Outcomes associated with scale-up of the Stepping On falls prevention program: A case study in redesigning for dissemination.

INTRODUCTION: Translating complex behavior change interventions into practice can be accompanied by a loss of fidelity and effectiveness. We present the evaluation of two sequential phases of implementation of a complex evidence-based community workshop to reduce falls, using the Replicating Effective Programs Framework. Between the two phases, workshop training and delivery were revised to improve fidelity with key elements. METHODS: Stepping On program participants completed a questionnaire at baseline (phase 1: n = 361; phase 2: n = 2219) and 6 months post-workshop (phase 1: n = 232; phase 2: n = 1281). Phase 2 participants had an additional follow-up at 12 months (n = 883). Outcomes were the number of falls in the prior 6 months and the Falls Behavioral Scale (FaB) score. RESULTS: Workshop participation in phase 1 was associated with a 6% reduction in falls (RR = 0.94, 95% CI 0.74-1.20) and a 0.14 improvement in FaB score (95% CI, 0.11- 0.18) at 6 months. Workshop participation in phase 2 was associated with a 38% reduction in falls (RR = 0.62, 95% CI 0.57-0.68) and a 0.16 improvement in FaB score (95% CI 0.14-0.18) at 6 months, and a 28% reduction in falls (RR = 0.72, 95% CI 0.65-0.80) and a 0.19 score improvement in FaB score (95% CI 0.17-0.21) at 12-month follow-up. CONCLUSIONS: Effectiveness can be maintained with widespread dissemination of a complex behavior change intervention if attention is paid to fidelity of key elements. An essential role for implementation science is to ensure effectiveness as programs transition from research to practice.

Residential proximity to concentrated animal feeding operations and allergic and respiratory disease.

BACKGROUND: Air emissions from concentrated animal feeding operations (CAFO) have been associated with respiratory and allergic symptoms among farm workers, primarily on swine farms. Despite the increasing prevalence of CAFOs, few studies have assessed respiratory health implications among residents living near CAFOs and few have looked at the health impacts of dairy CAFOs. OBJECTIVES: The goal of this study was to examine objective and subjective measures of respiratory and allergic health among rural residents living near dairy CAFOs in a general population living in the Upper Midwest of the United States. METHODS: Data were from the 2008-2016 Survey of the Health of Wisconsin (SHOW) cohort (n = 5338), a representative, population based sample of rural adults (age 18+). The association between distance to the nearest CAFO and the prevalence of self-reported physician-diagnosed allergies, asthma, episodes of asthma in the last 12 months, and asthma medication use was examined using logistic regression, adjusting for covariates and sampling design. Similarly, the association between distance to the nearest CAFO and lung function, measured using spirometry, was examined using multivariate linear regression. Restricted cubic splines accounted for nonlinear relationships between distance to the nearest CAFO and the aforementioned outcomes. RESULTS: Living 1.5 miles from a CAFO was associated with increased odds of self-reported nasal allergies (OR = 2.08; 95% CI: 1.38, 3.14), lung allergies (OR = 2.72; 95% CI: 1.59, 4.66), asthma (OR = 2.67; 95% CI: 1.39, 5.13), asthma medication (OR = 3.31; 95% CI: 1.65 6.62), and uncontrolled asthma, reported as an asthma episode in last 12 months (OR = 2.34; 95% CI: 1.11, 4.92) when compared to living 5 miles from a CAFO. Predicted FEV1 was 7.72% (95% CI: -14.63, -0.81) lower at a residential distance 1.5 miles from a CAFO when compared with a residence distance of 3 miles from a CAFO. CONCLUSIONS: Results suggest CAFOs may be an important source of adverse air quality associated with reduced respiratory and allergic health among rural residents living in close proximity to a CAFO.

Ranking composite Cancer Burden Indices for geographic regions: point and interval estimates.

PURPOSE: To develop a composite Cancer Burden Index and produce 95% confidence intervals (CIs) as measures of uncertainties for the index. METHODS: The Kentucky Cancer Registry has developed a cancer burden Rank Sum Index (RSI) to guide statewide comprehensive cancer control activities. However, lack of interval estimates for RSI limits its applications. RSI also weights individual measures with little inherent variability equally as ones with large variability. To address these issues, a Modified Sum Index (MSI) was developed to take into account of magnitudes of observed values. A simulation approach was used to generate individual and simultaneous 95% CIs for the rank MSI. An uncertainty measure was also calculated. RESULTS: At the Area Development Districts (ADDs) level, the ranks of the RSI and the MSI were almost identical, while larger variation was found at the county level. The widths of the CIs at the ADD level were considerably shorter than those at the county level. CONCLUSION: The measures developed for estimating composite cancer burden indices and the simulated CIs provide valuable information to guide cancer prevention and control effort. Caution should be taken when interpreting ranks from small population geographic units where the CIs for the ranks overlap considerably.

Case study: application of isometric progressive resistance oropharyngeal therapy using the Madison Oral Strengthening Therapeutic device.

PURPOSE: Isometric progressive resistance oropharyngeal (I-PRO) therapy improves swallowing function; however, current devices utilize a single sensor that provides limited information or are prohibitively expensive. This single-subject study presents results of I-PRO therapy, detraining, and maintenance using the 5-sensor Madison Oral Strengthening Therapeutic (MOST) device combined with upper esophageal sphincter (UES) dilatation. METHODS: A 56-year-old female nurse who was 27 months post stroke and subsequent to traditional behavioral interventions and UES dilatations presented limited to gastrostomy tube intake only and expectorating all saliva. She completed 8 weeks of I-PRO therapy, 5 weeks of detraining, and 9 weeks of I-PRO maintenance (reduced frequency) followed by a third UES dilatation post intervention. Data included diet inventory, lingual pressures (MOST), lingual volume (magnetic resonance imaging), postswallow residue (videofluoroscopy), UES and pharyngeal pressures (high-resolution manometry), and quality of life (QOL). RESULTS: Findings after 8 weeks of I-PRO therapy were progression to general oral diet, 15 lb weight gain, increased isometric pressures (Δ â‰¯16 kPa) with transference to swallowing pressures, increased lingual volume (8.3%), reduced pharyngeal wall residue (P = .03), increased pharyngeal pressures (Δ â‰¯ 43 mm Hg) and increased UES opening (nadir) pressures (Δ â‰¯ 9 mm Hg) with improved temporopressure coordination across the pharynx, and improved QOL. After detraining, decreased isometric pressures and reduced UES opening were noted. After I-PRO maintenance, isometric anterior lingual pressures returned to levels noted after the 8 weeks of intervention. CONCLUSION: I-PRO therapy, facilitated by the MOST device combined with instrumental UES dilatation, improved swallow safety, increased oropharyngeal intake, and facilitated UES opening while enriching QOL.

Cross-sectional study of vitamin D levels, immunologic and virologic outcomes in HIV-infected adults.

CONTEXT: Vitamin D is increasingly recognized as an important immunomodulator. Lower levels of 25-hydroxyvitamin D (25[OH]D) and 1,25-dihydroxyvitamin D (1,25[OH]2D) are observed in persons living with HIV. OBJECTIVE: The purpose of this study was to evaluate the relationship of 25(OH)D, and 1,25(OH)2D to HIV viral load, and CD4+ T cells in HIV-infected adults. DESIGN: This was a cross-sectional study completed between January 2010 and April 2011. SETTING: This study was conducted with volunteers who received HIV care in Wisconsin at either a University-based HIV clinic or an urban community HIV clinic. PATIENTS: One hundred twelve adults with HIV infection participated in this study. MAIN OUTCOME MEASURES: The primary outcome for this study was the relationship between 1,25(OH)2D and HIV viral load. Secondary outcomes included relationships between 25(OH)D and HIV viral load, 25(OH)D and 1,25(OH)2D to CD4+ T cells, and predictors of vitamin D deficiency. RESULTS: The 112 volunteers included 24 women and 3 transgender individuals; 68% were from the university clinic, and 32% were from the urban clinic. Mean age was 44.2 years. The mean 25(OH)D level was 22.5 ng/mL; mean 1,25(OH)2D level was 23.5 pg/mL. Twenty-two percent had 25(OH)D ≤10 ng/mL; 53% had values <20 ng/mL, and 73% were ≤30 ng/mL. There was no association between vitamin D and CD4. A nonlinear relationship between viral load and 1,25(OH)2D was found. For 1,25(OH)2D below 32 pg/mL, for each 10 pg/mL decrease in 1,25(OH)2D, (log10) viral load increased by 0.84 (95% CI: 0.16-1.51, P = .015). For 1,25(OH)2D above 32 pg/mL, for each 10 pg/mL increase in 1,25(OH)2D, (log10) viral load increased by 0.36 (95% CI: 0.15-0.57, P = .0009). CONCLUSION: Vitamin D deficiency was common in this HIV population, as seen in other HIV cohorts. A novel, U-shaped relationship between 1,25(OH)2D and viral load, with the lowest and highest 1,25(OH)2D levels seen with high viral loads, was found and deserves further study.

Use of the lowest vertebral body T-score to diagnose lumbar osteoporosis in men: is "cherry picking" appropriate?

In this study, we hypothesized that use of the lowest T-score among four lumbar vertebral bodies would lessen the impact of degenerative arthritis and other artifacts on diagnostic categorization at this site and increase study sensitivity, classifying more men with prior fracture as osteoporotic than the other two methods of lumbar spine analysis. Bone density studies of 533 male veterans measured between January and October 2002 were reviewed to determine diagnostic classification using the L1-L4 average, International Society for Clinical Densitometry (ISCD)-determined, and lowest lumbar vertebral body T-score. We calculated sensitivity and specificity of the three methods of spine analysis, using spine osteoporosis to indicate a positive test and prior fracture as the true indicator of osteoporosis. The lowest lumbar T-score performed with similar sensitivity and specificity to that of the lowest hip or wrist T-score in the ability to classify men with prior fracture as osteoporotic, whereas the average L1-L4 and ISCD-determined T-scores performed with lower sensitivity, but better specificity. In conclusion, this retrospective study suggests that use of the lowest vertebral body T-score among men increases diagnostic sensitivity of lumbar spine bone mass measurement. Prospective studies are needed to determine which of these three methods of lumbar spine analysis best predicts future fragility fracture in men and women.