Polygenic Risk Scores have high diagnostic capacity in ankylosing spondylitis.

OBJECTIVE: We sought to test the hypothesis that Polygenic Risk Scores (PRSs) have strong capacity to discriminate cases of ankylosing spondylitis (AS) from healthy controls and individuals in the community with chronic back pain. METHODS: PRSs were developed and validated in individuals of European and East Asian ethnicity, using data from genome-wide association studies in 15 585 AS cases and 20 452 controls. The discriminatory values of PRSs in these populations were compared with other widely used diagnostic tests, including C-reactive protein (CRP), HLA-B27 and sacroiliac MRI. RESULTS: In people of European descent, PRS had high discriminatory capacity with area under the curve (AUC) in receiver operator characteristic analysis of 0.924. This was significantly better than for HLA-B27 testing alone (AUC=0.869), MRI (AUC=0.885) or C-reactive protein (AUC=0.700). PRS developed and validated in individuals of East Asian descent performed similarly (AUC=0.948). Assuming a prior probability of AS of 10% such as in patients with chronic back pain under 45 years of age, compared with HLA-B27 testing alone, PRS provides higher positive values for 35% of patients and negative predictive values for 67.5% of patients. For PRS, in people of European descent, the maximum positive predictive value was 78.2% and negative predictive value was 100%, whereas for HLA-B27, these values were 51.9% and 97.9%, respectively. CONCLUSIONS: PRS have higher discriminatory capacity for AS than CRP, sacroiliac MRI or HLA-B27 status alone. For optimal performance, PRS should be developed for use in the specific ethnic groups to which they are to be applied.

Leveraging Multimedia Patient Engagement to Address Minority Cerebrovascular Health Needs: Prospective Observational Study.

BACKGROUND: Social inequities affecting minority populations after Hurricane Katrina led to an expansion of environmental justice literature. In August 2017, Hurricane Harvey rainfall was estimated as a 3000- to 20,000-year flood event, further affecting minority populations with disproportionate stroke prevalence. The Stomp Out Stroke initiative leveraged multimedia engagement, creating a patient-centered cerebrovascular health intervention. OBJECTIVE: This study aims to address social inequities in cerebrovascular health through the identification of race- or ethnicity-specific health needs and the provision of in-person stroke prevention screening during two community events (May 2018 and May 2019). METHODS: Stomp Out Stroke recruitment took place through internet-based channels (websites and social networking). Exclusively through web registration, Stomp Out Stroke participants (aged >18 years) detailed sociodemographic characteristics, family history of stroke, and stroke survivorship. Participant health interests were compared by race or ethnicity using Kruskal-Wallis or chi-square test at an α=.05. A Bonferroni-corrected P value of .0083 was used for multiple comparisons. RESULTS: Stomp Out Stroke registrants (N=1401) were 70% (973/1390) female (median age 45 years) and largely self-identified as members of minority groups: 32.05% (449/1401) Hispanic, 25.62% (359/1401) African American, 13.63% (191/1401) Asian compared with 23.63% (331/1401) non-Hispanic White. Stroke survivors comprised 11.55% (155/1401) of our population. A total of 124 stroke caregivers participated. Approximately 36.81% (493/1339) of participants had a family history of stroke. African American participants were most likely to have Medicare or Medicaid insurance (84/341, 24.6%), whereas Hispanic participants were most likely to be uninsured (127/435, 29.2%). Hispanic participants were more likely than non-Hispanic White participants to obtain health screenings (282/449, 62.8% vs 175/331, 52.9%; P=.03). Asian (105/191, 54.9%) and African American (201/359, 55.9%) participants were more likely to request stroke education than non-Hispanic White (138/331, 41.6%) or Hispanic participants (193/449, 42.9%). African American participants were more likely to seek overall health education than non-Hispanic White participants (166/359, 46.2% vs 108/331, 32.6%; P=.002). Non-Hispanic White participants (48/331, 14.5%) were less likely to speak to health care providers than African American (91/359, 25.3%) or Asian participants (54/191, 28.3%). During the 2018 and 2019 events, 2774 health screenings were completed across 12 hours, averaging four health screenings per minute. These included blood pressure (1031/2774, 37.16%), stroke risk assessment (496/2774, 17.88%), bone density (426/2774, 15.35%), carotid ultrasound (380/2774, 13.69%), BMI (182/2774, 6.56%), serum lipids (157/2774, 5.65%), and hemoglobin A1c (102/2774, 3.67%). Twenty multimedia placements using the Stomp Out Stroke webpage, social media, #stompoutstroke, television, iQ radio, and web-based news reached approximately 849,731 people in the Houston area. CONCLUSIONS: Using a combination of internet-based recruitment, registration, and in-person assessments, Stomp Out Stroke identified race- or ethnicity-specific health care needs and provided appropriate screenings to minority populations at increased risk of urban flooding and stroke. This protocol can be replicated in Southern US Stroke Belt cities with similar flood risks.

Lack of Racial, Ethnic, and Sex Disparities in Ischemic Stroke Care Metrics within a Tele-Stroke Network.

INTRODUCTION: Differences in access to stroke care and compliance with standard of care stroke management among patients of varying racial and ethnic backgrounds and sex are well-characterized. However, little is known on the impact of telestroke in addressing disparities in acute ischemic stroke care. METHODS: We conducted a retrospective review of acute ischemic stroke patients evaluated over our 17-hospital telestroke network in Texas from 2015-2018. Patients were described as Non-Hispanic White (NHW) male or female, Non-Hispanic Black (NHB) male or female, or Hispanic (HIS) male or female. We compared frequency of tPA and mechanical thrombectomy (MT) utilization, door-to-consultation times, door-to-tPA times, and time-to-transfer for patients who went on to MT evaluation at the hub after having been screened for suspected large vessel occlusion at the spoke. RESULTS: Among 3873 patients (including 1146 NHW male (30%) and 1134 NHW female (29%), 405 NHB male (10%) and 491 NHB female (13%), and 358 HIS male (9%) and 339 HIS female (9%) patients), we did not find any differences in door-to consultation time, door-to-tPA time, time-to-transfer, frequency of tPA administration, or incidence of MT utilization. CONCLUSION: We did not find racial, ethnic, and sex disparities in ischemic stroke care metrics within our telestroke network. In order to fully understand how telestroke alleviates disparities in stroke care, collaboration among networks is needed to formulate a multicenter telestroke database similar to the Get-With-The Guidelines.

Diagnostic outcome of muscle biopsy.

INTRODUCTION: We reviewed the diagnostic yield of muscle biopsy according to the presence or absence of muscle weakness, hyperCKemia, and electromyogaphic (EMG) abnormalities. METHODS: In a retrospective study, 698 muscle biopsy reports were analyzed. Logistic regression models for myopathy and specific myopathy were fit, and receiver-operating characteristic (ROC) curves were generated to assess prediction accuracy. The probability of finding specific myopathy was considered the main indication of a positive muscle biopsy. RESULTS: Isolated hyperCKemia was poorly predictive of either myopathy or specific myopathy. Combined myopathic EMG, proximal weakness, and hyperCKemia were predictive. The predictability increased proportionally to the creatine kinase (CK) level in patients with proximal weakness and myopathic EMG. Cross validation showed accuracy around 70% for a probability threshold of 50%. CONCLUSIONS: The presence of hyperCKemia, proximal weakness, and myopathic EMG together were associated with highly positive diagnostic outcome of muscle biopsy. Isolated hyperCKemia had a poor diagnostic yield.

Major Stressful Life Events and the Risk of Pancreatic, Head and Neck Cancers: A Case-Control Study.

BACKGROUND: Major stressful life events have been shown to be associated with an increased risk of lung cancer, breast cancer and the development of various chronic illnesses. The stress response generated by our body results in a variety of physiological and metabolic changes which can affect the immune system and have been shown to be associated with tumor progression. In this study, we aim to determine if major stressful life events are associated with the incidence of head and neck or pancreatic cancer (HNPC). METHODS: This is a matched case-control study. Cases (CAs) were HNPC patients diagnosed within the previous 12 months. Controls (COs) were patients without a prior history of malignancy. Basic demographic data information on major stressful life events was collected using the modified Holmes-Rahe stress scale. A total sample of 280 was needed (79 cases, 201 controls) to achieve at least 80% power to detect odds ratios (ORs) of 2.00 or higher at the 5% level of significance. RESULTS: From 1 January 2018 to 31 August 2021, 280 patients were enrolled (CA = 79, CO = 201) in this study. In a multivariable logistic regression analysis after controlling for potential confounding variables (including sex, age, race, education, marital status, smoking history), there was no difference between the lifetime prevalence of major stressful event in cases and controls. However, patients with HNPC were significantly more likely to report a major stressful life event within the preceding 5 years when compared to COs (p = 0.01, OR = 2.32, 95% CI, 1.18-4.54). CONCLUSIONS: Patients with head, neck and pancreatic cancers are significantly associated with having a major stressful life event within 5 years of their diagnosis. This study highlights the potential need to recognize stressful life events as risk factors for developing malignancies.

Prevalence and associated risk factors of sleep-disordered breathing symptoms in young and middle-aged Pakistani employed adults.

PURPOSE: The objective of this study was to evaluate the prevalence of self-reported sleep-disordered breathing (SDB symptoms and its associated risk factors in Pakistani employed adults. METHODS: Full-time employees (n = 3470) of a medical university were evaluated. Self-administered questionnaire elicited information about demographic data, symptoms of SDB, smoking and alcohol use, presence of nasal congestion, family history of snoring, and included the Epworth Sleepiness Scale. Prevalence of self-reported snoring and of combined SDB symptoms (snoring plus at least one other SDB symptom) was evaluated. Regression analyses were used to assess risk factors associated with self-reported snoring and combined SDB symptoms. RESULTS: Among the 2,497 (72%) responders, prevalence of self-reported snoring was 32%, and combined SDB symptoms 25%. A higher prevalence of snoring and combined SDB symptoms in male gender diminished with age. In univariate analysis, the odds of snoring was higher with age >or=35 yrs (odds ratio (OR) 2.6, confidence interval (CI) 2.2-3.2), body mass index >or=23 (OR 2.6, CI 2.2-3.1), and collar size above 40 cm (OR 2.7, CI 2.3-3.3). Self-reported nasal blockage (OR 1.9, CI 1.6-2.2) and family history of snoring (OR 2.9, 2.5-3.5) were other risk factors. In logistic regression analysis, significant risk factors for SDB symptoms were age, body mass index, collar size, nasal blockage, and family history of snoring. Male gender, smoking and alcohol were not significant risk factors for SDB symptoms. CONCLUSION: The prevalence of SDB symptoms in Pakistani employed adults was comparable to Western populations. However, male gender and smoking were not significant risk factors for SDB symptoms.

Chronic back pain in first-degree relatives (FDRs) of patients with ankylosing spondylitis: predictive value of HLA-B27 and persistence of inflammatory back pain over time.

BACKGROUND/PURPOSE: First-degree relatives (FDRs) of patients with ankylosing spondylitis (AS) may be at high risk of spondyloarthritis. We examined the frequency, characteristics of chronic back pain (CBP), associated features, persistence of symptoms, and HLA-B27 allele frequency in FDRs of AS patients, also comparing those FDRs with participants in NHANES 2009-2010 with CBP. METHODS: 399 FDRs of AS probands were divided into: (1) No CBP (subjects >40 years old at study visit without CBP) (n=162); (2) NICBP (non-inflammatory CBP) (n=82), and (3) CIBP (inflammatory CBP) (n=155). White FDRs with CBP were compared with 772 participants in NHANES 2009-2010 with CBP. FDRs were invited to return for reassessment. RESULTS: FDRs with CIBP had earlier onset of CBP than those with NICBP (p<0.001) and had higher frequency of heel pain than those without CBP (p=0.002). HLA-B27 occurred in 57% of FDRs with CIBP vs 39.6% of those without CBP (p=0.005, OR=1.9). Of 23 patients with CIBP at baseline re-evaluated 67.04±31.02 months later, 16 (73%) still had CIBP, whereas 4 (31%) of 13 NICBP patients seen 61.23±31.84 months later remained symptomatic. CONCLUSION: CIBP in FDRs of AS patients is HLA-B27-associated, has earlier onset and tends to persist compared to NICBP.

Genomewide Association Study of Acute Anterior Uveitis Identifies New Susceptibility Loci.

Purpose: Acute anterior uveitis (AAU) is a common intraocular inflammatory disease. AAU occurs in 30% to 50% of patients with ankylosing spondylitis (AS), and both conditions are strongly associated with human leukocyte antigen (HLA)-B27, implying a shared etiology. This study aims to apply genomewide association study (GWAS) to characterize the genetic associations of AAU and their relationship to the genetics of AS. Methods: We undertook the GWAS analyses in 2752 patients with AS with AAU (cases) and 3836 patients with AS without AAU (controls). There were 7,436,415 single-nucleotide polymorphisms (SNPs) available after SNP microarray genotyping, imputation, and quality-control filtering. Results: We identified one locus associated with AAU at genomewide significance: rs9378248 (P = 2.69 × 10-8, odds ratio [OR] = 0.78), lying close to HLA-B. Suggestive association was observed at 11 additional loci, including previously reported AS loci ERAP1 (rs27529, P = 2.19 × 10-7, OR = 1.22) and NOS2 (rs2274894, P = 8.22 × 10-7, OR = 0.83). Multiple novel suggestive associations were also identified, including MERTK (rs10171979, P = 2.56 × 10-6, OR = 1.20), KIFAP3 (rs508063, P = 5.64 × 10-7, OR = 1.20), CLCN7 (rs67412457, P = 1.33 × 10-6, OR = 1.25), ACAA2 (rs9947182, P = 9.70 × 10-7, OR = 1.37), and 5 intergenic loci. The SNP-based heritability is approximately 0.5 for AS alone, and is much higher (approximately 0.7) for AS with AAU. Consistent with the high heritability, a genomewide polygenic risk score shows strong power in identifying individuals at high risk of either AS with AAU or AS alone. Conclusions: We report here the first GWAS for AAU and identify new susceptibility loci. Our findings confirm the strong overlap in etiopathogenesis of AAU with AS, and also provide new insights into the genetic basis of AAU.

Methodological issues in trials of complementary and alternative medicine interventions.

BACKGROUND: Complementary and alternative medicine (CAM) use is widespread among cancer patients. Information on safety and efficacy of CAM therapies is needed for both patients and healthcare providers. Well-designed randomized clinical trials of CAM therapy interventions can inform both clinical research and practice. OBJECTIVES: The aim of this study was to review important issues that affect the design of randomized clinical trials for CAM interventions. METHODS: Using the methods component of the Consolidated Standards for Reporting Trials as a guiding framework and a National Cancer Institute-funded reflexology study as an exemplar, methodological issues related to participants, intervention, objectives, outcomes, sample size, randomization, blinding, and statistical methods were reviewed. DISCUSSION: Trials of CAM interventions designed and implemented according to appropriate methodological standards will facilitate the needed scientific rigor in CAM research. Interventions in CAM can be tested using proposed methodology, and the results of testing will inform nursing practice in providing safe and effective supportive care and in improving the well-being of patients.

Maternal fish consumption, mercury levels, and risk of preterm delivery.

BACKGROUND: Pregnant women receive mixed messages about fish consumption in pregnancy because unsaturated fatty acids and protein in fish are thought to be beneficial, but contaminants such as methylmercury may pose a hazard. METHODS: In the Pregnancy Outcomes and Community Health (POUCH) study, women were enrolled in the 15th to 27th week of pregnancy from 52 prenatal clinics in five Michigan communities. At enrollment, information was gathered on amount and category of fish consumed during the current pregnancy, and a hair sample was obtained. A segment of hair closest to the scalp, approximating exposure during pregnancy, was assessed for total mercury levels (70-90% methylmercury) in 1,024 POUCH cohort women. RESULTS: Mercury levels ranged from 0.01 to 2.50 pg/g (mean = 0.29 microg/g; median = 0.23 microg/g). Total fish consumption and consumption of canned fish, bought fish, and sport-caught fish were positively associated with mercury levels in hair. The greatest fish source for mercury exposure appeared to be canned fish. Compared with women delivering at term, women who delivered before 35 weeks' gestation were more likely to have hair mercury levels at or above the 90th percentile (> or = 0.55 microg/g), even after adjusting for maternal characteristics and fish consumption (adjusted odds ratio = 3.0; 95% confidence interval, 1.3-6.7). CONCLUSION: This is the first large, community-based study to examine risk of very preterm birth in relation to mercury levels among women with low to moderate exposure. Additional studies are needed to see whether these findings will be replicated in other settings.

Newborn care practices in low socioeconomic settlements of Karachi, Pakistan.

To explore traditional neonatal beliefs and care practices and to assess the predictors for giving prelacteal feeds, a qualitative and quantitative study was conducted in low socioeconomic settlements of Karachi, Pakistan. Five focus group discussions and 15 in-depth semi-structured interviews were conducted in July and August 2000; structured questionnaires were administered to 525 recently delivered women through November. Antenatal care coverage was common; a little over half of the women delivered at home with traditional birth attendants. Among the 387 women who reported at least one antenatal visit, most (78.6%) reported receiving counseling on breastfeeding by their healthcare provider. A significant proportion of women (44.8%) reported giving lacteals; colostrum (41.7%) or animal/formula milk (3.1%), as the first feed. Newborns were bathed immediately (82.1%) after delivery as the vernix was considered 'dirty looking' (78.5%), and it was felt it should be removed. To foster muscle relaxation (80.2%) and strengthen the bones (43.0%), daily massage was universally practiced, mustard oil (75.9%) being the most frequently used lubricant. Risky feeding practices such as giving prelacteals (55.0%) or supplementary feeds (71.3%), or delaying first feed (30.9%) were common. During the neonatal period, breast milk was the preferred feed (98.6%); however, honey (28.7%), ghutti (27.8%) and water (11.8%) were also given in order to 'reduce colic' or 'act as a laxative', which were perceived health benefits mentioned by mothers and traditional birth attendants. Ethnicity and birth attendant at delivery were strong predictors for women who gave prelacteals (after adjusting for education, socioeconomic status and facility delivery). Although administration of colostrum as the first feed was relatively common in this setting, the predominance of other risky traditional newborn care practices stresses the need for promoting health education programs on improving newborn care practices.

Recursive partitioning identifies greater than 4 U of packed red blood cells per hour as an improved massive transfusion definition.

BACKGROUND: Massive transfusion (MT) is classically defined as greater than 10 U of packed red blood cells (PRBCs) in 24 hours. This fails to capture the most severely injured patients. Extending the previous work of Savage and Rahbar, a rolling hourly rate-based definition of MT may more accurately define critically injured patients requiring early, aggressive resuscitation. METHODS: The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) trial collected data from 10 Level 1 trauma centers. Patients were placed into rate-based transfusion groups by maximal number of PRBCs transfused in any hour within the first 6 hours. A nonparametric analysis using classification trees partitioned data according to mortality at 24 hours using a predictor variable of maximum number PRBC units transfused in an hour. Dichotomous variables significant in previous scores and models as predictors of MT were used to identify critically ill patients: a positive finding on Focused Assessment with Sonography in Trauma (FAST) examination, Glasgow Coma Scale (GCS) score less than 8, heart rate greater than 120 beats/min, systolic blood pressure less than 90 mm Hg, penetrating mechanism of injury, international normalized ratio greater than 1.5, hemoglobin less than 11, and base deficit greater than 5. These critical indicators were then compared among the nodes of the classification tree. Patients omitted included those who did not receive PRBCs (n = 24) and those who did not have all eight critical indicators reported (n = 449). RESULTS: In a population of 1,245 patients, the classification tree included 772 patients. Analysis by recursive partitioning showed increased mortality among patients receiving greater than 13 U/h (73.9%, p < 0.01). In those patients receiving less than or equal to 13 U/h, mortality was greater in patients who received more than 4 U/h (16.7% vs. 6.0%, p < 0.01) (Fig. 1). Nodal analysis showed that the median number of critical indicators for each node was 3 (2-4) (≤4 U/h), 4 (3-5) (>4 U/h and ≤13 U/h), and 5 (4-5.5) (>13 U/h). CONCLUSION: A rate-based transfusion definition identifies a difference in mortality in patients who receive greater than 4 U/h of PRBCs. Redefining MT to greater than 4 U/h allows early identification of patients with a significant mortality risk who may be missed by the current definition. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Elevated blood lead levels among children living in a fishing community, Karachi, Pakistan.

Lead is a widespread environmental contaminant worldwide and is associated with adverse outcomes in children, including impaired neurobehavioral development and learning difficulties. A cross-sectional survey of 53 young children was conducted in a fishing village on an island adjacent to Karachi, Pakistan. Whole blood from each individual was tested for lead levels. Also tested were samples of cooked food, house dust, and drinking water from 36 households. Laboratory determinations were made by the Pakistan Council for Scientific and Industrial Research with quality control by the United States Centers for Disease Control and Prevention. Fifty-two subjects (98%) had blood lead levels above 10 microg/dl (mean 21.60 microg/dl), an internationally recognized threshold for potential neurotoxicity. The mean concentration was 3.90 microg/g in cooked food, 4.02 microg/l in drinking water, and 91.30 microg/g in house dust. These findings indicate possible major health concerns and suggest significant environmental contamination in this community as well as the need to identify locally relevant early childhood exposures.

Health-related quality-of-life outcomes: a reflexology trial with patients with advanced-stage breast cancer.

PURPOSE/OBJECTIVES: To evaluate the safety and efficacy of reflexology, a complementary therapy that applies pressure to specific areas of the feet. DESIGN: Longitudinal, randomized clinical trial. SETTING: Thirteen community-based medical oncology clinics across the midwestern United States. SAMPLE: A convenience sample of 385 predominantly Caucasian women with advanced-stage breast cancer receiving chemotherapy and/or hormonal therapy. METHODS: Following the baseline interview, women were randomized into three primary groups: reflexology (n = 95), lay foot manipulation (LFM) (n = 95), or conventional care (n = 96). Two preliminary reflexology (n = 51) and LFM (n = 48) test groups were used to establish the protocols. Participants were interviewed again postintervention at study weeks 5 and 11. MAIN RESEARCH VARIABLES: Breast cancer-specific health-related quality of life (HRQOL), physical functioning, and symptoms. FINDINGS: No adverse events were reported. A longitudinal comparison revealed significant improvements in physical functioning for the reflexology group compared to the control group (p = 0.04). Severity of dyspnea was reduced in the reflexology group compared to the control group (p < 0.01) and the LFM group (p = 0.02). No differences were found on breast cancer-specific HRQOL, depressive symptomatology, state anxiety, pain, and nausea. CONCLUSIONS: Reflexology may be added to existing evidence-based supportive care to improve HRQOL for patients with advanced-stage breast cancer during chemotherapy and/or hormonal therapy. IMPLICATIONS FOR NURSING: Reflexology can be recommended for safety and usefulness in relieving dyspnea and enhancing functional status among women with advanced-stage breast cancer.

Concordance between patient reports of cancer-related symptoms and medical records documentation.

CONTEXT: Two sources of symptom data, patient report and medical records documentation, have been used in studies focusing on chronic conditions. The concordance of patient-reported cancer-related symptoms and clinician reports as documented in the medical records needs to be evaluated. OBJECTIVES: To compare patient reports with medical record documentation of 12 disease- and treatment-related symptoms for women with advanced breast cancer undergoing chemotherapy or hormonal therapy for cancer control. METHODS: Women (n=384) were recruited from 13 oncology clinics in the midwestern U.S. They completed telephone interviews at intake, five, and 11 weeks, where they reported the presence of 12 symptoms using a checklist. Medical records were abstracted when women completed the study. The concordance between patient reports and medical record documentation was assessed using percent agreement, kappa statistics, and McNemar's tests. Administration of medication for symptoms and patient characteristics were investigated in relation to the agreement of the two sources of data. RESULTS: Poor to slight agreement was found, and disagreement was significant for all 12 symptoms. The concordance between symptom presence in the medical record and administration of medication for the management of those symptoms was moderate. Patient characteristics were not associated with agreement, except for age. The agreement was higher for older women for the symptom of mouth sores. CONCLUSION: Medical records may not provide adequate documentation of symptoms, and collection of patient-reported symptom data from women with advanced breast cancer is critical to quality clinical management.

Knowledge and attitude of general practitioners regarding autism in Karachi, Pakistan.

General practitioners (GPs) could have an important role in early diagnosis of autism. There have been no studies evaluating the knowledge of GPs regarding autism in Pakistan. We aimed to fill that gap by assessing knowledge and attitude of GPs in Karachi regarding autism. We conducted a cross-sectional survey of 348 GPs; only 148 (44.6%) had heard of "autism." Our results show that GPs less than 30 years of age and those who obtained their Medical Degree in the last 5 years are more likely to report knowledge about autism: OR = 3.0; 95% CI: 1.71, 5.31, and OR = 2.56; 95% CI: 1.48, 4.42, respectively. In addition, among those reporting knowledge about autism, many held misconceptions regarding the signs and symptoms and etiology.

Intervention fidelity: aspects of complementary and alternative medicine research.

BACKGROUND: The Treatment Fidelity Workgroup (TFW) established by the National Institutes of Health provides a 5-point structure for intervention fidelity: dosing, interventionists' consistency, intervention delivery, receipt, and enactment of the intervention. Using our reflexology trial, we apply the first 3 points. OBJECTIVES: Study objectives were to (1) evaluate key dosage dimensions associated with complementary and alternative medicine (CAM) research, (2) evaluate approaches to interventionists' consistency of delivery of CAM protocols, and (3) evaluate and discuss data that reflect CAM intervention fidelity. METHODS: Women with late-stage breast cancer (N = 318) were randomly assigned to either 4 weeks of reflexology, placebo, or standard care. RESULTS: Dosing consists of 3 dimensions: frequency (4 sessions), duration (30 minutes), and interval between sessions (5-9 days). Interventionist consistency revealed more than a 90% accuracy rate in following the protocol; 84% and 89% completion rate of the 4 sessions in the reflexology and placebo groups, respectively; and no differences in attrition after randomization between reflexology and placebo groups (17% and 15%, respectively). Intervention delivery, examined through debriefing data, indicated a significantly higher rate of correct guesses on group assignment in the reflexology group as compared with the placebo (82% vs 46%, P = .0002). CONCLUSION: This study points out the relevance of dosing, interventionists' consistency, and delivery data within a CAM clinical trial, as well as the challenges of blinding. IMPLICATIONS FOR PRACTICE: Monitoring intervention fidelity by using the key areas identified by the TFW ensures that findings from a clinical trial are meaningful and have the potential to be translated to clinical practice.

A life course perspective on depressive symptoms in mid-pregnancy.

OBJECTIVE: To examine the prevalence of depressive symptoms in mid-pregnancy and their relation to life circumstances across the life course in a community-based sample. METHODS: The Pregnancy Outcomes and Community Health (POUCH) Study enrolled women at 16-26 weeks' gestation from 52 clinics in five Michigan communities. At enrollment women completed a screening instrument for depressive symptoms (CES-D) and questions about life circumstances covering three "periods," i.e. previous 6 months, adulthood, and childhood. Questions were grouped into sub-constructs (e.g., abuse, economic, substance use, loss, and legal) for each "period" and evaluated in relation to CES-D scores. Analyses included 1321 POUCH participants divided into three subgroups: teens; women > or =20 years insured by Medicaid (disadvantaged); and women > or =20 years not insured by Medicaid (advantaged). RESULTS: A positive CES-D screen (> or =16) was more common in teens (46%) and disadvantaged women (47%) than in advantaged women (23%). Recent problems (previous 6 months) with abuse, economics, and substance use in someone close were each associated with higher adjusted mean CES-D scores (2.3-7.5 increase) in the three subgroups of women. In life course analyses, abuse and substance use in teens, and abuse and economic problems in disadvantaged and advantaged women were strongly linked to higher adjusted mean CES-D scores when these problems occurred both in childhood and adulthood (range 2.2-7.1 increase), whereas the associations were more modest when problems were confined to childhood. CONCLUSIONS: Strategies for addressing the public health problem of depressive symptoms in mid-pregnancy will benefit from a life course perspective.