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PubMed1999

Remote telemedical interpretation of neonatal echocardiograms: impact on clinical management in a primary care setting.

OBJECTIVE: The purpose of this study was to evaluate the utility of telemedical echocardiographically assisted neonatal cardiovascular evaluation in a primary care setting. BACKGROUND: Neonates with congenital heart disease are frequently born far from pediatric subspecialty centers and can be clinically unstable at presentation. Recent advances in telecommunication technology have made it possible to transmit echocardiographic images over long distances. This technology may be beneficial to newborns with heart defects who are born in primary care centers. METHODS: A retrospective review of all telemedical echocardiograms obtained from neonates (aged 1 day to 30 days) was performed. A telemedical link was created using a T-1 transmission line and a standard voice telephone line between the Mayo Clinic, Rochester, Minnesota (pediatric cardiology site), and the Altru Clinic, Grand Forks, North Dakota (primary care site), which is a general pediatric practice 400 miles from Rochester. Neonates with possible cardiac disorders were identified by the general pediatricians, who then requested telemedical echocardiography. RESULTS: The 133 neonates had 161 T-1 echocardiograms. Median patient age was two days (range, one day to 29 days). One hundred thirty-two of 133 initial echocardiograms (99%) were obtained because of urgent indications. Transmitted images provided adequate diagnostic information in all patients. Seventy-nine neonates (59%) had a change in medical management or required cardiology follow-up. An immediate change in management occurred in 32 patients (24%), including seven in whom emergency transfer was either arranged or avoided. CONCLUSIONS: Telemedical echocardiography provides accurate diagnostic data in neonates. Rapid telediagnosis facilitates appropriate care of sick neonates with possible congenital heart disease in the primary care setting. Unnecessary long-distance transfers can be avoided with this technology.

Heart Defects, Congenital↗
PubMed1995

Use of epidemiologic principles to identify risk factors associated with the development of diarrhea in calves in five beef herds.

The objective of the study reported here was to identify and measure risk factors associated with the incidence of diarrhea in calves in 5 beef herds in North Dakota. Risk factors associated with calves developing diarrhea during the 1992 calving season were used to develop the following intervention strategies that were implemented during 1993: heifers calved in a separate location, diarrheal calves and their dams were placed in a quarantine area, and pregnant cattle were fed a diet supplemented with protein and copper. The risk of calves developing diarrhea was 5 times higher during the first year, compared with the second year, suggesting that the management changes made during the second year were contributing factors in reducing the percentage of calves with diarrhea. The risk of diarrhea developing in calves born to heifers was 3.9 times greater than that in calves born to cows. Analysis of our data indicated that the use of an epidemiologic approach can identify risk factors, which can lead to the development of intervention procedures that may decrease the incidence of diarrhea in calves in beef herds.

Animals↗
PubMed1988

Knowledge and beliefs regarding the consequences of cigarette smoking and their relationships to smoking status in a biracial sample.

The purpose of this investigation was to evaluate carefully smoking-related knowledge and beliefs and their relationships to smoking status in a large, heterogeneous sample of smokers and nonsmokers in two settings: (a) a large, biracial southern city and (b) a small midwestern community. Participants were 611 (198 male, 413 female) adult respondents to a random-dialing telephone survey in Fargo, North Dakota (n = 200), and Memphis, Tennessee (n = 411). Each participant was given the Smoking Attitudes Survey, which assesses generalized health beliefs as well as health-related problems associated with smoking. Participants' knowledge of smoking-associated diseases (e.g., lung cancer) and of diseases not associated with smoking (e.g., kidney stones) was assessed. Stepwise regression analysis of composite knowledge scores revealed four independent predictors of the health consequences of smoking: education, race, smoking status, and income. Smokers, compared to nonsmokers, reported less knowledge related to the health consequences of smoking, were more likely to be male, were less concerned with the health consequences of smoking, and were more concerned about the health consequences of cholesterol. The best predictor of smokers who had never attempted cessation was their greater concern over weight control when compared to smokers with a history of smoking cessation attempts. The results are discussed in terms of smoking prevention and intervention efforts.

Black or African American↗
PubMedDate not supplied

Mineral deficiency and the use of the FETAX bioassay to study environmental teratogens.

The Frog Embryo Teratogenesis Assay: Xenopus (FETAX) bioassay has been employed extensively to screen compounds for teratogenic activity. Recent laboratory studies have indicated that low potassium concentrations retard Xenopus laevis development. The effects of varying concentrations of minerals on Xenopus laevis embryo length and development were examined to determine the utility of the FETAX bioassay in the study of environmental teratogens. Water samples collected from 18 wetlands in Minnesota and North Dakota correlated with low mineral levels, causing delayed embryonic development in the FETAX bioassay. When the concentration of sodium or potassium was <5 ppm, Xenopus laevis development was delayed. As a result, it was difficult to assess teratogenic activity after 96 h of incubation. Furthermore, the length of the embryos-an indication of development-paralleled changes in mineral composition. Comparisons between different wetlands based on changes in one specific mineral were not possible due to a synergism between various minerals. If the concentration of sodium and/or potassium was <5 ppm but > or =2 ppm, extension of the FETAX bioassay to 120 h allowed organogenesis to proceed through stage 46, as required for scoring in accordance with ASTM guidelines for the FETAX bioassay. In those cases in which the concentration of sodium and/or potassium were <2 ppm, the embryos could not develop to stage 46 within 120 h and the FETAX bioassay was not suitable for detecting teratogenic activity. Published in 2002 by John Wiley & Sons, Ltd.

Animals↗
PubMed2006

Performance of medical students in a nontraditional rural clinical program, 1998-99 through 2003-04.

PURPOSE: To compare knowledge acquisition as measured by test scores for students in nontraditional clinical clerkships to scores for students in traditional urban hospital-based clerkships. Interdisciplinary and continuity-of-care clerkships in rural areas are the focus of the study. METHOD: All the students' Medical College Admission Test (MCAT) scores, National Board of Medical Examiners (NBME) subject exam scores, and United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores over a six-year period, 1998-99 to 2003-04, were compared for third-year students in nontraditional and traditional clerkships at the University of North Dakota School of Medicine and Health Sciences. Cohorts were 29 students in our Rural Opportunities in Medical Education (ROME) program and 296 students in traditional third-year clerkships. NBME subject exam scores were those in pediatrics, internal medicine, surgery, and obstetrics and gynecology. The exam used for family medicine is not standardized to national standards, but controlled within the Department of Family Medicine. MCAT and USMLE Step 1 scores were used as a means of controlling for prior academic achievement and ability. RESULTS: There were no significant differences (p > or = .05) in MCAT scores, Step 1 scores, subject exam scores, or Step 2 scores between the two groups. In contrast, students from ROME scored higher (p < or = .05) on the internal medicine clinical preceptor assessments than did students from the traditional track. CONCLUSIONS: These findings suggest that students in remote, rural, longitudinal, integrated learning environments can attain fund-of-knowledge scores comparable to the scores of students in traditional clerkships, and may, as in this study, receive higher ratings for clinical proficiency.

Clinical Clerkship↗
PubMedDate not supplied

Capitation reimbursement: a progress report.

A capitation reimbursement experiment for inpatient hospital services was initiated in North Dakota and Massachusetts four years ago. The per capita fixed payment program provided participating hospitals with incentives to economize that are similar to those which physicians have in health maintenance organizations. The relationship between the insurance carrier (Blue Cross) and participating accounts (business firms) and subscribers did not change. At Harrington Memorial Hospital actions were taken to increase efficiency and effectiveness, expand market share, and address medical practice issues. The favorable variance in the total average charge per case between the treatment of patients at Harrington (home-hospital) versus other institutions (host-hospitals) was increased. The less expensive treatment at Harrington helped to produce a capitation surplus of $143,123 for home hospital claims. Final data for host hospital claims for FY 1982-1984 is not currently available. The most recent estimate indicates that Harrington will achieve an overall financial surplus of $312,406. At final settlement, the hospital will retain 75% of the surplus and Blue Cross will receive 25%.

Blue Cross Blue Shield Insurance Plans↗
PubMed2002

Pharmacy services in rural areas: is the problem geographic access or financial access?

Access to pharmacy services is an important rural health policy issue but limited research has been conducted on it. This article describes rural retail pharmacies in Minnesota, North Dakota, and South Dakota, including their organizational characteristics, staffing, services provided, and planned future changes; examines the availability of pharmacy services and pharmacy closures in rural areas of these three states; and briefly discusses policy issues that affect the delivery of pharmacy services in rural areas. Study data came from a phone survey of 537 rural pharmacies, an analysis of pharmacy licensure data, and phone interviews with clinic, public health, and social services staff in rural communities with potential pharmacy access problems. Using a standard of 20 miles to the nearest pharmacy, most rural residents of these three states currently have adequate geographic access to pharmacy services. However, rural pharmacists and clinic, public health, and social services staff rate financial access to pharmacy services for the elderly and the uninsured as a major problem. Key policy issues that will affect future access to pharmacy services in rural areas include pharmacy staffing and relief coverage; alternative methods of providing pharmacy services; thefinancial viability of rural pharmacies; and the potential impact of a Medicare prescription benefit on rural consumers and rural pharmacies.

Geography↗
PubMed2003

The attention-deficit hyperactivity disorder paradox: 2. Phenotypic variability in prevalence and cost of comorbidity.

The objective of this study was to use population-based data to estimate the cost and phenotypic variation of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). The North Dakota Department of Health's Claims Database was used to estimate the administrative prevalence, rates of comorbidity, and cost of care for subjects with ADHD. The case population was 7745 children. We then examined the 10 most frequent comorbidities for a defined condition in the International Classification of Diseases-9th edition (ICD-9). The observed prevalence of general health conditions was 12 to 70% less than expected. The presence of a comorbid condition resulted in increases in costs of care of dollar 381 to dollar 731 per case per year. The observed prevalence of comorbid mental health conditions was 97 to 5286% higher than expected. The prevalence of conditions comorbid with ADHD varies widely, with rates of general medical conditions decreased and rates of most mental disorders increased. The costs for comorbidity with general health conditions were offset by large decreases in prevalence rates compared with controls. We identified an ADHD paradox: decreased rates of comorbid general health conditions and increased rates of comorbid mental disorders. Further research on comorbidity in ADHD is required.

Attention Deficit Disorder with Hyperactivity↗
PubMedDate not supplied

Complementary therapy and older rural women: who uses it and who does not?

BACKGROUND: Despite the growing use of complementary therapy by consumers in the United States, very little is known about the factors associated with the use of these therapies among older rural women. OBJECTIVE: The aim of this study was to answer the following research question using data from a portion of a larger study: What factors predict the use of complementary therapy among older rural women? METHODS: Data were collected by telephone interview from a random sample of older residents of 19 rural towns in Montana and North Dakota. Interviews were conducted using a guide that included questions about the use of allopathic and complementary healthcare and related issues such as health status, health problems, and reasons for seeking care. A direct logistic regression analysis was performed on the use of complementary or alternative medicine (CAM) as outcome and eight potential predictors. Data from 156 women were included in this analysis. RESULTS: A total of 25.6% (n=40) of the women reported using CAM in the recent past. Rural women most likely to use CAM were those who were fairly well educated, not currently married, and in their early older years. They had one or more significant chronic illnesses and lower health-related quality of life due to emotional concerns. DISCUSSION: By improving the existing understanding of who is or is not likely to use CAM, the results of this study can be used in giving comprehensive care for rural women, including all healthcare practices, self-care and practitioner provided, and complementary and conventional.

Age Factors↗
PubMed1991

Educational achievement in non-verbal children: are they learning disabled?

From a data-base of all nonspeaking children in North Dakota we analyzed the data on those children functioning above the retarded range to determine the prevalence of children meeting the main inclusion criteria for learning disabilities (LD), a severe discrepancy between IQ and achievement. The mean IQ for this group of 38 nonspeaking, nonretarded children of 104.0 was significantly higher than IQ equivalent scores in the academic subjects of reading (66.4), math (70.4), written language (65.2), and spelling (71.2). Using a stringent criterion for an IQ-achievement discrepancy of 2 standard deviations, 27 of 38 (71%) met this criterion in at least one subject. Academic subjects dependent upon higher linguistic functioning, written language and reading, were more affected than spelling and math. While the vast majority (73%) of these 38 children were deaf, the prevalence of IQ-achievement discrepancies was also found in 57% of the nonspeaking children without hearing impairments. These data suggest the common practice of excluding a diagnosis of a learning disability in a deaf child on the basis of the child's hearing impairment may not be appropriate. Further research is needed on the role of speech in academic achievement.

Achievement↗
PubMed2003

Impact of smoking on cancer stage at diagnosis.

BACKGROUND: Studies evaluating the relationship between smoking and cancer spread are limited. METHODS: We studied the relationship between cancer stage at diagnosis (local, regional, or metastatic) and smoking history (current, previous, or nonsmoker). For lung cancer, patterns of spread were also studied. RESULTS: In a tumor registry for eastern North Dakota, northwestern Minnesota, and northern South Dakota, 11,716 cases were identified from 1986 to 2001. Current smokers (relative risk [RR], 2.11; 95% confidence interval, 1.93 to 2.32; P <.001) and previous smokers (RR, 1.56; 95% confidence interval, 1.42 to 1.72; P <.001) had an increased risk of metastatic disease at diagnosis. Current smokers (RR, 1.39; 95% confidence interval, 1.29 to 1.51; P <.001), but not previous smokers, also had an increased risk of regional disease. An increase in metastatic disease was most evident for prostate cancer (RR, 1.53; P =.003). An increase in regional disease was most evident for head and neck (RR, 3.53; P <.001), prostate (RR, 1.83; P =.030), and breast cancer (RR, 1.22; P =.005). Compared with previous smokers, current smokers with metastatic lung cancer were more likely to have involvement of the brain (33.6% v 23.0%; P =.004), bone marrow, adrenal gland, and pericardium (24.7% v 15.9%; P =.004). CONCLUSION: Previous or current smoking is a risk factor for increased cancer stage in a wide range of malignancies. Further study is required to determine whether this association is causal.

Adolescent↗
PubMed1995

Community perceptions of rural hospital closure.

Hospital closure, a devastating event in the life of small communities, can have long-lasting medical, economic, and psychological consequences. This study focuses on a 1991 closure that occurred in the rural North Dakota town of Beach that left local residents 40 and 61 miles away from the nearest hospitals. Two hundred residents of the hospital's former service area were selected via systematic random sampling to share their perceptions on the causes and effects of closing their local hospital. According to respondents, this hospital closure was caused by a number of influences, with the most commonly cited being under-utilization of services by local residents, exacting government rules and regulations, doleful economic climate, dwindling population, poor and unstable local physician care, and poor management of hospital matters. Findings further indicated that Beach area residents were most concerned with poor access to emergency medical care as a result of the closing. Area dwellers perceived that the hospital closure's aftermath would include the loss of local jobs, further declines in the local economy, the suffering of elderly and children, transportation problems, and out-migration of some area residents. These concerns, coupled with the notable decrease in hospital care access, motivated many area residents to think of solutions to these problems rather than to place blame on others for the closure.

Aged↗
PubMed2004

Evaluation of an outbreak of West Nile virus infection in horses: 569 cases (2002).

OBJECTIVE: To characterize an outbreak of West Nile virus (WNV) infection in horses in North Dakota in 2002, evaluate vaccine effectiveness, and determine horse characteristics and clinical signs associated with infection. DESIGN: Retrospective study. ANIMALS: 569 horses. PROCEDURE: Data were obtained from veterinary laboratory records, and a questionnaire was mailed to veterinarians of affected horses. RESULTS: Affected horses were defined as horses with typical clinical signs and seroconversion or positive results of virus isolation; affected horses were detected in 52 of the 53 counties and concentrated in the eastern and northeastern regions of the state. Among affected horses, 27% (n = 152) were vaccinated against WNV, 54% (309) were not, and 19% (108) had unknown vaccination status; 61 % (345) recovered, 22% (126) died, and 17% (98) had unknown outcome. The odds of death among nonvaccinated horses were 3 and 16 times the odds among horses that received only 1 or 2 doses of vaccine and horses that were vaccinated according to manufacturer's recommendations, respectively. Horses with recumbency, caudal paresis, and age > 5 years had higher odds of death, whereas horses with incoordination had lower odds of death, compared with affected horses without these characteristics. CONCLUSIONS AND CLINICAL RELEVANCE: Vaccination appears to have beneficial effects regarding infection and death caused by WNV.

Animals↗
PubMed1991

Hospital choice of Medicare beneficiaries in a rural market: why not the closest?

As part of a larger study of hospital choice, the travel patterns of more than 12,000 Medicare beneficiaries residing in three overlapping rural areas were examined. During 1986 these Medicare beneficiaries were admitted to one of 53 hospitals in an area that encompassed parts of Minnesota, North Dakota, and South Dakota. Information on ZIP code of residence, closest hospital, and hospital of admission were used to analyze hospital choices of the Medicare rural elderly residing in this area. To summarize their travel patterns, the admitting hospital was categorized based on whether it was urban or rural, its size and whether or not it was the closest facility. Findings indicated that 60 percent of these rural Medicare beneficiaries used hospital services at their closest rural hospital, regardless of its size. However, 79 percent of those whose closest hospital was larger than 75 beds used it, while only 54 percent of those whose closest rural hospital was fewer than 75 beds obtained services there. Overall, 30 percent of those residing in this rural market area went to an urban hospital. These patterns appeared to reflect an evaluation by the physician and/or individual of the relative attractiveness of the local hospital versus alternatives available, as well as the individual's characteristics. Travel patterns varied by the beneficiary's age as well as his or her relative complexity of illness, as measured by a Disease Staging methodology. Findings have implications for the provision and financing of hospital services in rural areas.

Aged↗
PubMed2003

Measuring inter-rater reliability of the sequenced performance inventory and reflective assessment of learning (SPIRAL).

PURPOSE: To measure the inter-rater reliability of the Sequenced Performance Inventory and Reflective Assessment of Learning (SPIRAL), a twenty-three item scoring rubric designed to assess first and second-year students' competencies such as "acquisition of knowledge," "peer teaching and communication skills," and "professional behavior" in a problem-based learning (PBL) curriculum at the University of North Dakota School of Medicine and Health Sciences. METHOD: In 2001, the authors constructed a 69-item multiple-choice questionnaire consisting of descriptions of "prototypical" (representing real students) PBL student performances. For each of the 23 SPIRAL items, the authors chose competency descriptions of an "emerging," a "developing," and an "advanced" student (69 prototypical students). These descriptions were obtained from narrative comments by PBL facilitators of real students in their classes in 2000-2001. Seventeen experienced facilitators (PBL tutors) were subsequently asked to rank the 69 prototypical students based on SPIRAL anchor points in the three competency levels. Kendall's coefficient of concordance was used to test inter-rater reliability. Modes were also determined to illustrate the extent to which the ratings of the 17 facilitators aligned with the ratings anticipated by the authors. RESULTS: Overall, inter-rater scoring for all items combined was considered to be reliable (Kendall's coefficient of concordance W =.75). Inter-rater scoring was also determined for each of the 23 SPIRAL items, with Ws ranging from.97 to.53. Facilitators rated students according to 55 of the 69 SPIRAL descriptors as the researchers anticipated. CONCLUSIONS: The scoring rubric is reliable. Further criterion-related validation study is warranted.

Clinical Competence↗
PubMed2006

Molecular characterization and antibiotic resistance profiling of Salmonella isolated from retail Turkey meat products.

Contaminated poultry meat has been identified as one of the principal foodborne sources of Salmonella. Molecular characterization of Salmonella is important in addressing methods to control this pathogen. Seventy-four retail turkey meat samples were collected from various stores in Fargo, North Dakota in the fall of 2003. Salmonella was recovered from 30 samples using the standard conventional culture method (FSIS, USDA). Isolated Salmonella were characterized by serotyping, pulsed-field gel electrophoresis (PFGE) analysis, plasmid analysis, and antibiotic resistance profiling. Five serotypes were identified among the isolates: Newport (n = 12), Hadar (n = 8), Heidelberg (n = 7), 4,12:nonmotile (n = 2), and Reading (n = 1). XbaI PFGE analysis revealed 13 PFGE types and succeeded in grouping the isolates according to their serotypes. Plasmid profiling identified 5 plasmid types (with 1 or 2 plasmids) among eleven isolates that harbored plasmids. Seventeen isolates were resistant to antibiotics. The Heidelberg serotype showed resistance to multiple antibiotics: 1 isolate had resistance to gentamicin, sulfamethoxazole, and streptomycin, and 6 isolates had resistance to tetracycline, gentamycin, sulfamethoxazole, kanamycin, and streptomycin. The Hadar serotype isolates were resistant to 2 or 3 antibiotics: tetracycline and streptomycin (1 isolate); tetracycline and kanamycin (1 isolate); and tetracycline, kanamycin, and streptomycin (6 isolates). The 4,12:nonmotile serotype isolates showed resistance to tetracycline only. The Newport and the Reading serotypes were susceptible to all 16 of the antimicrobials tested.

Animals↗
PubMed2006

Exposure to second-hand smoke air pollution assessed from bar patrons' urinary cotinine.

We used physical and pharmacokinetic modeling to estimate personal exposures to respirable particle (RSP) and carcinogenic particulate polycyclic aromatic hydrocarbon (PPAH) air pollution from second-hand smoke (SHS) from the increase in urinary cotinine of eight patrons of three bars in Bismarck, North Dakota. We compared SHS-RSP levels to the U.S. Air Quality Index (AQI), used to forecast outdoor air pollution conditions. We measured smoker density and air exchange rates to generalize our results. Urinary cotinine increased by an average of 4.28 ng/ml to 6.88 ng/ml to 9.55 ng/ml above preexposure background from 6-hr exposures in the three bars. Corresponding estimated SHS-RSP levels were, respectively, 246 microg/m3, 396 microg/m3, and 549 microg/m3, comparable to those measured in 6 Wilmington, Delaware, bars and in 14 western New York bars. Estimated personal SHS-RSP air pollution exposures for the eight subjects, when converted to the 24-hr averaging time of the AQI, were "code red" (unhealthy). Measured outdoor air quality RSP levels for the same period were 1%-3% of the indoor RSP levels in the three bars, and were AQI "code green" (healthy). Estimated SHS-PPAH levels were comparable to peak 3-hr PPAH levels reported at a highway tollbooth. Bismarck cotinine-estimated SHS-RSP varied with smoker density, as did measured SHS-RSP levels in smoking bars in Delaware and New York. Our results show that smoking in bars produces levels of personal air pollution for bar patrons that merit air pollution alerts when sustained in the outdoor air.

Adult↗
PubMed2004

Prophylactic cranial irradiation in limited-stage small-cell lung cancer: a retrospective analysis.

OBJECTIVE: It is well established that prophylactic cranial irradiation (PCI) decreases significantly the incidence of brain metastases (BM) and increases overall survival in limited-stage small-cell lung cancer (LS-SCLC) patients with complete response to induction therapy. The aim of this study was to complete a review analysis of PCI use among patients diagnosed with LS-SCLC in a community hospital. METHOD: A retrospective review of medical charts of patients diagnosed with LS-SCLC between January 1997 and December 2002 at a local community hospital in Fargo, North Dakota, was done to determine which of these patients subsequently received PCI. Data on patient's age, gender, body mass index at diagnosis, SCLC anatomical site, other comorbidies at diagnosis, treatment of SCLC, chemotherapeutic agents used at diagnosis of SCLC, response to induction treatment, PCI use, reason(s) for no PCI, BM status, BM site, metastases to other sites, and survival were abstracted. RESULTS: A total of 32 patients with LS-SCLC were identified. Twenty-three (71.9%) of the patients received concurrent chemotherapy and radiation therapy. Of the remaining 9 (28.1%) patients, 6 (18.7%) did not receive any treatment because of poor performance status, and 3 (9.4%) received only chemotherapy because of coexisting comorbidity. Thirteen (40.6%) of the patients achieved a complete response but only 4 (30.8%) patients had PCI. Among the 9 (69.2%) patients who appeared eligible to receive PCI, 1 (11.2%) refused, 4 (44.4%) had coexisting comorbidities, and 4 (44.4%) had no notes indicating why they did not receive PCI. Of those who had PCI, only 1 (25%) patient developed BM 35 months later. CONCLUSION: This review found that although only a few patients were eligible to receive PCI, nevertheless, the benefits could be significant. We concluded that oncologists should be more willing to offer this procedure.

Aged↗