group returned cards compared with 48.4% in the control group (P < 0.001). Patients who received a mailed reminder (OR 2.02; 95% CI: 1.48-2.74) or have a prior history of returning the FOBT cards (OR 1.87; 95% CI: 1.29-2.70) were more likely to return the FOBT cards. Patients with current or recent illicit drug use were less likely to return the FOBT cards (OR 0.26; 95% CI: 0.13-0.50)., Conclusion: A simple mailed educational reminder significantly increases compliance with FOBT for CRC screening.

Background: Suicidal behaviour and deliberate self harm are common among adolescents. Limited evidence exists regarding interventions that can reduce risk; however research indicates that maintaining contact either via letter or postcard with at-risk adults following discharge from services can reduce risk. The aim of the study is to test a postcard intervention among people aged 15-24 who presented to mental health services but are not accepted, yet are at risk of suicide., Methods/design: The study is a 3-year randomised controlled trial conducted at Orygen Youth Health Research Centre in Melbourne Australia. Participants are young help-seekers aged 15-24 who are at risk of suicide. Participants will be recruited over a 12 month period. The intervention comprises a regular postcard to be sent monthly for 12 months. The postcard enquires after their well being and includes information regarding individual sources of help and evidence-based self help strategies. Participants are assessed at baseline, 12 and 18 months., Discussion: This paper describes the development of a study which aims to reduce suicide risk in a sample of young help-seekers. If effective, this intervention could have significant clinical and research implications for a population who can be hard to treat and difficult to research., Trial Registration: The study was registered with the Australian Clinical Trials Registry; number: ACTRN012606000274572.

Environmental economists have long used surveys to gather information about people's preferences. A recent innovation in survey methodology has been the advent of web-based surveys. While the Internet appears to offer a promising alternative to conventional survey administration modes, concerns exist over potential sampling biases associated with web-based surveys and the effect these may have on valuation estimates. This paper compares results obtained from a travel cost questionnaire of visitors to Fraser Island, Australia, that was conducted using two alternate survey administration modes; conventional mail and web-based. It is found that response rates and the socio-demographic make-up of respondents to the two survey modes are not statistically different. Moreover, both modes yield similar consumer surplus estimates.

Objective: The aim was to study the most effective method for increasing response rates to postal questionnaires by comparing normal post with registered mail and to assess the cost implications of the two mailing methods., Study Design and Setting: General Practitioners in Victoria (n=1,550) were randomized to receive a research questionnaire via either normal post or registered mail., Results: The overall response rate for the study after two reminders was 76.1% (1,179/1,550). After the initial mail out the response rate for the registered mail arm was 55.9% (n=433) compared to the normal post arm, 40.1% (n=311, P-value <0.001). After the first and second reminders the response rates dropped, registered mail obtained a response rate of 47.4% (n=162) and 37.8% (n=68), respectively, compared to a response rate of 28.0% (n=130) and 22.5% (n=75) for normal post. Overall, the cumulative response rate for the registered mail was greater, 85.6% (n=663) compared to 66.6% (n=516) for the normal post arm (P-value <0.001) There was a total cost difference between the registered and normal method of AUD $1,531.50., Conclusion: Registered post when used for mail out of the initial questionnaire and all subsequent reminders is a more effective yet more expensive method for achieving a high response rate.

Objective: Contrary to the recommendations of the Institute of Medicine (IOM) report on Forging a Poison Prevention and Control System, a certified regional poison information center combined both primary and secondary education with another public health initiative to determine if there was an impact on poison center awareness., Methods: Poison Help stickers that contained the national toll-free poison center number were inserted into a quarterly publication from a children's hospital and mailed to 136,741 residents of a poison center service region. Benchmark data from a six-month period were used to compare call volume both before and after the initiative., Results: Call volume increased by a mean of 8.8% from the counties where at least 5% of residents received the mailing., Conclusions: A single passive mass-mailing education program that combined primary and secondary poison prevention education may have had a small, but positive impact on poison center call volume when a threshold of 5% of the residents received the information.

Study Design: Mail survey of participants with incomplete spinal cord injury (SCI)., Objective: To describe the incidence, circumstances, consequences, and perceived contributory factors associated with falls among ambulatory individuals with incomplete SCI., Setting: Southeast region of the United States., Methods: A survey instrument was developed largely from existing measures and mailed to individuals with incomplete SCI to collect self-reported information on participant characteristics and fall-related variables., Results: Seventy-five percent of study participants sustained at least one fall over the previous year. Even though most injuries were minor, 18% of fallers sustained a fracture and 45% reported reduced ability to get out into the community and engage in productive activity. Factors perceived to contribute to falls most often were decreased strength in the trunk and lower extremities, loss of balance, and hazards in the environment., Conclusions: Falls occur frequently and often have significant consequences among ambulatory individuals with SCI. These data may assist rehabilitation professionals to identify those at risk and implement fall prevention strategies., Sponsorship: This project was supported by a grant from the South Carolina Spinal Cord Injury Research Fund Grant # 0703.

Background: Missed test results are common in clinical practice and compromise patient safety. Direct reporting, whereby testing centers systematically notify both patients and providers of important test results, constitutes a potential solution, but provider acceptance is unknown., Objective: To assess provider interest in direct reporting of selected test results and how interest varied across different tests., Design, Setting, and Participants: Survey of primary care physicians at a tertiary care academic medical center., Measurement: Five-point Likert scores were used to gauge each physician's interest (1 = not at all interested to 5 = very interested) in scenarios pertaining to the direct reporting of 3 diagnostic tests of low (DXA scan), intermediate (genital herpes testing), and high (breast biopsy) "emotional impact" and whether interest varied with each test's result (normal vs abnormal). Physicians were also asked to cite specific advantages and disadvantages of direct reporting., Results: The response rate was 73% (148/202). Physician interest in direct reporting decreased progressively as scenarios shifted from low (DXA scan) to high (breast biopsy) emotional impact (P < .001); interest in direct reporting was also higher when results were normal rather than abnormal (P < .001). Common advantages of direct reporting cited by respondents were reductions in workload (selected by 75% of respondents) and reductions in missed diagnoses (38%). The most common concerns were that patients would become unnecessarily frightened (70%) and would seek unreliable information (65%)., Conclusion: Direct reporting of selected test results to patients is one system for insuring that important results are not missed, but implementation should consider the specific test in question, the test result, and provider preferences.

Background: Depression screening can improve identification and subsequent treatment of depression in general practice. Response of Turkish and Moroccan elderly is unknown., Objectives: (1) To assess the response of elderly Turkish and Moroccan general practice patients on a postal depression screening. (2) To trace reasons for non-response., Method: At 14 different primary care centres, elderly (55+) were screened with GDS-15. Turkish and Moroccan elderly were telephonically and house-to-house approached for tracing the reasons for non-response., Results: Response rate Dutch elderly (n=6060; 62%), Turks (n= 39; 31%) and Moroccans (n=117; 34%). Most important reason for non-response among Turkish elderly was "temporary other place of staying" (Turkey). Among Moroccans it was "illiteracy"., Conclusion: Response is very low by elderly migrants compared to Dutch elderly. The reasons for non-response implicate that other means to approach migrants' sub-populations should be sought.

If you were the CEO of Pitney Bowes, the postage meter maker, how would you envision the future of the business? The company has an undeniable core competence in the solutions it provides to high-volume postal service users. But with snail mail on the decline, some would say that core has about as much future as the buggy whip. In this article, Pitney Bowes chairman and CEO Michael Critelli gives us a glimpse of how he leads his company's strategy development--and how that development has supported a counterintuitive return to the company's core after decades of diversification. He and others in the company begin the process by tapping into deeply knowledgeable people and organizations to understand key trends in the business and the rate at which change is occurring. Then, it's a question of the firm reshaping the environment in which it does business, whether through R&D investments or work with regulators and policy makers who influence market forces; this is especially important in emerging markets. Focusing on a core business area enables a company to find adjacent high-margin opportunities and to offer comprehensive solutions to customers. What stands out most sharply in this account, however, is the importance of having a strategist's mind-set. Whether Critelli is reading the day's news, visiting a key account, or spending an hour with his own people working in the context of a customer mail room, he is constantly extrapolating possible long-term competitive implications from the immediate facts. Often inspired by strategic thinkers, Critelli believes that the greatest thing he can do for his organization is to shift the terms of the debate. "Rarely am I credited with sterling words or bold, symbolic actions", he writes. "Instead, I help people to see the business we are in differently and to reach a shared vision as to where we want to end up. And, little by little, things move in the right direction".

Objectives: To establish the prevalence of major depressive episode (MDE) in a large sample of veterans with multiple sclerosis (MS); to identify demographic characteristics, aspects of disease presentation, and perceptions of disability associated with greater concurrent risk for MDE; and to examine the relationship between MDE, service utilization, and activity participation., Methods: Veterans with MS (n = 1,032) were identified via computer database and surveyed by mail; 451 (43.7%) responded., Results: Twenty-two percent of the sample met criteria for current MDE. Low income, unemployment, presence of falls, younger age, absence of a marital partner, and high levels of perceived disability due to bowel functioning were independently associated with MDE. Disease subtype, disease duration, use of disease modifying therapies, and perceived disability due to mobility or bladder problems were unrelated to MDE. Current MDE was in turn associated with increased primary care visits and increased impact of disease upon activity participation. Similar correlates were associated with minor depressive episode., Conclusions: Unlike the general population, rates of depression in this predominantly male sample were similar to those found in predominantly female samples of persons with multiple sclerosis. Specific aspects of disability were differentially associated with depression, and depression was independently associated with increased service utilization and increased participation limitations.

Shared (Induced) Delusional Disorder commonly occurs in close relationships and involves a varying number of participants who may be nonconsanguineous. The disorder has been associated with forensic and fatal consequences. Its occurrence in three nonrelated, incarcerated individuals is described in this article. This case of folie à trois has forensic implications and raises several questions of ethics that relate to autonomy, confidentiality, safety, and risk estimation. The presentation, management, and outcome of the patients suggest that a high index of suspicion is needed to detect cases in similar settings. The report concludes that the rarity of the disorder in a forensic mental health population may be the result of underdetection, given that conditions are conducive to the development of the disorder. Telltale signs of its manifestation are hypothesized as being responsible for some events in incarcerated populations. Physical separation and antipsychotic medications remain the mainstay of treatment.

Aims: The dynamics of bioaerosol generation in specific occupational environments where mail is manually unpacked and sorted was investigated., Methods and Results: Total number of airborne particles was determined in four different size classes (0.3-0.5, 0.5-1, 1-5 and >5 microm) by laser particle counting. Time dependent formation of bioaerosols was monitored by culturing methods and by specific staining followed by flow cytometry. Besides handling of regular mail, specially prepared letters ('spiked letters') were added to the mailbags to deliberately release powdered materials from letters and to simulate high impact loads. These letters contained various dry powdered biological and nonbiological materials such as milk powder, mushrooms, herbs and cat litter. Regarding the four size classes, particulate aerosol composition before mail handling was determined as 83.2 +/- 1.0, 15.2 +/- 0.7, 1.7 +/- 0.4 and 0.04 +/- 0.02%, respectively, whereas the composition changed during sorting to 66.8 +/- 7.9, 22.3 +/- 3.6, 10.4 +/- 4.0 and 0.57 +/- 0.27%, respectively. Mail processing resulted in an increase in culturable airborne bacteria and fungi. Maximum concentrations of bacteria reached 450 CFU m(-3), whereas 270 CFU of fungi were detected., Conclusions: Indoor particle concentrations steadily increased during mail handling mostly associated with particles of diameters >1 microm. However, it was not possible to distinguish spiked letters from nonspiked by simple particle counting and CFU determinations., Significance and Impact of Study: The dynamics of bioaerosol generation have to be addressed when monitoring specific occupational environments (such as mail sorting facilities) regarding the occurrence of biological particles.

The objective of this study was to determine if correspondence sent by regular mail would be delivered more often than correspondence sent by certified mail. Correspondence was prospectively randomized and mailed by United States Postal Service using either regular mail service or certified mail service. Mailings were analyzed based on patient demographic information, whether or not mail was returned, and the reason for the return. Certified mail was sent to 145 patients; 58 (40%) of the mailings were returned. Wrong addresses accounted for only 23 (16%) of these, whereas the addressee never claimed 35 (24%). Regular mail was sent to 126 patients, and 19 (15%) of the letters were returned. Wrong addresses accounted for 18 (14%) of these letters, and only 1 (1%) was refused for delivery. In conclusion, when compared with certified mail, regular mail is a more effective means of reaching patients with follow-up information after an Emergency Department visit.

Sterilizing irradiation of the US mail has been proposed as a method to prevent delivery of viable anthrax spores. Because newborn screening samples (bloodspots) and cyclosporine and tacrolimus specimens (whole blood) are delivered routinely through the mail, we studied whether sterilizing gamma irradiation could affect these test results. Specimens were exposed to 18 kGy gamma irradiation (100 hours x 18,000 rad/h), a "kill dose" for Bacillus pumilus spore strips. Irradiation had no significant effect on whole blood cyclosporine or tacrolimus results, but it had a degradative effect on bloodspot phenylalanine, hemoglobins, biotinidase, galactose-1-phosphate uridyltransferase, thyroxine, and thyrotropin. Such irradiation potentially could cause false-negative results for the detection of phenylketonuria and likely would lead to an increase in secondary testing for hemoglobin variants, but it is unlikely to lead to false-negative or false-positive results for the remaining newborn screening tests. These experiments cannot rule out possible greater effects by larger doses or other types of irradiation.

The present study explored the prevalence and descriptive characteristics of hyperacusis, defined as unusual intolerance of ordinary environmental sounds. Two ways of collecting data were used in the study: the first was a postal survey of a random sample, to which 589 responded (59.7% response rate); the second was the internet, and 595 self-recruited individuals responded to a call for participants via a banner on a web page (51.9% response rate). The point prevalence rates of hyperacusis were 9% in the internet group and 8% in the postal group. Exclusion of participants who reported hearing impairment resulted in point prevalence rates of 7.7% (n = 39) and 5.9% (n = 28) respectively. The data collection format did not result in any substantial differences. Hyperacusis was associated with concentration difficulties, use of ear protection, avoidance, tension, and sensitivity to light/colours. The present data suggest that hyperacusis is a common problem.

Objective: The current study examined the efficacy of mailed personalized normative feedback (PNF) as a brief alcohol intervention for at-risk college drinkers, and investigated discrepancy as a possible mediator of the intervention effect., Method: Participants consisted of 100 at-risk college drinkers who completed an alcohol-use assessment at baseline, 6-week posttest and 6-month follow-up. Measures included number of drinks consumed per heaviest drinking week, frequency of heavy-drinking episodes, peak blood alcohol concentration and number of alcohol-related problems, all for the last month. Participants were randomly assigned to either a mailed brief intervention (MBI; n = 49) or attention-control (C; n = 51) group. The MBI group received mailed PNF that was based on baseline responses to the drinking measures; the C group received a psychoeducational brochure about alcohol., Results: Mixed-model, repeated measures ANOVAs were used to examine the effects of time, group and gender on discrepancy and the drinking variables. Following the intervention, the MBI group reported significantly higher perceived discrepancy between self and others' drinking than the C group. The MBI group reported consuming significantly fewer drinks per heaviest drinking week and engaging in heavy episodic drinking less frequently than the C group at the 6-week posttest; however, these differences were no longer evident at the 6-month follow-up. Hierarchical regression analyses did not provide evidence for the hypothesized mediating effect of discrepancy., Conclusions: Mailed PNF may be a cost- and time-efficient means of developing discrepancy and temporarily reducing heavy alcohol consumption among at-risk college drinkers.

Background: In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges., Objective: Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty., Methods: We conducted a mail survey of 1492 physicians--497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's chi2 and multivariate logistic regression., Results: Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding--both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions., Conclusions: Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics.