Exploring facilitators and barriers to patient-provider communication regarding diabetes self-management

Objective

Long-term type 2 diabetes management requires open communication between a patient and their provider for self-care adherence. This study explored facilitators and barriers to diabetes-specific communication in West Virginia, a medically underserved state with the highest prevalence of diabetes (16.2%) in the U.S.

Methods

A secondary qualitative analysis was conducted using data from semi-structured interviews (n = 34) and 4 focus groups (n = 23) with participants of a diabetes education program. Transcripts were analyzed using thematic analysis.

Results

Three facilitators to patient-provider communication emerged: "Patient-Provider Partnership", "Provider Accessibility", and "Empowerment Through Education". Partnership with providers, especially those who were accessible outside of scheduled appointments, and empowerment obtained through diabetes education facilitated diabetes-specific patient-provider communication. However, barriers included "Providers' Focus on 'Numbers' Rather than Patient Concerns", "Patient Lack of Preparation for Appointments", and "Providers 'Talking Down to' Patients".

Conclusion

The findings highlight patient- and provider-related factors that impact diabetes-specific communication.

Innovation

Previous interventions have trained providers in communication skills. Despite some success, challenges in implementation remain considering providers' limited time and overwhelming demands. This study suggests that diabetes education programs incorporating communication and self-advocacy skills could be a promising alternative as they can empower patients to communicate their diabetes-specific needs/preferences with providers.

Factors influencing the implementation of an intimate partner violence intervention in nurse home visiting: A qualitative descriptive study

AIMS

To identify factors that influenced: (1) integration of an intimate partner violence intervention into the Nurse-Family Partnership programme and (2) utilization of the intervention with fidelity to the clinical pathway by nurses in their home visits.

DESIGN

A qualitative descriptive study embedded in the intervention arm (n = 7 sites) of a 15-site cluster randomized clinical trial to evaluate the intimate partner violence intervention.

METHODS

Semi-structured interviews (n = 13) were conducted with supervisors. Nurses at the seven sites shared their experiences in focus groups conducted at two time points (n = 14 focus groups, 12 months after baseline and following collection of client trial data). Qualitative data were generated between May 2012 and September 2016, with this post hoc analysis completed in 2021. Focus group data were analysed using a rapid qualitative analysis technique. Conventional content analysis was used to categorize data from the supervisor interviews.

RESULTS

Integration was negatively impacted by: (1) a lack of centralized programme support and (2) competing programme demands. At the practice level, multiple factors related to supervisor capacity, preservation of the nurse-client relationship and nurse, client and intervention attributes influenced nurses' capacity to address intimate partner violence with fidelity to the clinical pathway. A lack of privacy in home visits was the most common barrier to addressing clients' experiences of violence. The need for increased time for nurses to develop clinical expertise prior to the evaluation of the intervention was also identified.

CONCLUSION

Before implementing an intimate partner violence intervention, home visitation programmes need to attend to site readiness, provide support to supervisors to facilitate implementation, and provide nurses with time to develop the expertise and clinical judgement required to use a complex intervention whilst also respecting clients' agency to determine when and how they will respond to the violence in their relationships.ImpactWhat problem did the study address? Given the positive impacts that participating in the Nurse-Family Partnership intimate partner violence education had on nurse home visitors' attitudes and confidence to address this type of violence experienced by first-time mothers, it was important to understand what factors contributed to the low fidelity of intervention implementation in practice, a factor that may help to explain the lack of client-level impacts on maternal outcomes. What were the main findings? Implementation of an intimate partner violence intervention in a nurse home visiting programme was influenced by contextual factors at both programme and practice levels. At the practice level, a lack of privacy in the home limited nurses' capacity to use the intervention. Supervisors were identified as having an important role to support nurses develop the expertise to use the intervention. Nurses also consistently balanced the intervention requirements to address intimate partner violence with an understanding of the complexity of this type of violence in young women's lives and respect for clients' agency to determine when and how they will respond to the violence in their relationships. Where and on whom will the research have an impact? These findings will be of interest to: (1) researchers developing and evaluating complex nursing interventions to address intimate partner violence in home visitation programmes and (2) stakeholders leading the implementation of novel innovations in the Nurse-Family Partnership programme.

Nurse-Family Partnership nurses' attitudes and confidence in identifying and responding to intimate partner violence: An explanatory sequential mixed methods evaluation

AIMS

To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice.

DESIGN

An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme.

METHODS

Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis.

RESULTS

Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence.

CONCLUSION

Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity.

IMPACT

These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.

Mentoring Multi-College Bystander Efficacy Evaluation - an Approach to Growing the Next Generation of Gender-Based Interpersonal Violence Intervention and Prevention (VIP) Researchers

The Centers for Disease Control and Prevention provided funding (U01 CE002668) to evaluate bystander program efficacy to reduce gender-based violence on college campuses (Aim 1) and to create a mentoring network (Aim 2) for young campus-based researchers interested in violence intervention or prevention (VIP). While an evaluation of this mentoring program is ongoing, our purpose here was to document the strategies used to create, implement, and begin evaluation of this national multi-college mentoring network. As each public college was recruited into this evaluation named multi-college Bystander Efficacy Evaluation (mcBEE), each college was invited to nominate a researcher interested in receiving mentorship as a mcBEE fellow. Senior faculty with active VIP research careers were recruited as mentors. Mentorship occurred through annual meetings over time (2015-2019), weekly to bimonthly calls or video conferencing with 2-3 other fellows, and a mentor forming a group with 3-4 mentees, termed a hive. The initial focus of hive meetings was 1) creating and maintaining an active daily writing practice and 2) developing productivity plans, to include research, personal, and professional goals. Manuscript and grant writing feedback was provided throughout the network electronically or 'live' workshops. Annual surveys were implemented to investigate program efficacy. Our mcBEE team was able to successfully assemble a national network of VIP fellows and provide small group and individualized mentoring. Our ultimate goal was that of supporting our fellows' own trajectories in gender-based VIP research, teaching, administration, or service. Evaluation of our fellow and mentor cohort is ongoing (2015-2019).

Effect of Addition of an Intimate Partner Violence Intervention to a Nurse Home Visitation Program on Maternal Quality of Life: A Randomized Clinical Trial

IMPORTANCE

Intimate partner violence (IPV) is a public health problem with significant adverse consequences for women and children. Past evaluations of a nurse home visitation program for pregnant women and first-time mothers experiencing social and economic disadvantage have not consistently shown reductions in IPV.

OBJECTIVE

To determine the effect on maternal quality of life of a nurse home visitation program augmented by an IPV intervention, compared with the nurse home visitation program alone.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-based, single-blind, randomized clinical trial at 15 sites in 8 US states (May 2011-May 2015) enrolling 492 socially disadvantaged pregnant women (≥16 years) participating in a 2.5-year nurse home visitation program.

INTERVENTIONS

In augmented program sites (n = 229 participants across 7 sites), nurses received intensive IPV education and delivered an IPV intervention that included a clinical pathway to guide assessment and tailor care focused on safety planning, violence awareness, self-efficacy, and referral to social supports. The standard program (n = 263 participants across 8 sites) included limited questions about violence exposure and information for abused women but no standardized IPV training for nurses.

MAIN OUTCOMES AND MEASURES

The primary outcome was quality of life (WHOQOL-BREF; range, 0-400; higher score indicates better quality of life) obtained through interviews at baseline and every 6 months until 24 months after delivery. From 17 prespecified secondary outcomes, 7 secondary end points are reported, including scores on the Composite Abuse Scale, SPAN (Startle, Physiological Arousal, Anger, and Numbness), Prime-MD Patient Health Questionnaire, TWEAK (Tolerance/Worry About Drinking/Eye-Opener/Amnesia/C[K]ut Down on Drinking), Drug Abuse Severity Test, and the 12-Item Short-Form Health Survey (physical and mental health), version 2.

RESULTS

Among 492 participants enrolled (mean age, 20.4 years), 421 (86%) completed the trial. Quality of life improved from baseline to 24 months in both groups (change in WHOQOL-BREF scores from 299.5 [SD, 54.4] to 308.2 [SD, 52.6] in the augmented program group vs from 293.6 [SD, 56.4] to 316.4 [SD, 57.5] in the standard program group). Based on multilevel growth curve analysis, there was no statistically significant difference between groups (modeled score difference, -4.9 [95% CI, -16.5 to 6.7]). There were no statistically significant differences between study groups in any of the secondary participant end points. There were no adverse events recorded in either group.

CONCLUSIONS AND RELEVANCE

Among pregnant women experiencing social and economic disadvantage and preparing to parent for the first time, augmentation of a nurse home visitation program with a comprehensive IPV intervention, compared with the home visitation program alone, did not significantly improve quality of life at 24 months after delivery. These findings do not support the use of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01372098.

Barriers to using new needles encountered by rural Appalachian people who inject drugs: implications for needle exchange

Background

Using a new needle for every injection can reduce the spread of infectious disease among people who inject drugs (PWID). No previous study has examined new needle use barriers among PWIDs residing in the rural Appalachian part of the United States, an area currently in the midst of a heroin epidemic.

Objective

Therefore, our primary aim was to explore self-reported barriers to using a new needle by PWID attending a needle exchange program (NEP).

Methods

We conducted a cross-sectional survey of PWID attending two NEPs in rural West Virginia located in the heart of Central Appalachia. A convenience sample of PWID (n = 100) completed the Barriers to Using New Needles Questionnaire.

Results

The median number of barriers reported was 5 (range 0–19). Fear of arrest by police (72% of PWID “agreed” or “strongly agreed”) and difficulty with purchasing needles from a pharmacy (64% “agreed” or “strongly agreed”) were the most frequently cited barriers.

Conclusions/Importance

Congruent with previous findings from urban locations, in rural West Virginia, the ability of PWID to use a new needle obtained from a needle exchange for every injection may be compromised by fear of arrest. In addition, pharmacy sales of new needles to PWID may be blunted by an absence of explicit laws mandating nonprescription sales. Future studies should explore interventions that align the public health goals of NEPs with the occupational safety of law enforcement and health outreach goals of pharmacists.

Electronic supplementary material

The online version of this article (10.1186/s12954-019-0295-5) contains supplementary material, which is available to authorized users.

Qualitative case study of needle exchange programs in the Central Appalachian region of the United States

Background

The Central Appalachian region of the United States is in the midst of a hepatitis C virus epidemic driven by injection of opioids, particularly heroin, with contaminated syringes. In response to this epidemic, several needle exchange programs (NEP) have opened to provide clean needles and other supplies and services to people who inject drugs (PWID). However, no studies have investigated the barriers and facilitators to implementing, operating, and expanding NEPs in less populous areas of the United States.

Methods

This qualitative case study consisted of interviews with program directors, police chiefs, law enforcement members, and PWID affiliated with two NEPs in the rural state of West Virginia. Interview transcripts were coded inductively and analyzed using qualitative data analysis software. Final common themes related to barriers and facilitators of past program openings, current program operations, and future program plans, were derived through a consensus of two data coders.

Results

Both NEPs struggled to find existing model programs, but benefited from broad community support that facilitated implementation. The largest operational barrier was the legal conundrum created by paraphernalia laws that criminalize syringe possession. However, both PWID and law enforcement appreciated the comprehensive services provided by these programs. Program location and transportation difficulties were additional noted barriers. Future program operations are threatened by funding shortages and bans, but necessitated by unexpected program demand.

Conclusion

Despite broad community support, program operations are threatened by growing participant volumes, funding shortages, and the federal government’s prohibition on the use of funds to purchase needles. Paraphernalia laws create a legal conundrum in the form of criminal sanctions for the possession of needles, which may inadvertently promote needle sharing and disease transmission. Future studies should examine additional barriers to using clean needles provided by rural NEPs that may blunt the effectiveness of NEPs in preventing disease transmission.

Evaluation of an Intimate Partner Violence Training for Home Visitors Using the Theory of Planned Behavior

INTRODUCTION

Intimate partner violence (IPV) is a public health issue with recent intervention focus by home visiting programs with at-risk families in the United States. Home visitors are typically required to assess IPV but feel unprepared to do so and desire training. Our aim was to evaluate the impact of a daylong IPV training on the intention to enact three key IPV behaviors (screening, making referrals, and safety planning) using the theory of planned behavior.

METHOD

Survey of 125 home visitors in West Virginia was conducted before and after a daylong IPV training.

RESULTS

The IPV training had a positive impact on intention to perform the three behaviors of interest, with the greatest impact on the intention to conduct IPV screenings.

DISCUSSION

Results provide important preliminary evidence supporting the effectiveness of professional development as a means of increasing intentions to conduct activities related to IPV. The impact on IPV screening intention is promising because screening is the first step in addressing IPV.

CONCLUSION

The IPV training proved beneficial in increasing intentions and such trainings should be expanded, but further study is needed to link intentions to subsequent behaviors to address IPV with at-risk families.

Needle exchange programs for the prevention of hepatitis C virus infection in people who inject drugs: a systematic review with meta-analysis

Background

Previous research on the effectiveness of needle exchange programs (NEP) in preventing hepatitis C virus (HCV) in people who inject drugs (PWID) has shown mixed findings. The purpose of this study was to use the meta-analytic approach to examine the association between NEP use and HCV prevention in PWIDs.

Methods

Study inclusion criteria were (1) observational studies, (2) PWIDs, (3) NEP use, (4) HCV status ascertained by serological testing, (5) studies published in any language since January 1, 1989, and (6) data available for measures of association. Studies were located by searching four electronic databases and cross-referencing. Study quality was assessed using the Newcastle Ottawa (NOS) scale. A ratio measure of association was calculated for each result from cohort or case–control studies and pooled using a random effects model. Odds ratio (OR) and hazard ratio (HR) models were analyzed separately. Results were considered statistically significant if the 95% confidence interval (CI) did not cross 1. Heterogeneity was estimated using Q and I² with alpha values for Q ≤ 0.10 considered statistically significant.

Results

Of the 555 citations reviewed, 6 studies containing 2437 participants were included. Studies had an average NOS score of 7 out of 9 (77.8%) stars. Concerns over participant representativeness, unclear adjustments for confounders, and bias from participant nonresponse and loss to follow-up were noted. Results were mixed with the odds ratio model indicating no consistent association (OR, 0.51, 95% CI, 0.05–5.15), and the hazard ratio model indicating a harmful effect (HR, 2.05, 95% CI, 1.39–3.03). Substantial heterogeneity (p ≤ 0.10) and moderate to large inconsistency (I² ≥ 66%) were observed for both models.

Conclusions

The impact of NEPs on HCV prevention in PWIDs remains unclear. There is a need for well-designed research studies employing standardized criteria and measurements to clarify this issue.

Trial registration

PROSPERO CRD42016035315

Electronic supplementary material

The online version of this article (doi:10.1186/s12954-017-0156-z) contains supplementary material, which is available to authorized users.

Identification and assessment of intimate partner violence in nurse home visitation

AIMS AND OBJECTIVES

To develop strategies for the identification and assessment of intimate partner violence in a nurse home visitation programme.

BACKGROUND

Nurse home visitation programmes have been identified as an intervention for preventing child abuse and neglect. Recently, there is an increased focus on the role these programmes have in addressing intimate partner violence. Given the unique context of the home environment, strategies for assessments are required that maintain the therapeutic alliance and minimise client attrition.

DESIGN

A qualitative case study.

METHODS

A total of four Nurse-Family Partnership agencies were engaged in this study. Purposeful samples of nurses (n = 32), pregnant or parenting mothers who had self-disclosed experiences of abuse (n = 26) and supervisors (n = 5) participated in this study. A total of 10 focus groups were completed with nurses: 42 interviews with clients and 10 interviews with supervisors. The principles of conventional content analysis guided data analysis. Data were categorised using the practice-problem-needs analysis model for integrating qualitative findings in the development of nursing interventions.

RESULTS

Multiple opportunities to ask about intimate partner violence are valued. The use of structured screening tools at enrolment does not promote disclosure or in-depth exploration of women's experiences of abuse. Women are more likely to discuss experiences of violence when nurses initiate nonstructured discussions focused on parenting, safety or healthy relationships. Nurses require knowledge and skills to initiate indicator-based assessments when exposure to abuse is suspected as well as strategies for responding to client-initiated disclosures.

CONCLUSION

A tailored approach to intimate partner violence assessment in home visiting is required.

RELEVANCE TO CLINICAL PRACTICE

Multiple opportunities for exploring women's experiences of violence are required. A clinical pathway outlining a three-pronged approach to identification and assessment was developed.

Characterization of drug and alcohol use among senior drivers fatally injured in U.S. motor vehicle collisions, 2008-2012

OBJECTIVE

Adults 65 years of age and older comprise the fastest growing demographic in the United States. As substance use is projected to increase in this population, there is concern that more seniors will drive under the influence of impairing drugs. The purpose of this analysis was to characterize the drug and alcohol usage among senior drivers fatally injured (FI) in traffic collisions.

METHODS

Data from the Fatality Analysis Reporting System were analyzed from 2008 to 2012. Commonly used classes and specific drugs were explored. Rates of drug use, multiple drugs, concomitant drug and alcohol use, and alcohol use alone were generated using Poisson regression with robust error variance estimation. Rates were compared to a reference population of FI middle-aged drivers (30 to 50 years old) using rate ratios.

RESULTS

Drug use among FI senior drivers occurred in 20.0% of those tested. Among drug-positive FI senior drivers, narcotics and depressants were frequent. The prevalence of testing positive for any drug, multiple drugs, combined drug and alcohol, and alcohol use alone among FI seniors were 47% less (relative risk [RR] = 0.53, 95% confidence interval [CI], 0.47, 0.62), 59% less (RR = 0.41, 95% CI, 0.34, 0.51), 87% less (RR = 0.13, 95% CI, 0.09, 0.19), and 77% less (RR = 0.23, 95% CI, 0.19, 0.28), respectively, compared to FI middle-aged drivers.

CONCLUSIONS

Though overall drug use is less common among FI senior drivers relative to FI middle-aged drivers, driving under the influence of drugs may be a relevant traffic safety concern in a portion of this population.

Exploring Health Insurance Status and Emergency Department Utilization

Emergency department (ED) use, by both insured and uninsured, leads to significant health care costs in the United States. While frequent ED use is often attributed to the uninsured, there is some evidence that insured populations also report utilizing the ED when otherwise preventable or nonurgent. We conducted in-person surveys of patients visiting the ED at a large research hospital and examined the differences in their characteristics based on the health insurance status. While less than the uninsured, insured individuals still report barriers to access to care outside the ED that include lack of access to another health care facility and unavailability of a doctor’s office or clinic.

The use of technology to reduce radiation exposure in trauma patients transferred to a level I trauma center

BACKGROUND

Patients with traumatic injuries transferred from rural hospitals to tertiary centers in West Virginia frequently undergo repeat computed axial tomography (CT) imaging upon arrival. The traditional method of sending images on a compact disc (CD) with EMS can be unreliable due to software incompatibility, CD malfunction, or misplacement of the CD. Given the known risks associated with ionizing radiation, physicians are increasingly aware of the need to avoid unnecessary CT imaging. Image storage applications such as ImageGrid provide a means to store images securely without the issues and inherent problems of a CD. These images can be uploaded at the referring hospital and may be viewed from any computer at the receiving facility, by multiple providers--even prior to patient arrival. The goal of this study was to determine if utilizing ImageGrid compared to traditional data transfer by CD resulted in a decrease in the amount and type of images obtained in the initial Emergency Department (ED) evaluation at the tertiary center.

METHODS

We analyzed data from the Jon Michael Moore Trauma Registry for patients transferred to the Emergency Department at WVU Hospitals from an outside facility. Two study periods were reviewed; prior to ImageGrid implementation and after implementation of the system. Medical records of all patients admitted to the Trauma Surgery Service after a trauma system activation in the ED were reviewed during these time periods. Number and type of CT studies obtained in the Emergency Department were recorded for analysis.

RESULTS

In the month of July 2010, 183 patients were admitted to the Trauma Surgery service after trauma team activation. Transfers from referring hospitals accounted for 77 of the 108 (42.1%). WVU Hospitals implemented ImageGrid during 2011. In July 2012, 243 patients were admitted to the Trauma Service, of which 105 (41.1%) were transfer patients. After implementation of ImageGridTM there was a significant decrease in the number of repeat CT Scans of the brain (19/27 [70.4%] vs. 18/40 [45.0%], p < .05), as well as CT scans of the chest, abdomen or chest/ abdomen/pelvis (9/18 [50.0%] vs. 2/23 [8.7%], p < .05). CT of the face showed a decreasing trend (5/9 [55.6%] vs. 1/9 [11%], p > .05 [p = 0.06]), but did not achieve statistical significance. After implementation of ImageGrid there was a marked decrease in total CT scans repeated (46/79 [58.2%] vs. 28/107 [26.2%], p < .05).

CONCLUSION

In West Virginia, the use of image archival systems such as ImageGrid appears to result in less repeat CT imaging upon arrival at a tertiary trauma center. Given risks associated with ionizing radiation and costs of repeat imaging the benefits have important implications for patient safety and cost containment.

Trauma patient access: the role of the emergency medical services system in North-Central West Virginia

Trauma patients face many obstacles as they access the healthcare system in North-Central West Virginia. This study highlights some of these barriers and discusses administrative and legislative initiatives that could help mitigate the disparities that rural trauma patients face.

METHODS

This is a retrospective, observational study utilizing information from the West Virginia University (WVU) MedCom Database. Trauma related Emergency Medical Services (EMS) calls from 2002 to 2011 were reviewed to determine many of the parameters of the care provided by EMS in the WVU MedCom catchment area. These 54,952 trauma related EMS contacts were reviewed to determine estimated time of arrival (ETA) at the receiving facility, level of EMS response, trauma activation criteria, time of day, and day of week of the transport.

RESULTS

The mean ETA for all transports was 11.7 minutes with mean transport ETA from the most rural county, Pendleton County, being 28.4 minutes. Emergency Medical Technician-B (BLS) providers covered 23% of the calls. Emergency Medical Technician-P (ALS) providers covered 76% of the calls. West Virginia State Trauma activation criteria were met for 30% of the transports. BLS providers transported 19% of these trauma activation criteria patients and ALS providers transported 78% of these transports.

CONCLUSIONS

In north-central West Virginia, there are many barriers facing the trauma patient as they access the healthcare system. Among these are extended transport times, the capabilities of the EMS provider responding, and the limitation that approximately 50% of counties have either no hospital at all or only a hospital with limited treatment capability for the trauma patient transported by EMS.

Abstract W P189: Characteristics of Rural Pre-Hospital Stroke Transports

Introduction: West Virginia (WV) is the second most rural state and has a stroke prevalence of 3%. According to the United States Census Bureau, 97.3% of the land is considered rural and 51.3% of the population lives in a rural area. EMS transport times in Northern WV often exceed 20 minutes in rural counties. Little data has been published about EMS response to acute stroke patients in the rural setting.

Methods: This was a retrospective cohort study of EMS response and interventions for patients with chief complaint of stroke in the MedCom database providing medical command for 26 northern WV counties. Stroke encounters from January 1, 2002 to December 31, 2011 were analyzed for EMS provider capability, receiving hospital capability, and pre-hospital interventions.

Results: There were 7,594 transports available for analysis. Basic Life Support (BLS) responders provided 7.0% of the care. The majority of the patients, 51.6%, were transported to an acute care hospital, 11.6% to a critical access hospital, and 36.9% to a designated stroke center. Blood glucose was determined by glucometer in 66.4% of patients with 2.0% treated for hypoglycemia. Vascular access was attempted in 92.6% of the patients and was successful in 81.5%. Cardiac monitor was applied in 92.4% of the patients and oxygen saturation was determined by pulse oximetry in 95.8%. Oxygen therapy was administered to 96.5% of the patients.

Discussion: In rural northern WV, 7% of the suspected stroke patients had care by only a BLS responder. Although evaluation at a designated stroke center has been shown to increase the chance for receiving acute thrombolytic intervention, less than 40% of patients in northern WV were initially seen at a designated stroke center and 11.6% were initially seen at a critical access hospital. Consequently, even critical access hospitals need to be prepared to rapidly evaluate and treat patients with suspected ischemic stroke. Blood glucose was not checked by EMS personnel in more than 30% of all transports. Additional studies are needed to assess the impact of these pre-hospital procedures and transport destination decisions on suspected stroke patient outcomes in the rural setting.

Falls and dilemmas in injury prevention in older West Virginians

Falls are the number one cause of injury-related morbidity and mortality in West Virginia senior citizens. Poor outcomes following falls are exacerbated by numerous comorbidities which are prevalent in the elderly population in West Virginia. This study describes the injury patterns, resource utilization and dispositions of WV seniors injured in a fall.

METHODS

This is a descriptive retrospective cohort study utilizing the West Virginia State Trauma System registry; which collects trauma data from 33 acute care facilities in West Virginia.

RESULTS

Data from 5498 cases were reviewed for patients enrolled in the Registry in 2010. Fall victims aged 65 and older were included. Most falls occurred in the home (75.2%) or in a residential institution (11.3%). Femur fractures (36.3%) and intracranial hemorrhages (8.2%) were the most common injury diagnoses. Disposition back home declined from 58.6% in the 60-65 age group to 20.9% returning home following falls in the age 90-94 group. Conversely, disposition to a skilled nursing facility rose from 20.1% in the age 60-65 group to 49.1% in the age 90-94 group. The case fatality rate for all the seniors enrolled in the trauma system was 3.3%.

DISCUSSION

Fall was the mechanism of injury for 83.3% of traumatic injuries in persons over the age of 65 enrolled in the WV trauma system. Older West Virginians suffer from numerous comorbidities that increase the risk of fall as well as the severity of injuries from a fall.

CONCLUSION

In West Virginia, there is a correlation between increasing age and less desirable outcomes and dispositions from trauma centers for senior citizens after a fall. West Virginia patients, families and care providers must frequently face complicated treatment dilemmas, especially as the related risk of falling and the co-morbid conditions are commonly seen in older West Virginians. Multi-modal fall prevention programs can reduce the risk of falls in senior citizens.

Injury prevention and recreational all-terrain vehicle use: the impact of helmet use in West Virginia

All-terrain vehicles (ATVs) are a popular source of outdoor activity in the United States, particularly in West Virginia. During the period of time from 1999 to 2007, deaths associated with ATVs in West Virginia increased by 28%. Helmet use among bicycle and motorcycle riders has been shown to decrease morbidity and mortality following trauma.

METHODS

We performed a retrospective observational study to compare injury patterns, hospital course, and resource utilization of non-helmeted and helmeted riders involved in ATV accidents using data from the West Virginia Trauma Center System. Descriptive statistics were calculated for all study variables and comparisons were made between helmeted and non-helmeted riders.

RESULTS

In 2010, there were 1,059 patients aged 18 and over with traumas resulting from ATV accidents within the System. Riders involved in ATV trauma occurring on farms and streets were significantly more likely to be non-helmeted, while those using ATVs for recreational purposes were more likely to be helmeted. Non-helmeted riders were significantly more likely to arrive to the hospital via helicopter than helmeted riders, and were less likely to be discharged home from the ED compared to helmeted riders. Non-helmeted riders sustained significantly more head, neck, soft tissue injuries, concussions, intracranial hemorrhages, facial fractures, skull fractures, and thoracic spine fractures than helmeted riders.

DISCUSSION

The findings of the current study support previous studies documenting that helmet use is protective against intracranial injury and other injuries of the head and neck. ATV use continues to be a significant contribution to trauma morbidity and mortality in West Virginia.

CONCLUSION

Efforts that focus on increased helmet use have the potential to significantly reduce morbidity and mortality following ATV trauma. Enforcement of the current West Virginia ATV Law should be encouraged. Legislation expanding the mandatory use of safety equipment and rider training should be enacted in West Virginia.

Multiple-Goal Heuristic Search

This paper presents a new framework for anytime heuristic search where the task is to achieve as many goals as possible within the allocated resources. We show the inadequacy of traditional distance-estimation heuristics for tasks of this type and present alternative heuristics that are more appropriate for multiple-goal search. In particular, we introduce the marginal-utility heuristic, which estimates the cost and the benefit of exploring a subtree below a search node. We developed two methods for online learning of the marginal-utility heuristic. One is based on local similarity of the partial marginal utility of sibling nodes, and the other generalizes marginal-utility over the state feature space. We apply our adaptive and non-adaptive multiple-goal search algorithms to several problems, including focused crawling, and show their superiority over existing methods.

Energy and symmetry of self-assembled two-dimensional dipole clusters in magnetic confinement

We report on confined two-dimensional (2D) dipole clusters formed by small ferromagnetic particles floating at the liquid-air interface and confined by nonuniform external magnetic field. The particles self assemble into hexagonally ordered clusters whose lattice constant can be magnetically tuned. We study the area S, the energy E, the chemical potential mu and the lattice constant a, of 2D clusters as functions of particle number N for N<130. We develop a continuum approximation which accounts fairly well for the smooth part of mu(N), S(N), and a(N) dependences. In addition to these dependences, we observe quasiperiodic fluctuations with dips at "magic" numbers corresponding to particularly symmetric particle configurations. We demonstrate that these fluctuations are related to the cluster symmetry and to the cluster center of mass position.

Spatial light modulator based on a deformed-helix ferroelectric liquid crystal and a thin a-Si:H amorphous photoconductor

We have developed an optically addressed spatial light modulator (OASLM) based on a deformed-helix ferroelectric liquid crystal (DHFLC) and a thin (0.5-mum) amorphous a-Si:H photoconductor. The thin photoconductor permits operation in the transmission mode of a read beam. The OASLM, operated in the integrated mode, exhibits gray levels, a high contrast (>1:40), and a high spatial resolution (exceeding 57 lines/mm). This is a significant improvement over previously reported OASLM's based on DHFLC's.

[The adjuvant chemotherapy of N(-) patients with breast cancer--when is it indicated?]

The object of this research is determination the necessity of leading of adjuvant chemotherapy with patients with breast cancer without metastases in axillary lymph nodes (N(-)), with disadvantages other prognostic factors (T > 20 mm, estrogen receptors (-), II and III stage grading). Post-operative with 52 women with high risk of recedives or metastases had been performed polychemotherapy (39-CMF and 13 FEC). Control group include 40 patients without adjuvant chemotherapy. Relapse are report with 6 of investigate and 8 of control group (pt > 0.05). The obtained results are discussed in connection with literature data.