Postoperative pressure injuries in adults having surgery under general anaesthesia: systematic review of perioperative risk factors.

BACKGROUND: Pressure injuries (PIs) after surgery affect thousands of people worldwide. Their management is expensive, a cost that can be reduced with proper preventive measures. Patients having surgery under general anaesthesia are at risk of developing PI, yet no specific tool has been developed to assess the risk in these patients. This review aimed to summarize the published data on perioperative risk factors associated with the development of PI in adults having surgery under general anaesthesia. METHODS: All studies reporting on risk factors associated with the development of PI were included. Data were extracted from all articles and meta-analysis was performed when three or more studies reported on a specific variable. RESULTS: The analysis identified five factors significantly associated with the development of PIs: cardiovascular disease, respiratory disease, diabetes mellitus, low haemoglobin level and longer duration of surgery. Factors not associated included serum albumin concentration, use of vasopressors during surgery, use of corticosteroids, sex and age. CONCLUSION: Cardiovascular disease, respiratory disease, diabetes mellitus, anaemia and duration of surgery should be taken into consideration when trying to identify surgical patients at high risk of developing PIs. These factors could be used to predict PIs after surgery.

ANTECEDENTES: Las úlceras por presión (pressure injuries, PI) son un problema de salud importante que afecta a millones de personas en todo el mundo. El tratamiento de las PI conlleva un coste elevado, que podría reducirse con medidas preventivas adecuadas. Aunque los pacientes a los que se realiza una cirugía bajo anestesia general tienen un mayor riesgo de desarrollar PI, no se han creado herramientas específicas para evaluar su riesgo. El objetivo de este trabajo es resumir los datos disponibles acerca de los factores de riesgo perioperatorios asociados al desarrollo de PI en pacientes adultos en los que se realiza un procedimiento quirúrgico bajo anestesia general. Un mejor conocimiento de los factores de riesgo de las PI podría permitir la estratificación de los pacientes antes de la cirugía y establecer mecanismos de prevención específicos. Número de registro Prospero CRD42019111877. MÉTODOS: Se incluyeron todos los estudios que analizaron los factores de riesgo asociados a las PI. Se obtuvieron los datos de todos los artículos y se realizó un metaanálisis cuando tres o más estudios presentaban información de una determinada variable. RESULTADOS: El análisis identificó cinco factores estadísticamente significativos asociados con el desarrollo de PI: enfermedad cardiovascular, enfermedad respiratoria, diabetes mellitus, mayor duración de la cirugía y hemoglobina baja. No se asociaron factores como la s-albúmina, la utilización de vasopresores durante la cirugía, el uso de corticoides, el sexo o la edad. CONCLUSIÓN: Se recomienda tener en cuenta la existencia de enfermedades cardiovasculares o respiratorias, diabetes mellitus, niveles bajos de hemoglobina y la duración de la cirugía a la hora de identificar a los pacientes quirúrgicos con riesgo elevado de desarrollar PI.

The nanoscopic molecular pathway through human skin.

BACKGROUND: Knowledge regarding the barrier properties of human skin is important for understanding skin pathology, developing of transdermal drug delivery systems and computational skin absorption models; however, the molecular pathways through human skin remains to be fully investigated on a nanoscopic level. In particular the nanoscopic pathway of molecules passing the intercellular lipid bilayers separating the corneocytes in the stratum corneum (SC) is not fully elucidated. METHODS: Using stimulated emission depletion microscopy (STED) and Förster resonance energy transfer (FRET) the molecular pathways through the SC, the main barrier of the skin, are determined for lipophilic and water-soluble molecules at a nanoscopic resolution. RESULTS: Using STED and confocal microscopy, water-soluble dyes, were observed to be present in both the corneocytes and in the intercellular lipid matrix, whereas the lipophilic dyes were predominately in the intercellular lipid bilayers. FRET was observed in the SC between the lipophilic and water-soluble dyes, the existence of a minimum possible distance between acceptor and donor molecules of 4.0 ±â€¯0.1 nm was found. CONCLUSIONS: The results indicate that lipophilic molecules penetrate the stratum corneum via the intercellular lipids bilayers separating the corneocytes in the SC, while the more water-soluble molecules penetrate the stratum corneum via the transcellular route through the corneocytes and intercellular lipid bilayers via the polar head groups of lipid molecules in the bilayers. GENERAL SIGNIFICANCE: Knowledge of the nanoscopic molecular pathways through human skin will help understand the skin barrier function and will be of use for computational skin absorption models and transdermal drug delivery strategies.

Temporal variation of Staphylococcus aureus clonal complexes in atopic dermatitis: a follow-up study.

BACKGROUND: A strong link between disease severity and Staphylococcus aureus colonization of the skin has been reported in patients with atopic dermatitis (AD). OBJECTIVES: To examine temporal variations in S. aureus colonization and S. aureus CC type in patients with AD, and to investigate links to disease severity, skin barrier properties and filaggrin gene (FLG) mutations. METHODS: This was a follow-up study of a cohort of 101 adult patients with AD recruited from an outpatient clinic. Bacterial swabs were taken at baseline and follow-up from lesional skin, nonlesional skin and the nose. Swabs positive for S. aureus were characterized by spa and the respective clonal complex (CC) type was assigned. Patients were characterized with respect to disease severity [Scoring Atopic Dermatitis (SCORAD)], skin barrier properties [transepidermal water loss (TEWL), pH] and FLG mutations. RESULTS: In total, 63 patients participated in a follow-up visit. Twenty-seven patients (43%) were colonized at both visits, 27 were colonized at only one visit and nine (14%) were not colonized at either visit. Of patients colonized at both visits, 52% remained colonized with the same CC type at follow-up. Change in CC type was related to an increase in SCORAD of 10·7 points; patients who carried the same CC type had a reduction in SCORAD of 4·4 points. Significantly higher skin pH was found in patients colonized at both visits, while change in CC type was not related to TEWL, pH or FLG mutations. CONCLUSIONS: The data indicate that temporal variation in S. aureus CC type is linked to flares of the disease.

Prophylactic incisional negative pressure wound therapy reduces the risk of surgical site infection after caesarean section in obese women: a pragmatic randomised clinical trial.

OBJECTIVE: To evaluate the reduction of surgical site infections by prophylactic incisional negative pressure wound therapy compared with standard postoperative dressings in obese women giving birth by caesarean section. DESIGN: Multicentre randomised controlled trial. SETTING: Five hospitals in Denmark. POPULATION: Obese women (prepregnancy body mass index (BMI) ≥30 kg/m2 ) undergoing elective or emergency caesarean section. METHOD: The participants were randomly assigned to incisional negative pressure wound therapy or a standard dressing after caesarean section and analysed by intention-to-treat. Blinding was not possible due to the nature of the intervention. MAIN OUTCOME MEASURES: The primary outcome was surgical site infection requiring antibiotic treatment within the first 30 days after surgery. Secondary outcomes included wound exudate, dehiscence and health-related quality of life. RESULTS: Incisional negative pressure wound therapy was applied to 432 women and 444 women had a standard dressing. Demographics were similar between groups. Surgical site infection occurred in 20 (4.6%) women treated with incisional negative pressure wound therapy and in 41 (9.2%) women treated with a standard dressing (relative risk 0.50, 95% CI 0.30-0.84; number needed to treat 22; P = 0.007). The effect remained statistically significant when adjusted for BMI and other potential risk factors. Incisional negative pressure wound therapy significantly reduced wound exudate whereas no difference was found for dehiscence and quality of life between the two groups. CONCLUSION: Prophylactic use of incisional negative pressure wound therapy reduced the risk of surgical site infection in obese women giving birth by caesarean section. TWEETABLE ABSTRACT: RCT: prophylactic incisional NPWT versus standard dressings postcaesarean in 876 women significantly reduces the risk of SSI.

Adipose-derived regenerative cells and fat grafting for treating breast cancer-related lymphedema: Lymphoscintigraphic evaluation with 1 year of follow-up.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a feared late complication. Treatment options are lacking at present. Recent studies have suggested that mesenchymal stromal cells can alleviate lymphedema. Herein, we report the results from the first human pilot study with adipose-derived regenerative cells (ADRCs) for treating BCRL with 1 year of follow-up. MATERIAL AND METHODS: We included 10 patients with BCRL. ADRCs were injected directly into the axillary region together with a scar-releasing fat grafting procedure. Primary endpoint was change in arm volume. Secondary endpoints were change in patient-reported outcomes, changes in lymph flow, and safety. RESULTS: During follow-up, no significant change in volume was noted. Patient-reported outcomes improved significantly with time. Five patients reduced their use of conservative management. Quantitative lymphoscintigraphy did not improve on the lymphedema-affected arms. ADRCs were well tolerated, and only minor transient adverse events related to liposuction were noted. CONCLUSIONS: In this pilot study, a single injection of ADRCs improved lymphedema based on patient-reported outcome measures, and there were no serious adverse events during the follow-up period. Lymphoscintigraphic evaluation showed no improvement after ADRC treatment. There was no change in excess arm volume. Results of this trial need to be confirmed in randomized clinical trials.

Cost-effectiveness of incisional negative pressure wound therapy compared with standard care after caesarean section in obese women: a trial-based economic evaluation.

OBJECTIVE: To evaluate the cost-effectiveness of incisional negative pressure wound therapy (iNPWT) in preventing surgical site infection in obese women after caesarean section. DESIGN: A cost-effectiveness analysis conducted alongside a clinical trial. SETTING: Five obstetric departments in Denmark. POPULATION: Women with a pregestational body mass index (BMI) ≥30 kg/m2 . METHOD: We used data from a randomised controlled trial of 876 obese women who underwent elective or emergency caesarean section and were subsequently treated with iNPWT (n = 432) or a standard dressing (n = 444). Costs were estimated using data from four Danish National Databases and analysed from a healthcare perspective with a time horizon of 3 months after birth. MAIN OUTCOME MEASURES: Cost-effectiveness based on incremental cost per surgical site infection avoided and per quality-adjusted life-year (QALY) gained. RESULTS: The total healthcare costs per woman were €5793.60 for iNPWT and €5840.89 for standard dressings. Incisional NPWT was the dominant strategy because it was both less expensive and more effective; however, no statistically significant difference was found for costs or QALYs. At a willingness-to-pay threshold of €30,000, the probability of the intervention being cost-effective was 92.8%. A subgroup analysis stratifying by BMI shows that the cost saving of the intervention was mainly driven by the benefit to women with a pre-pregnancy BMI ≥35 kg/m2 . CONCLUSION: Incisional NPWT appears to be cost saving compared with standard dressings but this finding is not statistically significant. The cost savings were primarily found in women with a pre-pregnancy BMI ≥35 kg/m2 . TWEETABLE ABSTRACT: Prophylactic incisional NPWT reduces the risk of SSI after caesarean section and is probably dominant compared with standard dressings #healtheconomics.

Meta-analysis of negative-pressure wound therapy for closed surgical incisions.

BACKGROUND: Postoperative wound complications are common following surgical procedures. Negative-pressure wound therapy (NPWT) is well recognized for the management of open wounds and has been applied recently to closed surgical incisions. The evidence base to support this intervention is limited. The aim of this study was to assess whether NPWT reduces postoperative wound complications when applied to closed surgical incisions. METHODS: This was a systematic review and meta-analysis of randomized clinical trials of NPWT compared with standard postoperative dressings on closed surgical incisions. RESULTS: Ten studies met the inclusion criteria, reporting on 1311 incisions in 1089 patients. NPWT was associated with a significant reduction in wound infection (relative risk (RR) 0·54, 95 per cent c.i. 0·33 to 0·89) and seroma formation (RR 0·48, 0·27 to 0·84) compared with standard care. The reduction in wound dehiscence was not significant. The numbers needed to treat were three (seroma), 17 (dehiscence) and 25 (infection). Methodological heterogeneity across studies led to downgrading of the quality of evidence to moderate for infection and seroma, and low for dehiscence. CONCLUSION: Compared with standard postoperative dressings, NPWT significantly reduced the rate of wound infection and seroma when applied to closed surgical wounds. Heterogeneity between the included studies means that no general recommendations can be made yet.

Moving towards personalised therapy in head and neck squamous cell carcinoma through analysis of next generation sequencing data.

Personalised medicine tumour boards, which leverage genomic data to improve clinical management, are becoming standard for the treatment of many cancers. This paper is designed as a primer to assist clinicians treating head and neck squamous cell carcinoma (HNSCC) patients with an understanding of the discovery and functional impact of recurrent genetic lesions that are likely to influence the management of this disease in the near future. This manuscript integrates genetic data from publicly available array comparative genome hybridization (aCGH) and next-generation sequencing genetics databases to identify the most common molecular alterations in HNSCC. The importance of these genetic discoveries is reviewed and how they may be incorporated into clinical care decisions is discussed. Considerations for the role of genetic stratification in the clinical management of head and neck cancer are maturing rapidly and can be improved by integrating data sets. This article is meant to summarise the discoveries made using multiple genomic platforms so that the head and neck cancer care provider can apply these discoveries to improve clinical care.

Validation of Self-Reported Power Take-Off Shielding Using On-Site Farm Audits.

Despite the substantial contribution of power take-off (PTO) entanglements to workplace morbidity and mortality among agricultural workers, the degree of proper PTO shielding on U.S. farms remains poorly characterized. Sampling from the New York data of the USDA National Agricultural Statistical Service (NASS), at least 200 each of dairy, livestock, crop, fruit, and vegetable farms were surveyed by phone to determine the extent of proper PTO shielding. In the same year, on-site audits were performed at 211 randomly selected New York livestock and dairy farms using a four-point scale to assess PTO shielding. Supplemental data were gathered on farm acreage, number of livestock, principal commodity, and operator experience. The phone survey data for livestock and dairy farms were then compared to the on-farm audit data. In the phone survey, 72.5% of farms reported having shields on all implements. The mean percentage of implements reported to be shielded was 90.2%. By on-farm audit, 10% of farms had all implements properly shielded, and the mean percentage of properly shielded implements was 56.7%, with shielding rates differing widely for different classes of implements. No significant predictors of PTO shielding were identified. The phone survey greatly overestimated proper PTO shielding rates when compared with the on-farm audits. These data suggest a lower level of proper shielding among farmers than is mandated by current industry safety standards. The results also identify a principal weakness of phone surveys in accurately assessing the true magnitude of on-farm risk for PTO entanglement.

Creating a National Coalition to Address Tractor Overturn Fatalities.

Tractor overturns continue to be the leading cause of death on U.S. farms. While rollover protective structures (ROPS) are effective in preventing these fatalities, they are underutilized due to a number of barriers. Past programs in the U.S. and abroad have targeted this area of agricultural safety; however, a national program is not yet in place for U.S. farmers. This study seeks to build a national partnership to address tractor overturn fatalities by increasing the number of tractors with ROPS. A diverse, multisector steering committee has been organized and is working together using Whole System in a Room methods. This method brings together partners from nine stakeholder groups to identify and commit to a collaborative solution to the issue.

Concept identification for a power take-off shielding campaign.

ABSTRACT Machinery entanglements, specifically power take-off (PTO) entanglements, are a leading cause of injuries and fatalities on farms. In order to address this life-threatening issue, a social marketing campaign is being developed to reduce barriers and emphasize motivators to shielding. This article discusses the process of designing, testing, and selecting concepts to be used in the campaign. Small-group discussions (triads) were held to test 13 message concepts. Participants were asked to provide feedback and select the two messages that they believed to be most powerful. Upon completion, three message concepts were selected to be finalized.

A qualitative analysis of power take-off driveline shields: barriers and motivators to shield use for New York State farmers.

Machinery entanglements are one of the top three causes of death in farming. Education on the risks of unshielded power take-off (PTO) equipment does not appear to significantly alter farmers' willingness to replace missing or broken shielding. Different assessments conducted in various regions of the U.S. indicate that as many as one-third to one-half of PTOs are inadequately shielded. Qualitative research was conducted with New York farmers to identify the factors that influence the decision to replace damaged or missing PTO driveline shields. Interview topics included: knowledge of entanglement risks, decisions regarding safety in general, decisions relating to PTO driveline shielding specifically, and the barriers and motivators to replacing missing or broken PTO driveline shields. Interviews with 38 farmers revealed the following themes: (1) farmers are fully aware of PTO entanglement risk, (2) insufficient time and money are primary barriers to purchasing or replacing damaged or missing PTO driveline shields, (3) PTO driveline shield designs are problematic and have led to negative experiences with shielding, and (4) risk acceptance and alternate work strategies are preferred alternatives to replacing shields. Our findings indicate that more innovative approaches will be required to make PTO driveline shield use a viable and attractive choice for farmers. New shield designs that address the practical barriers farmers face, as well as the provision of logistical and financial assistance for shield replacement, may alter the decision environment sufficiently to make replacing PTO driveline shielding a more attractive option for farmers.

Effect of detergents on the physicochemical properties of skin stratum corneum: a two-photon excitation fluorescence microscopy study.

OBJECTIVE: Understanding the structural and dynamical features of skin is critical for advancing innovation in personal care and drug discovery. Synthetic detergent mixtures used in commercially available body wash products are thought to be less aggressive towards the skin barrier when compared to conventional detergents. The aim of this work is to comparatively characterize the effect of a mild synthetic cleanser mixture (SCM) and sodium dodecyl sulphate (SDS) on the hydration state of the intercellular lipid matrix and on proton activity of excised skin stratum corneum (SC). METHOD: Experiments were performed using two-photon excitation fluorescence microscopy. Fluorescent images of fluorescence reporters sensitive to proton activity and hydration of SC were obtained in excised skin and examined in the presence and absence of SCM and SDS detergents. RESULTS: Hydration of the intercellular lipid matrix to a depth of 10 µm into the SC was increased upon treatment with SCM, whereas SDS shows this effect only at the very surface of SC. The proton activity of SC remained unaffected by treatment with either detergent. CONCLUSION: While our study indicates that the SC is very resistant to external stimuli, it also shows that, in contrast to the response to SDS, SCM to some extent modulates the in-depth hydration properties of the intercellular lipid matrix within excised skin SC.

Increases in ROPS pricing from 2006-2012 and the impact on ROPS demand.

In 2006, a social marketing campaign was developed to increase the installation of rollover protective structures (ROPS) on unprotected New York tractors. Using data gathered from the program's hotline, the impact of price increases on farmers' interest in ROPS is examined. Pricing data were obtained for all rigid ROPS kits commercially available in the U.S. since 2006. These data were stratified into two groups of ROPS suppliers: (1) tractor manufacturers that sell ROPS for their own tractors, referred to in this study as original equipment manufacturers (OEMs), and (2) aftermarket (AM) ROPS suppliers. The trend in price increases was contrasted with the change in the consumer price index (CPI), the probability of retrofitting within quintiles of cost was estimated, and the increase in ROPS prices over time was plotted The average price increase for a ROPS kit (excluding shipping and installation) over the six years of the study was 23.3% for OEM versus 60.5% for AM (p < 0.0001). Out-of-pocket expenses held steady for OEM versus a six-year increase of $203 for AM (p = 0.098). The probability of a farmer retrofitting dropped monotonically from 66.9% in the lowest ROPS cost quintile to 23% in the highest. If these trends continue, the proportion of inquiries resulting in a ROPS retrofit will fall below 20% by 2020 for AM ROPS. Based on other trends identified in the literature, it is reasonable to assume that decreases in ROPS installation are likely to affect the tractor owners who are most likely to need these safety devices.

Mesenchymal stem cells in oral reconstructive surgery: a systematic review of the literature.

This study evaluated clinical outcomes following intraoperative use of adult mesenchymal stem cells (MSCs) in various oral reconstructive procedures. PubMed was searched without language restrictions from 2000 to 2011 using the search words stem cell, oral surgery, tissue engineering, sinus lift, bone regeneration and combinations of these. Inclusion criteria were intraoperative use of MSCs in the study design. Reference lists of the articles found were searched for other related studies. Eighteen clinical trials using MSCs for sinus augmentation were found: five case reports on the repair of large bony defects and six studies on ridge augmentation and healing of alveolar sockets after third molar extraction. The findings suggest that MSCs are capable of producing in vivo bone, re-establishing lost tissue and facilitating placement of dental implants. Use of MSCs would reduce patient morbidity because of a less stressful harvesting technique than that of autogenous bone. The majority of clinical trials indicate that MSCs can produce bone in vivo. However, a satisfactory outcome was not seen in all studies, and due to the diversity of study designs, a 'golden approach' cannot be determined. Before use of MSCs can be considered as a first-choice treatment, more predictable outcomes and better long-term prognoses need to be established. Conventional bone grafting remains the gold standard.

Chronological age affects the permeation of fentanyl through human skin in vitro.

AIM: To study the influence of chronological age on fentanyl permeation through human skin in vitro using static diffusion cells. Elderly individuals are known to be more sensitive to opioids and obtain higher plasma concentrations following dermal application of fentanyl compared to younger individuals. The influence of age - as an isolated pharmacokinetic term - on the absorption of fentanyl has not been previously studied. METHOD: Human skin from 30 female donors was mounted in static diffusion cells, and samples were collected during 48 h. Donors were divided into three age groups: <30 years of age (n = 6), ≥30 and <60 years of age (n = 18) and ≥60 years of age (n = 6). RESULTS: The youngest group had a significantly higher mean absorption (3,100 ng/cm(2)) than the two other groups (2,000 and 1,475 ng/cm(2), respectively) and a significant larger AUC (young age group: 9,393 ng; middle and old age groups: 5,922 and 4,050 ng, respectively). Furthermore, the lag time and absorption rate were different between the three groups, with a significantly higher rate in the young participants versus the oldest participants. CONCLUSION: We demonstrate that fentanyl permeates the skin of young individuals in greater amounts and at a higher absorption rate than in middle-aged and old individuals in vitro.

Waiting times for diagnosis and treatment of head and neck cancer in Denmark in 2010 compared to 1992 and 2002.

BACKGROUND AND AIM: Significant tumour progression was observed during waiting time for treatment of head and neck cancer. To reduce waiting times, a Danish national policy of fast track accelerated clinical pathways was introduced in 2007. This study describes changes in waiting time and the potential influence of fast track by comparing waiting times in 2010 to 2002 and 1992. METHODS: Charts of all new patients diagnosed with squamous cell carcinoma of the oral cavity, pharynx and larynx at the five Danish head and neck oncology centres from January to April 2010 (n=253) were reviewed and compared to similar data from 2002 (n=211) and 1992 (n=168). RESULTS: The median time to diagnosis was 13 days (2010) versus 17 days (2002; p<0.001) and 20 days (1992; p<0.001). Median days from diagnosis to treatment start were 25 (2010) versus 47 (2002; p<0.001) and 31 (1992; p<0.001). Total pre-treatment time was median 41 days in 2010 versus 69 days (2002) (p<0.001) and 50 days (1992; p<0.001). Significantly more diagnostic imaging was done in 2010 compared to 2002 and 1992. When compared to current fast track standards the adherence to diagnosis improved slightly from 47% (1992) to 51% (2002) and 64% (2010); waiting time for radiotherapy was within standards for 7%, 1% and 22% of cases, respectively; waiting time for surgery was within standards for 17%, 22% and 48%, respectively. CONCLUSION: The study showed a significant reduction in delay of diagnosis and treatment of head and neck cancer in 2010, but still less than half of all patients start treatment within the current standards.

Selecting target populations for ROPS retrofit programs in Pennsylvania and Vermont.

Agriculture has the highest injury and fatality rates when compared with other U.S. industries, and tractor overturns remain the leading cause of agricultural fatalities. Rollover protection structures (ROPS) are the only proven devices to protect a tractor operator in the event of an overturn. These devices are 99% effective when used with a seatbelt. Nearly 49% of tractors in the U.S. are not equipped with a ROPS. Interventions such as social marketing, community awareness campaigns, and financial incentives have been directed at encouraging farmers to install ROPS on their unprotected tractors. The purpose of this study was to conduct similar comparisons of ROPS protection and readiness to retrofit in different segments of the Vermont and Pennsylvania farm communities. A telephone survey was used to collect data on ROPS prevalence, farm demographic characteristics, and farmer's stage of change relative to installing ROPS on farm tractors. Our data provide new and unique information on the prevalence of ROPS-equipped tractors relative to commodity, farm size, and a variety of other demographic variables. Extrapolating from these data, the commodities studied account for roughly 162,072 tractors across the two states. Of these, 85,927 (53%) do not have ROPS. Of these unprotected tractors, 77,203 are in Pennsylvania and 8,724 are in Vermont. Our other two research questions dealt with the farmer's stage of change and possible ways to segment this population. The stage of change portion of our work demonstrates that most Pennsylvania and Vermont farmers are not contemplating ROPS retrofitting in the near future. Since no major differences were found in the stage of change, the number of unprotected tractors was examined for each of the commodity groups. In Pennsylvania, 29% of all unprotected tractors were found on cash crop farms. This trend was even more apparent on smaller farms than large farms. This led to the selection of smaller cash crop farms as the target audience for social marketing messages. In contrast, researchers in Vermont found a bimodal distribution of unprotected tractors. Of all the commodity groups surveyed in Vermont, vegetable and cash crop farmers were least likely to have even one protected tractor to use on the farm. Probably the most encouraging finding from this study is that over 85% of Pennsylvania farms and over 87% of Vermont farms surveyed had at least one tractor available that had ROPS protection. Of those farms, 25.5% of the Pennsylvania farms and 46% of the Vermont farms have ROPS on all of their tractors. Both of these findings were greater than the findings from a 2006 survey of New York State farms, which found that 75% of surveyed New York farms have ROPS on at least one tractor and 18% have ROPS on all tractors. Even with these encouraging data, the goal of 100% of tractors with ROPS is far from being met. There are still an estimated 90,000 unprotected tractors on Pennsylvania and Vermont farms, and these farm owners are currently unmotivated to install ROPS. However as demonstrated in New York State, it may be possible to use social marketing that combines persuasive messages and cost-sharing to persuade these farmers that ROPS are indeed important and accessible.

Prominent barriers and motivators to installing ROPS: an analysis of survey responses from Pennsylvania and Vermont.

Tractor overturns contribute significantly to the number of work-related deaths that occur every year on U.S. farms. Although the agriculture, forestry, and fishing industries have the highest fatality rates of any industries, researchers predict that the elimination of tractor overturn fatalities could result in a noticeable reduction in the farm fatality rate. Rollover protection structures (ROPS) are 99% effective in preventing overturn fatalities. However, roughly 50% of U.S. tractors do not have a ROPS. In order to identify prominent barriers and motivators to installing ROPS, a phone survey was conducted with a random sample of farmers (n = 327) in Vermont and Pennsylvania, two states interested in developing ROPS installation programs. Results indicated that cost and perceived need were the most frequently highly rated barriers to ROPS installation in both states, while working near hills or ditches and concerns regarding liability were the most frequently highly rated motivators for installing ROPS. Additionally, older farmers identified limited use of a tractor as a highly rated barrier.