VOC exposures in California early childhood education environments

Little information exists about exposures to volatile organic compounds (VOCs) in early childhood education (ECE) environments. We measured 38 VOCs in single-day air samples collected in 2010-2011 from 34 ECE facilities serving California children and evaluated potential health risks. We also examined unknown peaks in the GC/MS chromatographs for indoor samples and identified 119 of these compounds using mass spectral libraries. VOCs found in cleaning and personal care products had the highest indoor concentrations (d-limonene and decamethylcyclopentasiloxane [D5] medians: 33.1 and 51.4 μg/m³, respectively). If reflective of long-term averages, child exposures to benzene, chloroform, ethylbenzene, and naphthalene exceeded age-adjusted "safe harbor levels" based on California's Proposition 65 guidelines (10^-5 lifetime cancer risk) in 71%, 38%, 56%, and 97% of facilities, respectively. For VOCs without health benchmarks, we used information from toxicological databases and quantitative structure-activity relationship models to assess potential health concerns and identified 12 VOCs that warrant additional evaluation, including a number of terpenes and fragrance compounds. While VOC levels in ECE facilities resemble those in school and home environments, mitigation strategies are warranted to reduce exposures. More research is needed to identify sources and health risks of many VOCs and to support outreach to improve air quality in ECE facilities.

Evaluation of ozone emissions and exposures from consumer products and home appliances

Ground-level ozone can cause serious adverse health effects and environmental impacts. This study measured ozone emissions and impacts on indoor ozone levels and associated exposures from 17 consumer products and home appliances that could emit ozone either intentionally or as a by-product of their functions. Nine products were found to emit measurable ozone, one up to 6230 ppb at a distance of 5 cm (2 inches). One use of these products increased room ozone concentrations by levels up to 106 ppb (mean, from an ozone laundry system) and personal exposure concentrations of the user by 12-424 ppb (mean). Multiple cycles of use of one fruit and vegetable washer increased personal exposure concentrations by an average of 2550 ppb, over 28 times higher than the level of the 1-h California Ambient Air Quality Standard for ozone (0.09 ppm). Ozone emission rates ranged from 1.6 mg/h for a refrigerator air purifier to 15.4 mg/h for a fruit and vegetable washer. The use of some products was estimated to contribute up to 87% of total daily exposures to ozone. The results show that the use of some products may result in potential health impacts.

Formaldehyde and acetaldehyde exposure and risk characterization in California early childhood education environments

Little information is available about air quality in early childhood education (ECE) facilities. We collected single-day air samples in 2010-2011 from 40 ECE facilities serving children ≤6 years old in California and applied new methods to evaluate cancer risk in young children. Formaldehyde and acetaldehyde were detected in 100% of samples. The median (max) indoor formaldehyde and acetaldehyde levels (μg/m³ ) were 17.8 (48.8) and 7.5 (23.3), respectively, and were comparable to other California schools and homes. Formaldehyde and acetaldehyde concentrations were inversely associated with air exchange rates (Pearson r = -0.54 and -0.63, respectively; P < 0.001). The buildings and furnishings were generally >5 years old, suggesting other indoor sources. Formaldehyde levels exceeded California 8-h and chronic Reference Exposure Levels (both 9 μg/m³ ) for non-cancer effects in 87.5% of facilities. Acetaldehyde levels exceeded the U.S. EPA Reference Concentration in 30% of facilities. If reflective of long-term averages, estimated exposures would exceed age-adjusted 'safe harbor levels' based on California's Proposition 65 guidelines (10^-5 lifetime cancer risk). Additional research is needed to identify sources of formaldehyde and acetaldehyde and strategies to reduce indoor air levels. The impact of recent California and proposed U.S. EPA regulations to reduce formaldehyde levels in future construction should be assessed.

Increases in ROPS pricing from 2006-2012 and the impact on ROPS demand

In 2006, a social marketing campaign was developed to increase the installation of rollover protective structures (ROPS) on unprotected New York tractors. Using data gathered from the program's hotline, the impact of price increases on farmers' interest in ROPS is examined. Pricing data were obtained for all rigid ROPS kits commercially available in the U.S. since 2006. These data were stratified into two groups of ROPS suppliers: (1) tractor manufacturers that sell ROPS for their own tractors, referred to in this study as original equipment manufacturers (OEMs), and (2) aftermarket (AM) ROPS suppliers. The trend in price increases was contrasted with the change in the consumer price index (CPI), the probability of retrofitting within quintiles of cost was estimated, and the increase in ROPS prices over time was plotted The average price increase for a ROPS kit (excluding shipping and installation) over the six years of the study was 23.3% for OEM versus 60.5% for AM (p < 0.0001). Out-of-pocket expenses held steady for OEM versus a six-year increase of $203 for AM (p = 0.098). The probability of a farmer retrofitting dropped monotonically from 66.9% in the lowest ROPS cost quintile to 23% in the highest. If these trends continue, the proportion of inquiries resulting in a ROPS retrofit will fall below 20% by 2020 for AM ROPS. Based on other trends identified in the literature, it is reasonable to assume that decreases in ROPS installation are likely to affect the tractor owners who are most likely to need these safety devices.

Screening Events to Reduce Farmers' Hazardous Exposures

Dairy farmers may be exposed to high levels of noise and dust. Protections against these hazards exist, but many farmers do not use them. An intervention consisting of hearing and respiratory screenings combined with personalized education was implemented. This study evaluates the impact of this intervention on farmers' self-reported use of personal protective equipment (PPE) and implementation of noise and dust abatement. Participants were screened as to noise (n=209) or dust (n=392) hazards and use of PPE. Following this, they were counseled on PPE use, and identification and reduction of noise or dust hazards. Counselors sought a pledge from the farmers to eliminate hazards and increase PPE use. Farmers were subsequently surveyed and asked whether they had implemented the changes. At baseline, 70% (146/209) of farmers exposed to high levels of noise reported poor use ("sometimes", "rarely", or "never") of hearing protection. Results indicated that two months after intervention, 25.2% (28/111) of these subjects had successfully improved their PPE use. At baseline, 79% (311/392) offarmers reported poor use of respiratory protection, with 27.3% (41/150) showing improvement in PPE use within the same time. Strategies to reduce noise hazards were identified by 92.8% (194/209) of hearing screening attendees; 13.2% (18/136) successfully reduced or removed exposure. These values for dust screening attendees were 98.2% (385/392) and 30.7% (54/176), respectively. Use of this intervention appears to be an effective method for increasing PPE use on the farm. However, it is not effective for reducing noise hazards.

Rollover protection on New York tractors and farmers' readiness for change

Tractor overturns contribute significantly to fatalities in New York State agriculture. On-site inspections a decade ago indicated that approximately 60% of tractors were without effective rollover protection. Our objectives were: to describe the current prevalence and distribution of rollover protective structures (ROPS) on New York farm tractors, to identify characteristics associated with the absence of ROPS, to explore segmenting the New York farm community on readiness for ROPS retrofitting, and to identify demographic characteristics that might assist in this segmenting. A random selection of 644 livestock, dairy, fruit, cash crop, vegetable, and organic farms were contacted for a telephone survey. Of 562 farms (87%) participating, 102 (18.1%) had all tractors equipped with ROPS and 138 (24.6%) had none. A disproportionate number of livestock, cash crop, and organic operations had no ROPS. Rates of ROPS-equipped tractors correlated directly with farm size and annual hours of tractor operation. Older farmers had a lower proportion of ROPS tractors. The presence of a child operator did not affect the proportion of ROPS tractors. After weighting the sample, the total number of non-ROPS tractors in New York is estimated at more than 80,000. In addition to providing key farm demographics, the survey enabled placement of farmers on a "stage of change" continuum related to readiness for retrofitting. Three-quarters of New York farmers are in the "precontemplation" stage of change relative to ROPS retrofitting, and this varies little by size of operation, age of farmer, or the presence of child tractor operators. Stage of change may relate to hours of tractor operation (p = 0.05) and does relate to commodity (p = 0.003) due primarily to the higher proportion of crop farmers in the earliest stage of change. The goal of retrofitting all New York farm tractors with ROPS appears nearly as daunting as it did a decade ago.

Risk Perceptions, Barriers, and Motivators to Tractor ROPS Retrofitting in the New York State Farm Community

The prevalence of tractor rollovers among agricultural workers has made the retrofitting of tractors with rollover protective structures (ROPS) and seat belts a public health priority for agricultural health and safety specialists. To address this concern, the New York Center for Agricultural Medicine and Health (NYCAMH) developed a seven-question survey, designed to assess perceptions of risk as well as potential motivators and barriers to retrofitting. Data from 465 phone surveys were gathered from New York State farmers representing various commodities and farm sizes. Analysis of responses to three qualitative questions contained in the survey indicated that most farmers in New York understand the importance of ROPS but lack the proper motivation to consider retrofitting. It appears that more convenient safety strategies, cost, and age of the tractor compete with a farmer's initiative to retrofit. In addition, survey responses illustrate that although many farmers believe ROPS are important in a general sense, many believe that this safety measure is not necessary for them in particular. Frequent motivators to retrofitting are concerns about safety, although the authors conclude that a more thorough analysis of these "general safety concerns" in qualitative interviews is important.

Estimating farmworker population size in New York State using a minimum labor demand method

Assessment of health needs and services for hand-harvest farmworkers requires reliable population estimates. In New York State, the only publicly available source for these is the Department of Labor (DOL). However, published production data exist that may enable estimation of minimum labor demand (MLD) for hand-harvest labor. Our objective was to develop an estimation process for minimum labor demand (MLD) for hand-harvested crops in NYS and contrast the results with DOL estimates. Four crop strata (below ground, ground, bush/vine, and orchard) were identified. MLD (measured in worker-seasons) was estimated by dividing the total annual harvest hours required for each crop stratum by the total hours worked by one worker in a season for that crop stratum. The MLD estimate of the total number of worker seasons combined for all strata (14,121) was higher than that of the DOL (8,230). Harvest acreage was unavailable for 21% of the 991 county-crop combinations studied; therefore, data were imputed from other sources. Within these strata, the greatest difference was found for ground crops, where the DOL count was 28% of the size of the MLD estimate. DOL and MLD estimates were closest in orchard crops (DOL 109% of MLD). Publicly available data provide a potentially valuable source of informationfor estimation of the MLD. Use of these methods implies that the DOL may substantially underestimate the size of this population. Differences seen between the two methods were sensitive to the crop type. County-level farm surveys to verify MLD estimation factors would enhance the method's accuracy.

The Otsego-Schoharie healthy heart program: prevention of cardiovascular disease in the rural US

OBJECTIVES

To describe a rural, hospital-based public health intervention program and to evaluate its effectiveness in cardiovascular disease (CVD) risk reduction using cross-sectional studies and a panel study.

METHODS

A rural population of 158,000 located in New York state comprised the intervention population. A similar but separate population was used for reference. A multifaceted, multimedia 5-year program provided health promotion and education initiatives to increase physical activity, decrease smoking, improve nutrition, and identify hypercholesterolemia and hypertension. To evaluate the effectiveness of the intervention, surveys were conducted at baseline in 1989 (cross-sectional) and at follow-up in 1994-95 (cross-sectional and panel). For cross-sectional studies, a random sample of adults was obtained using a three-stage cluster design. Self-reported and objective risk factor measurements were obtained. Comparison of pre- to post- changes in intervention versus reference populations was done using 2 x 2 randomized block ANOVA, 2 x 2 mixed ANOVA. and extension of the McNemar test.

RESULTS

Smoking prevalence declined (from 27.9% to 17.6%) in the intervention population. Significant adverse trends were observed for high-density lipoprotein cholesterol and triglycerides. Systolic blood pressure was reduced while diastolic blood pressure remained stable. Body mass index increased significantly in both populations.

CONCLUSIONS

This rural. 5-year CVD community intervention program decreased smoking. The risk reduction may be attributable to tailoring of a multifaceted approach (multiple risk factors, multiple messages, and multiple population subgroups) to a target rural population. The study period was too short to identify changes in CVD morbidity and mortality.

The Norsjö-Cooperstown healthy heart project: a case study combining data from different studies without the use of meta-analysis

OBJECTIVES

This paper aims to develop and describe a method for combining. comparing, and maximizing the statistical power of two longitudinal studies of risk factors for cardiovascular disease that did not have identical data collection methodologies.

METHODS

Subjects from a 1986 cross-sectional study (n = 180) were pair-matched with subjects of corresponding gender and age (+5 years) from a 1990 cross-sectional study. The methodology is described and results are calculated for various measures of cardiovascular risk or risk factors (e.g. cholesterol. Finnish Risk Score).

RESULTS

Box's test of equality and symmetry of covariance matrices gave chi-square values of 223.8 and 710.0 for two cardiovascular risk factors (cholesterol and cardiac risk score, respectively); these values were highly significant (p=0.0001) For the North Karelia Risk Score, repeated measures ANOVA revealed a borderline significant interaction for treatment by time (p=0.054) and a significant interaction for treatment by time by country (p=0.035). These probabilities compared favorably with a randomized blocks model.

CONCLUSIONS

Creation of a synthetic longitudinal control group resulted in a statistically valid ANOVA model that increased the statistical power of the study.

Different outcomes for different interventions with different focus!--A cross-country comparison of community interventions in rural Swedish and US populations

OBJECTIVES

There is a need among healthcare providers to acquire more knowledge about small-scale and low budget community intervention programmes. This paper compares risk factor outcomes in Swedish and US intervention programmes for the prevention of cardiovascular disease (CVD). The aim was to explore how different intervention programme profiles affect outcome.

METHODS

Using a quasi-experimental design, trends in risk factors and estimated CVD risk in two intervention areas (Norsjö. Sweden and Otsego-Schoharie County, New York state) are compared with those in reference areas (Northern Sweden region and Herkimer County, New York state) using serial cross-sectional studies and panel studies.

RESULTS

The programmes were able to achieve significant changes in CVD risk factors that the local communities recognized as major concerns: changing eating habits in the Swedish population and reducing smoking in the US population. For the Swedish cross-sectional follow-up study cholesterol reduction was 12%, compared to 5% in the reference population (p for trend differences <0.000). The significantly higher estimated CVD risk (as assessed by risk scores) at baseline in the intervention population was below that of the Swedish reference population after 5 years of intervention. The Swedish panel study provided the same results. In the US, both the serial cross-sectional and panel studies showed a > 10% decline in smoking prevalence in the intervention population, while it increased slightly in the reference population. When pooling the serial cross-sectional studies the estimated risk reduction (using the Framingham risk equation) was significantly greater in the intervention populations compared to the reference populations.

CONCLUSIONS

The overall pattern of risk reduction is consistent and suggests that the two different models of rural county intervention can contribute to significant risk reduction. The Swedish programme had its greatest effect on reduction of serum cholesterol levels whereas the US programme had its greatest effect on smoking prevention and cessation. These outcomes are consistent with programmatic emphases. Socially less privileged groups in these rural areas benefited as much or more from the interventions as those with greater social resources.

Design issues in the combination of international data from two rural community cardiovascular intervention programs

OBJECTIVES

To compare and contrast two rural cardiovascular community intervention programs (CCIP) in northern Sweden and the US by discussing the methods used to select and combine similar data from two separately designed and implemented CCIP in order to describe and evaluate their effectiveness in reducing cardiovascular risk.

METHODS

Two rural intervention populations and their reference populations were compared. A comparison was made of the intensity and duration of the intervention programs using an overall intervention intensity score. Population-based surveys were conducted at 5-year intervals in both countries. The methods used for data pooling and comparison are described. A description of statistical analyses using a mixed analysis of variance model is provided.

RESULTS

The data were pooled. taking into consideration comparable ages. New variables were created in order to define the relationship between similar data that did not permit direct comparison.

CONCLUSIONS

Combination and comparison of international data from two programs allowed evaluation of community intervention programs that were developed independently for similar communities. The effectiveness of interventions can be compared using such methods.

Predictors of dietary milk fat intake by preschool children

BACKGROUND

High-fat whole milk is the major dietary source of total and saturated fat for young children. Children from low-income families have higher total and saturated fat intakes and their parents have higher rates of cardiovascular disease compared with children from higher income families. We identified factors that predict the use of either high-fat whole milk or low-fat (1% and/or skim) milk by children to facilitate the development of targeted intervention strategies to reduce their dietary fat intakes.

METHODS

Adults (91% mothers) with children > or =1 through <5 years of age, participating in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) at 50 agencies throughout New York State, completed questionnaires.

RESULTS

Most (75%) of the 1,938 children drank whole milk, while only 6.9% consumed exclusively 1% and/or skim milk. The children tended to drink the same type of milk as other family members. In multivariate logistic regression, use of whole milk was associated with younger child age, black race or Hispanic ethnicity, parent/guardian belief that whole milk was healthier for children over 2, and parent/guardian having never tried reduced-fat milks (all P < 0.0001). In contrast, use of 1% and/or skim milk was associated with older child age, female gender, nonblack race, older parent/guardian age, parent/guardian belief that reduced-fat milks were healthier for children over 2, and parent/guardian having tried 1%-fat milk (all P < 0.01).

CONCLUSIONS

Individualized family-based strategies are needed to target specific behaviors and/or health beliefs held by different parent groups. For example, taste testing might be an effective strategy for parents who have never tasted reduced-fat milk. Interventions to overcome cultural barriers to the use of low-fat milk may require changing parental health beliefs, in addition to providing education about the health benefits of low-fat milk.

Underuse of invasive procedures among Medicaid patients with acute myocardial infarction

OBJECTIVES

The purpose of this study was to determine whether underuse of cardiac procedures among Medicaid patients with acute myocardial infarction is explained by or is independent of fundamental differences in age, race, or sex distribution; income, coexistent illness; or location of care.

METHODS

Administrative data from 226 hospitals in New York were examined for 11,579 individuals hospitalized with a primary diagnosis of acute myocardial infarction. Use of various cardiac procedures was compared among Medicaid patients and patients with other forms of insurance.

RESULTS

Medicaid patients were older, were more frequently African American and female, and had lower median household incomes. They also had a higher prevalence of hypertension, diabetes, lung disease, renal disease, and peripheral vascular disease. After adjustment for these and other factors, Medicaid patients were less likely to undergo cardiac catheterization, percutaneous transluminal coronary angioplasty, and any revascularization procedure.

CONCLUSIONS

Factors other than age, race, sex, income, coexistent illness, and location of care account for lower use of invasive procedures among Medicaid patients. The influence of Medicaid insurance on medical practice and process of care deserves investigation.

Socioeconomic status as an independent risk factor for hospital readmission for heart failure

The management of heart failure is characterized by high rates of hospital admission as well as rehospitalization after inpatient treatment of this disorder, whereas skillful medical care may reduce the risk of hospital admission. The purpose of this study was to examine the relation between income (as a measure of socioeconomic status) and the frequency of hospital readmission among a large and diverse group of persons treated for heart failure. We analyzed administrative discharge data from 236 nonfederal acute-care hospitals in New York State, involving 41,776 African-American or Caucasian hospital survivors with International Classification of Diseases, Ninth Revision, Clinical Modification codes for heart failure in the principal diagnosis position between January 1 and December 31, 1995. Household income was derived from postal ZIP codes and census data. We found that patients residing in lower income neighborhoods were more often women or African-Americans, had more comorbid illness, had higher use of Medicaid insurance, and were more often admitted to rural hospitals. There was a stepwise decrease in the crude frequency of readmission from the lowest quartile of income (23.2%) to the highest (20.0%) (p <0.0001 for Mantel-Haenszel chi-square test for trend across all quartiles; p <0.0001 for comparison between quartiles 1 and 4). After adjustment for baseline differences and process of care, income remained a significant predictor, with an increase in the risk of readmission noted in association with lower levels of income (adjusted odds ratio for quartile 1:4 comparison, 1.18; 95% confidence interval, 1.10 to 1.26, p <0.0001). We conclude that lower income patients hospitalized for treatment of heart failure in New York differ from higher income patients in important clinical and demographic comparisons. Even after adjustment for these fundamental differences and other potential confounding factors, lower income is a positive predictor of readmission risk.

Systolic versus diastolic heart failure in community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors

BACKGROUND

Among patients with heart failure, there is controversy about whether there are clinical features and laboratory tests that can differentiate patients who have low ejection fractions from those with normal ejection fractions. The usefulness of angiotensin-converting enzyme (ACE) inhibitors among heart failure patients who have normal left ventricular ejection fractions is also not known.

METHODS

From a registry of 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute-care community hospitals during 1995 and 1997, we identified 1291 who had a quantitative measurement of their left ventricular ejection fraction. Patients were separated into three groups based on ejection fraction: < or =0.39 (n = 741, 57%), 0.40 to 0.49 (n = 238, 18%), and > or =0.50 (n = 312, 24%). In-hospital mortality, prescription of ACE inhibitors at discharge, subsequent rehospitalization, quality of life, and survival were measured; survivors were observed for at least 6 months after hospitalization.

RESULTS

The mean (+/- SD) age of the sample was 75+/-11 years; the majority (55%) of patients were women. In multivariate models, age >75 years, female sex, weight >72.7 kg, and a valvular etiology for heart failure were associated with an increased probability of having an ejection fraction > or =0.50; a prior history of heart failure, an ischemic or idiopathic cause of heart failure, and radiographic cardiomegaly were associated with a lower probability of having an ejection fraction > or =0.50. Total mortality was lower in patients with an ejection fraction > or =0.50 than in those with an ejection fraction < or =0.39 (odds ratio [OR] = 0.69, 95% confidence interval [CI 0.49 to 0.98, P = 0.04). Among hospital survivors with an ejection fraction of 0.40 to 0.49, the 65% who were prescribed ACE inhibitors at discharge had better mean adjusted quality-of-life scores (7.0 versus 6.2, P = 0.02), and lower adjusted mortality (OR = 0.34, 95% CI: 0.17 to 0.70, P = 0.01) during follow-up than those who were not prescribed ACE inhibitors. Among hospital survivors with an ejection fraction > or =0.50, the 45% who were prescribed ACE inhibitors at discharge had better (lower) adjusted New York Heart Association (NYHA) functional class (2.1 versus 2.4, P = 0.04) although there was no significant improvement in survival.

CONCLUSIONS

Among patients treated for heart failure in community hospitals, 42% of those whose ejection fraction was measured had a relatively normal systolic function (ejection fraction > or 0.40). The clinical characteristics and mortality of these patients differed from those in patients with low ejection fractions. Among the patients with ejection fractions > or =0.40, the prescription of ACE inhibitors at discharge was associated favorable effects.

Socioeconomic status is an important determinant of the use of invasive procedures after acute myocardial infarction in New York State

BACKGROUND

Patient and hospital characteristics influence the use of invasive cardiac procedures. Whether socioeconomic status (SES) has an influence that is independent of these other determinants is unclear. The purpose of the present study was to examine the influence of household income as a measure of SES on the use of invasive cardiac procedures among a large group of patients with acute myocardial infarction.

METHODS AND RESULTS

We analyzed administrative discharge data from 231 nonfederal acute care hospitals in New York State that involved 28 698 black or white inpatients with International Classification of Diseases, Ninth Revision, Clinical Modification code 410.XX in the principal diagnosis position between January 1 and December 31, 1995. Household income was derived from postal ZIP codes and census data. The use of cardiac catheterization, PTCA, CABG, and any revascularization procedure was examined across groups stratified by income. Patients who resided in lower-income neighborhoods were more often female or black, had a higher prevalence of coexistent illness, had a higher use of Medicaid insurance, and were less often admitted to urban hospitals or hospitals that provide on-site CABG and PTCA. Crude and adjusted odds ratios for catheterization, PTCA, CABG, and any revascularization procedure were related to income in a graded fashion. After adjustment, patients in the highest quintile of income were 22% more likely to undergo catheterization, 74% more likely to undergo PTCA, 48% more likely to undergo CABG, and 76% more likely to undergo any revascularization procedure than were patients in the lowest quintile. The difference in cardiac catheterization did not fully account for income-based differences in revascularization, because income remained a significant determinant of revascularization after accounting for whether a catheterization was performed. Even among patients treated in hospitals that provide on-site CABG and PTCA, income was a significant determinant of procedures.

CONCLUSIONS

Lower-income patients hospitalized for acute myocardial infarction are more often female or black, have more coexisting illnesses, and are less often admitted to urban hospitals or hospitals that provide CABG and PTCA. Even after adjustment for these and other factors, lower income is a negative predictor of procedure use.

Biomarkers of human colonic cell growth are influenced differently by a history of colonic neoplasia and the consumption of acarbose

The nutritional effects of butyrate on the colonic mucosa and studies of transformed cells suggest that butyrate has anti-colon cancer effects. If butyrate has antineoplastic effects, mucosal growth contrasts between normal subjects and those with a history of colonic neoplasia would parallel changes in growth characteristics caused by butyrate in a colon neoplasia population. To test this hypothesis, rectal biopsies from a survey of colonoscopy patients (n = 50) with and without a history of colonic neoplasia (controls) were compared. Similarly, rectal biopsies were compared from subjects (n = 44) with a colon neoplasia history in an acarbose-placebo crossover trial. Control subjects in the colonoscopy survey had higher bromodeoxyuridine (BrdU) uptake than subjects with a history of neoplasia (P = 0.05). The control subjects also had a higher correlation of BrdU and Ki-67 labeling (P = 0.003). Both findings were paralleled by acarbose use. Acarbose augmented BrdU uptake (P = 0.0001) and improved the correlation of BrdU and Ki-67 labeling (P = 0.013). Acarbose also augmented fecal butyrate (P = 0.0001), which was positively correlated with Ki-67 labeling (P = 0.003). p52 antigen had an earlier pattern of crypt distribution in subjects with a history of colon neoplasia but was not affected by acarbose use. Lewis-Y antigen was expressed earlier in the crypt with acarbose but had similar expression in the colonoscopy survey groups. The use of acarbose to enhance fecal butyrate concentration produced mucosal changes paralleling the findings in control subjects as opposed to those with neoplasia, supporting the concept of an antineoplastic role for butyrate.

The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

PURPOSE

Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.

PATIENTS AND METHODS

This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.

RESULTS

Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.

CONCLUSIONS

The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.

Development and validation of an instrument to assess child dietary fat intake

BACKGROUND

brief dietary assessment instrument to assess dietary intakes of total fat, saturated fatty acids (SFA), and cholesterol in young children was developed and validated.

METHODS

Young children and their parent or primary caretaker were recruited from a general primary care health center and local Head Start programs. Dietary records, entered and analyzed using the Minnesota Nutrition Data System, were used to calculate children's mean dietary intakes. Stepwise linear regression analysis was used to select questionnaire items that best predicted total fat, SFA, and dietary cholesterol intakes.

RESULTS

This yielded a 17-item Child Dietary Fat Questionnaire (CDFQ); 9 questions correlated with total fat intake (r = 0.68, P < 0.0001); 15 questions correlated with SFA intake (r = 0.75, P < 0.0001); and 4 questions correlated with dietary cholesterol intake (r = 0.57, P < 0.0001). The test-retest reliabilities of the CDFQ in predicting children's dietary intakes of total fat, SFA, and cholesterol were 0.41, 0.66, and 0.64, respectively. The criterion-based validity of the CDFQ, evaluated against 4 days of dietary records, yielded correlations of 0.54 (P < 0.0001) for total fat, 0.36 (P < 0.01) for SFA, and 0.55 (P < 0. 0001) for dietary cholesterol intake.

CONCLUSIONS

The 17-item CDFQ is a brief, easy-to-use dietary assessment instrument that could be used to identify children with high, as well as low, dietary intakes of total fat, SFA, and/or cholesterol.

Race-related differences among patients with left ventricular dysfunction: observations from a biracial angiographic cohort. Harlem-Bassett LP(A) Investigators

BACKGROUND

This study was designed to describe race-related differences in left ventricular function among a consecutive series of patients undergoing cardiac catheterization and to identify racial differences in coexistent medical and social conditions that are associated with the development of heart failure (HF).

METHODS AND RESULTS

This was a prospective cohort study conducted at 2 university-affiliated teaching hospitals. We used the database of the Harlem-Bassett Lp(a) Study. We included all black (N = 143) or white (N = 313) patients from the main study database for whom complete survey, laboratory, coronary angiographic, and ventriculographic data were available. "Left ventricular dysfunction" was arbitrarily defined as an ejection fraction < or =0.40 or prior pharmacologic treatment for HF. We found that blacks were younger, had a higher proportion of women, and had fewer years of formal education than their white counterparts. Coronary artery disease was less common among blacks, although this group had a higher prevalence of hypertension, diabetes, cigarette smoking, illicit drug use, and alcohol consumption. Black patients had a higher prevalence of previous treatment for HF, larger left ventricular volumes, and lower ejection fractions than white patients. Blacks with left ventricular dysfunction were more likely to have had a previous myocardial infarction or a history of hypertension compared with those without left ventricular dysfunction.

CONCLUSIONS

Regarding left ventricular dysfunction and HF, we conclude that blacks seem to have a much higher burden of disease than whites. Our observations support prior evidence that hypertension is linked to race-related differences in the epidemiology of HF. The interaction between race and access to quality care for HF remains an important area for future investigation.

Differences between patients with heart failure treated by cardiologists, internists, family physicians, and other physicians: analysis of a large, statewide database

BACKGROUND

The management of heart failure (HF) by cardiologists may be better than that of other physicians in that cardiologists' treatment choices more frequently conform with published guidelines and the results of clinical trials. Whether cardiologists' management of HF is more or less cost-effective is up for debate.

METHODS

Information on all 1995 New York state hospital discharges assigned ICD-9-CM codes indicative of HF in the principal diagnosis position was obtained. Demographic and clinical characteristics, process of care, resource utilization, and short-term HF-related outcomes were compared between patients of cardiologists and patients of other physicians.

RESULTS

A total of 44,926 patients were identified, with 10,506 (23%) receiving care from cardiologists, 28,300 (63%) from internists, 4812 (11%) from family practitioners, and 1308 (3%) from other physicians. Patients of cardiologists were younger, more frequently male, and less frequently residents of nursing homes. They were more likely to have associated cardiovascular diagnoses but less likely to have comorbid general medical conditions. Patients of cardiologists were more likely to undergo cardiac catheterization (9%) than those of internists (3%) and family practice (2%) physicians but had similar adjusted hospital length of stay and charges. Mortality and hospital readmission rates for HF were similar among the groups. Patients in the "other" group (managed mostly by surgeons) were the youngest, underwent more invasive and cardiac surgical procedures, and had the longest length of stay and highest hospital charges.

CONCLUSIONS

Cardiologists' management of HF is not economically disadvantageous. The relations among physician specialty, process of care, resource utilization, and clinical outcomes require further study before rational and evidence-based health care staffing recommendations can be formulated.

Clinical outcomes in heart failure: report from a community hospital-based registry

PURPOSE

Most of the recent information on the prognosis of patients with heart failure has come from large clinical trials or tertiary care centers. This study reports current information from a community hospital-based heart failure registry.

SUBJECTS AND METHODS

We compiled data from 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute care community hospitals in New York State between 1995 and 1997. Patients were followed prospectively for 6 months after hospital discharge or until their death.

RESULTS

The mean (+/- SI)) age of the sample was 76 +/- 11 years. The majority of the patients were women (56%) and most were white (95%). Hospital length of stay averaged 7.4 +/- 7.6 days; hospital charges averaged $7,460 +/- $6,114. Mortality during the index admission was 5%. Among the 2,508 patients for whom mortality or follow-up data were available, an additional 411 died during follow-up, for a cumulative 6-month mortality of 23%. Progressive pump failure was the predominant cause of death in the hospital and after discharge. Although mean functional class (on a 1 to 4 scale) improved from 3.4 +/- 0.7 at hospital admission to 2.3 +/- 0.9 at 1 month after discharge, 43% of patients had at least one hospital readmission during follow-up and 25% had at least one recurrent admission for heart failure. The mean time from index discharge to first rehospitalization was 60 +/- 56 days. In all, 55% of patients (1,370 of 2,508) were rehospitalized or died during the study period.

CONCLUSIONS

Despite advances in the management of heart failure, patients recently hospitalized for this disorder remain at high risk of death, hospital readmission, and poor clinical outcome. Discovery or implementation of new or existing methods of prevention and treatment remain a high priority.

Ozone emissions from a "personal air purifier"

Ozone emissions were measured above a "personal air purifier" (PAP) designed to be worn on a lapel, shirt pocket, or neck strap. The device is being marketed as a negative ion generator that purifies the air. However, it also produces ozone within the person's immediate breathing zone. In order to assess worst-case potential human exposure to ozone at the mouth and nose, we measured ozone concentrations in separate tests at 1, 3, 5, and 6 in. above each of two PAPs in a closed office. One PAP was new, and one had been used slightly for 3 months. Temperature, relative humidity, atmospheric pressure, room ozone concentration, and outdoor ozone concentration also were measured concurrently during the tests. Average ozone levels measured directly above the individual PAPs ranged from 65-71 ppb at 6 in. above the device to 268-389 ppb at 1 in. above the device. Ozone emission rates from the PAPs were estimated to be 1.7-1.9 microg/minute. When house dust was sprinkled on the top grid of the PAPs, one showed an initial peak of 522 ppb ozone at 1 in., and then returned to the 200-400 ppb range. Room ozone levels increased by only 0-5 ppb during the tests. Even when two PAPs were left operating over a weekend, room ozone levels did not noticeably increase beyond background room ozone levels. These results indicate that this "PAP," even without significant background ozone, can potentially elevate the user's exposures to ozone levels greater than the health-based air quality standards for outdoor air in California (0.09 ppm, 1-hour average) and the United States (0.08 ppm, 8-hour average).

Cardiology or primary care for heart failure in the community setting: process of care and clinical outcomes

STUDY OBJECTIVES

Severity of illness, treatment choices, and clinical outcomes may vary with physician training. This study was performed to determine whether such differences exist among patients with congestive heart failure (CHF) treated by cardiologists and by noncardiologists in the community hospital setting.

DESIGN

Prospective cohort study.

SETTING

Ten acute-care community hospitals. PATIENTS, MEASUREMENTS, AND RESULTS: Two thousand four hundred fifty-four patients with CHF were identified and followed up for 6 months after hospital discharge. Patients who were not treated by a cardiologist (group I; n = 977) were compared with patients whose attending physician was a cardiologist (group II; n = 419) and patients who received consultative care from a cardiologist (group III; n = 1,058). When compared with group I patients, group II patients were more likely to receive the recommended diagnostic tests and treatment strategies, although some of these differences could be explained by variations in the case mix. Group II patients had higher hospital charges, but lower CHF readmission rates and better postdischarge quality-of-life measures. No differences in adjusted mortality rates were observed.

CONCLUSIONS

In the community-hospital setting, the clinical practices of cardiologists are more compatible with published treatment guidelines than the clinical practices of other physicians. The benefits of cardiology specialty care include lower CHF readmission rates and better postdischarge quality-of-life measures, rather than lower mortality rates, fewer hospital charges, or shorter length of stay.

Longitudinal changes in dehydroepiandrosterone concentrations in men and women

Dehydroepiandrosterone, an adrenal steroid, has many purported roles in the body and has been used as an oral supplement in the treatment of various illnesses. Because little is known about normal changes over time in dehydroepiandrosterone concentrations, we studied the 5-year change in plasma dehydroepiandrosterone concentrations in 614 free-living adults. Two hundred seventy-three males and 341 females had dehydroepiandrosterone and dehydroepiandrosterone sulfate concentrations measured in 1989 and 1994. Demographic data were also obtained. Dehydroepiandrosterone concentrations differed significantly by sex and 5-year age group. The average decline in dehydroepiandrosterone was 5.6%/year, and the rate of decline was directly related to age but not to sex, measures of adiposity, or serum glucose. Dehydroepiandrosterone sulfate concentrations differed significantly by sex and age group. The average decline in the sulfated hormone was 2.0%/year and was not related to age, sex, measures of adiposity, or serum glucose. Knowledge of the natural course of age-related changes in dehydroepiandrosterone and dehydroepiandrosterone sulfate concentrations is essential to our understanding of the relationship of dehydroepiandrosterone to chronic diseases.

Association between diuretic use, clinical response, and death in acute heart failure

Because the impact of diuretic use on mortality in acute congestive heart failure (CHF) is not known, we examined the association between drug use, fluid balance, and death among 1,150 patients hospitalized for evaluation and treatment of CHF. After adjusting for other relevant intergroup differences, we observed that less net weight loss and a greater number of intravenous drug doses retained significant predictive value for death, suggesting that more frequent diuretic dosing or diuretic resistance may be related to mortality in acute CHF.

Randomised controlled trial of psychological debriefing for victims of acute burn trauma

BACKGROUND

Psychological debriefing (PD) is widely used following major traumatic events in an attempt to reduce psychological sequelae.

METHOD

One hundred and thirty-three adult burn trauma victims entered the study. After initial questionnaire completion, participants were randomly allocated to an individual/couple PD group or a control group who received no intervention; 110 (83%) were interviewed by an assessor blind to PD status three and 13 months later.

RESULTS

Sixteen (26%) of the PD group had PTSD at 13-month follow-up, compared with four (9%) of the control group. The PD group had higher initial questionnaire scores and more severe dimensions of burn trauma than the control group, both of which were associated with a poorer outcome.

CONCLUSION

This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives.

Acarbose enhances human colonic butyrate production

Earlier studies suggest that butyrate has colonic differentiating and nutritional effects and that acarbose increases butyrate production. To determine the effects of acarbose on colonic fermentation, subjects were given 50-200 mg acarbose or placebo (cornstarch), three times per day, with meals in a double-blind crossover study. Fecal concentrations of starch and starch-fermenting bacteria were measured and fecal fermentation products determined after incubation of fecal suspensions with and without added substrate for 6 and 24 h. Substrate additions were cornstarch, cornstarch plus acarbose and potato starch. Dietary starch consumption was similar during acarbose and placebo treatment periods, but fecal starch concentrations were found to be significantly greater with acarbose treatment. Ratios of starch-fermenting to total anaerobic bacteria were also significantly greater with acarbose treatment. Butyrate in feces, measured either as concentration or as percentage of total short-chain fatty acids, was significantly greater with acarbose treatment than with placebo treatment. Butyrate ranged from 22.3 to 27.5 mol/100 mol for the 50-200 mg, three times per day doses of acarbose compared with 18.3-19.3 mol/100 mol for the comparable placebo periods. The propionate in fecal total short-chain fatty acids was significantly less with acarbose treatment (10.7-12.1 mol/100 mol) than with placebo treatment (13.7-14.2 mol/100 mol). Butyrate production was significantly greater in fermentations in samples collected during acarbose treatment, whereas production of acetate and propionate was significantly less. Fermentation decreased when acarbose was added directly to cornstarch fermentations. Acarbose effectively augmented colonic butyrate production by several mechanisms; it reduced starch absorption, expanded concentrations of starch-fermenting and butyrate-producing bacteria and inhibited starch use by acetate- and propionate-producing bacteria.

Eating attitudes and the irritable bowel syndrome

A series of 48 new patients with irritable bowel syndrome (IBS) were asked to complete an Eating Attitudes Test. The same test was given to a series of 32 patients attending an Eating Disorder clinic, a series of 31 patients attending a gastroenterology outpatient clinic with a diagnosis of inflammatory bowel disease (IBD), and to a group of 28 'normal' controls. The results showed that there was no significant difference between the IBD group and control groups for EAT score. The EAT score for the group with eating disorders was significantly higher than for all other groups. The EAT score for the IBS group was greater than those for the IBD and control group (p = 0.05) when all four groups were compared using analysis of variance and the Least Significant Difference test.

Farm tractors, and the use of seat belts and roll-over protective structures

Roll-over protective structures (ROPS) on farm tractors could significantly reduce the rate of fatal occupational injury on farms, but comparatively few tractors have them. Many of the policy discussions have focused on trying to identify the percentage of tractors that do not have ROPS, even though such a focus probably does not accurately represent effective protection by ROPS. This study investigates whether including differences in hours of usage, tractor activities, and seat belt use affects estimates of farm operators' protection by ROPS. In general, tractors used more hours a year were more likely to have ROPS. ROPS status also varied by tractor activity. When adjusting for seat belt use, effective ROPS protection is much less than when considering just ROPS status. Measures of the effective coverage of ROPS and policy responses should reflect these differences in hours, activities, and seat belt use.

Dietary guar gum alters colonic microbial fermentation in azoxymethane-treated rats

To assess the effects of guar gum on colonic microbial fermentation and cancer development, azoxymethane-treated rats were fed a partially hydrolyzed guar or control diet. Anaerobic fecal incubations were conducted at 8-wk intervals, either without added substrate or with cornstarch or hydrolyzed guar as substrates. Short-chain fatty acids in colonic contents and colonic carcinoma areas were measured at 27 wk. Fecal in vitro fermentation rates were higher for guar-fed rats than for control rats [three-way ANOVA (diet, time, in vitro substrates), P = 0.002]. Fecal in vitro butyrate production was greater for guar-fed rats than for control rats after 3-11 weeks of diet treatment (three-way ANOVA, P = 0.027). Butyrate concentrations of colonic contents at 27 wk were higher in guar-fed than in control rats and higher in the cecum than in the post-cecal colon (two-way ANOVA, P = 0.0001). A regression equation predicting colonic carcinoma area (r2 = 0.279) using propionate and butyrate concentrations of the contents of the post-cecal colon showed propionate as a positive predictor (P < 0.001) and butyrate as a negative predictor (P = 0.033). Our results show that patterns of short-chain fatty acid production may affect the results of fiber-carcinogenesis experiments. Dietary addition of hydrolyzed guar is associated with fecal fermentation low in propionate and high in butyrate; short-chain fatty acid concentrations are greater proximally than distally. These results suggest that butyrate protects against colonic neoplasia, whereas propionate enhances it, and demonstrate that colonic microbiota adapt to produce more butyrate if given time and the proper substrate.

Psychosocial morbidity and survival in adult bone marrow transplant recipients--a follow-up study

Previous reports have suggested that the presence of depression and other psychosocial variables may be associated with a poorer prognosis post bone marrow transplantation. Fifty-six patients had both unstructured clinical interviews and interviews using a structured diagnostic instrument (the Composite International Diagnostic Interview) and were followed up a mean of 82.1 months post-BMT. Of these, 42 patients were also interviewed using the Mental Attitude to Cancer Scale. Survival analysis revealed that factors such as depression or the presence of fighting spirit as the predominant coping style did not correlate with length of survival. Our results imply that survival may be more closely related to physical rather than psychosocial factors.

Nonsteroidal antiinflammatory drugs are associated with gastric outlet obstruction

Nonsteroidal antiinflammatory drug associated gastric ulcerations are often prepyloric and painless; when recurrent, such ulcers may lead to pyloric scarring and gastric outlet obstruction. We performed a retrospective case control study to seek an association between gastric outlet obstruction and nonsteroidal antiinflammatory drug use. The use of nonsteroidal antiinflammatory drugs in cases with gastric outlet obstruction was compared to an age- and sex-matched outpatient control group undergoing endoscopy. The proportion of drug use by patients with gastric outlet obstruction, seven of nine, was significantly higher than the proportion in controls, 29 of 90. The duration of nonsteroidal antiinflammatory drug use was also significantly longer in patients with gastric outlet obstruction than in control patients. Chronic nonsteroidal antiinflammatory drug use is associated with gastric outlet obstruction.

Steroid injection versus conservative treatment of anisometropia amblyopia in juvenile adnexal hemangioma

Because of serious side effects, the indications for intralesional steroid injection of adnexal hemangiomas are unclear. Of 23 children with such lesions who were examined over a period of 9 years, 9 had no evidence of amblyopia and needed no intervention. Five required steroids intralesionally and/or systemically because of threatened occlusion of the pupillary axis. The remaining 9 were considered at risk of anisometropic amblyopia because of induced astigmatism: 5 received injections and 4 were treated with glasses and/or patching alone. The visual, refractive, and cosmetic results of the injected and conservatively managed anisometropes were similar. We recommend that steroid injection be reserved for patients with threatened occlusion of the visual axis and for those with severe astigmatism or amblyopia refractory to conservative management.

Irritable bowel syndrome and family history of psychiatric disorder: a preliminary study

A series of 70 consecutive patients with irritable bowel syndrome (IBS) were interviewed concerning their family history of psychiatric disorders. A series of 60 consecutive patients with major depression (MDE) were also interviewed, as were a control group of 46 relatives of patients with organic brain disease. The results showed that both IBS and MDE groups had a similar, higher prevalence of relatives with psychiatric illness than controls, and that this was due to a higher prevalence of anxiety and depressive disorder in the relatives. The implications of these findings are discussed.

Challenges to implementing the current pediatric cholesterol screening guidelines into practice

OBJECTIVE

The Expert Panel on Blood Cholesterol Levels in Children and Adolescents of the National Cholesterol Education Program (NCEP) recommends selective screening of children for high blood cholesterol. We determined the number of children, who, according to the guidelines, should be targeted for cholesterol screening.

DESIGN

Population survey.

SETTING

Permanent household residents in Otsego County, NY.

PARTICIPANTS

Total population-based sample of 17,444 households (86.6% response rate) including 44,565 participants, of whom 10,457 were children, aged 2 through 19 years.

MAIN OUTCOME MEASURES

Percent of children qualifying for cholesterol screening under the NCEP Children's Panel guidelines.

RESULTS

Children from two-parent families were more likely to have known family history of coronary heart disease (CHD) before 60 years of age (41.8% vs 25.8%, P < .001), and twice as likely as children from single-parent families to have known parental hypercholesterolemia (18.8% vs 9.5%, P < .001). Only 39% of parents reported having had their cholesterol level checked; they were better educated and more likely to have health insurance. Parents with a first-degree relative with CHD before 60 years of age were more likely to report having their cholesterol level checked and to report a high cholesterol level. We calculated that 27% of children (18% of children from single-parent households and 29% of children from two-parent households) would report a known family history of premature CHD (ie, CHD before 55 years of age) and qualify for lipoprotein analysis, and that 11% of children would qualify for total cholesterol screening because of known parental hypercholesterolemia without a family history of premature CHD. Thirty-five percent of children had incomplete or unavailable family health history and/or unknown parental cholesterol status.

CONCLUSIONS

In this population, 38% of children would be targeted for cholesterol screening, exceeding the estimate of the NCEP Children and Adolescents Panel. The selection process, however, would tend to miss children from single-parent families, children with incomplete family health history, and children whose parents have not had their cholesterol levels measured. The currently recommended pediatric cholesterol screening policy needs to be evaluated further in additional communities and population settings. Alternative cholesterol screening strategies are needed when family health history is incomplete and/or parental cholesterol status is unknown.

A prospective study of psychosocial morbidity in adult bone marrow transplant recipients

Forty recipients of bone marrow transplantation were recruited prospectively and assessed pretransplant, at 1 month postdischarge, and at 6 months postdischarge between 1989 and 1990. Assessments included a psychiatric interview, a variety of standardized questionnaires (Hospital Anxiety and Depression Scale, Mental Attitude to Cancer Scale, Psychosocial Adjustment to Illness Scale), and a standardized diagnostic interview. The influence of factors such as depression and anxiety upon length of stay, survival, psychosocial adjustment, and negative prognostic attitudes were examined. In contrast to other studies, little influence was found for psychiatric illness on physical outcome variables, but they did affect psychosocial outcome. The implications of these findings are discussed.

Dairy barns and roll-over protection on farm tractors: work environment impacts on the adoption of roll-over protective structures

A mailed survey of one group of dairy farmers supports the informal perception that roll-over protective structure (ROPS)-equipped tractors are considered unusable for in-barn tasks. This attitude must be addressed in order to achieve greater use of safety equipment.