Development of a life events/icon calendar questionnaire to ascertain occupational histories and other characteristics of migrant farmworkers.

BACKGROUND: Specialized methods are necessary to collect data from migrant farmworkers for epidemiologic research. METHODS: We developed a questionnaire that collected lifetime occupational histories and other lifestyle risk factors via a life events/icon calendar, and administered the questionnaire to a convenience sample of 162 migrant farmworkers in nine areas of the U.S. RESULTS: The average duration of the interviews was about 1 h 30 min, with an average of 45 min for the work history section. The occupational histories covered a median of 27.6 years per person for men and 20.8 years per person for women. The median number of years spent in farm jobs was 11.3 for men and 5.8 for women. The median number of farm jobs (crop/task combination) per person was 59 among men and 27 among women. Many farmworkers performed the same crop/task combinations at multiple times throughout their lives, yielding a median of 13 unique farm jobs and 8 unique crops among men and 7 jobs and 5 crops among women. CONCLUSIONS: The project demonstrated that it is feasible to collect detailed work histories and other risk factor data from farmworkers, documented the complexity of work histories encountered among farmworkers, and yielded recommendations for refining a questionnaire that will facilitate future epidemiologic research on farmworkers.

Dementia in rural primary care practices in Lake County, Oregon.

Procedures used in assessing patients with dementia in rural settings are little studied. Among all patients aged 65 years and older in the four primary care practices in Lake County, Oregon, dementia cases were identified from computerized office databases using preselected International Classification of Diseases, Ninth Edition, codes. A semi-structured chart review determined (1) a dementia diagnosis, (2) cognitive and functional domains assessed, and (3) diagnostic studies performed. Of 1540 available records, 30 had dementia. Nineteen of them met National Institute of Neurological and Communicative Diseases and Stroke-Alzheimer's Disease and Related Disorders Association criteria for Alzheimer's disease (AD). Cognitive impairment was documented in 73% of the 51 identified charts and all with AD. Laboratory studies were recorded in 33% overall and in 42% with AD. Neuroimaging was documented in 18% overall and in 16% with AD. The prevalence of documented dementia in these rural practices may be low, possibly because cases of mild dementia may not be labeled as such. Laboratory studies were performed in a minority of cases of dementia.

Effects of Carbon Source, Carbon Concentration, and Chlorination on Growth Related Parameters of Heterotrophic Biofilm Bacteria.

To investigate growth of heterotrophic biofilm bacteria, a model biofilm reactor was developed to simulate a drinking water distribution system. Controlled addition of three different carbon sources (amino acids, carbohydrates, and humics) at three different concentrations (500, 1,000, and 2,000 ppb carbon) in the presence and absence of chlorine were used in separate experiments. An additional experiment was run with a 1:1:2 mixture of the above carbon sources. Biofilm and effluent total and culturable cells in addition to total and dissolved organic carbon were measured in order to estimate specific growth rates (SGRs), observed yields, population densities, and bacterial carbon production rates. Bacterial carbon production rates (µg C/L day) were extremely high in the control biofilm communities (range = 295-1,738). Both growth rate and yield decreased with increasing carbon concentrations. Therefore, biofilm growth rates were zero-order with respect to the carbon concentrations used in these experiments. There was no correlation between growth rate and carbon concentration, but there was a significant negative correlation between growth rate and biofilm cell density (r = -0.637, p = 0.001 control and r = -0.57, p = 0.021 chlorinated biofilms). Growth efficiency was highest at the lowest carbon concentration (range = 12-4.5%, amino acids and humics respectively). Doubling times ranged from 2.3-15.4 days in the control biofilms and 1-12.3 days in the chlorinated biofilms. Growth rates were significantly higher in the presence of chlorine for the carbohydrates, humics, and mixed carbon sources (p = 0.004, < 0.0005, 0.013, respectively). The concept of r/K selection theory was used to explain the results with respect to specific growth rates and yields. Humic removal by the biofilm bacteria (78% and 56% for the control and chlorinated biofilms, respectively) was higher than previously reported literature values for planktonic bacteria. A number of control experiments indicated that filtration of drinking water was as effective as chlorination in controlling bacterial biofilm growth.

Low back pain: predictors of absenteeism, residual symptoms, functional impairment, and medical costs in Oregon workers' compensation recipients.

BACKGROUND: Wide variations in disability duration and magnitude have been noted among recipients of workers' compensation for low back pain. Findings from recent studies have indicated that inclusion of a broad array of variables (i.e., physical, occupation, social, economic) is needed to understand differences in workers' responses to occupational low back pain. METHODS: Workers' compensation and questionnaire data from 340 Oregon workers with low back claims were merged to develop multivariate models predicting: (1) absenteeism days, (2) residual symptoms, (3) functional impairment, and (4) medical costs. RESULTS: Forty-two percent of the variation in low back symptoms was explained by: discontinuing physical fitness activities post-injury (beta = -.419), self-reported low energy/high fatigue (beta = -.227), poorer general health (beta = .137), and attorney involvement in claim (beta = .117), (adjusted R2 = .418, p < 0.001). Survival curves revealed significantly longer claim durations among workers who discontinued physical fitness activities post-injury, compared with workers who did not; these differences remained significant even after controlling for severity of the initial injury. CONCLUSION: Continuation of physical fitness activities during the recovery process was found to be a significant predictor in three of four regression models, providing evidence on behalf of a relationship between fitness and positive health outcomes. However, it was not possible to clearly differentiate pre-morbid from post-injury fitness, nor to determine if this relationship was due to a therapeutic effect on the back, the general restorative benefits of remaining active, or represents a proxy variable for workers' self-care efforts during recovery.

Development and structure of drinking water biofilms and techniques for their study.

Drinking water systems are known to harbour biofilms, even though these environments are oligotrophic and often contain a disinfectant. Control of these biofilms is important for aesthetic and regulatory reasons. Study of full-scale systems has pointed to several factors controlling biofilm growth, but cause-and-effect relationships can only be established in controlled reactors. Using laboratory and pilot distribution systems, along with a variety of bacterial detection techniques, insights have been gained on the structure and behaviour of biofilms in these environments. Chlorinated biofilms differ in structure from non-chlorinated biofilms, but often the number of cells is similar. The number and level of cellular activity is dependent on the predominant carbon source. There is an interaction between carbon sources, the biofilm and the type of pipe material, which complicates the ability to predict biofilm growth. Humic substances, which are known to sorb to surfaces, appear to be a usable carbon source for biofilms. The finding offers an explanation for many of the puzzling observations in full scale and laboratory studies on oligotrophic biofilm growth. Pathogens can persist in these environments as well. Detection requires methods that do not require culturing.

Design of a questionnaire: occupational and environmental risks for Parkinson's disease.

1. Research linking disease with occupational and environmental exposures is often predicated on obtaining accurate exposure information from affected persons. 2. Exposure history questionnaires are used to obtain comprehensive information about work history, residential history, behavioral patterns, and lifetime exposures. 3. The process of questionnaire development includes: establishing the conceptual background of the research; assuring integrity of the research questions; specifying the content domain of the questionnaire; wording, level, and formatting decisions; establishing evidence for questionnaire validity; assessment of questionnaire reliability; and final edit and polishing. 4. The careful and systematic development of an exposure history questionnaire can be a key determinant in the success of occupational health research.

Environmental antecedents of young-onset Parkinson's disease.

We conducted an exploratory study of young-onset Parkinson's disease (YOPD) to examine occupational and environmental factors associated with disease risk. This case-control study included 63 YOPD patients (diagnosis on or before age 50); controls (n = 68) were diagnosed with rheumatoid arthritis. Crude odds ratios (ORs) were computed to identify exposure variables for logistic regression analyses. After controlling for the variables of race, educational level, sex, age, age at diagnosis, and family history of Parkinson's disease (PD), PD was positively associated with insecticide exposure (OR = 5.75, p < 0.001), past residency in a fumigated house (OR = 5.25, p = 0.046), herbicide exposure (OR = 3.22, p = 0.033), rural residency at time of diagnosis (OR = 2.72, p = 0.027), and nuts and seed eating 10 years before diagnosis (OR = 1.49, p = 0.021). PD was inversely associated with cigarette smoking at 5 years (OR = 0.50, p = 0.027), 10 years (OR = 0.43, p = 0.012), and 15 years (OR = 0.37, p = 0.005) before diagnosis, farm residency (OR = 0.38, p = 0.018), and exposure to dimethyl sulfoxide (OR = 0.10, p < 0.001). These findings are consistent with hypotheses linking PD to exposure to pesticide agents.

Learning outcomes of an ambulatory care rotation in internal medicine for junior medical students.

OBJECTIVE: To assess the educational outcomes of training junior medical students in an eight-week combined ambulatory/inpatient rotation compared with those of training exclusively on inpatient services. DESIGN: Participants were randomly assigned to one of three groups: those who volunteered for the ambulatory/inpatient rotation and were randomly selected; those who volunteered and were not selected; and those who did not volunteer. SETTING: University-based internal medicine (IM) inpatient services and community-based clinics and private practices. PARTICIPANTS: Seventy-five third-year medical students taking the required eight-week IM clerkship. INTERVENTION: Assessment included both pre- and posttest measurement of students' knowledge of general internal medicine and a profile of the types of patients problems seen by students in ambulatory settings. RESULTS: While students' general medicine knowledge scores increased significantly from pre- to posttest (p < 0.001), there was no significant difference in scores between the ambulatory/inpatient and exclusive inpatient groups. Patient log data indicated notable differences in the diagnostic compositions of students' patient loads. For instance, 38% of the ambulatory diagnoses were infectious disease, neurologic, endocrine, rheumatologic, or dermatologic problems, and another 15% were non-IM (e.g., obstetric/gynecologic; ear, eye, nose, and throat) problems. Only 24% of the inpatient diagnoses reflected these specialty areas. CONCLUSIONS: Ambulatory training did not significantly affect students' knowledge gain compared with that for exclusive inpatient training, but student evaluations of the rotation plus patient log data suggested that ambulatory training can provide a more complete view of general medicine practice than can exclusive inpatient training.

A new rating form for use by nurses in assessing residents' humanistic behavior.

OBJECTIVE: To determine the reliability and validity of an evaluation form for assessing the humanistic behavior of internal medicine (IM) housestaff. The form is for use by nurses. DESIGN: Evaluations were gathered three times during the 1987-88 academic year. Generalizability coefficients (interpreted like traditional reliability coefficients) were generated to establish the form's reliability, while data from attending physicians and from housestaff evaluation committee members were used to help establish its validity. SETTING: Three hospitals in central Ohio: a large university tertiary care center, a large private hospital, and an urban community hospital. PARTICIPANTS: The nurse raters were volunteers solicited by their head nurses. The criteria governing their participation were two years of postgraduate experience in nursing and regular contact with residents, which was self-determined. All IM residents who had worked on a medicine inpatient service at least once during the months under study were included. A total of 493 nurses and 116 residents participated. RESULTS: Sixty-four percent of the generalizability coefficients were 0.90 or higher, and 82% were above 0.75, indicating stable, reliable ratings. The nurses' ratings were positively and significantly correlated with attending faculty's and evaluation committee members' ratings (r = 0.38, p less than 0.01; r = 0.49, p less than 0.001). CONCLUSIONS: The evaluation form and the nurses provided consistent, reliable information about medical residents' humanistic behavior; data from five to six nurses should provide statistically reliable ratings using this form. Also, nurses' data yielded information somewhat different from those provided by physicians, suggesting that the form is a useful instrument for assessing this dimension of residents' performance.

Nurses in resident evaluation. A qualitative study of the participants' perspectives.

This study complemented a large psychometric study using nurses to assess medical residents' humanistic behavior. It was designed to identify how nurses and residents defined humanistic qualities and behaviors and what factors affected their views of residents' performance and evaluation. The study also illustrates how qualitative methods were used to complement quantitative psychometric data and thereby yield a more complete assessment of the value of a new performance evaluation form. The results indicated that nurses' definitions of humanistic behavior often differed from residents', tending to reflect a broader perspective on the physician's role and responsibility in patient care. Nurses and residents disagreed about whether nurses were qualified to evaluate residents' humanistic behavior and about what nurses actually observed on the wards. Professional respect was an issue for both nurses and residents. The discussion section identifies some implications for resident training and nurse-resident relationships and supports the value of combining research strategies when evaluating complex human behavior.

Social support: the experience of hospice family caregivers.

The concepts of social support, reciprocity, cost, and conflict were examined through a methodological study that assessed the reliability and validity of Tilden's (1986) Cost and Reciprocity Index (CRI). The CRI was modified for the face-to-face interviews with 70 family members who were caring for a terminally ill relative enrolled in a hospice program. Item analyses was undertaken with the four subscales because of qualitative comments, a desire to streamline administration of the measure and an overall drop in the alpha coefficients compared with those previously reported. Based on this work 25 items were retained in the four subscales, 13 were eliminated. Cronbach's alpha coefficients and the average inter-item correlation for the revised subscales are reported. Correlation analysis of the revised subscales was also undertaken in order to explore the relationship among the subscales and with time since the care receiver's diagnosis.

Thinking upstream: nurturing a conceptual understanding of the societal context of health behavior.

This article addresses the issue of overreliance on theories that define nursing in terms of a one-to-one relationship at the expense of theoretical perspectives that emphasize the societal context of health. When individuals are perceived as the focus of nursing action, the nurse is likely to propose intervention strategies aimed at either changing the behaviors of the individual or modifying the individual's perceptions of the world. When nurses understand the social, political, and economic influences that shape the health of a society, they are more likely to recognize social action as a nursing role and work on behalf of populations.

How recent medical school graduates evaluate the clinical relevancy of their behavioral science curriculum.

Recent graduates of the University of South Carolina School of Medicine (n=108) evaluated the clinical relevancy of their behavioral science curriculum. The results indicate that a body of behavioral science data are clinically relevant to physicians regardless of their specialty. Additional behavioral science content areas are clinically relevant for practitioners in particular medical specialties. Suggestions are made for the role of behavioral science material in continuing medical education.

The stress of residency. A review of the literature.

A review of empiric studies of the stresses of residency training and descriptions of intervention programs and mental health resource surveys published since 1980 indicated that inadequate sleep and fatigue are major stressors for residents, but they are only part of a more complex situation influenced by time demands, social support, and maturational factors. Other important stressful aspects of training appear to be those that interfere with social support. Increased anger, not depression, is emerging as the predominant mood change during residency, but the effects of any mood change on patient care have not been studied. Despite growing evidence of the need for change in training programs, especially attention to the affiliative needs of residents, few intervention programs have been reported.