Standardized ultrasound protocol, trained sonographers and digital system for carotid atherosclerosis screening.

BACKGROUND AND PURPOSE: Carotid intima-media thickness (IMT), a valid measure of atherosclerotic disease, has been proposed to be included in the algorithms for cardiovascular risk stratification. However, assessment of carotid IMT is still not easily performed in an office setting. In the present study, we evaluated the reproducibility of a standardized protocol for carotid artery atherosclerosis screening. METHODS: Carotid arteries of 30 patients were scanned twice (interval 1-10 days) by six trained sonographers, using portable ultrasound systems. A screening protocol was adapted from methods used in clinical trials in which carotid IMT was the primary outcome measure. To test the reproducibility of the method, variability between the two scans was analyzed. RESULTS: A high level of agreement was found between the scans for measurement of mean common carotid IMT [mean difference S0.002, 95% confidence interval (CI) S0.011 to 0.006, PU0.435], maximum region common carotid IMT (mean difference S0.002, 95% CIS0.017 to 0.014, PU0.779) and mean maximum IMT including the common, bifurcation and internal carotid arteries (mean differences 0.021, 95% CI S0.006 to 0.047, PU0.166). No significant differences were found between scans with regard to the average number of carotid segments visualized, the number of atherosclerotic plaques or plaque burden. CONCLUSION: Reliable IMT measurements can be obtained using a standardized protocol performed by trained sonographers using a digital portable ultrasound system in an office setting.

Chronic pain: second, do no harm.

Pain may be undertreated--contributing to anguish, as reported by the World Health Organization. Pain may be overtreated--inadvertently contributing to drug addiction, drug diversion, and even death. Pain may be misunderstood-contributing to illness propagation, as reported in somatization literature. Pain words may even be presented as a tool of manipulation, where report of pain is verbiage in pursuit of utilitarian social consequence. Thus, primum non nocere--first, do no harm--is not easily achieved in the pharmacological treatment of pain, particularly in pain reported chronically. Herein, we examine the pharmacological treatment of chronic pain, and we suggest strategies for improved management that are based on solid principles derived from extensive experience which may protect against the problems derived from the vague and subjective nature of pain symptoms. Optimal treatment of chronic pain may be assisted by three paradigms: (1) an adequate model of appraisal, (2) treatment focused on pathophysiology (whether physical, psychosocial, or some combination of these), and (3) frequent reassessment of total social function. By these approaches, contribution to drug abuse, diversion, and life deterioration can be largely avoided. Whereas the emphasis here is pharmacological management, the principles may be more widely applied to other therapies of chronic pain.

Injectable calcium hydroxylapatite for orbital volume augmentation.

OBJECTIVE: To describe a new method of augmenting orbital volume for anophthalmic enophthalmos correction. METHODS: A retrospective medical record review was conducted of 4 consecutive patients who had injectable calcium hydroxylapatite (Radiesse) placed in the extraconal space to augment orbital volume. RESULTS: Four patients were treated with 1 to 2 vials (1.3 mL per vial) of injectable calcium hydroxylapatite. The mean amount of preoperative enophthalmos measured by Hertel exophthalmometry was 4 mm (range, 2-7 mm). The mean follow-up was 57 weeks (range, 45-71 weeks). A reduction of enophthalmos, ranging from 2 to 5 mm (mean, 2.75 mm), was observed when comparing preoperative with postoperative measurements of the anophthalmic orbit with prosthesis in place. All patients demonstrated clinical and aesthetic improvement that was observed to continue at almost 1 year or more postoperatively. In one patient, injection was complicated by a peribulbar hemorrhage related to local anesthesia administration, which resolved without incident. CONCLUSIONS: Injectable calcium hydroxylapatite provides a new, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit of 1 year or more with little volume loss. The filler seems to last longer in areas with less movement, blood supply, and lymphatic drainage. Injection can even be performed in an office setting using local anesthesia. The amount of volume replacement can be titrated, and the procedure is repeatable until adequate volume is obtained.

Autologous dermis graft at the time of evisceration or enucleation.

AIM: To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised. METHODS: A retrospective, interventional, non-comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon's capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications. RESULTS: Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site. CONCLUSIONS: This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility.

An internet-based method of selecting control populations for epidemiologic studies.

Identifying control subjects for epidemiologic studies continues to increase in difficulty because of changes in telephone technology such as answering services and machines, caller identification, and cell phones. An Internet-based method for obtaining study subjects that may increase response rates has been developed and is described. This method uses information from two websites that, when combined, provide accurate and complete lists of names, addresses, and listed phone numbers. This method was developed by use of randomly selected streets in a suburb of Salt Lake City, Utah, in June 2005.

Psychological disorders among children and the parents of children undergoing cancer workup.

OBJECTIVES: This paper evaluates the association between psychological problems and cancer workup in children aged less than 20 and their parents. Assessment of the potential psychological stress in these children and their parents has been inadequately studied in the past. METHODS: A retrospective cohort study of anxiety or depression among children and the parents of children undergoing cancer workup, based on Deseret Mutual Benefit Administrators (DMBA) claims data and corresponding enrollment files for dependent children aged less than 20, from 1998 to 2002 in the United States and Canada. RESULTS: Less than 20% of cancer workups are followed by cancer diagnosis and treatment. Children with a "cancer workup only" are 89% more likely to experience anxiety/depression than are children without a cancer-related claim; that is, the rate per 100,000 person-years of anxiety/depression is 7,222 for children with a cancer workup only compared with 3,824 for children without a cancer-related claim. Mothers of children with cancer workup are 37% more likely to experience anxiety/depression. Children are significantly more likely to experience anxiety/depression if one or both of their parents experience anxiety/depression. The increased risk is influenced by whether the child experiences both cancer workup and treatment (359% higher), by cancer workup only (308% higher), and by no cancer workup or treatment (295% higher). Finally, the rate of anxiety/depression among children with cancer workup and their mothers was significantly lower in homes with more children. CONCLUSIONS: A cancer workup alone is sufficient to significantly increase the risk of anxiety/depression in children undergoing cancer workup and in their parents. The ability of a child undergoing a cancer workup to cope is influenced by the mental health of their parents. More children in the home are protective against anxiety/depression in children undergoing cancer workup and in their mothers.

Thyroid disease associated with exposure to the Nevada nuclear weapons test site radiation: a reevaluation based on corrected dosimetry and examination data.

BACKGROUND: A study was begun in 1965 to 1966 to determine whether children exposed to radioactive iodine from nuclear weapons testing at the Nevada Test Site from 1951 through 1962 were at higher risk of thyroid disease. In 1993, we reported that among those examined in 1985 to 1986 (Phase II) there was an association between radiation from the Nevada Test Site and thyroid neoplasms. METHODS: We reevaluated the relationship between exposure to Nevada Test Site fallout and thyroid disease using newly corrected dose estimates and disease outcomes from the Phase II study. A prospective cohort of school children 12 to 18 years old living in Utah, Nevada, and Arizona was first examined for thyroid disease in 1965 to 1966 and reexamined in 1985 to 1986. In the Phase II report, 2497 subjects formed the basis for this analysis. Thyroid disease, including thyroid neoplasms and thyroiditis, was expressed as cumulative incidence and risk ratios (RRs) with a dose-response expressed as excess risk ratio (ERR/Gy). RESULTS: The RR between thyroid radiation dose in the highest dose group and thyroid neoplasms increased from 3.4 (in the earlier analysis) to 7.5. The RR for thyroiditis increased from 1.1 to 2.7 with an ERR/Gy of 4.9 (95% confidence interval = 2.0 to 10.0). There were too few malignant thyroid neoplasms to estimate risk. CONCLUSIONS: Persons exposed to radioactive iodine as children have an increased risk of thyroid neoplasms and autoimmune thyroiditis up to 30 years after exposure.

Mentor's hand hygiene practices influence student's hand hygiene rates.

BACKGROUND: There were 3 objectives for this prospective quasiexperimental study. The first was to determine the effect of mentor's hand hygiene practices on student's hand hygiene rates during clinical rotations. The second was to assess the difference in hand hygiene rates for students with and without prior medical experience. The third was to assess the student's opinion and beliefs regarding hand hygiene. METHODS: Sixty students enrolled in a certified nursing program were selected to participate in the study. Each study group was observed twice during the 30-day span. The first observational period was conducted on day 1 of clinical rotation. The second observational period was conducted on day 30 of clinical rotation. Students were observed for hand hygiene. Also assessed were medical experience, sex, gloving, age, and mentor's hand hygiene practices. After observational period 2, a brief questionnaire was given to students to determine their opinion and beliefs regarding hand hygiene. The questionnaire was divided into 5 sections: student's commitment to hand hygiene, their perception of hand hygiene inconvenience, the necessity of hand hygiene, the student's ability to perform hand hygiene, and their opinion on the frequency of medical staff's hand hygiene. RESULTS: The mentor's practice of hand hygiene was the strongest predictor of the student's rate of hand hygiene for both observational periods (P < .01). Furthermore, students without prior medical experience had a significant increase in hand hygiene rates when comparing observational period 1 to observational period 2 (P < .01). Glove usage was associated with increased hand hygiene rates by 50% during observational period 1 (P = .01) and 44% during observational period 2 (P < .01). Male students during observational period 1 practiced hand hygiene 30% less often than female students (P < .01); however, during observational period 2, there was no significant difference between hand hygiene rates for males and females (P = .82). Questionnaires were completed by 47 students, who reported a strong commitment to hand hygiene, belief in its necessity, and ability to perform hand hygiene (with scores in the high 90s on a 10 to 100 rating scale). CONCLUSION: Mentor's use of hand hygiene and glove usage was associated with increased hand hygiene among students. Even though students reported strongly positive attitudes toward hand hygiene, students had a low overall rate of hand hygiene.

Outcomes after decompressive craniectomy for severe traumatic brain injury in children.

OBJECT: Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution. METHODS: Children with severe TBI who underwent decompressive craniectomy at the Primary Children's Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King's Outcome Scale for Closed Head Injury (KOSCHI). Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months. CONCLUSIONS: Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.

Mohs micrographic surgery.

Mohs micrographic surgery is an approach to skin cancer removal that aims to achieve the highest possible rates of cure and to minimize the size of the wound and consequent distortions at critical sites such as the eyes, ears, nose, and lips. Mohs micrographic surgery is a two-step, same-day procedure performed with local anesthetic. It involves removing the tumor in stages by histologically confirming clear margins on frozen sections and by addressing the resultant defect. Options for healing include second intent, primary closure, local flaps, interpolation flaps, and grafts. Larger tumors may require referral for reconstructive surgery. Mohs micrographic surgery is the treatment of choice for skin tumors in critical sites, large or recurrent tumors, tumors in sites of radiation therapy, and tumors with aggressive histologic features.

Climate conditions and physical activity in the United States.

OBJECTIVE: To identify the influence season and climate have on physical activity among US adults. METHODS: Seven weather classifications from 255 weather stations were linked with 355 counties covered by the 2003 BRFSS. RESULTS: The percentage meeting the recommendations for physical activity ranged from 30.9% in Puerto Rico to 60.9% in Montana and significantly varied across seasons: 44.6% in winter, 46.2% in spring, 48.4% in summer, and 45.8% in fall. Counties in the top 25% meeting the recommendations for physical activity had the highest percentage of days with dry moderate conditions. Counties in the bottom 25% had the highest percentage of days with moist tropical conditions. CONCLUSION: Season and climate significantly influence physical activity in the United States.

Associations of body mass index with meniscal tears.

BACKGROUND: Meniscal tears are common knee injuries, with limited reported data on associated factors, let alone risk factors. The objective of this study was to determine whether associations exist between increasing obesity and meniscal tears leading to surgery. METHODS: We performed frequency-matched case-control studies using surgical case data for years 1996 to 2000 from administrative databases of two large Utah hospitals; each case was matched with three controls from a large cancer screening trial. Meniscal tear cases (262 male and 282 female) were determined by surgical procedures. Inclusion criteria were age (50 to 79) and body mass index (BMI) (17.00 to 54.99 kg/m(2)). Gender-specific, age-adjusted odds ratios with 95% confidence intervals (CIs) were calculated for BMI categories from <20.00 to >/=40.00. The referent BMI category was 20.00 to 22.49. RESULTS: Age-adjusted odds ratios for likelihood of meniscal surgery among those with a BMI of >/=40.00 were 15.0 (95% CI=3.8-59.0) for men, and 25.1 (95% CI=10.3-60.8) for women. All odds ratios for men and women with BMIs of >/=27.50 and >/=25.00, respectively, were statistically significantly elevated. CONCLUSIONS: Significant associations were demonstrated between increasing BMI and meniscal surgeries in both genders, including obese and overweight adults.

Physician preparedness for bioterrorism recognition and response: a Utah-based needs assessment.

The medical community accepts that they have a need to be prepared to recognize and respond to bioterrorism events. A needs assessment conducted among physicians throughout the state of Utah provided insights into their perceived training needs and preferred methods of learning. Physicians have many competing demands on their time and tailored educational offering can increase the intended audience's acceptance and learning.

Associations between body-mass index and surgery for rotator cuff tendinitis.

BACKGROUND: Rotator cuff tendinopathy is a common entity. We hypothesized that obesity, because of biomechanical and systemic risk factors, increases the risks of rotator cuff tendinitis, tears, and related surgical procedures. METHODS: A frequency-matched case-control study was conducted. Three hundred and eleven patients who were fifty-three to seventy-seven years old and who underwent rotator cuff repair, arthroscopy, and/or other repair of the shoulder in a large hospital from 1992 to 2000 were included in the study. These surgical procedures were used as proxies for the risk of rotator cuff tendinitis. These patients were age and frequency-matched to 933 controls, who were randomly drawn from a pool of 10,943 potential controls consisting of Utah state residents who were enrolled in a large cancer-screening trial. Age-adjusted odds ratios were calculated with use of the International Classification of Diseases, Ninth Revision procedural codes and body-mass-index groups. The data were stratified according to gender and age. Multiple linear regression analyses also were performed. RESULTS: There was an association between increasing body-mass index and shoulder repair surgery. The highest odds ratios for both men (odds ratio = 3.13; 95% confidence interval = 1.29 to 7.61) and women (odds ratio = 3.51; 95% confidence interval = 1.80 to 6.85) were for individuals with a body-mass index of > or =35.0 kg/m(2). Tests for trend also were highly significant for both men (p = 0.002) and women (p < or = 0.001). Multiple linear regression analysis also indicated a significant association between increasing body-mass index and shoulder surgery (beta = 1.57; 95% confidence interval = 0.97 to 2.17; p < or = 0.001). CONCLUSIONS: There is an association between obesity and shoulder repair surgery in men and women who are fifty-three to seventy-seven years of age. The results of the present study suggest that increasing body-mass index is a risk factor for rotator cuff tendinitis and related conditions.

Associations between breast cancer risk factors and religious practices in Utah.

BACKGROUND: Utah has the lowest female malignant breast cancer incidence rates in the United States, due in part to low rates among women who are members of the Church of Jesus Christ of Latter-day Saints (LDS or Mormon). Several established reproductive and non-reproductive breast cancer risk factors may be lower among LDS women because of their religious doctrine related to marriage, family, and health. This paper investigates the association between selected breast cancer risk factors and religious preference and religiosity in Utah. METHODS: A 37-item anonymous cross-sectional telephone survey was developed and conducted during March and April 2002. Results are based on 848 non-Hispanic white female respondents. RESULTS: Number of births (parity), prevalence of breastfeeding, and lifetime total duration of breastfeeding were highest among LDS women who attended church weekly. Average months of breastfeeding per child were greatest among weekly church attendees, regardless of religious preference. Oral contraceptive use and total duration of hormone replacement therapy use were greatest for individuals of any religion attending church less than weekly and for individuals with no religious preference. Comparisons of divergent reproductive behaviors between LDS and non-LDS, and between weekly and less than weekly church goers, provide strong support for the relatively low breast cancer incidence rates previously identified among LDS and, therefore, in Utah. CONCLUSIONS: High parity and breastfeeding coincide with comparatively low breast cancer incidence rates among LDS and are consistent with recent findings of the Collaborative Group on Hormonal Factors in Breast Cancer, showing the primary role parity and breastfeeding play in reducing breast cancer.

Timing intercourse to achieve pregnancy: current evidence.

Physicians who counsel women for preconception concerns are in an excellent position to give advice to couples regarding the optimal timing of intercourse to achieve pregnancy. The currently available evidence suggests that methods that prospectively identify the window of fertility are likely to be more effective for optimally timing intercourse than calendar calculations or basal body temperature. There are several promising methods with good scientific bases to identify the fertile window prospectively. These include fertility charting of vaginal discharge and a commercially available fertility monitor. These methods identify the occurrence of ovulation clinically and also identify a longer window of fertility than urinary luteinizing hormone kits. Prospectively identifying the full window of fertility may lead to higher rates of conception. Proper information given early in the course of trying to achieve pregnancy is likely to reduce time to conception for many couples, and also to reduce unnecessary intervention and cost.

Why health educators need epidemiology.

The aim of health education is to encourage health behaviors that promote a better quality of life and longer life expectancy. In the late 1960s, universities in the US began offering degree programs in health education. Most programs today require that at least one class be taken in epidemiology, where epidemiology involves the study of the distribution and determinants of disease frequency in human populations. In recent years, several competency areas have been set forth for health educators by the US National Commission for Health Education Credentialing. This paper specifically describes how training in epidemiology provides health educators with the ability to satisfy, in large part, these competency areas. The intent of this paper is to clarify to students and advisors of health education the rationale for requiring course work in epidemiology, as well as to emphasize that epidemiology is the cornerstone to all health education, whether conducted by physicians, nurses, or formally trained health educators.