Comfortably engaging: which approach to alcohol screening should we use?

PURPOSE

We wanted to compare 2 screening instruments for problem drinking, the CAGE and a single question, assessing frequency of use, patient and clinician comfort, and patient engagement in change.

METHODS

The study was a crossover, cluster-randomized clinical trial with 31 clinicians in Missouri and 13 in the American Academy of Family Physicians (AAFP) National Network for Family Practice and Primary Care Research; 2,800 patients provided data. The clinician was the unit of randomization. Clinicians decided whether to screen each patient; if they chose to screen, they used the screening approach assigned for that block of patients. The clinician and patient separately completed questionnaires immediately after the office visit to assess each one's comfort with screening (and any ensuing discussion) and the patient's engagement in change.

RESULTS

Missouri clinicians screened more patients when assigned the single question (81%) than the CAGE (69%, P = .001 in weighted analysis). There was no difference among AAFP network clinicians (96% of patients screened with the CAGE, 97% with the single question). Eighty percent to 90% of clinicians and 70% of patients reported being comfortable with screening and the ensuing discussion, with no difference between approaches in either network. About one third of patients who were identified as problem drinkers reported thinking about or planning to change their drinking behavior, with no difference in engagement between screening approaches.

CONCLUSIONS

Clinicians and patients reported similar comfort with the CAGE questions and the single-question screening tools for problem drinking, and the 2 instruments were equal in their ability to engage the patient. In Missouri, the single question was more likely to be used.

Saturation of tobacco smoking models and risk of alcohol and tobacco use among adolescents

PURPOSE

To examine how saturation of an adolescent's environment with models of cigarette smoking (e.g., parents, siblings, friends) affects the probability of tobacco and alcohol use among junior high and high school students.

METHODS

The Health and Smoking Questionnaire was administered to 806 adolescents (182 smokers and 624 nonsmokers; 57.2% female) average age of 15.1 years (SD = 1.6) in a mid-size Midwestern town. The questionnaire contains standardized items in five domains: demographics, smoking status and history, perceptions of risk and risk reduction, risk factors for tobacco use, and parenting style.

RESULTS

Risk for smoking or using alcohol increased dramatically as the number of models who smoke increased in an adolescent's environment. For instance, adolescents with one significant other who smoked were nearly four times (OR = 3.76, p <.001) more likely to smoke than someone with no significant others who smoked. However, if an adolescent had four significant others who smoked, they were over 160 times more likely to smoke (OR = 161.25, p <.001). Similar results were found for alcohol use; adolescents who had one significant other who smoked were more than 2.5 (OR = 2.66, p <.001) times more likely to drink than those without smoking models. Adolescents who had four significant other smoking models were 13 times (OR = 13.08, p <.001) more likely to drink.

CONCLUSIONS

As the number of cigarette smokers in an adolescent's environment increases, risk of tobacco and alcohol use increases substantially. These data suggest that multiple models of tobacco use will substantially increase risk for substance use in adolescents.

Assaultive behavior in state psychiatric hospitals: differences between forensic and nonforensic patients

Forensic patients are occupying an increasingly large number of beds in state psychiatric hospitals. The presence of these mentally ill offenders has raised concerns about the risk they present to nonforensic patients. This study compared the rate of assaults and factors associated with assaultive behavior among 308 nonforensic patients and two groups of forensic patients including 469 patients found not guilty by reason of insanity and 76 pretrial patients. Consistent with other studies, nonforensic patients had higher rates of assaults than either group of forensic patients. However, being a forensic patient did not affect the odds of assault when controlling for the effects of demographic and clinical variables in a multivariate logistic regression analysis. Factors associated with assaults in each of the three patient groups were identified using multivariate analyses. Implications are presented for treatment of assaultive behavior, mixing of forensic and nonforensic patients within state hospitals, forensic release policies, and future research.

Body Mass Index Change Between Pregnancies and Small for Gestational Age Births

OBJECTIVE

To estimate whether maternal weight changes between pregnancies influence the risk for small for gestational age (SGA) births.

METHODS

SGA cases (n = 8,062) below the tenth percentile birth weight for gestational age were selected from liveborn singletons born of Missouri residents during 1989-1997. Normal weight controls (n = 8,062) were selected according to birth year. The risk of SGA from interpregnancy body mass index (BMI) change and other maternal factors was estimated using logistic regression analysis.

RESULTS

An increase in BMI between pregnancies decreased SGA risk (adjusted odds ratio = 0.8; 95% confidence interval 0.7, 1.0). Other risk factors were prior SGA (4.4; 4.0, 4.8), preeclampsia/eclampsia (2.6; 2.1, 3.2), maternal cardiac disease (1.8; 1.1, 2.9), inadequate weight gain (1.9; 1.8, 2.2), and cigarette smoking (1.9; 1.7, 2.3 for 1-9 cigarettes per day; 2.5; 2.2, 2.8 for 10-19/d; and 2.8; 2.5, 3.3 for 20/d or more).

CONCLUSION

Increase in interpregnancy BMI lowers SGA risk, but adequate weight gain during pregnancy is more effective.

Predictors of outcome in geriatric patients with urinary tract infections

A study was conducted to determine the prognosis of geriatric patients with urinary tract infections (UTIs) and identify clinical factors associated with adverse outcomes. This retrospective, cohort study identified elderly patients (age > or =65 years) presenting to an academic, urban Emergency Department (ED) during a 16-week period with UTI, suggested by urinalysis and pertinent symptoms. There were 37 demographic and clinical variables analyzed as potential predictors of outcome. Morbidity was defined as in-hospital death, Intensive Care Unit (ICU) admission, hospital length of stay (LOS) >2 days, or hospital intravenous (i.v.) antibiotics >2 days. Factors identified by univariate analysis were combined using multiple logistic regression to identify independent predictors of morbidity. There were 284 patients who met selection criteria. Thirteen patients (4.6%) died during hospitalization and 27 (9.5%) had ICU admission, 139 (48.9%) had LOS >2 days, and 75 (26.4%) had i.v. antibiotics >2 days. Multivariate analysis identified the following variables as independent predictors of adverse outcomes: mental status change, frequent UTIs, other nonurinary infections, abnormal temperature, tachycardia, hypotension, elevated BUN, hyperglycemia, elevated WBC, and relative neutrophilia. Regression models for adverse outcomes had sensitivities from 74.8% to 96.2% and specificities from 31.1% to 69.0%. In conclusion, this study defines high rates of morbidity for geriatric patients with UTIs and describes predictive variables that may help identify low-risk patients. These data may lay the foundation for determining specific guidelines for disposition of this high-risk patient population.

Trauma stat and trauma minor: are we making the call appropriately?

OBJECTIVES

Trauma accounts for a significant number of pediatric emergency room visits and is the leading cause of death in pediatric patients over 1 year of age. To provide quality care, protocols are used to mobilize personnel to treat injured patients. We reviewed our experience at a level 1 pediatric trauma center, where a 2-tiered trauma activation protocol is used in treating children with significant injuries.

METHODS

We analyzed data in our trauma registry from 1994 to 1999 of patients with Injury Severity Score > or = 9 in whom trauma activations were called. Data reflected demographics, severity of injury, hospital course and outcome. Trauma activations were based on standard protocols that took physiologic status, anatomic area of injury, and mechanism of injury into account. Nineteen personnel were notified in a Trauma Stat Activation, and 8 were notified in a Trauma Minor Activation.

RESULTS

There were 470 trauma activations: Trauma Stat = 220 and Trauma Minor = 250. As a group, Trauma Stat patients were more hemodynamically unstable, had a lower GCS and a higher Injury Severity Score than Trauma Minor patients. Patients in the Trauma Stat group were also more likely to require intensive care and have a prolonged hospitalization. The Trauma Stat group had a mortality rate of 20%. There were no deaths in the Trauma Minor group.

CONCLUSIONS

Trauma activations result in heavy resource utilization and must be appropriate. The 2 trauma activation levels were associated with differences in injury severity, medical resource utilization, and outcome. With no deaths in the Trauma Minor group and a 20% mortality rate in the Trauma Stat group, we conclude that the protocol used was neither too conservative, nor too liberal.

Functional Outcome of Nonoperatively Managed Renal Injuries in Children

BACKGROUND

This study aimed to define better the functional outcome of nonoperatively managed renal injuries in children.

METHODS

All children who had blunt renal trauma managed nonoperatively were reviewed for injury grade, blood urea nitrogen (BUN), creatinine, blood pressure, and percentage of function according to technetium-99m-dimercaptosuccinic acid renal scan after complete healing.

RESULTS

Over a 2-year period, 17 children (mean age, 10.4 years) were managed conservatively for their renal injuries. There were two grade 2, two grade 3, nine grade 4, and four grade 5 injuries. Complete healing was documented in all cases within 3 months after injury. Renal scarring and volume loss were evident for all healed high-grade injuries (grades 4 to 5) at follow-up imaging. Technetium-99m-dimercaptosuccinic acid scanning demonstrated a decline in percentage of total renal function corresponding to injury severity (44.7 +/- 8.4% function for grades 2 and 3, 41.8 +/- 9.2% for grade 4 vs 29.5 +/- 7.9% for grade 5). Only two children (22%), however, with grade 4 injury had severe compromise of function (<30%). At the follow-up visit, all the children were asymptomatic and normotensive. None had abnormal BUN or creatinine (mean BUN, 10.5 +/- 5.1 mg/dL; mean creatinine, 0.6 +/- 0.2 mg/dL).

CONCLUSIONS

The functional outcome for children with nonoperatively managed kidney injuries is good and correlates with injury grade. Children with grades 2 to 4 injuries managed conservatively retain near normal function. Those with grade 5 injuries have a loss of function attributable to scarring and parenchymal volume loss. Long-term follow-up evaluation of these children may be warranted.

Characteristics and circumstances of falls in a hospital setting: a prospective analysis

OBJECTIVE

To describe the epidemiology of hospital inpatient falls, including characteristics of patients who fall, circumstances of falls, and fall-related injuries.

DESIGN

Prospective descriptive study of inpatient falls. Data on patient characteristics, fall circumstances, and injury were collected through interviews with patients and/or nurses and review of adverse event reports and medical records. Fall rates and nurse staffing levels were compared by service.

SETTING

A 1,300-bed urban academic hospital over 13 weeks.

PATIENTS

All inpatient falls reported for medicine, cardiology, neurology, orthopedics, surgery, oncology, and women and infants services during the study period were included. Falls in the psychiatry service and falls during physical therapy sessions were excluded.

MEASUREMENTS AND MAIN RESULTS

A total of 183 patients fell during the study period. The average age of patients who fell was 63.4 years (range 17 to 96). Many falls were unassisted (79%) and occurred in the patient's room (85%), during the evening/overnight (59%), and during ambulation (19%). Half of the falls (50%) were elimination related, which was more common in patients over 65 years old (83% vs 48%; P <.001). Elimination-related falls increased the risk of fall-related injury (adjusted odds ratio, 2.4; 95% confidence interval 1.1 to 5.3). The medicine and neurology services had the highest fall rates (both were 6.12 falls per 1,000 patient-days), and the highest patient to nurse ratios (6.5 and 5.3, respectively).

CONCLUSIONS

Falls in the hospital affect young as well as older patients, are often unassisted, and involve elimination-related activities. Further studies are necessary to prevent hospital falls and reduce fall injury rates.

Role of mental illness in drug use by urban pregnant heavy smokers

The object of the study was to test the hypothesis that mental illness is associated with drug abuse by pregnant smokers. We abstracted data from the State of Missouri Risk Appraisal of Pregnant Women database on 239 (115 black and 124 white) women who attended an inner-city hospital from 1999 through 2000. Thirty-four percent abused drugs, 16% used alcohol, and 8% reported having a history of mental illness or psychiatric treatment. On multivariable logistic regression analyses, pregnant smokers were more likely to use drugs if they had mental illness (odds ration [OR], 7), consumed alcohol (OR, 2), or were black (OR, 3). In conclusion, drug abuse is associated with mental illness, suggesting that this behavior may be a marker of underlying mental illness among pregnant smokers. Therefore, in addition to initiating social service intervention, the identification of drug abuse by pregnant smokers should prompt a mental health evaluation.

Pancreatitis in wild zinc-poisoned waterfowl

Four waterfowl were collected in the Tri-State Mining District (Oklahoma, Kansas and Missouri, USA), an area known to be contaminated with lead, cadmium and zinc (Zn). They were part of a larger group of 20 waterfowl collected to determine the exposure of birds to metal contamination at the site. The four waterfowl (three Branta canadensis, one Anas platyrhynchos) had mild to severe degenerative abnormalities of the exocrine pancreas, as well as tissue (pancreas, liver) concentrations of Zn that were considered toxic. The mildest condition was characterized by generalized atrophy of exocrine cells that exhibited cytoplasmic vacuoles and a relative lack of zymogen. The most severe condition was characterized by acini with distended lumens and hyperplastic exocrine tissue that completely lacked zymogen; these acini were widely separated by immature fibrous tissue. Because the lesions were nearly identical to the lesions reported in chickens and captive waterfowl that had been poisoned with ingested Zn, and because the concentrations of Zn in the pancreas and liver of the four birds were consistent with the concentrations measured in Zn-poisoned birds, we concluded that these waterfowl were poisoned by Zn. This may be the first reported case of zinc poisoning in free-ranging wild birds poisoned by environmental Zn.

Clinically relevant levels of depressive symptoms in community-dwelling middle-aged African Americans

OBJECTIVES

To identify the prevalence of and potentially modifiable risk factors for clinically relevant levels of depressive symptoms in a population-based sample of community-dwelling African Americans and the prevalence of treatment by prescription and alternative medications.

DESIGN

Cross-sectional survey, 2000-01.

SETTING

Community-based.

PARTICIPANTS

Nine hundred ninety-eight noninstitutionalized African Americans in St. Louis, Missouri, born between 1936 and 1950.

MEASUREMENTS

Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression scale (CES-D). Clinically relevant levels of depressive symptoms were defined as nine or more (equivalent to >/=16 on the 20-item CES-D). A comprehensive set of risk factors was considered that included three demographic variables, eight socioeconomic-access measures, four environmental factors, seven measures of functional status, 15 biomedical markers, one service utilization indicator, and three psychosocial measures. All analyses were weighted to the represented population. Treatment with an antidepressant was determined by examining subjects' medications compiled in their homes.

RESULTS

Two hundred ten subjects (21.1%) had clinically relevant levels of depressive symptoms. Several multivariate logistic regression approaches were used for model building, which identified a consistent set of nine predictive factors: female sex (odds ratio adjusted (AOR) for all factors in the final model=1.52; 95% confidence interval (CI)=1.01-2.27), lower objective income (AOR=1.62, 95% CI=1.08-2.43), perceived income inadequacy (AOR=2.33, 95% CI=1.49-3.65), lower assessment of home environment (AOR=1.07 per scale point, 95% CI=1.01-1.12), limitations in visual acuity (AOR=1.12 per scale point, 95% CI=1.04-1.21), being severely underweight (AOR=2.52, 95% CI=1.02-6.20), being obese (AOR=1.72, 95% CI=1.16-2.54), being hospitalized in the previous year (AOR=2.25, 95% CI=1.45-3.49), and lower social support (AOR=1.20 per scale point, 95% CI=1.16-1.26). Of these, social support was the most important (adjusted standardized odds ratio =2.41). Forty-one (19.5%) of the subjects with clinically relevant levels of depressive symptoms were taking prescription antidepressants.

CONCLUSION

The prevalence of clinically relevant levels of depressive symptoms in middle-aged African Americans was greater than that for the general U.S. population. Community-based health programs that screen for depression and refer individuals to clinical care sites with appropriately designed systems of care for depression management should be developed. For optimal effect, these programs should concentrate their efforts in socioeconomically disadvantaged areas and address socioeconomic factors such as income inadequacy and social support in addition to the biomedical risk factors. Given the pervasive adverse effects of depression, such interventions have the potential for significantly enhancing the health of African Americans in their later years and reducing current health disparities.

Epidemiology of a tuberculosis outbreak in a rural Missouri high school

OBJECTIVES

1) Demonstrate the importance of maintaining a tuberculosis (TB) control program even in low-incidence areas by studying a TB-contact investigation of a highly infectious high school student in rural Missouri, and 2) discuss factors that perpetuated or contained this school-based outbreak.

METHODS

A case review of the index patient, a 15-year-old high school student, established estimates of his level and duration of infectiousness. Contact investigations of his household (n = 5), high school (n = 781), and school bus (n = 67) were administered according to guidelines established by the Centers for Disease Control and Prevention. High school students were stratified further based on classroom exposure, and relative risks were calculated for each risk group.

RESULTS

The case review revealed that the index patient had evidence of a pulmonary cavity on chest radiograph 6 months before his TB diagnosis. Of the 5 household contacts, all were infected and 3 (60%) had developed active TB disease. Of the 781 high school students sought for TB screening, 559 (72%) completed testing, and 58 (10%) were PPD-positive. Sixty-seven bus riders were sought for testing and 7 (19%) were purified protein derivative (PPD)-positive, with 1 bus rider subsequently diagnosed with active disease. Risks were calculated based on classroom and bus exposure to the patient. The relative risks for a positive PPD were 3.2 for attending any class with the patient (n = 25), 4.2 for classes with less ventilation (n = 21), and 5.7 for > or =3 classes (n = 7) with the patient. A total of 62 students started treatment for latent TB infection, and 49 have completed it. Forty-two of these students received directly observed therapy through the local public health agency and the high school.

CONCLUSION

This investigation demonstrated widespread adult-type transmission from a pediatric TB case with a 6-month delay in diagnosis. Several actions contributed to the success of this investigation, including rapidly mobilizing the public health system, centralizing follow-up, and on-site testing and treatment with directly observed therapy. Pediatricians need to maintain awareness of TB and risk factors in children, even in low-incidence areas. Prompt diagnosis would have reduced the severity of illness in the patient and potentially prevented widespread school-based transmission. Public health authorities must maintain an infrastructure to respond to large TB outbreaks.

Evolving treatment in a decade of pediatric burn care

BACKGROUND

Over the last decade, an ambulatory burn care (ABC) and procedural sedation (PS) program was instituted at St Louis Children's Hospital (SLCH). This study assessed the effect of these interventions on resource utilization.

METHODS

The authors reviewed the hospital experience comparing 1993 with 2002 data regarding gender, age, burn depth, patient admissions, inpatient days, and ABC visits. Outcome measures included length of stay (LOS), incidence of infection, and hospital charges.

RESULTS

Gender, age, and burn depth were similar; 192 patients were admitted in 1993. In 2002, there were 167 admissions and 118 patients treated solely on an ABC basis resulting in a total of 285 burn patients treated (+48%). Hospital days decreased from 2,041 (1993) to 963 (2002 [-53%]). LOS declined from 10.4 +/- 8.3 days (1993) to 5.8 +/- 14.2 days (2002 [-44%; P <.05]). PS was used sporadically in 1993, and increased to 71% in patients in 2002. There were no ABC visits in 1993 and 501 visits in 2002. The incidence of infection was 5.2% in 1993 versus 3.0% in 2002 (P <.05) Average charge per patient fell 45% from 13,286 dollars (1993) to 7,372 dollars (2002), adjusted to 1993 dollars using medical care price index.

CONCLUSIONS

Over a 10-year period, the program achieved a significant reduction in resource utilization while increasing the number of patients treated and maintaining a low incidence of infection. This was due in large part to a shift to ABC and the use of PS.

Mechanisms of Pediatric Trauma Deaths in Canada and the United States: The Role of Firearms

BACKGROUND

This study aimed to determine whether firearms are a more prevalent cause of pediatric death in the United States than in Canada.

METHODS

All pediatric trauma deaths from 1991 to 1996 in Ontario and Missouri were reviewed. Socioeconomic data were compiled for the two jurisdictions.

RESULTS

During the period reviewed, there were 1,146 pediatric trauma deaths in Ontario (10.4 per 100,000 population) and 1,782 in Missouri (32.4 per 100,000 population). Firearm injuries accounted for 19% of the trauma deaths in Missouri and 0.5% of such deaths in Ontario. Overall, a child was 100 times more likely to die of firearm injury in Missouri (6 per 100,000 population) than in Ontario (0.06 per 100,000 population). The incidences of violent acts unrelated to firearms were similar between the two groups. Both populations were similar in terms of socioeconomic and education parameters, but differed in their rates for guns carried.

CONCLUSION

The significantly higher death rate from firearm injuries in Missouri likely reflects differing gun control attitudes and legislation, and provides a rationale for prevention and future investigation.

Respiratory viral infections are a distinct risk for bronchiolitis obliterans syndrome and death

Bronchiolitis obliterans syndrome (BOS) is the major obstacle to long-term survival after lung transplantation, in part because its pathogenesis is poorly understood and treatment options are limited. To identify unique risk factors for BOS and death, we performed a retrospective cohort study on 259 consecutive adult lung transplant recipients over a 5-year period. The demographic and clinical characteristics of this population were analyzed for an association between BOS or death and potential risk factors, including community-acquired respiratory viral (CARV) infections, acute rejection, and cytomegalovirus pneumonitis. Respiratory syncytial virus, parainfluenza, influenza, and adenovirus accounted for 21 CARV infections. Univariate and multivariate time-dependent Cox regression analyses demonstrated that this CARV group was more likely to develop BOS, death, and death from BOS. Furthermore, these trends were more pronounced in patients with evidence of lower respiratory tract-CARV (lower-CARV) infections. Notably, the CARV and lower-CARV infections were risk factors for BOS, death, and death from BOS distinct from the risk attributable to acute rejection. Identification of CARV and lower-CARV infections as BOS and mortality risk factors has important clinical implications and may provide insight into disease pathogenesis and accelerate the development of novel treatment strategies to modify post-CARV BOS.

The prevalence of diabetes and related services in Missouri and Missouri's progress towards meeting the Healthy People 2010 goals

Since 1988, diabetes in Missouri increased by almost 50%. We examined diabetes' prevalence and associations with sociodemographic, risk factor, and comorbidity variables in Missouri. Additionally, we examined Missouri's progress towards Healthy People 2010 diabetes-related goals and prevalence of risk factor counseling. Analysis indicates diabetes is an increasing public health problem in Missouri. To stem increases in the prevalence of diabetes and its costs, delivery of, and access to, preventative care and counseling should be improved.

Prognosis of patients with suspected primary CNS angiitis and negative brain biopsy

The authors retrospectively analyzed 25 patients who had a nondiagnostic brain biopsy for clinically suspected primary CNS angiitis to determine the effect of immunosuppressive therapy on 1-year outcome. Good outcome was seen in 6 of 10 treated patients and in 8 of 15 untreated patients (p= 0.93). These findings do not indicate that the addition of immunosuppressive therapy significantly enhances outcome of patients with clinically suspected primary angiitis of the CNS and a nondiagnostic brain biopsy.

Human monocytotropic ehrlichiosis, Missouri

To determine the incidence, clinical and laboratory characteristics, and utility of molecular diagnosis of human monocytotropic ehrlichiosis (HME) in the primary care setting, we conducted a prospective study in an outpatient primary care clinic in Cape Girardeau, Missouri. One hundred and two patients with a history of fever for 3 days (>37.7°C), tick bite or exposure, and no other infectious disease diagnosis were enrolled between March 1997 and December 1999. HME was diagnosed in 29 patients by indirect immunofluorescent antibody assay and polymerase chain reaction (PCR). Clinical and laboratory manifestations included fever (100%), headache (72%), myalgia or arthralgia (69%), chills (45%), weakness (38%), nausea (38%), leukopenia (60%), thrombocytopenia (56%), and elevated aspartate aminotransferase level (52%). Hospitalization occurred in 41% of case-patients. PCR sensitivity was 56%; specificity, 100%. HME is a prevalent, potentially severe disease in southeastern Missouri that often requires hospitalization. Because clinical presentation of HME is nonspecific, PCR is useful in the diagnosis of acute HME.

Posttraumatic Stress Disorder in Pregnancy: Prevalence, Risk Factors, and Treatment

OBJECTIVE

To estimate the prevalence of posttraumatic stress disorder and its treatment in economically disadvantaged pregnant women.

METHODS

The sample included 744 pregnant Medicaid-eligible women from Women, Infants and Children Supplemental Nutrition Program sites in 5 counties in rural Missouri and the city of St. Louis. Race (black and white) was proportional to clients seen at each site. Women were assessed by using standardized measures of posttraumatic stress disorder, 18 other psychiatric disorders, environmental stressors, and pregnancy characteristics. Logistic regression identified risk factors associated with posttraumatic stress disorder.

RESULTS

Posttraumatic stress disorder prevalence was 7.7% (n = 57/744). Comorbid disorders were common. Women with posttraumatic stress disorder were 5 times more likely to have a major depressive episode (odds ratio 5.17; 95% confidence interval 2.61, 10.26) and more than 3 times as likely to have generalized anxiety disorder (odds ratio 3.25; 95% confidence interval 1.22, 8.62). Besides these comorbid disorders, risk factors for posttraumatic stress disorder included a history of maternal separation for 6 months and multiple traumatic events. Although most women with posttraumatic stress disorder reported moderate impairment in their daily lives, only 7 of the 57 women with this disorder reported speaking with any health professional about it in the last 12 months.

CONCLUSIONS

The prevalence of posttraumatic stress disorder in pregnancy and low treatment rates suggest that screening for this disorder should be considered in clinical practice.

LEVEL OF EVIDENCE

II-2

Relationship of Nursing Personnel and Nursing Home Care Quality

The purpose of this study was to examine the associations between nurse staffing hours and 6 quality indicators: physical restraints, weight loss, incontinence, late loss activities of daily living decline, stages 1 to 4 pressure ulcers, and problem behaviors toward others. Increasing registered nurse staff hours may achieve better quality indicator scores for pressure ulcers. An increase in nurse aide hours should be carefully weighed with the amount of registered nurse staff time available for supervision and direction.

Nursing Home Quality and Pressure Ulcer Prevention and Management Practices

OBJECTIVES

To measure pressure ulcer quality indicator (QI) scores and to describe the self-reported skin integrity assessment, pressure ulcer risk assessment, and pressure ulcer prevention and treatment practices in long-term care facilities (LTCFs).

DESIGN

Retrospective analysis of a large data set and comparative survey.

SETTING

LTCFs in Missouri.

PARTICIPANTS

Three hundred sixty-two LTCFs participated in the survey. Three hundred twenty-one facilities had pressure ulcer QI scores between April 1 and September 30, 1999.

MEASUREMENTS

Pressure ulcer QI scores, Pressure Ulcer Prevention & Treatment Practices Survey.

RESULTS

The mean+/-standard deviation pressure ulcer QI score was 10.9+/-6.2%, with a risk-adjusted score of 15.7+/-8.9% for high-risk residents and 3.1+/-3.6% for low-risk residents. Minimizing head-of-bed elevation to less than 30 degrees was used by fewer than 20% of facilities. More than 40% of facilities used a risk assessment tool that was not evidence based. Fewer than 13% of facilities used the Agency for Health Care Policy and Research pressure ulcer prevention and treatment guidelines. No relationship was found between the number of prevention strategies (P=.892) or the number of treatment strategies (P=.921) and the pressure ulcer QI scores.

CONCLUSION

Valid and reliable pressure ulcer risk assessment tools are seriously underused. Evidence-based pressure ulcer prevention and treatment guidelines appear to be rarely implemented. This study provides a basis for developing educational and quality improvement programs and future research related to pressure ulcer prevention and treatment in LTCFs.

Osteoporosis screening is unjustifiably low in older African-American women

BACKGROUND

More than one million Americans suffer osteoporotic fractures yearly, resulting in a marked increase in morbidity and mortality. Despite a decrease in bone mineral density with increasing age in all ethnic groups and both genders, preventative and therapeutics efforts in osteoporosis have been focused on caucasian and Asian women. This study assesses the osteoporosis screening practices and the frequency of low bone density in a primarily African-American population of older women.

METHODS

Medical records of 252 women at risk for osteoporosis were reviewed for the diagnosis of osteoporosis, prior osteoporosis screening, prior breast cancer screening, and the use of calcium, vitamin D or estrogen. Subsequently, 128 women were assessed for risk factors for osteoporosis, and their bone mineral density was measured using a peripheral bone densitometer.

RESULTS

Osteoporosis screening had been performed in 11.5% of the subjects. Of the women evaluated by peripheral bone densitometry, 44.5% of all women, 40.4% of African-American women, and 53.3% of caucasian women had abnormally low bone density measurements. The frequency of abnormal bone density increased with both increasing age and decreasing body mass index.

CONCLUSIONS

Although few women in this population were previously screened for osteoporosis, low bone density occurred in African-American women at substantial rates. Increasing age and low body mass are important risk factors for low bone density in African-American women. Ethnicity should not be used as an exclusion criterion for screening for osteoporosis.

Ventilator-associated pneumonia in a multi-hospital system: differences in microbiology by location

OBJECTIVE

To determine whether there were differences in the microbiologic etiologies of ventilator-associated pneumonia in different clinical settings.

DESIGN

Observational retrospective cohort study of microbiologic etiologies of ventilator-associated pneumonia from 1998 to 2001 in a multi-hospital system. Microbiologic results were compared between hospitals and between different intensive care units (ICUs) within hospitals.

SETTING

Three hospitals--one pediatric teaching hospital, one adult teaching hospital, and one community hospital--in one healthcare system in the midwestern United States.

PATIENTS

Patients at the target hospitals who developed ventilator-associated pneumonia and for whom microbiologic data were available.

RESULTS

Seven hundred fifty-three episodes of ventilator-associated pneumonia had culture data available for review. The most common organisms at all hospitals were Staphylococcus aureus (28.4%) and Pseudomonas aeruginosa (25.2%). The pediatric hospital had higher proportions of Escherichia coli (9.5% vs 2.3%; P < .001) and Klebsiella pneumoniae (13% vs 3.1%; P < .001) than did the adult hospitals. In the pediatric hospital, the pediatric ICU had higher P aeruginosa rates than did the neonatal ICU (33.3% vs 17%; P = .01). In the adult hospitals, the surgical ICU had higher Acinetobacter baumannii rates (10.2% vs. 1.7%; P < .001) than did the other ICUs.

CONCLUSIONS

Microbiologic etiologies of ventilator-associated pneumonia vary between and within hospitals. Knowledge of these differences can improve selection of initial antimicrobial regimens, which may decrease mortality.

Factors affecting the validity of a Timeline Follow-Back interview

OBJECTIVE

The Timeline Follow-Back (TLFB) interview is a calendar-prompted, retrospective measure of alcohol consumption. This report examines limitations of the TLFB's validity by examining change in reported consumption going back in time.

METHOD

This report analyzes data from a case-control study. Cases (N = 2,517; 56.9% men) were patients presenting for care of an acute injury to one of three emergency departments in Boone County, MO. Two control groups were recruited. Community controls (N = 1,856; 51.1% men) were recruited by random-digit dialing and interviewed by telephone (response rate, 46.5%); medical patients (N = 2,103; 50.9% men) presenting for care of a noninjury illness were interviewed in person and, a few months later, by telephone (complete data obtained on 2,082). A 28-day TLFB interview was conducted with cases and community controls and an 8-day TLFB was done twice with medical controls.

RESULTS

A linear regression analysis was done on each individual's drinking over the 28 or 8 days. Averaging participants' regression slopes, cases as a group showed a significant decay in self-reported consumption (0.011 drink per day for each day going back in time). Among community controls, the decay was significantly greater (0.018 drink per day). Analyzing only the 8 days prior to the day of interview, medical controls showed more evidence of bias than either cases or community controls.

CONCLUSIONS

The smaller decay in cases' reporting is consistent with an effect of motivation (e.g., engagement in the interview process). Whether the interview is conducted in person (cases and first interviews with medical controls) or by telephone (community controls and second interviews with medical controls) may be relatively less important.

Differences in percutaneous injury patterns in a multi-hospital system

OBJECTIVE

Determine differences in patterns of percutaneous injuries (PIs) in different types of hospitals.

DESIGN

Case series of injuries occurring from 1997 to 2001.

SETTING

Large midwestern healthcare system with a consolidated occupational health database from 9 hospitals, including rural and urban, community and teaching (1 pediatric, 1 adult) facilities, ranging from 113 to 1,400 beds.

PARTICIPANTS

Healthcare workers injured between 1997 and 2001.

RESULTS

Annual injury rates for all hospitals decreased during the study period from 21 to 16.5/100 beds (chi-square for trend = 22.7; P = .0001). Average annual injury rates were higher at larger hospitals (22.5 vs 9.5 PIs/100 beds; P = .0001). Among small hospitals, rural hospitals had higher rates than did urban hospitals (14.87 vs 8.02 PIs/100 beds; P = .0143). At small hospitals, an increased proportion of injuries occurred in the emergency department (13.7% vs 8.6%; P = .0004), operating room (32.3% vs 25.4%; P = .0002), and ICU (12.3% vs 9.4%; P = .0225), compared with large hospitals. Rural hospitals had higher injury rates in the radiology department (7.7% vs 2%; P = .0015) versus urban hospitals. Injuries at the teaching hospitals occurred more commonly on the wards (28.8% vs 24%; P = .0021) and in ICUs (11.4% vs 7.8%; P = .0006) than at community hospitals. Injuries involving butterfly needles were more common at pediatric versus adult hospitals (15.8% vs 6.5%; P = .0001). The prevalence of source patients infected with HIV and hepatitis C was higher at large hospitals.

CONCLUSIONS

Significant differences exist in injury rates and patterns among different types of hospitals. These data can be used to target intervention strategies.