Creating a model to predict time intervals from induction of labor to induction of anesthesia and delivery to coordinate workload

BACKGROUND

Induction of labor continues to become more common. We analyzed induction of labor and timing of obstetric and anesthesia work to create a model to predict the induction-anesthesia interval and the induction-delivery interval in order to co-ordinate workload to occur when staff are most available.

METHODS

Patients who underwent induction of labor at a single medical center were identified and multivariable linear regression was used to model anesthesia and delivery times. Data were collected on date of birth, race/ethnicity, body mass index, gestational age, gravidity, parity, indication for labor induction, number of prior deliveries, time of induction, induction agent, cervical dilation, effacement, and fetal station on admission, date and time of anesthesia administration, date and time of delivery, and delivery type.

RESULTS

A total of 1746 women met inclusion criteria. Associations which significantly influenced time from induction of labor to anesthesia and delivery included maternal age (anesthesia P <0.001, delivery P =0.002), body mass index (both P <0.001), prior vaginal delivery (both P <0.001), gestational age (anesthesia P <0.001, delivery P <0.018), simplified Bishop score (both P <0.001), and first induction agent (both P <0.001). Induction of labor of nulliparous women at 02:00 h and parous women at 04:00 or 05:00 h had the highest estimated probability of the mother having her first anesthesia encounter and delivering during optimally staffed hours when our institution's specialty personnel are most available.

CONCLUSIONS

Time to obstetric and anesthesia tasks can be estimated to optimize induction of labor start times, and shift anesthesia and delivery workload to hours when staff are most available.

Combined spinal/caudal catheter anesthesia: extending the boundaries of regional anesthesia for complex pediatric urological surgery

BACKGROUND

Spinal anesthesia (SA) is an established anesthetic technique for short outpatient pediatric urological cases. To avoid general anesthesia (GA) and expand regional anesthetics to longer and more complex pediatric surgeries, the authors began a program using a combined spinal/caudal catheter (SCC) technique.

STUDY DESIGN

The authors retrospectively reviewed the charts of all patients scheduled for surgery under SCC between December 2016 and April 2018 and recorded age, gender, diagnosis, procedure, conversion to GA/airway intervention, operative time, neuraxial and intravenous medications administered, complications, and outcomes. The SCC technique typically involved an initial intrathecal injection of 0.5% isobaric bupivacaine followed by placement of a caudal epidural catheter. At the discretion of the anesthesiologist, patients received 0.5 mg per kilogram of oral midazolam approximately 30 min prior to entering the operating room. One hour after the intrathecal injection, 3% chloroprocaine was administered via the caudal catheter to prolong the duration of surgical block. Intra-operative management included either continuous infusion or bolus dosing of dexmedetomidine, as needed, for patient comfort and to optimize surgical conditions. Prior to removal of caudal catheter in the post-anesthesia care unit, a supplemental bolus dose of local anesthesia was given through the catheter to provide prolonged post-operative analgesia.

RESULTS

Overall, 23 children underwent attempted SCC. SA was unsuccessful in three patients, and surgery was performed under GA. The remaining 20 children all had successful SCC placement. There were 11 girls and nine boys, with a mean age of 16.5 months (3.3-43.8). Surgeries performed under SCC included seven ureteral reimplantations, two ureterocele excisions/reimplantations, two megaureter repairs, four first-stage hypospadias repairs, one distal hypospadias repair, one second-stage hypospadias repair, two feminizing genitoplasties, and one open pyeloplasty. Average length of surgery was 109 min (range 63-172 min). Pre-operative midazolam was given in 13/20 (65%). All SCC patients were spontaneously breathing room air during the operation, and there were no airway interventions. Only one SCC patient received opioids intra-operatively. There were no intra-operative or perioperative complications.

DISCUSSION

This pilot study shows that the technique of SCC allows one to do more complex urologic surgery under regional anesthesia than what would be possible under pure SA alone. The main limitations of the study include the relatively small number of patients and the small median length of the operative procedures. As a proof of concept, however, this does show that complex genital surgery bladder level procedures such as ureteral reimplantation can be performed under regional anesthesia.

CONCLUSION

SCC allows for more complex surgeries to be performed exclusively under regional anesthesia, thus obviating the need for airway intervention, minimizing or eliminating the use of opioids, and thus avoiding known and potential risks associated with GA. The latter is of particular importance given current concerns regarding hypothetical neurocognitive effects of GA on children aged below 3 years.

Need for additional anesthesia after single injection spinal analgesia for labor: a retrospective cohort study

BACKGROUND

There is little information about the use and efficacy of single injection spinal blocks for labor analgesia; specifically, how frequently subsequent analgesia or anesthesia is needed. This study determined how frequently an additional anesthetic intervention was needed in women who received single injection spinal analgesia.

METHODS

This retrospective study examined electronic medical records to find all single injection spinal analgesic blocks for labor analgesia over a 14-year (2003-2016) period. Patient and block characteristics and patient outcomes were recorded. The primary outcome was need for an additional anesthetic intervention following single injection spinal for labor analgesia.

RESULTS

Four-hundred-and-twenty-eight patients received single injection spinal blocks for labor and 60 (14.0%) needed an additional anesthetic either for labor analgesia (n=49) or an unexpected procedure (n=11). Two of these (0.5%) required general anesthesia. Parity of zero (nulliparous), a low cervical dilation at the time of the spinal injection, and induction of labor status, were associated with an increased risk of needing an additional anesthetic intervention.

CONCLUSIONS

This retrospective review provides evidence that single injection spinal anesthesia may be used for multiparous women with spontaneous labor and more advanced cervical dilation.

Association between exposure to anaesthesia and surgery and long-term cognitive trajectories in older adults: report from the Mayo Clinic Study of Aging

BACKGROUND

The link between exposure to general anaesthesia and surgery (exposure) and cognitive decline in older adults is debated. We hypothesised that it is associated with cognitive decline.

METHODS

We analysed the longitudinal cognitive function trajectory in a cohort of older adults. Models assessed the rate of change in cognition over time, and its association with exposure to anaesthesia and surgery. Analyses assessed whether exposure in the 20 yr before enrolment is associated with cognitive decline when compared with those unexposed, and whether post-enrolment exposure is associated with a change in cognition in those unexposed before enrolment.

RESULTS

We included 1819 subjects with median (25th and 75th percentiles) follow-up of 5.1 (2.7-7.6) yr and 4 (3-6) cognitive assessments. Exposure in the previous 20 yr was associated with a greater negative slope compared with not exposed (slope: -0.077 vs -0.059; difference: -0.018; 95% confidence interval: -0.032, -0.003; P=0.015). Post-enrolment exposure in those previously unexposed was associated with a change in slope after exposure (slope: -0.100 vs -0.059 for post-exposure vs pre-exposure, respectively; difference: -0.041; 95% confidence interval: -0.074, -0.008; P=0.016). Cognitive impairment could be attributed to declines in memory and attention/executive cognitive domains.

CONCLUSIONS

In older adults, exposure to general anaesthesia and surgery was associated with a subtle decline in cognitive z-scores. For an individual with no prior exposure and with exposure after enrolment, the decline in cognitive function over a 5 yr period after the exposure would be 0.2 standard deviations more than the expected decline as a result of ageing. This small cognitive decline could be meaningful for individuals with already low baseline cognition.

Increase in taxonomic assignment efficiency of viral reads in metagenomic studies

Metagenomics studies have revolutionized the field of biology by revealing the presence of many previously unisolated and uncultured micro-organisms. However, one of the main problems encountered in metagenomic studies is the high percentage of sequences that cannot be assigned taxonomically using commonly used similarity-based approaches (e.g. BLAST or HMM). These unassigned sequences are allegorically called « dark matter » in the metagenomic literature and are often referred to as being derived from new or unknown organisms. Here, based on published and original metagenomic datasets coming from virus-like particle enriched samples, we present and quantify the improvement of viral taxonomic assignment that is achievable with a new similarity-based approach. Indeed, prior to any use of similarity based taxonomic assignment methods, we propose assembling contigs from short reads as is currently routinely done in metagenomic studies, but then to further map unassembled reads to the assembled contigs. This additional mapping step increases significantly the proportions of taxonomically assignable sequence reads from a variety -plant, insect and environmental (estuary, lakes, soil, feces) - of virome studies.

Managed Care and Patient-Rated Quality of Care from Primary Physicians

The aim is to determine the associations between managed care controls and patient-rated quality of care from primary physicians. In a prospective cohort study, 17,187 patients were screened in the waiting rooms of 261 primary care physicians in the Seattle metropolitan area (1996-1997) to identify 2,850 English-speaking adult patients with depressive symptoms and/or selected pain problems. Patients completed 6-month follow-ups to rate the quality of care from their primary physicians. The intensity of managed care was measured for each patient’s health plan, primary care office, and physician. Regression analyses revealed that patients in more managed plans and offices had lower ratings of the quality of care from their primary physicians. Managed care controls targeting physicians were generally not associated with patient ratings.

Biodegradable polymeric stents for vascular application in a porcine carotid artery model: English version

Over the past years the development of biodegradable polymeric stents has made great progress; nevertheless, essential problems must still be solved. Modifications in design and chemical composition should optimize the quality of biodegradable stents and remove the weaknesses. New biodegradable poly-L-lactide/poly-4-hydroxybutyrate (PLLA/P4HB) stents and permanent 316L stents were implantedendovascularly into both common carotid arteries of 10 domestic pigs. At 4 weeks following implantation, computed tomography (CT) angiography was carried out to identify the distal degree of stenosis. The PLLA/P4HB group showed a considerably lower distal degree of stenosis by additional oral application of atorvastatin (mean 39.81 ± 8.57 %) compared to the untreated PLLA/P4HB group without atorvastatin (mean 52.05 ± 5.80 %). The 316L stents showed no differences in the degree of distal stenosis between the group treated with atorvastatin (mean 44.21 ± 2.34 %) and the untreated group (mean 35.65 ± 3.72 %). Biodegradable PLLA/P4HB stents generally represent a promising approach to resolving the existing problems in the use of permanent stents. Restitutio ad integrum is only achievable if a stent is completely degraded.

Prospective Benefit-Risk Monitoring of New Drugs for Rapid Assessment of Net Favorability in Electronic Health Care Data

BACKGROUND

Benefit-risk assessment (BRA) methods can combine measures of benefits and risks into a single value.

OBJECTIVES

To examine BRA metrics for prospective monitoring of new drugs in electronic health care data.

METHODS

Using two electronic health care databases, we emulated prospective monitoring of three drugs (rofecoxib vs. nonselective nonsteroidal anti-inflammatory drugs, prasugrel vs. clopidogrel, and denosumab vs. bisphosphonates) using a sequential propensity score-matched cohort design. We applied four BRA metrics: number needed to treat and number needed to harm; incremental net benefit (INB) with maximum acceptable risk; INB with relative-value-adjusted life-years; and INB with quality-adjusted life-years (QALYs). We determined whether and when the bootstrapped 99% confidence interval (CI) for each metric excluded zero, indicating net favorability of one drug over the other.

RESULTS

For rofecoxib, all four metrics yielded a negative value, suggesting net favorability of nonselective nonsteroidal anti-inflammatory drugs over rofecoxib, and the 99% CI for all but the number needed to treat and number needed to harm excluded the null during follow-up. For prasugrel, only the 99% CI for INB-QALY excluded the null, but trends in values over time were similar across the four metrics, suggesting overall net favorability of prasugrel versus clopidogrel. The 99% CI for INB-relative-value-adjusted life-years and INB-QALY excluded the null in the denosumab example, suggesting net favorability of denosumab over bisphosphonates.

CONCLUSIONS

Prospective benefit-risk monitoring can be used to determine net favorability of a new drug in electronic health care data. In three examples, existing BRA metrics produced qualitatively similar results but differed with respect to alert generation.

A unified framework for classification of methods for benefit-risk assessment

BACKGROUND

Patients, physicians, and other decision makers make implicit but inevitable trade-offs among risks and benefits of treatments. Many methods have been proposed to promote transparent and rigorous benefit-risk analysis (BRA).

OBJECTIVE

To propose a framework for classifying BRA methods on the basis of key factors that matter most for patients by using a common mathematical notation and compare their results using a hypothetical example.

METHODS

We classified the available BRA methods into three categories: 1) unweighted metrics, which use only probabilities of benefits and risks; 2) metrics that incorporate preference weights and that account for the impact and duration of benefits and risks; and 3) metrics that incorporate weights based on decision makers' opinions. We used two hypothetical antiplatelet drugs (a and b) to compare the BRA methods within our proposed framework.

RESULTS

Unweighted metrics include the number needed to treat and the number needed to harm. Metrics that incorporate preference weights include those that use maximum acceptable risk, those that use relative-value-adjusted life-years, and those that use quality-adjusted life-years. Metrics that use decision makers' weights include the multicriteria decision analysis, the benefit-less-risk analysis, Boers' 3 by 3 table, the Gail/NCI method, and the transparent uniform risk benefit overview. Most BRA methods can be derived as a special case of a generalized formula in which some are mathematically identical. Numerical comparison of methods highlights potential differences in BRA results and their interpretation.

CONCLUSIONS

The proposed framework provides a unified, patient-centered approach to BRA methods classification based on the types of weights that are used across existing methods, a key differentiating feature.

Comparison of survival outcomes among cancer patients treated in and out of clinical trials

BACKGROUND

Clinical trials test the efficacy of a treatment in a select patient population. We examined whether cancer clinical trial patients were similar to nontrial, "real-world" patients with respect to presenting characteristics and survival.

METHODS

We reviewed the SWOG national clinical trials consortium database to identify candidate trials. Demographic factors, stage, and overall survival for patients in the standard arms were compared with nontrial control subjects selected from the Surveillance, Epidemiology, and End Results program. Multivariable survival analyses using Cox regression were conducted. The survival functions from aggregate data across all studies were compared separately by prognosis (≥50% vs <50% average 2-year survival). All statistical tests were two-sided.

RESULTS

We analyzed 21 SWOG studies (11 good prognosis and 10 poor prognosis) comprising 5190 patients enrolled from 1987 to 2007. Trial patients were younger than nontrial patients (P < .001). In multivariable analysis, trial participation was not associated with improved overall survival for all 11 good-prognosis studies but was associated with better survival for nine of 10 poor-prognosis studies (P < .001). The impact of trial participation on overall survival endured for only 1 year.

CONCLUSIONS

Trial participation was associated with better survival in the first year after diagnosis, likely because of eligibility criteria that excluded higher comorbidity patients from trials. Similar survival patterns between trial and nontrial patients after the first year suggest that trial standard arm outcomes are generalizable over the long term and may improve confidence that trial treatment effects will translate to the real-world setting. Reducing eligibility criteria would improve access to clinical trials.

Glycemic control associated with secure patient-provider messaging within a shared electronic medical record: a longitudinal analysis

OBJECTIVE

To study differences in glycemic control and HbA1c testing associated with use of secure electronic patient-provider messaging. We hypothesized that messaging use would be associated with better glycemic control and a higher rate of adherence to HbA1c testing recommendations.

RESEARCH DESIGN AND METHODS

Retrospective observational study of secure messaging at Group Health, a large nonprofit health care system. Our analysis included adults with diabetes who had registered for access to a shared electronic medical record (SMR) between 2003 and 2006. We fit log-linear regression models, using generalized estimating equations, to estimate the adjusted rate ratio of meeting three indicators of glycemic control (HbA1c <7%, HbA1c <8%, and HbA1c >9%) and HbA1c testing adherence by level of previous messaging use. Multiple imputation and inverse probability weights were used to account for missing data.

RESULTS

During the study period, 6,301 adults with diabetes registered for access to the SMR. Of these individuals, 74% used messaging at least once during that time. Frequent use of messaging during the previous calendar quarter was associated with a higher rate of good glycemic control (HbA1c <7%: rate ratio, 1.26 [95% CI, 1.15-1.37]) and a higher rate testing adherence (1.20 [1.15-1.25]).

CONCLUSIONS

Among SMR users, recent and frequent messaging use was associated with better glycemic control and a higher rate of HbA1c testing adherence. These results suggest that secure messaging may facilitate important processes of care and help some patients to achieve or maintain adequate glycemic control.

Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation

STUDY DESIGN

A population-based, prospective cohort study.

OBJECTIVE

To identify demographic, job-related, psychosocial, and clinical factors associated with the use of magnetic resonance imaging (MRI) within 6 weeks from injury (early MRI) among workers' compensation claimants with acute occupational low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Early MRI may be associated with increased use of services for treatment and costs. To understand utilization and most appropriately apply guidelines, it is important to identify factors associated with early imaging use for occupational LBP.

METHODS

Workers (N = 1830) were interviewed 3 weeks (median) after submitting a workers' compensation claim for a back injury. Demographic, work, health, clinical, and injury characteristics were ascertained from interviews, medical records, and administrative data. Modified Poisson regression analyses identified factors associated with early MRI use.

RESULTS

Among respondents, 362 (19.8%) received an early MRI. Multivariable regression showed that male workers were 43% more likely to receive an early MRI than female workers (incident rate ratio [IRR]: 1.43, 95% confidence interval [CI]: 1.12-1.82). Initial visit type with a surgeon was associated with 78% greater likelihood of receiving an early MRI than that with a primary care physician (IRR: 1.78, 95% CI: 1.08-2.92). Having a chiropractor as the initial provider was associated with a reduced likelihood of early MRI (IRR: 0.53, 95% CI: 0.42-0.66). Workers with elevated work fear-avoidance, higher Roland scores, or increased injury severity were more likely to receive early MRI than counterparts with lower levels or scores.

CONCLUSION

Nearly 20% of the injured workers with LBP receive early MRI, a rate similar to that reported elsewhere. Early MRI may lead to greater subsequent interventions, potentially poorer outcomes, and increased health care expenditures. On the basis of the characteristics of patients with uncomplicated occupational LBP, providers may be able to provide tailored care, and providers and policy makers may better understand the utilization of imaging and adherence to clinical guidelines.

Improving low-wage, midsized employers' health promotion practices: a randomized controlled trial

BACKGROUND

The Guide to Community Preventive Services (Community Guide) offers evidence-based intervention strategies to prevent chronic disease. The American Cancer Society (ACS) and the University of Washington Health Promotion Research Center co-developed ACS Workplace Solutions (WPS) to improve workplaces' implementation of Community Guide strategies.

PURPOSE

To test the effectiveness of WPS for midsized employers in low-wage industries.

DESIGN

Two-arm RCT; workplaces were randomized to receive WPS during the study (intervention group) or at the end of the study (delayed control group).

SETTING/PARTICIPANTS

Forty-eight midsized employers (100-999 workers) in King County WA.

INTERVENTION

WPS provides employers one-on-one consulting with an ACS interventionist via three meetings at the workplace. The interventionist recommends best practices to adopt based on the workplace's current practices, provides implementation toolkits for the best practices the employer chooses to adopt, conducts a follow-up visit at 6 months, and provides technical assistance.

MAIN OUTCOME MEASURES

Employers' implementation of 16 best practices (in the categories of insurance benefits, health-related policies, programs, tracking, and health communications) at baseline (June 2007-June 2008) and 15-month follow-up (October 2008-December 2009). Data were analyzed in 2010-2011.

RESULTS

Intervention employers demonstrated greater improvement from baseline than control employers in two of the five best-practice categories; implementing policies (baseline scores: 39% program, 43% control; follow-up scores: 49% program, 45% control; p=0.013) and communications (baseline scores: 42% program, 44% control; follow-up scores: 76% program, 55% control; p=0.007). Total best-practice implementation improvement did not differ between study groups (baseline scores: 32% intervention, 37% control; follow-up scores: 39% intervention, 42% control; p=0.328).

CONCLUSIONS

WPS improved employers' health-related policies and communications but did not improve insurance benefits design, programs, or tracking. Many employers were unable to modify insurance benefits and reported that the time and costs of implementing best practices were major barriers.

TRIAL REGISTRATION

This study is registered at clinicaltrials.gov NCT00452816.

Does a large-scale organizational transformation toward patient-centered access change the utilization and costs of care for patients with diabetes?

The authors examined whether Group Health's Access Initiative changed the utilization and costs of care among enrollees with diabetes. Using a single (one-group) interrupted time series design, repeated-measures generalized estimating equation models were used to estimate changes in utilization and costs during the Initiative rollout (2002-2003) and to compare the slopes (annual rates of change) for utilization and costs during the Pre-Initiative period (1998-2002) to the slopes during Full-Implementation (2003-2006) among 9,871 members continuously enrolled from 1997 to 2006 with type 1 or 2 diabetes. Total costs increased in Full-Implementation, but the annual change in total costs did not change. Primary care visits declined, but primary care contacts grew, largely from the Initiative's introduction of secure messaging. Specialty visits did not change; however, the Initiative may have increased emergency visits. To reduce emergency visits, future access initiatives should include proactive and comprehensive outpatient care for patients with diabetes.

Differential disease phenotype of begomoviruses associated with tobacco leaf curl disease in Comoros

In the 2000s, tobacco plantations on the Comoros Islands were afflicted with a previously unobserved tobacco leaf curl disease characterised by symptoms of severe leaf curling and deformation. Previous molecular characterization of potential viral pathogens revealed a complex of African monopartite tobacco leaf curl begomovirus (TbLCVs). Our molecular investigation allowed the characterization of a new monopartite virus involved in the disease: tomato leaf curl Namakely virus (ToLCNamV). Agroinoculation experiments indicated that TbLCVs and tomato leaf curl viruses (ToLCVs) can infect both tomato and tobacco but that infectivity and symptom expression fluctuate depending on the virus and the plant cultivar combination.

Validating the use of ICD-9-CM codes to evaluate gestational age and birth weight

BACKGROUND

Efforts to reduce preterm and low-weight births are among the leading public health objectives in the United States and the world. A necessary component of any public health endeavor is surveillance. The Department of Defense (DoD) Birth and Infant Health Registry (Registry) uses electronic healthcare utilization data to assess reproductive health outcomes among military families. Infant health outcomes are coded using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The objective of this study was to determine the accuracy of using electronically derived ICD-9-CM codes for assessing gestational age and birth weight among Registry infants compared to medical records.

METHODS

The authors assessed birth outcome agreement by comparing electronic Registry data for infants born at military treatment facilities (MTFs) from 1999-2002 and 1,858 randomly selected birth medical records from 17 MTFs, with descriptive statistics and measures of agreement, including the kappa statistic.

RESULTS

Of the 1,858 reviewed infant records, 1,669 were successfully matched to the Registry analytic dataset for analyses. Despite small differences in parental demographics, this investigation established "near perfect" agreement for the primary outcomes: kappa of 0.83 for preterm and 0.87 for low birth weight. Subgroup analyses revealed no significant differences in gestational age and birth-weight agreement based on the presence of a birth defect, military parent rank, branch of military service, or specific hospital characteristics.

CONCLUSIONS

Electronically derived ICD-9-CM codes provide an accurate assessment of the gestational age and low birth weight reflected in the birth medical records of infants in a large birth and infant health registry. These findings support the integrity of Registry data for investigations assessing preterm and low-weight births among U.S. service member families.

Measuring family satisfaction with care and quality of dying in the intensive care unit: does patient age matter?

RATIONALE

Few studies have examined the role of patient age on family experiences of end-of-life care.

OBJECTIVES

To assess measurement characteristics of two family-assessed questionnaires across three patient age groups.

METHODS

Four hundred and ninety-six patients who died in an intensive care unit (ICU) at a single hospital were identified and one family member per patient was sent two questionnaires: 1) Family Satisfaction in the ICU (FS-ICU); and 2) Quality of Dying and Death (QODD). Two hundred and seventy-five surveys were returned (55.4%). We analyzed three age groups: <35, 35-64, and ≥65 years. Differences were evaluated using χ(2) tests to evaluate ceiling, floor, and missing responses; Kruskal-Wallis tests to compare median scores on items and total scores; and linear regression controlling for patient sex, race, diagnosis, and family-member sex, race, education, and relationship to provide adjusted comparisons of total and subscale scores.

RESULTS

Measurement characteristics varied by age groups for both questionnaires. Missing values and floor endorsements were more common for the younger age groups for six items and one overall rating score. Ceiling endorsements were more common for the older group for 11 items. Fifteen items and four total scores were significantly higher in the older group.

CONCLUSIONS

The FS-ICU and QODD questionnaires performed differently across patient age groups. Assessments of family satisfaction and quality of dying and death were higher in the oldest group, particularly in the area of clinician-family communication. Studies of the dying experience of older adults may not generalize to patients of other ages, and study instruments should be validated among different age groups.

Treatment of cavernous sinus tumors with linear accelerator radiosurgery

Since 1989, 79 patients with benign or malignant cavernous sinus tumors, have been treated at Stanford University with linear accelerator (linac) radiosurgery. Radiosurgery has been used as (1) a planned second-stage procedure for residual tumor following surgery, (2) primary treatment for patients whose medical conditions preclude surgery, (3) palliation of malignant lesions, and (4) definitive treatment for small, well-localized, poorly accessible tumors. Mean patient age was 52 years (range, 18 to 88); there were 28 males and 51 females. Sixty-one patients had benign tumors; 18 had malignant tumors. Mean tumor volume was 6.8 cm(3) (range 0.5 to 22.5 cm(3)) covered with an average of 2.3 isocenter (range, 1 to 5). Radiation dose averaged 17.1 Gy. Mean follow-up was 46 months. Tumor control or shrinkage, or both, varied with pathology. Radiographic tumor improvement was most pronounced in malignant lesions, with greater than 85% showing reduction in tumor size; benign tumors (meningiomas and schwannomas) had a 63% control rate and 37% shrinkage rate, with none enlarging. We concluded that stereotactic radiosurgery is a valuable tool in managing cavernous sinus tumors. There was excellent control and stabilization of benign tumors and palliation of malignant lesions.

NASP: a parallel program for identifying evolutionarily conserved nucleic acid secondary structures from nucleotide sequence alignments

SUMMARY

Many natural nucleic acid sequences have evolutionarily conserved secondary structures with diverse biological functions. A reliable computational tool for identifying such structures would be very useful in guiding experimental analyses of their biological functions. NASP (Nucleic Acid Structure Predictor) is a program that takes into account thermodynamic stability, Boltzmann base pair probabilities, alignment uncertainty, covarying sites and evolutionary conservation to identify biologically relevant secondary structures within multiple sequence alignments. Unique to NASP is the consideration of all this information together with a recursive permutation-based approach to progressively identify and list the most conserved probable secondary structures that are likely to have the greatest biological relevance. By focusing on identifying only evolutionarily conserved structures, NASP forgoes the prediction of complete nucleotide folds but outperforms various other secondary structure prediction methods in its ability to selectively identify actual base pairings.

AVAILABILITY

Downloable and web-based versions of NASP are freely available at http://web.cbio.uct.ac.za/~yves/nasp_portal.php

CONTACT

yves@cbio.uct.ac.za

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Development of a survey to identify vaccine-hesitant parents: the parent attitudes about childhood vaccines survey

OBJECTIVE

To develop a survey to accurately assess parental vaccine hesitancy.

RESULTS

The initial survey contained 17 items in four content domains: (1) immunization behavior; (2) beliefs about vaccine safety and efficacy; (3) attitudes about vaccine mandates and exemptions; and (4) trust. Focus group data yielded an additional 10 survey items. Expert review of the survey resulted in the deletion of nine of 27 items and revisions to 11 of the remaining 18 survey items. Parent pretesting resulted in the deletion of one item, the addition of one item, the revision of four items, and formatting changes to enhance usability. The final survey contains 18 items in the original four content domains.

METHODS

An iterative process was used to develop the survey. First, we reviewed previous studies and surveys on parental health beliefs regarding vaccination to develop content domains and draft initial survey items. Focus groups of parents and pediatricians generated additional themes and survey items. Six immunization experts reviewed the items in the resulting draft survey and ranked them on a 1-5 scale for significance in identifying vaccine-hesitant parents (5 indicative of a highly significant item). The lowest third of ranked items were dropped. The revised survey was pretested with 25 parents to assess face validity, usability and item understandability.

CONCLUSIONS

The Parent Attitudes about Childhood Vaccines survey was constructed using qualitative methodology to identify vaccine-hesitant parents and has content and face validity. Further psychometric testing is needed.

Respiratory illnesses at the 2009 U.S. Army ROTC Advanced Camp

Every summer the U.S. Army Reserve Officer Training Corps (ROTC) conducts the Leader Development Assessment Course (LDAC) for several thousand upcoming senior-year cadets. This study describes respiratory illnesses at 2009 ROTC LDAC after the emergence of the novel H1N1 influenza pandemic. This retrospective cohort study examines 5554 cadets and 1,616 cadres from 2009, and 5180 LDAC 2008 cadets. Respiratory clinic visits for 2009 cadets were higher than 2009 cadres and 2008 cadets, at 8.7, 2.0, and 4.2 visits per 1000 person-days available, respectively (p < 0.001). Further, respiratory illness hospitalizations and isolations were higher for 2009 cadets than cadres (p = 0.020). Although substantial efforts were made to prevent respiratory infections, there was considerable impact from respiratory illnesses, in the context of the novel H1N1 influenza pandemic, among 2009 ROTC LDAC participants. Our experience offers important lessons for future LDAC planning and for similar close quarters living circumstances.

Social marketing, stages of change, and public health smoking interventions

As a "thought experiment," the authors used a modified stages of change model for smoking to define homogeneous segments within various hypothetical populations. The authors then estimated the population effect of public health interventions that targeted the different segments. Under most assumptions, interventions that emphasized primary and secondary prevention, by targeting the Never Smoker, Maintenance, or Action segments, resulted in the highest nonsmoking life expectancy. This result is consistent with both social marketing and public health principles. Although the best thing for an individual smoker is to stop smoking, the greatest public health benefit is achieved by interventions that target nonsmokers.

Associations between minimum wage policy and access to health care: evidence from the Behavioral Risk Factor Surveillance System, 1996-2007

OBJECTIVES

We examined whether minimum wage policy is associated with access to medical care among low-skilled workers in the United States.

METHODS

We used multilevel logistic regression to analyze a data set consisting of individual-level indicators of uninsurance and unmet medical need from the Behavioral Risk Factor Surveillance System and state-level ecological controls from the US Census, Bureau of Labor Statistics, and several other sources in all 50 states and the District of Columbia between 1996 and 2007.

RESULTS

Higher state-level minimum wage rates were associated with significantly reduced odds of reporting unmet medical need after control for the ecological covariates, substate region fixed effects, and individual demographic and health characteristics (odds ratio = 0.853; 95% confidence interval = 0.750, 0.971). Minimum wage rates were not significantly associated with being uninsured.

CONCLUSIONS

Higher minimum wages may be associated with a reduced likelihood of experiencing unmet medical need among low-skilled workers, and do not appear to be associated with uninsurance. These findings appear to refute the suggestion that minimum wage laws have detrimental effects on access to health care, as opponents of the policies have suggested.