Cognitive ability is associated with suspected reporting errors on food frequency questionnaires.

OBJECTIVE: To examine potential for bias in reported total energy intake on a Food Frequency Questionnaire (FFQ) among older adults. DESIGN: Longitudinal cohort study. SUBJECTS/SETTING: 2,706 Community-dwelling Black and White older adults, aged 70-79 years, enrolled in the Health, Aging, and Body Composition study. Multivariate logistic regression analyses were conducted with potential errors on reported total energy intake on the Food Frequency Questionnaire (FFQ) as the outcome variable and with cognitive ability, measured by the Modified Mini Mental State Exam (3MS) as the primary independent variable. The regression model controlled for site, race, gender, age, body size, and physical activity. Separate models were fit using 3MS as a continuous variable and for multiple 3MS cutpoints. All models revealed similar findings. RESULTS: Cognitive ability was inversely associated with potential errors in reporting total energy intake, whereby a five-point increase in 3MS scores was associated with a 14% decreased likelihood of reporting errors (Odds Ratio=0.86, 95% Confidence Interval: 0.77, 0.95). Additionally, compared to White women, White men were 2 times more likely, and Black women and Black men were 3 times more likely, to have errors in reporting total energy intake. CONCLUSION: This study provides evidence that for older adults, lower cognition scores are associated with increased potential errors in reporting total energy intake. APPLICATIONS: Dietary reporting from older adults may be inaccurate due to cognitive deficits. A brief assessment of cognitive function may assist clinicians in dietary evaluations and recommendation and may benefit studies using FFQ data where the measure of cognitive function could be utilized to stratify data analyses and conduct sensitivity analyses.

Cost-effectiveness of clozapine monitoring after the first 6 months.

BACKGROUND: Clozapine is effective in treating patients with schizophrenia who do not respond to conventional neuroleptic drugs. The drug is unique in that it is available only with a US Food and Drug Administration-mandated system for weekly monitoring of patients' white blood cell counts. No study has been conducted to evaluate the cost-effectiveness of this mandatory monitoring system. METHODS: A benchmark case was established by utilizing cumulative incidence rates of agranulocytosis from a recent study with a large sample of clozapine-treated patients. We assumed a 20% mortality among patients with agranulocytosis, $30.61 in monitoring costs each week, and 14.4 years of remaining life expectancy after detection of agranulocytosis. Based on these bench-mark assumptions, cost-effectiveness ratios in dollars per quality-adjusted life-year were calculated for the first, second, and third 6-month periods during which a patient was receiving clozapine. Sensitivity analyses were performed with more conservative assumptions in 5 alternative scenarios. RESULTS: In the benchmark case, costs per quality-adjusted life-year gained were $61,694, $925,418, and $420,644 for the first, second, and third 6-month periods of clozapine treatment, respectively. In the alternative scenarios, these costs ranged from $7923 to $46,056 for the first 6-month period and from $54,025 to $690,850 for the second and third 6-month periods. CONCLUSIONS: While the costs of monitoring patients with schizophrenia in the first 6-month period of clozapine treatment seem to be justifiable, monitoring thereafter may not be cost-effective because of the very low incidence of agranulocytosis in the later periods.

Patterns of smokeless tobacco use by young adolescents.

The use of smokeless tobacco products by adolescents has reportedly increased. The purpose of this study was to examine the use of smokeless tobacco by young adolescents across geographic locations and to look at patterns of use and variables associated with continued use beyond experimentation. Participants were 2018 students in sixth through ninth grades. Forty-five percent were male and 76% were white. Use of smokeless tobacco products was reported by 12% of the total population, and 25% reported smoking. Smokeless tobacco use was associated with cigarette smoking, alcohol use, and parental substance abuse. Those reporting alcohol use were more than four times more likely to be users of smokeless tobacco than nondrinkers. We found increased age, being male, being white, smoking, drinking, perceived effects of smokeless tobacco use, and friends' smoking behavior to be significantly associated with continued use beyond experimentation. Smokeless tobacco use was reportedly greater in rural areas. Adolescents who reported initiating use between 6 and 8 years of age were using on a more frequent basis than those who had initiated use when older. This study demonstrated the need for targeting elementary schools for educational interventions aimed at reducing smokeless tobacco use.

Increased plasma levels of pancreatic polypeptide and decreased plasma levels of motilin in encopretic children.

OBJECTIVE: Abnormalities of hormones affecting gastrointestinal motility have been found in "functional" disorders of the gastrointestinal system in adults. One such disorder of childhood, encopresis, is frequently associated with constipation, the treatment of which often eliminates the soiling. We hypothesized that hormones affecting gastrointestinal motility were different between encopretic patients and matched controls. METHODS: Ten encopretic patients were matched by age, race, and sex with controls who had no history of encopresis or constipation. After an overnight fast, each child consumed a meal of Ensure, the amount of which was based on body weight. Plasma levels of gastrin, pancreatic polypeptide, cholecystokinin, motilin, thyroxine, estrogen, and insulin were measured 20 and 5 minutes before the meal, and 5, 10, 15, 30, 45, 60, 90, 120, 150, and 180 minutes after the meal. RESULTS: Postprandial levels of pancreatic polypeptide remained consistently higher and peaked earlier (P < .05) for encopretic patients. The motilin response was lower (P < .03) for encopretic children than for controls. CONCLUSIONS: We conclude that pancreatic polypeptide and motilin responses to a meal are different in encopretic children than in children in the control group. These gastrointestinal hormone findings may in part explain and/or be the result of the severe constipation that frequently underlies the fecal soiling found in these patients. These findings also suggest the motility of the stomach and small intestine may be abnormal in encopresis.

Risk factors and outcomes for failure to thrive in low birth weight preterm infants.

OBJECTIVE: To determine the epidemiology, clinical characteristics, and outcomes for low birth weight (LBW) infants with growth deficiency, or failure to thrive (FTT, the term commonly used by pediatric providers to describe growth deficiency or faltering in early childhood). DESIGN: Three-year prospective cohort study with matched case-control study of outcomes. SETTING: Eight large university hospital sites throughout the United States. SAMPLE: 914 LBW infants inborn at the sites and meeting study criteria. RESULTS: FTT was a common condition in this cohort, with 180 (19.7%) of 914 LBW infants meeting case criteria by 30 months. New cases of FTT peaked at 8 months gestation-corrected age. In addition to expected differences in growth between infants with and without FTT, infants with FTT had lower developmental indices and less stimulating home environments. At 36 months, FTT infants had lower IQ scores and were much smaller than infants without FTT. CONCLUSIONS: Growth deficiency, or FTT, is a common clinical condition for those involved in the follow-up care of LBW infants. Worse cognitive and growth outcomes were observed for those meeting the restrictive case criteria employed in this study. More than 80% of the cases in this LBW cohort did not involve any chronic medical disorders, but several biological and environmental differences were found between those who developed FTT and those who did not.

Malformations and minor anomalies in non-trisomic, autosomal aneuploidy.

We examined the medical records of 43 individuals with non-trisomic, autosomal aneuploidy evaluated by the Arkansas Genetics Program. Birthweight and the presence of malformations and minor anomalies by organ system were analyzed on each patient. Low birthweight was present in 28% (N = 12) of the patients, 72% (N = 31) of the subjects had a malformation, and 93% (N = 40) had a minor anomaly. Of the entire sample, the most common site of a malformation or minor anomaly was the limbs (79%). The most common site of a malformation was the head (21%), eyes (21%), or heart (26%). If a malformation was present, the head was significantly more likely (P < .04) than another body system to be the site of an additional malformation or minor anomaly. A malformation or minor anomaly of the ears was significantly more likely (P < .03) to be present when there was an associated eye anomaly than when no anomaly of the eye was identified. These data have implications for chromosome screening of individuals with malformations or minor anomalies and for the clinical evaluation of those found to have non-trisomic autosomal aneuploidy.

The effect of on-site extracorporeal membrane oxygenation on the therapy choice and outcomes of neonates with persistent pulmonary hypertension.

The effect of on-site extracorporeal membrane oxygenation (OS-ECMO) and selection criteria on the utilization rate of this technology is unknown. We retrospectively studied 55 neonates who were admitted to Arkansas Children's Hospital from 1985 to 1993. We compared the ECMO utilization, mortality, and morbidity rates for outborn neonates with moderate and severe persistent pulmonary hypertension (PPHN) before and after the establishment of an ECMO program with guidelines for its use at our institution. The rate of ECMO use was three times higher and the mortality rate was 13 times lower in the period after OS-ECMO compared with the period when ECMO was available only at other institutions. No differences were observed in the morbidity rates between the two periods. Physician decisions to initiate ECMO involved more than guidelines, since 37% of the increased ECMO use was not associated with use of the guidelines. Possible reasons for noncompliance with the guidelines are discussed. Neonates who had received medical therapy only and who had an oxygenation index > or = 30 and < 40 had no mortality. Our findings suggest that the need for ECMO in this group of neonates is low.

Perinatal lethal conditions: the effect of diagnosis on decision making.

OBJECTIVE: To identify factors influencing pregnancy management decisions following identification of a perinatal lethal condition. METHODS: One hundred thirty pregnancies with perinatal lethal conditions diagnosed before 24 weeks' gestation were examined. Information collected included demographic data, estimated gestational age at presentation, referral indication, nature of the defect, and performance of autopsy. RESULTS: Eighty-seven families elected to abort affected pregnancies and 43 elected to continue. Demographic factors did not influence decision making, nor did gestational age at diagnosis or referral indication. When comparing the diagnosis of one lethal condition with diagnoses of all other lethal conditions, pregnancies with a central nervous system defect or severe urinary tract defect were more often aborted; those with unexplained severe oligohydramnios and twin pregnancies in which at least one twin was affected were more often continued. Autopsy was obtained much more often in pregnancies that were aborted than in those that were continued. CONCLUSION: The type of defect correlates well with the pregnancy management decision. It is important to consider the type of malformation, certainty of the diagnosis, and level of medical understanding when counseling patients after the diagnosis of a lethal fetal defect. Because many patients will continue pregnancies diagnosed with a perinatal lethal condition, the physician should convey understanding and acceptance of a decision not to abort such a pregnancy. The importance of follow-up testing, including autopsy when appropriate, should be stated clearly.

The link between sexually transmitted disease clinics and HIV counseling and testing centers: who is not getting referred?

A total of 236 clients attending human immunodeficiency virus (HIV) counseling and testing (C&T) centers and sexually transmitted disease (STD) clinics were interviewed to evaluate who is being reached by C&T services and if STD clients are being referred to HIV C&T centers. Respondents receiving HIV C&T reported significantly more sexual risk based on characteristics of their partners, whereas STD clinics respondents more frequently reported previous STD diagnoses and sex with prostitutes. Over 50% of the high-risk individuals attending STD clinics were not referred to HIV C&T centers. The differences in perceived risk of current and future infection between STD and HIV C&T centers and the low referral rates of high-risk individuals for HIV C&T indicate a need for increased education efforts, more effective risk-assessment policies in STD clinics, and a tightening of the link between STD clinics and HIV C&T centers.

Functional limitations in women at midlife: the role of health conditions, behavioral and environmental factors.

This study examined risk factors for functional limitations in a community-based sample of 16,065 women from 5 ethnic groups, aged 40-55 years, enrolled in the Study of Women's Health Across the Nation. Almost 20% of this sample reported physical-functioning limitations. Functional limitations were associated with numerous disease conditions, including high blood pressure, diabetes, heart attack or angina, arthritis, osteoporosis, and cancer, and with several behavioral and environmental risk factors, including body mass index, difficulty paying for basics, and high levels of perceived stress. Consistent with findings in older women, this study shows that in addition to health conditions, potentially modifiable risk factors including high body mass index, difficulty paying for basics, and high levels of stress are associated with physical-functioning limitations of women at midlife.

Gender differences in rural adolescent drinking patterns.

PURPOSE: The purpose of this study was to examine differences in rural adolescent male and female drinking patterns, problem drinking behavior, and the factors associated with problem drinking behavior. METHODS: An anonymous written survey was administered to 2,297 adolescents, aged 12 to 18 years, in a rural Mississippi River Delta county. Potential risk factors for problem drinking behavior examined included demographic, behavioral, peer, and parental characteristics. Drinking patterns were examined separately for male and female adolescent drinkers. RESULTS: Individual factors associated with problem drinking behavior for these rural adolescents were consistent with previous research. However, these factors were gender specific in prevalence. Males were more likely than females to report all of the behavioral and peer risk factors associated with problem drinking, except depressive symptoms, which were more frequently reported by females than males. The interactions of gender with race and gender with peer approval of drinking were significantly associated with problem drinking. The ratio of male to female problem drinkers among African-American adolescents was twice as high as the ratio among Caucasian adolescents. Females were much more strongly influenced by peer disapproval of drinking than were males. CONCLUSIONS: Prevention and intervention programs may be more effective for rural females if they target depression and focus on support systems, whereas intensive programs for adolescents with multiple high risk behaviors may be more effective for rural males.

Alcohol availability and motor vehicle fatalities.

PURPOSE: To examine the association between the availability of alcohol and male (15-24-years-old) motor vehicle fatalities. METHODS: Assessed association between motor vehicle fatality rates for each of 75 counties for males with measures of alcohol availability (whether the county was wet or dry, number of licensed on-site and off-site alcohol outlets) after controlling for other variables for a 6-year period. Poisson regression models were employed. RESULTS: No significant relationships were found between county-level motor vehicle fatality rates and any of the alcohol availability measures examined. However, rural residence was associated with much higher fatality rates. CONCLUSIONS: Overall, ecologic models, employing a wide range of variables, account for little of the variance in motor vehicle fatality rates for young men. These findings support the position that further legal or regulatory restrictions on alcohol outlet licensing may not have an impact on fatalities. The higher rates associated with rural residence, while consistent with other work, cannot be explained by alcohol beverage outlets.

Adolescents' insight in heavy drinking.

PURPOSE: Because so few adolescents with alcohol problems seek treatment, this study examined the factors associated with adolescents' recognition or insight into having a substance use problem. METHOD: Data were extracted from a self-report questionnaire used in an epidemiological study of public middle school students on substance abuse in Arkansas. Those drinking heavily were divided into "admitters" and "deniers" based on their response to the question of having a substance use problem. Odds ratios were calculated to measure the association of several variables with admitting a problem. RESULTS: Of 3395 adolescents, 13.4% (455) met or exceeded our threshold for heavy drinking. Only 15.9% (65) of these heavy drinkers acknowledged having a substance use problem. Reporting more types of negative social events related to alcohol use and scoring higher on a measure of positive alcohol expectancies were significantly related to admitting to a substance use problem. Recent health care contact and perceived environmental factors did not independently contribute to insight. CONCLUSIONS: If these results are generalizable, treatment and educational interventions should emphasize linking alcohol use and negative social consequences.

Functional status and hearing impairments in women at midlife.

OBJECTIVES: The aim of this study was to address the prevalence of clinically assessed high-frequency hearing impairment (HFHI) and self-reported hearing impairment (SRHI) and examine the association of these hearing assessments with physical and mental functioning in African American and Caucasian women at midlife. METHODS: The sample included 467 women who participated in the Michigan Functioning Substudy of the Study of Women's Health Across the Nation. Outcomes examined were physical and mental functioning from the Medical Outcomes Trust SF-12 Health Survey. HFHI was defined as threshold averages of 25 dB or greater over 4000, 6000, and 8000 Hertz. RESULTS: Prevalence of unilateral HFHI was 26.6% (n = 68), and prevalence of bilateral HFHI was 12.0% (n = 56). Prevalence of SRHI was 16.7% (n = 78), with minimal overlap between HFHI and SRHI (n = 36). In multiple variable logistic regression analyses, HFHI in one ear only was not associated with physical or mental functioning and bilateral HFHI was associated with limited mental functioning only. SRHI was associated with limited physical and mental functioning. DISCUSSION: Poor correlation of HFHI and SRHI in this population, combined with the significant association of SRHI with both measures of functioning, indicates that the two methods may be measuring different aspects of impairment. SRHI may facilitate early identification of individuals with hearing-related functional limitations.

The effects of mental health factors on ambulatory care visits by rural teens.

This study sought to determine the effects of mental health variables on rural adolescents' use of ambulatory health care services and whether these effects varied across common outpatient settings. Using a cross-sectional survey design, 2,297 adolescents who attended public schools in grades 7 through 12 in one isolated rural Mississippi River Delta county were assessed via a standardized health behavior survey. This self-report measure inquired about relevant health behaviors such as alcohol use, depressive symptoms, and health service use. The students' mean age was 15 years and 58 percent of the sample were black. Approximately 11 percent of the sample reported symptoms of depression, 16.5 percent reported problem drinking, and slightly fewer than 6 percent reported both. After controlling for predisposing, enabling, and need factors, the reporting of depressive symptoms, problem drinking, or both was related to an increased number of outpatient visits in three of four sites examined. However, differences among sites were observed. These data suggest that mental health problems are associated with increased visits to ambulatory settings, and these problems affect service use differentially. Thus, effective interventions and better linkages between ambulatory settings and mental health providers may reduce unnecessary use.

Inadequate immunizations. Identification using clinic charts.

Immunizations are cost-effective measures for assuring public health. However, recent outbreaks of measles, mumps, and pertussis underscore the inadequacy of current immunization programs. A model identifying those children who are likely to be inadequately immunized could focus the use of limited health funds. A retrospective examination of the medical charts of 101 children in a large inner-city clinic was undertaken to determine if specific factors were associated with inadequate immunization status. Fifty percent of the children were inadequately immunized by 18 months of age (no measles-mumps-rubella or fewer than three diphtheria-pertussis-tetanus vaccinations). Logistic regression analyses showed that older maternal age, no recurrent or chronic illnesses, and vaginal delivery were independently associated with inadequate immunization status. However, on many charts, information on maternal, social, and environmental variables was incomplete. The increasing use of structured medical charts will enhance data collection and the determination of an appropriate index. A prospective study of the variables identified, along with standardization of medical records and inclusion of social history data, is necessary to further investigate the utility of screening criteria for inadequate immunizations.

Early indications of resilience and their relation to experiences in the home environments of low birthweight, premature children living in poverty.

The caregiving environment experienced by 243 premature, low birthweight (LBW) children living in poverty was examined to determine whether the quality of care such children receive affords them some measure of protection from the generally deleterious consequences of poverty and prematurity. Only 26 children were identified as functioning in the normal range for cognitive, social/adaptive, health, and growth parameters at age 3. These children, who showed early signs of resiliency, differed from nonresilient children in that they were receiving more responsive, accepting, stimulating, and organized care. They were also living in safer, less crowded homes. 6 "protective" aspects of caregiving were identified and used as part of a cumulative protection index. Children with less than 3 protective aspects of caregiving present at age 1 had only a 2% probability of being resilient, and only a 6% probability if fewer than 3 were present at age 3. Overall, premature LBW children born into conditions of poverty have a very poor prognosis of functioning within normal ranges across all the dimensions of health and development assessed. However, those raised in a setting with 3 or more protective factors were more likely to show early signs of resiliency.

Rurality and gender. Effects on early adolescent alcohol use.

Previous studies of adolescent alcohol use have focused almost exclusively on urban and suburban youth, although alcohol is the most important drug of abuse among rural adolescents. Young adolescents, aged 11 to 14 years (N = 1601), from urban, suburban, and two different rural areas (delta and highland), were surveyed about health-compromising behaviors, such as alcohol use. Significant differences in the number of adolescents using alcohol and the patterns of alcohol use were noted across areas by gender. Youths from the delta area, especially girls, reported drinking less frequently and in less abusive patterns than did adolescents from other areas, while youths from the highland area reported rates and patterns of drinking similar to those of urban adolescents. The reasons for intrarural variation in adolescent drinking are unknown.

Epidemiology of salmonellosis in Arkansas.

Human salmonellosis continues to be a major public health issue. Our epidemiologic review of cases from 1989 to 1992 was done to define the current reported rate of infection due to Salmonella species for the state of Arkansas, which might be expected to have higher rates of infection because it is a leading producer of poultry. Results showed that the reported case rate in Arkansas (18.0/100,000) did not differ from that of the United States at large (18.6/100,000). Age-specific rates, however, showed that children less than 1 year of age in Arkansas were infected at a higher rate than those in the remainder of the nation. Salmonella newport and S typhimurium were the most commonly isolated serotypes. Individuals living in a county with poultry processing plants and hatcheries were not more likely to have salmonellosis, and individuals residing in Arkansas do not appear to be at increased risk of salmonellosis because of the poultry industry.