US Mail Research Articles

AGING AND MASS MARKETING FRAUD: EVIDENCE ON REPEAT VICTIMIZATION USING PERPETRATOR DATA

Abstract Fraud complaint data indicates that adults in their 70s and 80s experience significantly greater fraud losses than middle aged and young adults, however older adults are less likely to self-report victimization overall. One explanation for older adults’ relatively higher financial losses may be that they experience a greater incidence of repeat victimization. In this study, we examine the relationship between age and repeat mass marketing fraud using a novel dataset of nearly one million US mail fraud victims. The data come from four mail fraud enterprises that were investigated by the US Postal Inspection Service and that ran overlapping scams between 2000 and 2018. The perpetrators collected information on victims (name, address, age) and how often they paid money in response to scam solicitations. Datasets were merged, cleaned, and deduplicated. We use a Prentice-Williams-Peterson adaptation of a Cox proportional hazards model to estimate the effect of age on the likelihood of experiencing a subsequent victimization, controlling for the number of prior victimizations. Compared to victims in their 50s, victims aged 70-79 and 80-89 had a 9% greater risk of experiencing another victimization, whereas victims in their 20s had a 24% lower risk of experiencing another victimization. Logistic regression analyses indicate that adults in their 70s and 80s are significantly more likely than those younger than 50 to experience victimization by multiple types of mail scams. This is the first study to use perpetrator data, rather than self-report, to show that older adults face a greater risk of repeat fraud victimization.

America’s First Interstate: The National Road, 1806–1853

America’s First Interstate: The National Road, 1806–1853

Effect of a Remotely Delivered Self-directed Behavioral Intervention on Body Weight and Physical Health Status Among Adults With Obesity

The effectiveness of remotely delivered, self-directed, weight loss programs in routine clinical practice is largely unknown. To test whether a self-directed, remotely administered behavioral lifestyle intervention improves weight and self-reported general health status compared with usual care. In this randomized clinical trial, 511 adults with a body mass index (BMI) of 30 or more and less than 45 (based on electronic health record [EHR] weight and height), were enrolled from 30 Veterans Health Administration (VHA) sites between February 15, 2018, and December 18, 2018 (final follow-up February 18, 2021). Participants were randomly assigned to the intervention group (n = 254) or the control group (n = 257). Both received usual care. Participants randomized to the intervention received Diabetes Prevention Program-based self-directed videos, handouts, and coaching messages via an online platform or US mail for 12 months. Coprimary outcomes were weight measured in primary care and recorded in the EHR and self-reported general health status using the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) physical component score (PCS; higher scores are better [range, 0-100]) at the 12-month follow-up. The between-group minimal clinically important differences are 3 kg for weight and 5 points for the SF-12 PCS. Linear mixed models used weights and SF-12 PCS measured at either time point, with participants analyzed according to randomization assignment. Statistical significance for each coprimary outcome was based on a 2-sided α level of .025. Among 511 participants randomized (mean age, 57.4 [SD, 13.9] years; 231 female [45%]), 429 (84.0%) had EHR-based weights and 410 (80.2%) had SF-12 PCS data at 12 months. The unadjusted mean weight at 12 months declined from 102.7 kg to 99.8 kg in the intervention group compared with 101.9 kg to 101.0 kg in the control group (adjusted between-group mean difference, -1.93 [97.5% CI, -3.24 to -0.61]; P = .001). At 12 months, the unadjusted mean SF-12 PCS scores declined from 44.8 to 44.3 among intervention participants compared with 44.5 to 43.2 among control participants (adjusted between-group mean difference, intervention minus control, 0.69 [97.5% CI, -1.11 to 2.49]; P = .39). Cardiovascular events represented the highest percentage of serious adverse events, accounting for 25% of events in the intervention group and 35% in the control group. Among adults with obesity, a remotely delivered self-directed, behavioral lifestyle intervention, compared with usual care, resulted in statistically significantly greater weight loss at 12 months, although the difference was not clinically important. There was no significant difference in self-reported general physical health status at 12 months. ClinicalTrials.gov Identifier: NCT03260140.

A new approach to postvasectomy semen analyses eliminates the need to evaluate a fresh specimen.

According to current guidelines, confirmation that vasectomy results in sterility depends on microscopic examination of postvasectomy semen for the presence of spermatozoa. Guidelines established in 2012 require examination of a fresh specimen within 2 h of collection, which necessitates the patient making an appointment with either the surgeon's office or a licensed clinical laboratory. Twenty-five to 42% of patients fail to comply with postvasectomy semen analysis (PVSA). To determine if an at-home semen collection kit can substitute for the evaluation of a fresh specimen and improve patient compliance with postvasectomy spermatozoa assessment. The kit contains a patented aldehyde-fixative that maintains spermatozoa and semen cells in suspension for quantitation. Patients order a PVSA kit to be delivered to their home and can collect a semen specimen and return it to the laboratory through regular US mail. From January 2011 through December 2018, 6096 men undergoing vasectomy by 184 urologists in 33 states in the US ordered PVSA kits, of which 5408 (89%) returned at least one for analysis. Of those, 398 men (7.4%) returned the first kit with greater than 10,000 spermatozoa/ml within a year of vasectomy, of which only 4.4% contained greater than 100,000 spermatozoa/ml 12 weeks postsurgery. This suggests that fewer than 5% of postvasectomy patients might need follow-up fresh semen analyses, greatly easing the logistical burden of PVSA. Ninety percent of surgeons returning a patient satisfaction questionnaire said their patients "never" complained about using PVSA kits. These data support the adoption of a new standard for PVSA that does not involve an initial evaluation of a fresh semen specimen.

Transfer Patient Imaging: A Novel Peer Feedback Program Beyond Institutional Boundaries

At our level 1 trauma center, we overread cross-sectional scans on all transferred patients, initially reported by community radiologists (CR). We designed a unique peer feedback learning model to address discrepancies encountered with outside overreads with the goal of practice improvement on the part of the CRs. Although there is ample literature on internal peer review and peer learning programs, no publications address errors committed by peers outside institutional boundaries. In this paper we describe our model and report a survey analyzing the perception of the program by the CRs. Outside CT and MR exams and reports of patients transferred to our level 1 trauma center were imported into PACS and prospectively overread by specialist trauma radiologists. Our report contained a summary of the outside findings as well as our findings. In the case of a significant discrepancy, a paper copy of our final report was sent by US mail to the originating CR. When the program had been active for 18 months, an invitation to participate in a survey was sent to all radiologists who had been sent reports. Eight thousand three hundred forty patients were transferred, of which 4331 (52%) had 9175 exams with outside reports (8666 CT scans and 509 MRI). One hundred seventy six final report letters containing significant discrepancies were sent to 139 individual radiologists. These 139 radiologists also later received our survey letter. Thirty-eight (27%) responses were received. Thirty-two respondents (84%) recalled receiving the report and reviewed the exam in question. Twenty-eight of them (85%) agreed with the overread and 30 (88%) believed that our feedback program should be continued. We have designed a novel peer feedback learning model to address discrepancies in outside overreads which is administratively simple and well received by the CRs getting feedback. Those CR who responded to the survey rated the experience favorably and wanted the practice continued, although the overall response rate did not allow statistical analysis. Also, institutions trying to design similar or new peer learning models can benefit from our experience.

Abstract TP35: Stroke Nurse Navigation-Evolving Care Delivery To Effectively Meet The Needs Of Stroke Patients And Families

Background: Research indicates the importance of life-style modification, risk factor management, and medication and physician follow-up compliance in the prevention of stroke. Nurse navigators are in a unique position to influence this care. The pandemic changed post-acute management of stroke by requiring increased virtual care as opposed to in-person care. A known disparity existed in the number of touch points between the patients utilizing the patient portal versus those reached only by phone. We aimed to evaluate how changes in navigator workflow influenced the frequency of touchpoints, operating under the assumption that increased touchpoints will improve post-hospital care. Methods: A retrospective analysis was completed for acute stroke patients discharged from January 2020 - March 2021 for 4 certified stroke centers. We implemented standardized time intervals for patient outreach, regardless of modality. Initial outreach was completed within 48 hours to avoid potential gaps in care. Motivational interview calls were focused on education that included life-style changes, compliance, risk factor control and follow-up, which mirrored the mobile application’s education. Branded individualized education materials were created and sent to patients using US Mail or via the patient portal. New flowsheets were developed in the EMR for future data collection and reporting. Hand written notes and cards of encouragement were also sent reinforcing the counseling received. Linear regression analysis evaluated our primary outcome: the relationship between monthly touchpoints over time. Results: A total of 1935 patients were diagnosed with acute stroke, discharged and managed post-hospitalization for 90 days. During the 90 day episode, navigators interacted with patients for M = 4.64 SD = 2.46. Regression analysis demonstrated a linear relationship between time and touchpoints ( p <0.001). Navigators also reported intangible results from patient and family feedback related to support and care received. Conclusions: Stroke care is complex and requires ongoing patient and caregiver support. Increasing availability to stroke experts, such as nurse navigators, provides support and tools to improve post-hospital care.

Feasibility of SARS-CoV-2 Antibody Testing in Remote Outpatient Trials.

BackgroundDuring the coronavirus disease 2019 (COVID-19) pandemic, clinical trials necessitated rapid testing to be performed remotely. Dried blood spot (DBS) techniques have enabled remote HIV virologic testing globally, and more recently, antibody testing as well. We evaluated DBS testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody testing in outpatients to assess seropositivity.MethodsIn 2020, we conducted 3 internet-based randomized clinical trials and offered serologic testing via self-collected DBS as a voluntary substudy. COVID-19 diagnosis was based on the Centers for Disease Control and Prevention case definition with epidemiological link to cases. A minority reported polymerase chain reaction (PCR) testing at an outside facility. We tested for anti-SARS-CoV-2 immunoglobulin via antibody detection by agglutination–PCR (ADAP) and compared the results with enzyme-linked immunosorbent assay (ELISA).ResultsOf 2727 participants in the primary studies, 60% (1648/2727) consented for serology testing; 56% (931/1648) returned a usable DBS sample. Of those who were asymptomatic, 5% (33/707) had positive ADAP serology. Of participants with a positive PCR, 67% (36/54) had positive SARS-CoV-2 antibodies. None of those who were PCR-positive and asymptomatic were seropositive (0/7). Of 77 specimens tested for concordance via ELISA, 83% (64/77) were concordant. The challenges of completing a remote testing program during a pandemic included sourcing and assembling collection kits, delivery and return of the kits, and troubleshooting testing. Self-collection was successful for >95% of participants. Delays in US mail with possible sample degradation and timing of DBS collection complicated the analysis.ConclusionsWe found remote antibody testing during a global pandemic feasible although challenging. We identified an association between symptomatic COVID-19 and positive antibody results at a similar prevalence as other outpatient cohorts.

Improving Fecal Immunochemical Testing Rates for Colon Cancer Screening in the Outpatient Setting.

The amount of colorectal cancer (CRC) screening using the noninvasive fecal immunochemical test (FIT) at a federally qualified health center, Five Rivers Health Clinic (Dayton, Ohio), has been low historically. Our quality improvement (QI) project aimed to improve CRC screening adherence in eligible patients who opted for FIT. Three hundred ninety-two patients with FIT orders for CRC were screened during an 11-month period. The preintervention group (pre-I) was enrolled from December 1, 2018 to May 31, 2019, and the postintervention group (post-I) from June 1, 2019 to October 31, 2019. Three interventions were used: resident physicians trained during clinic meetings regarding FIT education for patients, posters displayed in patient rooms outlining the benefits of CRC screening, and standardized US mail reminder letters sent to FIT patients. Patient demographics and clinical variables were collected along with return rate. The return rate for post-I was twice that of pre-I (74.4%, 95% confidence interval 64.6-82.3 vs 31.1, 95% confidence interval 26.2-36.6; P < 0.001). The pre-I/post-I groups did not differ on demographic and clinical characteristics, and, except for race, none of these variables was associated with returning the FIT screening card. The compliance rate for FIT completion and return more than doubled among our clinic patients after using a three-component QI intervention. Except for a difference in race, the lack of association between demographic and clinical characteristics with either pre-I/post-I group or return/no return of the FIT card leads us to conclude that our QI program for increasing FIT compliance is effective. Other settings where CRC screening is a prominent component of preventive care may benefit from adopting a similar QI intervention.

The effect of transport temperature and time on the recovery of antimicrobial-resistant Enterobacterales in stool

Surveillance for antibiotic-resistant (AR) bacteria is challenging. We evaluated AR Enterobacterales survival in stool over various transport conditions. Stool in Cary–Blair medium was spiked with AR Enterobacterales, held at 3 °C, 20 °C, or 37 °C, and cultured on days 3, 8, and 15. Stool from US international travelers sent through the US mail was also screened. We compared recovery rates using Fisher’s exact tests and linear regression models. AR Enterobacterales recovery reduced with time (86% versus 75% versus 61% at days 3, 8, and 15; Beta for linear trend=−0.02, r2=0.99, P=0.02) and colder temperatures [56% (3 °C) versus 89% (20 °C) versus 86% (37 °C); P=0.003]. Traveler sample recovery also reduced with transport time (Beta for linear trend=−0.03, r2=0.70, P=0.01) but not with season [20% (cold) versus 22% (warm), P=0.7]. AR Enterobacterales are found over variable transport conditions, providing rationale for expanding surveillance sample processing timelines.

A randomized trial of mailed HPV self-sampling for cervical cancer screening among ethnic minority women in South Florida.

HPV self-sampling has previously been shown to increase cervical cancer screening among ethnic minority and immigrant women. We conducted a randomized pragmatic trial to examine the effectiveness of HPV self-sampling delivered via in-person versus by US mail for medically underserved Hispanic, Haitian, and non-Hispanic Black women living in South Florida. We randomized women aged 30-65 who had not completed Pap smear screening in the past 3years into two groups: (1) HPV self-sampling delivered in-person (IP) by a community health worker (CHW; IP + SS) or (2) HPV self-sampling delivered via US mail (SS + Mail). Our primary outcome was HPV self-sampling completion by 6-month post-study enrollment. We enrolled 600 women. Approximately 65% were Hispanic and 35% were Haitian or non-Hispanic Black. Nearly half (43%) had an income of less than $20,000/year and 67% were uninsured. In intent-to-treat analyses, 71.6% of participants in the SS + Mail group and 81.0% of participants in the IP + SS group completed HPV self-sampling. Mailed HPV self-sampling is an effective strategy to increase cervical cancer screening among underserved immigrant and ethnic minority women.

Abstract P275: Prescription of PCSK9 Inhibitors in the United States, by Patient, Provider, and Payer Characteristics, 2016

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors were approved in 2015 for use by adults with familial hypercholesterolemia (FH) or clinical atherosclerotic cardiovascular disease (ASCVD) requiring additional low-density lipoprotein cholesterol lowering beyond use of diet modification and maximally tolerated statin therapy. This study describes the patient, provider and payer related characteristics of prescriptions filled for this new class of injectable medication during 2016. Methods: 2016 quarterly state-level prescription data were obtained from Symphony Health Solution’s PHAST 2.0. PHAST 2.0 includes data on over 90% of prescriptions filled from US retail and mail order pharmacies and, along with market purchasing data, are used to calculate state and national estimates. PCSK9 inhibitor fills among adults aged ≥18 years were characterized by quarter, patient age, provider type, and payer type. Per-capita fill rates across US states and total and patient spending per 30-day supply were calculated. Results: In 2016, 216,082 PCSK9 inhibitor prescriptions were filled. The number of fills per quarter increased from 20,348, in Q1, to 83,812, in Q4, and fill totals were greatest among those aged 65-74 years (39.3% of fills) (Figure). Cardiologists prescribed the majority of fills (60.5%). Commercial payers (43.3%) and Medicare (43.1%) were the most frequent payers. State per-capita fill rates (per 100,000) ranged from 12.1, in WY, to 191.9, in LA (median: 69.1). Total spending per 30-day supply was $951; patient spending was $58 per 30-day supply. Conclusion: Quarterly fills for PCSK9 inhibitors quadrupled during 2016, with substantial variation in per-capita fill rates across states. Cardiologists prescribed the majority of fills, which aligns with their indicated use among adults with FH or ASCVD. Total spending per 30-day supply was considerable. Tracking of prescribing trends for these medications is warranted as additional information about their efficacy becomes available.

The Scarlet Professor as Spectacle: Responding to the Opera from a Queer Studies Perspective

<i>The Scarlet Professor</i> as Spectacle: Responding to the Opera from a Queer Studies Perspective

Measurement of the Omega-3 Index in Dried Blood Spots

Background: The roles that the omega-3 fatty acids play in health and disease remains unclear. The conduct of epidemiological studies to explore this relationship can be facilitated by the use of dried blood spots (DBS) for sample collection and shipment. The Omega-3 Index [i.e. erythrocyte levels of the two major marine-derived omega-3 fatty acids, eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA)], is an emerging risk factor for cardiovascular disease mortality. The purpose of this report is to describe how the Omega-3 Index can be derived from an analysis of DBS fatty acid levels. Methods: A comparison of the Omega-3 Index and DBS EPA+DHA levels was conducted in 147 random samples received in the laboratory, and in 106 samples prospectively collected and processed through the US mail. The “in field” coefficient of variation of the DBSderived Omega-3 Index was calculated from 147 duplicate samples collected in an epidemiological study in Mexico. The stability of DBS EPA+DHA levels when collected on antioxidant-treated paper was tested for 44 days at room temperature, and for up to 4 years in the freezer. Findings: We found that the correlation between the DBS EPA+DHA level and the Omega-3 index was 0.97 (p 15% loss) for at least 6 weeks at room temperature, 4 weeks in a refrigerator, 3 years at -20°C and 4 years at -80°C. Conclusion: These data confirm the utility of this DBS system for estimating the Omega-3 index.

Abstract 18944: Efficacy of Clinical Notifications to Health Care Providers in Management of Heart Failure Patients

Introduction: Adherence to guideline recommendations for patients with heart failure improves short and long-term outcomes, and can potentially reduce healthcare costs. Hypothesis: Written communication to care providers of individuals with heart failure with reduced systolic function (HFrEF) will result in better adherence to guidelines. Methods: We prospectively enrolled providers of all outpatients with HFrEF at Oregon Health and Science University in 2012. We reviewed adherence to six evidence-based HF therapies in each patient [ACE-I/ARB, beta blocker, aldosterone antagonist, anticoagulation therapy for atrial fibrillation or flutter, CRT, and ICD]. We excluded patients with destination therapy, resolution of HFrEF, lost to follow-up or death. After implementation of exclusion criteria, of 320 patients evaluated, 114 patients were ultimately included. These patients’ providers were randomized to either receiving a standardized written communication (intervention) or none (control). The letter highlighted 2013 ACCF/AHA heart failure management guidelines, and was sent by US mail to providers in intervention group. Six months later, we re-evaluated all patients according to the same criteria at the outset. Results: Optimal medical therapy (OMT) in intervention group improved in only 9% of patients who were previously sub-optimally treated (p 0.83), but 31% of patients who had already been on OMT experienced deescalated therapies despite no clear documentation (p 0.65). In control group, 11% of patients had increased treatment according to guidelines, and 9% of patients who had already been receiving OMT had deescalated treatment. There were no new ICDs implanted as a result of intervention, while 6.5% of patients in control group did receive ICD (p 0.46). Conclusions: Identification of patients with HFrEF and assessment of adherence to guideline-based therapies is now feasible via electronic medical record enquiry. Written notifications do not result in improved adherence to evidence-based guidelines, nor do these letters seem to alter provider behavior at all. We speculated that the lack of response is a direct result of “notification-fatigue”, and that alternative provider behavior modification techniques need to be evaluated.

P17.08 Using grindr™, a smartphone social networking application, to increase hiv self-testing among men who have sex with men in los angeles

Introduction In Los Angeles County, about 25% of men who have sex with men (MSM) are unaware of their HIV positive status. Using smartphone social networking applications (apps) to promote free HIV self-testing might help reduce common barriers for testing, including poor access, stigma, and fear of loss of confidentiality. Methods We advertised free HIV self-tests on Grindr™, a smartphone geosocial networking app popular with MSM, from April 17 to May 29, 2014, and from October 13 to November 11, 2014. The advertisements linked users to http://freehivselftests.weebly.com/to choose a self-test delivery method: US mail, a drugstore voucher, or from a vending machine. African American or Latino MSM ≥18 years old were invited to take a survey on testing experiences. Results During the two waves of the campaign, the website received 16,328 unique visitors (average: 227 per day) and 667 self-test requests. Of those 667, 471 (71%) were requests for mailed self-tests, 157 (23%) were for vouchers, and 39 (6%) were to use the vending machine. Among 112 (63%) survey respondents of 178 invited, study-eligible participants, 64% were between 18–30 years old, 18% were Black/African American, 77% reported at least one episode of condomless anal sex in the past three months, and 38% last tested for HIV over a year ago or had never tested. One hundred six (95%) reported using the self-test was easy; 4 persons reported testing HIV positive and all 4 (100%) sought medical care. Conclusion Free HIV self-testing promotion through Grindr™ resulted in a large number of HIV self-test requests. Users preferred US mail self-test delivery, found the self-tests easy to use, and sought medical care if testing positive. Future work should evaluate different smartphone apps and compare smartphone social networking app promotion of self-testing with other HIV testing services. Disclosure of interest statement The authors have no conflicts of interest to disclose.

Tracking workforce diversity in dentistry: importance, methods, and challenges.

The objectives of this paper are to describe sources of data on underrepresented minority (URM) dental providers and to perform a structured critique of primary survey research on African American (AA), Hispanic/Latino (HL), and American Indian/Alaska Native (AI/AN) dentists. A national sample survey was conducted between October 2012 and March 2013, and secondary datasets were assessed for comparability. The survey used 21 sampling frames, with censuses of AI/AN and nonurban dentists, and assessed demographics, education, practice history, patient population, volunteerism, experiences with discrimination, and opinions on issues in dentistry. The survey was developed with constituent input, pilot-tested, and distributed online and through US mail with three reminder postcards, phone, and email follow-up. Continuing education credit and entry to a prize drawing were provided for participation. Existing data sources cannot answer critical research questions about URM dentists. Using best practices, the survey received a 34 percent adjusted response rate. Selection likelihood and measurable response bias were adjusted for using base and poststratification weights. The survey design was consistent with best practices, and our response analytics provide high confidence that the survey produced data representative of the URM dentist population. Enhanced study design, content, and response rates of existing survey efforts would be needed to provide a more robust body of knowledge on URM providers, perspectives, and practices.

Human Papillomavirus Infection in Women Who Submit Self-collected Vaginal Swabs After Internet Recruitment.

Submission of vaginal samples collected at home could remove barriers that women face in getting screened for cervical cancer. From December 2013 to January 2014, women aged 21-30 years were recruited online to participate in either (1) self-collected testing for human papillomavirus (HPV) infection and an online survey, or (2) an online survey regarding their perceptions of self-collected testing for HPV infection. Demographics, risk factors, testing perceptions, and satisfaction with self-collected testing were assessed with online questionnaires. Women who performed self-collection were sent a home sampling kit by US mail, which was returned via US mail for HPV testing. A total of 197 women were enrolled, with 130 completing the online survey and 67 participating in both the survey and self-collection. Of the 67 women who were sent kits, 62 (92.5%) were returned for testing. Sixty kits contained a sample sufficient for testing. The overall prevalence of HPV infection was 17.8%, however 6 women (9.7%) were infected with >1 type of HPV. Women who self-collected a sample reported more favorable attributes of self-collection compared to women who only participated in the online survey, including ease of sampling (87.1 vs. 18.9%), no pain during sampling (72.6 vs. 5.6%), and lack of embarrassment (67.7 vs. 12.9%). A high prevalence of HPV infection was demonstrated among women recruited via the internet. Online recruitment and at home screening methods have the potential to engage women in screening by offering an approach that might be more acceptable to women of different backgrounds.

Throwing in the Towel: Burnout among Practicing Interior Designers

Job turnover is often preceded by burnout, a psychological syndrome involving prolonged response to stressors on the job (Maslach &amp; Leiter, 2008). This phenomenon is measured along a continuum ranging from job engaged to full burnout. Higher levels of burnout can result in turnover, excessive absenteeism, and numerous physical and emotional symptoms among employees. The purpose of this study was to assess levels of burnout among practicing interior designers, and identify both individual and situational factors relative to burnout. The Maslach Burnout Inventory (MBI–GS) was used to measure burnout and a Job Satisfaction survey gathered basic demographic and situational (job–related) information from practicing interior designers ( N = 130). The voluntary and anonymous surveys were distributed via US Mail and the response rate was 52%. Results revealed that study participants were experiencing a moderate level of burnout. However, when compared with other professions, interior designers rated highest in cynicism and second only to nurses in exhaustion, as measured by the MBI–GS. Statistically significant correlations and regressions were found between burnout and the individual factors of age and years of professional practice as well as the situational factors of workload, control, reward, and fairness. The results and implications of the study are relevant to both interior design practitioners and academics and the discussion calls upon these communities to reconsider discipline–based traditions and expectations that may exacerbate burnout to keep practitioners healthy and positively engaged in the profession.

Roles of Nurse Practitioners and Physician Assistants in Rheumatology Practices in the US

A recent workforce study of rheumatology in the US suggests that during the next several decades, the demand for rheumatology services will outstrip the supply of rheumatologists. Midlevel providers such as nurse practitioners and physician assistants may be able to alleviate projected shortages. We administered a nationwide survey of midlevel providers during 2012. Invitations with the survey were sent with one followup reminder. The survey contained questions regarding demographics, training, level of practice independence, responsibilities, drug prescribing, use of objective outcome measures, and knowledge and use of treat-to-target (TTT) strategies. The invitation was sent to 482 eligible midlevel providers via e-mail and 90 via US mail. We received a total of 174 responses (30%). The mean age was 46 years and 83% were women. Nearly 75% had ≤10 years of experience and 53% had received formal training in rheumatology. Almost two-thirds reported having their own panel of patients. The top 3 practice responsibilities described were performing patient education (99%), adjusting medication doses (98%), and conducting physical examinations (97%). More than 90% felt very or somewhat comfortable diagnosing rheumatoid arthritis (RA) and a similar percentage prescribed disease-modifying antirheumatic drugs. Three-quarters reported using disease activity measures for RA and 56% reported that their practices used TTT strategies. Most respondents reported that they had substantial patient care responsibilities, used disease activity measures for RA, and incorporated TTT in their practice. These data suggest midlevel providers may help to reduce shortages in the rheumatology workforce and conform with recommendations to employ TTT strategies in RA treatment.

Anthrax vaccines: present status and future prospects

The management of anthrax remains a top priority among the biowarfare/bioterror agents. It was the Bacillus anthracis spore attack through the US mail system after the September 11, 2001, terrorist attacks in the USA that highlighted the potential of B. anthracis as a bioterrorism agent and the threat posed by its deliberate dissemination. These attacks invigorated the efforts toward understanding the anthrax pathogenesis and development of more comprehensive medical intervention strategies for its containment in case of both natural disease and manmade, accidental or deliberate infection of a non-suspecting population. Currently, efforts are directed toward the development of safe and efficacious vaccines as well as intervention tools for controlling the disease in the advanced fulminant stage when toxemia has already developed. This work presents an overview of the current understanding of anthrax pathogenesis and recent advances made, particularly after 2001, for the successful management of anthrax and outlines future perspectives.