Living will status and desire for living will help among rural Alabama veterans.

The purpose of this secondary analysis of data from an earlier intervention study to increase Veterans Administration health care enrollment in rural Alabama veterans was to determine the veterans' living will status, desire for help completing a living will, and relationships between these and demographic, health insurance, health self-report, cumulative illness, disability, and trust characteristics. Baseline data for 201 rural Alabama veterans were extracted from the larger study. Chi-square and t tests were used to analyze group differences in categorical and continuous variables. Logistic regression models were used to determine multivariate associations of variables with living will status and desire for help. Only 13% of participants had living wills. Of those without living wills, 40% expressed a desire for help completing a living will. African Americans were less likely to have living wills than were Caucasians. Participants with more than high school education were more likely to desire help completing living wills than were those with less education. With the exception of moderate-severe respiratory illness, moderate-severe illness was not associated with having a living will. With the exception of moderate-severe vascular illness, moderate-severe illness was not associated with desire for help completing a living will. The racial and educational disparities in living will status and desire for help and the number of participants who desired help completing a living will suggests a need for action to increase advance care planning among rural veterans.

Alabama Veterans Rural Health Initiative: a pilot study of enhanced community outreach in rural areas.

PURPOSE: Access, enrollment, and engagement with primary and specialty health care services present significant challenges for rural populations worldwide. The Alabama Veterans Rural Health Initiative evaluated an innovative outreach intervention combining motivational interviewing, patient navigation, and health services education to promote utilization of the United States Veterans Administration Healthcare System (VA) by veterans who live in rural locations. METHODS: Community outreach workers completed the intervention and assessment, enrolling veterans from 31 counties in a southern state. A total 203 participants were randomized to either an enhanced enrollment and engagement outreach condition (EEE, n = 101) or an administrative outreach (AO, n = 102) condition. FINDINGS: EEE participants enrolled and attended VA appointments at higher rates and within fewer days than those who received AO. Eighty-seven percent of EEE veterans attended an appointment within 6 months, compared to 58% of AO veterans (P < .0001). The median time to first appointment was 12 days for the EEE group and 98 days for the AO group (P < .0001). Additionally, a race by outreach group interaction emerged: black and white individuals benefited equally from the EEE intervention; however, black individuals who received AO took significantly longer to attend appointments than their white counterparts. CONCLUSIONS: Results provide needed empirical support for a specific outreach intervention that speeds enrollment and engagement for rural individuals in VA services. Planned interventions to improve service utilization should ameliorate ambivalence about accessing health care in addition to addressing traditional systems or environmental-level barriers.

Outcomes of root canal treatment in dental PBRN practices.

This study sought to quantify the incidence of root canal treatment (RCT) failure and identify its predictors in root canals that were performed or referred by general dentistry practices in a practice-based research network (PBRN). This retrospective cohort study involved 174 endodontically treated teeth. Mean duration from initial therapy to follow-up was 8.6 years. Permanent restorations were ultimately placed in 89% of teeth, although 18% of teeth were ultimately extracted anyway. Receiving a permanent restoration was a significant predictor of treatment failure (in other words, patients who did not receive a permanent restoration were more likely to experience RCT failure), whether failure was determined clinically or radiographically. This study of PBRN practices suggests a higher failure rate compared with studies that utilized highly controlled environments or populations with high levels of dental insurance.

Computed tomography attenuation and patient characteristics as predictors of complications after pancreaticoduodenectomy.

OBJECTIVES: Morbidity after pancreaticoduodenectomy (PD) remains high. Computed tomography (CT) of intra-abdominal tissue has not been thoroughly evaluated to establish associations with the occurrence of complications after PD. The current study sought to determine whether differences in non-enhanced visceral attenuation predicted complications after PD. METHODS: Outcomes in patients undergoing PD were analysed according to the Clavien system for classifying complications and the International Study Group on Pancreatic Fistula system for classifying postoperative pancreatic fistula (POPF). Preoperative non-enhanced CT scans were evaluated by a blinded investigator for attenuation of abdominal viscera and fat thickness. Data on pancreatic firmness and pancreatic duct size were collected. Univariate and multivariate analyses were performed. RESULTS: A total of 134 patients underwent PD for malignant and benign disease. Rates of morbidity, mortality and POPF at 90 days were 61%, 4% and 23%, respectively. Patients with a body mass index of > 25 kg/m(2) had higher rates of POPF (P = 0.05) and complications (P < 0.01). In multivariate analysis, patients were more likely to develop any complication as CT attenuation decreased for paraspinus muscle (P < 0.01), spleen (P < 0.03) and liver (P = 0.01) parenchyma. CONCLUSIONS: Postoperative complications after PD remain prevalent. Decreased CT attenuation of abdominal viscera is an independent predictor of morbidity after PD and suggests a high-risk patient physiology for pancreatic resection.

Should pancreatectomy with islet cell autotransplantation in patients with chronic alcoholic pancreatitis be abandoned?

BACKGROUND: Pancreatectomy or drainage has been advocated for pain due to chronic pancreatitis. Islet cell autotransplantation (IAT) may improve quality of life (QOL); optimal patient selection has not been established. STUDY DESIGN: Outcomes of 100 patients who underwent pancreatectomy with islet isolation between 2005 and 2012 were assessed by etiology (alcoholic pancreatitis [AP] 30%, and nonalcoholic pancreatitis [NAP] 70%). Insulin requirement, Short Form-36, and McGill Pain Questionnaires were assessed. Data were analyzed using SASv9.2. RESULTS: Of the 100 patients, isolation was unsuccessful in 9 patients due to fibrosis. Alcoholic pancreatitis was associated with 7 of 9 failed isolations (23% vs 3%, p < 0.01), and all of these patients are now diabetic. Ninety-one patients (age 44 years, follow-up 19 months, 23% AP) underwent resection with IAT. Total islet yield (islet cell equivalents [IEQ]) and IEQ/kg body weight were less for patients with AP (81,000 vs 150,000, p < 0.01; 1,260 vs 2,190, respectively, p = 0.01) overall and more specifically, for total pancreatectomy (92,000 vs 188,000, respectively, p = 0.02). Twenty-eight (34%) of all patients who had resections and 15% of those undergoing total pancreatectomy are insulin free. Multivariate analysis identified AP as an independent predictor of insulin units/day (p = 0.01). Complete pre- and postoperative QOL and pain surveys were available on 69 patients. Patients with AP had less QOL improvement (1 of 8 vs 5 of 8 domains, p < 0.01) and "present pain" improvement at 2 years from preoperative levels in those with NAP; no improvement in QOL was seen in those with AP (NAP 2.7 to 1.2, p < 0.01; AP 2.7 to 2.2, p > 0.05). CONCLUSIONS: After pancreatic resection with planned IAT, AP resulted in failed isolations, lower yields, higher insulin requirements, poor long-term QOL improvement, and no improvement in pain scores compared with NAP. Further studies should define criteria for resection and IAT for patients with alcoholic chronic pancreatitis.

Spiritually based intervention to increase colorectal cancer screening among African Americans: screening and theory-based outcomes from a randomized trial.

Colorectal cancer screening has clear benefits in terms of mortality reduction; however, it is still underutilized and especially among medically underserved populations, including African Americans, who also suffer a disproportionate colorectal cancer burden. This study consisted of a theory-driven (health belief model) spiritually based intervention aimed at increasing screening among African Americans through a community health advisor-led educational series in 16 churches. Using a randomized design, churches were assigned to receive either the spiritually based intervention or a nonspiritual comparison, which was the same in every way except that it did not contain spiritual/religious content and themes. Trained and certified peer community health advisors in each church led a series of two group educational sessions on colorectal cancer and screening. Study enrollees completed a baseline, 1-month, and 12-month follow-up survey at their churches. The interventions had significant pre-post impact on awareness of all four screening modalities, and self-report receipt of fecal occult blood test, flexible sigmoidoscopy, and colonoscopy. There were no significant study group differences in study outcomes, with the exception of fecal occult blood test utilization, whereas those in the nonspiritual intervention reported significantly greater pre-post change. Both of these community-engaged, theory-driven, culturally relevant approaches to increasing colorectal cancer awareness and screening appeared to have an impact on study outcomes. Although adding spiritual/religious themes to the intervention was appealing to the audience, it may not result in increased intervention efficacy.

Spiritually based intervention to increase colorectal cancer awareness among african americans: intermediate outcomes from a randomized trial.

Colorectal cancer screening, while effective for reducing mortality, remains underutilized particularly among underserved populations such as African Americans. The present study evaluated a spiritually based approach to increasing Health Belief Model-based pre-screening outcomes in a Community Health Advisor-led intervention conducted in African American churches. Sixteen urban churches were randomized to receive either the spiritually based intervention or a nonspiritual comparison of the same structure and core colorectal cancer content. Trained Community Health Advisors led a series of two educational sessions on colorectal cancer early detection. The educational sessions were delivered over a 1-month period. Participants (N = 316) completed a baseline survey at enrollment and a follow-up survey one month after the first session. Both interventions resulted in significant pre/post increases in knowledge, perceived benefits of screening, and decreases in perceived barriers to screening. Among women, the spiritually based intervention resulted in significantly greater increases in perceived benefits of screening relative to the nonspiritual comparison. This finding was marginal in the sample as a whole. In addition, perceived benefits to screening were associated with behavioral intention for screening. It is concluded that in this population, the spiritually based was generally as effective as the nonspiritual (secular) communication.

Patterns of postoperative pain medication prescribing after invasive dental procedures.

We investigated disparities in the prescription of analgesics following dental procedures that were expected to cause acute postoperative pain. Patients over the age of 19 years who had been treated by surgical and/or endodontic dental procedures were included in this study. We reviewed 900 consecutive charts and abstracted data on procedures, patients, and providers. We used chi-square and logistic regression models for analyses. There were 485 White subjects, 357 African American subjects included in this review; 81% of the African American and 78% of White patients received a postoperative narcotic prescription (p = .56). In multivariate regression models, patients over age 45 (p = .003), those with insurance that covered medication and those with preexisting pain (p = .004) were more likely to receive narcotic analgesics. Students prescribed more narcotics than residents (p = .001). No differences were found by race in prescribing analgesics.

Comparison of root canal preparation using reciprocating Safesiders stainless steel and Vortex nickel-titanium instruments.

OBJECTIVE: The aim of the present study was to assess several parameters related to the clinical usage of 2 root canal preparation instruments: Vortex .06 rotary nickel-titanium instruments, and Safesiders reciprocating stainless steel instruments. STUDY DESIGN: Fifty extracted mandibular molars with mesial root canal curvatures between 20° and 50° were divided into 2 groups and embedded in acrylic resin inside a modified Bramante muffle system. All root canals were prepared to ISO size 40 using either Vortex .06 rotary nickel-titanium-instruments in a low-torque motor or Safesiders stainless steel instruments in a proprietary reciprocating handpiece. The following parameters were evaluated: straightening of curved root canals, working safety issues (perforations, instrument breakages, canal blockages, loss of working length), postpreparation root canal cross-section, and working time. RESULTS: The Vortex .06 instruments maintained canal curvatures well, with the mean degree of straightening recorded as 0.72°. Safesiders instruments demonstrated significantly more canal straightening, with the mean degree of straightening recorded as 15.5°. More than 90% of the root canals prepared with the Vortex .06 instruments resulted in a round or oval cross-section, whereas the Safesiders instruments produced round or oval cross-sections 60% of the time. Neither of the 2 instruments could effectively prepare 100% of the root canal circumference. The area of dentin removed and the remaining dentin thicknesses from each region were similar for the 2 groups. Six procedural incidents were recorded for the Vortex .06 group, compared with 19 for the Safesiders group. There were no instrument fractures recorded in either group. Mean working time was significantly shorter for Vortex .06 (279 s) than for Safesiders (324 s). CONCLUSIONS: Vortex .06 maintained the original root canal curvatures well, whereas Safesiders instruments demonstrated significant straightening and irregular preparation shapes when used in sizes larger than ISO 20. Preparation of the complete circumference of the root canal was not possible with either system. Fewer procedural errors occurred with the Vortex instruments.

Outcomes of root canal treatment in Dental Practice-Based Research Network practices.

This study sought to quantify the incidence of root canal treatment (RCT) failure and identify its predictors in root canals that were performed or referred by general dentistry practices in a practice-based research network (PBRN). This retrospective cohort study involved 174 endodontically treated teeth. Mean duration from initial therapy to follow-up was 8.6 years. Permanent restorations were ultimately placed in 89% of teeth, although 18% of teeth were ultimately extracted anyway. Receiving a permanent restoration was a significant predictor of treatment failure (in other words, patients who did not receive a permanent restoration were more likely to experience RCT failure), whether failure was determined clinically or radiographically. This study of PBRN practices suggests a higher failure rate compared with studies that utilized highly controlled environments or populations with high levels of dental insurance.

Volumetric expansion of gutta-percha in contact with eugenol.

The aim of this study was to compare the volumetric expansion of gutta-percha in the presence of eugenol or physiologic saline over time. Sections of gutta-percha cones were scanned to determine their total volume and surface area. They were then placed in sealed test tubes with either 2 microL eugenol or 2 microL saline and allowed to soak for 24 hours, 7 days, or 30 days. The results were scanned again to determine the volumetric changes in the material after placement in the test solutions. The results were statistically analyzed by using t tests and analysis of variance. Specimens soaked in eugenol showed a dramatic increase in volumetric expansion versus the saline group at all time periods. Sealers that incorporate eugenol could be attributed to gutta-percha volumetric expansion over time, thereby creating a better seal of the obturation material.

Effect of lowering the pH of sodium hypochlorite on dissolving tissue in vitro.

Sodium hypochlorite (NaOCl), a common antimicrobial and tissue-dissolving irrigant, comes from the manufacturer at pH 12. When the pH is lowered, NaOCl becomes more antimicrobial. The aim of this study was to examine what effect lowering the pH has on the property of tissue dissolution. Seven groups were tested for dissolving porcine muscle tissue at varying pH, concentrations, and times. When groups were examined solely by pH, there was no significant difference between the pH 12 and 9 groups, but a statistically significant level was found between pH 12 and 9 versus the pH 6 groups (P < .05). Higher concentrations and greater time periods all led to greater amounts of tissue dissolution.

Comparison of preparation design and material thickness on microbial leakage through Cavit using a tooth model system.

Few studies have compared Cavit thickness and access design as factors in microbial leakage. The present study used an acrylic tooth model to measure leakage of Streptococcus mutans. Pilot studies confirming the sterility of Cavit showed it will inhibit microbial growth for 2 days. The experiments compared class I preparations where Cavit thickness was 4 mm with class II preparations where thickness was 2-3 mm. Accesses sealed with cotton pellets were compared with those without cotton. Results of the study showed no bacterial contamination in any of the class I samples (up to 14 days). Some class II samples showed contamination at day 1 (3 out of 14), with all contaminated at day 7 (14 of 14), yet only 1 contaminated at day 14 (1 out of 14). The results suggest that a 4-mm thickness of Cavit should prevent bacterial ingress for at least 2 weeks, but microbial leakage may occur if temporary thickness is less than 3 mm or in a complex access preparation.

The effect of preoperative acetaminophen or a combination of acetaminophen and Ibuprofen on the success of inferior alveolar nerve block for teeth with irreversible pulpitis.

This study compared preoperative administration of acetaminophen or a combination of acetaminophen and ibuprofen versus placebo for potential increased effectiveness of inferior alveolar nerve (IAN) block anesthesia. There were 40 patients with irreversible pulpitis randomly assigned to a drug or placebo group. Thirty minutes after ingestion of medication, an IAN block was administered. A cold test was done 15 minutes after the block, and if the patients had no sensitivity, endodontic therapy was initiated. If the patient had no pain on access, the IAN was recorded as successful. If the patient had sensitivity to cold or to the access procedure, it was recorded as a failure. Overall success was 60% for all three groups. Success was 71.4% for the acetaminophen group, 75.9% for the acetaminophen and ibuprofen group, and 46.2% for the placebo group. There was no significant difference between the groups; however, there was a trend toward higher success in the medication groups.

Symptoms of musculoskeletal disorders in ophthalmologists.

OBJECTIVE: To describe the presence of musculoskeletal disorders (MSDs) of the neck, low back, and upper extremity among ophthalmologists. DESIGN: Survey. METHODS: Mail survey using a pretested instrument to 2,529 ophthalmologists in the Northeastern United States; 697 ophthalmologists (28%) returned a completed survey. RESULTS: Self-reported prevalence of neck, upper body, or lower back symptoms in the prior month was 51.8%. Low back pain was present in 39% of respondents, followed by upper extremity symptoms (32.9%) and neck pain (32.6%). Approximately 15% of ophthalmologists were slightly to moderately limited in their work as a result of these symptoms. CONCLUSION: MSD symptoms appear to be common among ophthalmologists. With a relatively low response rate, however, it is plausible that asymptomatic subjects represent a large percentage of the nonrespondents. Additional investigation is warranted to evaluate ergonomic risk factor exposure and establish injury prevention guidelines.

Hypothyroidism and the development of open-angle glaucoma in a male population.

PURPOSE: To determine if hypothyroidism is associated with an increased risk of glaucoma using a large cohort of patients. DESIGN: Nested case-control study. PARTICIPANTS: Patients seen at the Veterans Affairs Medical Center in Birmingham, Alabama with newly diagnosed glaucoma between 1997 and 2001 were selected (n = 590) and age-matched to nonglaucoma controls (n = 5897). METHODS: Patient information was extracted from the Birmingham Veterans Affairs Medical Center data files containing demographic, clinical, and medication information. An index date was assigned to the glaucoma subjects corresponding to the time of diagnosis. Patients who had a glaucoma diagnosis before the observation period of the study were excluded. Ten controls were randomly selected for each patient and matched on age (+/-1 year) and an encounter on or before the index date of the matched case. MAIN OUTCOME MEASURES: Odds ratios (ORs) for the association between the prior diagnosis of hypothyroidism and the risk of developing glaucoma with adjustment for the presence of diabetes, lipid metabolism disorders, hypertension, cardiovascular disease, cerebrovascular disease, arterial disease, and migraines. RESULTS: After adjustment for the other potential risk factors, patients were significantly more likely to have prior hypothyroidism than controls (OR, 1.40; 95% confidence interval, 1.01-1.97). CONCLUSIONS: Our study has demonstrated a significantly greater risk of subjects with a preexisting diagnosis of hypothyroidism developing glaucoma, compared with controls, in a large Veterans Affairs Medical Center population.

Impact of an educational program on the safety of high-risk, visually impaired, older drivers.

BACKGROUND: Older drivers (licensed drivers aged 60 years and older) have among the highest rates of motor vehicle collision involvement per mile driven of all age groups. Educational programs that promote safe driving strategies among seniors are a popular approach for addressing this problem, but their safety benefit has yet to be demonstrated. The objective of this study was to determine whether an individualized educational program that promoted strategies to enhance driver safety reduces the crash rate of high-risk older drivers. DESIGN/ SETTING: Randomized, controlled, single-masked intervention evaluation at an ophthalmology clinic. PARTICIPANTS: A total of 403 older drivers with visual acuity deficit or slowed visual processing speed or both who were crash-involved in the previous year, drove at least 5 days or 100 miles per week or both, and were at least 60 years old. INTERVENTION: Patients were randomly assigned to usual care (comprehensive eye examination) or usual care plus an individually tailored and administered educational intervention promoting safe-driving strategies. MAIN OUTCOME MEASURE: Police-reported vehicle collision rate, expressed both in terms of person-years of follow-up and person-miles of travel for 2 years postintervention. RESULTS: The intervention group did not differ significantly from the usual care only group in crash rate per 100 person-years of driving (relative risk [RR], 1.08; 95% confidence interval [CI], 0.71-1.64) and per 1 million person-miles of travel (RR, 1.40; 95% CI, 0.92-2.12). The intervention group reported more avoidance of challenging driving maneuvers and self-regulatory behaviors during follow-up than did the usual care only group (p<0.0001). CONCLUSIONS: An educational intervention that promoted safe-driving strategies among visually impaired, high-risk older drivers did not enhance driver safety, although it was associated with increased self-regulation and avoidance of challenging driving situations and decreased driving exposure by self-report.

Impact of impulsiveness, venturesomeness, and empathy on driving by older adults.

PROBLEM: Although personality characteristics such as impulsiveness have been linked to the driving safety and driving habits of young and middle-aged adults, little research has focused on the role of personality in older driver behavior. METHOD: Using the IVE questionnaire in an exploratory study, three personality dimensions (impulsiveness, venturesomeness, and empathy) were measured in 305 older drivers (ages 57-87 years old). In addition, the Driving Habits Questionnaire was used to estimate driving exposure, and the Driver Behavior Questionnaire (DBQ) was used to estimate driving errors and violations. State-recorded crash data were made available by the state public safety agency. RESULTS: Subjects who reported four or more driving errors had higher impulsivity and empathy scores and lower venturesomeness scores. Subjects reporting driving violations were more likely to have high impulsivity scores. Driving six or more places per week was associated with lower levels of impulsivity. IMPACT: These results suggest that a comprehensive understanding of driving problems among older adults should also include a consideration of personality dimensions. In doing so, the challenges faced in the interpretation of self-report instruments on driving behaviors must be acknowledged, with a move in research toward greater reliance on more objective measures of driving behavior when assessing the impact of personality variables.

Racial differences in the association between optic disc topography and early glaucoma.

PURPOSE: To determine the structural characteristics of the optic disc that are associated with early glaucoma in African Americans and whites and whether these characteristics differ between the races. METHODS: Parameters of optic disc topography from 260 African American eyes and 193 white eyes were included in the analysis. One hundred forty-four eyes of African Americans and 109 eyes of normal white subjects were used as a control group. Logistic regression was used to calculate the association between early glaucoma, defined by the visual field, and cup, rim, and disc margin confocal scanning laser ophthalmoscopic (CSLO) parameters, using odds ratios at binary cut points. The cup, rim, and disc margin parameters identified as being independently associated with glaucoma in these reduced models were then included in a single multivariate model. Optic disc area was included in the analysis at each level of the model. This approach was used for the total study group and then separately for the African American and white groups. RESULTS: When accounting for difference in optic disc area, rim area had the highest independent association with early glaucoma in both groups, but this association was lower in African Americans (odds ratio [95% confidence interval]: 1.63 [1.12-2.36]) than in whites (odds ratio: 4.74 [2.18-10.28]). Additional independently associated parameters included cup shape, maximum elevation along the contour line, and the temporal-to-inferior contour line modulation ratio in whites and cup shape and the temporal-to-superior contour line modulation ratio in African Americans. CONCLUSIONS: Structural characteristics of the optic disc that are best associated with early glaucoma included cup shape and rim area in both groups, but with a less pronounced association in African Americans. In addition, several other race-specific parameters that were independently associated with early glaucoma differed significantly between African Americans and whites. These race-specific differences were independent from the effect of optic disc area.