Needle-Stick Injuries in the National Health Service: A Culture of Silence

Prevalence of needle stick and its related factors in Iranian health worker: an updated systematic review and meta-analysis

Background

Healthcare workers (HCWs) are at risk of acquiring blood-borne infections such as hepatitis B, hepatitis C, and human immunodeficiency virus through needlestick injuries (NSIs). We aimed to investigate the prevalence of needlestick injuries and other related indicators among HCWs in Iran through a systematic review and meta-analysis.

Methods

We searched various databases until the end of May 2023 for studies reporting the prevalence of NSIs among healthcare workers in Iran. We used a random model with 95% confidence intervals (CIs) to analyse the data and the Joanna Briggs Institute (JBI) tool to evaluate the quality of included studies. We conducted and reported the study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

We included 87 studies in the analysis and found that 47% (95% CI = 42-52, I2 = 98.9%) of Iranian HCWs experienced NSI. NSIs were most frequently related to syringe needles (58%; 95% CI = 52-65, I2 = 96.8%) and most often caused by recapping (30%; 95% CI = 22-38, I2 = 98.5%). In this study, 56% (95% CI = 45-67, I2 = 98.6%) of HCWs with NSIs did not report their injury. Moreover, the prevalence of NSIs the highest in the morning shift (0.44; 95% CI = 0.36-0.53, I2 = 97.2%), emergency unit (0.20; 95% CI = 0.16-0.24, I2 = 93.7%), and intensive care unit (0.20; 95% CI = 0.16-0.24, I2 = 94.3%).

Conclusions

To reduce the high prevalence of NSIs, HCWs, especially those in emergency departments, should use safety equipment. Healthcare managers should provide a calm and stress-free environment for HCWs, educate them on safety principles and standards, and support experienced HCWs with NSIs.

National Survey of Sharps Injuries Incidence Amongst Healthcare Workers in the United States

Purpose

Reporting sharps injuries is crucial for healthcare worker occupational safety. However, these incidents are often underreported, thus posing potentially dangerous working environments. Previous small and limited studies have quantified this underreporting in specific groups of healthcare workers. This study aims to expand on these studies by further quantifying sharps injury incidences through a national study, thus better understanding healthcare reporting behaviors and the reasons for underreporting.

Patients and Methods

This is a national, multi-center, cross-sectional study conducted via an online anonymous survey distributed through email among United States attending physicians, fellows, residents, medical students, and nurses of all specialties (ie, surgery, medicine, pediatrics). Data analysis used descriptive statistics and regressive modeling with significance defined as p<0.05.

Results

Of over 3000 surveys emailed, 460 (15.3%) healthcare workers responded. The most vulnerable cohort to report sharps injuries were medical students (0.87 injuries per year ±0.69, n=92) and Postgraduate Year (PGY) 1 (0.67±0.81, n=71), PGY2 (0.86±-0.82, n=48), and PGY3 (0.92±0.8, n=45) resident physicians. Healthcare workers in surgical fields reported significantly higher likelihoods (odds ratio=4.61, p<0.001, 95% confidence interval 2.83-7.26) of sharps injuries. Medical students reported sharps injuries the least (40%) and nurses reported sharps injuries the most frequently (71%). The three most common reasons for not reporting sharps injuries included (1) healthcare workers perceiving low infection risk based on patient medical history, (2) fear of peer perception, and (3) belief of lack of reporting utility or that reporting is inconsequential.

Conclusion

Medical students and physicians early in training, especially those in surgical fields, are more vulnerable to sharps injuries, but are less likely to report, while nurses are the most likely to report. Dedicated sharps training, education to reduce stigma around injury, and implementing a simplified reporting process may help encourage reporting as well as consistency in reporting, leading to improved workplace safety.

Underreporting of occupational blood and body fluid exposure in French university hospitals in 2017

BACKGROUND: Occupational blood and body fluid exposures (OBBFEs) are one of the biological risks run by health professionals, especially in hospitals. OBJECTIVE: The objectives of this study were to assess the occurrence and reporting of occupational blood and body fluid exposures (OBBFEs) in university hospital medical staff and to investigate factors associated to declared OBBFE and factors associated to reported OBBFE. METHODS: A self-administered questionnaire has been e-mailed to all junior and senior medical staff in four university hospital centers in one administrative region of France in 2017. RESULTS: 292 of the 1,228 respondents declared at least one OBBFE. More than two-thirds (70.2%) were under-reporters and more than half (53.8%) non-reporters. Younger subjects, surgical specialties and other associated work accidents were risk factors for OBBFE. Considering the reporting procedure too complex was a risk factor for underreporting. CONCLUSIONS: Underreporting by hospital medical staff was a persistent phenomenon, with a high rate. The OBBFE reporting procedure needs rethinking.

Reported Injuries from Sharp Objects among Healthcare Workers in Central Greece

Sharp injuries (SIs) are incidents or accidents caused by a needle, blades (such as scalpels) or other medical instruments which penetrate the skin. They are among the major work-related injuries in healthcare professionals. The purpose of this study is to estimate SIs in healthcare workers (HCWs) in Central Greece. Method: A cross-sectional descriptive study through an online survey in healthcare facilities in Central Greece was conducted. Snowball sampling contributed to further dissemination of the survey among the target population. The modified version of the EPINet questionnaire was used with self-reported answers of the participants via electronic Google form. Results: Analysis of collected data indicated that 74.1% of the participants had at least one injury, with the highest number of injuries occurring in nursing staff at 65.1% and 62.3% of injuries recorded in the morning shift. With respect to the site of the injury, participants reported 33.1% of the injuries in the patient’s room, 11.8% in the nurse’s station, 9.6% in the Emergency Department (ED), 9.2% in the Intensive Care Unit (ICU), 8.4% in blood sampling, 8.4% in surgery, and only 7.8% in laboratories or other places. Additionally, hands were the most frequently affected body part (96%), while 69.6% of the workers did not report the injury and 53% of them did not apply the procedures and guidelines defined by the healthcare organization (employer). Relative factors to the injury are age, level of education, shifts, and possibly sex. Conclusions: SIs are the “Achilles heel” of health workers. The high incidence and low reporting rate of SIs highlights the need for specialized training and education. Age, work experience, and shift appear to significantly affect the incidence of injury.

Underreporting of work accidents associated with blood-borne risk factors

BACKGROUND

Work accidents (WA) due to percutaneous or mucocutaneous injury are extremely frequent among health professionals. The notification of these accidents ensures not only the compliance with legal requirements, but it also enables health institutions to develop, implement and evaluate strategies to prevent them. This study aimed to estimate the proportion of underreporting of work accidents caused by percutaneous and mucocutaneous lesions in a hospital setting, as well as its determinants.

METHODS

A self-administered questionnaire was made available to all hospital employees. Age, gender, professional category and type of service adjusted odds ratios (OR) and 95% confidence intervals (95%CI) were computed by multivariate logistic regression models.

RESULTS

Underreporting of WA associated with biological risk factors was high, particularly in accidents by mucocutaneous injury (80.9%). Physicians were the professional category that least reported this type of work accidents (OR=4.64; 95%CI 2.20-9.78). The main determinants of underreporting were the underestimation of the risk of transmission and the excessive bureaucracy.

CONCLUSIONS

The underreporting of work accidents associated with biological risk factors was considerable and it contributes to a high degree of uncertainty on accidents' characterization.

Prevalence, emotional and follow-up burden of insulin injection-related needle-stick injuries among clinical nurses in Shaanxi Province, west of China: A cross-sectional study

Aims and objectives

The aim of this study was to investigate the prevalence, emotional and follow‐up burden of insulin injection‐related needle‐stick injuries among clinical nurses.

Background

needle‐stick injures introduce statistically significant occupational hazards to healthcare workers. Although the large proportion of the needles injuries attributed to insulin injection, research evidence about the prevalence, emotional and follow‐up burden of such injures is lacking.

Design

Cross‐sectional study.

Methods

5389 nurses were recruited from 45 hospitals in Shaanxi, China, from November 2018 to July 2019. Participants were administrated with a questionnaire specifically developed for this study. Descriptive statistics were used to present the findings.

Results

All 5,389 nurses responded to the survey, of which 396 (7.4%) participants experienced 620 insulin injection‐related needle‐stick injuries in the past year, representing an annual prevalence of 115.0 per 1000 nurses. The annual prevalence of infection caused by the injuries was 18.7 per 1000 nurses. The injuries occurred most frequently when nurses were recapping the needle (42.4%). In the majority (98.4%) of the injuries, the hurt nurses took proper immediate actions. However, only 30.3% of nurses reported the injuries to the administrative staff, and in 43.2% of the injuries, the nurses refused or discontinued the suggested follow‐up. A large proportion (58.6%) of the hurt nurses experienced emotional changes. Multivariate logistic regression showed that department, removing and/or setting back needle caps with bare hands, frequency of insulin pen and syringes are associated with the incidence of insulin injection‐related needle‐stick injuries. This paper is reported following the STROBE recommendations.

Conclusions

This survey demonstrated a considerably high prevalence of insulin injection‐related needle‐stick injuries among clinical nurses. Even though the majority of the hurt nurses took proper immediate actions, a large quantity of them failed to report the accidents to the administrative staff and complete the suggested follow‐up. Nurses who suffered from insulin injection‐related needle‐stick injuries were subject to various negative emotional changes. It portends a statistically significant risk to occupational health management for nurses.

Relevance to clinical practice

Scientific preventive and management strategies are desirable in order to minimize the consequences of insulin injection‐related needle‐stick injuries.

Incidence, Knowledge, Attitude and Practice Toward Needle Stick Injury Among Health Care Workers in Abha City, Saudi Arabia

Background

A needle stick injury is a serious occupational health hazard in health care settings. Health care workers are at risk of bloodborne diseases and the psychological consequences of these injuries. This study aims to estimate the incidence of needle stick injuries among healthcare workers during the previous 12 months and to assess their knowledge, attitude, and practice toward these injuries.

Methods

This cross-sectional study was conducted from 1st August 2019 till 15th February 2020, and included 786 healthcare workers in Abha city, Saudi Arabia. A structured questionnaire was used to collect the data.

Results

The incidence of needle stick injury among healthcare workers during the previous 12 months was (91/786) 11.57%. Nurses, females, and Saudis reported most needle stick injuries. More than half (52.7%) of the injuries went unreported. About 52.7% of needle stick injuries occurred during using sharp devices, and 42.9% of injuries happened in the patient room. The incidence of needle stick injury was significantly higher among those working at the secondary healthcare level (p = 0.003) and those practicing surgery (p < 0.001). Out of 786 participants, 94.7% knew the definition of needle stick injury, and 81.0% were aware of the procedure and guidelines to follow on sustaining a needle stick injury. Only 61.2% recognized that the recap of the needle is not recommended. Almost half of the participants (47.1%) agreed, and 33.6% strongly agreed that needle stick injury is preventable. A majority of healthcare workers (89.1%) had been vaccinated against Hepatitis B. Nearly 27.5% of healthcare workers incorrectly practiced recapping the needles with two hands and 8.7% bent needles before disposal. Recapping the needles was statistically significantly higher among healthcare workers who had a history of needle stick injury (p = 0. 046).

Conclusion

Needle stick injury and its under reporting among healthcare professionals is still a prevalent risk. Raising awareness among healthcare workers and improving the reporting systems for needle stick injuries to ensure more protection and early use of post-exposure prophylaxis is required. Implementation of safety precautions and safe injection practices and providing engineered safety devices may further reduce the risk.

The PRO-TEST Program: HIV and Hepatitis C Services at the Parole Office

This article describes an on-site program for HIV and hepatitis C (hep-C) services at a parole office in an impoverished U.S. state. Both officers and their supervisees participated in the program. The officers attended workshops on the biology of HIV, and hep-C, and workplace safety, and collaborated in development and implementation of the services. The supervisees received HIV and hep-C education, voluntary testing, and referral for treatment after a positive diagnosis. Test results showed that few supervisees were positive for HIV and 16% of White individuals were diagnosed with hep-C. These findings support the need for on-site services for supervisees in community corrections.

Fendrix® Vaccine Effectiveness in Healthcare Workers Who Are Non-Responsive to Engerix B® Vaccination

Hepatitis B (HBV) is a pathogen virus with transmission mechanisms that include contact with the infected blood or bodily fluids of the infected organism. Nowadays, healthcare workers are one of the most exposed groups to HBV. Conventionally, completing a vaccine series dosage with Engerix B^® lowers this risk by providing workers with immunity to the virus. However, through the years, we have encountered nonresponsive health personnel to the Engerix B^® vaccine; hence, the Occupational Health Service of Poniente Hospital studied the Fendrix^® adjuvanted vaccine as an alternative vaccine to develop immunological responses in healthcare workers who do not respond to vaccination with Engerix B^®. In our study, we employed a vaccination schedule with the Fendrix^® vaccine, performing serology tests on the cases after the application of each dose. The results obtained showed humoral immunity in 92.3% of the cases, with a remarkable increase in antibody titer after the first doses. These encouraging results support the future inclusion of this vaccine as one possible alternative for the immunization to HBV for healthcare workers nonresponsive to Engerix B^®.

Awareness About Sharps Disposal Leads to Significant Improvement in Healthcare Safety: an Audit of Compliance in the National Health Service During the COVID-19 Pandemic

Needle-stick injuries (NSIs) pose serious health risks and can transmit blood-borne diseases (BBDs), such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus from the patient to the staff member. The purpose of this study was evaluation of appropriate and safe disposal of sharps within a 730-bed acute district general hospital (DGH) in the UK. One hundred sharps containers were audited in November 2019 to assess whether they complied with the health and safety regulations across surgical, medical, and acute wards. Meetings with the appropriate staff members were organised and posters placed throughout the hospital to raise awareness. One hundred twenty-five sharps containers were re-audited in July 2020, in the midst of the COVID-19 pandemic to ascertain if there was an improvement. In November 2019, a total of 56% of sharps containers were overfilled and hence were non-compliant with safety regulations. A re-audit performed in July 2020 found only 17% of sharps containers to be overfilled, which was a significant improvement (p = 0.0064) in practice. We noted that the overall compliance improved from being 44% in 2019 to 82.64 in the year 2020. This audit showed a significant improvement in the compliance of sharps bin containers in a DGH, signifying the increased awareness. It is necessary to audit sharps management regularly to accurately assess practice and prevent exposure to BBDs.

Interdisciplinary differences in needlestick injuries among healthcare professionals in training: Improving situational awareness to prevent high-risk injuries

BACKGROUND

Needlestick injuries among healthcare professionals continue to be an occupational hazard, frequently and incorrectly regarded as low-risk, and exacerbated by underreporting. We aimed to investigate rates of needlestick injury, reasons for underreporting, and how explicit announcements that patients are "high-risk" (i.e., human immunodeficiency virus, hepatitis, or intravenous drug abuse history) might affect the actions of those at risk of sustaining an injury.

METHODS

A cross-sectional survey was administered to medical students (MS), nursing students (NS), and residents.

RESULTS

30/224 (13%) of MS, 6/65 (9%) of NS, and 67/126 (53%) of residents experienced needlestick injuries. 37% of MS, 33% of NS, and 46% of residents attributed "lack of concentration" as cause of injury. Residents had the lowest percentage of underreporting (33%), with rates of 40% and 83% among MS and NS, respectively. Top reasons for non-reporting included the injury being perceived as "trivial" (22%) and patient being "low-risk" (18%). A majority stated pre-operative "high-risk" announcements should be required (91%), and would promote "culture of safety" (82%), reporting of injuries (85%), and increased concentration during procedures (70%).

CONCLUSIONS

We recommend routine announcements during pre-operative time-out and nursing/resident hand-offs that state a patient is "high-risk" if applicable. We hypothesize such policy will promote a "culture of safety," situational awareness, and incident reporting.

Needlestick injuries among Malaysian healthcare workers

BACKGROUND

Needlestick injury (NSI) is a significant occupational health issue among healthcare workers (HCWs).

AIMS

To determine the national self-reported incidence and risk factors for NSI among Malaysian Ministry of Health (MOH) HCWs.

METHODS

Using data from the MOH national sharps injury surveillance programme, information on reported NSIs over a 1-year period (2016) for different HCW subgroups were extracted and analysed.

RESULTS

A total of 1234 NSI cases were reported in 2016, giving an overall incidence of 6 injuries per 1000 HCWs. Medical doctors recorded the highest incidence (21.1 per 1000 HCWs) followed by dental staff (7.5), pharmacy staff (4.2), nurses (3.7), medical assistants (3.4) and allied and auxiliary staff (1.0). Doctors had significantly increased risk of NSI compared with allied and auxiliary staff (relative risk [RR] = 20.7, 95% confidence interval [CI] 15.5-27.5), medical assistants (RR = 6.1, 95% CI 4.5-8.2), nurses (RR = 5.7, 95% CI 5.0-6.6), pharmacy staff (RR = 5.0, 95% CI 3.7-6.6) and dental staff (RR = 2.8, 95% CI 2.2-3.5). Significant differences were found in age and sharps- handling experience between occupational subgroups (P < 0.001 for both variables). Male employees had higher risk than females (RR = 1.33, 95% CI 1.18-1.50), with a significant difference seen in their sharps-handling experience (P < 0.01). Important risk factors included unsafe practices such as recapping of needles and their improper disposal.

CONCLUSIONS

The national incidence of NSI amongst Malaysian HCWs was lower compared with other countries, but unsafe practices remain an important concern. There is a need to formulate, implement and monitor safe and consistent practices for the different healthcare professionals.

Incidence of sharp and needle-stick injuries and mucocutaneous blood exposure among healthcare workers

Healthcare workers (HCWs) are exposed to biological hazards on a daily basis. The aim of the present study was to evaluate the risks of infection after occupational exposure to blood or body fluids among HCWs operating in the period 2013-2014, in a university hospital of Southern Italy. The frequency of accidents during the 2-year period was always lower than 5%. In 2013, 103 cases occurred; in 2014, the number of injuries had significantly decreased (n = 60). In 2013, an anti-hepatitis B surface antigen protective titer was only found in 70% of cases; in 2014, the subjects with a positive titer rose to 82%. No HCWs showed seroconversion to the main blood-borne pathogens. The implementation of strict prevention measures after the accidents reported in 2013 allowed the significant reduction of the number of injuries in 2014.

Prevalence of needle stick injury and its associated factors among nurses working in public hospitals of Dessie town, Northeast Ethiopia, 2016

OBJECTIVE

Nurses are exposed to dangerous and deadly blood borne pathogens through contaminated needle stick injuries. This study was designed to assess prevalence of needle stick injury and its associated factors among nurses working in hospitals. Institution-based cross-sectional study design was used among 258 randomly selected nurses. Collected data was entered into Epi-Data version 3.1 and transferred to SPSS Version 20.0 for analysis. The degree of variables were assessed using adjusted odds ratio and its 95% confidence interval with P value (< 0.05).

RESULTS

Eighty-nine (34.5%) nurses self-reported receiving a needle stick injury in the previous 12 months. Work experience, working hour, personal protective, infection prevention guide line utilization and infection prevention training were significantly associated to needle stick injury.

CONCLUSIONS

The needle stick injury in this study area was prevalent. The contributing factors to the injury were duration of working hours, experience, use of personal protective equipment and training.

Hepatitis B: prevention, protection and occupational risk

ABSTRACT 

Since 1992, the inclusion of HBV vaccination has been recommended by the WHO for all immunization programs implemented by nations. In Europe, the introduction of HBV vaccination has markedly reduced the incidence of acute HBV, and before the introduction of HBV vaccine, healthcare workers (HCW) were at considerable risk of infection. The present review discusses the main problems regarding three fundamental issues in hospital settings: prevention of HBV in HCW, protection induced by vaccination (problems regarding nonresponders) and risk for HCW exposed to blood-borne pathogens (occupational risk). The screening of HBV markers plays a decisive role in evaluating the degree of immune coverage in subjects exposed to biological risk and permits an increase in immune coverage through vaccine implementation.

Sharps injuries in ophthalmic practice

PURPOSE

Accidental sharps injuries are a potential route for transmission of blood-borne infection to healthcare workers. Ophthalmic staff in particular are at risk of sustaining such injuries due to the microsurgical nature of the speciality. Forthcoming European Union legislation aimed at reducing sharps injuries requires the development of risk-based sharps policy. The authors believe that this is the first study to assess the risks of sharps injuries and their management specific to ophthalmic practice within the European Union.

METHODS

A retrospective review of all reported sharps injuries across three eye units in the UK over a period of 6 years was undertaken. Data were analysed to determine the circumstances surrounding the injury, occupation of the injured person, and whether appropriate actions were taken following incidents.

RESULTS

A total of 68 sharps injuries were reported over the 6-year period. Nurses sustained 54.4% (n=37) of needlestick injuries, doctors 39.7% (n=27), and allied healthcare staff 5.9% (n=4). In all 51.5% (n=35) of sharps injuries occurred in the operating theatre, 30.9% (n=21) in the outpatient clinic, 13.2% (n=9) on the ophthalmic ward, and 4.4% (n=3) in unspecified locations. There was a median rate of 1.3 sharps injuries per 1000 surgical procedures per year and a range of 0.4-3.5 per 1000.

CONCLUSIONS

This study demonstrates the need to raise awareness of the unique risks of sharps injuries in ophthalmic practice. This is necessary in order to develop speciality-specific policy that promotes strategies to reduce such injuries, enhances the accuracy of reporting of such events, and provides guidance for appropriate management.

HIV testing of health care workers in England--a flawed policy

A new Department of Health policy in England, published in 2007, recommended changes to the pre-employment health checks performed on health care workers before taking up their employment. The policy proposed that all new health care workers should receive immunization against TB and hepatitis B and should be offered testing for hepatitis C and HIV. It also advanced a new requirement that staff who perform exposure-prone procedures must be tested for TB, hepatitis B and C and HIV and must test negative for these diseases. Essentially mandatory HIV testing has been introduced for a large number of health care workers. The aim of the recommendations is to protect patients from contracting serious communicable diseases from health care professionals. Secondary objectives of the directive are to maintain confidence in the workforce and reduce the burden of patient notification exercises. This essay explores some of the shortcomings of this policy and examines the reasons why this policy will fail to meet its objectives. The justification for this new guidance is questioned and some of the ethical issues are highlighted.

Hospital safety climate, psychosocial risk factors and needlestick injuries in Japan

To investigate the interactions between safety climate, psychosocial issues and Needlestick and Sharps Injuries (NSI), a cross-sectional study was undertaken among nurses at a university teaching hospital in Japan (89% response rate). NSI were correlated with various aspects of hospital safety climate including supporting one another at work, the protection of staff against blood-borne diseases being a high management priority, managers doing their part to protect staff from blood-borne disease, having unsafe work practices corrected by supervisors, having the opportunity to use safety equipment to protect against blood-borne disease exposures, having an uncluttered work area, and having minimal conflict within their department. In conclusion, this study has demonstrated the importance of hospital safety climate in Japanese health care practice, particularly its relationship with NSI. Although the provision of safer devices remains critical in preventing injuries, ensuring a positive safety climate will also be essential in meeting these important challenges for nurses' occupational health.

Occupational exposure to blood and body fluids among health care workers in a general hospital, China

OBJECTIVES

To understand current status of occupational exposure to blood and body fluids (BBF), and awareness of knowledge about occupational bloodborne pathogen exposures and universal precaution among hospital-based health care workers (HCWs).

METHODS

A cross-sectional study was conducted during April to May 2004 to study incidence of occupational exposure to BBF among 1,144 hospital-based HCWs.

RESULTS

The total incidence and the average number of episodes exposure to BBF was 66.3/100 HCWs per year and 7.5 per person per year in the past year, respectively. The incidence (per 100/HCWs per year) and the average number of episodes (per HCW per year) of percutaneous injury (PCI), mucous-membrane exposure (MME), and exposure to BBF by damaged skin was 50.3 and 1.8; 34.4 and 1.7; and 37.9 and 4.0, respectively. The leading incidence and the average number of episodes of PCI occurred in delivery room (82.6 and 1.8). The highest percentage of PCI's that occurred during the previous 2 weeks occurred during a surgical operation (22.8%). Of all sharp instruments, the suture needle contributed the highest percentage of PCI's (24.7%) among HCWs in the last 2 weeks. Over two-thirds (68.3%) of respondents were immunized with Hepatitis B vaccine; less than one-half (47%) of HCWs wore gloves while doing procedures on patients. The respondents demonstrated a lack of knowledge regarding transmission of bloodborne diseases and universal precautions.

CONCLUSIONS

Risk for potential exposure to BBF appears high in HCWs, and almost all of episodes are not reported. It is urgent to establish the Guideline for Prevention and Control of Occupational Exposure to Bloodborne Pathogens among HCWs. Am. J. Ind. Med. 52:89-98, 2009. (c) 2008 Wiley-Liss, Inc.