Heat-related fatalities in North Carolina 1999-2017

OBJECTIVES

Research shows the highest rates of occupational heat-related fatalities among farm laborers and among Black and Hispanic workers in North Carolina (NC). The Hispanic population and workforce in NC have grown substantially in the past 20 years. We describe the epidemiology of heat-related fatal injuries in the general population and among workers in NC.

METHODS

We reviewed North Carolina death records and records of the North Carolina Office of the Chief Medical Examiner to identify heat-related deaths (primary International Classification of Diseases, Tenth Revision diagnosis code: X30 or T67.0-T67.9) that occurred between January 1, 1999, and December 31, 2017. Decedent age, sex, race, and ethnicity were extracted from both the death certificate and the medical examiner's report as well as determinations of whether the death occurred at work.

RESULTS

In NC between 1999 and 2017, there were 225 deaths from heat-related injuries, and 25 occurred at work. The rates of occupational heat-related deaths were highest among males, workers of Hispanic ethnicity, workers of Black, multiple, or unknown race, and in workers aged 55-64. The highest rate of occupational heat-related deaths occurred in the agricultural industry.

CONCLUSIONS

Since the last report (2001), the number of heat-related fatalities has increased, but fewer were identified as workplace fatalities. Rates of occupational heat-related deaths are highest among Hispanic workers. NC residents identifying as Black are disproportionately burdened by heat-related fatalities in general, with a wider apparent disparity in occupational deaths.

Forty years of struggle in North Carolina: Workplace segregation and fatal occupational injury rates

OBJECTIVE

To assess workplace segregation in fatal occupational injury from 1992 to 2017 in North Carolina.

METHODS

We calculated occupational fatal injury rates within categories of occupation, industry, race, age, and sex; and estimated expected numbers of fatalities among Black and Hispanic male workers had they experienced the rates of White male workers. We also estimated the contribution of workforce segregation to disparities by estimating the expected number of fatalities among Black and Hispanic male workers had they experienced the industry and occupation patterns of White male workers. We assessed person-years of life-lost, using North Carolina life expectancy estimates.

RESULTS

Hispanic workers contributed 32% of their worker-years and experienced 58% of their fatalities in construction. Black workers were most overrepresented in the food manufacturing industry. Hispanic males experienced 2.11 (95% CI: 1.86-2.40) times the mortality rate of White males. The Black-White and Hispanic-White disparities were widest among workers aged 45 and older, and segregation into more dangerous industries and occupations played a substantial role in driving disparities. Hispanic workers who suffered occupational fatalities lost a median 47 life-years, compared to 37 among Black workers and 36 among White workers.

CONCLUSIONS

If Hispanic and Black workers experienced the workplace safety of their White counterparts, fatal injury rates would be substantially reduced. Workforce segregation reflects structural racism, which also contributes to mortality disparities. Root causes must be addressed to eliminate disparities.

25-Year fatal workplace suicide trends in North Carolina: 1992-2017

BACKGROUND

Suicide is a serious public health problem in the United States, but limited evidence is available investigating fatal suicides at work. There is a substantial need to characterize workplace suicides to inform suicide prevention interventions and target high-risk settings. This study aims to examine workplace suicide rates in North Carolina (NC) by worker characteristics, means of suicide used, and industry between 1992 and 2017.

METHODS

Fatal workplace suicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificate. Sex, age, race, ethnicity, class of worker, manner of death, and industry were abstracted. Crude and age-standardized homicide rates were calculated as the number of suicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% confidence intervals (CIs) were calculated, and trends over calendar time for fatal workplace suicides were examined overall and by industry.

RESULTS

81 suicides over 109,464,430 w-y were observed. Increased rates were observed in workers who were male, self-employed, and 65+ years old. Firearms were the most common means of death (63%) followed by hanging (16%). Gas service station workers experienced the highest fatal occupational suicide rate, 11.5 times (95% CI: 3.62-36.33) the overall fatal workplace suicide rate, followed by Justice, Public Order, and Safety workers at 3.23 times the overall rate (95% CI: 1.31-7.97).

CONCLUSION

Our findings identify industries and worker demographics that were vulnerable to workplace suicides. Targeted and tailored mitigation strategies for vulnerable industries and workers are recommended.

Twenty-five year occupational homicide mortality trends in North Carolina: 1992-2017

INTRODUCTION

Determining industry of decedents and victim-perpetrator relationships is crucial to inform and evaluate occupational homicide prevention strategies. In this study, we examine occupational homicide rates in North Carolina (NC) by victim characteristics, industry and victim-perpetrator relationship from 1992 to 2017.

METHODS

Occupational homicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificates. Sex, age, race, ethnicity, class of worker, manner of death, victim-perpetrator relationship and industry were abstracted. Crude and age-standardised homicide rates were calculated as the number of homicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% CIs were calculated, and trends over calendar time in occupational homicide rates were examined overall and by industry.

RESULTS

456 homicides over 111 573 049 w-y were observed. Occupational homicide rates decreased from 0.82 per 100 000 w-y for the period 1992-1995 to 0.21 per 100 000 w-y for the period 2011-2015, but increased to 0.32 per 100 000 w-y in the period 2016-2017. Fifty-five per cent (252) of homicides were perpetrated by strangers. Taxi drivers experienced an occupational homicide rate that was 110 times (95% CI 76.52 to 160.19) the overall occupational homicide rate in NC; however, this rate declined by 76.5% between 1992 and 2017. Disparities were observed among workers 65+ years old, racially and ethnically minoritised workers and self-employed workers.

CONCLUSION

Our findings identify industries and worker demographics that experienced high occupational homicide fatality rates. Targeted and tailored mitigation strategies among vulnerable industries and workers are recommended.

Forty-year trends in fatal occupational injuries in North Carolina

BACKGROUND

We describe progress in the control of deaths on-the-job due to fatal occupational injury in North Carolina over the period 1978-2017.

METHODS

Forty years of information on fatal occupational injuries in North Carolina has been assembled from medical examiners' reports and death certificates, supplemented by newspaper and police reports. Cases were defined as unintentional fatal occupational injuries among adults. Annual estimates of the population at risk were derived from US Census data, and rates were quantified using Poisson regression methods.

RESULTS

There were 4434 eligible deaths. The unintentional fatal occupational injury rate at the beginning of the study period was more than threefold the rate at the end of the study. The fatal occupational injury rate among men declined from 9.6 per 100,000 worker-years in the period 1978-1982 to 3.1 per 100,000 worker-years in the period 2013-2017. The fatal occupational injury rate among women declined from 0.3 per 100,000 worker-years in the period 1978-1981 to 0.1 per 100,000 worker-years in the period 2013-2017. Declines in rates were observed for young adults as well as older workers and were observed across all major industry categories. Average annual declines in rates were greatest in those industries and occupations that had the highest fatal injury rates at the start of the study period.

CONCLUSIONS

The substantial decline in fatal injury rates underscores the importance of injury prevention and demonstrates the ability to make meaningful reductions in unintentional fatal injury.

Fatal occupational injuries in North Carolina, 1992-2017

OBJECTIVES

After declining for several decades, fatal occupational injury rates have stagnated in the USA since 2009. To revive advancements in workplace safety, interventions targeting at-risk worker groups must be implemented. Our study aims to identify these at-risk populations by evaluating disparities in unintentional occupational fatalities occurring in North Carolina (NC) from 1992 to 2017.

METHODS

Our retrospective cohort study drew on both the NC Office of the Chief Medical Examiner system and the NC death certificate data system to identify unintentional fatal occupational injuries occurring from 1992 to 2017. Unintentional fatal occupational injury rates were reported across industries, occupations and demographic groups, and rate ratios were calculated to assess disparities.

RESULTS

Among those aged 18 and older, 2645 unintentional fatal occupational injuries were identified. Fatal occupational injury rates declined by 0.82 injuries/100 000 person-years over this period, falling consistently from 2004 to 2009 and increasing from 2009 to 2017. Fatal injury rates were highest among Hispanic workers, who experienced 2.75 times the fatal injury rate of non-Hispanic White workers (95% CI 2.42 to 3.11) and self-employed workers, who experienced 1.44 times the fatal injury rate of private workers (95% CI 1.29 to 1.60). We also observed that fatal injury rates increased with age group and were higher among male relative to female workers even after adjustment for differential distributions across occupations.

CONCLUSIONS

The decline in unintentional fatal occupational injury rates over this period is encouraging, but the increase in injury rate after 2009 and the large disparities between occupations, industries and demographic groups highlight the need for additional targeted safety interventions.

Efficacy of a Novel Telehealth Application in Health Behavior Modification and Symptomology in Military Service Members at Risk for Post-traumatic Osteoarthritis

INTRODUCTION

Mobile applications (apps) may be beneficial to promote self-management strategies to mitigate the risk of developing post-traumatic osteoarthritis in military members following a traumatic knee injury. This study investigated the efficacy of a mobile app in facilitating behavior modification to improve function and symptomology among military members.

MATERIALS AND METHODS

This is a preliminary pre and post hoc analysis of a randomized control trial. The MARX scale, Intermittent and Constant Osteoarthritis Pain (ICOAP) questionnaire, and the Knee Injury and Osteoarthritic Outcome Score Readiness to Manage Osteoarthritis Questionnaire were completed at baseline, 6-week, 6-month, and 12-month follow-up. Participants in the treatment arm completed the System Usability Scale. Data were analyzed using descriptive statistics, the Wilcoxon sum of ranks test, the Wilcoxon signed-rank test, and Cohen's d effect size.

RESULTS

A total of 28 participants were included. Between-group differences for baseline and 6-week follow-up were significantly improved in the injured knee ICOAP constant pain score for the treatment group (treatment: -4.2 ± 12, 95% CI: -11.5, 3.1; control: 5.5 ± 9.9, 95% CI: 0.9, 10.1; P = .035, effect size = 0.905). Within-group differences for baseline and 6-week follow-up demonstrated a significant decline in the injured knee ICOAP constant pain score among the control group (signed-rank: 16.0, P = .031, Cohen's d = 0.339). No other significant differences were observed. A good System Usability Scale score for usability was found (76.6 ± 8.8).

CONCLUSIONS

These results indicate that the mobile app is easy to use and may contribute to improved constant pain symptomology for patients at risk for post-traumatic osteoarthritis.

Prevalence of fentanyl in methamphetamine and cocaine samples collected by community-based drug checking services

BACKGROUND

Overdose deaths involving stimulants and opioids simultaneously have raised the specter of widespread contamination of the stimulant supply with fentanyl.

METHODS

We quantified prevalence of fentanyl in street methamphetamine and cocaine, stratified by crystalline texture, analyzing samples sent voluntarily to a public mail-in drug checking service (May 2021-June 2023). Samples from 77 harm reduction programs and clinics originated in 25 US states. Sample donors reported expected drug and physical descriptions. Substances were identified by gas chromatography-mass spectrometry. Negative binomial models were used to calculate fentanyl prevalence, adjusting for potential confounders related to sample selection. We also examined if xylazine changed donors' accuracy of detecting fentanyl.

RESULTS

We analyzed 718 lab-confirmed samples of methamphetamine (64%) and cocaine (36%). The adjusted prevalence of fentanyl was 12.5% (95% CI: 2.2%, 22.9%) in powder methamphetamine and 14.8% (2.3%, 27.2%) in powder cocaine, with notable geographic variation. Crystalline forms of both methamphetamine (Chisq=57, p<0.001) and cocaine (Chisq=18, p<0.001) were less likely to contain fentanyl: less than 1% of crystal methamphetamine (2/276) and no crack cocaine (0/53). Heroin was present in 6.6% of powder cocaine samples. Xylazine reduced donors' ability to detect fentanyl, with correct classification dropping from 92% to 42%.

CONCLUSIONS

Fentanyl was detected primarily in powder forms of methamphetamine and cocaine. Recommended interventions include expanding community-based drug checking, naloxone and fentanyl test strip distribution for people who use stimulants , and supervised drug consumption sites. New strategies to dampen variability in street drug composition are needed to reduce inadvertent fentanyl exposure.

Disparities in Fatal Occupational Injury Rates in North Carolina, 1978-2017: Comparing Non-Managerial Employees to Managers

BACKGROUND

We examined fatal occupational injuries among private-sector workers in North Carolina during the 40-year period 1978-2017, comparing the occurrence of fatal injuries among non-managerial employees to that experienced by managers.

METHODS

We estimated a standardized fatal occupational injury ratio by inverse probability of exposure weighting, taking the non-managerial workers as the target population. When this ratio measure takes a value greater than unity it signals settings in which non-managerial employees are not provided as safe a work environment as that provided for managers.

RESULTS

Across all industries, non-managerial workers in North Carolina experienced fatal occupational injury rates 8.2 (95%CI: 7.0, 10.0) times the rate experienced by managers. Disparities in fatal injury rates between managers and the employees they supervise were greatest in forestry, rubber, and metal manufacturing, wholesale trade, fishing and extractive industries, and construction.

CONCLUSIONS

The results may help focus discussion about workplace safety between labor and management upon equity, with a goal of providing a work environment for non-managerial employees as safe as the one provided for managers.

Trends in fatal occupational injury rates among older workers before and after the Great Recession of 2008

BACKGROUND

Older workers experience higher rates of fatal occupational injury than younger workers worldwide. In North Carolina, the population of older workers more than doubled between 2000 and 2017. In 2008, the Great Recession changed occupational patterns among all age groups. We examined annual rates and distribution of fatal occupational injuries experienced by older workers, comparing the pre-recession period (2000-2007) to the post-recession period (2009-2017).

METHODS

Detailed information on all fatal occupational injuries during the period between 1 January 2000 and 31 December 2017 were abstracted from the records of the North Carolina Office of the Chief Medical Examiner and the office of vital records. The decennial Census and American Community Survey were used to estimate the population at risk and derive annual rates of fatal occupational injury.

RESULTS

During the study period, 537 occupational fatalities occurred among workers 55+ years of age. The rate of fatal occupational injury among older workers declined 2.8% per year, with a 7.7% yearly decline in the pre-recession period compared with a 1.4% increase per year in the post-recession period. Workers 65+ years of age experienced rate increases in both periods. The highest rates of unintentional fatal occupational injury (injuries that were not purposefully inflicted) were observed in forestry, fishing hunting and trapping, and wood building manufacturing. Intentional fatal occupational injury rates (homicide, suicide) were highest in transportation, gas/service stations and grocery/food stores.

CONCLUSIONS

Older workers have persistently high rates of fatal occupational injury in North Carolina before and after the Great Recession.

Association of Traumatic Knee Injury With Radiographic Evidence of Knee Osteoarthritis in Military Officers

OBJECTIVE

The association between knee injury and knee osteoarthritis (OA) is understudied relative to its importance, particularly in younger populations. This study was undertaken to examine the association of knee injury with radiographic features of knee OA in military officers, who have a physically demanding profession and high rates of knee injury.

METHODS

Participants were recruited in 2015-2017 from an existing program that enrolled 6,452 military officers during 2004-2009. Officers with a history of knee ligament or meniscal injuries (n = 117 via medical record review) were compared to officers with no history of knee injury (n = 143). Bilateral posteroanterior knee radiographs were obtained using a standardized fixed-flexion positioning frame. All images were read for Kellgren/Lawrence (K/L) grade, osteophyte (OST), and joint space narrowing (JSN) scores. Data were analyzed using linear-risk regression models with generalized estimating equations.

RESULTS

Injured and noninjured participants were similar (mean age 28 years, mean body mass index 25 kg/m² , ~40% female). The mean time from first knee injury to imaging among injured participants was 9.2 years. Compared with noninjured knees, greater prevalence of radiographic OA (K/L grade ≥ 2), OST (grade ≥ 1), and JSN (grade ≥ 1) was observed among injured knees, with prevalence differences of +16% (95% confidence interval [95% CI] 10%, 22%), +29% (95% CI 20%, 38%), and + 17% (95% CI 10%, 24%), respectively. Approximately 1 in 6 officers with prior knee injury progressed to radiographic OA by age 30 years.

CONCLUSION

At the midpoint of a projected 20-year military career, officers with a history of traumatic knee injury have a markedly increased prevalence of knee radiographic OA compared to officers without injury.

Challenges with misclassification of American Indian/Alaska Native race and Hispanic ethnicity on death records in North Carolina occupational fatalities surveillance

As frequently segregated and exploitative environments, workplaces are important sites in driving health and mortality disparities by race and ethnicity. Because many worksites are federally regulated, US workplaces also offer opportunities for effectively intervening to mitigate these disparities. Development of policies for worker safety and equity should be informed by evidence, including results from research studies that use death records and other sources of administrative data. North Carolina has a long history of Black/white disparities in work-related mortality and evidence of such disparities is emerging in Hispanic and American Indian/Alaska Native (AI/AN) worker populations. The size of Hispanic and AI/AN worker populations have increased in North Carolina over the last decade, and North Carolina has the largest AI/AN population in the eastern US. Previous research indicates that misidentification of Hispanic and AI/AN identities on death records can lead to underestimation of race/ethnicity-specific mortality rates. In this commentary, we describe problems and complexities involved in determining AI/AN and Hispanic identities from North Carolina death records. We provide specific examples of misidentification that are likely introducing bias to occupational mortality disparity documentation, and offer recommendations for improved data collection, analysis, and interpretation. Our primary recommendation is to build and maintain relationships with local community leadership, so that improvements in the ascertainment of race and ethnicity are grounded in the lived experience of workers from communities of color.

Trends in fatal occupational injuries in Latino/a workers relative to other groups, North Carolina 2000-2017

BACKGROUND

Latino/a workers may experience higher fatal occupational injury rates than non-Latino/a workers. In North Carolina, the Latino/a population more than doubled between 2000 and 2017. We examined fatal occupational injuries among Latino/a and non-Latino/a workers in North Carolina over this period.

METHODS

Information on fatal occupational injuries was abstracted from records of the North Carolina Office of the Chief Medical Examiner and the death certificate records held by the North Carolina Office of Vital Records. Estimates of the working population were derived from the decennial census and American Community Survey. Estimates of annual rates of fatal occupational injury for the period January 1, 2000 to December 31, 2017 were derived for Latino/a workers and compared to Black and White workers not identified as Latino/a.

RESULTS

Over the study period, 1,783 fatal occupational injuries were identified among non-Latino/a workers and 259 fatal occupational injuries among Latino/a workers in North Carolina. The majority of fatal occupational injuries among Latino/a workers occurred among males employed in construction and agriculture. While the fatal occupational injury rate among Latino/a workers declined over the study period, the rate among Latino/a workers was higher than among non-Latino/a White and Black workers; moreover, fatal occupational injury rates for Latino/a workers trended upwards during the most recent years of the study period.

CONCLUSIONS

Latino/a workers in North Carolina have the highest fatal occupational injury rate of any race/ethnicity group.

Abuse-Deterrent Opioids: A Survey of Physician Beliefs, Behaviors, and Psychology

Objective

Evaluate beliefs and behaviors pertaining to abuse-deterrent opioids (ADFs).

Design

Survey in 2019 by invitation to all licensed physicians.

Setting

Commonwealth of Kentucky.

Participants

374 physicians.

Methods

Descriptive statistics, and hypothesis test that early adopter prescribers would have greater endorsement of opioid risk management.

Results

Of all prescribers, 55% believed all opioid analgesics should have ADF requirements (15% were unsure); 74% supported mandating insurance coverage. Only one-third considered whether an opioid was ADF when prescribing, motivated by patient family diversion (94%) and societal supply reduction (88%). About half believed ADFs were equally effective in preventing abuse by intact swallowing, injection, chewing, snorting, smoking routes. Only 4% of OxyContin prescribers chose it primarily because of ADF properties. Instead, the most common reason (33%) was being started by another prescriber. A quarter of physicians chose not to prescribe ADFs because of heroin switching potential. Early adopters strongly believed ADFs were effective in reducing abuse (PR 3.2; 95% CI 1.5, 6.6) compared to mainstream physicians. Early-adopter risk-management practices more often included tools increasing agency and measurement: urine drug screens (PR 2.0; 1.3, 3.1), risk screening (PR 1.3; 0.94, 1.9). While nearly all respondents (96%) felt that opioid abuse was a problem in the community, only 57% believed it was a problem among patients in their practice. Attribution theory revealed an externalization of opioid abuse problems that deflected blame from patients on to family members.

Conclusions

The primary motivator for prescribing ADFs was preventing diversion by family members, not patient-level abuse concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00343-z.

Implementation of mandatory opioid prescribing limits in North Carolina: healthcare administrator and prescriber perspectives

BACKGROUND

Recent increases in state laws to reduce opioid prescribing have demonstrated a need to understand how they are interpreted and implemented in healthcare systems. The purpose of this study was to explore the systems, strategies, and resources that hospital administrators and prescribers used to implement the 2017 North Carolina Strengthen Opioid Prevention (STOP) Act opioid prescribing limits, which limited initial prescriptions to a five (for acute) or seven (for post-surgical) days' supply.

METHODS

We interviewed 14 hospital administrators and 38 prescribers with degrees in medicine, nursing, pharmacy, business administration and public health working across North Carolina. Interview guides, informed by the Consolidated Framework for Implementation Research, explored barriers and facilitators to implementation. Interview topics included communication, resources, and hospital system support. Interviews were recorded and transcribed, then analyzed using flexible coding, integrating inductive and deductive coding, to inform analytic code development and identify themes.

RESULTS

We identified three main themes around implementation of STOP act mandated prescribing limits: organizational communication, prescriber education, and changes in the electronic medical record (EMR) systems. Administrators reflected on implementation in the context of raising awareness and providing reminders to facilitate changes in prescriber behavior, operationalized through email and in-person communications as well as dedicated resources to EMR changes. Prescribers noted administrative communications about prescribing limits often focused on legality, suggesting a directive of the organization's policy rather than a passive reminder. Prescribers expressed a desire for more spaces to have their questions answered and resources for patient communications. While hospital administrators viewed compliance with the law as a priority, prescribers reflected on concerns for adequately managing their patients' pain and limited time for clinical care.

CONCLUSIONS

Hospital administrators and prescribers approached implementation of the STOP act prescribing limits with different mindsets. While administrators were focused on policy compliance, prescribers were focused on their patients' needs. Strategies to implement the mandate then had to balance patient needs with policy compliance. As states continue to legislate to prevent opioid overdose deaths, understanding how laws are implemented by healthcare systems and prescribers will improve their effectiveness through tailoring and maximizing available resources.

Workplace violence and hospital security programs: regulatory compliance, program benchmarks, innovative strategies

The authors describe the issue of workplace violence in hospitals, a New Jersey state law and regula- tions regarding workplace vio- lence in healthcare, and some innovative strategies that are being utilized to help reduce the occurrence and risk of violence. The authors also discuss compli- ance with the New Jersey regula- tions.

Characteristics of workplace violence prevention training and violent events among home health and hospice care providers

BACKGROUND

In the rapidly growing home health and hospice industry, little is known about workplace violence prevention (WVP) training and violent events.

METHODS

We examined the characteristics of WVP training and estimated violent event rates among 191 home health and hospice care providers from six agencies in California. Training characteristics were identified from the Occupational Safety and Health Administration guidelines. Rates were estimated as the number of violent events divided by the total number of home visit hours.

RESULTS

Between 2008 and 2009, 66.5% (n = 127) of providers reported receiving WVP training when newly hired or as recurrent training. On average, providers rated the quality of their training as 5.7 (1 = poor to 10 = excellent). Among all providers, there was an overall rate of 17.1 violent events per 1,000 visit-hours.

CONCLUSION

Efforts to increase the number of home health care workers who receive WVP training and to improve training quality are needed.

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

IMPORTANCE

Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100,000 person-years in the first year of life.

OBJECTIVE

To assess the effectiveness of a statewide universal AHT prevention program.

DESIGN, SETTING, AND PARTICIPANTS

In total, 88.29% of parents of newborns (n = 405 060) in North Carolina received the intervention (June 1, 2009, to September 30, 2012). A comparison of preintervention and postintervention was performed using nurse advice line telephone calls regarding infant crying (January 1, 2005, to December 31, 2010). A difference-in-difference analysis compared AHT rates in the prevention program state with those of other states before and after the implementation of the program (January 1, 2000, to December 31, 2011).

INTERVENTION

The Period of PURPLE Crying intervention, developed by the National Center on Shaken Baby Syndrome, was delivered by nurse-provided education, a DVD, and a booklet, with reinforcement by primary care practices and a media campaign.

MAIN OUTCOMES AND MEASURES

Changes in proportions of telephone calls for crying concerns to a nurse advice line and in AHT rates per 100,000 infants after the intervention (June 1, 2009, to September 30, 2011) in the first year of life using hospital discharge data for January 1, 2000, to December 31, 2011.

RESULTS

In the 2 years after implementation of the intervention, parental telephone calls to the nurse advice line for crying declined by 20% for children younger than 3 months (rate ratio, 0.80; 95% CI, 0.73-0.87; P < .001) and by 12% for children 3 to 12 months old (rate ratio, 0.88; 95% CI, 0.78-0.99; P = .03). No reduction in state-level AHT rates was observed, with mean rates of 34.01 person-years before the intervention and 36.04 person-years after the intervention. A difference-in-difference analysis from January 1, 2000, to December 31, 2011, controlling for economic indicators, indicated that the intervention did not have a statistically significant effect on AHT rates (β coefficient, -1.42; 95% CI, -13.31 to 10.45).

CONCLUSIONS AND RELEVANCE

The Period of PURPLE Crying intervention was associated with a reduction in telephone calls to a nurse advice line. The study found no reduction in AHT rates over time in North Carolina relative to other states. Consequently, while this observational study was feasible and supported the program effectiveness in part, further programmatic efforts and evaluation are needed to demonstrate an effect on AHT rates.

How to engage small retail businesses in workplace violence prevention: Perspectives from small businesses and influential organizations

BACKGROUND

Small retail businesses experience high robbery and violent crime rates leading to injury and death. Workplace violence prevention programs (WVPP) based on Crime Prevention Through Environmental Design reduce this risk, but low small business participation limits their effectiveness. Recent dissemination models of occupational safety and health information recommend collaborating with an intermediary organization to engage small businesses.

METHODS

Qualitative interviews with 70 small business operators and 32 representatives of organizations with small business influence were conducted to identify factors and recommendations for improving dissemination of a WVPP.

RESULTS

Both study groups recommended promoting WVPPs through personal contacts but differed on other promotion methods and the type of influential groups to target. Small business operators indicated few connections to formal business networks.

CONCLUSIONS

Dissemination of WVPPs to small businesses may require models inclusive of influential individuals (e.g., respected business owners) as intermediaries to reach small businesses with few formal connections.

Understanding small business engagement in workplace violence prevention programs

PURPOSE

Worksite wellness, safety, and violence prevention programs have low penetration among small, independent businesses. This study examined barriers and strategies influencing small business participation in workplace violence prevention programs (WVPPs).

APPROACH

A semistructured interview guide was used in 32 telephone interviews.

SETTING

The study took place at the University of North Carolina Injury Prevention Research Center.

PARTICIPANTS

Participating were a purposive sample of 32 representatives of small business-serving organizations (e.g., business membership organizations, regulatory agencies, and economic development organizations) selected for their experience with small businesses.

INTERVENTION

This study was designed to inform improved dissemination of Crime Free Business (CFB), a WVPP for small, independent retail businesses.

METHODS

Thematic qualitative data analysis was used to identify key barriers and strategies for promoting programs and services to small businesses.

RESULTS

Three key factors that influence small business engagement emerged from the analysis: (1) small businesses' limited time and resources, (2) low salience of workplace violence, (3) influence of informal networks and source credibility. Identified strategies include designing low-cost and convenient programs, crafting effective messages, partnering with influential organizations and individuals, and conducting outreach through informal networks.

CONCLUSION

Workplace violence prevention and public health practitioners may increase small business participation in programs by reducing time and resource demands, addressing small business concerns, enlisting support from influential individuals and groups, and emphasizing business benefits of participating in the program.

Process evaluation of a statewide abusive head trauma prevention program

The current study used four dimensions of the RE-AIM framework (Reach, Adoption, Implementation, and Maintenance) to evaluate the implementation of a statewide abusive head trauma prevention program. Numerous methods, including telephone surveys, paper and pencil questionnaires, site visits, and program administrative data were used to conduct the process evaluation. Results indicate that the intervention was successfully implemented in all birthing hospitals (n=86) across the state with a high degree of fidelity. Furthermore, the majority of the hospitals reported incorporating the program into unit procedures and employee training. More than three-fourths indicated that they plan to continue the program after the study ends. The RE-AIM framework was applied and served as a useful guide for the process evaluation of a multifaceted, multi-system, universal public health intervention.

Factors influencing law enforcement decisions to adopt an evidence-based robbery prevention program

Homicide is the leading cause of workplace death among small retail and service businesses in the United States. Evidence-based programs have been shown to reduce robbery and robbery-related crimes in small retail businesses; however, reaching small businesses with programs has been difficult. As small businesses typically have no corporate backing or trade affiliation, police departments have been identified as potential vehicles for program dissemination. A national sample of 300 law enforcement agencies was surveyed to identify facilitators and barriers to adoption and sustainability of an evidence-based program. The questionnaire was developed using behavioral theory concepts and administered via telephone. Preliminary findings suggest the primary facilitators to program adoption included organizational capacity factors such as staff buy-in, dedicated personnel and financial support. Competing responsibilities was the primary barrier identified by agencies. Agency size and program complexity were identified as potential predictors of program adoption. Identifying agency and program-specific characteristics that influence program adoption by law enforcement agencies will be valuable for marketing programs to agencies that have the infrastructure to support and sustain program dissemination. Understanding these factors will optimize the reach of evidence-based strategies to small businesses.

Workplace violence prevention policies in home health and hospice care agencies

Workplace violence in the home health industry is a growing concern, but little is known about the content of existing workplace violence prevention programs. The authors present the methods for this study that examined workplace violence prevention programs in a sample of 40 California home health and hospice agencies. Data was collected through surveys that were completed by the branch managers of participating facilities. Programs were scored in six different areas, including general workplace violence prevention components; management commitment and employee involvement; worksite analysis; hazard prevention and control; safety and health training; and recordkeeping and program evaluation. The results and discussion sections consider these six areas and the important gaps that were found in existing programs. For example, although most agencies offered workplace violence training, not every worker performing patient care was required to receive the training. Similarly, not all programs were written or reviewed and updated regularly. Few program differences were observed between agency characteristics, but nonetheless several striking gaps were found.

Barriers to senior centre implementation of falls prevention programmes

This study examined the prevalence of senior centres providing multi-component falls prevention education and the perceived barriers in implementing this education. A telephone interview was conducted in 2006 with 500 senior centres nationwide. Centre directors were asked about the types of multi-component falls prevention education offered (ie, balance exercise classes, medication management, home safety information) and barriers to offering this education. Seventy percent of senior centres offered balance exercise classes, 68% offered medication management and 53% provided home safety information. Thirty-two percent offered all three components. Lack of staff, time and staff not feeling they had sufficient knowledge to deliver falls prevention education were the leading barriers to providing multi-component education. Senior centres provide components of effective falls prevention education and, while some may not address all components of a multifaceted programme, many have existing resources that may be adapted for translation of evidence-based programmes.

Parent ratings of behavioral functioning after traumatic brain injury in very young children

OBJECTIVE

The behavioral ratings of preschoolers who sustained traumatic brain injury (TBI) prior to the age of 2 years and a typically developing group were compared; predictors of behavioral functioning were examined.

METHODS

Eighty-two 3-year-olds comprised mild TBI (n = 31), moderate/severe TBI (n = 20), and typically developing (n = 31) groups, with Child Behavior Checklist (CBCL) as the primary outcome measure.

RESULTS

Groups differed on the CBCL Withdrawal Scale. No differences emerged in the proportion of children demonstrating clinical elevations, with average mean scores for each group. Exploratory analyses yielded no differences between inflicted, non-inflicted, and typical groups. Glasgow Coma Scale and Self-Report Family Inventory Leadership predicted Externalizing Problems; developmental level predicted Internalizing Problems.

CONCLUSIONS

After early TBI, preschoolers did not differ from one another or a matched comparison group in behavioral ratings; however, it may be premature to infer that preschoolers do not evidence behavioral dysfunction after early TBI.

Race matters in the prosecution of perpetrators of inflicted traumatic brain injury

OBJECTIVE

The goal was to examine the case flow of child physical abuse prosecutions through the judicial system and to examine determinants of charges and sentencing decisions.

METHODS

This prospective cohort study monitored all defendants in identified cases of inflicted traumatic brain injury in North Carolina in 2000 and 2001. Victims were identified prospectively through surveillance at all PICUs in North Carolina and the Office of the Chief Medical Examiner. Suspected perpetrators were identified through information from families, hospital records, newspaper clippings, the Department of Corrections, and Clerks of Superior Court. Judicial case flow from original charges through sentencing was mapped. The victims' injury characteristics and suspects' characteristics, including potential mitigating and aggravating factors, were examined. Suspected perpetrator and victim characteristics were entered into multivariate models for examination of associations with charges and sentencing decisions.

RESULTS

Original and final charges varied widely. The most frequent original and final charge was the lowest-class felony child abuse charge. The child's death was predictive of higher felony charges. Sentences ranged from probation to life in prison. Of the defendants who were found to be guilty, 63% were incarcerated for some period of time. Severe sentences were associated with perpetrator race.

CONCLUSIONS

Prosecutors frequently charged the lowest felony child abuse charge available unless the child died. Minority status was not important in the decision to bring charges against a suspect but was the most important measured factor in rendering a sentence. Although the most appropriate charges and sentences can be argued, there seems to be a statewide bias toward harsher sentences for minority perpetrators.

Neurodevelopmental consequences of early traumatic brain injury in 3-year-old children

OBJECTIVES

The purpose of this work was to determine cognitive and adaptive behavioral outcomes of children with traumatic brain injury acquired before age 2 years and to compare outcomes between inflicted versus noninflicted brain injury.

PATIENTS AND METHODS

All North Carolina children hospitalized in an ICU for a traumatic brain injury before age 2 years between the years 2000 and 2001 were eligible for study entry. A total of 112 surviving children were prospectively identified, 52 (46%) of whom had complete follow-up. Thirty-one control children were recruited from preschool settings. Control subjects were chosen to be demographically similar to case subjects. Child measures of cognition and adaptive behavior at age 3 years were measured and compared between children with and without traumatic brain injury and children with inflicted and noninflicted traumatic brain injury.

RESULTS

Sixty percent of injured children were > 1 SD below normal on cognitive testing. Forty percent of injured children scored > 1 SD below normal on adaptive behavior testing. Children with inflicted traumatic brain injury performed more poorly on tests of cognition and adaptive behavior. Glasgow Coma Scale > or = 13, absence of seizures, income above twice the poverty guidelines, and high social capital were associated with improved outcomes. Injured children had lower scores than uninjured control children after adjustment for socioeconomic status.

CONCLUSIONS

Very young children with mild-to-severe traumatic brain injury as measured by the Glasgow Coma Scale are at risk for global cognitive deficits more than a year after the time of injury. Inflicted brain injury is associated with more severe injury and worse outcomes. This is less optimistic than findings in this same cohort 1 year after injury. Family characteristics seem to play a role in recovery after injury.

Longitudinal follow-up of families and young children with traumatic brain injury

OBJECTIVES

To examine the stability of functional outcomes 2 years after injury among children who sustained a traumatic brain injury (TBI) before 2 years of age and to examine the characteristics of the families caring for these children.

METHODS

All North Carolina-resident children who were hospitalized between January 2000 and December 2001 in any of the state's 9 PICUs and survived a TBI that occurred on or before their second birthday were eligible to participate in the prospective cohort study. Child health status, use of ancillary medical resources, and family characteristics were assessed through maternal caregiver interviews approximately 2 years after injury. Comparisons were made among injury types (inflicted versus noninflicted).

RESULTS

There were 112 children who survived a TBI during the 2-year study period. Fifty-seven (79%) of the 72 maternal caregivers who had completed an interview 1 year after the child's injury participated in the year 2 interview. Most children (67%) had an outcome of mild disability or better at year 2, with 45% functioning at an age-appropriate level. Children's outcomes did not differ significantly at year 2 according to the mechanism of injury. The majority (67%) of children retained their Pediatric Overall Performance Category scores from year 1 to year 2. Children who changed were as likely to show improvement as deterioration. Children differed very little across time, as measured with the Stein-Jessup Functional Status II (Revised) scale. Families tended to have multiple environmental factors that could put their children at risk for poor developmental outcomes, including living below the poverty level (22%) and low social capital (39%).

CONCLUSIONS

The children in this cohort had relatively stable functional outcomes from year 1 to year 2 after injury. This population of children remains very vulnerable to poor developmental outcomes secondary to the effects of their TBI and environmental factors.

Child outcomes and family characteristics 1 year after severe inflicted or noninflicted traumatic brain injury

OBJECTIVE

To assess outcomes 1 year after severe traumatic brain injury (TBI) among young children and to compare outcomes between children with inflicted versus noninflicted injuries.

STUDY DESIGN

Prospective cohort study.

METHODS

All North Carolina-resident children who were hospitalized between January 2000 and December 2001 in any of the state's 9 PICUs and who survived a severe TBI that occurred on or before their second birthday were eligible to participate. Child health status, child use of ancillary medical resources, and family characteristics were determined through maternal caregiver interviews approximately 1 year after injury. Comparisons were made between family characteristics and child outcomes according to injury type.

RESULTS

Seventy-two interviews of maternal caregivers were completed among 112 survivors (64.3%). Children with inflicted injuries (n = 41) had worse outcomes than did children with noninflicted injuries (n = 31), as measured with the Pediatric Outcome Performance Category and Stein-Jessup Functional Status II (Revised) tools. However, approximately 50% of children with inflicted injuries had only mild deficits or better. Children with inflicted injuries had a higher use of ancillary medical resources. Families caring for the children did not differ substantively, with a large proportion of single, working, minority mothers.

CONCLUSIONS

Children with inflicted TBIs had worse outcomes than did children with other TBIs 1 year after injury. However, outcomes for these children were better than those reported previously. Many families caring for children after severe TBI are socially disadvantaged. Interventions to improve child outcomes may include enhanced family support.

Frequency of intracranial pressure monitoring in infants and young toddlers with traumatic brain injury

OBJECTIVE

To examine the use of intracranial pressure monitors and treatments for elevated intracranial pressure in brain-injured children of <2 yrs of age and compare them with the recently published management guidelines.

DESIGN

Prospective, population-based study.

SETTING

All pediatric intensive care units in the state of North Carolina.

PATIENTS

All patients of <24 months of age admitted to a pediatric intensive care unit with a traumatic brain injury between January 2000 and December 2001.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Use of intracranial pressure monitoring devices and treatments for elevated intracranial pressure were measured. There were 136 children admitted to a pediatric intensive care unit with brain injury. A total of 54 (39.7%) had an admission Glasgow Coma Score of < or =8, and 80% were infants. Thirty-three percent of children with a Glasgow Coma Score of < or =8 received monitoring. Hyperosmolar therapy was the most frequently used treatment (57.1%). Treatment for elevated intracranial pressure was more common in, but not limited to, children with monitors. Logistic-regression modeling showed that children of < or =12 months of age had an odds ratio of 0.2 (95% confidence interval, 0.1-0.6) of receiving a monitor compared with children aged 12-24 months.

CONCLUSIONS

Brain injury in young children may lead to many years of lost quality of life. The utility of monitoring intracranial pressure in infants has not been well established, which may be a reason for its low use. As most infants with traumatic brain injury survive, high-quality studies with neurodevelopmental measures as the primary outcome are urgently needed to document best practice in this subpopulation.

Iodine deficiency in Calabria: characterization of endemic goiter and analysis of different indicators of iodine status region-wide

The distribution of goiter prevalence in schoolchildren (no.=13,984, age 6-14 yr), the neonatal TSH results obtained from the congenital hypothyroidism screening program and the urinary iodine excretion values (no.=284) were employed for the assessment of iodine deficiency in Calabria, a Southern Italy region. Data were collected during the years 1990-1996. In the inland territory, goiter prevalence ranged from 19 to 64%. At sea level, there was a great variability of goiter prevalence, with values varying from 5.3 to 25.7%. The analysis of the neonatal hypothyroidism screening program data (no.=21,078) showed a 14.8% frequency of TSH levels >5 microU/ml whole blood in newborns from the inland territory and a 14.1% frequency at sea level. Urinary iodine excretion resulted (mean+/-SD) 53.8+/-43.4 microg/l (range: <20 to 189 microg/l) in the inland territory and 89.6+/-59.8 microg/l (range: 26 to 333 microg/l) at sea level. Median urinary iodine excretion values in 13 villages or small towns of the inland territory ranged from 31 to 57 microg/l. In 2 major towns located at sea level, the median iodine excretion values were 72 microg/l in Crotone main city and 94 microg/l in Reggio Calabria main city. The data indicated that moderate, with pockets of severe iodine deficiency is present in the inland region while iodine supply varies from sufficient to marginally low in the coastal areas. Mild iodine deficiency was found in a major town located at sea level.

Expression of nicotinamide adenine dinucleotide phosphate oxidase flavoprotein DUOX genes and proteins in human papillary and follicular thyroid carcinomas

Duox2, and probably Duox1 are glycoflavoproteins involved in the thyroid H2O2 generator functionally associated to thyroperoxidase (TPO). We investigated both DUOX1 and DUOX2 gene expressions using quantitative reverse transcription-polymerase chain reaction (RT-PCR) in 47 thyroid carcinomas, including 10 paired normal/tumoral tissues. In carcinomas, variations of DUOX1 and DUOX2 mRNA levels were parallel, indicating that control mechanisms of both gene expressions operate in tumors as well as in normal thyroid tissues; DUOX1 expression was in the normal range in 20, was decreased up to 50-fold in 8, and increased up to 7-fold in 19 samples. DUOX2 expression was in the normal range in 15, was decreased up to 200-fold in 10, and increased up to 5-fold in 22 samples. In the 10 paired samples, variations of DUOX and TPO gene expressions were not correlated. We analyzed Duoxl/2 protein expression in 86 tumor samples using an antipeptide antiserum reacting with both Duox proteins. In normal tissue, Duox proteins are localized at the apical pole of thyrocytes, with 40% to 60% of thyrocytes being stained. In the 86 cancer tissues, immunostaining was absent in 19 samples, was low in 32, and normal or even slightly increased in the other 35 samples. The expression of Duox proteins was related to tumor differentiation, being more frequently found in neoplastic tissues that were able to pick up radioiodine, and in those with a detectable expression of sodium iodide symporter (NIS), pendrin and TPO.

Sodium iodide symporter and pendrin expression in human thyroid tissues

Thyroid cells synthesize thyroid hormones through a multistep process during which iodide is transported through the basolateral and the apical membranes of thyrocytes. Two genes that participate in these transports and the corresponding proteins, namely sodium iodide symporter (NIS) and pendrin, the product of the Pendred syndrome gene, have recently been characterized. We studied NIS and pendrin expression at the mRNA and protein levels by a quantitative reverse transcription-polymerase chain reaction (RT-PCR) method and by single and double immunostaining in normal and pathological human thyroid tissues. In normal tissue, NIS and pendrin were detected in about 20% and 40%-60% of thyrocytes, respectively. The number of NIS- and pendrin-positive cells was much higher in hyperfunctioning tissue from Graves' disease or toxic adenoma. In hypofunctioning adenomas and carcinomas, the number of NIS- and pendrin-positive cells was low or nonexistent. Three types of follicular cells were observed in positive tissues: NIS-negative/pendrin-negative cells, NIS-positive/pendrin-positive cells, and NIS-negative/pendrin-positive cells. The first two types of cells appear to be resting and active cells, respectively, but the functional status of NIS-negative/pendrin-positive thyrocytes remains to be determined.

Expression of reduced nicotinamide adenine dinucleotide phosphate oxidase (ThoX, LNOX, Duox) genes and proteins in human thyroid tissues

The large homolog of NADPH oxidase flavoprotein LNOX2, and probably LNOX1, are flavoproteins involved in the thyroid H(2)O(2) generator. Western blot analysis of membrane proteins from normal human thyroid, using antipeptide antibodies, indicated that LNOX1,2 are 164-kDa glycoproteins and that N-glycosylated motifs account for at least 10-20 kDa of their total apparent molecular mass. Northern blot analysis of 23 different human tissues demonstrated that LNOX2 messenger RNA (mRNA) is strongly expressed only in the thyroid gland, although blast analysis of expressed sequence tags databases indicated that LNOX genes are also expressed in some nonthyroid cells. We investigated LNOX1,2 gene and protein expressions in normal and pathological human thyroid tissues using real-time kinetic quantitative PCR and antipeptide antibodies, respectively. In normal tissue, LNOX1,2 are localized at the apical pole of thyrocytes. Immunostaining for LNOX1,2 was heterogeneous, inside a given follicle, with 40-60% of positive follicular cells. Among normal and pathological tissues, variations of LNOX1 and LNOX2 mRNA levels were parallel, suggesting a similar regulation of both gene expressions. Whereas LNOX mRNAs seemed slightly affected in benign disease, the expression of protein was highly variable. In multinodular goiters, 40-60% of cells were stained. In hypofunctioning adenomas, LNOX immunostaining was highly variable among follicles, whereas sodium/iodide (Na+/I-) symporter immunostaining was decreased. In hyperfunctioning thyroid tissues, only few cells (0-10%) were weakly stained, whereas sodium/iodide symporter staining was found in the majority of follicular cells. In conclusion, LNOX proteins are new apical glycoproteins with a regulation of expression that differs from other thyroid markers.

Chromogranin A and the alpha-subunit of glycoprotein hormones in medullary thyroid carcinoma and phaeochromocytoma

Using specific immunoradiometric assays, we evaluated the clinical usefulness of chromogranin A and the alpha-subunit of glycoprotein hormones in neuroendocrine tumours of neuroectodermic origin. The serum alpha-subunit of glycoprotein hormones was only slightly increased in 2 out of 44 medullary thyroid carcinoma or phaeochromocytoma patients with increased calcitonin or 24-hour urinary metanephrine levels. Serum chromogranin A was increased in 12 of 45 (27%) medullary thyroid carcinoma patients with an elevated calcitonin level and in 4 of 16 medullary thyroid carcinoma patients (25%) with an undetectable calcitonin level, in 5 of 7 phaeochromocytoma patients with increased urinary catecholamine and metabolite excretion, and in 2 of 3 patients with a non-functioning phaeochromocytoma. During follow-up, the course of chromogranin A was found to parallel that of tumour burden and/or 24-hour urinary metanephrine in 5 phaeochromocytoma patients. We conclude that chromogranin A measurement is not recommended for the diagnosis of medullary thyroid carcinoma patients. It may be useful in patients with functioning and non-functioning phaeochromocytomas as a follow-up marker. In neuroendocrine tumour patients with elevated calcitonin secretion, the serum alpha-subunit of glycoprotein hormone measurement may help differentiate medullary thyroid carcinoma or phaeochromocytoma patients from other endodermal-derived neuroendocrine tumour patients in whom it is frequently elevated.

Endogenous subclinical hyperthyroidism affects quality of life and cardiac morphology and function in young and middle-aged patients

To determine the clinical impact of endogenous subclinical hyperthyroidism, specific symptoms and signs of thyroid hormone excess and quality of life were assessed in 23 patients (3 males and 20 females; mean age, 43 +/- 9 yr) and 23 age-, sex-, and lifestyle-matched normal subjects by using the Symptoms Rating Scale and the Short Form 36 Health Survey questionnaires. Because the heart is one of the main target organs of the thyroid hormone, cardiac morphology and function were also investigated by means of standard 12-lead electrocardiogram (ECG), 24-h Holter ECG, and complete Doppler echocardiography. Stable endogenous subclinical hyperthyroidism had been diagnosed in all patients at least 6 months before the study (TSH, 0.15 +/- 0.1 mU/L; free T(3), 6.9 +/- 1.1, pmol/L; free T(4), 17.2 +/- 2.3, pmol/L). Fifteen patients were affected by multinodular goiter, and eight patients by autonomously functioning thyroid nodule. The mean Symptoms Rating Scale score (9. 8 +/- 5.5 vs. 4.3 +/- 2.2, P: < 0.001) and both the mental (36.1 +/- 9.5 vs. 50.0 +/- 8.5, P: < 0.001) and physical (42.6 +/- 8.0 vs. 55. 6 +/- 4.1, P: < 0.001) component scores of Short Form 36 Health Survey documented a significant prevalence of specific symptoms and signs of thyroid hormone excess and notable impairment of quality of life in patients. Holter ECG showed a higher prevalence of atrial premature beats in endogenous subclinical hyperthyroid patients than in the controls, but the difference was not statistically significant, although the average heart rate was significantly increased in the patients (P: < 0.001). An increase of left ventricular mass (162 +/- 24 vs. 132 +/- 22 g, P: < 0.001) due to the increase of septal (P: = 0.025) and posterior wall (P: = 0.004) thickness was observed in patients. Systolic function was enhanced in patients as shown by the significant increase of both fractional shortening (P: = 0.005) and mean velocity of heart rate-adjusted circumferential fiber shortening (P: = 0.036). The Doppler parameters of diastolic function were significantly impaired in the patients as documented by the reduced early to late ratio of the transmitral flow velocities (P: < 0.001) and the prolonged isovolumic relaxation time (P: = 0.006). These data indicate that endogenous subclinical hyperthyroidism has a relevant clinical impact and that it affects cardiac morphology and function. Moreover, they suggest that treatment of persistent endogenous subclinical hyperthyroidism should be considered also in young and middle-aged patients to attenuate specific symptoms and signs of thyroid hormone excess, ameliorate the quality of life, and avoid the consequences to the heart of long exposure to a mild excess of thyroid hormone.

Treatment of advanced medullary thyroid cancer with an alternating combination of doxorubicin-streptozocin and 5 FU-dacarbazine. Groupe d'Etude des Tumeurs à Calcitonine (GETC)

Combinations of doxorubicin and streptozocin and 5-FU and dacarbazine were given alternately to 20 patients with metastatic medullary thyroid carcinoma. Three partial responses and 10 long-term stabilizations were observed. No unexpected toxicity occurred.

The statistical analysis of neonatal TSH results from congenital hypothyroidism screening programs provides a useful tool for the characterization of moderate iodine deficiency regions

TSH data from the congenital hypothyroidism screening program were analyzed in a mild to moderate iodine deficiency region. Neonatal TSH levels were measured at day 4-5 of life in 22,384 infants (99% coverage; 51.1% males, 48.9% females). The cut off TSH value for recall was established at 20 microUl/ml whole blood. TSH values > 20 microUl/ml were excluded from further analysis of the data. The frequency distribution analysis showed that the median neonatal TSH level was 2 microUl/ml and the mode (28% of newborns) corresponded to neonatal TSH values < 1 microUl/ml. TSH levels above 5 microUl/ml were observed in 14.4% children and the 97% cut off was 11 microUl/ml. When examined in relation to the areas of newborn origin, the individual 97% cut off values varied from 8 to 14 microUl/ml. Accordingly, the frequency of TSH levels above the 97% cut off value calculated for the entire newborn series (> 11 microUl/ml) ranged from 2.1% to 4.6%. A significant correlation was found between the frequency of neonatal TSH levels > 11 microUl/ml and both goiter prevalence (r2 = 0.88; p = 0.0019) and median urinary iodine excretion (r2 = 0.86; p = 0.0077) observed in those areas for which epidemiological data were available (n = 7). The results indicate that neonatal TSH data from the congenital hypothyroidism screening programs can be used for monitoring mild to moderate iodine deficiency regions.

Characterization of latent transforming growth factor-beta from human seminal plasma

PROBLEM

Human seminal plasma is known to exhibit immunosuppressive activity. Transforming growth factor beta (TGF-beta) has been identified as an immunosuppressive factor in human seminal plasma. Biologically active TGF-beta represents a family of 25-kDa homodimeric proteins linked with disulfide bonds. TGF-beta associates with high molecular weight proteins noncovalently to form a type of latency that is biologically inactive. Quantitative distribution of active form of TGF-beta versus inactive latent form of of TGF-beta, and mechanism of the TGF-beta activation in human seminal plasma remain to be elucidated.

PURPOSE

To characterize seminal plasma latent form of TGF-beta, including its concentration, and the mechanism underlying the activation of TGF-beta.

METHOD

Gel filtrations on ACA-34 and Biogel P-60 were used to fractionate seminal plasma. TGF-beta was measured by enzyme immunoassay using antibodies specific for TGF-beta 1 and TGF-beta 2, respectively. Radioreceptor assay with recombinant human [125I]-TGF-beta 1 was applied to qualitatively identify TGF-beta 1. Kinetic experiments with various pH, temperature and time, along with protease inhibitors, were performed to delineate the activation mechanism of latent TGF-beta 1.

RESULTS

Human seminal plasma contained both TGF-beta 1 and TGF-beta 2, predominantly in latent form. The total concentration of TGF-beta 1 averaged 238 ng/ml versus an average of 18 ng/ml for TGF-beta 2. The in vitro activation or release of TGF-beta 1 from latent TGF-beta 1 was achieved only at acidic pH of < 4.0, and was time and temperature dependent. At pH 3.7 and 37 degrees C, a significant activation of latent TGF-beta 1 was achieved after an incubation of only 15 min, reached the maximum at 120 min, and the activated TGF-beta 1 remained relatively stable for at least 24 h. The activation was not inhibitable by a series of protease inhibitors examined, alone or in combination (e.g., phenyl-methylsulfonyl fluoride, E-64, pepstatin, leupeptin, ethylenediamine tetraacetic acid). Competitive radioreceptor assay established the functional identity of TGF-beta 1 in human seminal plasma with recombinant human TGF-beta 1.

CONCLUSION

Human seminal plasma TGF-beta is biologically activated from high molecular weight latent TGF-beta by acid pH. The acidic environment of female lower genital tract could represent an in vivo physiological condition for activation of seminal plasma TGF-beta that may immunologically protect the integrity of sperm.

Drug withdrawal symptoms in children after continuous infusions of fentanyl

The purpose of this research was to determine the extent to which critically ill infants exhibited signs and symptoms of narcotic withdrawal after receiving continuous infusions of fentanyl. The convenience sample consisted of 12 pediatric intensive care unit (PICU) patients under 25 months of age who received fentanyl infusions for at least 24 hours. Drug withdrawal symptoms were monitored using the Neonatal Abstinence Score Tool (NAST), which assigns a score to each behavior indicative of withdrawal. A score of 8 or greater indicates Neonatal Abstinence Syndrome (NAS). Scoring began 4 hours after discontinuation of fentanyl and was conducted once per hour for 8 hours. Six subjects had a NAST score exceeding 8; these infants frequently exhibited tremors with or without stimulation, increased muscle tone, insomnia, and increased respiratory rate and effort. There were significant correlations between fentanyl dosage and NAST score (r = .76, p < 0.01), between length of infusion of fentanyl and NAST score (r = .70, p < 0.05), and between chloral hydrate dosage and NAST score (r = .62, p < 0.05). These findings suggest the need for an observation protocol and a possible weaning regimen after fentanyl is discontinued.

Transforming growth factor beta as an immunosuppressive protein in human seminal plasma

PROBLEM

Human seminal plasma is known to exhibit immunosuppressive activity in seminal plasma.

PURPOSE

The purpose was to characterize immunosuppressive proteins in seminal plasma.

METHOD

Gel filtration fractions of 100 to > 440 kDa were identified that inhibited DNA synthesis and killing activity of interleukin-2 stimulated lymphocytes.

RESULTS

The fractions exhibiting immunosuppression also inhibited DNA synthesis in a mink lung cell bioassay commonly used to measure the activity for transforming growth factor beta (TGF-beta). The negative growth activity was diminished by a TGF-beta neutralizing monoclonal antibody. TGF-beta was further detected in the active fractions by Western immunoblot.

CONCLUSIONS

These results identified TGF-beta as an immunosuppressive protein in human seminal plasma and may provide insight into the role of immunosuppression played by seminal plasma, such as in reproduction and neoplasia.

Determination of salivary digoxin with a dry strip immunometric assay

Analysis of salivary digoxin using a rapid dry chemistry, enzyme-labeled immunometric assay (ELIA) was compared with fluorescence polarization immunoassay (FPIA). Saliva and serum samples were obtained from 40 hospitalized patients who were taking digoxin chronically and from 8 patients just prior to treatment with digoxin. Unstimulated saliva samples were collected from 20 patients; however, saliva volumes from 10 pediatric patients were inadequate to permit analysis by FPIA, and 1 other had unmeasurable concentrations by both methods. Stimulated saliva was collected by having patients chew a small piece of Parafilm for 1-2 min. Salivary digoxin was analyzed using the same procedure recommended for serum digoxin by each manufacturer. There were no significant differences found between ELIA and FPIA determinations of unstimulated or stimulated salivary digoxin, serum digoxin, or saliva/serum concentration ratios. The saliva/serum ratio of the unstimulated group was approximately twice that of the stimulated group (p less than 0.01) by both methods, suggesting that salivary digoxin concentration decreases with increased saliva production rate. Excellent correlations were found between ELIA and FPIA salivary digoxin concentrations and between stimulated saliva and serum concentrations by both assays. Weaker correlations were observed between unstimulated saliva and serum concentrations. There was no evidence of assay interference with either method in eight nondigitalized patients, each taking an average of 6.5 medications. The ELIA appears to provide equivalent results compared with the FPIA for the determination of salivary digoxin concentration. Further investigations are needed before salivary digoxin concentration monitoring can be recommended as an acceptable alternative to serum monitoring.