Childhood cancer in children with congenital anomalies in Oklahoma, 1997 to 2009.

BACKGROUND: Data-linkage studies have reported an association between congenital anomalies and childhood cancer. However, few studies have focused on the differences in the effect of congenital anomalies on cancer as a function of attained age. We aimed to examine associations between anomalies and childhood cancer as a function of attained age among children born in Oklahoma. METHODS: Data were obtained from the Oklahoma State Department of Health from 1997 to 2009 (n = 591,235). We linked Vital Statistics records for singleton deliveries to the Oklahoma Birth Defects Registry and the Oklahoma Central Cancer Registry using name and birth date. To assess the relation between anomalies and childhood cancer, we used Cox regression analysis allowing for a nonproportional hazards for anomalies as a function of age. RESULTS: There were 23,368 (4.0%) children with anomalies and 531 (0.1%) children with cancer. When considering 3-year age intervals, we detected an increased hazard of any childhood cancer in children with anomalies compared with those without anomalies before 1 year of age (hazard ratio, 14.1; 95% confidence interval, 8.3-23.7) and at 3 years of age (hazard ratio, 2.3; 95% confidence interval, 1.6-3.2). The increased hazard declined with increasing time since birth, with the effect diminished by 6 years of age. CONCLUSION: Our results were consistent with previous studies indicating an increased rate of childhood cancer among children with anomalies at younger ages. Furthermore, our study added a methodological refinement of assessing the effect of anomalies as a function of attained age. Birth Defects Research (Part A) 106:633-642, 2016. © 2016 Wiley Periodicals, Inc.

Does the use of atypical antipsychotics as adjunctive therapy in depression result in cost savings? Comparing healthcare costs and utilization between second-line treatment options.

BACKGROUND: Several atypical antipsychotics (AAPs) are used as second-line agents for treatment resistant depression. AAPs can be expensive compared to other treatment options and can cause several side effects. OBJECTIVES: To estimate healthcare costs and utilization of AAPs compared to other second-line agents. METHODS: Observational study using Medicaid claims data (2006-2011). Subjects were depression-diagnosed adult members with at least two prescriptions of antidepressant medications followed by a second-line agent. Gamma generalized linear models (GLM) produced estimates of the difference in mean expenditures among treatment groups after adjusting for individual baseline characteristics using propensity scores. Negative binomial models produced estimates of the difference in number of hospitalizations and emergency department (ED) visits. RESULTS: A total of 3910 members received second-line treatment. Treatment groups were AAPs (n = 2211), augmentation agents other than AAPs (n = 1008), and antidepressant switching (n = 691). AAPs resulted in higher mean adjusted pharmacy costs and higher mean adjusted total mental health-related costs. Mean adjusted total healthcare costs and number of inpatient and ED visits were not different among treatments. CONCLUSION: The results show no evidence that AAPs used as second-line treatment for depression results in overall cost savings or lower inpatient and ED visits compared to other treatment strategies.

State-Level Correlates of Unassisted Quit Attempts and Success.

BACKGROUND: Although the majority of smokers attempting to quit do so without assistance, research in the area of unassisted quit behaviors is limited. The aim of this study was to investigate whether population-level policies and programs, such as smoke-free air policies and tobacco control programs, contribute to unassisted quit attempts and cessation. METHODS: The current study used the 2003 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) special Cessation Supplement (CS) to estimate unassisted quit attempt and success rates by state. Linear regression was used to examine whether state-level unassisted quit attempt and success rates were related to state-level policies and social norms. State-level factors investigated were tobacco control program funding, tobacco taxes, smoke-free air policies, state anti-smoking sentiment and recent change in smoking prevalence. RESULTS: Consistent with previous studies, this study found the majority of smokers who attempted to quit did so without assistance. This study also found unassisted quit attempt rates were higher than assisted attempt rates in every state and DC. Additionally, unassisted quit success rates were higher than assisted quit success rates in most states; however, some states had higher assisted quit success rates. State-level factors associated with unassisted quit attempt rates included anti-smoking sentiment and tobacco taxes; however, no significant relationships were uncovered between unassisted quit success rates and state-level factors. CONCLUSIONS: These results suggest that state-level factors may be more important in motivating smokers to attempt quitting, and other individual factors or unmeasured state factors may be related to quit success.

Comparison of autoantibody specificities between traditional and bead-based assays in a large, diverse collection of patients with systemic lupus erythematosus and family members.

OBJECTIVE: Replacement of standard immunofluorescence methods with bead-based assays for antinuclear antibody (ANA) testing is a new clinical option. The aim of this study was to evaluate a large, multiethnic cohort of patients with systemic lupus erythematosus (SLE), blood relatives, and unaffected control individuals for familial aggregation and subset clustering of autoantibodies by high-throughput serum screening technology and traditional methods. METHODS: Serum samples (1,540 SLE patients, 1,154 unaffected relatives, and 906 healthy, population-based controls) were analyzed for SLE autoantibodies using a bead-based assay, indirect immunofluorescence (IIF), and immunodiffusion. Autoantibody prevalence, sensitivity for disease detection, clustering of autoantibodies, and associations between newer methods and standard immunodiffusion results were evaluated. RESULTS: The frequencies of ANAs in the sera from African American, Hispanic, and European American patients with SLE were 89%, 73%, and 67%, respectively, by BioPlex 2200 bead-based assay and 94%, 84%, and 86%, respectively, by IIF. When comparing the serum prevalence of 60-kd Ro, La, Sm, nuclear RNP A, and ribosomal P autoantibodies across assays, the sensitivity of detection ranged from 0.92 to 0.83 and the specificity ranged from 0.90 to 0.79. Autoantibody cluster analysis showed associations of autoantibody specificities in 3 subsets: 1) 60 kd Ro, 52-kd Ro, and La, 2) spliceosomal proteins, and 3) double-stranded DNA (dsDNA), chromatin, and ribosomal P. Familial aggregation of Sm/RNP, ribosomal P, and 60-kd Ro in SLE patient sibling pairs was observed (P ≤ 0.004). Simplex-pedigree SLE patients had a greater prevalence of dsDNA (P = 0.0003) and chromatin (P = 0.005) autoantibodies compared to patients with a multiplex SLE pedigree. CONCLUSION: The frequencies of ANAs detected by a bead-based assay are lower than those detected by IIF in European American patients with SLE. These assays have strong positive predictive values across ethnic groups, provide useful information for clinical care, and provide unique insights into familial aggregation and autoantibody clustering.

The Communities Advancing Resilience Toolkit (CART): development of a survey instrument to assess community resilience.

While building community resilience to disasters is becoming an important strategy in emergency management, this is a new field of research with few available instruments for assessing community resilience. This article describes the development of the Communities Advancing Resilience Toolkit (CART) survey instrument. CART is a community intervention designed to enhance community resilience to disasters, in part, by engaging communities in measuring it. The survey instrument, originally based on community capacity and related literature and on key informant input, was refined through a series of four field tests. Community organizations worked with researchers in a participatory action process that provided access to samples and helped to guide the research. Exploratory factor analysis performed after each field test led to the identification of four interrelated constructs (also called domains) which represent the foundation for CART Connection and Caring, Resources, Transformative Potential, and Disaster Management. This model was confirmed using confirmatory factor analysis on two community samples. The CART survey can provide data for organizations and communities interested in assessing a community's resilience to disasters. Baseline data, preferably collected pre disaster can be compared to data collected post disaster and/or post intervention.

Prevalence of primary immune thrombocytopenia in Oklahoma.

To determine the prevalence of immune thrombocytopenia (ITP) in Oklahoma regardless of age, clinical characteristics, insurance status, and source of health care. Patients with ITP were identified by the administrative code ICD-9-CM 287.3 in Oklahoma hematologists' offices for a 2-year period, 2003-2004. Prevalence was estimated separately for children (<16 years old) and adults because of their distinct clinical characteristics. Oklahoma census data for 2000 was used as the denominator. Eighty-seven (94%) of 93 eligible Oklahoma hematologists participated; 620 patients with ITP were identified. The average annual prevalences were as follows: 8.1 (95% CI: 6.7-9.5) per 100,000 children, 12.1 (95% CI: 11.1-13.0) per 100,000 adults, and 11.2 (95% CI: 10.4-12.0) per 100,000 population. Among children and adults less than age 70 years, the prevalence was greater among women. Among adults aged 70 years and older, the prevalence was greater among men. The highest prevalence of ITP was among men age 80 years and older. These data document for the first time the prevalence of ITP regardless of age, clinical characteristics, insurance status, and source of health care. The methodology developed for this prevalence analysis may be adaptable for epidemiologic studies of other uncommon disorders which lack specific diagnostic criteria and are treated primarily by medical specialists. Am. J. Hematol. 2012. © 2012 Wiley Periodicals, Inc.

Determining a definite diagnosis of primary immune thrombocytopenia by medical record review.

The objective of this study is to establish a method to identify patients with primary immune thrombocytopenia (ITP) utilizing administrative data from diverse data sources that would be appropriate for epidemiologic studies of ITP, regardless of patients' age and source of health care. Medical records of the Oklahoma University Medical Center, 1995-2004, were reviewed to document the accuracy of the administrative code ICD-9-CM 287.3 for identifying children and adults with ITP, using novel, explicit levels of evidence to identify patients with a definite diagnosis. The proportion of patients diagnosed by hematologists compared to non-hematologists and the proportion of patients diagnosed as outpatients compared to inpatients were determined. For children, age <16 years, 323 outpatient medical records were reviewed; 225 adult outpatient medical records were reviewed. The positive predictive value for the administrative code for identifying patients with a definite diagnosis of ITP by a hematologist was 0.72 in children and 0.69 in adults. In 98% of children and 92% of adults seen as outpatients, the definite diagnosis of ITP was established by a hematologist. One hundred eighteen child and 141 adult inpatient medical records were reviewed. In 95% of children and 83% of adults, the definite diagnosis of ITP by a hematologist was established as an outpatient. This study confirmed the previously reported positive predictive value for the administrative code for identifying patients with ITP. Additionally, it was determined that analysis of hematologists' outpatient administrative codes identified most children and adults with ITP. Am. J. Hematol. 2012. © 2012 Wiley Periodicals, Inc.

B lymphocyte stimulator levels in systemic lupus erythematosus: higher circulating levels in African American patients and increased production after influenza vaccination in patients with low baseline levels.

OBJECTIVE: To examine the relationship between circulating B lymphocyte stimulator (BLyS) levels and humoral responses to influenza vaccination in systemic lupus erythematosus (SLE) patients, as well as the effect of vaccination on BLyS levels, and to investigate clinical and serologic features of SLE that are associated with elevated BLyS levels. METHODS: Clinical history, disease activity measurements, and blood specimens were collected from 60 SLE patients at baseline and after influenza vaccination. Sera were tested for BLyS levels, lupus-associated autoantibodies, serum interferon-α (IFNα) activity, 25-hydroxyvitamin D (25[OH]D), and humoral responses to influenza vaccination. RESULTS: Thirty percent of the SLE patients had elevated BLyS levels, with African American patients having higher BLyS levels than white patients (P = 0.006). Baseline BLyS levels in patients were not correlated with humoral responses to influenza vaccination (P = 0.863), and BLyS levels increased postvaccination only in the subset of patients with BLyS levels in the lowest quartile (P = 0.0003). Elevated BLyS levels were associated with increased disease activity, as measured by the SLE Disease Activity Index, physician's global assessment, and Systemic Lupus Activity Measure in white patients (P = 0.035, P = 0.016, and P = 0.018, respectively), but not in African Americans. Elevated BLyS levels were also associated with anti-nuclear RNP (P = 0.0003) and decreased 25(OH)D (P = 0.018). Serum IFNα activity was a significant predictor of elevated BLyS in a multivariate analysis (P = 0.002). CONCLUSION: Our findings indicate that African American patients with SLE have higher BLyS levels regardless of disease activity. Humoral response to influenza vaccination is not correlated with baseline BLyS levels in SLE patients, and only those patients with low baseline BLyS levels demonstrate an increased BLyS response after vaccination.

Effects of power wheelchairs on the development and function of young children with severe motor impairments.

PURPOSE: The purpose of this pilot randomized controlled study was to identify any effects of power wheelchairs on the development and function of young children with severe motor impairments. METHODS: Participants were 28 children with various diagnoses, aged 14 to 30 months when they entered the study. The Battelle Developmental Inventory (BDI), Pediatric Evaluation of Disability Inventory, and Early Coping Inventory were administered at entry and after 12 months. RESULTS: The on-protocol analysis comparing median change scores showed the experimental groups' BDI receptive communication scores, and their Pediatric Evaluation of Disability Inventory mobility functional skills, mobility caregiver assistance, and self-care caregiver scores improved significantly more than the control group's scores. An intention-to-treat analysis upheld the findings and revealed an additional difference between the groups' BDI total score. CONCLUSION: The results support use of power wheelchairs with children as young as age 14 months to enhance development and function, although additional research is needed.

Directness of transport of major trauma patients to a level I trauma center: a propensity-adjusted survival analysis of the impact on short-term mortality.

BACKGROUND: Whether severely injured patients should be transported directly to tertiary trauma centers, bypassing closer nontertiary facilities, or be transported first to nearby, less-specialized facilities for immediate care and stabilization has been studied with mixed findings. Differences in study locale, case mix, and variation in the structure and level of maturation of the trauma system may explain some of the discrepancy in findings. In addition, risk adjustment strategies used in these studies did not take into account prehospital baseline characteristics as well as time since injury. METHODS: This was a retrospective cohort study of 1,998 patients treated at a Level I trauma center between January 1, 2006, and December 31, 2007. Propensity-adjusted survival analyses were used to compare short-term mortality outcomes in transferred versus directly transported major trauma patients. RESULTS: A total of 1,398 patients were transported directly to the Level I trauma center and 600 patients were transferred from lower level facilities. After adjusting for the propensity to be transported directly, age, injury severity score, severe head injury, emergency medical service or emergency department intubation, comorbid conditions, and time to definitive Level I trauma care, the 2-week mortality risk in transferred patients was almost three-fold that of patients transported directly to a Level I trauma center (hazard ratio, 2.7; 95% confidence interval, 1.31-5.6). CONCLUSION: Transferred patients in a predominantly rural region are at an increased risk of short-term mortality. This suggests that severely injured patients should be transported directly to tertiary trauma centers. For patients requiring immediate stabilization at nontertiary facilities, this should be performed promptly without unnecessary delays.

A propensity score analysis of prehospital factors and directness of transport of major trauma patients to a level I trauma center.

BACKGROUND: Indications for direct transport may be strongly related to risk of future health outcomes, and these indications may not be adequately controlled by considering only in-hospital variables. This study was designed to identify prehospital factors associated with directness of transport. METHODS: The study included 2,062 patients treated at a Level I trauma center between January 1, 2006, and December 31, 2007. The outcome of interest was directness of transport to a Level I trauma center. A propensity score analysis was used to identify demographic, clinical, distance, and other injury scene-related variables associated with the probability of direct transport. RESULTS: A total of 1,459 patients were directly transported to the Level I trauma center and 603 were transferred from lower level facilities. Patients were more likely to be transported directly if they had lower Glasgow Comma Scale scores, had penetrating injuries, were involved in traffic-related injuries, were closer to a Level IV or I trauma center, and if an advanced life support emergency medical service agency transported them from the scene. Patients were more likely to initially stop if they required advanced airway management, met at least one anatomic criterion, were further away from a Level I trauma center, or closer to an intermediate facility. CONCLUSIONS: Confounding due to unadjusted prehospital factors may be present in studies evaluating the impact of directness of transport on short-term mortality outcomes. Propensity score analysis of treatment indications provides an additional and efficient method to reduce this bias.

The incidence of immune thrombocytopenic purpura in children and adults: A critical review of published reports.

Reports of the incidence of ITP are few and their methodology is variable. Accurate estimates of the incidence of immune thrombocytopenic purpura (ITP) are important to understand the medical and public health impact of the disease. To critically review all published reports on the incidence of ITP in children and adults, all articles identified on the Medline database (searched January 1, 1966-August 7, 2009) that reported data on the incidence of ITP were retrieved. Articles which directly estimated the incidence of ITP were selected for review. Eight articles reported the incidence of acute ITP in children. After review, four were determined to have the strongest estimates, based on the method of patient identification and study design. The lowest incidence estimate in these four studies was 2.2 per 10(5) children/year (95% confidence interval 1.9, 2.4) and the highest incidence estimate was 5.3 per 10(5) children/year (95% confidence interval 4.3, 6.4). Three studies reported the incidence of ITP in adults. The estimate from the article with the strongest methodology reported an incidence estimate of 3.3 per 10(5) adults/year. The current strongest estimate of the incidence of acute ITP in children is between 1.9 and 6.4 per 10(5) children/year; for adults the current strongest estimate of the incidence of ITP is 3.3 per 10(5) adults/year. An important limitation of these studies is that they are primarily from Europe and may not be generalizable to all regions.

Low adherence to national guidelines for thyroid screening in Down syndrome.

PURPOSE: To determine adherence to the American Academy of Pediatrics guidelines for thyroid screening in children with Down syndrome among primary care providers in the states of Oklahoma and Nebraska. METHODS: We sought to identify all children with Down syndrome born in Oklahoma and Nebraska between 1994 and 2004 and review their medical records for evidence of thyroid screening. Patients were identified through a State Department of Health birth defects registry in Oklahoma and through participation in genetics clinics and laboratories in Nebraska and Oklahoma. Charts obtained from primary care providers were reviewed and the number of actual thyroid screens was compared with the number of recommended screens for each individual during the study period. RESULTS: In Oklahoma, 13% of participating children received all thyroid screens recommended in the guidelines. In Nebraska, 14% of children received all recommended thyroid screenings. Among participants in Oklahoma, a mean of 34% of recommended thyroid screenings were performed. In Nebraska, a mean of 45% of recommended thyroid screenings were performed. CONCLUSIONS: The level of adherence to the American Academy of Pediatrics guidelines for thyroid screening in children with Down syndrome is low. Factors contributing to this low level of adherence need to be identified and addressed.

Economic effect of an expansion of pharmacy benefits on total health care expenditures by a state Medicaid program.

OBJECTIVES: To evaluate the economic effect of a pharmacy benefit expansion on a population of Oklahoma Medicaid recipients and to determine whether recipients who routinely maximized their monthly prescription limit (cap) before the benefit expansion benefited more from the expansion than the remainder of the study population. DESIGN: Retrospective study. SETTING: Oklahoma Medicaid claims data from January 1, 2003, to December 31, 2004. PATIENTS: Data from 15,936 Oklahoma Medicaid recipients. INTERVENTION: Retrospective administrative analysis using the Oklahoma Health Care Authority pharmacy and medical claims databases. MAIN OUTCOME MEASURES: Total health care expenditures per recipient per year, total medical expenditures per recipient per year, and total pharmacy expenditures per recipient per year. RESULTS: Total health care expenditures increased 17% after the benefit expansion (P < 0.0001). Of this increase, 65% was attributed to pharmacy expenditures and 35% to medical expenditures. However, a subpopulation of recipients who routinely reached their prescription limit before the expansion had a statistically significant increase in total and pharmacy expenditures; a statistically significant increase in medical expenditures was not observed. CONCLUSION: Although total health care expenditures increased after a monthly pharmacy benefit in a Medicaid population was expanded, a subpopulation of recipients identified as high pharmacy users before the expansion did not have a statistically significant increase in medical expenditures, whereas those who were non-high users experienced a significant increase. Additionally, this subpopulation experienced a nonsignificant decrease in hospital expenditures. These results could suggest that this subpopulation was affected differently than the overall population by the expansion of the Medicaid pharmacy benefit.

Associations between vitamin D levels and polycystic ovary syndrome phenotypes.

BACKGROUND: Studies comparing serum 25-hydroxyvitamin D concentrations in women with and without polycystic ovary syndrome (PCOS) have produced inconsistent results. Additionally, no previous studies have evaluated associations between vitamin D and specific PCOS phenotypes. METHODS: This case-control study was conducted among women undergoing intrauterine insemination. Cases (N.=137) were diagnosed with PCOS and then further classified into 3 diagnostic phenotypes based on combinations of the Rotterdam criteria (ovulatory dysfunction+polycystic ovaries [N.=55]; ovulatory dysfunction +androgen excess [N.=15]; and ovulatory dysfunction, +polycystic ovaries, +androgen excess [N.=67]). Controls (N.=103) were ovulatory women without PCOS who were undergoing IUI. Serum total 25-hydroxyvitamin D concentrations were categorized as deficient (≤20 ng/mL), insufficient (21-29 ng/mL), and sufficient (≥30 ng/mL). Prevalence odds ratios (PORs) were calculated using logistic regression. RESULTS: A higher proportion (59.9%) of PCOS cases lacked sufficient vitamin D levels compared to controls (47.6%; P value=0.06). The odds of vitamin D deficiency in all PCOS cases were twice that of controls (POR=2.03, 95% CI 0.97-4.26); however, the association was attenuated after adjusting for Body Mass Index (BMI) and race/ethnicity (adjPOR=1.43, 95% CI 0.62, 3.26). When examining PCOS phenotypes exhibiting androgen excess, crude associations were observed for deficient vitamin D levels (unadjPOR=2.93, 95% CI: 1.27, 6.77); however, the association decreased after adjustment for BMI and race/ethnicity (adjPOR=2.03, 95% CI: 0.79, 5.19). CONCLUSIONS: Vitamin D deficiency occurred more frequently in PCOS cases with androgen excess, but associations were attenuated after adjusting for BMI and race/ethnicity. Combining etiologically distinct PCOS subgroups may obscure associations with lower vitamin D levels and other potential risk factors.

Evaluating antidepressant treatment prior to adding second-line therapies among patients with treatment-resistant depression.

BACKGROUND: Patients with depression can be mistakenly labeled as treatment-resistant if they fail to receive an adequate first-line antidepressant trial. Adding second-line agents to the treatment regimens can create an additional burden on both the patients and the healthcare system. OBJECTIVES: To determine if depressed patients receive an adequate antidepressant trial prior to starting second-line therapy and to investigate the association between the type of second-line treatment and severity of illness or depression among unipolar versus bipolar patients. SETTING: Oklahoma Medicaid claims data between 2006 and 2011. METHODS: Subjects were depression-diagnosed adult patients with at least two prescriptions of antidepressants followed by a second-line agent. Patients were categorized into one of three groups: an atypical antipsychotic, other augmentation agents (lithium, buspirone, and triiodothyronine), or adding antidepressants, based on the type of second-line therapy. An adequate trial was defined per the American Psychiatric Association guidelines. Factors associated with the type of treatment were tested using multinomial logistic regression models stratified by type of depression (unipolar vs. bipolar patients). MAIN OUTCOME MEASURE: Variables used to measure receiving an adequate antidepressant trial included: trial duration, adherence, dose adequacy, and number of distinct antidepressant trials. RESULTS: A total of 3910 patients were included in the analysis. Most subjects reached the recommended antidepressant dose. However, 28 % of patients had an antidepressant trial duration <4 weeks and only 60 % tried at least two antidepressant regimens prior to adding second-line therapy. Approximately 50 % of the subjects were non-adherent across all groups. Severity of illness and receipt of an adequate antidepressant trial were not predictors of the type of second-line treatment. CONCLUSION: Many patients do not receive an adequate antidepressant trial before starting a second-line agent. The type of second-line treatment was independent of severity of depression. These findings support policies that require reviewing the recommended dose and duration of the first-line antidepressant before adding second-line agents. Healthcare providers need to review the patient's history and reconsider the evidence for prescribing second-line agents.

E-Cigarettes for Immediate Smoking Substitution in Women Diagnosed with Cervical Dysplasia and Associated Disorders.

The aim of this study was to determine if 31 women with cervical dysplasia and associated conditions exacerbated by smoking would be successful substituting cigarettes with their choice of either nicotine replacement therapy (NRT) or electronic cigarettes (EC). Women received motivational interviewing and tried both NRT and ECs, choosing one method to use during a six-week intervention period. Daily cigarette consumption was measured at baseline, six, and 12 weeks, with differences analyzed by the Wilcoxon signed-rank test. Study analysis consisted only of women choosing to use ECs (29/31), as only two chose NRT. At the 12-week follow-up, the seven day point prevalence abstinence from smoking was 28.6%, and the median number of cigarettes smoked daily decreased from 18.5 to 5.5 (p < 0.0001). The median number of e-cigarette cartridges used dropped from 21 at the six-week follow-up to 12.5 at the 12-week follow-up. After initiating EC use, women at risk for cervical cancer were able to either quit smoking or reduce the number of cigarettes smoked per day. Although a controlled trial with a larger sample size is needed to confirm these initial results, this study suggests that using ECs during quit attempts may reduce cigarette consumption.

A multiple motive/multi-dimensional approach to measure smokeless tobacco dependence.

BACKGROUND: Unlike various research studies conducted to address dependence among smokers, only a few studies have examined smokeless tobacco (ST) dependence. The Fagerström Tolerance Questionnaire (FTQ) and Fagerström Test for Nicotine Dependence (FTND) based scales are the most widely used measures of nicotine dependence for both ST users and smokers. These scales were initially developed to measure physical dependence and tolerance and not to assess other salient dimensions of dependence such as craving, compulsion, or withdrawal, as defined by DSM-IV and ICD-10. The aim of this study is to develop and validate a multidimensional scale that has better content coverage, factor structure, and psychometric properties to measure dependence among ST users. METHODS: 100 adult male smokeless tobacco users were recruited through email distribution lists and community referral. Participants completed three different nicotine dependence questionnaires and provided information related to their tobacco use and demographic characteristics. They also provided a saliva sample for cotinine measurement. In order to develop the new ST scale, subscales and items were selected based on correlation and factor analysis of the modified WISDM-68. Reliability and validity of the new scale, Oklahoma Scale for Smokeless Tobacco Dependence (OSSTD) were also assessed. RESULTS: The new ST scale identified seven latent constructs including 23 items to measure ST dependence. Internal consistency as measured by Cronbach's coefficient (α=0.925) indicated better reliability of OSSTD than FTND-ST. Concurrent validity of OSSTD as evaluated by comparing it with dependence diagnosis and FTND-ST was affirmative. There was a significant correlation between the OSSTD total score and the cotinine levels and tobacco use characteristics among study participants. CONCLUSION: OSSTD possesses better psychometric properties and provides an effective and efficient tool to measure ST dependence as a multidimensional construct.

Building community resilience to disasters through a community-based intervention: CART applications.

The Communities Advancing Resilience Toolkit (CART)* is a community-driven, publicly available, theory-based, and evidence-informed community intervention designed to build community resilience to disasters and other adversities. Based on principles of participatory action research, CART applications contribute to community resilience by encouraging and supporting community participation and cooperation, communication, self-awareness, and critical reflection. The primary value of CART lies in its ability to stimulate analysis, collaboration, skill building, resource sharing, and purposeful action. In addition to generating community assessment data, CART can be used as a vehicle for delivering other interventions and creating sustainable capacity within communities. Two models for CART implementation are described.

Direct transport of geriatric trauma patients with pelvic fractures to a Level I trauma center within an organized trauma system: impact on two-week incidence of in-hospital complications.

BACKGROUND: Undertriage of elderly trauma patients to tertiary trauma centers is well documented. This study evaluated the impact of directness of transport to a Level I trauma center on morbidity in geriatric trauma patients sustaining severe pelvic fractures. METHODS: This was a retrospective cohort study of 87 geriatric trauma patients diagnosed with potentially unstable pelvic fractures, treated at a Level I trauma center between 2008 and 2010. RESULTS: Of the 87 patients, 39% (34 of 87) initially were transported to a nontertiary trauma center. After adjusting for presence of comorbidity and injury severity, the 2-week incidence of complications was 54% higher in transferred patients compared with those directly transported (rate ratio, 1.54; 95% confidence interval, .95-2.54). In particular, transferred patients had increased odds of developing pneumonia/systemic inflammatory response syndrome. CONCLUSIONS: Despite lacking precision, results of this study suggest an increased risk of complications in transferred geriatric trauma patients with severe pelvic fractures compared with their directly transported counterparts.