Strategies for integrated employment and mental health services.

OBJECTIVE: Individual placement and support (IPS) supported employment for people with mental illness is most effective when mental health and employment services are fully integrated within teams in a single agency. Despite this evidence, there are times when separate mental health and employment agencies must collaborate rather than integrate. This article examines how 3 state implementation teams helped separate agencies to partner on IPS supported employment. METHOD: The authors used qualitative interviews and direct observations to examine successful collaborations in 3 states. We visited IPS programs on multiple occasions, interviewed multiple stakeholders, and evaluated adherence to the principles of IPS. RESULTS: Leaders used 4 strategies to promote successful collaborations: (a) ensuring that employment specialists, and in some cases, vocational rehabilitation counselors, attended mental health treatment team meetings; (b) providing office space for employment staff at the mental health agency; (c) involving supervisors from both agencies in the implementation; and (d) using fidelity reviews to assess the quality of collaboration. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Practitioners from separate agencies can coordinate services effectively, but successful coordination requires leadership at the state and local levels.

Work exposures, injuries, and musculoskeletal discomfort among children and adolescents in dairy farming.

Little research is available about the specifics of child or adolescent work on dairy farm operations. The objective of this study was to investigate work performed by children and adolescents on these operations. The authors administered mail questionnaires to a community-based, age- and operation size-stratified sample of individuals aged 6 to 18 (n = 240) who worked on dairy operations in Wisconsin. Data were collected in 1999. The 197 children and adolescents reported averaging 567 hours of dairy farm work in the last year (10.9 hours/week) and completed over 1/3 of all calf feeding, 1/5 of the milking, 1/5 of cow feeding, and 1/10 of tractor operation hours on their farm during the weeks they worked. Some of these young workers reported accomplishing duties also judged by some experts as hazardous work, including nearly half of the 9- to 11-year-olds driving tractors. Six nonfatal injuries were reported that required stopping work (14.6 per 100 full time equivalents per year), including those that required medical attention. Musculoskeletal discomfort and disability reports were unremarkable compared to existing studies of general and working populations. Wisconsin dairy farm youth appeared to be working no more hours per week than their peers in other studies of agricultural populations. Adolescents and some children largely performed the same range of tasks and often the same scope of work as adults, including some performing hazardous work. There is a need for further investigations with larger samples of dairy youth to confirm these findings. The exposures of very young workers to hazardous tractor driving and tower silo tasks suggest that there is an urgent need for improved and validated interventions to reduce these exposures.

Applying the International Classification of Headache Disorders to the emergency department: an assessment of reproducibility and the frequency with which a unique diagnosis can be assigned to every acute headache presentation.

STUDY OBJECTIVE: Although almost 2 decades have passed since the International Headache Society first introduced its International Classification of Headache Disorders (ICHD), the applicability of this classification scheme in the emergency department (ED) has not been assessed. As a first step toward identifying the role the ICHD should play in the ED, we address 2 questions: Can a structured interview and adherence to the ICHD allow ED headache patients to be classified in a reproducible manner? With the ICHD, how often can one specific diagnosis be assigned to each ED headache presentation? METHODS: This was a structured interview and medical record review of patients with nontraumatic headache, performed in an urban ED from March 2004 through August 2005. Using the data from the interview and the subject's ED record, 2 emergency medicine investigators independently classified each of the headaches twice: first, to determine presence or absence of a primary headache disorder, and then to determine presence or absence of a secondary headache disorder. If a primary headache was present, it was further classified as migraine, tension-type headache, trigeminal autonomic cephalalgia, chronic daily headache, or primary headache unclassifiable. Interobserver discordance was adjudicated by an experienced headache specialist. RESULTS: Four hundred eighty patients were enrolled in the study. The emergency medicine investigators had a high level of interobserver agreement on secondary headaches (agreement 94% [95% confidence interval (CI) 92% to 96%]) and primary headaches (agreement 91% [95% CI 88% to 93%]). Among the 480 subjects, 122 (25%) had a secondary headache disorder, 309 (64%) had a primary headache disorder, 49 (10%) had a coexisting primary and secondary headache, and for 95 (20%) subjects, neither a primary nor a secondary headache could be diagnosed. Of 309 subjects with a primary headache, 186 (60%) had migraine, 34 (11%) had tension-type headache, 2 (1%) had trigeminal autonomic cephalalgia, and 77 (26%) had an unclassifiable primary headache. Overall, a specific ICHD headache diagnosis could not be assigned to 36% of subjects either because a specific primary headache disorder could not be identified or because neither a primary nor a secondary headache disorder could be diagnosed. CONCLUSION: Although a detailed structured interview in the ED and adherence to the ICHD resulted in reproducible classification of headache patients, more than one third of acute headache patients could not readily be given a specific ICHD diagnosis in the ED.

Comparison of stoop versus prone postures for a simulated agricultural harvesting task.

Physical and psychophysical differences between working in the stooped and prone postures were compared while performing a simulated agricultural harvesting task for 30 min. Fifteen male subjects participated. The measures used to compare the two postures included perceived discomfort, electromyography (EMG), and heart rate (HR). Average hamstrings localized discomfort (0-10 scale) was 6.17 (SD=2.9) for the stoop posture and 0.67 (SD=1.29) for the prone posture. Erector spinae and hamstring EMG RMS increased 68% and 18%, respectively, while mean power frequency for the hamstrings decreased 13% for the stoop task. Mean power frequency for the middle trapezius muscle decreased in both postures (stoop 4.13%, prone 3.79%). Average heart rate during the last work cycle was 35% greater than the resting heart rate for the stoop posture while average heart rate was 17% greater for the prone posture. Subjects worked on the prone workstation without rest during the 15 min work simulations with less discomfort, no localized fatigue in the back or leg muscles tested, and lower working heart rates than subjects working in the stoop posture.

Safety and efficacy of hydromorphone as an analgesic alternative to morphine in acute pain: a randomized clinical trial.

STUDY OBJECTIVE: We compare a standard weight-based dose of intravenous hydromorphone (Dilaudid) to a standard weight-based dose of intravenous morphine in adults presenting to the ED with acute severe pain. METHODS: This was a prospective, randomized, double-blind, clinical trial conducted in an academic medical center. Of the 198 adult patients presenting to the ED with acute severe pain who were randomized to receive either intravenous hydromorphone at 0.015 mg/kg or intravenous morphine at 0.1 mg/kg, 191 patients had sufficient data for analysis. The main outcome measure was the difference between the 2 groups in pain reduction at 30 minutes as measured on a validated numeric rating scale. Adverse effects, pain reduction at 5 minutes and 2 hours postbaseline, and additional analgesics and antiemetics were tracked as secondary outcome measures. RESULTS: The mean change of pain from baseline to 30 minutes postbaseline in patients allocated to intravenous hydromorphone was -5.5 numeric rating scale units versus -4.1 in patients allocated to intravenous morphine (difference -1.3; 95% confidence interval -2.2 to -0.5). Adverse effects were similar in both groups, with the exception of pruritus, which did not occur in patients receiving hydromorphone (0% versus 6% [difference -6%; 95% confidence interval -11% to -1%]). No patient required naloxone. CONCLUSION: For the treatment of acute, severe pain in the emergency department, intravenous hydromorphone at 0.015 mg/kg represents a feasible alternative to intravenous morphine at 0.1 mg/kg.

Evaluation of an intervention to reduce musculoskeletal hazards among fresh market vegetable growers.

OBJECTIVES: We conducted an intervention to convince small, fresh market vegetable operations to adopt mesh bags and standard containers, two production practices that aid in crop handling and that are known to improve labor efficiency and reduce exposures to musculoskeletal injury hazards. METHODS: The intervention disseminated information about the practices to growers through trade publications, public events, university Extension, and growers already using the practices. A mail questionnaire was administered to vegetable growers (n=243 and 207) before and after the intervention. Strawberry growers were used as a comparison group and also received questionnaires (n=50 and 35). RESULTS: After the intervention, more vegetable growers reported seeing information about mesh bags in trade publications (37% vs. 59%) and information about standard containers at public events (33% vs. 49%). Levels of self-reported adoption increased for containers (38% vs. 54%) and approached significance for bags (8% vs. 17%). Aware, non-adopting grower perceptions of bag profitability improved (2.6 vs. 3.8). Strawberry grower control results were unchanged. CONCLUSIONS: Better information flow to growers may be able to increase the speed with which agricultural practices with better ergonomics are adopted, especially when the practices are more profitable.