Preferences for seafood consumption advice in pregnant American women.

Many women of childbearing age, and pregnant and nursing women in particular, do not consume enough seafood to derive optimal health benefits for themselves and their children. We sought to identify how seafood consumption advice could be designed to encourage pregnant women to eat recommended amounts of seafood. In three focus groups with pregnant or recently pregnant American women, we examined reactions to three aspects of seafood consumption advice. First, we found focus group participants preferred gain-framed statements emphasizing benefits of taking action vs. loss-framed statements emphasizing costs of failing to take action. Many participants indicated the gain-framed statements would encourage them to eat seafood and increase their consumption. Second, we compared responses to a recommendation to eat seafood and a recommendation to eat lower mercury seafood because fear of mercury is a known barrier to seafood consumption by pregnant women. We found no clear preference in our focus groups for either message, suggesting potential value of both messages in communication. Lastly, we examined preferences for systems of categorizing seafood into different consumption categories where the number of categories and the number of species listed in each category varied. We found shorter, dichotomous lists of species to eat and avoid were preferred by some participants for their clarity and ease of use. Longer, more comprehensive lists with additional species and consumption categories (e.g., eat once a week), however, were preferred by many participants because they provided more options and were more likely to be used as a reference. These findings suggest using a layered approach to communication might be helpful by providing short, dichotomous lists of best seafood to eat and seafood to be avoided followed by a link to a longer, more complete list of recommended seafood to be eaten and seafood that should be avoided.

Estimated exposure to mercury from fish consumption among women anglers of childbearing age in the Great Lakes region.

Women of childbearing age (WCBA) are advised by state, tribal, and federal agencies to limit their consumption of certain fish, in part, because of concerns about the ingestion of methylmercury and its impact on the development of fetuses. We studied the fish-eating habits of WCBA who had a fishing license and lived near the Great Lakes, where mercury in locally-caught fish is a concern, as these women were likely at greater risk of elevated mercury exposure than the general population. We used a web-based diary method to gather fish consumption data from WCBA anglers over a 4-month period in the summer of 2014. We estimated mercury intake based on reported mercury content of species consumed, frequency of consumption, and meal portion size, and calculated percent exceeding the USEPA reference dose (RfD). Based on these calculations, we estimated that study participants (n = 1395) ingested 0.031 ±â€¯0.002 (95% CI) ug/kg/d of methylmercury (arithmetic mean). We also found that 3.4% of study participants exceeded the RfD when we averaged estimated intake over the 4-month study period. While most (82%) of the fish meals WCBA anglers ate were purchased fish meals generally low in mercury, study participants ingested a disproportionate amount of mercury from locally-caught fish meals (18% of meals contributed 37% of mercury intake). We estimated 11% of WCBA anglers who did not follow state and federal guidelines in effect at the time of our study exceeded the mercury RfD, whereas fewer than 1% of WCBA anglers who followed the guidelines exceeded the RfD. These findings highlight the importance of encouraging WCBA to follow guidelines from agencies for locally-caught fish, in combination with guidelines for purchased fish.

Effects of a Personal Narrative in Messages Designed to Promote Healthy Fish Consumption Among Women of Childbearing Age.

Women of childbearing age (WCBA) can attain health benefits of fish consumption while minimizing risks by following state and federal fish consumption guidelines, but many women avoid fish out of concerns about mercury exposure. This study tested the impact of brochures, informed by communication theory and research, to promote healthy fish consumption among licensed female anglers. We conducted a randomized, two-wave longitudinal experiment between May 2014 and September 2015 among 1,135 women ages 18-48 years (at baseline), drawn from a sample of licensed anglers in the Great Lakes region of the United States. We randomly assigned women to one of five groups, to either be sent one of four brochures in spring 2015 using a two (including a short personal narrative or not) by two (using certain or uncertain language) factorial design, or to a no-exposure control arm. Participants reported their fish consumption in summer 2014 and summer 2015 via an online diary. Exposure to brochure versions that included a short personal narrative helped move women whose baseline levels of fish consumption were furthest from federal recommendations closer to these guidelines; effects were clearest among women confirmed, by self-report or web tracking, to have seen the brochure. Narratives hold promise as a strategy to communicate effectively about the benefits of healthy fish consumption and risks of overconsumption among WCBA, but widespread dissemination may be necessary to achieve these effects.

Simply delivered meals: a tale of collaboration.

Western medicine is undergoing a transition toward transparency of quality and costs, and healthcare systems are striving to achieve the Triple Aim, a framework for improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare. Meanwhile, there is growing recognition of the impact of social determinants of health and a new federal requirement for nonprofit hospitals to implement prevention strategies. A specialized meal delivery program called Simply Delivered for ME (SDM) was formed in an effort to improve care and reduce 30-day hospital readmission rates.The Maine Medical Center (MMC) partnered with the Southern Maine Agency on Aging to offer SDM on a voluntary basis to high-risk Medicare patients already enrolled in the Community-based Care Transition Program (CCTP) at MMC. We report the results of the 2-year intervention in terms of 30-day hospital readmission rates and cost measures (ie, return on investment and cost savings).Of the 622 MMC patients who received SDM during the 24 months, the 30-day readmission rate was 10.3% (compared with the 16.6% 30-day rate of hospital readmission at baseline [ie, before the adoption of CCTP]) for all-cause readmissions. The cost savings for reduced readmissions were $212,160. The return on investment was 387%, or a benefit-cost ratio of $3.87 for every $1.00 spent on meals. Programs such as SDM may reduce the rate of hospital readmission among high-risk older adults and, thereby, yield lower healthcare costs.

Effects of an Advisory Brochure on Fish Consumption of Urban Anglers in the Great Lakes Region.

Past research has suggested that urban anglers are a group at high risk of being exposed to contaminants from fish consumption. Fish consumption advisories have been used in many regions to encourage healthy fish-eating behaviors, but few studies have been designed to assess whether these advisories actually influence behavior as intended. We conducted a large-scale, randomized experiment to test the influence of an advisory brochure on urban anglers' fish consumption. We collected detailed information on anglers' fish consumption in three urban counties in the Great Lakes region in the summers of 2014 and 2015. We provided a treatment group with fish consumption guidelines in an advisory brochure before the summer of 2015 and compared their change in fish consumption to a control group. The brochure led to a reduction in fish consumption for anglers who ate the most fish; these anglers reduced their consumption of high-contaminant purchased fish (by ≥0.2 meals/summer for those in 72nd percentile of fish consumption or above), high-contaminant sport-caught fish (by ≥0.4 meals/summer for those in 87th percentile and above), and low-contaminant sport-caught fish (by ≥0.3 meals/summer by those in 76th percentile and above). The brochure also reduced sport-caught fish consumption among those anglers who exceeded the advisories in 2014 (by 2.0 meals/summer). In addition, the brochure led to small increases in sport-caught fish consumption (0.4-0.6 meals/summer) in urban anglers who ate very little sport-caught fish (≤1 meal/summer).

Using a Web-Based Diary Method to Estimate Risks and Benefits from Fish Consumption.

Accurate estimates of the amount and type of fish people eat are necessary to determine the health benefits and risks of consuming fish, and to assess compliance with fish consumption guidelines issued for fish affected by chemical contaminants. We developed a web-based and mobile-phone-enabled diary methodology to collect detailed fish consumption information for two 16-week periods in the summers of 2014 and 2015. We recruited study participants from two populations living in the Great Lakes region-women of childbearing age (WCBA) and urban residents who had purchased fishing licenses. In this article, we describe the methodology in detail and provide evidence related to participation rates, the representativeness of our sample over time, and both convergent validity and reliability of the data collection methods. Overall, 56% of WCBA and 50% of urban anglers provided complete data across both data collection periods. Among those who provided information at the beginning of Year 2, 97% of both audiences provided information throughout the entire 16-week period. Those who participated throughout the two-year period were slightly older on average (1.9-2.5 years) than other members of our original samples. We conclude that using diaries with web and smartphone technology, combined with incentives and persistent communication, has strong potential for assessing fish consumption in other areas of the country or for situations where the potential risks associated with fish consumption are substantial and the cost can be justified.

The potential impact of aquatic nuisance species on recreational fishing in the Great Lakes and Upper Mississippi and Ohio River Basins.

Concern over the potential transfer of aquatic nuisance species (ANS) between the Great Lakes basin and the Upper Mississippi River basin has motivated calls to re-establish hydrologic separation between the two basins. Accomplishing that goal would require significant expenditures to re-engineer waterways in the Chicago, IL area. These costs should be compared to the potential costs resulting from ANS transfer between the basin, a significant portion of which would be costs to recreational fisheries. In this study, a recreational behavior model is developed for sport anglers in an eight-state region. It models how angler behavior would change in response to potential changes in fishing quality resulting from ANS transfer. The model also calculates the potential loss in net economic value that anglers enjoy from the fishery. The model is estimated based on data on trips taken by anglers (travel cost data) and on angler statements about how they would respond to changes in fishing quality (contingent behavior data). The model shows that the benefit to recreational anglers from re-establishing hydrologic separation exceeds the costs only if the anticipated impacts of ANS transfer on sport fish catch rates are large and widespread.

Urban anglers in the Great Lakes region: Fish consumption patterns, influences, and responses to advisory messages.

The U.S. Environmental Protection Agency and many state advisory programs consider urban anglers at high risk of being exposed to contaminants through fish consumption because the urban poor may be dependent on fish they catch for food and lack access to non-contaminated fishing sites. Past research has supported this characterization of urban anglers, but most studies have been site-specific and limited to subsets of urban anglers. We used a mail survey and focus groups to (a) explore how urban anglers living in the Great Lakes region of the United States differed from rural and suburban anglers and (b) characterize their fishing patterns, fish consumption, factors influencing their fish consumption, and response to fish consumption advisory messages. Although we detected some differences between licensed urban, suburban, and rural anglers, their magnitude was not striking. Lower income urban anglers tended to consume less purchased and sport-caught fish than higher income urban anglers and were not at high risk as a group. Nevertheless, focus group data suggested there may be subpopulations of urban anglers, particularly from immigrant populations, that consume higher amounts of potentially contaminated fish. Although urban anglers in general may not require a special approach for communicating fish consumption advice, subpopulations within this group may be best targeted by using community-based programs to communicate fish consumption advice.

Fish consumption among women anglers of childbearing age in the Great Lakes region.

Fish consumption advisories are issued by the federal government for women of childbearing age (WCBA). These advisories make recommendations about the amount and types of fish that should be consumed to provide the greatest health benefits to women and their children while avoiding risks from chemical contaminants. We used diary methods to study fish consumption patterns of 1395 WCBA in the Great Lakes coastal region who purchased fishing licenses, a group which has significant opportunity to eat larger quantities of fish. Very few members of this group reported exceeding the federal recommendations for total fish consumption (between 3% and 5% depending on assumptions about portion sizes), consumption of canned "white" tuna (0%), or consumption of "do not eat" species (4%). They did report eating more fish on average than recent national study estimates, but they did not report consuming as much fish as is recommended to obtain the greatest health benefits of fish consumption. Only 10-12% of study participants reported eating within the recommended range of 8-12oz. of fish per week, with 84-87% eating less than the recommended amount. Additional efforts are likely needed to encourage WCBA to eat more low-risk fish, even among this group of higher-than-average fish consumers.

Phase 3 pharmacokinetics and safety study of a posaconazole tablet formulation in patients at risk for invasive fungal disease.

BACKGROUND: Antifungal prophylaxis with a new oral tablet formulation of posaconazole may be beneficial to patients at high risk for invasive fungal disease. A two-part (Phase 1B/3) study evaluated posaconazole tablet pharmacokinetics (PK) and safety. METHODS: Patients with neutropenia following chemotherapy for haematological malignancy or recipients of allogeneic HSCT receiving prophylaxis or treatment for graft-versus-host disease received 300 mg posaconazole (as tablets) once daily (twice daily on day 1) for up to 28 days without regard to food intake. Weekly trough PK sampling was performed during therapy, and a subset of patients had sampling on days 1 and 8. Cmin-evaluable subjects received ≥6 days of dosing, and were compliant with specified sampling timepoints. Steady-state PK parameters, safety, clinical failure and survival to day 65 were assessed. ClinicalTrials.gov, NCT01777763; EU Clinical Trials Register, EUDRA-CT 2008-006684-36. RESULTS: Two hundred and ten patients received 300 mg posaconazole (as tablets) once daily. Among Cmin-evaluable subjects (n = 186), steady-state mean Cmin was 1720 ng/mL (range = 210-9140). Steady-state Cmin was ≥700 ng/mL in 90% of subjects with 5% (10 of 186) <500 ng/mL and 5% (10 of 186) 500-700 ng/mL. Six (3%) patients had steady-state Cmin ≥3750 ng/mL. One patient (<1%) had an invasive fungal infection. The most common treatment-related adverse events were nausea (11%) and diarrhoea (8%). There was no increase in adverse event frequency with higher posaconazole exposure. CONCLUSIONS: In patients at high risk for invasive fungal disease, 300 mg posaconazole (as tablets) once daily was well tolerated and demonstrated a safety profile similar to that reported for posaconazole oral suspension: most patients (99%) achieved steady-state pCavg exposures >500 ng/mL and only one patient (<1%) had a pCavg <500 ng/mL.

Using Theory to Identify Beliefs Associated with Intentions to Follow Fish Consumption Advisories Among Anglers Living in the Great Lakes Region.

Fish consumption advisories are issued by states, tribes, and federal agencies to provide guidance to consumers about eating sport-caught fish potentially affected by chemical contaminants. Previous work has found that while anglers report being aware that advisories are available, awareness and use of specific advisory recommendations is low. This study uses the Integrative Model of Behavioral Prediction (IMBP) to identify beliefs with potential to increase intentions to follow fish consumption advisories in Great Lakes states. We conducted a mail survey of 1,712 licensed anglers in seven of eight Great Lakes states (excluding Ohio) to gauge advisory awareness, cognitive factors influencing fish consumption behaviors (informed by the IMBP), and sociodemographic characteristics. Results show that most anglers reported being generally or vaguely aware of fish consumption advisories and try to follow them, but far fewer report being aware of specific advice needed to decide whether or not to consume different types of sport-caught fish. Informed by the IMBP, we also identify several behavioral, normative, and control beliefs that have sufficient room to change, strong associations with intentions to follow the advisories, and potential to be modified if targeted with strategic risk messages. Targeting these beliefs with strategic communication holds potential to increase the proportion of anglers intending to follow fish consumption advisory recommendations in choosing which fish to eat.

How can more women of childbearing age be encouraged to follow fish consumption recommendations?

Several studies show that most women do not consume enough fish during pregnancy (and afterward) to derive the maximum health benefits for themselves and their babies, according to the USDA guidelines. We engaged in a two-part study to better understand what might be done to encourage women of childbearing age to eat healthy fish-a mail survey of women who recently gave birth in Minnesota, Wisconsin, and Pennsylvania, and six focus groups with women of childbearing age living in the Great Lakes region. Similar to other studies, we found that many women changed their behavior and consumed less fish during pregnancy than before. Most women reported receiving information, primarily during pregnancy, about the types of fish and how much fish to eat. As a result, increasing access to information during pregnancy likely would not result in increasing many women's fish consumption. Based on our examination of factors influencing women to try to follow the recommendations, the strongest connection with trying to follow the recommendations was receiving enough information to decide and believing that eating fish was good for the baby. Focus group participants also reported that messages about the specific health benefits of fish consumption for their children were particularly influential. These findings suggest that refining messages through testing might be a valuable approach toward increasing women's consumption of less-contaminated fish.

Phase 1b study of new posaconazole tablet for prevention of invasive fungal infections in high-risk patients with neutropenia.

Posaconazole tablets, a new oral formulation of posaconazole, can be effective when given as antifungal prophylaxis to neutropenic patients at high risk for invasive fungal infection (e.g., those with acute myelogenous leukemia or myelodysplastic syndrome). Such effectiveness might be specifically important to patients with poor oral intake because of nausea, vomiting, or chemotherapy-associated mucositis. This was a prospective, global study in high-risk patients to characterize the pharmacokinetics and safety profile of posaconazole tablets and to identify the dose of posaconazole tablets that would provide exposure within a predefined range of exposures (steady-state average concentration [area under the concentration-time curve/24 h] of ≥500 ng/ml and ≤2,500 ng/ml in >90% of patients). The study evaluated two sequential dosing cohorts: 200 mg posaconazole once daily (n = 20) and 300 mg posaconazole once daily (n = 34) (both cohorts had a twice-daily loading dose on day 1) taken without regard to food intake during the neutropenic period for ≤28 days. The exposure target was reached (day 8) in 15 of 19 (79%) pharmacokinetic-evaluable patients taking 200 mg posaconazole once daily and in 31 of 32 (97%) patients taking 300 mg posaconazole once daily; 300 mg posaconazole once daily achieved the desired exposure target. Posaconazole tablets were generally well tolerated in high-risk neutropenic patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT01777763.).

The risk manager's contribution to patient safety and risk management in the ambulatory or physician practice setting.

The landscape of healthcare delivery in the United States is quickly changing. Hospitals and health systems are acquiring physician practices at a rapid rate. Healthcare risk management professionals may be tasked with additional responsibilities associated with physician practices, some of which may not have necessary policies or processes in place to reduce risk. Risk management professionals from the hospital setting may be required to provide additional guidance to office practices. This article describes basic risk management considerations for those who have responsibilities in these settings.

Economic impacts of zebra mussels on drinking water treatment and electric power generation facilities.

Invasions of nonnative species such as zebra mussels can have both ecological and economic consequences. The economic impacts of zebra mussels have not been examined in detail since the mid-1990s. The purpose of this study was to quantify the annual and cumulative economic impact of zebra mussels on surface water-dependent drinking water treatment and electric power generation facilities (where previous research indicated the greatest impacts). The study time frame was from the first full year after discovery in North America (Lake St. Clair, 1989) to the present (2004); the study area was throughout the mussels' North American range. A mail survey resulted in a response rate of 31% for electric power companies and 41% for drinking water treatment plants. Telephone interviews with a sample of nonrespondents assessed nonresponse bias; only one difference was found and adjusted for. Over one-third (37%) of surveyed facilities reported finding zebra mussels in the facility and almost half (45%) have initiated preventive measures to prevent zebra mussels from entering the facility operations. Almost all surveyed facilities (91%) with zebra mussels have used control or mitigation alternatives to remove or control zebra mussels. We estimated that 36% of surveyed facilities experienced an economic impact. Expanding the sample to the population of the study area, we estimated 267 million dollars (BCa 95% CI = 161 million dollars - 467 million dollars) in total economic costs for electric generation and water treatment facilities through late 2004, since 1989. Annual costs were greater (44,000 dollars/facility) during the early years of zebra mussel infestation than in recent years (30,000 dollars). As a result of this and other factors, early predictions of the ultimate costs of the zebra mussel invasion may have been excessive.