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Late-repair craniosynostosis (LRC), defined as craniosynostosis surgery beyond 1 year of age, is often associated with increased complexity and potential complications. Our study analyzed data from the 2010–2019 Nationwide Readmissions Database to investigate patient factors related to LRC. Of 10 830 craniosynostosis repair cases, 17% were LRC. These patients were predominantly from lower-income families and had more comorbidities, indicating that socioeconomic status could be a significant contributor. LRC patients were typically treated at teaching hospitals and privately owned investment institutions. Our risk-adjusted analysis revealed that LRC patients were more likely to belong to the lowest-income quartile, receive treatment at privately owned investment hospitals, and use self-payment methods. Despite these challenges, the hospital stay duration did not significantly differ between the two groups. Interestingly, LRC patients faced a higher predicted mean total cost compared with those who had surgery before turning 1. This difference in cost did not translate to a longer length of stay, further emphasizing the complexity of managing LRC. These findings highlight the urgent need for earlier intervention in craniosynostosis cases, particularly in lower-income communities. The medical community must strive to improve early diagnosis and treatment strategies in order to mitigate the socioeconomic and health disparities observed in LRC patients. [ABSTRACT FROM AUTHOR]

Most psychologists and educators assume that intelligence is a linear construct, meaning that smart people simply have more intelligence than their less gifted peers. Likewise, individuals with mental retardation are thought to have less intelligence. In contrast to this widely accepted belief, the authors posed an alternative hypothesis--that intelligence is qualitatively different in various populations. Using factor analysis of a standardization sample of the Woodcock-Johnson Test of Cognitive Ability (R. W. Woodcock & M. B. Johnson, 1989), the authors examined the nature of intellect across ability. Results indicated that the amount of variance attributable to Spearman's g declined as measured intellectual ability increased. (Contains 3 tables and 2 figures.)

(1) Introduction: Traumatic brain injury (TBI) is a leading cause of injury and mortality worldwide, carrying an estimated cost of $38 billion in the United States alone. Neutrophil to lymphocyte ratio (NLR) has been investigated as a standardized biomarker that can be used to predict outcomes of TBI. The aim of this review was to determine the prognostic utility of NLR among patients admitted for TBI. (2) Methods: A literature search was conducted in PubMed, Scopus, and Web of Science in November 2022 to retrieve articles regarding the use of neutrophil to lymphocyte ratio (NLR) as a prognostic measure in traumatic brain injury (TBI) patients. Inclusion criteria included studies reporting outcomes of TBI patients with associated NLR values. Exclusion criteria were studies reporting only non-primary data, those insufficiently disaggregated to extract NLR data, and non-English or cadaveric studies. The Newcastle-Ottawa Scale was utilized to assess for the presence of bias in included studies. (3) Results: Following the final study selection 19 articles were included for quantitative and qualitative analysis. The average age was 46.25 years. Of the 7750 patients, 73% were male. Average GCS at presentation was 10.51. There was no significant difference in the NLR between surgical vs. non-surgical cohorts (SMD 2.41 95% CI −1.82 to 6.63, p = 0.264). There was no significant difference in the NLR between bleeding vs. non-bleeding cohorts (SMD 4.84 95% CI −0.26 to 9.93, p = 0.0627). There was a significant increase in the NLR between favorable vs. non-favorable cohorts (SMD 1.31 95% CI 0.33 to 2.29, p = 0.0090). (4) Conclusions: Our study found that NLR was only significantly predictive for adverse outcomes in TBI patients and not surgical treatment or intracranial hemorrhage, making it nonetheless an affordable alternative for physicians to assess patient prognosis. [ABSTRACT FROM AUTHOR]

While LGBTQ youth may be victims of bullying at greater rates than heterosexual youth, research examining in-school bullying and cyberbullying victimization disparities through an intersectional framework is limited. Using the 2017 Youth Risk Behavior Survey, the present study examined the prevalence of in-school bullying and cyberbullying victimization across sexual orientation, gender, race, and grade (N = 13,567). Results position sexual minority youth at higher odds of experiencing in-school bullying and cyberbullying than heterosexual youth and show that bisexual youth were more likely than gay/lesbian youth to be cyberbullied. Findings from intersectional analyses show within-group variation in bullying victimization across sexual orientation based on gender, grade, and race. Specific intersectional results and implications for in-school bullying and cyberbullying prevention and intervention efforts are discussed. [ABSTRACT FROM AUTHOR]

Lung cancer remains the top cause of cancer-related death in the United States. Metastases to the distal phalanges are rare. This case illustrates an interesting presentation of metastatic adenocarcinoma of the lung that was mistaken for a benign condition of the toe. [ABSTRACT FROM AUTHOR]

It is shown that space–time smoothed outgoing longwave radiation (OLR) indices of equatorial Pacific seasonal variability can give an interestingly different perspective on El Niño than is obtained from sea surface temperature (SST) indices or the Southern Oscillation index (SOI). In particular, the index defined by averaging over an eastern-central region exhibits strong event like character—more so than in any other El Niño–Southern Oscillation (ENSO) warm-phase index known to the authors. Although the historical record for OLR is much shorter than for SST or SOI, OLR offers a direct connection to anomalous atmospheric heating. It is suggested that the years identified as events by this OLR index deserve particular recognition; and it is noteworthy that they all meet the criteria for “El Niño” years. Other years, whose warm-ENSO status differs depending upon the index favored, are not particularly distinctive from an OLR perspective, and a case could be made that either the other years do not deserve special classification or that they should be identified as different from the OLR-distinguished El Niño years. [ABSTRACT FROM AUTHOR]

It is shown that space–time smoothed outgoing longwave radiation (OLR) indices of equatorial Pacific seasonal variability can give an interestingly different perspective on El Niño than is obtained from sea surface temperature (SST) indices or the Southern Oscillation index (SOI). In particular, the index defined by averaging over an eastern-central region exhibits strong event like character—more so than in any other El Niño–Southern Oscillation (ENSO) warm-phase index known to the authors. Although the historical record for OLR is much shorter than for SST or SOI, OLR offers a direct connection to anomalous atmospheric heating. It is suggested that the years identified as events by this OLR index deserve particular recognition; and it is noteworthy that they all meet the criteria for “El Niño” years. Other years, whose warm-ENSO status differs depending upon the index favored, are not particularly distinctive from an OLR perspective, and a case could be made that either the other years do not deserve special classification or that they should be identified as different from the OLR-distinguished El Niño years. [ABSTRACT FROM AUTHOR]

The article presents a study focusing on the prevalence of the amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) among zoo and pet store collections in the Northeastern U.S. The findings include instances of infection in the three L. catesbeianus which were not surprising as the species is a globally well-known vector of Bd, and the infection found in H. cinerea sold at the chain pet store posed a potentially devastating risk because it is a commonly sold pet amphibian in the U.S.

Introduction: Extracorporeal membrane oxygenation (ECMO)-associated compartment syndrome (CS) is a rare complication seen in critically ill patients. The epidemiology and management of ECMO-associated CS in the upper extremity (UE) and lower extremity (LE) are poorly defined in the literature. We sought to determine the epidemiology and characterize treatment and outcomes of UE-CS compared to LE-CS in the setting of ECMO therapy., Methods: Adult patients undergoing ECMO therapy were identified in the Nationwide Readmission Database (2015-2019) and followed up for 6 months. Patients were stratified based on UE-CS versus LE-CS. Primary outcomes were fasciotomy and amputation. All-cause mortality and length of stay were also collected. Risk-adjusted modeling was performed to determine patient- and hospital-level factors associated with differences in the management UE-CS versus LE-CS while controlling for confounders., Results: A total of 24,047 cases of ECMO during hospitalization were identified of which 598 were complicated by CS. Of this population, 507 cases were in the LE (84.8%), while 91 (15.5%) were in the UE. After multivariate analysis, UE-CS patients were less likely to undergo fasciotomy (50.5 vs. 70.9; P = 0.013) and were less likely to undergo amputation of the extremity (3.3 vs. 23.7; P = 0.001) although there was no difference in mortality (58.4 vs. 65.4; P = 0.330)., Conclusions: ECMO patients with CS experience high mortality and morbidity. UE-CS has lower rates of fasciotomy and amputations, compared to LE-CS, with similar mortality. Further studies are needed to elucidate the reasons for these differences., (Published by Elsevier Inc.)

Abstract: Most hospitalized children experience pain that is often inadequately assessed and undertreated. Exposure to undertreated childhood pain is associated with negative short-term and long-term outcomes and can detrimentally affect families, health services, and communities. Adopting electronic medical records (EMRs) in pediatric hospitals is a promising mechanism to transform care. As part of a larger program of research, this study examined the perspectives of pediatric clinical pain experts about how to capitalize on EMR designs to drive optimal family-centered pain care. A qualitative descriptive study design was used and 14 nursing and medical experts from 5 countries (United States, Canada, United Kingdom, Australia, and Qatar) were interviewed online using Zoom for Healthcare. We applied a reflexive content analysis to the data and constructed 4 broad categories: "capturing the pain story," "working with user-friendly systems," "patient and family engagement and shared decision making," and "augmenting pain knowledge and awareness." These findings outline expert recommendations for EMR designs that facilitate broad biopsychosocial pain assessments and multimodal treatments, and customized functionality that safeguards high-risk practices without overwhelming clinicians. Future research should study the use of patient-controlled and family-controlled interactive bedside technology to and their potential to promote shared decision making and optimize pain care outcomes., (Copyright © 2023 International Association for the Study of Pain.)

Background: Premature and sick neonates may require weeks of hospitalization in a noisy neonatal intensive care unit (NICU) environment with sound levels that may reach 120 decibels. The American Academy of Pediatrics recommends a maximum sound level of 45 decibels., Purpose: To measure sound levels in a level III NICU and to describe contributing environmental factors., Methods: Descriptive quantitative study. Sound levels were measured using a portable sound meter in an open-bay level III NICU. Contributing environmental factors were recorded and analyzed., Results: Mean sound levels for day, evening, and night shifts were 83.5, 83, and 80.9 decibels, respectively. Each period of time exceeded the recommended guidelines 90% of the time and was almost double the American Academy of Pediatrics' recommendation. Multiple linear regression findings demonstrated significant factors associated with elevated sound levels including number of neonates, number of people, number of alarms, acuity level, and shift type. Observational data explain 14.5% of elevated sound levels., Implications for Practice: An understanding of baseline sound levels and contributing environmental factors is the first step in developing strategies to mitigate excessive noise in the NICU., Implications for Research: Research should focus on effective and sustainable ways to reduce sound levels in the NICU, including inside the isolette, in order to provide an environment that is conducive to optimal growth and neurodevelopment for preterm and sick infants., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the National Association of Neonatal Nurses.)

Objectives: Suprachoroidal injection of triamcinolone acetonide is the first Food and Drug Administration-approved treatment for macular edema associated with uveitis. A cost-effectiveness analysis was performed comparing this treatment with best supportive care (BSC) for the management of this indication from US Medicare and commercial payer perspectives., Methods: A patient-level simulation was developed per the patient characteristics and changes in best-corrected visual acuity letter scores observed in a phase III study of triamcinolone acetonide (PEACHTREE). The wholesale acquisition cost of triamcinolone acetonide was $1650/injection; suprachoroidal injection cost was assumed at $200/injection. Healthcare costs were informed by a US claims-based analysis. Mortality risk associated with severe vision loss and blindness was modeled by applying a hazard ratio to all-cause mortality rates of the US general population. Health-related quality of life weights, obtained from a regression model fitted to the Visual Function Questionnaire-25 data from PEACHTREE, were applied based on the best-corrected visual acuity scores of both eyes. Costs (2020 US dollar) and benefits were discounted at 3% annually. Incremental cost-effectiveness ratios were estimated over a 10-year horizon., Results: In the base-case, the incremental cost-effectiveness ratio comparing triamcinolone acetonide with BSC was $28 479 per quality-adjusted life-year gained. The wholesale acquisition cost for triamcinolone acetonide for suprachoroidal use was ∼68%, ∼56%, and ∼27% below the willingness-to-pay thresholds of $150 000, $100 000, and $50 000 per quality-adjusted life-year gained, respectively. Results were robust in sensitivity and scenario analyses., Conclusions: Triamcinolone acetonide for suprachoroidal use is cost-effective compared with BSC for patients with macular edema associated with uveitis., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: Millions of people present to the emergency department (ED) with chest pain annually. Accurate and timely risk stratification is important to identify potentially life-threatening conditions such as acute coronary syndrome (ACS). An ED-based observation unit can be used to rapidly evaluate patients and reduce ED crowding, but the practice is not universal. We estimated the number of current hospital admissions in the United States (US) eligible for ED-based observation services for patients with symptoms of ACS., Methods: In this cross-sectional analysis we used data from the 2011-2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were included if patients presented with symptoms of ACS (eg, chest pain, dyspnea), had an electrocardiogram (ECG) and cardiac markers, and were admitted to the hospital. We excluded patients with any of the following: discharge diagnosis of myocardial infarction; cardiac arrest; congestive heart failure, or unstable angina; admission to an intensive care unit; hospital length of stay > 2 days; alteplase administration, central venous catheter insertion, cardiopulmonary resuscitation or endotracheal intubation; or admission after an initial ED observation stay. We extracted data on sociodemographics, hospital characteristics, triage level, disposition from the ED, and year of ED extracted from the NHAMCS. Descriptive statistics were performed using sampling weights to produce national estimates of ED visits. We provide medians with interquartile ranges for continuous variables and percentages with 95% confidence intervals for categorical variables., Results: During 2011-2015 there were an estimated 675,883,000 ED visits in the US. Of these, 14,353,000 patients with symptoms of ACS and an ED order for an ECG or cardiac markers were admitted to the hospital. We identified 1,883,000 visits that were amenable to ED observation services, where 987,000 (52.4%) were male patients, and 1,318,000 (70%) were White. Further-more, 739,000 (39.2%) and 234,000 (12.4%) were paid for by Medicare and Medicaid, respectively. The majority (45.1%) of observation-amenable hospitalizations were in the Southern US., Conclusion: Emergency department-based observation unit services for suspected ACS appear to be underused. Over half of potentially observation-amenable admissions were paid for by Medicare and Medicaid. Implementation of ED-based observation units would especially benefit hospitals and patients in the American South.

Background: An interlaboratory study was performed to compare the performance of the 3 mL TransFix®/EDTA Vacuum Blood Collection Tube (TVT), with the 5 mL Cyto-Chex® BCT tube (BCT). Both devices are intended for collection and storage of whole blood specimens for immunophenotyping of leukocytes by flow cytometry for up to 14 days., Methods: One site in the United States and two in the United Kingdom tested samples from 10 HIV positive patients and four healthy subjects for a total of 42 samples. From each subject, three blood samples were collected: a BD 4 mL K 3 EDTA Vacutainer (Vacutainer), a TVT, and a BCT. At all sites, samples were analyzed on a BD FACS Canto II flow cytometer for a full lymphocyte subset count within 6 h of collection (all devices) and on Day 11 and Day 15 (TVT and BCT only). Data obtained from the Vacutainer were used as the control data set with which TVT and BCT data were statistically compared., Results and Conclusions: Statistical concordance was demonstrated for both devices in relation to cell absolute count recovery. For cell marker signal, both devices exhibited a significant decrease in mean fluorescence intensity (MFI) for the detection of lymphocyte subsets and their target markers. There was a marked increase in autofluorescence observed for BCT stabilized lymphocytes whereas values for the TVTs were comparable to the control. There were eight instances of statistical equivalence between the level of antibody autofluorescence observed in the control tube and the TVT across both patient cohorts, versus two for the BCT. © 2018 International Clinical Cytometry Society., (© 2018 International Clinical Cytometry Society.)

The ACC/AHA blood cholesterol treatment guidelines recommend statin therapy for all patients after experiencing an acute cardiovascular event. Previous analyses have shown that physicians have been slow to adopt guidelines, and many patients remain untreated or undertreated with statins after a cardiovascular event. However, reasons for this remain unknown. This analysis used electronic medical records and patient chart data from Reliant Medical Group (Worcester, Massachusetts) to evaluate physician adherence to the 2013 ACC/AHA blood cholesterol guidelines when treating patients with evidence of acute atherosclerotic cardiovascular disease and the reasons for the observed treatment decisions. Less than 50% of acute atherosclerotic cardiovascular disease patients were treated according to the ACC/AHA guidelines. Nearly 42% of patients not treated according to guidelines received a lower statin intensity than recommended. The most common reason cited by 41.8% of physicians for treating with a statin intensity below the recommended intensity was low-density lipoprotein cholesterol stable or at goal, despite ACC/AHA guidelines recommending specific statin intensities rather than specific low-density lipoprotein cholesterol levels. In conclusion, physician and patient education on the importance of maximizing lipid-lowering therapy in this high-risk patient population should be emphasized., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

U.S. State Medicaid programs for the medically indigent strive to deliver quality health care services with limited budgets. An often used cost management strategy is prior authorization of services or prescription medications. The goal of this strategy is to shape the pharmaceutical market share in the most efficient manner for the particular state Medicaid program, much like commercial managed care organizations. These policies are often scrutinized due to the population Medicaid serves, which in the past was largely composed of individuals with vulnerable health status. Unintended consequences can occur if these policies are not carried out in an appropriate manner or if they greatly restrict services. The data used for policy implementation research is prone to certain problems such as skewness and multimodality. Previous guidelines have been published regarding the best practices when analyzing these data. These guidelines were used to review the current body of literature regarding prior authorization in Medicaid. Further discussed are additional characteristics such as therapeutic areas researched and the outcomes identified. Finally, the importance of considering state-specific characteristics when reviewing individual policies and the usefulness of these results for other programs are also considered., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aims: Older and disabled rheumatoid arthritis (RA) patients are often not present in large numbers in clinical trials or registries. A novel, claims-based clinical effectiveness algorithm provides the potential to compare the effectiveness of different biologics among this population using large administrative databases., Method: Using Medicare 2006-2010 data for 100% of patients with RA, we identified biologic naïve users of abatacept, adalimumab, etanercept and infliximab, defined as no biologic use during the 12 months before the biologic initiation. The effectiveness was evaluated at 365 days after biologic initiation, determined using a validated claims-based algorithm. We compared the proportion meeting effectiveness criteria for each biologic using robust Poisson regression to compute risk ratios (RRs) adjusted for potential confounders. One year cost per effectively treated patient was calculated by different biologics., Results: The study included biologic naïve users of abatacept (n = 2129), adalimumab (n = 2944), etanercept (n = 3517) and infliximab (n = 5654). The algorithm classified the medications as 26% effective for abatacept, 24% for adalimumab, 28% for etanercept and 23% for infliximab, indicating comparable effectiveness. However, after adjustment and compared with infliximab, the RRs for effectiveness were 1.17 (95% CI 1.06, 1.30) for abatacept, 1.11 (95% CI 1.02, 1.23) for adalimumab and 1.27 (95% CI 1.17, 1.39) for etanercept. Older patients had a higher effectiveness than patients who were disabled (RR = 1.18, 95% CI 1.08, 1.28). Infliximab had highest cost per effectively treated patient., Conclusion: Abatacept, adalimumab and etanercept are more effective than infliximab among RA patients initiating biologics. Effectiveness was significantly higher among older patients compared with disabled RA Medicare patients., (© 2015 The British Pharmacological Society.)

Objective: Intrathecal (IT) morphine improves pain control and decreases opioid requirements in children following thoracic and abdominal surgery. However, studies in children report variable durations of analgesia following IT morphine. The purpose of this study is to describe the duration of analgesia in children undergoing surgical correction of idiopathic scoliosis., Design: Retrospective chart review., Setting: Pediatric hospital within a tertiary care academic medical center., Participants: Forty-four pediatric patients with idiopathic scoliosis who received IT morphine following posterior spinal fusion (PSF)., Main Outcome Measure(s): Mean opioid exposure 0-12 hours and 13-24 hours post-IT morphine., Results: Mean opioid exposure was significantly increased during the 13-24-hour compared to the 0-12-hour time period (23.0 ± 12.5 mg parenteral morphine vs 15.9 ± 1.7 mg; p = 0.0006). The only factors significantly associated with morphine exposure during the 0-12-hour period included the median pain score (0-12 hours) (odds ratio [OR], 1.92; 95% confidence interval [CI], 0.033-3.80; p = 0.046) and total acetaminophen dose (OR, 0.003; 95% CI, 0.0008-0.005; p = 0.011)., Conclusions: These data indicate that patients experienced improved analgesia for at least 12 hours following IT morphine. Increased use of adjuvant analgesics such as acetaminophen may reduce opioid requirements following PSF procedures. More studies are needed to investigate the combination of adjuvants and IT morphine to reduce postoperative pain in this population.

Background: Patients receiving long-term parenteral nutrition (PN) are at increased risk of aluminium (Al) toxicity because of bypass of the gastrointestinal tract during PN infusion. Complications of Al toxicity include metabolic bone disease (MBD), Al-associated encephalopathy in adults, and impaired neurological development in preterm infants. Unlike the United States, there are no regulations regarding Al content of large- and small-volume parenterals in Canada. We, therefore, aimed to present our data on plasma Al concentration and Al intake from our cohort of pediatric patients receiving long-term PN., Methods: Plasma Al concentration was retrospectively gathered from the patient charts of all 27 patients with intestinal failure (IF) receiving long-term PN at The Hospital for Sick Children, Toronto, Canada, and compared with age- and sex-matched controls recruited for comparison. In addition, Al concentration was measured in PN samples collected from 10 randomly selected patients with IF and used to determine their Al intake., Results: The plasma Al concentration of patients with IF receiving long-term PN was significantly higher than that of control participants (1195 ± 710 vs 142 ± 63 nmol/L; P < .0001). In the subgroup of 10 patients for whom Al intake from their PN solution was determined, mean ± SD Al intake from PN was 15.4 ± 15 µg/kg, 3 times the Food and Drug Administration upper recommended intake level, and Al intake was significantly related to plasma Al concentration (P = .02, r (2) = 0.52)., Conclusion: Pediatric patients receiving long-term PN for IF in Canada are at risk for Al toxicity., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Background: Post-traumatic stress disorder (PTSD) in response to the World Trade Center (WTC) disaster of 11 September 2001 (9/11) is one of the most prevalent and persistent health conditions among both professional (e.g. police) and non-traditional (e.g. construction worker) WTC responders, even several years after 9/11. However, little is known about the dimensionality and natural course of WTC-related PTSD symptomatology in these populations., Method: Data were analysed from 10 835 WTC responders, including 4035 police and 6800 non-traditional responders who were evaluated as part of the WTC Health Program, a clinic network in the New York area established by the National Institute for Occupational Safety and Health. Confirmatory factor analyses (CFAs) were used to evaluate structural models of PTSD symptom dimensionality; and autoregressive cross-lagged (ARCL) panel regressions were used to examine the prospective interrelationships among PTSD symptom clusters at 3, 6 and 8 years after 9/11., Results: CFAs suggested that five stable symptom clusters best represent PTSD symptom dimensionality in both police and non-traditional WTC responders. This five-factor model was also invariant over time with respect to factor loadings and structural parameters, thereby demonstrating its longitudinal stability. ARCL panel regression analyses revealed that hyperarousal symptoms had a prominent role in predicting other symptom clusters of PTSD, with anxious arousal symptoms primarily driving re-experiencing symptoms, and dysphoric arousal symptoms primarily driving emotional numbing symptoms over time., Conclusions: Results of this study suggest that disaster-related PTSD symptomatology in WTC responders is best represented by five symptom dimensions. Anxious arousal symptoms, which are characterized by hypervigilance and exaggerated startle, may primarily drive re-experiencing symptoms, while dysphoric arousal symptoms, which are characterized by sleep disturbance, irritability/anger and concentration difficulties, may primarily drive emotional numbing symptoms over time. These results underscore the importance of assessment, monitoring and early intervention of hyperarousal symptoms in WTC and other disaster responders.

Background: Public policymakers often struggle with increased membership and limited budgets. Restrictions, commonly in the form of prior authorizations, are often placed on more costly pharmaceuticals, especially when lower cost or more effective products are available. Restrictions placed on products for difficult-to-manage disease states must be reviewed in order to ensure that unintended clinical consequences do not occur., Objective: To assess the impact of a prior authorization policy for montelukast on clinical outcomes for asthma and allergic rhinitis among children and adolescent members of Oklahoma Medicaid (MOK) from 2007 through 2010., Methods: Monthly individual-level utilization data were collected from MOK paid pharmacy and medical claims from January 1, 2007, through December 31, 2010, for members with asthma and/or allergic rhinitis. Members who were continuously eligible for the entire 48-month review period were included. The effect of a prior authorization policy for montelukast on emergency room (ER) utilization, disease-related physician office visits (DRV), and antibiotic prescription utilization (ABX) was analyzed using segmented logistic regression., Results: For all 3 outcomes, decreases in mean number of claims per member per month were detected when comparing the pre-implementation and post-implementation prior authorization periods for all 3 disease states of asthma, allergic rhinitis, or both. Odds of having an ER event at the point of prior authorization implementation were 0.71 (P  less than  0.001) and were 1.29 (P  less than  0.001) and 1.26 (P  less than  0.001) for DRV and ABX, respectively. Overall trend in odds was 1.02 (P  less than  0.001), 0.93 (P  less than  0.001), and 0.95 (P  less than  0.001) for ER, DRV, and ABX, but during the post-implementation period, the odds were 0.92 (P  less than  0.001) for ER and 1.03 (P  less than  0.001) for both DRV and ABX. The final result was an increasing trend prior to implementation for ER, a decrease at implementation, and a continued decrease in odds of an event in the post-implementation period. However, for DRV and ABX, there was an overall decrease in trend regardless of period, with a small increase in odds at the point of implementation., Conclusions: While there was a point increase at implementation for DRV and ABX, the overall trend remained negative, indicating that no unexpected adverse clinical outcomes occurred. Additionally, no signal was found in ER use after implementation to indicate that unintended consequences occurred, particularly for those patients with asthma.

First-year turnover of newly licensed registered nurses is reported as high as 40%-60%. Turnover can be reduced to 10% or less with a nurse residency program. This study compared three best practices within a single health system. The three aims were to determine first-year turnover of newly licensed registered nurses for three sites, compare outcomes after one-year posthire, and examine intent to stay. Although there were only a few statistically significant differences, the trend was positive for the site with a nurse residency program.

Background: Thousands of rescue and recovery workers descended on the World Trade Center (WTC) in the wake of the terrorist attack of September 11, 2001 (9/11). Recent studies show that respiratory illness and post-traumatic stress disorder (PTSD) are the hallmark health problems, but relationships between them are poorly understood. The current study examined this link and evaluated contributions of WTC exposures., Method: Participants were 8508 police and 12 333 non-traditional responders examined at the WTC Medical Monitoring and Treatment Program (WTC-MMTP), a clinic network in the New York area established by the National Institute for Occupational Safety and Health (NIOSH). We used structural equation modeling (SEM) to explore patterns of association among exposures, other risk factors, probable WTC-related PTSD [based on the PTSD Checklist (PCL)], physician-assessed respiratory symptoms arising after 9/11 and present at examination, and abnormal pulmonary functioning defined by low forced vital capacity (FVC)., Results: Fewer police than non-traditional responders had probable PTSD (5.9% v. 23.0%) and respiratory symptoms (22.5% v. 28.4%), whereas pulmonary function was similar. PTSD and respiratory symptoms were moderately correlated (r=0.28 for police and 0.27 for non-traditional responders). Exposure was more strongly associated with respiratory symptoms than with PTSD or lung function. The SEM model that best fit the data in both groups suggested that PTSD statistically mediated the association of exposure with respiratory symptoms., Conclusions: Although longitudinal data are needed to confirm the mediation hypothesis, the link between PTSD and respiratory symptoms is noteworthy and calls for further investigation. The findings also support the value of integrated medical and psychiatric treatment for disaster responders.

Introduction: Rheumatoid arthritis (RA) is a chronic disease that if left untreated may substantially impair physical functioning. Etanercept, infliximab, and adalimumab are tumor necrosis factor (TNF) blockers whose FDA-approved indications in the US include moderate to severe RA. TNF-blocker dose escalation has been well documented in the literature; however, the comparative effectiveness of these agents remains uncertain., Objective: To compare the effectiveness and dose escalation rates of etanercept, adalimumab, and infliximab in US community settings. We hypothesized that etanercept would be equivalent to infliximab and adalimumab in patient-reported disability 9-15 months after therapy initiation, and that fewer etanercept patients would experience dose escalation., Methods: This is a retrospective analysis of the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS). Adult patients with no biologic use 6 months before TNF-blocker initiation (index) and with Health Assessment Questionnaire Disability Index (HAQ-DI) scores at index and 9-15 months after index were analyzed (218 etanercept, 93 infliximab, and 40 adalimumab)., Results: HAQ-DI change scores at 9-15 months did not differ by treatment (-0.12, -0.10, and -0.08 points for etanercept, infliximab, and adalimumab, respectively; p = 0.52). Dose increases were observed in 1.4% of etanercept, 10.8% of infliximab (p < 0.001), and 12.5% of adalimumab patients (p = 0.004). HAQ-DI change was associated with pre-index HAQ-DI score (p < 0.0001) and disease duration (p = 0.001)., Conclusions: Fewer etanercept patients escalated dose than infliximab or adalimumab patients, but improvements in functional disability were similar. These differences may have been influenced by package labeling, mode of administration, or other factors. RA treatment with infliximab and adalimumab in community settings, characterized by dose escalation, did not yield greater disability improvements compared to etanercept, which remained at a relatively stable dose. Uncontrolled treatment selection in this observational design may have influenced outcomes, and prior methotrexate treatment may partly explain disability improvements smaller than typically observed in clinical trials.

Social media use has moved beyond just being a way for family and friends to keep in touch. Now it is imperative that all businesses implement a social media strategy into their overall marketing plan. Medical practices are no exception. Using social media within your medical practice will allow you take your marketing to a new level of success. It also allows you to connect with patients on a more personal, less corporate level.

Background: More than 20,000 responders have been examined through the World Trade Center (WTC) Medical Monitoring and Treatment Program since September 11, 2001. Studies on WTC firefighters have shown elevated rates of sarcoidosis. The main objective of this study was to report the incidence of "sarcoid like" granulomatous pulmonary disease in other WTC responders., Methods: Cases of sarcoid like granulomatous pulmonary disease were identified by: patient self-report, physician report and ICD-9 codes. Each case was evaluated by three pulmonologists using the ACCESS criteria and only "definite" cases are reported., Results: Thirty-eight patients were classified as "definite" cases. Six-year incidence was 192/100,000. The peak annual incidence of 54 per 100,000 person-years occurred between 9/11/2003 and 9/11/2004. Incidence in black responders was nearly double that of white responders. Low FVC was the most common spirometric abnormality., Conclusions: Sarcoid like granulomatous pulmonary disease is present among the WTC responders. While the incidence is lower than that reported among firefighters, it is higher than expected., (Copyright © 2010 Wiley-Liss, Inc.)

Background: There is growing concern over increasingly limited access to local health care, including pharmacies, for rural citizens of the United States. Although geographically distant from most competitors, rural pharmacies may still struggle to generate an acceptable profit to remain economically viable. Therefore, a method for calculating the economic viability for a community pharmacy to recruit a potential new owner to assume the entrepreneurial risk is an important issue to consider when evaluating rural pharmacy access., Objectives: The primary objective of this study was to use a modified break-even analysis to predict the future financial potential of the current pharmacy business to attract a new owner. The secondary objective was to forecast a risk level for a Nebraska county to sustain the number of pharmacies in the country beyond current ownership., Methods: This research used data provided by pharmacies that responded to a Nebraska Medicaid cost of dispensing (COD) survey in addition to data from the US Census Bureau, US Office of Management and Budget, and the Nebraska State Board of Pharmacy. Break-even analysis was used to determine the point where the prescription volume of the pharmacy not only covered the variable and fixed costs but also maintained a reasonable profit to attract new ownership. Counties were classified into 3 risk levels based on the projected available prescription volume and the number of pharmacies in each county. Sensitivity analysis was performed on the risk levels to determine the impact of variance in projected available prescription volume on the projected future outlook for the pharmacies in each county., Results: Regression analysis of responses to the COD survey indicated that the annual break-even prescription volume ranged from 44,790 to 49,246 prescriptions per pharmacy per annum. The number of rural Nebraska pharmacies was projected to decline from 126 to 78. The number of counties in Nebraska without a single pharmacy was projected to increase from 19 to 26, and the number of counties with just one pharmacy was projected to increase from 17 to 31. Thus, the number of counties with 1 or no pharmacy was projected to increase to 57 out of the total 93 Nebraska counties., Conclusions: The forecasted closure of pharmacies in rural areas will cause significant portions of the state to be without a pharmacy. Low county populations will be unable to sustain a local prescription volume large enough to remove them from the high risk of pharmacy closure., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objective: This brief report describes the engagement strategy used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a nine-month family psychoeducation program for veterans with serious mental illness or posttraumatic stress disorder (PTSD)., Methods: A motivational interviewing-based strategy was created and implemented in a Veterans Affairs hospital to engage providers and veterans and their families into the intervention., Results: Of the 1,539 veterans told about the program, 41% had a family member living nearby and were willing to meet with a provider to learn more. REACH providers met with 505 veterans for a motivational-interviewing session to explore family participation. Of the 436 veterans who were eligible to participate in REACH, 28% of veterans with PTSD, 34% of veterans with an affective disorder, and 25% of veterans with a schizophrenia spectrum disorder went on to participate in at least one session of the REACH program with a family member; these rates compare favorably with those for programs requiring a much shorter commitment., Conclusions: This engagement strategy shows promise as an effective tool in recruiting veterans and their families into family psychoeducation.

Background: The World Trade Center (WTC) attacks exposed thousands of workers to hazardous environmental conditions and psychological trauma. In 2002, to assess the health of these workers, Congress directed the National Institute for Occupational Safety and Health to establish the WTC Medical Monitoring and Treatment Program. This program has established a large cohort of WTC rescue, recovery, and cleanup workers. We previously documented extensive pulmonary dysfunction in this cohort related to toxic environmental exposures., Objectives: Our objective in this study was to describe mental health outcomes, social function impairment, and psychiatric comorbidity in the WTC worker cohort, as well as perceived symptomatology in workers' children., Methods: Ten to 61 months after the WTC attack, 10,132 WTC workers completed a self-administered mental health questionnaire., Results: Of the workers who completd the questionnaire, 11.1% met criteria for probable post-traumatic stress disorder (PTSD), 8.8% met criteria for probable depression, 5.0% met criteria for probable panic disorder, and 62% met criteria for substantial stress reaction. PTSD prevalence was comparable to that seen in returning Afghanistan war veterans and was much higher than in the U.S. general population. Point prevalence declined from 13.5% to 9.7% over the 5 years of observation. Comorbidity was extensive and included extremely high risks for impairment of social function. PTSD was significantly associated with loss of family members and friends, disruption of family, work, and social life, and higher rates of behavioral symptoms in children of workers., Conclusions: Working in 9/11 recovery operations is associated with chronic impairment of mental health and social functioning. Psychological distress and psychopathology in WTC workers greatly exceed population norms. Surveillance and treatment programs continue to be needed.

Continuous Speech Recognition Technology implementation is expensive, and the failure of leading companies in this niche can hamper usefulness. C-SRT, if deployed and used with speech macros, experiences vastly improved implementations and drastically reduces medical transcription costs.A speech macro is a short phrase that is automatically translated into a block of text or a graphic display. A more powerful form of speech macro can bring up predefined templates and insert spoken text into the proper position automatically, based on its interpretation. Cases from the author's consulting experiences and from medical journals emphasize the need for speech macros from a cost-benefit standpoint. A prototype program is introduced that facilitates the process of creating macros. The need for macro management software is reconciled with current research on speech recognition and technology adoption. A planned experiment is discussed.

Laboratory animal allergy (LAA) is a significant occupational disease that may affect up to one third of personnel exposed to laboratory animals. Research has characterized the relative risks of exposure, in terms of intensity, frequency, and duration, associated with given tasks and work areas in the animal facility. Studies have shown that reduced exposure to animal allergens can reduce the incidence of LAA and relieve symptoms among affected workers. A combination of measures to eliminate or control allergen exposure, including engineering and administrative controls and personal protective equipment, have been integral components of effective LAA management programs. The author provides a comprehensive review of exposure control options, considerations, and " best practices" relative to laboratory animal allergen in the context of traditional industrial hygiene methods.

Objective: To determine the safety of the zidovudine (ZDV) regimen utilized in the Pediatric AIDS Clinical Trial Group (ACTG) 076 study., Design: ACTG 076 was a randomized, double-blind, placebo-controlled trial which demonstrated that a ZDV regimen could prevent mother-to-child HIV-1 transmission. Infants were followed through 18 months of age and women were followed through 6 months postpartum., Methods: Maternal complications, pregnancy outcomes, growth and development of the uninfected infants, and HIV-1 disease progression in the women were monitored prospectively., Results: Maternal therapy was well tolerated. There was no serious pattern of adverse pregnancy outcomes associated with ZDV use. Amongst the ZDV-exposed infants, the only recognized toxicity was anemia within the first 6 weeks of life; the risk for anemia was not associated with premature delivery, duration of maternal treatment, degree of maternal immunosuppression, or maternal anemia. ZDV treatment was not associated with an increased incidence of newborn structural abnormalities. At 18 months of age, uninfected infants did not differ in growth parameters or immune function. No childhood neoplasias were reported in either group. In the women, at 6 months postpartum, there were no differences in clinical, immunologic, or virologic disease progression., Conclusion: There were no identified problems that would alter current recommendations for the routine use of ZDV for the prevention of mother-child HIV-1 transmission.

Background: Preventable drug-related morbidity and mortality within nursing facilities represent a serious problem urgently requiring expert medical attention. The health care costs of drug-related problems can be both immense and avoidable. However, the research to date has been narrow in scope, focusing on the drug costs avoided and failing to consider the wider range of possible negative outcomes and potential drug-related problems., Objectives: To develop a model of therapeutic outcomes resulting from drug therapy within nursing facilities, to estimate the magnitude of the cost of drug-related morbidity and mortality within nursing facilities in the United States, and to assess the impact of pharmacist-conducted, federally mandated, monthly, retrospective review of nursing facility residents' drug regimens in reducing the cost of drug-related morbidity and mortality., Methods: Using decision analysis techniques, a probability pathway model was developed to estimate the cost of drug-related problems within nursing facilities. An expert panel consisting of consultant pharmacists and physicians with practice experience in nursing facilities and geriatric care was surveyed to determine conditional probabilities of therapeutic outcomes attributable to drug therapy. Health care utilization and associated costs derived from negative therapeutic outcomes were estimated., Results: Baseline estimates indicate that the cost of drug-related morbidity and mortality with the services of consultant pharmacists was $4 billion compared with $7.6 billion without the services of consultant pharmacists., Conclusions: Drug-related morbidity and mortality in nursing facilities represent a serious economic problem. For every dollar spent on drugs in nursing facilities, $1.33 in health care resources are consumed in the treatment of drug-related problems. With the current federally mandated drug regimen review, it is estimated that consultant pharmacists help to reduce health care resources attributed to drug-related problems in nursing facilities by $3.6 million.

Background: Poison exposures are a significant public health concern. Despite the impact that regional poison control centers have on reducing morbidity and mortality associated with poison exposures, they are facing a serious financial crisis today resulting in an increased emphasis on their economic justification., Methods: Using decision-analysis techniques, the cost-effectiveness of the treatment of poison exposures with the services of a regional poison control center compared with treatment without access to any poison control center was evaluated. The relative cost-effectiveness was modeled based on 2 outcomes (morbidity and mortality) for each of 4 typical poison exposures. Additionally, analyses were conducted to test the sensitivity of the cost-effectiveness ratios to outcome probability, average inpatient and emergency department costs, and proportion of poison exposures treated on site by the regional poison control center. A societal perspective was adopted., Results: The regional poison control center was substantially more cost-effective than the treatment of poison exposures without the services of a regional poison control center for both outcomes (morbidity and mortality) in each of the poison exposures considered. The results of the sensitivity analyses demonstrated that the outcomes of the decision analyses do not change regardless of the type of poison exposure, outcome considered, clinical outcome probabilities, average inpatient and emergency department costs, and proportion of poison-exposure cases treated on site by a regional poison control center., Conclusions: The regional poison control center is consistently more cost-effective in the treatment of poison exposures with an average cost-effectiveness ratio (cost per successful outcome) approximately half of that achieved without the services of a regional poison control center. Finally, significant cost savings to society are realized for each additional successful outcome obtained with a regional poison control center.

To identify the significant inputs, activities, and outputs of a regional poison control center, a production model is described and its potential application to the conduct of economic evaluations delineated. The model can help the researcher identify the significant inputs (costs) incurred through the provision of poison control center services. These inputs directly influence the activities that the poison center is capable of undertaking. Activities undertaken by a poison center are intermediate steps between the inputs and outputs, and serve to convert the various inputs into associated outputs. They form the basis for determining the outputs produced by the poison center services. The outputs derived from poison center services provide the conceptual framework for assessing the effectiveness of a poison center in an economic analysis. Also described are potential applications of the production model in conducting poison center cost-effectiveness and cost-benefit analyses.

Objectives: The purpose of this study was to determine the involvement in and attitudes toward managed care by cardiovascular specialists and the influence of such programs on their practices., Background: No in-depth study has measured the impact of managed care on cardiovascular specialists. Therefore, we conducted a mail survey to determine the prevalence of managed care arrangements among cardiovascular specialists and variations among pediatric and adult cardiologists and cardiovascular surgeons; the types of managed care arrangements in which cardiovascular specialists are engaged; the reasons why those not participating in managed care have chosen not to do so; and the general attitudes among cardiovascular specialists with regard to various aspects of managed care. In addition, we evaluated the impact of managed care among several aspects of cardiovascular practice., Methods: A questionnaire was mailed in the spring of 1993 to 4,577 practicing, domestic, American College of Cardiology (ACC) members selected at random from within each primary cardiovascular specialty group (adult cardiologists, pediatric cardiologists and cardiovascular surgeons). Additional data concerning practice characteristics were cross tabulated using results from the 1992 ACC membership profile survey., Results: In total, 1,961 of the 4,577 members responded to the survey, representing a 43% response rate. Of all survey respondents, 76% reported entering into at least one relationship with a health maintenance organization (HMO) or preferred provider organization (PPO). Of those not participating in managed care arrangements, the most frequently mentioned reason was "concern over the quality of care." This reason was cited by 51% of those not entering into HMO relationships and 41% of those not participating in PPOs. The majority of respondents indicated that they do not strongly object to the gatekeeper approach to managing nonemergent patients, although more than half indicated concern that gatekeepers may not be appropriate in the management of cardiac emergencies. In addition, cardiovascular specialists report that under managed care, referrals have not increased, income has decreased, and managed care formularies have not substantially affected their ability to prescribe appropriate medication to their patients., Conclusions: Despite concerns over the quality of care and contract requirements and general philosophical opposition of cardiovascular specialists, most are becoming integrated into managed care environments.