Early physician notification of patient disability risk and clinical guidelines after low back injury: a randomized, controlled trial

STUDY DESIGN

Back-injured workers with high disability risk scores on a predictive questionnaire participated in a randomized, controlled trial of physician notification, with outcomes follow-up 3 months after injury.

OBJECTIVES

To test whether physician intervention improves return to work and self-assessment outcomes for people at relatively high risk for disability.

SUMMARY OF BACKGROUND DATA

Only a small number of back-injured workers suffer significant disability. Quick identification of these people would facilitate more efficient targeting and trials of interventions. Controlling variations in practice through practice guidelines has been recommended as a promising strategy for improving care and reducing disability.

METHODS

Workers filing back injury reports responded to a disability prediction questionnaire. Those with high risk scores were randomly assigned to control or intervention groups. Patient-designated physicians in the intervention group received two letters identifying the patient's risk and making recommendations for care, including the Agency for Health Care Policy and Research's algorithms for acute low back pain. Predictive accuracy of the questionnaire and efficacy of physician intervention were evaluated on the basis of work status and self-assessments 3 months after injury.

RESULTS

Of the 268 workers completing the questionnaire portion of the study, 32 (12%) were out of work because of back pain 3 months after injury. The questionnaire's predictive accuracy included maximum kappa of 0.277 and a receiver operating curve area of 0.78. Fifty-three people completed the physician intervention trial. The intervention had no significant impact on return to work, self-assessed pain, or satisfaction with health care.

CONCLUSIONS

Stratification of back-injured people according to disability risk can can increase intervention efficiency by identifying those who require treatment and sparing those who do not. The apparent failure of risk notification and practice guidelines to reduce disability in this study may be improved by different application methods in the future.

Back to the future: sweatshop conditions on the Mexico-U.S. border. II. Occupational health impact of maquiladora industrial activity

Present working conditions in one of the most active areas of the maquiladora system along the Mexico-U.S. border are reminiscent of nineteenth-century U.S. sweatshops. The organization of production is Tayloristic and authoritarian, with detailed division of labor, repetitive simple tasks, and piecework wages. Modern participative management styles are not apparent in the maquiladora setting. This study consists of two separate but interrelated surveys conducted in 1992, one of community leaders and this one of workers in maquiladora enterprises in the towns of Matamoros and Reynosa, Mexico. The community survey evaluated the economic and psychosocial impact of the maquiladora enterprise and was conducted simultaneously to the workers' survey and in the same Mexican towns where the workers lived and worked. The community leaders acknowledged the employment opportunities that maquiladora factories had brought to the region but believed them to have high environmental and psychosocial costs. For the occupational component, a community-based survey of 267 maquiladora workers was conducted. participants were chosen with more than a year seniority in the industry and living in the two Mexican cities surveyed. They responded to an extensive questionnaire given by trained canvassers. The workers' survey found evidence that maquiladora workers (81% female) report symptoms from musculoskeletal disorders related to working conditions. Acute health effects compatible with chemical exposures were also identified. Prevalence of symptoms was correlated with increasing duration of exposure to ergonomic risk factors and qualitative chemical exposure indexes. Other chronic disease was not apparent. The survey demonstrated inequalities in salary, working hours, and safety training between the two communities. Matamoros workers are substantially better paid and work fewer hours per week than Reynosa workers. Most hazards reported in the worker's survey have been well studied in the general occupational health literature with respect to adverse health effects. Therefore, it is recommended that hazard surveillance studies would be more useful towards the goal of prevention than further etiologic studies. Specific recommendations on policy and remediation interventions are also made.

Nondiagnostic fine needle aspiration biopsy of the thyroid gland: a diagnostic dilemma

OBJECTIVE

To evaluate all nondiagnostic fine needle aspiration biopsy (FNAB) specimens from the thyroid gland with subsequent histopathologic diagnoses at Ottawa Civic Hospital. The criterion for specimen adequacy used in our institution was also reexamined to determine if it was too stringent.

STUDY DESIGN

Review of 114 nondiagnostic FNAB samples from 91 patients with subsequent histopathologic diagnoses formed the basis of this study. Specimen adequacy was determined by the presence of 8-10 fragments of well-preserved follicular cells on at least two smears.

RESULTS

Review of the 91 surgical specimens found 50 nodular goiters, 23 follicular adenomas, 6 macrofollicular adenomas, 5 cases of thyroiditis, 5 true cysts, 1 papillary carcinoma and 1 minimally invasive follicular carcinoma. Forty-two percent of lesions showed cystic change. In addition, nine cases of papillary microcarcinoma were diagnosed. A considerable difference in the rate (22% vs. 45%) of inadequate thyroid FNAB samples was identified among different groups of physicians at our institution.

CONCLUSION

Ninety-eight percent of the patients with nondiagnostic FNAB of the thyroid gland had benign lesions. This finding encouraged us to continue using our criteria for adequacy because of the importance of a negative report. The higher rate of nondiagnostic thyroid aspiration in our series may reflect the varied experience of the different aspirators at our institution and/or the cystic nature of many of the lesions.

Early prediction of chronic disability after occupational low back injury

STUDY DESIGN

An inception cohort design was used to study a consecutive sample of back-injured workers.

OBJECTIVE

To refine and to test the Vermont Disability Prediction Questionnaire's ability to indicate an individual's relative risk for chronic disability after occupational low back injury.

SUMMARY OF BACKGROUND DATA

Although most back-injured workers return to work quickly, the minority who do not account for the majority of associated costs and health care. Early identification of workers at high risk for disability would facilitate intervention strategies.

METHODS

During the study recruitment period, people aged 18-60 years reporting occupational low back injury to the Vermont Department of Labor and Industry within 11 days of onset were eligible. A Vermont Disability Prediction Questionnaire was mailed to the 442 subjects who could be contacted and who gave informed consent. One hundred sixty-three of the 166 subjects who completed and returned the questionnaire within 15 days of initial injury were telephoned 3 months later to determine work status. Those who returned the questionnaire were compared with those who would not consent or did not return the questionnaire in time according to age, sex, residence, wages, work hours per week, and length of employment. Employment status (inability to work because of low back pain) was evaluated by telephone interview 3 months after initial injury.

RESULTS

The follow-up interviewer was blinded to the Vermont Disability Prediction Questionnaire scores. of the 163 subjects, 16 (10%) were not working because of low back pain. Using a simple dichotomous scoring system for 11 questionnaire items, a cut-off score of 0.48 identified 3-month postinjury work status, with 0.94 sensitivity and 0.84 specificity.

CONCLUSIONS

The Vermont Disability Prediction Questionnaire is a brief, easily administered and scored tool for identifying back-injured workers at relative risk for chronic disability. Such early identification should increase the efficiency of disability prevention strategies by directing them toward people who need them most. The accuracy of the questionnaire needs to be tested in a variety of different clinical and socioeconomic settings.

Educational assessment of general practice experience for psychiatric trainees

Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at a baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitation of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of 'closed psychological' and 'checking-out' questions. It appears that psychiatric trainees' interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.

A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain

STUDY DESIGN

A randomized prospective trial of manipulation, massage, corset and transcutaneous muscle stimulation (TMS) was conducted in patients with subacute low back pain.

OBJECTIVES

The authors determined the relative efficacy of chiropractic treatment to massage, corset, and TMS.

SUMMARY OF BACKGROUND DATA

Although all of these treatments are used for subacute low back pain treatment, there have been few comparative trials using objective outcome criteria. Patients were enrolled for a period of 3 weeks. They were evaluated once a week by questionnaires, visual analog scale, range of motion, maximum voluntary extension effort, straight leg raising and Biering-Sorensen fatigue test. The dropout rate was highest in the muscle stimulation and corset groups and lowest in the manipulation group. Rates of full compliance did not differ significantly across treatments. A measure of patient confidence was greatest in the manipulation group.

RESULTS

After 3 weeks, the manipulation group scored the greatest improvements in flexion and pain while the massage group had the best extension effort and fatigue time, and the muscle stimulation group the best extension.

CONCLUSION

None of the changes in physical outcome measures (range of motion, fatigue, strength or pain) were significantly different between any of the groups.

Lactic acidosis and acute ethanol intoxication

Ethanol intoxication has been widely reported as a cause of lactic acidosis. To determine the frequency and severity of ethanol-induced lactic acidosis, patients who presented to an emergency department with a clinical diagnosis of acute ethanol intoxication and a serum ethanol concentration of at least 100 mg/dL were studied. Arterial blood was sampled for lactate and blood gas determinations. A total of 60 patients (mean age, 41 years) were studied. Twenty-two patients sustained minor trauma. Ethanol concentrations ranged from 100 to 667 mg/dL (mean, 287 mg/dL). Lactate concentrations were abnormal (> 2.4 mmol/L) in seven patients (11.7%). In all cases, blood lactate was less than 5 mmol/L. Of the patients with elevated lactate, other potential causes for lactic acidosis, including hypoxia, seizures, and hypoperfusion, were also present. Only one case with elevated blood lactate concentration had associated acidemia. Significant elevations of blood lactate are uncommon in acute ethanol intoxication. In patients with ethanol intoxication who are found to have lactic acidosis, other etiologies for the elevated lactate level should be considered.

"You couldn't beat the medical corps"

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Vital fluorescence: a new measure of periodontal treatment effect

The purpose of the current study was to determine, by means of a fluorescence test, the ratio between vital and dead bacteria in dental plaque before and two weeks following professional dental prophylaxis. A solution of fluoresceindiacetate (FDA) and ethidium bromide (EB) in normal saline was applied to plaque samples from 82 healthy adults both prior to and 14 days following professional prophylaxis. Living microorganisms were colored green by the FDA while the EB introduced a red color into the nucleic acids of dead cells. The relationships between the vital fluorescence scores and standard clinical measures, plaque index (PlI) and gingival index (GI) were analyzed. Two weeks following professional prophylaxis, a significant decrease was observed in the PlI scores (0.9 +/- 0.4, Day 0; 0.6 +/- 0.3, Day 14, p < 0.001) and the GI scores (1.1 +/- 0.2, Day 0; 0.7 +/- 0.3, Day 14, p < 0.001), while there was a statistically significant increase in the vitality of the dental plaque (74 per cent +/- 9, Day 0; 78 per cent +/- 7, Day 14, p < 0.001). The vital fluorescence (VF) technique may provide an additional explanation of periodontal treatment effect.

Collaboration of health care professionals: the dental hygienists' role

Dental hygienists are primary health care professionals concerned with oral health and general well-being of the public. This paper discusses collaboration amongst the health professions to further the wellness of Canadians.

Efficacy of Listerine, Meridol and chlorhexidine mouthrinses as supplements to regular tooth cleaning measures

The anti-plaque, anti-gingivitis and anti-microbial efficacies of a phenolic compound (Listerine) and 2 different amine/stannous fluoride mouthwashes (Meridol I, II) were compared when these solutions were used in addition to usual tooth cleaning. A placebo preparation was utilized as a negative control and a chlorhexidine solution as a positive control in this double-blind study. After professional tooth cleaning, 49 volunteers continued their habitual, self-performed and non-supervised oral hygiene for a period of 2 weeks, in order to have a more standard baseline. At day 0, they began to rinse twice daily with 1 of the 5 mouthwashes. After 3 weeks of rinsing, plaque indices remained the lowest in the chlorhexidine and the Meridol I groups, while subjects using Listerine or Meridol II demonstrated similar indices significantly lower than that of individuals rinsing with the placebo solution. Through this period, the gingival index scores were similar in the Meridol, Listerine and chlorhexidine groups. At day 21, the mean GI scores in the chlorhexidine group were significantly lower than the scores in the placebo group. The plaque vitality scores showed a bacterial effect in vivo of chlorhexidine and, to a lesser extent, of the Meridol solutions. No substantial evidence of an antibacterial effect in vivo was found for Listerine. This study has demonstrated that when mouthrinses are used to supplement habitual mechanical oral hygiene, chlorhexidine remains the most powerful solution. Furthermore, it was also shown that a combination of habitual self-performed and non-supervised oral hygiene with Meridol or Listerine is more beneficial for plaque control than the use of mechanical oral hygiene alone.

A survey of long-term care elderly patients in the South West Thames Region

This paper describes a survey which focuses on the patients in National Health Service long-term care beds. It examines the dependency levels and mental impairment of geriatric patients in 15 Departments of Geriatric Medicine, and determines the extent and distribution of patient dependency, including the number of independent patients. The findings support the view that there is a need for National Health Service long-term care beds.

Major Mustard and me

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Measuring patient satisfaction with life in a long-stay psychiatric hospital

A survey of patient satisfaction with physical and social conditions was carried out in the long-stay wards of a large inner city psychiatric hospital in London, Britain. Patient satisfaction was assessed by means of an administered questionnaire which was developed specifically for this purpose. Factor analysis identified eight components of patient satisfaction. Of 143 eligible patients, 104 (73%) successfully completed the interview. Responses showed that patients were generally satisfied with life in the hospital, although levels of satisfaction varied significantly among wards. The factors causing greatest dissatisfaction related to failure to be treated as individuals and to feelings of isolation and apathy. Our findings showed that patients can express views about their conditions which should be useful in planning improvements in care. The questionnaire proved a simple and effective method of measuring satisfaction and may be useful to others concerned with improving the quality of the environment of patients.

Sensitivity to change and the effect of mode of administration on health status measurement

A measure of global health status, the McMaster Health Index Questionnaire (MHIQ), was assessed to determine two important measurement properties related to its reliability and validity--sensitivity to change and the effect of mode of administration. Ninety-six patients in a physiotherapy clinic were randomly assigned to three mode-of-administration study groups, administered the MHIQ at four points in time including at admission and discharge from the clinic, and assessed for change by their physiotherapist. MHIQ physical function, social function, and emotional function retest scores obtained by self-completion within a 1-week interval were most stable. Physical function scores by any of self-completion, telephone interview, or personal interview were sensitive to change, that is, they improved dramatically by the time of discharge from the clinic. Mode of administration did not affect the size of the change scores. Changes reflected by the physical function scores correlated with changes in physical function reported by a patient's physiotherapist. No systematic changes occurred with social and emotional function scores; this is not surprising in a group of patients with predominantly physical function problems.

Bowels: beliefs and behaviour

A postal questionnaire about knowledge, beliefs, and experiences of bowel function was returned by 171 patients aged 55 years and over from a group general practice in London. Of the respondents, 10% reported no predictable frequency of movement, a higher proportion being women than men; 79% believed that a daily movement is important and 90% that 'regularity' is necessary for good health; 14% were dissatisfied with their bowel habits and 16% regularly self-treated; 95% gave reasonable definitions of 'regular' and 'diarrhoea'; a tenth were unsure about the definition of 'constipation'. Although 76% believed there were bowel symptoms which require immediate medical attention, 98% would in the first instance treat themselves for constipation, 90% for diarrhoea, and 25% for rectal bleeding. To reduce delay in the diagnosis of colorectal cancer, it is suggested that consultations for disturbance of bowel function be encouraged among the middle-aged and the elderly. Doctors should examine such patients with the diagnosis of malignancy in mind.

Children's multiple vitamins: overuse leads to overdose

A suburban Ontario community hospital encountered 21 +/- 1 overdoses of children's multiple vitamins yearly between 1978 and 1981. Of these, 35% involved one particular cartoon character preparation. Parents were surveyed to determine whether this particular preparation resulted in a disproportionate number of accidental overdoses. However, the use of vitamins with a cartoon character format did not lead to a greater risk of overdose than did conventional preparations. Of the 1051 families who had given multiple vitamins to their children 34 (3%) had experienced an overdose. The number of vitamin preparations used by each family was the most powerful determinant of overdose (p less than 0.001). The risk of accidental overdose increased from 1.5% with one multiple-vitamin preparation to 8% with four or more preparations. Among all the variables examined, exposure was the most important element in the risk of multiple-vitamin overdose.

Behavioral therapy: its application to reduce disruptive behaviors of the elderly in nursing homes

Nurses who care for the elderly in nursing homes and auxiliary hospitals have many goals. They provide for the health, recreational, social and emotional needs of their patients. They also strive to increase their patients' levels of self-care and self-respect. Unfortunately, because many patients exhibit disruptive behaviors--striking staff or other patients, throwing temper tantrums, lying on the floor in corridors, refusing to take medication and so on, these desirable goals cannot always be met. What nurses need, in addition to their specialized, medically oriented training, is training in a consistent strategy for handling these problems. Behavioral therapy provides this strategy.