A food desert in Detroit: associations with food shopping and eating behaviours, dietary intakes and obesity.

OBJECTIVE: Currently 67 % of the US population is overweight or obese and obesity is associated with several chronic medical conditions. Geographic areas where individuals lack access to healthy foods have been termed 'food deserts'. The study aim was to examine if area of residence within Metro Detroit was associated with dietary intake, food and shopping behaviours, and BMI. DESIGN: Cross-sectional study. SETTINGS: Participants were recruited in the waiting area of four primary-care clinics. SUBJECTS: Individuals (n 1004) completed a questionnaire comprising four sections: demographics; personal health status including self-reported height and weight; a modified diet, transportation and shopping survey; and a subscale from the Diet and Health Knowledge Survey. RESULTS: Seventy-four per cent of participants were female and the mean age was 46·7 (sd 15·0) years. In univariate analyses, living in Detroit was associated with being African American, unemployment, less education, no regular exercise, worse health self-rating and obesity (P < 0·0005 for all). Participants living in Detroit had a 3·06 (95 % CI 1·91, 4·21) kg/m2 larger BMI compared with people living outside the city (P < 0·0005) in univariate analyses, but the effect was attenuated when adjusted for demographics, disease status, shopping and eating behaviours, dietary intakes and diet knowledge (ß = −0·46 kg/m2, 95 % CI −2·23, 1·30 kg/m2, P = 0·60). CONCLUSIONS: Overweight and obesity are highly prevalent both inside (82·9 %) and outside (72·8 %) the city of Detroit, presenting a major public health problem. However, living in this food desert was not significantly associated with BMI after potential covariates were considered.

Retroperitoneal hematoma in patients undergoing cardiac catheterization.

OBJECTIVE: To retrospectively study demographic, clinical and hospital outcomes in patients who developed RPH following cardiac catheterization. METHODS: Charts of patients with RPH from cardiac catheterization, between January 1, 2000 and July 30, 2005 were reviewed and compared with two control groups (Grp-I, 90 patients with local groin complications and Grp-II, 98 patients with no bleeding complications). RESULTS: 31 cases of RPH (0.13%) were identified with 84% females. Most common presentation was hypotension (87%) and hemoglobin drop (96%). CT scan was the diagnostic modality in 93% cases. The mean body surface area in RPH group (1.77 ± .23) was significantly lower than in control group I (1.93 ± .28) and II (1.98 ± .27). The use of larger sheath size was significantly higher in the RPH group (61.3%) than control groups I (26.7%) and II (21.4%). Left groin access was significantly more in RPH group (16.1%) and control group I (17.8) than control group II (0%). The use of antiplatelets and anticoagulants were significantly higher in the RPH group. 13% of patients with RPH were treated surgically. The average hospital stay was 8.6 days, 4.5 days and 3.5 days and mortality 12.9%, 3.3% and 1% in RPH group, control group I and II respectively. CONCLUSION: Our study is the second largest series of RPH following cardiac catheterization and predicts female gender, large sheath size, left groin access and low body surface area as risk factors for RPH.

Effect of establishing guidelines on appropriate urinary catheter placement.

OBJECTIVES: Avoiding placement of unnecessary urinary catheters (UCs) in the emergency department (ED) affects UC utilization during hospitalization. The authors sought to evaluate the effect of establishing institutional guidelines for appropriate UC placement coupled with emergency physician (EP) education on UC utilization. METHODS: Urinary catheter utilization was measured before and after the establishment of guidelines and EP education. Data collected included the presence of a UC on ED arrival, placement of a UC in the ED, documentation of a physician order for UC placement, reasons for placement, and compliance with the guidelines. Chi-square analyses were used to study the association between pre- and postintervention time periods and catheter use. RESULTS: A total of 377 (15%) patients had UCs; only 151 (47%) UCs initially placed in the ED had a physician order documented. UC placement was appropriately indicated in 75.5% of patients with a documented physician order, but in only 52% of cases without a documented physician order (p<0.001). The physician intervention was associated with an overall reduction in UC utilization from 16.4% to 13% (p=0.018). Physicians ordered 40% fewer UCs postintervention compared to preintervention. Preintervention, a physician order for UC placement was found indicated in 72.6% patients, compared to 82.2% patients with UC placed postintervention (p=0.21). CONCLUSIONS: Establishing guidelines for UC placement and physician education in the ED were associated with a marked reduction in utilization. However, addressing appropriate UC utilization may require evaluating other factors such as nursing influence on utilization.

Health literacy instrument in family medicine: the "newest vital sign" ease of use and correlates.

BACKGROUND: Health literacy has been defined as the ability to obtain, process, and understand the basic information needed to make appropriate health decisions. Half of adults lack the health literacy skills needed for our complex health care environment. In 2005, Weiss et al introduced the Newest Vital Sign (NVS), an instrument that can be used to quickly assess health literacy. The purpose of this study was to determine the acceptability and timeliness of using the NVS to measure the level of health literacy in various suburban, urban, and rural primary care settings. A secondary purpose was to determine the influence of taking a health class on one's level of health literacy. METHODS: In this cross-sectional design, adults were recruited from 4 primary care settings and student athletes were recruited during preparticipation sports physicals. The NVS was administered and health literacy rates were compared with known trends. A subset of 50 patients was timed during test administration, and refusals were logged throughout. The adults and the athletes were analyzed separately. RESULTS: One thousand fourteen patients (including athletes) agreed to participate (response rate, 97.5%). Average time needed to complete the NVS was 2.63 minutes. Of the adults tested, 48.1% demonstrated adequate health literacy. In logistic regression analysis, younger age, more formal education, health class participation, and body mass index were positive predictors of adequate health literacy among adults. An interaction term was used for gender/race, with white women used as the comparator. The gender/race odds ratio negatively affected literacy, with white men at 0.497 (95% CI, 0.328-0.753), non-white women at 0.177 (95% CI, 0.111-0.282), and non-white men at 0.210 (95% CI, 0.110-0.398). Among the participating middle- and high-school athletes, 59.7% had adequate health literacy. In logistic regression of this population, body mass index was a positive predictor whereas gender/race was a negative predictor. CONCLUSION: The NVS revealed health literacy status in less than 3 minutes, was widely accepted, and provided results comparable to more extensive literacy tests. Particularly, taking a health education class was associated with higher levels of health literacy among adults.

Is seasonal variation another risk factor for postpartum depression?

INTRODUCTION: Postpartum depression (PPD) occurs in the first 6 months after delivery in 10% to 20% of mothers. Despite the availability of screening tools, there is a general consensus that PPD is under-diagnosed. A number of risk factors contributing to PPD have been investigated, but role of seasonal variability in PPD is unclear. Our purpose was to assess whether seasonal variation is another risk factor for PPD. METHODS: This cross-sectional pilot study was conducted at 2 family medicine clinics and an obstetrics/gynecology clinic over 24 months. During their postpartum visit, mothers who gave consent were asked to fill out a survey requesting demographic data, followed by the Edinburgh Postpartum Depression Scale (EPDS). The EPDS is a well-validated tool shown to be highly effective in detecting postnatal depression. A score >12 on the EPDS indicated a likely risk of PPD. RESULTS: Of the 556 patients approached, 530 completed the EPDS. Mean (+/-SE) patient age was 24.9 +/- 0.2 years; 71% were African Americans; 74% were single mothers; and 39% had at least some college education. On the EPDS, 17.8% scored > or =13. Of the depressed patients, 18.1% had babies born during the winter, 19.2% had babies born during the spring, 13.4% during the summer, and 21.5% during autumn (chi(2); P = .342). Mothers with very good or excellent support at home had lower EPDS scores (12.6%) than mothers with just adequate support (44.0%) or very little or no support (30.8%; P < .0005). A greater proportion of women with a history of depression (42.9% vs 12.9%) or who were currently taking antidepressives (58.3% vs 15.9%) were in the depressed group (P < .0005). Logistic regression analysis with the above variables, excluding education and income (excess missing data), on the 452 women with complete datasets found 4 significant predictors of an EPDS score >12. Predictors were history of depression (odds ratio [OR], 4.003; 95% CI, 2.016-7.949); parity (OR, 1.431; 95% CI, 0.204-1.701); social support (OR, 3.904; 95% CI, 2.08-7.325); and currently taking medication for depression (OR, 3.613; 95% CI, 1.207-10.817). CONCLUSION: The slight seasonal variation in PPD in our pilot study was not statistically significant. Our study was underpowered to detect the projected differences in seasons. Additional patients are needed to diversify the participants and provide an adequate sample to test the projected seasonal differences. The high ORs found for greater parity, weak social support, history of depression, and currently taking antidepressants suggest that new mothers with these characteristics should be questioned about symptoms of PPD.

Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients.

OBJECTIVE: To determine the effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheters (UCs). DESIGN: Quasi-experimental study with a control group, in 3 phases: preintervention, intervention, and postintervention. SETTING: Twelve medical-surgical units within a 608-bed teaching hospital, from May 2006 through April 2007. INTERVENTION: A nurse trained in the indications for UC utilization participated in daily multidisciplinary rounds on 10 medical-surgical units. If no appropriate indication for a patient's UC was found, the patient's nurse was asked to contact the physician to request discontinuation. Data were collected before the intervention (for 5 days), during the intervention (for 10 days), and 4 weeks after the intervention (for 5 days). Two units served as controls. RESULTS: Of 4,963 patient-days observed, a UC was present in 885 (for a total of 885 "UC-days"). There was a significant reduction in the rate of UC utilization from 203 UC-days per 1,000 patient-days in the preintervention phase to 162 UC-days per 1,000 patient-days in the intervention phase (P = .002). The postintervention rate of 187 UC-days per 1,000 patient-days was higher than the rate during the intervention (P = .05) but not significantly different from the preintervention rate (P = .32). The rate of unnecessary use of UCs also decreased from 102 UC-days per 1,000 patient-days in the preintervention phase to 64 UC-days per 1,000 patient-days during the intervention phase (P < .001); and, significantly, the rate rose to 91 UC-days per 1,000 patient-days in the postintervention phase (P = .01). The rate of discontinuation of unnecessary UCs in the intervention phase was 73 (45%) of 162. CONCLUSIONS: A nurse-led multidisciplinary approach to evaluate the need for UCs was associated with a reduction of unnecessary UC use. Efforts to sustain the intervention-induced reduction may be successful when trained advocates continue this effort with each team.

Utility of B-type natriuretic peptide and N-terminal pro B-type natriuretic peptide in evaluation of respiratory failure in critically ill patients.

STUDY OBJECTIVES: B-type natriuretic peptide (BNP) and N-terminal pro BNP (NTproBNP) have been shown to correlate with pulmonary arterial wedge pressure (PAWP) in patients with heart failure. We studied whether BNP and/or NTproBNP can differentiate high- vs low-PAWP respiratory failure in ICU patients. We also evaluated if BNP and NTproBNP will reflect accurately cardiac dysfunction and predict 30-day survival. DESIGN: Prospective observational study of ICU patients in an urban teaching hospital. PATIENTS: Forty-one consecutive patients with hypoxic respiratory failure undergoing pulmonary artery catheterization were enrolled between January and December, 2003. INTERVENTIONS: BNP and NTproBNP were assayed from a venous blood sample. Hemodynamic variables were obtained at the time blood was drawn. Survival was documented at day 30. MEASUREMENTS AND RESULTS: BNP and NTproBNP correlated significantly with each other (r = 0.656, p < 0.001) and inversely with hemodynamic markers of contractility: BNP with cardiac index (CI) [r = - 0.481, p < 0.02], and left ventricular stroke work index (LVSWI) [r = - 0.384, p < 0.02]; NTproBNP with CI (r = - 0.441, p < 0.02) and LVSWI (r = - 0.623, p < 0.001). BNP and NTproBNP did not correlate with PAWP. We created receiver operating characteristic (ROC) curves for detection of contractile dysfunction using different LVSWI cutoffs. Area under the ROC (AUROC) values were larger and more consistent for NTproBNP than for BNP. For LVSWI < 35 g.m/m(2): BNP AUROC = 0.643, NTproBNP AUROC = 0.885 (p < 0.02); for LVSWI < 30 g.m/m(2): BNP AUROC = 0.754 (p < 0.02) and NTproBNP AUROC = 0.884 (p < 0.001). Mean (+/- SE) concentrations did not differ between the survivors and non-survivors: BNP, 909.3 +/- 264.2 pg/mL vs 840.9 +/- 171.2 pg/mL; NTproBNP, 11,630.6 +/- 3,181.8 pg/mL vs 11,777.6 +/- 2,989.9 pg/mL, respectively. CONCLUSIONS: NTproBNP and BNP failed to differentiate high- vs low-PAWP respiratory failure but were inversely correlated with indexes of cardiac contractility. With higher accuracy, NTproBNP may be a more discerning marker than BNP in patients with milder cardiac dysfunction. Neither peptide predicted short-term mortality.

Do resident physicians use antibiotics appropriately in treating upper respiratory infections? A survey of 11 programs.

We surveyed resident physicians of 11 primary care programs regarding the management of upper respiratory infections and antibiotic resistance. Although they viewed excess antibiotic use as the most important factor increasing resistance, they had little knowledge regarding antimicrobial resistance and were willing to prescribe antibiotics for common viral illnesses.

Lateral column symptomatology following plantar fascial release: a prospective study.

Plantar fasciitis or heel spur syndrome usually resolves with conservative management, but for patients with continued pain, surgical intervention is often pursued. In some cases, plantar fasciitis is relieved, but pain in the lateral column area appears postoperatively. This lateral column pain may be debilitating for the patient and often overlooked by the foot and ankle surgeon. The goal of the study was to identify the maximum amount of plantar fascia that can be surgically released to treat recalcitrant heel pain effectively while preventing the development of lateral column symptoms. All patients undergoing plantar fasciotomy after failing conservative treatment were eligible to participate. Patients rated their pain with an 11-point (0-10) visual analog scale (VAS) and described its location prior to and at monthly intervals after their surgery. Surgeons recorded whether 25, 50, or 66% of the plantar fascia was released during surgery. Open procedures were performed 72% of the time, and endoscopically in 28% of the patients. Key outcome variables included degree of fascial release and foot structure. Patients (n = 47) with lateral column pain after surgery (n = 15 feet) had a mean +/- S.E. of 60.6 +/- 3.0% of their plantar fascia released while those without pain (n = 35 feet) had only 48.7 +/- 1.9% of this fascia released during surgery (ANOVA, p = .019). Age, weight, body mass index, gender, smoking status, comorbidities, general health, surgical procedure, postoperative care, calcaneal inclination angle, and talar declination angle did not differ for these groups (p > .146). For this patient population, regardless of surgical technique (endoscopic or open release), lateral column symptoms were more likely to result when more than 50% of the plantar fascia was released. The report proposes that a maximum of 50% of the plantar fascia be released during surgery.

Cryogenic neuroablation for the treatment of lower extremity neuromas.

A prospective study testing the efficacy of cryosurgery on lower extremity neuromas was performed. Thirty-one neuromas in 20 patients were percutaneously denervated using a Westco Neurostat-III cryoneedle. All patients were surgical candidates who had failed prior conservative treatment. Patient evaluation consisted of a 10-point visual analog scale (VAS) that was administered pre- and postoperatively. Periodic evaluation with the VAS and patient satisfaction was conducted for a 1-year period following the procedure. Immediately after the procedure, all patients reported complete relief of pain and were permitted to return to full activity. Two weeks after the index procedure, patients were categorized into one of three groups: those who remained completely pain free (38.7%), those who had reduced pain (45.2%), and those who had reverted to preprocedure pain levels (16.1%). The pain score of those patients who had reduced pain decreased from a mean of 8.5+/-0.4 preprocedure to 3.5+/-0.4 (p < .002). All five patients with no improvement had previous local neurectomies. Even though fewer than 40% of the patients had complete pain relief, an overwhelming 90% stated they would have the procedure performed again. Cryogenic neuroablation appears to be a viable treatment option for patients with lower extremity neuromas. The success rate is similar to surgical excision with little to no disability period and high patient satisfaction.

Strength comparison of allogenic bone screws, bioabsorbable screws, and stainless steel screw fixation.

Allogenic bone screws are new to the fixation market and have yet to be tested against current fixation materials. An in vitro comparison of the same sizes of stainless steel, bioabsorbable, and allogenic bone screws was undertaken to assess screw resistance to the forces of bending, pullout, and shear. Using aluminum plates to support the screws, forces up to 1000 Newtons were applied to six to eight samples of each type of screw. During each test, stainless steel screws withstood the maximum force that could be exerted by the testing apparatus without failing (bending, 113.9 +/- 11.8 N mean +/- SE; pullout 999.1 +/- 33.7 N; and shear, 997.5 +/- 108.8 N). In each test, compared to bioabsorbable screws, allogenic bone screws failed faster (pullout, allogenic: 12.4 +/- 1.1 seconds vs. bioabsorbable, 120.6 +/- 13.8 seconds; p = .001; bending, allogenic: 53.4 +/- 4.8 seconds vs. bioabsorbable, 201.9 +/- 11.1 seconds; p = .001; shear, allogenic 13.5 +/- 1.4 seconds vs. bioabsorbable, 43.8 +/- 0.9 seconds; p = .001) under equivalent (pullout: bioabsorbable, 385.0 +/- 18.4 N vs. allogenic, 401.0 +/- 35.9 N; p = .001) or lower (bending, allogenic: 4.7 +/- 0.2 N vs. bioabsorbable, 11.0 +/- 0.9 N; p = .675; shear, allogenic: 312.1 +/- 15.5 N vs. bioabsorbable 680.9 +/- 8.5 N; p = .001) loads, and in a highly variable fashion. Overall, the bioabsorbable screws withstood the forces of bending, pullout, and shear better than the allogenic screws, and stainless steel screws outperformed both bioabsorbable and allogenic screws. Despite these results, allogenic screws could still be useful in compliant patients who would benefit from their osteoconductive properties.