Safety and Health Programs in Alaska's Seafood Processing Industry: Interviews with Safety and Health Managers.

Background: The seafood processing industry is critical to Alaska's economy and hazardous to workers; however, limited research has addressed workers' safety and health. Safety and health program management is a decisive factor in preventing fatalities, injuries, and illnesses. We interviewed managers to gain their views on their safety and health programs.Methods: Semi-structured interviews were conducted with 14 upper-level managers who oversaw programs for Alaskan worksites. Interviews were audio-recorded and transcribed. Qualitative content analysis techniques, including inductive coding, were utilized to explore participants' experiences and views regarding: management and workers' roles; hazard control systems; safety and health training; regulatory and economic factors; and programs' challenges and successes.Results: The 14 participants represented 13 companies that operated 32 onshore plants and 30 vessels with processing capabilities. Participants reported managing programs for an estimated 68% of the Alaskan seafood processing industry's workforce. Based on participants' responses, we identified five factors that could be modified to improve safety and health industry-wide: manager training and knowledge sharing; worker training; organizational aspects related to safety culture; application of ergonomic principles; and work hours. Participants reported that fully engaging workers in programs was beneficial.Conclusions: Industry members should more widely share their best practices for protecting workers' safety and health. Occupational safety and health practitioners and researchers should support the development and evaluation of (a) training for non/limited-English-speaking-workers, (b) ergonomic interventions, and (c) fatigue risk management systems. Future research should engage worksite managers and workers to characterize their safety and health experiences and needs.

Postoperative chylothorax development is associated with increased incidence and risk profile for central venous thromboses.

This study tested the hypothesis that pediatric patients who develop chylothorax (CTX) after surgery for congenital heart disease (CHD) have an elevated incidence and risk profile for central venous thrombosis (CVT). We evaluated 30 patients who developed CTX after surgery for CHD. All but one CTX patient were surgery-, anatomy-, and age-matched with two controls (NON-CTX) to compare their relative risk and incidence of CVT. Using conditional logistic regression analyses, CTX development was associated with significantly longer ventilator dependence (14.8 +/- 10.9 vs. 6.1 +/- 5.9 days, p = 0.003) and a non-significant trend towards more days of central venous catheters (CVC) (19.1 +/- 16.6 vs. 12.2 +/- 10.0 days; p = 0.16) when comparing the period prior to CTX development with the entire hospitalization in NON-CTX patients. CTX development was associated with a significantly elevated mortality risk (Odds Ratio 6.2, 95% CI 1.3-30.9). Minimum and mean daily central venous pressures were significantly higher in the CTX group. Post operative need for extracorporeal membrane oxygenation conferred an increased risk of CTX development in this sample of patients (Odds Ratio 9.9, 95% CI 2.2-44.8). Incidence of documented CVT was 26.7% in the CTX group versus 5.1% in the NON-CTX group. Prospective screening for CVT risk and formation, combined with early removal of CVC may help reduce the incidence of CTX.

Colpocleisis for pelvic organ prolapse: patient goals, quality of life, and satisfaction.

OBJECTIVE: To assess patient-centered colpocleisis outcomes in women. METHODS: This is a prospective cohort study. Between March 2000 and December 2005, 94 patients underwent colpocleisis. Patients completed follow-up questionnaires about their personal postoperative goal attainment satisfaction with care, regrets about surgery, as well as the Incontinence Impact Questionnaire and Urogenital Distress Inventory. RESULTS: Forty patients (42.6% of all patients) returned questionnaires with complete data on study outcomes. Mean age was 75.4 years (+/-6.8 years), and mean weight was 70.9 kg (+/-10.8 kg). Mean follow up was 2.75 years (+/-1.90 years). Most women agreed or strongly agreed that their goals were met for vaginal pressure (100%), urinary incontinence (84.9%), bladder emptying (76.4%), urinary frequency/urgency (91.2%), physical activity (88.6%), restoration of normal anatomy (95 %), colorectal symptoms (65.0%), and self-image (96.9%). Mean goal attainment (1.4+/-0.6) was associated with the postsurgery Urogenital Distress Inventory (r=-0.45, P=.003.) although not the Incontinence Impact Questionnaire. Mean scores improved presurgery to postsurgery for both the Urogenital Distress Inventory (39.9+/-24.9 versus 21.0+/-20.3, P<.01) and the Incontinence Impact Questionnaire (35.4+/-29.3 versus 17.3+/-24.6, P<.01). Ninety-five percent of respondents were either "very satisfied" or "satisfied" with their surgical outcome, while 5% reported postoperative regret. Of the entire series, 19.1% experienced postoperative complications. CONCLUSION: Colpocleisis results in improved quality of life and substantial goal attainment, with a low proportion of regret. LEVEL OF EVIDENCE: II.

Are men at greater risk for Parkinson's disease than women?

Parkinson's disease seems to occur more commonly in men than women based primarily on studies of death rates and prevalence. In recent years, several population based incidence studies of Parkinson's disease that included sex data have been conducted in a variety of populations around the world. To investigate whether these incidence studies suggest an increased risk of Parkinson's disease in men, a meta-analysis was performed of the differences in incidence of Parkinson's disease between men and women reported in seven studies that met the inclusion criteria. A significantly higher incidence rate of Parkinson's disease was found among men with the relative risk being 1.5 times greater in men than women. Possible reasons for this increased risk of Parkinson's disease in men are toxicant exposure, head trauma, neuroprotection by oestrogen, mitochondrial dysfunction, or X linkage of genetic risk factors.

Risk factors for perineal injury during delivery.

OBJECTIVE: We sought to identify risk factors for anal sphincter injury during vaginal delivery. STUDY DESIGN: This was a retrospective, case-control study. We reviewed 2078 records of vaginal deliveries within a 2-year period from May 1, 1999, through April 30, 2001. Cases (n = 91) during the study period were defined as parturients who had documentation of greater than a second-degree perineal injury. Control subjects (n = 176), who were identified with the use of a blinded protocol, included women who were delivered vaginally with less than or equal to a second-degree perineal injury. For each patient, we reviewed medical and obstetrics records for the following characteristics: maternal age, race, weight, gestational age, parity, tobacco use, duration of first and second stages of labor, use of oxytocin, use of forceps or vacuum, infant birth weight, epidural use, and episiotomy use. RESULTS: Of the 2078 deliveries that were reviewed, we discovered 91 cases (4.4%) of documented anal sphincter injury. The mean maternal age of our sample was 24.9 +/- 5.9 years). Nearly two thirds (63.2%) were white; 26.7% were black, and 10.1% were of other racial backgrounds. Forceps were used in 51.6% of deliveries that resulted in tears (cases), compared to 8.6% of deliveries without significant tears (control subjects, P <.05). Using cases and control subjects with complete data (cases, 82; control subjects, 144), delivery with forceps was associated with a 10-fold increased risk of perineal injury (odds ratio, 10.8; 95% CI, 5.2-22.3) compared to noninstrumented deliveries. The association was similar after adjustment for age, race, parity, mode of delivery, tobacco use, episiotomy, duration of labor (stages 1 and 2), infant birth weight, epidural, and oxytocin use (odds ratio, 11.9; 95% CI, 4.7-30.4). Nulliparous women were at increased risk for tears (adjusted odds ratio, 10.0; 95% CI, 3.0-33.3) compared with multiparous patients, but parity did not reduce the association between forceps-assisted deliveries and anal sphincter injuries. Increasing fetal weight was also a risk factor in both unadjusted and adjusted analyses. The performance of a midline episiotomy was associated with an increased risk of anal sphincter tear compared with delivery without an episiotomy in the univariate analysis (odds ratio, 4.9; 95% CI, 2.5-9.6), but this association was reduced in the adjusted analysis (odds ratio, 2.5; 95% CI, 1.0-6.0). The increased duration of both the first and second stages of labor increased injury risk in the unadjusted, but not adjusted, analysis. No significant association was observed between case status and the use of oxytocin or epidural anesthesia. Greater, but not significant, increased risk was associated with maternal indications for operative delivery compared with fetal indications. CONCLUSION: Our results are consistent with recent reports that identify forceps delivery and nulliparity as risk factors for recognized anal sphincter injury at the time of vaginal delivery. Further investigation should focus on the determination of whether the association of injury to instrumentation is causal or, in fact, modifiable. Because of the established association between sphincteric muscular damage and anal incontinence, patients should be counseled about the risk of anal sphincter injury when operative vaginal delivery is contemplated. Such patients should be followed closely in the postpartum setting to assess for the development of potential anorectal complaints.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway.

OBJECTIVE: To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied. METHODS: During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared. RESULTS: After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings. CONCLUSIONS: Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

The impact of disease management on outcomes and cost of care: a study of low-income asthma patients.

An asthma disease management program designed specifically for low-income patients experiencing significant adverse events can improve health outcomes substantially, while lowering costs. The Virginia Health Outcomes Partnership aimed to help physicians in a fee-for-service primary care case management program manage asthma in Medicaid recipients. Approximately one-third of physicians treating asthma in an area designated as the intervention community volunteered to participate in training on disease management and communication skills. This large-scale study discovered that the rate of emergency visit claims for patients of participating physicians who received feedback reports dropped an average of 41% from the same quarter a year earlier, compared to only 18% for comparison community physicians. Although only a third of the intervention community physicians participated in the training, emergency visit rates for all intervention community physicians nonetheless declined by 6% relative to the comparison community among moderate-to-severe asthma patients when data for participating and nonparticipating physicians were combined. At the same time, the dispensing of some reliever drugs recommended for asthma increased 25% relative to the comparison community. A cost-effectiveness analysis projected direct savings to Medicaid of $3 to $4 for every incremental dollar spent providing disease management support to physicians. The results of this study demonstrate the potential this program offers, especially for Medicaid programs in other states that want to improve the care of their primary care case management networks and, at the same time, manage costs.

Internet-based monitoring and benchmarking in ambulatory surgery centers.

BACKGROUND: Each year the number of surgical procedures performed on an outpatient basis increases, yet relatively little is known about assessing and improving quality of care in ambulatory surgery. Conventional methods for evaluating outcomes, which are based on assessment of inpatient services, are inadequate in the rapidly changing, geographically dispersed field of ambulatory surgery. Internet-based systems for improving outcomes and establishing benchmarks may be feasible and timely. METHODS: Eleven freestanding ambulatory surgery centers (ASCs) reported process and outcome data for 3,966 outpatient surgical procedures to an outcomes monitoring system (OMS), during a demonstration period from April 1997 to April 1999. ASCs downloaded software and protocol manuals from the OMS Web site. Centers securely submitted clinical information on perioperative process and outcome measures and postoperative patient telephone interviews. Feedback to centers ranged from current and historical rates of surgical and postsurgical complications to patient satisfaction and the adequacy of postsurgical pain relief. RESULTS: ASCs were able to successfully implement the data collection protocols and transmit data to the OMS. Data security efforts were successful in preventing the transmission of patient identifiers. Feedback reports to ASCs were used to institute changes in ASC staffing, patient care, and patient education, as well as for accreditation and marketing. The demonstration also pointed out shortcomings in the OMS, such as the need to simplify hardware and software installation as well as data collection and transfer methods, which have been addressed in subsequent OMS versions. DISCUSSION: Internet-based benchmarking for geographically dispersed outpatient health care facilities, such as ASCs, is feasible and likely to play a major role in this effort.

Dietary intake of long-chain n-3 polyunsaturated fatty acids and the risk of primary cardiac arrest.

Whether the dietary intake of long-chain n-3 polyunsaturated fatty acids (PUFAs) from seafood reduces the risk of ischemic heart disease remains a source of controversy, in part because studies have yielded inconsistent findings. Results from experimental studies in animals suggest that recent dietary intake of long-chain n-3 PUFAs, compared with saturated and monounsaturated fats, reduces vulnerability to ventricular fibrillation, a life-threatening cardiac arrhythmia that is a major cause of ischemic heart disease mortality. Until recently, whether a similar effect of long-chain n-3 PUFAs from seafood occurred in humans was unknown. We summarize the findings from a population-based case-control study that showed that the dietary intake of long-chain n-3 PUFAs from seafood, measured both directly with a questionnaire and indirectly with a biomarker, is associated with a reduced risk of primary cardiac arrest in humans. The findings also suggest that 1) compared with no seafood intake, modest dietary intake of long-chain n-3 PUFAs from seafood (equivalent to 1 fatty fish meal/wk) is associated with a reduction in the risk of primary cardiac arrest; 2) compared with modest intake, higher intakes of these fatty acids are not associated with a further reduction in such risk; and 3) the reduced risk of primary cardiac arrest may be mediated, at least in part, by the effect of dietary n-3 PUFA intake on cell membrane fatty acid composition. These findings also may help to explain the apparent inconsistencies in earlier studies of long-chain n-3 PUFA intake and ischemic heart disease.

Effect of different types of Medicaid managed care on childhood immunization rates.

Medicaid managed care can improve access to prevention services, such as immunization, for low-income children. The authors studied immunization rates for 7,356 children on Medicaid in three managed care programs: primary care case management (PCCM; n = 4,605), a voluntary HMO program (n = 851), and a mandatory HMO program (n = 1,900). Immunization rates (3:3:1 series) in PCCM (78%) exceeded rates in the voluntary HMO program (71%), which in turn exceeded those in the mandatory HMO program (67%). Adjusting for race, urban residence, and gender, compared to children in PCCM, children in the voluntary HMO program were less likely to complete the 3:3:1 series (OR = 0.75, CI = 0.63, 0.90), and children in the mandatory HMO program were even less likely to complete the series (OR = 0.59, CI = 0.51, 0.68). Results differed by individual HMOs. Monitoring of outcomes for all types of managed care by Medicaid agencies is imperative to assure better disease prevention for low-income children.

Assessing Medicaid recipient access and satisfaction. Fee-for-service, case management, and capitation.

Medicaid increasingly requires enrollment in managed care programs. This study assessed access to care, satisfaction with care, and appointment wait times during the transition from fee for service to managed care using three annual Medicaid recipient surveys. There was little evidence of dissatisfaction or poorer access among managed care recipients. Fee-for-service recipients, compared to primary care case management, reported greater general (91 vs. 78%, p < .01) and specialty care access (92 vs. 80%, p < .01). When appointments were required, adult HMO enrollees, compared to case management, had longer waits for routine care in the second (5.8 +/- 8.2 days vs. 4.0 +/- 6.6) and third surveys (5.5 +/- 6.9 days vs. 3.8 +/- 7.3); waits for other appointments did not consistently differ by program. There were no significant program differences in overall satisfaction. Findings are tempered by the potential for response bias and geographic confounding. Continued monitoring is crucial to assure that access and satisfaction remain high in Medicaid managed care.

Access, satisfaction, and utilization in two forms of Medicaid managed care.

We determined access and satisfaction of 2,598 recipients of Virginia's Medicaid program, comparing its health maintenance organizations (HMOs) to its primary care case management (PCCM) program. Positive responses were summed as sub-domains either of access, satisfaction, or of utilization, and adjusted odds ratios were calculated for HMO (vs. PCCM) sub-domain scores. The response rate was 47 per cent. We found few significant differences in perceived access, satisfaction, and utilization. Both HMO adults and children more often perceived good geographic access (adults, OR, [CI] = 1.50, [1.04-2.16]; children, OR, [CI] = 1.773 [1.158, 2.716]). But HMO patients less often reported good after-hours access (adults, OR, [CI] = 0.527 [0.335, 0.830]; children, OR, [CI] = 0.583 [0.380, 0.894]). Among all patients reporting poorer function, HMO patients more often reported good general and preventive care (OR, [CI] = 2.735 [1.138, 6.575]). We found some differences between Medicaid HMO versus PCCM recipients' reported access, satisfaction, and utilization, but were unable to validate concerns about access and quality under more restrictive forms of Medicaid managed care.

Lipid-lowering medication and risk of injury.

Meta-analyses of early primary prevention trials of lipid-lowering therapies suggested increased risk of injury deaths among treated persons. Our population-based case-control study examined the association of lipid-lowering medication use with fatal and nonfatal injuries in 298 cases and 332 controls. No increased injury risk was observed among current (OR = 0.46, 95% CI 0.18-1.21) or past users (OR = .92, 95% CI 0.44-1.95), after adjustment for behavioral disorders, medical conditions, and health status. Stratified analyses did not reveal sub-groups at significantly increased risk. These results, consistent with recent clinical trials and meta-analyses, suggest no increased injury risk associated with lipid-lowering medications.

Effect of cholesterol-lowering diets on indices of depression and hostility.

Increased injury deaths have been reported among treatment groups in cholesterol lowering trials, leading to speculation that lipid lowering may result in behavioral disorders. We investigated this in 319 men enrolled in a 2-year trial of lipid lowering diets who completed measures of depression and hostility at entry and 24 months later. Mean Beck Depression Inventory (BDI) scores were lower after 24 months (3.8 versus 3.3,p<0.05) and Symptom Checklist 90-Revised (SCL-90) depression and hostility scores were unchanged. After adjustment for potential confounding, 24-month hostility and BDI scores were unrelated to lipid changes. A small inverse association of borderline statistical significance (B=0.034,p=0.08) was noted between 24-month SCL-90 depression scores and lipid changes. Lipid lowering diets had no significant adverse effect on psychological function and are consistent with current dietary recommendations.

Caffeine intake in relation to the risk of primary cardiac arrest.

We conducted a population-based case-control study in King County, WA, to evaluate the association between usual caffeine intake and primary cardiac arrest. We identified primary cardiac arrest cases (N = 362) without a history of clinical heart disease or major comorbidity through paramedic incident reports during the period 1988-1994. We identified controls (N = 581), individually matched to cases on age (+/-7 years) and gender and meeting the same general health criteria, through random digit dialing. We interviewed the spouses of cases and controls to obtain information on usual caffeine intake from coffee, tea, and cola during the prior year. After adjusting for cigarette smoking and other risk factors, we observed little association between daily consumption of the caffeine equivalent of fewer than 5 cups per day of drip coffee (< 687 mg per day) and primary cardiac arrest. High usual caffeine consumption (> or = 687 mg per day) was associated with a modestly elevated risk of primary cardiac arrest [odds ratio = 1.44; 95% confidence interval (CI) = 0.82-2.53]. The elevated risk associated with high caffeine consumption appeared to be restricted to never-smokers (odds ratio for > or = 687 mg per day = 3.2; 95% CI = 1.3-8.1).

The Northwest Lipid Research Clinic Fat Intake Scale: validation and utility.

OBJECTIVES: This paper describes the Northwest Lipid Research Clinic Fat Intake Scale, a brief dietary questionnaire to screen and monitor dietary intake related to plasma cholesterol levels. METHODS: The 12-item instrument assesses intake of foods high in fat, saturated fat, and cholesterol. Test-retest reliability was assessed on 194 men and 116 women with high cholesterol prior to a dietary intervention study. To measure validity and responsiveness to dietary change, scores were compared with 4-day food records before and after diet education classes. RESULTS: Test-retest correlation coefficients were .88 for men and .90 for women (2 weeks between scores). Scores for men and women were correlated with nutrients shown by food records at baseline (.47 and .54, total fat; .50 and .51, saturated fat) and 18 months postintervention (.52 and .58, total fat; .56 and .64, saturated fat; all Ps < .001). Mean scores decreased from about 30 to 23 (P < .001, paired t test). CONCLUSIONS: The Fat Intake Scale, a qualitative instrument, has acceptable reliability and validity for estimating the level of cholesterol-related diet components and reflects dietary modification. The format of the instrument also lends itself to patient education and goal setting.

Predicting participation in a dietary intervention to lower cholesterol among individuals with hyperlipidemia.

Adult men and women (N = 8,748) were given blood cholesterol tests and completed a measure of fat intake and a staging questionnaire that assessed readiness to adopt a cholesterol-lowering diet. Eligibility for the trial was based on plasma cholesterol levels and self-reported dietary intake. Of 772 eligible participants, 545 (70.6%) agreed to join. In multivariate analyses, joiners did not differ from nonjoiners by age, total cholesterol levels, or self-reported dietary fat intake. Women were more likely than men to join the study. Individuals in the preparation stage (defined on the basis of a staging algorithm derived from the transtheoretical model of change) were more likely to join the trial than were precontemplators. An understanding of the determinants of participation in a dietary intervention may be important in the enhancement of high-risk individuals' acceptance of recommendations to make dietary changes.

Spouse support and long-term adherence to lipid-lowering diets.

Social support is inversely associated with heart disease risk. Support may influence heart disease by encouraging health behavior change in high-risk individuals. This study examined the association between spouse support and maintenance of low-fat diets in men with hypercholesterolemia. Participants were 254 men enrolled in a 24-month randomized trial of lipid-lowering diets initiated in 1985 in Seattle, Washington. The Evaluation of Spouse Support, which assesses the extent to which spouses supported maintenance of lipid-lowering diets, was administered after the last of eight dietary classes and at 3, 12, and 24 months postinstruction. Attainment of dietary goals was determined from food records completed at the end of the class and at 3, 12, and 24 months. Compared with those in the lowest quartile, those in the highest quartile of support were more likely to attain dietary goals at 3 months (odds ratio (OR) = 4.5, 95% confidence interval (CI) 1.9-10.4), 12 months (OR = 5.5, 95% CI 2.4-12.5), and 24 months (OR = 3.9, 95% CI 1.7-9.3). Support was not associated with end-of-class dietary goal achievement. Social support may be an important factor in the maintenance of low-fat diets.

Relationship of self-effecacy to cholesterol lowering and dietary change in hyperlipidemia.

This study examined whether self-efficacy was associated with lipid lowering and dietary change among men undergoing dietary counseling to lower cholesterol levels. Twenty-five hyperlipidemic men (total cholesterol ≧220 mg/dL) participated in four weeks of dietary instruction. Plasma lipids were measured prior to treatment, at posttreatment, and at three- and twelvemonth follow-up. Dietary intake and self-efficacy as measured by the revised Eating Self-Efficacy Scale (ESES-R) were assessed at pretreatment, posttreatment, and three-month follow-up. Pre-treatment to posttreatment increases in self-efficacy in situations characterized by negative affect were related to extent of lipid lowering and dietary change. Although subjects showed significant reductions in cholesterol levels following treatment, by one year, lipid levels had returned to pretreatment values. Factors related to long-term maintenance of dietary change and lipid lowering among hyperlipidemics merit further research.