Reaching Ambulatory Older Adults with Educational Tools: Comparative Efficacy and Cost of Varied Outreach Modalities in Primary Care.

BACKGROUND: Providing patients with access to health information that can be obtained outside of an office visit is an important part of education, yet little is known about the effectiveness of outreach modalities to connect older adults to online educational tools. The objective was to identify the effectiveness and cost of outreach modalities providing online information about advance care planning (ACP) for older adults. METHODS: Six different outreach modalities were utilized to connect patients to online educational tools (ACP video decision aids). Participants were 13,582 patients aged 65 and older of 185 primary care providers with appointments over a 30-month period within a large health system in the greater New York City area. Main outcome measures were number of online video views and costs per outreach for each modality. KEY RESULTS: There were 1150 video views for 21,407 remote outreach events. Text messages, sent to the largest volume of patients (8869), had the highest outcome rate (9.6%) and were the most economical ($0.09). Characterization of phone calls demonstrated 21.7% engagement in the topic of ACP but resulted in minimal video views (<1%) and incurred the highest cost per outreach ($2.88). In-office handouts had negligible results (<1%). CONCLUSIONS: Text was the most cost-effective modality to connect older adults to an online educational tool in this pragmatic trial, though overall efficacy of all modalities was low.

Social disadvantage and cardiovascular disease: development of an index and analysis of age, sex, and ethnicity effects.

BACKGROUND: Social disadvantage is defined by adverse socio-economic characteristics and is distributed unequally by age, sex, and ethnicity. We studied the relationship between social disadvantage, cardiovascular risk factors, and cardiovascular disease (CVD) among men and women from diverse ethno-racial backgrounds. METHODS: A total of 1227 men and women of South Asian, Chinese, Aboriginal, and European ancestry were randomly selected from four communities in Canada to undergo a health assessment. Socio-economic factors, conventional and novel CV risk factors, atherosclerosis, and CVD were measured. A social disadvantage index was generated and included employment status, income, and marital status. Social disadvantage was examined in relation to risk factors for CVD, atherosclerosis, and prevalent CVD. RESULTS: Social disadvantage was higher among older people, women, and non-white ethnic groups. Cigarette smoking, glucose, overweight, abdominal obesity, and CRP were higher among individuals with higher social disadvantage, whereas systolic blood pressure, lipids, norepinephrine, and atherosclerosis were not. Social disadvantage is an independent predictor of CVD after adjustment for conventional and novel risk markers for CVD (OR for 1 point increase = 1.25; 95% CI 1.06-1.47). CONCLUSION: The social disadvantage index combines social and economic exposures into a single continuous measure. Significant variation in social disadvantage by age, sex, and ethnic group exists. Increased social disadvantage is associated with an increased burden of some CV risk factors, and is an independently associated with CVD.

Language skills of delinquent and nondelinquent adolescent males.

A comparison of language skills between adolescent juvenile delinquent males and matched nondelinquent peers was made using an informal language sample analysis (a modified Clinical Discourse Analysis) and the TOAL-2 measure. Twenty-four institutionalized delinquents and 24 nondelinquents ranging in age from 14.4 to 17.9 years were subjects. Their respective mean full scale intelligence quotients were 99.75 and 101.25 and they had no known verified handicapping conditions. Two one-way ANOVAs showed that there were significant differences for language skills on the dependent measures between the two groups. Differences between the groups also were observed from descriptive statistics for academic performance. Implications for assessment and treatment of "at-risk" populations are addressed.

Managing the education function.

The challenge of hospital-based education is to motivate change in the participant to benefit the organization as a whole, while increasing individual competence and positively affecting the quality of service. Enabling people to transfer learning into effective work behavior is the goal of hospital education staff. To ensure a successful future, the manager of the education function needs to be passionately committed to service of the organization. The manager must be able, be seen as able, and be unafraid to assume the evolving role. On the cover of Jim Lundy's book, Lead, Follow or Get Out of the Way, he addresses a memo to those who lead or aspire to lead. He recommends the following: Share your goals and aspirations. Let the implementers be involved in the planning. Achieve clear understanding of expected results. Evaluate progress periodically and fairly. Reinforce the importance of others. Coach your subordinates for growth. Emphasize and reemphasize teamwork. Search constantly for improvement in understanding, performance, and results! (Lundy, 1986) These leadership strategies will serve the manager of the education function well. Choose to lead, follow, or get out of the way! Marilyn Ferguson shared in her 1986 address to the ASHET annual conference, "We can fear the future . . . or by taking courage from each other and tapping our hidden resources, we can help create it" (Ferguson, 1986).

The need for speed. I. Fast reactions and myelinated axons in copepods.

A rapid and powerful escape response decreases predation risk in planktonic copepods. Calanoid copepods are sensitive to small and brief hydrodynamic disturbances: they respond with multiple nerve impulses to a vibrating sphere. Some species, such as Pleuromamma xiphias and Labidocera madurae, respond with very large spikes (1-4 mV), whereas maximum spike heights are an order of magnitude smaller in others, such as Undinula vulgaris and Neocalanus gracilis. A comparative study of the escape responses showed that all species reacted within 10 ms of the initiation of a hydrodynamic stimulus. However, U. vulgaris and N. gracilis had significantly shorter reaction times (minimum reaction times: 1.5 ms and 1.6 ms) than the other two, P. xiphias (6.6 ms) and L. madurae (3.1 ms). Examination of the first antenna and the central nervous system using transmission electron microscopy revealed extensive myelination of sensory and motor axons in the two species with the shorter reaction times. Axons of the other two species resembled typical crustacean unmyelinated fibers. A survey of 20 calanoids revealed that none of the species in two of the more ancient superfamilies possessed myelin, but myelination was present in the species from three more recently-evolved superfamilies.

The need for speed. II. Myelin in calanoid copepods.

Speed of nerve impulse conduction is greatly increased by myelin, a multi-layered membranous sheath surrounding axons. Myelinated axons are ubiquitous among the vertebrates, but relatively rare among invertebrates. Electron microscopy of calanoid copepods using rapid cryofixation techniques revealed the widespread presence of myelinated axons. Myelin sheaths of up to 60 layers were found around both sensory and motor axons of the first antenna and interneurons of the ventral nerve cord. Except at nodes, individual lamellae appeared to be continuous and circular, without seams, as opposed to the spiral structure of vertebrate and annelid myelin. The highly organized myelin was characterized by the complete exclusion of cytoplasm from the intracellular spaces of the cell generating it. In regions of compaction, extracytoplasmic space was also eliminated. Focal or fenestration nodes, rather than circumferential ones, were locally common. Myelin lamellae terminated in stepwise fashion at these nodes, appearing to fuse with the axolemma or adjacent myelin lamellae. As with vertebrate myelin, copepod sheaths are designed to minimize both resistive and capacitive current flow through the internodal membrane, greatly speeding nerve impulse conduction. Copepod myelin differs from that of any other group described, while sharing features of every group.

Closed Zickel nailing.

A closed technique for Zickel nail insertion decreases morbidity, blood loss, and operative time. The Zickel intramedullary nail was originally developed as an open fixation device for fractures of the proximal third of the femur and subtrochanteric area. The open technique requires a lengthy incision, moderate blood loss, and time for insertion. For pathologic or impending pathologic fractures in sick patients, such a major operation is undesirable. The closed technique has been used successfully in five impending pathologic, three pathologic, and two traumatic subtrochanteric fractures. For these ten patients, the average operating time was one hour and 28 minutes with an average blood loss of 400 ml, a reduction of 40 minutes and 460 ml, respectively, over other available data. Time to ambulation and length of hospital stay are comparable to fractures treated openly. The closed technique is ideal for impending pathologic fractures, but may also be applicable to any pathologic or traumatic fractures that do not require an open procedure for alignment or supplementary fixation.

Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: the Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP).

BACKGROUND: Little is known about the rates of cardiovascular disease (CVD), atherosclerosis, and their risk factors among Canada's Aboriginal people. To establish the relative prevalence of risk factors, atherosclerosis, and CVD, we undertook a population-based study among people of Aboriginal and European ancestry in Canada. METHODS: We randomly recruited 301 Aboriginal people from the Six Nations Reservation, and 326 people of European origin from Hamilton, Toronto, and Edmonton, Canada. Clinical CVD was defined by history or electrocardiographic findings, atherosclerosis was measured by B-mode carotid ultrasonography, and conventional and new CVD risk factors were measured using standardised methods. FINDINGS: Aboriginal people had significantly more carotid atherosclerosis (mean of the maximum intimal-medial thickness 0.82 (SD 0.20) mm vs 0.78 (0.20) mm, p=0.027), and had a higher frequency of CVD (18.5% vs 7.6%, p=0.00002) compared with Europeans. Aboriginal people had significantly higher rates of smoking, glucose intolerance, obesity, abdominal obesity, and substantially higher concentrations of fibrinogen, and plasminogen activator inhibitor-1. Aboriginal people had significantly higher rates of unemployment and a lower annual household income. For any given income level, Aboriginal people had higher rates of risk factors and CVD compared with the Europeans. INTERPRETATION: A significant proportion of Aboriginal people live in poverty which is associated with high rates of CVD and CVD risk factors. Improvement of the socioeconomic status of Aboriginal people might be a key to reduce CVD in this group.