Lower total cholesterol and triglyceride levels in ankylosing spondylitis than non-inflammatory rheumatic disease controls in a 1978-98 study: a potential effect of increased physical energetics in manual occupations in the pre-2000 chronologic era.

OBJECTIVES: No article on serum lipids in ankylosing spondylitis (AS) and control subjects has been reported from USA. The primary aim of this study was to determine if any difference occurred in serum lipid levels in AS and control rheumatic disorders in two time periods, 1978-98 and 2000-10. The secondary aim was to investigate variables associated with lipid levels and if a difference was found between AS and control disorders. METHODS: The AS patients were compared to non-inflammatory rheumatic disorders (NIRDs) in 1978-98 and 2000-10 surveys and to rheumatoid arthritis (RA) in the 2000-10 survey. Patients were matched within 5 years of age, sex, and clinic or hospital source. RESULTS: In the 1978-98 survey, entry mean (SEM) serum cholesterol level [mg/dL] was highly (p<0.001) significantly lower in 69 AS [179.0 (4.8)] than 69 matched NIRD controls [208.0 (5.6)]. In 29 pairs of AS and NIRD subjects having manual labour occupations, mean (SEM) cholesterol level was additionally lower in AS [156.7 (5.9)] and higher in 29 NIRD controls [213.3 (8.6)] (p<0.001). In manual labour workers, mean (SEM) serum triglyceride was significantly lower (p=0.004) in 15 AS [110.3 (14.1)] than 14 NIRD controls [185.2 (19.3)]. In the 2000-10 survey, no lipid difference was found between AS vs. NIRD control patients. CONCLUSIONS: In the 1978-98 survey, AS had significantly lower mean serum cholesterol and triglyceride levels than NIRD control patients. Associated manual labour occupations may have significantly contributed to results, possibly related to increased energy expenditures from physical activity in the pre-2000 era.

Hereditary, socio-behavioural, and immuno-hormonal predictors of incident rheumatoid arthritis and therapy response influences on survival versus matched control subjects using a generalised structural equation model.

OBJECTIVES: Incident onset and survival outcomes involve multiple risk factors and complex interactions preferably investigated in a single study. A generalized structural equation model (GSEM) was used to build an integrative framework to analyse multiple risk factors for incident rheumatoid arthritis (RA) and factors affecting long-term survival outcome. METHODS: Incident RA cases (n=54) had onsets between 1977 and 1994, after cohort entry in 1974. Four cohort control (CN) subjects (n=216) were matched on entry to each case in the community-based CLUE cohort and 270 subjects were followed from 1995 through 2017. Baseline variables included demographic, RA family history, behavioural factors and z-score levels of serum immunological, cytokine, isotype rheumatoid factors (RFs), adrenal steroids, luteinising hormone, prolactin and sex steroids. Four numerical integration methods of GSEM were performed in Stata 15. RESULTS: Cohort entry factors predicting RA onset included family history of RA, cigarette smoking and IgM RF. Total survival time from cohort entry was associated with incident RA and baseline variables of age, years of completed education, cigarette smoking, immunoreactive proteins and androgenic-anabolic steroids. Mortality of RA was significantly greater than CN subjects for cases having less than good therapy responses in 1995 and only for RA onset before age 60 years. Androgenic-anabolic steroid z-scores significantly correlated with improved survival only in CN subjects with assigned onset before the age of 60. CONCLUSIONS: Successful use of GSEM is feasible in analyses of prospective incident and subsequent survival data and promises to advance understanding of risk factors, survival, and casual pathways.

Preclinical biomarker associations with both incident rheumatoid arthritis and its subsequent mortality: sex effects in a 41-year, community-based, case-control cohort study.

OBJECTIVES: To identify sex effects and preclinical serum biomarker associations with both incident rheumatoid arthritis (RA) and its subsequent mortality, using a 41-year, community-based, case-control cohort. METHODS: After cohort entry in 1974, incident RA cases (n=54) had clinical onsets between 1977 and 1994. Cohort control (CN) subjects were individually matched on entry to cases (4 CN:1 RA, n=216). All subjects were followed for survival from 1995 through 2015. Ranks (1-5) of preclinical z-scores within each set of 1 RA and 4 matched CN were analysed for associations with incident RA and mortality. Survival was evaluated using Cox proportional hazards models. RESULTS: Preclinical serum IgG RF z-score ranks associated with incident RA in 90 males (18 RA, 72 CN). Cigarette smoking, androstenedione, pregnenolone, and sIL-2Rα ranks associated with incident RA in 180 females (36 RA, 144 CN). Total percentile mortality was greater (p=0.003) in RA (70.4) vs. CN (49.9) and equivalently increased in female RA (69.4) vs. CN (49.3) and in male RA (72.2) vs. CN (43.1) subjects. Percentile respiratory-related CODs were greater (p=0.009) only in the female RA cases (16.7) vs. CN (3.5). Ranks of preclinical hsCRP (p=0.028) and sIL-2Rα (p=0.030) independently associated with 140 total deaths, as did sTNF-R1 (p=0.003) and hsCRP (p=0.005) with 50 CVD deaths. Latter biomarker association were significant in females. Therapy responses in 1995 significantly associated with subsequent mortality. CONCLUSIONS: Sex effects were important in preclinical biomarker associations with incident RA, total and CVD mortality as well as occurrence of respiratory deaths.

Increased mortality of incident rheumatoid arthritis versus matched non-RA control subjects: a community-based long-term prospective cohort study.

OBJECTIVES: This study aimed to critically investigate all-cause and major-cause mortality of incident rheumatoid arthritis (RA) cases versus matched non-RA comparison (CN) subjects in a long-term prospective cohort. METHODS: Baseline 1974 cohort entry demographic and serum biomarker data on 54 incident RA patients and 216 matched CN subjects were related to their mortality from 1995 through 2015. Mortality of RA patients was also analysed by 3 categories of course responses to therapy assigned by the sole community rheumatologist in 1995 (19 good, 23 fair, and 12 limited). Cox proportional hazards regression models including baseline covariates were used to determine survival from all-causes, cardiovascular disease (CVD), respiratory-related, malignancies, and other causes of death (CODs). RESULTS: Total deaths occurred in 38 (70.4 percent) of 54 RA and 102 (47.7 percent) of 216 CN (p=0.003). Total mortality remained greater (p=0.011) in RA versus CN subjects after adjustment for baseline demographic covariates (HR= 1.66, 95% CI 1.12-2.46). Respiratory-related CODs were also greater (p=0.047) in RA versus CN (HR= 2.69, 95% CI 1.02-7.14) subjects. The RA patients' responses to therapy in 1995 significantly (p=0.004) predicted total mortality. Baseline serum immunological and steroid biomarkers independently predicted total, CVD, and other and unknown CODs. Pre-clinical (1974) ranked biomarker z-score values (1 = lowest, 5 = highest) within matched sets of 1 RA and 4 CN study subjects independently associated with mortality from 1995 through 2015, for both total (CRP, p=0.028 and sIL-2Rα, p=0.030) and CVD (CRP, p=0.005 and sTNF-R1, p=0.003) deaths. CONCLUSIONS: Total mortality and respiratory-related CODs were greater in incident RA versus CN subjects. The 35 RA cases who had fair or limited course responses to rheumatologist's therapy had greater mortality than their matched CN, whereas the 19 good RA responders had equivalent survival to CN subjects. The independent CRP and sTNF-R1 biomarker associations with CVD deaths were enhanced by a gradient of their dichotomous z-score values in survival models.

The 'Lumbar Fusion Outcome Score' (LUFOS): a new practical and surgically oriented grading system for preoperative prediction of surgical outcomes after lumbar spinal fusion in patients with degenerative disc disease and refractory chronic axial low back pain.

In order to evaluate the predictive effect of non-invasive preoperative imaging methods on surgical outcomes of lumbar fusion for patients with degenerative disc disease (DDD) and refractory chronic axial low back pain (LBP), the authors conducted a retrospective review of 45 patients with DDD and refractory LBP submitted to anterior lumbar interbody fusion (ALIF) at a single center from 2007 to 2010. Surgical outcomes - as measured by Visual Analog Scale (VAS/back pain) and Oswestry Disability Index (ODI) - were evaluated pre-operatively and at 6 weeks, 3 months, 6 months, and 1 year post-operatively. Linear mixed-effects models were generated in order to identify possible preoperative imaging characteristics (including bone scan/99mTc scintigraphy increased endplate uptake, Modic endplate changes, and disc degeneration graded according to Pfirrmann classification) which may be predictive of long-term surgical outcomes . After controlling for confounders, a combined score, the Lumbar Fusion Outcome Score (LUFOS), was developed. The LUFOS grading system was able to stratify patients in two general groups (Non-surgical: LUFOS 0 and 1; Surgical: LUFOS 2 and 3) that presented significantly different surgical outcomes in terms of estimated marginal means of VAS/back pain (p = 0.001) and ODI (p = 0.006) beginning at 3 months and continuing up to 1 year of follow-up. In conclusion,  LUFOS has been devised as a new practical and surgically oriented grading system based on simple key parameters from non-invasive preoperative imaging exams (magnetic resonance imaging/MRI and bone scan/99mTc scintigraphy) which has been shown to be highly predictive of surgical outcomes of patients undergoing lumbar fusion for treatment for refractory chronic axial LBP.

Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting.

OBJECTIVE: This study attempts to determine if newer indirect laryngoscopes or intubating devices are superior to a standard laryngoscope for intubation success among helicopter emergency medical service (HEMS) personnel. METHODS: Flight nurses and paramedics intubated standardized mannequins with a normal airway, a trauma airway, and a difficult airway using a standard laryngoscope, a gum elastic bougie, the Airtraq laryngoscope (King System Corp, Noblesville, IN), the Glidescope Ranger laryngoscope (Verathon Inc, Bothell, WA), and the S.A.L.T. device (Microtek Medical, Inc, Lehmberg, IN) in grounded helicopters wearing helmets and flight gear. Participant demographics, time to glottic view, the modified Cormack-Lehane score, total intubation time, number of attempts, and overall successful intubation were recorded for each type of airway. RESULTS: Two-hundred thirty-six subjects were initially enrolled across 107 bases in 15 states, and 177 completed the study. First-attempt success rates did not vary by device for the normal airway (P = .203), but the Airtraq laryngoscope and the S.A.L.T. device were highest in the difficult airway (82.0% and 85.0%, respectively; P < .0001). The time to first-attempt success in the difficult airway was lowest for the S.A.L.T. device and the Airtraq laryngoscope (mean = 9.72 seconds and 19.70 seconds, respectively; P < .0001). CONCLUSION: Using HEMS providers, the Airtraq laryngoscope and the S.A.L.T. device showed the fastest and highest intubation success on the first attempt in difficult simulated HEMS airway scenarios.

Greater Resting Lumbar Extensor Myofascial Stiffness in Younger Ankylosing Spondylitis Patients Than Age-Comparable Healthy Volunteers Quantified by Myotonometry.

OBJECTIVE: To quantify resting lumbar erector myofascial stiffness in younger patients with ankylosing spondylitis (AS) and age-comparable healthy control subjects using a handheld mechanical impulse-based myotonometric device. DESIGN: A case-control study of 24 patients with AS and 24 age-comparable healthy control subjects. SETTING: University physical therapy department. PARTICIPANTS: Patients with AS (men: n=19; women: n=5; total: N=24) and healthy volunteers (men: n=19; women: n=5; total: N=24) without low back pain (age range, 18-46y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Lumbar myofascial stiffness. RESULTS: At the initial measurements, median stiffness (Nm) of the averaged right- and left-sided values was greater (P=.021) in 24 patients with AS than 24 control subjects (268.9 vs 238.9, respectively). Repeated measurements after a 10-minute prone resting period were also greater (P=.007) in patients with AS than control subjects (281.0 vs 241.4, respectively). The 48 averaged right- and left-sided values from baseline and 10-minute measurements were compared in each subject group. The patients with AS more frequently (P=.012) had stiffness values >250 Nm (35 [72.9%] vs 22 [45.8%] in control subjects). CONCLUSIONS: Lumbar myofascial stiffness was greater in 24 patients with AS than in the control subjects. A hypothesized biomechanical concept of increased resting lumbar myofascial stiffness in AS may be supported by this preliminary controlled study.

Effectiveness of a pediatric verbal lead exposure screening protocol in emergency department patients.

PURPOSE: The population demographics found in many urban emergency departments (EDs) often mirrors those of children at risk for elevated serum lead levels. We evaluated the effectiveness of a verbal lead screening program for screening high-risk children presenting to the ED. METHODS: A prospective observational cohort study was conducted of children aged 9 months to 6 years, living in 2 target counties and presenting to an urban, academic, Midwestern ED. Those with a prior lead level, enrolled in a program requiring lead testing, or with an unstable medical condition were excluded. A 6-question validated verbal survey was administered to all parents of eligible children, and the results recorded in the patient's electronic medical record. Children who screened positive were referred to their local health department for blood lead testing. Health department records were reviewed for follow-up visits and blood lead levels. RESULTS: During the study period, 3513 children were eligible (mean age, 2.6 years; 53.3% male), with 815 patients screened and 209 (25.6%) screening positive. Most positively screened patients (71.8%) documented only 1 affirmative question, most often indicating they lived in a home built before 1978. Of those children who screened positive, 14.8% (31/209) had a blood lead level performed within 6 months. Of those tested, 4 children had an elevated lead level (>10 µg/dL). CONCLUSIONS: Use of an ED verbal lead exposure screening tool identified children requiring additional follow-up testing. However, health department-referred children had poor follow-up, and few children were ultimately documented with elevated lead levels.

The concept of incomplete fibromyalgia syndrome: comparison of incomplete fibromyalgia syndrome with fibromyalgia syndrome by 1990 ACR classification criteria and its implications for newer criteria and clinical practice.

BACKGROUND: The 1990 American College of Rheumatology (ACR) classification criteria for fibromyalgia/fibromyalgia syndrome (FMS) has 2 components: (a) widespread pain (WSP) and (b) presence of 11 or more tender points (TP) among possible 18 sites. Some clinic patients fulfill 1 component but not the other. We have considered these patients to have incomplete FMS (IFMS). The purpose of this study was to examine the clinical and psychological differences between IFMS and FMS (by 1990 ACR criteria) because such comparison may be helpful to diagnose patients in the clinic. METHODS: Six hundred consecutive patients referred to our rheumatology clinic with a diagnosis of FMS were examined by a standard protocol to determine whether they fulfilled the 1990 criteria for FMS. Both IFMS and FMS groups were compared in demographic, clinical, and psychological variables using appropriate statistical methods. RESULTS: One hundred twelve (18.7%) patients did not satisfy the 1990 ACR criteria and were classified as IFMS. Symptoms in IFMS and FMS were similar, generally with less frequent and less severe symptoms in the IFMS group. In IFMS, no significant difference was found among the WSP and TP component subgroups. Both TP and WSP were correlated with important features of FMS. CONCLUSIONS: Fulfillment of the ACR 1990 criteria is not necessary for a diagnosis of FMS in the clinic. For diagnosis and management of FMS in the clinical setting, IFMS patients, along with consideration of the total clinical picture, may be considered to have FMS, albeit generally mild.

Core Practical Objectives: a means to standardize the 4th-year emergency medicine clerkship.

BACKGROUND: Core Practical Objectives (CPOs) are clinical emergency medicine (EM) experiences (including suggested number of patient encounters) that students use to self-direct clerkship progress. PURPOSE: This study investigates feasibility of implementing EM clerkship CPOs, describes characteristics of students fulfilling CPO guidelines, and relates CPO completion to outcome measures (exam scores and grades). METHODS: Cross-sectional research was conducted comparing students completing and not completing CPOs by gender, month of rotation, total patients evaluated, clerkship exam score, and final grade. RESULTS: Over 4 years, 117 students completed an EM clerkship utilizing CPO guidelines. Gender and clerkship month were not associated with fulfilling CPOs. Total CPOs completed correlated positively with percent score on written exam and grade for rotation. Completion of specific CPOs was associated with exam scores and final grade. CONCLUSIONS: CPOs were successfully integrated into an EM clerkship. Preliminary data suggest that CPO guidelines can be used to standardize EM clerkships.

Epidemiology of community-onset Staphylococcus aureus infections in pediatric patients: an experience at a Children's Hospital in central Illinois.

BACKGROUND: The nation-wide concern over methicillin-resistant Staphylococcus aureus (MRSA) has prompted many clinicians to use vancomycin when approaching patients with suspected staphylococcal infections. We sought to characterize the epidemiology of community-onset S. aureus infections in hospitalized children to assist local clinicians in providing appropriate empiric antimicrobial therapy. METHODS: From January 2005-June 2008, children (0-18 years old) admitted to the Children's Hospital of Illinois with community-onset S. aureus infections were identified by a computer-assisted laboratory-based surveillance and medical record review. RESULTS: Of 199 patients, 67 (34%) had invasive infections, and 132 (66%) had skin and soft tissue infections (SSTIs). Among patients with invasive infections, S. aureus isolates were more likely to be susceptible to methicillin (MSSA 63% vs. MRSA 37%), whereas patients with SSTIs, S. aureus isolates were more likely to be resistant to methicillin (MRSA 64% vs. MSSA 36%). Bacteremia and musculoskeletal infections were the most common invasive infections in both groups of S. aureus. Pneumonia with empyema was more likely to be caused by MRSA (P = 0.02). The majority (approximately 90%) of MRSA isolates were non-multidrug resistant, even in the presence of healthcare-associated risk factors. CONCLUSION: Epidemiological data at the local level is important for antimicrobial decision-making. MSSA remains an important pathogen causing invasive community-onset S. aureus infections among hospitalized children. In our hospital, nafcillin in combination with vancomycin is recommended empiric therapy in critically ill patients with suspected invasive staphylococcal infections. Because up to 25% of MSSA circulating in our area are clindamycin-resistant, clindamycin should be used cautiously as empiric monotherapy in patients with suspected invasive staphylococcal infections.

Association of serum prolactin and oxytocin with milk production in mothers of preterm and term infants.

The present study was designed to compare milk production and hormone responses (prolactin [PRL], oxytocin [OT]) and to determine associations of hormone levels with milk production in mothers of preterm (PT) and term (TM) infants during the first 6 weeks postpartum. Mothers of PT infants (n = 95) were all pump dependent; mothers of TM infants (n = 98) were all feeding their infant at breast. Mothers of nonnursing PT infants produced less milk over time compared to mothers of TM infants. A higher proportion of PT mothers had lower basal PRL levels compared with TM mothers. PRL and frequency of breast stimulation combined positively influenced milk production in PT mothers. OT levels were higher in PT versus TM mothers, but OT was not related to milk production. Further study is warranted regarding interventions to enhance milk production, particularly in pump-dependent mothers of PT infants.

Comparison of milk output between breasts in pump-dependent mothers.

This article reports the naturally occurring pattern of milk output beginning day 6 through day 42 postpartum from each individual breast in 95 pump-dependent mothers of a non-nursing preterm infant. Of the 3488 study days, milk output was greater from the left breast on 51.6% (n = 1800) of the study days, from the right breast 45.8% (n = 1598) of the study days, and equal 2.6% (n = 90) of the study days. Overall, total left and right breast milk output for the entire study (37 days) was 52.6% and 47.4%, respectively. There was no significant relationship between individual breast milk output and maternal handedness, parity, or breastfeeding experience. Clinicians need to assess the total milk output as well as individual breast output in lactating mothers, as there may be significant disparities in milk production.

Predictors of preterm infant feeding methods and perceived insufficient milk supply at week 12 postpartum.

As part of a large, nonexperimental, prospective, longitudinal study, 94 pump-dependent mothers of a nonnursing preterm infant were queried via telephone at weeks 8 to 12 post-partum about their infant feeding method. At week 12, 44.6% provided own mother's milk, 26.6% provided own mother's milk + artificial milk, and 28.7% provided artificial milk only. Logistic regression analyses identified the following predictors for risk of artificial milk at week 12 postpartum: multiple birth, week 6 inadequate milk supply, maternal age younger than 29 years, and intended length of lactation less than 34 weeks. Predictors for risk of maternal perceived insufficient milk supply for weeks 8 to 12 postpartum included week 6 inadequate milk supply, unemployment, and infant hospital discharge after postpartum day 42. Further research is needed to assist pump-dependent mothers of preterm infants with sustaining their milk supply.

Maternal perceived quality of life following childbirth.

OBJECTIVE: To examine preterm, near-term, and term mothers' self-reported quality of life in the early postpartum period. DESIGN: Prospective, longitudinal repeated measures design. SETTING: Four medical centers in the Midwest. PATIENTS/PARTICIPANTS: A convenience sample of 184 mothers of either a preterm, near-term, or term infant. MAIN OUTCOME MEASURE: Maternal Postpartum Quality of Life tool. RESULTS: Mothers of preterm infants scored significantly lower on the subscale psychological/baby of the Maternal Postpartum Quality of Life tool compared to mothers of near-term and term infants. CONCLUSIONS: Infant gestational age at birth has relevance for maternal quality of life during the postpartum period. Health care professionals need to be cognizant relative to infant gestational age and individualize nursing care.

Alcohol reduction in the first trimester is unrelated to smoking, patient or pregnancy characteristics.

INTRODUCTION: Studies show alcohol-preferring mice reduce their alcohol intake during pregnancy; this study questions if the same is true for humans. The current investigation compares women's pre-pregnancy and first trimester alcohol consumption, examines if women with problem drinking diminish their alcohol intake during pregnancy, and determines if prenatal alcohol reduction is associated with characteristics of pregnancy, patients or smoking. METHODS: 126 participants in weeks 1-12 of pregnancy, recruited from Obstetric and Family Practices, completed a survey during their initial prenatal visit including two gender-specific AUDITs (Alcohol Use Disorders Identification Tests) querying current and pre-pregnancy alcohol use. AUDIT-C (AUDIT items 1-3) scores measuring pre-pregnancy and first trimester alcohol consumption were compared, analyzed and tested using general linear model repeated. A p ≤ 0.05 was accepted as significant. RESULTS: Most participants were multiparous, Caucasian high school graduates experiencing nausea and vomiting. Pre-pregnancy alcohol use was significantly (p = 0.019, Fisher's exact) higher among women seeing obstetricians. Pre-pregnancy AUDIT-C scores (m (mean) = 2.22, sd (standard deviation) = 2.19) were significantly higher (p < 0.001) than first trimester scores (m = 0.143, sd = 0.532). Among 49 with pre-pregnancy AUDIT-C scores ≥ 3, 45/49 (92%) reduced their alcohol use to zero during the first trimester. Age, race, education, marital status, parity, nausea and vomiting, gestational age and smoking were non-factors in score reduction. CONCLUSIONS: Women reported reducing their alcohol consumption during pregnancy, including those screening positive for pre-pregnancy problem drinking. First trimester alcohol reduction cannot be accounted for by smoking, patient or pregnancy characteristics; public health initiatives, psychological factors and hormonal mechanisms may be implicated.

Sex hormones and risks of rheumatoid arthritis and developmental or environmental influences.

Sex hormone relationships for onset risks of rheumatoid arthritis (RA) were analyzed in a nested case-control study, derived from a large community-based prospective cohort. A self-reported history of RA in a first-degree relative, heavy cigarette smoking, and positive rheumatoid factor (RF) were confirmed predictors of subsequent RA onset in this data set. In the 11 premenopausal onset cases, lower serum dehydroepiandrosterone sulfate levels were observed as was an imbalance in serum IL-1beta to IL-1ra levels; the latter was not observed in the 43 controls (CNs). In the 18 male cases, significantly higher serum cortisol was observed in the six cases with positive family history versus the 12 with a negative history. To the contrary, a small minority of the male cases had combined low serum cortisol and testosterone, which was not observed in the 72 CNs. Significant gender dimorphism was observed between the sex hormones and serum log RF titers as well as in the correlations of serum log testosterone and estradiol. Principal component analysis of multiply-imputed data sets extracted four uncorrelated components, which provided concordant neuroendocrine immune relationships to the previously investigated univariate and multivariate analyses. The literature on developmental and environmental influences on sex hormones and risks of RA was reviewed.

Mood states and milk output in lactating mothers of preterm and term infants.

The purpose of this study is to compare psychological distress via both negative and positive mood states between 2 different groups of lactating mothers during the first 6 weeks postpartum with a large sample. Mood states were measured using the Multiple Affect Adjective Check List-Revised by a convenience sample of newly delivered mothers from 4 tertiary care units in Illinois. Preterm mothers' negative mood states of anxiety, depression, hostility, and dysphoria were significantly greater than those reported for term mothers. For the positive mood states of positive affect and PASS (positive affect + sensation seeking), preterm mothers had significantly lower scores than term mothers; there were no differences for the positive mood state, Sensation Seeking. Maternal perceived mood states had no apparent effect upon lactation as measured by milk volume produced. Further study is warranted to determine what factors influence milk output in mothers of preterm and term infants who are at risk for lactation failure.

Software design to facilitate information transfer at hospital discharge.

Discharge communication between inpatient and outpatient physicians is often an inefficient and error-prone process. Adverse events result from poor communication at the time of discharge. The objective of this study was to describe development of discharge software to overcome communication barriers. The secondary objective was to assess factors that influence the time to complete tasks with the software. Methods were a performance improvement model and database analysis of 336 discharges. Software design specifications included computerised physician order entry, immediate utility, minimal development and deployment costs, acceptability to physician-users, and satisfaction of primary care physicians, patients and pharmacists. Design features included simple 'just-in-time' prompts and point-of-care prescribing resources. The dependent variable for analysis was physician time to complete discharge prescriptions and instructions while using the software. General linear and mixed-effects regression models adjusted for physician effects and other predictors. Results revealed that physician factors significantly affected the time to complete a discharge while using the software. As the number of accesses (log-ins) and free text typing increased, then time to complete the computerised discharge increased. Patient-related factors that increased physician time were discharge diagnoses, prescriptions and length of stay. In conclusion, discharge software can help inpatient physicians transfer timely, complete and legible information to outpatient physicians, pharmacists and patients. Physician and patient factors influence the time to complete discharges using the software.

Maternal Postpartum Quality of Life Questionnaire.

This article summarizes the development and psychometric properties of the first self-administered, paper-and-pencil instrument that measures maternal quality of life during the early postpartum period. The definition, domains, and conceptual model by Ferrans and Powers (QLI) were used to develop the Maternal Postpartum Quality of Life (MAPP-QOL) tool. A convenience sample of 184 mothers completed the MAPP-QOL at week 1 and 3 postpartum. Component analysis revealed five domains: psychological/baby; socioeconomic; relational/spouse-partner; relational/family-friends; and health & functioning. Internal consistency reliability for the five subscales resulted in Cronbach's alpha coefficients ranging from .82 to .96. Stability reliability ranged from .66 to .76. The MAPP-QOL and a single-item measure of life satisfaction correlated (r = .69), suggesting convergent validity; discriminant validity was supported by negative correlations with the three negative mood states of the Multiple Affect Adjective Check List-Revised (MAACL-R) as well as poor sleep and fatigue scores. Acceptable reliability and construct validity suggest that the MAPP-QOL may be used in research. Further testing with larger and more diverse samples is recommended.