Trajectories of Nutritional Risk: The Manitoba Follow-Up Study.

OBJECTIVES: To identify patterns of nutritional risk among older men over a four-year period and to project their survival rates over the next two and a half years. DESIGN: A prospective longitudinal study. SETTING: Canada. PARTICIPANTS: Three hundred and thirty-six male survivors of the Manitoba Follow-up Study (MFUS) cohort with an average age of 90 years in 2011. MEASUREMENTS: Four years of nutritional risk SCREEN II scores (five waves) from the male survivors of the MFUS cohort. The semi-parametric group-based trajectory approach and survival analysis were used to investigate the trajectories of nutritional risk. RESULTS: Of the participants, 30% lived alone. Five distinct developmental trajectory groups for nutritional risk score were identified. Significant statistical differences were found among the five trajectory groups for SF-36 mental health (p=.02), SF-36 physical health (p=<.001), perception of aging successfully (p=.04) and living alone (p=<.001). Among the five groups, the most pairwise differences were found in appetite, intake of meat and alternatives, and vegetables and fruit, weight change, skipping meals and eating with others. Men in the poorest nutritional risk trajectory group were two times more likely to die within a 2 1/2 year period compared to men in the best nutritional risk trajectory group (hazard rate = 2.33, p=.07). CONCLUSION: Distinct nutritional risk trajectories were found for older men over a four year period. Poor nutritional risk trajectories are associated with higher risk of mortality for very old men over a short period of time. Timely nutritional assessments by health professionals are needed to identify older men at nutritional risk. Subsequent nutrition education and follow-up may be important in preventing further decline.

Food group consumption and self-rated diets of elderly community-dwelling canadian men. The manitoba followup study.

BACKGROUND: Healthy eating perceptions and food group consumption practices of elderly men are largely unexplored. Understanding eating practices of elderly men and how this relates to their quality of life is important for the implementation of practical health promotion strategies. OBJECTIVE: Examine the frequency of food items consumed (daily, most days, or rarely), and the association of self-rated diet and food group consumption of elderly community-dwelling Canadian men. DESIGN: Self-reported nutrition data, obtained via mailed questionnaires in spring 2000, from 1,211 Canadian male respondents (mean age 82 years) participating in the Manitoba Follow-up Study were analyzed. RESULTS: Respondents consumed vegetables/fruit (64%) and grain products (58%) daily, and meat/alternatives (81%) most days. Milk products were equally consumed daily (47%) or most days (47%). Using multiple logistic regression models, controlling for demographic variables, a positive relationship was found between the increasing consumption of vegetables/fruit and grain products and healthier self-rated diets. Daily consumption of vegetables/fruit or grain products significantly predicted healthier self-rated diets compared to men consuming those food categories most days, OR=2.42 (95%CI=1.88, 3.11) and OR=2.18 (95%CI=1.70, 2.79), respectively. Those consuming meat/alternatives or milk products "daily" or "rarely" rated their diets as healthier than those consuming these items "most days". CONCLUSION: Daily consumption of fruits, vegetables, and grain products is viewed as important for overall health and is positively associated with healthier self-rated diets among elderly Canadian men.

The relationship of the transcutaneous oxygen tension, pulse waves and systolic pressures to the risk for limb amputation in patients with peripheral arterial disease and skin ulcers or gangrene.

AIM: Our aim was to determine how the risk associated with presence of low transcutaneous oxygen tension (tcPO2) for subsequent major amputation in patients with skin ulcers or gangrene and peripheral arterial disease, compares with the risks associated with low peripheral pressures and low amplitude of pulse waves. Secondly, we determined whether combination of measurements of oxygen tension with that of the pressures or pulse wave amplitude predicts amputation better than pressure, wave or oxygen tension measurements alone. METHODS: Measurements were carried out to obtain foot tcPO2, ankle and toe pressures, pressure indices, and toe pulse wave amplitude in 75 limbs with skin lesions and arterial disease of 66 patients referred to the vascular laboratory. These variables were related to the risk of a subsequent major amputation during a median time of 4.2 years, using Cox proportional hazards model. RESULTS: Low oxygen tension was associated with increased risk of amputation (relative risks 2.16 and 2.55 for tcPO2 < or = 10 mmHg and < or = 20 mmHg, respectively, P<0.05; relative risk 2.22 for tcPO2 < or = 30 mmHg, P=0.07). The relative risks associated with cutoff values of ankle and toe pressures and pressure indices varied from 2.53 (toe < or = 20 mmHg, P<0.05) to 5.83 (ankle < or = 50 mmHg, P<0.001) and the relative risk associated with low wave amplitude (< or = 4 mm) was 3.41, P<0.01. The cutoff values of tcPO2 became insignificant when included in the models together with each pressure variable or pulse amplitude separately. In contrast, wave amplitude remained significantly associated with increased risk of amputation after controlling for each pressure variable (P<0.05). CONCLUSIONS: TcPO2 < or = 10 mmHg and < or = 20 mmHg are related significantly to increased risk of amputation in patients with skin lesions and arterial disease, but these relative risks are similar in magnitude or smaller than those associated with low cutoff values of pressures, pressure indices or pulse wave amplitude. Low wave amplitude does provide significant information in addition to peripheral pressures with respect to the risk of amputation. On the other hand, low tcPO2 does not provide significant information in addition to peripheral pressures or pulse wave amplitude.

Effectiveness of overhead lifting devices in reducing the risk of injury to care staff in extended care facilities.

Patient and/or resident handling is a major cause of injury to healthcare workers. The effectiveness of an overhead ceiling lift programme at mitigating the risk of injury from resident handling was evaluated by comparing injury data and staff perceptions before and after implementation of the programme, and by comparison with a similar unit that did not implement an overhead ceiling lift programme. A questionnaire was used to assess perceived risk of injury and discomfort, preferred resident handling methods, frequency of performing designated resident handling tasks, perceived physical demands, work organization, and staff satisfaction. Staff preferred overhead ceiling lifts to other methods of transfer (manual or floor lifts) when lifting or transferring residents. A significant reduction was observed in the perceived risk of injury and discomfort to the neck, shoulders, back, hands, and arms of care staff. Compensation costs due to lifting and transferring tasks were reduced by 68% for the intervention unit and increased by 68% for the comparison unit. Overhead ceiling lifts were not beneficial in reducing the perceived risk of injury, pain or discomfort, or compensation costs when used to reposition residents. The study demonstrated an overall cost-savings associated with the installation of the overhead lifts, and highlighted areas for further improvement.

Analysis of nursing assessments in a cohort patients with ruptured cerebral aneurysms.

Patients admitted with subarachnoid hemorrhage are monitored for symptoms of vasospasm. A prospective study was designed to compare two monitoring instruments: a standard neurological tool (SNR) and the National Institutes of Health Stroke Scale (NIHSS). The two assessment tools were compared to evaluate their concordance and to identify areas where efficiency in recording assessments might be improved. We found no statistical difference between the two tools in detecting symptomatic cerebral vasospasm. Substantial discrepancies in the documentation of observations were noted, particularly in the assessment of limb drift. Avoidance of these discrepancies may require further definition in the SNR tool. A qualitative component consisting of a review of the nurses' notes regarding neurological status in the patients' charts was conducted. It was demonstrated that nurses commonly document information in the progress notes that is already captured in the SNR. Further education of nurses in the use of assessment tools is therefore recommended to avoid redundancies and increase efficiency in recording clinical observations.

Comparison of a standard neurological tool with a stroke scale for detecting symptomatic cerebral vasospasm.

The purpose of this study was to critically analyze the effectiveness of two tools used by nurses to assess neurological status of individuals at risk of developing cerebral vasospasm following aneurysmal subarachnoid hemorrhage due to aneurysm rupture. Early detection of vasospasm provides an opportunity for prompt treatment so that further ischemia or infarction can be prevented. We hypothesized that the National Institutes of Health Stroke Scale would detect symptomatic vasospasm earlier than the standard neurological record currently used in the practice setting of a tertiary care teaching hospital. Thirty participants were entered into the study, and a differential diagnostic process identified 15 with symptomatic vasospasm. Quantitative prospective and retrospective analysis showed that there was no statistical difference between the two scales in early detection of vasospasm. This finding may partially be explained by the clinical similarities between the vasospasm and nonvasospasm groups and by the challenges experienced by nurses in administering the stroke scale. Clinically relevant observations suggested the stroke scale was more effective in the assessment of focal symptoms. Qualitative content analysis of nursing notes also provided insight into clinical findings not captured on either scale regarding generalized changes such as restlessness, impulsiveness, and unusual behavior. This study demonstrates the need to develop a more appropriate tool for early detection of vasospasm.

A comparison of the Canadian Occupational Performance Measure and the Health Assessment Questionnaire.

The Canadian Occupational Performance Measure (COPM) is receiving international attention as an important assessment for directing occupational therapy interventions and measuring client-centred outcomes. The COPM measures individuals' perceptions of disability by identifying those tasks that are important to them and difficult to perform. The Health Assessment Questionnaire (HAQ) has been used extensively with persons with arthritis and measures individuals' perceived difficulty in performing predetermined tasks of daily living. The HAQ has been shown to correlate with actual performance and has reported concurrent validity with a number of similar scales. In this study, 13 participants diagnosed with rheumatoid arthritis were assessed with the COPM and the disability dimension of the HAQ. Participants scored performance limitations on both the COPM and the HAQ; the correlation coefficient between the scores was not statistically significant. However, when the COPM and the HAQ scores for similar activities were compared, a statistically significant correlation was found. These findings support the use of the COPM as a valid measure of self-reported performance.

A randomized controlled trial to prevent patient lift and transfer injuries of health care workers.

STUDY DESIGN: Randomized controlled trial (RCT). OBJECTIVES: To compare the effectiveness of training and equipment to reduce musculoskeletal injuries, increase comfort, and reduce physical demands on staff performing patient lifts and transfers at a large acute care hospital. SUMMARY OF BACKGROUND DATA: Back injury to nursing staff during patient handling tasks is a major issue in health care. The value of mechanical assistive devices in reducing injuries to these workers is unclear. METHODS: This three-armed RCT consisted of a "control arm," a "safe lifting" arm, and a "no strenuous lifting" arm. A medical, surgical, and rehabilitation ward were each randomly assigned to each arm. Both intervention arms received intensive training in back care, patient assessment, and handling techniques. Hence, the "safe lifting" arm used improved patient handling techniques using manual equipment, whereas the "no strenuous lifting" arm aimed to eliminate manual patient handling through use of additional mechanical and other assistive equipment. RESULTS: Frequency of manual patient handling tasks was significantly decreased on the "no strenuous lifting" arm. Self-perceived work fatigue, back and shoulder pain, safety, and frequency and intensity of physical discomfort associated with patient handling tasks were improved on both intervention arms, but staff on the mechanical equipment arm showed greater improvements. Musculoskeletal injury rates were not significantly altered. CONCLUSIONS: The "no strenuous lifting" program, which combined training with assured availability of mechanical and other assistive patient handling equipment, most effectively improved comfort with patient handling, decreased staff fatigue, and decreased physical demands. The fact that injury rates were not statistically significantly reduced may reflect the less sensitive nature of this indicator compared with the subjective indicators.

Prevalence of asthma symptoms among adults aged 20-44 years in Canada.

BACKGROUND: Reported prevalence rates of asthma vary within and between countries around the world. These differences suggest environmental factors in addition to genetic factors in the cause of the disease and may provide clues for preventive strategies. We examined the variability of asthma-related symptoms and medication use among adults in 6 sites across Canada (Vancouver, Winnipeg, Hamilton, Montreal, Halifax and Prince Edward Island) and compared our findings with those from sites that had participated in a recent European survey. METHODS: We used the same sampling strategy and standardized questionnaire as those used in the European Community Respiratory Health Survey (ECRHS). The 6 Canadian sites were selected to represent different environments with respect to climate, air pollution and occupational exposure. Community-based samples of 3000 to 4000 people aged 20-44 years were randomly selected in each site. Subjects were asked to complete the questionnaire by mail between March 1993 and November 1994. Prevalence rates (and 95% confidence intervals [CIs]) of asthma symptoms, self-reported asthma attacks and use of asthma medication were compared across the Canadian sites and with sites that had participated in the ECRHS. RESULTS: The overall response rate of those selected to receive the questionnaire was 86.5% (range 74.5%-92.8%). The prevalence rates of most asthma symptoms varied significantly among the Canadian sites. For instance, 21.9% (Montreal) to 30.4% (Halifax) of the men and 24.0% (Vancouver) to 35.2% (Halifax) of the women reported wheezing in the year before the survey. Depending on the site, 4.4% to 6.3% of the men and 5.2% to 9.5% of the women reported an asthma attack in the last year, and 4.0% to 6.1% of the men and 4.9% to 9.7% of the women were currently using asthma medication. Prevalence rates of symptoms, asthma attacks and medication use did not change with age, but they were higher among women than among men. Compared with the results from the ECRHS sites, those from the Canadian sites were among the highest. INTERPRETATION: Significant variation in the prevalence of asthma symptoms, asthma attacks and use of asthma medication between Canadian sites and international sites suggests environmental influences. Different combinations of factors in different sites may be responsible for the high prevalence rates and should be the subject of further research to guide clinical management and public health intervention.

The value of toe pulse waves in determination of risks for limb amputation and death in patients with peripheral arterial disease and skin ulcers or gangrene.

OBJECTIVES: The purpose of this study was to determine whether the presence of low amplitude of pulse waves recorded from the toes is related to the risk of subsequent amputation and death in patients with skin ulcers or gangrene and peripheral arterial disease, and how the risk of low wave amplitude relates to the risk associated with low peripheral pressures. METHODS: A total of 309 patients with 346 limbs with skin lesions and arterial disease referred to the vascular laboratory were followed up for an average of 5 years (range, 1-8 years). Measurements were carried out to obtain ankle and toe pressures, pressure indices, and toe pulse wave amplitude. These variables were related to the risks of major amputation and total and cardiovascular death by means of the Cox proportional hazards model. RESULTS: Low toe pulse wave amplitude (< or = 4 mm) was associated with increased risk of amputation (relative risks 4.20 in all limbs and 2.63 in those with toe pressure < or = 30 mm Hg; P <.01). Wave amplitude remained significantly associated with increased risk of amputation after controlling for each pressure variable (P <.01). Low pulse wave amplitude and toe/brachial index were associated with increased risks of both total and cardiovascular death in all patients (relative risks ranged from 1.43-1.73; P <.05) and in those with toe pressure of 30 mm Hg or less (relative risks 1.56-1.90; P <.05). CONCLUSIONS: Low toe pulse wave amplitude is related significantly to increased risks of amputation and death in patients with skin lesions and arterial disease. The presence of low wave amplitude provides significant information in addition to peripheral pressures with respect to the risk of amputation.

Health-risk perception in the inner city community of Centro Habana, Cuba.

Perceptions of health risks were surveyed in the inner city of Centro Habana, Cuba. A questionnaire developed by community leaders and experts was administered to 348 residents to determine the level of perceived risk for each of 41 risk items. Ecologic-level data on morbidity, mortality, and environmental indicators were also gathered. Using factor analysis to reduce the dimensionality of the data, five factor groupings accounted for 60% of the variance, as follows: social environment (40.8%); infectious agents and other health-risk factors of immediate concern (6.1%); lifestyle risks (4. 9%); environmental sanitation (4.1%); and living conditions (3.3%). A relationship between the perception of risk and the ecologic data was found, with inconsistencies largely attributable to factors known to influence risk perception. The greatest concern identified throughout the municipality was housing conditions, highest in the neighborhood that had already begun to address this problem. The analysis was useful in planning targeted health promotion campaigns and prioritizing further interventions. Repeat evaluation of risk perception will be conducted following the completion of interventions.

Predictors of time loss after back injury in nurses.

STUDY DESIGN: A 2-year prospective inception cohort study of back injury in nurses. OBJECTIVES: To determine the extent to which characteristics of nurses, of the injury, and of the workplace predict occurrence and duration of time loss from work after back injury. SUMMARY OF BACKGROUND DATA: During 2 years, 320 nurses incurred 416 back injuries at a large teaching hospital in Winnipeg, Canada. Nurses injured on preselected wards were targeted for early intervention, including provision of modified work, whereas nurses injured on other wards received the usual care. METHODS: Time loss attributable to the back injury during the 6 months after injury was analyzed. Three statistical models were used to examine occurrence of time loss (logistic regression), duration of time loss (Tobit regression), and duration of time loss once an injury incurring time loss had been documented (least-squares regression). RESULTS: In 218 of the 416 injuries, the injured nurse consented to interview. Whereas perceived disability was related to whether a time loss injury would ensue, self-reported pain was strongly related to the duration of time loss once an injury had become a time loss injury. Duration of time loss was reduced by participation in the return-to-work program. Mechanism of injury, specifically injury occurring while lifting patients, resulted in greater time loss. CONCLUSIONS: Focusing on reducing the perception of disability at the time of injury is critical to preventing time loss, but once time loss has occurred, offer of modified work and attention to pain reduction are warranted. The findings add to the evidence that workplace-based intervention programs can be effective in reducing the morbidity resulting from back injury.

Satisfaction of women attending the Manitoba breast screening program.

BACKGROUND: This study evaluated the satisfaction of women who attended the Manitoba Breast Screening Program (MBSP) during the first 17 months of operation and examined differences in satisfaction by screening location and screening result. The setting was the province of Manitoba, Canada. METHODS: A breast screening program satisfaction questionnaire comprising six subscales was mailed to 1,331 randomly chosen women in five different categories who attended the MBSP. Four categories were based on location of screen (city of Brandon vs city of Winnipeg) and screen result (normal vs abnormal) and one category comprised women who were screened at a mobile unit. Eighty-eight percent of all questionnaires were returned. Data analyses included analyses of variance to examine the effect of location and result on satisfaction scores and logistic regression to explore the variables associated with reported satisfied and not satisfied responses to each satisfaction subscale. RESULTS: All satisfaction scores were above 80 of 100, indicating high levels of satisfaction. A significant difference in satisfaction scores between women in Winnipeg and women in Brandon was found for the convenience and accessibility (P = 0.0153) and the information transfer subscales (P = 0.0150). A significant difference was found between women with abnormal and women with normal screen results for all subscales (P < 0.01). Women were 4.5 times more likely to be dissatisfied on the general satisfaction subscale if they had an abnormal screen result (95% CI 1.9,10.4). CONCLUSIONS: High levels of satisfaction were reported for all aspects of screening at the MBSP. However, women were less likely to be satisfied with program convenience and accessibility. Women with an abnormal result reported lower levels of satisfaction on all subscales. Some women with an abnormal screening result were confused about what their results meant and why they were sent for additional diagnostic tests. As a result of these findings, numerous changes were made to the MBSP.

Components of initial and residual disability after back injury in nurses.

STUDY DESIGN: A pre- versus postintervention with concurrent control group design was used to investigate the effect of a workplace-based early intervention program on perception of disability in nurses with low back injury. OBJECTIVES: This report examines changes over time in the components of the Oswestry Low Back Pain and Disability Questionnaire in two groups of back-injured nurses-those who received the early intervention program (study) and those who were not offered the program (control). SUMMARY OF BACKGROUND DATA: Early intervention programs can decrease morbidity, time lost from work, and compensation costs. Although perception of disability decreases, some residual disability remains, the nature of which is not clear. METHODS: The Oswestry Low Back Pain and Disability Questionnaire scores of 40 study nurses and 118 control nurses at time of injury and at 6 months after injury were examined. Analysis of variance was used to compare changes in mean overall scores over time. The proportion of nurses reporting disability on individual components of the Oswestry Low Back Pain and Disability Questionnaire at each time period was compared with the results of a chi-square test. RESULTS: Overall Oswestry Low Back Pain and Disability Questionnaire scores were similar between study and control nurses at time of injury, but were significantly lower in study nurses at 6 months after injury. However, scores of individual Oswestry Low Back Pain and Disability Questionnaire components that related to job demands increased over time; this was most apparent in lifting, particularly in study nurses. CONCLUSIONS: Although overall perception of disability decreased 6 months after injury, particularly in study nurses, disability in job-related activities persisted. Residual disability after back injury should be addressed in workplace-based prevention programs.

The effect of age on risk factors for ischemic heart disease: the Manitoba Follow-Up Study, 1948-1993.

PURPOSE: The purpose of this paper is to determine the age-specific relationships between risk factors at age 40 through 75 years and ischemic heart disease (IHD), and to determine the effects of aging on these relationships in a cohort of 3983 Canadian males. METHODS: The Manitoba Follow-Up Study is the prospective investigation of cardiovascular disease as it develops in a cohort of 3983 young men. Over a period of 45 years, from 1948 to 1993, 1094 study members (27%) developed clinical evidence of IHD. Blood pressure, body weight, smoking, and presence of diabetes mellitus have been recorded at regular intervals throughout the follow-up period. Using measurements from examinations every 5 years between ages 40 and 75 years, age-specific Cox proportional hazard models were fit to relate these risk factors to IHD. RESULTS: The adjusted relative risk of IHD for systolic blood pressure, diastolic blood pressure and smoking were found to significantly (p < 0.001) decline with advancing age. The adjusted relative risk for body mass index and presence of diabetes mellitus for ischemic heart disease did not vary with age (p > 0.05). After age 65 years, these risk factors were of little value for the prediction of IHD. CONCLUSIONS: The relative risk and statistical significance of blood pressure and smoking, as risk factors for IHD, decline with age.

Respiratory symptoms in a susceptible population due to burning of agricultural residue.

STUDY OBJECTIVES: To identify characteristics associated with respiratory symptoms due to an episode of air pollution. DESIGN: Mail survey. SETTING: In October 1992, the population of the city of Winnipeg was exposed to elevated levels of particulate matter (total and <10 microm size), carbon monoxide, nitrogen dioxide, and volatile organic compounds due to smoke from adjacent fields where farmers were burning agricultural residue (straw and stubble). PARTICIPANTS: We surveyed 428 participants in the ongoing Lung Health Study (35 to 64 years old, both sexes) with mild to moderate airways obstruction (mean FEV1 percent predicted 73+/-12%), and a high level of airways hyperreactivity (23% of men and 37% of women). RESULTS: While 37% of subjects were not bothered by smoke at all, 42% reported that symptoms (cough, wheezing, chest tightness, shortness of breath) developed or became worse due to the air pollution episode and 20% reported that they had breathing trouble. Those with symptoms were more likely to be female than male and were more likely to be ex-smokers than smokers. Subjects with asthma and chronic bronchitis were also more likely affected. The degree of airways obstruction and the level of bronchial hyperresponsiveness were not associated with increased susceptibility. CONCLUSIONS: Gender, smoking habit, and respiratory symptoms but not bronchial hyperresponsiveness or the degree of airways obstruction are factors influencing susceptibility to symptoms due to air pollution in adult smokers and former smokers.

Cardiac structure and exercise blood pressure in urban and rural Canadian men of Icelandic descent.

The objective of the study was to determine the relationship between exercise systolic blood pressure (ESBP), during bicycle ergometry, and echocardiographically determined left ventricular structure in rural and urban Canadian men of Icelandic descent. The study was cross-sectional in design. The settings were urban Winnipeg and the rural Interlake District in the province of Manitoba, Canada. Subjects were adult male volunteers from families of wholly Icelandic descent. The subjects were 30 to 60 years of age and had supine blood pressure < 160/95 mm Hg. Anthropomorphic measurements, echocardiography and sphygmomanometry, at rest and during bicycle ergometry, were performed on all subjects. Prevalence of exaggerated ESBP (> or = 200 mm Hg) and left ventricular hypertrophy (LVH) was not significantly different in the two groups. In all but one individual LVH was classified as eccentric hypertrophy. In both urban and rural subjects with exaggerated ESBP, left ventricular mass index (LVMI) was greater than in those subjects without exaggerated ESBP. The LVMI correlated with ESBP at the highest workloads (> or = 150 W). Multivariate analysis of all subjects showed that cardiac index, ESBP, body mass index, and low exercise heart rate were predictive of LVMI. There was no significant difference in prevalence of ESBP or LVH between urban and rural Manitobans of Icelandic descent. However, LVMI levels were lower, and values for ESBP greater, in the rural group compared with the urban group. Within each of the two groups there was a positive association between ESBP and LVMI; hence, the study supports findings of our previous investigation showing evidence of early target organ effects in normotensive men with an exaggerated ESBP.

Effect of an early intervention program on the relationship between subjective pain and disability measures in nurses with low back injury.

STUDY DESIGN: The effect of a workplace-based early intervention program on perceptions of pain and disability in nurses with low back injury was studied using a preintervention versus postintervention design with concurrent control group. OBJECTIVES: To examine the relationship and changes over time between pain and disability measures in two groups of back-injured nurses--those who received the early intervention program (study) and those who were not offered the program (control). SUMMARY OF BACKGROUND DATA: The relationship between back pain and disability is not straightforward. The effects of an intervention program on changes in perceptions of pain and disability over time have not been widely reported. METHODS: The Oswestry Low Back Disability Questionnaire and a visual analog pain scale were administered to 46 study nurses and 137 control nurses at time of injury and at 6 months after injury. Correlation and regression analyses were used to explore the relationships between the two measures. Changes over time were compared with analyses of variance. RESULTS: Pain and disability were positively correlated in both groups at time of injury and at follow-up evaluation. Mean scores for pain and disability were lower at follow-up evaluation than at initial injury in both groups; study nurses had significantly (P < 0.01) lower scores at 6 months than nurses in the control group. Disability at time of injury predicted disability at 6 months only for nurses in the control group. CONCLUSIONS: This workplace-based early intervention program decreased levels of pain and disability in back-injured nurses and altered the relationship between these two variables over a 6-month time interval.

Using an alternative data source to examine randomization in the Canadian National Breast Screening Study.

Criticisms of the Canadian National Breast Screening Study (NBSS) assert that reported findings (more deaths in women aged 40-49 allocated to mammography versus no mammography and no difference in mortality between women who had mammography and physical examination versus physical examination alone for those aged 50-59) may be due to more women with prior breast disease being allocated to the mammography arms of the study. The possibility that allocation was not random was examined for NBSS participants in Manitoba, Canada, using health insurance data that were external to and independent of the NBSS. The study design consisted of a retrospective observation study using health insurance (claims) data to construct health histories of breast disease prior to NBSS entry. Self-reported breast disease from the NBSS entry questionnaires was compared to breast disease histories on the basis of health insurance claims. The setting consisted of one NBSS screening center in Winnipeg, Canada. The patient population consisted of 9477 women with at least one health insurance claim in the 24 months prior to NBSS entry. We determined the proportions of women within each study arm who had claims for breast disease, breast disease investigation, or xeromammograms in the 24 months prior to NBSS entry, and compared the proportion of women's self-reports of breast disease or xeromammography with the presence/absence of a claim prior to NBSS entry for breast disease or xeromammography. No significant differences in the proportion of women with prior histories of benign breast disease, investigation, or xeromammograms (p > 0.05) were found across the study arms. Nine women in the mammography group versus one in the no mammography group had one prior health insurance claim for breast cancer, but eight of these women had no subsequent claims for breast cancer. There were no differences across the study arms in the proportion of women who reported a prior history of breast disease or a prior xeromammogram for whom an insurance claim was found. Using data external to the NBSS for Manitoba participants, the study found no definitive evidence to support a nonrandom allocation of women with prior breast disease to the mammography arms of the study. However, generalizability to the other NBSS centers cannot be assured.

Value of toe pulse waves in addition to systolic pressures in the assessment of the severity of peripheral arterial disease and critical limb ischemia.

PURPOSE: Although pressure measurements are useful in the assessment of the severity of the arterial obstruction, they do not completely identify limbs with and without critical limb ischemia. Our objective was to test whether addition of the measurements of toe pulse waves (PW), which depend on distal perfusion, to pressure measurements could improve the determination of the severity of arterial disease and the presence of critical limb ischemia. METHODS: We measured toe pressure (TSP) and ankle/brachial index (ABI) and recorded PW with photoplethysmography in 358 limbs of 182 patients. RESULTS: TSP, ABI, and PW amplitude were lower in 67 limbs with rest pain, skin lesions, or both, with mean differences of 29 mm Hg, 0.12, and 16 mm, respectively (p < 0.01). Similarly, in the subgroup of 107 limbs with TSP < or = 30 mm Hg, TSP, and PW amplitude, but not ABI, were lower in 53 limbs with rest pain, skin lesions, or both, with mean differences of 10 mm Hg and 7 mm (p < 0.01). Multiple logistic regression showed that after controlling was done for TSP and ABI, the odds ratio for the presence of rest pain, skin lesions, or both associated with PW amplitude < or = 4 mm was 4.3 (95% confidence interval 1.7, 11.0; p < 0.01). In the subgroup with TSP < or = 30 mm Hg, this odds ratio was 3.5 (95% confidence interval 1.0, 11.6; p < 0.05). CONCLUSIONS: The findings indicate that addition of PW recording to pressure measurements is likely to increase the accuracy of assessment for critical limb ischemia.