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Causes for employee absenteeism vary. The commonest cause of work absenteeism is "illness-related." Mongolia's capital city, Ulaanbaatar, experiences high employee absenteeism during the winter than during other seasons due to the combination of extreme cold and extreme air pollution. We identified direct and indirect costs of absenteeism attributed to air pollution among private-sector employees in Ulaanbaatar. Using a purposive sampling design, we obtained questionnaire data for 1,330 employees working for private-sector companies spanning six economic sectors. We conducted 26 employee focus groups and 20 individual employer in-depth interviews. We used both quantitative and qualitative instruments to characterize the direct and indirect costs of absence due to illnesses attributed to severe air pollution during wintertime. Female employees and employees with a young child at home were more likely to be absent. Respiratory diseases accounted for the majority of reported air pollution-related illnesses. All participants perceived that air pollution adversely affected their health. Individual employee direct costs related to absence totaled 875,000 MNT ($307.10) for an average of three instances of three-day illness-related absences during the winter. This sum included diagnostic and doctor visit-related, medication costs and hospitalization costs. Non-healthcare-related direct cost (transportation) per absence was 50,000₮ ($17.60). Individual indirect costs included the value of lost wages for the typical 3-day absence, amounting to 120,000₮ ($42.10). These total costs to employees, therefore, may amount to as much as 10% of annual income. The majority of sick absences were unpaid. Overall, the cost of wintertime absences is substantial and fell disproportionately on female employees with young children.

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The current study used diffusion tensor imaging to examine patterns/degree of brain connectivity in 12 college-aged binge drinking (BD) and 12 moderate drinking individuals. Voxel-level and region-of-interest analyses revealed increased connectivity of the BD brain in the right corona radiata, right external capsule, and both the right and left cingulum. Also, fractional anisotropy and axial diffusivity values of these regions correlated with a number of drinking behaviors of the BD as well as both groups combined. It is hypothesized that increased connectivity in the BD may produce difficulties with regulatory control, contributing to their propensity to binge.

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BACKGROUND: Few studies have examined the impact of community-based smoke alarm (SA) distribution programmes on the occurrence of house fire-related deaths and injuries (HF-D/I). OBJECTIVE: To determine whether the rate of HF-D/I differed for programme houses that had a SA installed through a community-based programme called Operation Installation, versus non-programme houses in the same census tracts that had not received such a SA. METHODS: Teams of volunteers and firefighters canvassed houses in 36 high-risk target census tracts in Dallas, TX, between April 2001 and April 2011, and installed lithium-powered SAs in houses where residents were present and gave permission. We then followed incidence of HF-D/I among residents of the 8134 programme houses versus the 24 346 non-programme houses. RESULTS: After a mean of 5.2 years of follow-up, the unadjusted HF-D/I rate was 68% lower among residents of programme houses versus non-programme houses (3.1 vs 9.6 per 100 000 population, respectively; rate ratio, 0.32; 95% CI 0.10 to 0.84). Multivariate analysis including several demographic variables showed that the adjusted HF-D/I rate in programme houses was 63% lower than non-programme houses. The programme was most effective in the first 5 years after SA installation, with declining difference in rates after the 6th year, probably due to SAs becoming non-functional during that time. CONCLUSIONS: This collaborative, community-based SA installation programme was effective at preventing deaths and injuries from house fires, but the duration of effectiveness was less than 10 years.

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OBJECTIVE: To measure the effect of the WHO Safe Communities model approach to increasing child restraint use in motor vehicles. DESIGN: Pre- and post-intervention observations of restraint use in motor vehicles in several sites in the target area, and in a comparison area community. SETTING: Community; southeast Dallas, Texas, 2003-2005. INTERVENTIONS: A multifaceted approach to increasing use of child safety seats, booster seats and seat belts that included efforts in schools, day care centres, neighbourhoods and a local public clinic, along with child safety seat classes and a low-cost distribution programme. MAIN OUTCOME MEASURES: Prevalence of restraint use among children 0-8 years old riding in motor vehicles. RESULTS: In the target area, the adjusted child restraint use increased by 23.9 percentage points versus 11.8 in the comparison area (difference 12.1; 95% CI 9.9 to 14.3), and adjusted driver seat belt use increased by 16.3 percentage points in the target area versus 4.9 in the comparison area (difference 11.4; 95% CI 11.0 to 11.7). Multivariable multilevel analysis showed that the increase in the target area was significantly greater than in the comparison area for child restraint use (OR 1.6; 95% CI 1.2 to 2.2), as well as for driver seat belt use and proportion of children riding in the back seat. CONCLUSIONS: The Safe Communities approach was successful in promoting the use of child restraints in motor vehicles through a multifaceted intervention that included efforts in various community settings, instructional classes and child safety seat distribution.

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BACKGROUND: There have been many reports of complications of central venous lines in children but limited discussion of the specific problem of retained intravascular fragments after attempted removal. We report on a series of 6 patients from 2 tertiary pediatric hospitals that had intravascular segments of long-term central venous lines that could not be removed and so were left in situ. METHODS: We conducted a retrospective multiinstitutional review of long-term central venous lines (Broviacs, Port-A-Caths, and Hickmans) removed in the operating room with a focused chart review and prospective follow-up of those patients that had a failed attempt at removal. RESULTS: A total of 299 central venous lines were removed with 6 patients identified as having fragments of lines left behind (2%). The lines had been in place for an average of 37 +/- 12 months. The average follow-up period is now 5.4 +/- 3.9 years; none of the patients have developed any symptoms, evidence of thrombus, infection, or catheter migration. CONCLUSION: Given the 2% incidence rate, the issue of managing a stuck long-term central venous line will face most individuals who place these lines. We have demonstrated that simply ligating the catheter and leaving the fragment in place appears to be a safe option with minimal risk to the patient.

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OBJECTIVE: To examine preterm births among African-American and Hispanic women who delivered at an inner-city public hospital in the context of contemporaneously increasing rates in the United States. METHODS: The rates of preterm birth, defined as birth before 37 weeks of gestation, for singleton neonates with birth weights of 500 g or higher delivered to women who had prenatal care at Parkland Hospital between 1988 and 2006 were compared with similar births in the United States from 1995 to 2002. Preterm birth rates also were compared for white, African-American, and Hispanic women as were disparity in these rates using white women as the referent. RESULTS: The Parkland Memorial Hospital cohort included 260,197 women, of whom 70% were Hispanic, 20% African-American, and 8% white. The U.S. cohort included 29,366,816 women, of whom 61% were white, 19% Hispanic, and 14% African-American. Between 1995 and 2002, the rate of preterm birth in the United States increased from 9.4% to 10.1% (P<.001). Between 1988 and 2006, the rate of preterm births at Parkland decreased from 10.4% to 4.9% (P<.001). Moreover, the rates of preterm birth were significantly lower in Hispanic and African-American women who delivered at Parkland compared with the same ethnicity/race groups in the U.S. cohort. The decline in preterm births at Parkland Memorial Hospital coincided with increased prenatal care use. CONCLUSION: Preterm birth significantly decreased in minority women delivered at an inner-city public hospital. We hypothesize that the reduction in preterm births was the result of a public health care program specifically targeting minority pregnant women.

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Lack of health insurance is more prevalent in the state of Texas than in the rest of the country. To get necessary medical care, uninsured Texans must rely on safety net hospitals. Economic turmoil and fluctuating public support routinely threaten the financial stability of these hospitals. Safety net hospitals must be identified to craft public policy solutions that ensure their viability. In this paper, we propose a new method to identify these hospitals by incorporating criteria established previously by economists with additional measures of community value. Our data indicate that safety net hospitals continue to face financial challenges. Texas will need to move forward along several policy fronts to preserve this vital system of care.

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OBJECTIVE: To explore the epidemiology of pedestrian deaths in Dallas County, Texas, and to compare factors associated with pedestrian deaths on expressways versus those that occurred on other roadways. METHODS: We studied all pedestrian deaths among persons 15 years of age or older in Dallas County, Texas, from 1997 to 2004 by linking data from Medical Examiner's office, the Fatality Analysis Reporting System, and local police records. Univariate and multivariate analysis compared various factors associated with death on an expressway. RESULTS: Among 437 pedestrian deaths who were 15 years of age or older, 197 (45%) occurred on expressways; the proportion that occurred on expressways was highest among 15- to 29-year-olds (65%) and was lower with advancing age group (p < 0.01, chi square for trend). At least 36% of these expressway-related pedestrian deaths were known to have been "unintended pedestrians," who had exited a vehicle after being on the roadway, compared with 11% of pedestrian deaths on surface streets (OR 4.6, 95% CI, 2.7-8.1), and this was also highest among younger age groups. Pedestrian deaths on an expressway, compared with deaths on surface streets, remained strongly associated with having been an "unintended pedestrian" (OR 6.2, 95% CI, 3.1-14.0), after controlling for several other variables, including age, sex, race, nighttime of crash, and alcohol involvement. CONCLUSIONS: Expressways are the predominant site of fatal pedestrian crashes among young adults in this urban area. Since many of these deaths were "unintended pedestrians," procedures for management of occupants of disabled vehicles on expressways could have a large impact on pedestrian deaths in young adults.

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The American healthcare system is in need of fundamental change. With more than a decade of annual forums on quality improvement in healthcare and alarming statistics ranking medical errors among the top 10 causes of death in the United States, hospitals and health systems across the country are responding with a coordinated approach to quality improvement. Parkland Health & Hospital System believes the ideal public hospital system requires three critical components to achieve the Institute of Medicine's quality aims: (I) an emphasis on quality that is embraced by senior leadership, (2) careful measurement selection, and (3) the development of a robust infrastructure for outcomes research. This article describes Parkland's approach to each component and takes a look at selected processes and outcomes.

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Thrombosis occurs in 37% of children with acute lymphoblastic leukaemia (ALL) and is related to an L-asparaginase-induced acquired antithrombin (AT) deficiency. The incidence dictates the need for anticoagulant prophylaxis. Direct thrombin inhibitors (DTI) are independent of AT for effect and may thus have advantages in this population. The objective of this study was to determine the interaction of an AT deficiency with the anticoagulant effects of a DTI and a low molecular weight heparin (LMWH). Plasma samples from children with ALL were pooled (mean AT 0.53 U/ml). LMWH 0.3 and 0.7 U/ml or melagatran 0.3 and 0.5 micromol/l were added to the pools, then divided and AT was added back to one aliquot. In additional experiments, AT was added to AT immuno-depleted plasma. Endogenous thrombin generation capacity (ETGC) was assessed by the continuous method. In plasma with LMWH, there was a 66-88% decrease in ETGC in AT-normalised samples compared with neat. Conversely, no significant difference in ETGC with or without AT added for melagatran was seen. Experiments with AT-depleted plasma showed no effect of AT level on anticoagulant activity of DTI, but a significant relationship for LMWH. By contrast to LMWH, DTI provides a consistent anticoagulant response independent of AT levels in children with AT deficiency.

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Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.

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The current system of regional medical service delivery in Texas places large demands on the state's urban public hospitals. To assess the nature and scope of such demands, we examined financial data from five of the state's largest public hospital districts. During fiscal year 2002, these hospitals reported 103,381 encounters with out-of-county patients, resulting in 66 million dollars in unreimbursed costs. Given the current economic outlook, Texas requires a more effective regional model that centralizes tertiary care, disperses primary and secondary care, and preserves key public health goods.

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Document imaging and management The authors urge practices that haven't fully implemented a complete electronic medical record or computerized patient record system to consider some sort of document imaging and management system (DIMS).

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An association has been reported between thrombotic events and the use of L-asparaginase (ASP) in children with acute lymphoblastic leukaemia (ALL). The mechanism for thrombosis is likely related to an acquired antithrombin deficiency. Since a primary prophylaxis using antithrombin concentrates may prevent thrombosis, the PARKAA (Prophylactic Antithrombin replacement in kids with ALL treated with L-asparaginase) study was performed. The objectives of PARKAA were to determine if there was a trend to efficacy and safety of antithrombin treatment as assessed by 1) incidence of thrombosis 2) incidence of bleeding and 3) plasma markers of endogenous thrombin generation as surrogate outcomes for thrombosis. The study was not powered to answer the question of efficacy and safety, but rather to detect a trend. PARKAA was an open, randomised, controlled study in children with ALL being treated with ASP. Children were randomised to receive antithrombin infusions or no antithrombin treatment. All thrombotic events were confirmed using bilateral venography, ultrasound, echocardiography and MRI. The incidence of thrombosis in patients treated with antithrombin was 28% (95% CI 10-46%), compared to 37% (95% CI 24-49%) in the non treated arm. Two minor bleeds occurred in patients in the treated arm, but were not considered to be related to antithrombin. No significant differences were seen in plasma markers by the treatment group. In conclusion, treatment with antithrombin concentrate shows a trend to efficacy and safety. In contrast, there was no difference in surrogate markers for thrombosis. Carefully designed clinical trials are needed to test the efficacy and safety of antithrombin in this population.

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BACKGROUND: Thrombotic events (TEs) are serious secondary complications in children with acute lymphoblastic leukemia (ALL) who receive L-asparaginase (ASP) therapy; however, the prevalence of TEs has not been established. The primary objective of the Prophylactic Antithrombin Replacement in Kids with Acute Lymphoblastic Leukemia Treated with Asparaginase (PARKAA) Study was to determine the prevalence of TEs. The secondary objective was to detect any association of TEs with the presence of congenital or acquired prothrombotic disorders. METHODS: Children with ALL were screened for TEs at the end of ASP treatment using bilateral venograms, ultrasound, magnetic resonance imaging, and echocardiography. Symptomatic TEs were confirmed by appropriate radiographic tests. All tests were read by a blinded central adjudication committee. RESULTS: Twenty-two of 60 children had TEs, a prevalence of 36.7% (95% confidence interval, 24.4-48.8%). TEs were located in the sinovenous system of the brain in 1 patient, the right atrium in 3 patients, and the upper central venous system in 19 patients. TEs detected by venography resulted in 1) 25-100% occlusion, with 1 in 3 patients showing occlusion of > 75% of the greatest vessel dimension, and 2) the presence of collaterals in 60% of patients, with 40% categorized as major. No children with TEs were positive for factor V Leiden or prothrombin gene 20201A, and four of eight children with antiphospholipid antibodies had a TE. CONCLUSIONS: The prevalence of TEs is exceedingly high in this population, and it is likely that the extent of occlusion is likely clinically significant. No trend was seen toward an association between TEs and the presence of congenital prothrombotic disorders. A trend was seen toward an association between TEs and antiphospholipid antibodies. Carefully designed clinical trials of primary prophylaxis for the prevention of TEs are required in this patient population.

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