Physical activity, particularly percussive activities with adequate energy intake may influence bone mineral density (BMD) in young female adults. Unfortunately, it is common to see energy deficiencies in this population that can put them at risk of health issues including lower BMD PURPOSE: To determine the influence of the type of sport and energy intake on BMD in female athletes compared to sedentary students. METHOD: Seventy-three female students (age 20.8± 1.9 y, height 167.4± 8.8 cm, weight 62.3± 9.2) from McGill University were evaluated (44 from McGill Varsity Teams: basketball (BB n=13), volleyball (VB n=11), figure skating (FS n =13), and synchronized swimming (SS n=7); and 29 sedentary healthy women (controls). Dietary intake (kcal/day) was assessed using a 3-day Food Log and analysed with the Food ProcessorTM Software. Lumbar spine (LS) (L1-L4) and femoral neck (FN) BMD were assessed by DXA scanning. A one-way ANOVA explored between-group differences and an ANCOVA examined the influence of energy intake on BMD. RESULTS: A significant difference in BMD at the LS and FN sites was observed between the type of sports (F(4,68) = 8.6, p < .001, η2 = .335; F(4,68) = 6.3, p < .001, η2 = .272, respectively). Also, BB (LS = 1.7± 1.53, p < .001; FN = 1.7± 1.13, p = .001) and VB (LS = 1.5 ± 1.55, p = .001; FN = 1.7 ± 1.66, p = .002) players had a significantly higher BMD in both sites compared to their non-athletic counterparts (LS = -0.3 ± 1.19; FN = 0.1 ± 1.04). The FS and SS athlete’s bone densities were not different from the control group (p = .719; p = .246). No significant association was observed between BMD at both sites and total energy intake/day across all groups (F(1,67) = .496, p = .484 , η2 = .007; F(1,67) = .035, p = .852, η2 = .001). There was a significant difference between the delta energy intake (recommended intake minus actual intake) in both BB and SS groups compared to the control group (p = .003 and p = 0.02, respectively). CONCLUSION: The type of sport revealed an influence on BMD. However, no significant relationship was observed between energy intake and BMD. A significant discrepancy was found between the required versus actual energy intake in some athletes. These data suggest that female varsity athletes should work closely with sports dieticians to promote healthy eating and optimize bone health.

Physical activity (PA) is one of the strongest predictors of successful long-term weight management and is a recommended adjunct to bariatric surgery. However, post-surgical adoption and maintenance of PA is consistently low. Women with obesity are more likely to be physically inactive compared to men, which may compromise post-surgical outcomes. Qualitatively investigating obese women’s experiences with PA will have implications for understanding the challenges female bariatric patients may face when adopting and maintaining PA. In the present study, 12 women (age= 47±9 years), who had undergone bariatric surgery within 9 to18 months, were individually interviewed to explore their perceptions of PA. Three themes emerged from thematic analysis: (i) Somatic Experiences, (ii) Appraisal of the Physical and Social Self, and (iii) Negotiating the Exercise Environment. Women reported struggling with weight-restricted mobility, side effects of surgery, low stamina, body dissatisfaction, compromised psychological health, competing responsibilities, a lack of exercise self-efficacy and social support, reduced access to accommodating facilities, lack of exercise knowledge, as well as northern climate. On the other hand, post-surgical weight loss, weight and health maintenance, enjoyment, body image, supportive active relationships, as well as access to accommodating facilities and exercise knowledge were discussed as factors that promoted PA efforts. As the first study to explore women’s perceptions of PA around bariatric surgery, these findings may inform PA programming strategies for healthcare and exercise professionals working with this unique population. PA and health promotion initiatives can also benefit from a cultural paradigm shift away from weight-based representations of health.

The association between physical activity (PA) and C-reactive protein (CRP) is inconsistent, with nearly all studies using self-report measures of PA. The purpose of this study was to examine the association between objectively measured PA and CRP in US adults and children. Adults (N=2912) and children (N=1643) with valid accelerometer data and CRP data were included in the analyses. Logistic regression analysis was used to assess the odds of meeting PA guidelines across CRP quartiles for children and among adults with low, average, and high CRP levels. For adults, after adjustments for age, gender, race, body mass index, smoking, diabetes, and high-density lipoprotein cholesterol (HDL-C), compared with those with low CRP levels, odds ratios were 0.59 (CI=0.450.77) and 0.46 (CI=0.280.76) for participants with average and high CRP levels, respectively. For children, after adjustments for age, gender, race, weight status, and HDL-C, compared with those in CRP quartile 1, odds ratios were 0.96 (CI=0.51.84), 1.23 (CI=0.712.12), and 0.79 (CI=0.331.88) for participants in quartiles 2, 3, and 4, respectively. Objectively measured PA is inversely associated with CRP in adults, with PA not related to CRP in children.

The association between physical activity (PA) and C‐reactive protein (CRP) is inconsistent, with nearly all studies using self‐report measures of PA. The purpose of this study was to examine the association between objectively measured PA and CRP in US adults and children. Adults ( N =2912) and children ( N =1643) with valid accelerometer data and CRP data were included in the analyses. Logistic regression analysis was used to assess the odds of meeting PA guidelines across CRP quartiles for children and among adults with low, average, and high CRP levels. For adults, after adjustments for age, gender, race, body mass index, smoking, diabetes, and high‐density lipoprotein cholesterol (HDL‐C), compared with those with low CRP levels, odds ratios were 0.59 (CI=0.45–0.77) and 0.46 (CI=0.28–0.76) for participants with average and high CRP levels, respectively. For children, after adjustments for age, gender, race, weight status, and HDL‐C, compared with those in CRP quartile 1, odds ratios were 0.96 (CI=0.5–1.84), 1.23 (CI=0.71–2.12), and 0.79 (CI=0.33–1.88) for participants in quartiles 2, 3, and 4, respectively. Objectively measured PA is inversely associated with CRP in adults, with PA not related to CRP in children.

Systems of care provide comprehensive services to children with emotional and behavioral disorders through a network of local agencies and providers that function as a multi-agency case review team. A primary objective in any system of care is to provide individuals with access to appropriate services. In the present study, access is defined as services received relative to those recommended by a multi-agency review team and barriers to services identified by that team. These indicators, which provide a system-level assessment of service access and function as a proxy for the development of the system of care, fill a gap in the existing literature for more system-level indicators of outcome. A total of 2073 children and youth are assessed upon entry into Rhode Island's behavioral health system of care and then followed for three months to determine the extent of services received relative to those recommended as well as barriers to services identified at service entry. Multi-agency reviews are conducted over an 8-year-period through three phases of system of care implementation-early in the establishment of the system of care, at the midpoint of implementation after substantial funding was received for service enhancements, and after full implementation of the system of care philosophy. The results indicate that, as a system of care matures, access increases significantly on both of these indicators, and that more and different types of children are served and agencies are involved in the system of care. The results are discussed for their implications for assessing systems of care through establishment of system-level empirical benchmarks of service system development.

OBJECTIVE:The objective of this study was to describe the nursing documentation of telephone communication with physicians in community nursing homes.DESIGN:We conducted a prospective observational study evaluating nursing documentation of all telephone calls to one physician group.SETTING:We studied two proprietary community nursing homes in Baltimore, Maryland.MEASUREMENTS:Data were collected by physicians at the time of each call regarding the time, day, nursing facility, reason for the call, and any orders given. Calls were also categorized as to whether documentation was necessary by defined criteria. The nursing home charts were then reviewed for the presence of documentation of 1) the issue that prompted the call, 2) physician's participation in the matter, and 3) any orders given by the physician. The relationships between the characteristics of the telephone calls and the rates of documentation were then analyzed.RESULTS:There were 248 calls from the two nursing homes during the 2-month study period. Nursing documentation of the issue that prompted the call was present for 80% of total calls. This documentation was more likely to be present with calls for change of patient status and notification of laboratory/radiograph results compared with calls for other issues (117 of 125 [94%] vs. 57 of 63 [90%] vs. 24 of 60 [40%], respectively; chi(2) = 78.3, P <0.0001). Calls that were categorized as "documentation necessary" by the Medical Director were more likely to be documented than calls that were not (132 of 150 [88%] vs. 9 of 35 [26%], respectively; chi(2) = 60.8, P <0.001). Of the 198 calls with any form of documentation, specific mention of physician participation in the communication was present in 89% of these calls. This documentation of physician participation was more likely to be present with calls for laboratory/radiograph notification than with calls for change of patient status or calls for other reasons (57 of 57 [100%] vs. 99 of 117 [85%] vs. 20 of 24 [83%], respectively; chi(2) = 10.0, P = 0.007). Physicians indicated that orders were given during 69% of calls, but orders were only documented for 79% of these interactions. No characteristics of the call were associated with likelihood of order documentation.CONCLUSIONS:In this study, documentation of issues that lead to telephone calls to physicians was not always present. Similarly, orders given by the physician were absent over 20% of the time. Nurses, physicians, and facilities should develop efficient and routine strategies to optimize rates of documentation of telephone communication with physicians.

Objective To describe physician telephone management of newly admitted nursing home residents before direct evaluation by the physician, and the effect on resident outcomes. Design Retrospective chart review of 111 consecutive discharge records from two proprietary community nursing homes in Baltimore, Maryland in 1999. Measurements Data regarding the admission process were collected, with an emphasis on physician telephone orders at admission and all subsequent telephone orders before the first physician visit. Physicians were categorized as attending physicians or on-call physicians. Unexpected outcomes defined as an unplanned admission to an acute hospital or an unanticipated death within 14 days of admission to the nursing home were identified. The relationships among resident, physician, and admission characteristics and unexpected outcomes were analyzed. Results Most residents (97 of 111 (87%)) were admitted from an acute hospital, and the remaining 13% were admitted from home or another nursing home. An attending physician confirmed admission orders for 87 of 111 (78%) residents, and an on-call physician confirmed admission orders for the remainder. Physicians changed medications at the time of admission, as compared with preadmission medications, in 58 of 111 (52%) residents and ordered laboratory studies or radiographs in 59 of 111 (53%). On-call physicians were just as likely to make both types of changes as attending physicians. In the time interval after the initial telephone contact but before the first physician visit, medication changes were made in 35 of 111 (32%) residents and testing was ordered in 16 of 111 (14%). Nineteen of 111 (17%) residents were either readmitted to the hospital or died within 14 days of admission to the nursing home. These unexpected outcomes were statistically less likely to occur in the group of residents for whom physicians made medication changes at the time of admission as compared to the group for whom no medication changes were made [6 of 58 (10%) versus 13 of 53 (25%), P = 0.04, respectively], and in the group for whom tests were ordered at the time of admission as compared to not ordered [4 of 59 (7%) versus 15 of 51 (29%), P = 0.002, respectively]. There were no differences in the likelihood of unexpected outcomes when physicians made medication changes or ordered tests after the time of admission but before the first physician visit. Conclusions In this study, physicians made adjustments in medications and ordered tests for newly admitted nursing home patients before seeing the resident in the majority of cases. Unexpected outcomes including readmission to the hospital or death within 14 days of admission were less common among those residents when such changes were made at the time of admission. Further studies are needed to identify those changes as well as those resident and physician characteristics that might lead to improved outcomes. To describe physician telephone management of newly admitted nursing home residents before direct evaluation by the physician, and the effect on resident outcomes. Retrospective chart review of 111 consecutive discharge records from two proprietary community nursing homes in Baltimore, Maryland in 1999. Data regarding the admission process were collected, with an emphasis on physician telephone orders at admission and all subsequent telephone orders before the first physician visit. Physicians were categorized as attending physicians or on-call physicians. Unexpected outcomes defined as an unplanned admission to an acute hospital or an unanticipated death within 14 days of admission to the nursing home were identified. The relationships among resident, physician, and admission characteristics and unexpected outcomes were analyzed. Most residents (97 of 111 (87%)) were admitted from an acute hospital, and the remaining 13% were admitted from home or another nursing home. An attending physician confirmed admission orders for 87 of 111 (78%) residents, and an on-call physician confirmed admission orders for the remainder. Physicians changed medications at the time of admission, as compared with preadmission medications, in 58 of 111 (52%) residents and ordered laboratory studies or radiographs in 59 of 111 (53%). On-call physicians were just as likely to make both types of changes as attending physicians. In the time interval after the initial telephone contact but before the first physician visit, medication changes were made in 35 of 111 (32%) residents and testing was ordered in 16 of 111 (14%). Nineteen of 111 (17%) residents were either readmitted to the hospital or died within 14 days of admission to the nursing home. These unexpected outcomes were statistically less likely to occur in the group of residents for whom physicians made medication changes at the time of admission as compared to the group for whom no medication changes were made [6 of 58 (10%) versus 13 of 53 (25%), P = 0.04, respectively], and in the group for whom tests were ordered at the time of admission as compared to not ordered [4 of 59 (7%) versus 15 of 51 (29%), P = 0.002, respectively]. There were no differences in the likelihood of unexpected outcomes when physicians made medication changes or ordered tests after the time of admission but before the first physician visit. In this study, physicians made adjustments in medications and ordered tests for newly admitted nursing home patients before seeing the resident in the majority of cases. Unexpected outcomes including readmission to the hospital or death within 14 days of admission were less common among those residents when such changes were made at the time of admission. Further studies are needed to identify those changes as well as those resident and physician characteristics that might lead to improved outcomes.

To the Editor: Hip fractures are associated with numerous adverse outcomes such as death, nursing home placement, and loss of function,1-7 and their incidence is steadily rising in the United States. The best approach to limit morbidity and mortality from hip fractures is primary prevention, but when fractures do occur, healthcare systems need innovative services that minimize complications and maximize chances for recovery of function and lifestyle. A small body of literature supports the use of joint orthopedics-geriatrics teams that use early interdisciplinary care to optimize outcomes of patients with acute hip fractures.8-10 Here, we describe the conception and implementation of a Hip Fracture Service (HFS) at our institution. HFS development began with a directive from leaders of the orthopedics department and geriatrics division to improve the care of these complex patients. During planning meetings, relevant staff identified goals and reached consensus on standards of care. With approval from the medical board, the HFS became an admitting service team. To help answer common questions, reassure patients and families, and build lines of communication, patients and families receive a brochure that describes expectations for hospital course, goals for the patient, and contact numbers for various disciplines upon admission. Education of clinical staff from all involved disciplines occurs formally via a monthly case conference to discuss key clinical care issues for patients on the HFS. The HFS team uses preprinted medical orders and care maps for emergency department care, preoperative admission orders, and postoperative care. Examples of standardized care include pain medications with “geriatric-friendly” doses, prophylactic antibiotics, thromboprophylaxis, postoperative calcium and vitamin D, bowel regimens, and early mobilization. Figure 1 provides an overview of the flow of care. In the emergency department, once a diagnosis of hip fracture is suspected, HFS orders are activated and the orthopedics house staff is alerted. Once the fracture is confirmed, the geriatrician is notified by 24-hour-a-day pager. The geriatrician evaluates the patient as soon as possible, often while the patient is still in the emergency department. Stable patients are admitted to the surgical floor; unstable patients are admitted to the intensive care unit, with the HFS team following along with the intensive care unit clinicians. The hip fracture service flow of clinical care. The bold font and thick arrows draw attention to the routine path of service for most patients. The normal font and thin arrows demonstrate possible deviations from this path. HFS = Hip Fracture Service; ED = emergency department; CCU = coronary care unit; MICU = medical intensive care unit; rehab = rehabilitation. Most data suggest that prompt surgical repair is important;11-18 surgical delay is likely prudent with acute and unstable cardiac or pulmonary diseases.1, 19 Surgery may be forgone entirely when no functional improvement can reasonably be expected from surgical treatment.6 The orthopedic and anesthesia physicians arrange operating room time as soon as the patient is deemed medically stable. Orthopedic surgeons perform the operative repair with the goal of fracture stabilization or repair. Postsurgery, the majority of patients are transferred back to the surgical floor, although unstable patients are cared for in the intensive care unit. All patients receive daily evaluation by geriatricians and orthopedists, who discuss active problems and reach a consensus on a treatment plan. Patients usually begin physical therapy on the first postoperative day. For uncomplicated cases, the goal is to transfer patients to home or to a rehabilitation setting by postoperative Day 3. Challenges to optimal implementation of the HFS arise from several sources. Cooperation between anesthesiology and medicine is indispensable in reaching a reasonable consensus regarding preoperative evaluation on a case-by-case basis. Involvement of patients' primary care physician and family and accurate flow of information are important. Here, the orthopedist dictates the discharge summary, and the geriatrician edits it and dictates a cover letter to the primary care physician to enhance flow of information. For the many issues for which data do not exist to guide determination of standards of care, research is needed. We have found that a dedicated team with orthopedics and geriatrics leadership has led to improved efficiency and quality of care for patients. The epidemic of hip fractures in the aging population behooves health systems to develop more effective methods for returning patients to independence.

Objectives. This study examined the relationship between acculturation and leisure-time physical inactivity among Mexican American adults. Methods. Using data from the Third National Health and Nutrition Examination Survey, we estimated the prevalence of physical inactivity according to place of birth and language used at home. Results. Spanish-speaking Mexican Americans had a higher prevalence of physical inactivity during leisure time than those who spoke mostly English, independent of place of birth. Conclusions. Acculturation seems to be positively associated with participation in leisure-time physical activity.

BACKGROUND:Discussions about advance directives should be offered to all nursing home residents. Managed Medicare programs for nursing home residents allow for the development of performance improvement initiatives to ensure that these discussions occur and are documented. PURPOSE:To assess the effectiveness of an intervention to increase discussion and documentation of advance directives for enrollees in a managed Medicare program for nursing home residents, and to evaluate whether this intervention affected preferences for cardiopulmonary resuscitation (CPR) and hospitalization among enrollees. SUBJECTS:Participants were 4,248 enrollees in a managed Medicare program in 1996, and 6,598 enrollees in 1997, in Georgia, Maryland, Massachusetts, Minnesota, Arizona, and Florida. DESIGN:Descriptive study of a quality improvement initiative. METHODS:A chart review was conducted in the fall of 1996 to determine the prevalence of documented advance directive discussions among all enrollees, and the preferences regarding CPR and hospitalization. Because the discussion rates varied across sites, and were lower than expected, each site developed strategies to improve advance directive discussion and documentation. One year later, a similar survey was conducted to determine the efficacy of the interventions, as well as to assess the impact, if any, on rates of desire for CPR and hospitalization. RESULTS:Documented discussions of advance directives increased across the six sites from 73% to 85% (P < 0.001). The overall percentage of patients desiring CPR did not change following the intervention (18%). However, there were geographical differences in the desire for CPR among enrollees, with those in Minnesota (8%), Arizona (11%), and Florida (12%) desiring it the least, and those in Massachusetts (20%), Georgia (29%), and Maryland (29%) desiring it the most. The overall percentage of desire for hospitalization decreased from 65% to 62% (P < 0.001). Enrollees in Georgia were most likely to want hospitalization (87%), and enrollees in Minnesota were the least likely to want hospitalization (57%). CONCLUSIONS:In a managed care program, documentation of advance directive discussions can be increased with focused efforts. Overall, most enrollees did not desire CPR, but a majority desired hospitalization. Despite the similarity of interventions and program philosophy across sites, significant geographic variations in desire for CPR and hospitalization remained.