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INTRODUCTION: It is essential that professional standards of excellence are demonstrated in the continuing medical education (CME) curriculum and research. METHODS: This review examines 20 randomized controlled trial (RCT) studies in CME and their effect on physician performance and/or patient health care outcomes. A systematic evaluation of the 20 RCT articles was performed. The investigators of the trials were interviewed using a standardized interview schedule. Citations from science and social science publications were compiled to obtain an unobtrusive measure of the influence of the trials. RESULTS: Investigators were most often motivated to build on earlier research of others, their own earlier research, or a combination of others' earlier research and their own. The most effective educational strategies used multiple interventions, two-way communications, printed and graphic materials in person, and locally respected health personnel as educators. Statistically significant findings more often related to physician performance than to patient health care outcomes. The most effective studies were the ones in which the educational methods were cost effective, findings could be generalized to other physician groups, the studies were implemented elsewhere in multisite health care and health-related programs and had the most citations. Investigators interviewed about their RCTs provided advice for future directions of CME curriculum development and research. DISCUSSION: CME program directors should determine what physicians need to learn, should reach out to nonparticipating physicians, and should focus on relevant problem areas. These problem areas should be ones in which it is possible to make changes, particularly in patient health care outcomes. [ABSTRACT FROM AUTHOR]

Abstract To dissect the haplotype structure of candidate genes for disease association studies, it is important to understand the nature of genetic variation at these loci in different populations. We present a survey of haplotype structure and linkage disequilibrium of chemokine and chemokine receptor genes in 11 geographically-distinct population samples (n = 728). Chemokine proteins are involved in intercellular signalling and the immune response. These molecules are important modulators of human immunodeficiency virus (HIV)-1 infection and the progression of the acquired immune deficiency syndrome, tumour development and the metastatic process of cancer. To study the extent of genetic variation in this gene family, single nucleotide polymorphisms (SNPs) from 13 chemokine and chemokine receptor genes were genotyped using the 5' nuclease assay (TaqMan). SNP haplotypes, estimated from unphased genotypes using the Expectation-Maximization-algorithm, are described in a cluster of four CC-chemokine receptor genes (CCR3, CCR2, CCR5 and CCRL2) on chromosome 3p21, and a cluster of three CC-chemokine genes [MPIF-1 (CCL23) PARC (CCL18) and MIP- 1α (CCL3)] on chromosome 17q11-12. The 32 base pair (bp) deletion in exon 4 of CCR5 was also included in the haplotype analysis of 3p21. A total of 87.5 per cent of the variation of 14 biallelic loci scattered over 150 kilobases of 3p21 is explained by 11 haplotypes which have a frequency of at least 1 per cent in the total sample. An analysis of haplotype blocks in this region indicates recombination between CCR2 and CCR5, although long-range pairwise linkage disequilibrium across the region appears to remain intact on two common haplotypes. A reduced-median network demonstrates a clear relationship between 3p21 haplotypes, rooted by the putative ancestral haplotype determined by direct sequencing of four primate species. Analysis of six SNPs on 17q11-12 indicates that 97.5 per cent of the variation is explained by 15 haplotypes, representing at least 1 per cent of the total sample. Additionally, a possible signature of selection at a non-synonymous coding SNP (M106V) in the MPIF-1 (CCL23) gene warrants further study. We anticipate that the results of this study of chemokine and chemokine receptor variation will be applicable to more extensive surveys of long-range haplotype structure in these gene regions and to association studies of HIV-1 disease and cancer.

Abstract Chemokine signals and their cell-surface receptors are important modulators of HIV-1 disease and cancer. To aid future case/control association studies, aim to further characterise the haplotype structure of variation in chemokine and chemokine receptor genes. To perform haplotype analysis in a population-based association study, haplotypes must be determined by estimation, in the absence of family information or laboratory methods to establish phase. Here, test the accuracy of estimates of haplotype frequency and linkage disequilibrium by comparing estimated haplotypes generated with the expectation maximisation (EM) algorithm to haplotypes determined from Centre d'Etude Polymorphisme Humain (CEPH) pedigree data. To do this, they have characterised haplotypes comprising alleles at 11 biallelic loci in four chemokine receptor genes (CCR3, CCR2, CCR5 and CCRL2), which span 150 kb on chromosome 3p21, and haplotyes of nine biallelic loci in six chemokine genes [MCP-1(CCL2), Eotaxin(CCL11), RANTES(CCL5), MPIF-1(CCL23), PARC(CCL18) and MIP-1α(CCL3) ] on chromosome 17q11-12. Forty multi-generation CEPH families, totalling 489 individuals, were genotyped by the TaqMan 5'-nuclease assay. Phased haplotypes and haplotypes estimated from unphased genotypes were compared in 103 grandparents who were assumed to have mated at random. For the 3p21 single nucleotide polymorphism (SNP) data, haplotypes determined by pedigree analysis and haplotypes generated by the EM algorithm were nearly identical. Linkage disequilibrium, measured by the D' statistic, was nearly maximal across the 150 kb region, with complete disequilibrium maintained at the extremes between CCR3-Y17Y and CCRL2-1243V. D'-values calculated from estimated haplotypes on 3p21 had high concordance with pairwise comparisons between pedigree-phased chromosomes. Conversely, there was less agreement between analyses of haplotype frequencies and linkage disequilibrium using estimated haplotypes when compared with pedigree-phased haplotypes of SNPs on chromosome 17q11-12. These results suggest that, while estimations of haplotype frequency and linkage disequilibrium may be relatively simple in the 3p21 chemokine receptor cluster in population samples, the more complex environment on chromosome 17q11-12 will require a higher resolution haplotype analysis.

CONTEXT: Although the first commercial polyurethane condom was approved for use several years ago, no U.S. clinical trial has compared its performance to that of the latex condom. METHODS: In a masked crossover study, 360 couples were randomized to use three polyurethane condoms and three latex condoms. After each use, couples recorded condom breaks, condom slips and other aspects of performance. At completion of the study, couples compared the sensitivity, ease of use, fit and lubrication of the two types of condoms. RESULTS: The clinical breakage rate of the polyurethane condom was 7.2%, compared with 1.1% for the latex condom (relative risk of 6.6, 95% confidence interval of 3.5-12.3). The complete slippage rate (combining incidents during intercourse and withdrawal) of the polyurethane condom was 3.6%, compared with 0.6% for the latex condom (relative risk of 6.0, 95% confidence interval of 2.6-14.2). Most male users preferred the sensitivity provided by the polyurethane condom to that of the latex condom. CONCLUSIONS: The clinical breakage rate of the polyurethane condom is significantly higher than that of the latex condom. However, nearly half of the users preferred the polyurethane condom, which provides an option for couples who have rejected conventional condoms or who cannot use latex products. [ABSTRACT FROM AUTHOR]

Research from the past few decades has highlighted the long- and wide-reaching effects of adverse childhood experiences (ACEs). These experiences can negatively affect mental and physical health, as well as behaviors and interpersonal relationships well into adulthood. While it is generally understood that ACEs are prevalent in correctional populations, no prior studies have measured this issue using a large representative and racially and ethnically diverse sample of both male and female adult correctional populations in the United States. The data used for this study were collected via an assessment administered to more than 2,100 adults in Minnesota's prison system. Descriptive findings revealed that multiple and varied forms of ACEs were common in the histories of this state's incarcerated population, particularly among females and incarcerated persons who identified as Black, White/non-Hispanic, and American Indian/Alaskan Native. The multivariate results revealed that past exposure to ACEs increased the likelihood and speed of disciplinary convictions after admission to prison for males, but not for females. Overall, the results underscored the importance of assessing for responsivity factors upon admission to prison, including ACEs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Objective: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates., Methods: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis., Results: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive., Conclusions: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care., Competing Interests: Dr. Landes reports serving as a consultant for RAND and UTHealth Houston. Dr. Kirchner reports serving as a consultant for ViiV Healthcare. Dr. Brenner reports receiving editorial remuneration from Wolters Kluwer and royalties from the American Psychological Association and Oxford University Press and serving as a consultant for sports leagues. Dr. Trafton reports being employed by the Institute for Brain Potential. The other authors report no financial relationships with commercial interests.

The current qualitative study assessed leadership and staff perceptions related to resident safety at Department of Veterans Affairs (VA) nursing homes with a range of safety climates. We recruited a purposive sample of six VA nursing homes from geographically diverse regions of the United States and with diverse overall safety climate ratings. We conducted semi-structured phone interviews with 43 senior and middle level nursing home leaders and frontline providers (medical and nursing). We performed a thematic analysis of interview data to assess participant perceptions of factors that influence resident safety at higher and lower safety climate sites. Analyses identified two factors that differentiated VA nursing homes with high safety climate ratings from those with medium or low ratings: (1) communication about resident safety, particularly the important role of accessibility of physicians and managers; and (2) leadership support for and responsiveness to resident safety issues raised by frontline staff. Findings from high safety climate nursing homes underscore the importance of leadership accessibility, communication, support, and follow through regarding resident safety concerns. These results may provide a basis for designing safety climate interventions, such as those designed to improve communication, teamwork, and quality improvement structures and processes. [ Journal of Gerontological Nursing, 49 (2), 13-17.].

Objectives: Staff values and beliefs about resident safety (safety climate) represent one potential driver of nursing home safety. Staff with more work experience (length of service) may possess richer knowledge of resident safety for strengthening safety climate. We investigated the association of length of service with safety climate in the U.S. Department of Veterans Affairs nursing homes or Community Living Centers (CLCs)., Methods: Fifty-six of 134 CLCs participated in 2017 and then 2018 in the previously validated CLC Employee Survey of Attitudes about Resident Safety, which comprised 7 safety climate domains and employee characteristics. We conducted 2 cross-sectional analyses of length of service on each safety climate domain, controlling for occupation, shift, work hours, and clustering by VA hospital, service network, and geographic region, in mixed random-effect regression models., Results: A total of 1397 and 1645 staff participated in the survey (26% and 28% response rates) at round 1 and 2, respectively. At each round participants working greater than 6 months were less positive than those working less than 6 months about supervisor commitment to safety, coworker interactions around safety, and CLC global ratings., Conclusions: Differences in work experience contributed to incongruence in perceptions about supervisors, coworkers, and the facility. Workers with more experience may have higher perceived job aptitude and thus higher expectations of supervisory recognition and more criticisms of coworkers. Pairing experienced workers with newer ones may narrow the knowledge gap and increase collaboration. Huddles, team meetings, and organizational initiatives represent opportunities to recognize and leverage experienced workers' accumulated safety knowledge., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: A stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, we examined the link between organizational readiness to change and safety climate., Methods: Seven safety climate domains and organizational readiness to change were measured with validated Community Living Center/CLC Employee Survey of Attitudes about Resident Safety and Organizational Readiness to Change Assessment. Safety climate domains comprised of safety priorities, supervisor commitment to safety, senior management commitment to safety, safety attitudes, environmental safety, coworker interactions around safety, and global rating of CLC. We specified models with and without readiness to change to explain CLC- and person-level variance in safety climate domains., Results: One thousand three hundred ninety seven workers (frontline staff and managers) responded from 56 US Veterans Health Administration CLCs located throughout the US. Adding readiness to change reduced baseline CLC-level variance of outcomes (2.3-9.3%) by > 70% for interpersonal domains (co-workers, supervisors, and senior management). Readiness to change explained person-level variance of every safety climate domain (P < 0.05), especially for interpersonal domains., Conclusions: Organizational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety., (© 2021. The Author(s).)

Background: Relatively little guidance exists on how to use virtual implementation facilitation to successfully implement evidence-based practices and innovations into clinical programs. Yet virtual methods are increasingly common. They have potentially wider reach, emergent public health situations necessitate their use, and restrictions on resources can make them more attractive. We therefore outline a set of principles for virtual external implementation facilitation and a series of recommendations based on extensive experience successfully using virtual external implementation facilitation in a national program., Model and Recommendations: Success in virtual external implementation facilitation may be achieved by facilitators applying three overarching principles: pilot everything, incorporate a model, and prioritize metacognition. Five practical principles also help: plan in advance, communicate in real time, build relationships, engage participants, and construct a virtual room for participants. We present eight concrete suggestions for enacting the practical principles: (1) assign key facilitation roles to facilitation team members to ensure the program runs smoothly; (2) create small cohorts of participants so they can have meaningful interactions; (3) provide clarity and structure for all participant interactions; (4) structure program content to ensure key points are described, reinforced, and practiced; (5) use visuals to supplement audio content; (6) build activities into the agenda that enable participants to immediately apply knowledge at their own sites, separate from the virtual experience; (7) create backup plans whenever possible; and (8) engage all participants in the program. These principles represent a novel conceptualization of virtual external implementation facilitation, giving structure to a process that has been, to date, inadequately described. The associated actions are demonstrably useful in supporting the principles and offer teams interested in virtual external implementation facilitation concrete methods by which to ensure success. Our examples stem from experiences in healthcare. But the principles can, in theory, be applied to virtual external implementation facilitation regardless of setting, as they and the associated actions are not setting specific.

Objectives: Adverse events in nursing homes are leading causes of morbidity and mortality, prompting facilities to investigate their antecedents. This study examined the contribution of safety climate-how frontline staff typically think about safety and act on safety issues-to adverse events in Veterans Affairs (VA) nursing homes or Community Living Centers (CLCs)., Design: Cross-sectional study., Setting and Participants: A total of 56 CLCs nationwide, 1397 and 1645 CLC staff (including nurses, nursing assistants, and clinicians/specialists), respectively, responded to the CLC Employee Survey of Attitudes about Resident Safety (CESARS) in 2017 and 2018., Methods: Adverse events (pressure ulcers, falls, major injuries from falls, and catheter use) were measured using the FY2017-FY2018 Minimum Data Set (MDS). Safety climate was defined as 7 CESARS domains (safety priorities, supervisor commitment to safety, senior management commitment to safety, personal attitudes toward safety, environmental safety, coworker interactions around safety, and global rating of CLC). The associations between safety climate domains and each adverse event were determined separately for each frontline group, using beta-logistic regression with random effects., Results: Better ratings of supervisor commitment to safety were associated with lower rates of major injuries from falls [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.11-0.97, clinicians] and catheter use (OR 0.42, 95% CI 0.21-0.85, nurses), and better ratings of environmental safety were associated with lower rates of pressure ulcers (OR 0.23, 95% CI 0.09-0.61, clinicians), major injuries from falls (OR 0.48, 95% CI 0.24-0.93, nurses), and catheter use (OR 0.55, 95% CI 0.32-0.93, nursing assistants). Better global CLC ratings were associated with higher rates of catheter use. No other safety climate domains had significant associations., Conclusions and Implications: Nursing homes may reduce adverse events by fostering supportive supervision of frontline staff and a safer physical environment., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the cost-effectiveness of routine use of cell salvage during caesarean section in mothers at risk of haemorrhage compared with current standard of care., Design: Model-based cost-effectiveness evaluation alongside a multicentre randomised controlled trial. Three main analyses were carried out on the trial data: (1) based on the intention-to-treat principle; (2) based on the per-protocol principle; (3) only participants who underwent an emergency caesarean section., Setting: 26 obstetric units in the UK., Participants: 3028 women at risk of haemorrhage recruited between June 2013 and April 2016., Interventions: Cell salvage (intervention) versus routine care without salvage (control)., Primary Outcome Measures: Cost-effectiveness based on incremental cost per donor blood transfusion avoided., Results: In the intention-to-treat analysis, the mean difference in total costs between cell salvage and standard care was £83. The estimated incremental cost-effectiveness ratio (ICER) was £8110 per donor blood transfusion avoided. For the per-protocol analysis, the mean difference in total costs was £92 and the ICER was £8252. In the emergency caesarean section analysis, the mean difference in total costs was £55 and the ICER was £13 713 per donor blood transfusion avoided. This ICER is driven by the increased probability that these patients would require a higher level of postoperative care and additional surgeries. The results of these analyses were shown to be robust for the majority of deterministic sensitivity analyses., Conclusions: The results of the economic evaluation suggest that while routine cell salvage is a marginally more effective strategy than standard care in avoiding a donor blood transfusion, there is uncertainty in relation to whether it is a less or more costly strategy. The lack of long-term data on the health and quality of life of patients in both arms of the trial means that further research is needed to fully understand the cost implications of both strategies., Trial Registration Number: ISRCTN66118656., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Caesarean section is associated with blood loss and maternal morbidity. Excessive blood loss requires transfusion of donor (allogeneic) blood, which is a finite resource. Cell salvage returns blood lost during surgery to the mother. It may avoid the need for donor blood transfusion, but reliable evidence of its effects is lacking., Objectives: To determine if routine use of cell salvage during caesarean section in mothers at risk of haemorrhage reduces the rates of blood transfusion and postpartum maternal morbidity, and is cost-effective, in comparison with standard practice without routine salvage use., Design: Individually randomised controlled, multicentre trial with cost-effectiveness analysis. Treatment was not blinded., Setting: A total of 26 UK obstetric units., Participants: Out of 3054 women recruited between June 2013 and April 2016, we randomly assigned 3028 women at risk of haemorrhage to cell salvage or routine care. Randomisation was stratified using random permuted blocks of variable sizes. Of these, 1672 had emergency and 1356 had elective caesareans. We excluded women for whom cell salvage or donor blood transfusion was contraindicated., Interventions: Cell salvage (intervention) versus routine care without salvage (control). In the intervention group, salvage was set up in 95.6% of the women and, of these, 50.8% had salvaged blood returned. In the control group, 3.9% had salvage deployed., Main Outcome Measures: Primary - donor blood transfusion. Secondary - units of donor blood transfused, time to mobilisation, length of hospitalisation, mean fall in haemoglobin, fetomaternal haemorrhage (FMH) measured by Kleihauer-Betke test, and maternal fatigue. Analyses were adjusted for stratification factors and other factors that were believed to be prognostic a priori. Cost-effectiveness outcomes - costs of resources and service provision taking the UK NHS perspective., Results: We analysed 1498 and 1492 participants in the intervention and control groups, respectively. Overall, the transfusion rate was 2.5% in the intervention group and 3.5% in the control group [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.42 to 1.01; p  = 0.056]. In a planned subgroup analysis, the transfusion rate was 3.0% in the intervention group and 4.6% in the control group among emergency caesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 1.8% in the intervention group and 2.2% in the control group among elective caesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p  = 0.46, suggesting that the difference in effect between subgroups was not statistically significant). Secondary outcomes did not differ between groups, except for FMH, which was higher under salvage in rhesus D (RhD)-negative women with RhD-positive babies (25.6% vs. 10.5%, adjusted OR 5.63, 95% CI 1.43 to 22.14; p  = 0.013). No case of amniotic fluid embolism was observed. The additional cost of routine cell salvage during caesarean was estimated, on average, at £8110 per donor blood transfusion avoided., Conclusions: The modest evidence for an effect of routine use of cell salvage during caesarean section on rates of donor blood transfusion was associated with increased FMH, which emphasises the need for adherence to guidance on anti-D prophylaxis. We are unable to comment on long-term antibody sensitisation effects. Based on the findings of this trial, cell salvage is unlikely to be considered cost-effective., Future Work: Research into risk of alloimmunisation among women exposed to cell salvage is needed., Trial Registration: Current Controlled Trials ISRCTN66118656., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 2. See the NIHR Journals Library website for further project information.

Background: Excessive haemorrhage at cesarean section requires donor (allogeneic) blood transfusion. Cell salvage may reduce this requirement., Methods and Findings: We conducted a pragmatic randomised controlled trial (at 26 obstetric units; participants recruited from 4 June 2013 to 17 April 2016) of routine cell salvage use (intervention) versus current standard of care without routine salvage use (control) in cesarean section among women at risk of haemorrhage. Randomisation was stratified, using random permuted blocks of variable sizes. In an intention-to-treat analysis, we used multivariable models, adjusting for stratification variables and prognostic factors identified a priori, to compare rates of donor blood transfusion (primary outcome) and fetomaternal haemorrhage ≥2 ml in RhD-negative women with RhD-positive babies (a secondary outcome) between groups. Among 3,028 women randomised (2,990 analysed), 95.6% of 1,498 assigned to intervention had cell salvage deployed (50.8% had salvaged blood returned; mean 259.9 ml) versus 3.9% of 1,492 assigned to control. Donor blood transfusion rate was 3.5% in the control group versus 2.5% in the intervention group (adjusted odds ratio [OR] 0.65, 95% confidence interval [CI] 0.42 to 1.01, p = 0.056; adjusted risk difference -1.03, 95% CI -2.13 to 0.06). In a planned subgroup analysis, the transfusion rate was 4.6% in women assigned to control versus 3.0% in the intervention group among emergency cesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 2.2% versus 1.8% among elective cesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46). No case of amniotic fluid embolism was observed. The rate of fetomaternal haemorrhage was higher with the intervention (10.5% in the control group versus 25.6% in the intervention group, adjusted OR 5.63, 95% CI 1.43 to 22.14, p = 0.013). We are unable to comment on long-term antibody sensitisation effects., Conclusions: The overall reduction observed in donor blood transfusion associated with the routine use of cell salvage during cesarean section was not statistically significant., Trial Registration: This trial was prospectively registered on ISRCTN as trial number 66118656 and can be viewed on http://www.isrctn.com/ISRCTN66118656.

Objective: Failure on performance validity tests (PVTs) is common in Veterans with histories of mild traumatic brain injury (mTBI), leading to questionable validity of clinical presentations., Participants: Using diffusion tensor imaging, we investigated white matter (WM) integrity and cognition in 79 Veterans with history of mTBI who passed PVTs (n = 43; traumatic brain injury [TBI]-passed), history of mTBI who failed at least 1 PVT (n = 13; TBI-failed), and military controls (n = 23; MCs) with no history of TBI., Results: The TBI-failed group demonstrated significantly lower cognitive scores relative to MCs and the TBI-passed group; however, no such differences were observed between MCs and the TBI-passed group. On a global measure of WM integrity (ie, WM burden), the TBI-failed group showed more overall WM abnormalities than the other groups. However, no differences were observed between the MCs and TBI-passed group on WM burden. Interestingly, regional WM analyses revealed abnormalities in the anterior internal capsule and cingulum of both TBI subgroups relative to MCs. Moreover, compared with the TBI-passed group, the TBI-failed group demonstrated significantly decreased WM integrity in the corpus callosum., Conclusions: Findings revealed that, within our sample, WM abnormalities are evident in those who fail PVTs. This study adds to the burgeoning PVT literature by suggesting that poor PVT performance does not negate the possibility of underlying WM abnormalities in military personnel with history of mTBI., Competing Interests: The authors report no conflicts of interests.

The Power of People (PoP) is a personal leadership development course that was originally developed in a non-correctional setting and now serves as a prison-based life skills course. This study examined PoP's effect on four different types of recidivism: rearrest, reconviction, reincarceration, and technical violation revocation. The results of the analyses revealed that PoP does not have a significant effect on any of the four measures of recidivism. Following established principles of effective correctional treatment, we make several recommendations that could improve PoP's effectiveness on recidivism outcomes. Overall, this study provides guidance on how to make programs not originally designed for correctional systems into effective recidivism-reducing tools., (© The Author(s) 2013.)

Using three waves of data from 5,165 male and 5,924 female teenagers surveyed in the National Longitudinal Study of Adolescent Health, this study tested whether drug use, alcohol use, depression, and offending mediate the link between a serious violent criminal victimization and a subsequent serious violent revictimization. Results indicated that victimization at Wave 1 significantly predicted changes in violent offending, delinquency, and drug use at Wave 2, even controlling for all other lagged mediators. Violent offending emerged as a robust and consistent mediator of the victimization-revictimization link for males. For females, all the mediators together produced a significant and large indirect effect that reduced the direct effect of prior victimization to nonsignificance, but no one single mediator was significant. This study demonstrates that revictimization is partially the result of behavioral changes following victimization. The fact that mediation between victimization and revictimization occurred through a cluster of changed behaviors and moods suggests that the impact of victimization is greater for females than males. This evidence that victimization changes behavior and increases risks and that these risks differ by gender has implications for both mental health care and law enforcement.

A 22-year-old primiparous woman with known glycogen storage disease type 3a presented to our hospital during her 12th week of pregnancy. Glycogen storage disease type 3 is a rare inherited disorder resulting from a deficiency of the glycogen debranching enzyme, causing the accumulation of abnormal short-chain glycogen in liver, blood cells, myocardium and striated muscle. Symptoms improve after puberty but the increased metabolism of pregnancy predisposes to hypoglycaemia, ketosis and lactic acidosis. Cardiomyopathy, distal weakness and peripheral neuropathy may present after the third decade. The patient was managed antenatally with regular cornflour feeds and was scheduled for elective caesarean delivery. She presented in early labour at 38 weeks and delivered a healthy neonate by urgent caesarean delivery under spinal anaesthesia. Intravenous dextrose infusion and regular blood glucose monitoring were used during the perinatal period to prevent hypoglycaemia. An arterial line was inserted in the operating room for frequent blood sampling and to avoid muscle cramps which could be induced by the intermittent inflation of the automated blood pressure cuff. Obstetric, anaesthetic and neonatal outcomes were uneventful., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Keeping firearms at home may increase personal safety but it may also increase the risk of injury. This study uses data from three waves of the National Longitudinal Study of Adolescent Health to assess the extent to which adolescents' easy access to firearms at home increases the risk of violent offending and violent victimization. Access to firearms was higher for males, Whites, and adolescents having two parents, especially fathers. Current access to firearms at home significantly increased the odds of both violent offending and violent victimization, even after controlling for prior access, prior offending, and prior victimization. This relationship persisted into early adulthood; access to firearms still significantly increased the odds of violent offending and violent victimization.

Background: Despite controversy over the haemodynamically safest blockade for caesarean section in women with severe preeclampsia, an increasing number of anaesthetists now opt for spinal anaesthesia. In a previous study we found that spinal compared to epidural anaesthesia offered an equally safe but more effective option for these patients. The current study was designed to compare the hypotension induced by spinal anaesthesia, as measured by ephedrine requirement, between 20 normotensive and 20 severely preeclamptic but haemodynamically stabilised women., Method: Standardised spinal anaesthesia was instituted and ephedrine was given in boluses of 6 mg if the systolic pressure fell >20% from the baseline, or if the patient exhibited symptoms of hypotension., Results: The mean ephedrine requirement of the normotensive group (27.9+/-11.6 mg) was significantly greater (P<0.01) than that of the preeclamptic group (16.4+/-15.0 mg)., Conclusion: This suggests that the hypotension induced by spinal anaesthesia in women with severe but haemodynamically stabilised preeclampsia, is less than that of normotensive patients.

Background: Although public health programs invest heavily in the male latex condom, its efficacy in preventing pregnancy and sexually transmitted disease has been based primarily on in vitro and retrospective studies., Methods: We combine the results from two randomized, controlled contraceptive efficacy trials that used commercial latex condoms brands (Ramses Sensitol, LifeStyles, Trojan-Enz) in the control arms. Combining data from the two studies, we obtained longitudinal data covering 3526 menstrual cycles contributed by approximately 800 couples who used latex condoms exclusively for up to six menstrual cycles. Both trials also collected 3715 detailed breakage and slippage reports from the first five study condom uses. The second trial also tested 243 postcoital vaginal samples collected after the first study condom use for the presence of prostate-specific antigen (PSA) and spermatazoa., Results: The combined clinical breakage rate for the first five condom uses was 0.4% for the three latex brands and the combined clinical slippage rate was 1.1%. The combined six-cycle typical-use pregnancy rate for the latex condoms was 7.0% (95% confidence interval 5.0-9.0). The combined six-cycle consistent-use pregnancy rate was 1.0% (95% confidence interval 0.0-2.1). PSA was detected in only 1.2% of postcoital vaginal samples collected after the first use of an intact study condom. There were no differences in performance or efficacy among the three latex brands tested., Conclusions: The male latex condoms rarely broke or slipped off during intercourse and provided high contraceptive efficacy, especially when used consistently. Risk of semen leakage from intact condoms was very low.

The anaesthetic management of a pregnant quadriplegic woman with a history of autonomic hyperreflexia is discussed. Autonomic hyperreflexia is a life-threatening complication of high spinal cord transection, for which labour is a well known stimulus. It can lead to uncontrolled hypertension. We discuss the anaesthetic considerations in planning the care of this patient, who was managed for elective caesarean section and post partum hypertension with epidural anaesthesia.

Context: To reduce unintended pregnancy and HIV infection, it is critical to develop reliable male condoms that will attract consumers who reject conventional latex condoms., Methods: In a prospective clinical trial conducted in 1998-2000, 830 monogamous couples were randomized in equal numbers to use either a nonlatex condom or a commercial natural latex condom for six months as their only method of birth control. Couples completed detailed reports for the first five condom uses and recorded intercourse and condom use in coital diaries. Pregnancy rates associated with typical and consistent condom use were calculated using life-table analysis. Rates of clinical failure (condom breakage or slippage) were determined for the first five condom uses., Results: During the first five uses, the nonlatex condom had a higher frequency of breakage or slippage during intercourse or withdrawal (4.0%) than latex condoms (1.3%); the breakage rate for the nonlatex condom was about eight times that of latex condoms. The six-cycle typical-use pregnancy rate did not differ significantly between users of nonlatex (10.8%) and latex condoms (6.4%). The six-cycle consistent-use pregnancy rate was higher for nonlatex condom users than for latex condom users (4.9% vs. 1.0%)., Conclusions: The data present strong indirect support for public health messages that promote the use of latex condoms and, for individuals who cannot or are unwilling to use latex condoms, the use of nonlatex condoms for prevention of pregnancy and disease.

Accurate measurement of semen exposure resulting from condom failures can refine public health messages and improve predictions of condom efficacy in preventing pregnancy and HIV transmission. Eight hundred and thirty couples enrolled in a condom efficacy study were asked to collect a baseline sample of ejaculate from the inside of the first study condom they used and to collect a postcoital vaginal sample whenever a study condom broke or slipped off during intercourse. All samples were quantitatively tested for prostate-specific antigen (PSA), a substance found only in human semen, using rocket immunoelectrophoresis, and inspected microscopically for presence of sperm. Sixty-eight baseline ejaculate samples collected from the inside of the first study condom by couples who subsequently experienced a condom failure averaged 13.4 microg PSA per swab and 79% of the samples averaged one or more sperm per high power field (hpf). Seventy-nine postcoital vaginal samples obtained after a condom break averaged 5.7 microg PSA per swab and only 38% averaged one or more sperm per hpf. The PSA results indicated a 50% reduction in semen exposure compared to baseline levels (p = 0.0001). Seventeen samples obtained after a condom slip-off averaged 2.5 microg PSA per swab and none of the samples averaged one or more sperm per hpf. The PSA results indicated an 80% reduction in semen exposure compared to baseline levels (p = 0.0001). Our results suggest that even condoms that fail reduce the risk of pregnancy and the transmission of sexually transmitted disease compared to unprotected intercourse. We also used PSA results to adjust a model designed to predict consistent-use pregnancy rates from condom breakage and slippage data.

We investigated the necessity for administration of supplementary oxygen to mothers undergoing elective Caesarean section under spinal anaesthesia. Sixty-nine women undergoing elective Caesarean section were randomly allocated to one of three groups to be given either oxygen (40%) by facemask, air by facemask or oxygen at 2 l x min(-1) by nasal cannulae. Umbilical arterial and venous blood samples were taken and analysed immediately after delivery. The results showed that there were no significant differences in the umbilical arterial or venous pH, partial pressure of oxygen and partial pressure of carbon dioxide between any of the three groups. We also assessed the patient acceptability of oxygen administered by facemask vs. nasal cannulae should the need for supplementary oxygen arise. It was found that use of the facemask impeded communication.

The ability of condoms to retain all elements of semen during intercourse has been assessed by postcoital visual inspection and in vitro permeability studies. Yet, these observations may not be sufficiently precise or realistic. This pilot study evaluated prostate-specific antigen (PSA) as a semen marker of inapparent failure of the condom barrier under conditions of actual use. Twelve couples collected samples from the vagina and surfaces of the condom using sterile cotton swabs. We obtained precoital and postcoital samples for 24 acts of unprotected intercourse, 54 acts of intercourse using intact condoms, and 40 acts of intercourse using condoms that had been deliberately punctured. We used electrophoresis to determine the amount of PSA present in the samples. PSA was detected in 100% (24/24) of vaginal samples collected immediately after unprotected intercourse and in none of the vaginal samples collected more than 24 h after intercourse (0/90). PSA was also present in 98% (83/85) of the samples collected from the inside of the condom that had failed during intercourse. Excluding uses where the condom failed during intercourse, PSA was detected in 2% (1/47) of the postcoital vaginal samples collected after use of intact condoms and in 41% (14/34) of the samples collected after use of condoms with known 1-mm punctures. We conclude that PSA shows great promise as a semen biomarker in clinical trials of barrier methods. We recommend that future studies further investigate the ability of this biomarker to identify condom failures and quantify the extent of semen exposure associated with various types of condom failures.

Context: Condoms made of latex are not comfortable or appropriate for all consumers. Polyurethane condoms may provide a needed alternative., Methods: In a double-masked study, 805 monogamous couples were randomized to use either the polyurethane condom or the latex condom for six months. Couples recorded the frequency of intercourse, of condom use and of breakage and slippage throughout the trial in coital diaries and in detailed reports on the first five uses. Breakage and slippage rates were determined, and typical-use and consistent-use pregnancy rates were calculated using life-table analysis, adjusted for use of emergency contraception., Results: The six-month pregnancy rate during typical use (adjusted for use of emergency contraception) was 4.8% for the polyurethane condom and 6.3% for the latex condom. Similarly adjusted pregnancy rates during consistent use over six completed menstrual cycles--2.4% for the polyurethane condom and 1.1% for the latex condom--did not differ significantly. Clinical failure rates (including breakage and slippage occurring during either intercourse or withdrawal) were 8.5% for the polyurethane condom and 1.6% for the latex condom. In general, male participants were more satisfied with the latex condom, and users of latex were significantly less likely to drop out of the study for condom-related reasons than were users of polyurethane., Conclusions: Although polyurethane and latex condoms provide equivalent levels of contraceptive protection, the polyurethane condom's higher frequency of breakage and slippage suggests that this condom may confer less protection from sexually transmitted infections than does the latex condom.

We audited the appropriateness of blood ordering in our obstetric unit, by analysing the ratio of number of units of blood cross-matched to number transfused (C:T ratio), both overall and for specific indications. Based on this information, we devised a new blood ordering policy, and repeated the audit once this was in operation. The new policy resulted in a substantial increase in the efficiency of blood ordering. The overall C:T ratio fell from 10.9 to 3.0, and there were particularly large falls for caesarean section (from 34.3 to 6.2), high risk labours (from 67.8 to 9.1) and post-partum haemorrhage/retained placenta (from 4.3 to 1.9).

Analgesia with preoperative naproxen after laparoscopic sterilization was assessed in a prospective, double-blind, randomized study of 80 women; 42 women received oral naproxen 1 g, approximately 90 min before surgery, and 38 received placebo. Preoperative naproxen did not significantly influence postoperative pain scores, but was associated with a reduction in parenteral opioid administration (P = 0.04).

Purposes: To determine: 1) prevalence of significant colorectal lesions by demographics and risk factors; 2) frequency of 1 and 2 or more lesions by type, location, and size; 3) relation among villous component, location, and size of adenomas; and 4) frequency of nonsignificant lesions among patients with and without significant lesions.;, Method: One thousand asymptomatic patients, 45 years of age and older, with negative fecal occult blood tests, were screened using 60-cm flexible sigmoidoscopy and, if indicated, using colonoscopy., Results: Thirty-six of the patients had 62 significant lesions (11 patients had 2 or more lesions). Fifty-four of the lesions were discovered by sigmoidoscopy in 1,000 patients, and 8 additional lesions were discovered in 5 of the 36 patients by colonoscopy. Lesions with villous components were more likely to be found in patients with 2 or more lesions (P = 0.0006). Smokers were more likely than nonsmokers to have significant lesions (P = 0.002). Among these patients, smoking and drinking were associated (P = 0.007). Males were more likely to have significant lesions than females (P = 0.006). Hemorrhoids, diverticulosis, and hyperplastic polyps were not associated with significant lesions., Conclusions: The relationship between smoking and significant lesions provides further evidence that asymptomatic patients should stop smoking. Physicians should pay particular attention to men who smoke, even if they have negative occult blood tests.

A postal questionnaire on blood ordering practices and blood availability was sent to 89 randomly selected maternity units within the United Kingdom. The replies demonstrated a wide variation in crossmatching practices. Of those units that replied, 56% crossmatch for elective and 64% for emergency Caesarean section, 54% for manual removal of placenta, and 29% for fetal distress in labour. The remainder 'group and screen' for these indications. Lack of 24 h cover by a resident haematology technician, and location of blood banks distant to the obstetric unit were associated with significant delays in blood availability. More extensive use of the 'group and screen' technique may reduce unnecessary crossmatching without jeopardizing patient safety, and is advocated for maternity units.

262 obstetric patients received epidural analgesia during labour or for delivery. 6-8 weeks post partum they received a postal questionnaire. No association was found between backache and maternal age, height, weight, parity or mode of delivery, operator or difficulty with epidural insertion. However, in women who had had epidural analgesia, post-partum backache was associated with shorter labours. Difficult epidural insertions were more common in short women.

Background: Although the American Cancer Society and others have established guidelines for colorectal cancer screening, questions of who and how to screen still exist., Methods: A 60-cm flexible sigmoidoscopy was performed on 1000 asymptomatic patients, 45 years of age or older, with negative fecal occult blood tests, who presented for routine physical examinations. Patients with clinically significant lesions were referred for colonoscopy. The proportion of lesions that would not have been found if the 24-cm rigid or the 30-cm flexible sigmoidoscope had been used was identified., Results: Using the 60-cm flexible sigmoidoscope, lesions were found in 3.6% of the patients. Eighty percent of the significant lesions were beyond the reach of the 24-cm rigid sigmoidoscope and 37% were beyond the reach of the 30-cm sigmoidoscope. Thirty-six patients with lesions were referred for colonoscopy; additional lesions were found in 14%. A total of 62 lesions were discovered, including tubular adenomas, villous adenomas, tubular villous adenomas (23 of the adenomas with atypia), and one adenocarcinoma. The highest percentage of lesions discovered were in the sigmoid colon and the second highest percentage were in the ascending colon., Conclusions: The 60-cm flexible sigmoidoscope was able to detect more lesions than either the 24-cm or 30-cm sigmoidoscope when used in asymptomatic patients, 45 years of age and over, with negative fecal occult blood tests. When significant lesions are discovered by sigmoidoscopy, colonoscopy should be performed.

The demographic, life-style, and self-reported health characteristics of a convenience sample of 207 male and 70 female, non-Hispanic White, heavy marijuana users in Los Angeles County were compared with those of more representative county and national samples. Consistent with other researchers' findings, heavy marijuana users were found to differ significantly in living arrangements, job stability, and income. Heavy marijuana users did not differ in completed education, self-reported physical health, or use of alcohol and cigarettes. Heavy marijuana users were less likely to be married than nonusers, but reported the same number of close friends with whom they interacted more frequently than same-aged comparison groups. Our findings suggest that heavy marijuana users are not homogeneous, and that female users differ significantly from male users.

This study addresses two questions: (a) Are depressive-symptom scales equally indicative of depression in different racial/ethnic groups and (b) are there mean differences between the groups in the underlying depressive disorder assessed by these scales? The data consist of interviews obtained from a large community survey of depression in Los Angeles County. Four racial/ethnic groups were considered: Anglos, blacks, English-speaking Hispanics, and Spanish-speaking Hispanics. Confirmatory factor analysis was used to test both one-factor and two-factor models of depression. An invariant factor pattern was demonstrated. No significant mean differences on a factor of Depression were found, but the groups were found to differ on a Well-Being factor. Implications for survey research on psychiatric impairment among different racial/ethnic groups are discussed.