The long reach of juvenile and criminal legal debt: How monetary sanctions shape legal cynicism and adultification

Previous research has established the deleterious long-term effects of juvenile legal system involvement such as increased risk of criminal legal system involvement as adults. This paper examines retrospective accounts of how that process occurs by exploring the following research question: how does one's involvement in the juvenile legal system, which includes monetary sanctions, shape peoples' views of law and legal institutions and with what consequences? Based on 19 interviews with adults who have legal debt from both juvenile and criminal legal systems, the paper focuses on four aspects of the long-reaching effects of juvenile legal involvement and juvenile monetary sanctions: legal socialization, adultification, legal cynicism, and future aspirations. In all these aspects, we show the organizational constraints that shape individuals' perspectives about the law and the impact of monetary sanctions on their lives. In doing so, the paper shows how monetary sanctions associated with juvenile cases add to the cumulative disadvantage of legal system involvement.

The contingent effect of incarceration on state health outcomes

Introduction

This study examines how growth in the population of former prisoners affects rates of communicable diseases such as tuberculosis, syphilis, chlamydia, and HIV.

Methods

We estimate state-level fixed effects count models showing how the former prisoner population affected communicable disease in U.S. states from 1987 to 2010, a period of dramatic growth in incarceration.

Results

We find contingent effects, based on how specific diseases are recognized, tested, and treated in prisons. The rate of former prisoners increases diseases that are poorly addressed in the prison health care system (e.g., chlamydia), but decreases diseases that are routinely tested and treated (e.g., tuberculosis). For HIV, the relationship has shifted in response to specific treatment mandates and protocols. Data on prison healthcare spending tracks these contingencies.

Discussion

Improving the health of prisoners can improve the health of the communities to which they return. We consider these results in light of the relative quality of detection and treatment available to underserved populations within and outside prisons.

Readiness for the aging population in private dental practices

BACKGROUND

As more adults reach advanced age with natural teeth, there is an increasing need for dental and dental hygiene practices to provide care for older adults and individuals living with dementia. Little is known about how well these populations are accommodated in private practice.

METHODS

Following approval from the Research Ethics Board at Mount Allison University, a survey was sent to the 517 practising dental hygienists in New Brunswick, Canada. They were asked to rate on 5-point scales their geriatric oral care knowledge, their willingness to receive more education on the topic, and how frequently they adjusted their care provision to meet the needs of older (age 70+) clients and those living with dementia.

RESULTS

A total of 121 dental hygienists responded (23.4% response rate). Overall, respondents were willing to learn more about geriatric care, but lacked knowledge about the oral health effects of certain medications frequently used by older adults, and about techniques for accessing the oral cavity of clients with dementia. Many accommodations recommended by geriatric specialists were not consistently carried out.

DISCUSSION

Given that older adults and adults with dementia make up an increasingly large part of the population in need of oral care, geriatric and dementia oral care needs should be emphasized in dental and dental hygiene practices and continuing education for dental hygienists.

CONCLUSION

More research is required on the impact of integrating accommodations for older clients and clients with dementia into clinical practice, as well as how oral care is experienced by these populations.

Felon history and change in U.S. employment rates

In recent decades, the share of U.S. adults with felony-level criminal records has risen and the growth in the employment rate has slowed. Sociological theories of labeling and stigmatization, as well as economic theories of statistical discrimination, suggest a possible causal connection between the two phenomena. Surveys of employers have shown increasing reliance on criminal background checks, for example, and audit studies reveal explicit discrimination against people with felony-level criminal records. This paper draws on novel, state-level annual measures of individuals with felony-level records to estimate pooled cross-sectional, panel models predicting changes in aggregate employment rates. Estimates from these models indicate that a 1 percentage point increase in the share of a state's adult population with a felony history is associated with 0.3 percentage point increase in non-employment (being unemployed or not in the labor force) among those aged 18 to 54. Subgroup analysis shows that effects are stronger for women and whites. These results suggest that the stigma of a felony record may play an important part in aggregate employment rates as well as in individual hiring practices.

Rock glaciers represent hidden water stores in the Himalaya

In the high mountains of Asia, ongoing glacier retreat threatens human and ecological systems through reduced water availability. Rock glaciers are climatically more resistant than glaciers and contain valuable water volume equivalents (WVEQ). Across High Mountain Asia (HMA) the WVEQ of rock glaciers is poorly quantified, and thus their hydrological significance versus glaciers is unknown. Here we present the first systematic assessment of Himalayan rock glaciers, totalling ~25,000 landforms with an areal coverage of ~3747 km². We calculate the WVEQ of Himalayan rock glaciers to be 51.80 ± 10.36 km³. Their comparative importance versus glaciers (rock glacier: glacier WVEQ ratio) is 1:25, which means that they constitute hydrologically valuable long-term water stores. In the context of climate-driven glacier recession, their relative hydrological value will likely increase. These cryospheric stores should be included in future scenario modelling to understand their role in sustainable water management for HMA.

Implementation of a COVID-19 Mass Vaccination Clinic to College Students in Montana

We describe a large-scale collaborative intervention of practice measures and COVID-19 vaccine administration to college students in the priority 1b group, which included Black or Indigenous persons and other persons of color. In February 2021, at this decentralized vaccine distribution site at Montana State University in Bozeman, we administered 806 first doses and 776 second doses by implementing an interprofessional effort with personnel from relevant university units, including facilities management, student health, communications, administration, and academic units (e.g., nursing, medicine, medical assistant program, and engineering). (Am J Public Health. Published online ahead of print September 9, 2021:1776-1779. https://doi.org/10.2105/AJPH.2021.306435).

Anaerobes Direct from Blood Culture Bottles Can Be Identified by Early Matrix-Assisted Laser Desorption Ionization/ Time-of-Flight Mass Spectrometry (MALDI-TOF MS) at 24 Hours or Less

Introduction/Objective

Matrix-assisted laser desorption ionization/ time-of-flight mass spectrometry (MALDI-TOF MS) direct from positive blood culture bottles has facilitated drastic drops in turn-around times for microorganism identification but has been poorly studied for anaerobes. We investigated the ability of MALDI-TOF to provide early anaerobe identification at 4 hours and 18-24 hours of growth on agar from anaerobic blood culture bottles.

Additionally, we reviewed medical records of such patients to ascertain impact of early identification on antimicrobial treatment.

Methods

Over 9 months, we ran MALDI-TOF on early growth from blood cultures positive for growth in BACTEC™ Lytic/ 10 Anaerobic/F bottles. Broth from each bottle was subbed to sheep blood agar (4 hours, 5% CO2) and 2 CDC (BD-BBL™) anaerobic blood agar plates (examined 18-24 hours and 48 hours). Bruker Biotyper® RUO v7854 and Mayo Clinic Custom MALDI-TOF MS libraries were used for identification.

Results

144/184 (78%) bottles resulted in growth of aerobic bacteria. Of the remaining bottles with growth of anaerobes, 38 were assessed by early MALDI-TOF. Early MALDI-TOF at 4 hours identified 3 Clostridium perfringens (8%) and an additional 26/38 (68%) isolates at 18-24 hours (both Gram-positive and –negative). Routine 48 hour identification was required for 9 (24%) isolates. In 7 cases, early MALDI-TOF resulted in a change to more appropriate antimicrobial therapy, most often for Bacteroides.

Conclusion

29/38 (76%) of anaerobes from blood culture bottles were identified by early MALDI-TOF and reported to the clinician at least 24 hours before routine review of anaerobic sub plates for growth. All C. perfringens and Bacteroides were identified by 4 and 24 hours, respectively. Although early MALDI-TOF resulted in antimicrobial therapy adjustments in a minority of cases, it may allow for more targeted and earlier antimicrobial therapy. Early MALDI-TOF from anaerobic blood culture bottles should be considered for improved patient care and antimicrobial stewardship.

PROBATION AND MONETARY SANCTIONS IN GEORGIA: EVIDENCE FROM A MULTI-METHOD STUDY

Georgia leads the nation in probation supervision, which has been the subject of recent legislative reforms. Probation supervision is the primary mechanism for monitoring and collecting legal financial obligations (LFOs) from people sentenced in Georgia courts. This Article analyzes how monetary sanctions and probation supervision intersect in Georgia using quantitative data from the Department of Community Supervision as well as interviews with probationers and probation officers gathered as part of the Multi-State Study of Monetary Sanctions between 2015 and 2018. Several key findings emerge: (1) there is substantial variation between judicial districts in the amount of fines and fees ordered to felony probationers in Georgia, with fines and fees in rural areas much higher than those in urban areas; (2) probationers express fear of incarceration solely for lack of ability to pay; (3) probation officers consider collecting LFOs as a distraction from their true mission of public safety; and (4) both probationers and probation officers question the purpose, effectiveness, and fairness of monetary sanctions in Georgia. This Article concludes with a discussion of reforms to date and further options for reform based on the findings from this research.

Connecting the right to health and anti-extractivism globally

ABSTRACT Natural resources are essential to health and are global commons. Recognizing the devastating damage posed by extraction to health and the environment, as well as the erosion of the sovereignty of our governments that have increasingly conceded people’s health in the interest of profit and development, is important in framing our resistance. Our communities experience growing displacement, the loss of social services, of land, water and livelihood, heightened militarization, violence and repression, and increased incidence of communicable diseases and health problems resulting from exposure to toxics. All of these are linked to an extractivist project driven by global financial capital promoting an unsustainable and inequitable development model that threatens people’s health and the health of the planet. Is it compatible with the right to health to finance national health systems with revenues of activities that intrinsically destroy life? The essay portrays the inconsistency of development policies that fund health/right to health with extractivism and depicts examples of resistance to extractive industries tied to the People’s Health Movement (Canada,Turkey, India and Ecuador) in different types of governments. The need to strengthen the link between the right to health struggles and anti-extractive resistance is highlighted.

Growth In SNAP Retailers Was Associated With Increased Client Enrollment In Georgia During The Great Recession

Policies to improve food accessibility in underserved areas often use direct financial incentives to attract new food retailers. Our analysis of data on the Supplemental Nutrition Assistance Program (SNAP) in Georgia before and after the Great Recession suggests that increased program enrollment improves access to food for SNAP beneficiaries by acting as an indirect subsidy to retailers. We divided food stores into four categories: large, midsize, small, and specialty retailers. Between 2008 and 2011 the number of SNAP enrollees increased by 87 percent, and between 2007 and 2014 the number of SNAP retailers in Georgia increased by 82 percent, primarily because of growth in the number of authorized small retailers. Inside metropolitan Atlanta, changes in the numbers of SNAP enrollees and authorized retailers were positively and significantly associated for small retailers. For the areas outside of metropolitan Atlanta, the association between changes in numbers of enrollees and authorized retailers was strongest for small retailers; more modest associations were also seen for large and specialty retailers. Policy makers should consider how retailers' sensitivity to and reliance on SNAP funding can be leveraged to improve not only food availability, but also access to healthy foods.

Monetary Sanctions: Legal Financial Obligations in US Systems of Justice

This review assesses the current state of knowledge about monetary sanctions, e.g., fines, fees, surcharges, restitution, and any other financial liability related to contact with systems of justice, which are used more widely than prison, jail, probation, or parole in the United States. The review describes the most important consequences of the punishment of monetary sanctions in the United States, which include a significant capacity for exacerbating economic inequality by race, prolonged contact and involvement with the criminal justice system, driver's license suspension, voting restrictions, damaged credit, and incarceration. Given the lack of consistent laws and policies that govern monetary sanctions, jurisdictions vary greatly in their imposition, enforcement, and collection practices of fines, fees, court costs, and restitution. A review of federally collected data on monetary sanctions reveals that a lack of consistent and exhaustive measures of monetary sanctions presents a unique problem for tracking both the prevalence and amount of legal financial obligations (LFOs) over time. We conclude with promising directions for future research and policy on monetary sanctions.

The Cost of Being Cool: How Adolescent Pseudomature Behavior Maps onto Adult Adjustment

During adolescence, one's status among peers is a major concern. Such status is often largely a function of popularity and establishing oneself as "cool." While there are conventional avenues to achieving status among adolescents, engaging in adult-like, or pseudomature, behaviors such as substance use or sexual activity is a frequent occurrence. Although past research has examined the consequences of adolescent delinquency, what remains unclear is the long-term fate of adolescents who are both popular and antisocial. Using data from a sample of African American males (N = 339) we employ latent class analysis to examine the adult consequences of achieving popularity during adolescence by engaging in pseudomature behavior. Our results identified four classes of adolescents: the conventionals, the pseudomatures, the delinquents, and the detached. The conventionals were low on popularity, pseudomature behavior, and affiliation with deviant peers but high on academic commitment. The pseudomatures were high on popularity, adult-like behavior, and academic commitment but low on affiliation with delinquent peers. The delinquents were low on popularity and school achievement but high on pseudomature behavior and affiliations with delinquent peers. Finally, the detached were low on school commitment, popularity and pseudomature behavior but they report high involvement with a delinquent peer group. By early adulthood, the costs of adolescent adult-like behavior were evident. Early popularity and academic commitment did not portend later social competence or college completion for the pseudomatures. Instead, they frequently experienced an early transition to parenthood, a likely consequence of precocious sexual activity. These findings suggest that interventions should not focus only on the most delinquent adolescents but also need to attend to the pseudomature students who are brimming with promise but are flirting with behaviors that may subvert realization of this potential.

Risk managers' descriptions of programs to support second victims after adverse events

Guidelines call for healthcare organizations to provide emotional support for clinicians involved in adverse events, but little is known about how these organizations seek to meet this need. We surveyed US members of the American Society for Healthcare Risk Management (ASHRM) about the presence, features, and perceived efficacy of their organization's provider support program. The majority reported that their organization had a support program, but features varied widely and there are substantial opportunities to improve services. Provider support programs should enhance referral mechanisms and peer support, critically appraise the role of employee assistance programs, and demonstrate their value to institutional leaders.

Competitive context alters plant-soil feedback in an experimental woodland community

Recent findings on feedback between plants and soil microbial communities have improved our understanding of mechanisms underlying the success and consequences of invasions. However, additional studies to test for feedback in the presence and absence of interspecific competition, which may alter the strength or direction of feedbacks, are needed. We tested for soil microbial feedback in communities of the invasive grass Microstegium vimineum and commonly co-occurring native plant species. To incorporate competitive context, we used a factorial design with three plant treatments (M. vimineum alone, M. vimineum with the native plant community, and the native community without M. vimineum) and two soil inoculum treatments (experimentally invaded and uninvaded soil). When competing with M. vimineum, native communities were 27% more productive in invaded than uninvaded soil. In contrast, soil type did not significantly affect M. vimineum biomass or fecundity. At the community level, these results indicate a net negative soil microbial feedback when native plants and M. vimineum are grown in competitive mixture, but not when they are grown separately. Since positive, not negative, feedback is associated with dominance and invasion, our findings do not support plant-soil feedback as a driver of invasion in this species. Our results do show that the importance of soil feedback can change with competitive context. Such context-dependency implies that soil feedback may change when competitive interactions between natives and invading species shift as invasions progress.

International dialogue on end of life: challenges in the UK and USA

AIM

The aim of this paper was to increase international collaboration on end of life care (EoLC) in critical care. Objectives included highlighting key challenges for critical care nurses in EoLC through a transcribed interview between a clinician, an educationalist and a researcher who all hold an EoLC focus.

BACKGROUND

EoLC continues to hold high profile within international health care arenas, including critical care units. Whilst end of life care remains well debated, it still presents many challenges for everyday practitioners. Dialogue with international colleagues and disciplines may provide opportunity for further understanding of this complex and sensitive area.

CONCLUSIONS

A key issues to arise from this venture of shared learning was that futility of treatment is problematic for all. This is further complicated in the USA where the concept of (family) autonomy strongly shapes EoLC decision making.

RELEVANCE TO CLINICAL PRACTICE

This paper demonstrates that there are opportunities for nurses within health care teams which could be addressed through education and professional development initiatives. Furthermore, knowledge from other disciplines can provide a useful lens through which to improve our understanding of EoLC.

Critically appraised topics (CATs)

Journal reading is the number one educational activity for radiologists and is the resource Canadian radiologists use most often when adopting innovations into practice. The goal of the Canadian Association of Radiologists Journal (CARJ) is to provide Canadian radiologists with high-quality, peer-reviewed scientific and educational content. This paper introduces a new publication format for the CARJ, the critically appraised topic or CAT.

The sinister significance of dysphagia

BACKGROUND

The majority of patients presenting with oesophageal cancer have symptoms for more than three months and advanced disease at presentation. Most appear unaware of the significance of dysphagia as a symptom. Cancer awareness programmes focus on symptoms such as lumps and bleeding.

AIM

To sample the level of public awareness of the potentially sinister significance of the symptom of dysphagia.

METHODS

A community survey was conducted using a questionnaire to evaluate the subjects' impression of the significance of dysphagia, and compare it with their perception of the significance of breast lump. Patients were stratified to male and female, under and over 45 years.

RESULTS

There were 164 subjects interviewed. Seventy-five per cent stated that they would visit their doctor within one week of developing dysphagia compared with 87 per cent questioned about a breast lump (96 per cent females, 80 per cent males). Only 17 per cent felt that cancer was a probable explanation for dysphagia compared with 80 per cent who would consider cancer a likely cause of breast lump.

CONCLUSION

There is evident need of an awareness programme of the potential significance of dysphagia if prognosis for oesophageal cancer is to be improved.

Identification of cervical radiculopathies: optimizing the electromyographic screen

OBJECTIVE

To determine the optimal electromyography screening examination of the upper limb that ensures detection of those cervical radiculopathies, which can be electrodiagnostically confirmed, yet minimizes the number of muscles studied.

DESIGN

A prospective multicenter study was conducted from May 1996 to September 1997 at five institutions. Patients who were referred to participating electrodiagnostic laboratories with suspected cervical radiculopathy were recruited. A standard set of muscles were examined by needle electromyography. Patients with electrodiagnostically confirmed cervical radiculopathies, based on electromyography findings, were selected for analysis. Muscle screens were tested against this group to determine whether the screen identified the patients with radiculopathy.

RESULTS

There were 101 patients with cervical radiculopathies representing all cervical root levels. When paraspinal muscles were one of the screening muscles, five muscle screens identified 90% to 98% of radiculopathies, six muscle screens identified 94% to 99%, and seven muscle screens identified 96% to 100%. When paraspinal muscles were not part of the screen, eight distal limb muscles recognized 92% to 95% of radiculopathies.

CONCLUSION

This study demonstrated that six muscle screens including paraspinal muscles yielded consistently high identification rates. Studying additional muscles led to marginal increases in identification.

Self-directed learning and continuing professional development

This is the first of a series of articles on topics that will be relevant to radiologists planning personal learning projects and continuing professional development (CPD) activities for the Maintenance of Certification Program. Topics of future articles include: program development, needs assessment, small-group learning, problem-based learning and evidence-based radiology.

Writing a structured abstract

This article is part of the education initiative of the Canadian Association of Radiologists Journal to deliver information that will be of practical use and help to enhance the skills necessary for the continuing professional development of Canadian radiologists. The first article in the continuing professional development skills series is on writing a structured abstract. Future "how to" articles will focus on other skills such as critical appraisal. You can earn CPD credits in section 6 (Educational Development, Teaching and Research) for writing an abstract and in section 4 (Structured Learning Projects) if you use this information for a personal learning project. The call for abstracts for the 2001 CAR Annual Meeting in Vancouver, September 21-23, has gone out. The deadline for submitting abstracts for the meeting is March 31, 2001. If you need more information or an abstract form, visit the CAR Web site at www.car.ca.

Identifying lumbosacral radiculopathies: an optimal electromyographic screen

OBJECTIVE

The objective of this study was to determine prospectively the optimal electromyographic screening examination of the lower limb that ensures identification of those lumbosacral radiculopathies that can be electrodiagnostically confirmed, yet minimizes the number of muscles studied.

DESIGN

A prospective multicenter study was conducted from May 1996 to September 1997. Patients with suspected lumbosacral radiculopathy referred to participating electrodiagnostic laboratories were recruited and examined by needle electromyography using a standard set of muscles. Patients with electrodiagnostically confirmed lumbosacral radiculopathies were selected for analysis. Various muscle screens were tested against this group of patients with radiculopathies to determine the frequency with which each screen identified the patient with radiculopathy.

RESULTS

There were 102 patients identified. When paraspinal muscles were one of the screening muscles, four-muscle screens identified 88-97% of the radiculopathies, five-muscle screens identified 94-98%, and six-muscle screens 98-100%. When paraspinal muscles were not part of the screen, identification rates were lower for all screens, and eight distal muscles were necessary to identify about 90% of the radiculopathies.

CONCLUSIONS

Six-muscle screens with paraspinal muscles yielded consistently high identification rates. Studying additional muscles produced no improvements in identification.

Predicting electrodiagnostic outcome in patients with upper limb symptoms: are the history and physical examination helpful?

OBJECTIVE

To determine the effectiveness of medical history and physical examination in predicting electrodiagnostic outcome in patients with suspected cervical radiculopathy.

METHODS

Data on 183 subjects prospectively collected at five different electrodiagnostic laboratories were analyzed (96 cervical radiculopathies, 45 normal studies, and 42 abnormal electrodiagnostic findings other than radiculopathy). The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratios were determined for symptoms and neurologic signs.

RESULTS

Symptoms of numbness, weakness, and tingling were associated with twice the probability of having abnormal electrodiagnostic study results in general, yet were not helpful in identifying a cervical radiculopathy. All single and combined physical examination components had poor sensitivities, with the exception of weakness, but much higher specificities. Patients with either weakness or reduced reflexes on physical examination were up to five times more likely to have abnormal electrodiagnostic findings. In subjects with any abnormal neurologic sign, the sensitivity improved to 84%, the positive predictive value was 79%, but the specificity was low (44%). Of those subjects with normal physical examination results, almost one half had an abnormal electrodiagnostic study result (negative predictive value 52%).

CONCLUSIONS

In a population of patients with suspected cervical radiculopathy, medical history and physical examination are helpful yet not sufficient to predict the electrodiagnostic outcome.

Fine lattice lines on the corneal surface after laser in situ keratomileusis (LASIK)

PURPOSE

To present an example of a pattern of lines resembling fine lattice on the corneal surface subsequent to laser in situ keratomileusis (LASIK). This subtle phenomenon may be relatively common and may affect visual outcome.

METHOD

Case report.

RESULTS

A 41-year-old year old man with high myopia and best-corrected visual acuity of 20/20 +2 in each eye underwent laser in situ keratomileusis (LASIK). No operative or postoperative complications occurred. No striae were evident on slit-lamp examination with direct illumination and retroillumination at the time of surgery or in the postoperative period. Postoperative uncorrected visual acuity was 20/25 with a best-corrected spectacle correction of 20/25 in both eyes. Fine lines in a lattice pattern were seen only with fluorescein dye in the precorneal tear film as areas of "negative stain" within the LASIK flap. With tear film supplementation, the lines were less evident and visual acuity improved. One year postoperatively, his uncorrected visual acuity was 20/25 in both eyes. The best-corrected spectacle visual acuity was RE: 20/20 -2, LE: 20/25. The fine lines were still present within the flap. A soft contact lens improved visual acuity to 20/20 in both eyes. Although all four puncta were occluded, he had no epiphora.

CONCLUSION

Fine lines in a lattice pattern that may represent folds in the epithelium or Bowman layer may be present within the flap after LASIK and may adversely affect visual acuity. They may be visible as areas of negative stain with fluorescein dye in the precorneal tear film in the absence of any striae visible in the flap. These superficial lines have been seen more in patients with high degrees of correction and in patients with dry eye. If visual acuity is affected, it may be improved with punctal occlusion, tear supplements, or a contact lens.

Symptom duration and spontaneous activity in lumbosacral radiculopathy

OBJECTIVES

A long-held notion in the electrodiagnostic literature is that paraspinal muscles tend to show spontaneous activity (fibrillations and positive sharp waves) on needle electromyography, early on in a lumbosacral radiculopathy, and that more distal muscles become abnormal later in the disease process. The purpose of this study was to determine whether paraspinal muscle and other major proximal and distal muscle spontaneous activity is related to a lumbosacral radiculopathy symptom duration.

METHODS

A multicenter, prospective study that collected standard information on history, physical examination, and electrodiagnostic findings in patients with electrodiagnostically confirmed lumbosacral radiculopathies was undertaken.

RESULTS

Multivariate probit analyses of 96 patients identified with a lumbosacral radiculopathy showed no evidence of correlation between spontaneous activity in the paraspinal muscles and symptom duration. Symptom duration was also nonsignificant in nine of the remaining ten lower limb muscles analyzed.

CONCLUSION

These findings emphasize the limitations of using symptom duration when interpreting electrodiagnostic findings in lumbosacral radiculopathy.

Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy

OBJECTIVE

To determine the extent to which the history and physical examination predict the outcome of the electrodiagnostic (EDX) evaluation in patients with suspected lumbosacral radiculopathy.

DESIGN

Data for 170 subjects referred for low-back and lower limb symptoms were prospectively collected at five EDX laboratories. The sensitivity, specificity, positive and negative predictive values, and odds ratios were determined for symptoms and neurologic signs.

RESULTS

Symptoms were not significantly associated with an EDX study or a lumbosacral radiculopathy. The physical examination was better at predicting that an EDX study would be abnormal in general than it was at predicting a lumbosacral radiculopathy in particular. Of those subjects with normal physical examinations, 15%-18% still had abnormal EDX findings.

CONCLUSIONS

In a population of patients referred for an EDX study, the history and physical examination alone cannot reliably predict electrodiagnostic outcome.

A controlled evaluation of a national continuing medical education programme designed to improve family physicians' implementation of diabetes-specific clinical practice guidelines

AIMS

New approaches to continuing medical education will facilitate the implementation of clinical practice guidelines. This study assessed the short and long-term impact of a 7-h, small group workshop on family physicians' attitude, knowledge and self-reported practice patterns regarding diabetes mellitus.

METHODS

One hundred and seventy-seven of 1807 family physicians who participated in this nationwide workshop, and 113 non-participant controls completed two validated questionnaires. Participants completed one questionnaire before the workshop and a second equivalent questionnaire 1 month later. Non-participant controls also completed the two questionnaires 1 month apart. Between 8 and 24 months later, these individuals were mailed the same questionnaire they completed on the first occasion; 143 participants and 50 controls returned this third questionnaire.

RESULTS

Participants were more likely to be female (P = 0.03), not certified in family practice (P = 0.02), in a smaller centre (P = 0.0005), recent medical graduates (P = 0.001) and seeing fewer patients per month (P = 0.01) than controls. Compared to controls, participants had improved their attitude (P<0.0001), knowledge (P = 0.04) and self-reported practice patterns (P<0.002) regarding diabetes after 1 month but not after 1 year.

CONCLUSIONS

An interactive, small group, diabetes continuing education programme effectively disseminates practice guidelines to family physicians. The impact of such a programme declines after 1 year.

Folds and striae in laser in situ keratomileusis flaps

PURPOSE

To classify striae and folds seen after laser in situ keratomileusis.

METHODS

The authors' experience and review of the literature form the basis for the proposed classification.

RESULTS

Five types of folds and striae are described: loose epithelium, hinge ridge, hinge fold, deep stromal striae, deep epithelial/Bowman's striae.

CONCLUSION

Linear striae in laser in situ keratomileusis flaps have a variety of appearances and different postoperative courses that require accurate diagnosis and management.

Cervical radiculopathies: relationship between symptom duration and spontaneous EMG activity

The purpose of this multicenter study was to prospectively examine whether denervation in paraspinal muscles (PSM) and in other major proximal and distal muscles is related to symptom duration in cervical radiculopathies (CRs). Information was collected on 93 electrodiagnostically confirmed CRs using standardized history, physical examination, and electromyographic (EMG) screens. Multivariate, maximum-likelihood estimates showed no evidence of correlation between PSM spontaneous activity and symptom duration. Symptom duration was also nonsignificant in eight of the remaining nine upper limb muscles analyzed. We conclude that the probability of spontaneous activity is not related to symptom duration. Clinicians, therefore, should refrain from interpreting electrodiagnostic findings based upon duration of symptoms.

Predictive validity of the emergency physician and global job satisfaction instruments

OBJECTIVE

To evaluate the predictive validity of the Emergency Physician Job Satisfaction (EPJS) and Global Job Satisfaction (GJS) instruments.

METHODS

Prospective mail survey of 223 Canadian emergency physicians (EPs) using a 42-item questionnaire, including 14 items evaluating their reasons for leaving emergency medicine (EM). Original (1990) EPJS and GJS scores were analyzed using 1-way ANOVA and Scheffe's test comparing the physicians who left EM with those still in their original jobs, and those who had left their original jobs but who stayed in EM. Mean scores on the 14 "reason for leaving" items were compared with scores from an earlier sample of U.S. physicians using a t-test for independent means. Criteria for statistical significance were set at alpha = 0.05 for all analyses.

RESULTS

The response rate for the primary study questions was 99.1%. Of the respondents, 29.4% had left their original jobs, and 10.4% had left EM altogether. The GJS scores for the physicians who left EM were significantly different from those for the physicians who stayed (p = 0.004). The EPJS scores for the physicians who left EM were not significantly different from those for the physicians who stayed (p = 0.56). There was no significant difference in scores between the Canadian and U.S. physicians' reasons for leaving EM (all p-values > 0.05). Shiftwork scored the highest as a reason to leave EM.

CONCLUSIONS

A low GJS score is associated with physicians' leaving EM, but not with changing jobs. The EPJS instrument was not associated with either outcome. Canadian and U.S. EPs place similar levels of importance on potential reasons for leaving EM.

72-hour discharge after cesarean delivery: results in a selected Medicaid population

The purpose of this study was to determine the safety and cost savings of discharging low income patients at 72 hours following cesarean delivery. Predetermined criteria were used to allow discharge. Selection criteria were no medical problems, an afebrile postoperative course, documented bowel function, to have tolerated at least one regular meal, and to have reached 72 hours postdelivery by 6 o'clock PM at discharge. Each patient returned to clinic 2-3 days postdischarge for staple removal. Physicians also discharged some low income patients home at 72 hours even though strict eligibility criteria were not met. Maternal outcome and financial data were compared between patients discharged after meeting eligibility criteria versus those who did not. Of 1,299 cesareans performed from July 1, 1993-July 31, 1995, 906 (70%) were performed in low income patients and 399 (44%) of these women were discharged at 72 hours. Twenty-seven women were lost to follow-up and 286 (77%; Group A) met the eligibility criteria for 72-hour discharge. Eighty-six women (23%; Group B) who did not meet criteria were also discharged at 72 hours. When maternal outcome data from the two groups were compared, Group B patients (did not meet criteria) were more likely to have been readmitted at < or = 30 days (7 of 86; 8% vs. 8 of 286; 3%; P = 0.05) and had longer hospital stays (27 days vs. 22 days) than Group A patients (met criteria). Net cost savings in 2 years was $448 per discharge for Group A, but only $333 per discharge for Group B. In our selective 72-hour discharge program, failure to abide by predetermined guidelines established to select only low risk, afebrile patients for 72-hour discharge resulted in more hospital readmissions, and longer stays and thus was not as cost effective.

Interrater reliability in myofascial trigger point examination

The myofascial trigger point (MTrP) is the hallmark physical finding of the myofascial pain syndrome (MPS). The MTrP itself is characterized by distinctive physical features that include a tender point in a taut band of muscle, a local twitch response (LTR) to mechanical stimulation, a pain referral pattern characteristic of trigger points of specific areas in each muscle, and the reproduction of the patient's usual pain. No prior study has demonstrated that these physical features are reproducible among different examiners, thereby establishing the reliability of the physical examination in the diagnosis of the MPS. This paper reports an initial attempt to establish the interrater reliability of the trigger point examination that failed, and a second study by the same examiners that included a training period and that successfully established interrater reliability in the diagnosis of the MTrP. The study also showed that the interrater reliability of different features varies, the LTR being the most difficult, and that the interrater reliability of the identification of MTrP features among different muscles also varies.