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BACKGROUND In recent years, use of the herbal supplement kratom has increased in the United States. The reasons for use include pain relief, particularly as a substitute for opioids. OBJECTIVES To describe epidemiologic trends in kratom-related exposures among older adults reported to U.S. poison centers. DESIGN Retrospective analysis of American Association of Poison Control Center's National Poison Data System (NPDS). SETTING Data from all U.S. poison centers from 2014 to 2019 were examined. PARTICIPANTS Kratom exposure cases involving adults aged 18 and older. Kratom cases were identified by product and NPDS generic codes. Non-human and information-only calls were excluded. Data were examined for all calls for exposures among adults, with a focus on older adults aged 60-69 years and above 70 years. MEASUREMENTS Descriptive analyses were used to characterize individual demographic, exposure information, clinical effects, and medical outcomes associated with kratom exposures among older adults. Comparisons across age groups (18-59, 60-69, and 70+ years) were made using Fisher's exact tests. RESULTS Among 3484 kratom-related exposures reported between 2014 and 2019, 4.6% (n = 162) were among adults over 60 years. The number of kratom-related exposures increased over time. Most cases originated with calls from healthcare facilities (81.1%) and involved kratom as a single ingestant (63.0%). The reason for most ingestions was intentional (74.5%). One in five exposures among adults aged 70 and older involved an adverse reaction (e.g., drug interaction; 21.9%), compared with 12.3% among ages 60-69 and 9.6% among ages 18-59 years. Neurological and cardiovascular clinical effects were observed. Twenty-three deaths were observed among older adults. CONCLUSION Healthcare providers and older adult patients should be aware of the potential risks of kratom use, including medication interactions and falls. When reviewing medication lists, providers should query this population for all medications and substances being used, especially in people being treated for pain.

Objectives To evaluate the "Quit Happens" program launched to reduce tobacco use in low-income populations in a federally qualified nonprofit health center with clinics in Washington and Idaho. Quit Happens was implemented in 2015 and involved a public health nurse, patient, provider, clinic, health system, and community components. Design and sample This smoking cessation program was assessed using a pre-post evaluation design. Nine clinics in a single system of federally qualified nonprofit health centers participated in this program. Intervention The Quit Happens program was implemented across nine clinics in Washington and Idaho. A specialized public health nurse led the tobacco cessation training of all clinic staff and assisted with development of the smoking cessation program. The 5A model was used as the framework for the training. Measurements The proportion of patients identifying as a current or former smoker was measured using data extracted from electronic health records. Results Declines in patient reports of currently smoking were observed between 2016 and 2018. The percent of current smokers identified in electronic health records decreased 18.7% and percent of former smokers doubled. Conclusion This community-based tobacco cessation program had wide clinic and community support and self-reported smoking behavior declined over time. A public health nurse's leadership in offering training and program development around tobacco cessation to a local community organization can contribute to reductions in smoking rates.

Transitioning into independent professional practice may be a difficult and trying process for newly licensed nurses, who may be at risk for burnout and quitting their jobs. Issues related to new nurses’ well-being at work may also impact their personal lives. Using thematic analysis within the framework of Total Worker Health, this study examined factors related to the overall work, safety, and health of newly licensed nurses that should be addressed in work environments to promote well-being and prevent burnout and attrition. The main component of Total Worker Health is to find and understand the relevant issues that lead to safety and health risks in the workplace and affect workers’ well-being at work and home. The overarching concept of Balance between Work and Life included three main themes: Health, Work Environment, and Learning to Be (a nurse). These themes with their subthemes described the difficulties participants had in balancing the complex interactions of work conditions and social life changes during the transition from student to professional nurse. Participants identified new physical health problems, mental health challenges, physical violence, lack of support structures at work, and alterations in family and friend relationships. However, they also developed protective factors from new connections with coworkers. These findings showed that new nurses are vulnerable to many factors at home and work that affect well-being and may lead to burnout and attrition. Implications include interventions at work that focus on health promotion, group support, and safety risk prevention through occupational nurse management.

This cross-sectional study uses 2017 to 2019 data from the US National Mental Health Services Survey and examines whether there are disparities in the availability of youth-serving mental health facilities associated with suicide risk in rural vs urban youth.

Background and purpose Nurse practitioners (NPs) frequently treat acute conditions presenting in children and adolescents in the outpatient setting. No evidence-based guidance exists pertaining to the treatment of concussion with medications. The purpose of this study was to examine recommendations by NPs for pharmacotherapy of acute symptoms for adolescent concussion. Methods This is a secondary analysis of data from a web-based census survey of all licensed NPs in Oregon and Washington State, where they practice as independent providers with prescriptive authority. Based on a standardized adolescent patient scenario video, NPs were asked to indicate prescription or nonprescription medication recommendations for concussion symptoms. Open-ended descriptions of medication recommendations were coded, summarized, and described. Conclusions In narrative text, 78.4% of the 991 respondents recommended at least one type of prescription or nonprescription medication. Prescription medications (recommended by 17.2%) included antiemetics and antimigraine medications; nonprescription medications (recommended by 75.5%) included nonsteroidal anti-inflammatory drugs, over-the-counter pain relievers, and herbal medications. Pharmacotherapy recommendations varied by NP practice setting and rurality. Implications for practice Nurse practitioners have full prescriptive authority in many states. No guidelines inform medication use in managing acute concussion symptoms, yet many providers recommend their use.

Background Early magnetic resonance imaging (MRI) for acute low back pain (LBP) has been associated with increased costs, greater health care utilization, and longer disability duration in workers' compensation claimants. Objectives To assess the impact of a state policy implemented in June 2010 that required prospective utilization review (UR) for early MRI among workers' compensation claimants with LBP. Research design Interrupted time series. Subjects In total, 76,119 Washington State workers' compensation claimants with LBP between 2006 and 2014. Measures Proportion of workers receiving imaging per month (MRI, computed tomography, radiographs) and lumbosacral injections and surgery; mean total health care costs per worker; mean duration of disability per worker. Measures were aggregated monthly and attributed to injury month. Results After accounting for secular trends, decreases in early MRI [level change: -5.27 (95% confidence interval, -4.22 to -6.31); trend change: -0.06 (-0.01 to -0.12)], any MRI [-4.34 (-3.01 to -5.67); -0.10 (-0.04 to -0.17)], and injection [trend change: -0.12 (-0.06 to -0.18)] utilization were associated with the policy. Radiograph utilization increased in parallel [level change: 2.46 (1.24-3.67)]. In addition, the policy resulted in significant decreasing changes in mean costs per claim, mean disability duration, and proportion of workers who received disability benefits. The policy had no effect on computed tomography or surgery utilization. Conclusions The UR policy had discernable effects on health care utilization, costs, and disability. Integrating evidence-based guidelines with UR can improve quality of care and patient outcomes, while reducing use of low-value health services.

OBJECTIVE To examine racial differences in mental health service utilization after hospitalization for traumatic brain injury (TBI) among children with Medicaid insurance. DESIGN AND MAIN MEASURES Retrospective analysis of the MarketScan Multi-State Medicaid database from 2007 to 2012 was performed. Outpatient mental health service utilization (psychiatric and psychological individual and group services) was compared at TBI hospitalization, from discharge to 3 months and from 4 to 12 months after discharge, between children of non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and "Other" racial groups. Multivariable mixed-effects Poisson regression models with robust standard errors were utilized. RESULTS A total of 5674 children (aged

Nursing students make an abrupt transition from traditional classes to clinical rotations and shift work. Little is known about students’ sleep, sleep disturbances, and safe practice behaviors during this critical phase of professional development. The purpose of this study was to identify nursing students’ perceptions of problems and potential solutions related to shift work and long work hours. This qualitative, descriptive study used two nursing student focus groups which engaged in a two-round participatory process aimed at framing future interventions. Participants identified problems and solutions related to personal and workplace well-being. Findings will inform undergraduate curricular revisions, and hospital hiring and managerial practices.

Introduction Nurse practitioners (NPs) are authorized to manage concussion recovery. Common adolescent activities, like driving, are omitted from guidelines. We investigated NP driving guidance and its clinical basis for restriction or limitation following adolescent concussion. Method NPs completed a web-based questionnaire after viewing a scripted video scenario of an adolescent describing symptoms of concussion occurring 72 hours prior. Driving recommendations were collected using an open-ended query, then coded and categorized by type, characteristic, and basis. Results 1,051 (20%) responded to the question of interest. The majority (93.8%) provided driving recommendations: 32.6% based on time, 49.8% based on symptoms, and 28.5% based on health care utilization. 5.3% mentioned fatigue and sleep symptoms. 1% advised use of a standardized assessment tool. Discussion Symptomatology, examination, and time were key factors in clinical decision-making for post-concussion driving, rather than use of standardized tools. Persistent symptoms that can impact driving, such as sleep and visual disturbances, may warrant consideration.

Background and purpose To evaluate the effect of patient sex and type of activity on concussion assessment and management recommendations. Methods We administered a web-based survey to all nurse practitioners (NPs) actively licensed in Washington and Oregon. Participants were randomized to view one of four standardized patient scenario videos of an adolescent seeking care for a concussion, portraying the same symptomology but differing by sex and activity (soccer/hiking). Respondents provided assessment and management recommendations. Conclusions In total, 1021 NPs provided sufficient data for analysis. Most NPs correctly identified the injury as a concussion (92.8%); fewer identified it as a mild traumatic brain injury (55.3%). NPs who viewed hiking videos were 40% more likely to indicate that the patient was definitely or likely safe to return to activity in 1 week, compared to a soccer player, after adjusting for covariates (RR = 1.40, 95% CI [1.16, 1.68]). Implications for practice While most assessment and management recommendations did not vary according to patient sex, providers may manage concussions differently based on etiology. Appropriate and consistent concussion assessment and management is important, as NPs are authorized to assess adolescents with concussions and make determinations regarding return to activity or school.

Purpose The costs facing families after pediatric concussion are not limited to medical expenses for treatment and rehabilitation care. The objective of this research was to examine the economic hardship facing families following concussion. Design and methods: Eighteen youth (10–18 years old) with a diagnosed concussion injury and sixteen parents (13 parent/youth dyads) answered open-ended questions regarding experiences associated with concussion care and recovery, specifically as they related to cost. Participants were recruited from a concussion clinic, social media, and via snowball sampling. Interviews were audio recorded, transcribed verbatim, and coded using deductive qualitative content analysis. Results In addition to direct health care expenses (e.g. copays and deductibles), families of youth with concussion faced indirect costs associated with tutoring and transportation to medical appointments, in some cases over long distances. Financial cost-sharing for concussion care varied widely across participants. Conclusions Lost productivity included parents missing work to care for their child and for travel to appointments. Research that describes costs of care using claims or survey data lack the experiential perspective of the economic burden on families following concussion. Practice implications : To fully understand the impact of concussion on patients and families, healthcare providers must consider non-monetary costs, such as opportunity costs, transportation required to obtain healthcare, or the productivity cost associated with missed work and school.

Objective: To examine rural-urban differences in college students’ cardiovascular risk perceptions. Participants: College students in rural (n = 61) and urban (n = 57) Kentucky counties were recrui...

This cross-sectional study examines reports of cannabis exposure at US poison control centers for trends in patient and product characteristics, stratified by manufactured cannabis products and plant materials.

This study examined nurse practitioners’ (NPs) previous experiences and comfort levels in treating adolescents with work-related injuries in two states where NPs have statutory authority to treat work-related injuries. The authors surveyed all actively licensed NPs in Washington and Oregon ( N = 4,849). Factors associated with NPs’ previous experiences and comfort in treating adolescents with work-related injuries were identified using modified Poisson regression. Less than a quarter of respondents (21.1%, n = 225) reported having ever treated an adolescent for a work-related injury. Nearly half (43.6%) of respondents reported being uncomfortable or very uncomfortable in treating adolescents with work-related injuries. Previous experience and male gender were associated with greater likelihood of feeling comfortable ( p < .01). Nurse practitioners serve as primary care providers for adolescents who may experience work-related injuries. This study documents the need for developing educational and outreach efforts to better prepare NPs to treat adolescents’ work-related injuries.

Purpose The purpose of the study was to describe associations between employment and marijuana use among adolescents 2 years before passage of 2012 ballot initiative and 2 years after the implementation of retail recreational marijuana sales took place in Washington. Methods We used 2010 and 2016 data from Washington's statewide school-based Healthy Youth Survey, which is completed by more than 76,000 youth annually and representative of 8th, 10th, and 12th graders in public schools. We used “difference-in-differences” regression to estimate the odds of current, past 30-day marijuana use by working status and hours worked per week compared with nonworking youth. Results Working adolescents in all grades had higher prevalence of recent marijuana use compared with nonworking adolescents. Youth working in formal settings, such as retail and service sectors, were more likely to use marijuana than nonworking and youth working in informal settings, such as babysitting. Between 2010 and 2016, marijuana use decreased significantly among working and nonworking 8th and 10th graders. Among working 12th graders, marijuana use increased significantly over time relative to nonworking youth (adjusted odds ratio: 1.34, 95% confidence interval: 1.22–1.48). Associations were stronger for youth who worked more hours per week. Conclusions Working youth were more likely to use marijuana before and after Washington's legalization of retail marijuana. Legalization was associated with increases in marijuana use specifically among 12th-grade working youth. States legalizing marijuana may consider implementing interventions to support healthy behaviors among working youth.

Background/Purpose Our objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma. Methods We queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18 years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics. Results The 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children's = $6575 [$4333–$10,862], nonchildren's $7027 [$4230–$12,219] p = 0.47) and high-grade (children's = $10,984 [$6211- $20,007] nonchildren's $10,156 [$5439–$18,404] p = 0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CR = 2.35 95% CI 2.02, 2.74, high-grade CR = 2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status. Conclusion Hospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients. Level of evidence III

Objectives. This study sought to estimate total health care costs for mild, moderate, and severe pediatric traumatic brain injury (TBI) and to compare individual- and population-level costs across levels of TBI severity. Methods. Using 2007 to 2010 MarketScan Commercial Claims and Encounters data, we estimated total quarterly health care costs 1 year after TBI among enrollees (aged Results. Mild TBI accounted for 96.6% of the 319 103 enrollees with TBI; moderate and severe TBI accounted for 1.7% and 1.6%, respectively. Adjusted individual health care costs for moderate and severe TBI were significantly higher than mild TBI in the year after injury (P Conclusions. Individually, moderate and severe TBI initially generated costs that were markedly higher than those of mild TBI. At the population level, costs following mild TBI far exceeded those of more severe cases, a result of the extremely high population burden of mild TBI.

Despite being a high-risk population, epidemiological research about injuries among homeless individuals is limited. We sought to describe injury characteristics among individuals identified as homeless in the National Electronic Injury Surveillance System (NEISS), and to compare them to age- and sex-matched controls. We searched text narratives for all patients with product-related injuries who presented to NEISS emergency departments from 2007 to 2011 to identify homeless cases (N = 268). A random sample of 2680 age- and sex-matched controls was identified for the same time period. The incident location differed between groups, and the mention of substance use was significantly more common among homeless cases than controls. The body part injured differed significantly between cases and controls for all age groups, with the exception of older adults. Among homeless cases, injuries occurred most frequently to the lower extremities, and sprains/strains, contusions/abrasions and burns were most common. Additional research on injury among homeless individuals is warranted in order to identify meaningful preventive strategies for this at-risk population.

Clinical practice guidelines for acute low back pain (LBP) consistently agree that routine spinal imaging tests within 4–6 weeks of symptom onset are not necessary for patients who do not present with complications, or “red flags” (American College of Occupational and Environmental Medicine 2007; Bradley 2007; Chou et al. 2007; Davis et al. 2008; ABIM Foundation 2012). Red flags include age under 20 or over 70 (or 50, depending on the guideline), history of cancer, intravenous drug use, prolonged use of corticosteroids, osteoporosis, infection, or focal neurologic deficit with progressive or disabling symptoms (Davis et al. 2008). After 4–6 weeks, patients with persistent LBP or signs of radiculopathy or spinal stenosis should be evaluated with magnetic resonance imaging (MRI) or computed tomography (CT) only if they are expected to benefit from invasive treatments, such as surgery or epidural steroid injection (Chou et al. 2007). Recent research suggests that ∼20 percent of LBP cases among workers’ compensation claimants receive early (within the first 4–6 weeks of symptoms) MRI, a proportion of whom may be receiving unnecessary care (Webster and Cifuentes 2010; Graves et al. 2012). The propensity to adopt and utilize new technologies for advanced imaging, combined with a general lack of utilization controls, generates concern from the perspective of payers, especially public payers facing increasing budgetary constraints. Use of costly procedures, such as MRI for LBP, may also be associated with increased subsequent treatment and costs, without concomitant improvements in health outcomes (Jarvik et al. 2003; Gilbert et al. 2004b). With the potential for early MRI to lead to additional, more intensive or more invasive treatment for LBP, a patient who had early MRI may utilize more health care resources than an equivalent patient who waited 6 weeks before receiving MRI (Waddell 1996). In Washington State, back injuries constitute 18 percent of all claims and 23 percent of all workers’ compensation costs (). In 2008, lumbar MRI costs exceeded $7.4 million for WA injured workers (). In response to rapidly increasing imaging costs, the WA legislature mandated that State health care agencies consider methods to implement best practice guidelines for the use of advanced imaging in 2009 (Washington State Legislature 2009). This population-based cohort study evaluates health care utilization and costs associated with non-adherence to clinical practice guidelines for early MRI among WA workers’ compensation claimants with acute, non-specific LBP who missed at least 4 days of work.

Objective To evaluate the trend in utilization of repeat (i.e. ≥2) computed tomography (CT) and to compare utilization patterns across body regions for trauma patients admitted to a level I trauma center for traffic-related injuries (TRI). Materials and Methods We linked the Harborview Medical Center trauma registry (1996–2010) to the billing department data. We extracted the following variables: type and frequency of CTs performed, age, gender, race/ethnicity, insurance status, injury mechanism and severity, length of hospitalization, intensive care unit (ICU) admission and final disposition. TRIs were defined as motor vehicle collisions, motorcycle, bicycle and pedestrian-related injuries. Logistic regression was used to evaluate the association between utilization of different body region repeat (i.e. ≥2) CTs and year of admission, adjusting for patient and injury-related characteristics that could influence utilization patterns. Results A total of 28,431 patients were admitted for TRIs over the study period and 9499 (33%) received repeat CTs. From 1996 to 2010, the proportion of patients receiving repeat CTs decreased by 33%. Relative to 2000 and adjusting for other covariates, patients with TRIs admitted in 2010 had significantly lower odds of undergoing repeat head (OR = 0.61; 95% CI: 0.49–0.76), pelvis (OR = 0.37; 95% CI: 0.27–0.52), cervical spine (OR = 0.23; 95% CI: 0.12–0.43), and maxillofacial CTs (OR = 0.24; 95% CI: 0.10–0.57). However, they had higher odds of receiving repeat thoracic CTs (OR = 1.86; 95% CI: 1.02–3.38). Conclusion A significant decrease in the utilization of repeat CTs was observed in trauma patients presenting with traffic-related injuries over a 15-year period.

Objective This study describes injury characteristics and costs of work-related traumatic brain injury (WRTBI) among 16-24 year olds in Washington State between 1998 and 2008. Methods WRTBIs were identified in the Washington Trauma Registry (WTR) and linked to workers' compensation (WC) claims data. Medical and time-loss compensation costs were compared between workers with isolated TBI and TBI with other trauma. Results Of 273 WRTBI cases identified, most (61.5%) were TBI with other trauma. One-third of WRTBI did not link to a WC claim. Medical costs averaged $88,307 (median $16,426) for isolated TBI cases, compared to $73,669 (median $41,167) for TBI with other trauma. Conclusions Results highlight the financial impact of WRTBI among young workers. Multiple data sources provided a more comprehensive picture than a single data source alone. This linked-data approach holds great potential for future traumatic occupational injury research. Impact on Industry TBI among young workers not only involves long-term health and psychological impacts, but is costly as well.

Objectives To evaluate the incidence of snow-sports-related head injuries among children and adolescents reported to emergency departments (EDs), and to examine the trend from 1996 to 2010 in ED visits for snow-sports-related traumatic brain injury (TBI) among children and adolescents. Methods A retrospective, population-based cohort study was conducted using data from the National Electronic Injury Surveillance System for patients (aged ≤17 years) treated in EDs in the USA from 1996 to 2010, for TBIs associated with snow sports (defined as skiing or snowboarding). National estimates of snow sports participation were obtained from the National Ski Area Association and utilised to calculate incidence rates. Analyses were conducted separately for children (aged 4–12 years) and adolescents (aged 13–17 years). Results An estimated number of 78 538 (95% CI 66 350 to 90 727) snow sports-related head injuries among children and adolescents were treated in EDs during the 14-year study period. Among these, 77.2% were TBIs (intracranial injury, concussion or fracture). The annual average incidence rate of TBI was 2.24 per 10 000 resort visits for children compared with 3.13 per 10 000 visits for adolescents. The incidence of TBI increased from 1996 to 2010 among adolescents (p Conclusions Given the increasing incidence of TBI among adolescents and the increased recognition of the importance of concussions, greater awareness efforts may be needed to ensure safety, especially helmet use, as youth engage in snow sports.

BACKGROUND: Nurse practitioners (NPs) are statutorily authorized to provide assessment and cognitive recommendations for concussion in most states. Their scope of practice includes assessment and management of concussion sequalae including anxiety, insomnia, and depression, as well as return to school and activity guidance. OBJECTIVES: Analysis of symptom-based diagnosis of mild traumatic brain injury (TBI) in adolescents, including return to school and school workload recommendations comparing psychiatric and nonpsychiatric NPs. DESIGN: Cross-sectional Web-based survey with embedded videos using standardized actors and scripts randomized for patient sex and sport. A total of 4,849 NPs licensed in Oregon or Washington were invited by e-mail to view and respond to this study, with a response rate of 23%. RESULTS: Psychiatric mental health nurse practitioners (PMHNPs) were 44% less likely than family NPs to report using standardized concussion tools. 17% had completed continuing education on mild TBI compared to 54.5% of family NPs. Seven PMHNPs provided additional feedback related to discomfort in completing the survey due to lack of comfort or experience. Return to school recommendations and reduced workload advice did not significantly differ by NP type. CONCLUSION: PMHNPs may support individualized assessment through concussion evaluation, use of standardized tools, and differential consideration of TBI for mental health symptoms. More research is required related to the role and contribution of cognitive rest to full recovery.

Study Design. A population-based, prospective cohort study. Objective. To identify demographic, job-related, psychosocial, and clinical factors associated with the use of magnetic resonance imaging (MRI) within 6 weeks from injury (early MRI) among workers' compensation claimants with acute occupational low back pain (LBP). Summary of Background Data. Early MRI may be associated with increased use of services for treatment and costs. To understand utilization and most appropriately apply guidelines, it is important to identify factors associated with early imaging use for occupational LBP. Methods. Workers (N = 1830) were interviewed 3 weeks (median) after submitting a workers' compensation claim for a back injury. Demographic, work, health, clinical, and injury characteristics were ascertained from interviews, medical records, and administrative data. Modified Poisson regression analyses identified factors associated with early MRI use. Results. Among respondents, 362 (19.8%) received an early MRI. Multivariable regression showed that male workers were 43% more likely to receive an early MRI than female workers (incident rate ratio [IRR]: 1.43, 95% confidence interval [CI]: 1.12–1.82). Initial visit type with a surgeon was associated with 78% greater likelihood of receiving an early MRI than that with a primary care physician (IRR: 1.78, 95% CI: 1.08–2.92). Having a chiropractor as the initial provider was associated with a reduced likelihood of early MRI (IRR: 0.53, 95% CI: 0.42–0.66). Workers with elevated work fear-avoidance, higher Roland scores, or increased injury severity were more likely to receive early MRI than counterparts with lower levels or scores. Conclusion. Nearly 20% of the injured workers with LBP receive early MRI, a rate similar to that reported elsewhere. Early MRI may lead to greater subsequent interventions, potentially poorer outcomes, and increased health care expenditures. On the basis of the characteristics of patients with uncomplicated occupational LBP, providers may be able to provide tailored care, and providers and policy makers may better understand the utilization of imaging and adherence to clinical guidelines.

Study design A population-based, prospective cohort study. Objective To evaluate the association of early imaging and health and disability status 1 year following acute low back injury, among a population-based sample of Washington State workers' compensation claimants. Summary of background data Use of early diagnostic magnetic resonance imaging (MRI) for low back pain (LBP) contributes to increasing health care costs but may not lead to better outcomes than delayed imaging. In the worker's compensation system, LBP is common and costly. This research examines the association between early MRI among workers with LBP and health outcomes (pain intensity, Roland disability score, and 36-Item Short Form Health Survey scores) and disability status 1 year after injury. Methods This nonrandomized prospective cohort study of Washington State workers' compensation claimants with nonspecific LBP used administrative claims and interview data. Multivariable regression methods were used to estimate change in health outcome scores, the relative risk of disability at 1 year, and the rate of recovery 1 year after injury. Results Of 1226 participants, 18.6% received early MRI. Most (77.9%) had mild/major sprains and 22.1% had radiculopathy. Participants with early MRI differed significantly at baseline in pain, function, and psychosocial variables. After adjusting for covariates, early imaging was not associated with substantial differences in 1-year health outcomes for sprains or radiculopathy. For workers with mild/major sprain, early imaging was associated with a 2-fold increase in the likelihood of work disability benefits at 1 year (adjusted relative risk: 2.03, 95% confidence interval: 1.33-3.11). Early imaging was not associated with an increased risk of long-term disability for workers with radiculopathy (adjusted relative risk: 1.31, 95% confidence interval: 0.84-2.05). For both groups, early MRI was associated with longer disability duration (P Conclusion Among workers with LBP, early MRI is not associated with better health outcomes and is associated with increased likelihood of disability and its duration. These associations warrant further testing in a randomized controlled trial. Our findings suggest that adherence to evidence-based guidelines is an important factor in ensuring that workers receive the highest quality care for occupational injuries.

Background Factors that contribute to student success in accelerated degree nursing programs are poorly understood and may vary by gender. Purpose Examine associations between satisfaction with peer and mentor support, gender, and academic outcomes among students in accelerated degree nursing programs. Methods We used data (demographic variables, satisfaction with peer and mentor support, graduation, and attempts of National Council Licensure Examination for Registered Nurses) from the American Association of Colleges of Nursing and Robert Wood Johnson Foundation's New Career in Nursing Program. Multivariable mixed effects regression models were used to examine associations among gender, satisfaction with support, and academic outcomes. Findings Males had an increased probability of reporting high satisfaction with peer support. Both males and females who were very dissatisfied with peer support were less likely to graduate than students who were very satisfied with peer support. Gender did not moderate the relationships between satisfaction with peer and mentor support and academic outcomes. Conclusion Peer support is an important aspect of graduation among students in accelerated degree nursing programs. Continuous quality improvement strategies to improve student peer support may be warranted.

The relationship between sleep and occupational injury risk has not been adequately explored for working adolescents.Data were analyzed from the 2010 Washington State Healthy Youth Survey of 8th, 10th, and 12th grade public school students. Teens reported average school and weekend night sleep hours and history of work-related injury that received medical treatment. Multivariable logistic regression evaluated the association between sleep duration and occupational injury.Of 4,144 working teens, 6.4% reported ever having an occupational injury. Teens who sleep ≤5 hr/school night had greater odds of a history of occupational injury than those sleeping 8 hr (OR:2.91, 95% CI:1.85-4.57). No significant association was observed for weekend night sleep duration.Reduced school night sleep was associated with increased odds of work-related injury in adolescents. Long hours and late night schedules may contribute to decreased sleep time and potentially have other health and developmental impacts for youth.

Objectives To examine hospital-level factors associated with the use of a dedicated pediatric dose-reduction protocol and protective shielding for head CT in a national sample of hospitals. Methods A mixed-mode (online and paper) survey was administered to a stratified random sample of US community hospitals (N = 751). Respondents provided information on pediatric head CT scanning practices, including use of a dose-reduction protocol. Modified Poisson regression analyses describe the relative risk (RR) of not reporting the use of a pediatric dose-reduction protocol or protective shielding; multivariable analyses adjust for census region, trauma level, children's hospital status, and bed size. Results Of hospitals that were contacted, 38 were ineligible (no CT scanner, hospital closed, do not scan infants), 1 refused, and 253 responded (35.5% response rate). Across all hospitals, 92.6% reported using a pediatric dose-reduction protocol. Modified Poisson regression showed that small hospitals (0-50 beds) were 20% less likely to report using a protocol than large hospitals (>150 beds) (RR: 0.80, 95% confidence interval [CI]: 0.65-0.99; adjusted for covariates). Teaching hospitals were more likely to report using a protocol (RR: 1.10, 95% CI: 1.02-1.19; adjusted for covariates). After adjusting for covariates, children's hospitals were significantly less likely to report using protective shielding than nonchildren's hospitals (RR: 0.64, 95% CI: 0.56-0.73), though this may be due to more advanced scanner type. Conclusion Results from this study provide guidance for tailored educational campaigns and quality improvement interventions to increase the adoption of pediatric dose-reduction efforts.

School-based handwashing programs are challenging to establish and sustain, especially in low-resource settings. This qualitative study described teacher perspectives associated with implementing and sustaining a handwashing program in primary schools participating in the Nyando Integrated Child Health and Education (NICHE) project. Structured key informant interviews were conducted with teachers. Prevalent concepts and themes were grouped into themes and topic areas using an iterative, open coding approach. Forty-one teacher respondents reported favorable expectations and benefits of handwashing programs. The importance of available resources (e.g., reliable water) was cited as a primary concern. Other challenges included time and personal or institutional financial commitment necessary to ensure program sustainability. Handwashing programs in low-income, rural schools, where infrastructure is lacking and “student ambassadors” extend the intervention to the surrounding community, hold great promise to improve community health. Teachers must have adequate support and resources to implement and sustain the programs.

The goal of this study was to generate national estimates of injuries associated with mechanical home exercise equipment, and to describe these injuries across all ages. Emergency department (ED)-treated injuries associated with mechanical home exercise equipment were identified from 2007 to 2011 from the National Electronic Injury Surveillance System. Text narratives provided exercise equipment type (treadmill, elliptical, stationary bicycle, unspecified/other exercise machine). Approximately 70 302 (95% CI 59 086 to 81 519) mechanical exercise equipment-related injuries presented to US EDs nationally during 2007–2011, of which 66% were attributed to treadmills. Most injuries among children (≤4 years) were lacerations (34%) or soft tissue injuries (48%); among adults (≥25 years) injuries were often sprains/strains (30%). Injured older adults (≥65 years) had greater odds of being admitted, held for observation, or transferred to another hospital, compared with younger ages (OR: 2.58; 95% CI 1.45 to 4.60). Mechanical exercise equipment is a common cause of injury across ages. Injury awareness and prevention are important complements to active lifestyles.

Purpose To examine variation in pediatric trauma head CT imaging protocols in Washington State trauma centers (TCs) in 2012 and compare to a previous survey conducted in 2008-2009. Methods A mixed-mode (online and paper) survey was sent to all adult and pediatric Washington State TCs (levels 1-5). Respondents provided information about the CT scanner used for pediatric head scans and technical information about pediatric dose reduction protocols. Mean head effective dose and organ dose for a female baby were estimated. Results were compared with previous data. Results Sixty-one of 76 TCs responded to the 2012 survey (response rate, 80.3%, versus 76% for 2008-2009 survey). In 2012, 91.7% reported having a dedicated pediatric protocol (87.7% in 2008-2009). Protective shielding use ranged from 80% to 100% across both survey years. In 2012, 2.5 times more TCs provided sufficient information to conduct dose calculations than in 2008-2009. Estimated mean CT dose index was 23.1 milliGray (mGy) in 2012, compared with 34.8 mGy in 2008-2009 ( P = . 01). Estimated mean dose length product was also significantly lower in 2012 than 2008-2009 (307.6 mGy × cm versus 430.1 mGy × cm, respectively; P = . 04). Wide variation in mean effective dose was observed for level 3 and 4 TCs in 2012, similar to variation observed in 2008-2009 among level 4 TCs. Mean organ dose was significantly lower in 2012 for eye lens and brain, but higher for thyroid than in 2008-2009 ( P Conclusions Although most Washington State TCs employ dose reduction protocols for pediatric head CTs, and some measures were lower in 2012, variation in protocols use and estimated dose continues to exist. More complete responses in 2012 suggest improved understanding of the importance of pediatric dose reduction efforts. Education and institutional protocols are necessary to reduce pediatric radiation dose from head CTs.