Temporal optimization of exercise to lower fasting glucose levels.

Exercise stimulates glucose uptake and increases insulin sensitivity acutely. Temporally optimizing exercise timing may minimize the nocturnal rise in glucose levels. This study examined the effect of exercise timing on evening and overnight glucose concentrations in individuals who were non-obese with normal fasting glucose levels (Non-Ob; n = 18) and individuals with obesity (OB) with impaired fasting glucose levels (OB+IFG) and without (n = 16 and n = 18, respectively). Subjects were studied on three occasions (no exercise (NOEX)), morning exercise (AMEX; 0700 h) and evening exercise (PMEX; 2000 h). The evening meal was provided (1800 h) and blood samples were taken from 1740 to 0700 h and morning endogenous glucose production (EGP) was measured. Glucose and insulin concentrations increased with the dinner meal with peak concentrations being higher in OB+IFG than in OB and Non-Ob (P = 0.04). In OB+IFG, evening glucose concentrations rose above baseline levels at about 2300 h, with the glucose concentrations staying somewhat lower with AMEX and PMEX until ∼0500 h than with NOEX. In OB+IFG, insulin concentrations decreased following the dinner meal and waned throughout the night, despite the rising glucose concentrations. In the OB and Non-Ob individuals following the dinner meal, no increase in glucose concentrations occurred in the evening period and insulin levels mirrored this. No difference was observed in the morning fasting glucose levels between study days or between groups. Regardless of time of day, exercise delays the evening rise in glucose concentrations in adults with OB+IFG but does not lower morning fasting glucose levels or improve the synchrony between glucose and insulin concentrations. KEY POINTS: Insulin resistance and type 2 diabetes have been linked to disturbances of the core clock, and glucose tolerance demonstrates a diurnal rhythm in healthy humans with better glucose tolerance in the morning than in the afternoon and evening. Skeletal muscle is a primary site for insulin resistance in people with impaired glucose tolerance. In individuals with obesity and impaired fasting glucose levels (OB+IFG), following a dinner meal, glucose concentrations started to rise and continues throughout the night, resulting in elevated glucose levels, while concomitantly, insulin levels are waning. Exercise, regardless of the time of day, suppressed the rise in glucose levels in OB+IFG for many hours during the night but did not lower morning fasting glucose levels. Morning exercise was not quite as effective as evening exercise.

Longitudinal Impact of APRNs on Nursing Home Quality Measures in the Missouri Quality Initiative.

OBJECTIVES: To measure the impact of advanced practice nurses (APRNs) on quality measures (QM) scores of nursing homes (NHs) in the CMS funded Missouri Quality Initiative (MOQI) that was designed to reduce avoidable hospitalizations of NH residents, improve quality of care, and reduce overall healthcare spending. DESIGN: A four group comparative analysis of longitudinal data from September 2013 thru December 2019. SETTING: NHs in the interventions of both Phases 1 (2012-2016) and 2 (2016-2020) of MOQI (n=16) in the St. Louis area; matched comparations in the same counties as MOQI NHs (n=27); selected Phase 2 payment intervention NHs in Missouri (n=24); NHs in the remainder of the state (n=406). PARTICIPANTS: NHs in Missouri Intervention: Phase 1 of The Missouri Quality Initiative (MOQI), a Centers for Medicare and Medicaid (CMS) Innovations Center funded research initiative, was a multifaceted intervention in NHs in the Midwest, which embedded full-time APRNs in participating NHs to reduce hospitalizations and improve care of NH residents. Phase 2 extended the MOQI intervention in the original intervention NHs and added a CMS designed Payment Intervention; Phase 2 added a second group of NHs to receive the Payment. Intervention Only. MEASUREMENTS: Eight QMs selected by CMS for the Initiative were falls, pressure ulcers, urinary tract infections, indwelling catheters, restraint use, activities of daily living, weight loss, and antipsychotic medication use. For each of the monthly QMs (2013 thru 2019) an unobserved components model (UCM) was fitted for comparison of groups. RESULTS: The analysis of QMs reveals that that the MOQI Intervention + Payment group (group with the embedded APRNs) out-performed all comparison groups: matched comparison with neither intervention, Payment Intervention only, and remainder of the state. CONCLUSION: These results confirm the QM analyses of Phase 1, that MOQI NHs with full-time APRNs are effective to improve quality of care.

Results of the Missouri Quality Initiative in Sustaining Changes in Nursing Home Care: Six-Year Trends of Reducing Hospitalizations of Nursing Home Residents.

OBJECTIVES: The purpose of this article is to present six-year findings of the Missouri Quality Initiative (MOQI) to reduce unnecessary hospitalizations for long-stay nursing home residents. DESIGN: A CMS funded demonstration project analyzed over 6-years using a single group design. SETTING AND PARTICIPANTS: The setting was 16 Midwestern US nursing homes ranging in size between 121 and 321 beds located in urban and rural areas in one geographic region. The sample of eligible residents averaged from 1819 in 2014 to 1068 in 2019. MEASURES: Resident data were analyzed using descriptive methods of aggregate facilities' hospital transfer rates per 1000 resident days and changes per year of average hospital transfer rates. Individual facility transfer rates were grouped by level of performance (best, mixed, and low). Leadership turnover and engagement were also described. INTERVENTION: Full-time advanced practice registered nurses (APRN) and an operations support team focused on reducing unnecessary hospitalizations for long-stay nursing home residents. RESULTS: Total transfers for 2014-2019 was 6913 and the average transfer rate per 1000 resident days declined from 2.48 in 2014 to a low of 1.89 in 2018 and slightly increased to 1.99 in 2019. Eleven nursing homes achieved sustained improvement, five did not. Differences in leadership turnover and engagement were noted by level of performance; however, three outlier facilities were identified. CONCLUSIONS/IMPLICATIONS: The MOQI intervention achieved improved outcomes over six-years in the majority of nursing homes in the project. The embedded APRN's daily focus on project goals supported by a multi-disciplinary operations team facilitated success. Facility leadership stability and engagement in the project likely contributed to outcomes. Full-time presence of APRNs coupled with an operations' support team improved nursing homes outcomes, however Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services. This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished.

Reliability of health-related quality-of-life indicators in cancer survivors from a population-based sample, 2005, BRFSS.

OBJECTIVE: The current emphasis in cancer survivorship research, which includes health-related quality of life (HRQoL), drives the need to monitor the nation's cancer burden. Routine, ongoing public health surveillance tools, such as the Behavioral Risk Factor Surveillance System (BRFSS), may be relevant for this purpose. STUDY DESIGN: A subsample of the 2005 Missouri BRFSS was used to estimate test-retest reliability of HRQoL questions among persons who did and did not report a personal cancer history. METHODS: Retest interviews were conducted by telephone 14-21 days after the initial data collection (n=540, 67% response rate). Reliability was estimated overall and by cancer history using intraclass correlation coefficients (ICCs) and kappa statistics. RESULTS: The majority of retest respondents were White, female and married, with 13% reporting a history of cancer. Overall, point estimates of the reliability coefficients ranged from moderate to excellent (kappa=0.57-0.75). There were no statistically significant differences in test-retest reliability between persons with and without a history of cancer, except for self-reported pain (ICC=0.59 and ICC=0.78, respectively). CONCLUSIONS: In general, BRFSS questions appear to have adequate reliability for monitoring HRQoL in this community-dwelling population, regardless of cancer history.

Randomized clinical trial of a quality improvement intervention in nursing homes.

PURPOSE: The purpose of the study was to determine if simply providing nursing facilities with comparative quality performance information and education about quality improvement would improve clinical practices and subsequently improve resident outcomes, or if a stronger intervention, expert clinical consultation with nursing facility staff, is needed. DESIGN AND METHODS: Nursing facilities (n = 113) were randomly assigned to one of three groups: workshop and feedback reports only, workshop and feedback reports with clinical consultation, and control. Minimum Data Set (MDS) Quality Indicator (QI) feedback reports were prepared and sent quarterly to each facility in intervention groups for a year. Clinical consultation by a gerontological clinical nurse specialist (GCNS) was offered to those in the second group. RESULTS: With the exception of MDS QI 27 (little or no activity), no significant differences in resident assessment measures were detected between the groups of facilities. However, outcomes of residents in nursing homes that actually took advantage of the clinical consultation of the GCNS demonstrated trends in improvements in QIs measuring falls, behavioral symptoms, little or no activity, and pressure ulcers (overall and for low-risk residents). IMPLICATIONS: Simply providing comparative performance feedback is not enough to improve resident outcomes. It appears that only those nursing homes that sought the additional intensive support of the GCNS were able to effect enough change in clinical practice to improve resident outcomes significantly.

Comparing stimulation-induced pain during percutaneous (intramuscular) and transcutaneous neuromuscular electric stimulation for treating shoulder subluxation in hemiplegia.

OBJECTIVE: To determine whether percutaneous (intramuscular) neuromuscular electric stimulation (perc-NMES) is less painful than transcutaneous neuromuscular electric stimulation (trans-NMES) for treating shoulder subluxation in hemiplegia. DESIGN: Double-blind, crossover trial. SETTING: University-affiliated tertiary care hospital. PARTICIPANTS: A convenience sample of 10 hemiplegic subjects with at least 1 fingerbreadth of glenohumeral subluxation. INTERVENTIONS: All subjects received 3 randomly ordered pairs of perc-NMES and trans-NMES to the supraspinatus and posterior deltoid muscles of the subluxated shoulder. Both types of stimulation were optimized to provide full joint reduction with minimal discomfort. MAIN OUTCOME MEASURES: Pain was assessed after each stimulation with a 10-cm visual analog scale (VAS) and the McGill Pain Questionnaire, using the Pain Rating Index (PRI) scoring method. Subjects were asked which type of stimulation they would prefer for 6 weeks of treatment. Wilcoxon's signed-rank test was used to compare median differences in VAS and PRI between perc-NMES and trans-NMES. RESULTS: Median VAS scores for perc-NMES and trans-NMES were 1 and 5.7, respectively (p = .007). Median PRI scores for perc-NMES and trans-NMES were 7 and 19.5, respectively (p = .018). Nine of the 10 subjects preferred perc-NMES to trans-NMES for treatment. CONCLUSION: Data suggest that perc-NMES is less painful than trans-NMES in the treatment of shoulder subluxation in hemiplegia.

Effects of stress management on pain behavior in rheumatoid arthritis.

OBJECTIVE: To examine the effects of stress management training on pain behavior exhibited by persons with rheumatoid arthritis (RA) and the relationship of change in pain behavior with certain patient characteristics as well as change in self-reported levels of pain. METHODS: Patients with RA (n = 131) were randomly assigned to 1 of 3 groups: a stress management group, an attention control group, or a standard care control group. The stress management and attention control groups received a 10-week intervention followed by a 15-month maintenance phase. RESULTS: The 3 groups did not differ significantly in the change in pain behavior at any of the assessment periods. However, persons with RA who had less disease activity tended to exhibit positive changes in pain behavior over time. Changes in self-reported pain were not significantly related to changes in pain behavior. CONCLUSION: The results indicate that stress management interventions do not reduce total pain behaviors exhibited by persons with RA. Changes in pain behaviors appear to be related to disease activity, age, and disease duration, but not to changes in self-reported measures of pain.

Application of a short form of the Category Test for individuals with a traumatic brain injury: a cautionary note.

The Category Test, notable for its length, has been the subject of many proposed short-form versions. In our present managed care era, the pressure to utilize short forms of various tests with clinical populations has increased, yet the appropriateness of using short forms with various populations must be demonstrated not assumed. The present study examined the appropriateness of applying the short form of the Category Test proposed by Charter and colleagues (1997) with a sample of 100 outpatients with traumatic brain injuries referred for neuropsychological testing. Both variance accounted for by the short-form Category Test and the residuals or errors of prediction resulting from the use of the short-form Category Test were examined. While the short form of the Category Test accounted for 93% of the variance of full-form Category Test scores, examination of residuals indicated clinically significant (approximately 10 points or greater) estimation errors for 25% of the subjects. In light of the clinical significance of such extreme estimation errors, it was not recommended that this short form of the Category Test be used for individuals with a traumatic brain injury.

Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS.

OBJECTIVE: To describe the prevalence, incidence, management, and predictors of venous ulcers in residents of certified long-term-care facilities using the Minimum Data Set. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: 32,221 residents admitted to long-term-care facilities in Missouri between January 1, 1996, and October 30, 1998. MAIN OUTCOME MEASURES: Version 2.0 of the Minimum Data Set was utilized. Assessment items included selected measures from background information, disease diagnoses, physical functioning and structural problems, health conditions, oral/nutritional status, and skin condition. MAIN RESULTS: Venous ulcer prevalence on admission was 2.5%. The incidence of venous ulcer development for long-term-care residents admitted without an ulcer at 90, 180, 270, and 365 days after admission was 1.0%, 1.3%, 1.8%, and 2.2%, respectively. The most frequent skin treatments for residents with a venous ulcer were ulcer care, dressings, and ointments. Factors associated with venous ulcer development within a year of admission were diabetes mellitus, peripheral vascular disease, and edema. CONCLUSION: Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at-large. Residents with a venous ulcer are likely to have comorbid conditions such as diabetes mellitus, peripheral vascular disease, congestive heart failure, edema, wound infection, and pain. Based on these data, risk factors such as history of leg ulcers, recent edema, diabetes mellitus, congestive heart failure, or peripheral vascular disease should prompt clinicians to carefully plan care that will manage a resident's risk for venous ulcer development.

Neuropsychological predictors of distress following traumatic brain injury.

Emotional and behavioural difficulties are one of the most common difficulties following traumatic brain injury (TBI), although it is not clear which individuals with TBI become most distressed. Numerous factors contribute to adjustment following TBI, and the current study examined degree of cognitive decline as one potential contributor to distress following TBI. The relationship between cognitive functioning and distress may be conceptualized as being related to (a) an individual's absolute level of cognitive ability following TBI, or (b) relative degree of decline following TBI (i.e. the greater the decline, the greater the distress, regardless of absolute level of ability). The current study tested these hypotheses by comparing a measure of global emotional distress with measures of absolute level of neuropsychological functioning and indices of cognitive decline. In contrast to hypotheses, regression analyses indicated that estimated pre-morbid ability accounted for more variance in distress following TBI than either absolute level of functioning or indices of cognitive decline, with individuals with higher estimated pre-morbid abilities reporting lower levels of distress. Treatment implications are discussed.

Initial field testing of an instrument to measure: observable indicators of nursing home care quality.

The "Observable Indicators of Nursing Home Care Quality" instrument was developed as a new measure of nursing home care quality. The instrument is based on a theoretical model of quality nursing home care grounded in data from provider and consumer focus groups. The instrument was piloted in 10 Missouri nursing homes. Subsequent versions were tested in 109 Missouri and 11 Icelandic nursing homes. Content validity was established using experts. Concurrent and known groups validity was evaluated using Minimum Data Set quality indicators, survey citations, and a process of care measure. Interrater and test-retest reliabilities were calculated as well as coefficient alpha. The "Observable Indicators of Nursing Home Care Quality" instrument is a new measure that can be used by researchers, and potentially by regulators, consumers, or providers, to observe and score specific indicators of quality care following a 20- to 30-minute inspection of a nursing home.

Setting thresholds for quality indicators derived from MDS data for nursing home quality improvement reports: an update.

BACKGROUND: Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas in nursing home care is critical for preparing reports for nursing homes to use in their quality improvement programs. This article builds on the work of an earlier panel of experts that set thresholds for quality indicators (QIs) derived from Minimum Data Set (MDS) assessment data. Thresholds were now set for the revised MDS 2.0 two-page quarterly form and Resource Utilization Groups III (RUGS III) quarterly instrument. SETTING THRESHOLDS: In a day-long session in October 1998, panel members individually determined lower (good) and upper (poor) threshold scores for each QI, reviewed statewide distributions of MDS QIs, and completed a follow-up Delphi of the final results. REPORTING MDS QIS FOR QUALITY IMPROVEMENT: The QI reports compiled longitudinal data for all residents in the nursing home during each quarter and cumulatively displayed data for five quarters for each QI. A resident roster was provided to the nursing home so that the quality improvement team could identify the specific residents who developed the problems defined by each QI during the last quarter. Quality improvement teams found the reports helpful and easy to interpret. SUMMARY AND CONCLUSIONS: As promised in an earlier report, to ensure that thresholds reflect current practice, research using experts in a panel to set thresholds was repeated as needed. As the MDS instrument or recommended calculations for the MDS QIs change, thresholds will be reestablished to ensure a fit with the instrument and data.

Stress management in rheumatoid arthritis: what is the underlying mechanism?

OBJECTIVE: To test whether change in cognitive-behavioral variables (such as self-efficacy, coping strategies, and helplessness) is a mediator in the relation between cognitive behavior therapy and reduced pain and depression in persons with rheumatoid arthritis (RA). METHODS: A sample of patients with RA who completed a stress management training program (n = 47) was compared to a standard care control group (n = 45). A path analysis testing a model including direct effects of comprehensive stress management training on pain and depression and indirect effects via change in cognitive-behavioral variables was conducted. RESULTS: The path coefficients for the indirect effects of stress management training on pain and depression via change in cognitive-behavioral variables were statistically significant, whereas the path coefficients for the direct effects were found not to be statistically significant. CONCLUSION: Decreases in pain and depression following stress management training are due to beneficial changes in the arenas of self-efficacy (the belief that one can perform a specific behavior or task in the future), coping strategies (an individual's confidence in his or her ability to manage pain), and helplessness (perceptions of control regarding arthritis). There is little evidence of additional direct effects of stress management training on pain and depression.

Inhaled carbon monoxide concentration during halothane or isoflurane anesthesia in horses.

OBJECTIVE: The purpose of this study was to assess carbon monoxide (CO) exposure during equine anesthesia with either halothane (H) or isoflurane (I) delivered in a circle rebreathing system. STUDY DESIGN: Prospective clinical investigation. ANIMALS: Fifty client-owned horses. METHODS: Horses were randomly assigned for anesthetic maintenance with H (n = 26) or I (n = 24). Two large animal anesthetic machines were used and assigned to a single agent for 2-4 weeks at a time. Machines were disassembled and soda lime changed prior to switching anesthetic agents. Inhalant anesthetic concentration and CO concentration were measured in gas samples obtained from the inspiratory limb of the anesthetic circuit. Values were recorded at 15 minute intervals for 90 minutes. Soda lime status (new or used) and mode of ventilation (spontaneous or mechanical) were also recorded. Data were analyzed using a five-factor ANCOVA with repeated measures. RESULTS: Inspired CO concentration for H and I increased from 1 +/- 3 and 6 +/- 11 ppm at baseline to 54 +/- 33 and 21 +/- 18 ppm at 90 min, respectively (mean +/- sd). H was associated with significantly greater CO concentrations than I at 30 to 90 min, although baseline CO was significantly greater in the I group than the H group. Oxygen flow rates were 9.9 +/- 0.5 L/min at baseline for H and I, and 5.0 +/- 0.4 and 5.0 +/- 0.7 L/min at 90 min for H and I, respectively. There were no significant differences between groups for O2 flow at any time point. Neither mechanical ventilation nor new versus used soda lime affected CO concentration. CONCLUSIONS: Significantly higher concentrations of CO were recorded during the administration of H than I. CLINICAL RELEVANCE: Levels of CO observed during the administration of either H or I for 90 minutes to horses were not clinically significant.

Contraction force generated by tarsal joint flexion and extension in dogs with golden retriever muscular dystrophy.

Force generated due to torque caused by tarsal joint flexion and extension was measured noninvasively at 3, 4.5, 6, and 12 months of age in dogs with the Duchenne homologue, golden retriever muscular dystrophy (GRMD). Absolute and body-weight-corrected GRMD twitch and tetanic force values were lower than normal at all ages (P<0.01 for most). Tarsal flexion and extension were differentially affected. Flexion values were especially low at 3 months, whereas extension was affected more at later ages. Several other GRMD findings differed from normal. The twitch/tetany ratio was generally lower; post-tetanic potentiation for flexion values was less marked; and extension relaxation and contraction times were longer. The consistency of GRMD values was studied to determine which measurements will be most useful in evaluating treatment outcome. Standard deviation was proportionally greater for GRMD versus normal recordings. More consistent values were seen for tetany versus twitch and for flexion versus extension. Left and right limb tetanic flexion values did not differ in GRMD; extension values were more variable. These results suggest that measurement of tarsal tetanic force should be most useful to document therapeutic benefit in GRMD dogs.

Inhibitory casting decreases a vibratory inhibition index of the H-reflex in the spastic upper limb.

OBJECTIVE: To test the hypothesis that application of an inhibitory cast to the spastic upper limb will decrease a vibratory inhibition index (VII) of the H-reflex in the spastic upper limb. DESIGN: Prospective, nonrandomized, open-label trial. SETTING: University tertiary care center. PARTICIPANTS: Eight adults with upper limb spasticity. INTERVENTION: Fiberglass cast application spanning the wrist to the upper arm. MAIN OUTCOME MEASURE: The amplitude of the H-reflex with and without continuous 60Hz vibration to the tendon of the flexor carpi radialis was measured, and the VII was calculated using the formula: [H-reflex amplitude (vibrated)/H-reflex amplitude (control)] x 100%. RESULTS: Mean VII decreased from baseline (70.7) on day 1 (67.6, p = .699), day 2 (55.9, p =.066), and day 3 (43.5, p = .033) of casting, and increased on day 4 (89.9, p = .146) after removal of the cast. CONCLUSION: Findings lend support to the idea that during application of an inhibitory cast motor neuron excitability is decreased in the spastic upper limb.

The usefulness of the Brief Symptom Inventory in the neuropsychological evaluation of traumatic brain injury.

Changes in the health care delivery system are forcing clinicians to use less timely and more cost efficient measures. In rehabilitation, more efficient measures of emotional-behavioural functioning are being administered to patients with traumatic brain injury (TBI), including the Brief Symptom Inventory (BSI), a 53 item short version of the Symptom Checklist-90 that assesses nine different dimensions of emotional-behavioural functioning. Because the BSI was developed for use with psychiatric populations, research of the measure with TBI populations is needed. The current study evaluated the utility of the BSI in a sample of 62 patients (34 male, 28 female, average age 35, average education 12 years) with TBI evaluated as outpatients at a midwestern rehabilitation hospital. Results indicated that: (1) subjects endorsed clinically elevated distress on seven of the nine subscales when compared to the normative sample; (2) the Obsessive-Compulsive (OC) subscale achieved the highest t-score (70.31); 3) the most frequent two-point profiles included the OC-Somatic (21%) and OC-Psychoticism (13%) subscales; and (3) the Global Symptom Index was significantly correlated with all nine subscales. It was concluded that caution must be used when administering the BSI to individuals with TBI due to a lack of a TBI standardization sample, the limited number of test items per subscale, and questionable labels for the different subscales (e.g. OC subscale items appear to be more reflective of TBI-related cognitive impairment than obsessive-compulsive traits).

A confirmatory factor analysis of the Center for Epidemiologic Studies Depression Scale in rheumatoid arthritis patients: additional evidence for a four-factor model.

OBJECTIVE: To examine the factor structure of the Center for Epidemiologic Studies Depression Scale (CES-D) in a sample of patients with rheumatoid arthritis (RA), testing all of the alternative models suggested by the previous evidence. METHODS: The CES-D was administered to a group of RA patients (n = 685) during a structured telephone interview. The telephone interview was repeated 6 months later (n = 537) and 12 months later (n = 453). Confirmatory factor analyses were conducted to test alternative models. RESULTS: The correlated 4-factor model and the second-order 4-factor model were the best fitting models. CONCLUSION: The factor structure of the CES-D previously found in the general population was replicated in an RA sample. The results are consistent with previous evidence of criterion contamination in the CES-D when used in an RA sample and provide support for the view that a single summary score may not be the most informative index of the CES-D.

Topical morphine in a canine model: a pilot study.

OBJECTIVE: To determine if topical morphine can enter the synovial cavity and the effect of ultrasound on this process. DESIGN: A randomized control trial to investigate which body fluids morphine enters after topical application. SETTING: A university animal laboratory. SUBJECTS: Ten mongrel dogs raised by the Comparative Medicine Department. All animals were certified to be free of disease, all had received standard scheduled immunizations, and none had been used for any other research. INTERVENTION: Topical morphine and ultrasound or topical morphine and sham ultrasound was applied to the knees of the dogs. Samples were obtained afterward from synovial fluid, serum, and urine, and were analyzed for the presence of morphine. MAIN OUTCOME MEASURES: Blood samples were collected every 60 minutes for 240 minutes, urine samples were collected at 120 minutes and 240 minutes, and synovial joint fluid was collected at 120 minutes and 240 minutes. The process of collection and analysis was the same for dogs treated with topical morphine and ultrasound and those treated with topical morphine and sham ultrasound. Fisher's exact test was used to test for an association between the use of ultrasound and the presence of morphine in the synovial fluid, serum, or urine. Two-sample t tests were used to test for group differences in mean body weight. RESULTS: All samples (synovial fluid, serum, and urine) were negative at time zero. All of the subsequent serum samples were negative for morphine. Two or three of the dogs in each group of five (ultrasound or sham ultrasound) had positive urine and synovial fluid samples at 120 and 240 minutes. Ultrasound did not affect the results. Body weight of the dogs influenced the results, with lighter animals having a significantly larger percentage (p=.03) of synovial fluid samples positive for morphine. CONCLUSION: Ultrasound did not affect the absorption of topical morphine in this canine model. Body weight may have influenced the results. Dogs that tested positive for morphine in synovial fluid had a lower mean body weight than dogs that did not test positive (p=.03).

Implementing smoking bans in American hospitals: results of a national survey.

OBJECTIVES: To determine how well hospitals complied with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) tobacco control standards, which required banning smoking in hospital buildings; to explore issues involved in developing and implementing smoking bans; and to ascertain the perceived success of the policies. DESIGN: Postal survey conducted January through June 1994. PARTICIPANTS: Stratified random sample of American hospitals surveyed by JCAHO (n = 1055). MAIN OUTCOME MEASURES: Enacting smoking policies more restrictive than the JCAHO standard; the respondent's judgment of the relative success of the hospital's smoking policy. RESULTS: More than 96% of hospitals complied with the smoking ban standard; 41.4% enacted policies that were more restrictive than required by JCAHO. Several characteristics were associated with exceeding JCAHO requirements: location in a "non-tobacco state"; having fewer than 100 beds; location in a metropolitan statistical area; having unionsed employees; and having no psychiatric or substance abuse unit, favour having the same tobacco policy in psychiatry and substance abuse units as the rest of the hospital. More than 95% of respondents viewed their hospital's policy as successful. The JCAHO requirements and concern for employees' health were the major forces influencing hospitals to go smoke-free. Negative employee morale and lack of acceptance by visitors and patients were the most commonly cited barriers to overcome when implementing smoke-free policies. CONCLUSIONS: Smoking bans were successfully implemented in American hospitals, with many restricting smoking beyond the JCAHO standard. Other industries wishing to follow hospitals' lead would be most likely to succeed in the context of a social norm favouring a smoking ban and regulation by an outside agency.