Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage.

OBJECTIVES: Mild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation. METHODS: A retrospective study of patients with blunt head injury with GCS 13-15 and CT head from Jan 2014-Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost. RESULTS: A total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600. CONCLUSION: Defining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.

Experiences of intimate-partner violence and contraception use among ever-married women in Jordan.

This study explored the relationship between intimate partner violence (IPV) and current contraception use among ever-married women in Jordan. Analysing a sample (n = 3434) from the 2007 Jordan demographic and health survey, women who reported ever experiencing severe physical violence from their husband were significantly less likely to use contraception than women who did not report severe physical violence (OR = 0.34). Conversely, women who reported ever experiencing sexual IPV were significantly more likely to use contraception (OR = 1.50). Emotional and less severe physical IPV were not significantly related to contraception use. Education, wealth, age, number of children, and fertility preferences were positively associated with contraception use, while residence in the Badia area and consanguineous marriages were negatively associated with contraception use. The findings have implications for the provision of IPV screening and contraception services in Jordan, as well as the specification of services for women most vulnerable to IPV.

Assessing the validity of health impact assessment predictions regarding a Japanese city's transition to core city status: a monitoring review.

BACKGROUND: The validity of health impact assessment (HIA) predictions has not been accurately assessed to date. In recent years, legislative attempts to promote decentralization have been progressing in Japan, and Kurume was designated as a core city in April 2008. An HIA into the transition of Kurume to a core city was conducted before the event, but the recommendations were not accepted by city officials. OBJECTIVE: The aim of this study was to examine the validity of predictions made in the HIA on Kurume by conducting a monitoring review into the accuracy of the predictions. METHOD: Before Kurume was designated as a core city, the residents completed an online questionnaire and city officials were interviewed. The findings and recommendations were presented to the city administration. One year after the transition, a monitoring review was performed to clarify the accuracy of the HIA predictions by evaluating the correlation between the predictions and reality. RESULTS: Many of the HIA predictions were found to conflict with reality in Kurume. Prediction validity was evaluated for two groups: residents of Kurume and city officials. For the residents, 17% (2/12 items) of the predictions were found to be compatible, 58% (7/12) were incompatible and 25% (3/12) were difficult to evaluate. For city officials, the analysis was divided into those whose department was directly involved in tasks transferred to them (transfer tasks) and those whose department was not. For the city officials in departments responsible for conducting core city transfer tasks, 33% (3/9 items) of the predictions were found to be compatible, 33% (3/9) were incompatible and 33% (3/9) were difficult to evaluate. However, for the city officials whose responsibilities were unrelated to core city transfer tasks, 11% (1/9) of predictions were found to be compatible, 78% (7/9) were incompatible and 11% (1/9) were difficult to evaluate. CONCLUSION: Although it was possible to validate some of the HIA predictions, the results of this monitoring review found substantial discrepancies between the predictions and reality 1 year after the transition of Kurume to a core city. This suggests that the accuracy of HIA predictions may be called into question. However, it should be noted that the review was conducted very soon after the transition and the steering group was very small, which may explain why the HIA predictions were inaccurate. Further, long-term studies may be needed to assess the accuracy of HIA predictions in similar contexts.

Associations between hazard indices of di-n-butylphthalate and di-2-ethylhexylphthalate exposure and serum reproductive hormone levels among occupationally exposed and unexposed Chinese men.

The knowledge on the dose-response relationships between cumulative phthalate exposure and reproductive hormones in human are lacking. To assess the characteristics of the associations between hazard index (HI) of cumulative di-n-butylphthalate (DBP) and di-2-ethylhexylphthalate (DEHP) exposures and serum concentrations of free testosterone (fT), estradiol, luteinizing hormone (LH) and follicle-stimulating hormone (FSH), we used restricted cubic spline function to characterize the dose-response curves between the HI values and reproductive hormones for 74 male workers occupationally exposed to high levels of DBP and DEHP, and 63 male construction workers as comparison group matched for age and smoking status. The median of HI value was 5.30 for exposed workers, 53.0-fold that of unexposed workers (0.10). 89.2% of exposed workers and 1.6% of unexposed workers have HI over 1.00. We observed a borderline significantly negative association between HI and fT in exposed workers (r=-0.195, p=0.096), but not in unexposed workers. The exposed workers showed inverted long-tailed J-shaped fT and FSH curves, and small changes in the LH curve, whereas unexposed workers had inverted and flattened-S-shaped fT and mirror-S-shaped LH and FSH curves. Both T production and hypothalamo-pituitary-testis (HPT) axis function were damaged in workers with high HI of phthalate exposures. HPT feedback function was activated in workers with both high and low HI, and plays an important role in preventing fT level from further decreasing with a rise in HI.

Health impact assessment of the transition to a core city in Japan.

OBJECTIVE: To discover whether a health impact assessment (HIA) is applicable in Japan with respect to the transition to a core city. STUDY DESIGN: Ecological study. METHODS: A rapid HIA was applied based on typical HIA guidelines. A rapid HIA consists of screening, scoping and assessment. In the assessment or policy analyses, information on the official opinions of Kurume was compiled and interviews were undertaken in Nagasaki, which had already become a core city (hereinafter, 'predecessor core city'). For qualitative and quantitative data, a survey of the 35 predecessor core cities was performed, together with an online questionnaire for the cities of Kurume and Aomori. RESULTS: The construction of new public health centres with the transition to core cities held major significance. In an effort to promote advantages, regionally co-ordinated health activities were quickly introduced, systems whereby residents can voluntarily participate in health activities were strengthened, and facilities where government and residents came together were built. To minimize disadvantages, special features of districts with good health services were applied to other districts, the provision of conventional health services throughout the city was improved, and prefectural and national offices opened consultation corners regarding employee or budgetary shortages. CONCLUSION: This paper reports the first use of an HIA in Japan with respect to governmental policy. However, this HIA was not a pre-assessment in principle, but rather a concurrent HIA. In the future, HIAs should be performed in Japan to make suggestions to government decision makers whenever policy is being formulated or programmes are being changed.

Environmental assessment of sewage sludge recycling options and treatment processes in Tokyo.

Tokyo has historically suffered from a shortage of final disposal sites for the treated sewage sludge. Given this situation, sludge recycling and incineration have been promoted to reduce the volume of treated sludge conveyed to the disposal site, and the recycling options have changed since the late 1990s. This study aims to revisit the sewage sludge treatment and recycling processes in Tokyo and to evaluate different recycling options (brick, aggregate, refuse derived fuel and slag) from the energy consumption perspective by clarifying the complex flow of treated sludge within Tokyo's 23 wards. The study also estimates environmental loads associated with the operation of the whole sludge management system in the area. The environmental loads include: (1) total energy consumption and (2) gas emissions (greenhouse and acidification gases). The estimation was carried out for the years 1995, 1997, 1999 and 2001, during which a drastic change in recycling options occurred. The results indicated that the production of refuse derived fuel was the most energy consuming recycling option while aggregate production is the least energy consuming. They also showed that despite the increasing sludge volume, the energy consumption associated with the operation of the whole system decreased during the period while the gas emissions increased.

The assessment of dermatomal level of surgical anesthesia after spinal tetracaine.

UNLABELLED: Transcutaneous electrical stimulation (TES), a 60-mA, 50-Hz continuous square wave, has been considered equivalent to surgical incision. We examined whether TES at a smaller current (10 mA) can be used to predict surgical anesthesia and compare the results with sensory block to cold, pinprick, and touch after the administration of spinal tetracaine. Two groups of 40 consecutive patients, 17-69 yr old and 70 yr old or older received a subarachnoid injection of 0. 5% tetracaine in 10% glucose or saline according to the type of surgery. Patients undergoing abdominal surgery received glucose solution, and those scheduled for lower extremities surgery received saline solution, and thus, the resultant four groups of patients were studied. Neural block was assessed by the loss of sensation to cold, pinprick, touch, and TES at 10 mA (T10s), and tolerance (i.e., the loss of pain or discomfort) to TES at 10 (T10p) and 60 (T60) mA. Dermatomal levels of sensory block to cold, pinprick, and touch that were cephalad to T60 varied widely. In contrast, dermatomal levels of T10s and T10p cephalad to T60 were less variable, and the difference between T10s and T60 was the smallest among all the differences in any groups. Our results demonstrate that, regardless of patient age and baricity of a local anesthetic solution, T10s is a good predictor of T60 equivalent to the dermatomal level of surgical anesthesia. IMPLICATIONS: Our results show that the loss of sensation to transcutaneous electrical stimulation at 10 mA, but not cold, pinprick, or touch, is a good predictor of the dermatomal level of block to transcutaneous electrical stimulation at 60 mA, which is considered equivalent to the dermatomal level of surgical anesthesia after the administration of spinal anesthesia.

The effects of operator implementation cost on planfulness of problem solving and learning.

This paper explores the idea that problem solving search strategies are chosen so as to optimize performance within the constraints of a particular situation. Four experiments are reported that examine the hypothesis that the cost of performing an operation affects "planfulness"--the level of planning during problem solving. The first experiment investigated problem solving with the 8-puzzle and compared strategies adopted when there was a high versus a low cost of making a move, manipulating cost in terms of command length. The second experiment used protocol analysis to provide more direct evidence for increased planning. The third and fourth experiments looked at the effects of these different strategies on learning: the third examined how problem solving performance on a direct manipulation interface is affected by prior problem solving experience in the same domain with either a high cost or low cost command-driven interface, demonstrating improved performance as a result of training on an interface with high cost operations; the fourth experiment, like the third, examined the effects of prior problem solving experience with either a high cost or low cost interface on subsequent problem solving performance in a different domain using a direct manipulation interface showing no effect to training interface on subsequent performance.

The market for occupational medicine managed care.

The metamorphosis of the health care market has opened a window of opportunity for occupational medicine programs and practices to assume a critical role in the delivery of managed occupational and personal health care services. This chapter offers practical suggestions and tips.

Mission, staffing, and budget data of flight programs in the United States.

INTRODUCTION: Manage care and other health care reform initiatives have forced all hospitals to evaluate their work processes. In this era of cost containment, many flight programs are examining the structure of their programs to determined whether they are functioning in an efficient, cost-effective fashion. METHODS: A survey was sent to the chief flight nurse of 240 flight programs in the United States. RESULTS: Eighty-five programs (35.4%) responded. Data were collected on demographics, management structure, mission information, staffing issues, and budgets. Results in each program varied widely. CONCLUSION: Benchmark data are available against which programs can compare themselves. Such comparisons may allow the discovery of opportunities to enhance program efficiency and cost-effectiveness.

Noninvasive assessment of right heart function by 81mKr equilibrium radionuclide ventriculography in chronic pulmonary diseases.

Noninvasive multigated equilibrium radionuclide ventriculography with krypton-81m (81mKr) was used to assess right heart relaxation in patients with chronic pulmonary diseases (CPD). The subjects consisted of 30 patients with CPD and 8 patients free of cardiopulmonary diseases admitted to our department. A region of interest (ROI) was selected on both the right atrium (RA) and right ventricle (RV). A time activity curve was obtained for each ROI. As a diastolic index of the right heart performance, the right atrial early emptying rate (RAER) was obtained from the right atrial time activity curve, while the right ventricular rapid filling rate (RVRFR) was obtained from the right ventricular time activity curve. The mean RAER was significantly lower in CPD patients compared with the control (CPD, 9.5 +/- 4.5; control, 16 +/- 3.4%/100 ms). Similarly, the mean RVRFR was significantly lower in CPD patients compared with the control (CPD, 27.3 +/- 9.9; control, 34 +/- 8.5%/100 ms). A strong negative correlation was noted between the mean pulmonary arterial pressure (mPAP) and RAER (r = -0.77; p < 0.001) and between the mPAP and the RVRFR (r = -0.63; p < 0.001). Our results suggest that RAER and RVRFR measured by 81mKr are clinically useful in the noninvasive assessment of right heart relaxation in patients with CPD.

Differences in the assessment of postoperative pain when evaluated by patients and doctors.

This study was undertaken to compare the assessment of pain intensity by 59 patients and by their doctors according to a visual analogue scale (VAS) at rest and when coughing at 5 and 20 hr after major abdominal surgery. The rating given by the patients, who received epidural analgesia to relieve postoperative pain, was significantly above, and moreover, significantly correlated with that given by the doctors at any time or under any condition of the assessment. However, the correlation between the ratings given by patients and doctors at rest at 5 hr after surgery was low (r = 0.39, rs = 0.38) and significantly different from that when coughing at 20 hr after the operation (r = 0.79, rs = 0.80). Our findings indicate that the assessment of postoperative pain may be associated with some unreliability, especially during early periods, when using the subjective or objective-rated VAS at rest separately, and thus requires the combined use or the concomitant use of the VAS when coughing. Substitutional use of the objective-rated VAS for the subjective-rated VAS is not advised.

People's minds should be properly prepared.

PIP: The approach to family planning in Ghana that has proven successful in establishing trust between rural populations and health workers is through consistent provision of health services in clinics and community visits. The Integrated Family Planning Nutrition and Parasite Control Project (IP), a Planned Parenthood of Ghana (PPAG) program, has promoted birth spacing after improving health, nutrition, and environmental sanitation. Key field workers and staff and the structure of the program are identified. 3 field workers are in charge of 1-4 communities with community populations ranging from 200 to 5000. Field workers meet with people in their houses to discuss health and family planning, and advise and teach Local Steering Committee members. For example, Agnes Boakye visits Ojobi (population; 3800) and Bontrase (population; 4300) 2 days every week. She meets her supervisor Cecilia Colcraft and manager Nii Adote Addo every week to receive help in planning weekly programs and to receive comment on her work. Once a month the Local Steering Committee meets with her. Even though Boakye's workweek is Monday through Friday, she visits with the community on Sunday. The villagers love her and find her trustworthy, helpful, and resourceful for their many problems, including marital ones, because she takes care to be nice, respectful, and is convinced her work helps the community. The 3 field workers travel in 1 car together Tuesday through Friday to the villages and use the time to advise and consult each other. The car sometimes serves as an ambulance to transport serious cases which they are unable to treat to Awutu or Accra. Villagers are asked to pay at least the cost of medicine, although income-generating activities are necessary so that most of the villagers can afford the family planning and health services. This project manager maintains that with encouragement, villagers are motivated to keep their children clean, clear rubbish and sources of mosquitoes, collect safe water, and control soil-transmitted helminths. Health worker trust developed during worm treatment insures that villagers will be receptive to family planning. Neighboring communities are requesting IP, and all await the 1991 formal evaluation.^ieng

Maternal perception, tocodynamometric findings and real-time ultrasound assessment of total fetal activity.

"Total" fetal motor activity was determined in 111 healthy patients between 25 weeks of pregnancy and term using two real-time ultrasound devices simultaneously. Furthermore tocographic findings and also maternal perception of fetal movements of the same patients were stored synchronously on magnetic tape. A comparison was drawn between these three methods, i.e. real-time ultrasonography, maternal perception and tocographic tracings ("spikes" indicating fetal movements). Of all fetal movements, as assessed by real-time ultrasonography, the mothers perceived a total of 38% whereas "spikes" in tocographic tracings corresponded with fetal motor activity (excluding "breathing") in only 25% of the cases (P less than 0.001). Also major statistically significant differences could be found between maternal perception of fetal body movements with or without fetal limb movements in 56% and routine- tocography in 37% (P less than 0.001). Also isolated limb movements were most often detected by mothers (23%) than were revealed by tocographic findings (14%; P less than 0.001). Maternal signals were truly positive in 74% compared to tocography in only 56% of the cases (P less than 0.001). It is concluded that maternal perception of fetal movements is a more reliable method of monitoring fetal motor activity than analysis of tocographic tracings.

The value of EEG and cerebral evoked potentials in the assessment of neonatal intracranial hemorrhage.

The EEG, visual and auditory evoked potentials (VEP, AEP) were evaluated in 16 full-term newborn infants who had intracranial hemorrhage documented by computerized tomography (CT). Three of them had supratentorial, three, supra- and infratentorial hemorrhage, while the other ten had infra- or pri-tentorial bleeding. Three died during the neonatal period. Eight of the 13 surviving infants were neurologically normal and five were abnormal at the time of the follow-up. Those who had normal or mildly abnormal background EEGs all developed normally, while those whose neonatal EEG was severely abnormal subsequently developed neurological sequelae irrespective of the extent of intracranial hemorrhage. The EEG, VEP or AEP is of little value in the diagnosis of intracranial bleeding but the EEG is valuable in assessing the degree of associated parenchymatous damage and is of great prognostic significance.