Identifying a 'super-responder' phenomenon in three African countries: Implications for prehospital emergency care training.

BACKGROUND: Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The WHO recommends training lay first responders (LFRs) as the first step toward EMS development while Disease Control Priorities (DCP) suggests training 0.5%-1% of a population for adequate emergency catchment. After launching three LFR programs in Africa, this study investigated subsequent skill usage and conducted demographic analyses to inform future recruitment of high-responding LFRs. METHODS: Demographic characteristics and individual LFR intervention frequencies were collected from a pooled sample of 887 of 1,291 total LFRs (68.7%) trained across programs launched in a staggered fashion between 2016-2019 in Uganda, Chad, and Sierra Leone. A Kruskal-Wallis Rank-Sum test assessed between-group differences among demographics in each location. Spearman's r was used to determine the relationship between response frequency and LFR characteristics. RESULTS: Most LFRs trained did not use skills post-training (median LFR interventions=0.0 interventions/year [IQR:0.0,5.0]). Right-skewed intervention frequency distributions demonstrate high-responding outlier responder groups do exist in all locations (p<0.0001). Median LFR interventions of the top quartile of these active LFRs ("super-responders") was 26.0 interventions/year (IQR:16.7,35.0). "Super-responders" witnessed more road traffic injuries (RTIs) prior to training (p=0.033). LFRs who never responded were significantly younger (p=0.0020). Significant correlations were demonstrated between pooled RTIs witnessed and intervention frequency (r=0.13, p=0.032) and age and intervention frequency in Sierra Leone (r=-0.15, p=0.019). CONCLUSION: Current DCP-recommended training of 0.5-1% of a given population for adequate emergency catchment may be an inefficient means of building emergency care capacity. Recruiting "super-responders" with select characteristics may achieve similar coverage while conserving valuable training resources in resource-limited African settings.

Mental health consequences of chemical and radiologic emergencies: a systematic review.

This article reviews the literature pertaining to psychological impacts in the aftermath of technological disasters, focusing on the immediate psychological and mental health consequences emergency department physicians and first responders may encounter in the aftermath of such disasters. First receivers see a wide spectrum of psychological distress, including acute onset of psychiatric disorders, the exacerbation of existing psychological and psychiatric conditions, and widespread symptomatology even in the absence of a diagnosable disorder. The informal community support systems that exist after a natural disaster may not be available to communities affected by a technological disaster leading to a need for more formal mental health supportive services.

Boosting workplace stair utilization: a study of incremental reinforcement.

PURPOSE: This study was designed to determine whether engagement in stair taking can be increased in a worksite setting through the provision of an employer-sponsored, behavior-based incentive system in which employees (members) accumulate points that can be redeemed for merchandise. METHODS/DESIGN: ChipRewards implemented stair utilization in one employer as a part of a larger health incentive engagement program. Using an AB (baseline-intervention) design, members (N = 216) were observed for 6 months (6.17.10 to 12.14.10 or 129 weekdays after excluding 52 weekend days) before the intervention (baseline) and after 6 months (1.1.11 to 6.30.11 with the same number of weekdays) of implementation. RESULTS: Members were 84% female, 51% Caucasian, 48% African American, 3% Hispanic, and 45 years average age. The number of total stair transactions for all members for all days monitored increased from 5,070 to 38,900, and the average number of stair transactions per day rose from 39 to 301, representing over a 600% increase. The overall cost of incentives for stair utilization was $3,739.30 or $17.55 per member on average. CONCLUSION/IMPLICATIONS: This study supports that stair usage in the workplace is a viable way to increase physical activity. This study adds to existing research that attempted to increase stair utilization through promotion only by adding a behavioral reinforcement strategy. Finally, this study demonstrates that a physical activity among employees at the worksite can be increased with minimal relative cost.

Providing general and preconception health care to low income women in family planning settings: perception of providers and clients.

This study examines both provider and client perceptions of the extent to which general health concerns are addressed in the context of publicly supported family planning care. A mail survey of family planning providers (n = 459) accepting Medicaid-covered clients in Arkansas and Alabama gathered data on reported actions and resource referral availability for ten categories of non-contraceptive health concerns. A telephone survey of recent family planning clients of these providers (n = 1991) gathered data on the presence of 16 health concerns and whether and how they were addressed by the family planning provider. Data were collected in 2006-2007. More than half (56%) of clients reported having one or more general health concerns. While 43% of those concerns had been discussed with the family planning providers, only 8% had been originally identified by these providers. Women with higher trust in physicians and usual sources of general health care were more likely to discuss their concerns. Of those concerns discussed, 39% were reportedly treated by the family planning provider. Similarly, over half of responding providers reported providing treatment for acute and chronic health conditions and counseling on health behaviors during family planning visits. Lack of familiarity with referral resources for uninsured clients was identified as a significant concern in the provision of care to these clients. Greater engagement by providers in identifying client health concerns and better integration of publicly supported family planning with other sources of health care for low income women could expand the existing potential for delivering preconception or general health care in these settings.

Referral and referral facilitation behavior of family planning providers for women with HIV infection in the southern United States.

BACKGROUND: Many women receive family planning (FP) services from federally supported FP providers. These FP services include testing for sexually transmitted infections (STD), including the human immunodeficiency virus (HIV). FP providers are expected to refer patients with non-FP conditions, including HIV, to other providers for treatment. Prompt HIV treatment improves outcomes and survival, yet many women face barriers to accessing treatment. Facilitation of referrals improves referral follow-up. However, little is known about the referral practices and facilitation activities of FP providers for their clients testing positive for HIV. METHODS: To fill this gap, this article reports the findings of a study that used a mail survey of FP providers (n = 456) to document referral practices and facilitation activities when providers see HIV-positive patients. RESULTS: The study found that nearly all FP providers report referring HIV-infected clients to another provider rather than providing treatment themselves. Factors associated with significantly more facilitation of referrals included perception of less competent patients, perception of more referral resources, personal relationships with referral providers, rural locality, and information support staff. CONCLUSIONS: Some factors associated with low facilitation (such as perception of few referral resources and no personal relationships with referral providers) are amenable to change. Interventions targeting these factors should be designed and tested to increase facilitation of referrals and the follow-up with referrals for HIV treatment.

Family planning provider referral, facilitation behavior, and patient follow-up for abnormal Pap smears.

OBJECTIVES: Family planning (FP) clinics are important access points for cervical cancer screening and referrals for follow-up care for abnormal Papanicolaou (Pap) smears for a substantial number of U.S. women. Because little is known about referral and facilitation practices in these clinics or client action based on referrals, we sought to determine FP provider referral and facilitation practices when seeing FP clients with abnormal Pap smear results, and FP client follow-up for abnormal Pap smears due to FP provider referrals. METHODS: We conducted a mail survey of Medicaid-enrolled FP providers in Arkansas and Alabama, and conducted a telephone survey with a sample of FP clients of those providers responding to the provider survey. RESULTS: Major provider factors associated with referral included rural location, health department and clinic institutional setting, large Title X practice/clinic size, and high FP clinic focus. Major factors associated with facilitation included rural location, non-physician specialty, health department and clinic institutional setting, and small Title X clinic size. Of women reporting abnormal results, 62.4% reported follow-up care. Of those who received follow-up care, 40.0% received some care and a referral from their FP provider. A major factor associated with clients seeking follow-up care was being told by their FP provider where to go for follow-up care. Age was a major factor associated with clients actually obtaining follow-up care. CONCLUSIONS: Where follow-up care is not available at the FP site, referrals are critical and are a major factor associated with whether women seek care for the condition. Interventions to increase follow-up rates should focus on provider and system features, rather than clients.

Improvement in gastrointestinal symptoms and quality of life after cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure. This study assesses the effectiveness of LC on reduction in gastrointestinal (GI) symptoms and the impact on quality of life (QOL). METHODS: A prospective cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys (GISS) and SF36 QOL surveys. The GISS was developed to quantify the magnitude, severity, and distressfulness of 16 GI symptoms. Surveys were scored and evaluated using paired t tests. RESULTS: Fifty-five subjects were included in the final analysis. The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC (P > .05). Significant improvement was seen in QOL (P < .01). CONCLUSION: This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients' general QOL.

Randomized pilot of a self-guided internet coping group for women with early-stage breast cancer.

BACKGROUND: Internet-based methods for provision of psychological support and intervention to cancer survivors hold promise for increasing the public impact of such treatments. PURPOSE: The goal of this controlled pilot study was to examine the effect and potential mechanisms of action of a self-guided, Internet-based coping-skills training group on quality of life outcomes in women with early-stage breast cancer. METHODS: Sixty-two women completed baseline evaluations and were randomized into either a small online coping group or a waiting-list control condition. RESULTS: No main effects for treatment were observed at the 12-week follow up. However, there was a significant interaction between baseline self-reported health status and treatment, such that women with poorer self-perceived health status showed greater improvement in perceived health over time when assigned to the treatment condition. Linguistic analyses revealed that positive changes across quality of life variables were associated with greater expression of negative emotions such as sadness and anxiety, greater cognitive processing, and lower expression of health-related concerns. CONCLUSIONS: These results demonstrate the potential efficacy of self-guided Internet coping groups while highlighting the limitations of such groups.

The necessity of routine clinic follow-up visits after third molar removal.

PURPOSE: This randomized clinical trial was conducted to evaluate the clinical necessity of routine follow-up visits after third molar removal under local anesthesia and intravenous sedation in patients aged 15 to 35 years. PATIENTS AND METHODS: Sixty consecutive cases that required surgical removal of impacted third molars in an outpatient basis were performed by board-certified oral and maxillofacial surgeons. Sixty patients were divided randomly into 2 groups: one group received a 2-week postoperative follow-up appointment and the other received no follow-up. All patients received postoperative instructions and were contacted by telephone on the day after surgery. At 2 weeks postoperatively, all patients either returned to the clinic or were interviewed by telephone. RESULTS: Forty-eight patients were included in this study. The mean age was 20.35 years (range, 15 to 33 years). There were no statistical differences in the number of patients and gender between groups of patients who received clinic or telephone follow-up (significance <.05). Seventy-three percent (35 of 48) of total patients preferred telephone follow-up, and 27% (13 of 48) of patients preferred clinic follow-up. Eighty-five percent (29 of 34) of patients who did not have any complaints on postoperative day 1 preferred telephone follow-up (significance <.01). CONCLUSIONS: A routine follow-up visit following third molar removal under intravenous sedation is not necessary in patients between 15 and 35 years of age. However, preoperative and postoperative instruction should be clearly specified. A selective review policy may be appropriate if a patient is mentally retarded, is taking psychoactive drugs, or has an intraoperative complications or a complaint registered via telephone call.

Cluster Analysis and Chronic Pain: An Empirical Classification of Pain Subgroups in a Spinal Cord Injury Sample.

OBJECTIVE: To demonstrate the presence of homogeneous spinal cord injury (SCI) pain subgroups. DESIGN: Prospective longitudinal design. PARTICIPANTS: Persons with traumatic onset SCI (n = 1,334) with self-reported pain, pain interference, and depression. OUTCOME MEASURES: Pain (Verbal Analogue Scale); Pain Interference (item from Short Form 12); Depression (Brief Patient Health Questionnaire). RESULTS: Multivariate clustering indicated four SCI pain subgroups: (1) Low Pain (low pain intensity, pain interference, and depression); (2) Positive Adaptation to Pain (high pain intensity, low pain interference and depression); (3) Minimal Distress (high pain intensity, high pain interference, and low depression); and (4) Chronic Pain Syndrome (high pain intensity, pain interference, and depression). CONCLUSIONS: Homogeneous SCI pain subgroups may be important for clinicians to consider in treatment planning and research.

Re-examination of the cost-effectiveness of surgical versus medical therapy in patients with gastroesophageal reflux disease: the value of long-term data collection.

OBJECTIVES: For patients with reflux esophagitis, long-term therapeutic options include proton pump inhibitor (PPI) therapy and/or antireflux surgery. An earlier cost-effectiveness analysis concluded that at 5 yr, medical therapy was less expensive but similarly effective to fundoplication, but the results were sensitive to estimates on quality of life and long-term medication usage, which were derived from "expert opinion." Recently, data from randomized controlled trials addressing these variables have become available. We have incorporated these new data into a revised Markov model to examine the cost-effectiveness of surgical versus medical therapy in patients with severe reflux esophagitis. METHODS: A Markov simulation model was constructed using specialized software (DATA PRO 4.0, Williamstown, MA). Total expected costs and quality-adjusted life-years were calculated for long-term medical therapy and for laparoscopic Nissen fundoplication. Probabilities were obtained from the medical literature using Medline. Procedural and hospitalization costs used were the average Medicare reimbursements at our institution. Medication costs were the average wholesale price. The analysis was extended over a 10-yr time horizon at a discount rate of 3%. RESULTS: The discounted analysis shows that medical therapy is associated with total costs of 8,798 dollars and 4.59 quality-adjusted life-years, whereas the surgical strategy is more expensive (10,475 dollars) and less effective (4.55 quality-adjusted life-years). The results were robust to most one-way sensitivity analyses. CONCLUSIONS: Long-term medical therapy with proton pump inhibitors is the preferred strategy for patients with gastroesophageal reflux disease and severe esophagitis. Our study highlights the importance of using primary, patient-derived data rather than expert opinion.

Improving the effectiveness of adjuvant psychological treatment for women with breast cancer: the feasibility of providing online support.

Many well-designed studies have shown psychosocial treatments for cancer to be efficacious for improving patients' quality of life, but the actual impact of these treatments may be limited by low rates of participation. Web-based treatment formats could improve effectiveness by increasing availability and accessibility. Two phases of a feasibility study are reported in this article. In the first phase, we sought to assess internet access and perceived interest in online support among 136 women with breast cancer (June-October, 1999). Levels of interest in participating in an online psychosocial treatment were associated with age, outcome expectancy, and barriers to using the internet but not stage or time since diagnosis. In the second phase, we document accrual rates among several methods of recruitment during a randomized trial (February-December, 2001) and report changes over time in internet access. Recruitment rates were substantially higher when a study representative was available in clinic to provide information about the treatment than for all other methods of recruitment. Access to the internet increased between 1999 (63%) and 2001 (70%) and varied across age groups. These results suggest that internet-based psychosocial treatments, with notable limitations, are feasible for increasing the impact of psychosocial care.

Personal characteristics, health status, physical activity, and quality of life in cardiac rehabilitation participants.

The purpose of this study was to examine the relationships between personal factors, health status, and adherence to physical activity behavior, and quality of life in cardiac rehabilitation participants. The record of 146 subjects, who met inclusion criteria were obtained from the University Cardiac Rehabilitation Database. Change scores in physical activity were used as a proxy for adherence. Participants who were categorized as not working, female gender, and at high-risk health status had lower means and lower improvement scores from repeated measures analysis of variance. This study found that some personal factors and health status are significant factors influencing the participant's adherence to physical activity recommendations and quality of life in this cardiac rehabilitation program.

Use of the internet for information and support: disclosure among persons with breast and prostate cancer.

The present study examined the feasibility of evaluating online communication of cancer patients using an automated content analysis program modified for application to cancer-related communication. Public messages posted to the Breast Cancer Discussion List and the Prostate Problems Mailing List were content analyzed uasing an augmented version of Linguistic Inquiry and Word Count to evaluate communication styles within these two cancer types. Breast cancer patients were more likely to submit multiple messages to the list and made greater use of words related to emotional disclosure and cognitive processing compared with prostate cancer patients. Prostate cancer patients were less likely to seek emotional support or repeated interaction with other patients, and more of their communication focused on cancer-related information. Use of cancer-specific word libraries significantly increased word identification within these samples. Content analysis of online communication appears to be a promising method for detecting communication differences among subgroups of cancer patients.

Incomplete response to endoscopic sphincterotomy in patients with sphincter of Oddi dysfunction: evidence for a chronic pain disorder.

OBJECTIVES: The efficacy of endoscopic treatment of sphincter of Oddi dysfunction (SOD) with endoscopic sphincterotomy (ES) remains controversial. Although some studies have shown a positive impact on patient symptoms after treatment, these reports have been largely qualitative and evaluated on short-term response. The aim of our study was to quantitatively measure the long-term outcomes of endoscopic therapy in patients with SOD. METHODS: Thirty-three patients with suspected SOD underwent selective sphincter of Oddi manometry (SOM) of the biliary and/or pancreatic sphincter. Each patient completed a telephone-based survey measuring symptomatic pain before and after SOM +/- ES. The questioner was blinded to the results of SOM. The patients with normal SOM or SOD but who did not undergo ES served as controls. RESULTS: Of these 33 patients (27 women, mean age 48.7 yr, range 13-74), 19 (57.5%) were found to have SOD (12 biliary, six pancreatic, one both). The average follow-up was 18.1 months (range 7-34). Of the patients with SOD, 17 (89%) underwent ES. At follow-up of the 19 patients undergoing ES, five were taking narcotics for persistent pain, two were taking antidepressants, and 15 identified the endoscopic therapy as the reason for their relief. Of the 14 controls, seven were taking narcotics, seven were taking antidepressants, and two identified the endoscopy as the reason for their relief; some patients were taking both antidepressants and narcotics. CONCLUSIONS: Patients found to have SOD who undergo ES are more likely to be improved on long-term follow-up when compared with patients with suspected SOD but normal manometry without ES. However, almost uniformly, despite ES, patients continue to have pain, which is consistent with most chronic pain disorders and which suggests a multifactorial cause for the pain.

Differing symptoms of abused versus nonabused women in obstetric-gynecology settings.

OBJECTIVE: The purpose of this study was to document the prevalence rates of reported abuse in obstetric/gynecology settings and to characterize physical symptoms, function, and psychologic distress of women who report abuse. STUDY DESIGN: This was a descriptive study of 118 patients who reported physical or sexual abuse in the past year and 2800 patients who reported no abuse at seven obstetric/gynecology practices. The Patient Health Questionnaire measured psychiatric diagnoses, somatic complaints, and psychosocial stressors. The Medical Outcomes Study Short Form 20 assessed health status, and self-reported health care use was measured. RESULTS: Four percent of women reported recent abuse. Patients who reported abuse had more psychiatric diagnoses, more severe psychologic distress, more somatic symptoms, more psychosocial stressors, more physician visits, and poorer reported health status compared with nonreporters of abuse. CONCLUSION: Enhanced recognition of possible abuse through screening may identify women in need of intervention and help to reduce the need for continued medical intervention.

Psychological disorders and distress in older primary care patients: a comparison of older and younger samples.

BACKGROUND: Community studies have documented prevalence rates of psychological disorders among older individuals. Further, a growing number of studies have examined depression in older medical patients. However, little is known about the prevalence of a broad range of psychological disorders and psychosocial stressors among older primary care patients. The purpose of the present study was to characterize psychological disorders and psychosocial stressors in older primary care patients and identify differences with younger patients. METHODS: Descriptive survey; criterion standard. Five hundred thirty-four patients 65 years and older and 2466 patients less than 65 years old recruited from eight primary care sites. The Patient Health Questionnaire (PHQ) was employed to assess major depressive disorder, other depressive disorder, panic disorder, other anxiety disorder, probable alcohol abuse/dependence, somatoform disorder, bulimia nervosa, and binge eating disorder. Common psychosocial stressors were also assessed. Patient-reported health status was measured by the Medical Outcomes Study Short Form 20 (SF-20). RESULTS: Older patients were much less likely than younger patients to have a psychological disorder (5% vs. 17%). Also, older patients had significantly less severe psychological symptom (4.7 vs. 8.0) and psychosocial stressor (2.3 vs. 4.7) scores. Worrying about health (10%), weight (9%), and a recent bad event (8%) were the most common stressors among the older group. Like younger patients, older patients who suffered from psychological symptoms and disorders experienced substantial functional impairment. CONCLUSIONS: Prevalence rates of psychological disorders and psychosocial stressors differ greatly between younger and older primary care patients and, somewhat contrary to clinical intuition, are lower among older patients.

Characterization of long-term outcomes after Toupet fundoplication: symptoms, medication use, and health status.

GOALS AND BACKGROUND: Fundoplication is increasingly used for the treatment of gastroesophageal reflux disease (GERD). Few studies have tracked patient outcomes of the Toupet method for more than 1 year. Further clinical, physiologic, and patient-based outcome measures have not been well characterized for this method. The current study conducts a long-term, comprehensive outcome evaluation in patients receiving Toupet fundoplication. STUDY: Fifty-five patients who had previously undergone fundoplication were examined. In a subset of 24 patients, esophagogastroduodenoscopy was used to assess the severity of reflux esophagitis. Manometry and ambulatory pH monitoring also were performed. RESULTS: Patients were studied 2.9 (+/- 0.7) years after surgery. Sixty-seven percent of the sample reported heartburn, 51% reported postoperative bloating, 33% reported regurgitation, and 20% reported dysphagia. Thirty-three percent reported the use of prescription medications for GERD-related symptoms. Health status was diminished relative to population norms. Degree of GERD severity was associated with symptom reports and medication use. CONCLUSIONS: Although fundoplication is thought to be a curative procedure, the current findings suggest that many patients take symptomatic therapies and report symptoms and diminished health status up to 2 years after the procedure. These outcomes are associated with physiologic findings. Thus, these findings suggest that symptom-free status and absence of medication use cannot be assumed for all patients after Toupet fundoplication.

One-year follow-up of first onset low back pain.

Efforts to examine the process and risk of developing chronic back pain have relied generally upon retrospective study of individuals with already established pain. In an alternative approach to understanding the clinical course and evolution of low back disorders, a cohort of 76 men experiencing their first episode of back pain was assessed prospectively at 2, 6 and 12 months following pain onset. Standard measures of pain (Descriptor Differential Scale: DDS), disability (Sickness Impact Profile: SIP), and distress (Beck Depression Inventory: BDI) were employed to classify the sample into five groups: Resolved, Pain Only, Disability/Distress Only, Pain and Mild Disability/Distress, and Clinical Range. At both 6 and 12 months post pain onset, most (78%, 72% respectively) of the sample continued to experience pain. Many also experienced marked disability at 6 months (26%) and 12 months (14%). At 12 months, no participants had worsened relative to the 2-month baseline. Doubly multivariate analyses of variance (MANOVAs) were employed to compare baseline groups (Pain Only, Pain and Mild Disability/Distress, Clinical Range) on the DDS, SIP, and BDI across time. The group by time interaction from 2 through 12 months was reliable, with greatest change occurring in the Clinical Range group in disability and distress; interestingly, the decrease in pain was comparable among all groups. Follow-up tests across measures demonstrated greater change in the early (2-6-month) interval and relative stability in the later (6-12-month) interval. Comparison of those classified as 'improvers' with those who did not improve from 2 to 12 months showed similar findings. The clinical course of first onset back pain may be prolonged for many patients, and involves a continuum of related disability and distress. Individuals at risk for marked symptoms 1 year after an initial episode of back pain can be identified early, and prompt treatment might reduce the risk of pain chronicity.

Psychosocial factors discriminate multidimensional clinical groups of chronic low back pain patients.

Previous studies have empirically defined clinical subgroups of chronic low back pain (CLBP) patients, based on differing patterns of pain, disability and emotional distress. Because these identified groups generally are comparable in terms of physical and demographic variables, variation in functional status cannot be adequately explained by medical or social factors. In the present study we evaluated whether other psychosocial factors (stress, coping attempts, and satisfaction with social supports) might differentiate the observed groups. A discriminate function analysis indicated that ratings of life adversity, coping, and social support statistically differentiate clinical groups of CLBP patients. Patients categorized as chronic pain syndrome (i.e., high levels of pain, disability and depression) reported greater life adversity, more reliance on passive/avoidant coping strategies, and less satisfaction with social support networks. Patients categorized as having good pain control (i.e., low levels of pain, disability and depression) reported less life adversity, less reliance on passive/avoidant coping strategies, and more satisfaction with social support networks. Finally, a mixed picture of less life adversity, but more reliance on passive/avoidant coping strategies and more satisfactory social support networks was reported by patients categorized in the positive adaptation to pain group (i.e., high levels of pain, but relatively low levels of disability and depression). These findings suggest that psychosocial factors may be important and complex correlates of multidimensional clinical presentations of CLBP. Psychosocial factors may also offer an avenue for intervention across 3 key dimensions of CLBP.