Predictors of opioid use for rib fractures in a regional Australian hospital.

BACKGROUND: Rib fractures (RFs) are the leading type of single serious injury in New South Wales trauma patients. Uncontrolled pain drives the sequelae of atelectasis, pneumonia, respiratory failure, and death in severe cases. Opioids are the mainstay of management; however, they carry numerous adverse effects. Understanding patient or injury factors which predict opioid requirement is important to tailor management. Existing evidence is limited to metropolitan trauma centres (MTCs). METHODS: We conducted an observational, retrospective, single-centre cohort study of all admissions to Albury Wodonga Health diagnosed with one or more RFs and discharged between January 1st, 2017, and December 31st, 2022, inclusive. Data collected included demographics, injury characteristics, and management, including analgesia. LASSO regression was performed to determine predictors of average daily opioid use for the first five days of admission in oral morphine equivalents (mg). R2 and root mean square error (RMSE) were calculated to assess model performance. RESULTS: We included 624 patients. LASSO selected number of RFs, fracture displacement score, pulmonary contusion, new injury severity score, age, chest tube use, chronic pain history, opioid history and upper or middle lateral RF location categories as predictors. Sex, middle anterior, middle posterior, and lower RF location categories were excluded by LASSO. The out of sample R2 was 28.6 %. On the scale of log OME, the RMSE was 1.08. CONCLUSION: The model is effective at identifying predictors of opioid use in this regional centre, which are similar to those described in evidence from MTCs. However, the low R2 with wide prediction intervals limits its utility on an individual level.

Improving the implementation of diabetes self-management: findings from the Alliance to Reduce Disparities in Diabetes.

To enhance the health and well-being of patients managing type 2 diabetes, the five grantees comprising the Alliance to Reduce Disparities in Diabetes implemented evidence-based approaches to patient self-management education as part of their programs. This article describes strategies implemented by the grantees that may help explain program success, defined as improvement in clinical values and patient-reported outcomes. A process evaluation of grantee programs included interviews and document review at the beginning, midpoint, and end of the Alliance initiative. A total of 97 interviews were conducted over time with 65 program representatives. The Alliance programs served 2,328 people from diverse racial and ethnic backgrounds and provided 36,826 diabetes self-management sessions across the intervention sites. Framework analysis of the interviews identified four key themes that emerged across time and program sites that may help account for program success: empowerment, increasing access and support, addressing local needs and barriers, and care coordination. The overall evaluation findings may help other diabetes self-management programs seeking to translate and implement evidence-based approaches to reduce disparities and enhance patient well-being.

Cross-site evaluation of the Alliance to Reduce Disparities in Diabetes: clinical and patient-reported outcomes.

Alliance programs implemented multilevel, multicomponent programs inspired by the chronic care model and aimed at reducing health and health care disparities for program participants. A unique characteristic of the Alliance programs is that they did not use a fixed implementation strategy common to programs using the chronic care model but instead focused on strategies that met local community needs. Using data provided by the five programs involved in the Alliance, this evaluation shows that of the 1,827 participants for which baseline and follow-up data were available, the program participants experienced significant decreases in hemoglobin A1c and blood pressure compared with a comparison group. A significant time by study group interaction was observed for hemoglobin A1c as well. Over time, more program participants met quality indicators for hemoglobin A1c and blood pressure. Those participants who attended self-management classes and experienced more resources and support for self-management attained more benefit. In addition, program participants experienced more diabetes competence, increased quality of life, and improvements in diabetes self-care behaviors. The cost-effectiveness of programs ranged from $23,161 to $61,011 per quality-adjusted life year. In sum, the Alliance programs reduced disparities and health care disparities for program participants.

Mapping the low palmitate fap1 mutation and validation of its effects in soybean oil and agronomic traits in three soybean populations.

KEY MESSAGE: fap 1 mutation is caused by a G174A change in GmKASIIIA that disrupts a donor splice site recognition and creates a GATCTG motif that enhanced its expression. Soybean oil with reduced palmitic acid content is desirable to reduce the health risks associated with consumption of this fatty acid. The objectives of this study were: to identify the genomic location of the reduced palmitate fap1 mutation, determine its molecular basis, estimate the amount of phenotypic variation in fatty acid composition explained by this locus, determine if there are epistatic interactions between the fap1 and fap nc loci and, determine if the fap1 mutation has pleiotropic effects on seed yield, oil and protein content in three soybean populations. This study detected two major QTL for 16:0 content located in chromosome 5 (GmFATB1a, fap nc) and chromosome 9 near BARCSOYSSR_09_1707 that explained, with their interaction, 66-94 % of the variation in 16:0 content in the three populations. Sequencing results of a putative candidate gene, GmKASIIIA, revealed a single unique polymorphism in the germplasm line C1726, which was predicted to disrupt the donor splice site recognition between exon one and intron one and produce a truncated KASIIIA protein. This G to A change also created the GATCTG motif that enhanced gene expression of the mutated GmKASIIIA gene. Lines homozygous for the GmKASIIIA mutation (fap1) had a significant reduction in 16:0, 18:0, and oil content; and an increase in unsaturated fatty acids content. There were significant epistatic interactions between GmKASIIIA (fap1) and fap nc for 16:0 and oil contents, and seed yield in two populations. In conclusion, the fap1 phenotype is caused by a single unique SNP in the GmKASIIIA gene.

Was what ail'd ya what kill'd ya?

Making use of those Union Army veterans for whom death certificates are available, we compare the conditions with which they were diagnosed by Civil War pension surgeons to the causes of death on the certificates. We divide the data between those veterans who entered the pension system early because of war injuries and those who entered the pension system after the 1890 reform that made it available to many more veterans. We examine the correlation between specific medical conditions rated by the surgeons and death causes to gauge support for the hypothesis that death is attributable to something specific. We also examine the correlation between the accumulation of rated conditions to the length of time until death to gauge support for the "insult hypothesis." In general, we find support for both hypotheses. Examining the hazard ratios for dying of a specific condition, there is support for the idea that what ail'd ya' is what kill'd ya'.

Development and validation of an instrument to measure resources and support for chronic illness self-management: a model using diabetes.

PURPOSE: Few comprehensive and practical instruments exist to measure the receipt of self-management support for chronic illness. An instrument was developed to measure resources and support for self-management (RSSM) for the survey component of the evaluation of the Robert Wood Johnson Foundation's Diabetes Initiative. It includes items to measure an ecological range of RSSM. This article describes the development and validation of the instrument, focusing on individuals' reported access to RSSM from providers and from nonclinical, social, and community sources. METHODS: Cross-sectional analyses of the second wave of a survey of participants in the Diabetes Initiative (68% response rate, n = 957) were used. RESULTS: Confirmatory factor analyses supported grouping the 17 items into 5 subscales, measuring key aspects of RSSM: individualized assessment, collaborative goal setting, enhancing skills, ongoing follow-up and support, and community resources (comparative fit index = 0.97, Tucker-Lewis fit index = 0.99, and root means square error of approximation = 0.06). The overall scale and 5 subscales were internally consistent (Cronbach alpha >or= .70) and were significantly, positively related to diabetes self-management behaviors, supporting their construct validity. CONCLUSIONS: This instrument shows promise for measuring RSSM. Although it was developed for diabetes programs, its ecological orientation and link to the broad framework of chronic care suggest broader application.

Symptoms, diagnoses, and time to key diagnostic procedures among older U.S. women with ovarian cancer.

OBJECTIVE: To examine the types of symptoms and diagnostic procedures reported in Medicare claims 12 months before diagnosis for women with ovarian cancer by stage, and to assess the association between types of symptoms and time to key diagnostic procedures. METHODS: Medicare claims linked to records in the Surveillance, Epidemiology, and End Results (SEER) cancer registries were used to examine diagnosis and procedure codes in 3,250 women aged 65 years and older before a diagnosis of ovarian cancer. RESULTS: Over 81% of women with ovarian cancer had at least one target sign or symptom before diagnosis. Gastrointestinal symptoms such as nausea and vomiting (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.40-2.98), and constipation, diarrhea, or other digestive disorders (aOR 2.01, 95% CI 1.58-2.56) were associated with later-stage cancer. In contrast, gynecologic symptoms such as abnormal bleeding (aOR 0.44, 95% CI 0.34-0.58) and genital organ pain (aOR 0.66, 95% CI 0.53-0.80) were associated with earlier disease. Among those with at least one symptom, the rate at which women with gynecologic symptoms went to surgery was higher (hazard ratio 5.5, 95% CI 5.1-6.0) than the rate for women with other nongastrointestinal ovarian cancer-related symptoms. CONCLUSION: Women with ovarian cancer presenting with gastrointestinal symptoms were more likely to have later-stage disease and longer time to key diagnostic tests than those with gynecologic symptoms. Clinicians should be aware of the potential for unresolved gastrointestinal symptoms to be indicators for ovarian cancer.

The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

PURPOSE: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS: Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS: The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

Race/ethnic disparities in utilization of lifesaving technologies by Medicare ischemic heart disease beneficiaries.

OBJECTIVE: The objective of this study was to explain race/ethnic disparities in hospitalizations, utilization of high-technology diagnostic and revascularization services, and mortality of elderly ischemic heart disease (IHD) patients. DESIGN: A longitudinal Medicare claims database of all Part A hospital and Part B physician services provided elderly patients admitted for IHD in 1997 is used to construct admission, utilization, and mortality rates for whites and blacks, Asians, Hispanics, and American Indians. Z-scores are used to test differences in rates between whites and minorities at the 99% confidence level. Logistic and proportional hazard models are used to predict the likelihood of revascularization and its effects on race/ethnic survival 2 years postdischarge. SETTING: The setting of this study was an acute hospital supplemented by all ambulatory Part B outpatient providers of care. PATIENTS/PARTICIPANTS: Participants included all 700,000 age 65+ Medicare beneficiaries in fee-for-service identified with IHD as a primary diagnosis on admission in 1997. MEASUREMENTS AND MAIN RESULTS: Whites were 26% more likely to be admitted for IHD than blacks, 50% more likely than Asians, 5% more than American Indians, but 3% less likely than Hispanics. Once admitted, elderly blacks and American Indians undergo invasive diagnostic and surgical revascularization far less often than whites (P < 0.01), although blacks are equally as likely as whites to be admitted to an open heart hospital. Controlling for other factors, whites reduce their 2-year mortality by 20% by undergoing revascularization 41% of the time. Blacks gain only 11% as a result of much lower rates and gains to revascularization than whites. Asians and Hispanics were slightly more likely than whites to undergo revascularization but gain less than whites from the procedure. CONCLUSIONS: Despite having similar Medicare health insurance coverage, elderly utilization and IHD mortality rates differ markedly not only between whites and minorities, but within minority groups themselves. A large, nationally representative survey of physicians and patients is needed to distinguish between systemwide "failures to refer" and patient "aversions to surgery" as explanations for lower black rates of surgical interventions.

Experimental injury study of children seated behind collapsing front seats in rear impacts.

In the mid 1990's the U.S. Department of Transportation made recommendations to place children and infants into the rear seating areas of motor vehicles to avoid front seat airbag induced injuries and fatalities. In most rear-impacts, however, the adult occupied front seats will collapse into the rear occupant area and pose another potentially serious injury hazard to the rear-seated children. Since rear-impacts involve a wide range of speeds, impact severity, and various sizes of adults in collapsing front seats, a multi-variable experimental method was employed in conjunction with a multi-level "factorial analysis" technique to study injury potential of rear-seated children. Various sizes of Hybrid III adult surrogates, seated in a "typical" average strength collapsing type of front seat, and a three-year-old Hybrid III child surrogate, seated on a built-in booster seat located directly behind the front adult occupant, were tested at various impact severity levels in a popular "minivan" sled-buck test set up. A total of five test configurations were utilized in this study. Three levels of velocity changes ranging from 22.5 to 42.5 kph were used. The average of peak accelerations on the sled-buck tests ranged from approximately 8.2 G's up to about 11.1 G's, with absolute peak values of just over 14 G's at the higher velocity change. The parameters of the test configuration enabled the experimental data to be combined into a polynomial "injury" function of the two primary independent variables (i.e. front seat adult occupant weight and velocity change) so that the "likelihood" of rear child "injury potential" could be determined over a wide range of the key parameters. The experimentally derived head injury data was used to obtain a preliminary HIC (Head Injury Criteria) polynomial fit at the 900 level for the rear-seated child. Several actual accident cases were compared with the preliminary polynomial fit. This study provides a test efficient, multi-variable, method to compare the injury biomechanical data with actual accident cases.