Extent of documented adherence to recommended prenatal care content: provider site differences and effect on outcomes among low-income women.

The aim of this study is to examine the relationship between prenatal care (PNC) provider site and the extent of documented adherence to recommended PNC content, and the relationship between adherence to recommended PNC content and adverse pregnancy outcomes among women in Illinois' Medical Assistance Program (MA). Utilizing the medical record, MA claims, and birth certificate data of 374 women who gave birth in 2003 and 2004 in four high-risk communities in Chicago, crude and adjusted analyses of the relationship between provider site and the extent of documented adherence to PNC content, and between adherence to PNC content and the incidence of low birthweight (LBW) and preterm birth (PTB) were conducted. The extent of documented adherence to recommended PNC content was measured from medical records as the percentage of 19 components of standard obstetrical practice that were delivered during pregnancy, converted to a three level categorical variable (low 50%, medium 50-79% and high 80% or greater). The majority of women had less than 80% of the recommended PNC content documented in their medical records. Among high-risk women, a greater proportion of women served by hospitals received care in which the extent of documented adherence was high (≥80%) compared to women served by physicians'offices (P < 0.05). Among low-risk women, a greater proportion of women served by FQHCs received care in which the extent of documented adherence was high compared to women served by hospitals (P < 0.10). Lower adherence to PNC content was significantly associated with LBW and PTB among women receiving prenatal care from physicians. Examination of the extent of adherence to recommended PNC content and its relationship to adverse pregnancy outcomes provides valuable data to inform potential interventions. In particular, a relationship between adherence to recommended PNC content and LBW and PTB among women receiving PNC at physicians' offices suggests the importance of increased quality assurance and provider education efforts.

Cardiac risk scores in high-risk Hispanics and the predictive value of BNP.

AIMS: The purpose of this study was to calculate cardiac risk scores in Hispanic subjects and to determine the predictive value of adding B-type natriuretic peptide in identifying those with asymptomatic left ventricular dysfunction as a measure of cardiovascular disease. BACKGROUND: Hispanics have higher rates of cardiovascular risk factors leading to coronary heart disease, asymptomatic left ventricular dysfunction and cardiovascular events. Assessing cardiac risk in these groups is important to identify those at high risk for future cardiovascular events. The use of biomarkers such as B-type natriuretic peptide may increase the accuracy of risk prediction. DESIGN: This study used a descriptive, cross-sectional study design to determine the utility of the standard risk assessment tools (Adult Treatment Panel III and the Framingham Risk Scores risk calculator) and the B-type natriuretic peptide biomarker to estimate coronary heart disease risk in low-income, Hispanic participants. METHODS: A sample of 71 patients (age 52 SD 11, 69% female) with multiple cardiovascular risk factors seen at an ambulatory clinic at a county facility was enrolled in the study. Sociodemographic and medical history information were obtained. Two widely used risk calculators (Adult Treatment Panel III and Framingham Risk Scores) were used to estimate 10-year coronary heart disease risk in each subject. Baseline B-type natriuretic peptide measurement and echocardiography were performed with each subject to evaluate presence of asymptomatic left ventricular dysfunction. Receiver operating curve analyses were performed to compare predictability, sensitivity and specificity of the traditional risk scores against the B-type natriuretic peptide level to detect asymptomatic left ventricular dysfunction. RESULTS: Overall mean risk scores were 5% (SD 5%) (Adult Treatment Panel III) and 10% (SD 7%) (Framingham Risk Scores). Mean B-type natriuretic peptide levels were 108·5 (SD 191·5) pg/ml. Echocardiogram results revealed a high proportion of subjects with asymptomatic left ventricular dysfunction (74·6%). The receiver operating curves showed an area under the curve of 0·67 for B-type natriuretic peptide (p < 0·05), 0·64 (p = NS) for Adult Treatment Panel III and 0·56 (p = NS) for Framingham Risk Scores, evidence that B-type natriuretic peptide does significantly better than Adult Treatment Panel or Framingham Risk Scores in predicting asymptomatic left ventricular dysfunction. CONCLUSION: The inclusion of B-type natriuretic peptide with traditional risk scores may be helpful in predicting risk and asymptomatic left ventricular dysfunction in high-risk Hispanics. RELEVANCE TO CLINICAL PRACTICE: Cardiac risk scores can assist clinicians in identifying patients at high risk for developing coronary heart disease.

Correlates of adult assault among homeless women.

The purpose of this study was to assess predictors of sexual and physical assault among homeless women. A multivariate, correlation design was utilized to identify independent correlates of adult physical and sexual assault. The sample consisted of 202 homeless women residing in shelters or living on the street in the Skid Row area of Los Angeles. Respondents reporting a history of child sexual abuse were almost four times more likely to report being sexually assaulted as adults and were almost two and one third times more likely to report being physically assaulted as adults. A range of factors increase homeless women's risk of adult physical and sexual victimization, including child sexual abuse, substance use, lifetime sex trade activity, and previous incarceration. It is important for homeless service providers to develop an individual risk profile for homeless women and to intervene in order to decrease their risk of re-victimization.

Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys.

INTRODUCTION: Smoking by health care professionals poses a barrier to interventions with patients. This study reports smoking status changes among health care professionals using the Tobacco Use Supplement-Current Population Surveys (TUS-CPS). METHODS: TUS-CPS self-reported smoking status (current, former, and never) identified by occupation (physicians, physician assistants, registered nurses [RNs], licensed practical nurses [LPNs], respiratory therapists, dentists, and dental hygienists), were analyzed for the 2003 (N = 4,095) and 2006/2007 (N = 3,976) cohorts. Quit ratios among U.S. health care professionals were calculated by dividing the number of former smokers by the number of ever-smokers using weighted estimates. RESULTS: In 2006/2007, LPNs (20.55%) and respiratory therapists (19.28%) had the highest smoking prevalence. Physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and RNs (10.73%) had the lowest prevalence. Data from 2006/2007 indicate that physicians, pharmacists, dentists, and physician assistants had the highest quit ratios; all groups had quit ratios higher than the general public, except LPNs (.52 vs. .46, respectively). Current smoking varied by group but did not significantly decline from 2003 to 2006/2007. The majority of health care professionals were never-smokers. CONCLUSIONS: These data indicate that only 4 health care professional groups met the Healthy People 2010 goal of 12% smoking prevalence. LPNs were the only group with quit ratios lower than the general population. The lack of significant decline in smoking rates among health professionals was similar to the "flat" rate seen among adults in the United States. This is of concern as smoking among health care professionals limits their interventions with smokers and their involvement in tobacco control.

Predictors of hepatitis knowledge improvement among methadone maintained clients enrolled in a hepatitis intervention program.

This randomized, controlled study (n = 256) was conducted to compare three interventions designed to promote hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination completion, among clients undergoing methadone maintenance treatment (MMT) in Los Angeles and Santa Monica. The participants were randomized into three groups: Motivational Interviewing-Single Session (MI-Single), Motivational Interviewing-Group (MI-Group), or Nurse-Led Hepatitis Health Promotion (HHP). All three treatment groups received the 3-series HAV/HBV vaccine. The MI sessions were provided by trained therapists, the Nurse-Led HHP sessions were delivered by a research nurse. The main outcome variable of interest was improvement in HBV and HCV knowledge, measured by a 6-item HBV and a 7-item HCV knowledge and attitude tool that was administered at baseline and at 6-month follow-up. The study results showed that there was a significant increase in HBV- and HCV-related knowledge across all three groups (p < 0.0001). There were no significant differences found with respect to knowledge acquisition among the groups. Irrespective of treatment group, gender (P = 0.008), study site (P < 0.0001) and whether a participant was abused as a child (P = 0.017) were all found to be predictors of HCV knowledge improvement; only recruitment site (P < 0.0001) was found to be a predictor of HBV knowledge. The authors concluded that, although MI-Single, MI-Group and Nurse-Led HHP are all effective in promoting HBV and HCV knowledge acquisition among MMT clients, Nurse-Led HHP may be the method of choice for this population as it may be easier to integrate and with additional investigation may prove to be more cost efficient.

Predictors of HAV/HBV vaccination completion among methadone maintenance clients.

This randomized, controlled study (N = 256) was conducted to compare three interventions designed to promote hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination completion among clients undergoing methadone maintenance (MM) treatment. Participants were recruited from five MM treatment sites in Southern California and randomized into three groups: Motivational Interviewing-Single (MI-Single), Motivational Interviewing-Group (MI-Group); and Nurse-Led Hepatitis Health Promotion (HHP). All were offered the three-series HAV/HBV vaccine. A total of 148 participants completed the vaccine. Groups did not differ in rate of vaccination completion (73.6%, HHP group, vs. 65% and 69% for the MI-Single and MI-Group, respectively). The equivalence of findings across groups suggests the value of including nurses with a comprehensive health focus in promoting vaccination completion.

Gabapentin improves cold-pressor pain responses in methadone-maintained patients.

Individuals on methadone maintenance for the treatment of addiction (MM) are demonstrated to be hyperalgesic to cold-pressor pain in comparison to matched controls and ex-opioid addicts, a finding described as clinical evidence of opioid-induced hyperalgesia (OIH). Interestingly, opioids induce hyperalgesia via many of the same neuro-inflammatory and central sensitization processes that occur with the development of neuropathic pain. Evaluated in this study was the efficacy of a key pharmacotherapy for neuropathic pain, gabapentin (GPN), to reverse OIH in MM patients. Utilizing a clinical trial design and double blind conditions, changes in cold-pressor pain threshold and tolerance following a 5-week trial of GPN (titrated to 2400mg/day) were evaluated at peak and trough methadone plasma levels in a well-characterized MM sample. Drug abstinence was encouraged via an escalating payment schedule, and compliance monitored via pill counts and GPN plasma levels; entered into the analyses were only those subjects compliant and abstinent throughout the study (approximately 45%). Utilizing change scores from baseline, significant improvements in cold-pressor pain threshold and pain tolerance were observed at both peak and trough methadone levels (p<0.05). Notably, drop-out rates due to medication side effects were low (2%) and the medication was well-tolerated. These results support that GPN, as prescribed for the treatment of neuropathic pain, is effective in decreasing OIH in patients who are abstinent and stable in methadone treatment.

Safer Sexual Practices and HIV Screening Behavior among Rural California American Indians.

This paper reports on safer sexual practices and HIV screening behavior among rural California American Indians. Thirteen Indian health clinic registries formed the random household survey sampling frame (N=457). Measures included socio-demographics, safer sexual practices, HIV testing, high-risk behaviors, perception of wellness, general health status, neglect, physical and sexual abuse history. Statistical tests included chi-square and Fisher's exact tests, as well as multiple logistic regression analysis. Respondents who practiced safer sex were younger, not married, reported lower annual income, changed sexual behavior in the last 12 months, were not in a monogamous relationship, and had a higher perception of wellness. Those who were tested for HIV were younger, had at least a high school education, consumed alcohol, had significantly higher suicide ideation and attempts, changed their sexual behavior in the last 12 months, and reported a history of sexual abuse as a child and adult. Very little is known about HIV prevention and screening behaviors in rural American Indian populations. Identifying predictors of unsafe sexual practices and non-HIV testing tendencies help to plan for measures to protect the population from this devastating disease. We make recommendations for implementing HIV prevention education and screenings at American Indian clinics.

Hypothalamic--pituitary-- adrenal axis dysregulation in women with irritable bowel syndrome in response to acute physical stress.

Irritable bowel syndrome (IBS) supports the concept of a dysregulated hypothalamic-pituitary-adrenal (HPA) axis. This study investigates the neuroendocrine and psychological responses to the acute physical stress of a lumbar puncture (LP) in women with diarrhea-predominant IBS by assessing central and peripheral HPA activity and affective measures. Blood samples have been collected at baseline and immediately post- and 1 hr following LP from 13 women with IBS and 13 controls. Plasma adrenocorticotropic hormone (ACTH), cortisol, epinephrine, and norepinephrine levels are analyzed. A single measure of cerebrospinal fluid (CSF) concentrations of corticotropin-releasing factor (CRF(CSF)) and norepinephrine(CSF) is noted. Affective assessments are used to rate anxiety and depression with the Hospital Anxiety and Depression Scale (HADS) and acute mood state is rated using the Stress Symptom Rating questionnaire (stress, anxiety, anger, arousal). The women with IBS display blunted ACTH and cortisol responses to the LP along with a profile of affective responsiveness suggestive of chronic psychosocial stress, although no CRF(CSF) differences between groups are observed.

The effect of therapeutic touch on behavioral symptoms and cortisol in persons with dementia.

BACKGROUND: Between 75-90% of nursing home (NH) residents with dementia develop behavioral symptoms (BSD) which may be associated with a stress response. Therapeutic touch has been shown to decrease restlessness in NH residents, however the mechanism is unknown. The purpose of this randomized controlled trial (RCT) was to examine the effect of therapeutic touch on BSD and basal cortisol levels among NH residents with dementia. PARTICIPANTS AND METHODS: Using a double blind experimental interrupted time series ABAB design, 65 participants were assigned to one of three groups. The experimental group received therapeutic touch with contact on the neck and shoulders delivered twice daily for 3 days (administered over 2 separate treatment periods); the placebo group received a mimic treatment identical in appearance, and the control group received routine care. Study outcomes were BSD, measured by the modified Agitated Behavior Rating Scale (mABRS), and salivary cortisol levels, measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: 64 residents, aged 67-93 years (M = 85.5, SD = 5.50), completed the study. Restlessness was significantly reduced in the experimental group compared to the control group (p = 0.03). There was a significant difference in morning cortisol variability among groups across time periods (<0.0001). Findings suggest that therapeutic touch may be effective for management of symptoms like restlessness coupled with stress reduction. At a time when cost containment is a consideration in health care, therapeutic touch is an intervention that is non-invasive, readily learned, and can provide a non-pharmacologic alternative for selected persons with BSD.

Correlates of heavy smoking among alcohol-using methadone maintenance clients.

This cross-sectional study examines predictors of heavy smoking among 256 male and female methadone maintenance therapy (MMT) clients from five MMT clinics in the Los Angeles area. The authors find that women report lower rates of heavy smoking than men (47% vs. 54%, respectively), in concordance with current literature pointing to gender differences in smoking behaviors. In particular, men who report heavy drinking, fair or poor health, and recent heroin use are more likely to report heavy smoking compared with men not reporting these factors. Women who report recent heroin use, a lifetime history of sex trade, and who have been ill enough to require a blood transfusion also have greater odds of reporting heavy cigarette smoking. Findings from this study may aid not only in designing gender-based smoking cessation programs for MMT clients but also in addressing the gender-based issues related to smoking in such a population.

Agreement between CASA parent reports and provider records of children's ADHD services.

This study examines agreement between parental reports of children's ADHD outpatient services ascertained with the Child and Adolescents Services Assessment (CASA) and provider records among a sample of elementary school students who participated in an epidemiologically based health services study. Parental reports of any outpatient mental health treatment, services intensity, and medication regimens were compared to records of the specified mental health and primary care providers using intraclass correlations and kappa estimates. Results indicated that parental reports using the CASA produced valid data on whether any outpatient ADHD services had been received in the past 12 months (83% agreement), and on details of the child's medication regimens (kappas above 0.90), but that agreement was poor on how many times the child had been seen (intraclass correlation 0.29), without agreement differences by provider type. These findings support the validity of using parental report for ADHD services in primary care settings and for study of medication regimens.

Social networks, caregiver strain, and utilization of mental health services among elementary school students at high risk for ADHD.

OBJECTIVE: This study explores whether parental support networks vary by sociodemographic factors among children at high risk for attention-deficit/hyperactivity disorder (ADHD) and whether network characteristics influence the receipt of mental health treatment for the child. METHOD: A school district-wide, two-phase screening study design was used to identify 266 children at high risk for ADHD. Parents completed standardized instruments assessing network structure and function, DSM-IV diagnoses of disruptive disorders, caregiver strain, and treatment receipt, and children self-reported internalizing symptoms. Relationships were examined with analysis of variance and multivariate prediction, adjusting for sociodemographic characteristics, psychopathology, and parental strain. RESULTS: Network characteristics varied by race and socioeconomic status (SES), but not by child gender. African-American and disadvantaged parents reported smaller network sizes, but more frequent contact and higher levels of support than their white and high-SES counterparts. High levels of instrumental support lowered the odds of ADHD treatment during the 12 months before (OR =.7, p <.001) and after (OR =.7, p <.001) the network assessment interview. In contrast, parental strain increased the likelihood of ADHD treatment during both periods. CONCLUSIONS: Clinicians should anticipate high levels of caregiver strain and low levels of instrumental support among their patients' parents and address the potential high need for respite care in treatment plans.

Child temperament, ADHD, and caregiver strain: exploring relationships in an epidemiological sample.

OBJECTIVE: To investigate the relationship between child-reported dimensions of temperament and attention-deficit/ hyperactivity disorder (ADHD), as well as other indicators of child psychopathology, including disruptive disorders, depression, and anxiety. It also examined whether difficult child temperament scores independently predicted caregiver strain. METHOD: A school-district-wide, two-phase screening design (response rate 70% for phase 2) identified elementary school children at high risk for ADHD. Two hundred high-risk children and their parents completed standardized instruments to assess child temperament, diagnoses of disruptive disorders, children's symptoms of anxiety and depression, and caregiver strain. Relationships were examined using analysis of variance, correlations, and multivariate prediction models, adjusting for child sociodemographic characteristics and psychopathology. All estimates were weighted for sampling design and differential participation. RESULTS: Combined subtype ADHD was associated with lower scores on task orientation and higher scores on general activity level. Depressive symptoms correlated significantly with all but one difficult temperament dimension, in a pattern consistent with clinical symptoms of depression. Child temperament did not vary by ADHD treatment status. Among these high-risk children, maternal caregiver strain experiences were increased by male gender, inattention symptoms, and oppositional defiant disorder, but not by difficult temperament scores. CONCLUSION: This study provides support for Graham and Stevenson's hypothesis of continuity between specific temperament traits and certain child psychiatric disorders, namely ADHD and depressive disorders.