Use of a public telephone hotline to detect urban plague cases.

Current methods for vector-borne disease surveillance are limited by time and cost. To avoid human infections from emerging zoonotic diseases, it is important that the United States develop cost-effective surveillance systems for these diseases. This study examines the methodology used in the surveillance of a plague epizootic involving tree squirrels (Sciurus niger) in Denver Colorado, during the summer of 2007. A call-in centre for the public to report dead squirrels was used to direct animal carcass sampling. Staff used these reports to collect squirrel carcasses for the analysis of Yersinia pestis infection. This sampling protocol was analysed at the census tract level using Poisson regression to determine the relationship between higher call volumes in a census tract and the risk of a carcass in that tract testing positive for plague. Over-sampling owing to call volume-directed collection was accounted for by including the number of animals collected as the denominator in the model. The risk of finding an additional plague-positive animal increased as the call volume per census tract increased. The risk in the census tracts with >3 calls a month was significantly higher than that with three or less calls in a month. For tracts with 4-5 calls, the relative risk (RR) of an additional plague-positive carcass was 10.08 (95% CI 5.46-18.61); for tracts with 6-8 calls, the RR = 5.20 (2.93-9.20); for tracts with 9-11 calls, the RR = 12.80 (5.85-28.03) and tracts with >11 calls had RR = 35.41 (18.60-67.40). Overall, the call-in centre directed sampling increased the probability of locating plague-infected carcasses in the known Denver epizootic. Further studies are needed to determine the effectiveness of this methodology at monitoring large-scale zoonotic disease occurrence in the absence of a recognized epizootic.

Diagnostic capabilities of fractal dimension and mandibular cortical width to identify men and women with decreased bone mineral density.

UNLABELLED: Dental panoramic radiographs could be used to screen for osteopenia. We found the fractal dimension to be a good discriminator of osteopenia in both men and women but that the mandibular cortical width (MCW) did not perform as well in men. The fractal dimension may be a valid screening tool. INTRODUCTION: The aim of this study was to assess the diagnostic capability of the fractal dimension and MCW measured from dental panoramic radiographs in identifying men and women with decreased bone mineral density (BMD). METHODS: The MCW and fractal dimension were measured from dental panoramic radiographs as surrogates for BMD. These measures were then compared to the results from dual-energy X-ray absorptiometry (DXA) performed for clinical purposes. A total of 56 subjects with the panoramic radiograph taken within 6 months of the DXA exam were used in the analysis for this study. RESULTS: The area under the curve of the fractal dimension for identifying low BMD (T-score <-1.0) was 0.81 (0.67, 0.95) and 0.78 (0.49, 1.00) for men and women, respectively. For the MCW, the area under the curve was found to be 0.53 (0.34, 0.72) and 0.80 (0.58, 1.00) for men and women, respectively. CONCLUSIONS: In this largely male study population, the fractal dimension was found to be a good discriminator of low BMD in both men and women. The MCW did not perform as well in men.

Childhood growth and age at diagnosis with Type 1 diabetes in Colorado young people.

OBJECTIVE: Studies have suggested that the age at diagnosis of Type 1 diabetes (T1D) is decreasing over time. The overload hypothesis postulates that risk factors, such as accelerated growth, may be responsible for this decrease. We assessed changes in age, body mass index (BMI), weight and height at diagnosis with T1D in non-Hispanic white (NHW) and Hispanic (HISP) young people from Colorado, using data from the IDDM Registry and SEARCH Study. METHODS: In three time periods, 656 (1978-1983), 562 (1984-1988) and 712 (2002-2004) young people aged 2-17 years were newly diagnosed with T1D. Age, weight, height and presence of diabetic ketoacidosis (DKA) at diagnosis with T1D were obtained from medical records. Trends over the three time periods were assessed with regression analyses. RESULTS: Age at diagnosis decreased by 9.6 months over time (P = 0.0002). Mean BMI standard deviation score (SDS), weight SDS and height SDS increased over time (P < 0.0001), while prevalence of DKA decreased (P < 0.0001). Increasing height over time accounted for 15% (P = 0.04) of the decreasing age at diagnosis with T1D. CONCLUSIONS: Our study provides evidence that increased linear growth, but not increased BMI or weight over time, may account, at least in part, for the younger age at diagnosis of T1D in Colorado children. This finding supports the hypothesis that increasing environmental pressure resulting from changes in potentially preventable risk factors may accelerate the onset of T1D in children.

A new method to assess fetal head descent in labor with transperineal ultrasound.

OBJECTIVES: To assess the feasibility and reproducibility of measuring fetal head station and descent during labor using transperineal ultrasound (TPU) imaging, to compare the evaluation of fetal station through digital examinations with concurrent TPU assessments, and to assess its utility in distinguishing patients whose pregnancy will result in spontaneous vaginal delivery from those who will require operative vaginal delivery or Cesarean section for failure to progress. METHODS: TPU and digital examinations were performed in 88 term laboring patients with a singleton fetus in cephalic presentation. Using TPU imaging, head descent was quantified by measuring the angle between the long axis of the pubic symphysis and a line extending from its most inferior portion tangentially to the fetal skull. Intraobserver and interobserver variability were calculated using variance component analysis. TPU imaging was used to measure the angle of head descent during the second stage of labor in 23 of the women. RESULTS: Analysis of replicated measurements on 75 subjects, by the same observer at approximately the same time, yielded an average SD (intraobserver variability) of approximately 2.9 degrees for the measurement of angle of head descent on TPU examination. A separate variance component analysis on a subset of 15 assessments for which measurements were repeated by a second observer, with two to four replicate measurements obtained by each, yielded an interobserver error estimate of 1.24 degrees. A significant linear association was found between clinical digital assessments and measurement of angle of head descent by TPU examination (P < 0.001). An angle of at least 120 degrees measured during the second stage of labor was always associated with subsequent spontaneous vaginal delivery. In six pregnancies ending in Cesarean section the mean angle of descent measured at last TPU examination was only 108 degrees. CONCLUSIONS: The angle of head descent measured by TPU imaging provides an objective, accurate and reproducible means for assessing descent of the fetal head during labor.

Anatomic relationship between the pubic symphysis and ischial spines and its clinical significance in the assessment of fetal head engagement and station during labor.

OBJECTIVE: To develop a geometric model from computed tomographic (CT) images in non-pregnant women that would objectively reflect clinical head station in laboring patients, against which to test the accuracy of digital examinations. METHOD: CT scans were performed in 70 non-pregnant women to determine, using a geometric model, which angle in a mid-sagittal transperineal ultrasound (TPU) image best coincided with the mid-point of a line drawn between the ischial spines (zero station). Using a geometric algorithm, TPU angles were then assigned for other clinical stations (-5 to + 5). Finally, clinical station was assessed by digital examination and simultaneous TPU assessments in 88 laboring patients to see how closely the clinical examination correlated with the station calculated from the above geometric model. RESULTS: The mean angle between the long axis of the symphysis pubis and the mid-point of the line connecting the two ischial spines for the 70 non-pregnant subjects was 99 degrees . The geometric model developed allowed us to build an algorithm to assign a specific set of theoretical angles to each computed station. Relationships between digitally assessed fetal head station, TPU angle for each station, and the geometrical model created with CT data, are reported. Clinical digital assessment of station correlated poorly with computed station, especially at stations below zero, where it could have greater clinical impact. CONCLUSION: The TPU angle of 99 degrees correlated with zero station, and each station above or below this station could be assigned a specific corresponding angle for reference.

The WeeFIM [R] instrument--a paediatric measure of functional independence to predict longitudinal recovery of paediatric burn patients.

INTRODUCTION: Burns create a myriad of complications that affect the child's developmental, functional and aesthetic status. The WeeFIM is a standardized measure of functional performance developed for use in children 6-months to 8-years of age but with application through adolescence. It includes 18 domains of performance which are scored on a 7-point scale from 'total assistance' to 'complete independence'. In this study, the WeeFIM was used to evaluate the influence of burn size on functional independence and on time to recovery. METHODS: Children, 6 months to 16 years of age, with total body surface area (TBSA) bums of 10-100% burn injury were recruited for a 2-year longitudinal study. Due to unstable WeeFIM measurements on children 6 months to 6 years, analyses on normalized WeeFIM scores among subjects 6-16 years are presented. Children were evaluated at discharge from acute care, 6 months, 1 year and 2 years after burn injury. FINDINGS: In this analysis, 454 WeeFIM evaluations from 249 patients, 6-16 years of age, were reviewed. While mean WeeFIM scores varied significantly at discharge based on the size of burn, there were no significant differences in any of the WeeFIM scales at 24 months post-burn. At 24 months, the mean WeeFIM score for all children, independent of size of their bum, indicated full independence. Hands-on assistance was not required for performing activities of daily living (ADLs). The rates of improvement differed statistically by size of bum. Maximum improvement was attained by 6 months for 10-15% TBSA burns, 12 months for 16-30% burns, 12 months for 31-50% burns and 24 months for 51-100% TBSA. CONCLUSION: The WeeFIM can be utilized by burn centres to describe diminished functional capacity at discharge from acute care for severely burnt children. The tool can be used to track return to baseline independence after a major burn injury in a paediatric population.

Impairment after burns: a two-center, prospective report.

Impairment rating is regularly reported for trauma and other conditions but rarely for burns. The purposes of this study were: (1) to report impairment collected prospectively at our burn center, (2) to relate this impairment to measures of psychosocial and functional outcome, and (3) to compare these data to similar data from another burn center to verify that rating impairment is standardized and that the impairments are similar. We studied 139 patients from the University of Washington (UW) Burn Center and 100 patients from the University of Texas (UT) Southwestern Burn Center. The average whole person impairment (WPI) ratings at the University of Washington were 17% and this correlated with total body surface area burned and days off work. It did not correlate with Brief Symptom Inventory (BSI), Functional Independence Measure (FIM), Short-Form 36-Item Health Survey (SF-36), Satisfaction With Life Scale (SWLS), and the Community Integration Questionnaire (CIQ). Average whole person impairment ratings at UT Southwestern were similar at 19%. Several components of the impairment rating, however, differed at the two institutions. To minimize this variation, we recommend: (1) use the skin impairment definitions of the fifth edition of the Guides to the Evaluation of Permanent Impairment (or the most recent published versions of the Guide), and (2) include sensory impairment in healed burns and skin grafts in the skin impairment.

Management practices among primary care physicians and thyroid specialists in the care of hypothyroid patients.

Prospective studies are not available to address various issues commonly encountered in the management of hypothyroid patients. We have conducted a case-based mail survey of American Thyroid Association (ATA) members and primary care providers (PCP) regarding hypothyroidism management issues. A majority of ATA members and a minority of PCPs used antithyroid antibody testing in the evaluation of hypothyroidism. Approximately 2/3 of all respondents indicated that they would treat patients with mild thyroid failure when antithyroid antibodies are negative; 77% of PCPs and 95% of ATA members recommended treatment when antibodies are positive. For a young patient with mild thyroid failure, 71% of ATA members would initiate a full levothyroxine (LT4) replacement dose of 1.6 microg/kg per day or slightly lower; PCPs were more likely to start with a low dose and titrate upwards. For a young patient with overt hypothyroidism, 42% of PCPs and 51% of ATA respondents recommended an initial full LT4 replacement dose. The majority of all respondents would start with a low LT4 dose and adjust the dose gradually in an elderly patient, regardless of the severity of thyroid hormone deficiency. More than 40% of ATA respondents chose a target thyrotropin (TSH) range of 0.5-2.0 microU/mL for a young patient while 39% favored a goal of 1.0-4.0 microU/mL for an elderly patient. PCPs more often chose a broader TSH goal of 0.5-5.0 microU/mL. In conclusion, the current practice patterns of PCPs and ATA members that were elicited in this survey differ significantly in regard to the evaluation and management of hypothyroidism.

Time off work and return to work rates after burns: systematic review of the literature and a large two-center series.

The literature on time off work and return to work after burns is incomplete. This study addresses this and includes a systematic literature review and two-center series. The literature was searched from 1966 through October 2000. Two-center data were collected on 363 adults employed outside of the home at injury. Data on employment, general demographics, and burn demographics were collected. The literature search found only 10 manuscripts with objective data, with a mean time off work of 10 weeks and %TBSA as the most important predictor of time off work. The mean time off work for those who returned to work by 24 months was 17 weeks and correlated with %TBSA. The probability of returning to work was reduced by a psychiatric history and extremity burns and was inversely related to %TBSA. In the two-center study, 66% and 90% of survivors had returned to work at 6 and 24 months post-burn. However, in the University of Washington subset of the data, only 37% had returned to the same job with the same employer without accommodations at 24 months, indicating that job disruption is considerable. The impact of burns on work is significant.

Motor vehicle crash fatalities: A comparison of Hispanic and non-Hispanic motorists in Colorado.

STUDY OBJECTIVES: We compare the population-based death rates from traffic crashes in the Hispanic and non-Hispanic white populations in a single state, and compare fatally injured Hispanic and non-Hispanic drivers with respect to safety belt use, alcohol involvement, speeding, vehicle age, valid licensure, and urban-rural location. METHODS: Hispanic and non-Hispanic white motorists killed in traffic crashes in 1991-1995 were studied (n=2,272). Data from death certificates (age, sex, education, race, and ethnicity) and the Fatality Analysis Reporting System (FARS; driver, vehicle, and crash information) were merged. Average annual age-adjusted fatality rates were calculated; to compare Hispanic and non-Hispanic white motorists, rate ratios (RR) and 95% confidence intervals (CIs) were calculated. Odds ratios (ORs), adjusted for age, sex, and rural locale, were calculated to measure the association between Hispanic ethnicity and driver and crash characteristics. RESULTS: Eighty-five percent of FARS records were matched to death certificates. Compared with non-Hispanic white motorists, Hispanics had higher crash-related fatality rates overall (RR 1.75, 95% CI 1.60 to 1.92) and for drivers only (RR 1.62, 95% CI 1.41 to 1.85). After adjustment for age, sex, and rural locale, Hispanic drivers had higher rates of safety belt nonuse (OR 1.81, 95% CI 1.20 to 2.72), legal alcohol intoxication (OR 2.73, 95% CI 1.97 to 3.79), speeding (OR 1.36, 95% CI 0.99 to 1.88), and invalid licensure (OR 2.58, 95% CI 1.78 to 3.75). The average vehicle age for Hispanic drivers (10.1 years, 95% CI 9.3 to 11.0) was greater than for non-Hispanic white motorists (8.8 years, 95% CI 8.4 to 9.2). CONCLUSION: Compared with non-Hispanic whites, Hispanic drivers have higher rates of safety belt nonuse, speeding, invalid licensure and alcohol involvement, with correspondingly higher rates of death in traffic crashes. As traffic safety emerges as a public health priority in Hispanic communities, these data may help in developing appropriate and culturally sensitive interventions.

Optimal gestational age and birth-weight cutoffs to predict neonatal morbidity.

BACKGROUND: Gestational age (GA) and birth weight (BW) criteria are used to identify newborns at risk for neonatal morbidity. Currently, preterm is GA less than 37 weeks; low birth weight is BW less than 2,500 grams; and small for gestational age (SGA) is BW less than the tenth percentile weight for the infant's GA. The optimal classification system balances the misclassification cost of false negatives against the cost of false positives. OBJECTIVE: To calculate the relative misclassification costs implied by the current 37-week and 2,500-gram cutoffs, and to test the validity of the current definition of SGA as a predictor of term morbidities. METHODS: GA, BW, and morbidity information were collected for 22,606 infants born between July 1981 and December 1992. Using this dataset, logistic regression coefficients were obtained modeling GA or BW as predictors of morbidities associated with prematurity. For a subset of 18,813 infants with GAs between 37 and 41 weeks, coefficients were obtained modeling both GA and BW as independent predictors of term morbidities. The logistic regression coefficients were used to calculate optimal birth weight, gestational age, and birth-weight-for-gestational-age cutoffs. RESULTS: The current definitions of low birth weight and preterm imply that it is 18 to 28 times more costly to misclassify a sick infant as low-risk than to misclassify a well infant as high-risk. CONCLUSIONS: Gestational age alone is better than birth weight alone at predicting preterm morbidities. No birth-weight cutoff can adequately predict term morbidities. A single weight-percentile cutoff for all gestational ages should not be used to identify newborns at high risk for neonatal morbidity.

Surgical management of uncomplicated otitis media in a pediatric Medicaid population.

The objective of this study was to document the frequency and timing of otitis media-related visits, audiological consultations, and surgical interventions following a new episode of otitis media. A retrospective descriptive study was performed on a Medicaid administrative database that follows individual patients over time. The study included 14,453 children enrolled in Medicaid during 1991 and 1992 who were 30 months of age or younger and had a "new" episode of otitis media. Among 14,321 patients with an uncomplicated episode of otitis media, there were 10,443 with additional otitis media visits. Audiological testing was performed in 1,134 (10.9%). The testing occurred within 2 months of the onset of otitis media in 52.2% of the children and within 3 months in 66.6%. Physicians referred 400 children (3.8%) to an otolaryngologist; 299 (75%) underwent 1 or more surgical procedures. These surgical interventions included placement of ventilating tubes in 296 children, adenoidectomy in 34 children (all of whom also had placement of ventilating tubes), mastoidectomy in 2 children, and tympanoplasty in 1 child. The proportion of children who underwent surgical placement of ventilating tubes who had prior audiological testing was 174 of 296 (58.8%). The overall surgical rate for ventilating tubes was 2.9%. Among children who underwent surgery, the procedure occurred within 2 months of the onset of otitis media in 21.4% of children. Attempts to rationalize the management of otitis media in early childhood must deal with the difficulties in distinguishing among the otitis media conditions. The findings of this study suggest a need to know whether insertions of ventilating tubes within 3 months after a new episode of otitis media are related to unresponsive or recurrent infections.

Direct expenditures related to otitis media diagnoses: extrapolations from a pediatric medicaid cohort.

BACKGROUND: Treatment of otitis media in children is associated with substantial expenditures because of its high frequency during childhood. Vaccines against respiratory pathogens causing otitis media are now being developed. Information about otitis media-related medical expenditures will be needed to determine the cost-effectiveness of these preventive interventions. METHODS: This study used utilization data from claims to impute otitis media-related expenditures for medical visits, pharmaceuticals, and surgical procedures for 87 057 children 13 years of age and younger who were continuously enrolled in Colorado's fee-for-service Medicaid program during 1992. International Classification of Disease, Ninth Revision diagnostic codes were used to identify visits for otitis media. An antibiotic was considered to have been prescribed to treat otitis media if it was dispensed up to 24 hours before or within 48 hours after a physician encounter showing a diagnosis of otitis media. All tympanostomies, mastoidectomies, and adenoidectomies were assumed to be related to otitis media. Expenditures were imputed from utilization using a Medicaid fee schedule. National expenditures for 1992 to treat otitis media were extrapolated from Colorado's Medicaid data. We adjusted for differences between Colorado and the United States as a whole in terms of price, number, and intensity of services; for differences in reimbursement rates by service between Medicaid and private insurance; and for differences in utilization between Medicaid enrollees and the uninsured. To provide a more current expression of medical expenditures for otitis media, we inflated the 1992 expenditure estimates to 1998 dollars using the Consumer Price Index published by the US Bureau of Labor Statistics. RESULTS: Twenty-eight percent of children experienced at least 1 episode of diagnosed otitis media. The proportion of children with a diagnosis of otitis media was highest (42%-60%) in the 7-month to 36-month age range. The proportion was also higher among white (34.5%) and Hispanic (25.3%) children than among black children (18.5%), as well as among rural (34.5%) compared with urban children (27.2%). Children 19 to 24 months of age incurred the highest total annual expenditures per child with otitis media ($239.68). Expenditures for drugs, visits, and procedures were all highest for this group. The per-patient cost to Medicaid was greater for visits than for drugs or procedures across all age groups. Total per-patient expenditures were higher for males ($174.67) than for females ($154.47) and higher for white children ($176.59) than for Hispanic ($154.12) or black children ($134.44). The differences among the ethnic groups can be attributed almost entirely to differences in expenditures for procedures and drugs. Although mean expenditures per patient varied substantially by some patient characteristics (eg, race), these differences accounted for only a small fraction of the enormous variation in costs per patient. Including children with and without otitis media, age-specific estimated expenditures per child peaked among children 1 ($132.94) and 2 years of age ($88.72). Children 3 to 6 years of age incurred expenditures only one third as great as those incurred by children 1 year of age. Total national expenditures were estimated to have been approximately $4.1 billion in 1992 dollars and $5.3 billion in 1998 dollars. Over 40% of national expenditures to treat otitis media in children younger than 14 years of age were incurred for children between 1 and 3 years of age ($453 per capita in 1992 dollars over these 2 years vs $1027 for all years of age from 2 to 13). Nationally, expenditures for visits remained the largest component of expenditures. LIMITATIONS: This study assessed expenditures from the point of view of the health care system; that is, no social costs, such as lost work time, or expenditures not normally covered by insurance, such as those for transportation, we

Analysis of construction injury burden by type of work.

BACKGROUND: To lay groundwork for identifying patterns of injury etiology, we sought to describe injury experience associated with types of work performed at construction sites by examining workers' compensation (WC) claims for the 32,081 construction workers who built Denver International Airport (DIA). METHODS: Injury rates and WC payment rates were calculated for 25 types of work based on claims and payroll data reported to DIA's owner-controlled insurance program according to National Council on Compensation Insurance job classifications. By linking DIA claims with corresponding lost-work-time (LWT) claims filed with Colorado's Workers' Compensation Division, we were also able to obtain and examine both total and median lost days for each type of work. RESULTS: Injury experience varied widely among the types of construction work. Workers building elevators and conduits and installing glass, metal, or steel were at particularly high risk of both LWT and non-LWT injury. Median days lost by injured workers was highest (202 days) for driving/trucking. Median days lost for most types of work was much greater than previously reported for construction: 40 days or more for 18 of the 25 types of work analyzed. WC payment rates reflect both number and severity of injuries and were generally not significantly different from expected losses. They were, however, significantly higher than expected for driving/trucking, metal/steel installation, inspection/analysis, and elevator construction. CONCLUSIONS: Analysis of injury data by type of work allows targeting of safety resources to high risk construction work and would be useful in prospective surveillance at large construction sites with centrally administered workers' compensation plans.

Individual and community risks of measles and pertussis associated with personal exemptions to immunization.

CONTEXT: The risk of vaccine-preventable diseases among children who have philosophical and religious exemptions from immunization has been understudied. OBJECTIVES: To evaluate whether personal exemption from immunization is associated with risk of measles and pertussis at individual and community levels. DESIGN, SETTING, AND PARTICIPANTS: Population-based, retrospective cohort study using data collected on standardized forms regarding all reported measles and pertussis cases among children aged 3 to 18 years in Colorado during 1987-1998. MAIN OUTCOME MEASURES: Relative risk of measles and pertussis among exemptors and vaccinated children; association between incidence rates among vaccinated children and frequency of exemptors in Colorado counties; association between school outbreaks and frequency of exemptors in schools; and risk associated with exposure to an exemptor in measles outbreaks. RESULTS: Exemptors were 22.2 times (95% confidence interval [CI], 15.9-31.1) more likely to acquire measles and 5.9 times (95% CI, 4.2-8.2) more likely to acquire pertussis than vaccinated children. After adjusting for confounders, the frequency of exemptors in a county was associated with the incidence rate of measles (relative risk [RR], 1.6; 95% CI, 1.0-2.4) and pertussis (RR, 1.9; 95% CI, 1.7-2.1) in vaccinated children. Schools with pertussis outbreaks had more exemptors (mean, 4.3% of students) than schools without outbreaks (1. 5% of students; P =.001). At least 11% of vaccinated children in measles outbreaks acquired infection through contact with an exemptor. CONCLUSIONS: The risk of measles and pertussis is elevated in personal exemptors. Public health personnel should recognize the potential effect of exemptors in outbreaks in their communities, and parents should be made aware of the risks involved in not vaccinating their children.

The influence of having an assigned Medicaid primary care physician on utilization of otitis media-related services.

OBJECTIVE: This study documents the influence of having an assigned Medicaid primary care physician (PCP) on the utilization of otitis media-related services. DESIGN/METHODS: This is a retrospective study using the 1991 Colorado Medicaid administrative database that followed 28 844 children <13 years who had at least 1 visit for otitis media. RESULTS: Children continuously enrolled in Medicaid throughout the entire year were >4 times (odds ratio: 4.2 and 4.89, respectively) as likely to always or sometimes have a PCP compared with children who were discontinuously enrolled. The likelihood of ever using the emergency department for an otitis media-related visit was increased by 26% and 50%, respectively, when a child sometimes or never had a PCP compared with always having a PCP. The likelihood of ever filling an antibiotic for otitis media was reduced by 23% and 34%, respectively, when a child sometimes or never had a PCP compared with always having a PCP. The likelihood of ever having otitis media-related surgery was not affected by PCP status, but young children, 13 to 18 months of age, had higher referral rates when they had an assigned PCP. CONCLUSIONS: These findings suggest that having an assigned Medicaid PCP influences the utilization patterns of some otitis media-related medical services.

Contractor safety practices and injury rates in construction of the Denver International Airport.

BACKGROUND: We sought to explain the variation in injury rates found for categories of companies and contracts involved in the construction of the Denver International Airport (DIA) by surveying contractors about company and contract-level safety practices. METHODS: We conducted 213 telephone interviews (83% response) with representatives of contracts with payrolls of more than $250,000. We investigated the bivariate relationship between safety actions reported in the survey and injury occurrence by calculating the aggregate injury rates (lost work-time (LWT) rates and non-LWT rates) for the group of respondent contracts reporting always taking the action and for the group not always taking the action. Using Poisson regression, we examined the association between contract injury rates and contract safety practices while controlling for variables previously shown to affect contract-level injury rates. RESULTS: In Poisson regression, two actions, 1) disciplinary action always resulting when safety rules were violated and 2) always considering experience modification ratings when selecting subcontractors, were associated with lower LWT injury rates. Three actions or contract characteristics resulted in lower non-LWT rates: management always establishing goals for safety for supervisors, conducting drug testing at times other than badging or after an accident, and completing the DIA contract on budget, rather than over budget. Reportedly consistent use of a number of accepted safety practices was associated with significantly higher injury rates in bivariate and multivariate analyses. CONCLUSIONS: The pattern of counterintuitive results found in this study suggests that questions reflecting agreed-upon safety practices, when asked of the person responsible for all on-site construction activities, are likely to elicit normative responses. Objective validation of reported safety practices is critical to evaluating their efficacy in reducing injury rates, along with measures of both time at risk and outcome and control for prevailing risk of the work performed.

Comparison of health status, socioeconomic characteristics, and knowledge and use of HIV-related resources between HIV-infected women and men.

OBJECTIVES: The authors compared socioeconomic characteristics, and knowledge and use of human immunodeficiency virus (HIV)-related resources and health status measures between HIV-infected women and men registered within the Denver Health and Hospitals health care system. METHODS: Data collected through two Centers for Disease Control-funded surveillance initiatives (Adult Spectrum of Disease and Supplement to HIV/AIDS Surveillance) were linked. Health status measures were obtained using the Medical Outcomes Study (MOS-20) questionnaire. To compare health status measures between genders, men were matched to women based on disease stage, intravenous drug use, race, years of education, employment status, and age. RESULTS: Among all patients interviewed (n = 419), women (n = 52) were more likely to be minority, uneducated, intravenous drug users, and at earlier stages of HIV-disease than men (n = 367). Employment status was not significantly different. Knowledge of available services was generally good among both genders. Women received public assistance and had health insurance (Medicaid) more often than men. Women used support services, social work, and shelter assistance less often than men. The matched pairs analysis (n = 46 pairs) showed no significant differences between genders in physical and social function, mental health, pain, or general health perceptions; however, role function was better in women than in men (P<0.02). CONCLUSIONS: When controlling for factors that may influence health and access to health care, HIV disease generally impacts the health status of both genders similarly. Women scored higher in role function which may reflect family caretakers' responsibilities. Although knowledge of HIV-related resources was similar by gender, men made contact more often suggesting areas for enhanced outreach toward women.

Multiple organ failure can be predicted as early as 12 hours after injury.

BACKGROUND: The failure of therapies aimed at modulating systemic inflammatory response syndrome and decreasing multiple organ failure (MOF) has been attributed in part to the inability to identify early the population at risk. Our objective, therefore, was to develop predictive models for MOF at admission and at 12, 24 and 48 hours after injury. METHODS: Logistic regression models were derived in a data set with 411 adult trauma patients using indicators of tissue injury, shock, host factors, and the Acute Physiology Score-Acute Physiology and Chronic Health Evaluation III (APS-APACHE III). RESULTS: MOF was diagnosed in 78 patients (19%). Injury Severity Score, platelet count, and age emerged as predictors in all models. Transfused blood, inotropes, and lactate were significant predictors at 12, 24, and 48 hours, but not at admission. The APS-APACHE III emerged only in the 0- to 48-hour model and offered minimal improvement in predictive power. Good predictive power was achieved at 12 hours after injury. CONCLUSION: Postinjury MOF can be predicted as early as 12 hours after injury. The APS-APACHE III added little to the predictive power of tissue injury, shock and host factors.