Integrating the Transtheoretical Model: A Quantitative Analysis in the Area of Sun Exposure

The constructs involved in the Transtheoretical Model (TTM) have been shown to have similar relationships to the Stages of Change across a variety of behaviors. While much work has been done investigating the way the constructs interact cross-sectionally and longitudinally, a completely integrated look at all the constructs of the TTM has not yet been successful. This study integrated all constructs of the TTM related to increase of sun protective behavior across three time points. The sample used in this study is a portion of a sample collected for three larger, multiple behavior intervention studies. Assessments were collected at baseline, 6-, and 12-month intervals. At baseline, these larger samples included 1472 people in worksites, 1816 parents, and 3875 physician patients at risk for sun exposure. Of these, 341 worksite, 4 31 parent, and 1012 physician had data at all three time points with all necessary variables. Structural equation modeling was utilized to evaluate panel designs involving seven TTM constructs at baseline, 6-, and 12-month time points. Different models were run within each pre-action Stage of Change. Due to the complexity of the model, a step approach was taken to evaluate the relationships among the constructs. The Precontemplation group showed relationships between Experiential Processes, Pros and sun protective behavior. The Contemplation and Preparation samples both showed important relationships between Cons and Confidence with behavior. There were more significant paths in the Preparation model indicating greater variance possibly due to more stage movement at follow-up time points. While not all paths found confirm expectations based on the TTM, there was strong support for the theory. Additional work needs to be done to further investigate these relationships among individual stage transitions or transition groups. A better understanding of the empirical relationships between these constructs will help further understanding of the theory and improve interventions based on the TTM

The potential for constructed wetlands to treat alkaline bauxite-residue leachate: phragmites australis growth

High alkalinity (pH > 12) of bauxite-residue leachates presents challenges for the long-term storage and managements of the residue. Recent evidence has highlighted the potential for constructed wetlands to effectively buffer the alkalinity, but there is limited evidence on the potential for wetland plants to establish and grow in soils inundated with residue leachate. A pot-based trial was conducted to investigate the potential for Phragmites australis to establish and grow in substrate treated with residue leachate over a pH range of 8.6–11.1. The trial ran for 3 months, after which plant growth and biomass were determined. Concentrations of soluble and exchangeable trace elements in the soil substrate and also in the aboveground and belowground biomass were determined. Residue leachate pH did not affect plant biomass or microbial biomass. With the exception of Na, there was no effect on exchangeable trace elements in the substrate; however, increases in soluble metals (As, Cd and Na) were observed with increasing leachate concentration. Furthermore, increases in Al, As and V were observed in belowground biomass and for Cd and Cr in aboveground biomass. Concentrations within the vegetation biomass were less than critical phytotoxic levels. Results demonstrate the ability for P. australis to grow in bauxite-residue leachate-inundated growth media without adverse effects

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient‐Centered Empathy in Emergency Care

Background Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers. Methods We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate in order to rapidly create trust, enhance patient perception that the physician understood the patient's point of view, needs, concerns, fears, and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors and by consensus, 5 major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter‐rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants. Results Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: Provider transparency, Acknowledgement of patient's emotions, Provider disposition, Trust in physician, and Listening. Participants also highlighted the need for authenticity, context and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the “Empathy Circle”. Conclusions Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the “Empathy Circle”, a novel concept map that can serve as the framework to teach empathy to emergency care providers

Prospective Study of the Frequency and Outcomes of Patients with Suspected Pulmonary Embolism Administered Heparin Prior to Confirmatory Imaging

Objectives The administration of empiric systemic anticoagulation (ESA) before confirmatory radiographic testing in patients with suspected pulmonary embolism (PE) may improve outcomes, but no data have been published regarding current practice. We describe the use of ESA in a large prospective cohort of emergency department (ED) patients and report the outcomes of those treated with ESA compared with patients not receiving ESA. Methods 12-center, noninterventional study of ED patients who presented with symptoms concerning for PE. Clinical data including pretest probability and decision to start ESA were recorded at point of care by attending physicians. Patients were followed for adverse in-hospital outcomes and recurrence of venous thromboembolism. Results ESA was initiated 342/7932 (4.3%) of enrolled patients, including 142/618 (23%) patients with high pretest probability. Patients receiving ESA had more abnormal vital signs and were more likely to have a history of venous thromboembolism than those who did not receive ESA. Overall, 481/7,932 (6.1%) had PE diagnosed, 72/481 (15.0%) with PE had ESA, and 72/342 (21%) of ESA patients had PE. Three patients (0.9%, 95%CI: 0.2-2.5%) who received ESA suffered hemorrhagic complications compared with 38 patients (0.5%, 95%CI: 0.4-0.7%) who did not receive ESA. Conclusions In this multicenter sample, ED physicians administered ESA to a small, generally more acutely ill subset of patients with high pretest probability of PE, and very few had hemorrhagic complications. ESA was not associated with any clear difference in outcomes. More study is needed to clarify the risk versus benefit of ESA

Etomidate as an Induction Agent in Septic Patients: Red Flags or False Alarms?

Despite its widespread use in North America and many other parts of the world, the safety of etomidate as an induction agent for rapid sequence intubation in septic patients is still debated. In this article, we evaluate the current literature on etomidate, review its clinical history, and discuss the controversy regarding its use, especially in sepsis. We address eight questions: (i) When did concern over the safety of etomidate first arise? (ii) What is the mechanism by which etomidate is thought to affect the adrenal axis? (iii) How has adrenal insufficiency in relation to etomidate use been defined or identified in the literature? (iv) What is the evidence that single dose etomidate is associated with subsequent adrenal-cortisol dysfunction? (v) What is the clinical significance of adrenal insufficiency or dysfunction associated with single dose etomidate, and where are the data that support or refute the contention that single-dose etomidate is associated with increased mortality or important post emergency department (ED) clinical outcomes? (vi) How should etomidate’s effects in septic patients best be measured? (vii) What are alternative induction agents and what are the advantages and disadvantages of these agents relative to etomidate? (viii) What future work is needed to further clarify the characteristics of etomidate as it is currently used in patients with sepsis? We conclude that the observational nature of almost all available data suggesting adverse outcomes from etomidate does not support abandoning its use for rapid sequence induction. However, because we see a need to balance theoretical harms and benefits in the presence of data supporting the non-inferiority of alternative agents without similar theoretical risks associated with them, we suggest that the burden of proof to support continued widespread use may rest with the proponents of etomidate. We further suggest that practitioners become familiar with the use of more than one agent while awaiting further definitive data

High Discordance of Chest X-ray and CT for Detection of Pulmonary Opacities in ED Patients: Implications for Diagnosing Pneumonia

Objective To evaluate the diagnostic performance of chest x-ray (CXR) compared to computed tomography (CT) for detection of pulmonary opacities in adult emergency department (ED) patients. Methods We conducted an observational cross-sectional study of adult patients presenting to 12 EDs in the United States from July 1, 2003, through November 30, 2006, who underwent both CXR and chest CT for routine clinical care. CXRs and CT scans performed on the same patient were matched. CXRs and CT scans were interpreted by attending radiologists and classified as containing pulmonary opacities if the final radiologist report noted opacity, infiltrate, consolidation, pneumonia, or bronchopneumonia. Using CT as a criterion standard, the diagnostic test characteristics of CXR to detect pulmonary opacities were calculated. Results The study cohort included 3423 patients. Shortness of breath, chest pain and cough were the most common complaints, with 96.1% of subjects reporting at least one of these symptoms. Pulmonary opacities were visualized on 309 (9.0%) CXRs and 191 (5.6 %) CT scans. CXR test characteristics for detection of pulmonary opacities included: sensitivity 43.5% (95% CI, 36.4%-50.8%); specificity 93.0% (95% CI, 92.1%-93.9%); positive predictive value 26.9% (95% CI, 22.1%-32.2%); and negative predictive value 96.5% (95% CI, 95.8%-97.1%). Conclusion In this multicenter cohort of adult ED patients with acute cardiopulmonary symptoms, CXR demonstrated poor sensitivity and positive predictive value for detecting pulmonary opacities. Reliance on CXR to identify pneumonia may lead to significant rates of misdiagnosis

The Man of La Mancha press release

April 7-11 and 14-18, 1982. University Theatre, Viertes Haus 100. Book by Dale Wasserman. Lyrics by Joe Darion. Music by Mitch Leigh. Based on the novel Don Quixote by Miguel de Cervantes. Directed by Therald Todd. Music Director Joseph Rohm. Choreography by Lee Brooke and Sue Steele. Costumes by Jaqueline Easter. Set design by H. Paul Mazer. Starring Kurt E. Payne as Captain of the Inquisition; R. J. Musser as Miguel de Cervantes, Don Quixote, Alonso Quijana; J. R. Vega as Sancho Panza.https://digitalcommons.fiu.edu/theatre_posters/1125/thumbnail.jp

D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography

Background:  Increasing the threshold to define a positive D-dimer could reduce unnecessary computed tomographic pulmonary angiography (CTPA) for a suspected pulmonary embolism (PE) but might increase rates of a missed PE and missed pneumonia, the most common non-thromboembolic diagnosis seen on CTPA. Objective:  Measure the effect of doubling the standard D-dimer threshold for ‘PE unlikely’ Revised Geneva (RGS) or Wells’ scores on the exclusion rate, frequency and size of a missed PE and missed pneumonia. Methods:  Patients evaluated for a suspected PE with 64-channel CTPA were prospectively enrolled from emergency departments (EDs) and inpatient units of four hospitals. Pretest probability data were collected in real time and the D-dimer was measured in a central laboratory. Criterion standard was CPTA interpretation by two independent radiologists combined with clinical outcome at 30 days. Results:  Of 678 patients enrolled, 126 (19%) were PE+ and 93 (14%) had pneumonia. Use of either Wells’ ≤ 4 or RGS ≤ 6 produced similar results. For example, with RGS ≤ 6 and standard threshold (< 500 ng mL−1), D-dimer was negative in 110/678 (16%), and 4/110 were PE+ (posterior probability 3.8%) and 9/110 (8.2%) had pneumonia. With RGS ≤ 6 and a threshold < 1000 ng mL−1, D-dimer was negative in 208/678 (31%) and 11/208 (5.3%) were PE+, but 10/11 missed PEs were subsegmental and none had concomitant DVT. Pneumonia was found in 12/208 (5.4%) with RGS ≤ 6 and D-dimer < 1000 ng mL−1. Conclusions:  Doubling the threshold for a positive D-dimer with a PE unlikely pretest probability could reduce CTPA scanning with a slightly increased risk of missed isolated subsegmental PE, and no increase in rate of missed pneumonia

Vulnerable Populations and the Transition to Adulthood

D. Wayne Osgood, E. Michael Foster, and Mark E. Courtney examine the transition to adulthood for youth involved in social service and justice systems during childhood and adolescence. They survey the challenges faced by youth in the mental health system, the foster care system, the juvenile justice system, the criminal justice system, and special education, and by youth with physical disabilities and chronic illness, as well as runaway and homeless youth