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PubMed1996

Spinal manipulation as a valid treatment for low back pain.

The practice of chiropractic has been regulated in the State of Delaware since 1937. Since that time, the battle lines in the state between medicine and chiropractic have been drawn. This war has existed on both the political and clinical fronts, and although it has always been believed by the chiropractic profession that once the "scientific evidence" of the benefit of chiropractic was proven, the war would end. This has not occurred to the extent believed. Even with its 1980 victory over the AMA, chiropractic has still been unable to achieve full acceptance as a clinical discipline among other professions. Many hospitals in this country have opened their doors to DCs. This by and large, has solely been for economic reasons and not as a recognition of the clinical benefit of manipulation. There is, however, a growing population of primary care physicians and researchers suggesting the benefit of manipulation for low back pain as well as suggesting that increased cooperation between MDs and DCs could be of extreme benefit to the patient population at large. This group continues to be in the minority. However, with increased knowledge of the benefits of spinal manipulation and the scientific evidence that now exists to support its efficacy, it is now believed that this interprofessional referral pattern will increase. In addition, many managed care programs now require primary care physicians to determine the necessity for referral to a chiropractor, thus causing a need for the primary physician to have some knowledge of spinal manipulation. This paper is presented to inform the physician community of Delaware of some of the evidence pointing to the efficacy of spinal manipulation as a treatment for low back pain.

Chiropractic↗

PubMed1997

Improving childhood immunizations in a family practice office.

PURPOSE: In the fall of 1993, the Family Medicine Center (FMC) of the Medical Center of Delaware instituted an office-based program designed to improve preventive care for children. This study examined whether the "Pediatric Prevention Program" (PPP) resulted in an improvement in childhood immunization rates for FMC patients. METHODS: Using chart review, we compared the percentage of two-year-old FMC patients who had completed appropriate immunizations before and after the PPP. We examined completion rates for the primary series of each immunization, for booster immunizations and for the combined total immunization series (four DPTs, three OPVs, one MMR, four HIBs). We also determined whether immunization rates were affected by patient demographics, pattern of office visits, and physician level of experience. RESULTS: After implementation of the program, the percentage of 2-year-old children who had completed the appropriate immunizations increased for all types of immunizations. The increase was greatest for HIBs (6 percent for the primary HIB series and 7 percent increase for the HIB booster) and for the combined total series (10 percent increase). Children who made few office visits were the least likely to have completed immunizations, but also saw the greatest benefit from the PPP. CONCLUSIONS: This study shows the positive impact of an office-based intervention for improving childhood immunizations. However, the improvements are relatively small and not sufficient to achieve optimal immunization rates throughout the community. In order to achieve these goals, additional interventions are needed which target high risk children, especially those who change physicians or who visit their physician infrequently. Targeting such children will likely require better data systems to track immunizations both in the office and across the community. These efforts should be given a high priority in Delaware.

Child, Preschool↗

PubMed1988

Act of 11 July 1988.

This Act establishes a registry of all sperm banks and tissue banks operating in Delaware. It requires all donors of semen for the purposes of artificial insemination, or donors of corneas, bones, organs, or other human tissue for the purpose of injecting, transfusing, or transplanting them in the human body to be tested for evidence of exposure to the AIDS virus.

AIDS Serodiagnosis↗

PubMed1996

Preventable disease in correctional facilities. Desmoteric foodborne outbreaks in the United States, 1974-1991.

BACKGROUND: Various disease outbreaks have been reported among prisoners. Recent foodborne outbreaks in correctional facilities in Georgia and Delaware prompted us to review the epidemiological characteristics of such outbreaks reported in the United States. METHODS: Foodborne outbreaks reported to the Centers for Disease Control and Prevention as part of routine surveillance from 1974 to 1991 were examined to identify outbreaks in jails, prisons, correctional facilities, and juvenile detention centers. Outbreak sizes, temporal trends, food vehicles, pathogens, and hygienic transgressions were analyzed. RESULTS: Eighty-eight desmoteric foodborne outbreaks involving 14307 cases of illness were reported from 31 states and territories. The mean outbreak size was 163 cases, compared with a mean of 31 cases for the 9107 reported outbreaks not involving prisoners. No fatalities among prisoners were reported. No pathogen was identified in 47 (53%) of the 88 outbreaks Salmonella species accounted for 15 (37%) of 41 outbreaks of known cause from 1974 to 1991, Clostridium perfringens for 14 (34%), and Staphylococcus aureus for 9 (22%). Fourteen of 15 Salmonella outbreaks occurred from 1984 to 1991. Food vehicles were reported for 63 (72%) of the outbreaks. Beef and poultry each were implicated in 9 (14%) of these, followed by fish or poultry salads and Mexican food, which accounted for 6 outbreaks (10%). Food-handling errors were reported for 69 (78%) of the 88 outbreaks. Improper food storage was reported in 62 (90%) of these. CONCLUSIONS: Foodborne outbreaks are reported regularly from correctional facilities in the United States. Outbreaks caused by Salmonella species, a special threat to prisoners with human immunodeficiency virus infection, seem to be increasing. Food production in correctional facilities should meet minimum safety standards, including sufficient refrigeration facilities, training of food handlers, and exemption of ill food handlers from work.

Centers for Disease Control and Prevention, U.S.↗

PubMed2004

Racial variations in causes of vision loss in nursing homes: The Salisbury Eye Evaluation in Nursing Home Groups (SEEING) Study.

OBJECTIVE: To determine the prevalence and causes of low vision in a large sample of nursing home residents. METHODS: Twenty-eight nursing homes on the Eastern Shore of Maryland and Delaware were enrolled in a clinical trial to assess the impact of vision restoration/rehabilitation on nursing home residents. Visual acuity was measured using both recognition charts and preferential looking techniques. An ophthalmologist examined all residents with visual acuity worse than 20/40 in the better-seeing eye and determined the primary cause for decreased vision. Results are reported for the better-seeing eye. RESULTS: Of 2544 eligible residents, 1591 (63%) participated, but 286 residents were unable to respond to visual acuity testing. Of the remaining 1307 residents, 496 (37%) had best-corrected visual acuity worse than 20/40 in the better-seeing eye. Causes were ascribed for 412 subjects. Rates of low vision were similar between African American subjects and white subjects (39% and 38%, respectively; age-adjusted P =.18). Cataract was the leading cause of low vision, responsible for 37% of low vision among white subjects and 54% of low vision among African American subjects. Macular degeneration was responsible for 29% of low vision among white subjects but only 7% among African American subjects. Glaucoma caused low vision in 4% of white subjects and 10% of African American subjects. Refractive error was not a frequent cause of low vision in nursing home residents. CONCLUSIONS: Low vision is highly prevalent among nursing home residents, with 37% having visual acuity worse than 20/40 in the better-seeing eye. Differences in causes of low vision between African American subjects and white subjects were noted, with African American subjects more likely to have vision loss on the basis of cataract, a readily treated condition. Appropriate interventions for nursing home residents, who face significant obstacles in accessing eye care services, have the potential to improve the quality of life of this at-risk older population.

Aged↗

PubMed2005

Poor uptake of cataract surgery in nursing home residents: the Salisbury Eye Evaluation in Nursing Home Groups study.

OBJECTIVE: To compare the uptake of cataract surgery in nursing homes in which assistance was provided in obtaining services with that in control homes. METHODS: The Salisbury Eye Evaluation in Nursing Home Groups (SEEING) project is a randomized clinical trial studying the effect of a comprehensive vision restoration-rehabilitation program, including the provision of cataract surgery services when needed. Twenty-eight nursing homes in the Eastern Shore area of Maryland and Delaware were matched in pairs by size and payment type. Nursing homes within each pair were randomized to usual care or targeted intervention. Persons with cataract causing visual acuity in the better eye to be worse than 20/40 were informed of the possible benefit of cataract surgery. For those in intervention homes, additional support was provided in obtaining cataract surgery. RESULTS: Of residents with vision-impairing cataract in intervention homes, 31% underwent cataract surgery vs 2% in usual-care facilities. Residents with cataract compared with all residents without visual impairment, regardless of nursing home assignment, tended to be older (mean age, 86.7 vs 82.1 years; P<.001), were more likely to be black (age-adjusted P<.001), had lower Mini-Mental State Examination scores (mean, 11.7 vs 16.2; age-adjusted P<.001), and longer length of stay (mean, 42.3 vs 24.4 months; P<.001). Furthermore, cataract was associated with significant visual impairment and with functional limitations, with 20% of those recommended for surgery having a visual acuity of 20/100 or worse in the better-seeing eye. CONCLUSIONS: Screening for and identifying cataracts as a cause of vision loss rarely results in uptake of cataract surgery services in nursing homes. The addition of a support system to facilitate the process of scheduling surgery and getting to and from the hospital dramatically increases uptake rates.

Aged↗

PubMedDate not supplied

Exploring perceptions of smoking cessation among high school smokers: input and feedback from focus groups.

BACKGROUND: Despite many approaches to smoking cessation for youths, few programs have been thoroughly evaluated and found successful. To help the American Medical Association develop, implement, and evaluate an effective program, formative research was conducted. METHODS: Four focus groups were conducted with high school smokers in the Chicago area to obtain input into interventions. Subsequently, five similar focus groups were conducted in Delaware and Denver, and a focus group of school health providers was conducted as well, to obtain feedback on a draft protocol and ideas. RESULTS: Participants did not consider quitting smoking serious or urgent. They are unfamiliar with the idea of a smoking cessation program. People they would trust to help them quit include people who care about them, successful quitters, and psychologists. They had mixed reactions to physicians. They did not trust school personnel and locations. Participants found it hard to imagine what might draw them to a cessation program, except money, small enticements, and short sessions. They might keep coming to progress toward their own objectives or for interesting activities. Lecturing, nagging, and preaching would repel them. They doubted that a program would do anything else. They were highly sensitive about confidentiality. CONCLUSIONS: Attracting participants is critical. Program component ideas include personal physicians; adding other topics for a more attractive bundle; ensuring confidentiality; and ensuring no lecturing, preaching, or nagging.

Adolescent↗

PubMed1994

Quantitative assessment of groundwater quality using a biological indicator: some preliminary observations.

The genotoxicity of groundwater was evaluated, using a novel application of the SOS microplate assay (SOSMA). Organic residues were extracted from groundwater samples from Maryland, Pennsylvania, and Delaware by using C-18 bonded silica solid phase extraction tubes. Total organic carbon content (TOC) of water samples was also determined. The genotoxicity of the extracts was determined by the SOSMA. Relative activity (RA) as determined by the SOSMA is a quantitative measure of genotoxicity based on a comparison to the activity of the mutagen, 4-nitroquinoline oxide. Low levels of RA (about 2x background) were detected in waters from sites within these states. There was considerable temporal and spatial variation in the observed RA, but no definite patterns were observed in the variation. Between sampling sites there was a positive correlation between RA and TOC; however, this relationship appeared to be reversed occasionally within a sampling site. The extraction and bioassay methods provide an easy and relatively inexpensive means of determining water quality.

Delaware↗

PubMed1990

Dietitians' beliefs about the importance of health promotion practices.

Registered dietitians throughout the state of Delaware (N = 146) were surveyed by mail to assess their beliefs about the importance of health promoting behaviors to the health of the average person. Respondents were instructed to rate each of 25 health promotion practices on a Likert scale. Results were compared with investigations of other health care providers. "Eating a balanced diet" was rated among the top five items. "Taking vitamin supplements" received the lowest mean rating. Results of the present study compared well with the beliefs of pharmacists and physicians. Ratings by other registered dietitians from an earlier study tended to be more conservative. Dietitians are supportive of health promotion and disease prevention. Their current role in health promotion activities needs further investigation.

Adult↗

PubMed1996

Medical waste in the environment: do anesthesia personnel have a role to play?

STUDY OBJECTIVE: To conduct a feasibility study of the mechanics of recycling single-use anesthesia breathing systems and practices of anesthesiologists and nurse-anesthetists in a tri-state region. STUDY DESIGN: Two-part, open, prospective analysis using pre-printed questionnaire and cost/time analysis of labor and materials. SETTING: Questionnaire sent to 413 anesthesiology departments in Pennsylvania, New Jersey, and Delaware, and hospital/recycling facility for evaluation of time and cost. MEASUREMENTS AND MAIN RESULTS: Time to disassemble and sort the breathing circuits, analysis of costs and obtainable income from byproducts of recycling, and standard survey questionnaire concerning demographic characteristics of respondents and individual department/hospital practitioners. Data analysis included analysis of variance and Kruskal-Wallis tests. Pilot analysis: Sorting of circuits to economic component required ten minutes at an average cost of $1.60 Value of scraps obtainable was $3.44, leaving a gross margin of $1.84 for a box of 18 circuits. Benefit analysis: Extended reduction in the regulated medical waste in our operating room of 16,875 lb, saving $4,387.50 per year. With generation of revenue from scrap, the net gain is $5,994.64 per yr. Questionnaire: Majority (83%) of departments polled would participate in recycling implemented by suppliers. Most respondents would not consider (58%) recycling unless mandated by law. CONCLUSION: The program described is cost-effective and environmentally beneficial.

Anesthesiology↗

PubMed2005

Treatment during transition from prison to community and subsequent illicit drug use.

This study examined the effects of postrelease transitional therapeutic community treatment on the drug use and employment rates of drug involved prisoners in the Delaware corrections system followed for up to 5 years after release. A comparison group received standard postrelease supervision. Abstinence rates were 32.2% in the treatment group and 9.9% in the no-treatment group, and the treatment group had a higher overall proportion of time free of drug use. Time to relapse was a mean of 28.8 months in the treatment group versus 13.2 months in the no-treatment group. Relapse was defined as any use of any drug and was confirmed by urinalysis. Positive effects were seen even for those who did not complete treatment. The treatment group had a significantly higher rate of employment after leaving work release (54.6%) than did the no-treatment group (45.4%). Treatment during the transitional period between prison and community showed substantial and persistent benefits even for a cohort marked with extensive criminal history, low rates of marital bonds, and substantial unemployment.

Adult↗

PubMed2006

Factors affecting detoxification readmission: analysis of public sector data from three states.

The objective of this study was to understand the rate of detoxification readmissions and the factors associated with readmission within a public sector population. The study sample was drawn from an integrated database that includes Medicaid and state mental health and substance abuse agency data from three states (Delaware, Oklahoma, and Washington) for 1996-1998. Clients with at least one state agency-sponsored detoxification event in 1996 or 1997 were included in the study. Twenty-seven percent of the sample was readmitted for detoxification within 1 year of their index detoxification. Clients who received two or more substance-abuse-related services within 30 days of their index detoxification were less likely to be readmitted and had a longer time until their second detoxification admission. Detoxification readmission is common in the public sector. Engaging patients in treatment following detoxification may reduce readmission rates and time to readmission.

Adult↗

PubMed1999

Metal and sediment ingestion by dabbling ducks.

The chemical analysis of intestinal digesta from hunter-killed carcasses or of wildlife scat is a promising means of estimating the exposure of wildlife to those environmental contaminants that, like lead, are poorly absorbed in the digestive tract. When evaluating contaminants at a site, biologists may find the results of this non-destructive approach more straightforward to interpret in terms of exposure to wildlife than would be analyses of soils, sediments, water, or wildlife tissues. To illustrate the approach, we collected digesta from 47 waterfowl shot by hunters at Prime Hook National Wildlife Refuge, in Delaware, USA. The waterfowl digesta contained an average of approximately 2.4% sediment, estimated from the Al concentrations in the digesta, a marker for sediment. Al concentrations were significantly correlated with concentrations of Cr (Spearman's rank correlation coefficient, r = 0.57), V (r = 0.70), Ni (r = 0.31), and Pb (r = 0.55), and we concluded that these metals were ingested mainly with sediment. American widgeon (Anas americana) ingested sediment at a rate of about four times that of three other species of dabbling ducks (Anas crecca, A. acuta, A. rubripes) and had several times the exposure to the sediment-associated metals. The digesta of one American black duck contained a high concentration of lead (70 mg/kg, dry wt.), presumably from lead shot, but none of the other samples had notably elevated metal concentrations. We suggest that scat and digesta be analyzed more widely by biologists and resource managers seeking a simple, inexpensive assessment of contaminants in local wildlife habitat.

Aluminum↗

PubMed2002

Evaluating component effects of a prison-based treatment continuum.

A continuum of correctional-based therapeutic community (TC) treatment programs for drug-involved offenders has been functioning for several years in Delaware. Previous evaluations have shown the efficacy of the full continuum for up to three years posttreatment, though there has been some question of the benefits of treatment within prison. The particular focus here is on the relative impact of the within-prison, transitional, and aftercare treatment components upon criminal recidivism and relapse to illicit drug use. The relative benefit of participation in each component is supported, over and above the effects of differences in demographics and histories of criminal behavior and illicit substance use. However, the residential transitional program effects are generally larger and more long lasting. Additionally, the two outcomes appear differentially sensitive to the degree of completion of the continuum.

Continuity of Patient Care↗

PubMed1996

Development, testing, and validation of two scales measuring nursing home management of subjects with mental disorder.

This paper describes the development, testing, and validation of summary scales measuring nursing processes commonly used in caring for elderly nursing home residents with cognitive, mood, and behavior problems, or other markers of mental disorder. Data were obtained from a cross-sectional study of 1017 residents from a proportionate random sample in Delaware nursing facilities, to determine the prevalence of mental disorders and to describe distinguishing characteristics and treatments. An exploratory factor analysis was performed on 11 frequently encountered nursing management strategies as applied to 808 subjects with some indicator of mental disorder. Two factors emerged, which were subsequently conceptualized as separate scales (composed of six and five elements, respectively) that measure the basic approaches termed Encouragement and Control. Alpha reliability levels determined internal consistency for each scale. Cognitive, behavioral, and mood correlates were identified for each scale using multiple regression. Replication and validation were achieved when similar findings were obtained using a random sample of 290 residents at Hebrew Rehabilitation Center for Aged, a 725-bed long-term care facility in Boston. LISREL analyses confirmed the presence of at least two dimensions in behavior management strategies. The identification of these approaches is significant in providing non-pharmacologic and non-restraint alternatives to managing elderly residents with symptom distress.

Aged↗

PubMed2001

Reproductive risk factors for epithelial ovarian cancer according to histologic type and invasiveness.

PURPOSE: Differences in histology among the subtypes of epithelial ovarian tumors suggest possible differences in their etiologies. We examined reproductive risk factors for epithelial ovarian cancer according to histologic subtype and tumor invasiveness. METHODS: We conducted a population-based, case-control study of associations between reproductive risk factors and epithelial ovarian cancer in the Delaware Valley from 1994 to 1998. Cases age 20 to 69 years with a recent diagnosis of epithelial ovarian cancer (n = 767) were compared to community controls (n = 1367) frequency matched by age. RESULTS: With few exceptions, we found significant risk reduction for each histologic subtype of epithelial ovarian cancer by using oral contraceptive, bearing children, and having a tubal ligation; for each subtype, there was significant increased risk associated with a family history of the disease. There were no significant differences among histologic subtypes in the magnitude of the odds ratios for OC use, parity, breastfeeding, tubal ligation, hysterectomy, family history of breast or ovarian cancer, use of noncontraceptive estrogens, age at menarche, and age at menopause. There were also few differences between invasive and borderline tumors, except that women with borderline tumors were significantly younger than women with invasive disease (44.7 years vs. 52.0 years, p < 0.001). Among serous tumors only, women with borderline tumors were more likely to use oral contraceptives than women with invasive tumors (OR = 2.28 95% CI 1.20-4.35). CONCLUSION: The results of this study suggest that reproductive risk factors do not differ among histologic subtypes of epithelial ovarian cancers.

Adult↗

PubMed1997

Social factors predicting postpartum choice of Norplant among African-American and non-Hispanic white adolescents.

PURPOSE: This study was designed to determine the factors associated with Norplant choice for postpartum teens. METHODS: A total of 151 teenagers, ages 12-20 years, who delivered at the Medical Center of Delaware from July to December 1992, were offered insertion of Norplant within 48 h postpartum. A structured interview was conducted in the postpartum period after nondirective counseling sessions including a physical demonstration using anatomical models of various contraceptive methods. Student's t-tests, chi-square, and multivariate analyses were used. RESULTS: Eighty-six teenagers were African-American (mean age = 17.3 +/- 1.9 years) and 65 non-Hispanic white (NHW) (mean age = 18.3 +/- 1.5 years). The NHW teenagers were older (p < 0.001); the African-American teenagers were more likely to have Medicaid (49% vs. 14%; p < 0.001) and to have one or more friends who use Norplant (62% vs. 34%; p < 0.001). In multivariate analyses, NHW teenagers were more likely to choose Norplant if they had discussed their choice with a parent or guardian [adjusted odds ratio (AOR) = 14.6, 95% confidence interval (CI), 2.12-100.57]; had Medicaid funding (AOR = 12.1; 95% (CI), 10.6-91.34); and had any friends who used Norplant (AOR = 6.3; 95% (CI), 1.38-28.40). However, for African-American teenagers, the strongest predictor for choice of Norplant was number of prior children delivered. After two deliveries, there was a better than four-fold likelihood (AOR = 4.8; 95% (CI), 1.47-15.94) that African-American teenagers would choose Norplant. For the African-American teenagers, parental discussion, Medicaid status, and friends' use of Norplant were not as important as family size, but far greater percentages of the African-American teenagers had access to Medicaid funding and peers who used Norplant. CONCLUSIONS: NHW and African-American teenagers choose Norplant for different reasons. Lack of funding may have been a barrier to choosing Norplant. Discussions with parents and friends have a positive influence on choosing Norplant for NHW teenagers. African-American teenagers were more likely than NHW to have Medicaid coverage, and more frequently choose Norplant if the current birth was their third child.

Adolescent↗

PubMed2002

Benefits of a mobile, point-of-care anticoagulation therapy management program.

BACKGROUND: Current guidelines recommend anticoagulation therapy for a number of medical conditions, but this therapy also has the potential for serious complications, particularly bleeding complications. Maintenance of anticoagulation within a narrow therapeutic window usually entails frequent monitoring with a blood test called the international normalized ratio (INR). Anticoagulation therapy management (ATM) clinics lead to improvements in quality of care, in terms of improved INR control and reduced complications. This study examined the impact of a mobile multisite, office-based ATM program that operated in seven cardiology offices in all three counties in Delaware. ATM PROGRAM: The ATM program was managed by a trained nurse who rotated among all seven offices. Patients made office visits to the nurse and received patient education, point-of-care INR testing, and medication adjustment based on a physician-approved algorithm. METHODS: This retrospective cohort study compared INR levels in the year before (May 1998-Apr 1999) and the year after (Aug 1999-Jul 2000) the start of the ATM program. RESULTS: From the year before to the year after implementation of the ATM program, the percentage of in-range INRs increased from 40.7% to 58.5% (p < 0.001). The percentage in the modified target range also increased (50.0% to 62.9%, p < 0.001). DISCUSSION: This study demonstrates the positive impact of a statewide office-based ATM program. If similar programs could be implemented in other networks of specialty offices or primary care offices, they could have a significant benefit to quality of care for patients who require anticoagulation therapy.

Adolescent↗