Five-county Area Research Articles

Bridging workforce skills gaps in rural America amid ‘the great resignation' by leveraging a triple helix collaboration

The COVID-19 pandemic dramatically impacted the job market through a surge in layoffs and the mass resignation of employees leading to the emergence of ‘The Great Resignation’. This study explores the perspectives of employers regarding skills gaps and hiring challenges with a focus on rural communities. A collaboration led by a prominent rural university department of Community and Workforce Development included industry partners, governmental agencies, a partner university, primary and secondary schools (K-12), vocational institutions, Chambers of Commerce, and Small Business Development Centers. Their objective was to examine the gap between employer needs and worker readiness. Leveraging the Triple Helix approach, a grant was awarded to fund a stackable pathway skills development program for high-demand industries in a rural five-county area. This program, the Industry Engaged Workplace Ready Program Model, is a two-phase, rapid-response approach for meeting emergent workforce needs by providing accessible training, education, networking, and mentoring to employable candidates. Findings revealed success in the program with mixed outcomes and room for program revision.

NUTRITIONAL STATUS AS A RISK FACTOR FOR DEPRESSION AMONG OLDER ADULTS RECEIVING COMMUNITY-BASED AGING SERVICES

Abstract Nutritional status is a significant determinant of overall health and well-being among older adults and is linked to adverse mental health outcomes, such as depression. This study examined nutritional status as a risk factor for depression among 4,469 older adults receiving home- and community-based services from agencies overseen by a five-county Area Agency on Aging in west central Florida. It was hypothesized that older adults with a higher nutritional score (i.e., increased risk of malnourishment) would be more likely to have elevated depressive symptoms compared to those with lower nutritional risk. The cross-sectional study used secondary data from the AAA, including demographic and social variables, a 20-point nutritional risk score, and the Patient Health Questionnaire-9 (PHQ-9; not depressed = 0-9, depressed = >10) from clients in the AAA planning and service area. In logistic regression, the most significant predictor of depression was the client’s nutrition score (OR= 1.22, p < 0.0001). This OR suggests that, for every 1-point increase of the nutrition score, the odds of being depressed increases by 22%. The findings suggest that older adults receiving aging services with worse nutritional status are at increased risk of depression, consistent with other studies. The findings suggest that programs focused on improving nutritional status among older adults may reduce depressive symptoms may improve and may potentially improve long-term physical and mental health outcomes and decrease healthcare burden.

Screening and Priority-Setting to Determine Home- and Community-Based Aging Services for Older Floridians.

The National Aging Network serves millions of older Americans seeking home- and community-based services, but places others on waitlists due to limited resources. Little is known about how states determine service delivery and waitlists. We therefore conducted a process evaluation and analyzed data from one five-county Area Agency on Aging in Florida, where an algorithm calculates clients' priority scores for service delivery. From 23,225 screenings over 5.5 years, clients with higher priority scores were older, married, living with caregivers, and had more health problems and needs for assistance. Approximately 51% received services (e.g., meals/nutrition, case management, caregiver support), 11% were eligible/being enrolled, and 38% remained on waitlists. Service status was complex due to multiple service enrollments and terminations, funding priorities, and transfers to third-party providers. More research is needed regarding how other states determine eligibility and deliver services, potentially informing national standards that promote optimal health in older Americans.

Risk perception, trust and support for wildlife reintroduction and conservation

SummaryWildlife reintroduction projects often face resistance from local residents who see potential conflicts with the species or lack trust or confidence in the agencies and professionals involved in reintroduction. Yet the linkages between trust, confidence, risk perceptions, attitudes towards the species and local support for its reintroduction are not well known. The Dual-Mode Model of Cooperation and Cognitive Hierarchy Model were theoretical frameworks used to shed light on these linkages by exploring the potential roles trust and confidence play as mediators between risk perceptions and attitudes towards, and support for, reintroduced elk in Tennessee (USA). A mail survey of 1005 residents living in the five-county area surrounding the North Cumberland Elk Restoration Zone assessed resident attitudes and risk perceptions towards the reintroduced elk, trust towards the managing wildlife agency and support for continued conservation efforts. A structural equation model revealed that trust and confidence play positive roles in mitigating risk perceptions and improving support for the reintroduction of elk. The findings confirm the roles public trust and confidence play in wildlife reintroductions and should help agencies work towards building local trust and confidence, minimizing risks, improving attitudes and increasing the chances for successful outcomes for the species and people.

Housing, Vaccinations, Parasites and Other Dry Cow Problems

I would like to tell you something about my practice area. In the five-county area which we cover, there are about 60 dairies, ranging in size from 100 to 10,000 cows (the average having 300 to 400 cows). We are responsible for about 10,000 of these cows. My brother, who is also a veterinarian, is in practice with me. We have an 800-cow dairy which he manages while I1'1anage the practice. This arrangement has helped us tremendously because it has convinced us and our clients that a dairy manager cannot run a dairy and keep up with the changes in veterinary medicine. We know that a veterinarian is a valuable member of the dairy management team.
 The greatest cause of health problems in our area is high temperature, high humidity, and high water. When I say high water, I mean deep mud. I have seen charts that combine temperature and wind velocity to arrive at a chill factor. I wish someone would chart a heat factor from temperature and humidity. We can have 80° weather with 80-90% humidity and the cows will hunt any kind of shade, even a fence post, and stand or lie breathing heavily with tongues hanging out. Our worst months are June through September or October. Average daytime temperature is over 90° and 80% relative humidity. We have more than 70 days during these months with temperatures over 90°. At the same time we have over 63% of our annual rainfall which is over 54 inches.

Discussing End-of-Life Care Preferences With Family: Role of Race and Ethnicity.

This study examined racial, ethnic, and other factors associated with whether older adults discussed their end-of-life (EOL) care wishes with family. A sample of 223 White, 95 African American, and 46 Hispanic adults aged 50 and older from a five-county area of Florida answered questions about sociodemographics, health, and preferences for involving family/friends in health-care decision-making. Analyses describe associations between whether discussions occurred and race/ethnicity and other factors, including preferences for family/friend involvement in health care. In descriptive analyses, one third (n = 113) had not discussed EOL care. No differences were evident between African Americans and non-Hispanic Whites. In multivariate analyses, EOL care discussions were less likely for Hispanics. Further analysis showed this lower likelihood existed among Hispanics with lesser family/friend involvement. Ethnicity influences EOL care discussion, moderated by family/friend involvement, though results are considered preliminary. Knowing the involvement of patients' family/friends could help providers initiate EOL care discussions.

Expecting the Unexpected: Frontier Medicine from a Student Perspective.

Expecting the Unexpected: Frontier Medicine from a Student Perspective Susan Wik The University of South Dakota Sanford School of Medicine offers the opportunity for third-year medical students to complete a nine-month immersion experience in rural medicine through their Frontier And Rural Medicine (FARM) program. I applied for the program and was placed in a town of 3,500 people. The 25-bed Critical Access hospital and emergency room serve a five-county area with a population of 17,000, including a large reservation, based approximately 100 miles from a tertiary center. My role as a student in this community gave me a unique opportunity to be privy to many ethical dilemmas associated with frontier medicine. I watched providers navigate ethical issues and then reflected on those issues through my ethics course work. My education has allowed me to explore the unparalleled ethical dimensions to providing care in rural and frontier medicine, as shown by a recent trauma code involving multiple stab wounds. It was a quiet afternoon in the internal medicine clinic when I got called into the emergency room for a trauma code. Without time to change into scrubs, I threw a plastic gown on over my dress clothes and helped transfer the patient from the ambulance gurney to a bed. He was a young, Native American man, maybe twenty-one or twenty-two years old. He was clearly agitated and confused as to his location. The paramedics relayed to us that he sustained multiple stab wounds on his abdomen and upper back. We needed to assess the wounds for ourselves, but our patient was quickly becoming combative. I remember him lashing out at me, grabbing me by the stethoscope around my neck. It all happened very quickly, and a nurse pulled his hands off me while calming him down. He finally stopped fighting, whether that was due to the calming nature of the middle-aged nurse sitting at his head or his increasingly unstable vital signs, I’ll never know. He was mildly hypotensive and mildly tachycardic. We started an IV bolus of normal saline and were finally able to assess his wounds. There was a superficial laceration below the umbilicus and a deeper puncture wound to the left of the umbilicus. The wounds on his back were deemed to be superficial as well, but a portable chest x-ray was taken to be sure a pneumothorax was not present. Meanwhile, the on-call provider called for an air transport from a tertiary center approximately 100 miles away. Despite two liters of normal saline, his blood pressure continued to drop with systolic numbers in the low 70s, and his heart rate was creeping into the 130s. His skin was cold and clammy to the touch. The Bair Hugger, a forced-air patient warming system and our only method of warming, was wheeled into the emergency room and attached to the patient to try to raise his temperature while we debated a blood transfusion. The hospital’s blood bank is supplied by the tertiary center 100 miles away; a very limited supply is kept on site. A unit of O negative blood was hung, and the transfusion began as we did not have time to wait for the type and screen to return. This situation poses an interesting dilemma unique to rural healthcare centers: what happens if another patient needs blood as well? In a larger tertiary center, blood banks are well-stocked. In a [End Page 96] rural hospital, the supply dwindles quickly, and there may not be enough to treat multiple patients. Thankfully, we did not encounter this situation. Our patient received two units of O negative blood. It was determined that the patient was experiencing internal bleeding from the abdominal wound. A few months prior, the general surgeon on staff retired; his position had been filled, but the new surgeon had not yet started, leaving no option to move to the operating room for exploratory surgery. Recruiting physicians to a rural area poses a difficult task for hospital administration. There is only enough funding for one general surgeon to be on staff, which means this person is tasked with on-call hours 24...

Comparing the 2014–2016 Flint Water Crisis to the 1993 Milwaukee Cryptosporidium Outbreak

Contrasting the 1993 Cryptosporidium parvum outbreak in Milwaukee to the 2014–2016 Flint Water Crisis through an environmental justice perspective examines how the cities’ population demographics influenced the local, state, and national governmental responses and outcomes. In October 2014, the Flint Emergency Manager switched from Detroit's water system to the Flint River. Without corrosion controls applied, Legionnaires’ disease cases increased, and childhood lead poisoning levels spiked twofold in Flint. In Milwaukee, the cryptosporidium outbreak impacted the five-county area serviced by Milwaukee Water Works. City officials shut down the contaminated treatment facility and began preventative measures. While the city of Milwaukee boosts a high minority population and low median income, Milwaukee's surrounding areas are predominantly white, and the median income is nearly double of the city. The socioeconomic makeup in the City of Flint triggered the government's denial of problems with the Flint River's water and the lack of response, thus demonstrating that the Flint Water Crisis is an example of environmental injustice. In many ways, Milwaukee's income and demographics parallel Flint. However, the distribution of cryptosporidium, where mainly white individuals became ill, influenced the recognition and long-term solutions applied. Comparing the origins of the crises and costs concludes that the populations shaped political responses. Thus, situational environmental injustice explains differential outcomes. The localized governmental response in Milwaukee and impacted population effectively ended the cryptosporidium outbreak. However, the state control in Michigan and inadequate coordination with other agencies have prolonged the Flint Water Crisis. Finally, long-term policies are suggested for Flint.

A New Method of Identifying Characteristics of Needing Help to Take Medications in an Older Representative Community-Dwelling Population: The Older Adults Medication Assist Scale.

To determine the sociodemographic characteristics, health conditions, and cognitive and functional status associated with baseline prevalence and new need for help taking medication 3years later and to construct a brief scale indicative of need for help taking medications. Retrospective cross-sectional and 3-year longitudinal study. Five-county area in north-central Piedmont, North Carolina. Representative community-dwelling sample of black and white individuals aged 65 and older (N= 4,136). Information was obtained in person in participants' homes using structured questionnaires. Health conditions included sensory impairment and self-report of physician-diagnosed conditions. Cognitive status was assessed using the 10-item Short Portable Mental Status Questionnaire. Functional status was assessed using the three-item Rosow-Breslau scale, the five-item Katz activity of daily living scale, and a modified six-item Older Americans Resources and Services instrumental activities of daily living scale. Characteristics associated with need for help taking medications were aged 80 and older, being male, living with others, having four or more chronic conditions, and impaired cognitive or functional status (c-statistic 0.94, 77.1% sensitivity, 87.9% specificity). Predictors of new need for help with medications 3years later included aged 75 and older at baseline, being male, and impaired cognitive and functional status (c-statistic 0.75). This brief scale can help identify persons needing help with medications and could be useful in assisting clinicians with medication management.

Community-Based Multidisciplinary Computed Tomography Screening Program Improves Lung Cancer Survival

Lung cancer is the most common cause of cancer deaths in the United States. Overall survival is less than 20%, with the majority of patients presenting with advanced disease. The National Lung Screening Trial, performed mainly in academic medical centers, showed that cancer mortality can be reduced with computed tomography (CT) screening compared with chest radiography in high-risk patients. To determine whether this survival advantage can be duplicated in a community-based multidisciplinary thoracic oncology program, we initiated a CT scan screening program for lung cancer within an established health care system. In 2008, we launched a lung cancer CT screening program within the WellStar Health System (WHS) consisting of five hospitals, three health parks, 140 outpatient medical offices, and 12 imaging centers that provide care in a five-county area of approximately 1.4 million people in Metro-Atlanta. Screening criteria incorporated were the International Early Lung Cancer Action Program (2008 to 2010) and National Comprehensive Cancer Network guidelines (2011 to 2013) for moderate- and high-risk patients. A total of 1,267 persons underwent CT lung cancer screening in WHS from 2008 through 2013; 53% were men, 87% were 50 years of age or older, and 83% were current or former smokers. Noncalcified indeterminate pulmonary nodules were found in 518 patients (41%). Thirty-six patients (2.8%) underwent a diagnostic procedure for positive findings on their CT scan; 30 proved to have cancer, 28 (2.2%) primary lung cancer and 2 metastatic cancer, and 6 had benign disease. Fourteen patients (50%) had their lung cancer discovered on their initial CT scan, 11 on subsequent scans associated with indeterminate pulmonary nodules growth and 3 patients who had a new indeterminate pulmonary nodules. Only 15 (54%) of these 28 patients would have qualified as a National Lung Screening Trial high-risk patient; 75% had stage I or II disease. Overall 5-year survival was 64% and 5-year cancer specific survival was 71% in the screened patients, whereas nonscreened lung cancer patients during that time in WHS had an overall survival of only 19% (p < 0.001). A community-based multidisciplinary lung cancer screening program can improve survival of patients with lung cancer outside of a large multicenter study. This survival advantage was caused by a significant stage shift to earlier disease. Lung cancer CT screening may also benefit patients not meeting the National Lung Screening Trial criteria who are at moderate or high risk for lung cancer.

Household Food Insecurity and Health among African American Women in Black Belt Counties of Alabama: Evidence from Mixed-Methods Research

Background: African Americans are more vulnerable to food insecurity than the American population overall. In Alabama’s Black Belt, food insecurity is more than three times the national average level. Yet, little is known about the association between food insecurity and health among African American women in the region. The purpose of this study is to assess the relationship between food insecurity and health among African American low income mothers in Alabama’s Black Belt. Method: We conducted qualitative and quantitative research among 220 low-income African American mothers in a five-county area of Alabama’s Black Belt region that included Bullock, Dallas, Lowndes, Macon and Wilcox counties. Household food insecurity was measured with the United States Department of Agriculture Household Food Security Survey Module. Bivariate and multiple regression analysis were used to estimate the association between household food insecurity and health status. Results: Over 51% of the mothers and their children live in food insecure households. We present qualitative and quantitative evidence that food insecurity is significantly associated with self-rated health. The mothers living in food insecure household are more likely to report poor general health. Nearly one-fifth of the women interviewed complained of health problems, including high blood pressure, back pain, depression and asthma. Conclusion: The association of food insecurity with health, regardless of causal direction, shows the precarious situations poor single mothers in rural areas face. Reducing food insecurity among these mothers may improve their health status. The future direction of food insecurity research must go beyond just monitoring food insecurity to linking it with medical related out outcomes including health status.

Abstract T P381: Implementing a Rural Stroke Prevention Clinic Using Telemedicine

Introduction: One in eight strokes is preceded by a transient ischemic attack (Science Daily, 2009). Our primary stroke center serves a five-county area and provides support for stroke care to five rural critical access hospitals. Limited appointment availability and distance to resources were identified as obstacles preventing patients who experienced TIA’s from obtaining essential stroke-prevention work-up. Lack of appointment availability, compounded with the distance to services, resulted in week-long delays before full evaluations could be performed and interventions implemented. Using telemedicine technology, we developed a stroke prevention (TIA) clinic in a rural hospital in Washington State. Referrals for physical therapy, occupational therapy, nutritional counseling, etc. were made to departments of the rural hospital. Follow-up care was conducted in person at the neurologist's office. Patients were seen within one week of symptoms. Patients were also enthusiastic about receiving their care locally and there was a high participation rate (e.g. low no-show rate) for appointments. Hypothesis: If stroke prevention assessment services were provided at the local community level, TIA patients identified via the local emergency department would be more likely to attend the medical appointment, obtain needed assessments and receive essential stroke prevention education. Methods: The clinic was initially staffed with a neuroscience nurse practitioner who performed patient assessments and presented the patient to the attending neurologist. The neurologist participated remotely via telemedicine. The nurse practitioner and neurologist reviewed pertinent positives and developed a treatment plan in collaboration with the patient. Required testing was performed at the rural facility. Metrics, including revenue generation and patient satisfaction were gathered. Results: Patient attendance was excellent and patient satisfaction rated very high. The clinic proved to be a positive revenue generator for the hospital. Conclusions: The model has been so successful that we plan to expand the service to our other rural partner hospitals.

Racism Reported by Direct Care Workers in Long-Term Care Settings

This article focuses on reports of racism experienced by direct care workers (DCWs). These DCWs provide the majority of hands-on care to older residents/clients that need help with activities of daily living such as bathing and dressing in long-term care (LTC) settings. Interviews were conducted with 644 DCWs working in three types of LTC settings. Proportionate random sampling techniques were used to select 49 LTC agencies from a five-county area in northeast Ohio. The DCWs included nurse assistants in nursing homes, resident assistants in assisted living facilities, and home care aides in home health agencies. Analyses reported include frequencies, chi-square tests, and analysis of variance. Hearing racial and ethnic remarks, particularly from residents/clients, was widely reported by DCWs. Despite this, DCWs were likely to believe that remarks from residents/clients were not intended to hurt their feelings. Although DCWs heard fewer racial/ethnic remarks from family members or other staff, they were likely to believe that such remarks were intended to hurt their feelings. At the organizational level, DCW reports of hearing racial/ethnic remarks in nursing homes were more frequent than those in other LTC settings. Further, DCWs in organizations in which racial differences between them and the residents/clients that they served was very large reported hearing significantly more racial/ethnic remarks. These findings have important implications for addressing racism in LTC agencies with anti-discrimination policies and programs.

Seasonal Patterns for Entomological Measures of Risk for Exposure toCulexVectors and West Nile Virus in Relation to Human Disease Cases in Northeastern Colorado

We examined seasonal patterns for entomological measures of risk for exposure to Culex vectors and West Nile virus (family Flaviviridae, genus Flavivirus, WNV) in relation to human WNV disease cases in a five-county area of northeastern Colorado during 2006-2007. Studies along habitat/elevation gradients in 2006 showed that the seasonal activity period is shortened and peak numbers occur later in the summer for Culex tarsalis Coquillett females in foothills-montane areas >1600 m compared with plains areas <1600 m in Colorado's Front Range. Studies in the plains of northeastern Colorado in 2007 showed that seasonal patterns of abundance for Cx. tarsalis and Culex pipiens L. females differed in that Cx. tarsalis reached peak abundance in early July (mean of 328.9 females per trap night for 18 plains sites), whereas the peak for Cx. pipiens did not occur until late August (mean of 16.4 females per trap night). During June-September in 2007, which was a year of intense WNV activity in Colorado with 578 reported WNV disease cases, we recorded WNV-infected Cx. tarsalis females from 16 of 18 sites in the plains. WNV infection rates in Cx. tarsalis females increased gradually from late June to peak in mid-August (overall maximum likelihood estimate for WNV infection rate of 8.29 per 1000 females for the plains sites in mid-August). No WNV-infected Culex mosquitoes were recorded from sites >1600 m. The vector index for abundance of WNV-infected Cx. tarsalis females for the plains sites combined exceeded 0.50 from mid-July to mid-August, with at least one site exceeding 1.00 from early July to late August. Finally, we found that abundance of Cx. tarsalis females and the vector index for infected females were strongly associated with weekly numbers of WNV disease cases with onset 4-7 wk later (female abundance) or 1-2 wk later (vector index).

A Modification to the NOAH LSM to Simulate Heat Mitigation Strategies in the New York City Metropolitan Area

Abstract A new approach to simulating the urban environment with a mesocale model has been developed to identify efficient strategies for mitigating increases in surface air temperatures associated with the urban heat island (UHI). A key step in this process is to define a “global” roughness for the cityscape and to use this roughness to diagnose 10-m temperature, moisture, and winds within an atmospheric model. This information is used to calculate local exchange coefficients for different city surface types (each with their own “local roughness” lengths); each surface’s energy balances, including surface air temperatures, humidity, and wind, are then readily obtained. The model was run for several summer days in 2001 for the New York City five-county area. The most effective strategy to reduce the surface radiometric and 2-m surface air temperatures was to increase the albedo of the city (impervious) surfaces. However, this caused increased thermal stress at street level, especially noontime thermal stress. As an alternative, the planting of trees reduced the UHI’s adverse effects of high temperatures and also reduced noontime thermal stress on city residents (and would also have reduced cooling energy requirements of small structures). Taking these results together, the analysis suggests that the best mitigation strategy is planting trees at street level and increasing the reflectivity of roofs.

Urbanization's impact on sustained yield management as perceived by forestry professionals in central New York

The urbanizing forested landscape in the United States is creating challenges for resource managers and land-use planners. Logistic regression models developed to assess urbanization's effect on forestland for the mid-Atlantic and southern states found that population density was the best predictor of reduced commercial harvest opportunity. We applied similar methodologies in central New York to assess urbanization's impact on sustained yield management. We surveyed professional foresters in a five-county area and asked them to rate the potential for sustained yield management by township. We utilized those expert opinions to develop a logistic regression model that predicted the probability of sustained yield management in central New York while exploring the factors that influence sustained yield management. We found that road density was the primary variable influencing the likelihood of sustained yield management in central New York. Population density, which is highly correlated with road density, also proved to be a strong determinant of sustained yield management. The results suggest that the potential for sustained yield management approaches 10% at a road density of 3 mi/mi 2, 50% at 2.5 mi/mi 2, and 90% at 2 mi/mi 2. The corresponding figures for population density were 150 people per square mile (ppsm), 75 ppsm and 25 ppsm, respectively. In addition, we determined that the probability of sustained yield management approaches 100% for a property that is approximately 30 acres and drops to 50% for a parcel that is between 15 and 20 acres. This study provides resource managers and land-use planners a guide in which to effectively gauge the cumulative effect of urbanization on the forest resource in central New York. Unlike other regions of the United States, central New York's growth pattern is characterized by stagnant population growth (declining in some places) combined with continued urbanization and low-density sprawl. Because growth patterns vary regionally, different indicators may be needed to accurately assess the urbanizing forested landscape across the United States.

Civil Engineering, Legal, and Political Collaboration: Solving Denver’s Drainage Infrastructure Dilemma

The archaic infrastructure and disjointed drainage policies in place in the six-county Denver metropolitan area during the 1960s left the growing area in a public health and safety predicament. In 1968, city, county, state, and federal engineers; lawyers; and politicians united to address and solve the core problems. Through the development of a comprehensive manual and the formation of a governmental entity responsible for drainage and flood control oversight of a five-county area, the seeds of a solution were sown. This endeavor required the cooperation and input of many experts, state legislation, public funding, and the genuine desire of all involved to work for “the common good.”

Community-Based Care Model for High-Risk Adults with Severe Disabilities

Objective: Evaluate the effectiveness of a home-based intervention for adults with serious physical disabilities at high risk for poor health outcomes. Design: A pretest/post-test design; content analysis of case studies. Setting: Five-county Philadelphia metropolitan area. Patients and Other Participants: Forty-nine community-dwelling adults aged 20—55. Intervention: Six-month comprehensive care management intervention implemented by Advanced Practice Nurses (APNs) focused on improvement of functional status or prevention of functional decline; management of health problems; and enhancement of self-direction of care by subjects and caregivers. Main Outcome Measures: Functional status; total hospitalizations, emergency department (ED) and acute care physician visits; symptom management; depression; quality of life; and satisfaction with care. Results: Between baseline assessment and nine months post-APN intervention, functional status improved (mean = 33.42 → 24.97, p = 0.014). There was a trend toward reductions in average hospitalization rate from 1.10 at baseline to 0.68 nine months post-APN intervention and ED rates from 0.90 to 0.50. Acute care visits to physicians increased from 0.52 to 0.95 from baseline to nine months post-APN intervention. The use of home health aides (mean = 2.72 → 1.37, p = 0.008) and physical therapists (mean = 1.16 → 0.42, p = 0.001) also decreased from baseline to nine months post-APN intervention. Facilitators and barriers to care are identified. Conclusions: Findings suggest potential benefit of a comprehensive, individualized intervention coordinated by APNs in improving health and functional outcomes and decreasing the use of

Impact of Genetic Counseling and DNA Testing on Individuals with Colorectal Cancer with a Positive Family History: A Population-Based Study

What is the impact of a genetic evaluation for colorectal cancer susceptibility? We previously reported a study of individuals diagnosed with colorectal cancer at 60 years of age or less in a five-county area of New York including Rochester. Subjects reporting at least one first- or second-degree relative with colorectal cancer were invited to receive genetic counseling and DNA testing. Of the 37 persons tested, we previously reported that 6 were found to have deleterious mutations in MSH2 or MLH1. A mutation has since been found in a seventh subject in another laboratory. To evaluate the impact of the testing experience, we followed-up on 36 of these 37 subjects at 3 and 12 months after communicating their DNA test result. We ascertained their knowledge of colon cancer, whether they told relatives their test result, their surveillance behavior, and their mental health. Three months after receiving their result, subjects knew more about colon cancer if they had more cancer of all types in their family (p = 0.02). At 12 months, they knew more if they had been found to have a mutation (p < 0.001), were younger when DNA tested (p < 0.01), or were younger when diagnosed with cancer (p < 0.03). All but 1 of those found to have an abnormality told relatives. Relatives of 3 subjects in whom a mutation had been found came to us to be tested themselves. At 12 months, surveillance for colon and endometrial cancer was more adherent if there were more total cancers in the family (p < 0.05) or if the testee were more worried about cancer (p < 0.05). Self-assessed mental health at 12 months was better for those who were married (p < 0.05). This study suggests that individuals undergoing a genetic evaluation for an inherited susceptibility to colorectal cancer pursue recommended surveillance and inform relatives of their result.

Cholinesterase Levels Among Agricultural Pilots and Mixer/Loaders

ABSTRACT Agricultural pilots and mixer/loaders are potentially exposed to pesticides, but few studies have assessed the extent of their exposure. This study assessed the work habits and measured the cholin-esterase levels of a group of agricultural pilots and mixer/loaders in a five-county area of northeastern Arkansas, a cotton-growing area. Work habits were ascertained through questionnaires. Cholinesterase levels were measured at baseline and during the active spraying season. Pyrethroids were the predominant pesticides used, although most respondents reported at least some organophosphate use. Most reported having received pesticide training, but few used personal protective equipment. There was no decline in acetylcholinesterase (AChE) levels associated with pesticide use. These results indicate that agricultural pilots and mixer/loaders in northeastern Arkansas show no evidence of overexpo-sure to AChE inhibitors, suggesting that current pesticide use patterns and work practices are successfully protecting them.